Thomas J. Van Brakel

Objectives: This study aimed to evaluate the long-term efficacy and safety of isolated and hybrid thoracoscopic atrial fibrillation (AF) ablation using a bipolar irrigated radiofrequency clamp in a multicentre registry. Methods: A retrospective multicentre registry of patients undergoing AF ablation using the bipolar clamp was conducted over the past 13 years (2010-2023). The primary efficacy outcome was freedom of atrial tachyarrhythmias (ATAs), with and without the use of Class I/III antiarrhythmic drugs (AADs). Antiarrhythmic drug use during follow-up was not uniformly documented across centres. The primary safety outcome was the rate of periprocedural complications. Results: The cohort of 678 patients consisted of a minority of female patients (17.4%), with most patients having longstanding persistent AF (LSPAF) (66.7%), a mean duration of 61 months of AF duration and 33.3% had undergone prior catheter ablation. Freedom from ATA while allowing Class I/III AAD use was 82.3%, 71.5%, and 52.4% at 1, 3, and 5 years, respectively. Freedom from ATA off Class I/III AAD declined from 71.7% at 1 year to 44.2% at 5 years, underscoring the progressive nature of AF and the need for long-term rhythm strategies. Women presented with a more advanced cardiovascular risk profile than men, including older age (60.3 vs 57.3 years), higher CHA2DS2-VA-scores, and more comorbidities. Despite these differences, there were no significant sex-based differences in long-term ATA freedom. There were no significant unadjusted differences in long-term ATA freedom between paroxysmal AF (PAF) and non-PAF. Major complication rate was low. Conclusions: Isolated and hybrid thoracoscopic AF ablation using the Gemini Clamp demonstrated favourable outcomes with a low complication rate. However, variability in ATA detection methods among centres may have influenced the primary outcome and should be considered when interpreting long-term efficacy results. Clinical trial registry number: METC-number 2022-3561.

Objectives: Acute type A aortic dissection (ATAAD) carries high mortality, with emergency surgery being the cornerstone of treatment. The German Registry for Acute Type A Aortic Dissection (GERAADA)-score is advocated in guidelines to predict 30-day mortality after ATAAD surgery. This study investigates its performance in a Dutch cohort, with an emphasis on malperfusion definitions, age groups, and sex. Methods: Adults undergoing emergency surgery for ATAAD at 5 Dutch centres (2007-2024) were included in a multicentre database. External validation of the GERAADA-score was performed with these data, using discrimination (area under the curve [AUC]) and calibration (Brier score, Hosmer-Lemeshow test, and calibration plots). A logistic regression with GERAADA variables was fitted on the study population, and assumptions were checked. Subgroup analyses were conducted based on sex, age groups, and malperfusion definitions (including imaging and clinical definitions). Results: A total of 1,146 patients underwent emergency surgery for ATAAD. Observed early mortality was 16.9% (n = 194). Of 1,130 patients included in the external validation cohort, 92.2% had low-intermediate risk (GERAADA-score ≤ 30%). The GERAADA-score showed moderate discrimination (AUC = 0.649, 95% confidence interval = 0.604-0.694), with a higher AUC for younger patients (50-59 years). The malperfusion definition including ischaemia confirmed by imaging showed the best discriminative power. Calibration was good (Hosmer-Lemeshow, P = .754, Brier score = 0.131). Logistic regression identified age, catecholamine use, ventilation support, and coronary and peripheral malperfusion as independent risk factors for 30-day mortality, with signs of multicollinearity between preoperative catecholamine use and resuscitation. Conclusions: In the Dutch setting, the GERAADA-score demonstrated moderate discriminative power and good calibration across relevant subgroups. Adaptations of the GERAADA-score, including conducting a haemodynamic instability variable, may be considered to avoid redundant predictions and boost reproducibility.

