75岁以上老年瓣膜手术临床特征及手术安全性评价

目的研究75岁以上老年瓣膜手术临床特征及手术效果。方法回顾性分析2014年1月至2019年1月我院75岁以上老年瓣膜手术患者资料,总共73例,占同期心脏瓣膜手术的5.3%(73/1372)。其中男46例,女27例;平均年龄77.35岁(75~88岁),诊断为二尖瓣关闭不全28例(38.3%),二尖瓣狭窄8例(11.0%),主动脉瓣关闭不全7例(9.6%),主动脉瓣狭窄合并主动脉瓣关闭不全7例(9.6%),主动脉瓣狭窄6例(8.2%)。行二尖瓣置换联合三尖瓣成术28例(38.4%),主动脉瓣置换术20例(27.4%),二尖瓣置换术11例(15.1%)。同期安装起搏器2例(2.7%),同期行冠状动脉旁路移植术14例(19.2%)。结果手术前后左心房舒张期末内径(LA)、左心室舒张期末内径(LV)、右心房舒张期末内径(RA)及左心室射血分数(EF)差异有统计学差异(P<0.05)。与随机抽取的150例60岁以下瓣膜手术相比,手术阻断时间、体外循环时间、术后呼吸机时间、ICU时间、手术并发症、术后肝肾功能不全及病死率两组间差异无统计学意义(P>0.05)。结论75岁以上老年瓣膜病以二尖瓣关闭不全发病率最高,手术后心脏结构改善明显,且手术风险与正常年龄组相同,因此常规瓣膜手术在75岁以上老年人群中是安全的。     

老年风湿性二尖瓣病变行二尖瓣修复术与生物瓣膜置换术中期效果比较

目的比较60岁以上老年患者风湿性二尖瓣修复(MVP)与生物瓣膜置换(MVR)的中期效果。方法选取2014年1月至2016年1月北京安贞医院瓣膜外科诊疗中心行风湿性二尖瓣修复或生物瓣置换手术的60岁以上老年风湿性二尖瓣病变患者,包括同期行三尖瓣修复术及房颤射频消融术患者;排除合并主动脉瓣手术、冠状动脉旁路移植手术、二次手术患者,最终纳入患者82例。根据二尖瓣手术方式分为二尖瓣修复组(MVP组,25例)和生物瓣置换组(MVR组,57例)。采用Kaplan-Meier法进行生存分析并绘制曲线,通过Log Rank方法比较两组患者5年生存率的差异。结果围手术期全组患者平均年龄(66.37±4.41)岁。54.9%的患者心功能(NYHA分级)Ⅲ级。两组患者在体外循环时间(P=0.99),主动脉阻断时间(P=0.88),术后住院时间(P=0.76)差异均无统计学意义。MVR组3例患者住院期间死亡,病死率5.3%;MVP组无住院期死亡(P=0.24)。随访5年,最长随访63个月,平均随访47.03个月。MVR组6例死亡,其中4例死于心脑血管不良事件,2例死于非心脑血管不良事件。MVP组无死亡。两组均无再手术病例。结论风湿性二尖瓣病变的老年患者采用二尖瓣修复手术治疗能够获得较好的中期效果。     

肺肿瘤切除和心脏同期手术14例

目的 对肺部肿瘤同时伴有严重心脏疾病的病人采用同期肺切除和心脏手术方法治疗.方法 2003年至2008年,共完成肺肿瘤切除和心脏同期手术14例,其中男11例,女3例,平均年龄64岁.同期手术中肺叶切除9例,肺楔形切除5例;其中鳞癌4例、腺癌6例、未分化癌1例、错构瘤2例、硬化性血管瘤1例.同期心脏手术为冠状动脉旁路移植术12例,二尖瓣置换及二尖瓣修复加射频消融各1例.结果 全组无手术死亡和术后开胸止血.1例术后发生房颤很快转复,1例发生肺炎、ARDS,经气管切开等治疗后痊愈出院.结论 冠状动脉不停跳旁路移植手术手术风险明显减少,为保证肺癌治疗效果在同期手术中采取第二切口行肺切除和系统纵隔淋巴结清扫,此法手术并发症少且病人可接受.     

