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Objective: We sought to evaluate mitral valve repair for anterior leaflet perforation., Methods: Between October 1987 and October 2006, 26 patients with mitral valve anterior leaflet perforation underwent mitral valve repair (median age, 54 years; 18 [69%] were male)., Results: The indication for operation was severe mitral regurgitation only in 14 patients, both aortic regurgitation and mitral regurgitation in 11, and ventricular septal defect repair in 1. Twenty-four (92%) patients had endocarditis and 13 (50%) had at least mild aortic regurgitation preoperatively. Left atriotomy was performed in 17 (65%) and aortotomy in 8 (31%). Six (23%) patients had visible vegetations at the time of repair. For anterior leaflet repair, a patch was used in 11 (42%) patients and primary suture closure in 15 (58%). Eighteen patients underwent concomitant cardiac surgical procedures. Postoperative follow-up (mean, 6 years) was available for 25 (96%) patients. There was 1 early death from multiorgan failure and 2 late deaths. Patient survival was 95% at 1 year and 90% at 5 years. Left ventricular end-diastolic dimension improved significantly after mitral valve repair at dismissal (n = 16; -9.4 mm; P < .01) and during follow-up (n = 11; -10.8 mm; P < .01). Only 1 (4%) patient had mitral valve reoperation after 7 years owing to recurrent endocarditis 6 months after repair., Conclusions: Mitral valve anterior leaflet perforation may be safely repaired with good midterm survival and durability., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Gross tumor pulmonary embolism from renal carcinoma is rarely diagnosed preoperatively. Individual cases of intraoperative embolization of tumor during radical resection of the kidney have been reported. We report on 9 patients who underwent pulmonary arterial tumor removal concomitant with nephrectomy., Methods: Between 2000 and 2008, 9 patients underwent simultaneous nephrectomy and removal of gross embolic tumor from the pulmonary arteries. In 7 of these patients the diagnosis was made preoperatively by either computed tomography or magnetic resonance imaging. Cardiopulmonary bypass was used in all cases. Bilateral removal of pulmonary artery tumor was required in 7 patients and unilateral in 2., Results: All patients survived to hospital discharge after a median stay of 8.8 days (mean, 6-17 days). Two patients are currently alive 4 and 56 months after the operation. Six patients died of distant metastasis or local recurrence of disease after 6, 9, 12, 17, 25, and 29 months. Actuarial survival at 6 months, 1, 2, and 3 years was 100%, 75%, 50%, and 25%, respectively., Conclusions: Pulmonary artery embolic tumor removal concomitant with nephrectomy for renal carcinoma can be performed safely. Survival of patients with combined surgery is comparable with that of patients with the same stage of renal neoplasm without pulmonary tumor embolism. The pulmonary tumor embolism in patients with renal carcinoma should be considered as extension of vena caval tumor but not as a distant metastasis. Pulmonary tumor removal provides symptomatic relief and may provide a survival benefit in these patients., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: This study was undertaken to determine hemodynamic and clinical outcomes of annuloplasty with a standard-sized (63 mm) posterior band in adult patients undergoing mitral valve repair for degenerative valve disease., Methods: We studied 511 patients who underwent isolated mitral valve repair for degenerative disease with a 63-mm posterior band used for annuloplasty. Operations were performed between 1994 and 2001, and average follow-up was 4.8 +/- 3.1 years. Echocardiographic data were reviewed, with specific focus on the relationship between patient size and residual mitral regurgitation and gradient., Results: Mean age at the time of operation was 59.3 +/- 13.5 years, and 72% were male. Body mass index was 25.8 +/- 4.1 kg/m(2), and body surface area was 1.97 +/- 0.24 m(2). Preoperative mean ejection fraction was 64% +/- 7%, and 96% of patients had severe mitral regurgitation on preoperative echocardiography. The 30-day mortality was 0.8%. At hospital discharge, the mean gradient was 4.7 +/- 3.1 mm Hg. Body surface area, body mass index, and weight were not associated with postoperative gradients or residual regurgitation at discharge. At last follow-up, 89% of patients had no or mild regurgitation, and the mean ejection fraction was 58% +/- 9%. At 5 years, survival was 95% and cumulative risk of reoperation was 3%., Conclusion: A standard-sized (unmeasured) posterior annuloplasty band provided excellent intermediate results with good durability. There were neither excess gradients in larger patients nor excess regurgitation in smaller patients. Measured annuloplasty is unnecessary for most adults undergoing mitral valve repair.

Objective: Recovery of ventricular function after surgical correction of mitral regurgitation is often incomplete. We studied clinical and echocardiographic factors influencing return of normal left ventricular ejection fraction after mitral valve repair or replacement for mitral regurgitation caused by leaflet prolapse., Methods: We evaluated 1063 patients who had mitral valve repair or replacement between January 1, 1980, and December 31, 2000. A total of 2488 echocardiograms with follow-up ejection fractions were available for analysis., Results: Of the patients, 761 were men, 924 had valve repair, and 85% underwent surgery during the study's second decade. Compared with patients who had the operation in the 1980s, patients who had surgery in the 1990s had significantly smaller preoperative left heart dimensions and a 2.4-fold greater likelihood of an ejection fraction more than 60% during follow-up. Factors independently associated with higher ejection fraction at follow-up included valve repair (vs replacement), freedom from preoperative myocardial infarction, operation in the 1990s, greater preoperative ejection fraction, and smaller left ventricular dimensions. Patients with an ejection fraction of less than 50% at discharge were 3.5-fold less likely to recover normal ejection fraction during long-term follow-up (P < .001). Patients had a greater likelihood of a follow-up ejection fraction more than 60% if preoperative ejection fraction was more than 65% (hazard ratio, 1.7) or left ventricular end-systolic dimension was less than 36 mm (hazard ratio, 2.0)., Conclusion: Early repair of mitral regurgitation caused by leaflet prolapse, before deterioration in left heart size or function, increases the likelihood of subsequent normalization of left ventricular ejection fraction.

Objective: The optimal management of moderate functional mitral regurgitation at the time of aortic valve replacement remains undefined., Methods: We retrospectively identified 686 consecutive patients undergoing aortic valve replacement between 1993 and 2006 with at least moderate (grade 2 or more) functional mitral regurgitation. Patients with structural valve abnormalities or significant coronary artery disease were excluded, leaving 190 in the study. Analyses for predictors of residual mitral regurgitation and survival were performed. The impact of mitral regurgitation on survival was further analyzed among 91 patients case matched for age, gender, and left ventricular ejection fraction to individuals without mitral regurgitation undergoing isolated aortic valve replacement., Results: The mean age of the study group was 74 +/- 11years, 45% were male, and 78% had New York Heart Association III or IV Class classification. The mean preoperative ejection fraction was 48% +/- 17%. Operative mortality was 5% (n = 9). Follow-up echocardiographic data were available for 88% of patients at discharge and 57% of patients at midterm. Mitral regurgitation was improved at discharge in 76% of patients and at mid-term follow-up in 67% of patients. Independent predictors of improved mitral regurgitation were lesser degrees of preoperative tricuspid regurgitation or prebypass mitral regurgitation, absence of cerebrovascular disease, and lower left ventricular ejection fraction. Postoperatively, 89% of patients were New York Heart Association Class I or II Symptom; No reoperations for mitral regurgitation were performed. Survival was 68% at 5 years and 42% at 10 years. Independent predictors of late mortality were increasing age, diabetes, dialysis-dependent renal failure, and increased tricuspid regurgitation severity. The survival of 91 patients from this cohort did not differ from case-matched patients without mitral regurgitation undergoing aortic valve replacement (P = .33)., Conclusion: Moderate functional mitral regurgitation improved in most patients after aortic valve replacement. Residual mitral regurgitation did not affect survival independently of left ventricular function.

