Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting.

BACKGROUND: Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting. METHODS: The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed. RESULTS: Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%. CONCLUSIONS: Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.

Effectiveness of carotid council in the treatment of carotid artery disease: Early-term outcomes of the multidisciplinary approach.

OBJECTIVES: Carotid arterial stenosis could be treated by surgical or percutaneous stenting. In this study, we aimed to investigate the effectiveness of the carotid council on the outcomes of patients with carotid artery disease. METHODS: In this retrospective study, we analyzed the patients who had undergone carotid arterial revascularization from April 2014 to July 2022 in our hospital. All patients were evaluated in carotid council, which is constituted by neurologist, cardiologist and cardiovascular surgeon. Patient-specific treatment procedure was decided in the council. Demographics and early-term follow-up results of the patients were evaluated. RESULTS: Totally 95 procedures in 85 patients were analyzed during the study period. 27.4 % of the patients had significant contralateral carotid arterial stenosis. In 88 (92.6%) procedures, patients were treated by carotid endarterectomy, and 5 procedures were performed under regional anesthesia. Shunt usage was 6.0% during the surgery, and arteriotomy was repaired with primary sutures in 87.3%. Stent implantation was performed in 7 patients. There were 5 neurological adverse events after the carotid endarterectomy and 2 neurological events were after carotid arterial stenting. In each treatment group, one patient died after the procedure. In the follow-up period, restenosis was observed just in a patient who was treated with carotid endarterectomy and primary repair. CONCLUSION: Although carotid artery disease could be treated in accordance with the guidelines, treatment procedures should be patient-specific. Carotid councils might be helpful in giving patient-specific decisions, thereby providing the patient-based treatment procedure and improving the outcomes of the patients with carotid artery disease.

Early-term outcomes of the pulmonary embolism response team.

Objective: Treatment of pulmonary embolism varies according to the different clinical presentations. Pulmonary embolism response teams (PERT) might improve outcomes of pulmonary embolism with faster evaluation and increased usage of advanced treatment methods. In this study, the effects of PERT for the treatment of pulmonary embolism were investigated. Methods: In this retrospectively analyzed study, patients diagnosed with PE in our hospital between March 1st, 2019 and February 28th, 2022 were included. Patients' medical records were evaluated according to the treatment procedures and early outcomes. Results: Ninety-eight patients with pulmonary embolism were evaluated by the PERT during the study period. The mean age was 62.8+16.4 years and 59% were male. All patients with intermediate-low risk were treated medically. About 59.2% of the patients were hospitalized. The rate of catheter-directed thrombolysis was 37.8% (n=37). Systemic thrombolytic therapy was performed on two patients. One patient with a metastatic brain tumor was treated with low-molecular-weight heparin. Catheter-directed procedures were performed in 37 patients. The time from diagnosis to reperfusion was 243 minutes. There was one pericardial effusion and one mortality. In the 30-day follow- up there was no re-hospitalization and mortality. Conclusion: PERT might help early triage and treatment of patients with pulmonary embolism. Experienced specialists in this team might contribute to clinical recovery by performing advanced treatment methods and decreasing the risk of chronic thromboembolic pulmonary hypertension in the long term.

Intra-aortic balloon pump experience: a single center study comparing with and without sheath insertion.

Introduction: The mechanical circulation support used in treatment of low cardiac output at most is the intra-aortic balloon pump (IABP). Its usage fields are the complications occurring due to ischemic heart disease, disrupted left ventricle function, and the low cardiac output syndrome occurring during coronary artery by-pass surgery. Methods: During 28 years from 1985 to 2013, IABP support has been implemented to 3135 patients in our cardiac surgery operating theater and intensive care unit. The mean age of the patients was 61.4 ± 13.2 years (16-82). 2506 patients (80%) were the ones whom the cardiac surgery has been implemented. IABP support has been provided for 629 (20%) patients for medical treatment. We utilized IABP most frequently in coronary artery patients (70%). The first choice for placing the balloon catheter is the femoral artery in 3093 cases (98.7%). Results: The most frequently observed balloon complication was the lower extremity ischemia in 383 cases (12.2%).The leg ischemia was statistically significantly more frequent in patients with sheath (P=0.004). The extremity ischemia has developed in 4 of 12 patients with balloon placed from upper extremity. The local bleeding and balloon rupture were more frequent in patients whom the balloon has been placed without sheath. The mortality due to IABP has occurred in only 5 patients. Conclusion: Despite increase in IABP usage frequency rapidly, the complications due to catheter are still seen. We believe that the leg ischemia that is the most frequently seen complication can be prevented via IABP use without sheath.