2261例二尖瓣及主动脉瓣联合瓣膜置换术临床结果与随访

目的　总结 2 2 6 1例二尖瓣及主动脉瓣联合瓣膜置换术的临床结果与随访。方法　 1977年至 2 0 0 0年间 ,2 2 6 1例病人行二尖瓣及主动脉瓣联合瓣膜置换手术。男 12 0 6例 ,女 10 5 5例。年龄14～ 6 9岁 ,平均 (43 73± 9 2 9)岁。其中风湿性心脏病 2 0 6 2例 ;术前心功能 (NYHA)III～IV级者 136 4例。4 6例为二次瓣膜置换 ,39例同期行冠状动脉旁路移植术。胸部正中纵劈胸骨 2 173例 ,胸部正中部分纵劈胸骨或右侧腋下小切口 88例。全部切除二尖瓣者 1978例 ,保留后瓣者 16 4例 ,保留前瓣者 6例 ,保留全瓣者 91例。 4 99例同期行三尖瓣成形 ,5例同期行三尖瓣置换。共置换人工心脏瓣膜 4 5 2 7枚。结果　手术死亡率为 2 6 5 % ,术后早期并发症发生率为 10 30 %。术后总随访率为 88 80 % ,实际生存率在术后第 5、10、15年时分别为 (95 .76± 0 .70 ) %、(92 .90± 1.6 4 ) %、(74 .32± 16 .6 7) %。结论　二尖瓣及主动脉瓣联合瓣膜置换术是治疗严重联合瓣膜疾病的可靠、有效手段 ,尤其近年手术结果令人鼓舞     

冠状动脉旁路移植术同期行心脏瓣膜置换手术59例临床分析

目的 研究冠状动脉旁路移植同时行心脏瓣膜置换手术治疗非缺血性心脏瓣膜疾病合并冠心病的疗效.方法 59例冠状动脉旁路移植同时行瓣膜置换手术,包括二尖瓣瓣膜病变40例及主动脉瓣瓣膜病变11例,联合瓣膜病变8例,共搭桥132支.根据患者年龄及病变血管情况选用乳内动脉或大隐静脉作为血管桥.结果 本组1例术后1d死亡,死亡原因是严重的低心排综合征,搭桥4根.其他病例术后随访2个月至7年,均没有明显心绞痛复发并且心功能得到改善.结论 非缺血性心脏瓣膜疾病合并冠心病患者一般无典型心绞痛病史,有冠心病高危因素的患者术前应该常规行冠状动脉造影检查明确是否合并冠心病.采取术前改善心功能状态,缩短手术及心肌缺血时间等措施,同时行冠状动脉旁路移植手术及心脏瓣膜手术是有效可行的治疗手段.     

≥65岁老年人心脏瓣膜病的外科治疗

目的总结老年人瓣膜病的手术效果。方法 1993年至2004年252例≥65岁老年瓣膜病病人接受瓣膜手术,占同期瓣膜手术5．5％(252／4546例),其中男147例,女105例;平均年龄(67．9± 2．9)岁。风湿性瓣膜病201例(79.8％),非风湿性瓣膜病51例(20．2％)。术前心功能Ⅲ-Ⅳ级141例 (56．0％)。主动脉瓣置换63例,二尖瓣置换93例,二尖瓣成形42例,主动脉瓣置换+二尖瓣置换或成形47例,三尖瓣置换或成形7例。同期行冠状动脉旁路移植术34例。结果手术死亡23例(9．1％), 逐年病死率有下降趋势。与同期瓣膜手术16-64岁组相比,术后ICU时间显著延长[(60．1±101．2)h对 (43．0±70．6)h,P=0．00],术后带气管插管时间明显延长[(30．6±42.8)h对(24．1±45．0)h,P=0．02], 术后并发症发生率明显高(10．6％对6．4％,P=0．01),住院时间明显延长[(25．7±41．3)d和(19．6± 14．4)d,P=0．00]。手术死亡病人术前心功能级别明显高于生存者[(2．8±1．0)级对(2.4±1．0)级,P< 0．05];术前射血分数差异无统计学意义(55．8％对59．5％)。结论老年人瓣膜病手术总体手术病死率可以接受,近2年手术病死率已接近5％。多元回归分析显示,并行冠状动脉旁路移植术、主动脉瓣和二尖瓣双瓣手术、术后急性肾衰需要透析、体外循环时间长、主动脉阻断时间长是住院病死率的独立预测因子。     

