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We present a case of a 66-year-old patient with infective endocarditis of an aortic valve bioprosthesis with major dehiscence and extensive "rocking motion" but without any diastolic paravalvular regurgitation as assessed with radiography and transesophageal echocardiography.

Background: Because of a high prevalence of coronary artery disease in patients with aortic valve disease, coronary angiography is recommended before aortic valve replacement. However, during the last three decades, a decline in mortality due to coronary heart disease has been observed in the general population in both Western Europe and the United States. It is unknown whether preoperative angiography is still mandatory in all patients., Aim: To assess the prevalence of angiographically defined coronary artery disease in patients with aortic valve replacement and trends during a ten-year period., Methods: We performed a retrospective cross-sectional study of patients undergoing aortic valve replacement between 1988 and 1998 in our institution. Patients with a history of coronary artery disease and patients younger than 25 years were excluded. Coronary atherosclerosis was defined as one or more coronary artery luminal stenosis of 50% or more on preoperative coronary angiography., Results: During the study period 1339 patients had aortic valve replacement in our institution, data on 1322 (98%) were available for analysis. Previous coronary artery disease was documented in 124 patients (10%). After exclusion of 17 patients (no angiography), data on a total of 1181 patients were analysed. Coronary atherosclerosis was present in 472 patients (40%) on preoperative coronary angiography. Several well-known risk factors of ischaemic heart disease were associated with coronary atherosclerosis. The prevalence of angiographically defined coronary atherosclerosis varied between 30% and 50% per year. There was, however, no significant trend during the study period. Multivariate analyses, to adjust for potential differences in risk factors during the observation period, did not change this conclusion., Conclusions: The prevalence of angiographically defined coronary artery disease in patients scheduled for aortic valve replacement is still high. From 1988 to 1998, no significant change was observed in angiographic measures of coronary atherosclerosis in patients with aortic valve replacement. Therefore, it is advised to perform coronary angiography before aortic valve surgery.

Objectives: We sought to assess the relationship between completeness of revascularization and adverse events at one year in the ARTS (Arterial Revascularization Therapies Study) trial., Background: There is uncertainty to what extent degree of completeness of revascularization, using up-to-date techniques, influences medium-term outcome., Methods: After consensus between surgeon and cardiologist regarding the potential for equivalence in the completeness of revascularization, 1,205 patients with multivessel disease were randomly assigned to either bypass surgery or stent implantation. All baseline and procedural angiograms and surgical case-record forms were centrally assessed for completeness of revascularization., Results: Of 1,205 patients randomized, 1,172 underwent the assigned treatment. Complete data for review were available in 1,143 patients (97.5%). Complete revascularization was achieved in 84.1% of the surgically treated patients and 70.5% of the angioplasty patients (p < 0.001). After one year, the stented angioplasty patients with incomplete revascularization showed a significantly lower event-free survival than stented patients with complete revascularization (i.e., freedom from death, myocardial infarction, cerebrovascular accident and repeat revascularization) (69.4% vs. 76.6%; p < 0.05). This difference was due to a higher incidence of subsequent bypass procedures (10.0% vs. 2.0%; p < 0.05). Conversely, at one year, bypass surgery patients with incomplete revascularization showed only a marginally lower event-free survival rate than those with complete revascularization (87.8% vs. 89.9%)., Conclusions: Complete revascularization was more frequently accomplished by bypass surgery than by stent implantation. One year after bypass, there was no significant difference in event-free survival between surgically treated patients with complete revascularization and those with incomplete revascularization, but patients randomized to stenting with incomplete revascularization had a greater need for subsequent bypass surgery.

