Scimitar syndrome manifesting in adulthood can easily be overlooked owing to mild symptoms. Once diagnosed, operative correction should not be delayed as it can cause severe right heart dysfunction. There are several surgical approaches to recreating normal flow conditions. To identify the best suitable method, one needs to take into account the individual patient’s anatomy.

BACKGROUND:Patients (pt) with mitral valve prolapse (MVP) due to Barlow disase (BD) have an increased incidence of ventricular arrhythmias (VA; including ventricular tachycardias VT) and sudden cardiac death (SCD). Data on the effect of MV repair on VA are scarce. METHODS:Pre- and postoperative VA in severe mitral regurgitation (MR) with MVP due to BD undergoing surgical mitral valve repair were analyzed. Patients with degenerative mitral valve disease not fulfilling BD criteria were excluded. Information was from charts, ECG/Holter ECG and/or pacemaker/ implantable cardioverter defibrillator (ICD) data. SCD, sustained VT>30 sec and/or ventricular fibrillation necessitating an ICD-shock were considered major events. Event probability was calculated using the Kaplan-Meier estimator throughout the follow-up period of 20.7 years. RESULTS:There were 82 pts (61% males), mean age at surgery 62±14 years. Bileaflet MVP was present in 54%, mitral annular dysjunction (MAD) in 37% and left ventricular ejection fraction (LVEF) <50% in 12%. MV repair included ring annuloplasty in all and artificial chords in 48%. Mean follow-up was 3.1 years (0.2 to 14.2 years). Postoperative rhythm surveillance by Holter ECG and/or pacemaker was available in 67%. A VA load of ≥10% and/or any VT was noted in 26% before and 32% after surgery (P=0.44). Postoperative VA load was not predicted by MAD, artificial chords, LVEF of <50%, age at surgery >50 years and/or residual ≥moderate MR (all P<0.05), it correlated only with bileaflet MVP (P=0.009). Major events occurred in 3 pts: SCD in 2 pts and ICD for sustained polymorphic VT in 1 pt (incidence 1.2%/year). The event probability of receiving a SCD or an ICD-shock was 4.9%. CONCLUSIONS:VA burden does not seem to change after MV repair in MVP due to BD. The occurrence of major arrhythmic events can not be predicted reliably, thus, patients with MVP due to BD may need lifelong postoperative follow-up, especially in bileaflet MVP which was an independent risk factor for increased VA burden in this retrospective long-term study in a small but well selected patient group.

Our objective was to assess differences in early outcome after completely arterial myocardial revascularization with (on-pump coronary artery bypass grafting or ONCAB) or without cardiopulmonary bypass (off-pump coronary artery bypass grafting or OPCAB). Fifty-eight OPCAB and 91 ONCAB patients receiving exclusively arterial grafts were analyzed. OPCAB patients had more single-vessel ðP , 0:0001Þ; less triple-vessel ðP , 0:0001Þ or left main disease ðP ¼ 0:0021Þ; higher angina class ðP ¼ 0:003Þ; more unstable angina ðP , 0:0001Þ and previous percutanueous transluminal coronary angioplasty (PTCA; P , 0:0001), but similar EuroScores ðP ¼ n:s:Þ: ONCAB was associated with longer operation time ðP ¼ 0:0001Þ and more anastomoses/patient ðP , 0:0001Þ: Internal thoracic artery (ITA) use was identical, whereas single left ITA use ðP , 0:0001Þ and left ITA jump anastomoses ðP , 0:0001Þ were more frequent in OPCAB. Radial artery (RA) use ðP , 0:0001Þ and RA jump anastomoses ðP , 0:0001Þ were more frequent in ONCAB. Complication rates were similar concerning mortality, arrhythmias, cerebro-vascular accidents (CVA), and renal failure with shorter ventilatory support ðP , 0:0001Þ and a trend towards less perioperative myocardial infarction (PMI) ðP ¼ 0:12Þ and low output ðP ¼ 0:089Þ; and more respiratory complications ðP ¼ 0:056Þ after OPCAB. Arterial OPCAB patients have less extensive CAD, but more severe symptoms. Early outcome is similar concerning mortality, arrhythmias, CVA, renal failure, or intensive care unit and hospital stay, but with shorter ventilatory support and a trend towards lower PMI and low output, and higher respiratory complication rates after OPCAB. q 2003 Elsevier B.V. All rights reserved.

