Ablation of atrial fibrillation using microwave energy--early experience.

Between Dec 12, 2002 and Aug 22, 2004, 84 operative patients with chronic atrial fibrillation (AF) were subjected to AF ablation with microwave energy. Of these, 49 patients were female; their ages ranged between 20 and 72 years (mean, 43.1 years). Most patients suffered from mitral disease, accompanied in over one third of cases with tricuspid insufficiency. Thirteen patients had aortic valve disease, mostly with mitral involvement. Three patients had coronary artery disease, three had atrial septal defect and one had a left atrial (LA) myxoma. Seventy-two patients underwent endocardial ablation and 12 patients underwent epicardial ablation. Operative mortality was 4 (4.8%), and there were no major untoward postoperative events. Fifty seven patients (71.3%) had their AF converted to sinus rhythm immediately after surgery. Amiodarone or sotalol was used in all postoperative patients for 6 months, except in 8 who had bradycardia. Electrical defibrillation was utilized in cases of atrial flutter or persistent AF. Seventy patients were followed for at least 6 months. In total, 52 of them (74.3%) are still in sinus rhythm. We believe microwave ablation is a satisfactory and safe method of AF ablation, and because it is brief, it can be added to surgical procedures without undue risk to the patient.

Giant substernal goiter with chylothorax.

A 60-year-old woman presented with a huge goiter extending from the lower jaw to the diaphragm. Right pleurocentesis produced chylous fluid. A cervicothoracic incision was used to totally excise the substernal goiter, with near-total excision of the cervical goiter, and repair of the lymphatic leakage.

Left ventricular volume reduction surgery in the middle East.

Heart transplantation is not yet socially acceptable in the Middle East, and left ventricular assist facilities are not generally available in this region. Therefore, left ventricular volume reduction surgery was attempted in 41 patients with end-stage heart failure (33 males; median age, 36.3 years) in 4 Middle Eastern tertiary referral centers between February 1996 and January 2001. Heart failure was due to idiopathic cardiomyopathy in 21 patients, ischemia in 11, rheumatic valvular disease in 8, and viral myocarditis in 1. Associated procedures were aortic valve replacement in 5 patients, mitral valve repair in 25, mitral valve replacement in 7, tricuspid valve repair in 6, and coronary bypass grafting in 8. Hospital mortality was 31.7%. Five patients were lost to follow-up. The survival rate of hospital survivors at 18 months was 65.2%. Three of the surviving patients did not benefit from the operation. Although our results were somewhat disappointing, this operation remains an option for surgeons working in developing areas of the world. It is hoped that better patient selection and new techniques of left ventricular volume reduction that avoid resection of viable muscle will further improve the outcome of this operation.

Reflections on a heart surgery career with insights for Western-trained medical specialists in developing countries.

Herein, I describe my experience (spanning 40 years) in helping to develop the specialty of cardiovascular surgery in Syria. Especially in the early years, the challenges were daunting. We initially performed thoracic, vascular, and closed-heart operations while dealing with inadequate facilities, bureaucratic delays, and poorly qualified personnel. After our independent surgical center was established in early 1976, we performed 1 open-heart and 1 closed-heart procedure per day. Open-heart procedures evolved from the few and simple to the multiple and complex, and we solved difficulties as they arose. Today, our cardiac surgical center occupies an entire 6-floor building. We have 12 cardiac surgeons, 10 surgical residents, a formal 6-year surgical residency program, a pediatric cardiac unit, an annual caseload of 1,600, and plans to double our productivity in 2 years. The tribulations of establishing sophisticated surgical programs in a developing country are offset by the variety of clinicopathologic conditions that are encountered, and even more so by the psychological rewards of overcoming adversity and serving a population in need. This account may prove to be insightful for Western-trained physicians who seek to develop specialized medical care in emerging societies.

Update on the mitral pulmonary autograft.

Between July 1997 and August 2004, 92 patients with irreparable mitral valves underwent replacement with a pulmonary autograft. This report brings the follow-up data of these patients up to date. Eighty-eight patients had a successful Ross II operation; 4 were lost to follow-up. The mean follow-up period was 94 months. Transesophageal echocardiography revealed a successful outcome in all 88 patients immediately after the operation. Operative mortality was 4.6%, and late mortality definitely related to the operation was 12.5%. At a mean follow-up of 94 months, freedom from structural valve deterioration (significant mitral stenosis and/or regurgitation) was 93.4%, freedom from reoperation was 92.0%, and freedom from all causes of death was 82.9%. Two autografts were explanted because of endocarditis. Two patients developed significant pulmonary stenosis, one of whom underwent operative repair. These data compare favorably with those of mitral valve replacement using modern bioprostheses. This procedure remains an option for the relatively young patient when life-long anticoagulation is contraindicated or impractical. It is also an option to consider in infants with complex irreparable mitral valve disease.