Objective: In the majority of patients with chronic atrial fibrillation the arrhythmia will persist after correction of the underlying structural abnormality. The maze procedure is an effective surgical method to eliminate atrial fibrillation and to restore atrial contractility., Methods: In this study we used radiofrequency energy to create lines of conduction block in both atria during cardiac surgery as a modification of the maze III procedure. One hundred twenty-two patients with atrial fibrillation for at least 1 year and structural heart disease underwent open heart operation and a radiofrequency modified maze procedure., Results: In 108 (89%) of 122 patients mitral valve surgery was performed, and in this group 86 patients (80%) underwent 121 concomitant procedures. Fourteen patients (11%) underwent cardiac surgery not involving the mitral valve. The additional crossclamp time required for the left atrial part of the radiofrequency modified maze procedure was 14 +/- 3 minutes. The in-hospital mortality rate was 4.1%. The overall 39-month survival was 90%, and freedom of atrial flutter or atrial fibrillation was 78.5% +/- 5.1%. Eighty-nine survivors with sinus, atrial rhythm, or atrioventricular sequential pacemaker had Doppler echocardiography, and right atrial transport function was documented in 83% and left atrial transport function in 77% of patients., Conclusion: We concluded that the radiofrequency modified maze procedure as an adjunctive procedure is safe, time-sparing, and effective in eliminating atrial fibrillation and restoring atrial transport function.

An adult female was admitted for emergency surgery of a massively bleeding suspected aneurysm of the descending aorta. It proved to be a rupture of an aneurysm of a nonpatent ductus arteriosus or ductal diverticulum, a very rare lesion that is usually diagnosed on post-mortem. Adhesion of a previous ipsilateral lobectomy contributed to her survival. The aneurysm was resected.

Objective: To describe the causes and circumstances of death regarding patients who died in 1994 and 1995 while on a waiting list for cardiac surgery in the Netherlands., Design: Retrospective multicentre case study., Setting: 11 Dutch cardiac surgery centres., Patients: All patients reported as dying while on the waiting list for cardiac surgery in 1994 and 1995., Main Outcome Measures: Classification of death by an independent adjudication committee into "erroneously reported", "waiting list related" or "not waiting list related". Death was judged as "waiting list related" if the clinical course would have been substantially different if there had been unrestricted surgical capacity., Results: 138 and 129 deaths were reported in 1994 and 1995, respectively. 43 deaths (16%) were considered as erroneously reported. 181 of the remaining 224 cases were adjudicated as waiting list related. Median time from acceptance for surgery to death was 35 days (interquartile range 14-75 days). 97 of 181 deaths occurred within six weeks following addition to the waiting list. The estimated incidence of death ranged from 1.33 per 1000 patient-weeks during weeks 2-4 to 0.68 per 1000 patient-weeks after 12 weeks., Conclusions: The causes and circumstances of death are waiting list related for approximately 100 patients per year in the Netherlands. At least half of the deaths may occur within the first six weeks. Waiting lists for cardiac surgery engender high risks for the patients involved.

If the aortic arch requires repair or replacement due to an aneurysm or dissection, conventional cardiopulmonary bypass (CPB) is not possible during the period in which the aortic arch is excluded from the circulation. This creates a situation in which there is no cerebral circulation. The brain needs adequate protection from this ischaemic insult. Hypothermic circulatory arrest (HCA), antegrade/selective cerebral perfusion (ASCP) and retrograde cerebral perfusion (RCP) are reported to exhibit their cerebral protective capabilities during procedures involving the aortic arch. HCA can provide adequate protection in procedures of short duration and avoids the complications associated with cerebral perfusion techniques. The main disadvantage of HCA is that the 'safe' duration of circulatory arrest is not clearly defined. Topical cooling of the head may enhance cerebral hypothermia and provide additional protection. If longer periods of circulatory arrest are anticipated or occur unexpectedly, we suggest that ASCP can offer improved cerebral protection by providing adequate brain perfusion and improved cerebral cooling. By using a coronary sinus perfusion catheter as a carotid artery cannula, it is not necessary to snare or clamp the carotid arteries. This technique minimizes the chance of damaging the carotid arteries. In this report, we describe our set-up and ASCP perfusion protocol for the surgical repair of an aortic arch aneurysm.

The surgical correction of aneurysms in the descending thoracic aorta necessitates clamping the aorta both proximal and distal to the aneurysm. The affected length can vary from a few centimetres to large portions of the upper and lower descending aorta. Clamping times can vary from a few minutes to more than one hour. No matter which technique is applied, these operations are often accompanied by excessive blood loss and the need for rapid transfusion, resulting in substantial haemodynamic fluctuations. Hypothermia may become a problem in these patients because most blood warmers are unable to warm blood adequately ( greater than 35 degrees C) at high flow rates (>100 cc/min). This may result in clotting problems. For this reason, our clinic decided from November 1990 to integrate a reservoir with its own heat exchanger (Cobe) into our left-left bypass system. This system largely regulates transfusion during partial extracorporeal circulation (PECC). The advantages of such a system are that (1) the transfusion rate can be adapted to blood loss and is not dependent on the quality and quantity of the infusion systems; (2) blood products and other infusion liquids are filtered; and (3) the transfusion blood is warmed. In this article, we describe our experience with this application of PECC on three patients who suffered excessive blood loss during operations for large thoracic aneurysms.

