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Objective: The MAZE procedure has proven effective for surgically treating atrial fibrillation, but its acceptance has been limited due to the complex dissection pattern. A new simplified operative technique, that comprises two important components of the MAZE procedure, has been evaluated in an established animal model of induced sustained atrial fibrillation., Methods: In eight sheep, median sternotomy was performed for cardiopulmonary bypass via femoral and bicaval cannuiation. Bipolar atrial and ventricular electrodes (16) were applied for computerized EKG-sampling. Atrial fibrillation was induced during continuous theophylline infusion (0.5 mg/kg/min) by repetitive (10x) biatrial stimulation. Atrial response was monitored and mapped. The operative procedure was accomplished in induced ventricular fibrillation: Right and left atrial appendices were resected and a circumferential transmural incision around all pulmonary veins was performed and closed. After defibrillation, the atria were stimulated again using the above protocol and EKGs were sampled., Results: Sustained atrial fibrillation was inducible in all animals (80 stimulation episodes, median duration 31 s, 6 incessant episodes) prior to dissection. Post resection of the atrial appendices and pulmonary vein isolation, atrial fibrillation was not inducible in any of the eight animals (80 stimulation episodes). A significant interatrial (104 +/- 13 ms) and atrioventricular (208 +/- 19 ms) conduction delay was observed post dissection., Conclusion: We conclude that the described procedure is effective for the inhibition of sustained atrial fibrillation in morphologically unaltered atria. The operative approach involves less dissection than the MAZE procedure, which could facilitate its use in concomitant mitral procedures. The clinical significance of the observed AV-Delay has to be evaluated.

Objective: Even in the age of extensive aortic replacement special circumstances may warrant the insertion of extraanatomic thoracic aortic bypass grafts. Our experience with 17 patients is analyzed., Methods: Between 1988 and 1994, ten female and seven male patients (mean age 37.5 years, range 9-69 years) were treated for the following indications: (1) complex CoA (n = 5); (2) reoperation for CoA (n = 6); (3) extensive aortic occlusive disease (n = 4); and (4) complicated aneurysm (n = 2). Routing of the grafts was: ascending-descending aorta (8); ascending-abdominal aorta (4); left subdavian artery- descending aorta (2); descending-descending aorta (2); and descending-abdominal aorta (1). Eight procedures were reoperations. In four patients concomitant cardiac operations were performed: one aortic valve replacement, one patch plasty of the LCA, and two composite graft replacements of aortic valve and ascending aorta, one of them with CABG., Results: Three early deaths occurred. two after emergency operation in thoracic aneurysm under dire conditions (one perforation, one infection), one after ascending-abdominal aortic grafting with multiple branch revascularization. The underlying pathology was relieved successfully in all 14 survivors. In the two patients with concomitant aortic valve and isthmic stenosis, critical anterior motion of the mitral valve, presumably because of the massive afterload reduction of the left ventricle, complicated the perioperative course. One patient was reoperated because of aneurysm 4 years after descending-descending aortic grafting for complex CoA with poststenotic dilatation., Conclusions: In complex aortic coarctation or hypoplasia extraanatomic bypass grafts are expedient and effective procedures, especially for reoperation. Their use in the treatment of aneurysmal lesions remains an exception.

The development of coronary vasculopathy is the main determinant of long-term survival in cardiac transplantation. The identification of risk factors, therefore, seems necessary in order to identify possible treatment strategies. Ninety-five out of 397 patients, undergoing orthotopic cardiac transplantation from 10/1985 to 10/1992 were evaluated retrospectively on the basis of perioperative and postoperative variables including age, sex, diagnosis, previous operations, renal function, cholesterol levels, dosage of immunosuppressive drugs (cyclosporin A, azathioprine, steroids), incidence of rejection, treatment with calcium channel blockers at 3, 6, 12, and 18 months postoperatively. Coronary vasculopathy was assessed by annual angiography at 1 and 2 years postoperatively. After univariate analysis, data were evaluated by stepwise multiple logistic regression analysis. Coronary vasculopathy was assessed in 15 patients at 1 (16%), and in 23 patients (24%) at 2, years. On multivariate analysis, previous operations and the incidence of rejections were identified as significant risk factors (P < 0.05), whereas the underlying diagnosis had borderline significance (P = 0.058) for the development of graft coronary vasculopathy. In contrast, all other variables were not significant in our subset of patients investigated. We therefore conclude that the development of coronary vasculopathy in cardiac transplant patients mainly depends on the rejection process itself, aside from patient-dependent factors. Therapeutic measures, such as the administration of calcium channel blockers and regulation of lipid disorders, may therefore only reduce the progress of native atherosclerotic disease in the posttransplant setting.

