Persistent atrial fibrillation ablation concomitant to coronary surgery.

OBJECTIVE: This analysis was undertaken to evaluate the results of persistent atrial fibrillation (pAF) ablation procedures concomitant to coronary surgery and to identify the risk factors for pAF recurrence. METHODS: Since 2001, a total of 126 consecutive patients with pAF (duration: 0.5-33 years) underwent ablation concomitant to coronary surgery (isolated or in combination with valve surgery), whereby two encircling isolation lesions around the left and the right pulmonary veins and a connecting lesion between both was created using radiofrequency ablation. Patients were reevaluated at discharge, 3 months and 3 years after surgery. RESULTS: Survivals at the time of reexamination were 96.8, 95.1 and 94.7 %, respectively. Stable sinus rhythm (SR) could be documented in 66.4, 75.1 and 75.9 % of surviving patients. Long-term pAF before surgery and a larger left atrium (LA) were predictive of postoperative pAF return ( P < 0.01). Statistical analysis demonstrated a cut-off point of 5 years for pAF and 50 mm for LA diameter: 89.1 % of patients with pAF duration of < 5 years and 86.2 % of patients with LA size of ≤ 50 mm were in stable SR at late follow-up. Cardiac rhythm at 3 months was predictive for long-term rhythm prognosis ( P < 0.01). Age, gender and concomitant diseases (e.g. arterial hypertension, diabetes, renal insufficiency), and the underlying cause of heart disease did not significantly influence the postoperative cardiac rhythm. CONCLUSIONS: The duration of pAF and the LA size are the most reliable preoperative variables to predict the success rate of ablation in patients undergoing coronary surgery. The probability of re-establishing stable SR is excellent when pAF duration is short and LA size is small.

Early and late results of permanent atrial fibrillation ablation surgery in aortic valve and CABG patients.

OBJECTIVE: The study investigates the early and late results of permanent atrial fibrillation (AF) ablation surgery concomitant to coronary artery bypass grafting (CABG) and/or aortic valve (AV) surgery. METHODS: Between February 2001 and April 2006, a selective group of 80 patients with permanent AF (median: 48 months [Perc25/75 24/110; range: 6 - 360 months]) underwent either bipolar (n = 60) or monopolar (n = 20) radiofrequency (RF) ablation procedures concomitant to CABG and/or AV surgery (CABG: n = 39; AV: n = 30; AV + CABG: n = 11). All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 +/- 1 months) and late after surgery (30 +/- 15 months). Data were analyzed exploratively. RESULTS: Survival at 3 and 30 months was 98 % and 96 %, respectively. Stable SR could be documented in 73 % and 77 % of patients. Long-term AF before surgery and larger LA size were predictive for AF return after surgery ( P = 0.004 and P = 0.032, respectively). Neither age, gender, the application modus of the RF energy nor the underlying cardiac disease influenced the postoperative cardiac rhythm significantly. NYHA class improved significantly after surgery ( P < 0.0005), particularly when stable SR was achieved ( P = 0.049). CONCLUSION: Preoperative permanent AF duration time and larger LA size are useful variables to predict the success rate of concomitant ablation surgery in CABG and/or AV patients. Further it could be demonstrated that established SR remained stable over time.

Early and late results of restrictive mitral valve annuloplasty in 121 patients with cardiomyopathy and chronic mitral regurgitation.

