RESUMEN

OBJECTIVE: To analyze (1) associations between postoperative atrial fibrillation (POAF) after CABG and long-term cardiovascular outcome, (2) whether associations were influenced by AF during follow-up, and (3) if morbidities associated with POAF contribute to mortality. METHODS: An observational cohort study of 7145 in-hospital survivors after isolated CABG (1996-2012), with preoperative sinus rhythm and without AF history. Incidence of AF was compared with matched controls. Time-updated covariates were used to adjust for POAF-related morbidities during follow-up, including AF. RESULTS: Thirty-one percent of patients developed POAF. Median follow-up was 9.8 years. POAF patients had increased AF compared with matched controls (HR 3.03; 95% CI 2.66-3.49), while AF occurrence in non-POAF patients was similar to controls (1.00; 0.89-1.13). The observed AF increase among POAF patients compared with controls persisted over time (> 10 years 2.73; 2.13-3.51). Conversely, the non-POAF cohort showed no AF increase beyond the first postoperative year. Further, POAF was associated with long-term AF (adjusted HR 3.20; 95% CI 2.73-3.76), ischemic stroke (1.23; 1.06-1.42), heart failure (1.44; 1.27-1.63), overall mortality (1.21; 1.11-1.32), cardiac mortality (1.35; 1.18-1.54), and cerebrovascular mortality (1.54; 1.17-2.02). These associations remained after adjustment for AF during follow-up. Adjustment for other POAF-associated morbidities weakened the association between POAF and overall mortality, which became non-significant. CONCLUSIONS: Patients with POAF after CABG had three times the incidence of long-term AF compared with both non-POAF patients and matched controls. POAF was associated with long-term ischemic stroke, heart failure, and corresponding mortality even after adjustment for AF during follow-up. The increased overall mortality was partly explained by morbidities associated with POAF.

Asunto(s)

Fibrilación Atrial/epidemiología , Puente de Arteria Coronaria/efectos adversos , Complicaciones Posoperatorias/epidemiología , Anciano , Fibrilación Atrial/complicaciones , Fibrilación Atrial/mortalidad , Estudios de Cohortes , Puente de Arteria Coronaria/métodos , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/mortalidad , Humanos , Incidencia , Accidente Cerebrovascular Isquémico/epidemiología , Accidente Cerebrovascular Isquémico/etiología , Accidente Cerebrovascular Isquémico/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/fisiopatología

RESUMEN

PURPOSE: Epicardial pulmonary vein isolation has become an increasingly used therapy for medically resistant atrial fibrillation. The purpose of the present study was therefore to evaluate if epicardial pulmonary vein isolation combined with ganglionated plexi ablation affects the size and mechanical function of the left atrium, and whether the effects are dependent on the extensiveness of the ablation applications. METHODS: A total of 42 patients underwent an echocardiographic examination prior to and 6 months after a minimal invasive epicardial pulmonary vein isolation procedure for the assessment of the effects on left atrial size and function. In 27 patients, who had sinus rhythm both at baseline and follow-up, was a comparison of atrial size and function possible at these time intervals. Fractional area changes were obtained from the left atrial end-systolic and end-diastolic areas in the apical four-chamber view. Pulsed-Doppler was used to assess the transmitral flow velocities to evaluate mechanical function. RESULTS: Left atrial size and function at 6-month follow-up had not changed significantly from those at baseline as indicated by left atrial maximal area (17.1 ± 4.6 vs. 18.7 ± 5.3, p = 0.118), minimal area (12.5 ± 3.8 vs. 13.4 ± 4.7, p = 0.248), fractional area change (27.4 ± 8.2 vs. 28.7 ± 10.6, p = 0.670), and E/A ratio (1.49 ± 0.47 vs. 1.54 ± 0.67, p = 0.855). CONCLUSIONS: Radiofrequency ablation for epicardial pulmonary vein isolation combined with ganglionated plexi ablation has no major effects on atrial function or size. A preserved atrial function for those maintaining sinus rhythm may have important implications for thromboembolic risk after surgery, but warrants confirmation in larger trials.

