To Örebro University

OBJECTIVES: Minimally invasive surgical ablation for atrial fibrillation is an alternative to catheter ablation. Achieving lasting sinus rhythm in long-standing persistent atrial fibrillation is challenging and long-term data after surgery are limited. In 2016 we published a randomized trial comparing totally endoscopic box lesion ablation of the left atrium (case) to medical therapy (control) during one year in patients with long-standing persistent atrial fibrillation. This study presents data from a follow-up of our previous cohort to investigate the rhythm outcome long-term.

METHODS: This was an observational follow-up study. Most recent heart rhythm, time from totally endoscopic ablation to first relapse in atrial fibrillation, re-ablation, stroke, medication, left ventricular ejection fraction and mortality were gathered from medical records and analyzed with descriptive statistics and survival analysis.

RESULTS: At the end of the randomized trial, 80% of the cases had sinus rhythm without antiarrhythmic drugs. During a mean follow-up of 9 years, 43% of cases and 74% of controls had undergone additional ablation procedures (p = 0.009). At last follow-up 21% of cases and 5% of controls were in SR. After totally endoscopic ablation, mean time from surgery to first relapse in atrial fibrillation was 23 months (14-31 [95% CI] p <0.001).

CONCLUSIONS: In this population of patients with long-standing persistent atrial fibrillation, totally endoscopic box lesion ablation of the left atrium had short-term efficacy in restoring sinus rhythm. Long-term efficacy could not be demonstrated, with a high proportion of relapse in atrial fibrillation beyond one year post ablation.

BACKGROUND: Atrial fibrillation is a common arrhythmia in patients with ischaemic heart disease. New-onset atrial fibrillation after coronary revascularisation is associated with adverse cardiovascular outcomes. This study aimed to determine the long-term cumulative incidence of new-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting surgery.

METHODS: A prospective observational cohort study in a real-world population setting, conducted at three tertiary centres, on new-onset atrial fibrillation incidence after percutaneous coronary intervention (N=123) or coronary artery bypass grafting (N=123). Heart rhythm was monitored the first 30 days in hospital by telemetry and on discharge using a handheld thumb ECG device three times a day, and thereafter for 2-week periods at 3, 12 and 24 months. The primary endpoint was the cumulative incidence of new-onset atrial fibrillation 24 months after the index procedure. Secondary objectives were to describe the incidence of cerebral ischaemic stroke and bleeding, myocardial infarction and major bleeding events during 24 months follow-up.

RESULTS: Mean age was 67 years, and male sex was more prevalent. At 30 days, the cumulative incidence of atrial fibrillation was 56% (69/123) in the coronary artery bypass graft group and 2% (3/123) in the percutaneous coronary intervention group. At 24 months, the cumulative incidence of atrial fibrillation was 58% (71/123) in the coronary artery bypass graft group and 6% (7/123) in the percutaneous coronary intervention group. Stroke, myocardial infarction and major bleeding were infrequent during follow-up.

CONCLUSION: Over 24 months of follow-up, incident new-onset atrial fibrillation mainly occurred during the first 30 days after coronary artery bypass grafting but was more evenly distributed during 24 months after percutaneous coronary intervention.

TRIAL REGISTRATION NUMBER: NCT04307225.

BACKGROUND: Lung cancer is one of the most frequently diagnosed cancers, and the leading cause of cancer deaths worldwide. Surgical resection is the primary curative treatment. The World Health Organization (WHO) recommends that all adults, including cancer survivors, should engage in at least 150 to 300 min of moderate-intensity aerobic physical activity per week. Positive associations have been found between self-reported physical activity and health-related quality of life (HRQoL) after lung cancer surgery. However, there is a lack of studies concerning objectively measured physical activity levels, and longer follow-ups are also missing. This study investigated the relationship between objectively measured physical activity levels and HRQoL in patients 3 and 12 months after lung cancer surgery.

METHODS: Utilizing a cross-sectional design, patients were followed up 3 (n = 83) and 12 (n = 57) months after lung cancer surgery. HRQoL was assessed with the cancer-specific questionnaire EORTC QLQ-C30 and the lung-cancer-specific module LC13. Physical activity was measured with a tri-axial accelerometer (ActiGraph GT3X+).

RESULTS: At 3 months after surgery, 51% (n = 42) of the patients reached the level of physical activity recommended by the WHO; the corresponding result at 12 months was 42% (n = 24). Patients who reached the recommended level of physical activity reported a better HRQoL, with better global health status and physical function as well as lower symptoms of fatigue, at both 3 and 12 months postoperatively.

