Abstract Introduction: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. Objective: Identify predictors of clopidogrel following CABG. Methods: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. Results: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). Conclusion: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.

INTRODUÇÃO: O implante valvular aórtico percutâneo (IVAP) vem se desenvolvendo rapidamente nos últimos anos. A manipulação da valva aórtica degenerada pode acarretar complicações. O IVAP direto, sem pré-dilatação com balão e com menor manipulação, seria uma alternativa. O objetivo deste estudo é apresentar uma série de 8 casos de IVAP direto com seguimento a médio prazo realizado no Instituto de Cardiologia do Rio Grande do Sul. MÉTODOS: Série de 8 casos com descrição da técnica e resultados imediatos e a médio prazo do implante do dispositivo CoreValveTM sem valvuloplastia com balão. RESULTADOS: No total, 7 pacientes do sexo masculino e 1 do sexo feminino, com média de idade de 76 anos e EuroSCORE logístico variando de 6% a 62%, foram submetidos ao implante do dispositivo CoreValveTM. Houve significativa queda dos gradientes entre o ventrículo esquerdo e a aorta. Foram registrados três casos de insucesso do implante, um óbito no período pós-implante imediato e um óbito aos 6 meses, sem relação com o procedimento. No seguimento de um ano, não houve novos casos de implante de marca-passo e eventos embólicos. CONCLUSÕES: O IVAP direto sem pré-dilatação com balão mostrou-se uma alternativa potencialmente eficaz. Quando realizado com sucesso, determina melhora dos sintomas, diminuição sustentável do gradiente transvalvar aórtico e aumento da área valvar aórtica. Não está claro, contudo, qual o paciente e qual a condição anatômica ideal para essa abordagem. Estudos adicionais e seguimento mais prolongado ainda são necessários para definir o exato papel e as precisas indicações dessa variação da técnica.

BRACKGROUND: Percutaneous aortic valve implantation (PAVI) has been developing rapidly in recent years. The manipulation of the degenerated aortic valve may lead to complications. PAVI without balloon pre-dilatation may be an alternative. The objective of this study is to report a series of 8 cases of direct PAVI with midterm follow-up, performed at the Instituto de Cardiologia do Rio Grande do Sul. METHODS: Series of 8 cases with technical description and immediate and mid-term results of CoreValveTM device implantation without balloon pre-dilatation. RESULTS: A total of 7 male patients and 1 female patient, with mean age of 76 years and logistic EuroSCORE ranging from 6% to 62%, were submitted to the CoreValveTM device implantation. There was a significant decrease in the gradient between the left ventricle and the aorta. Three cases of implant failure, one death in the immediate post-implant period and one death at 6 months, with no relationship with the procedure, were reported. In the one-year follow-up, there were no new cases of pacemaker implantation and embolic events. CONCLUSIONS: Direct PAVI without balloon pre-dilatation proved to be a potentially effective alternative technique. When performed successfully, it improves symptoms, provides a sustainable aortic transvalvular gradient decrease and aortic valve area increase. It is not clear, however, which patients and what anatomical conditions are optimal for this approach. Additional studies and longer follow-up are still required to define the exact role and appropriate indications for this change in technique.

Cardiopatia isquêmica grave com angina refratária a formas convencionais de tratamento apresenta-se em uma crescente incidência. Para tratar angina refratária, terapias alternativas na tentativa de redução da isquemia miocárdica e alívio de sintomas têm sido estudadas. Neste contexto, a terapia gênica representa uma opção, pela possibilidade de induzir angiogênese, estabelecer circulação colateral e reperfundir miocárdio isquêmico. Diversos ensaios clínicos têm sido conduzidos e, com exceção de casos isolados e específicos de efeitos adversos, há indicação de segurança, viabilidade e potencial eficácia da terapia. O benefício clínico não está bem definido. Neste artigo, revisamos os ensaios clínicos que utilizaram terapia gênica para tratamento de pacientes cardiopatas isquêmicos. A abordagem inclui: (1) isquemia miocárdica e angiogênese, sobre os aspectos fisiopatológicos envolvidos; (2) fatores de crescimento, tratando sobre aspectos específicos e justificando a utilização em pacientes cardiopatas isquêmicos sem opções pela terapêutica convencional; (3) ensaios clínicos controlados, onde é apresentado um resumo dos principais estudos envolvendo terapia gênica para tratamento da cardiopatia isquêmica grave; (4) nossa experiência, especialmente sobre resultados preliminares do primeiro ensaio clínico de terapia gênica do Brasil e (5) perspectivas.

