Thiopurine S-methyltransferase gene polymorphism is predictive of azathioprine-induced myelosuppression in heart transplant recipients.

Azathioprine (AZA) is metabolized via the cytosolic enzyme thiopurine S-methyltransferase (TPMT). TPMT activity exhibits genetic polymorphism with four prevalent (75%) mutant alleles TPMT*2 (G238C) and TPMT*3 (A719G and/or G460A) and a wild-type allele TPMT*1. To test the hypothesis that presence of these mutations is associated with greater toxicity of AZA in heart transplant recipients, 30 consecutive patients treated with AZA were followed up for the first month after heart transplant. Mutation of TPMT gene (mutation-specific polymerase chain reaction-based methods) was observed in four patients (A719G: n = 2; A719G plus G460: n = 2). Agranulocytosis did not occur in patients with the wild genotype. It occurred in the two patients with mutation A719G and there was a 40% drop in neutrophils in the two other patients. Discontinuation of AZA in the four mutant patients corrected for the drop. Presence of TPMT mutations is associated with a greater likelihood of agranulocytosis. Determination of these mutations could reduce the risk for hematological side-effects.

Heart-lung transplantation in a 16-month-old infant.

A 16-month-old boy who had a heart-lung transplantation is doing well 16 months postoperatively. The HLT can be a successful treatment for very young patients. Most of the postoperative management can be assessed with noninvasive techniques. Normally, the allograph grows with the recipient.

Traumatic tricuspid insufficiency. An underdiagnosed disease.

Twelve cases of traumatic tricuspid insufficiency (only three of which already have been published), collected in the same city, are reported. This figure strongly contrasts with the limited number of cases published to date in the literature. Emphasis is placed on the difficulty of diagnosis, the utility of echocardiography and Doppler ultrasound and therapeutic problems of this lesion.

Flow-induced release of endothelium-derived relaxing factor during pulsatile bypass: experimental study in the fetal lamb.

OBJECTIVE: This study was initiated to test the hypothesis that fetal hemodynamic changes observed under pulsatile flow bypass might be related to the release of endothelium-derived relaxing factor through oscillating shear stress. METHODS: Normothermic bypass was instituted in utero in 21 preterm fetal lambs for a 1-hour period through the right atrium and main pulmonary artery. Ultrasonic flowmeters were positioned around the descending aorta and the umbilical artery. The circuit consisted of an oxygenator and a pump set to either continuous flow (n = 7) or pulsatile flow (n = 7) and adjusted to maintain a fetal main arterial pressure of 50 mm Hg. In seven other animals, endothelium-derived relaxing factor was blocked by a continuous infusion of N omega-nitro-L-arginine after 30 minutes of pulsatile flow. RESULTS: During the first 30 minutes of bypass, pump flows were significantly lower in the continuous-flow group than in the pulsatile-flow or blocked-flow groups (respectively, 612 +/- 144, 907 +/- 153 and 987 +/- 228 ml/min), with similar changes in aortic and umbilical flows. Systemic vascular resistances were significantly lower in the pulsatile-flow and blocked-flow groups than in the continuous-flow group (550 +/- 106 vs 821 +/- 212 dynes/sec/cm-5). However, after blockade of endothelium-derived relaxing factor, resistances increased gradually in the blocked-flow group to reach the level of that of the continuous-flow group at the end of bypass (943 +/- 77 vs 556 +/- 143 dynes/sec/cm-5 in the pulsatile-flow group). CONCLUSIONS: Blockade of endothelium-derived relaxing factor after 30 minutes of pulsatile flow returns fetal hemodynamics to continuous flow conditions. The specific inhibitor of endothelium-derived relaxing factor used in this experiment suggests that nitric oxide may be released by fetal endothelium during pulsatile bypass.

Use of the Abiomed BVS System 5000 as a bridge to cardiac transplantation.

