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We herein report a 48-year-old man with a history of chronic atrial fibrillation (AF) and repeated hemoptysis after radiofrequency ablation. Contrast tomography showed soft tissue thickening of the left hilar region and left pulmonary vein stenosis. We performed bronchial artery embolization, but the hemoptysis did not disappear, and AF was not controlled. We performed left lung lobectomy and maze procedures since we considered surgical removal necessary as radical treatment. After the surgery, hemoptysis and atrial fibrillation did not recur. Refractory hemoptysis after catheter ablation is rare, but occasionally occurs in patients with severe pulmonary vein stenosis.

Objective: Cox Maze procedure is an effective surgical treatment of atrial fibrillation and it is often performed concomitantly with mitral valve surgery. However, some patients still experience atrial tachyarrhythmia post-surgery, which adversely affects heart function as well as their quality of life. Method: We present the case of a 66-year-old female patient who underwent mitral valve replacement with a bio-prosthesis and Cox-Maze procedure; she was later admitted to our center after 14 months due to pneumonia and atrial tachycardia. An electrophysiology study/ intervention was performed. Result: We successfully determined the mechanism and ablated the atrial tachyarrhythmia. The sinus rhythm was restored and was maintained 3 months post-procedure, with amelioration of the left ventricular function. Conclusion: Electrophysiology study with electro-anatomy mapping can help to determine the mechanism of arrhythmia to guide successful ablation of post-operative arrhythmia

Cardiac adipose tissue is a well-known risk factor for the recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation, but its correlation with maze surgery remains unknown. The aim of this study was to investigate the correlation between the recurrence of AF and the adipose component of the left atrium (LA) in patients who underwent a modified Cox maze (CM) III procedure. We reviewed the pathology data of resected LA tissues from 115 patients, including the adipose tissue from CM-III procedures. The mean follow-up duration was 30.05 ± 23.96 months. The mean adipose tissue component in the AF recurrence group was 16.17% ± 14.32%, while in the non-recurrence group, it was 9.48% ± 10.79% (p = 0.021), and the cut-off value for the adipose component for AF recurrence was 10% (p = 0.010). The rates of freedom from AF recurrence at 1, 3, and 5 years were 84.8%, 68.8%, and 38.6%, respectively, in the high-adipose group (≥10%), and 96.3%, 89.7%, and 80.3%, respectively, in the low-adipose group (

Background Recurrence of any atrial arrhythmia after surgical ablation is known as a negative predictor of cardiovascular events and total mortality. However, there have been no focused studies for atrial fibrillation (AF) recurrence prediction in patients with significant tricuspid regurgitation (TR), and the risk-benefit estimation of surgical ablation in tricuspid valve (TV) surgery is not fully established. Objectives In this study, we analyzed predictors of AF recurrence, safety, and efficacy of the modified Cox maze (CM) procedure in patients with AF undergoing TV operation.Method We screened 421 patients who underwent a TV operation between 1994 and 2017. After excluding patients who did not undergo a maze operation, 158 patients were enrolled. Enrolled patients were divided by recurrence of AF.We analyzed the difference between the AF recurrence group and no AF recurrence group, and AF recurrence factors in terms of clinical risk factors and echocardiographic risk factors. The hazard ratio (HR) and 95% confidence intervals (CIs) were presented using a Cox proportional hazard model.ResultS Among 158 patients, AF recurred in 65 patients within 10 years. For AF prediction, age was most the important clinical factor and right atrium (RA) diameter was the most important echocardiographic parameters. In patients with a larger RA diameter over 49.2mm, the prevalence of AF recurrence was higher (HR 4.322, 95% CI [2.185-8.549], log rank p value < 0.001). In clinical outcome, there was no significant difference between the AF recurrence group and the no recurrence group in terms of death, TR recurrence, heart failure and stroke. However, the risk of permanent pacemaker (PPM) insertion was higher in the AF recurrence group (HR 4.706, 95% CI [0.975-22.708], log rank p value 0.034) compared to the no recurrence group. Conclusion Age and RA enlargement are key predictors of AF recurrence after TV operation with the CM procedure in patients with significant TR.

Aims.To assess the outcomes of atrial fibrillation (AF) treatment by radiofrequency ablation for patients with mitral valve replacement, the analysis of short-term results of 128 patients was performed.Methods.Mean age of the patients was 56,7±9,6 (29 - 79) years, males - 39, females - 89. Most of the patients had longstanding persistent AF - 81 (63,3%), 28 (21,9%) had persistent AF and 19 (14,8%) - paroxysmal AF. The indications for surgery were: rheumatic mitral valve disease in 105 patients (82%), degerative mitral valve disease - in 21 (16,4%) and with treated infectious endocarditis - in 2 (1,6%). Maze IV procedure was carried out in all cases.Results.Hospital mortality was 0,8% (1 patient). Ten patients (7,9%) required pacemaker implantation. The indications were sinus node dysfunction in 7 patients, bradycardia AF - in 2 patients, AV node dysfunction - in 1. At the discharge 88 patients (69,3%) had a sinus rhythm, 10 (7,9%) - atrial rhythm, pacemaker rhythm with sinus node dysfunction patients - in 4 (3,1%) and AF - in 25 (19,7%). Thus, the rate of freedom from atrial fibrillation was 80,3% (102 patients). The effectiveness of ablation for paroxysmal AF was 100%, persistent - 74,1%, longstanding persistent - 77,8% (p=0,006). To reveal other predictors of freedom from AF at the discharge each ECHO parameter was included in the simple logistic regression analysis. Statistically significant p-value was obtained for the preoperative right atrial size (p=0,005), and close to it for the left atrial size, especially for the index left atrial volume/body surface area (p=0,052).Conclusion.Thus, the radiofrequency ablation is an effective method for treatment of AF in patients undergoing mitral valve replacement. The rate of freedom from AF at the discharge is 80,3%. The predictors of freedom from AF at the discharge are preoperative form of AF and preoperative size of atria.

