[Surgical results of Konno and Ross procedures in children and Bentall and David procedures in adults].

The surgical management of complex aortic root lesions has developed over 3 decades both in pediatric and adults patients. To avoid permanent anticoagulation and prosthetic materials as much as possible, we had introduced Ross procedure as an alternative to Konno procedure in pediatric patients and David procedures in adults patients. We sought to evaluate the surgical results of Konno, Ross, Bentall and David procedures. The Konno procedure has excellent long term results and anticoagulation-related complication and endocarditis were major causes of re-operation. Ross procedure has excellent long term results, and autograft failure and right ventricular outflow tract (RVOT) obstruction were causes of re-opertion Bentall procedure is certainly effective and has excellent long term results. Pseudoaneurysmal formation in coronary reconstruction was a major cause of reoperation. David procedure is certainly an attractive option especially for young patients. Early result was satisfactory but durability of this operation should be reevaluated.

[Open stent implantation for ascending aorta aneurysm with severe calcification].

A 77-year-old woman had an ascending aortic aneurysm and aortic regurgitation due to aortitis syndrome. Computed tomography showed that ascending aorta was 55 mm in diameter and had severe calcification between the ascending aorta and distal aortic arch involves neck vessels. We performed open stent implantation and aortic valve replacement with bioprostheses valve. No adverse event occurred after the operation and the patient was discharged on the 28th postoperative day. The open stent implantation was useful for the treatment of the aneurysm in high risk patients.

[Dissection of descending aorta with spinal paralysis].

A 56-year-old man had undergone ascending aorta and total arch replacement because of aortic dissection (Stanford type A) in 1997. He had onset of diplegia of the lower limb and vesicorectal disability. Computed tomography (CT) showed serpentine aneurysm in the descending aorta, it was seen between the left subclavian artery and diaphragm level. It was 80 mm of maximum diameter. Magnetic resonance imaging (MRI) was performed for identified Adamkiewicz artery, but we could not identify it. We performed a graft replacement. The 8th intercostal artery was reconstructed with a branch graft. The postoperative course was uneventful. We conclude that graft replacement for spinal ischemia can be effective.

Angiotensin II type 2 receptor mediates vascular smooth muscle cell apoptosis in cystic medial degeneration associated with Marfan's syndrome.

BACKGROUND: Cystic medial degeneration (CMD) is a histological abnormality that is common in the aortic diseases associated with Marfan's syndrome (MFS). Although little known about the mechanism underlying CMD, several recent reports have demonstrated that vascular smooth muscle cell (VSMC) apoptosis could play a substantial role in CMD. On the other hand, angiotensin II (Ang II) has been reported to play an important role in the regulation of VSMC growth and apoptosis via the Ang II type 1 receptor (AT1R) and type 2 receptor (AT2R). METHODS AND RESULTS: To elucidate the role of Ang II signaling via the Ang II receptors in CMD, we investigated AT1R and AT2R mRNA expression and tissue concentration of Ang II in MFS aortas (n=10) and control aortas (n=12). Furthermore, we examined the effects of an ACE inhibitor, an AT1R blocker, and an AT2R blocker on serum deprivation-induced VSMC apoptosis by organ culture system. AT1R expression was significantly decreased (P<0.01) and AT2R expression was significantly increased (P<0.001) in MFS aortas compared with control aortas, and tissue Ang II concentration was significantly higher in CMD than in the control condition (P<0.01). Both the ACE inhibitor and AT2R blocker significantly inhibited serum deprivation-induced VSMC apoptosis (P<0.05), although the AT1R blocker did not inhibit apoptosis in cultured aortic media from MFS patients. CONCLUSIONS: Accelerated ACE-dependent Ang II formation and signaling via upregulated AT2R play a pivotal role in VSMC apoptosis in CMD, and the ACE inhibitor could have clinical value in the prevention and treatment of CMD.

Total and partial cardiac sympathetic denervation after surgical repair of ascending aortic aneurysm.

