Spontaneous Coronary Artery Dissection and Papillary Muscle Rupture in Patient With Undiagnosed Vascular Ehler-Danlos Syndrome

We present the case of a woman with acute coronary syndrome on the basis of spontaneous coronary artery dissection causing a papillary muscle rupture with severe mitral regurgitation and acute heart failure. The patient subsequently underwent successful emergent surgery of both the mitral and tricuspid valves. Postoperatively, the patient was diagnosed with vascular Ehlers-Danlos syndrome. (Level of Difficulty: Advanced.)

A 33-year follow-up after valvular surgery for carcinoid heart disease

AIMS

Valvular surgery has improved long-term prognosis in severe carcinoid heart disease (CaHD). Experience is limited and uncertainty remains about predictors for survival and strategy regarding single vs. double-valve surgery. The aim was to review survival and echocardiographic findings after valvular surgery for CaHD at our institution.

METHODS AND RESULTS

Between 1986 and 2019, 60 consecutive patients, median age 64 years, underwent valve surgery for severe CaHD. Operations involved combined tricuspid valve replacement (TVR) and pulmonary valve replacement (PVR) in 42 cases, and TVR-only or TVR with pulmonary valvotomy (no PVR) in 18 patients. All implanted valves were bioprosthetic. Preoperative echocardiography, creatinine, NT-pro-brain natriuretic peptide (NT-pro-BNP), and 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) were obtained. 30-Day mortality was 12% (n=7), and 8% for the most recent decade 2010-2019. Median survival was 2.2 years and maximum survival 21 years. Patients undergoing combined TVR and PVR had significantly higher survival compared with operations without PVR (median 3.0 vs. 0.9 years, P = 0.02). Preoperative levels of NT-pro-BNP and 5-HIAA in the top quartile predicted poor survival. On preoperative echocardiograms, pulmonary regurgitation was severe in 51% and indeterminate in 17%. Postoperative echocardiography confirmed relatively good durability of bioprostheses, relative to the patients' limited oncological life expectancy.

CONCLUSION

Valvular surgery in CaHD has an acceptable perioperative risk. Survival for combined TVR and PVR was significantly higher compared with operations without PVR. Bioprosthetic valve replacement appears to have adequate durability. Preoperative echocardiography may underestimate pulmonary pathology. Combined TVR and PVR should be considered in most patients.

Surgical aspects of valve replacement in carcinoid heart disease

Tricuspid and pulmonary valve replacement in patients with advanced carcinoid heart disease (CaHD) reduces right heart failure and improves prognosis. The surgical literature is limited concerning description of technical aspects of valve replacement in CaHD. Although a dedicated multidisciplinary care is required for these frail patients, optimization of surgical technique is important and may lead to better postoperative outcomes.

Large inferolateral left ventricular aneurysm

The majority of cardiac left ventricular aneurysms involve the anterior and/or apical wall. We present a case of a 50-year-old man with heart failure caused by a large inferolateral left ventricular aneurysm and associated mitral regurgitation, managed by aneurysmectomy, mitral valvuloplasty, and surgical revascularization.

Long-Term Risk of Ischemic Stroke After the Cox-Maze III Procedure for Atrial Fibrillation

BACKGROUND

The long-term risk of stroke after surgical treatment of atrial fibrillation is not well known. We performed an observational cohort study with long follow-up after the "cut-and-sew" Cox-maze III procedure (CM-III), including left atrial appendage excision. The aim was to analyze the incidence of stroke/transient ischemic attack (TIA) and the association to preoperative CHA₂DS₂-VASc (age in years, sex, congestive heart failure history, hypertension history, stroke/TIA, thromboembolism history, vascular disease history, diabetes mellitus) score.

METHODS

Preoperative and perioperative data were collected in 526 CM-III patients operated in four centers 1994 to 2009, 412 men, mean age of 57.1 ± 8.3 years. The incidence of any stroke/TIA was identified through analyses of the Swedish National Patient and Cause-of-Death Registers and from review of individual patient records. The cumulative incidence of stroke/TIA and association with CHA₂DS₂-VASc score was estimated using methods accounting for the competing risk of death.

RESULTS

Mean follow-up was 10.1 years. There were 29 patients with any stroke/TIA, including 6 with intracerebral bleedings (2 fatal) and 4 with perioperative strokes (0.76%). The remaining 13 ischemic strokes and six TIAs occurred at a mean of 7.1 ± 4.0 years postoperatively, with an incidence of 0.36% per year (19 events per 5,231 patient-years). In all CHA₂DS₂-VASc groups, observed ischemic stroke/TIA rate was lower than predicted. A higher risk of ischemic stroke/TIA was seen in patients with CHA₂DS₂-VASc score 2 or greater compared with score 0 or 1 (hazards ratio 2.15, 95% confidence interval: 0.87 to 5.32) but no difference by sex or stand-alone versus concomitant operation. No patient had ischemic stroke as cause of death.

