This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content

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<