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Current evolutions and substantial amendments of the German health care system in combination with distinguished progress in cardiac surgery over the past years require both a reflection of principles in patient-centered care and an update of basic standard requirements for a department of cardiac surgery in Germany. In due consideration of the data from the voluntary registry of the German Society for Thoracic and Cardiovascular Surgery, this article accurately defines core requirements for a cardiac surgical department (cardiac surgery on-site), subdivided into facilities, staff and processes. If based on these standards, one may anticipate that cardiac surgical care is performed under appropriate conditions leading to an intrinsic benefit for patients., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients., Methods and Results: One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years., Conclusions: Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.

Background: For children who require aortic valve replacement, the pulmonary autograft may be the ideal substitute. However, re-operations for conduit exchange in the pulmonary position are inevitable. In addition, re-operations on the autograft may be necessary due to dilatation and neo-aortic insufficiency. We sought to assess predictors for re-intervention in an international Ross-operated paediatric population., Methods: Data of 152 children below 16 years of age at the time of the Ross operation were analysed using Cox proportional hazard modelling. Mean follow-up time was 6.1+/-4.2 years., Results: The median age at the time of the Ross operation was 10.1 years (range 54 days to 15 years). Early mortality was 2.6%. Survival at 5 and 10 years was 93.9+/-2.0% and 90.4+/-3.1%, respectively. Seven patients required autograft re-intervention (explantation n=6 and reconstruction n=1). Freedom from autograft re-intervention at 5 and 10 years was 99.3+/-0.7% and 95.5+/-2.7%, respectively. Prior endocarditis (p=0.061), prior aortic regurgitation (p=0.061) and longer follow-up time (p=0.036) emerged as risk factors for autograft re-intervention. Seventeen patients required 36 conduit re-interventions (replacement n=16, percutaneous valvuloplasty n=10). Freedom from conduit re-intervention at 5 and 10 years was 89.3+/-2.9% and 79.6+/-6.1%, respectively. Implantation of an aortic homograft (p=0.013), and smaller conduit size (p=0.074) emerged as risk factors for conduit re-intervention., Conclusions: There is a consistent need for conduit re-intervention following the Ross operation in children. Re-interventions on the autograft are rare within the first decade after surgery. However, the number of autograft re-interventions may increase after the first decade, since longer follow-up time is a risk factor for autograft failure., (Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve autograft function and improve durability. The aim of this study is to evaluate this hypothesis., Methods and Results: 1335 adult patients (mean age:43.5+/-12.0 years) underwent a Ross procedure (subcoronary, SC, n=637; root replacement, Root, n=698). 592 patients received R of the annulus, sinotubular junction, or both. Regular clinical and echocardiographic follow-up was performed (mean:6.09+/-3.97, range:0.01 to 19.2 years). Longitudinal assessment of autograft function with time was performed using multilevel modeling techniques. The Root without R (Root-R) group was associated with a 6x increased reoperation rate compared to Root with R (Root+R), SC with R (SC+R), and without R (SC-R; 12.9% versus 2.3% versus 2.5%.versus 2.6%, respectively; P<0.001). SC and Root groups had similar rate of aortic regurgitation (AR) development over time. Root+R patients had no progression of AR, whereas Root-R had 6 times higher AR development compared to Root+R. In SC, R had no remarkable effect on the annual AR progression. The SC technique was associated with lower rates of autograft dilatation at all levels of the aortic root compared to the Root techniques. R did not influence autograft dilatation rates in the Root group., Conclusions: For the time period of the study surgical autograft stabilization techniques preserve autograft function and result in significantly lower reoperation rates. The nonreinforced Root was associated with significant adverse outcome. Therefore, surgical stabilization of the autograft is advisable to preserve long-term autograft function, especially in the Root Ross procedure.

Background: For children who require aortic valve replacement, the Ross operation provides a unique advantage of growth potential of the pulmonary autograft in the aortic position. This study assessed the progression of autograft root diameters and its effect on aortic regurgitation (AR)., Methods: Neoaortic echo dimensions from 48 children (<16 years) undergoing Ross operation who had follow-up echocardiograms before age 20 were analyzed (mean follow-up, 5.1 +/- 3.3 years)., Results: The mean age at the time of the Ross operation was 10.0 +/- 4.3 years. Mean z values of the neoaortic annulus (1.5 +/- 0.4), sinus (2.5 +/- 0.4), and sinotubular junction (2.6 +/- 0.9) when the autograft was implanted were significantly larger compared with normal values (p < 0.001, all). The mean z values significantly increased with follow-up at the level of the sinus (0.5 +/- 0.1/year, p < 0.001) and the sinotubular junction (0.7 +/- 0.2, p < 0.001), but not at the level of the annulus (0.1 +/- 0.1, p = 0.59). AR increased with follow-up time (0.07 +/- 0.02 grade/year, p < 0.001). AR increased with sinotubular junction diameter (p = 0.028), but there was not significant evidence of an association with annulus diameter (p = 0.25) or sinus diameter (p = 0.40)., Conclusions: Children undergoing Ross operation have larger neoaortic root dimensions than healthy children. Growth of the annulus matches somatic growth. The diameters of the sinus and the sinotubular junction increase significantly relative to somatic growth. The latter may explain the development of AR.