CONCLUSIONS: Physical activity was positively associated with HRQoL. Encouraging and supporting patients to engage in regular physical activity could contribute to better HRQoL after lung cancer surgery.

TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov (NCT01961700), registration date 20,131,009.

OBJECTIVES: To report long-term survival and predictors of mortality in patients included in a large, contemporary, multicentre, multinational database: Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD), which consists of 8 centres in 4 Nordic countries.

METHODS: Currently, NORCAAD includes 1159 patients operated between 2005 and 2014. In 30-day survivors (n = 955, 82%), the Kaplan-Meier and Cox proportional hazard methods were used to analyse medium-term (up to 8 years) survival and relative survival versus a matched normal population. Pre- and intraoperative predictors were expressed as hazard ratio (HR) with 95% confidence interval (95% CI).

RESULTS: Cumulative follow-up was 3514 patient-years with a median of 3.2 years (range 0-10.2 years). Survival was 95% (95% CI 93-96) at 1 year, 86% (95% CI 83-88) at 5 years and 76% (95% CI 72-81) at 8 years. Relative survival versus a matched normal population was 95% (95% CI 94-97) at 1 year, 90% (95% CI 87-93) at 5 years and 85% (95% CI 80-90) at 8 years. In multivariable analysis, increased age (HR 1.05 per year, 95% CI 1.04-1.07), previous abdominal or thoracic aortic repair (HR 3.2, 95% CI 1.6-6.4) and chronic renal disease (HR 2.7, 95% CI 1.2-6.2) were associated with increased medium-term mortality. Open distal anastomosis (HR 0.55, 95% CI 0.35-0.87) and operation in the 2010-2014 period (HR 0.90, 95% CI 0.83-0.97) were associated with decreased medium-term mortality.

CONCLUSIONS: Medium-term survival after acute Type A aortic dissection in the NORCAAD registry is satisfactory, close to a matched normal population and improved in the later part of the study period. The use of open distal anastomosis was associated with decreased medium-term mortality.

Objectives: To study pre- and postoperative atrial fibrillation and its long-term effects in a cohort of aortocoronary bypass surgery patients.

Design: Altogether 615 patients undergoing aortocoronary bypass graft surgery in 1999-2000 were studied. Forty-four (7%) had preoperative atrial fibrillation. Postoperative atrial fibrillation occurred in 165/615 patients (27%) while 406/615 patients (66%) had no atrial fibrillation. After a median follow-up of 15 years, symptoms and medication in survivors were recorded, and cause of death in the deceased was obtained.

Results: Death due to cerebral ischaemia was most common in the pre- and postoperative atrial fibrillation groups (7% and 5%, respectively, v. 2% among those without atrial fibrillation, p = 0.038), as were death due to heart failure (18% and 14%, v. 7%, p = 0.007) and sudden death (9% and 5%, v. 2%, p = 0.029). The presence of pre- or postoperative atrial fibrillation was an independent risk factor for late mortality (hazard ratios 1.47 (1.02-2.12) and 1.28 (1.01-1.63), respectively).

Conclusions: Patients with pre- or postoperative atrial fibrillation undergoing aortocoronary bypass surgery have increased long-term mortality and risk of cerebral ischemic and cardiovascular death compared with patients in sinus rhythm.

INTRODUCTION: Cat bite infections usually involve a mix of anaerobic and aerobic bacteria including species of Pasteurella, Streptococcus, Staphylococcus, Bacteroides, and Fusobacterium. We report a case of Pasteurella multocida infection from cat bites leading to endocarditis and subsequent aortic valve replacement.

PRESENTATION OF CASE: A 70-year-old male was admitted because of fever, tachycardia, and malaise. He had a history of alcohol abuse and was living alone with a cat in a rural area. A sepsis of unknown origin was suspected, and intravenous treatment with gentamicin and cefotaxime was initiated. Blood cultures yielded Pasteurella multocida, and the patient history revealed repeated cat bites. After four days, the patient was discharged with oral penicillin V treatment. Two weeks later, the patient returned with fever and a new systolic murmur. An aortic valve endocarditis was diagnosed, and it became clear that the patient had not completed the prescribed penicillin V treatment. The patient underwent a biological aortic valve replacement with debridement of an annular abscess, and the postoperative course was uneventful.