While lung retransplantation remains the only therapeutic option in early or late graft failure, its value is viewed controversially. Of 134 patients undergoing pulmonary transplantation in our institution, 13 patients underwent 14 redos following heart-lung transplantation (n = 3), bilateral lung transplantation (n = 5), and unilateral lung transplantation (n = 5). Indications for retransplantation were acute graft failure (n = 2), persistent graft dysfunction (n = 3), airway complications (n = 2), and chronic graft failure (n = 7). Prior to retransplantation, six patients had been in stable respiratory failure, the remaining eight patients were on mechanical ventilation or extracorporeal membrane oxygenation (n = 2). Four patients died, 19, 43, 142, and 683 days following retransplantation due to pneumonia (n = 2), early onset of obliterative bronchiolitis (n = 1), and pulmonary embolism (n = 1). There was no correlation between mortality and intubation prior to re-operating, timing of operation, donor cytomegalovirus (CMV) status, or type of operation. Postoperative need for intensive care treatment was prolonged in patients undergoing acute retransplantation (P < 0.05). Actuarial 1- and 2-year survival rates were calculated at 77 and 64%. This was slightly lower than in the overall population following primary isolated lung transplantation (83 and 80%). Actuarial freedom from obliterative bronchiolitis (stage 3) at 1 and 2 years was calculated at 88 and 27% (primary grafts: 88% vs 72%; P < 0.05). Retransplantation is a realistic option in early and late graft failure after lung transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

The surgical therapy of ventricular tachyarrhythmias (VTA) in ischemic heart disease is attracting attention, since current medical therapies are showing limited long-term efficacy. The curative concept of electrophysiologically guided endocardial resection (ER) and palliation with the implantable cardioverter/defibrillator (ICD) are compared retrospectively. From 1980-1992, 121 patients (55 +/- 9 years, 108 males, 13 females) underwent ER and 203 patients (59 +/- 9 years, 195 males, 8 females) received an ICD for ischemic VTA. Concomitant coronary revascularization was performed in 38/121 patients with ER (31%) and in 62/203 patients (31%) with ICD. Perioperative mortality was 8% (10/121 patients) for ER and 5% (10/203 patients) for ICD (P = n.s.). Hundred eleven patients with ER (mean follow-up 41 +/- 37 months) and 193 with ICD (mean follow-up 22 +/- 20 months) were available for survival analysis: freedom from sudden death was comparable for the two groups at 1 year (99% for ICD, and 94% for ER) and at 5 years (90% for ICD and 90% for ER) (P = n.s.). Freedom from cardiac death also showed no differences between the groups at 1 year (94% for ICD, and 84% for ER) and at 5 years (74% for ICD and 74% for ER) (P = n.s.). Left ventricular function, indicated by left ventricular ejection fraction, was comparable (34 +/- 9% in ER, 30 +/- 11% with ICD) (P = n.s.) in the two groups. The linearized incidence of DC-shocks was 10.3/year in ICD patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors' method for uniting the dissected aortic wall layers with the help of gelatine-resorcinol adhesive is described focusing on special instruments used in this conjunction.

Unlabelled: The long-term prognosis following lung transplantation (LTX) depends mainly on the development of chronic rejection which appears clinically as deterioration of the lung function while, histologically, obliterative bronchiolitis (OB) is found. However, it still remains questionable whether heart-lung (HL), double or single lung (DL/SL) transplants behave similarly with regard to incidence and time pattern. Eighty-two patients, transplanted until August 92, were analyzed. Early and late deaths within 180 days postoperatively were excluded. A total of 64 patients at risk could be evaluated. By repeated lung function tests, obstructive airway disease was defined by a drop of 25% or more of the forced expiratory volume in one second (FEV1) in percent of the inspiratory vital capacity., Results: The functional optimum after transplantation was reached after a comparable time-span postoperatively in all groups. Chronic deterioration of the lung function developed earlier following DLTX compared to HLTX and SLTX. Obstructive airway disease was diagnosed in 9/20 (45%) HL, 7/19 (37%) DL, and 7/25 (28%) SL patients. Of these, 4 died and 4 had to be retransplanted for the disease while an additional 15 patients are currently under investigation. It is concluded that the development of obstructive airway disease represents a serious problem in all types of lung transplantation. There is a tendency to earlier development following DLTX--perhaps caused by the greatest immunological potential in this group of patients.

