Search

Three men, aged 67 years, 80 years and 53 years, respectively, developed signs and symptoms of progressive right-sided heart failure following open heart surgery. They were diagnosed with constrictive pericarditis based on echocardiography, cardiac magnetic resonance and cardiac catheterisation. Following pericardiectomy, two of the patients fully recovered, while one, the 80-year-old man, died during convalescence. When signs and symptoms of progressive right-sided heart failure develop after open heart surgery, a diagnosis of constrictive pericarditis should be considered. Constrictive pericarditis after open heart surgery may be caused by inflammation of the pericardium; an old, fibrotic haemopericardium, which may be diffuse or loculated; pericardial adhesions; or a combination of these entities. Diagnosing constrictive pericarditis is difficult and may take a long time. However, it is important to recognise this disorder early before it has progressed to an advanced stage. Pericardiectomy is the only effective therapy. When performed too late, survival is significantly reduced.

Different lesion sets and ablation techniques have been performed. We compared these outcomes in search of the best method. We performed a retrospective analysis of patients who have undergone AF surgery different from the maze III. The surgical lesion sets were pulmonary vein isolation (PVI) alone, left atrial maze (LAM) and bi-atrial maze (BAM) and were made with different ablation techniques. During surgery one patient died due to bleeding of a pulmonary vein. The number of patients in the PVI-, LAM-, BAM-groups was 12, 28 and 26, respectively, with freedom from AF at latest follow-up [22.0+/-15.6 (3.1-81.2) months] of 33%, 59% and 60%, respectively. Atrial flutter occurred less in the BAM-group (4%) than in the left-sided procedures (15.4%) (P=0.231). Multivariate analysis demonstrated a higher recurrence of AF for PVI alone (OR 4.42, CL 0.95-20.6, P=0.0583) and a lower recurrence for the 'cut-and-sew' technique (OR 0.13, CL 0.030-0.60, P=0.0084). Left- and bi-atrial maze procedures are equally effective in the suppression of AF, whereas omission of right-sided lesions results in a higher prevalence of atrial flutter. The 'cut-and-sew' technique is superior in terms of freedom from AF compared to bipolar and unipolar radiofrequency.

Selective antegrade coronary artery perfusion is a commonly used procedure to obtain myocardial preservation during cardiac surgery. This report describes a patient operated for severe aortic valve stenosis and insufficiency, mitral valve and tricuspid insufficiency. Cardioplegia was administered by selective antegrade coronary artery blood perfusion. Antegrade blood cardioplegia was complicated by dissection of the left coronary main stem. The dissection induced a myocardial infaction and the patient finally died due to heart failure.

Objectives: We studied the persistence of favorable outcome, the occurrence of new atrial arrhythmias, and sinus node dysfunction in patients who underwent the maze III procedure., Methods: Preoperative, in-hospital, and follow-up data of 203 patients who underwent the maze III procedure between June 1993 and June 2003 were collected. A total of 139 patients underwent the maze procedure for lone atrial fibrillation, and 64 patients underwent the maze procedure and concomitant cardiac surgery., Results: There was no 30-day postoperative mortality. During a mean follow-up of 4.0 +/- 2.6 years, 12 patients (6%) died (2 cardiac related). At the end of follow-up, freedom from supraventricular arrhythmias was 80% for the lone atrial fibrillation group and 64% for the concomitant atrial fibrillation group. Freedom from stroke during follow-up was 100% in the lone atrial fibrillation group and 97% in the concomitant group. Multivariate analysis revealed that rhythm at 1-year follow-up (P < .001; odds ratio 9.56, 95% confidence limits 3.92-23.31) and preoperative left atrium dimension (P = .028; odds ratio 1.06 for every millimeter, 95% confidence limits 1.01-1.12) were predictors of success at the end of follow-up., Conclusions: This study shows that the favorable results of the maze III procedure in terms of freedom from supraventricular arrhythmias persist in most patients for at least 4 years.

Objective: To assess the short- and long-term results following the unmodified maze procedure in patients with medication-refractory or nearly refractory atrial fibrillation., Design: Retrospective., Methods: We retrospectively collected and analysed preoperatively in-hospital and follow-up data from patients with atrial fibrillation with or without structural heart disease who underwent the unmodified maze procedure in the St. Antonius hospital, Nieuwegein, the Netherlands., Results: In the 11-year period 1993-2004, 203 patients underwent the procedure: 139 underwent the maze procedure only and 64 underwent combined surgery for concomitant atrial fibrillation and structural heart disease. There were no in-hospital deaths. During a mean follow-up period of 4 years, 2 ofthe 203 patients died from cardiac causes; both had undergone combined surgery. With a mean follow-up period of 4 years, the rate of atrial fibrillation-free survival was 90% in patients with lone atrial fibrillation and 70% in patients with concomitant atrial fibrillation. For patients who had no recurrent atrial fibrillation 1 year after surgery, the risk of recurrence after 4 years was small (odds ratio: 9.56). Risk factors for recurrence included a large left atrium and a long duration of atrial fibrillation (more than 5 years)., Conclusion: The maze procedure was a successful surgical intervention for patients with atrial fibrillation, both in the short and long term. This procedure can be considered when medication and electrical cardioversion are ineffective.

In this study we reviewed the history of the surgical treatment of atrial fibrillation (AF). Of the various types, the maze operation has become nowadays the most successful surgical treatment of AF with or without concomitant cardiac surgery. We report on our 10-year experience with conventional maze III surgery: 203 patients were operated on without in-hospital mortality and acceptable morbidity. Success defined as the freedom of AF and other supraventricular arrhythmias was 80.1% for the patients with lone AF and 64.5% for the patients with concomitant AF after a mean of 4 years after surgery. We conclude that despite the complexity of the maze III operation this approach remains the golden standard from which future surgical and other ablative treatments of AF will be derived.

Three female patients, a 22-year-old Moroccan woman, a 25-year-old Turkish woman and a 35-year-old Iraqi woman, became increasingly dyspnoeic during their pregnancy; this was a symptom of congestive heart failure due to mitral valve stenosis. Since all patients were refractory to medical treatment, they underwent invasive therapy by percutaneous transvenous mitral balloon valvotomy (PTMV). In two patients this therapy was successful, but in one patient a closed mitral valvotomy was needed. All three women delivered healthy infants, two immediately following the PTMV; at follow-up 2-4 years later, the women and infants were all doing well. The prevalence of mitral valve stenosis in the western world is increasing because of changing immigration patterns. When pregnant patients start complaining about dyspnoea, especially if they are immigrants, one should be aware of the possibility of mitral valve stenosis. PTMV is a safe and successful treatment for these patients and is preferred above surgical therapy because of its low morbidity and mortality for both mother and foetus. PTMV must be performed in a thoracic surgery centre by an experienced team and the X-ray exposure should be minimised.