espanolIntroduccion: La cirugia mediante mini-toracotomia lateral presenta ventajas comparativas sobre el acceso convencional comomenor trauma quirurgico, reducida morbimortalidad y un resultado estetico superior, pero plantea dificultades en caso denecesitar estimulacion electrica temporal.Objetivo: Valorar el empleo terapeutico del cateter de Swan-Ganz con marcapasos incorporado como solucion a dicho problemay analizar sus complicaciones.Material y metodos: Se incluyeron pacientes programados para cirugia mini-invasiva mitral mediante mini-toracotomia lateral.Se definio empleo terapeutico del cateter al uso debido a bradiarritmias o trastornos de conduccion o necesidad de incrementarla frecuencia cardiaca con fines hemodinamicos. Pacientes intervenidos de urgencia o emergencia, fueron excluidos del estudio.Resultados: Fueron incluidos 517 pacientes (289 de sexo masculino, con edad promedio de 68,3 ± 10,4 anos); se efectuaron 115(22,2%) reemplazos y 402 (77,7%) plasticas mitrales. Simultaneamente, se realizaron 294 (56,9%) procedimientos de Maze, 182(35,2%) cierres de orejuela izquierda, 9 (1,7%) cierres de defectos septales y 14 (2,7%) plasticas tricuspideas. Ciento sesenta ydos (313%) pacientes necesitaron ser marcapaseados; debido a bradiarritmias, 85 (52,47%) pacientes; por trastornos de conduccion,50 (30,86%) pacientes; mientras que otros 27 (16,66%) requirieron incrementar su frecuencia debido a bajo volumenminuto. La mortalidad resulto de 12 (2,32%) casos. Catorce (2,7%) pacientes presentaron perdida de captura y se resolvieroncon el reposicionamiento del cateter, mientras que 2 (0,6%) pacientes presentaron atrapamiento y requirieron reintervencion.Conclusiones: Casi un tercio de los pacientes intervenidos mediante mini-toracotomia lateral requirieron del empleo terapeuticodel cateter de Swan-Ganz con marcapasos. Dos pacientes presentaron atrapamiento y requirieron resolucion quirurgica. EnglishThe use of a lateral mini-thoracotomy presents several advantages over the standard access, such as less surgical trauma, reduced morbidity and mortality, shorter recovery time and better cosmetic results, but presents difficulties iftemporary pacing is required.Objective: The aim of this study was to evaluate the therapeutic use of a Swan-Ganz catheter with pacing capabilities andanalyze its complications.Methods: Patients undergoing scheduled minimally invasive mitral valve surgery through lateral mini-thoracotomy wereincluded in the study. Therapeutic use of the pacing catheter was defined as the need for pacing due to bradyarrhythmiasor conduction disorders or need of increasing heart rate in case of hemodynamic instability. Patients undergoing urgent oremergency surgery were excluded from the study.Results: A total of 517 patients were included in the study; mean age was 68.3 ± 10.4 years and 289 (55.9%) were men; 115 patients(22.2%) underwent mitral valve replacement and 402 (77.7%) mitral valve repair. The following concomitant procedureswere carried out: 294 (56.9%) Maze procedures, 182 (35.2%) left atrial appendage closures, 9 (1.7%) atrial septal defect closuresand 14 (2.7%) tricuspid valve repair surgeries. In the postoperative period 162 (31.3%) patients required pacing due to bradyarrhythmiasin 85 cases (52.47%), conduction disorders in 50 (30.86%), and need to increase heart rate in 27 (16.66%) patientswith low cardiac output syndrome. Postoperative mortality was 2.32% (n=12). Fourteen (2.7%) patients presented loss of capturethat was resolved with catheter repositioning, while 2 (0.6%) patients presented catheter entrapment requiring reintervention.Conclusion: Almost one-third of the patients undergoing lateral mini-thoracotomy required therapeutic use of the pacingSwan-Ganz catheter. Two patients presented catheter entrapment and required surgical reintervention

Although the hemodynamic burden and structural substrate contribute to valvular atrial fibrillation (VAF) mechanisms, the role of catheter ablation has rarely been reported. We investigated the clinical characteristics, mapping findings, and long-term rhythm outcomes after catheter ablation of hemodynamically corrected VAF.We compared 77 patients with VAF (46.8% male, 52.7±8.8 years old, 46.8% paroxysmal AF, 24.7% with maze procedures) and 2244 patients with non-VAF (NVAF) who underwent catheter ablation. Among the VAF patients, 44 (57.1%) had mechanical valve AF (MV-AF) and 33 (42.9%) underwent a prior mitral valvuloplasty (MVP-AF). We analyzed the catheter ablation rhythm outcomes for MV-AF and MVP-AF.The left atrial (LA) diameter was greater (p0.001), LA voltage lower (p0.001), and procedure-related complication rate higher (mainly sinus node dysfunction, p=0.004) for VAF than NVAF. During 70.2±1.8 months of follow-up, the rhythm outcome of VAF did not significantly differ from that of NVAF after catheter ablation (log rank p=0.399), even after excluding patients with maze procedures (log rank p=0.629). The clinical recurrence rates did not differ between the MV-AF and MVP-AF groups (log rank p=0.244), or between patients with prior maze procedures and those without (log rank p=0.651). The main conduction recovery sites of previous maze procedures were the perimitral (84.2%) and cavotricuspid isthmus (84.2%) areas, and recurrence mechanisms were macroreentry (63.2%) and focal/microreentry (26.3%) at scar border zones.Although hemodynamically corrected VAF was associated with advanced LA remodeling, the rhythm outcome did not significantly differ from that of NVAF after catheter ablation.

Clinicians can feel confident about performing mitral repair/replacement in patients who have previously undergone mammoplasty. It may also have applications in performing atrial septal defect closure, Maze procedures for atrial fibrillation, and tricuspid valve surgery in patients with breast implants.

