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Abstracts for The European Society for Cardiovascular Surgery 53rd International Congress, Ljubljana, Slovenia, June 2--5, 2004

C1.1

MAGNETIC ANASTOMOSIS IN MIDCAB SURGERY

Klima U., Fischer S., Maringka M., Kirschner S., Bagaev E., Haverich A.

Hannover Medical School Thoracic- and Cardiovascular Surgery

Objective: The MIDCAB procedure is a well established operative procedure. However it is technically demanding and is therefore somewhat under-utilised. New automatic anastomotic devices might facilitate anastomoses in small access beating heart surgery. We evaluated the clinical and angiographic outcome of patients undergoing a MIDCAB procedure with the Ventrica MVP^® System. This system maintains a secure anastomosis by the magnetic coupling of two specially designed magnetic graft and target artery ports

Methods: A Ventrica MVP System was used in 20 selected MIDCAB patients (12 male; mean age 62.4±10.8 yrs). The system consists of 6 magnetic clips, 3 clips forming a set. One magnetic clip set is positioned at the arteriotomy of the target artery and of the bypass graft using a pre-loaded delivery system. These ports then form an anastomosis by magnetic coupling. The MIDCAB operation was performed via a lateral minithoracotomy on the beating heart. Seventen procedures required no machanical stabilization during the anastomosis. Three patients had an angiogram at the time of discharge and 12 patients 6 month after surgery.

Results: The mean anastomotic time was 138.0±136.2 secs. Ischemic time during the anastomosis was 70.0±49.5 secs. The total procedure time was 124.4±14.4 min. There were no in-hospital complications and no device-related adverse events. All 3 predischarge and 12 six months angiograms showed patent anastomoses. One graft showed TIMI III flow requiring PTCA and stenting of the native LAD.

Conclusions: The magnetic vascular port facilitates the MIDCAB procedure significantly and reduces the ischemic time during the anastomosis. Hence, this minimally invasive procedure has the potential to be an alternative to PTCA and stenting in proximal LAD stenosis and may expand the acceptance of hybrid procedures.

C1.2

APPLICATION OF BONE MARROW DERIVED STEM CELLS IN COMBINATION WITH TRANSMYOCARDIAL LASER REVASCULARISATION REGENERATES ISHEMIC MYOCARDIUM

Ghodsizad A., Klein M., Borowski A., Gams E.

University of Duesseldorf Department of Thoracic and Cardiac surgery; Heinrich-Heine University; Thoracic and Cardiovascular Surgery; Heinrich-Heine-University Visceral and General Surgery

Objective: To restore tissue viability in ischemic myocardium not amenable to coronary bypass grafting transplantation of bone marrow derived stem cell (BMC) and Transmyocardial Laser Revascularisation (TMLR) have been used in clinical setting.

Methods: A new method for intraoperative isolation of AC 133+stem cells during a limited period of time was developed and used in 8 patients. Autologous AC 133+stem cells were injected in a defined constellation in predefined region within hibernating myocardium of the anterior wall, which was not amenable to CABG in all patients. The last two patients were therapied with AC 133+cell and TMLR alone.

Results: The intraoperative processing of AC 133+stem cells is safe and effective. We were able to isolate up to 9 x10(6) autologous AC 133+bone-marrow cells with a purity of up to 97%. Improvement of the regional function in the predefined region was observed 3 months postoperatively. Two patients (AC 133+stem cell therapy and TMLR as sole therapy) showed marked improvement of perfusion and contractility.

Conclusions: Our method of rapid cell isolation opens new perspectives for intraoperative application of stem cells for patients scheduled for elective and for emergency revascularisation. We see the combination of TMLR and stem cell application as a new therapeutic option for regeneration of ishemic myocardium.

C1.3

EMERGENCY MYOCARDIAL REVASCULARIZATION FOR ACUTE CORONARY INSUFFICIENCY

Papadakis, Fragoulis S., Astras G., Triantafillou C., Vassili M., Lidoriki E., Palatianos G.

Onassis Cardiac Surgery Center Third Department of Cardiac Surgery

Objective: Emergency myocardial revascularization (EMR) for acute coronary insufficiency (ACI) is associated with increased morbidity. To evaluate the effectiveness of our surgical protocol for EMR, we reviewed our 10-year experience with coronary artery bypass.

Methods: From 11/1993 to 12/2003, 4727 adult cardiac surgery operations were performed in our Department. Of them, 3340 were isolated coronary revascularizations. EMR for ACI was performed in 34 patients (1.02%). ACI expressed with electrocardiographic changes and hemodynamic instability. Unstable angina was present in 6 patients. Seven patients had an evolving myocardial infarction, and 2 had infarct-related mechanical complications. ACI was diagnosed during angioplasty in 17 patients and during catheterization in 2. Prompt EMR was performed upon presentation of ischemia and unstable hemodynamics. Intraaortic balloon was placed preoperatively in 31 patients and intraoperatively in 3. Cardiopulmonary bypass (CPB) was used in 32 patients. Intraoperative myocardial protection included cold (7 °C) blood cardioplegia delivered retro- and antegrade and leukocyte-filtered myocardial reperfusion. The remaining 2 patients were operated without CPB. Arterial grafts were implanted in 17 patients (50%). Six patients had to be transferred to the ICU with an open sternum to control hemodynamic instability or bleeding. They had a delayed sternal closure.

Results: Operative mortality was 1 patient (2.9%) presented with unstable angina 6 years after coronary artery bypass who died the 4th postoperative day of multiple organ failure and sepsis after EMR without CPB. Overall ICU stay was 2.5 to 8.5 days, mean 5.5 days. The following major postoperative complications occurred: Low cardiac output (n=12), bleeding requiring exploration (n=6), acute renal failure requiring dialysis(n=6), peripheral vascular complications (n=3) and jaundice (n=6).

Conclusions: EMR for ACI using prompt surgical intervention and advanced myocardial protection technique can be performed with satisfactory results.

C1.4

A 7-YEAR FOLLOW UP OF PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING WITH A LEFT VENTRICULAR EJECTION FRACTION OF 30% OR LESS

Le Guyader A.

CHU Dupuytren Thoracic and Cardio-Vascular Surgery

Objective: Evaluation of long term results in coronary artery bypass grafting patients with an ejection fraction of 30% or lower.

Methods: From 1992 to 1999, patients with severely depressed left ventricular function (ejection fraction of 25.2+/– 4.5%) undergoing on-pump coronary artery bypass grafting were evaluated in our institution. The long term follow-up was evaluated clinically and by echocardiography.

Results: Fifty patients (63.8+/– 8.8 years old) were recruted, 70% had a 3-vessel disease. Hospital mortality occured in 3 patients (6%), 2 from a ventricular fibrillation and one acute myocardial infarction. The mean follow up was 5.6+/– 2.6 years. The actuarial survival was respectively at 1, 2, 5 and 7 years 92, 84, 65 and 54%. Half of the patients died from a cardiologic event (4 myocardial infarction, 4 cardiac decompensation with pulmonary oedema and 3 ventricular arythmias). The free actuarial survival of non cardiologic events was respectively at 1, 2, 5 and 7 years 92, 87, 74 and 70%. 78% patients were free of angina and 73% were NYHA II or less. The echocardiography performed in 27 patients did not significantly improved after surgery

Conclusions: Myocardial revascularisation was able to provide these patients improvement of life expectancy and freedom of recurrent angina and severe dyspnea. CABG still represents a good alternative to heart transplantation for patients with severely depressed left ventricular ejection fraction when coronary arteries are accessible to revascularisation.

C1.5

CARDIAC REVASCULARISATION IN DIABETIC PATIENTS-OUR EXPERIENCE

Tomaszewski P., Foremny, J., Dunas-Tomaszewska E., Krason M., Knapik P., Zembala M.

Silesian Centre for Heart Disease Department of Cardiology; Silesian Centre for Heart Disease; Department of Cardiac Surgery and Transplantology; Silesian Centre for Heart Disease Department of Cardioanesthesia

Objective: Hyperglicemia is a risk factor for death and complications after coronary artery surgery. We measured the association between perioperative blood glucose level in diabetics and non-diabetics for

Methods: Patients groups

• Group I (182 pts) - insulin treated DM
  
• Group II (51 pts) - drug treated DM
  
• Group III (47 pts.) - new developed DM
  
• Group IV (849 pts.) - non-diabetic patients (control group)
  

Patients were treated with continuous insulin infusion using "sliding scale" in group A or modified Portland Protocol in group B, to keep average glucose level between 120 and 180 mg% (6.7-10.0 mmol/l).Outcomes were 30-day mortality, low cardiac output syndrome, cardiac arrhythmias, infections rates and resources

Results: In Silesian Heart Center from 1.10.2002 to 1.09.2003, 1130 patients underwent elective coronary procedures. Among them, 280 patients (24.78%) were with hyperglycemia. Type of operations and complications were showed in table below. Table 14

Conclusions: The results of cardiac revascularisation in diabetics are as good as in non-diabetic population if in perioperative period we keep them normoglicemic.

C1.6

OPCAB IN HIGH-RISK PATIENTS: BETTER EARLY OUTCOME BUT MORE RECURRENCE OF ANGINA

Caus T., Bakkali A., Serée Y., Khairi M., Marin P., Metras D.

University Hospital Timone, Department of Adults Cardiac Surgery

Objective: To compare outcome of CABG performed ON or OFF-pump for a consecutive series of 308 patients operated on by a same surgeon trained to both techniques.

Methods: Monocentric study including all patients operated on for CABG through median sternotomy between 2000 and 2002. All mono-lesions concerning LAD were electively treated OFF-pump as well as multivessel diseases especially in high-risk patients. Expected mortality was given by the Euroscore value assessed pre-operatively for each patient. Patients with an Euroscore 5 were categorized as "high-risk".

Results: Both techniques were equally employed (154 patients each). Patients with left main or multivessel disease were more often treated ON-pump (p=0.001 each respectively) resulting in a higher mean number of anastomosis per patient in the ON-pump group (3.1±0.8 vs. 2±0.8, p=0.001). Expected mortality in the ON and OFF-pump groups was 3.5±2.3% and 4.3±2.9% (p=0.017) for an observed mortality of 2.6% and 1.3% respectively. Difference in preoperative prognosis was mainly due to a higher proportion of patients with LV dysfunction (p=0.003) or critical status (p=0.02) in the OFF-pump group. Moreover, within multivessel disease cases treated OFF-pump, the proportion of high-risk patients was higher (p=0.028). Survival at three years was 91.5 and 93.8% in the ON and OFF-pump groups respectively. During on-going follow-up 2.6% of patients operated ON-pump presented recurrence of angina versus 6.6% operated OFF-pump (p=0.17)

Conclusions: Promoting OFF-pump CABG for complete revascularization in high-risk patients is an appropriate alternative strategy to conventional ON-pump surgery despite a slight increase in residual or new onset of angina post-operatively.

C1.7

INFLUENCE OF OBESITY ON IN-HOSPITAL AND EARLY MORTALITY AND MORBIDITY AFTER MYOCARDIAL REVASCULARIZATION

Noyez L.

University Medical Center St. Radboud Nijmegen Cardiac Surgery 414

Objective: Obese patients are thought to have an increased risk for complications in coronary artery bypass surgery. Several risk stratification systems do not identified obesity as a variable for risk adjustment. The aim of this study was to evaluate the in-hospital and early (one year) mortality and morbidity in obese and non-obese patients after a CABG in the UMC St Radboud.

Methods: The data of 1130 patients undergoing a myocardial revascularization from January 2000 to August 2002 were analyzed. Obesity was measured by the body mass index. A BMI 30 kg/m2 was defined as obese. We compared 206 obese patients with 924 non-obese patients. Uni- and multivariate analysis was used to analyze the results. The one-year survival was analyzed using Kaplan-Meier methods.

Results: There were no significant differences between obese and non-obese patients according to postoperative myocardial infarction, re-operation for bleeding, in-hospital mortality, renal complications, neurological complications, pulmonary complications, gastrointestinal complications, reintubation, re-admission on intensive care, ventilation time, days on intensive care, days in hospital and late mortality. Only the incidence of postoperative wound infections was increased in obese patients, 8.3% in the obese versus 4.4% in the non-obese (p=0.02) Multivariate analysis identified obesity only as risk factor for postoperative for wound infections (p=0.04, odds ratio:1.97)

Conclusions: Obese patients do not have an increased risk of in-hospital and early (1 year) mortality after CABG. However, obese patients have an increased risk of postoperative wound infections compared to non- obese patients.

C1.8

BENEFICIAL EFFECTS OF TOTAL ARTERIAL GRAFTING IN DIBETIC PATIENTS UNDERGOING CORONARY SURGERY

Muneretto C., Bisleri G., Negri A., Manfredi J., Gavezzoli D.

European Society Cardiovascular Surgery UDA di Cardiochirurgia; University of Brescia Medical School Cardiac Surgery; University of Brescia Medical School Cardiac Surgery; University of Brescia Medical School Cardiac Surgery; University of Brescia Medical School Cardiac Surgery

Objective: Several studies reported that diabetes is an independent risk factor for adverse outcome after coronary surgery. However, data are lacking regarding the influence of the type of conduit (arteries vs veins) used for myocardial revascularization in diabetics. We therefore assessed the advantages of total arterial myocardial revascularization in a specific population of diabetic patients.

Methods: Between 1999 and 2002, 110 of 502 diabetics underwent CABG with total arterial grafts (Group 1,G1) at our institution. These patients were compared to 110 diabetics who underwent conventional CABG using saphenous veins (Group 2,G2), matched for Euroscore, age, smoking history, obesity, hypertension, LVEF, previous myocardial infarction, peripheral vascular disease and COPD.

Results: Patients in both groups had a similar number of diseased coronaries (G1=2.7 vs G2=2.8) and received a similar number of grafted vessels (G1=2.3 vs G2=2.4). Both groups showed comparable early outcomes regarding ventilatory support (G1=10.65 vs G2=10.55 hrs), ICU stay (G1=2611 vs G2=2512 hrs) and incidence of post-operative complications, such as atrial fibrillation (G1=24.5% vs G2=27.2%), myocardial infarction (G1=1.8% vs G2=2.7%), sternal wound complications (G1=4.5% vs G2=3.6%), renal insufficiency (G1=4.5% vs G2=5.4%) and prolonged ventilatory support (G1=5.4% vs G2=4.5%). Hospital mortality was 2.7% in both groups. Angiography, completed at 18 months in 63.5% and 66.3% of hospital survivors in G1 and G2 respectively, demonstrated a significantly higher patency rate in G1 (G1=97.5% vs G2=87.7%; p<0.05) with 4 occluded arterial conduits (3 radial arteries and 1 right ITA) in G1 and 21 occluded saphenous vein grafts in G2. Patency of the LITA/LAD grafts was 100% in both groups. At mean follow-up of 229 months, patients in G1 showed a significantly lower incidence of recurrent myocardial ischemia(G1=5 vs G2=18 pts;p<0.05), myocardial infarction(G1=3 vs G2=11 pts;p<0.05) and coronary reintervention (G1=1 vs G2=13 pts;p<0.01), while late deaths were similar in both groups (G1=3 vs G2=4 pts;p=NS).

Conclusions: Total arterial grafting in diabetic patients was associated with a considerable improvement in mid-term graft patency along with a significantly decreased incidence of late cardiac events when compared with conventional CABG surgery. The use of arterial conduits should be therefore preferred to venous grafts, especially in presence of diabetes.

C1.9

OFF-PUMP SURGERY FOR CORONARY ARTERY REVASCULARIZATION: EXPERIENCE IN A SINGLE INSTITUTION

Djordjevic M., Thalmann M., Wandschneider W.

LKH Klagenfurt Abteilung für Herz-und Thoraxchirurgie

Objective: There is still an ongoing debate about the role of opcab surgery in myocardial revascularisation although numerous papers report benefits and/or superiority of opcab surgery, especially in high risk patients.

Methods: Of 1624 isolated cabg procedures performed between march 1998 and december 2003, 535 patients (33%) were operated on using the opcab technique. 20 patients underwent a midcab procedure. retrospective data analysis of those 535 patients included demographic factors, pre-operative risk score (euroscore), operative details, clinical outcomes and early follow-up data.

Results: Average graft number was 2,4 grafts/patient (range 1-5 grafts). 40 patients were converted to a conventional on-pump procedure (conversion rate 7.5%). Hospital mortality was 3.0% (16 patients, including 3 patients in the conversion group; mortality rate in the conversion group was 7.5%). Early graft failure was found in 2 patients. both of them underwent early redo surgery with the opcab technique again. postoperative atrial fibrillation rate was 15%. The rate of cerebrovascular accident was 0.9%.

Conclusions: Opcab technique yield excellent results in routine coronary artery revascularisation. The average number of grafts and the rate of complete revascularisation are equivalent to on-pump procedures. Necessity for conversion to on-pump operation and early graft failure were both independent risk factor for high intrahospital mortality and morbidity.

SCIENTIFIC SESSION C2 MISCELLANEOUS

C2.1

NOVEL PHARMACODYNAMIC ASSAYS OF T-CELL FUNCTIONS FOR THERAPEUTIC DRUG MONITORING IN HEART TRANSPLANT RECIPIENTS

Barten, M.D. M., Rahmel A., Garbade J., Richter M., Mohr F., Gummert J.

University Leipzig, Heart Center Leipzig Cardiac Surgery; University Leipzig, Heart Center Leipzig Cardiac Surgery; University Leipzig, Heart Center Leipzig Cardiac Surgery; University Leipzig, Heart Center Leipzig Cardiac Surgery; University Leipzig, Heart Center Leipzig Cardiac Surgery; University Leipzig, Heart Center Leipzig Cardiac Surgery

Objective: Recently, sirolimus (SRL) has been proved to be an optional drug for recovery of renal dysfunction caused by cyclosporine (CsA) or tacrolimus (TRL) in heart transplant recipients (HTx). However, the unknown absolute bioavailability and the large inter- and intra-individual variability of the blood concentrations (pharmacokinetic, PK) of SRL make therapeutic drug monitoring (TDM) only relying on measuring PK of SRL problematic. Therefore, we assessed the pharmacodynamics (PD) of SRL after switch from CsA or TRL immunosuppression in HTx with severe renal dysfunction using our novel PD assays of T-

Methods: 8 HTx were treated 28 h after the last CsA or TRL dose with a fixed SRL dosing regime QD: 6 mg/kg at day 1; 2 mg/kg at days 2 and 3. All patients received mycophenolate mofetil (MMF) co-therapy 0.5 or 1 gm BID. SRL was always given 4 h after the other morning medication. PK-levels for CsA, TRL and SRL were measured with LC-MS/MS. PD effects on expression of diverse T-cell functions in whole blood were assessed with FACS: proliferation (PCNA, BrdU), activation receptors (CD25, CD71, CD95, CD134, CD152, CD154) or cytokine production (IFN-g, TNF-a, IL-2, -4, -8, -10).

Results: Examples of 2 patients show the individual data of PK and PD at Ctrough under SRL (days 1—3) compared with PK and PD before SRL therapy (day 0): Patient I: day 0: CsA: 151 ng/ml, BrdU: 1%, CD25: 7%, CD95: 15%, TNF-a: 12%; day 1: SRL 8.4 ng/ml; BrdU: 6%, CD25: 17%, CD95: 11%, TNF-a: 19%; day 2: SRL 15.7 ng/ml, BrdU: 4%, CD25: 11%, CD95: 14%, TNF-a: 25%; day 3: SRL 5.4 ng/ml, BrdU: 2%, CD25: 25%, CD95: 14%, TNF-a: 23%; Patient II: day 0: TRL 8 ng/ml, CD25: 9%, CD95: 14%, TNF-a: 20%, day 1: SRL 4.3 mg/L, BrdU. 7%, CD25: 6%, CD95: 4%, TNF-a: 18%; day 2: SRL 11 ng/ml, BrdU: 5%, CD25: 8%, CD95: 8%, TNF-a: 9%; day 3: SRL 5.4 ng/ml, BrdU: 4%, CD25: 8%, CD95: 5%, TNF-a: 6%.

Conclusions: For the first time, the switch of immunosuppression in HTx was assessed using novel PD assays of diverse T-cell functions in whole blood. These data show that PK monitoring does not always predict the immunosuppressive effect actually achieved. TDM by assessing the PD effects on T-cell functions may be a useful tool for individual monitoring of immunosuppressive drugs to avoid toxicity and enhance efficacy.

C2.2

IMPACT OF SUB-OPTIMAL DONORS ON THE IMMEDIATE POST OPERATIVE OUTCOME AFTER EMERGENCY HEART TRANSPLANTATION

Forni A., Faggian G., Favaro A., Innocente F., Mazzucco A.

Division of cardiac surgery verona heart transplant; division of cardiac surgery heart transplant; division of cardiac surgery heart transplant; division of cardiac surgery heart transplant; division of cardiac surgery

Objective: To evaluate the impact of organs retrieved from sub-optimal donors on the early outcome after emergency heart transplantation (HTX) our experience was reviewed. Inclusion criteria for sub-optimal donors were: age over than 45 y., one or more episodes, either of cardiac arrest, or, of prolonged hypotension and the infusion of inotropic drugs at high dosage.

Methods: Among 200 pts. undergone to HTX from May 1994 to December 2003, 25 pts. had their OHT performed as an emergency procedures. There were 4 females (16%) and 21 males (84%), ranging in age from 18 to 67 years. They were considered on status one according UNOS classification. Indications for surgery were: chronic rejection, 4%, acute graft's failure, 4%, post cardiotomy syndrome, 15%, failed PTCA, 8%, and end stage heart diseases, 68%. Preoperative mechanical assistance devices employed were either Intra Aortic Pump, (IABP) in 88%, or Left—Right Ventricular assisting devices (L VAD, R VAD) along with IABP in the remaining 12%. Patients (7 pts., 28%,) who had organs retrieved from sub optimal donors were assigned to Group1, while the remaining 17 pts. were enrolled in Group 2. No statistically signaficant difference in terms of age distribution and indication for surgery were detected among the two groups.

Results: Four pts. (16%, 2 G1 and 2 G2, p.v., n.s.) died in the immediate post operative postoperative period. Causes of death were: acute graft's failure (1 G1 and 1 G2 pt., p.v. n.s.) and infections (1 G1 and 1 G2 pt.., p.v. n.s). Morbidity cofactors such as renal failure, respiratory failure, multiple organs failure, did not show any statistically significant difference among the two groups.

Conclusions: The use of sub-optimal donors does not influence early post operative outcome and may expand the present reduced donor's pool.

C2.3

PROMISING RESULTS OF CARDIAC SURGERY AFTER RENAL TRANSPLANTATION

Berman M.

Rabin Medical Center, Beilinson Campus Cardiothoracic surgery

Objective: Renal transplantation remains a mainstay of therapy for end-stage renal failure. Cardiac disease has a high prevalence in this patient population. This study reviews the factors and outcomes associated with cardiac surgery in renal transplant recipients.

Methods: We performed a retrospective review from 01/2003 till 12/2003 of all patients with a functioning renal allograft admitted at our institution for cardiac surgery.

Results: During the 12 months follow-up, 5 patients with a functioning renal allograft underwent cardiac surgery in our institute. Mean age 52 years old, 2 females and 3 males’ patients. Two of the patients were transferred from another hospital and the rest were scheduled electively for operation. One patient suffered from moderate COPD. Modified Parsonnet score ranged from 6.5-24.5. The patients were 3-8 years post transplantation, under cyclosporine A maintenance treatment and creatinine levels 1.5-2.9. Two patients underwent AVR and CABG; 2 patients underwent on pump CABG and another patient coronary bypass without pump. Three patients had an uneventful recovery and were discharged up to 6 days post operation. The OPCAB and another patient, who had the highest Parsonnet scores, complicated with sepsis due to pneumonia and had a prolonged intubation. They were discharged up to 1 month post surgery. In all patients, the function of the renal allograft was not impaired by open heart operation. All patients reported significant improvement

Conclusions: Although the total number of patients in this study is limited, we believe that renal transplant patients can undergo safely enough cardiac operations with generally good results.

C2.4

CARDIOSURGICAL TREATMENT OF CARDIAC TUMORS: 25 YEARS OF EXPERIENCE IN 60 PATIENTS

Keeling I., Knez I., Rigler B., Trantina A., Oberwalder P., Anelli-Monti M., Bergmann P.

Medical University of Graz Division of Cardiac Surgery, Department of Surgery; Medical University of Graz Div of Cardiac Surgery, Dept of Surgery; Medical University of Graz Div of Cardiac Surgery, Dept of Surgery; Medical University of Graz Div of Cardiac Surgery, Dept of Surgery; Medical University of Graz Div of Cardiac Surgery, Dept of Surgery; Medical University of Graz Div of Cardiac Surgery, Dept of Surgery; Medical University of Graz Div of Cardiac Surgery, Dept of Surgery

Objective: In this single-center study we reviewed our experience with a significant number of cardiac tumor cases occurring over the past 25 years.

Methods: From February 1978 to February 2004, 52 (87%) pat. with benign and 8 (13%) pat. with malignant cardiac tumors were surgically treated at our center. Primary benign tumors included 52 myxomas, 1 angiofibroma, 1 pericardial cyst, 1 cavernous/AV haemangioma. Primary malignant cardiac tumors were 1 rhabdomyosarcoma, 1 B-cell lymphoma, 1 phaeochromocytoma, 2 angiosarcoma. A single secondary cardiac tumor was found, namely a metastatic osteosarcoma. One pat. had a recurrence of the myxoma.

Results: Most cardiac tumors originated from the left atrium (88%), but also much less frequently from the mitral valve (6%), from the right atrium (4%), from both atria (1.5%), from the pericardium (1.5%), and from the ventricular myocardium (1.5%). Multiple myxomas were found in 20% of the pat.. The size of the tumors ranged between 1.2 and 10 cm. Cardiac signs appeared in 94%. Preoperative embolic events had occurred in 22%. For resection of most myxomas, a bilateral atriotomy was used. For exposure of a sarcoma, a more individual approach, however with a very unfavourable prognosis, was required. For benign tumors, the early mortality rate was (2%) and the late mortality rate was (6%). Long-term prognosis was excellent in these cases with an actuarial survival rate of 0.74. Following the resection of a benign tumor, 81% of the pat. remained entirely asymptomatic, 8% reported cardiopulmonary symptoms, and 12% had supraventricular arrhythmias. The rate of reoperation for a cardiac myxoma was 2%.

Conclusions: Cardiac tumors were usually detected and operated on in symptomatic patients. A high index of suspicion seems important for early diagnosis. Immediate surgical treatment was indicated also for benign tumors because of the high risk of embolization or of sudden cardiac death. Furthermore, a familial genesis must be excluded in myxoma patients.

C2.5

A THIRTY YEAR STUDY INTO ATRIAL MYXOMAS—A SINGLE CENTRE EXPERIENCE

Hickey E., Allemby-Smith O., Livesey S., Langley S., Monro J.

Wessex Cardiothoracic Centre Southampton General Hospital; Wessex Cardiothoracic Centre Southampton General Hospital; Wessex Cardiothoracic Centre Southampton General Hospital; Wessex Cardiothoracic Centre Southampton General Hospital; Wessex Cardiothoracic Centre Southampton General Hospital

Objective: Arial Myxomas, though rare, are the commonest cardiac tumour and require urgent surgery to prevent catastrophic complications. Their low incidence makes their study difficult. We aimed to study all atrial myxomas presenting to our unit over a thirty year period to elucidate any important characteristics regarding their presentation, management and outcome.

Methods: Between 1973 and 2003, 66 patients (20 male) were admitted to our centre for resection of atrial myxoma. Surgical case notes of all 66 patients have been retrieved and studied retrospectively with respect to mode of presentation, mode of investigation, surgical technique and outcome.

Results: 26 (39%) presented with palpitations or proven arrhythmia, 19 of whom had atrial flutter/fibrillation. 23 (35%) had signs of congestive cardiac failure. 12 (18%) were incidental diagnoses. 14 patients (21%) had embolised systemically on presentation—11 cerebral, 2 femoral a mesenteric and a brachial. 62 (94%) underwent pre-operative echocardiographic evaluation and 12 (18%) underwent coronary angiography. None of the 66 patients had coronary disease warranting simultaneous coronary bypass procedures. All 66 patients underwent surgical resection. There were no early mortalities. 79% were left-sided myxomas, 2 (3%) left ventricular and the remainder right atrial. 65% arose from the interatrial septum. 57 (86%) underwent emergency resection at which both atria were explored in 43 (71%). 24 (36%) required patch repairs to the interatrial septum. 25 patients (38%) were discharged in atrial fibrillation—resection had no statistical

Conclusions: This is one of the longest and most detailed reviews of atrial myxoma presentations in the literature. The results indicate the varied mode of presentation. Cardiac symptoms appear the most common presentation, though importantly, atrial arrhythmias are not significantly affected by surgical resection. Echocardiography remains the key mode of investigation. Our results suggest that coronary angiography should not be a priority in the pre-operative assessment, as the coincidental requirement for coronary bypass is low. Surgical resection, in our unit typically utilising the Dubost trans-atrial technique, should be undertaken expeditiously and offers low operative risk, and excellent long-term prognosis.

C2.6

SURGICAL EXPERIENCE WITH 80 CARDIAC TUMORS

Bossert T., Gummert J., Battellini R., Falk V., Walther T., Mohr F.

University of Leipzig, Heart Center Department of Cardiac Surgery

Objective: To assess the prognosis and to develop management strategies for primary cardiac tumors all patients were included in an ongoing study.

Methods: From October 1994 until December 2003 we prospectively evaluated all patients with cardiac tumors. Follow up examinations were performed every 12 months.

Results: There were a total of 80 cardiac tumors. 73 were benign: myxoma (n=59), papillary fibroelastoma(n=11), lipoma (n=2) and fibroma (n=1). The myxoma group consisted of 19 male and 40 female aged 12 to 88 years. Myxomas were located in the: left atrium in 50 (85%), left ventricle in 3 (5%), right atrium in 4 (7 %) and on the mitral valve in 2 patients (3%). Papillary fibroelastoma was located on the aortic valve (n=4), right atrium (n=2), mitral valve (n=1), left ventricle (n=3) and right ventricle (n=1), while the two lipoma were located in the right atrium and one fibroma was located in the left ventricle. There were 4 primary cardiac sarcomas, located in the right ventricle (n=2), the pulmonary valve (n=1) and left atrium (n=1) and 3 patients with solitary cardiac metastases. Minimal invasive right thoracotomy was utilized in 19 of 73 patients all with benign tumor. There were two early deaths (3%): a myxoma patient with triple vessel disease and a LVEF less than 30% and one sarcoma patient. No recurrence or late death has been observed in the group of benign tumors. However, two patients with sarcoma had recurrent disease 10 and 15 month later, respectively. All patients were followed up with a total follow up of 235 patient years.

Conclusions: Surgical excision of benign cardiac primary tumors is a safe and curative treatment, which is feasible using minimally invasive right thoracotomy approach and provides excellent results. However, therapy of malignant cardiac tumors continues to have a poor prognosis despite individualization of approach.

C2.7

VENTRICLES’ TUMORS OF THE HEART: A 17 -YEAR EXPERIENCE

Popov V., Sytar L, Knyshov G., Beshlyaga V., Vitovsky M.

Institute of Cardiovascular Surgery, Kyiv, Ukraine

Objective: To analyze details of surgical treatment of ventricles’ tumors (VT) and recommend optimum technique based on these results.

Methods: 369 patients (pts) with tumors of the heart were consequtive operated from 01.01.1984 till 01.01.2001 yy in Institute of Cardiovascular Surgery. In 29 (7.9%) of them tumors based at the ventricles: left ventricle (LV) n=11(37.9%) pts and right ventricle (RV) n=18 (62.1%) pts. Malignant forms of VT were in 8 (27.6%) pts: LV (n=1), RV (n=7). In other cases myxomas were marked in 71.4% (n=15/21): LV (60.0% -n=6/10), RV (81.8%—n=9/11). Mean age of pts was 34.4+8.2 year (range 1 m—63 yy). Females—17 (58.6%), males—12 (41.4%). In the most of pts the bottom of the non-malignant VT was based on any part of the endocardium. Maternal basement of RA’ myxomas was removed by complete resection. Malignant tumor of the ventricles was removed with resection of tissue as possible but not very traumatic and not radical in all pts. All operations were performed with CPB and moderate hypothermia.

Results: Hospital mortality for malignant VT was 37.5% (n=8/3): LV (n=1/0), RV (n=7/3) and for other forms—9.5% (n=21/2): LV (n=10/2), RV (n=11/0) The main reasons of hospital mortality were heart failure (as a rule, giant VT). At the late period there were not any episodes of myxoma's recurrence.

Conclusion: Surgical correction of malignant form of VT isn't successful but for not-malignant forms of RV results of correction is good.

SCIENTIFIC SESSION C3 VALVE

C3.1

HOMOGRAFT AORTIC VALVE REPLACEMENT—FOLLOW UP TO THIRTY YEARS IN 200 PATIENTS

Hickey E., Allemby-Smith O., Langley S., Monro J.

Wessex Cardiothoracic Centre Southampton General Hospital; Wessex Cardiothoracic Centre Southampton General Hospital; Wessex Cardiothoracic Centre Southampton General Hospital; Wessex Cardiothoracic Centre Southampton General Hospital

Objective: Prior to the bioprosthetic era, homograft valves were the principle alternative to mechanical devices for valve replacement. Differing techniques in sterilisation, preservation and implantation may influence valve longevity. Our aim was to determine long-term results from a single unit of homograft aortic valve replacement (AVR) using a single sterilisation, preservation and implantation technique.

Methods: Between 1973 and 1983, 200 patients underwent subcoronary aortic valve replacement (AVR) using a homograft sterilised in antibiotics and preserved at 4 degrees Celcius. Surviving patients have been followed up to the end of 2003 providing a minimum follow-up period of twenty years. Follow up was 96% complete. Mean age was 50 years and 121 (61%) male. Pre-operative aortic stenosis was present in 80 patients, regurgitation in 42 and mixed disease in 78. Homograft valve sizes ranged between 18 and 22mm. Mean patient follow-up was 16 years with a total of 3164 patient years.

Results: There were three early deaths. Autopsy was carried out and in all three the homograft was structurally intact and in a satisfactory position. Kaplan-Meier survival, including early death was 81.2%+/– 2.8 (1SE) at 10 years, 58.0%+/– 3.7 at 20 years and 52%+/– 5.1 at 25 years. Redo AVR has been undertaken in 78 patients giving a freedom from re-operation for any reason on 86.4%+/– 2.6, 39.6+/– 5.2 and 35.0%+/– 5.4 at 10, 20 and 25 years respectively. Homograft endocarditis has only occurred in 6 patients, giving an overall freedom from endocarditis of 94% at 25 years. 7 of the original cohort are known to be alive with their original homograft valve in situ, and of these the longest follow-up period is 29.8 years.

Conclusions: This is the longest follow-up series relating to homograft valve replacement in the literature. Homograft AVR with antibiotic sterilised valves stored at 4 degrees Celcius in the subcoronary position offers low operative mortality and good long- term survival. The relatively high freedom from degeneration and excellent freedom from endocarditis make it an attractive choice for patients requiring AVR without anticoagulation. Seven patients retain their functional homograft in situ more than twenty years on, with one at 29.8 years, highlighting perhaps the understated success of these grafts.

C3.2

HEART VALVE REPLACEMENT USING SJM PROSTHESES

Langanay T., Agninio A., de Latour B., Verhoye J., Derieux T., Alami A., Corbineau H., Leguerrier A.

Chru PonTCHAILLOU SERVICE CHIRURGIE CARDIOVASCULAIRE RENNES

Objective: To evaluate valve related complications and mortality associated to SJM prosthesis in aortic or/and mitral position.

Methods: From October 1979 to December 1987, 743 prostheses have been implanted: 257 (41%) aortic valve replacements (AVR), 244 (39%) mitral valve replacements (MVR) and 121 (20%) double valve replacements (DVR).There were 622 patients (332 males—290 females) aged 18 to 79 years-old (mean

Results: Hospital mortality was 8.3% (51 pts) with 3 valve related deaths. Follow-up is 96% complete with a total follow-up of 7242 years (maximum 24 years and mean 11.8±6.4 years). There were 227 late deaths, 40 were valve related (6.5%). Twenty-year survival is 52.1%±4.4 (AVR), 41.8±4.8 (MVR) and 47.1±5.1 (DVR). 133 valve related complications occurred (linear rate 2.11% patient- years): 42 thrombo embolic events (0.63% P-Y), 53 haemorrhages (0.77%P-Y), 29 non structural dysfunctions (0.44%P-Y), 7 endocarditis (0.1% P-Y), 21 reoperations (0.32% P-Y). At 20 years, actuarial freedom from valve related death was 89.5%±1.7, valve related complication 70.4%±2.4, thomboembolism 90.3±1.5, haemorrhage 88.3%±0.1, reoperation 93.9%±1.5. At late survey, 95% of the patients were in functional class I or II.

Conclusions: Very low valve related mortality and morbidity are associated in this early experience with the use of SJM prostheses either in aortic nor mitral position.

C3.3

BRAVO 400 STENTLESS PORCINE AORTIC VALVE BIOPROSTHESIS. TEN YEARS MEAN FOLLOW UP

Polvani G., Alamanni F., Barili F., Poqueddu M., Segura G., Pompilio G., Sala A., Biglioli P.

Centro Cardiologico Monzino, University of Milan Department of Cardiovascular surgery; Centro Cardiologico Monzino, University of Milan Department of Cardiac Surgery; Ospedale di Circolo Division of Cardiac Surgery

Objective: This study was undertaken to evaluate long-term clinical and echocardiographic outcome after aortic valve replacement with the Bravo 400 stentless porcine aortic valve bioprosthesis.

Methods: Between February 1992 and January 1994 we implanted the Bravo 400 bioprosthesis in 67 patients(37 male, 30 female) at the Centro Cardiologico Monzino, University of Milan. The mean age was 68±7 years. We performed a free hand technique in 30 patients, inclusion technique in 35 patients and total aortic root replacement in 2 patients. Bioprosthesis employed were: 10 size 21 mm, 25 size 23 mm, 22 size 25 mm, 10 size 27 mm. We did not observe perioperative and in-hospital mortality and morbidity. Survival and time- related event analysis was performed with the Kaplan-Meier method. Mean follow up was ten years.

