Background: The Core Curriculum Review Course in Cardiovascular and Thoracic Surgery is a 4-day educational program consisting of 77 didactic lectures that provide a comprehensive review of the material required for surgeons preparing for the American Board of Thoracic Surgery competency written examination. The lectures are supplemented with a written syllabus and interactive audience participation system. We sought to determine whether participation in this course could improve participants' performance on a cardiothoracic subject-based test. Methods: Sixty-five participants attended the 2018 course. Before beginning the course lectures, a multiple-choice pretest consisting of 77 questions was administered via mobile application to gauge the participants' baseline knowledge. A second multiple-choice posttest was made available beginning 7 weeks after the course, also by mobile application. Results: Twenty-nine participants completed both the pretest and the posttest. The median pretest score was 47% (36 of 77 correct answers). The median posttest score was 61% (47 of 77 correct answers), representing an increase of 14%. The Wilcoxon signed-rank test indicated a significant difference between the pretest and posttest scores (z = -4.36; P = .00). Overall, 25 participants (86%) improved their posttest score. Conclusions: The core curriculum review course was successful in improving participants' performance on the course tests, indicating that the participants' fund of knowledge was likely increased by attendance at the program. Additional strategies should be considered to address particular areas of study both for individual participants and for residents currently in training.

OBJECTIVE:This study compares clinical results of the standard Maze III operation, a highly effective treatment for atrial fibrillation, to less complex variations of the Maze III operation utilizing unipolar and bipolar radiofrequency ablation and pulmonary vein isolation.METHODS:Records were reviewed of 377 patients who had operations for treatment of atrial fibrillation at a single institution over a 10-year period. Standard Maze III was performed in 220 patients, unipolar radiofrequency Maze III in 60, bipolar radiofrequency Maze III in 65, and radiofrequency pulmonary vein isolation in 32. Electrocardiograms were obtained at discharge and 3-, 6-, and 12-month intervals. Chi-square test, logistic regression, and Bayesian theory analyses were performed to determine significant associations between operative procedures and outcomes.RESULTS:Mean age was 65.1 years (range 22-87). There were 13 hospital deaths (3.4%) and 16 deaths during follow-up. Most patients (90.2%, 340/377) had concomitant operations. Electrocardiogram analysis was available in 344 patients at 3 months and 313 patients at 6 months. Freedom from atrial fibrillation at 6 months was superior after standard Maze III compared with radiofrequency modifications. Subanalysis according to surgeon experience demonstrated good results regardless of operative experience.CONCLUSIONS:This single-institution experience suggests that the standard Maze III operation is superior to radiofrequency operations for treatment of atrial fibrillation. Radiofrequency modifications of the Maze III operation are also effective treatments for atrial fibrillation and can achieve good results regardless of surgeon experience.

Background: Repeat operation on the heart composes about 20% of procedures in contemporary practice of cardiac surgery. A sheet of material providing a barrier against cardiac adhesion to the sternum would be desirable. Methods: Anterior pericardiectomy was performed in rats. BioGlue((R)) milled to a 0.4 mm sheet was applied to the anterior surface of the heart in 16 rats; Surgicel((R)) plus liquid BioGlue5 in seven; Surgicel alone in three; and nothing (control) in eight. The operative site was reexamined for gross evidence of adhesion, scarring, and residual BioGlue((R)) 1, 3, and 6 months later. Results: There was formation of a loose connective tissue barrier containing blood vessels without scar formation in all animals treated with milled BioGlue((R)). Surgicel((R)) plus BioGlueO resulted in a barrier containing more denser connective tissue with Collagen fibers. Surgicel((R)) alone resulted in a similar barrier. No barrier formed in the control experiments. Conclusions: A sheet of milled BioGlue((R)) applied over the surface of the heart but not attached to it after partial pericardiectomy has been shown to stimulate formation of a loose connective tissue barrier containing blood vessels. This barrier is unique compared to dense fibrous scar which usually forms after opening the pericardium for cardiac operations.

