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The rising costs of health care have forced policy makers to make choices, and new treatments are increasingly assessed in terms of the balance between additional costs and additional effects. The recent recognition that stenting has a major and long-lasting effect enhancing balloon PTCA procedure has made it imperative to compare in patients with multivessel disease the standard surgical procedure with multiple stenting in a large scale multinational and multicentre approach (19 countries, 68 sites). Selection and inclusion of patients is based on a consensus of the cardiac surgeon and interventional cardiologist on equal 'treatability' of patients by both techniques with analysis of clinical follow-up (event-free survival) on the short (30 day), medium (1 year), and long-term (3 and 5 year) with analysis of cost-effectiveness and quality of life (EuroQol and SF-36). Of the entire trial, the primary null hypothesis which needs to be rejected is that there will be no difference in event-free survival or effectiveness (E), at 1 year and also that the direct and indirect costs (C) per event-free year are not different between surgery or stenting. For this to become significant with a power of 90% one needs 1200 patients. Between April 97 and June 98, 1205 patients have been randomized with a monthly recruitment of 83 patients. Expected costs, effects and cost-effectiveness ratio (CE ratio) are: Stent high costs 2 VDStent high costs 3 VDStent low costs 2 VDStent low costs 3 VDCABG costs (C)$19.297$24.566$16.638$20.456$21.350 effects (E)81%81%81%81%88% CE ratio$23.876$30.397$20.586$25.322$24.348 Clinically, stenting is not expected to be more effective than CABG, but should be cost effective in both the 2- and 3-VD group when using the lower cost estimate and in the 2 VD group when using the higher cost assumptions., (Copyright 1999 Harcourt Publishers Ltd.)

Objective: The temporal response to endoventriculoplasty (EVP) has not been well defined. We have evaluated the long-term clinical and functional results of this technique., Methods: From 1988 to 1997, 121 patients underwent aneurysmectomy by EVP associated with myocardial revascularization for anteroapical left ventricular postinfarction aneurysm. Among these, 39 patients (43%) underwent early post-operative cardiac catheterization (within 3 months maximum), and were available to be revaluated after a mean follow-up time of 56+/-28 months, by means of a new hemodynamic study. Left ventricular silhouettes were analyzed by means of a special software., Results: The mean New York Heart Association functional class decreased from 2.5+/-0.9 to 1.6+/-0.8 (P<0.001) late postoperatively. The global ejection fraction improved early postoperatively from 43+/-13 to 61+/-13% (P<0.001), and late postoperatively slightly decreased to 42+/-13% (ns) versus preoperative values. Left ventricular end diastolic pressure early postoperatively fell from 16.8+/-7 to 15.7+/-6.7 (ns), and late postoperatively increased to 21.6+/-8.8 (ns) versus preoperative values. Pulmonary artery pressure rose early postoperatively from 31.5+/-6.4 to 32.1+/-6.7 (ns), and late postoperatively to 34.9+/-8.9 (ns). The global contractility score decreased early postoperatively from 42.3+/-9.6 to 28.4+/-13.6 (P<0.001); the global late postoperative contractily was 35+/-14 (ns) versus preoperative values. Patients who benefit most from the operation were those with a normal postoperative contraction pattern, where ejection fraction improved respectively early postoperatively from 43+/-13 to 63+/-11% (P<0.001), and late postoperatively to 49+/-10% (P<0.001) versus preoperative values. Occlusion or critical stenosis of bypass grafts occurred in 10 patients (25.6%). There were no significant differences in hemodynamic data and hypokinesis score changes between patients with patent or occluded bypass graft, and between patients with mono or multivessel disease. The operative mortality was 6.3%, and 8.8% needed intraaortic balloon counterpulsation. The actuarial survival rates at 5 and 7 years were 73+/-6 and 61+/-6%. The mean follow-up period was 68 months (with 112 months maximum)., Conclusions: We conclude that, in our patients group, EVP of left ventricular aneurysm associated with coronary grafting improves clinical status after operation. We registered a trend for a mild hemodynamic worsening, irrespective of coronary artery disease except in those patients who had shown a normal postoperative contraction pattern.

