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Interact CardioVasc Thorac Surg 2007;6:S223-S280. doi:10.1510/icvts.2007.0000S7 © 2007 European Association of Cardio-Thoracic Surgery
AbstractsSuppl. 3 to Vol. 6 (September 2007)
F1 FLOW-SENSITIVE 4D MAGNETIC RESONANCE IMAGING: PATHOLOGICAL BLOOD FLOW PATTERNS IN ASCENDING AORTIC ANEURYSMS E. Weigang1, F. Kari1, M. Luehr1, J. Kobba1, A. Frydrychowicz2, M. Markl2, C. Heilmann1, F. Beyersdorf1 1University Cardiovascular Centre, Freiburg, Bad Krozingen, Germany; 2University Medical Centre, Freiburg, Germany Objectives: Aortic aneurysms are characterized by pathological blood flow patterns. However, these changes are poorly understood. We therefore analysed local blood flow in aneurysms of the ascending aorta using flow-sensitive 4D-MRT. Methods: Data were acquired on a 3 Tesla-MRT with a 4D (time-resolved 3D) sequence protocol (ECG-gating, respiration control). Flow was visualised as 3D-streamlines and 3D-particle traces using the software EnSight. Healthy volunteers and six patients with ascending aortic aneurysms were investigated. Results: Healthy individuals presented a right-handed helix extending into the proximal arch (1.5 revolutions) and vortical flow in the sinuses. Two patients with atherosclerotic aneurysms had either increased right-handed helical flow (3.5 revolutions) with flow acceleration along the great curvature, or multiple vortical flows in the sinuses and middle of the ascending aorta, respectively. One typical Marfan-associated aneurysm exhibited increased vortical flow in the dilated sinuses. One aneurysm of the proximal anastomosis of a supracoronary replacement showed extensive vortex formation inside the aneurysm's lumen. An aneurysm in one patient with a bicuspid aortic valve revealed a major vortex formation directly above the valve with unusual spatial and directional orientation. An aneurysm following congenital valvular stenosis and commissurotomy in childhood was characterised by a vortex along the small curvature and helical diastolic backflow in the central ascending aorta. Conclusions: Six patients with similar pathomorphology presented considerable differences in local flow patterns in the ascending aorta compared to healthy volunteers and among themselves. Insight into the role of flow may contribute to predicting the individual course of ascending aortic aneurysms.
1Leids Universitair Medisch Centrum, Leiden, The Netherlands; 2HemoLab Cardiovascular Engineering, Eindhoven, The Netherlands Objectives: The isolated heart model provides a multifunctional test platform in which function and physiology can be studied. In order to achieve satisfactory pre- and after load of the left and right side of the heart respectively we created an ex-vivo working heart-lung model. Methods: Porcine heart and lungs are isolated from slaughterhouse pigs following a special, authorized protocol. The protocol takes into account that no additional suffering to the animal takes place and that the quality of heart and lungs are preserved. The heart is arrested with cardioplegia and the lung circulation flushed with ringer-heparin solution. The heart-lung is prepared so that it can be mounted to the test platform. The heart is resuscitated and working in Langendorff mode and the lungs ventilated. After achieving good right venricular function the membrane oxygenation in the Langendorff circulation is being switched off so that the oxygenation is fully depending on the ventilation of the lungs. Results: We were able to achieve and maintain an ex-vivo working 2-chamber heart-lung model for at least 3 h with good right ventricular function and sufficient oxygenation by the lungs. Conclusions: After successfully achieving a four chamber working heart-model with the ability to visualize all heart valves this is the first step in achieving a fully working ex-vivo four-chamber heart-lung model test platform.
Division of Cardiac Surgery, S Raffaele Hospital, Milan, Italy Objectives: Despite its efficacy and swiftness, bipolar radiofrequency is generally not used on the left isthmus for concern of injuring a coronary branch. Incomplete lesion sets or use of an additional unipolar device are often considered. We report a technique to perform a full left lesion set involving the mitral line using a standard bipolar radiofrequency device. Methods: Coronary angiogram is carefully pondered. After beating-heart pulmonary vein isolation on-pump, coronary anatomy is inspected to identify the coronary-free area of the A-V groove. An hypodermic needle is stuck in the middle of such area, into the left atrial wall, behind the coronary sinus. The projection of the needle marker on the mitral annulus is then identified through the atriotomy. The needle is removed. An ablation is performed clamping the bipolar device endo-epicardially on the atrial wall, involving the A-V groove, the coronary sinus, and the annulus. The lesion set is then completed by connecting the encirclings and the left appendage, which is then sutured. Results: Since May 2005, 65 mitral patients with atrial fibrillation had the described ablation. Haematoma of the A-V groove was observed during retrograde cardioplegia in one case. All patients survived. No patient had myocardial ischaemia or re-exploration for bleeding (median 310 cc, 240; 400 cc). At nine months (5; 13 months), 55/65 patients (85%) were free from atrial fibrillation. No patient had left flutter. Conclusions: The mitral line can be safely performed with bipolar radiofrequency in all patients. A transmural, complete lesion set performed with a single device yields excellent early results.
Ege University Medical Faculty, Department of Cardiovascular Surgery, Izmir, Turkey Objectives: Problems in the distal aorta after proximal aortic operation in young patients with Marfan syndrome affects the long-term outcome. Progressive dilatation of the aorta as well as development of aneursyms from the Carrel patches after repair of thoracoabdominal aortic aneurysms (TAAA) are major concerns. Replacement with commercially available multi-branched grafts may be a solution. We present a case of Marfan syndrome who underwent replacement of extensive TAAA by using a multi-branched graft. Operation and perfusion techniques were shown in this video presentation. Methods: A 25-year-old man with Marfan syndrome was admitted to our clinic due to progressive enlargement of his thoracoabdominal aorta detected in follow-up CT scans. He underwent Bentall operation and replacement of the proximal descending aorta after development of acute type III dissection, 8 and 3 years ago, respectively. Thoracoabdominal incision with retroperitoneal approach was used for aortic exposure. Operation was performed under hypothermic circulatory arrest and selective visceral and pelvic perfusion by using femorofemoral bypass. The period of brain ischemia was 18 min. Results: Patient awoke neurologically intact. He did not develop any complications and was discharged seven days after the operation. Conclusions: The use of multi-branched graft enables anastomosis of visceral and renal arteries without large buttons of diseased aorta in repair of extensive TAAA. This graft has other advantages like possibility to perfuse individual branches and easier visualisation and control of anastomotic leakage.
Hopital Jean Minjoz, Besancon, France Objectives: This aggregate video describes the monobloc aorto-mitral homograft implantation technique, from two such implantations performed in our department. Methods: Both patients were males in their thirties. The first episode of endocarditis involved only the mitral valve in the first, and both the aortic and mitral valves, with an abscess of the aortic annulus, in the second patient. The first operation consisted in a complex mitral valvuloplasty in the first patient. In the second patient both, aortic and mitral valves were replaced by mechanical prostheses, the abscess was removed and replaced by an autologous pericardium. Results: The second episode treated by monobloc aorto-mitral homograft implantation, happened respectively 7 and 3 months after the first episode. Conclusions: Both patients are doing well with 9 and 4 months follow-up.
001 PREOPERATIVE LONG SAPHENOUS VEIN MAPPING PREDICTS VEIN QUALITY AND ANATOMY LEADING TO IMPROVED POSTOPERATIVE LEG MORBIDITY H. Luckraz1, T.B. Esmael1, N. Pugh2, J. Lowe1, A. Luer-English1, D. Mehta1, E.N. Kulatilake1, A.A. Azzu1 1Cardiothoracic Unit University Hospital of Wales, Cardiff, UK; 2Doppler Ultrasound Department University Hospital of Wales, Cardiff, UK Objectives: Long saphenous vein harvesting for coronary bypass surgery is associated with significant morbidity. Furthermore, vein quality is often variable sometimes requiring incisions in both legs. The aim of this study was to assess the usefulness of preoperative long saphenous vein mapping in terms of conduit quality and location, incision lengths and postoperative morbidity.
Methods: A prospective randomisation control trial was carried out with patients either having their long saphenous vein assessed and mapped preoperatively by venous Doppler ultrasound (n=31) or not (n=30). The study was powered to 0.9 with an Results: There was no significant difference between the two groups in terms of age, gender and pre-op incidence of diabetes, peripheral vascular disease, smoking history, ejection fraction, priority of surgery and body surface area. The size and anatomical distribution of the long saphenous vein was well predicted by the ultrasound study (correlation coefficient=0.87). Intra-operatively, the mean length of leg wound per vein graft performed was significantly less in the mapped group [16.8 (4.0) vs. 24.1 (10.4) cm, P=0.005]. This translated in a shorter operative time for vein harvesting per length of vein graft needed [36 (13) vs. 47 (17) min, P=0.04]. Postoperatively there was a tendency to less leg wound complications in the mapped group (P=0.08). Conclusions: Long saphenous vein mapping preoperatively predicts the size and anatomy of the vein appropriately. This led to a selective leg wound incision and reduced operative time with the benefit of reduced leg complication postoperatively.
Katholieke Universiteit Leuven, Leuven, Belgium Objectives: A heart valve prosthesis constructed from acellular, moderately cross-linked photo-oxidised bovine pericardium (POP) can become completely recellularised after three day intraperitoneal preseeding. In this study we tested these valves (n=19) up to five months implantation in pulmonary position in sheep and compared them to controls (n=20). Methods: Haemodynamics were evaluated by transthoracic echocardiography (TTE) at 1 week and 1, 3 and 5 months. Post-mortem we assessed calcification, morphometry, matrix properties, recellularisation and biophysical properties. Results: TTE revealed that all valves remained functional and that IP valves had a slight, but significantly increased, peak gradient and regurgitation prevalence. This might be caused by the observed remodelling of these valves: in contrast to controls they became thicker but shorter. All valves studied had calcium contents in the range of native valves. The POP was slowly degradable, as shown by the significant decreases in organised collagen, E modulus, strength and maximal force. The IP valves were completely recellularised in contrast to the controls. The cells did produce new extracellular matrix containing collagen and ground substance but the amount of new matrix was 4.4-fold higher in IP valves, which coincided with the 2.7-fold increase in cell number in these valves. The cell fractions expressing myofibroblast or smooth muscle cells markers (ASMA, SMMS-1 and Smoothelin) were similar in both groups but significantly exceed those of native pulmonary valves. Conclusions: IP seeding resulted in complete recellularisation and neomatrix deposition. However, remodelling, most probably caused by an increased fraction of cells with contractile properties, influenced haemodynamic and biophysical properties.
Day General Hospital, Tehran, Iran Objectives: The aim of this study was to investigate the feasibility of performing papillary muscle repositioning for subvalvular-sparing mitral valve replacement procedures in an LV- dysfunction population and to determine the early and late effects of this procedure on the clinical outcome and left ventricular mechanics. Methods: One hundred patients with ejection fraction <40, who were candidates for isolated surgical correction of mitral insufficiency, were prospectively randomized into either total chordal-sparing or papillary muscle repositioning mitral valve replacement groups. Fifty subjects underwent papillary muscle repositioning (PMR group), and the remaining 50 had complete preservation of all chordal structures (CMVR group). Echocardiography was performed preoperatively, at discharge and after two years to determine dimensions, left ventricular shape and function. Results: End-diastolic and systolic volumes decreased in both groups initially and continued to decline. Decreasing volumes, however, were more significant in the PMR group, in which the significant decrease in the sphericity index continued for another two years. In contrast, the sphericity index in the CMVR group had no significant changes at discharge and at two years. In terms of systolic performance, ejection fraction had no significant changes in the CMVR group, whereas it exhibited a significant increase in the PMR group. Conclusions: Papillary muscle repositioning could result in more favourable left ventricular remodelling compared with complete retention of the mitral subvalvular apparatus during mitral valve replacement. It confers a significantly early and late advantage by causing a more significant reduction in the left ventricular chamber volume, sphericity index and systolic performance.
004 INDIVIDUAL RISK PREDICTION OF METASTASIS FOR PATIENTS WITH TYPICAL BRONCHIAL CARCINOID TUMOURS J.C. Neves-Pereira2, J.F. Bernaudin2, J.R. de-Campos-Milanez1, M. Riquet2, V.L. Capelozzi1, C. Danel2, P. Bagan2, F.B. Jatene1 1Sao Paulo University Medical School, Sao Paulo, Brazil; 2Pierre et Marie Curie University, Paris, France Objectives: Despite bronchial-typical-carcinoid tumours being low-grade malignancies, metastasis are diagnosed in some patients. It is imperative to predict the individual risk of metastasis. Predictive models can be used with this aim. Our objective is to predict the individual risk of metastasis for patients operated-on by bronchial-typical-carcinoid based on a logistic regression model in function of candidate clinical, pathological and tumour biomolecular variables. Methods: A multicentre retrospective cohort study, including 330 (202 French/128 Brazilian) consecutive patients operated-on by bronchial-typical-carcinoid and followed-up during a period longer than ten years in two university hospitals was performed. Logistic regression was used as a predictive model (SPSS Illinois-Chicago). The following clinical, pathological and tumour biomolecular data were analysed as independent variables candidates to predict individual risk of metastasis: age, gender, ethnical-group, weight loss, chest pain, TNM-staging, tumour diameter and location (central/peripheral) and tumour p53, Ki67 and Bcl-2/Bax immunostaining and microscopic density of: collagen/elastic fibres and angiogenesis (neoformed microvessels immunostained by the monoclonal antibody anti-CD34). Results: Lymph node metastasis incidence was 11% and 10% for Brazilian and French patients respectively and 5% for haematogenic metastasis in both groups. Univariated analysis related metastasis (P<0.05) to: elder age, male gender, ethnic group (African-American), weight loss, chest pain, low extracellular fibers density, high Ki67 and elevated angiogenesis (neoformed CD34-immunostained microvessels density). Multivariated logistic regression analysis showed that angiogenesis (neoformed CD34-immunostained microvessels density) is an independent variable that predicts these metastasis (B=0.3; P=0.0001). Conclusions: Individual risk of metastasis for patients operated on for bronchial typical carcinoid can be predicted by a logistic regression model in function of tumour-neoformed microvessels density (angiogenesis).
St Luc Hospital UCL, Brussels, Belgium Objectives: Non-small cell lung cancer (NSCLC) has a poor prognosis even for early stages of the disease (Stage I and II). Adjuvant chemotherapy is currently advised only for Stage II tumours. This is to evaluate whether FDG uptake can predict survival in Stage I and II NSCLC. Methods: Retrospective study of 97 patients with NSCLC. 18F-FDG-PET performed for pretherapeutical staging. Histopathological stage was either Stage I (n=76) or Stage II (n=21). FDG uptake was measured as maximal SUVbw (SUVmax). Mean follow-up time was 45+30 months (1–142 months). Death or survival occurrences were recorded. Results: SUVmax were higher for Stage II than for Stage I (10.5±4.5 vs. 8.5±5, P=0.04). Mean tumour volumes were equivalent for both stages (33 cm3), excluding a partial volume effect. Median SUVmax was 7.8. Mean actuarial survival was significantly reduced for patients with higher tumour uptake: 127 months if SUVmax7.8 (P=0.0003). For Stage I tumours (n=76), high FDG uptake was associated to reduced survival: 127 months if SUVmax7.8 (P=0.0017). For Stage II tumours (n=21), no statistical difference was observed: 72 months vs. 40 months for SUVmax7.8, respectively (P=0.11). Conclusions: FDG uptake is a prognostic indicator for overall survival in NSCLC. However, this prognostic value applies only to Stage I tumours (i.e. T1N0, T2N0). This study suggests that a subgroup of patients with stage I disease (i.e. those with a high FDG uptake, SUVmax>7.8) have a reduced survival and might therefore benefit from adjuvant chemotherapy.
National Cancer Centre, Goyang, Korea (South) Objectives: Delayed gastric emptying after oesophagectomy occurs in up to 50%. Good quality of life after oesophagectomy may depend on both dietary adaptation and the improvement of gastric motility itself. The objective of study was to investigate the effect of pyloric balloon dilation on delayed gastric emptying after oesophagectomy. Methods: Between April 2003 and March 2006, balloon dilatation of pylorus was performed in 14 patients who suffered from sustained symptoms of delayed gastric emptying after oesophagectomy for oesophageal cancer despite the use of prokinetics. Gastric drainage procedure was routinely undergone during oesophagectomy. Intrathoracic gastric emptying of solid food was evaluated by radioisotope before and after the balloon dilatation of pylorus in nine patients. The 50% gastric emptying time over 180 min was defined as delayed. We assessed the changes of the intrathoracic gastric emptying time and symptoms after pylorus dilatation for delayed gastric emptying. Results: The symptoms for delayed gastric emptying were improved after pylorus dilatation in most of patients. Pyloric balloon dilatation was performed twice in two patients. In four of nine patients (44.4%), delayed gastric emptying rate was much improved from 24.2% to 77.0% together with symptoms. The others showed the sustained delay of gastric emptying. Conclusions: This result shows the objective effect of balloon dilatation of pylorus on delayed gastric emptying by measuring gastric emptying time with radioisotope. Balloon dilatation of pylorus is useful to treat the sustained delay of intrathoracic gastric emptying after oesophagectomy. However, factors other than pylorus would be considered to determine the intrathoracic gastric emptying rate.
007 DOES CONTEGRA MATCH ALLOGRAFT PERFORMANCE IN INFANT TRUNCUS ARTERIOSUS REPAIR? E.J. Hickey1, B.W. McCrindle1, E.H. Blackstone2, T. Yeh Jr3, F. Pigula4, D. Clarke7, C. Tchervenkov6, J. Hawkins5 1The Congenital Heart Surgeon's Society, Toronto, Canada; 2Cleveland Clinic Foundation, Cleveland, USA; 3University of Texas Southwestern Medical Center, Dallas, USA; 4Boston Children's Hospital, Boston, USA; 5Primary Children's Medical Centre, Salt Lake City, USA; 6Montreal Children's Hospital, Montreal, USA; 7Children's Hospital, Denver, USA Objectives: Limited availability and durability of allograft conduits require that alternatives be considered. We compared Contegra and allograft performance in 107 infants who survived truncus arteriosus repair. Methods: Children were prospectively recruited between 2003 and 2007 from 17 institutions. Median age and weight at conduit implantation were 11 days (range 1–127) and 3.1 kg (range 1.7–9) respectively and were not different between the groups. The median z-score for Contegra (n=27, all 12 mm) was +2.1 (range +1.2 to +3.2) and allografts (n=80, 9–15 mm) was +1.7 (range –0.4 to +3.6). Propensity-adjusted comparison of conduit survival and function (using 745 available echocardiograms) was undertaken using parametric risk-hazard analysis and bootstrap resampling. Results: Overall conduit survival was 66±6% at three years. Conduit replacement was for conduit stenosis (n=16), pulmonary artery stenosis (n=18) or regurgitation (n=1). The propensity-adjusted 3-year freedom from replacement for conduit stenosis was 97% (±4) for Contegra and 69% (±7) for allograft (P=0.05). The risk of intervention for branch pulmonary artery stenosis was independent of conduit type. Smaller conduit z-score predicted poor conduit performance (P<0.01) with best outcome between +1 and +3. Although Contegra conduits were a uniform diameter, their z-score more consistently matched this ideal. Contegra exhibited a non-significant trend towards slower RVOT gradient progression. However, catheter intervention was more successful at slowing gradient progression with Contegra than with allograft (P=0.01). Conclusions: Contegra does match allograft performance and may be advantageous. It is an appropriate first choice for repair of truncus arteriosus, and perhaps other small infants requiring RVOT reconstruction.
1Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK; 2Paediatric Intensive Care Unit, Birmingham's Children Hospital, Birmingham, UK; 3Statistical Advisory Service, Birmingham Children's Hospital, Birmingham, UK Objectives: To investigate tissue lactate, pyruvate and lactate: pyruvate (LP) ratio post cardiac surgery and the relationship of cardiac index and oxygen delivery to ‘late onset’ hyperlactataemia, developing during the first 12 h in ICU. Methods: Prospective study of 10 children, mean (S.D.) age 4.9 (0.4) years, post-Fontan operation admitted to ICU with a normal blood lactate (<3 mmol l–1). Tissue lactate, pyruvate and LP ratio were monitored postoperatively every 30 min for 12 h via a subcutaneous microdialysis catheter placed in the abdominal wall subcutaneous tissue. Blood lactate and cardiac index, measured by femoral artery thermodilution (PiCCO), were measured at 0, 4, 8, and 12 h. Results: Mean (S.D.) blood lactate rose from 2.23 (0.49) to 3.73 (1.16) mmol l–1 in the first 4 h (P=0.006), and only one child failed to show an increase in blood lactate above 3 mmol l–1. Tissue monitoring revealed a corresponding rise in lactate (Pearson correlation 0.73, P=0.02), with a parallel rise in pyruvate. LP ratio remained constant and below 20, suggesting a cause for hyperlactataemia other than tissue oxygen debt. Cardiac index increased from 2.83 (0.63) to 3.77 (1.34) l min–1 m–2 over the same 4 h period (P=0.05), with a corresponding increase in oxygen delivery from 4556 (1094) to 6076 (2322) ml min–1 (P=0.04). Conclusions: Tissue microdialysis is a simple technique that provides continuous measurement of lactate, pyruvate and other metabolites. A rise in blood and tissue lactate is common in children post cardiac surgery. This is not associated with a low or falling cardiac index.
1UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, UK; 2Policlinico San Donato Milanese IRCCS, Milan, Italy Objectives: To evaluate the effects on ventricular function and volumes following percutaneous pulmonary valve implantation (PPVI) and right ventricular outflow tract reconstruction (RVOTR) with pulmonary homograft replacement (PVR). Methods: Thirty-six patients were prospectively examined. (Group 1) Those who had PPVI for pulmonary regurgitation alone (11, mean age 20±9 years, 64% Tetralogy of Fallot) were compared to (Group 2) those who had PVR with RVOTR (25, mean age 21±13 years, 96% Tetralogy of Fallot). Mean age at primary repair did not differ between the two groups (4.3±6.6 years) Magnetic resonance imaging was performed prior to, and one year following interventions. Results: Before procedure, NYHA was similar in both groups 2.1±0.5. Following interventions, there was a significant reduction of RV volumes in both groups, this was greater in the surgical patients [end-diastolic: 106±27 to 89±25 ml/m2 (1) vs. 151±49 to 97±32 ml/m2 (2), P=0.004; end-systolic: 49±20 to 40±16 ml/m2 (1) vs. 80±43 to 46±23 ml/m2 (2), P=0.002]; both group had a similar significant improvement in RV [53±14 to 67±16 ml/beat (1) vs. 63±20 72±16 ml/beat (2), ns] and LV effective stroke volume [60±25 to 74±17 ml/beat, (1) vs. 61±18 to 73±16 ml/beat, (2), ns]. Conclusions: Following PVR with RVOTR and PPVI, there was a significant reduction in RV volumes and an improvement in RV function. Importantly, in both groups, LV effective stroke volume increased, and this may be the parameter to judge the success of the procedure. These preliminary results support PPVI as an extra dimension in complex RVOT management.
010 ASCENDING AORTIC CURVATURE AS AN INDEPENDENT RISK FACTOR FOR TYPE A DISSECTION, AND ASCENDING AORTIC ANEURYSM FORMATION: A MATHEMATICAL MODEL M. Poullis1, R. Warwick1, M. Field1, A. Oo1, R.J. Poole2 1CTC, Liverpool, UK; 2Department of Engineering, Liverpool University, Liverpool, UK Objectives: To develop a mathematical model to demonstrate that ascending aortic curvature is an independent risk factor for type A dissections, in addition to hypertension, bicuspid aortic valve, aneurysm of ascending aorta, and intrinsic aortic tissue abnormalities, like Marfans syndrome. Methods: A steady state one-dimensional flow analysis was performed, utilising Newton's third law of motion. For calculation purposes the following cardiovascular values were utilised, cardiac output 5 l/min, systolic blood pressure 110–150 mmHg, ascending aortic diameter 20–40 mm. Aortic curvature from 10 to 90 degrees. Results: As the angle of curvature of the ascending aorta increases from 10° to 90°, the force imparted on the aortic wall increases by a factor of 11. As aortic diameter increases from 20 mm to 40 mm, with a 90° aortic curvature, the force imparted on the aortic wall increases from 8 N to 33 N, a 4-fold increase. Increasing systolic blood pressure from 110 to 150 mmHg, resulted in a 1.4-fold increase on the force exerted on the aortic wall. Conclusions: Aortic curvature is more important that aortic diameter or blood pressure, with regard to the force acting on the aortic wall. This may explain why some patients with normal diameter ascending aorta and no connective tissue defects develop type A dissections, and aneurysms. Aortic curvature should influence timing of aortic replacement surgery.
1University of Freiburg Medical Center, Freiburg, Germany; 2University of Pittsburgh Medical Center, Pittsburgh, USA Objectives: Dilatation of the aorta at the landing zone potentially limits long-term results of endovascular therapy. After thoracic stent graft placement, we evaluated growth patterns and morphology of the growing thoracic aorta in young piglets. Methods: Eight domestic piglets (37±2 kg) had an endovascular stent placed in the proximal descending thoracic aorta using retroperitoneal access. Aortic size was documented after thoracotomy by intraoperative measurement and angiography. At implantation, the stent was oversized by 10%. Subsequently the piglets were grown to adult size (181±42 kg). At explantation 10 months later, CT-scan and surgical evaluation for endoleaks was performed. Pathological assessment of the explanted aorta was performed.
Results: No endoleak or stent migration occurred even in 230-kg pigs. The stents expanded to full size, but there was no further aortic growth in the stented area. The aortic diameter increased significantly by 33±8% 1 cm proximal to the stents (P=0.0006) and by 52±12% 1 cm distal to the stents (P=0.0022). The stented area grew less than the proximal and distal aorta (P Conclusions: Endovascular stent grafting inhibits growth of the non-atherosclerotic normal aorta and leads to fibrosis in the inner media part adjacent to the stent. This observation could lead to review of the concept that non-atherosclerotic dilatative aortic disease should not be treated with endovascular therapy.
Mount Sinai School of Medicine, New York, USA Objectives: Spinal cord blood flow (SCBF) after sacrifice of thoracic and abdominal aortic segmental arteries (TAASA) during thoracoabdominal aortic aneurysm (TAAA) repair remains poorly understood. Methods: Fourteen juvenile Yorkshire pigs underwent complete serial TAASA sacrifice (T4-L5). Six control pigs underwent cooling to 32 °C with no TAASA sacrifice. In the experimental animals, spinal cord function was continuously monitored using motor evoked potentials (MEP) until 1 h (h) after clamping. Fluorescent microspheres enabled segmental measurement of SCBF before, and 5 min, 1 h, 5 h, 24 h and 72 h after complete TAASA sacrifice. A modified Tarlov score was obtained for three days postoperatively. Results: All the pigs with complete TAASA sacrifice retained normal cord function (MEP) until 1 h after TAASA ligation. Seven pigs (50%) with complete TAASA sacrifice recovered after 72 h; seven pigs suffered paraparesis (5) or paraplegia (2). Intraoperatively, and until 1 h postoperatively, SCBF was similar among the three groups. Postoperatively, SCBF in pigs with ischaemic cord injury was significantly lower at 5 h than in controls in the T8-L2 (P=0.0002) and L3-S segments (P=0.0007): the T8-L2 values predicted functional recovery (P=0.003). At 24 h, SCBF in injured pigs remained marginally lower from T8 caudally; at 72 h, SCBF was similar in all groups. Conclusions: This study suggests that critical spinal cord ischemia after complete TAASA sacrifice does not occur immediately, but is delayed 1–5 h or longer after clamping. The short duration of low SCBF suggests that haemodynamic manipulation lasting only 24–72 h might safeguard cord function despite sacrifice of all TAASA during surgical or endovascular repair of TAAA.
013 PERIVASCULAR TISSUE OF INTERNAL THORACIC ARTERY RELEASES POTENT NITRIC OXIDE AND PROSTACYCLINE-INDEPENDENT ANTICONTRACTILE FACTOR M. Malinowski1, M.A. Deja1, K.S. Go  ba2, T. Roleder2, S. Wo 1 1Second Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland; 2Department of Cardiology, Medical University of Silesia, Katowice, Poland Objectives: It was recently suggested that perivascular tissue releases hypothetic adipocyte derived relaxing factor (ADRF). The aim of the study was to assess anticontractile properties of perivascular adipose tissue of human internal thoracic artery (ITA). Methods: Human ITA rings were studied in vitro. First, skeletonised and pedicled ITA reactivity to serotonin was compared. In subsequent experiments fragments of ITA were skeletonised and divided into two preparations. One was incubated alone, the other together with adipose perivascular tissue floating freely in the bath. Concentration response curves to serotonin (n=10) and angiotensin (n=11) were constructed. Tissue was then transferred from one to the other bath and dose-response curves were reconstructed. The same protocol was applied with the inhibition of nitric oxide synthase with L-NMMA (10–4 M) and cyclooxygenase with indomethacin (10–5 M) (n=13). Results: Skeletonisation augmented contractile response to serotonin (Emax 16±2 vs. 43±4 mN, pedicled and skeletonised ITA respectively; P<0.001). Presence of perivascular tissue in the bath caused Emax decrease from 40±9 to 19±3 mN; P=0.04 and from 32±5 to 12±2 mN; P=0.002 (serotonin and angiotensin, respectively). Adipose tissue presence did not change ITA sensitivity (EC50) to serotonin or angiotensin. NO and prostacycline inhibition failed to abolish anticontractile properties of perivascular tissue. Perivascular fat decreased Emax from 43±3 to 33±4 mN, P=0.03 for serotonin and from 32±4 to 19±2, P=0.01 for angiotensin. Conclusions: Perivascular tissue of ITA releases potent, soluble, nitric oxide and prostacycline-independent anticontractile factor. Preservation of perivascular tissue may thus protect against vasospasm of ITA graft in clinical settings.
