[Unexplained right-sided heart failure following open heart surgery: mind the pericardium]. / Onverklaarde rechtsdecompensatie na een openhartoperatie: denk aan het hartzakje.

Three men, aged 67 years, 80 years and 53 years, respectively, developed signs and symptoms of progressive right-sided heart failure following open heart surgery. They were diagnosed with constrictive pericarditis based on echocardiography, cardiac magnetic resonance and cardiac catheterisation. Following pericardiectomy, two of the patients fully recovered, while one, the 80-year-old man, died during convalescence. When signs and symptoms of progressive right-sided heart failure develop after open heart surgery, a diagnosis of constrictive pericarditis should be considered. Constrictive pericarditis after open heart surgery may be caused by inflammation of the pericardium; an old, fibrotic haemopericardium, which may be diffuse or loculated; pericardial adhesions; or a combination of these entities. Diagnosing constrictive pericarditis is difficult and may take a long time. However, it is important to recognise this disorder early before it has progressed to an advanced stage. Pericardiectomy is the only effective therapy. When performed too late, survival is significantly reduced.

Selective antegrade cardioplegic perfusion complicated by left main stem dissection.

Selective antegrade coronary artery perfusion is a commonly used procedure to obtain myocardial preservation during cardiac surgery. This report describes a patient operated for severe aortic valve stenosis and insufficiency, mitral valve and tricuspid insufficiency. Cardioplegia was administered by selective antegrade coronary artery blood perfusion. Antegrade blood cardioplegia was complicated by dissection of the left coronary main stem. The dissection induced a myocardial infaction and the patient finally died due to heart failure.

[Favourable long-term results using the unmodified maze procedure in patients with medication-refractory or nearly refractory atrial fibrillation; experience from 1993/'04]. / Gunstige langetermijnresultaten van de originele 'maze'-operatie voor patiënten met medicamenteus moeilijk of niet te behandelen boezemfibrilleren; ervaringen van 1993/'04.

OBJECTIVE: To assess the short- and long-term results following the unmodified maze procedure in patients with medication-refractory or nearly refractory atrial fibrillation. DESIGN: Retrospective. METHODS: We retrospectively collected and analysed preoperatively in-hospital and follow-up data from patients with atrial fibrillation with or without structural heart disease who underwent the unmodified maze procedure in the St. Antonius hospital, Nieuwegein, the Netherlands. RESULTS: In the 11-year period 1993-2004, 203 patients underwent the procedure: 139 underwent the maze procedure only and 64 underwent combined surgery for concomitant atrial fibrillation and structural heart disease. There were no in-hospital deaths. During a mean follow-up period of 4 years, 2 ofthe 203 patients died from cardiac causes; both had undergone combined surgery. With a mean follow-up period of 4 years, the rate of atrial fibrillation-free survival was 90% in patients with lone atrial fibrillation and 70% in patients with concomitant atrial fibrillation. For patients who had no recurrent atrial fibrillation 1 year after surgery, the risk of recurrence after 4 years was small (odds ratio: 9.56). Risk factors for recurrence included a large left atrium and a long duration of atrial fibrillation (more than 5 years). CONCLUSION: The maze procedure was a successful surgical intervention for patients with atrial fibrillation, both in the short and long term. This procedure can be considered when medication and electrical cardioversion are ineffective.

Increased dispersion of "refractoriness" in patients with idiopathic paroxysmal atrial fibrillation.

The average interval between local depolarizations during atrial fibrillation, the so-called atrial fibrillation interval, was used as an index for local "refractoriness." This was based on the assumption that during fibrillation, cells are reexcited as soon as their refractory period ends. A very good correlation was found between refractory periods determined with the extrastimulus technique at a basic cycle length of 400 ms and atrial fibrillation intervals measured at the same epicardial sites of the right atrium. This new technique was used to assess dispersion in atrial fibrillation intervals in 10 patients with idiopathic paroxysmal atrial fibrillation and in a control group of 6 patients who were undergoing cardiac surgery. After a routine median sternotomy a multiterminal grid with up to 40 electrodes was placed over the right atrium, and atrial fibrillation was induced by premature stimulation. The average fibrillation interval in the test group, recorded at 247 sites, was 152 +/- 3 ms and that in the control group, recorded at 118 sites, was 176 +/- 8.1 ms (p less than 0.05). Dispersion in atrial fibrillation intervals, defined as the variance of the fibrillation intervals at all the recording sites, was three times larger in the group with paroxysmal atrial fibrillation than in the control group. This study suggests that both a shorter refractory period and a larger dispersion in refractoriness are responsible for the recurrence of atrial fibrillation.

