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Introduction: Excellent results regarding clinical efficacy and cost reduction are achieved by using certified reprocessed single-use medical devices (SUMDs). This explains why this practice is common in most hospitals across the USA and Germany. However, this is not a common practice at a national level and there are no reports regarding its use in Portugal. We present our experience using these methods at Centro Hospitalar de São João (CHSJ) in Porto. Objective: The aim of this study was to compare the clinical results and the financial impact of the use of 2 SUMDs, original and reprocessed, namely the linear suture machine GIA CovidienTM and Harmonic ACE® scissors. Method: A group of 733 patients operated in 2014 was evaluated. Of these patients, 316 were operated on with reprocessed SUMDs and 417 with original SUMDs. Variables referring to the clinical and financial results were analyzed through clinical and management information provided by Unidade de Gestão Autónoma de Cirurgia. A comparison between groups was performed using the χ2 test and the Mann-Whitney test. Results: Indicators related to clinical efficacy show that the use of these SUMDs, professionally reprocessed, did not represent any added risk in comparison to the use of original devices. Regarding costs, there is a very significant difference between the use of a new medical device and that of a reprocessed one. In the case of the Harmonic ACE® scissors and of the linear suture machine GIA CovidienTM, savings were up to 50% per device. Conclusion: This study, the first in Portugal, confirms the economic advantages of reprocessing these 2 devices. The financial benefit was obtained with maintenance of the same clinical results as the ones achieved using original devices. These results are in line with the published literature, proving the validity of using SUMDs after professionally certified reprocessing. RESUMO - Introdução: Os excelentes resultados da eficácia clínica e da redução de custos, obtidos com o reprocessamento certificado dos Dispositivos Médicos de Uso Único (DMUU) justificam que seja prática corrente na maior parte dos hospitais, nos Estados Unidos da América e na Alemanha. No entanto, a nível Nacional ainda não é prática comum, não existindo bibliografia sobre a experiência nacional. Apresentamos os resultados obtidos com esta prática no Centro Hospitalar de São João (CHSJ), Porto. Objetivo: Comparar os resultados clínicos e o impacto financeiro da reutilização de dispositivos médicos de uso único, reprocessados profissionalmente. Foram utilizados dois dispositivos de “uso único,” a máquina de sutura linear GIA CovidienTM e a tesoura Harmonic ACE®. Método: Analisamos um grupo de 733 doentes operados em 2014 que inclui todos os doentes operados no referido período e em que foram utilizados estes dispositivos. Destes doentes 316 foram operados com DMUU reprocessados, e 417 com DMUU originais. As variáveis referentes aos resultados clínicos e financeiros foram analisadas através dos respetivos registos clínicos e da informação de gestão fornecida pela Unidade de Gestão Autónoma de Cirurgia. A comparação entre grupos foi realizada pela aplicação dos testes de Qui-quadrado e Mann-Whitney. Resultados: Os indicadores relativos à eficácia clínica, comprovaram que o uso destes DMUU reprocessados profissionalmente utilizados nas intervenções cirúrgicas não representou qualquer risco acrescido em comparação com os dispositivos originais. Em termos financeiros, há uma diferença muito significativa entre a aquisição de um dispositivo médico novo ou reprocessado. A diferença no caso da tesoura Harmonic ACE® e na máquina de sutura linear GIA CovidienTM acarretou poupanças cerca de 50%. Conclusão: Este primeiro estudo, realizado em Portugal, confirma as vantagens económicas do reprocessamento destes dois dispositivos. O benefício financeiro foi obtido com manutenção da mesma qualidade clínica que se obteve com os dispositivos originais. Os resultados obtidos estão em conformidade com os publicados na literatura, o que confirma que a utilização de alguns dispositivos médicos de uso único após reprocessamento profissional é um método eficiente. info:eu-repo/semantics/publishedVersion

