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Fontan operation in heterotaxy patients has been associated with high mortality. We studied whether adoption of the extracardiac conduit (EC) total cavopulmonary connection (TCPC) in heterotaxy demonstrated comparable results to non-heterotaxy population.A retrospective medical record review of 35 consecutive patients with heterotaxy and 70 consecutive patients without heterotaxy syndrome who underwent EC TCPC between 2000 and 2018 was performed.In the 35 heterotaxy patients, 30 were right and 5 were left atrial isomerism. Anomalies of venous return included bilateral superior vena cava in 20 (57.1%), separated hepatic vein in 8 (22.9%), interrupted inferior vena cava in 3 (8.6%), total anomalous pulmonary venous return in 7 (20%), and partial in 2 patients (5.7%). All patients underwent EC TCPC under beating-heart cardiopulmonary bypass except in four patients (11.4%) cardioplegic arrest was needed for cardiac repair. The surgical mortality rate was lower in heterotaxy patients (0% vs. 5.7%; p = 0.299) but statistically not significant. The follow-up ranged from 2 months to 17.8 years (mean 9.4 ± 5.6 years). At 15 years, there was no significant difference between the heterotaxy and non-heterotaxy patients regarding the long-term survival (70% vs. 78.6%; p = 0.443), freedom from reoperation (81.9% vs. 96.5%; p = 0.057), and postoperative arrhythmia (17.1% vs. 7.1%; p = 0.174).EC TCPC can be performed in heterotaxy patients with comparable early and late results to the non-heterotaxy population. However, the late morbidities regarding the Fontan circulation needs careful follow-up.

Background MicroRNAs (miRs) regulate gene expression in heart failure. Circulating miRs as biomarkers for heart failure in mitral regurgitation patients (MR) remain unexplored. Methods This case–control study enrolled 32 MR patients with heart failure, 16 asymptomatic MR patients, and 12 control subjects without heart failure. We used next generation sequencing to study the gene expression profiles in the sera, and quantitative RT-PCR to study serum and tissue miRs in the left atria. Results Next generation sequencing analysis and enrichment analysis showed that 25 miRs were differentially expressed in the sera of MR patients with heart failure compared to control subjects. The circulating miR-148b-3p (p=0.002) and miR-409-3p (p=0.010) were significantly down-regulated in the MR patients with heart failure compared to control subjects. However, only circulation miR-148b-3p was significantly down-regulated in the MR patients without heart failure compared to control subjects (p=0.009). The tissue miR-409-3p was significantly down-regulated in the MR patients with heart failure compared to 3 purchased normal controls (p=0.041). Notably, the tissue RASGRP3 mRNA, target gene of miR-409-3p, was significantly up-regulated in the MR patients with heart failure compared to normal controls (p=0.010). The tissue FRY (p=0.010) and GADD45A (p=0.010) mRNAs, target genes of miR-148b-3p, were significantly up-regulated in the MR patients with heart failure compared to normal controls. Conclusions Circulating miR-148b-3p might serve as biomarker for future development of heart failure and miR-409-3p might serve as biomarker for incident heart failure in MR patients.

Neonatal rupture of the chordae of tricuspid valve with severe regurgitation is rare and disastrous. We report on a full-term female neonate presented with cyanosis caused by severe tricuspid regurgitation (TR) due to anterior leaflet chordal rupture. After initial stabilization by prostaglandin E1 infusion, successful early repair was achieved with artificial chordae implantation. The unique pathophysiology and the therapeutic strategy of this situation will be described.

Background: Lipid expression is increased in the atrial myocytes of mitral regurgitation (MR) patients. This study aimed to investigate key regulatory genes and mechanisms of atrial lipotoxic myopathy in MR. Methods: The HL-1 atrial myocytes were subjected to uniaxial cyclic stretching for eight hours. Fatty acid metabolism, lipoprotein signaling, and cholesterol metabolism were analyzed by PCR assay (168 genes). Results: The stretched myocytes had significantly larger cell size and higher lipid expression than non-stretched myocytes (all p &lt, 0.001). Fatty acid metabolism, lipoprotein signaling, and cholesterol metabolism in the myocytes were analyzed by PCR assay (168 genes). In comparison with their counterparts in non-stretched myocytes, seven genes in stretched monocytes (Idi1, Olr1, Nr1h4, Fabp2, Prkag3, Slc27a5, Fabp6) revealed differential upregulation with an altered fold change &gt, 1.5. Nine genes in stretched monocytes (Apoa4, Hmgcs2, Apol8, Srebf1, Acsm4, Fabp1, Acox2, Acsl6, Gk) revealed differential downregulation with an altered fold change &lt, 0.67. Canonical pathway analysis, using Ingenuity Pathway Analysis software, revealed that the only genes in the &ldquo, superpathway of cholesterol biosynthesis&rdquo, were Idi1 (upregulated) and Hmgcs2 (downregulated). The fraction of stretched myocytes expressing Nile red was significantly decreased by RNA interference of Idi1 (p &lt, 0.05) and was significantly decreased by plasmid transfection of Hmgcs2 (p = 0.004). Conclusions: The Idi1 and Hmgcs2 genes have regulatory roles in atrial lipotoxic myopathy associated with atrial enlargement.

Background/Purpose Fontan operation has evolved from atriopulmonary connection to total cavopulmonary connection (TCPC) due to its advantages in terms of hemodynamics and reduction of atrium-related complications. We analyzed the early and intermediate-term results of extracardiac conduit TCPC (EC-TCPC) procedure in patients with functional single ventricle to investigate the risk factors of surgical mortality and intermediate failure. Methods Retrospective review of the medical records of 88 consecutive patients with functional single ventricle who underwent EC-TCPC from 2000 to 2013 was conducted. Results The follow-up was 100% complete, ranging from 3 months to 13 years (mean 7.0 ± 3.8 years). There were two (2.3%) hospital and 18 (20.4%) late deaths. The estimated event-free survival rates at 1 year, 5 years, and 10 years were 90.6%, 89.3%, and 77.2%, respectively. On univariate analysis, fenestration was the only risk factor for surgical mortality (p = 0.027). On multivariate analysis, the significant atrioventricular valve regurgitation was the only risk factor for intermediate failure (p = 0.017). Conclusion The clinical results of EC-TCPC in patients with functional single ventricle were satisfactory. The patients who needed fenestration during operation had higher risk of surgical mortality. Significant atrioventricular valve regurgitation had negative impact on intermediate survival.

