AIM:This study aimed to examine contemporary burden and treatment trends of atrial fibrillation (AF) in patients undergoing cardiac surgery in Australia and New Zealand. This allows comparison of contemporary practice with the Society of Thoracic Surgeons guideline recommendations for the surgical treatment of AF in patients undergoing cardiac surgery. METHOD:A 10-year retrospective review of the Australian & New Zealand Society of Cardiac & Thoracic Surgeons National Cardiac Surgery Database was performed, examining all adult cardiac surgery patients from 2011 to 2021. Patients were grouped by the presence or absence of AF, and simple descriptive statistical analysis was performed to assess baseline demographics and premorbid condition of the patients. The incidence of AF was analysed by type of surgery. Trends for surgical treatment of AF were then analysed using simple descriptive statistics, examining isolated left atrial appendage ligation, isolated surgical ablation, and combined ligation and ablation. RESULTS:In the last 10 years, the Australian & New Zealand Society of Cardiac & Thoracic Surgeons database has recorded 140,680 patients who underwent cardiac surgery. Atrial fibrillation (AF) was present in 21,077 patients (14%). Patients with AF were generally older (72.25 vs 66.65 years; p<0.001). Among patients undergoing cardiac surgery, AF was more common in female than in male patients (18% vs 13%, respectively). Patients with AF more often had a higher classification of dyspnoea according to the New York Heart Association and lower ejection fractions compared with their AF-free counterparts. The incidence of AF as a comorbid condition was more frequent in patients undergoing mitral valve surgery or combined coronary artery bypass grafting and valve surgery (aortic, mitral, or both) compared with those undergoing isolated coronary or aortic surgery. Only 11.90% (n=2,509) of patients with AF received a combined ablation and left atrial appendage ligation, and 19.54% (n=693) of those received a Cox-Maze IV ablation. CONCLUSIONS:The burden of concomitant AF in patients undergoing cardiac surgery in Australia is higher than previously reported (14% vs 5%-11%). Despite strong recommendation for the surgical management of AF in patients undergoing cardiac surgery and clear evidence of its benefit, both left atrial appendage ligation and surgical ablation independently or concomitantly remain heavily underutilised in this cohort.

A 55-year-old gentleman presented to his local hospital with troponin positive chest pain.Angiography revealed multi-vessel coronary artery disease as well as an ectatic circumflex with an unusual course.(Figure 1A).A CT coronary angiogram suggested a circumflex coronary artery to superior vena cava fistula (Figure 1B). 1Intra-operative transesophageal echocardiography demonstrated flow from an aberrant left circumflex artery into the superior vena cava as well as ischaemic cardiomyopathy and mitral regurgitation (Figure 2, Video).A sternotomy was performed and cardiopulmonary bypass established.Coronary artery bypass was performed to the left anterior descending artery and two obtuse marginal branches.The fistulous portion of the circumflex was ligated (figure 3).The mitral valve was repaired with annuloplasty and cleft closure.The patient made an uneventful recovery.At follow-up, there was resolution of his pre-operative symptoms as well as improved left ventricular function and no mitral regurgitation on his postoperative echocardiogram.

Radiation-associated cardiovascular disease is well-described yet under-recognized. Mediastinal radiation is known to affect any component of the heart. We present a case of valvular, coronary, and conduction abnormalities up to decades after initial radiotherapy.

Background Injection drug use (IDU) associated infective endocarditis (IE) is clinically challenging due to social issues this population endures. Rates of IDU are rising globally, however, there is a lack of clear guidelines for IDU associated IE. The aim of this study is to assess the epidemiology of the IDU and non-IDU populations and compare their long-term outcomes to help guide future management. Methods An observational cohort study was conducted on all 350 patients treated for IE at St Vincent's Hospital Melbourne between 1999 and 2015. Follow up was performed until death or January 2021. Primary outcome was all-cause mortality. Results IDU patients are younger (p<0.001), more likely to have concurrent infections (p<0.001), and other addiction disorders (p<0.001), while non-IDU patients are older with a higher level of comorbid illnesses (p<0.001). IDU and non-IDU patients received similar management during their admissions and experienced similar levels of in-hospital outcomes, except for non-IDU patient being more likely to develop pneumonia post-surgery (p = 0.03). IDU patients are more likely to become reinfected (p = 0.034) but have better long-term survival, with survival estimates at 15-years being 64.98% (95%CI: 50.94-75.92%) for IDU patients compared to 26.67% (95%CI: 19.76-34.05%) for non-IDU patients (p<0.001). Conclusion Despite having higher levels of reinfection, IDU patients have better long-term survival compared to non-IDU patients. Therefore, we suggest IDU patients should not have blanket restrictions on the management they are offered unless at the individual level there is a contraindication to therapy.