Severe ischemic heart disease with refractory angina, occurs in increasing incidence. Alternative forms of treatment, in an attempt to reduce myocardial ischemia and relief of symptoms has been studied. In this context, gene therapy is an option, for the possibility of inducing angiogenesis, establish collateral circulation and reperfuse ischemic myocardium. Several clinical trials have been conducted and, except for specific cases of adverse effects, there is indication of safety, feasibility and potential effectiveness of therapy. The clinical benefit, however, is not yet well established. In this article we review the clinical trials of gene therapy for patients with ischemic heart disease. The approach includes: (1) myocardial ischemia and angiogenesis on the pathophysiological aspects involved, (2) growth factors, dealing with specific aspects and justifying the use in cardiac patients with no option for conventional therapy, (3) controlled clinical trials, where a summary of the main studies involving gene therapy for severe ischemic heart disease is presented, (4) our experience, especially on preliminary results of the first gene therapy clinical trial in Brazil and (5) future prospects.

FUNDAMENTO: As vantagens do reparo valvar para tratamento de insuficiência mitral degenerativa estão bem estabelecidas. O procedimento está associado com baixas taxas de morbimortalidade, e foram relatados baixos índices de reoperação, eventos tromboembólicos e endocardite. Na maior parte das séries, são implantados anéis para anuloplastia, mas algumas instituições preferem valvoplastia sem suporte. OBJETIVO: Avaliar a evolução clínica de pacientes submetidos à valvoplastia sem suporte para tratamento de insuficiência mitral degenerativa. MÉTODOS: Entre janeiro de 1980 e janeiro de 2003, 116 pacientes foram submetidos ao procedimento. Sessenta e dois (53,4%) eram do sexo masculino, e a media de idade era 47,2 ± 16,5 anos. Os procedimentos empregados foram: Anuloplastia tipo Wooler (65,5%), anuloplastia unilateral (15,5%), ressecção quadrangular da cúspide posterior (35,3%), encurtamento de corda tendínea anterior (20,7%), encurtamento de corda tendínea posterior (6,9%) e desbridamento do cálcio (0,9%). O período médio de acompanhamento foi de 6,5 ± 5,1, e o acompanhamento mais longo foi de 24 anos. RESULTADOS: A mortalidade precoce foi de 0,86% (1 paciente), e a mortalidade tardia foi de 6,03% (7 pacientes). A sobrevida atuarial foi de 85,3% em vinte anos. A maioria dos pacientes (55,2%) apresentava classe funcional III no período pré-operatório, enquanto no período pós-operatório a classe funcional I foi mais freqüente (66,4%). Quatro pacientes (3,4%) tiveram complicações tromboembólicas, e não foi observada correlação com fibrilação atrial. A sobrevida livre de eventos tromboembólicos foi de 94,8%, e resultados semelhantes foram observados para endocardite bacteriana. A sobrevida livre de reoperação foi de 79% e 53% aos 5 e 10 anos, respectivamente. CONCLUSÃO: Valvoplastia sem suporte é um procedimento eficaz e seguro para tratamento de insuficiência mitral degenerativa, representando uma alternativa terapêutica adequada para determinados casos.