We report a modification of the Norwood stage I procedure in a neonate with right aortic arch and complete atrio-ventricular canal in a variant of hypoplastic heart syndrome. Because of the unusual anatomy, the neo-aorta was reconstructed with a specially trimmed homograft patch and the pulmonary flow was maintained with implantation of a right ventricle to pulmonary artery shunt on the left side of the aorta. The patient had a favourable outcome and is now awaiting the stage II procedure.

Although U-clip anastomoses were studied for hemodynamics and patency, their potential for unimpeded growth after congenital cardiovascular surgery has not been investigated yet. In 53 children aged 2.1+/-3.3 years operated on between March 1998 and August 2005 growth of U-clip (U) vs. polypropylene running sutured (P) anastomoses in coarctation repair (Coarc; n=26), bi-directional Glenn (BDG; n=13) and arterial switch operation (ASO; n=14) was retrospectively analysed. Coarc showed 2.39+/-4.33 vs. 3.09+/-2.24 mm of growth during the observation period (21+/-16 vs. 30+/-27 months); no growth (0 vs.16%), restenosis (14 vs. 37%) and reinterventions (14 vs. 11%) were similar (all in U vs. P, P=ns). BDG showed 3.68+/-3.43 vs. 2.50+/-2.55 mm (P=ns) of growth during 15+/-5 vs. 29+/-18 months (P=0.046); no growth (17 vs. 0%), stenosis (0 vs. 14%) and reinterventions (0%) were similar in U vs. P, respectively (P=ns). Main pulmonary artery (MPA) anastomosis in ASO showed 0.28+/-1.73 vs. 1.30+/-3.16 mm of growth during 8+/-14 vs. 28+/-28 months; no growth (60 vs. 14%), stenosis (50 vs. 63%) and reinterventions (0%) were similar (all in U vs. P, P=ns). Anastomotic growth, stenosis and reintervention rates show no difference between interrupted U-clip and polypropylene running sutured technique in Coarc repair, BDG and MPA anastomosis in ASO.

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In a 9-year-old boy, bridging to transplantation was successful with an external biventricular device, the Berlin Heart Excor (Berlin Heart, Berlin, Germany), during a 7-month period. Main long-term complications consisted of infection and hypercoagulability with clotting inside the chambers necessitating six pump exchanges, but without thromboembolic events. This report reviews hemostasis monitoring and management of long-term mechanical circulatory support.

