Argon laser ablation of malignant ventricular tachycardia associated with coronary artery disease.

The long-term clinical efficacy and safety of intraoperative mapping-guided argon laser ablation alone or in conjunction with standard surgical methods were assessed in 20 consecutive patients with refractory sustained ventricular tachycardia (VT) or ventricular fibrillation. A 15-W argon ion gas laser was used and pulsed laser energy was delivered through a fiberoptic catheter delivery system. Pre- and intraoperative mapping was used to localize the arrhythmogenic tissue. Postoperative clinical, ambulatory electrocardiographic and electrophysiologic evaluations were performed before discharge and at 1 year of follow-up. Thirty-eight VT morphologies were mapped and ablated with laser energy alone (82%), combined laser ablation and mechanical resection (13%) or mechanical resection alone (5%). Concomitant coronary artery bypass surgery was performed in 15 patients and in 1 patient it was performed with mitral value replacement. Postoperative 30-day mortality was 5%. One patient (5%) required postoperative antiarrhythmic drug therapy, and all survivors had suppression of inducible sustained VT at discharge. Mean left ventricular ejection fraction increased from 34 +/- 12% preoperatively to 41 +/- 13% postoperatively (p = 0.001). Efficacy rates for ablation of VT sites associated with anterior myocardial infarction and inferior or posterior myocardial infarction were comparable (100 vs 96%, respectively, p greater than 0.2). At 1-year follow-up no sudden deaths had occurred and total survival rate was 90%. Intraoperative pulsed argon laser ablation alone or in conjunction with standard surgical techniques improves the efficacy of surgical ablation procedures for VT or ventricular fibrillation and reduces the need for additional postoperative antiarrhythmic drug or device therapy.

Intraoperative mapping-guided argon laser ablation of malignant ventricular tachycardia.

Intraoperative mapping-guided laser ablation of arrhythmogenic myocardium was performed in 5 patients with refractory sustained ventricular tachycardia (VT). Using a 15-W argon laser coupled to a 300-mu optical fiber, a bloodless laser ventriculotomy was successfully performed in 4 patients with VT. Visually- and mapping-guided endocardial ablation of 7 VT morphologic patterns was performed. Five of the 7 sites of VT origin were unresectable using standard resection techniques. Postoperatively, spontaneous and inducible VT was suppressed in all patients (without antiarrhythmic drugs in 4 patients and with a previously ineffective drug 1 patient). Mean pulmonary capillary wedge pressure, cardiac index and left ventricular ejection fraction were unchanged (p greater than 0.2) from preoperative values. Mean maximal creatinine kinase-MB isoenzyme concentration was 139 +/- 75 IU. All patients were New York Heart Association functional class II at discharge. During follow-up, no spontaneous arrhythmia has recurred in any patient. Thus, intraoperative argon laser ablation is effective for VT ablation alone or in conjunction with standard surgical resection techniques.

Usefulness of an implantable antitachycardia pacemaker system for supraventricular or ventricular tachycardia.

The Cordis Omni-Orthocor model 234A, an implantable antitachycardia system, was evaluated in 13 patients. Two patients had recurrent sustained supraventricular tachycardia (SVT) and 11 had ventricular tachycardia (VT). The system was used for SVT or VT termination (group 1: SVT, 2 patients; VT, 4 patients) or for demand pacing and noninvasive electrophysiologic studies for tachycardia induction and serial electrophysiologic testing alone (group 2: VT, 7 patients). The overdriver was used successfully in 4 of 6 patients in group 1 for repeated tachycardia termination (SVT and VT) during a mean follow-up period of 18 months. One patient had 1 sustained VT episode unresponsive to pacing and 1 patient had no recurrence of tachycardia. Tachycardia termination zones varied when using the system in 2 patients receiving long-term amiodarone therapy. Eighteen noninvasive electrophysiologic studies for serial drug testing were performed, 4 in group 1 and 14 in group 2. Clinical tachycardia was induced and successfully terminated by use of the overdriver in 12 studies. It is concluded that implantable antitachycardia systems can be used successfully for noninvasive tachycardia induction and termination and for reliable serial electrophysiologic studies. Such systems provide improved patient safety and acceptability and are reasonable in cost.

Meralgia paresthetica after coronary bypass surgery.