PURPOSE: Pectus excavatum is a challenging clinical problem in the adult or adolescent patient due to the more rigid thoracic wall and advanced body self image. Long-term results of the sternal eversion technique are not currently described.

BACKGROUND:This study was performed to evaluate and compare the early, intermediate, and long-term outcomes of the bidirectional Glenn procedure and Fontan procedure in patients who live at moderately high altitude. METHODS:The outcome of each method of palliation for patients with a functionally single ventricle was retrospectively evaluated from a review of medical records. RESULTS:The bidirectional Glenn procedure was performed in 177 patients from October 1984 to June 2004. The Fontan procedure was performed in 149 patients from June 1978 to June 2004. Cardiovascular death or heart transplantation occurred in 8% of patients after the bidirectional Glenn procedure and 17% of patients after the Fontan procedure. Complications of systemic thromboembolic events, bleeding associated with anticoagulation therapy, protein losing enteropathy, and arrhythmias requiring implantation of a pacemaker, cardioversion, or radiofrequency ablation occurred in 7% of patients after the bidirectional Glenn procedure and 47% of patients after the Fontan procedure. Cardiovascular deaths and heart transplantation occurred less frequently when the Fontan procedure was performed in patients with a previous bidirectional Glenn procedure. However, the actuarial transplant-free survival and freedom from complications was not superior for a subgroup of patients who had a Fontan procedure after a bidirectional Glenn procedure in comparison to a subgroup of patients who had a bidirectional Glenn procedure alone. CONCLUSIONS:The bidirectional Glenn procedure can be used for long-term palliation of patients with a functionally single ventricle. Additional palliation with a Fontan procedure may increase the risk of stroke, protein losing enteropathy and arrhythmias without improving survival.

Disease of the aortic valve is frequently associated with morphologic abnormalities of the ascending aorta and the aortic arch. Ectasia of the ascending aorta is commonly associated with bicuspid aortic valve. Degenerative aortic valve disease is often associated with atherosclerotic deposits or aneurysm in the ascending aorta and the aortic arch. Aortic valve disease causing hemodynamic burden sufficient to affect left ventricular structure or function is indication for operation to replace the aortic valve. Current practice dictates replacement of the ascending aorta and/or arch in combination with replacement of the aortic valve because the aortic disease usually does not stabilize and, in fact, progresses despite resolution of disease of the aortic valve. Similarly, aortic disease requiring primary operative intervention in the presence of morphologic abnormalities of the aortic valve is best treated by combined replacement operation because of the frequency of early reoperation on the aortic valve. More aggressive treatment of combined aortic valve and aortic disease has been prompted by the frequent necessity of reoperation for progression of associated morphologic abnormalities, availability of improved aortic valve bioprostheses, and improved ability of surgeons to treat associated disease in a single operation. This article demonstrates use of a stentless aortic root bioprosthesis to replace the aortic valve and aortic root for aortic valve disease associated with (1) aneurysm of ascending aorta; (2) extensive atherosclerotic ulcerated plaque disease of aorta; and (3) coarctation of aorta. These operations are applied in adults and in all cases used the Medtronic Freestyle® aortic root bioprosthesis (Medtronic, Inc., Minneapolis, MN). This device was chosen because of proven efficacy and durability, excellent hemodynamic performance, and no requirement for anticoagulant therapy.1Bach D.S. Kon N.D. Dumesnil J.G. et al.Ten-year outcome after aortic valve replacement with the freestyle stentless bioprosthesis.Ann Thorac Surg. 2005; 80: 480-486Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar A midline sternotomy incision is made. An aortic perfusion cannula is placed in the distal part of the aortic arch with the tip in the upper portion of the descending thoracic aorta beyond the origin of the left subclavian artery. Alternatively, the right axillary artery may be perfused via a 6-mm tubular polyester prosthesis anastomosed to the side of the artery. A two-stage venous