Objective: Contact of blood with artificial surfaces and air as well as ischemia/reperfusion injury to the heart and lungs mediate systemic and local inflammation during cardiopulmonary bypass (CPB). Activation of complement and coagulation cascades leads to and accompanies endothelial cell damage. Therefore, endothelial-targeted cytoprotection with the complement inhibitor and endothelial protectant dextran sulfate (DXS, MW 5000) may attenuate CBP-associated myocardial and pulmonary injury. Methods: Eighteen pigs (DXS, n = 10; phosphate buffered saline [PBS], n = 8) underwent standard cardiopulmonary bypass. After aortic cross-clamping, cardiac arrest was initiated with modified Buckberg blood cardioplegia (BCP), repeated after 30 and 60 min with BCP containing either DXS (300 mg/10 ml, equivalent to 5 mg/kg) or 10 ml of PBS. Following 30 min reperfusion, pigs were weaned from CPB. During 2 h of observation, cardiac function was monitored by echocardiography and invasive pressure measurements. Inflammatory and coagulation markers were assessed regularly. Animals were then sacrificed and heart and lungs analyzed. Results: DXS significantly reduced CK-MB levels (43.4 +/- 14.8 ng/ml PBS, 35.9 +/- 11.1 ng/ml DXS, p = 0.042) and significantly diminished cytokine release: TNF alpha (1507.6 +/- 269.2 pg/ml PBS, 222.1 +/- 125.6 pg/ml DXS, p = 0.0071), IL1 beta (1081.8 +/- 203.0 pg/ml PBS, 110.7 +/- 79.4 pg/ml DXS, p = 0.0071), IL-6 (173.0 +/- 91.5 pg/ml PBS, 40.8 +/- 19.4 pg/mt DXS, p = 0.002) and IL-8 (304.6 +/- 81.3 pg/ml PBS, 25.4 +/- 14.2 pg/ml DXS, p = 0.0071). Tissue endothelin-1 levels were significantly reduced (6.29 +/- 1.90 pg/100 mg PBS, 3.55 +/- 1.15 pg/100 mg DXS p = 0.030) as well as thrombin-anti-thrombin formation (20.7 +/- 1.0 mu g/ml PBS, 12.8 +/- 4.1 mu g/ml DXS, p = 0.043). Also DXS reduced cardiac and pulmonary complement deposition, neutrophil infiltration, hemorrhage and pulmonary edema (measured as lung water content, 81 +/- 3% vs 78 3%, p = 0.047), indicative of attenuated myocardial and pulmonary CPB-injury. Diastolic left ventricular function (measured as dp/dt(min)), pulmonary artery pressure (21 +/- 3 mmHg PBS, 19 +/- 3 mmHg DXS, p = 0.002) and right ventricular pressure (21 +/- 1 mmHg PBS, 19 +/- 3 mmHg DXS p = 0.021) were significantly improved with the use of DXS. Conclusions: Addition of DXS to the BCP solution ameliorates post-CPB injury and to a certain extent improves cardiopulmonary function. Endothelial protection in addition to myocyte protection may improve post-CPB outcome and recovery. (c) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

BACKGROUND:Pulmonary regurgitation (PR) occurs frequently after tetralogy of Fallot (TOF) repair, impairing long-term prognosis and necessitating reinterventions. Myocardial damage, invasiveness, and the risks of pulmonary valve replacement (PVR) therefore need to be minimized. The new Shelhigh Injectable Stented Pulmonic Valve (Shelhigh Inc, Union, NJ) allows implantation without cardiopulmonary bypass (CPB) under direct control.METHODS:Twelve symptomatic patients (age, 21.3 +/- 12.5; range, 5.8 to 53.5 years) with severe PR and progressive right ventricular (RV) dilatation with dysfunction received the Shelhigh valve in sizes 21 (n = 1), 25 (n = 4), 27 (n = 3), 29 (n = 2), and 31 mm (n = 2).RESULTS:Valve insertion was successful and hemodynamic performance excellent in all: peak systolic gradient, 14.5 +/- 4.6 (range, 10 to 20) mm Hg; mean gradient, 6.3 +/- 1.6 (range, 4 to 8) mm Hg. Four patients underwent concomitant procedures on CPB: one reduction plasty of a dilated main pulmonary artery, two tricuspid valve repairs, and one VSD closure. Early recovery was uneventful. There were no reoperations. During a mean follow-up of 5.4 +/- 4.3 months (range, 0.3 to 10.6 months) echocardiography showed good results, with low gradients and recovered RV function in all. All presented in New York Heart Association functional class 1 at the latest follow-up.CONCLUSIONS:The Shelhigh valve allows easy PVR without CPB up to large valve sizes, with less invasiveness compared with a conventional approach. Further follow-up is needed to assess its durability and long-term performance.

Objective: Technical refinements in the last 25 years lead to a continuous improvement in the treatment of patients with acute type B aortic dissections (AADB). We assessed patients characteristics, modality of treatment and outcome in patients with AADB in the last 25 years.