Bioprosthetic leaflet immobility is under-recognised and is highlighted by an article by Naser et al. [ [1] Naser J.A. Crestanello J.A. Nkomo V.T. Luis S.A. Thaden J.T. Geske J.B. et al. Immobile leaflets at time of bioprosthetic valve implantation: A novel risk factor for early bioprosthetic failure. Heart Lung Circ. 2022; 31: 1165-1175 Abstract Full Text Full Text PDF Scopus (2) Google Scholar ] in this edition of Heart, Lung and Circulation. The authors assert in their conclusions that “Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised intra-operatively and appears to be associated with early bioprosthetic dysfunction and worse clinical outcome”. The valves assessed were predominantly porcine and while the number of cases is small, there was not much detail on the overall percent incidence of this issue. However, the presence of early bioprosthetic valve regurgitation and leaflet hypomobility is something that most cardiac surgeons and cardiac anesthetists are aware of, even if reported findings are uncommon. Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure: A Novel Risk Factor for Early Bioprosthetic FailureHeart, Lung and CirculationVol. 31Issue 8PreviewThe clinical implications of finding immobile leaflet(s) at the time of bioprosthetic valve implantation but with acceptable prosthetic haemodynamics are uncertain. We sought to determine the characteristics of such patients and their impact on outcome. Full-Text PDF Clinical Outcomes in Surgical and Transcatheter Aortic Valve Replacement: An ANZSCTS Database Review 2001-2019Heart, Lung and CirculationVol. 31Issue 8PreviewSince the last formal publication reporting on the findings of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database on surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in 2016, transcatheter approaches have become common practice. There has been an increase in use of TAVR following large, randomised control trials that only report on short-term outcomes in a selective cohort. This study aims to report on primary outcome measures and identify complications associated with SAVR and TAVR from a large national database. Full-Text PDF

Background: Concomitant mitral regurgitation (MR) is frequently seen in patients undergoing surgical aortic valve replacement (AVR) for severe aortic stenosis (AS). When the severity of MR is moderate or less, the decision to undertake simultaneous mitral valve intervention can be challenging. Methods: A systematic search of Medline, PubMed (NCBI), Embase and Cochrane Library was conducted to qualitatively assess the current evidence for concomitant mitral valve intervention for MR in patients with AS undergoing AVR. The primary outcome for this systematic review was the postoperative change in the severity of MR and other outcomes of interest included factors that predict improvement or persistence of MR and long-term impacts of residual MR. Results: A total of 17 studies were included. The percentage of patients demonstrating improvement in MR severity following AVR ranged from 17.2% to 72%; the studies that exclusively included patients with moderate functional MR and reported longer term echocardiographic follow-up of greater than 12 months demonstrated an improvement in MR severity of 45% to 72%. Conclusion: This systematic review demonstrates that a proportion of patients can exhibit an improvement in MR following isolated surgical AVR, but whether this confers any long-term morbidity and mortality benefit remains unclear.

Background Infective endocarditis (IE) remains a life-threatening condition. Intravenous drug use (IVDU) adds to the clinical challenge associated with IE due to clinical aberrations caused by the social issues associated with this population. Aim To improve survival, this study aimed to characterize the contemporary IVDU-associated IE population seen at our tertiary hospital, determine their long-term outcomes and find risk factors associated with mortality. Design Retrospective observational cohort study. Methods A total of 79 patients accounting for 89 presentations were treated for IVDU-associated IE at St Vincent's Hospital Melbourne (SVHM) between 1999 and 2015. Patients were followed-up until death or January 2021. The primary outcome was all-cause mortality and Kaplan-Meier survival analysis was used to calculate long-term survival estimates. Cox proportional hazards analysis was used to examine risk factors for mortality. Results The IVDU population treated at SVHM had a high rate of multivalvular IE, at 18.98%. Multivariate analysis revealed that multivalvular IE is significantly associated with an increased risk of mortality in a dose-dependent relationship (two valves affected: HR = 4.73, P = 0.006, three valves affected: HR = 14.19, P = 0.014). The IVDU population has survival estimates of 83.78% (95%CI: 73.21-90.45%) at 1-year and 64.98% (95%CI: 50.94-75.92%) at 15-years. Conclusion IVDU patients have high rates of multivalvular endocarditis, which is associated with increased risk of mortality and difficult to identify on echocardiography. Clinicians should be suspicious of multivalve involvement in the IVDU population and decisions related to medical management/intervention should be made with the understanding that these patients are at a higher risk of death.