Objective Newly published guidelines made the highest level recommendation for surgical treatment for atrial fibrillation. However, the number of patients without a mitral valve procedure with atrial fibrillation who are treated with concomitant surgical ablation is still low (15%-25%), because surgeons are reluctant to perform procedures in patients who would not otherwise require left atriotomy. The purpose of this study was to compare the outcomes of concomitant Cox maze with and without mitral valve procedures. Methods Patients who underwent concomitant Cox maze procedures were prospectively followed since September 2005. Of the 711 patients, 238 did not receive mitral valve surgery. Propensity score matching was conducted to balance preoperative characteristics between patients with and without mitral valve procedures (164/group after matching). Results Before matching, patients in the mitral valve group were younger (65 vs 67 years, P = .047) and had higher euroSCORE II (European System for Cardiac Operative Risk Evaluation; 3.2% vs 2.6%, P = .002), larger mean left atrial size (5.3 vs 4.8 cm, P Conclusions The Cox maze procedure is safe and effective with comparable outcomes when performed concomitant to mitral valve or non–mitral valve surgery. Surgeons should base the decision to perform surgical ablation procedures on atrial fibrillation pathophysiology and the benefit to patients, not on the type of concomitant procedure.

Significant recurrence of atrial tachyarrhythmias are observed after the surgical Cox Maze procedure (CMP). We retrospectively enrolled 11 consecutive patients who had atrial tachyarrhythmias (ATAs) that recurred after a biatrial CMP and underwent catheter ablation. Information including the site of any incomplete lesions and the etiology of the clinical ATAs was shared with the surgical team as feedback. In a total of 11 patients, 12 clinical ATAs were identified. They consisted of 2 atrial fibrillations and 10 atrial tachycardias (ATs). In 6 patients, the CMP was performed after the beginning of this investigation. In a total of 10 ATs, we diagnosed 5 mitral annular flutters, 2 roof-dependent flutters, 1 pulmonary vein (PV)-reentrant AT, and 1 localized reentrant AT. A total of 6 patients had reconnected perimitral block lines. PV reconnections were observed in 3 and posterior wall (PW) residual conduction was also observed in 3 cases. However, no residual conduction of the pulmonary vein isolation (PVI) and only 1 residual conduction of the PW were observed in 5 patients who underwent their index surgery after the beginning of this investigation. This fact may implicate that sharing the information from the electrophysiological study of postsurgical ATAs with the surgical team may contribute to the refinement of the CMP in each facility.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States and remains a major cause of significant morbidity and mortality. Current treatment options include medical management, catheter ablation, and surgical techniques, which have been improved over the past decades through surgical innovation and advancement in instrumentation. The gold standard of surgical treatment for AF is the Cox-maze procedure (CMP). First introduced clinically in 1987, the procedure used multiple incisions in the left and right atria to eliminate AF. This cut-and-sew technique was subsequently replaced by the CMP-IV with the advent of bipolar radiofrequency and cryoablation technology. The modern ablation devices have made the CMP technically faster and more amenable to minimally invasive approaches. This manuscript reviews the surgical technique of the CMP-IV through a median sternotomy approach.

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia. It increases the risk of thromboembolic stroke, anticoagulation induced bleeding, and the overall mortality. Restoration of the sinus rhythm may improve the quality of life and reduce the mortality. The classic ‘cut and sew’ cox maze procedure is the gold standard; however, it is complex. Bipolar radiofrequency ablation is faster and simpler. Methods: This study included 129 patients. They underwent bipolar radiofrequency ablation for their AF in concomitant with their cardiac surgery from 2008 throughout 2016 in Morriston hospital in UK. Patients were followed up for 6 months and divided according to their rhythm at 6 months into sinus group and AF group. Peri-operative data were collected. Comparison between the two groups was done to determine the predicting factors for the restoration of the sinus rhythm. Results: 42 patients were in AF in 6 months, while 87 patients restored their sinus rhythm. The two groups were compared according to different parameters. The results were tabulated and analysed using different tests. The significant predicting factors were left atrial diameter (P=0.004), type of AF (P=0.005), duration of AF (P

Bo Jiang,* Ji-Wei Gu,* Yan-Yan Song, Lei Bai, Xu-Dong Liu, Yu-Jing Zhang, Ming-Liang Li, Jian Yang, Li Liu, Yun Wang Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yun WangDepartment of Cardiovascular Surgery, General Hospital of Ningxia Medical University, No. 804 Shengli South Street, Xingqing District, Yinchuan, 750004, People’s Republic of ChinaTel/Fax +86 6743014Email wangyun_21dr@163.comObjective: To investigate the therapeutic effects of a modified simultaneous unipolar saline-irrigated radiofrequency ablation by intracardiac operation under direct vision in patients with mitral valve diseases combined with atrial fibrillation (AF).Methods: A total of 168 patients with mitral valve diseases combined with AF who underwent unipolar saline-irrigated radiofrequency ablation modified maze procedures were enrolled and divided into the mitral stenosis (MS) group (n = 87) and the mitral insufficiency (MI) group (n = 81).Results: Those with a left atrium diameter (LAD) < 55 mm had a better cardioversion effect during the mid-term post-operation than those with a LAD ≥ 55 mm (P < 0.05). The cardioversion effect during the mid-term post-operation was better in those with a duration of AF < 2 years than those with AF ≥ 2 years (P < 0.05). The LAD reduced significantly during the early postoperative period in the MS group (P < 0.05). Compared with the early postoperative period, LAD further reduced, and the EF increased significantly during the mid-term post-operation (P< 0.05). The LAD reduced significantly during the early postoperative period in the MI group (P < 0.05), together with relatively decreased EF (P < 0.05). Compared with the early postoperative period, LAD further reduced, and the EF increased significantly during the mid-term post-operation (P< 0.05). The improvement of LAD in the MI group during the mid-term post-operation was better than that in the MS group (P < 0.05).Conclusion: The cardioversion effects and the improvement in cardiac function during the mid-term post-operation were good in the radiofrequency ablation by intracardiac operation under direct vision in patients with different mitral valve diseases combined with AF. The cardioversion effects during the early postoperative period and the mid-term post-operation were better in patients with MI than in those with MS.Keywords: mitral stenosis, mitral insufficiency, atrial fibrillation, radiofrequency ablation, therapeutic effect

Objectives Despite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines. Methods All consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm). Results Among 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all P ≥ .2) except for more atrial fibrillation and larger left ventricle (both P ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all P ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P = .09. for patients with TA versus without. Conclusions In this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.

