Objective: This report describes the early and midterm results after intraoperative radiofrequency ablation of atrial fibrillation for patients with isolated chronic atrial fibrillation or atrial fibrillation in combination with additional valvular and nonvalvular cardiac diseases.Methods: From August 1998 to March 2001, a total of 234 patients with chronic atrial fibrillation underwent isolated intraoperative radiofrequency ablation alone (n ϭ 74, 31.6%) or in combination with other cardiac procedures, such as mitral valve reconstruction (n ϭ 57, 24.4%), mitral valve replacement (n ϭ 38, 16.2%), aortic valve replacement (n ϭ 11, 5.1%), coronary artery bypass grafting (n ϭ 8, 5.0%), or a combination of the last with other cardiac procedures (n ϭ 46, 19.7%). In all cases anatomic reentrant circuits confined within the left atrium were eliminated by placing contiguous lesion lines involving the mitral anulus and the orifices of the pulmonary veins through the use of radiofrequency energy application (exposure time, 20 seconds). A median sternotomy was used in 101 cases (43.2%), and video assistance through a right lateral minithoracotomy was used in 133 cases (56.8%).Results: A total of 188 patients (83.9%) were discharged in sinus rhythm, 17 patients (7.6%) had atrial fibrillation, and 19 patients (8.5%) had atypical flutter. Pacemakers were implanted in 23 patients (9.8%). There were 10 in-hospital deaths (4.2%), and 30-day mortality was 5 patients (2.1%). In 3 cases (1.3%) an atrioesophageal fistula developed, necessitating surgical repair. Six months' follow-up was complete for 122 (61.0%) of 200 patients, with 99 patients still in stable sinus rhythm (81.1%, 95% confidence interval 73.1%-89.9%). Twelve months' follow-up was complete for 80 (90.9%) of 88 patients, with 58 patients still in sinus rhythm (72.5%, 95% confidence interval 61.3%-83.2%). Conclusions:Intraoperative radiofrequency ablation is a curative procedure for chronic atrial fibrillation. It is technically less challenging than the maze procedure and can be applied through a minimally invasive approach. Protection of the esophagus seems mandatory to avoid the deleterious complication of a left atrioesophageal fistula, such as was observed in 3 cases.

Standards for best practice in mitral valve repair were defined by multidisciplinary consensus. This study gives centres undertaking mitral valve repair an opportunity to benchmark their care against agreed standards that are challenging but achievable. Working towards these standards should act as a stimulus towards improvements in care.

The vascular endothelium is a complex modulator of a variety of biological systems and may well be the key to definitive success in the treatment of cardiovascular disorders. Surgically-induced endothelial injury may occur preoperatively during cardiac catheterization and intraoperatively from mechanical manipulation, ischemia, hypothermia, and exposure to cardioplegic solutions. The normal endothelium is antithrombogenic and yet promotes platelet aggregation and coagulation if injured. Vasospasm, occlusive intimal hyperplasia, and accelerated arteriosclerosis can also all occur as a result of endothelial injury. Furthermore, endothelial injury is harmful even in the absence of disruption of its monolayer integrity. Thus, preservation of the endothelium should be an additional objective for all cardiovascular surgeons. Synthetic vascular grafts, cardiac valves, and artificial ventricles do not spontaneously endothelialize and thus usually require some form of anticoagulation to maintain patency. Hence, endothelialization of prosthetic implants became an attractive concept. A number of different methods of obtaining an endothelial lining of prosthetic material has since been developed; these include facilitated endothelial cell migration, and endothelial cell seeding by using either venous or microvascular endothelial cells. Manipulating the endothelium might well provide the next major advancement for therapeutic and preventative measures for cardiovascular disease. (J Card Surg 1993;8:32-60)In 1628 William Harvey discovered the circulation of the blood and yet, even in the 1950s with the advent of vascular prostheses and cardiopulmonary bypass, the vascular endothelium was still considered to be merely a hemocompatible barrier to the blood stream. However, this monolayer of squamous cells (Fig. l), which has a total surface area of approximately 1,000 m 2,1,2 is now known to be a complex modulator of a variety of biological systems.In spite of this deepened understanding of endothelial cell function, the causative association of endothelial injury and surgical failure is still not appropriately appreciated. The reason for this negligence of cell biological events lies in the endurance of a mechanistic attitude, typical for the early days of surgery. Part of this attitude is the continual conviction of many surgeons that most of the severe cardiovascular disorders are mechanical in nature and thus susceptible to mechanical solutions. The astonishing success of surgical techniques further explains why the vast majority of surgeons realized only so late that the limitations of their techniques were of a biological rather than mechanical nature. Meanwhile, physiologists and cell biologists have long identified the endothelium as the key to definite success in the treatment of cardiovascular disorders.As an initial step toward the integration of surgeons into current scientific concepts of therapy, a modern cardiovascular surgeon needs to understand the basic function of endothelium, its extent of intraoper...

Noonan's syndrome is one of the commonest hereditary syndromes with cardiac involvement. We report a rare presentation of this syndrome, associated with giant aneurysms of the left and non-coronary sinuses of Valsalva, resulting in symptomatic aortic valve regurgitation. The patient's clinical investigations and operative management are presented. Histological examination of aortic tissues offers insight into the pathogenesis of these complications.