CONCLUSIONS

This multicenter study showed a low incidence of perioperative and long-term postoperative ischemic stroke/TIA after CM-III. Although general risk of ischemic stroke/TIA was reduced, patients with CHA₂DS₂-VASc score 2 or greater had a higher risk compared with score 0 or 1. Complete left atrial appendage excision may be an important reason for the low ischemic stroke rate.

The Berglin apical stitch: a simple technique to straighten things out in atrial fibrillation surgery

In the Cox-Maze IV procedure, or in endocardial left atrial ablation, correct positioning of the surgical ablation probe within the left atrium might be difficult due to bulging or folds in the posterior left atrial wall. The Berglin apical stitch is a simple trick of the trade to create a smooth surface in the posterior left atrium that facilitates performing a safe transmural lesion and, consequently, may increase antiarrhythmic efficiency.

Learning what works in surgical cryoablation of atrial fibrillation: results of different application techniques and benefits of prospective follow-up

Atrial fibrillation (AF) in cardiac surgical patients is detrimental in the long perspective. Concomitant surgical ablation of AF is recommended in guidelines and performed in most centers. The article describes the experiences in a single institution with concomitant surgical argon-based cryoablation in 115 patients using three different application techniques (epicardial left atrium, endocardial left atrium, biatrial cryo-maze) and a structured local follow-up to one year postoperatively. Results showed cryoablation to be safe with few complications related to the ablation procedure and few thromboembolic events. In this study, a complete biatrial lesion set according to the classic Cox-maze III (CM III) lesion pattern yielded a higher success rate than left atrial procedures. At 12 months, patients in sinus or pacing rhythm, free of AF without antiarrhythmic drugs, were 27/39 (69%), 24/32 (74%) and 36/44 (82%) in the EpiLA, EndoLA and cryo-maze groups, respectively. A consistent prospective follow-up is essential not only for research purposes but also for assessing the local results of AF surgery in everyday practice. It may direct and develop the surgical ablation program, guide individual postoperative arrhythmia management and is needed to increase overall quality of surgical AF ablation.

Late cardiac tamponade by chylous pericardial effusion after coronary artery bypass surgery: case report

Chylopericardium is an uncommon but serious complication after open heart surgery that often necessitates surgical treatment. We describe a case of continuous and severely symptomatic chylous pericardial effusion after coronary artery bypass grafting in which the diagnosis was established by lipid electrophoresis. Initial conservative management failed, and ligation of the thoracic duct and pericardial fenestration were finally required for a successful outcome.

The biatrial cryo-maze procedure for treatment of atrial fibrillation: a single-center experience

OBJECTIVES

The Cox-maze III procedure is the benchmark for atrial fibrillation (AF) surgery but has been replaced by surgical ablation. We evaluated our experience with biatrial cryoablation using the full Cox-maze III lesion pattern, and adhering follow-up to current guidelines.

DESIGN

Forty-three patients underwent the biatrial cryo-maze procedure as a concomitant (n = 37) or stand-alone procedure (n = 6). Mean age was 64.8 ± 9.5 years. Overall, AF was paroxysmal/persistent/permanent in 28/14/58%. Mean AF duration was 5.2 ± 6.5 years. Follow-up included prospective evaluation at 1, 3 and 12 months, long-term monitoring and transthoracic echocardiography.

RESULTS

No mortality and no complications related to the ablation procedure occurred. One patient suffered a stroke at 12 months. In the concomitant group, rhythm was sinus/pacing without AF/AF in 65/16/19% at three months, and 59/22/19% at 12 months. Five patients received new pacemakers (12%). In the stand-alone group, 5/6 (83%) patients had sinus rhythm with no AF at three and 12 months. Overall, 35/43 patients (81%) had sinus/paced rhythm at 12 months with no AF and no anti-arrhythmic drugs. Echocardiography showed satisfactory results in all patients.

CONCLUSIONS

The biatrial cryo-maze procedure is safe and effective in surgical patients with concomitant AF, and could be considered for selected patients with lone AF.

Hemodynamics at rest do not match clinical improvement after surgical ventricular restoration

OBJECTIVES

The aim was to study the change in cardiac index (CI) and pulmonary artery pressure (PAP) by intra-cardiac measurements after surgical ventricular restoration (SVR) in patients with left ventricular aneurysm and symptoms of heart failure. Aspects of functional improvement were analyzed as secondary outcomes.

