Simple method for direct cannulation of ascending aortic aneurysms.

A simple method for direct cannulation of aneurysms of the ascending aorta is described. It avoids the need for femoral artery cannulation and offers an easy route for retrograde cerebral perfusion during deep hypothermic circulatory arrest.

Elevations in antidiuretic hormone and aldosterone as possible causes of fluid retention in the Maze procedure.

BACKGROUND: Reduced levels of atrial natriuretic peptide (ANP) has been suggested as a cause of fluid retention after combined Maze and valvular surgery. This study aimed to assess hormonal activation in the perioperative setting of isolated Maze procedures. METHODS: Changes in ANP, brain natriuretic peptide (BNP), antidiuretic hormone (ADH), aldosterone, and angiotensin II were measured in 16 patients (mean age 53+/-9 years) without concomitant heart disease undergoing the Maze (III) procedure. Ten matched patients (mean age 56+/-9 years) undergoing multivessel coronary artery bypass grafting served as controls. Measurements with hemodynamic correlates were obtained at baseline and after ventricular pacing (100 stimulations/minute), directly preoperatively, postoperatively and the first postoperative day. Weight gain and diuretic requirements were recorded. RESULTS: The major differences in hormonal response were significantly higher plasma levels of ADH (Maze preoperative 1.1+/-0.4, postoperative 24.9+/-16.7 pmol/L; controls preoperative 1.1+/-0.1, postoperative 3.7+/-3.5 pmol/L) and aldosterone (Maze preoperative 106+/-94, postoperative 678+/-343 pmol/L; controls preoperative 124+/-79, postoperative 171+/-93 pmol/L) in the Maze group on the first postoperative day (p < 0.001). Preoperative baseline plasma levels of ANP and pulmonary capillary wedge pressures (PCWP) were higher in the Maze group but this difference was abolished by pacing, and postoperatively, ANP levels changed in parallel to the PCWP in both groups. Diuretic requirements were significantly higher in the Maze group. CONCLUSIONS: Substantial increases in ADH and aldosterone were observed after the Maze procedure, indicating these hormones as important determinants in postoperative fluid retention. The role for ANP in this setting may be a less prominent than previously reported.

Abnormally high platelet activity after discontinuation of acetylsalicylic acid treatment.

Production of 12-L-hydroxy-5, 8, 10-heptadecatrienoic acid (12-HHT) from platelets and bleeding times were studied in 32 males during acetylsalicylic acid (ASA) treatment and 1 and 2 weeks after withdrawal. All patients (age 42-77 years) had ASA treatment because of angina pectoris. The metabolite 12-HHT is formed in the same amount as the proaggregatory and vasoactive metabolite thromboxane A2. Initially the daily ASA dose was 75 mg (n = 15), 160 mg (n = 12) or 250-300 mg (n = 5). In all patients, median 12-HHT level increased from 40 to 240g/750 x 10(6) platelets (P < 0.001) 1 week after withdrawal of ASA, and four patients had abnormally high values. Median bleeding time decreased from 312 to 268 s (P = 0.003) in the 75 mg group and from 315 to 235 s in the 160 mg group (P = 0.01). Two weeks after withdrawal of ASA, median 12-HHT was 390g/750 x 10(6) platelets and eight patients (25%) had abnormally high values. One patient still had a prolonged bleeding time. Wide interindividual variations were observed in all groups. Our results indicate that rapid withdrawal of ASA, may cause abnormally high 12-HHT levels reflecting increase of thromboxane A2 with possible hazardous effects in patients with cardiovascular disease.

The efficacy of the Cox/maze procedure combined with mitral valve surgery: a matched control study.

OBJECTIVE: To evaluate the results of the maze procedure combined with mitral valve (MV) surgery in patients with chronic atrial fibrillation (AF). METHODS: From 1994--1999, 47 patients with chronic AF underwent the maze procedure combined with MV surgery (maze group). They were compared to 47 patients matched for age, sex, left ventricular function and type of MV surgery (non-maze group). The maze group had less severe symptoms but larger left atrium, and AF of longer duration than the non-maze group. One surgeon performed all operations in both groups of patients. RESULTS: There were two early deaths in the maze group (4.5%) and one (2.2%) in the non-maze group. The duration of cardiopulmonary bypass (P=0.0001) and aortic crossclamping (P=0.0001) were greater in the maze group. Mean follow-up was 26+/-3 months in the maze group and 32+/-4 months in the non-maze group, and was 100% complete. Three-year survival was 96+/-3% for the maze group compared to 85+/-7% for the non-maze group (P=0.16). At the latest follow-up, 75% of the maze patients were in sinus rhythm compared to 36% of the non-maze patients (P=0.0004); 38% of the maze group were on coumadin postoperatively, compared to 69% in the non-maze group (P=0.003); and patients in the maze group were on fewer antiarrhythmic medications (P=0.0002). Three-year freedom from thromboembolic complications was 100% for the maze group compared to 83+/-7% for the non-maze group (P=0.03). CONCLUSIONS: In this retrospective study the maze procedure did not seem to increase operative mortality of MV surgery, was effective in eliminating atrial fibrillation, and reduced the risk of thromboembolic complications and the need for long-term anticoagulation after mitral valve repair or replacement with a bioprosthesis.

