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Objective: In order to determine the optimal surgical strategy for acute ascending aortic dissection, the graft inclusion technique was compared with the open resection technique., Methods: Between 1985 and 1995 a consecutive series of 193 patients (77% male, mean age 58 years) had emergency surgery during a mean interval of 13.2 h after onset of symptoms. Graft replacement of the ascending aorta was performed in all patients (supracoronary graft 143/193=74%, aortic root replacement 50/193=26%, aortic valve replacement 73/193=38%, arch replacement 44/193=20%) The open resection technique was applied in 93 patients and the inclusion technique in 100 patients with a Cabrol-shunt in 26%. Preoperative risk factors were equally distributed between groups (inclusion technique vs. open technique): left ventricular ejection fraction<45% (13 vs. 2%, not significant (n.s.)), neurological deficit (31 vs. 25%; n.s.), systolic blood pressure<90 mm Hg (20 vs. 15%, n.s.) pericardial tamponade (25 vs. 9%, n.s.), renal failure (6 vs. 4%; n.s.)., Results: The overall early mortality was 24%. Following graft inclusion it was 31% compared with 16% in the open technique group (P=0.0154). Postoperative complications (graft inclusion vs. open technique): myocardial infarction (9 vs. 12%, n.s.), low cardiac output (40 vs. 32%, n.s.), reexploration for hemorrhage (23 vs. 25%, n.s.). Survival at 8 years was significantly increased in the open technique group (P=0.0300). Pseudoaneurysm formation occurred in 3% of patients and only after graft inclusion. Freedom from reoperation was 80% at 8 years and did not differ between groups. Graft inclusion was an independent significant predictor of early (P=0.0069; relative risk=2.3673) and late mortality (P=0.0119; relative risk=2.0981)., Conclusions: Surgery of acute ascending aortic dissection still carries a considerable early mortality whereas the late outcome is satisfactory. The open resection technique is the method of choice showing superior early and late results and avoiding pseudoaneurysm formation. The inclusion technique may be indicated in situations with increased risk of bleeding. A consequent decompression of the perigraft-space could reduce the rate of pseudoaneurysms.

A 72-year-old patient with heparin-induced thrombocytopenia (HIT) and global cardiac decompensation underwent cardiac surgery using an extracorporeal circuit (ECC). For systemic anticoagulation r-Hirudin (lepirudin, Refludan) was administered as a heparin substitute during extracorporeal circuit. During cardiopulmonary bypass (100 min) the concentration of r-Hirudin was between 2.9 and 4.6 mcg/ml under continuous infusion of r-Hirudin at between 1.5 and 4.5 mcg/kg/min. The operation was successful and during its course no abnormal bleeding or fibrin formation in the extracorporeal circuit was observed. One hour after operation haemorrhage occurred and rethoracotomy was performed without discovering the cause of the surgical bleeding. After substitution with fresh frozen plasma, thrombocytes and Prothromblex the bleeding stopped on the operation day. The further postoperative course was uncomplicated. After 3 days the patient came to nursing station and was discharged from hospital to a rehabilitation centre after 13 days. After a further 3 weeks he went home in a good general condition.

A large coronary aneurysm, originating from a side branch of the right coronary artery, caused recurrent ischemia resulting in myocardial infarction. Successful surgical excision, without concomitant coronary artery bypass grafting, is described.

