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Background and Aim of the Study: The choice of aortic valve substitutes remains controversial. Malfunction and systemic valve complications affect the results of mechanical and tissue valves. Two devices--the Sorin Monocast (tilting disk) valve and the Hancock Standard valve were compared, the study aim being to determine whether the valve model is a marker or a causal influence of poor outcome after aortic valve replacement (AVR)., Methods: Between January 1970 and January 1984, patients aged < 70 years and operated on for aortic valve disease were selected. A total of 379 patients received either Sorin (group S) valves (n = 213; median age 51 years) or Hancock Standard (group HcK) valves (n = 192; median age 50 years) (p = NS). Total follow up was 2,471 patient-years (pt-yr) for group S and 2,368 pt-yr for group HcK. Follow up was 98% complete; median duration was 15 pt-yr for group S and 13.2 pt-yr for group HcK. Propensity matching for available patient intrinsic and operative risk factors was ultimately used to investigate whether biological or mechanical valve models impact upon outcome after aortic valve surgery. Patient survival was analyzed according to the 'intention to treat' principle., Results: The 30-day mortality was 7.5% for group S and 10.9% for group HcK (p = NS). The 19-year Kaplan-Meier freedom from valve-related mortality was 84% (group S) and 82% (group HcK) (p = NS), while overall survival was 42% (group S) and 35% (group HcK) (p = NS). Structural valve deterioration (SVD) was the major cause of reoperation in the HcK group. The 19-year freedom from all valve-related complications was 43% (group S) versus 19% (group HcK) (p = 0.0001). By propensity score, 61% of the valve replacements (247/405) were perfectly matched for available risk factors, with an equal distribution of risk covariates. When SVD and reoperation due to SVD were excluded, survival and freedom from all valve-related complications of the matched patients were identical between the prostheses under comparison., Conclusion: In this relatively young population, the Sorin valve showed a significantly lower valve-related complication rate than the Hancock Standard valve. The latter valve showed a significantly increasing rate of reoperation due to SVD, and thereby a relative inadequacy for use in younger patients. When analyzed according to an 'intention to treat' principle, the 19-year survival and freedom from valve-related complications of patients with the same propensity score for selection of either valve type were similar.

Unlabelled: We describe the surgical repair in three infants presenting with one pulmonary artery arising from the ascending aorta, the other artery arising normally from the right ventricle via the pulmonary trunk. Repair consisted of reimplantation of the anomalous pulmonary artery to the pulmonary trunk, in association with repair of associated intracardiac malformations. All patients survived the surgical procedures, and were discharged in stable clinical condition. Subsequently, two of the three patients developed stenosis at the surgical anastomosis relatively early after the initial procedure, and underwent reoperation. Although survival after operation is now expected for this malformation, reports of late results are lacking. Larger numbers of operations are needed before we can reach definitive conclusions. The origin of one branch pulmonary artery from the ascending aorta in the presence of a pulmonary valve and main pulmonary artery is a very rare congenital cardiac anomaly., Patients and Methods: Between January 1995 and June 2003, 3 infant girls presented with the origin of one branch artery from the ascending aorta, while the other pulmonary artery originated from the pulmonary trunk which was in continuity with the right ventricular outflow tract. The pulmonary artery that arose from the right ventricle was left in 2 and right in 1 patient., Results: At the age 13, 48 and 62 days respectively, the patients underwent surgical repair consisting with reimplantation of the anomalous pulmonary artery branch to the pulmonary trunk in association with repair of intracardiac malformations. There were no hospital deaths. Postoperative complications included: prolonged intubation in two patients (10 and 16 days), low output syndrome in 1 patient, cardiac tamponade in 1 patient and seizures in 1 patient. All patients were discharged in good clinical condition. There have been no late deaths. Subsequently, two of the three patients developed stenosis at the surgical anastomosis relatively early after the initial procedure, and after unsuccessful balloon dilation, underwent surgical reoperation., Conclusions: Although operative survival is now possible for this malformation, reports of late results are lacking. Two of the three patients developed stenosis at the surgical anastomosis relatively early after surgery. Larger numbers of operations are necessaries to reach definitive conclusions.