Meralgia paresthetica is a neurologic disorder characterized by localized paresthesia and numbness on the anterolateral aspect of the thigh and involving the lateral femoral cutaneous nerve. It involves no motor deficits. Meralgia paresthetica, which may result from a variety of causes, has been observed as a rare complication in heart operations. Its cause when associated with such operations is uncertain but may be prolonged relaxed positioning on the operating table and recovery room stretcher. Another possible cause of meralgia paresthetica after heart operations is the "frog-leg" position of the legs during vein harvesting. Patients with this condition should be advised of its untreatable, but benign and self-limiting, nature.

Coronary artery bypass grafting in patients with ejection fractions below forty percent. Early and late results in 466 patients.

The outcome of patients undergoing coronary artery bypass grafting with preoperative ejection fractions below 40% was evaluated to determine if a specific level of ventricular dysfunction resulted in unacceptably poor short-term or long-term survival rates. Left ventricular ejection fractions were segregated into groups of five percentage points each starting from 35% to 39% and progressing down to 10% to 14%. In evaluating the six ejection fraction groups between 10% and 39%, we found no significant differences among them with regard to previous myocardial infarctions, left ventricular end-diastolic pressure (LVEDP), age, preoperative New York Heart Association (NYHA) class, or number of vessels bypassed. Eighty-four percent were men and 16% women. From 1976 through 1982, 466 patients were distributed among these groups, all having ejection fractions below 40% (mean 30% +/- 3% SEM). There were significant differences (p = 0.001) in both the hospital and long-term survival (36 months) of patients with preoperative ejection fractions from 20% to 39% (425 patients) as compared to those with preoperative ejection fractions from 10% to 19% (41 patients). Hospital survival rate was 89% for patients with ejection fractions from 20% to 39% but only 63% for patients with ejection fractions below 20%. Similarly, at 3 years, patients with ejection fractions of 20% to 39% had an average survival rate of 60% as compared to an average survival rate of 15% for those with ejection fractions below 20%. Neither the preoperative LVEDP nor the intraoperative ischemic arrest time significantly predicted survival. In all survivors, NYHA class decreased from an average of 3.00 to 1.25 in surviving patients following bypass at a mean follow-up of 29 +/- 5 months. It is concluded that ejection fraction is an excellent predictor of short-term and long-term survival following coronary artery bypass grafting. Patients with ejection fractions of 10% to 19% have a significantly reduced short-term and long-term survival rate as compared to patients with ejection fractions of 20% or more.

Coronary angioplasty versus coronary bypass. Three-year follow-up of a matched series of 250 patients.

Two hundred fifty consecutive patients treated for one or two vessel coronary artery disease with either balloon angioplasty or surgical bypass were monitored for 3 years in a study designed to determine the comparative long-term effectiveness of each treatment. The 125 patients having angioplasty were matched with the 125 patients having bypass, so that both groups had a similar number of patients with single or double vessel disease. The two groups did not significantly differ in age, male:female ratio, New York Heart Association class, or risk factors. The ejection fraction was 54 +/- 11 in the angioplasty group and 49 +/- 12 mmHg in the surgical patients (p = 0.0031). Angioplasty was deemed initially successful in 88% (110/125), unsuccessful in 10% (12/125), and in 2% (3/125) the lesion could not be crossed. Emergency bypass was performed in 10% (12/125). Four of the 125 angioplasty patients (3%) died within 30 days. Coronary artery bypass grafting was successfully performed on the matched set of surgical patients with 99% (124/125) discharged well. There was one (1%, 1/125) surgical death. The average hospital stay per patient was 4.8 +/- 3.1 days for angioplasty and 12.1 +/- 4.2 days for bypass grafting (p = 0.0000). Three-year postprocedure follow-up was obtained on 96% (236) of the 245 patients discharged alive. A second angioplasty was required in 18%, and 11 angioplasty patients subsequently required surgical bypass. Overall, 19% (23/121) of the angioplasty patients ultimately required bypass. Four late deaths occurred in the angioplasty group, which brought the early and late mortality rates to 7% (8/121). There were two late surgical deaths, which brought the combined surgical mortality to 2.5% (3/120), p = 0.1263. Patient evaluation reveals that 63% (76/121) of the angioplasty group are alive and in New York Heart Association class I or II 3 years after one or two angioplasty procedures. This figure compares with 92% (110/120) of surgical patients alive and in the same two New York Heart Association classes (p = 0.0000).

Timing of coronary revascularization after acute myocardial infarction. Early and late results in patients revascularized within seven weeks.