Objective: The European System for Cardiac Operative Risk Evaluation has been used to define a particularly high-risk group of patients for aortic valve replacement in whom alternative procedures, such as stent-mounted percutaneous valve procedures, may be appropriate. Our objective was to assess the validity of this risk assessment at a large-volume, tertiary cardiac surgical center., Methods: From January 1, 2000, to December 30, 2006, a total of 1177 patients underwent isolated aortic valve replacement at the Mayo Clinic. Patient and operative demographics were recorded in a prospective database. Early mortality (< or = 30 days) was obtained. Additive and logistic European System for Cardiac Operative Risk Evaluations were calculated for each patient., Results: The mean patient age was 68.0 years (+/-14.7 years) at the time of surgery, and 36.8% were female. Variables used in the calculation of the European System for Cardiac Operative Risk Evaluation included chronic lung disease (15% of our cohort), extracardiac arteriopathy (13.8%), neurologic dysfunction (0.2%), previous cardiac surgery (23.2%), renal failure (6.5%), active endocarditis (3.1%), recent myocardial infarction (1.1%), unstable angina (0.1%), and severe pulmonary hypertension (6.5%). The ejection fraction was severely reduced (< or = 30%) in 4.9% of patients and moderately reduced (< or = 50%) in 12.7% of patients. One percent of patients were in a critical state, and operation was performed urgently in 3.4% of patients. Although mean mortality estimates were 6.9% +/- 3.4% (additive European System for Cardiac Operative Risk Evaluation) and 10.9% +/- 12.7% (logistic European System for Cardiac Operative Risk Evaluation), actual overall operative mortality in our patients was 2.5%. Additive and logistic European System for Cardiac Operative Risk Evaluations overestimated operative mortality in low, intermediate, and high-risk subgroups by up to 17.8%., Conclusions: The European System for Cardiac Operative Risk Evaluation should not be used to determine the operability of patients for isolated aortic valve replacement. Elevated European System for Cardiac Operative Risk Evaluations alone do not appropriately define a population for use of a percutaneous aortic valve.

Objective: We sought to echocardiographically examine the early changes in left ventricular size and function after mitral valve repair or replacement for mitral regurgitation caused by leaflet prolapse., Methods: Preoperative and early postoperative echocardiograms of 861 patients with mitral regurgitation caused by leaflet prolapse who underwent mitral valve repair or replacement (with or without coronary revascularization) were studied. Among the patients, 625 (73%) were men and 779 (90%) had mitral valve repair., Results: The rate of valve repair increased from 78% in the first decade of the study to 92% in the second decade. At early echocardiography (mean, 5 days postoperatively), we observed significant decreases in left ventricular ejection fraction (mean, -8.8) and left ventricular end-diastolic dimension (mean, -7.5). The magnitude of the early decline in ejection fraction was similar in patients who had mitral valve repair and replacement. The decrease in postoperative ejection fraction was independently associated with a lower preoperative ejection fraction, the presence of atrial fibrillation, advanced New York Heart Association functional class, greater left ventricular end-diastolic and end-systolic dimensions, and larger left atrial size., Conclusion: Surgical correction of mitral regurgitation results in an early decrease in ejection fraction, particularly in symptomatic patients with increased left heart dimensions.

Objective: We sought to compare clinical and pathologic characteristics of ventricular tumors and to detect whether differences exist in short- and long-term survival after resection., Methods: From 1964 to 2005, 323 patients had cardiac surgery for resection of primary cardiac tumors; 53 (16%) patients had primary ventricular tumors. We randomly sampled 53 characteristics of ventricular tumors., Results: Patients with ventricular tumors were younger than those with atrial tumors (34.8 vs 54.6 years; P < .0001). New York Heart Association functional status was similar at presentation, although patients with atrial tumors had increased risk of atrial fibrillation (P < .05), thromboembolic events (P = .04), and mitral stenosis (P = .008) at the time of presentation. Patients with ventricular tumors had an increased incidence of myocardial invasion (14% vs 2%; P = .02) and had significantly longer cardiopulmonary bypass (80 vs 65 minutes; P < .05) and crossclamp (52 vs 39 minutes; P = .03) times. Operative mortality was 4% and 0% in the ventricular and atrial groups, respectively (P = not significant). Follow-up was obtained in 89% of patients at a mean follow-up time of 7.21 years. A Kaplan-Meier survival plot demonstrated no difference in survival characteristics of both groups. At follow-up, 81% and 74% of ventricular and atrial tumors, respectively, were minimally symptomatic (New York Heart Association class I/II; P = .13). Patients with atrial and ventricular tumors had a 6% and 0% tumor recurrence rate, respectively (P = .12)., Conclusion: Surgical resection for ventricular tumors is effective and results in excellent long-term outcome. Early surgical treatment should be strongly considered in patients with primary ventricular tumors.

Objective: Improved durability of bioprostheses has led some surgeons to recommend biologic rather than mechanical prostheses for patients younger than 65 years. We compared late results of contemporary bioprostheses and bileaflet mechanical prostheses in patients who underwent aortic valve replacement between 50 and 70 years old., Methods: In this retrospective study, patients received either St Jude bileaflet valves or Carpentier-Edwards bioprostheses. Operations were performed between January 1991 and December 2000, and groups were matched one-to-one according to age, sex, need for coronary artery bypass grafting, and valve size., Results: Four hundred forty patients were matched, and follow-up was 92% complete, with median durations of 9.1 years for patients who received mechanical valves and 6.2 years for patients who received bioprostheses. The 5- and 10-year unadjusted survivals were 87% and 68% for mechanical valves and 72% and 50% for bioprostheses, respectively (P < .01). Freedoms from reoperation at 10 years were 98% for mechanical valves and 91% for bioprostheses (P = .06). Rates of late stroke or other embolic events and of endocarditis were similar between groups. Hemorrhagic complications necessitating hospitalization occurred in 15% of patients with mechanical valves and 7% of patients with bioprostheses (P = .01). Notably, 19% of patients with bioprostheses were receiving warfarin sodium at last follow-up. After adjustment for unmatched variables, including diabetes, renal failure, lung disease, New York Heart Association functional class, ejection fraction, and stroke, the use of a mechanical valve was protective against late mortality (hazard ratio 0.46, P < .01)., Conclusion: In this study, patients aged 50 to 70 years who underwent aortic valve replacement with mechanical valves had a survival advantage relative to matched patients who received bioprostheses. These findings question recommendations of bioprostheses for younger patients and suggest that a randomized trial may be warranted.

Objective: The prevalence of aortic valve stenosis increases with age, and often the diagnosis is made by echocardiography before symptoms develop. To address the controversies in management of asymptomatic patients with severe aortic stenosis, we assessed the early and late outcomes of aortic valve replacement in these patients., Methods: We analyzed data of 622 patients, aged 72 +/- 11 years, with isolated asymptomatic severe aortic stenosis. Patients were identified with a peak systolic velocity of greater than 4 m/s by transthoracic echocardiography and monitored for the development of symptoms and need for aortic valve replacement., Results: After the initial diagnosis, 166 (27%) patients who were initially asymptomatic experienced the development of chest pain, shortness of breath, or syncope and had aortic valve replacement at Mayo Clinic. Another 97 (16%) patients had aortic valve replacement in the absence of symptoms. Symptomatic patients were more likely to undergo coronary bypass grafting (P < .01) and have diabetes, hypercholesterolemia, and a lower ejection fraction (P < .05 for each). Operative mortality was 2% for symptomatic patients and 1% for asymptomatic patients (P = .43). The survival of the 263 patients who underwent aortic valve replacement was not significantly different from an age- and sex-matched population (P = .99); 10-year survival was 64% (95% confidence interval [CI] 57%-72%) for symptomatic patients and 64% (95% CI 54%-75%) for asymptomatic patients (P = .92). At 3 years after diagnosis of severe aortic stenosis, 52% (95% CI 48%-56%) of 622 patients had had symptoms develop, undergone aortic valve replacement, or died. Among the entire cohort, older age at diagnosis (hazard ratio [HR] 1.1 per year, P < .001), diabetes (HR 1.7, P < .001), decreased ejection fraction (HR 1.1 per 1% downward arrow, P = .01), symptoms (HR 2.13, P < .001), and absence of aortic valve replacement (HR 3.53, P < .001) were identified as independent risk factors for mortality., Conclusion: Among patients with severe aortic stenosis who underwent aortic valve replacement, early and late outcomes were similarly good in patients who had symptoms before the operation compared with those who were asymptomatic. It is important to note that among patients with asymptomatic severe aortic stenosis, the omission of surgical treatment was the most important risk factor for late mortality.

