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OBJECTIVE: This analysis was undertaken to evaluate the results of persistent atrial fibrillation (pAF) ablation procedures concomitant to coronary surgery and to identify the risk factors for pAF recurrence. METHODS: Since 2001, a total of 126 consecutive patients with pAF (duration: 0.5-33 years) underwent ablation concomitant to coronary surgery (isolated or in combination with valve surgery), whereby two encircling isolation lesions around the left and the right pulmonary veins and a connecting lesion between both was created using radiofrequency ablation. Patients were reevaluated at discharge, 3 months and 3 years after surgery. RESULTS: Survivals at the time of reexamination were 96.8, 95.1 and 94.7 %, respectively. Stable sinus rhythm (SR) could be documented in 66.4, 75.1 and 75.9 % of surviving patients. Long-term pAF before surgery and a larger left atrium (LA) were predictive of postoperative pAF return ( P < 0.01). Statistical analysis demonstrated a cut-off point of 5 years for pAF and 50 mm for LA diameter: 89.1 % of patients with pAF duration of < 5 years and 86.2 % of patients with LA size of ≤ 50 mm were in stable SR at late follow-up. Cardiac rhythm at 3 months was predictive for long-term rhythm prognosis ( P < 0.01). Age, gender and concomitant diseases (e.g. arterial hypertension, diabetes, renal insufficiency), and the underlying cause of heart disease did not significantly influence the postoperative cardiac rhythm. CONCLUSIONS: The duration of pAF and the LA size are the most reliable preoperative variables to predict the success rate of ablation in patients undergoing coronary surgery. The probability of re-establishing stable SR is excellent when pAF duration is short and LA size is small.

ObjectiveThis analysis was undertaken to evaluate the results of persistent atrial fibrillation ablation procedures concomitant to open surgery and to identify risk factors for persistent atrial fibrillation recurrence.MethodsSince 2001, a total of 325 consecutive patients with persistent atrial fibrillation (duration, 0.5–33 years) have undergone persistent atrial fibrillation ablation concomitant to open surgery by creating 2 encircling isolation lesions around the left and right pulmonary veins and a connecting lesion between both with the use of radiofrequency ablation procedures. Patients were restudied at discharge, 3 months, and 3 years after surgery.ResultsSurvivals at the time of reexamination at discharge, 3 months, and 3 years were 97.8%, 96.2%, and 94.4%, respectively. Stable sinus rhythm could be documented in 72.1%, 73.9%, and 75.6% of surviving patients, respectively. Long-term persistent atrial fibrillation before surgery and a larger left atrium were predictive of postoperative persistent atrial fibrillation return (P

OBJECTIVE: The study investigates the early and late results of permanent atrial fibrillation (AF) ablation surgery concomitant to coronary artery bypass grafting (CABG) and/or aortic valve (AV) surgery. METHODS: Between February 2001 and April 2006, a selective group of 80 patients with permanent AF (median: 48 months [Perc 25/75 24/110; range: 6 - 360 months]) underwent either bipolar (n = 60) or monopolar (n = 20) radiofrequency (RF) ablation procedures concomitant to CABG and/or AV surgery (CABG: n = 39; AV: n = 30; AV + CABG: n = 11). All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 ± 1 months) and late after surgery (30 ± 15 months). Data were analyzed exploratively. RESULTS: Survival at 3 and 30 months was 98 % and 96 %, respectively. Stable SR could be documented in 73 % and 77 % of patients. Long-term AF before surgery and larger LA size were predictive for AF return after surgery ( P = 0.004 and P = 0.032, respectively). Neither age, gender, the application modus of the RF energy nor the underlying cardiac disease influenced the postoperative cardiac rhythm significantly. NYHA class improved significantly after surgery ( P < 0.0005), particularly when stable SR was achieved ( P = 0.049). CONCLUSION: Preoperative permanent AF duration time and larger LA size are useful variables to predict the success rate of concomitant ablation surgery in CABG and/or AV patients. Further it could be demonstrated that established SR remained stable over time.

BACKGROUND This study analyzed 7 years of results for monopolar endocardial radiofrequency (RF) ablation of permanent atrial fibrillation (pAF) concomitant to mitral valve (MV) surgery. METHODS Between 2001 and 2007, 152 patients who had experienced pAF for a median of 4.0 years (interquartile range, 1.5-8.0 years; range, 0.5-33 years) underwent monopolar endocardial RF ablation procedures (pulmonary vein isolation plus a connecting lesion) concomitant to MV surgery. All patients were reexamined to assess survival, conversion rate to stable sinus rhythm (SR), and New York Heart Association (NYHA) class at 8 +/- 1 days after surgery and follow-ups at 3 +/- 1 months and 41 +/- 24 months postoperatively. Data were analyzed exploratatively. RESULTS The survival rates at the 3 reexamination times were 97%, 95%, and 92%, respectively (6 cardiac and 6 noncardiac deaths), and the corresponding SR rates were 74%, 75%, and 73%. The NYHA class of the patients improved significantly after surgery (P = .006), particularly when a stable SR had been achieved (P = .039). Long-term pAF prior to surgery and a larger left atrium (LA) preoperatively were predictive of the return of postoperative AF (P = .0002, and P = .0003, respectively). Ninety-one percent of the patients with a preoperative pAF duration of