Background The efficacy of catheter-based or thoracoscopic ablation for treating long-standing persistent atrial fibrillation (AF) with a dilated atrium remains suboptimal. This study aimed to assess the feasibility and initial results of simultaneous hybrid ablation with a new biatrial lesion set in these patients. Methods Twenty-seven consecutive patients with long-standing persistent AF and dilated atrium underwent simultaneous hybrid ablation with a new biatrial lesion set consistent with the principle of the Cox maze procedure at our institution. Patients were followed up at 3, 6, and 12 months after the procedure and annually thereafter. Results After thoracoscopic epicardial ablation, endocardial mapping confirmed complete bilateral pulmonary vein isolation in 25 patients (96.2%). All patients were followed for a mean of 18.7 ± 8.9 months. Freedom from atrial tachyarrhythmia at 1 year after the single hybrid procedure was 64% with antiarrhythmic drugs and 60% without antiarrhythmic drugs. Freedom from atrial tachyarrhythmia at latest follow-up after the hybrid procedure and redo catheter ablation was 77.8% with antiarrhythmic drugs and 74.1% without antiarrhythmic drugs. In patients with sinus rhythm restoration, mean left atrial diameter decreased from 54.4 ± 4.3 mm to 45.2 ± 4.1 mm (P, Graphical abstract

Papillary fibroelastomas represent the second most common benign cardiac tumour, secondary only to cardiac myxoma. A majority of patients are asymptomatic on presentation. The most common clinical manifestations include stroke, transient ischaemic attack, myocardial infarction and angina. Echocardiography remains the primary imaging modality for identification of these tumours. The majority of papillary fibroelastomas arise from the valves. Simple surgical excision is the mainstay of treatment, carrying an excellent prognosis. We present an unusual case of cardiac papillary fibroelastoma originating from the coumadin ridge (CR) in a 70-year-old woman. The patient exhibited increasing paroxysms of her atrial fibrillation and was pursuing a MAZE procedure. Preoperatively, a transesophageal echocardiogram revealed a 0.7×1 cm intracardiac mass that had echocardiographic appearance of a fibroelastoma. Surgical resection and MAZE procedures were performed. The gross specimen and histopathology findings were consistent with papillary fibroelastoma. This case reports the seventh documented case of fibroelastoma originating from the CR.

Objectives Stand-alone surgical ablation of atrial fibrillation is indicated in patients with refractory atrial fibrillation who have failed medical or catheter-based ablation. Few reports of late outcomes after stand-alone surgical ablation exist using comprehensive follow-up with strict definitions of success. This study examined our late outcomes of the stand-alone Cox-Maze IV procedure. Methods Between January 2003 and December 2019, 236 patients underwent a stand-alone Cox-Maze IV for refractory atrial fibrillation. Freedom from atrial tachyarrhythmias was assessed by electrocardiography, Holter, or pacemaker interrogation for up to 10 years, with a mean follow-up of 4.8 ± 3.5 years. Rhythm outcomes were compared in multiple subgroups. Factors associated with recurrence were determined using Fine-Gray regression, allowing for death as the competing risk. Results The majority of patients (176/236, 75%) had nonparoxysmal atrial fibrillation. Median duration of preoperative atrial fibrillation was 6.2 years (interquartile range, 3-11). Fifty-nine percent of patients (140/236) failed 1 or more prior catheter-based ablation. Thirteen patients (6%) experienced a major complication. There was no 30-day mortality. Freedom from atrial tachyarrhythmias was 94% (187/199), 89% (81/91), and 77% (24/31) at 1, 5, and 10 years, respectively. There was no difference in freedom from atrial tachyarrhythmias between patients with paroxysmal atrial fibrillation versus nonparoxysmal atrial fibrillation (P > .05) or those undergoing sternotomy versus a minimally invasive approach (P > .05). Increased left atrial size and number of catheter ablations were associated with late atrial fibrillation recurrence. For patients who experienced any atrial tachyarrhythmia recurrence, the median number of recurrences was 1.5 (1.0-3.0). Conclusions The stand-alone Cox-Maze IV had excellent late efficacy at maintaining sinus rhythm in patients with symptomatic, refractory atrial fibrillation, with low morbidity and no mortality. The Cox-Maze IV, in contrast to catheter-based ablation, was equally effective in patients with paroxysmal and nonparoxysmal atrial fibrillation.

A prominent v wave on a capillary wedge or left atrial pressure tracings classically signify significant mitral regurgitation. However, infiltrative disease involving the left atrium and left atrial scar from prior catheter ablation or Maze procedures, may produce a similar waveform due to noncompliance of the left atrium.

Untreated atrial fibrillation is associated with an increased risk of all-cause mortality and morbidity. Despite the current guidelines recommending surgical ablation of atrial fibrillation at the time of coronary artery bypass surgery, most patients with concomitant atrial fibrillation and coronary artery disease do not receive surgical ablation for their atrial fibrillation. This review reports the efficacy of different surgical ablation techniques used for the treatment of atrial fibrillation during coronary artery bypass. PubMed was systematically searched for studies reporting outcomes of concomitant surgical ablation in coronary artery bypass patients between January 2002 and March 2018. Data were independently extracted and analyzed by two investigators. Twenty-four studies were included. Twelve studies exclusively reported outcomes of surgical ablation in patients undergoing coronary artery bypass, whereas the remaining 12 reported outcomes of concomitant cardiac surgery with subgroup analysis. Only four studies performed the concomitant Cox-Maze procedure. Freedom from atrial tachyarrhythmia was reported as high as 98% at 1 year and 76% at 5 years with Cox-Maze procedure, whereas lesser lesion sets had more variable outcomes, ranging from 35% to 93%. In most studies, the addition of surgical ablation was not associated with increased morbidity and mortality. Although the Cox-Maze procedure had the greatest short- and long-term success rates, most studies comprising the evidence documenting the safety and efficacy of adding surgical ablation were of low or moderate quality. There was a great deal of heterogeneity among study populations, follow-up times, methods, and definition of failure. To establish a consensus regarding a surgical ablation technique for atrial fibrillation in coronary artery bypass population, larger multicenter randomized controlled studies need to be designed.

