Efficacy of the Stand-Alone Cox-Maze IV Procedure in Patients with Longstanding Persistent Atrial Fibrillation

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow-up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat. Methods & Results: Between May 2003 and March 2020, 174 consecutive patients underwent a stand-alone CMP-IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine-Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range [IQR] 4.0-12.0 years), with 71% (124/174) having failed at least one prior catheter-based ablation. There were no 30-day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence. Conclusion: Despite the majority of patients having a long-duration of preoperative AF and having failed at least one catheter-based ablation, the stand-alone CMP-IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand-alone CMP-IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation.

Pre-existent 1st degree AV-Block before TAVI with Sapien 3 – is prolonged monitoring required?

Introduction Pre-existing right bundle branch block (RBBB) is a well stablished risk factor for the development of high grade conduction abnormalities (CAs) after TAVI. The association of pre-existing 1st degree AV-Block (AVB1) with high grade CAs after TAVI has been inconsistent. A recently published Expert Consensus Document classifies patients with AVB1 in the lowest risk group, allowing for discharge at day 1 post-TAVI. We aimed to study the risk of these patients of developing delayed high grade CAs requiring pacemaker implantation (PM). Methods We studied the development CAs in 1447 consecutive patients treated with Sapien 3 between January 2014 and December 2019. After excluding valve-in-valve procedures (n=30) and pts with previously implanted PM (n=167) 1254 patients remained for analysis. All patients were monitored for at least 7 days, as this was our institutional policy during the study period. We analyzed if pre-existing ECG abnormalities predict early and delayed (>24h) high grade CAs with a multivariable logistic regression model. Results Of 1254 pts, 159 (12.5%) required a permanent PM after TAVI. In 104 (65%) CAs requiring PM occurred intraprocedural or during the first 48h while in the remaining 35% developed with more delay. We analyzed the presence of previous CAs in pts still free from indication for PM after the first 48h after TAVI (n=1150) in order to identify characteristics that may predict delayed PM requirement (Table). In the multivariable model not only RBBB (OR 5.42, CI95% 2.69–10.94, p<0.0001) but also AVB1 was significantly associated to delayed high grade CAs requiring PM implantation (OR 2.25, CI95% 1.24–4.08, p=0.005). Conclusion In this study, in pts requiring PM implantation after TAVI, the high grade CAs occurred after 48h in 35% of patients. Not only RBBB but also AVB1 was an independent predictor of delayed high grade CAs. These results question the safety of considering patients with pre-existing AVB1 as low-risk patients and suggest a more prolonged monitoring also for them. Funding Acknowledgement Type of funding source: None

DOZ047.122: Inadequate response of atretic esophagus during acidic gastroesophageal reflux

Patients with atretic esophagus (OA) are candidates to severe gastroesophageal reflux. In a previous study, we observed that in OA operated children the complete transmission of contractions during the whole day and during acid reflux periods is poor compared to controls (C). Investigate the motor response of OA during periods of meal (M) and periods of acid reflux (GOR) in OA patients. Methods Prolonged monitoring of esophageal motor function recorded with three sensors: P1 above and P2, P3 below the suture, combined with pH-metry between P2 and P3. Number/min and amplitude of contractions and transmissions between P1-2-3 or P2-3 are compared during total time, meal and reflux periods and between OA with or without GOR. Population 13 operated patients (OA) mean age 7.75 years and 10 controls (C). Results Contractions/min in OA at P1 M = 1.4 SD 1.2 versus GOR = 0.8 SD 1.1: P < 0.05 at P2 M = 2.0 SD 1.4 versus GOR = 1.4 SD1.4: P < 0.05 at P3 M = 2.2 SD 1.3 versus GOR = 1.5 SD1.4: P < 0.05 Complete transmission (P1-2-3) in OA during M compared with total time (T) is increased (29 vs. 32%: P < 0.5), but not during GOR (29 vs. 28%: NS). No difference in distal transmission (P2-3) between C and OA during M (68.8 vs. 63.2) but difference during GOR (69.8 vs. 43 P < 0.01). Contractions/min are not different during M between 7/13 patients with normal (OAN) and 6/13 with abnormal (OAR) reflux index but differ during GOR: P2 OAN = 2.1 vs. P2 OAR = 0.6, P < 0.01; P3 OAN = 2.2 vs. OAR = 0.6, P < 0.05. Complete transmission (P1-2-3) in OAN is not different during M or GOR but different in OAR (M: 74.2 SD 33.5 vs. GOR 54.7 SD 30.5: P < 0.005); distal transmission (P2-3) is not different between OAN and OAR during M and RGO periods. Conclusion Esophageal motility remains impaired in the operated OA. GOR stimulations produce weaker responses than meals. In OAR alterations of response to GOR are more important in terms of decreased number of distal contractions and total transmission suggesting a motility disorder but also an altered sensitivity reducing primary peristaltic response to reflux.

What is the Diagnosis?

A 54 years old woman patient, with complaints of sporadic palpitations, without medication and with a structurally normal heart, presents itself in the clinic where the electrocardiogram, observing prolonged monitoring of the D2 derivation with sensitivity 2N.