Background: Following mitral valve replacement, surgical closure of paravalvular leaks is usually advised in severely symptomatic patients and in those requiring blood transfusions for persisting haemolysis. However, the long-term prognosis of less symptomatic patients or those not needing blood transfusions is unknown., Methods: Between 1987 and 1997, we observed 96 patients with mitral paravalvular leakage. A paraprosthetic leak was diagnosed after a median time of 119 days (range: 1 day-23 years) after primary mitral valve replacement. During an average follow-up of 5 years (range: 1-23 years), 50/96 patients were referred for surgical closure., Results: Compared with patients who received conservative treatment, those referred for surgery had a significantly lower mean preoperative haematocrit (P = 0.002) with a higher proportion of patients being in the NYHA class III/IV (P = 0.03). Age, gender, left ventricular function and number and size of leaks did not differ between the groups. The 30-day postoperative mortality for valve reoperation was 6% (3/50); during follow-up three further patients died, resulting in an overall mortality rate of 12%. In the group treated conservatively there was a mortality rate of 26% (12/46). Thus, the actuarial survival for patients referred for surgery was 98, 90 and 88% after 1, 5 and 10 years, compared with 90, 75 and 68% for patients treated conservatively (long-rank P = 0.03). In addition, there was a significant increase in mean haematocrit levels (P = 0.0001) and an improvement in NYHA class III/IV symptoms (P = 0.002), vertigo (P = 0.001) and fatigue (P = 0.001) after surgery., Conclusions: Following mitral valve replacement, a more aggressive surgical treatment is recommended for patients with paraprosthetic leaks. Surgery should be offered to less symptomatic patients, as well as those not requiring blood transfusion.

The successful application of single-lead VDD pacing during the last few years has generated the idea of single-lead DDD pacing. Preliminary data from several single-lead VDD studies attempting to pace the atrium by a floating atrial dipole are unsatisfactory, causing an unacceptably high current drain of the device. We studied the feasibility as well as the short- and long-term stability of atrioventricular sequential pacing, using a new single-pass, tined DDD lead. In eight consecutive patients (age 73+/-16 years) with symptomatic higher degree AV block and intact sinus node function, this new single-pass DDD lead was implanted in combination with a DDDR pacemaker. Correct VDD and DDD function was studied at implantation; at discharge; and at 1, 3, and 6 months of follow-up. At implant, the atrial stimulation threshold was 0.6+/-0.1 V/0.5 ms. During follow-up, the atrial pacing thresholds in different every day positions averaged 2.1+/-0.5 V at discharge, 2.9+/-0.5 V at 1 month, 3.8+/-0.4 V at 3 months, and 3.4+/-0.4 V at 6 months (pulse width always 0.5 ms). The measured P wave amplitude at implantation was 4.5+/-2.2 mV; during follow-up the telemetered atrial sensitivity thresholds averaged 2.1+/-0.3 mV. Phrenic nerve stimulation at high output pacing (5.0 V/0.5 ms) was observed in three (38%) patients at discharge and in one (13%) patient during follow-up; an intermittent unmeasurable atrial lead impedance at 3 and 6 months follow-up was documented in one (13%) patient. This study confirms the possibility of short- and long-term DDD pacing using a single-pass DDD lead. Since atrial stimulation thresholds are still relatively high compared to conventional dual-lead DDD pacing, further improvements of the atrial electrodes are desirable, enabling lower pacing thresholds and optimizing energy requirements as well as minimizing the potential disadvantage of phrenic nerve stimulation.