uptake catheter is placed in the right atrium. Cardiopulmonary bypass is established with systemic cooling of the body toward a target temperature of 16 to 20°C. An occlusion clamp is placed on the ascending aorta, and the heart is cooled to 4°C via a catheter placed in the coronary sinus. Retrograde perfusion of the coronary sinus is repeated at 20-minute intervals to maintain heart temperature below 20°C throughout the operation. The aorta is divided 1 cm above the sinotubular junction and just below the occlusion clamp. A tubular polyester vascular prosthesis is selected for replacement of the aorta. The diameter chosen should be approximately equal to the diameter of the distal aorta at the endpoint of the resection. An end-to-end anastomosis of the graft to the aorta is constructed using continuous stitches of 3/0 or 4/0 polypropylene suture. The anastomosis is sealed with BioGlue® (CryoLife, Inc., Kennesaw, GA). Placing a Hegar dilator or valve size calibrator the same diameter as the aortic graft into the anastomosis through the graft when the glue is applied achieves better sealing by smoothing small kinks or folds in the tissue and fabric. Cardiopulmonary bypass is restarted by slowly filling the aorta while agitating the arch arterial branches to dislodge air or to allow debris to float out through the open proximal end of the graft. The occlusion clamp is replaced on the aortic graft. Pump flow is increased and the body temperature is increased toward normal. Cannulation for cardiopulmonary bypass is the same as described previously except axillary artery perfusion may be favored. A soft spot in the distal aortic arch may also be cannulated, provided the tip of the cannula is beyond the origin of the left subclavian artery. Cardiopulmonary bypass is established and the temperature of the body is lowered toward a target temperature of 16°C. Extreme care is taken when occluding the ascending aorta. The occlusion clamp must be placed on a disease-free area as best as can be ascertained by gentle palpation with limited manipulation of the aorta. There is usually a good spot near the sinotubular junction even when one finds extensive disease in the ascending aorta. Cold cardioplegic solution is administered intermittently by retrograde perfusion of the coronary sinus. The aorta is divided at the sinotubular junction and the aortic root is prepared for replacement as described previously. Part of the replacement may be accomplished during the longer body cooling period required to reach 16°C to assure a safe circulatory arrest time of up to 60 minutes. The patient is prepared for operation as described previously. Cardiopulmonary bypass is established and the body temperature is lowered to provide hypothermic protection of the spinal cord. While the body is cooling, the ascending aorta is occluded, and the heart is protected by retrograde cold cardioplegia. The aortic root is excised and prepared for replacement with an appropriate size aortic root bioprosthesis. The dilated portion of the ascending aorta is excised. When the body temperature reaches 18 to 20°C, cardiopulmonary bypass is discontinued. The aortic occlusion clamp is removed, all dilated aorta are excised, and the distal anastomosis of a tubular polyester graft to the aortic arch is performed as described previously. Figure 2The aortic valve is excised and calcareous deposits are removed from the aortic root. The coronary arteries are separated from the aorta retaining a generous button of sinus aorta around the orifice. Mobilization of the coronary arteries is minimal, if at all. The noncoronary sinus aorta is removed. The diameter of the aorta at the “annulus” is calibrated and an appropriate size aortic root bioprosthesis is selected. The diameter of the bioprosthesis may be the same size or 2 mm larger than the diameter of the aortic annulus. The bioprosthesis is taken through the standard rinsing process to remove glutaraldehyde. By this stage of the operation the body temperature has usually reached the target temperature.View Large Image Figure ViewerDownload (PPT)Figure 3Cardiopulmonary bypass is discontinued and blood is drained from the patient to the reservoir of the oxygenator. The patient is placed in deep head-down position. The occlusion clamp is removed from the aorta. Abnormal aorta is excised, going through the aortic arch if necessary. The aortic excision should be complete and extend until the aorta becomes normal diameter. Aortic dilation extending into the descending thoracic aorta