Introduction The treatment of Ischaemic Heart Disease is the improvement of blood flow to underperfused myocardium. The mainstay of this treatment are Coronary Artery Bypass Graft surgery (CABG) and Percutaneous Transluminal Coronary Angioplasty PTCA). Even with the success of these interventions, there remain many patients with disabling angina who are not candidates for these procedures because of diffuse and small vessel disease, endstage coronary . vascular disease, low LVEF or elderly population over 65 patients of age with associated reversible risk factors . Like anaemia, Congestive Heart Failure, Systemic. Material & Methods To benefit the older population from the highly sophisticated technology of TMR we have evaluated 23 patients retrospectively. This analysis revolves round the pre and post-operative date and results with view to follow up regarding clinical improvement, regression of anginal class, complications in a detailed analysis. There are 18 males and 5 females with age range of 65 years - 8 3 years and a mean average age of 6 9 . 0 8 years. 21 are Saudi national. 20 patients belonged to stable angina group while 3 had unstable angina. The coronary angiograms revealed 20 patients with 3VD, 2 patients with 2VD and only 1 patient had single vessel. 14 patients hadnon graftable diffuse small vessel disease while 9 were graftable. 1 7 patients underwent left anterior thoracotomy while 6 underwent sternotomy. Risk factor evaluation revealed that 1 7 patients were hypertensive, 1 5 were diabetic and 5 were obese, 3 patients had hypercholesterolaemia and 1 patient had peripheral artery disease of both legs. Results All the patients were followed up at 6 months and 12 months and were compared to their values pf pre TMR level and data were analysed. Conclusion The prevalence and severity of coronary atherosclerosis increases so dramatically with age that more than one-half of all deaths in people aged 65 years of older are due to coronary disease and about three fourth of all deaths from ischaemic heart disease occurs in the elderly.

Aggressive therapy is needed in the presence of resistance Acute Left Ventricular Failure, commonly seen after large Myocardial Infarction or following Cardio Pulmonary Bypass if myocardial function may be severely depressed. When Ac. pump failure is so severe that adequate ,Cardiac Output cannot be maintained, hypotension may ensure despite an ele vated Perepheral Resistance, presenting picture of cardiogenic shock. Catecholamines or other symp athomimetic ammies maybe required in this setting. These agents exert potent inotropic effects by stimul ation of the beta I. adrenergic receptors.Although structurally dissimilar from one another and from the methyxanthines, these agents appear to inhibit phosphodiesterase (PDE) fraction III, the cyclic AMP specific cardiac phosphodiesterase, selectively and potently. Blocking the normal breakdown of cyclic nucleobide by PDE should also increase intrac ellular cyclic AMP levels increase contractility. Alt hough the traditional PDE inhibitors, e.g., theophyll ine, exert this effect, hut they are non selective and non potent.

Heart transplantation is not yet socially acceptable in the Middle East, and left ventricular assist facilities are not generally available in this region. Therefore, left ventricular volume reduction surgery was attempted in 41 patients with end-stage heart failure (33 males; median age, 36.3 years) in 4 Middle Eastern tertiary referral centers between February 1996 and January 2001. Heart failure was due to idiopathic cardiomyopathy in 21 patients, ischemia in 11, rheumatic valvular disease in 8, and viral myocarditis in 1. Associated procedures were aortic valve replacement in 5 patients, mitral valve repair in 25, mitral valve replacement in 7, tricuspid valve repair in 6, and coronary bypass grafting in 8. Hospital mortality was 31.7%. Five patients were lost to follow-up. The survival rate of hospital survivors at 18 months was 65.2%. Three of the surviving patients did not benefit from the operation. Although our results were somewhat disappointing, this operation remains an option for surgeons working in developing areas of the world. It is hoped that better patient selection and new techniques of left ventricular volume reduction that avoid resection of viable muscle will further improve the outcome of this operation.

