How to establish a successful and sustainable surgical atrial fibrillation program: key considerations on the arrhythmia, training and treatment strategies.

Establishing a successful and sustaining atrial fibrillation (AF) program should be current standard of care in cardiac surgery by providing not only sinus rhythm restoration but improving survival significantly. Recognition of AF as a serious cardiac disease impacting a considerable number of patients in terms of stroke, heart failure development and mortality is key when implementing a protocol to identify patients suitable for surgical ablation and a treatment standard according to the underlying pathology. The ablation strategy resulting in the best potential rhythm outcome should be chosen, and the applied access should follow this decision in a way that the optimal lesion set can be executed completely.

Thoracoscopic ablation for the treatment of atrial fibrillation: a systematic outcome analysis of a multicentre cohort.

Aims: To perform a systematic outcome analysis in order to provide cardiologists and general pactitioners with more adequate information to guide their decision making regarding rhythm control. Totally thoracoscopic maze (TTmaze) for the treatment of atrial fibrillation (AF) is recommended as a Class 2a indication mainly based on single centre studies including small patient cohorts and inconsistent lesion sets.

Methods And Results: We studied consecutive patients undergoing TTmaze in three European referral centres (2012-15).

Intraoperative Defibrillation Testing Should Not Be Generally Abandoned for All ICD Procedures-A Multicenter Study on 4,572 Consecutive Patients.

 The ongoing technical advances in development of new implantable cardioverter defibrillator (ICD) systems led some investigators to question the routine use of intraoperative defibrillation testing (DT). Therefore, we evaluated retrospectively in a multicenter study effectiveness, safety, and usefulness of intraoperative DT on unbiased large patient population.  Data from 4,572 consecutive patients undergoing any ICD intervention were retrospectively analyzed.

Performing the Left Atrial Maze Ablation Pattern Without Atriotomy.

The need to perform an additional atriotomy is a major concern that keeps many surgeons from performing an extended left atrial lesion set in patients with atrial fibrillation during procedures such as aortic valve replacement. This does result either in a suboptimal lesion set or even in ignoring the rhythm disorder, leaving the patient exposed to an increased risk of stroke and possible hemodynamic compromises. This report describes a technique how pulmonary vein isolation, an isolation of the posterior left atrial wall and an anterior mitral annular line, which substitutes for the mitral isthmus line in order to prevent perimitral atrial flutter, can be performed during aortic valve replacement without the need for an atriotomy.

European multicenter experience with valve-sparing reoperations after the Ross procedure.

Background: Autograft valve preservation at reoperation may conserve some of the advantages of the Ross procedure. However, results of long-term follow-up are lacking. In this retrospective multicenter study, we present our experience with valve-sparing reoperations after the Ross procedure, with a focus on long-term outcome.

Freezing Equals Freezing? Performance of Two Cryoablation Devices in Concomitant Mitral Valve Repair.

 Recent guidelines have recommended the addition of ablation in cardiac surgery for patients presenting with atrial fibrillation (AF). Currently available cryoablation devices use either nitrous oxide or argon gas as cooling agent. Our study aimed to compare success rates of two different devices currently available on the market and applied during concomitant cardiac surgery.

The David procedure for salvage of a failing autograft after the Ross operation.

Background: Dilatation of the pulmonary autograft is a major fear after the Ross procedure. We analyzed the results after reoperation for autograft dysfunction using a valve-sparing reimplantation technique (David procedure).

Methods: From 1995 to 2012, 645 Ross operations were performed, with 630 (98%) of these as freestanding root replacements (mean follow-up, 8.

Epicardial ablation performance of a novel radiofrequency device on the beating heart in pigs.

Purpose: Only bipolar clamps create reliable transmural lesions on the beating heart. This study evaluated the performance of a new radiofrequency (RF) device on the beating heart in an acute porcine model.

Description: Six domestic pigs were ablated with a novel bipolar RF linear device on the beating heart (ablation time of 40 s, 3 each on right and left atria and 1 each on superior and inferior vena cavae).

Safeguards and pitfalls in minimally invasive mitral valve surgery.

Minimally invasive mitral valve surgery has been established in many institutions worldwide. Appropriate indications and patient selection for this procedure must be based on a thorough understanding of its limitations and specific pitfalls. Particular risks can be minimized with careful attention to detail when planning and performing the surgery.

Quo vadis pulmonary autograft--the ross procedure in its second decade: a single-center experience in 645 patients.

Background: The enthusiasm about the advantages of a viable autologous transplant faded with recent reports of autograft deterioration and associated reoperations after the Ross procedure. This report evaluates predictors for autograft failure and outcomes extending into the second decade after a Ross procedure.