Slow potentials in the atrioventricular junctional area of patients operated on for atrioventricular node tachycardias and in isolated porcine hearts.

OBJECTIVES: The purpose of this study was to 1) investigate extracellular electrograms in the atrioventricular (AV) junctional area of patients with AV node reentrant tachycardia, 2) compare them with recordings made in isolated porcine hearts, and 3) study their origin. BACKGROUND: Electrograms with slow components have been used to target the delivery of radiofrequency energy for the cure of AV node reentrant tachycardia. The origin of these electrograms is unknown. METHODS: In 12 human and 19 porcine hearts, extracellular recordings were made simultaneously from 64 sites. In five other porcine hearts, intracellular recordings were made at sites at which extracellular electrograms revealed slow potentials. Histologic investigations were carried out in four of these hearts. RESULTS: Electrograms with slow components were recorded in five human and eight porcine hearts. These signals were found at sites up to 12 mm from the His bundle. Characteristics of the electrograms did not differ significantly among human and porcine hearts. Electrophysiologic evidence for multiple pathways was present in four hearts. Superficial impalements with microelectrodes at sites with slow potentials showed action potentials with AV node characteristics. In the majority of these recordings, the upstroke coincided with the downstroke of slow potentials. Histologic investigations of the sites of impalement revealed transitional cells directly underneath the endocardium. CONCLUSIONS: Slow potentials were recorded in both human and porcine hearts in similar measure. They arise from transitional cells and have action potentials similar to N cells.

Macroreentry in the infarcted human heart: the mechanism of ventricular tachycardias with a "focal" activation pattern.

Endocardial mapping of electrical activity was carried out in 150 patients to guide antiarrhythmic surgery for drug-resistant ventricular tachycardia in the chronic phase of myocardial infarction. In 20 of these patients, the activation pattern of 27 distinct tachycardias was focal and diastolic potentials were recorded at three or more sites. In 26 tachycardias, the sequence of diastolic potentials progressed from the area of latest activation of one cycle toward the "origin" of the next cycle. In two patients, the heart was stimulated during tachycardia, resulting in entrainment of the tachycardia in both. Late potentials were recorded during entrainment at sites where diastolic potentials occurred during tachycardia. In 11 of the 20 patients, endocardial mapping was performed during sinus rhythm. In four of these, late potentials were observed during sinus rhythm at sites where diastolic potentials were recorded during tachycardia. In two patients without late potentials during sinus rhythm, late potentials were observed during stimulation and induced ectopic beats. The results support the concept that the mechanism of several of these tachycardias is based on reentry in a macrocircuit comprising a tract of surviving tissue traversing the infarct and the remaining healthy tissue. They also indicate that the absence of late potentials during sinus rhythm does not guarantee the absence of arrhythmogenic pathways.

The maze operation as a surgical treatment of atrial fibrillation.

In this study we reviewed the history of the surgical treatment of atrial fibrillation (AF). Of the various types, the maze operation has become nowadays the most successful surgical treatment of AF with or without concomitant cardiac surgery. We report on our 10-year experience with conventional maze III surgery: 203 patients were operated on without in-hospital mortality and acceptable morbidity. Success defined as the freedom of AF and other supraventricular arrhythmias was 80.1% for the patients with lone AF and 64.5% for the patients with concomitant AF after a mean of 4 years after surgery. We conclude that despite the complexity of the maze III operation this approach remains the golden standard from which future surgical and other ablative treatments of AF will be derived.