DISCUSSION: Endocarditis due to Pasteurella is extremely rare, and there are only a few reports in the literature. Predisposing factors in the present case were alcohol abuse and reduced compliance to treatment.

CONCLUSION: Cat bites are often deep, and in rare circumstances can lead to life-threatening endocarditis. Proper surgical revision, antibiotic treatment, and patient compliance are necessary components in patient care to avoid this complication.

Objectives: The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) is a collaborative effort of Nordic cardiac surgery centers to study acute type A aortic dissection (ATAAD). Here, we outline the overall objectives and the design of NORCAAD.

Design: NORCAAD currently consists of eight centers in Denmark, Finland, Iceland and Sweden. Data was collected for patients undergoing surgery for ATAAD from 2005 to 2014. A total of 194 variables were retrospectively collected including demographics, past medical history, preoperative medications, symptoms at presentation, operative variables, complications, bleeding and blood transfusions, need for late reoperations, 30-day mortality and long-term survival.

Results: Information was gathered in the database for 1159 patients, of which 67.6% were male. The mean age was 61.5 +/- 12.1 years. The mean follow-up was 3.1 +/- 2.9 years with a total of 3535 patient years.

Conclusions: NORCAAD provides a foundation for close collaboration between cardiac surgery centers in the Nordic countries. Substudies in progress include: short-term outcomes, long-term survival, time interval from diagnosis until operation, effects of surgical techniques, malperfusion syndrome, renal failure, bleeding and neurological complications on outcomes and the rate of late reoperations.

Objectives: Total endoscopic ablation of atrial fibrillation is an alternative to catheter ablation, but its clinical role needs further evaluation. The aim of this study was to compare total endoscopic ablation with rate control in patients with long-standing persistent atrial fibrillation and to examine the effect of endoscopic ablation on heart rhythm, symptoms, physical working capacity and myocardial function during 1 year of follow-up.

Methods: In a prospective controlled study, 36 patients aged >50 years with symptomatic long-standing persistent atrial fibrillation were randomized to either total endoscopic ablation (n = 17, after two drop-outs before ablation n = 15) or rate control therapy (n = 19). In the ablation group, a box lesion encircling the pulmonary veins was performed, using temperature-controlled radiofrequency energy. Loop recorders were implanted in all patients. Echocardiography and quality-of-life assessment were performed at 6 and 12 months, and physical working capacity assessment at 6 months.

Results: There was no mortality or thromboembolic event. In the control group, all patients were in permanent atrial fibrillation during 12 months of follow-up. In the ablation group, the proportion of patients in sinus rhythm without antiarrhythmic drugs was 12/15 (80%) at 12 months. The median freedom of atrial fibrillation at 3-12 months was 95% in the ablation group and the proportion of patients with an atrial fibrillation burden of <5% at 3-12 months was 8/15 (53%). The left ventricular ejection fraction increased during follow-up in the ablation group compared with the control group (from 53.7 ± 8.6 to 58.8 ± 6.5%, P = 0.003), combined with a reduction in the left atrial area (from 29.2 ± 5.5 to 27.2 ± 6.3 cm(2), P = 0.002). The physical working capacity increased in the ablation group compared with the control group (from 94 ± 21.4 to 102.9 ± 14.4%, P = 0.011). The subjective physical and mental capacity scale also improved during follow-up in the ablation group, but not in the control group (P =0.003 and 0.018, respectively).

Conclusions: Total endoscopic ablation in patients with long-standing persistent atrial fibrillation significantly reduced atrial fibrillation burden 12 months after intervention compared with controls. The left ventricular function, physical working capacity and subjective physical and mental health were improved. These results need to be confirmed in larger randomized trials.

Pleural effusion following cardiac surgery is a common complication that sometimes requires invasive treatment. Conventional methods for evacuation include needle aspiration and chest tube insertion. We present an effective, easy and potentially time-saving method of thoracocentesis, using a single-lumen central venous catheter.

Total endoscopic ablation of atrial fibrillation is a treatment option in symptomatic patients after unsuccessful catheter ablation or when catheter ablation is considered inappropriate. We describe a technique of endoscopic ablation of the left atrium using temperature-controlled unipolar or bipolar radiofrequency. A left atrial box lesion encircling the pulmonary veins is created using three ports in the right hemithorax. The technical aspects and preliminary results of the procedure are discussed.