Resumo: Em doentes portadores de próteses valvulares mecânicas, a ocorrência de disfunção protésica constitui um evento clínico relevante. Ocasionalmente, a demonstração do seu mecanismo etiológico e gravidade podem revelar-se difíceis.Apresenta-se o caso clínico de um doente de 50 anos, portador de duas próteses valvulares mecânicas nas posições aórtica e mitral, internado por descompensação de insuficiência cardíaca. Nos antecedentes apresentava uma história longa de doença plurivalvular reumática com três cirurgias cardíacas prévias.No internamento a investigação conduziu ao diagnóstico de disfunção grave de ambas as próteses mecânicas, sendo a etiologia e o mecanismo diferente em cada caso: recidiva de pannus no caso da prótese aórtica e bloqueio intermitente do encerramento dos discos por interposição de uma corda rota do aparelho subvalvular, no caso da prótese mitral. O doente foi reoperado, tendo havido melhoria significativa da classe funcional. Abstract: Prosthetic valve dysfunction is a significant clinical event. Determining its etiological mechanism and severity can be difficult. The authors present the case of a 50-year-old man, with two mechanical valve prostheses in aortic and mitral positions, hospitalized for decompensated heart failure. He had a long history of rheumatic multivalvular disease and had undergone three heart surgeries. On admission, investigation led to a diagnosis of severe dysfunction of both mechanical prostheses with different etiologies and mechanisms: pannus formation in the prosthetic aortic valve and intermittent dysfunction of the mitral prosthesis due to interference of a ruptured chorda tendinea in closure of the disks. The patient was reoperated, leading to significant improvement in functional class. Palavras-chave: Disfunção de prótese valvular mecânica, Pannus, Disfunção protésica intermitente, Keywords: Mitral and aortic prosthesis, Pannus, Chordae tendineae

Prosthetic valve dysfunction is a significant clinical event. Determining its etiological mechanism and severity can be difficult. The authors present the case of a 50-year-old man, with two mechanical valve prostheses in aortic and mitral positions, hospitalized for decompensated heart failure. He had a long history of rheumatic multivalvular disease and had undergone three heart surgeries.On admission, investigation led to a diagnosis of severe dysfunction of both mechanical prostheses with different etiologies and mechanisms: pannus formation in the prosthetic aortic valve and intermittent dysfunction of the mitral prosthesis due to interference of a ruptured chorda tendinea in closure of the disks. The patient was reoperated, leading to significant improvement in functional class. Resumo: Em doentes portadores de próteses valvulares mecânicas, a ocorrência de disfunção protésica constitui um evento clínico relevante. Ocasionalmente, a demonstração do seu mecanismo etiológico e gravidade podem revelar-se difíceis.Apresenta-se o caso clínico de um doente de 50 anos, portador de duas próteses valvulares mecânicas nas posições aórtica e mitral, internado por descompensação de insuficiência cardíaca. Nos antecedentes apresentava uma história longa de doença plurivalvular reumática com três cirurgias cardíacas prévias.No internamento a investigação conduziu ao diagnóstico de disfunção grave de ambas as próteses mecânicas, sendo a etiologia e o mecanismo diferente em cada caso: recidiva de pannus no caso da prótese aórtica e bloqueio intermitente do encerramento dos discos por interposição de uma corda rota do aparelho subvalvular, no caso da prótese mitral. O doente foi reoperado, tendo havido melhoria significativa da classe funcional. Keywords: Mitral and aortic prosthesis, Pannus, Chordae tendineae, Palavras-chave: Disfunção de prótese valvular mecânica, Pannus, Disfunção protésica intermitente