DESIGN

Mean PAP and CI were obtained before and 6 months postoperatively in 22 patients who underwent SVR.

RESULTS

There were no significant changes in CI (2.3 vs. 2.4 L/min/m(2); p=0.91) or mean PAP (22 vs. 22 mmHg; p=0.64) at rest before and six months after surgery. Left ventricular ejection fraction improved from 25 to 38% (p<0.001). Before surgery 15 patients (68%) were in NYHA class III-IV and 6 months after the operation 19 (86%) patients were in NYHA class I-II (p<0.001).

CONCLUSIONS

Invasive hemodynamic measurements under resting conditions do not correspond well to the significant clinical improvement noted in these patients. Studies during exercise conditions are necessary to further evaluate this procedure.

Surgery for ventricular tachycardia and left ventricular aneurysm provides arrhythmia control

OBJECTIVES

Report long-term freedom from ventricular tachycardia (VT), survival, and causes of death in patients with left ventricular aneurysm and VT, who underwent a combined procedure for VT and surgical ventricular restoration (SVR).

DESIGN

The primary outcome measures VT, survival, and cause of death, were ascertained by review of patients' records, interrogation of implanted cardioverter-defibrillators and use of national registers.

RESULTS

Mean follow-up was 5.2 years. Overall survival was 62% at 5 years and 51% at 9 years. Freedom from spontaneous VT was 89%. In 32 patients who were non-inducible at postoperative testing, there was no occurrence of VT during a mean follow-up of 6.0 years. Causes of death were cardiac in 17 patients, and non-cardiac in 6 patients. No patient died from ventricular arrhythmia.

CONCLUSIONS

Direct surgery for VT combined with SVR resulted in a very low risk of late recurrence of VT and good long-term survival. Implantation of a cardioverter-defibrillator can safely be withheld in patients who are non-inducible on postoperative programmed electrical stimulation.

Versatility of the endoventricular patch technique in repair of postinfarction left ventricular rupture

Surgical ventricular restoration by the endoventricular patch technique (Dor procedure) is a surgical option designed to restore left ventricular shape and volume in patients with ischaemic heart disease and heart failure. Surgical ventricular restoration includes complete revascularisation, left ventricular reconstruction to restore near-normal shape and volume, and when necessary, mitral valve repair and surgery for ventricular tachycardia. However, the endoventricular patch technique is versatile and can also be used in other cases. We report the successful use of this technique in two emergent postinfarction cases, one with left ventricular free-wall rupture and one with ventricular septal defect. The aim of these case reports is to illustrate the flexibility of the endoventricular patch technique.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration: The Karolinska approach

This article presents a review on the efficacy of surgical ventricular restoration and direct surgery for ventricular tachycardia in patients with left ventricular aneurysm or dilated ischemic cardiomyopathy. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. A practical guide to the pre- and postoperative management of these patients is provided.

Edge-to-edge mitral repair without annuloplasty in combination with surgical ventricular restoration

BACKGROUND

Functional mitral regurgitation is common in ischemic dilated cardiomyopathy. Edge-to-edge repair is an option for correction and can be performed through the ventriculotomy during surgical ventricular restoration (SVR). This report describes the durability of the edge-to-edge repair without annuloplasty in combination with SVR.

METHODS

From March 1997 to July 2002, 31 patients with left ventricular aneurysm or ischemic dilated cardiomyopathy and functional ischemic mitral regurgitation grade II (n = 18), III (n = 10), and IV (n = 3) underwent SVR and edge-to-edge repair without annuloplasty with concomitant coronary artery bypass grafting. Long-term valve competence was assessed by echocardiography. Early and late survival and hospital readmission for heart failure were analyzed.

RESULTS

Early mortality was 5 (16%) of 31 patients. At 1, 3, and 5 years, actuarial survival was 77%, 55%, and 48%. The cumulative follow-up was 117 patient-years (4.5 years mean follow-up). Late echocardiograms performed at a mean of 3.1 years postoperatively showed patients had mitral regurgitation at grade 0 (n = 4), I (n = 10), II (n = 9), and III (n = 1). Two patients underwent reoperation owing to grade III-IV recurrent mitral regurgitation. Freedom from hospital readmission or cardiac death was 56% at 1 year and 48% at 3 years.

CONCLUSIONS

Combined mitral valve repair and SVR carries high operative risk and long-term prognosis is worse than after SVR alone. The edge-to-edge repair without annuloplasty for functional ischemic mitral regurgitation seems to be fairly durable in conjunction with SVR. To improve results a transventricular annuloplasty may be added.

