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Interact CardioVasc Thorac Surg 2008;7:S205-S254. doi:10.1510/icvts.2008.0000S7 © 2008 European Association of Cardio-Thoracic Surgery
AbstractsSuppl. 3 to Vol. 7 (September 2008)
001 SYMPTOMATIC SEVERE AORTIC STENOSIS: THERAPEUTIC DECISIONS AND THEIR CONSEQUENCES IN 179 PATIENTS M.W.A. van Geldorp, M. van Gameren, A.P. Kappetein, B. Arabkhani, L.E. de Groot-de Laat, J.J.M. Takkenberg, A.J.J.C. Bogers Erasmus University Medical Center, Rotterdam, The Netherlands Objectives: Symptomatic severe aortic stenosis is an indication for aortic valve replacement according to current guidelines. However, little is known about the proportion, characteristics and prognosis of symptomatic patients with aortic stenosis who are denied intervention. We studied the characteristics, treatment decisions and survival of patients with symptomatic severe aortic stenosis. Methods: Medical records of 255 patients presenting with severe aortic stenosis in our reference area, between 2004 and 2007, were retrospectively analysed. Results: One hundred and seventy-nine patients were symptomatic (mean age 71 years, 50% male). During follow-up (mean 17 months, 99% complete) only 76 (42%) patients were scheduled for aortic valve replacement (64 conventional, 9 percutaneous, 1 transapical, 2 waiting list) vs. 101 (56%) who received medical treatment. Reasons for non-surgical treatment were: perceived high operative risk (33%), symptoms regarded as mild (19%), stenosis perceived non-severe (14%) and patient preference (10%). In 20% the decision was documented insufficiently, and in 5% was indecisive. Mean age of the surgical group was 68 vs. 73 years for the medically treated patients (P=0.06). Predicted mortality (EuroSCORE) was 6.9% vs. 10.1% (P=0.006). During follow-up 12 patients died in the surgical group, vs. 28 in the medical group. Two-year survival was 90% vs. 69% (P=0.01). Conclusions: A large proportion (56%) of symptomatic patients do not undergo aortic valve replacement although anticipated operative risk is not extremely high. Reasons for not referring seem often based on individual (doctor-) preference. Given the lower survival rates in conservatively treated symptomatic patients, referral for surgical treatment should be encouraged in this patient group. 002 INTRAMYOCARDIAL INJECTION OF ERYTHROPOIETIN AUGMENTS STEM CELL RECRUITMENT AND RESTORES CARDIAC FUNCTION IN A RAT MYOCARDIAL INFARCTION MODEL C. Klopsch, D. Furlani, R. Gaebel, W. Li, M. Ugurlucan, L.L. Ong, N. Ma, G. SteinhoffDepartment of Cardiac Surgery of the University of Rostock, Rostock, Germany Objectives: Experimental approaches illustrate reasons for the assumption that erythropoietin (EPO) protects the myocardium from ischaemic injury and mediates cardiac regeneration. We hypothesise that stem cell recruitment modulated by EPO could contribute to its beneficial potential. Methods: Following permanent LAD ligation in rats, EP0 (3000 U/kg; group 1, n=99) or saline (group 2, n=95) was delivered along the infarction border. In control animals without myocardial infarction (group 3, n=55) saline was injected accordingly. After six weeks follow-up, left and right ventricles were catheterised, physical activity was evaluated by Porsolt Forced Swim test and heart weight, wall thickness and histopathologic effects were recorded. Throughout the first two weeks, rats were sacrificed for haematological, biochemical, FACS, histological and reverse transcription-PCR analyses. Results: Local EPO delivery enhanced left ventricular performance both at baseline levels and under dobutamine stress (P<0.05) and normalised right ventricular loading (P<0.05). In addition physical activity increased (P=0.008), and heart-to-body weight ratio (P=0.003) and interventricular septum wall thickness decreased (P=0.014), capillary density increased (P<0.01) and infarction area was less extended (P<0.001). The first two weeks evaluations revealed higher EPO plasma level, moderate haematocrit increase and remarkable Troponin-T reduction (P<0.05). Tissue expressions of SDF-1, c-Kit and CD34 temporarily augmented whereas TNF-alpha and EPO-receptor minimised (P<0.05). Moreover, improved mobilisation of c-Kit+ and CD34+ cells to circulation was accompanied by elevated c-Kit+ and CD34+ cell numbers inside infarction area (P<0.05). Conclusions: Intramyocardial EPO injection magnifies stem cell chemoattraction and attests cardio-protective effects. Preclinical advances may confirm its therapeutic potency for ischaemic heart injury in CABG surgery and cardiopulmonary bypass procedures. 003 PREDICTION OF POSTOPERATIVE LEFT VENTRICULAR SYSTOLIC FUNCTION IN PATIENTS WITH CHRONIC AORTIC REGURGITATION UNDERGOING VALVE REPLACEMENT: A STRAIN RATE IMAGING STUDY A. Marciniak, G.R. Sutherland, M. Marciniak, A. Kourliouros, B. Bijnens, M. JahangiriSt. George's Hospital, London, UK Objectives: Postoperative left ventricular systolic function is an important prognostic factor in patients undergoing aortic valve replacement. Preoperative myocardial deformation may be impaired without reduction in conventional indices like ejection fraction (EF). Strain rate (SR) imaging is very sensitive in detecting regional systolic abnormalities and might allow the diagnosis of subclinical changes in systolic LV function before surgery. We aimed to investigate the value of preoperative regional myocardial peak systolic SR as a predictor of postoperative LV systolic function. Methods: We studied 32 patients (age 52±12) with severe chronic AR who underwent aortic valve replacement. A standard echo examination, extended with tissue Doppler, was performed immediately before and 3, 6 and 12 months after surgery. To assess LV longitudinal deformation, SR data were acquired from the mid lateral (LW) and anterior (Ant) walls. Results: Patients were divided into two groups based on postoperative EF: group 1 with EF>50% and group 2 with EF<50%. Group 1 had a significantly (P<0.005) higher preoperative SR (LW: -1.8±0.38 s-1; Ant: -1.8±0.4 s-1) compared to group 2 (LW: -1.0±0.29 s-1; Ant: -0.95±0.4 s-1). SR/EDV index also showed significant changes (P<0.001) at baseline between the groups. For detecting subclinical changes in deformation of the LW, a cut off value of the SR/EDV<0.006 had 89% sensitivity and 93% specificity; for the Ant wall, SR/EDV<0.005 had 88% sensitivity and 92% specificity. Conclusions: A significant reduction in preoperative SR in patients with apparently preserved function (preoperative EF>50%) predicts postoperative LV dysfunction. SR imaging detects subclinical changes in LV function before they can be detected by global standard parameters and might thus be used to optimise the timing of surgery. 004 DIFFERENT FLOW PATTERNS DUE TO COMPETITIVE FLOW OR STENOSIS IN THE LIMA-LAD ANASTOMOSIS ASSESSED BY TRANSIT-TIME FLOWMETRY IN THE PIG H.B. Nordgaard1, D. Nordhaug2, I. Kirkeby-Garstad2, L. Løvstakken1, N. Vitale1, R. Haaverstad11Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; 2Department of Cardiothoracic Surgery, St Olav's University Hospital, Trondheim, Norway Objectives: Stenotic anastomosis and competitive flow from native coronary arteries alter graft flows. The aim is to assess altered patterns of competitive flow or stenosis by waveform analysis of transit-time flowmetry (VeriQ flowmeter, MediStim). Methods: Six pigs (65±3 kg) underwent OPCAB with LIMA-LAD anastomosis. Blood flows were measured in the proximal LAD and in the LIMA graft in baseline conditions (proximal LAD totally snared), and during competitive flow or stenotic anastomosis. Competitive flow was obtained by releasing the adjustable vascular occluder proximal to the LAD flow probe. A stenotic anastomosis was created by a deep stitch at the toe of the anastomosis and assessed by epicardial ultrasound. Data were expressed as percentage of baseline flow conditions and analysed by Wilcoxon test. Results: Overall, competitive flow had a lower mean graft flow than stenotic anastomosis (53±28% vs. 83±21%, respectively; P=0.08). Flow components were as follows: diastolic antegrade flow (competitive flow 42±19% vs. 82±24% stenosis; P=0.05); systolic antegrade flow (competitive flow 97±33% vs. 98±42% stenosis; P=0.75). Diastolic filling (diastolic/total flowx100) was significantly lower (41±5 vs. 61±11; P=0.03) and retrograde graft flow (retrograde/total flowx100) was significantly higher (19±12 vs. 6±7; P=0.05) at competitive flow compared with stenosis. Pulsatility index was not significantly different (competitive flow 8.4±5.6 vs. 4.9±3.0 stenosis; P=0.25). Conclusions: Competitive flow and stenotic anastomosis present different flow patterns. Competitive flow determines greatest reduction of graft mean flow and diastolic filling with higher retrograde flow, especially in early systole. Stenotic anastomosis shows less relevant changes of flow patterns, but more diastolic filling than competitive flow.
