Tension-free vaginal tape for the treatment of stress urinary incontinence in geriatric patients

OBJECTIVE: To evaluate the safety and efficacy of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence (SUI) in geriatric patients. PATIENTS AND METHODS: Fifty-one women, aged 65-80 (mean 72.3) years, underwent a TVT procedure for genuine SUI from 2001 to 2004. A urodynamic test together with uroflowmetry were performed. The patients' SUI bother score was assessed using a visual analog scale (VAS). RESULTS: The mean operative time was 25 (range 14-29) min and mean hospitalization time was 1.2 (range 1-2) days. Bladder perforation occurred in 3 cases (5.8%) and was managed conservatively. Pre- and postoperative maximum flow rate were not significantly different (p > 0.05). The patients' SUI bother score estimated by the VAS was statistically significantly improved (p < 0.0001). After a mean follow-up of 35.6 (range 14-60) months, 49 patients (96%) had no SUI, while 2 patients (3.9%) had persistent SUI. Also, during the follow-up 5 patients (9.8%) were diagnosed with de novo urgency due to detrusor overactivity and 1 patient (1.9%) had persistent dysuria that was resolved with urethrolysis. CONCLUSIONS: SUI in elderly women can be safely treated with the TVT procedure in the vast majority of the patients. However, bladder perforation during surgery and de novo urgency postoperatively should be taken into account.     

Value of Maximum Urethral Closure Pressure in Predicting the Outcome of Tension‐Free Vaginal Tape and Transobturator Tape Procedure

Objectives: The short‐term results for the tension‐free vaginal tape procedure (TVT) and the transobturator tape procedure (TOT) for stress urinary incontinence (SUI) were compared using the preoperative maximum urethral closure pressure (MUCP). Methods: A total of 278 patients treated for SUI was considered: 165 who underwent TVT and 113 who underwent TOT retrospectively. The MUCP in a preoperative urodynamic study before and 3 months after surgery were evaluated. Results: At 3 months after TVT, 159 patients (96.4%) were cured and four patients failed. The mean MUCP of the patients who failed was 22.5 ± 5.3 cmH₂O, which was significantly lower than that among the cured patients (P < 0.007). At 3 months after TOT, 100 patients (88.5%) were cured and seven patients failed. The mean MUCP of the patients who failed was 27 ± 6.3 cmH₂O, which was significantly lower than that among the cured patients (P < 0.001). Furthermore, the mean MUCP among the patients who were cured after TOT was significantly higher than that among the patients who were cured after TVT (P < 0.01). A further analysis using a ROC curve indicated that the MUCP value in the successful patients after TVT was ≧ 24 cmH₂O and that in the failures after TOT was ≦ 30 cmH₂O with selection sensitivity at 80%. Conclusion: These results suggest that the failure cases after TVT or TOT are often found in SUI with a low MUCP and that TVT might be superior to TOT in SUI with a MUCP ≦ 30 cmH₂O.     

Experience with Tension‐free Vaginal Tape (TVT)‐SECUR for Female Stress Urinary Incontinence

Objectives: Tension‐free vaginal tape (TVT)‐SECUR is a technique specifically designed to place a short suburethral mesh sling for the treatment of female stress urinary incontinence (SUI). The aim of the technique is to decrease surgical morbidity. We report our experience of applying this technique on 10 patients. Methods: From June 2007 to July 2007, 10 female patients with SUI underwent TVT‐SECUR placement operation. The sling was inserted in a suprapubic direction over the inner surface of pubic bone (U‐shaped technique). Nine of the patients underwent videourodynamic study (VUDS). The maximal bladder neck decent distance (MBND) by abdominal straining was determined. We identified intrinsic sphincter deficiency (ISD) as a valsalva leak point pressure lower than 60 cm H₂O and hypermobility as MBND more than 2 cm. Results: Two patients had pure ISD, three had hypermobility, and four had both ISD and hypermobility. All patients remained continent for first month after surgery. SUI recurred in five of nine patients at an average of 2.5 months. The recurrence appeared in all three groups of patients. The recurrent SUI was so severe that three patients required repeat surgery using percutaneous prolene tape sling. After surgery, no further SUI was noted in the three patients. During surgery the TVT‐SECUR sling was found to have firmly adhered to perivesical tissue rather than to the pubic bone. Conclusion: Our experience shows that the current design of the TVT‐SECUR results in unpredictable outcomes. Some placed slings may migrate away from the inner surface of the pubic bone. To act as a reliable “hammock”, the sling must be securely fixed on immobile structures independent from the bladder/urethra.     