dictates a staged operation. Generally, the abnormal aorta can be encompassed by oblique excision of the aortic arch and the aortic perfusion cannula need not be removed.View Large Image Figure ViewerDownload (PPT)Figure 4The aortic root is replaced with the previously selected aortic root bioprosthesis.2Doty D.B. Cardiac Surgery: Operative Technique. Mosby, St. Louis, MO1997: 236-237Google Scholar Retraction stitches placed at the apex of the aortic valve commissures enhance exposure. Continuous stitches of 3/0 polypropylene are used to attach the inflow suture cuff of the bioprosthesis to the aortic valve annulus. The bioprosthesis is placed in anatomic position relative to the coronary arteries. A small taper-cut needle makes perforation of the sewing cuff easier. Markers on the sewing cuff are used to align the device with the commissures. The bioprosthesis is held apart from the annulus as the suture loops are placed. A heavy silk suture (2/0 or 0) is passed around every third suture loop to make pulling up of the suture loops easier. Suturing begins below the commissure between the left and right aortic sinuses and proceeds clockwise to the mid point of the noncoronary sinus. Returning to the starting point, the opposite end of the suture is used proceeding counterclockwise below the left sinus to completion in the noncoronary sinus. The bioprosthesis is seated in the aortic root by pulling up on the silk tension sutures sequentially. The suture line is sealed with BioGlue®.View Large Image Figure ViewerDownload (PPT)Figure 5The porcine left coronary artery is removed from the bioprosthesis to create a generous opening. The left coronary artery usually fits perfectly to the prosthesis. Continuous stitches of 5/0 polypropylene suture are used to anastomose the coronary artery button to the graft.View Large Image Figure ViewerDownload (PPT)Figure 6The right coronary artery may not exactly approximate the position of the porcine right coronary artery on the bioprosthesis. Thus, the site of the opening into the right coronary sinus is adjusted appropriately but usually includes some of the graft right coronary artery. The right coronary button is anastomosed to the graft using 5/0 polypropylene suture. Coronary artery anastomoses are sealed with BioGlue®.. Evidence of myocardial ischemia after aortic root replacement is indication for relocation of the coronary anastomosis or coronary artery bypass graft.View Large Image Figure ViewerDownload (PPT)Figure 7The aortic graft is shortened appropriately and the aortic root bioprosthesis and aortic graft are beveled with the lateral walls longer than medial to achieve a natural shape of the aorta and reduce chance for kinking. A cuff of the graft is fashioned and placed over the graft to cover the anastomosis. An end-to-end anastomosis of the bioprosthesis to the graft is constructed using continuous stitches of 4/0 polypropylene suture to complete the repair. BioGlue® is infused under the reinforcing cuff to attach it to and seal the anastomosis.View Large Image Figure ViewerDownload (PPT)Figure 8Degenerative aortic valve disease may be accompanied by atherosclerotic disease of the ascending aorta and arch. Ulcerated atherosclerotic plaques in the aorta place the patient at risk for intraoperative stroke due to atheroemboli. Addressing this risk factor during aortic root replacement should improve survival and reduce neurologic comorbidity.View Large Image Figure ViewerDownload (PPT)Figure 9Cardiopulmonary bypass is discontinued when body temperature reaches 16°C. The occlusion clamp is removed from the aorta. The aorta is divided just proximal to the origin of the brachiocephalic artery. The entire ascending aorta is excised. The aortic arch is examined and the extent of atherosclerotic involvement is determined. Part of the aortic arch can be excised by oblique incision across the inferior aspect. Dissection plane is opened between the aortic media and adventitia.View Large Image Figure ViewerDownload (PPT)Figure 10Working through the open end of the aorta, an endarterectomy of the affected portion of the arch is performed. This may require removing all of the arch intima-media and extending the dissection into the arch arterial branches. Smooth attachment of arterial intima must be assured at the endpoint of the endarterectomy when atheromatous disease is removed from arch branches. Endarterectomy extending into the artery beyond visualization of the intima (blind endarterectomy) may be required but adds risk to the procedure.View