BackgroundStraight leg raise (SLR) while supine increases intra‐abdominal pressure. We hypothesized that elevations in intra‐abdominal pressure would transmit into the thoracic cavity if the esophagogastric junction (EGJ) was disrupted.MethodsConsecutive patients undergoing esophageal HRM were included if they had adequate SLR (hip flexion with knees extended for ≥ 5 seconds while supine). EGJ morphology was subtyped based on lower esophageal sphincter (LES) and crural diaphragm (CD) location (type 1: LES and CD overlap; type 2: separation of < 3 cm; type 3: separation of ≥ 3 cm). EGJ tone was assessed using EGJ contractile integral (EGJ‐CI). HRM studies were analyzed according to Chicago Classification v3.0. Mean and peak intra‐thoracic and abdominal pressures were measured at baseline and during SLR using on‐screen software tools. Trans‐EGJ gradients were compared, and pressure gradient < 1 mmHg denoted the equalization of pressures.Key ResultsOf 430 patients, 248 (57.5 ± 0.9 years, 69.4% F) completed SLR. EGJ morphology was type 1 in 122 (49.2%), type 2 in 56 (22.6%) and type 3 in 40 (16.1%). In types 1 and 2 EGJ, neither the mean nor peak trans‐EGJ pressure gradient changed with SLR (P ≥ .17 for each). In contrast, in type 3 EGJ, peak pressure gradient decreased significantly following SLR (3.5 ± 1.8 mmHg vs. −8.6 ± 4.8 mmHg, P = .01). More type 3 EGJ patients equalized peak (65%) pressures across EGJ compared with types 1 and 2 (27%, P < .001).Conclusions and InferencesThe evaluation of intra‐abdominal and intra‐thoracic pressures with SLR during esophageal HRM can provide evidence of physiological disruption of the EGJ barrier.

Objectives Most patients with atrial fibrillation (AF) undergoing cardiac surgery do not receive concomitant ablation. This study reviewed outcomes of patients with AF undergoing Cox-Maze IV (CMIV) with radiofrequency and cryoablation and CABG at our institution. Methods Between the introduction of radiofrequency ablation in 2002 and 2015, 135 patients underwent left- or bi-atrial CMIV with CABG. Patients undergoing other cardiac procedures, except mitral valve repair, or who had emergent, reoperative or off-pump procedures were excluded. Eighty-three patients remained in the study group after exclusion criteria were applied. Freedom from atrial tachyarrhythmias (ATA) was ascertained using EKG, Holter monitor, or pacemaker interrogation at 1 to 5 years postoperatively. Results Operative mortality was 3%. Freedom from ATA at 1 year in the CMIV group was 98%, with 88% off antiarrhythmic drugs; freedom from ATA and antiarrhythmic drugs was 70% at 5 years. Conclusions The addition of CMIV to CABG resulted in excellent freedom from ATA at one-to-five years. These patients are at increased risk for nonfatal complications compared with others undergoing concomitant surgical ablation.

Background: Straight leg raise (SLR) is a provocative maneuver that assesses esophagogastric junction (EGJ) barrier function during high-resolution manometry (HRM). We evaluated the value of SLR in symptomatic reflux patients undergoing ambulatory reflux monitoring. Methods: Adult patients being evaluated for reflux symptoms with esophageal physiologic testing off antisecretory therapy over a 12 month period were studied. Demographics, clinical presentation, HRM studies, and reflux monitoring studies were analyzed. Intra-abdominal and intra-esophageal pressures were extracted at baseline and during SLR from HRM studies. Acid exposure time (AET) was derived from reflux monitoring studies, and EGJ morphology and tone from HRM studies. SLR pressure metrics predicting abnormal AET were evaluated. Key Results: Of 122 patients, 70 (57.4%) had ≥50% peak intra-abdominal pressure increase during SLR (58.0 ± 1.4 years, 75.7% female). Peak intra-esophageal pressure gradient between baseline and SLR predicted pathologic AET when ≥100% (AUC 0.78, sensitivity 71%, specificity 75%, P < .001), seen in 60.7% with AET > 6%, but only 23.7% with AET < 4% (P = .01). Peak intra-esophageal pressure gradient ≥100% was most discriminative in identifying abnormal acid burden in type 1 EGJ morphology (P = .005) but trended toward significance in type 2 and type 3 morphology (P = .1). Normal and abnormal EGJ contractile integral did not associate with peak intra-esophageal pressure gradient either collectively or when subdivided by EGJ morphology (P ≥ .2). Conclusions & Inferences: Analysis of intra-esophageal pressure gradients during SLR, a simple HRM maneuver, may augment evaluation of symptomatic GERD, and provide adjunctive evidence supporting GERD.