Background: Limited comparative data are available on the efficacy of cryoablation versus radiofrequency ablation in patients with atrial fibrillation. This study aimed to compare radiofrequency ablation and cryoablation with regard to clinical outcomes and the restoration of sinus rhythm or atrial contractility. Methods: A total of 239 patients who underwent surgical ablation between August 2003 and December 2016 at our institution were included. The patients were divided into 2 groups according to the energy device that was used (group A: n=140, radiofrequency ablator; group B: n=99, cryoablator). Echocardiographic data, overall survival, and major cardiovascular and cerebrovascular event (MACCE)-free survival were compared between the 2 groups. Results: At 1 year of follow-up, the atrial contractility recovery rate was 32.2% (19 of 59) in group A and 48.8% (21 of 44) in group B. In addition, cryoablation was found to be a predictive factor for the recovery of atrial contractility (cryoablation vs. radiofrequency ablation: odds ratio, 2.540; 95% confidence interval, 1.063-6.071; p=0.036). The left ventricular ejection fraction was significantly higher in group B (53.1%±11.5% vs. 59.1%±6.3%, p=0.001). The median follow-up duration was 36 months. The 5-year overall survival rate was 80.1%±3.6% in group A and 92.1%±2.9% in group B (p=0.400). The 5-year MACCE-free survival rate was 70.3%±4.0% in group A and 70.9%±5.6% in group B (p=0.818). Conclusion: Cryoablation was associated with a higher atrial contractility restoration rate and better left ventricular function than radiofrequency ablation. However, no significant relationship was observed between the energy source and overall or MACCE-free survival.

The exact mechanism of atrial fibrillation (AF) is still incompletely understood. A number of alterations that impact focal electrical discharge, the atrial substrate and modulating factors contribute to its pathogenesis. Atrial remodelling (resulting in atrial cardiomyopathy) sets the stage for AF development. Once present, AF results in the loss of synchronized atrial contraction, which affects ventricular filling and atrial reservoir and conduit functions. Passive atrial function is particularly important in patients with left ventricular diastolic dysfunction. AF can cause tachycardiomyopathy, a mostly reversible cardiac alteration induced by tachycardia. At a structural level, atrial support is also instrumental to the function of atrioventricular valves. All of these functions can be recovered to variable degrees via rhythm control strategies. Surgical and hybrid ablation show very promising results, especially in patients with a more advanced disease substrate. This review highlights the pathophysiological aspects of AF related to left atrial function and their practical implications for surgical rhythm management.

The incidence of atrial fibrillation (AF) in patients older than 75 years of age is expected to increase, and its treatment remains challenging. This study evaluated the impact of age on the outcomes of surgical ablation of AF.A retrospective review was performed of patients who underwent the Cox-maze IV procedure at a single institution between 2005 and 2017. The patients were divided into a younger (age75 years, n = 548) and an elderly cohort (age ≥75 years, n = 148). Rhythm outcomes were assessed at 1 year and annually thereafter. Predictors of first atrial tachyarrhythmia (ATA) recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.The mean age of the elderly group was 78.5 ± 2.8 years. The majority of patients (423/696, 61%) had nonparoxysmal AF. The elderly patients had a lower body mass index (P .001) and greater rates of hypertension (P = .011), previous myocardial infarction (P = .017), heart failure (P .001), and preoperative pacemaker (P = .008). Postoperatively, the elderly group had a greater rate of overall major complications (23% vs 14%, P = .017) and 30-day mortality (6% vs 2%, P = .026). The percent freedom from ATAs and antiarrhythmic drugs was lower in the elderly patients at 3 (69% vs 82%, P = .030) and 4 years (65% vs 79%, P = .043). By competing risk analysis, the incidence of first ATA recurrence was greater in elderly patients (33% vs 20% at 5 years; Gray test, P = .005). On Fine-Gray regression adjusted for clinically relevant covariates, increasing age was identified as a predictor of ATAs recurrence (subdistribution hazard ratio, 1.03; 95% confidence interval, 1.02-1.05, P .001).The efficacy of the Cox-maze IV procedure was worse in elderly patients; however, the majority of patients remained free of ATAs at 5 years. The lower success rate in these greater-risk patients should be considered when deciding to perform surgical ablation.

The onset of recurrent atrial tachyarrhythmia (ATA) following the Cox maze procedure (CMP) is commonly encountered, and may be associated with increased perioperative mortality. The majority of recurrent ATA cases are localized to the left atrium following surgical ablation. Right atrial flutter (AFL) following the CMP is a less-frequent occurrence, and may pose a diagnostic challenge due to uncharacteristic surface electrocardiogram (ECG) and intracardiac activation patterns. In this case, a 68-year-old male who had previously undergone left-sided surgical ablation with left atrial reduction for the treatment of persistent atrial fibrillation during coronary artery bypass and mitral valve repair developed symptomatic atypical AFL. The patient was intolerant to amiodarone, and was thus scheduled for ablation. Given the patient’s history of extensive left atrial instrumentation and surface ECG findings indicating an atypical AFL, the decision was made to proceed with left atrial mapping. During the electrophysiology study, initial activation mapping was not suggestive of a cavotricuspid isthmus reentrant arrhythmia. Here, we describe the possible mapping pitfalls associated with a persistent tachyarrhythmia that was ultimately proven to be a right AFL, despite atypical activation patterns.

