Percutaneous transcatheter closure of an aorto-cardiac fistula in a six-year-old Warmblood mare with atrial fibrillation.

This report describes a rare case of an aorto-cardiac fistula in a six-year-old French Warmblood mare presented with atrial fibrillation, decreased performance, ventral oedema, bounding arterial pulsation and pathological jugular venous pulse. A 2.7-cm-diameter fistula connected the right aortic sinus of Valsalva to the right atrium. Atrial fibrillation was likely due to volume overload of the right heart due to left-to-right shunting. The horse was treated by percutaneous transcatheter closure of the fistula delivered under general anaesthesia using a transarterial approach. The operation was initially successful, and clinical signs of congestive heart failure improved immediately. However, the device dislodged six days after procedure, and the general condition of the horse deteriorated quickly. A second closure attempt to deliver the occluder using a transvenous approach in the standing horse failed, and the horse was eventually euthanized. Procedural aspects and several possible risk factors for device dislodgement are discussed.

Active or passive bio-coating: does it matters in extracorporeal circulation?

BACKGROUND: Two types of surface coating for cardiopulmonary bypass (CPB) are used: bioactive (heparin, nitric oxide) and biopassive (albumin, polyethyleneoxide (PEO), phosphorylcholine). When haemocompatible coatings are combined with the separation of pleuro-pericardial aspiration, attenuation of both the coagulation and complement cascades, as well as better platelet preservation, has been demonstrated. This study wants to investigate if the combination of a bioactive with a biopassive coating (unfractionated heparin embedded in a phosphorylcholine matrix) combines the beneficial effects of both approaches. MATERIALS AND METHODS: Thirty patients undergoing elective CABG were prospectively randomized into two groups of 15 patients. The sole exclusion criterion was an ejection fraction of less than 40%. In the control group (PC), the whole CPB circuit was coated with phosphorylcholine (PC). In the study group (XPC), unfractionated heparin was embedded in the PC matrix of the oxygenator and arterial line filter. RESULTS: No differences were found for haemolytic index, thrombin-anti-thrombin complex (TAT), IL-6, IL-10 and blood loss. PF4 plasma concentration increased from 27.6±22.0 IU/mL to 165.7±43.9 IU/mL (p<0.001) at 15 minutes of CPB in the PC and from 16.0±9.7 IU/mL to 150.9 ± 61.3 IU/mL (p<0.001) in the XPC group. Terminal complement complex (TCC) increased over time in both groups until the end of CPB (Figure 2A). Within each group, TCC generation was statistically significantly higher after the release of the aortic cross-clamp (p<0.001) and at the end of CPB (p<0.001). Total TCC generation was statistically significantly higher in the XPC group compared to the PC group (p=0.026). The difference was statistically significant after the release of the aortic cross-clamp (p=0.005) and at the end of CPB (p=0.001). CONCLUSIONS: Based on our results, there is no additional benefit in combining phosphorylcholine with unfractionated heparin in elective patients undergoing coronary artery bypass grafting (CABG). Massive haemodilution leads to enhanced complement activation.

A large-scale multicentre study of patient skin doses in interventional cardiology: dose-area product action levels and dose reference levels.

For 318 patients in 8 different Belgian hospitals, the entire skin-dose distribution was mapped using a grid of 70 thermoluminescence dosimeters per patient, allowing an accurate determination of the maximum skin dose (MSD). Dose-area product (DAP) values, exposure parameters and geometry, together with procedure, patient and cardiologist characteristics, were also registered. Procedures were divided into two groups: diagnostic procedures (coronary angiography) and therapeutic procedures (dilatation, stent, combined procedures (e.g. coronary angiography + dilatation + stent)). The mean value of the MSD was 0.310 Gy for diagnostic and 0.699 Gy for therapeutic procedures. The most critical projection for receiving the MSD is the LAO90 (left anterior oblique) geometry. In 3% of cases, the MSD exceeded the 2 Gy dose threshold for deterministic effects. Action levels in terms of DAP values as the basis for a strategy for follow-up of patients for deterministic radiation skin effects were derived from measured MSD and cumulative DAP values. Two DAP action levels are proposed. A first DAP action level of 125 Gy cm(2) corresponding to the dose threshold of 2 Gy would imply an optional radiopathological follow-up depending on the cardiologist's decision. A second DAP action level of 250 Gy cm(2) corresponding to the 3 Gy skin dose would imply a systematic follow-up. Dose reference levels - 71.3 Gy cm(2) for diagnostic and 106.0 Gy cm(2) for therapeutic procedures - were derived from the 75 percentile of the DAP distributions. As a conclusion, we propose that total DAP is registered in patient's record file, as it can serve to improve the follow-up of patients for radiation-induced skin injuries.