The role of genetics in coronary artery bypass surgery patients under 30 years of age.

AIM: We undertook genetic assessment of coronary artery disease (CAD) in 20 patients aged 30 years or less undergoing coronary artery bypass grafting (CABG) surgery, to investigate the prognostic value of pre-defined genes. METHODS: Twenty patients, who underwent CABG surgery between December 2001 and May 2013, were retrospectively analysed to find out the role their genetic make-up played in their disease. We used three genetic diagnostic tests, the plasminogen activator inhibitor (PAI) -1 gene, the A1/A2 polymorphism of glycoprotein IIIa (GpIIIa) gene, and common polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene. RESULTS: The mean age of patients was 26.35 ± 3.51 (19-30) years, and 90% were male (n = 18). One patient had diabetes, three had hypertension, 11 (55%) had dyslipidaemia and 16 (80%) were smokers. Eight of the patients (40%) had left ventricular ejection fraction (LVEF) < 50%, and functional capacity was poor in only two (10%) patients (NYHA III-IV). Follow up was completed in all patients (100%). We found five homozygous and 11 heterozygous mutations in the MTHFR gene, which predisposes individuals to coronary artery disease or deep-vein thrombosis. Eight patients were found to have a GpIIIa gene polymorphism, which is associated with increased risk of myocardial infarction (MI). Fifteen patients had a polymorphism in the promoter region of the PAI-1 gene, which is a major inhibitor of the fibrinolytic system. CONCLUSION: MTHFR C677T polymorphism, and GpIIIa and PAI-1 genes are risk factors for CAD. In young patients, genetic studies promise to revolutionise early diagnosis, treatment and prevention of CAD and MI.

Surgery for Aortic Root Abscess: A 15-Year Experience.

Aortic root abscess is the most severe sequela of infective endocarditis, and its surgical management is a complicated procedure because of the high risk of morbidity and death. Twenty-seven patients were included in this 15-year retrospective study: 21 (77.8%) with native- and 6 (22.2%) with prosthetic-valve endocarditis. The surgical reconstruction of the aortic root consisted of aortic valve replacement in 19 patients (70.4%) with (11) or without (8) a pericardial patch, or total aortic root replacement in 7 patients (25.9%); 5 of the 27 (18.5%) underwent the modified Bentall procedure with the flanged conduit. Only one patient (3.7%) underwent subaortic pericardial patch reconstruction without valve replacement. A total of 7 patients (25.9%) underwent reoperation: 6 with prior valve surgery, and 1 with prior isolated sinus of Valsalva repair. The mean follow-up period was 6.8 ± 3.7 years. There were 6 (22.2%) in-hospital deaths, 3 (11.1%) of which were perioperative, among patients who underwent emergent surgery. Five patients (23.8%) died during follow-up, and the overall survival rates at 1, 5, and 10 years were 70.3% ± 5.8%, 62.9% ± 6.4%, and 59.2% ± 7.2%, respectively. Two of 21 patients (9.5%) underwent reoperation because of paravalvular leakage and early recurrence of infection during follow-up. After complete resection of the perianular abscess, replacement of the aortic root can be implemented for reconstruction of the aortic root, with or without left ventricular outflow tract injuries. Replacing the aortic root with a flanged composite graft might provide the best anatomic fit.

The relationship between elevated magnesium levels and coronary artery ectasia.

BACKGROUND: Coronary artery ectasia (CAE) without specific symptoms is the localised or diffuse swelling of the epicardial coronary arteries. Magnessium (Mg) plays an important role in cardiac excitability, vascular tonus, contractibility, reactivity and vasodilatation. In our research, we aimed to study the vasodilatory effect of Mg in the aetiopathogenesis of ectasia. METHODS: Patients identified during routine coronary angiograms in our clinic between January 2010 and 2013 were included in the study. Sixty-two patients with isolated CAE, 57 with normal coronary angiograms (NCA), 73 with severe coronary artery disease (CAD), and 95 with stenosis of at least one coronary artery and CAE (CAD + CAE) were included in the study. Serum Mg levels were measured in mg/dl after 12 hours of fasting. RESULTS: There were no statistically significant differences between the groups in terms of age, hypertension, smoking, hyperlipidaemia, diabetes mellitus, family history of coronary artery disease and medications used. Serum glucose, thyroid stimulating hormone (TSH), urea, total cholesterol, triglyceride, low-density lipoprotein (LDL) cholesterol, sodium and potassium levels were similar in all groups. Serum Mg levels were 1.90 ± 0.19 mg/dl in patients with isolated CAE, 1.75 ± 0.19 mg/dl in those with CAD, 1.83 ± 0.20 mg/dl in those with CAD + CAE, and 1.80 ± 0.16 mg/dl in the NCA group. These results show that Mg levels were higher in ectasia patients with or without CAD. CONCLUSIONS: The histopathological characteristics of patients with CAE were similar to those with CAD. The specific mechanism of abnormal luminal dilatation seen in CAE however remains to be elucidated. Mg is a divalent cation with powerful vasodilatory effects. In our study, serum Mg levels were found to be statistically higher in ectasia patients with or without CAD.