Objective: In acute type A dissection long-term results of conservative aortic root surgery were compared with the outcome of primary valve and/or root replacement., Methods: Between 1985 and 1995, 199 patients (mean age 59 years, 154 men) were operated on. The aortic root was involved in the dissection process and valve incompetence of varying degree was present without exception. Replacement of a proximal aortic segment was standard procedure in all patients. The aortic valve was preserved in 126 patients: commissural suture resuspension (12 patients), root reconstruction with GRF-glue (gelatine-resorcin-formaldehyde/glutaraldehyde-glue) (114 patients). Valve replacement was performed in 73 patients (50 composite grafts, 23 valve prostheses with separate supracoronary grafts). Preoperative risk factors (valve replacement vs. preservation): coronary artery disease (11 vs. 8%, NS), tamponade (18 vs. 17%, NS), unstable hemodynamics (22 vs. 15%, NS), renal failure (4 vs. 6%, NS), neurologic disorder (19 vs. 32%, NS)., Results: The overall early mortality was 23.6% (47/199 patients) and increased after commissural suture resuspension compared with GRF-glue reconstruction (P = NS). Parameters of the early postoperative period did not differ between conservative treatment and root/valve replacement: low cardiac output, 34 versus 38% (P = NS); myocardial infarction, 10 versus 11% (P = NS); hemorrhage, 25 versus 23% (P = NS); duration of intensive care (P = NS). Survival was 61% after 8 years without difference between the two principal treatment groups (P = NS) and between the two conservative subgroups (P = NS). At 2 years, GRF-glue reconstruction had an increased freedom from reoperation on the aortic root (92 vs. 70%, P = 0.0253) and event free survival (77 vs. 41%, P = 0.0224) compared with suture resuspension. Commissural suture resuspension was an independent, significant predictor for reoperation (P = 0.0221, relative risk = 4.7130)., Conclusion: Surgery for acute type A dissection still carries a considerable early risk. Preservation of the aortic root is safe in the absence of Marfan or annuloaortic ectasia, but a certain incidence of reoperations on the aortic valve and the aortic root has to be accepted. Root reconstruction using GRF-glue is the method of choice and is superior to suture resuspension, with a significantly better reoperation-free and event-free survival.

About 30% of patients develop AF after open heart surgery. Biatrial synchronous pacing (BSP) has been shown to promote sinus rhythm in patients with paroxysmal AF refractory to drug therapy. We conducted a prospective, randomized study to test the effect of BSP via epicardial electrodes on the incidence of AF after heart surgery, as compared to conventional therapy. To apply BSP, we attached two epicardial electrodes to the right and one to the left atrium. Immediately following surgery, BSP was initiated in the AAI-Mode at a rate of 10 beats/min above the underlying rhythm (maximum 110 beats/min) and continued for 3 days, during which the rhythm was continually monitored. After 21 (age 63 +/- 9 years) of the planned 200 patients, the study was prematurely aborted because of the proarrhythmic effect of BSP: 6 of the 12 patients treated with BSP developed sensing failure (P amplitude < 1 mV), which provoked AF in 5 of these 6 patients. BSP was discontinued due to diaphragmal stimulation in two patients and due to ventricular stimulation by a dislocated left atrial electrode in one patient. Two patients in the control group (n = 9) developed AF. Using the available standard technology, BSP via epicardial electrodes is not suitable to suppress AF after heart surgery, primarily due to postoperative deterioration of atrial sensing and its profibrillatory effect. In patients requiring atrial pacing after heart surgery, sensing thresholds must be closely monitored to prevent induction of AF.

Pulmonary thromboendarterectomy is a surgical technique for treating pulmonary hypertension caused by unresolved pulmonary embolism. It has been recommended to perform this procedure under deep hypothermic circulatory arrest. Here we describe two technical modifications: (1) improved exposure to the right pulmonary artery by division of the superior caval vein and (2) thromboendarterectomy in normothermic cardiopulmonary bypass, with beating heart or electrically induced ventricular fibrillation. These modifications allow complete endarterectomy of both pulmonary arteries under normothermic conditions, thus avoiding hypothermic circulatory arrest, which results in short cardiopulmonary bypass times and reduces the morbidity and mortality of this procedure.

Background: In acute type A dissection of the aorta, local repair with glue-aortoplasty was compared with aortic replacement., Methods: Between 1992 and 1996, 106 consecutive patients (mean age, 59 years; 84 men) were operated on average 14.5 hours after onset of dissection. A local repair (gelatin-resorcine-formaldehyde/glutaraldehyde glue, Trigon AG, Monchengladbach, Germany) without graft replacement was performed in 21 patients. Graft replacement and reinforcement of aortic stumps with gelatin-resorcine-formaldehyde/glutaraldehyde glue was performed in 85 patients (supracoronary graft, 68; aortic root replacement, 17)., Results: Survival was 79% after 30 days and 69% after 2 years. There was no difference in early mortality (p = 0.2240) and survival (p = 0.07649). Risk factors for early mortality were preoperative shock, neurologic disorder, duration of crossclamp, and extracorporeal circulation. The rate of reoperation on the proximal aorta was 31.6% (6 of 19) after local repair and 9% (6 of 64) after aortic replacement (p = 0.0157). Local repair was a significant predictor for reoperation (p = 0.0087), with decreased reoperation-free survival (p = 0.01164). In all reinterventions (four supracoronary grafts, including two valve replacements; two composite grafts; two arch replacements) breakdown of the aortoplasty was confirmed., Conclusion: Local repair has satisfactory early results but an increased incidence of reoperations due to a breakdown of the glue-aortoplasty. Indications for local repair should be restricted to high-risk patients requiring a minimal emergency surgical procedure.

