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Objectives: While open surgical repair remains the gold standard for thoracoabdominal aortic aneurysm (TAAA) treatment, there is still no consensus regarding perioperative neuromonitoring technique for prevention of spinal cord ischaemia., Methods: In this systematic review, we aimed to explore the effects and practices of neuromonitoring during the open TAAA repair. A systematic literature search in PubMed, Embase via Ovid, Cochrane library and ClinicalTrialsGov until December 2022 was performed., Results: A total of 535 studies were identified from the literature search, of which 27 studies including a total of 3130 patients met the eligibility criteria. Most studies (21 out of 27, 78%) investigated the feasibility of motor-evoked potentials (MEP), while 15 analysed somatosensory-evoked potentials (SSEP) and 2 studies analysed near-infrared spectroscopy during open TAAA repair., Conclusions: Current literature suggest that rates of postoperative spinal cord ischaemia can be kept at low levels after open TAAA repair with the adequate precautions and perioperative manoeuvres. Neuromonitoring with MEP provides the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and SSEP is a reliable method that can rapidly detect important findings and direct adequate protective manoeuvres during open TAAA repair., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Studies concerning factors associated with long-term outcomes in adult congenital heart disease (ACHD) patients after infective endocarditis (IE) are scarce, while IE-related mortality in these patients remains a burden. We evaluated the factors associated with long-term survival in ACHD patients admitted for IE., Methods: We performed a retrospective single-centre study of all ACHD patients admitted for IE to a tertiary cardiothoracic centre between 1999 and 2015. Underlying ACHD, detailed echocardiographic and clinical data, surgical treatment and long-term follow-up were analysed., Results: We identified 151 ACHD patients admitted due to 176 episodes IE with 30-day, 6-month and 1-, 5- and 10-year survival of 95.4%, 92.7%, 92.7%, 84.7% and 75.6%, respectively. In a multivariable analysis, adjusted estimated probability of death was consistently higher after an IE episode among patients with complex as compared to simple/moderate ACHD: 10.6% vs 2.4% at 30 days, 15.0% vs 3.4% at 6 months and 1 year, 30.4% vs 7.8% at 5 years and 44.9% vs 13.1% at 10 years. Risk of death was higher among patients with prosthetic valve in comparison with those without (risk ratios 1.73-1.92). Surgical treatment was required in 76 (43.2%) episodes with 30-day mortality of 3.9%. Risk of death appeared to be lower than in the conservatively treated subgroup (risk ratios 0.71-0.78)., Conclusions: We demonstrated satisfactory long-term survival in ACHD patients who were treated for IE in a tertiary cardiothoracic centre. Early mortality tended to be lower in the surgically treated subgroup. Factors negatively associated with long-term survival were complex ACHD and presence of prosthetic valve., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-Maze procedure, which is currently the gold standard treatment for atrial fibrillation (AF), data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited., Objective: We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies comparing the mid-term mortality and recurrence of AF after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up., Methods: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. Additionally, a meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques., Results: Three RCTs and three observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that the concomitant Cox-Maze procedure was associated with higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimates pooled across the three RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (risk ratio = 1.58, 95% CI: 0.91-2.73). In two out of three higher-quality observational studies, 12-month AF recurrence was higher in PVI than in the Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated the survival benefit of Cox-Maze., Conclusions: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required to clarify the benefits of concomitant Cox-Maze in AF patients during MV surgery., (© 2022 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

On 3 December 1967, Christiaan Barnard performed the first heart transplantation in the world at Groote Schuur Hospital in Cape Town, South Africa. In the succeeding months, heart transplantations in the USA, Asia and Europe followed. On 14 April 1969, Åke Senning successfully accomplished the first heart transplantation in Switzerland at the former Cantonal Hospital in Zurich. In the summer of 1969, he undertook a second heart transplantation. Although the surgical procedure went well technically, both patients died within weeks to months after transplantation. Causes of death were infection in the first and rejection in the second patient. Senning’s colleagues around the world had similar experiences. Survival after heart transplantation was unacceptably low. The heart transplant community recognised the lack of knowledge about immunological processes and appropriate immunosuppressive regimens as underlying reason for the early deaths. Most transplant centres decided to refrain from heart transplantation until sufficient immunological insight became available. After the introduction of the new immunosuppressive drug ciclosporin into the clinic and the availability of tools to monitor rejection in the early 1980s, heart transplant programmes were restarted all over the world. The legal recognition of brain death allowed procurement of donor hearts without exposure to warm ischaemia, and the principle of cold storage enabled prolongation of ischaemia time and acceptance of donors in distant hospitals, resulting in enlargement of the donor pool. In Switzerland, Marko Turina resumed heart transplantation in 1985 at Senning’s former workplace in Zurich. The number of heart transplants in Switzerland and in the world grew rapidly because the outcome markedly improved. Particularly over the long-term, survival in Zurich surpassed the outcome worldwide. Zurich created internationally recognised milestones such as transplantation of patients with grown-up congenital heart disease, the implementation of the bicaval instead of the right atrial anastomosis during the transplant procedure and the dual transplantation of one heart. Since the middle of the 1990s, however, the number of heart transplants has plateaued, mainly because of donor shortage. The current era is characterised by efforts to increase the number of donors. The utilisation of marginal donors, the change from informed to presumed consent for organ donation and donation after cardiocirculatory-determined death have been proposed to augment the donor pool.