Effect of ejection fraction on left ventricular remodeling in aortic insufficiency.

BACKGROUND: Due to ventricular compensatory mechanisms, patients with severe aortic regurgitation are generally asymptomatic. Severe left ventricular dysfunction develops annually in 20% of non-operated cases, and the prognosis in those cases is poor. Although surgery is recommend in patients with left ventricular dysfunction, surgeons are wary. We investigated the changes in ventricular and effort capacity after surgery in patients with normal and abnormal left ventricular function. METHODS: We retrospectively examined the data of patients with aortic regurgitation who underwent aortic valve replacement in our clinic between 1993 and 2013. Those who had previous cardiac surgery, chemotherapy, radiotherapy, renal dysfunction, diabetes mellitus, or preoperative arrhythmias were excluded. The 113 patients were divided into 2 groups according to ejection fraction. RESULTS: In patients with ejection fraction <50%, interventricular septal thickness, posterior wall thickness, and left ventricular mass were significantly greater than in the ejection fraction ≥50% group (p < 0.01). No significant differences in intensive care unit stay and hospitalization were determined. No mortality was observed. Ejection fraction and effort capacity increased significantly after aortic valve replacement in both groups, and interventricular septal thickness, posterior wall thickness, and left ventricular mass decreased in both groups. CONCLUSIONS: Significant left ventricular functional improvements can be achieved after aortic valve replacement in patients with severe aortic regurgitation who develop left ventricular dysfunction. Despite the reported higher surgical mortality in this patient group, surgical treatment offers a survival benefit. We recommend surgical treatment in patients with severe aortic regurgitation who develop left ventricular dysfunction.

Thermoreactive nitinol clips: Propensity score comparison with Robicsek technique.

OBJECTIVE: To compare the use of thermoreactive nitinol clips with the classic Robicsek technique for treatment of sternal dehiscence after cardiac surgery. METHODS: Eighty-two (2.3%) of 3564 open heart surgery patients underwent reoperation for sternal dehiscence between October 2011 and 2012. Prospectively collected data from 26 (31%) consecutive patients who underwent reoperation using thermoreactive nitinol clips were compared with those of a retrospective cohort of 42 (51.2%) who were treated with the classic Robicsek technique. To overcome baseline and operative variations, we constructed a propensity model using logistic regression. RESULTS: Overall mortality occurred in 3 (5%) patients and a second revision was performed in 2 (7.7%) in the nitinol clip group and 2 (6.3%) in the control group (p > 0.05). Postoperative results were similar except for the mean time of operation which was significantly shorter in the nitinol clip group, and patients in this group required substernal dissection slightly less frequently than those in the control group. CONCLUSIONS: Thermoreactive nitinol clips allow the surgeon to perform a rapid and less challenging technique for sternal reoperations, without additional complications. Using this technique in an identical group with a finite sample size, we accomplished similar early results to those of the classic Robicsek technique.

Effect of standard versus patient-targeted in-patient education on patients' anxiety about self-care after discharge from cardiovascular surgery clinics.

We compared standard and patient-targeted in-patient education in terms of their effect on patients' anxiety. One hundred and ninety-eight patients who were hospitalised for coronary artery bypass surgery were given standard education (group 1) or individualised education (group 2) on the management of their healthcare after discharge. Patients in group 2 were assessed on the patient learning needs scale and were given education according to their individual needs. The level of anxiety was measured by the state-trait anxiety inventory. Anxiety scores were significantly lower in group 2 than group 1 after education (p < 0.001). While state anxiety did not change after education in group 1 (p = 0272), it decreased significantly in group 2 (p < 0.001). For cardiovascular surgery patients, patient-targeted in-patient education was more effective than standard education in decreasing anxiety levels, therefore the content of the education should be individualised according to the patient's particular needs.

Simultaneous coronary artery bypass grafting and carotid endarterectomy can be performed with low mortality rates.

