Concomitant Cardiac Surgery Research Articles

Preoperative statin therapy does not improve surgical ablation outcome for atrial fibrillation in patients undergoing concomitant cardiac surgery

Preoperative statin therapy does not improve surgical ablation outcome for atrial fibrillation in patients undergoing concomitant cardiac surgery

Concomitant surgical treatment of dental and valvular heart diseases

Invasive dental procedures are often indicated before cardiac valve surgery. The purpose of this case-control study was to determine the risks and benefits of concomitant dental and thoracic surgery. Critically ill cardiac inpatients requiring cardiac valve surgery were referred by the Department of Thoracic and Cardiovascular Surgery to our Oral Medicine consult service. Those requiring dental extractions were considered for dental treatment during the same general anesthetic as the cardiac surgery. These study patients were compared with control patients who had extractions before valve surgery in a different setting. There was no attempt to analyze the impact of this practice on the development of infective endocarditis. All patients received broad-spectrum antibiotics during dental surgery. Twenty-one patients had concomitant oral and cardiac valve surgery. Seventeen patients were in the control group. There were no statistically significant differences between cases and controls in demographics, length of stay, nature of the dental surgery, mean number of teeth removed, oral bleeding, or postoperative infections. One patient in the control group developed prosthetic valve endocarditis versus none in the concomitant surgery group. This case-control study suggests that concomitant surgical procedures for dental and valvular heart disease can be accomplished without clinically significant oral complications. Given the risk from poor oral health following cardiac valve surgery, this approach should be considered for patients who would benefit by avoiding a second general anesthetic and/or a delay in cardiac surgery, and by having their oral surgery performed in the safest environment.

Prospective randomized comparison of left atrial and biatrial radiofrequency ablation in the treatment of atrial fibrillation

The aim of this study was to compare, in patients with permanent atrial fibrillation (AF), the efficacy and safety of left atrial ablation with that of a biatrial procedure and to assess the risk factors for late failure of sinus rhythm restoration. Between January 2004 and January 2007, 299 consecutive patients underwent the radiofrequency ablation procedure for AF associated with concomitant cardiac surgery. According to a prospective, open, and randomized trial, 149 patients underwent left atrial plus cavotricuspid isthmus ablation (left atrial group), while 150 patients underwent biatrial ablation (biatrial group). The postoperative and mid-term follow-up results were compared between the two groups. Both univariate and multivariate analyses were used to assess the risk factors for late recurrence of AF. There were seven in-hospital deaths (2.3%), including two in the left atrial group (1.3%) and five in the biatrial group (3.3%), and there were no differences in the incidence of the mortality and complications during the postoperative and follow-up periods between the groups. At discharge, sinus rhythm was maintained in 77.1% of the patients, including 78.2% of those in the left atrial group and 75.9% in the biatrial group (p=0.68). Follow-up was completed in 97% of the patients, with a mean time of 28+/-5 months. At the latest follow-up, two deaths occurred in the biatrial group. Sinus rhythm was documented in 237 (85.0%) out of all the patients, including 85.2% (121/142) in the left atrial group and 84.1% (116/138) in the biatrial group patients (p=0.87). Using a multivariate analysis, a left atrial diameter of >/=80 mm (p=0.02) was an independent predictor for a late recurrence of AF. Both the left atrial combined with cavotricuspid isthmus ablation and biatrial maze procedure is safe and effective in treating patients with AF, with an acceptable sinus conversion rate, mortality and morbidity. A left atrial dimension of >/=80 mm was a significant predictor for a late recurrence of AF.