Objectives: Updated knowledge about perioperative myocardial ischaemia (MI) after coronary artery bypass grafting (CABG) and treatment of acute graft failure is needed. We analysed main factors associated with perioperative MI and effects of immediate coronary angiography-based treatment strategy on patient outcome., Methods: Among 1119 consecutive patients with coronary artery disease who underwent isolated CABG between January 2011 and December 2015, 43 (3.8%) patients underwent urgent coronary angiography due to suspected perioperative MI. All the data were prospectively collected and retrospectively analysed. The primary endpoint was 30-day mortality; postoperative left ventricular ejection fraction) and major adverse cardiac events were secondary endpoints. Results Overall, 30-day mortality in patients with CABG was 1.4% while in patients who developed perioperative MI was 9% (4 patients). Angiographic findings included incorrect graft anastomosis, graft spasm, dissection, acute coronary artery thrombotic occlusion and ischaemia due to incomplete revascularisation. Emergency reoperation (Redo) was performed in 14 (32%), acute percutaneous coronary intervention (PCI) in 15 (36%) and conservative treatment (Non-op) in 14 patients. Demographic and preoperative clinical characteristics between the groups were comparable. Postoperative LVEF was significantly reduced in the Redo group (45% post-op vs 53% pre-op) and did not change in groups PCI (56% post-op vs 57% pre-op) and Non-op (58% post-op vs 57% pre-op)., Conclusions: Urgent angiography allows identification of the various underlying causes of perioperative MI and urgent treatment when this is needed. Urgent PCI may be associated with improved clinical outcome in patients with early graft failure., Competing Interests: Competing interests: None declared.

We describe the resection for lipomatous hypertrophy of the interatrial septum which necessitated complete reconstruction of the right atrium with Dacron grafts connecting the superior and inferior vena cava with the tricuspid orifice, and connection of the pulmonary veins to the mitral orifice with xenopericardium., (© 2016 Wiley Periodicals, Inc.)

Introduction: Acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles' tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations., Methods: Twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation., Results: Median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n = 3), or retroperitoneal access (n = 2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascular re-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair., Discussion: Our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome., (Copyright © 2011. Published by Elsevier Ltd.)

Endovascular treatment of the thoracic aorta (TEVAR) is rapidly expanding, with new devices and techniques, combined with classical surgical approaches in hybrid procedures. The present guidelines provide a standard format for reporting results of treatment in the thoracic aorta, and to facilitate analysis of clinical results in various therapeutic approaches. These guidelines specify the essential information and definitions, which should be provided in each article about TEVAR: It is hoped that strict adherence to these criteria will make the future publications about TEVAR more comparable, and will enable the readership to draw their own, scientifically validated conclusions about the reports.

Background: In this retrospective study we evaluate the causative mechanisms underlying postoperative atrioventricular block (AVB) following mitral valve replacement and mitral valve annuloplasty., Methods: Between January 1990 and December 2003, 391 patients underwent mitral valve replacement or ring annuloplasty and quadrangular resection. Exclusion criteria were preoperative AV block, two or three valvular procedures, reoperations and procedures combined with coronary artery bypass grafting. The presence of the postoperative AVB was compared with preoperative and intraoperative variables. On 55 post-mortem specimens the relationship between the AV node, AV node artery and mitral valve annulus was investigated., Results: The mean age was 59+/-14 years and 44% of patients were female. Postoperatively AVB occurred in 92 (23.5%) patients. AVB III was found in 17 (4%) patents, in whom a pacemaker was implanted within median interval of 4 days. Second degree AVB occurred and first degree AVB in five (1.3%) and in 70 (18%) patients respectively. In dry dissected human hearts in 23% of investigated cases the AV node artery was discovered to run close to the annulus of the mitral valve., Conclusions: Data collected in this study showed that, sotalol and amiodarone as well as a prolonged cross-clamp time may slightly influence the 23% incidence of postoperative AVB. The morphological investigation showed that the AV node artery runs in close proximity to the annulus in 23% of cases. We speculate that damage of the AV node artery may play a role in development of AVB.

