Differences in clinical manifestations in patients with bicuspid and tricuspid aortic valves undergoing surgery of the aortic valve and/or ascending aorta.

A bicuspid aortic valve is found in approximately 2 % of the population. The data in the literature concerning the incidence of clinical manifestations are inconsistent, and a detailed comparison with patients with tricuspid aortic valve is not yet available. We analyzed the clinical manifestations and demographic data of patients with bicuspid and tricuspid aortic valves who underwent an operation on the aortic valve and/or the ascending aorta over a five-year period. The subjects were 2570 adult patients, of whom 555 (21.6 %) had a bicuspid aortic valve. The patients with a bicuspid aortic valve were, on average, 10 years younger at surgery than those with a tricuspid aortic valve (57.0 +/- 13.1 vs. 66.4 +/- 11.8 years, P < 0.0001). The spectrum of diseases necessitating aortic valve surgery was the same in both groups of patients. An increased diameter of the ascending aorta > or = 4.5 cm was seen significantly more often in patients with bicuspid aortic valve (22.7 % vs. 5.5 %, P < 0.0001). We conclude that there are important differences in clinical manifestations between patients with bicuspid and tricuspid aortic valves, so that patients with bicuspid valve need special attention.

Early and mid-term results of the Shelhigh stentless bioprosthesis in patients with active infective endocarditis.

AIMS: This study investigated the early and mid-term results following valve replacement with the new Shelhigh stentless bioprosthesis made entirely of biological material in patients with active infective endocarditis (AIE). MATERIAL AND METHODS: Between 02/2000 and 12/2004, 164 patients (n = 122 men, mean age 59, 18-85 years) received implantation of an AIE Shelhigh stentless bioprosthesis in the aortic, mitral, tricuspid or pulmonary position. A total of 119 patients (72.6%) had native AIE and 45 (27.4%) prosthetic AIE. A large proportion of the patients reached the operating room in a condition of cardiac decompensation: 37 (22.6%) patients were intubated, 40 (24.4%) had protracted septic shock and 41 (25.0%) required intensive catecholamine treatment. Surgery was regarded as urgent in 94 patients (57.4%) and was performed as an emergency procedure in 70 (42.6%). The mean follow-up time is 1.5 +/- 0.11 years (range, 5 months to 5.2 years). Echocardiographic follow-up examinations were performed early postoperatively and after 12 months. RESULTS: In terms of the operative indication, we found a highly significant difference in the survival rate between patients who were operated on urgently vs in an emergency. In patients who died within 30 days, the main cause of death was septic multiorgan failure (67.6%). Only three patients required reoperation due to reinfection of the Shelhigh bioprostheses; this represents a reinfection rate of 1.8% in relation to the whole cohort. The postoperative echocardiographic examinations showed the Shelhigh valves to have very good hemodynamics without relevant pressure gradients. CONCLUSION: Our experience in the use of Shelhigh bioprostheses in patients with native and prosthetic endocarditis show the early and mid-term results, in particular the low reinfection rate and the good hemodynamics, to be comparable with the results achieved using homografts. Since these prostheses are readily available and their implantation straightforward, they are increasingly being used in patients with endocarditis. These promising results need to verified in the long term.

Myocardial viability assessment in patients with highly impaired left ventricular function: comparison of delayed enhancement, dobutamine stress MRI, end-diastolic wall thickness, and TI201-SPECT with functional recovery after revascularization.

This study compared different magnetic resonance imaging (MRI) methods with Tl(201) single photon emission computerized tomography (SPECT) and the "gold standard" for viability assessment, functional recovery after coronary artery bypass grafting (CABG). Twenty patients (64+/-7.3 years) with severely impaired left ventricular function (ejection fraction [EF] 28.6+/-8.7%) underwent MRI and SPECT before and 6 months after CABG. Wall-motion abnormalities were assessed by stress cine MRI using low-dose dobutamine. A segment with a nonreversible defect in Tl(201)-SPECT and a delayed enhancement (DE) in an area >50% of the entire segment, as well as an end-diastolic wall thickness <6 mm, was defined as nonviable. The mean postoperative EF (n=20) improved slightly from 28.6+/-8.7% to 32.2+/-12.4% (not significant). Using the Tl(201)-SPECT as the reference method, end-diastolic wall thickness, MRI-DE, and stress MRI showed high sensitivity of 94%, 93%, and 84%, respectively, but low specificities. Using the recovery of contractile function 6 months after CABG as the gold standard, MRI-DE showed an even higher sensitivity of 99%, end-diastolic wall thickness 96%, stress MRI 88%, and Tl(201)-SPECT 86%. MRI-DE showed advantages compared with the widely used Tl(201)-SPECT and all other MRI methods for predicting myocardial recovery after CABG.