无张力阴道尿道悬吊术治疗老年女性尿失禁六例临床分析

目的 探讨无张力阴道尿道中段悬吊术(TVT)治疗老年女性尿失禁的临床意义和疗效。方法 采用SPRAC吊带系统对6例单纯性压力性尿失禁老年女性进行TVT治疗，分析其疗效及并发症。结果 6例TVT手术均在硬膜外麻醉下完成，平均手术时间31．6min，术中平均出血36．2ml，5例手术后24h内自行排尿，1例合并肥胖和阴道前壁膨出患者留置尿管1周后自行排尿。术后随访10～28个月，5例尿失禁治愈，1例手术后3个月再次发生尿失禁，2例术后伴不同程度的尿频、尿急，1例自觉耻骨后轻度不适。结论 TVT易操作、创伤小、疗效好，对绝经后老年女性合并肥胖和阴道前壁膨出的压力性尿失禁患者治疗有明显疗效。     

Efficacy of Synthetic Suburethral Slings in Female Urinary Stress Incontinence with Overactive Bladder

Objectives: The aim of the present study was to investigate the efficacy of synthetic suburethral slings in female stress urinary incontinence (SUI) patients with overactive bladder (OAB). Methods: From May 2002 to April 2005, a total of 295 women with SUI underwent suburethral sling procedure. Of the 295 women, only those who were followed up for at least 12 months were included in the study, yielding 236 patients. The patients were divided into three groups: pure SUI; SUI with OAB dry; and SUI with OAB wet. Telephone questionnaires by were used to evaluate the postoperative improvement of SUI and storage symptoms. Results: There were significant differences in preoperative symptom score, quality of life (QoL) score, and preoperative voided volume among the three groups. There were no significant differences among the three groups in terms of the cure rate for the stress component (group 1, 88.6%; group 2, 86.2%; group 3, 86.7%; P = 0.943). Eighty percent of group 1 patients improved in frequency, but two patients (2.3%) complained of de novo urgency. In group 2, 81.5 and 82.7% improved in frequency and urgency, respectively, but one patient (1.7%) complained of de novo urge incontinence. In group 3, 76.9 and 84.4% improved in frequency and urge incontinence, respectively. Conclusion: Suburethral slings are simple, safe and highly effective in treating SUI with OAB.     

Simultaneous Treatment of Female Urethral Diverticulum and Stress Urinary Incontinence with Urethral Diverticulectomy and Suburethral Synthetic Mesh Sling

Objectives: Pubovaginal fascial sling along with urethral diverticulectomy has been advised as the most appropriate anti‐incontinence procedure for female stress urinary incontinence (SUI) with concomitant urethral diverticula (UD). We believe that suburethral synthetic mesh tape sling can also be safely used in some patients with concomitant SUI and UD. Herein, we present our experience for simultaneous treatment of UD and SUI with urethral diverticulectomy and suburethral synthetic mesh tape sling. Methods: From 2003 to 2008, there are three patients with UD and SUI in our institution. They received transvaginal urethral diverticulectomy and suburethral synthetic mesh tape sling simultaneously. Videourodynamics was done before and three months after the surgery. Results: Preoperative pelvis magnetic resonance imaging and videourodynamic study showed UD over distal urethra and SUI in all three patients. Urinalysis disclosed mild pyuria in two of the patients, and they both received intravenous antibiotics treatment to eradicate the infection prior to the surgery. They all underwent urethral diverticulectomy with suburethral synthetic mesh tape sling. The postoperative videourodynamic study showed no recurrence of UD and SUI. With a mean follow up of 33.3 months, there was no infection or exposure of synthetic mesh tape. Conclusions: In patients with UD and SUI, suburethral sling using synthetic mesh can be as effective and safe as facial sling in selected patients.     