Repair of aortic coarctation was performed in 152 adolescent and adult patients (mean age 28.5 years, range 14-67 years). Ninety patients were treated with patch plasty, 33 with end-to-end anastomosis, 18 with interposition of a tubular graft, 6 with prosthetic bypass and 5 with direct plasty. There were two (1.3%) early and ten (6.6%) late deaths after 2.9 to 11.8 (mean 6.6) years. Of the remaining 140 patients, 129 (92.1%) were reexamined with computed tomography and angiography after 1.5 to 17.2 (mean 9.1) years postoperatively. In 27 patients (35.1%) of the patch plasty group significant dilatation at the operative site was observed and reoperation for aneurysm formation was required in 15 patients (19.5%). Resection of the intimal crest did not increase the probability of aneurysm formation, whereas Dacron as patch material and late hypertension had a significant influence. Six of the ten late deaths occurred in the patch plasty group. Rupture of an aneurysm at the operative site was proved in two of these patients, and three patients died suddenly for unknown reasons. In the other groups significant dilatation was observed in 13 patients and 3 local aneurysms required reoperation (2 after end-to-end anastomosis and 1 after direct plasty). We conclude that patch plasty repair of coarctation should be abandoned in adults. End-to-end anastomosis is advisable only if possible without excessive tension. Reoperation with interposition of a tubular graft on left heart bypass proved to be a safe method.

Despite omental wrap and avoidance of prophylactic administration of corticosteroids in the early postoperative phase, ischemic bronchial complications still represent an important source of early morbidity and mortality following lung transplantation. In a retrospective analysis, the effect of pharmacological enhancement of pulmonary collateral flow on bronchial healing was investigated. Thirty-nine consecutive unilateral or bilateral transplant procedures (Tx) were analyzed. Immunosuppression consisted of rabbit antithymocyte globulin (RATG), cyclosporine A, and azathioprine. In group 1 (10 Tx, 12 anastomoses) routine immunosuppression was employed and the anastomoses wrapped with an omental or pericardial pedicle. In group 2 (29 Tx, 41 anastomoses) PGI2 (4 ng/kg per min x 48 h), heparin (200 U/kg per day), and prednisolone (0.5 mg/kg per day) were added to the therapeutic regimen. The 2 groups were comparable with respect to age and sex of the patients, primary diagnosis, type of transplant, intraoperative use of extracorporeal circulation, graft ischemia, duration of mechanical ventilation, and mortality. Bronchoscopic evidence of a significant bronchial ischemia (extending more than 1 cartilaginous ring beyond the anastomosis) was seen in 8 of 12 anastomoses in group 1 vs 14 of 53 anastomoses in group 2 (P = NS). In group 1, significant bronchial stenosis required implantation of an endobronchial silicone stent in 6 of 12 anastomoses, whereas in group 2, no significant bronchial stenosis occurred (P less than 0.01). No negative effects possibly related to the prophylactic administration of corticosteroids could be observed.(ABSTRACT TRUNCATED AT 250 WORDS)

The occurrence of severe graft failure after lung transplantation which appears refractory to conventional treatment represents a difficult situation with regard to the therapeutic strategies available. Of 17 patients undergoing single lung transplantation at our center, 2 developed early graft failure. In both, temporary artificial cardiopulmonary support by means of extracorporeal membrane oxygenation became necessary as a bridge to retransplantation. Both patients were successfully retransplanted after 8 h and 232 h, respectively, of extra-corporeal support. Postoperatively, there was a variety of complications. The first patient completely recovered from temporary severe cerebral dysfunction diagnosed as "locked-in syndrome". She was discharged from hospital on the 93rd postoperative day and remains alive and well 10 months after her operation. The other patient recovered well early after retransplantation. Later, however, airway problems developed, requiring the implantation of endotracheal stents. Cachexia and several episodes of viral pneumonia contributed to the progressive deterioration of her clinical status. She finally died after being hospitalized for 5 months after the original operation. These two cases illustrate the feasibility of using extracorporeal membrane oxygenation as a bridge to pulmonary transplantation.

This study reviews eight patients, 39-63 years old, with tumor-related obstruction of the inferior vena cava (IVC) extending into the right atrium (n = 5) and ventricle (n = 3). Five patients suffered from renal cell carcinoma, 3 from sarcomatous disease. The general approach was a median sternotomy and laparotomy with hypothermic circulatory arrest (17.0-20.5 degrees C; 23-46 min) in six patients, while in two patients, the IVC was clamped sequentially under moderate hypothermia and extracorporeal circulation. Four patients had tumor infiltration of the IVC necessitating partial caval resection. In three, the IVC was reconstructed by fabric patches or tubular prothesis. In one patient, the continuity of the IVC was interrupted permanently. Three patients underwent nephrectomy during the same procedure, two before and one after IVC disobliteration. In one patient each, pulmonary embolectomy and intrahepatic IVC stenting were performed. Two patients died early, one due to uncontrollable hemorrhage the other due to non-cardiogenic pulmonary edema. Six patients were discharged in good physical condition and are still alive at a mean follow-up of 24 months. Five patients have since remained free of recurrence, one patient underwent three further surgical interventions for bone metastases. We feel that IVC desobliteration is feasible in selected cases with extended tumor-related obstruction with an acceptable early risk and late outcome.