Epicardial Ultrasonic Ablation of Atrial Fibrillation During Concomitant Cardiac Surgery Is a Valid Option in Patients With Ischemic Heart Disease

Surgical therapy of atrial fibrillation concomitant to coronary bypass grafting using epicardial Ultrasound technology was assessed after a minimum 6-month follow-up. A cohort of 98 consecutive patients with a mean age of 72+/-7.58 years and a primary diagnosis of ischemic heart disease had surgery for structural disease. Coronary artery bypass grafting was isolated (n=51) or associated (n=47) with various combinations of aortic, mitral, tricuspid, and left ventricular restoration surgery. Atrial fibrillation duration ranged from 6 to 360 months (mean 71 months) and was permanent in 47 patients, paroxysmal in 34, and persistent in 17. Left atrial mean diameter was 48+/-6.71 mm. A circumferential ablation was performed off-pump, before the concomitant procedure, and was always associated with an epicardial mitral line lesion using the same technology. At 3-, 6-, and 12-month visits, patients were routinely evaluated by physical examination, ECG, chest X-ray, and 24-hour Holter. There were 1 early death (1%) and 4 extracardiac late deaths. A pacemaker was implanted in 4 patients. Mean follow-up time was 325 days, 2 patients being lost to follow-up. Freedom from atrial fibrillation and flutter at the 6-month visit was 84% for the entire population, 76% in patients with permanent, and 91% in patients with paroxysmal atrial fibrillation. At the 1-year visit, 85% were free from atrial fibrillation or flutter. Epicardial beating heart ablation using therapeutic ultrasound is safe, reliable, and can easily treat atrial fibrillation in a difficult surgical population of patients with primary ischemic heart disease.

Achieving Metrics during Beating-Heart Ex-Maze Procedures Improves Outcomes

Current surgical treatments for atrial fibrillation (AF) lack intraoperative metrics that predict long-term outcomes. The extracardiac maze (Ex-Maze) procedure is a beating-heart maze procedure that causes spontaneous conversion to sinus rhythm (SR) during lesion creation. Spontaneous conversion and confirmation of pulmonary vein exit block are 2 important predictors of long-term freedom from AF. A beating-heart Ex-Maze procedure was performed in 54 AF patients (paroxysmal, n = 2; persistent, n = 11; longstanding persistent, n = 41) undergoing concomitant cardiac surgery (mitral valve replacement [MVR] = 23, aortic VR [AVR] = 7, coronary artery bypass graft [CABG] = 17, CABG +/- AVR = 3, CABG +/- MVR = 2, atrial-septal defect = 2). The Ex-Maze lesion set is a comprehensive, biatrial ablation pattern created epicardially with unipolar, radiofrequency energy applied by a vacuum-integrated device. Electrocardiogram data were collected during the procedure and at 1, 3, 6, and 12 months postoperatively; 24-hour Holter monitors data were also obtained 12 month postprocedure. Mean left atrial size was 5.4 cm. Average procedure time was 39 minutes. There were no device- or procedure-related complications. At the time of surgery 48 patients were in AF; 32 (67%) patients spontaneously converted to SR during lesion creation. At a mean follow-up of 262 days, 42 of 48 patients (88%) were free from AF, 39 of 48 (81%) were in SR; and 35 of 47 (74%) were free from AF and had discontinued class I and III antiarrhythmic drugs. In 32 of 33 patients (97%), exit block at 15 mA was confirmed, in which pulmonary vein isolation was tested. Follow-up was completed for 30 of the exit-block patients; freedom from AF was observed in 29 of 30 (97%), SR in 26 of 30 (87%), and freedom from AF and class I/III antiarrhythmic drugs in 25 of 29 (86%). Recent advances in techniques and technologies permit the creation of a comprehensive biatrial lesion pattern on the epicardium of a beating heart. Observation of spontaneous conversion and confirmation of pulmonary vein exit block are important metrics that predict improved long-term outcomes.

