BACKGROUND:Complete revascularization has been the standard for coronary bypass grafting. However, surgical intervention has evolved with increasing use of arterial conduits and off-pump techniques. METHODS:Patients undergoing non-redo bypass surgery from January 1998 through December 2000 were followed up with questionnaires and telephone contact. Incomplete revascularization was defined as absence of bypass grafts placed to a coronary territory supplied by a vessel with 50% or greater stenosis. RESULTS:One thousand thirty-four patients were followed for a mean of 3.3 +/- 1.6 years. Complete revascularization was found in 937 (90.6%) patients, and incomplete revascularization was found in 97 (9.4%) patients. Eight hundred twenty-seven (80.4%) patients underwent on-pump operations, and 207 (19.6%) underwent off-pump operations. Incomplete revascularization was more prevalent in off-pump versus on-pump operations (21.7% vs 6.3%, P < .001). Multivariable Cox regression analysis indicated that in-hospital cerebrovascular accidents (hazard ratio, 5.49; P < .001), chronic obstructive pulmonary disease (hazard ratio, 1.97; P = .019), and incomplete revascularization (hazard ratio, 1.85; P = .040) predicted an increased hazard (risk) of cardiac death. Left internal thoracic artery (hazard ratio, 0.38; P = .047), right internal thoracic artery (hazard ratio, 0.25; P = .019), and radial artery (hazard ratio, 0.36; P < .001) grafting reduced the risk of cardiac death. The 5-year unadjusted survival rate was 52.6% versus 82.4% in patients undergoing incomplete and complete revascularization ( P < .001), with cardiac survival rates of 74.5% versus 93.1%, respectively ( P < .001). However, this difference in cardiac survival was smaller in octogenarians with incomplete versus complete revascularizations (77.4% vs 87.6%, P = .101) and was essentially absent in off-pump versus on-pump operations if complete revascularization was achieved in both cases (93.6% vs 93.1%, P > .200). CONCLUSIONS:Complete revascularization and arterial grafting improve 5-year survival. Off-pump techniques do not affect survival. Complete revascularization should be performed whenever possible.

BACKGROUND:In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair. METHODS:We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group. RESULTS:No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 +/- 0.14 versus 0.44 +/- 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p < 0.01). The combined surgical group had a greater reduction in IMR grade (2.7 +/- 0.1 grades versus 0.2 +/- 0.1 grade), a lower postoperative IMR grade (0.9 +/- 0.1 versus 2.3 +/- 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p < 0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% +/- 5% versus 41% +/- 7%, p = 0.53). Independently predictive of higher early mortality (< or = 30 days) by Cox analysis were longer pump time (p < 0.001) and older age (p < 0.02). Predictive of late mortality (> 30 days) were older age (p < 0.001), fewer bypass grafts (p < 0.01), and lower ejection fraction (p < 0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure. CONCLUSIONS:In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients.

Previous studies indicate ethnic differences in the distribution of cytokine alleles and genotypes. Ethnic differences may affect allograft rejection and survival.

Background: We hypothesized that total orthotopic heart transplantation (TOHT) improves hemodynamics during cellular rejection compared with biatrial transplantation (SOHT).Methods: We reviewed 1942 biopsies from 134 patients (pts) and right heart catheterization data obtained at endomyocardial biopsy. Biopsies that displayed cellular rejection grade 1B as classified according to International Society for Heart and Lung Transplantation (ISHLT) criteria were analyzed. Pts with pacemakers, atrial fibrillation, or P-blocker therapy at the time of biopsy were excluded. Twenty-three pts after TOHT and 38 after SOHT were identified to match these criteria.Results: Demographic data and pretransplant hemodynamics were similar. TOHT pts had a higher mean cardiac index than SOHT recipients (3.3 +/- 0.8 vs 2.7 +/- 0.5 L/min/m(2); P = .002). Right atrial mean pressure was lower after TOHT (8 +/- 4 vs 11 +/- 4 mm Hg; P = .006). Pulmonary pressures, pulmonary vascular resistance, and heart rate were similar.Conclusions: TOHT offers improved hemodynamics during cellular rejection grade 1B as evidenced by higher cardiac output and index with lower right atrial pressures. Future studies must examine the potential benefits of TOHT during more severe rejection events.