Introduction: Surgical repair of the mitral valve is in most cases limited to the posterior leaflet of the mitral valve and to the annulus fibrosus. The term annulus fibrosus is still used in anatomical and clinical terminology and is described as a cord like structure providing the attachment of the mitral vale. However, to date no evidence exists of a ring-or cord-like structure at this area. Herein, we describe the attachment of the mitral valve by using the macroscopical and microscopical techniques., Material and Methods: The ventricular attachment of the posterior mitral valve leaflet was investigated in 10 human hearts. In dry dissected specimens, the intraventricular illumination was used to identify the attachment of the mitral valve to the left ventricular muscle. Using the histological techniques, we verified the position of the annulus fibrosus., Results: The attachment of the posterior mitral valve leaflet is a band-like structure positioned between the left ventricular muscle and the left atrium. This fibrous band illustrates the morphological attachment of the mitral valve and, as thus, was interpreted as the annulus fibrosus of the mitral valve., Conclusion: Based on our data, no ring-like structure was found corresponding to the anatomical description of the annulus fibrosus, instead the band-like fibrous tissue was identified positioned between the mitral valve and the left ventricle. Histologicaly, we detected that this structure is part of the greater structural system that is directly connected to the membranous septum, to the left and right fibrous trigone and the attachment aortic root to the left ventricular muscle.

Objective: To discuss geometric factors, which may influence long-term results relating to homograft competence following the Ross procedure, we describe the 3D morphology of the pulmonary and aortic roots., Materials: Measurements were made on 25 human aortic and pulmonary roots. Inter-commissural distances and the heights of the sinuses were measured. For geometrical reconstruction the three commissures and their vertical projections at the root base were used as reference points., Results: In the pulmonary root, the three inter-commissural distances were of similar dimensions (17.9+/-1.6mm, 17.5+/-1.4mm and 18.6+/-1.5mm). In the aortic root, the right inter-commissural distance was greatest (18.8+/-1.9mm), followed by the non-coronary (17.4+/-2.0mm) and left coronary sinus commissures (15.2+/-1.9mm). The mean height of the left pulmonary sinus was greatest (20+/-1.7mm) followed by the anterior (17.5+/-1.4mm) and right pulmonary sinus (18+/-1.66mm). In the aortic root, the height of the right coronary sinus was the greatest (19.4+/-1.9mm) followed by the heights of the non-coronary (17.7+/-1.8mm) and left coronary sinus (17.4+/-1.4mm). Measured differences between parameters determine the tilt angle and direction of the root vector. The tilt angle in the pulmonary root averaged 16.26 degrees , respectively; for the aortic roots, it was 5.47 degrees ., Conclusions: Herein we suggest that the left pulmonary sinus is best implanted in the position of the right coronary sinus, the anterior pulmonary in the position of the non-coronary sinus and the right pulmonary sinus in the position of the left coronary sinus. In this way, the direction of the pulmonary root vector will be parallel to that of the aortic root vector.

Background: The internal thoracic artery (ITA) is the conduit of choice in coronary bypass grafting, due to the excellent long-term results achieved using it. However, increased incidence of sternal infections after pedicled ITA harvesting has revived interest in the morphology of sternal blood supply. Our aim was to discuss the topography of the sternal branches with emphasis on internal thoracic artery harvesting., Methods: This study was conducted on 50 fresh specimens of the anterior thorax wall. Radio-opaque material was injected and angiograms of the ITA were performed. Subsequently, the specimens were preserved and a dry dissection of each ITA and its branches was carried out., Results: In dry dissected specimens, four types of vessels were identified that have the potential to carry blood to the sternum after harvesting the ITA. In the first group, the artery to the sternum also supplies the intercostal space. In the second morphologic variant, the sternal branch gives off the perforating and anterior intercostal arteries. In the third group, we classified the common branch of the sternal and perforating arteries. In the fourth group, the sternal artery originated from the ITA as an independent branch., Conclusions: For sternal-intercostal, perforating-intercostal, and sternal-perforating branches to function as collaterals after ITA harvesting, the common trunk of origin must remain intact. Based on morphologic data, we recommend ligating the common trunk as close as possible to the ITA; in this way, collateral blood flow to the sternum remains intact.