Evidence of ischemia after acute myocardial infarction is a serious complication. If angiography reveals significant coronary artery disease, the precise timing of myocardial revascularization may be of critical importance. From 1978 through 1982, 174 patients underwent myocardial revascularization within 7 weeks of a documented myocardial infarction. The male:female ratio was 138:36, the average age was 58 +/- 1 (SEM) years; and the ejection fractions averaged 41% +/- 1%. Forty-four (25%) patients required preoperative intra-aortic balloon pump support, and an additional 18 (10%) required intra-aortic balloon pumping to be separated from cardiopulmonary bypass. An average of 2.9 +/- 0.1 vessels per patient were bypassed. The hospital mortality for these 174 patients was 16%. When mortalities were categorized according to the postinfarction week in which operation was performed, hospital mortality fell from 46% for those patients operated upon within 1 week of infarction to 6% for those patients operated upon 7 weeks after infarction. Of those patients operated upon within the first week after infarction, 23% were in cardiogenic shock and 62% required preoperative balloon pumping. Clearly the most critically ill patients were operated upon during the early postinfarction period. However, there was a marked difference in survival when patients in each of the seven weekly groups were classified according to ejection fraction. All patients with an ejection fraction greater than or equal to 50% (50 patients) operated upon at any time after infarction survived their hospital course, with only one late death. Conversely, among the 124 patients with an ejection fraction less than 50% operated upon during this 7 week interval, there were 27 (22%) hospital deaths. In this latter group, survival rates steadily improved if revascularization was performed at a time more remote from the infarction. The difference in early and late survival rates of patients operated upon with an ejection fraction greater than or equal to 50% compared to patients with an ejection fraction less than 50% is highly significant (p less than 0.001). We conclude that myocardial revascularization is safe at any time after myocardial infarction for those individuals with an ejection fraction greater than or equal to 50%. However, if the ejection fraction is less than 50%, then operation after myocardial infarction should be delayed at least 4 weeks.

Emergency operation after failed angioplasty.

A group of patients with failed angioplasty who then required emergency coronary bypass was compared with a historically matched group of patients who had had elective bypass grafting. The two groups were well matched in age, sex, ejection fraction, and New York Heart Association classification and in the incidence of diabetes and hypertension. Significant differences were found in the prevalence of mortality (12% versus 1.5%), hemorrhage (28% versus 13%), cardiac tamponade (10.5% versus 1.5%), myocardial infarction (28% versus 9%), and length of hospital stay (15.3 days versus 13.4 days). Cardiogenic shock carries the worst prognosis; four of the five patients with this condition died. Because emergency operation after failed angioplasty carries with it significant postoperative morbidity and mortality, this procedure cannot be considered equivalent to elective coronary bypass grafting.

Limb ischemia during intra-aortic balloon pumping: indication for femorofemoral crossover graft.

Catheter insertion for intra-aortic balloon pumping (IABP) was successful in 91% of 332 candidates. Fifty-three patients (16.5%) had significant catheter-associated vascular complications, of which lower extremity ischemia with threatened limb loss was the most prevalent (70%). Thirty-six of these patients required an angioplastic repair or vascular grafting. Of the 36, 19 patients with ischemia who needed continued balloon support received femorofemoral (F-F) grafts to restore and maintain adequate limb perfusion. Wound infection occurred in six of the patients but there was no limb loss. F-F grafting is a simple procedure that requires little time and allows one to maintain IABP for prolonged periods without concern for critical obstruction to limb perfusion.

Endarterectomy of the left anterior descending and mainstem coronary arteries: a technique for reconstruction of inoperable arteries.

The proximal left anterior descending coronary artery (PLAD) is an area of predilection for such severe and diffuse calcific arteriosclerosis that reconstruction of these vessels often is impossible. The branches of this segment include the septal perforators, median artery, the left anterior descending coronary artery, and its first and second diagonal branches. Successful endarterectomy, therefore, would revascularize large areas of the left ventricle and interventricular septum. We have performed 45 such operations during the past 13 months. Following endarterectomy there are several methods of reconstructing the endarterectomized vessel, the preferable technique being the addition of a saphenous vein bypass to the endarterectomized segment. Patients selected for this operation were mostly in the fair (58%) and poor risk (42%) categories; there were no good risk patients. Diffuse arterial disease was the rule. The average ejection fraction was 0.48. The operation was successful with respect to graft patency, bypass flow rates, and symptomatic relief. The operative mortality rate in the entire group was 15%, including the 19 poor risk patients in six of whom elective preoperative use of an antra-aortic balloon pump was required. Most of the surviving patients (92%) were either symptom free or greatly improved. Only two patients were clinically unchanged. There was one late sudden death. This operation is indicated when there is extensive involvement of the life main, the proximal left anterior descending coronary artery and its major branches. It is the only possible way to revascularize otherwise inoperable arteries.