OBJECTIVE: This study investigated the early and late results of restrictive mitral valve (MV) annuloplasty in patients with chronic mitral regurgitation (MR) and advanced ischemic (ICM) or dilated cardiomyopathy (DCM). METHODS: From October 2001 to September 2006, 121 patients (age: 69 +/- 9 years) with a left ventricular ejection fraction (LVEF) of 30 +/- 9 % and chronic MR grade 3 - 4 (ICM: n = 102, DCM: n = 19) underwent restrictive prosthetic ring annuloplasty (downsizing of 2.7 +/- 0.8 ring sizes). Eighty-five ICM-patients had indications for concomitant coronary artery bypass grafting (CABG). All patients were restudied at 7 +/- 1 days, 3 +/- 1 and 30 +/- 12 months after surgery to assess survival, residual MR, New York Heart Association (NYHA) class and left ventricular (LV) function (end-systolic/end-diastolic dimensions/volume indexes and LVEF). Data were analyzed exploratively. RESULTS: 30-day mortality was 3.3 %; survival at follow-up was 95 % and 91 %, respectively. Postoperative recurrence of significant MR (> grade 2) was absent in all patients. NYHA class, LV dimensions/volume indexes and LVEF improved significantly after surgery in both groups ( P < 0.0005). A prediction of continuous postoperative improvement of myocardial function in the sense of reverse remodeling could be demonstrated by univariate logistic regression for ischemic etiology and concomitant CABG ( P = 0.0001). In DCM-patients or ICM-patients without CABG, the postoperative benefit on myocardial function was limited. CONCLUSION: Restrictive mitral valve (MV) annuloplasty corrected chronic MR in cardiomyopathy patients with low mortality and improved contractility. Surgery also prevented recurrence of significant MR, although the phenomenon of postoperative continuous reverse myocardial remodeling could not be verified in cases with a non-ischemic etiology or ICM without concomitant CABG.

Ablation surgery failure after combined permanent atrial fibrillation ablation and mitral valve surgery.

OBJECTIVE: The aim of this study was to evaluate the early and late results of a permanent atrial fibrillation (pAF) ablation concept carried out concomitantly with mitral valve (MV) surgery and to identify risk factors for ablation surgery failure. METHODS: Between February 2001 and April 2006, 109 patients with pAF over a median time of 48 months (Perc25/75; range 6 - 396 months) underwent monopolar endocardial radiofrequency ablation procedures concomitantly with MV surgery. All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 +/- 1 months) and late after surgery (36 +/- 19 months). For data assessment an explorative data analysis including univariate and multivariate binary logistic regression was performed. RESULTS: Early and late survival was 95 % and 91 %, respectively; at follow-up stable SR was documented in 76 % (74 %) of patients. NYHA class improved significantly after surgery ( P = 0.009), particularly when stable SR was achieved ( P = 0.042). Among these MV patients left atrial (LA) enlargement and pAF of long-time duration prior to surgery were detected as risk factors for postoperative recurrence and persistence of atrial fibrillation ( P = 0.026 and P = 0.002); furthermore, advanced age and significant tricuspidal regurgitation at the time of surgery were also relevant. The best prediction (95 % of patients) for SR, as demonstrated in a multivariate model, was based on the factors LA size and pAF duration ( P = 0.052 and 0.005). CONCLUSION: Particularly the preoperative LA size and pAF duration seem to be useful parameters to evaluate the success rate of ablation performed concomitantly with MV surgery. It could be demonstrated that an established SR remains stable over time.

Changes of myocardial function after combined coronary revascularization and mitral valve downsizing in patients with ischemic mitral regurgitation and advanced cardiomyopathy.

OBJECTIVE: At present not much data is available on changes in myocardial function after combined coronary artery bypass grafting (CABG) and downsizing of the mitral valve (MV) by restrictive prosthetic ring annuloplasty in patients with chronic ischemic mitral regurgitation (IMR) and advanced cardiomyopathy. METHODS: 63 patients with coronary artery disease, chronic IMR grade 3 - 4+, ischemic cardiomyopathy and reduced left ventricular (LV) function (LV ejection fraction [LVEF] of 30 +/- 9 %; range 12 - 45 %) underwent combined CABG and MV downsizing. Clinical follow-up and serial echocardiographic studies were performed to assess survival, New York Heart Association (NYHA) class, mitral regurgitation (MR), leaflet coaptation height (LCH), left atrial (LA) and LV end-systolic/end-diastolic dimensions/volumes and volume indices (LVESD, -EDD; LVESV, -EDV; LVESVI, -EDVI), fractional shortening (FS) and LVEF to evaluate the changes in myocardial function after surgery. RESULTS: Early mortality (< 30 days) was 1.6 %, survival at follow-up was 95 % (3 +/- 1 months) and 83 % (2 +/- 1 years), respectively. Functional class improved significantly after surgery; recurrence of relevant MR was absent in all patients. In general, LA/LV dimensions/volumes and volume indices, FS and LVEF improved significantly, even in patients with already severely reduced preoperative LV function (LVEF

Permanent atrial fibrillation ablation surgery in CABG and aortic valve patients is at least as effective as in mitral valve disease.