[Coronary artery bypass grafting in patients with highly impaired ventricular function. Long-term outcome]. / Koronarbypassoperation bei hochgradig eingeschränkter Ventrikelfunktion - Langzeitergebnisse.

BACKGROUND AND OBJECTIVE: Left ventricular function is the most important predictor of survival in patients with coronary artery disease. It is also an important indicator for hospital mortality after operation for end-stage coronary artery disease. In our study we investigated, how preoperative ventricular dysfunction influences long term survival after coronary bypass surgery. PATIENTS AND METHODS: Between 4/1986 and 12/2000, 1751 patients (1440 men/311 women) with left ventricular ejection fraction (LVEF) 10-30% underwent coronary bypass grafting (CABG) at the Deutsches Herzzentrum Berlin. The age of the patients was calculated to an average of 59,2 years. The prime criterion for CABG was ischemia ("hibernating myocardium") diagnosed by myocardial scintigraphy, echocardiography and in some cases with magnetic resonance imaging and positron emission tomography. RESULTS: Operative mortality for the group was 7,1%. The actuarial survival rate was 87,6% after 2 years, 76,0% after 5, and 53,3% after 9. 455 had LVEF 10-20%, in these actuarial survival was 79,8% after 2 years, 63,0% after 5 and 45,7% after 9 years. CONCLUSION: We conclude that CABG can be used successfully to improve life expectancy of patients with end-stage coronary artery disease. CABG leads to acceptable prognosis for these high-risk patients when the myocardium is preoperatively identified as being viable.

Surgical management of acute aortic root endocarditis with viable homograft: 13-year experience.

OBJECTIVE: Cryopreserved homograft valves have been used for acute infective aortic root endocarditis with great success but it is compounded by its availability in all sizes. The long-term clinical results of geometric mismatched homografts are not well defined and addressed. METHODS: Over a 15-year period (April 1986-June 2001), 816 patients presented with active infective endocarditis. One hundred and eighty-two of the patients aged between 9 and 78 years (mean: 51.0 +/- 1.13 years) consisting of 142 males and 40 females received homograft aortic valves. One hundred and ten patients were in NYHA functional class III and 72 in class IV and in cardiogenic shock. Of the patients, 2.7% suffered from septic embolism. One hundred and twenty-four (68.1%) patients presented with periannular abscesses and 58 (31.9%) with no abscess while 107 native valve (NVE) and 75 prosthetic valve (PVE) endocarditis were diagnosed preoperatively by transesophageal echocardiography (TEE) and confirmed intraoperatively. Freehand subcoronary implantation (FSCI) was used in 106 patients and root replacement in 76 patients. RESULTS: The operative death was 8.5% and for patients in NYHA functional class IV and in cardiogenic shock was 14.5%. Late mortality rate was 7.9%. Patient survival after discharge from hospital at 1 year was 97% and at 10 years was 91%, respectively. Thirty-one (22.1%) patients underwent reoperation after 1.7 years (mean) with two deaths (6.4%). Early (< or = 60 days) and late reinfection rate was 2.7 and 3.6%, respectively. Freedom from reoperation for matched and undersized homografts at 10-13 years was 85 and 55%, respectively. The univariate model identified undersized homograft (P=0.002), FSCI (P=0.09) and reinfection (P=0.0001) as independent risk factors for developing early and late valve dysfunction resulting in reoperation and homograft explant. CONCLUSION: Early aggressive valve replacement with homograft for active infective aortic root endocarditis with periannular abscesses is more successful than delayed last resort surgery. Homografts exhibit excellent clinical performance and durability with a low rate of reinfection, if properly inserted. Undersized homograft is an incremental risk factor for early and late reoperation.

Decreased plasma concentration of brain natriuretic peptide as a potential indicator of cardiac recovery in patients supported by mechanical circulatory assist systems.