Different sling procedures for stress urinary incontinence: A lesson from 453 patients

Several midurethral sling (MUS) procedures, such as tension-free vaginal tape (TVT), TVT obturator (TVT-O), tension-free vaginal tape SECUR (TVT-S), and pubovaginal sling (PVS), have been used for the treatment of female stress urinary incontinence (SUI); however, which method is best for a particular patient group is not known. This study aimed to identify the best rationale for choosing the optimal MUS procedure for each patient. In total, 453 consecutive female patients with SUI who were treated with MUSs in West China Hospital of Sichuan University from September 2003 to September 2011 were enrolled in this study. All the patients underwent comprehensive pre-, intra-, and postoperative evaluations, including collection of demographic information, pelvic examination, and urodynamic testing, and operation-related complications were recorded. The Incontinence Quality of Life questionnaire was also completed. Under local or general anesthesia, 105 cases were treated with TVT, 243 with TVT-O, 90 with TVT-S, and 15 with PVS. Patients with different profiles in terms of age, symptom duration, concomitant procedures, urodynamic parameters, and pelvic organ prolapse (POP) quantification score were treated successfully; the body mass index did not differ significantly among the various treatment options. The cure and improvement rates were similar among the treatment groups: 97.14% (102/105) in TVT, 100% (243/243) in TVT-O, 98.89% (89/90) in TVT-S, and 100% (15/15) in PVS. Only minor complications were experienced by the patients. In conclusion, each MUS procedure was observed to be safe and effective in different subpopulations of patients, and the results suggest that appropriate patient selection is crucial for the success of each MUS procedure.     

Evaluation and Management of Urinary Retention and Voiding Dysfunction After Sling Surgery for Female Stress Urinary Incontinence

Female urethral sling surgery is the most common procedure performed to treat stress urinary incontinence with cure rates in excess of 85?%. In a small minority of patients however, postoperative voiding dysfunction develops, in the form of: urinary retention; high post-void residual; poor urinary flow; urinary frequency; urinary urgency; urinary urge incontinence; or pelvic pain. This article reviews the occurrence of voiding dysfunction after sling surgery and outlines the current evaluation and management of patients with these complaints.     

"ReMeEx", the adjustable-tension suburetral sling in the treatment of stress urinary incontinence due to intrinsic sphincteric dysfunction (type III)

The anti-incontinence methods "tension free" may be insufficient in the treatment of stress urinary incontinence (IUS) due to intrinsic sphincteric dysfunction (ISD). We report our findings on the use of the suburetral sling with adjustable tension "Remeex" sistem in the treatment of 24 patients. METHODS. Between May 2002 and February 2008, 24 patients with IUS of type III, were subjected to suburetral sling "Reemex." Positioning. The intervention provides a vaginal access to the positioning of suburetral sling and an access to the positioning of a varitensor which the wires are connected at the sling seats, recovered by the passage of a Stamey needle carrier of. The average operative time was approximately 70 minutes, the resignation was in I-II day. The tension of the sling was adjusted the day following intervention by turning the screw connected to the varitensor. Patients were followed with physical examination and completed the Korman's questionnaire about the quality of life. RESULTS. At a follow-up average 30 months, 21 patients (87.5%) were perfectly continent with improvement of quality of life. Among the complications, wound infection occurred in 2 patients (8%); 1 (4%) with mild recurrence IUS; 1 (4%) reported "de novo" urgency, 1 (4%) reported urinary retention. CONCLUSIONS. Our data show that the use of the suburetral sling "ReMeEx" is a effective option in the treatment of IUS due to ISD which is a condition often secondary to urogynecologic surgery and refractory to common techniques antincontinence.     

Risk Factors for De Novo Mixed Urinary Incontinence and Stress Urinary Incontinence Following Surgical Removal of a Urethral Diverticulum

Objectives: The aim of the present study was to investigate the risk factors for the development of de novo stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) after surgical removal of a urethral diverticulum (UD). Methods: We identified 35 consecutive women that underwent surgical removal of a UD between November 2002 and December 2009, and we retrospectively reviewed their medical records, including patient demographics, pelvic magnetic resonance imaging (MRI), presenting symptoms related to voiding, and outcomes. Results: Among the 35 patients we identified, 28 were included in the study. After UD removal, five of the 28 patients (17.8%) developed de novo MUI, and four of the 28 patients (14.2%) developed de novo SUI. The incidences of SUI and MUI were significantly higher in patients who had a UD that measured over 3 cm in diameter and in patients in whom the UD was located in the proximal urethra. Of the seven patients with a diverticulum over 3 cm, SUI occurred in three (42.8%) (P = 0.038) and MUI occurred in five (45.4%) (P < 0.001). Of the 11 patients with a diverticulum located in the proximal urethra, SUI occurred in five (45.4%) (P = 0.011) and MUI occurred in four (36.4%) (P = 0.011). Conclusion: Significant risk factors for the development of SUI and MUI after transvaginal simple diverticulectomy include a UD measuring over 3 cm and a UD located in the proximal urethra.     