BACKGROUND: Data on combined permanent atrial fibrillation (pAF) surgery and coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) are scarce, and the mid- and long-term effects on survival and cardiac rhythm are unknown. MATERIAL AND METHODS: In a prospective analysis 125 patients (Group I: CABG and/or AVR, n = 50; Group II: mitral valve [MV] surgery, n = 75) with pAF (> or = 6 months) underwent either concomitant monopolar (Group I: n = 20; Group II: n = 75) or bipolar (Group I: n = 30) radiofrequency (RF) ablation procedures. Group I patients had a significantly smaller left atrial (LA) size than Group II patients (LA-diameter: 47.7 +/- 4.6 vs. 58.2 +/- 6.1 mm; p < 0.01). Regular follow-up was performed from 3 to 36 months after surgery to assess survival, NYHA-class, and conversion rate to stable sinus rhythm (SR). RESULTS: Early mortality (< 30 days) of Group I patients was 0% (Group II: 2.7%), cumulative survival at long-term follow-up was 0.95 vs. 0.82 (p = 0.31) and NYHA-class improved significantly in both groups, particularly in cases with stable SR. At follow-up 80% of Group I patients had SR (Group II: 70%). In Group I patients the bipolar approach was associated with significantly shorter ablation procedure times compared to the monopolar procedure (12.1 +/- 3.4 vs. 18.9 +/- 1.6 min; p < 0.05). CONCLUSIONS: Concomitant pAF ablation surgery in CABG and/or AVR is safe and at least as effective as in MV surgery, presumably because severe LA enlargement is exceptionally rare in this group.

[Papillary fibroelastoma of the aortic valve--a rare cause of thromboembolic cerebral infarct]. / Papilläres Fibroelastom der Aortenklappe--Eine seltene Ursache für einen thrombembolischen Hirninfarkt.

We report on a case of papillary fibroelastoma of the aortic valve in a 55 year old female patient, who had thrombembolic complications and subsequent stroke. The tumor was resected without disturbing the structure and function of the aortic valve.

Proximal aortic dissection late after aortic valve surgery: 119 cases of a distinct clinical entity.

BACKGROUND: Besides systemic hypertension and Marfan syndrome, only previous aortic valve replacement (AVR) is independently associated with proximal (type A) aortic dissection. Little, however, is known to date about the characteristic features of this clinical entity. METHODS: Clinical, prognostic and predisposing profiles in 119 cases of dissection and/or aneurysm occuring 1 month to 16 years after routine AVR were analyzed comprising 62 cases from our database and 57 reported cases. RESULTS: Dissection after AVR has been observed in 0.6% of all routine AVR procedures in the past four decades. With clinical signs, symptoms and anatomical features different from classic aortic dissection post-AVR dissection is a distinct clinical entity with a high intraoperative mortality of 44% and a 30-day and 5-year survival of 62% and 43%, respectively. Aortic regurgitation and a thin and/or fragile aortic wall at AVR, however, predict late dissection. Using a prediction model, the risk of late dissection can be stratified based on information obtained during AVR surgery. CONCLUSIONS: Aortic dissection following AVR is likely to represent a distinct clinical entity which can be predicted and possibly prevented at AVR.

Predictors of proximal aortic dissection at the time of aortic valve replacement.