Objective: Despite concern that small aortic valve prostheses can lead to prosthesis-patient mismatch with diminished left ventricular mass regression and poor long-term outcome after aortic valve replacement, there remains reluctance to perform aortic root enlargement procedures. We therefore examined the operative risks of aortic valve replacement with and without root enlargement., Methods: We reviewed perioperative outcomes among patients undergoing aortic valve replacement at our institution between January 1993 and December 2001. Risk factors for operative death were evaluated by means of multivariable analysis., Results: Of 2366 patients undergoing aortic valve replacement with (1173) or without (1193) concomitant procedures, 249 (10.5%) underwent posterior root enlargement. Patients undergoing complex root enlargement (Konno-Rastan procedures) were excluded. Patients undergoing aortic root enlargement were significantly younger, twice as often female, and more often undergoing a reoperation but were similar with respect to functional class. The mean valve implant size was less in the aortic root enlargement group (21.5 +/- 1.6 vs 23.2 +/- 2.3 mm, P < .0001). As expected, mean crossclamp time and bypass time were somewhat longer with root enlargement. Raw operative mortality was higher with aortic root enlargement (5.6% vs 2.9%, P = .0324); however, by means of multivariable analysis, advanced functional class (P = .0020; odds ratio, 1.87), preoperative congestive heart failure (P < .0001; odds ratio, 3.22), and smaller valve implant size (P = .012; odds ratio, 1.16), but not aortic root enlargement, were independent risk factors for operative death., Conclusions: Aortic root enlargement itself does not increase operative risk, although it is most often required among high-risk patients. Surgeons should not be reluctant to enlarge the aortic root to permit implantation of adequately sized valve prostheses.

Objective: Extra-anatomic bypass of complex thoracic aortic disease through a median sternotomy has been reported as a safe alternative to thoracotomy. Our objective was to examine intermediate-term outcomes., Methods: We retrospectively reviewed 50 consecutive patients with congenital aortic coarctation or recurrent coarctation who underwent ascending-descending posterior pericardial aortic bypass between January 1985 and November 2005. Demographic data, in-hospital and postoperative morbidity and mortality, and resolution of hypertension were determined by examination of the medical record., Results: The mean age at operation was 42 years; 27 (54%) were men. There were no perioperative deaths. Upper-extremity blood pressure after coarctation repair with ascending-descending aortic bypass was significantly improved. Mean systolic blood pressure decreased from 158 +/- 25 mm Hg preoperatively to 123 +/- 14 mm Hg postoperatively (P < .001). There were no graft-related deaths or complications in follow-up extending up to 20 years., Conclusions: The ascending-descending aortic bypass through a posterior pericardial approach is a safe operation and is effective in relieving obstruction and improving hypertension.

Objective: The study objective was to describe the independent effect of preoperative atrial fibrillation on the outcome of coronary artery bypass grafting, including the causes of death (cardiac vs noncardiac)., Methods: We analyzed the outcome of patients with preoperative atrial fibrillation who underwent on-pump coronary artery bypass grafting between 1993 and 2002 and compared them with matched controls in sinus rhythm; matching variables were age, gender, ejection fraction, and numbers of diseased coronary arteries and distal anastomoses. Direct patient follow-up focused on late complications and reinterventions, and we investigated causes for all deaths., Results: Operative mortality (1.6% vs 1.9%, P = .79) was similar in patients with preoperative atrial fibrillation (n = 257) compared with patients in sinus rhythm (n = 269). The patients with atrial fibrillation had longer hospital stays (9 +/- 6 days vs 8 +/- 6 days, P = .0008) and a trend to more frequent early readmissions (13% vs 9%, P = .08). During follow-up (median 6.7 years, maximum 12 years), late hospital admission was more frequent in patients with atrial fibrillation (59% vs 31%, P < .0001). Risk of late mortality (all causes) in patients with atrial fibrillation was increased by 40% compared with patients in sinus rhythm (P = 0.02), and the late cardiac death rate in the atrial fibrillation group was 2.8 times that of the sinus rhythm group (P = .0004). Major adverse cardiac events occurred in 70% of patients with preoperative atrial fibrillation compared with 52% of patients in preoperative sinus rhythm (P < .0001). Subsequent rhythm-related intervention, including pacemaker implantations, was more common in the atrial fibrillation group (relative risk = 2.1, P = .0027)., Conclusions: Uncorrected preoperative atrial fibrillation in patients undergoing coronary artery bypass grafting is associated with increased late cardiac morbidity and mortality and poor long-term survival. These data support consideration of atrial fibrillation surgery at the time of coronary artery bypass grafting.

Objective: The natural history and management of patients with systolic anterior motion after mitral valve repair are uncertain., Methods: We performed a retrospective chart review and survey follow-up of all patients in whom systolic anterior motion developed intraoperatively after mitral valve repair., Results: From January 1993 to December 2002, mitral valve repair was performed in 2076 patients, and in 174 cases (8.4%) systolic anterior motion was identified on intraoperative echocardiography. These patients form the study group. Initially, patients were managed with a combination of beta-blockade, vasoconstriction with phenylephrine, and/or intravascular volume expansion. Four patients had revision of repair because of persistent systolic anterior motion, and 3 additional patients had revision of repair because of mitral regurgitation from other causes. The median follow-up of the remaining 167 patients was 5.4 years (range 0-13.2 years). There were 2 late reoperations, but none were caused by systolic anterior motion or left ventricular outflow tract obstruction. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV. Echocardiograms were available for review in 93 patients at a median interval of 5.4 years (range 0.2-12.2 years); 13 patients had systolic anterior motion, and 4 patients had systolic anterior motion with left ventricular outflow tract obstruction., Conclusions: In this experience, most cases of systolic anterior motion resolved with conservative measures including beta-blockade, vasoconstriction, and fluid administration. Persistent systolic anterior motion with left ventricular outflow tract obstruction was documented in 2.3% of patients who had early systolic anterior motion, but late reoperation was not required. Furthermore, the clinical outcomes of patients with systolic anterior motion are comparable to the current norms for mitral valve repair. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV.

Objective: We sought to evaluate the clinical and echocardiographic outcomes of reoperation for failed mitral valve repair., Methods: One hundred forty-five patients with recurrent mitral regurgitation after primary mitral valve repair of degenerative leaflet prolapse underwent mitral valve reoperations between January 1, 1970, and January 1, 2005. The mean age was 66 years, and 102 (70%) were men., Results: The mean duration from initial repair to reoperation was 4.1 years (standard deviation = +/- 5.1 years). Indications for reoperation were regurgitation alone (n = 109 [75%]), hemolysis (n = 27 [19%]), obstruction from systolic anterior motion (n = 3 [2%]), endocarditis (n = 3 [2%]) and stenosis-other (n = 3 [2%]). New pathology was found in 80 (55%) patients, and failure of the initial repair was found in 61 (42%) patients. The mitral valve was re-repaired in 64 (44%) patients and replaced in 81 (56%) patients. Early operative mortality was similar after re-repair and replacement (1.6% vs 4.9%, P = .38). Independent predictors of improved survival on multivariate analysis were mitral re-repair (hazard ratio = 0.44, P = .03), younger age (hazard ratio = 1.06, P = .001), and an operative indication of mitral regurgitation alone (hazard ratio = 0.31, P = .005). Seven patients had a third mitral operation (all replacements), 6 after re-repair and 1 after replacement. At last follow-up echocardiogram (n = 96), ejection fraction was greater (P < .001) and left ventricular end-systolic dimension was smaller (P = .009) in patients undergoing re-repair compared with values in those undergoing valve replacement., Conclusion: Recurrent mitral regurgitation after prior repair is frequently caused by new valve pathology. Mitral re-repair is performed in almost half of patients and is associated with superior survival, improved ejection fraction, and greater regression in ventricular dimension compared with valve replacement.

Objectives: Freedom from anticoagulation is the principal advantage of bioprosthesis; however, the American Heart Association/American College of Cardiology and the American College of Chest Physicians guidelines recommend early anticoagulation with heparin, followed by warfarin for 3 months after bioprosthetic aortic valve replacement. We examined neurologic events within 90 days of bioprosthetic aortic valve replacement at our institution., Methods: Between 1993 and 2000, 1151 patients underwent bioprosthetic aortic valve replacement with (641) or without (510) associated coronary artery bypass. By surgeon preference, 624 had early postoperative anticoagulation (AC+) and 527 did not (AC-). In the AC- group, 410 patients (78%) received antiplatelet therapy. Groups were similar with respect to gender (female, 36% AC+ vs 40% AC-, P = .21), hypertension (64% AC+ vs 61%, P = .27), and prior stroke (7.6% AC+ vs 8.5% AC-, P = .54). The AC+ group was slightly younger than the AC- group (median, 76 years vs 78 years, P = .006)., Results: Operative mortality was 4.1% with 43 (3.7%) cerebrovascular events within 90 days. Excluding 18 deficits apparent upon emergence from anesthesia, we found that postoperative cerebrovascular accident occurred in 2.4% of AC+ and 1.9% AC- patients. By multivariable analysis, the only predictor of operative mortality was hypertension ( P < .0001). Postoperative cerebrovascular accident was unrelated to warfarin use ( P = .32). The incidence of mediastinal bleeding requiring reexploration was similar (5.0% vs 7.4%), as were other bleeding complications in the first 90 days (1.1% vs 0.8%). No variables were predictive of bleeding by multivariate analysis., Conclusions: Although these data do not address the role of antiplatelet agents, early anticoagulation with warfarin after bioprosthetic aortic valve replacement did not appear to protect against neurologic events.