INTRODUCTION: There is controversy over the best approach for patients with concomitant carotid and coronary artery disease. In this study, we report on our experience with simultaneous carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) surgery in our clinic in the light of data in the literature. METHODS: Between January 1996 and January 2009, a total of 110 patients (86 males, 24 females; mean age 65.11 ± 7.81 years; range 44-85 years), who were admitted to the cardiovascular surgery clinic at our hospital, were retrospectively analysed. All patients underwent simultaneous CEA and CABG. Demographic characteristics of the patients and a history of previous myocardial infarction (MI), hypertension, diabetes mellitus, hyperlipidaemia, peripheral arterial disease and smoking were recorded. RESULTS: One patient (0.9%) with major stroke died due to ventricular fibrillation. Peri-operative neurological complications were observed in seven patients (6%). Complications were persistent in two patients. Four patients (3%) had postoperative major stroke, whereas three patients (2%) had transient hemiparesis. No peri-operative myocardial infarction was observed. CONCLUSION: Simultaneous CEA and CABG can be performed with low rates of mortality and morbidity.

A case report on concomitant coronary artery bypass operation and renal transplantation.

Renal transplantation is successfully implemented in patients undergoing coronary bypass surgery. We performed concomitant coronary bypass surgery and renal transplantation in a patient found to have a left main coronary artery lesion after coronary angiography, which was performed in our clinic during preoperative evaluation of renal transplantation. We suggest the application of coronary-artery bypass grafting (CABG) or stent implantation 2 months after renal transplantation in asymptomatic patients with coronary artery disease. But, if severe coronary artery disease is detected in symptomatic patients, we suggest the concurrent application CABG and renal transplantation.

How to approach aortic valve disease in the elderly: a 25-year retrospective study.

OBJECTIVE: In the last decade, the number of elderly patients suffering from aortic valve disease has significantly increased. This study aimed to identify possible factors that could affect surgical and long-term outcomes in the light of a literature review regarding the management of aortic valve disease in the elderly. METHODS: Between January 1990 and December 2012, a total of 114 patients (64 males, 50 females; mean age 76.6 ± 3.6 years; range 70-87 years) with aortic valve replacement (AVR) alone, or combined with coronary artery bypass grafting (CABG) or mitral surgery in our hospital, were retrospectively analysed. RESULTS: In-hospital mortality was seen in 19 patients. The major causes of in-hospital mortality were low-cardiac output syndrome in eight patients (42.1%), respiratory insufficiency or infection in six (31.5%), multi-organ failure in four (21%), and stroke in one patient (5.2%). The main postoperative complications included arrhythmia in 26 patients (22.8%), renal failure in 11 (9.6%), respiratory infection in nine (7.9%), and stroke in three patients (2.6%). The mean length of intensive care unit and hospital stays were 6.4 ± 4.3 and 18 ± 12.8 days, respectively. During follow up, late mortality was seen in 28 patients (29.4%). Possible risk factors for long-term mortality were type of prosthesis, EuroSCORE ≥ 15, postoperative pacemaker implantation, respiratory infection, and haemodialysis. Among 65 long-term survivors, their activity level was good in 53 (81.5%) and poor in two. CONCLUSIONS: Our study results demonstrated that an individually tailored approach including scheduled surgery increases short- and long-term outcomes of AVR in patients aged ≥ 70 years. In addition, shorter cardiopulmonary bypass time may be more beneficial in this high-risk patient population.

[Pulsatile thoracal mass: a rare case of large left ventricular pseudoaneurysm]. / Pulsatil torakal kitle: Nadir görülen bir sol ventrikül psödoanevrizmasi.

Left ventricular pseudoaneurysms (LVPA) develop after myocardial infarction, trauma, infection and either valvular or ventricular surgery. We present here an unusual case of LVPA appearing like a pulsatile mass, which was easily seen from the chest wall. A 55-year-old woman was admitted to our clinic with a pulsatile mass and trill, easily seen on the anterior chest wall 6 weeks after coronary artery bypass graft (CABG) surgery and endoaneurysmorrhaphy operation. Contrast-enhanced tomography showed a soft tissue mass detected close to the subcutaneous fat tissue of the anterior chest wall located in the left hemithorax. Left ventriculography was consistent with a large pseudoaneurysm in the apical wall of the left ventricle. Cardiopulmonary bypass was established with femoral cannulation, and endoaneurysmorrhaphy and CABG x 1 operations were carried out. The patient was discharged home on postoperative day 15. Follow-up echocardiography showed successful repair and shrinkage of the aneurysm, and the patient remained asymptomatic without any clinical event during our follow-up. LVPA usually present with heart failure. However, some patients may have recurrent tachyarrhythmia, progressive dyspnea, nonspecific chest pain, or thromboembolism, or remain clinically silent. When a patient is seen after cardiac surgery with a pulsatile mass detected on the chest wall, LVPA should be considered in the differential diagnosis.