冠状动脉旁路移植术同期瓣膜手术的经验

目的 探讨同期施行冠状动脉旁路移植术和瓣膜手术的方法,疗效及影响因素。方法 回顾分析１９９５～１９９８年间１５例冠状动脉旁路移植术时,同期行二尖瓣置换或成形、主动脉瓣置换、联合瓣膜置换、Ｂｅｎｔａｌｌ术。结果 瓣膜病病因中,风湿性８例,退行性４例,缺血性３例,手术病死率为６．７％（１／１５）‘４例发生低心输出量综合征,其中３例需行主动脉内球反博;５例二尖瓣成形术后,反流面积从６．５～１５．０ｃｍ＾     

乳内动脉在70岁以上患者冠状动脉旁路移植手术中的应用

目的 总结70岁以上患者冠状动脉旁路移植手术中应用乳内动脉的利弊.方法 2010年7月1日至2012年8月20日,1471例70岁以上患者行单纯冠状动脉旁路移植手术共,占同期6156例单纯CABG手术者的23.10％.其中男1030例,女441例,年龄(73.3±3.9)岁.1395例采用非体外循环冠状动脉旁路移植术(off-pump CABG),76例采用体外循环(on-pump CABG),其中12例采用体外循环不停跳(on-pump beating heart CABG).旁路移植移植旁路血管(3.12±0.68)支.按移植血管材料分为2组:A组:564例全部应用大隐静脉;B组:907例患者应用左乳内动脉建立与左前降支旁路移植手术,其中42例应用桡动脉及胃网膜右动脉进行全动脉化旁路移植手术,其余靶血管均应用大隐静脉作为血管移植物旁路移植.结果 A组死亡12例(2.12％),B组死亡19例(2.09％),组间差异无统计学意义.B组术后早期引流量明显高于A组,二次开胸止血、恶性心律失常、脑卒中、伤口愈合不良和IABP使用例数等指标两组之间差异均无统计学意义.结论 70岁以上高龄患者旁路移植冠状动脉旁路移植选择左乳内动脉作为左前降支的旁路移植旁路血管材料,不增加手术死亡和术后严重并发症的发生率.乳内动脉在远期通畅率方面的优势明显,建议70岁以上高龄患者旁路移植优先选择左乳内动脉作为左前降支的旁路移植旁路移植血管.     

左心辅助循环治疗术后顽固性左心衰竭的体会

辅助循环是治疗顽固性心力衰竭的外科方法 ,其中最常用的是左心辅助循环治疗顽固性左心衰竭[1] 。 1993年12月～ 1999年 10月 ,我科为 13例心内直视手术后顽固性左心衰竭患者施行了左心辅助循环手术。现报告如下。1.临床资料 :本组 13例中 ,男 6例 ,女 7例 ;年龄 10～ 6 4岁。重症紫绀型法乐四联症 (Ｆ4)纠治术ｌ例 ,二尖瓣重度狭窄小左心室行二尖瓣替换术 (ＭＶＲ)后ｌ例 ,重症冠状动脉搭桥术 (ＣＡＢＧ)后 3例 ,主动脉瓣重度狭窄行主动脉瓣环扩大主动脉瓣替换术 (ＡＶＲ)后ｌ例 ,左室血栓 (心肌梗塞后 )摘除及冠状动脉旁路移植术后ｌ例 ,…     

重症心脏瓣膜病的外科治疗

目的总结重症心脏瓣膜病的外科治疗结果,探讨提高早期生存率的措施。方法自2000年6月至2005年7月,对78例重症心脏瓣膜病患者施行瓣膜替换术。其中单纯二尖瓣置换12例,二尖瓣置换 三尖瓣成形22例,单纯主动脉瓣置换8例,二尖瓣 主动脉瓣置换 三尖瓣成形35例,二尖瓣置换 冠状动脉旁路移植术1例。结果死亡6例,其中术后并发低心排血量5例,心室颤动治疗无效死亡1例,死亡率7.69%。随访53例,平均随访2.5年,死亡5例。结论对重症心脏瓣膜病患者,注重改善术前心功能,掌握手术时机,尽量保留瓣下组织,选择合适瓣膜,重视围手术期处理,可提高手术成功率。     

Ten-year survival following aortic valve replacement: A multivariate analysis of coronary bypass as a risk factor