The scarcity of suitable donors for single lung and heart-lung transplantation calls for methods of medium-term pulmonary preservation to allow for distant organ procurement. At our institution, the first five grafts (four heart-lung, one single lung) were cooled by means of a transportable extracorporeal circulation unit, while the last eight grafts (four heart-lung, four single lung) were flush-perfused with modified cold Euro-Collins solution. The technique of extracorporated circulation included aortic and right atrial cannulation and cooling to 12 degrees-14 degrees C (rectal temperature) using a bubble oxygenator. Bypass times ranged between 41 and 52 min. Following excision, the organs were transported in ice-cold donor blood for ischemic times from 171 to 310 min. For cold flush preservation, simultaneous coronary (cold St. Thomas's solution) and pulmonary artery perfusion (Euro-Collins solution, 50 ml/kg over 4 min) were initiated simultaneously. The organs were transported in cold Euro-Collins solution for ischemic times of 175 to 270 min. In heart-lung transplantations the first postoperative arterial PO2 upon arrival at the intensive care unit was 120 +/- 38 Torr in the extracorporeal circulation and 140 +/- 38 Torr in the Euro-Collins solution group. Six of eight patients were extubated within 48 h after cardiopulmonary grafting. We conclude that pulmonary function following heart-lung or single lung preservation with simple hypothermic flush is as good or better than that following extracorporeal circulation. Since distant organ retrieval is much more convenient without the latter, preservation using Euro-Collins solution is preferred.

Coarctation of the aorta (CoA) is often associated with complex congenital heart disease. Patients with such a combination may not benefit from coarctectomy alone. Eight children who presented with complex malformations of the heart underwent simultaneous repair of CoA and intracardiac surgery via sternotomy. After extensive mobilization of the aortic arch, cardiopulmonary bypass was established. During the cooling phase for deep hypothermic circulatory arrest (six cases), a persistent temperature gradient between the upper and lower half of the body confirmed the significance of CoA. One child was operated upon in deep hypothermia with low flow and one underwent valve repair on cardiopulmonary bypass. Mobilization of the descending aorta enabled CoA resection and end-to-end anastomosis with a running absorbable suture. The average descending aortic cross-clamping time was 15 min. By this time, the patient had been cooled sufficiently for the intracardiac procedure. There were two operative deaths not related to coarctectomy. The remaining children showed no arm-to-leg pressure gradient. Five were discharged from hospital and one patient died late from septicaemia. In our hands, this technique has served to accomplish simultaneous relief of CoA and repair of the intracardiac lesion thus sparing critically ill infants the hazards of repeated procedures.

The mitral valve was approached through a modified incision in the roof of the left atrium in 100 consecutive patients to study exposure of the valve, complications of the method and the incidence of dysrhythmia. There were five deaths: one related to difficult atrial closure and another to breakdown of the atrial suture line. Two major and two minor non-fatal haemorrhagic complications occurred. Exposure of the valve was found to be superior to that of conventional atrial incisions in the great majority of cases. When comparing the incidence of perioperative dysrhythmia in our 100 patients with that of 56 patients approached through the conventional atrial incisions, no significant differences were found even though the sinus node artery is likely to be divided when incising the roof of the left atrium.

We present our experience in the treatment of life-threatening ventricular tachycardia using electrophysiologically guided surgery (97 patients), automatic implantable cardioverter defibrillator (AICD) (42 patients), and orthotopic heart transplantation (15 patients). Eighty-three percent of these patients had ischemic and 17%, nonischemic heart disease. Our results of electrophysiologically directed surgery show an early mortality of 10% and a recurrence of 5% in the ischemic group. In the nonischemic group, the recurrence was 45%. The AICD was implanted in 31 patients with ischemic heart disease, in 5 with ventricular dysplasia, and in 6 with dilative cardiomyopathy, the ejection fractions ranging from 12% to 65%, with a mean of 30%. Early and late mortalities were 5% and 19%, respectively. The AICD was effective in all patients. Survival rate at 1 year was 83% +/- 6.4%. Thirteen of 15 patients have survived heart transplantation for 3-20 months (mean: 11 months). Ejection fractions prior to transplantation ranged from less than 10% to 34% (mean: 16%). We conclude that electrophysiologically guided surgery is highly effective in most cases of ischemia-related ventricular tachycardia. The AICD is considered a palliative alternative in patients with either poor ventricular function, no electrophysiological substrate, or multimorphological tachycardia. Heart transplantation has to be considered especially in young patients in whom progression of the underlying disease can be anticipated. Bridging by AICD is possible when transplantation is not immediately available or recommendable.