Background: We analyzed the intermediate experience, survival, and prosthetic complications of patients who received the Biocor valve, a new-generation porcine valve, in the mitral position., Methods: At the University of Padua, between May 1992 and January 2004, 154 consecutive patients (102 female and 52 male patients; mean age, 72.3 +/- 6 years; age range, 37-86 years) received 158 mitral Biocor prostheses (Biocor Industria e Pesguisa Ltda, Belo Horizonte, Brazil). Thirty-five percent of the patients had previous mitral operations, 24% had coronary artery bypass grafting, and 34.6% had other procedures. Median preoperative New York Heart Association class was III. Echocardiography was performed in 75% of the long-term survivors. Follow-up included 609.4 patient-years and was 100% complete, with a median time of 4 patient-years (range, 0.02-11.3 years). At 8 years, 20 (14%) of 142 operative survivors were still at risk., Results: Early mortality was 13.6%. According to univariate analysis, New York Heart Association class III to IV, ejection fraction of less than 40%, urgency, male sex, and coronary artery bypass grafting were significant perioperative risk factors. Eight- and 10-year actuarial survival was 51.1% +/- 5.6% (40 deaths). Eight-year actuarial freedom from valve-related death, thromboembolism, anticoagulant-related hemorrhage, endocarditis, paravalvular leak, and valve-related complications were 85.2% +/- 5%, 85.7% +/- 4.4%, 92.6% +/- 3.7%, 94.1% +/- 3%, 91.8% +/- 3%, and 70.2% +/- 5.7%, respectively. Freedom from structural valve deterioration was 100%. Actual freedom from reoperation was 93.2% +/- 2.2%. By Doppler echocardiography, the peak and mean transprosthetic gradients were 15 +/- 5 mm Hg and 6.3 +/- 3 mm Hg, respectively (mean follow-up, 4.2 +/- 2.7 years)., Conclusion: At intermediate follow-up, the Biocor prosthesis in the mitral position showed excellent results in terms of valve durability when compared with other second-generation tissue valves.

Surgical treatment of atrial fibrillation recently gained new popularity since the introduction of different energy sources and the development of minimally invasive techniques as an alternative to the original "cut-and-sew" technique. However, closed-chest ablation procedures are not feasible in presence of pericardial or pleural adhesions. To our knowledge, this is the first report of surgical treatment of atrial fibrillation in a conscious patient by means of a high epidural anesthesia. Since evidence of fibrothorax was found, a conscious patient suffering from lone atrial fibrillation underwent a beating-heart pulmonary veins isolation with a microwave device through a standard sternotomic approach. At 6 months follow-up, the patient is in stable sinus rhythm, without any palpitation nor electrocardiographic evidence (Holter monitoring) of recurrent atrial fibrillation.

Atrial fibrillation represents nowadays one of the most important burdens in the field of arrhythmia. Albeit often inadequate, medical treatment is still considered the "first-step" approach. Non-pharmacological strategies, either surgical or interventional, recently gained an increasing interest among both cardiac surgeons and electrophysiologists. From the surgical standpoint, the introduction of different energy sources and the development of minimally invasive techniques as an alternative to the original "cut-and-sew" technique allowed a new dawn in the surgical treatment of atrial fibrillation. In the meanwhile, electrophysiologists developed more complex ablation systems that allowed the creation of linear lesions, similar to the surgical ones, while mapping the atria with three-dimensional (3D) navigation systems. Nevertheless, the success rate in terms of sinus rhythm restoration was around 80%-85% in both fields. We foresee that the combination of the two approaches (i.e., surgical and percutaneous approach), in common hybrid approach, will allow a substantial reform for the definitive cure of atrial fibrillation, either paroxysmal or permanent, providing the highest success rates along with the best care for patients' health.