Results: There were 16 late death at nine-years follow-up. The actuarial freedom from death at five and eleven years was ninety-four and seventy-two percent respectively. The mean survival time was ten years. The actuarial freedom from valve-related death at five and eleven years was ninety-eight and ninety-three percent respectively. There were four valve related-death. The actuarial freedom from cardiac-related death at five and eleven years was ninety-eight and ninety respectively. Two patients died for myocardial necrosis. The actuarial freedom from non cardiac-related death at five and nine years was ninety-five and eighty percent respectively. The most important cause of death in this sub-group was tumor. The mean age at death was seventy-five years. The actuarial freedom from thromboembolism at five and eleven years was ninety- eight percent and ninety-two percent respectively. No hemorrhagic events were registered in follow-up. Aortic biological prosthesis replacement was necessary in five patients for degeneration of the prosthesis(max trans-prosthesis gradient 88.6±13 mmHg, mean trans-prosthesis gradient 63±15 mmHg). The rest of our study group showed at echocardiographic control a good haemodynamic performance of the stentless prosthesis: the mean trans-prosthesis gradient ranged from 16±5 mmHg for 21 to 8±3 mmHg for 27 mm bioprosthesis, the mean effective orifice area was 1.84±0.42.

Conclusions: The Bravo 400 aortic prosthesis has provided good clinical and hemodynamic results up until 10 years of mean follow-up.

C3.4

THE NICKS-NUNEZ SURGICAL APPROACH IN THE SMALL AORTIC ROOT

Rammos K. R., DAGHER A., STAMATIADIS I., ARGYRAKIS N., KETIKOGLOU D.

Interbalkan Medical Center Cardiovascular Surgery

Objective: The Nicks-Nunez posterior approach is one of the surgical options in enlarging the small aortic root when AVR is planned. Prosthetic material or pericardium can be used, enlarging the annulus by 2-3mm, thus accepting a larger prosthesis avoiding the consequences of a smaller size one.

Methods: During the period 11/1995—2/2004 in a total of 153 AVR's, operated by the author and his team, 11 patients, all women, aged 60-75 (median age 66 years) underwent the Nicks-Nunez posterior enlargement of small aortic roots. This procedure was deemed necessary when the surgeon could not implant a size #21 prosthesis or when a #19mm prosthesis was not compatible with the patient's activities and BSA. One patient underwent concomitant endarterectomy of the ascending aorta, 2 patients coronary bypass grafting and one patient AVR+MVR+CABGx3. In 3 patients autologus pericardium was used, in 2 Gore-tex graft and in 6 Vascutek graft. All cases were managed with CPB at 34o C, crystalloid cardioplegic arrest, local hypothermia and LV venting. All cases were guided by TEE. Four patients received a bioprosthesis and seven a

Results: The postoperative course was uneventful in all cases, although the ventilatory support was a few hrs longer (18 hrs vs 10 hrs). Immediate echo showed an average 17 mmHg (range 15-20 mmHg) gradient, which has remained to an average 19 mmHg (range 10-25 mmHg) during the follow-up period (1mo—84mo).

Conclusions: The Nicks-Nunez posterior enlargement of the small aortic root is an effective procedure, which retains its effect in the long follow up period.

C3.5

VALVE SURGERY IN OCTOGENARIANS: DEFINITION OF THE RISK FACTORS

Panza A., Di Benedetto G., Bossone E., Frigiola A., Masiello P., Iesu S., Cirri S., Distante A.

Cardiac Surgery Division, A.O. "S. Giovanni di Dio e Ruggi d'Aragona" Cardiology and Cardiac Surgery Department; Istituto Clinico S. Ambrogio Anesthesiology and Intensive Care Departmenet; National Research Council, Southern Italy Cardiology Department

Objective: The aging of the population and the resulting higher incidence of ischemic, degenerative and calcific valve disease have caused more octogenarians being referred for valve surgery. However, the pre-operative risk factors and the early and long-term outcomes in this age group are less known.

Methods: We evaluated 307 consecutive patients age >80 years undergoing valve surgery in 3 cardiac centers (age 83±2.4 yrs, females=60%). Majority of patients had aortic valve surgery (AVS) either alone (n=134) or with CABG (n=94), aortic surgery (n=3) or mitral valve surgery (MVS, n=26). The remaining patients underwent MVS alone or with CABG or tricuspid valve repair.

Results: Most common hospital complications included atrial arrhythmias (50%), need for inotropic support >48 hours (37%), renal insufficiency (28%), congestive heart failure (23%), respiratory failure (22%), and stroke (6%). Death at 30-day occurred in 30 patients (9.7%). Multivariate logistic regression identified: NYHA class IV (OR=5.2, 95% CI=1.9-14.0; p=0.001); diabetes (OR=2.8, 95% CI=1.1-7.1; p=0.027); hypertension (OR=3.7, 95% CI=1.2-11; p=0.025); renal insufficiency at presentation (OR=3.4, 95% CI=1.2-9.4; p=0.022); rheumatic etiology (OR=3.8, 95% CI=1.1-12.9; p=0.030) and left ventricular ejection fraction <45% (OR=6.2, 95% CI=1.1-35.3; p=0.041) as predictors of hospital death. At follow-up (42±30 months, range=1-134 months), there were 45 more deaths. Mortality was similar in patients undergoing MVS isolated (n=3/30, 13.%) or combined (n=8/49, 21%) compared to AVS isolated (n=17/134, 13.7%) or combined (n=17/94, 20.7%). However, among long term survivors (n=232), the NYHA class improved between pre- (3.0+0.7) to post-operative (1.7+0.6) periods (p<0.0001).

Conclusions: For selected symptomatic octogenarians with valve disease, surgery may be an effective therapeutic option associated with good long-term survival and improvement in functional class. The risk factors of hospital death among these patients identified in our study may help physicians while counselling patients, who are candidates for valve surgery.

C3.6

COMPARISON OF BLOOD AND HTK CARDIOPLEGIA IN DOUBLE VALVE REPLACEMENT OPERATIONS

Palatianos G. P., Fragoulis S., Kantidakis G., Chronidou F., Astras G., Papadakis E., Triantafillou C., Vassili M.

Onassis Cardiac Surgery Center Third Department of Cardiac Surgery

Objective: We reviewed our experience with double valve replacement (DVR) and we retrospectively compared two cardioplegia techniques.

Methods: From 5/1994 to 12/2003, 72 patients (36 female) underwent simultaneous replacement of mitral and aortic valve in our Department. In 55 patients, standard blood cardioplegia was used (group BL) whereas in the remaining 17, cardioplegic protection was achieved with crystalloid Bretschneider HTK cardioplegia (group HTK). Patient age was 62.3±9.3 years. All patients had two-dimensional echocardiography and cardiac catheterization preoperatively.

Results: There was no difference in preoperative symptomatology or ejection fraction between the two groups. Mechanical valves were implanted in 59 patients (46 in group BL and 13 in group HTK) whereas bioprosthetic valves in 13 (9 in group BL and 4 in group HTK). Concomitant coronary revascularization was performed in 7 patients (6 in group BL and 1 in group HTK). Aortic crossclamp time was 159±35.3 min in group BL, and 148.3±27.1 min in group HTK (p=NS), and perfusion time 193.9±41.3 min and 166.3±31.9 min, respectively (p=0.0198-Wuilcoxon test). Overall operative (30-day) mortality was 3/72 patients (4.2%). In group BL, mortality was 3/55 (5.5%). There was no mortality in group HTK. Postoperative complications in group BL versus group HTK were: atrial fibrillation, 8 (14.5%) vs. 5 (29.4%); low cardiac output, 2 (3.6%) vs. zero; complete AV block, zero vs. 1 (5.8%); primary ventricular contractions, 1 (1.8%) vs. zero; prolonged (>48 hours) intubation, 5 (9.1%) vs. 1 (5.8%); renal failure, 2 (3.6%) vs. zero; hemorrhagic stroke, 1 (1.8%) vs. zero; bleeding, 2 (3.6%) vs. 1 (5.8%); endocarditis, 1 (1.8%) vs. zero; jaundice 2 (3.6%) vs. zero. There were no thromboembolic complications. All patients were followed up for 50.9±31.5 months. Late mortality was 2 patients (both in group BL) who died 48 and 83 months postoperatively. Overall postoperative symptomatology was class 1.3±2.0, and ejection fraction was 49.5±7%.

Conclusions: Our study showed satisfactory early and intermediate results with DVR using either blood or HTK crystalloid cardioplegia. However, HTK cardioplegia was associated with shorter perfusion times

C3.7

FRESH ANTIBIOTIC STERILIZED AORTIC HOMOGRAFT FOR PROCEDURES ON THE AORTIC VALVE AND ASCENDING AORTA—15 YEAR EXPERIENCE

Peric M., Huskic R., Djukanovic B., Nezic D., Ciesla-Dul M., Knezevic A., Cirkovic M., Jovic M.

Dedinje Cardiovascular Institute Cardiac Surgery; Dedinje Cardiovascular Institute Cardiac Surgery; Clinic for Cardiovascular Diseases, Krakow cardiac surgery; Dedinje Cardiovascular Institute Cardiac Surgery; Dedinje Cardiovascular Institute Cardiac Surgery; Dedinje Cardiovascular Institute anaesthesia and intensive care

Objective: To evaluate short and long-term results of reconstructive procedures on aortic valve (AV) and ascending aorta using fresh antibiotic sterilized aortic homograft (AH).

Methods: From Jan 1st, 1989 through Jan 31st, 2004, AH has been used in 93 pts (76 male, average age 59.3+9.5 yrs). Indications were: infective endocarditis of the native AV (22 pts), prosthetic endocarditis of the AV (5 pts), prosthetic endocarditis of the composite graft (4 pts), chronic ascending aortic aneurysm (6 pts), aortic insufficiency (16 pts), aortic stenosis (25 pts), combined aortic insufficiency and stenosis (14 pts) and aortic insufficiency with ostium primum defect in 1 pt. There were 10 redo procedures, while 5 procedures were performed using deep hypothermic circulatory arrest.

Results: Hospital mortality was 5.4% (5/93). One pt required early substitution of the AH. There were no cases of recurrent AV endocarditis. Two pts required replacement of the AH due to chronic aortic insufficiency. Eleven pts died during a follow-up (actuarial survival of 77% at 10 years), 7 due to cardiac causes. Significant degeneration of the AH (AI III) is present in 4 pts. Other pts (75, 80%) are in NYHA class I/II. Initial average gradient over the AH was 6.3+7.7 mmHg (0-12), while average aortic insufficiency was

Conclusions: Fresh, antibiotic sterilized AH proved to be still an excellent and durable biologic material, particularly in pts with native or prosthetic aortic valve endocarditis. Hemodynamic characteristics of the AH are superior to the mechanical prosthesis (particularly in sizes <23), while long-term durability (up to 174 months, average 63.4 months) is satisfactory.

C3.8

SURGICAL REINTERVENTION IN MITRAL PROSTHETIC DISFUNCTION

Castells E., Flajsig I., Rotela J., del Percio H., Ortiz D., Calbet J., Saura E., Fontanillas C.

Univ. Hospital Bellvitge Heart surgery (pl.3); Univ. Hospital Bellvitge Heart surgery (pl.3); Univ. Hospital Bellvitge Heart surgery (pl.3); Univ. Hospital Bellvitge Heart surgery (pl.3); Univ. Hospital Bellvitge Heart surgery (pl.3); Univ. Hospital Bellvitge Heart surgery (pl.3); Univ. Hospital Bellvitge Heart surgery (pl.3); Univ. Hospital Bellvitge Heart surgery (pl.3)

Objective: Mitral prosthesis dysfunction is frequently present problem in readmision and reoperation in prosthetic valvular patients. Surgical acces and technique is frequently object of discusion. Here we would like to present our experience in the last 15 years.

Methods: Group of 86 patients was reoperated after mitral valve replacement procedure (38 women and 48 men, 44% / 56%).The mean age was 57±11 years. Free interval was 11±6 years. Fourthy eight patients(56%) was in functional class IV. As an emergent case were operated 31 (36%) patients. Predicted risc score (Parsonnet) was 15.9%. Twenthy nine patients (34%) had a tissue prosthesis dysfunction and 57 (66%) mechanical prosthesic dysfunction. Morfology was: dehiscence in 36 patients, thrombosys/pannus in 18 and structural deterioration in 2 patients. Endocarditis was found in 16 (18%) patients. In 26 (30%) patients was a third-fifth operation. We performed 83 resternotomies and 3 lateral thoracotomies, with 69 prosthetic replacements, 15 sutures or patch closure of dehiscences and 2 thrombectomies. In 15 (17%) patients another valve was operated. Diagnostic of prosthesis disfunction was considered by ecocardiography.

Results: Observed mortality was in 9% (8) patients, in 3 patients caused by cardiac insuficiency and 3 with infection. One patients die with SIRS and 1 with MOF. Long term results were satisfactory.

Conclusions: Ecocardiography can offer sufficient data about morfology in any suspicious of prosthesic malfunction although regurgitations can be magnified. We prefered resternotomy because better accessibility. Prosthesis exchange was a choice. Only in patients without endocarditis is possible correction of dehiscence with simple suture or closure of the orifice with a patch (an original technique). Prosthesis thrombectomy was better (8%).

C3.9

RESULTS OF THE AORTIC VALVE REPLACEMENT IN THE NINTH DECADE

Demaria R.

Arnaud de Villeneuve hospital, CHU Montpellier Cardiovascular surgery

Objective: Aortic valve stenosis is the most common valvular disorder encountered in elderly patients. The aim of this study is to evaluate the safety and efficacy of aortic valve replacement (AVR) in the

Methods: In a retrospective study, we relate our experience with 103 consecutive octogenarian patients having had AVR between 1993 and 2002 in the same institution. All patients but two were implanted with a bioprosthesis. The average age was 82.1 years (range: 80 to 87 years) and 48.54% were men. Pre-operative NYHA classification of patients was I (1.98% of cases), II (56.44%), III (35.64%) and IV (5.94%). Eighty one patients had AVR alone, and 22 patients had concomitant coronary artery bypass (CABG) surgery (21.36%). The indication for surgery was aortic stenosis (79.6%), insufficiency (3.9%), or mixed (16.5%). Five patients (4.9%) were urgent procedures.

Results: Median intensive care unit and hospital stay were 3 and 15 days, respectively. The overall 30-day survival was 92.37% with 93.3% for AVR alone and 88.42% for AVR+CABG (p=0.33). Univariate predictor of hospital death was peroperative complication alone. Early complications were atrial fibrillation (32.9%), atrio- ventricular block (19.1%), respiratory failure (18.9%), stroke (6.3%), hemorrage (6.3%), and renal failure (2.1%). Mean follow-up was 22.2 months. One patient was lost of follow-up. The overall actuarial survival at 1, 3, and 5 years was 89.93%, 83.03%, and 83.03% respectively. The overall 1, 3, and 5 year survival was 90.27%, 81.86%, and 81.86% for AVR alone and 88.42%, 88.42%, and 88.42% for AVR+CABG.

Conclusions: These results show that AVR is a safe procedure in octogenarians and coronary artery bypass grafting does not increase the mortality in the post-operative period and in the long term follow-up.

SCIENTIFIC SESSION C4 MISCELLANEOUS

C4.1

VACUUM-ASSISTED CLOSURE SYSTEM FOR THE TREATMENT OF STERNAL WOUND INFECTIONS AFTER CARDIAC SURGERY

Bapat V., Noorani A., Muttardi N., Young C., Roxburgh J., Venn G.

Guys and St Tomas’ Hospital, London Cardiothoracic Surgery; Guys and St Thomas’ Hospital Cardiothoracic Surgery; Guys and St Thomas’ Hospital Plastic Surgery; Guys and St Thomas’ Hospital Cardiothoracic Surgery; Guys and St Thomas’ Hospital Cardiothoracic Surgery; Guys and St Thomas’ Hospital Cardiothoracic Surgery

Objective: Post sternotomy wound infection after cardiac surgery continues to be a difficult complication to manage and vacuum-assisted closure (VAC) has recently been reported in its management. We report our experience in use of VAC in the treatment of post sternotomy wound infection with emphasis on recurrent wound related problems after the use of VAC; and their specific treatments.

Methods: Between July 2000 and June 2003, 2706 patients underwent various cardiac procedures via median sternotomy. Fifty three patients were diagnosed with postoperative sternal wound infection (1.9%) of which 49 were managed with VAC. Superficial sternal wound was defined as infection and dehiscence of the skin, subcutaneous tissue but with a stable sternum (28 patients). Deep sternal wound infection was defined as wound infection with sternal instability (21 patients). Upon diagnosis bacteriological cultures were obtained immediately and appropriate antibiotic treatment was started at the earliest. In the superficial sternal wound infection group, 23 patients had VAC as a definitive treatment (Group A), while 5 patients (Group B) had VAC followed by surgical closure. Similarly in the deep sternal wound infection group, 12 patients had VAC as definitive treatment (Group C), while 9 patients had VAC followed by surgical closure (Group D). Patients were discharged after satisfactory wound closure. Upon discharge patients were followed up at interval of 3-6 months. Recurrent sternal problems when identified were investigated and additional surgical procedures were carried out when necessary.

Results: There were nine deaths, all due to unrelated causes except in one patient who died of right ventricular rupture (in Group C). Nine patients in Group A had recurrent wound problems of which 6 had VAC system for more than 21 days. Three patients underwent extensive debridement due to sternal osteomyelitis. All survivors in Group B presented with chronic wound related problems and underwent multiple debridements and eventually flap assisted closure with laparoscopic omental flaps in four patients. In contrast 14 patients (in Group B and D) who were treated with a shorter duration of VAC followed by either a flap or primary surgical closure, did not present with recurrent problems.

Conclusions: Vacuum assisted closure is an acceptable modality of treatment for post sternotomy wound infections but should be used as an adjunct to conventional surgical treatment rather than a definitive form of treatment. Chronic complications are common after its prolonged use, necessitating multiple surgical Table 1

SURGICAL TACTICS IN WOUNDS OF THE HEART

Ljubic B., Ristic M., Vranes M., Djukic P., Velinovic M., Mikic A., Kocica M., Panic G.

Clinical Centre of Serbia Belgrade Clinic for Cardiac Surgery

Objective: Heart injuries are present in about 10% of all chest injuries. According to the mechanism, we classify heart injuries in three groups: penetrating (low velocity—knives, and high velocity—missiles), blunt (blunt forces), and iatrogenic. Wounds to the heart represent a significant surgical challenge because of their unique clinical course and the need for emergent operative care. The clinical presentation in most cases is tamponade or shock (distension of cervical veins, hypotension, muffled heart sounds). In stable patients other diagnostic tests can be used: ECG, ECHO, TEE, chest x-ray, CT-scanning... Treatment consists of resuscitation with rapid volume infusion and surgery. The management of heart injuries has undergone a transition from simple pericardiocentesis to cardiac ultrasound evaluation in the stable patient, and emergency thoracotomy and repair of myocardial wounds in the unstable patient in extremes.

Methods: A retrospective review of 30 cardiac injuries treated in our Institute from 1980 through 2004 was examined. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury.

Results: We had 12 patients with penetrating wounds (9 stab wounds and 3 gunshot wounds), 4 with blunt injuries (traffic accidents) and 14 iatrogenic. Cardiac chambers injured included the right ventricle in 21, left ventricle in 4 patients. 2 patients had injuries of coronary artery, 2 had pericardial injuries and 1 injuries of the mitral valve. 27 patients underwent thoracotomy (median sternotomy) and surgical repair. In 22 patients we sutured right or left ventricles with polyprophylene sutures with pledgets. 2 patients were treated with CABG. We drained pericardial effusion in 2 patients, and replaced a mitral valve in 1 patient. 3 patients were not operated. Mortality rate was 10%. (3 patients died: 2 with sutured right ventricle from gunshot injuries, and 1 with CABG (injured coronary artery)).

Conclusions: With the improvement in emergency medical services, including speed of transportation of these patients, better resuscitation, more patients with heart injuries will survive and reach the operating room. Surgery must be performed at the same time as antishock and reanimation therapy. Success of operation depends on time of patient's transport to hospital, quality of performed surgery, postoperative treatment and severity of patient's state. Severity of patient's state is determined by location of the wound, its sizes and injuries of other organs.

C4.3

FEATURES OF SURGICAL TREATMENT OFTHE PATIENTS BY COMPLICATED FORMS INFECTIOUS ENDOCARDITIS (IE)

Khubulava G., Shikhverdiev N., Peleshok A.

Kuprijanov's cardiovascular clinic cardiosurgery

Objective: On the basis of the analysis results of surgical treatment of the patients by complicated forms IE to determine optimum tactics of surgical treatment such patients.

Methods: The remote results of operative treatment 64 patients IE, operated on a background of sepsis were analyzed. All patients were divided into 2 groups: 1)IE of the right chambers 2) IE of the left chambers.

Results: The program of before operative treatment was determined by prevalence in clinical current intoxication or multiorgan failure. At 37.5% patients took place the hearths of distruction in lungs. At 28.1% patients took place infarcts of the spleen. Emboli of cerebral arteries with infringement of sight, presence of the hearth neurological symptomatic less than 6 months before operation took place at 12.5% patients, and more than 6 months at 15.6% patients. Emboli of the arteries of infrailiac segment 14% patients. To all patients was carried out sanation of chambers heart, at 28.2% patients were executed valve safe operation and at 71.8% patients prosthesis valves. At presence of the hearths of destruction in lungs at the patients IE, become complicated by development pyopneumothorax and empyema were carried out drainaged of pleura cavity. Two patients needed imposing thoracostoma. Both patients were executed sanation of chambers heart and prosthesis valve with favorable outcome. At development emboli of cerebral arteries the operation is possible in 2 weeks after transferred ishemic insult and not earlier than 2 months at presence cerebral haemorrhage. At presence of the centers of destruction in spleen, emboli of others arteries with development of aneurysm or at presence ishemia of extremities the operative intervention concerning such complications, was carried out up to the basic stage of operation. At the analysis of the reasons of failures it is necessary to note long conservative treatment before operations resulting in formation abscesses, development embolic complications, heart failure and multiorgan failure.

Conclusions: 1. The duly establishment of the indications in operative treatment IE leads to decrease of frequency of development its complicated forms and, accordingly, to improvement of results surgical treatment.

2. At presence of extracardial complications IE tactics of treatment depends on a degree of the importance of available infringements function of the struck bodies and in most cases requires their elimination before operation on heart.

C4.4

THE EFFECTS OF HYPOTHERMIC CARDIOPULMONARY BYPASS ON BIS SCORES AND ANESTHETIC REQUIREMENT

Pocan S., Ozkan S., Us M., Gokben M., Ozturk O.

Gulhane Military Medical Academy Haydarpasa Training Hospital Anesthesiology Department; Gulhane Military Medical Academy Haydarpasa Training Hospital Anesthesiology Department; Gulhane Military Medical Academy Haydarpasa Training Hospital Heart Surgery Department

Objective: This study was designed to assess the effect of hypothermia during CPB on BIS and anesthetic requirement.

Methods: Thirty consenting patients scheduled for elective cardiac surgery were studied. Anesthesia was induced with fentanyl (3 µg/kg), propofol (2.5 mg/kg) and vecuronium (0.1 mg/kg). Anesthesia was maintained using isoflurane (0.6-0.8%), fentanyl and dormicum. Anesthetic agents were adjusted according to BIS value of 55 in group I. Blood gas analysis, mean arterial pressure, BIS scores, inhalational and intravenous anesthetic amounts were recorded after induction (T1), during cooling bladder 36oC (T2), bladder 33oC (T3), the deepest hypothermia (T4), rewarming bladder 33oC (T5), bladder 36oC (T 6) and after perfusion (T7).

Results: In group I anesthetic requirements were decreased, in group II BIS scores were decreased by temperature during cooling (T3) and at deepest temperature (T4) compaired to preCPB period (p<0.05). No patients experience awareness during operation. BIS scores and anesthetic requirements were decreased during hypothermic CPB.

Conclusions: Bispectral analysis is a reliable monitor to measure anesthetic requirement and hypnotic state under this conception.

C4.5

OPERATIVE MORTALITY AFTER VALVULAR REOPERATIONS

Toker M., Eren E., Özen Y., Kirali K., Güler M., Ipek G., Balkanay M., Yakut C.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Kosuyolu Heart and Research Hospital Cardiovascular Surgery

Objective: The purpose of this study is to determine the factors influencing the operative mortality in patients undergoing valvular reoperations.

Methods: Between January 1993 and December 2003, 309 valvular reoperations were performed in our clinic. Data were collected retrospectively. Of 200 (64.7%) patients were males and 109 (35.2%) patients were females. The mean age was 42.06±13.25. The indications for reoperations were bioprosthetic dsyfunction in 92 (29.7%), after reconstruction in 110 (35.5%), new valve degeneration in 12 (3.8%), paravalvular leakage in 32 (10.3%), infective endocarditis in 12(3.8%), stuck valve in 30 (9.7%) and thrombosis in 21 (6.7%). Operative techniques and valve positions were as follows: mitral valve replacement in 235 (76%), aortic valve replacement 32 (10.3%), aortic and mitral valve replacement in 24 (7.7%), mitral and tricuspid valve replacement in 2 (0.6%), mitral paravalvüler leakage repair in 13 (4.2%) and aortic paravalvular leakage repair in 3 (0.9%). Additional procedures were tricuspid reconstruction in 66 (21.3%), ascending aorta replacement in 13 (4.2%) and CABG in 2 (0.6%). Of 45 (14.5%) patients were operated urgently.

Results: Overall operative mortality was 14.2% (44/309). Mortality for mitral valve replacement in 12.7% (30/235), aortic valve replacement 18.7% (6/32), mitral and aortic valve replacement 20.8% (5/24), mitral and tricuspid replacement 50% (1/2), mitral paravalvular leakage repair 7.09% (1/13), aortic paravalvular leakage repair 33.3% (1/3). In additional procedures; mortality for tricuspid reconstructions was 18.7% (16/10), ascending aortic replacement 53.8% (7/13). The mean aortic cross clamp time was 83.69±37.8 minutes, the mean total perfusion time was 125.7±59.7. Mortality for emergency operations was 35.5% (16/45) and elective operations 10.6% (28/264). Multivariate analysis revealed that age >60 (p=0.002;Odds 7.4;95%CI 2-26.5), ascending aortic replacement (p<0.001;Odds 21.8;95% CI 5-95.8), previous cerebrovascular accident (p=0.004;Odds 9.5;95% CI 2-44.2) and emergency operations (p=0.002;Odds 6.1;CI 95%CI 1.9-19.3) were the important determinants for operative mortality.

Conclusions: Although the valvular reoperations in elective patients have acceptable operative mortality rates, emergency cases have still increased the overall mortality rates.

C4.6

BIOIMPEDANCE MEASUREMENT FROM ELECTRODES CONNECTED TO HEART STABILIZATOR

Kink A., Rätsep I.

SmartImplant Ltd. research; SmartImplant Ltd

Objective: In off-pump coronary artery bypass surgery (OPCAB) a segment of ventricular wall is immobilized to perform distal anastomosis. Ischaemic changes in myocytes lead to cellular, hydrostatic changes in perfusion to extracellular oedema. In our experimental study the effect of duration and degree of vacuum applied to myocardium by stabilizer was demonstrated.

Methods: Myocardial electrical impedance correlates with regional and global ischemia to determine pathologic tissue ultrastructural changes and oedema. Measurements were performed on isolated blood perfused human-size animal heart setup described by us previously. A pair of electrodes integrated to the myocardial surface of stabilizer pads connected to electrical impedance monitor (SmartImplant, Estonia) was used for tissue impedance measurements (Fig.1). A 10 mikro A current was used at frequencies below 1kHz. Measurements were performed creating 200- 500 mmHg suction force for 1 to 30 minutes. According to recorded impedance spectrum prevelance of ischaemic or hydrostatic component in tissue damage was diagnosed.

Results: Baseline electrical impedance for all 6 hearts was 53±7 ohms (range 9 ohms). Negative pressure 0 to 300 mmHg did not change impedance values significantly even when suction lasted 30 minutes. Vacuum 400 mmHg and more resulted in augmentation of tissue impedance for about 30% (86±12 ohms). The myocardial electrical impedance was significantly increased at the end of mechanical traction period as compared to baseline values (Fig.2).

Conclusions: Higher suction pressure and longer duration attenuates oxygen delivery to myocardium causing regional oedema which could be responsible for compression of epicardial arteries consequently decreasing graft flow and patency. This additional device could be easily integrated to stabilizers available for OPCAB surgery. Real time measurement may indicate the need for repositioning of the heart or need for double stabilizer.

C4.7

ACUTE MITRAL VALVE REGURGITATION AFTER BLUNT CHEST TRAUMA

de Latour B., Langanay T., Verhoye J., de Latour M., Corbineau H., Leguerrier A.

CHRU PONTCHAILLOU SERVICE CHIRURGIE CARDIOVASCULAIRE RENNES

Objective: Mitral valve injury after blunt chest trauma is a rare but serious event. It is frequently associated with other life-threatening lesions and may be hidden among those.

Methods: From 1972 to 2000, eight patients, 18 to 77 years-old, have had a traumatic acute mitral valve regurgitation. On admission, five patients suffered of multiple life-threatening lesions. Mitral valve injury was immediatly suspected,6 patients, because of a systolic murmur or a pulmonary edema (4 patients). In one case, the diagnostic was delayed for 72 hours after admission. For the last one, it was discovered 6 months later because well tolerated. Valvular injury consisted of papillary muscle rupture (7 patients) and/or chordae tendinae rupture (3 patients).

Results: Five patients underwent valve replacement (1 bioprostheses and 4 mechanicals), two had a mitral valve repair (quadangular resection associated to a prosthetic ring) and one was not operated because of a well tolerated mild regurgitation. Hospital mortality amounts to 3 patients: a severe myocardial contusion, a pulmonary contusion and a prosthetic valve endocarditis. The oldness of several cases explains the predominance of valve replacement in this series. Associated myocardial contusion makes it often difficult to repair the valve especially in case of papillary muscle rupture.

Conclusions: Management and outcome of traumatic mitral valve regurgitation depends on its severity and the magnitude of associated injuries. When possible, valve repair should always be preferred to valve replacement in order to preserve left ventricular function and to avoid long term anticoagulation which is likely to worsen associated lesions.

C4.8

ASCENDING AORTA—THE OPTIMAL SITE FOR SAFE DOWNSTREAM BALLOON INSERTION IN CASE OF PROLONGED CONTRAPULSATION WITHOUT NEED FOR RETORACOTOMY

Uzdavinys G., Miniauskas S., Kalinauskas G., Norkunas G., Semetiene G., Sirvydis V.

Clinic of Heart Diseases, Vilnius University Heart Surgery Center; Clinic of Heart Diseases, Vilnius University Heart Surgery Center; Clinic of Heart Diseases, Vilnius University Heart Surgery Center

Objective: An intraaortic balloon pump (IABP) is a device that increases blood flow to the heart muscle and decreases the heart's workload, a process called contrapulsation. It can take over about 20% of the heart's workload. IABP assistance from the IABP can be live-saving for a patient with severe heart failure—postcardiotomic cardiogenic shock. However the risk of complications from an IABP has dropped in the past few years. People are encouraged to speak with cardiac surgeons about the benefits and risks of this device.

Methods: At Vilnius University Cardiac Surgery Center, the method of this treatment was started in 1976. Four types of balloon insertion have been used: trough a.iliace incision—337, a.femoralis transcutaneus punction -291, ascending aorta—178 and by means of incision the, ascending aorta with tourniquets—101. Total number of patients undergone the treatment of IABP contrapulsation after open heart surgery are 907. The heart pathology that required IABP contrapulsation: coronary arteries bypass grafting (CABG)—377, multi heart valve replacement or and repair -289, aortic valve replacement—181 and patients, others 60.

Results: The best results we achieved in CABG group. The IABP was removed for 81% patients and 79% of them were discharged. In the aortic valve replacement group IABP were removed for 73% patients and 70% were discharged from hospital. Main complications: limb ischemia 47(5.6%) aortic balloon thrombosis 35(3.8%) rupture of balloon 6(0.6%) aortic dissection—4(0.4%) peripheral artery dissection 3(0.3%) bleeding in site of balloon insertion—2(0.2%). Total—97(10.6%). IABP contrapulsation duration was from 3.5 to 141 hours.

Conclusions: IABP contrapulsation is an effective method of treatment for post cardiotomic patients with progressive heart failure, when maximal inotropic therapy is without effect. The new method of IABP insertion through aorta ascending does not need restenotomy to remove a balloon.

SCIENTIFIC SESSION C5 CORONARY

C5.1

DOES MYOCARDIAL REVASCULARIZATION IMPROVE LEFT VENTRICULAR FUNCTION IN POST-ISCHEMIC MITRAL VALVE SURGERY?

Battaglia F., Prifi E., Leacche M., Bonacchi M.

Università degli Studi di Firenze Cardiochirurgia; Università degli Studi di Firenze Cardiochirurgia

Objective: In post-ischemic mitral valve regurgitation the advantages of valve repair and CABG vs valve replacement or CABG only are investigated.

Methods: Between 1995 and 2003, 180 consecutive patients with impaired LV function and chronic ischemic MVR underwent cardiac surgery. 54pts (Group I), MVR (grade III-IV) underwent simultaneous MV surgery and CABG; 40pts (Group II) MVR (grade II-III) and 86pts (Group III) MVR (grade I-II) underwent CABG alone. All Group I patients had a LVEF (%)27.2±5, LVEDP (mmHg) 27.7±6.8, LVESD(mm) 51.7±7, LVEDD (mm) 67.4±7, mean PAP (mmHg)35±5. MV repair was performed in 36pts (Group IA) and MV replacement in 18pts (Group

Results: Hospital deaths were 5 (9.3%) patients in Group I, 5 (12.5%) in II (p=Ns) and 6 (6.8%) in III(p=NS). The actuarial free-event survival was significantly lower in Group II versus III (p=0.0045) and I (p=0.038). The overall actuarial survival was significantly higher in Group IA versus Group IB patients (p=0.027). Postoperatively the LVEF (p<0.001) and CI (p<0.001) improved significanly in Group I. LV dimensions decreased significantly in this group (LVEDD (p<0.001) and LVESD (p<0.01)), instead of a moderate significant improvement in the other groups. The RF decreased significantly in Group I and III after surgery (p<0.001 and p=0.003 respectively). Postoperative NYHA improved significantly in all patients but more in

Conclusions: Both MV repair and replacement preserving subvalvular apparatus in patients with impaired LV function offer acceptable outcome in terms of morbidity and survival. MV repair simultaneously to myocardial revascularization improves significantly the LV function and its geometry.The surgical correction of the moderate mitral regurgitation in patients with impaired LV function should be taken in consideration yielding in better survival and LV function.

C5.2

FIVE YEARS EXPERIENCE IN MIDCAB (KOLESOV) OPERATION

Kotelnikov I., Repossini A.

Cliniche Humanitas Gavazzeni Cardiac Surgery; Cliniche Humanitas Gavazzeni Cardiac Surgery

Objective: Direct anastomosis between the most important LAD coronary artery and the most important conduit, left internal thoracic artery (LITA), through left minithoracotomy is effective operation, which permits a minimal invasion without sternotomy, cardiac arrest, cardiopulmonary by pass and manipulation on the aorta. But sometimes unfavourable anatomic and haemodynamic conditions can make the continuation of the operation difficult or even impossible.

Methods: From May 1997 to October 2002 the MIDCAB (Kolesov procedure) has been performed in 372 patients with single vessel (LAD) disease—231pts, double vessels -114 pts, triple vessel -26 pts and left main coronary artery disease—1 patient. In other 13 patients minithoracotomy approach during operation for some reasons was converted in median sternotomy. LITA was harvested by sceletonizing technique without thoracoscopy. Precondition (7 min cross clamp of LAD and 1 min of reperfusion) was applied in all cases.

Results: The intraoperative haemodynamics were stable in 97.5% of cases. Intraoperative Dobutamin was needed only in 8 pts (2.2%). Cardiovertion for ventricular fibrillation, happened during precondition, was necessary in one case (0.27%). In one patient haemodynamic instability made a conversion to sternotomy and conventional cardiopulmonary by pass necessary. Cause of conversion in sternotomy in other 12 patients were, non visible LAD in 7 pts, too lateral LAD—in 3 pts, total calcification of LAD in 1 pts, and too small LAD in 1 pt. When necessary, to avoid tension of the graft, the elongation of LITA was achieved by harvesting it distally through an additional fifth intercostal space access and proximally to permit free inspiration movements of the lung above the graft. Mortality rate was 0.27% (one patient), acute myocardial infarction perioperatively was in 6 pts (1.6%), reopening for bleeding—in 8 pts (2.2%), wound problems—in 8 (2.2%), haemotransfusion—in 15 pts (4%). Double and triple vessels disease patients had good tolerance of this surgical procedure. Only 5 (3.5%) of them had ischemia in the second stenotic vessel area early postoperatively with consequent successful angioplasty. High risk patients had a very low postoperative morbidity and were good candidates for this operation.

Conclusions: Dislocation of LAD (intramural course, too lateral..) was the main factor that created difficulties in the operation and the main cause of conversion to sternotomy. Surgical experience can increase up to 96.5% feasibility of successful Kolesov operation including difficult anatomic or haemodinamic situations.

C5.3

PRELIMINARY EXPERIENCE IN ROBOTIC CLOSED CHEST CORONARY BYPASS

JEGADEN O., FARHAT F., AUBERT S., METON O., BLANC P.

CHU LYON Cardio-Vascular Surgery and Transplantation; CHU LYON Cardio-Vascular Surgery and Transplantation; CHU LYON Cardio-Vascular Surgery and Transplantation; CHU LYON Cardio-Vascular Surgery and Transplantation; CHU LYON Cardio-Vascular Surgery and Transplantation

Objective: With the introduction of robotic surgical system, performing closed chest coronary artery bypass grafting is become a reality.