[Electrical conversion of atrial fibrillation. Superior effects of biphasic transthoracic method when compared with the conventional monophasic method]. / Elektrisk konvertering av förmaksflimmer. Bifasisk transtorakal metod överlägsen konventionell monofasisk.

Can biphasic electrical conversion of atrial fibrillation replace the standard monophasic method? This report reviews factors facilitating the electrical conversion of atrial fibrillation and describes a clinical trial, showing superior effects of biphasic versus monophasic electrical conversion of atrial fibrillation. We conclude that the most important factors for successful electrical conversion of atrial fibrillations are 1) a biphasic impulse, 2) low transthoracic impedance and 3) a short history of atrial fibrillation.

[A new surgical technique in atrial fibrillation. The maze procedure restores sinus rhythm]. / Ny hjärtkirurgisk metod vid förmaksflimmer. Maze-operation återställer sinusrytm.

Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity and increased mortality, partly due to the increased risk of stroke. The maze procedure, introduced by James Cox of the USA, is an internationally established surgical alternative in cases of unsuccessful medical or catheterised treatment of paroxysmal or chronic AF. It is an open heart procedure, involving multiple transmural incisions and continuous suture lines in both atria. By creating a maze of atrial tissue, the re-entrant circuits causing the AF are interrupted, hence re-establishing regular sinus rhythm and atrioventricular synchronization. The article reviews the initial 3-year experience of the procedure in 10 patients with AF, either paroxysmal (n = 5) or chronic (n = 5). The indications for surgery were disabling symptoms in all 10 cases, medical treatment failure in nine cases, previous AF-associated stroke in three cases, and a significant atrial septal defect in one case. All patients underwent extensive investigation both pre- and post-operatively. Postoperatively, nine of the 10 patients manifested regular sinus or atrial rhythm and freedom from or amelioration of preoperative symptoms associated with AF. There were no deaths, neurological complications or long-term recurrence of arrhythmia. One patient had an early recurrence of AF that was not amenable to medical treatment, and was subsequently treated with His' bundle ablation. Of the remaining nine patients, seven manifested signs of some postoperative atrial contraction at echocardiography, the occurrence of which needs to be borne in mind with a view to reducing the risk of future thromboembolic events. We recommend the maze procedure as an attractive surgical option in cases of unsuccessful medical treatment of paroxysmal or chronic AF.

Versatility of the endoventricular patch technique in repair of postinfarction left ventricular rupture.

Surgical ventricular restoration by the endoventricular patch technique (Dor procedure) is a surgical option designed to restore left ventricular shape and volume in patients with ischaemic heart disease and heart failure. Surgical ventricular restoration includes complete revascularisation, left ventricular reconstruction to restore near-normal shape and volume, and when necessary, mitral valve repair and surgery for ventricular tachycardia. However, the endoventricular patch technique is versatile and can also be used in other cases. We report the successful use of this technique in two emergent postinfarction cases, one with left ventricular free-wall rupture and one with ventricular septal defect. The aim of these case reports is to illustrate the flexibility of the endoventricular patch technique.

Acetylsalicylic acid may protect the patient by increasing fibrin gel porosity. Is withdrawing of treatment harmful to the patient?

The effect of acetylsalicylic acid in preventing cardiovascular complications is ascribed to acetylation of the enzyme cyclo-oxygenase thereby inhibiting prostaglandin synthesis. Acetylsalicylic acid, however, also acetylates fibrinogen. In the present pilot study, we investigated the permeability, i.e. porosity, of the fibrin gel in male patients with stable angina pectoris treated with this drug before and at 1 and 2 weeks after withdrawal. Ten patients were treated with 75 mg and eight with 160 mg. The results were compared to those in seven untreated healthy controls. Bleeding times were longer during treatment and were reduced after withdrawal indicating patient compliance. Fibrin gels were more porous during treatment although there were large inter-individual variations in porosity. One week after withdrawal, the porosity was reduced by 30 41%, i.e. the network became tighter (75 mg group P = 0.001; 160 mg group P = 0.002). The tightness was more pronounced after withdrawal than in the untreated controls. In conclusion, the protective effect of acetylsalicylic acid may be ascribed to its effect not only on platelets but also on fibrinogen. The withdrawal of acetylsalicylic acid may clause a markedly reduced fibrin gel porosity that we assume is disadvantageous in patients with cardiovascular disease.

The Maze operation for treatment of atrial fibrillation. Early clinical experience in a Scandinavian institution.

The Maze operation is a potentially curative surgical option in patients with disabling atrial fibrillation (AF) refractory to conventional treatment. The aim of this study was to evaluate the initial 4-year Maze experience in our institution. The study included 26 patients (19 males, mean age 55 years) who had undergone the Maze (III) operation between 1994 and 1998. Nine patients had surgery for concomitant heart disease. Follow-up was 3-55 (median 18) months. No deaths or neurological complications occurred; 22 patients are at present in regular sinus-, or junctional rhythm, 2 patients have permanent atrial pacing for symptomatic sinus node dysfunction, and 2 patients have had persistent AF, post surgery. Sinus node dysfunctions were detected in five patients, though not requiring pacemakers. Out of the total 26 patients, 23 are free of anti-arrhythmic drugs. Echocardiographic signs of left atrial contraction were recorded in 50% of the patients. The Maze operation offers a safe alternative to conventional therapy, with attractive results justifying expansion in the use of this treatment for AF.