OBJECTIVE Limited availability of donor organs has led to the progressive expansion of the criteria for donor selection, particularly a higher age limit of potential donors. We retrospectively reviewed the outcomes of patients who underwent heart transplantation using cardiac allografts 50 years of age and older and compared them with patients who had donor organs younger than 50 years. METHOD Between September 1989 and May 2000, 20 patients underwent orthotopic heart transplantation using donor hearts 50 years of age and older (range 50-56 years, mean 52.7 +/- 1.8 years) and were compared with 267 patients who received donor organs less than 50 years of age (range 9-49.9 years, mean 27.2 +/- 8.6 years). Patient and donor criteria were identical in both groups. Follow-up was 4 to 128 months with a mean of 37.4 +/- 2.8 months in the older donor group and 52.6 +/- 2.4 months in the younger donor group. RESULTS There were no differences between these 2 cohorts of patients regarding age, sex, cardiomyopathy, preoperative cytomegalovirus status, New York Heart Association class, and transplant status at transplantation. Donor characteristics, including sex, left ventricular ejection fraction, diabetes, cytomegalovirus status, and allograft ischemic times, were also similar in the 2 groups. Donor/recipient cytomegalovirus matching showed no differences as well. Thirty-day or to discharge operative mortality was similar in the older and younger donor groups (5% +/- 4.8% vs 3.5% +/- 1.1%; P =.84). Actuarial survival at 1 and 5 years was also similar in both groups (89.7% +/- 6.9% vs 91% +/- 1.8% and 53.1% +/- 14.7% vs 71.0% +/- 3.1%, respectively; P =.59). No patient in the older donor group required coronary artery bypass grafting or retransplantation during the follow-up period, whereas 2 patients in the younger donor group required coronary artery bypass, and 5 patients underwent retransplantation (P > or =.50). Two patients in the older donor group died of nonspecific allograft failure, whereas 3 patients in the younger donor group experienced similar posttransplant complication (P > or =.50). CONCLUSIONS Carefully selected donor hearts 50 years of age and older can be used for heart transplantation with long-term survival and related outcomes similar to those of younger donor organs. This use of selective cardiac allografts maximizes donor organ usage and expands the donor pool effectively without an adverse impact on long-term results.

BACKGROUND:Avoiding cardiopulmonary bypass in coronary artery bypass grafting is thought to reduce early mortality and morbidity.METHODS:We used our prospective database to compare all patients having off-pump coronary surgery (n = 389) with those having on-pump coronary surgery (n = 2412) between March 15, 1995, and November 1, 2000. Patients were grouped by age (years) in decades (>90, 80-89, 70-79, 60-69, <60 years). The Northern New England risk model was applied. Thirty-two independent variables were entered into a stepwise logistic regression analysis with the end points being surgical mortality and postoperative stroke.RESULTS:Patients undergoing off-pump operations were older (70.9 +/- 12 vs 68.1 +/- 11 years; P <.001), and their Northern New England predicted risk was higher (11.9% +/- 13% vs 9.2% +/- 10%; P <.001). However, patients having on-pump bypass had significantly more bypass grafts constructed (3.3 +/- 0.8 vs 1.9 +/- 0.8; P <.001) and triple-vessel coronary artery disease (58% vs 28%; P <.001). There were no significant differences in postoperative mortality, stroke rate, complications, and length of stay between the groups. Logistic regression analysis did not show that cardiopulmonary bypass was a risk factor for either surgical mortality (odds ratio, 1.08; P =.83) or stroke (odds ratio, 1.59; P =.27).CONCLUSION:Off-pump coronary bypass did not reduce early mortality and morbidity. Early and late results should be compared in a prospective randomized study.

