Reconstructive surgery of the aortic valve is feasible with low mortality in many individuals with aortic regurgitation. Freedom from valve-related complications after valve repair seems superior compared to available data on standard aortic valve replacement.

Background— Vasodilatory therapy of Raynaud’s phenomenon represents a difficult clinical problem because treatment often remains inefficient and may be not tolerated because of side effects. Methods and Results— To investigate the effects of sildenafil on symptoms and capillary perfusion in patients with Raynaud’s phenomenon, we performed a double-blinded, placebo-controlled, fixed-dose, crossover study in 16 patients with symptomatic secondary Raynaud’s phenomenon resistant to vasodilatory therapy. Patients were treated with 50 mg sildenafil or placebo twice daily for 4 weeks. Symptoms were assessed by diary cards including a 10-point Raynaud’s Condition Score. Capillary flow velocity was measured in digital nailfold capillaries by means of a laser Doppler anemometer. While taking sildenafil, the mean frequency of Raynaud attacks was significantly lower (35±14 versus 52±18, P =0.0064), the cumulative attack duration was significantly shorter (581±133 versus 1046±245 minutes, P =0.0038), and the mean Raynaud’s Condition Score was significantly lower (2.2±0.4 versus 3.0±0.5, P =0.0386). Capillary blood flow velocity increased in each individual patient, and the mean capillary flow velocity of all patients more than quadrupled after treatment with sildenafil (0.53±0.09 versus 0.13±0.02 mm/s, P =0.0004). Two patients reported side effects leading to discontinuation of the study drug. Conclusions— Sildenafil is an effective and well-tolerated treatment in patients with Raynaud’s phenomenon.

Depending on individual root pathologic condition, both the remodeling and the reimplantation techniques appeared to have their individual merits. Both result in adequate restoration of aortic valve function and elimination of pathologic aortic dilatation.

Background-Reconstruction of the aortic valve for aortic regurgitation (AR) remains challenging, in part because of not only cusp or root pathology but also a combination of both can be responsible for this valve dysfunction. We have systematically tailored the repair to the individual pathology of cusps and root. Methods-Between October 1995 and August 2003, aortic valve repair was performed in 282 of 493 patients undergoing surgery for AR and concomitant disease. Root dilatation was corrected by subcommissural plication (nϭ59), supracommissural aortic replacement (nϭ27), root remodeling (nϭ175), or valve reimplantation within a graft (nϭ24). Cusp prolapse was corrected by plication of the free margin (nϭ157) or triangular resection (n ϭ36), cusp defects were closed with a pericardial patch (nϭ16). Additional procedures were arch replacement (nϭ114), coronary artery bypass graft (nϭ60) or mitral repair (nϭ24). All patients were followed-up (follow-up 99.6% complete), and cumulative follow-up was 8425 patient-months (mean, 33Ϯ27 months). Results-Eleven patients died in hospital (3.9%). Nine patients underwent reoperation for recurrent AR (3.3%). Actuarial freedom from AR grade ՆII at 5 years was 81% for isolated valve repair, 84% for isolated root replacement, and 94% for combination of both; actuarial freedom from reoperation at 5 years was 93%, 95%, and 98%, respectively. No thromboembolic events occurred, and there was 1 episode of endocarditis 4.5 years postoperatively. Conclusions-Aortic valve repair is feasible even for complex mechanisms of AR with a systematic and individually tailored approach. Operative mortality is low and mid-term durability is encouraging.

In this standardized experimental setting remodeling of the aortic valve provides significantly smoother valve movements. This might contribute to preservation of a better valve performance during long-term follow-up.

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SummaryBackground: Physical and mental stress as well as sexual activity are potential triggering factors of acute coronary events and sudden cardiac death.Hypothesis: These factors may also trigger recurrence of spontaneous ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators (ICDs).Methods: We performed a case-crossover study in 43 consecutive patients with 95 symptomatic, ICD-documented tachyarrhythmic events and calculated the relative risk of tachyarrhythmia recurrence during physical and mental stress. Physical and mental activity was graded on a 4-step intensity scale, and stress was defined as physical exertion or mental stress with an intensity grade ≥ II during or up to 1 h before arrhythmia recurrence. Relative risk was determined taking into account the habitual weekly stress frequency of each patient.Results: Physical stress was present in 26% (n = 25), mental stress in 24% (n = 23), and sexual activity in 2% (n = 2) of analyzed events. The weekly habitual stress frequency was 8 ± 8 (median 7) for physical stress, 6 ± 6 (median 4) for mental stress, and 0.5 ± 0.5 (median 0.25) for sexual activity. Thus, relative risk of arrhythmia recurrence during the presence of stress was 7.5 for physical activity (95% confidence interval [CI] 5.2-11.1), 9.5 (CI 6.3-14.5) for mental activity, and 7.5 (CI 2.3-24.8) for sexual activity.Conclusions: Physical and mental stress as well as sexual activity are factors that significantly increase relative risk of spontaneous recurrence of sustained ventricular tachyarrhyth-

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