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Surgical ablation for atrial fibrillation (AF) performed at the time of other valvular- or nonvalvular cardiac procedure is a mainstay of therapy; yet the data regarding its influence on remote survival are sparse. We aimed to evaluate late survival in patients undergoing mitral valve (MV) surgery with concomitant surgical ablation for AF.Procedure-related data from the Polish National Registry of Cardiac Surgery Procedures (Krajowy Rejestr Operacji Kardiochirurgicznych) were retrospectively collected. A total of 11,381 patients with baseline AF (46.6% men; mean age 65.6 ± 9.0 years) undergoing MV surgery between 2006 and 2017 in 37 reference centers across Poland and included in the registry were analyzed. Median follow-up was 5 years (mean, 4.6 years; interquartile range, 1.9-7.9 years). Cox proportional hazards models were used for computations. Propensity score matching for the comparison of MV + ablation versus MV alone was performed.Of included patients, 2449 (21.5%) underwent surgical ablation for AF. Patients in this group were significantly younger (63.8 ± 8.7 years vs 66.1 ± 9.0 years; P .001) and were at lower baseline surgical risk (EuroSCORE, 2.86 vs 3.69; P .001). During the 12-year study period, there was a significant survival benefit (hazard ratio, 0.71; 95% confidence interval, 0.63-0.79; P .001) for MV + ablation compared with MV alone. After rigorous propensity matching (logit model, 1784 pairs) surgical ablation was associated with nearly 20% improved survival (hazard ratio, 0.82; 95% confidence interval, 0.70-0.96; P = .011). Benefit of surgical ablation was maintained in subgroup analyses, yet most benefit was appraised in low-risk patients such as those with EuroSCORE of 2 to 5 or age 50 years.Concomitant surgical ablation for AF in patients undergoing mitral valve procedures is safe, feasible, and significantly improves late survival.

The purpose of the present study was to analyze the effects of transmyocardial laser revascularization (TMLR) on myocardial perfusion. The value of 99mTc-MIBI scintigraphy in the detection of changes in perfusion of the lased and nonlased segments was assessed as well. In 15 patients before TMLR and then 3 and 6 months afterwards, MIBI scintigraphy and a stress test were carried out. At the beginning of the study, all patients were classified as having angina pectoris class III or IV (according to the criteria of the Canadian Cardiac Society); their ejection fraction was >30%. The parameters of the stress test increased significantly in 70% of the patients. Cardiac scintigraphy revealed improved perfusion of 33.7% of the transient defects within 3 months after TMLR which persisted at 6 months with a clear trend towards further improvement in the lased segments. TMLR has been found to be particularly beneficial in patients in whom other invasive methods of treatment cannot be applied.

Background: Aortic valve disease is an important and frequent clinical problem with a mortality rate as high as 50–80% in a 5-year natural history of patients with severe aortic valve disease. Biological or mechanical prosthesis implantation is the only way to improve prognosis. Hypothesis: The aim of our study was to assess the clinical outcome of aortic valve replacement according to the underlying valve pathology and the type of replacement device, that is, aortic homografts versus mechanical prostheses. Methods: The study group consisted of 143 patients with a mean follow-up period of 4.1 ± 2.7 years. All patients had annual clinical and Doppler echocardiographic evaluation. Results: Total 8-year mortality was 4.9% (7/143) including early mortality of 1.4%. Eight-year survival probability was not significantly higher in the homograft than in the mechanical prosthesis recipients. No differences were found among subgroups with aortic stenosis, insufficiency, and combined disease. Overall early and late complication rate (13.3 and 24.8%, respectively) was similar in homograft and mechanical valve recipients. The most common late complications were ventricular arrhythmia (10%) (Lown class I–III), pre-dominantly in the homograft recipients (17.7 vs. 3.7%), and heart failure (9.2%), more frequent in mechanical valve recipients (14.8 vs. 1.6%). Thromboembolic events occurred in 6.3%, infective endocarditis in 4.2% (more common in mechanical valve recipients), serious bleeding in 3.7% (only in mechanical valve recipients). There was no significant difference in early and late complication rate among subgroups (aortic stenosis, insufficiency, and combined disease). Of the patients studied, 91.6% improved in functional status after surgery, with significantly better outcome in homograft recipients. The type of preexisting valve disease did not influence clinical improvement. Conclusion: Early and late mortality as well as estimated probability of survival and hemodynamic improvement at 8-year follow-up after aortic valve replacement are independent of the type of implanted valve. Complication rate does not depend upon the type of preexisting valve pathology, but severe late complications are more common after mechanical valve implantation than after homograft implantation.

