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7. Does Preoperative Atrial Fibrillation Reduce Survival After Cabg?
Mohammed A. Quader; *Patrick M. McCarthy; *A. Marc Gillinov; Joan M. Alster; *Delos M. Cosgrove; *Bruce W. Lytle; Eugene H. Blackstone
The Cleveland Clinic Foundation , Cleveland , Ohio

Background:

Atrial fibrillation (AF) has been identified as a risk factor for long-term survival after coronary artery bypass grafting (CABG). This study sought to determine whether AF is merely a MARKER for high-risk patients or an INDEPENDENT risk factor for time-related mortality.

Methods:

Between 1972 and 2000, 46,992 patients underwent primary isolated CABG; 451 (0.96% prevalence) had EKG-documented preoperative atrial fibrillation (411) or flutter (40). Characteristics of patients with and without AF were contrasted by multivariable logistic regression to form a propensity score. With this, comparable groups with and without AF were formed by pair-wise matching to assess time-related all-cause mortality.

Results:

Patients with preoperative AF were older (67±9.0 vs. 59±9.8 years, P<.0001), had more left ventricular dysfunction (61% vs. 50%, P<.0001) but less severe angina (39% moderate or severe vs. 49%, P<.0001), and were more likely to be hypertensive (73% vs. 59%, P<.0001) or have left main stenosis of any degree (38% vs. 26%, P=.04). Many of these factors were themselves predictors of increased time-related mortality. In propensity-matched patients, survival at 30 days and 1 and 10 years for patients with vs. without AF was 97.0%vs. 92.6%, 90% vs. 81%, and 58% vs. 37% (Figure). In propensity-matched patients, those with AF experienced increased risk of mortality both early (P=.009) and late (P<.0001) after CABG.

Conclusions:

AF in patients undergoing CABG is a MARKER for high-risk patients; however, AF ITSELF substantially reduces long-term survival. Thus, consideration of surgical intervention for AF with CABG is warranted.

8. Lvad Performance In The Rematch (randomized Evaluation Of Mechanical Assistance For The Treatment Of Congestive Heart Failure) Trial: Implications For Patient Management And Device Design
Walter Dembitsky, James W Long, Soon J Park, Alfred Tector, William Piccione, Jr, Satoshi Furukawa, Lopa Gupta, Nuala Rona, Bryan Foy, Alan D Weinber, George Magovern, Jr., O Howard Frazier
Background:

The REMATCH trial demonstrated significant improvement in survival and quality of life of end-stage heart failure patients (N=68) treated with Heartmate LVADs compared to controls (N=61) treated with optimal medical management. However, LVAD patients were subject to considerable morbidity and mortality. Because device failure was the second most common cause of death (15%), we examined the time course and etiology of such failure in the LVAD patient cohort.

Methods:

Prospective survival and adverse event (AE) data were adjudicated by a morbidity and mortality committee. Failed devices were examined for failure etiology.

Results:

One and two-year actuarial survival rates were 52% and 26% in LVAD patients. One and two-year freedom from device failure rates were 100% and 85%. LVAD malfunction (events/patient-year), typically manifested by device alarms, was 0.87, while the rate of LVAD system failure was 0.06. Inflow valve regurgitation was the most common cause of device failure, while others included motor bearing wear, outflow valve regurgitation, and diaphragm rupture. 13 patients underwent replacement of failed devices with 23% 60-day mortality. 7 patients currently survive from 56 to 384 days following reoperation. 75% of the mechanical modes of malfunction were correctable.
Conclusions:

Device performance was reliable enough to provide significant survival advantage. Design improvements that reconfigure the inflow valve and limit pressure generation in the LVAD may decrease the frequency of inflow valve failure. Improvements in motor control, limiting device rate, reducing pressure generation and valve failures could enhance pump durability. Such corrective engineering and management strategies are essential for successful long-term LVAD therapy.

9. WITHDRAWN

10. Total Arterial Off-pump Coronary Artery Bypass Grafting For Revascularization Of Total Coronary System- The Clinical Outcome And Angiographic Evaluation.
Osamu Tagusari; *Junjiro Kobayashi; *Ko Bando; Kazuo Niwaya; Hiroyuki Nakajima; Michiko Ishida; Takeshi Nakatani; Toshikatsu Yagihara; *Soichiro Kitamura
National Cardiovascular Center , Osaka , Japan

Background:

The objective of this study was to assess the clinical outcome and angiographic study of total arterial off-pump coronary artery bypass (OPCAB) grafting for revascularization of total coronary system which consists of left anterior descending coronary artery, circumflex and right coronary system.

Methods:

In 382 consecutive cases of OPCAB performed between April 2000 and July 2002, 180patients (154 male and 26 female) with triple vessel disease received total arterial OPCAB for revascularization of total coronary system. The mean age was 65+9.

Results:

662 vessels were bypassed (average number of grafts 3.7+0.8). Internal thoracic artery (ITA), radial artery (RA), and gatroepiploic artery (GEA) grafts were used for revascularezation of 227, 417, and 18 vessels, respectively. Composite grafts which consisted of in situ ITA and free grafts were used in 171 patients (Y shaped 143, I shaped 30, K shaped 15, X shaped 2, T shaped 1). Hospital death occurred in 3 patients (1.7%) and late death in 1 patient. There was no clinical underperfusion syndrome or new IABP insertion. Cerebral infarction occurred in 1 patient during the postoperative angiography and 2 patients after the discharge. Early postoperative angiography was performed for 623 grafts in 172 patients (96%) and graft patency was 100% (169/169) in LAD, 97% (60/62) in Dx, 98% (55/56) in OM, 97% (144/149) in PL, 100% (47/47) in 4PL, 98%(122/125) in 4PD, and 100%(15/15) in RCA.

Conclusions:

Total arterial OPCAB provided extremely hight graft patency rate in revascularization of total coronary system and good clinical results.

11. Longterm Results Of Irrigated Radiofrequency Modified Maze Procedure In 200 Patients With Concomitant Cardiac Surgery. A Six Years Experience.
Hauw T Sie; Willem P Beukema; Arif Elvan; Anand R Ramdat Misier
Isala Clinics , Zwolle , Netherlands

Background:

The Cox’s Maze procedure is considered the gold standard in the surgical treatment of atrial fibrillation (AF).
In spite of its excellent results the Cox’s Maze has not been widely accepted because of the complexity and the hazards of the procedure.
We report the longterm results of a modification of the Cox's Maze using irrigated radiofrequency(RF)to create continuous endocardial lesions in patients undergoing concomitant cardiac surgery.Using this technique almost all surgical incisions are being replaced by endocardial RF ablation lines.
Methods:

Between November 1995 and June 2001 in 200 patients(pts) eligible for open heart surgery and suffering of chronic/permanent atrial fibrillation the irrigated RF modified maze was performed as an additional procedure to cure AF. Mean age was 68 yrs(31-84yrs), 108 females (54%).
Mean follow up was 40.7 months(12-80mths).

Results:

Hospital mortality was 3.5% (7pts). late mortality 13.5 %(27pts). Eight pts(4%) were lost to follow up(FU).
FU was completed in the remaining 158 pts.
At the latest FU 116pts(73.4%) were in SR or atrial rhythm, 10pts(6.3%) had an atrio-ventricular seqential pacemaker.
32pts(20.3%) were in atrial fibrillation or flutter.
Conclusions:

The simplified irrigated RF modification can be adapted in every pt. eligible for open heart surgery suffering of chronic AF with neglible additional risk and promising longterm results.