In our population, permanent atrial fibrillation (pAF) is a serious concomitant problem in patients scheduled for open heart surgery. The high incidence necessitates reliable methods of treating pAF efficiently. We report our 3-year experience with a safe concept of using monopolar and bipolar radiofrequency (RF) ablation procedures.Ninety patients (mitral, n = 56; aortic, n = 22; aortic and mitral, n = 1; coronary artery bypass grafting, n = 11) underwent either monopolar (n = 77) or, recently, bipolar (n = 13) RF ablation procedures that produced encircling isolation lesions around the left and the right pulmonary veins (PVs) and a connection line between the two. Amiodarone was given for 3 months after surgery.Hospital mortality was 2.2%. At follow-up, 75% of the patients were in stable sinus rhythm (SR). Preoperative pAF duration, etiology of heart disease, and type of RF energy application were not predictive of the risk of persisting pAF after surgery. Whereas patients (50 of 90) with small preoperative left atrial (LA) diameters (56 mm) had SR in almost 90% of cases, large preoperative LA diameters (or=56 mm; 40 of 90 patients) were associated with a significant risk of persisting pAF (P.05).Particularly in cases of small preoperative LA diameters, isolation of the PVs using either monopolar or bipolar RF ablation procedures in combination with amiodarone therapy represents a safe and efficient option for curing pAF in patients undergoing open heart surgery.

Objective Surgical intervention is an option for treating the remodeled and dilated left ventricles of patients with heart failure. Providing end-diastolic support with an innovative mesh-like cardiac support device reduces mechanical stress, improves function, and reverses cardiac remodeling in animal models without safety issues. The objective of this study was to review the global clinical safety and feasibility experience of this device. Methods The Acorn CorCap cardiac support device (Acorn Cardiovascular, Inc, St Paul, Minn) has been implanted worldwide in more than 130 patients with dilated cardiomyopathy with or without concomitant cardiac surgery. The device is positioned around the ventricles and given a custom fit. A series of 48 patients were implanted with the device in initial safety and feasibility studies, of whom 33 also received concomitant cardiac surgery. Results At implantation, 11 patients were in New York Heart Association class II, 33 were in class III, and 4 were in class IV. The average CorCap implantation time was 27 minutes. The mean intraoperative reduction in left ventricular end-diastolic dimension was 4.6% ± 1%. There were no device-related intraoperative complications. Eight early and 9 late deaths occurred during follow-up extending to 24 months. Actuarial survival was 73% at 12 months and 68% at 24 months. There were no device-related adverse events or evidence of constrictive disease, and coronary artery flow reserve was maintained. Ventricular chamber dimensions decreased, whereas ejection fraction and New York Heart Association class were improved in patients overall and in those patients implanted with the CorCap device without concomitant operations. Conclusions The CorCap device appears safe for patients with dilated cardiomyopathy. Randomized clinical trials are underway in Europe, Australia, and North America.

The incidence of abdominal complications after cardiopulmonary bypass is low but associated with a high mortality. From January 1991 to October 1996, 4288 patients, of a mean age of 62.5 years, underwent open-heart surgery. Fifty-nine (1 of 4) of these patients developed early abdominal complications. These included 36% with a paralytic ileus, 21% with erosive gastritis, 18% with upper gastrointestinal haemorrhage, 12% with intestinal ischaemia, 5% with pseudo-obstruction of the colon, 6% with acute cholecystitis and 2% with acute pancreatitis. After coronary artery bypass grafting mean cardiopulmonary bypass time was 94.4 min. There were abdominal complications in 1.0% and one hospital death. After valve surgery and combined surgery the mean cardiopulmonary bypass time was 129 min. There were abdominal complications in 2.4% (alpha = 0.01) and seven deaths. Fourteen patients (24%) underwent abdominal operations: three had caecostomies for pseudo-obstruction of the colon, seven had a hemicolectomy, two had a cholecystectomy and two had resection of the ventricle. The hospital mortality rate was 13.5%. Abdominal complications were significantly more frequent after valve or combined operations of the coronaries and valves in comparison with isolated coronary artery bypass grafting. Cardiac operations with extended cardiovascular bypass time were more likely to produce abdominal complications.