Equivalent Performance of Epicardial Versus Endocardial Permanent Pacing in Children: A Single Institution and Manufacturer Experience

Children requiring permanent pacing have a lifelong need for follow-up. Epicardial leads have traditionally fared worse than endocardial counterparts. We tested the hypothesis that steroid-eluting epicardial and endocardial leads had equivalent outcomes. We reviewed medical records of 148 children, mean age 8.2 +/- 4.8 years, in whom a dual-chamber pacemaker system with steroid-eluting leads from a single manufacturer was implanted. Primary outcome was mortality. Secondary outcomes included freedom from lead failure and pacemaker system reintervention. Loss of capture-sensing, lead displacement-fracture, exit block, and high thresholds constituted lead failure. Reintervention included need for lead revision or generator change. There was no early mortality. Late mortality occurred once (0.5 +/- 0.5 deaths/1,000 patient-months) and eight times (3.4 +/- 1.2 deaths/1,000 patient-months) in the endocardial and epicardial groups, respectively. The relative hazard of endocardial versus epicardial site for lead failure was 0.408 (p = 0.038) and for reintervention was 0.629 (p = 0.002). Endocardial and epicardial groups differed in important ways: concomitant cardiac surgery 5% (3 of 61) versus 27% (27 of 99); congenital heart disease 33% (20 of 61) versus 90% (89 of 99); single ventricle physiology 13% (8 of 61) versus 52% (51/99); and age (10.5 +/- 4.5 years vs 5.5 +/- 5.2 years). Adjusting for these covariants, the relative hazard for freedom from lead failure for endocardial versus epicardial leads was 0.546 (p = 0.360). The adjusted relative hazard for freedom from reintervention was 0.157 (p = 0.045). Technologic advances attenuate important differences in lead failure rates between endocardial and epicardial steroid-eluting pacing leads and thus bridge the performance gap between these fixation modes.

Simplified technique for surgical ligation of the left atrial appendage in high-risk patients

Simplified technique for surgical ligation of the left atrial appendage in high-risk patients

Tricuspid Regurgitation in Patients Undergoing Pericardiectomy for Constrictive Pericarditis

Tricuspid regurgitation (TR) may complicate pericardial constriction; however, its incidence, impact on outcome, and appropriate management are not defined. Between January 1993 and March 2006, 481 adult patients underwent pericardiectomy at Mayo Clinic, Rochester, Minnesota. Excluding those with pericardiectomy for reasons other than constriction, previous tricuspid valve surgery, malignant infiltration, and those undergoing other concomitant cardiac operations, 261 patients remained for evaluation of echocardiographic TR before and after surgery as well as early and late survival. Tricuspid regurgitation was present in 71% of patients (185 of 261); in 20% (54 of 261), TR was graded moderate or severe. Operative mortality was higher (7 of 54, 13%) among those with moderate/severe TR (7 of 54, 13%, versus 9 of 207, 4.3%; p = 0.019), and by multivariate analysis, moderate/severe TR was an independent predictor of late mortality (hazard ratio: 2.9, 95% confidence level: 1.5 to 5.6; p < 0.001). After excluding patients with prior radiation, moderate/severe TR was no longer a predictor of operative risk, but remained associated with poorer late survival (5-year survival 47% with versus 87% without). Among those with moderate/severe TR, operative mortality was similar if repair was or was not undertaken (2 of 20, 10%, versus 5 of 34, 15%; p = not significant), and late survival was not impacted. Without intervention, however, TR improved in only 29% (8 of 28). Tricuspid regurgitation frequently complicates constrictive pericarditis, and when moderate or severe, is associated with increased mortality. Although valve repair has little impact on late survival, TR seldom improves with pericardiectomy alone, and may be considered to reduce symptoms, as it can be undertaken without increasing operative risk.

Ultrasonic Cardiac Ablation for Atrial Fibrillation During Concomitant Cardiac Surgery: Long-Term Clinical Outcomes