The Abiomed BVS System 5000 (Abiomed Cardiovascular, Inc., Danvers, Mass.) is a gravity-filled, pneumatically driven external prosthetic ventricle that has been implanted as a circulatory support device in six patients 9 to 58 years of age, presenting with a refractory heart failure nonamenable to any type of corrective operation. Three (including a 9-year-old girl) had an end-stage nonobstructive myocardiopathy, and two (including one patient who had had a massive recent myocardial infarction) had an ischemic heart disease. When first seen, the 58-year-old patient had an acute rejection and graft failure occurring 2 months after a first transplantation. All patients showed evidence of a low-output state (cardiac index less than 1.5 L/min/m2), with renal failure (mean urinary output, less than 27 ml/min) and hypoxia (mean arterial oxygen pressure = 56 torr under 80% forced inspiratory oxygen), despite maximum pharmacologic support (dobutamine, 16 to 18 gamma/kg/min; dopamine, 3 to 18 gamma/kg/min; adrenaline, 0.2 to 0.7 gamma/kg/min; furosemide, 7 to 17 gamma/kg/min). The device was implanted through a midline sternotomy and under peripheral normothermic bypass. Five patients received a biventricular support, and one a single left prosthetic ventricle. The cannulation included a right-angled cannula in both the left and right atrium and a suture of the arterial Dacron tubes onto the ascending aorta and main pulmonary artery. After careful deairing of the tubing and ventricles, the console was activated and the bypass progressively discontinued. Heparin infusion was begun 3 hours after chest closure and was continued for the duration of assist pumping, which was 2 to 11 days (mean duration, 7.43 days). The system could provide a complete support of the circulation with both right and left ventricular index remaining stable at 2.4 to 3 L/min/m2. After a dramatic improvement at the time of the system activation, the urinary output remained adequate, thus allowing for a decreasing need for diuretic therapy. In two cases, including one of isolated left ventricular assist pumping, the circulation could be totally supported during 11 hours and 23 hours, respectively, of refractory ventricular tachycardia. Four of six patients were shortly weaned from inotropic agents. Hematologic studies showed a moderate decrease of the coagulation factors level during the first 6 hours of circulatory support, and this remained stable and within normal limits thereafter. There have been three cases of bleeding complications necessitating surgical revision on the sixth hour, the twelfth hour, and the sixth day, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term clinical and hemodynamic evaluation of porcine valved conduits implanted from the right ventricle to the pulmonary artery.

OBJECTIVE: This retrospective study was initiated to evaluate the long-term results of valved prosthetic conduits implanted in the right ventricular outflow tract in patients with complex ventricular-pulmonary discontinuity. METHODS: A cohort of 103 patients out of 127 (24 early deaths, 19%) operated on between 1973 and 1996 with porcine valved conduits was available for evaluation, with a follow-up ranging from 1 to 21.6 years (mean follow-up 8.4 +/- 6 years). A total of 74 hemodynamic studies were performed after the operation, 50 patients having undergone at least 1 cardiac catheterization during the follow-up period. RESULTS: There were 16 late deaths, and the actuarial survivals, including early mortality, were 72.9% +/- 4% at 5 years, 63.1% +/- 5% at 10 years, and 58.2% +/- 5% at 15 years, at which time 20 patients were still available for review and exposed to the risk of dying. The mean peak systolic gradient across the right ventricular outflow tract was plotted as a function of time, showing a gradual increase and a significant step-up after the eighth year, from 43 +/- 36 to 69 +/- 19 mm Hg (P < .005). Reoperation was required for progressive conduit obstruction between 1.1 and 17.7 years after implantation (mean 7.4 +/- 4.8 years) in 25 patients (24%, 70% CL 15%-33%), with generally very few symptoms, or for residual ventricular septal defect in 3 patients. Freedom from reoperation was 79.5% +/- 5% at 10 years and 65.8% +/- 7% at 15 years. CONCLUSIONS: Porcine conduits may represent a valuable alternative to biologic substitutes with similar long-term results. Given the few symptoms, progressive conduit stenosis after the eighth postoperative year imposes a yearly noninvasive patient evaluation during the follow-up.