To investigate possible influence of aprotinin on graft patency, a randomized, double-blind group comparative study was carried out in male patients selected for primary bypass surgery. One hundred and ten patients received either placebo treatment or aprotinin according to the Hammersmith Hospital regimen(n = 55 per group). Graft patency was evaluated by angiography in 44 aprotinin and 35 placebo patients between the 18th and 35th day postoperatively. There was no difference in overall graft occlusion. Among the aprotinin patients, 73% (32/44) hsd grafts patent compared with 71% (25/35) of the placebo group. Graft occlusion was not accompanied by signs of myocardial infarction in any case. Blood loss within 6 h postoperatively was reduced by 58.5% in the aprotinin group (P0.001). of these patients 51% (26/51) did not need donor blood compared with 21% (10/47) of the placebo patients (P = 0.003). Mean transfusion requirements per patient were 1.1 and 2.7 units in the aprotinin and placebo groups, respectively.

We prospectively evaluated 49 consecutive hospital survivors of the arterial switch operation for complete transposition and intact ventricular septum by clinical examination, echocardiography, cardiac catheterization, 12-lead and 24-h Holter ECG. The mean length of follow-up was 40 +/- 18 months. Forty-six children are clinically asymptomatic without medication, 2 died due to coronary related left ventricular dysfunction 3 and 12 months after surgery, and 1 required reoperation because of severe bilateral pulmonary branch stenoses. Except for this case, cardiac catheterization (n = 23) revealed a mean gradient of only 17 +/- 8 mmHg between the right ventricle and distal pulmonary arteries. Left ventricular end-diastolic volume was within normal limits except for 2 cases with volumes slightly below normal, the mean ejection fraction was 78 +/- 5%, and end-diastolic and end-systolic ventricular shapes were normal. The mean cardiac index was 4.14 +/- 0.69 l/min/m2. Left ventricular end-systolic wall stress to velocity of fiber shortening relation was normal in all cases examined (n = 15), indicating normal myocardial contractility. Significant neoaortic valve insufficiency was never observed despite considerably enlarged aortic roots. Twenty-four-hour Holter ECG records (n = 46) provided no evidence of serious atrial arrhythmias, especially sinus node dysfunction. These encouraging intermediate-term results make the arterial switch operation the treatment of choice at present, for neonates with simple transposition.

Since February 1985 the arterial switch operation (ASO) has become the surgical treatment of choice for newborns with simple TGA, appropriate forms of complex TGA and double outlet right ventricle (DORV) as well at our institution. Between 1985 and 1990 a total of 87 patients underwent surgery. In 60 patients with simple TGA and 8 patients with complex TGA or DORV, respectively, an arterial switch-operation was performed. Because of coronary artery anomalies (n = 13), dysplastic pulmonary valves (n = 3) or pressure drop in the left ventricle (n = 1), the initially planned arterial switch operation was discarded and a Mustard type procedure was in 17 patient. Finally there were two primarily performed Mustard operations. The hospital mortality after arterial switch for simple TGA was 15% (9/60), 0/8 in patients with complex TGA. Late mortality was calculated to be 12% (1/8) in patients with complex TGA and 3/60 in patients with simple TGA. Within the Mustard group there were 2/19 hospital deaths and one late death. Causes of early death after arterial switch were: intraoperative myocardial infarct (n = 3) low cardiac output syndrome (n = 2), intractable bleeding (n = 2), metabolic acidosis (n = 1), and septicemia (n = 1). Late after surgery there was one death due to chylothorax after thrombotic obstruction of the SVC, and 3 more deaths secondary to intraoperative infarct, progressive LV dysfunction and meningitis, respectively. Among the long-term survivors 2 patients developed a severe supravalvulary pulmonary stenosis. There were no significant arrhythmias, supravalvulary pulmonary aortic stenoses, aortic insufficiency or myocardial perfusion disturbances.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-six infants and children with congenital heart disease (CHD) undergoing cardiac surgery were investigated for alterations in myocardial β-adrenoceptor density. The patients were divided into three groups according to type and severity of CHD: group I consisted of 6 patients with acyanotic shunt lesions of moderate severity; group II comprised 13 children with severe acyanotic shunt and valve lesions and group III included 7 children with cyanotic CHD. The myocardial β-adrenoceptor density was determined using (−)3-[125I] Iodocyanopindolol ([125I]ICYP) and was reduced by approximately 50% in severe acyanotic CHD (33.6 fmol/mg protein) and cyanotic CHD (35.3 fmol/mg protein) in comparison with the group with less severe acyanotic shunt defects (64.4 fmol/mg protein). The affinity dissociation constant (Kd, ICYP) did not differ statistically between the groups. The proportion of β1- and β1-subpopulation was evaluated by ICI 118,551-[125I]ICYP competition studies. In group II (61.5%) and group III (69.1%) significant lower portions of β1-adrenoceptors were found compared with group I (78.2%). This shift of subpopulations was due to a decreased β1-receptor density while β2-receptor density was unchanged in all groups. While the plasma noradrenaline levels of group I were similar to those of a control group of 13 healthy children, respective values of group II and III were significantly elevated. A significant negative correlation was found between plasma noradrenaline levels and myocardial β-adrenoceptor density. It is concluded that exposure of these receptors to increased circulating catecholamines, due to an enhanced sympathetic tone, leads to a reduction of their density. Noradrenaline, a preferential agonist of β1-adrenoceptors, is most probably responsible for the shift of the β-adrenoceptor subpopulations from the β1- to β2-subtype, depending on severity and type of cardiac disease.