OBJECTIVES: We sought to investigate the relationship between the plasma concentration of brain natriuretic peptide (BNP), echocardiographic findings and the clinical outcome of patients supported with ventricular assist devices (VADs) to determine the role of BNP as a predictor for cardiac recovery. BACKGROUND: Ventricular unloading in patients with end-stage heart failure supported by VADs may lead to myocardial recovery. The BNP is produced in the myocardium in response to chronic volume overload, but the effects on it of ventricular unloading by VADs are largely unknown. METHODS: Twenty-one patients diagnosed with nonischemic cardiomyopathy and supported by VADs were evaluated for echocardiographic data and blood chemistry including BNP. They were divided into patients who died while on mechanical support (group I; n = 9), patients who were transplanted (group II; n = 8) and patients who were successfully weaned off the system and did not require transplantation (group III; n = 4). RESULTS: Brain natriuretic peptide plasma concentrations decreased significantly after initiation of mechanical circulatory support (p = 0.017). Furthermore, the changes in BNP plasma concentrations showed a faster decrease to normal levels within the first week after implantation of the VAD in patients who were weaned off the system (group III) compared to patients in group I and group II. CONCLUSIONS: This study shows that ventricular unloading with VADs decreases BNP plasma concentrations in patients who suffer from end-stage heart failure. Furthermore, we hypothesize that an early decrease of BNP plasma concentration may be indicative of recovery of ventricular function during mechanical circulatory support.

Predictors of survival 1 hour after implantation of an intra-aortic balloon pump in cardiac surgery.

From July 1996 to March 2000, 391 patients with intraoperative cardiac low-output syndrome who underwent surgery with heart-lung bypass and had an intra-aortic balloon pump (IABP) implanted were analyzed in a prospective study. Of these 391 patients, 153 (39%) were operated on in an emergency situation, and 238 (61%) patients had elective surgeries. The perioperative mortality was 34% (133 patients). Clinical parameters were analyzed 1 hour after IABP support began. Statistical multivariate analysis showed that patients with an adrenaline requirement higher than 0.5 microg/kg/min, a left atrial pressure higher than 15 mmHg, output of less than 100 mL/hour, and mixed venous saturation (SvQ2) of less than 60% had poor outcomes. Using this data, we developed an IABP score to predict survival early after IABP implantation in cardiac surgery. We conclude that the success or failure of perioperative IABP support can be predicted early after implantation of the balloon pump. In patients with low-output syndrome despite IABP support, implantation of a ventricular assist system should be considered.

Geometric mismatch between homograft (allograft) and native aortic root: a 14-year clinical experience.

OBJECTIVES: We evaluated the effect of homograft/native aortic root geometric matching and mismatching on valve survival and myocardial remodeling. METHODS: Between January 1, 1987 and March 2000, a total of 292 patients, aged 1.5-78 years (mean, 46.2 years), underwent freehand subcoronary aortic valve (AVR; n=207) and root (ARR; n=85) replacement with matched and mismatched cryopreserved homografts. All patients had pre- and postoperative two-dimensional Doppler echocardiographic studies. Two-hundred and forty-three survivors, excluding children with complete data on sizing, were followed at a total follow-up time of 1269 patient-years. Seventy percent received matched and 30% received mismatched aortic homografts. The homograft valve sizes ranged from 19 to 28 mm. RESULTS: Hospital death for elective first operation was 2.3%, and late death after a mean follow-up of 52 months was 7.9%. The patient survival at 14 years was 92+/-2%. By linear regression analysis, matched homografts were equal to or 1-2 mm less than the native aortic annulus (r(2)=0.73). The valve survival in patients with AVR and ARR was 72+/-4 and 80+/-8% at 14 years, respectively. The freedom from reoperation was 92+/-5, 77+/-4 and 48+/-10% at 14 years for matched, oversized and undersized homografts, respectively (P=0.001). The postoperative cardiac index of patients with 22 and 24 mm homografts was 3.8-4.1 l/m(2), and there was a regression of the left ventricular mass and end-diastolic diameter (P=0.001). CONCLUSIONS: The aortic homograft offers an excellent long-term clinical result. A mismatched homograft is a risk factor for postoperative aortic incompetence, reinfection with pseudoaneurysmal formation and reoperation for the freehand subcoronary implantation technique during the first 7 years of the postoperative period. It is prudent therefore to avoid mismatched homografts and use rather a properly sized stentless xenograft if a root replacement is not indicated.