Wakayama Medical University School of Medicine, Wakayama, Japan Objectives: Neuronal nitric oxide synthase (nNOS) is apparently related to cardiac function, both under physiological conditions and in disease states. Direct nNOS delivery could thus constitute a powerful therapeutic tool. However, direct delivery of nNOS into the heart in vivo has not been reported. We developed a novel technique for directly delivering biologically active protein into cardiomyocytes in vivo. We used this technique to investigate the effect of targeted, direct delivery of nNOS and the Japan envelope (HVJ-E) vector transduced with a haemaglutinating virus into rat cardiomyocytes after acute myocardial infarction (AMI). Methods: We ligated the left anterior descending branch of the coronary arteries of Wistar rats to induce AMI and then 90 min later, we injected nNOS with the HVJ-E vector (NV group, n=8), ß-galactosidase with HVJ-E vector (BV group, n=7), nNOS alone (N group, n=6) or HVJ-E vector alone (V group, n=6) into the hearts and removed them 3 h later. Sections were histochemically stained with TTC and infarcted areas were colorimetrically evaluated. Results: The infarcted areas in sections from the NV group were significantly narrower than those from the B, N and V groups (P=0.001). Conclusions: Our findings suggest that direct nNOS transduction into cardiomyocytes rapidly diminished the size of infarcted areas after AMI. This type of targeted delivery should have wide application in terms of delivering therapeutic nNOS to the heart, and provide a powerful therapeutic tool with which to treat ischaemic heart disease.
Beth Israel Deaconess Medical Centre, Boston, USA Objectives: Growth-factor based angiogenesis, with or without cell therapy, is a promising therapeutic modality for patients with coronary artery disease (CAD). We compared the relative efficacies of surgically delivered VEGF and FGF-2 in a swine model of hypercholaesterolemia-induced endothelial dysfunction which captures many of the pathophysiological abnormalities of human CAD. Methods: Yucatan mini-swine (20–30 kg), fed a high cholesterol diet for 13 weeks, underwent circumflex ameroid placement to create chronic myocardial ischaemia, followed three weeks later by perivascular administration of VEGF (n=6), FGF-2 (n=6), or placebo (n=7) in the ischaemic territory. Normocholaesterolemic animals (n=7) served as controls. Four weeks later, endothelial function, collateral-dependent perfusion, as well as myocardial protein and mRNA levels of angiogenic mediators were assessed. Results: Endothelial dysfunction was demonstrated in all hypercholaesterolemic animals. VEGF administration improved baseline-adjusted collateral-dependent perfusion (–0.03±0.04 vs. –0.11±0.05, VEGF vs. placebo, P=0.07), but FGF-2 delivery caused a significantly greater improvement in perfusion compared to either group (+0.15±0.03, P<0.01 vs. placebo), both at rest and with pacing. Molecular analysis revealed increased eNOS expression (135%±8%, P=0.03 vs. placebo) in growth factor treated animals and increased expression of FGF receptor, FGFR1, (156%±13%, P=0.03 vs. placebo) in FGF-2 treated animals. No significant changes were demonstrated in other angiogenic mediators including Akt, Syndecan-4, or iNOS. Conclusions: In the setting of hypercholaesterolemic endothelial dysfunction, FGF-2 is more effective than VEGF at enhancing collateral-dependent perfusion and thus, may be a better candidate than VEGF for angiogenic therapy in patients with end-stage CAD.
016 AGE CUT-OFF FOR THE LOSS OF BENEFIT FROM BILATERAL INTERNAL THORACIC ARTERY GRAFTING S. Mohammadi, F. Dagenais, D. Doyle, P. Mathieu, R. Baillot, J. Perron, E. Charbonneau, P. Voisine Quebec Heart Institute, Quebec City, Canada Objectives: To identify the age-related benefit of single and bilateral internal thoracic artery (ITA) grafting on long-term cardiac-related survival in patients who survived from primary isolated coronary artery bypass grafting (CABG). Methods: A unicenter study was conducted on 13,172 consecutive survivors from primary isolated CABG who received single (n=10,400 patients) or bilateral (n=1470 patients) ITA grafts, or vein grafts only (n=1302 patients) between 1992 and 2004. The follow-up study was extended two years after the last enrolled patient. Age was a significant covariate into the statistical model. Results: The mean follow-up was 6.2±3.7 years. After adjustments for patient selection and length of follow-up, the cardiac-related survival benefit in patients undergoing CABG with two ITAs was superior to that of single ITA grafting up to 65 years of age, displaying a constant decrease over time (40–45 years old: HR=0.2, P=0.007; 46–50 years old: HR=0.4, P=0.005; 51–55 years old: HR=0.5, P=0.007; 56–60 years old: HR=0.7, P=0.01; 61–65 years old: HR=0.8, P<0.05; 66–70 years old: HR=1.1, P=0.7; 71–75 years old: HR=1.4, P=0.5; >75 years old: HR=1.8, P=0.4). The use of a single ITA was beneficial on cardiac-related survival in all age groups, including octogenarians, compared to patients receiving only vein grafts. The rate of benefit reduction was linearly correlated with ageing. Conclusions: The use of at least one ITA is associated with increased cardiac-specific survival in all age groups compared to venous-only CABG. The additional survival benefit of using a second ITA, however, is lost after 65 years of age.
1Department of Thoracic and Cardiovascular Surgery, Frankfurt, Germany; 2Department of Heart Surgery, Lübeck, Germany Objectives: Increasing interest in the use of pulmonary autografts for replacements of the diseased aortic valve has been reported with excellent long-term results. Aim of the study was the evaluation of postoperative endocarditis of the auto (AG)- and homograft (HG) after Ross procedures. Methods: Between 1990 and 2007, a total of 1040 patients of the German Ross registry were evaluated for overall mortality, death due to endocarditis, reoperation and echocardiography results. One hundred and ninety seven patients were operated on due to aortic valve endocarditis. Results: The overall mortality was 4% (40/1040). Twenty-five patients died due to cardiac, 14 due to non-cardiac and one to unknown reasons. In 22 endocarditis (AG 14, HG 8) occurred during the follow-up period, 14 patients were reoperated and 8 were treated conservatively. Nine of the 14 AG endocarditis patients were reoperated, 4 were explanted and 5 repaired. Five of the 8 HG endocarditis were reoperated, in all cases an explantation was necessary. Two of the 22 endocarditis patient died. One patient showed a Grade III° and four showed a Grade II° aortic regurgitation at mean 4.6 years after re-operation. No endocarditis occurred in one of the 197 patients operated due to aortic valve endocarditis. Conclusions: Our long-term follow-up data shows excellent results with a low rate of postoperative endocarditis. AG endocarditis can be repaired in >50%, but HG infections results in an explantation. Excellent echocardiographic results can be expected even after repair. The Ross procedure is an excellent therapeutic option for patients after endocarditis and provides low mortality and re-endocarditis. Further studies aimed at clarifying risk factors for endocarditis as well as preventing pulmonary homograft explantation in case of endocarditis.
1Division of Cardiothoracic Surgery, Saint Vincent Mercy Medical Centre, Toledo, Ohio, USA; 2Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio, USA Objectives: The fact that multiple arterial grafts are associated with improved long-term survival in the general CABG population is well-accepted. Yet, a large study comparing single vs. bilateral internal thoracic artery (ITA) grafting in diabetic patients did not demonstrate a 10-year survival benefit of two arterial grafts. Whether this is true when radial is the second arterial conduit is unknown. Methods: We obtained complete death follow-up in 1516 consecutive diabetic [64±10 years (mean±S.D.); 540 insulin-dependent] primary isolated CABG patients, all with ITA grafts, at a single institution. Using a radial-use propensity score and accounting for insulin-dependence, we one-to-one matched 477 of 626 (76%) radial grafting patients to 477 vein patients. Kaplan–Meier 11-year survival was calculated. Results: Before risk-matching, survival was markedly better (P<0.0001) for radial (94.3%, 86.7% and 70.4% at 1, 5 and 10 years) vs. vein (91.8%, 74.5% and 53.8%, respectively) patients. Propensity matching removed inequalities in demographics, comorbidities, coronary disease severity and completed grafts. In matched-patients, 1-, 5- and 10-year survival was essentially identical for radial (93.7%, 85.4% and 69.4%) vs. vein (95.4%, 83.0% and 66.2%) cohorts (P=0.85). Conclusions: As in the case of two vs. one ITA, utilisation of a radial artery as a second arterial conduit did not confer a 10-year survival benefit in diabetic patients. The lack of multiple arterial grafts benefit is possibly related to the more malignant coronary atherosclerosis characteristic of diabetics. Our results suggest that the survival advantage of multiple arterial grafts demonstrated in the general CABG population lies primarily in non-diabetics where this advantage may be underestimated.
Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy Objectives: To assess the evolution of tricuspid regurgitation (TR) in dilated cardiomyopathy (DCM) patients undergoing mitral repair for functional mitral regurgitation (MR).
Methods: 91 DCM patients (mean age 61±11.3) submitted to MV repair (±tricuspid repair) for functional MR were included. Preoperative EF was 37±10%, LV end-diastolic volume 150±56 ml, LV end-systolic volume 103±51 ml, functional MR
Results: At follow-up (mean 1.8±1.2 years), echocardiographic assessment of the tricuspid valve showed that 12% of the patients (11/91) still had 3–4+ TR due to failure of the tricuspid repair or progression of untreated
Conclusions: A significant number of patients undergoing mitral repair for functional MR present
020 FUNCTIONAL AND HAEMODYNAMIC OUTCOME ONE YEAR AFTER PULMONARY THROMBOENDARTERECTOMY D.H. Freed, B. Thomson, S.S. Tsui, K. Shears, J. Pepke-Zaba, D.P. Jenkins Papworth Hospital, Cambridge, UK Objectives: Chronic thromboembolic pulmonary hypertension (CTEPH) results in severe symptoms and impaired survival. Pulmonary thromboendarterectomy (PTE) is considered the gold standard treatment. Many units have reported excellent early results post PTE, but there is little information on whether benefit is sustained. We sought to determine the medium term functional and haemodynamic outcome for patients following PTE.
Methods: Data was collected prospectively on all patients who underwent PTE in the UK between 1997 and 2005. Patients were reassessed at 3 and 12 months after operation. Postoperative data was compared to initial assessment values using a paired t-test and Results: One hundred and sixty three patients underwent PTE, survived to hospital discharge, and completed follow-up. At three months after operation, there was a significant reduction in mean pulmonary artery pressure (47–27 mmHg, P<0.0001), a significant increase in cardiac index (1.9–2.5, P<0.0001) and a significant increase in 6-min walk distance (270–374 m, P<0.0001). At 12 month follow-up, the haemodynamic improvements were sustained and there was a further increase in 6-min walk distance (374–401 m, P=0.01). NYHA class was significantly reduced at three months, with the improvement sustained at 12 months. Conclusions: PTE is a very effective therapy for CTEPH. This is the first report, from a continuous national series, to fully characterise haemodyamic and functional outcome one year after PTE. Patients enjoy continued improvement in haemodynamics that translates into better exercise capacity and reduced symptoms.
1Toronto General Hospital, Toronto, Canada; 2Princess Margaret Hospital, Toronto, Canada Objectives: The role of induction therapy for NSCLC invading the thoracic inlet is unclear. We reviewed our experience with induction chemo-radiation followed by surgical resection for NSCLC invading the thoracic inlet. Methods: Retrospective review of 44 consecutive patients with NSCLC invading the thoracic inlet treated with induction chemo-radiation (2 cycles of cisplatin and etoposide concurrently with 45 Gy of radiation) followed by surgical resection between 1996 and 2007. Results: All patients underwent chest wall resection (1–5 ribs, mean 3) with resection of the first rib through an anterior (n=15), posterior (n=18), or combined approach (n=11). Lobectomy was performed in 40 cases (90%), pneumonectomy in 2 (5%), and wedge resection in 2 (5%). Resection of subclavian vessels or portions of vertebrae was performed in 5 (11%) and 15 (34%) patients, respectively. Hospital mortality was 5% (n=2). R0-resection was achieved in 39 patients (89%). On pathological examination, 13 patients (30%) showed complete response (pCR) to induction therapy, and 15 (34%) showed minimal residual disease (90%–99% tumour necrosis). The mean follow-up was 32±37 months and overall 5-year survival was 58%. Sixteen patients (36%) developed recurrence, either local (n=5) or distant (n=11). The 5-year survival in patients with pCR was 91%, 77% in those with minimal residual disease, and 12% in those with no relevant response, (P=0.0005). Response to induction therapy was the only significant prognostic factor in multivariate analysis. Conclusions: Resection of NSCLC invading the thoracic inlet can be performed safely after induction chemo-radiation therapy. The response rate after induction therapy is a strong predictor of survival
Cliniques Universitaires Saint Luc, Brussels, Belgium Objectives: In recent studies focusing on the prognostic significance of histologic features of NSCLC tumours, vessels invasion was correlated to survival across all surgical stages. We similarly analyzed whether intra-tumoral permeation could affect survival in subgroups of Stage I and II NSCLC. Methods: A single institution retrospective analysis of a prospectively computed database. Specimens were analyzed for intra-tumoral vascular, lymphatic and nervous permeation. Overall mortality was determined and for each stage, a Cox-regression analysis of selected variables was performed. Detailed histologic information was available in 328 patients. Follow-up was 100% complete (mean=54 months). Results: From 1989 to 2004, we operated on 240 patients with pStage I (73.1%) and 88 patients with pStage II (26.9%). Sixty-seven pneumonectomies, 255 lobectomies and 6 lesser resection were performed (respectively 20.4%, 77.8% and 1.8%). In-hospital mortality was 2%. The completeness resection rate was 97%. The incidence of intra-tumoral permeation was 13.7% (44/321). Permeation correlated both with T status (P=0.02), N status (P=0.04) and stage (P=0.001). Median survival and overall 5-year survival for patients with and without permeation were 37.6 and 72.1 months respectively; and 43% and 54%, respectively (P=NS). Intra-tumoral permeation was a not a significant predictor for overall death [HR=1.2 (CI=0.8–1.8)]. Conclusions: In this large institutional study of early stage NSCLC, the presence of intra-tumoral permeation was correlated both to T, N status, as well as to stage. However, in contrast to recent reports, we did not found that intra-tumoral permeation adversely affects long-term survival.
Hopital Marie Lannelongue, Le Plessis Robinson, France Objectives: To identify factors that could affect operative mortality and morbidity and long-term survival after completion pneumonectomy (CP). Methods: A retrospective study was conducted at our department in Marie Lannelongue Hospital to review all patients who underwent CP. Results: From January 1996 to December 2005, 69 consecutive patients underwent CP for either a benign (n=22) or a malignant disease (n=47), accounting for 15% of all pneumonectomies performed during the same period. Malignant disease included a second primary lung cancer (n=22), a local recurrence (n=19) and metastasis (n=6). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality and morbidity rates were 12% and 50% respectively. Factors adversely affecting early mortality included obesity (P=0.005), coronary artery disease (P=0.03), right completion pneumonectomy (P=0.02), advanced age (P=0.02) and renal failure (P<0.0001). Preoperative renal failure was the only significant risk factor for morbidity (P=0.036). A bronchopleural fistula occured in seven patients (10%) and was more frequent in right CP (P=0.04) and in mechanichal stump closure (P=0.03). Overall 3 and 5 years survival rates were 53 and 33% respectively. Long-term survival was not affected by indication for CP. Conclusions: Although long-term survival is acceptable, CP remains associated with high postoperative mortality and morbidity rates confirming thus its reputation of a challenging procedure. However, postoperative bad results were found mainly in patients with significant associated comorbidity and in right CP. Better selection of patients should improve the postoperative outcome.
024 IMPROVING THE OUTCOME OF HIGH-RISK NEONATES WITH HYPOPLASTIC LEFT HEART SYNDROME (HLHS): HYBRID PROCEDURE OR CONVENTIONAL SURGICAL PALLIATION? C. Pizarro, C. Prospero, C.D. Derby, J.M. Baffa, K.A. Murdison, W.A. Radtke Nemours Cardiac Centre, Alfred I duPont Hospital for Children, Wilmington, USA Objectives: Despite significant progress, surgical outcomes for high-risk patients with hypoplastic left heart syndrome (HLHS) remain suboptimal. The hybrid palliation lessens the initial operative insult and is expected to improve overall survival; however the outcome of this management sequence is unknown. Methods: Retrospective review of all high-risk neonates (prematurity, low birth weight, associated genetic or co-morbid conditions) undergoing initial palliation for HLHS either by hybrid or Stage I Norwood procedure at a single institution between January 2001 and December 2006. The end-point for outcome was defined as survival after Stage II. Results: The cohort included 33 patients (14 hybrid and 19 Norwood) with a mean age of 3.8±2.4 days, weight of 2.6±0.6 kg, and Aristotle comprehensive score of 18.7±2.5. Aortic atresia was present in 5/14 hybrid and 12/19 Norwood patients. The mean gestational age was 36.8±2.2 weeks, six patients under 36 weeks in each group. Patients undergoing hybrid palliation had a larger aorta (3.2±1.7 mm vs. 2.7±1.0 mm) and a lower preoperative pH (7.14±0.2 vs. 7.25±0.05). Hospital mortality 7/33 (21%) for the entire cohort, was lower for the hybrid procedure (2/14 (14.3%) vs. 5/19 (26.3%) P<0.05). Interstage mortality was 3/12 (25%) hybrid and 3/14 (21.4%) Norwood group. Of the original 33 patients only 16 (48.5%) were alive following the second stage procedure (7/14 hybrid and 9/19 Norwood). Conclusions: Regardless of the type of palliation, high-risk neonates with HLHS continue to have decreased survival. Although the hybrid approach reduces the initial surgical insult, important interstage mortality and ongoing morbidity result in survival no different than with conventional surgical palliation.
1Clinic for Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany; 2Clinic of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University, Munich, Germany; 3Department of Anaesthesia, German Heart Centre Munich at the Technical University, Munich, Germany Objectives: The arterial switch operation (ASO) is the method of choice for correction of patients with transposition of the great arteries and the Taussig-Bing heart. The long-term results are encouraging but caution is demanded in some issues like the fate of the neo-aortic valve. Methods: We reviewed our experience with the ASO over the last 20 years and could identify 419 long-term survivors. Follow-up data were collected and analyzed with a special focus on the fate of the neo-aortic valve. Results: With increasing time after ASO, an increase in the incidence of aortic insufficiency (AI) is evident. From all the surviving patients, seven required an aortic valve replacement (AVR) at a mean time of 9.8 years after ASO. One patient died two years after AVR. At follow-up, six patients suffer from at least moderate AI. Freedom from AVR or moderate AI is 100%, 99.1% and 97% at 5, 10 and 15 years respectively. Risk factors for AVR were Taussig-Bing heart (P=0.003), previous operation before ASO (P=0.029) and postoperative AI (P<0.001). Conclusions: Although aortic insufficiency is progressive after ASO, the rate of AVR is low. Especially patients with Taussig-Bing heart have a higher risk of developing AI and should remain under close follow-up.
Great Ormond Street Hospital, London, UK Objectives: Percutaneous pulmonary valve insertion (PPVI) is an evolving alternative to surgical pulmonary valve insertion. The aim of this study is to review the acute complications of PPVI requiring emergency rescue surgery. Methods: Between September 2000 and January 2007, 152 patients (pts), mean age 16.8 years received a PPVI. Patient's charts were reviewed in retrospect. Results: Emergency rescue surgery (ERS) took place in 6 pts (3.9%). Indications for ERS were: homograft rupture 2 pts, dislodgement of the stented valve in a dilated right ventricular outflow tract 2 pts, occlusion of the right pulmonary artery 1 pt and compression of the left main coronary artery 1 pt. Cardiopulmary bypass was established through repeat sternotomy incision with femoro-femoral canulation in 2/6 patients, the stented valve was removed in five and replaced with a homograft in four and a valved conduit in 1 pt. One ruptured homograft was repaired leaving the stented valve in situ. All patients survived, one sustained mild neurological impairment. Conclusions: Although some of the complications of PPVI were probably related to a learning curve (four among the first 50 pts and two among the last 102 pts) the need for ERS is unlikely to be completely abolished. This experience highlights the importance of close collaboration between cardiologist and surgeons in these evolving technologies. Highly skilled and sufficiently responsive surgical back-up is necessary to support the introduction and to sustain institutional programmes such as PPVI.
1Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, UK; 2Clinical Operational Research Unit, University College, London, UK; 3The Hospital for Sick Children, Toronto Canada Objectives: Databases almost invariably contain some errors and improvements to the quality of recorded data are costly. We sought to assess the extent to which a given level of error in a clinical database can lead to misleading mortality rates being derived. Methods: We deliberately seeded a large database concerning congenital heart surgery (>14,000 patients), which we assumed to be error-free, with errors at known rates of 0–5%. The effects of two different types of random error were explored: the miscoding of outcomes (alive or dead) and the miscoding of procedures. For each error type, we compared the mortality rates calculated from the ‘seeded’ database to those calculated from the pristine database. Results: For lower risk procedures, introducing a 5% chance of error to the coding of outcome resulted in a doubling or worse of the true mortality rate. If procedure types are miscoded, procedure-specific mortality estimates for high-risk operations decrease and those for low-risk operations increase, the overall mortality remaining the same. A mathematical model was developed which can be used to accurately replicate these and other error-seeding experiments. Software to implement this model is freely available on the internet. Conclusions: Even small levels of data input error have substantial effects on the estimates of mortality rates, especially for low-risk operations. These errors could lead to misleading analysis of institutional and individual surgeons’ results. Our results suggest that caution is warranted in interpreting the mortality estimates derived from clinical databases. More emphasis is needed on minimizing data input error.
028 CARDIAC CO-MORBIDITY IS NOT A RISK FACTOR FOR MORTALITY AND MORBIDITY FOLLOWING SURGERY FOR PRIMARY NON-SMALL CELL LUNG CANCER P.K. Mishra, R. Pandey, M.J. Shackcloth, J. McShane, A.D. Grayson, M.H. Carr, R.D. Page The Cardiothoracic Centre, Liverpool, UK Objectives: We examined the effect of cardiac co-morbidity on mortality and postoperative complications following surgery for primary non-small cell lung cancer. Methods: September 2001 to December 2005, 1067 consecutive patients underwent lung resection for primary cancer within a single centre; patient data was collected prospectively. Two hundred and seventy one patients had a history of cardiac co-morbidity which included 196 angina, 118 myocardial infarction, 36 revascularisation, ten congestive cardiac failure and 19 rhythm disorders (numbers not mutually exclusive). To account for differences in case-mix we used logistic regression to develop a propensity score for cardiac co-morbidity group membership and then performed a propensity-matched analysis. Kaplan–Meier curves used to assess follow-up mortality. Results: Patients with cardiac co-morbidity were more likely to be hypertensive, have severe dyspnoea, diabetes, current or ex-smokers and were older. After performing propensity-matching to account for these differences we successfully matched 199 patients with cardiac co-morbidity to 398 patients with no cardiac history. There was no difference in in-hospital mortality (2.5% vs. 3%, P=0.73), myocardial infarction (0.5% vs. 0.3%, P>0.99), arrhythmia (15.6% vs. 14.1%, P=0.62), renal failure (2% vs. 1.5%, P=0.65), stroke (0.5% vs. 0.3%, P>0.99), respiratory insufficiency (4% vs. 3.3%, P=0.64), reintubation (1% vs. 2.5%, P=0.35), tracheostomy (4% vs. 7.8%, P=0.08), intensive care readmission (8.5% vs. 6.5%, P=0.37) and length of stay (8 days vs. 8 days, P=0.98). Three-year mortality was similar (38.6% vs. 43.8%, P=0.39). No differences in outcomes existed with different cardiac conditions. Conclusions: Patients with cardiac co-morbidity are not at increased risk of mortality and postoperative complications following lung resection.
Siauliai Public Hospital, Siauliai, Lithuania Objectives: We examined factors associated with low- and high-risk of oesophageal cancer (EC) generalisation after complete (R0) oesophagectomies (E). Methods: We analyzed data of 126 consecutive EC patients (ECP) (age=56.8±7.9 years; tumour size D=5.4±2.5 cm) radically operated and monitored in 1975–2007 (males=98, females=28; Lewis=89, Garlock=37; combined operations=40; D2=59, D3=67; adenocarcinoma=93, squamos=31, mix=2; T1=25, T2=38, T3=29, T4=34; N0=55, N1=23, M1a=48; M1b=0; stI=22, IIA=24, IIB=13, III=19, IVA=48; only surgery-S=97, adjuvant chemoimmunoradiotherapy-AT=29: 5-FU=thymalin/taktivin+radiotherapy 45–50 Gy). Variables selected for 5-year survival (5YS) study were input levels of 45 blood parameters, TNMG, D. Cox modeling, clustering, discriminant analysis, SEPATH, Monte Carlo, bootstrap and neural networks computing were used to determine any significant dependence. Results: Cumulative 5YS was 50.5%, 10-year survival, 38.3%. Sixty-four ECP (50.8%) were alive, 39 ECP (31%) lived more than five years (life span: LS=3544.3±1712.5 days) and 17 ECP, ten years (LS=5000.1±1639 days) without EC. Fifty-five ECP (43.7%) died because of EC (LS=621.4±366 days). AT significantly improved ECP 5YS after E (P=0.023 by log-rank test). Cox modeling displayed that 5YS of ECP after E significantly depended on: T, N, histology, stage, combined procedures, AT, age, blood cell subpopulations (P=0.000–0.039). Neural networks computing, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS of ECP and N, sex, EC growth, T, histology, combined procedures, G, residual nitrogen, haemorrhage time, chlorides, AT, neutrophils, D, thrombocytes, monocytes. Correct prediction of ECP survival after E was 100% by neural networks computing (area under ROC curve=1.0; error=0.001). Conclusions: Optimal treatment strategies for ECP are: screening and early detection of EC; availability of experienced surgeons because of complexity E; aggressive en block surgery for completeness; precise prediction; AT for ECP with unfavourable prognosis.
Thoracic Surgery Unit, University Hospital, Salamanca, Spain Objectives: Early identification of patients at high-risk of emergency hospital readmission (EHR) after major lung resection would allow us to develop strategies to prevent it. We hypothesised that detection of EHR patients could be done faster and accurately analyzing preoperative variables with a decision tree methodology, obviating the need for postoperative variables being recorded and included in the analysis for successful prediction. Methods: A decision tree methodology was retrospectively applied to two subsets of variables prospectively recorded in 964 patients scheduled for major lung resection. Series A included preoperative variables only: age, sex, body mass index (BMI), estimated postoperative FEV1 (ppo FEV1), preoperative FEV1, extent of resection scheduled and diagnosis. Series B included pre- and postoperative variables: length of stay (LOS), type of resection, reintervention and postoperative morbidity. The dependent variable was EHR. Results: EHR rate was 6% and in 38% of cases was secondary to pleural empyema after discharge. The most important variables influencing EHR in Group A were ppo FEV1, preoperative FEV1, BMI and age. In Group B, preoperative FEV1, ppo FEV1, morbidity, age, pleural infection after discharge and emergency reoperation. The accuracy of the Group A model to predict EHR was 51% against 43.6% for the Group B model. Conclusions: The inclusion of postoperative variables for decision tree analysis does not improve the accuracy of the model. An analysis including preoperative variables only allows us to determine the risk for EHR, thus resulting in time profit and better prevention planning.
1Erasmus MC, Rotterdam, The Netherlands; 2University of Florida, Shands Jacksonville, Jacksonville, USA Objectives: Conflicting reports exist regarding the power of post-procedural cardiac enzyme elevation in predicting mortality. Long-term impact of CK-MB elevation following multivessel coronary stenting or CABG was evaluated. Methods: Prospective substudy of the randomised multicentre arterial revascularisation therapies study (ARTS) comparing coronary stenting to CABG for multivessel disease, conducted from 1997–1999. One thousand and twenty eight patients were included (496 CABG and 532 stent). Blood samples were collected to evaluate CK-MB levels at baseline, 6, 12 and 18 h after the procedure. Patients were stratified according to CK-MB level into four groups: normal, 1–3 times, 3–5 times, and >5 times the upper limit of normal. Mortality and major adverse coronary and cerebral events at 1, 3 and 5 years were determined. Results: Five-year follow-up was complete. Periprocedural enzyme elevation was 27.6% and 61.9% in stent and CABG group, respectively. CABG patients with CK-MB >3 times the upper limit had a higher mortality compared to those with CK-MB <3 times (16.0 vs. 4.5%, P<0.001). In the stent group increased enzyme elevation was not related with mortality at follow-up. A CK-MB level >3 times ULN was an independent predictor of mortality in the CABG group, but not in the stent group. Conclusions: CK-MB levels >3 times the upper limit in the bypass arm were independently associated with mortality at 5-year follow-up. No such association was seen in the stent arm. The results from the CABG arm suggest that a CK-MB value >3 times ULN is a better cut-off for the diagnosis of post-procedural myocardial infarction.
032 BILATERAL THORACOSCOPY, MEDIASTINOSCOPY AND LAPAROSCOPY, IN ADDITION TO CAT, MRI AND PET IMAGING, APPEARS ESSENTIAL TO CORRECTLY STAGE AND TREAT PATIENTS WITH MESOTHELIOMA PRIOR TO TRIMODALITY THERAPY J.M. Alvarez, A. Hasani, D. Zelei, A. Segal, G. Sterrett, A. Nowak, M. Millward, W. Musk Sir Charles Gairdner Hospital, Perth, Australia Objectives: Trimodality therapy (pleuropneumonectomy, chemotherapy, radiotherapy) offers the potential of optimal survival for selected stages 1–2 non-sarcomatous mesothelioma. We hypothesized that CAT, MRI and PET scanning were inadequate to accurately stage these patients. Therefore, patients prior to pleuropneumonectomy, had bilateral thoracoscopy, mediastinoscopy and laparoscopy (surgical staging). Methods: Patients referred for trimodality therapy had CAT, MRI and PET scans confirming stage 1–2 disease. Surgical staging was also performed. CAT scans were performed 6 monthly, quality of life assessments (ECOG and Karnofsky) yearly. Results: From 1 June 2004 to February 28, 2007, 35 patients were referred; mean age was 66 years (range: 44–69). Surgical staging was performed in 31 patients; 24 patients were confirmed as Stage 1–2. However, 6 were upstaged, 5 as stage 4 disease (2 contralateral chest, 3 contralateral chest and abdomen) and 1 mediastinal node positive; two patients were reclassified histologically (1 sarcomatous, 1 biphasic). These eight patients reclassified by surgical staging fared poorly, 62% dying within one year. Post surgical staging, three patients declined pleuropneumonectomy, 19 patients proceeded to surgery, three were unresectable and 16 had pleuropneumonectomies. Follow-up of all 35 patients is complete. Thirty-day operative mortality was 6.3% (1/16). Two patients experienced abdominal recurrence within 12 months. A trend towards improved survival and better quality of life was evident with trimodality therapy. Conclusions: Surgical staging identified 26% of patients who would have received no benefit from pleuropneumonectomy and been exposed to unnecessary risk. For trimodality therapy to demonstrate a proven survival benefit surgical staging is essential.
Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK Objectives: To compare outcome in three distinct type of debulking surgery for malignant mesothelioma (MM) in patients unsuitable for extrapleural pneumonectomy (EPP). Methods: Retrospective study in a single institution of 165 consecutive patients (147 male, mean age 64.5 years) over a 10-year period. VATS pleurectomy/decortication (P/D) (n=72), open simple P/D preserving the diaphragm (n=50) or radical P/D (n=43) were performed as an alternative to EPP because of stage (T4, N2) or fitness (age, low FEV1). Univariate and multivariate analysis tested potential predictors of survival. Results: Epithelial cell type was predominant (66.7%). The three groups were similar for age, gender and histology. Thirty-day and 90-day mortality rates were 3.6% and 14.6%, respectively. Postoperative morbidity rate was 24.8%. Mean hospital stay was 11.3 days. Overall 1-year and 2-year survival rates were respectively 60.5% and 50.6% for radical P/D, 52.7% and 18.1% for VATS P/D, 32% and 8.9% for open simple P/D. On univariate analysis, radicality of debulking was a significant prognostic factor (P<0.0001). Sarcomatoid histological type had a significant negative impact on survival (P<0.0001). On multivariate analysis, nonepitheliod histology (P=0.006) and absence of adjuvant chemotherapy (P=0.02, HR: 2.6, 95%CI: 1.16–5.7) were independent bad prognostic indicators. Conclusions: In patients with non-sarcomatoid MM unfit for EPP, debulking pleurectomy/decortication is feasible; it should be as radical as possible and should be consolidated by adjuvant chemotherapy. For non-epithelial histology, the benefit on survival of debulking surgery remains uncertain.
Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK Objectives: In the preoperative workup for radical surgery for malignant pleural mesothelioma (MPM), mediastinal lymph node staging, diagnostic pleural biopsies and effusion control with talc pleurodesis are required. We present a new technique combining these objectives via a single cervical incision using the video-mediastinoscope and demonstrate its clinical benefits. Methods: Video-assisted cervical thoracomediastinoscopy (VACT) was attempted in 15 patients (13 male, mean age 57 years), who were potential candidates for radical surgery. Following conventional cervical videomediastinoscopy, a 5-mm thoracoscope was advanced into the relevant pleural cavity through the mediastinoscope via a mediastinal pleurotomy. Pleural biopsies were taken followed by talc insufflation and cervical tube drainage. The clinical outcome was compared with 26 patients undergoing a staged preoperative workup during the same period. Results: VACT was successful in ten patients (66.6%). In five patients, (three right and two left) thoracoscopy was abandoned due to excessive mediastinal fat (1), thick pleura (2) and inability to enter the left hemithorax (2). Mean operative time was 71 (65–90) min and hospital stay 4 (3–7) days. One patient suffered recurrent laryngeal nerve palsy and one had persistent air leak. Ten patients subsequently underwent radical surgery. Time to radical surgery was significantly reduced by nearly two months in VACT patients (28±17 vs. 87±56 days, P<0.001). Conclusions: The benefits of this approach include reduction in postoperative pain, risk of biopsy site tumour seeding, and preoperative delay to radical surgery. VACT is feasible in right sided mesothelioma but has not yet been validated on the left.
Guys Hospital, London, UK Objectives: To evaluate the accuracy of integrated 18-Fluorodeoxyglucose Positron Emission Tomography and Computer Tomography (PET-CT) in the preoperative staging of patients undergoing extra pleural pneumonectomy (EPP) as part of trimodality therapy for (MPM). Methods: We prospectively studied all patients undergoing trimodality therapy for MPM and reviewed 17 consecutive patients [15 male; median age 62 years (range 52–68)] who underwent EPP following induction chemotherapy for MPM (12 epithelioid, 5 biphasic) over a 36-month period in a single surgical practice. PET-CT findings were correlated with final histology to determine the accuracy of PET-CT staging. Results: PET-CT was performed a median 100 days (range 3–229) prior to EPP. It correctly identified T stage in 2 cases (11.7%); understaged in 12 (70.5%) and overstaged in 3 (17.6%). PET-CT failed to identify six patients with T4 disease. Extrapleural nodal disease (N2), present in seven patients (41%) on final histology, was predicted by PET–CT with a sensitivity of 14%; specificity of 90% and accuracy of 59%. Conclusions: PET-CT does not stage intrathoracic tumour extent accurately but it is useful in excluding from radical surgery patients with unsuspected advanced stage disease (M1).
1Department of Surgery, University Hospital, Magdeburg, Germany; 2Division of General Thoracic Surgery, University Hospital, Bern, Switzerland Objectives: Bronchus stump insufficiency is one of the major complications after pneumonectomy, we analyzed all patients who underwent extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) in order to detect the role of muscle flap on preventing early and late stump insufficiency. Methods: From January 2000 to December 2005, 42 patients were admitted with MPM for further investigation at our institution. Thirty patients were suitable for surgery thus received a combined treatment modality approach with neo adjuvant chemotherapy using cisplatine and gemcitabine, extra pleural pneumonectomy (EPP) followed by 54-Gy adjuvant radiotherapy. Data were collected from the surgical and oncological records. Age, sex, concomitant diseases, risk factors, staging, operative procedures, tumour histology, time of hospital stay, early and late complications, and overall survival were analyzed. Results: There were 37 (88%) male patients, the median age was 65 years (range 40–83 years). Nicotine abuse was found in 22 (52%) patients, 38 (90%) patients had asbestos exposure. The histological findings in all patients were: (1) epithelial (n=32), (2) papillary (n=2), (3) biphasic (n=2), and (4) sarcomatoid type (n=4). The operative procedures were EPP with muscle flap through an anterolateral thoracotomy. One patient (3%) died on the 2nd postoperative day due to lung embolism. Mild complications were noticed in the early postoperative phase in eight (25%) patients. There was no early or late stump insufficiency during the 15 month follow-up. One patient had local recurrence within three months postoperative (3%), and after 12 months in eight (25%) patients. The over-all survival after 15 months is 60%. Conclusions: Surgical technique using muscle flap seems to play a major role in prevention bronchus stump insufficiency especially after neo adjuvant chemotherapy
037 SURGICAL CORRECTION OF TETRALOGY OF FALLOT. A SINGLE CENTRE EXPERIENCE OF 1181 CORRECTIVE PROCEDURES OVER FIVE DECADES E.J. Hickey, T. Bradley, A. Gengsakul, C. Manlhiot, W.G. Williams, G.D. Webb, B.W. McCrindle The Hospital for Sick Children, Toronto, Canada Objectives: We sought to characterize our long-term experience of corrective surgery for Tetralogy of Fallot (TOF) in a cohort of patients who have now all reached adulthood. Methods: One thousand one hundred and eighty one patients born 1927–1983 (including pure TOF=1069, PAVSD=88 and TOF/Absent PV=15) underwent corrective surgery at our institution. Repair strategies included RVOT patch (n=327), transannular patch (n=370), no patch (n=333), or RV-PA conduit (n=54). Late follow-up was undertaken by direct consultation with patients or their records. Analysis was through parametric competing risks techniques. Results: Overall survival was 80±1% at 30 years. Mean age at corrective surgery progressively decreased with era from 15.2 years to 4.2 years for children born in the 1940s and 1980s, respectively. Adjusted for era, death was predicted by main pulmonary artery/branch stenosis, Down's syndrome, right aortic arch and variants of TOF (all P<0.001) but was independent of corrective surgery type. The hazard for reoperation was early and gradually reducing thereafter. Freedom from re-operation was 67±2% and 55±2% at 20 and 30 years, respectively. Branch PA stenosis, DiGeorge syndrome, anomalous coronary arteries, variants of TOF and the use of an RV-PA conduit were predictors of reoperation/catheter re-intervention. The risk of subsequent pulmonary valve replacement was a slow constant hazard (88±2% free from PVR at 30 years) and was predicted by the use of an RV-PA conduit. Conclusions: Late survival into adulthood is favourable and independent of type of TOF variant or repair. Efforts to avoid RV-PA conduits and minimize branch PA stenosis are likely to translate in the best chance of avoiding re-intervention.
Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea (South) Objectives: There has not yet been a consensus on the long-term fate of the unifocalized major aortopulmonary collateral arteries (MAPCAs) after surgery for pulmonary atresia with ventricular septal defects (VSD) and MAPCAs. We sought to evaluate surgical outcomes of these patients and growth potential of the unifocalized MAPCAs. Methods: From July 1988 to April 2006, 40 patients (median age, 8.5 months; 26 days–16 years) underwent surgery for pulmonary atresia, VSD, and MAPCAs. During the study period, patients had 104 sternotomies and thoracotomies to perform 56 shunts, 38 MAPCAs unifocalizations, 19 right ventricular outflow tract reconstructions, 17 Rastelli, and 6 redo-Rastelli operations. Results: The concurrent follow-up rate was 80% (8 follow-up loss). The hospital mortality of the preparatory procedures was 1.2% (1/81). Seventeen (42.5%) patients had a complete repair at their age of 5.2 years (median 3, 0.3–15 years). The hospital mortality of the repair was 11.8% (2/17), and no late death occurred after repair. The patients with pulmonary artery index >100 mm2/m2 have the more chance of complete repair. The overall survival of all patients to the age of 22.2 years was 70.9%. The overall survival 15 years after complete repair was 87.5%. Cox analysis demonstrated that increased number of MAPCAs (P=0.019, HR=1.666) taken as a continuous variable was significant factor predictive of poor late survival for each additional number of MAPCAs and complete repair (P=0.025, HR=0.141) was the independent risk factor for favourable prognosis. On angiography, serial measurements of MAPCAs showed decrease in their size (from 5.2 to 4.1 mm after a mean of 20 months) (P<0.0001). Conclusions: Long-term survival into adulthood of patients with pulmonary atresia, VSD, and MAPCAs has been achieved with integrated approach. However, late survival depends exclusively on the complete repair. Growth potential of the unifocalized MAPCAs was not definite.
1Department of Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany; 2Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University, Munich, Germany Objectives: Atrial switch procedures for transposition of the great arteries are associated with reoperations mainly for systemic ventricular dysfunction and baffle complications. This study aims at identifying the incidence and the results of reoperations following the Senning operation. Methods: Records of 314 hospital survivors after the Senning operation were reviewed. Results: Mean follow-up time was 18.2±5.7 years. Freedom from reoperation and survival at 25 years was 88.0±2.1% and 90.9±2.3%, respectively. Survival of patients reoperated for systemic ventricular failure (arterial switch and Senning take down without prior pulmonary artery banding n=2, with prior banding n=3, banding without conversion n=4, tricuspid valve repair n=3) was significantly lower compared to patients who did not undergo reoperations (P<0.001), whereas survival of patients reoperated for baffle complications (n=11), or left ventricular outflow tract obstruction (n=7) was not. Mean follow-up time after the first reoperation was 7.7±5.9 years. Survival after reoperation for systemic ventricular failure, at 30 days, 1 year, and 5 years was 91.7±8.0%, 83.3±10.8%, and 64.8±14.3%, respectively. Survival after reoperation for baffle complications and left ventricular outflow tract obstruction at five years was 85.7±13.2% and 83.3±15.2%, respectively. Conclusions: Reoperations following the Senning operation are rare. Reoperations for baffle complications or left ventricular outflow tract obstruction can be performed with good results in the mid-term. However, reoperations for systemic ventricular failure are demanding, and are associated with a high operative and mid-term mortality.
Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea (South) Objectives: Some patients with pulmonary atresia and intact ventricular septum (PAIVS) have to undergo single ventricle repair. In these patients, presence of the non-functioning right ventricle (RV) may lead to the aggravation of RV to coronary connections and left ventricular diastolic dysfunction. To prevent the deleterious effects, the RV was excluded surgically. Methods: Between December 2000 and February 2006, ten patients with PAIVS underwent RV exclusion in conjunction with cavo-pulmonary anastomosis (n=6) or systemic-to-pulmonary artery shunt (n=4). The median age at surgery was 5 (0.2 13.8) months. The median z-value of the tricuspid value was –4 (–6.5–1.3). The tricuspid valve was closed with patch (n=2) or directly (n=8). Thrombotic materials were inserted into the cavity in eight patients. Follow-up was completed in all survivors for a period up to 75 (median 24) months. Results: There was no mortality. Six patients underwent a Fontan procedure and the other four are waiting. Seven patients showed totally obliterated RV, two still had small communications between RV and coronary artery, and one had remaining RV cavity impairing the diastolic function of the left ventricle. In this patient, tricuspid valve had been closed directly without the use of thrombotic materials because of sizable RV cavity. Conclusions: RV exclusion can be performed safely in a subgroup of patients with PAIVS. Obliteration of the RV cavity would be easier when performed at earlier stage of palliation if the patient is expected to follow single ventricle correction.
Hospital for Sick Children and the University of Toronto, Toronto, Canada Objectives: Arterial-switch operation (ASO) for management of Taussig-Bing anomaly is associated with important morbidity. We examined efficacy of single-stage repair strategy tailored to address all abnormalities on individual basis. Methods: Thirty-three children (infants, n=29) with Taussig-Bing underwent ASO (1979–2005). Group 1 (n=17): initial palliation: pulmonary-artery band (n=9), coarctation repair (n=6), atrial septostomy (n=3) followed by ASO. Group 2 (n=16): single-stage total correction: ASO+ventricular septal defect closure+baffling of left ventricle to neoaorta performed in neonates with arch obstruction (n=8), or at age six weeks in those with no arch obstruction (n=8). Relief of right-ventricle outflow-tract obstruction (RVOTO) was required in 14. Demographics and operative variables affecting outcomes were analysed. Results: Mean age at operation for Groups 1 and 2 was 312±477 and 42±31 days (P<0.0001). One-year survival for Groups 1 and 2 was 47±5% and 100% (P=0.001). Associated anomalies such as arch obstruction, unusual coronaries were not significant risk factors on multivariable analysis. Ten-year freedom from RVOT and arch re-operation was 55±5% and 96±4%. Five-year event–free survival for Groups 1 and 2 was 35±6% and 87±1% (P=0.0016). Significant factors affecting event–free survival were group 1 (HR 108, P=0.0005), and larger weight at surgery (HR 1.3, P=0.02). Conclusions: Taussig-Bing anomaly is complex and often associated with other cardiac anomalies (arch obstruction, RVOTO, unusual coronary pattern). Advances in peri-operative care have significantly mitigated mortality. Event-free survival especially freedom from RVOT re-operation is significantly improved with single-stage repair.
Tokyo Women's Medical University, Tokyo, Japan Objectives: Various issues on the long-term survivors of arterial switch operation (ASO) have been clarified according to the improvement of surgical mortality. We reviewed the long-term results and social independence level after ASO. Methods: Two hundred and four patients over 15 years after ASO were studied retrospectively. ASO was performed as primary operation (Group I, n=99) or as secondary operation (Group II, n=105). Lecompte procedure was performed in 197 patients, modified Aubert procedure in five and original Jatene procedure in two. The follow-up period was 17.7±4.0 years. Results: There were 11 late deaths (sudden death in 4, CHF in 2, pulmonary hypertension in 2, infection in 2, cancer in 1). Kaplan–Meier survival rate was 96.1% at 5 years, 95.1% at 10 years and 94.6% at 20 years. Forty-five re-operations per 40 patients were performed (Konno in 2, AVR in 5, AVP in 2, DVR in 1, RVOTR in 31, others in 4). The event free rate including late death was 85.2% at 5 years, 80.4% at 10 years and 75.9% at 20 years. One hundred and seventy eight patients were classified as NYHA in class I and seven patients as class II. All the patients schizophrenia (1) and mental retardation (3) is going to school or working well. There was no significant difference in left ventricular function between Groups I and II, within normal range. Conclusions: The long-term (>15 years) outcome of ASO survivors was satisfactory. Most patients show excellent cardiac function and could be socially independent.
043 PERICARDIAL PATCH AUGMENTATION FOR REPAIR OF INCOMPETANT BICUSPID AORTIC VALVES AT FOUR YEARS M. Doss, A. Sirat, P. Risteski, S. Martens, A. Moritz Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany Objectives: Reoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves. Methods: Autologous pericardium is sutured to the free edge of the prolapsing bicuspid leaflet. A large coaptation surface is created and competence of the bicuspid valve is achieved. Forty patients underwent reconstruction of their bicuspid aortic valves by pericardial patch augmentation. Patients were followed-up at regular intervals by echocardiography for four years. Results: There were no perioperative deaths. One year postoperatively, one patient died due to endocarditis. Seven patients (17.5%) had aortic regurgitation Grade I, and the other 33 patients had non- or trivial aortic regurgitation at discharge. At four years postoperatively, only four patients (10%) had aortic regurgitation Grade I. There were no cases of progression of regurgitation. Planimetric effective orifice areas ranged above 2 cm2. Mean aortic gradients were 8.2±4.8 mmHg and the mean height of coaptation surface was 14.7±2.1 mm. Conclusions: The pericardial patch augmentation technique increases coaptation surface, and thus provides reliable early and midterm competence of reconstructed bicuspid aortic valves.
Universite Catholique de Louvain, Brussels, Belgium Objectives: The different techniques to correct aortic cusp prolapse are central plication (CP), triangular resection with direct suture (TR) and oversewing of the free margin with PTFE (OS). We retrospectively analyzed our result with those techniques. Methods: Between January 1996 and December 2006, 307 patients (age 11–84) underwent elective aortic valve (AV) repair. In 142 of them, a prolapse of one, two or three cusps was found. Cusp prolapse was defined as a lower height of the cusps’ free margin compared to the other(s) or a relative low coaptation level of the cusps when appropriate suspension is applied on the commissures. Seventy-four patients had bicuspid valve and 75 had root or ascending aorta dilatation. A single technique was used to correct the prolapse in 79 patients (Group A: CP, TR or OS) and two techniques were used in 63 (Group C: CP+OS or TR+OS). Results: There was no hospital mortality. Immediate reoperation for recurrent AR occurred in three patients (2.1%), one was re-repaired. During the follow-up (range: 4–135 months, mean: 43±25 months), one patient died from trauma and three patients needed late reoperation for recurrent AR, one of them has developed concomitant AV stenosis on progressive calcification. At 1/6 years freedom from reoperation was 97%/93% (A), 98%/96% (B) and freedom from AR > Grade 2 was 98%/80% (A), 98%/90% (B). Conclusions: In all aortic valve repairs, cusp prolapse must be tracked and corrected aggressively. The different techniques of repair and their association show equivalent and good long-term durability.
1Cardiac Surgery Unit, Bichat University Hospital APHP, Paris, France; 2Vascular Surgery Unit, Ambroise Pare University Hospital APHP, Boulogne Billancourt, France; 3Cardiac Surgery Unit, Pitie Salpetriere University Hospital, Paris, France; 4Cardiology Unit, Saint Antoine University Hospital APHP, Paris, France; 5International Heart Institute of Montana Foundation, Missoula, USA Objectives: Aortic valve repair is developed as an alternative to valve replacement for treatment of aortic insufficiency (AI). In order to standardize surgical management, we suggest a classification based on echographic and operative analysis of valvular lesions. Methods: We retrospectively analyzed AI mechanisms of 781 adults operated electively (1997–2004). Results: AI was isolated [406 patients (52%)], associated with supra-coronary aneurysm [97 cases (12.4%)], or with aortic root aneurysm [278 patients (35.6%)]. Aetiologies were respectively rheumatic and dystrophic in 22.5% and 77.5% of cases. Lesional classification is based on the analysis of AI mechanisms defining Type I with central jet (354 cases, 45.3%) and Type II with eccentric jet (54.7%). Type Ia is defined as isolated dilation of sino-tubular junction (STJ, 47 supra-coronary aneurysms), and Type Ib as dilation of both STJ and aortic annular base (233 root aneurysms, 74 isolated AI). The Type II associates dilation of STJ and annular base to a valvular lesion: Type IIa cusp prolapse (95 aneurysms, 200 isolated AI), Type IIb cusp retraction (132 rheumatic AI), Type IIc cusp tear (endocarditis, traumatic). Conclusions: This lesional classification aims to standardize the surgical management of aortic insufficiency towards valve repair: Type Ia, supra-coronary graft; Type Ib, subvalvular aortic annuloplasty associated to the remodelling technique (aortic root aneurysm) or double sub and supra valvular annuloplasty (isolated AI). For AI Type II, aortic annuloplasty associated to the remodelling technique or double sub and supra valvular annuloplasty is combined with cusp resuspension (IIa), cusp reconstruction with autologous pericardium (IIb), or cusp resuspension and/or autologous pericardium patch (IIc).
Rajaee Cardiovascular Medical Center, Tehran, Iran Objectives: As an invaluable surgical tool, autologous pericardium has been successfully used to repair a myriad of cardiac lesions. The encouraging results from its use in repairing the heart valves are taken advantage of to repair tricuspid valve regurgitation (TR). In the present study, we report our preliminary results using autologous pericardium as a new surgical technique in repairing tricuspid valve insufficiency. Methods: From June 2002 to November 2006, 22 patients (mean age 39.7 years) with heart valve disease underwent tricuspid valve repair by anterior leaflet augmentation with glutaraldehyde-treated autologous pericardium. Nineteen patients (86.4%) had pure tricuspid valve regurgitation, while the remaining three patients (13.6%) had significant associated tricuspid valve stenosis in whom commissurotomy was carried out systematically. TR was considered severe in 18 patients and moderate to severe in four cases. All had associated left-sided heart valve surgery except two patients. Concomitant adjustable tricuspid annuloplasty by pericardial band was performed in 12 patients. The mean follow-up period was 10.39 months (ranging from 1 to 42 months). Results: There was one in-hospital death due to postoperative multi-organ failure. One patient developed partial detachment of pericardial patch, which was successfully repaired. Echocardiography data showed a significant decrease in the severity of TR: trivial to mild in 68.2% (n=15), mild to moderate in 22.7% (n=5), and moderate to severe in 9.1% (n=2) of the patients. Conclusions: Anterior tricuspid leaflet augmentation is a safe, effective and appealing surgical technique in dealing with patients with tricuspid valve regurgitation. Further studies are, however, mandatory to evaluate its long-term outcome.
1Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany; 2Department of Cardiothoracic Surgery, Friedrich Schiller University, Jena, Germany; 3Department of Cardiothoracic Surgery, University Cologne, Cologne, Germany Objectives: Recent studies could prove the safety of the aortic valve reimplantation technique. Studies demonstrating the superiority of this procedure compared to alternative standard operations are missing so far. This study compared the results of the David operation aortic composite replacement regarding survival, follow-up complications and quality of life. Methods: Within a six-year period until December 2005, 143 patients received either an aortic composite replacement (composite-group, n=67) or the David-I-operation (David-group, n=76). Demographics of both groups were comparable (age: 56±12 vs. 58±14 years, gender: female 21 vs. 26%, EuroSCORE: 7±4 vs. 8±3, follow-up: 31±19 vs. 24±21 months, acute aortic dissection: 22% vs. 24%). The quality of life was evaluated postoperatively by the SF-36 added by specific questions at the earliest six months postoperatively. Results: Hospital survival (91.0% vs. 97.4%, P=0.102) as well as actuarial 1-year (88.1% vs. 93.4%) and three-year survival (84.7% vs. 93.4%) were better for the David-group (P=0.127). Valve related complications were not documented within the postoperative follow-up for any of both groups. Quality of life was found to be impaired in all of the scales for patients of the Composite-group (physical functioning 67.0±25.8 vs. 75.4±24.0, P=0.172; role physical 59.2±44.2 vs. 69.5±30.4, P=0.481; bodily pain 72.7±28.1 vs. 80.9±22.5, P=0.196; general health 54.5±23.3 vs. 67.0±19.1, P=0.006; vitality 53.0±24.2 vs. 59.8±17.5, P=0.147; social function 79.1±22.8 vs. 81.8±23.2, P=0.424; role emotional 69.0±19.3 vs. 76.3±16.5, P=0.058). These patients were additionally compromised by the prosthetic valve noise (P<0.001), by the necessity of anticoagulants (P<0.001) as well as by the fear for valve damage (P=0.02). Conclusions: This study demonstrates the superiority of the aortic valve re-implantation compared to the aortic composite replacement.
048 BLUNT TRAUMA AND ACUTE AORTIC SYNDROME: A THREE LAYER FINITE ELEMENT MODEL OF THE AORTIC WALL A. Zhao3, K. Digges3, M. Field1, D. Richens2 1The Cardiothoracic Centre, Liverpool, UK; 2The Trent Cardiac Centre, Nottingham, UK; 3FHWA NHTSA National Crash Analysis Centre, Ashburn, USA Objectives: Acute pathologies of the aorta, ranging from intimal tear, through intra-mural haematoma (IMH), to aortic dissection, are part of a disease continuum termed acute aortic syndrome (AAS). Typically, blunt traumatic aortic rupture follows high speed impacts and involves immediate and catastrophic wall failure. Following lower speed impacts a partial thickness injury is observed -typically intimal tear or IMH, which may be under diagnosed. The behaviour of IMH is difficult to predict and equally difficult to examine experimentally. Our hypothesis was that a detailed finite element model of the aortic wall would allow us to begin to understand the dynamic behaviour of AAS. Methods: A novel three-layer finite-element aortic model was created. A rubber-like material model from LS-DYNA was selected for the simulations. The Arbitrary-Lagrangian Eulerian (ALE) approach was adopted to simulate the interaction between the blood and the aorta. The mechanical behaviour of the aortic wall, including the tunica-intima, media and adventitia, were studied under loading conditions. Results: The model successfully predicted rupture of the tunica layers separately, with a primary intimal injury. It was found that traction force is an important factor for intimal rupture. Intimal bending stress is high in narrow radius and may induce delamination of the tunica media. Other factors included blood pressure, tensile loading, and multi-axis loading. Conclusions: The three-layer finite-element model of the aortic wall correctly simulates aspect of AAS. Ultimately, we hope to predict the behaviour of AAS, including the characteristics of that IMH, which is likely to spontaneously regress, thus allowing tailoring of interventional treatment.
Medical University Vienna, Vienna, Austria Objectives: To determine mid-term durability of endovascular stent-graft placement in patients with perforating atherosclerotic ulcers (PAU) involving the thoracic aorta and to identify risk factors for death as well as early and late cardiovascular adverse events. Methods: From 1997 through 2006, 27 patients (mean age 66 years) presented with PAU (rupture n=7). Mean numeric EuroSCORE was 11 and mean logistic EuroSCORE was 35. Median follow-up was 35 (2–86) months, being complete in all patients. Outcome variables included death and occurrence of early and late cardiovascular adverse events. Results: In-hospital mortality was 11%. Primary success rate was 100%. Actuarial survival rates at 1, 3 and 5 years were 93%, 78% and 70% and actuarial event-free survival rates were 89%, 74% and 62%, respectively. Haemodynamic instability (OR 2.5; P=0.034) as well as logistic EuroSCORE (OR 2.8; P=0.019) were identified as independent predictors of early and late cardiovascular adverse events. Conclusions: Endovascular stent-graft placement in patients with PAU is an effective palliation for a life-threatening sign of a severe systemic process. Haemodynamic instability at referral and a high preoperative risk score predict adverse outcome. During mid-term follow-up, patients are mainly limited by sequelae of their underlying disease.
1University of Pittsburgh Medical Center, Pittsburgh, USA; 2University of Freiburg Medical Center, Freiburg, Germany Objectives: Endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) in combination with open surgical revascularization may be an alternative to conventional surgical repair. We analyzed our patient outcomes after elective and emergent endovascular TAAA repair. Methods: Between January 2000 and September 2006, 24 patients with TAAA were treated with endovascular repair by a cardiovascular surgeon. Mortality risk estimates for open surgery (OS) were calculated. An integrated neuroprotective approach was used. Results: Of the 24 patients, 10 had an acute presentation: rupture (7), acute pain (10), and malperfusion (2). The coeliac axis was over-stented in 15. Nine hybrid open surgical procedures were performed: visceral/renal arteries (5), infrarenal aorta (2), complete arch revascularization (2). Overall hospital mortality rate was 4.2% (1/24, predicted OS value 9.1%), 1-year survival was 85%. The hospital death occurred due to ischaemic colitis after inferior mesenteric artery over-stenting. No patient with acute presentation died (predicted OS mortality 17%). There was no paraplegia (predicted OS rate 12%) and one minor left pontine stroke, which resolved completely. No new late endoleaks occurred after initial complete aneurysm exclusion. There were five early and two late reinterventions due to persistent endoleak. There were two late major adverse events including one stent infection leading to multiorgan failure and death and one late mediastinal wound infection. Conclusions: Endovascular treatment of thoracoabdominal aneurysms with selective visceral and renal revascularization is associated with low mortality and can only be performed by a surgeon. Patients with acute presentation appear to benefit most from this therapy. One-year results of this therapy are encouraging, but long-term results are unknown.