Objective: We examined operative risk factors for postoperative death after surgery for acute type A aortic dissection., Methods: Between 1974 and 1999, 252 patients, 163 men and 89 women (mean+/-SD age, 58+/-12 years) underwent surgery for acute type A aortic dissection. Fifty-eight (23.0%) were in cardiogenic shock at time of surgery. Most patients underwent ascending aorta replacement which was combined with aortic valve replacement by means of a composite graft in 30 (11.9%) patients and an isolated aortic valve replacement in 16 (6.3%) patients., Results: The overall operative mortality rate was 25.0% (n=63); 27.0% for patients operated upon with aortic cross-clamping, 23.7% after deep hypotherm circulatory arrest and 23.3% after antegrade selective cerebral perfusion (ASCP) (p=0.73). Multivariate analysis revealed iatrogenic dissection (p=0.0096, odds ratio=5.7), preoperative cardiopulmonary resuscitation (p=0.0095, odds ratio=5.5) and every quarter of an hour longer extracorporeal circulation (p=0.049, odds ratio=1.1) as independent risk factors for operative mortality. Aortic valve replacement or Bentall procedure (p=0.0185, odds ratio=0.3) were protective factors. There were 44 new postoperative strokes: 4.7% in the group operated upon with and 20.1% in the group without ASCP (p=0.01)., Conclusion: In order to avoid cardiogenic shock and preoperative cardiopulmonary resuscitation, patients with acute type A aortic dissection should be treated promptly. The choice to use an aortic valve prosthesis or Bentall procedure when applicable seems to benefit the postoperative early survival. The risk of new postoperative neurological events might be reduced by avoiding the appliance of an aortic cross-clamp and by using ASCP.

Aim: Mitral valve surgery seldom suppresses atrial fibrillation (AF), present prior to surgery. Maze III surgery eliminates AF in >80% of cases, the reason why combining this procedure with mitral valve surgery in patients with AF seems worthwhile. We prospectively studied the outcome of combining the Maze III procedure with mitral valve surgery., Methods: Thirty-five patients with AF and a mean age of 64 years undergoing mitral valve surgery were prospectively randomized according to a 2.5:1 ratio to surgery with (n=25), or without (n=10) maze III and followed for at least 1 year., Results: At discharge and after 12 months freedom from AF was 56% and 92%, respectively, in the maze group, and 0% and 20%, respectively, in patients without maze (group differences at discharge p=0.002, after 12 months p=0.0007). Sinus node incompetence was seen in 1 of 25 maze patients requiring pacing. No in-hospital or late death occurred; stroke was observed in 1 patient (without maze). Quality of life markedly improved after surgery, but did not differ between patients with or without maze surgery., Conclusions: This first prospective randomized study shows that combining maze III with mitral valve surgery resulted in a significantly better elimination of preoperative AF than mitral valve surgery alone. As the quality of life did not differ between patients with, or without maze surgery, additional maze surgery is primarily recommended in patients in whom anticoagulation therapy can be avoided after surgery, specifically in patients with scheduled mitral valve plasty.

Background: Tissue mass and structure are relevant for initiation and persistence of fibrillation. Modification of the right atrium during maze surgery may change the arrhythmogenic substrate of atrial fibrillation (AF)., Methods and Results: Epicardial mapping was performed in 9 patients undergoing unmodified maze III surgery for lone paroxysmal AF. Simultaneous recording of AF on the right and left atrium was carried out with two spoon-electrodes each harbouring 64 terminals. Activation maps of AF were made to study AF wavelet organization. The recording position on right and left atria was outside the surgical field and remained unchanged before and after surgery. Before surgery, mean right and left fibrillatory intervals were 174+/-23 ms, and 175+/-26 ms, respectively, and did not differ. After completed right atrial surgery, these fibrillary intervals remained unchanged. Mean right and left atrial dispersion of refractoriness (expressed as the coefficient of variation) were 4.2+/-0.8 and 5.2+/-3.8 ms. Only right atrial dispersion of refractoriness increased significantly after right-sided surgery. Prior to surgery, activation patterns of the left atrium were more complex than that of the right atrium. The left activation patterns became less complex afterwards; the right atrial activation patterns did not change., Conclusion: The right atrial modification of maze III surgery neither affects atrial refractoriness during human lone AF nor changes AF wavelet organization. Thus, right atrial surgery does not modify the arrhythmogenic substrate of AF. These findings may imply that maze surgery can be restricted to the left atrium., (Copyright 2003 The European Society of Cardiology.)

This article investigates the influence of body surface mapping on outcome of ventricular antiarrhythmic surgery. Preoperative mapping is advocated to optimize map-guided antiarrhythmic surgery of postinfarction ventricular tachycardia. We sequentially analyzed the results of catheter activation sequence mapping, body surface mapping, and intraoperative multielectrode mapping in 54 patients and made a comparison with 30 control patients (group B) in whom catheter activation sequence mapping was omitted. Endpoints were actuarial survival, freedom of arrhythmia, and comparability of the localisation of sites of ventricular tachycardia origin. A total of 128 morphologically different monomorphic sustained ventricular tachycardias were mapped in group A. In group A, 87 ventricular tachycardias were mapped preoperatively with body surface mapping and 30 ventricular tachycardias with catheter activation sequence mapping. In 19 of 24 ventricular tachycardias (79%) that were localized with both mapping methods the ventricular tachycardia exit site was similar. In-hospital death was 1 of 85 (1.2%). Actuarial freedom from ventricular arrhythmias at 4-year follow-up was 74.1 +/- 6.0% in group A vs. 90.0+/-5.5% in group B (P =.10). In group A 14 of 54 patients died (29.6%), whereas 4 of 30 patients (13.3%) died in group B (P =.09). Arrhythmia freedom and survival is as good in patients mapped with body surface mapping only as in patients mapped with body surface mapping and catheter activation sequence mapping.

Objective: To evaluate our initial experience with the reimplantation technique of the aortic valve., Design: Retrospective., Method: From January 1st 1998 to January 31st 2000, 13 patients were operated on by the technique as described by David. Mean age was 52.2 years (SD: 11). Median preoperative New York Heart Association (NYHA) functional class was 2/4 and median preoperative degree of aortic regurgitation was 3/4. Surgical indications were initially limited to aneurysmal disease of the aortic root (n = 6) and ascending aorta (n = 4), all complicated by aortic regurgitation. Later on, we also applied the technique in type A aortic dissection (n = 3). The repair was evaluated peroperatively by transoesophageal and postoperatively, by transthoracic echocardiography. The patients were followed postoperatively in the outpatient department., Results: No technical problems arose that necessitated change or adjustment of the technique. Mean cardiac arrest time was 184 min (SD: 40) and cardiopulmonary bypass time 254 min (SD: 74). The primary aetiology on histopathological examination was medial necrosis in 5 patients and degenerative disease in the others. There was no early nor late mortality and none of the patients was reoperated upon the aortic root. Follow-up was complete at a mean of 12.3 months (SD: 8). Median aortic regurgitation at follow-up was 0.5 (p = 0.0001 versus preoperative) and median NYHA functional class at follow-up was 1 (p = 0.02 versus preoperative)., Conclusion: David's aortic valve reimplantation technique was carried out with a low surgical risk and a low degree of residual aortic regurgitation in aneurysm of the aortic root, aneurysm of the ascending aorta and type A dissection with major destruction of the aortic root.