Experimental right ventricle to pulmonary artery discontinuity: outcome of polyurethane valved conduits.

OBJECTIVE: The ideal substitute for the treatment of ventricle-pulmonary artery discontinuity remains a topic of controversy, because of calcifications and degeneration of biologic substitutes leading to subsequent reoperations. Because polyurethane valves used in ventricular assist devices show a satisfactory biocompatibility, the aim of this study was to evaluate a valved conduit composed of a Dacron graft incorporating a trileaflet 25 mm polyurethane valve. METHODS: The conduit was implanted between the right ventricle and the main pulmonary artery in adult sheep, with ligation of the proximal pulmonary artery. The animals received no medications. Serial hemodynamic data were collected at the time of implantation and at postoperative intervals of 6 and 12 months. RESULTS: The peak pressure gradient across the valve increased significantly between implantation (0.17 +/- 5.6 mm Hg) and 6 months after operation (7.3 +/- 3 mm Hg, p = 0.0007) and remained stable thereafter (6.7 +/- 3 mm Hg at 12 months), whereas the cardiac output remained unchanged (4.6 +/- 0.6 L/min at implantation, 4 +/- 0.6 L/min at 6 months, and 3.9 +/- 1.1 L/min at 12 months). At the completion of the study, valve samples were processed and vapor coated with carbon for microscopic examination. There was one instance of nonadherent thrombus formation inside a cusp but no structural failures. The other valves were free of calcium deposits and no significant amounts of phosphorus could be detected by scanning electron microscopy and energy dispersive spectrometry. CONCLUSIONS: These data demonstrate the good hemodynamic performance, low thrombogenicity, and acceptable durability of the polyurethane valves implanted in the right side of the heart in a chronic sheep model.

Effects of various flow types on maternal hemodynamics during fetal bypass: is there nitric oxide release during pulsatile perfusion?

OBJECTIVE: This study investigates the role of various flow conditions on maternal hemodynamics during fetal cardiopulmonary bypass. METHODS: Normothermic fetal bypass was conducted under pulsatile, or steady flow, for a 60-minute period. Fetal lamb preparations were randomly assigned to 1 of the 3 groups: steady flow (n=7), pulsatile flow (n=7), or pulsatile blocked flow bypass (n=7), where fetuses were perfused with Nomega-nitro-L-arginine after the first 30 minutes of pulsatile flow to assess the potential role of endothelial autacoids. RESULTS: Maternal oximetry and pressures remained unchanged throughout the procedure. Under fetal pulsatile flow, maternal cardiac output increased after 20 minutes of bypass and remained significantly higher than under steady flow at minute 30 (8.8+/-0.7 L x min(-1) vs 5.9+/-0.5 L x min(-1), P=.02). Maternal cardiac output in the pulsatile group also remained higher than in both steady and pulsatile blocked flow groups, reaching respectively 8.7+/-0.9 L x min(-1) vs 5.8+/-0.4 L x min(-1) (P=.02) and 5.9+/-0.3 L min(-1) (P=.01) at minute 60. Maternal systemic vascular resistances were significantly lower under pulsatile than under steady flow after 30 minutes and until the end of bypass (respectively, 9.1+/-0.6 IU vs 12.7+/-1.1 IU, P=.02 and 8.9+/-0.5 IU vs 12.9+/-1.2 IU, P=.01). Infusion of Nomega-nitro-L-arginine was followed by an increase in systemic vascular resistances from 9.3+/-0.7 IU, similar to that of the pulsatile group, to 13.5+/-1 IU at 60 minutes, similar to that of the steady flow group. CONCLUSIONS: Maternal hemodynamic changes observed under fetal pulsatile flow are counteracted after infusion of Nomega-nitro-L-arginine, suggesting nitric oxide release from the fetoplacental unit under pulsatile fetal flow conditions.

Better preservation of endothelial function and decreased activation of the fetal renin-angiotensin pathway with the use of pulsatile flow during experimental fetal bypass.