We report on a patient with a giant aneurysm arising from the right coronary artery leading to infarction due to a steal phenomenon. Emergency coronary angiography was performed. The orifice of the aneurysm was occluded by balloon catheter restoring blood flow and resolving ischemia. Aneurysmectomie was done subsequently. The patient recovered very soon, and the following course was uneventful. This case illustrates that occasionally causes other than usual coronary atherosclerosis may lead to acute coronary syndromes.

A special surgical technique is required for minimal-invasive cardiac surgery. The view for the coronary artery anastomosis under beating heart conditions is important and coronary artery blood might prevent a clear view of the opened coronary artery vessel. A new system called VisoFlo promises to improve visualisation at the surgical site. VisoFlo delivers a column of air to help provide a clear view of anastomosis site and in addition has a controllable mist to help prevent desiccation of the graft and surrounding tissue. This system was tested on 45 patients with coronary-artery-bypass graft surgery under beating heart conditions and at 65 patients with standard coronary-artery-bypass graft surgery. Our conclusions are, that the VisoFlo system is easy to use, guarantees a clear view of the anastomosis site and the surgical work will not be impaired.

Short- and long-term results for DDD pacing using a single-pass DDD lead are presented for 3 patients. Single-lead DDD pacing is feasible and may provide major advantages by eliminating the necessity of a second lead.

Objective: In a prospective, randomized study, postoperatively prolonged antibiotic prophylaxis is evaluated in a high-risk group of patients undergoing cardiac operations. These patients had postoperative low cardiac output necessitating inotropic support and intraaortic balloon pumping., Methods: Between January 1991 and 1994, 53 patients were enrolled in the study (42 men, mean age 65 years). All patients received the usual perioperative (24 hours) cefazolin prophylaxis. In the study group (n = 28) a prolonged regimen of prophylaxis with ticarcillin/clavulanate was performed for 2 days and vancomycin was added in a low dose until removal of the intraaortic balloon pump. The control group (n = 25) did not receive a prolonged regimen of prophylaxis. Follow-up ended at hospital discharge., Results: Early mortality was 7 of 28 patients (25%) in the prophylaxis group and 8 of 25 patients (32%) in the control group (p = 0.397). Defined infections (pneumonia, n = 22; sepsis, n = 8; deep sternal wound infection, n = 2) occurred in 50% of the study group and 68% of the control group (p = 0.265). In all patients with septicemia, only coagulase-negative staphylococci could be isolated from the bloodstream (5 patients in the prophylaxis group vs 3 in the control group). Infectious parameters were controlled daily and did not differ significantly between groups. A total of 1158 bacteriologic tests were performed (blood cultures, n = 389; intravascular catheters, n = 208; bronchial aspirates, n = 411; intraaortic balloon pumps, n = 42; wound secretions, n = 108) showing bacterial growth in 322 (28%) without a significant difference between the groups. In the prophylaxis group, 13 intravascular catheters and intraaortic balloon pumps showed bacterial growth versus 11 in the control group. No side effects were seen., Conclusions: In a high-risk group of patients undergoing cardiac operations, infectious outcome could not be effectively influenced by an additional and prolonged postoperative prophylaxis regimen with low-dose vancomycin and ticarcillin/clavulanate. Low-dose vancomycin did not reduce the rate of infections or colonizations of intravascular catheters with gram-positive organisms.