UNLABELLED The aim of our study was to analyze circadian distribution of premature ventricular contractions (PVC) and its coupling interval (CI) in patients after orthotopic heart transplantation (HTx). Forty-two patients (5 females, 37 males) were monitored from 2 weeks to 5 years after HTx; 180 24-hour Holter ECG studies were performed. All recordings were divided into two groups: group I, within 1 month after HTX; and group II, after 1 month. Patients with more than 250 PVC/24 hours were selected for distribution of PVC and CI evaluation. CONCLUSIONS Ventricular arrhythmias occur frequently in patients after heart transplantation. In patients with high Lown scale arrhythmias low occurrence (< 250/24 hours) of PVC was frequently observed (IVa: 81.8%; IVb: 84.7%). Similar patterns of circadian distribution (CD) of PVC and CD of HR in denervated heart after HTx suggest the influence of circulating catecholamines on their occurrence.

The increasing use of the aortic homograft as aortic valve substitute and the limited availability of donor valves prompted us to consider the pulmonary homograft as an alternative substitute for aortic valve replacement. The aim of our study is to compare the ultrastructural and biomechanical properties of pulmonary homograft leaflets with those of their aortic counterpart and to present the early results of using the pulmonary homograft for aortic valve replacement. Light and transmission electron microscopy have shown that pulmonary homograft leaflets are thinner than the aortic with a lesser content of elastic tissue in the ventricularis layer. However there were no substantial differences in the ultrastructure. Uniaxial tensile tests were done on 69 cusps from human pulmonary and aortic valves using an Instron testing machine. The strain at 200 KPa was found to be similar for both pulmonary and aortic leaflets (8.20% ± 2.87% versus 8.98% + 1.90%) cut circumferentially. Radial strips appear to be more extensible in pulmonary leaflets than in aortic (32.6% ± 7.5% and 28.6% + 11.1%, respectively). The ultimate tensile strength for circumferential strips was found to be similar for both aortic and pulmonary valves (1460 ± 857 kPa versus 1450 ± 689 kPa), but there was relatively little difference between the radial strips (295 ± 95 kPa versus 252 ± 104 kPa). A total of 123 patients whose ages ranged between 13 and 78 years received either fresh antibiotic sterilized or cryopreserved pulmonary homografts for aortic valve replacement. The pulmonary homograft was inserted in place of the patient's diseased aortic valve by using one of two different techniques: freehand in the subcoronary position or as a "short cylinder" inside the aortic root. There were three hospital deaths (2.43%; 70% confidence limits=1.08% to 4.83%). Cumulative follow-up was 184 patient-years (range 1 to 39 months). All surviving patients have been followed up with serial color flow Doppler echocardiography. There were no late deaths. Actuarial late survival was 97.5% (70% confidence limits=95.7% to 98.6%) at 3 years. Four patients (2.2% /pt-yr) underwent reoperation because of severe aortic regurgitation (1, 4, 12, and 15 months after the operation) because of technical problems (mismatch in size between the pulmonary homograft and aortic anulus) in three patients and probably because of graft rejection in one patient. At 3 years the actuarial rate of freedom from reoperation was 95.5% (70% confidence limits=92.7% to 97.3%). Mild aortic regurgitation has been detected in three patients (2.6%). No patients incurred thromboembolic episodes or infective endocarditis. According to our results the pulmonary homograft has ultrastructural and biomechanical properties similar to those of the aortic homograft. Furthermore, the pulmonary homograft is more pliable and easier to insert, giving promising short-term results.