Continued propranolol administration following coronary bypass surgery. Antiarrhythmic effects.

One hundred consecutive patients requiring propranolol hydrochloride before undergoing isolated aortocoronary bypass procedures were examined. In half the patients, propranolol therapy was discontinued, whereas the other half continued to receive intraoperative and postoperative propranolol regardless of clinical events. Although there were no preoperative differences in the apparent degree of coronary arterial disease or left ventricular function in the two groups, postoperative supraventricular arrhythmias were less frequent in the propranolol-treated group, most noticeably in those receiving less than 320 mg preoperatively. In patients who had received large preoperative doses (greater than or equal to 320 mg/day), there were no significant differences in postoperative supraventricular tachycardias. Continued propranolol therapy following isolated coronary bypass surgery appears to be a safe and efficacious method of decreasing the incidence of postoperative supraventricular tachycardias.

Vascular complications of intra-aortic balloon pumping.

Vascular injury or occlusion from intra-aortic balloon pumping (IABP) that results in actual or potential limb ischemia occurs more frequently than reported. In a series of 79 IABP patients, 36 lived long enough to have the balloon catheter removed; thirteen (36%) of them had vascular complications. The complications were in three patients with an injury at the insertion site, eight patients with arterial thromboses, and two with arterial occlusion by the large balloon catheter. Local artery revision, thrombectomy alone, or thrombectomy with femorofemoral cross-over grafting was required in 11 patients. Femorofemoral crossover graft was utilized when arterial occlusion would have ordinarily required premature balloon removal or when immediate arterial occlusion by the catheter was recognized at the time of balloon insertion. This was preferable to transferring, replacing, or discontinuing IABP, since the same factors that led to thrombosis in the first place would have eventually come into play again. Patients should be observed frequently and have Doppler limb pulse determinations every four hours to avoid ischemic catastrophies. Proper IABP weaning and the use of a Fogarty catheter at the time of balloon removal is mandatory to prevent complications. Femorofemoral crossover graft is indicated for ischemic limbs when IABP must be continued.

Pulmonary venous aneurysm presenting as a mediastinal mass in ischemic cardiomyopathy.

True aneurysm of the pulmonary vein is a rare lesion and may present as a mediastinal mass. Acquired aneurysm of the right superior pulmonary vein presenting as a middle mediastinal mass in a patient with ischemic cardiomyopathy associated with severe mitral regurgitation and dilated left atrium is described. Though the natural history of this lesion is uncertain, it may progressively enlarge and become symptomatic. Presence of this lesion in this patient with cardiomyopathy may require a modification of surgical technique at cardiac transplantation or surgical resection of an aneurysm without cardiopulmonary bypass.

Management of catheter-induced pulmonary artery perforation: a rare complication in cardiovascular operations.

BACKGROUND: Pulmonary artery perforation is a rare but often fatal complication of the pulmonary artery catheter occurring in cardiovascular operations and at catheterization facilities. We used our experience and a review of the literature to formulate diagnostic and management strategies. METHODS: During a 13-year period, 12 patients with pulmonary artery perforations were treated in a center that performed an average of 860 open-heart procedures per year. Clinical presentation varied from minor hemoptysis to major airway hemorrhage, hypoxia, exsanguination, and cardiac arrest. Airway bleeding occurred shortly after weaning from cardiopulmonary bypass in 5 patients or postoperatively after wedging the catheter in 6. One patient developed a hemothorax and had a cardiac arrest. Treatment included assurance of gas exchange, endobronchial lavage, isolation of the bleeding bronchus and control of hemorrhage by conservative therapy, pulmonary resection, pulmonary artery repair, and arterial embolization. RESULTS: Five of the 12 patients died (42%). Recurrent hemorrhage occurred in 40% of patients (2 of 5) treated conservatively compared with none of the patients (0 of 7) having surgical treatment. Forty three percent of patients (3 of 7) treated surgically died; 20% of patients (1 of 5) treated conservatively died. One patient succumbed without treatment. CONCLUSIONS: Pulmonary artery perforation is a rare and often fatal complication of pulmonary artery catheterization. This was apparent with patients who had airway hemorrhages as a result of weaning from cardiopulmonary bypass or after balloon inflation. Recurrent and fatal hemorrhage was frequent in patients treated by conservative therapy alone. Surgical intervention was effective in control of hemorrhage but did not reduce the number of deaths. Treatment remains highly individualized. It is advisable to be cautious in inserting Swan-Ganz catheters and to avoid their use unless absolutely necessary.