Background: Surgical management of coronary artery disease has improved dramatically over the last decades in terms of short- and long-term results. Nevertheless, elderly patients (more than 75 years); patients with reduced ejection fraction (less than 0.25), heavily calcified aorta, or coexisting noncardiac diseases; and patients requiring cardiac reoperation have an increased perioperative risk when operated on with cardiopulmonary bypass. Successful minimally invasive coronary artery bypass grafting without cardiopulmonary bypass has been reported in selected cases., Methods: In 8 of 40 high-risk patients undergoing operation on a beating heart, minimally invasive coronary bypass grafting was combined with vascular (carotid endarterectomy, n = 3; aortic replacement, n = 2) and abdominal procedures (a second look after combined pancreas and kidney transplantation) or defibrillator implantations (n = 2)., Results: Postoperatively, there was no mortality, no morbidity, and no blood transfusion. Patients are free of symptoms at an average follow-up time of 5.5 +/- 5 months., Conclusions: Our results indicate that minimally invasive coronary artery bypass grafting technique can be particularly useful if noncardiac procedures have to be performed in high-risk patients with significant coronary artery disease.

In contrast to type A aortic dissection, the indication for acute surgical repair as treatment of choice in type B aortic dissection is not the actual dissection, but the complications resulting from the dissection (rupture, potential rupture and ischemic syndromes of the aortic branches). Between 1978 and 1994, 92 patients underwent surgical repair of type B aortic dissection at our institution. Following diagnostic confirmation by echocardiography and/or CT scan, all patients received conservative antihypertensive therapy. 52% of the patients underwent emergency surgical repair. Symptoms prompting surgical repair were: visceral ischemia (23%), pleural effusion (19%), paraparesis (17%), refractory hypertension (12%), further aortic enlargement (12%), and rupture (10%). In chronic type B aortic dissection, the main symptom in 84% of the cases was further enlargement of the aorta. The early mortality decreased in the course of initial treatment from 33% to 16%, and to 8% after exclusion of patients operated on for ruptured aorta. Improved early mortality has led to an increase in acute surgical repair. In cases of chronic dissection, strict antihypertensive therapy is indicated and regular checks on the width of the aorta, as well expeditious diagnostic confirmation of its enlargement, are important.

Background: Long-term observations in patients with Kartagener's syndrome (situs inversus, bronchiectasis, and sinusitis) are rare. The role of additional cardiac malformations and their surgical repair is not well known., Methods: Nine patients (5 female and 4 male) with Kartagener's syndrome were identified and followed. Four patients had associated cardiac anomalies; 4 underwent total surgical repair at the ages of 4 (2 patients), 7, and 34 years., Results: The postoperative period was uneventful, and these 4 patients are doing well 7 months and 2, 9, and 19 years after repair. The other patients are being treated with conservative therapy and are in relatively good condition., Conclusions: This disease can be temporarily benign when treated with antibiotics and physiotherapy. Associated cardiac anomalies seem to be quite common, and such patients need careful cardiologic follow-up. Surgical intervention can be safely performed in patients suffering from Kartagener's syndrome associated with a congenital cardiac malformation and produces good long-term results. Bilateral lung transplantation seems to be the therapy of choice in patients with respiratory insufficiency but without concomitant cardiac anomalies.