Effects of prosthetic valve placement on mitral annular dynamics and the left ventricular base.

Insertion of a rigid mitral prosthesis impairs the function of the mitral annulus and induces systolic narrowing of the left ventricular outflow tract (LVOT). To study this mechanism, we investigated dynamic changes in the left ventricular (LV) base, which consists of the mitral annulus and LVOT orifice. In seven patients with mechanical mitral valve prostheses and eight normal subjects, the image of the LV base was reconstructed three-dimensionally and its dynamic change during systole was studied. In the patients, the rigid prosthetic valve (=mitral annulus) tilted toward the left ventricle with a hinge point at the posterior mitral annulus during systole. The left ventricular base exhibited contraction, but the size of the prosthetic valve was constant. As a consequence, the prosthetic valve occupied more of the left ventricular base, which resulted in narrowing of the LVOT. In the normal subjects, the mitral annulus did not interfere with the region of the LVOT orifice during systole as the mitral annulus underwent both dorsiflexion and contraction. Thus, fixation of the mitral annulus induces an anti-physiologic motion of the annulus. Conscious preservation of annular flexibility in mitral valve surgery is important in avoiding potential dynamic LVOT obstruction.

Annular stabilization in mitral repair without a prosthetic ring.

BACKGROUND AND AIM OF THE STUDY: Annular stability is not guaranteed after mitral repair without a prosthetic ring. We introduce a newly developed plication technique and detail its stabilizing effect on the mitral annulus after Gerbode plasty. METHODS: Patients suffered degenerative mitral valve prolapse with chordal rupture restricted to the middle scallop of the posterior leaflet. Between 1986 and 1997, 102 patients underwent Gerbode plasty with or without annular reinforcement with a pericardial strip or modified Paneth plasty (group C). The mean (+/- SD) follow up was 70.4 +/- 41.1 months. Since 1996, 32 patients have undergone a newly developed annuloplasty technique (group N), where a pericardial strip was tightly anchored to the bilateral trigones and posterior annulus, which was folded by Gerbode plasty. With the final anchoring suture the intention was to prevent plication breakdown of this portion. Mean follow up for this group was 17.6 +/- 7.1 months. Progression of mitral regurgitation after surgery in both groups was studied. RESULTS: In group C, postoperative progression of mitral valve regurgitation occurred in 41.1% of patients (5.9% to grade 1, 17.6% to grade 2, 17.6% to grade 3). Among these patients, reoperation was due to plication breakdown of the Gerbode plasty in six cases (5.9%), and to either chordal rupture or annular dilatation in 10 cases each (9.8%). In contrast, no reoperation due to recurrent severe mitral regurgitation was needed in group N. Progression of mitral regurgitation after surgery was seen in six patients (two to grade 1; four to grade 2). CONCLUSION: The newly developed annuloplasty technique may be useful in stabilizing the mitral annulus after Gerbode plasty.

[Ventricular septal aneurysm in a patient with Marfan syndrome]. / Ventrikelseptumaneurysma bei einer Patientin mit Marfan-Syndrom.

This is the first description of a patient with Marfan syndrome and an aneurysm of the ventricular septum. Apart from a borderline dilatation of the ascending aorta, there were no cardiovascular manifestations of Marfan syndrome. A transesophageal echocardiographic examination showed a large aneurysm of the ventricular septum. To prevent the imminent rupture and the acute occurrence of a significant left-to-right-shunt on the ventricular level, as well as increasing irritation of tricuspid valve, an elective operation was performed. Besides the routine cardiological diagnostics, the search for intracardial defects is also necessary in patients with Marfan syndrome.

Tricuspid valve dysfunction and surgery after orthotopic cardiac transplantation.