Large Image Figure ViewerDownload (PPT)Figure 11A tubular polyester vascular graft is tailored obliquely when part of the arch has been removed. Placing the short angle of the graft medially on the aortic arch prevents kinking of the graft as it is brought down to the aortic root. An end-to-end anastomosis of the graft to the aortic arch is constructed using continuous stitches of 4/0 polypropylene suture. The anastomosis is sealed with BioGlue® as described previously. Cardiopulmonary bypass flow is restored and air and debris are removed from the aorta as described previously. The aortic root is replaced with an aortic root bioprosthesis and the aortic graft is anastomosed to the root bioprosthesis as described previously to complete the repair. The bioprosthesis to ascending aorta graft anastomosis is sealed with BioGlue®.View Large Image Figure ViewerDownload (PPT)Figure 12Coarctation of the aorta is frequently associated with bicuspid aortic valve diagnosed during infancy. Dilation or aneurysm of the ascending aorta is acquired later in life. Coarctation treated during infancy or childhood may present with residual or recurrent aortic obstruction when associated aortic valve disease has progressed and requires aortic valve replacement. Approaching the upper descending aorta at reoperation carries considerable risk of not only hemorrhage but also spinal cord injury. Bypass of the aortic obstruction is an acceptable and probably preferable safe single-stage operation in patients at adult or near-adult body size.View Large Image Figure ViewerDownload (PPT)Figure 13The heart is elevated from the pericardial sac and retracted superiorly. The pericardial sac posterior to the heart is opened over the descending aorta. Minimal dissection is required to expose sufficient aorta to allow occlusion with “C”-shaped vascular clamp. If the aorta is small, two 20°-angle vascular clamps may work better. The aorta is incised longitudinally. A 10-mm-diameter externally supported tubular polytetrafluoroethylene graft is selected. An end-to-side anastomosis of the graft to the aorta is constructed using continuous stitches of 4/0 or 5/0 polypropylene. Placing several or even all suture loops between the graft and aorta before approximating the graft to the aorta simplifies the anastomosis. BioGlue® is used to seal the anastomosis. Cardiopulmonary bypass flow is restored and the body temperature is increased. The aortic occlusion clamp is moved from the aorta to the graft. Hemostasis is assured at this point of the operation because it is difficult to get back to the anastomosis after the heart is filled and beating.View Large Image Figure ViewerDownload (PPT)Figure 14An opening is made in the pericardial reflection posterior to the inferior vena cava. The graft is pulled through this opening so that it lies in the pericardial sac between the inferior vena cava and the right inferior pulmonary vein, taking a course along the interatrial groove to the right lateral aspect of the aorta.3Doty D.B. Extra-anatomic aortic bypass for thoracic aortic obstruction (letter).J Thorac Cardiovasc Surg. 2001; 121: 1222-1223PubMed Google ScholarView Large Image Figure ViewerDownload (PPT)Figure 15The aortic root is replaced with an aortic root bioprosthesis. The aortic graft is anastomosed to the aortic root bioprosthesis. An opening is made in the right lateral aspect of the aortic graft above the level of the junction of the superior vena cava with the right atrium. The aortic bypass graft is anastomosed to the ascending aorta graft in end-to-side fashion using continuous stitches of 4/0 polyprolene suture (Fig. 16). The anastomosis is sealed with BioGlue®.View Large Image Figure ViewerDownload (PPT) Three techniques are described herein which allow one-stage treatment of aortic problems associated with aortic root disease. Similarly, aortic root replacement in conjunction with treatment of primarily aortic pathologic change may be accomplished in a one-stage operation providing thorough correction of all abnormalities. Complete repair of aortic and aortic valve malformations should reduce comorbidity and prevent interim progression of disease which could lead to reoperation prematurely.

This report demonstrates the method of resection of a left atrial tumor involving the right superior pulmonary vein. The unique features are use of adjacent pericardium as an in situ patch to reconstruct the left atrium when there is no margin of left atrium remaining on the pulmonary veins and cardiac autotransplantation.