Minimally invasive cardiac surgery through a partial sternotomy or a ministernotomy is popular. However, the transverse nonunion of the sternum will be a potential complication. Valid and valuable techniques have been introduced for securing the sternotomy fixation. Most of them are focused on the materials or methods for extrinsic reinforcement. A new concept, focused on the intramedullary reinforcement of the sternal fixation, was designed by incarcerating a cancellous portion of the autologous xiphoid in the marrow space of the inter-segmental junction of the partial sternotomy. This autologous xiphoid tenon method is simple, reliable, and reproducible without additional requirement of device implantation or an iliac incision for the bone grafting.

Background: The radiofrequency (RF) maze procedure can effectively restore sinus rhythm in most patients with persistent atrial fibrillation (AF) and mitral disease. However, long-term results and predictors for late AF recurrence are still under investigation. Methods: From December 1995 to November 2011, 207 consecutive patients with persistent AF and mitral disease underwent RF maze procedure and concomitant mitral surgery. The mean age was 54±12.4 year-old. Mitral surgery was performed in all patients and concomitant procedures including tricuspid surgery, aortic valve surgery, and atrial septal defect closure were carried on 164 patients. Results: The in-hospital mortality was 3.9% (n=8) and late mortality was 8.2% (n=17). After a mean follow-up period of 101±50.9 months, 154 patients (74.4%) had long-term sinus conversion. A permanent pacer was implanted in 8 patients (3.9%). By Cox multivariate survival regression analysis, predictors for long-term sinus conversion were identified to be the duration of persistent AF, preoperative left atrial (LA) diameter, preoperative right atrial (RA) area, and preoperative beta-blocker use. The receiver operating characteristic (ROC) curve analysis showed that the best cutoff value for persistent AF duration, preoperative LA diameter, and preoperative RA area were 59.5 months, 59.85 mm, and 25.65 cm 2 . Conclusions: Longer persistent AF duration, larger preoperative LA diameter, larger preoperative RA area and preoperative beta-blocker use were the predictors for negative long-term outcome of RF maze procedure for the patients with persistent AF underwent concomitant mitral surgery. Timely referral of patients for surgery is mandatory.

Background. Left atrial enlargement is a mortality and heart failure risk factor in primary mitral regurgitation (MR) patients. Pig models of MR have shown differential expression of genes linked to the renin-angiotensin system. Therefore, the aim of this study was to investigate the key genes of the renin-angiotensin that are expressed differentially in the left atrial myocardium in MR patients. Methods. Quantitative RT-PCR was used to compare gene expression in the renin-angiotensin system in the left atrium in MR patients, aortic valve disease patients, and normal subjects. Results. Plasma angiotensin II concentrations did not significantly differ between MR patients and aortic valve disease patients (P=0.582). Compared to normal controls, however, MR patients had significantly downregulated expressions of angiotensin-converting enzyme, angiotensin I converting enzyme 2, type 1 angiotensin II receptor, glutamyl aminopeptidase, angiotensinogen, cathepsin A (CTSA), thimet oligopeptidase 1, neurolysin, alanyl aminopeptidase, cathepsin G, leucyl/cystinyl aminopeptidase (LNPEP), neprilysin, and carboxypeptidase A3 in the left atrium. The MR patients also had significantly upregulated expressions of MAS1 oncogene (MAS1) and mineralocorticoid receptor compared to normal controls. Additionally, in comparison with aortic valve disease patients, MR patients had significantly downregulated CTSA and LNPEP expression and significantly upregulated MAS1 expression in the left atrium. Conclusions. Expressions of genes in the renin-angiotensin system, especially CTSA, LNPEP, and MAS1, in the left atrium in MR patients significantly differed from expressions of these genes in aortic valve disease patients and normal controls. Notably, differences in expression were independent of circulating angiotensin II levels. The results of this study provide a rationale for pharmacological therapies or posttranslational regulation therapies targeting genes expressed differentially in the renin-angiotensin system to remedy structural remodeling associated with atrial enlargement and heart failure progression in patients with MR.

Apoptosis occurs in atrial cardiomyocytes in mitral and tricuspid valve disease. The purpose of this study was to examine the respective roles of the mitochondrial and tumor necrosis factor-α receptor associated death domain (TRADD)-mediated death receptor pathways for apoptosis in the atrial cardiomyocytes of heart failure patients due to severe mitral and moderate-to-severe tricuspid regurgitation. This study comprised eighteen patients (7 patients with persistent atrial fibrillation and 11 in sinus rhythm). Atrial appendage tissues were obtained during surgery. Three purchased normal human left atrial tissues served as normal controls. Moderately-to-severely myolytic cardiomyocytes comprised 59.7±22.1% of the cardiomyocytes in the right atria and 52.4±12.9% of the cardiomyocytes in the left atria of mitral and tricuspid regurgitation patients with atrial fibrillation group and comprised 58.4±24.8% of the cardiomyocytes in the right atria of mitral and tricuspid regurgitation patients with sinus rhythm. In contrast, no myolysis was observed in the normal human adult left atrial tissue samples. Immunohistochemical analysis showed expression of cleaved caspase-9, an effector of the mitochondrial pathways, in the majority of right atrial cardiomyocytes (87.3±10.0%) of mitral and tricuspid regurgitation patients with sinus rhythm, and right atrial cardiomyocytes (90.6±31.4%) and left atrial cardiomyocytes (70.7±22.0%) of mitral and tricuspid regurgitation patients with atrial fibrillation. In contrast, only 5.7% of cardiomyocytes of the normal left atrial tissues showed strongly positive expression of cleaved caspase-9. Of note, none of the atrial cardiomyocytes in right atrial tissue in sinus rhythm and in the fibrillating right and left atria of mitral and tricuspid regurgitation patients, and in the normal human adult left atrial tissue samples showed cleaved caspase-8 expression, which is a downstream effector of TRADD of the death receptor pathway. Immunoblotting of atrial extracts showed that there was enhanced expression of cytosolic cytochrome c, an effector of the mitochondrial pathways, but no expression of membrane TRADD and cytosolic caspase-8 in the right atrial tissue of mitral and tricuspid regurgitation patients with sinus rhythm, and right atrial and left atrial tissues of mitral and tricuspid regurgitation patients with atrial fibrillation. Taken together, this study showed that mitochondrial pathway for apoptosis was activated in the right atria in sinus rhythm and in the left and right atria in atrial fibrillation of heart failure patients due to mitral and tricuspid regurgitation, and this mitochondrial pathway activation may contribute to atrial contractile dysfunction and enlargement in this clinical setting.