BACKGROUND: Type I aortic dissection develops in 0.6% of patients late after aortic valve replacement (AVR), and 13% of patients with type I aortic dissections have a history of AVR. Predictors of aortic dissection at AVR, however, have not been characterized. METHODS AND RESULTS: A study group of 33 patients with type I aortic dissection had aortic surgery 49+/-55 months after routine AVR. A group of 101 controls, who did not have morphological progression of aortic diameters >/=6 years after AVR, was used to identify predictors of postsurgical dissection. Multivariate analysis identified aortic regurgitation (P<0.002) and fragility (P<0.001) or thinning of the aortic wall (P<0.007) at AVR as predictors, associated with a 14%, 22%, and 7% probability of late aortic dissection, respectively. Clamping times, types of valve prostheses, concomitant coronary artery bypass grafting, and mean ascending aortic diameters of 43+/-10 mm at AVR did not predict late dissection. A separate analysis of 29 nondissecting aneurysms of the ascending aorta developing 104+/-64 months after routine AVR revealed younger age at AVR (P<0.003) and congenitally bicuspid aortic valves (P<0.03) as predictors of late aneurysm formation. CONCLUSIONS: Aortic regurgitation combined with fragile and thinned aortic walls in patients with moderate aortic dilation may reflect aortic root disease, with a high risk for postsurgical aortic sequelae if it is treated incompletely by isolated valve replacement.

Incidence and prognosis of abdominal complications after cardiopulmonary bypass.

The incidence of abdominal complications after cardiopulmonary bypass is low but associated with a high mortality. From January 1991 to October 1996, 4288 patients, of a mean age of 62.5 years, underwent open-heart surgery. Fifty-nine (1 of 4) of these patients developed early abdominal complications. These included 36% with a paralytic ileus, 21% with erosive gastritis, 18% with upper gastrointestinal haemorrhage, 12% with intestinal ischaemia, 5% with pseudo-obstruction of the colon, 6% with acute cholecystitis and 2% with acute pancreatitis. After coronary artery bypass grafting mean cardiopulmonary bypass time was 94.4 min. There were abdominal complications in 1.0% and one hospital death. After valve surgery and combined surgery the mean cardiopulmonary bypass time was 129 min. There were abdominal complications in 2.4% (alpha = 0.01) and seven deaths. Fourteen patients (24%) underwent abdominal operations: three had caecostomies for pseudo-obstruction of the colon, seven had a hemicolectomy, two had a cholecystectomy and two had resection of the ventricle. The hospital mortality rate was 13.5%. Abdominal complications were significantly more frequent after valve or combined operations of the coronaries and valves in comparison with isolated coronary artery bypass grafting. Cardiac operations with extended cardiovascular bypass time were more likely to produce abdominal complications.

[Personal experiences with emergency coronary artery revascularization after failed PTCA--early and late results]. / Eigene Erfahrungen mit der koronararteriellen Notfallrevaskularisation nach fehlgeschlagener PTCA--frühe und späte Ergebnisse.

In recent years the equipment and techniques for percutaneous transluminal coronary angioplasty (PTCA) have been improved and today complex and distal stenoses are also treated in this way. Subsequent to failed PTCA some patients undergo emergency CABG. Between January 1991 and March 1995 3,520 patients have been treated by PTCA in our hospital. 61 patients (1.7%), mean age 61.1 years, underwent subsequent emergency CABG after PTCA. 46% had single-, 33% double and 21% had triple-vessel-disease, the mean left ventricular function (LVEF) was 65%. The mean number of bypass grafts was 1.9. The internal mammary arteries were never used under these emergency conditions. 9 patients (15%) developed perioperative myocardial infarction and in two of them the LVEF decreased under 30%. The hospital mortality was 6.6% (= 4 perioperative deaths). 6 of 61 patients were lost for follow-up; 90% of the hospitals survivors were followed for 244 months (mean 17). During this period there were 4 late deaths (3 cardiac and 1 non-cardiac). Actuarial survival at one year was 90%. 80% of the long-term survivors were in the NYHA functional classes I and II. In patients with double- or triple-vessel-disease PTCA almost always effects an incomplete revascularisation. Emergency CABG following failed PTCA is associated with an increased mortality and morbidity. The long-term prognosis is similar to that of an age-sex matched general population.

Abdominal complications following cardiac surgery.

Type and frequency of abdominal complications after open heart surgery are described. Out of 3,312 patients, 48 patients (1.4%) developed early postoperative abdominal complications with a mortality rate of 14.5%. Paralytic ileus, erosive gastritis and gastrointestinal hemorrhage were the most frequent complications, whilst intestinal ischemia, acute cholecystitis and acute pancreatitis were less frequently observed. The comparison of the frequency of abdominal complications in cardiac surgery patients with the same complications in other operated patients showed no significant difference (hi-square test), with the exception of COLD which was more frequent in the group with abdominal complications. No association was found between perioperative treatment with aprotinine and the development of abdominal complications.