Background: The optimal management for critical aortic stenosis in early infancy continues to challenge cardiologists and cardiac surgeons. We present a review of our experience with the surgical treatment of residual aortic valve disease after percutaneous balloon dilation for critical aortic stenosis in early infancy., Methods: Since 1989, 11 of the 38 patients who survived aortic balloon dilation (28.9%) have undergone surgical treatment for residual aortic valve dysfunction. Median time from aortic balloon dilation to surgical intervention was 7 months (range 1 to 56 months). Residual aortic stenosis was the predominant problem in 8 patients and aortic regurgitation was predominant in 2 patients., Results: Aortic valvuloplasty was possible in 5 children; pulmonary autograft replacement of the aortic valve was performed in 6 children. Two children underwent a Ross-Konno procedure because of annulus hypoplasia and severe left ventricular outflow tract obstruction. Two early deaths occurred after a Ross-Konno procedure, both with findings of severe left ventricular fibroelastosis at the pathologic examination. Median follow-up time was 5 years (range 1 month to 11.9 years). No late deaths occurred. One patient with moderate-severe aortic valve regurgitation after aortic valvuloplasty underwent a successful Ross operation. All 9 patients are asymptomatic and are in good clinical condition., Conclusions: We are convinced that the best aortic valve in the pediatric age group is the native one, provided it can function acceptably. However, in cases where conservative surgical treatment fails to yield a functional aortic valve, replacement of the valve is indicated, and the best aortic valve substitute in infants is the pulmonary autograft because of its potential for growth.

Objective: Hemodynamic performances of mechanical valve prostheses in patients with aortic valve stenosis and a small aortic annulus are crucial. We analyzed the in vitro hydrodynamics of 5 currently available bileaflet mechanical prostheses that fitted a 21-mm-diameter valve holder of a Sheffield pulse duplicator., Methods: Three samples of 5 high-performance production-quality prostheses, including the sewing ring cuffs, were tested in the aortic chamber of a Sheffield pulse duplicator. Sizes of the prostheses fitting the 21-mm valve holder were as follows: 18-mm ATS, 19-mm SJM Regent, 19-mm Sorin Bicarbon Slimline, 19-mm On-X, and 21-mm Carbomedics Top Hat. The tests were carried out at a fixed pulse rate (70 beats/min) and at increasing cardiac outputs of 2, 4, 5, and 7 L/min. Each valve was tested 10 times for each different cardiac output. This resulted in a total of 40 tests for each valve and 120 tests for each valve model. The aortic pressure was set at 120/80 mm Hg (mean pressure, 100 mm Hg) throughout the experiment for all cardiac outputs. Forward flow pressure decrease, total regurgitant volume, closing and leakage volumes, effective orifice area, and stroke work loss were recorded while the valve operated under each cardiac output., Results: The SJM Regent valve and the Sorin Bicarbon Slimline prosthesis showed the lowest mean and peak gradients at increasing cardiac outputs. The closure volume was higher for the SJM Regent and Sorin Bicarbon Slimline prostheses, unlike with the ATS prosthesis at 7 L/min of cardiac output. The ATS and SJM Regent prostheses showed the largest regurgitant volume, whereas the Sorin Bicarbon Slimline prosthesis showed the lowest regurgitant volume. The calculated effective orifice area and stroke work loss were significantly better with the SJM Regent and Sorin Bicarbon Slimline prostheses., Conclusion: Assuming that the 21-mm valve holder in which all the tested prostheses were accommodated is comparable with a defined aortic valve size, this hydrodynamic evaluation model allowed us to compare the efficiency of currently available valve prostheses, and among these, the SJM Regent and the Sorin Bicarbon Slimline exhibited the best performances.

Background: BIOSA is a single sheet, two-cuspal-shaped ("bileaflet") glutaraldehyde fixed bovine pericardial valve prosthesis (BP), designed to minimize stress and prevent mechanical failure. We tested this device in the adult sheep model., Methods: Seven BIOSA and two Baxter Carpentier-Edwards (Perimount) pericardial BPs, 25 mm in size, were implanted in the tricuspid position of adult sheep. A mid term BIOSA explant (81 days) died of infective endocarditis. The remaining BPs were divided in three early explants (0-3 days: two BIOSA and one Perimount) and five late explants (162-189 days: four BIOSA and one Perimount). Protocol of the study included gross examination, mammography X-ray (score 0-4), histology, scanning (SEM) and transmission (TEM) electron microscopy and atomic absorption spectroscopy., Results: (a) Early explants: The mesothelium was detached, collagen-elastic fibers and pericardiocytes of the fibrosa showed optimal preservation. Calcium content in BIOSA BPs was 6.22 mg/g dry weight (mean) versus 7.75 mg/g of the Perimount BP. (b) Late explants: At naked eye all BPs showed regular cusp pliability and coaptation, without tears, perforations, fibrous pannus or calcific deposits. X-ray was either negative (three BPs) or exhibited score 1 (two BPs). Microscopic features were excellent both in terms of collagen-elastic fibers preservation and absence of inflammation. The calcium content was 4.95 mg/g dry weight (mean) in BIOSA BPs versus 5.29 mg/g in the Perimount BP., Conclusions: Tissue characteristics of BIOSA BPs were optimal, without difference with Perimount BPs and in this animal model no case of structural valve deterioration occurred in the long term.