Changing trends in the management of Klatskin tumor

BACKGROUND/AIMS: To evaluate the long-term outcome of a multidisciplinary approach for advanced Klatskin tumor involving the hepatic hilus. METHODOLOGY: A retrospective analysis was undertaken in 110 patients between 1993 and 2003. The patients were divided into Group A (n=42) and Group B (n=58). Group A patients underwent local excision of the tumor and Group B patients underwent combined tumor and liver resection with or without resection of the regional vascular structures. On admission, all patients underwent percutaneous transhepatic biliary drainage. Where hepatectomy was planned, portal vein branch ligation and transection was done ipsilateral to the liver lobe where the tumor was present. An arterial catheter was introduced into the hepatic artery at the end of the surgery, for adjuvant locoregional immunochemotherapy, which was carried out in all patients. The second-stage resectional surgery was carried out 35 days later. RESULTS: The overall mean survival for Group A patients was 29 months (range 14 to 76). The mean disease-free survival was 28 months (range 10-52). Five-year survival rate was 5% and five-year disease-free survival was 0%. The overall mean survival for Group B patients was 39 months (range 28 to 79). The mean disease-free survival was 32 months (range 17-72). Five-year survival rate was 20% and five-year disease-free survival was 10%. CONCLUSIONS: The concept of a multidisciplinary approach has significantly improved survival in patients with a grave disease like Klatskin tumor.     

Reinterventions on cardiac valve prosthesis

From January 1978 to December 1984, 214 patients underwent a total of 243 reoperations for repair or replacement of a prosthetic heart valve. On the basis of the number of valve reoperations in the same anatomic position within the heart, the patients were divided into three groups. Overall hospital mortality was 23.4% (CL 20.3-26.7) in Group I (214 patients), 48% (CL 36.1-60.1) in Group II (25 patients), 25% (CL 3.3-62.6) in Group III (4 patients). Hospital mortality appeared to be related to urgency of reoperation (p less than 0.001 in Group I; p = 0.037 in Group II), primary indication for reoperation (p = 0.034 in Group I; p = 0.022 in Group II), association with other cardiac surgical procedures (p = 0.00253 in Group I). Hospital mortality in Group I was significantly higher (p = 0.0056) when reoperation was performed within one year after valve replacement. No significant differences in urgency and emergency rate were noted between reoperations on mechanical heart valves and bioprostheses. No significant differences in bleeding complications were noted between reoperations and initial valve replacement. Mean follow-up is 37.4 +/- 21.8 months (range 2 to 85 months). Actuarial survival rate is 82.8 +/- 3.1% at 1 year, 78.7 +/- 3.5% at 2 years and 71.5 +/- 5.1% at 5 years; 90.9% (CL 87.4-93.6) of the followed patients are in I or II NYHA class. The results appear to suggest that when significant (on clinical or instrumental criteria) prosthetic disfunction is diagnosed, reoperation should be undertaken early to minimize operative risk. The Authors point out that surgery in such patients also ensures satisfying long-term results.     

Prospective Study Comparing the Suprapubic Arc (Sparc) Procedure and the Transobturator (Monarc) Procedure for Treating Female Stress Urinary Incontinence

Objectives: In a comparative trial we evaluated the efficacy and safety of the suprapubic arch (Sparc) and transobturator (Monarc) procedures for the treatment of female stress urinary incontinence (SUI). Methods: Between November 2003 and May 2004, 46 women with SUI who underwent the Sparc procedure and 42 women who underwent the Monarc procedure were analyzed. The preoperative evaluation included history taking, physical examination, voiding diary, stress and 1‐h pad tests and a comprehensive urodynamic examination. Postoperative evaluation included a stress test, 1‐h pad test, and uroflowmetry with postvoid residuals. Results: After 1 year of follow up, the rates of cure and satisfaction were 93.5 and 93.0%, respectively, in the Sparc group. The rates of cure and satisfaction were 95.2 and 85.7%, respectively, in the Monarc group. After 2 years of follow up, the rates of cure (93.5 vs 92.9%) and satisfaction (84.8 vs 83.3%) were similar between the two groups. No bladder injury occurred in the Monarc group. Bladder injury occurred in 6.5% (n = 3) of the patients in the Sparc group. Vaginal wall perforation occurred in 4.8% (n = 2) of the patients in the Monarc group (P > 0.05). Late complications included de novo urge symptoms (8.7 vs 11.9%) and voiding dysfunction (10.9 vs 9.5%). Conclusions: The transobturator Monarc procedure appears to be as efficient and safe as the retropubic Sparc procedure for the treatment of SUI.     

