Results of surgery for aortic root aneurysm in patients with the Marfan syndrome.

OBJECTIVE: To evaluate the results of two operations, aortic valve-sparing and aortic root replacement, in patients with aortic root aneurysm and the Marfan syndrome. METHODS: A retrospective review of 78 consecutive patients with aortic root aneurysm and the Marfan syndrome according to the Gent criteria indicated that 42 patients with normal aortic cusps had an aortic valve-sparing operation, and 36 patients had aortic root replacement (mechanical valve in 25 patients and biological valve in 11). The mean age was similar in both groups, but patients who had aortic root replacement had larger aneurysms, higher grade aortic insufficiency, worse left ventricular function and more cardiac co-morbidity than patients who had aortic valve-sparing operations. The mean follow-up was 41+/-35 months for patients who had aortic valve-sparing, and 65+/-50 months for those who had aortic root replacement. RESULTS: Kaplan-Meyer estimates of survival at 5 years was 100% for patients who had aortic valve-sparing, and 88+/-6% for those who had aortic root replacement (P=0.04). Five patients who had aortic root replacement required seven aortic root re-replacements: three for endocarditis and four for valve failure (biological valves). There have been no reoperations in patients who had aortic valve-sparing operations and annual Doppler echocardiography revealed mild or no aortic insufficiency in 39 patients and moderate aortic insufficiency in three. CONCLUSIONS: These data suggest that aortic valve-sparing operations are safe in patients with the Marfan syndrome and may provide better clinical outcomes than aortic root replacement. Since the size of the aneurysm often determines the feasibility of a valve-sparing procedure, we now recommend surgery when the diameter of the aortic root reaches 50 mm in patients with the Marfan syndrome who have echocardiographically normal aortic valve cusps.

Transmyocardial laser revascularization in the treatment of end-stage coronary artery disease.

Transmyocardial laser revascularization has been used in 171 patients suffering from severe angina pectoris unresponsive to medical therapy at Deutsches Herzzentrum Berlin within the period from 7/1994 to 12/1997. In all patients conventional bypass surgery or PTCA, did not seem to offer the possibility of success. Postoperatively, the majority of the patients experienced a significant decrease in angina and better physical endurance. A statistically significant increase in myocardial perfusion or left ventricular contractility has not been detected. Perioperative mortality after TMR decreased from 8% among the first 40 patients to 2.5% among the 40 patients operated on most recently, with an overall mortality of 7%. The relief of angina symptoms and the improved quality of life after TMR seems to justify the use of the method in patients who presented with urgent indications for CABG surgery, although their coronary vessel status did not seem to promise success for this procedure. However, considering its experimental foundation and long-term effects, it seems that a conclusive assessment of TMR is not yet possible.

Secondary transmyocardial laser revascularization in the treatment of end-stage coronary artery disease.

Transmyocardial laser revascularization (TMR) has received more acceptance within the last few years. The vast majority of TMR users report impressive clinical benefits. The underlying mechanism for benefit by TMR, however, remains somewhat unclear. Between July 1994 and September 1997, 165 patients underwent TMR at our institution. In three of our TMR patients after an initial angina-free interval of 1 to 2 years we decided to repeat the laser operation. This article focuses on the three re-TMR patients who underwent a second TMR operation 12 to 14 months after the first one. Two of the three patients are well and experience significantly less angina than preoperatively.

[Histomorphology after transmyocardial laser revascularization]. / Histomorphologie nach transmyokardialer Laserrevaskularisation.

From 11/1994 to 4/1997 we enrolled 140 patients with diffuse CAD refractory to maximum antianginal therapy who are not candidates for PTCA or CABG for transmyocardial laser revascularisation (TMLR). Of these patients aged 63.5 +/- 15 years, 98 had coronary 3-vessel disease, and the average left ventricular ejection fraction was 44%. Eleven out of these 140 patients died from different reasons (pneumonia, myocardial infarction, septicemia). Seven patients who died between the 1st and 20th postoperative day underwent a postmortem examination with histological analysis of the areas treated by TMLR. On the seven investigated ventricles a total of 220 channels were created. The predominant finding in specimens within five days after TMLR was recently closed channels. Furthermore, a zone of necrosis with an average extension of 500 microns on each side of the channel was evident. Many changes were noticeable in specimens from patients who died two or three weeks after TMLR. Freshly clotted material had been replaced by a granular tissue of variable density. High macrophage and monocyte activity was evident. The extent of this cellular activity could be depicted by staining with a special proliferation marker, such as MiB. On the one hand numerous dividing macrophages were observed, on the other, active fibroblasts indicative for the transformation into scar-like tissue. After staining for type-4-collagen, typical for the basal membrane of capillaries, a large number of stained structures was noticeable in the closed channel lumen. Numerous garlandlike structures became visible under higher magnification. By CD 31 incubation, these structures, were found to be lined with endothelium. Further research will be required to indicate whether the laser channels later are partially or completely open, from where the capillaries are supplied, and whether they even connect to the ventricle lumen. But in conclusion, it seems unlikely, that TMLR follows the mechanism of the amphibian heart.

Rhythm disturbances after mitral valve surgery: comparison between left atrial and extended trans-septal approach.

This study was undertaken to determine the incidence of postoperative arrhythmias in mitral valve surgery through the left atrium as compared with the extended trans-septal approach. All patients undergoing mitral valve surgery for acquired valve disease between 1 January 1991 and 31 December 1993 were reviewed. Only patients with preoperative normal sinus rhythm were included in this study. End-points for analysis were: 'any supraventricular arrhythmia'; 'atrial fibrillation of flutter'; and 'ectopic atrial or junctional rhythm'. All predictive factors with a P-value < 0.10 in univariate analysis were entered into the multivariate proportional hazard model of Cox. Some 72 patients were included for analysis. No variables were independently predictive of 'any supraventricular arrhythmia'. Age is an independent predictor of 'atrial fibrillation or flutter' and surgical approach of 'ectopic atrial or junctional rhythm'.

Local complications after arterial bypass grafting.

We have documented prospectively the problems occurring after 496 arterial bypass grafts (149 aortoiliac, 238 femorodistal, 65 extra-anatomic, and 44 others) implanted during the period 1987 to 1991 in a district general hospital. Postoperative bleeding occurred early in 14 (2.8%), and later (because of infection) in 3 (0.6%). Early graft occlusion (< 30 days) was seen in 2.9% aortofemoral, 10.4% femoropopliteal, and 25.3% femorotibial grafts, and amputation was required after 6.9% grafts. Wound problems were most common after femorotibial bypass--weeping of fluid in 3% and dehiscence or infection in 13.9%. Lymphatic collections occurred after 1.2% operations involving groin incisions. Graft sepsis was usually late, affecting 6% aortofemoral, 2.9% femorodistal, and 7.7% extra-anatomic grafts, but no intra-abdominal aortic grafts. These figures are probably representative of the complication rates seen by many surgeons and serve as an example for comparison and criticism.