UNLABELLED: Sympathetic cardiopulmonary nerves arise from the cervical sympathetic trunks and travel alongside the great arteries to innervate the ventricles. Because of the proximity of the nerve and artery, cardiac sympathetic denervation may occur in patients who have just undergone surgery for the repair of an ascending aortic aneurysm. METHODS: To evaluate the cardiac sympathetic activity in aortic aneurysm, we performed cardiac 123I-metaiodobenzylguanidine (MIBG) imaging on 12 patients (mean age +/- SD, 47 +/- 17 y) before and after the surgical repair of an aneurysm. Seven patients scheduled for coronary artery bypass grafting also underwent 123I-MIBG imaging as controls for open-chest surgery. Planar images were obtained at 15 min (early) and 4 h (delayed) after injection of 111 MBq 123I-MIBG, and the cardiac 123I-MIBG uptake was graded quantitatively and visually. The quantitative evaluation was based on the heart-to-mediastinum ratio (H/M), and visual evaluation was performed by assigning a score of 0-3 (0 = absent, 1 = severely reduced, 2 = reduced, and 3 = normal). Heart rate variability using 24-h Holter electrocardiography was analyzed before and after the operation to generate a time-domain index of heart rate variability as an index of autonomic balance. RESULTS: In patients with aortic aneurysms, both early and delayed H/Ms were significantly decreased after the operation (early H/M: 1.84 +/- 0.16 before vs. 1.40 +/- 0.16 after, P = 0.001; delayed H/M: 1.79 +/- 0.38 before vs. 1.27 +/- 0.18 after, P = 0.004). Visual analysis of 123I-MIBG accumulation in early images showed absence of 123I-MIBG accumulation in 3 of 12 patients, a score of 1 in 7 patients, and a score of 2 in 2 patients. In contrast, no significant difference between H/M before surgery and H/M after surgery was seen in patients who underwent coronary artery bypass grafting. The time-domain index of heart rate variability was significantly lower after the operation than before (135 +/- 40 after vs. 96 +/- 27 before, P < 0.05). CONCLUSION: Cardiac sympathetic nerves are totally or partially denervated after the surgical repair of ascending aortic aneurysm.

Open-position fixation of bioprostheses for more physiological performance. Fluoroscopic observations of leaflet movements in vivo.

A new model of the stent-mounted porcine aortic bioprosthesis was prepared with 0.625% glutaraldehyde while the valve was partially open. A radiopaque marker was attached to the center of the free margin of each leaflet so that the leaflet movements could be observed in an in vivo testing unit by fluoroscopic cinematography. This valve was compared with a porcine xenograft that currently is available commercially. While the heart was beating, the specially prepared leaflets showed some characteristics that contrasted with those of the currently used bioprosthesis. These features included (1) uniformity versus asymmetry of leaflet excursions under low flow conditions, (2) slower and more gradual closing (actual closing time averaging 536 msec versus 81 msec), and (3) more prolonged period of valve opening, the duration of opening averaging 60% versus 49% of the cardiac cycle. These features support the validity of open-position fixation as a means of further improving xenograft durability.

Ostial stenosis of coronary arteries after complete replacement of aortic root using gelatin-resorcinol-formaldehyde glue.

Coronary ostial stenosis between an interposition graft and coronary artery is rare and fatal. A 46-year-old woman who had reconstruction of both coronary arteries using interposition grafts for type A acute dissecting aneurysm presented with acute chest pain. Emergent coronary artery bypass grafting was done with saphenous vein grafts. Inappropriate use of gelatin-resorcinol-formaldehyde glue can be associated with ostial stenosis in the long term. Transesophageal echocardiography is useful to diagnose ostial stenosis of the coronary arteries.

Extensive aortic reconstruction for aortic aneurysms in Marfan syndrome.

BACKGROUND: Marfan syndrome patients frequently develop aneurysms or dissections involving multiple segments of the aorta, and occasionally require staged replacement of the entire aorta. This study reviews the surgical outcome of patients with Marfan syndrome who underwent extensive aortic reconstruction. Extensive reconstruction is defined as reconstruction of more than two segments of the ascending, arch, descending thoracic, or abdominal aorta. METHODS: From March 1973 to December 1997, 101 patients with Marfan syndrome underwent aortic operation. Twenty-six patients (25.7%) had extensive aortic reconstruction. All 26 patients suffered from aortic dissection: 13 patients had Stanford type A and 13 had type B dissection. Twenty-three patients (88.4%) had annuloaortic ectasia and aortic regurgitation. Surgical procedures included composite valve graft replacement (n = 23, 88.4%), aortic arch reconstruction (n = 15, 57.7%), graft replacement of the descending thoracic aorta (n = 6, 23.1%), and graft replacement of the thoracoabdominal aorta (n = 16, 61.5%). Five patients (19.2%) had total thoracoabdominal aortic replacement, and three patients (11.5%) had replacement of the entire aorta. Twenty-one patients (80.8%) required multiple operations. RESULTS: Follow-up was complete in all patients. The 30-day survival rate was 88.5%. None of the survivors had paraplegia or paraparesis. The overall long-term survival rate was 88.5 +/- 6% at 1 year, and 81.7 +/- 9% at 9 years. CONCLUSIONS: Aortic surgery prolongs survival in patients with Marfan syndrome, and currently there is a relatively low associated morbidity and mortality even for aggressive surgical treatment.

