History of cardiac surgery in Germany--in consideration of her relation to the German Cardiac Society.

As late as the end of World War II (1945), cardiac surgery did not play a clinical role worldwide. Successful cardiac operations were singular events often caused by unexpected circumstances. In contrast, the first successful suture of a cardiac stab wound by Ludwig Rehn (1896 in Frankfurt am Main) followed after experimental investigation of this topic in the laboratory. With a certain justification, this event can be mentioned as the beginning of clinical cardiac surgery. Operative procedures in patients with constrictive pericarditis followed, at that time, the ideas of Ludolf Brauer (precordial pericardiolysis) and were developed to perfection by Viktor Schmieden (subtotal pericardiectomy) during the 1920s. The first successful pulmonary embolectomy was performed in 1924 by Martin Kirschner; up to this date the sometimes used method of Friedrich Trendelenburg, already described in 1908, remained without success. The first successful operation of a ventricular aneurysm by Ferdinand Sauerbruch (1931) and the first successful closure of a patent duct (Botalli) by Emil Karl Frey (1938) occurred during operations undertaken under the circumstances of a preoperatively incorrect diagnosis. The results of the important experimental work of Ernst Jeger (monography 1913) and the first catheterization of the human heart by Werner Forssmann (1931) were not noticed by the surgical community at that time. In contrast to the time before World War II, in which German surgery was at the forefront, after the war there was a commanding need to approach the scientific and clinical level that meanwhile had been developed in the western countries, while there had been a standstill in Germany caused by its isolation since 1933 and the war since 1939. Surgeons in western Europe, the United States of America, and in Canada proved to be real friends. After one to two decades, the international clinical and scientific standard could be reached at some sites. A widespread clinical care for all patients became possible only in the late 1980s. This development was hampered even more in the eastern parts of the country. Above-average efforts there, equalized the degree of clinical care in a few years. The co-operation between the German Cardiac Society (founded 1927) and the German Society for Thoracic and Cardiovascular Surgery (founded 1971) was of great benefit for this satisfying development.

Cardiac efficiency during coronary occlusion and during reperfusion after emergency revascularization under cardioprotection.

Myocardial infarction in consequence of a coronary artery occlusion presents a serious problem. It is the aim of any emergency revascularization to minimize the ischemia-induced damage or to salvage reversibly injured myocardium. In experiments on 8 anesthetized pigs, myocardial protection by orthograde perfusion with a high-volume cardioplegic solution was studied under controlled conditions. The left anterior descending artery (LAD) was occluded for 60 min. Then cardiopulmonary bypass was instituted and cardioplegia induced by 8 min perfusion of Bretschneider HTK solution into the aortic root. After 15 min global ischemia, the LAD was "revascularized' and 150 min reperfusion followed. Except for the early relaxation (dP/dtmin) and mean thickening velocity in the ischemic myocardium, all variables remained essentially unchanged during LAD occlusion. During the entire reperfusion, heart rate was significantly increased compared to control: 93 +/- 23 vs. 126 +/- 20/min. Left-ventricular (LV) peak pressure was significantly decreased at the end of the reperfusion, 104 +/- 33 and 77 +/- 22 mmHg, as was dP/dtmax:2155 +/- 655 vs. 1720 +/- 895 mmHg/s. Cardiac output was insignificantly decreased at the end of reperfusion, 2.6 +/- 0.6 vs. 2.4 +/- 0.5 L/min, whereas stroke-work index exhibited a significant deterioration: 1.2 +/- 0.6 vs. 0.5 +/- 0.3 mmHg.ml/kg. LV dP/dtmin was significantly impaired after ischemia and at the end of reperfusion, -1575 +/- 385 vs. -855 +/- 310 mmHg/s, while LV end-diastolic pressure exhibited only a moderate increase: 8 +/- 5 vs. 9 +/- 3 mmHg. MVO2, in turn, remained almost constant throughout the protocol for each of two methods by which it was predicted. The results show that global work, MVO2, and external efficiency were unchanged during early and late occlusion compared to control. During the entire reperfusion the myocardium was stunned, i.e. cardiac work was decreased at maintained MVO2. Thus, external efficiency was decreased. From these results we conclude that in reperfused myocardium after cardioplegic arrest, the oxygen is only inefficiently converted to develop force.