Background/Purpose Thymectomy may benefit patients with generalized myasthenia gravis (MG) or myasthenia with thymomas. Currently, video-assisted (VA) thoracic surgery is popular and plays an important role in thymectomy. We compared the clinical outcomes of VA thymectomy with conventional transsternal (TS) approach to investigate the effectiveness of VA technology in the current era. Methods A retrospective review of our thymectomy results for patients with MG from 1998 to 2011 was conducted. A total of 83 consecutive patients were enrolled. According to the surgeons’ and patients’ preference, 39 patients received conventional TS thymectomy and 44 were operated on in a VA fashion. The results were categorized and analyzed according to the Myasthenia Gravis Foundation of America (MGFA) postintervention statuses with some modification. Results No obvious difference between conventional TS thymectomy and VA thymectomy was noted regarding the remission statuses and the clinical outcomes by the modified MGFA score. However, the patients who received VA thymectomy showed shorter intensive care unit (ICU) stays (4.2 ± 3.3 days vs. 2.3 ± 1.5 days, p = 0.001). Conclusion Compared with the conventional TS thymectomy, the VA approach is similarly effective with shorter ICU stays.

Varied methods for total chordal preservation in mitral valve replacement (MVR) have been presented with significant long-term advantage. However, it is difficult to preserve whole the mitral apparatus in the case of rheumatic mitral valvulopathy. Previously, we reported a technique for redo MVR referred to as conduit-onvalve replacement with satisfactory result. Based on the same concept, a procedure wherein a valved conduit is implanted on the undisturbed mitral apparatus was developed for preserving the whole mitral apparatus in the most physiologic orientation with minimal technical demand.

Background Differentially expressed genes in the left atria of mitral regurgitation (MR) pigs have been linked to peroxisome proliferator-activated receptor (PPAR) signaling pathway in the KEGG pathway. However, specific genes of the PPAR signaling pathway in the left atria of MR patients have never been explored. Methods This study enrolled 15 MR patients with heart failure, 7 patients with aortic valve disease and heart failure, and 6 normal controls. We used PCR assay (84 genes) for PPAR pathway and quantitative RT-PCR to study specific genes of the PPAR pathway in the left atria. Results Gene expression profiling analysis through PCR assay identified 23 genes to be differentially expressed in the left atria of MR patients compared to normal controls. The expressions of APOA1, ACADM, FABP3, ETFDH, ECH1, CPT1B, CPT2, SLC27A6, ACAA2, SMARCD3, SORBS1, EHHADH, SLC27A1, PPARGC1B, PPARA and CPT1A were significantly up-regulated, whereas the expression of PLTP was significantly down-regulated in the MR patients compared to normal controls. The expressions of HMGCS2, ACADM, FABP3, MLYCD, ECH1, ACAA2, EHHADH, CPT1A and PLTP were significantly up-regulated in the MR patients compared to patients with aortic valve disease. Notably, only ACADM, FABP3, ECH1, ACAA2, EHHADH, CPT1A and PLTP of the PPAR pathway were significantly differentially expressed in the MR patients compared to patients with aortic valve disease and normal controls. Conclusions Differentially expressed genes of the PPAR pathway have been identified in the left atria of MR patients compared with patients with aortic valve disease and normal controls.

Background Radiofrequency catheter ablation for paroxysmal atrial fibrillation is well established but not drawback free. Pulmonary vein stenosis is one of the complications and usually treated with stenting with the disadvantages of high re-stenosis rate and anticoagulant dependence. Case presentation Herein, we present the case of a 47 year-old lady, who suffered from fever and hemoptysis due to right inferior pulmonary vein occlusion after radiofrequency catheter ablation for paroxysmal atrial fibrillation. Eventually, thoracoscopic right lower lung lobectomy was inevitable with satisfactory result. Conclusions Pulmonary vein stenosis is a major complication after radiofrequency ablation of atrial fibrillation. High suspicion and early detection in patients with pulmonary manifestations are mandatory for salvage the injured lung in early. If delayed, surgical resection of the involved lung, especially through the thoracoscopic approach will eradicate the problem with minimal complication.

Summary Reparative surgery for degenerative mitral valve regurgitation or insufficiency has been the subject of countless articles in the literature over the past five decades. During this period, a wealth of experience has contributed to greater understanding of mitral valve anatomy and pathophysiology. Excellent surgical techniques for the treatment of mitral regurgitation have been developed and are undergoing further refinement. With the efforts of the pioneers, standard surgical techniques, strategies, and guidelines have been well established. These achievements significantly prolong the life-expectancy of patients, provide excellent long-term durability of the repaired valve, and reduce the risk of endocarditis. Mitral valve repair for degenerative mitral regurgitation also contributes to reduced risk of thromboembolic events and the need for life-long anticoagulation after mitral valve replacement.

Objective A transpulmonary arterial approach to repair type I ventricular septal defect is the standard. However, the possible adverse effect on the pulmonary valve by this technique has not been investigated. Methods A retrospective study reviewing type I ventricular septal defect repair from January 1991 to May 2010 was conducted. Of the 142 cases, the ventricular septal defect was repaired via the transpulmonary arterial route in 77 patients (54.2%, PA group) and via the subpulmonic route in 65 patients (45.8%, SP group). All patients received serial annual transthoracic color Doppler echocardiographic evaluation of pulmonary valve function. Results The age at operation ranged from 1.2 to 272 months (median, 35.0 months; mean, 50.4 months). The mean follow-up period was 96.2 months (range, 2–234 months). Between the PA and SP groups, there was no significant difference in age, body weight, ventricular septal defect size, left to right shunt amount, mean pulmonary arterial pressure, and preoperative pulmonary stenosis or regurgitation. Postoperatively, there was no significant difference in the ejection fraction or incidence of residual ventricular septal defect, right bundle branch block, and pulmonary stenosis. However, the incidence of postoperative pulmonary regurgitation of more than moderate and the total scale of postoperative pulmonary regurgitation were both significantly higher in the PA group (16.9% vs 4.6% and 1.7 ± 0.1 vs 1.4 ± 0.1, P = .031 and .019, respectively). Conclusions Although the transpulmonary arterial approach for type I ventricular septal defect repair has been advocated for decades, considering the adverse effect on pulmonary valve competency, the subpulmonic approach may be an alternative.