Asunto(s)

Fibrilación Atrial/cirugía , Función del Atrio Izquierdo/fisiología , Ablación por Catéter/métodos , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/diagnóstico por imagen , Estudios de Cohortes , Ecocardiografía Doppler/métodos , Electrocardiografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

BACKGROUND: The long-term risk of stroke after surgical treatment of atrial fibrillation is not well known. We performed an observational cohort study with long follow-up after the "cut-and-sew" Cox-maze III procedure (CM-III), including left atrial appendage excision. The aim was to analyze the incidence of stroke/transient ischemic attack (TIA) and the association to preoperative CHA2DS2-VASc (age in years, sex, congestive heart failure history, hypertension history, stroke/TIA, thromboembolism history, vascular disease history, diabetes mellitus) score. METHODS: Preoperative and perioperative data were collected in 526 CM-III patients operated in four centers 1994 to 2009, 412 men, mean age of 57.1 ± 8.3 years. The incidence of any stroke/TIA was identified through analyses of the Swedish National Patient and Cause-of-Death Registers and from review of individual patient records. The cumulative incidence of stroke/TIA and association with CHA2DS2-VASc score was estimated using methods accounting for the competing risk of death. RESULTS: Mean follow-up was 10.1 years. There were 29 patients with any stroke/TIA, including 6 with intracerebral bleedings (2 fatal) and 4 with perioperative strokes (0.76%). The remaining 13 ischemic strokes and six TIAs occurred at a mean of 7.1 ± 4.0 years postoperatively, with an incidence of 0.36% per year (19 events per 5,231 patient-years). In all CHA2DS2-VASc groups, observed ischemic stroke/TIA rate was lower than predicted. A higher risk of ischemic stroke/TIA was seen in patients with CHA2DS2-VASc score 2 or greater compared with score 0 or 1 (hazards ratio 2.15, 95% confidence interval: 0.87 to 5.32) but no difference by sex or stand-alone versus concomitant operation. No patient had ischemic stroke as cause of death. CONCLUSIONS: This multicenter study showed a low incidence of perioperative and long-term postoperative ischemic stroke/TIA after CM-III. Although general risk of ischemic stroke/TIA was reduced, patients with CHA2DS2-VASc score 2 or greater had a higher risk compared with score 0 or 1. Complete left atrial appendage excision may be an important reason for the low ischemic stroke rate.

Asunto(s)

Fibrilación Atrial/cirugía , Isquemia Encefálica/epidemiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Predicción , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo/métodos , Apéndice Atrial/cirugía , Isquemia Encefálica/etiología , Procedimientos Quirúrgicos Cardíacos/métodos , Causas de Muerte/tendencias , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Pronóstico , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Suecia/epidemiología

RESUMEN

AIMS: The low efficacy rates reported for conventional catheter ablation of longstanding persistent atrial fibrillation (LPAF) have led to the development of alternative techniques such as minimal invasive surgical ablation, aiming for durable and contiguous transmural lesions. The aim was to evaluate the efficacy and safety of total thoracoscopic epicardial left atrial ablation (TELA-AF) procedures in a prospective study of severely symptomatic patients with either drug-resistant AF and/or failed attempts of catheter ablation. METHODS AND RESULTS: The TELA-AF surgical technique includes pulmonary vein isolation, left atrial (LA) 'box lesion', and partial vagal denervation. The LA appendage was excluded if deemed safe. Patients were followed with clinical evaluations and 12-lead electrocardiograms at 3, 6, and 12 months after the surgical intervention, complemented with a 7-day Holter monitoring after 6 and 12 months. Sixty patients, of whom 38 (63%) suffered from LPAF, underwent TELA-AF between November 2008 and December 2010. One patient with LPAF was lost to follow-up. At 12-month follow-up, 55/59 patients (93%) were free from atrial fibrillation (AF), while 7/59 patients (12%) suffered from recurrent LA tachycardia. Among patients with LPAF, 32/37 (86%) maintained sinus rhythm after 12 months. Adverse events included four perioperative bleedings requiring conversion to sternotomy in three cases, two ischaemic strokes and one transient ischaemic attack. CONCLUSION: The total thoracoscopic surgical ablation procedure is highly effective even in patients with LPAF, and it seems safe. The high rate of iatrogenic LA re-entrant tachycardia, however, warrants further improvement of the technique.