Resumo: A principal limitação da sobrevida a longo prazo após-transplante cardíaco é a doença vascular do aloenxerto que consiste na hiperplasia concêntrica e difusa da íntima arterial. A doença continua a ter uma incidência significativa estimada em 30% aos 5 anos pós-transplante cardíaco. Por ser uma doença clinicamente silenciosa, o seu diagnóstico é um desafio. A angiografia coronária complementada pela ecografia intravascular é o método de diagnóstico mais sensível. No entanto, novas técnicas de diagnóstico não invasivas podem vir a ter relevância clínica no futuro. O seu diagnóstico, o mais precocemente possível, é essencial de forma a permitir atrasar a progressão da doença a fim de melhorar o seu prognóstico. Em Julho de 2010, foi publicada uma nova nomenclatura recomendada para a vasculopatia do aloenxerto, elaborada pela Internacional Society for Heart and Lung Transplantation (ISHLT) e que permite uma uniformização da definição. Em simultâneo, foram publicadas as novas recomendações da ISHLT que procuram uma uniformização no diagnóstico e no manejo destes doentes. Este artigo faz uma revisão dos conceitos atuais da fisiopatologia, diagnóstico, prevenção e tratamento da vasculopatia do aloenxerto, realçando áreas em investigação. Abstract: The major limitation of long-term survival after cardiac transplantation is allograft vasculopathy, which consists of concentric and diffuse intimal hyperplasia. The disease still has a significant incidence, estimated at 30% five years after cardiac transplantation. It is a clinically silent disease and so diagnosis is a challenge. Coronary angiography supplemented by intravascular ultrasound is the most sensitive diagnostic method. However, new non-invasive diagnostic techniques are likely to be clinically relevant in the future. The earliest possible diagnosis is essential to prevent progression of the disease and to improve its prognosis. A new nomenclature for allograft vasculopathy has been published in July 2010, developed by the International Society for Heart and Lung Transplantation (ISHLT), establishing a standardized definition. Simultaneously, the ISHLT published new guidelines standardizing the diagnosis and management of cardiac transplant patients. This paper reviews contemporary concepts in the pathophysiology, diagnosis, prevention and treatment of allograft vasculopathy, highlighting areas that are the subject of ongoing research. Palavras-chave: Transplante cardíaco, Vasculopatia do aloenxerto, Ecografia intracoronária, Microcirculação, Keywords: Heart transplantation, Cardiac allograft vasculopathy, Intravascular ultrasound, Microcirculation

The major limitation of long-term survival after cardiac transplantation is allograft vasculopathy, which consists of concentric and diffuse intimal hyperplasia. The disease still has a significant incidence, estimated at 30% five years after cardiac transplantation. It is a clinically silent disease and so diagnosis is a challenge. Coronary angiography supplemented by intravascular ultrasound is the most sensitive diagnostic method. However, new non-invasive diagnostic techniques are likely to be clinically relevant in the future. The earliest possible diagnosis is essential to prevent progression of the disease and to improve its prognosis. A new nomenclature for allograft vasculopathy has been published in July 2010, developed by the International Society for Heart and Lung Transplantation (ISHLT), establishing a standardized definition. Simultaneously, the ISHLT published new guidelines standardizing the diagnosis and management of cardiac transplant patients. This paper reviews contemporary concepts in the pathophysiology, diagnosis, prevention and treatment of allograft vasculopathy, highlighting areas that are the subject of ongoing research. Resumo: A principal limitação da sobrevida a longo prazo após-transplante cardíaco é a doença vascular do aloenxerto que consiste na hiperplasia concêntrica e difusa da íntima arterial. A doença continua a ter uma incidência significativa estimada em 30% aos 5 anos pós-transplante cardíaco. Por ser uma doença clinicamente silenciosa, o seu diagnóstico é um desafio. A angiografia coronária complementada pela ecografia intravascular é o método de diagnóstico mais sensível. No entanto, novas técnicas de diagnóstico não invasivas podem vir a ter relevância clínica no futuro. O seu diagnóstico, o mais precocemente possível, é essencial de forma a permitir atrasar a progressão da doença a fim de melhorar o seu prognóstico. Em Julho de 2010, foi publicada uma nova nomenclatura recomendada para a vasculopatia do aloenxerto, elaborada pela Internacional Society for Heart and Lung Transplantation (ISHLT) e que permite uma uniformização da definição. Em simultâneo, foram publicadas as novas recomendações da ISHLT que procuram uma uniformização no diagnóstico e no manejo destes doentes. Este artigo faz uma revisão dos conceitos atuais da fisiopatologia, diagnóstico, prevenção e tratamento da vasculopatia do aloenxerto, realçando áreas em investigação. Keywords: Heart transplantation, Cardiac allograft vasculopathy, Intravascular ultrasound, Microcirculation, Palavras-chave: Transplante cardíaco, Vasculopatia do aloenxerto, Ecografia intracoronária, Microcirculação