Retrograde cerebral perfusion for aortic arch surgery: analysis of risk factors.

BACKGROUND: Retrograde cerebral perfusion (RCP) has been widely adopted during aortic arch surgery under hypothermic circulatory arrest (HCA). However, the risks in terms of mortality and morbidity in aortic arch surgery using HCA with RCP have not yet been confirmed. METHODS: The present study is a retrospective review of 249 patients who underwent aortic arch surgery at three Japanese cardiovascular centers where RCP is a routine adjunct. The median age was 65 years, and 38 patients were more than 75 years old. The pathology in the aortic arch was atherosclerotic aneurysm in 133 patients and dissection in 116. Seventy patients had surgery on an emergency basis. Surgery was performed through a median sternotomy in 182 patients and through a left thoracotomy in 67. Using HCA with RCP, graft replacement of the total aortic arch was performed in 109, the distal arch in 63, and the ascending aorta and hemi-arch in 66; 11 patients had patch repair. RESULTS: The overall hospital mortality was 25/249 (10%), and 12/70 (17%) in emergent surgery. Stroke developed in 11 patients (4%). The median duration of RCP was 46 minutes (range, 5 to 95). Univariate analysis of risk factors revealed that an age of 75 years or more (p < 0.001), and urgency of surgery (p = 0.02) affected hospital mortality. Multivariate logistic analysis revealed that pump time (p = 0.0001), age (p = 0.0001) and RCP time (p = 0.05) are the most significant risk factors for mortality. The risk factors for mortality and neurological morbidity combined are pump time (p = 0.0001), age (p = 0.0002), and urgency of surgery (p = 0.07); RCP time is marginally significant (p = 0.15). CONCLUSIONS: The dominant risk factors for mortality and morbidity are pump time, urgency of the surgery, and age. RCP is a simple and useful adjunct for aortic arch surgery with up to 80 minutes of HCA, although prolonged RCP is a risk factor for mortality and morbidity.

Current strategy of temporary circulatory support for severe cardiac failure after operation.

BACKGROUND: After open heart operations about 1% of patients still need temporary circulatory support for severe cardiac failure, and over half of those patients die during or after the support. This study assessed the efficacy of the current strategy of circulatory support. METHODS: We assessed clinical outcome of 64 consecutive patients (1.5% of pump cases) who had temporary circulatory support associated with perioperative variables. The results were analyzed by logistic regression analysis. RESULTS: The weaning and discharge rates were 50.0% and 26.7% with venoarterial bypass, 76.2% and 57.1% with biventricular bypass, 87.5% and 37.5% with isolated left ventricular bypass, and 60.0% and 40.0% with pulsatile left ventricular assistance, respectively. Logistic regression analysis identified presupport cardiogenic shock (odds ratio, 9.922) and support type (14.684) as factors significantly associated with nonweaning from the temporary support, and cardiogenic shock (28.268), support duration (2.948), and support type (14.184) as factors significantly associated with mortality during or after the circulatory support. CONCLUSIONS: The current strategy of temporary circulatory support improved clinical outcome of patients with severe cardiac failure. Early application of circulatory support before profound cardiogenic shock and proper selection of the support type might be key factors for successful circulatory support postoperatively after operation.

Operation for type B aortic dissection: introduction of left heart bypass.