Aims: Postoperative atrial fibrillation (POAF) occurs in 15–40% of patients following coronary artery bypass grafting (CABG). Existing risk scores are unsuited to its transient nature, and evidence for long-term oral anticoagulation (OAC) remains limited. Although guidelines suggest balancing thromboembolic and bleeding risk, unclear recommendations and limited real-world data drive practice variation. This study evaluated OAC use and outcomes in a national POAF cohort after CABG. Methods and results: This retrospective study included adults undergoing isolated CABG (2013–2022) from the Netherlands Heart Registration, linked to mortality and pharmacological data from Statistics Netherlands. Patients with prior atrial fibrillation or preoperative OAC were excluded. Outcomes included short-term complications and long-term cause-specific mortality, comparing OAC with antiplatelets. Among 44 601 CABG patients, 11 054 (24.8%) developed POAF. Of these, 10 750 were successfully linked. Mean age was 68.9 years; 81.7% were male. OAC therapy was initiated in 43.6% of patients, rising from 38.7% (2013) to 53.7% (2022). Within 30 days, mortality was 1.6%, cerebrovascular events 1.3%, and bleeding reintervention 5.4%. Most discontinued OAC after 1 year, while 10.3% continued for 10 years. Crude thromboembolic mortality was lower among OAC users (0.04 vs. 0.42 per 100 patient-years), while bleeding-related mortality remained low (0.00 vs. 0.08). However, survival analyses from 30 days postoperatively showed no significant differences between groups. Conclusion: Among POAF patients after CABG, crude mortality was lower in OAC users, but no survival benefit was observed from 30 days onward. Low long-term OAC continuation without excess thromboembolic mortality suggests the potential value of time-limited anticoagulation strategies.

Background and Aims: This study aimed to evaluate clinical outcomes in patients developing post-operative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and characterize variations in oral anticoagulation (OAC) use, benefits, and complications. Methods: A systematic search identified studies on new-onset POAF after CABG and OAC initiation. Outcomes included risks of thromboembolic events, bleeding, and mortality. Furthermore, a meta-analysis was conducted on these outcomes, stratified by the use or non-use of OAC. Results: The identified studies were all non-randomized. Among 1 698 307 CABG patients, POAF incidence ranged from 7.9% to 37.6%. Of all POAF patients, 15.5% received OAC. Within 30 days, thromboembolic events occurred at rates of 1.0% (POAF: 0.3%; non-POAF: 0.8%) with 2.0% mortality (POAF: 1.0%; non-POAF: 0.5%). Bleeding rates were 1.1% for POAF patients and 2.7% for non-POAF patients. Over a median of 4.6 years, POAF patients had 1.73 thromboembolic events, 3.39 mortality, and 2.00 bleeding events per 100 person-years; non-POAF patients had 1.14, 2.19, and 1.60, respectively. No significant differences in thromboembolic risks [effect size −0.11 (−0.36 to 0.13)] and mortality [effect size −0.07 (−0.21 to 0.07)] were observed between OAC users and non-users. However, OAC use was associated with higher bleeding risk [effect size 0.32 (0.06–0.58)]. Conclusions: In multiple timeframes following CABG, the incidence of complications in patients who develop POAF is low. The use of OAC in patients with POAF after CABG is associated with increased bleeding risk.