Three-dimensional rotational angiography of a patient with pulmonary atresia intact septum and coronary fistulas.

Three-dimensional rotational angiography (3D-RA) was used to image the coronary arteries of a 2(1/2)-year-old boy with pulmonary atresia intact septum and coronary fistulas. As seen in the accompanying video clips and stills, this imaging method is advantageous in depicting the coronary anatomy. Furthermore, less contrast is used for patients undergoing diagnostic coronary angiography with 3D-RA compared with biplane angiography.

An experimental model of coronary anastomosis without suturing.

OBJECTIVE: The aim of the study is to explore the feasibility and mid-term patency of an easier anastomotic technique for Minimally Invasive Direct Coronary Bypass Grafting (MIDCAB). METHODS: Eight mongrel dogs (+/-15 kg) underwent direct anastomosis between the left internal thoracic artery (LITA) and the left anterior descending coronary artery (LAD) via inferior sternotomy on the beating heart. After positioning the graft, the distal part of the LAD was opened to allow retrograde filling of the LITA-graft. The anastomosis was secured by the use of biological glue (BioGlue, Cryolife, Marietta, GA, USA). No intravascular suture material was used. Ischemic time averaged 6 min. The proximal LAD was occluded upstream the arteriotomy. All survivors were angiographically controlled for patency after 6-8 weeks. Consequently, four dogs were sacrificed after 6 weeks and the remaining after 3 months for anatomo-pathological and histological examination by light and electron microscopy of the anastomotic site. RESULTS: All procedures were successful except for one animal that died of uncontrollable bleeding at the anastomotic site. Another sustained post-operative transmural anterior myocardial infarction due to a late graft occlusion. All angiographically controlled grafts were patent with two vascular strings near the anastomotic site. Histology showed early macrophage infiltration into the glue. At post-mortem examination, new endothelialization was noticed in 80% of the cases. However, ultrastructural examination detected marked differences in endothelial fibroblastic lining compared to normal histology. CONCLUSIONS: Good mid-term permeability of the LITA grafts was observed in this new anastomotic technique for MIDCAB in the canine model. Although neo-endothelialization was present in most cases, ultrastructural differences were noticed after 3 months in the neo-intima compared to normal.

Tissue factor as the main activator of the coagulation system during cardiopulmonary bypass.

OBJECTIVE: This study investigates the influence of foreign material and blood aspirated from nonvascular structures on activation of coagulation, hemolysis, and blood loss. METHODS: The series comprises 3 randomized groups (groups C, S, and S+P) of 10 patients undergoing routine coronary artery bypass grafting with cardiopulmonary bypass. In group C, the control group, all aspirated blood was returned into the circulation. In group S suction blood was discarded, whereas group S+P was identical to group S, with surfaces coated with phosphorylcholine. Plasma concentrations of beta-thromboglobulin, thrombin generation, haptoglobin, and free hemoglobin, as well as blood loss, were measured. RESULTS: A steady increase in free plasma hemoglobin, as well as an increased generation of thrombin, was noticed in group C. Moreover, a close correlation (r = 0.916) between the generation of thrombin and its inhibition (thrombin-antithrombin complexes) was observed. Platelets were clearly activated in group C and, to a lesser extent, in group S. In contrast, platelet activation in group S+P was negligible, resulting in a 30% decrease in blood loss (P =.05). CONCLUSIONS: Aspirated blood contaminated by tissue contact is the most important activator of the coagulation system and the principal cause of hemolysis during cardiopulmonary bypass. Contact with a foreign surface is not a main variable in the procoagulant effect of bypass. Mimicking the outer cell membrane structure resulted in decreased platelet activation and decreased blood loss.

