AimsSurgical ablation procedure can restore sinus rhythm (SR) in patients with atrial
fibrillation (AF) undergoing cardiac surgery. However, it is not known whether it has
any impact on long-term clinical outcomes.Methods and resultsThis multicentre study randomized 224 patients with AF scheduled for valve and/or
coronary surgery: group A (left atrial surgical ablation, n =
117) vs. group B (no ablation, n = 107). The primary efficacy
outcome was the SR presence (without any AF episode) during a 24 h electrocardiogram
(ECG) after 1 year. The primary safety outcome was the combined endpoint of
death/myocardial infarction/stroke/renal failure at 30 days. A Holter-ECG after 1 year
revealed SR in 60.2% of group A patients vs. 35.5% in group B
(P = 0.002). The combined safety endpoint at 30 days occurred
in 10.3% (group A) vs. 14.7% (group B, P = 0.411).
All-cause 1-year mortality was 16.2% (A) vs. 17.4% (B, P
= 0.800). Stroke occurred in 2.7% (A) vs. 4.3% (B) patients
(P = 0.319). No difference (A vs. B) in SR was found among
patients with paroxysmal (61.9 vs. 58.3%) or persistent (72 vs. 50%) AF,
but ablation significantly increased SR prevalence in patients with longstanding
persistent AF (53.2 vs. 13.9%, P < 0.001).ConclusionSurgical ablation improves the likelihood of SR presence post-operatively without
increasing peri-operative complications. However, the higher prevalence of SR did not
translate to improved clinical outcomes at 1 year. Further follow-ups (e.g. 5-year) are
warranted to show any potential clinical benefit which might occur later.
Background—
Off-pump coronary bypass surgery has become a widely used technique during recent years. However, limited data are available with regard to 1-year patency of bypass grafts implanted on the beating heart in unselected consecutive bypass surgery candidates. The aim of this study was to compare 1-year angiographic patency of bypass grafts done on the beating heart (off pump) with those done classically (on pump).
Methods and Results—
The PRAGUE-4 trial randomized 400 consecutive nonselected cardiac surgery candidates into group A (on pump; n=192) and group B (off pump; n=208). One-year follow-up coronary angiography was done in 255 patients. The arterial graft patency after 1 year was 91% in both groups. Saphenous graft patency was 59% (on pump) versus 49% (off pump;
P
=NS). Saphenous graft patency per patient was lower in the off-pump group: 0.7 patent anastomosis per patient versus 1.1 patent anastomosis in the on-pump group (
P
<0.01). There were 46% on-pump patients with all grafts patent versus 52% off-pump patients (
P
=NS). Grafts anastomosed distally to collateralized chronic total occlusions of native coronary arteries remained patent in 100% on the left anterior descending artery compared with 23% on other arteries (
P
<0.0001).
Conclusions—
The patency of arterial coronary bypass grafts done on the beating heart is excellent and equal to grafts done on pump. The off-pump procedure in the unselected patient population results in fewer patent saphenous grafts per patient.
Engraftment of BMNCs shows dynamic changes within the first 20 h after intracoronary injection. Persistent myocardial engraftment was noted only in a subset of patients with acute myocardial infarction.
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