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Of 1041 patients with consecutive aortocoronary bypass operations, 53 (5.1%) underwent reoperation during a mean follow-up time of three and a half years. The operative mortality of first operations was 1.2%, and of reoperations 3.8%. The anatomical reason for reoperation was failure of the bypass graft in 41 (77%) patients, which in 18 was accompanied by progression of disease. Progression alone was seen in seven (13%). When symptoms occurred within six months after the first operation, failure of the bypass graft(s) was nearly always found--in 32 out of 36 instances. Progression in non-bypassed arteries was seen only when symptoms occurred later. Late results in angina pectoris were less favourable in the group undergoing reoperation: 31 (65%) of the 48 operated on twice and 406 (46%) of the 877 patients operated on once still had angina at late follow-up. The same fraction in both groups was improved by operation: 88% versus 89%. [ABSTRACT FROM PUBLISHER]

The incidence of angina pectoris (AP) after bypass surgery was assessed in 1041 patients operated on consecutively between 1971 and 1980. Of the 977 survivors, 920 (94%) participated in the study with a followup time varying from 1 to 10 years (mean 3.5 years). Post-operative angina pectoris was present at 1 year in 277 patients (30%), at 3 years in 46%, at 8 years in 50%. The pain limited usual physical activities in 17.5%, 30% and 25%, respectively at these times. Nonetheless, 89% of the respondents felt improved by surgery. Factors without predictive value for late outcome were sex, number of pre-operative diseased vessels, and pre-operative ejection fraction. A correlation was found between post-operative AP and younger age at surgery in the males only (P< 0.001); between AP and patency rate of the bypass graft (P<0.005) and with the status of the coronary arterial tree at three years post-operatively (P<0.001) in both sexes. The percentage of patients with recurrent AP increased with time after surgery up to 3 years, but remained stable thereafter. In conclusion, post-operative AP seems initially related to decreased functioning of the bypass graft, later to progression of coronary sclerosis in the native circulation. [ABSTRACT FROM PUBLISHER]

From 1972 to 1979 intra aortic balloon pumping (IABP) was attempted in 181 patients; catheter insertion failed in 13 (8%). More complications occurred with prolonged treatment but all three lethal complications (2%) were related to catheter insertion. Seventy-six patients had clinical cardiogenic shock after myocardial infarction (CSMI). Haemodynamically, 23 were classified as preshock: 15 (66%) could be weaned, 12 (53%) survived over 3 months; whereas only 27/51 patients (51%) haemodynamically classified as shock could be weaned and 21 (40%) survived over 3 months. Of forty-two patients with refractory angina at rest, 41 had prompt relief of pain after IABP, and subsequently underwent coronary artery bypasss grafting (CABG). Perioperative infarction rate was 8% (4/41), perioperative mortality was 7% (3/41). Total infarction rate was 11% (5/42), and total mortality 7% (3/41). Pain relief was prompt in 14/17 patients (82%) with refractory angina after infarction. Pain persisted in three patients: all three sustained an infarction, one died. Two patients were excluded from surgery. Twelve patients underwent CABG; none died, none developed MI. In eight patients persistence of pain suggested a slowly evolving MI, IABP abolished pain in seven. Conclusion: IABP has demonstrated its efficacy both in pump failure and in refractory ischaemia. However, its use is not without risks. [ABSTRACT FROM PUBLISHER]