Background: The Ross operation may be the ideal aortic valve replacement in pediatric patients. However, reoperations for replacement of the homograft in the pulmonary position are inevitable. This study determined influencing factors for the development of homograft stenosis and regurgitation in pediatric Ross patients., Methods: Follow-up echocardiograms of 116 children (86 boys) undergoing Ross operations at a mean age, 9.3 +/- 4.9 years were analyzed using hierarchic multilevel modeling. Mean duration of the echocardiographic follow-up was 5.3 +/- 4.2 years (609 patient-years, 398 examinations)., Results: Median homograft diameter z value was 0.3 (range -2.2 to +7.3). Mean homograft pressure gradient at implantation was 5.0 mm Hg with a significant increase of 4.2 mm Hg/y (p < 0.001) within the first 2 years and a steady state thereafter. Older donor age was significantly associated with lower mean pressure gradient at implantation (p = 0.037). Larger z value had no significant influence on the annual increase of pressure gradient (p = 0.87). Mean grade of regurgitation at implantation was 0.9, without significant annual increase (0.02 grade/y, (p = = 0.32). Older recipient (p = 0.005) and donor age (p < 0.0001) were significantly associated with lower mean regurgitation at implantation. Larger z value was associated with a higher annual increase of regurgitation (p = 0.014)., Conclusions: Relevant midterm homograft regurgitation is rare in children after the Ross operation. However, a significant annual increase occurs in the pressure gradient that cannot be influenced by larger graft size. Homograft oversizing may lead to a higher annual increase of regurgitation.

Background: Although the Ross operation requires double-valve replacement for aortic valve pathology, it is the only autologous, aortic valve replacement available. We report a single-unit's 11-year experience., Methods: Before August 2006, 467 patients (mean age, 41 +/- 15 years; 358 males) underwent a Ross operation. The right ventricular outflow tract was repaired with a cryopreserved pulmonary homograft. Follow-up was 94.4% complete., Results: The 30-day mortality was 0.6%. The Kaplan-Meier survival estimate at 120 months was 94.4% +/- 2.9% (standard error [SE], 0.0146). Reoperation was due to autograft failure in 15 patients (7 repairs, 8 replacements), with a Kaplan-Meier freedom from autograft failure measured as reoperation or regurgitation exceeding grade II at 120 months of 94.2% +/- 2.8% (SE, 0.0142). Homograft replacement, mostly due to stenosis, occurred in 11 patients. Freedom from homograft dysfunction, defined as homograft reoperation or peak homograft gradient of 30 mm Hg or more, at 120 months was 79.3% +/- 7.3% (SE, 0.0372). Freedom from all autograft- and homograft-related reoperations at 120 months was 85.9% +/- 6.3% (SE, 0.0321). Autograft or homograft endocarditis occurred in 8 patients, and 1 patient had simultaneous endocarditis of both valves., Conclusions: Patient survival and freedom from prostheses-related events over 11 years still compares favorably with conventional heart valve prostheses. Mortality and morbidity remain low. Reoperation for autograft or homograft failure is higher than our previous reports, and endocarditis is also evident, 1.9% (9 of 467). Homograft dysfunction is higher in younger recipients.

We studied the efficacy of propafenone in preventing atrial tachyarrhythmias after cardiac surgery, and the possible relationships between CYP2D6 polymorphism and the efficacy, pharmacokinetics, and tolerability of propafenone. One hundred and sixty patients were randomized (double blind) to receive propafenone (n= 78) or placebo (n= 82) for 1 week after cardiac surgery. The patients who were assigned to the propafenone group received 1 mg/kg infused in 1 h, followed by a continuous infusion at a rate of 4 mg/kg/24 h until the following morning, and subsequently 450 mg/day orally until the sixth postoperative day. Thirty-seven patients completed the trial in the propafenone group and 45 in the placebo group. The frequency of occurrence of atrial tachyarrhythmia was lower in the propafenone group than in the placebo group (29.7% vs. 53.3%, P< 0.05; relative risk, 0.56). Plasma propafenone concentrations were markedly influenced by CYP2D6 genotype-derived phenotype.