The first 1041 patients who underwent an isolated aorto-coronary bypass operation in the same institution since it opened in 1971, were followed for up to 10 years to determine their prognosis. The mean follow-up time was 3.5 years. The probability of survival at five years was 94 +/- 2% (95% confidence limits). This was similar to the survival of the general Dutch population matched for age and sex. Multivariate survival analysis with the proportional hazards model did reveal a relationship of the rate of death with sex and age at operation; however this was not significant. There was a trend to a higher death rate with more vascular involvement (rate ratio of 3 vessel-versus 1 vessel disease of 1.9, N.S.) and a significant association with a low ejection fraction (EF) (ratio EF less than or equal to 0.30 v. EF greater than or equal to 0.55 of 2.7. P less than 0.05). Though surgery seems to eradicate the poor longterm outlook for patients with more serious vascular disease, the adverse influence of decreased left ventricular function on survival is not changed.

The usefulness of intraoperative epicardial two-dimensional (2D) echocardiography using a commercially available 5 MHz mechanical sector scanner was evaluated in 200 patients. The scanhead was inserted into a gas sterilized plastic bag and placed on the exposed heart. Unsuspected new diagnoses were made in 7 patients. In 68 patients additional morphologic information was obtained. This information influenced surgical management in 32 patients. Intraoperative echocardiographic analysis of the surgical correction revealed the expected results in 184 patients. In 16 patients the investigation provided important information in the decision of immediate reoperation. We conclude that epicardial two-dimensional echocardiography performed by the surgeon familiar with the interpretation of echocardiographic cross-sections yields important information for surgical management. The technique has become an important adjunct in our cardiac surgery department for immediate decision making and leads to optimal results.

Six patients with complicated native and prosthetic aortic valve endocarditis were operated on. The data from cineangiocardiography and from precordial and intraoperative two-dimensional echocardiography were compared with the surgical findings. Surgical inspection revealed a mycotic aneurysm in six patients. In addition, a fistulous connection to the right atrium, an abscess in the interventricular septum, and mitral valve endocarditis were found in one of the patients. The pathologic conditions disclosed during the operation were correctly visualized with two-dimensional epicardial echocardiography, done before cardiopulmonary bypass. Cineangiography provided this information in one patient, and precordial two-dimensional echocardiographic analysis was correct in two patients. Thus, intraoperative two-dimensional echocardiography provides detailed information in complicated native and prosthetic aortic valve endocarditis that is of importance in the surgical management.

A 37-year-old woman who presented with systemic lupus erythematosus was found to have a membranous obstruction of the inferior vena cava above the hepatic veins, with an extensive collateral circulation. The obstruction was relieved by a renal vein-right atrial interposition graft, and this was followed by disappearance of the anti-nuclear and anti-DNA antibodies. We postulate that the systemic lupus erythematosus might have been provoked by life-long immune stimulation due to bowel-derived antigens bypassing the hepatic reticuloendothelial system and reaching the systemic circulation, or by immune hyperreactivity associated with the abnormal abdominal venous circulation.

Of 1041 patients with consecutive aortocoronary bypass operations, 53 (5.1%) underwent reoperation during a mean follow-up time of three and a half years. The operative mortality of first operations was 1.2%, and of reoperations 3.8%. The anatomical reason for reoperation was failure of the bypass graft in 41 (77%) patients, which in 18 was accompanied by progression of disease. Progression alone was seen in seven (13%). When symptoms occurred within six months after the first operation, failure of the bypass graft(s) was nearly always found--in 32 out of 36 instances. Progression in non-bypassed arteries was seen only when symptoms occurred later. Late results in angina pectoris were less favourable in the group undergoing reoperation: 31 (65%) of the 48 operated on twice and 406 (46%) of the 877 patients operated on once still had angina at late follow-up. The same fraction in both groups was improved by operation: 88% versus 89%.