BACKGROUND: The advantages of valve repair for treatment of degenerative mitral regurgitation are well established. The procedure is associated with low mortality and morbidity rates, and low indices of reoperation, thromboembolic events and endocarditis have been reported. In most series, annuloplasty rings are implanted, but some institutions give preference to unsupported valvuloplasty. OBJECTIVE: To assess the clinical outcome of patients submitted to unsupported valvuloplasty for degenerative mitral regurgitation. METHODS: Between January 1980 and January 2003, 116 patients were submitted to the procedure. A total of 62 (53.4%) were men, and mean age was 47.2 ± 16.5 years. The procedures included: Wooler annuloplasty (65.5%), unilateral annuloplasty (15.5%), quadrangular resection of the posterior leaflet (35.3%), anterior chordal shortening (20.7%), posterior chordal shortening (6.9%), and calcium debridement (0.9%). Mean follow-up was 6.5 ± 5.1 years, and the longest follow-up was 24 years. RESULTS: Mortality was 0.86% (1 pt) early and 6.03% (7 pt) late. Actuarial survival was 85.3% in 20 years. Most patients (55.2%) presented preoperative NYHA functional class III, whereas class I was more frequent in the postoperative period (66.4%). Thromboembolic complications were observed in 4 patients (3.4%), and no correlation was seen with atrial fibrillation. Freedom from thromboembolic events was 94.8%, and similar results were observed for bacterial endocarditis. Survival free from reoperation was 79%, and 53% at 5 and 10 years, respectively. CONCLUSION: Unsupported valvuloplasty is effective and safe for treatment of degenerative mitral regurgitation, representing an adequate therapeutic alternative for selected cases.

OBJETIVO: Analisar os resultados de dois modos de tratar a fibrilação atrial (FA): com cirurgia do Labirinto e com Isolamento de Veias Pulmonares (IVP), comparando com grupo controle, para estabelecer o melhor tratamento aos portadores desta arritmia. MÉTODO:Todos os pacientes tinham indicação cirúrgica por outra lesão cardíaca, concomitantemente tratada. Foram randomizados 51 pacientes no período de julho de 1999 a setembro de 2003. Em nenhum paciente foi utilizada crioablação. Analisamos inicialmente as seguintes variáveis: tempo de circulação extracorpórea (CEC), pinçamento aórtico (ISQ), taxa de reversão a ritmo sinusal na alta hospitalar, e complicações do trans e pós-operatório imediato. RESULTADOS: Houve dois óbitos intra-hospitalares, um no grupo Labirinto e um no grupo IVP. O grupo Labirinto apresentou o maior tempo de CEC (p<0,001). Seguimento médio de 28,4±14,1 meses, sem diferença entre os grupos. O grupo IVP teve a maior taxa de sucesso com 84,2% de reversão a ritmo sinusal na alta e 88,9% após seguimento. No grupo Labirinto, 78,5% de ritmo sinusal à alta, e após seguimento, 84,6%. No grupo controle, 87,5% dos pacientes tiveram alta em FA, e após seguimento 56,3% seguem assim. A classe funcional pela NYHA não foi diferente entre os grupos após o seguimento (p=0,56), e os pacientes do grupo controle apresentaram mais complicações (p=0,017). CONCLUSÃO: Estes resultados mostram que qualquer das técnicas empregadas para correção de FA, Labirinto ou IVP, apresenta vantagens sobre a operação tradicional de simples correção de cardiopatias quando associadas à FA.

OBJECTIVE: To analyze the results of techniques in the treatment of atrial fibrillation: the Maze procedure and Isolation of Pulmonary Veins were compared together with Control group, to establish the best treatment for this arrhythmia. METHOD: All patients were referred for surgery due for other cardiac lesions, which were treated concurrently. From July 1999 to September 2003, fifty-one patients where randomly allocated to the different groups. No cryoablation or other source of energy was used. The following variables were initially analyzed: total bypass time, aortic clamping time, sinus rhythm at discharge, and trans-operative and immediate post-operative complications. RESULTS: There were two intra-hospitalar deaths, one in the Maze group and one in the Isolation of Pulmonary Veins group. The Maze group had the longest bypass time (p<0,001). The duration of follow-up of 28.4 ±14 months was similar between the groups. The Isolation of Pulmonary Veins achieved the best results concerning reversion to sinus rhythm with 84.2% at hospital discharge and 88.9% after follow-up. In the Maze group, 78.5% of sinus rhythm was seen detected at discharge and 84.6% at the end of follow-up. In the Control group 87.5% of the patients have atrial fibrillation at discharge and after follow-up atrial fibrillation remained at 56.3% of the patients. There was no difference in the NYHA class between the groups after follow-up (p=0.56) and Control group patients had more complications (p=0.017). CONCLUSION: These results show that both techniques, the Maze and Isolation of Pulmonary Veins, have advantages over simple correction of cardiac lesions when associated to atrial fibrillation.