The additional risk of coronary bypass surgery was analysed in 664 patients over 40 years of age undergoing aortic valve replacement between 1969 and 1981. Four hundred sixty-seven patients underwent aortic valve replacement alone, while 197 patients with coronary artery disease underwent combined aortic valve replacement and coronary bypass surgery. There were no significant differences in the preoperative hemodynamic characteristics of the two groups of patients. There were 41 (9%) operative deaths following aortic valve replacement alone and 20 (10%) following aortic valve replacement with coronary bypass surgery. Since 1976, operative mortality has fallen to 5% and perioperative myocardial infarction to 2% following the combined procedure. Ten-year actuarial survival (standard error) was 56 (3%) following aortic valve replacement and 49 (6%) following aortic valve replacement and coronary bypass surgery. A multivariate analysis including both groups of patients revealed that age, functional class and year of operation significantly affected ten-year survival (p less than 0.05). The same analysis showed that coronary artery disease requiring coronary bypass surgery also decreased ten year survival in patients undergoing aortic valve replacement (p = 0.06).     

Aortic root replacements in reoperations

We evaluated 4 patients who had undergone previous cardiac surgery underwent reoperation involving aortic root replacement. Subjects were a 55-year-old man who had undergone separate valve graft replacement for a dissecting aneurysm (DeBakey type I) 3.25 years earlier; a 51-year-old woman who had undergone separate valve graft replacement for a dissecting aneurysm (DeBakey type I) 6 years earlier; a 66-year-old woman who had undergone aortic valve replacement and single coronary artery bypass grafting for severe aortic regurgitation, angina pectoris, and aortitis syndrome 11 years earlier; a 47-year-old man who had undergone mitral valve replacement and 3-coronary artery bypass grafting for severe mitral regurgitation and angina pectoris 4 years earlier. Development of a surgical technique, coupled with myocardial protection, and pharmacological treatment at reoperation yielded excellent early surgical results. To reduce the incidence of reoperation and ensure satisfactory long-term results, we recommend radical management for the individual case be selected at initial operation and entire resections be conducted for aneurysmal degeneration or dissected segments.     

Ascending aorta dissection associated with bicuspid aortic valve

Aortic dissection etiology involve many factors that are difficult to identify clearly. We report a 47-year-old man who underwent a Bentall operation with reattachment of bypass grafts for a dissecting aneurysm (DeBakey type II) 4 years after combined triple coronary artery bypass grafting and mitral valve replacement. This case appeared to be associated with factors leading to dissecting aneurysm although it remains unclear which was more influential congenital bicuspid aortic valve or proximal anastomosis of venous grafts or both. This case suggests the need to consider appropriate timing in surgical intervention for cases of congenital bicuspid aortic valves and the selection of additional aortic valve replacement in initial surgery.     

Mitral valve repair in redo cardiac surgery

An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible. A right anterior thoracotomy approach is preferred in most patients, coupled with hypothermic fibrillatory arrest. A repeat sternotomy may be favored in select circumstances such as when there is a need for bypass grafting or moderate aortic insufficiency is present. Special attention to cannulation techniques, perfusion conditions, valve exposure, and de-airing maneuvers are all important to ensure good clinical results. Using a tailored approach we have performed mitral valve repair in 22 patients with a patent left internal mammary artery graft following coronary artery bypass grafting between July 1992 and February 2000 with acceptable morbidity and low mortality.     

Mitral Valve Repair in Redo Cardiac Surgery

ABSTRACT An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible. A right anterior thoracotomy approach is preferred in most patients, coupled with hypothermic fibrillatory arrest. A repeat sternotomy may be favored in select circumstances such as when there is a need for bypass grafting or moderate aortic insufficiency is present. Special attention to cannulation techniques, perfusion conditions, valve exposure, and de-airing maneuvers are all important to ensure good clinical results. Using a tailored approach we have performed mitral valve repair in 22 patients with a patent left internal mammary artery graft following coronary artery bypass grafting between July 1992 and February 2000 with acceptable morbidity and low mortality.     

