ObjectiveTo assess the authors' hypothesis that with modern techniques, the current risks of repair for both complete and partial atrioventricular canal (AVC) are equal. Summary Background DataRepair of complete AVC in infancy has traditionally carried a substantial mortality. In contrast, partial AVC has been considered low-risk for repair and can be performed later in childhood. MethodsThis was a retrospective review of 63 infants and children who underwent complete (n ϭ 40) or partial AVC repair (n ϭ 23) from 1990 to 2001. Among complete AVC patients, the ventriculoseptal defect was repaired via an individualized approach according to each patient's specific anatomy: direct suturing without a patch (n ϭ 5) and/or interposition of a small pericardial patch with a running suture (n ϭ 35). In all 63 patients the left AV valve cleft was closed with interrupted sutures, and all atrial defects were closed with a pericardial patch. Data were analyzed with the Student t test and Fisher exact test. ResultsResults are expressed as the mean Ϯ SEM. Age at operation was 6.3 Ϯ 2.0 months for complete AVC and 47.5 Ϯ 6.1 months for partial AVC (P Ͻ .001). Bypass time was 65.2 Ϯ 2.3 minutes for complete AVC and 58.3 Ϯ 3.9 minutes for partial AVC (P ϭ .1). Reoperation rate was 7.5% (3/40) for complete AVC and 13.0% (3/23) for partial AVC (P ϭ .6). Early mortality was 2.5% (1/40) for complete AVC and 0% (0/23) for partial AVC (P ϭ .6). ConclusionsCompared to partial AVC, patients presenting for complete AVC repair are significantly younger and manifest more complex anatomy and pathophysiology. However, utilizing modern techniques, including an individualized surgical approach to the ventricular component, repair of complete AVC yields reoperation and early mortality rates similar to those of partial AVC.Current wisdom dictates that complete atrioventricular canal (AVC) should be repaired within the first 6 months of life to avert the onset of progressive pulmonary hypertension.1,2 In previous decades repair of complete AVC in infancy was attended by a substantial early mortality. 2-4Although early outcomes have improved in recent years, the preferred operative technique for complete AVC repair remains somewhat controversial. For example, there continue to be proponents of either the single-or double-patch technique, with either approach yielding acceptable results. 2-5Additional controversies have focused on the necessity of dividing the bridging leaflets to facilitate ventricular septal exposure in the two-patch technique, as well as whether the septal commissure (i.e., "cleft") of the left AV valve should be closed or left open.These unresolved controversies regarding the optimal surgical management of complete AVC were but one factor inspiring us toward a different approach. In addition, we realized that the pathologic anatomy of complete AVC is highly variable among patients with this lesion, 6 -8 indicat-

The latest European Society of Cardiology guideline on the management of acute coronary syndromes without persistent ST-elevation stipulates several acceptable pathways through which patients presenting with chest pain can be assessed for unstable coronary disease. This article reviews the data behind the “rule-in and rule-out algorithm,” which can exclude acute myocardial infarction within 1 hour of presentation through the use of fifth generation high-sensitivity troponin assays.

The aim of this study was to investigate whether asymptomatic patients with known coronary artery disease and demonstrable myocardial ischemia warrant revascularization on prognostic grounds. A Medline and PubMed search was performed, including 7 trials with data discussed and concise reviews of prominent articles in the field. The magnitude of inducible ischemia in those with known coronary disease correlates closely with poor cardiovascular outcomes in terms of death, myocardial infarction, hospitalization, and revascularization. Patients with ≥10% inducible ischemia experience a survival advantage when revascularized with a reduction in mortality of greater than 50% regardless of symptoms (P < 0.00001). Evidence also suggests that left ventricular function remains preserved in those who are revascularized when compared with medical therapy alone; left ventricular ejection fraction 53.9% versus 48.8% (P < 0.001). Silent ischemia is a useful prognostic marker in those with known coronary disease. It is recommended that asymptomatic patients with known coronary disease be revascularized on prognostic grounds if ≥10% ischemia can be demonstrated on nuclear or myocardial perfusion scan, ≥3 segments of regional wall motion abnormality on stress echocardiography/cardiac magnetic resonance imaging, or ≥2 segments with perfusion deficits on stress perfusion cardiac magnetic resonance imaging.