Objective: Atrial fibrillation (AF) persisting after mitral valve surgery reduces survival due to heart failure and thrombo-embolisms, and impairs quality of life. Arrhythmia surgery for AF shows today very satisfying results and therefore mitral valve surgery with AF surgery appears appealing. This study explores whether combined surgery in view of today's results of mitral valve surgery is indicated., Methods and Results: An outcome analysis of the arrhythmia outcome of patients undergoing exclusive mitral valve surgery with or without tricuspid repair was done. Preoperative baseline characteristics including arrhythmia pattern, surgical methods and follow-up findings were reviewed. Postoperative management of AF was not protocolized. Between 1990 and 1993, 162 consecutive patients underwent mitral valve surgery; follow-up was a mean of 3.3+/-1.9 years. In-hospital and late mortality were 1 and 9%, respectively. Sinus rhythm was preserved in 40 of 57 (70%) patients with preoperative sinus rhythm whereas AF persisted in 58 of 68 (85%) of patients with preoperative chronic AF (>1 year present). Sinus rhythm without AF was observed in 10 of 29 (34%) patients with preoperative paroxysmal AF. The 4-year Kaplan-Meier survival did not differ between patients with preoperative sinus rhythm (95.2%), paroxysmal AF (89.2%) and chronic AF (82.9%) but AF persisting after surgery tended to determine survival (P=0.05). Gender, age and right ventricular pressure and tricuspid valve repair were risk factors for postoperative recurrence of AF in patients with sinus rhythm at discharge, relative risk 0.35, 1.06, 1. 04 and 2.9, respectively., Conclusion: Current mitral valve surgery with or without tricuspid valve repair does not eliminate preoperative paroxysmal or chronic AF. Secondly, because preoperative AF did not determine survival after mitral valve surgery, whereas postoperatively persisting AF was weakly associated with survival, atrial arrhythmia surgery primarily aims to reduce morbidity due to AF. Some characteristics can identify patients with increased propensity for persisting AF after surgery. Randomized studies of AF surgery are needed to identify suitable candidates for combined surgery.

Adequate atrial lead performance consists of stable sensing and pacing properties. To evaluate whether the CPI 4269 bipolar lead, covered with mannitol (Sweet Tip), in the atrial position encounters these properties, we performed a prospective study of this lead. After complete dissolution of the mannitol helix, mapping of the atrium to obtain the highest electrogram and lowest threshold was followed by screw-in into the endocardium. Intraoperative measurements were performed and long-term follow-up was scheduled every 6 to 12 months to measure threshold and perform an intracardial electrogram. Between February 1993 and December 1996, a total number of 73 leads in the atrial position in a consecutive series of patients was implanted. Implantation was performed in 28 patients receiving an AAIR and 45 patients a DDDR pacemaker. Reason for pacemaker implantation was a third-degree AV block in 37% of patients, type II second-degree AV block in 25%, sick sinus syndrome in 35%, and drug refractory paroxysmal atrial fibrillation following His-bundle ablation in 3%. The intraoperative bipolar atrial electrogram had a mean voltage of 4.25 +/- 2.1 mV. The acute atrial bipolar threshold was 0.63 +/- 0.43 V, and current was 1.35 +/- 0.81 mA at a 1.0-ms pulse duration. The mean acute resistance of the lead was 572 +/- 86 Ohm. After a mean follow-up of 18.3 months, the bipolar intracardial electrogram was 3.37 +/- 2.00 mV, the mean atrial threshold measured at the last outpatient clinic visit was 0.99 +/- 0.74 V and the mean impedance was 640 +/- 127 Ohm. A sensing problem due to traction of the atrial lead occurred in only one patient. Acute and late dislodgement did not occur. The CPI 4269 (Sweet Tip) lead is manufactured with a dissolvable capsule covering the helix tip electrode, permitting a safe passage through the venous system. This interim analysis shows that this lead in the atrial position has favorable acute and chronic results.

Background: An evaluation of early and long-term results of aortic root replacement with cryopreserved aortic allografts and echocardiographic follow-up of allograft valve function was performed., Methods: From September 1989 through May 1998, 132 patients aged 17 to 77 years (mean, 50.8 +/- 14.8 years) underwent freestanding aortic root replacement with a cryopreserved aortic allograft. Eighty-six (65.1%) patients had New York Heart Association class III or IV functional status before operation, and 27 (20.5%) patients underwent emergency operation. Fifty-nine (44.7%) patients had undergone previous cardiac operations. The cause of aortic disease was acute endocarditis in 63 (47.7%) patients, healed endocarditis in 15 (11.3%), degenerative in 20 (15.2%), congenital in 20 (15.2%), failed prosthesis in 10 (7.6%) and rheumatic in 4 (3.0%). Follow-up was complete, with a mean of 42 months., Results: There were 12 hospital deaths (9.1%; 70% confidence limits [CL], 6.6% and 11.6%); 9 of them were operated on for active endocarditis (p = 0.062). Multivariate analysis determined age older than 65 years (p = 0.012) and emergency operation (p = 0.009) as independent risk factors for hospital mortality. During follow-up, 6 (5.0%; 70% CL, 3.0% and 7.0%) patients died. Cumulative survival rate for the entire group was 81.8% +/- 5.4% at 8 years. Freedom from reoperation for structural valve failure was 100%, freedom from reoperation for any cause was 96.3% +/- 1.8% at 8 years. Freedom from endocarditis at 8 years was 97.9% +/- 1.4%. Follow-up of allograft valve function showed no or trivial aortic regurgitation in 97% of patients and absence of stenosis of the allograft in 100%., Conclusions: Aortic root replacement with cryopreserved aortic allografts can be performed with acceptable hospital mortality and long-term results. The durability of cryopreserved aortic allografts is good, and reoperation for structural valve failure is absent at 8 years.

Aims: Although arrhythmia surgery and radiofrequency catheter ablation to cure atrioventricular nodal reentrant tachycardia differ in technical concept, the late results of both methods, in terms of elimination of the arrhythmogenic substrate and procedure-related new and different arrhythmias, have never been compared. This constituted the purpose of this prospective follow-up study., Methods and Results: Between 1988 and 1992, 26 patients were surgically treated using perinodal dissection or 'skeletonization', and from 1991 up to 1995, 120 patients underwent radiofrequency modification of the atrioventricular node for atrioventricular nodal reentrant tachycardia. The acute success rates of surgery and radiofrequency catheter ablation were 96% and 92%, respectively. Late recurrence, rate in the surgical and radiofrequency catheter ablation groups was 12% and 17%, respectively. Mean follow-up was 53 months in the surgical group and 28 months in the radiofrequency catheter ablation group. The final success rate after repeat intervention was 100% in the surgical group and 98% in the radiofrequency catheter ablation group. Comparison of the initial and recent series of radiofrequency catheter ablated patients showed an increased initial success rate with fewer applications. In the radiofrequency catheter ablation group, a second- or third-degree block developed in three patients (2%), requiring permanent pacing, whereas in the surgical group no complete atrioventricular block was observed. Inappropriate sinus tachycardia needing drug treatment was observed in 13 patients (11%), mostly after fast pathway ablation, but was never observed after surgery. New and different supraventricular tachyarrhythmias arose in 27% of the patients in the surgical group and in 11% of the radiofrequency catheter ablation group, but did not clearly differ., Conclusion: This one-institutional follow-up study demonstrated comparable initial and late success rates as well as incidence of new and different supraventricular arrhythmias following arrhythmia surgery and radiofrequency catheter ablation for atrioventricular nodal reentrant tachycardia. Today radiofrequency catheter ablation has replaced arrhythmia surgery for various reasons, but the late arrhythmic side-effects warrant refinement of technique.