Background Oxidative stress is linked with several cardiovascular diseases. However, the NADPH oxidase activity in severe mitral regurgitation patients with and without atrial fibrillation has not yet been explored. Methods This study involved 16 adult patients (eight patients with persistent atrial fibrillation and eight with sinus rhythm) with severe mitral and moderate-to-severe tricuspid regurgitation and five control patients without mitral and tricuspid disease. Atrial tissues of the right and left atrial appendages were obtained during surgery. Superoxide anion production was measured by lucigenin-enhanced chemiluminescence, and the expression of nox2 containing NADPH oxidase mRNA was measured by quantitative real-time RT-PCR. Additionally, immunohistochemical study was performed. Results NADPH-stimulated superoxide release was significantly higher than basal superoxide production from right [5671.9±3498.7 vs. 232.7±70.0 relative light units per second per milligram of protein (RLU s −1 mg protein −1 ), P =.008) and left atrial homogenates (6475.1±1890.8 vs. 229.0±79.6 RLU s −1 mg protein −1 , P =.008) in atrial fibrillation patients. The NADPH-stimulated superoxide release from right atrial homogenates was also significantly higher than basal superoxide production in sinus patients (6809.1±1327.1 vs. 244.2±65.5 RLU s −1 mg protein −1 , P =.008). Additionally, there was a borderline significant correlation between NADPH-stimulated superoxide production from left atrial homogenates and left atrial sizes ( r =0.683, P =.062) in atrial fibrillation patients. Membrane-bound nox2 containing NADPH oxidase mRNA expression was increased and was similar in both the atrial fibrillation patients and sinus patients. The NADPH-stimulated superoxide production in right atrial homogenates in control atrial samples was 1863.7±137.2 RLU s −1 mg protein −1 . Immunohistochemical study demonstrated increased expression of nox2 in myocytes with moderate-to-severe myolysis and hypertrophy. Conclusions Results of this study demonstrate that membrane-bound nox2 containing NADPH oxidase activity and expression in the atrial myocardium is increased in patients with severe mitral regurgitation, possibly contributing to atrial remodeling in this clinical setting.

Background The reported presence of DNA breaks, based on a positive reaction to the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP in situ nick end-labelling (TUNEL) assay, in fibrillating human right atria of cardiac valve disease may suggest apoptotic myocyte death. However, TUNEL positivity may reflect conditions other than cell death. Methods This study comprised 27 adult patients (14 patients with persistent atrial fibrillation and 13 in sinus rhythm) with significant mitral and tricuspid valve diseases. Atrial tissues were obtained during surgery. Results Immunohistochemical study demonstrated that 31.1±12.2% of the myocytes had TUNEL-positive nuclei in the fibrillating right atria whereas 37.4±23.2% of the myocytes had TUNEL-positive nuclei in the right atrial myocardium in sinus rhythm ( p =0.505). However, most nuclei of TUNEL-positive myocytes in the right atria also expressed proliferating cell nuclear antigen (PCNA), an indicator of DNA replication and repair but never Ki-67, a replication-associated antigen (TUNEL + /PCNA + vs. TUNEL + /PCNA − , 30.5±10.8% vs. 1.2±1.5%, p =0.005, in the atrial fibrillation group and 32.8±18.6% vs. 4.6±8.1%, p =0.003, in the sinus group), suggesting that most TUNEL-positive myocytes were undergoing DNA repair. In addition, the incidence of TUNEL-positive myocytes significantly and positively correlated with the incidence of PCNA-positive myocytes ( r =0.5, p r =0.661, p Conclusions Cell death by apoptosis occurs in a small percentage of atrial cardiomyocytes in mitral and tricuspid valve diseases and DNA repair is more important and preserves the cardiomyocytes.

Eur J Clin Invest 2011; 41 (3): 299–307 Abstract Background Myolysis of atrial cardiomyocytes occurs in patients with severe mitral and tricuspid regurgitation. This morphological remodelling may involve autophagy. Methods This study comprised 20 patients (10 with long-standing persistent atrial fibrillation and 10 with sinus rhythm) with severe mitral and tricuspid regurgitation. Atrial appendageal tissues were obtained during surgery. The appearance of autophagosomes (LC3B) in myocytes can reflect autophagy induction. Complement 9 is used as a reliable marker of oncosis. Results In the fibrillating right atria, 68·4 ± 18·9% of total myocytes showed moderate-to-severe myolysis, while 64·2 ± 15·8% of total myocytes comprised these cells in right atrial myocardium with sinus rhythm. Immunohistochemical study revealed LC3B-positive myocytes in 8·0% of myocytes without myolysis, 11·9% of myocytes with mild myolysis and 49·4% of myocytes with moderate-to-severe myolysis in right atrial myocardium with sinus rhythm (P

Absent pulmonary valve syndrome is rare. We report the case of a child with absent pulmonary valve syndrome noted after birth. Progressive dilatation of the main pulmonary artery and ascending aorta were noted by echocardiography and confirmed by heart computed tomography. He underwent ascending aorta graft replacement and pulmonary artery reduction angioplasty at the age of 6. Good outcome was achieved at 18-month follow-up where subsequent computed tomography revealed a normal size ascending aorta and main pulmonary artery.

Background: Atrial enlargement occurs in patients with significant mitral regurgitation. However, the time frame of the development of atrial enlargement induced by mitral regurgitation remains unknown. Methods: Fourteen Lanyu miniature pigs (age = 6.6 ± 0.9 months) were studied. Mitral regurgitation was created by placing a predefined hole on the middle scallop of the posterior mitral leaflet under cardiopulmonary bypass. The parasternal long-axis atrial dimension was measured by transthoracic echocardiographic examinations. Results: All animals exhibited grade 3 mitral regurgitation immediately after surgery. Seven pigs expired within 2 weeks after the operation [technical complications (n = 1), acute cardiac tamponade (n = 1), and acute and subacute heart failure (n = 5)]. Seven pigs remained alive at a mean follow-up of 7.7 ± 2.1 months. The left atrial diameter indices of the 7 pigs increased significantly at 1 month (33.1 ± 8.6 mm, p = 0.018) and 3 months (41.3 ± 12.6 mm, p = 0.018) after surgery compared with baseline values (22.8 ± 5.2 mm), and the left atrial diameter index increased significantly at 3 months compared to 1 month (p = 0.018). Conclusions: Left atrial enlargement develops rapidly and progresses after the creation of significant pure mitral regurgitation.