Options for managing heart failure patients with cardiogenic shock refractory to inotropic and intra-aortic balloon pump (IABP) therapy are limited. Ventricular assist devices (VADs) can bridge these patients to heart transplantation. However, controversy exists over whether extracorporeal membrane oxygenation (ECMO) before VAD placement is beneficial. We report our use of biventricular assist devices (BiVADs) as a direct bridge to transplant. Since July 1999, 19 Thoratec BiVADs were implanted for heart failure unresponsive to medical therapy. Patient ages ranged from 20 to 67 years. Causes of heart failure included idiopathic 32%, ischemic 26%, postcardiotomy 21%, and other 21%. All patients were in cardiogenic shock, and three were receiving cardiopulmonary resuscitation (CPR) before implant. Preimplant conditions included IABP 89%, mechanical ventilation 68%, three or more inotropes 84%, hyperbilirubinemia 59%, acute renal failure 63%, and hemodialysis 16%. Fifty-nine percent of patients bridged successfully to transplantation, with 90% posttransplant survival. Duration of BiVAD support ranged from 0 to 91 days, with two patients currently on support awaiting transplantation. Complications included bleeding requiring reoperation 26%, stroke 11%, infection (any positive culture) 68%, and cannula site infection 5%. The Thoratec BiVAD can successfully be used as a direct bridge to transplantation in heart failure patients with cardiogenic shock.

Activations in Permanent Atrial Fibrillation. Introduction: Activation patterns during permanent atrial fibrillation (AF) in patients with organic heart diseases are unclear. Methods and Results: We studied six patients with permanent AF and organic heart diseases undergoing surgery. The duration of AF averaged 4.9 ± 7.6 years. Computerized epicardial mappings of the right atrial (RA) free wall and the left atrial (LA) posterior wall were simultaneously performed with 224 bipolar electrodes at 3‐mm spatial resolution. In the RA, large wavefronts and conduction blocks were frequently observed. The lines of block correlated with the crista terminalis and large pectinate muscles. In contrast, the LA had rapid repetitive activities originated from corners of the electrode plaque, near the four pulmonary veins (PVs). On average, 2.8 ± 1.2 sites of rapid repetitive activities were identified per patient. They activated continuously, intermittently, or alternately during AF. The mean activation cycle length in the RA (196 ± 22 msec) was significantly longer than that in the LA (179 ± 26 msec; P = 0.004). The maximum dominant frequency in the LA was higher than that in the RA (6.41 ± 1.18 Hz vs 5.66 ± 0.55 Hz; P = 0.049). The maximum dominant frequency was consistently located in areas with rapid repetitive activations near the PVs. Conclusion: During human permanent AF associated with organic heart diseases, the activation cycle length was shorter in the LA posterior wall than in the RA free wall. Rapid repetitive activities are consistently observed in the LA posterior wall, at or near the PVs.

OBJECTIVE:We sought to compare outcomes with tissue and St Jude Medical mechanical valves over a 20-year period.METHODS:Valve-related events and overall survival were analyzed in 2533 patients 18 years of age or older undergoing initial aortic, mitral, or combined aortic and mitral (double) valve replacement with a tissue valve (Hancock, Carpentier-Edwards porcine, or Carpentier-Edwards pericardial) or a St Jude Medical mechanical valve. Total follow-up was 13,390 patient-years. There were 666 St Jude Medical aortic valve replacements, 723 tissue aortic valve replacements, 513 St Jude Medical mitral valve replacements, 402 tissue mitral valve replacements, 161 St Jude Medical double valve replacements, and 68 tissue double valve replacements. The mean age was 68 +/- 13.3 years (St Jude Medical valve, 64.5 +/- 12.9; tissue valve, 72.0 +/- 12.6).RESULTS:There were no overall differences in survival between tissue and mechanical valves. Multivariable analysis indicated that the type of valve did not affect survival. Analysis by age less than 65 years or 65 years or older and presence or absence of coronary disease revealed similar long-term survival in all subgroups. The risk of hemorrhage was lower in patients receiving tissue aortic valve replacements but was not significantly different in patients receiving mitral valve or double valve replacements. Thromboembolism rates were similar for tissue and mechanical valve recipients. However, reoperation rates were significantly higher in patients receiving both aortic and mitral tissue valves. The reoperation hazard increased progressively with time both in patients receiving aortic and in those receiving mitral tissue valves. Overall valve complications were initially higher with mechanical aortic valves but not with mechanical mitral valves. However, valve complication rates later crossed over, with higher rates in tissue valve recipients after 7 years in patients undergoing mitral valve replacement and 10 years in those undergoing aortic valve replacement.CONCLUSIONS:Tissue and mechanical valve recipients have similar survival over 20 years of follow-up. The primary tradeoff is an increased risk of hemorrhage in patients receiving mechanical aortic valve replacements and an increased risk of late reoperation in all patients receiving tissue valve replacements. The risk of tissue valve reoperation increases progressively with time.