Background. Inappropriate sinus tachycardia (IST) is a rare clinical disorder characterized by an elevated resting heart rate and an exaggerated rate response to exercise or autonomic stress. Pharmacologic therapy and catheter ablation are considered first-line treatments for IST but can yield suboptimal relief of symptoms. The results of surgical ablation at our center were reviewed for patients with refractory IST. Methods. Between 1987 and 2018, 18 patients underwent surgical sinoatrial (SA) node isolation for treatment-refractory IST. All 18 patients had previously failed pharmacologic therapy, and 15 patients had failed catheter ablation of the SA node. Results. Ten patients underwent a median sternotomy, and 8 patients underwent a minimally invasive right thoracotomy. The SA node was isolated with the use of surgical incisions, cryoablation, or bipolar radiofrequency ablations. Sinus tachycardia was eliminated in 100% of patients in the immediate postoperative period. Long-term follow-up data were available for 17 patients, with a mean follow-up of 11.4 ± 7.9 years. At last follow-up, 100% of patients were free from recurrent symptomatic IST. More than 80% of patients were completely asymptomatic, whereas 3 patients reported occasional palpitations. Four patients were on b-blockers, and 5 patients required subsequent pacemaker implantation. All 8 patients who underwent minimally invasive isolation were in normal sinus rhythm at last follow-up, and only 1 patient complained of palpitations. Conclusions. Surgical isolation of the SA node is a feasible treatment for IST refractory to pharmacologic therapy and catheter ablation. A minimally invasive surgical approach offers a less morbid alternative to traditional median sternotomy.

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Objective Septal myectomy remains the criterion standard for the treatment of patients with hypertrophic obstructive cardiomyopathy refractory to medical therapy. There have been few reports of minimally invasive approaches. This study compared a minimally invasive septal myectomy performed at our institution with the traditional full-sternotomy approach. Methods Patients receiving a stand-alone septal myectomy were retrospectively reviewed from November 1999 to December 2016 (N = 120). Patients were stratified by surgical approach: traditional full sternotomy (n = 34) and ministernotomy (n = 86). Preoperative and perioperative variables were compared as well as follow-up symptomatic and echocardiographic outcomes. Results Both groups had a significant decrease in New York Heart Association class heart failure symptoms ( P < 0.001). At a mean ± SD follow-up time of 2.0 ± 3.4 years, postoperative New York Heart Association class distribution was similar between ministernotomy and full sternotomy ( P = 0.684). Follow-up resting left ventricular outflow tract gradient was also similar between ministernotomy and full sternotomy (11 mm Hg ± 15 vs 9 mm Hg ± 13, P = 0.381). Perioperatively, ministernotomy was not significantly different from full sternotomy in median cardiopulmonary bypass time (81 minutes vs 78 minutes, P = 0.101) but had a slightly longer median cross-clamp time (39 minutes vs 35 minutes, P = 0.017). Major complications were similar in the two groups. There was one 30-day mortality in the full-sternotomy group, but no in-hospital deaths. Conclusions Septal myectomy performed using a minimally invasive approach has similar outcomes to the criterion standard operation done through a full sternotomy. It represents a feasible option for patients with hypertrophic obstructive cardiomyopathy unresponsive to medications.