Background: The surgical treatment of vascular infection is associated with a substantial early and late mortality. Cryopreserved homografts were evaluated for in situ reconstruction in aortic infections., Methods: Between January 1991 and July 1995, homografts were used in 19 patients (mean age, 61 +/- 13 years; range, 40-85 years) with mycotic aneurysms (9/19; 47%) or infected grafts (10/19; 53%) in the thoracic (7/19; 37%) or abdominal (12/19; 63%) aorta. Sepsis was present preoperatively in 14 of 19 (74%) patients, and 18 of 19 (95%) had received antibiotic treatment for 6.4 +/- 6 months (range, 1-36 months). Up to ten previous vascular procedures had been done in 11 of 19 patients (58%)., Results: There was one (5.2%) early and two (11%) late deaths, with one (5.5%) of the late deaths being homograft related. The mean hospital stay was 27 +/- 26 days (range, 7-84 days). Antibiotics were given postoperatively for 30 +/- 12 days (range, 4-84 days). During the follow-up period of 18.6 +/- 13 months (range, 7-60 months), there were no instances of reinfection, suture line rupture, homograft stenosis, or anastomotic aneurysms., Conclusions: Cryopreserved arterial homografts allow safe in situ reconstruction, decrease early and midterm mortality, and reduce antibiotic requirements. Early and midterm reoperations are unnecessary.

Acute mesenteric ischemia is a rare and often fatal event after cardiopulmonary bypass. We describe a diagnostic and therapeutic algorithm and present a patient with nonocclusive intestinal ischemia who had a successful conservative treatment.

The therapy of acute myocardial infarction has made major advances in the last 10 years. Cardiac surgeons have to adapt their strategies to the more aggressive management of acute myocardial infarction. Only in mechanical complications of acute myocardial infarction is cardiac surgery nowadays the therapy of choice. In cardiac rupture and ventricular septal defect, surgery is the only therapeutic option. In ischemic mitral regurgitation, cardiac surgery is required in the event of concomitant cardiogenic shock and pulmonary edema after intra-aortic balloon pump placement. Coronary artery bypass surgery my be indicated at low risk in patients with unstable angina pectoris when PTCA is not feasible or has failed, or in catheter emergencies.

A series of 200 consecutive patients with acute Stanford type A dissection (157 men, 78%; 43 women, 22%) was analyzed to assess the validity of aortic valve preservation or repair. Indication for the operation in most cases was based on echocardiographic examination alone, to reduce the delay. In the majority of patients (111/200, 56%) the aortic valve was preserved or repaired if necessary. Aortic root replacement with a composite graft was performed in 66 of 200 patients (33%), mainly because of an enlarged aortic anulus and sinus. Replacement of the aortic valve and the supracoronary ascending aorta was performed in 23 of 200 patients (12%) with a diseased aortic valve (e.g., bicuspid valve) but an acceptable aortic sinus. Follow-up totaled 656 patient-years (maximum 14 years). Actuarial analyses as a function of type of repair and type of aortic valve provided the following probabilities plus or minus errors (95%): overall survival of the 200 patients was 78.3% +/- 2.9% after 30 days, 74.95% +/- 3.1% after 1 year, 67.9% +/- 3.6% after 5 years, and 48.5% +/- 6.1% after 10 years. Actuarial probability of freedom from reoperation for valve failure in the complete series was calculated as 100.0% +/- 0.0% after 30 days, 99.3% +/- 0.7% after 1 year, 97.5% +/- 1.5% after 5 years, and 95.1% +/- 2.8% after 10 years. During long-term follow-up, there was no significant difference among groups with regard to structural deterioration, valve thrombosis, thromboembolic complications, anticoagulant-induced hemorrhage, and endocarditis. Freedom from valve failure and valve-related complications are similar for preserved, repaired, mechanical, and biologic valves. Valve-related reoperations are rare during at least 5 years of follow-up. Hence preservation or repair of the aortic valve can be recommended in the majority of patients with acute type A dissection.

A 72-year-old patient was operated on because of an acute type A aortic dissection with the primary entry located in the aortic arch and with retrograde involvement of the ascending aorta. Complete replacement of the aortic arch and the ascending aorta was performed after the dissected aortic layers had been readapted and sealed with gelatin-resorcin-formaldehyde biologic glue. Postoperative neurologic status was judged to be normal. The patient died 3 weeks postoperatively of septic shock. Postmortem examination of the brain revealed several small lesions, and microscopy showed very small particles of polymerized glue in the afferent vessels of ischemic cerebral and meningeal regions.