Objectives: The aim of this study was to analyze the 8-year experience, survival, prosthetic complications, and hemodynamics of patients who received the Biocor valve, a new-generation tissue valve, in the aortic position., Methods: From May 1992 through May 2001, 257 consecutive patients (129 women and 128 men; mean age, 75 +/- 6 years; age range, 45-91 years) received 258 aortic Biocor porcine prostheses. One female patient who received 2 Biocor valves in the aortic position during 2 consecutive operations was entered twice in the statistical analysis. Twelve (4.6%) patients had previous aortic valve operations. Preoperatively, 82 (32%) patients were in New York Heart Association functional class III or IV. Associated surgical procedures included coronary artery bypass grafting in 56 (21.7%) patients, aortic annular enlargement or aortoplasty in 20 (8%) patients, and others in 8 (3%) patients. Echocardiography was performed in the majority of long-term survivors (91.6%). Follow-up included 1215 patient-years and was 100% complete, with a median time of 5 patient-years (range, 0.4-10.5 years)., Results: There were 16 (6.2%) early deaths. According to a univariate analysis, New York Heart Association functional class III or IV, concomitant procedures, ejection fractions of less than 40%, and urgent operations were identified as significant perioperative risk factors. At follow-up, 75 patients died; 8-year actuarial Kaplan-Meier survival was 48% +/- 5%. At 8 years, the actuarial freedom from valve-related death was 92% +/- 2.6%, the freedom from thromboembolism was 93% +/- 2%, the freedom from anticoagulant-related hemorrhage was 95% +/- 2%, the freedom from endocarditis was 99% +/- 0.6%, the freedom from paravalvular leak was 96% +/- 1.5%, the freedom from all valve-related complications was 78% +/- 4.5%, and the freedom from structural valve deterioration was 95% +/- 3.7%. At 8 years, the actuarial freedom from structural valve deterioration was 89% +/- 10% and 95.8% +/- 4% in patients younger and older than 65 years, respectively. At 10 years, in patients older than 65 years, the actual freedom from structural valve deterioration was 97.9% +/- 2.1%, and the freedom from reoperation was 97% +/- 1.3%. New York Heart Association status was I or II in 90% of patients at the end of follow-up. The mean echocardiographic follow-up time was 4.6 +/- 2 years. By using Doppler echocardiography, the peak and mean transprosthetic gradients were determined to be 30.8 +/- 9.3 mm Hg and 16.6 +/- 5.3 mm Hg, respectively. Mean mass/volume ratio and left ventricular end-diastolic volume were 1.37 +/- 0.17 g/mL and 63.4 +/- 22.6 mL/m(2), respectively. The majority of patients showed a persistent left ventricular hypertrophy., Conclusion: The Biocor is an effective bioprosthesis with a low incidence of valve-related complications comparable with that of other second-generation bioprostheses. This stented porcine prosthesis provides satisfactory results in terms of hemodynamics, valve durability, and freedom from reoperation.