Phosphorylcholine coating offers natural platelet preservation during cardiopulmonary bypass.

Return of blood activated by tissue factor is the main culprit for triggering the coagulation cascade. When this activated blood is diverted from the cardiopulmonary bypass (CPB) circuit, it becomes possible to evaluate the effect of surface treatment on platelet and complement activation. Twenty adult patients undergoing elective coronary artery bypass grafting (CABG) were randomly assigned either to a control group (n=10) or to a group in which the CPB circuit was completely coated with phosphorylcholine (n=10). Plasma concentrations of platelet factor 4 (PF4), beta-thromboglobulin (betaTG), C3, C3d, C4, TCC, thrombin generation, haptoglobin and free haemoglobin, as well as blood loss, were measured. No significant differences between the two groups were found for haemolysis and thrombin generation. The mean total release of PF4 and betaTG during CPB was 9338+/-17303 IU/ml/CPB and 3790+/-4104 IU/ml/CPB in the coated group versus 22192+/-13931 IU/ml/CPB (p=0.011) and 8040+/-3986 IU/ml/CPB (p=0.005) in the control group. Blood loss was 30% less in the coated group compared to the control group. Phosphorylcholine coating appears to have a favourable effect on blood platelets, which is most obvious after studying the changes during CPB. Clinically, this effect resulted in a 30% reduction in blood loss.

Preinfarction angina protects against out-of-hospital ventricular fibrillation in patients with acute occlusion of the left coronary artery.

OBJECTIVES: The goal of this study was to evaluate the effect of preconditioning on out-of-hospital ventricular fibrillation (VF) in patients with acute myocardial infarction (AMI). BACKGROUND: More than half of the deaths associated with AMI occur out of the hospital and within 1 h of symptom onset. In humans, preinfarction angina (PA), which can serve as a surrogate marker for preconditioning, reduces infarct size, but the protective effect against out-of-hospital VF has not been investigated. METHODS: Preinfarction angina status and acute coronary angiographic findings of 72 consecutive patients with AMI complicated by out-of-hospital VF were compared with 144 matched controls without this complication. RESULTS: Preinfarction angina is associated with a lower risk for VF (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.18 to 0.88). In patients with acute occlusion of the left coronary artery (LCA) (n = 136), the risk reduction is pronounced (OR: 0.25, 95% CI: 0.10 to 0.66), whereas, in patients with acute occlusion of the right coronary artery (RCA) (n = 67), the protective effect of PA on VF was not observed (OR: 2.25, 95% CI: 0.45 to 11.22). Subgroup and multivariate analyses show that the protective effect is independent of cardiovascular risk factors, preinfarction treatment with beta-adrenergic blocking agents or aspirin, the presence of collaterals or residual antegrade flow or the extent of coronary artery disease. CONCLUSIONS: Preinfarction angina protects against out-of-hospital VF in patients with acute occlusion of the LCA. This protection is independent of risk factors or coronary anatomy. A larger study is needed to examine the apparently different effect in patients with acute occlusion of the RCA.

Fibrinogen and C-reactive protein on admission as markers of final infarct size after primary angioplasty for acute myocardial infarction.