005 EFFECT OF ENDOSCOPIC THORACIC SYMPATHECTOMY (FOR PRIMARY HYPERHIDROSIS) ON CARDIOPULMONARY FUNCTION J.M. Cruz, J. Sousa, A.G. Oliveira, L.S. Carvalho Cirurgia Cardio-Toracica, Hospital de Santa Maria, Lisboa, Portugal Objectives: Endoscopic thoracic sympathectomy (ETS) is performed for the treatment of primary hyperhydrosis (PH). The second and third sympathetic thoracic ganglions excised in ETS also innervate the heart and lung. In the present work we studied the cardiopulmonary effects of the ETS in a group of patients with PH. Methods: We performed a prospective analysis of pulmonary function and maximal, symptom-limited, incremental exercise tests in 38 patients with severe essential hyperhydrosis one week before and six months after ETS. Data are expressed as mean and S.D. and compared using the paired Student's test. Differences were considered significant when P<0.05. Results: In pulmonary function tests we found a significant decrease of mean forced expiratory flow in small airways and a statistically significant increase of residual volume (P<0.05). Concerning the cardiopulmonary exercise tests, we demonstrated a significant decrease of rest and ‘peak’ heart rate and a statistically significant increase of oxygen pulse (O2 pulse) and oxygen peak uptake (VO2 peak) after ETS (P<0.05). Conclusions: These results suggest that in essential hyperhydrosis patients, the airway bronchomotor tone is influenced by sympathetic innervation. The increase in VO2 peak is, to our knowledge, the first report in the literature assessing the ETS cardiopulmonary effects in primary hyperhydrosis patients. 006 MODERN SURGICAL APPROACH TO PLEUROPULMONARY TUBERCULOSIS C.A. Kerti2, I. Miron1, G.V. Cozma1, O.N. Burlacu1, C.P. Tunea1, V. Voiculescu1, E.F. Memu1, A.C. Nicodin11Municipal Clinical Emergency Hospital, Timisoara, Romania; 2Victor Babes Clinical Hospital of Infectious Diseases and Pneumology, Timisoara, Romania Objectives: Pleuropulmonary tuberculosis is a relatively frequent condition (the incidence of TB is 176/100000 in our county) and some of these patients are undergoing surgical interventions. The authors share their experience in surgical treatment of pleuropulmonary tuberculosis, based on minimal invasive techniques such as VATS and filling the residual cavities with pediculated muscle or skin-muscle grafts. Methods: The authors are retrospectively revising 144 patients between 01 January 2001 and 31 December 2007, who underwent surgical treatment for pleuropulmonary tuberculosis in this period. Results: Two hundred and thirteen surgical procedures were performed for pleuropulmonary tuberculosis, representing 4% of all the procedures done in the department. For most of the patients the aetiological diagnosis was not established until the operation. The diagnoses at the admittance were: pulmonary nodules or tumours (42 patients), pleural collections (46), pleural thickening and post-tuberculosis syndromes (46), fibrocavitary tuberculosis (6), tuberculous pericarditis (4). Of all the procedures applied 14 were pulmonary resections, 50 atypical resections, 70 VATS, nine patients needed muscle or skin-muscle flap for residual pleural cavities. Eleven patients had to undergo secondary surgery due to complications. No in-hospital mortality was registered. The mean hospitalisation period was 10.1±2.4 days. Conclusions: Our results suggest that modern surgical techniques such as VATS and muscle grafts for filling the residual cavities tend to successfully replace classical invasive surgery in the treatment of pleuropulmonary tuberculosis. 007 REDUCED INCIDENCE OF AIR LEAKS AFTER AWAKE NON-RESECTIONAL LUNG VOLUME REDUCTION SURGERY F. Tacconi, E. Pompeo, T.C. MineoDepartment of Thoracic Surgery Policlinico, Tor Vergata University, Rome, Italy Objectives: Postoperative air leaks occur frequently after lung volume reduction surgery (LVRS) and can negatively affect both morbidity and hospital stay. We hypothesised that awake non-resectional LVRS could reduce occurrence of air leaks in emphysema patients. Methods: This analysis included 66 patients undergoing awake, unilateral plication of the most emphysematous lung regions under sole epidural anaesthesia. Primary outcome measure was the incidence of prolonged (>7 days) air leaks; secondary outcome measures were: median duration of air leaks, hospital stay and early discharges (<4 days). All results were retrospectively compared with those of a similar control group undergoing resectional LVRS under general anaesthesia. Criteria for discharge were standardised. Results: Intergroup comparison (awake vs. non-awake) showed that demographics and baseline data were well matched. There was no mortality. Prolonged air leaks occurred in 12 (18.2%) vs. 27 (40.9%) (P=0.007); Median air leaks duration was 4.5 days vs. 6.0 days (P<0.0002), with a hospital stay of 6 days vs. 9 days (P<0.0001). Other non-fatal complications occurred in 7 patients vs. 11 patients (P=0.4). Yet, early discharges were 12 (18%) vs. 4 (6%) (P=0.06). Reoperation for persistent air leaks was necessary in 0 vs. 2 patients (P=0.5). A significant correlation between prolonged air leaks and other complications was found in the awake group only (R=0.35, P=0.004). At 12 months, postoperative gain in functional parameters (FEV1 and RV/TLC ratio) was significant in both groups. Conclusions: In this study, awake non-resectional LVRS was associated with a reduced incidence and duration of air leaks when compared with the resectional procedure. 008 THE UTILITY OF N-TERMINAL PRO-B-TYPE NATRIURETIC PEPTIDE (NT-PROBNP) IN PREDICTING POSTOPERATIVE CARDIAC COMPLICATIONS IN PATIENTS UNDERGOING LUNG RESECTION SURGERY C.Y. Lee, S.H. Cho, K.Y. ChungYonsei University College of Medicine, Seoul, Korea (South) Objectives: Cardiovascular complications following non-cardiac thoracic operations are a major cause of morbidity and mortality. Recent studies have demonstrated that NT-proBNP levels can predict postoperative cardiac complications after non-cardiac major surgery as well as cardiac surgery. However, there is little information on correlation between lung resection surgery and NT-proBNP. Therefore, we evaluated the role of NT-proBNP as a possible marker for risk stratification of postoperative cardiac complications in patients undergoing lung resection surgery. Methods: Ninety-eight patients undergoing scheduled lung resection surgery were studied retrospectively. Postoperative cardiac events were defined as myocardial injury or ECG evidence of ischaemia or arrhythmia or heart failure or cardiac death. Results: Postoperative cardiac complications were documented in nine patients (9.2%). Atrial fibrillation occurred in three patients, ischaemic change on postoperative ECG occurred in two patients and heart failure occurred in four patients. Preoperative NT-proBNP levels were raised in patients who suffered postoperative cardiac complications (median 200.2 vs. 45.0 ng/l, P=0.009) and NT- proBNP predicted this outcome with an area under the receiver operating characteristic curve of 0.76 (95% CI 0.545–0.988, P=0.01). A preoperative NT-proBNP value of 160 ng/l achieved a positive predictive value of 0.857 and a negative predictive value of 0.978 for detecting postoperative cardiac complications. Other factors associated with cardiac complications were a higher American Society of Anesthesiologists grade, a higher NYHA functional class and history of hypertension. But in a multivariate analysis NT-proBNP>160 ng/l was the only independent factor. Conclusions: An elevated preoperative NT-pro BNP level is an independent predictor of postoperative cardiac complications after lung resection surgery.