Objective: The contemporary risk of reoperative aortic valve replacement is ill-defined. We therefore compared the recent early results of reoperative and primary aortic valve replacement in our institution., Methods: Between January 1993 and January 2001, a total of 162 patients underwent reoperative aortic valve replacement with or without coronary artery bypass grafting, and 2290 underwent primary aortic valve replacement with or without coronary artery bypass grafting. The reoperative and primary groups were similar with regard to gender (37% female in both), preoperative New York Heart Association functional class (2.8 +/- 1 vs 2.8 +/- 1), and ejection fraction (58% +/- 15% vs 57% +/- 15%). Patients undergoing reoperative aortic valve replacement were younger than those undergoing primary aortic valve replacement (64 +/- 15 years vs 70 +/- 13 years, P < .001). Previous prostheses were xenografts in 77 patients (48%), homografts and autografts in 25 (15%), and mechanical prostheses in 60 (37%). Mean time to reoperation was 9.7 +/- 6.8 years., Results: Early mortality for reoperative aortic valve replacement (8/162, 5%) was not statistically different from that for primary aortic valve replacement (71/2290, 3%, P = .20). Endocarditis was more common in the reoperative group (22% vs 3%, P < .001); when endocarditis was excluded from the analysis, early mortality was 3% in both groups. Multivariate predictors for early mortality were prosthetic valve endocarditis ( P < .001, odds ratio 9.8), advanced preoperative functional class ( P < .001, odds ratio 2.0), peripheral vascular disease ( P = .008, odds ratio 2.0), preserved left ventricular ejection fraction ( P = .004, odds ratio 0.98), and male gender ( P = .009, odds ratio 0.49). After adjustment for these factors, there was no difference in early mortality between the groups ( P = .095)., Conclusion: The risk of reoperative aortic valve replacement is similar to that for primary aortic valve replacement. These data support the expanded use of bioprosthetic valves in younger patients.

Objective: To assess outcome of valve repair in patients with aortic valve regurgitation with emphasis on incidence and risk of reoperation., Methods: We retrospectively reviewed 160 consecutive patients (127 men) who underwent aortic valve repair between 1986 and 2001. Ages ranged from 14 to 84 years (mean 55 +/- 17 years). Patients were categorized according to the main etiology of valve disease; 63 patients (39%) had annular dilation leading to central leakage, 54 (34%) had bicuspid valve, 34 (21%) with tricuspid valve had cusp prolapse, and 9 (6%) had cusp perforation. Repair methods included commissural plication (n = 154, 96%), partial cusp resection with plication (n = 47, 29%), resuspension or cusp shortening (n = 44, 28%), and closure of cusp perforation (n = 10, 6%)., Results: There was 1 early death (0.6%). Two patients required re-repair of the aortic valve during initial hospitalization. During a mean follow-up of 4.2 years, there were 16 late deaths. Overall, 16 of 159 hospital survivors had late reoperation on the aortic valve (mean interval 2.8 years) without early mortality. Risks of reoperation on the aortic valve were 9%, 11%, and 15% at 3, 5, and 7 years, respectively., Conclusions: Aortic valve repair can be performed with low risk and excellent freedom from valve-related morbidity and mortality. Late recurrence of aortic valve regurgitation led to reoperation in 8.8% of patients, but mortality associated with subsequent procedures is low. Aortic valve repair appears to be a good option for selected patients, particularly young patients who wish to avoid chronic anticoagulation with warfarin.

Objectives: In animals the Cardeon Cobra catheter (Cardeon Corp, Cupertino, Calif) allows independent control of aortic arch and descending aortic temperatures and profoundly reduces cerebral embolization during bypass. This investigation describes the first clinical use of the device during adult cardiac surgery. The purpose of the study was to confirm that the Cobra catheter delivers adequate cerebral and systemic perfusion while providing simultaneous cerebral hypothermia and systemic normothermia during cardiopulmonary bypass., Methods: In a prospective multicenter study the Cobra aortic catheter was placed in 20 adults undergoing cardiopulmonary bypass. Arch and corporeal temperatures, bypass flows, and arterial blood pressures were recorded intraoperatively. Jugular bulb and mixed venous oxygen saturation was used to assess the adequacy of cerebral and systemic perfusion., Results: Surgeons at 3 institutions placed the Cobra catheter in patients undergoing coronary artery bypass grafting (n = 13), valve (n = 3), and combined valve-bypass (n = 4) operations. Mean total bypass flows of 2.1 +/- 0.2 L x min(-1) x m(-2) maintained mean arterial pressures in arch and descending aortic circulations of greater than 55 mm Hg. A mean differential of 4.3 degrees C between arch and descending aortic temperatures was established before crossclamp application, and a mean maximum temperature differential of 7 degrees C was established during bypass. A 2.4 degrees C temperature differential was maintained at crossclamp removal. Cerebral and systemic venous oxygen saturation remained greater than 65% during bypass., Conclusions: The Cobra device met all expectations for an arterial cannula with adequate perfusion to the arch and corporeal circulations. Dual perfusion with the Cobra catheter allows for independent temperature control during cardiopulmonary bypass with simultaneous cerebral hypothermia and systemic normothermia.

Background: The purpose of this investigation was to determine whether temperatures of the aortic arch and descending aortic circulations could be controlled independently during cardiopulmonary bypass with a cannula possessing an endoaortic baffle (Cobra; Cardeon, Cupertino, Calif)., Methods: After Institutional Animal Care and Use Committee approval, 12 pigs weighing 60 kg were started on bypass through a sternotomy. A dual-lumen endoaortic cannula with a deployable baffle was used for arterial cannulation. Bypass was initiated at 37 degrees C, and control measurements were obtained. The baffle was then inflated with saline solution, segmenting blood flow along the greater and lesser curvatures of the aortic arch. Parallel heat exchangers were used to independently control temperature of the arch and descending aortic perfusates. Cerebral and systemic temperatures were recorded continuously., Results: During cardiopulmonary bypass, mean flow and arterial pressure were maintained at 2.4 to 2.6 L x min(-1) x m(-2) and 60 to 70 mm Hg, respectively. With aortic flow distributed by the baffle, a 5 degrees C temperature differential between brain (30 degrees C) and body (35 degrees C) was established in a mean of 5 +/- 2 minutes. Mean brain and corporeal temperatures of 27 degrees C and 35 degrees C were then maintained over 60 minutes. Relative to control, internal jugular and inferior vena cava oxygen saturations increased during targeted temperature control with the device., Conclusions: The Cobra cannula allows for independent control of brain and body temperature while providing satisfactory hemodynamics. Application of this temperature management strategy may offer cerebral protection and the advantages of warm systemic bypass temperature.

Objectives: Recently, valvular regurgitation has been observed in patients who have taken fenfluramine or dexfenfluramine with or without phentermine. This study describes the clinical, echocardiographic, and pathologic findings of anorexigen-associated valvular heart disease and the surgical interventions required to treat it., Methods: We reviewed clinical information on 14 patients with severe anorexigen-associated valvular disease who underwent cardiac operations., Results: Thirteen women (mean age 44.2 +/- 5.3 years) received fenfluramine, 58.5 +/- 22.3 mg/day, and phentermine, 32.1 +/- 11.4 mg/day, for an average of 12.1 +/- 7.3 months before presentation. One woman received dexfenfluramine, 30 mg/day for 13 months, and phentermine, 60 mg/day, concomitantly for 6 months. Presenting symptoms included dyspnea (12 cases), palpitations (3), and atypical chest pain (3). Six patients had heart failure, and 4 had a new murmur. Echocardiography demonstrated severe mitral valve regurgitation in all patients. Seven also had aortic regurgitation, and 4 had significant tricuspid regurgitation. Four patients had successful mitral valve repair, 1 with concomitant aortic valve repair. Ten additional patients eventually required mitral valve replacement, 5 with concomitant aortic valve replacement. Excised valves demonstrated a glistening white appearance with plaque-like encasement of leaflets and chordae. Focal surface proliferation and fibrosis with a "stuck-on" appearance was consistently found., Conclusions: Anorexigen use may lead to severe multivalvular regurgitation with characteristic echocardiographic and pathologic findings. Recognition of drug-induced valvulopathy is important because of widespread use of these medications and the uncertain natural history of the disease. Early surgical experience suggests that valve repair is possible in these young patients.