Asunto(s)

Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Atrios Cardíacos/cirugía , Toracoscopía/métodos , Adulto , Anciano , Ablación por Catéter/efectos adversos , Supervivencia sin Enfermedad , Electrocardiografía Ambulatoria , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Venas Pulmonares/cirugía , Recurrencia , Suecia , Toracoscopía/efectos adversos , Resultado del Tratamiento

RESUMEN

BACKGROUND: The Cox-maze III (CM-III) procedure is the gold standard for surgical treatment of atrial fibrillation (AF). Excellent short-term results have been reported, but long-term outcomes are lesser known. The aim was to evaluate current cardiac rhythm in a nationwide cohort of CM-III patients with very long follow-up. METHODS: Perioperative characteristics were retrospectively analyzed in 536 "cut-and-sew" CM-III patients operated on from 1994 to 2009 in 4 centers. Of these, 54 patients had died and 20 were unavailable at follow-up. The remaining 462 patients received a survey concerning arrhythmia symptoms, rhythm, and medication; of these, 320 patients (69%), comprising 252 men, with a mean age of 67 years (range, 47 to 87 years), and 83% with stand-alone CM-III, returned a current 12-lead electrocardiogram. Long-term monitoring was evaluated in 40 sinus rhythm patients. Postoperative stroke/transient ischemic attack was evaluated by register analysis. RESULTS: Mean follow-up was 111 ± 44 months (range, 36-223 months). Electrocardiogram analysis showed sinus rhythm in 219 of 320 patients (68%), and regular supraventricular rhythm (sinus, nodal, or atrial pacing) in 262 (82%), with 75% off class I/III antiarrhythmic medication. This group had lower arrhythmia symptom scores and medication use. Rhythm outcome did not differ by gender, age, type of AF, or stand-alone vs concomitant operation. Patients with more than 10 years of follow-up had a lower rate of regular supraventricular rhythm (69% vs 91%, p = 0.02). Long-term monitoring showed freedom from AF/atrial flutter in 38 of 40 patients (95%). The incidence of stroke/transient ischemic attack was 0.37% per year (11 patients). CONCLUSIONS: In a single-moment electrocardiogram evaluation 9 years after the cut-and-sew CM-III, 82% of patients were in sinus rhythm or other regular supraventricular rhythm. These findings support a long-lasting positive effect of the CM-III procedure, which is relevant when evaluating current nonpharmacologic therapies for AF.

Asunto(s)

Fibrilación Atrial/cirugía , Anciano , Anciano de 80 o más Años , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Electrocardiografía , Femenino , Estudios de Seguimiento , Frecuencia Cardíaca , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

AIMS: Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients. METHODS AND RESULTS: All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued <24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or >120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. >120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012]. CONCLUSION: The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.

Asunto(s)

Adenosina/análogos & derivados , Puente de Arteria Coronaria/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Hemorragia Posoperatoria/prevención & control , Ticlopidina/análogos & derivados , Adenosina/efectos adversos , Anciano , Transfusión Sanguínea/estadística & datos numéricos , Clopidogrel , Femenino , Humanos , Masculino , Hemorragia Posoperatoria/inducido químicamente , Sistema de Registros , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Suecia , Ticagrelor , Ticlopidina/efectos adversos , Factores de Tiempo

RESUMEN

In the Cox-Maze IV procedure, or in endocardial left atrial ablation, correct positioning of the surgical ablation probe within the left atrium might be difficult due to bulging or folds in the posterior left atrial wall. The Berglin apical stitch is a simple trick of the trade to create a smooth surface in the posterior left atrium that facilitates performing a safe transmural lesion and, consequently, may increase antiarrhythmic efficiency.