Background and Aim of the Study: The study aim was to describe the topographical relationship of the atrioventricular (AV) node artery and mitral valve annulus fibrosus with regard to AV node dysfunction following mitral valve replacement or ring annuloplasty., Methods: The anatomy of the AV node artery was analyzed in 55 human hearts without previous pathological alterations. Selective coronary angiograms were performed to identify the AV node origin. Run-off of the AV node artery and its topographical relationship to the mitral valve attachment was analyzed in dry-dissected hearts. The position of the AV node was verified by histological sectioning., Results: The AV node artery originated from the right coronary artery in 73% of examined cases, and from the left coronary artery in 27% of cases. The left AV node artery was closely related to the mitral valve attachment, especially at the area of the left proximal part of the posterior leaflet., Conclusion: These morphological data were compared to clinical reports emphasizing the postoperative incidence of AV block after mitral valve implantation and ring annuloplasty. The occurrence of early postoperative AV node block ranged from 20% to 37%. By comparing the present data with available literature, it can be stated that there is a high risk of intraoperative damage to the left AV node artery during manipulation of the mitral valve annulus fibrosus.

Although coronary artery bypass surgery has provided major advances in the treatment of coronary artery disease, narrowing of bypass vessels still constitutes a drawback of this therapy. Although this event is most frequently caused by intraluminal processes, obstruction from external structures is extremely rare. We report such a case in which external bypass compression was provoked by deep inspiration causing typical anginal symptoms. Percutaneous coronary intervention including stent placement provided bypass patency independent from the patient's respiratory phase. Disappearance of symptoms and absence of myocardial ischemia in perfusion scans confirmed successful treatment.

Ascending aortic dissection is a known complication of cardiac surgery. Off-pump coronary artery bypass surgery seems to be associated with a higher risk for this event as compared with on-pump bypass surgery. This increased risk may result from aortic side-clamping under pulsatile flow as opposed to continuous flow in conventional bypass surgery. Mechanical devices allowing performance of proximal bypass anastomoses without aortic side-clamping are supposed to reduce the risk for aortic dissection. We report a case in which ascending aortic dissection occurred 8 days after off-pump bypass surgery, most likely arising from a mechanically performed proximal bypass anastomosis.

The Senning operation has evolved from being the initial surgical correction that allowed survival in complete transposition of the great arteries to an integral part of the anatomic repair of congenitally corrected transposition. In patients with complete transposition, the Senning operation has given satisfactory initial and long-term surgical results, but the potential for right ventricular failure and atrial arrhythmias have drastically reduced its indications in the current era. The long-term follow-up and pertinent postoperative issues of the Senning operation will be reviewed, along with its newfound role in the anatomic repair of congenitally corrected transposition.

Objective: Pulmonary hypertension (PH) and elevated pulmonary vascular resistance (PVR) lead to poor outcome after heart transplantation due to postoperative failure of the non-conditioned right ventricle. The role of continuous flow left ventricular assist device (LVAD) support in the reduction of elevated PVR was evaluated in a series of clinical implants., Methods: Among 17 patients with terminal heart failure receiving a MicroMed DeBakey LVAD as bridge to transplant, there were six patients with pulmonary hypertension (mean systolic PAP 47 mmHg) and high PVR (398 dynes/cm5), previously not considered suitable for heart transplantation, who underwent serial right heart catheters during their LVAD support period., Results: In these patients mean systolic pulmonary pressure dropped to 29 mmHg and PVR decreased to a mean 167 dynes/cm5 under LVAD support. Clinical improvement was significant in all patients. Four patients were successfully transplanted without major postoperative difficulties (mean duration 130 days support) and all are doing well to date. Post-transplant-PVR remained in the normal range in all transplanted patients., Conclusions: Elevated PVR and severe PH were both previously considered as contraindication for heart transplantation. A period of LVAD pumping leads to a progressive decrease of PVR and normalization of pulmonary pressures, making these patients amenable for heart transplantation. LVAD as bridge to heart transplantation is safe and highly beneficial for terminal heart failure patients with severe PH.

Background: Mitral valve homograft implantation and reconstruction of the left ventricular subvalvular apparatus requires a good knowledge of the morphology of the left papillary muscles. A comprehensive description of the left ventricular subvalvular apparatus is presented to aid in this procedure and to support conventional and endoscope-assisted reconstruction of the chordae tendineae., Material/methods: The subvalvular apparatuses of 100 unfixed human hearts were investigated. Papillary muscles were endoscopically examined on the hearts in situ, then the hearts were explanted and the subvalvular apparatus was macroscopically inspected. The geometrical arrangement of the chordae tendineae was determined., Results: We defined three groups of the left ventricular papillary muscle. In group I the basal part and the apex of the muscle were undivided. In group II there were two heads; in subgroup II/A the base of the papillary muscle was undivided and in II/B it was divided into two separate parts. In group III the papillary muscle had three heads. In subgroup III/A the base was undivided, while in III/B it was made up of two and in III/C three separate parts., Conclusions: We propose a classification of the left ventricular subvalvular apparatus based on the macroscopic and endoscopic investigations. It emphasizes the morphology of the apical and basal parts of papillary muscles and includes the geometrical arrangement of the chordae tendineae. Thus it may be of a great value in endoscopic and conventional mitral valve replacement or reconstruction of the chordae tendineae and in mitral valve homograft implantation.