Objective The Cox-Maze IV procedure has been shown to be an effective treatment for atrial fibrillation when performed concomitantly with other operations either via median sternotomy or right minithoracotomy. Few studies have compared these approaches in patients with lone atrial fibrillation. This study examined outcomes with sternotomy versus minithoracotomy in stand-alone Cox-Maze IV procedures at our institution. Methods Between 2002 and 2015, 195 patients underwent stand-alone biatrial Cox-Maze IV. Minithoracotomy was used in 75 patients, sternotomy in 120. Freedom from atrial tachyarrhythmias was ascertained using electrocardiography, Holter, or pacemaker interrogation at 3 to 60 months. Predictors of recurrence were determined using logistic regression. Results Of 23 preoperative variables, the only differences between groups were that minithoracotomy patients had a higher rate of New York Heart Association 3/4 symptoms and a lower rate of previous stroke. Minithoracotomy and sternotomy patients had similar atrial fibrillation duration and type. Minithoracotomy patients had a smaller left atrial diameter (4.5 vs 4.8 cm, P = 0.03). More minithoracotomy patients received a box lesion (73/75 vs 100/120, P = 0.002). Minithoracotomy patients had a shorter hospital stay (7 vs 8 days, P = 0.009) and a similar rate of major complications (3/75 (4%) vs 7/120 (6%), P = 0.74). There were no differences in mortality or freedom from atrial tachyarrhythmias. Predictors of atrial fibrillation recurrence included a preoperative pacemaker, omission of the left atrial roof line, and New York Heart Association 3/4 symptoms. Conclusions Stand-alone Cox-Maze IV via minithoracotomy was as effective as via sternotomy with a shorter hospital stay. A minimally invasive approach is our procedure of choice.

The surgical treatment of atrial fibrillation (AF) has evolved significantly over the last 20 years and even more so in the last 5 years. There are now many clinically successful surgical procedures focused on eliminating AF and AF-related stroke. This review discusses the current types of surgical AF procedures, including minimally invasive and hybrid, and may assist clinicians in understanding the various surgical AF options available to patients today.

In patients with atrial fibrillation (AF), the addition of surgical ablation to aortic valve replacement (AVR) does not increase procedural morbidity or mortality. However, efficacy in this population has not been carefully evaluated. This study compared outcomes between patients undergoing stand-alone Cox-Maze IV with those undergoing surgical ablation and concomitant AVR.From January 2002 to May 2014, 188 patients received a stand-alone Cox-Maze IV (n = 113) or surgical ablation with concomitant AVR (n = 75). In the concomitant AVR group, patients underwent Cox-Maze IV (n = 58), left-sided Cox-Maze IV (n = 3), or pulmonary vein isolation (n = 14). Thirty-one perioperative variables were compared. Freedoms from AF on and off antiarrhythmic drugs were evaluated at 3, 6, 12, and 24 months.Follow-up was available in 97% of patients. Freedom from AF on and off antiarrhythmic drugs in patients receiving a stand-alone Cox-Maze IV versus concomitant AVR was not significantly different at any time point. The concomitant AVR group had more comorbidities, paroxysmal AF, pacemaker implantations (24% vs 5%, p = 0.002), and complications (25% vs 5%, p0.001). Freedoms from AF off antiarrhythmic drugs for patients receiving an AVR and pulmonary vein isolation at 1 year was only 50%, which was significantly lower than patients receiving an AVR and Cox-Maze IV ( 94%, p = 0.001).A Cox-Maze IV with concomitant AVR is as effective as a stand-alone Cox-Maze IV in treating AF, even in an older population with more comorbidities. Pulmonary vein isolation was not as effective and is not recommended in this population. A Cox-Maze IV should be considered in all patients undergoing AVR with a history of AF.

There is a growing trend to perform off-bypass surgical ablation for atrial fibrillation (AF) because it is perceived to be safer and more effective than the Cox-Maze procedure with cardiopulmonary bypass (CPB) support. In this systematic review, we compared three minimally invasive stand-alone surgical ablation procedures for AF: the endocardial Cox-Maze procedure, epicardial surgical ablation and a hybrid epicardial surgical and catheter-based endocardial ablation procedure (hybrid procedure). Relevant studies were identified in MEDLINE and the Cochrane Database of Systematic Reviews according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From 565 initial studies, 37 were included in this review. The total number of patients across all studies was 1877 (range 10-139). Two studies reported on endocardial Cox-Maze procedures (n = 145), 26 reported on epicardial surgical ablation (n = 1382) and 9 reported on hybrid surgical ablation (n = 350). For minimally invasive Cox-Maze, epicardial and hybrid groups, operative mortality rates were 0, 0.5 and 0.9%, perioperative permanent pacemaker insertion rates were 3.5, 2.7 and 1.5%, incidence of conversion to median sternotomy was 0, 2.4 and 2.5%, and reoperation for bleeding was 1.0, 1.5 and 2.2%, with mean length of stay (days) of 5.4, 6.0 and 4.6, respectively. At 12 months, rates of sinus rhythm restoration were 93, 80 and 70%, and sinus restoration without anti-arrhythmic medications was 87, 72 and 71%, for Cox-Maze, epicardial and hybrid procedures, respectively. Of the three procedures, the minimally invasive Cox-Maze procedure with CPB support was most effective for the treatment of stand-alone AF and had important safety advantages in conversion to sternotomy and major bleeding. The minimally invasive Cox-Maze procedure with CPB support also demonstrated the potential for a higher success rate 12 months following the procedure.

Background Rhythm control is challenging in patients with extended atrial fibrillation (AF) duration and persistent/long-standing persistent AF. Among surgical approaches to treat AF, the Cox maze procedure performed using alternative energy sources remains superior to other beating heart techniques. We examined permanence of safety and success for the on-pump, minimally invasive, stand-alone Cox maze procedure 5 years after surgery. Methods and Results Stand-alone, right 5 cm minithoracotomy, Cox maze III/IV procedure for nonparoxysmal AF was conducted in 133 patients (mean follow-up=65±34 months). Data collected prospectively at 3, 6, 9, 12, 18, 24 months and yearly thereafter and reported per Heart Rhythm Society Guidelines. Paired-samples t tests evaluated quality of life changes. Mean age was 57.3±9.2 years, mean LA size was 4.9±1.1 cm, median AF duration was 51 months, and 78% had long-standing persistent AF. All procedures performed with no conversion to midsternotomy, no renal failure, strokes, or operative mortality ( Conclusions Successful ablation for nonparoxysmal AF is challenging. Therefore, periprocedural safety and long-term efficacy of minimally invasive Cox maze procedures should be noted. Continued refinement of decision-making techniques is warranted to improve patient selection for the appropriate intervention to treat AF.