Various support techniques for surgical treatment of type B aortic dissection have been used and recommended in many medical centers. In the last 21 years, 55 patients with type B aortic dissection underwent 65 operations including 10 reoperations, and 10 cases showed Marfan's syndrome. As circulatory support during operation, venoarterial bypass mainly was used until March 1987 (period I) and low-dose heparinized left heart bypass was applied since April 1987 (period II). Surgical results were compared among subgroups by the Kaplan-Meier actuarial method and Cox-Mantel statistical analysis. After the operation, early mortality was 27.3% in 33 patients in period I and 9.4% in 32 patients in period II (p = 0.06). The incidence of fatal hemorrhagic complications was decreased significantly by using the left heart bypass technique (p < 0.02). The 5-year actuarial survival of type B dissection was 60.6% in period I and 79.2% in period II (p = 0.07). These results suggest that surgical results of type B aortic dissection in this series might be improved with the introduction of left heart bypass and extended surgical procedures.

Operation for type A aortic dissection: introduction of retrograde cerebral perfusion.

Circulatory support during operation for type A aortic dissection is controversial among many medical centers. In the last 21 years, 100 patients with type A aortic dissection underwent 102 operations including 2 reoperations, and 29 patients showed Marfan's syndrome. During operation, no cerebral perfusion technique was used through February 1985 (period I), antegrade cerebral perfusion was applied since March 1985 (period II), and retrograde cerebral perfusion was introduced in November 1990 (period III). Surgical results were compared among these subgroups. Operative mortality was 12.1% in 33 chronic and 57.1% in 7 acute patients in period I, 11.1% in 27 chronic and 54.5% in 11 acute patients in period II, and 6.7% in 15 chronic and 0% in 9 acute patients in period III (period II versus III; p = 0.04). Retrograde cerebral perfusion decreased permanent brain complications. The 5-year actuarial survival was 59.7% in period I and 63.2% in period II (not significant), and the 3-year survival of period III was 91.7%. Actuarial survival of period III was significantly higher than those of periods I and II (p < 0.05). Surgical repair of aortic arch with cerebral perfusion techniques reduced the residual aneurysms. These results show that surgical results of type A aortic dissection in this series improved with the introduction of retrograde cerebral perfusion and extended surgical procedures.

Heart valve operation in acromegaly.

BACKGROUND: Intractable congestive heart failure is known as a serious complication of acromegaly, but valvular heart disease rarely occurs in acromegalic patients. We experienced 5 surgical cases of valvular heart disease associated with acromegaly. We describe the features of those cases in this report. METHODS: The patient characteristics and operative and pathologic findings were retrospectively studied. RESULTS: There were 4 men and 1 women. Age at operation was 59 +/- 5.5 years. Cardiac lesions consisted of 1 case of aortic regurgitation associated with mitral regurgitation, 1 of aortic regurgitation, and 3 of mitral regurgitation. Operative procedures consisted of 1 double valve replacement (aortic and mitral valve replacement), 1 aortic valve replacement, and 3 mitral valve replacements. The causes of aortic valvular regurgitation were aortic valvular degeneration and aortic annular dilatation. The causes of mitral regurgitation were chordal rupture and mitral valvular degeneration. Histopathologic examination of the excised valves showed mucopolysaccharide deposits and myxomatous degeneration of the leaflets. The myocardium showed fibrosis of interstitial spaces and endocardium, and disarrangement of muscle fibers. CONCLUSIONS: We report 5 successful surgical cases of valvular heart disease associated with acromegaly. Earlier operation is recommended for such cases because of acromegalic cardiomyopathy.

Medium-term results after surgery for aortic arch aneurysm with hypothermic cerebral perfusion.

We have used two techniques of hypothermic cerebral perfusion (CP) for the surgical treatment of aortic arch aneurysm in the last 10 years. Between March 1985 and December 1993, 83 patients underwent surgery for aortic arch aneurysm. Fifty-one cases had aortic dissection (AD) in the transverse arch and/or its branches, and 32 cases showed true aneurysm (TA) of the aortic arch. In those 83 patients, 37 cases received antegrade CP and 46 cases underwent retrograde CP. Surgical results were compared among the groups by Kaplan-Meier actuarial method and Cox-Mantel statistical analysis. The early mortality after surgery for aortic arch aneurysm was 11.8% in the AD group and 21.9% in the TA group. The early mortality was 21.6% with antegrade CP and 10.9% with retrograde CP. The 6-year actuarial survival rate was 71.7% in the TA group and 67.1% in the AD group. In the AD group, the 3-year survival rate was 93.9% with retrograde CP and 61.1% with antegrade CP (P < 0.005). In the TA group, the 3-year survival rate was similar for antegrade CP (73.3%) and retrograde CP (69.2%). These results suggest that current surgical results of aortic arch aneurysm with hypothermic CP are acceptable and the retrograde CP technique might be recommended, especially for surgery of aortic arch aneurysm with AD.