In highly developed nations, valve surgery will be increasing applied in older people, with more co-morbidities and a higher incidence of concomitant coronary artery disease. Valve surgeons will be facing increased competition from the catheter-based procedures, both for valve repair and replacement; these are already applied clinically, and their numbers will rise in near future. Early mortality in double valve procedures and in combined CABG and valve operations remains substantial, and there is ample room for improvement of surgical results. New valve prostheses are slow in development, due to financial restraints and exceeding cost of certification. Tissue-engineered valves are being developed, but are not ready for larger clinical trials. Cardiac surgery is undergoing a rapid transformation; radical changes both in scope and workload of cardiosurgical units in Europe can be expected in near future. Socio-economic factors and recent advances in medical technology contribute to these changes.

Objective: Arterial perfusion through the right subclavian artery is proposed to avoid intraoperative malperfusion during repair of acute type A dissection. This study evaluated the clinical and neurological outcome of patients undergoing surgery of acute aortic type A dissection following subclavian arterial cannulation compared to femoral artery approach., Methods: From 1/97 to 1/03, 122 consecutive patients underwent surgery for acute type A aortic dissection. Subclavian cannulation was performed in 62 versus femoral cannulation in 60 patients. Clinical characteristics in both groups were similar. Mean age was 61 years (SD+/-14 years, 72% male) and mean follow-up was 3 years (+/-2 years). Patient outcome was assessed as the prevalence of clinical complications, especially neurological deficits, mortality at 30 days, perioperative morbidity and time of body temperature cooling and analyzed by nominal logistic regression analysis for odds ratio calculation., Results: Arterial subclavian cannulation was successfully performed without any occurrence of malperfusion in all cases. Patients undergoing subclavian cannulation showed an odds ratio of 1.98 (95% CI 1.15-3.51; P=0.0057) for an improved neurological outcome compared to patients undergoing femoral cannulation. Re-exploration rate for postoperative bleeding was significantly reduced in the subclavian group (P<0.0001), as well as occurrence of myocardial infarction (P<0.0001) and duration for body temperature cooling (P=0.004). The 30-day mortality of patients with femoral cannulation was significantly higher compared to patients with subclavian artery cannulation (24 versus 8%; P=0.0179)., Conclusions: Arterial perfusion through the right subclavian artery provides an excellent approach for repair of acute type A dissection with optimized arterial perfusion body perfusion and allows for antegrade cerebral perfusion during circulatory arrest. The technique is safe and results in a significantly improved clinical and especially neurological outcome.

We describe the case of a patient implanted with a DeBakey left ventricular assist device (LVAD) as bridge to transplant who survived 7 h of ventricular fibrillation. He was successfully converted into a stable sinus rhythm.

Objective: Anatomical reconstruction of the aortic arch following aortic arch surgery is challenging. The placement of an extra-anatomical aortic bypass has been proposed for these difficult cases. This approach is not ideal in children due to possible long-term complications. This study presents the results of our policy to reconstruct the aortic arch in recurrent obstruction in children, which are not amenable to balloon dilatation., Methods: Seven children with a median age of 8 years (range 1 month-15 years) were operated for aortic arch obstruction following correction of an aortic coarctation. Six children presented another intra-cardial lesion (2 subaortic membranes; 2 VSDs, 1 ostium stenosis of the left main coronary artery, and 1 mitral valve insufficiency). The surgical approach involved a sternotomy, cardiopulmonary support using two arterial inflow cannulas (one above and one below the aortic arch), and moderate hypothermia. Enlargement of the aortic arch was performed by a sliding plasty in four patients and by a patch plasty in three patients. Associated cardiac defects were corrected as well., Results: It was technically possible to perform the planned operation in all patients. All patients survived and none presented significant postoperative complications. There were no residual gradients in six patients and a gradient of 10 mmHg in one patient postoperatively. One patient showed transient recurrent nerve palsy which recovered within 6 weeks. Follow-up echocardiographic and MRI studies revealed a normal appearing aortic arch with laminar flow., Conclusions: Although more demanding, an anatomical reconstruction of the aortic arch can be performed in infants and children with recurrent obstruction of the aortic arch with excellent initial results. This approach may prove superior to an extra-anatomic bypass in the long-term.