Objective: To compare the long-term results of surgical modification and of radiofrequency (RF) catheter modification of the atrioventricular node (AV node), to combat recurrent atrioventricular nodal re-entrant tachycardia (AVNRT)., Design: Retrospective descriptive., Setting: St. Antonius Hospital, Nieuwegein, the Netherlands., Method: In the period 1988-1992, 26 patients underwent surgical modification and in 1991-1996, 120 patients were subjected to RF catheter modification of the AV node for recurrent AVNRT. The follow-up amounted to at least one year., Results: Surgery was immediately successful in 96%, and RF catheter ablation in 92%. A recurrence AVNRT was seen in 12 and 17% respectively, the ultimate success rates (after retreatment) were 100 and 98%. Three patients (3%) in the RF catheter ablation group developed a second or third-degree AV block necessitating pacemaker implantation. No third-degree AV block was seen in the surgical group. Mean follow-up was 53 months in the surgical group and 28 months in the RF catheter ablation group. Both procedures were accompanied by other supraventricular tachycardias, viz. in 27% of the surgical and in 11% of the RF catheterization ablation group., Conclusion: RF catheter ablation for the treatment of AVNRT had early and long-term results comparable with those of rhythm surgery. Since catheter treatment is far less taxing to the patient than rhythm surgery, RF catheter ablation now constitutes the most appropriate method for treatment of this arrhythmia.

Background: A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome., Methods: A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period., Results: Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease., Conclusions: Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.

Background: Bronchopeural fistula after pneumonectomy, with associated empyema, has no standard therapy. The transsternal, transpericardial approach was used in all patients presenting with a large fistula., Methods: From 1974 through 1995, 55 patients underwent transsternal, transpericardial closure of a bronchopleural fistula. Mean age was 62.7 years (range, 33 to 78 years). Malignant disease had been the indication for pneumonectomy in 50 patients and benign lesions in 5 patients. The fistula was right-sided in 41 patients (74.5%), and the bronchial stump was less than 2 cm in 25 (45.5%). Treatment of the concomitant empyema was by closed drainage in 2 patients, by repeated needle aspiration in 17, and by open thoracostomy in 36 patients. Reamputation and closure of the stump was possible in 51 patients; in 4 a primary carinal resection was done., Results: Three patients died within 30 days after operation (5.4%, 70% confidence interval 2.4%-10.7%). Ten patients died late during hospitalization, total hospital mortality, 23.6% (70% confidence interval 17.3% to 31.0%). Recurrent fistula symptoms were caused by a large recurrency in 6 patients (all died), by a small one in 7 (one death due to pulmonary embolism). Mean duration of hospital stay was 56 days (range, 2 to 174 days). At follow-up of 42 patients, there were no recurrent fistulas. All patients with benign lesions are alive and well. Of 37 cancer patients, 29 died, more than half due to malignancy. Risk factors for death included recurrent fistula, short interval between pneumonectomy and onset of fistula, and closing technique. Risk factors for recurrent fistula were a short bronchial stump and the nonuse of an open thoracostomy., Conclusions: Long-term results of transsternal closure are good, but hospital mortality is high. The present treatment of patients with large postpneumonectomy bronchopleural fistula includes early open thoracostomy, improvement of nutritional status, transsternal closure using resorbable sutures, and closure of the pleural space 3 weeks later.

Introduction: Currently, surgery- and catheter-mediated ablation is applied when drug refractoriness of atrial fibrillation is evident, although little is known about the long-term incidence of new atrial arrhythmia and the preservation of sinus node function., Methods and Results: To address this issue, 30 patients with successful corridor surgery for lone paroxysmal atrial fibrillation and normal preoperative sinus node function were followed in a single outpatient department. Five years after surgery, the actuarial proportion of patients with recurrence of atrial fibrillation arising in the corridor was 8% +/- 5%, with new atrial arrhythmias consisting of atrial flutter and atrial tachycardia in the corridor 27% +/- 8%, and with incompetent sinus node requiring pacing therapy 13% +/- 6%. Right atrial transport was preserved in 69% of the patients without recurrence of atrial fibrillation and normal sinus node function. Stroke was documented in two patients., Conclusions: Corridor surgery for atrial fibrillation is a transient or palliative treatment instead of a definitive therapy for drug refractory atrial fibrillation. This observation strongly affects patient selection for this intervention and constitutes a word of caution for other, nonpharmacologic interventions for drug refractory atrial fibrillation.

Objective: To describe the results of treatment of patients with a life-threatening arrhythmia by implantation of an second generation implantable cardioverter defibrillator with transvenous electrodes., Design: Descriptive., Setting: St.-Antonius Hospital, Nieuwegein, the Netherlands., Method: In the period October 1991-February 1996 the ICD with transvenous electrodes was implanted in 44 patients. After a year the quality of life was assessed by written questionnaire., Results: The in-hospital mortality was 1/44 (2%), without peroperative death. During follow-up 4 patients died: 3 due to congestive heart failure and 1 due to sudden cardiac death. Within one year 50% of the patients had a therapeutical ICD discharge. In 30/44 (68%) patients antiarrhythmic drugs were prescribed to reduce the number of ICD discharges or because they were suffering from paroxysmal atrial fibrillation with high heart rates, which could result in an inappropriate ICD discharge. Quality of life analysis showed a good acceptance of the ICD, although 86% of the patients considered it a very serious limitation that they were not allowed to drive a motor vehicle anymore., Conclusion: The ICD constitutes a major step forward in the treatment of life-threatening ventricular arrhythmias because the implantation is easier and follow-up shows adequate antiarrhythmic effects and survival.

Background: This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction., Methods: From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 +/- 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class was 3.4. Staphylococcus epidermidis (50%) and Enterococcus faecalis (19%) were the predominant causative microorganisms. Annular abscesses were found in 26 patients (81%), aortic-mitral discontinuity in 14 patients (43%), and left ventricular-aortic discontinuity in 11 patients (34%). A cryopreserved allograft was used in 31 patients (97%) and a fresh antibiotic-treated allograft was used in 1 patient (3%). Mean aortic cross-clamp time was 150 +/- 29 minutes. Mean duration of the postoperative antibiotic treatment was 38.5 +/- 11.8 days., Results: There were three operative deaths (9.4%); causes of death were multiorgan failure in 2 patients (6.2%) and low cardiac output in 1 patient (3.2%). Six patients (18%) had complete heart block (4 patients already before the operation), 3 patients (9.4%) had temporary respiratory insufficiency, and 1 patient (3.2%) needed temporary hemodialysis. Mean follow-up was 37.4 +/- 22.4 months. Two late deaths occurred: 1 patient had recurrent endocarditis, leading to a false aneurysm, and died at reoperation; another patient died of lung cancer. Actuarial 5-year survival was 87.3% (70% confidence interval, 76.8% to 97.8%); actuarial 5-year freedom from recurrent endocarditis was 96.5% (70% confidence interval, 90.0% to 100%)., Conclusions: Allograft aortic root replacement is a valuable technique in the complex setting of prosthetic valve endocarditis with involvement of the periannular region. Mortality and morbidity are low.