Partial left ventriculectomy (PLV) was recently introduced for end-stage dilated cardiomyopathy to improve ventricular function. Since November 1996 we have performed PLV in 14 patients; preoperatively 4 patients had idiopathic dilated cardiomyopathy and 10 had ischemic dilated cardiomyopathy. 57.1% of patients were in New York Heart Association functional Class IV. The mitral valve was replaced in 11 patients. Postoperative echocardiography showed a reduction of left end-diastolic diameter (55.4 +/- 5.4 mm) and an increase in forward ejection (cardiac index from 2.19 +/- 0.571 min/m2 to 2.67 +/- 0.931/min/m2). The 30-day mortality was 28.6% and 20-month survival was 57.2%. Only one patient was not in NYHA functional class due to postoperative progressive mitral incompetence. Prognostic factors should be identified to avoid early failure. However, even if the mortality rate for PLV high, this operation is a valid choice for the treatment of end-stage dilated cardiomyopathy.

Objective: To investigate the effects of endoventriculoplasty (EVP) and myocardial revascularization on left ventricular function and on sympathovagal balance modulating sinus node and vasomotor activity, we studied patients with left anterior, septal or anteroseptal ventricular aneurysm, before and after surgery. It has been demonstrated that, compared to the standard aneurismectomy, EVP associated with coronary grafting has a lower operative mortality and improves ventricular function, clinical status and prognosis., Methods: We collected pre- and post-operative echocardiographic and angiographic data to determine morphological and hemodynamic changes. The pre- and post-operative neural cardiovascular control was assessed by power spectrum analysis of heart rate and systolic arterial pressure (SAP) variabilities during rest and tilt., Results: As expected, post-operative ventricular function improved significantly: ejection fraction increased from 33 +/- 2 to 46 +/- 3% (p < 0.01) when assessed by echocardiography and from 40 +/- 4 to 55 +/- 5% (p < 0.01) when assessed by angiography; left ventricular end-diastolic pressure fell from 22 +/- 3 to 13 +/- 2 mmHg (p < 0.05). Pre-operatively sympathovagal balance responsiveness was blunted: tilt test did not induce, in respect to resting values, any significant change in low frequency (LFRR) and high frequency (HFRR) components of RR variability (in normalized units, n.u.) and in LFSAP. Post-operatively, tilt induced significant changes in LFRR and HFRR (in n.u.), in LF/HF ratio and LFSAP in respect to resting values. The pre- and post-operative percent differences--delta%--, from rest to tilt, of LFRR, HFRR, LF/HF and LFSAP were also significantly different (p < 0.01, p < 0.05, p < 0.05, p < 0.05). In addition, we compared data obtained from survivors and non-survivors (6 out of 19 patients died within 4 months because of heart failure). Non-survivors were characterized by significantly lower RR variance (184 +/- 80 vs. 1193 +/- 309 ms2 at rest, 196 +/- 87 vs. 546 +/- 104 ms2 during tilt, p < 0.05) and lower LFRR (15 +/- 7 vs. 61 +/- 6 at rest, 23 +/- 10 vs. 58 +/- 6 during tilt, in n.u., p < 0.01)., Conclusions: (1) The improvement of ventricular function induced by EVP and myocardial revascularization is accompanied by a restored capability to oscillate of cardiovascular neural regulatory mechanisms; (2) the drastic reduction of variance and LF component from RR variability seems to be associated with an ominous outcome.

Objective: A prospective angiographic study was undertaken to investigate, with an objective analysis, the global and regional wall response to myocardial revascularization., Methods: Thirty-one patients (30 men and 1 woman, mean age, 61 years) with a left ventricular ejection fraction of less than 0.30 were admitted to our institution between 1992 and 1995 for two- or three-vessel coronary artery disease requiring myocardial revascularization. All patients underwent isolated coronary artery bypass grafting and were studied 3 months later with angiography. Preoperative and postoperative wall motion were analyzed using special software that computed a segmental left ventricular ejection fraction, generating a segmental score. Computerized analysis allowed us to distinguish patients with diffuse hypokinesis and a symmetric contraction pattern from patients with akinesis involving at least two segments and an asymmetric contraction pattern., Results: There were no operative deaths and no patient required intraaortic balloon counterpulsation. One patient had postoperative enzymatic evidence of myocardial infarction. Postoperative angiography showed a graft patency rate of 84%. Global analysis showed a small but significant rise in the left ventricular ejection fraction (0.25 +/- 0.51 to 0.31 +/- 0.70, p < 0.001) and a fall in the left ventricular end-diastolic pressure (23.7 +/- 10 to 16.5 +/- 9 mm Hg, p < 0.01). Mean scores always have been lower after the operation than before it, with the best results obtained for the apex and the worst for the anterobasal segment. The group with a symmetric contraction pattern showed a trend toward a better hemodynamic response than the group with an asymmetric contraction pattern. Regression analysis revealed two important predictors of segmental functional improvement: (1) the absence of an echocardiographic scar, and (2) the presence of a collateral circulation., Conclusions: Coronary artery bypass grafting produced a small but substantial improvement in patients with ischemic cardiomyopathy. The greater benefit occurred in patients with a symmetric contraction pattern. The absence of an echocardiographic scar and the presence of a collateral circulation predicted segmental functional improvement.