Reversed-J inferior versus full median sternotomy: which is better for awake coronary bypass surgery.

BACKGROUND: The aim of this study was to ascertain whether the approach with a less invasive reversed-J inferior sternotomy could improve intraoperative patient compliance and postoperative recovery than the standard median sternotomy. METHODS: Seventeen patients underwent elective single coronary artery bypass graft operation under high thoracic epidural anesthesia without endotracheal intubation. The reversed-J sternotomy was performed in 10 patients (Group A) and full sternotomy in 7 patients (Group B). The technical and surgical difficulties, pulmonary functions (by spirometric tests) and hospital stay were assessed. RESULTS: Through the reversed-J sternotomy coronary revascularization was accomplished without any additional technical difficulties and with a good exposure of both the left anterior descending artery and the left internal thoracic artery. No conversion to standard sternotomy and no intubation were observed. Additional doses of local anesthetic at jugular notch was not required in Group A. Pleura was opened more in Group B (57% vs. 20%; p = 0.14). Oxygen saturation was better in Group A during the surgical procedure (98.8 +/- 0.7% vs. 97.1 +/- 2.1%; p = 0.033), however, intraoperative PaCO2 was similar in both the groups. The patients in Group A were discharged from the hospital earlier (3.2 +/- 1.5 vs. 7.3 +/- 3.5 days; p = 0.004). CONCLUSIONS: Less invasive approach to coronary artery bypass graft operations is possible through combination of the high thoracic epidural anesthesia and a reversed-J sternotomy. This technique is less traumatic for patient and provides practical better oxygenation and shorter hospital stay.

Operative mortality after valvular reoperations.

BACKGROUND: To determine the incidence and risk factors of mortality and morbidity in valvular reoperations. METHODS: Between January 1993 and December 2003, 309 valvular reoperations were performed. The reasons for reoperations were reconstructive surgery in first operation (110 patients, 35.5%), prosthetic valve endocarditis (12 patients, 3.8%), periprosthetic leakage (32 patients, 10.3%), new valve degenerations (12 patients, 3.8%), bioprosthetic dysfunction (92 patients, 29.7%), acute thrombotic stuck valve (30 patients, 9.7%), and pannus formation (21 patients, 6.7%). Mitral valves were replaced in 235 patients, aortic valves were replaced in 32 patients, 24 patients had aortic and mitral valve replacements, 2 patients had mitral and tricuspid valve replacements, and reconstruction of periprosthetic leakage was held in 16 patients. 264 patients had elective surgery, whereas 45 were operated on emergency basis. RESULTS: Hospital mortality was 14.23%. Mortality rate was found to be 10.6% for elective cases and 35.5% for emergency cases. Permanent pacemaker was required in 12 patients, 3 patients had cerebrovascular events, and mediastinitis was observed in 1 patient. Multivariate analysis demonstrated that age > 60 (P = .006; OR 7.3, 95% CI 1.7-30.1), emergency surgery (P = .001; OR 8.1, 95% CI 2.4-27.7), preoperative cerebrovascular accident (P = .003; OR 11.8, 95% CI 2.458.7), and concomitant ascending aorta replacement (P < .001; OR 27.4, 95% CI 6-127) were independent risk factors. CONCLUSION: Valvular reoperations can be carried out with acceptable morbidity and mortality in elective operations but mortality rates are still very high in emergent cases.

Mitral clefts and interatrial septum defects: 15-year results.

Between 1985 and 2002, 60 patients (58% female) with a mean age of 20.3 +/- 12.1 years (range, 2-55 years) were treated for anterior mitral leaflet cleft. There was a primum atrial septal defect in 52 patients (87%) and a secundum type in 8 (13%). Concomitant cardiac defects were patent foramen ovale in 6 patients, cleft tricuspid valve in 3, ventricular septal defect in 2, cor triatriatum in 1, and persistent left superior vena cava in 1. Mean grade (1-4) of mitral insufficiency was 2.28 +/- 0.74. Atrial septal defects were closed with a pericardial patch in 45 patients, with a prosthetic patch in 11, and primarily in 4. Mitral leaflet clefts were repaired using interrupted sutures. There was no early or late mortality. Two patients (3%) needed a permanent pacemaker. Postoperatively, severe (> or =grade 3) mitral insufficiency developed in 2 patients; valve replacement was performed in one, cleft recurrence and leakage from the patch were treated in the other. Freedom from reoperation was 92.2% +/- 5.6% at 15 years. Surgical intervention can be performed for congenital anterior mitral leaflet cleft and interatrial septal defect with good results in both pediatric and adult age groups.