Background. A variety of indications (eg, prosthetic heart valves, atrial fibrillation, etc.) exist for the use of unfractionated heparin (UFH) and enoxaparin (ENOX) in the early postoperative period following open-heart surgery. However, the overall postoperative risk for hemorrhage from the use of UFH and ENOX are not known. Methods. From 1998 to 2001, 2,977 consecutive open-heart or valve surgery patients were retrospectively evaluated. Postoperatively, 2,037 received no UFH or ENOX, 579 received intravenous UFH, and 361 received ENOX. Baseline characteristics were collected, patients who required surgical re-exploration for postoperative bleeding and time between surgery and re-exploration were followed-up.Results. Average patient ages were 64 +/- 13, 65 +/- 12, and 68 +/- 10 years receiving none, UFH (p < 0.01 vs none), and ENOX (p < 0.01 vs none; p < 0.01 vs UFH), respectively. Rates of surgical re-exploration were 2.7% for none, 7.8% for UFH, and 8.9% for ENOX (vs none, adjusted hazard ratio = 2.8; p < 0.001 for UFH; hazard ratio = 3.3; p < 0.001 for ENOX). Males were also at higher risk for re-exploration (hazard ratio = 1.4; p = 0.07). For those requiring re-exploration, the interval between surgery and first re-exploration was prolonged (> 4 days) among those receiving ENOX (37.5%, odds ratio = 36.7; p = 0.001) and UFH (20.0%, odds ratio = 14.7; p = 0.01) compared with none (1.8%). Prolonged times with ENOX had a greater proportion of prolonged times than UFH (odds ratio = 2.5; P = 0.09).Conclusions. Early postoperative use of ENOX and UFH is associated with a significant increase in reexploration for postoperative bleeding, often at a significantly delayed time period after the initial surgery. This delay was especially common with ENOX suggesting the need for prospective studies.

Background. Stentless aortic bioprostheses offer excellent hemodynamics and potentially improved durability compared with other bioprostheses. The present report describes the clinical and hemodynamic outcomes for the Freestyle aortic root bioprosthesis in a large, multicenter cohort prospectively followed up for 10 years.Methods. A total of 725 patients at 8 centers in North America (668 [92%] aged more than 60 years) were followed up prospectively after aortic valve replacement with the Freestyle stentless bioprosthesis. Implant technique was subcoronary in 509, total root in 178, and root inclusion in 38. Follow-up was 4,488 patient-years (mean 6.2 years/patient).Results. For subcoronary, full root, and root inclusion groups, 10-year actuarial freedom from structural valve deterioration was 97.0% +/- 2.2%, 96.0% +/- 4.5%, and 90.9% +/- 11.2%, respectively; and actuarial freedom from reoperation was 91.7% +/- 3.5%, 92.3% +/- 6.0%, and 92.0% +/- 10.7%, respectively. Mean pressure gradient at 10 years was 8.9 +/- 7.9 mm Hg for subcoronary, 7.0 +/- 4.1 mm Hg for full root, and 10.0 +/- 11.1 mm Hg for root inclusion groups; effective orifice area was 1.6 +/- 0.5 cm(2), 1.6 +/- 0.6 cm(2), and 1.7 +/- 0.5 cm(2), respectively. Freedom from moderate or more aortic regurgitation at 10 years was good for all three implant groups, but slightly higher for full root (97.7% +/- 1.6%) compared with subcoronary (87.2% +/- 2.8%) patients (p < 0.005).Conclusions. The Freestyle stentless aortic root bioprosthesis is a versatile option for aortic valve replacement. Measures of clinical outcomes and prosthesis durability remain excellent through 10 years.