OBJECTIVE: Pulsatile flow was shown to overcome the progressive rise in peripheral and placental vascular resistances observed during steady-flow bypass, this rise being counteracted by inhibition of nitric oxide synthase. This study quantifies the release of endothelial vasoactive substances during a 60-minute in utero model of fetal bypass. METHODS: Fetuses were randomly allocated into 1 of 2 groups (steady flow, n = 8, or pulsatile flow, n = 13) and subjected to bypass through central cannulation and perfusion with either a centrifugal or pulsatile (125 beats x min(-1)) blood pump. RESULTS: Lactate concentration was high, starting at fetal exteriorization and increasing during fetal preparation in the 2 groups. Once bypass was established, the rise was significant only in the steady-flow group. Plasma nitric oxide metabolites, similar before bypass, reached higher levels during pulsatile flow at the end of bypass (99+/-9 vs. 82+/-23 micromol x L(-1); P =.037). Levels of urinary nitric oxide metabolites were significantly higher in the pulsatile-flow than in the steady-flow group (764+/-143 vs. 508+/-240 micromol x L(-1); P =.005). Plasma cyclic guanosine monophosphate levels increased after 30 minutes of bypass in the pulsatile-flow group (25+/-18 vs. 12+/-8 pmol x mL(-1); P =.004), and urinary cyclic guanosine monophosphate excretion was higher in the pulsatile-flow group (517+/-450 vs. 118+/-78 pmol x mL(-1); P =.024). Plasma endothelin-1 levels increased in the 2 groups and were higher in the steady-flow group at 30 minutes (27+/-5 vs. 23+/-2 pg x mL(-1); P =.04) and 60 minutes of bypass (39+/-7 vs 32 +/- 6 pg x mL(-1); P =.04). Plasma renin concentration increased significantly during bypass only in the steady-flow group (26+/-10 vs. 57+/-42 in ng A1 x mL(-1) x h(-1); P =.04). CONCLUSIONS: Improved placental and peripheral perfusion during fetal pulsatile-flow bypass may be mediated by preservation of fetal/maternal endothelial nitric oxide biosynthetic mechanisms and/or decreased activation of the fetal renin-angiotensin pathway.

Influence of technique of coronary artery implantation on long-term results in composite aortic root replacement.

BACKGROUND: Long-term results after composite graft aortic root replacement may depend on the insertion technique. The aim of this study is to assess the influence of the technique of coronary artery implantation on long-term results in composite aortic root replacement. METHODS: One hundred fifty consecutive patients (mean age, 55 years; 119 men) with different disorders of the ascending aorta who underwent aortic root replacement with a composite graft prosthesis between January 1985 and December 1999 were retrospectively studied. Thirteen patients had previously undergone cardiovascular surgery. The open button technique was performed in 65 patients (43.3%, group 1) and the inclusion technique in 85 patients (56.7%, group 2). Mean follow-up was 70.5 months. Surgery was elective in 110 procedures (73%). RESULTS: Global actuarial survival was 76.1% +/- 4.3% for group 1 and 73.7% +/- 3.9% for group 2 at 10 years (p = 0.22). Freedom from reoperation excluding early deaths was 81% +/- 3% for group 1 and 86% +/- 2.2% for group 2 at 10 years (p = 0.62). Group 2 demonstrated a statistically significantly higher occurrence of pseudoaneurysm formation versus group 1 (p = 0.04). CONCLUSIONS: Composite graft aortic root replacement is a safe and effective therapy for proximal aortic aneurysm and dissection, resulting in good early and long-term results irrespective of the anastomotic technique. However, the open button technique seems to avoid late false aneurysm formation at the anastomotic sites.

Effects of hypothermia on cochlear micromechanical properties in humans.