二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全

目的 评估二尖瓣成形术治疗感染性心内膜炎的可行性和疗效.方法 1990年10月至2007年7月,83例感染性心内膜炎致二尖瓣关闭不全的病人接受二尖瓣手术.男62例,女21例.41例(49.4%)行二尖瓣成形术(MVP),42例(50.60%)行二尖瓣置换术(MVR).同时行主动脉瓣置换术37例,三尖瓣成形术12例,室间隔缺损修补术4例,冠状动脉旁路移植术2例,主动脉瓣成形术1例,房间隔缺损修补术1例,股动脉取栓术1例.术中18例行食管超声检查评估二尖瓣反流情况.结果 MVP与MVR组病人比较,术前左室收缩末内径(41.63±8.60)mm对(37.69±6.38)mm,P＜0.05;术前射血分数0.62±0.07对0.66±0.76,P＜0.05;术前心功能分级平均(2.88±0.61)级对(2.45±0.71)级,P＜0.01.体外循环47～265min,平均(117.06±46.77)min;主动脉阻断26～210min,平均(86.95±39.07)min;呼吸机辅助呼吸5～120h,平均(21.49±16.06)h.MVP与MVR组病人体外循环和主动脉阻断时间均差异无统计学意义,MVP组气管插管和住ICU时间均显著低于MVR组(P＜0.05).MVR组病人瓣叶赘生物明显多于.MVP组病人(P＜0.05).MVP组术者相对固定.住院死亡3例(3.6%),均为二尖瓣置换病人.出院时病人心功能均为Ⅰ级或Ⅱ级.随访1～165个月,平均(39.33±39.76)个月,随访率95%.MVR组发生瓣周漏1例,反复胸腔积液1例,脑出血2例,其中1例死亡,10年生存率75%.MVP组无死亡,10年生存率100%.结论 感染性心内膜炎二尖瓣病变的病人瓣叶毁损不严重,如术者临床经验丰富,大多可行二尖瓣成形术,并取得良好手术结果.

Abstract：

Objective Valve replacement is a conventional therapy for the mitral insufficiency caused by IE. Mitral valve repair as an optional procedure for the disease has become feasible in recent years. However, concerns from surgeons about the recurrence of endocarditis after mitral valve repair remained. in this study we evaluated the long-term clinical outcomes of patients treated with surgery for the mitral insufficiency caused by infective endocarditis (IE). Methods Between July 1990 and July 2007, 83 consecutive patients (male 62, female 21) with mitral valve IE were enrolled in this study. Forty-one (49.4% )patients received mitral valve repair ( MVP,group A) and 42(50. 6% ) patients received mitral valve replacement ( MVR, group B). Thirty-seven cases had concomitant aortic valve replacement; 1 patient had aortic valve repair; 4 cases had ventricular septal defect repair; 1 case had atrial septal defect repair, 12 cases had bicuspid valve repair; 2 cases had coronary artery bypass graft and 1 case had femoral artery thrombus. Intraoperative transesophageal echocardiography were performed in 18 cases for the evaluation of mitral valve regurgitation. Mean cardiopulmonary bypass time, aortic clamping time and postoperative ventilation time were recorded and analyzed. Mid- and long-term clinical and echocardiographic outcomes were assessed.Results Preoperative left ventricular end systolic diameter, left ventricular ejection fraction and the classification of New York Heart Association in group A were significantly lower than those in group B (P ＜ 0. 05), but no difference was observed between the 2 groups in the cardiopulmonary bypass time and the crossclamping time. However, the intubation time and ICU time were shorter in group A than those in group B ( P ＜ 0.05 ). More vegetations were seen in the MVR group than in the MVP group. Three (3.6% ) patients died after the operation in group B. All patients were assessed as in NYHA Ⅰ-Ⅱ at discharge.A follow-up was done between 1 to 165 months (mean 39 months) with a mean follow-up rate of 95%. In the MVR group, peri-valvular leakage happened in 1 case, cerebral hemorrhage happened in 2 cases and repetitive pleura! effusion in 1 case. One death happened in the MVR group and none in the MVP group. The 10-year survival rate (100% ) in group A was nonsignificantly higher in group A than that (75% ) in group B(P =0.081). Conclusion Mitral valve repair is feasible for treating mitral valve lesions caused by endocarditis, and may provide an optimistic long-term outcome to the patients. The indication for mitral valve repair is mild to moderate mitral valve lesion. Experienced cardiac surgeons, use of antibiotics before and after the operations based on drug-sensitivity test and blood test, as well as follow-up the patients yearly, are important factors for the favorite outcomes.     