[The value of CKMB and myoglobin determinations during reperfusion after regional myocardial ischemia in the anesthesized pig]. / De Wert von CKMB- und Myoglobin-Bestimmungen währen Reperfusion nach regionaler Myokardischämie am narkotisierten Schwein.

The efficacy of a revascularization treatment after acute coronary artery occlusion can be evaluated by different diagnoses. The ECG and the time-course of, for example, the CK isoenzyme MB are widely used as quick, objective, and almost noninvasive tools. In addition, the assessment of functional recovery of the postischemic myocardium or the evaluation of the magnitude of irreversibly injured myocardium is essential for therapeutic strategies. In the present study, myoglobin that is not yet routinely established, is compared with CKMB to answer the following questions: do measurements of serum-CKMB and serum-myoglobin reliably demonstrate 1) the success of a revascularization treatment? 2) the functional recovery of the postischemic myocardium? 3) the magnitude of irreversibly injured myocardium? To answer these questions, the left anterior descending coronary arteries of 17 anesthetized pigs were occluded for 60 min and reperfused for 180 min after successful "revascularization". The major findings of this study on anesthetized pigs are: 1) The time-course of both the CKMB activity and the myoglobin concentration exhibit the successful revascularization. 2) The CKMB maximum does not exhibit the recovery of the ventricular function, whereas the myoglobin maximum moderately correlated with the contractile state (dP/dtmax) at the end of reperfusion and significantly with the recovery of dP/dtmax during reperfusion. Recovery of the regional function (= mean thickening velocity) within the 180 min reperfusion is predicted neither by CKMB nor myoglobin analysis. 3) Both investigated markers correlate closely with the magnitude of the irreversibly injured myocardium.

Left aortic arch and right descending aorta--interruption or severe coarctation of the aortic arch in the newborn.

Three consecutive neonates (aged 7, 14 and 30 days, body-weight 2980 g, 3000 g and 3400 g respectively) with interruption of the aorta (n = 2) and severe coarctation (n = 1) in the presence of left aortic arch and right descending aorta are reported. Associated lesions were an aortopulmonary window in the first case and an unrestrictive ventricular septal defect in the two others. Intractable heart failure and the complexity of the malformation led to the decision of a staged operation. A prosthetic graft was interposed between the ascending and descending aorta via a right thoracotomy in order to bridge the atretic or hypoplastic segment without using extracorporeal circulation. There was no intraoperative complication. One patient developed a thrombocytopenia within the frame of a sepsis syndrome and died on day 5 after operation, death being caused by a massive bleeding into the left thoracic cavity, although the operation was carried out via a right thoracotomy. Angiography 1 year after operation revealed a good flow through the grafts and no stenosis at the site of the anastomoses. The two surviving infants are clinically well without any medication. The reported operative technique provides an alternative palliative possibility to manage critically ill neonates without any obstacle to later definitive repair.

[Principles of duplex ultrasound diagnosis of the internal thoracic artery]. / Grundlagen zur Ultraschall-Duplexsonographie der Arteria thoracica interna.

Because of its better long term patency the internal thoracic artery has become the conduit of choice for myocardial revascularization. Thirty healthy young volunteers were investigated to prove the suitability of the duplex system for investigating the internal thoracic artery. The mean systolic peak flow velocity was 1.15 m/s in the proximal vessel decreasing to 0.55 m/s in the peripheral course of the artery. Mean internal thoracic artery diameters at the origin were calculated as 2.18 mm for the left and 2.43 mm for the right internal thoracic artery. The flow curves represent those of elastic-type vessels, whereas in a small number resistance curves occurred representing the muscular type. The combination of two-dimensional B-mode and Doppler unit allows visualization of the internal thoracic artery and assessing the flow velocities within the vessel. Ultrasonic duplex scanning is a noninvasive diagnostic tool for investigation of the internal thoracic artery.

Duplex sonography of the internal thoracic artery. Preoperative assessment.