Arizona Heart Institute, Phoenix, USA Objectives: To evaluate the feasibility and safety of thoracic endografting in the octogenarian population. Methods: Between February 2000 and August 2005, 249 patients with a mean age of 69±12.3 years (range 23–91) underwent thoracic endografting. Forty-four patients (27 males and 17 females) were octogenarians with a mean age of 84±2.7 years. Indications for intervention included: atherosclerotic aneurysms (26/44, 59.1%), acute and chronic dissections (9/44, 20.5%), penetrating aortic ulcers (6/44, 13.6%) and contained rupture (3/44, 6.8%). Results: Endovascular repair was achieved in all octogenarian patients (44/44, 100%). Mean length of stay was 4.7±3.6 days. Two cardiac-related deaths and one retrograde dissection death occurred (3/44, 6.8%). Complications included haemipaeresis (n=2) with full recovery at discharge, groin haematoma (n=1), pneumonia (n=2) and stroke (n=1) (5/44, 11.4%). Endoleaks were diagnosed in three patients (3/44, 6.8%) (2 Type I, 1 Type II) at 30-day follow-up. Two patients developed an endoleak beyond 30-days (2/44, 4.5%) (1 Type I, 1 Type II). Two re-interventions were necessary at 30 days (1 Type I, 1 Type II). Mean follow-up was 22 months and there were no device migrations or aortic ruptures. No statistical differences in overall mortality were noted between octogenarians and non-octogenarians at 30 days (6.8% vs. 5.9%, P=NS), 12 months (18.2% vs. 12.7%, P=NS) and 24 months (27.3% vs. 15.1%, P=NS). However, at five years post-procedure, octogenarians had a significantly higher overall mortality than non-octogenarians (31.8% vs. 17.1%, P=0.038). Conclusions: Advanced age is not a contraindication to thoracic endografting with favourable short and mid-term outcomes compared to non-octogenarians.
Deutsches Herzzentrum Berlin, Berlin, Germany Objectives: Retrograde Type A aortic dissection is a dreaded complication of thoracic stent-grafting. We analyzed seven cases with consecutive ascending aortic repair. Methods: In 236 patients thoracic endografts were implanted. Primary indications were Type B dissections in 90 cases (38%) and aneurysms or traumatic ruptures in 146 (62%). Retrograde Type A dissection was noted in six cases (overall 3.0%) with five cases in the dissection group (5.5%) and in two cases in the non-dissection group (1.4%). It occurred within the first week in three cases, after 3–4 weeks in three and late (after two years) in one case. In five cases the stent-graft had been placed inside the aortic arch covering the left subclavian artery (LSA), in five cases distal of the LSA. The dissection had involved the LSA in three cases. Results: In all six patients the ascending aorta was replaced by a supracoronary tube graft with the distal anastomosis performed in circulatory arrest. Intraoperative evidence of previous unrecognized dissection of the ascending aorta was found in four cases (50%). Four patients recovered well. One patient acquired severe brain damage and one suffered paraplegia. Conclusions: Retrograde Type A dissection associated with stent-grafts was rare and related mainly to Type B dissection as the primary indication. Risk seemed increased with involvement of the LSA into the dissection and with stent-grafts placed in the distal aortic arch. The configuration of the proximal end of the stent-graft obviously played a minor role. Institutions performing thoracic aortic stent-grafting should be able to handle this serious complication.
Arizona Heart Institute, Phoenix, USA Objectives: Retrograde Type A dissection during or after endoluminal graft repair of the descending thoracic aorta is a potentially lethal complication unique to thoracic endografting. Our aim is to increase its awareness and to review possible etiological factors. Methods: Two hundred and eighty seven patients with different thoracic aortic pathologies were treated with endovascular prostheses over the last six years under a single-site protocol. A retrospective review was conducted to identify any retrograde aortic dissections by both chart and film review. Factors that may have contributed to its formation were also documented. This population was analyzed for the complication of retrograde aortic dissection as well as the factors related to its occurrence. Results: Seven patients (2.4%) with a gender distribution of 1:1.3, M/F experienced a retrograde Type A dissection within this sample. The mean age was 74, years (range 53–83). Aortic pathologies included aortic dissections (n=5) and penetrating aortic ulcers (n=2). Two female patients (28.6%) had this event identified within their initial hospitalization with fatal consequences. Overall mortality was 57% (n=4) with extension of dissection the primary cause of death in (n=3), and complications relating to, open surgical repair (n=1). Balloon Angioplasty was performed in 42.9% (n=4). Conclusions: Female gender, use of stent-grafts for dissection and possible aggressive balloon angioplasty may play a role in the cause of retrograde Type A dissection. A close surveillance program is recommended when using thoracic endografts outside the recommended device instructions for use.
054 INR SELF-TESTING AFTER MECHANICAL HEART VALVE REPLACEMENT-EXPERIENCE OF A SINGLE CENTRE H. Mair, B. Reichart, I. Kaczmarek, R. Sodian, P. Brenner, D. Rassoulian, S. Daebritz University of Munich, Munich, Germany Objectives: Management of oral anticoagulation (OA) is a key determinant to prevent thromboembolic or hemorrhagic complications after mechanical heart valve (MHV) replacement. We report a single centre experience with self-management of OA. Methods: Follow-up was performed on 957 patients who received MHV between 1992 and 2004. To all INR self-management was offered. Follow-up was 97%. Only 349 (39.4%) patients, age: 59.8±10.4 years wanted INR self-management (Group 1). Five hundred and eight (60.6%) patients, age: 65.3±9.8 years (P=0.008) preferred conventional OA by family physicians (Group 2). In Group 1, 76% of patients had higher education vs. 25% in Group 2 (P<0.001). Results: Follow-up was 5.6±3.0 years representing 4873 patient-years. In the last 12 months patients of Group 1 measured OA more often and were within the therapeutic range for a median of 74% vs. Group 2 in 57% (P<0.001). During follow-up 1.9% of Group 1 had severe bleedings vs. 5% of Group 2 (n.s.) and 0.6% of Group 1 had severe thrombembolic-events vs. 5.5% of Group 2 (P<0.01). Group1 was more satisfied with OA and their health status (P<0.001). Actuarial-survival after 1, 5 and 10 years was in Group 1 99%, 98% and 94% vs. in Group 2 99%, 95% and 81% (P<0.001). Risk factors for mortality were univariate: age (P<0.05), type of operation (P<0.05) and conventional OA (P<0.001), but multivariate only conventional OA (P<0.001). From 1993–2005 the percentage of patients with INR self testing was 36±6% (27%–45%/year) and didn't increase in the period. Conclusions: Self-management of oral anticoagulation improves long-term outcome and treatment quality. However, application is not increasing, probably due to lack of awareness and acceptance of physicians.
Klinikum Oldenburg, Oldenburg, Germany Objectives: The technically demanding full root aortic valve replacement necessitating coronary ostia reimplantation leads to controversial hesitation by some surgeons despite superior haemodynamics and excellent long-term clinical performances of the stentless xenografts. To determine the justification we analysed our clinical data of stentless full root replacements. Methods: From April 1999 to March 2007, 317 adult patients underwent the modified Bio-Bentall procedure using the Medtronic Freestyle xenograft as a full root replacement. Results: Mean patient age was 70.3±10.2 (range 17.6–94.0); 32 patients 80. Concomittant procedures included coronary artery bypass grafting (n=82) mitral valve reconstruction (n=11) and aortic arch replacement (n=36). Mean operative time for isolated valve/root replacement was 190±57 min with a clamp time of 88±27 min. Mean operative time for the combined procedures was 282±93 min with a clamp time of 110±32 min. Overall 30-day mortality was 6.0% (19/317 patients). Thirty-day mortality for isolated root replacement was 3.4% (7/203 patients). Mean ICU stay was 4.9±8.1 days, mean hospital stay being 9.8±8.1 days. Necessity for bail out bypass surgery was low with 1.5%, comparable to stented xenograft implantations. Echocardiography demonstrated excellent clinical results. Conclusions: Our study results demonstrate that full root stentless valve implantation preserving porcine root integrity is a valuable option in aortic valve surgery. The technically more challenging operation including coronary ostia reimplantation does not correlate with increased perioperative morbidity and mortality but can be beneficial for the patients especially in cases of small aortic annulus.
1Department of Thoracic and Cardiovascular Surgery, Essen, Germany; 2Department of Neurology, Essen, Germany; 3Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen, Germany Objectives: Early cognitive decline is well recognized after on-pump coronary artery bypass grafting (CABG) and has been generally assumed to be transient. More recently, however, the possibility of late decline in cognition after CABG has been reported. We assessed the course of cognitive performance three years after cardiac valve replacement and sought to identify factors that may predict outcome. Methods: A total of 30 patients (64.9±9.8 years) undergoing elective isolated cardiac valve replacement were prospectively investigated at discharge, three months and three years after surgery. Neuropsychological performance was evaluated with 11 standardized tests to seven cognitive domains, and high-resolution magnetic resonance imaging (MRI) including diffusion-weighted technique was performed to detect cerebral ischemia.
Results: Cognitive deficits (i.e. drop of Conclusions: Cognitive decline after cardiac valve replacement is benign and frequently resolves within weeks. The few cognitive deficits years later are most likely related to age and not to the operation itself.
Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany Objectives: The feasibility of the Ross procedure in the geometric mismatch between the pulmonary autograft and a bicuspid aortic root has not yet been fully evaluated. To prevent geometrically caused valve dysfunction, a modification in surgical technique is necessary. Methods: Between January 1996 and January 2007, 50 patients (33 male, 17 female; mean age 50±14 years; range 13–63 years) underwent replacement of a diseased bicuspid aortic valve (stenosis in 14 cases; insufficiency in 21; combined disease in 15) with a Ross procedure. The pulmonary autograft was inserted as a partial supra-annular implantation to correct the geometric mismatch between the non-coronary sinus and the right/left coronary sinus. In 24 of these patients, additional tailoring of the non-coronary sinus was necessary. In eight patients the non-coronary sinus was covered with a glutaraldehyde-treated autologous pericardial patch to prevent pseudoaneurysm. Patients were followed-up one, two and five years, postoperatively. Results: There were no early or late deaths. Three patients were reoperated for formation of sub annular pseudoaneurysm, 9 and 30 months postoperatively. Another patient was reoperated for closure of a paravalvular leak. Echocardiography follow-up of the remaining patients showed no evidence of residual or recurrent pulmonary autograft regurgitation or progression of aortic root dilatation. Conclusions: Bicuspid aortic valve replacement is a challenge in adjusting the geometric mismatch. Valve dysfunction is avoided by supra-annular implantation technique, but pseudoaneurysm formation due to lack of tissue in growth into the non-coronary sinus is a worrying aspect. Patch-annuloplasty may solve this issue.
Heart Institute Lahr, Lahr, Germany Objectives: The impact of prosthesis-patient mismatch on long-term outcome estimated by various variables as indexed projected effective orifice area, internal geometric orifice area obtained from in vivo or in vitro published data is still controversial.
Methods: The effective orifice area (EOA) was measured by echocardiography in 533 patients. Mean age of the patients was 71±9 years. Mean follow-up time was 4.7±2.2 years. The impact of severe (indexed EOA Results: Echocardiographic determined effective orifice area, the difference to the projected effective orifice area from published in vivo data and the percentage of severe mismatch were: 1.4 cm2, 0.55 cm2, 24% for St. Jude Medical HP, 1.35 cm2, 0.74 cm2, 26% for Medtronic Hall, 1.15 cm2, 0.28 cm2, 47% for Medtronic Mosaic, 1.3 cm2, 0.4 cm2, 27% for Freestyle (subcoronary) and 1.6 cm2, 0.34 cm2, 10% for Freestyle (full root). Severe mismatch [Hazard Ratio: 1.86 (1.08–2.54)] was a significant predictor of higher mortality after adjustment by age, LVEF, atrial fibrillation, NYHA class, serum creatinine and haemoglobin level. The 5- and 8-year survival rates were 71±4% and 45±9% for patients with severe mismatch, 83±4% and 80±4% for patients with no mismatch. The correlation between projected and measured indexed effective orifice area was of low strength (r2=0.2). Projected indexed effective orifice area was no predictor for long-term outcome, neither as continuous (P=0.39) nor as categorical variable (P=0.67). Conclusions: Severe prosthesis-patient mismatch estimated by measured effective orifice area was an independent risk factor of long-term mortality, whereas projected indexed effective orifice area does not sufficiently predicts mismatch.
1Department of Cardiothoracic and Respiratory Sciences at Second University of Naples, Naples, Italy; 2Department of Biochemistry and Biophysics at Second University of Naples, Naples, Italy Objectives: B-type natriuretic peptide (BNP) is synthesized in response to increased wall stress (WS) and myocardial hypertrophy. We report the preliminary results of a prospective investigation on serum levels of pro-BNP in patients undergoing aortic valve replacement (AVR) for severe pure aortic regurgitation (AR). Methods: Blood samples for pro-BNP measurement were retrieved preoperatively, fifteen days postoperatively, at 6 and 12 months of follow-up in twenty consecutive patients. Two-dimensional echocardiography was performed concomitantly: left ventricular (LV) dimensional and functional parameters were evaluated, and WS indirectly estimated. Correlations between pro-BNP, clinical and echocardiographic data were assessed by non-parametric statistics. Results: Preoperative pro-BNP was normal or mildly increased in most patients (group A: median 135 pg/ml; IQR=68–319 pg/ml), remarkably increased in few others (group B: 1755 pg/ml; 1604–2738 pg/ml). In group A preoperative pro-BNP was correlated with systolic LV dimension (r=0.56; P=0.01) and inversely with ejection fraction (r=–0.69; P=0.003) and length of diagnosis-to-operation time (r=–0.43; P=0.009). BNP levels increased at 15 days postoperatively (593 pg/ml; IQR=449–831 pg/ml, vs. 288 pg/ml; 91–961 pg/ml preoperatively; P=0.08), then significantly decreased at six months (144 pg/ml; 47–252 pg/ml; P<0.001) to remain stable at one year (108 pg/ml; 54–211 pg/ml; P=0.16). BNP at 15th day was not correlated to operative times or postoperative troponin peak, while it was affected by age (r=0.49; P=0.004), medication (P<0.05) and systolic WS (r=0.56; P=0.01). Long-term BNP levels showed direct correlation with preoperative diastolic parameters (P<0.05), but inverse correlation with LV mass (r=–0.63; P=0.006) and diastolic volume (r=–0.56; P=0.01) at follow-up. Conclusions: Perioperative BNP variations may help understanding the pathophysiology of LV remodelling before and after AVR for AR.
1University of Heidelberg, Heidelberg, Germany; 2Edwards Lifesciences, Irvine, USA; 3Carolinas Medical Center, Charlotte, USA; 4University of Ottawa, Ottawa, Canada Objectives: Aortic root motion was previously identified as an additional risk-factor for aortic dissection. This study analyzed if the magnitude of aortic root motion changed in patients after aortic valve replacement (AVR) and acute proximal aortic dissection. Methods: An institutional database (1984–2005) was used to measure the downward motion of the aortic root (perpendicular to the plane of the sinotubular junction) in contrast injections in 48 patients with aortic insufficiency (AI), aortic stenosis (AS) and proximal aortic dissection pre- and postoperatively, when available. Results: In case of AI, aortic root motion was significantly reduced after AVR (4.3 vs. 13.7 mm). When functional AI due to paravalvular leak was present post-AVR, aortic root motion was unchanged (9.4 vs. 9.0 mm). In case of AS, aortic root motion was significantly increased post-AVR (11.8 vs. 5.8 mm). Aortic root motion ranged between 4 and 17 mm pre-dissection (mean: 10 mm), and varied between 2 and 23 mm in acute dissection (mean: 8 mm); it was increased when AI was present. At re-dissection, aortic root motion was in a lower range, with a mean of 4.0 mm. Conclusions: Restored aortic valve competence is associated with reduced aortic root motion. By contrast, removal of aortic stenosis is associated with increased aortic root motion. High magnitude aortic root motion values may contribute to acute dissection, while even low values may lead to re-dissection after prosthetic ascending aortic replacement.
University of Munich, Munich, Germany Objectives: This study investigated determinants of long-term outcome after surgical treatment of the aorta with special focus on the performance of biological heart-valves (HV) in aortic surgery assuming higher risk due to more challenging reoperations. Methods: From 1970 to 2005, 759 patients were treated for aortic valve disease and ascending aortic aneurysm (n=382) or Type A dissection [n=377 (264 acute)]. Aortic valve replacement was performed with 426 (56%) mechanical HV, 263 (35%) biological HV and 70 (9%) homografts. Operative technique for aortic surgery was in 49% valve replacement and supracoronary graft, in 42% composite graft and in 9% homograft plus ascending aortic graft. Extended surgery, including the aortic arch or more segments, was performed in 18%. Results: Cumulative survival was 89%, 81%, 70%, 57% and 45% at 1, 5, 10, 15 and 20 years, respectively. During follow-up, 98 patients needed at least one reoperation. Reoperations were necessary in 13% after biological HV implantation, in 15% after mechanical HV replacement and in 17% when homograft was implanted. There were no significant differences regarding type of HV prosthesis and reoperation. Multivariate analysis did not reveal the type of valve prosthesis (e.g. bioprosthesis or homograft) as significant determinant for overall survival (multivariate P=0.26; univariate P<0.001). Operative technique for replacement of the ascending aorta did not reach statistical significance as independent risk-factor for long-term survival. Extended surgery to the arch, age, Marfan-Syndroms, poor clinical status, op-time, acute dissection, surgery before 1985, and emergency operation were significant risk factors for mortality (all P<0.01). Conclusions: Type of valve prosthesis had no negative impact on survival after aortic surgery.
1Department of Cardiovascular Surgery, German Heart Center, Munich, Germany; 2Institute of Medical Statistics, Technical University, Munich, Germany; 3Department of Anesthesiology, German Heart Center, Munich, Germany Objectives: Most patients who undergo tricuspid valve (TV) surgery have severe disease and require concomitant mitral or aortic valve surgery. These patients face a high-risk of operative mortality and long-term outcome is poor. In this study we reviewed our experience with TV surgery in patients with acquired TV disease focusing on long-term survival and incidence of reoperation. Methods: Retrospective analysis of 416 consecutive patients operated on between 1974 and 2003. The follow-up is 97% complete (mean 5.9±6.3 years). Three hundred and sixty six patients (88%) underwent concomitant mitral (n=340) or aortic (n=100) valve surgery. The TV-valve was repaired in 309 patients (74%) and replaced in 107 (26%). A bioprosthesis was used in 68 patients (64%). Mean age at TV repair and replacement was 61±12.5 and 50±11 years, respectively (P<0.001). Results: Overall 30-day mortality was 18.7% and decreased from 22.8% (1974–1989) to 15% (1990–2003). Thirty-day mortality after TV-repair and replacement was 13.9% and 32.7%, respectively. Ten-year actuarial survival after TV-repair and replacement was 47±3.5% and 37±4.8%, respectively (P=0.002). Forty-four patients (11%) required a TV related reoperation after 7.7±5.1 years. Freedom from reoperation, 10 years after TV-repair and replacement with a biological or mechanical prosthesis was 83±3.6%, 80±7.5% and 84±8.4%, respectively (P>0.05). Conclusions: Patients, who require tricuspid valve surgery, constitute a high-risk group. In most patients TV repair is feasible and leads to superior results even in older patients. TV repair and replacement have comparable reoperation rates. When valve replacement is necessary we recommend the use of a bioprosthesis due to the poor long-term survival.
063 SURGICAL MANAGEMENT OF COMPLICATIONS OF COLON BYPASS P.E. de Delva, J.C. Wain, C.D. Wright, D.J. Mathisen Massachusetts General Hospital, Boston, USA Objectives: Complications following colon bypass are acute or chronic and often devastating. Creative strategies are needed to preserve the conduit or develop alternatives when it cannot be salvaged. Methods: The records of patients undergoing revision surgery of colon bypass between 1965 and 2005 were reviewed. Results: Thirty-seven patients with revision of colon bypass were identified. Twenty-one patients underwent one operation, nine required multiple operations to manage one problem and seven developed more than one distinct problem requiring several operative interventions. The most common indications for revision included leak or graft necrosis (n=16), redundancy (n=12), stricture (n=9) and obstructed conduit (n=4). Twenty-six patients required revision of a viable colon conduit. Eleven patients had loss of intestinal continuity as a consequence of leak or colon graft necrosis. The most common operations for patients with a preserved colon conduit were anastomotic revision (n=12), segmental colonic resection (n=6), and stricturoplasty (n=4). Loss of intestinal continuity was successfully reversed in eight patients with an intestinal conduit (n=5) or myocutaneous oesophagoplasty (n=3). No intraoperative deaths occurred. Three patients with conduit leak or necrosis did not survive enough time to allow for intestinal reconstruction (36 days to 11 months). Swallowing was restored in 33 of the remaining 34 patients. Five patients required reoperation after a failed revision at our institution. Swallowing was restored in all. Conclusions: Complications developing after colon bypass present major challenges for surgeons to maintain swallowing and quality of life. We present successful strategies to manage these devastating complications. It is the largest report dealing with a wide variety of complications of colon bypass.
Royal Infirmary of Edinburgh, Edinburgh, UK Objectives: The aim of this study is to review the immediate and long-term results of video-imaged thoracoscopic Heller's myotomy (THM). Methods: All patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire and oesophageal manometry and/or 24 h pH monitoring were undertaken when clinically indicated. Results: Fifty-six consecutive patients (32 males, 24 females, mean age 45±18.7 years) suffering from grade 4 dysphagia underwent THM between 1993 and 2007. Preoperative mean lower oesophageal sphincter (LOS) pressure was 38.4±10.6 mmHg. Eighteen patients (32.1%) had undergone previous pneumatic dilatations. There were no hospital deaths. Oesophageal perforation occurred in two patients; one repaired thoracoscopically and one at thoracotomy. Mean hospital stay was 4±1.37 days. At mean follow-up of 5.9±4.66 years, freedom from any reintervention was 87% (49/56). Twenty-nine patients (52%) were asymptomatic. In patients with residual or recurrent symptoms (n=27), their severity was significantly reduced from the preoperative period (dysphagia score 1.37±0.77 vs. 4±0; P=0.05). Nine patients (17.9%) with troublesome residual or recurrent grade 3–4 dysphagia underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8±6.1 mmHg to 30±5.4 mmHg (P=0.01). Of these patients, three with Grade 4 dysphagia were reoperated: one open Heller's myotomy and two by cardia resection. Eleven patients complained of troublesome postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in nine (16.9%) and all were successfully managed with medical therapy. Conclusions: The results of thoracoscopic treatment for achlasia are at least equivalent to historical outcomes obtained with open surgery but the patient is spared major thoracotomy or the acid reflux associated with a laparoscopic approach.
Emergency Medicine Institute N I Pirogov, Sofia, Bulgaria Objectives: The carcinoma of the terminal part of the oesophagus and gastroesophageal junction is an aggressive disease with poor outcome. We present our experience with the left thoracotomy approach described by Garlock and modified by Belsey. Methods: For a period of ten years (1997–2007) we have treated 250 patients with oesophageal cancer (EC). Ninty-two cases underwent a left thoracotomy in the 7th intercostal space, circumferential phrenotomy and oesophageal resection. Two field lymphadenectomy and gastric substitution of the oesophagus were performed in all patients with 50 (54%) or without 42 (46%) metastatic deposits in the regional lymph nodes. The surgical borders of the resected oesophagus were sent for frozen section analysis in all cases. Adenocarcinoma was the most common histological finding in the cases with gastroesophageal junction localization of the process (70%). Fifty-three patients (58%) were Stage 2a and 2b and 39 were Stage 3. After February 2000 all gastroesophageal anastomosis were performed with a mechanical stapler instead of hand sutured double layer technique. Results: The early postoperative mortality rate (within 30 days) was 6.5% (six patients). The causes were complications arising from accompanying diseases, not directly related to the operation. Anastomotic leak presented in five patients and was treated successfully with local drainage. Good clinical results were obtained in the rest of the patients. Conclusions: The preopertative staging and histology are decisive for the respectability and the surgical approach. Reduction of the operating time and the accessible lymph node dissection are obvious advantages of the left transthoracic approach for lower EC.
Povisa Hospital, Vigo, Spain Objectives: Minimally invasive oesophageal surgery has the potential to improve mortality, hospital stay, and functional outcomes when compared with open methods. Although technically complex, combined laparoscopic and thoracoscopic oesophageal resection is feasible. The aim of this report was to present our preliminary experience with minimally invasive oesophagectomy. Methods: Between November 2005 and December 2006, 11 patients underwent minimally invasiveoesophageal surgery. This study was a review of a prospective database. The purpose was to evaluate early results with thoraco-laparoscopic total oesophagectomy for malignant disease. Neoadjuvant chemo-radiotherapy was used in six patients. Laparoscopic transhiatal approach was used in two patients and thoraco-laparoscopic oesophageal mobilisation were performed in nine. Results: All minimally invasive total oesophagectomies performed were completed successfully. The average age of the patients was 60 years. Indications for surgery were malignancy in all patients. The average operating time was 258 min (range 200–300 min). Median blood loss was 250 ml (range 150–350 ml). The median intensive care unit stay was two days, and the median hospital length of stay was 12 days. The average of lymph nodes removed was 22 (8–39). The 30 days mortality was 0. Major complications occurred in five patients (four anastomotic leaks, one chilothorax) and minor respiratory complications in four. Conclusions: The application of minimally invasive techniques in the field of oesophageal surgery continues to evolve. This approach has the potential to improve mortality, hospital stay, and other outcomes when compared with open methods. Although technically complex, laparoscopic total oesophagectomy is feasible.
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland Objectives: Prospective evaluation of intrathoracic airway reconstructions using pedicled muscle flaps for bridging airway defects regarding morbidity, mortality and airway complications. Methods: From January 1996 to June 2006, 39 patients underwent intrathoracic airway reconstructions using pedicled muscle flaps for bridging airway defects (Latissimus dorsi LD, n=23, serratus anterior SA, n=18, pectoralis major PM, n=2). Airway defects resulted from bronchopleural fistula (BPF) with short desmoplastic bronchial stumps (n=14); right pneumonectomy and carinal wedge resection for NSCLC after neoadjuvant radiochemotherapy (n=11); partial non-circumferential tracheal resections for tumours, oesophago-tracheal fistulas (TEF) and delayed tracheal injuries (n=11); airway defects after carinal resection associated with sleeve lobectomy (n=3). The airway defects ranged from 3x2 cm to 8x4 cm. Follow-up (minimum six months) consisted of clinical examination, bronchoscopy, pulmonary function testing and CT scanning. Results: Ninety-day mortality was 8%. Four patients (10%) revealed muscle flap necrosis requiring re-operation, debridement and bridging of the airway defect by SA or PM, respectively, without mortality. Thirty-five of the 36 surviving patients (97%) had no airway stenosis or dehiscence during follow-up and bronchoscopy revealed epithelialisation of the bridged airway defects. There was no recurrence of BPF or TEF. Conclusions: Intrathoracic airway defects of several centimetre length can be safely bridged by use of pedicled extrathoracic muscle flaps, even if associated with complex airway reconstructions.
Thoracic Surgery, University of Padova, Padova, Italy Objectives: Laryngotracheal stenosis represents a challenging problem requiring a complex management. Surgical approach allowing permanent chance of airway restoration is the preferred treatment. Purpose of study is to evaluate short and late outcome following laryngotracheal resection and anastomosis. Methods: From 1994 to 2006, 37 patients (26 males and 11 females, median age 35 years) underwent surgery. Causes of stenosis were post-intubation or post-tracheostomy injury in 28 cases and idiopathic in 9. Pearson's technique was used for antero-lateral crico-tracheal resection (n=23) and Grillo's technique providing a posterior flap of tracheal membranous for circumferential stenosis (n=14). Since 1998, in 21 cases we modified the techniques using a continuous 4/0 polydioxanone suture for posterior part of anastomosis. Thirty-three (89.2%) patients received a total of 62 preoperative interventions including laser (n=21), tracheostomy (n=26) and endotracheal prosthesis (n=15). Results: No perioperative mortality was recorded. Three (8.1%) patients developed major complications (2 fistulae and 1 early stenosis) that required a second surgical look. We had 16 minor complications in 14 (37.8%) patients: granulation tissue (n=5), anastomotic oedema (n=4), temporary vocal cord dysfunction (n=4), wound infection (n=2), anastomotic fibrin deposit (n=1). Late results were excellent in 30 (81.1%) patients, good in 5 (13.5%), satisfactory in 1 (2.7%), unsatisfactory in 1 (2.7%). Conclusions: Single-staged laryngotracheal resection is a demanding operation, but can be performed successfully with acceptable morbidity in specialised centres. The continuous suture in posterior part of anastomosis simplifies the procedure without technique-related complications. In our experience this procedure guaranteed excellent and good long-term results in more than 90% of patients.
Lungenklinik Merheim Kliniken der Stadt Köln GmbH, Cologne, Germany Objectives: Sleeve resections were introduced to preserve lung function in patients with limited pulmonary reserve. Ischemia and infection of the distal part of the anastomosis is the leading cause of bronchial anastomotic leakage. We have learned from our experience in lung transplantation that inhalation with tobramycin helps prevent anastomotic insufficiency. We would like to present our experience in patients with tracheobronchial sleeve and prophylactic tobramycin inhalation. Methods: Retrospective analysis of 114 patient records, between 1 January 2005 and 31 December 2006, where a bronchial anastomosis (patients with tracheal resection were excluded) was performed. All patients received tobramycin inhalation (2x80 mg/day for 7 days). Data analysed was length of chest tube drainage in days, complications, morbidity and hospital mortality. Results: In 694 patients an anatomic resection was performed. Of these 114 (16%) were sleeve resections and 63 (9%) pneumonectomies. In 21 women and 93 men, between 25 and 84 years old, sleeve lobectomy was performed 104 times and carinal resection 10 times. A preoperative neoadjuvant therapy had been given in 26%. Radical (R0) resection was possible in 94%. Patients were discharge after 11 days. The rate of bronchial anastomotic leakage was 4.4%. Two patients with postoperative respiratory insufficiency and mechanical ventilation, two patients with technical failure required early correction of the suture and one patient with a necrosis of the anastomosis. Thirty-day hospital mortality was 2.6% (3/114). Conclusions: Increasing experience with sleeve resection has reduced the rate of pneumonectomy below 10%. Although some of the patients had received neoadjuvant therapy the carinal rate of necrosis and infection of the anastomosis was low. We therefore recommend use of local antibiotic inhalation after sleeve resection.