Surgical experience with cardiac echinococcosis.

Cardiac echinococcosis is a rare affliction of the heart encountered in areas where the tapeworm Echinococcus is endemic. During the 15 years to September 2005, 19 consecutive patients (11 female; mean age, 25.6 +/- 12.8 years) with cardiac echinococcosis were operated on at Damascus University. Diagnosis was mainly established by 2D-echocardiography. Twelve patients also had extracardiac hydatidosis. All patients were operated on using cardiopulmonary bypass and cardioplegia. Intact cysts were generally enucleated, ruptured cysts were exteriorized, and interventricular septal cysts were managed by controlled puncture and aspiration. There was no operative mortality. All patients were placed on mebendazole postoperatively for periods appropriate to the extent of their hydatidosis. There were 4 known late deaths due to systemic extension of the disease. Cardiac echinococcus is a serious disease that should be managed surgically without delay. Enucleation of intact cysts under cardiopulmonary bypass and cardiac arrest is our preferred method of excision. Anthelmintic medical treatment is a valuable and necessary adjunct to surgical management.

Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations.

OBJECTIVE: The study objective was to find a mitral valve substitute that does not require lifelong anticoagulation and is not affected by tissue degeneration in the long term. METHODS: Between July 14, 1997, and August 8, 2004, a total of 92 patients with irreparable mitral valve disease underwent mitral valve replacement with the pulmonary autograft encased within a Dacron tubing for support. In 4 patients, the autograft had to be sacrificed at the initial operation. Of the remaining 88 patients, 62 were female, and the age ranged from 4 to 64 years (mean 39 years). Eighty-six patients had rheumatic mitral disease, and 2 patients had congenital mitral disease. RESULTS: Operative transesophageal echocardiography initially showed adequate valve characteristics (mean valve area 2.8 cm2, mean gradient 3.9 mm Hg, no significant regurgitation) in all 88 patients. Operative mortality was 4.6%, and late mortality definitely related to the operation was 7.9%. Four patients were lost to follow-up; the mean follow-up was 60 months. Progressive regurgitation and stenosis developed in 9 patients over 2 to 5 years, 4 of whom had their grafts explanted. The autograft was explanted in 1 patient because of endocarditis. Mild pulmonic stenosis developed in 3 patients, and critical pulmonic stenosis developed in 1 patient. At 5 years follow-up, freedom from degeneration was 93.4%, freedom from reoperation was 94.2%, and freedom from all death was 86.0%. CONCLUSION: Although the Ross II operation is difficult and harbors significant risk, it remains an option for patients with irreparable mitral disease who have a long life expectancy and who cannot be placed on lifelong anticoagulation.

The mitral pulmonary autograft: assessment at midterm.

BACKGROUND: There is a dire need, especially in emergent societies, for a mitral substitute that does not require anticoagulation, and is not affected by early degeneration. METHODS: Between 1997 and 2003, 80 patients had successful mitral valve replacement with a pulmonary autograft. Fifty-five patients were female, and the mean age was 39.3 years. Seventy-eight patients had rheumatic mitral disease and 2 congenital. The autograft was placed inside a rigid Dacron tubing for support, and the right ventricular outflow was reconstructed with a xenograft or a homograft. Recently we have used microwave energy to ablate atrial fibrillation when present. RESULTS: Intraoperative transesophageal echocardiography revealed adequate mitral valve areas (mean area 2.76 cm2) and acceptable mitral gradients (mean 4.3 mm Hg) in all 80 patients. There was no mitral regurgitation or trace amounts in 61 patients, and mild regurgitation in 19. Operative mortality was 5.0%, and late mortality clearly related to the procedure 6.25%. Follow-up was complete except for 2 lost patients, with a mean of 25 months, and echocardiographic findings were generally stable during follow-up. One patient developed uncritical mitral stenosis and another uncritical stenosis and insufficiency during 4 to 5.5 years. Four more patients had progression of mitral regurgitation from "mild" to "moderate" over a period from 8 months to 3 years. Uncritical xenograft pulmonic stenosis developed in 2 patients. Most of the surviving patients (83%) remain in class I status. CONCLUSIONS: We believe the pulmonary autograft is a good mitral substitute at the disposal of cardiac surgeons, especially when patients are young and when life anticoagulation is contraindicated or impractical.