OBJECTIVES:We sought to determine the incidence of self-reported neurologic hand complications after radial artery harvest for coronary artery bypass grafting.METHODS:Between February 20, 1996, and December 31, 1999, 615 patients underwent coronary bypass operations with radial arteries. A scripted telephone interview was performed, collecting data on perceived thumb weakness and sensation abnormalities in the distribution of the radial nerve in 560 patients. The average time to follow-up interview was 14.5 +/- 9 months.RESULTS:Neurologic complications were reported in 30.1%, decreased thumb strength in 5.5%, and any sensation abnormality in 18.1% of patients. There was a high rate of symptom improvement over an average of 8.7 +/- 7.5 months, such that only 12.1% of patients reported symptoms without any improvement. Associations between thumb weakness and sensory abnormalities imply median nerve damage in some patients. There were statistically significant associations between neurologic complications and diabetes, peripheral vascular disease, elevated creatinine levels, smoking, and number and site of radial artery harvest.CONCLUSIONS:The overall rate of self-reported neurologic complications after radial artery harvest was higher than previously reported. These symptoms may be attributable to radial and median nerve injury caused by trauma and devascularization. These data have important implications not only in attempting to improve harvesting techniques but also in guiding informed consent before coronary artery bypass grafting.

Objective: Advanced age has traditionally been considered a contraindication for heart transplantation because of the reported adverse effect of increased age on long-term survival. However, as the field of transplantation continues to evolve, the criteria regarding the recipient's upper age limit have been expanded and older patients are being considered as potential candidates. We analyzed the outcome of heart transplantation in patients 70 years of age and older and compared these results with those in younger patients (<70 years) over a 4-year period. Method: We retrospectively analyzed the results of 15 patients 70 years of age and older who underwent heart transplantation between November 1994 and May 1999 and compared them with results in 98 younger patients undergoing transplantation during the same period Results: The older age group had a higher preoperative left ventricular ejection fraction (P =.02), higher incidence of female donors (P =.02), and longer cardiac allograft ischemic time (P =.01). No differences were found regarding incidence of diabetes mellitus, donor age, donor/recipient weight ratio, and mismatch (<0.80). The 30-day or to-discharge operative mortality was similar in both groups (0% in the older vs 5.1% in younger patients). Actuarial survival at 1 year and 4 years was not statistically different between the older and younger patients (93.3% ± 6.4% vs 88.3% ± 3.3% and 73.5% ± 13.6% vs 69.1% ± 5.8%, respectively). The length of intensive care unit stay and total post-transplantation hospital stay, incidence of rejection, and incidence of cytomegalovirus infection were similar between the groups. Conclusions: Heart transplantation in selected patients 70 years of age and older can be performed as successfully as in younger patients (<70 years of age) with similar morbidity, mortality, and intermediate-term survival. Advanced age as defined (≥70 years) should not be an exclusion criterion for heart transplantation. The risks and benefits of transplant surgery should be applied individually in a selective fashion. (J Thorac Cardiovasc Surg 2001;121:532-41)