Summary Ischaemic mitral regurgitation (IMR) is defined as functional MR with systolic restriction of leaflet motion, apical and lateral displacement of the subvalvular apparatus, and annular dilatation in the presence of a morphologically normal mitral valve. IMR is usually caused by LV dilatation in the setting of ischaemic or idiopathic dilated cardiomyopathy (CMP). Left ventricular dilatation leads to dilatation of the mitral annulus and to apical and lateral displacement of one or both papillary muscles with tethering of the valve leaflets and consecutive IMR. Therefore, IMR begets IMR with a vicious cycle of increased volume load leading to ventricular dilatation, leading to more IMR etc. Although MR is thought to unload the LV, wall stress is increased due to LV dilatation according to Laplace’s law. IMR is therefore thought to be primarily a ventricular and not a valvular problem. IMR is known to be prognostically important irrespective of LV function and of IMR severity at rest, because it is very dynamic and sensitive to loading conditions. IMR may frequently be severe during daily activity inducing LV failure on the long term. Therefore, dynamic testing is becoming the method of choice for assessment of these patients. Medical therapy has been shown to be inferior to surgery in the setting of IMR. Although still controversial with regard to what surgical method may be best not only to correct IMR, but also to induce a change in LV size and shape – the so-called reverse remodeling – surgical treatment is indicated with a documented effective regurgitant orifice area (EROA) >20 mm 2 and a regurgitant volume (Rvol) >30 ml by transthoracic echocardiography (TTE) at rest or with an increase of EROA >13 mm 2 in exercise TTE. Furthermore, intraoperative provocative testing may help identify significant IMR. Correction of IMR is usually done by restrictive annuloplasty with aggressive undersizing of a conventional closed and semirigid annuloplasty ring. Improved LV function and a decreased need for cardiac transplantation has been seen in published series. With the advent of new rings and devices specifically designed for correction of IMR, results may further improve. Modern specific annuloplasty rings are designed to correct the down- and outward displacement of the subvalvular apparatus by inducing an acute valvular and ventricular reshaping. With the choice of various models, IMR may be corrected more precisely by selecting a type of ring according to the geometry of the regurgitant jet and the distortion of the valve leaflets. In case of ischaemic CMP, not only complete revascularisation, but also resection of aneurysmatic myocardial scar tissue and surgical LV remodeling is usually performed. With the help of new devices such as the ACORN CorCap ® device further dilatation may effectively be prevented and may even improve LV function in selected patients. Alternatively, cardiac transplantation, implantation of an assist device for destination therapy in patients not qualifying for cardiac transplantation or resynchronisation therapy may be evaluated in very advanced cases.

Objective: Assessment of postoperative quality of life in patients over 80 years after cardiac surgery including coronary artery bypass grafting (CABG), aortic valve replacement (AVR) and combined procedures. Methods: Quality of life of n = 136 patients over 80 years at operation (82.3 +/- 2.1 years), undergoing isolated CABG in 61 patients (45%), isolated AVR in 34 patients (25%) and a combination of CABG and AVR in 41 patients (30%) between January 1999 and December 2003 was reviewed. Preoperatively 66.2% presented in NYHA-class III/IV or CCS-class III/IV. Mean ejection fraction (EF) was 59.5% +/- 14.0 (range 25-90%). Quality of life assessment was performed via a Seattle Angina Questionnaire. Follow-up was 100% complete for a total of 890 days (69-1853 days). Results: Five-year survival was 70% for the CABG group, 75% for the AVR group and 65% for the CABG/AVR group. Quality of life was remarkable in all of the three groups after surgery. Overall 97 patients (81%) were not or little disabled in their daily activity. One hundred and twelve patients (93%) were free or considerably less symptomatic. Seventy-eight patients or 65% reported to be very satisfied with their current quality of life and 112 patients (93%) felt very reassured to have continuous full access to medical treatment despite of their advanced age. Conclusions: A remarkable quality of life and important improvement in the functional status after cardiac surgery in patients over 80 paired with a satisfactory medium-term survival justify early intervention for heart disease in this age group. Therefore, referral practice for patients over 80 years for heart surgery should be handled liberally. (C) 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