Este relatório descreve o caso de um homem de 62 anos, admitido por infarto do miocárdio recorrente e artérias coronárias normais, causado por embolia coronária a partir de fibroelastoma papilar aórtico. Outros quadros que causam a síndrome coronariana aguda são discutidos, assim como as artérias coronárias normais. Nesse quadro clínico, faz-se necessária a avaliação cuidadosa, por meio de ecocardiograma transtorácico e transesofágico. A excisão cirúrgica do tumor é segura e curativa.

This paper proposes two new measures to assess performance of surgical practice based on observed mortality: reliability, measured as the area under the ROC curve and a living score, the sum of individual risk among surviving patients, divided by the total number of patients. A Monte Carlo simulation of surgeons' practice was used for conceptual validation and an analysis of a real-world hospital department was used for managerial validation. We modelled surgical practice as a bivariate distribution function of risk and final state. We sampled 250 distributions, varying the maximum risk each surgeon faced, the distribution of risk among dead patients, the mortality rate and the number of surgeries performed yearly. We applied the measures developed to a Portuguese cardiothoracic department. We found that the joint use of the reliability and living score measures overcomes the limitations of risk adjusted mortality rates, as it enables a different valuation of deaths, according to their risk levels. Reliability favours surgeons with casualties, predominantly, in high values of risk and penalizes surgeons with deaths in relatively low levels of risk. The living score is positively influenced by the maximum risk for which a surgeon yields surviving patients. These measures enable a deeper understanding of surgical practice and, as risk adjusted mortality rates, they rely only on mortality and risk scores data. The case study revealed that the performance of the department analysed could be improved with enhanced policies of risk management, involving the assignment of surgeries based on surgeon's reliability and living score.

OBJECTIVES A cardiopulmonary bypass technique was developed with the aim of achieving a less invasive approach to right-sided lesions of the heart or to avoid extensive dissection in reoperations. METHODS Cavae endoluminal balloon occlusion (CEBO) was achieved with balloon catheters, introduced through cannulas inserted in the right jugular and one of the femoral veins. This procedure can be used in association with a standard femoral cardiopulmonary bypass or with the port-access technique. RESULTS Twenty-two patients were operated, through a right thoracotomy, for atrial septal defect (19) and tricuspid valve regurgitation associated with mitral valve pathology (3). There were two intra-operative complications, partially related with the development of this technique and lack of appropriate designed material. There was no mortality and a shorter and easier postoperative care was achieved in almost all patients. CONCLUSIONS The CEBO technique is an useful and safe adjunct to perform miniinvasive or complex reoperations on the right side of the heart.