[Abdominal complications after heart surgery interventions]. / Abdominelle Komplikationen nach kardiochirurgischen Eingriffen.

OBJECTIVE: Risk factors of abdominal complications after cardiac surgery are largely unknown. We undertook this study to determine different types of abdominal complications after cardiac surgery and to identify patients at risk. PATIENTS AND METHODS: 3312 adult patients were operated between Jan. 91 and Oct. 95 (2352 males, 960 females, 62.6 +/- 0.18y). We included all patients who suffered from abdominal complications within 30 days postoperatively. RESULTS: Abdominal complications are rare after cardiac surgery using cardiopulmonary bypass (CPB) (1.4%), but they are associated with high mortality (14.5%) in our department. Abdominal complications like paralytic ileus (43.8%), erosive gastritis (22.9%) and gastrointestinal bleeding (18.8%) are more often, compared with acute cholecystitis (14.5%), acute pancreatitis (8.3%) and intestinal ischemia (19.5%). Patients with intestinal ischemia are at high risk and do have a high mortality (83%). Abdominal complications can be found more often in connection with prolonged myocardial ischemia and valve replacement or combined operations. Prediction of complications on the basis of anamnestic data alone was not possible. CONCLUSION: Abdominal complications after cardiac surgery, especially intestinal ischaemia, are life-threatening. Prediction of abdominal complications is impossible. We have to concentrate on an early diagnosis and therapeutic intervention to lower mortality. A close cooperation between cardiac and general surgeons is mandatory for a successful treatment of life-threatening abdominal complications such as intestinal ischemia.

Re-graft patency and clinical efficacy of aprotinin in elective bypass surgery.

To investigate possible influence of aprotinin on graft patency, a randomized, double-blind group comparative study was carried out in male patients selected for primary bypass surgery. One hundred and ten patients received either placebo treatment or aprotinin according to the Hammersmith Hospital regimen(n = 55 per group). Graft patency was evaluated by angiography in 44 aprotinin and 35 placebo patients between the 18th and 35th day postoperatively. There was no difference in overall graft occlusion. Among the aprotinin patients, 73% (32/44) hsd grafts patent compared with 71% (25/35) of the placebo group. Graft occlusion was not accompanied by signs of myocardial infarction in any case. Blood loss within 6 h postoperatively was reduced by 58.5% in the aprotinin group (P < 0.001). of these patients 51% (26/51) did not need donor blood compared with 21% (10/47) of the placebo patients (P = 0.003). Mean transfusion requirements per patient were 1.1 and 2.7 units in the aprotinin and placebo groups, respectively.

Unruptured aneurysms of the non-coronary and left sinuses of Valsalva accompanied by severe aortic valve regurgitation.

This report describes a case of giant unruptured aneurysms of the left and non-coronary sinuses of Valsalva of the aortic valve associated with severe aortic regurgitation. Repair was accomplished by replacement of the aortic valve and the aortic root with a 25 mm St. Jude composite graft utilizing a modified Bentall technique.

Simultaneous measurement of pulmonary venous flow by intravascular catheter Doppler velocimetry and transesophageal Doppler echocardiography: relation to left atrial pressure and left atrial and left ventricular function.