The aim of the present experiment was to investigate the influence of hypothermia on transient evoked otoacoustic emissions (TEOAEs) in humans. Hypothermic alterations were brought about directly by cooling the cardiovascular system of young children during open heart bypass surgery. This condition caused TEOAE levels to decrease with a significant positive correlation between total and frequency band TEOAE amplitudes during cooling. TEOAEs were totally abolished at tympanic temperatures around 30 degrees C, without it being possible to find differences in TEOAE alteration among the frequency components. During rewarming, the changes reversed and TEOAEs returned to their initial prehypothermia status, although sometimes only partially. Despite large possible metabolic changes caused by this hypothermic condition at various levels, it is concluded that the motile properties of outer hair cells (OHCs), that are related to TEOAEs, are temperature-sensitive. The total suppression found in deep hypothermia (above 30 degrees C) could conceivably be attributable to a process involving a temperature-dependent energy source.

Bilateral internal thoracic artery harvesting under robotic video-assistance.

BACKGROUND: Following upon the recent development of minimally invasive coronary robotic surgery, we set out to evaluate the feasibility of bilateral internal mammary artery (IMA) harvesting using the voice-controlled AESOP 2000 video assisted robot. METHODS: The robot is placed on the right side of the patient. The left IMA is first totally video-harvested, with the arm of the robot crossing over the patient to reach the left chest. The voice-controlled movement of the arm allows the surgeon to obtain the best video image of the artery. After completion of the dissection, the arm is positioned on the right part of the chest. The right IMA is then harvested using the same technique. RESULTS: Two patients underwent harvest of a bilateral IMA using this technique. The time of dissection was 52 min and 86 min, respectively. CONCLUSION: This technique allows a more precise, faster, tremor-free dissection, as compared to a conventional thoracoscopic harvesting.

Video-assisted tricuspid valve surgery: a new surgical option in endocarditis on pacemaker.

A patient presenting with a pacemaker lead infection and tricuspid regurgitation underwent a minimally invasive video-assisted tricuspid valve replacement. The valve was approached through a right anterior mini thoracotomy. Under thoracoscopic vision and peripheral cardiopulmonary bypass, a catheter was placed on the ascending aorta for antegrade cardioplegia delivery. A transthoracic aortic cross-clamp was introduced through the third right intercostal space. Tricuspid valve replacement added to the pacemaker leads ablation was exclusively performed under thoracoscopic vision, providing an excellent video-image in this reduced operative field. After 22 months of follow up, the patient is asymptomatic, the echocardiography showing a normally functioning valve.

Mechanical valve in aortic position is a valid option in children and adolescents.

OBJECTIVE: The choice of a valve substitute remains a challenge in young patients, with numerous reports of early degeneration and calcification of biological valves in this age group. Therefore an assessment of the long-term results after mechanical aortic valve replacement in children was initiated. METHODS: A retrospective study was conducted in 54 consecutive patients aged 1.1 to 17 years (mean 12.8 +/- 4 years) operated on between 1975 and 1993. Aetiology was congenital in 34 patients, rheumatic in 13, infectious in 5, and dystrophic in 2. Concomitant surgery included mitral valve replacement (10), aortic annulus enlargement (9), correction of truncus arteriosus (7), Bentall operation (2), coarctation repair (2), tricuspid valvuloplasty (2), correction of double outlet right ventricle (1), and replacement of a right ventricle to pulmonary artery conduit (1). A Bjork-Shiley valve was implanted in 14 patients, and a St Jude Medical valve in 40. All patients were given Warfarin with a monthly INR control. Follow-up was completed through questionnaires mailed to referring physicians and direct clinical examination. RESULTS: Overall early mortality was 13% (7 cases), and 6% (2 cases) in the 32 patients operated on after 1984. Follow-up was complete in 45 survivors (2 lost to follow-up), with a total follow-up of 261 patient-years. There were 6 late deaths, 4 being cardiac and due to persistent LV dysfunction, and 2 valve-related, due respectively to major gastro-intestinal bleeding and massive thromboembolism. Linearized rates of valve thrombosis and anticoagulant-related hemorrhage were both 0.3% per patient-year. Actuarial survival rate was respectively 84.5% at 5 years and 70.2% at 10 years. Reoperation was necessary in 3 patients for recurrent LV outflow tract obstruction. One patient with severe LV dysfunction is awaiting a heart transplant. CONCLUSION: We conclude that the longterm outcome after mechanical aortic valve replacement in children and adolescents is satisfactory and comparable to currently available reports on biological substitutes. The mandatory anticoagulant therapy is well tolerated in this age group.

