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

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

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

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

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