OBJECTIVES: The aim of our study was to compare measurements of pulmonary venous flow velocity obtained either by transesophageal Doppler echocardiography or by intravascular catheter Doppler velocimetry. Furthermore, the relation among pulmonary venous flow velocity, left atrial compliance and left atrial pressure was evaluated. BACKGROUND: Data about the relation between left atrial pressure and pulmonary venous flow velocity are controversial. METHODS: A total of 32 patients undergoing elective open heart surgery for coronary artery bypass grafting were included prospectively in the study. Pulmonary venous flow velocity (Doppler catheter) and left atrial pressure (microtip pressure transducer) were recorded simultaneously with recordings of pulmonary venous flow velocity obtained by transesophageal Doppler echocardiography. RESULTS: Agreement between Doppler catheter and Doppler echocardiographic measurements of pulmonary venous flow velocity (n = 18 patients) was analyzed using the Bland-Altmann technique. The 95% limits of agreement were -0.16 to +0.11 m/s for systolic peak velocity, -0.14 to +0.09 m/s for diastolic peak velocity and -0.12 to +0.10 m/s for atrial peak velocity. The closest agreement between both methods was found for the ratio of systolic to diastolic peak velocity, the ratio of systolic to diastolic flow duration and the time from Q deflection on the electrocardiogram to maximal flow velocity. Mean left atrial pressure was strongly correlated with the ratio of systolic to diastolic peak velocity (r = -0.829), systolic velocity-time integral (r = -0.653), time to maximal flow velocity (r = 0.844) and the ratio of systolic to diastolic flow duration (r = -0.556). The ratio of systolic to diastolic peak velocity and the time to maximal flow velocity were identified as strong independent predictors of mean left atrial pressure. Left atrial compliance was not found to be an independent predictor of mean left atrial pressure. CONCLUSIONS: Flow velocity in the left upper pulmonary vein can be reliably recorded by transesophageal pulsed wave Doppler echocardiography. Our data reveal further evidence that mean left atrial pressure can be estimated by the pattern of pulmonary venous flow velocity.

[Surgery of tachycardic cardiac arrhythmias. Surgical treatment of life threatening tachycardias: indications, surgical possibilities, results]. / Chirurgie tachykarder Herzrhythmusstörungen. Die chirurgische Behandlung lebensbedrohlicher Tachykardien: Indikation, operative Möglichkeiten, Ergebnisse.

Electrophysiologic operations for surgical treatment of malignant tachyarrhythmias include a preoperative electrophysiologic study (EPS) to assess the characteristics and dignity of the arrhythmia, intraoperative electrophysiologic mapping to identify and localize the arrhythmogenic morphologic substrate, surgical ablation of the arrhythmogenic tissues, and early postoperative EPS to evaluate the result of the operation and the post-surgical prognosis. The majority of patients undergoing an electrophysiologic operation suffer from supraventricular tachyarrhythmias due to accessory atrioventricular bypass tracts (Wolff-Parkinson-White syndrome) and malignant ventricular tachycardias in the setting of coronary artery disease. In comparison of the natural (non-surgical) history of those rhythm problems their prognosis as regards mortality and morbidity is significantly improved by operation. Possibly the spectrum and the role of electrophysiologic antiarrhythmic surgery will be changed during the next decade by the increasing application of interventional cardiologic measures as catheter ablation (PTCA) thrombolysis.

Intermediate-term clinical and hemodynamic results of the neonatal arterial switch operation for complete transposition of the great arteries.

We prospectively evaluated 49 consecutive hospital survivors of the arterial switch operation for complete transposition and intact ventricular septum by clinical examination, echocardiography, cardiac catheterization, 12-lead and 24-h Holter ECG. The mean length of follow-up was 40 +/- 18 months. Forty-six children are clinically asymptomatic without medication, 2 died due to coronary related left ventricular dysfunction 3 and 12 months after surgery, and 1 required reoperation because of severe bilateral pulmonary branch stenoses. Except for this case, cardiac catheterization (n = 23) revealed a mean gradient of only 17 +/- 8 mmHg between the right ventricle and distal pulmonary arteries. Left ventricular end-diastolic volume was within normal limits except for 2 cases with volumes slightly below normal, the mean ejection fraction was 78 +/- 5%, and end-diastolic and end-systolic ventricular shapes were normal. The mean cardiac index was 4.14 +/- 0.69 l/min/m2. Left ventricular end-systolic wall stress to velocity of fiber shortening relation was normal in all cases examined (n = 15), indicating normal myocardial contractility. Significant neoaortic valve insufficiency was never observed despite considerably enlarged aortic roots. Twenty-four-hour Holter ECG records (n = 46) provided no evidence of serious atrial arrhythmias, especially sinus node dysfunction. These encouraging intermediate-term results make the arterial switch operation the treatment of choice at present, for neonates with simple transposition.