Improved Health-Related Quality of Life and Functional Status After Surgical Ventricular Restoration

BACKGROUND

Surgical ventricular restoration (SVR) has been shown to improve hemodynamics and survival among patients with coronary artery disease, left ventricular aneurysm, and heart failure. The aim of this study was to investigate functional status and health-related quality of life after SVR.

METHODS

Over a period of 2 years beginning in March 2003, 23 patients with left ventricular aneurysm and depressed left ventricular function were included in a prospective study. Functional status and quality of life was analyzed preoperatively, 6 months postoperatively, and at late follow-up by assessment of New York Heart Association (NYHA) functional class, 6-minute walk test, and the Medical Outcome Study 36-Item Short Form.

RESULTS

There was no early mortality. Before surgery, 17 patients (74%) were in NYHA class III to IV; and 6 months after SVR, 20 patients (87%) were in NYHA class I to II (p < 0.001). At late follow-up, (mean, 22 months postoperatively), all patients alive (n = 20) were in NYHA class I to II. Mean 6-minute walk distance increased by 41 meters (p = 0.06) at 6 months postoperatively and by 57 meters (p = 0.03) at late follow-up. Quality of life, assessed by the physical component summary score of the Medical Outcome Study 36-Item Short Form, improved significantly (p = 0.04) at 6 months postoperatively. A significant and clinically relevant improvement in both physical aspects (+25%, p < 0.001) and mental aspects (+37%, p = 0.003) of quality of life was found at late follow-up.

CONCLUSIONS

Functional status and quality of life improved 6 months after SVR, and the improvement was sustained at late follow-up almost 2 years after surgery.

Changes in B-type natriuretic peptides after surgical ventricular restoration

OBJECTIVE

The aim of this study was to prospectively investigate changes in brain natriuretic peptide (BNP) and amino terminal pro-BNP (NT-pro-BNP) in relation to functional status after surgical ventricular restoration (SVR).

METHODS

Between March 2003 and May 2006, 29 patients (20 men and 9 women, mean age 65 years, mean ejection fraction 24%) with post-infarction left ventricular aneurysm and depressed left ventricular function underwent SVR according to the Dor technique at our institution. Twenty-two patients (76%) were in New York heart association (NYHA) functional class III or IV. Multi-vessel disease was present in 26 patients. Natriuretic peptides, functional status, ejection fraction and left ventricular volumes were analyzed at baseline, after 6 months, and late postoperatively.

RESULTS

There was no early mortality. Survival at 24 months was 93%. Six months postoperatively 25/29 (86%) patients were in NYHA class I and II (p<0.001) and at late (mean 21 months) follow-up, all patients were in NYHA class I and II. There was a persistent reduction of NT-pro-BNP (2406 pg/ml vs 1510 pg/ml; p=0.03 and 975 pg/ml; p=0.03) and BNP (312 pg/ml vs 228 pg/ml; p=0.12 and 191 pg/ml; p=0.20) 6 months postoperatively and at late follow-up, respectively. Ejection fraction improved from 24% to 37% (p<0.001) at 6 months. End-diastolic (110 ml/m(2) vs 90 ml/m(2), p=0.009) and end-systolic (75 ml/m(2) vs 52 ml/m(2), p=0.006) volume index were reduced at 6 months. Functional improvement correlated significantly with reduction in BNP (r=0.61, p=0.01) and NT-pro-BNP (r=0.58, p=0.003) 6 months after surgery. Ejection fraction correlated inversely with BNP (r=-0.58, p=0.02) and NT-pro-BNP (r=-0.51, p=0.04), and end-systolic volume correlated with BNP (r=0.65, p=0.03) and NT-pro-BNP (r=0.62, p=0.03) 6 months after surgery.

CONCLUSIONS

Heart failure secondary to post-infarction left ventricular remodeling can be reversed by SVR. Improvement in these patients was associated with reduced levels of B-type natriuretic peptides 6 months after surgery. Clinical improvement was maintained and peptide levels were further reduced at late follow-up.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration

This article is a presentation of direct surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. Perioperative considerations and a short overview of the literature are presented.

Risk factors for mortality and hospital re-admission after surgical ventricular restoration

BACKGROUND

Surgical ventricular restoration is an option in patients with coronary artery disease, heart failure, postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy with or without ventricular tachycardia. The aims of this study were to investigate survival and re-admission for heart failure and to identify predictors for early and long-term mortality and re-admission after surgical ventricular restoration.