Objectives: Our objectives were to characterize the outcome of coronary artery bypass grafting in patients with previous mediastinal radiation therapy and to identify special features of this condition that relate to surgical management., Patients and Methods: We conducted a retrospective review of 47 patients (28 women, 19 men) with a mean age of 63.5 +/- 12.8 years (range 31.0-82. 9 years) from 1976 through December 1996 undergoing coronary artery bypass graft after mediastinal radiation therapy., Results: The mean interval between mediastinal radiation therapy and coronary artery bypass grafting was 15.1 +/- 9.8 years (range 1.1-37.8 years). In the 44 patients with isolated coronary surgery, operative mortality was 3 patients (6.8%). Sternal wound infection occurred in 3 patients (6.8%). Actuarial survival at 1 and 5 years was 87.2% +/- 4. 9% and 71.6% +/- 7.1%, respectively. Total follow-up was 293.7 patient-years (mean 6.2 +/- 5.1 years). There were 17 late deaths (malignancy, n = 7; heart failure, n = 6; stroke, n = 1; other noncardiac causes, n = 2; and sudden death, n = 1). Twelve of 43 discharged patients had the development of valvular disease demonstrated by follow-up echocardiography., Conclusions: The early results of coronary artery bypass grafting for the treatment of ischemic heart disease after mediastinal radiation therapy are good. Late survival, however, is limited by malignancy, either recurrent or new, and the development of heart failure. Inasmuch as 25 other patients after radiation therapy required concomitant valve surgery and 12 of 43 (28%) discharged patients had later development of valvular disease, with 2 requiring reoperation, careful assessment of any valvular lesion is important during the initial coronary artery bypass grafting. Careful follow-up, including regular echocardiographic screening, is recommended in this patient population.

Objective: The purpose of this study was to determine the minimum hematocrit value that can support whole body oxygen consumption during normothermic cardiopulmonary bypass. The effect of hemodilution on peripheral resistance, whole body oxygen delivery, and oxygen consumption was determined over a range of hematocrit values., Methods: Measurements were obtained during 38 degrees C cardiopulmonary bypass with progressive normovolemic hemodilution (hematocrit value 40% to 9%) in nine dogs. Dextran 70 (6%) was used as a diluent. Anesthesia consisted of high-dose fentanyl and midazolam. A mean arterial pressure of 60 mm Hg was maintained throughout cardiopulmonary bypass via increases in pump flow., Results: Progressive hemodilution was associated with a decreasing total peripheral resistance. During normothermic cardiopulmonary bypass with a whole blood prime, the whole body oxygen consumption approximated values previously reported in dogs under nonbypass conditions. Oxygen delivery and whole body oxygen uptake were maintained between a hematocrit value of 39% and 25%. Significant decreases for both were seen when the hematocrit value was reduced to 18% and below., Conclusions: A hematocrit level greater than 18% was needed to maintain systemic oxygen delivery and consumption during warm cardiopulmonary bypass. The critical hematocrit value may be higher under bypass than nonbypass conditions because the flow increases that are practical during cardiopulmonary bypass do not approximate those seen in response to hemodilution of the intact circulation. Finally, the critical hematocrit value for the body may be higher than that required for the brain during warm cardiopulmonary bypass.

Methods: Between November 1985 and July 1995, 36 patients underwent allograft aortic valve replacement for endocarditis. The mean age of the 29 men and seven women was 53 years (range 25 to 79 years). Previous procedures included mechanical (n = 9), bioprosthetic (n = 5), and allograft (n = 2) aortic valve replacement, aortic valvotomy (n = 1), and orthotopic heart transplantation (n = 1). Infecting organisms were Staphylococcus and Streptococcus species in 69% of patients and fungi in 6%. Intraoperative findings demonstrated valvular vegetations (n = 25), annular abscesses (n = 25), and cusp destruction (n = 13). Complex reconstruction of the aortic anulus was required in 25 patients, and associated procedures included mitral valve repair (n = 2), mitral valve replacement (n = 3), coronary artery bypass grafting (n = 8), repair of ventricular septal defect (n = 4), left ventricular aneurysmectomy (n = 1), and repair of atrial septal defect (n = 1). Allograft valve insertion was performed by the scalloped technique in seven, intraaortic cylinder technique in 19, and allograft aortic root replacement in 10., Results: Follow-up was 100% complete at a mean of 2.6 +/- 2.8 years after valve replacement. Operative mortality was 13.8%. Complications included low cardiac output (n = 10), bleeding (n = 2), myocardial infarction (n = 1), stroke (n = 1), renal insufficiency (n = 2), respiratory insufficiency (n = 3), and heart block (n = 8). Late echocardiogram (mean 2.6 +/- 1.8 years) demonstrated grade III/IV aortic regurgitation in five patients. There were seven late deaths (five cardiac, not valve-related; two noncardiac). No patient has had recurrence of endocarditis. Actuarial survival at 5 years was 53.1% +/- 11.5%. Univariate analysis demonstrated prosthetic valve endocarditis to adversely affect late survival (p = 0.04). Cumulative risk of reoperation at 5 years was 8.0% +/- 5.6%., Conclusion: Allograft aortic valve replacement facilitated reconstruction of complex aortic valve endocarditis with a low reoperation rate and no recurrent endocarditis in this series.

Recent reports have described cerebral venous oxygen desaturation during and after rewarming from hypothermic cardiopulmonary bypass. Additionally, patients undergoing normothermic cardiopulmonary bypass may be at higher risk for neurologic injury. This study was designed to determine whether patients undergoing normothermic cardiopulmonary bypass are at increased risk for sustained cerebral desaturation. Fifty-two patients undergoing first-time coronary artery bypass grafting were randomized to receive normothermic (37 degrees C, n = 26) or hypothermic (27 degrees C, n = 26) cardiopulmonary bypass. The anesthetic was standardized and alpha-stat pH management was used. A 4F oximetric catheter was placed in the jugular bulb and cerebral venous and radial arterial blood were sampled. Oxygen partial pressure and saturation were measured at six intervals from cerebral venous blood and from radial arterial blood. Patients receiving normothermic cardiopulmonary bypass had lesser values of oxygen partial pressure and saturation in cerebral venous blood than patients subjected to hypothermia during the first 40 minutes of bypass. Cerebral venous desaturation (oxygen saturation in cerebral venous blood of 50% or less) was observed in 54% of patients in the normothermic group and 12% of patients in the hypothermic group during cardiopulmonary bypass. In the normothermic group, cerebral desaturation occurred primarily in early bypass (14 of 26). The three episodes of desaturation in the hypothermic group occurred during rewarming. During cardiopulmonary bypass, the arteriovenous oxygen content difference was greater in the normothermic group than in that in the hypothermic group, suggesting higher oxygen consumption. Differences in glucose utilization during early cardiopulmonary bypass between the groups was also detected. One patient in the hypothermic group had an embolic stroke and subsequently died. There were no other perioperative strokes or deaths in the study population. The present study demonstrates that patients undergoing normothermic cardiopulmonary bypass are at greater risk for cerebral desaturation. Because it is a global assessment, cerebral venous oxygen saturation may be insensitive to focal ischemic events. It remains to be seen whether these differences in cerebral physiologic states translate into differences in clinical outcome.