Malignant neoplasms following cardiac transplantation.

OBJECTIVE: Malignancies have long been recognized as a complication of long lasting immunosuppressive therapy. We reviewed our experience to investigate the incidence and the spectrum of non cutaneous de novo malignant neoplasms. METHODS: Between March 1987 and March 1996, 296 patients underwent 303 cardiac transplantation in our service. The population at risk consists of all patients surviving more than 1 month after transplantation, leading to a total of 267 patients. A triple-immunosuppressive therapy was employed. Moderate doses of antilymphocyte globulin was used as an induction immunotherapy. RESULTS: Neoplasms developed in 18 (6.7%) of the 267 patients at risk. Seventeen patients were male. Mean age was 56 +/- 7 years. Fourteen patients (78%) reported a significant smoking history. Mean interval between transplantation and clinical diagnosis was 36 months. Lung neoplasms (especially adenocarcinoma) were the most commonly encountered tumors (11 of 268 patients, 4.1%). Three Non-Hodgkins' Lymphoma (NHL) were identified (1.1%). No Kaposi's sarcoma were diagnosed. Mean survival after a diagnostic of tumor was 11.7 months. CONCLUSIONS: The incidence of NHL is low in our transplant recipients. Conversely, we observed a high incidence of lung neoplasms (especially adenocarcinoma) which can be correlated with a heavy cigarette use in the study population.

Primary melanoma of the heart: case report of an association with coronary stenosis.

A 63-year-old man presented with unstable angina. The coronary angiogram revealed a proximal left anterior descending artery (LAD) stenosis and an irregularity on the anterior wall of the left ventricle. Intraoperatively, a malignant melanoma, independent of the coronary stenosis, was identified and resected, and an internal mammary graft was inserted. No primary tumor was found. The patient is alive 18 months after operation, with a normal magnetic resonance imaging (MRI), which seems to be the technique of choice for following-up heart melanomas.

Long-term results of heart transplantation deteriorate more rapidly in patients over 60 years of age.

It is generally agreed that the upper age limit for heart transplantation is 60 years. However, an increasing number of elderly candidates are accepted for heart transplantation. We retrospectively analyzed our experience with a total of 204 consecutive transplantations, performed in 195 adult patients (9 retransplantations) between March 1987 and September 1993. There were 48 patients older than 60 years (mean 62.9 +/- 3), group I (gr I) and 156 patients between 20 and 59 years old (mean 47.5 +/- 8), group II (gr II). The two groups were matched for sex-ratio (female 10.4 vs 14.2%), indications (cardiomyopathy, ischemic, others), and hemodynamic parameters (pulmonary artery pressure, capillary wedge pressure, cardiac index). A ventricular assist device was used in 14 patients as bridge to transplantation in gr II vs 0 to gr I. There were seven early deaths in gr I (14.6%) vs 14 in gr II (8.97%, NS). A total of 183 survivors (41 vs 142) have been followed up for 1 month-6.3 years (mean follow-up 20.4 +/- 19.3 months in gr I, 35.4 +/- 23 in gr II). No patient was lost to follow-up. There were 11 late deaths in gr I vs 16 in gr II. The most common cause was malignancy (n = 4) in gr I and sudden death (n = 9) in gr II, with a significant difference. The actuarial survival was 68.8% in gr I vs 88.5% in gr II at 1 year 43.5% in gr I vs 76.4% in gr II at 5 years. In conclusion, transplanted patients over 60 years of age have a significantly poorer late survival than younger patients, despite similar good early results. Moreover, the causes of late deaths were different in the two groups. So, heart transplantation in patients over 60 years of age should be carefully considered.