Background: Autograft regurgitation and root dilatation after the Ross procedure is of major concern. We reviewed data from the German Ross Registry to document the development of autograft regurgitation and root dilatation with time and also to compare 2 different techniques of autograft implantation., Methods and Results: Between 1990 and 2006 1014 patients (786 men, 228 women; mean age 41.2+/-15.3 years) underwent the Ross procedure using 2 different implantation techniques (subcoronary, n=521; root replacement, n=493). Clinical and serial echocardiographic follow up was performed preoperatively and thereafter annually (mean follow up 4.41+/-3.11 years, median 3.93 years, range 0 to 16.04 years; 5012 patient-years). For statistical analysis of serial echocardiograms, a hierarchical multilevel modeling technique was applied. Eight early and 28 late deaths were observed. Pulmonary autograft reoperations were required in 35 patients. Initial autograft regurgitation grade was 0.49 (root replacement 0.73, subcoronary 0.38) with an annual increase of grade 0.034 (root replacement 0.0259, subcoronary 0.0231). Annulus and sinus dimensions did not exhibit an essential increase over time in both techniques, whereas sinotubular junction diameter increased essentially by 0.5 mm per year in patients with root replacement. Patients with the subcoronary implantation technique showed nearly unchanged dimensions. Bicuspid aortic valve morphology did not have any consistent impact on root dimensions with time irrespective of the performed surgical technique., Conclusions: The present Ross series from the German Ross Registry showed favorable clinical and hemodynamic results. Development of autograft regurgitation for both techniques was small and the annual progression thereof is currently not substantial. Use of the subcoronary technique and aortic root interventions with stabilizing measures in root replacement patients seem to prevent autograft regurgitation and dilatation of the aortic root within the timeframe studied.

Objective: The arterial filter (AF) and the dynamic bubble trap (DBT) reduce the number of air microbubbles passing through these devices. The aim of the study was to confirm that the DBT diminishes microbubbles in the arterial line similar to, or better than, the AF, and can replace it., Methods: In a clinical study, we evaluated 60 patients undergoing cardiopulmonary bypass surgery, divided into two groups (30 patients each). In the first group, we used an open extracorporeal system, and in the second group, a closed system. For 15 patients in each group, the AF was incorporated, the other 15 patients received the DBT. The microbubbles were counted before and after the AF or DBT, using two-channel-ultrasonic Doppler devices., Results: The exposure of patients to small bubbles (< 45 microm) is significantly higher in the AF than in the DBT group. The DBT reduces large bubbles (> 45 microm) better than the AF, with a rate exceeding 16%., Conclusion: The use of the DBT instead of the AF yields higher air microbubble removal efficacy, allowing replacement of the AF, assuming the AF is used for air removal purpose only.

Background: The Ross operation is increasingly accepted as an alternative to conventional valve prostheses for children, adolescents, and young adults. We review patients younger than 20 years of age., Methods: Of 404 Ross operations done before November 2004, 60 were young patients with a median age of 12 years (range, 1 to 20 years). The pulmonary autograft technique universally was as a free root. A cryopreserved pulmonary homograft reconstructed the right ventricular outflow tract., Results: Early postoperative complications were reentry for bleeding in 2 patients and one pacemaker insertion. No thromboembolic or hemorrhagic events occurred during the follow-up of 42 +/- 27 months. Two late deaths occurred, one from myocardial infarction after 3 months and another sudden death after 5 years, probably from critical pulmonary homograft stenosis. Echocardiographic follow-up revealed a median peak gradient of 6.3 +/- 3 mm Hg across the autograft. The median pulmonary homograft peak gradient of 19.1 +/- 13.7 mm Hg was increased to more than 30 mm Hg in 6 patients. Another 6 patients had moderate but clinically insignificant pulmonary homograft regurgitation. Altogether, 6 patients required reoperation for replacement of stenotic homografts. No autograft related reoperation occurred., Conclusions: Young patients with the Ross operation had good mid-term autograft function and no perioperative mortality. Factors that justify the choice of the Ross operation for young patients are the normal physiologic hemodynamics and growth of the autograft as well as freedom from anticoagulation. A 10% reoperation rate, elevated pulmonary homograft gradients, and the surgical complexity remain limiting factors.