During a period of 25 years (1979-2004), 24060 operations with extracorporeal circulation were performed. Of them 9536 (39.6%) were valvular procedures and 763 were combined with coronary bypass grafting. 4315 pts were operated (45.3% of valvular operations) because of mitral valve disease 5559 mitral valves were corrected, including multivalvular and combined procedures. Initially, mitral surgeries were predominant, but currently aortic valves are operated two times more frequently. In 85.5% of cases mitral valve replacement was necessary (with prosthetic valve), but 803 pts underwent reconstructive surgery (445 commissurotomies and 358 valvo/annuloplasties, including 135 implantations of annuloplasty rings). Additionally, 421 DeVega tricuspid valve annuloplasties were performed, and 15 tricuspid rings were implanted. Because of infective endocarditis 182 mitral valves were corrected, including the replacement of 78 infected prostheses. The pts age varied between 10 and 85. In 1980 the mean age was 40, but currently it has increased to 55, and the pts with coronary artery disease are approximately 10 years older. The general mortality among pts with ECC was 4.2% in 2003, and after valvular procedures 4%. The mortality after mitral valve replacement diminished from 12% to 4.5-5%, and after reconstructions was two times lower. The mortality among pts with endocarditis was 11.8%. Several characteristic trends were observed: increase of the number of elder pts, decrease of mitral valve procedures in comparison with aortic ones, more common coincidence of coronary artery disease, better preoperative status of the pts, and decrease of the operative risk.

Allogenic aortic valves are widely used in case of native aortic valve or root disease as well as failed prosthetic valves with great success. At the Department of Cardiovascular Surgery and Transplantology of the Jagiellonian University in Cracow, aortic valve or aortic root replacement with allogenic aortic valve has been performed for 23 years. Allogenic heart valve bank was founded in 1980. In the bank we prepare both aortic allografts for adult cardiac surgical procedures and pulmonary allografts that are mostly used for repair of congenital heart disease.Allogenic aortic valves implantation was usually considered in our clinic for older patients, patients with infective endocarditis of the native or prosthetic valve, young women in reproductive age and patients with Marfan syndrome. Allografts exhibit excellent clinical performance and acceptable durability with no early failure if properly inserted. Between 1980 and 1992, allografts were obtained only from cadavers during routine autopsies. More than 10% of prepared allografts were exported to other cardiac surgery centres in Poland and foreign countries. Aortic valve replacement using allogenic aortic valves can be performed with acceptable mortality and good long-term results. The procedure although surgically more challenging has the advantage of not requiring anticoagulation therapy, hemodynamic performance of the allogenic valve is excellent, it demonstrates freedom from thromboembolism and infective endocarditis. We would like to emphasize the importance and advantages of the fact that allogenic heart valve bank is placed in the department of cardiovascular surgery and it is able to supply the department in heart valve allografts 24 h a day.

The study aim was to assess histological and mineralogical properties of leaflets in human, antibiotic-preserved aortic homograft valves (recovered during surgical replacement) in order to identify factors accounting for pathological changes leading to accelerated graft dysfunction. A comparison was made with aortic valves prepared for grafting, with a view to assessing morphological and mineralogical characteristics as a potential preimplantation risk factor.Valve leaflets were examined with light and scanning electron microscopy. Mineralization was assessed histochemically, and also physicochemically by atomic absorption spectroscopy (AAS).All explanted homograft valve leaflets revealed prominent degenerative changes seen as decreased surface area, fibrosis, mineralization and focal thrombosis. Substantial loss of endothelium and fibroblasts, reduced collagen bundles crimping, inflammation (81%) and disappearance of layered structure (59%) was identified. The elastic elements were relatively stable, though a gradual age-dependent loss was observed in both groups. Accelerated mineralization was seen in all explanted homografts; inorganic deposits were composed mainly of hydroxyapatite. Two types of mineralization were identified: large limited nodular structures, and diffuse mineral deposits. Homografts with moderately elevated mineralization, well-preserved layered structure and sporadic infective changes proved to have the greatest durability. Homograft durability was also affected by the difference in host and donor age.Preimplantation factors affecting pathological changes determining homograft durability included morphological status of the graft itself and donor age; host-related factors included recipient age, endocarditis, native valve calcification, and host-donor matching (age difference between host and donor). A limited molecular mineralization may increase valvular durability, provided that no focal nodular calcifications exist that might adversely affect overall homograft integrity.