OBJETIVO: Analisar a eficácia do isolamento cirúrgico das veias pulmonares para restabelecer ritmo sinusal em pacientes com fibrilação atrial secundária à doença mitral. MÉTODOS: 33 pacientes com indicação de correção cirúrgica da valva mitral e com fibrilação atrial permanente, foram submetidos ao isolamento cirúrgico das veias pulmonares, sendo 67% mulheres. Média de idade de 56,3±10 anos, classe funcional NYHA pré-operatória de 3,2±0,6, tamanho de átrio esquerdo de 5,5± 0,9 cm, fração de ejeção de 61,3±13%. A técnica cirúrgica consistiu de incisão circunferencial ao redor das 4 veias pulmonares, excisão do apêndice atrial esquerdo e de incisão perpendicular desde a borda inferior da incisão, isolando as veias pulmonares, até o ânulo da valva mitral. Arritmias precoces foram tratadas, agressivamente, com cardioversão. RESULTADOS: O seguimento médio foi de 23,9±17 meses e ocorreram 3 óbitos no pós-operatório. Dez pacientes necessitaram de cardioversão elétrica no pós-operatório; 87% apresentavam ritmo sinusal na última consulta e 33% estavam em uso de amiodarona. CONCLUSÃO: Isolamento das veias pulmonares associado à cirurgia da valva mitral é uma técnica efetiva e segura na manutenção de ritmo sinusal em pacientes com fribilação atrial permanente.

OBJECTIVE: To assess the efficacy of surgical isolation of the pulmonary veins for re-establishing sinus rhythm in patients with atrial fibrillation secondary to mitral valve disease. METHODS: Thirty-three (67% were women) patients with permanent atrial fibrillation and indication for surgical correction of the mitral valve underwent surgical isolation of the pulmonary veins. Their mean age was 56.3±10 years, preoperative NYHA functional class was 3.2±0.6, left atrial size was 5.5±0.9 cm, and ejection fraction was 61.3±13%. The surgical technique consisted of a circumferential incision surrounding the 4 pulmonary veins, excision of the left atrial appendage, and a perpendicular incision originating in the inferior margin of the circumferential incision isolating the pulmonary veins down to the mitral valve. Early arrhythmias were aggressively treated with cardioversion. RESULTS: The mean follow-up was 23.9±17 months, and 3 patients died in the postoperative period. Ten patients required electrical cardioversion in the postoperative period; 87% had sinus rhythm in the last medical visit, and 33% were using amiodarone. CONCLUSION: Isolation of the pulmonary veins associated with mitral valve surgery is an effective and safe technique for maintaining sinus rhythm in patients with permanent atrial fibrillation.

OBJETIVO: Dinâmica computacional foi utilizada para avaliar a influência de fatores geométricos no funcionamento de modelo da cirurgia de Blalock-Taussig modificada (BTm), ou interposição de enxerto de politetrafluoretileno (PTFE) entre as artérias subclávia e pulmonar. MÉTODO: A cirurgia de BTm, realizada em 10 pacientes, serviu para compor modelo geométrico tridimensional parametrizado, avaliado quanto a diferentes diâmetros de artéria subclávia e PTFE e ângulo proximal da anastomose. Foi empregado o código de dinâmica computacional FLOTRAN baseado no método de elementos finitos conhecido como "Streamline Upwind/Petrov-Galerkin". RESULTADOS: Nas simulações, a porcentagem de fluxo desviada pelo enxerto aumenta com a relação entre diâmetros do PTFE e da artéria subclávia. Um ângulo de 110º na anastomose proximal mostra maior porcentagem de sangue desviado, enquanto que 30º, 60º e 90º mostram desvios de fluxo quase similares. Contudo, ângulos de 30º e 110º tornam excessivo o fluxo pulmonar em uma das artérias pulmonares, em detrimento da outra. O pico de pressão no PTFE varia conforme o ângulo adotado, sendo maior em 30º . Quando o ângulo da anastomose aumenta, a região de maior pressão se desloca do enxerto para a artéria subclávia. CONCLUSÕES: No modelo experimental, o diâmetro do enxerto de PTFE é regulador principal da porcentagem de fluxo desviado. Na análise computadorizada, um ângulo de 60º a 90º entre artéria subclávia e enxerto de PTFE parece mais adequado para anastomose, considerando-se percentagem de fluxo desviado, sua distribuição entre ramos pulmonares e pico de pressão na zona da anastomose.