Background: In patients with postinfarction sustained ventricular tachycardia showing one or more antiarrhythmic drug failures, the question is how long to proceed with new drug trials before deciding to perform map-guided arrhythmia surgery. Although the techniques of this surgery developed rapidly in the early 1980s, this therapy may be offset by damage to residual left ventricular function. However, surgery has been shown to be very effective in selected groups of patients., Methods: A randomized study was carried out in patients with postinfarction ventricular tachycardia and eligible for arrhythmia surgery based on residual left ventricular function. Therapy failure was defined by the occurrence of the following events: spontaneous recurrence of ventricular tachycardia or ventricular fibrillation, sudden cardiac death, inducibility of sustained ventricular tachycardia or ventricular fibrillation with programmed stimulation of the heart, symptomatic non-sustained ventricular tachycardia requiring therapy or side-effects of antiarrhythmic drugs requiring withdrawal. In the drug limb, failure of the first antiarrhythmic drug was accepted but failure of a second and different drug was regarded as true therapy failure., Results: After randomization, antiarrhythmic drug therapy was administered in 33 patients, and 30 patients underwent surgery. Neither group differed in baseline characteristics, and the mean number of drug failures before randomization was 2.7. The Kaplan-Meier therapeutic failure of antiarrhythmic drugs was 39 +/- 11%, 42 +/- 11% and 51 +/- 18% at 0.5-, 1- and 4-year follow-up, respectively, whereas the therapeutic failure of cardiac surgery was 37 +/- 11%, 37 +/- 11% and 50 +/- 20% at 0.5, 1 and 4 years, respectively, showing no statistical difference. The 1- and 4-year Kaplan-Meier survival of the antiarrhythmic drug-treated group was 91 +/- 6% and 78 +/- 15%, respectively, and of the surgical group 92 +/- 6% and 59 +/- 20%, respectively, and did not differ between either group. However, the relative risk for total cardiac death was higher in the surgical limb than in the drug limb (relative risk 2.2, CI 0.68-7.48)., Conclusion: This study demonstrated no difference between the therapeutic result of continuation of two different antiarrhythmic drugs and that of arrhythmia surgery. Despite the small number of patients studied, it is recommended that drug therapy should continue as long as this regimen is tolerated by the patient. When true drug refractoriness or side-effects of drugs arise, arrhythmia surgery offers a valuable alternative. However, when additional reasons for cardiac surgery exist, arrhythmia surgery should be undertaken earlier and may become the first choice of treatment of postinfarction ventricular tachycardia.

The purpose of this study was to assess the usefulness of left heart bypass in thoracoabdominal aortic aneurysm surgery. Data from 50 patients who underwent thoracoabdominal aortic aneurysm repair between July 1987 and October 1993 were retrospectively reviewed. In all of them a left heart bypass (left atrium to left femoral artery) with a centrifugal pump (without systemic heparinization) was used. Patient-, disease-, and operation-related variables were analyzed using univariate methods. There were no intraoperative deaths. The in-hospital mortality rate was 8% (n = 4). Survival rates were 77% (+/- 6.5) at 2 years and 62% (+/- 8.7) at 5 years. Renal failure requiring dialysis occurred in five (10%) patients and paraplegia in five (10%). Sixteen (32%) patients had respiratory insufficiency requiring prolonged (> 8 days) ventilation. After univariate analysis, the risk factors for developing a need for postoperative dialysis were found to be the preoperative creatinine level (p = 0.002) and the presence of preoperative arterial hypertension (p = 0.018). A history of peripheral vascular occlusive disease (p = 0.008) was an important risk factor for predicting late death. No factors retained significance in the univariate analysis of hospital deaths and postoperative paraplegia. Renal and spinal ischemic times were substantially reduced in comparison to the theoretic times calculated if cross-clamping had been used. Bypass-related complications were completely absent. The use of a left heart bypass during thoracoabdominal aortic aneurysm surgery may not reduce the global complication rate; the results were similar to those achieved using simple cross-clamping. However, this technique appears to be the method of choice for protecting organ systems at risk during difficult repairs.

Background: Postinfarction ventricular tachycardias (VTs) may degenerate into ventricular fibrillation (VF), but this does not happen in all patients. The underlying mechanism is not exactly known, but dispersion of refractory periods is considered a major factor in both induction and persistence of reentrant arrhythmias in general. Hypertrophied, noninfarcted myocardium has altered electrophysiological characteristics. We hypothesized that noninfarcted ventricular tissue may provide the heterogeneities that cause the transition from VT into VF. Local fibrillation intervals, ie, the average interval between local activations during VF, have previously been shown to correlate well with local refractoriness in human and canine atrium and in porcine and canine ventricle and may therefore be used as an index of local refractoriness. This technique permits simultaneous assessment of refractoriness at multiple sites., Methods and Results: We measured local fibrillation intervals at 32 to 64 sites in the noninfarcted part of the left ventricle in patients undergoing antiarrhythmic surgery for symptomatic, drug-refractory, postinfarction ventricular tachyarrhythmias. The grid of electrodes (interelectrode distance, 7 mm) was attached to the epicardium of the left ventricle remote from the infarcted tissue. Group 1 consisted of 7 patients with hemodynamically tolerable sustained VT (VT group). Group 2 consisted of 7 patients with cardiac arrest and documented VF (VF group). With the patients on cardiopulmonary bypass, VF was induced by multiple premature stimulation. The VF interval was not significantly different in the two study groups (VT group, 136 +/- 5.5 ms; VF group, 129 +/- 3.4 ms, mean +/- SEM). However, spatial dispersion of the VF intervals (remote from the infarcted area) expressed as the coefficient of variation of VF intervals (SD x 100/mean VF interval in each heart) was significantly larger in the VF group. It was 3.63 +/- 0.56 in the VF group and 1.55 +/- 0.40 in the VT group (mean +/- SEM; P < .01). Differences between the shortest and longest VF intervals in one and the same heart and the largest difference between two adjacent sites were also larger in the VF group (P < .02 and P < .05, respectively)., Conclusions: This study shows larger dispersion in VF intervals and therefore suggests larger dispersion of refractory periods in parts of the myocardium remote from the infarction in patients with postinfarction VF than in patients with postinfarction VT.

Objective: The authors sought a statistical model that permits the calculation of the chance of postoperative dialysis in patients undergoing thoracoabdominal aortic aneurysm repair. The preoperative risk of each individual patient was assessed., Summary Background Data: Acute renal failure requiring dialysis after thoracoabdominal aortic aneurysm surgery is a common complication. Despite modern intensive care facilities, it continues to be associated with high morbidity and mortality., Methods: The authors studied the influence of preoperative and intraoperative variables thought to be important clinically in the development of serious acute renal failure in 88 consecutive patients. Simple cross-clamping was used with the Crawford's graft inclusion technique without shunts or heparin. Statistical methods used include univariate and multivariate analysis (stepwise logistic regression analysis and Cox proportional hazard model)., Results: The hospital mortality was 11.4% (n = 10). Long-term survival at 2 years was 78% (+/- 4.4), and at 5 years was 54% (+/- 5.3). A logistic regression model with only two explanatory variables to predict postoperative dialysis showed an almost perfect fit (chi 2 = 4.2, p = 0.84): the risk factors of postoperative dialysis were age (p = 0.003) and the preoperative serum creatinine level (p = 0.04). As determined by stepwise Cox regression analysis, postoperative dialysis also was a significant risk factor for late death (p = 0.002)., Conclusions: Using this statistical model, the chances of postoperative dialysis can be estimated exactly before operation; age and preoperative serum creatinine level are the only variables predictive for postoperative dialysis.