009 EARLY TIMING OF SURGICAL INTERVENTION IN PATIENTS WITH EBSTEIN'S ANOMALY PREDICTS SUPERIOR LONG-TERM OUTCOME C.C. Badiu, C. Schreiber, D.J. Ruzicka, J. Hoerer, M. Krane, R. Lange German Heart Centre Munich, Munich, Germany Objectives: Various surgical valve repair and replacement techniques have been developed over the last decades for patients with Ebstein's anomaly. Determination of the appropriate moment for surgery, however, has not been elucidated clearly enough. Methods: From 1976 to 2007, 130 patients (mean age 23.8 years, range 1 month to 73.6 years) underwent surgery for Ebstein's anomaly at our centre. In 115 (88.5%) patients, a tricuspid valve repair was feasible. Valve replacement or palliation was necessary in 12 (9.2%) and 3 (2.3%) patients, respectively. Follow-up was 94.6% complete with a cumulative follow-up of 1315.6 patient years. Results: There were 2 (1.5%) hospital deaths. Eighteen patients died during follow-up (7 of cardiac insufficiency, 2 of rhythm disturbance, 2 of CVA, 1 of viral infection, 1 of digitalis intoxication, 1 of multiorgan failure and 4 of unknown causes). All of these patients were preoperatively in NYHA classes III and IV and 15 exhibited a CTR>0.60. Actuarial survival rates at 20, 25 and 30 years were 84.9±4%, 81±5.4% and 60.2±14.7%, respectively. Considering the NYHA classification at time of the operation, the actuarial survival rates for NYHA I or II were 100% and for NYHA III or IV, 56.1±14.0% at 30 years. Considering the CTR, the actuarial survival rates for CTR<0.60 and CTR>0.60 at 30 years were 93.6±4.4% and 34.1±24.5%, respectively. Conclusions: To date, reconstruction as opposed to replacement is feasible in the vast majority of Ebstein valves. If patients present in poor clinical state, the long-term outcome but not the perioperative mortality is significantly poorer. Therefore, timely operation seems warranted in this complex entity. 010 SYNERGISTIC INTERACTION BETWEEN RIGHT VENTRICULAR DYSSYNCHRONY AND PULMONARY REGURGITATION DETERMINES EARLY OUTCOME FOLLOWING TETRALOGY OF FALLOT REPAIR E.W.K. Peng, S. Lilley, B. Knight, J. Sinclair, F. Lyall, K.J.D. MacArthur, J.C.S. Pollock, M.H.D. DantonRoyal Hospital for Sick Children, Glasgow, UK Objectives: Right ventricular electro-mechanical dyssynchrony and pulmonary regurgitation (PR) are known risk factors for late outcome following Fallot (TOF) repair. However, the extent of RV dyssynchrony and its effect on early outcome remain unknown. Methods: Twenty-three TOFs and 10 non-Fallot controls (VSD/AVSD) were prospectively studied (mean age 15.8±14.7 months). Tissue Doppler echocardiography was performed preoperatively and on postoperative day 1. Segmental dyssynchrony, defined as out-of-phase peak myocardial contraction, was determined at the base, mid, apical segments of the septum, RV and LV free walls. Postoperative outcome measures included cardiac index (CI), mixed venous oxygen saturation (SvO2), serum lactate, ventilation and ITU times.
Results: Preoperatively, biventricular contractions were synchronous in both groups. Postoperatively, dyssynchronous segments were identified in RV and septum in both groups, whilst the LV remained spared. The extent of segmental involvement was greater in TOF: Conclusions: TOF patients developed significant RV dyssynchrony in the early postoperative period which interacted synergistically with pulmonary regurgitation to influence RV dimension and early outcome. 011 THE INFLUENCE OF THYMUS EXTIRPATION IN EARLY INFANCY ON DEVELOPMENT OF A MATURE IMMUNE SYSTEM H. Kurobe1, T. Tominaga3, Y. Hayabuchi2, T. Kitaichi1, M. Nagashima4, Y. Egawa3, Y. Takahama5, T. Kitagawa11Department of Cardiovascular Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan; 2Department of Pediatrics, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan; 3Division of Cardiovascular Surgery, Kagawa Children's Hospital, Kagawa, Japan; 4Division of Cardiovascular Surgery, Ehime Prefectural Central Hospital, Ehime, Japan; 5Division of Experimental Immunology, Institute for Genome Research, University of Tokushima, Tokushima, Japan Objectives: Extirpation of the thymus is often performed to improve the operative field at repair of complex congenital heart defects (CCHD) in early infancy. However, how thymus extirpation in early infancy influences the development of the immune system in human remains to be elucidated. The aim was to assess the development of immune function after thymus extirpation in early infancy. Methods: Thirty-one infants with CCHD have been enrolled in this survey from 2005. Fourteen underwent repairs with thymus extirpation (group C), nine with partial thymectomy (group P), and eight patients without thymectomy (group W). Clinical infective events were recorded every six months after repair. The CD-3 (T-cell), -4 (helper T cell), -8 (killer T cell) and CD19 (B cell) positive cells were measured in blood by flow-cytometry before, and every six months after repair. Results: In group C, 6, 12 and 18 months after repair, the number of lymphocytes and the number of CD-3, CD-4, and CD-8 positive cells decreased significantly. However, in group P and group W, 6, 12 and 18 months after repair, they increased. There was no difference in the number of CD-19 positive cells between groups P, W and C. In particular there were no early or late deaths and none with severe infective complications after repair. Conclusions: Thymus extirpation in early infancy delays the development of the cellular immune system. It is important to conserve the thymus in early infancy to achieve mature immune function. 012 QUALITY OF LIFE OF GROWN-UPS WITH CONGENITAL HEART DISEASE PATIENTS AFTER CONGENITAL HEART SURGERY O. Loup1, C. von Weissenfluh1, B. Gahl1, F. Immer1, M. Schwerzmann2, T. Carrel1, A. Kadner11Department of Cardiovascular Surgery, University Hospital, Berne, Switzerland; 2Department of Cardiology, University Hospital, Berne, Switzerland Objectives: Due to better early and long-term outcome, Grown-Ups with Congenital Heart Disease (GUCH) represent an increasing population and raise Quality of Life (QoL) issues, which were previously not considered. The present study analyses the QoL of GUCH patients after surgery. Methods: Two hundred and ninety-five patients (median age 25.7±10.9 years), operated for isolated VSD, TGA, and TOF, were assessed by SF-36 questionnaire (health-related QoL), HADS-test (anxiety/depression aspects), and an additional questionnaire on GUCH-specific problems. The scores were compared with age- and gender-matched standard population data and in relation to the underlying congenital heart disease (CHD).
Results: In the long-term, QoL is excellent and comparable to standard population in all SF-36 and HADS health dimensions, regardless of the initial CHD. Age and gender do not affect QoL ( Conclusions: QoL in GUCH following surgical repair of isolated VSD, TOF, and TGA is excellent in all scales and not different from the healthy population, regardless of the underlying CHD. However, reoperation reduces significantly QoL and psychological functioning. Additional aspects, not evaluated by standardised questionnaires, such as SF-36 and HADS, are important in this population and have to be considered to assess GUCH-specific problems of daily life.