Background: Tricuspid valve replacement (TVR) is an uncommon procedure. The use of biological vs mechanical prostheses in TVR has pros and cons. Therefore, we debate the choice between the different types of valves by means of a meta-analysis of studies of the last decade., Methods: The heading "tricuspid valve replacement and (bio* or mec*)" was used to retrieve studies from Medline, Current Contents, and Embase. Eight out of 11 studies met the preset strict criteria: intra-institutional comparison of results of biological or mechanical TVR. Survival of hospital-discharged patients was recalculated to reduce the effect of unbalanced perioperative risk factors on overall survival. Hazard ratio was obtained from actuarial survival graphics comparison and at-risk groups, according to the method described by Parmar. If missing, the number of patients at risk was approximated assuming constant and noninformative censoring. Hazard pooling was done according to study heterogeneity. Bioprostheses were assumed as the gold standard and mechanical prostheses assumed as the challenging device. Therefore, a hazard more than 1 pointed to a higher risk of mechanical prostheses. Our 1998 study was updated for this analysis., Results: In this study, 1,160 prostheses and 6,046 follow-up years were analyzed. The pooled survival hazard ratio of mechanical prostheses versus bioprostheses was 1.07 (0.84 to 1.35, p = 0.60). The pooled freedom from reoperation hazard ratio was 1.24 (0.67 to 2.31, p = 0.67). Pooled survival differences were trivial, favoring mechanical prostheses at 1 (-0.04%) and 15 years (-1.1%) and favoring bioprostheses (+1.8%) at 10 years., Conclusions: There is not a gold standard in tricuspid prostheses replacement. Prosthetic choice is left to the surgeon's clinical judgment, taking into consideration each patient's characteristics and needs.

An asymptomatic 4-year-old child was referred to our Institution with a provisional diagnosis of severe aortic valvar regurgitation in association with a ventricular septal defect. Intraoperatively, the aortic valve appeared bicuspid, and a tunnel of 7 mm diameter extending between the aorta and the left ventricle was found dividing the anterior commissure into two hemi-commissures. Repair was achieved by reconstructing the anterior commissure by direct reapproximation, and simultaneous obliteration of the aortic side of the tunnel. The aortic valvar leaflet was resuspended onto the arterial wall. This combined approach will hopefully reinforce the poorly supported aortic sinus, and may maintain aortic valvar competence over the long term. Our intraoperative diagnosis of aorto-left ventricular tunnel suggests consideration of this diagnosis when evaluating any patient with suspected aortic valvar incompetence.

Video assisted thoracoscopic surgery for closure of the persistently patent arterial duct is an effective answer to the modern effort of seeking repair of congenital cardiac malformations with minimally invasive techniques. Between June, 1994, and December, 2002, 150 consecutive patients with an echocardiographic diagnosis of isolated patency of the arterial duct were referred to our Institution for video assisted thoracoscopic closure. The median age at the time of operation was 45 months, with a range from 3 to 161 months, and mean weight was 18 kg, with a range from 4.2 to 73 kg. Video assisted closure was possible in 139 patients (93%). The mean operative time was 37 min, with a range from 14 to 89 min. In the remaining 11 patients (7%), seen early in our experience, we converted to a mini-thoracotomy to achieve closure. In no instance did we encounter major haemorrhage requiring blood transfusion, and there were no hospital deaths. The mean period of stay in hospital was less than 24 h in 61 patients, less than 48 h in 88 patients seen earlier in our experience, and 21 days in 1 patient because of a persistent chylothorax. Other complications included palsy of the left recurrent laryngeal nerve in 1 patient, with partial regression at 6 months follow-up. We conclude that closure of the arterial duct by video-assisted thoroscopy combines the advantages of safe and complete extraluminal occlusion with an excellent clinical and aesthetic result, minimal postoperative pain, and short stay in hospital at low cost.

Objective: We sought to assess the efficiency of 2 different sternal wiring techniques in preventing deep sternal wound infection or sternal instability., Methods: Seven hundred patients were randomized to 2 different groups according to chest-closure techniques. Three hundred fifty patients who underwent a peristernal double crisscross wire closure were included in group X, whereas 350 patients who underwent a standard transsternal closure were included in group T. After sternal closure, the technique for wound suturing was the same for both groups, namely triple-layer sutures up to the intracutaneous skin. All data were prospectively collected and entered in our institute database., Results: The 2 groups of patients were comparable for sex, age, preoperative risk factors, and operative procedures. The overall mortality rate was 4.3% in group X and 4.6% in group T. Postoperative morbidity and mortality were comparable between the 2 groups, unlike for sternal wound complications. None of the patients included in group X had superficial or deep wound complications, whereas in group T 7 (2%) patients presented with a superficial sternal wound infection, 6 (1.7%) presented with a deep chest wound infection with sternal instability requiring re-exploration (P <.05), and 3 presented with a sternal instability caused by sternum disruption without infection. Among patients with deep wound infection and sternal instability, 1 patient died, resulting in a mortality rate of 16.7%., Conclusions: The peristernal double crisscross wiring technique achieved a greater sternal stability, resulting in a lower incidence of wound infection in association with triple-layer closure of suprasternal tissues.