Human uterine transplantation was performed on 6 April 2000 on a 26-year-old female who lost her uterus 6 years earlier due to post-partum hemorrhage. The donor, a 46-year-old patient with multiloculated ovarian cysts, underwent a hysterectomy modified to preserve tissue and vascular integrity. The donor uterus was connected in the orthotopic position to the recipient's vaginal vault and additional fixation was achieved by shortening the uterosacral ligament. The uterine arteries and veins were extended using reversed segments of the great saphenous vein, then connected to the external iliac arteries and veins, respectively. Immunosuppression was maintained by oral cyclosporine A (4 mg/kg/body wt.), azathioprine (1 mg/kg/body wt.) and prednisolone (0.2 mg/kg/body wt.). Allograft rejection was monitored by Echo-Doppler studies, magnetic resonance imaging (MRI), and measurement of the CD4/CD8 ratio in peripheral blood by fluorescence activated cell sorter (FACS scan). An episode of acute rejection was treated and controlled on the ninth day with anti-thymocytic globulin (ATG). The transplanted uterus responded well to combined estrogen--progesterone therapy, with endometrial proliferation up to 18 mm. The patient had two episodes of withdrawal bleeding upon cessation of the hormonal therapy. Unfortunately, she developed acute vascular thrombosis 99 days after transplantation, and hysterectomy was necessary. Macro- and microscopic histopathological examination revealed acute thrombosis in the vessels of the uterine body, with resulting infarction. Both fallopian tubes remained viable, however, with no evidence of rejection. The acute vascular occlusion appeared to be caused by inadequate uterine structure support, which led to probable tension, torsion, or kinking of the connected vascular uterine grafts.

BACKGROUND:Thrombosis of mechanical prosthetic heart valves (TMPHV) is one of the major complications that accounts for the highest morbidity and mortality related to Bileaflet Mechanical Prosthetic Heart Valves (BMPHV).MATERIALS AND METHODS:During the last six years we had ten cases of bileaflet mechanical valve thrombosis. All patients had undergone emergency surgical interventions except one who developed systemic embolization and massive brain insult immediately after admission for surgery and died two months later. We divided the patients in two groups, first group includes five patients who came in acute pulmonary edema and emergency operation was done either to replace the thrombosed BMPHV (in two) or successful thrombectomy was achieved (in three) and all of them have survived. The second group (four patients) presented with cardiogenic shock and required emergency femoro-femoral bypass. Two patients survived after thrombectomy and the other two could not come off bypass after changing the TMPHV and in spite of Intra-aortic balloon pump, they died 24 and 48 hours after the procedure. All patients received intravenous heparin on admission. Preoperative i.v. Streptokinase was given in two cases, of which one required thrombectomy and the other had valve replacement and died 24 hours later.RESULTS:Early diagnosis and operation still had the best results in TMPHV though thrombolytic therapy was successful in few reported early presented cases. All patients who had thrombectomy of the TMPHV have survived without any morbidity. Follow up of survived patients ranged between two months and six years with a mean of 24.1 months. It is worth attempting thrombectomy of the thrombosed BMPHV rather than re-replacement which carries higher morbidity and mortality, because of the longer ischemic arrest during operation which further depletes the energy of the myocardium.CONCLUSIONS:Though this is a small number of patients to make a definite conclusion, thrombectomy was more feasible in CarboMedics Prosthetic Heart Valves, since its in situ rotation that allows reorientation of its leaflets and declotting of valve hinge to be performed.

Conventional treatment of coronary artery disease consists of either Coronary Artery Bypass Grafting (CABG), medical therapy or percutaneous transluminal coronary angioplasty (PTCA) or a combination. However, certain group of patients do not even qualify for CABG. Transmyocardial Laser Revascularization (TMR) is a unique new surgical modality specially for that sub group of patient population who have small and diffuse coronary artery disease not suitable for grafting. King Fahad Heart Center initiated its TMR program in February, 1994 and until February, 1996, 100 patients under went the TMR procedure. Eighty-one were males and 19 females with a mean average age of 55 years. Seventy-nine patients had 3 vessel disease (VD) and 66 patients had non-graftable small vessels. Ten patients had left ventricular ejection fraction (LVEF) less than 30%. All the patients underwent a strict protocol of follow-up. The pre and post TMR assessment at six months and 12 months follow-up showed an increase in LVEF at six and 12 months as compared to pre TMR level. The exercise time also increased from a base line level at six months and showed further improvement at 12 months which was statistically significant (p < 0.05) along-with VO2 max, which also showed improvement. Clinically, haemodynamically and symptomatically these patients showed significant improvement and use of anti-anginal drugs (87%) was reduced to minimum. Isotope myocardial perfusion scan on 15 segment viability score showed an improvement from pre TMR level of 33.8 to 45.9 at post TMR 12 months follow up. The surgical mortality in this high risk TMR population was 10%. TMR was found to be a reasonable alternative to medical treatment in patients with angina due to diffuse and or small vessel disease or occluded previous grafts not amenable to CABG.