013 AT WHAT SIZE SHOULD THE ASCENDING AORTA BE REPLACED TO PREVENT AORTIC DISSECTION? L.M. Parish, J.E. Bavaria, J.H. Gorman III, R.C. Gorman Hospital of the University of Pennsylvania, Philadelphia, USA Objectives: Dissection is the most common reason for emergent surgical intervention on the aorta. The accepted indication for elective replacement of the ascending aorta in non-marfanoid patients is a transverse dimension of 5.0–5.5 cm. This value has not changed in decades in spite of improved results of elective surgery and the fact that aortas of this size are nearly 5 standard deviations above the established upper limit of normal. We sought to elucidate the size distribution of the ascending aorta in a large cohort of patients presenting with acute type A aortic dissection. Methods: The intraoperative transoesophageal echocardiograms of a consecutive cohort of non-marfanoid patients with tricuspid aortic valves who presented to one hospital with acute type A aortic dissection were assessed to determine the maximal size of the ascending aorta or sinus segment prior to surgical repair. Results: One hundred and seventy-seven patients presented over a 10-year period. 5.1% of patients presented with an ascending aortic or sinus segment diameter of <4.0 cm, 19.3% of patients presented with diameters between 4–4.5 cm, 23.0% at 4.6–5.0 cm, 19.8% at 5.1–5.5 cm and 32.8% at >5.6 cm. Conclusions: About half of patients who present with acute type A aortic dissection have an ascending aortic dimension below the established surgical indication for elective repair. Given the excellent survival and long-term outcomes commonly achieved with elective replacement of the ascending aorta at experienced centres, our data would suggest that the indication for elective intervention be reduced to 4.5 cm. 014 SIGNIFICANTLY REDUCED LATE MORTALITY AND DISEASE-FREE SURVIVAL CONFIRM ADVANTAGE OF SUBCLAVIAN ARTERY PERFUSION FOR TYPE A DISSECTION: LONG-TERM RESULTS U.P.F. Schurr1, O. Reuthebuch1, K.E. Lory3, B. Seifert2, M.L. Lachat1, R. Prêtre1, M.I. Turina1, M. Genoni11Clinic of Cardiovascular Surgery, University Hospital, Zurich, Switzerland; 2Institute for Biostatistics, University of Zurich, Zurich, Switzerland; 3Cardiovascular Centre, Department of Cardiology, University Hospital, Zurich, Switzerland Objectives: Right subclavian artery perfusion is considered to be advantageous over femoral arterial cannulation for the surgical repair of type A dissection. A significant reduction of perioperative mortality and neurological complications has been shown in the short-term, however, long-term data regarding this approach are limited. This study presents our long-term results using subclavian and femoral arterial cannulation for type A dissection, with special regard to disease-free and late survival. Methods: Between January 1992 and December 2005, 290 consecutive patients (mean age, 61±13 years, 74% male) underwent surgery for acute type A dissection. Subclavian cannulation (SC) was performed in 120 vs. femoral cannulation (FC) in 170 patients. Clinical characteristics were similar in both groups. Follow-up is 92% complete with a median of 42 months (range, 3–83 months) in the SC group and 69 months in the FC group (range, 2–143 months). Long-term outcomes were evaluated for prevalence of clinical complications, persistence of neurological deficits, mortality, and reoperations for the dissection. Results: Patients undergoing SC demonstrated significantly improved neurological outcomes (P=0.008) compared to patients following FC. Disease-free survival was significantly better in the subclavian group (P=0.044), as well as late survival (P=0.022). SC: 5-year survival 85±4%/5-year disease-free survival 77±5%. FC: 5-year survival 71.5±3.5%/5-year disease-free survival 61±4%. Conclusions: Right subclavian artery perfusion provides an excellent approach to repair acute type A dissection. Besides a significantly reduced mortality rate and improved neurological outcome, a significantly higher disease-free survival rate and a reduced late mortality rate is observed in long-term follow-up. 015 SELECTIVE CEREBRAL PERFUSION AT 28 °C: IS THE SPINAL CORD SAFE? C.D. Etz, M. Luehr, F.A. Kari, H.M. Lin, K.A. Plestis, D.J. Weisz, G. Kleinman, R.B. GrieppMount Sinai School of Medicine, New York, USA Objectives: To shorten cooling/rewarming associated with hypothermic neuroprotection strategies during complex aortic arch surgery, selective cerebral perfusion (SCP) at 28 °C has recently been advocated, although its safe limits, especially with regard to the ischaemic tolerance of the spinal cord, have not been systematically examined. Methods: Twenty juvenile Yorkshire pigs (30.2±2.9 kg) were randomly allocated to undergo circulatory arrest and SCP at 28 °C for 90 min (group A, n=12) or 120 min (group B, n=8) at 50 mmHg using alpha-stat pH management. Spinal cord blood flow (SCBF) was assessed using fluorescent microspheres at baseline (prior to SCP), at 5 and 80 min during SCP, and 1 and 5 h after CPB. A modified Tarlov score was used to evaluate neurobehavioral recovery in all survivors blindly from videotapes for five days postoperatively. Histological ischaemic spinal cord injury was scored after sacrifice. Results: All pigs could be weaned from CPB and ventilation, but 7 pigs (58%) in group A and 5 (63%) in group B developed multi-organ failure and died within 24 h. SCBF diminished immediately after initiation of SCP and was absent throughout SCP in all segments below T8/9, recovering to baseline 1 h after SCP at all cord levels. All survivors suffered moderate-to-severe histological lumbar spinal cord damage, more severe in group B (P<0.049). Three of five group A pigs recovered normal function, but two suffered paraparesis. Group B survivors had a worse neurologic outcome (P<0.0001): all suffered paraplegia (one immediate and two on day 2, after initial recovery). Conclusions: SCP provides insufficient SCBF below T8/9 to sustain cord viability. At 28 °C, the ischaemic tolerance of the cord may be sufficiently exceeded by 90 min to impair function; by 120 min, SCP at 28 °C invariably results in paraplegia. 016 ENDOVASCULAR TREATMENT OF ADULT COARCTATION AND ITS COMPLICATIONS H. Shennib, J. Rodriguez-Lopez, V. Ramaiah, G. Wheatley, J. Kpoduno, E. DiethrichArizona Heart Institute and Mercy Gilbert Medical Center, Phoenix, USA Objectives: To determine the effectiveness of endovascular therapy for adult aortic coarctations discovered de novo or presenting long-term after treatment as recurrence or pseudo-aneurysms. Methods: Retrospective review of endovascular treatment of 22 adults (age, 40±18 years) with primary or recurrent coarctations (11) or pseudo-aneurysms (11). Of these, 13 patients had had previous interventions (10 open thoracotomy repair, 2 prior stenting and 1 endoluminal grafting (ELG) 22.3±18 years before). Results: Treatment was percutaneous insertion of balloon expandable Palmaz stents in 11 primary or recurrent coarctations and ELGs in other 11 pseudo-aneurysm patients. Open iliac artery access was required in 2/11 ELGs. ELG coverage of left subclavian artery necessitated carotid-subclavian bypass in 5/11 patients (45%). Coarctation diameter increased from 10+4 to 19+4 mm (mean+S.D.) post-treatment (P=0.0001) and pressure gradient decreased from 49+16 to 4+7 mmHg (P=0.0001). Three patients had intraoperative slippage of Palmaz stents requiring additional stents. One patient required emergency left carotid subclavian bypass one day postoperatively. Hospital stay was 2.2+1 day. At follow-up of 31+16 months there were no mortalities. Follow-up included CT-Scans at day 1, 3–6 months, and yearly after. One patient developed type II leak and another developed pseudo-aneurysm. All had improvement of symptoms and hypertension. Conclusions: Endovascular treatment of adult coarctation and its complications is safe and effective at mid-term follow-up. Improvement of gradient across stenosis is associated with clinical improvement. Half of patients with covered subclavian artery require carotid-subclavian bypass. As in open treatment, long-term follow-up is necessary as recurrence and pseudo-aneurysms may occur years after primary treatment.