BACKGROUND: In acute myocardial infarction (AMI) treated conservatively or with thrombolysis, marked increases of C-reactive protein (CRP) and fibrinogen have been observed. No data are however available concerning a possible relation between CRP and fibrinogen levels on admission and markers of infarct size after obtaining thrombolysis in myocardial infarction (TIMI) flow III by primary angioplasty. METHODS: We studied 34 patients with a first AMI (29 men, mean age 54+/-11 years) who were treated with primary angioplasty (TIMI flow III in all patients, no concomitant treatment with glycoprotein IIb-IIIa antagonists) within 6 h of onset of pain. CRP and fibrinogen levels on admission were determined and related to the following markers of infarct size: peak creatine kinase MB (CKMB) levels, radionuclide left ventricular ejection fraction (LVEF) at discharge and thallium-201 single-photon emission computed tomography (SPECT) infarct size at 1 month. RESULTS: Median CRP levels were 0.4 mg/dl (range 0.09-3 mg/dl), median fibrinogen levels 412 mg/dl (range 198-679 mg/dl), mean CKMB was 178+/-151 U/l, mean LVEF 52+/-8% and mean thallium-201 infarct size 7+/-6%. Although CRP levels were related to fibrinogen levels on admission (r=0.56, P=0.002), only fibrinogen levels were related to markers of infarct size (r=0.58, P=0.001 for CKMB, r=-0.44, P=0.01 for LVEF and r=0.64, P=0.001 for thallium-201 infarct size). No relation was found between CRP or fibrinogen levels on admission and the extent of coronary artery disease or the myocardial area at risk. In multiple regression analysis, the relation between fibrinogen and markers of infarct size was independent of CRP levels and the duration of pain on admission. CONCLUSIONS: These findings indicate a relation between fibrinogen levels on admission and myocardial infarct size in patients treated with primary angioplasty for AMI. This relation seems to be independent of CRP levels and the duration of pain on admission. If confirmed in larger patient populations, fibrinogen levels on admission could have an important value for risk stratification and more aggressive reduction of infarct size in patients who are treated with primary angioplasty.

Dosimetry of 192Ir sources used for endovascular brachytherapy.

An in-phantom calibration technique for 192Ir sources used for endovascular brachytherapy is presented. Three different source lengths were investigated. The calibration was performed in a solid phantom using a Farmer-type ionization chamber at source to detector distances ranging from 1 cm to 5 cm. The dosimetry protocol for medium-energy x-rays extended with a volume-averaging correction factor was used to convert the chamber reading to dose to water. The air kerma strength of the sources was determined as well. EGS4 Monte Carlo calculations were performed to determine the depth dose distribution at distances ranging from 0.6 mm to 10 cm from the source centre. In this way we were able to convert the absolute dose rate at 1 cm distance to the reference point chosen at 2 mm distance. The Monte Carlo results were confirmed by radiochromic film measurements, performed with a double-exposure technique. The dwell times to deliver a dose of 14 Gy at the reference point were determined and compared with results given by the source supplier (CORDIS). They determined the dwell times from a Sievert integration technique based on the source activity. The results from both methods agreed to within 2% for the 12 sources that were evaluated. A Visual Basic routine that superimposes dose distributions, based on the Monte Carlo calculations and the in-phantom calibration, onto intravascular ultrasound images is presented. This routine can be used as an online treatment planning program.

Total occlusion trial with angioplasty by using laser guidewire. The TOTAL trial.

AIMS: A randomized trial was performed to assess the safety and efficacy of a laser guidewire, in the treatment of chronic coronary occlusions. METHODS AND RESULTS: In 18 European centres, 303 patients with a chronic coronary occlusion were randomized to treatment with either the laser guidewire (n=144) or conventional guidewires (mechanical guidewire, n=159). The primary end-point of the study was treatment success, defined as reaching the true lumen distal to the occlusion by the allocated wire within 30 min of fluoroscopic time: laser guidewire vs mechanical guidewire; 52.8% (n=76) vs 47.2% (n=75), P=0.33. Serious adverse events following the initial guidewire attempt were 0% (laser guidewire) and 0.6% (mechanical guidewire), respectively. Angioplasty (performed following successful guidewire crossing) was successful in 179 patients (91%, laser guidewire n=79, mechanical guidewire n=100), followed by stent implantation in 149 (79%). At the 6-month angiographic follow-up, the difference in binary restenosis rate (laser guidewire vs mechanical guidewire; 45.5% vs 38.3 %, P=0.72) or reocclusion rate (25.8% vs 16.1%, P=0.15) did not reach statistical significance. At 1, 6 and 12 months, angina and event-free survival were 69%, 35% and 24% (laser guidewire) vs 74%, 40% and 31% (mechanical guidewire). CONCLUSION: Although laser guidewire technology was safe, the increase in crossing success did not reach statistical significance.