Objective The aim of this study was to examine the serum oxidative stress in patients with severe mitral regurgitation. Design and methods This study analyzed serum oxidative stress index in patients with severe mitral regurgitation [persistent atrial fibrillation (AF) or sinus rhythm], paroxysmal lone AF patients and healthy subjects. Results The serum oxidative stress index was significantly higher in the mitral regurgitation AF group and sinus group than in the lone AF group and healthy subjects (p

Background: Although recent studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) achieves clinical outcomes comparable to coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (ULMCA) disease, long-term studies are rarely performed. Methods and Results: This study reviewed outcomes in 363 patients undergoing CABG (n=216), PCI with DES (n=94) or PCI with bare-metal stent (BMS) (n=53) for ULMCA stenosis between January 2000 and March 2007. The CABG group had more patients with diabetes (50.5%) and 3- or 4-vessel disease (77.3%) than the PCI group. Kaplan-Meier survival estimates showed higher TLR-free survival and revascularization-free survival in CABG group. Although cardiac-death-free survival did not significantly differ between the 3 groups, the DES group had the highest overall survival. Age (hazard ratio (HR): 1.060; 95% confidence interval (CI): 1.017-1.104) and diffuseness score (HR: 1.157; 95%CI: 1.019-1.313) were significant independent risk factors for cardiac death. Conclusions: There was higher TLR in the PCI group with either DES or BMS, but cardiac death did not significantly differ between the 3 groups. Advanced age and diffuse coronary atherosclerosis may increase the risk of cardiac death following revascularization. (Circ J 2009; 73: 705 - 712)

Intramural hematoma (IMH) of the aorta is a well-known variant of aortic dissection; however, the optimal initial treatment strategy for type A IMH remains controversial. An English language search of Medline for manuscripts on the treatments and outcomes of IMH with the keywords 'intramural hematoma', 'ascending aorta or type A', 'aortic disease' with cross-references was performed for articles dating from January 1986 to September 2006. Primary outcomes of interest were initial treatment strategies as well as the early and overall mortality rates. Earlier publications studying overlapping patient groups from the same institutions were excluded. Case reports and small series of less than 10 patients were not enrolled. Data from 328 reported cases in 12 studies were extracted. Initial surgery and medical treatment were performed for 168 (51.2%) and 160 (48.8%) patients, respectively. Nine out of 12 studies (75%) came from Asia. The early mortality rate was 10.1% (17/168) and 14.4% (23/160) in patients who received initial surgery and medical treatment, respectively (p=0.37). The optimal initial treatment strategy for type A IMH may still be individualized. Initial medical treatment and timed surgical therapy seems to be associated with higher early mortality rates in patients with type A IMH, even in a primarily Asian cohort. The impact of either initial treatment strategy on long-term survival must be evaluated in further study.

OBJECTIVES Traditional Cox maze III is the gold standard for treatment of atrial fibrillation (AF). Because of its invasiveness, it has been replaced by a simplified procedure involving radiofrequency ablation of modified Cox maze IV. Although the modified Cox maze IV has the advantages of simplicity and less morbidity, a lower rate of sinus rhythm conversion has been reported. We try to establish a scoring system to predict the outcome of this procedure. METHODS AND RESULTS The derivation group consisted of 287 patients with structural heart disease and chronic AF who underwent cardiac surgery and modified Cox-maze IV procedure between August 2005 and March 2013. Demographics, clinical and laboratory variables were retrospectively collected as sinus conversional predictors. Overall sinus conversion rate was 75.8%. The parameters of the Soft Markers Scoring system included AF duration, preoperative left atrial (LA) size, rheumatic pathology and postoperative LA remodeling. We compared 80 patients from another hospital between January 2004 and December 2011 as a validation group to evaluate the power of the scoring system. Soft Markers Score indicated a good discriminative power by using the areas under the receiver operating characteristic curve (AUROC: 0.759 ± 0.032). The score was further divided into three groups: low (0-2), intermediate (3-5), and high (6-10), with predicted sinus conversion rates of 92.4%, 74.2%, and 47.8%, respectively. CONCLUSIONS In patients with chronic AF receiving modified Cox-maze IV procedure, the Soft Markers Score demonstrated good discriminative power of predicting sinus recovery in our patients and applied well to the other validation populations.

We assessed whether the simultaneous sequential strategy could (1) achieve additional sinus restoration for those patients who were not in sinus rhythm while coming off bypass after modified left maze procedure and (2) attain the same long-term success rates as the bi-atrial maze procedure in patients with persistent atrial fibrillation (AF) and mitral valve disease.Twenty-seven consecutive patients - ten men and 17 women with a mean age of 52 +/- 13 years, all with persistent AF and mitral valve disease - underwent the modified maze procedure with the simultaneous sequential strategy. In the first phase, the modified left atrial maze operation was carried out with concomitant valvular surgery; the right side maze operation was subsequently carried out as a second phase of the sequential strategy only if AF re-appeared following the spontaneous restoration of heart beats during the operation.Twenty patients (74.1%) underwent the left atrial maze procedure only, and seven patients (25.9%) required the subsequent right atrial maze procedure as part of the sequential strategy. At a mean follow-up of 15.1 +/- 7.7 months, six of the 27 patients (22.2%) who underwent additional right atrial maze procedure had restored sinus rhythm. At a mean follow-up of 17.8 +/- 7.3 months, 24 of the 27 patients (88.9%) had restored sinus rhythm and 22 patients (81.5%) had restored bi-atrial transport function (right atrial filling fraction: 40.8 +/- 11.7%; left atrial filling fraction: 22.9 +/- 8.1%) after application of the sequential strategy.Compared with modified left atrial maze procedure, the application of the simultaneous sequential strategy successfully restored sinus rhythm in an additional 22.2% of patients with persistent AF. The overall sinus conversion rate of 88.9% was comparable with that of the standard bi-atrial maze procedure.