Mannitol, furosemide, and dopamine infusion in postoperative renal failure complicating cardiac surgery.

BACKGROUND: Acute renal failure occurring in the postoperative period, requiring dialysis after cardiac surgery is an important risk factor for an early mortality, and the overall mortality of this complication is as high as 40% to 60%. Dialysis in the early postoperative period is often complicated by acute hemodynamic, metabolic, and hematologic effects that adversely affect cardiopulmonary function in patients stabilizing from recent surgery. The purpose of this study was to avoid the need for dialysis by infusion of the solution of mannitol, furosemide, and dopamine in the early postoperative period in oliguric renal failure. METHODS: One hundred patients with postoperative oliguric or anuric renal failure despite adequate postoperative cardiac output and hemodynamic function were randomized. Forty patients (group A) were given intermittent doses of diuretics (furosemide, bumetadine, and ethracrynic acid) and fluids. Sixty patients (group B) were given continuous infusion of the solution of mannitol, furosemide, and dopamine; the infusion was started within 6 hours (mean 3.5 hours) in subgroup B1 (n = 30), and later than 6 hours (mean 7.5 hours) in subgroup B2 (n = 30) after the onset of renal failure. RESULTS: Diuresis occurred in 93.3% of group B (n = 56) versus 10% in group A (n = 4; patients with preop normal renal function). Ninety percent of group A (n = 36) required dialysis versus only 6.7% of group B (n = 4; patients with preexisting renal disease of subgroup B2). Renal function returned to preoperative normal (serum creatinine 0.9 +/- 0.05, p < 0.0001) or baseline value (serum creatinine 2.5 +/- 0.01, p < 0.0001) after first postoperative week in subgroup B1 and third postoperative week in subgroup B2. CONCLUSIONS: Infusion of solution of mannitol, furosemide, and dopamine promoted diuresis in patients with acute postoperative renal failure with adequate postoperative cardiac output and had decreased the need for dialysis in the majority of patients. Early administration of this solution in acute renal failure caused early restoration of renal function to normal or baseline status. It remains to be determined whether routine administration of this solution in the early postoperative period for oliguric renal failure influences the long-term mortality and morbidity in those patients who do require dialysis.

Pleuropulmonary and skeletal lymphangiomatosis with chylothorax and chylopericardium.

Congenital lymphangiomatosis of lung and bone, with or without chylothorax, is a rare but often fatal systemic lymphatic malformation. In those who survive infancy and early childhood, parietal pleurectomy with excision of lymphatic lakes and ligation of the thoracic duct can be successful. Two patients with lymphangiomatosis are described, 1 with chylothorax and chylopericardium with generalized skeletal lesions and the other with pleuropulmonary lesions and chylothorax. Both were successfully treated with parietal pleurectomy, excision of lymphatic lakes, and ligation of lymphatics, including the thoracic duct. To our knowledge, the triad of generalized skeletal lymphangiomatosis, chylopericardium, and chylothorax has not been previously reported.

Long-term efficacy of subendocardial resection in refractory ventricular tachycardia: relationship to site of arrhythmia origin.

Subendocardial resection is performed in patients with ventricular tachycardia (VT), but its efficacy as related to the site of origin of VT is problematic. We analyzed the efficacy of subendocardial resection in 24 patients with coronary artery disease and VT. All patients underwent preoperative and intraoperative mapping before subendocardial resection. Postoperative electrophysiologic studies were performed in the drug-free state 7 to 14 days after subendocardial resection. Group 1 (n = 14) had anterior, septal, or lateral sites of origin, and Group 2 (n = 10) had inferior or posterior sites of origin. Localization of presystolic electrical activity during VT by preoperative and intraoperative mapping was comparable in both groups (100%). Resectability of the site of origin was higher in Group 1. Induction of VT during a postoperative electrophysiological study was higher in Group 2. Perioperative mortality was comparable. Postoperative antiarrhythmic therapy was instituted more frequently in Group 2. Actuarial survival analysis showed improved patient survival at one year after subendocardial resection for both groups. The efficacy of subendocardial resection is related to site of origin of VT: Subendocardial resection is less efficacious in VT with inferior or posterior sites of origin because of nonresectability of the arrhythmogenic area.