Surgical treatment of thoracoabdominal aortic aneurysms by simple crossclamping. Risk factors and late results.

Between 1981 and 1987, 88 consecutive patients were operated on for a thoracoabdominal aortic aneurysm by simple crossclamping and a graft inclusion technique (without shunts or heparin). This article presents an analysis of the operative outcome and long-term follow-up. Patient- and operation-related variables are age (mean 64.3 years, range 28 to 82 years), sex (82% men), rupture (20.5%), diabetes (2.3%), renal insufficiency (34.1%), chronic obstructive pulmonary disease (27.3%), previous aortic operation (31.8%), arterial hypertension (66%), postdissection (18.2%) versus degenerative (80.7%) origin, preoperative shock (11.4%), ischemic cerebrovascular (12.5%) or ischemic heart (17%) disease, peripheral vascular disease (14.8%), renal (mean 48 minutes, range 0 to 83 minutes) and lower spinal cord (mean 21 minutes, range 0 to 68 minutes) ischemic time, number of reattached intercostals, blood loss, and extent of the aneurysm (Crawford classification: type I, 16 patients [18.2%]; type II, 21 patients [23.8%]; type III, 29 patients [33%]; and type IV, 22 patients [25%]. Intraoperative mortality is 1.1% (n = 1). Thirty-day mortality is 5.9% (n = 5). Hospital mortality is 11.4% (n = 10): 7% for elective cases and 28% for ruptured aneurysms (p = 0.014). The survival at 2 years is 78% +/- (4.4%) and at 5 years 54% +/- (5.3%). Postoperative spinal cord injury occurred in 12 patients (13.8%) (5 had paraplegia and 7 had paraparesis) and postoperative renal dysfunction necessitating dialysis in 12 patients (14.1%). Risk stratification for hospital death, late death, renal failure, and spinal cord dysfunction was performed by means of multivariate logistic regression and Cox proportional hazard regression as appropriate. The best fitting model to predict hospital death includes preoperative shock (p = 0.02), female sex (p = 0.06), preoperative elevated serum creatinine level (p = 0.06), and preoperative myocardial infarction (p = 0.08). Variables predictive for late death are postoperative dialysis (p = 0.002), age (p = 0.008), and rupture (p = 0.04). The risk factors of postoperative dialysis are age (p = 0.003) and preoperative serum creatinine level (p = 0.04). The risk of postoperative spinal cord dysfunction increases with longer lower spinal cord ischemic time (p = 0.02) and with the presence of preoperative shock (p = 0.06).

Second primary lung cancer after bronchial sleeve resection. Treatment and results in eleven patients.

During the years 1960 to 1989, 145 patients underwent sleeve lobectomy or sleeve resection of a main bronchus. Follow-up was complete except for one patient, who was no longer available for follow-up 4 years after operation. Eleven patients (7.6%) had a second primary cancer in the lung; 10 of these patients (90.9%) were men. Mean age at sleeve operation was 61.2 +/- 11.6 years. Mean interval between sleeve operation and development of second primary cancer was 53.8 months (range, 6 to 197 months). All second primary cancers occurred on the contralateral side. In five cases there was squamous cell carcinoma, in two there was adenocarcinoma, in one there was adenosquamous carcinoma, in two there was small cell carcinoma, and in one patient no definite histologic type could be established. Five patients had different histologic type from the initial, resected primary tumor. Seven patients (64%) were operated on: five underwent lobectomy and two underwent segmentectomy. In one patient the tumor was judged to be unresectable. Chemotherapy was given to the two patients with small cell carcinoma and radiotherapy was given to one patient with bone metastases. Follow-up was complete for these 11 patients. Data were calculated from detection of second primary cancer. There was one postoperative death from myocardial infarction. Eight other patients died during follow-up: five died of recurrent tumor or metastases, two died of acute cardiac failure, and one died of a perforated ulcer. The 1- and 4-year actuarial survivals were 41% and 30%, respectively. For the patients operated on, 1- and 4-year survivals were 57% and 43%, respectively. There were no survivors at 5 years. Sleeve resection is a valuable method of preserving functional lung tissue. It offers a chance of subsequent resection in patients who have second primary cancer, with acceptable results.