Cardiac involvement in pheochromocytoma.

We report the details of a 40-year-old farmer, a cigarette smoker, who was admitted with general malaise, nausea, vomiting, upper abdominal pain, with ST-elevation on ECG suggestive of an acute anterolateral myocardial infarction. He was treated with nitrates, heparin, beta-blockade and angiotensin-converting enzyme (ACE) inhibitors. Because of the presence of some blood while vomiting no thrombolysis was given and abdominal echography was performed. This revealed a nodular mass at the right adrenal gland. Urinary catecholamines and abdominal magnetic resonance imaging confirmed the suspected diagnosis of pheochromocytoma. Before adrenectomy, a coronary angiography under alpha blocker therapy was performed, which demonstrated no significant coronary artery disease, although the patient showed ST-elevations on ECG. Pathological examination of the adrenal tumor was compatible with a diagnosis of pheochromocytoma. Postoperatively urinary catecholamines dropped dramatically, and the ECG normalised slowly over time. After 8 months the patient is still well. Blood pressure is well controlled with no antihypertensive drugs and exercise testing shows no evidence of myocardial ischaemia.

Correlation of patient skin doses in cardiac interventional radiology with dose-area product.

The use of X-rays in cardiac interventional radiology has the potential to induce deterministic radiation effects on the patient's skin. Guidelines published by official organizations encourage the recording of information to evaluate this risk, and the use of reference values in terms of the dose-area product (DAP). Skin dose measurements were made with thermoluminescent dosemeters placed at eight different locations on the body. In addition, DAP was recorded in 100 patients for four types of interventional radiology procedures. Mean, median and third quartile for these results are presented. Maximum skin dose values found were 412 mGy, 725 mGy, 760 mGy and 1800 mGy for coronary catheterization, coronary catheterization with left ventricle investigation, and percutaneous transluminal angiography without and with stenting, respectively. Median DAPs for these same procedures were, respectively, 5682 cGy cm2, 10,632 cGy cm2, 10,880 cGy cm2 and 13,161 cGy cm2. The relationship between DAP and skin dose was investigated. We found a poor correlation of DAP with maximum skin dose (r = 0.77) and skin dose indicator (r = 0.78). Using conversion factors derived from Monte Carlo simulations, skin dose distributions were calculated based on the measured DAPs. Agreement between the calculated skin dose distribution, using DAP values averaged over a group of patients who underwent coronary catheterization and left ventricle investigation, and the measured skin dose averaged over the same group of patients was very good. However, there were large differences between the calculated skin doses using the individual DAP data per patient and measured skin doses for individual patients (r = 0.66). Hence, calculation of individual skin doses based on the specific DAP data per patient is not reliable and therefore measuring skin dose is preferable.

Out-of-hospital ventricular fibrillation in patients with acute myocardial infarction: coronary angiographic determinants.