This case-report describes a large pseudoaneurysm of the proximal left anterior descending coronary artery, fissured in the pericardium, developed 4 days after rotational and directional atherectomy followed by stent implantation. A successful percutaneous repair was obtained with 2 vein-covered stents implanted and expanded under ultrasound guidance.

This is a selected series of 28 patients with myxomatous mitral regurgitation that underwent correction of the anterior leaflet prolapse caused by chordal elongation by means of a running suture involving the chordal-cusp junction. Postoperative echocardiograms showed correction of anterior leaflet prolapse and mitral regurgitation in all patients. This technique is effective and easy to perform, and increases the number of options for restoring mitral valvular function.

Objective: Chordal transposition was advocated for correction of anterior mitral prolapse. We have evaluated the early and late results of this technique in different anatomical presentations., Methods: From 1986 to 1995, 185 mitral valve repairs were carried out for pure mitral regurgitation due to a degenerative disease. Eighty-nine patients had either an anterior prolapse (39) or prolapse of both leaflets (50) at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Twenty patients presented a complex pathology and 26 had chordal elongation of mural leaflet. Annular calcifications were found in 9 patients. Seven patients required shortening of transposed chordae and two patients the additional shortening of an anterior chorda., Results: Operative mortality was 3.3% and follow-up was 95% complete (average 41 months). There were five postreconstruction valve replacements (two earlier and three later) for a probability of freedom from late reoperation or 3+ mitral regurgitation of 88.6 +/- 4.8% at 5 years. Of the patients 79% presented no or trivial residual MR, 17% moderate MR and 4% severe MR. The presence of a complex pathology or posterior chordal elongation did not influence the entity of postoperative residual regurgitation. On the contrary, the patients with annular calcifications had a residual regurgitation/left atrium area ratio greater than patients without annular calcification (15.8 +/- 11.5% vs. 6.1 + 9.9%; P = 0.009)., Conclusions: Chordal transposition is an effective and easily carried out technique for the correction of anterior mitral prolapse. The presence of a complex pathology or posterior chordal elongation do not rule out the procedure. The absence of annular calcification is important in order to obtain a satisfactory correction.

Mitral annuloplasty has always been a target for the cardiac surgeon, even before the era of open heart surgery. We describe here commisural annuloplasty, annular reduction with rings, and supported annular reduction without rings, which are, at the present time, the three types of annuloplasties employed. The increasing incidence of mitral valve surgery for degenerative disease suggests reconstructive surgery with autologous patients tissue as the gold standard.

A case of iatrogenic aortic insufficiency due to laceration of the aortic right coronary leaflet at the time of diagnostic heart catheterization is presented. The situation was remedied by repairing the lacerated leaflet.

Background: We studied the long-term results of a technique of mitral annuloplasty using autologous pericardium., Methods: Between June 1989 and December 1994, 113 mitral valvuloplasties were performed for myxomatous degenerative disease. Repair of isolated anterior leaflet prolapse was performed in 26 patients (23%), posterior leaflet prolapse in 38 (33.6%), and prolapse of both leaflets in 49 (43.4%). Posterior pericardial annuloplasty was performed in all patients. In 20 patients, the pericardial graft was marked with metal clips for postoperative cinefluoroscopic assessment of annulus motion., Results: The operative mortality rate was 2.7% (3/113). One patient died of myocardial infarction and 2 of low cardiac output syndrome. One patient required replacement of the mitral valve 2 days after operation because of dehiscence of the annular plication. Follow-up (average length, 32.41 +/- 20.09 months; range 1 to 71 months) was 97% complete and revealed good clinical and functional results: 95 patients (84.1%) were in New York Heart Association class I and had no regurgitation or only mild residual regurgitation. Postoperative transmitral flow indices were almost normal (mitral valve area = 3.7 +/- 0.4 cm2; peak flow velocity = 1.06 +/- 0.2 m/s). Only 3 patients had reoperation within 3 years (actuarial 5-year reoperation-free rate, 89.7%) and event-free survival at 5 years was 91%. In patients with metal clips marking autologous pericardium, planimetry of the area derived by fluoroscopic examination showed systolic narrowing of annulus size (8.5% +/- 6.4%; p < 0.01) and a slight systolic fall in the anteroposterior diameter of the annulus contour (5.9% +/- 3.8%; p < 0.01)., Conclusions: Posterior pericardial annuloplasty seems to be a safe, effective and easily performed technique and a more physiologic correction that preserves mitral annulus motion.