Therapeutic ultrasound as an alternative to the maze procedure was evaluated in this large US experience. Safety and efficacy were assessed at 6-, 12-, and 18-month visits with systematic 24-hour Holter monitoring. From February 2005 to February 2007, 220 patients were prospectively enrolled in a single center study, and among them 129 patients with concomitant cardiac surgery and at least 6-month follow-up were reviewed. Primary procedures were mitral surgery in 50% of the cases, coronary bypass in 32%, and aortic surgery in 16%. Atrial fibrillation was permanent in 66 (51.1%), paroxysmal in 43 (33.3%), and persistent in 20 (15.5%) patients. An epicardial and circumferential left atrial encircling line was created on the beating heart. Routinely a mitral isthmus line was also created from the left atrium epicardium using an ultrasonic handheld device. No morbidity or mortality was device-related. There were four (2.33%) early deaths and six late extra-cardiac deaths. Follow-up ranged from 6 to 670 days with a mean follow-up of 358.5 days, median 340 days with two patients lost to follow-up. Freedom from atrial fibrillation or left-sided flutter was 83.2%, 84.4%, and 86.2% at 6, 12, and 18 months, respectively. A pacemaker was implanted in seven patients (5.4%). Male gender and left atrial dimension were significant risk factors for failure. The study confirms the excellent safety record of the technology, and the efficacy at the level reported in a previous European multicenter study. Efficacy is also maintained at longer (12 and 18 months) follow-up.

Initial clinical experience with a new end graft holder for anastomosis in coronary surgery

We assessed the feasibility and effectiveness of a novel end graft holder for coronary artery bypass grafting (CABG) and evaluated anastomotic patency and early clinical results. The end graft holder was applied to 45 consecutive patients. Operative characteristics were off-pump CABG in 22.2%, emergency in 28.9%, and concomitant cardiac surgery in 13.3%. The device was used safely without graft injury or inadequate gripping on grafts. Postoperative angiography showed that the patency rate of distal anastomosis was 96.7% (arterial, 100%; venous, 94%). All proximal aortic and composite graft anastomoses were patent without stenosis. The rate of 30-day major adverse cardiac and cerebrovascular events was 13.3% (operative deaths, 3; repeated CABG, 1; percutaneous coronary arterial intervention, 1; and cerebral infarction, 1). None of the elective patients died during hospitalization. Our initial clinical experience demonstrated that the new end graft holder was safe, reliable, and effective during CABG. The excellent fixation and visualization of the graft with the device might be particularly beneficial for off-pump CABG or for teaching trainees.

Thromboembolic events early after mitral valve repair: Incidence and predictive factors

Background and objectives The incidence of thromboembolic events (TE) in the early period following mitral valve repair (MV repair) is poorly documented. The aim of this prospective study was to evaluate it, and to determine predictive factors. Methods and results In this prospective multicenter non-randomized study, 350 consecutive patients were included after MV repair and monitored until post-operative day 44 ± 6. 65.7% received Vitamin K antagonists (VKA), 18.8% aspirin (ASA), 5.4% ASA + VKA and 10% received no antithrombotic therapy (AT). All patients with AF received VKA or VKA + ASA. Twelve patients had a cerebral TE during follow-up:14.3% among untreated patients, 3.0% in the VKA group, and 0% in the ASA and in the ASA + VKA groups ( p = 0.03 for comparison no AT group versus the three other combined groups; p = NS for VKA versus ASA). In univariate analysis, only the absence of post-operative AT was related to the risk of TE (HR = 6.7, CI 95%[2.1–21], p = 0.0002). In a prespecified subgroup ( n = 185) of patients with sinus rhythm and without concomitant cardiac surgery (in which the choice of AT is not influenced by these associate conditions), only the absence of post-operative AT remained related to the risk of TE (HR = 10.0, CI 95%[2.45–40], p = 0.001). Conclusion In the first six weeks following MV repair, the incidence of thromboembolic events is far from negligible (3.5%), even in patients with sinus rhythm. The main predictive factor for thromboembolic event determined in this study is the absence of an antithrombotic therapy.