1Paediatric Airway Unit and Division of Paediatric Surgery, Hospital Universitario Doce de Octubre, Madrid, Spain; 2Paediatric Institute of the Heart Hospital, Universitario Doce de Octubre, Madrid, Spain Objectives: To evaluate the safety and clinical effectiveness of stent placement in children with tracheobronchial obstruction. Methods: Patients with severe airway stenosing disease in which stent placement was performed between 1993 and 2006. Selection of the type of stent depended on the site of the lesion and the patient's age. The following data were retrospectively evaluated: type of obstruction, stent properties, technical and clinical success, complications and related reinterventions, outcome and follow-up period. Results: Thirty-three stents were placed in the trachea (n=18) and/or bronchi (n=15) of 21 patients, aged 9 days to 19 years (median, 6 months). Etiology of the airway obstruction included severe tracheomalacia and/or bronchomalacia in 19 cases (90%), and tracheal stenosis in two. Twelve children had a total of 20 balloon-expandable metallic stents placed, and 10 had 13 silicone-type stents (one patient had both). In nine patients (42%) more than one device was placed. Stent positioning was technically successful in all but one patient. Clinical improvement was observed in 18 patients (85%) but complications (granulation tissue) occurred in five of them compelling final stent removal in four. Six patients died during follow-up but only in one case it was related to airway stenting. Long-term good result has been achieved in 13 patients (62%) with a mean follow-up of 35 months (range, 5 months to 13 years). Conclusions: Although the results were based on a small series, placement of stents in the paediatric airway seems to be safe and effective for the treatment of tracheobronchial obstruction.
1Department of Thoracic Surgery, University of Rome LaSapienza, SantAndrea Hospital, Rome, Italy; 2Department of Thoracic Surgery, University of Rome LaSapienza, Policlinico Umberto I, Rome, Italy; 3Department of Anesthesiology, University of Rome LaSapienza, SantAndrea Hospital, Rome, Italy Objectives: We report our 16-year experience with laryngotracheal resections for benign stenoses, evaluating surgical outcome and long-term results. Methods: Between 1991 and 2006, 35 consecutive patients (19 males, 16 females) underwent laryngotracheal resection for subglottic postintubation (32) or idiopathic (3) stenosis. Mean age was 43 years (range 14–71). At the time of surgery 13 patients presented with tracheostomy and seven patients with Dumon stent. The upper limit of the stenosis was from 0.6 to 1.5 cm below the vocal cords and the airway diameter reduction ranged between 60% and 100%. Technically, we employed the Pearson repair in all patients. The length of airway resection ranged betweeen 1.5 and 6 cm. Suprahyoid release was performed in two patients and pericardial release in one. Mean follow-up is 61 months (range 3–194). Results: Thirty patients (85.7%) had excellent or good anatomic and functional results. Four patients (11.4%) presented restenoses at a distance of 25–110 days from the operation. Restenosis was successfully treated by laser ablation of granuloma in three patients and by mechanical dilatation for circumferential scar stenosis in one patient. One patient (2.8%) presented with anastomotic dehiscence which required a temporary tracheostomy closed after one year with no sequelae. Three patients (8.5%) had wound infection. There was no perioperative mortality. Conclusions: Laryngotracheal resection can be performed with low operative risk as standard curative treatment for benign subglottic stenoses and leads to a high rate of successes with no mortality. Surgical complications can be successfully managed by non-operative procedures in most of patients.
072 NATIVE TISSUE AORTIC ARCH RECONSTRUCTION IN NORWOOD PROCEDURE: RESULTS WITH A NEW MODIFIED TECHNIQUE M. Nosal, I.C. Omeje, R. Poruban, M. Sagat, P. Valentik, A.S. Nagi Children's Heart Centre, Bratislava, Slovak Republic Objectives: In direct anastomosis technique of aortic arch in Norwood procedure (NP) concerns have been raised regarding mediastinal structures compression such as pulmonary arteries and bronchi and a higher risk of aortic arch obstruction. We describe intermediate-term results with a modified technique. Methods: Between October 2003 and February 2007, 35 consecutive patients with hypoplastic left heart syndrome and its variants underwent first stage palliation. Median age at operation was six days (range 1–60 days) and median weight 3 kg (range 2.5–4.3 kg). The technique consists of resection of ductal tissue and anastomosis of the back wall of the descending aorta to the transverse arch. The pulmonary trunk is sutured directly to the anterior aspect of the descending aorta extending into the ascending aorta, simultaneously patching the aortic arch, thus creating a ‘tripod-like’ anastomosis. Results: The median circulatory arrest time was 34 min (range 26–51 min). Eight patients died postoperatively. Nineteen patients underwent second stage palliation at median age of 7.4 months (range 3.5–18.5 months). Four patients died before stage II. Three patients (15%) required left pulmonary artery plasty at the second stage. The mean gradient on the aortic arch was 12 mmHg; four patients (21%) had balloon dilation of recoarctation prior to stage II. Overall freedom from pulmonary artery and aortic arch reintervention was 82% and 79%, respectively. No patient developed symptoms of bronchial compression. Six patients underwent fenestrated Fontan operation. Mean follow-up was one year. Overall survival at 1.3 and 24 months postoperatively were 80%, 64% and 51%, respectively. Conclusions: The tripod modification of arch reconstruction in NP offers reasonably short arrest times and creates a sufficiently large mediastinal window thus minimizing pulmonary artery distortion and bronchial compression while ensuring good aortic arch patency.
Birmingham Children's Hospital, Birmingham, UK Objectives: To assess the surgical results of the Norwood procedure and subsequent clinical outcome in the setting of TGA with left ventricular dependant circulation. Methods: Among 486 patients who underwent the Norwood procedure from 1988 to 2007 at one Institution, there were 37 patients with TGA and left ventricular dependant circulation with the following associated lesions: DILV (n=24), Tricuspid Atresia (n=9), VSD with hypoplastic RV (n=4). Outcomes for all three staged procedure were compared with the overall group. Results: Early mortality was 21.6% (8/37) compared to 26.7% (120/449) in the overall group (P=ns). There was only one subsequent death giving a 5 and 10 year actuarial survival of 72.8±7.4% compared to 55.3±2.6% and 52±2.9%, respectively at 5 and 10 years for the overall series (P=0.06). Median follow-up was 4.7 (0.7–10.2) years. Eighteen patients underwent stage III completion at a mean of 3.9±1.5 years from the second stage with no mortality. Preoperative mean PA pressure and transpulmonary gradient were, respectively, 11.6±3.4 mmHg and 5.2±3.3 mmHg. All patients had graded good LV at time of stage III. All are currently in NYHA I. One patient (with DILV) had congenital heart block and required a pacemaker. There was no postoperative heart block. The systemic outflow was unobstructed in all patients and no patient has required any intracardiac procedure. Conclusions: The Norwood procedure provides good palliation in this subgroup of patients and avoids the need for subsequent intracardiac operations, maintaining unobstructed systemic outflow tract and avoiding the risk of postoperative heart block.
1Clinic for Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany; 2Clinic of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University, Munich, Germany Objectives: Patients with functional univentricular heart require staged procedures. Our current policy is to perform a bidirectional cavopulmonary connection (BCPC) without additional blood flow, even at a very young age. Methods: Between 2001 and 2006, 124 patients had a BCPC followed by an extracardiac total cavopulmonary connection (TCPC). Twenty-eight patients were below six months of age at the time of BCPC. Mean weight was 5.9±1 kg. Of these, 22 had a previous shunt procedure. Most common diagnosis was a hypoplastic left heart syndrome in ten patients. Review of all angiograms before BCPC and TCPC allowed for analysis of haemodynamic findings and sizes of the pulmonary arteries (PA). Results: No patient died either after BCPC or after TCPC. After a mean time of 18.2±5.8 months a TCPC was completed. In eight patients the PA were augmented at the time of BCPC and in none at the time of TCPC. Mean PA size was 6±1.7 mm for the left PA before BCPC and increased to 6.6±1.8 mm before TCPC (P<0.01). The right PA size was 7.2±1.8 mm before BCPC and increased to 9.1±1.6 mm before TCPC (P=0.02). The mean LA pressure decreased from 4.9 to 4.5 mmHg prior to TCPC. The mean PA pressures decreased after BCPC from 17.8 to 13 mmHg. Conclusions: Early unloading of the functional univentricular heart by means of BCPC without additional blood flow is feasible even in very young patients. Favourable haemodynamics and reasonable increase in pulmonary artery size allow for early completion to TCPC.
1Clinic for Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany; 2Clinic of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich at the Technical University, Munich, Germany Objectives: In patients with a functional univentricular heart, our standard approach includes a staged palliation with a bidirectional cavopulmonary connection (BCPC) without any additional blood flow. This is followed by an early total extracardiac cavopulmonary connection (TCPC). Methods: Between 2001 and 2006, a total of 124 patients had completion to a TCPC. Review of 84 angiograms before BCPC and CPC allowed for analysis of haemodynamic findings and measurement of the pulmonary arteries (PA). Results: Median age at BCPC was seven months (range 2.3–97.6), TCPC was performed at a median of 16.7 months (range 5.9–98) after BCPC. There was no postoperative mortality after BCPC, one patient died after TCPC (1.2%). The mean oxygen saturation increased after BCPC from 74.4 to 79.6% (P<0.01). The mean PA pressures decreased after BCPC from 15.1 to 13.5 mmHg (n.s.). The mean LA pressure decreased from 5.8 to 4.9 mmHg prior to TCPC (P=0.06). The pulmonary/systemic blood flow ratio was 1.4 prior to BCPC and decreased to 0.67 prior to TCPC (P=0.04). The pulmonary/systemic resistance ratio decreased also from 0.19 to 0.07 prior to TCPC (P<0.01). The right PA, as well as the right lower lobe PA, showed a significant increase in diameter after BCPC (P<0.01). The left PA did also increase in size, although this was not statistically significant. Conclusions: After BCPC without additional blood flow, haemodynamic findings are favourable for completion of TCPC. A staged palliation to completion of the TCPC can be achieved with excellent results even at an early age.
St. Christopher's Hospital for Children, Philadelphia, USA Objectives: Results of Fontan's procedure have improved considerably, but peri-operative mortality still occurs, attributed to ventricular dysfunction, stroke, arrhythmia, thromboembolism, and multi-organ dysfunction. Our protocols of operative and ICU management address these potential issues, and have been associated with zero mortality, even with many high-risk candidates. Methods: From 1996 through 2006, all Fontan patients were managed as follows: operative strategy based on aortic and single atrial cannulation, cooling on full-flow bypass, and hypothermic circulatory arrest to create Fontan pathway. No direct caval cannulation. Use of central venous lines was completely avoided. Fresh whole blood used for pump prime and volume restoration. Inotropic/vasodilator therapy continued for at least 48 h. Aspirin used exclusively as anti-thrombotic therapy. Pleural drainage with small pig-tail catheters. The usual Fontan pathway was by lateral atrial tunnel (84), with extracardiac conduit when dictated by anatomy (16). Results: One hundred Fontan operations were performed with no operative mortality, and one death six years later. All patients extubated by postop day 1. Hospital stay was 10±5 days. Complications were: bleeding (1), re-intubation (1), fenestration closure (1), pericardial effusion (4), and seizures (1). Risk factors included Fontan to one lung (4), diminutive PAs and unifocalized MAPCAs (1), discontinuous PAs (3), RV dependant coronaries (3), neonatal pulmonary venous obstruction (3), and heterotaxy (10). No candidate was excluded. Conclusions: While many try to avoid bypass or aortic clamping, the strategies we have employed facilitate safe accomplishment of Fontan's operation in diverse anatomic groups with multiple risk factors, with avoidance of operative mortality in 100 cases.
Yonsei University, Seoul, Korea (South) Objectives: Extracardiac pericardial-flap lateral tunnel Fontan operation has theoretical advantage of growth potentiality of the extracardiac tunnels. The mid-term results of this technique and morphologic change of the lateral tunnel were studied. Methods: Forty-two patients underwent extracardiac pericardial-flap lateral tunnel Fontan operation between November 1993 and December 2004. The age was 2.8±1.5 years. Extracardiac tunnel was constructed using the pedicled pericardium with its base undetached. By reviewing the follow-up cardiac angiogram and computer tomogram, diameter and cross-sectional area of the lateral tunnel were compared to those of inferior vena cava (IVC). Results: Four patients died of low cardiac output after operation (9.8%). Postoperative morbidity includes prolonged pleural effusion in five patients and heart block in one patient. The follow-up duration of the survivors was 3.8±2.2 years. There were two late deaths due to gastrointestional bleeding and sudden death of unknown cause. Two patients required reoperation due to subaortic stenosis and stenosis between inferior vena cava and lateral tunnel. In one patient, bradyarrhythmia was anew. There was no thromboembolic complication. Follow-up anteroposterior and lateral diameter ratio of lateral tunnel to IVC were 1.1±0.5 and 1.2±0.5. The cross-sectional area ratio was 2.6±2.3. In five patients, dilatation of the lateral tunnel was observed, but in the remaining patients, the lateral tunnel showed tubular morphology with good haemodynamics. Conclusions: The mid-term results of extracardiac pericardial-flap lateral tunnel Fontan operation were favourable, and the extracardiac tunnel maintains favourable morphology with the growth of patients.
National Cardiovascular Center, Suita, Japan Objectives: We have initiated the off-pump Fontan procedure by placing a temporary bypass from the inferior vena cava (IVC) to the atrium, and have advanced the procedure in certain patients by simply cross-clamping the IVC. We hypothesized that the off-pump Fontan procedure could ameliorate the morbidity of the effusion. Methods: We retrospectively reviewed 74 patients (<4 years old) who underwent the extracardiac TCPC from 2001. The patients were classified into 3 groups by assistant techniques: Group T (n=15) with a temporary bypass, Group S (n=32) with simply cross-clamping the IVC, and Group O (n=27) with the CPB. Both bilateral chest and peritoneal tubes were placed for all patients. The total volume of the effusion was measured at 6, 12, 24, 48, and 72 h postoperatively, and was corrected by the body weight (kg) and intervals (h).
Results: There were no hospital deaths in all groups. Significantly less effusion (ml/kg/h) was found in Group T than Group S and O at 6 h (T, 4.48; S, 9.77; O, 9.85, P=0.005) and 12 h (T, 2.20; S, 4.32; O, 5.82, P=0.008). Preoperative factors of Rp and VEDP were lower in the patients who required short-term drainage ( Conclusions: The off-pump Fontan procedure with a temporary bypass decreases the effusion, and higher preoperative VEDP is a strong predictor for long-term drainage.
Indiana University School of Medicine, Indianapolis, USA Objectives: Surgical alternatives to biventricular repair of complex forms of double outlet right ventricle (DORV) remain controversial. The available knowledge of the Fontan operation (FO) for children with this anomaly is limited. The aim of this report is to analyze the results and risk factors of the FO performed as an alternative to the biventricular repair of complex DORV. Methods: Between 1990 and 2006, 44 patients with complex forms of DORV underwent a modified FO. Concomitant defects included non-committed, subpulmonary or multiple VSDs, anomalies of atrioventricular (AV) valves and/or caval veins, and ventricular hypoplasia. Twenty-nine patients (66%) have undergone a hemi-FO and 34 patients (77%; 10 children without previous hemi-Fontan) have had a completion FO without mortality or Fontan takedown. Risk factors for adverse outcomes were determined by multivariate analyses. Results: There was one early and four late deaths. The follow-up period ranged from 1 to 16 years (mean, 5.4+4.6). The actuarial survival was 96% at 1 year, 89% at 5 and 15 years. Multivariate analysis identified preoperative left or common AV valve insufficiency (P=0.001) and decreased left ventricular ejection fraction (4.0 Woods U/m2) (P=0.005). Conclusions: FO provides good early and late results in the treatment of complex forms of DORV. The increased preoperative pulmonary vascular resistance was a significant negative risk factor for adverse outcome in this patient population.
1Cardiac Surgery, Sejong General Hospital, Bucheon, Korea (South); 2Paediatric Cardiology, Sejong General Hospital, Bucheon, Korea (South) Objectives: Varying degrees of pulmonary AV malformations (PAVMs) have been reported to be developed after Kawashima operation in patients with single ventricle and left isomerism. We reviewed the incidence of PAVMs after Kawashima procedure and evaluated the change of PAVMs after hepatic vein (HV) inclusion to the pulmonary circulation. Methods: Between 1996 and 2005, HV inclusion procedures were performed in 17 patients undergoing Kawashima operation. HV inclusion techniques were extracardiac conduit Fontan completion (n=16) and anastomosis of HV to azygos vein (n=1). The severity and change of PAVMs was assessed by contrast echocardiography, pulmonary angiography, and lung perfusion scan before and after HV inclusion. Results: There was one early death after HV inclusion because of intractable hypoxia. Before HV inclusion procedure, all but two showed varying degrees of PAVMs, and among them, 8 (47%) developed clinical PAVMs. The development of clinical PAVMs was not related to age at Kawashima operation, an interval between Kawashima and HV inclusion procedures, and pulsatility. A follow-up was done after HV inclusion (median, 55 months). There were no late deaths. Among 14 survivors showing preoperative PAVMs, 10 showed regression of PAVMs. However, four patients showed exacerbation of PAVMs and three of them underwent conduit takedown and rerouting of HV to azygos vein because of progressive hypoxia. These four patients showed contralateral position of the extracardiac conduit and azygos vein and uneven hepatic blood flow to the lungs. Conclusions: The majority of patients after Kawashima operation showed subclinical or clinical PAVMs. Most of PAVMs have improved after HV inclusion procedures. However, some PAVMs did not improve or were exacerbated even after HV inclusion procedures, which may be related to inadequate hepatic blood flow to the lungs.
081 ANGIOGRAPHIC RESULTS OF RADIAL ARTERY GRAFT PATENCY ACCORDING TO THE DEGREE OF NATIVE CORONARY STENOSIS: A PROSPECTIVE CLINICAL TRIAL K. Yie, C. Na, S. Oh, J. Kim, S. Shin, H. Seo Sejong General Hospital, Sejong Heart Institution, Bucheon, Korea (South) Objectives: The radial artery (RA) is gaining widespread acceptance as complementary arterial conduits for surgical myocardial revascularization, but there are limited reports about its angiographic patency compared with that of internal thoracic artery (ITA) or saphenous vein (SV) according the degree of native coronary stenosis. So, we tried to evaluate mid-term angiographic results of RA graft patency focusing on the native coronary stenotic status with a prospective manner. Methods: From March 2000 to September 2006, 488 patients randomly-assigned underwent CABG using RA. Of these, 132 patients, mean age 58.2 years (34–73 years) enrolled in a prospective trial underwent postoperative angiography at 32 months. Angiograms were assessed visually and quantitatively. Results: A total of 412 distal anastomosis were performed and 376 anastomosis remained patent (91.2%). LITA showed the most excellent patency in all of the conduits (137/139, 98.5%). Overall RA graft patency was 90.8% (169/186). Patency was significantly worse for targets of the right coronary system (left coronary system 135/143, 94.4% vs. right coronary system 34/43, 79.1%. P<0.005). RA showed more a higher patency rate with severe stenotic lesions preoperatively more than 90% than in the less severe (<90%) lesion (98/110, 89% vs. 60/76, 78%. P<0.005). The site of proximal anastomosis failed to affect RA patency (P=0.078). Conclusions: RA conduit shows good midterm patency when it is grafted beyond severe stenotic lesion of more than 90% in the left coronary system. But one should pay close attention to the grafting strategy when preoperative coronary angiogram reveals <90% of stenosis, especially in the right coronary system.
1Austin Hospital, Melbourne, Australia; 2University of Melbourne, Statistical Consulting Centre, Melbourne, Australia Objectives: In order to determine the best conduit for targets other than the left anterior descending artery (LAD), long-term clinical outcomes following revascularisation with a radial artery or saphenous vein graft were evaluated as part of the radial artery patency and clinical outcomes (RAPCO) study. Methods: As part of the protocol for this prospective, randomised, single-centre trial, patients aged >70 years undergoing primary CABG were randomly assigned to a radial artery (n=113) or saphenous vein (n=112) to revascularise the best non-LAD coronary vessel. Follow-up was annual. Primary clinical endpoints were death, myocardial infarction or need for revacularisation. Analysis was by intention to treat. Results: The preoperative demographics (age, gender, presence of hypertension or diabetes mellitus) and urgency of surgery did not differ significantly between the groups. The allocated arterial or venous conduit was utilised as intended in 104/113 and 110/112 patients, respectively. Mean number of grafts was 3.2±0.9 and 3.3±0.7 in the two groups. During follow-up of mean duration 6.0 years (maximum 10.3 years) there were 15 deaths in each group, and 21 vs. 26 events in the radial and saphenous groups, respectively. These outcomes did not differ significantly (log rank P=0.86 for survival and P=0.88 for event free survival). Conclusions: Use of a radial artery or saphenous vein for the second graft during primary CABG does not significantly influence clinical outcome at five years. Mean 5-year angiographic patency data are awaited, but from the patient's perspective the likelihood of a satisfactory long-term result is equivalent whichever conduit is used.
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland Objectives: To compare at ten years coronary artery bypass grafting (CABG) with percutaneous coronary intervention and stent implantation (S) in patients with proximal, isolated de novo left anterior descending (LAD) coronary artery disease. Methods: The patients were randomly assigned to S or to CABG. The primary clinical composite end point was event-free survival, including death, myocardial infarction, and the need for additional revascularisation. Secondary end points were functional class, anti-anginal treatment, and quality of life. Results: Of 123 randomised patients, 59 underwent CABG, and 62 S (two patients were excluded because of protocol violation). At 10 years follow-up, a primary end point had occurred in 24 patients (39%) in the S group and in 9 (15%) in the CABG group (P<0.001). This significant difference in clinical outcome is due to a higher incidence of additional revascularization in the stent group. The incidence of death and myocardial infarction being similar (10% vs. 10%, respectively; P=0.90). Progression of the disease requiring additional revascularization was rare and similar for the two groups (5% for both group). The functional class showed no significant differences between the two groups. Conclusions: Both stent implantation and CABG are safe and highly effective treatments to relieve symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. The long-term prognosis remains very favourable with an overall survival of 91%. However, elective stent placement remains hampered by a higher need for repeated intervention because of restenosis.
1Heart Centre Leipzig, Leipzig, Germany; 2Erasmus Center Rotterdam, Rotterdam, The Netherlands Objectives: To characterize the current patient population and pattern of coronary artery disease in routine cathlab practice with special focus on de novo three-vessel coronary artery disease and/or left main disease (CAD-3/LM) during SYNTAX study enrolment. Methods: During SYNTAX study enrolment a total of 3.319 consecutive adult patients undergoing cardiac catheterisation were prospectively recorded. Patients with de novo CAD-3/LM were evaluated in the daily Heart Team Conference by interventionalists and cardiac surgeons concerning suitability for study enrolment. Results: Six hundred and ninety four of all patients (20.9%) presented CAD-3/LM. Two hundred and seventy one patients had history of CABG and 232 of PCI procedure or needed additional cardiac surgery. 6.8% presented AMI high enough for study exclusion. One hundred and four patients (15.0% of 3-CAD and 3.1% of all patients.) fulfilled all study inclusion criteria and were potentially suitable for study enrolment. Thirteen refused study participation, ten patients presented uncertain protocol adherence and six participated on other cardiovascular studies. As a result 67 patients were enrolled representing 9.7% of CAD-3/LM and 2.0% of all patients. Patients non-amenable for PCI (CABG registry) had more complex coronary lesions (Syntax Score 25.5 vs. 34.5, P=0.003) and significant more chronic coronary occlusions (30% vs. 85%, P=0.04). Randomised patients were comparable in age (PCI 69.7 vs. CABG 67.2y), additive EuroSCORE (5.0 vs. 4.1), EF (57.8% vs. 52.4%), number of coronary lesions (4.5 vs. 4.6), left main disease (42.9% vs. 52.6%) and total RCA occlusion (19.0 vs. 21.1%). Conclusions: Patients with de novo 3-CAD/LM represented 15% of CAD-3/LM and only 3.1 of all patients undergoing cardiac catheterization in the routine cathlab practice. Chronic coronary occlusions of Cx and LAD were the main coronary characteristic to refuse PCI treatment by the interventionalists.
1Clinique St Luc, Namur, Belgium; 2Cliniques Universitaires St Luc, Brussels, Belgium Objectives: Bypass surgery and percutaneous coronary interventions (PCI) improve the clinical status of patients with left anterior descending (LAD) coronary artery disease. However, these techniques differ in invasiveness and in the need for subsequent reinterventions. The development of minimally invasive coronary artery bypass surgery (MIDCAB) and of drug eluting stents (DES) offers perspectives to close this gap. Methods: We compared the long-term clinical outcome of 308 patients after revascularization for isolated LAD coronary artery disease. One hundred and fifty-four patients were treated with MIDCAB and 154 with PCI and DES implantation. Results: Both groups were similar in age (63±13 and 62±10 years), EuroSCORE (3.3±2.8 and 3.4±2.6) and mean duration of follow-up (30±17 and 24±10 months). Two-year survival was similar after MIDCAB and after DES (97.4% and 94.8%). During follow-up, four patients (2.6%) of the MIDCAB group and 21 patients (13.6%) of the DES group needed subsequent revascularization of the target vessel (P=0.001). Revascularization of a non-target vessel was needed in 11 patients (7%) of the MIDCAB group and in 17 patients (11%) of the DES group (NS). Neurological complications included two transient ischaemic accidents and two strokes in the MIDCAD group but three fatal cerebral haemorrhages and one stroke in the DES group. Major adverse coronary and cerebrovascular events (MACCE) rates were 14% in the MIDCAB and 31% in the DES group. Conclusions: MIDCAB and DES implantation showed similar rates of mortality but a higher reintervention rate after DES. Anticoagulation implications remain critical for the future of DES.
Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland Objectives: Many studies enlighten the effect of modified risk factors after coronary artery bypass grafting (CABG) on mortality and morbidity. Our retrospective survey evaluates changing habits after CABG between 1990 and 2003 with focus on correlation between lifestyle habits and freedom from symptoms or regained exercise tolerance. Methods: We reviewed 2270 patients after CABG between 1990 and 2003. We designed a questionnaire evaluating lifestyle modifications and outcome with regard to quality of life for up to five-years after surgery. Results: We found a significant reduction of changing dietary 1.6% vs. ±habits after surgery 2000–2003 compared to 1990–1998 (15.9%, 2.6%; P±24.7% <0.001) and desire for nutritional counselling constantly 1.4%; P±7.9% vs. 26.6% ±decreased (35.1% <0.001). Especially men from 50–59 years neglect strict diet (m: 20.0% vs. f: 41.5%; P=0.001). Patients suffering from recurrent angina consult more often with nutritionists than patients without angina (36.6% vs. 29.8%; P=0.016). The more patients are restricted regarding physical fitness, the more they pay attention to healthy nutrition (NYHAIII: 22.2% vs. NYHAII: 14.6% vs. NYHAI: 10.2%; P<0.001). Additionally, 60–79 years old 4.9%; P±2.4% vs. 51.1%±men exercise more often than women (72.4% <0.001) and 4.0% vs. ±suffer less frequently from recurrent angina (13.4%, 10.8%; P=0.002) ±28.8%. Conclusions: Over the years patients after CABG pay significantly less attention to their nutrition, despite the knowledge of hypercholesterolemia or obesity advantaging coronary heart disease. We believe that especially male patients over 50 years after CABG would benefit from dietary education. Similarly women over 60 years might profit from more physical activity. Patients obviously tend to delayed lifestyle modification until symptoms occur. Hence, there is still a need for underlining the importance of healthy nutrition and adequate physical activity.
087 DEVELOPMENT OF A BIOLOGICAL CARDIAC PACEMAKER USING GENE THERAPY IN A PRECLINICAL MODEL A. Ruhparwar1, M. Niehaus2, K. Kallenbach1, C. Bara2, G. Klein2, M. Makoui2, A. Haverich2, M. Karck1 1University of Heidelberg, Heidelberg, Germany; 2Hannover Medical School, Hannover, Germany Objectives: When cardiac atrioventricular nodal cells are damaged by disease, the implantation of an electronic cardiac pacemaker becomes necessary. Several limitations and problems of artificial pacemakers have emerged during the past decades. In children and newborn babies with arrhythmia, initial size mismatch and their growth can pose a problem. Lead extraction and infections have additional risks. The aim of our study was the development of a biological cardiac pacemaker by in-vivo adenoviral transfection of ventricular cardiomyocytes in a large animal model with the gene encoding for adenylate-cyclase type VI (ACVI) in order to increase the intracellular concentration of cAMP and intrinsic rhythmic rate of the transfected cells, enabling ectopic pacing from the injection site. Methods: Using an adenoviral vehicle, the adenylate cyclase gene was injected into the free wall of the left ventricle of adult pigs via anterolateral thoracotomy. The control group received the same amount of ß-galactosidase reporter genes. After 12 days, the animals under went fluoroscopy and the AV-node was interventionally ablated with simultaneous three-dimensional cardiac mapping using the ENSITE®-system in order to locate the origin of the escape rhythm. Results: All animals treated with the ACVI-gene exhibited an escape rhythm which originated in the left ventricle while the animals of the control group all had a right-ventricular escape rhythm. Western blot analysis confirmed a significantly higher expression of ACVI at the site of gene injection. Conclusions: Gene therapy for transformation of ventricular cardiomyocytes into pacemaker cells may open a new perspective for the treatment of cardiac arrhythmia such as atrioventricular block.
