Giant aneurysm of the right atrial appendage repaired by minimally invasive approach

A 59‐year‐old female patient who was diagnosed with giant right atrial appendage aneurysm (75 × 87 mm) underwent minimally invasive repair via right mini‐thoracotomy. The aneurysm was completely excluded by linear method under beating heart without cardiac arrest. The postoperative recovery was uneventful and she was discharged home without symptoms 16 days after surgery.     

Cor triatriatum in adulthood with mitral valve regurgitation and atrial fibrillation

Cor triatriatum is a rare congenital heart disease. A 57‐year‐old woman had cor triatriatum with severe mitral valve regurgitation (MR) and atrial fibrillation (AF). We performed mitral valve repair, left atrial appendage resection, and maze procedure by resection of the anomalous septum in the left atrium. As a result, MR was controllable and AF disappeared after the operation. Although there is no established maze procedure with cor triatriatum, removing the septum was effective to complete it.     

Surgical treatment of congenital right atrial aneurysm in an adult patient

A 52-year-old man with atrial flutter was diagnosed as having a large congenital aneurysm or diver-ticulum of the right atrium. Surgical resection of the aneurysm under beating heart condition promptly eliminated atrial flutter. The patient has maintained sinus rhythm during the past 18 months of follow-up period.     

Congenital aneurysm of the right atrium

Congenital aneurysm of the right atrium is described in a 1-year-old girl who presented with cardiomegaly and symptoms of paroxysmal supraventricular tachycardia. Echocardiography and cineangiography both established the definitive diagnosis and surgical resection was successful. The rarity of this condition is pointed out and its main features outlined.     

Radiofrequency modified maze procedure for chronic atrial fibrillation

Background We studied the effectiveness of Radiofrequency (RF) modified maze in early and late restoration of sinus rhythm in patients with rheumatic heart disease (RHD). Methods We studied 84 patients with RHD over 23.6±12.5 months after the RF modified maze and another group of 64 patients over six months after valvular surgery alone (the Non-Maze group). Any thromboembolic episodes and NYHA class of the patient were recorded. The short term survivors in sinus rhythm, underwent stress test and echocardiography for atrial transport function at 3–6 months after surgery. Results In the Maze group, sinus rhythm was restored in 60/70 patients (85.71%) immediately and sustained in 55/70 patients (78.57%) over the follow-up as against an immediate conversion rate of 5.3% (5/53 patients, p<0.001) in the Non-maze group. The additional Cardiopulmonary (CP) bypass time (p=0.13) and cross clamp time (p=0.511) needed for maze is not statistically significant. Left atrial (LA) transport function was preserved in 41/51 patients (80.4%) and Right atrial (RA) transport function in 51/51 patients (100%). Stress test showed good chronotropic response in all the 41 patients in whom it was performed. In the Maze group one patient presented with acute valve thrombosis and subsequently, succumbed to it. In the non maze group 3/55 patients (5.66%) were hospitalized for stroke. No patient needed permanent pacemaker nor was sinus node dysfunction seen. The immediate postoperative morbidity and mortality was comparable in the two groups. Conclusions The RF modified maze is safe, effective and brief without any additional risk. It restores sinus rhythm in the majority, however there is an attrition in some.     

微波消融治疗心房颤动在瓣膜手术中的应用

目的探索瓣膜手术同期微波消融治疗心房颤动的初步经验。方法对90例心脏瓣膜病合并持续性心房颤动患者,在瓣膜手术同期行心内膜微波消融。结果全组平均微波消融时间为(14.3±2.9)min。术后随访1~24个月,复发14例,治愈率84.4%,无消融相关并发症。结论瓣膜手术同期微波消融治疗心房颤动安全、有效。     

Experience with unipolar radiofrequency ablation for atrial fibrillation

BACKGROUND: The cut and sew Cox maze procedure for atrial fibrillation (AF), although effective, is not widely used because of technical complexity, prolonged duration and significant risk of postoperative bleeding. This study reviews our experience with the unipolar radiofrequency ablation (RFA) procedure, which was used to create a modified maze to treat AF. METHODS: A retrospective review of 31 patients undergoing consecutive cardiac surgery who had concomitant RFA for AF over a 16-month period was carried out. A Cobra unipolar RFA probe (EPT; Boston Scientific, San Jose, CA, USA) was used to create a standard set of lesions. RESULTS: There were 20 men and 11 women (mean age, 66 +/- 9 years; range, 48-87 years). AF was continuous in 21 patients and intermittent in 10. The median duration of AF leading up to surgery was 48 months (range, 6 months-20 years). Left atrium was enlarged in 81% of the patients. Operations included mitral valve repair (7 patients), replacement (5), coronary artery bypass (10), aortic valve replacement (1) and combined procedures (8). There were no complications directly attributable to RFA. There were three early deaths. One patient required a permanent pacemaker. Median follow up was 22 months (range, 12-30 months). One patient died 2 years after the operation from a stroke. Cardioversion was attempted in five patients within 3 months of operation and was successful in four. At 2 years following the procedure, the probability of the patient remaining in sinus rhythm was 0.71 +/- 0.15. CONCLUSION: Surgical RFA can be carried out as a useful adjunct to conventional cardiac surgery. Although the results were satisfactory in this series, further studies are needed to refine the indication of the procedure and to assess its longer-term efficacy.     