Combined endocardial and epicardial radiofrequency modified Maze procedure in the treatment of atrial fibrillation

To evaluate the effectiveness of the combined endocardial and epicardial saline-irrigated radiofrequency modified maze procedure for the treatment of atrial fibrillation (AF). During a period of 3 years, 295 patients with AF having concomitant cardiac surgery underwent the procedure. Patients underwent either the endocardial and epicardial group (n=185) or the endocardial group (n=110) radiofrequency ablation. There were 124 males, 171 females with a mean age of (52 +/- 11) year old. Mean duration of preoperative AF was 36 +/- 43 months. And about 90.8 percent valve pathology was rheumatic. Valve operation was performed in 289 patients, coronary artery bypass graft surgery in 19 patients and congenital heart disease operation in 6 patients respectively. Follow-up for the whole patients ranged from 3 to 47 months (mean 28 +/- 5 months). Ten patients died postoperatively (3.4%). Four patients died of low cardiac output, five patients died of multisystem and organ failure, one patient died of cerebral hernia. There were 2 patients died of nerves system complication during follow-up. At the end of the procedure 228 patients (77.3%) were sinus rhythm, including 78 patients (70.9%) in endocardial group while 150 patients (81.1%) in endocardial and epicardial group (P<0.05). At late follow-up, 191 of 259 patients (73.7%) were in stable sinus rhythm. Sinus rhythm was present in 64 patients (66.0%) in endocardial group while 127 patients (78.4%) in endocardial and epicardial group (P<0.05). Histopathology of the endocardial group revealed foci coagulative necrosis was limited to the endocardial side. While endocardial and epicardial ablation had full-thickness alteration of atrial tissue besides ill defined borders and inflammatory cell infiltration. Combined endocardial and epicardial saline-irrigated radiofrequency modified maze procedure was performed safely and efficiently. And it restored sinus rhythm better than endocardial ablation only.

An Overview of Energy Sources in Clinical Use for the Ablation of Atrial Fibrillation

Recent years have seen many developments in the field of alternative energy sources for arrhythmia surgery. The impetus behind these advances is to replace the traditional, "cut-and-sew" Cox maze III procedure with lesion sets that are simpler, shorter, and safer but just as effective. There is demand for technology to make continuous, linear, transmural ablations reliably with a versatile energy source via an epicardial approach. This would make minimally invasive endoscopic surgical ablation of atrial fibrillation (AF) without cardiopulmonary bypass and with a closed chest feasible. These advances would shorten cardio-pulmonary bypass and improve outcomes in patients having surgical ablation and concomitant cardiac surgery. This review summarizes the technology behind alternative energy sources used to treat AF. Alternative energy sources include hypothermic sources (cryoablation) and hyperthermic sources (radiofrequency, microwave, laser, ultrasound). For each source, the biophysical background, mode of tissue injury, factors affecting lesion size, and advantages and complications are discussed.

Ablation of Atrial Fibrillation with Concomitant Cardiac Surgery

Atrial fibrillation is present in approximately 35% of patients presenting for mitral valve surgery and in 1 to 6% of adult patients undergoing other forms of cardiac surgery. If left untreated, atrial fibrillation is associated with increased morbidity, and, in some subgroups, increased mortality. Therefore, concomitant management of the arrhythmia is indicated in most cardiac surgery patients with preexisting atrial fibrillation. Although the cut-and-sew Cox-maze III procedure is extremely effective, it has been supplanted by newer operations that rely on alternate energy sources to create lines of conduction block. Early and mid-term results are good with a variety of technologies. Choice of lesion set remains a matter of debate, but results of ablation appear to be enhanced by a biatrial lesion set. Targeted areas for improvement in concomitant ablation include acceptance of uniform standards for reporting results, development of improved technology for ablation and intraoperative assessment, and creation of instrumentation that facilitates minimally invasive approaches.

The effect of ablation technology on surgical outcomes after the Cox-maze procedure: A propensity analysis