Treatment of severe post-prostatectomy stress urinary incontinence using AdVance sling

Severe stress urinary incontinence (SUI) is usually treated by the implant of artificial sphincter positioned around bulbar urethra. AdVance sling is a functional, non-obstructive, anti-incontinence device that showed good results especially for mild and moderate SUI. We present our experience with AdVance sling in 7 patients with severe SUI unfit for artificial sphincter. Our results, after a follow-up of more than 6 months, showed a continence rate of 28% and an improvement rate of 43%, while 2 patients did not show any benefit. The success of AdVance sling depends on the integrity of urethral sphincter and can be applied also in selected cases for the treatment of severe post-prostatectomy stress urinary incontinence.     

Lower urinary tract and bowel dysfunction after incontinence and prolapse interventions

The incidence of anti-incontinence procedures and surgery for prolapse repairs has increased significantly over the past decade. As more clinicians have embarked on performing these surgeries using new techniques and variations on traditional repairs, complications are starting to be recognized. We review the literature, focusing on postoperative lower urinary tract and bowel dysfunction following surgery for incontinence and pelvic prolapse. We performed a comprehensive review of the literature on interventions for urinary incontinence and pelvic prolapse using MEDLINE and resources cited in those peer-reviewed papers. Postoperative voiding dysfunction including symptomatic bladder outlet obstruction, de novo urgency and urge incontinence, and recurrent stress urinary incontinence appear to be the most common voiding issues after anti-incontinence surgery, with rates varying based on the type of sling used. Bowel dysfunction following prolapse surgery can occur after rectocele repair and sacrocolpopexy or other apical repair and may vary based on the surgical technique and graft reinforcement used. Success rates for incontinence and prolapse repairs remain stable. With the introduction of new techniques, it is important to consider potential postoperative bladder and bowel effects so that clinicians may counsel their patients appropriately prior to intervention.     

Evaluation and Treatment of Persistent Stress Urinary Incontinence after Male Anti-Incontinence Procedure – AUS or Sling

The two most common anti-incontinence procedures performed for postprostatectomy incontinence (PPI) are placements of the artificial urinary sphincter (AUS) and male sling. While both procedures offer high success rates, 10-30 % of patients after AUS and 20-45 % of patients after male sling require evaluation for persistent PPI. The goals of evaluation for persistent PPI should be to verify the diagnosis of stress urinary incontinence (SUI) and to assess for concurrent bladder dysfunction. If the initial procedure was an AUS, and recurrent intrinsic sphincter deficiency is diagnosed, it is vital to distinguish among mechanical failure, urethral atrophy and erosion. If a repeat sling is considered, it is necessary to verify the degree of intrinsic sphincter deficiency (ISD) and assess for persistent or recurrent proximal urethral mobility. Because of diminished urethral compliance that results from prior AUS or male sling surgery, implantation of an AUS remains the treatment of choice for persistent SUI, as it is the most reliable method of providing the circumferential urethral compression necessary for adequate coaptation even in the setting of urethral fibrosis.     

Monoprosthesis for simultaneous correction of stress urinary incontinence and cystocele: A 3-year follow-up

Background: Stress Urinary Incontinence (SUI) and cystocele can occur simultaneously because they have identical predisposing factors. This procedure reinforces pubourethral ligaments and the vesicovaginal fascia, solving SUI and Cystocele. Methods: 57 patients with grade III or higher cystocele were enrolled in this trial; SUI was present in 20% of patients (mean age: 57 years). NAZCA TC? was used as monoprosthesis. Prolapse was evaluated using the POP-Q System, sexuality using the FSFI questionnaire, and LUTS using the OAB-SF questionnaire. Results: After surgery, there were positive changes, sustained during the follow-up: SUI was cured in 80% patients; there was only one patient with de novo SUI and a single case of prolapse recurrence. Conclusions: These results suggest that NAZCA TC? is safe and effective, adding the advantage of correcting SUI at the same time.     