OBJECTIVE This study investigated the early and late results of restrictive mitral valve (MV) annuloplasty in patients with chronic mitral regurgitation (MR) and advanced ischemic (ICM) or dilated cardiomyopathy (DCM). METHODS From October 2001 to September 2006, 121 patients (age: 69 +/- 9 years) with a left ventricular ejection fraction (LVEF) of 30 +/- 9 % and chronic MR grade 3 - 4 (ICM: n = 102, DCM: n = 19) underwent restrictive prosthetic ring annuloplasty (downsizing of 2.7 +/- 0.8 ring sizes). Eighty-five ICM-patients had indications for concomitant coronary artery bypass grafting (CABG). All patients were restudied at 7 +/- 1 days, 3 +/- 1 and 30 +/- 12 months after surgery to assess survival, residual MR, New York Heart Association (NYHA) class and left ventricular (LV) function (end-systolic/end-diastolic dimensions/volume indexes and LVEF). Data were analyzed exploratively. RESULTS 30-day mortality was 3.3 %; survival at follow-up was 95 % and 91 %, respectively. Postoperative recurrence of significant MR (> grade 2) was absent in all patients. NYHA class, LV dimensions/volume indexes and LVEF improved significantly after surgery in both groups ( P < 0.0005). A prediction of continuous postoperative improvement of myocardial function in the sense of reverse remodeling could be demonstrated by univariate logistic regression for ischemic etiology and concomitant CABG ( P = 0.0001). In DCM-patients or ICM-patients without CABG, the postoperative benefit on myocardial function was limited. CONCLUSION Restrictive mitral valve (MV) annuloplasty corrected chronic MR in cardiomyopathy patients with low mortality and improved contractility. Surgery also prevented recurrence of significant MR, although the phenomenon of postoperative continuous reverse myocardial remodeling could not be verified in cases with a non-ischemic etiology or ICM without concomitant CABG.

This study analyses the 5-year results of permanent atrial fibrillation (pAF) bipolar radiofrequency (RF) ablation surgery concomitant to coronary artery bypass grafting (CABG) and/or aortic valve (AV) surgery. Eighty-five patients with pAF (0.5-30 years) underwent bipolar RF ablation procedure concomitant to CABG/AV surgery. All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class at 8+/-1 days and at 3+/-1 and 32+/-15 months after surgery. Survival at time of re-examination was 100%, 98% and 96%, respectively (three non-cardiac deaths), SR could be documented in 61%, 74% and 78% of patients. Long-term AF before surgery and larger size of the left atrium (LA) were predictive for postoperative AF return (P=0.005, P=0.03); 88% of patients with small preoperative LA-size (

OBJECTIVE The aim of this study was to evaluate the early and late results of a permanent atrial fibrillation (pAF) ablation concept carried out concomitantly with mitral valve (MV) surgery and to identify risk factors for ablation surgery failure. METHODS Between February 2001 and April 2006, 109 patients with pAF over a median time of 48 months (Perc25/75; range 6 - 396 months) underwent monopolar endocardial radiofrequency ablation procedures concomitantly with MV surgery. All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 +/- 1 months) and late after surgery (36 +/- 19 months). For data assessment an explorative data analysis including univariate and multivariate binary logistic regression was performed. RESULTS Early and late survival was 95 % and 91 %, respectively; at follow-up stable SR was documented in 76 % (74 %) of patients. NYHA class improved significantly after surgery ( P = 0.009), particularly when stable SR was achieved ( P = 0.042). Among these MV patients left atrial (LA) enlargement and pAF of long-time duration prior to surgery were detected as risk factors for postoperative recurrence and persistence of atrial fibrillation ( P = 0.026 and P = 0.002); furthermore, advanced age and significant tricuspidal regurgitation at the time of surgery were also relevant. The best prediction (95 % of patients) for SR, as demonstrated in a multivariate model, was based on the factors LA size and pAF duration ( P = 0.052 and 0.005). CONCLUSION Particularly the preoperative LA size and pAF duration seem to be useful parameters to evaluate the success rate of ablation performed concomitantly with MV surgery. It could be demonstrated that an established SR remains stable over time.