In order to assess the value of surgical revascularization of coronary arteries in patients with unstable angina pectoris, a series of 551/3397 consecutive patients belonging to New York Heart Association (NYHA) class IV was investigated. Fulfillment of at least two of the following criteria is mandatory for diagnosis unstable angina pectoris: slightly increased CK (< 300 IU/l), modified ECG at rest (decreased ST-T, increased ST), therapy-resistant post-infarction angina, therapy-resistant angina at rest, increased severity, duration or frequency of angina attacks within the last three months, insufficient therapeutic response. Patients with acute myocardial infarction were excluded from analysis. 362/551 patients out of the investigated cohort fulfilled criteria of unstable angina pectoris NYHA class IV; in 189/551 patients, criteria of stable angina pectoris NYHA class IV were fulfilled (controls). The mean follow-up period for these patients was 72 +/- 33 months (24 +/- 144 months). There were no differences regarding age, percentage of patients with three vessel disease, ejection fraction of the left ventricle and of cardiogenic shock. The mean number of aortocoronary grafts was 3.8 +/- 1.3 in patients with unstable angina, compared to 3.4 +/- 1.5 in patients with stable angina pectoris (p < 0.05). An intra-aortic balloon pump had to be applied in 8% of patients with unstable angina compared to 3% in stable angina. A mortality of 2% within 30 days of surgery was registered in unstable compared to 3% in stable angina pectoris (n.s).(ABSTRACT TRUNCATED AT 250 WORDS)

Refinement in surgical technique and perioperative management have considerably improved morbidity and mortality rates of carotid endarterectomy and abdominal aortic surgery, thus allowing a more aggressive approach in the treatment of carotid stenosis, abdominal aortic aneurysm and aorto-iliac occlusive disease in the elderly population (> 70 years). We review our experience with 446 consecutive patients undergoing surgery of the abdominal aorta: 295 patients (mean age 75.5 years) underwent resection of an abdominal aortic aneurysm (asymptomatic but > 5-6 cm, (n = 193), symptomatic (n = 67) or ruptured (n = 35). Additionally, 198 patients were treated surgically for aorto-iliac occlusive disease. A small group of 13 patients was deferred for combined operation, including prior myocardial revascularization and subsequent vascular surgery during the same anesthesia. The majority of patients had several cardiovascular risk factors and/or significant associated diseases. Mortality (< 30 days) was 3.5% following aorto-iliac bypass in the treatment of arterial occlusive disease and 8.4% after aneurysm repair (asymptomatic, symptomatic and ruptured aneurysms all included). 5-year survival was 74% and 64% after repair of aortic aneurysm and treatment of aorto-iliac occlusive disease respectively. On the basis of these results, we believe that major vascular surgery is still justified in elderly patients and can be achieved with reasonable mortality and morbidity. Main goals of the surgery, e.g. to relieve suffering, restore function so as to limit disability and dependency, and prolongation of life expectancy in a dignified and meaningful life-style, are realized the majority of operative survivors.

Atrioventricular (AV) valve dysfunction with tricuspid regurgitation is a common finding after orthotopic heart transplantation (HTx). In 20 patients the heart transplantation was performed with bicaval anastomoses and the results were compared to the precedent 20 patients operated with the standard technique. The right atrium of the recipient was completely removed and the caval anastomoses were performed on the beating heart during reperfusion. Using an interrupted suture line, no stenoses at the venous anastomoses were seen as known from the early implantation technique in heart-lung transplantation. Due to a more stable sinus rhythm only 15% of the patients in the bicaval group needed prolonged pacing (> 30 min) versus 55% (P < 0.01) in the group with standard operation. One to 3 months after surgery the transthoracic echocardiographic evaluation of the AV valve function showed tricuspid valve regurgitation (TVR) in 20% of the patients with bicaval anastomoses versus 75% with a right atrial anastomosis (P < 0.001). Tricuspid valve regurgitation during the first 2 weeks (in 31% of recipients with bicaval and in 70% with atrial anastomoses) improved in all recipients with bicaval anastomoses and in 14% of the recipients with atrial anastomosis. The modification of the operation technique did not result in significantly longer bypass time (75 +/- 14 versus 68 +/- 14 min) and ischemia time (44 +/- 12 versus 41 +/- 9 min with local organ procurement and 111 +/- 24 versus 101 +/- 19 min with distant organ procurement). The AV valve function and the postoperative rhythm after orthotopic HTx can be improved by implanting the heart with bicaval anastomoses.