Asunto(s)

Fibrilación Atrial/cirugía , Criocirugía/métodos , Técnicas de Sutura , Fibrilación Atrial/diagnóstico , Humanos , Resultado del Tratamiento

RESUMEN

OBJECTIVES: To evaluate the effect of concomitant cardiac resynchronization therapy (CRT) on health related quality of life (QoL) in patients with heart failure (HF) and ventricular dyssynchrony undergoing cardiac surgery. METHODS: Twenty-eight patients received permanent epicardial CRT in connection to coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) (CRT group). Thirty-seven HF patients without concomitant CRT served as a comparison group (non-CRT group). SF-36 was used to assess QoL in the two groups and was also compared with the general Swedish population. RESULTS: The median follow-up time was 28 months after surgery (range 8 to 44 months). No difference in QoL could be shown between the CRT group and the comparison group. Several subscales of QoL in the CRT group were in range with the general Swedish population. CONCLUSION: Concomitant CRT for patients with HF and ventricular dyssynchrony undergoing CABG and/or AVR did not result in a higher estimated QoL compared to HF patients without CRT.

RESUMEN

BACKGROUND: The cut-and-sew Cox-maze III procedure is the gold standard for surgical treatment of atrial fibrillation. The aim was to study early and long-term mortality based on registry analyses in Swedish Cox-maze III patients. METHODS: Preoperative and early postoperative data were analyzed in 536 patients (male/female (425/111), mean age 57 ± 8.6 years), operated from 1994 to 2009 in 4 centers; 422 (79%) underwent stand-alone Cox-maze III. Atrial fibrillation was paroxysmal in 38% and non-paroxysmal in 62%, mean duration was 7.8 ± 6.3 years. Patients were followed for survival or death in a validated national Cause-of-Death registry. Risk factors associated with observed survival were identified in univariable and multivariable analyses in a standard Cox proportional hazards model. RESULTS: Four early deaths (0.7%) occurred due to technical complications. At follow-up, 41 of 536 (7.6%) patients had died. Cause of death was cardiovascular in 19 of 536 (3.5%). No ischemic stroke-related death was registered. Univariable risk factors for all-cause mortality included hypertension (hazard ratio [HR] 2.8, confidence interval [CI] 1.5 to 5.3), heart failure (HR 2.4, CI 1.3 to 4.3), concomitant surgery (HR 2.2, CI 1.1 to 4.1), and postoperative complications (HR 2.5, CI 1.3 to 4.8). Gender, non-paroxysmal atrial fibrillation and long arrhythmia duration did not confer increased risk of death. Multivariable risk factors were hypertension (HR 2.9, CI 1.5 to 5.5) and postoperative complications (HR 2.4, CI 1.2 to 4.6). Survival for cardiovascular death at 5, 10, and 15 years was 98%, 96%, and 93%, respectively. CONCLUSIONS: Registry-based follow-up showed low early and long-term cardiovascular mortality and no stroke-related mortality. This is important baseline information when evaluating current surgical and nonsurgical treatment of atrial fibrillation.

Asunto(s)

Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/mortalidad , Adulto , Anciano , Fibrilación Atrial/mortalidad , Procedimientos Quirúrgicos Cardíacos/métodos , Causas de Muerte , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Sistema de Registros

Asunto(s)

Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Ablación por Catéter/métodos , Consenso , Humanos , Guías de Práctica Clínica como Asunto , Suecia , Resultado del Tratamiento

RESUMEN

Atrial fibrillation (AF) is a common arrhythmia among patients scheduled for open heart surgery and is associated with increased morbidity and mortality. According to international guidelines, symptomatic and selected asymptomatic patients should be offered concomitant surgical AF ablation in conjunction with valvular or coronary surgery. The gold standard in AF surgery is the Cox Maze III ("cut-and-sew") procedure, with surgical incisions in both atria according to a specified pattern, in order to prevent AF reentry circuits from developing. Over 90% of patients treated with the Cox Maze III procedure are free of AF after 1 year. Recent developments in ablation technology have introduced several energy sources capable of creating nonconducting atrial wall lesions. In addition, simplified lesion patterns have been suggested, but results with these techniques have been unsatisfactory. There is a clear need for standardization in AF surgery. The Swedish Arrhythmia Surgery Group, represented by surgeons from all Swedish units for cardiothoracic surgery, has therefore reached a consensus on surgical treatment of concomitant AF. This consensus emphasizes adherence to the lesion pattern in the Cox Maze III procedure and the use of biatrial lesions in nonparoxysmal AF.