To examine late outcome of mitral valve repair in patients with preoperative atrial fibrillation, we reviewed the cases of 323 consecutive patients who underwent mitral valvuloplasty for mitral regurgitation from 1980 to 1991; average age of 215 men and 108 women was 64 years (range 14 to 88 years), and 224 patients (70%) were in New York Heart Association class III or IV before operation. The main indications for operation were severe mitral regurgitation (76%), coronary artery disease with associated mitral regurgitation (15%), and aortic valve disease (6%). At the time of mitral valve repair, coronary artery bypass grafting was done in 35% of patients, aortic valve replacement was done in 7%, and multiple other procedures were done in 10%. For all patients, the 30-day mortality rate was 2.5% (70% confidence limits 1.6% to 3.4%) and survivorships at 3 and 5 years were 81% and 76%, respectively. Before operation, 216 patients were in sinus rhythm and 97 patients had atrial fibrillation; in the latter group, 11 had recent onset of atrial fibrillation within 3 months preceding mitral valve repair. Comparing patients with preoperative atrial fibrillation to those with sinus rhythm, we found no significant difference in operative mortality (3% versus 1.9%) or 5-year survivorship (74.3% +/- 6.3% versus 76.9% +/- 4.0%). At late follow-up, atrial fibrillation was present in 5% of patients with preoperative sinus rhythm, 80% of patients with preoperative chronic atrial fibrillation, and 0% of patients with preoperative recent onset atrial fibrillation (p < 0.01). The left atrial size by echocardiography was larger in patients with preoperative atrial fibrillation compared with that in those with sinus rhythm (59 +/- 1.4 mm versus 50.9 +/- 0.7 mm; p < 0.05). There was, however, only a weak correlation between preoperative left atrial size and late atrial fibrillation. Further, age, gender, and associated coronary artery disease did not correlate with presence of atrial fibrillation at late follow-up. Prevalence of late thromboembolic events was similar in patients with preoperative sinus rhythm compared with that in those with atrial fibrillation. These data suggest that mitral valve repair should be done before or soon after the onset of atrial fibrillation to maximize the chance of postoperative sinus rhythm and avoid long-term anticoagulation with warfarin. However, the early and late results of mitral valve repair in patients with chronic atrial fibrillation are good, and concomitant operation for supraventricular arrhythmia must have negligible morbidity and no adverse effect on operative mortality.

Cardiac valve replacement with use of only the Björk-Shiley prosthesis was performed in 1253 patients between January 1973 and December 1982. There were 828 patients having aortic valve replacement, 280 patients having mitral valve replacement, and 145 patients having double valve replacement with aortic and mitral valve prostheses. Patient outcome was stratified according to multiple variables, including valve position and valve model (spherical versus convexo-concave discs). No valve failure due to strut fracture was identified in 26 high-risk patients (mitral valve replacement with greater than or equal to 29 mm implanted in patients less than or equal to 50 years of age) followed up for a mean of 10 years postoperatively. Fifteen patients had late thrombosis of their Björk-Shiley prosthesis (0.28 per 100 patient-years), but there was no significant difference in risk of valve thrombosis comparing the spherical and convexo-concave discs (0.27 per 100 patient-years versus 0.27 per 100 patient-years). One hundred two patients had 128 thromboembolic episodes; rates of thromboembolism after aortic valve replacement, mitral valve replacement, and double valve replacement were 2.1, 4.3, and 4.6 per 100 patient-years, respectively. Percentages of patients free from thromboemboli after aortic valve replacement, mitral valve replacement, and double valve replacement were 93% +/- 1%, 86% +/- 2%, and 89% +/- 3% at 5 years postoperatively and 87% +/- 2%, 79% +/- 5%, and 77% +/- 8% 10 years postoperatively. There was no significant difference in the rates of thromboemboli for spherical and convexo-concave discs for all patients and for each of the subgroups. Ten-year actuarial survival estimates for patients dismissed alive from the hospital after aortic valve replacement, mitral valve replacement, and double valve replacement with the Björk-Shiley valve were 65% +/- 4%, 63% +/- 5%, and 55% +/- 8%, respectively. Overall event-free survival (freedom from death, thromboembolism, anticoagulant-related bleeding, endocarditis, and reoperation) was similar for the three patient groups. Performance of the Björk-Shiley valve as judged by late patient follow-up is similar to other mechanical valves, and modifications in disc design do not appear to have reduced the threat of late valve thrombosis and thromboemboli. Evidence does not support elective explantation of this prosthesis.

The need to support the distal circulation during aortic crossclamping and the subsequent effects on hemodynamics and organ perfusion prompted our review of 51 patients who underwent repair of aneurysm of the descending thoracic aorta from 1983 through 1987. Forty-three patients had aneurysms originating distal to the left subclavian artery, and eight had aneurysms involving the distal aortic arch and the proximal descending aorta; 10 patients had emergency operation for aneurysm rupture. Three different techniques were used: Seventeen patients had left atrial-distal aorta arterial bypass with a centrifugal pump, 18 patients had a Gott shunt, and 16 patients had no circulatory support during aneurysm repair. Location and type of aneurysm, age, sex, diabetes, preoperative hypertension, and serum lipid levels were similar in the three groups. Duration of crossclamping was 54 +/- 12 minutes for left atrial-aortic assist, 45 +/- 5 for the shunt group, and 34 +/- 4 for patients without circulatory support. With crossclamping, all groups had similar and significant increases in heart rate (p less than 0.03). Proximal systolic blood pressure did not change during left atrial-aortic assist, but a transient increase occurred in patients with shunts (p less than 0.01), and a sustained increase occurred in patients without circulatory support (p less than 0.05). With crossclamp release, arterial pH and capillary pulmonary wedge pressure decreased significantly (p less than 0.05) in patients without shunt or bypass. Postoperative renal function did not vary significantly when circulatory support was used, but serum creatinine rose transiently in patients with unsupported aortic crossclamping. We conclude that support of the distal circulation during thoracic aortic crossclamping stabilizes hemodynamics and prevents systemic acidosis and renal ischemia. Further, our data suggest that the centrifugal pump may provide better protection than a passive shunt.

Records of 231 patients (171 males, 60 females; aged 10 months to 83 years [median 45 years]) who underwent operation for constrictive pericarditis at the Mayo Clinic from 1936 through 1982 were reviewed. All had had hemodynamically significant pericardial constriction preoperatively, and pericardial disease was confirmed at operation. Preoperatively, 69% were in New York Heart Association Class III or IV and 81% had peripheral edema or ascites. Pericardiectomy was performed through a left anterolateral thoracotomy (34%), a median sternotomy (27%), a U incision (Harrington) (21%), or a bilateral anterior thoracotomy (18%). Postoperatively, 28% of patients had evidence of low cardiac output; 70% of the 32 deaths within 30 days of operation were due to low cardiac output. Operative risk was significantly (p less than 0.001) related to preoperative disability (1% for Class I or II; 10% for class III; 46% for Class IV). Median postoperative follow-up was 9 years (longest was 43 years). Probability of survival for patients dismissed alive from the hospital was 84% at 5 years, 71% at 15 years, and 52% at 30 years. Long-term survival (excluding operative mortality) was not significantly influenced by the disability class preoperatively, the operative approach, or the development of low cardiac output in the immediate postoperative period. At the end of the follow-up interval, there were 141 patients in whom functional capacity could be assessed; 140 were in Class I or II. We conclude that a poor hemodynamic result after complete pericardiectomy relates to the preoperative degree of constriction and resultant cardiomyopathy. We recommend early pericardiectomy when pericardial constriction is diagnosed, and we continue to use a left anterolateral thoracotomy as the preferred approach for most patients.

From 1965 through 1983, 43 patients underwent concomitant cardiac and pulmonary procedures at our institution. Most patients presented with cardiac symptoms and were incidentally found to have a roentgenographically indeterminate lung nodule. The pulmonary diagnosis of 38 patients was unknown preoperatively, and nine of these had a malignant lesion. All 43 cardiac procedures necessitated extracorporeal circulation. Thirty-one patients had benign pulmonary disease, 10 had bronchogenic carcinoma, and two had metastatic carcinoma. Concomitant pulmonary procedures were performed via median sternotomy and included single wedge resections in 32 patients, lobectomy in seven, multiple wedge resections in three, and pneumonectomy in one. Most resections were performed either before or after institution of bypass, without systemic anticoagulation. Of the two operative deaths (4.6%), one was related to intraparenchymal pulmonary hemorrhage after multiple wedge resections during anticoagulation. Thus, pulmonary resections performed during anticoagulation may be associated with increased risk and probably should be avoided. The second death was cardiac in origin and not related to pulmonary resection. The remaining patients recovered uneventfully. Definitive correction of both cardiac and pulmonary disease can be performed at one operation via a single incision with safety and benefit to the carefully selected patient.