Since its introduction in 1987, the Cox-maze procedure has been the gold standard for the surgical treatment of atrial fibrillation. At our institution, this procedure has evolved from the cut-and-sew technique (Cox-maze III procedure) to one using bipolar radiofrequency energy and cryoablation as ablative sources to replace most incisions (Cox-maze IV procedure). This study compared surgical outcomes of patients undergoing the Cox-maze III procedure versus those of patients undergoing the Cox-maze IV procedure by using propensity analysis. From April 1992 through July 2005, 242 patients underwent the Cox-maze procedure for atrial fibrillation. Of these, 154 patients had the Cox-maze III procedure, and 88 had the Cox-maze IV procedure. Logistic regression analysis was used to identify covariates among 7 baseline patient variables. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 58 patients each. Operative outcomes were analyzed for differences. Late follow-up was available for 112 (97%) patients. Freedom from atrial fibrillation recurrence and survival was calculated at 1 year by using Kaplan-Meier analysis. The Cox-maze III procedure had significantly longer crossclamp times. There was no significant difference in intensive care unit and hospital stay, 30-day mortality, permanent pacemaker placement, early atrial tachyarrhythmias, late stroke, and survival. Freedom from atrial fibrillation recurrence was greater than 90% in both groups at 1 year. The use of bipolar radiofrequency ablation has simplified the Cox-maze procedure, making it applicable to virtually all patients with atrial fibrillation undergoing concomitant cardiac surgery. The Cox-maze IV procedure produces similar surgical outcomes to the Cox-maze III procedure at 1 year of follow-up.

Surgery for Permanent Atrial Fibrillation: Impact of Patient Factors and Lesion Set

Whether a complete Cox-maze procedure is needed to ablate permanent atrial fibrillation in patients undergoing concomitant cardiac surgery is unknown. Our objective was to assess the effectiveness of different lesion sets in such patients. From November 1991 to January 2004, 575 patients underwent surgical treatment of permanent atrial fibrillation (duration > 6 months); mitral valve disease was the primary indication for surgery in 74%. Procedures included pulmonary vein isolation alone (n = 68, 12%), pulmonary vein isolation with left atrial connecting lesions (n = 265, 46%), and Cox-maze (n = 242, 42%). Rhythm documented on 5,120 postoperative electrocardiograms was used to estimate time-related prevalence of, and risk factors for, atrial fibrillation. Prevalence of postoperative atrial fibrillation peaked at 46% two weeks after operation, declining to 24% at one year. Patient-related risk factors for increased prevalence included older age (p < 0.0001), larger left atrium (p < 0.0001), and longer duration of preoperative atrial fibrillation (p = 0.0008). The Cox-maze procedure and lesion sets resembling it created with alternative energy sources had a similarly low prevalence of late postoperative atrial fibrillation; in contrast, pulmonary vein isolation and lesion sets that did not include a lesion to the mitral anulus were less effective. This study suggests that in cardiac surgical patients with permanent atrial fibrillation the left atrial lesion set should include wide pulmonary vein isolation, at least one connection between right and left pulmonary veins, and a connection to the mitral anulus. Availability of alternative energy sources to create lesions sets has virtually eliminated the need for the cut-and-sew Cox-maze procedure.

Single-stage repair of adult aortic coarctation and concomitant cardiovascular pathologies: a new alternative surgical approach

BackgroundCoarctation of the aorta in the adulthood is sometimes associated with additional cardiovascular pathologies that require intervention. Ideal approach in such patients is uncertain. Anatomic left-sided short aortic bypass from the arcus aorta to descending aorta via median sternotomy allows simultaneuos repair of both complex aortic coarctation and concomitant cardiac operation.MaterialsFour adult patients were underwent Anatomic left-sided short aortic bypass operation for complex aortic coarctation through median sternotomy using deep hypothermic circulatory arrest. Concomitant cardiac operations were Bentall procedure for annuloaortic ectasia in one patient, coronary artery bypass grafting for three vessel disease in two patient, and patch closure of ventricular septal defect in one patient.ResultsAll patients survived the operation and were alive with patent bypass at a mean follow-up of 36 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia.ConclusionWe conclude that single-stage repair of adult aortic coarctation with concomitant cardiovascular lesions can be performed safely using this newest technique.