Endoventriculoplasty with pericardial patch has been advocated to repair anteroseptal ventricular aneurysm, but not studies have reported the influence of this technique on diastolic left ventricular function. We have evaluated the changes on ventricular filling by means of pulsed Doppler recording of diastolic transmitral flow. Doppler analysis reveals three distinct spectral patterns: (1) normal, (2) inverted, and (3) restrictive. We have found an abrupt change from a preoperative normal to postoperative restrictive pattern in a significant minority of patients (8%) who underwent endoventriculoplasty. These patients had clinical and hemodynamic signs (New York Heart Association class, time from anterior myocardial infarction, left ventricular end-diastolic pressure, pulmonary hypertension, and mitral regurgitation) of severe impairment but no differences were found in ejection fraction, aneurysmal extension, or remote myocardial function. Moreover, after operation they had a satisfactory ejection fraction, a low end-diastolic volume, and an apex-base length shorter than the predicted value for a normal population. The presence of a postoperative restrictive pattern of diastolic filling is a strong predictor of 3-month mortality and makes the medical treatment difficult. Caution must be taken to perform endoventriculoplasty in patients who are severely ill, especially those recently affected by myocardial infarction. When the clinical conditions dictate the operation, a nonenthusiastic volume reduction seems to be a prudent option.

The safety and efficacy of amiodarone and propafenone in converting atrial fibrillation or flutter after cardiac surgery were compared in a randomized double-blind trial. Eighty-four patients with sustained atrial tachyarrhythmias of more than 30 min' duration, stable hemodynamic status and neither preoperative atrial arrhythmias nor treatment with other antiarrhythmis drugs, were randomized to receive amiodarone (46 patients: 5 mg/kg over 15 min and then 15 mg/kg over the subsequent 24 h for non-converting) or propafenone (38 patients: 2 mg/kg over 15 in and then 10 mg/kg over the subsequent 24 h for non-converting). Nine of the 46 patients (19.5%) receiving amiodarone converted to sinus rhythm within 1 h following bolus injection compared with 17 of 38 patients (44.7%) treated with propafenone (P < 0.05). Within the 24 h study, 38 of 46 patients (82.6%) given amiodarone and 26 of 38 patients (68.4%) given propafenone were converted to sinus rhythm (P = NS). A significantly progressive reduction in ventricular response, already evident at 10th min from the start of treatment, was achieved in both groups of patients. Side effects occurred in six patients given propafenone (15.7%) and in five given amiodarone (10.8%) (P = NS). The two drugs were equally effective in converting postoperative atrial fibrillation and/or flutter after 24 h although propafenone was superior within the first hour.

Allopurinol reduces formation of cytotoxic free radicals during myocardial ischemia/reperfusion in animals. To evaluate the effect of allopurinol on cardiac performance and metabolism after coronary bypass in humans, we divided 33 patients into two groups: 15 patients (controls) received no allopurinol and 18 patients received 200 mg allopurinol intravenously (i.v.) 1 h preoperatively. Hemodynamic measurements were made with a triple-lumen thermodilution pulmonary artery catheter before cardiopulmonary bypass (CPB), 30 min after completion of CPB and 6 h later in the intensive care unit (ICU). A catheter placed into the coronary sinus was used for blood sampling for measurement of lactate and creatine phosphokinase MB. Peripheral blood was obtained for measurement of xanthine oxidase activity (XO), uric acid, and thiol groups. A myocardial biopsy was taken for measurement of thiol group content and XO before CPB and after heparin neutralization with protamin (a few minutes after CPB). Treated patients had better recovery of cardiac output (CO) and left ventricular stroke work (LVSW) 30 min and 6 h after completion of CPB than did controls. Allopurinol significantly reduced plasma XO. Plasma concentrations of uric acid increased significantly in both groups 30 min after completion of CPB, but the increase in controls was greater (p < 0.02) than with allopurinol. Thiol group levels increased (p < 0.05) only in controls. Our results demonstrate improvement of cardiac function in coronary artery bypass surgery with allopurinol that is related to its metabolic effects consistent with protection against XO catalyzed free radical-mediated injury.