Ultrasonic duplex scanning was used to examine 211 internal thoracic arteries. The investigating vessels were classified as normal, abnormal, and occluded. The results of the duplex examination were compared with angiography as the reference method. The diameter measurements showed virtually no differences between the two methods. Normal internal thoracic arteries showed a continuous decrease of the systolic flow velocities from proximal to distal and a narrow to moderate spectral flow curve, whereas arteries classified as abnormal showed a velocity profile distinct from that--in particular, no decrease of the systolic peak velocities and an increased spectral broadening during systole with peak frequencies greater than 4 kHz at 60 degrees (> 1.2 m/sec). In occluded vessels no flow could be detected. The majority of changes were found in the proximal part of the internal thoracic artery. All lesions were detected by duplex sonography. Six normal vessels were misjudged as abnormal by the duplex method. The sensitivity, specificity, and accuracy of duplex sonography compared with angiography as the reference method were 100% (95% CI, 74.4% to 100%), 96.9% (95% CI, 93.2% to 98.8%), and 97.2% (95% CI, 93.6% to 98.8%), respectively. Duplex sonography is a reliable, noninvasive technique for the preoperative assessment of the internal thoracic artery. It allows the detection of potential atherosclerotic changes in the internal thoracic artery and the assessment of adequacy of caliber and flow.

Lower intensity anticoagulation therapy results in lower complication rates with the St. Jude Medical prosthesis.

Six hundred consecutive patients were operated on between September 1978 and October 1982 for isolated aortic (n = 298), mitral (n = 215), or multiple valve replacement (n = 87) with the St. Jude Medical bileaflet prosthesis. Mean age of the 303 female and 297 male patients was 50.7 +/- 9.6 (range 12 to 83) years. All patients were followed up prospectively; follow-up was complete and averaged 122.2 +/- 1.1 months for operative survivors. Total follow-up for aortic patients was 2904.1 patient-years, for mitral replacement 1859.5 patient-years, and for multiple valve replacement 736 patient-years. When the prothrombin times measured with different thromboplastins were converted into an international normalized ratio, four patient groups could be separated; that is, the groups comprised patients whose anticoagulation was maintained during the follow-up within an international normalized ratio corridor of 4.0 to 6.0, 3.0 to 4.5, 2.5 to 3.5, or 1.75 to 2.75. Less intensive anticoagulation in terms of the international normalized ratio values caused only a mild increase in the incidence of thromboembolic complications but a highly significant decrease in the rate of bleeding. Severe bleeding complications in the aortic valve group were highest with an international normalized ratio of 4.0 to 6.0 (1.15 per patient-year) and lowest with an international normalized ratio of 1.75 to 2.75 (0.24 per patient-year). The same held true for patients with single St. Jude Medical mitral valve replacement (2.09 per patient-year versus 0.72 per patient-year) and multiple valve replacements (4.45 per patient-year versus 1.20 per patient-year). These results suggest that the generally recommended international normalized ratio of 3.0 to 4.5 may be too high for patients with St. Jude Medical aortic valve replacement and also for patients with St. Jude Medical prostheses in the mitral position if, with respect to the thromboembolic hazard, there is not a predominating patient-related comorbidity. A large multicenter prospective randomized study is therefore proposed to establish the safe international normalized ratio levels accompanied by the lowest complication rates for both bleeding and thromboembolic events after St. Jude Medical prosthesis implantation (German experience with low intensity anticoagulation study).

Internal thoracic artery: prevalence of atherosclerotic changes.

Use of the internal thoracic artery for myocardial revascularization has regained general acceptance because it offers better long-term results than do venous conduits. The aim of this study was to ascertain the prevalence of atherosclerosis in the internal thoracic artery and to correlate the prevalence with other known risk factors. A total of 117 patients (male/female ratio 84:33; mean age 56.8 years) were investigated. Sixty-eight patients had coronary artery disease, 25 had combined coronary artery and valvular heart disease, 14 had acquired valvular heart disease, and 10 had other types of heart disease. All but one patient underwent bilateral semiselective internal thoracic arteriography. Evidence of atherosclerotic change was present in 6.6% of the opacified vessels in 11.1% of the investigated individuals. Although all patients with atherosclerotic lesions in the internal thoracic artery had coronary artery disease, no correlation could be found between coronary artery disease and internal thoracic atherosclerosis. Peripheral vascular disease and hyperlipidemia could be identified as predictors of atherosclerotic changes in the internal thoracic artery. Atherosclerosis is somewhat more prevalent in the internal thoracic artery in this study than in the literature. Although the internal thoracic artery is a protected vessel, there is a certain extent of atherosclerosis, that correlates with known risk factors. Our observations should not preclude use of the internal thoracic artery, but they should be considered for patients who are at risk for atherosclerotic changes of the internal thoracic artery.

Prognosis of patients with hypertrophic obstructive cardiomyopathy after transaortic myectomy. Late results up to twenty-five years.