Objective: The objective of this study was to assess the safety of directly closing the septum primum during the correction of atrioventricular canal defects., Methods: We performed a retrospective analysis of our experience with direct closure of the septum primum during the repair of atrioventricular canal defect. The series consisted of 28 consecutive patients presenting with a partial (15 patients) and complete (13 patients) atrioventricular canal defect. The cleft in the atrioventricular valve was closed completely in 25 patients and partially in 3 patients (those with a small left lateral leaflet). In complete atrioventricular canal, the ventricular septum defect was closed with a patch of polytetrafluoroethylene (Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) or xenopericardium. Follow-up was complete and ranged from 3 to 21 months (median 11 months)., Results: There were no early or late deaths and no surgical complications. The septum primum defect was closed completely in all patients as assessed by echocardiography. All the patients were in sinus rhythmus, and none had even a temporary complete atrioventricular block. The surgical result and heart rhythm have remained stable over time., Conclusions: Direct closure of the septum primum is an easy, quick, and safe procedure during repair of atrioventricular defects.

Harmonious reduction of the posterior annulus of the mitral valve can be a useful adjunct to obtain complete valve competence in case of annular dilatation. We present a technique with the use of two resorbable sutures that overlap over the middle third of the posterior annulus that was used in 10 children with good short-term results. Resorption of the sutures should permit subsequent normal growth of the mitral valve. If the primary cause of valvular regurgitation was corrected, it can be expected that the repair will remain stable after resorption of the sutures.

Background: Reducing the negative side effects associated with extracorporeal circulation is the major advantage of off-pump revascularization. However, side clamping of a calcified aorta for proximal anastomoses can cause emboli, resulting in neurologic damage. This problem has been addressed by introducing a mechanical anastomosis device (Symmetry, St Jude Medical) that allows vein-to-aorta anastomosis without manipulating the aorta. This report describes our experience with this device., Methods: Between June 2001 and April 2002, 77 connectors (1.3 per patient) were deployed in 61 patients (51 men and 10 women; mean age, 68 +/- 8.6 years) undergoing off-pump coronary artery bypass grafting or beating-heart revascularization. Intraoperative quality assessment included transit-time flow measurement (Medistim) and indocyanine green-based angiography (Spy, Novadaq)., Results: The surgeons were meticulously trained in loading of the device. No postoperative neurologic deficits were detected. Fifty-three patients had an uneventful course. However, 8 (13.1%) patients with 12 implanted connectors were symptomatic within 8 months (1 day to 8 months). Angiography revealed significant (95%) stenosis or even occlusion of the proximal vein-to-aorta anastomosis at the level of all connectors. Four patients underwent reoperation (2 dilated-stented and 2 treated with drugs)., Conclusion: On the basis of these observations, the routine use of the connector was halted at our institution. At the moment, the use of this therapy is reserved for patients with severely calcified aortas with no technical alternative. Further investigations appear necessary to evaluate the clinical patterns of this otherwise promising technology.

Heart valve replacement represents the most common surgical therapy for end-stage valvular heart diseases. One major drawback that all heart valve replacements have in common is the lack of growth, repair, and remodeling capability once implanted into the body. The emerging field of tissue engineering is focusing on the in-vitro generation of functional, living semilunar heart valve replacements. This review presents a state-of-the-art overview of the physiological and biomechanical requirements of semilunar heart valves, focusing on the aortic valve. Moreover, recent heart valve tissue engineering is summarized and future options and improvements on the way towards clinical applications are discussed.

Background: Surgical closure of isolated ventricular septal defect (VSD) through partial inferior sternotomy offers the advantages of a much shorter, cosmetically superior skin incision, potentially improved sternal stability, a lower rate of infection, and less postoperative pain. We report our technique and results of use of inferior partial sternotomy for closure of isolated VSD in children., Patients and Methods: From July 2002 to July 2003, 24 consecutive patients with a median age of 4.5 months (range, 1 month-4.5 years) underwent partial inferior sternotomy for isolated VSD closure. The length of the incision ranged from 4 to 6 cm. Special features of the approach included T incision of the lower sternum (from the fourth intercostal space to the xiphoid), establishment of cardiopulmonary bypass with central cannulation, aortic cross-clamping, and cardioplegic arrest. All VSDs were approached through right atriotomy. Perimembranous VSDs were exposed after detachment of the anterior leaflet of the tricuspid valve and were closed with a continuous suture. Muscular VSDs were approached directly. Perioperative and postoperative echocardiographic findings were available for all patients. Follow-up was complete., Results: There was no mortality or significant surgical morbidity. Median cross-clamping and cardiopulmonary bypass times were 43 and 103 minutes, respectively. All patients were in sinus rhythm. Perioperative and postoperative echocardiography confirmed the absence of any residual defects in perimembranous VSDs and the presence of a trace residual VSD in 4 patients with muscular VSDs. Optimal healing of the partial sternotomy was obtained in all patients., Conclusions: Inferior partial sternotomy is less invasive than and cosmetically superior to full sternotomy. It provides excellent results when applied to isolated VSD with standard surgical techniques.