Surgical drainage for effusive pericardial disease is usually accompanied by pericardial resection to obtain tissue for analysis and to lessen the chance of recurrent effusion or late constriction. The purpose of this study was to determine the relationship between the extent of resection and the development of late complications. From 1960 through 1983, 145 patients with pure pericardial effusive disease underwent operative drainage. The effusions were malignant in 72 patients (49.7%) and benign in 73 (50.3%). The patients were divided into three groups according to the extent of resection: complete in 72 patients (49.7%), partial in 36 (24.8%), and window in 37 (25.5%). The 30 day mortality was 19.4% for patients with malignant effusions and 5.5% for those with benign effusions (p less than 0.05). All survivors had immediate improvement in symptoms. The actuarial 1 year survival rate was 23.4% (mean 4.2 months) for patients with malignant disease and 85.6% for patients with idiopathic effusions (p less than 0.001). Survival was not influenced by the extent of resection. Fifteen patients (10.3%) had late constriction or recurrent effusion. Six of these required reoperation, all after having had a window procedure. Actuarial probability of reoperation or late complication was greater with window procedures than other resections, both for all patients (p = 0.0001) and for those with benign disease (p = 0.0001). Transthoracic complete pericardiectomy is the procedure of choice for effusive pericardial disease. Subxiphoid drainage has immediate advantages for selected patients but has a statistically greater chance of late complications.

A prospective randomized trial involving 91 patients undergoing cardiopulmonary bypass compared the effects of bubble oxygenators (with and without methylprednisolone sodium succinate) and membrane oxygenators on complement activation and transpulmonary sequestration of leukocytes. Patients were divided as follows: Group I, 30 patients, bubble oxygenator; Group II, 31 patients, bubble oxygenator and methylprednisolone sodium succinate (30 mg/kg); Group III, 30 patients, membrane oxygenator. In Group I, C3a increased from 323 +/- 171 ng/ml during cardiopulmonary bypass to 1,564 +/- 785 ng/ml at 25 minutes after bypass (p less than 0.0001). A significant decrease in C3a was found in Groups II and III compared to Group I (p less than 0.0001). C5a did not change significantly during cardiopulmonary bypass in any group. Reestablishment of pulmonary circulation at the end of bypass produced significant transpulmonary leukocyte sequestration in Group I; the median cell difference was 1,700/microliter. Transpulmonary sequestration was significantly (p less than 0.0001) less in Group II (median cell difference = 200/microliter) and in Group III (median cell difference = 400/microliter) than in Group I. We conclude that cardiopulmonary bypass with a bubble oxygenator alone initiates significantly (p less than 0.0001) more C3a activation and leukocyte sequestration than when methylprednisolone sodium succinate (30 mg/kg) is given 20 minutes before the start of cardiopulmonary bypass with a bubble oxygenator or when a silicone membrane oxygenator is used.

From 1958 through 1980, 131 patients had repair of ruptured chordae tendineae of the mitral valve; 62% were men. Ages ranged from 5 to 70 years (median 57). Chordae to the anterior mitral leaflet were ruptured in 44 patients (34%), to the posterior mitral leaflet in 85 (65%), and to both leaflets in two patients (1%). The mitral valve was repaired by leaflet plication without resection in 116 patients, plication after wedge resection of the unsupported leaflet in six, Ivalon sponge buttress of the posterior leaflet in three, resuspension of chordae in two, and annuloplasty alone in the remaining four. Mitral valve annuloplasty was performed in addition to leaflet repair in 115 patients (88%). Operative (less than 30 days) mortality was 6.1%. Survival rate of patients dismissed from the hospital was 92% at 5 years and 73% at 10 years. There were no differences in late survival or risk of reoperation for recurrent or residual mitral insufficiency between patients with ruptured chordae to the anterior leaflet and those with ruptured chordae to the posterior leaflet. Survival was significantly better for the group with repair than it was for a group that underwent mitral valve replacement for ruptured chordae during this same time interval (5 year survival rate, 92% versus 72%, p less than 0.003). The incidence of thromboembolism after repair was 1.8 episodes/100 patient-years compared with 8.0 episodes/100 patient-years after replacement. Our data indicate that valvuloplasty is the procedure of choice for most patients with mitral regurgitation owing to ruptured chordae tendineae, including selected patients with ruptured chordae to the anterior leaflet.

The internal mammary artery has excellent long-term patency when used as a conduit for coronary artery bypass, and clinical and experimental studies have shown that blood flow through an internal mammary artery graft is satisfactory for most coronary artery branches. Multiple distal anastomoses from a single internal mammary artery, either with sequential anastomoses or with a Y-graft, might require additional blood flow through the vessel, and there has been concern that the flow capacity of the internal mammary artery is insufficient with these techniques. To better define the immediate postoperative flow capacity and pattern of the internal mammary artery, we performed experiments in seven dogs in which the left internal mammary artery was anastomosed to the circumflex coronary artery. In situ, blood flow in the internal mammary artery was 27 ml/min. Blood flow was 63 ml/min in the circumflex coronary artery and 42 ml/min in the left anterior descending coronary artery. After anastomosis of the left internal mammary artery to the circumflex coronary artery, the left main coronary artery was ligated; flow through the bypass graft increased to 92 ml/min, and systemic hemodynamics remained stable. Isoproterenol stimulation further increased flow through the left internal mammary artery graft to 160 ml/min. This study suggests that the canine internal mammary artery is capable of substantial early increase in flow and can, in fact, support the entire left coronary circulation.

Five hundred fifty-two patients underwent a total of 617 reoperations for repair or replacement of a prosthetic heart valve. Operative mortality for first reoperation (530 patients) was 5.9% for the aortic position and 19.6% for the mitral position. Overall operative mortality was 14% for second reoperation (69 patients) and 7% for third reoperation (14 patients). In addition to valve position, operative mortality for first reoperation appeared to be related to pre-reoperation functional class and urgency of operation. First reoperation for mitral valve patients in New York Heart Association (NYHA) Class II was 4.2%; for Class III, 9.3%; and for Class IV, 41%. In the aortic position, operative mortality was 2.4% for Class I, 1.6% for Class II, 6.3% for Class III, and 20.8% for Class IV. The mortality for elective mitral valve reoperation was 0%; for urgent operation, 20.3%; and for emergency procedures, 54.5%. Elective aortic valve reoperation carried a 1.4% mortality; urgent procedures, 8%; and emergency procedures, 37.5%. No significant differences in bleeding complications were noted between reoperations and initial valve replacement. The data appear to suggest that when significant valve dysfunction is first noted, reoperation should be undertaken to minimize operative risk.

We reviewed the results of early (less than 24 hours) coronary artery bypass after unsuccessful percutaneous coronary artery angioplasty in 146 patients treated between October 1979 and July 1986. Overall operative mortality was 2.7%, and risk was significantly increased among patients with hemodynamic instability and new occlusion or further narrowing of the dilated vessel (3.8 versus 0%, p less than 0.05). Actuarial analysis was used to compute the rates of cardiac events during the follow-up interval, and event rates were also estimated in a comparison group of 776 patients who had successful first-time PTCA during the same time period. At a follow-up interval of 5 years, the cumulative risks of recurrence of angina and need for an additional procedure (bypass or angioplasty) were significantly (p less than 0.05) lower for patients who had undergone bypass than for those who had successful angioplasty (angina 21% versus 56%, PTCA 2% versus 21%, CAB 6% versus 16%). Cumulative risks of myocardial infarction and death were 4% versus 9% and 6% versus 9% in the two groups. The differences between late outcomes in the bypass and angioplasty groups persisted when patients were stratified into cohorts with single-vessel and multivessel disease, and the highest late event rate occurred in patients in the angioplasty group who had incomplete revascularization. The difference in late events after bypass or angioplasty was greatest during the first year. These late data should be considered when the mode of revascularization (bypass or angioplasty) is selected for symptomatic patients, especially those with multivessel disease.