Systemic mechanical heart valve replacement in children under 16 years of age

We report the early and late outcome following left-sided mechanical heart valve replacement in children. Between 10/1981 and 02/2001, 27 children (13 male, mean age 7.2 +/- 5.2 years, range 0.53-15.7 years) underwent mechanical mitral (MVR 16), aortic (AVR 9) or double valve replacement (DVR 2) with St. Jude Medical valves. Eighteen children (66.7%) had undergone previous cardiac surgery. Valve disease was congenital in 23, due to endocarditis in 2 and rheumatic in 2 patients. Concomitant cardiac surgery was performed in 12 patients (44.4%). Operative mortality was 3.7% (1/27). Perioperative complications were complete heart block (5) and myocardial infarction (1). Mean follow-up was 6.5+/-5.9 years (range 0.4-19 years, total 169.9 patient-years). There was one valve-related late death due to mitral valve thrombosis without phenprocoumon. Actuarial survival after 1, 5 and 10 years was 93, 93 and 93%. Late complications included endocarditis (2), minor hemorrhagic event (1) and stroke (1). Overall 10-year freedom from any anticoagulation-related adverse event under phenprocoumon was 91% (1.3%/patient year). Eight patients required reoperations: re-MVR (5; outgrowth of the prostheses (3), pannus overgrowth (2)), closure of paravalvular leak after AVR (2), and re- DVR (1; endocarditis). Actuarial freedom from reoperation after 1, 5 and 10 years was 96, 88 and 76%. Mechanical valve prostheses are a valuable option for left-sided heart valve replacement in pediatric patients with good results. Operative mortality and the incidence of any valve-related events as endocarditis, reoperation, thromboembolism or anticoagulation related bleeding is acceptable.

Surgical Management of Distal Arch Aneurysm: Another Approach With Improved Results

Surgical treatment for distal arch aneurysm carries the risk of stroke. Although left thoracotomy has been used for repair of distal arch aneurysm as a standard approach, we have performed total arch replacement under deep hypothermia with circulatory arrest through a midsternotomy for this subset of aneurysms. From January 1998 to February 2003, 119 patients underwent elective total arch replacement (mean age, 72.3 +/- 6.0 years) for distal arch aneurysm under deep hypothermia with circulatory arrest. Antegrade selective cerebral perfusion was used for brain protection. Arch vessels were independently reconstructed using quadrifurcated grafts. Concomitant procedures included tricuspid annuloplasty in 1 patient, aortic valve operations in 2, sinotubular junction plication in 6, and coronary artery grafting in 22. The early mortality rate was 0.84% (1 of 119). The mean duration of circulatory arrest was 67.1 +/- 19.7 minutes. Perioperative stroke rate was 0.84% (1 of 119). This stroke occurred 9 days postoperatively in an 81-year-old man with a history of cerebral infarction. Other complications were reexploration for bleeding in 1 patient (0.84%) and respiratory failure in 6 (5.0%). This operative approach for distal arch aneurysm featured a low mortality rate and low risk of perioperative stroke. Concomitant cardiac surgery could be performed routinely in standard fashion. Distal arch aneurysms that do not involve a large segment of the descending thoracic aorta can thus be repaired with low mortality and few cerebral complications through a midsternotomy.

The mid-term outcome of the Cox maze III procedure and complex concomitant cardiac surgery

Objective. Many surgeons do not deal with atrial fibrillation or choose modifications of the maze procedure when performing additional cardiac surgery. The Cox maze III procedure as an adjunct to other sometimes very complex cardiac surgery was examined. Design. 40 patients (27 men), 36 to 76 years, underwent a full Cox maze III operation in combination with other cardiac surgery, reflecting the case mix of a modern practice. Permanent fibrillation was presented by 82%, the others suffering from persistent or paroxysmal fibrillation. Pre-operative duration of atrial fibrillation was 0.5 to 39 years. Follow-up was 22 to 82 months. Results. The 30-day mortality was 2.5%; there was one case of intra aortic balloon-pump, two re-operations because of bleeding (5%), and one re-operation because of systolic anterior motion of the anterior mitral leaflet. Follow-up was 95% complete. Late mortality was 2.5%. Five patients (14%) required postoperative pacemakers. Freedom of atrial fibrillation was 97%. Conclusion. The addition of the Cox maze III procedure to other sometimes very complex cardiac surgery is safe and efficient in controlling atrial fibrillation.