Methods: From October 2003 to February 2004, 10 patients underwent robotic coronary bypass grafting (all males, mean age 59 years). Seven patients suffered from one-vessel disease and three patients from double-vessel disease. In all patients, IMAs were safely harvested endoscopically (both IMA in 2, one IMA in 8). A off-pump procedure was done in all cases. In 8 patients a complete closed chest procedure was done (TECAB) with bilateral IMA bypass grafting in one case. In 2 patients, after a closed chest IMA bypass to LAD, a MIDCAB procedure was associated to perform the second anastomosis: vein graft to the right coronary artery (1), left IMA to the marginal artery (1).

Results: There was no mortality. On average, operation time was 4.5 hours, IMA harvesting time was 40 min each and anastomosis time was 40 min each. On average, extubation time was 5.5 hours, ICU stay was 1 day. On average, troponin level (24°hrs) was 1 UI and blood loses (24°hrs) was 250 ml. Hospital stay was 4 days and all patients were discharged to home. Today, there has been no reintervention.

Conclusions: According to our preliminary experience, robotic closed chest coronary bypass is a realistic goal, even with the use of both IMA. However, in multiple vessel disease, combined techniques have to be discussed and the association of TECAB and MIDCAB during the same procedure may be useful.

C5.4

A META-ANALYSIS OF RANDOMISED TRIALS ON THE EFFECT OF OFF-PUMP CABG

van der Heijden G., Nathoe H., Jansen E., Grobbee D.

University Medical Center Utrecht Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht Department of Cardiology; University Medical Center Utrecht Department of Cardio-Thoracic Surgery; University Medical Center Utrecht Julius Center for Health Sciences and

Objective: To summarise the evidence on the effect of off-pump CABG (i.e. without cardiopulmonary bypass) regarding the post-operative risk for death, stroke and myocardial infarction (MI). We pool the results of randomised trials comparing the risk of off-pump CABG and conventional CABG (i.e. with cardiopulmonary bypass).

Methods: Full trial reports, published before January 01, 2004, were harvested from PubMed, EMBASE, CINAHL, CENTRAL and Web of Science. After methods appraisal and data extraction, results of individual trials are expressed as odds-ratio (OR) with their 95% confidence intervals (95%CI). Subsequently we pooled these trials using a random effects model, and according to the inverse variance method as proposed by Liard and DerSimonian (meta procedure in STATA 7.0), and expressed the results as the polled OR and 95%CI.

Results: In total 52 reports were traced, together concerning 42 randomised trials. For 12 only a meeting abstract was available, and for 3 trials insufficient data on endpoints were reported. Hence, 27 trails (including 2061 patients; 1031 off-pump, 1030 on-pump) were pooled. Most trials included relatively many young and male patients with up to 3 vessel disease, while off-pump patients received a little bit fewer grafts. Except for MI at 2-week follow-up, the pooled effect for all endpoints consistently favour off-pump CABG. For the composite endpoint of death, stroke and MI the risk reduction in favour of off-pump CABG was 24%, 25%, 45% and 35% respectively at 2-week, 1-month, 3-month and 1-year follow-up. None of these risk reductions, however, reached statistical significance at the conventional level. But the lack of significance was borderline at 3-month and 12-week follow-up.

Conclusions: This meta-analysis shows that off-pump CABG is at least as save and very likely more effective than on-pump CABG. The pooled results show important reductions in risk of death, stroke and MI, that clearly favour off-pump CABG. But these reductions fail to reach statistical significance. Between January 01 and March 15, 2004, already 9 new randomised trials are reported as full paper, while several trials await first full publication, or publication of extended follow-up. These new data will improve statistical power, and it is therefore expected that statistical significance in favour of off-pump CABG will be reached soon.

C5.5

OFF PUMP CORONARY ARTERY BYPASS GRAFTING: SEVEN YEARS EXPERIENCE

Alamanni F., Polvani G., Agrifoglio M., Zanobini M., Urso S., Grillo F., Roberto M., Biglioli P.

Centro Cardiologico Monzino, University of Milan Department of Cardiovascular surgery; Centro Cardiologico Monzino, University of Milan Department of Cardiac Surgery

Objective: Redo coronary artery bypass surgery (rCAB) is considered a high risk procedure for perioperative mortality and mobidity. This study presents our experience throughout seven years of off pump coronary artery bypass (OPCABG).

Methods: From January 1995 to January 2004, we performed 173 rCAB, of whom 102 (58.95%) off-pump. In the period 2000-2003, rCAB off- pump represented the 95.5 of total reoperations versus 28.7% of period 1995/1999 (p> 0.02). Mean age was 66.5 vs 64.3, mean ejection fraction 54.5% vs 53%. The average number of bypass per patient reaches 2.4 over the period 2000/2003. The standard technique included a traction suture in the posteriuor pericardiurm, the use of cardiac wall stabilization. We used intracoronary shunts in 100% cases and transesophageal echocardiography as intraoperative monitoring.

Results: Through the entire period we had no cases of on pump conversion; no intrahospital death, 2 case of perioperative MI (1.96%), 1 case of perioperative stroke (0.98%) on day 5, 25 patients (24.50%) had postoperative atrial fibrillation, no reoperation for postoperative bleeding, 32 (31.37%) patients had perioperative blood transfusion. The mean in hospital stay was 7. 0 days.

Conclusions: We think (OPCABG) is at least as effective as on-pump operation to achieve a complete and safe revascularisation in rCAB. Off-pump approach is now our first choice for rCAB. A complete revascularisation is possible with a low incidence of major adverse events.

C5.6

COMPLETE CORONARY REVASCULARIZATION UNDER USE OF CARDIO-BYPASS (CB) WITH THE MEDOS DELTASTREAM^® BLOOD-PUMP-SYSTEM IN AN ANIMAL MODELL

Litmathe J., Feindt P., Boeken U., Gams E.

Heinrich-Heine-University Thoracic- and Cardiovascular Surgery

Objective: On-pump or off-pump revascularization is still under discussion with all known arguments, such as techniqually higher demands to the surgeon and evaluation of the correct indication in case of triple vessel disease for OPCAB performance. For this purpose we combined off-pump revascularization with only cardio- bypass using the Medos Deltastream^® blood-pump-system in order to achieve a complete revascularization.

Methods: A group of each 6 Munich mini-pigs was subjected to extracorporeal bypass circuit using the Medos Deltastream^® blood pump-system consisting of a rotation-pump with a diagonal streamed mixflow, however without the use of an oxygenator. Anastomosis under luxation of the heart were performed in the area of the circumflex artery using different kinds of support: 1.) right atrium—A. pulmonalis, 2.) right atrium—Aorta ascendens, 3.) left atrium—Aorta ascendens. Oxygenation, LDH, and CK, CK-MB fraction were studied.

Results: No statistical significant differences concerning the three groups could be observed. Best oxygenation was slightly pronounced in group 3 (pO2 340+/–98 mmHg vs. 310+/–80 mmHg in group 1 and 320+/–100 mmHg in group 2). Hemolysis and ischemic parameters were comparable in all three groups and did not overstep normal values significantly (LDH 190+/–31 U/l in gr. 1, 210+/–42 U/l in gr. 2, 183+/–21 U/l in gr. 3; MB fraction in all groups below 11 U/l). Concerning the surgical practicability the support from left atrium to the aorta ascendens (group 3) seems to be the most easy access.

Conclusions: Our results suggest the feasibility of mixed off-pump/on-pump CABG. The Medos Deltastream^® blood pump system represents a promising device for minimizing the extracorporeal circulation and hence reducing blood-trauma.

C5.7

DETERMINATION OF CRITERIA FOR DUPLEX CAROTID SCREENING PRIOR TO CORONARY ARTERY SURGERY

LASKAR M., ABOYANS V., BERTIN F., EL REFY A., ORSEL I., CHEVREUIL C., CORNU E., LACROIX

CHU Dupuytren Thoracic and Cardio-Vascular Surgery

Objective: Stroke remains one of the most severe complications occurring after coronary bypass artery grafting (CABG). Its prevalence remained stable during these last 15 years, mainly due to the aging of the candidates and a growing prevalence of multifocal atherosclerotic patients. As one half of these post- operative events are due to the high prevalence of cerebrovascular disease in these patients, we aimed to detect the risk factors of presence of significant carotid lesions in these patients in order to optimize the

Methods: We prospectively performed neck arteries Duplex scanning on 1043 consecutive patients prior to CABG. A first subgroup of 825 patients was studied to establish the predictive model. In addition to their clinical and coronary angiography data, the results of physical examination and ankle-brachial index (ABI) measurements were also noted. Those with an artery stenosis >50% were considered as having significant lesions. A multivariate analysis by logistic multiple regression was then performed to determine significant risk factors. The following 218 patients benefited from the same assessment protocol, and the ability of the model to predict >50% stenosis of the neck arteries has been assessed, compared to Duplex.

Results: Among the first 825 patients, 108 (13.1%) had at least one significant lesion on their neck arteries. The independent risk factors were: past history of stroke or transient ischemic attack, neck bruit, patent peripheral arterial disease (PAD), subclinical PAD (ABI<0.85), and age >70 years. Neck auscultation alone had a very poor sensitivity (23%). Among the subsequent 218 patients, the presence of at least one of these factors was able to detect 24 out of 26 (92.3%) patients with a significant stenosis, and could rule out 41% of them from a systematic Duplex screening. The overall sensitivity of this approach is at 90%, with a negative predictive value of 96%, permitting to reduce dramatically the number of Duplex assessments by excluding

Conclusions: With the inclusion of the ABI measurement, this risk assessment approach is able to perform a cost-effective screening of cerebrovascular disease in CABG patients.

C5.8

APPLICATION OF EUROSCORE AND LOGISTIC EUROSCORE IN PATIENTS UNDERGOING OFF-PUMP CORONARY PROCEDURE

Pacholewicz J., Szafron B., Maruszewski M., Farmas A., Szafranek A., Zembala M.

Silesian Center for Heart Disease Cardiac Surgery and Transplantology Department

Objective: Operative risk evaluating scales are constantly developing. This should lead to improved risk stratification and optimal procedure selection in various patients. We have attempted to compare the usefulness of EuroSCORE to logistic EuroSCORE in coronary patients who form the majority of our patients. Almost half of coronary operations performed in our institution are off-pump procedures (OPCAB), so we have chosen this group of patients for our analysis.

Methods: There were investigated 218 consecutive patients (63F/155M) who underwent direct myocardial revascularization without cardiopulmonary bypass. Both risk stratification scales were applied in all patients in order to estimate the mortality rate. The predicted values have been compared to our operative results.

Results: The average EuroSCORE for the whole group was 3.3pts. as compared to mean logistic EuroSCORE 2.89% in this group. The mortality rate for the whole population was 3.67% (8/218). The patients were also divided into low (86pts.), medium (96pts.) and high (37pts.) risk groups with average logistic EuroSCORE for these groups as follows: 1.47% vs. 2.76% vs. 6.43%. The mortality rate in these groups was following: 1.16% (1/86) vs. 6.25% (6/96) vs. 2.7% (1/37).

Conclusions: Although evidence suggests that logistic EuroSCORE gives more nearing mortality prediction, the EuroSCORE is also useful in some cases. In all groups our actual mortality differs from the predicted ones, which proves that further development of risk stratification tables is necessary.

C5.9

INFLUENCE OF CPB IN NEUROLOGICAL OUTCOME AND CEREBRAL MARKERS RELEASE IN CORONARY SURGERY

Battaglia F., Prifti E., Leacche M., Maiani M., Bonacchi M.

Università degli Studi di Firenze Cardiochirurgia

Objective: S-100ß protein and NSE have been suggested as markers of brain damage following cardiac surgery. Aim of this study was to examine whether their serum concentrations are different in OPCABG versus on-pump surgery and relate it to neurological outcome particularly to postoperative neurocognitive

Methods: Between January 2002 and December 2003, 42 patients undergoing first time CABG were enrolled prospectively. Exclusion criterias were: LVEF<35%, age>70years, previous MI, associated valvular disease, cerebrovascular disease, abnormal preoperative carotid vessels, renal dysfunction, coagulopathy. They were divided randomly in Group I (n=24patients) undergoing on-pump CABG and Group II (n=18patients) undergoing OPCAB. There was no autotransfusion of shed blood and cardiotomy suction. Transcranical Doppler was performed during operation. Neurocognitive test were performed pre and post-operatively.

Results: There was no difference according the numbers of grafts per patients (p=ns). The total surgical procedure duration resulted significantly higher in I versus II (p<0.021). Mean ICU and hospital stay were significantly higher in Group I than II (p=0.005 and p=0.036 respectively). There were no significative differences in preoperativeS-100ß and NSE serum concentrations between groups. The postoperative S- 100beta and NSE levels were increased in both groups, but in II were 0.5±0.11 (microg/l) and 8.6±4.2 (microg/l)respectively, significantly lower than in I (p<0.001). Linear regression analysis revealed a significant correlation between CBP duration and S-100ß and NSE peak levels(p<0.0021 r=0.36 and p<0.0001 r=0.81 respectively). There were no evidence of a relationship between these markers and High- IntensivityTransientSignals (HITS) in both groups; instead we found a strong correlation between cerebral markers level and alterations in neurocognitive tests.

Conclusions: The release of NSE and S-100ß protein and the perioperative cerebral impairment are increased in patients undergoing on-pump CABG. The main mechanism of brain damage seems to be the blood-barrier impairment and cerebral cell injury due to inflammatory response caused by CPB.

C5.10

OFF-PUMP CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION

Mirmohamad-Sadeghi M.

Chamran Hospital Cardiovascular Center Chamran Hospital

Objective: Patients with left ventricular dysfunction and low ejection fraction (EF) are at high-risk of morbidity and mortality after coronary artery bypass grafting (CABG). The potential success of off-pump CABG in this high-risk population has yet to be determined. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups.

Methods: In a double blind clinical trial study, between April 2002 and Feb 2003, 100 patients (51 women and 49 men) candidated for CABG with low ejection fraction (EF<35%) were randomized into two groups. All patients were operated on through a median sternotomy. In on-pump group, 50 patients underwent coronary artery surgery on cardiopulmonary bypass. In 50 patients who underwent off-pump coronary artery bypass (OPCAB) octopus was used as mechanical stabilizer and 4% of the patients required conversion to CPB. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared

Results: The mean age of the patients was 59.7+/– 9.2 in patients operated on-pump and 57.4+/– 8.3 in patients operated off-pump. Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. The mortality was 4% and 6% (p=0.1) in off-pump and on- pump groups respectively. Use of intraaortic balloon pump (6%) was rarely required. Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time, mean blood, atrial fibrillation, and prolonged ventilation were less in OPCAB group. Intensive care unit stay (20+/– 8 hours) and hospital stay (6+/– 3 days) were significantly less in the OPCAB group (p<0.001). Short-term follow-up documented the immediate safety of the OPCAB procedure including efficacy and patency rates compared to on-pump procedures.

Conclusions: Off-pump coronary artery bypass grafting with revascularization of all coronary artery segments is a safe and effective procedure in patients with poor left ventricular function and can be performed with equal or improved outcomes and shorter surgical lengths of stay compared with CABG with cardiopulmonary bypass.

SCIENTIFIC SESSION C6 CONGENITAL HEART DISEASE

C6.1

RISK FACTORS FOR RIGHT VENTRICULAR OUTFLOW TRACT ANEURYSM FORMATION AFTER COMPLETE REPAIR OF TETRALOGY OF FALLOT

Demyanchuk V., Mokryk I., Perepeka I., Misura A., Lazoryshynets V.

Amosov Institute of Cardiovascular Surgery Cardiac surgery; Amosov Institute of Cardiovascular Surgery Cardiac surgery; Amosov Institute of Cardiovascular Surgery Cardiac surgery; Amosov Institute of Cardiovascular Surgery Cardiac surgery; Amosov Institute of Cardiovascular Surgery

Objective: Right ventricular outflow tract (RVOT) aneurysm has been recognized as one of the complications that can occur in the follow-up after complete repair of TOF. The aim of this study was to determine the incidence and identify risk factors for RVOT aneurysm formation.

Methods: We retrospectively reviewed 212 patients with a median age 22.1±10.1 months (range, 3 to 36 months) who underwent the complete repair of TOF between January 1991 and January 2001. For the reconstruction of RVOT, transannular repair was performed in 126 (59.4%) patients—99(78.3%) received classic transannular patch (TAP), 27(21.7%) autopericardial monocusp. Non-transannular repair was performed in 84(39.6%) patients—39(46.7%) received patch within RVOT, 24(29.5%) transatrial repair and 20(23.8%) double patches. 2(1%) patients received autopericardial conduit. Patch was implanted into RVOT on a beating heart in 38(18%) patients. The follow-up was complete, average 5.6±1.9 years (range, 0.1 to 9.4 years). The patients were followed by serial echocardiography examination. We used diagnosis aneurysm when RVOT diameter was more than two times bigger comparing subjects with the same BSA.

Results: Late mortality was 1.4% (3 from 212). The causes of mortality were bacterial endocarditis, stroke and pneumonia correspondingly. Late survival was 98%. During follow-up 11 patients (5.2%) required reoperation—aneurysmectomy. Univariate analysis identified double patches technique (p=0.04), RVOT repair on a beating heart (p=0.05) and a peak systolic pressure gradient through the RVOT > 39 mmHg (p=0.0001) as significant predictors of aneurysm formation. There was no mortality after reoperations. Kaplan-Meier freedom from aneurysm was 100, 86, 65% at 1, 5 and 10 years, respectively.

Conclusions: RVOT aneurysm formation was the main reason for reoperation. Major risk factors for aneurysm formation were double patches technique, RVOT repair on a beating heart, a peak systolic pressure gradient through the RVOT > 39 mm Hg.

C6.2

RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION AFTER ARTERIAL SWITCH OPERATION FOR REPAIR OF THE TAUSSIG-BING ANOMALY

Sinzobahamvya N., Wetter J., Miyamoto T., Fink C., Brecher A., Asfour B., Urban A.

Deutsches Kinderherzzentrum Sankt Augustin Paediatric Cardio-Thoracic Surgery

Objective: Right ventricular outflow tract obstruction (RVOTO) remains the most frequent cause of reoperation after arterial switch operation (ASO) for transposition of the great arteries (TGA), with a relatively early occurrence within the first two postoperative years and as much as 10% to 20% of cases in the literature. RVOTO incidence could be expected to be higher after ASO repair of the Taussig-Bing anomaly as this lesion is usually associated with subvalvular aortic stenosis and hypoplastic aortic arch. The purpose of this study was to evaluate the risk to develop RVOTO after arterial switch operation for the Taussig-Bing

Methods: All 29 patients who underwent ASO repair of the Taussig-Bing anomaly from 1986 through December 2003 were reviewed. Postoperative RVOTO was defined as a peak echo-gradient of at least 30 mm Hg across the right ventricular outflow tract (RVOT). Freedom from RVOTO occurrence was estimated according to Kaplan-Meier method.

Results: Twenty two patients (76%: 22/29) had preoperative subaortic RVOTO which was resected during ASO repair. In 8 patients, the right coronary artery passed in front of the aorta and crossed RVOT. There was one operative death: operative mortality of 3.5%. Three patients died late and one death was not cardiac related. At discharge from hospital, 5 patients had echocardiographic RVOTO. Four patients were reoperated on (one of these twice) for RVOTO after 28 days, 8, 11, 12 and 25 months. At follow-up, RVOTO was present in 13 patients. The risk to develop RVOTO was 35.4%±9.6% at 1 year, increasing slowly and leveling out at 58.8%±11.4% at year 5. The site of RVOTO was always subvalvular or valvular.

Conclusions: The risk to develop RVOTO after ASO correction of the Taussig-Bing anomaly is higher than after ASO repair of simple TGA and TGA with ventricular septal defect. RVOTO occurs despite resection of the obstructing subaortic conal tissue at the time of repair and evolves over time. The level of obstruction is subvalvular and valvular, whereas it is usually supravalvular after TGA ASO repair. The pathogenesis might be the mismatch in size between both great arteries with a small aortic annulus at the time of arterial switching. This mismatch may set off a process of increasing adaptive infundibular hypertrophy. Surgery is indicated when RVOTO becomes significant or symptomatic.

C6.3

THE BIDIRECTIONAL CAVOPULMONARY (GLENN) SHUNT WITHOUT CARDIOPULMONARY BYPASS: IS ITA SAFE OPTION?

Hussain S.

All India Institute of Medical Sciences Department of Cardiothoracic and vascular Surgery

Objective: The bidirectional cavopulmonary (Glenn) shunt (BDG) is a routine first stage procedure for total cavopulmonary connection in children with single-ventricle physiology. It is usually performed with cardiopulmonary bypass (CPB) with its associated adverse effects. We report our early results of BDG operation done without CPB.

Methods: Between January 2002 and July 2003, a total of 37 patients underwent BDG operation by one surgeon. Of these, 22 patients had the procedure performed without cardiopulmonary bypass. The diagnoses were tricuspid atresia (n=9), complex DORV situations (n=5), hypoplastic right ventricle (n=4), dTGA, VSD, PS which were not suitable for Rastelli (n=3) and single ventricle complex (n=1). Eleven patients had earlier undergone a modified Blalock-Taussig shunt (BTS) and one had a pulmonary artery banding done. Age of the patients ranged from 7 months to 11 years. The procedure was done with temporary clamping of the superior vena cava, and BTS and PDA were left open until the completion of the operation. Four patients had bilateral BDG done and one had additional RPA plasty done. All the patients underwent complete neurological examination, CT scan of head and developmental quotient (D.Q.)/ intelligence quotient (I.Q.) test both preoperatively as well as postoperatively.

Results: There was no operative mortality in our patients. The follow-up has ranged from 3-19 months (mean 3.09 years). The rise of central venous pressure on clamping the SVC ranged from 17-57 mm Hg (mean 34.2 mm Hg). The clamp time ranged from 4.5-10 minutes (mean 6.8 min). There was no hemodynamic instability during any of the procedures and the oxygen saturation was maintained throughout the procedure. The average ICU stay was 1 day. There were no neurological events in the ICU in any of the patients. All had a clinically normal neurological examination at the time of discharge from the hospital. There was no evidence of any obvious brain injury on the postoperative CT scan of head in any of our patients. The mean pre-op and post- op D.Q. scores were 87.13+/– 10.87 and 89.45+/–10.66 respectively (p<0.001). None of the patients showed deterioration of D.Q. / I.Q. score during follow-up evaluation.

Conclusions: Our early results show that in selected patients, bidirectional Glenn operation without CPB is a safe procedure. It avoids CPB related problems and the brain function seems to be well protected.

C6.4

DEEP HYPOTHERMIA FOR RECONSTRUCTIVE CARDIAC SURGERY IN PEDIATRIC PATIENTS

Chira M., BUTYKA R., BARSAN M.

"N. Stancioiu" Heart Institute Cardiovascular Surgical Clinic

Objective: Analysis of the conduit of perfusion, techniques and physiopathology of the pediatric patients undergoing reconstructive cardiac surgery.

Methods: We reviewed 52 pediatric patients operated on, between Oct.1998 and July 2003 in our hospital, aged between 6 days and 3 years, (mean—13 months), weighting between 2.9 kg and 14.5 kg, (mean—6.15 kg), with a BSA between 0.22 m2 and 0.66 m2 (mean—0.32 m2). The pathology of the operated patients was: T. Fallot—18 patients, TGA—18 patients, TAPVC—6 patients, DORV—5 patients, AVSD—3 patients, Truncus—2 patients.

Results: The priming volume was 285 ml (patient weight up to 5 kg) or 485 ml (patient weight 5 to 15 kg). We used low flow bypass technique in all cases and additional variable periods of circulatory arrest in 20 patients (5 min.—25 min). The mean clamping time was 112 min, the mean circulation time was 179 min. We used 1:1 blood cardioplegia every 20 min and conventional ultrafiltration (mean-163 ml) and modified ultrafiltration (mean- 185 ml). The patients’ initial hematocrit has a mean of 43.7%, the minimal hematocrit on ECC has a mean of 23.9% and the final hematocrit has a mean of 41.8%. The mean values of K were: initial- 3.25, postcardioplegia—5.5 and final—3.83. Our most important concern in perfusion management is reduction to minimal prime volume by choosing adequate low prime volume oxigenator and shortening the circuit lines; another concern is removal of added volume during ECC by conventional and modified ultrafiltration. During circulatory arrest we maintained high blood glucose levels using 33% glucose solution, in order to protect cerebral function. We used also vitamin C in priming and during rewarming, thus decreasing oxidative stress in neonates undergoing CPB. Because the aorta is crossclamped even if deep hypothermia and low flow are used, we feel necessary to have myocardial protection, by administration of repeated doses of cardioplegia or maintaining high levels of K (5.5-6.5mEq/l). The perioperative mortality in the operated patients under deep hypothermia was 11.5%.

Conclusions: For reconstructive cardiac surgery in pediatric patients, deep hypothermia with low flow bypass and small periods of circulatory arrest is in our opinion the procedure of choice, in complex techniques. Conventional and modified ultrafiltration regulates the fluid balance and inflammatory response, improving the patients outcome.

C6.5

REINTERVENTIONS AFTER REPAIR OF TETRALOGY OF FALLOT—A 40 YEARS EXPERIENCE

Martin D., Knez I., Martin A., Gamillscheg A., Dacar D., Rigler B.

Medical University of Graz Division of Cardiac Surgery, Department of Surgery; University Clinic of Surgery Graz Austria Thoracic Surgery; University Clinic of Surgery Graz Austria Thoracic Surgery

Objective: Evaluation of longterm follow up with respect to survival and reinterventions.

Methods: Longterm follow up of 302 patients operated on with Tetralogy of Fallot (TOF) between 1963-2003 was reanalyzed. Mean follow up of the 176 male and 126 female patients was123.6 (range 1-429) yrs. Mean age was 4.9 years. Associated malformations were presented in 192 patients. 34% of the patients primarily required palliative procedures. 44% had transannular patch reconstruction of the RVOT at repair. Statistical analysis included univariant analysis of perioerative variables. Kaplan Meier estimate was used to describe longterm survival and morbidity.

Results: Hospital mortality decreased significantly during the past 40 years from 15.1% (1963-1983) to 5.3% (1984-2003). Actuatial survival at 460 months of the entire group of survivos was 79.4%. Totally required reinterventions at a mean time interval of 50 month after primary repair. In patients with transannular RVOT- patch operated on between 1963-1983 actuarial freedom from RVOT reintervention was 50% but 81% when operations were performed between 1984-2003. Freedom from reintervention due to RVOT-reconstruction in patients with non-transannular patch was 82% (1963-1983) and 81% (1984-2003).

Conclusions: Longterm survival up to 40 years was excellent following transannular and non-transannular patch plasty of RVOT. However late reoperations due to RVOT-patch and longlasting follow up

C6.6

CONVENTIONAL AND MODIFIED ULTRAFILTRATION IN PEDIATRIC CARDIAC SURGERY- SEVEN YEAR EXPERIENCE OF ONE CENTRE

STAJEVIC-POPOVIC M., EREMIJA L., SEHIC I., MILOVANOVIC V.

Mother and Child Health Institute of Serbia "Dr Vukan Cupic" Department of Pediatric Cardiac Surgery

Objective: Ultrafiltration in cardiac surgery dates from thirty years ago. Initially, this method was used only during CPB. Modified ultrafiltration in pediatric cardiac surgery was introduced twenty years later. At our department, conventional ultrafiltration (CUF) was implemented in 1997 and modified (MUF) in 1998. The objective of this paper is to show our experience and positive effects of ultrafiltration on operative and postoperative morbidity in our center.

Methods: Ninety patients operated from VSD, below one year of age were used in this study. We compared a nonfiltered group with the group conventionally filtered and the group where both types of filtration were used. The compared operative post CPB parameters were systolic and mean blood pressure, hemoglobin, blood glucose, serum calcium and protein levels. In the postoperative course, we assessed the presence/ absence of renal and neurological complications, diuretic intake and platelet count.

Results: Our results showed positive results in the filtred groups. Systolic and mean blood pressures were higher in the filtered groups.Blood glucose levels post CPB was lower in the MUF group, but showed no difference in the other two groups. MUF allowed designing of hemoglobin post CPB. Serum calcium and protein levels showed no significant differences between the groups. Patient showed no renal impairment post surgery, but the use of diuretics was significantly lower in the MUF group. There were no neurological complications. Platelet count was higher in the MUF group. Problems related to MUF were arterial pressure drops at the beginning of the procedure, occasional air emboluses which stoped the ultrafiltration and postoperative transient hematuria in five patients. Three patients were significantly hypovolemic post MUF

Conclusions: Conventional and modifoed ultrafiltration is a safe and useful procedure in pediatric cardiac surgery. This method has improved the hemodynamic and coagulation status of the operated children, decreased use of diuretics and lowered the blood glucose levels. Ultrafiltration is a routine technique in our hospital

C6.7

CAVOPULMONARY ANASTOMOSIS: TOPOLOGICAL MODEL

PELIZZONI F.

Azienda Ospedaliera -Ospedale Niguarda Cà Granda- Divisione di Cardiochirurgia "A. De Gasperis"

Objective: Cavopulmonary anastomosis is used for palliation of cyanotic disease. The procedure creates modifications to pulmonary physiology: exclusion of inferior vena caval effluent, blood flow reduction, arteriovenous malformations. Critical point is the expression of angiogenic and stress-related proteins. We apply a topological model -the catastrophe teory- to embrace such phenomena.

Methods: Waddington's multi-dimensional space-time system is the conceptual application. By previous Western blotting results, related to VEGF, HO1, GLUT1 genes upregulation, we develop the behaviour surface in order to define the attractor phenomena.

Results: In the devolpmental fields, or chreods, we identify points of divergence: angiogenic response and endothelial stress response are subjected to an array of physical and chemical parameters which change temporally and spatially.

Conclusions: Topological models based upon the catastrophe theory can be employed not only as conceptual framework but they provide verification and clarification.

C6.8

SUPRAVALVULAR CONGENITAL AORTIC STENOSIS: VARIATIONS OF SURGICAL TECHNIQUE AND RESULTS

Liekiene D., Lebetkevicius V., Tarutis V., Sudikiene R., Lankutiene L., Lankutis K., Sirvydis V.

Clinic of Heart Diseases, Vilnius University Heart Surgery Center; Clinic of Heart Diseases, Vilnius University Heart Surgery Center; Clinic of Heart Diseases, Vilnius University Heart Surgery Center

Objective: Congenital supravalvular aortic stenosis (SVAS) is rare obstructive lesion of the left ventricle outflow tract. It is mostly recognized in cases of Williams's syndrome (loss-of function mutation of the elastine gene on chromosome 7q11.23) together with a peculiar face ("elfin face") and mental retardation. It is also recognized with peripheral pulmonary artery stenosis—Williams-Beuren syndrome. Clinical experience with supravalvular aortic stenosis is limited. Several techniques for symmetric reconstruction of the SVAS have been developed, but the general treatment strategies and the superiority of modifications remains to be determinate. We review our experience in surgical treatment of supravalvular aortic stenosis.

Methods: 9 consecutive patients with mean age of 5.1 year (varied from 1 to 11 years) underwent surgical treatment of SVAS in Vilnius Heart Surgery Center from 1994 till 2003 year. There were 4 boys and 5 girls. 6 of them had William's syndrome and 3—William's-Beuren syndrome (stenosis of peripheral pulmonary arteries were included). Different surgery technique was used. 2 patients underwent correction with pericardial patch. 3 patients underwent correction using bifurcated patch plasty. 4 patients underwent correction of SVAS using original method of our clinic—homograft with coronary insertion.

Results: There was no postoperative death. All patients were discharged from the hospital with mean gradient in ascending aorta of 16.88 (varied from 0 to 30) mm Hg, when before surgery it was 72.2 (varied from 26 to 100) mm Hg. For one patient 1 year after surgery developed restenosis of aorta and pulmonary arteries. She underwent balloon angioplasty of ascending aorta and pulmonary arteries and later—PTCA of right pulmonary artery. After procedure gradient in ascending aorta decreased from 37 to 15 mm Hg.

Conclusions: 1) Relief of the supravalvular aortic stenosis requires variety of surgical technique, because of difference and extent of pathological lesions.

2) Despite of very radical and extensive surgical technique restenosis of aorta or pulmonary artery could occur in long-term follow-up and could need angioplastic procedure or even reoperation.

SCIENTIFIC SESSION C7 VALVE REPAIR

C7.1

AORTIC VALVE-SPARING OPERATIONS: REIMPLANTATION WITH VASCUTEK VALSALVA PROSTHESIS

Martìn-Suàrez S., Pacini D., Di Marco L., Ferlito M., Rocchi G., Begonzini M., Pilato E., Di

Cardiac Surgery Division Cardiac Surgery Department- S.Orsola-Malpighi Hosp; Cardiac Surgery Division Cardiac Surgery Department- S.Orsola-Malpighi Hosp; Cardiac Surgery Division Cardiac Surgery Department- S.Orsola-Malpighi Hosp; Cardiology Department Cardiology Department; Cardiology Department Cardiology Department; Cardiac Surgery Division Cardiac Surgery Department- S.Orsola-Malpighi Hosp; Cardiac Surgery Division Cardiac Surgery Department S.Orsola-Malpighi Hosp; Cardiac Surgery Division Cardiac Surgery Department- S.Orsola-Malpighi

Objective: Dilatation of the proximal aorta is known to be associated with valve anomaly as bicuspid valve regurgitation and may be responsible of aortic valve insufficiency even with normal aortic valve. Reimplantation technique has already been demonstrated an useful procedure in these cases. There is still discussion about the durability of the procedure and long term degeneration of aortic valve cusps. In order to avoid this problem, a new conduit which mimic the natural Valsalva sinuses (Vascutek Valsalva) has been designed. We present our results performing reimplantation with this prosthesis.

Methods: From September 2001 to March 2004, 81 patients have been operated using sparing aortic valve procedures. In 58 patients (71.6%), reimplantation technique was performed. Of them, in 52 cases, a new conduit, has been used. Associated bicuspid valve repair has been performed in many cases.

Results: 30-days morbidity was low and 30-days mortality was about 3.7% (3 cases). Freedom from reoperation at a mean follow-up time of 29 months, is about 95.8%. At this time, the 94% of patients, present trivial or mild aortic regurgitation.

Conclusions: The sparing valve operations are feasible techniques when aortic valve cusps are intact also in bicuspid valve. Our results with the reimplatation technique, using the Vascutek Valsalva conduit, are really satisfactory, and echocardiographic and angiographic controls demonstrated the maintenance of natural anatomy of aortic root and coronary artery relationship. However, longer follow-up time is mandatory to check if the new conduit Vascutek Valsalva prevents cusp deterioration.

C7.2

VALVE SPARING AORTIC ROOT RECONSTRUCTION: OPERATIVE AND SHORT TERM RESULTS

Mangini A., Innorta A., Spina A., Gelpi G., Lemma M., Antona C.

"L.Sacco" Hospital Cardiovascular Surgery

Objective: Patients with aneurysm involving the ascending aorta or the aortic root may have associated aortic valve incompetence (AI). We have reviewed our experience with procedures of aortic root remodelling and reconstruction of the sino-tubular junction.

Methods: Fifty-eight patients were operated on between February 2000 and December 2003. There were 18 females (31%) and 40 males (69%). Mean age was 63.7±11 years. Six patients (10.34%) had concomitant coronary artery disease. Pre-operative echocardiography showed grade III or IV AI in 19 patients (32.7%). All patients but one had a normal three leaflet aortic valve. Twenty patients (34.4%)underwent aortic root remodelling with sparing of the aortic valve, 11 (18.9%) had replacement of all three sinuses and 9 (15.5%) of one or two sinuses. Reconstruction of the sino-tubular junction alone was performed in 38 patients (65.5%), implanting tubular prostheses whose diameter was less than 80% of the aortic annulus.

Results: There was one perioperative death(1.7%). One patient with aortic root remodelling of the non- coronary sinus underwent aortic valve replacement for evidence of grade IV AI at intraoperative transoesophageal echocardioghraphy. There were no major postoperative complications. Pre-dischrarge echoacardiography showed no or trivial AI in all patients. Mean follow up was 10.7±6.0 months. Two patients (3.5%) underwent aortic valve raplacement due to recurrent severe AI. There were no procedure related death. Transthoracic echocardiography showed no progression of AI in 40 patients and moderate AI in 15.

Conclusions: Valve sparing aortic root reconstruction is feasible with low perioperative morbidity and mortality and good early and short-term results

C7.3

RECONSTRUCTION OF MITRAL AND TRICUSPID VALVES IN PATIENTS WITH HEART FAILURE

RADOVANOVIC N., Petrovic L., Mihajlovic B., Nicin S., Jonjev Z., Zorc M.

Institute Of Cardiovascular Disease University Clinic Of Cardiovascular Surgery; Surgery; Institute Of Cardiovascular Disease University Clinic Of Cardiovascular Surgery; Institute Of Cardiovascular Disease University Clinic Of Cardiovascular Surgery; Institute Of Cardiovascular Disease University Clinic Of Cardiovascular Surgery; Medical Faculty Institute Of Histology

Objective: Patients with dilated cardiomyopathy exhibit extensive remodeling of the fibrous skeleton of the heart, annular dilatation, and consecutive mitral and tricuspid regurgitation. These changes increase perioperative morbidity and mortality, and put that patient candidacy for heart transplantation. The aim of this study is to show immediate and long-term results after Reductive Annuloplasty of Double (mitral and tricuspid) Orifices (RADO) in patients with primary (PDCM) and ischemic dilated cardiomyopathy (IsDCM).

Methods: There were 272 patients (67%) with IsDCM and 133 patients (33%) with PDCM. Mitral regurgitation was corrected with posterior semicircular annuloplasty, Carpantier ring annuloplasty and bileaflet prosthesis implantation in 298, 49, and 58 patients respectively. In all cases modified De Vega's tricuspid annuloplasty was performed. In patients with IsDCM, RADO procedure was performed in addition to myocardial

Results: Postoperative 30-day mortality was 6.6% for IsDCM and 2.2% for PDCM. Survival rates for IsDCM were 61.5±4.0% at 5 years and 38.2±8.0% at 10 years. Patients with PDCM had 5 and 10 year's survival rates of 43.9±5.6% and 21.3±8.5% respectively. Significant reduction in postoperative medications and number of decompensations were also observed.