Objective: Through a retrospective study on the use of fresh homografts in 655 aortic valve replacement patients over a period of 23 years, we aimed to assess the reasons for eventual reoperation and causes of valve dysfunction. Methods: Between January 1980 and December 2002, 655 patients received fresh homografts. All homografts were antibiotic sterilized and stored at 4 8C. During this time, 139 patients (116 male and 23 female) with a mean age of 46.7 years (range 18– 72) required reoperation. Results: The 30-day hospital overall mortality was 2.87%. The mean durability for all homografts was 12.4 ^ 4.54 years (1 month to 23 years). The cumulative rates for freedom from reoperation for any cause were 94.09 ^ 2% at 5 years and 87.9% ^ 4% at 10 years, 76.6 at 15 years, 49.55 at 20 years. The major cause of valve dysfunction and indication for reoperation was degeneration in 111 patients (79.8%). Predominant aortic valve insufficiency in 87 patients (62.5%) and predominant stenosis in 24 patients (17.26%). Endocarditis occurred in 21 patients (15.1%). Early endocarditis was diagnosed in five patients (3.59%), late endocarditis in 16 patients (11.5%). Additional causes for reoperation included ascending aortic aneurysm, mitral valve insufficiency and congestive cardiomyopathy. Seventeen patients (12.2%) required concomitant procedures. Coronary artery bypass grafting was performed in six cases (4.3%), mitral valve replacement in five cases (3.59%), mitral valve annuloplasty in six (4.3%). The primary reoperative procedure was artificial/mechanical aortic valve implantation. In five cases, St. Jude Medical conduit grafts were implanted due to ascending aortic aneurysms. Homograft reimplantation was performed in four cases. One patient underwent mitral valve replacement and one patient received a heart transplant. Conclusion: The results of the study suggest that reoperation in patients with aortic homografts is a low-risk procedure as compared to alternative therapies. Primary allograft aortic valve replacement can give acceptable results for up to 23 years. The major cause of valve dysfunction and indication for reoperation was degeneration. Cumulative rates for freedom from reoperation for any cause in age groups suggest careful selection and indications in homograft implantation in the younger patients. Young age is a risk factor for an early homograft structural deterioration (degeneration). q 2003 Elsevier Science B.V. All rights reserved.

This case study presents two patients with aortic stenosis and infective endocarditis (IE) who underwent homograft aortic valve replacement. The first patient is a 67 year old practicing surgeon. Twenty one years ago, he was admitted to our department for critical aortic stenosis, infective endocarditis (IE) and heart failure. He underwent homograft aortic valve replacement. After the surgery his condition improved dramatically and he returned to his practice. Current echocardiographic study shows normal function of the left ventricle and normal gradient across homograft aortic valve. The next case, a 33-year old happy mother of 5 children, is particularly interesting. When she was 15 years old, she was referred to surgery, diagnosed with bicuspid aortic valve stenosis, subaortic muscular stenosis and aneurysm of aortic sinus of Valsalva. She underwent homograft aortic valve and root replacement and excision of the sub-aortic muscle bulge. Eleven months later, she required another operation due to active IE. The St. Jude Medical aortic valve was implanted. Two months after the surgery a dysfunction of the implanted artificial valve was diagnosed. She again underwent the homograft aortic valve and root replacement with good long-term results. In the period spanning 1987-1997, she managed to deliver five babies without any complications whatsoever. Seventeen years later, the homograft aortic valve is still functioning fairly well. The homograft aortic valve replacement may be regarded as a viable option for patients with aortic stenosis and IE and for young women suffering from aortic valve disease who intend to be prospective mothers.