Background: Return of left ventricular mass to normal is considered to be a favorable result of aortic valve replacement. The Ross procedure provides near normal hemodynamics and thus allows studies of left ventricular (LV) reverse remodeling. LV mass regression may be influenced by surgical technique (subcoronary [SC] versus root replacement [RR])., Methods and Results: Data from the German Ross Registry were analyzed. A total of 646 patients (mean age: 43.6+/-12.7 years, range: 16 to 71 years; SC technique n=295, RR technique n=351) underwent a Ross procedure in 7 participating centers from 1990 to 2004. The patients underwent preoperative and postoperative echocardiographic evaluations. Mean follow-up time was 3.5+/-2.5 years (range 0.12 to 13.7 years). Follow-up completeness was 97%. The LV mass index (LVMI) decreased significantly during follow-up in both groups (SC: 209+/-53 preoperatively to 154+/-48 at 1-year follow-up, [P<0.01 versus preoperative values] to 149+/-51 g/m2 at 2-year follow-up, [P=NS 1-year versus 2-year follow-up] versus RR: from 195+/-56 preoperatively to 144+/-51 at 1-year follow-up [P<0.01 versus preoperative values] to 140+/-49 g/m2 [P=NS 1-year versus 2-year follow-up]). LVMI regression remained stagnant 1 year after the Ross procedure in most patients in both groups. On the basis of multivariate analysis, predictors for incomplete LVMI regression after the autograft procedure were high preoperative LVMI, smoking, and uncontrolled diastolic hypertension., Conclusions: At mid-term echocardiographic follow-up, patients of both groups had favorable autograft hemodynamics. Risk factors for incomplete postoperative LVMI regression in our study were smoking and persistent diastolic hypertension. This emphasizes the importance of cessation of smoking and treatment of arterial hypertension, even in younger patients, after corrected aortic valve disease.

Purpose: We present an early series to determine the technical feasibility of simultaneous aortic valve and complete ascending aortic replacement using a longer stentless aortic xenograft, harvested with an extended root., Description: The stentless xenograft valved conduits commercially available are too short for complete ascending aorta replacement, and usually a prosthetic tube graft is required distally., Evaluation: To avoid this extra prosthetic conduit distally a number of stentless aortic xenografts with extended conduit were obtained from a supplier (Medtronic Inc). They were inserted in 6 elderly patients (67.8 +/- 7.1 years) who all required aortic valve and ascending aorta replacements owing to pathologic dilation., Conclusions: In all cases an extra prosthetic conduit was avoided, and the length of the available biological conduit comfortably allowed total ascending aortic replacement without tension. The advantages therefore were one less suture line, cost saving regarding the prosthetic conduit, shorter cross-clamping time, and possibly shorter time spent on hemostasis.

Background and Aim of the Study: The Ross operation as aortic valve replacement has undergone technical evolution. Originally described as a subcoronary implant, the full-root replacement technique is now more common worldwide. It remains unclear which of the two techniques has the better results. Hence, the hemodynamic performances of the two implantation methods, as applied by two experienced centers, were compared as part of the German Ross Registry., Methods: In total, 132 (Group 1, root replacement, mean age 40 +/- 14 years) and 249 (Group 2, subcoronary implant, mean age 48 +/- 14 years) consecutively operated patients were compared clinically and echocardiographically. Data were analyzed focusing on pulmonary autograft and homograft function at mid-term (2.78 +/- 1.89 versus 2.26 +/- 2.11 years)., Results: Echocardiography revealed autograft peak systolic gradients of 5.0 +/- 2.7 mmHg for Group 1 and 6.7 +/- 3.7 mmHg for Group 2 (p < 0.05), and an indexed effective orifice area (EOA) of 1.98 +/- 0.57 cm2/m2 and 1.64 +/- 0.43 cm2/m2 (p < 0.05), respectively. Homograft peak systolic gradients were 15.6 +/- 9.0 mmHg and 11.7 +/- 6.8 mmHg for Groups 1 and 2 (p < 0.05) respectively, and the indexed EOA with regard to the homograft was 1.08 +/- 0.49 cm2/m2 and 1.26 +/- 0.50 cm2/m2 (p < 0.05). Autograft insufficiency grade > I was present in 1.5% (2/132) of Group 1 and 2.8% (7/249) of Group 2 patients. Pulmonary insufficiency grade > I was 17.4% (23/132) for Group 1 and 4.8% (12/249) for Group 2 (p < 0.05)., Conclusion: Although both groups enjoyed excellent hemodynamics in the mid-term, the root replacement technique had the advantage of larger annulus diameters and greater aortic EOA. Clinically relevant autograft regurgitation in both groups was gratifyingly rare, and seemed to be independent of surgical technique. Long-term durability of the more demanding subcoronary technique versus the problems of larger dimensions of the sinus of Valsalva and sinotubular junction in the free-root technique, remains to be proven. Apparent differences in pulmonary homograft hemodynamics can most likely be explained by surgical differences, younger patients in Group 1, and by homograft variation.

