James R. Edgerton M.D.

Filardo, G., B. da Graca, D. M. Sass, J. Hamilton, B. D. Pollock and J. R. Edgerton (2019). “Preoperative B-Blockers as a Coronary Surgery Quality Metric: The Lack of Evidence of Efficacy.” Ann Thorac Surg Sep 9. [Epub ahead of print].

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BACKGROUND: Two quality measures used in public-reporting and value-based payment programs require beta-blockers be administered <24 hours before isolated coronary artery bypass graft surgery (CABG) to prevent atrial fibrillation (AF) and mortality. Questions have arisen about continued use of these measures. METHODS: We conducted a systematic search for randomized controlled trials (RCTs) examining the impact of pre-operative beta-blockers on AF or mortality following isolated CABG to determine what evidence of efficacy supports the measures. RESULTS: We identified 11 RCTs. All continued B-blockers post-operatively, making it unfeasible to separate the benefits of pre- vs post-operative administration. Meta-analysis was precluded by methodological variation in beta-blocker utilized, timing and dosage, and supplemental and comparison treatments. Of the 8 comparisons of beta-blockers/beta-blocker+digoxin versus placebo (n=826 patients), 6 showed significant reductions in AF/supraventricular arrhythmias. Of the 3 comparisons (n=444) of beta-blockers versus amiodarone, 2 found no significant difference in AF; the third showed significantly lower incidence with amiodarone. One RCT compared beta-blocker+amiodarone versus each of those drugs separately; the combination reduced AF significantly better than the beta-blocker alone, but not amiodarone alone. 7 RCTs reported short-term mortality, but this outcome was too rare and the sample sizes too small to provide any meaningful comparisons. CONCLUSIONS: Existing RCT evidence does not support the structure of quality measures that require B-blocker administration specifically within 24 hours prior to CABG to prevent post-operative AF or short-term mortality. Quality measures should be revised to align with the evidence, and further studies conducted to determine optimal timing and method of prophylaxis.

Edgerton, J. R. (2019). “Invited Commentary.” Ann Thorac Surg 108(2): 450-451.

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In this issue of The Annals of Thoracic Surgery, the Washington University group reports the results of surgical ablation of atrial fibrillation (AF) in 34 patients with tachycardia-induced cardiomyopathy (TIC) defined as left ventricular ejection fraction less than 41% and absent another etiology. Excluding 1 death, 33 patients were available for follow-up, and 27 of these patients had an evaluable echocardiogram at approximately 12 months. At 12 months, 94% of patients were free of atrial tachyarrhythmias with or without antiarrhythmic drugs. Mean left ventricular ejection fraction improved from 32% to 55%. Of 11 patients in New York Hearth Association Class III/IV, 8 patients improved to Class I/II. These changes reached statistical significance. It is important to note that LV function improved in all patients, and it improved to greater than 55% in 19 of 27 patients. The prognostic significance of the presence of fibrosis (inhibits recovery of function), as reported in the CAMERA-MRI (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction) study and reiterated in this report, should be stressed. In patient selection, it is important to differentiate between TIC and a dilated cardiomyopathy with secondary AF. The patient with TIC is likely to be helped by performing a Maze whereas the patient with a dilated cardiomyopathy secondary to AF is not. To differentiate, the authors perform a cardiac magnetic resonance imaging (MRI) to assess for myocardial viability and the degree of left ventricular fibrosis by late gadolinium enhancement. On multivariate analysis, only the absence of late gadolinium enhancement was found to predict left ventricular ejection fraction normalization. Any presence of fibrosis rules the patient out as a candidate for surgical ablation. If there is any other abnormality on cardiac MRI, or a high index of suspicion, endomyocardial biopsies are performed. Thus, preoperative MRI will help the clinician in deciding whether to operate for TIC. Although the numbers of patients are small, documenting these findings is significant. It would be easy for a reader to dismiss this article as a small retrospective series of little significance. This would be a grave error. Yes, the numbers are small, but few groups have adequate volume to accumulate this many patients, and most lack the investigatory rigor to document the postoperative course in such detail. In addition, few groups have preoperative MRI for these patients. As the authors point out, current guideline statements on the treatment of TIC, “include only non-surgical rhythm control strategies.” This is the true significance of this article. Considering the findings documented here, a Class IIa, Level of Evidence B-NR is justified for surgical ablation of AF in patients with TIC who are undergoing cardiac surgery for another reason or who have failed antiarrhythmic drugs and catheter ablation. Future guideline committees need to consider this work when revising current guidelines. (Full text of this commentary.)

Curcio, N., L. Philpot, M. Bennett, J. Felius, M. B. Powers, J. Edgerton and A. M. Warren (2019). “Anxiety, depression, and healthcare utilization 1 year after cardiac surgery.” Am J Surg 218(2): 335-341.