Noninvasive recording of ventricular late potentials and intraoperative endocardial mapping at 36 sites were performed in 24 patients with left ventricular aneurysm and drug-resistant sustained ventricular tachycardia due to coronary artery disease. Their mean age was 55 +/- 8 years. Mean ejection fraction was 28 +/- 12%. For detection of late potentials on the signal-averaged QRS complex, 3 different algorithms were used. Late potentials were found in 54, 67 and 67% of the patients, respectively. In patients with a late potential on the signal-averaged electrocardiogram (ECG), delayed local activation (greater than 40 ms beyond the QRS complex on the intraoperative surface ECG) was recorded at 5.5, 5.5 and 5.6 endocardial sites. In patients without a late potential, this type of delayed local activation was detected at 2.4, 1.1 and 0.9 of 36 endocardial sites, respectively (p less than 0.05; p less than 0.01; p less than 0.002). The mean delay of local endocardial activity was 38, 35 and 37 ms in patients with a late potential on the body surface recording versus 20, 19 and 11 ms, respectively, in patients without a late potential (p less than 0.05; p less than 0.05; p less than 0.002). There was no correlation between the duration or amplitude of the late potential, if present, and the number of endocardial sites exhibiting delayed activity (r = -0.23, r = -0.05, r = 0.21; correlation not significant for each) or the mean duration of the endocardial delayed activity (r = -0.25, r = -0.14, r = -0.07; correlation not significant for each). These results indicate that the presence of late potentials on the signal-averaged surface ECG is related to the mean duration of endocardial late activity as well as to the number of endocardial sites exhibiting a given degree of delayed activation. Thus, it is dependent on the mass of slowly activated tissue. However, a direct conclusion from the duration or the amplitude of a late potential to the amount of delayed activation or the extent of endocardial time delay does not seem possible.

A simple strategy to abolish permanent atrial fibrillation (AF) in patients undergoing heart valve surgery is described. The concept includes: (1) endocardial radiofrequency (RF) ablation creating two encircling isolation lesions around the left and the right pulmonary veins (LPV, RPV) and a connection line between both; (2) antiarrhythmic protection with amiodarone for 3 months. Between 02/01 and 02/02 29 patients underwent surgical AF ablation procedures associated with primary valve operations (mitral, n=22; aortic, n=6; aortic+mitral, n=1). Six months after surgery 87.5% (14 of 16) were in sinus rhythm (SR), particularly all patients with an LA diameter of

BACKGROUND Data on combined permanent atrial fibrillation (pAF) surgery and coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) are scarce, and the mid- and long-term effects on survival and cardiac rhythm are unknown. MATERIAL AND METHODS In a prospective analysis 125 patients (Group I: CABG and/or AVR, n = 50; Group II: mitral valve [MV] surgery, n = 75) with pAF (> or = 6 months) underwent either concomitant monopolar (Group I: n = 20; Group II: n = 75) or bipolar (Group I: n = 30) radiofrequency (RF) ablation procedures. Group I patients had a significantly smaller left atrial (LA) size than Group II patients (LA-diameter: 47.7 +/- 4.6 vs. 58.2 +/- 6.1 mm; p < 0.01). Regular follow-up was performed from 3 to 36 months after surgery to assess survival, NYHA-class, and conversion rate to stable sinus rhythm (SR). RESULTS Early mortality (< 30 days) of Group I patients was 0% (Group II: 2.7%), cumulative survival at long-term follow-up was 0.95 vs. 0.82 (p = 0.31) and NYHA-class improved significantly in both groups, particularly in cases with stable SR. At follow-up 80% of Group I patients had SR (Group II: 70%). In Group I patients the bipolar approach was associated with significantly shorter ablation procedure times compared to the monopolar procedure (12.1 +/- 3.4 vs. 18.9 +/- 1.6 min; p < 0.05). CONCLUSIONS Concomitant pAF ablation surgery in CABG and/or AVR is safe and at least as effective as in MV surgery, presumably because severe LA enlargement is exceptionally rare in this group.