Background: Survival and prosthetic complications of patients receiving the Hancock II second-generation bioprosthesis (Medtronic, Inc, Minneapolis, Minn) in the aortic, mitral, mitral-aortic, and tricuspid positions were analyzed at 15 years' follow-up., Methods: Between May 1983 and December 1993, 212 patients (104 men and 108 women; mean age, 63 +/- 9 years; age range, 29-81 years) received 66 aortic, 114 mitral, 26 mitral-aortic, and 6 tricuspid Hancock II valves. Thirty-one percent of patients had previous valve operations, 15% had concomitant cardiac procedures, and 87% were in New York Heart Association class III or IV. Follow-up included 1704 patient-years and was 98% complete, with a median of 9 patient-years (range, 0.013-17.4 years). Forty-six patients were at risk at 14 to 15 years, and 30 were at risk after 15 years., Results: One hundred twenty-two (57%) of 212 patients died, 20 of them perioperatively. Fifteen-year actuarial Kaplan-Meier survival was 35.2% +/- 3.8%, and freedom from valve-related mortality was 84% +/- 3.5%, with no difference on the basis of position or age (<65 or >or=65 years). Percentages for freedom from thromboembolism, anticoagulant-related hemorrhage, endocarditis, and paravalvular leak were, respectively, 78.2% +/- 4%, 83.5% +/- 3.6%, 95.7% +/- 2%, and 97.3% +/- 1.4%, with no significant difference between the aortic and mitral positions. Freedom from structural valve deterioration was 71.8% +/- 5.6%: 88.9% +/- 6.2% in the aortic position versus 59.5% +/- 3.9% in the mitral position (P =.01) and 64.3% +/- 3% in the mitral-aortic position. In patients younger than 65 years, actual freedom from structural valve deterioration was less than that seen in older patients (84.5% +/- 3.5% vs 95% +/- 3.0%) and was better in the aortic versus the mitral position (92% +/- 4.5% vs 82% +/- 4.2%)., Conclusion: The Hancock II porcine valve showed excellent 15-year durability. We recommend its use in patients 65 years of age, as well as in younger patients undergoing aortic replacement.

Background and Objectives: The Hancock II bioprosthesis is a second-generation porcine valve xenograft treated with the detergent sodium dodecyl sulphate (T6) to retard calcification. The aim of this investigation was to study the gross and microscopic features in Hancock II explants to assess the structural changes occurring with time., Methods: Among 1382 Hancock II bioprostheses (701 isolated aortic, 421 isolated mitral, 130 double) implanted from 1983 to 1997 in 1252 patients, 22 (16 mitral, 6 aortic) were removed at reoperation until 1999 and were available for pathological investigation: infective endocarditis occurred in 5 and structural deterioration in 8, whereas in the remaining 9 xenografts reoperation was performed for nonstructural valve deterioration (paravalvular leak in 4 and prophylactic replacement in 5). Morphological investigation consisted of gross examination and x-ray, histologic, immunohistochemistry, electron microscopic, and atomic absorption spectroscopic examination., Results: The cause of structural valve deterioration was dystrophic calcification in 4 cases (1 aortic, 3 mitral; range of time graft was in place, 101 to 144 months), non-calcium-related tears in 3 cases (all mitral, range 121 to 163 months), and commissural dehiscence in 1 (aortic, range 156 months). Five of the nonstructural valve deterioration explants (range 42 to 122 months) showed only pinpoint mineralization at the commissures. Mean calcium content in nonstructural deterioration explants was 14.70 +/- 22.33 versus 99.11 +/- 81.52 mg/g in explants with structural valve deterioration. Electron microscopic examination showed early nuclei of mineralization mostly consisting of calcospherulae upon cell debris. Local or diffuse lipid insudation was observed in all but 2 explants and consisted of cholesterol clefts, lipid droplets, and lipid-laden macrophages featuring foam cells. The lipid insudation was the most plausible cause of tearing in 2 explants., Conclusions: These pathologic findings support the clinical results of a delayed occurrence of structural failure of Hancock II bioprostheses and a mitigation of mineralization by the anti-calcification treatment. However, other factors such as lipid insudation may come into play in the long term.