Thirty one patients underwent early valve replacement for infective endocarditis during a 10-year period (between September 1973 and December 1983). Intractable heart failure, persistent infection and systemicemboli were the indications for urgent surgical intervention. Native valve endocarditis had been present in 22 patients (71%) and surgery was performed 14–105 (mean 51) days after the onset of symptoms. Nine patients (29%) had prosthetic valve endocarditis and surgery was performed within 6 to 51 (mean 28) days. The aortic valve was replaced in 22 patients (71%), the mitral valve in 5 patients (16%) and both valves in 4 patients (13%). Four patients (12.9%) died during hospitalization. There were no late deaths or reinfection in this series. The remaining 27 patients were discharged and after a mean follow-up period of 36 months, 25 patients were in NYHA functional class I or II. Only 9 patients (29%) underwent cardiac catheterizaiion prior to surgery and the other patients were operated upon on the basis of echocardiographic data alone. The post-operative results with a survival rate of 87%, justify an aggressive surgical approach in order to prevent serious complications and cardiovascular deterioration. It appears that surgical decision-making can be made on the basis of echocardiography. The risk of cardiac catheterization can be avoided with the newer generation of echocardiographic equipment which allows a detailed and complete analysis of cardiacabnormalities and function. [ABSTRACT FROM PUBLISHER]

The usefulness of intraoperative epicardial two-dimensional (2D) echocardiography using a commercially available 5 MHz mechanical sector scanner was evaluated in 200 patients. The scanhead was inserted into a gas sterilized plastic bag and placed on the exposed heart. Unsuspected new diagnoses were made in 7 patients. In 68 patients additional morphologic information was obtained. This information influenced surgical management in 32 patients. Intraoperative echocardiographic analysis of the surgical correction revealed the expected results in 184 patients. In 16 patients the investigation provided important information in the decision of immediate reoperation. We conclude that epicardial two-dimensional echocardiography performed by the surgeon familiar with the interpretation of echocardiographic cross-sections yields important information for surgical management. The technique has become an important adjunct in our cardiac surgery department for immediate decision making and leads to optimal results. [ABSTRACT FROM PUBLISHER]

Of 510 patients admitted to hospital with acute myocardial infarction, 34 had coronary artery bypass grafting before discharge (6-43 days (median 20) after infarction). The patients who were given grafts generally had a smaller infarction with less functional impairment than the 476 patients who were not. The outcome of coronary artery bypass grafting was investigated in a retrospective matched pair study. Patients were matched on the basis of the presence of postinfarction angina, left ventricular ejection fraction, location of the infarction, peak creatine kinase activity, Killip clinical class, and severity of coronary disease with 34 patients who were given medical treatment only. At one year follow up fewer of the operated patients had symptoms than did the matched non-operated patients. Survival at one year in the operated and non-operated groups respectively was 94% vs 91%; angina within one year occurred in 3% vs 68%; congestive heart failure in 3% vs 6%; and 0% vs 32% were referred for later bypass grafting or coronary angioplasty. It is concluded that coronary artery bypass grafting can be performed safely soon after myocardial infarction provided that left ventricular function is not seriously compromised. Such treatment is more effective than medical treatment for relief of angina during the first year after infarction. [ABSTRACT FROM PUBLISHER]

On Friday 22 June 1984 a patient was waiting in Rotterdam to be moved to Brussels for a heart transplant. The Dutch heart surgery centres tried to mutually agree on the place where the first heart transplant should be performed. When this proved impossible, the decision was made by the cardiac surgeons from Rotterdam and Leiden. In this article we will reconstruct the events that took place at that time, partly on the basis of a recent 'witness seminar'.