Objective: To analyze the mechanism(s) underlying homograft degeneration, we designed an experimental model in which the behavior of cryopreserved autografts and homografts, as well as fresh autografts, implanted in the same animal was compared. Methods: A cryopreserved homograft was implanted in the aorta of 14 sheep. The excised aortic autologous segment was then subjected to cryopreservation, and 1 to 8 weeks later it was implanted 1 to 2 cm below the cryopreserved homograft. The intermediate segment of the native aorta, the fresh autograft, was dissected at this point. Animals were put to death at different times and the implanted segments were harvested together with a portion of native aorta. Histologic and immunohistochemical analyses, as well as cell viability assessments, were then performed on the explanted segments. Similar studies were also conducted on fragments of cryopreserved autografts and homografts before implantation. Results: With the exception of a partial loss of the endothelium, cryopreserved specimens retained cell viability and morphologic integrity before implantation. Explanted cryopreserved homografts showed profound changes affecting all strata, as well as a decline in cell viability. Lymphocyte infiltrates were found up to 12 months after implantation. Endothelium was always absent in cryopreserved homografts. However, a reendothelialization of the cryopreserved autografts was observed. After an initial period of neuronal degeneration, reenervation of the cryopreserved autograft segment occurred 6 to 12 months after the operation. Findings regarding the fresh autografts were similar to those of the cryopreserved autografts. Conclusion: Our results suggest that the immunologic reaction rather than the cryopreservation process is responsible for the degenerative process occurring in cryopreserved homografts. (J Thorac Cardiovasc Surg 1997;113:1014-21)

A possible way of analyzing the immune response triggered by the allograft and the cellular viability is to compare immunocompetent and immunosuppressed patients, such as those having valve replacement and heart transplantation, respectively. These groups differ in immunosuppression therapy, preparation methods, valve hemodynamics. In the present study, we investigated polymerase chain reaction-amplified DNA flanking hypervariable (CA)n regions obtained from valve leaflets taken from patients having valve replacement or heart transplantation and performed a histologic analyses of the cells. In addition, we assessed an autograft valve to compare the hemodynamic effects on the cellular composition of the valve leaflet. We conclude that leaflet cellularity of the heart transplantation and autograft patients is superior to that of the valve replacement patients. These differences were consistent with the occurrence of an immune response in the valve replacement group, which was prevented or abrogated by immunosuppressive therapy administered to the heart transplantation group. However, it cannot be excluded that preparation procedures have a long-term effect on the extracellular matrix, leading to deterioration of cell adhesion and homing conditions.

Assessment of the cellular origin of allograft valves is essential in comprehending their biologic behavior and is improving preparation methods. In this study we retrospectively analyzed 10 allografts obtained form patients who underwent valve replacement or heart transplantation. Histologic evaluation and deoxyribonucleic acid amplification by polymerase chain reaction technology with fluorescence labeled primers was performed on different parts of the valve leaflets. Automated analyses of the obtained amplifiers showed in the heart transplantation group the presence of receptor cells intersperses with native donor cells in three cases. Preliminary results for the valve replacement group are inconclusive as yet. ( J THORAC CARDIOVASC SURG 1995;109:218-23)

This report describes a case of a 62 year-old man admitted for recurrent myocardial infarction and normal coronary arteries, caused by coronary embolism from aortic papillary fibroelastoma. Other conditions causing acute coronary syndrome and normal coronary arteries are discussed. A careful evaluation by transthoracic and transesophageal echocardiography is required in this clinical setting. Surgical excision of the tumor is safe and curative.

Renal insufficiency is associated with increased mortality and morbidity from cardiac surgery. Serum creatinine (SCr) values are routinely used for the assessment of renal dysfunction. However, this parameter can overestimate renal function, especially in low-weight and elderly patients, who can have normal creatinine values despite impaired renal function.1) To evaluate the prevalence and prognostic impact of different degrees of preoperative renal dysfunction (RD); 2) to assess the prevalence of normal SCr values among patients in different stages of RD.This was a retrospective study of 1314 consecutive adult patients (836 male, mean age 66 +/- 11 years) undergoing cardiac surgery. Patients were assigned to one of the five stages of RD of the National Kidney Foundation classification according to their glomerular filtration rate (GFR), estimated by the Cockcroft-Gault equation and indexed to body surface area. The impact of each stage of RD on in-hospital mortality was assessed after adjusting for all the other EuroSCORE components in multivariate analysis.The median logistic EuroSCORE was 3.8 (interquartile range: 1.9-7.0). In-hospital mortality was 3.4% (n = 35). The prevalence of stages 3, 4 and 5 RD was 30.2% (n = 397), 3.4% (n = 45) and 4.3% (n = 56) respectively. Increasing in-hospital mortality was observed across ascending stages of RD. After adjustment for other EuroSCORE risk factors. stage 3 or higher RD was an independent predictor of in hospital mortality--OR 2.0 (95% CI: 1.1-3.9, p = 0.03). Among patients with stage 3 or higher RD, 61% (n = 304) had SCr values1.50 mg/dl and 83% (n = 414) had SCr2.26 mg/dl (the EuroSCORE cutoff value).Renal impairment is common among patients undergoing cardiac surgery and the presence of even mild forms of RD is associated with increased mortality. SCr values within the normal range frequently correspond to moderate or even severe RD, indicating that GFR should be calculated systematically to avoid underestimation of surgical risk.