Mechanical versus biological isolated aortic valvular replacement after the age of 70: equivalent long-term results.

OBJECTIVE: In order to evaluate the long-term outcome of valvular substitutes in the elderly, we retrospectively analyzed two comparative groups of patients consecutively operated on by the same team for an isolated valvular aortic replacement using either a mechanical or a pericardial prosthesis. METHODS: From 1982 to 1996, 206 patients over 70 years (mean 76.5+/-4.4) underwent an isolated aortic valvular replacement using either a St. Jude Medical (Group I, n = 93) or a Mitroflow (Group II, n= 113) prosthesis depending on the surgeon's preference at the time of surgery. Both groups matched for the following pre-operative variables: sex ratio, type of aortic valve disease, NYHA status, cardiac rhythm, mean pulmonary arterial pressure, left ventricular end-diastolic pressure, LV-AO gradient, cardiac index and ejection fraction. RESULTS: Given an early mortality rate of 6.4% in Group I and 4.4% in Group II (NS), follow-up (mean 4.4+/-3.7 years in Group I and 5.3+/-3.1 years in Group II) was 100% complete. Actuarial survival was 69.9+/-6 and 70.2+/-4.6% at 5 years for Group I and Group II, respectively, and 49.6+/-7.7 vs. 51.4+/-6.3% at 10 years (NS). Freedom from valve-related death was 86.5+/-4.8% in Group I vs. 82.7+/-4% in Group II at 5 years (NS) and 66.7+/-8.7 vs. 66.3+/-7% at 10 years (NS). There were no anticoagulant-related deaths or severe accidents in Group 1. A secondary valvular replacement was necessary in 4 patients in Group II vs. none in Group I. CONCLUSION: The study shows a similar late survival in both groups, with a strikingly low incidence of anticoagulant-related deaths in this population. Given a higher rate of reoperation after biological valve replacement, the use of mechanical valve in this aging population seems to be a valid option.

Anomalous origin of left coronary artery from the pulmonary artery: evolution of left ventricular function and perfusion after surgery in a 44-year-old man.

Anomalous origin of left coronary vessel from the pulmonary artery is an almost universally fatal form of congenital heart disease unless appropriate corrective surgery is performed at an early age. A case was diagnosed in a symptomatic 44-year-old man who presented an impairment of systolic left ventricular function. The abnormality was successfully treated with ligation of the left coronary artery combined with left internal mammary artery anastomosis. Left ventricular function improved dramatically six months after surgery, both at rest and during exercise. Such an evolution suggests that surgery may be indicated not only in infants but also in adults with this congenital heart abnormality.

The BVS 5000 biventricular assist device. The worldwide registry experience.

The BVS 5000 is an extracorporeal pulsatile assist device for temporary univentricular or biventricular support. A registry of BVS 5000 usage has enrolled 420 patients between June 1987 and February 1994. Data were voluntarily contributed from more than 60 centers in 15 countries. The device has been implanted for post-cardiotomy shock (n = 211), cardiomyopathy (n = 94), acute myocardial infarction (AMI) shock (n = 44), failed transplant (n = 45), and other indications (n = 26). Device support was biventricular in 65% of patients, left in 29%, and right in 5%. Mean length of support was 5.2 days. Of the patients, 78% were men and 81% were 60 years of age or younger. In the post-cardiotomy group, 116 (55%) were weaned or bridged, and 27% were discharged. Seventy percent of cardiomyopathy patients went on to transplant, of which 39 (58%) were discharged. Of the patients with AMI shock, 52% underwent transplant, and 16 (70%) of these were discharged. The use of ventricular support in the setting of post-cardiotomy is explored and compared with the standard practice of supporting patients with inotropes and intra-aortic balloon pumps (IABP). Analysis of the poor outcomes and high cost of standard practice suggests that ventricular assist may positively affect outcomes in this population. This multi-institutional experience supports the use of the BVS 5000 for short-term ventricular assistance and suggests the need for additional study of ventricular support in the post-cardiotomy setting.