Objectives: The purpose of this study was to 1) investigate extracellular electrograms in the atrioventricular (AV) junctional area of patients with AV node reentrant tachycardia, 2) compare them with recordings made in isolated porcine hearts, and 3) study their origin., Background: Electrograms with slow components have been used to target the delivery of radiofrequency energy for the cure of AV node reentrant tachycardia. The origin of these electrograms is unknown., Methods: In 12 human and 19 porcine hearts, extracellular recordings were made simultaneously from 64 sites. In five other porcine hearts, intracellular recordings were made at sites at which extracellular electrograms revealed slow potentials. Histologic investigations were carried out in four of these hearts., Results: Electrograms with slow components were recorded in five human and eight porcine hearts. These signals were found at sites up to 12 mm from the His bundle. Characteristics of the electrograms did not differ significantly among human and porcine hearts. Electrophysiologic evidence for multiple pathways was present in four hearts. Superficial impalements with microelectrodes at sites with slow potentials showed action potentials with AV node characteristics. In the majority of these recordings, the upstroke coincided with the downstroke of slow potentials. Histologic investigations of the sites of impalement revealed transitional cells directly underneath the endocardium., Conclusions: Slow potentials were recorded in both human and porcine hearts in similar measure. They arise from transitional cells and have action potentials similar to N cells.

Objective: To investigate the long-term results of the corridor operation in the treatment of symptomatic atrial fibrillation refractory to drug treatment., Background: The corridor operation is designed to isolate from the left and right atrium a conduit of atrial tissue connecting the sinus node area with the atrioventricular node region in order to preserve physiological ventricular drive. The excluded atria can fibrillate without affecting the ventricular rhythm. This surgical method offers an alternative treatment when atrial fibrillation becomes refractory to drug treatment., Patients: From 1987 to 1993, 36 patients with drug refractory symptomatic paroxysmal atrial fibrillation underwent surgery. The in hospital rhythm was followed thereafter by continuous rhythm monitoring and with epicardial electrograms. After discharge Holter recording and stress testing were regularly carried out to evaluate the sinus node function and to detect arrhythmias; whereas Doppler echocardiography was used to measure atrial contraction and size., Main Outcome Measures: Maintained absence of atrial fibrillation without drug treatment after operation; preservation of normal chronotropic response in the sinus node., Results: The corridor procedure was successful in 31 (86%) of the 36 patients. After a mean (SD) follow up of 41 (16) months 25 (69%) of the 36 patients were free of arrhythmias without taking drugs (mean (SE) actuarial freedom at four years 72 (9)%)). Paroxysmal atrial fibrillation recurred in three patients; paroxysmal atrial flutter (two patients) and atrial tachycardia (one patient) developed in the corridor in three others. Among the 31 patients in whom the operation was successful sinus node function at rest and during exercise remained undisturbed in 26 and 25 patients respectively (mean (SE) actuarial freedom of sinus node dysfunction at four years (81(7)%)). Pacemakers were needed in five (16%) of the 31 patients for insufficient sinus node rhythm at rest only. Doppler echocardiography showed maintenance of right atrial contribution to right ventricle filling in 26 of the 31 patients after operation in contrast to the left atrium, which never showed such contribution. His bundle ablation was performed and a pacemaker implanted in the five patients in whom the corridor operation was unsuccessful., Conclusion: These results substantiate the idea of this surgical procedure. Modification of the technique is, however, needed to achieve a reliable isolation between left atrium and corridor, which would make this experimental surgery widely applicable in the treatment of drug refractory atrial fibrillation.

A retrospective follow-up study in the Netherlands on the risk of fracture of Björk-Shiley convexo-concave valves concluded that prophylactic replacement is advisable for certain groups of patients. We have examined valves explanted from twenty-two patients because they met epidemiological criteria for reoperation, with or without the presence of moderate cardiac impairment, or because there were other cardiac complaints not related to the valve. No information was available before explanation to suggest a valve defect. All patients survived their operations. Of the twenty-four valves, seven (29% [95% CI 13-52]) had fracture of one of the legs of the outlet strut (single-leg strut fracture [SLF]). Two other valves had features that suggested fatigue defects. As in the previous study, 70 degrees valves had the highest risk of SLF (five of sixteen, two aortic and three mitral). However, two of eight 60 degrees valves (both aortic) also had SLF. Current hazard calculations and explanation recommendations may need to be revised. Since several of the defective valves were welded by the same person, knowledge of manufacturing details may help in estimation of fracture risk for an individual patient.

Between 1981 and 1987, 88 consecutive patients were operated on for a thoracoabdominal aortic aneurysm by simple crossclamping and a graft inclusion technique (without shunts or heparin). This article presents an analysis of the operative outcome and long-term follow-up. Patient- and operation-related variables are age (mean 64.3 years, range 28 to 82 years), sex (82% men), rupture (20.5%), diabetes (2.3%), renal insufficiency (34.1%), chronic obstructive pulmonary disease (27.3%), previous aortic operation (31.8%), arterial hypertension (66%), postdissection (18.2%) versus degenerative (80.7%) origin, preoperative shock (11.4%), ischemic cerebrovascular (12.5%) or ischemic heart (17%) disease, peripheral vascular disease (14.8%), renal (mean 48 minutes, range 0 to 83 minutes) and lower spinal cord (mean 21 minutes, range 0 to 68 minutes) ischemic time, number of reattached intercostals, blood loss, and extent of the aneurysm (Crawford classification: type I, 16 patients [18.2%]; type II, 21 patients [23.8%]; type III, 29 patients [33%]; and type IV, 22 patients [25%]. Intraoperative mortality is 1.1% (n = 1). Thirty-day mortality is 5.9% (n = 5). Hospital mortality is 11.4% (n = 10): 7% for elective cases and 28% for ruptured aneurysms (p = 0.014). The survival at 2 years is 78% +/- (4.4%) and at 5 years 54% +/- (5.3%). Postoperative spinal cord injury occurred in 12 patients (13.8%) (5 had paraplegia and 7 had paraparesis) and postoperative renal dysfunction necessitating dialysis in 12 patients (14.1%). Risk stratification for hospital death, late death, renal failure, and spinal cord dysfunction was performed by means of multivariate logistic regression and Cox proportional hazard regression as appropriate. The best fitting model to predict hospital death includes preoperative shock (p = 0.02), female sex (p = 0.06), preoperative elevated serum creatinine level (p = 0.06), and preoperative myocardial infarction (p = 0.08). Variables predictive for late death are postoperative dialysis (p = 0.002), age (p = 0.008), and rupture (p = 0.04). The risk factors of postoperative dialysis are age (p = 0.003) and preoperative serum creatinine level (p = 0.04). The risk of postoperative spinal cord dysfunction increases with longer lower spinal cord ischemic time (p = 0.02) and with the presence of preoperative shock (p = 0.06).

Background: Björk-Shiley convexo-concave heart valves have an increased risk of mechanical failure. One might consider prophylactic rereplacement as a preventive measure to avert the disastrous consequences of these failures. We investigated the effect that prophylactic rereplacement has on survival of individual patients and on the medical costs., Methods and Results: Quantitative estimates for the surgical risks of prophylactic replacement of Björk-Shiley valves, long-term survival, and the risk of outlet strut fracture were derived insofar as possible from a detailed analysis of a follow-up study conducted in The Netherlands, including 2303 patients with a mean follow-up of 6.6 years. On the basis of these estimates, we calculated life expectancy with and without prophylactic replacement. For the various valve types, age thresholds were determined below which rereplacement prolongs (discounted quality-adjusted) life expectancy. We also calculated the cost per year of life gained as a function of age. The age thresholds below which prophylactic rereplacement increases life expectancy (expressed in simple future years of life) for male patients without comorbidity, if the surgical mortality after rereplacement is equivalent to that of primary replacement, are 27, 48, 51, and 65 years for small and large 60 degrees and for small and large 70 degrees mitral valves, respectively. For aortic valves, these age thresholds lie somewhat higher: 39, 52, 56, and 76 years, respectively. Repeat analyses indicated that for women, all age thresholds lie about 1 or 2 years higher. These age thresholds decrease considerably if the surgical mortality after rereplacement is considered to be higher after prophylactic rereplacement than after primary replacement or if comorbidity is present. The costs per discounted and quality-adjusted year of life gained depend on type and position of the Björk-Shiley convexo-concave heart valve and rise steeply as the patient's age approaches the threshold for rereplacement., Conclusions: The results of the Dutch follow-up study allow guidance for prophylactic replacement of the Björk-Shiley convexo-concave valve on an individual basis. Rereplacement compares favorably with expectant management in some patient subgroups with both 60 degrees and 70 degrees valves. Age thresholds may serve as a first step in identifying patients in whom rereplacement might be beneficial.