The treatment of complex aortic pathologies involving the ascending aorta, the aortic arch, and the descending aorta remains a challenging issue in aortic surgery. The frozen elephant trunk procedure effectively combines surgical and interventional technologies in the treatment of extensive aortic aneurysms and dissections. We present two patients with complex aortic lesions involving all three segments of the thoracic aorta. The device used in our series is the new E-vita open hybrid prosthesis consisting of a proximal woven polyester tube and a distal self-expandable nitinol stent graft, which can be delivered antegrade into the descending aorta.

Mathias H. Aazami Torkel Aberg Clemens Aigner Cary W. Akins Nawwar Al-Attar Johannes M. Albes Ivan Aleksic Joseph Alex Vladimir Alexi-Meskishvili Christos Alexiou Ottavio R. Alfieri Zohair Y. Al-Halees Cem H. Alhan Imtiaz S. Ali Marco Alifano Nelson Alphonso Sharif Al-Ruzzeh Muhammad Muneer Amanullah Joseph J. Amato Vincenzo Ambrogi Marcello Carlo Ambrogi Gabriel Amir Luca Ampollini Robert H. Anderson Udo Christian Anegg Gianni D. Angelini Marco Anile Martine Antoine Carlo Antona Manuel J. Antunes Anelechi Anyanwu Jose I. Aramendi Jose Luis Aranda Olgun Kadir Aribas Kitipan V. Arom Hisao Asamura Athanasios C. Athanasiou Kalliopi Athanassiadi Tim Attmann Stephane Aubert Adel Khader Ayed Omer Aziz Jacques F. Azorin Jean Bachet Akin Eraslan Balci Xavier Baldo Yaron Bar-El Hendrick B. Barner David J. Barron Murat Basaran Cristina Basso Roberto Rafael Battellini Eugene Baudet Erwin P. Bauer Robert Bauernschmitt Urs Bauersfeld Yusuf Bayrak Matthias Bechtel David F. Beggs Ion P. Bellenis Jaroslav Benedik Federico Jose Benetti John R. Benfield Stefano Benussi Pascal A. Berdat Marius Berman Jose M. Bernal Marc-Andre Bernath Richard G. Berrisford Antoine A. Beuchat Friedhelm Beyersdorf Olivier Michel Bical Benjamin Bidstrup Paolo Biglioli Dietrich E. Birnbaum Gianluigi Bisleri Hartmuth B. Bittner Edward Black Antonio Bobbio Massimo Bonacchi Johannes Bonatti Pramod Bonde Philipp Bonhoeffer Andreas A. Boning Damien Bonnet Robert Stuart Bonser Michael A. Borger Ahmad Boseila Torsten Bossert Wolfgang Bothe Dietmar Bothig Tomaso Bottio Denis Bouchard Edward Thomas Brackenbury Michael Brandt William J. Brawn Pierre-Yves Brichon Christian Pierre Brizard Ivan Bruschweiler Alan J. Bryan Eric E. Buchser Gerald D. Buckberg Eric Gordon Butchart Jose M. Caffarena Antonio M. Calafiore Ayten K. Cangir Massimo Caputo Paolo Carbognani John Alfred Carr Thierry Carrel Angelo Carretta Raymond Cartier Aaron R. Casha Thierry Caus Alfredo Giuseppe Cerillo Stepan Cerny Alfredo Cesario Juan C. Chachques David J. Chambers Dominique Chapelle Pierre-Guy Chassot Nilanjan Chaudhuri Sylvain Chauvaud Olivier Chavanon Massimo Chello Yih-Sharng Chen Rene Chiolero Ray Chu-Jeng Chiu Cliff K. Choong Emmanuel Choukroun Thomas Decker Christensen Jan T. Christenson Paola Ciriaco Ali Civelek Massimiliano Codispoti Dennis V. Cokkinos Juan V. Comas John V. Conte Massimo Conti Graham J. Cooper Antonio F. Corno Joseph S. Coselli Maurizio Cotrufo Jacques Cotting Elvio Covino Jeremiah N. Cox Jochen T. Cremer John C. Criscione Martin Czerny Sabine H. Dabritz Willem Daenen Mark H.D. Danton Otto E. Dapunt John Dark Hiroshi Date Tirone E. David Michele De Bonis Tiziano De Giacomo Marc R. de Leval Sergio A. de Oliveira Ruggero De Paulis Marc de Perrot Raffaele De Simone Marek Andrzej Deja Alain Francois Delabays Dominique Delay Roland G. Demaria Murat M. Demirtas Thomas Deneke Joseph J. DeRose Paola D’Errigo Mohan P. Devbhandari Roberto Di Bartolomeo Duccio Di Carlo Roberto Di Donato Marco Di Eusanio Verdi J. Di Sesa Giovanni Dialetto Interactive CardioVascular and Thoracic Surgery 6 (2007) 143–146