Conclusions: RADO corrects remodeling of the fibrous skeleton of the heart, changes spherical geometry of the left and right ventricles, improves hemodynamic action, and slows down progression of heart failure. RADO procedure could be successfully used as an important associated procedure in IsDCM, and a new surgical option in the early stage of PDCM.

C7.4

AORTIC VALVE-SPARING OPERATIONS IN PATIENTS WITH ANEURYSMS OF THE AORTIC ROOT OR ASCENDING AORTA: PRELIMINARY RESULTS

Settepani F., Gallotti R., Eusebio A., Manasse E., Silvaggio G., Ornaghi D., Barbone A., Citterio E.

Istituto Clinico Humanitas Unità Operativa di Cardiochirurgia

Objective: Aortic valve-sparing operations were developed to preserve the native aortic valve in patients with aneurysms of the aortic root or ascending aorta and normal aortic valve leaflets. This paper describes our initial experience with valve-sparing operations and early clinical and echocardiographic results obtained.

Methods: From October 2002 to January 2004, 28 consecutive patients underwent aortic valve-sparing operations at our Institute. Patients were predominantly male and mean age was 59±13 (range 28-83). Preoperative transesophageal echocardiography showed moderate or severe aortic incompetence (AI) in 13 patients (46%). Twenty-six patients underwent reimplantation of the aortic valve and 2 patients remodeling of one sinus. In 2 cases prolapsing cusp repair was carried out. The graft size was 28 millimetres (mm) in 3 (11%) patients, 30 mm in12 (43%) and 32 mm in 13 (46%).

Results: There were no intraoperative deaths. At discharge, two-dimensional echocardiogram showed no or trivial AI in 15 (54%) patients and mild AI in 11 (39%); 2 (7%) patients had severe AI requiring mechanical aortic valve replacement respectively 4 and 6 weeks after the aortic valve reimplantation procedure. The first patient was a 28 years-old man with Marfan syndrome, the second, with a bicuspid aortic valve, had during the first operation a prolapsing cusp repair by shortening of the free margin. Two more patients required reoperation for non-valve related complications. One patient developed a pseudoaneurysm for a leak at the left coronary anastomosis 1 month after the first operation; the second developed a constrictive pericarditis three months after the first procedure. Both of them recovered completely after the reoperation.

Conclusions: The valve-sparing procedures showed good preliminary results, thus encouraging further use of this type of repair. However further larger studies and long-term results are needed in order to define the durability of these techniques.

C7.5

EARLY AND LATE RESULTS OF MITRAL VALVE RECONSTRUCTION-CLINICAL EXPERIENCE FROM 237 PATIENTS

Zembala M.

Silesian Center for Heart Disease Cardiac Surgery and Transplantology Department

Objective: Reconstructive mitral valve operation in now the preferred technique for the surgical treatment of mitral valve disease. The aim of the study was to identify mitral valve pathology most suitable for reconstruction procedures with best short and long term results, patients’ survival and quality of life

Methods: Among 237 consecutive patients undergoing mitral valvuloplasty—232 (97.9%) survived the operation and were studied to assess the early and late efficacy of this metod of treatment. Patients age ranged from 16 to 74 years. Mitral valve insufficiency was due to rheumatic disease in 127 pts (53.6%), degenerative disease—56 (23.6%) 14 pts with Barlow Syndrome, ischemic disease 31 pts (13.1%) and congenital malformation 7 pts (2.9%), endocarditis 12 pts (5.1%) and idiopatic dilated cardiomyopathy 4 (1.7%). Operative technique included open commissurotomy (92 pts), annular ring annuloplasty (124 pts), partial leaflet resection (83 pts), sliding plasty (27 pts), transposing the posterior leaflet segment (9 pts), chordal repair (10 pts), edge to edge technique (22 pts) and leaflet extension (4 pts). 13 patients with chronic atrial fibrillation underwent concomitant surgical ablation, five surgical ventricular remodeling, 20 pts CABG and 24 pts additional aortic valve replacement or repair. Also 43 pts underwent tricuspid valvuloplasty.

Results: Early results were good in 232 pts (97.9%). Long term follow up was available in 215 patients (92.7%) from 3 months till 14 years (mean 58 months). The valve related events and valve related death were as follow: Thromoemboli (TE): 7 pts died 2, anticoagulant bleed (ACRH) 3 pts, one died. Infective endocarditis (IE): 7 pts, 1 died, reoperation (MVR) 7 pts, one patient died.

Conclusions: Freedom from the reoperation was significantly higher in the group with degenerative disease than in group with rheumatic disease.

C7.6

AORTIC ROOT REPLACEMENT WITH PULMONARY AUTOGRAFT. BENEFIT IN CHILDREN AND ADULTS. FOLLOW UP RESULTS

Sudikiene R., Lebetkevicius V., Tarutis V., Karalius R., Liekiene D., Lankutiene L., Sirvydis V.

Clinic of Heart Diseases, Vilnius University Heart Surgery Center

Objective: The aim of the study is to evaluate postoperative follow up results in children and adults in order to determinate who benefit mostly after the Ross procedure.

Methods: 104 patients underwent Ross procedure between December 1993 and February 2004. Follow-up results were compared between two groups. Group I- 56 patients, mean age 12 years (range 4 to 18), group II—48 patients, mean age 34 years (range 19 to 54). Function of the neoaortic valve and pulmonary homograft at rest and during exercise, changes of the size of neoaortic root, function of the LV and RV, ECG changes were assessed.

Results: Postoperative early passive dilatation of the neaortic valve root was noted in both groups. No or trivial regurgitation was in 33 (63.4%) patients versus 20 (61.9%) patients (between group I and II), mild in 10 (30.3%) versus 15 (35.7%) patients, moderate in 1 (1.9%) patient of the group I. There were no gradient at rest and after exercise through neoaortic valve, but gradient though pulmonary homograft after exercise almost in all patients of both groups increased double. Gradient through the pulmonary homograft < 20mmHg was in 26 patients (50%)- group I and 25 patient (59.5%)—group II, gradient between 20-40mmHg in 20 patients (38.4%) and 20 patients (47.6%), > 40mmHg in 6 patients (11.5%) and 1 patient (2.3%). Replacement of pulmonary homograft was in three patients, balloon angioplasty of the pulmonary homograft stenosis was performed in two patients of the group I. Regression of LVH and decrease in LV size was in all patients in group I, in group II it was not complete in all patients. LV ejection fraction decreased in 5 (11.9%) patients in group II. ECG changes were in patients of group II with residual LVH and longer duration of the aortic valve disease. Patients with pulmonary homograft stenosis have ectopic beats in group I. RV function was impaired in 5 patients group I.

Conclusions: Ross procedure leads to regression of LVH and LV size due to excellent heamodynamics of the neoaortic valve if operation is performed in optimal time. Dilatation of the neoaortic root was in all patients. Rhythm disturbances more often were in adult group with residual LVH and in younger group with homograft degeneration. Pulmonary homograft degeneration with it replacement or intervention developed more rapidly in the group of the younger patients.

C7.7

PORT-ACCESS MITRAL VALVE REPAIR WITH ANNULOPLASTY RING IN 100 PATIENTS

Barbone A.

Istituto Clinico Humanitas Unità Operativa di Cardiochirurgia

Objective: Port-Access mitral valve surgery has reached widely diffusion and constitutes an alternative technique to standard sternotomy. Reduced trauma, low morbidity, fast recovery and better cosmetic results are the goals of this technique.

Methods: From October 1999 to December 2003, 100 patients (mean age: 56.7) underwent mitral valve repair with ring annuloplasty, with Port-Access technique. valce pathology was degenerative in the majority of cases. In 48 patients was used a flexible-ring, whereas in the other 52 was inserted a rigid one. Severe (4+) MR was seen in 72 patients (72%). In 5 patients (5%) contemporary closure of atrial septal defect was performed. Redo-procedures accounted for the 2%. 18 patients had chronic or persistent AF which was treated with cryo or microwave LA ablation.

Results: Hospital mortality was 1% (one patient, 81 y.o., who died of multi organ failure). Mean cross-clamp time was 64.8±13.6 min. Re-entry for bleeding was necessary in 11 cases (11%). Two patients had conversion to sternotomy (femoral vessels too small for cannulation, anatomy not suitable). No case of aortic dissection was seen. Mean hospital stay was 5.4±5.8 days. One patients suffered of neurological damage at discharge, two had transient episodes with full recovery at discharge. Post-operative atrial fibrillation, in patients previously in sinus rhythm, was present at 23.8% rate. Follow-up showed trivial or no mitral regurgitation in 83 cases (83%), whereas in 13 cases (13%) mild to moderate MR was seen. Four patients underwent MV replacement during the follow up period, two of them for endocarditis

Conclusions: Port-Access mitral valve repair, with the insertion of a prosthetic ring, constitutes an alternative approach to the standard sternotomic access. Mid-term results observed are good. Early discharge, and reduced trauma, constitute a marked advantage, surgical treatment of atrial fibrillation is also feasible.

C7.8

"EUROPLASTY" FOR CORRECTION OF BILEAFLET MITRAL VALVE PROLAPSE

Chiavarelli M., Berti L., Lisi G., Maccherini M., Fantozzi G.

University of Siena Policlinico Le Scotte Cardiothoracic Surgery; UNIVERSITY OF SIENA DEPARTMENT OF CARDIOTHORACIC SURGERY; University of Siena Policlinico Le Scotte Cardiothoracic Surgery; University of Siena Policlinico Le Scotte Cardiothoracic Surgery; University of Siena Policlinico Le Scotte Cardiology

Objective: To describe a novel approach to repair mitral regurgitation caused by bileaflet prolapse

Methods: Five patients (age 71.7±6.3; gender M/F 3/2) with severe mitral insufficiency underwent valve reconstruction with the europlasty technique, a surgical approach that consists of creating a double orifice mitral valve with a euro-shaped () pericardial ring. The ring was implanted onto the posterior annulus and had a central flap anchored at the middle point of the free edges of both leaflets and at the level of the anterior annulus. An echocardiographic study was performed after cardiopulmonary bypass, at discharge, and at

Results: Cardiopulmonary bypass time was 127.8±9 minutes and crossclamp time was 89.6±13.7. The double orifice combined mitral valve area was 3.53±0.7 cm² (Hegar dilators). There was no hospital mortality or morbidity. Intraoperative transesophageal echocardiography showed absent (n=2) or trivial (n=3) regurgitation. No late deaths occurred. At the latest follow-up, extending to 18.2 months (mean 12.9; median 10.2), all patients were in NYHA class I with trace (n=2) or mild regurgitation (n=3). No transvalvular gradient was detected. Mitral valve area was 3.12±0.55 cm². A significant reduction of pulmonary artery pressure and left ventricular end-systolic dimensions was demonstrated (table) Table 2

C7.9

PRELIMINARY EXPERIENCE WITH PORTACLAMP IN VIDEO ASSISTED MINIMALLY INVASIVE CARDIAC SURGERY

Viganò M., Spreafico P., Rinaldi M., Marchetto G., Cattadori B., Alloni A.

IRCCS Policlinico San Matteo Divisione di Cardiochirurgia; IRCCS Policlinico San Matteo Divisione di Cardiochirurgia; IRCCS Policlinico San Matteo Divisione di Cardiochirurgia; IRCCS Policlinico San Matteo Divisione di Cardiochirurgia; IRCCS Policlinico San Matteo Divisione di Cardiochirurgia; IRCCS Policlinico San Matteo Divisione di Cardiochirurgia

Objective: Video assisted minimally invasive cardiac surgery (VAMICS) with endo-aortic balloon clamp is routinely performed in our Institution. New approaches for aortic clamping have to be defined in order to simplify the procedure and minimize potential aortic complications

Methods: From December 2003 to March 2004, 26 patients (14/12 M/F, median age 64, range 35-80) underwent VAMICS in our Institution via a 5.5±0.6 cm right lateral minithoracotomy using femoro-femoral CPB. Indications for surgery were: mitral valve insufficiency (11 mixomatous degeneration, 4 post-rheumatic, 5 IDCM with secondary mitral regurgitation, 1 post-endocarditis), 2 mitral stenosis and 3 ASD/PFO. Aortic cross clamping was accomplished with the use of Portaclamp (Cardio Life Research S.A.): a flexible guide wire is introduced through a thoracic port into the transverse sinus to encircle the pulmonary and aorta arteries and to guide two jaws in a mandrel locking system to achieve aortic cross clamping. Cold crystalloid antegrade cardioplegia was delivered through a conventional aortic root catheter. Surgical procedures were mitral valve repair in 12 patients (1/12 redo, status post ASD closure 1980), mitral valve replacement in 10, open commissurotomy in 1 and PFO/ASD closure in 3

Results: There was no perioperative mortality. No patients required conversion to conventional approach or reopening for bleeding. 23/26 patients had a ITU stay of less than 24 hours. We recorded one femoral vein thrombosis successfully treated conservatively

Conclusions: VAMICS with Portaclamp is a feasible safe and effective technique that can be promptly adopted in Centres experienced in VAMICS

SCIENTIFIC SESSION C8 CARDIAC ARRHYTMIAS

C8.1

MID-TERM RESULTS IN BEATING-HEART SURGICAL TREATMENT OF ATRIAL FIBRILLATION WITH MICROWAVE ABLATION

Accord R., Nijs J., van Brakel T., Maessen J.

CARIM, University hospital Maastricht Department of cardiothoracic surgery; CARIM, University Hospital Maastricht cardio-thoracic surgery; CARIM, University Hospital Maastricht cardio-thoracic surgery; CARIM, University Hospital Maastricht cardio-thoracic surgery

Objective: Using microwave ablation catheters it is possible to create linear transmural lesions giving electrical isolation of the pulmonary veins in a safe manner, even during a beating-heart procedure. Although several studies have proven efficacy and safety of microwave ablation for AF, midterm and long-term follow-up results are limited. This report shows the midterm follow-up results of 66 patients after epicardial beating-heart pulmonary vein isolation using microwave ablation during CABG, valve and combined CABG

Methods: Sixty-six consecutive patients with either paroxysmal (48.5%) or chronic atrial fibrillation underwent epicardial beating heart microwave pulmonary vein ablation in combination with on- or off-pump CABG (n=23), valve surgery (n=33) or combined CABG/valve surgery (n=10). Epicardial beating-heart pulmonary vein isolation was performed, constructing a figure-8 lesion in the early cases, simplified to a box lesion in the later ones. The left atrial appendage was resected using a stapling device in all patients. All patients received routinely low-dose Sotalol orally starting on the first post-operative day and standard anti-arrhythmic drug and anti-coagulants according to AHA/ACC guidelines.

Results: This patient population with an average age of 68.7 years (range: 42-80) had a AF duration of 78.2 months (range: 2-264 months). The epicardial approach allowed a totally off-pump procedure in 52.2% of patients undergoing only CABG. In those patients undergoing valve surgery, concomitant AF surgery was performed on the beating heart in 79% of cases. No intra operative mortality occurred, while the in-hospital and the late mortality was respectively 7.6% (5) and 3% (2). At a mean follow-up of 15.2 months (range: 2- 29 months), 76.2% of the CABG-group were in normal sinus rhythm. From patients who underwent valve surgery, 66.7% were in NSR at latest follow-up. This even though many of these patients experienced postoperative recurrence of AF, 43.8% of valve- group showing AF on discharge ECG. No thromboembolic events occurred during follow-up.

Conclusions: Both in patients undergoing only CABG or (combined) valve surgery, epicardial beating heart pulmonary vein isolation using microwave was safe and successful. A comparative study is currently being conducted to evaluate whether differences in success rate between CABG and valve surgery patients is related to the amount in which substrate reduction by the primary surgical procedure is obtained.

C8.2

FEASIBILITY OF AN INNOVATIVE THORACOSCOPIC SURGICAL TREATMENT OF LONE ATRIAL FIBRILLATION

Bisleri G., Bottio T., Manzato A., Negri A., Manfredi J., Gavezzoli D., Muneretto C.

University of Brescia Medical School Cardiac Surgery

Objective: Surgical treatment of atrial fibrillation (AFIB) recently gained new popularity since the introduction of different energy sources for the ablative therapy as an alternative to the original Maze technique. However, most of the cases have been performed along with other type of cardiac surgical procedures and mainly through a standard sternotomic approach.

Methods: Four patients suffering from isolated AFIB underwent an innovative procedure of thoracoscopic epicardial pulmonary veins ablation: mean age was 59.25 years, mean left atrial diameter was 41.25 mm, mean AFIB duration was 48.25 months. AFIB was paroxysmal in 2 pts.(50%) and permanent in the other 2 pts. All patients had been refractory to at least one pharmacological treatment; mean number of pre-operative electrical cardioversions was 2.25.

Results: We performed an innovative closed-chest thoracoscopic technique for pulmonary veins epicardial isolation (box lesion set) by means of a microwave energy source. A bilateral thoracoscopic approach was used in the first 3 patients of this series. We recently developed a new modification of this technique that allowed a monolateral approach in the last patient. Mean ablation time was 14.75 minutes, while the overall operative time was 3 hours. No complication occurred during any of the procedures: all patients were extubated in the operating room and transferred directly to the ward, thus avoiding any ICU stay. Post- operative stay was uneventful in all cases; 2 pts. were discharged in sinus rhythm while the remaning two pts. still showed episodes of AFIB recurrency. At a mean follow up of 54 days all pts. are alive: one pt. is in stable sinus rhythm while the remaining ones still have recurrent bouts of AFIB. One patient experienced an

Conclusions: Despite a wider series of patients is required for its validation, our initial experience proved the safety and feasibility of this innovative closed-chest procedure. Additionally, a longer follow-up period of at least 6 months is required in order to assess the efficacy of sinus rhythm restoration.

C8.3

TREATMENT OF POSTOPERATIVE ATRIAL FIBRILLATION IN CARDIAC SURGERY. A COMPARATIVE STUDY BETWEEN INTERNAL CARDIOVERSION (SYNCRUSTM TEMPORARY EPICARDIAL WIRE ELECTRODES) AND AMIODARONE

Vasilikos K., Argyriou M., Hountis P., Antonopoulos N., Charitos C., Lolas C.

"Evaggelismos" General Hospital, Athens, Greece 2nd Department of Cardiac Surgery

Objective: Atrial fibrillation (A.F.) is the most common postoperative (P.O.) complication in cardiac surgery that threats patient's hemodynamic stability and prolongs hospitalization with proportional increase of both morbidity and costs. There are many protocols of preventing and/or treating P.O.A.F.; preoperative administration of amiodarone and beta-blockers, biatrial pacing and transthoracic cardioversion are the most documented to mention. The aim of our study is to compare the efficacy between internal defibrillation using temporary epicardial electrodes and pharmacological treatment with amiodarone.

Methods: In a 9 month period 146 patients (mean age 65) that underwent in C.A.B.G. were enrolled in our study and divided in a study group of 36 patients and in a control group of 110 patients. During open-heart surgery, temporary epicardial wire electrodes (SyncrusTM Guidant Co.) were sutured on both atria and right ventricle in the study group while conventional pace wire electrodes were sutured in the control group. In the study group, every P.O.A.F. attack was treated with an internal shock of 6 Joules as starting energy and continued with progressive increase up to 10 joules in case of treatment failure or early recurrence of AF; the control group was treated by a standard pharmacological protocol with amiodarone.

Results: In total there were registered 61 episodes of P.O.A.F. (41.78%), from which 13 in the study group (36.1%) and 48 in the control group (43.6%). Primary cardioversion success occurred in 10 from the 13 patients of the study group; 7 of them developed early recurrence AF, which was successfully resolved in the following applications of cardioversion (mean application 2.1). From the remaining patients from the study group 2 were converted to sinus rhythm with pharmacological administration of amiodarone and 1 had to be treated with anticoagulants due to resistant P.O.A.F. In the control group 38 patients were successfully converted pharmacologically in sinus rhythm and discharged with oral maintenance antiarrhythmic medication, 2 had to be defibrillated transthoracically due to hemodynamic instability and 8 were discharged with anticoagulants because of the AF resistance (although were hemodynamically stable).

Conclusions: Our study proves that low energy internal cardioversion using temporary epicardial electrodes, is an easy to practice, well tolerated method that can be used as a valid alternative to the pharmacological treatment of the P.O.A.F.

C8.4

CRYOABLATION FOR ATRIAL FIBRILLATION

Barbone A.

Istituto Clinico Humanitas Unità Operativa di Cardiochirurgia

Objective: Surgical left atrial ablation for atrial fibrillation is a technique rapidly spreading for number of patients that each year undergo the procedure and for energy sources that are available. In this study we summarizes cases performed at our institution using cryoablation

Methods: From April 1998 to December 2003, 105 patients with permanent (mean duration 65 months) or persistent (28%) atrial fibrillation have undergone three different ablation patterns (all endocardial), and 2 different ablation systems: Frigitroncis and Cryocath. Mean antero-posterior left atrial diameter was 73.2 mm. We prospectively collected information regarding patients’ demographics, disease's characteristics and type of surgical ablation employed, presence of sinus rhythm either at discharge and at the follow up. A logistic regression analysis was used to estimate the association between the collected variables and sinus rhythm restoration.

Results: In-hospital and late mortality rate were 2.6 and 5.2% respectively. At discharge 83 patients (74.1%) were in sinus rhythm while at a average follow-up of 2 years, 77.3% of 106 surviving patients are in sinus rhythm. Major adverse events rate like cardiac reoperation, pace-maker implantation and cerebrovascular accident were 8.5, 4.7% and 4.2%, respectively. We couldn't relate any pre-operative factor (atrial fibrillation duration, left atrial dimension and type of heart pathology associated) with long term success. Although lesion pattern and rhythm at discharge were significant predictive factors. Survival is significantly higher for patients who converted to sinus rhythm at discharge (P=0.014) with respect to those who remained in atrial

Conclusions: Permanent and persistent atrial fibrillation associated to a major cardiac disease can be safely treated with a linear ablation of the left atrial posterior wall: we had one technique related decease in the very first set of patients. We couldn't identify any predictor factor for long term outcome, but this may be due to the small patient population for each group. Indeed we noticed a trend of better outcome (non-significant) with the Cryocath system and this could be due to a bias in patient population that in the years became slightly younger, shorter duration of AF and smaller atrium. Lesion pattern showed significant difference in the outcome, thus we recommend connection of the mitral annulus to the Left-Inferior PV. In our series life expectancy appears to be longer if sinus rhythm is restored.

C8.5

OUTCOME AFTER MICROWAVE ABLATION FOR CHRONIC VALVULAR ATRIAL FIBRILLATION

Zembala M.

Silesian Center for Heart Disease Cardiac Surgery and Transplantology Department

Objective: Surgical ablation in chronic atrial fibrillation in patients with mitral valve disease seems to be most effective and safe method restoring sinus rhythm. The aim of this study was to retrospectively evaluate potential risk factors that may have influenced early and intermittent outcome in group of patients who undergone microwave energy ablation for chronic atrial

Methods: 62 patients with duration of chronic atrial fibrillation from 1.5 to 13 years underwent surgical microwave ablation concomitant with mitral valve replacement or repair. Logistic regression analyses were performed to evaluate effect of potential risk factors on post-ablation rhytm status at discharge and latest follow-up examination.

Results: 49 patients were on sinus rhythm on discharge. 13 had reccurent atrial fibrillation at discharge tender to have preoperative AF of significantly longer duration and larger left atrium diameter after adjustment for age, length of follow up time and presence of early arrhythmia recurrence.

Conclusions: Longer arrhythmia duration and greater left atrial diameter seem to be factors independently influencing early and hospital discharge and there seems to be a self protective effect of the presence of sinus rhytm at discharge. Therefore we conclude that surgical ablation stands for standard procedure in patients suffering from chronic atrial fibrillation. In patients with large left atrium diameter (>6 cm) partial atrial wall removal or atrial remodelling is necessary in order to achieve good late results.

C8.6

LEFT MINI THORACOTOMY AS A PRIMARY AND/OR SECONDARY ALTERNATIVE TO FAILURE OF THE TRANSVENOUS LEAD IMPLANTATION FOR BIVENTRICULAR RESYNCHRONIZATION

Vasilikos K., Argiriou M., Hountis P., Panagiotakopoulos V., Charitos E., Charitos C., Lolas C.

"Evaggelismos" General Hospital, Athens, Greece 2nd Department of Cardiac Surgery

Objective: Biventricular pacing -although under investigation- is a challenging option for the treatment of heart failure. Stimulation through coronary sinus is the current technique of choice, but it is technically difficult, requires experience and often is time spending without warranting the proper placement and function of the lead. Surgical epicardial lead implantation (mini thoracotomy, robotic approach, V.A.T.S.) on the left ventricle is an alternative that allows, through direct vision, to select the appropriate site of implantation.

Methods: 8 patients with heart failure N.Y.H.A. Class III refractory to pharmacological treatment (mean age 55±6) underwent in a left mini thoracotomy (via the 4th—5th intercostals space) in order to implant the lead, since the attempt -that preceded the surgery- of placing the lead transvenously through coronary sinus had failed or considered inappropriate. Two different varieties of lead were used: a steroid and a screwed type, equally distributed among the patients.

Results: No perioperative or postoperative complications occurred in any patient and no lead dislodgement was observed in a 3 months follow up. There was a 5±3 minutes time sparing in the screwed lead placement. Postoperative N.Y.H.A. class status improved in all patients and the improvement was confirmed subjectively and objectively from our cardiologic department.

Conclusions: Epicardial lead implantation for biventricular pacing is a valid alternative to the transvenous coronary sinus placement that offers the advantage of the direct vision of the optimal site of placement and it is safe, quick and efficient reducing the incidence of no responders from lead dislodgement or the non optimal placement of the later. Also the surgical variety can be adopted either as a first choice or secondary to failure of the transvenous method and can be used immediately or after a certain period of time from the transvenous attempt. In addition we observed a slight advantage in the postoperative thresholds of the steroid lead vs. the screwed one but with a small time sacrificing in the operating duration.

C8.7

LEFT ATRIAL APPENDAGE EXCLUSION DURING SURGICAL TREATMENT OF ATRIAL FIBRILLATION: IS IT A REAL ADVANTAGE?

Bisleri G., Negri A., Manfredi J., Gavezzoli D., Nodari I., Muneretto C.

University of Brescia Medical School Cardiac Surgery

Objective: Left atrial exclusion(LAA) has been commonly advocated in the original Maze procedure. However, several recent studies reported conflicting results about the real advantages of routinary LAA removal during surgical treatment of atrial fibrillation(AFIB).

Methods: We retrospectively reviewed our experience with exclusion of LAA in patients undergoing surgical treatment of AFIB. Since 1999, 39 patients with AFIB were treated: 35 pts.(89.7%) had a concomitant cardiac surgical procedure, while 4 pts.(10.3%) underwent a thoracoscopic approach for lone AFIB treatment. Mean age was 65 years, mean Euroscore was 4.8; risk factors for ischemic events, as diabetes, peripheral vascular disease and hypertension were present in 4 pts.(10.2%), in 5 pts.(12.8%) and in 14 pts.(36%) respectively; moreover, 3 pts.(7.8%) had a pre-operative evidence of thrombi in the LAA and 5 patients(12.8%) had a previous history of cerebrovascular accidents. Mean left atrial diameter was 47 mm; AFIB was intermittent in 14 pts.(35.9%) and continuous in 25 pts.(64.1%); mean AFIB duration was 53 months.

Results: The surgical ablative procedure was endocardial in 25 pts.(64%) and epicardial in 14 pts.(36%). The energy sources used for AFIB treatment were unipolar radiofrequency in 25 pts.(64%), bipolar radiofrequency in 3 pts.(7.8%) and microwave in 11 pts.(28.2%); four patients underwent a thoracoscopic procedure for treatment of lone AFIB. Mean ablation time was 16 minutes. The LAA was removed in 5 pts.(12.8%): 3 pts. with a pre-operative evidence of thrombi and 2 pts. with a severely enlarged LAA. Hospital mortality in this series of patients was 5.1%. No patient experienced early post-operative ischemic events. At a mean follow- up of 17 months, all hospital survivors were alive and normal sinus rhythm was observed in 76% of patients. Late thromboembolic events occurred only in 2 pts.: both of them did not have their LAA removed at the time of the operation (1 pt. had a pre-operative thrombo-embolic event while the other patient did not have risk factors for embolism at the time of the operation).

Conclusions: In our series, LAA removal seems not to be mandatory. Preservation of LAA was associated with a low early and mid-term risk of thromboembolic events, thus depicting that this procedure may be restricted only to patients with specific risk factors for embolism.

C8.8

VIDEOTHORACOSCOPIC-ENHANCED BIVENTRICULAR RESYNCHRONIZATION: AN ALTERNATIVE TO FAILED ATTEMPTS IN ENDOVENOUS CARDIAC RESYNCHRONIZATION THERAPY FOR CHRONIC HEART FAILURE

Knez I., Schweiger S., Prenner G., Gabor S., Baken k., Tscheliessnigg K., Rigler B.

University of Graz Department of cardiacsurgery; University Clinic of Surgery Graz Austria Cardiac Surgery; University Clinic of Surgery Graz Austria Transplantation Surgery; University Clinic of Surgery Graz Austria Thoracic Surgery; Bakken Research Center Medtronic Europe Maastricht Netherlands. ; University Clinic of Surgery Graz Austria Cardiac Surgery

Objective: Ventricular resynchronization might be achieved in a minimally invasive fashion using a video- thoracoscopic assisted (VAT), direct left ventricular (LV) epicardial approach.The purpose of this clinical, prospective, multicentric study was to evaluate the feasibility of a new operation technique (Malleable Tool 10626 and epimyocardial lead 5071, Medtronic)for critical heart failure patients (CE certification).

Methods: 15 patients with congestive heart failure (NYHA class 3.5+/–0.4) and a widened QRS complex (186+/–33 ms),1 pt with pacemaker decubitus and sepsis, underwent transvenous right cardiac electrode positioning and surgical VAT assisted LV lead placement after failed coronary sinus cannulation. Mean patient age was 60+/–5 years, LV ejection fraction (EF) was 24+/–3%,8 patients had previous cardiac or thoracic surgery, surgical technique see picture.

Results: 16 epicardial leads were successfully placed on the posterobasal surface of the LV. Intraoperative lead threshold was 1.21+/–0.57 V at 0.5 ms, R-wave was 12.6+/–5.4mV, and impedance was 609+/–153 Ohms at 0.5 V, time of final electrode position (incl.measurements) was only 5.7+/–1.4 minutes, time of skin-skin procedure was 68+/–23 minutes.There were no surgical complica-tions. Improvements in exercise tolerance (14 of 16 patients), EF(34+/–8%) and QRS duration (150+/–18 ms) were significant at three to six months follow-up p<0.001). Lead thresholds have remained unchanged (1.4+/–0.28 V at 0.5 ms) and a significant drop in impedance (410+/–67 Ohms, p<0.001) has been measured.

Conclusions: Surgical VAT assisted LV lead placement with Malleable Tool 10626 and epimyocardial Lead 5071 is an effective and novel technique for biventri-cular pacing in critical heart failure patients.

SCIENTIFIC SESSION C9 CORONARY

C9.1

RADIAL ARTERY HARVESTING FOR CORONARY BYPASS OPERATIONS: A DIRECT MEASURE OF THE LOCAL NEUROLOGICAL DAMAGE

Reyes G., Rodriguez H., Cuerpo G., Lopez J., Lopez L., Traba A., Pinto A., Vallejo J.

Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular; Hospital General Universitario Gregorio Marañón Cardiovascular; Hospital General Universitario Gregorio Marañón Cardiovascular; Hospital General Universitario Gregorio Marañón Cardiovascular; Hospital General Universitario Gregorio Marañón Neurology; Hospital General Universitario Gregorio Marañón Nueroelectrophysiology; Hospital General Universitario Gregorio Marañón Cardiovascular; Hospital General Universitario Gregorio Marañón Cardiovascular

Objective: The radial artery (RA) has become more popular as a bypass graft because the issues of spasm have been addressed by the use of vasodilators and for the good mid-term patency. Neurologic complications of RA harvest can be quite common and it is not easy to determinate the real frecuency. In this study we sought to measure and objetivize the neurological alterations in forearm after radial artery (RA) harvest for coronary artery bypass grafting.

Methods: Observational prospective study performed in a tertiary hospital. 15 consecutives patients who's RA was harvested, were included. A neuroelectrophysiological study was carried out in median, radial and ulnar nerve before surgery and then two weeks and two months after procedure by an expert in neuroelectrophysiology. We measured the amplitude, the latency and the nerve conduction velocity. The amplitude was recorded to check axonal damage. Latency and nerve conduction velocity (NCV) was measured to test mielinic damage. An electromyogram was also performed. This was studied in every component of each nerve. We also measured the self-reported rate of sensory and motor deficits related to

Results: Median nerve: A decrease in amplitude was found after surgery. After two months the amplitude was recovered(24.7 mV vs. 13.7mV vs. 19.4mV; p<0.001).(Graphic 1)

Ulnar nerve: A fall in PAMC latency(p=0.097) and in ulnar V branch amplitude was evident after surgery (13.1—8.9—10.9 Pms;p=0.006).

Radial nerve: There was a decrease in the superficial radial NCV (48.9m/s vs. 46.7m/s vs. 47.8m/s;p=0.097).

The second study showed improvement of all neuroelectrophysiological parameters but PAMC latency. No alterations were found in the electromyogram. Clinically, there were 3 patients who complained of disestesias in the median territory and one in the ulnar territory. Symptoms also improved over time. There was not relation between alterations in the

Conclusions: There are neurological changes in all patients who's RA was harvested. RA harvesting causes a decrease in median and V branch ulnar amplitude, showing an axonal transitory damage. There is also a decrease in PAMC latency and superficial radial nerve NCV, meaning a mielinic alterations. These changes and the symptomatology of patients recovered over time, suggesting the safety of RA harvesting.

C9.2

JUSTIFY FAVORABLE MORBIDITY AND LOWER TOTAL COST USING THE RELATIVE EXPENSIVE AORTIC CONNECTORS?

Benedík J., Cernú ., Tichácek D., Michálek P., Kolouch P., Jehlicka P., Ferda J.

Na Homolce Hospital Heart surgery; Na Homolce Hospital Heart surgery; Na Homolce Hospital Heart surgery; Na Homolce Hospital Anesthesiology; Na Homolce Hospital Heart surgery; Na Homolce Hospital Heart surgery; University Hospital Pilsen Radiology

Objective: The goal of this study was to compare postoperative neurological complication rate and total cost between OP-CABG with aortic connectors and "classical" on-pump CABG.

Methods: The cohort of patients was operated by one surgeon in the January 2000-December 2003 period. We have collected two groups from total amount of CABG patients. Both of them had tree CABG; one arterial (LIMA to LAD) and two separate venous grafts with two separate proximal anastomoses to ascending aorta. First group was named "Clamp" and operated with cardiopulmonary bypass with clamping of ascending aorta and crystalloid cardioplegia and with constructing of the proximal anastomoses on partial side clamp during reperfusion period (83 patients). Second group was named "Connectors" and operated "off pump" with construction of two vein-aortic anastomoses using aortic connectors before construction of distal vein- coronary anastomoses (54 patients). Peri- and postoperative complications and total cost were compared and statistical significance was assessed with use "chi-square test" and "test of fit". p value < 0.05 was evaluated

Results: There were no differences between groups covering age, sex and frequency of comorbities. The blood loss in "Clamp" group was significantly higher (722+259 versus 480±183 mL); extubation time, ICU stay, total hospital stay and total incidence of the neurological complications were also significantly higher (p < 0.05). Postoperative hypertension, need of inotropic support, incidence of myocardial infarctions, postoperative atrial fibrillations were slightly higher in "clamp group", but without statistical significance (p > 0.05). Total cost was mark up by price of two aortic connectors which was comparable with total cost of uncomplicated "Clamp" patients. Lower blood loss and neurological complications reduce ICU and total hospital stay of "Connector" patients, which finally reduce a total cost of these patients.

Conclusions: The use of aortic connectors during OP-CABGs reduce total hospital cost compared with on pump CABGs by reduction of neurological complications and ICU and total hospital stay. Slightly lower patency rate of connectors reported previously, have changed our strategy of using connectors. We prefer to use connectors for patients with affected ascending aorta (atheromatous or calcified plaques) and for patients with higher neurological risk. We suppose, that reduced manipulation with ascending aorta is a right way to decrease morbidity and mortality of CABG patients. We believe, that the novel, second generation of connectors comparable with drug eluting stents in coronary intervention may motivate the surgeons for its wilder use in CABG surgery.

C9.3

USING OF RIMA IN OPCAB REOPERATIONS

Eren E., Toker M., Kaya E., Ersahin S., Güler M., Balkanay M., Yakut C.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery

Objective: In situ right internal mammary artery is a graft of choice in primary on-pump coronary artery bypass grafting as well as in reoperative off-pump coronary artery bypass grafting unless it would not have been used previously. However, there are no many data about angiographic findings of the in situ right internal mammary artery in reoperative coronary artery bypass grafting for single-vessel coronary artery disease using off-pump technique.

Methods: From September 1993 to January 2004, a total of 3,086 patients underwent operations on the beating heart at our clinic. Of 64 patients (2.07%) underwent reoperation CABG using off-pump and on-pump techniques. We reviewed the postoperative course and the graft patency of 12 selected patients who underwent off-pump reoperative CABG for the left anterior descending artery lesion using pedicled RIMA.

Results: There were no early or late deaths during a mean follow-up period of 34.7±34.9 months (range, 1-80 months). The mean interval from primary operation to secondary operation was 67.1 plus or minus 54 months (range, 4 to 135 months). Postoperative coronary angiographies of all patients showed the patency rate 100% for both the patients who in situ graft or composite graft were used.