METHODS

Pre- and postoperative data were collected for 136 consecutive patients who underwent surgical ventricular restoration for postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy during 1994-2005. Survival and risk factors for mortality and hospital re-admission were analyzed by using multivariable models.

RESULTS

Early mortality was 10/136 (7.4%). At 1, 3, 5 and 9 years overall actuarial survival was 89%, 80%, 68% and 62%. Increasing age, diabetes and mitral regurgitation grade III-IV were associated with an increased risk for late mortality. Freedom from re-hospitalization due to heart failure or cardiac death in operative survivors at 1, 3 and 5 years was 78%, 72% and 58%. Risk factors for re-hospitalization or cardiac death in operative survivors were increasing age and increasing grade of mitral regurgitation.

CONCLUSIONS

Surgical ventricular restoration by the Dor procedure can achieve good long-term survival and a high degree of freedom from readmission for heart failure in patients with advanced ischemic heart disease. We found a strong association between increasing grade of mitral regurgitation and both long-term mortality and re-admission for heart failure.

Left ventricular reconstruction as an alternative to heart transplantation: a case report

A 57-year-old man with dilated cardiomyopathy was referred to our institution to be assessed for heart transplantation. He had symptoms of severe heart failure and left ventricular dysfunction. We proposed surgical ventricular restoration (the Dor procedure) as an alternative to heart transplantation. The patient underwent successful surgery and an uneventful postoperative course. Pre- and postoperative investigations are presented. One year after surgery, the patient is in good clinical and functional condition. This case illustrates that surgical ventricular restoration can be an alternative to heart transplantation.

Surgery for Ventricular Tachycardia in Patients Undergoing Left Ventricular Reconstruction by the Dor Procedure

BACKGROUND

Surgical ventricular restoration (the Dor procedure) is an option in patients with coronary artery disease and postinfarction left ventricular aneurysm. The procedure can be extended to treat ventricular tachycardia (VT). The aim of this study was to evaluate the Dor procedure including VT surgery in our institution.

METHODS

From July 1997 to December 2003, 53 consecutive patients with left ventricular aneurysm and VT underwent surgical ventricular restoration including nonguided endocardiectomy and cryoablation. Twenty-four patients had at least one preoperative episode of spontaneous VT, of which 8 were survivors of sudden cardiac death. Twenty-nine patients had inducible-only VT. In 45 patients, who underwent preoperative programmed stimulation, sustained uniform VT could be initiated. Arrhythmia control was evaluated by programmed stimulation or analysis of events registered by implanted defibrillators and by review of patient's records.

RESULTS

Early mortality was 2 of 53 (3.8%). Mean follow-up was 3.7 years. At 1, 3, and 5 years overall actuarial survival was 94%, 80%, and 59%, respectively. Surgical success rate in patients with preoperative spontaneous VT was 91%. Inducible VT was found in 5 of 35 patients who underwent postoperative programmed stimulation. There was no arrhythmia-related late death and there was no loss to follow-up.

CONCLUSIONS

The Dor procedure including VT surgery is an effective treatment for postinfarction left ventricular aneurysm and VT and eliminates the need for an implantable defibrillator in most patients. Early and long-term results are good in terms of survival and arrhythmia control.

[Left ventricular reconstruction in ischemic heart disease. Good surgical alternative in advanced heart failure]

Left ventricular (LV) dilatation occurs after myocardial infarction and leads to heart failure. LV reconstruction or surgical ventricular restoration (SVR) by means of the Dor procedure reduces LV volume and restores normal LV shape. Mitral repair and surgery for ventricular tachycardia are performed as needed. SVR improves LV function and early and long-term results are good in terms of survival and arrhythmia control. International results as well as the experience of the procedure at Karolinska University Hospital are presented and illustrated with a case report.

The Dor procedure for left ventricular reconstruction. Ten-year clinical experience

OBJECTIVE

Surgical ventricular restoration by means of the Dor procedure is a surgical option in patients with coronary artery disease, postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy with or without ventricular tachycardia. The aim of this study was to evaluate the 10-year clinical experience of this procedure in our institution.

METHODS

From May 1994 to June 2004, surgical ventricular restoration was performed in 101 patients (77 males), mean age 63.8 (35-80) years. All patients presented with angina and/or heart failure and/or ventricular tachycardia. Postinfarction left ventricular aneurysm was present in 97 patients and ischemic dilated cardiomyopathy with a large akinetic left ventricle in 4. The preoperative left ventricular ejection fraction was 27+/-10 (7-50) %. Multi-vessel disease was present in 80 patients. Ventricular tachycardia was diagnosed in 53 patients (spontaneous VT in 25). Mitral regurgitation more than grade 2 was found in 13 patients. The mean Euroscore was 7.1+/-2.9 (3-17).