One hundred transmyocardial revascularization procedures were performed between February 1994 and January 1996, using the C02 Heart Laser on 90 patients with stable angina and 10 with unstable angina. This was the sole therapy in 98 cases and utilized in combination with open-heart surgery in 2 others. Most patients (96) had this procedure without having undergone previous coronary artery bypass graft surgery; 66 patients were deemed to have nongraftable vessels, while 34 patients had coronary artery anatomy that was favorable to bypass graft surgery but elected to undergo laser revascularization instead. The majority (86%) were male and ages ranged from 30 to 82 (mean 55) years. At 12 months after the procedure, 92% of patients reported that they were free of angina, while mean exercise tolerance increased from 7 minutes preoperatively to 15 minutes, and metabolic equivalent units rose from 4.8 to 10.2. The average increase in Karnofsky performance score was 51%, and oxygen consumption improved by 93%. The increase in left ventricular ejection fraction was not statistically significant. Most patients resumed work within 18 days of the procedure. Consumption of antianginal medication was reduced to minimal in 83% of the patients at the end of one year. There were 10 deaths in the series, chiefly in patients with extremely low ejection fractions. We conclude that the application of this rapidly evolving procedure as a primary therapy in ungraftable patients, appears to be safe and deserving further study.

Pulmonary alveolar microlithiasis (P.A.M.) is a rare pulmonary disorder that pursues usually an asymptomatic course and can culminate in severe respiratory failure. We report a 48 year old Saudi female patient with P.A.M. who deteriorated rather steadily after the initial 18 years of asymptomatic course until a frank type I respiratory failure is established. Single lung transplantation (S.L.T.) was performed successfully and the patient returned to full daily activity and has now survived 12 months post S.L.T. The immunosuppression consisted of Cyclosporine-A 10 mg/kg/day, azathioprine (immuran) 2 mg/kg/day and prednisolone 10 mg daily. The bronchial anastomosis was done by telescoping the recipient and donor main bronchus without omental wrap. A significant bronchial stricture of the anastomotic site occurred 4 months post S.L.T. which was dilated endoscopically with good clinical and bronchoscopic result. No episodes of rejection or infection were encountered so far.

A 30-year-old woman underwent mitral valvotomy for severe mitral stenosis. Extracorporeal circulation by means of cardiopulmonary bypass and systemic hypothermia, in addition to local topical hypothermia using iced saline solution and slushed ice, was used. Fatal bilateral phrenic nerve paralysis with inability to wean her from the ventilator occurred. This report is presented to illustrate the pathophysiology, pathology, and means of possible prevention of such a potentially highly fatal injury following hypothermic open heart surgery.

A 9-year-old female child with serious central cyanosis was found to have right to left shunt across a large secundum atrial septal defect despite normal right-sided pressures. Preoperative cross-sectional echocardiography suggested the presence of large sinus venosus eustachian and thebesian valves as the mechanism responsible for diversion of the inferior caval and coronary sinus venous return to the left atrium across the interatrial secundum defect. Surgical excision of the unduly prominent sinus venosus valve and patch closure of the atrial septal defect resulted in complete disappearance of the cyanosis and physiological and clinical cure.

A narrow aortic root and a small aortic annulus made aortic valve replacement in a 35-year-old female patient with calcified aortic stenosis rather difficult. At the end of the procedure, it was noticed that the aortic root was badly torn. The tear started at the end of the aortotomy incision, near the commissure between the non-coronary and left coronary cusps, ran flush with the prosthetic ring and extended beneath and a few millimeters beyond the ostium of the left coronary artery. Only a thin rim of the aortic wall was left proximally, which was not strong enough to support the sutures. The aorta was repaired using a pericardium covered Goretex patch, bolstered by the left atrial appendage.