Sao Paulo University Medical School, São Paulo, Brazil Objectives: Infections are the commonest cause of mortality after transplants. We hypothesized cyclosporine A (CsA) impairs mucociliary clearance by decreasing mucus secretion. Our purpose was to assay CsA effects on mucus secretion and mucociliary transport in rats. Methods: Twenty-one rats were assigned to three groups: control (n=5), saline (n=8) and CsA (n=8; 10 mg/kg/day). After 30 days, they were killed and lungs were removed from thoracic cavity. Mucus samples were collected and in vitro transportability was evaluated by using a bullfrog palate model. In situ mucociliary transport (MCT) was timed by direct view of particles trapped on mucus moving across the respiratory tract. Finally, we measured the amount of stored mucins in the goblet cells of the respiratory epithelium. Results: In vitro transportability rate was statistically minor (P<0.001) in CsA group. Also, in situ MCT was decreased in all CsA-treated animals (P=0.02). Mucus quantity measurements showed a significant decrease on both acid (P=0.01) and neutral (P=0.02) mucus production from goblet cells in the animals submitted to CsA therapy. The correlation between the percentage of total mucus and in vitro transportability rate was positive and significant (r=0.706, P<0.001), as well as between the percentage of total mucus and in situ MCT (r=0.688, P=0.001). Conclusions: Our results show that CsA plays an important role on the impairment of the mucociliary clearance. This fact can help us to understand the high-level of infection after transplants. Further studies with others immunosuppressant drugs will give us a major comprehension about this phenomenon.
1Department of Cardiovascular Surgery, Medical School University of Patras, Patras, Greece; 2Biology Department, University of Patras, Patras, Greece Objectives: Paraplegia is the most devastating complication of thoraco-abdominal aorta procedures. A primary mechanical insult elevates free radicals causing oxidative stress. In this study we examined the influence of Amifostine, a triphosphate agent, on oxidative stress of spinal cord ischemia in rabbits. Methods: Eighteen male, New Zealand white rabbits were anaesthetized and spinal cord ischemia was induced by inflation of a coronary artery balloon catheter, advanced to descending thoracic aorta through the femoral artery. The animals were random divided into three groups. Group I functioned as control. In Group II the aorta was occluded for 30 min and then reperfused for 75 min. In the Group III, during the second half-time of ischemia-time, 500 mg Amifostine were infused into the distal aorta. At the end of reperfusion all animals were sacrificed and spinal cord specimens were examined for superoxide radicals by ultra sensitive fluorescent assays. Results: Superoxide radical levels ranged, in Group I between 1.52 to 1.76 (1.64±0.10), in group II between 1.96 to 2.50 (2.10±0.23), and in group III between 1.21 to 1.60 (1.40±0.19) (P=0.00), shown a decrease of 43% in Group of amifostine. A lipid peroxidation marker measurements ranged, in Group I between 0.278 to 0.305 (0.296±0.013), in group II between 0.427 to 0.497 (0.463±0.025), and in group III between 0.343 to 0.357 (0.350±0.007) (P<0.00), shown a decrease of 38% after amifostine administration. Conclusions: By direct and indirect methods of measuring the oxidative stress of spinal cord after ischemia/reperfusion, it is suggested that intraaortic Amifostine infusion, significantly attenuates the spinal cord injury.
1University Hospital of Geneva, Geneva, Switzerland; 2Virginia Commonwealth University, Richmond, USA Objectives: Vascular tissue engineered vascular grafts necessitates degradable materials as matrix. Our group has previously shown good biocompatibility of degradable PDS (polydioxanone) vascular grafts in the systemic arterial circulation of the rat except aneurysm formation within three weeks. Our effort is now to delay degradation time by the mixing of slower degradable polymers with PDS. This study evaluates patency, aneurysm formation and intimal healing characteristics of the co-polymer polydioxanone-polylactic acid (PLA) compared to ePTFE grafts. Methods: PDS (50%)-PLA (50%) grafts were produced by random nanofibre electrospinning technique. PDS-PLA (n=9) and ePTFE grafts (n=9) were interposed in the rat abdominal aorta with the same diameter (2 mm) and length (15 mm). Animals were followed for 3, 6 and 12 weeks. At the end of follow-up, grafts were explanted after aortography. Computed morphometry was used to analyse of neoendothelialization (% of whole graft length) and intimal hyperplasia (IH) (µm2/µm). Results: At all time points, the grafts of both groups were patent without anastomotic stenoses. Only degradable grafts had aneurysmal degeneration at six (1/3 grafts) and twelve weeks (1/3 grafts). Neoendothelialization was found to be better for PDS-PLA compared to ePTFE grafts (for 3, 6 and 12 weeks; 74, 88, 92 vs. 15, 33, 53%; P=0.064, 0.050, 0.046, respectively). PDS-PLA grafts had an increased IH after six weeks compared to ePTFE (8, 90, 86 vs. 5, 8, 16 µm2/µm; P=1.0, 0.050, 0.050, respectively). Conclusions: Mixture of PDS with PLA can delay degradation-induced aneurysm formation compared to PDS alone. The endothelialization of PDS-PLA grafts is significantly better compared to ePTFE. This information may eventually be useful to improve the neoendothelialization of artificial surfaces by the use of degradable polymer coating.
1Innsbruck Medical University, Innsbruck, Austria; 2Bezirkskrankenhaus Hall, Hall, Austria Objectives: The antiproliferative substance paclitaxel is clinically used as coronary stent coating. Local treatment of veins before CABG might prevent vein graft disease. Methods: Saphenous vein remnants from 13 CABG patients were investigated by organ culture developing neointimal hyperplasia. The treatment group received paclitaxel in the culture medium. Results: Veins treated with 1 µmol/l paclitaxel showed an intimal thickness increase of 2 µm (range: 76–46) from baseline levels, whereas untreated control veins increased by 15 µm (range: 3–142) (P=0.022). 10 µmol/l paclitaxel treatment reduced the intimal thickness growth to 1 µm (range: 82–212) above baseline levels (P=0.035 vs. controls). Treatment with 25 or 50 µmol/l paclitaxel did not further inhibit intimal hyperplasia. The neointimal smooth muscle actin (SMA) amount of paclitaxel 1 µmol/l treated veins was significantly higher than baseline values (P=0.037). Desmin was predominant in the media, less frequently in the intima, without difference between controls and paclitaxel treated veins. Ki-67 was commonly present in the circumferential media, and rarely in the (inner) longitudinal media and intima. Elastic fibers were present in the media and intima before and after organ culture without significant differences between groups. Collagen fibers (Massons trichrome) were found abundantly (80%) in the inner longitudinal media, less common (20%) in the outer circumferential media, and were intimally absent without difference between groups. Conclusions: Local paclitaxel treatment reduces neointimal hyperplasia in cultured human saphenous veins, without changing elastic or collagen fiber amount. Paclitaxel-treated veins show an increased amount of the contractile protein SMA and might have therapeutic potential for vein graft disease prevention.
1Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany; 2Veterinary Pathology, University of Leipzig, Leipzig, Germany Objectives: Recent studies have suggested the ability of bone marrow-derived stem cells (BMCs) to enhance contractility and reverse remodelling in non-ischaemic cardiomyopathy, but possible mechanisms and cell interactions are controversial discussed. This study evaluates the hypothesis that the right ventricular transplantation of autologous BMCs affects LV-contractility of doxorubicin-induced failing hearts. Methods: Heart failure was induced in White New Zealand rabbits by injection of doxorubicin (3 mg/kg), followed by randomization: transplant group (Tx, 1.5–2.0x106 BMCs, n=8), sham group (M-group, medium, n=8), healthy group (HG, n=10) and diseased group (no therapy, n=6). Cells were isolated by bone marrow aspiration and transplanted locally in the right ventricle. Four weeks later, cardiac function was assessed. For angiogenesis capillary density (CD31), VEGF and bFGF mRNA-expression were measured. All analyzes were carried out in LV, septum and RV. Results: Fractional shortening, ejection fraction and developed dp/dt were significant higher in the Tx-group vs. M-group (FS: 22±5% vs. 14±5%, P<0.05; EF: 29.2±7% vs. 19.0±5%, P<0.05; maximum dp/dt: 1008±99 vs. 624±70, P<0.05 and minimum dp/dt: –677±68 vs. –420±50, P<0.05, Mean±S.E.M.). Outside of cell transplantation, the capillary density (capillaries/HPF) increased in the left (LV: 28.4±5.2 vs. 18.2±4.0, P<0.05) and right (RV: 26.0±5.2 vs. 14.5±3.9, P<0.05) ventricles and in the septum (26.7±4.5 vs. 19.6±4.5, P<0.05) compared to M-group. Additional, VEGF and bFGF mRNA expression was higher in Tx-group. Conclusions: Right ventricular cell transplantation improves LV-function in doxorubicin-induced cardiomyopathy. Despite local cell transplantation reverse remodelling and enhanced angiogenesis are regulated.
Heart Centre Leipzig and University of Leipzig, Leipzig, Germany Objectives: Two forms of hypertrophy exist in heart muscle, pathological (mostly due to pressure-overload) and physiological (exercise-induced) differing in their substrate oxidation patterns. The regulatory mechanisms of these differences in substrate use are not well known. We aimed to assess the expression of metabolic genes and their regulators in exercise-induced and pressure-overload hypertrophy in rat heart. Methods: Exercise-induced hypertrophy was induced by treadmill-running of male Sprague-Dawley rats for ten weeks. Pressure-overload hypertrophy was induced by aortic banding for 14 days. Contractile function was assessed by echocardiography. Expression of genes encoding for glucose and fatty acid oxidation, as well as regulators of metabolic gene expression, were assessed by RT-PCR.
Results: Both interventions caused significant hypertrophy (heart-to-body-weight ratio +17.0% banding, +14.3% exercise, P<0.05) without affecting left ventricular function (FS, EF). Exercise-induced hypertrophy did not cause any changes in the expression of fatty-acid-oxidation (FAO)-genes or the PPAR Conclusions: There is a significant down regulation of substrate oxidation enzymes in pathological hypertrophy, potentially limiting energy consumption and ATP generation. This down-regulation is not present in physiological hypertrophy. The decrease in substrate oxidation machinery may be a reason why pathological hypertrophy proceeds to heart failure and physiological hypertrophy does not.
1Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; 2Department of Paediatric Cardiology, University of Heidelberg, Heidelberg, Germany Objectives: Tetrahydrobiopterin (BH4) is an important co-factor of endogenous nitric oxide synthesis. In the present pre-clinical study, we investigated the effects of BH4 on cardiac and pulmonary function during reperfusion in an experimental model of cardioplegic arrest and extracorporal circulation. Methods: Twelve anaesthetized dogs underwent hypothermic cardiopulmonary bypass. After 60 min of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n=6), or tetrahydrobiopterin (n=6). Left ventricular end-systolic pressure volume relationship (Ees) was measured by a combined pressure-volume-conductance catheter at baseline and after 60 min of reperfusion. Left anterior descendent coronary blood flow (CBF) and pulmonary blood flow (PBF), endothelium-dependent vasodilatation to acetylcholine (ACH) and endothelium-independent vasodilatation to sodium nitroprusside (SNP) and alveolo-arterial O2 gradient were determined. Results: The administration of tetrahydrobiopterin led to a significantly better recovery (given as percent of baseline) of Ees 76±9% vs. 46±6%, P<0.05. CBF and was also significantly higher in the BH4 group (38±4 vs. 25±4, ml/min, P<0.05). While the vasodilatatory response to SNP was similar in both groups, ACH resulted in a significantly higher increase in CBF (77±6% vs. 31±5%, P<0.05) and PBF (49±7% vs. 36±6%, P<0.05) in the tetrahydrobiopterin group. Alveolo-arterial O2 gradient was significantly lower in the tetrahydrobiopterin group (80±6 vs. 43±5 mmHg, P<0.05). Conclusions: Application of tetrahydrobiopterin improves myocardial, endothelial and pulmonary function after cardiopulmonary bypass with hypothermic cardiac arrest.
University of Pennsylvania School of Medicine, Philadelphia, USA Objectives: Paradoxical systolic bulging following myocardial infarction can impair LV function and promote both adverse remodelling and poor long-term prognosis. We hypothesized that thickening the infarcted territory of the LV wall by means of intramyocardial injection would both attenuate paradoxical systolic bulging and improve segmental contractile function within remote regions of the LV. Methods: Fifteen adult male sheep underwent a series of coronary ligations that create a highly reproducible anteroapical myocardial infarction followed by intramyocardial injection of 1.3 ml of a viscous hydroxyapetite-based preparation into the infarcted territory. Real-time three-dimensional echocardiography was performed at baseline, 30 min after MI and 30 min after intramyocardial injection. Multiple geometric and functional indexes were calculated at each observation time. Results: End diastolic and end systolic volumes increased from 44.3±3.0 ml and 23.0±1.6 ml, respectively, at baseline to 61.4±3.8 ml (P<0.001) and 38.4±2.4 ml (P<0.001) 30 min after MI, while ejection fraction decreased from 45.1±2.6% to 34.8±2.0% (P<0.001). Following intramyocardial injection, end diastolic and end systolic volumes decreased to 57.9±3.6 ml (P<0.001) and 35.0±2.3 ml (P<0.001), while global EF increased 36.7±2.3% (P<0.05). Normalized mid-systolic apical bulging decreased from 18±15% to –5±4% (P=0.14) following injection while mid-ventricular and basal ejection fractions increased from 45.6±4.8% and 43.8±2.9% to 52.8±2.7% (P=0.08) and 48.9±2.9% (P=0.05). Conclusions: Intramyocardial left ventricular restraint reduces paradoxical systolic bulging within the infarct territory and improves contractile function within the non-ischaemic basal myocardium. This may both attenuate post-infarction LV remodelling and improve long-term cardiac function.
F6 ISOLATED AORTIC VALVE REPAIR: THE TALE OF THE DOUBLE RING E. Lansac1, I. Di Centa2, F. Raoux3, T. Joudinaud1, N. Al Attar1, R. Raffoul1, C. Acar4, P. Nataf1 1Cardiovascular Surgery, Bichat University Hopital, APHP, Paris, France; 2Vascular Surgery, Ambroise Pare University Hospital, APHP, Boulogne Billancourt, France; 3Cardiology Saint Antoine University Hospital, APHP, Paris, France; 4Cardiovascular Surgery, Pitie Salpetriere University Hospital, APHP, Paris, France Objectives: Characteristic lesions of isolated dystrophic aortic insufficiency are the constant dilation of aortic annular base and sinotubular junction (STJ) diameters, associated or not with cusp prolapse. We suggest a standardized approach for isolated aortic valve repair, performing a double sub and supravalvular annuloplasty. Procedure is based on the implantation of external expansible open rings, in order to treat dilated diameters while preserving aortic root dynamics. Methods: Dissection is performed step by step on a fresh cadaver heart. Aorta is transected 1 cm above the STJ. External dissection of the root down to the aortic annular base reaches the subvalvular plane, clearing the space under the coronaries, without detaching them from the aortic wall. Choice of external prosthetic rings size is based on annular base inner diameter. Results: Five subvalvular U stitches are placed from the inside out below the nadir of each cusp, and at the base of the interleaflet triangles (except between the right and non-coronary sinuses to avoid injury to the bundle of His). Three supra-valvular stitches are passed at each commissure level. Plication of a prolapsed cusp free edge is performed when needed. Stitches are passed through the subvalvular ring, tied at the aortic annular base level. Aortotomy is closed and the commissural stitches are passed through the supra-valvular ring, tied at the STJ level. Conclusions: Double sub and supra valvular aortic annuloplasty is a standardized technique of valve repair for isolated dystrophic aortic insufficiency that respects the aortic annulus dynamics, while increasing level of valvular coaptation.
Asan Medical Center of Ulsan University, Seoul, Korea (South) Objectives: Comprehensive Aortic Root and Aortic Valve Repair Technique (CARVAR) has been used on almost all types of aortic regurgitant disease in the past ten years at our institute. Recently, the indication for this technique has been extended to the treatment of aortic stenosis. Methods: A 46-year-old female patient is presented with severe aortic stenosis. The heart was approached by median sternotomy. A thickened and heavily calcified aortic valve was resected. The annular and STJ diameters were measured with a specially designed sizer. The resultant fibrous and muscular annular dimensions were both 28 mm, obviating the need for additional annular reduction. The diameter of STJ was measured and ideal STJ ring size was determined as 26 mm. Based on these dimensions, three bovine pericardial leaflets were tailored with a specially designed template and sutured on to each of the native aortic valve scallops. Afterwards, a pledgetted mattress suture was placed at the commissural sites. At the STJ level, the inner and outer STJ rings were placed and secured with multiple mattress sutures. A further stitch was placed on the apposing leaflets at the commissural level to optimize AV coaptation. Finally, the aortotomy was closed and the aneurismal ascending aorta was wrapped with an opened strip of Dacron graft. Results: Postoperative echocardiography showed normal aortic valve appearance and motion. The patient was discharged on the 6th postoperative day uneventfully. Conclusions: This film showed that CARVAR technique is applicable not only to treatment of aortic regurgitation but aortic stenosis safely.
Center of Cardiac Surgery, Chelyabinsk, Russian Federation Objectives: Combination of CAD and its complications with aneurysm of descending thoracic aorta is not rare. Each of the concomitant lesions can affect the results of the isolated surgical treatment of the other. Therefore, it is important to search for optimal surgical techniques that would enable execution of combined surgery. Methods: Video record of simultaneous multi-vessel CABG (LIMA to diagonal artery; Y-shaped autovein graft to obtuse marginal and circumflex arteries with formation of proximal anastomosis with synthetic descending aortic prosthesis), mitral annuloplasty for IMR correction and replacement of descending aortic aneurysm with linear synthetic prosthesis is provided. Operation was performed with CPB (26 °C) through the left thoracotomy with cannulation of ascending aorta and right atrium. Ascending aorta was not clamped. All stages of procedure were performed during ventricular fibrillation. The circulatory arrest (20 °C) was used during formation of proximal suture line between unclamped descending aorta and synthetic prosthesis. Results: Patient's postoperative course was prolonged by delay wound healing. This case has cleared up several technical points that seem as optimal for combined procedure: Avoidance of manipulations on ascending aorta (excluding arterial cannulation in our case):
Targeting for revascularization of all coronary regions through left thoracotomy. Possibility to perform most of the intracardiac procedures (mitral repair and replacement, maze procedure, left ventricular reconstruction) through left thoracotomy. Conclusions: This film is presented to emphasize feasibility and to accentuate some technical points facilitating performance of the combined operation.
Great Ormond Street Hospital, London, UK Objectives: To present the technical details for the Pulmonary Autograft Root Replacement (Ross Procedure) in particular the harvest of the pulmonary autograft and the implantation using an interrupted suture technique. Methods: The MPA is transacted just proximal to its bifurcation. The pulmonary valve is inspected to ensure it is normal. The base of the pulmonary valve is separated from the aortic root by sharp dissection. An incision is made in the infundibulum 3–4 mm below the lowest point of the leaflet attachment. Using an endocardial incision within the RVOT and going obliquely such that the endocardial incision is deeper than the epicardial component helps avoid the septal branch of the LAD.Bleeding points are visualised and controlled during delivery of cardioplegia. The pulmonary autograft is implanted in a subannular position to utilize the strength of the fibromuscular tissue in the LVOT, the proximal suture line is reinforced with a strip of autologous pericardium. Interrupted 4/0 Tycron sutures are used, which we believe allows better orientation of the autograft. A distal aortoplasty to optimise the sinotubular dimensions is undertaken as indicated. Results: At our institution we have performed 187 Ross procedures since 1987. The age range is 5 days to 49 years. Since 1997 all the procedures have been with an interrupted suture technique. Our overall mortality is 3%. The reintervention rate for neoaortic regurgitation is 1%. Conclusions: The Ross procedure remains a widely applicable option with a low mortality and morbidity rate.
General and Cardiothoracic Surgery, Graduate School of Medicine Gifu University, Gifu-City, Japan Objectives: To present a technical movie of mitral repair for anterior leaflet prolapse and valve sparing aortic root replacement for Marfan Syndrome. Methods: The patient was 56-year-old male, who had been asymptomatic. The anterior mitral leaflet was billowing and had redundant area, which length was shortened by scimitar-shape cutting of the leaflet and sewing. A 5-0 Gore-tex suture was placed between the anterior papillary muscle and the rough zone of the leaflet to repair the prolapse. After deploying Physioring, mitral regurgitation disappeared. Water leak test showed almost normal aortic valve function. The annulus allowed 29 mm sizer to pass. The end of 34 mm sealed graft was plicated down to 29 mm, which was sewn on the annulus using 15 2-0 sutures. The scalloped aortic wall was sewn onto the graft using 5-0 polypropylene running sutures. Because of shorter and larger graft than David-I operation, the running suture became easier. Water leak test showed good cusp coaptation. The coronary buttons were connected on the graft. The distal end of the graft was again plicated down to 17 mm making new sinus of Valsalva. A 24 mm sealed graft was interposed between the root graft and the ascending aorta. Results: Intraoperative TEE showed no mitral regurgitation, nor aortic regurgitation. The shape of the graft looked like sinus of Valsalva. Conclusions: Anterior mitral leaflet prolapse was repaired with partial resection and placement of artificial chordae. David-V operation brought easy access to root repair and ideal shape of sinus of Valsalva.
096 TRANSAPICAL MINIMAL INVASIVE AORTIC VALVE IMPLANTATION-THE INITIAL 50 PATIENTS T. Walther, V. Falk, J. Kempfert, M.A. Borger, J. Fassl, J. Ender, G. Schuler, F.W. Mohr Heart Centre Leipzig, Leipzig, Germany Objectives: To evaluate the feasibility of minimally invasive transapical beating heart aortic valve implantation (TAP-AVI) for high-risk patients with aortic stenosis. Methods: TAP-AVI was performed via a small anterolateral minithoracotomy in 51 patients since February 2006. A pericardial xenograft fixed within a stainless steel, balloon expandable stent (Edwards SAPIENTM THV, Edwards Lifesciences, Irvine, CA, USA) was used. Mean age was 82.3±5 years and 76.5% were female. Implantation was performed in a hybrid operative theatre using fluoroscopic and echocardiographic visualization. Average EuroSCORE predicted risk for mortality was 27.4±12%. Seven patients were reoperations with open bypass grafts. Results: TAP valve implantation (13x23 mm and 38x26 mm) was performed on the beating heart during brief periods of rapid ventricular pacing; it was performed completely off-pump in 68.6%. Three patients required conversion due to proximal dislocation at implant, aortic root dissection after catheterization and coronary occlusion in presence of severe calcification. Two of those were successfully discharged. There was no migration of the prosthesis and all had good haemodynamic function. Echocardiography revealed minor incompetence in 23 patients, mostly paravalvular, without any signs of haemolysis. Mortality was due to the overall health condition and non-valve related in all patients. Actuarial survival at 1 and 6 months was 93.4±3.7% and 76.5±7.6%, respectively. Conclusions: Transapical minimally invasive aortic valve implantation is feasible using an off-pump technique. Good results have been achieved in the initial 50 patients, especially when considering the overall high-risk profile of these patients.
Heart Centre, Leipzig, Germany Objectives: There has been concern that minimal-invasive MV surgery will not meet the standard of open techniques, because such possible repair may lead to unnecessary MV-replacement or inferior repair. Methods: Of more than 2300 patients who underwent isolated MV-surgery between March 1999 and February 2007, 1760 patients were operated in minimal-invasive technique using a right-lateral mini-thoracotomy and femoral cannulation for CPB. One thousand five hundred and thirty-six of these patients (891 males) were diagnosed with isolated MV-regurgitation (mean grade 3.4±0.5) and are reported herein. One thousand two hundred and fifty-six patients presented dilatation of the annulus, 1028 had MV-prolapse. Mean age was 60.9±12.6 years, mean EF was 59.3±15.1% Results: Successful MV-repair was performed in 87.7% (1348). Repair techniques consisted of ring-annuloplasty in over 1300, chordae-replacement on AML (PML) in 260 (415) patients. Carpentier type resection on AML (PML) was performed in 29 (348) with and without sliding-plasty. Alfieri-plasty was used as bail-out procedure in 44 patients. Concomitant procedures were ablation (305), tricuspid-valve surgery (94), and PFO-closure (95). Mean duration of CPB was 122±41 min, mean aortic-clamp-time was 70±35 min. The procedure was successfully performed in all but seven patients. Mean hospital-stay was 12.7±10 die. Early and mid-term echocardiographic follow-up confirmed the high quality of intraoperative TEE. Mean follow-up time was 28.4±23.5 months, follow-up rate was 99%. Thirty-day mortality following MV-repair was 2.4% and 1-year mortality 5%. Thirty-day-mortality after MV replacement was 3.7% and 1-year mortality 11.2%. Present data correspond favourably to published data for mid- and long-term MV repair which define the golden standard. Conclusions: Minimal-invasive techniques for MV-surgery are highly successful although it seems to be more difficult and requires specialized training and new techniques to obtain optimal results.
Division of Cardiac Surgery, Catholic University, Rome, Italy Objectives: To evaluate the potential for application of percutaneous aortic prosthesis implantation (PAPI) in the real world.
Methods: In January 2003, we started a prospective registry preliminary to the introduction of percutaneous aortic valve replacement at our Institution. All patients were potential candidates for PAPI on the basis of the current guidelines were included. Main inclusion criteria were aortic stenosis with surgical indication and EuroSCORE Results: Between January 2003 and January 2007, a total of 1695 patients were screened; 161 entered the registry (9.5%). Ninety-eight of these patients had at least one among the following conditions compromising the safety/feasibility of PAPI: coronary disease requiring concomitant bypass grafting (74 total cases), severe peripheral arterial disease (34 cases), and non-clampable ascending aorta (41 cases). Thus, only 63 patients (3.7% of the total) were ultimately potential candidates for PAPI. The annual percentage of cases potential candidates to PAPI was 5.8% in 2003, 3.8% in 2004, 3.2% in 2005, 2.2% in 2006 and 1.9% in the first two months of 2007 (P=0.16, OR 3.23, CI 0.72–20.19). Conclusions: The percentage of patients who are potential candidates for PAPI is extremely limited, representing <4% of the overall number of aortic valve patients referred at our Institution during the study period. Moreover, the annual incidence of potential PAPI candidates dropped steadily; this is mainly due to the increase of the prevalence of clinical conditions daunting the application of PAPI. These findings raise concern over the potential impact of percutaneous technique of aortic prosthesis implantation.
Heart Centre Leipzig, Leipzig, Germany Objectives: Mitral valve (MV) repair with premeasured Gore-Tex Loops was introduced in 1999. Since its introduction, the Loop technique is our preferred method of repair for all types of MV leaflet prolapse. Methods: Four hundred and ninety-three patients (348 male, 145 female) underwent MV repair with Gore-Tex Loops. Four hundred and one operations were performed via a mini-thoracotomy (mean age 57.9±12.4 years) and 92 patients received a full sternotomy (mean age 65.8±12.4 years). Early postoperative echo was performed in all patients and clinical follow-up was obtained. Results: Loops were used to correct prolapse of the posterior leaflet only in 237 patients, the anterior leaflet only in 117 patients, and both leaflets in 139 patients. The mean length of Gore-Tex Loops was 20.3±3.3 mm for the A2 segment and 14.6±3.0 mm for the P2 segment. Concomitant procedures consisted of atrial cryoablation in 105 patients, tricuspid valve repair in 22 patients, coronary bypass surgery in 60 patients, and aortic valve surgery in 13 patients. The mean aortic cross-clamp and cardiopulmonary bypass times were 91±31 and 138±45 min, respectively. Early postoperative echocardiography revealed that 76% of patients had grade 0 mitral insufficiency, 22.4% had grade 1, and 1.6% had grade 2. Thirty-day survival was 98.8%, and 1-year survival was 96.4%. Nine patients (1.8%) required reoperation: three early reoperations for occlusion of the circumflex artery, three repeat MV repairs for recurrent mitral insufficiency and three MV replacements for recurrent insufficiency. Conclusions: MV repair with premeasured Gore-Tex Loops results in excellent early and mid-term outcomes for all types of leaflet prolapse. The Loop technique facilitates minimal invasive MV repair without compromising surgical outcomes.
1Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland; 2Department of Radiology, University Hospital, Zurich, Switzerland; 3Division of Experimental Surgery, University Hospital, Zurich, Switzerland Objectives: Transapical aortic valve replacement has been introduced into clinical practice from which also patients with failing biological valves might profit: valve-in-valve procedure. Aim of study was to determine the fate of biological valves in long-term follow-up (FU) and to evaluate topography and dimensions for transapical access via Multislice-CT scan (MSCT). Methods: Twenty-three patients (mean age 82±15 years, range 38–85 years) underwent 64-MSCT, eight patients at five years and 15 patients at ten years after porcine aortic valve replacement. Measurements: inner-diameter of prosthesis and valve orifice, distances of right/left coronary ostium (R/LCO) to prosthesis, calcium distribution of valve leaflets and annulus, valve function. In 12 patients illustration of chest topography and distances apex-chest wall (5th intercostal space, ICS), distance inner wall-aortic annulus, thickness ventricular apex, angle of surgical approach for device introduction. Results: Inner-diameter of prosthesis was 23.1±1.7 mm (no difference to implanted valve sizes). Valve orifice 2.2±0.5 mm2. No leaflet calcification in 18 valves, 5 minimally-calcified (no difference 5-/10-FU). Four valves showed no, 18 valves minimal and 1 moderate ring calcification (no difference 5-/10-FU). One valve with central insufficiency and one with paravalvular leak. Distances from LCO/RCO-to-prosthesis were 1.2±0.48 and 1.5±0.53, respectively. From fifth ICS distance skin-to-apex was 93.1±14 mm, apex-to-annulus 74.2±7.6 mm and angle skin-apex-annulus 101.6°±7.2°. Myocardial thickness at access point was 19.2±15 mm. Conclusions: Biological valves show good long-term results with minimal failure rate and limited calcification. Leaflet calcification might be problematic if unevenly distributed which endanger the very close LCO. These measurements represent a prerequisite for preoperative planning and increase the awareness to detect potential procedural problems of the valve-in-valve concept.
Brigham and Women's Hospital, Boston, USA Objectives: Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience of minimally invasive aortic valve surgery. Methods: From July 1996 to December 2006, 1005 consecutive patients underwent minimally invasive aortic valve surgery. Early and late outcomes were retrospectively analysed.