Methods: From 1995 through 2012, 645 consecutive patients (mean age, 42.

The impact of previous catheter-based ablation on the efficacy of the Cox-maze IV procedure.

Background: Failed catheter-based ablation for the treatment of atrial fibrillation is an indication for the Cox-maze procedure. Many patients are referred for the Cox-maze IV procedure with recurrent atrial fibrillation after a previous catheter-based ablation, but the efficacy and safety of surgical management in these patients remains unclear.

Methods: Data were collected prospectively on 129 consecutive patients who underwent a stand-alone Cox-maze IV procedure.

[Surgical ablation of atrial fibrillation. Indications, techniques and results].

Catheter ablation has been the preferred choice of treatment for many patients with atrial fibrillation (AF) and advanced to a first line treatment option. However, incomplete ablation lines and varying long-term success rates remain a problem in certain subgroups, especially patients with persistent AF or large left atria. Alternative energy sources and advances in the device design have shifted the surgeons' focus on less invasive procedures.

[Surgical closure of the left atrial appendage in patients with atrial fibrillation. Indications, techniques and results].

Cardiac embolisation in patients with atrial fibrillation accounts for the most serious complication of cerebral infarction. The left atrial appendage resembles the origin of these cardiac emboli in the majority of cases, although other anatomical areas of the left atrium might also be prerequisites for thrombus formation. Surgical closure of the left atrial appendage during an ablation therapy incorporates the theoretical possibility of reducing the rate of cardiac cerebral infarction.

Evaluation of a novel cryoablation system: in vivo testing in a chronic porcine model.

Objective: Cryoablation is commonly used at present in the surgical treatment of atrial fibrillation (AF). However, there have been few studies examining the efficacy of the commonly used ablation devices. This report compares the efficacy of two cryoprobes in creating transmural endocardial lesions on the beating heart in a porcine model for chronic AF.

Evaluation of a novel cryoablation system: in vitro testing of heat capacity and freezing temperatures.

Objective: Cryoablation has been used to ablate cardiac tissue for decades and has been shown to be able to replace incisions in the surgical treatment of atrial fibrillation. This in vitro study evaluates the performance of a novel cryoprobe and compares it with existing commercially available devices.

Methods: A new malleable 10-cm aluminum cryoprobe was compared with a rigid 3.

The David procedure in different valve pathologies: a single-center experience in 236 patients.

Background: Reports of the long-term outcome after the David procedure in different valve pathologies are limited. We compared our results in patients with tricuspid and bicuspid aortic valves, including those who required additional cusp repair.

Methods: Between 1997 and 2011, 236 patients (76% males; mean age, 56 ± 15; range, 12 to 79 years) underwent valve-sparing aortic root replacement (David procedure) for aortic regurgitation and were prospectively followed up clinically and echocardiographically.

Strategies for biological heart valve replacement: stentless xenografts fail to evolve into an alternative pulmonary valve substitute in a Ross procedure.

The Ross operation is a complex procedure for aortic valve replacement in which the pulmonary autograft is replaced by a homograft. However, homograft availability is becoming limited. This report evaluates the performance of porcine stentless prostheses as alternative pulmonary substitutes.

Approaching a paradigm shift: endoscopic ablation of lone atrial fibrillation on the beating heart.

Background: Percutaneous catheter ablation has been the preferred treatment strategy for many patients with symptomatic drug-refractory atrial fibrillation (AF). However, incomplete ablation lines and varying success rates remain a problem in certain subgroups. This article evaluates the feasibility and efficacy of endoscopically performed left atrial ablation in patients with lone AF.

Successful postoperative activation of an adjustable annuloplasty ring (MiCardia) in recurrent ischemic mitral valve regurgitation.

We report the case of a 73-year-old patient with severe ischemic mitral regurgitation (MR). She subsequently underwent combined coronary artery revascularization and mitral valve annuloplasty using the adjustable enCorSQ device (MiCardia Corporation, Irvine, CA). Three months later she experienced recurrent symptomatic severe MR.

Impact of differential right-to-left shunting on systemic perfusion in pulmonary arterial hypertension.

Objectives: This study aimed at identifying the ideal right-to-left shunt-fraction to improve cardiac output (CO) and systemic perfusion in pulmonary arterial hypertension (PHT).

Background: Atrial septostomy (AS) has been a high-risk therapeutic option for symptomatic drug-refractory patients with PHT. Results have been unpredictable due to limited knowledge of the optimal shunt-quantity.