The aim of the study was to assess the long-term results of surgical treatment with homogenic aortic grafts (HAGs) implantation in patients with Marfan syndrome. There were 31 patients with Marfan syndrome and aortic aneurysm who were operated on between 1980 and 1996. Aortic dissection was diagnosed in 14 patients, DeBakey Type I in six patients and Type II in eight patients. Four patients had to be operated urgently in cardiogenic shock with cardiac tamponade. Sealing up and reinforcement with strip of felt or Gore-Tex has been applied in 22 patients. The surgical modifications mentioned above have been applied since 1987 in all patients with the diameter of the aortic ring exceeding 30 mm or with active infective endocarditis or during reoperation. In 16 patients the space between the aortic homograft and patients own aortic wall was joined to the right atrial auricle. Patients were followed up for 12–179 months (average: 94.6±499). Three patients died in the early postoperative period and four patients died in the late postoperative period. Rethoracotomy because of bleeding complications was necessary in five patients. HAG damage was responsible for six other reoperations—new HAGs have been implanted in three patients and artificial prostheses were implanted in the other three patients. In the late follow-up period significant improvement in cardiac performance was observed in 24 patients (NYHA I or II). Survival probability of 15 years for the whole group was 80%. The lowest survival probability has been shown in the group of patients with DeBakey Type I aortic dissection (35% survived 15 years after operation). Echocardiographic follow-up has shown that the pressure gradient in HAG was low (7.4±6.2 mmHg). Only in two patients did the HAG gradient exceeded 20 mmHg. There were no significant differences concerning aortic ring diameters, dimensions of HAG and echocardiographic parameters between the group with surgical modifications, i.e. sealing up and reinforcement with strip of felt or Gore-Tex applied and the group in which these modifications were not applied. Homogenic aortic graft implantation as a method of surgical treatment of aortic aneurysm in patients with Marfan syndrome avoids postoperative anticoagulation, results in substantial improvement of cardiac performance and prolongs life. Surgical treatment should be considered in asymptomatic patients with large aneurysms (exceeding 55–65 mm) in patients with Marfan syndrome because there is a high risk of death in this group of patients in the case of dissection.

The aim of the study was to assess the influence of aortic valve replacement on left ventricular size and muscle hypertrophy according to the type of preexisting valve disease (aortic stenosis, insufficiency or combined disease). The study group consisted of 143 consecutive patients (pts) after aortic valve replacement (109 men, 34 women, mean age 48.1 +/- 10.9 years). Reason for the operation was aortic stenosis in 35 pts, aortic insufficiency in 64 pts and combined disease in 44 pts. Echocardiography was performed before surgery, 1 month and 1 year after operation, and yearly during 5-year follow-up. Transvalvular aortic pressure gradients decreased significantly after valve replacement in all subsets without further changes during follow-up (Pmax (mmHg): from 54.2 +/- 20.7 to 17.9 +/- 9.6 in combined disease pts, from 72.3 +/- 19.9 to 21.6 +/- 14.6 in aortic stenosis and from 34.5 +/- 24.2 to 15.6 +/- 11.3 in aortic insufficiency pts, respectively, P0.0005). One year after surgery the diastolic dimension of the left ventricle decreased significantly in all subjects, whereas the systolic dimension only in aortic insufficiency and combined disease pts (from 44 +/- 11.8 to 31.6 +/- 5.4 mm, P0.001 and from 41.9 +/- 11.5 to 33 +/- 6.7 mm, P0.05, respectively). Further decrease of both diastolic and systolic dimensions was observed only in the aortic insufficiency group. Ejection fraction of left ventricle increased only in combined disease pts (from 51.6 +/- 10% to 56.8 +/- 8.2%, P0.05). Wall thickness of the left ventricle decreased 1 year after valve replacement only in the aortic stenosis group and in further follow-up in the aortic stenosis and combined disease group. Normalization of left ventricular size is observed in more than 90% of patients during 5-year follow-up as opposed to left ventricular muscle hypertrophy, regressed only in less than a half of the study population. In patients with aortic valve disease the greatest hemodynamic improvement is observed 1 year after valve replacement. This is expressed by marked reduction of the left ventricular dimensions and wall thickness, without significant improvement of the ejection fraction. Further regression of left ventricle dimensions occurs in patients operated on due to predominant valve insufficiency, whereas regression of left ventricular hypertrophy is observed in patients with preexisting valvular stenosis.

The choice of optimal substitute, mechanical or biological, for aortic valve replacement is still discussed (4, 7, 8, 14, 15). The use of fresh, unstented, antibiotic-sterilised allografts (homografts) for replacement of aortic valve, aortic root or for correction of some complex congenital malformations, is emphasized by many authors (4–6, 9, 13–15, 17). The method was introduced into clinical practice in the early 1960s, particularly by Ross and Barratt-Boyes (2, 12). The well documented followup studies demonstrate that the results of allograft implantation are comparable or better than those of mechanical valves (5, 8, 11).

Bleeding is the most frequent complication related to implantation of a mechanical cardiac assist device. 1 Recombinant activated factor VII (NovoSeven; Novo Nordisk, Bagsvaerd, Denmark) was developed as a prohemostatic agent. We report the successful use of recombinant activated factor VII to control bleeding abnormalities in a patient with a left ventricular assist device (LVAD). Clinical Summary