Progress in the treatment of aneurysms of the distal aortic arch: approach through median sternotomy.

AIM: A review of past and current operative procedures for the treatment of aneurysms of the distal aortic arch is presented in conjunction with a series of 43 patients. In this study, distal aortic arch aneurysm refers to an aneurysm involving at least the origin of the left subclavian artery, but not extending beyond the left common carotid artery. We excluded dissection aneurysm and extended aneurysm to the descending thoracic aorta from this study. METHODS: Between January, 1985, and March, 2000, 43 consecutive patients (37 males, 6 females; mean age 67.5 years) underwent repair of aneurysms of the distal aortic arch. The approach to the aneurysm was through a left thoracotomy in 4 patients and a median sternotomy in 39 patients, including an additional left thoracotomy continued to a median sternotomy in 2 patients. The supportive methods during surgery were left heart bypass using a centrifugal pump in 4 patients (LHB group), cardiopulmonary bypass with selective cerebral perfusion in 11 patients (SCP group), and cardiopulmonary bypass with continuous retrograde cerebral perfusion in 28 patients (RCP group). In the RCP group, the "aortic no-touch technique" was applied in 21 patients. The operative methods were patch closure in 4 patients, graft replacement of the distal arch using the inclusion technique in 14 patients, and total arch replacement using the exclusion technique in 25 patients. RESULTS: There were 5 hospital deaths: 1 patient in the LHB group, intractable bleeding; 1 patient in the SCP group, rupture of the distal anastomosis; 3 patients in the RCP group, stroke, rupture of the dissection arising from the distal anastomosis, and perioperative myocardial infarction. Stroke occurred in 1 patient (25%) with LHB, 3 patients (27.2%) with SCP, and 1 patient (3.6%) with RCP. Among the postoperative survivors, a new onset of left recurrent nerve palsy occurred in 2 patients (66.7%) with LHB, 1 patient (10%) with SCP, and in 1 patient (4%) with RCP. No neurological injury or left recurrent nerve palsy occurred in the patients who underwent the "aortic no-touch technique". CONCLUSION: Total arch replacement with the graft exclusion technique under profound hypothermic circulatory arrest using RCP through the median sternotomy is a promising surgical treatment for atherosclerotic distal aortic arch aneurysm. The "aortic no-touch technique" further improved the surgical results of the distal aortic arch aneurysm.

Long-term results after De Vega's tricuspid annuloplasty.

BACKGROUND: Although some surgeons prefer to use artificial valve rings for tricuspid valve annuloplasty, we have mainly performed De Vega's tricuspid annuloplasty for functional tricuspid regurgitation, because it is a simple and effective technique for reducing tricuspid regurgitation due to annular dilatation. We evaluated long-term results of the De Vega's tricuspid annuloplasty up to 19 postoperative years. METHODS: Between January 1980 and June 1999, 408 patients underwent De Vega's tricuspid annuloplasty. Long-term results after De Vega's tricuspid annuloplasty were analyzed. RESULTS: There were 14 (3.4%) early deaths within 30 postoperative days. There were 63 (15.4%) late deaths during the follow-up period. The actuarial survival rate at 15 years after operation was 74.0%, the 15-year freedom from re-operation was 91.6%, and the 15-year freedom from all events was 58.7%, respectively. CONCLUSIONS: These results suggest that De Vega's tricuspid annuloplasty was an effective and reliable procedure of choice for secondary tricuspid regurgitation with annular dilatation.

Current strategy of circulatory support for profound heart failure.

The purpose of this study is to assess the current strategy of mechanical circulatory support for profound heart failure. In the last 10 years, 37 patients with profound heart failure underwent mechanical circulatory support after open heart surgery and 9 patients with non-cardiotomy cardiogenic shock received emergency circulatory support. All patients showed severe cardiac failure and/or fatal ventricular arrhythmia and required circulatory support as a life-saving measure. After cardiovascular surgery, 12 of those patients underwent venoarterial bypass (VAB), 13 had biventricular bypass (BVB), 8 had left ventricular bypass (LVB) and the remaining 4 patients received left ventricular assist device (LVAD). And 9 patients with non-cardiotomy cardiogenic shock received percutaneous cardiopulmonary support (or PCPS) as an emergency assist system. Weaning and discharge rates of the patients by the type of circulatory supports were 41.7% and 25.0% with VAB, 69.3% and 46.2% with BVB, 87.5% and 37.5% with LVB, 75.0% and 50.0% with LVAD, and 44.4% and 11.1% with PCPS, respectively. Clinical results of post-cardiotomy circulatory support (64.9% of weaning and 37.8% of discharge) were acceptable, but the patients with non-cardiotomy cardiac failure needed early application of more advanced circulatory support.