Background. Different studies have analyzed the potential impact of the underlying pathologic process and the use of deep hypothermic circulatory arrest on outcome and quality of life after surgery on the thoracic aorta. The aim of this study is to analyze the impact of different surgical procedures on outcome and quality of life. Methods. Between June 2001 and December 2003, 244 patients underwent surgery for various diseases of the ascending aorta with or without involvement of the aortic valve or root. They were divided according to the operative procedure: 76 patients ( 31.2%) underwent isolated replacement of the ascending aorta, 42 patients ( 17.2%) received separate aortic valve replacement and supracoronary replacement of the ascending aorta, 86 patients ( 35.2%) received a mechanical composite graft, and 40 patients ( 16.4%) received a biologic composite graft. All in- hospital data were assessed, and a follow- up was performed in all survivors after 26.6 +/- 8.8 months, focusing on outcome and quality of life ( SF- 36). Results. Overall in- hospital mortality was 6.1%, and late mortality was 5.7%, with no significant difference between groups. Independent of the surgical technique and the extent of surgery, there was no difference in quality of life between the surgical collective and an age- matched and sex- matched standard population. Conclusions. Operations of the ascending aorta and aortic valve are very safe, with low in- hospital mortality and favorable midterm outcome regarding late mortality and morbidity. Quality of life after operations of the ascending aorta and aortic valve is equal to a standard population and is not affected by the surgical procedure. Liberal use of aortic root replacement is therefore justified to radically treat the diseased aortic segment.

Myocardial depression after cardiac surgery is modulated by cardiopulmonary bypass (CPB) and the underlying heart disease. The sodium pump is a key component for myocardial function. We hypothesized that the change in sodium pump expression during CPB correlates with intraoperative and postoperative laboratory and clinical parameters in neonates and children with various congenital heart defects. Sodium pump isoforms alpha1 (ATP1A1) and alpha3 (ATP1A3) mRNA expression in right atrial myocardium, excised before and after CPB, was quantified. Groups were assigned according to presence (VO group, n = 8) or absence (NO group, n = 8) of right atrial volume overload. CPB and aortic clamp time correlated with postoperative troponin-1 values and ICU stay. ATP1A1 (P = 0.008) and ATP1A3 (P = 0.038) mRNA expression were significantly reduced during CPB. Longer aortic clamp times were associated with lower postoperative ATP1A1 (P = 0.045) and ATP1A3 (P = 0.002) mRNA expression. Low postoperative ATP1A1 (P = 0.043) and ATP1A3 (P = 0.002) expressions were associated with high troponin-I values. These results were restricted to the VO group. No correlation of sodium pump mRNA expression was found with the duration of ICU stay or ventilation. The postoperative troponin-I and clinical parameters correlated with the length of CPB, regardless of volume overload. In contrast, only dilated right atrium seemed to be susceptible to CPB in terms of sodium pump expression, showing a reduction during the operation and a correlation of sodium pump with postoperative troponin-I values.