Purpose: Blood pumps are routinely used for circulatory and pulmonary support. However, blood trauma and pump failure remain severe drawbacks of currently available pump models. This study evaluated the first clinical application of a new, totally bearingless centrifugal blood pump (CentriMag)., Material and Methods: A centrifugal pump consisting of an electromagnetic suspended impeller was used as a blood pump during beating-heart coronary artery bypass grafting in 11 patients (mean weight, 77.4 kg). Heparin in a bolus of 150 IU/kg body weight was administered, and activated clotting time was maintained at approximately 180 to 250 seconds during extracorporeal circulation. Pump-induced blood trauma was evaluated by measurement of plasma free hemoglobin (PFH), lactate dehydrogenase (LDH), hematocrit, total bilirubin, and platelet levels., Results: Mean pump flow was 3.3 +/- 0.62 L/min, and mean pressure gradient through the oxygenator was 69 +/- 4 mm Hg. No pump dysfunction occurred during a mean application time of 105 +/- 26 minutes. Inspection of the pump housings showed no internal thrombus formation despite low-dose heparinization. Only slight hemolysis was observed with a mean PFH level of 1.96 micromol/L; LDH, 460 U/L; hematocrit, 33%; total bilirubin, 25 micromol/L; and platelets, 191 x 10(3)/microL., Conclusions: The bearingless CentriMag blood pump is a safe and reliable new device that produces only minimal hemolysis. It seems to be suited for long-term evaluation as a blood pump for extracorporeal membrane oxygenation or as ventricular assist device.

Intractable ventricular tachycardia was investigated in a 51-year-old man with isolated left ventricular non-compaction during implantation of an automated internal cardioverter-defibrillator. Favorable bridging to cardiac transplantation was achieved with the DeBakey left ventricular assist device (LVAD).

Background: Our basic aim was to describe the topographic relation between the sinus node artery and the superior posterior border of the interatrial septum with regard to the sinus node dysfunction that follows the superior transseptal approach to the mitral valve., Methods: During our study 50 human hearts without previous pathologic alterations were analyzed. The position of the sinus node and the course of the sinus node artery were investigated. For identification of the origin of the artery, selective coronary angiograms were performed. The course of sinus node artery and its topographic relation to the interatrial septum was identified by the dry dissections of the hearts. Based on histologic and dry dissected specimens the exact position of the sinus node was determined., Results: We found that the sinus node artery originates from the right coronary artery in 66% of examined cases and from the left coronary artery in 34% of cases. The sinus node artery crosses the superior posterior border of the interatrial septum in 54% of cases., Conclusions: Our results were compared with clinical studies focusing the incidence of the sinus rhythm disturbance after the superior transseptal approach. The incidence of rhythm disturbance varies from 52% to 60% of cases. Comparing our morphologic and clinical results we can state that the risk for intraoperative damage to the sinus node artery during the superior transseptal approach to the mitral valve is high.

Objectives: Ischemia/reperfusion injury is characterized by endothelial cell activation leading to increased expression of adhesion molecules such as inter-cellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1, endothelial- and platelet-selectin (E- and P-selectin), and to the subsequent recruitment of leukocytes. The aim of the present study was to investigate the respective effects of a proinflammatory cytokine (tumor necrosis factor alpha, TNF-alpha), hypoxia and/or reoxygenation on adhesion molecule expression and natural killer (NK) cell adhesion in an in vitro model of I/R., Methods: Human aortic endothelial cells (HAEC) were stimulated in vitro for 8h with TNF-alpha (1000 U/ml) and exposed to hypoxia (1% O(2)), reoxygenation (21% O(2)) or different combinations thereof. Cell surface expression of ICAM-1, VCAM-1 and E-/P-selectin on HAEC was analyzed by flow cytometry, and culture supernatants were tested for soluble adhesion molecules by ELISA. Rolling adhesion of NK cells on HAEC was determined using a rotating assay., Results: Untreated HAEC constitutively expressed ICAM-1 on their surface but neither expressed E-/P-selectin, VCAM-1, nor shedded soluble adhesion molecules. Exposure of HAEC to hypoxia or hypoxia and reoxygenation did not upregulate cell surface expression or shedding of adhesion molecules. In contrast, TNF-alpha significantly upregulated cell surface expression of ICAM-1, VCAM-1, and E-/P-selectin and led to the shedding of ICAM-1 and E-selectin. Combined treatment of HAEC with TNF-alpha, hypoxia and reoxygenation reduced E-/P-selectin surface expression and enhanced E-selectin shedding, but did not further influence ICAM-1 and VCAM-1. Soluble VCAM-1 was not detected. NK cell adhesion on HAEC increased 4-fold after TNF-alpha stimulation, but was not affected by hypoxia or hypoxia and reoxygenation., Conclusions: Both the expression of endothelial adhesion molecules and rolling NK cell adhesion was upregulated by TNF-alpha but not by hypoxia alone or hypoxia followed by reoxygenation supporting the view that anti-inflammatory treatment may reduce ischemia/reperfusion injury.