Open heart surgery in the elderly

Of 3254 open heart surgical cases performed since 1972, 126 patients (3.9%) were 70 years of age or older. The mean age was 72 years, the oldest being 82. Sixty-seven per cent were male. The following procedures were performed: coronary artery bypass grafting (CABG) 51, aortic valve replacement (AVR) 44, AVR + CABG 16, mitral valve replacement (MVR) 3, MVR + CABG 6, MVR + AVR 4, and other, 2. Of those undergoing CABG, 33% came from the Coronary Care Unit and 24% had left main coronary artery stenosis. There was one peri-operative death (2.0%). Of those undergoing AVR, 43% had coronary artery disease and 13% triple vessel disease. Operative mortality for AVR, and AVR + CABG was 11.4% (5/44) and 18.8% (3/16), respectively. Twenty-six per cent of operative survivors had significant postoperative complications (excluding atrial arrhythmias). The postoperative hospital stay for CABG, AVR and other cases was 11, 13 and 16 days, respectively. Seven year survival of all patients was 61.2 +/- 6.5% (+/- 1 SE) and for AVR +/- CABG was 51.5 +/- 8.6%. Five year survival for CABG was 83.9 +/- 6.3%. We conclude that, in selected cases, CABG can be performed safely in the elderly. Although valvular and combined surgery may result in significant morbidity and mortality, the satisfactory long term results in survivors justifies surgery in this group of patients.     

Surgery for atrial fibrillation using radiofrequency catheter ablation

OBJECTIVE: We present the results obtained in 40 patients with chronic atrial fibrillation using direct intraoperative radiofrequency to perform atrial fibrillation surgery. METHODS: Between April 2001 and June 2002, 40 patients underwent surgery for atrial fibrillation using radiofrequency ablation and cardiac surgery at the Department of Cardiovascular Surgery of the University of Bologna [corrected]. There were 8 men and 32 women with a mean age of 62 +/- 11.6 years (range: 20 to 80 years). RESULTS: Concomitant surgical procedures were: mitral valve replacement (n = 13), mitral valve replacement plus tricuspid valvuloplasty (n = 11), combined mitral and aortic valve replacement (n = 8), and combined mitral and aortic valve replacement plus tricuspid valvuloplasty (n = 5). Moreover, 1 patient underwent tricuspid valvuloplasty plus atrial septal defect repair, another required aortic valve replacement plus coronary artery bypass graft, and a third underwent aortic valve replacement. After the mean follow-up time of 16.5 +/- 2.5 months survival was 92.8% and the overall cumulative rate of sinus rhythm was 88.5%. CONCLUSIONS: We conclude that the radiofrequency ablation procedure is a safe and effective means of curing atrial fibrillation with negligible technical and time requirements, allowing recovery of the sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who underwent cardiac surgery (88.5% of our study population).     

Combined surgery for valvular and ischemic heart disease

Combined coronary artery bypass (CAB) and valve surgery is one of the most challenging surgical procedures, but the operative results have improved over the years. We discuss several important points in combined surgery. The first point is cardioplegia, which should be perfect in such complex operations. Sufficient antegrade cold blood cardioplegia should be used in combined CAB and mitral valve surgery. Continuous retrograde cardioplegia is required in CAB and aortic valve surgery. The second point is the prosthesis and grafts. A mechanical prosthesis and arterial grafts should be used in younger patients, while a bioprosthesis and vein grafts with a left internal thoracic artery graft should be used in older ones. Finally, the choice of valve repair or replacement must be considered in mitral surgery with CAB. Valve repair is the choice in patients with mitral prolapse due to chordal rupture, because a perfect repair can be achieved using a well-known procedure. In cases in which repair appears difficult, replacement must be carried out as soon as possible. In mitral valve replacement the continuity between the papillary muscles and the mitral ring must be preserved for good left ventricular performance.     

Coronary artery bypass surgery in patients seventy years of age and older.

Fifty patients 70 years of age and older underwent coronary artery bypass surgery for disabling angina pectoris or congestive heart failure or both (two quadruple, 11 triple, 25 double grafts, 12 single). Twenty additional procedures were done (11 mitral valve replacements for papillary muscle dysfunction, six ventricular aneurysmectomies, four aortic valve replacements, and one repair of ventricular septal defect). Surgical mortality rate was 8 per cent (four patients). Total mortality rate was 14 per cent, after a mean follow-up of 17 months. Of 30 patients undergoing coronary artery bypass surgery alone, two died during surgery and none of follow-up. Age alone should not be a contraindication for coronary artery bypass surgery. Surgical risk is acceptable in older patients, and improvement can be expected in the majority of patients.