Starting in November 1999, we performed a left atrial radiofrequency ablation procedure concomitantly to a variety of cardiac surgical procedures. By January 2001, this ablation procedure had been performed on 100 patients (age 65.7 +/- 10.4 years, 53 % male, 47 % female, left atrium 51.0 +/- 7.5 mm) suffering either from chronic or paroxysmal atrial fibrillation. Primary cardiac pathology was mitral valve disease in most cases (43), aortic valve disease (28) or coronary heart disease (27). After bilateral pulmonary veins isolation, an additional ablation line was directed from the left pulmonary veins to the mitral valve annulus (Thermaline probe, Boston Scientific Corporation, USA). Finally, the left atrial appendage was resected. Surgical success was evaluated in the immediate postoperative course, 3 and 6 months postoperatively (ECG and echocardiography), and every year after that. Operative time was 229.7 +/- 56.5 min, ablation time 18.8 +/- 6.9 min. Follow-up is 95 % complete at the time of writing. Mean follow-up time was 7.3 months, ranging from 3 to 23 months. Success (sinus rhythm and atrial contraction) was proven in 72 out of 90 patients (80.0 %) (75.0 % mitral valve surgery, 84.0 % other cardiac surgery). The reported results support a broad spectrum of indications for this left atrial ablation procedure.

Background: The Ross operation has an established position in young patients. We address the question of whether any age group profits most from the Ross operation, and we compare the results in various ages., Methods: From February 1995 to August 2001 we performed 250 Ross operations. Group 1 consisted of 46 patients, ages 2 to 25 years (median age, 15 years). Group 2 consisted of 123 patients, ages 26 to 49 years (median age, 39 years). Group 3 consisted of 81 patients, ages 50 to 67 years (median age, 55 years). Echocardiography was performed perioperatively, at 2 to 6 months, and then yearly., Results: Mean follow-up for the three groups was 32, 31, and 28 months, respectively (p = 0.36). One patient from group 2 died after 25 months caused by suppurative pneumonia and 3 patients from group 3 died (1 from suspected acute thoracic aorta dissection at 40 months, 1 from ventricular fibrillation after 25 months, and 1 from an undiagnosed sudden death at 5 months). Autograft replacement was necessary for 3 patients from group 2 and 1 from group 3. Autograft repair was necessary for 1 patient from group 2, and pulmonary homograft reoperation was necessary for 1 patient from group 1. All other autografts currently have physiologic gradients and clinically insignificant regurgitation. Median peak gradient across the right ventricular outflow tract was 23.6 +/- 18 mm Hg for group 1, 14.6 +/- 8 mm Hg for group 2, and 11.5 +/- 7 mm Hg, which was significantly lower for group 3 patients (p < 0.001). Eleven patients are under close follow-up for right ventricular outflow tract gradients > or = 40 mm Hg; eight of these patients are from group 1, 3 are from group 2, and there are none from group 3., Conclusions: Although the Ross operation provides excellent results in all age groups, the problem of right ventricular outflow tract stenosis has not been seen in patients older than 50 years, which implies that it offers superior results for aortic valve disease in middle aged and older patients.

From January 1996 to April 2001, we treated eight patients with subdivided left atrium. Their ages at diagnosis ranged from newborn to 6.4 years. Prominent clinical symptoms were failure to thrive, respiratory symptoms, demand for oxygen, and congestive cardiac failure. Diagnosis was made by transthoracic echocardiography in all cases. Cardiac catheterization was necessary only in those patients who had associated cardiac anomalies, or suspected signs of pulmonary hypertension. In 7 patients, surgery was performed immediately after diagnosis, but one preterm infant died before operation due to neonatal sepsis and respiratory distress syndrome. In the postoperative period, one patient developed a severe capillary leak syndrome, and died due to irreversible congestive cardiac failure. The other 6 patients have all been followed up, with good results in the short- and intermediate-term at a mean of 34.3+/-20.2 months. The infants were thriving, had a reduction in the frequency of infections of the respiratory tract, no significant arrhythmias, and showed early recovery from pulmonary hypertension and right ventricular hypertrophy.

Background and Aim of the Study: The Ross operation, introduced more than 30 years ago, has recently undergone several modifications to improve both technical feasibility and results. At the authors' institution, the Ross operation, performed as root replacement in all cases, was commenced in February 1995., Methods: A total of 225 patients (177 males, 48 females; mean age 39+/-15 years; range: 2 to 67 years) were operated on up to December 2000. Aortic regurgitation was present in 80 patients, stenosis in 69, and combined disease in 73; prostheses were replaced in three patients. Combined procedures were performed in 51 patients. Nine patients had active endocarditis. Follow up was 98% complete and totaled 471 patient-years., Results: There was no early mortality, and no thromboembolic or hemorrhagic events. Complications included prolonged ventilation in two patients, perioperative myocardial infarction in three, pacemaker implants in three and perioperative bleeding in six. One patient died at 25 months from hemoptysis, and one at five months of unknown cause. In the long term, four patients required reoperation due to autograft regurgitation (one autograft repair, three autograft replacements). Routine aortic annulus support, a lowered threshold in replacing all dilated ascending aorta and keeping the autograft short to the level of the sinotubular junction seems to have prevented further autograft failure. Pulmonary homograft stenosis led to reoperation in one patient. Six patients with elevated gradients are currently under observation. Echocardiography revealed autograft median peak gradients of 5.1+/-2.8 mmHg, pulmonary homograft gradients of 14.2+/-11.5 mmHg, and no significant regurgitation, except in one additional patient with recently diagnosed aortic insufficiency (grade >2)., Conclusion: Mid-term excellent hemodynamic results, low morbidity and reoperation requirement support the evolved root replacement technique and justify its further utilization.