017 (1) THE SYNERGY BETWEEN PERCUTANEOUS CORONARY INTERVENTION AND CARDIAC SURGERY (SYNTAX) STUDY: THE DESIGN AND RATIONALE OF A COMPREHENSIVE STUDY COMPARING PERCUTANEOUS CORONARY INTERVENTION USING TAXUS DRUG-ELUTING STENT WITH CORONARY ARTERY BYPASS GRAFT TREATMENT IN PATIENTS REQUIRING REVASCULARISATION FOR DE NOVO THREE-VESSEL DISEASE AND/OR LEFT MAIN DISEASE P. Serruys1, M.-C. Morice2, A.P. Kappetein1, M. Mack3, E. Ståhle4, J.L. Pomar5, K. Dawkins6, F.W. Mohr7 1Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; 2L'Institut Cardiovasculaire Paris Sud, Paris, France; 3Medical City Hospital, Dallas, USA; 4University Hospital, Uppsala, Sweden; 5Hospital Clinico y Provincial, Barcelona, Spain; 6Boston Scientific, Natick, USA; 7Herzzentrum Universität Leipzig, Germany Objectives: Percutaneous coronary intervention (PCI) with drug-eluting stents is challenging coronary artery bypass surgery (CABG) as the gold standard for treatment of three-vessel (3VD) and/or left main (LM) coronary disease. SYNTAX is a novel trial comparing PCI with paclitaxel-eluting TAXUS stents to CABG for 3VD and LM patients. The design and rationale of SYNTAX will be described and final enrollment numbers will be reported. Methods: In the SYNTAX trial, investigators at 85 sites (62 European/23 U.S.) collected safety and outcomes data for patients with de novo 3VD and/or LM disease treated by PCI with TAXUS stents or CABG. A Heart Consultation Team (surgeon and interventionalist) determined the eligibility of all consecutive patients for each revascularisation treatment option. If suitable for both options, patients were randomised to TAXUS or CABG (stratified by LM disease and diabetes) and if suitable for only one treatment option, they were entered into a nested registry. A SYNTAX score was calculated to quantify the complexity of coronary artery disease by taking into account the number and location as well as the complexity of each lesion independently. For the primary randomised controlled trial endpoint of 12-month MACCE (major adverse cardiac and cerebral events), a non-inferiority comparison will be performed. Specifically, if the upper one-sided 95% confidence bound for the difference in 12-month MACCE rates (test minus control) is less than a delta of 6.6% (at a 5% significance level), PCI with TAXUS will be considered to be non-inferior to CABG in the population of patients being analysed. Results: Trial enrollment is complete with 1800 patients in the RCT (1090 3VD and 710 LM). In addition, 198 patients were enrolled in the PCI registry (60% LM and 40% 3VD) and 1077 in the CABG registry (52% 3VD and 48% LM). Conclusions: SYNTAX is a novel trial that will provide evidence-based medicine to determine the optimal revascularisation method, PCI or CABG, for patients with de novo 3 VD and/or LM disease. 017 (2) PRIMARY ENDPOINT OF THE SYNERGY BETWEEN PERCUTANEOUS CORONARY INTERVENTION AND CARDIAC SURGERY (SYNTAX) STUDY: A COMPREHENSIVE STUDY COMPARING PERCUTANEOUS CORONARY INTERVENTION (PCI), USING TAXUS EXPRESS2 PACLITAXEL-ELUTING STENT, WITH CORONARY ARTERY BYPASS GRAFT (CABG) TREATMENT IN PATIENTS REQUIRING REVASCULARISATION FOR DE NOVO THREE-VESSEL DISEASE (3VD) AND/OR LEFT MAIN (LM) DISEASE F.W. Mohr1, A.P. Kappetein2, M.-C. Morice3, M. Mack4, E. Ståhle5, J.L. Pomar6, K. Dawkins7, P. Serruys21Herzzentrum Universität Leipzig, Germany; 2Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; 3L'Institut Cardiovasculaire Paris Sud, Paris, France; 4Medical City Hospital, Dallas, USA; 5University Hospital Uppsala, Sweden; 6Hospital Clinico y Provincial, Barcelona, Spain; 7Boston Scientific, Natick, USA Objectives: The SYNTAX trial was designed to compare percutaneous coronary intervention (PCI) with TAXUS stents versus coronary artery bypass surgery (CABG) for the treatment of de novo three-vessel (3VD) and/or left main coronary disease (LM). Methods: SYNTAX is a prospective, multicentre, multinational, randomised clinical trial (RCT) with nested registries. Consecutive patients with de novo 3VD or LM disease were screened by a Heart Consultation Team (surgeon and interventionalist) to determine eligibility for PCI or CABG. If amenable for both, they were randomised to TAXUS or CABG, stratified at each site by LM disease and diabetes. If a patient was suitable for only one treatment option, they were entered into the PCI registry for CABG-ineligible patients or CABG registry for PCI-ineligible patients. Results: A total of 1800 patients were randomised (1090 3VD and 710 LM) at 85 sites. Additionally, 198 patients were enrolled in the PCI registry and 1077 in the CABG registry. The TAXUS and CABG groups in the RCT were well-matched for baseline characteristics. The primary endpoint of SYNTAX, 12-month MACCE (major adverse cardiac and cerebrovascular events, defined as all-cause death, stroke, MI, or repeat vascularisation), and outcomes of the nested registries will be available at the time of the presentation. Conclusions: SYNTAX is a novel trial that will provide evidence-based medicine to determine the optimal revascularisation method, PCI or CABG, for patients with de novo 3 VD and/or LM disease, while defining the patient populations that are amenable for only one of these treatment options. 018 LONG-TERM OUTCOME AFTER PULMONARY ENDARTERECTOMY FOR CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: A SINGLE INSTITUTION EXPERIENCE N. Saouti, W.J. Morshuis, R.H. Heijmen, R.J. SnijderSt Antonius Hospital, Nieuwegein, The Netherlands Objectives: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is the first treatment of choice with good short-term results. Only limited data are available concerning the long-term outcome after PEA. The purpose of this study is to evaluate the long-term survival and functional outcome after PEA with nearly 10 years experience. Methods: In the period December 1998–December 2007, 120 patients were referred with CTEPH of whom 72 underwent PEA. The clinical data were collected retrospectively. Results: In-hospital mortality was (5/72) 6.9%. Since 2004 one patient died in the hospital (1/38, 2.9%). Two patients died during long-term follow-up with a median observation of three years. The overall 1-, 3- and 5-year survival was 93%, 91% and 88%, respectively. Prior to surgery patients were in WHO functional class III (58) and IV (14) with a mean pulmonary vascular resistance of 548 (SE 34.9) dynes s cm-5. The following data were compared before and after operation: mean pulmonary artery pressure (mPAP) decreased from 43 (SE 1.3) to 24 (SE 1.0) mmHg (P<0.0001), pro-BNP improved from 1516 (SE 262) to 238 (SE 39) pg/ml (P<0.0001), 6 min walk distance from 350 (SE 16.9) to 514 (SE 16.5) m (P<0.0001), and almost all patients returned to functional class I or II (P<0.0001). Conclusions: Pulmonary endarterectomy for patients with CTEPH has shown a dramatic improvement of clinical status with excellent long-term survival. 019 TRANSAPICAL VALVE REPLACEMENT: OFF-PUMP MITRAL VALVED STENT IMPLANTATION G. Lutter1, R. Quaden1, N. Edwards2, J. Cremer1, L. Lozonschi21University of Kiel, Department of Cardiovascular Surgery, Medical School, Kiel, Germany; 2University of Wisconsin, Department of Cardiothoracic Surgery, Medical School, Madison, Wisconsin, USA Objectives: Transcatheter aortic and pulmonary valve replacement is currently being tested in clinical trials. Efforts to create a valved stent to replace the atrioventricular valves have shown minimal success. This is mostly due to their central location inside the heart and their complex anatomy and function. Methods: A new valved stent was designed to overcome the difficulties associated with deployment and anchoring of a valved stent in the mitral position. Results: A valved stent carrying either a bovine pericardial valve or porcine aortic valve was deployed successfully into the mitral position without cardiopulmonary bypass in a series of acute experiments in adult pigs (n=6). This was performed through a lower mini-sternotomy and a standard transapical approach under transoesophageal echocardiographic (TEE) guidance. The valved stent is fully retrievable and precise deployment and accurate adjustment of its intra-annular position is achievable to eliminate paravalvular leakages. The deployment time ranged from 127–255 s and the blood loss from 70 to 220 cc. Mitral regurgitation in all cases was minimal (trace in 4/6 and mild in 1/6 in the echo; in the ventriculogram no insufficiency was observed in 5/6 and 1/6 showed mild regurgitation). The animals remained haemodynamically stable (6/6) and without TEE or ventriculographic changes throughout the observation period. Conclusions: Successful transapical mitral valve implantation with a new valved stent is feasible and reproducible in an acute experimental setting. Additional chronic experiments will be necessary to demonstrate its use for humans. 020 MECHANISMS OF FAILURE OF AORTIC VALVE REPAIR: AN INTRAOPERATIVE TRANSOESOPHAGEAL ECHOCARDIOGRAPHIC STUDY J.-B. le Polain de Waroux, A.-C. Pouleur, A. Pasquet, M. Van Dyck, P. Noirhomme, J.L.J. Vanoverschelde, G. El KhouryCliniques Universitaires, St Luc Universite Catholique de Louvain, Brussels, Belgium Objectives: This echocardiographic study examines the intraoperative features associated with ‘late failure’ of valve repair, eventually necessitating reoperation. Methods: Intraoperative TEE after cardiopulmonary bypass was reviewed in 251 consecutive patients undergoing valve repair for AR over a 10-year period. From this cohort, we carefully reviewed all clinical, preoperative, intraoperative and follow-up TEE data of 112 patients (group A) with no AR at follow-up and 39 patients (group B) with recurrent severe AR, of whom 22 needed reoperation. The cause of repair failure was identified as rupture of a pericardial patch in three patients, residual cusp prolapse in 25 patients, restrictive cusp motion in eight patients, aortic dissection in two patients and endocarditis in the remaining patient. Results: After cardiopulmonary bypass, the coaptation length was shorter (2.2 vs. 6.8 mm, P<0.001), the level of coaptation was lower (0.5 vs. 6.9, P<0.001), the aortic annulus was larger (26 vs. 21, P<0.001) and the vena contracta was wider (2.5 vs. 0.06, P<0.001) in group B than in group A patients. Interestingly, 20/25 patients in whom recurrent AR was due to a cusp prolapse, had eccentric AR jets before leaving the operating room. With multivariate analysis, only the presence of an eccentric jet (OR=52.6, P<0.001), a coaptation length <5 mm (OR=27.0, P<0.01), the level of coaptation relative to the aortic annulus (OR=12.6, P<0.01) and the diameter of the aortic annulus (OR=1.4, P=0.04) were found to independently predict late AR recurrence. Conclusions: Our results demonstrate that intraoperative TEE can be used to identify patients undergoing AR repair who are at increased risk for late repair failure.