Our goal was to evaluate the outcome of valve-sparing root replacement (VSRR) and to compare the outcomes to those of patients having composite valve–graft conduit aortic root replacement (CVG-ARR) in a cohort of patients with aortic root aneurysm ± valve insufficiency, without valvular stenosis. Although valve-sparing procedures are preferable in young patients, there is a lack of comparative data in comparable patients. The VSRR procedures were performed in 2005 patients, and 218 patients underwent a CVG-ARR procedure. Exclusion criteria included aortic dissection, endocarditis and valvular stenosis. Propensity score matching (3:1 ratio) was applied to compare VSRR (reimplantation 33% and remodelling 67%) and CVG-ARR. We matched 218 patients with CVG-ARR to 654 patients with VSRR (median age, 56.0; median follow-up was 4 years in both groups; interquartile range 1–5 years). Early mortality was 1.1% of those who had VSRR versus 2.3% in those who had CVG-ARR. Survival was 95.4% [95% confidence interval (CI) 94–97%] at 5 years in patients who had VSRR versus 85.4% (95% CI 82–92%) in those who had CVG-ARR; P = 0.002. Freedom from reintervention at 5 years was 96.8% (95% CI 95–98%) with VSRR and 95.4% (95% CI 91–99%) with CVG-ARR (P = 0.98). Additionally, there were more thromboembolic, endocarditis and bleeding events in the patients who had CVG-ARR (P = 0.02). This multicentre study shows excellent results after valve-sparing root replacement in patients with an ascending aortic aneurysm with or without valve insufficiency. Compared to composite valve-graft aortic root replacement, survival is better and valve-related events are fewer. Consequently, valve-sparing procedures should be considered whenever a durable repair is feasible. We advocate a valve-sparing strategy even in more complex cases when performed in experienced centres.

Ventricular tachyarrhythmias (VTs) are common in the pathologically remodelled heart. These arrhythmias can be lethal, necessitating acute treatment like electrical cardioversion to restore normal rhythm. Recently, it has been proposed that cardioversion may also be realized via optically controlled generation of bioelectricity by the arrhythmic heart itself through optogenetics and therefore without the need of traumatizing high-voltage shocks. However, crucial mechanistic and translational aspects of this strategy have remained largely unaddressed. Therefore, we investigated optogenetic termination of VTs (i) in the pathologically remodelled heart using an (ii) implantable multi-LED device for (iii) in vivo closed-chest, local illumination. In order to mimic a clinically relevant sequence of events, transverse aortic constriction (TAC) was applied to adult male Wistar rats before optogenetic modification. This modification took place 3 weeks later by intravenous delivery of adeno-associated virus vectors encoding red-activatable channelrhodopsin or Citrine for control experiments. At 8–10 weeks after TAC, VTs were induced ex vivo and in vivo, followed by programmed local illumination of the ventricular apex by a custom-made implanted multi-LED device. This resulted in effective and repetitive VT termination in the remodelled adult rat heart after optogenetic modification, leading to sustained restoration of sinus rhythm in the intact animal. Mechanistically, studies on the single cell and tissue level revealed collectively that, despite the cardiac remodelling, there were no significant differences in bioelectricity generation and subsequent transmembrane voltage responses between diseased and control animals, thereby providing insight into the observed robustness of optogenetic VT termination. Our results show that implant-based optical cardioversion of VTs is feasible in the pathologically remodelled heart in vivo after local optogenetic targeting because of preserved optical control over bioelectricity generation. These findings add novel mechanistic and translational insight into optical ventricular cardioversion.

(1) Background: The pathophysiologic basis of an acute type A aortic dissection (TAAD) is largely unknown. In an effort to evaluate vessel wall defects, we systematically studied aortic specimens in TAAD patients. (2) Methods: Ascending aortic wall specimens (n = 58, mean age 63 years) with TAAD were collected. Autopsy tissues (n = 17, mean age 63 years) served as controls. All sections were studied histopathologically. (3) Results: Pathomorphology in TAAD showed predominantly moderate elastic fiber fragmentation/loss, elastic fiber thinning, elastic fiber degeneration, mucoid extracellular matrix accumulation, smooth muscle cell nuclei loss, and overall medial degeneration. The control group showed significantly fewer signs of those histopathological features (none-mild, p = 0.00). It was concluded that the dissection plane consistently coincides with the vasa vasorum network, and that TAAD associates with a significantly thinner intimal layer p = 0.005). (4) Conclusions: On the basis of the systematic evaluation and the consistent presence of diffuse, pre-existing medial defects, we hypothesize that TAAD relates to a developmental defect of the ascending aorta and is caused by a triple-hit mechanism that involves (I) an intimal tear; and (II) a diseased media, which allows (III) propagation of the tear towards the plane of the vasa vasorum where the dissection further progresses.