Objective: Some patients submitted to cardiac surgery have concomitant atrialfibrillationand a previously implanted pacemaker. Because it is unknown if there is any potential for these patients to reassume a regular rate sinus rhythm after ablation of atrial fibrillation, we reviewed the results of all patients with pacemaker enrolled in the Registry of Atrial Fibrillation. Materials: Thirty-six patients were included in this study. Twenty-six had valve disease,seven had coronarydiseaseand three had congenital heart disease.They were submitted concomitantly to ablation of atrialfibrillation using biatrialapproaches (seven patients),left sided (27), or right sided(three patients).Thirty-threehospital survivors had a mean follow-up of 18 months, and a maximum of 25 months. Results: At 1 year (n = 21), patients’ rhythm was sinus non-pacing dependent (52%), sinus pacing-dependent (14%), and atrial fibrillation (14%). At 2 years (n = 14), patients’ rhythm was sinus non-pacing dependent (57%) and atrial fibrillation (43%). The only factor that may have had impact on the recovery of sinus rhythm at 1 year was the small size of the left atrium (p = 0.05). Conclusions: We conclude that in a significant number of patients, having a pacemaker before surgery does not preclude sinus rhythm recovery after a cardiac operation and ablation for concomitant atrial fibrillation. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

We present images of a permanent pacing lead implanted in the coronary sinus of a patient with a tricuspid prosthesis.

Pulmonary hypertension is a significant problem to take into account in the post-operative management of cardiac patients, especially valvular patients. Inhaled nitric oxide allows more effective control of pulmonary pressure and other hemodynamic parameters, with better post-operative results. We present a clinical case of a patient with mitral stenosis and severe pulmonary hypertension, with post-operative hemodynamic instability, in which we used inhaled nitric oxide for better control of pulmonary pressures and to help ventilator weaning.

Background— The primary results of Arterial Revascularization Therapy Study reported a greater need for repeated revascularization after percutaneous coronary intervention with stenting (PCI). However, PCI was less expensive than coronary artery bypass grafting (CABG) and offered the same degree of protection against death, stroke, and myocardial infarction. Methods and Results— Patients with multivessel disease (n=1205) were randomly assigned to either CABG or PCI and followed up for up to 3 years. Survival rates without stroke or myocardial infarction were similar in each group at 1 year and 3 years (90.5% versus 91.4% for PCI versus CABG at 1 year and 87.2% versus 88.4% for PCI versus CABG at 3 years). However, the respective repeat revascularization rates were 21.2% and 26.7% at 1 and 3 years in patients allocated to PCI, compared with 3.8% and 6.6% in patients allocated to CABG ( P P P P at 1 year but decreased to 10 492 at 3 years. It remained at 142 391 at 3 years when revascularization procedures were excluded in the efficacy end point, however. Conclusions— Three-year survival rates without stroke and myocardial infarction are identical in both groups, and the cost/benefit ratio of stenting is determined primarily by the increasing need for revascularization in the PCI group.