021 CLINICAL OUTCOMES OF VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS) FOR THYMOMAS A. Thirugnanam1, J.L. Soon2 1National Cancer Center, Singapore; 2National Heart Center, Singapore Objectives: Although video-assisted thoracoscopic surgery (VATS) for small thymomas (<2 cm) is well established, its role in larger and invasive thymomas remains controversial. We review our experience to assess VATS safety and oncological efficacy. Methods: Retrospective chart reviews of 58 cases of VATS thymectomy done between 1998 and 2007 were reviewed. ‘No touch’ technique was employed during dissection of the tumour to prevent breach of tumour capsule and risk of seeding. All specimens were removed via endobag and larger tumours were extracted by extension of one of the port incisions. An harmonic scalpel was used routinely in the dissection. Adjacent perithymic fat, phrenic nerve, pericardium and wedge of lung were removed en bloc with the tumour if found invading at time of VATS. Modified Masoaka staging was used for staging. Results: Mean age was 52.3 years (range, 22–83 years). 44.8% were males. The right-sided approach was used in 79.3% and bilateral approach in one case. Mean duration of surgery was 149.8 min (range, 60–289 min). Mean length of stay was five days (range, 2–15 days). Thirty-two (55.2%) patients had associated myasthenia gravis. There was no operative mortality and operative morbidity was 6.9%. Mean size of thymomas was 50 mm (range, 10–30 mm). Twenty-five (48.5%) were in Masoaka stage I, 25 in stage II, 7 in stage III and 1 in stage IV. In stage III, phrenic nerve was sacrificed in 3, pericardium in 3 and wedge of lung in 1. Thirty-four percent of cases had adjuvant radiotherapy. Mean follow-up was 3.4 years (range, 0.4–8.5 years). To date there were two local recurrences, one in stage 1 and one in stage 3 groups. 93.8% of myasthenia patients improved after surgery with 25% in complete remission. Conclusions: With modification in techniques, VATS can be used safely in removal of selected large and invasive thymomas without oncological compromise. 022 PLASMAPHERESIS BEFORE THYMECTOMY IN MYASTHENIA GRAVIS: ROUTINE VS. SELECTIVE PROTOCOLS K. Al-Kattan1, H. El-Bawab1, W. Hajjar2, M. Rafay1, A. Bamousa1, A. Khalil11King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; 2King Khalid University Hospital, Riyadh, Saudi Arabia Objectives: The value of thymectomy in management of myasthenia gravis (MG) is well recognised. Plasmapheresis (PP) before thymectomy appears to improve the postoperative outcome. As PP has its own complications, selective use of PP preoperatively for patients at risk of post-thymectomy complications should improve the postoperative outcome, and decrease PP-related complications. The aim of this study is to evaluate the effectiveness and safety of routine vs. selective use of PP before thymectomy. Methods: We performed a retrospective analysis of two different protocols in two institutions comparing the routine (group I) vs. selective (group II) use of pre-thymectomy PP. The computerised database and the medical records of 164 patients diagnosed with MG who underwent thymectomy between 1998 and 2006, were reviewed. Results: In group I, 74 patients were treated with PP before thymectomy. In group II (90 patients), 35 patients were identified as high-risk and were treated with PP before thymectomy, and in 55 patients thymectomy was performed without preoperative PP. There were significant differences in the recorded plasmapheresis-related complications between group I and group II; 25.7% (19 patients) vs. 8.9% (8 patients), respectively. There was no difference between the two groups as regards the duration of postoperative mechanical ventilation, ICU stay, and hospital stay. Conclusions: The present study demonstrated that selective use of plasmapheresis before thymectomy may reduce the incidence of plasmapheresis-related complications without affecting the overall outcome. 023 ASSOCIATION OF THYMOMA AND MYASTHENIA GRAVIS: ONCOLOGICAL AND NEUROLOGICAL RESULTS OF SURGICAL TREATMENT M. Lucchi, F. Melfi, P. Dini, F. Davini, L. Duranti, A. Viti, A. MussiAzienda Ospedaliera Universitaria Pisana, Pisa, Italy Objectives: Thymoma occurs in about 10–20% of myasthenic patients. Surgery is mandatory in this subset of myasthenic patients. The objectives of this study were to analyse the clinical features of these patients and the oncological and neurological outcomes after thymectomy. Methods: Clinical and pathological data, complete remission rate, as well as overall and disease-free survival, were retrospectively analysed in a cohort of myasthenic patients who underwent extended thymectomy for thymoma between 1993 and 2006. Results: One hundred and twenty-three patients (60 M and 63 F) with a mean age of 56 years (range, 22–83) underwent extended thymectomy. The WHO histologic classification was: A in 22 cases, AB in 18, B1 in 33, B2 in 22 and B3 in 28. The Masaoka clinical staging was: I in 10 cases, IIA in 33, IIB in 50, III in 14, IVA in 15 and IVB in 1. We experienced two postoperative deaths. With an overall mean follow-up of 76 months, 42 patients had a complete remission, 39 had remission with medications, 35 an improvement of symptoms, 3 remained nearly in the same status and 4 worsened. At the last follow-up, 112 patients were alive; 11 with disease. Four deaths were related to the tumour. Actuarial 5-year and 10-year survival was 93.4% and 79.6%, respectively. Conclusions: Neurologic outcomes of myasthenic thymoma patients were comparable or even better than those of non-thymoma patients. Overall and disease-free survival was dependent on the Masaoka stage and WHO classification. 024 EARLY MASAOKA STAGE AND COMPLETE RESECTION IS IMPORTANT FOR THE PROGNOSIS OF THYMIC CARCINOMA: FROM THE 20-YEAR EXPERIENCE OF A SINGLE INSTITUTION C.Y. Lee, I.K. Park, M.K. Bae, K.Y. ChungDepartment of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea (South) Objectives: Primary thymic carcinomas are rare tumours with poor prognosis due to delayed diagnosis and highly malignant behavior without standardised treatment protocol. We analysed the risk factors of thymic carcinoma. Methods: Sixty patients who were diagnosed and treated for thymic carcinoma from 1986 to 2005 were reviewed retrospectively. The influences of demographic characteristics, Masaoka stage, histologic grade, completeness of resection and adjuvant treatment on survival were evaluated. Results: There were 42 male and 18 female patients and mean age was 54.0±14.4 years. The 5-year overall survival rate was 40.4% and median survival time was 35.6 months. The most common histologic type was squamous cell carcinoma (n=29). Five (8.3%) were in Masaoka clinical stage I, 5 (8.3%) in II, 19 (31.7%) in III, 15 (25%) in IVa and 16 (26.7%) in IVb. Of 40 patients who underwent surgical resection, complete resection could be achieved in 13. The 5-year survival rate after complete resection (83.9%) was statistically significantly better than after incomplete resection (32.1%, P=0.003) and non-surgical treatment (21.1%, P<0.001). However, no survival difference could be found between the incomplete resection and non-surgical treatment groups (P=0.188). The 5-year survival rate of early Masaoka stage was significantly higher than advanced Masaoka stage (90.0% vs. 30.4%, P=0.005). The recurrence rate within three years after R1 resection (65.4%) was significantly higher than that after R0 resection (16.1%, P=0.003). Conclusions: In thymic carcinoma, early diagnosis and subsequent complete resection are most important for disease control and long-term survival. 025 LONG-TERM OUTCOME OF EXTENDED THORACOSCOPIC THYMECTOMY FOR NONTHYMOMATOUS MYASTHENIA GRAVIS E. Pompeo, F. Tacconi, R. Massa, G. Bernardi, T.C. MineoDepartment of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy Objectives: Thoracoscopic thymectomy has shown promise in the integrated management of myasthenia gravis (MG) although there are scant data on long-term results. The aim of this study was to analyse long-term (>5 years) results of extended thoracoscopic thymectomy in non-thymomatous MG. Methods: We retrospectively reviewed 32 patients operated on up to March 2003. MG-Foundation of America clinical classification (MGFA), symptom duration, and acetylcholine receptor antibodies were evaluated with annual follow-up. Anti-MuSK antibody titre was also assessed at the last follow-up. Remission and improvement rates were calculated with the Kaplan–Meier method. Results: There were 21 females and 11 males with a mean age of 32±10 years. Ten patients were seronegative for acetylcholine receptor antibodies. Utility minicervicotomy was performed in 21 patients. Patients in MGFA class I, II, III and IV were 7 (22%), 14 (44%), 9 (28%), and 2 (6%), respectively. Duration of symptoms was 11±6 months. Two patients required conversion to median sternotomy. There was no mortality or major morbidity. Mean hospital stay was 4.3±3.8 days. Ectopic thymic tissue was found in 18 (56%) patients. Follow-up averaged 75±7 months. Six-year and 10-year remission rates were 35% and 50%, respectively. At 72 months, 27 (84.3%) patients were improved or in remission. On univariate analysis, a significant relationship existed between ectopic thymic tissue and non-response (patients not improved) (R=–0.42, P=0.01), and between MuSK-positive subjects and non-response (R=0.89, P<0.001). Conclusions: VATS thymectomy yields satisfactory long-term results in patients with non-thymomatous myasthenia gravis although MuSK-positivity and presence of ectopic thymic tissue correlated with poor response to operation.