Asunto(s)

Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Algoritmos , Fibrilación Atrial/patología , Ablación por Catéter/métodos , Consenso , Atrios Cardíacos/patología , Atrios Cardíacos/cirugía , Humanos , Suecia

RESUMEN

The objective of this study was to identify and evaluate predictors of postoperative atrial fibrillation (POAF) in a large coronary artery bypass grafting (CABG) cohort. This was a single centre study of 7115 consecutive patients with preoperative sinus rhythm who underwent isolated CABG between January 1996 and December 2009. Independent risk factors for POAF were identified with multiple logistic regression. The predictive quality of the final model was evaluated by comparing predicted and observed events of POAF, in an effort to find patients at high risk of developing POAF. After CABG, 2270 patients (32%) developed POAF during hospital stay. Independent risk factors of POAF included advancing age (odds ratio, OR 2.0-7.3), preoperative S-creatinine ≥ 150 µmol/l (OR 1.6), male gender (OR 1.2), New York Heart Association class III/IV (OR, 1.2), smoking (OR 1.1), prior myocardial infarction (OR 1.1) and absence of hyperlipidemia (OR 0.9). The final prediction model was moderate (area under curve, 0.62; 95% confidence interval, 0.61-0.64). Patients with POAF had more postoperative complications, including a higher incidence of stroke and increased length of hospital stay. In conclusion, several risk factors for POAF were identified, but the moderate value of the prediction model confirms the difficulty of identifying patients at high risk of developing POAF after CABG.

Asunto(s)

Fibrilación Atrial/etiología , Puente de Arteria Coronaria/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/prevención & control , Distribución de Chi-Cuadrado , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Medición de Riesgo , Factores de Riesgo , Suecia , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

OBJECTIVES: The limited information available on thoracoscopic pulmonary vein isolation combined with ganglionated plexi ablation and the lack of studies regarding its effect on quality of life and physical capacity urged us to study its acute and long-term results in patients with atrial fibrillation. METHODS: Forty-three patients (mean age 57.1 years) with symptomatic atrial fibrillation referred for thoracoscopic off-pump epicardial pulmonary vein isolation and ganglionated plexi ablation using radiofrequency energy were included. RESULTS: The physical capacity improved significantly at 6-month follow-up compared with baseline (mean +/- standard deviation, 165.2 +/- 65 Watt versus 155.9 +/- 57 Watt, P = .02). Quality of life (Short Form-36 health survey) significantly improved 12 months after surgery compared with baseline in all subscales except for bodily pain. The symptom severity questionnaire score decreased significantly from mean 15.2 +/- 4.0 points to 10.7 +/- 4.8 points (P = .02). Overall, 25 of 33 patients (76%) followed up for 12 months had no symptomatic atrial fibrillation recurrences or atrial fibrillation episodes on 24-hour Holter recordings. The corresponding figures were 79% (19/24) for patients with paroxysmal atrial fibrillation, 100% (2/2) for persistent atrial fibrillation, and 57% (4/7) for permanent atrial fibrillation. The most common complication was bleeding events (9%) during pulmonary vein dissection. CONCLUSIONS: Epicardial off-pump pulmonary vein isolation combined with ganglionated plexi ablation improved quality of life, symptoms, and exercise capacity and therefore may be considered for patients with atrial fibrillation who fail endocardial pulmonary vein ablation or as a first-line procedure if left atrial appendage exclusion is warranted.