See Article by Ad et al In this issue, Ad et al1 report their results with a stand-alone minimally invasive Cox maze procedure. Their sizeable cohort consists of patients with largely long-standing persistent atrial fibrillation (AF).1 Ad et al1 should be congratulated on achieving such excellent surgical results over a long duration with an open-heart surgical procedure. In this group of difficult-to-treat patients, they achieved 78% freedom from atrial arrhythmias off antiarrhythmic drugs after 5 years, using Heart Rhythm Society follow-up guidelines. The patients also had improved quality of life and a remarkably low stroke rate despite the fact that 81% of the patients were eventually taken off anticoagulation. If all patients could be offered a single procedure to achieve 78% success at 5 years with no risk of mortality, the clinics of cardiac surgeons would be filled beyond capacity. Unfortunately, this is not the case, and we should be doing better. The current report adds to the numerous studies in the literature demonstrating that surgical ablation reduces AF burden, is associated with a low postoperative stroke risk, and improves …

BACKGROUND Administrative billing codes for electrical cardioversion and ablation/maze procedures may be useful for atrial fibrillation (AF) research if the codes are accurate relative to medical record documentation. HYPOTHESIS Administrative billing codes accurately identify occurrence of electrical cardioversion and ablation/maze procedures in AF patients. METHODS We studied adults ages 30 to 84 who experienced new-onset AF between October 2001 and December 2004 in Group Health Cooperative (acquired by Kaiser Permanente in 2017), an integrated healthcare system in Washington state and northern Idaho. Using medical record review as the gold standard, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for 3 administrative billing codes for electrical cardioversion and 3 codes for AF ablation/maze procedures. RESULTS Of 1953 study participants, during a mean (SD) of 1.5 (0.7) years of follow-up after AF onset, 470 (24%) experienced electrical cardioversion and 44 (2%) experienced ablation/maze procedures, according to medical record review. For electrical cardioversion, individual codes had 7.7% to 76.4% sensitivity, >99% specificity, 83.7% to 96.5% PPV, and 77.3% to 93.0% NPV. Considering any of 3 codes (code 1 or code 2 or code 3) improved sensitivity to 84.9%. For ablation/maze, individual codes had 18.2% to 47.7% sensitivity, >99% specificity, 66.7% to 95.5% PPV, and >98% NPV. Considering any of 3 codes improved sensitivity to 84.1%. CONCLUSIONS Administrative billing data accurately identified electrical cardioversion and ablation/maze procedures and can be used instead of medical record review. Our findings apply to healthcare settings with available administrative billing databases.

Objective Atrial fibrillation (AF) is associated with increased early and long-term morbidity/mortality following valve surgery. This study examined long-term influence of concomitant full Cox maze (CM) and mitral valve procedures on freedom from atrial arrhythmia and stroke. Methods This sample comprised patients who underwent CM with a mitral valve procedure (N = 473). Data on rhythm, medication status, and clinical events captured according to Heart Rhythm Society guidelines at 6, 9, 12, 18, and 24 months and yearly thereafter up to 7 years. Results Mean age was 65 years, mean left atrium size was 5.3 cm, and 15% had paroxysmal AF. Perioperative stroke occurred in 2 patients (0.4%) and operative mortality was 2.7% (n = 13). Return to sinus rhythm regardless of antiarrhythmic drugs at 1, 5, and 7 years was 90%, 80%, and 66%. Sinus rhythm off antiarrhythmic drugs at 1, 5, and 7 years was 83%, 69%, and 55%. Freedom from embolic stroke at 7 years was 96.6% (0.4 strokes per 100 patient-years) with a majority of patients off anticoagulation medication. Greater odds of atrial arrhythmia recurrence during 7 years was associated with longer AF duration (odds ratio [OR], 1.07; P = .001), whereas lower odds were associated with cryothermal energy only (OR, 0.64; P = .045) and greater surgeon experience (OR, 0.98; P = .025). Conclusions This study suggests that the addition of CM to mitral valve procedures, even with a high degree of complexity, did not increase operative risk. In long-term follow-up, the CM procedure demonstrated acceptable rhythm success, reduced AF burden, and remarkably low stroke rate. Individual surgeon experience and training may notably influence long-term surgical ablation for AF success.

Background The Cox maze (CM) procedure is routinely performed using surgical ablation technology. Reports are scarce on long-term outcomes of CM, especially for a large series of patients. This study examined the potential impact of surgical ablation energy source on safety and long-term efficacy of concomitant CM procedures. Methods The study sample consisted of 709 concomitant CM-treated patients operated on with cryothermal energy only (group 1; n = 386) or combination of cryothermal and bipolar radiofrequency (group 2; n = 323). Data were collected prospectively on perioperative outcomes, rhythm status, survival, and clinical events. Propensity score matching conducted by energy source resulted in 298 patients per group. Results Perioperative outcomes included stroke (n = 4), reoperation for bleeding (n = 23), renal failure requiring temporary dialysis (n = 18), readmissions before 30 days (n = 86), and operative death before 30 days (n = 16; ratio of observed to expected mortality [O/E ratio], 0.50). Independent predictors for 1-year and 5-year rhythm success were a shorter history of atrial fibrillation (1-year odds ratio [OR], 0.93, p = 0.001; 5-year OR, 0.93, p = 0.042) and cryothermia alone (1-year OR=1.77, p = 0.020; 5-year OR = 2.29, p = 0.009). After matching, group 1 had significantly higher sinus rhythm without antiarrhythmic drugs at 6 months (79% vs 70%; p = 0.016), 36 months (81% vs 69%; p = 0.010), and 60 months (75% vs 57%; p = 0.008). Stroke incidence was lower for group 1 (0.7% vs 3%; p = 0.033), with no difference in major bleeding (10% vs 11%; p = 0.597). Groups had similar survival rates (log rank, 0.6; p = 0.452). Conclusions Concomitant CM procedures performed with cryothermal energy alone or combined with bipolar radiofrequency ablation are safe and exceedingly effective. The association of cryothermal energy alone with higher rates of sinus rhythm and stroke reduction should be investigated further.