Background: Because of a high prevalence of coronary artery disease in patients with aortic valve disease, coronary angiography is recommended before aortic valve replacement. However, during the last three decades, a decline in mortality due to coronary heart disease has been observed in the general population in both Western Europe and the United States. It is unknown whether preoperative angiography is still mandatory in all patients., Aim: To assess the prevalence of angiographically defined coronary artery disease in patients with aortic valve replacement and trends during a ten-year period., Methods: We performed a retrospective cross-sectional study of patients undergoing aortic valve replacement between 1988 and 1998 in our institution. Patients with a history of coronary artery disease and patients younger than 25 years were excluded. Coronary atherosclerosis was defined as one or more coronary artery luminal stenosis of 50% or more on preoperative coronary angiography., Results: During the study period 1339 patients had aortic valve replacement in our institution, data on 1322 (98%) were available for analysis. Previous coronary artery disease was documented in 124 patients (10%). After exclusion of 17 patients (no angiography), data on a total of 1181 patients were analysed. Coronary atherosclerosis was present in 472 patients (40%) on preoperative coronary angiography. Several well-known risk factors of ischaemic heart disease were associated with coronary atherosclerosis. The prevalence of angiographically defined coronary atherosclerosis varied between 30% and 50% per year. There was, however, no significant trend during the study period. Multivariate analyses, to adjust for potential differences in risk factors during the observation period, did not change this conclusion., Conclusions: The prevalence of angiographically defined coronary artery disease in patients scheduled for aortic valve replacement is still high. From 1988 to 1998, no significant change was observed in angiographic measures of coronary atherosclerosis in patients with aortic valve replacement. Therefore, it is advised to perform coronary angiography before aortic valve surgery.

Objective: In the majority of patients with chronic atrial fibrillation the arrhythmia will persist after correction of the underlying structural abnormality. The maze procedure is an effective surgical method to eliminate atrial fibrillation and to restore atrial contractility., Methods: In this study we used radiofrequency energy to create lines of conduction block in both atria during cardiac surgery as a modification of the maze III procedure. One hundred twenty-two patients with atrial fibrillation for at least 1 year and structural heart disease underwent open heart operation and a radiofrequency modified maze procedure., Results: In 108 (89%) of 122 patients mitral valve surgery was performed, and in this group 86 patients (80%) underwent 121 concomitant procedures. Fourteen patients (11%) underwent cardiac surgery not involving the mitral valve. The additional crossclamp time required for the left atrial part of the radiofrequency modified maze procedure was 14 +/- 3 minutes. The in-hospital mortality rate was 4.1%. The overall 39-month survival was 90%, and freedom of atrial flutter or atrial fibrillation was 78.5% +/- 5.1%. Eighty-nine survivors with sinus, atrial rhythm, or atrioventricular sequential pacemaker had Doppler echocardiography, and right atrial transport function was documented in 83% and left atrial transport function in 77% of patients., Conclusion: We concluded that the radiofrequency modified maze procedure as an adjunctive procedure is safe, time-sparing, and effective in eliminating atrial fibrillation and restoring atrial transport function.

An adult female was admitted for emergency surgery of a massively bleeding suspected aneurysm of the descending aorta. It proved to be a rupture of an aneurysm of a nonpatent ductus arteriosus or ductal diverticulum, a very rare lesion that is usually diagnosed on post-mortem. Adhesion of a previous ipsilateral lobectomy contributed to her survival. The aneurysm was resected.

The surgical correction of aneurysms in the descending thoracic aorta necessitates clamping the aorta both proximal and distal to the aneurysm. The affected length can vary from a few centimetres to large portions of the upper and lower descending aorta. Clamping times can vary from a few minutes to more than one hour. No matter which technique is applied, these operations are often accompanied by excessive blood loss and the need for rapid transfusion, resulting in substantial haemodynamic fluctuations. Hypothermia may become a problem in these patients because most blood warmers are unable to warm blood adequately ( greater than 35 degrees C) at high flow rates (>100 cc/min). This may result in clotting problems. For this reason, our clinic decided from November 1990 to integrate a reservoir with its own heat exchanger (Cobe) into our left-left bypass system. This system largely regulates transfusion during partial extracorporeal circulation (PECC). The advantages of such a system are that (1) the transfusion rate can be adapted to blood loss and is not dependent on the quality and quantity of the infusion systems; (2) blood products and other infusion liquids are filtered; and (3) the transfusion blood is warmed. In this article, we describe our experience with this application of PECC on three patients who suffered excessive blood loss during operations for large thoracic aneurysms.