OBJECTIVE: The study examines the prevalence of tricuspid regurgitation and biopsy-induced flail tricuspid leaflets after orthotopic heart transplantation and evaluates the results of the tricuspid valve surgery. METHODS: By a computerized search of the databases 647 of 889 patients who survived heart transplantation for more than 30 days were identified for this study. The primary tool for rejection monitoring in our institution is the daily observation of intramyocardial ECG (IMEG) based on day-by-day changes of the maximal QRS complex amplitude. Endomyocardial biopsy with 45-cm-long sheath bioptome was performed only in doubtful IMEG and echocardiographic data and at times of annual routine heart catheterization. Tricuspid regurgitation was diagnosed clinically and by echocardiography as mild, moderate and severe. Eleven patients received prosthetic valve replacements (four bioprostheses and seven mechanical valves) and six patients underwent valve reconstruction. The choice of xenograft valve was dictated by the condition of renal function. Patient survival and incidence of tricuspid regurgitation and freedom from operation for severe tricuspid regurgitation were analyzed with Kaplan-Meier method. RESULTS: The prevalence of tricuspid regurgitation was 20.1%. Mild and moderate tricuspid regurgitation was seen in 14.5 and 3.1% of the patients, respectively, who were responsive to medical therapy and remained clinically stable in NYHA class I-II. Severe tricuspid regurgitation was seen in 16 (2.5%) patients who presented signs of an acute right heart dysfunction. Tricuspid valve pathology at operation revealed biopsy-induced rupture of the Chordae tendineae at various valve segments mostly the anterior and posterior leaflets. There was one hospital death (<30 day) and five late deaths due to infection, arrhythmia and trauma and no procedural-related or directly cardiac related death. Ten patients (62.5%) are alive at a mean follow-up time of 29.9 months (range 4-81 months) and nine survivors are in NYHA class I-II and one in class III. CONCLUSIONS: Severe tricuspid regurgitation in transplanted hearts is associated mainly with biopsy-induced injury or endocarditis. Other regimes of rejection monitoring may help to eliminate this complication. Apart from our preference of valve repair, the choice of valve substitute may be influenced by the presence or the prospect of chronic renal failure. Heart transplant patients can safely undergo valve surgery with acceptable mortality, low morbidity and excellent intermediate-term clinical results. Mild to moderate functional tricuspid regurgitation is responsive to medical therapy and non-progressive and occur in 17.6% of orthotopic transplanted hearts without having a detrimental effect on the right ventricular performance.

Surgical treatment of active infective aortic valve endocarditis with associated periannular abscess--11 year results.

AIMS: The aim of the study was to evaluate the long-term results of allograft and prosthetic valve replacement in the treatment of infective aortic valve endocarditis with periannular abscess. METHODS: Between March 1988 and March 1996, 65 patients underwent surgery for active aortic valve endocarditis and paravalvular abscess. The indications for surgery were congestive heart failure, systemic emboli and atrioventricular block III. The pre-operative evaluation was performed with transoesophageal echocardiography. Aortic valve replacement was performed with allografts in 47 cases, with mechanical valves in 15, and bioprosthetic valves in three cases. All patients with total ventricular-aortic dehiscence and prosthetic valve endocarditis were treated with allografts. RESULTS: The 30-day mortality rate was 23.5% in the prosthetic group, when compared with 8.5% in the patients treated with allografts. The rate of recurrent valve infections during the 11-year follow-up period was 27.1% in the prosthetic group and 3.2% in the allograft group. The actuarial 11-year survival rate was 82.1% in the allograft group and 64.7% in the prosthetic group. CONCLUSION: Aortic allografts are an effective treatment for infective aortic valve endocarditis with associated periannular abscess. The operative mortality and recurrent infection rates are lower than in the prosthetic group, resulting in a significantly higher survival rate. Diagnosis and surgical management of these cases should be based on pre-operative transoesophageal echocardiography.

Mitral valve reconstruction and replacement for ischemic mitral insufficiency: seven years' follow up.