RESULTS

All patients underwent the Dor procedure, which in 53 patients included a non-guided endocardectomy and cryoablation for treatment of ventricular tachycardia. Coronary artery bypass grafting was performed in 99 patients and a mitral valve procedure was performed in 29. Intra-aortic balloon pumping was used postoperatively in 14 cases and 24 patients needed inotropic support for more than 24 h. Mean time on the ventilator was 16+/-25 (3-168) hours and mean stay in the intensive care unit was 2.1+/-2.2 (0-13) days. Postoperative stroke occurred in 7 patients. Early mortality was 8/101 (7.9%). Mean follow-up in operative survivors was 4.4+/-2.8 (0.1-10.4) years. Actuarial survival at 1, 3 and 5 years was 88, 79 and 65%.

CONCLUSIONS

The Dor procedure is a reproducible surgical option for treatment of postinfarction left ventricular aneurysm. Early and long-term results are good in terms of survival.

Repair of acute mediastinoscopic injury to the pulmonary artery using an intravascular approach and deep hypothermic circulatory arrest

A potentially serious but rare complication of mediastinoscopy procedures is acute damage to any of the great vessels in the region of the distal trachea and carina. We report a case of serious hemorrhage from a mediastinoscopic biopsy-injury to the posterior aspects of the right pulmonary artery (RPA), which required sternotomy, cardiopulmonary bypass, division and retraction of the ascending aorta, incision of the RPA, intermittent deep hypothermic circulatory arrest, and suturing from the inside of the RPA for a successful repair.

Electrophysiological Evaluation of the Sinus Node and the Cardiac Conduction System Following the Maze Procedure for Atrial Fibrillation

Transient sinus node dysfunction has been demonstrated by noninvasive methods following the maze procedure for atrial fibrillation (AF). However, extensive data from invasive electrophysiological studies have not been previously reported. Thirty-seven patients, mean age 54 +/- 10 years, underwent the maze (III) procedure. Electrophysiological studies with recordings of SNRT, CSNRT, AVN-ERP, point of Wenckebach block, AH, PA, and HV interval, were performed preoperatively and 6 and 15 months postoperatively. Induction of atrial flutter/AF was attempted postoperatively. Based on electrophysiological study evaluation, the maze (III) procedure did not cause permanent damage to the sinus node in any patient with a documented normal sinus node function preoperatively (CSNRT max 541 +/- 210 vs 587 +/- 437 ms, P = 0.26). Postoperative AV node function was normal in all patients with a documented normal AV node function before surgery. One patient had an iatrogenic third degree AV block. There was no difference in PA or HV interval after surgery. Sustained atrial tachyarrhythmias could be induced in 5 patients, of whom 4 developed permanent AF/atrial flutter late after surgery. At late follow-up, (mean 45 months), 27 (73%) patients were in sinus rhythm, 5 (13%) patients had permanent pacing, and 5 patients had recurrent AF requiring His bundle ablation (n = 2) or medical treatment (n = 3). Based on electrophysiological studies, the maze (III) procedure does not cause permanent damage to the sinus or AV nodes or to the right atrial and His-Purkinje conduction systems. Electrophysiological study evaluation may predict the need for postoperative pacemaker. Induction attempts of atrial arrhythmias may predict future recurrences and guide therapeutic efforts.

Improved neurohormonal markers of ventricular function after restoring sinus rhythm by the Maze procedure

BACKGROUND

Clinical results of the Maze procedure for treatment of atrial fibrillation (AF) are excellent, suggesting improved ventricular function after restoring sinus rhythm. However, long-term corresponding effects on the release of cardiac natriuretic peptides and other vasoactive hormones are incompletely investigated after isolated Maze surgery.

METHODS

Plasma levels of brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP), antidiuretic hormone, aldosterone, and angiotensin II were measured in 15 patients (mean age, 52 +/- 11 years) undergoing isolated surgical Maze (III) procedures for medically refractory AF, preoperatively and 6 months postoperatively. At the time of blood sampling, hemodynamic correlates were obtained at baseline and after 6 and 12 minutes of rapid ventricular pacing at 150 stimulations/minute.

RESULTS

All patients were free of AF at 6-month follow-up. The measured plasma levels of BNP, ANP, and angiotensin II were all significantly lower (p = 0.03) late after the isolated Maze procedure. Cardiac output was significantly higher postoperatively (p < 0.01). Other hemodynamic values and left atrial size were unchanged after surgery. Ventricular pacing caused almost identical hemodynamic changes in atrial pressures before and late after surgery, but the associated plasma ANP response was significantly attenuated postoperatively (p < 0.001).