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BACKGROUND: While it is known that depression and anxiety influence cardiac surgery recovery, the mechanisms of such remain unclear. We examined the influence of anxiety and/or depression on health care utilization and quality of life (QOL) in the 12 months following cardiac surgery. METHODS: (N=306) patients at two North Texas hospitals were assessed pre-operatively, at 30 days, and one year post-operatively using the Hospital Anxiety and Depression Scale and Kansas City Cardiomyopathy Quality of Life measures. Patient healthcare utilization metrics included length of stay, outpatient visits, hospital stays, emergency department (ED) visits, and home healthcare. RESULTS: At 12 months post-surgery, anxious patients sustained more outpatient visits (p = 0.0129) than those without anxiety. Depressed patients differed significantly from non-depressed patients with significantly lower QOL (p<0.01), as well as more readmissions, ED visits, home healthcare use, and a longer length of stay (all p<0.05). CONCLUSIONS: Depressed patients utilized more expensive healthcare services and had lower QOL at 12 months follow up compared to non-depressed patients. Targeting depressed patients for intervention may foster a faster recovery and reduce excessive healthcare burden.

Edgerton, J. R. (2019). “Surgical Ablation of Atrial Fibrillation in Patients with Tachycardia-Induced Cardiomyopathy (Commentary).” Ann Thorac Surg. Apr 2. [Epub ahead of print].

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In this issue of The Annals of Thoracic Surgery, the Washington University group reports the results of surgical ablation of atrial fibrillation in 34 patients with tachycardia induced cardiomyopathy (TIC) defined as left ventricular ejection fraction (LVEF) <41% and absent another etiology. Excluding one death, 33 patients were available for follow-up and 27 of these had an evaluable echo at about 12 months. At 12 months 94% of patients were free of atrial tachyarrhythmias with/without antiarrhythmic drugs (AADs). Mean LVEF improved from 32% to 55%. Of 11 pts in NYHA Class III/IV, 8 improved to Class I/II. These changes reached statistical significance. It is important to note that LV function improved in all patients and it improved to >55% in 19/27 patients. The prognostic significance of the presence of fibrosis (inhibits recovery of function), as reported in the CAMERA-MRI study and reiterated in this report, should be stressed. In patient selection, it is important to differentiate between TIC and a dilated cardiomyopathy with secondary atrial fibrillation (AF). The former will not be helped by performing a Maze and the latter will. To differentiate, the authors perform a cardiac MRI to assess for myocardial viability and the degree of left ventricular fibrosis by late gadolinium enhancement (LGE). On multivariate analysis, only the absence of LGE was found to predict LVEF normalization. Any presence of fibrosis rules the patient out as a candidate for surgical ablation. If there is any other abnormality on cardiac MRI, or a high index of suspicion, endomyocardial biopsies are performed. Thus, a pre-op MRI will help the clinician in deciding whether to operate for TIC. Although the numbers of patients are small, documenting these findings is very significant. It would be easy for a reader to dismiss this paper as a small retrospective series of little significance. This would be a grave error. Yes, the numbers are small, but few groups have adequate volume to accumulate this many patients and most lack the investigatory rigor to document the post-op course in such detail. Additionally, very few groups have pre-op MRIs on these patients. As the authors point out, current guideline statements on the treatment of TIC, “include only non-surgical rhythm control strategies.” This is the true significance of this paper. Based on the findings documented here, a Class IIa, LOE B-NR is justified for surgical ablation of AF in patients with TIC who are undergoing cardiac surgery for another reason or have failed AADs and catheter ablation. Future guideline committees need to consider this work when revising current guidelines. (Excerpt from text, p. 1 of article-in-press.)

Yarlagadda, B., T. Deneke, M. Turagam, T. Dar, S. Paleti, V. Parikh, L. DiBiase, P. Halfbass, P. Santangeli, S. Mahapatra, J. Cheng, A. Russo, J. Edgerton, M. Mansour, J. Ruskin, S. Dukkipati, D. Wilber, V. Reddy, D. Packer, A. Natale and D. Lakkireddy (2019). “Temporal relationships between esophageal injury type and progression in patients undergoing atrial fibrillation catheter ablation.” Heart Rhythm 16(2): 204-212.

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BACKGROUND: Currently, little is known about the onset, natural progression, and management of esophageal injuries after atrial fibrillation (AF) ablation. OBJECTIVES: We sought to provide a systematic review on esophageal injury after AF ablation and identify temporal relationships between various types of esophageal lesions, their progression, and clinical outcomes. METHODS: A comprehensive search of PubMed and Web of Science was conducted until September 21, 2017. All AF ablation patients who underwent upper gastrointestinal endoscopy within 1 week of the procedure were included. Patients with esophageal lesions were classified into 3 types by using our novel Kansas City classification: type 1: erythema; type 2a: superficial ulcers; type 2b: deep ulcers; type 3a: perforation without communication with the atria; and type 3b: perforation with atrioesophageal fistula. RESULTS: Thirty studies met our inclusion criteria. Of the 4473 patients, 3921 underwent upper gastrointestinal evaluation. The overall incidence of esophageal injuries was 15% (570). There were 206 type 1 lesions (36%), 222 type 2a lesions (39%), and 142 type 2b lesions (25%). Six of 142 type 2b lesions (4.2%) progressed further to type 3, of which, 5 were type 3a and 1 was type 3b. All type 1 and type 2a and most type 2b lesions resolved with conservative management. One type 3a and 1 type 3b lesions were fatal. CONCLUSION: Based on our classification, all type 1 and most type 2 lesions resolved with conservative management. A small percentage (4.2% [6 of 142]) of type 2b lesions progressed to perforation and/or fistula formation, and these patients need to be followed closely.