BACKGROUND AND AIMS OF THE STUDY: Patients with ischemic mitral incompetence have a high operative risk whether the valve is repaired or replaced. The advantage of repair over replacement is unclear in this subgroup of patients. METHODS: Between April 1986 and December 1998, 337 patients underwent surgery for ischemic mitral valve insufficiency. Coronary artery bypass grafting (CABG) was carried out concomitantly in 314 cases (93.2%). Valve repair was performed in 140 patients (operative mortality rate 12.1%). The surgical risk in patients with a left ventricular ejection fraction (LVEF) of 10-30% was higher (operative mortality rate 33.3%) than in those with LVEF >30% (operative mortality rate 8.4%). Actuarial survival rates were 75.4%, 66.8% and 61.7% after 2, 5 and 7 years, respectively. Mitral valve replacement was performed in 197 patients (operative mortality rate 14.2%). The surgical risk in patients with a LVEF of 10-30% (operative mortality rate 30.3%) was greater than in those with a LVEF of >30% (operative mortality rate 11.0%).Actuarial survival rates after replacement were 78.6%, 73.4% 67.2% after 2, 5 and 7 years, respectively. RESULTS: Our initial analysis showed that, after mitral valve repair, mortality during follow up was greater in patients with residual mitral valve insufficiency of more than grade I. Subsequent outcome was superior when repair was evaluated perioperatively with transesophageal echocardiography. When mitral insufficiency was persistently more than grade I after repair, mitral replacement was performed. A total of 105 patients was analyzed with no or maximum grade I mitral insufficiency following valve repair; actuarial survival rates were 81%, 78.4% and 77.2% after 2, 5 and 7 years' follow up. CONCLUSIONS: Patients with highly impaired LV function and ischemic mitral insufficiency are at high risk during valve repair or replacement, and cardiac transplantation should be considered for this group. However, patients with ischemic mitral insufficiency and moderately impaired LV function can undergo valve repair or replacement with an acceptable prognosis. The goal of mitral valve repair should be to reduce valvular insufficiency to at least grade I. If this is not the case, then the prognosis of repair is worse than after valve replacement. Thus, the surgeon should replace the valve during the same operation.

The Cox maze iii procedure: parallel normalization of sinus node dysfunction, improvement of atrial function, and recovery of the cardiac autonomic nervous system.

OBJECTIVE: The Cox maze III procedure includes isolation of the pulmonary veins and multiple incisions in both atria in what corresponds to partial autotransplantation and partial denervation of the heart. The aim of this prospective longitudinal study was to identify physiologic effects of reinnervation on changes in heart rate at rest and in response to various stimulations and on atrial function after the Cox maze III procedure. PATIENTS AND METHODS: Power spectral analysis of heart rate variability, exercise testing, 24-hour Holter monitoring, electrocardiography, and transthoracic and transesophageal echocardiography were performed in 30 adult patients after the combined Cox maze III procedure and mitral valve surgery (maze group). They were prospectively followed up at 1, 3, 6, and 12 months after the operation. The results were compared with those of 15 heart transplant recipients (transplant group) and normal probands (healthy adults, n = 12). RESULTS: The physiologic effects of denervation with no differences in cardiac autonomic activity between the groups were seen early after the operation. Later, evidence of autonomic reinnervation was observed only in the maze group but not in the transplant group. Inappropriate heart rate responses during physical exercise were clearly evident in both groups after 1 and 3 months, with progressive improvement seen between 6 and 12 months only in the maze group. Left atrial function after the Cox maze procedure improved parallel to the recovery of sinus node function. CONCLUSION: Progressive improvement of sinus node function and atrial contractions with significant functional normalization 1 year after the Cox maze procedure corresponded to functional reinnervation and recovery of the autonomic nervous system.

Identification of P waves after the Cox-maze procedure: significance of right precordial leads V3R through V6R.

BACKGROUND: The maze circuit lengthens the period of atrial depolarization and may lead to small or absent P waves, which may not be readily apparent in a standard 12-lead electrocardiogram. In this prospective study, we investigate if the right precordial leads V3R through V6R can improve detection of P waves and identification of atrial electrical activity. METHODS: Standard 12-lead electrocardiograms (with leads I through III, aVR, aVL, aVF, and V1 through V6) and right precordial electrocardiograms (V3R through V6R) were recorded in 30 consecutive patients during the first 5 postoperative days and 1, 3, 6, 12, and 24 months after combined Cox-maze III procedure and mitral valve surgery. The P wave identification as an indication of atrial electrical activity and atrial contraction was proved by transesophageal echocardiographic identification of atrial contractions. RESULTS: Despite echocardiographically identifiable atrial contractions, the P waves were not visible on standard 12-lead electrocardiograms in 7 (23%) patients after 1 and 3 months, and in 4 patients after 6 months. In contrast, right precordial electrocardiograms showed P waves in all of these patients that were best seen in lead V4R. Twelve and 24 months postoperatively, only 2 patients had no visible P waves in the standard leads that were still present in the right precordial leads. However, if P waves were easily identifiable in standard 12-lead electrocardiograms (23 patients at 1 and 3 months after surgery), the right precordial leads showed P waves only in 15 patients. CONCLUSIONS: Right precordial electrocardiogram with leads V3R through V6R is a helpful tool for visualizing P waves after the Cox-maze procedure. Standard 12-lead electrocardiogram should be combined with right precordial electrocardiogram in all patients after the Cox-maze procedure.