Conclusions: Using the in situ right internal mammary artery with off-pump technique for coronary artery bypass grafting can be a safe and reliable option in reoperative coronary artery bypass grafting for the left anterior descending artery disease.

C9.4

FUNCTIONAL AND GEOMETRICAL RESTORATION OF LEFT VENTRICLE AFTER SURGICAL RECONSTRUCTION IN PATIENTS WITH POST-INFARCTION ANEURYSMS

Bletkin A., Shevchenko Y., Borisov I., Lomakin A., Volkova L., Stonogin A.

Moscow Medical Academy Institute of Thoracic surgery cardiac surgery

Objective: The main aim of left ventricle reconstruction, regarding all modern principles of its surgical restoration, is the maximal approximation of the intracavitary characteristics to physiological. We examined our post-infarction aneurysm repair experience to assess the functional effect in aspects of geometrical LV

Methods: Between January 1990 and December 2003, 594 patients underwent surgical treatment for LVA. 84.3% (501) of patients was in 3-4 functional classes by NYHA The cause of development of an aneurysm at all patients was the transmural myocardial infarction. Localization of aneurysm in 72.2% (429) of patients was with involvement of the interventricular septum. Severely depressed myocardial contractility, EF25, was present in 8.6% (51) of cases, in 68.9% (409) of patients EF ranged 25-40%, in 22.6% (134) cases was 40%. After resection of aneurysm in 62.6% (372) of cases we performed the Dor procedure with autologous patch repair. In 29.6% (176) patients the linear plastic or plication was used and in 7.7% (46) patients left ventricle was reconstructed by Jatene maneuver. Mural thrombi were removed in 45.8% of the

Results: Analysis of treatment efficiency was based on data of complex clinical examination before operation, at early and late (5 year) follow-up. Postoperative data showed reduction in left ventricular end diastolic and systolic volumes (p<0.01), EF increased up to normal or subnormal values (p<0.01). Dynamic changes of indices, characteristics and parameters describing LV geometry, myocardial stiffness, chamber compliance and wall kinetics showed LV physiological shape restoration in majority of patients. Hospital mortality rate was 6.9% (41). Five year survival rate was 82.6% (457). Practically all the patients had a significant reduction in postoperative heart failure: 56 (10.1%) of patients remained NYHA III-IV in late follow

Conclusions: The most clinical and hemodynamic effects after LV reconstruction can be achieved with adequate decrease of volume indices and maximally physiological restoration of intracavitary geometry.

C9.5

REVASCULARIZATION OF LEFT CORONARY SYSTEM WITH IN SITU BILATERAL SKELETONIZED INTERNAL MAMMARY ARTERIES: TECHNICAL ASPECTS AND LONG-TERM OUTCOME

Battaglia F., Prifti E., Leacche M., Bonacchi M.

Università degli Studi di Firenze Cardiochirurgia

Objective: The aims of this retrospective study was to investigate the technical aspects of employing the insitu bilateral internal mammary arteries using RIMA for the circumflex system revascularization, and to evaluate the early and late outcome.

Methods: Between January 1997 and July 2003, 552 consecutive patients underwent grafting of the circumflex artery system with an in situ skeletonized RIMA routed via the transverse sinus (eventually retrocaval). Mean age was 63.8±11years. 331 (60%) patients underwent total arterial myocardial revascularization.The mean follow-up was 26±9 months.

Results: The success rate of skeletonized RIMA grafting to the circumflex branch was 100%. There were 19 (3.4%) hospital deaths. Perioperative myocardial infarction occurred in 12 (2.2%) patients. In 155 patients undergoing postoperative angiography were found: 2 occluded RIMA; 3 RIMA and 1 LIMA string-like phenomenon. Three RIMA and three LIMA presented stenotic lesion. The patency RIMA and LIMA rates were 94% and 97.4% respectively. Strong predictors for non functional IMA grafts were the diameter of recipient coronary artery <1.5mm (p=0.022), stenosis less of 60% of the recipient coronary artery (p=0.015), diffuse stenotic lesions of the recipient coronary artery (p=0.018) and small IMAs caliber (p=0.0001). Cumulative actuarial survival at 3 was 96.4% and free-event cumulative survival was 93.8%.

Conclusions: The bilateral IMAs employment, offers the possibility of various configuration construction making possible total arterial myocardial revascularization with a minimum number of arterial conduits.The skeletonized RIMA via the trasverse sinus and eventually retrocaval, is able to reach most branches of the circumflex system and is associated with an excellent patency rate. Patients who received BIMA grafts for left coronary system revascularization had improved early and late outcome, decreasing risks of death, reoperation, and angioplasty.

C9.6

AORTOCORONARY BYPASS GRAFTING IN PATIENTS OVER 75 YEARS: INCIDENCE, OUTCOME, AND RISK ANALYSIS OF POSTOPERATIVE RENAL FAILURE

Meco M., Meco M., Babbini M., Caratti A., Khlat B., Marotta A., Cirri S.

Sant'ambrogio Hospital Cardiac Surgery; Sant'Ambrogio Hospital Cardiovascular surgery

Objective: Study objectives: The aim of this study was the evaluation of incidence, outcome and risk factors of postoperative renal failure in patients over 75 years undergoing coronary artery bypass surgery.

Methods: Patients and Methods: 154 patients over 75 years consecutively operated on in our institution, from January 1999 and January 2000, were retrospectively evaluated. 46 preoperative, operative and postoperative variables have been considered. Univariate and multivariate statistical analysis were performed, in order to evaluate the independent risk factors of postoperative renal failure in this class of patients.

Results: 9 patients died (5.8%). 22 patients developed postoperative renal failure. 6 patients with postoperative renal failure died. Independent risk factors are: preoperative creatinine values > 1.7 go/dl., postoperative low output syndrome and a low number of distal anastomosis.

Conclusions: This class of patients is at high risk. The off pump coronary artery bypass grafting is probably the best choice for this patients, particularly for those with high preoperative creatinine values and those with chronic obstructive pulmonary disease. The revascularization must be always complete. Table 3

CARDIAC OUTPUT MONITORING DURING OFF PUMP MYOCARDIAL REVASCULARIZATION: COMPARISON BETWEEN THERMODILUITION AND LITHIUM DILUITION DERIVED MEASUREMENTS

Mazzanti V., Spina A., Innorta A., Gepi G., Lemma M., Condemi A., Duca P., Antona C.

"L.Sacco" Hospital Cardiovascular Surgery; "L.Sacco" Hospital Cardiovascular Surgery; "L.Sacco" Hospital Cardiovascular Surgery; "L.Sacco" Hospital Cardiovascular Surgery; "L.Sacco" Hospital Cardiovascular Anesthesia; Università degli Studi di Milano Dipartimento di Statistica e Biometria; "L.Sacco" Hospital Cardiovascular Surgery

Objective: To compare conventional thermodiluition cardiac output (TDCO) determinations with measurements obtained by a system (PulseCO) that calculate cardiac output (CO) continuously from the analysis of the arterial pressure waveform. PulseCO is easly calibrated with a single lithium diluition CO (LidCO) mesurement. This study assessed the agreement between pulmonary artery catheter and PulseCO cardiac output determinations in off pump surgery at basal conditions and during different degrees of cardiac displacement.

Methods: Nineteen patients undergoing off pump coronary revascularization were recruited (male/females=18/1; mean age=71±8 years). After a one time PulseCO calibration, three determinations of CO by Swan Ganz catheter were measured after sternotomy (basal group; n=19), after positioning of the cardiac stabilizer on the left anterior descending coronary artery and diagonal artery (LAD/D; n=24), obtuse marginal branch and postero-lateral branch (OM/PL; n=14), posterior descending coronary artery (PDA; n=9) and at the end of the operation after heparin reversal (end basal; n=19). Meanwhile each patient underwent

Results: There were no complications related to Swan Ganz and PulseCo devices. Cardiac index (CI) for TDCO versus PulseCO was as follows (L/m²): basal=2.32±0.59 vs 2.15±0.62 (p=0.08); LAD/D=2.19±0.54 vs 2.33±0.72 (p=0.28); OM/PL=1.89±0.37 vs 1.96±0.54 (p=0.67); PDA=2.27±1.05 vs 1.87±0.55 (p=0.28); end basal=2.43±0.40 vs 2.49±0.92 (p=0.76). Differencies betweeen TDCO and PulseCO CI measurements (L/m²) were computed for basal group (mean difference=0.18±0.41; 95% ci=–0.02/0.38), LAD/D (mean difference=–0.14±0.63; 95% ci=–0.41/0.12), OM/PL (mean difference=–0.06±0.56; 95% ci=–0.39/0.26), PDA (mean difference=0.41±1.06; 95% ci=–0.41/1.22), end basal (mean difference=0.06±0.81; 95% ci=–0.45/0.33) and all groups (n=85; mean difference=0.02±0.69; 95% ci=–0.3/0.17). A one-way paired analysis of variance (ANOVA) of TDCO and PulseCO CI differencies and a regression analysis of CI measurements were performed. A significant difference between groups was noted at ANOVA statistics (between groups p<0.0001; within group p=0.76). All data CI linear regression analysis gave a slope of 1.250 (95% ci 1.008|1.628) and a y (PulseCO) intercept of -0.588 L/m²(95% ci -1.402 L/m²|—0.111 L/m²).

Conclusions: Our analisys showed the presence of discrepancies in CI evaluation between the two techniques related to heart displacement during the operation. TDCO and PulseCO measurements changes observed during the different phases of off pump procedures were significantly different. Moreover PulseCO seems to overestimate CI when compared to TDCO.

C9.8

LEFT VENTRICLE SURGICAL REMODELING IN PATIENTS WITH ISCHEMIC MYOCARDIAL DYSFUNCTION—A "SAVER" PROCEDURE

Semrad M., Urban T., Tosovsky J., Vondracek V., Stritesky M., Kristof J., Romaniv S.

General Teaching Hosp., Charles University Prague Dept. of Cardivascular Surgery; General Teaching Hosp., Charles University Prague Dept. of Cardiovascular Surgery; General Teaching Hosp., Charles University Prague Dept. of Cardiovascular Surgery; General Teaching Hosp., Charles University Prague Dept. of Cardiovascular Surgery; General Teaching Hosp., Charles University Prague Dept. of Anesthesiology; General Teaching Hosp., Charles University Prague Dept. of Anesthesiology; General Teaching Hosp., Charles University Prague Dept. of Cardiovascular Surgery

Objective: The majority of heart failure is caused by ischemic disease associated with ventricular dilatation. The predominant cause of mortality and morbidity in congestive heart failure is ventricular dilatation. Surgical ventricular restoration (SAVER) is indicated in patients with dilated ventricle following anterior infarction, akinetic or dyskinetic region > 35%, with adequate inferior or lateral muscle function, left ventricle end -systolic volume index > 60 ml/m2, and ejection fraction < 35%.

Methods: SAVER, that has evolved from procedures described by Cooley, Jatene and Dor; excludes either dyskinetic or akinetic segments to reduce ventricular volume. This procedure corrects and restores left ventricular architecture by creating new apex, re-aligning contractile fibers and decreasing ventricular strain. The surgical technique, adopted on the base of "the RESTORE Group" investigations, is further discussed.

Results: From July 2003 to February 2004, 17 patients underwent surgery. Early and 3-months outcomes were investigated. Concomitant procedures included coronary artery bypass grafting (CABG) in 100%, mitral surgery in two, and ventricular septal dephect (VSD) repair in one patient. Hospital mortality was 5%. Few patients required IABP (10%). Postoperatively, ejection fraction increased from 32+/– 15.3% to 43+/– 14% and left ventricular end systolic volume index decreased from 88+/– 45 to 53+/– 39 ml/m2 (P < 0.05).

Conclusions: SAVER is a safe, reproducible and effective procedure for treating the remodeled dilated anterior ventricle following anterior myocardial infarction.

C9.9

NATIVE CORONARY ARTERY PROGRESSION FOLLOWING CABG PROCEDURE

Borowski A., Vchivkov I., Ghodsizad A., Gams E.

Heinrich-Heine-University Vascular Surgery and Kidney Transplantation; Heinrich-Heine-University Thoracic and Cardiovascular Surgery; Heinrich-Heine University Thoracic and Cardiovascular Surgery; Heinrich-Heine University Thoracic and Cardiovascular Surgery

Objective: Few long term studies exist about the atherosclerotic progression following CABG procedure. The purpose of the study was to evaluate the long-term (> 3 yrs) alterations of the native coronary arteries in patients who underwent re-do revascularisation.

Methods: For the study, the angiographic images of 23 patients done before the first and re-do revascularisation were evaluated and compared for significant (>75%) short (<1 cm) and long (>1 cm) stenosis (SS) or total occlusion (TO).

Results: Mean time interval between the first and second CABG was 10.2 yrs (range 3-19 yrs). LCA (left main stem): in 7 pts with SS no change after a mean of 7.5 yrs (range 3-14 yrs) was observed, 4 pts developed new SS after a mean time period of 16.5 yrs (range 11-18 yrs). In the CX-supply area: 22 SS (18<1 cm, 4>1 cm length) and 1 TO before the first, and 19 SS (13<1 cm, 6>1 cm length) and 10 TO before the second revascularisation procedure, and in the LAD-supply area: 25 SS (14<1 cm and 11>1 cm length) and 3 TO before the first, and 19 SS (6<1 cm, and 13>1 cm length) and 14 TO before the second procedure, and in the RCA-supply area 21 SS (12<1 cm, 9>1 cm length) and 4 TO before the first, and 19 SS (14<1 cm, 5>1 cm length) and 14 TO before the second procedure, were observed. Among those pts with previous intact RCA, 4 pts had TO after a mean of 13.2 yrs (range 4-19 yrs), and 2 pts SS (after 2 and 8 yrs). 3/23 pts showed progression in the RCA-, and 3/23 pts in the LAD-supply area beyond the distal graft anastomosis.

Conclusions: Following CABG, the progression of native coronary artery stenosis is characterized by an increased occurence of long stenosis (1>cm) and TO affecting the proximal coronary artery segments (comparable incidence for all three supply areas). Generally, there is a low incidence of progression in the distal segments of the grafted coronary arteries.

SCIENTIFIC SESSION C10 EXPERIMENTAL

C10.1

PROSPECTS FOR AN IMPLANTABLE COUNTERPULSATOR: THE SKELETAL MUSCLE VENTRICLE

Ramnarine I., Capoccia M., Ashley Z., Sutherland H., Li F., Summerfield N., Salmons S., Jarvis J.

University of Liverpool Human Anatomy & cell Biology; University of Liverpool The Department of Human Anatomy & Cell Biology; University of Liverpool Human Anatomy & cell Biology; University of Liverpool Human Anatomy & cell Biology; University of Liverpool Human Anatomy & cell Biology; University of Liverpool The Department of Veterinary Clinical Sciences; University of Liverpool Human Anatomy & cell Biology; University of Liverpool Human Anatomy & cell Biology

Objective: The recent decrease in the number of available donor hearts has led to a decline in the number of transplant operations performed. But, the number of patients requiring heart transplantation is increasing. This highlights the need for alternative approaches to the management of end-stage heart failure. The use of transposed skeletal muscle to provide cardiac assist is an attractive option. It is potentially cheaper than transplantation or the use of mechanical assist devices and requires neither immunosuppression nor externally mounted apparatus. The intra-aortic balloon pump (IABP) is the clinical device most commonly used to provide circulatory support during ventricular dysfunction. A skeletal muscle ventricle (SMV) can be configured to provide counterpulsation similar to that of an IABP.

Methods: In ten anaesthetized pigs SMVs were connected to the thoracic aorta. IABPs were simultaneously placed into the thoracic aorta. Haemodynamic parameters were recorded during periods in which either the SMV or the IABP was active. Haemodynamic data acquired during an SMV or an IABP assisted (Assist) beat was compared with data acquired during the preceding (Pre-assist) beat.

Results: All values were expressed as mean±standard error of mean. Student's paired t test was used to compare Pre-assist and Assist values; P values are given for this comparison. SMV and IABP assist both produced highly significant improvements in the diastolic mean aortic pressure, LAD flow and EVR over pre-assist values. The haemodynamic effects of the SMV and the IABP were not significantly different.

Conclusions: In all cases the SMV was an effective counterpulsator and had effects that were at least equal to those of the clinically proven IABP. The SMV therefore offers the potential for providing the known benefits of the IABP in an ambulant patient. The IABP can be a useful tool in screening which patients might benefit from SMV support. Table 4

PROBNP LEVELS IN CARDIAC SURGERY: DO WE HAVE A NEW WEAPON FOR THE MANAGEMENT OF THESE PATIENTS?

Reyes G., Rodriguez H., Cuerpo G., López J., Fores G., Moreno C., Pinto A., Vallejo J.

Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular; Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular; Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular; Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular; Hospital General Universitario Gregorio Marañón Anesthesology; Hospital General Universitario Gregorio Marañón Boichemical; Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular; Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular

Objective: ProBNP level increases in patients with ventricular dysfunction and it has been proved that it is an excellent marker for NYHA class, heart failure evolution and treatment efficacy. In this study we wanted to determine proBNP levels in patients undergoing cardiac surgery and its possible usefulness as a marker of treatment efficacy.

Methods: Prospective cohort analysis, including 83 consecutive patients following elective cardiac surgery(coronary and valvulars). Preoperative, intraoperative and postoperative data were collected. ProBNP levels were measured before surgery, the afternoon of the surgery, twice the following day and then once per day to a total of nine determinations.

Results: 33.7% were CABG patients with no other surgery intervention. Mean age was: 65±11.8 years. An Euroscore >6 was found in 30% of patients. NYHA classification was as followed: I: 27.7%; II 47%; III:25.3%. Preoperative AF was seen in 20.5% of patients. In the early postoperative period 18.1% of patients required inotropic agents. 34.9% of patients suffered complications, being the AF the most frequent (20.5%). Only one patient died during the study period and until hospital discharge. Preoperative proBNP levels were 857+1409 pg/ml (6.3-8854). Preoperative levels were higher in high risk patients (Euroscore >6) (p=0.021), with worse NYHA class (p=0.020) and in patients with preoperative AF (1767+2205 vs 621+1017 pg/ml) (p=0.001). The first day after surgery proBNP levels start increasing until the fourth day (p=0.03), decreasing afterwards (p=0.019). Levels were significantly higher in those patients that required inotropic agents after surgery; (p<0.001). We did not find any relationship between proBNP levels and complications rate (p=0.59).

C10.3

L-ARGININE AND CARDIOPLEGIA: A PROSPECTIVE RANDOMIZED STUDY

Colagrande l., FORMICA F., PORTA F., BRUSTIA M., AVALLI L., SANGALLI F., PAOLINI G.

Osp.san gerardo cardiac surgery

Objective: L-Arginine in addiction to cardioplegia solution stimulates the release of nitric oxide (NO) and increase coronary blood flow, decreasing platelets activation and leukocyte adhesion. The aim of our study was to determine the feasibility and the efficiency of the addiction of L-Arginine to antegrade and retrograde blood cardioplegia somministrated according to Buckberg protocol.

Methods: 28 consecutive patients who underwent coronary artery bypass grafting were randomized to receive 7.5g of L-Arginine in 500 mL in cardioplegic solution. Haemodynamic evaluations were performed before sternum opening, at sternum closure, and 1 hour after the arrival in intensive care unit to measure cardiac index (CI), systemic vascular resistances (RVSI), pulmonary vascular resistances (RVPI) and pulmonary capillary wedge pressure (WP). Blood samples were taken from the retrograde coronary sinus catheter for lactate, IL-2 receptor, Il-6 and TNF levels. Serum samples (preoperatively, 2, 18 and 42 hours after aortic clamping removal) were also analyzed to measure CPK, CK-MB MASS, cardiac Troponin T, platelets (PLT). Leukocytes (LEUCO).Transesophageal echocardiography was performed to assess myocardial contractility.

Results: We found statistical differences for RVSI, WP, IL-2 R, Il-6, TNF, PLT, LEUCO in advantage for the treated group, and decreasing trends in CK-MB MASS and Troponin T measures.

Conclusions: The present study shows the positive effects of the addiction of L-Arginine to the cardioplegic solution. Reducted Il-2 R, Il-6 and TNF indicate a decrease in myocardial stress. The lower values of RVSI and WP we observed in treated group postoperatively seems to improve the patient's outcome in terms of a reduced needs of inotropic drugs. Moreover the decrease of PLT consumption and of the LEUCO count we found in treated group might express a reduced no-reflow phenomenon and a decrease in inflammatory reaction, limiting the endothelial injury caused by oxygen radical production.

C10.4

CARDIODEPRESSIVE EFFECT OF DIFFERENT CONCENTRATIONS OF 2,3-BUTANDIONE MONOXIME IN ISOLATED RAT HEART EX VIVO—HOW DOES IT WORK PRECISELY?

Krason M., Tyrpien M., Zembala M., Olejnik R., Zembala M.

Silesian Centre for Heart Disease Department of Cardiac Surgery and Transplantology

Objective: 2,3-butanedione monoxime (BDM) is a strong cardiodepressive factor with negative inotropic and vasodilating action. It prevents actin and miosine from interaction during cardiac cycle, counteracts ischemic contracture in long term cardiac storage models. It can also have positive action on calcium homeostasis. It's action is reversible and depends on concentration used. Although it has been proposed as an additive to various cardioplegic solutions it's action on specific cardiac parameters is poorly understood. Aim of the study: The aims of the study were 1) to assess effects of BDM used in small concentrations ranging from 2.5 mmol/l to 12.5 mmol/l on chosen parameters of heart function, 2) to find minimal concentration of BDM that could effectively stop hemodynamic heart function.

Methods: In experimental model of isolated working rat heart perfused with modified Krebs-Henseleit (KH) solution under preload 12 mmHg and afterload 70 mmHg selected parameters of heart function were examined in five groups with different BDM concentrations given in KH solution in five minutes period. Following concentrations were tested: 2.5(n=7); 5(n=7); 7.5(n=8);10(n=8) and 12.5 mmol/l (n=7). All parameters measured in 5th minute of BDM action were compared with initial values that were collected during control period in last five minutes before BDM administration.

Results: Maximal (systolic) pressure was reduced by BDM to following values: (statistically significant changes where p<0.01 are underlined) 91% (2.5mmol/l), 76% (5mmol/l), 63% (7.5mmol/l), 55% (10mmol/l), 21% (12.5mmol/l). Aortic flow decreased to 85%, 51%, 16%, 3%, 0% respectively. Coronary flow increased to 115%(2.5mmol/l), 104%(5mmol/l), and in groups with higher BDM concentrations decreased (due to much weaker contractility) to 84%(7.5mmol/l), 66%(10mmol/l) and 10%(12.5mmol/l) of control values. Stroke volume of LV was significantly decreased in concentrations higher than 2.5 mmol/l. Cardiac output was lowered to 92%, 65%, 39%, 20% i 3% depending on BDM concentration. Heart rate increased significantly during BDM perfusion in all drug concentrations used. After stopping of BDM administration all parameters recovered to 91-100% of control values

Conclusions: BDM acts as a strong cardiodepressive factor that stops effective isolated rat heart contraction in concentration of 12.5 mmol/l. It affects all parameters of heart function. It acts in dose dependent and reversible fashion.

C10.5

AN IMPORTANT PARAMETER USED IN CARDIAC SURGERY: MIXED VENOUS OXYGEN SATURATION

Ege T.

Trakya University Cardiovascular Surgery

Objective: To define the changes in blood gas analysis of peripheric artery, pulmonary artery and right atrium during cardiopulmonary bypass (CPB) and postoperative period in patients who had coronary artery bypass surgery.

Methods: 45 patients who had coronary artery bypass surgery at Trakya University Faculty of Medicine Department of Cardiovascular Surgery were taken into the study. After introduction of anaesthesia a thermo dilution catheter was placed and PO2, PCO2, pH and O2 saturation were measured from the blood samples taken right atrium, pulmonary artery and peripheric artery. Same measurements were repeated in the beginning of CPB, in hypothermia (280C), at the end of CPB and 2, 6, 12 and 24 hours after CPB. Cardiac output and cardiac index were measured before CPB and 2, 6, 12 and 24 hours after CPB.

Results: There was no statistically significant difference in PO2 and O2 saturation values before CPB (pulmonary artery PO2=49.0±12.4 and O2 saturation=79.1±6.0, right atrium PO2=44.0±11.3 and O2 saturation=75.3±10.8). It was found that oxygenation is higher in pulmonary artery (PO2=78.2±40.2 and 191.1±94.5, O2 saturation 87.1±7.8 and 86.1±11.9) than right atrium (PO2=47.8±10.4 and 48.8±7.8, O2 saturation 78.0±9.3 and 68.4±11.2) in measurements performed in the beginning of CPB and hypothermia stage. It was observed that when body temperature reached 370C, PO2 level and O2 saturation differences between right atrium and pulmonary artery diminished (PO2 in pulmonary artery=40.3±5.3 and O2 saturation= 70.9±7.0, in right atrium PO2=42.7±8.5 and O2 saturation=71.3±8.8). It was detected that pulmonary artery and right atrium saturations have significant relationship with cardiac output and cardiac index measurements

Conclusions: Since the oxygen content of the venous system in lower and upper parts of the body are different, blood samples for investigation of mixed venous oxygen values are taken from pulmonary artery. But if the mixed venous oxygen levels will be investigated under CPB, blood sample taken from the pulmonary artery may cause different results.

C10.6

CHANGES IN THE COAGULATION AND FIBRINOLYSIS SYSTEMS DURING CABG PROCEDURES IN HYPOTHERMIC AND NORMOTHERMIC CARDIOPULMONARY BYPASS

Kustrzycki W.

Wroclaw Medical University Clinic of Cardiac Surgery

Objective: Coagulation may be one of the systems affected by temperature during CPB. The aim of the study was to assess the influence of the bypass temperature during coronary artery bypass grafting (CABG) on the coagulation and fibrinolytic systems.

Methods: One hundred and two randomised patients with the mean age of 57.7±8.9 (41-77) years, undergoing first-time elective CABG, were studied. The patients were randomly divided into two groups: operated in normothermia (group N, n=52) or in moderate hypothermia (28 °C; group H, n=50). All the patients were operated by the same surgeon and the same anaesthesiological methods were used in all cases. Intermittent, antegrade blood cardioplegia was used in every patient.

Blood samples were obtained six times:

• after anaesthesia (sample 1)
  
• after administration of heparin (sample 2),
  
• after weaning from CPB (sample 3),
  
• after heparin neutralisation by protamine sulphate (sample 4),
  
• on the first postoperative day (sample 5) and
  
• on the seventh postoperative day (sample 6).
  

The following parameters were measured: platelets count, activated partial thromboplastin time- APTT, thrombin time—TT, prothrombin time expressed by the international normalised ratio—INR as well as the concentrations of: fibrinogen, D-dimers, antithrombin III, thrombin-antithrombin III complexes (TAT) and plasmin-2antiplasmin complexes (PAP).

Results: The analysed groups didn't differ in the duration of the procedure, aortic cross-clamp time and the number of performed distal anastomoses. Perioperative stroke occurred in two patients from group H, leading to the death of one of them. The postoperative ventilation was significantly shorter in patients from group N (13.1±5.5 h vs. 16.1±5.8 h, p=0.008). The patients from group N required shorter stay at the intensive care unit (1.4±0.7 days vs. 1.9±1.3 days, p=0.07). The 24 h postoperative bleeding was (mean values): group N- 795±355 ml, and in group H: 827±407 ml (difference not significant). The values of the performed laboratory tests will be shown during the presentation.

Conclusions: It has been concluded, on the basis on the presented results, that the coronary artery bypass grafting performed in the cardiopulmonary bypass induces higher thrombin generation and activation of the fibrinolytic system, whereas the bypass temperature within the range used during the study (28-37 °C) did not influence the postoperative bleeding, nor the changes in the coagulation and fibrinolytic systems. Normothermic cardiopulmonary bypass leads to shorter postoperative ventilation and shorter ICU stay of the patient.

SCIENTIFIC SESSION C11 CORONARY

C11.1

HYBRID MYOCARDIAL REVASCULARIZATION

Barbone A.

Istituto Clinico Humanitas Unità Operativa di Cardiochirurgia

Objective: Combined revascularization with MIDCAB to the LAD associated with PTCA of other arteries with focal lesions can be an alternative method to treat patients with multivessel coronary disease, to achieve full multivessel revascularization, with minimally invasive procedure. Hybrid revascularization hasn't yet reached a widespread diffusion, and some criticism is connected with this procedure. We reviewed our experience from September 1997 to December 2003

Methods: 60 consecutive patients were treated (a group of a wider number of 233 treated with MICAB). All had unfavourable LAD lesion for PTCA (total occlusion or long, diffuse stenosis). Mean age was 61.5, 53 male. 36 (60%) had history of previous myocardial infarction, and 8 patients (13.3%) had been already previously treated with PTCA on LAD. 53 patients (88.3%) were treated for two vessel disease, whereas 7 (11.3%) had three vessel disease. The target vessel for PTCA was right coronary artery in 29 (43.3%), circumflex artery in 21 (31.3%), the diagonal branch in 7 (10.4%), the obtuse marginal branch in 7 (10.4%), in 2 cases (2.9%) intermediate branch, and left main stem in 1 (1.5%). PTCA procedure was performed before MIDCAB in 36 cases (60%) and after surgery in the remaining.

Results: No in-hospital dead was observed. During the follow-up, two patients were medically treated for recurrent angina (3.3%), three patients (5%) underwent re-PTCA on one target vessels previously treated. One case of myocardial infarction was observed in a patient with a new onset lesion on circumflex artery. At six years cardiac mortality was 3.3% (two patients) and 1.6% (one patient) non cardiac mortality.

Conclusions: Hybrid revascularization can be considered a secure and effective procedure, with good early and midterm results. The advantage of avoiding sternotomy must be taken into account in diabetic patients, when a severe calcified aortic root is present and under the request of the patient himself. The need of repeated procedures is low. Thus can be considered a "niche" procedure, together with other revascularization techniques offered by the continuous improvement of surgical techniques.

C11.2

CARDIAC REVASCULARISATION IN NONAGENARIANS

Tomaszewski P., Wojarski J., Zembala M., Pacholewicz J., Przybylski R., Hrapkowicz T., Knapik P.

Silesian Centre For Heart Disease Cardiac Surgery and Transplantology Department; Silesian Centre for Heart Disease Department of Cardiac Surgery and Transplantology; Silesian Centre for Heart Disease Department of Cardiac Surgery and Transplantology; Silesian Centre for Heart Disease Department of Cardiac Surgery and Transplantology; Silesian Centre for Heart Disease Department of Cardiac Surgery and Transplantology; Silesian Centre for Heart Disease Department of Cardiac Surgery and Transplantology; Silesian Centre for Heart Disease Department Cardiac Anaesthesia

Objective: The number of old patients reffered to coronary revascularization is growing because of the ageing of population and progress in surgical and anestetic technics and postoperative care. The aim of present study is to review our experience with cardiac revascularization in nonagenarians.

Methods: The study group consisted of 35 (28 male and 7 female) patients, mean age 84.5years (range 80-89 years), underwent surgical revascularisation between 1st January 2001 and 30th June2003. Main risk factors in this group were: hypercholesterolemia(71.43%), arterial hypertension(54.28%), obesity (45.71%), diabetes (31.43%). 3 of them were after cerebral insult,13 have one and 18 two myocardial infarction and 11 patients have severe peripheral atherosclerosis.In angiography the dominant was triple vessel disease (77.15%). Surgery were performed on 4 (11.43%) as an emergence and 22 (62.86%) on an urgent basis. Pre operatively 27 (77.15%) were NYHA functional class 3 or 4. Average Euroscore was 9.3 (range 5-16 points). In 22 (62.86%) cases LITA were used for LAD grafting, the average number of grafts were 3.2 (range 2-5) anastomosis for patients. Operation were performed with extracorporeal circulation and blood cardioplegic cardiac arrest in 29 patients (82.86%), and in OPCAB technique in 6 (17.14%) patients.

Results: Periperatively, 2 (5.72%) patients died due to low cardiac output syndrome and in consequence MOF, for another 4 we succesfully used IABP and for 19 (54.28%) inotropic support. 5 14.28%) patients needs longer than average 8 hours postoperatively mechanical ventilation. Exercise test m. Bruce performed 6 month postoperatively in 24 cases were negative, only one patient was with exertion angina. 24 (68.56%) patients were in NYHA functional class 2. Actuarial survival was 91.43% and 85.72% at 1 and 2

Conclusions: -Surgical revascularization could be performed in a selected nonagenarians with acceptable mortality and morbidity.

– Post operatively old patients attain an excellent quality of life and survival.

– The main risk factor is urgent operation for unstable angina with low ejection frection.

C11.3

AORTOCORONARY BYPASS GRAFTING IN PATIENTS OVER 75 YEARS. PROPENSITY SCORE ANALYSIS OF ON-VERSUS OFF-PUMP, EARLY AND MIDTERM RESULTS

Meco M., Caratti A., Khlat B., Marotta A., Meco M., Babbini M., Cirri S., Casselman F.

Sant'Ambrogio Hospital Cardiac Surgery; Sant'Ambrogio Hospital Cardiovascular surgery; Sant'Ambrogio Hospital; Sant'Ambrogio Hospital; OLV clinic cardiovascular surgery

Objective: Bypass surgery in the elderly (age >75 years) results in increased mortality and morbidity, which may be related to the cardiopulmonary bypass system.

Methods: Using the propensity score analysis, we have selected two homogeneous groups of elderly patients undergoing coronary surgery: 41 patients operated with cardiopulmonary bypass (CPB-CABG), and 78 patients operated without cardiopulmonary bypass (OPCABG). All preoperative and postoperative variables were similar and outcomes were compared.

Results:. Perioperative mortality was higher in the patient group operated with CPB (12.2%) as compared to patients operated without CPB (1.3%, p=0.01). Perioperative complications were more frequent in CPB-CABG group. Logistic regression analysis showed that avoiding cardiopulmonary bypass was an independent protective factor for mortality and morbidity. Midterm survival, freedom from angina, freedom from reintervention, and CSS class were comparable between the two groups. Table 5

C11.4

OFF-PUMP CORONARY ARTERY BYPASS SURGERY IN PATIENTS HAVING SECONDARY PATHOLOGIES

Ozsoyler I., Bozok S., Yilik L., Kestelli M., Özbek C., Gürbüz A.

Atatürk Education and Research Hospital Cardiovascular Surgery

Objective: Off-pump coronary artery bypass (OPCAB) surgery had nearly become a routine procedure in some of the clinics whereas most of the clinics had designed their own indications. OPCAB surgery can decrease the complication incidence in the patients who have poor renal function or severe chronic obstructive lung disease (COLD), in the patients who cannot put up with immune suppression (Malignancies etc.), and in the patients whose central nervous system had been affected or may be affected. We are introducing in this study the patients to whom we applied OPCAB surgery with these indications.

Methods: OPCAB surgery is routinely used in our clinic for the patients who have isolated left anterior descending artery lesions or additional right coronary artery lesions, without circumflex artery lesions. In addition to this, OPCAB surgery was applied to 17 of the 19 patients who had been in chronic dialysis program or who had been in close follow-up by the nephrologists for their poor renal function, to 8 of the 11 patients who had severe COLD, to all of the 10 patients who had malignancies (Gastric cancer: 2 patients, colon cancer: 2 patients, breast cancer: 2 patients, urinary bladder cancer: 3 patients, central nervous system cancer: 1 patient), and to 2 patients who had a recent stroke history. Off-pump full revascularization was applied to all of the patients by the help of some cardiac stabilizers (Octopus and/or Starfish). OPCAB surgery could not be applied to 5 of the patients because of technical difficulties (Like diffuse calcification or

Results: No mortality or morbidity after OPCAB surgery had been met due to any cardiac originated condition or coexisting other pathology.

Conclusions: Cardiopulmonary bypass adversely affects the physiology of a patient in many ways. OPCAB surgery decreases the mortality and morbidity in the patients who have poor renal function, COLD, malignancy and in the patients whose central nervous system are under risk.

C11.5

CORONARY AND CAROTID ARTERY OCCLUSIVE DISEASE—OPERATIVE TACTICS AND RESULTS

Kovacevic P., Petrovic L., Nicin S., Fabri M., Radovanovic M., Milosavljevic A., Redzek A.,

INSTITUTE OF CARDIOVASCULAR DISEASE UNIVERSITY CLINIC OF CARDIOVASCULAR SURGERY

Objective: Aim of the study was to evaluate the risk for combined coronary and carotid surgery.

Methods: During the period from 1982—December 31, 2003, 11902 aortocoronary bypass operations have been performed at our Clinic with operative mortality—30 days 2.9%. In 508 patients an additional endarterectomy of carotid arteries was also performed. Cardiac status of these patients was: bad left ventricle (EF<30%) in 113 pts (22.2%), left main stenosis 66 pts (13.7%), unstable angina 111 pts, endarterectomy of coronary arteries because of diffuse and distal coronary artery occlusive disease 175 pts (34.4%). Our operative tactics was as follows: two-stage procedures in 327 pts (64%), three-stage procedures (bilateral

Results: We had complete neurological deficit in 4 pts and transitory ischemic attacks in 6 pts. Operative mortality was 19 pts (3.1%). The causes of death were cardiac 10 pts, neurologic 5 pts, and pulmonary embolism 2 pt.

Conclusions: Operative risk in these polivascular patients is slightly elevated—3.1%, while the highest risk in our experience exists in case of simultaneous procedures.

C11.6

OFF-PUMP CORONARY REVASCULARIZATION IN AWAKE PATIENTS

Kirali K.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery

Objective: High thoracic epidural anesthesia supports awake coronary artery bypass (CABG), completely avoiding the drawbacks of mechanical ventilation and general anethesia in high-risk patients.

Methods: We operated 20 patients aged between 35 and 71 years using TEA between 1 October 2003 and 10 February 2004. Three of them were female. The mean diseased vessel number was 1.35±0.6; single CABG was performed in 14 patients, and 6 patients received multivessel CABG. One patient had left main coronary artery disease. Fifteen operations were performed through a median sternotomy and 5 patients were operated via partial sternotomy. Left internal thoracic artery (ITA) was harvested in whole patients and right ITA in 6 patients, and left radial artery in 1 patient. ITAs were skeletonized in 17 patients. Five patients received double bypass grafting, one patient received triple bypass grafting and 11 patients received one bypass grafting. Coronary artery endarterectomy was performed in two patients.