Telomerase activity is suppressed in normal somatic tissues but is activated in most cancer cells. We have previously found that all six telomerase subunit proteins, including hTERT and hsp90 are needed for full enzyme activity. Telomerase activity has been reported to be upregulated by protein kinase C (PKC), but the mechanism is not clear. In this study, we examined how PKC regulates telomerase activity in head and neck cancer cells. PKC inhibitor, bisindolylmaleimide I (BIS), inhibited telomerase activity but had no effect on the expressions of telomerase core subunits. RNA interference (RNAi) and in vitro phosphorylation studies revealed that PKC isoforms alpha, beta, delta, epsilon, zeta specifically involved in telomerase regulation, and the phosphorylation target was on hTERT. Treatment with the hsp-90 inhibitor novobiocin dissociated hsp90 and hTERT as revealed by immunoprecipitation and immunoblot analysis and reduced telomerase activity. Treatment with the PKC activator SC-10 restored the association of hsp90 and hTERT and reactivate telomerase, suggesting that hTERT phosphorylation by PKC is essential for telomerase holoenzyme integrity and function. Analysis on clinical normal and tumour tissues reveal that the expressions of PKC alpha, beta, delta, epsilon, zeta were higher in the tumour tissues, correlated with telomerase activity. Disruption of PKC phosphorylation by BIS significantly increased chemosensitivity to cisplatin. In conclusion, PKC isoenzymes alpha, beta, delta, epsilon, zeta regulate telomerase activity in head and neck cancer cells by phosphorylating hTERT. This phosphorylation is essential for telomerase holoenzyme assembly, leading to telomerase activation and oncogenesis. Manipulation of telomerase activity by PKC inhibitors is worth exploring as an adjuvant therapeutic approach.

Although several studies have found overexpression of epidermal growth factor receptor (EGFR) proteins EGFR and Her-2 in head and neck cancers, the clinical relevance of the finding varies. We examined the expression and clinical association of these molecules with oral squamous cell carcinoma in an area where betel chewing is prevalent. EGFR and Her-2 proteins were measured in 59 paired (grossly normal and cancer) tissues by an enzyme immunoassy method. The cutoff value for gene overexpression was defined as the level of mean expression in normal tissue plus two s.d. A total of 59% of the patients consumed alcohol, 90% smoked tobacco, and 90% chewed betel quid. Of the patients assayed, 34 (58%) and 24 (41%) had EGFR and Her-2 overexpression, with average 3.5- and 1.5-fold elevations. EGFR overexpression has been shown to be statistically associated with T stage, N stage, overall TMN stage, primary tumour depth, lymph node extra-capsular spread, and poor survival. Her-2 overexpression, however, did not demonstrate a similar association with clinicopathological parameters or therapeutic outcome. On multivariant analysis, EGFR overexpression (P=0.041) and N stage (P=0.024) were the only independent factors for overall survival. These results indicate that the molecular targeting therapy to EGFR may be a treatment for oral cavity cancer in the betel quid-chewing prevalent area.

Left atrial enlargement associated with mitral regurgitation (MR) predicts a poor prognosis. However, the underlying regulatory mechanisms of atrial remodeling remain unclear. We used high-density oligonucleotide microarrays and enrichment analysis to identify the alteration of RNA expression pattern and biological processes involved in the atrial remodeling of pigs with and without MR. Gene arrays from left atria tissues were compared in 13 pigs (iatrogenic MR pigs [n = 6], iatrogenic MR pigs treated with valsartan [n = 4], and pigs without MR [n = 3]). A total of 22 genes were differentially upregulated by altered fold change2.0 (Log2FC 1), and 49 genes were differentially downregulated by altered fold change0.5 (Log2FC -1) in the left atria of the MR pigs compared with the pigs without MR. Enrichment analysis showed that renin-angiotensin system was identified in the Kyoto Encyclopedia of Genes and Genomes pathway. Notably, 12 of the 22 upregulated genes were identified to be downregulated by valsartan and 10 of the 49 downregulated genes were identified to be upregulated by valsartan. The tissue concentrations of angiotensin II and gene expression of hypertrophic gene, myosin regulatory light chain 2, ventricular isoforms, and fibrosis-related genes were significantly increased in the MR pigs compared with pigs without MR. In conclusion, differentially expressed transcriptome and related biological pathways have been identified in the left atria of the MR pigs compared with pigs without MR. Additionally, some of the differentially expressed genes could be regulated by type I angiotensin II receptor blocker.

BackgroundLeft atrial enlargement in mitral regurgitation (MR) predicts a poor prognosis. The regulatory mechanisms of atrial myocyte hypertrophy of MR patients remain unknown.Methods and resultsThis study comprised 14 patients with MR, 7 patients with aortic valve disease (AVD), and 6 purchased samples from normal subjects (NC). We used microarrays, enrichment analysis and quantitative RT-PCR to study the gene expression profiles in the left atria. Microarray results showed that 112 genes were differentially up-regulated and 132 genes were differentially down-regulated in the left atria between MR patients and NC. Enrichment analysis of differentially expressed genes demonstrated that "NFAT in cardiac hypertrophy" pathway was not only one of the significant associated canonical pathways, but also the only one predicted with a non-zero score of 1.34 (i.e. activated) through Ingenuity Pathway Analysis molecule activity predictor. Ingenuity Pathway Analysis Global Molecular Network analysis exhibited that the highest score network also showed high association with cardiac related pathways and functions. Therefore, 5 NFAT associated genes (PPP3R1, PPP3CB, CAMK1, MEF2C, PLCE1) were studies for validation. The mRNA expressions of PPP3CB and MEF2C were significantly up-regulated, and CAMK1 and PPP3R1 were significantly down-regulated in MR patients compared to NC. Moreover, MR patients had significantly increased mRNA levels of PPP3CB, MEF2C and PLCE1 compared to AVD patients. The atrial myocyte size of MR patients significantly exceeded that of the AVD patients and NC.ConclusionsDifferentially expressed genes in the "NFAT in cardiac hypertrophy" pathway may play a critical role in the atrial myocyte hypertrophy of MR patients.

A 73-year-old diabetic, hypertensive man sustained acute inferolateral wall myocardial infarction 2 days before a syncopal episode, and he was resuscitated on the way to the hospital and during the preoperative examination. An extensive tear of the left posterolateral pericardium with massive left hemothorax and left ventricular free wall rupture with pulsatile bleeding were found during surgery. Iatrogenic pericardial tear due to vigorous cardiac massage could temporarily relieve the pericardial tamponade due to the postinfarction ventricular rupture and allowed the timely surgery to be conducted.