Six cases of acute myocardial infarction with blood in the pericardial sac are described. In one case rapid death followed myocardial rupture leaving no time for the possibility of intervention. Of two other cases acute symptoms developing after myocardial rupture, one was operated on promptly and the other, whose condition improved on pericardiocentesis, after a delay of a few hours. Both are now long term survivors A fourth patient probably had two episodes of rupture which apparently sealed off. He underwent cardiac catheterization, but no epicardial leak was found. Subsequently at operation a sealed myocardial rupture was detected and sutured over. The fifth patient suffered a silent myocardial rupture. A false aneurysm was diagnosed four months later and he withstood successful surgery. In the sixth patient, the course was similar to that of case 1, namely rapid death with a clinical picture suggestive of tamponade. Postmortem examination showed a covert rupture with some evidence of attempts to plug the opening. The purpose of this report is to emphasize the varying course which myocardial rupture can take.

Twenty-five patients with class III or class IV left ventricular failure (Myocardial Infarction Research Unit criteria) after a recent myocardial infarction were treated with intraaortic balloon pumping between December 1, 1972 and December 1, 1976. Three patients had no improvement and died during pumping. Two patients with improvement died during at attempt at weaning from circulatory assistance. Of 20 patients successfully weaned, 6 died within 3 months, 5 of these within 10 days after the weaning procedure. Of 14 patients who survived for more than 3 months, 13 were alive on February 15, 1977. Twelve of these 13 were in functional class II and 6 had resumed professional activities. Intraaortic balloon pumping proved an effective method for treating severe left ventricular failure after an acute myocardial infarction. Even withour surgery, 14 of 25 patients survived 3 or more months after an acute infarction complicated by serious pump failure.

Long-term follow-up of 62 consecutive patients with severe left ventricular dysfunction (ejection fraction = less than 0.30) and disabling angina pectoris following aorto-coronary bypass surgery was investigated. Prior to surgery all patients had angina pectoris and a history of remote myocardial infarction, 35% were in congestive heart failure (CHF). Significant stenoses in 3 major coronary vessels were present in 51 patients (82%). An average of 3.5 grafts per patient were employed. Operative mortality (30 days) rate was 4.8% (3 patients) and 13 patients died during the following period. The average follow-up was 37 months (range: 6 to 116 months). At follow-up, the 5-year survival probability for these patients was 70% (SD = 9%). Thirty-one patients (67%) of the 46 survivors had complete relief of angina, but signs of CHF were still evident in 17 patients (36%). Compared to patients with ejection fractions above 0.30% (surgical mortality 1.4% and 5-year survival rate 94% (SD = 3%] the outcome of coronary artery bypass grafting in patients with poor left ventricular function showed a significantly higher surgical mortality (P = 0.03) and impaired long-term survival (P = 0.02). However, aorto-coronary bypass grafting can be performed in patients with severe left ventricular dysfunction with reasonable relief of angina and with an acceptable surgical mortality.

The incidence of angina pectoris (AP) after bypass surgery was assessed in 1041 patients operated on consecutively between 1971 and 1980. Of the 977 survivors, 920 (94%) participated in the study with a followup time varying from 1 to 10 years (mean 3.5 years). Post-operative angina pectoris was present at 1 year in 277 patients (30%), at 3 years in 46%, at 8 years in 50%. The pain limited usual physical activities in 17.5%, 30% and 25%, respectively at these times. Nonetheless, 89% of the respondents felt improved by surgery. Factors without predictive value for late outcome were sex, number of pre-operative diseased vessels, and pre-operative ejection fraction. A correlation was found between post-operative AP and younger age at surgery in the males only (P less than 0.001); between AP and patency rate of the bypass graft (P less than 0.005) and with the status of the coronary arterial tree at three years post-operatively (P less than 0.001) in both sexes. The percentage of patients with recurrent AP increased with time after surgery up to 3 years, but remained stable thereafter. In conclusion, post-operative AP seems initially related to decreased functioning of the bypass graft, later to progression of coronary sclerosis in the native circulation.