Anticoagulation strategy in patients with atrial fibrillation after carotid endarterectomy

Aim: Carotid artery stenosis and atrial fibrillation are diseases of the aging patient population. Literature lacks precise anticoagulation treatment protocols for patients with atrial fibrillation following carotid endarterectomy. We present our experiences with anticoagulation strategy in this particular patient population.

Patients and methods: Between June 2001–September 2017, 165 patients with chronic or paroxysmal atrial fibrillation out of 1594 cases from three different institutions whom received Coumadin and aspirin and required carotid endarterectomy were reviewed, respectively. Mean age was 63.4?±?7.9 years. Male/female ratio was 102/63. There were 67 diabetic and 138 hypertensive cases.

Results: Patients are followed a mean of 64.4?±?16.9 months. Early mortality occurred in two patients due to intracranial bleeding and heart failure. Another patient was lost due to intracerebral hemorrhage and 16 other patients died due to various causes in the late follow-up. Three patients required exploration against bleeding.

Conclusion: Combination of warfarin with an aim to keep the INR value between 2 and 3, and aspirin at a dosage of 100?mg per day seemed feasible and in our modest patient cohort. Further studies including multicenter larger data are warranted in order to establish a precise anticoagulation treatment protocol for patients with atrial fibrillation after carotid endarterectomy.     

超声心动图预测心房颤动患者左心房血栓形成

心房颤动(房颤)可促进左心房血栓形成,而血栓脱落后引起的血栓栓塞是其最严重的并发症之一。准确预测房颤患者左心房血栓的形成,对房颤术前风险评估及临床抗凝治疗方案的选择有重要价值。超声心动图具有无创、经济等优点,可为预测房颤患者左心房血栓的形成提供可靠信息。     

The peri-operative management of atrial fibrillation

Atrial fibrillation is a common arrhythmia frequently seen in surgical patients. The onset of new atrial fibrillation during the peri-operative period is less common. There are many possible precipitating factors, although volatile agents themselves may have an antifibrillatory action. The management of atrial fibrillation includes removal of any precipitating factors and treatment of the arrhythmia itself. Immediate management of acute-onset atrial fibrillation is usually direct current cardioversion. Alternatively, anti-arrhythmic drugs can be used to achieve cardioversion. In patients with rapid, chronic atrial fibrillation or those refractory to cardioversion, priority is given to control of the ventricular rate. Thrombo-embolism is a significant risk if atrial fibrillation is paroxysmal or persists for more than 48 h.     

心脏超声对风湿性瓣膜病术后房颤自动复律的预测

目的对风湿性心脏病（风心病）心房颤动患者术后自动恢复窦性心律与不能恢复窦性心律患者的心脏超声指标进行对比分析，探讨自动恢复窦性心律的可能因素。方法选择风心病二尖瓣置换术患者515例，术前心电图检查均示有房颤，按照术后自动恢复窦性心律情况分为非自动恢复窦律对照组及自动恢复窦律组，对左房直径（LAD）、右房直径（RAD）、心脏射血分数（EF）、左室缩短率（FS）等超声指标进行比较分析。结果术后维持窦律时间较长组LAD、左房容积（LAV）明显低于非自动复律组（P〈0．01），而EF、FS则明显高于非自动复律组（P〈0．01）。结论从心脏超声指标分析，风心病瓣膜置换术后房颤自动恢复窦性心律及窦性心律维持时间与左房大小及心功能有密切关系。     

实时三维经食管超声心动图定量评价心房颤动患者左心耳形态及功能

目的探讨实时三维经食管超声心动图(RT-3D-TEE)定量评估心房颤动(AF)患者左心耳(LAA)形态和功能的可行性。方法选取56例拟接受射频消融术的阵发性AF患者(阵发组)、26例持续性AF患者(持续组)及同期11名健康人(对照组),采用RT-3D-TEE测量3组LAA各参数。结果与对照组比较,阵发组LAA舒张末期容积(LAA-EDV)、收缩末期容积(LAA-ESV)、开口最大面积(A_(max))及最小面积(A_(min))均增大,射血分数(LAA-EF)、最大排空速度(Vep)、面积变化率(A%)及直径变化率(D%)均减小(P均0.05);持续组LAA-EDV、LAA-ESV、A_(max)、A_(min)增大,LAA-EF、Vep、A%、D%减小(P均0.05);阵发组与持续组间各参数差异均无统计学意义(P均0.05)。LAA-EF与ESV (r=-0.73,P0.01)、EDV(r=-0.64,P0.01)、A_(max)(r=-0.36,P0.01)及年龄(r=-0.27,P=0.02)呈负相关,与A%、D%、Vep呈正相关(r=0.86、0.74、0.55,P均0.01),与D_(max)无明显相关(P0.05)。结论 RT-3D-TEE能定量分析AF患者LAA形态及功能变化,对于评估AF患者病情具有一定临床意义。     