Delayed sternal closure following open-heart operation.

Between June, 1976, and December, 1980, 29 patients underwent delayed sternal closure at the Newark Beth Israel Medical Center. The indications were enlarged heart with tamponade when the mediastinum was closed, poor lung compliance, hemodynamic instability due to intractable arrhythmias or coagulopathy, and presence of a mediastinal assist device. Following an open-heart procedure, the retrosternal space may no longer accommodate the heart and approximation of the sternum will produce hypotension and elevation of right and left end-diastolic pressures. In such instances, only the skin is closed and between one to four days later, the wound is closed in a routine manner. There are several advantages of the procedure: hemodynamic stability; quick access to the heart for massage or evacuation of clots; and possibility of removing an intraaortic balloon in the ascending aorta without leaving a large Dacron tube. Of the 29 patients treated, 19 were long-term survivors and only 1 patient had a minor superficial wound infection. Although it is not recommended that this procedure be utilized routinely or indiscriminately, its judicious use will add flexibility in the management of selected and difficult cases.

Pulmonary inactivation of vasopressors following cardiac operations.

Vasoactive drugs were infused through catheters in the right atrium and then the left atrium of 34 patients who required either vasopressor or vasodilator support following cardiac operation to determine if the route of infusion affected the aortic blood concentration of these agents. Drugs were given through the right atrium for one hour and then the left atrium for an hour. Both central aortic and pulmonary arterial blood were assayed for drug concentrations, and hemodynamic measurements were made. Sixteen patients receiving dopamine hydrochloride through the left atrium had a 36 +/- 12% (+/- standard error of the mean) increase in aortic concentration of the drug (p less than 0.005) and a 37 +/- 14% increase in cardiac index (p less than 0.005) compared with administration through the right atrium. Seven patients receiving epinephrine showed a 59 +/- 21% increase in aortic concentration (p less than 0.05) and a 21 +/- 10% increase in cardiac index (p greater than 0.05, not significant). Eleven patients receiving sodium nitroprusside achieved a 99 +/- 25% increase in aortic concentration (p less than 0.005) and a 20 +/- 7% increase in cardiac index (p less than 0.05). In all instances, significantly higher central aortic blood concentrations were achieved during left atrial (LA) versus right atrial (RA) infusions. Changes in blood concentration of the drug between the pulmonary artery and the aorta during RA infusion suggest removal or inactivation of these drugs in the pulmonary vasculature.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valve replacement in geriatric patients: determinants of in-hospital mortality.

BACKGROUND: Aortic valve replacement is a common procedure in elderly patients. There has been a great deal of controversy about the risks associated with early mortality. Uncertainty of the risk associated with a small valve continues to remain controversial. This study was designed to identify the risk factors influencing early mortality and establish an accurate model for the prediction of in-hospital mortality. METHODS: One hundred eighty septuagenarians and octogenarians (58% women; mean age, 76 +/- 4.7 years) underwent primary isolated aortic valve replacement between 1986 and 1997. There was an overall mortality of 16.7% (n = 180). Patients with a body surface area less than 1.8 m2 had an in-hospital mortality of 23.2% (n = 95) compared with 8.1% (n = 74; p = 0.009) for patients with a body surface area of 1.8 m2 or more. Patients with a cardiopulmonary bypass time of less than 100 minutes experienced an early mortality of 8.9% (n = 56) compared with a 10.2% (n = 59) early mortality for patients on bypass time between 100 and 124 minutes and a 29.6% (n = 64) early mortality in patients with a pump time longer than 124 minutes (p = 0.040). RESULTS: Multivariate logistic regression analysis identified small body surface area and long cardiopulmonary bypass time as independent risk factors. A higher mortality was seen in female patients and patients receiving smaller valves. However, there was a strong correlation between small body surface area, small valve size, and female gender. CONCLUSIONS: Small body surface area and long cardiopulmonary bypass time are two independent risk factors in early mortality for elderly patients undergoing primary isolated aortic valve replacement. The use of small valves does not influence early mortality.