Surgical angioplasty of the left main coronary artery for severe ostial stenosis in a thirty-five-year-old oriental woman suffering from Takayasu's disease was performed by use of an onlay autologous pericardial patch through an anterior aortotomy approach. This procedure was performed to reestablish a physiologic antegrade coronary arterial flow and to avoid use of internal mammary arteries, which have little flow in Takayasu's disease, or the saphenous veins, which can also be involved in the inflammatory process. The procedure also avoids a lengthy, time-consuming triple coronary artery bypass procedure and the use of saphenous veins, which are prone to certain slow or rapid attrition.Total clinical improvement with disappearance of angina and return of the patient to NYHA functional class I with normal treadmill exercise response was immediately obtained. Angiographic restudy six months after the surgical angioplasty revealed excellent results with complete wide patency of the ostium. This represents the first report in the world literature of surgical angioplasty of a left main coronary arterial ostial stenosis in Takayasu's disease.

During reoperation for replacement of a regurgitant aortic bioprosthesis (a 23-mm bovine pericardial valve), it was judged that total removal of the valve would be difficult, and hazardous to the patient. Therefore, its leaflets were excised and its sewing ring left in situ. A 21-mm Carbomedics bileaflet mechanical valve was sutured to the bioprosthetic sewing ring and implanted in the orifice of the bioprosthesis, resulting in excellent hemodynamic performance. We report this new technique to illustrate its feasibility, safety, and efficiency, as an alternative to complete removal of defective prostheses in the aortic position.

We report a case of erosion of an aneurysm of the right sinus of Valsalva into the interventricular septum. The mode of presentation, the preoperative evaluation, and the echocardiographic and nuclear magnetic resonance imaging features are presented, and the cardiac catheterization findings and surgical management of this very rare cardiac pathology are discussed.

A case of paradoxical embolus that caused initial ischemic changes on the electrocardiogram monitor and later a massive myocardial infarction and cardiac arrest with death is presented. This occurred during a pulmonary wedge biopsy to determine the operability in a twenty-eight-year-old patient with ventricular septal defect and high pulmonary artery pressure diagnosed by catheterization. Autopsy revealed a long blood clot measuring 6 cm in length and 0.5 cm in width sitting and completely blocking the orifice of the left coronary artery. This caused the coronary insufficiency. A similar clot was found on the tip of the central venous pressure catheter when the right atrium was opened.The causes of and means of preventing this fatal complication in patients with left and right-heart communications are discussed in detail.

Twenty four patients underwent pericardectomy for constrictive pericarditis. There were 2 operative deaths. Tuberculosis was the aetiological factor in 20 patients and a post surgical aetiology was found in 2 patients. The aetiology remained unclear in 2 patients.

79 consecutive patients with documented acute myocardial infarction were admitted. 29 of these patients underwent early cardiac catheterisation, coronary arteriography and intracoronary streptokinase injection usually in response to post-myocardial infarction angina. Satisfactory reperfusion occurred in 80% of the patients with the least morbidity and mortality rate compared with medically anticoagulation treated group. 32 patients underwent elective catheterisation and coronary angiography between 1-16 days (average 7.6 days). 18 patients were not catheterised at all. This study evaluates our results of early thrombolytic, angioplastic or surgical revascularisation, and reviews the risk benefit value of early cardiac catheterisation and coronary angiography in patients with acute myocardial infarction.

661 consecutive children below the age of 14 years underwent open and closed heart surgery at the Saudi Heart Centre during a 4-year period for congenital cardiopathies of simple and complex nature with an average mortality rate of 10.5%. Congenital cardiopathies in Saudi Arabia differ from those seen in the Western world by the relative frequency of cyanotic heart disease, the presence of multiple complex congenital anomalies together, the advanced pulmonary hypertension, a rather aggressive nature of the cardiac diseases, and late referral of the children who often suffer also from congestive heart failure, reduced general condition and a malnutritional state.