OBJECTIVES: The study intended to compare the acute coronary anatomy of patients with acute myocardial infarction (AMI) complicated by out-of-hospital ventricular fibrillation (VF) versus patients with AMI without this complication. BACKGROUND: More than half of the deaths associated with AMI occur out of the hospital and within 1 h of symptom onset. The angiographic determinants of out-of-hospital VF in patients with AMI have not been investigated in detail. METHODS: Acute coronary angiographic findings of 72 consecutive patients with AMI complicated by out-of-hospital VF were compared with findings from 144 matched patients with AMI without this complication. RESULTS: Patients with an acute occlusion of the left anterior descending coronary artery (LAD) or left circumflex coronary artery (LCx) had a higher risk for out-of-hospital VF compared with patients with an acute occlusion of the right coronary artery (RCA) (odds ratio and 95% confidence interval, respectively, 4.82 [2.35 to 9.92] and 4.92 [2.34 to 10.39]). With regard to extent of coronary artery disease (CAD), the location of the culprit lesion in the coronary arteries (proximal vs. mid or distal), the flow in the infarct related artery (IRA), the presence or absence of collaterals to the IRA and chronic occlusions, there were no differences between the two groups. CONCLUSIONS: Acute myocardial infarction due to occlusion in the left coronary artery (LCA) is associated with greater risk for out-of-hospital VF compared to the RCA. The location of occlusion within LCA (LAD, LCx, proximal or distal), amount of myocardium at risk for necrosis and extent of CAD are not related to out-of-hospital VF.

An organotypical in vitro model for vascular tissue remodelling and its application to study radiation effects.

An organotypic in vitro model, to study vascular tissueremodeling, was evaluated as a function of culture period. Inorder to validate the model as a tool for studying vascularresponses to damage, a dose-response analysis to ionizingirradiation was included.Rat aortic rings were explanted in vitro after being irradiatedwith single doses of (60)Co gamma-rays, namely 0, 5, 10, 15, 20or 25 Gy. Irradiated and sham-irradiated aortic rings werecultured for 3 weeks. Explant outgrowth on an adhesivesubstrate was evaluated by macroscopical scoring, and ringsderived from each irradiation group together with theoutgrowths were fixed and embedded in paraffin after 2, 7, 14and 21 days. Bromodeoxyuridine incorporation, alpha smoothmuscle actin and collagen types I and III were scored onimmunohistochemically stained sections. For each studiedparameter, irradiated and sham-irradiated rings were compared.In cultures of sham-irradiated rings, alterations from acontractile towards a synthetic/migratory smooth muscle cellphenotype were confirmed. After 3 weeks, fullgrown cultures hadformed. Irradiation slowed down the phenotypical modifications.After 15 Gy, irradiation explant outgrowth was already retarded;after 25 Gy, the outgrowth was completely blocked. On the otherhand, a dose of 15 Gy or more induced an increased collagen Iproduction in the tunica media.In conclusion, the present organotypical in vitro model fits toanalyse dynamics in the original vascular tissues as well as inthe primary outgrowth. It enables to confirm features oftissular reorganization and effects of ionizing radiationdescribed in vivo.

Monte Carlo calculations of dose distributions around 32P and 198Au stents for intravascular brachytherapy.

3D dose distributions are calculated for a 32P impregnated stent and a 198Au stent for intravascular brachytherapy with the EGS4 Monte Carlo simulation code. The stents were modeled as a combination of eight helicoidal struts. This allowed investigation of the effect of the stent geometry and the electron absorption in the strut material on the dose distributions. Absorbed dose to water was calculated at radial distances ranging from 50 microm to 5 mm from the stent surface. The dose distributions around the stents are compared to the dose distribution around an intravascular brachy-therapy 192Ir source, also calculated with the EGS4 Monte Carlo code. The dose profiles near the struts show hot spots. At 50 microm distance a peak to valley ratio of 3 for 32P and 6 for 198Au in the dose distribution is obtained. For both the isotopes the inhomogeneities decrease with distance and at a radial depth of 350 microm the effect becomes negligible. The calculations showed the importance of the effect of the absorption in the stent material as this leads to a dose decrease to 67% for the 198Au stent and to 77% for 32P near the stent at a distance of 2 mm from the stent axis. It is concluded that from the dosimetric point of view, the 198Au stent is inferior to the 32P stent and the 192Ir source. Application of the 198Au stent in clinical practice requires further investigation of the importance of the adventitia in the restenosis process, and the tolerance dose of the intima.

Reverse redistribution on thallium-201 single-photon emission tomography after primary angioplasty: a one-year follow-up study.