Results: Median patient age was 68 years (range: 24–95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 28 (2.7%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Median cardiopulmonary bypass and aortic cross-clamp times were 101 and 70 min. Nineteen patients (1.9%) had deep hypothermic circulatory arrest. Operative mortality was 1.9% (19/1005). The incidences of reoperation for bleeding and deep sternal wound infection were 2.4% (25/1005) and 0.5% (5/1005). Median length of stay was six days and 733 patients (72%) were discharged home. Actuarial survival was 91% at five years and 88% at ten years. In the subgroup of the elderly ( Conclusions: Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement and reoperative surgery can be performed with these approaches. These procedures are well-tolerated in the elderly.
1Department of Thoracic and Cardiovascular Surgery, West German Heart Centre, Essen, Germany; 2Department of Cardiology, West German Heart Centre, Essen, Germany; 3Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany Objectives: Aortic valve replacement (AVR) with extracorporeal circulation (ECC) is currently the treatment of choice for symptomatic aortic stenosis. However, patients with multiple high-risk comorbid conditions may benefit from reduced ECC-time and thus, reduced myocardial ischemia, by the use of sutureless AVR. We describe the initial experience and 1-year results of our first 3F-Enable AVR implants. Methods: Between September 2005 and December 2005, six patients (age 74±1.8 years; 3 females) with symptomatic aortic stenosis (NYHA III) underwent AVR with an equine pericardial and nitinol-stented sutureless prosthesis. Echocardiography was performed preoperatively, intra-operatively, at 6 and 12 months follow-up. Clinical data, adverse events and patient outcome were recorded prospectively. Results: Prothesis sizes were 27 mm (n=3), 25 mm (n=1), 23 mm (n=1) and 21 mm (n=1). ECC time was 87±32 min, aortic clamp time was 56±24 min. Prosthesis deployment time was 148±173 s. There were no intraoperative deaths or complications. At 12 months follow-up mean pressure gradients (MPG) were 6.8±3.5 mmHg and aortic valve area (AVA) was 2.2±0.5 cm2. One patient underwent successful redo AVR after eight months due to severe paravalvular leakage, and one patient died due to lung cancer ten months after surgery. At 12 months follow-up 4/6 patients are alive and asymptotic (NYHA I) with the 3F-Enable aortic valve prosthesis, however, one patient showed mild paravalvular leakage. Conclusions: These first 1-year follow-up data suggests the feasibility of this new concept of sutureless aortic valve implantation. However, severe aortic insufficiency at eight months and paravalvular leakage at 1-year follow-up should prompt further procedural and device enhancements.
1Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland; 2Clinic for Nuclear Medicine, University Hospital, Zurich, Switzerland; 3Division of Experimental Surgery, University Hospital, Zurich, Switzerland Objectives: Latest techniques enable positioning of devices into the coronary sinus (CS) for mitral valve (MV) annuloplasty. We evaluate the feasibility of non-invasive assessment to determine CS anatomy and its relation to MV annulus and coronary arteries by Multislice CT (MSCT) in normal and insufficient MV. Methods: Thirty-one patients (19 M, 12 F, age 66±11 years) were studied retrospectively by 64-MSCT scans for anatomical criteria regarding CS and its relation to MV annulus and circumflex artery (CX). We included 13 patients with severe mitral insufficiency and 18 with no MV disease. Diameter of MV, of proximal and distal ostium of CS, length and volume of CS, angle between anterior interventricular vein (AIV) and CS were analysed. Different anatomical correlations were demonstrated: distance of MV annulus to CS, CX to CS. Results: Diameter of proximal CS ostium was significantly larger in normal compared to insufficient MV (11.3±2.8 mm vs. 9.3±2.2 mm; P<0.039). CS was significantly longer in patients with insufficient MV (122.9±24.3 mm vs. 100.5±11.9 mm; P<0.002) without differences in volume of CS. Significant difference in annulus diameter, 47.5±7.5 mm (insufficient MV) vs. 39.6±6.2 mm, P<0.005. Angle CS-AIV was 110 degrees, range 60–166°, no difference between groups (N.S.). Distance of MV annulus to CS measured 14.9±3.1 mm without significantly difference between groups. In ten patients CX runs under CS, in 17 patients CS ran over and in four patients parallel to the CX. Conclusions: There is a significant anatomic difference between normal and insufficient MV which might be the basis for any interventional approaches through the CS. Exact measurements of all structures and its anatomic correlations are possible with MSCT which allows pre-interventional planning.
104 NON-SMALL CELL LUNG CANCER WITH IPSILATERAL PULMONARY METASTASIS: PROGNOSIS ANALYSIS AND STAGING ASSESSMENT J. Lee, C. Lee, D. Kim, K. Chung, I. Park Yonsei University College of Medicine, Seoul, Korea (South) Objectives: Although designated as T4 or M1 in THE lung cancer staging system revised in 1997, non-small cell lung cancer (NSCLC) with ipsilateral pulmonary metastasIs (IPM) is treated as locally advanced disease and reported survival is not so poor. We analysed the prognosis of IPM and validated the current staging system. Methods: Data of surgically treated 1213 patients with NSCLC, from January 1990 to December 2004 were retrospectively reviewed. Prognosis of IPMs and other T-stages were obtained by Kaplan–Meier method and compared by log rank test. Results: Among 49 patients with IPM, 23 patients had metastasis in same lobe (IPM1) and 26 had metastasis in another lobe (IPM2). Majority of IPM1 (61%) were treated by lobectomy and almost IPM2 (85%) were treated by pneumonectomy. Five-year overall survival rate and disease free survival rate after surgical treatment of IPM1 and IPM2 were not different (30.3% vs. 30.7%, P=0.95/21.9% vs. 23.1%, P=0.78). Prognosis of IPMs were not statistically different with T3 stage (30.1%/26.6%). But T1 (70.8%/62.8%) and T2 (51.2%/45.8%) stages shown significantly better prognosis than IPMs. Prognosis of resected T4 disease other than IPM1 (16.2%/7.5%) was not statistically different with IPM1 and IPM2. Conclusions: Prognosis of IPM1 and IPM2 after surgical treatment are relatively good and not different from T3 and T4 resectable disease. In terms of prognosis, it seems that current lung cancer staging system is not appropriate for IPMs, especially IPM2. Revision of current staging for IPMs is necessary and the staging system revised in 1992 can be a reasonable model for new revision.
Department of Thoracic Surgery, Torino, Italy Objectives: The management of patients with non-small cell lung cancer (NSCLC) and intrapulmonary metastases (IM) is controversial. The purpose of this study was to analyse the prognostic significance of patients with IM NSCLC. Methods: From January 1993 to December 2006, 2013 patients affected by NSCLC underwent surgical resection at our Institution. The distribution of patients by pathologic stage was: Stage Ia, 361 patients (18%), Stage Ib, 705 (35%), Stage II, 416 (21%), Stage IIIa, 359 (18%), Stage IIIb, 104 (5%) and Stage IV, 68 (3%). Among patients at Stage IIIb and IV, 67 presented with IM. Thirty-six had one or more lesions in the same lobe (T4) and 31 in a different lobe (M1). Of these, 32 were node-negative (N0) (16 T4N0M0 and 16 T1–2N0M1). Results: The 3-year overall actuarial survival by stage was: Stage Ia, 75%, Stage Ib, 65%, Stage II, 55%, Stage IIIa, 30%, Stage IIIb, 20% and Stage IV, 10%. Overall survival of patients with IM was 20%. When considering only patients with node-negative IM, 3-year survival was 40% (T4) and 41% (M1). By comparison, survival of node-negative non-IM Stage IIIb and IV patients was 22% (P=0.28). Conclusions: The prevalence of patients with NSCLC and IM in our experience (3%) is lower than that reported by most authors. Preoperative diagnosis of IM is sometimes difficult and most often diagnosis is made intraoperatively. Prognosis of patients with node-negative IM is better than that of other N0 Stage IIIb and IV patients.
1University Surgical Hospital, Split, Croatia (Hrvatska); 2Clinical Hospital, Split, Croatia (Hrvatska) Objectives: The extent of lymph node involvement in patients with non-small cell lung cancer (NSCLC) is the most important prognostic factor and influences multimodality treatment. We studied safety, accuracy and characteristics of intraoperative ultrasound guided systematic mediastinal nodal dissection in patients with resected NSCLC. Methods: Intraoperative hand held ultrasound probe was used in systematic mediastinal nodal dissection in 54 patients after radical surgery for NSCLC. Mapping of the lymph nodes by their number and station followed by histopathologic evaluation was performed. Data were compared with 58 patients who underwent standard systematic mediastinal nodal dissection for NSCLC within the same time period at our institution. Statistical analysis was carried out. Results: The surgical procedure used depended on the extent of the disease, as well as the cardiopulmonary reserve of the patients and was comparable in both groups. Operating time was prolonged for 12 (6–20) min in patients with US-guided mediastinal nodal dissection, but number and stations of evaluated lymph nodes was significantly higher (P>0.001) at the same group of patients. Skip nodal metastases were found in 24% of patients without N1 nodal involvement. Standard staging system seemed to be improved in US guided mediastinal lymphadenectomy patients. Complications rate showed no difference between analysed groups of patients. Conclusions: Higher number and location of analysed mediastinal nodal stations in patients with resected NSCLC using hand held ultrasound probe suggested to be of great oncology significance. Procedure showed improved safety and higher accuracy. Our results indicate that intraoperative ultrasound may have important staging implication.
Emory University, Atlanta, USA Objectives: Standard treatment for patients with early stage non-small cell lung cancer (NSCLC) is lobectomy with complete lymph node dissection. When patients have marginal pulmonary function a formal resection is not recommended. Unfortunately, a limited resection (segmentectomy or wedge excision) is performed knowing local recurrence is increased and overall survival may be comprised. The impact of lymph node (LN) sampling on survival at the time of the limited resection is not known. Methods: Information on relative, observed, and expected survival with stage IA NSCLC treated with complete (formal and limited) surgical resection was retrieved from the population-based Surveillance, Epidemiology and End Results database for the period from 1988 through 1998. Results: A total of 309,270 patients were included in the study: 292,508 underwent formal resection and 16,762 had a limited resection; 4935 limited patients (42%) had LN sampling. In patients who underwent complete resection with LN sampling the observed 5-year survival was 67% and relative 5-year survival was 78%, respectively. Patients with limited resection and LN sampling had an observed 5-year survival of 58% and relative 5-year of 69%, whereas in patients undergoing a limited resection without LN sampling survival was significantly less (P=0.05) with an observed 5-year survival of 48% and relative 5-year survival of 54%. Expected 5-year survival was the same for all groups. Conclusions: Survival following limited resection is significantly reduced compared to patients who underwent formal resection for Stage IA NSCLC. Patients who underwent LN sampling at the time of a limited resection had improved survival compared to patients who did not undergo LN sampling. LN sampling should be performed with any type of resection for NSCLC.
1Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Antwerp, Belgium; 2Department of Thoracic Surgery, Hospital Mutua de Terrassa, Terrassa, Spain Objectives: Precise restaging of NSCLC after induction therapy is of utmost importance. ReMS remains a controversial procedure. In a combined, updated series of two thoracic centres accuracy and survival of ReMS were determined. Methods: From November 1994 to August 2005, ReMS was performed in 104 patients (98 men, 6 women) after induction therapy for locally advanced NSCLC. Mean age was 64.3 years (range 38–85). Neoadjuvant chemotherapy was given in 79 patients and chemoradiotherapy in 25. Follow-up data were completed in January 2007. Results: ReMS was technically feasible in all patients. ReMS was positive in 40 patients and negative in 64; the latter group underwent thoracotomy. There were 17 false negative ReMS. Sensitivity of ReMS was 70%, specificity 100% and accuracy 84%. Follow-up was complete for all patients; 69 patients died, mostly of distant metastases. Median survival time (MST) for the whole group was 18 months [95% confidence interval (CI) 11–25]. MST in patients with a positive ReMS was 14 months (95% CI, 8–20), with a negative ReMS 28 months (95% CI, 15–41) and with a false negative ReMS 24 months (95% CI, 3–45). In univariate analysis the difference between positive and negative ReMS was highly significant (P=0.001). In a multivariate analysis including sex, age, histology, centre, and nodal status at ReMS, only nodal status was a significant independent prognostic factor (P=0.008). Conclusions: ReMS is a valuable restaging procedure after induction therapy. Persisting mediastinal nodal involvement proven at ReMS heralds a poor prognosis.
1Department of Cardio-Thoracic Surgery, University of Pisa, Pisa, Italy; 2Department of Surgery, Pisa, Italy; 3Nuclear Medicine, Department of Oncology, Pisa, Italy Objectives: We previously reported the results achieved in detecting SLN. We applied the molecular techniques (RT-PCR) to improve the detection of micrometastasis in order to evaluate an improvement of staging in early NSCLC patients. Methods: Since January 2005, we applied the SLN-mapping in 22 Stage I-NSCLC patients. A dose of 37 MBq (1 ml 99mTc-nanocolloid® suspension) was administered. The intralesional injection was performed under CT-guidance (seven patients), by using bronchoscopy (five patients), VAT (two patients) and at time of the thoracotomy (eight patients). RT-PCR analysis for cytokeratin 7–19, was used to identify tumour-derived material in LN. Each SLN was bisected: half was used for conventional examination (H&E staining/by IHC), half was snap frozen to –80 °C for RNA-detection of cytokeratin 7–19. Results: SLN was not identified in three patients (due to incorrect technique). SLN was detected in 16 patients. Conventional pathologic examination showed Stage I disease in 13 patients, T3N0 disease in one patient, N2 in five patients. The IHC analysis identified lymph-node metastasis in 7 (37%) patients (2 evaluated N0 according to H&E staining). Micrometastasis was detected in 6/10 patients who underwent RT-PCR analysis (4 evaluated N0 according to conventional analysis). Any N0 patients (by RT-PCR staging) had recurrences. Conclusions: SLN technique could provide a subgroup of patients in which they use RT-PCR, could be applied on a well-focused target. This approach may be useful for stratifying N0 patients histologically into higher risk and lower risk groups.
Kyoto Prefectural University of Medicine, Kyoto, Japan Objectives: To evaluate the efficacy of 18-fluorodeoxyglucose (FDG) positron emission tomography (PET) for the detection of postoperative recurrence in patients with lung cancer. Methods: Ninety-seven patients with surgically-resected non-small cell lung cancer were evaluated with 205 cases of FDG-PET at 3, 6, 9, 12, 18, and/or 24 months over a 2-year period after surgery. Imaging abnormalities were considered positive for recurrence when the clinical and radiological follow-up data were strongly suggestive. Results: A recurrent tumour was detected by FDG-PET in 2/52 patients with pathological Stage IA disease, 8/29 with Stage IB, 1/4 with Stage IIA, 4/5 with Stage IIB, 2/5 patients with Stage IIIA, and 0/2 with Stage IIIB. No recurrent tumours were detected in 31 patients at three months after surgery. FDG-PET results showed recurrent tumours in 6/54 patients at six months with 100% sensitivity and 77% specificity, 1/6 at nine months with 100% sensitivity and 40% specificity, 5/49 patients at 12 months with 100% sensitivity and 73% specificity, 5/34 at 18 months with 100% sensitivity and 79% specificity, and 1/31 at 24 months with 100% sensitivity and 87% specificity. Conclusions: FDG-PET after six months is useful in the treatment follow-up of patients with surgically-resected non-small cell lung cancer over a period of two years.
Cardiothoracic Surgery Centre, Krasnodar, Russian Federation Objectives: About 5% patients with lung cancer are not operated on due to the heart diseases which are to be treated surgically. Methods: From 23 December, 2003 to 23 March, 2007 in this centre, we have performed 2302 pulmonary resections for primary lung cancer. Myocardial revascularisation (MR) was required in 61 cases due to unstable angina pectoris, in 43 of these cases MR and pulmonary resections were performed simultaneously through the sternotomy, and in two cases through the thoracotomy (off-pump). Surgery was combined with aortic valve (2) and mitral valve (1) grafting. In other cases we performed two-stage surgery. Mean age was 62 years, there were 54 males. One-stage surgery was performed with systematic lymph node dissection following revascularisation with continued CPB. Results: Mean operative time was 3.3±0.4 h, CPB timing 51±17 min, mean intraoperative blood loss was 580±170 ml, mean drainage discharge 860±370 ml, extubation time 1–14 h, ICU stay 1–3 days. Total rate of complications and mortality was 14% and 4.7%, respectively. There were no differences in mortality and complication rates in groups with systematic lymphodissection and staged surgery. Three-year survival was 65%. Conclusions: One-stage MR and pulmonary resection with CPB are to be recommended as an operation of choice for lung cancer and unstable angina pectoris, which is accompanied with normal complication and mortality rates comparable with usual pulmonary surgery and at the greater operation comfort for a surgeon and less complications for a patient.
Thoracic Surgery, University of Padova, Padova, Italy Objectives: Sleeve lobectomy represents an effective surgical therapy for NSCLC. We sought to analyse our experience to verify mortality, early and late morbidity, and long-term survival in two consecutive periods (1980–1995 vs. 1996–2005). Methods: From 1980 to 2005, 199 patients underwent sleeve procedures: 135 on right side and 64 on left side. Pathology revealed 167 squamous carcinomas, 23 adenocarcinomas, 7 large cells carcinomas, 2 adenosquamous carcinomas. In 39 patients a vascular procedure was associated. Twenty-eight (14.8%) patients had preoperative irradiation and 24 (12.1%) had preoperative chemotherapy. Results: Overall 5-year survival rate was 37.9% and stage by stage analysis revealed a significant survival difference between stage I-II and III (P<0.01). Overall postoperative morbidity was 18.6% and mortality was 4.5%. Preoperative radiotherapy, but not chemotherapy, was identified as significant risk factor for early bronchial complications (P=0.02) and perioperative mortality (P=0.007). In 1980–1995 and 1996–2005, 84 and 115 sleeve resections were performed, respectively. In second period, compared to first period, we used less frequently preoperative radiotherapy (P=0.003) and more frequently induction chemotherapy (P=0.0003) and an associated vascular procedure (P=0.01). No differences in survival, early and late morbidity were observed, but mortality was significantly higher in the first period (9.5% vs. 0.8%, P=0.03). Conclusions: Bronchoplastic procedures are a safe and effective therapy for NSCLC. Pathologic Stage III was associated with a worse prognosis. Overtime trend showed a significant lower mortality in the last period. Vascular procedures and the use of induction chemotherapy did not increase mortality and morbidity; otherwise, the use of preoperative irradiation is not recommended.
Operative Unit of Thoracic Surgery, University and Scientific Institute H San Raffaele, Milan, Italy Objectives: The aim of the study was to assess the results of surgical treatment of multiple primary adenocarcinomas of the lung (MPAL). Methods: From 1988 to 2005, 26 patients (21 male, 5 female, mean age 63 years) with MPAL underwent surgical treatment at our department, for a total number of 52 tumours. Three patients had synchronous and 23 metachronous tumours. Mean interval between the diagnosis of metachronous lesions was 52 months. Results: Thirty-seven tumours were classified as solid, two as ground-glass opacities (GGO) and 13 as mixed solid/GGO tumours at CT scan. Histology showed 26 adenocarcinomas, five adenocarcinomas with bronchioloalveolar (BAC) pattern (adenocarcinoma/BAC) and 21 BAC. Surgery consisted of 18 wedge resections, 33 lobectomies and a completion pneumonectomy. There was no postoperative mortality. Postoperatively 48 tumours were stage I, three stage II and one stage IIIa. Median follow-up was 82 months. Five-year survival of patients with synchronous tumours was 66%. Overall five-year survival of patients with metachronous tumours was 95% after the first operation and 70% after the second. Patients with stage II and IIIa tumours had a significantly reduced survival (P<0.05). In patients with metachronous tumours five-year survival from the second operation was 74%, 100% and 66% respectively, for solid, GGO and mixed tumours, and 70%, 100%, 66% respectively, for adenocarcinomas, adenocarcinoma/BAC and BAC. Survival was 60% after lobectomy and 78% after wedge resections. Conclusions: Surgical treatment of MPAL is associated with favourable results. When technically feasible, sublobar resections allow an adequate oncological treatment to be obtained.
South Manchester University Hospital, Manchester, UK Objectives: To ascertain the causes of delay in treatment, all patients, presenting to our centre, with a working diagnosis of lung cancer were entered prospectively into a ‘tracking study’. Methods: Of 342 confirmed cases of newly diagnosed lung cancer presenting between September 2003 and December 2005, 193 were general practitioner referrals and 149 presented through casualty and internal referrals. The former group formed the basis of the study. Of GP referral patients, 92 had a positive diagnostic bronchoscopy (Group Bronch+). Their waiting times were compared with 94 others with negative result (Group Bronch-). For uniformity of comparison the non-GP referral patients were excluded from this study. Results: There were no significant differences in the demographics, presentation or clinical staging of the two groups. Bronch+ group had higher proportion of squamous cell carcinoma and Bronch- group had higher prevalence of adenocarcinoma (P<0.05). Though the median intervals (days) between the referral to first chest outpatient appointments were similar between the two groups (1 vs. 1), the intervals from out patient to decision-to-treat (33 vs. 57) and decision-to-treat to treatment (8 vs. 12) were significantly longer for Bronch- group. Overall the median referral to treatment interval for Bronch- was significantly longer compared to Bronch+ (45 vs. 75) (P<0.01). Most of this delay occurred in the interval of outpatient to decision-to-treat. Conclusions: A negative initial bronchoscopy results in a significant delay in treatment. Most of the delay occurs in the interval from the outpatient to decision-to-treat. Patients with negative bronchoscopy require a more concerted effort to achieve a timely diagnosis and treatment.
The University of Chicago, Chicago, USA Objectives: Patient preoperative status for major lung resection has deteriorated over time owing to expanded patient selection despite the increasing use of multimodality therapy for cancer and a rising incidence of obesity. We determined how patient preoperative status and outcomes of resection have changed over time.
Methods: We reviewed a prospectively collected database of patients undergoing major lung resection 1980–2006. Patient characteristics and immediate outcomes of resection were compared for three decade periods (1980–1989, 1990–1999, 2000–2006). Data were compared using ANOVA and Results: One thousand and forty-six patients underwent resection for cancer (862) and other problems. There was an increasing percentage of women over time (40.6%, 43.6%, 50.8%; P=0.02). There was worsening of preoperative status with an increase in hypertension rate (28.6%, 34.1%, 52.8%; P=0.02), mean performance status (0.45, 0.56, 0.73; P<0.001), obesity rate (11.8%, 22.1%, 28.1%; P<0.001), mean EVAD (combination of age, FEV1%, DLCO%) risk score (6.5, 6.6, 7.4; P<0.001), and use of induction therapy (7.5%, 5.6%, 16.1%; P<0.001). Despite the worsening of preoperative status, outcomes improved over time, with a decrease in operative mortality (8.8%, 7.1%, 3.2%; P=0.005), cardiopulmonary complications (29.3%, 20.1%, 15.6%; P<0.001), and overall complications (39.8%, 30.1%, 26.1%; P=0.001). Conclusions: Outcomes of major lung resection have improved over time despite a worsening of patient preoperative status. This suggests that operative and perioperative management have improved. The use of current rather than historical lung resection outcomes is vital in assessing risk for purposes of patient selection, outcomes modelling, and resource allocation.
116 A NEUTROPHIL ELASTASE INHIBITOR, SIVELESTAT (ONO-5046, ELASPOL), IMPROVES PULMONARY FUNCTION IN INFANTS AFTER VENTRICULAR SEPTAL DEFECT CLOSURE Y. Shiokawa1, Y. Turuhara1, S. Sata1, R. Tominaga2 1Kumamoto City Hospital, Kumamoto, Japan; 2Department of Cardiac Surgery, Kyushu University, Fukuoka, Japan Objectives: The neutrophil elastase inhibitor, Sivelestat (ONO-5046, Elaspol), is believed to improve pulmonary function in patients with acute lung injury caused by cardiopulmonary bypass (CPB). However, there has been no report regarding the effect of Sivelestat in infants undergoing open-heart surgery as far as we know. We sought whether Sivelestat improved pulmonary function in infants after cardiac surgery using CPB. Methods: Sivelestat was intravenously administered in 25 infants undergoing VSD closure for 24 h immediately after commencement of CPB (group-S). Another 25 infants undergoing VSD closure did not receive Sivelestat (group-C). Postoperative pulmonary function, PaO2/FiO2 ratio and alveolar-arterial O2 tension gradient (A-aDO2), and leukocyte count were compared in two groups. Results: PaO2/FiO2 ratio was not different in two groups from the point of the discontinuation of CPB until 6 h after CPB. However, at 7 h, it was significantly higher in group-S (511±49 mmHg vs. 208±106 mmHg, P=0.0033). A-aDO2 was significantly lower in group-S at 5 and 7 h after CPB (5 h: 211±86 mmHg vs. 298±128 mmHg, 7 h: 112±48 mmHg vs. 357±118 mmHg). Leukocyte count was significantly larger in group-S after one day after CPB, and as for fractional count, neutrophil was markedly increased in group-S (12940±3310 vs. 9800±2350, P=0.0039). Conclusions: This study suggests that Sivelestat has beneficial effect on acute lung injury induced by cardiopulmonary bypass in infants. Reduced leukocyte count in group-S implies the likelihood of inhibitory effect of Sivelestat on leukocyte pulmonary sequestration.
1Congenital Cardiac Surgery Department, University Hospital, Gent, Belgium; 2Paediatric Cardiology Department, University Hospital, Gent, Belgium; 3Paediatric Cardiology Department, University Hospital, Antwerp, Belgium Objectives: In patients undergoing total cavopulmonary connection (TCPC) pleural effusions are still the major source of prolonged hospital stay. In this study the duration of pleural drainage and the influence of lisinopril are investigated in relation to the perioperative profiles of antidiuretic hormone (ADH), renin and aldosteron. Methods: In a prospective randomized trial 21 patients with univentricular heart, undergoing a TCPC were divided into two groups: group I received oral lisinopril from postoperative day 2, group II received no ACE-inhibitor. Serial blood samples for plasma concentration of ADH, renin and aldosteron were drawn until postoperative day 5. Both groups were comparable for age at operation, preoperative hematocrit, ECC duration, cross clamp time, and preoperative hormone levels. Results: All but one patient were extubated within 12 h postoperatively. The hormone profiles in both groups changed significantly after operation compared to baseline (P<0.05). Mean duration of pleural drainage was comparable in both groups (group I: 9.6±8 days vs. group II: 10±7 days; P=0.78). However, a significant positive correlation (P<0.05) was found between the duration of pleural drainage and ECC duration, aldosteron level at 24 h postoperatively, and renin and ADH levels at 1 and 24 h postoperatively. Conclusions: The TCPC procedure induces significant changes in the levels of ADH, aldosteron and renin. Prolonged pleural drainage correlates with early increase of aldosteron and renin levels, and seems not to be influenced by lisinopril administration postoperatively. However, the eventual adjunct therapy with aldosterone antagonists warrants further study in this setting.
1Great Ormond Street Hospital, London, UK; 2Clinical Operational Research Unit, University College London, London, UK Objectives: We sought to evaluate recent outcomes for congenital heart surgery using a risk model based on RACHS-1 and age developed using an earlier data-set from our unit. Additionally, we sought to assess the extent to which our findings could be attributed to the intrinsic characteristics of the risk model. Methods: Data were collated concerning all operations performed between June 2004 and October 2006. An existing risk model was used to calculate a predicted risk of in-hospital mortality for each patient. A Variable Life Adjusted Display (VLAD) chart was constructed for these recent cases. We used a graphical tool called MADCAP to assess the performance of the risk model across the whole range of risk using the earlier data (2000–2003). We then compared the recent case-mix to that in the 2000–2003 data. Results: In the recent data, there were 19 deaths among 903 cases (2.1%, exact 95% confidence interval 1.3–3.3%). The VLAD chart indicated that recent outcomes were consistently and appreciably better than those predicted using the risk model. This finding was not due to the observed characteristics of the risk model, which performs well at predicted risks >3%, under-estimates mortality at 2–3% and over-estimates mortality below 2% predicted risk. There were no important differences in case-mix between the recent and earlier data sets. Conclusions: When interpreting risk-adjusted outcomes, it is important to account for any known intrinsic characteristics of the risk model. Our outcomes are encouraging but raise the question of whether, when striving for continuing improvement, we should update the risk-models used.
Okayama University Hospital, Okayama, Japan Objectives: Even though Damus-Kaye-Stansel anastomosis (DKS) sometimes results in minimal semilunar valve insufficiency, the mechanism behind this phenomenon remains to be elucidated. The purpose of this study was to verify the semilunar valve function after DKS, and compared End-to-Side DKS and Double-Barrel DKS. Methods: Thirty-nine patients who underwent DKS at our institute between June 1993 and June 2006 were retrospectively reviewed. Norwood type operation was excluded. The median age at the time of operation was 19 months (1–276). Thirty-seven patients were Fontan candidates. Thirty-three patients underwent PAB before DKS. The semilunar valve function was evaluated with echocardiography by a pediatrician. Results: Twenty patients underwent End-to-Side DKS, while 27 patients underwent Double-Barrel DKS. The mean follow-up period was 68 months (9–165). Although there were four deaths, no death was related to DKS. In six cases, the semilunar valve regurgitation mildly deteriorated (PR 5, AR 1). PR deteriorated from none to grade 2 in two patients, from none to grade 1 in two patients, and from grade 1 to grade 2 in one patient. Semilunar valve regurgitation did not affect to the patient's circulatory condition. End-to-Side DKS demonstrated a greater PR deterioration than Double-Barrel DKS (4/12 vs. 1/27, P<0.03). No DKS stenosis was observed. Conclusions: Double-Barrel DKS is superior to End-to-Side DKS for the prevention of postoperative PR.