A complete clinical study was performed for 364 patients with hypertrophic obstructive cardiomyopathy who were operated on in the years 1963 to 1991 (217 male, 146 female, mean age 40 years, range 5 months to 76 years). Transaortic subvalvular myectomy was performed in 272 patients (hospital mortality 2.9%), and 92 patients needed additional cardiac procedures simultaneously (hospital mortality 10.9%). A complete follow-up study (100%) included 346 patients who survived the operation. The shortest follow-up time was 2 months and the longest 25.2 years (mean 8.2 years). Most of the patients improved clinically by one to three classes (New York Heart Association). During the observation period 38 patients (10.4%) died. The death of 17 patients was closely related to the original disease (4.9%). Other causes, unrelated to hypertrophic obstructive cardiomyopathy, were responsible for the death of 21 patients (5.8%). In consideration of these data, the yearly total death rate was 2.2%; in close relation to hypertrophic obstructive cardiomyopathy it was about 0.6%. The cumulative survivals were 88% after 10 years and 72% after 20 years. In our long-term clinical experience it is increasingly evident, despite the restrictions of a retrospective study, that patients with symptomatic hypertrophic obstructive cardiomyopathy and failing medical therapy benefit from transthoracic subvalvular myectomy.

[Clinical long-term results after corrective surgery of tetralogy of Fallot]. / Klinische Langzeitergebnisse nach Korrekturoperation einer Fallotschen Tetralogie.

We studied 246 consecutive patients, mean age 11.9 +/- 6.7 years, with primary (n = 155) or secondary (n = 91) complete repair of tetralogy of Fallot (TOF) between 1961 and 1972. Prospective follow-up was complete and ranged from 18.1 to 29.3 (mean: 20.3 +/- 4.2) years. There were 46 operative and 21 late deaths. Cumulative survival was 0.76 +/- 0.03 after 1 year, 0.72 +/- 0.03 (10 years), 0.68 +/- 0.04 (20 years) and 0.63 +/- 0.05 (25 years). After 20 years of follow-up, which was a follow-up time available for all patients, cumulative complication rates were 0.17 +/- 0.03 for documented ventricular tachycardias/fibrillation, 0.16 +/- 0.03 for right-heart failure, 0.13 +/- 0.03 for left-heart failure and 0.11 +/- 0.03 for infective endocarditis. Eighteen of the 21 late deaths were from cardiac causes: sudden (n = 9), infective endocarditis (n = 4), left-heart failure (n = 3), and right-heart failure (n = 2). The hazard for ventricular arrhythmias was inconstant and increasing with time from the initial operation. After 20 years of follow-up, the cumulative incidence of sudden death, documented ventricular tachycardia/fibrillation was 0.81 +/- 0.07. Younger age at surgery resulted in a significantly better long-term prognosis (p = 0.03) with cumulative survival rates after 20 years being 0.90 +/- 0.06 (ages 1-9 years), 0.92 +/- 0.04 (10 to 14 years), 0.83 +/- 0.09 (15 to 19 years) and 0.69 +/- 0.11 for patients being operated beyond age 20. Twenty years following TOF repair 59.2% of the late survivors were in NYHA functional class I and 36.2% in NYHA II.

Unexpected findings concerning thromboembolic complications and anticoagulation after complete 10 year follow up of patients with St. Jude Medical prostheses.

Five hundred and four St. Jude Medical valves (SJM) were implanted in 435 patients between September 1978 and March 1982. There were 234 females and 201 males with a mean age of 52.8 +/- 10.1 years (range 12-83 years), who underwent 204 aortic, 163 mitral, 67 mitral plus aortic and one triple valve replacements. All patients were followed prospectively. Follow up was 100% complete and averaged 122.2 +/- 1.1 months for operative survivors. The total follow up for aortic patients was 1968.5, for mitral patients 1520.4, and for double valve replacement 573.9 pty. For the entire patient population the total follow up was 4080.8 pty. Early mortality was 2% after aortic, 4.3% after mitral and 5.9% after mitral plus aortic valve replacement. There were 68 late deaths representing a linearized incidence of 1.37%/pty in the aortic, 1.71%/pty in the mitral and 2.61%/pty in the double valve replacement groups. The corresponding cumulative survival after ten years at risk was 85% in the aortic, 78% in the mitral and 72% in the double valve replacement groups. The ten year event-free survival was 64% in the aortic, 57% in the mitral and 47% in the double valve replacement groups. The linearized incidence for thromboembolic events was 3.71%/pty taking all events into account, and 2.67%/pty taking only the first or most severe of several events into account for aortic, 5.1%/pty and 4.08%/pty for mitral, and 6.62%/pty and 5.40%/pty for double replacements, respectively. There were two cases of valve thrombosis, both with proven inadequate anticoagulation. When the prothrombin times measured with the different thromboplastize used in this patient group were converted to INR, the so far homogeneous values could be separated into three groups: INR = 3.0 to 4.5, 2.5 to 3.2 and 1.8 to 2.7. Low INR values caused only a marginal increase in the rate of embolism but a highly significant decrease in the rate of bleeding. These results suggest that the generally recommended INR of 3.0 to 4.5 is too high for the SJM. A large, multicenter, prospective randomized study is therefore proposed to establish the safe INR levels with low intensity anticoagulation after SJM implantation.