In 32 patients with aortic regurgitation, angiographic evaluation of global left ventricular performance before and after aortic valve replacement was carried out by means of a computer-analyzed contractility scoring system. A strong correlation was detected between the preoperative and postoperative contractility score. Postoperatively, the score decreased in all but 3 patients, becoming normal or near normal in 21 of 27 patients whose preoperative value had been less than 40. However, all 5 patients with a preoperative contractility score of 40 or greater exhibited a persistently elevated score after operation that indicated the presence of irreversible contractile dysfunction. Patients in groups A and B (preoperative score, 0 to 40) experienced a good surgical outcome, and at 5-year follow-up were in New York Heart Association functional class I. Patients in group C (preoperative score, > 40) altogether had a very poor surgical outcome, although they did experience a short to midterm period of symptomatic relief. It is important to offer aortic valve replacement to patients with aortic regurgitation before their chances for a good functional result are lost. The computer-analyzed contractility score may be a useful index for determining the optimal timing of operation in these patients, particularly those who show features consistent with impaired left ventricular function but are asymptomatic and who should undergo aortic valve replacement before symptoms of definitive left ventricular failure develop.

Of 127 consecutive patients who underwent surgical repair of degenerative mitral valve incompetence between 1986 and 1992, 55 received posterior annuloplasty reinforced by an autologous pericardial tube. All patients had echocardiographic assessment before surgery and at discharge from hospital. There was one hospital death (0.78%) and one patient (0.79%) required early reoperation because of suture dehiscence. Postoperative fluoroscopy and echocardiography ascertained excellent relieve of the mitral regurgitation without any distortion of the annulus. It is concluded that early results with autologous pericardial annuloplasty are very promising, and a prospective follow up study is underway to assess mid to long term results.

From 1988 to 1991, 48 patients with left ventricular aneurysm underwent endoventriculoplasty with a circular patch to preserve the left ventricular geometry. Of these patients, 98% underwent concomitant myocardial revascularization, and in 77% the left anterior descending coronary artery was bypassed. The overall operative mortality rate was 4.1%. The 3-year survival rate was 91%, and 67% of patients had no further cardiac complications. Cardiac performance was assessed postoperatively by ventriculography in 28 patients. The global ejection fraction rose from 0.39 +/- 0.11 to 0.57 +/- 0.14 (p < 0.001); the left ventricular end-diastolic pressure fell from 20 +/- 7.5 mm Hg to 15 +/- 7.8 mm Hg (p < 0.05). Computerized analysis of regional contraction revealed a significant improvement in the anterolateral and apical segments and in the transitional zone. In 61% of the patients, a normal contraction pattern resumed, whereas in the remaining 39%, a residual deformity of the left ventricular chamber was present. The best results were obtained in patients with a preserved proximal septum at echocardiography.

Endothelial damage of human saphenous vein (HSV) during the preparation for bypass grafting could affect graft patency. Improving the preservation of HSV could provide a longer and better patency of coronary artery bypass grafts. An electron microscopic comparative analysis of the effects of three different preservatives on HSV morphology was carried on in order to determine the best method to prevent or minimize possible endothelial damage. Distal segments of HSVs were harvested from 15 patients with a "no-touch" technique. Each segment was divided into seven specimens after a low pressure distension with saline solution. The first of them was fixed immediately after harvesting with 2.5% glutaraldehyde solution, for basal evaluation. Three were fixed after 30 min and three after 5 h preservation at 4 degrees C in a) autologous, oxygenated, and heparinized blood (AOHB), b) heparinized saline solution with papaverine (HSSP) and c) University of Wisconsin solution (UWS). The specimens preserved in AOHB showed marked endothelial cell detachment and endothelial cell loss after both preservation times (30 min and 5 h). The specimens preserved in HSSP for 30 min showed no alteration in endothelium in 12 cases, while a partial endothelial detachment with intracellular edema was present in the last 3 cases; all 5 h specimens showed only a few remnants of endothelial cells. The specimens preserved in UWS for 30 min showed a morphology comparable to specimens preserved in the saline solution for the same time; in the 5 h specimens a well preserved endothelium was found in 11 cases and partial endothelial detachment and subendothelial edema in the other 4.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1988 to 1992, 65 patients underwent endoventriculoplasty (EVP) for anteroapical left ventricular aneurysm. The operative mortality was 4.6%, and 9.2% needed intraaortic balloon counterpulsation (IABP). Forty-three patients were restudied by ventriculography and the preoperative and postoperative silhouettes were analyzed by means of a special computer program. In 24 patients computerized analysis showed a restored left ventricular (LV) geometry with symmetrical contraction pattern and a contractile apical segment. Residual deformity of the LV chamber associated with an asymmetrical contraction pattern was present in 19 cases. Data from these 43 patients were analyzed to detect predictive factors for successful heart geometry reconstruction. Univariate analysis revealed that the preoperative ejection fraction, global contraction score, and a non-aneurysmatic segments contraction score did not determine successful reconstruction. The presence of a preserved proximal septum (2.5 cm or more) on echocardiography was the only significant predictor. We would recommend liberal use of the EVP technique in patients with anteroapical LV aneurysm and preserved proximal septum in order to restore satisfactory LV geometry with a low operative risk. Caution must be taken when performing EVP in patients with fibrotic proximal septum.