From July 1983 to May 1987, 172 orthotopic heart transplantations were performed in 165 patients. Of these, 46 recipients (39 male, 7 female), aged between 26 and 56 years (mean age 47), suffered from ischaemic cardiomyopathy. Postoperative immunosuppression consisted of a triple drug regimen of cyclosporine A, azathioprine and, in the last 31 patients, low-dose steroids. The actuarial survival in this group of patients at 1 year and at 2 years was 71.9%. There were five early deaths: three due to acute rejection and two from multiple-organ failure and sepsis. Of the eight late deaths, two could be attributed to acute cardiac rejection and four to bacterial infections. In two patients, sudden death occurred in the presence of accelerated graft atherosclerosis. Mild-to-moderate coronary artery lesions were seen in five other patients undergoing angiography one year after transplantation. Apart from the well-known postoperative risk factors in cardiac transplant recipients, accelerated graft atherosclerosis appears to be an additional hazard in the subgroup surgically treated for ischaemic cardiomyopathy.

A new method of treating acute type-A dissection of the aorta is described and illustrated. It involves the reconstruction of both the valve and the ascending aorta. This procedure was employed in 17 patients, 2 of whom succumbed early of complications unrelated to the method while one committed suicide at a later date. One of the surviving patients required reoperation due to breakdown of a resuspended aortic commissure. Two patients show minor non-progressive valve regurgitation in the absence of annulo-aortic ectasia. Two patients have developed dilatation of the aortic root--one will require reoperation in the foreseeable future. In our hands, this method has served to make emergency operation for acute aortic dissection both simpler and safer. The limitations of its use are discussed.

Cardiac beta-adrenoceptor density and subtype distribution has been determined in different kinds of heart failure. A decrease in cardiac beta-adrenoceptor function appears to be a general phenomenon in all kinds of heart failure. However, cardiac beta 1- and beta 2-adrenoceptors seem to be differentially affected in different kinds of heart failure: while in end-stage idiopathic dilated cardiomyopathy the diminished cardiac beta-adrenoceptor function is due to a selective loss in beta 1-adrenoceptors, in mitral valve disease, tetralogy of Fallot and end-stage ischaemic cardiomyopathy it is characterized by a concomitant reduction in beta 1- and beta 2-adrenoceptors. Chronic treatment of heart failure patients with beta-adrenoceptor antagonists leads to an up-regulation of cardiac beta-adrenoceptors, but in a subtype-selective fashion: beta 1-selective antagonists increase only cardiac beta 1-adrenoceptors, whereas non-selective antagonists increase both beta 1- and beta 2-adrenoceptors. Such a (subtype-selective) 'recovery' of cardiac beta-adrenoceptors may be one reason for the beneficial effects of low-dose beta-adrenoceptor antagonist treatment in patients with severe heart failure.

Functional results and data concerning the incidence and severity of graft atherosclerosis (GASC) and tricuspid incompetence (TI) in the intermediate term after orthotopic heart transplantation (HTX) are still striking. We examined 92 patients 1, 2, and 3 years after HTX by right and left heart catheterization in order to evaluate pump function, the status of the coronary arteries and the extend of TI, using a double indicator thermodilation technique. Mean left ventricular volumes and ejection fraction were normal 1 and 2 years post-transplant. The incidence of GASC was 8/87 (9.2%) at 1, and 11/92 (12%) at 2 years. It was more frequent (16%) in patients with preexisting coronary artery disease (IHD) than in patients with underlying dilative cardiomyopathy (DCM) (11%). At the end of the 1st postoperative year, 62% of patients were free of TI, whereas only 38% had normal valve function 2 years posttransplant. In 9/14 (64%) of patients, consecutively assessed at 1 and 2 years, TI had increased between both investigations. Preoperative haemodynamics, the number of endomyocardial biopsies and rejection episodes as well as preoperative cardiac size did not correlate with TI. Left ventricular volumes and ejection fraction are normal in the intermediate term after HTX. The incidence of GASC was less than 10% at 1 year and did not significantly increase thereafter. TI is a frequent and yet unexplained finding after HTX showing a considerable tendency to increase with time, but with little or not haemodynamic consequence.