Transient sinus node dysfunction after the Cox-maze III procedure in patients with organic heart disease and chronic fixed atrial fibrillation.

OBJECTIVES: This prospective study examined types, frequency and time dependency of the electrophysiologic manifestation of the sinus node dysfunction after the Cox-maze III procedure--the technique of choice for the management of medically refractory atrial fibrillation-in patients with organic heart disease, chronic fixed atrial fibrillation and no preoperatively overt dysfunction of the sinus node. BACKGROUND: The original maze procedure was modified twice in order to reduce the high incidence of the sinus node inability to generate an appropriate sinus tachycardia in response to maximal exercise, and occasional left atrial dysfunction. Despite these modifications, postoperative disturbance of sinus node function can be frequently observed. METHODS: In 15 adult patients, standard electrocardiogram, 24-h Holter monitoring, power spectral analysis of heart variability, exercise testing, Valsalva maneuver and rapid positional changes were performed 3, 6 and 12 months after the Cox-maze III procedure and mitral valve surgery or closure of atrial septal defect. RESULTS: Electrocardiographic manifestations of sinus node dysfunction were identified in 12 patients at 3 months, in 6 patients at 6 months, and in 0 patients at 12 months after surgery. The heart rate response to exercise during the first 6 months was reduced in the maze group and became fully normal at 12 months. Power spectral analysis of heart rate variability showed very low power values at 1 month with inhibited cardiac autonomic activity and no response on sympathetic stress. A potential of recovery of cardiac autonomic activity was documented 12 months after surgery. CONCLUSIONS: The manifestations of sinus node dysfunction following the Cox-maze III procedure were time dependent and their frequency and intensity progressively decreased and disappeared within 12 months after surgery.

["Cox/Maze-III operation" as surgical therapy of chronic atrial fibrillation during mitral valve and atrial septal defect II operation]. / "Cox/Maze-III-Operation" als chirurgische Therapie des chronischen Vorhofflimmerns während Mitralklappen-und ASD-II-Operation.

PROBLEM: Atrial fibrillation is associated with significant morbidity and mortality. The increased risk of thromboembolism makes constant anti-coagulation necessary, while the absence of atrial contraction worsens the hemodynamic situation. In this study we examined the results of simultaneous surgical treatment of chronic atrial fibrillation through "Cox/Maze-III-procedure" while mitral valve surgery and atrial septal closure. PATIENTS AND METHODS: Between February 1995 and July 1997 sixteen patients aged 50 to 72 y (mean: 59 y) underwent open heart surgery (mitral valve replacement n = 10, reconstruction n = 3; mitral valve reconstruction and atrial septal closure n = 1, atrial septal closure n = 1, thrombectomy from left atrium n = 1) and "Cox/Maze-III-procedure" in one session. Preoperative duration of chronic atrial fibrillation was between 2 and 12 y (mean: 5.0 y). The patients were examined preoperatively and postoperatively 3, 6, 12, and 24 months after surgery using the following methods: transesophageal echocardiography (TEE), ECG, long-term ECG, and stress ergometry. RESULTS: During the early postoperative period (< 7 d) all of the patients were in sinus rhythm or atrial pacing; eight patients intermittently had atrial fibrillation. In the follow-up period from 1 to 27 months (mean 14 months), 15 patients have a stable sinus rhythm (94%). One patient, preoperatively known to have intermittent tachybradycardia, received a pacemaker 2 months postoperatively for sinus bradycardia. Postoperatively in TEE patients showed left atrial contraction with improvement of hemodynamic situation. Stress ergometry 6 months postoperatively showed lower increasements of heart rate, at 12 months normal frequency. CONCLUSION: The surgical treatment of chronic atrial fibrillation through "Cox/Maze-III-procedure" can be performed combined with other heart operations without increased perioperative or postoperative risks. The Maze-procedure is an effective surgical therapy of chronic atrial fibrillation. Postoperatively there is an improvement of the hemodynamic situation because of sinus rhythm and synchrone atrioventricular contraction.