Recently the Symmetry Bypass System (SJM, St. Paul, MN) became available. Now the system is frequently applied for vein-graft to aorta anastomoses in off-pump coronary artery bypass operations. This report describes a complication associated with the use of the Symmetry Bypass System (SJM) in a patient undergoing a standard off-pump coronary artery bypass procedure. A novel imaging system (SPY, Novadaq, Toronto, Canada) was applied for intraoperative assessment of graft function, and this system immediately diagnosed the occlusion of the proximal mechanical anastomosis caused by a mobile atheromatous aortic plaque.

Background: Exposing the developing tissue to flow and pressure in a bioreactor has been shown to enhance tissue formation in tissue-engineered heart valves. Animal studies showed excellent functionality in these valves in the pulmonary position. However, they lack the mechanical strength for implantation in the high-pressure aortic position. Improving the in vitro conditioning protocol is an important step towards the use of these valves as aortic heart valve replacements. In this study, the relevance of large strains to improve the mechanical conditioning protocol was investigated., Methods: Using a newly developed device, engineered heart valve tissue was exposed to increasing cyclic strain in vitro. Tissue formation and mechanical properties were analyzed and compared to unstrained controls., Results: Straining resulted in more pronounced and organized tissue formation with superior mechanical properties over unstrained controls. Overall tissue properties improved with increasing strain levels., Conclusions: The results demonstrate the significance of large strains in promoting tissue formation. This study may provide a methodological basis for tissue engineering of heart valves appropriate for systemic pressure applications.

Background: Detachment of the septal leaflet of the tricuspid valve has been described for better access to perimembranous ventricular septal defects. Detachment confined to the anterior leaflet is less known, although it provides a better exposure of the subaortic area and puts less jeopardy on the conduction tissues., Methods: Data regarding 49 consecutive patients who had congenital perimembranous ventricular septal defect closure were retrospectively reviewed. Thirty-three patients (67%) underwent temporary detachment of the anterior leaflet of the tricuspid valve. The defect was closed with a Gore-Tex patch and a continuous suture. In 10 patients (29%), concomitant right ventricular outflow tract enlargement was performed. Follow-up was obtained in every patient (median time, 11 months; range, 2 to 26 months)., Results: No early or late death occurred. Closure of the ventricular septal defect was complete, with no more than trivial residual jet leaks found in perioperative echocardiography. All patients were in sinus rhythm. The tricuspid valve never showed more than mild insufficiency after repair. No patient showed subaortic obstruction., Conclusions: Detachment of the anterior leaflet of the tricuspid valve to expose the ventricular septal defect is a safe approach that allows rapid closure of the defect with a continuous suture and provides excellent results.

Background: We previously demonstrated the successful tissue engineering and implantation of functioning autologous heart valves based on vascular-derived cells. Human marrow stromal cells (MSC) exhibit the potential to differentiate into multiple cell-lineages and can be easily obtained clinically. The feasibility of creating tissue engineered heart valves (TEHV) from MSC as an alternative cell source, and the impact of a biomimetic in vitro environment on tissue differentiation was investigated., Methods and Results: Human MSC were isolated, expanded in culture, and characterized by flow-cytometry and immunohistochemistry. Trileaflet heart valves fabricated from rapidly bioabsorbable polymers were seeded with MSC and grown in vitro in a pulsatile-flow-bioreactor. Morphological characterization included histology and electron microscopy (EM). Extracellular matrix (ECM)-formation was analyzed by immunohistochemistry, ECM protein content (collagen, glycosaminoglycan) and cell proliferation (DNA) were biochemically quantified. Biomechanical evaluation was performed using Instron(TM). In all valves synchronous opening and closing was observed in the bioreactor. Flow-cytometry of MSC pre-seeding was positive for ASMA, vimentin, negative for CD 31, LDL, CD 14. Histology of the TEHV-leaflets demonstrated viable tissue and ECM formation. EM demonstrated cell elements typical of viable, secretionally active myofibroblasts (actin/myosin filaments, collagen fibrils, elastin) and confluent, homogenous tissue surfaces. Collagen types I, III, ASMA, and vimentin were detected in the TEHV-leaflets. Mechanical properties of the TEHV-leaflets were comparable to native tissue., Conclusion: Generation of functional TEHV from human MSC was feasible utilizing a biomimetic in vitro environment. The neo-tissue showed morphological features and mechanical properties of human native-heart-valve tissue. The human MSC demonstrated characteristics of myofibroblast differentiation.