Background: Leaflet escape is a mode of structural valve failure for mechanical prostheses. This complication previously has been reported for both monoleaflet and bileaflet valve models. We report 2 leaflet escape occurrences observed in 2 patients who underwent valve replacement with a TRI Technologies valve prosthesis., Methods and Results: At the University of Padua, between November 2000 and February 2002, 36 TRI Technologies valve prostheses (26 aortic and 10 mitral) were implanted in 34 patients (12 women and 22 men) with a mean age of 59.9+/-10.3 years (range, 30 to 75 years). There were 5 deaths: 3 in hospital, 1 early after discharge, and 1 late. Two patients experienced a catastrophic prosthetic leaflet escape; the first patient was a 52-year-old man who died 10 days after aortic valve and ascending aorta replacement, and the second was a 58-year-old man who underwent a successful emergency reoperation 20 months after mitral valve replacement. Examination of the explanted prostheses showed in both cases a leaflet escape caused by a leaflet's pivoting system fracture. Prophylactic replacement was then successfully accomplished so far in 12 patients, without evidence of structural valve failure in any of them. Among other significant postoperative complications, we observed 3 major thromboembolisms, 1 hemorrhage, and 1 paravalvular leak., Conclusions: These catastrophes prompted us to interrupt the implantation program, and they cast a shadow on the durability of the TRI Technologies valve prosthesis because of its high risk of structural failure.

Background: The incidence of atrial fibrillation is similar in the clinical history of patients with atrial septal defect, either surgically corrected and uncorrected. We present an unpublished technique for treating atrial fibrillation by left endocardial radiofrequency ablation through the lone right atrium incision, coupled to atrial septal defect septum primum and secundum closure, thus reducing the surgical trauma related to paraseptal left atrium incision., Patients and Methods: We treated 2 patients through a lone right atrium incision by radiofrequency ablation because of congenital atrial septal defect and chronic atrial fibrillation., Results: The patients after defect closure were weaned off cardiopulmonary bypass in sinus rhythm. The postoperative hospital stay was uneventful and at more than 1 year of follow-up they are still in sinus rhythm., Conclusions: The radiofrequency ablation procedure is possible through the lone right atrium incision, avoiding any further incision and new source of possible bleeding when in presence of interatrial septal defects, and the technique is simple and useful.

We prospectively compared, according to their preoperative clinical profiles, the in-hospital outcomes of patients operated on consecutively (but without randomization) for isolated coronary artery disease with on-pump or off-pump techniques. During 2001, 324 patients underwent coronary artery bypass grafting: 216 patients (mean age, 66.7 +/- 8.9 years; range, 41-85 years) underwent on-pump revascularization, and 108 patients (mean age, 676 +/- 10 years; range, 37-90 years) underwent full-sternotomy off-pump revascularization. The 2 groups were homogeneous with regard to female sex (22.6% vs 26.8%), previous cardiac operation (2.8% vs 4.6%), cardiogenic shock (1.3% vs 1.9%), diabetes (30% vs 33%), and chronic renal failure that required hemodialysis (3% vs 3.5%). Postoperative complications, including bleeding, myocardial infarction, acute renal failure, mediastinitis with sternal dehiscence, cerebrovascular events, and prolonged respiratory assistance were more frequent in on-pump patients (P = 0.004). The total number of grafts and the grafts per patient ratio were significantly higher in on-pump patients (P = 0.0001), whereas the total number of full arterial revascularizations was higher in off-pump patients (P = 0.0001). Off-pump patients showed a significantly shorter intensive care unit stay (P = 0.02), and less need for intra-aortic balloon pump insertion (P = 0.04). In-hospital mortality was 2.8% in on-pump patients and 2.7% in off-pump patients (P = NS). Although the hospital mortality rate was comparable for the 2 techniques, the in-hospital comparison between the 2 groups showed how the avoidance of cardiopulmonary bypass can significantly reduce the cumulative postoperative incidence of complications in patients undergoing coronary artery bypass grafting.