Synchronous operation for ischemic cardiac and cerebrovascular disease: early results and long-term follow-up.

The late follow-up of 230 patients who underwent synchronous operation for extensive, obstructive extracranial and coronary artery disease from 1974 to 1989 was analyzed. Mean age at operation was 62.5 years; 161 patients (70%) were in New York Heart Association class III or IV, 185 (80%) had triple-vessel disease, and 67 (29%) had left main stem lesions of 50% or more. Previous myocardial infarctions were present in 132 patients (57%). Only 78 had normal left ventricular function. Included were 16 patients undergoing coronary reoperations, 17 patients with additional cardiac procedures, and 3 with synchronous pulmonary procedures. Symptomatic extracranial vascular disease or stabilized neurological deficits were present in 108 patients. Bilateral hemodynamically significant carotid disease was present in 91 patients and arch vessel lesions in 37. The hospital mortality in 8 patients (3.5%) was due to cardiac (n = 4), neurological (n = 1), or multiorgan failure (n = 3). Operative morbidity was mainly neurological (n = 20, 8.7%): 7 reversible deficits and 7 major strokes occurred, 2 reversible and 5 major strokes were related to the operated side(s), and 4 postoperative myocardial infarctions occurred. Actuarial survival at 5 years was 74% (+/- 3.3), at 10 years 54% (+/- 4.9), and at 15 years, 35% (+/- 6.6). This was mainly determined by late cardiac death (41/66). Late morbidity was mainly attributable to cardiac causes rather than neurological causes. At 5 and 10 years, respectively, 72% and 44% of the patients were free of major cardiac and neurological events or death. Synchronous revascularization can be performed relatively safely. The long-term outcome is determined by the extent and severity of the cardiovascular disease.

Transsternal closure of bronchopleural fistula after pneumonectomy.

BACKGROUND: Bronchopeural fistula after pneumonectomy, with associated empyema, has no standard therapy. The transsternal, transpericardial approach was used in all patients presenting with a large fistula. METHODS: From 1974 through 1995, 55 patients underwent transsternal, transpericardial closure of a bronchopleural fistula. Mean age was 62.7 years (range, 33 to 78 years). Malignant disease had been the indication for pneumonectomy in 50 patients and benign lesions in 5 patients. The fistula was right-sided in 41 patients (74.5%), and the bronchial stump was less than 2 cm in 25 (45.5%). Treatment of the concomitant empyema was by closed drainage in 2 patients, by repeated needle aspiration in 17, and by open thoracostomy in 36 patients. Reamputation and closure of the stump was possible in 51 patients; in 4 a primary carinal resection was done. RESULTS: Three patients died within 30 days after operation (5.4%, 70% confidence interval 2.4%-10.7%). Ten patients died late during hospitalization, total hospital mortality, 23.6% (70% confidence interval 17.3% to 31.0%). Recurrent fistula symptoms were caused by a large recurrency in 6 patients (all died), by a small one in 7 (one death due to pulmonary embolism). Mean duration of hospital stay was 56 days (range, 2 to 174 days). At follow-up of 42 patients, there were no recurrent fistulas. All patients with benign lesions are alive and well. Of 37 cancer patients, 29 died, more than half due to malignancy. Risk factors for death included recurrent fistula, short interval between pneumonectomy and onset of fistula, and closing technique. Risk factors for recurrent fistula were a short bronchial stump and the nonuse of an open thoracostomy. CONCLUSIONS: Long-term results of transsternal closure are good, but hospital mortality is high. The present treatment of patients with large postpneumonectomy bronchopleural fistula includes early open thoracostomy, improvement of nutritional status, transsternal closure using resorbable sutures, and closure of the pleural space 3 weeks later.

Allograft aortic root replacement in prosthetic aortic valve endocarditis: a review of 32 patients.