Results: All patients completed the procedure awake. No patient had postoperative pain. There was no morbidity or myocardial ischemia during the procedure. In six (35%) patients pleura opened widely during surgical intervention. The pleura was intact in 10 patients and it was repaired in 4 patients. The median hospital stay was 5 days.

Conclusions: This new strategy for CABG can be performed safely. Partial sternotomy can prevent any respiratory problem during single vessel CABG in conscious patients.

C11.7

COMPARISON OF OFF-PUMP AND ON-PUMP MULTIVESSEL CORONARY-ARTERY BYPASS SURGERY

Trantina-Yates A., Mächler H., Keeling I., Knez I., Rigler B.

Med-Uni Graz, Department for Surgery Division of Cardiac Surgery

Objective: 17 years ago the use of coronary-artery bypass surgery without cardiopulmonary bypass and cardiac arrest (off-pump) was established. The heart-lung-machine might be responsible for several adverse postoperative outcomes, including systemic inflammatory response, kidney failure, respiratory distress, neurological complications or even multiple organ dysfunction. In our retrospective study we analysed perioperative data and clinical outcome in off-pump surgery with conventional on-pump surgery.

Methods: All elective patients with mulivessel coronary heart disease who were operated between January 2002 and April 2003 were part of the study. Surgical technique was standarized due to the fact that the patients were operated by one single surgeon. Intraoperative bypass patency and flow (ml/min) was evaluated with a Doppler probe. Postoperative data was analysed and the follow-up was done by telephonic

Results: The mean age of the patients was 68 years and 87 percent were male. The on-pump group was 58 patients and the off-pump 81. There were no differences in the preoperative data in both groups. The operation time in the off-pump group was 182 minutes and in the on-pump 222 (ns). The on-pump group received a mean of 2.75 grafts, and the off-pump group 2.25 (ns). Flow bypass values showed no significant difference in the RCA and the LAD, but there was less flow measured in the circumflexa artery in the off- pump group (p=0.009). Respiratory time and transient neurological dysfunction was comparable in both groups. Hospital mortality was 0%. Mean follow-up was 16.3 months and quality of life and cardiac reintervention showed no statistical difference between both groups.

Conclusions: In this study, off-pump coronary surgery was as safe as on-pump surgery. Concerning mortality, morbidity and quality of life, results showed no statistical significant difference. Accordingly, we could assume that the standard of a modern high-tec heart-lung-machine compensates the benefit of the off-pump technique.

C11.8

POSTINFARCTION FREE WALL RUPTURE:SURGICAL TREATMENT- OUR EXPERIENCE

Flajsig I., Castells E., Calbet J., Fontanillas C., Saura E., Benito M., Granados J., Miralles A.

Univ. Hospital Bellvitge Heart surgery (pl.3)

Objective: To analyze the results of surgical treatment of left ventricular free wall rupture after acute myocardial infarct. The diagnosis and treatment present some dificulties and are debatable.

Methods: In the last 20 years, 28 patients (13 women and 15 men) were surgically treated in our Center for left ventricular free wall rupture after acute myocardial infarction. Their mean age was 63 years (range, 42- 80). Cardiac symptoms (chest pain and/or dyspnea) prior to admission were recorded in 5 patients. Two patients had acute myocardial infarction of the anterolateral wall, 6 patients of the lateral wall, 14 patients of the anterior wall, 4 patients of the inferior wall, and one patient had a right ventricle infarction. Thrombolytic therapy was administered in 12 patients, according to the criteria of the American Heart Association and Spanish Society of Cardiology criteria. In all patients, the final diagnosis was established

Results: All patients underwent surgical intervention on an emergency basis. Extracorporeal circulation was used in the first 9 cases, whereas the next 19 patients had off-pump surgery. Three patients had heart arrest during off-pump surgery, which required extracorporeal circulation support. One patient was found false positive for rupture only at surgery. In the first 4 cases, we preformed a direct suture after excisinginfarcted tissue and in the next 15 cases we sutured a patch over the infarction zone, and in the last 8 patients we used Teflon patch fixed with fibrin glue and polypropylene and stitched to the epicardium with a continuous suture. Out of 27 patients, 9 died: one in the surgical room from uncontrolable bleeding and another 8 died between 30 and 90 days after the surgery in the intensive care unit. All of them underwent surgery with extracorporeal

Conclusions: The left ventricle free wall rupture, as a complication of acute myocardial infarction, can be diagnosed early and treated on time. Rapid diagnosis and emergency surgery are crucial for successful treatment of patients with impending heart rupture. Off-pump surgery and "patch with glue" technique seem to yield best results.

C11.9

RADIAL ARTERY FOR CORONARY ARTERY BYPASS GRAFTING—8 YEARS EXPERIENCE

Schneider Y.

Medical Academy of Postgraduate Studies Cardiac Surgery

Objective: The aim of this study is to present our 8 years experience of routine use of the radial artery (RA) in coronary artery bypass grafting.

Methods: From 1995 till 2003 we used radial artery in 561 coronary grafting procedures. The results of the operations were studied using angiography, ECG monitoring, tredmill test. Patients characteristics were the following: angina class III (CSS)—41.8%, IV—29.4%, unstable angina—17.3%. recent MI—4%, smoking—74%, arterial hypertension—57%, ejection fraction < 40—31.2%, left main artery desease—21.1%, 3 vessel

Results: In short-term follow-up 28 (5%) patients died from non-cardiac reasons. In 18 autopsies from 19 cases RA grafts were patent. In 1 case we found graft thrombosis. 6.5% of patients had postoperational myocardial infarction but only in 2 cases (0.3%) it was in RA graft area. During 28 cases of resternotomy all grafts were patent. There were no hand complications. In 42 (7.9%) patients we found some skin hyperesthesia. In 86 (15.3%) pateints tredmill test was done. Loading tolerance increased from 23.7 to 68.4 W. Mean angina class decreased from 3.3 to 1.0. Nobody had ECG ischemia in RA graft area. 18 Patients had postoperative angiography. All grafts were patent. Long-term results of 8 years after operation were studied in 231 patient. During a mean term of observation of 4.3 years survival rate was 97.9%. 6.3% of patients had myocardial infarction. Recurrence of angina was in 8.3% patients. 3 (1.3%) patients had myocardial infarction in RA graft area. Angiography was performed in 16 patients. In 13 (82%) patients RA graft was widely patent. In 3 cases we could not visualize the graft.

Conclusions: We consider that RA is a second conduit of choice after internal thoracic artery with good short-term and long-term results and we recommend it for further use in coronary operations.

C11.10

REVERSED-J INFERIOR STERNOTOMY FOR CORONARY ARTERY BYPASS SURGERY UNDER HIGH THORACIC EPIDURAL ANESTHESIA

Kirali K., Kayalar N., Özen Y., Sareyyüpoglu B., Koçak T., Yakut C.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Kosuyolu Heart and Research Hospital Cardiovascular Surgery

Objective: Many approaches for minimally invasive cardiac surgery are available and to further decrease the invasiveness, coronary artery bypass grafting has been performed under high thoracic epidural anesthesia without endotracheal intubation in the last years. The aim of this study is to ascertain whether approach with a less invasive reversed-J inferior sternotomy can improve patient compliance and postoperative recovery.

Methods: Seventeen patients underwent elective single coronary artery bypass graft operation under high thoracic epidural anesthesia without endotracheal intubation. Reversed-J sternotomy was performed in ten patients (Group A) and full sternotomy in seven Patients (Group B). The technical difficulties, pulmonary functions (by spirometric tests) and hospital stay were assessed.

Results: Through reversed-J sternotomy coronary revascularization was accomplished without any additional technical difficulties and with a good exposure of both left anterior descending artery and left internal mammarian artery. No conversion to standard sternotomy and no intubation was observed. Additional doses of local anesthetic at jugular notch was not required. Pleura was opened more in Group B (57% versus 25%; p =0.14). O2 saturation was better in Group A during surgical procedure (98.8%±0.7% versus 97.1%±2.1%; p =0.033). Intraoperative PCO2 was similar in both group. The patients in Group B were discharged from the hospital more earlier (3.2±1.5 versus 7.3±3.5 days; p=0.004).

Conclusions: Less invasive approach to coronary artery bypass graft operations is possible through combination of high thoracic epidural anesthesia and a reversed-J sternotomy. This technique is less traumatic for the patient and provides practical better oxygenation and shorter hospital stay

C11.11

IS NO NEWS GOOD NEWS? ORGANIZED FOLLOW-UP, AN ABSOLUTE NECESSITY FOR THE EVALUTION OF MYOCARDIAL REVASCULARIZATION

Noyez L., Wouters C.

University Medical Center St. Radboud Nijmegen Cardiac Surgery 414; UMCN St. Radboud, Nijmegen cardiac surgery 414

Objective: Shortening the length of postoperative stay has been advocated as a means of reducing cost of cardiac surgery. Especially after CABG and this even in an aging patient population with an increasing number of patients with comorbidty. On the other hand, it is known, that in high-risk patients, there is a prolongation of the early postoperative risk. Hospital or 30-day mortality, morbidity, are frequently used as endpoints for quality control, this despite an evaluation over a longer period is recommended. Because follow-up is time-, and money-consuming most cardiac surgery centers content themselves with the information returned by cardiologists and general practionars. The intention of this study is to evaluate if this registered follow-up information is sufficient for quality control of performed surgery

Methods: Of 1720 patients undergoing a CABG between 01 January 1999 and 31 December 2002, follow-up data are registered by two ways. The non-organized follow-up (NOFU) contains information given by cardiologists and general practitioners. The organized follow-up (OFU) consists of an annually survey directly to the patient. Completeness of the follow-up, as well as mortality and events, defined as return of angina, myocardial

Results: The OFU was 97% complete, the NOFU 49%. (P<0.05) The NOFU registered only 9 deaths in contrast with 20 patients in the OFU (P=0.1). In the OFU 112 patients were registered with an event, in the NOFU 62 patients (P<0.05). The time period between the operation and the NOFU-data had a mean of 144 days and a median of 90 days.

Conclusions: OFU improves the completeness of the follow-up, as expected, but informs superior about mortality and events. That in the NOFU for 50% of the patients the information is at the most 90 days postoperative old, let suppose that a lot of early (6 months) postoperative information is even missed by a NOFU. The organization of an organized follow-up and feedback of mortality and events after myocardial revascularization becomes indispensable.

SCIENTIFIC SESSION C12 VALVE

C12.1

TEN YEARS OF AORTIC ROOT REPLACEMENT USING A COMPOSITE GRAFT (CARBOSEAL): A SINGLE CENTRE EXPERIENCE

Hickey E., Allemby-Smith O., Livesey S., Langley S., Monro J.

Wessex Cardiothoracic Centre Southampton General Hospital

Objective: Aortic root replacement using a composite conduit has become increasingly popular. We report the single centre results using a bileaflet mechanical valve incorporated into a gelatin-impregnated, ultra-low porosity, woven polyester graft (Carbo-Seal; Sulzer Carbomedics, Inc, Austin, Texas).

Methods: Between 1993 and 2003, 135 patients underwent aortic root replacement using a Carbo-Seal composite graft. All operations were carried out within a single centre using a similar (modified) Bentall's technique. The indications for surgery were acute type A dissection in 35 (26%), chronic dissection in 2 (1.5%) and aneurysmal dilatation in 98 (73%). 23 (17%) had undergone previous sternotomy and 61 (45%) were deemed emergencies. 105 (78%) were male, and 23 (17%) marfanoid. Arch or hemi-arch replacements were undertaken in 13 patients, and hypothermic circulatory arrest was required in 34 (25%). Patients and their clinical records have been followed up to provide a total of 265 patient-years. Follow-up is 100% complete.

Results: There were 4 early deaths (2.9%). At autopsy, complications of coronary buttons were attributable in 2, but the remaining 2 were not related to graft position or function. Two early deaths occurred in those (23) have re-do aortic procedures. Permanent neurological events occurred in 5 (3.7%). Kaplan-Meier survival analysis, including early death, is 96.2%+/– 1.7 (1SE) at 6 months, 95.1%+/– 1.9 at 12 months and 90.7%+/– 3.8 at 3 years. Survival remains over 90% at total mean follow-up of 6.4 years. Of all the late deaths, none are graft or valve related. Freedom from re-operation is 100% at 1 year and 97.2%+/– 2.0 at 3 years. Of 4 re-operations, only one was for a valve-related complication (the only case of prosthetic valve endocarditis).

Conclusions: Aortic root replacement using a Carbo-Seal composite device represents an extremely attractive surgical option for ascending aortic pathology. This single-centre study, using a single implantation technique demonstrates low operative mortality, with good medium-term survival and freedom from re-operation and excellent freedom from prosthetic valve endocarditis. The absence of late deaths related to the Carbo-Seal prosthesis in this follow-up period are encouraging for a favourable long-term picture.

C12.2

INTERMEDIATE CLINICAL AND ECHOCARDIOGRAPHIC RESULTS OF THE BIOCOR PORCINE VALVE IN ISOLATED MITRAL POSITION

Rizzoli G., Bottio T., Vida V., Thiene G.

Università degli Studi di Padova Clinica di Chirurgia Vascolare; Università degli Studi di Padova Department of Cardiac Surgery; Università degli Studi di Padova Department of Cardiac Surgery; Università degli Studi di Padova Department of Cardiac Pathology

Objective: the intermediate clinical and echocardiographic performance of the Biocor valve, a new generation porcine valve, in isolated mitral position was analyzed.

Methods: between May 1992 and January 2004, 154 consecutive pts (102 females and 52 males; mean age 72.3±6 years, range 37-86) received 158 mitral Biocor prostheses. Fifty-five pts (35%) had previous mitral operations. Associated surgical procedures included coronary artery bypass grafting in 38 (24%), radiofrequency ablation and carotid endarterctomy in 4 cases each (2.5%), other procedures in 12 cases (7.6%). Mean pre-operative NYHA class was 2.5±0.8. Echocardiography was performed in the majority of long-term survivors (64%). Follow-up included 609.4 pt-years and was 100% complete with a median time of 4 pt-years (range 0.02-11.3 years). At 8-year 20/136 operative survivors (15%) were still at risk.

Results: Early mortality was 10% (95%c.l. 5.9-16%) (16 pts; mean age 72.5±4.8 years). According to univariate analysis NYHA class III-IV, ejection fraction<40%, urgent operations, male sex and concomitant CABG were significant peri-operative risk factors. At follow-up 43 pts died; 8- and 10-year actuarial Kaplan-Meier survival was 50.6±5.6% versus 70% 10-year survival of the age-sex matched Italian population. Actuarial freedom from valve related death (11 cases) was 85.2±5% at 8 and 10-year. Eight-year actuarial freedom from thromboembolism, anticoagulant-related-hemorrhage, endocarditis, and paravalvular-leak were 85.7±4.4%, 92.6±3.7%, 94.1±3%, 91.8±3%, respectively. Overall 8- and 10-year actuarial-freedom from structural valve deterioration (SVD) was 100%. Reoperation was performed in 9 pts (5 paravalvular leak, 1 pseudoaneurysm, 1 endocarditis, 2 new valve involvement); linearized-rate was 1.58% patient-years. Eight-year actual reoperation freedom was 93.2±2.2%. Actuarial-freedom from valve-related complications at 8-year was 70.2±5.7%. The mean echocardiographic follow-up time was 4.2±2.7 years. By Doppler echocardiography the peak and mean transprosthetic gradients were 15±5 mmHg and 6.3±3 mmHg, respectively. In the 49 pts who underwent repeated echocardiograms the valves showed, over the time, stable mean and peak transvalvular gradients.

Conclusions: At intermediate follow-up the Biocor prosthesis in mitral position showed excellent results in terms of valve durability when compared to other second-generation tissue-valve.

C12.3

HEMODYNAMIC PERFORMANCE OF THE MEDTRONIC ADVANTAGE^® PROSTHETIC HEART VALVE IN AORTIC POSITION: ECHOCARDIOGRAPHIC AND CLINICAL EVALUATION

Litmathe J., Boeken U., Feindt P., Gramsch-Zabel H., Gams E.

Heinrich-Heine-University Thoracic- and Cardiovascular Surgery

Objective: The bileaflet mechanical heart valve is the most widely implanted prosthesis design. Although advancements in valve design recently have been made, prosthetic stenosis and thrombogenicity remain cahracteristics of mechanical valves that require specific therapy. The design of the Advantage^® valve (Medtronic, Minneapolis, USA) was established with these issues in mind. The aim of the study was to present the early clinical and echocardiographic follow-up of patients who underwent aortic valve replacement (AVR) with this prothesis.

Methods: Between 8/02 and 12/03 20 patients underwent AVR using the Advantage^® prosthesis (15 male, 5 female). The mean age was 65 years (range: 61 to 74 years). Surgery was performed for aortic stenosis (n=8), as well as for insufficiency (n=2) or mixed lesions (n=10). Advantage^® aortic valves sized from 21 to 27 mm. Concomitant surgery (coronary artery bypass grafting) was performed in 7 patients. Postoperative follow-up was available in all cases and consisted of physical and echocardiographic examination.

Results: Clinical improvement of at least one class of NYHA was reached in all patients. The mean pressure gradient in cases of stenosis or mixed lesions was reduced significantly (45+/–19 mm Hg to 11+/–3 mmHg postoperatively). Concerning other commercial availabe valves the postoperative mean p ranges between 9+/–2 and 18+/–2 mmHg dependent on the orificium size. Regurgitation was trivial in 14 patients and mild in 6. A clue for thrombosis could not be observed.

Conclusions: The results of the early follow-up show a promising performance of the Advantage^® valve. Echocardiographic as well as clinical data of this initial patient group was comparable or better to other available mechanical heart valves.

C12.4

SURGUICAL TREATMENT OF CALCIFIC AORTIC STENOSIS WITH STENTLESS VALVE IN THE ELDERLY

Vaccari G., BARRETTA A., GUERRA F.

Cardiovascular Surgery Department Villa Maria Pia Torino Italy Cardiovascular Surgery Villa Maria Pia; VILLA MARIA PIA CARDIAC SURGERY; VILLA MARIA Pia CARDIAC SURGERY

Objective: In calcific aortic stenosis in the elderly many areas of the aortic root are involved. We describe our surgical experience in these patients using Elan stentless valve.

Methods: From October 2000 to May 2003 96 consecutive patients with a mean age of 74.3 years+/– 5 years (65 female 31 male), underwent aortic valve replacement using a stentless valve and concomitant aortic root remodelling: the valsalva sinuses were remodelled in 15 pt.(16%) and in 57 (59%) an aortic buttress ring was implanted on sinus tubular junction (STJ). Of These, 19 to reduce STJ dilatation and in 38 to prevent late dilatation. Concomitant procedures were: 34 coronary artery bypass; 1 mitral valve repair 3 mitral valve replacement, 1 interventricular septal defect closure. In 63 patients the interventricular septal myectomy was also performed.

Results: There were no early deaths but two late deaths (2%) which were not valve related. Follow-up was completed for 90 patients (95.7%) and ranged from 6 months to 36 months (mean 19.5 months). 2 patients were in NYHA III, 75 patients (80%) were in NYHA II and 19 (20%) in NYHA I. Postoperative transthoracic echocardiography.showed excellent haemodinamic results. Mean and peak transvalvular gradients were 16+/– 5 mmHg and 10+/– 4 mmHg respectively. In 13 patients trivial aortic insufficiency was found in two patients mild regurgitation. The repaired root showed normal morphology with favourable functional anatomy with no discrepancy between the aortic root components.There have been no reoperations or functional deterioration, while left ventricular mass regression is evident after 6 months.

Conclusions: Based on our experience in elderly patients with aortic stenosis and major aortic root component involvement we recommended repair as describe in the majority of such patients.

C12.5

ASCENDING AORTOPLASTY: MID-TERM RESULTS

Polvani G., Roberto M., Dainese L., Agrifoglio M., Kunkl A., Tartara P., Alamanni F., Biglioli P.

Centro Cardiologico Monzino, University of Milan Department of Cardiovascular surgery; Centro Cardiologico Monzino, University of Milan Department of Cardiac Surgery

Objective: Ascending aortoplasty has been normally proposed for ascending aortic dilatation, especially in case of post-stenotic dilatation and for elderly patients. This technique presents several advantages as it is less radical than Dacron graft replacement. The aim of this study is to analyse our mid-term results in

Methods: From January 1998 to December 2003, 55 patients underwent aortic valve replacement and reduction aortoplasty. The mean age was 60 years old (range 77-36). 27 patients (49%) presented aortic valve stenosis, 17 patients (31%) presented aortic valve regurgitation, most of the cases associated with a slight aortic stenosis, while 11 patients (20%) had aortic valve bicuspidy. 15 patients (27%) underwent other associated procedures (9 CABG, 3 mitral valve replacement, 3 mitral valve repair). Perioperative ascending aortic diameter has been assessed with CT-scan and/or intraoperative transesophageal echocardiography, mean preoperative aortic diameter was 50.8 mm (range 34-70 mm). Mean postoperative aortic diameter was 37.8 mm. Follow-up was available on 100% of patients, ascending aortic diameter has been analysed with CT scan,

Results: There were no perioperative mortality and morbidity. One patient had a transient cerebral ischemia at 16 months. 5 patients (9%) underwent aortic redilatation, 3 of them underwent aortic reoperation (ascending aortic substitution) while the other 2 did not, in consideration of the stability of the aortic dilatation and because of their advanced age. 3 patients deceased, one patient for cerebral infarction at 39 month, one patient for pulmonary cancer at 36 month and one patient for prostates cancer at 34 months. At 64 months cardiac related survival is 94.12%, cumulative survival is 86.5%, freedom from reoperation is 85.71% and freedom from redilatation is 69.96%. We divided our patients in two groups, patients who underwent redilatation and patients who did not, then we compared preoperative and postoperative characteristics to evidence which ones could present a significative difference into those two groups; we found out a significative difference in case of a preoperative aortic diameter bigger than 55 mm.

Conclusions: Reduction aortoplasty can be accomplished with quite good mid-term results. Our preliminary mid-term results show a low mortality and morbidity, while there is a high incidence of redilatation in case of preoperative diameter bigger than 55 mm.

C12.6

REAL STENTLESS AORTIC VALVE BIOPROSTHESIS- EARLY CLINICAL APPROACHES

Anguseva T., Mitrev Z., Petrovski V.

Special Hospital fro Cardiosurgery "Fillip II" cardiosurgery and intensive care

Objective: Stenotic changes of aortic valve lead to severe hemodynamic disorders in pts.Mechanical eather bilogic prosthesis have some disadvantages such are continuous anticoagulative therapy, lost Valsalva-sinus influence on aortic blood flow, or middle pressure gradient.Natural tissue stentless valves have no ring, but still takes influence on normal Valsalva function and their use is limited by size of pts.’s aorta ring.The aim of study was to evaluate early clinical results of pts with implanted real stentless aortic valve.

Methods: We created our first stentless valve using porcine pericardium and replacing valve cusps on aortic fibrous ring of patient.We named it real stentless, because we use ring of patient's aorta as guide for its size.Radius of aortic ring is measured at base of aorta and multiplied by 3, which gives us length of 3cusps.Porcine pericardium then is cut by calculated length and 2 cm wide, folded 3 times and tailored in shape of heart.Leaflets are implanted using continuous sutures at newly created commissurae, keeping normal Valsalva sinuses.Including criteria for this study was:aortic valvular stenosis(regardless of ethyology) with normal aortic wall.Pts. were monitored by intraoperative and postoperative TEE.

Results: 38pts with aortic stenosis(21with atherosclerotic,15with rheumatic ethyology,2 with subacute endocarditis and chronic haemodyalisis)had been included in study.Intraoperative TEE showed aortic morphology similar as normal, dp/dt ratio was 0.07, equal opening and closing time, average valve systolic gradient was 18. Middle aorta cross-clamping time was 87min, and bypass time-105min. Average extubating time was 6h.Significant bleeding was noted in 2pts.(1with/1without surgical ethyology).Stroke and rhythm disturbances, notified at 1patient.Pts have been treated with aspirin 0.1mg/day.1patient reoperated, due to severe aortic

Conclusions: Real stentless aortic valveis a bio-prostheses with a similar haemodynamic parameters as a normal valve and simple way of implantation. It ensures normal opening and closing time of leaflets, and larger indexed effective orifice area of the aorta.Longer follow-up is requiring assessing the durability of unstented pericardium in the aortic position, but early results are encouraging.

C12.7

MECHANICAL PROSTHETIC HEART VALVE USAGE FOR VALVULAR REPLACEMENT IN TREATMENT OF INFECTIVE ENDOCARDITIS

Yilik L., Özsöyler I., Gökalp O., Ilhan G., Emrecan B., Karahan N., Akçay A., Gürbüz A.

Atatürk Education and Research Hospital Cardiovascular Surgery; Izmir Ataturk Education and Research Hospital Cardiovascular Surgery

Objective: Infective endocarditis is a disease that has high mortality and morbidity rates. Homografts have favorable effects on the outcome of the surgical treatment. But homografts are really hard to provide. For this reason mechanical prosthetic heart valves are commonly used for the treatment pf infective endocarditis. We report the results of the 14 patients for whom we used mechanical heart valve for valvular

Methods: 6 patients were female and 8 were male. Mean age of the patients was 36.6. Six patients had only artic valve endocarditis, 4 patients had only mitral valve endocarditis and 4 patients had both aortic and mitral valve endocarditis. The patients had intense medical treatment with antibiotics for mean 4.3 weeks

Results: The patients were operated on standard cardiopulmonary bypass. Ten aortic valve replacements, 6 mitral valve replacements and 2 mitral valve repairs were done to the patients. Mechanical prosthetic heart valves were used for valvular replacement. Radical debridement was done for the infected tissues. Valves were implanted by using single pledgetted U-sutures. Sewing rings and pledgets were washed with rifamycin. The patients were followed-up for mean 22.3 months. No mortality or morbidity was seen in the postoperative period.

Conclusions: Mechanical prosthetic heart valves can be used in infective endocarditis when homograft usage is not feasible.

C12.8

ANALYSIS OF RISK FACTORS OF MORTALITY IN CARDIAC REOPERATIONS FOR MITRAL BIOPROSTHESIS DYSFUNCTION

Erdogan H., Ömeroglu S., Erentug V., Göksedef D., Kirali K., Ipek G., Akinci E., Yakut C.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery

Objective: Aim of the study was to evaluate risk factors of mortality in reoperations for mitral bioprosthesis dysfunction.

Methods: Between 1993 and 2003, 97 patients (mean age 47.1±11.4 years) were reoperated for bioprosthesis dysfunction at mitral position. Mean folllow up after first operation was 122.1±34.8 months. Indications for reoperation were structural degeneration in 91 patients, endocarditis in 4 patients and paravalvular leakage in 2 patients.

Results: Mortality in reoperations was 8.2%. NYHA class, urgent-emergent procedures, renal dysfunction (creatinin 1.5 mg/dl), total perfusion time, aortic cross clamp time, pulmonary hypertension, concomitant procedures for tricuspid valve were found to be risk factors for operative mortality by univariate analysis. Multivariate analysis documented that pulmonary hypertension (p=0.05; OR 8.8, 95% CI 0.9-78.7) and concomitant procedures for tricuspid valve (p=0.02; OR 19.5, 95% CI 1.6-237.9) were significant risk factors.

Conclusions: Reoperation for mitral bioprosthesis dysfunction before development of right heart failure might reduce operative mortality.

C12.9

OUTCOME OF SURGERY FOR FUNCTIONAL TRICUSPID REGURGITATION LATE AFTER MITRAL VALVE SURGERY

Ahn H., Hong J., Kim K., Kim K.

Seoul National University Hospital Thoracic and cardiovascular surgery

Objective: Functional tricuspid valve regurgitation(TR) may persist or progress despite correction of left-sided pathologic condition, and it results in poor hemodynamics. But, decisions of surgery are difficult, because repair for TR carries high mortality and morbidity. We have reviewed our experience with 13 patients who underwent tricuspid valve surgery late after mitral valve surgery.

Methods: Between Dec. 1999 and Feb. 2004, thirteen TVRs were performed for functional TR, 7 years to 17 years after mitral valve surgery(mean 11.8 years). There were 3 males and 8 females with mean age of 52.8 years. The mean duration of follow up was 16.7 months. Previous operations were MVR in 7 patients and MVR with AVR in 6 patients. All patients had normal prosthetic mitral valve function and left ventricular function at the time of tricuspid valve surgery. Five Patients were preoperative New York Heart Association(NYHA) class II, 5 patients were class III, and 3 patients were class IV, despite of medication. Hepatomegaly was present in all patients(2FB-5FB). TR severity was graded by echocardiography, and 11 patients were severe TR, 2 patients were moderate to severe TR. Since 2003, we evaluated preoperative right ventricular ejection fraction (RVEF) using gated-blood pool scan in 4 patients and mean RVEF was 42.5%(39-43%). The mean duration from diagnosis of TR to surgery was 38.2 months(4-88 months).

Results: Hospital mortality was 15.4%(2 patients), and causes of death were low cardiac output in 1 patient, aspiration pneumonia in 1 patient. Median ICU stay was 7 days(2-72days). Mean hospital stay was 32.3 days(12-92 days). There was persistent right heart failure in 1 patient, delayed bleeding in 1 patient. There was no late mortality. At the end of follow up, 7 patients were NYHA class I, 3 patients were class II, and one patient was class III. Hepatomegaly persisted in 3 patients. Among the 3 patients with preoperative NYHA class IV, one patient died due to low cardiac output. Right heart failure persisted in one patient, and improved

Conclusions: Tricuspid surgery for functional TR late after mitral valve surgery can be performed with acceptable mortality and morbidity, but preoperative evaluation of right heart function and careful patient selection are mandatory. Preoperative NYHA class IV was a risk factor for poor outcome. For prevention of late tricuspid valve operation, it is important to evaluate and correct TR at the time of mitral valve surgery.

C12.10

SMALL DIAMETER PROSTHESES WITHOUT ENLARGING AORTA TECHNIQUES: IS IT JUSTIFIED?

Morozov A.

Institute of Thoracic surgery Moscow medical academy cardiac surgery

Objective: The use of small aortic valve prostheses is still controversial. Replacement of the aortic valve with a mechanical prosthesis when the annular diameter is small, can present significant haemodynamic and technical problems. It is well known that prostheses less than 23 mm in diameter may create significant obstruction because of small valve size and patient-prosthesis mismatch (PPM), that are both considered to decrease long-term survival.

Methods: In the current study results of surgical treatment of 33 patients with aortic valve desease between 2001-2003 has been retrospectively analyzed (19 male, 14 female, mean age 46.7±9.6 years old, all in NYHA class III—IV). All patients underwent aortic valve replacement (AVR) with small diameter prostheses. Body square area (BSA) varied from 1.49-2.12?² (mean 1.82±0.19). Peak gradient was 58.0±20 mm Hg, left ventricle ejection fraction (LVEF)—66±5.4%. Mechanical prostheses were used for all patients (bi-leaflet—16, tilting-disk—17). There was no enlarging the aortic root need to accommodate a prosthesis. A 19 mm prostheses is used in patients with BSA less than 1.7 square meters. Pressure gradient over the prosthesis related to increasing flow show that the 19 mm devices are not nearly as good as the 21 mm devices. The 23

Results: Mean and peak gradients (MG, PG) and indexed effective orifice area (IEOA) were measured by trans-thoracic and trans-esophageal echo postoperatively (6month-2 yrs). There was no significant difference in post-operative gradients and left ventricle ejection fraction (LVEF) between normal and small aortic root groups (mean 24±5.7 mm Hg and 32±6.3 mm respectively). Hospital mortality was 2 (6.1%) patients. Long-term follow-up included 23 patients- there weren't any valve-related complications or deaths. Gradients meanings during the follow-up period haven't been changed.

Conclusions: This retrospective study suggests that the use of small valve prosthesis in aortic valve replacement in the presence of valve lesion carries a favourable prognosis in terms of postoperative survival and does not confer any additional risk in relation to perioperative or long-term results. In some cases PPM and the size of valve implanted do not influence post-operative hemodynamic conditions and long-term survival. Gradient should be considered as it relates to the resolution of left ventricular hy-pertrophy. In some cases 19 mm prosthetic heart valves have prohibitive pressure gradi-ents, but 21 and 23 mm were satisfactory.

C12.11

RISK FACTORS FOR REQUIREMENT OF PERMENANT PACEMAKER IMPLANTATION AFTER AORTIC VALVE REPLACEMENT: ANALYSIS OF 401 CASES

Erdogan H., Erentug V., Kayalar N., Aydin C., Kirali K., Akinci E., Yakut C.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Kosuyolu Heart and Research Hospital Cardiology; Kosuyolu Heart and Research Hospital Cardiology; Kosuyolu Heart and Research Hospital Cardiology; Kosuyolu Heart and Research Hospital Cardiology; Kosuyolu Heart and Research Hospital Cardiology; Kosuyolu Heart and Research Hospital Cardiology; Kosuyolu Heart and Research Hospital Cardiology

Objective: The aim of this study was to evaluate the frequency of requirement for permanent pacing and related risk factors after aortic valve replacement.

Methods: Among 401 patients operated between 1994 and 2003, 17 patients (4.2%, mean age 46.6±15.4 years) required the implantation of a permanent pacemaker. Most of the were female (64.7%). The main indication was aortic stenosis (88.2%). Severe annular calcification was documented in 76.5% them, and the aortic valve was bicuspid in 58.8%. The mean perfusion time was 95.8±12.1 min.

Results: Female sex, hypertension, native valve pathology, preoperative ejection fraction, total perfusion time, aortic cross clamp time and preoperative treatment with calcium channel blockers were associated risk factors by univariate analysis. Multivariate analysis showed that age (p=0.03; OR 0.9, 95% CI 0.9-1), female sex (p < 0.001; OR 0.1, 95% CI 0.02-0.4), annular calcification (p < 0.001; OR 25.7, 95% CI 5.7-122.9), bicuspid aortic valve (p=0.007; OR 5.4, 95% CI 1.5-18.7), preoperative treatment with calcium channel blockers (p=0.0018; OR 9.8, 95% CI 1.4-59.1) and total perfusion time (p=0.007; OR 1, 95% CI 1-

Conclusions: Requirement for implantation of permanent pacemaker after aortic valve replacement is rare. Risk factors are female sex, bicuspid aorta, annular calcification and preoperative calcium channel blocker treatment.

SCIENTIFIC SESSION C13 MISCELLANEOUS

C13.1

CAROTID DOPPLER MICROEMBOLIC SIGNALS IN PATIENTS ONE YEAR AFTER HEART VALVE SURGERY

Dalinin V., Dalinin V., Svennevig J., Lingaas P.

Institute of Thoracic surgery Moscow medical academy Cardiac surgery; Institute of Thoracic surgery Moscow medical academy Cardiac surgery; National hospital Thoracic and Cardiovascular surgery; National hospital Thoracic and Cardiovascular surgery

Objective: Tromboembolism is a feared complication following heart valve replacement. Cerebral microembolic signals may be detected using Doppler ultrasonography. Doppler ultrasound has been used to detect microemboli during CPB. MES has also been detected in association with myocardial infarction, left ventricle aneurysm, atrial fibrillation and carotid artery stenosis. The aim of the present study was to examine the frequency of MES in patients one year after heart valve replacement, to look for possible risk factors associated with MES and for any correlation with cerebral events.

Methods: One hundred patients (mean age was 66.3 (+\-12.4), 69 male and 31 female) were examined one year after heart valve replacement (group A). Frequently used mechanical valves—Carbomedics, On-X. Thirty patients who had undergone various cardiovascular operations but without heart valve pathology (mean age was 62.5 (+\- 8.7), 39% male and 61% female) served as controls (group B). A newly developed microemboli detector, EMEX-25 (Hatteland Instrumentering, Norway) was used to detect microembolic signals

Results: In group A MES were detected in 62%, in group B in 46% of the patients. The difference between valve patients and non-valve patients was not statistically significant (p=0.2). In group A a correlation was found between the number of MES and postoperative stroke, smoking, previous cardiovascular operations and the EUROScore (p<0.05). There was no correlation between the total number of MES and anticoagulation (INR and anticoagulation therapy), atrial fibrillation, cholesterol level, NYHA class, gender, age, valve type or valve position. In group B a correlation was found for age, elevated serum creatinine level (>200 uMol/L), atrial fibrillation and EUROScore. Cerebral events were diagnosed in 15 patients in group A and their correlation with the total number of MES was statistically significant.

Conclusions: MES were detected in valve patients as well as in non-valve patients one year after surgery. The difference between the two groups was not statistically significant. The association between possible risk factors and MES varied between valve patient and non-valve patients. A strong correlation between number of MES and postoperative cerebral events was found.

C13.2

COMPLETE REVASCULARISATION WITH OR WITHOUT CARDIOPULMONARY BYPASS USING ARTERIAL GRAFTS: ANGIOGRAPHIC RESULTS IN 6 MONTHS

Kirali K., Elevli G., Göksedef D., Sareyyüpoglu B., Izgi A., Saglam M., Kirma C., Yakut C.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Kosuyolu Heart and Research Hospital Cardiovascular Surgery; Research Hospital Cardiology; Kosuyolu Heart and Research Hospital Cardiovascular Surgery

Objective: Off-pump CABG has become popular, and with the aid of new devices, a reliable method for complete coronary revascularization. This study investigated early angiographic results of arterial grafts used in off-pump and on-pump CABG operations.

Methods: A total of 40 patients, 20 in off-pump group and 20 in cardiopulmonary bypass group, with a mean age of 55.2±9.2 and three vessel coronary artery disease have been completely revascularized with arterial grafts. Each group had 3 female patients. Twenty LIMA, 18 RIMA and 18 radial artery grafts were used in the operations in off-pump group; and 20 LIMA, 19 RIMA and 17 radial artery in on-pump group. Radial arteries were used as a sequential graft in 8 operations, 4 for each group.