Treatment of humoral rejection after heart transplantation.

BACKGROUND: Until a few years ago, the incidence of humoral rejection after heart transplantation was underestimated. These episodes were frequently very aggressive and often fatal, because the maintenance and emergency immunosuppression available at the time only inadequately covered the humoral branch of the immune response. In spite of individual case reports, the effects of blood purification procedures or cyclophosphamide in this situation can only be insufficiently estimated. METHODS: To evaluate this therapy concept, 20 dog-lymphocyte-antigen-matched dogs underwent heterotopic neck-heart transplantation. Fourteen dogs underwent transplantation after having been previously sensitized through multiple skin transplantations, 6 dogs were not sensitized (control). The animals received an induction with 3x 250 mg prednisolone, as well as triple immunosuppression (cyclosporine, azathioprine, and cortisone). Biopsy (light microscopy, immunofluorescence), intramyocardial voltage, electric myocardial impedance (>200 kHz, <10 kHz), and echocardiographic (left ventricular wall thickness, diastolic relaxation velocity) examinations were performed daily to monitor rejection. Rejection therapy was continued for 3 days according to the following regimen: apheresis, cortisone boluses (CB), and cyclophosphamide in group A1 (n = 4), apheresis and CB without cyclophosphamide in group A2 (n = 4), and CB only in group C (n = 6). The subsequent course under triple immunosuppression was then observed. RESULTS: In the sensitized animals the onset of severe humoral rejection on the fifth day deteriorated cardiac function down to 75% (70% to 80%) of the initial values. In groups A1 and A2, apheresis resulted in recovery to near-control values (89% to 94%) within two hours, and indeed to complete recovery (97% to 101%) after the second apheresis, that is, within 1 day. In group C recovery was delayed (2 days) and incomplete (84% to 91 %). After therapy was discontinued, rejection-related functional deterioration recurred immediately in group C, and from 2 to 3 days after apheresis, regardless of whether cyclophosphamide therapy was performed (group A1) or not (group A2). In the control group all animals showed a rejection-free posttransplantation course. CONCLUSIONS: By diluting inflammatory mediators, apheresis leads to a rapid improvement in cardiac function during severe humoral rejection after head transplantation. Neither apheresis nor cyclophosphamide therapy are able to have an immediate positive influence on the activation of the immune cascade and to prevent an ongoing rejection.

Decision-making in end-stage coronary artery disease: revascularization or heart transplantation?

BACKGROUND: Left ventricular function is the most important predictor of survival in patients with coronary artery disease. It is also an important indicator for hospital and late mortality after operation for endstage coronary artery disease. METHODS: Between April 1986 and December 1994, 514 patients with end-stage coronary artery disease and left ventricular ejection fraction between 0.10 and 0.30 underwent coronary artery bypass grafting at the German Heart Institute Berlin. Two hundred twenty-five of these patients had been referred as possible candidates for heart transplantation. The prime criterion for bypass grafting was ischemia diagnosed by myocardial scintigraphy and echocardiography ("hibernating myocardium"). RESULTS: Operative mortality for the group was 7.1%. The actuarial survival rate was 90.8% after 2 years, 87.6% after 4, and 78.9% after 6. Left heart catheterizations performed 1 year after the operation showed that left ventricular ejection fraction had increased from a mean of 0.24 +/- 0.03 preoperatively to 0.39 +/- 0.06 postoperatively (p < 0.0001). Preoperatively 91.6% of the patients were in New York Heart Association (NYHA) class III or IV; 6 months postoperatively 90.2% of the surviving patients were in NYHA class I or II. Two hundred thirty-one patients with end-stage coronary artery disease and predominant heart failure underwent heart transplantation. Their actuarial survival rate was 74.9% after 2 years, 73.2% after 4, and 68.9% after 6. All of the patients could be recategorized into NYHA class I or II after the operation. CONCLUSIONS: We conclude that coronary artery bypass grafting and heart transplantation can be used successfully to improve the life expectancy of patients with end-stage coronary artery disease. Coronary artery bypass grafting leads to an excellent prognosis for these high-risk patients when the myocardium is preoperatively identified as being viable.