The effect of chordal preservation on late outcome after mitral valve replacement: a randomized study.

Postoperative survival, hemodynamic status and exercise tolerance with or without posterior chordal preservation were compared in a case-limited prospective randomized manner in 100 patients who underwent isolated mitral valve replacement with size 29mm or 31mm St. Jude Medical prostheses. The preoperative clinical and hemodynamic parameters were comparable in the two groups. The mean follow up was 293.3 months for those with and 263.1 months for patients without chordal preservation. Right heart cardiac catheterization was performed in every patients at the end of the follow up period and it demonstrated significantly better results with than without chordal preservation (cardiac index 2.81 +/- 0.47 vs. 2.63 +/- 0.52, p < 0.05; pulmonary arterial pressure 30 +/- 11 mmHg vs. 37 +/- 13 mmHg at 30 Watts bicycle exercise, p < 0.01; end-diastolic volume index 75 +/- 22 vs. 86 +/- 38 ml/m2, p < 0.02; and maximum exercise tolerance 1.8 +/- 0.3 vs. 1.2 +/- 0.5 Watt/kg, p < 0.01). Actuarial freedom from complications was 78.1 +/- 4.2% with and 70.7 +/- 6.2% without chordal preservation (p < 0.02). In particular, patients with severe mitral regurgitation benefited from the preservation of the posterior mitral leaflet with its chordal and papillary structure (p < 0.001).

Defibrillation energy requirements with single endocardial (Endotak) lead.

The need for thoracotomy in usually high risk patients has limited the use of the implantable cardioverter defibrillator. Initial clinical results with endocardial and subcutaneous patch electrodes (SQPs) are encouraging. Using a single endocardial lead in the absence of a SQP for chronic implantation of the cardioverter defibrillator, the goal of the study was to obtain defibrillation thresholds (DFTs) of 15 Joules (J) or less and to investigate changes in DFT over time. We tested 19 consecutive patients (15 men, 4 women) age 62 +/- 8.5 years with malignant ventricular arrhythmias (14 VT/5 VF). The underlying heart disease was coronary artery disease in 15 patients, dilative cardiomyopathy in two patients, and primary electrical disease in two patients. Four patients had undergone previous cardiac surgery. Left ventricular ejection fraction ranged between 14% and 66% (39% +/- 12.6%). Pacing thresholds (0.54 +/- 0.17 V at 0.5 msec), R wave amplitude for pacemaker sensing (14.2 +/- 7.0 mV), slew rate (2.12 +/- 1.4 V/sec), and resistance (500.3 +/- 73.9 W) were sufficient in all patients. Eighteen patients met our endocardial implant criteria with a DFT < or = 15 J (10.05 +/- 4.03 J) using monophasic (14 patients) or biphasic (four patients) pulse wave forms. In the one remaining patient, with a DFT of 20 J, we implanted a SQP but there was no reduction of the DFT. All patients tested showed successful defibrillation prior to discharge. During follow-up of 88 patient-months (1-9 months), 114 spontaneous VT/VF episodes occurred in five patients and were all successfully terminated. Eleven patients with a minimum follow-up of 2 months were reassessed.(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of the site and severity of obstruction in hypertrophic cardiomyopathy by color flow mapping and continuous wave Doppler echocardiography.