Results: Mean follow up time of the patients was 12.2±4.1 months. There was no early or late mortality. All patients had a control coronary angiography with a mean time interval of 6.7±3.3 months postoperatively. All LIMAs were patent in both groups. In off-pump group, patency rate of RIMA and radial artery were 100% and 94.4% respectively. In on-pump group, RIMA patency rate was 94.7% and radial artery patency rate was 94.1%. No statistically significant difference was found in patency rates of the grafts in control angiographic

Conclusions: Full revascularization can be achieved by off-pump bypass techniques in three-vessel coronary artery disease using arterial grafts as efficiently as in patients operating under cardiopulmonary bypass.

C13.3

THE RENIN-ANGIOTENSIN SYSTEM GENETIC POLYMORPHISMS AND RHEUMATIC MITRAL VALVE DISEASE

Ozisik K., Emir M., Ulus T., Kaplan S., Misirlioglu M., Tuncer S., Katircioglu F.

Ankara Numune Education and Research Hospital Cardiovascular Surgery; TYIH, Department of Cardiovascular Surgery, Ankara, Turkey Cardiovascular Surgery; TYIH, Department of Ankara, Turkey; Metis Biotechnology Ltd., Ankara, Turkey; TYIH, Department of Cardiovascular

Objective: Angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism, angiotensinogen (AGT) gene polymorphism and angiotensin II type 1 receptor (AT1R) polymorphism in relation to rheumatic mitral valve disease were examined as a case-control study to investigate possible relationships between these gene polymorphisms and rheumatic mitral valve disease in patients undergoing mitral valve

Methods: A total of 50 patients with rheumatic mitral valve disease undergoing MVR was compared with 50 normal, age and sex matched control subjects. ACE I/D, AGT gene M235T and AT1R- adenine/cytosine 1166 (A1166C) genotype polymorphisms were identified by polymerase chain reaction (PCR) based restriction

Results: ACE I/D polymorphism differed significantly between the groups. Although, control group mostly represents the heterozygotes ID allele (74%), study group has a frequency that is distributed 60% to the homozygous DD and II alleles. MM homozygote frequency was significantly higher in control but TT homozygote frequency was significantly higher in study group. AT1R-A1166C genotype polymorphism also differed significantly difference between groups; the MVR group had 73.7% of the AC heterozygotes allele, while controls had 64.4% of the AA and 66.7% of the CC homozygote alleles.

Conclusions: These results provided evidence of an association between ACE I/D polymorphism, M235T polymorphism and AT1R-A1166C genotype polymorphism and rheumatic mitral valve disease.

C13.4

EARLY VALVE REPAIR IN ACTIVE INFECTIVE ENDOCARDITIS PATIENTS: DOES IT IMPROVE THE OUTCOME?

Shikhverdiev N., Khubulava G., Marchenko S.

Kuprijanov's cardiovascular clinic cardiosurgery

Objective: Mitral valve repair has been suggested as providing a better postoperative outcome than valve replacement for mitral regurgitation in active infective endocarditis, but this impression has been obscured by differences in baseline characteristics and has not been confirmed in multivariate analyses with particular regard to the early operations in septic patients.

Methods: The present study was based on a review of our experience with valve repair and valve replacement for the surgical correction of mitral and tricuspid regurgitation in IE. Included in the study were patients who had repair or replacement of the mitral and/or tricuspid valve performed between January 1, 1996, and December 31, 2003.

Results: Surgical repair of the mitral valve involved subvalvular, valvular (mostly resection or plication), and annular (linear segmental annuloplasty) interventions. The outcomes in 65 patients (34 mitral and 31 tricuspid) underwent valve repair and 214 valve replacement for mitral or tricuspid regurgitation in IE were compared using multivariate analysis. All patients had preoperative echocardiographic assessment of mitral valve functional anatomy and left ventricular function. After valve repair, compared with valve replacement overall operative mortality was 2.9% in patients with tricuspid IE, 3.2% in patients with mitral IE versus 9.8%. Multivariate analysis indicated an independent beneficial effect of valve repair on overall survival. There was significant difference between valve repair and valve replacement groups regarding the need for reoperation (free of reoperation: at 5 years, 96.9% and 91.6%, respectively) and the incidence of bacterial endocarditis (at 5 years, 98.5% and 93.5% were free of endocarditis, respectively).

Conclusions: Valve repair significantly improves postoperative outcome in patients with mitral and tricuspid IE and should be the preferred mode of surgical correction. The low operative mortality is an incentive for early surgery before ventricular dysfunction occurs. In patients operated for IE the overall survival after valve repair was significantly superior to that after valve replacement

C13.5

ARTERIAL VERSUS VENOUS GRAFTS IN COMPLETE OFF-PUMP SURGERY: ANGIOGRAPHIC RESULTS IN 6 MONTHS

Kirali K.

Kosuyolu Heart and Research Hospital Cardiovascular Surgery

Objective: Complete revascularization is the goal in all patients undergoing OPCAB surgery. Arterial and venous grafts can be used for this procedure.

Methods: Between December 2002 and February 2004, 81 patients underwent complet OPCAB surgery with a mean age of 60.6±9.1. Apical suction device and pressure stabilizator were used during all procedures. Control angiographies were performed with a mean time interval of 6±4.1 months after the OPCAB

Results: LIMA was used in all patients. RIMA was used in 23, radial artery was used in 19 and saphenous vein graft was used in 44 patients. Thirty-two patients had full arterial revascularization. Three patients (3.7%) had to be converted to on-pump procedure. Perioperative myocardial infarction was seen in 2 patients (2.5 %). There were 2 early mortalities due to respiratory failure and pneumonia. Postoperative control angiography was performed to 40 patients. The patency rate of LIMA was 100%, and the patency rates for RIMA, radial and saphenous vein were 92.4%, 91.2% and 82.3% respectively.

Conclusions: Complete revascularisation with OPCAB is a reliable, effective and safe procedure. Early angiographic results shows that the patency rates of arterial grafts are superior to venous grafts in OPCAB operations.

SCIENTIFIC SESSION C14 MISCELLANEOUS

C14.1

EVALUATION OF THE EFFICACY OF AN EASY AND INEXPENSIVE INTERVENTION TO OPTIMISE SECONDARY PREVENTION MEASURES IN PATIENTS AFTER CARDIAC SURGERY

Reyes G., Rodriguez H., Cuerpo G., López J., Bueno H., Ruiz M., Pinto A., Vallejo J.

Hospital General Universitario Gregorio Marañón Cirugía Cardiovascular

Objective: To assess whether a hospital intervention as a docuement can improve the use of secondary prevention (SP) measures in patients who undergo cardiac surgery in order to make a continuous quality improvement.

Methods: The indications of SP pharmacological therapies were reviewed in a number of clinical guidelines and the conclusions abstracted, presented and accepted by all the members of the Cardiac Surgery Department. A document that included a) the indications of SP interventions, b) their use, c) cause of non use, and d) alternative therapy employed was created. It was accepted by consensus to fill the document for each patient before hospital discharge during year 2003 (n=298, 11 months) in order to check that all the SP was fully completed. With the same document, the use of SP measures on patients discharged during year 2002 (n=372) was retrospectively recorded and results pre- and postintervention were compared.

Results: Baseline characteristics, prevalences of coronary artery disease, peripherical artery disease, left ventricle systolic dysfunction, and atrial fibrillation were similar in both groups, with the exception of smoking (41% in 2002, 30% in 2003; p=0.005) and cerebrovascular disease (10.6% in 2002, 4.3% in 2003; p=0.003). Table shows the rate of use of SP pharmacological interventions in optimal candidates (those with indication and without absolute or relative contraindications) before and after the intervention. Table 6

C14.2

REGIONAL MODIFICATION OF EUROSCORE. IS IT A REAL OPTION?

Szafron B., Szafranek A., Zembala M.

Silesian Centre For Heart Disease Cardiac Surgery and Transplantology Department

Objective: To assess how well EuroSCORE works in a centre not involved in its development. To attempt regional modification of the system in order to increase its predicting power.

Methods: Retrospective, single centre study. Clinical data of 1283 randomly chosen patients operated on in our institution in years 2001-2002 were reviewed. The area under Receiver Operating Characteristic (ROC) curve was calculated in order to assess the sensitivity and specificity of logistic EuroSCORE. The same analysis was performed for all cardiac surgery patients (group A, n=1283), isolated CABG patients (group B, n=933) and valve surgery patients (group C, n=226). Additionally the attempt was made to upgrade the system. By means of maximum likelihood method new regression coefficients were calculated for all variables in the logistic version of EuroSCORE in order to review their influence on the outcome. Finally the ROC curve analysis was made for the modified version.

Results: The area under ROC curve for modified logistic EuroSCORE increased remarkably in each group comparing to the original version:

group A: 0.76 (original) vs. 0.78 (modified)

group B: 0.74 (original) vs. 0.82 (modified)

group C: 0.79 (original) vs. 0.84 (modified)

Conclusions: EuroSCORE seems to be a universal risk estimator in European cardiac surgery presenting good predicting ability, especially in valve surgery patients. It is possible however to modify the logistic version of EuroSCORE in order to make it institution specific and therefore increase its predicting power.

C14.3

CARDIOSI: AN ELECTRONIC MEDICAL RECORD OPTIMIZED FOR CARDIAC SURGERY

Chiavarelli M., Cimato R.

University of Siena Policlinico Le Scotte Cardiothoracic Surgery; UNIVERSITY OF SIENA Cardiothoracic Surgery

Objective: Electronic medical records decrease health care cost and this advantage appears obvious for high technology subspecialties like cardiac surgery. Critical evaluation of relevant data is necessary to improve the effectiveness of resource allocation, quality evaluation, and to allow clinical research. The "CardioSI" is a fully functional medical record dedicated to cardiac surgery patients including heart transplant recipients

Methods: A clinical supervisor and a database administrator have designed an initial dataset on the basis of a paper medical record, which was originally planned following the problem-oriented knowledge-based system. Each user category has a different authority to enter and validate. For example the surgical procedure is a single table originating from four different views, which are compiled by the primary surgeon, the anesthesiologist, the operating room nurse, and the perfusionist

Results: Data quality is defined by a dynamic dictionary which contains unequivocal field definitions, which are displayed on demand for critical fields. Each form can be closed by the user, once validity checks are passed. Some of the fields are automatically derived and utilized for diagnostic and result classifications, and compilation of summary lists.

Database Design and Constraints:

• Relational database based on Microsoft SQL Server connecting 16 workstations (to be expanded to 42) which has been normalized to include over 2200 data fields divided in 16 tables
  
• Types of entry: pre-defined dynamic value lists, buttons, mouse-driven, keyboard-driven
  
• Entry is easy and direct; vital parameters are acquired on line and validated on demand
  
• Types of data definitions: 1018 text variables with only 26 free entries, 721 numeric, 70 date, 398 three-state variables, and 21 memo fields. Seventy-two percent are calculation fields
  
• Ninety-three percent of underived fields contain a predefined value list minimizing data entry errors and lost of critical information
  
• Users consist of cardiac surgeons, cardiac anesthesiologists, nurses, perfusionists, and data coordinators
  
• Validity checking (on crucial data)
  
• Cardiac surgery activity is monitored by predefined queries
  

Conclusions: The "CardioSI" is a cardiac surgery-oriented database designed to have meaning to allied health professionals caring for cardiac surgery patients. This bank of information is the basis of our electronic medical record and is utilized for analyzing clinical results in terms of risk stratification and preoperative scores, mortality and morbidity, and survival studies. The rapid evolution of cardiac surgery will require a high degree of flexibility to include new developments, customizations and expansions, that are present in our tool

C14.4

QUALITY OF LIFE AND LONG TERM SURVIVAL AFTER OPEN HEART SURGERY

POTIC Z., POTIC M., JAKOVLJEVIC D., MIHAJLOVIC B., RADOVANOVIC N.

INSTITUTE OF CARDIOVASCULAR DISEASE UNIVERSITY CLINIC OF CARDIOVASCULAR SURGERY

Objective: The aim of this study was to estimate long term benefit of open heart surgery in seven year period, using quality of life and cumulative survival as outcomes. For assessment of quality of life, we used diseases and treatment specific health related quality of life questionnaire and derived integral numeric QOL index QOLi-NS (0-100). Zero value represents complete inability for any functioning and value 100 means perfect health. The cumulative survival rate was calculated using actuarial method.

Methods: The prospective study involved 787 consecutive patients. The survival adjusted QOL (QOLadj) was calculated according the following formulae QOLadj(t)=QOLi-NS(t) * Survival(t). The benefit of operation was calculated as difference between postoperative survival adjusted QOL and preoperative QOL (QOLi-NS=

Results: See attached table.

Conclusions: Patients’ benefit, concerning survival adjusted QOL, is the greatest at one year after the surgery and declines during the follow-up period, but is very clinically and statistically significant. The mean QOL benefit in seven year follow-up period is 29. The survival adjusted QOL could be the most appropriate measure for the evaluation of open heart surgery outcome. Table 7

QUALITY OF LIFE AFTER SURGERY FOR ISCHEMIC HEART FAILURE

MIHAJLOVIC B., Jakovljevic D., Radovanovic N., Potic Z., Potic M., Pekic R.

INSTITUTE OF CARDIOVASCULAR DISEASE UNIVERSITY CLINIC OF CARDIOVASCULAR SURGERY

Objective: To compare quality of life (QOL) in patients with preoperative heart failure, ejection fraction (EF) lower or equal to 30% and to those with EF higher than 30%, before and during 5 year follow-up period after the myocardial revascularisation.

Methods: We analyzed 607 consecutive patients, 558 with EF > 30% (80% males, mean age 57 years) and 49 with EF lower or equal to 30% (76% males, mean age 59 years). QOL assessment was done using a self-designed questionnaire consisting of four domains: physical status, mental status, social interaction and self-perception of health. For statistical analysis of QOL, we used pairwise and independent samples t-test of QOLi-NS, that represents integral overall numerical value of QOL.

Results: See attached table.

Conclusions: QOL after myocardial revascularisation (1, 2, 3, 4, 5 years) was statistically significantly better than before operation, in both groups. There was no difference in QOL between patients with preoperative heart failure and those with EF > 30% during 5 year follow-up. These facts confirm benefit from myocardial revascularisation in coronary patients with preoperative heart failure. Table 8

APPLICABILITY OF EUROSCORE (EUROPEAN SYSTEM FOR CARDIAC OPERATIVE RISK EVALUATION) RISK SCORING SYSTEM IN TURKISH PATIENTS

Kaplan M., Kut M., Cimen S., Demirtas M.

Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey Cardiovascular Surgery

Objective: European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the scoring systems used to predict postoperative mortality before cardiac operations. We aimed to investigate applicability and adequacy of EuroSCORE in Turkish patient population.

Methods: We prospectively used EuroSCORE system for risk scoring in our consecutive cardiac surgery patients. A total of 320 patients (216 male, 104 female) with a mean age of 54.9 ± 12.6 were included. Coronary artery bypass grafting operation was done in 225 patients (Group 1) and 95 patients had valvular operations (Group 2). Patients were allocated to risk groups as follows: 179 low-risk patients (mean risk score: 0.99 ± 0.84), 115 intermediate-risk patients (mean risk score: 3.79 ± 0.79) and 26 high-risk patients (mean risk score: 6.58 ± 0.93).

Results: Predicted and actual mortality in all patients were 2.53 ± 1.63 and 3.75 (p=0376), respectively. Corresponding figures were as follows for specific risk groups: low-risk patients: 1.38% ± 0.24 and 1.67% (p= 1), intermediate-risk patients: 2.83% ± 0.80 and 4.35% (p=0.722), high-risk patients: 6.48% ± 1.55 and 15.38% (p=0.668). When risk scores were analyzed in terms of operation type, predicted and actual mortality were 2.51 ± 1.74 and 3.11 (p=1) for group 1 and 2.29 ± 1.64 and 5.26 (p=0.721) for group 2, respectively. Area under the curve of ‘Receiver Operating Characteristic’ was 0.767 in all patients, 0.749 in group 1 and

Conclusions: When predicted and actual mortality rates are analyzed, EuroSCORE scoring system seems to be an appropriate and easily applicable system for coronary artery bypass grafting and valvular operations in Turkish patient population.

RABAGO PRIZE

R1CORRELATION OF PANEL REACTIVE ANTIBODIES (PRA) OCCURRENCE WITH PERIOPERATIVE COURSE IN PATIENTS UNDERGOING ELECTIVE CARDIOSURGERY PROCEDURES

Maruszewski M., Zakliczynski M., Krynicka A., Zembala M.

Silesian Centre for Heart Disease Department of Cardiosurgery and Transplantology

Objective: Aim of the study was to assess correlation of PRA occurrence in patients undergoing elective cardiosurgery procedures with its influence on perioperative course.

Methods: Material and methods. Blood samples for PRA testing were obtained prior to operation in 24 subjects (20M/4F; 52.6±9.8 y/o) admitted for primary elective cardiosurgery procedure—CABG (n=15), CABG+valve implantation (n=2) or valve procedure (n=7). Pts. were divided according to PRA results performed after discharge from the hospital into: Group A (n=14) with PRA >1%, and Group B (n=10) with PRA 1%. None of results exceeded 10%. Frequency of PRA occurrence was characterized with comparison between study group and 38 pts. evaluated for heart transplantation at the same time.

Results: Frequency of PRA >1% occurrence was significantly higher in study group, when compared with heart transplant candidates (58 vs. 0%; p<0.00001). Procedure types were equally distributed between groups, as well as majority of analyzed pre- and perioperative factors. However, left ventricle ejection fraction was significantly lower in group B (54 vs. 42%; p=0.005). There was also a trend of higher catecholamines application in group B postoperatively (p=0.07). Despite this, Group A required over 1 day more of postoperative hospitalization (6.0 vs. 4.8 day, p=0.046) and was characterized by more arrhythmias (including atrial fibrillation 21 vs. 0% in Group B; p=0.08), higher blood products requirement and more re-interventions

Conclusions: Occurrence of PRA in patients undergoing elective cardiosurgery procedures is correlated with more perioperative complications, resulting in prolongation of hospital stay, despite lower indicators of heart sufficiency in PRA negative subjects.

R2

PERIVASCULAR APPLICATION OF SIROLIMUS ATTENUATES NEOINTIMAL HYPERPLASIA IN EXPERIMENTAL VEIN GRAFTS

Schachner T., Burnett C., Buckley H., Sheen A., Williams G., Bonatti J.

Innsbruck University Hospital Dept. of Cardiac Surgery; North Manchester General Hospital Department of Vascular Surgery; North Manchester General Hospital Department of Vascular Surgery; North Manchester General Hospital Department of Vascular Surgery; North Manchester General Hospital Department of Vascular Surgery; Innsbruck University Hospital Dept. of Cardiac Surgery

Objective: Sirolimus (Rapamycin) is an immunosuppressive agent which also exhibits marked antiproliferative properties. Sirolimus coated stents have been demonstrated to suppress restenosis in experimental and clinical studies of percutaneous coronary catheter intervention. We investigated whether Sirolimus can reduce neointima formation in a mouse model of vein graft disease.

Methods: C57BL6J mice underwent interposition of the inferior vena cava from isogenic donor mice into the common carotid artery using a previously described cuff technique. In the treatment group 100µg or 200µg of Sirolimus were applied locally in pluronic gel. The control group did not receive local treatment. Grafts were harvested at 1, 2, 4, and 6 weeks and underwent morphometric analysis as well as immunohistochemical analysis.

Results: In grafted veins without treatment (controls) median intimal thickness was 9.6 (6.4-29)µm, 11.9 (7.9-39.9)µm, 46.6 (12.4-57.7)µm and 57.5 (32.5-71.1)µm after 1, 2, 4 and 6 weeks respectively. Treatment with 100µg or 200µg Sirolimus showed a dose dependant reduction of intimal thickness. In the 200µg Sirolimus treatment group the intimal thickness was 4.3 (3.4-5.6)µm, 3.8 (3.2-6.3)µm, 17.1 (4.8-63)µm and 33.9 (11.3-80.3)µm after 1, 2, 4 and 6 weeks respectively. This difference of intimal thickness of 200µg treated animals compared with controls was statistically significant at 1 and 2 weeks. Immunohistochemically the reduction of intimal thickness was associated with a decreased amount of infiltration of CD-8 positive cells and a decreased amount of metallothionein positive cells in the Sirolimus treated grafts.

Conclusions: We conclude that perivascular application of Sirolimus inhibits neointimal hyperplasia of vein grafts in a mouse model. These results suggest that Sirolimus may have a therapeutic potential for the treatment of vein graft disease.

R3

FACTORS INFLUENCING THE EARLY POSTOPERATIVE PERIOD AFTER MODIFIED BLALOCK-TAUSSIG SHUNT IN PATIENTS WITH UNIVENTRICULAR PHYSIOLOGY

Nevvazhai T., Lubomudrov V., Mihailova E., Menshugin I.

Childrens hospital #1 cardiac surgery; Children's hospital #1 cardiac surgery; Children's hospital #1 cardiac surgery; Children's hospital #1 cardiac intensive care unit

Objective: Overall frequency of single ventricle (SV) variants are 7.7%, when expressed as a fraction of all congenital heart defects. About 70% of patients with SV have pulmonary stenosis (PS) as a component of heart malformation. The majority part of patients requires surgical intervention at early age because of high natural mortality within the first months of life. The modified Blalock-Taussig shunt remains most common infant/neonatal palliation for univentricular physiology. The aim of the study was to identify predictors for a poor outcome and complications in early postoperative period.

Methods: We retrospectively reviewed clinical records of 70 patients with functional SV and PS, who were palliated by modified Blalock-Taussig shunt alone between 1990 and 2002. The age, weight, pre- and postoperative values of oxygen saturation, the presence of heterotaxy syndrome, the preoperative prostaglandin E1 treatment, the pulmonary blood flow index (ratio of patient weight to shunt diameter) were studied. The influence of these factors on the duration of mechanical ventilation, duration of inotropic support ICU stay and outcome were studied.

Results: The patients had a median age was 47 days (1 day-9 years) and a median weight 3.9 kg (1.9-23 kg). The shunt ranged in size from 3 mm to 6 mm. Early postoperative mortality was 7.1%. The median duration of mechanical ventilation was 119 hours, median duration of inotropic support—76 hours and ICU stay—204 hours. The negative correlation between weight and duration of mechanical ventilation and ICU stay was found (p=0.015). All patient with heterotaxy syndrome and all receiving prostaglandin E1 before operation had longer stay in ICU, duration of mechanical ventilation and duration of inotropic support (p=0.001). It was found that patient with pulmonary blood flow index<100 had more complicated early postoperative period with significantly increased ICU stay time (p=0.03).

Conclusions: In our experience, heterotaxy syndrome, and preoperative ductus-dependent circulation with necessity of prostaglandin E1 administration were the factors of complicated early postoperative period. Excessive pulmonary blood flow can be estimated as another risk factor of difficult early postoperative period. Pulmonary blood flow index could be used as an indirect parameter reflecting the volume of pulmonary blood flow. Patients with the index < 100 had prolonged ICU stay, longer ventilation and inotropic support.

R4

EFFECT OF ROXYTHROMYCIN ON ARTERIAL VASOACTIVITY

Berman M.

Rabin Medical Center, Beilinson Campus Cardiothoracic surgery

Objective: Inflammatory disease can damage vascular functioning and advance atherosclerosis. Coronary events and a higher flow of the brachial artery have been reported in patients treated with macrolides. The aim was to determine the function of the macrolide, roxythromycin (RX) on arterial vasoactivity.

Methods: Vascular rings were obtained from human and rat internal mammary arteries (IMA), attached to a force transducer and immersed into organ chambers with oxygenated Krebs Henseleit (KH) solution. Vascular integrity in response to norepinephrine (NE), acetylcholine (ACh), sodium nitroprusside (SNP) was investigated. After restabilization, 10-6M NE, 10-7-10-4M RX, followed by 10-5M SNP, were added. The mechanism of RX action was tested in rats using solutions containing KH; KH+L-NAME, nitric oxide (NO) production inhibitor; KH+calcium ionophore (Ca); KH+indomethacin, a prostaglandin inhibitor; KH+glibenclamide; KH+5-Hydroxydecanoic acid, membrane and mitochondrial K channel inhibitors (10-6M

Results: IMA and rat aorta exhibited similar contraction and relaxation rates in response to NE, RX, and ACh. RX relaxation (4 to15%) was dose dependent and similar to ACh, lower than SNP. Relaxation was significantly reduced in the presence of Ca, L-NAME, 5-HD, (p<0.005). Glibenclamide and indomethacin had no effect on relaxation.

Conclusions: RX relaxation is mediated by calcium, mitochondrial K ATP channels and NO production. Thus, RX offers a therapeutic advantage, for coronary diseased patients needing macrolide treatment.

R5

INFLUENCE OF SILENT HERPES VIRAL INFECTIONS ON PERIOPERATIVE COURSE IN PATIENTS UNDERGOING ELECTIVE CARDIOSURGERY PROCEDURES

Maruszewski M., Krynicka A., Zakliczynski M., Zembala M.

Silesian Centre for Heart Disease Department of Cardiosurgery and Transplantology

Objective: Assessment of influence of silent Cytomegalovirus (CMV) and Ebstein-Barr virus infection on perioperative course in patients undergoing electve cardiosurgery procedures.

Methods: Blood samples for EBV and CMV testing were obtained before operation in 70 subjects admitted for primary elective cardiosurgery procedure. Pre- and perioperative risk factors (including EuroSCORE), procedure type and complications rate were analyzed. Patients were divided according to CMV and EBV results performed after discharge from the hospital into: Group A (n=51) with serological symptoms of active Herpes viral infection and Group B (n=19) with negative serological findings.

Results: Preoperative factors were equally distributed between groups. Surgical procedures were constituted of coronary operations in 74% (47% OPCAB) in group A and 84% (56% OPCAB) in group B. Perioperative course was complicated in 8 patients of group A and none of group B (p=0.07). Although insignificantly, more patients in group A developed arrhythmias, pulmonary hypertension and had to be reoperated due to hemorrhage than in group B. Group A required over 1 day more of postoperative hospitalization (5.1 vs. 6.3 day, p=0.002) and was characterized by larger blood products requirement (24% vs. 0%, p=0.03).

Conclusions: Occurrence of clinically silent Herpes viral (CMV and EBV) infections is correlated with more perioperative complications, resulting in prolongation of hospital stay and greater blood products requirement.

R6

EVALUATION OF INTRAPLEURAL PETHIDINE WITH AND WITHOUT BUPIVACAINE ON POSTOPERATIVE PAIN AFTER OPEN HEART SURGERY

Aghadavoudi O.

Chamran Hospital Cardiovascular Center Chamran Hospital

Objective: Pain impulses in thoracic surgery can result from many foci in the chest. No any unique technique has proved to be efficient in controlling postoperative pain. Intraarticular narcotics have been used but their efficacy in pleural space has not been documented. So considering many nerve endings in pleural space, this study was designed.

Methods: In a double blind clinical trial study, between January and May 2003, 90 ASA 2 & 3 patients undergoing open-heart surgery (CABG or valvular surgery) were randomized into four groups as intravenous pethidine (group 1), intrapleural pethidine (group 2), intrapleural pethidine and bupivacaine (group3) and intrapleural bupivacaine (group 4). At the end of surgery intrapleural catheter was placed and drugs were prescribed through it in these four groups. During the first 24 hours in the cardiac intensive care unit, narcotic requirements, pain scores according to visual analogue scale (VAS), homodynamic parameters and arterial Co2 pressure were registered. Collected data were analyzed by chi-square, Duncan and analysis of variance tests and p value< 0.05 was considered significant.

Results: There were significant differences among four groups according to narcotic requirements and VAS pain scores during the first 24 hours in the ICU. Pain score and narcotic requirements were less in group 3 and group 4 compared with group 1 and group 2.Other variables including arterial Co2 pressure were the same among four groups.

Conclusions: Although according to other studies using intraarticular narcotics reduces pain, intrapleural pethidine does not change pain scores or narcotic requirements in the cardiac ICU after open-heart surgery and using intrapleural bupivacaine is more effective and is recommended.

R7

EPIAORTIC SCANNING IN CABG SURGERY—RISK FACTORS OF ASCENDING AORTIC ATHEROSCLEROSIS

Schachner T., Burnett C., Buckley H., Sheen A., Williams G., Kacani A.

Innsbruck University Hospital Dept. of Cardiac Surgery; North Manchester General Hospital Department of Vascular Surgery; North Manchester General Hospital Department of Vascular Surgery; North Manchester General Hospital Department of Vascular Surgery; North Manchester General Hospital Department of Vascular Surgery; Innsbruck University Hospital Dept. of Cardiac Surgery

Objective: The indication for epiaortic scanning in coronary artery surgery is still a matter of debate. It is unclear whether this test should be carried out selectively or on a routine basis. The aim of this study was to find factors which predict the presence of atherosclerotic ascending aortic wall thickening in CABG patients.

Methods: 500 CABG patients underwent epiaortic scanning using a high frequency linear ultrasonic probe. Maximum ascending aortic wall thickness (MAAWT) was measured and correlated with patient related

Results: MAAWT significantly correlated with the following factors: age (rho=0.321, p < 0.001), preoperative creatinine level (rho=0.128, p=0.004), EURO score (rho=0.343, p<0.001), and maximum descending aortic wall thickness (rho=0.448, p<0.001) whereas BMI, and LVEF showed no correlation with MAAWT. From categorical variables hypertension, unstable angina, COPD, cerebrovascular disease, and peripheral vascular disease where associated with an increased MAAWT. Whereas male gender, diabetes mellitus, and redo-surgery showed no association with an increased MAAWT in our series.

Conclusions: If epiaortic scanning is not carried out on a routine basis for detection of ascending aortic atherosclerosis it would be useful to perform it in patients with old age, hypertension, unstable angina, COPD, CVD, PVD, elevated creatinine levels, higher risk in the EURO score, and increased wall thickness of the descending aorta.

R8

THE EFFECT OF AMIODARONE VERSUS PROPRANOLOL FOR PROPHYLAXIS OF ATRIAL FIBRILLATION AFTER CABG IN LOW EF PATIENTS

BIGDELIAN H., BIGDELIAN H., BEHDAD G., AGHADAVODI O., SAMI M.

Chamran Hospital Cardiovascular Center Chamran Hospital; ESFAHAN MEDICAL UNIVERSITY Cardiovascular Surgery; ESFAHAN MEDICAL UNIVERSITY Cardiovascular Surgery; Chamran Hospital Cardiovascular Center Chamran Hospital; Chamran Hospital Cardiovascular Center Chamran Hospital

Objective: Mortality rate after coronary artery by pass graft (CABG) surgery is about 1-3%, due to postoperative arrhythmias, hemorrhage, tamponade, infection, and ischemia. Atrial fibrillation (AF) is a common postoperative arrhythmia in patients undergoing CABG. Therefore physicians usually prescribe various drugs especially beta-blockers for prophylaxis of AF. Regarding the possibility of reducing cardiac output by these drugs in-patients with low Ejection Fraction (<35%), there is the need to study about the use

Methods: In one randomized double-blinded clinical trial study 130 patients undergoing CABG surgery (aged 40-75 y/o) were divided into two groups (A and B groups). Group A received 150 mg of intravenous amiodarone during 30 minutes immediately after the operation, and 150mg/6h up to 48 hours postoperatively and then followed with oral amiodarone 400-mg/12 h until discharge (6 day ordinarily). Patients in B group received Propranolol (Inderal) 10 mg/h after Extubation for six days. ECG monitoring was done continuously in the cardiac ICU and continually in surgery ward by taking complete ECG recording and any arrhythmia was recorded including AF.

Results: The AF incidence in-patients that had been received amiodarone for prophylaxis (group A) was 6.15% (4/65) and in another group (group B) that had been received propranolol was12.3% (8/65) (P>0.05).Seven patients out of 12 in which the AF occurred, had a risk factor and there was not any significant difference between the two groups (P>0.05). Postoperatively the incidence of low EF (EF<35%) was 15.4% (10/65) in amiodarone group versus 21.5% (14/65) in propranolol group (p>0.05).

Conclusions: According to AF incidence in both groups and regarding that amiodarone has less adverse effect in reducing EF, we can use amiodarone for postoperative prophylaxis of AF after CABG, as an alternative instead of propranolol, and in addition for controlling ventricular arrhythmias (PVC, VT).

R9

VIRTUAL REALITY SIMULATORS FOR CARDIAC SURGEONS. VALIDATION STUDY

Dalinin V., Dalinin V., Halvorsen F., Fosse E.

Institute of Thoracic surgery Moscow medical academy Cardiac surgery; Institute of Thracic surgery Moscow medical academy cardiac surgery; University of Oslo, University hospital; National Hospital Interventional center

Objective: Robotically assisted endoscopic procedures are associated with a definite learning curve. The standard way of gaining the necessary surgical technical skills has until recently been training in dry lab followed by animal experiences. VR-simulators surgical training was proposed few years ago and this form of training holds the potential of reducing the more expensive and ethical questionable use of animals in surgical training without compromising surgical outcome in the OR. Also VR-trainng could seriously decrease the cost of robotic related training procedures. The aim of the study was to determine if training robotically assisted suturing skills on the VR-simulator equals similar training in the dry lab.

Methods: Twenty-eight students attending the second to the final year of study from the University of Oslo, Faculty of Medicine, volunteered to participate in the study. The students had none minimal prior surgical experience. The students were randomly assigned to one of the two groups. All students received an initial theoretical introduction. It was used Zeus telemanipulator system and SimLap-Zeus VR-simulator. Both groups then underwent a pre- and post-test on an isolated pig heart. Group S then had three training sessions during two weeks using the simulator. Group D had three training sessions for the same period of time using the robot to place continues sutures on a rubberglove with premarked dots. The same evaluation critereas were

Results: The results from the pre-test showed no statistical significant difference between the two groups, the same being true for the post-test results. When comparing the post-test to the pre-test the, results showed a significant improvement for both group S and group D. The learning curve assessed during training examination showed a closer proximity to the learning curve assessed by the pre- and post-test for group S than for group D, when concerning the rate of improvement, since the difference between the third training examination is different than the results of the post-test in group D.

Conclusions: The main finding of our study is that training robotically assisted anastomosis suturing using VR-simulator without additional training equals training in dry lab, and that VR training can replace the standard way of training during the early part of training. Similar results also apply to more experienced surgeons, or if VR-training equals the standard way of training only in novice surgeons, require further studies. VR-simulators could be used for more complicated procedures.

R10

INCREASED RISK OF SURGICAL COMPLICATIONS IN PATIENTS RECEIVING RAPAMYCIN BEFORE OR IMMEDIATELY AFTER HEART TRANSPLANTATION

Maruszewski M., Zakliczynski M., Przybylski R., Wojarski J., Zembala M.

Silesian Centre for Heart Disease Department of Cardiosurgery and Transplantology

Objective: Rapamycin (RAPA) can impair wound healing. Our goal was to assess an influence of RAPA given before or immediately after transplantation on surgical complications in heart transplant recipients.

Methods: Study group I consisted of 20 male heart recipients receiving 15mg of RAPA before operation, 10mg of RAPA at the 1st day after procedure and than 5mg daily till the introduction of cyclosporine-A (CyA). Study group II consisted of 8 pts. (6M, 2F) receiving RAPA (5mg daily) from the 2nd day after transplantation because of poor renal function. Control group was composed of 22 pts. (20M, 2F) receiving CyA. We compared number of re-ops, volume of drainage and blood products use among groups.

Results: Average age was 50.7 in study group I, 45.5 I study group II and 45.0 in control group. Number of pts requiring re-operation was 11 (55%), 5 (63%) and 8 (36%) in study I, II and control groups, respectively. Number of pts. requiring tamponade decompression was 5 (25%), 2 (25%) and 1 (5%). Number of pts. treated for sternum instability was 5 (25%), 2 (25%) and 2 (9%). None of pts. presented signs of wound infection. Volume of drainage was 4158, 4352 and 2511 mL, respectively. Blood products use was the highest in study group I with 8.25 units of red cell concentrate, and 5.5 units of fresh frozen plasma per pt, comparing with 6.75 and 2.4 units respectively for study group II, and 4.8 and 3.0 units for control group. Frequency of biopsy-proven rejection was comparable among groups. Occurrence of infection was similar in all groups, except CMV which was less frequent in pts receiving RAPA.

Conclusions: A possibility that RAPA given before, or immediately after heart transplantation, can increase the risk of surgical complications should be strongly considered.

CARDIAC SYMPOSIUM

CS.1

DEATH RECEPTOR MEDIATED APOPTOTIC PATHWAY IS ACTIVATED IN THE TRANSITION TO PRESSURE OVERLOAD INDUCED HEART FAILURE

Moorjani N., Catarino P., Al-Ahmed S., Trabzuni D., Meyer B., Al-Mohanna F., Ahmad M., Westaby S.

Oxford Heart Centre Department of Cardiothoracic Surgery; Oxford Heart Centre Department of Cardiothoracic Surgery; King Faisal Specialist Hospital & Research Centre Department of Biological and Medical Research

Objective: Cardiomyocyte apoptosis is implicated in the pathogenesis of heart failure and the death receptor mediated pathway plays an important role in this mode of cell death. Binding of death ligands to their cognate cell surface receptors (including Fas) induce a series of intracellular conformation changes triggering cleavage of initiator and effector caspases-3 & 8, resulting in DNA fragmentation. In this study, activity of this apoptotic pathway was assessed during the transition to heart failure.