Central MessageThickened mitral valve leaflets can made more pliable by the PED technique, enhancing the prospect of repair in these patients. Thickened mitral valve leaflets can made more pliable by the PED technique, enhancing the prospect of repair in these patients. The burden of mitral valve disease has doubled over the past 30 years, linked to the aging of society, with an estimated 12.6 million deaths in 2017.1Yadgir S. Johnson C.O. Aboyans V. Adebayo O.M. Adedoyin R.A. Afarideh M. et al.Global, regional, and national burden of calcific aortic valve and degenerative mitral valve diseases. 1990-2017.Circulation. 2020; 141: 1670-1680Crossref PubMed Scopus (155) Google Scholar Mitral repair remains the intervention of choice where possible, avoiding the need for anticoagulation therapy or prosthetic degeneration.2Baumgartner H. Falk V. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Crossref PubMed Scopus (2) Google Scholar,3Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar Options for repair become limited in the presence of severe valvular thickening and subvalvular fibrosis due to technical challenges. Repair techniques have been described in patients with rheumatic heart disease to deal with thickened mitral valve leaflets,4Choudhary S.K. Talwar S. Dubey B. Chopra A. Saxena A. Kumar A.S. Mitral valve repair in a predominantly rheumatic population. Long-term results.Tex Heart Inst J. 2001; 28: 8-15PubMed Google Scholar, 5Kumar A.S. Rao P.N. Restoration of pliability to the mitral leaflets during reconstruction.J Heart Valve Dis. 1995; 4: 251-253PubMed Google Scholar, 6Chen S.-W. Cheng C.-Y. Wu V.C.-C. Chou A.-H. Cheng Y.-T. Chang S.-H. et al.Mitral valve repair versus replacement in patients with rheumatic heart disease.J Thorac Cardiovasc Surg. 2022; 164: 57-67.e11https://doi.org/10.1016/j.jtcvs.2020.07.117Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar by either leaflet peeling or cusp thinning. This has not been described in detail in nonrheumatic mitral valve diseases. We have used the current technique in patients with myxomatous mitral valve disease, infective endocarditis, functional mitral regurgitation, and connective tissue disorders to reduce the thickness of the leaflets using a combination of peeling, endarterectomy, and decortication (PED). We illustrate this with a typical application in a patient with myxomatous mitral valve disease who had significant thickening of both leaflets with posterior leaflet prolapse. The mitral valve is exposed using standard techniques and analyzed using the saline test. This is accompanied by standard valve assessment techniques. The elements of the PED technique can be applied to mitral leaflets that appear fibrotic or thickened (Figure 1, A). This technique can be applied to 1 or both leaflets. If both leaflets appear thickened, the PED repair begins along the posterior leaflet. Typically, a square-ended forceps is used to gently develop the plane of fibrous layer near the annulus and at times from the posterior wall of the left atrium. This layer usually peels off from the entire leaflet surface up to the coaptation zone. The plane on the anterior leaflet is then developed using a No. 15 blade or using 2 sets of forceps, starting from the junction of the leaflet and the annulus. Gentle retraction is provided either through the free edge of the valve or the fibrous layer itself using a DeBakey forceps. Once the plane has been entered, elevation and freeing up of the fibrous rind may be aided by a Watson-Cheyne dissector, peeling from the annular border to the free edge of the leaflet (Figure 1, B). This is analogous to an endarterectomy. Once fibrous tissue has been dissected off the valve and is only attached at the free edge of the valve, it may be excised using a Metzenbaum scissors. Once PED is complete, the valve leaflets appear translucent (Figure 1, C) and the valve is tested in standard fashion. Repair of the posterior leaflet is performed as required, using a triangular resection and leaflet reconstruction. Annular repair is then undertaken using a flexible annuloplasty band or ring. Figure 2 shows intraoperative images of a typical PED repair that was as an adjunct to a posterior leaflet prolapse with a very thickened posterior leaflet. Adjunctive procedures such as leaflet resection and repair in this case, are easily combined with the PED repair. For purposes of reporting this case, tissue removal and assessment along with outcomes evaluation are approved through the Ethics Committee, protocol No: HREC/73660/Austin-2021, and also approved for multisite use at the University of Melbourne Hospitals. The patients provided informed written consent for the procedure and the publication of their study data. The PED technique provides a useful primary technique in a spectrum of mitral valve pathology where there is thickening of the mitral valve, including in patients with nonrheumatic heart disease. The current technique extends the option of repair to a spectrum of patients who would otherwise require valve replacement due to fibrous restriction of the leaflets. This technique is useful as an adjunctive procedure to other repair techniques, improving the quality of repair by facilitating increased mobility of the mitral valve leaflets. The underlying leaflets seem more pliable and have greater surface area for coaptation. This technique allows the removal of fibrous endocardium, analogous to endarterectomy of plaque filled arteries. The need for leaflet augmentation is virtually eliminated with the PED technique. Methods addressing thickened mitral valves are crucial for both rheumatic and nonrheumatic pathologies. In this setting, the PED technique likely represents an addition to the armamentarium of techniques available for valvular repair, avoiding the need for conversion to valve replacement, which could subject patients to complications of anticoagulation or bioprosthetic degeneration. A key component of this repair is to be able to get into the right plane or develop the plane between the fibrous rind and the underlying leaflet. Repair of leaflets can be undertaken if small perforations occur during the peeling process. However, we find it uncommon in our experience. This technique is not advised if there is calcification of the leaflets or calcified changes to the fibrous rind. However, as experience grows, mildly or partially calcified rinds can be removed safely. Our contention is that a fibrous rind is removed as in decortication of the lung. Intraoperative visual assessment of the adequacy of decortication are similar in both the lung and the mitral valve leaflets. However, long-term follow-up will inform us as to whether there is an influence on recurrence of fibrosis. Mitral valve repair has evolved from leaflet resection of varying grades to leaflet preservation, chordal transfer to neochords, rigid to semi-rigid and flexible rings, and edge-to-edge repairs to MitraClip (Abbott) implants, based on intraoperative evaluations. The PED repair is another arrow in the quiver of a mitral valve repair surgeon. This technique utilizes favorable outcomes seen in rheumatic valve repair where the leaflet tissues are able to withstand the long-term hemodynamic stresses after repair. Although our article focuses on the technique, we have deployed this in more than 135 patients since 2009 in multiple institutions in North America and Australia. A detailed publication focusing on clinical and echocardiographic follow-up is being compiled. We have described a new method for surgical repair using a PED combination technique, by illustrating its use in a patient with myxomatous mitral valve disease. This repair technique has not been well described in the literature to the best of our knowledge.