A 55-year-old woman presented with fever and malaise. Three blood cultures were positive for Streptococcus sanguis. A diagnosis of endocarditis was made and the patient was treated with intravenous penicillin and gentamicin. Endocardiography revealed a large left atrial tumour. At operation a myxoma covered by deposits of fibrin was excised. Microscopy revealed massive infiltrates of neutrophils and remnants of bacteria, indicating that this myxoma was a nest for infection.

In 212 patients aged 75 years and older the immediate and long-term results of percutaneous transluminal coronary angioplasty (PTCA) were assessed. For 293 stenoses the primary angiographic success rate was 96% and the overall clinical success rate was 90.6%. Angioplasty caused a myocardial infraction in 7 patients (3.3%), 2 patients (0.9%) needed emergency aorto coronary bypass surgery, and 4 patients (1.9%) died following the procedure. Actuarial 7 year survival was calculated at 69.3% with a standard deviation (SD) of 8%. Actuarial cardiac survival at 7 years was 92.1% (SD 3%), whereas non-cardiac survival at 7 years was 75.3% (SD 9%). Actuarially, at 7 years 98.5% (SD 1%) were estimated to remain free from myocardial infarction in the angioplasty-related area, 95.7% (SD 2%) to remain free from any myocardial infarction, 93.9% (SD 2%) to remain free from re-PTCA because of a recurrence, 84.7% (SD 5%) to remain free from any re-PTCA, and 97.1% (SD 2%) to remain free from (re)-operation. Fifty-two point three percent (SD 8%) were estimated to remain free from any cardiac event. If recurrence of angina is taken into account, only 25.8% (SD 13%) remain asymptomatic during 7 years follow-up. After successful angioplasty in patients aged 75 and older the chance of remaining free from any event or angina at 7 years actuarial follow-up gets as low as 15.7% (SD 9%). We conclude that in selected elderly patients angioplasty can be performed with a high success rate, although the periprocedural mortality and morbidity appear to be higher than in the younger age group. During long-term follow-up, most of the patients remain free of cardiac events and survival appears to be largely dependent on noncardiac factors. However, long-term relief from angina is probably less than in younger patients.

The average interval between local depolarizations during atrial fibrillation, the so-called atrial fibrillation interval, was used as an index for local "refractoriness." This was based on the assumption that during fibrillation, cells are reexcited as soon as their refractory period ends. A very good correlation was found between refractory periods determined with the extrastimulus technique at a basic cycle length of 400 ms and atrial fibrillation intervals measured at the same epicardial sites of the right atrium. This new technique was used to assess dispersion in atrial fibrillation intervals in 10 patients with idiopathic paroxysmal atrial fibrillation and in a control group of 6 patients who were undergoing cardiac surgery. After a routine median sternotomy a multiterminal grid with up to 40 electrodes was placed over the right atrium, and atrial fibrillation was induced by premature stimulation. The average fibrillation interval in the test group, recorded at 247 sites, was 152 +/- 3 ms and that in the control group, recorded at 118 sites, was 176 +/- 8.1 ms (p less than 0.05). Dispersion in atrial fibrillation intervals, defined as the variance of the fibrillation intervals at all the recording sites, was three times larger in the group with paroxysmal atrial fibrillation than in the control group. This study suggests that both a shorter refractory period and a larger dispersion in refractoriness are responsible for the recurrence of atrial fibrillation.

During the years 1960 through 1989, 145 patients underwent sleeve lobectomy or sleeve resection of a main bronchus. Completion pneumonectomy was performed in 19 patients (13.1%). Indications were bronchostenosis without malignancy in 10 patients, positive resection margins in 3, recurrent tumor in 5, and anastomotic dehiscence in 1. Mean age at sleeve operation was 59.3 years. In 18 patients the histology was squamous cell carcinoma and in 1 patient, carcinoid tumor. The mean interval between sleeve resection and completion pneumonectomy was 5.7 months (range, 3 to 16 months) for the patients with stenosis and 6.6 months (range, 1 to 17 months) for the others. There were 3 operative deaths (15.8%). The mean follow-up was 53.2 months. Five-year and 10-year survival rates after completion pneumonectomy for the patients with stenosis were 54% and 41%, respectively, and for the others, 52% and 52%.

Patients with paroxysmal atrial fibrillation may be extremely disabled despite medical therapy. Based on recent concepts of atrial fibrillation, a surgical open heart procedure was designed to isolate a "corridor" from the right and the left atrium. The corridor consists of the sinus node area, the atrioventricular nodal junction, and the connecting right atrial mass, small enough to prevent atrial fibrillation. Between 1987 and 1990, 20 patients with severely disabling symptoms due to frequent paroxysmal atrial fibrillation underwent the corridor operation, with permanent success in 16 patients. In 8 patients, left atrium to corridor conduction reappeared shortly after the procedure. Reoperation was performed in these patients without extracorporeal circulation. The site of persistent conduction between the left atrium and the corridor could consistently be localized adjacent to the coronary sinus. Nevertheless, reoperation failed to isolate permanently the corridor in 4 patients. During a mean follow-up of 20 months, atrial fibrillation dominating the ventricles was never observed nor inducible in the corridor in the 16 patients with a successful operation. In all cured patients, sinus node function remained undisturbed. Paroxysmal atrial flutter inside the corridor arose in 1 patient and a paroxysmal focal tachycardia in another. All 16 cured patients experienced a clear improvement in quality of life. Refinement of the surgical technique to obtain persistent isolation between the left atrium and the corridor is needed. These results demonstrate that the concept of the corridor operation is sound and justify its use in the treatment of drug-refractory paroxysmal atrial fibrillation.

The late follow-up of 230 patients who underwent synchronous operation for extensive, obstructive extracranial and coronary artery disease from 1974 to 1989 was analyzed. Mean age at operation was 62.5 years; 161 patients (70%) were in New York Heart Association class III or IV, 185 (80%) had triple-vessel disease, and 67 (29%) had left main stem lesions of 50% or more. Previous myocardial infarctions were present in 132 patients (57%). Only 78 had normal left ventricular function. Included were 16 patients undergoing coronary reoperations, 17 patients with additional cardiac procedures, and 3 with synchronous pulmonary procedures. Symptomatic extracranial vascular disease or stabilized neurological deficits were present in 108 patients. Bilateral hemodynamically significant carotid disease was present in 91 patients and arch vessel lesions in 37. The hospital mortality in 8 patients (3.5%) was due to cardiac (n = 4), neurological (n = 1), or multiorgan failure (n = 3). Operative morbidity was mainly neurological (n = 20, 8.7%): 7 reversible deficits and 7 major strokes occurred, 2 reversible and 5 major strokes were related to the operated side(s), and 4 postoperative myocardial infarctions occurred. Actuarial survival at 5 years was 74% (+/- 3.3), at 10 years 54% (+/- 4.9), and at 15 years, 35% (+/- 6.6). This was mainly determined by late cardiac death (41/66). Late morbidity was mainly attributable to cardiac causes rather than neurological causes. At 5 and 10 years, respectively, 72% and 44% of the patients were free of major cardiac and neurological events or death. Synchronous revascularization can be performed relatively safely. The long-term outcome is determined by the extent and severity of the cardiovascular disease.

