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Notes: The attractiveness of the aortic allograft in any form, whether It be free style or root, is the high 10-year freedom from thromboembolism, absence of requirement for anticoagulants, use in active infections, excellent homodynamic, and freedom from reparation. The 10-year freedom from all valve related complications has been reported to be around 92% versus only 75% for the porcine bioprosthetic valve. Gradients across the allograft aortic valve are comparable to that of the St. Jude valve (St. Jude Medical, St. Paul, MN, USA) with valve areas approaching 2 cm2 in the extremely large homograft. Between November 1986 and September 1993, the author used the aortic allograft as a freehand procedure In 51 patients and for root replacement in 22 patients. Stimulus for use of limited root replacement with the allograft in aortic valve replacement has occurred because of the unpredictability of the freehand operation with regard to valve Insufficiency. This has been done in spite of the Ross modification of retaining the noncoronary sinus. Evaluation of freehand allograft function by echo analysis has demonstrated an unacceptable incidence of insufficiency not found when a small segment of the allograft root is used. The native coronary arteries, however, must be transposed to the donor root, which of itself has the potential of introducing new problems not seen with other valve substitutes. Complications with the freehand allograft have consisted of explantation in eight patients, four early and four late. Six of the early and late explantations have been for insufficiency. Techniques of valve and valve root implantation will be presented In detail. In my experience, justification for Its use has been rather rigid and the technique has been used only where insertion of this type of valve would be an obvious advantage to the patient. Follow-up has included 32 patients having a late echo evaluation for allograft function. In the future, use of the allograft root appears to be the procedure of choice when this valve is the desirable substitute for the aortic valve. This procedure preserves the entire aortic cylinder and guarantees valve competency. (J Card Surg 1994;9[Suppl):188–191)

Notes: Abstract Preparation of the internal mammary artery (IMA) for coronary bypass grafting is depicted. It is felt that this technique offers a simple, safe method for providing an IMA of maximum caliber and flow that allows not only end-to-side but sequential IMA grafting to a coronary artery. Use of this technique prepares the mammary artery to be used for both in situ and free grafting procedures to allow maximum utilization of the IMA as a superior conduit. The technique described has been used in several thousand operations.

Notes: Indications for specific valve types, whether they be mechanical or bioprosthetic, have been rigorously defined in recent years. Candidates for bioprosthetic valves would be: older patients, patients who are noncompliant or have contraindications to anticoagulation, patients in normal sinus rhythm, and young females desirous of future pregnancy. Recent data suggest that patient age and presence of coronary artery disease may significantly alter the indications for mechanical or tissue valves. There is mounting evidence that patients without coronary disease in their 60s and 70s who require valve replacement are better served with a mechanical prosthesis. At Emory University Hospitals, 440 patients operated upon between 1974 and 1981 were followed for a mean period of 8.3 years. No patients having coronary artery disease were included in the cohort. Survival at 10 years was 64%. The actuarial freedom from all major valve related complications at the end of 10 years is compared to other series. Data suggests that patient survival for mitral valve replacement is affected by the etiology of the valve disease necessitating the operation. The best survival occurs in patients in whom the mitral valve replacement is for myxoid degeneration and may explain the excellent survival to be expected for mitral valve repair and concomitant coronary bypass. The most significant factor increasing morbidity and mortality in patients with mitral valve replacement and coronary artery disease is high end-diastolic pressure associated with significant depression of regional wall motion. Experience at our institution on the interaction of age and coronary disease on patient survival after valve replacement has identified some important factors that may be of value in selecting the type of valve (tissue vs mechanical) to be used. Survival was extensively examined in 1365 patients without coronary disease after mitral valve replacement and operated upon between 1974 and 1991. Median survival for mitral valve replacement in the 60-and 70-year-old groups was 11.4 years if there was no coronary disease, but only 5.5 years if coronary artery bypass had to be performed. This was highly statistically significant. We have concluded from these studies that other factors being equal, tissue valves appear most appropriate for mitral valve patients with coronary artery disease over age 60. In patients 60 to 70 years of age without coronary disease, survival after mitral valve replacement is similar to that after aortic valve replacement and suggests mechanical valves may be preferable, as it is in all patients less than 60 years of age. (J Card Surg 1994;9[Suppl]:218–221)

Notes: Intraoperative dissection and late ascending aortic dissection and aneurysm formation infrequently complicate cardiac operations but remain a significant source of morbidity and mortality. A review of 11, 145 consecutive cardiac operations at Emory University from January, 1982 through December, 1988 yielded 27 patients with an intraoperative ascending aortic dissection (incidence 0.24%) occurring at the time of the original procedure, with a hospital mortality of 14.8%. Nine additional patients with ascending aortic dissection or aneurysm, presenting late after a previous cardiac operation, were treated during this same period with three deaths.The technical aspects and decision making for application of closed aortic plication, open aortic reconstruction ascending aortic replacement based directly on the extent of the intraoperative dissection is detailed. An individualized technical approach tailored to the pathology encountered is outlined for the reoperative group of patients. Etiology, risk factors, principles of prevention indications for operation are also discussed.

Notes: Eight patients with β thalassaemia major suffering from leg ulcers, were treated over an 8-week period with 3 g ascorbic acid daily in a controlled double-blind crossover study. The ulcers of all the patients showed a high rate of either complete or partial healing.

Notes: Occurrence of Salterella rugosa Billings on Nordaustlandet, Svalbard, is reported for the first time. The rocks that produced these fossils belong to the upper part of the Kapp Sparre Formation. This unit can be correlated with the Oslobreen Dolomite in Ny Friesland (Spitsbergen, Svalbard) from which the same species has been reported earlier; these fossils have not been illustrated previously. In both areas many specimens are poorly preserved, and it is becoming increasingly evident that the difference between Salterella and Volborthella simply may be the result of loss of the outer shell in the Volborthella.