Patient Reported Goal Achievement Following the Midurethral Sling Procedure for Female Stress Urinary Incontinence

Objectives: Patient perspective is very important for evaluating surgical outcomes. We investigated patient reported goal achievement, overall satisfaction and objective outcome following the midurethral sling (MUS) procedure for female stress urinary incontinence (SUI). Methods: The study prospectively enrolled 88 SUI patients who underwent the MUS procedure between August 2006 and December 2006. Patient examination included medical history, physical examination and an urodynamic study prior to surgery. Before surgery, patients were shown a list and asked to nominate one goal which they most wanted to achieve with surgery (i.e., the target goal). The goals were classified as: symptom‐related, daily life‐related, personal relationship‐ and emotion‐related, and others. Before and after the surgery, patients completed a Bristol Female Lower Urinary Tract Symptom‐Short Form questionnaire. At 1 year postoperatively, patients were assessed in terms of achievement of the target goal, overall satisfaction and cure rate. Results: At the 1‐year follow‐up, overall target goals were achieved in 90.1% of patients, 82 (93.2%) patients were satisfied with the treatment, and 82 (93.2%) patients were cured. For most patients, the target goals were symptom‐related (47 patients, 53.4%). The patients whose goal achievement was less than overall goal achievement were significantly less satisfied than those who fully achieved their goal, and goal achievement was also related to objective cure. Conclusion: Achievement of patient goals was high and could be a good measure of surgical success following MUS for female SUI.     

Meta-analysis of four different surgical treatments for stress urinary incontinence

INTRODUCTION: Multiple surgical approaches for the correction of stress urinary incontinence (SUI) have been described. In an attempt to determine which procedure may be superior, we performed a meta-analysis comparing the needle suspensions (i.e. Gittes, Stamey), Raz, Burch/MMK colposuspension, and urethral sling. METHODS: The most complete 87 of 310 articles relating to the surgical therapy for SUI published between 1982 and 1995 were selected by Medline search for review. These articles incorporated patients operated on from 1965 to 1995. Fixed effects Baysian and variance weighted models were applied to derive estimates and confidence intervals. Bonferroni multiple comparison procedures wee also incorporated. RESULTS: The mean reported success rates were 81% for the needle suspensions, 84% for the Raz, 85% for the colposuspension, and 85% for the sling. There was a significant difference between the sling and needle suspension as well as between the colposuspension and needle suspension (P<0.05). There was no correlation between length of follow-up and the success rate (P>.05). CONCLUSION: There is currently a general impression among urologists that the sling has the best success rates for the treatment of SUI and that the Raz and colposuspension are clinically superior to the needle suspension. Recent literature also indicates a significant increase in the failure rate over time. Our meta-analysis of the best 25% of SUI papers does not support either view entirely. This may be due to publication bias and incomplete reporting by the authors. Prior to developing ever "improved" procedures, urologist must start to report their results in a consistent fashion to allow meaningful conclusions concerning the risks and benefits of our existing procedures.     

Chronic aortic insufficiency with major left ventricle failure.ion. Results of aortic valve replacement and study of prognosis

Twenty four patients with chronic aortic incompetence and major left ventricular dysfunction underwent aortic valve replacement. Left ventricular failure was responsible for severe symptoms: NYHA Classes III and IV. It was defined by the following haemodynamic criteria: LV ejection fraction (EF) 40 p. 100 (mean 37 +/- 13 p. 100), LV end diastolic volume 250 ml/m2 (mean 254 +/- 82 ml/m2), LV end diastolic pressure 20 mmHg (mean 26 +/- 10 mmHg), AV difference 6 vol p. 100 (mean 7,07 +/- 1,77). The mean cardiac index was 2,03 +/- 0,59 l/m2. Of the 24 patients, 9 died (Group A). There were 3 perioperative deaths and 6 deaths 5 to 60 months after surgery. One patient died suddenly after improving 3 years after surgery; 3 patients died with moderate persistent cardiac failure and 2 patients died without regression of cardiac failure after surgery. Of the 15 survivors, (mean follow-up 16 months), Group B, 6 were operated within the last three months and rapidly improved. Nine patients were followed up for 8 to 55 months after surgery and had significant symptomatic improvement (NYHA: Class II). No preoperative clinical, electrocardiographic or echocardiographic prognostic criteria were found to distinguish between these two groups of patients. There were no significant differences in cardiac surface area (1,89 +/- 34 compared to 1,95 +/- 23), LVEDP (26 +/- 11 compared to 26 +/- 10 mmHg), LVEDV (257 +/- 21 compared to 252 +/- 60 ml/m2), EF (31 +/- 11 compared to 40 +/- 13) or cardiac index (2,0 +/- 0,58 compared to 2,0 +/- 0,61 l/m2).(ABSTRACT TRUNCATED AT 250 WORDS)