Primary cardiac angiosarcoma of the right atrium undiagnosed by transvenous endocardial tumor biopsy.

A 50-year-old man was admitted with acute pericarditis. Echocardiography demonstrated a large mass on the right atrial free wall along with a pericardial effusion. We performed transvenous biopsy of this mass under transesophageal echocardiographic guidance. Though the biotome obtained the mass, the pathological findings were of organized thrombus. Two weeks later, a new precordial mass appeared around the left third rib and was suspected to be a metastasis. Incisional biopsy of this mass gave the diagnosis of angiosarcoma.

Determinants of clinical results of mechanical circulatory support for ventricular failure after cardiotomy.

To clarify determinants of clinical results of circulatory support for ventricular failure after cardiotomy, we examined 53 patients (33 men and 20 women) who underwent circulatory support for post operative heart failure from 1984 to October 1995. Their ages ranged from 22 to 74 years (mean, 51 years). In 53 patients, 32 had valvular, 19 had ischemic, and 2 had congenital heart disease. After operation, 21 patients underwent venoarterial bypass, 20 underwent biventricular bypass, and 8 underwent left ventricular bypass. The remaining 4 patients received a pulsatile left ventricular assist device. Weaning and discharge rates of the patients by type of support were 52.4% and 28.6% with venoarterial bypass, 75.0% and 55.0% with biventricular bypass, 87.5% and 37.5% with left ventricular bypass, and 75.0% and 50.0% with left ventricular assist device, respectively. The results of this series (67.9% weaning rate and 41.5% discharge rate) were acceptable. Peri-operative variables before and during circulatory support were analyzed multivariately by logistic regression analysis. Selected independent determinants (odds ratio) of significant difference (p < .05) were type of support (7.547) for non weaning and pre support cardiogenic shock (17.246), and type of support (8.780) and support duration (1.487) for mortality. These results suggest that early application before profound shock and appropriate selection of type of support might be key factors in successful circulatory support for ventricular failure occurring after cardiotomy.

[Postoperative therapy using human atrial natriuretic peptide in cases of valve replacement].

The effect of hANP (atrial natriuretic peptide) was investigated clinically in 40 patients who underwent isolated valve replacement. Patients were divided into four groups: aortic regurgitation (AR), aortic stenosis (AS), mitral regurgitation (MR) and mitral stenosis (MS). Each group was divided into two subgroups: one was administered hANP after the operation until leaving ICU, and the other was not administered hANP. We measured the levels of hANP and c-GMP and blood pressure, pulmonary artery pressure, central venous pressure and levels of Na, K of urine and blood prcoperatively, immediately postoperatively and 1, 2, 4, 6 hours after operation. First, to examine the relationship between preoperative level of hANP and cardiac function, the relationship between preoperative level of hANP and history of cardiac failure and pulmonary artery wedge pressure (PAWP) were evaluated. Also, we evaluated the relationship between preoperative level of hANP and each dimension on echocardiography. There was a weak statistical relationship between hANP and PAWP (row = 0.39 (p = 0.04) Pearson correlation method) and there was no statistical relationship between hANP and duration of cardiac failure (row = 0.00445 (p = 0.98) Pearson correlation method). Preoperatively Left atrial diameter (LAD) showed a statistical relationship with level of hANP in every group using Spearman correlation method. Other dimensions such as left ventricular diastolic diameter (LVDd) and left ventricular systolic diameter (LVDs) and also fractional shortening (FS) did not show a strong correlation with preoperative level of hANP. Especially, in AS group there was a strong relationship between every dimension and preoperative level of hANP. Only in MS group LAD and the level of hANP were negatively related. This finding suggests that atrial dilatation results in reduction of secretion of hANP in cases of MS on long term follow up. Finally, hNAP therapy was shown to have a continuous diuretic effect, with stable hemodynamics.