Background Right-sided infective endocarditis (IE) carries favourable prognosis compared to left-sided IE. However, the prognostic significance of vegetation size in right-sided IE is less well defined. This study reports the clinical, microbiological, and echocardiographic findings associated with right-sided IE and examines the predictors of adverse outcomes. Methods Consecutive adults admitted with isolated right-sided IE at an Australian tertiary referral centre between June 1999 and May 2017 were retrospectively reviewed. Patients were stratified according to intravenous drug user (IVDU) status. Culprit organisms, sepsis severity, treatment regimens, inpatient complications, and vegetation size were recorded. Hospital survivors were followed mean 6.964.8 years for late mortality and IE recurrence. Results Of 318 consecutive cases of IE, 60 (19%) were isolated right-sided IE and included in this study. Forty-three (43) (72%) patients were current IVDUs, who were younger and more likely to have hepatitis. The majority (90%) of patients were medically managed with multi-agent antimicrobial regimens (median three agents) for a total duration of median 91 days. In-hospital mortality was 3% (2/60). Septic emboli were found in 82% (49/60) of patients, were significantly more common among IVDUs but were not related to vegetation size. Survival after hospital discharge was 100% at 1 year, 96% at 3 years, and 89% at 5 years. Vegetation size >2 cm, chronic kidney disease, and Pitt bacteraemia score were independent predictors of all-cause late mortality. Freedom from IE recurrence was 93% at 1 year, 87% at 3 years, and 84% at 5 years. Vegetation >2.5 cm, prisoner status, and multivalvular IE involvement conferred higher risks of recurrence. Conclusions Patients with right-sided IE and small vegetations do well with medical management and this should continue to be the preferred strategy. However, those with large vegetations have poorer late outcomes and may require more aggressive treatment and closer follow-up.