From 1986 to 1992 102 mitral valve repairs were done for mitral regurgitation due to a degenerative disease. Forty-eight patients had an anterior prolapse or prolapse of both leaflets at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Operative mortality was 2.9%, and follow-up (average 22 months) was 100% complete. There were three postreconstruction valve replacements (one earlier and two later) for a probability of freedom from reoperation of 91.5% +/- 5.2% at 3 years. Freedom from all morbidity was 85.5% +/- 5.5% at 3 years. Postoperative echocardiographic studies demonstrated a good mitral valve function: (1) Eighty-seven percent of patients presented no or mild residual regurgitation; (2) transmitral flow indexes were within the norm; (3) left ventricular outflow tract flow was normal in all patients. This study shows that chordal transposition is a safe and effective technique for prolapse of anterior or both leaflets and improves the chances of repair in patients with mitral degenerative disease.

In the last years the number of HIV-positive patients needing cardiac surgery has greatly increased. Cardiopulmonary bypass is suspected to have a role in the progression of HIV-infection to acquired immunodeficiency syndrome (AIDS). From October 1988 to December 1990, 6 intravenous drug addicts underwent cardiac surgery for infective endocarditis at our Department. Preoperative and postoperative absolute lymphocyte T-helper (CD4) and T-suppressor (CD8) counts did not show a close association between the temporary lymphopenia induced by cardiopulmonary bypass and progression to AIDS.

Objectives: To assess whether the use of autologous blood transfusion may affect the incidence of post-transfusion hepatitis in transfused patients who undergo cardiac surgery., Methods: One thousand one hundred and twelve polytransfused patients having undergone cardiac surgery were studied from October 1982 through September 1990. Patients were transfused with homologous blood from selected volunteer donors; autologous blood collection or blood saving were introduced in September 1986. Routine laboratory tests were carried out upon hospitalization and monthly for a six-month period. Patients with hepatitis were followed for at least 24 months and liver biopsy was performed in those with chronic hepatitis., Results: Ninety-four (9.8%) of the 959 polytransfused patients developed non-A, non-B post-transfusion hepatitis; anti-hepatitis C virus antibodies were present in 52 out of the 72 patients tested. The mean incubation period for post-transfusion hepatitis was 70 days; hospitalization was required in 47.9% of the patients. The mean number of transfused units was 12.9 in patients who developed post-transfusion hepatitis and 6.96 in the those who did not. Hepatitis was chronic in 42% of the 94 patients; in the others alanine aminotransferase levels normalized in a mean period of 10.3 months. None of the 237 patients who received autologous blood had hepatitis., Conclusion: In our study the role of surgical teams in preventing post-transfusion hepatitis was shown to be essential. The high percentage of chronicity and symptom-free hepatitis observed is a further reason to reduce homologous blood transfusions and instore careful follow-up of polytransfused patients.