Methods: Ten adult male sheep were banded with a variable aortic constriction device. This was progressively inflated to increase left ventricular (LV) afterload. The sheep were monitored echocardiographically, measuring LV Mass Index (LVMI), diastolic LV Internal Diameter (LVIDd) and Fractional Shortening (FS). Serial LV endomyocardial biopsies were obtained to measure expression of Fas by Reverse Transcription Polymerase Chain Reaction (RT-PCR). Activity of caspases-3 & 8 were also measured using specific fluorogenic peptide substrates analysed in a spectrofluorometer at 400 nm excitation and 505 nm emission

Results: Over the first 3-4 weeks, the sheep developed hypertrophy (LVMI 79.5±4.6 vs. 44.0±3.0g/m2, p<0.01), followed by gradual LV dilatation (LVIDd 4.23±0.08 vs. 3.39±0.07 cm, p<0.01). Ventricular function remained stable until 7-8 weeks post banding, when there was significant deterioration (FS 18.3±2.4 vs. 46.9 ±2.6%, p<0.01), associated with clinical heart failure. Biopsies taken at these echocardiographically distinct stages (LV hypertrophy, LV dilatation and LV failure), during the transition to heart failure, were then compared to biopsies taken prior to the operative procedure. Upregulation of Fas expression was demonstrated in the LV hypertrophy and LV failure groups (1.43±0.07 and 1.62±0.17 vs. 1.00±0.13, p<0.05, respectively, see graph). Increased activity of death receptor-triggered caspases 3 & 8 was also observed in the transition to heart failure, particularly with the onset of myocardial dysfunction (caspase-3 791.5±118.8 vs. 100.0±1.5 and caspase-8 194.5±21.1 vs. 100.0±3.6 relative fluorescent units, p<0.05, see graph).

Conclusions: Upregulation of the death receptor mediated apoptotic pathway occurs during the transition to heart failure. These changes were most marked in the left ventricular failure group and are thought to be triggered by increased diastolic wall stress, causing stretch induced activation of this pathway. Further knowledge of these molecular mechanisms may stimulate development of anti-apoptotic therapies to delay progression of heart failure.

CS.2

RESVERATROL, A NATURAL ANTIOXIDANT AGENT PRESENT IN WINE, REDUCES PROINFLAMMATORY CYTOKINE EXPRESSION IN A MOUSE LUNG ISCHEMIA-REPERFUSION MODEL

Kaplan S., Bisleri G., A. Morgan J., H. Cheema F., W. Vigilance D., Liao H., J. Pinsky D., C. Oz M.

College of Physicians and Surgeons, Columbia University Division of Cardiothoracic Surgery; College of Physicians and Surgeons, Columbia University Department of Medicine; College of Physicians and Surgeons, Columbia University Division of Cardiothoracic Surgery

Objective: Ischemia/reperfusion injury still represents a major issue in heart-lung transplation. Aim of this study was to investigate the potential protective effect of resveratrol, a natural antioxidant agent present in wine, on the expression of proinflammatory cytokines and leukocyte activity in a mouse lung

Methods: Twenty-four mice were assigned to three groups of 8 animals each receiving high-dose resveratrol (1000 µg/kg, group A), low-dose resveratrol (100 µg/kg, group B), or intravenous saline (group C) respectively. All animals were given 0.15 cc saline containing resveratrol (Sigma Chemical Co., St. Louis, MO, USA) or saline alone through the penile vein. Fifteen minutes later, the left pulmonary hilum was transiently cross-clamped for 30 minutes. Following a 2-hour period of reperfusion, blood samples were collected from the right atrium and the left lung was excised. Serum level of several cytokines, including interleukin-1a (IL-1a), interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor-a (TNF-a) were measured by ELISA. Myeloperoxidase activity was also measured from the lung tissue samples, in order to evaluate the effect of resveratrol in the activation of recruited leukocytes.

Results: IL-1a, IL-6, IL-10 and TNF-a expression was significantly reduced in both groups, group A and group B, receiving resveratrol before ischemia/reperfusion injury when compared with group C (receiving intravenous saline): IL-1a was 1.70±0.48 pg/mL in group A, 1.51±0.44 pg/mL in group B and 4.93±1.77 pg/mL in group C (p<0.001, ANOVA); IL-6 was 1.25±0.59 pg/mL in group A, 1.75±1.08 pg/mL in group B and 4.40±1.22 pg/mL in group C (p<0.001, ANOVA); IL-10 was 31.75±7.09 pg/mL in group A, 39.87±8.14 pg/mL in group B and 56.49±16.24 pg/mL in group C (p<0.001, ANOVA); TNF-a was 2.24±1.04 pg/mL in group A, 2.48±1.29 pg/mL in group B, 7.27±2.25 pg/mL in group C (p<0.001, ANOVA). Additionally, myeloperoxidase activity in groups A and B was consistently decreased when compared with group C (group A=1.68±0.47 nm/min, group B=2.13±0.72 nm/min, group C=3.75±0.78 nm/min; p<0.001, ANOVA).

Conclusions: Resveratrol was effective in reducing the production of proinflammatory cytokines and lung tissue neutrophil infiltration in an experimental model of lung ischemia/reperfusion injury. Despite further studies are required for its validation, the use of resveratrol may provide a new therapeutic option to improve organ function in the setting of a lung ischemia/reperfusion injury.

CS.3

ASCENDING AORTA REPLACEMENT COMBINED TO AORTIC ARCH STENT POSITIONING FOR TYPE A ACUTE AORTIC DISSECTION: AN ENDOSCOPIC VIEW

Saccani S., Borrello B., Agostinelli A., Spaggiari I., Fragnito C., Budillon A., Beghi C., Gherli T.

Ospedale Maggiore of Parma Cardiac Surgery; University of Parma Cardiac Surgery; University of Parma Cardiac Surgery; Ospedale Maggiore Cardiac Surgery; Ospedale Maggiore Cardiac Surgery; University of Parma Cardiac Surgery; University of Parma Cardiac Surgery; University of Parma

Objective: Surgical treatment of Type acute aortic dissection is still debated. While in consideration of the high risks connected to emergent aortic arch replacement traditional intervention has always been ascending aorta replacement, more recently some authors advocate emergency total replacement of aortic arch as the best option to prevent later complications and death.

Methods: We report two cases of Type A aortic dissection with primary entry tear located in ascending aorta in which a traditional ascending aorta replacement was combined to a new open web stent placement in aortic arch. Procedure was performed during moderate hypothermic circulatory arrest and cerebral perfusion. This new device (Djumbodis dissection system Saint Come-Chirurgie; Marseille, France), consists of an open web stent mounted on a compliant balloon. It was inserted under direct vision in the aortic arch and inflated till the internal and external layer of the aortic wall well coapted. Correct opening and positioning of the stent was verified with TEE and for the first time through a 7 mm endoscope inserted within the aortic arch.

Results: Patients were both discharged on post-operative day 7 and CT scan before dimission showed in both cases the occlusion of the false lumen in the aortic arch.

Conclusions: In all cases of acute Type A aortic Dissection with intimal tear in ascending aorta, replacement of the ascending aorta combined to insertion of the Djumbodis dissection system can be a valid option to extend treatment to the aortic arch with an easily reproducible and safe procedure in order to prevent later complications.

CS.4

CRYOPRESERVATION DOES NOT ADVERSELY AFFECT THE BIOCHEMICAL AND MECHANICAL PROPERTIES OF PORCINE AORTIC VALVE MATRICES

Narine K., Claeys E., Cornelissen M., Beele H., Vanlangenhove L., Vandekerckhove M., Sandra K.,Van Nooten G.

University Hospital Ghent Cardiac Surgery

Objective: Readily available scaffolds of consistent quality for cell seeding are necessary in tissue valve engineering. We examined the biochemical and mechanical effects of cryopreserving porcine aortic valve matrices.

Methods: Matrices prepared according to a modified enzymatic decellularisation protocol were examined before and after up to six monthe of cryopreservation. Collagen content was determined by a hydroxyproline assay. Uronic acid (proteoglycan) content was estimated chemically and by capillary electrophoresis. Mechanical properties were determined by tensile measurements using a computerised texture analyser. Histological and ultrastructural examinations were by light and electron microscopy.

Results: Collagen content before and after cryopreservation in aortic wall was 14.4% and 25.7%, and in aortic leaflets 42.9% and 78.2% respectively. Uronic acid content was uninfluenced by cryopreservation (aortic wall: 1.78 vs. 2.15 µg/mg with p=0.283 and aortic leaflets: 6.96 vs. 6.72 µg/mg with p=0.865). The average tensile strength before and after cryopreseration was 37.1 and 33.3 Newton (N) respectively (p=0.334). For leaflets the corresponding values were 19.8 and 21.1 N (p=0.647). The extensibility as depicted on the stress strain curve, a reflection of the elastic modulus, of both aortic wall and leaflet tissue was increased after cryopreservation. Histological and ultrastructural sections confirmed the structural integrity of both aortic wall and leaflet matrices before and after cryopreservation.

Conclusions: Cryopreservation does not adversely affect porcine aortic valve matrices. Increased elastic modulus after cryopreservation might imply improved matrix durability. Cryopreserved porcine aortic valve matrices can ensure readily available scaffolds of various sizes and reliable quality for tissue valve engineering.

CS.5

DAMAGES OF CRIOPRESERVATION ON AORTIC VALVE GLYCOSAMINOGLYCANS: THE ULTRASTRUCTURAL BASIS OF ALLOGRAFT MECHANICAL DEGENERATION

Dainese L., Barili F., Magee M., Porqueddu M., Pompilio G., Kunkl A., Polvani G., Biglioli P.

Centro Cardiologico Monzino, University of Milan Department of Cardiovascular surgery; Centro Cardiologico Monzino, University of Milan Department of Cardiac Surgery

Objective: The pathophysiology of allograft failure is far to be completely clarified. Recent studies pointed out the role of damaged extracellular matrix in rapid degeneration of allograft valves. We hypothesized that GAGs content can be altered by cryopreservation, according to the different stresses area and cusp's position. The present investigation was undertaken to evaluate glycosaminoglycans content in three different cuspal areas cryopreserved with leaflets on diastolic or systolic position.

Methods: Twenty-one aortic porcine valves were harvested. Five were immediately analysed. Sixteen were placed in a small containers with a low dose of antibiotic solution for 24 hours at 4 °C. Eight aortic valves were placed in closed position and eight in open position using a prolene 6-0 stiches in Hemofreeze Bag with cryopreservation solution; than were cryopreserved in a programmed freezer that lowered the temperature± 1 °C per minute down to -80 °C. Finally the valve is maintained in liquid nitrogen vapours (-196 °C). After 48 hours of storage, the specimens were thawed rinsed, deprived of adventitia layer and analysed. Aortic wall, leaflet flexion zone and leaflet were cut separately and processed. The methodology used for isolation and characterization of GAG includes delipidation, proteolytic digestion, anion-exchange chromatography, ethanol precipitation and acetate cellulose electrophoresis.

Results: We pointed out a significant GAG decrease at leaflet flexion zone in diastolic position after cryopreservation (2.396+0.47 µg hexuronate/mg DDT in open position, 1.671+0.34 hexuronate/mg DDT in closed position, p=0.03).

Conclusions: We revealed a relationship between GAG degeneration during cryopreservation and stresses distributions on aortic leaflets. In contrast with previous reports, we pointed out a decrease in GAGs content at leaflet insertion, also at thawing before implantation. It can represent the ultrastructural basis of allograft mechanical degeneration.

CS.6

THE INTRAOPERATIVE EFFECTS OF PENTOXIFYLLINE ON PLATELET FUNCTIONS OF CARDIAC SURGERY PATIENS UNDERGOING CARDIOPULMONARY BYPASS

Kagli K., Kunt A., Emir M., Bakuy V., Ulas M., Korkmaz K., Sener E., Pac M.

TURKIYE YUKSEK IHTISAS HOSPITAL DEPARTMENT OF CARDIOVASCULAR SURGERY

Objective: The catastrophic effects of cardiopulmonary bypass (CPB) mediated extensive endothelial cell damage is known as Systematic Inflammatory Response Syndrome (SIRS). After the initiation of CPB, blood comes into contact with the various biomaterials of the perfusion circuit. This contact activates coagulation, complement, fibrinolytic, plasma protein systems and stimulates cells of blood like platelets, neutrophils, monocytes, and lymphocytes. In addition to inflammatory response, activation of blood cells causes major CPB complications; bleeding, thromboembolism, massive edema, multiple organ failure. The aim of this study is to observe the effects of pentoxifyilline on platelet functions of patient going coronary artery surgery under cardiopulmonary bypass.

Methods: Forty patients going coronary artery surgery under cardiopulmonary bypass were included in this prospective study between April 2001 and June 2001 in Türkiye Yüksek htisas Hospital, Cardiovascular Surgery Department. The first blood samples were taken after induction of anesthesia and just before skin incision. Randomly selected twenty patients, forming the study group received 200 milligrams of pentoxifylline in 500 ml 0.9% NaCl and infused at 180 minutes intravenously. And also 100 mg dose of pentoxifylline was added to warm cardioplegic solution. The control group of 20 patients, 500 ml 0.9%NaCl was given as placebo and pentoxifylline was never administered. The other blood samples were taken on the 30th minute after weaning of CPB, 2-6th hours and 18-24th hours of postoperative period.

Results: In both groups the only statistically significant difference of platelet functions and Platelet Factor-4 (PF4) levels were observed on 18-24th hours of postoperative period. Also the increase in PF4 levels was found less in the study group than the control group and return to normal values rapidly.

Conclusions: Large study groups are needed to demonstrate the protective effects of pentoxifylline on platelet functions. We believe that oral or intravenous administration of pentoxifylline before the operation prevents the negative outcomes of anesthesia and insertion of invasive catheters (central venous line, arterial line vs.) and also after admission to the ICU this medication can be carried out. Therefore pentoxifylline can be used routinely for patients having low platelet counts and functions, risk factors for postoperative bleeding and prolonged CPB time.

CS.7

TOTAL ARTERIAL REVASCULARISATION IN PATIENTS WITH END-STAGE HEART FAILURE

MItrev Z., Anguseva T., Petrovski V., Vasileva A., Ampova V.

Special Hospital fro Cardiosurgery "Fillip II" cardiosurgery and intensive care

Objective: Patients with terminal coronary arthery disease(TCAD) in time developed ischemic dilative cardiomyopathy(ICD) and left ventricle aneurysm. The radial artery (RA) has been used extensively by us as a way of reducing the use of the saphenous vein. Flow in arterial grafts, in patients with TCAD, is adapted according to myocardial need for oxygen. The aim of this study was to determine survival and outcome in a patients with a TCAD, after total arterial revascularisation(TAR) and left ventricular(LV) reconstruction.

Methods: From 08/2001-09/2003, 91pts with TCAD(NYHA classIV) underwent (TAR) and LV reconstruction. After preparation of left internal mammary(LIMA) as a main graft, and patient full heparinisation, radial artery(RA) was connected in LIMA's middle parts as a "T" graft. Than we started with extracorporeal circulation, LV aneurysm is resected, after which LIMA is anastomozed with LAD, and RA with other arterias in a jump fashion.We compared preoperative and postoperative echocardiographic, radioisotopic ventriculogrphy, haemodynamic data and coronarographic findings.

Results: Left internal mammary artery (IMA) was used at 91(100%), right IMA in 17(18.6%), left radial artery as a T graft to LIMA in 61(67%)pts, as a T-T anastomosis to RIMA in 1patient and as a free graft in21(23.5%).Postoperative echocardiographia and hemodynamic improvemenmt was notified in all patients: EDV/ESV decreased for 40%/37.5%, EF increased from 20%on35%.(confirmed with radionuclid viability assessment after 6 months). 35(41.2%)pts get mitral and tricuspid annuli reconstruction. Early mortality rate was 6.6%.Control coronarographia showed better arterial graft flow, and increased diameter of RA, compared with preoperatively.

Conclusions: TAR in combination with LV surgical reconstruction in patients with TCAD ensuring better myocardial flow according on myocardial demand, results with better clinical outcome. Good early angiographic results have been achieved by using radial artery in coronary surgery. Early and mid-term results are acceptable to choose this method as an alternative to transplantation.

CS.8

GRAFT VESSEL DISEASE IS AN OVERSHOOT OF A NORMAL TRANSPLANT-ASSOCIATED VASCULAR ACTIVATION—A HISTOMORPHOMETRIC STUDY IN TRANSPLANTED HEARTS

Hiemann N., Hetzer R., Meyer R., Wellnhofer E.

Deutsches Herzzentrum Berlin Cardiothoracic and Vascular Surgery

Objective: Limited endothelial activation and smooth muscle cell proliferation may reflect a physiological reaction to immunologic challenge in transplanted hearts. Graft vessel disease is hypothesized to be a failure of regulation and limitation of this process.

Methods: We evaluated right ventricular endomyocardial biopsies from 41 heart transplant patients (n=272) and 38 non-transplanted hearts (n=38) that were refused for transplantation. Graft vessel disease was present (angiography) in 15 of 41 HTx patients (n=99 biopsies). Coronary artery disease was found in 17 non-transplanted hearts (n=17 biopsies). These biopsies were stained for H&E and immunohistochemical reactions were performed with alphy-actin (smooth muscle cells), CD31 (glycoprotein on endothelial cells) and Factor VIII (von Willebrand factor, marker for endothelial injury).

Results: All transplanted hearts showed more alpha-actin- and Factor VIII-positive blood vessels (p<0.01) and fewer CD31-positive blood vessels than non-transplanted hearts (p<0.05). The number of alpha-actin-, Factor VIII- and CD31-positive blood vessels did not differ in non-transplanted hearts with and without coronary artery disease. Transplanted hearts with graft vessel disease had more alpha-actin- and Factor VIII-positive blood vessels than transplanted hearts without graft vessel disease (p<0.01).

Conclusions: Proliferation of vascular smooth muscle cells and endothelial injury occur in all patients after heart transplantation. Graft vessel disease reflects an overshoot of a physiological reaction to immunologic challenge.

CS.9

FROM MINIMALLY INVASIVE TO TOTALLY ENDOSCOPIC CLOSURE OF ATRIAL SEPTAL DEFECTS

Schachner T.

Innsbruck University Hospital Dept. of Cardiac Surgery

Objective: Remote access perfusion and robotics have enabled totally endoscopic closure of atrial septal defects (ASD) or patent foramen ovale (PFO). We report on a stepwise approach towards a totally endoscopic

Methods: 17 patients (2 male, 15 female), age 38 (21-55) years underwent limited access ASD or PFO closure. As a preparative step the operation was carried out through minithoracotomy in 11 patients. Remote access perfusion was performed using the ESTECHTM RAP cannula. 6 patients were operated in a totally endoscopic fashion using the daVinciTM telemanipulator.

Results: In the endoscopic approach significant learning curves were noted for cardiopulmonary bypass time y(min)=225.5-41.2 * ln(x) (p=0.011) and aortic cross clamp time y(min)=133.5-41.5* ln(x) (p=0.039) (x=procedure number). There was no hospital mortality and no residual shunts were detected in the postoperative echocardiography. Ventilation time was 8h (0-19) for the minithoracotomy group and 6h (4-19) for the totally endoscopic group. ICU stay was 20h (18-24) and 18h (18-120) respectively.

Conclusions: Totally endoscopic closure of ASD or PFO can be safely implemented into a heart surgery program. An intermediate step performing the operations through minithoracotomy and adapting to remote access perfusion systems seems worthwhile. Learning curves are steep and adequate defect closure can be achieved by the totally endoscopic approach.

CS.10

HIGH RISK OF CARDIAC SURGERY IN THE PRESENCE OF PREOPERATIVE RENAL FAILURE

Devbhandari M., Raco L., Au J., Duncan A.

Blackpool Vitoria Hospital Cardiothoracic Surgery; Blackpool Vitoria Hospital Cardiothoracic Surgery; Blackpool Vitoria Hospital Cardiothoracic Surgery; Blackpool Vitoria Hospital

Objective: Renal failure is an important risk factor for cardiac surgery, although elevations in creatinine >200mmol/l and dialysis dependency attract only modest risk weighting. The objective of this study is to quantify the real impact of renal failure on clinical outcome after cardiac surgery.

Methods: Data was prospectively collected from 4 regional cardiac centers in the northwest of England for a 3-year period. Patients were divided into three groups on the type of operation: CABG, AVR, AVR+CABG. They were further subdivided on the degree of renal failure present; none [creatinine 0-199mmol/l], renal failure [creatinine greater than 200mmol/l but not dialysis dependent] and dialysis dependency.

Results: The mortality for CABG patients with no renal failure (n=9201) was 2.6%. This was significantly [p<0.05] lower than the mortality of 9.2% and 14.5% in renal failure group (n=142) and dialysis group (n=48) respectively. The mortality for AVR in patients with no renal failure (n=968) was 3.6%. This was significantly [p<0.001] lower than the mortalities of 21% and 20% in patients with renal failure (n=19) and dialysis dependency (n=5) respectively. The mortality for AVR+CABG in patients with no renal failure (n=658) was 4.9%. This was significantly [p<0.001] lower than the mortalities of 41.2% and 26.7% for those with renal failure (n=17) and dialysis dependency (n=7). Postoperative hospital stay and ITU stay were significantly longer in the presence of renal failure irrespective of the need for dialysis.

Conclusions: Renal failure and dialysis dependency are both associated with poor outcomes in patients undergoing CABG, AVR or AVR+CABG surgery.

CS.11

NEW TECHNOLOGIES IN THE TREATMENT OF TYPE A ACUTE AORTIC DISSECTION: OUR EXPERIENCE IN THE USE OF THE DJUMBODIS DISSECTION SYSTEM

Saccani S., Agostinelli A., Borrello B., Fragnito C., Zoffoli G., Colli A., Beghi C., Gherli T.

Ospedale Maggiore of Parma Cardiac Surgery; University of Parma Cardiac Surgery; University of Parma Cardiac Surgery; Ospedale Maggiore Cardiac Surgery; University of Parma Cardiac Surgery; University of Parma Cardiac Surgery; University of Parma Cardiac Surgery; University of Parma

Objective: The aim of this study is to report an initial experience with aortic arch stenting in type A acute dissection.

Methods: Between January and December 2003 10 patients, mean age 56.8 years, were operated for type A acute aortic dissection; in 7 patients the entry tear was in ascending aorta and in 3 in aortic arch. All were submitted to ascending aortic prosthetic replacement and stenting of the aortic arch with open web Djumbodis Dissection System stent (Saint Come, Marseille, France) during hypothermic ECC. The device consists of an uncovered stent made of Steel 316 L, provided in three lengths (4, 9, and 14 cm) and mounted on a compliant balloon. The balloon is inflated to adapt the stent to the shape of the aortic arch and to coapt aortic layers. The deployed device presents a large-meshed wet and can be superimposed at the origin of epiaortic vessels without any danger of obstruction. Mean extracorporeal circulation time was 173 minutes with a total circulatory arrest time ranging from 17 to 54 minutes.

Results: Three patients died within 30 days, respectively for myocardial infarction, bowel infarction and stroke. Complete thrombosis of false channel was obtained in 3 patients, incomplete deployment of distal end of the web occurred in 1 patient without symptoms and another patient required reoperation for proximal leakage. At two and nine months follow up two patients required transfemoral thoracic aorta endovascular stent-grafting for residual type B dissection.

Conclusions: Initial experience attests the feasibility of aortic arch stenting with Djumbodis Dissection System. It appears a useful procedure mainly in high-risk situations such as elderly patients with comorbidities in which aortic arch replacement has a prohibitive surgical risk. Djumbodis Dissection System has also facilitated distal aortic procedures permitting a safe proximal landing zone for deployment of thoracic aortic stent grafts.

CS.12

PREDICTING MORTALITY IN HIGH RISK PATIENTS: LIMITATIONS OF THE ADDITIVE AND LOGISTIC EUROSCORE MODELS COMPARED TO A LOCALLY DERIVED MODEL

Lu J., GARYSON A., JACKSON M., RASHID A., Au J., GROTTE G., BRIDGEWATER B.

The Cardiothoracic Centre NHS Trust Cardiothoracic Surgery; THE CARDIOTHORACIC CENTRE NHS TRUST CARDIOTHORACIC SURGERY; The Cardiothoracic Centre NHS Trust Cardiothoracic Surgery; The Cardiothoracic Centre NHS Trust Cardiothoracic Surgery; BLACKPOOL VICTORIA INFIRMARY NHS TRUST CARDIOTHORACIC SURGERY; MANCHESTER ROYAL INFIRMARY NHS TRUST CARDIOTHORACIC SURGERY; WYTHENSHAWE HOSPITAL NHS TRUST CARDIOTHORACIC SURGERY

Objective: High-risk patients comprise about 15% of total cardiac surgical practice, but 50% of observed mortality is seen in this group. We studied the predictive ability of the EuroSCORE to predict mortality in high-risk patients, compared to a locally derived model.

Methods: Data was prospectively collected for 7,670 consecutive high-risk patients from all 4 centres providing adult cardiac surgery in the north-west of England between April 1997 and March 2003. High-risk patients defined as any cardiac operation with greater than 5% predicted risk of death, according to the additive EuroSCORE tool. Predictive abilities of the additive EuroSCORE and logistic EuroSCORE were compared with actual mortality rates. Logistic regression was used to investigate the influence of various risk factors on mortality for this population. The area under the receiver operating characteristic (ROC) curve was calculated to assess the performance of all models.

Results: In-hospital mortality was 8.2% (n=631). Predicted mortality by additive and logistic EuroSCORE were 7.9% and 12.8%, respectively. The ROC curve for additive and logistic Euroscore were both 0.70. Additive EuroSCORE under predicted observed mortality for patients with a score of 10 or more. Logistic EuroSCORE significantly over predicted observed mortality. The ROC curve for a locally derived logistic model was 0.74.

Comparison of Prediction Tool Table 15

CARDIAC: POSTER—MINIPRESENTATION 1

CORONARY

CPmp1.1

OFF-PUMP CORONARY ARTERY BYPASS SURGERY IN PATIENTS HAVING SECONDARY PATHOLOGIES

Ozsoyler I., Bozok S., Yilik L., Kestelli M., Özbek C., Gürbüz A.

Atatürk Education and Research Hospital Cardiovascular Surgery

Objective: Off-pump coronary artery bypass (OPCAB) surgery had nearly become a routine procedure in some of the clinics whereas most of the clinics had designed their own indications. OPCAB surgery can decrease the complication incidence in the patients who have poor renal function or severe chronic obstructive lung disease (COLD), in the patients who cannot put up with immune suppression (Malignancies etc.), and in the patients whose central nervous system had been affected or may be affected. We are introducing in this study the patients to whom we applied OPCAB surgery with these indications.

Methods: OPCAB surgery is routinely used in our clinic for the patients who have isolated left anterior descending artery lesions or additional right coronary artery lesions, without circumflex artery lesions. In addition to this, OPCAB surgery was applied to 17 of the 19 patients who had been in chronic dialysis program or who had been in close follow-up by the nephrologists for their poor renal function, to 8 of the 11 patients who had severe COLD, to all of the 10 patients who had malignancies (Gastric cancer: 2 patients, colon cancer: 2 patients, breast cancer: 2 patients, urinary bladder cancer: 3 patients, central nervous system cancer: 1 patient), and to 2 patients who had a recent stroke history. Off-pump full revascularization was applied to all of the patients by the help of some cardiac stabilizers (Octopus and/or Starfish). OPCAB surgery could not be applied to 5 of the patients because of technical difficulties (Like diffuse calcification or

Results: No mortality or morbidity after OPCAB surgery had been met due to any cardiac originated condition or coexisting other pathology.

Conclusions: Cardiopulmonary bypass adversely affects the physiology of a patient in many ways. OPCAB surgery decreases the mortality and morbidity in the patients who have poor renal function, COLD, malignancy and in the patients whose central nervous system are under risk.

CPmp1.2

REUSING THE OCTOPUS TISSUE STABILISER AND THE STARFISH APICAL FIXATION DEVICE

Pieris R., Basnayake S., Govil A.

Apollo Hospital Cardiothoracic Surgery; Apollo Hospital Cardiac Surgery; Apollo Hospital Cardiac

Objective: Due to economic we are forced to re-use the Octopus and Starfish. We present a prospective observational study to examine whether it is feasible and safe to re use these

Methods: 82 patients who had beating heart CABG by a single surgeon in a new Cardiac Surgical unit, from September 2002 to September 2003 were included in this study. The Octopus and Starfish were numbered and details about each use were catalogued. 9 Octopus instruments were used for all the above surgeries with an average use of 9.78 times per Octopus. Minor repairs were carried out 7 times; 0.77 average 6 Starfish instruments were used with an average use of 14 times use per Starfish Minor repairs were carried out 13 times; 2.17 average

Results: 87.8% of cases were done Off pump with re-use of instruments. Our bacteriological screens have all come negative. We have not had any unexplained or post operative problems. There were no acute infarctions in the group. There was no readmission for angina. Vast majority of our patients have shown improvement of Ejection fraction. Mortality rate was 2.44%

Conclusions: In our setting, re-using the Octopus and Starfish is both feasible and safe.

CPmp1.3

THE MAMMARY LOOP TECHNIQUE AND ITS APPLICATIONS

Stoica L., CHOCRON S., FALCOZ P., KAILI D., ETIEVENT J.

Jean Minjoz Hospital Department of Thoracic and Cardiovascular Surgery

Objective: To present the technique of the mammary loop which allows complex coronary by-pass with the mammary arteries.

Methods: The distal end of the skeletonized left internal thoracic artery (LITA) is anastomosed to its proximal part to form a loop. The loop is cut open at the desirable level just before the coronary anastomosis. This enable accurate measurement of the length of the two branches. The final result is an adjustable Y graft made just with LITA.

Results: The loop technique allows to by-pass the left anterior descending (LAD) artery and the diagonal artery or the intermediate branch when the coronary topography is inappropriate for a sequential by-pass. The mammary loop technique can also be used to simplify the construction of a graft. First we perform a Y graft with the two skeletonized ITAs. A loop is made by anastomosing the end of the LITA on itself or on the RITA. When the loop is cut open we obtain a graft. We expose the variants of this technique which can be adapted to each case. We used this technique in 20 patients. Post-operative angiographies have shown no adverse effect on blood flow in the reversed portion of the ITA

Conclusions: The mammary loop is a simple technique that allows to develop complex arterial grafting constructions for on-pump or off-pump coronary surgery.

CPmp1.4

MYOCARDIAL REVASCULARISATION IN HIGH RISK CORONARY PATIENTS

RADOVANOVIC N., Mihajlovic B., Nicin S., Jonjev Z., Kovacevic P., Fabri M.

INSTITUTE OF CARDIOVASCULAR DISEASE UNIVERSITY CLINIC OF CARDIOVASCULAR SURGERY

Objective: Coronary surgery in patients with low ejection fraction (EF) 30% and poor distal coronary bed, still remains of special interest because of high operative risk. Many of these patients are considered as candidates for cardiac transplantation.

Methods: During a period of 20 years, 2201 coronary patients with EF30% and 3505 with poor distal coronary bed were operated at our Clinic. Among those, there was a group of 442 patients in end stage heart failure, EF20%. Endarterectomy of coronary arteries was done in all 3505 pts with poor distal coronary bed. The most frequent associated procedures were mitral and tricuspid valve repair, left ventricular aneurysmectomy, mitral valve replacement and aortic valve replacement.

Results: See attached table.

Conclusions: In many institutions, the majority of the patients with failing left ventricle, especially with EF20%, are considered as inoperable and are on the waiting list for heart transplantation. In our series postoperative mortality is acceptable and we think that patients can derive benefit from conventional surgery. According to our experience poor distal coronary bed is not a contraindication to myocardial revascularisation even in patients with low ejection fraction. Table 9

DO PATIENTS TREATED BY CABG AFTER INITIALLY SUCCESFUL PTCA HAVE A HIGHER IN HOSPITAL- AND EARLY MORBIDITY AND MORTALITY RISK?

Noyez L.

University Medical Center St. Radboud Nijmegen Cardiac Surgery 414

Objective: An increasing number of patients undergoing CABG have undergone previously successful PTCA. This study examines the influence of a successful PTCA upon preoperative patient profile, peroperative management and postoperative, including one-year follow-up, results.

Methods: From January 1999 through December 2001, 1141 patients (91%) underwent primary CABG as the primary intervention for myocardial revascularization (group A) and 113 patients (9%) underwent primary CABG after an initially successful PTCA (group B). Patients undergoing CABG after a failed PTCA were not

Results: Patients in group B were statistically significant younger, 61.5±10.9 years versus 64.2±10.6 years (p=0.010), and more patients had peripheral arterial vascular disease (p=0.015) and renal disease (p=0.036). The percentage of patients with a left main coronary artery stenosis was significantly lower in group B (p=0.004), but the vessel disease didn't differ between the two groups (p=0.080). The mean duration of extra corporal circulation was shorter in group B (p=0.039), and less distal anastomoses were performed (p=0.001). Postoperatively there was no statistical significant difference, neither in the percentages of myocardial infarction, rhythm problems, reinterventions and neurological, renal and pulmonary problems, nor in hospital mortality. Follow-up results didn't show any statistical significant difference in cardiac related mortality (p=0.25) or return of ischemic events (p=0.27).

Conclusions: Patients undergoing primary CABG after previously successful PTCA have an extended form of atherosclerosis. The lower number of distal anastomoses suggests a good result of the previous PTCA. There is no indication that this previous PTCA results in a higher postoperative mortality or morbidity or poorer results after CABG.

CPmp1.6

THE OPCAB SURGERY WITH THE USE OF II-CIRCUIT:THE PROCEDURE OF CHOICE FOR OCTOGENARIANS (PLEASE SEE ATTACHED FILE FOR TITLE)

PRAPAS S., PANAGIOTOPOULOS J., PROTOGEROS D., SIDIROPOULOS A., LINARDAKIS J., KOTSIS

HENRY DUNANT HOSPITAL CARDIOTHORACIC SURGEON; HENRY DUNANT HOSPITAL CARDIOTHORACIC SURGERY; HENRY DUNANT HOSPITAL CARDIOTHORACIC SURGERY; HENRY DUNANT HOSPITAL CARDIOTHORACIC SURGERY; HENRY DUNANT HOSPITAL CARDIOTHORACIC SURGERY; HENRY DUNANT HOSPITAL CARDIOTHORACIC SURGERY

Objective: The use of heart-lung machine and the aortic manipulations during the classical coronary surgery lead in a high mortality rate (over 5%) and morbidity. We evaluate the role of OPCAB surgery with the use of the arterial -circuit in these patients. Between February 2001 and October 2003, 908 isolated coronary patients were operated on.63 of them (7%) were over 80 years old. The preoperative Euroscore was 5.7 and the mean number of anastomosis 2.32.

Methods: The operative technique, which was performed in all cases, consisted of the application of the - circuit to the diseased bed.This circuit is based on preconstructions (compositions, extensions or sequential grafting) on the two pedicled skeletonized IMA's for total arterial, off-pump and aorta non-touch revascularization.One patient was supported with IABP preoperatively.

Results: The mortality rate was 0%. Only two patients suffered a major complication. One of them was reopened due to bleeding and another one developed renal deterioration. Atrial fibrillation rate was close to 15%. There were no neurological events.

Conclusions: OPCAB combined with the use of -circuit is the method of choice since it almost abolishes the perioperative events.

CPmp1.7

DOES WOMEN HAVE HIGHER PERIOPERATIVE MORTALITY THAN MEN IN CORONARY BYPASS GRAFT SURGERY?

Vergles D., Sutlic Z., Biocina B., Rudez I., Baric D., Unic D.

University Hospital Dubrava Department of Cardiac Surgery

Objective: Numerous studies have shown that women have higher morbidity and mortality rates than men following coronary artery bypass graft surgery. In view to this evidence, we compared outcomes of CABG procedures in women and men.

Methods: From January 1998 till December 2003, 1291 operative procedures of myocardial revascularization were performed at our department. There were 237 female and 1054 male patients. We analyzed patient preoperative risk factors (age, LVEF, diabetes mellitus, arterial hypertension, hypercholesterolemia, myocardial infarct and cerebrovascular insult), number of grafts and perioperative complications (reopening for bleeding, perioperative myocardial infarct, sternal wound infections both superficial and deep, atrial and ventricular fibrillation, cardiac decompensation) and mortality.

Results: Women had more risk factors and comorbidities than man, including age, arterial hypertension and hypercholesterolemia but had less severe atherosclerosis and higher left ventricular ejecton fraction. There is no statistically significant difference in perioperative complications between women and men. Mean comparisons reveal that the perioperative mortality, for women (3.4%) is higher than for men (2.9%) but not statistically significant (p=0.724).

Conclusions: Evidence suggests that perioperative complications and mortality in CABG surgery is the same in women and in men.

CPmp1.8

MYOCARDIAL REVASCULARIZATION IN PATIENTS WITH EJECTION FRACTION LESS THAN 30%

Velinovic M., Mikic A., Ljubic B., Kocica M., Vranes M., Djukic P., Panic G., Ristic M.

Clinical Centre of Serbia Belgrade Clinic for Cardiac Surgery

Objective: In this paper we present factors that depict the risk level for myocardial revascularization in patients with chronic ischemic cardiomyopthy and ejection fraction less than 30%.

Methods: We analyze 50 patients with disfunction of left ventricle and reduced ejection fraction from 1995 to 2002. Most patients were males. The youngest patient was 42, and the oldest 75. The mean age was 58.26. There are 62% patients with positive family history of cardiovascular diseases. 60% were smokers. 58% patients had hypertension, 40% Diabates Mellitus, and 60% hyperlipidemia. Previous Myocardial Infarction (MI) had 76% patients (60% with one MI, 32% with two MI and 8% with three MI). 76% patients had disease of three coronary arteries, and 18% patients had left main stenosis. All patients were underwent to standard coronary bypass procedure after coronarography.

Results: Statistical analyses show that there are great statistical significance between results of operation and Diabetes Mellitus, previous MI, diseased all coronary arteries and left main stenosis.

Conclusions: Analyzing ECHO parameters (EF, FS, LVEDD, LVESD, LVEDV, LVESV, LVESVI) in patients who survived, we concluded that there are great statistical significance between preoperative and postoperative values. We also concluded there are great statistical significance in these values between patients who survived and didn't survive operation. We concluded that the most predictive indicator for survival was LVESVI.

CPmp1.9

OUTCOMES AND RISK FACTORS FOR EARLY POSTOPERATIVE COMPLICATIONS OF CORONARY ARTERY BYPASS GRAFT SURGERY IN THE ELDERLY

Khubulava G., Volkov A., Lukyanov N., Lyubimov A.