We report that systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction can occur after mitral valve reconstruction without using an annuloplasty ring. A 69-year-old male patient with mitral regurgitation and ischemic heart disease underwent combined mitral valve reconstruction without an annuloplasty ring, and coronary artery bypass grafting. Intraoperative transesophageal echocardiography performed at the end of the operation revealed systolic anterior motion of the mitral valve with significant outflow tract obstruction requiring a second pump run with return to cardiopulmonary bypass and additional mitral valve replacement during the same thoracotomy.

Between 1984 and 1992, 79 patients were operated for occlusion of the infrarenal abdominal aorta. 12/79 (15%) of the patients underwent emergency procedure for an acute Leriche syndrome. 67/79 (85%) of the patients with a chronic occlusion were treated electively. The surgical management includes in our series in 57/79 (72%) cases aortoiliac or aortofemoral prosthetic bypass, in 11/79 (14%) cases aortoiliac endarterectomy, in 6/79 (8%) cases embolectomy and in 5/79 (6%) extraanatomical axillofemoral bypass. For chronic total occlusion of the aorta the most common procedure was prosthetic bypass in anatomical position. For emergency cases embolectomy was performed in 42%. Early morbidity rate was 26% (21/79). The most frequent complications were thromboembolic events in 7 patients, myocardial infarction in 4 patients and renal insufficiency in 4 cases. The 30-day mortality 2.5% (2/79); the cause in both cases myocardial infarction. For atherosclerotic occlusive disease of the infrarenal abdominal aorta the prosthetic bypass is the first-choice surgical procedure. For embolic occlusions and for risk patients other less burdening procedures are available.

Severe late complications after reconstruction of the abdominal aorta are unusual; when they occur, they demand a different strategy to treat the patient with success and to achieve a durably favourable long term outcome. These complications include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for the lower extremities. In patients who survived graft removal and extra-anatomic bypass, a source of major arterial inflow should be at least considered in order to secure a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypass and as a valid alternative to avoid dense adhesions in the abdomen or retroperitoneum. We present our experience with 8 patients in whom the aorta had been previously oversewn below the renal arteries (resection of infected graft [n = 4], repair of aorto-enteric fistula [n = 3]) or avoided because of dense adhesions after radiotherapy (n = 1). Temporary extra-anatomic reconstruction consists of an axillo-femoral (-popliteal) bypass on the right side with femoro-femoral cross-over graft. This method avoids surgery in the left thoraco-abdominal region, thus facilitating the definitive repair. Proper preoperative radiographic evaluation with inflow and outflow details is essential before conversion into thoraco-bifemoral bypass. Posterolateral thoracotomy is performed and the chest entered in the 7th interspace. The thoracic aorta is clamped tangentially and a bifurcated graft is anastomosed to the aorta. The bypass is passed through a retroperitoneal tunnel and anastomosed end-to-end with the distal portion of the previously inserted grafts; this technique avoids a second dissection of the vessel itself.(ABSTRACT TRUNCATED AT 250 WORDS)

Vague abdominal pain after cardiac surgery was caused by ectopic ossification in the distal part of sternotomy. The rarity of this complication (one case seen in recent years, operation volume: 1200 cases/year) prompted us to review the literature, where only 6 cases are described. Diagnostic problems and therapy are discussed.