OBJECTIVES: To study the influence of geometric factors upon the function of modified Blalock-Taussig anastomoses (mBT) using a computational dynamic code based upon the method of finite elements. METHODS: The mBT operation, performed in 10 patients, was graphically reconstructed to create a parametric 3-dimensional geometric model. Using Streamline Upwind/Petrov-Galerkin approximations, blood flow and distribution were evaluated in different diameters of subclavian arteries and polytetrafluoroethylene grafts (PTFE) and angles of proximal anastomoses. RESULTS: The percentage of blood flow derived through the PTFE grows as its diameter increases in relation to subclavian artery diameter. Variations in the PTFE diameter do not interfere with pulmonary artery flow distribution. An angle of 110º in proximal anastomoses results in a high percentage of blood derivation to the graft, while angles of 30º, 60ºand 90º present with almost similar flow rates. However, angles of 30º and 110º produce an excessive flow to one of the pulmonary arteries, in detriment of the other. Peak pressure in the PTFE is affected by the proximal angle of anastomosis, with 30º resulting in higher and 110º in lower values. As the angle increases, the region of higher pressure shifts from the PTFE to subclavian artery. CONCLUSION: In the experimental model, percentage of flow derived in the PTFE is directly related to the diameter of the graft. The ratio between the diameters of subclavian artery and graft is an important regulator of flow deviation to the anastomosis. Angles of the anastomosis between the subclavian artery and the PTFE of 60º to 90º result in favorable pulmonary artery flow distribution and the location of the peak pressure.

OBJECTIVE: To assess the occurrence of late thromboembolism after surgical repair of chronic atrial fibrillation (AF) simultaneously with repair of mitral valve using the Cox-Maze procedure. METHODS: 69 patients underwent Cox 3 procedure, with no cryoablation simultaneously with mitral valvuloplasty or prosthesis. Mean age was 49.9±13.2 years. Mean follow-up was of 31.7±19 months. Types of lesion were as follows: 33 (48%) stenoses, 23 (33%) insufficiencies, and 13 (19%) double lesions. Procedures were: 64 (93%) valvuloplasties, 3 (4%) biological and 2 (3%) mechanical prosthesis placement. There were 9 (13%) patients with previous systemic embolism and 2 (3%) had left atrial thrombi. RESULTS: Early mortality was 7% and late 1%. 2 patients (3%) were reoperated for mitral placement. At last evaluation, 10 patients (15%), were in AF. The remaining 59 (85%) were either in sinus / atrial rythm (74%) or under pacing (12%). There were no occurrence of early or late, systemic or pulmonary embolism. Permanent anticoagulation was employed in 16 cases, 10 in regular rythm and 6 in AF. The remaining 47 (75%), 2 in AF and 45 in regular rythm, did not receive anticoagulants. CONCLUSIONS: These results are in accordance with others series, where the occurrence of embolism was rare after maze procedure. Permanent systemic anticoagulation seems to be unnecessary in those cases.

OBJECTIVE: To analyze late clinical evolution after surgical treatment of children, with reparative and reconstructive techniques without annular support. METHODS: We evaluated 21 patients operated upon between 1975 and 1998. Age 4.67±3.44 years; 47.6% girls; mitral insufficiency 57.1% (12 cases), stenosis 28.6% (6 cases), and double lesion 14.3% (3 cases). The perfusion 43.10±9.50min, and ischemia time were 29.40±10.50min. The average clinical follow-up in mitral insufficiency was 41.52±53.61 months. In the stenosis group (4 patients) was 46.39±32.02 months, and in the double lesion group (3 patients), 39.41±37.5 months. The echocardiographic follow-up was in mitral insufficiency 37.17±39.51 months, stenosis 42.61±30.59 months, and in the double lesion 39.41±37.51 months. RESULTS: Operative mortality was 9.5% (2 cases). No late deaths occurred. In the group with mitral insufficiency, 10 (83.3%) patients were asymptomatic (p=0.04). The majorit y with mild reflux (p=0.002). In the follow-up of the stenosis group, all were in functional class I (NYHA); and the mean transvalve gradient varied between 8 and 12mmHg, average of 10.7mmHg. In the double lesion group, 1 patient was reoperated at 43 months. No endocarditis or thromboembolism were reported. CONCLUSION: Mitral stenosis repair has worse late results, related to the valve abnormalities and associated lesions. The correction of mitral insufficiency without annular support showed good long-term results.