OBJECTIVES:We sought to describe the hemodynamic and clinical outcomes for the Freestyle aortic root bioprosthesis (Medtronic, Inc, Minneapolis, Minn) in a large multicenter cohort prospectively followed for 8 years.METHODS:A total of 700 patients (651 [93%] >60 years of age) at 8 centers in North America were followed prospectively after aortic valve replacement with the Freestyle stentless bioprosthesis; the implant technique was subcoronary in 500, total root in 162, and root inclusion in 38. Follow-up was 3395 patient-years (4.9 +/- 2.3 years per patient). Clinical and echocardiographic follow-up was prospectively obtained at yearly intervals.RESULTS:For the subcoronary, total root, and root inclusion groups, actuarial freedom from valve-related death was 96.8% (SE 3.0%), 92.3% (SE 7.7%), and 90.9% (SE 11.2%), respectively, and freedom from structural deterioration was 98.6% (SE 2.0%), 100.0% (SE 0.0%), and 100.0% (SE 0.0%), respectively. Hemodynamics remained excellent at 6 years. Freedom from moderate or more aortic regurgitation was 86.0% (SE 5.1%), 98.7% (SE 3.9%), and 97.3% (SE 6.6%), respectively. Gradients were slightly lower (P =.0009), and the effective orifice area (P =.02) and freedom from aortic regurgitation were slightly higher (P =.03) with total root than subcoronary implantation.CONCLUSIONS:The Freestyle stentless aortic root bioprosthesis is a versatile option for aortic valve replacement. Measures of clinical outcomes and prosthesis durability remain excellent in multicenter follow-up through 8 years in a population predominantly older than 60 years at the time of the operation.

A 24-year-old woman experienced severe tricuspid valve regurgitation 6 years after heart transplantation. Tricuspid valve replacement was performed using a cryopreserved mitral valve homograft.* Severe tricuspid valve regurgitation recurred within 4 months, associated with an increase in the panel reactive antibody titers from zero to 72%. Tricuspid valve replacement was repeated with a porcine bioprosthesis with excellent recovery and function for >2 years. The mitral valve homograft displayed inflammatory features consistent with humoral immune-mediated destruction. Copyright (C) 2004 by the International Society for Heart and Lung Transplantation.

This article reviews the fundamentals of surgical treatment of atrial fibrillation. The clinical classification, pathophysiology, medical treatment strategy, and catheter-based interventions are also included. The Cox-Maze III procedure was developed over based on experiences of several operations which proceeded it. The operation is complex but results are excellent with over 90% of patients in normal sinus rhythm or regular atrial rhythm. Several modifications have been devised using various energies to ablate atrial myocardium as a means of extending surgical incisions to simplify the Maze III operation. Techniques and results of these operations are reviewed. Modified operations offering about 80% restoration of sinus rhythm are attractive to more surgeons because of the reduced complexity and time of operation.

Background. The incidence of rheumatic heart disease (RHD) has increased recently in the western United States. We reviewed our 18-year surgical experience with RHD in children to examine current surgical techniques and results.Methods. From 1985 until 2003, 596 children (<21 years) with rheumatic fever were seen at Primary Children's Medical Center. Rheumatic carditis was diagnosed in 366 patients (61.4%). Twenty-six with carditis (26/366, 7.1%) required operation for rheumatic valve disease including 8 for mitral regurgitation, 7 for mitral and aortic regurgitation, 4 for aortic regurgitation, 4 for mitral regurgitation and stenosis, 2 for combined mitral stenosis and regurgitation with aortic insufficiency, and 1 for mitral and tricuspid regurgitation.Results. Mean age at operation was 13.5 +/- 4 years. Three patients required operation during the acute phase of rheumatic fever (<6 weeks), 2 during the subacute phase (<6 months), and 21 during the chronic phase after the episode of rheumatic fever (6.7 +/- 3 years). Mitral valve repair was possible in 19 of 22 patients who required mitral operation. Aortic valve repair was possible in 4 patients whereas replacement was necessary in 9, including 2 Ross procedures. No operative deaths were recorded and 2 late deaths occurred at 4.6 and 10 years. Actuarial survival was 94% at 5 years and 78% at 10 years. Six patients required reoperation; actuarial freedom from reoperation was 78% at 5 years, 65% at 10 years, and 49% at 15 years. All survivors are in New York Heart Association class I or II.Conclusions. Children with RHD in the United States uncommonly require valve operation. Mitral repair with a technique that allows annular growth is possible in most children with good long-term functional results. Long-term surveillance of children with RHD is necessary because of the possible need for late valve operation. (C) 2004 by The Society of Thoracic Surgeons.