Six cases of acute myocardial infarction with blood in the pericardial sac are described. In one case rapid death followed myocardial rupture leaving no time for the possibility of intervention. Of two other cases acute symptoms developing after myocardial rupture, one was operated on promptly and the other, whose condition improved on pericardiocentesis, after a delay of a few hours. Both are now long term survivors A fourth patient probably had two episodes of rupture which apparently sealed off. He underwent cardiac catheterization, but no epicardial leak was found. Subsequently at operation a sealed myocardial rupture was detected and sutured over. The fifth patient suffered a silent myocardial rupture. A false aneurysm was diagnosed four months later and he withstood successful surgery. In the sixth patient, the course was similar to that of case 1, namely rapid death with a clinical picture suggestive of tamponade. Postmortem examination showed a covert rupture with some evidence of attempts to plug the opening. The purpose of this report is to emphasize the varying course which myocardial rupture can take.

Twenty-five patients with class III or class IV left ventricular failure (Myocardial Infarction Research Unit criteria) after a recent myocardial infarction were treated with intraaortic balloon pumping between December 1, 1972 and December 1, 1976. Three patients had no improvement and died during pumping. Two patients with improvement died during at attempt at weaning from circulatory assistance. Of 20 patients successfully weaned, 6 died within 3 months, 5 of these within 10 days after the weaning procedure. Of 14 patients who survived for more than 3 months, 13 were alive on February 15, 1977. Twelve of these 13 were in functional class II and 6 had resumed professional activities. Intraaortic balloon pumping proved an effective method for treating severe left ventricular failure after an acute myocardial infarction. Even withour surgery, 14 of 25 patients survived 3 or more months after an acute infarction complicated by serious pump failure.

Six patients with complicated native and prosthetic aortic valve endocarditis were operated on. The data from cineangiocardiography and from precordial and intraoperative two-dimensional echocardiography were compared with the surgical findings. Surgical inspection revealed a mycotic aneurysm in six patients. In addition, a fistulous connection to the right atrium, an abscess in the interventricular septum, and mitral valve endocarditis were found in one of the patients. The pathologic conditions disclosed during the operation were correctly visualized with two-dimensional epicardial echocardiography, done before cardiopulmonary bypass. Cineangiography provided this information in one patient, and precordial two-dimensional echocardiographic analysis was correct in two patients. Thus, intraoperative two-dimensional echocardiography provides detailed information in complicated native and prosthetic aortic valve endocarditis that is of importance in the surgical management.

Cardiogenic shock and severe left ventricular failure after acute myocardial infarction, refractory angina pectoris at rest either of new onset or superimposed on stable angina pectoris, or occurring in the post infarct (less than 2 weeks) period, and the suspicion of a slowly evolving infarction are the main indications for intra-aortic balloon pumping at the Thoraxcenter. 76 patients were treated with intra-aortic balloon pumping for cardiogenic shock after acute myocardial infarction and left ventricular failure, 42/76 (55%) could be weaned, 9 (12%) died within 3 months, 33 (43%) survived over 3 months, to date 29 are alive. 42 patients with refractory angina at rest were treated with intra-aortic balloon pumping. Pain relief was prompt in 41 (98%), who subsequently underwent coronary artery bypass grafting. Total myocardial infarction rate was 11% (5/42), total mortality rate was 7%. Perioperative myocardial infarction rate was 8% (4/42) and perioperative mortality was 7% (3/42). Pain relief was prompt in 14/17 patients (82%) with post infarct refractory angina. In 3 patients pain persisted despite intra-aortic balloon pumping, all sustained a myocardial infarction, 1 died, 2 other patients were excluded for surgery. 12 patients underwent coronary artery bypass grafting, none died, none developed acute myocardial infarction, 3 have mild stable angina. In 8 patients a slowly evolving myocardial infarction was suspected. Pain relief was prompt in 7/8 (88%) after institution of intra-aortic balloon pumping. Intra-aortic balloon pumping improves prognosis in cardiogenic shock after myocardial infarction, and abolishes refractory ischemic pain.