OBJECTIVES: Quality assessment is an important element in providing surgical cancer care. The main objective of this study was to develop a new composite measure ‘textbook outcome’, to evaluate and improve quality of surgical care for patients undergoing a resection for non-small-cell lung cancer (NSCLC). METHODS: All patients undergoing an anatomical resection for NSCLC from 2012 to 2016 registered in the nationwide Dutch Lung Cancer Audit were included in an analysis to assess usefulness of a composite measure as a quality indicator. Based on expert opinion, textbook outcome was defined as having a complete resection (negative resection margins and sufficient lymph node dissection), plus no 30-day or in-hospital mortality, no reintervention in 30 days, no readmission to the intensive care unit, no prolonged hospital stay (<14 days), no hospital readmission after discharge and no major complications. The percentage of patients with a textbook outcome was calculated per hospital. Between-hospital variation in textbook outcome was analysed using case-mix adjustment models. RESULTS: In total, 5513 patients were included in this study. Textbook outcome was achieved in 26.4% of patients. Insufficient lymph node dissection had the most substantial effect on not realizing textbook outcome. If ‘sufficient lymph node dissection’ was not included as a criterion, textbook outcome would be 60.7%. Case-mix adjusted textbook outcome proportions per hospitals varied between 13.2% and 37.7%. CONCLUSIONS: In contrast to focusing on a single aspect, the composite measure textbook outcome provides insight into comprehensive performance in NSCLC surgery. It can be used to evaluate both individual hospitals and national performance and provides the opportunity to give benchmarked feedback to thoracic surgeons.

Gorlin–Chaudhry–Moss syndrome (GCMS) is a rare disorder consisting of craniofacial dysostosis, hypertrichosis, underdeveloped genitalia, and ocular and dental anomalies. Recently, GCMS has been reclassified together with Fontaine syndrome as Fontaine progeroid syndrome (FPS), after a common genetic basis was found. It was previously thought that GCMS/FPS was not associated with aortopathy, but in recent years 3 patients with aortic disease have been described. We describe the fourth case, who is the oldest patient with GCMS/FPS reported in the medical literature: a 45-year-old patient who presented with acute aortic dissection. We therefore recommend screening patients previously diagnosed with GCMS/FPS for aortic pathology to aid early detection and avoid patient presentation in an acute setting.

Barlow’s disease is the most severe form of degenerative mitral valve disease, commonly characterized by bileaflet prolapse. Abnormal mitral annular dynamics is typically present and results in functional prolapse of the mitral leaflets that may be addressed with annular stabilization alone. Between January 2001 and December 2015, 128 patients with Barlow’s disease and bileaflet prolapse underwent valve repair. This included anterior mitral valve leaflet (AMVL) repair in 70 patients, whereas 58 patients were identified as having functional prolapse and underwent no specific AMVL repair. During the course of the study, the proportion of patients undergoing specific AMVL repair decreased (77% in the first and 33% in the second 64 patients). Semirigid ring annuloplasty was performed in all cases. The median clinical and echocardiographic follow-up duration was 6.5 years [interquartile range (IQR) 2.9–10.5 years; 93.9% complete] and 4.7 years (IQR 2.2–10.2 years; 94.4% complete), respectively. Early mortality was 1.6%. Postoperative echocardiogram demonstrated no residual mitral regurgitation in all but 1 patient (AMVL repair group). There was no significant difference in the overall survival rate at 6 years after operation between both groups. At 6 years, the freedom from recurrent ≥Grade 2+ mitral regurgitation rate was 90.7% (IQR 82.9–98.5%) and 89.1% (IQR 75.8–100%) for patients with and patients with no AMVL repair, respectively (P = 0.43). Three patients required late mitral valve reintervention, all from the AMVL repair group. Annular stabilization can effectively resolve the functional prolapse of the AMVL. Careful discrimination between functional and true AMVL prolapse allows for a technically less challenging operation that provides excellent repair durability.