BACKGROUND: This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction. METHODS: From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 +/- 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class was 3.4. Staphylococcus epidermidis (50%) and Enterococcus faecalis (19%) were the predominant causative microorganisms. Annular abscesses were found in 26 patients (81%), aortic-mitral discontinuity in 14 patients (43%), and left ventricular-aortic discontinuity in 11 patients (34%). A cryopreserved allograft was used in 31 patients (97%) and a fresh antibiotic-treated allograft was used in 1 patient (3%). Mean aortic cross-clamp time was 150 +/- 29 minutes. Mean duration of the postoperative antibiotic treatment was 38.5 +/- 11.8 days. RESULTS: There were three operative deaths (9.4%); causes of death were multiorgan failure in 2 patients (6.2%) and low cardiac output in 1 patient (3.2%). Six patients (18%) had complete heart block (4 patients already before the operation), 3 patients (9.4%) had temporary respiratory insufficiency, and 1 patient (3.2%) needed temporary hemodialysis. Mean follow-up was 37.4 +/- 22.4 months. Two late deaths occurred: 1 patient had recurrent endocarditis, leading to a false aneurysm, and died at reoperation; another patient died of lung cancer. Actuarial 5-year survival was 87.3% (70% confidence interval, 76.8% to 97.8%); actuarial 5-year freedom from recurrent endocarditis was 96.5% (70% confidence interval, 90.0% to 100%). CONCLUSIONS: Allograft aortic root replacement is a valuable technique in the complex setting of prosthetic valve endocarditis with involvement of the periannular region. Mortality and morbidity are low.

Surgical therapy of paroxysmal atrial fibrillation with the "corridor" operation.

Patients with paroxysmal atrial fibrillation may be extremely disabled despite medical therapy. Based on recent concepts of atrial fibrillation, a surgical open heart procedure was designed to isolate a "corridor" from the right and the left atrium. The corridor consists of the sinus node area, the atrioventricular nodal junction, and the connecting right atrial mass, small enough to prevent atrial fibrillation. Between 1987 and 1990, 20 patients with severely disabling symptoms due to frequent paroxysmal atrial fibrillation underwent the corridor operation, with permanent success in 16 patients. In 8 patients, left atrium to corridor conduction reappeared shortly after the procedure. Reoperation was performed in these patients without extracorporeal circulation. The site of persistent conduction between the left atrium and the corridor could consistently be localized adjacent to the coronary sinus. Nevertheless, reoperation failed to isolate permanently the corridor in 4 patients. During a mean follow-up of 20 months, atrial fibrillation dominating the ventricles was never observed nor inducible in the corridor in the 16 patients with a successful operation. In all cured patients, sinus node function remained undisturbed. Paroxysmal atrial flutter inside the corridor arose in 1 patient and a paroxysmal focal tachycardia in another. All 16 cured patients experienced a clear improvement in quality of life. Refinement of the surgical technique to obtain persistent isolation between the left atrium and the corridor is needed. These results demonstrate that the concept of the corridor operation is sound and justify its use in the treatment of drug-refractory paroxysmal atrial fibrillation.

Completion pneumonectomy after bronchial sleeve resection: incidence, indications, and results.

During the years 1960 through 1989, 145 patients underwent sleeve lobectomy or sleeve resection of a main bronchus. Completion pneumonectomy was performed in 19 patients (13.1%). Indications were bronchostenosis without malignancy in 10 patients, positive resection margins in 3, recurrent tumor in 5, and anastomotic dehiscence in 1. Mean age at sleeve operation was 59.3 years. In 18 patients the histology was squamous cell carcinoma and in 1 patient, carcinoid tumor. The mean interval between sleeve resection and completion pneumonectomy was 5.7 months (range, 3 to 16 months) for the patients with stenosis and 6.6 months (range, 1 to 17 months) for the others. There were 3 operative deaths (15.8%). The mean follow-up was 53.2 months. Five-year and 10-year survival rates after completion pneumonectomy for the patients with stenosis were 54% and 41%, respectively, and for the others, 52% and 52%.

TNM staging and long-term follow-up after sleeve resection for bronchogenic tumors.