Objective: Data of combined mitral downsizing by restrictive prosthetic ring annuloplasty and coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy and moderately severe to severe mitral regurgitation (MR) are rare, and little is known about the effect on reverse left ventricular (LV) and left atrial (LA) remodeling. Methods: Thirty-eight patients (70.6G8.3 years) with coronary artery disease, ischemic cardiomyopathy (LV ejection fraction [LVEF] 31G8%) and moderately severe to severe MR (grade 3.6G0.5) underwent CABG and mitral downsizing by 2–4 ring sizes. Clinical follow-up and serial transthoracic echocardiographic studies were performed after surgery (discharge, 3G 0.5 months, 13G7 months) to assess survival, NYHA class, MR, leaflet coaptation height, LA and LV dimensions/volumes, fractional shortening (FS) and LVEF. Results: Early mortality (!30 days) was 2.6%, survival at follow-up was 92 and 85%, respectively. NYHA class improved from 3.3G 0.6 to 1.5G0.6 (P!0.001). Residual MR at discharge and at follow-up was grade 0.5 and 0.6, respectively (P!0.001). Leaflet coaptation height was 8G1 mm and did not change over time. LV end-diastolic, end-systolic and LA dimensions decreased from 60G 7t o 57G8 mm, from 47G 9t o 42G9 mm and from 51G 5t o 45G4 mm, FS increased from 23G 9t o 28G10% (P!0.001); LV end-diastolic and end-systolic volumes decreased from 188G33 to 171G30 ml and from 129G35 to 105G33 ml, LVEF increased from 31G 8t o 39G10% (P!0.001). Conclusions: Combined mitral downsizing and CABG surgery was performed with excellent clinical results: only minimal residual MR, a significant reduction of LA dimension and an increase of LV contractility due to reverse remodeling were observed. Q 2005 Elsevier B.V. All rights reserved.

Objective: In our population permanent atrial fibrillation (pAF) is a frequent concomitant problem in patients undergoing open heart surgery. A 3-year experience with a treatment strategy using mono- and bipolar radiofrequency (RF) ablation procedures in a heterogeneous group of patients is reported. Methods: In a prospective analysis the incidence of pAF among all patients undergoing open heart surgery in our department between February 2001 and July 2004 was evaluated. In a second step a selective group of 106 patients with pAF (primary mitral: n=63; aortic: n=24; CABG: n=16; aortic+mitral: n=3) underwent either monopolar (n=86) or bipolar (n=20) RF ablation procedures creating two encircling isolation lesions around the left and the right pulmonary veins (PVs) and a connection line between both. In addition amiodarone was given for 3 months after surgery. Regular follow-ups were performed 3, 6, 9, 12, 18, 24 and 36 months after surgery. Results: The incidence of pAF in the total group of 4.110 patients was 3.6%. While the rate was low in cases without severe heart valve disease (1.1%), a significantly higher presence of pAF in patients scheduled for heart valve surgery (10.3%) was observed (P< 0.0001). The incidence was 30-39% in patients with degenerative and rheumatic mitral valve (MV) disease, and further particularly high in the older aged compared to younger patients (4.2-8.3% at 70-99 years; P

This article has been retracted at the request of the Editor-in-Chief after a reader brought to our attention that the data described in this article were the same as those included in 'Early and late results of permanent atrial fibrillation ablation surgery in aortic valve and CABG patients' by Geidel et al., published in Thorac Cardiovasc Surg 2008;56:386–90 (doi: 10.1055/s-2008-1038783). When submitting this article to Interactive CardioVascular and Thoracic Surgery, the corresponding author, on behalf of his co-authors, declared explicitly that the work was original and that it had neither been submitted nor published elsewhere. The corresponding author has admitted to infringing submission and copyright policies of the two journals. We apologise to the readers of Interactive CardioVascular and Thoracic Surgery and the Thoracic and Cardiovascular Surgeon journal for this redundant publication and any inconveniences this retraction may cause. doi of original article: doi:10.1510/icvts.2008.179622

In 11 patients with left ventricular aneurysm and ventricular tachyarrhythmia unresponsive to conventional antiarrhythmic therapy surgical treatment was performed by resection of the aneurysm. One patient underwent epicardial electrophysiological mapping intraoperatively, and the site of earliest activation during tachycardia was established. One patient did 11 hours postoperatively. Three patients are cured from their tachycardia 3 to 22 months after surgery. Six patients have still persistent premature ventricular beats which are now controlled satisfactorily with antiarrhythmic drugs. Our results demonstrate the therapeutic value of aneurysmectomy in the treatment of related ventricular tachyarrhythmias. The practical relevance of intraoperative electrophysiological mapping procedures for localizing the origin of ventricular tachyarrhythmias is a subject which merits further discussion.

In seven patients with documented ventricular tachycardia (VT) and prior myocardial infarction, late potentials (LP) were recorded at the end of or after the QRS complex from the body surface using high-gain amplification and the signal averaging technique (RC filter settings 100 to 300 Hz). In 6 to 7 patients VT could be initiated by programmed right ventricular stimulation; in one case, VT was inducible only from the left ventricle during surgery. Surgery was guided by epi- and endocardial mapping. In most cases besides resection of scar tissue, a partial or complete subendocardial encircling ventriculotomy was performed. Postoperatively, LPs were abolished in five cases, VT being no longer inducible. In the remaining two patients, LPs were still present. VT was still inducible in one of these two cases whereas in the other case, no programmed testing was done postoperatively. These data suggest that the abolition of LPs by surgery is closely related to the disappearance of the propensity to stimulus-induced VT. Thus, the averaging technique represents a new approach to the noninvasive control of the efficacy of surgery in patients with VT and prior myocardial infarction.