We compared long-term survival in three cohorts of patients with known ischemic mitral regurgitation (MR). The cohorts consisted of (a) patients undergoing coronary bypass (CABG) with uncorrected mitral regurgitation (CABG+norep), (b) CABG and mitral repair (CABG+mrep) and (c) CABG and mitral replacement (CABG+mrepl). We found that overall, there was a poorer survival in patients undergoing mitral repair and replacement. When matched and stratified according to the severity of mitral regurgitation, mitral surgery did not improve survival in mild, moderate or severe regurgitation. We conclude that mitral valve surgery does not improve survival in patients with ischemic mitral regurgitation. These data may be explained by patient selection bias or the concept that the dominant pathology in ischemic mitral regurgitation is the ischemia, not the mitral valve abnormality.

We assessed the utility of milrinone to predict recovery of function after surgical myocardial revascularization in patients with severe baseline left ventricular systolic dysfunction caused by coronary artery disease (CAD). Prediction of viable myocardial segments that will regain function after revascularization may help in the selection of patients who will benefit from coronary artery bypass graft surgery (CABG) as well as aid in the choice of target sites for coronary revascularization. We investigated 20 consecutive patients with CAD and left ventricular ejection fraction < or = 40% who had evidence of myocardial viability by either thallium scan or dobutamine viability test and were candidates for elective CABG. Left ventricular regional wall motion and global ejection fraction were assessed by transesophageal echocardiography in the operating room. Measurements were done before and 10 minutes after milrinone infusion, and immediately after CABG. Left ventricular wall motion score was derived by means of a 12-segment model. Functional improvement for each segment was defined as a wall motion change > 1. Baseline ejection fraction was 27% +/- 5% (mean +/- SD). Ejection fraction increased to 35% +/- 5% after milrinone infusion (P < .0001) and to 36% +/- 6% after CABG (P < .0001). Post-CABG ejection fraction was significantly correlated with postmilrinone ejection fraction (r = 0.65, P < .0001). Milrinone infusion resulted in augmentation of contraction in 98 of the 209 abnormal segments (wall motion score > or = 2); 91 (92.9%) of these improved after CABG. One hundred nine of the 111 segments that showed no improvement with milrinone did not improve after revascularization (98.2%). Seventy-three segments were akinetic or dyskinetic at baseline; 46 (63.0%) of these improved with milrinone. Improvement in regional wall motion after revascularization was detected in 84.8% of the segments that improved with milrinone versus only 3.7% of the segments that did not improve with milrinone. In patients with ischemic cardiomyopathy, improvement in left ventricular function (segmental wall motion and global ejection fraction) during milrinone infusion is highly predictive of improvement after CABG.

Objectives: Combined heart-kidney transplantation with allografts from the same donor has been long proved to be a feasible approach for selected patients with coexisting end-stage cardiomyopathy and renal disease. The purpose of this retrospective study is to analyze our long-term results and compare these results with heart-only transplantation over a 7-year period. Methods: Between June 1992 and April 1999, 10 patients underwent combined heart-kidney transplantation at Cedars-Sinai Medical Center. They were all men from 44 to 70 years old (mean age, 59 ± 8.3 years) who had a mean left ventricular ejection fraction of 19.4% ± 5.0% (range, 9%-25%) and a mean creatinine clearance of 25.4 mL/min (range, 10-39 mL/min). Four patients underwent pretransplantation dialysis. Results: There was no operative mortality. The actuarial survival at 1, 2, and 5 years was 100%, 88% ± 11.7%, and 55% ± 20.1%, respectively. By comparison, the operative mortality of 169 patients who underwent heart-only transplantation during the same time interval was 2.4%, with an actuarial survival at 1, 2, and 5 years of 92% ± 2.1%, 84% ± 2.8%, and 71% ± 3.9%, respectively (P = .37). Eight patients showed no evidence of significant (≥1B) cardiac allograft rejection postoperatively, and the actuarial freedom from rejection at 30 days, 1 year, and 2 years was 90% ± 9%, 80% ± 13%, and 80% ± 13%, respectively. Renal allograft survival was 90% at 1 and 2 years. Conclusions: Combined heart-kidney transplantation yields satisfactory long-term results similar to those for heart-only transplantation, with a low incidence of cardiac allograft rejection and renal allograft survival when both allografts are from the same donor. This approach effectively expands the selection criteria for heart-only and kidney-only transplantation in potential candidates with coexisting end-stage cardiac and renal disease.