Background: In this report we address the question whether the Ross operation can be recommended in combined and complicated cardiac procedures., Methods: From February 1995 to July 2000, we performed 203 Ross operations, 129 with ideal clinical presentation (group 1: mean age 41 +/- 13 years, male 105). In 74 patients, the clinical presentation was complex (group 2: mean age 35 +/- 17 years, male 57), defined as previous aortic or cardiac operations in 32, active endocarditis in 8 or combined procedures in 40 patients. Follow-up is 95 % complete., Results: Neither early mortality nor thromboembolic events were observed. Complications in group 1 vs. group 2 were prolonged ventilation in 1 vs. 1, pacemaker insertion in 1 vs. 2, minor myocardial infarction in none vs. 2 and postoperative bleeds in 2 vs. 3 patients. In group 1, one patient died of hemoptysis at 25 months, and in group 2 one sudden death occurred at 5 months. In the long term, two patients required reoperation for autograft failure in group 1, and one on group 2. Pulmonary stenosis required surgical treatment in one patient of group 2. Echocardiography revealed physiological gradients across the autograft with no significant regurgitation in either group., Conclusion: The Ross operation has excellent mid-term results and is a safe and attractive therapeutic approach, both in combined procedures and complex clinical presentations.

Background: The Ross operation approaches the ideal aortic valve replacement. Between February 1995 and February 2000 we performed 186 procedures. This article reviews modifications introduced reflecting our experience., Methods: In all patients the Ross operation was performed as root replacement. Echocardiographic follow-up was complete in 94% of patients., Results: No operative death or early mortality occurred, nor did thromboembolic or hemorrhagic events. One patient died at 25 months from hemoptysis with pulmonary valve vegetations. Three patients required reoperation for autograft insufficiency. In 1 patient a tethered cusp was repairable and in 2 patients progressive autograft dilatation required autograft replacement. After routinely incorporating support into the aortic annulus and replacing all dilated ascending aorta, autograft dilatation did not recur. For the pulmonary homograft, one outflow patch was placed to relieve a symptomatic gradient. Nine patients with elevated gradients were under observation. Echocardiography revealed autograft median peak systolic gradients of 4.6+/-2.8 mm Hg, pulmonary homograft gradients of 14.8+/-9.6 mm Hg, and nil or insignificant regurgitation., Conclusions: The aortic annulus must be supported and the dilated ascending aorta replaced. Root replacement with a short autograft allows consistent results. Pulmonary homograft dysfunction is rare but unpredictable.

With the introduction of the maze operation Cox was able to show that the surgical treatment of atrial fibrillation (AF) is feasible. However, the maze operation remains surgically demanding and time-consuming as it requires multiple incisions in both atria. This has led to the development of various modifications. With new ablative technology and the acceptable results of an exclusively left atrial maze procedure in combination with mitral valve surgery, it has become possible to simplify the maze operation radically. Thirty-one patients ( mean age 62.3 years) with chronic or intermittent AF underwent a modified radiofrequency procedure in combination with some other cardiac surgical operation. Mitral valve disease coexisted in 17 patients, aortic valve disease in 9, coronary heart disease in 4 patients and 1 had an atrial septal defect (ASD). After left atriotomy and with the use of the Thermaline radiofrequency ablator probe, bilateral pulmonary vein isolation was carried out. An additional ablation line was directed from the left pulmonary veins to the posterior mitral valve annulus, and finally the left atrial appendage was resected. The complete procedure added an average of only 18.2 minutes to the operation. In the early postoperative course AF or atrial flutter recurred in 12 patients but at discharge only 8 patients (24%) still had an arrhythmia. We concentrated on the first 26 patients of our series who had received a follow-up examination 3 months postoperatively. At discharge 18 of the 26 patients were in sinus rhythm (69,2%), and at 3 months after surgery 23 of 26 patients were in sinus rhythm (88.5%), with recovery of atrial contraction confirmed echocardiographically. Only 4 patients still required medication for arrhythmias. The modified radiofrequency ablation procedure of the left atrium proved to be simple to perform, quick and reliable. It offers the possibility of a surgical cure for AF when performed together with another cardiac operation, and the early results indicate a high rate of success for this simple procedure.