026 EARLY OUTCOME OF PAEDIATRIC HEART TRANSPLANTATION FOR CONGENITAL HEART DISEASE IS COMPARABLE TO THAT FOR CARDIOMYOPATHY IN THE CURRENT ERA J. Simmonds, V. Tsang, M. de Leval, C. van Doorn, M. Kostolny, H. Dawkins, M. Burch, M. Elliott Great Ormond Street Hospital for Children, London, UK Objectives: Historically, results of paediatric heart transplantation for congenital heart disease (TxCHD) have been worse than those for cardiomyopathy (TxCM), due mainly to a higher early attrition. This study aimed to deduce whether CHD continues to be a risk factor for early death. Methods: Since 1988, 257 paediatric heart transplants have been performed at our institution. Nine re-transplants were removed from this analysis, leaving 248 first transplants (73 TxCHD). The patients were split into two eras (1988–1999, and 2000-present), and then subdivided into CM and CHD patients. Pre-2000, 72 patients were transplanted for CM (mean age 6.85 years, 6 infants), and 38 for CHD (7.34 years, 5 infants). Post-2000, there were 103 (7.95 years, 15 infants) and 35 (8.17 years, 3 infants), respectively. Results: One-year survival for TxCHD improved from 66% pre-2000 to 90% post-2000 (P=0.005). One-year survival for TxCM was 82% and 94%, respectively (P=0.001). Prior to 2000, 1-year survival for TxCHD was significantly worse than TxCM (P=0.036). There was no significant difference in 1-year survival for TxCHD compared to TxCM in the current era (90% vs. 94%, P=0.756). Conclusions: Early results of paediatric heart transplantation continue to improve significantly. CHD is no longer a risk factor for early death in our institution, which represents one of the largest single series of paediatric transplantation for CHD. It is likely that better preoperative patient selection, a refinement in the intraoperative procedures, and improved postoperative management have all contributed to this progress. 027 CLINICAL RESULTS OF NORWOOD PROCEDURE WITH TOTAL BODY PERFUSION: EXPERIENCE OF 71 CONSECUTIVE CASES T. Nakano, H. Kado, K. Hinokiyama, A. Shiose, M. Kajimoto, T. SakuraiFukuoka Children's Hospital, Fukuoka, Japan Objectives: We retrospectively reviewed the results of the Norwood procedure with total body perfusion and assessed its safety and efficacy. Methods: From 1998, 71 neonates underwent the Norwood procedure using total body perfusion technique. Mean age and body weight at operation were 12 days and 2.8 kg. After median sternotomy, a 3 (or 3.5) mm PTFE graft was anastomosed to the innominate artery for selective cerebral perfusion. A 2-mm arterial cannula was inserted into the descending thoracic aorta just above the diaphragm for lower body perfusion. With bicaval cannulation, high-flow total body perfusion was maintained throughout the operation. Perioperative course and surgical results were reviewed. Results: During arch reconstruction, perfusion flow rate and rectal temperature were 179.5±17.2 ml/kg/min and 30.0±0.9 °C. Flow distribution between upper and lower body was 1.35:1 (n=14). There was no laterality in cerebral blood flow velocity measured by transcranial Doppler sonography (n=5). Mean cerebral and renal oxygen saturation measured by near-infrared spectroscopy were 68.2% and 74.8% (n=8). There were no complications related to descending aorta cannulation. Urine output (ml/kg) during CPB and the first 24 h in the ICU was 22.6±37.9 and 64.6±35.9. Early mortality was 19.7% and no patient experienced neurological complications or renal failure. Preoperative shock was not a risk factor for early mortality in this group of patients. Conclusions: The Norwood procedure can be safely performed with total body perfusion with good results. This perfusion technique is beneficial by protecting whole body from ischaemia and possible adverse effects of deep hypothermia. 028 RESULTS OF THE DOUBLE SWITCH OPERATION FOR CONGENITALLY CORRECTED TRANSPOSITION OF THE GREAT ARTERIES A. Serraf, M. Ly, E. Belli, O. Grollmuss, C. Kortas, B. Leobon, C. PlancheMarie Lannelongue Surgical Center, Le Plessis Robinson, France Objectives: Congenitally corrected TGA (ccTGA) is characterised by discordant atrioventricular and ventriculo-arterial connections. In the absence of right ventricular outflow tract obstruction (RVOTO), repair by atrial and arterial switches remains a challenging procedure for which long-term follow-up is uncertain. Methods: From May 1995 to September 2007, 20 patients (median age: 26 months) with ccTGA had a double switch procedure. Segmental anatomy was S.L.L in all, dextocardia in 2, mesocardia in 2. VSD was present in 18, aortic coarctation in 2 and interrupted aortic arch (IAoA) in 1. Five patients had tricuspid valve incompetence. Six had AV blocks, four already with pacemaker. PAB was performed in 17, for congestive heart failure (15) or left ventricular retraining (2). In three patients (including one with IaoA) the procedure was performed when indexed LV mass to LV volume ratio was above 1.5. A median follow-up of 60 months was achieved in all. Results: There were no deaths. Pacemaker implantation was required in 3. Reoperation for Senning obstruction was necessary once, and pacemaker battery replacement once. One patient had mild neoaortic insufficiency, two had mild tricuspid regurgitation and two had mild mitral regurgitation. All were in NYHA I–II. Actuarial survival at 10 years was 100%. Freedom from reoperation at 5 and 10 years was 93% and 77.4%, respectively. Conclusions: Double switch for ccTGA without RVOTO can be performed with no mortality and low morbidity. Since these results seem to last for several years, it should be considered as the optimal procedure. 029 ROSS AND YASUI OPERATIONS FOR ‘COMPLEX’ BIVENTRICULAR REPAIR IN INFANTS WITH CRITICAL LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION E.J. Hickey1, T. Yeh Jr3, J.P. Jacobs5, C.A. Caldarone1, C.I. Tchervenkov6, B.W. McCrindle1, F.G. Lacour-Gayet4, C. Pizarro21The Hospital for Sick Children, Toronto, Canada; 2Alfred I duPont Hospital for Children, Wilmington, USA; 3Tulane University, New Orleans, USA; 4The Children's Hospital of Denver, Denver, USA; 5The Congenital Heart Institute of Florida, St Petersburg, USA; 6Montreal Children's Hospital, Montreal, Canada Objectives: To define outcomes following Ross and Yasui operation for ‘complex’ biventricular repair of critical LVOTO. Methods: Of 1211 neonates presenting with critical LVOTO enrolled with Congenital Heart Surgeons Society studies (1994–2008), 52 underwent Ross or Yasui operation and their outcomes were investigated using univariate and multivariable parametric models. Results: Yasui (n=13). Yasui repair (median age 22 days) was usually the primary intervention (9/13) but occasionally followed Norwood palliation (4/13). All had a VSD and none were emergent. Survival was 69±13% at 10 years, which is not significantly different from other biventricular repair strategies in neonates. Aortic atresia was associated with better survival than stenosis (90±12% vs. 30±14% at 3 years, P=0.039). None were later reverted to univentricular repair. Ross (n=39). Ross operation (median age 87 days) was rarely the primary intervention (6/39). Iatrogenic aortic regurgitation after balloon valvotomy was a common indication for Ross (16/39, 41%), four of which were emergencies with poor survival (17±15% at 1 year). Younger age was associated with worse outcome (24±13% for neonates vs. 76±8% for age >3 months, P=0.0013). However, younger age correlated with other risks, including: emergent clinical condition, mitral dysfunction, patent ductus and ASD. Severe postoperative ventricular dysfunction or need for ECMO conferred negligible survival. Conclusions: Emergency neonatal Ross to rescue failed aortic valvotomy is rarely successful. However, non-emergency Ross or Yasui offer favourable outcome. To optimise outcomes of ‘complex’ biventricular repair, initial decision-management must assess both appropriateness for biventricular repair and nature of index procedure.