From 1960 to 1989, 145 patients (132 men and 13 women) with a mean age of 60.3 years underwent sleeve lobectomy or sleeve resection of a main bronchus for a bronchogenic tumor. Squamous cell carcinoma was predominantly found (116 patients, 80.0%), followed by carcinoid tumor in 13 patients (9.0%). Postoperative staging was: stage I, 61 patients (42.1%); stage II, 47 (32.4%); stage IIIA, 33 (22.8%); and stage IIIB, 4 (2.7%). Thirty-day mortality was 4.8% (7 patients). Follow-up was complete except for 1 patient who was lost to follow-up 4 years after operation. For the whole group, 5-, 10-, and 15-year survival rates were 49%, 37%, and 18%, respectively. Better survival was noted in patients with carcinoid tumor and squamous cell carcinoma. Considering 112 patients with T2 and T3 squamous cell carcinoma, 5- and 10-year survival rates for N0 disease (52 patients) were 59% and 47%, for N1 disease (51 patients) 21% and 0%, and for N2 disease (9 patients) 44% and 0%. Differences between N1 and N2 disease were not statistically significant. Survival after sleeve resection is best for carcinoid tumors and squamous cell carcinoma with negative nodes. Presence of N1 or N2 disease significantly worsens prognosis, with no 10-year survivors and no difference between N1 and N2 status.

Endocardial mapping of electrical activity was carried out in 150 patients to guide antiarrhythmic surgery for drug-resistant ventricular tachycardia in the chronic phase of myocardial infarction. In 20 of these patients, the activation pattern of 27 distinct tachycardias was focal and diastolic potentials were recorded at three or more sites. In 26 tachycardias, the sequence of diastolic potentials progressed from the area of latest activation of one cycle toward the "origin" of the next cycle. In two patients, the heart was stimulated during tachycardia, resulting in entrainment of the tachycardia in both. Late potentials were recorded during entrainment at sites where diastolic potentials occurred during tachycardia. In 11 of the 20 patients, endocardial mapping was performed during sinus rhythm. In four of these, late potentials were observed during sinus rhythm at sites where diastolic potentials were recorded during tachycardia. In two patients without late potentials during sinus rhythm, late potentials were observed during stimulation and induced ectopic beats. The results support the concept that the mechanism of several of these tachycardias is based on reentry in a macrocircuit comprising a tract of surviving tissue traversing the infarct and the remaining healthy tissue. They also indicate that the absence of late potentials during sinus rhythm does not guarantee the absence of arrhythmogenic pathways.

From 1980 to 1988 direct arrhythmia surgery was performed in 121 patients suffering from postinfarction drug-refractory ventricular tachycardia (VT). By 1986 the initially high in-hospital mortality of 26% (18 of 69 patients) had decreased to 1.9% (1 of 52 patients). The 3-year actuarial survival of patients operated since 1986 is 90%. From 1985 the results of surgical therapy of VT have improved: 86% of the patients remained arrhythmia-free without drugs; none died suddenly. Residual left ventricular function was related to the prognosis, but the interval between the last myocardial infarction and time of surgery or the surgical technique were not. These results demonstrate that direct surgery has become a valuable method in the treatment of postinfarction VT, at least in patients with sufficient residual left ventricular function.

Between June 1983 and December 1987, 52 patients underwent resection of a descending thoracic aortic aneurysm under simple aortic cross-clamping without the use of shunting or bypass techniques. The 30-day mortality rate was 11.5%; 4.8% for elective cases and 36.5% for patients operated on in emergency. Two patients (4%) had spinal cord injury. One patient had paraplegia, and the other had mild paraparesis but completely recovered. Both patients were operated on for ruptured aneurysms. Four patients (7.5%) had severe postoperative renal dysfunction that was strongly related to intraoperative hypotension. The cumulative proportional survival rate was 81% at 1 year and 66% at 2 years for the total group. 85% at 1 year and 72% at 2 years for the patients first seen with nonruptured aneurysms. Aneurysms of the descending thoracic aorta can be safely resected without the use of shunting or bypass techniques. Surgery definitely improves the outcome for these patients who have a poor prognosis if left untreated.

A multivariate analysis of 130 consecutive patients operated during one month in our hospital was carried out to determine the influence of age and blood flow during cardiopulmonary bypass on the renal response to cardiac surgery. The postoperative level of serum creatinine could be related to three variables: preoperative serum creatinine, age and lowest blood flow during cardiopulmonary bypass. A higher blood flow is needed during cardiopulmonary bypass in older patients and in patients with a raised pre-operative serum creatinine to prevent deterioration in renal function postoperatively. A nomogram is given for the lowest blood flow during CPB, corrected for age and the pre-operative serum creatinine level, which will result in a desired postoperative serum creatinine of 110 mumol/l.

Between June 1983 and December 1987, 52 patients underwent resection of a thoracic descending aortic aneurysm. Thirty-day mortality was 11.5%; 4.8% for elective cases and 36.5% for patients operated upon in emergency. Spinal cord injury was present in two patients (4%). One patient was paraplegic, the other showed mild paraparesis, which was completely resolved. Both patients were operated for ruptured aneurysms. Severe postoperative renal dysfunction was present in 4 patients (7.5%) and was strongly related to intraoperative hypotension. The cumulative proportional survival rate was 81% at one year and 66% at two years of the total group, 85% at one year and 72% at two years for the patients presenting with nonruptured aneurysms. Aneurysms of the thoracic descending aorta can be resected with an acceptable mortality and morbidity. Just as in abdominal aneurysms, surgery definitely improves the outcome for these patients, who have a rather poor prognosis if left untreated.

Disabling monomorphic ventricular bigeminy has not been described as an indication for surgery. Three young patients with this arrhythmia sometimes deteriorating into ventricular tachyarrhythmias and in whom drug therapy failed completely were accepted for surgical ablation of the arrhythmogenic area. The earliest endocardial site of origin was located preoperatively by catheter mapping of the spontaneously occurring ventricular bigeminy in the left and right ventricles. For maximum preservation of myocardial muscle and function, the preoperative mapping and surgical procedure were performed through the aortic root; mapping by transaortic multipolar balloon was done during normothermic coronary perfusion and cryocoagulation was done during cardioplegic arrest. Cryocoagulation of the endocardial site was performed using the transaortic approach and epicardial cryocoagulation at the opposite site was done afterwards. In the two patients in whom the preoperative mapping results were consistent with those of preoperative catheter mapping, the arrhythmia could be abolished, as documented during long-term follow-up. In the only patient in whom the mapping results were not in agreement, the ventricular arrhythmia reoccurred and was the cause of death at five months after surgery. Postoperative wall-motion studies performed in the two surviving patients showed limited scars in the area of cryocoagulation and minor damage to the coronary arteries in that area. The transaortic approach can be considered as a new and important surgical option for endocardial mapping and cryocoagulation which prevents the damaging effects of a left ventriculotomy.