From June 1984 to December 1990, 96 patients underwent "open" coronary endarterectomy and reconstruction. In 50 patients (group 1), a saphenous vein (SV) graft was used to reconstruct and bypass 54 coronary vessels. In 46 patients (group 2), 46 coronary vessels were reconstructed with an SV patch and then bypassed with the internal mammary artery (IMA): Seventy-four LAD coronary arteries (36 in group 1 and 38 in group 2) were treated with these procedures. Operative mortality was 8% in group 1 and 2.1% in group 2. Five patients (10%) in group 1 and 1 patient (2.1%) in group 2 developed perioperative myocardial infarction. The early postoperative patency of the reconstructed vessels was 84.6% in group 1 and 92.5% in group 2. Angiographic controls were performed between 30 and 36 months after operation in 18 patients (72%) of group 1 and in 16 patients (69%) of group 2 with patency rates of 66.7% and 81.5%, respectively. A further angiographic study performed between 54 and 60 months after operation of 9/22 patients of group 1 and 5/9 patients of group 2 did not show any additional closure of the endarterectomized vessels. Three- and 5-year survival analyzed by the Kaplan-Meier method was 79.6% and 69.7%, respectively, in group 1 and 86.8% for both the 3- and 5-year survival in group 2. After a mean follow-up of 51.0 and 35.5 months, 62.8% of the surviving patients of group 1 and 75.6% of group 2 were asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

This report reviews the most recent technical advances that improve the results of coronary artery bypass grafting and discusses advantages and limitations in revascularization by extensive employment of arterial grafts. There is evidence that the use of the second internal mammary artery for coronary grafting, in selected cases, gives excellent long-term results. The use of alternative arterial conduits in conjunction with both internal mammary arteries in order to achieve complete revascularization with arterial grafts only has yielded good short-term results. However, for late results further and larger studies are necessary. In diffuse coronary artery disease, complex vessel endarterectomy and reconstruction procedures are currently performed by several surgeons with low operative risk and good midterm clinical results. Favorable results concerning the patency of the endarterectomized coronary arteries and related grafts have been reported.

Congenital tracheal obstruction, though not notably uncommon in infancy, is rarely due to isolated tracheomalacia, especially when characterized by complete absence of cartilaginous rings. A 5-year-old boy underwent successful tracheal resection and anastomosis following severe tracheal obstruction due to aplasia of cartilaginous rings.

Since the introduction of the annuloplasty ring, many attempts have been made to obtain a flexible ring that preserves the physiological motion of the mitral annulus. We experimented with a new technique using autologous pericardium to construct a more flexible ring. Twenty patients underwent mitral valve repair for degenerative disease and were treated by a posterior pericardial annuloplasty and the usual valvuloplasty procedures. A long strip of pericardium was prepared, marked with metal clips and rolled up in a tubular fashion with the serosal surface on the outside. The pericardial tube was apposed on the posterior annulus just beyond the commissures. No patient required early or late reoperation. Doppler analysis showed good valve function: 18 patients had no or mild, and 2 had moderate regurgitation. Transmitral flow indexes were nearly normal (MVA = 3.7 +/- 0.4 cm2; flow velocity peak = 1.06 +/- 0.2 m/s). Fluoroscopic examination was employed for assessing annular motion using the metal clips as radiopaque markers. Planimetry of the hemiarea showed a mild narrowing (mean 8.5% +/- 6.4%) of annular size during ventricular systole. There was a trend toward a systolic reduction of the anteroposterior diameter of the annulus. These findings demonstrate that the mitral orifice preserves its flexible properties after this type of annuloplasty. Posterior pericardial annuloplasty seems to be a physiological correction of annular dilatation in patients with degenerative disease.

The internal mammary artery (IMA) is the graft of choice for CABG but has a limited number and length. For multivessel coronary disease, saphenous vein grafts have to be added but they show poorer long-term patency. Investigation to provide adjunctive reliable grafts has recently focussed on the right gastroepiploic artery (GEA) and encouraging results have been reported employing this vessel as a pedicled graft to bypass distal coronary vessels. From December 1988 to February 1989, to achieve complete myocardial revascularization with only arterial grafts we used a GEA free graft in combination with the two IMAs in 20 consecutive patients under 70 years of age undergoing elective surgery. Before starting, histological studies were carried out and a significant similarity between IMA and GEA was found. In the 20 patients, 76 coronary anastomoses were performed (3.8 bypasses/patient), the GEA graft revascularized the right coronary artery in 9 patients, the circumflex in 8 patients and the anterior descending and/or diagonal in 3 patients; in 7 patients the GEA graft was used for sequential anastomoses. No perioperative deaths, no myocardial infarctions and no gastroenterological complications occurred. Coronary angiographic postoperative control showed 20/20 patent GEA grafts. After follow-up ranging from 7 to 9 months, all patients are free from angina. The GEA free graft is not difficult to harvest, is easier than the pedicled GEA graft to handle in the pericardium and is suitable for sequential anastomoses. The use of GEA graft however increases the complexity of bypass operations.(ABSTRACT TRUNCATED AT 250 WORDS)

A 49-year-old woman with isolated atresia of the left main coronary artery is presented. The patient who suffered from angina underwent myocardial revascularization 14 years after the onset of symptoms. A left internal mammary artery to left anterior descending coronary artery bypass was performed. Twenty months after the operation, the patient is free from angina and leads a normal life. The clinical features, diagnosis and management of the left main coronary atresia in adults are discussed.