Background Several surgical techniques such as the Ross operation or total correction of tetralogy of Fallot require incisions of the upper ventricular septum. Very few reports on the anatomy of the septal arteries of the pathologic heart can be found in the literature. To get a more precise knowledge of the large septal arteries in pathologic hearts, we have compared the anatomy of normal hearts with that of hearts with aortic valve disease and of tetralogy of Fallot. Methods Twenty-six normal heart specimens (group A), 11 with aortic valve disease (group B), and 4 with tetralogy of Fallot (group C) were dissected. Results In groups B and C a single large septal artery was always found. The large septal artery had the orientation previously described for normal hearts. Still, its course in the lower border of the anterior extension of the septomarginal trabecula was deeper. The anterior extension of the septomarginal trabecula was 4 ± 3 mm deep in group A, 6 ± 2 mm in group B, and 3 mm in group C. The interventricular septum was much thicker in groups B and C than in group A. Conclusions The position of the large septal artery can be predicted from coronary angiography and from the morphology of the anterior extension of the septomarginal trabecula. Knowledge of its position can improve the safety of operations performed on the outflow of the interventricular septum.

The aim of this study is to establish anatomical landmarks for the trajectory of the large septal artery. Thirty hearts were dissected, 20 of which had no cardiac pathology and the remaining with different cardiac conditions. One large septal artery was located in 27 of these hearts, two large septal arteries in 2 and three large septal arteries in 1. For all cases there existed one large septal artery in the lower border of the anterior limb of the septomarginal trabecula. When more than one large septal artery was encountered, the first was located within the subendocardial outflow tract of the left ventricle, the second was in the lower border of the anterior limb of the septomarginal trabecula and the third 1.5 cm below the second.

outflow obstruction, is rare, and the presence of 2 myxomas originating in the right ventricle involving both right ventricular inflow and outflow tract has never been reported. Symptoms may be variable and are determined by the tumor location and size. Inflow or outflow obstruction, embolism, syncopal episodes, and arrhythmias are the most common. After the diagnosis of acute right ventricular obstruction resulting from a cardiac mass, prompt surgical resection is indicated because of imminent embolization and inflow or outflow obstruction, resulting in sudden death. Several surgical techniques have been suggested, but in each case it depends on the site of the tumor. This case report highlights the fact that right ventricular outflow obstruction associated with episodes of syncope during exercise may be related to a cardiac myxoma, despite the right-sided, very low incidence of this tumor. Transesophageal echocardiography accurately identifies the presence of right ventricular multiple tumors and aids the surgical procedure.

The pathogenesis of atrial fibrillation (AF) is not completely understood. The role of pulmonary veins (PV) in AF initiation is documented, and the recent demonstration of persistent fibrillatory activity in an isolated PV suggests that the PV play a role in the maintenance of AF.Since AF is facilitated by multiple reentry circuits in atrial tissue with short effective refractory periods (ERP) and prolonged conduction times, we investigated whether PV have shorter ERP compared with the left atrium (LA).The study population consisted of five male patients, between 45 and 78 years of age, with normal sized LA; three had coronary artery bypass surgery (and no previous history of atrial arrhythmias) and two had paroxysmal lone AF refractory to antiarrhythmic drugs and were referred for percutaneous ablation with radiofrequency energy. In the surgical patients, epicardial bipolar pacing wires were inserted in the PV ostia and LA roof at the end of the procedure. Post-operatively, the pacing wires were used to determine atrial thresholds and ERP in the PV ostia and LA roof. In the AF patients, atrial thresholds and ERP at these locations were obtained with the mapping/ablation catheter before and after PV isolation. ERP were determined with a basic pacing cycle length of 500 ms and a single extrastimulus with an initial coupling interval of 350 ms, gradually decreased (10 ms at a time) until atrial capture failure or AF induction.ERP in the LA roof were longer than 210 ms. The shortest ERP was always obtained in a PV ostium, with the shortest in the left PV ostia. The ERP values of the right inferior PV most resembled those of the LA roof. In patients referred for ablation, AF was induced when PV ostia with ERP shorter than 200 ms were stimulated.In the present study, the ERP of PV ostia were shorter than LA ERP, possibly explaining not only the presence of ectopic foci in the PV ostia, but also sustained fibrillatory activity in isolated PV, despite conversion of the atria to sinus rhythm. This fact may also explain the higher success rate and the preference for PV isolation in AF ablation.