CONCLUSIONS

Levels of cardiac natriuretic peptides and angiotensin II as markers of ventricular function are improved in the long term after clinically successful isolated Maze procedures. ANP response to hemodynamic challenge by ventricular pacing was attenuated postoperatively, possibly due to atrial scarring.

[Acute papillary muscle rupture and mitral valve insufficiency after myocardial infarction. Serious condition, but potentially curable through emergency surgery]

Acute papillary muscle rupture resulting in severe mitral regurgitation is an infrequent but extremely serious mechanical complication of myocardial infarction. The immediate and severe volume overload on the pulmonary circulation may cause pulmonary edema and circulatory shock with secondary organ failure. Diagnosis is preferably based on echocardiography, and urgent mitral valve replacement is the treatment of choice. This paper describes two such patients who were successfully treated by surgery despite cardiogenic shock. In addition, it illustrates the known fact that a papillary muscle rupture may be caused by a myocardial infarct of limited size but with an unfortunate location.

[Electrical conversion of atrial fibrillation. Superior effects of biphasic transthoracic method when compared with the conventional monophasic method]

Can biphasic electrical conversion of atrial fibrillation replace the standard monophasic method? This report reviews factors facilitating the electrical conversion of atrial fibrillation and describes a clinical trial, showing superior effects of biphasic versus monophasic electrical conversion of atrial fibrillation. We conclude that the most important factors for successful electrical conversion of atrial fibrillations are 1) a biphasic impulse, 2) low transthoracic impedance and 3) a short history of atrial fibrillation.

Elevations in antidiuretic hormone and aldosterone as possible causes of fluid retention in the Maze procedure

BACKGROUND

Reduced levels of atrial natriuretic peptide (ANP) has been suggested as a cause of fluid retention after combined Maze and valvular surgery. This study aimed to assess hormonal activation in the perioperative setting of isolated Maze procedures.

METHODS

Changes in ANP, brain natriuretic peptide (BNP), antidiuretic hormone (ADH), aldosterone, and angiotensin II were measured in 16 patients (mean age 53+/-9 years) without concomitant heart disease undergoing the Maze (III) procedure. Ten matched patients (mean age 56+/-9 years) undergoing multivessel coronary artery bypass grafting served as controls. Measurements with hemodynamic correlates were obtained at baseline and after ventricular pacing (100 stimulations/minute), directly preoperatively, postoperatively and the first postoperative day. Weight gain and diuretic requirements were recorded.

RESULTS

The major differences in hormonal response were significantly higher plasma levels of ADH (Maze preoperative 1.1+/-0.4, postoperative 24.9+/-16.7 pmol/L; controls preoperative 1.1+/-0.1, postoperative 3.7+/-3.5 pmol/L) and aldosterone (Maze preoperative 106+/-94, postoperative 678+/-343 pmol/L; controls preoperative 124+/-79, postoperative 171+/-93 pmol/L) in the Maze group on the first postoperative day (p < 0.001). Preoperative baseline plasma levels of ANP and pulmonary capillary wedge pressures (PCWP) were higher in the Maze group but this difference was abolished by pacing, and postoperatively, ANP levels changed in parallel to the PCWP in both groups. Diuretic requirements were significantly higher in the Maze group.

CONCLUSIONS

Substantial increases in ADH and aldosterone were observed after the Maze procedure, indicating these hormones as important determinants in postoperative fluid retention. The role for ANP in this setting may be a less prominent than previously reported.

The Maze operation for treatment of atrial fibrillation. Early clinical experience in a Scandinavian institution

The Maze operation is a potentially curative surgical option in patients with disabling atrial fibrillation (AF) refractory to conventional treatment. The aim of this study was to evaluate the initial 4-year Maze experience in our institution. The study included 26 patients (19 males, mean age 55 years) who had undergone the Maze (III) operation between 1994 and 1998. Nine patients had surgery for concomitant heart disease. Follow-up was 3-55 (median 18) months. No deaths or neurological complications occurred; 22 patients are at present in regular sinus-, or junctional rhythm, 2 patients have permanent atrial pacing for symptomatic sinus node dysfunction, and 2 patients have had persistent AF, post surgery. Sinus node dysfunctions were detected in five patients, though not requiring pacemakers. Out of the total 26 patients, 23 are free of anti-arrhythmic drugs. Echocardiographic signs of left atrial contraction were recorded in 50% of the patients. The Maze operation offers a safe alternative to conventional therapy, with attractive results justifying expansion in the use of this treatment for AF.