Asunto(s)

Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Venas Pulmonares/cirugía , Calidad de Vida , Cirugía Torácica Asistida por Video/métodos , Vagotomía/métodos , Adulto , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Ablación por Catéter/efectos adversos , Estudios de Cohortes , Electrocardiografía , Electrocardiografía Ambulatoria , Tolerancia al Ejercicio/fisiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Probabilidad , Recurrencia , Medición de Riesgo , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Análisis de Supervivencia , Resultado del Tratamiento , Nervio Vago/cirugía

RESUMEN

OBJECTIVES: Sternal wound infection after cardiac operations leave physical, cosmetic and mental scar i.e. low quality of life (QoL). To better understand and evaluate health related to QoL we used SF-36 and also analysed if there were any different outcome in SWI subgroups due to different surgical techniques. DESIGN: Between January 1, 1998 and June 30, 2002 a total of 97 patients developed SWI at our department. The patients were followed up in terms of survival by computerised linkage to a continuously updated population register. On January 1, 2003, 84 patients could be identified as being alive and constituted the study group (SWI group) and compared with 42 patients prior to coronary artery bypass grafting (CABG) and evaluated one year postoperative (CABG group), and matched for time of the operation, age and sex. RESULTS: The median follow-up time after cardiac surgery was 20 months (range 7-40). Late mortality was 13.4% (13/97 patients) with the median time of 5 months (range 0.5-26) postoperative. The response rate was 86.9% and SF-36 showed that SWI patients deviated significantly from the normative data for the general Swedish population. QoL for the SWI patients was comparable to QoL assessed prior to cardiac surgery i.e. the CABG group. The different surgical techniques used were comparable as they did not affect the outcome of QoL. CONCLUSIONS: Our results confirm that if the patients survive, SWI is a very serious complication concerning QoL. At follow up the SWI patients did not improve their QoL, with no difference in surgical technique used, although they had undergone open heart surgery.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos/efectos adversos , Isquemia Miocárdica/cirugía , Calidad de Vida , Infección de la Herida Quirúrgica/etiología , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Humanos , Masculino , Persona de Mediana Edad , Infección de la Herida Quirúrgica/cirugía

RESUMEN

Vacuum-assisted closure therapy is a recently introduced technique for treatment of deep sternal wound infections after cardiac surgery. We present five cases of vacuum-assisted closure therapy-related major bleeding complications due to rupture of the right ventricle. This potentially lethal complication may be avoided by covering the heart with protective layers of paraffin gauze dressings.

Asunto(s)

Lesiones Cardíacas/etiología , Ventrículos Cardíacos/lesiones , Osteítis/terapia , Presión/efectos adversos , Esternón , Infección de la Herida Quirúrgica/terapia , Vacio , Anciano , Puente de Arteria Coronaria , Resultado Fatal , Femenino , Lesiones Cardíacas/prevención & control , Humanos , Laceraciones/etiología , Masculino , Persona de Mediana Edad , Osteítis/etiología , Vaselina , Poliuretanos , Estudios Retrospectivos , Choque Hemorrágico/etiología , Choque Hemorrágico/mortalidad , Esternón/cirugía , Tapones Quirúrgicos de Gaza

RESUMEN

UNLABELLED: To better understand the pathogenesis of postoperative atrial fibrillation (AF), the mode of onset of AF after coronary artery bypass grafting was analyzed with respect to the autonomic balance, the heart rate (HR), and the presence of arrhythmias preceding the onset of sustained AF. METHOD: Holter recordings of 24 hours, obtained from the first postoperative morning until clinically documented sustained AF, were analyzed in 29 untreated patients and in 13 patients treated with thoracic epidural anesthesia (TEA), who all developed AF after coronary artery bypass grafting. The presence of arrhythmias, the HR, and the autonomic balance, assessed by heart rate variability in the frequency domain, were analyzed at predefined time intervals within the 3-hour period before AF onset. Supraventricular premature beats (SPBs) and ventricular premature beats triggering the onset of AF were also evaluated. RESULT: An SPB triggering the onset of AF can be identified in 21 (72.4%) of 29 untreated patients and in 12 (100%) of 12 TEA-treated patients in whom the recordings permitted such an analysis. The heart rate variability components analyzed during 5-minute periods for 30 minutes before AF onset did not differ significantly from those at corresponding times at the first postoperative day in either patient group. The HR during the 8 beats immediately before AF onset was lower in TEA-treated than in untreated patients. CONCLUSION: The finding of an SPB at the onset of postoperative AF in most of the patients and irrespective of changes in HR supports the hypothesis that postoperative AF is primarily triggered by latent focal atrial activity. The autonomic tone did not seem to be of major importance in the population studied.