Late potentials occurring after the QRS complex were searched for from the body surface using high-gain amplification and signal averaging techniques with filler sellings between 100 and 300 Hz at a sampling rate of 10 kHz. The number of repetitions of the averaging process ranged between 150 and 300 Hz. Sixty-seven patients were studied. In 11 control subjects, no late potentials were delected within the ST segment. Late potentials were observed in 3/27 patients without previously documented ventricular tachycardia all having left ventricular aneurysms. All three patients had evidence of increased ventri-l cular vulnerability (one dying from ventricular tachycardia; one with stimulus-inducible ventricular tachy–cardia; one with multiple episodes of ventricular fibrillation after surgery). In patients with previously k documented ventricular tachycardia and/or fibrillation, late potentials occurred in 7/14 cases (50%), mainly in those with aneurysms (6/8 patients = 7596/ In another 15 patients with ventricular tachycardia and/or fibrillation who were on an effective long-term antiarrhylhmic regimen no late potentials were found. Mean onset of late potentials after the QRS complex was 38 ± 20.1 ms, mean amplitude was 3.9 ± 2.0 uv, and mean duration was 17.1 ± 5.4 ms. We conclude that late potentials which represent late depolarization of a mass of ventricular tissue after slow conduction, herald increased susceptibility to ventricular tachyardia mainly in patients with ventricular aneurysms.

Isolated ventricular inversion is a term used for a congenital heart malformation with the segmental arrangement atrioventricular (A V) discordance and ventriculoarterial concordance. It discribes a condition which from a physiological point of view resembles complete transposition of the great arteries. We have recently seen two patients with this anomaly. Both underwent intracardiac repair by means of a Mustard operation at 10 years and 10 months of age, respectively. Associated lesions in the first patient were an AV septal defect with two AV orifices (partial AV canal, ostium primum defect), partial anomalous pulmonary venous return, and anomalies in the systemic venous drainage. A perimembranous ventricular septal defect complicated the condition in the second patient.

Between June 1978 and 1986, 93 consecutive patients underwent electrophysiologically guided operations for life-threatening recurrent sustained ventricular tachycardia mostly associated with other surgical procedures, such as left ventricular resection (aneurysmectomy) and coronary artery bypass grafting. Data: Eighty-seven percent of the surviving patients were free of spontaneous ventricular tachycardia return or sudden death 1 year after the operation and 77% at 5 years. The instantaneous risk of ventricular tachycardia return was highest immediately after operation, declined rapidly, and by 2 weeks postoperatively had merged with the constant hazard phase, which persisted as long as the patients were observed. Endocardial resection, rather than encircling endocardial myotomy, increased the risk of spontaneous ventricular tachycardia return/sudden death. Survival rates, including hospital deaths, were 95% at 30 days, 89% at 1 year, and 70% at 5 years after operation. The most prevalent mode of death was heart failure. The absence of anterolateral left ventricular aneurysms and the use of more extended encircling incisional techniques for ventricular tachycardia ablation increased the risk of early and late death. Survival was particularly poor in that subset of patients in whom recurrent sustained ventricular tachycardia returned after operation; the most prevalent mode of death in this group was also progressive left ventricular failure. Inferences: (1) Complete and partial encircling endocardial myotomy incisions are the most effective surgical techniques for malignant ventricular tachycardia ablation. (2) Because of their adverse effects on left ventricular structure and function, the arrhythmogenic tissues have to be localized as precisely as possible, and the encompassing incisions should be kept as limited as possible. (3) The late return of ventricular tachycardia may be more related to a progressive ischemic left ventricular cardiomyopathy than to an inadequate operation.

Between 1971 and 1982, 41 patients were operated upon for recurrent sustained ventricular tachycardia. All but three had severe coronary artery disease with a history of myocardial infarction. In 10 patients (Group I) simple aneurysmectomy with or without aorta-coronary bypass grafting was done. Thirty-one patients (Group 11) had an electrophysiologically guided procedure, mainly partial or complete encircling endocardial ventriculotomy (EEV) at the earliest source of electrical activity during ventricular tachycardia. The results in the two groups indicate a clear superiority of electrophysiologically guided procedures over simple aneurysmectomy regarding early and late disappearance of tachycardiac rhythm problems (p = 0.01); the differences between the two groups in hospital mortality (p = 0.43) and long-term survival are not significant. We compared our data with results in 160 cases of simple aneurysmectomy and 224 cases of electrophysiologically guided operations recently published in the literature. This comparison confirms the higher efficiency of mapping-guided procedures in eradicating ventricular tachycardias. The improvements in hospital and long-term survival, again, are not significant.