OBJECTIVE: We investigated whether the site and severity of an obstruction in hypertrophic cardiomyopathy can be accurately predicted by the combined use of color-coded and continuous wave Doppler echocardiography. BACKGROUND: Predicting the site of obstruction by end-systolic cavity shape is not reliable. Therefore, hemodynamic localization of the obstruction is required before surgery is performed. Such localization should be possible with color flow imaging, which provides two-dimensional velocity mapping reflecting the distribution of pressures within the left ventricle. Discrepancies in assessment of the pressure gradient by Doppler echocardiography and cardiac catheterization (which are usually not performed simultaneously) may be due to spontaneous variation of the dynamic obstruction in addition to technical factors related to both methods. METHODS: Twenty consecutive patients with hypertrophic cardiomyopathy were examined 1 day before transseptal left heart catheterization. The obstruction site was defined by color flow mapping. The pressure gradient was determined by continuous wave Doppler echocardiography. Measurements were also performed simultaneously in 10 patients during cardiac catheterization. RESULTS: Midventricular obstruction was correctly identified in 4 patients and subvalvular obstruction in 15 patients. One patient had no obstruction at rest. Invasively and noninvasively determined pressure gradients correlated well (r = 0.89, SEE = 16.3 mm Hg). Multiple single-beat analysis in 10 patients, also simultaneously examined with Doppler echocardiography and catheterization, yielded an excellent correlation (r = 0.97, SEE = 13.1 mm Hg). Comparing the simultaneous (r = 0.96, SEE = 12.5 mm Hg) and nonsimultaneous (r = 0.81, SEE = 23.8 mm Hg) recordings in these patients, we found that the spontaneous variation of the dynamic obstruction mainly accounted for discrepancies (p less than 0.05). CONCLUSION: The combined use of color-coded and continuous wave Doppler echocardiography provides the relevant hemodynamic information required for decision-making in patients with hypertrophic cardiomyopathy who are considered for transaortic myectomy.

Results of randomized mitral valve replacement with mechanical prostheses after 15 years.

Between 1974 and 1976 150 consecutive patients (pts) were operated on for isolated mitral valve replacement (MVR). Björk-Shiley (BS), Lillehei-Kaste (LK), and Starr-Edwards (SE) (type 6210) prostheses were implanted at random. All survivors were prospectively followed by regular clinical examinations every 6 to 12 months for 15 years. The mean follow-up time was 14.8 years. A constant subjective improvement after 15 years was reported in 62% of pts with BS, 30% with LK, and 49% with SE. The cumulative 14-year survival rate was 0.62 +/- 0.13 (BS), 0.56 +/- 0.16 (SE), and 0.54 +/- 0.15 (LK), respectively. Late mortality was due to thromboembolic events (n = 3), bleeding complications (n = 3), congestive heart failure (n = 7), documented arrhythmias or sudden death (n = 6). Thrombotic valve thrombosis (1 BS, 1 LK, 2 SE) required reoperations. Linearized cumulative rates after 14 years for thromboembolic complications were 14.2 +/- 3.1 (BS), 15.8 +/- 3.7 (SE), 24.3 +/- 4.2 (LK). The cumulative risk of severe bleeding complications was not different: BS: 35.8, LK: 35.2, SE: 34.3. During the first years of observation no significant differences between these mechanical prostheses could be observed, however, after 14 years of long-term follow-up the cumulative event-free rates were more favorable for the BS prosthesis.

[Hypertrophic obstructive cardiomyopathy: surgical therapy]. / Hypertrophische obstruktive Kardiomyopathie: chirurgische Therapie.

Surgical treatment of hypertrophic obstructive cardiomyopathy (HOCM), which may present in a typical (subaortic) or atypical (mid-ventricular) form, is indicated only after prior long-term drug treatment. The results obtained in 353 patients presenting with a symptomatic form of HOCM operated on between 1963 and 30 June 1991 are reported. The operative procedure took the form of transaortic subvalvular myectomy (TSM) as described by Morrow, modified by extending the myectomy. The patients comprised 210 males and 143 females aged between 6 and 76 years (average age 41.7 years). With few exceptions, all patients were in clinical stage III or IV (NYHA). The overall hospital mortality rate was 4.8% (n = 17); for TSM alone 3.1% (n = 8 out of 261 patients), for combination surgery with additional surgical measures 9.8% (n = 9 out of 92 patients). Among the last 194 patients (since 1984), the mortality rate was 2.06% (n = 4). To date, follow-up show an improvement in the symptoms and physical performance, and an annual mortality rate of about 1.8-4% among patients treated with drugs, and a post-operative mortality of about 1.1%, so that in HOCM patients with symptoms despite prior drug treatment, surgery can be recommended.