Asunto(s)

Fibrilación Atrial/etiología , Complejos Atriales Prematuros/complicaciones , Puente de Arteria Coronaria , Frecuencia Cardíaca/fisiología , Complicaciones Posoperatorias/etiología , Anciano , Anestesia Epidural , Fibrilación Atrial/fisiopatología , Electrocardiografía Ambulatoria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/fisiopatología , Taquicardia Supraventricular/fisiopatología

RESUMEN

AIMS: To evaluate if elevated biochemical marker levels after coronary artery bypass grafting (CABG) correspond to the amount of peri-operatively infarcted myocardium, quantified by magnetic resonance imaging (MRI) post-operatively. METHODS AND RESULTS: A total of 23 patients without evidence of previous myocardial infarction or myocarditis and with normal pre-operative ECG and left ventricular function and who underwent elective, primary CABG, without any other concomitant cardiac surgery, were included. Plasma creatinine kinase MB (CK-MB) and troponin I and T were measured on the first, second and fourth post-operative days. Between the fourth and ninth post-operative days, cardiac MRI was carried out. Infarctions were found in 18 patients. The infarction mass at MRI was numerically largest in patients with transmural infarctions, all of whom had a CK-MB more than five times the upper normal limit. All three cardiac markers correlated to the mass of infarction. CONCLUSION: Elevated biochemical markers after CABG correspond to the amount of peri-operatively infarcted myocardium.

Asunto(s)

Medios de Contraste , Puente de Arteria Coronaria/métodos , Infarto del Miocardio/cirugía , Anciano , Biomarcadores/sangre , Femenino , Humanos , Cuidados Intraoperatorios/métodos , Angiografía por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico

RESUMEN

The Maze III procedure is a surgical operation for curative treatment of AF. The procedure is extensive, however, with multiple incisions in both atria, and its effects on autonomic regulation of the heart rhythm are not known. This study comprises 17 patients, 10 with paroxysmal AF and 7 with chronic AF, who had no concurrent cardiac disease known to affect heart rate variability (HRV). A 24-hour Holter recording was performed preoperatively and 2 months (early) and 7 months (late) after surgery, for analysis of HRV in the time and frequency domains. Early after the Maze procedure all HRV components were markedly reduced compared to baseline (mean +/- 1 SD): SDNN 73 +/- 13 versus 148 +/- 50 (ms), total power 168 +/- 126 versus 560 +/- 1567 (ms2), low frequency (LF) power 47 +/- 67 versus 826 +/- 677 (ms2), high frequency (HF) power 47 +/- 40 versus 678 +/- 666 (ms2), and LF:HF 1.22 +/- 0.9 versus 2.55 +/- 1.4. Late after the Maze procedure all variables were still reduced. Only total power increased significantly between early and late follow-up (168 +/- 126 vs 496 +/- 435 ms2). Late after Maze surgery, values of the different HRV components did not differ between the patients with paroxysmal AF and chronic AF. Early after the Maze procedure there is a marked decrease of all HRV components, which is maintained 7 months after surgery, a pattern consistent with denervation of the heart.

Asunto(s)

Fibrilación Atrial/cirugía , Desnervación Autonómica , Corazón/inervación , Electrocardiografía Ambulatoria , Femenino , Atrios Cardíacos/cirugía , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Persona de Mediana Edad , Procesamiento de Señales Asistido por Computador