Background. With the rapid growth of the elderly segment of the population, more octogenarians are referred for complex cardiac interventions, including reoperations. Data regarding the outcomes, quality of life, and long-term results after reoperative open-heart surgical procedures in octogenarians are scarce.Methods. We retrospectively studied 113 consecutive octogenarians (mean age, 83 +/- 2.6 years) who underwent reoperative cardiac procedures within a 13-year period. Coronary artery bypass grafting (CABG) was performed in 49 patients (CABG group), valvular procedures (aortic, mitral, or tricuspid valve, alone or in combination) in 35 (valve group), and combined CABG and valve intervention in 29 (combined CABG and valve group).Results. The 30-day mortality rate was 8% (4 of 49) for the CABG group, 9% (3 of 35) for the valve group, and 17% (5 of 29) for the combined CABG and valve group. One- and 5-year actuarial survival rates were, respectively, 85% +/- 5% and 58% +/- 10% for the CABG group, 78% +/- 7% and 53% +/- 12% for the valve group, and 69% +/- 9% and 63% +/- 10% for the combined CABG and valve group. Sixty-one percent of patients in the CABG group, 40% in the valve group, and 38% in the combined CABG and valve group were in New York Heart Association class I or II postoperatively at a mean follow-up time of 2.1 +/- 2.4 years. Similarly 91%, 85%, and 80%, respectively, thought that they had an improved quality of life and were satisfied with their functional status.Conclusions. Cardiac reoperations can be performed successfully in most octogenarians, although with an increased risk, particularly in the combined CABG and valve group. Long-term survival is acceptable with improved quality of life and functional status. However, it is possible that these results could be improved in this high-risk group of patients with earlier referral and surgical intervention, for the effective use of health care resources. (C) 1999 by The Society of Thoracic Surgeons.

Critical Mass for Human Ventricular Fibrillation. Introduction: The critical mass for human ventricular fibrillation (VF) and its electrical determinants are unclear, The goal of this study was to evaluate the relationship between repolarization characteristics and critical mass for VF in diseased human cardiac tissues.Methods and Results: Eight native hearts from transplant recipients were studied. The right ventricle was immediately excised, then perfused (n = 6) or superfused (n = 2) with Tyrode's solution at 36 degrees C. The action potential duration (APD) restitution curve was determined by an S-1-S-2 method, Programmed stimulation and burst pacing were used to induce VF. In 3 of 8 tissues, 10 mu M cromakalim, an ATP-sensitive potassium channel opener, was added to the perfusate and the stimulation protocol repeated. Results show that, at baseline, VF did not occur either spontaneously or during rewarming, and it could not be induced by aggressive electrical stimulation in any tissue. The mean APD at 90% depolarization (APD(90)) at a cycle length of 600 msec was 227 +/- 49 msec, and the mean slope of the APD restitution curve was 0.22 +/- 0.08, Among the six tissues perfused, five were not treated with any antiarrhythmic agent. The weight of these five heart samples averaged 111 +/- 23 g (range 85 to 138). However, after cromakalim infusion, sustained VF (> 30 min in duration) was consistently induced. As compared with baseline in the same tissues, cromakalim shortened the APD,, from 243 +/- 32 msec to 55 +/- 18 msec (P < 0.001) and increased the maximum slope of the APD restitution curve from 0.24 +/- 0.11 to 1.43 +/- 0.10 (P < 0.01).Conclusion: At baseline, the critical mass for VF in diseased human hearts in vitro is > 111 g. However, the critical mass for VF can vary, as it can be reduced by shortening APD and increasing the dope of the APD restitution curve.