Simple method for direct cannulation of ascending aortic aneurysms

A simple method for direct cannulation of aneurysms of the ascending aorta is described. It avoids the need for femoral artery cannulation and offers an easy route for retrograde cerebral perfusion during deep hypothermic circulatory arrest.

[A new surgical technique in atrial fibrillation. The maze procedure restores sinus rhythm]

Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity and increased mortality, partly due to the increased risk of stroke. The maze procedure, introduced by James Cox of the USA, is an internationally established surgical alternative in cases of unsuccessful medical or catheterised treatment of paroxysmal or chronic AF. It is an open heart procedure, involving multiple transmural incisions and continuous suture lines in both atria. By creating a maze of atrial tissue, the re-entrant circuits causing the AF are interrupted, hence re-establishing regular sinus rhythm and atrioventricular synchronization. The article reviews the initial 3-year experience of the procedure in 10 patients with AF, either paroxysmal (n = 5) or chronic (n = 5). The indications for surgery were disabling symptoms in all 10 cases, medical treatment failure in nine cases, previous AF-associated stroke in three cases, and a significant atrial septal defect in one case. All patients underwent extensive investigation both pre- and post-operatively. Postoperatively, nine of the 10 patients manifested regular sinus or atrial rhythm and freedom from or amelioration of preoperative symptoms associated with AF. There were no deaths, neurological complications or long-term recurrence of arrhythmia. One patient had an early recurrence of AF that was not amenable to medical treatment, and was subsequently treated with His' bundle ablation. Of the remaining nine patients, seven manifested signs of some postoperative atrial contraction at echocardiography, the occurrence of which needs to be borne in mind with a view to reducing the risk of future thromboembolic events. We recommend the maze procedure as an attractive surgical option in cases of unsuccessful medical treatment of paroxysmal or chronic AF.

Acetylsalicylic acid may protect the patient by increasing fibrin gel porosity. Is withdrawing of treatment harmful to the patient?

The effect of acetylsalicylic acid in preventing cardiovascular complications is ascribed to acetylation of the enzyme cyclo-oxygenase thereby inhibiting prostaglandin synthesis. Acetylsalicylic acid, however, also acetylates fibrinogen. In the present pilot study, we investigated the permeability, i.e. porosity, of the fibrin gel in male patients with stable angina pectoris treated with this drug before and at 1 and 2 weeks after withdrawal. Ten patients were treated with 75 mg and eight with 160 mg. The results were compared to those in seven untreated healthy controls. Bleeding times were longer during treatment and were reduced after withdrawal indicating patient compliance. Fibrin gels were more porous during treatment although there were large inter-individual variations in porosity. One week after withdrawal, the porosity was reduced by 30 41%, i.e. the network became tighter (75 mg group P = 0.001; 160 mg group P = 0.002). The tightness was more pronounced after withdrawal than in the untreated controls. In conclusion, the protective effect of acetylsalicylic acid may be ascribed to its effect not only on platelets but also on fibrinogen. The withdrawal of acetylsalicylic acid may clause a markedly reduced fibrin gel porosity that we assume is disadvantageous in patients with cardiovascular disease.

Abnormally high platelet activity after discontinuation of acetylsalicylic acid treatment

Production of 12-L-hydroxy-5, 8, 10-heptadecatrienoic acid (12-HHT) from platelets and bleeding times were studied in 32 males during acetylsalicylic acid (ASA) treatment and 1 and 2 weeks after withdrawal. All patients (age 42-77 years) had ASA treatment because of angina pectoris. The metabolite 12-HHT is formed in the same amount as the proaggregatory and vasoactive metabolite thromboxane A2. Initially the daily ASA dose was 75 mg (n = 15), 160 mg (n = 12) or 250-300 mg (n = 5). In all patients, median 12-HHT level increased from 40 to 240g/750 x 10(6) platelets (P < 0.001) 1 week after withdrawal of ASA, and four patients had abnormally high values. Median bleeding time decreased from 312 to 268 s (P = 0.003) in the 75 mg group and from 315 to 235 s in the 160 mg group (P = 0.01). Two weeks after withdrawal of ASA, median 12-HHT was 390g/750 x 10(6) platelets and eight patients (25%) had abnormally high values. One patient still had a prolonged bleeding time. Wide interindividual variations were observed in all groups. Our results indicate that rapid withdrawal of ASA, may cause abnormally high 12-HHT levels reflecting increase of thromboxane A2 with possible hazardous effects in patients with cardiovascular disease.