Background Long-term management of oral anticoagulation (OAC) after ablation for atrial fibrillation (AF) is an ongoing challenge. Heart Rhythm Society (HRS) guidelines provide no specific recommendations for OAC after surgical ablation. The purpose of this study was to determine the necessity of OAC protocols after surgical ablation. Methods Patients (N = 691) who underwent the Cox-Maze procedure with left atrial appendage (LAA) management were followed prospectively. All patients were discharged on OAC unless contraindicated. Cardiac rhythm, bleeding, and embolic stroke or transient ischemic attack (TIA), or both, were verified during follow-up. Results Over a mean follow-up of 47.3 ± 30.3 months, stroke/TIA was reported in 14 patients (5.1 cases per 1,000 person-years) and major bleeding events were found in 46 patients (16.9 cases per 1,000 person-years). Patients with major bleeding events had higher median CHADS 2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) scores (2 [range, 1–3] versus 1 [range, 1–2]; p = 0.012), but no association was found between incidence of stroke/TIA and median CHADS 2 score (1 [range, 0–2.25] versus 1 [range, 1–2]; p = 0.377). Patients with CHADS 2 scores of 2 or greater had the same rates of stroke/TIA ( p = 0.787) but a higher incidence of major bleeding ( p = 0.009) as did patients with CHADS 2 scores less than 2. Adjusting for OAC discontinuation and stable sinus rhythm, patients with CHADS 2 scores of 2 or greater did not have higher stroke/TIA risk (hazard ratio [HR], 0.84; p = 0.759). Conclusions Our results indicate that the decision to discontinue OAC after the Cox-Maze procedure should not be based solely on CHADS 2 scores; rather, rhythm status, echocardiographic findings, and patient risk for bleeding should be considered. These findings underscore the need for an OAC protocol for patients who have undergone the Cox-Maze procedure with appropriate LAA management.

Objective One of the challenges that exists when discussing the Cox maze procedure for atrial fibrillation (AF) with patients is predicting the success for a given patient. The purpose of the present study was to develop a scoring system using well-established clinical factors to predict the probability of sinus rhythm (SR) after surgery. Methods The data from patients 1 and 2 years postoperatively were analyzed using logistic regression to predict SR, including the most accepted variables associated with failure (age, left atrium size, AF duration, AF type). Regression models were applied using hypothetical patients to examine the predicted probability of SR. Results The predictors of 1-year SR were a shorter AF duration and greater surgeon experience performing surgical ablation. The predictors at 2 years were a shorter AF duration and smaller left atrium. The 1-year prediction model applied to hypothetical data found a 1-cm increase in left atrial size associated with a 0.4% reduction in SR probability, a 5-year increase in AF duration associated with a 0.8% reduction, and a reduction by 50 cases of surgeon experience associated with a 1.0% reduction. The 2-year model found a 1-cm increase in left atrial size associated with a 1.0% reduction in SR probability, a 5-year increase in AF duration associated with a 0.8% reduction, and a reduction by 50 cases of experience associated with a 0.2% reduction. Conclusions Our findings are the first step in establishing a risk scoring system to better predict the outcomes after surgical ablation for AF and improve the ability to discuss the risk and benefits with patients.

Background: To improve sinus rhythm conversion, the Cox maze III procedure with narrow mazes (width: ≤3.0cm) was performed in combination with left atrial volume reduction. Methods: From October 2007 to April 2013, 87 patients with atrial fibrillation (paroxysmal in 3, persistent in 14, and permanent in 70) underwent the Cox maze procedure concomitant with another cardiac procedure. They were followed-up with serial electrocardiographic and echocardiographic studies. We used 24-hour Holter monitoring tests to evaluate postoperatively symptomatic patients. Results: At the mean follow-up time of 36.4 months, 81 patients (94.2%) had sinus rhythm and two were on anti-arrhythmic medication (one on a beta-blocker and the other on amiodarone). Five patients (5.8%) with postoperative recurrent and persistent atrial fibrillation never experienced sinus rhythm conversion; however, they did not require any medication for rate control. On postoperative echocardiography, the left atrial A waves were more frequently observed after concomitant mitral valve repair than after concomitant mitral valve replacement (82.4% vs. 40.4%, respectively; p＜0.001). Conclusion: For the Cox maze procedure, narrow mazes and atrial volume reduction resulted in excellent sinus rhythm conversion without the preventive use of anti-arrhythmic drugs, and they did not affect the presence of the left atrial A waves on echocardiography.

BACKGROUND: The clinical benefit of concomitant atrial fibrillation (AF) ablation at the time of aortic valve replacement (AVR) is uncertain. METHODS AND RESULTS: A total of 124 patients with AF who underwent AVR with (n=50) or without (n=74) a concomitant maze procedure, between 2000 and 2011, were evaluated. There were no significant differences in early postoperative outcomes. During a median clinical follow-up of 18.1 months (interquartile range: 6.9-47.8 months), 19 late deaths (15.3%) and 33 valve-related complications (26.6%) occurred, but the differences between groups were not statistically significant. Major event-free survival at 5 years was 60.9±9.9% vs. 57.0±10.3% (P=0.41). After adjustment, the maze group demonstrated similar risks for major adverse cardiac events (hazard ratio, 1.18; 95% confidence interval, 0.56-2.49; P=0.67). However, the rate of sinus rhythm restoration at 4 years was significantly higher in the maze group (80.6% vs. 3.6%, P

We performed a right atrial reduction plasty combined with the Cox‐maze procedure in a patient with a giant right atrium and permanent atrial fibrillation. The reduction plasty involved excisions of the redundant atrial wall along two ablation lines of the maze procedure, and excision of the redundant thin septum primum. This procedure achieved a 60% dimension reduction and an 80% volume reduction. The reduced atrial size and sinus rhythm were maintained after 3.5 years. doi: 10.1111/jocs.12542 (J Card Surg 2015;30:544–546)