We reviewed the Mayo Clinic records of 56 patients who underwent operation for cardiac myxoma and 29 cases in which cardiac myxoma was found at autopsy. Five patients had a "complex" of unusual findings including multiple pigmented skin lesions (lentiginosis), myxoid fibroadenomas of the breast, skin myxomas, and primary pigmented nodular adrenocortical disease (a cause of Cushing's syndrome). Four of these five patients had multiple cardiac myxomas. Three of the four patients who underwent surgical excision of the cardiac myxomas had recurrent myxomas (the only recurrences in our series), and one of these patients had a second recurrence. The occurrence of multiple and recurrent myxomas in patients with the complex was significantly (p less than 0.001) higher than in our 80 patients with sporadic myxomas. The world literature was searched for cases of cardiac myxomas with the unusual associations of the complex, and also for familial, multiple, and recurrent myxomas. A group of patients were identified who had unusual biologic behavior including early development of myxomas, atypical myxoma locations, and a high risk for the development of recurrent myxomas. For these patients, we recommend a thorough search for multiple tumors at operation, close postoperative follow-up, and careful screening of family members.

Patch enlargement of the aortic root or anulus is a widely accepted technique when restrictive anatomy is encountered during aortic valve replacement. Patches made of prosthetic material have been used almost exclusively, and patches of autogenous pericardium have not received wide acceptance. Although pericardium is advantageous because of its low cost, ready availability, and ease of handling, its long-term durability has not been fully established. From 1965 to 1981, 96 patients had autogenous pericardial patches placed during aortic valve replacement at the Mayo Clinic. In 81 patients, the patches were placed solely in a supravalvular position to facilitate aortic closure, while in 15 patients, the patches were placed in both subvalvular and supravalvular positions, allowing for annular expansion and insertion of a larger prosthesis. In a mean follow-up of 5.4 years, none of the 92 operative survivors has had clinical evidence of sudden patch failure and none has had patch aneurysms detected by routine chest roentgenography. One patient required reoperation for a perivalvular leak at the point where the prosthesis had been sutured to the patch. Objective data concerning the late postoperative status of the patch were available on 48 patients: 24 underwent reoperation, 16 underwent two-dimensional echocardiography, two underwent aortic root angiography, and six underwent postmortem examination. Patch aneurysms were universally absent, and in every patient the patches were well incorporated into the adjacent tissues. This proven durability suggests that autogenous pericardium is a satisfactory patch material when required during aortic valve replacement.

This study compares patency and histologic structure of in situ internal mammary artery grafts, free internal mammary artery grafts, stripped, free internal mammary artery grafts, and stripped, free superficial femoral artery grafts (a muscular artery model) in a canine model of coronary artery bypass. Twenty-four adult mongrel dogs underwent bypass of the circumflex coronary artery with one of the above grafts. Three months postoperatively, graft patency was assessed by angiogram, and postmortem specimens were studied by intraluminal injection of a dilute barium solution proximal to the graft. Proximal, mid, and distal segments of each graft were examined microscopically. In situ internal mammary artery grafts and free internal mammary artery grafts were not significantly different in regard to patency, vascular wall cellular structure, or perfusion of the vasa vasorum. The stripped, free internal mammary artery group had a higher incidence of thrombosis, intimal thickening, and medial injury than the pedicled (in situ and free internal mammary artery) grafts. This difference may be due to early vascular wall ischemia as a result of poor early perfusion of the vasa vasorum. The stripped, free superficial femoral artery grafts were all patent, but all had adventitial injury.

To determine late survival and functional status after second revascularization procedures for coronary artery disease, we studied 106 consecutive patients operated on between June, 1969, and December, 1980. The mean age of the 96 men and 10 women was 49 +/- 8 years (range 22 to 65 years). Before reoperation, 101 patients (95%) were judged to be in New York Heart Association Class III or IV with angina, and 81 patients (76%) had three-vessel involvement. Angina recurrence was most commonly caused by bypass graft occlusion alone and in combination with progressive disease of the native arteries (60 patients, 57%). Three patients (2.8%) died within 30 days of reoperation; each death resulted from myocardial infarction. An average of 2.2 coronary arteries were bypassed in each patient. Complete follow-up data (mean 43 months) were available for 105 patients. Actuarial survival of patients dismissed alive is 94% at 5 years and 89% at 7 years. All late cardiac-related deaths occurred in patients with three-vessel disease. When recurrence of any angina, need for a third operation, and myocardial infarction are included with cardiac-related deaths, event-free survival is 28% at 5 years and 26% at 7 years. Late survival and functional status could not be predicted by the cause of recurrent angina or the presence of risk factors. Repeat myocardial revascularization can apparently be undertaken with low risk and with prospects for excellent long-term survival. After reoperation, recurrence of mild angina is not uncommon, but freedom from serious cardiac events and relief of severe symptoms were noted in more than 60% of patients 5 years later.

Between 1965 and 1984, 109 patients underwent simultaneous aortic and mitral valve replacement and tricuspid valve repair at the Mayo Clinic, with a perioperative mortality of 21%. The only variable predictive of perioperative mortality on multiple regression analysis was New York Heart Association class IV disability. The median follow-up was 5.6 years (range 1 to 20 years). Cumulative 5-, 10-, and 15-year survival rates in patients discharged from the hospital were 70% +/- 5%, 42% +/- 6%, and 33% +/- 7%. Multivariate analysis identified advanced age and class IV disability as significant predictors of poor survival. Five-year survival rates were similar in patients undergoing operation between 1965 and 1974 and after 1975, despite an increase in age and in the severity of preoperative symptoms in the recent group. Late mortality was due to sudden death in 38% of the patients, heart failure in 21%, reoperation in 5%, endocarditis in 2%, and thromboembolism and bleeding in 4%. Late complications included systemic emboli in 22% (embolism rate 4.5 events/100 patient-years), bleeding in 17%, reoperation in 14%, myocardial infarction in 8%, permanent pacemaker implantation in 5%, and infective endocarditis in 3%. Of 43% of the patients still alive, 79% are in class I or II.

Operative treatment of dissections of the ascending aorta differs from that for the descending aorta, not only because of the need for cardiopulmonary bypass, but also because of the frequent occurrence of aortic valve insufficiency. To determine the early and late results of operative repair, we have reviewed the case histories of 121 consecutive patients who underwent repair of ascending aortic dissections between 1962 and 1985. Ages ranged from 16 to 79 years (mean 56 +/- 14 years); 54 patients had operation within 2 weeks of onset of symptoms (acute), and the remainder had later repair (chronic). Seventy patients (58%) had clinical evidence of aortic insufficiency at the time of admission. During repair of acute dissection, 10 patients (19%) had aortic valve resuspension and 15 patients (28%) had aortic valve replacement. During repair of chronic dissection, eight patients (12%) had resuspension and 43 patients (64%) had replacement. Overall operative mortality was 22%, significantly higher for patients with acute than for those with chronic dissections (39% versus 9%, p less than 0.01). Operative risk was similar for patients who underwent repair of ascending aortic dissections without valve resuspension or replacement (31%) versus those who had repair with aortic valve resuspension (17%) or replacement (17%). During a follow-up period ranging from 1 to 208 months, aortic regurgitation developed in only two patients who did not have aortic insufficiency at the time of repair. Late aortic regurgitation necessitating reoperation developed in one of the 15 survivors who had aortic valve resuspension. Eight patients undergoing aortic valve replacement had complications of their prostheses, including one periprosthetic leak and four mechanical failures. We conclude that resuspension or replacement of the aortic valve does not increase the risk of repair of ascending aortic dissections. Selective management of aortic insufficiency (with valve repair whenever possible) yields satisfactory long-term results.

Seven patients (one woman) have been seen with ascending aortic dissections at a mean of 8.8 years (6 months to 20 years) after cardiac operation. Previous cardiac operations included saphenous vein coronary artery bypass grafts (CAB) (two), aortic valve replacement (AVR) (one), aortic valvulotomy (one), AVR plus CAB (two), and patch closure of a ventricular septal defect and repair of a perforated aortic cusp (one). During the initial operation, three of seven patients had dilatation of the ascending aorta. Five of seven patients were hypertensive at the time of diagnosis of dissection. Six patients were managed by operation. A composite prosthetic aortic valve and ascending aortic graft with implantation of coronary ostia and saphenous vein grafts was utilized in three patients. In three the repair was by graft replacement of the ascending aorta alone. Five of six patients survived repair and were asymptomatic at discharge. Subsequent problems resulting from distal, descending thoracic, or abdominal aortic extension of the dissection were frequent and necessitated fenestration (one patient) or a graft replacement of the infrarenal aorta (one patient). We conclude that patients may be predisposed to aortic dissection occurring late after cardiac operation, possibly related to prior aortic valvular disease or systemic arterial hypertension. Operative repair is feasible and relatively safe. Follow-up for potential complications of distal aortic problems seems indicated. Techniques of operative repair in these patients are emphasized.