A system providing high quality direct arterial blood pressure recordings and electrocardiograms in ambulatory patients was devised using a modified commercially available Holter type magnetic tape recorder together with a microminiature Millar (3F) tip transducer. This system did not require a perfusion line and solved the major drawbacks of other available systems. Pressure and electrocardiographic data were fed directly from the playback unit into a minicomputer for automatic beat to beat waveform analysis. Thus the blood pressure and RR interval variability signals could be simultaneously analysed with autoregressive modelling techniques to provide a quantitative estimate of sympathovagal balance in ambulant patients. The system was reliable, simple, and safe to use.

On the assumption that alterations in the adrenergic system may play a role in generating ventricular tachycardia in patients with myocardial post-infarction apical aneurysm, we evaluated norepinephrine concentration, number and affinity of both beta 1 and beta 2 adrenoceptors in perianeurysmatic tissue in twelve patients operated upon for congestive heart failure and recurrent sustained ventricular tachycardia. Concentration of norepinephrine in perianeurysmatic tissue was 0.1 +/- 0.05 micrograms g-1 tissue (n = 8), this value being much lower than that found in papillary muscle (n = 10) from patients with mitral valve stenosis (0.8 +/- 0.02 micrograms g-1 tissue) (P less than 0.01). The total number of beta adrenoceptors (71.4 +/- 7.8 v. 48.0 +/- 5.1 fmol mg-1 protein; P less than 0.01) and the percentage of beta 1 subtype were found to be higher in perianeurysmatic tissue (approximately 90%) than in papillary muscle (approximately 68%). Out of twelve patients with aneurysm, beta 2 adrenoceptors had considerably decreased in three patients and were absent in the remaining nine. Decrease in the neuronally released norepinephrine associated with contrasting behaviours of beta 1 and beta 2 adrenoceptors suggests the presence of a profound alteration in the sympathetic innervation of the perianeurysmatic myocardial tissue that may contribute to the genesis of sustained ventricular tachycardia in patients with postinfarction apical aneurysm.

Fibrin adhesive was used 72 times in a group of 67 patients undergoing elective coronary artery bypass graft surgery. The indications were prophylactic sealing of potential sources of bleeding, topical hemostasis (control of bleeding sites dangerous or difficult to suture), and fixation of the graft in the optimal position. The method of glue application under varying circumstances is described and the results are reported. This experience suggests that in some cases the glue expedites the operation and makes it safer. We conclude that the fibrin sealing represents a valid aid in coronary artery bypass graft surgery.

Over a 19-month period (from November 1985 to June 1987), 18 patients underwent open coronary endarterectomy combined with vein patch reconstruction and internal mammary artery (IMA) grafting. All 18 patients had disabling angina and severe, diffuse coronary atherosclerosis that prevented revascularization by conventional means. Thirteen underwent open endarterectomy of the left anterior descending coronary artery, and the remaining five had open endarterectomy of the right coronary artery. All patients received additional bypass grafts to other coronary arteries (2.6 grafts per patient). There was no operative mortality, but one patient had a perioperative myocardial infarction that was unrelated to the open endarterectomy. Postoperative angiography in 16 cases showed that only one of the grafts to the endarterectomized artery was occluded. After a mean follow-up of 8.7 months, all the patients but one were angina-free. No late deaths occurred. Although the long-term clinical results and graft patency have yet to be evaluated, the early results of this series encourage us to continue using this technique in patients whose diffuse coronary artery disease is untreatable by conventional means.

A case of massive coronary air embolism occurred during cardiopulmonary bypass because the rotation of the pump suction line, which was connected to the aortic root vent needle, was mistakenly reversed. An embolism injured the heart and caused severe functional impairment. After completion of the procedure (double vein bypass graft), the patient could not be disconnected from bypass. However, successful management with temporary retrograde coronary sinus perfusion was quickly achieved.

A simple technique for quicker and safer "redo" operations, is presented. The atrioventricular valves are approached through a right anterolateral thoracotomy without pericardial dissection.