From 1960 to 1989, 145 patients (132 men and 13 women) with a mean age of 60.3 years underwent sleeve lobectomy or sleeve resection of a main bronchus for a bronchogenic tumor. Squamous cell carcinoma was predominantly found (116 patients, 80.0%), followed by carcinoid tumor in 13 patients (9.0%). Postoperative staging was: stage I, 61 patients (42.1%); stage II, 47 (32.4%); stage IIIA, 33 (22.8%); and stage IIIB, 4 (2.7%). Thirty-day mortality was 4.8% (7 patients). Follow-up was complete except for 1 patient who was lost to follow-up 4 years after operation. For the whole group, 5-, 10-, and 15-year survival rates were 49%, 37%, and 18%, respectively. Better survival was noted in patients with carcinoid tumor and squamous cell carcinoma. Considering 112 patients with T2 and T3 squamous cell carcinoma, 5- and 10-year survival rates for N0 disease (52 patients) were 59% and 47%, for N1 disease (51 patients) 21% and 0%, and for N2 disease (9 patients) 44% and 0%. Differences between N1 and N2 disease were not statistically significant. Survival after sleeve resection is best for carcinoid tumors and squamous cell carcinoma with negative nodes. Presence of N1 or N2 disease significantly worsens prognosis, with no 10-year survivors and no difference between N1 and N2 status.

Cryopreserved aortic allografts for aortic root reconstruction: a single institution's experience.

BACKGROUND: An evaluation of early and long-term results of aortic root replacement with cryopreserved aortic allografts and echocardiographic follow-up of allograft valve function was performed. METHODS: From September 1989 through May 1998, 132 patients aged 17 to 77 years (mean, 50.8 +/- 14.8 years) underwent freestanding aortic root replacement with a cryopreserved aortic allograft. Eighty-six (65.1%) patients had New York Heart Association class III or IV functional status before operation, and 27 (20.5%) patients underwent emergency operation. Fifty-nine (44.7%) patients had undergone previous cardiac operations. The cause of aortic disease was acute endocarditis in 63 (47.7%) patients, healed endocarditis in 15 (11.3%), degenerative in 20 (15.2%), congenital in 20 (15.2%), failed prosthesis in 10 (7.6%) and rheumatic in 4 (3.0%). Follow-up was complete, with a mean of 42 months. RESULTS: There were 12 hospital deaths (9.1%; 70% confidence limits [CL], 6.6% and 11.6%); 9 of them were operated on for active endocarditis (p = 0.062). Multivariate analysis determined age older than 65 years (p = 0.012) and emergency operation (p = 0.009) as independent risk factors for hospital mortality. During follow-up, 6 (5.0%; 70% CL, 3.0% and 7.0%) patients died. Cumulative survival rate for the entire group was 81.8% +/- 5.4% at 8 years. Freedom from reoperation for structural valve failure was 100%, freedom from reoperation for any cause was 96.3% +/- 1.8% at 8 years. Freedom from endocarditis at 8 years was 97.9% +/- 1.4%. Follow-up of allograft valve function showed no or trivial aortic regurgitation in 97% of patients and absence of stenosis of the allograft in 100%. CONCLUSIONS: Aortic root replacement with cryopreserved aortic allografts can be performed with acceptable hospital mortality and long-term results. The durability of cryopreserved aortic allografts is good, and reoperation for structural valve failure is absent at 8 years.

Completion pneumonectomy: analysis of operative mortality and survival.

BACKGROUND: A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome. METHODS: A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period. RESULTS: Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease. CONCLUSIONS: Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.

Mitral valve surgery and atrial fibrillation: is atrial fibrillation surgery also needed?