The first 1041 patients who underwent an isolated aorto-coronary bypass operation in the same institution since it opened in 1971, were followed for up to 10 years to determine their prognosis. The mean follow-up time was 3.5 years. The probability of survival at five years was 94 +/- 2% (95% confidence limits). This was similar to the survival of the general Dutch population matched for age and sex. Multivariate survival analysis with the proportional hazards model did reveal a relationship of the rate of death with sex and age at operation; however this was not significant. There was a trend to a higher death rate with more vascular involvement (rate ratio of 3 vessel-versus 1 vessel disease of 1.9, N.S.) and a significant association with a low ejection fraction (EF) (ratio EF less than or equal to 0.30 v. EF greater than or equal to 0.55 of 2.7. P less than 0.05). Though surgery seems to eradicate the poor longterm outlook for patients with more serious vascular disease, the adverse influence of decreased left ventricular function on survival is not changed.

A 37-year-old woman who presented with systemic lupus erythematosus was found to have a membranous obstruction of the inferior vena cava above the hepatic veins, with an extensive collateral circulation. The obstruction was relieved by a renal vein-right atrial interposition graft, and this was followed by disappearance of the anti-nuclear and anti-DNA antibodies. We postulate that the systemic lupus erythematosus might have been provoked by life-long immune stimulation due to bowel-derived antigens bypassing the hepatic reticuloendothelial system and reaching the systemic circulation, or by immune hyperreactivity associated with the abnormal abdominal venous circulation.

The ability of preoperative M-mode echocardiography to predict the clinical course and the decrease in left ventricular size was assessed in 42 patients after uncomplicated valve replacement for isolated aortic insufficiency. During follow-up study, one patient died of chronic heart failure. The New York Heart Association functional class of the 41 survivors improved from 2.4 to 1.2. All patients had a preoperative M-mode echocardiogram. Serial echocardiographic measurements, available in 33 patients, showed a sustained decrease in left ventricular end-diastolic dimension after the first postoperative year from 73 +/- 8 to 57 +/- 9 mm at 6 to 12 months and to 53 +/- 9 mm at 3 years postoperatively (p less than 0.01). Left ventricular cross-sectional area decreased from 31 +/- 8 to 26 +/- 7 cm2 and then to 23 +/- 5 cm2 at the latest follow-up study (p less than 0.01). At 3 years postoperatively, M-mode echocardiograms were available in 37 patients: 24 had a normal left ventricular dimension (group 1), while 13 still had an enlarged left ventricle (group 2). The clinical course in these two groups was similar. The best preoperative predictor of persistent left ventricular enlargement was the end-diastolic dimension (p less than 0.05), whereas fractional shortening and the end-diastolic radius/thickness ratio were not predictive.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence of angina pectoris (AP) after bypass surgery was assessed in 1041 patients operated on consecutively between 1971 and 1980. Of the 977 survivors, 920 (94%) participated in the study with a followup time varying from 1 to 10 years (mean 3.5 years). Post-operative angina pectoris was present at 1 year in 277 patients (30%), at 3 years in 46%, at 8 years in 50%. The pain limited usual physical activities in 17.5%, 30% and 25%, respectively at these times. Nonetheless, 89% of the respondents felt improved by surgery. Factors without predictive value for late outcome were sex, number of pre-operative diseased vessels, and pre-operative ejection fraction. A correlation was found between post-operative AP and younger age at surgery in the males only (P less than 0.001); between AP and patency rate of the bypass graft (P less than 0.005) and with the status of the coronary arterial tree at three years post-operatively (P less than 0.001) in both sexes. The percentage of patients with recurrent AP increased with time after surgery up to 3 years, but remained stable thereafter. In conclusion, post-operative AP seems initially related to decreased functioning of the bypass graft, later to progression of coronary sclerosis in the native circulation.