Background. Previous studies have shown that the maze operation can restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation. The purpose of this study was to test the feasibility of the application of radiofrequency and cryoablation as an alternative to the classic maze operation. Methods. Twelve patients undergoing mitral valve procedures were included in this study. Radiofrequency and cryoablation were applied to create lesions in both atria to simulate the classic maze operation. Results. There were two surgical deaths. At the mean follow-up of 10.25 months for the remaining 10 patients; 6 were in sinus rhythm, 2 in atrial rhythm, 1 in paroxysmal atrial tachycardia, and 1 in atrial fibrillation. Doppler echocardiography at 6-month follow-up showed emergence of biatrial transport function in 3 patients and right atrial contractility in 8. At 12-month follow-up of 5 patients, Doppler echocardiography showed biatrial transport function in 3 and right atrial contractility in 4. Conclusions. Our modified maze procedure during valvular operation is effective for achieving an acceptable success rate to restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation.

Tricuspid valve detachment has been used for decades in the repair of type II ventricular septal defects (VSDs); however, the procedure can damage the tricuspid valve and conduction system. We retrospectively reviewed 177 consecutive type II VSD repairs performed at our hospital from 1997 through 2004. Patients were included if they had symptoms, pulmonary hypertension, or a Qp/Qs ratio1.5: 86 underwent tricuspid valve detachment (TVD group) and 84 underwent VSD repair without this detachment (non-TVD group). There was no significant difference between groups in age, body weight, VSD size, Qp/Qs ratio, follow-up duration, or incidence of residual shunting. Cross-clamp times (109.6±42.6 vs 92.2±38.1 min) and cardiopulmonary bypass times (155.1±53.8 vs 137±47 min) were longer in the TVD group. No patients developed tricuspid stenosis or heart block. After excluding patients who underwent tricuspid repair, we found similar grades of postoperative tricuspid regurgitation in both groups. In applying our novel criterion (last postoperative regurgitation grade minus preoperative regurgitation grade) to evaluate changes between preoperative and postoperative tricuspid regurgitation, we found significant deterioration in the non-TVD group (P=0.018). Had conventional evaluation methods been used, severity in the groups would not have differed significantly. Our method enables additional evaluation of late tricuspid function in individual patients. Tricuspid valve detachment is safe for type II VSD repair and has no adverse effect on late tricuspid valve function. In addition, we recommend the interrupted-suture technique for leaflet reattachment.

We describe an aneurysm originating from the right sinus of Valsalva, with right ventricular outflow tract obstruction associated with ventricular septal defect, in a 9-year-old boy. Diagnosis was made by echocardiography and cardiac catheterization. Successful surgical repair of ventricular septal defect and aortic valvuloplasty resulted in symptomatic improvement.

Pocket hematoma is a troublesome complication associated with the implantation of cardiac implantable electronic devices (CIEDs). This study aims to determinate the risk factors of pocket hematoma complications in relation to different antithrombotic strategies and severity of thrombocytopenia in Chinese patients.We conducted a retrospective study of 1093 consecutive patients undergoing implantation of CIEDs and divided them into 3 groups: no antithrombotic group (n = 512), continuing antiplatelet group (n = 477), and temporarily discontinuing warfarin with or without heparin bridging strategy (n = 104).A pocket hematoma developed in 40 patients (3.7%). The temporarily discontinuing warfarin group (7.7%) had a higher incidence of pocket hematoma than no oral antithrombotic group (2.1%) and continuing antiplatelet group (4.4%) (P = 0.012). The dual antiplatelet group (16.2%) and the heparin bridging strategy group (14.0%) had significantly higher incidence of pocket hematoma compared with the no antithrombotic group (2.1%; P0.001, both). Patients having aspirin or clopidogrel alone had low incidence of pocket hematoma (3.9% and 1.2%, respectively), similar to the no antithrombotic group (P = not significant). Multivariate analysis revealed that dual antiplatelet agents (P = 0.004), heparin bridging strategy (P0.001), and moderate to severe thrombocytopenia (P = 0.007) were independent predictors for pocket hematoma complications.The use of dual antiplatelet agents, heparin bridging strategy, and the presence of moderate to severe thrombocytopenia significantly increased the risk of pocket hematoma complications in the periprocedural period of CIED implant. Aspirin or clopidogrel alone did not increase the risk of pocket hematoma complications.

A total of 82 consecutive patients with recurrent or persistent spontaneous pneumothorax were considered for thoracoscopic blebectomy or bullectomy and pleurodesis. The median age was 47 years, and 70% were men. All the patients were successfully treated using a video-assisted thoracoscopic technique. There were no deaths attributable to the procedure. Complications occurred in 6 patients (7.3%). Three patients (4%) with diffuse bullous lung disease had prolonged intubation (9, 11, and 12 days, respectively). Persistent air leaks lasting from 10 to 14 days occurred in 2 patients (3%). One patient had an endoloop slip from the lung parenchyma after a forceful sneeze 2 days after the operation. Air leak subsided after the second operation using a conventional suturing technique. Blebs or bullae were present in 69 patients (83%). These were ablated by endoscopic stapling (37 patients) and through thoracoscopic ligation using an endoloop technique (32 patients). In this group of patients, the median postoperative hospital stay was 5 days. Thirteen patients with air leaks and diffuse bullous lung disease received only talc insufflation thoracoscopically. All of them showed good lung expansion after the operation. There are no recurrences, with a mean follow-up of 22 months. These results suggest that thoracoscopic ablation of blebs or bullae and pleurodesis may be applicable to patients with spontaneous pneumothorax who require surgical intervention.

1. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using the “elephant trunk” prosthesis. Thorac Cardiovasc Surg. 1983; 31:37-40. 2. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991; 5:491-9. 3. Coselli JS, Oberwalder P. Successful repair of mega aorta using reversed elephant trunk procedure. J Vasc Surg. 1998;27:183-8. 4. Westaby S, Katsumata T. Proximal aortic perfusion for complex arch and descending aortic disease. J Thorac Cardiovasc Surg. 1998;115:162-7. 5. Minale C, Splittberger F, Wendt G, Messmer BJ. One-stage intrathoracic repair of extended aortic aneurysms. J Card Surg. 1994;9:604-13. 6. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Lindell HP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994;331: 1729-34. 7. Palma JH, Almeida DR, Carvalho AC, Andrade JC, Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk). Ann Thorac Surg. 1997;63:1081-4. 8. Orihashi K, Sueda T, Watari M, Okada K, Ishii O, Matsuura Y. Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting. Eur J Cardiothorac Surg. 2001;20:973-8. 9. Griepp RB. Cerebral protection during aortic arch surgery. J Thorac Cardiovasc Surg. 2001;121:425-7. 10. Bachet J, Guilmet D, Goudot B, Dreyfus GD, Delentdecker P, Brodaty D, et al. Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann Thorac Surg. 1999;67:1874-8. 11. Hagl C, Ergin MA, Galla JD, Lansman SL, McCullough JN, Spielvogel D, et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg. 2001;121:1107-21.