INTRODUÇÃO: Fibrilação atrial tem sido tratada pelo procedimento do Labirinto (Cox) e suas modificações. Há, no entanto, evidências de que o isolamento dos óstios das veias pulmonares ou exclusão do átrio esquerdo poderia ser eficaz para este fim. CASUÍSTICA E MÉTODOS: Avaliamos os resultados iniciais da técnica simplificada de isolamento cirúrgico dos óstios das veias pulmonares para tratar fibrilação atrial crônica em pacientes operados por lesão valvar mitral. Foram tratados 7 pacientes por esta técnica (grupo IVP) e comparados com série prévia de 57 casos submetidos a cirurgia do Labirinto (Cox 3). RESULTADOS: A idade média foi de 49±8 anos vs 49±11 anos, (IVP vs. Cox3), sendo 71% e 72% (IVP vs. Cox 3) do sexo feminino. Dimensões do átrio esquerdo 5,5±0,7 cm vs. 6,0±1,1 cm (IVP vs. Cox 3). Fração de ejeção ventricular 63±10% vs. 64±6% (IVP vs. Cox 3). Tempo CEC 91±33 min vs. 104±29 min (IVP vs. Cox 3). Tempo de isquemia71±23 min vs. 83±26 min (IVP vs. Cox 3). Ritmo pós-operátório sinusal/atrial n(%): 6(86) vs. 46(80) (IVP vs. Cox 3). Ritmo marcapasso n(%):1 (14) vs. 4 (7) (IVP vs. Cox 3). Fibrilação atrial n(%): 0 vs. 7 (13) (IVP vs. Cox 3). CONCLUSÕES: Resultados iniciais mostram reversão a ritmo sinusal na maioria dos casos em ambos procedimentos e manutenção do ritmo a longo prazo. Foi iniciado estudo prospectivo randomizado para avaliar o IVP comparativamente ao procedimento Cox 3.

INTRODUCTION: Atrial fibrillation, nowadays, has been treated surgically by the maze procedure and its modifications. However, there is some evidence that points to the pulmonary vein ostia as trigger point for this arrhythmia. We postulate a surgical approach of pulmonary vein isolation or left atrial isolation in order to treat this disease. In this study we show the initial results of this technique in patients with chronic atrial fibrillation associated with mitral valve disease. MATERIAL AND METHODS: Seven patients were operated on by pulmonary vein isolation (IVP) and compared to the past results of the 57 patients in which the maze procedure had been done (Cox 3). RESULTS: Age - 49±8 years vs. 49±11 years (IVP vs. Cox 3), 71% and 72% (IVP vs. Cox 3) were female. Left atrium size was 5.5±0.7 cm vs. 6.0±1.1 cm (IVP vs. Cox 3). Ventricular EF 63±10% vs. 64±6% (IVP vs. Cox 3). Extracorporeal circulation time 91±33 min vs.104±29 min (IVP vs. Cox 3). Aortic cross-clamping 71±23 min vs. 83±26 min (IVP vs. Cox 3). Cardiac rhythm: sinusal / atrial n(%): 6(86) vs. 46(80) (IVP vs. Cox 3). Cardiac pace rhythm n(%):1 (14) vs. 4 (7) (IVP vs. Cox 3). Atrial fibrillation n(%):0 vs. 7 (13) (IVP vs. Cox 3). CONCLUSIONS: The initial results show sinus rhythm restoration and its maintenance. We have already started a double-blind randomized trial between these two surgical techniques.