A 58-year-old male was admitted for surgical removal of a right pelvic sarcoma. His medical history included a liposarcoma excised from his right thigh (15 years previous) and right elbow (4 years previous). Staging computed tomography (CT) and Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) scans in the month prior had revealed no sign of metastatic disease. An electrocardiograph (ECG) taken at a similar time showed normal sinus rhythm. He had a normal exercise tolerance and no cardiac history and he did not have a preoperative transthoracic echocardiogram (TTE).

Objectives: There have been reports of postoperative conduction disturbances after rapid-deployment aortic valve replacement. Our objective was to assess electro-cardiogram changes in patients undergoing this procedure and review the literature on this topic. Methods: In this retrospective case series, clinical data were extracted from patient records at St Vincent's Hospital Melbourne and the Australia New Zealand Society of Cardiac and Thoracic Surgeons database. Electrocardiogram data were obtained at baseline and postoperatively on day 5 and at week 6 and reviewed for rhythm disturbances and intracardiac conduction problems. Pacemaker status was also recorded. Results: From 2013 to 2017,100 consecutive patients underwent rapid-deployment aortic valve replacement with 1 valve type at our institution. Three patients were excluded because of paced rhythm preoperatively, leaving 97 patients (mean age 74.7 +/- 8.12 years; 56.7% male) for analysis. Some 18.6% of patients developed new left bundle branch block at 5 days postoperatively and only 4.1% of patients found with persistent left bundle branch block at 6-week follow-up compared with preoperatively. No significant changes were observed in the frequencies of atrial fibrillation, first-degree heart block, and right bundle branch block. However, there was evidence of increases in paced rhythm and subsequent need for a permanent pacemaker. A total of 14 patients (14.4%) had a permanent pacemaker implanted at an average of 11.1 +/- 2.9 days postoperatively. Conclusions: Rhythm disturbances and conduction abnormalities are noted with the rapid-deployment aortic valves used at our institution, but appear comparable to other rapid-deployment aortic valve replacement bioprostheses. These abnormalities may be related to the effect of the sub-annular stent frame of the valve system and implantation technique.

Background. Cardiac surgery results in complications for some patients that lead to a longer hospital stay and higher costs. This study identified the presurgery characteristics of patients that were associated with the cost of their hospital stay and estimated how much of that cost could be attributed to a bleeding event, defined as requiring 3 units or more of packed red blood cells or returning to the operating room for bleeding. We also identified the presurgery characteristics that were associated with the bleeding event. Methods. This prospective cohort of patients (n = 1459) underwent cardiac surgery at 3 tertiary referral hospitals in Australia during 2014 and 2015. Clinical data included the variables held by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry. Cost data were collected as part of a state-level hospital data collection. Results. Many of the baseline patient characteristics were associated with the total cost of cardiac surgery. After adjusting for these characteristics, the cost of cardiac surgery was 1.76 (confidence interval, 1.64-1.90) times higher for patients who had a bleeding event (P < .001), thus resulting in a median increase in costs (in Australian dollars) of $33,338 (confidence interval, $21,943-$38,415). Several baseline characteristics were strongly associated with a bleeding event. Conclusions. The impact of a bleeding event on the cost of cardiac surgery is substantial. This study identified a set of risk factors for bleeding that could be used to identify patients for discussion at the heart team level, where measures to minimize the risk of transfusion may be initiated. (C) 2020 by The Society of Thoracic Surgeons

Infective endocarditis (IE) of the mitral valve is an illness associated with significant morbidity and mortality. We describe the long‐term outcomes of mitral valve endocarditis at a single centre.

Introduction: The coronavirus 2019 disease (COVID-19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pre-existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID-19, and COVID-19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders. Main recommendations: Common acute cardiac manifestations of COVID-19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five-to tenfold higher case fatality rate with COVID-19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need. Changes in management as a result of this statement: Cardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID-19 among CVD patients, upskill in the management of COVID-19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS-CoV-2 infection.