The prognostic significance of reverse redistribution (RR) on thallium-201 single-photon emission tomography (SPET) images after acute myocardial infarction (AMI) has not been studied in detail. Moreover, RR data in patients treated with primary angioplasty are lacking. Fifty consecutive patients (including 40 men with a mean age of 54+/-11 years) with a first AMI were treated with primary angioplasty and followed up for 13+/-5 months for the following end-points: death, reinfarction and recurrent angina requiring revascularisation. Admission and peak creatine kinase myocardial enzyme (CKMB) and ejection fraction (EF) at discharge were studied as markers of myocardial damage. Thallium-201 stress-redistribution SPET studies at 1 month were analysed using a 13-segment, 4-point scoring system. Segments showing a worsening of perfusion by at least 1 point on redistribution studies were defined as showing RR. RR was present in 13 (26%) patients (group 1) and absent in 37 (74%) (group 2). Both groups were comparable for age, sex, peak CKMB release, EF and Q-wave myocardial infarctions. TIMI flow 3 was obtained in 92% in group 1 and 95% in group 2 (P = 0.95). On admission, CKMB was significantly lower in group 1 (18+/-14 vs 44+/-41 U/l, P = 0.03). Also, segments showing reversible perfusion were significantly more frequent in group 2 (1/169 vs 57/481, P = 0. 01). During follow-up, no death occurred and the combined documented endpoint of reinfarction and recurrent angina requiring angioplasty or coronary artery bypass grafting was significantly more frequently reached in group 2 (0/13 vs 10/37, P = 0.046). In conclusion, RR is common (26%) after primary angioplasty for a first AMI and is associated with lesser myocardial damage on admission. Patients with RR rarely have reversible segments on 201Tl SPET and tend to have a favourable outcome after 1 year of follow-up.

Stentless or stented aortic valve implants in elderly patients?

OBJECTIVE: To assess differences in indication and mid-term results between stentless and stented procedures in elderly patients, we followed aortic valve patients over a period of 5 years. METHODS: In a consecutive series of 154 elderly aortic patients in regular sinus rhythm from 1992 to 1997, we inserted 103 stentless (Toronto SPVTM, St Jude Medical Inc., St Paul, Minneapolis, MN) and 51 stented (Carpentier-Edwards supra annular porcine, Baxter Inc., Irvine, CA) bioprostheses in the aortic position. RESULTS: All 154 patients seemed preoperatively eligible for a stentless procedure. Mean age was 74.8 years (range 67-86 years) with a majority of female patients. The surgeon's (in)experience, major dilatation or calcifications of the ascending aorta and aberrant coronary anatomy were the most common reasons for drawback from the stentless procedure (51/154 patients). Aortic clamp time was significantly higher in the stentless vs. stented group (70 vs. 57 min, P < 0.0001). The large average 25.3 mm size of the stentless prostheses (vs. 23.7 mm stented) stands in full contrast with the low mean body surface area of 1.68 m2 (vs. 1.70 m2) of the patients. We encountered. respectively. 5 and 2 hospital-deaths (P = n.s.). The follow-up period ranged from 6 to 66 months and was 97% complete, yielding, respectively, 302 and 139 patient-years. Survival (Kaplan-Meier method) was statistically higher in favor of the stentless procedures (log rank: P = 0.03). All survivors progressed markedly to a mean postoperative NYHA class 1.3 respectively, 1.4 (vs. preop. 3.3 and 3.2). Echocardiographic transvalvular gradients compared favorable for the stentless group in the small under 25 mm valves (P = 0.02 for 23 mm sized valves between groups) with improved left ventricular function and a significant decrease of left ventricular end diastolic diameter (LVEDD 48.0 vs. 56.5 mm) at 1 year follow-up. Cusp calcifications on control echocardiography were detected earlier (beyond 3 years) in the stented group, without signs of early significant regurgitation or dysfunction in both groups, except for one patient necessitating re-operation. CONCLUSION: Although the implantation technique is much more demanding for stentless procedures, reflected by a longer aortic clamp-time, and remains impossible in some cases, elderly, small sized patients take full benefit of their large, non-obstructive prostheses.