Patients with tetralogy of Fallot and unfavorable anatomy of the right ventricular outflow tract or hypoplastic pulmonary arteries may require primary palliation and subsequent repair (two-stage repair). The concept of palliation includes improvement of the lung perfusion and relief of systemic hypoxia by means of some type of arteriopulmonary arterial shunt or a Brock-type operation. At repair a previously constructed aorto-pulmonary anastomosis has to be closed, which can be done without increased risk for hospital death or postoperative morbidity.

UNLABELLED During the recent 10 years period worldwide more than 1000 patients underwent an electrophysiologically guided direct operation for malignant ventricular tachycardia in the setting of chronic ischemic heart disease. The published results of these operations as regards relief of ventricular tachycardia and survival are highly variable. The data presented here are largely based on a multi-institutional registry series (n = 665) and the combined Dusseldorf-Birmingham/Alabama (DUS-UAB) ventricular tachycardia surgery experience (n = 216). DATA Survival (hospital deaths included) was 75% one year after operation and 45% at 5 years (DUS-UAB). The respective data of the registry series were 78% and 55%. The most prevalent mode of death in both analyses was acute/subacute/chronic heart failure. More extensive encircling procedures (incisional/cryo) for ventricular tachycardia ablation and the combination of encircling cryoablation and endocardial resection increased the risk of progressive left ventricular dysfunction and death; however, by multivariate analysis the severity of the underlying ischemic heart disease (indicated by NYHA functional class, LVEDP, No. of previous infarcts, and extensiveness of coronary disease) and the absence of a discrete left ventricular aneurysm were more powerful predictors for early and late postoperative mortality than the use of alternative surgical techniques for ventricular tachycardia ablation. Survival was particularly poor after the return of spontaneous sustained ventricular tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)

To assess the efficacy of map-guided antitachycardia surgery, induction of ventricular tachycardia has mostly been performed using endocardial stimulation. In addition, epicardial stimulation can be done using temporary epicardial wires, thus not requiring post-operative catheterization. However, the diagnostic value of epicardial versus endocardial stimulation for the post-operative evaluation of patients undergoing map-guided surgery for drug-refractory ventricular tachycardia is not known, especially with regard to the induction of non-clinical tachyarrhythmias. Therefore, we compared the results of epicardial and endocardial programmed ventricular stimulation in 58 consecutive patients in whom pairs of steel wires were placed over the right ventricle during surgery. The stimulation protocol consisted of single and/or double premature stimuli during sinus rhythm and paced ventricular drives of 500, 430, 370 and 330 ms. Pre-operatively, all patients had inducible monomorphic ventricular tachycardia by endocardial stimulation. Post-operatively, 36 patients were not inducible by either epicardial or endocardial programmed ventricular stimulation, whereas epicardial and endocardial stimulation induced the clinical ventricular tachycardia in six patients and non-clinical ventricular tachycardia in three patients (45/58 patients, 77% concordant). However, in two patients the clinical ventricular tachycardia was induced only by endocardial programmed ventricular stimulation. Non-clinical ventricular tachycardia was inducible in three patients by epicardial stimulation only, and in eight patients by endocardial stimulation only (13/58 patients, 23% discordant). Thus, in 77% of patients an identical result of programmed ventricular stimulation was obtained using epicardial and endocardial stimulation, whereas the results were discordant in 23%. Therefore, epicardial stimulation alone is not sufficient for the post-operative evaluation after map-guided surgery.

The report concerns 5 patients with straddling or overriding atrioventricular valves. The overriding phenomenon was found 4 times in tricuspid, once in mitral position. In addition to this malformation, 2 patients had congenitally corrected transposition of the great arteries (CTGA), one patient had transposition of the great arteries (TGA), and another a double outlet right ventricle (DORV). In 2 instances corrective surgery was done without compromising the anatomical and functional integrity of the straddling valve. Three patients with straddling degree B-C received palliative procedures, the ventricular septal defect (VSD) was left open in order to save the straddling atrioventricular valve and pulmonary artery banding was done for protection of the pulmonary vascularity. One corrected patient died in the early postoperative period.

Encircling endocardial ventriculotomy (EEV) as surgical treatment for recurrent sustained ventricular tachycardia (VT) in the setting of coronary artery disease was introduced in 1978 by Guiraudon [1]. Since then this technique has proved to be a highly efficient approach to eradicating enhanced ventricular electrical vulnerability and tachycardiac rhythm disturbances of the reentry type [2–4]. The mechanism of this antiarrhythmic effect is not quite clear; interruption of reentry circuits [1] or initiation of an ischemic injury to the arrhythmogenic tissues [5] are possibilities under discussion.