Prognostic impact of heart rate in elderly with systolic heart failure and concomitant atrial fibrillation

Objective: The present study aimed to investigate the impact of resting heart rate (HR) on 5-year all-cause mortality in patients ≥80 years with heart failure (HF) with reduced ejection fraction (HFrEF) and concomitant atrial fibrillation (AF) after optimal up-titration of beta-blockers (BBs).

Methods: Patients (n?=?185) aged ≥80 years with HF and left ventricular ejection fraction ≤40% were included between January 2000 and January 2008 from two university hospitals, Sahlgrenska and Östra and retrospectively studied from January 2 to May 30, 2013. Up-titrations of guideline recommended medications were performed at HF outpatient clinics.

Results: Of whole study population, 54% (n=?100) had AF. After optimal up-titration of BBs and angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), mean HR in patients with AF was 73?±?15 beats/minute (bpm), 36% had resting HR?≤65 bpm. Five-year all-cause mortality among patients with AF was significantly lower in patients with HR?≤65 bpm (63%) compared to HR?>65 (80%). Cox proportional-hazard regression analysis adjusted for clinically important baseline variables and doses of ACEIs/ARBs and BBs demonstrated resting HR?≤65 bpm as an independent predictor of improved survival compared to resting HR?>65 bpm (HR 0.3, 95%CI 0.1–0.7, P 0.005).

Discussion: In octogenarians with HFrEF and concomitant AF, lowering resting HR to levels as low as HR?≤65 bpm was still associated with improved survival from all-cause mortality. Our data indicate that mortality in AF became comparable to SR when patients were on maximally up-titrated beta-blocker doses with HR as low as 75 bpm.     

Predicting the risk of atrial fibrillation after coronary artery bypass surgery

Atrial fibrillation (AF) is the most common arrhythmia, with an incidence of 17–33%, after coronary artery bypass grafting (CABG) and it increases the cost of operative treatment. β‐Blocker therapy reduces markedly the incidence of postoperative AF. The more effective preventive methods, e.g. amiodarone therapy or atrial pacing, are not cost‐effective for all the patients. Thus, identification of patients at high risk of AF after CABG would be helpful. This review summarizes the predictors of postoperative AF and the current methods for risk stratification. In summary, identification of the patients at high risk of postoperative AF remains a challenge. The clinical usefulness of most of the conventional factors, e.g. age or history of AF, is low. Even attempts to build logistic regression models based on the pre‐ and intraoperative variables have failed to provide powerful predictors for postoperative AF after CABG. From the new predictors, the P‐wave duration in signal‐averaged ECG looks promising. Sensitivity and negative predictive value are high, positive predictive value remains low, which limits its usefulness. Contrary, even detailed analysis of standard 12‐lead ECG or measure of heart rate variability has failed to provide useful information for risk stratification. A new method for risk stratification has been developed in our centre. The diagnostic accuracy of high‐rate atrial pacing seems to be sufficient to identify a group of patients to whom prophylactic treatment could be proactively targeted. Further experience is, however, warranted to verify significance of this method in everyday clinical practice.     

Paroxysmal atrial fibrillation is uncommon in outpatients with chronic heart failure

Objectives. The objective was to evaluate the prevalence of paroxysmal atrial fibrillation (PAF) in patients with heart failure (HF) due to systolic dysfunction. Design. We included 79 patients (age 68 years, LVEF 30%) with HF and sinus-rhythm (SR) referred to a HF outpatient clinic. A 48 hours Holter ECG and a follow-up ECG were performed. Results. One patient had one episode of PAF. Thirty-two (41%) patients had episodes of irregular atrial runs (AR). The numbers of QRS complexes during AR were 7.2±2.9 (mean±SD). Patients with AR were older than patients with SR, p =0.02 and more often of female sex, p =0.04. Multivariate logistic regression analysis showed that age and female sex were independently correlated with AR with adjusted OR of 1.1 (per year, 95% CI 1.02–1.14, p =0.01) and 4.0 (1.05–15.07, p =0.04), respectively. The presence of AR did not predict development of new-onset AF. Conclusion. Outpatients with HF due to systolic dysfunction did not present with PAF during 48 hours Holter, but had several episodes of AR. The clinical and prognostic importance of AR deserves further investigation.