A 41-year-old woman with recent onset of heart failure and angina due to aortic valve incompetence and critical left coronary ostium stenosis in the setting of Takayasu's arteritis is reported. The patient was successfully surgically treated by aortic valve replacement and coronary artery bypass with saphenous vein graft, showing a cardiac event-free 17 months follow-up. Takayasu's arteritis must be included among the possible causes of coronary artery disease and aortic valve incompetence in young female patients. Although chronic inflammation of the aortic wall may result in late graft occlusion, surgical therapy is effective for short and mid-term clinical improvement.

Background: Prosthetic cardiac valves have increased life expectancy of patients (pts) with valvular heart disease. Bioprosthetic complications required devices replacements within 10 years of implantation; structural valve deterioration (SVD) has emerged as the major cause of reoperation. We reviewed survival and prosthetic complications of Biocor porcine bioprostheses implanted in mitral, aortic and mitro-aortic position., Methods: Between January 1991 and January 2001 446 pts (192 males; 254 females; mean age 73.4+/-6.7 year, range 40-91) received 258 aortic, 138 mitral and 50 mitro-aortic Biocor porcine valves; of these 83 pts have previous different types of prosthetic devices (15 aortic, 53 mitral and 15 double). Concomitant cardiac procedures, namely myocardial revascularization, were performed in 91/446 pts (20.5%). All explanted bioprostheses (BPS) were available for pathologic investigation. Follow-up included 1319 pt.-years and was 98% complete with a median time of 36 pt.-months., Results: Perioperative mortality was 6.8% (30/446 pts; 12 aortic, 17 mitral and 1 double) and was mostly related to reoperations. At the end of follow-up 18.5% of pts died (77/416), 12 deaths were valve-related with freedom from valve related mortality of 94% at 9 years. Survival was 54% at 9 years. It was 63%, 41% and 62% for aortic, mitral and double valve replacement, respectively. At follow-up 87% of pts. were in NYHA I-II class and 13% were in III-IV class; 55% were in sinus rhythm, 36% in atrial fibrillation and 9% had a pace-maker. Eighty-five percent of pts were anticoagulated. There were 6 thromboembolic and 5 anticoagulant-related haemorrhagic episodes with no significant difference between aortic and mitral position (p=0.7). The event freedom was respectively 92% and 98.5% at 9 years. Prosthetic valve endocarditis (PVE) and non-SVD freedom were 96% and 93% at 9 years. SVD due to tissue degeneration, calcification and cusp's tears affected 2 pts with 94% freedom at 9 years. Overall freedom from all valve-related complications was 80% at 9 years and freedom from reoperation was 92% at 9 years., Conclusions: (1) Our intermediate-term follow-up of the Biocor porcine valve (BPS) showed excellent durability in all positions. (2) The aortic patients and especially the oldest group had better results than the mitral patients (41% vs. 63% 9 years survival, p=0.0004). (3) Higher mitral risk was related to higher prevalence of reoperations. (4) The incidence of anticoagulation-related complications is low in both aortic and mitral position without significant difference (p=0.7). 4) A longer follow-up is required to get more information about SVD timing.

A 77-year-old woman was found accidentally to be in atrial fibrillation. Two-dimensional echocardiography revealed the presence of a mass attached to the anterior papillary muscle of the mitral valve. She was mildly symptomatic for dyspnea and asthenia. The patient was successfully operated on to excise the left ventricular mass and preserve the mitral valve apparatus. Morphological examination of the excised tissue led to a diagnosis of papillary fibroelastoma. Surgical treatment must be considered when such a tumor is diagnosed, even though asymptomatic, and especially if left-sided because of the high risk of systemic embolization.