OBJECTIVE: Atrial fibrillation (AF) persisting after mitral valve surgery reduces survival due to heart failure and thrombo-embolisms, and impairs quality of life. Arrhythmia surgery for AF shows today very satisfying results and therefore mitral valve surgery with AF surgery appears appealing. This study explores whether combined surgery in view of today's results of mitral valve surgery is indicated. METHODS AND RESULTS: An outcome analysis of the arrhythmia outcome of patients undergoing exclusive mitral valve surgery with or without tricuspid repair was done. Preoperative baseline characteristics including arrhythmia pattern, surgical methods and follow-up findings were reviewed. Postoperative management of AF was not protocolized. Between 1990 and 1993, 162 consecutive patients underwent mitral valve surgery; follow-up was a mean of 3.3+/-1.9 years. In-hospital and late mortality were 1 and 9%, respectively. Sinus rhythm was preserved in 40 of 57 (70%) patients with preoperative sinus rhythm whereas AF persisted in 58 of 68 (85%) of patients with preoperative chronic AF (>1 year present). Sinus rhythm without AF was observed in 10 of 29 (34%) patients with preoperative paroxysmal AF. The 4-year Kaplan-Meier survival did not differ between patients with preoperative sinus rhythm (95.2%), paroxysmal AF (89.2%) and chronic AF (82.9%) but AF persisting after surgery tended to determine survival (P=0.05). Gender, age and right ventricular pressure and tricuspid valve repair were risk factors for postoperative recurrence of AF in patients with sinus rhythm at discharge, relative risk 0.35, 1.06, 1. 04 and 2.9, respectively. CONCLUSION: Current mitral valve surgery with or without tricuspid valve repair does not eliminate preoperative paroxysmal or chronic AF. Secondly, because preoperative AF did not determine survival after mitral valve surgery, whereas postoperatively persisting AF was weakly associated with survival, atrial arrhythmia surgery primarily aims to reduce morbidity due to AF. Some characteristics can identify patients with increased propensity for persisting AF after surgery. Randomized studies of AF surgery are needed to identify suitable candidates for combined surgery.

A randomized study of combining maze surgery for atrial fibrillation with mitral valve surgery.

AIM: Mitral valve surgery seldom suppresses atrial fibrillation (AF), present prior to surgery. Maze III surgery eliminates AF in >80% of cases, the reason why combining this procedure with mitral valve surgery in patients with AF seems worthwhile. We prospectively studied the outcome of combining the Maze III procedure with mitral valve surgery. METHODS: Thirty-five patients with AF and a mean age of 64 years undergoing mitral valve surgery were prospectively randomized according to a 2.5:1 ratio to surgery with (n=25), or without (n=10) maze III and followed for at least 1 year. RESULTS: At discharge and after 12 months freedom from AF was 56% and 92%, respectively, in the maze group, and 0% and 20%, respectively, in patients without maze (group differences at discharge p=0.002, after 12 months p=0.0007). Sinus node incompetence was seen in 1 of 25 maze patients requiring pacing. No in-hospital or late death occurred; stroke was observed in 1 patient (without maze). Quality of life markedly improved after surgery, but did not differ between patients with or without maze surgery. CONCLUSIONS: This first prospective randomized study shows that combining maze III with mitral valve surgery resulted in a significantly better elimination of preoperative AF than mitral valve surgery alone. As the quality of life did not differ between patients with, or without maze surgery, additional maze surgery is primarily recommended in patients in whom anticoagulation therapy can be avoided after surgery, specifically in patients with scheduled mitral valve plasty.

[The surgical treatment of aneurysms of the descending thoracic aorta]. / De chirurgische behandeling van aneurysmata van de aorta thoracalis descendens.

Between June 1983 and December 1987, 52 patients underwent resection of a thoracic descending aortic aneurysm. Thirty-day mortality was 11.5%; 4.8% for elective cases and 36.5% for patients operated upon in emergency. Spinal cord injury was present in two patients (4%). One patient was paraplegic, the other showed mild paraparesis, which was completely resolved. Both patients were operated for ruptured aneurysms. Severe postoperative renal dysfunction was present in 4 patients (7.5%) and was strongly related to intraoperative hypotension. The cumulative proportional survival rate was 81% at one year and 66% at two years of the total group, 85% at one year and 72% at two years for the patients presenting with nonruptured aneurysms. Aneurysms of the thoracic descending aorta can be resected with an acceptable mortality and morbidity. Just as in abdominal aneurysms, surgery definitely improves the outcome for these patients, who have a rather poor prognosis if left untreated.