Congenital Cardiac Centre, Sankt Augustin, Germany Objectives: Surgical options in children with aortic valve disease remain limited. There is no ideal valve substitute; therefore, valve repair should take preference over any type of valve replacement. The aim of the study was to analyze short-term outcome of aortic valve reconstruction (AVR). Methods: Between 2002 and 2006, 72 patients underwent AVR using various techniques ranging from simple reconstructions (valvotomy, cusp shaving) to complex repair (cusp reduction plasty, annulus reduction, conversion of bicuspid to tricuspid valve, cusp extension/replacement with autologous pericardium). Median age at operation was 6.4 years (19 days–18 years) and weight 20.7 kg (2.9–92). Based on the underlying pathophysiology, three groups were analyzed: Group I (31 patients) with predominantly aortic stenosis, Group II (15 patients) with predominantly aortic regurgitation and Group III (16 patients) with mixed lesion. Results: One patient died due to myocardial failure (1.2%). There was one early and one late failure of reconstruction requiring valve replacement. There was a significant (P<0.05) reduction of peak gradient and degree of regurgitation. At the mean follow-up of 36 months acceptable post repair residual lesions with mild degree of aortic stenosis (peak gradient <40 mmHg) and trivial to mild aortic regurgitation and normalisation of ventricular dimension were noted. All patients are in NYHA I-II. Conclusions: AVR has demonstrated a low mortality and failure rate and is considered to be a good temporary solution as it offers reduction of regurgitation and stenosis, and stabilization of the ventricular dimensions until the patients grow older.
1Silesian Centre of Heart Disease, Zabrze, Poland; 2Department of Physiology, Silesian Academy of Medicine, Zabrze, Poland Objectives: The hemodynamic consequences of bicuspid aortic valve (BAV) could be related to the type of cusps fusion orientation, which influence the progression of ascending aorta (AA) dilatation and subsequent fatal complications. The aim of the study was to determinate the differences in mechanical properties of both anterior (ant) and posterior (post) wall of AA in BAV patients (pts) with various types of cusps fusion orientation using tissue doppler imaging (TDI). Methods: The study group consisted of 30 patients with BAV and 28 healthy with tricuspid aortic valve (normals). BAV patients were divided into N+R group (n=16)-with noncoronary and right coronary cusps (RCC) fused and L+R (n=14)-with left coronary (LCC) and RCC fused. The groups were sex and age matched. Peak systolic velocity (m/s)(VEL) and acceleration (m/s2) (ACC) of ant and post AA wall were derived from TDI tracings collected in long axis parasternal view. Results: Acceleration of anterior and posterior wall was lower in N+R vs. L+R group-ANT: 1.02±0.27 vs. 1.59±0.9 (P<0.05) and POST: 0.69±0.3 vs. 1.37±0.7 m/s2 (P<0.05), respectively. Velocities of anterior and posterior wall were significantly lower in N+R vs. L+R groups-ANT: 0.044±0.012 vs. 0.064±0.029 (P<0.05) and POST: 0.033±0.012 vs. 0.05±0.02 m/s (P<0.05), respectively. Acceleration of anterior and posterior wall in L+R group was lower in comparison to control group-ANT: 1.59±0.9 vs. 1.13±0.41 (P<0.05) and POST: 1.37±0.37 vs. 1.01±0.4 (P<0.07). Velocity of anterior and posterior wall was significantly higher in L+R group than in controls-ANT: 0.064±0.029 vs. 0.042±0.01 (P<0.05) and POST: 0.05±0.02 vs. 0.035±0.013 m/s (P<0.05), respectively. In multivariable analysis all above results were independent of other variables including aortic regurgitation and stenosis degree. Conclusions: The BAV cuspidal fusion orientation results in different blood flow distribution in AA. The fusion of RCC and LCC unfavourably affects the mechanical properties of AA during ejection. AA wall velocity measurement by TDI is a feasible method to monitor disease severity in BAV patients.
Asan Medical Center, Seoul, Korea (South) Objectives: Recurrent or newly developing aortic regurgitation (AR) is a critical problem after the repair of ruptured sinus Valsalva aneurysm (RSVA). We hypothesized that trans-aortic repair of RSVA may cause distortion of the sinus of Valsalva and postoperative AR. Methods: A retrospective review of 56 patients, who underwent surgical repair of RSVA between June 1990 and August 2006, was performed. Mean age at operation was 33.2±11.4 years (14–64 years). Rupture of right coronary sinus (RCS) to right ventricle (RV) was the most common anatomic type (39/56, 69.6%). Preoperative AR equal to or greater than grade II (n=8, 17.9%) was managed by repair (n=5) or replacement (n=3). RSVA was repaired primarily (n=5) or by patching (n=12) through aortotomy in 17 patients (Trans-aortic group or TA group). In the remaining patients (n=39), RSVA was repaired from the chamber where the corresponding aortic sinus ruptured into, and reinforced with a supporting patch (Non-trans-aortic group or non-TA group). Results: Median follow-up duration was 21.9 months (0.4–158.3 months). There were two late deaths (one in each group). Excluding three patients with aortic valve replacement, eight patients (8/53, 15.1%) showed recurrent or newly developing significant AR during follow-up. Postoperative AR was more frequent in TA group (5/16, 31.3%) compared to non-TA group (3/37, 8.1%, P=0.045). Five-year freedom from significant AR for TA group and non-TA group were 65.6±15.2% and 94.0±4.1%, respectively. Conclusions: Trans-aortic repair of RSVA may cause postoperative AR by progressive distortion of the aortic sinus geometry.
1Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland; 2Department of Biostatistics, Institute for Social and Preventive Medicine, Zurich, Switzerland; 3Division of Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; 4Paediatric Intensive Care, University Children's Hospital, Zurich, Switzerland Objectives: Congenital subaortic stenosis entails a lesion spectrum, ranging from an isolated obstructive membrane, to diffuse tunnel narrowing of the left outflow associated with complex cardiac defects. We review our experience with this anomaly, and analyse risk factors leading to restenosis requiring reoperation. Methods: From 1994–2006, 58 children (median age 4.3 years, range 7 days–13.7 years) underwent primary relief of subaortic stenosis. Patients were divided into simple lesions (n=43), or complex ones (n=15) when associated with other major cardiac defects. Age, preoperative gradient over the left outflow, associated aortic or mitral valve insufficiency, chromosomal anomalies, arteria lusoria, and operative technique [membrane resection (22) vs. associated myectomy (34) vs. Konno (2)] were analyzed as risk factors for reoperation (Kaplan–Meier, Cox regression). Results: There was no operative mortality. Median follow-up spanned 2.7 years (range 0.1–10), with one late death at four months. Reoperation was required for recurrent stenosis in 11 patients (19%) at 2.6 years (range 0.3–7.5) after initial surgery. Two patients needed a second reoperation. Risk factors for reoperation, achieved without mortality, included complex defects (hazard ratio 6.7, P=0.003), younger age (hazard ratio 0.7 per year, P=0.012), and the presence of an arteria lusoria (hazard ratio 5.7, P=0.014). Conclusions: Surgical relief of congenital subaortic stenosis, even with complex associated heart defects, yields excellent results. Reoperation is not infrequent, and should be anticipated with younger age at operation, associated complex defects, and an arteria lusoria. Systematic myectomy concomitant to membrane resection does not provide enhanced freedom from reoperation, and should be performed according to anatomic findings.
King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia Objectives: Left atrio-ventricular valve (LAVV) regurgitation is the most common cause of late morbidity and frequent indication for re-operation following atrio-ventricular septal defect (AVSD) repair. We report LAVV re-operations results and examine variables predictive of outcome. Methods: Medical records of patients who underwent LAVV re-operations were examined (1990–2005). Demographics and operative variables affecting outcomes were analyzed. Results: Thirty-eight patients following partial (n=9) or complete (n=29) AVSD-repair underwent 44 LAVV re-operations. Median age was 11.3 months (24 days–7.6 years) at initial AVSD repair and 3.3 years (0.2–13.9 years) at subsequent LAVV re-operation with median interval between AVSD repair and first LAVV re-operation of 1.95 years (1 day–12.9 years). First LAVV re-operation included repair (n=18) or replacement (n=20). Operative mortality was 3/38 (7.9%). All deaths were in children who required LAVV repair at the same admission following AVSD repair. No significant factors for mortality were detected on logistic-regression analysis. Time-related survival at 5-years was 78±8%. During the follow-up period, six patients required repeat re-operations with 5-years freedom for those who had repair vs. replacement 67±12% and 91±9% (P=0.47). On multi-variable analysis, LAVV repair (P=0.011) was significant predictor for repeat re-operation. In both groups, NYHA class (91% in class I/II, P<0.001), the degree of LAVV-regurgitation (86% mild or less, P<0.001), and ventricular volumes (Left-ventricle end-diastolic dimension Z-score 0.05+0.36) significantly improved. Conclusions: LAVV surgery is associated with significant clinical improvement and lasting recovery in ventricular chamber size. Operative mortality is influenced by early need for LAVV operation after AVSD repair. Overall survival is acceptable, however, further re-operation is common and most commonly due to failed repair.
1Department of Cardiovascular Surgery, German Heart Centre, Technical University, Munich, Germany; 2Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre, Technical University, Munich, Germany Objectives: The surgical concepts for patients with congenitally corrected transposition of the great arteries (CCTGA) are addressed to associated lesions, such as ventricular septal defect (VSD), pulmonary stenosis (PS), tricuspid insufficiency (TI), or functionally single ventricle (SV). Outcome after univentricular palliation or biventricular repair with or without correcting discordant connections was investigated. Methods: All patients with CCTGA, who underwent biventricular repair either without correcting discordant connections (n=39), or with correcting discordant connections (n=6), or univentricular palliation (n=11), between 1978 and 2006 were analyzed. Associated lesions were present in all patients (VSD n=48, PS n=39, TI n=19, and SV n=11). Results: Thirty-day mortality rate was 4%. During a mean follow-up of 7.2±7.1 years (maximum 27 years) there were six deaths and two heart transplantations. Freedom from death or transplantation at ten years was not significantly different between patients who underwent biventricular repair with correcting discordant connections, without correcting discordant connections, or univentricular palliation (83.3±15.2%, 79.7±6.9%, 90.9±8.7%, respectively). Among associated lesions, type of operation, and age at the time of operation, presence of TI emerged as the only risk factor for death or transplantation in multivariate analysis (P=0.01, hazard rate 6.0, 95% confidence interval 1.5–23.8). Sixteen patients required reoperation, mainly for TI (n=8) and conduit failure (n=5). Freedom from reoperation at ten years was 62.0±9.6%. Conclusions: Biventricular repair with correcting discordant connections, without correcting discordant connections and univentricular palliation yield equivalent mortality in the mid-term. The outcome in terms of mortality and freedom from reoperation is strongly influenced by the status of the tricuspid valve.
Shanghai Children Medical Centre, Affiliated Medical College, Shanghai Jiao Tong University, Shanghai, China Objectives: To compare the early results of the management of D-TGA/VSD/PS by Nikaidoh's and Rastelli's and modified Lecompte procedure. Methods: Twenty-seven patients underwent Nikaidoh's or Rastelli's and M. Lecompte procedure for the management of D-TGA/VSD/PS. In the Nikaidoh group (n=11), with a median age of 16 months and reconstruction of RVOT by autograft of pericardium patch, including a homograft only. In the Rastelli group (n=11), the reconstruction of RVOT was made by homograft. In the M. Lecompte group (n=5), re-constructed RVOT with main pulmonary artery downward to ventriculotomy and autograft of pericardium patch. All patients had not previous palliative procedure. Results: One death result in severe heart failure in the Nikaidoh group, no death in the Rastelli group. One patient died in the M. Lecompte group, because of residual LVOTO and RVOTO, and arrhythmias. In Nikaidoh's, there was significant longer term of mean bypass and aortic cross clamp time compared with others (P<0.05). The intubations time in Nikaidoh group were longer than the other groups (P<0.01). The CICU period was significantly shorter both of groups (Rastelli and M. Lecompte)(P=0.04). The postoperative Echo showed no residual RVOTO or LVOTO in Nikaidoh group, but there were 20–27% cases with RVOTO or LVOTO in the other groups (P<0.05), and PI were frequently in Nikaidoh group (87.5%) and M. Lecompte group (60%)(P<0.05). There was no significance difference in the heart function all of groups, but lower surgical age in Nikaidoh group. Conclusions: The three procedures are all valuable surgical option for the management of D-TGA/VSD/PS. But Nikaidoh procedure is suitable for younger age and results in a more anatomically correct alignment between the ventricle and great artery. It would be further required to control study for the outcome of long-term follow-up in three procedures. Supporting Foundation: Major Natural Science Foundation of Shanghai Science Technology Committee (044119627).
1Clinic for Cardiovascular Surgery, German Heart Centre, Technical University, Munich, Germany; 2Clinic of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre, Technical University, Munich, Germany Objectives: Homografts are a well-established option for reconstruction of the right ventricular outflow tract (RVOT) in patients with congenital heart disease. The availability of small size homografts is limited, especially for newborns and infants. Methods: Since 1994 we have performed a size reduction of large homografts through a bicuspidalization. Durability and echocardiographic performance of 53 patients with a bicuspidalized homograft and 46 patients with a small size homograft were compared. Results: Both groups were comparable regarding age (mean 18.4 months) and weight (mean 8.8 kg). The mean size reduction of the bicuspidalized homografts was 66.2±4.5%, resulting in a mean size of 14.4 mm, as opposed to 15.4 mm for small size homografts of. From the 88 survivors, 21 (24%) needed a homograft exchange at a mean time of 4.7±3 years. Freedom from homograft replacement for bicuspidalized homografts was 94.8±3.6%, 91.3±4.9%, 43.6±16.9% at 1, 5 and 10 years, respectively, compared to 95.6±3%, 86.8±5.6% and 40.2±14.1% for small size homografts (P=0.7). At a mean follow-up time of 5.4±3.1 years, the mean gradient over the RVOT was 30.4 mmHg for bicuspidalized homografts compared to 29.5 mmHg for small size homografts (P=0.9). Conclusions: There is no difference in durability and function of bicuspidalized homografts compared to small size homografts. Downsizing homografts is, therefore, a good option for reconstruction of the RVOT if small size homografts are not available.
128 LOW IMPACT BLUNT TRAUMATIC AORTIC RUPTURE: SHOULD WE HAVE A HIGHER INDEX OF CLINICAL SUSPICION? P. Sastry1, M. Field1, R. Cuerden3, D. Richens2 1The Cardiothoracic Centre, Liverpool, UK; 2The Trent Cardiac Centre, Nottingham, UK; 3The Transport Research Laboratory, Crowthorne, UK Objectives: Blunt traumatic aortic rupture (BTAR) is assumed to occur following major trauma and is associated with a high mortality (98%). However, it is occasionally observed that some victims sustain BTAR following what would generally be considered minor trauma, so-called low impact BTAR (LIBTAR). Our hypothesis was that a significant proportion of BTAR occurs at speeds less that the ATLS trigger for suspicion of BTAR and transfer to Level I trauma centres. Methods: This work is part of the Co-operative Crash Injury Study (CCIS). Following road traffic accidents, an analysis of the vehicle was performed, allowing calculation of equivalent test speeds -a surrogate of impact. Car occupant injury information was collected from hospital records, coroners’ reports and questionnaires sent to survivors. We designated an equivalent test speed of (40 mph), to distinguish high impact from low impact BTAR, keeping in mind the limitations of ETS. Results: A total of 184 victims were identified with aortic injuries. These were sub-divided into frontal impacts (63, 58% LIBTAR) and side-impacts (41, 73% LIBTAR). Frontal impacts were divided into seat-belted (35) and unseat-belted (28), while side-impacts were divided into struck-side (21) and non-stuck-side (20). A variable but significant proportion of these injuries occurred at an ETS <40 mph. A higher proportion of LIBTAR victims were frontal unbelted (67% vs. 51%) and struck side (93% vs. 45%). Conclusions: Our hypothesis is correct and clinical suspicion of BTAR should remain high even following low impact trauma, as defined here, particularly in certain victim sub-groups. ATLS guidelines should reflect this finding.
1Cardiovascular Clinic, Bad Neustadt, Germany; 2Neurological Clinic, Bad Neustadt, Germany Objectives: To evaluate the role of anatomical completeness of the circle of Willis for adequate brain perfusion and the methodology of its preoperative and intraoperative assessment. Methods: Ninety-nine consecutive patients who underwent elective open arch surgery were enrolled in the study prospectively. Preoperative diagnostics included Doppler ultrasonography of the extracranial arteries, cranial CT-angiography, transcranial Doppler, and functional carotid occlusion test. Transcranial Doppler, electroencephalography, measurement of evoked somato-sensory potentials, and arterial pressure in both radial arteries served as intraoperative monitoring. Brain protection was performed in all patients using unilateral cerebral perfusion during circulatory arrest under mild hyperthermia (30 °C) with a mean duration of 18 min (range, 7–70). Results: CT-angiography showed an incompleteness of the circle of Willis within the anterior- and posterior-communicating arteries in two patients who underwent complete arch replacement. Anterior communicating arteries were missing in two additional patients. Thirty-five patients had lanky posterior communicating arteries on one (19) or both sides (16). Nevertheless, functional tests during carotid artery cross-clamping as well as intraoperative neuro-monitoring including transcranial Doppler showed no pathology in any patients and only one patient with severe aortic valve calcification suffered from postoperative minor stroke. Conclusions: The anatomical status of the circle of Willis assessed with CT-angiography does not correlate with functional and intraoperative tests examining the cerebral cross perfusion. Preoperative Doppler ultrasonography of the extracranial arteries is the basic examination for choosing the appropriate brain-supplying artery to be perfused. Transcranial Doppler and pressure measurements in both radial arteries are very reliable for intraoperative monitoring.
Hyogo College of Medicine, Hyogo, Japan Objectives: To examine the long-term outcome after entry closure and aneurysmal wall plication for type B chronic dissecting aneurysm. This procedure uses no artificial graft and preserves all intercostal arteries. Methods: The records of consecutive 40 patients who underwent this procedure between September 1983 and December 2002, were reviewed. The mean age at operation was 59 years (range, 38–79 years). The mean follow-up was 9.8±5.1 years (range, 4–23 years). Follow-up was completed in 37 patients (93%). The latest CT (n=18) was taken at average 8.8±4.2 years after surgery. Results: There were no operative deaths, and 14 late deaths. No late death was related to aneurysm. No paraplegia or paraparesis occurred. The survival rate was 97±3% at five years and 68±10% at ten years; 23 patients are alive. Follow-up CT revealed that the mean diameter of the plicated descending aorta was 37±8 mm (range, 25–50 mm) except in two patients. In one, reoperation for recurrent aneurysm was required nine years after surgery; in the other, the diameter of plicated aorta was 60 mm at 12 years. Freedom from reoperation was 92±7% at 10 years. Conclusions: This procedure is associated with excellent outcomes and low long-term mobidity. It could be the procedure of choice in selected patients, although graft replacement is the standard for chronic aortic dissecting aneurysm.
Toho University, Tokyo, Japan Objectives: Our hospital performs hemi-arch repair with transapical aortic cannulation for Stanford A-type acute aortic dissection as the standard procedure. Transapical aortic cannulation is antegrade, i.e. physiological, and the procedure is simple. Good outcomes have been obtained even in Debakey Type I and no case required re-surgery for postoperative expansion of the residual dissection cavity after hemi-arch repair alone. We report the early outcomes. Methods: Hemi-arch repair was performed with transapical aortic cannulation in 23 patients with Stanford A-type acute aortic dissection, between September 2003 and June 2006. In all patients, blood was supplied to the apex under hypothermic conditions, and the peripheral-side end of an artificial blood vessel with a single branch was anastomosed in an open distal manner under circulatory arrest and retrograde cerebral perfusion, followed by re-starting blood supply via the graft, and the central side was anastomosed. Results: In 17 patients with dissection over the region lower than the aortic arch, the pseudocavity was thrombosed in 8. In the other 9, expansion of the cavity was <5 mm on contrast aortic CT repeated between one month and one year after the 1st CT, and the maximum aortic diameter was <45 mm in all cases, requiring no re-surgery. There was no fatal case of cerebrovascular complications, and the survival rate was 95.6%. Conclusions: Hemi-arch repair with transapical aortic cannulation for Stanford A-type acute aortic dissection may lead to good outcomes, in addition, to saving patients from the critical state.
Department of Cardiovascular Surgery, Hiroshima University Graduate School of Medicine, Hiroshima, Japan Objectives: In order to determine whether critical intercostal artery is present in the aneurysm during descending thoracic or thoracoabdominal aortic surgery, changes of transcranial motor-evoked potentials (Tc-MEPs) were monitored following infusion of cold blood into the aorta as an adjunct ‘on-site assessment’. Accuracy of this method was evaluated. Methods: Fourteen patients were examined for Tc-MEP changes following infusion of cold blood (4 °C, 300–450 ml) into the aneurysm. The intercostal arteries in the aneurysm were reconstructed when the Tc-MEPs amplitude decreased to below 50% of the baseline within 3 min after cold blood infusion. When the amplitude did not decrease, every intercostal artery in the aneurysm was ligated. Results: The Tc-MEP amplitude did not decrease in eight cases (57.1%), while it decreased in six cases (42.9%). In the former, no case presented with paraplegia in spite that every intercostal artery was ligated. In the latter, the amplitude recovered after reconstruction in four patients, who had no paraplegia postoperatively. In the remaining two cases, however, the amplitude did not recover: one died of multiple organ failure with postoperative assessment unfeasible; the other developed paraplegia following surgery. Except one case with operative death, both sensitivity and specificity of our criteria with cold blood infusion was 100% in this series. Conclusions: Cold blood infusion into the clamped segment of aorta accelerates Tc-MEP changes and can possibly reduce ischaemic insults of spinal cord during diagnostic process, while it accurately detects presence of critical intercostal artery in the segment. This method appears to be promising adjunct on-site assessment.
University of Texas Medical School at Houston, Houston, USA Objectives: We recently identified creatine kinase (CK) and urine and serum myoglobin following thoracoabdominal aortic surgery as risk factors for acute renal failure (ARF). We hypothesised that myoglobin nephrotoxicity might arise from leg ischemia caused by femoral cannulation, which is required for distal aortic perfusion. Lacking complete historical data on CK and myoglobin, we studied somatosensory evoked potential (SSEP) changes in the leg (a functional marker of leg ischemia), as a predictor of acute postoperative renal failure. Methods: Intraoperative leg SSEP function and preoperative glomerular filtration rate (GFR, a renal risk stratification variable) were available for 245 patients. Change in SSEP was defined as 10% increase in latency or 50% decrease in amplitude. Acute renal failure was clinical diagnosis of ARF or need for dialysis postoperatively. Results: Change in SSEP in the cannulated leg occurred in 87/245 (35.5%) of cases intraoperatively. All patients recovered normal SSEP function at decannulation. Patients with SSEP changes had 27/87 (31%) postoperative renal failure compared to 30/158 (19%) without (odds ratio 1.9, p80 ml) and no SSEP changes, postoperative ARF was 9%. Conclusions: This is the first study to show a relationship between intraoperative skeletal muscle ischemia and postoperative renal failure. It provides circumstantial evidence that the ischaemic leg may be an important contributor to rhabdomyolysis-like renal morbidity after thoracoabdominal aortic surgery.
Division of Thoracic and Cardiovascular Surgery, Medizinische Hochschule Hannover, Hannover, Germany Objectives: The results of two different techniques for distal perfusion in replacements of the thoraco-abdominal aorta were compared in a retrospective study. Methods: From 1986 to 2004, 112 patients underwent an elective, standardised replacement of the thoraco-abdominal aorta with circulatory support by a femoral-to-femoral distal perfusion with peripheral cardiopulmonary bypass (CPB) in mild hypothermia. In contrast, aortic-to-femoral left heart bypass (LHB) was applied in 20 patients. Crawford classification and patient characteristics of both groups were comparable. No additional technique to avoid spinal cord injury was applied in this series. Results: Application of CPB was associated with a 30-day mortality rate of 10.0% and a 1, 5, and ten-year survival of 78%, 63.3%, and 57.9%, respectively. In contrast, when a left heart bypass was used, the mortality was 31.6% (P<0.01) and the survival was reduced to 62%, 40%, and 40% (P<0.02). Times of operation (318±80 vs. 273±83 min), bypass (126±55 vs. 65±47 min), and clamping (98±43 vs. 70±22 min) were significantly longer in the CPB group. However, significantly less transfusions (2406±2032 vs. 9500±6466 ml) and cell-safer blood (262±644 vs. 6036±1045 ml) were required in the CPB group. Postoperative serum lactate levels were significantly higher in patients undergoing thoraco-abdominal procedures with LHB (1.6±1.4 vs. 8.3±10.9 mmol/l). The incidences of paraplegia (16.2% vs. 15.8%) and stroke (5.5% vs. 5.3%) were not different. Conclusions: Application of CPB significantly improved the outcome of patients undergoing repair of the thoraco-abdominal aorta.
National Cardiovascular Centre, Osaka, Japan Objectives: The optimal site of arterial cannulation of cardiopulmonary bypass in repair of acute aortic dissection (AAD) is still controversial. We have employed axillary approach for the right axillary arterial cannulation (RAAC) in combination with femoral arterial cannulation to overcome the drawbacks of the single cannulation. Methods: From January 2000 to August 2006, 88 patients underwent emergent surgical repair of aortic arch (mean age 65±13, 37 male) for AAD. All patients had RAAC and femoral arterial cannulation. All operations were performed under hypothermic circulatory arrest with antegrade selective cerebral perfusion. Nine patients were in shock status and 18 patients showed malperfusion preoperatively. Results: The average duration of circulatory arrest was 52±17 min and the average duration of myocardial ischaemic time was 135±53 min. Operative procedures were total aortic arch replacement in 47 patients and hemiarch aortic replacement in 41. Concomitant operations were aortic valve resuspension in 54 patients, aortic root replacement in 3, aortic root reconstruction in 4, and CABG in 2. The hospital mortality rate was 2.3% (2/88), and the two patients were in shock status preoperatively. Peri-operative stroke rate was 5.7% (5/88). Among the 18 patients with preoperative malperfusion, hospital mortality rate was 5.6% (1/18) and the patient had a coronary malperfusion. Conclusions: RAAC combined with femoral arterial cannulation in repair of AAD was safe and secure to establish the cardiopulmonary bypass at short times. This approach for AAD showed low mortality even in the patients with malperfusion.
Bakoulev Scientific Centre of Cardiovascular Surgery, Moscow, Russian Federation Objectives: The purpose of this study was to determine the usefulness of preoperative detection of the spinal cord blood supply in aortic aneurysms surgery. Methods: Between November 2005 and December 2006, 24 patients underwent multi-detector row CT. There were 15 men (62.5%) and 9 women (37.5%) aged 40–64 years (mean, 53.2 years). Sixteen (66.7%) patients had thoracoabdominal aortic dissection, 5 (20.8%) patients had thoracoabdominal aortic aneurysm and 3 (12.5%) patients had descending thoracic aortic aneurysm. Results: The artery of Adamkiewicz (AKA) were detected in 17 (70.2%) of 24 patients, the anterior spinal artery (ASA) was visualised on the scans of all patients (100%). In seven (29.8%) patients was detected multiplicital type of spinal cord blood supply. In 17 patients it originated from intercostal arteries branching from the left side and in 16 (94.1%) originated between Th8 and L1. Two AKAs were found in 1 (5.8%) of 17 patients in whom AKAs were detected. All patients underwent surgical repair by using cardiopulmonary bypass. The type of aortic reconstruction in ‘critical segmental arteries’ zone (intimectomy, reimplantation by an island cuff technique or preservation in a beveled distal or proximal aortic anastomosis) was depended upon the spinal cord blood supply, which had been preoperatively detected. Paraplegia or paraparesis did not occur in any of the patients. Conclusions: Preoperative detection of the spinal cord blood supply is possible, and is very useful for reducing the incidence of ischaemic injury of the spinal cord.
Mount Sinai School of Medicine, New York, USA Objectives: Repair of thoracic aneurysms (TA) involving the ascending, arch, and descending aorta results in substantial morbidity and mortality. This study evaluates outcomes with a 2-stage elephant trunk (ET) technique.
Methods: Two hundred and seventeen consecutive patients underwent total arch replacement using an ET (February 1990 to December 2006). Group 1, 133 patients (median age: 70; 20–87 years) had extensive descending TA (
Results: Hospital mortality following ET was 7% in Group 1 (9/133; descending Conclusions: The low mortality after Stage 1 justifies liberal use of the ET-technique to facilitate future open or endovascular TA repair in the distal aorta. The cumulative mortality curves, however, suggest that staged repair of extensive TA is superior to 1-step repair only if Stage 2 can be done before rupture occurs. If 1-step repair is possible, it may be preferable for patients unlikely to return for a second operation.
Department of Cardiovascular Surgery, University Hospital, Bern, Switzerland Objectives: This study was undertaken to assess the influence of transient neurological dysfunction (TND) on outcome after ascending aorta/hemiarch replacement. The effect on long-term Quality of Life (QoL) has not yet been studied. Methods: Nine hundred and seven patients undergoing ascending aorta/hemiarch replacement at our institution were included. Two hundred and ninty patients (31.9%) underwent surgery for acute Type A dissection (AADA). Five hundred and forty seven patients (60.3%) had deep hypothermic circulatory arrest (DHCA). All in-hospital data have been assessed. TND was defined as a Glasgow coma scale value lower than 13. All surviving patients had a follow-up and QoL was assessed with the SF-36 questionnaire. Results: Mortality was 8.3%. TND occured in 89 patients (9.8%). The group with TND was older (66.4 vs. 59.9 years; P<0.05), more emergent procedures (53% vs. 32.2%; P<0.05) and surgery under DHCA (84.3% vs. 57.7%; P<0.05). Subgroup analysis in patients with DHCA revealed no differences in terms of duration of DHCA (23.6 min vs. 21.1 min; P<0.05) nor the extend of surgery and other intraoperative variables. Postoperative course in patients with TND revealed more pulmonary complications, prolonged mechanical ventilation and more neurological complications (16.3% vs. 6%; P<0.05). While QoL in the group without TND is comparable with a age and sex-matched average p |
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Monday 17 September 2007...
of 0.01. 
0.0002). In all pigs, the distal aorta was larger than the proximal overstented segment. Histology showed fibrosis of the inner 1/3 of the media with loss of smooth muscle cells and compression of the elastic fibers but normal architecture in the outer 2/3 of the media. 
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2-test where appropriate. 
-coactivators (PGC)-1