Polytetrafluoroethylene grafts have become the alternative to arteriovenous fistulas for hemodialysis access. The most frequent complication of prosthetic grafts is thrombotic occlusion, caused especially by hypotension after hemodialysis and excessive compression for hemostasis. We describe a technique using the ringed polytetrafluoroethylene graft for constructing an upper arm curved graft to overcome external compression. It yields favorable results.

Hypothermic circulatory arrest is commonly used to facilitate repair of complex congenital heart defects and aortic lesions and for complex neurosurgical procedures. However, extended periods of circulatory arrest may impair cerebral metabolism and cause ischemic injury. Retrograde cerebral perfusion has been applied recently in aortic surgery to protect the brain. From January 1991 to December 1993, 29 patients underwent emergency operations to repair acute type A aortic dissection with the aid of hypothermic circulatory arrest. Six patients received hypothermic circulatory arrest without retrograde cerebral perfusion with a rectal temperature of 16.4° ± 0.9° C (mean ± standard error of the mean, group 1). Retrograde cerebral perfusion during hypothermic circulatory arrest was performed in 15 patients with a rectal temperature of 15.9° ± 0.5° C (group 2) and in eight patients with a rectal temperature of 21.7° ± 0.8° C (group 3). The hypothermic circulatory arrest times were 25 ± 4, 42 ± 4, and 63 ± 6 minutes, respectively ( p p

Thoracoscopy has assumed a major role in the management of a variety of surgical diseases of the chest. This technique, which was primarily devised for diagnostic purposes, has subsequently come to be used for therapeutic applications in most centers today. In this report we review 300 cases of therapeutic thoracic procedures in which a video-assisted technique was used. We describe mainly our own experience and the basic approach strategies we found helpful in the video-assisted procedures. No complications or deaths were attributable to these procedures. Our conclusions were as follows: (1) Video-assisted thoracic surgery can be as effective therapeutically as many formal thoracotomy. (2) Excellent exposure can be obtained by the use of double-lumen endotracheal tubes. (3) Video-assisted thoracic surgery is an excellent alternative treatment for pneumothorax, blebs, and bullous disease. (4) Video-assisted thoracic surgery allows safe, complete, visually guided wedge resection of lung lesions, lobectomy, pericardiectomy, removal of mediastinal tumor, esophagectomy, and reconstruction of the thoracic esophagus. (5) Video-assisted thoracic surgery also allows management of a broad scope of other general thoracic diseases such as empyema, pleural effusion, and chest trauma (hemothorax), as well as cancer staging. (6) Video-assisted thoracic surgery will not compromise the primary diagnostic and therapeutic goals set forth for the patient. (7) Because conventional instruments and extended manipulation incisions can be used, video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened stays in the hospital, and therefore savings in cost. Accordingly, we are now using video-assisted thoracic surgery to treat the majority of patients with surgical diseases of the chest.

Coronary artery endothelium exhibits functional impairment after ischemia and reperfusion. Canine left anterior descending coronary arteries were exposed to ischemia (60 minutes) followed by reperfusion (60 minutes) through a left internal mammary artery graft. In organ chamber experiments, control (left circumflex coronary artery) and reperfused (left anterior descending coronary artery) arterial segments were contracted with prostaglandin F2 alpha and exposed to hypoxia (oxygen tension = 35 +/- 5 mm Hg). Reperfused coronary rings with endothelium exhibited contractions to hypoxia that were significantly greater than contractions in control rings with endothelium (+78% +/- 8% and +14% +/- 5%, respectively; p < 0.05). This phenomenon could be blocked by NG-monomethyl-L-arginine. Electron microscopic studies showed platelet adhesion and aggregation, denudation of the endothelium and disruption of the intercellular junctions, edematous subendothelial matrix, and vesiculation of the smooth muscle cells in reperfused LAD. Swelling, vacuole formation, and loss of neurofilament occurred in the nerve fibers accompanying the vessels. These phenomena were not observed in control vessels. This study demonstrates that early after coronary artery bypass grafting, hypoxia can induce coronary vasospasm mediated by an L-arginine-dependent metabolic pathway in the endothelium. The ultrastructural changes in the coronary endothelium include platelet adhesion, aggregation, and platelet-induced contraction of coronary smooth muscle. The endothelium-dependent hypoxic coronary vasospasm and ultrastructural changes in the coronary endothelium may play an important role in the pathogenesis of myocardial ischemia and infarction after coronary artery bypass grafting.

Prosthetic rings are customarily used for mitral annuloplasty to plicate and reinforce the annulus and keep the annulus from further dilating. From July 1984 to Match 1992, mitial annular plication using polytetrafluoroethylene (PTFE) graft material was performed on 73 patients (age range, 15 to 69 years; mean, 35.7 years) with mitral regurgitation. The cause of the mitral regurgitation was rheumatic in 50.7% and degenerative in 36.9% of the patients. After other repair procedures on the mitral valve apparatus had been performed, a PTFE graft (3 mm) was tailored to the length of the free edge of the anterior leaflet and then inserted at the posterior part of the mitral annulus between the commissures. The operative mortality was 2.7%. Follow-up ranged from 0.7 to 8.5 years (mean, 5.6 years). Postoperative echocardiography confirmed that 94.2% of the survivors had either no or only mild mitral regurgitation with a large mitral valve area (2.7 ± 0.3 cm 2 ) and almost no pressure gradiant across the mitral valve or left ventricular outflow tract. Two patients successfully underwent redo PTFE mitral annuloplasty. Two patients died, one 15 and the other 20 months later, due to myocardial failure, with no mitral regurgitation. The event-free survival rate was 90% ± 4% at 8 yean. We conclude that PTFE mitral annuloplasty is an effective procedure that yields good long-term results.

The skeletal changes of severe hyperparathyroidism, known as osteitis fibrosa cystica, are now rarely encountered, because hyperparathyroidism is currently being diagnosed and treated at an early stage. Herein, a case of brown tumor of the sternum is reported; our report adds histologic data on this type of tumor to the literature.