Hybrid coronary revascularization is a safe alternative to coronary artery bypass grafting in many patients with multivessel coronary artery disease. However, in high-risk patients with complex coronary artery disease (≥33 SYNTAX/>5 euroSCORE), coronary artery bypass grafting is superior to hybrid coronary revascularization.

ImportanceIn patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.ObjectiveTo report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.Design, Setting, and ParticipantsSURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.InterventionPatients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.Main Outcomes and MeasuresThe prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.ResultsA total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.Conclusions and RelevanceAmong intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

Delirium occurs in at least 1 in 5 patients after transcatheter or surgical aortic valve replacement. Delirium is less likely to develop in the transcatheter group but is associated with higher mortality in both groups.

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fibrillation (AF). The original procedure targeted focal triggers of AF arising from within the pulmonary veins (PVs). This technique generated minimal left atrial (LA) scar but was complicated by the development of PV stenosis (1). Pulmonary vein antral isolation (PVAI) creates circular ablation lines within the left atrium, minimizing the risk for PV stenosis, and has become the preferred procedure for paroxysmal AF ablation. However, when PVAI is combined with adjunctive ablation, as much as 40% of the LA myocardium may be replaced by scar during a single catheter ablation (2), raising a concern that the procedure may adversely affect the ability of the left atrium to act as a contractile chamber (transport function) and/or compliance chamber (reservoir function). Although prior studies have examined the effect of AF ablation (3) and scar (4) on LA contractility, the effect on LA compliance has received less attention. We report 3 patients with histories of multiple LA ablations who presented with unexplained dyspnea on exertion and demonstrated hemodynamic findings consistent with LA hypertension.All 3 patients had histories of multiple catheter ablations for AF and presented with unexplained dyspnea up to 6 years later. Right-heart catheterization with volume challenge was performed. Large V waves were defined as 7 mm Hg greater than mean pulmonary wedge pressure (PWP) (5) and LA hypertension as a mean PWP Ͼ12 mm Hg. Patient #1 was a 68-year-old woman who underwent focal atrial tachycardia and crista terminalis ablation in 2001; LA tachycardia ablation, PV isolation, and lateral and septal mitral annular ablation in 2002; and PVAI and superior vena cava isolation in 2004. Patient #2 was a 69-year-old man who underwent PVAI in 2003 and 2004, with a third PVAI, cavotricuspid isthmus ablation, and LA posterior and septal wall debulking in 2007. Patient #3 was a 74-year-old man who underwent PVAI with left linear ablation and superior vena cava isolation in 2008, followed by repeat PVAI later in 2008. On presentation, each patient had echocardiographic evidence of elevated right ventricular systolic pressure (65, 48, and 48 mm Hg, respectively). Records were available for each patient documenting no significant elevation of right ventricular systolic pressure before his or her final ablation (37, 24, and 30 mm Hg, respectively). No evidence of PV stenosis, left ventricular (LV) systolic dysfunction, or significant mitral valve (MV) disease was found as the cause of elevated right ventricular systolic pressure.Right-heart catheterization demonstrated large V waves on PWP tracings. Mean PWP increased with volume challenge (from 17 to 33 mm Hg, from 6 to 13 mm Hg, and from 11 to 19 mm Hg in each patient, respectively). V waves increased from 31 to 56 mm Hg, from 13 to 26 mm Hg, and from 19 to 36 mm Hg, respectively (Fig. 1). LV end-diastolic pressure was normal in all 3 patients.Thus, all 3 patients shared the distinctive feature of large unexplained V waves on PWP tracings that were further accentuated with volume...