Atrial fibrillation surgery is an evolving procedure. The maze operation, developed by James Cox,1 has been the standard operation since the early nineties. However, the maze operation is a complex procedure with bleeding potential that always requires the use of cardiopulmonary bypass and a long myocardial ischemic time. Because of the complexity of the maze operation, different alternatives have been proposed aiming at simplifying the techniques and reducing the time and risks of the operation.2–4 The final goal of each particular procedure is to create scars in the atrial wall in such a way that the initiators, the perpetuators or both mechanisms of atrial fibrillation will be eliminated.

Objective: Several medical, interventional and surgical techniques are used to treat atrial fibrillation, aimed at different goals and having variable success rates. To be able to assess and compare all these techniques a methodology of study and a classification is proposed. Methods: We developed a five grade score, named the Santa Crus Score, based upon the post-operative atrial rhythm and the effective atrial contraction. Score 0 corresponds to a persistence of atrial fibrillation, the presence of a regular rhythm is grade 1, 2 or 3 if there is no atrial contraction; right atrial contraction; or bilateral atrial contraction, respectively. Score 4 corresponds to sinus rhythm and bilateral atrial contraction. Surgery for atrial fibrillation was performed on 51 patients since 1992. All patients but two had associated mitrial surgery. Three different maze techniques were performed on 17 patients and the pulmonary viens isolation procedure on 34 patients. Patients were reassessed at 1, 6, 12, 24 and 36 months. Results: After the maze I procedure atrial fibrillation eradication was achieved in 88% of patients but none scored 4. Three patients changed score during the first year. All maze III patients scored 0 initially and one changed to score 3 in the first year. Sixty percent of the maze IIIA patients scored 4, but one evolved to score 0 at 6 months. The pulmonary veins isolation technique eliminated atrial fibrillation in 71% of the patients initially, and in 60% after 1 year, and achieved a score of 4 in a third of the patients. Conclusion: This classification considers the intermediate grades of success that can occur with absence of atrial fibrillation and is applicable to all forms of therapy. © 1997 Elsevier Science B.V.

Mechanical and biological heart valve substitutes have evolved in parallel, since, in 1951, Hufnagel implanted the first mechanical prosthesis in the descending aorta and attempted, although without success, to implant valve allografts in the same position (reviewed in 35). Five years later, Murray, following the experimental work by Lam and colleages (20), succeeded where Hufnagel had failed, when by placing an allograft in the descending aorta succeeded in reducing an aortic valve insufficiency (29).

Initial results obtained with a new flexible ring, adjustable from outside of the heart after interruption of extracorporeal circulation, are presented. Twenty-five rings have been inserted in 20 patients, 14 in the mitral position and 11 in the tricuspid position. In 8 of the 14 patients receiving mitral annuloplasty, other standard mitral valve repair techniques were used. Adjustment, assisted by intraoperative transesophageal color Doppler echocardiography, was done for 10 (71%) of the mitral rings and for 8 (73%) of the tricuspid rings. Residual mitral regurgitation disappeared or became minimal in 9 (90%) patients, and a mild regurgitation remained in 1. In all patients who received tricuspid rings regurgitation was abolished after the adjustment. There was no hospital or late mortality. After a maximum follow-up of 6 months results are comparable in the tricuspid and mitral positions and echocardiographic evaluation revealed stable competent valves in all patients but one, who underwent reoperation because of failure of a mitral valve chordae shortening procedure. The use of externally adjustable rings for the mitral and tricuspid valves is a safe alternative for atrioventricular valve annuloplasty and has the additional advantage of reducing postrepair regurgitation. (J THORAC CARDIOVASC SURG 1995;110:1333-7)