Background: The excellent results of the Cox-Maze-III operation showed that a surgical treatment of atrial fibrillation is possible. The maze operation is surgically demanding and time-consuming. This fact led to the development of simplified modifications. Due to the good results of an exclusive left atrial maze procedure in combination with mitral valve surgery and new technologies of ablation, it seems reasonable to perform these techniques concomitant to cardiac surgery on a large number of patients.¶   , Methods: From November 1999 until June 2000 a modified maze procedure concomitant to a cardiac surgical intervention was performed on 42 patients, with a mean age of 62.2 years, suffering from chronic or intermittent atrial fibrillation. Primary cardiac disease was mainly cardiac valve disease (mitral valve disease 19 patients, aortic valve disease 10 patients) or coronary heart disease (8 patients). After left atriotomy and with the use of the Thermaline probe (Boston Scientific, Corporation, San Jose, California, USA) a bilateral pulmonary veins isolation was carried out by radiofrequency ablation. An additional ablation line was directed from the left pulmonary veins to the posterior mitral valve anulus. Finally, the left atrial appendage was resected. An evaluation of the therapeutic success was carried out in the immediate postoperative course and 3 months after surgery, at that point of time operation-related influences on the refractory period of the atrial myocardium were negligible.¶   , Results: At the time of discharge 32 patients (76.2%) showed a regular supraventricular rhythm. Twenty-one patients have already undergone the 3-month follow-up examination. At the time of discharge 13 out of these 21 patients (61.9%) were in sinus rhythm and at 3 months after surgery 18 out of these 21 patients (85.7%) showed a sinus rhythm with a restoration of atrial transport function echocardiographically determined. Three patients were still receiving antiarrhythmic medication.¶   , Conclusion: The modified maze procedure in combination with cardiac surgical interventions proved to be easy, quick and reliable to perform. The early results suggest a high success rate of this technique. The long-term results have to be verified with further, regular follow-up examinations of the patients.

History and Admission Findings: A few days after uneventful surgical reconstruction of the mitral valve a 43-year-old man was found to have a systolic murmur due to prolapse of the posterior leaflet, suggesting renewed mitral regurgitation., Investigations: Echocardiography revealed haemodynamically significant left ventricular outflow tract obstruction (LVOT) with a left ventricle to aorta systolic gradient of 83 mm Hg. In addition there was moderately severe mitral regurgitation as well as a pericardial effusion but no signs of tamponade., Treatment and Course: The obstruction was at first treated with verapamil, later with sotalol. The pericardial effusion was interpreted as part of a postcardiotomy syndrome. The effusion regressed under steroid administration, and the LVOT and mitral regurgitation also decreased. A provocation test five months postoperatively no longer brought about an outflow gradient. The good results were still present 12 months postoperatively., Conclusion: The described, rarely seen form of LVOT was probably caused by a combination of a very large anterior mitral leaflet, postoperative pericardial effusion and pharmacological effects. If the obstruction first occurs postoperatively, appropriate medication may improve the cardiac status and reoperation may be avoided. Echocardiography is an important method of diagnosis and serial monitoring.

Background: The pulmonary autograft approaches the ideal aortic valve substitute but numerous technical modifications are debated. The valves involved often differ in diameter and shape of the recipient annulus. We previously reported simplified surgical rules and early results of 52 patients and here we extend the report to 76 patients and analyze the mid-term results with respect to valve mismatch., Methods: We studied the influence of geometric discrepancies. Valve regurgitation and gradient are compared for size discrepancies up to or more than 3 mm between recipient annulus and pulmonary autograft. The normal tricuspid recipient aortic annulus is compared with the flat circular redo-prosthetic or bicuspid annulus. Patients with plication of the aortic annulus and remodeling of the distal aorta are reviewed, and lastly donor homograft to pulmonary autograft discrepancies up to and more than 3 mm are compared., Results: The results were comparable in all groups and no significant differences were observed., Conclusion: The pulmonary autograft operation may be simplified, with good results at the least in the first year despite operative tailoring due to valve discrepancies.

Background: The pulmonary autograft operation has achieved broad acceptance and may be the ideal aortic valve substitute. Both the pulmonary autograft and the aortic homograft are more complicated procedures than prosthetic valve replacement. The trend to insert the pulmonary autograft as a root replacement rather than in the subcoronary position has achieved greater uniformity in the results, but there is still confusing diversity in opinions on technical details and anatomical dimensions. The importance of both size and shape mismatches between the three valves involved has received little attention. The valves often differ in diameter and in the shape of the recipient aortic annulus. This uncertainty and the diversity of opinions on essential technical details was disconcerting when we proceeded from aortic homograft-to-pulmonary autograft operations, this was compounded by only a single homograft being available for every operation as we have no homograft bank., Methods: We compared the hemodynamic results regarding various geometric mismatches. All operative details were the same and patients were studied at regular intervals. Comparisons were made in patients with mismatch between recipient aortic annulus and pulmonary autograft. Patients with a normal tricuspid aortic annulus were compared to those with either a circular redo prosthetic valve annulus or a bicuspid recipient annulus. Thirdly we compared the patients with plication of the aortic annulus to those with remodeling of the distal aorta. Lastly we compared mismatch between donor homograft and pulmonary autograft., Results: No influence of geometric mismatch between the three valves could be found on the results of the pulmonary autograft operation., Conclusions: Good results are obtainable without a painful learning curve if one keeps to certain surgical principles. It need not be a complicated operation and geometric mismatches between the three valves involved may be compensated for adequately.