A Best Evidence Topic in cardiac surgery was written according to a structured protocol. The question addressed was-"In patients who undergo cardiac surgery, is preoperative angiotensin-converting enzyme inhibitor therapy associated with postoperative renal dysfunction?" Altogether, 339 papers were found using the reported search. Ten (10) were chosen which best answered the clinical question. The papers were evaluated for bias and heterogeneity using validated tools and the collected results analysed qualitatively. Evidence in the current literature is inconclusive that preoperative administration of angiotensin-converting enzyme inhibitor therapy affects postoperative renal dysfunction in patients undergoing cardiac surgery.

Background. Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) and is associated with increased short-term and long-term mortality. While the precise etiology of POAF remains unclear, inflammation is a known contributing factor. Preliminary studies have suggested that an elevated preoperative platelet-to-lymphocyte ratio (PLR), an inexpensive and readily available novel inflammatory biomarker, may be associated with increased incidence of POAF after CABG. This study sought to further investigate this hypothesis. Methods. The study cohort included all patients undergoing isolated CABG, with no prior history of arrhythmia, who were operated on between August 1, 2010, and December 31, 2018, at a major Australian tertiary center (n = 1457). Patients were divided into low (86) or high (>= 86) PLR groups based on an optimal cutoff derived from receiver-operating characteristic curve analysis. The incidence of POAF was then compared. Categorical variables were analyzed using the chi-square test and continuous variables using logistic regression. Results. Of 1457 patients, 495 (34.0%) developed POAF. There was no statistically significant difference in the incidence of POAF between patients in the high-PLR and low-PLR groups (34.8% vs 31.0%; P = .22). Using multivariable logistic regression analysis, high PLR was not independently associated with POAF (odds ratio, 1.04; P =.78). Conclusions. Elevated preoperative PLR is not independently associated with POAF in patients undergoing isolated CABG. The findings of this study differ from those of 2 previous smaller studies. (C) 2020 by The Society of Thoracic Surgeons

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, "In patients who have undergone Coronary Artery Bypass Grafting, does aspirin plus clopidogrel postoperatively improve vein graft patency when compared to aspirin alone?" Altogether, 165 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. Overall analysis of these papers demonstrated similar rates of vein graft patency between the two groups. There was no difference between the groups with regard to mortality, adverse bleeding-related outcomes, or composite vascular events.

A best evidence topic in cardiac surgery was written according to a structured protocol addressing the question 'for post-cardiac surgery atrial fibrillation (AF), do clinical outcomes differ between rate or rhythm control strategies?' Altogether, 2174 papers were found using the reported searches, of which 5 represented the best evidence to answer the clinical question. Hospital length of stay ranged from 5.0 to 13.2 days for rate control and 5.2 to 10.3 days for rhythm control. Freedom from AF at follow up was achieved in 84.2-91 and 84.2-96% in rate and rhythm control groups respectively. Minimal serious adverse events were noted in all studies analysed and there was no difference between rate and rhythm control groups. We conclude that in the management of post-cardiac surgery, AF, rate control and rhythm control are equivalent in terms of hospital length of stay, freedom from arrhythmia at follow up and complication rates.

BACKGROUND:Atrial fibrillation (AF) affects 1.5-2% of the population and is associated with a five-fold increased lifetime risk of stroke [1]. The left atrial appendage (LAA) is the source of embolic strokes in up to 90% of patients with non-valvular AF with clots in the left atrium [2].METHODS:We reviewed the clinical notes and echocardiographic findings of 20 patients who underwent open cardiac surgery in which concurrent AtriClip (Atricure Inc, Westchester, OH, USA) device insertion was attempted at our institution from July 2013 to February 2015. This was to examine the safety and efficacy of LAA exclusion with clip devices during open cardiac surgery. Indications for LAA exclusion included a history or suspicion of atrial arrhythmia, left ventricular dilatation, or a history of transient ischaemic attacks.RESULTS:All 20 of the 20 participants had successful placement of the clip device (100% success rate). There were no adverse events related to the device and no perioperative mortality. There were three late deaths due to chronic obstructive pulmonary disease (COPD), leukaemia, and refractory congestive cardiac failure. No late device related complications were found on follow-up imaging in the remaining patients.CONCLUSIONS:The results of our study demonstrate the LAA exclusion during open cardiac surgery with the AtriClip device is safe, has a 100% success rate, and appears to be stable over time.