We report the case of a young woman in whom endaortitis developed at the site of a coarctation of the aorta after the invasive investigation of right fossa iliac pain. The organism responsible suggests a causal relationship to the investigations without antibiotic prophylaxis, and we emphasize the need for antibiotic prophylaxis in these cases. Invasive investigation of isolated coarctation in a young adult or adolescent is probably superfluous.

125 preterm infants with persistent ductus arteriosus (PDA) had surgical ligation between November 1978 and December 1984. In an additional case the situation was complicated by severe coarctation, which had not been diagnosed prior to surgery. The mean birth weight was 1340 +/- 448 g (85 infants weighed less than 1500 g). Gestational age was 30.6 +/- 2.5 weeks. Age at surgical ligation was 13 +/- 7 days for all patients. Preterm infants from our hospital were operated on with a mean age of 9.5 days. Indications for surgical ligation were clinical and radiographic signs of large PDA, during the last two years supported by the results of pulsed doppler ultrasonography. Only one preterm infant with PDA and coarctation died intraoperatively. The overall results showed a mortality rate of 21.6%. This rate has decreased from 30.4 to 11.7% in the last year. Important improvement could be obtained by early ligation, with carefully maintained body temperature during surgery. Preoperative ventilation parameters were kept constant and changes in arterial blood pressure during operation were avoided. The percentage of permanent handicaps was lowered from 15.2 to 5.9% in the last year of our study. According to failure of indomethacin therapy in the very beginning of PDA treatment, it is our policy now to ligate PDA in preterm infants early and without delay by a trial with indomethacin therapy.

Fifty infants ranging in age from 13 days to 18 months (mean age 6 months) and weighing from 1.7 to 8.2 kg (mean weight 4.5 kg) underwent patch closure of a ventricular septal defect (VSD) with use of deep hypothermic circulatory arrest. Seventeen infants were under 3 months of age. The principal indication for operation was intractable chronic congestive heart failure; All infants were below the third percentile for weight preoperatively; Three patients (6%) died postoperatively within the second month of life. There was no late mortality. Seven infants (14%) had seizures; these were associated with a low output state in 2 infants, with hypoxic episodes in 4 infants, and occurred postoperatively in 1 infant. Postoperatively, 8 (17%) of the surviving infants developed right bundle-branch block and left anterior hemiblock, and 16 (32%) developed right bundle-branch block alone. One year postoperatively, catheterization studies in 24 children revealed normal pulmonary artery pressure and pulmonary vascular resistance in all; there were no significant residual ventricular septal defects. Because of these results we continue to be enthusiastic about primary closure of VSD irrespective of age or weightk0

From 1970 to 1986, 43 patients with pulmonary atresia and ventricular septal defect (PA-VSD) were diagnosed in our hospital. 19 children had a collateral lung perfusion via a ductus botalli (DB), three children had a DB and systemico-pulmonary collateral arteries (SPCA), and 21 children had only SPCA. Patients with a DB alone had significantly larger pulmonary arteries. Children with SPCA always had hypoplastic pulmonary arteries and intrapulmonary arborization anomalies and in a high percentage (19 patients) they showed intrapulmonary stenoses. 26 palliative operations were performed in 24 children. After palliative operations in 15 cases (patients with DB: RVOT-Patch: one patient, aortopulmonary shunt: three patients, Brock procedure: one patient, patients with SPCA: RVOT-Patch: five patients, aortopulmonary shunt: four patients, Brock procedure: one patient) we checked the possibility of corrective surgery with the equation of Alfieri. According to this equation, corrective surgery without excessive right ventricular pressure would have been possible in all post-operatively catheterized patients with DB after primary palliative operations but, due to the pulmonary artery anomalies, only in seven out of nine patients with SPCA (one patient of the latter group was operated twice, Brock procedure and RVOT-Patch). In four cases we could prove the value of the Alfieri equation after corrective operations. There was an excellent correlation between the predicted relation of PRV/PLV and the actually measured pressures. In our opinion, the Alfieri equation forms a valuable aid in the preoperative assessment of children with PA-VSD.