030 A RANDOMISED TRIAL OF ATORVASTATIN FOR REDUCTION OF MYOCARDIAL DAMAGE DURING CABG: THE ARMYDA-4 STUDY (ATORVASTATIN FOR REDUCTION OF MYOCARDIAL DAMAGE) D. Candura, M. Chello, M. Lusini, G. Patti, R. Barbato, G. Di Sciascio, E. Covino University Campus Bio-Medico of Rome, Rome, Italy Objectives: Even small releases of CKMB or cTnI reflect myocardial damage (MD) and are associated with increased risk of early and late mortality. ARMYDA-4 is the first randomised, prospective, placebo-controlled trial, evaluating the effects of preoperative atorvastatin administration on postoperative MD. Methods: Two hundred patients undergoing elective CABG were randomised to receive preoperatively placebo (n=99) or 40 mg/day atorvastatin (n=101). Primary endpoint: incidence of postoperative MD (cTnI >3.1 µg/l at 12 h) or infarction (new ECG and ECHO changes, plus cTnI values >3.1 µg/l at 12 h and/or five-fold increase of preoperative CKMB). Secondary endpoints: length of hospital stay; postoperative incidence of MACCE; postoperative CRP levels. Results: The incidence of postoperative MD was 18.5% (37/200 patients); it occurred in 13/101 patients (12.8%) in the atorvastatin vs. 24/99 patients (24%) in the placebo arm (P=0.045). Mean cTnI values at 12 h were 2.5±3.4 in statin vs. 4.5±3.3 µg/l in the placebo group (P=0.008). Mean CKMB values at 12 h were 23.1±16 in statin vs. 38.0±28 ng/dl in the placebo group (P=0.0001). Perioperative AMI occurred in six patients (1 in the statin and 5 in the placebo group, P=0.01). Four patients died postoperatively (2%), one in the atorvastatin and three in the placebo arm (P=0.36). Mean hospital stay was significantly lower in the atorvastatin group (6.3±1.2 vs. 6.9±1.4 days, P=0.001). No MACCE were observed at 30 days in either group. Postoperative CRP levels were significantly lower in the atorvastatin group. Conclusions: Preoperative treatment with atorvastatin significantly decreases postoperative MD, AMI, and length of stay after elective CABG. 031 CORONARY ARTERY BYPASS GRAFTING VS. DRUG-ELUTING STENTS IN MULTIVESSEL CORONARY DISEASE: A META-ANALYSIS OF 21,832 PATIENTS U. Benedetto, G. Melina, B. Fiorani, E. Angeloni, S. Refice, A. Roscitano, C. Comito, R. SinatraDepartment of Cardiac Surgery, II Faculty of Medicine, University of Rome, Rome, Italy Objectives: Coronary artery bypass grafting (CABG) has been shown to provide better results than percutaneous coronary intervention (PCI) in multivessel coronary disease. Drug-eluting stents (DESs) have significantly improved results of PCI but the advantages of such a treatment compared to CABG remain uncertain. This meta-analysis summarises available data comparing the results of CABG vs. DESs in patients with multivessel coronary disease. Methods: We performed a systematic literature search for prospective randomised, non-randomised and retrospective studies comparing CABG vs. DESs in patients with multivessel coronary disease (including left main disease). A total of 11 studies (CABG, n=9592 and DESs, n=12,240) were identified. Outcomes included overall death, myocardial infarction, repeat revascularisation (CABG or PCI), cerebrovascular accident (CVA) and major adverse cardiac and cerebrovascular events (MACCE). Results: Meta-analysis showed that CABG does not improve overall death (RR 1.04; 95% CI 0.93–1.16; P=0.46) but significantly reduces the rate of myocardial infarction (RR 0.65; 95% CI 0.54–0.77; P<0.0001), repeat revascularisation (RR 0.07; 95% CI 0.06–0.09; P<0.0001) and MACCE (RR 0.36; 95% CI 0.34–0.38; P<0.0001) compared to DESs. Even if the rate of CVA was low after both CABG and PCI, it was significantly higher in CABG (2% CABG vs. 0.5% DESs; RR 2.66; 95% CI 1.25–5.68; P=0.011). When the analysis is restricted to subgroups of patients such as diabetics (n=7,646) or left main disease (n=670), the results are similar to those observed in the pooled study population. Conclusions: In patients with multivessel coronary disease, CABG still provides better results than PCI with DESs. However efforts should be made to reduce the risk of cerebrovascular accidents after CABG. 032 ELECTIVE BYPASS SURGERY AFTER DISCHARGE IN SURVIVORS OF ACUTE CORONARY SYNDROMES IN CLINICAL PRACTICE: RATIONALE AND TIMING OF OPERATION. RESULTS FROM PL-ACS REGISTRY M. Zembala1, M. Gasior1, M. Gierlotka1, R. Przybylski1, J. Pacholewicz1, A. Bochenek2, S. Wos2, L. Polonski11Silesian Centre for Heart Diseases, Zabrze, Poland; 2Silesian Centre of Cardiology, Katowice, Poland Objectives: A number of patients with acute coronary syndromes (ACS) meet criteria for elective bypass surgery (CABG) and are discharged home after the acute phase of ACS. The aim of this analysis was to present current clinical practice in those patients and its impact on 12-month outcome. Methods: Between October 2003 and August 2006, a total of 35,632 consecutive patients with ACS were enrolled into the ongoing, prospective registry of acute coronary syndromes (PL-ACS) in the Silesia Region of Poland (46 hospitals). Follow-up data were collected from the National Health Fund database. Results: Coronary angiography was done in 17,268 (48.4%), followed by PCI in 13,902 (80.5%) of them. CABG was planned in 2293 (13.3%), 994 (43%) of them after PCI as a combined revascularisation strategy. During index hospitalisation 235 (10.3%) of CABG were done with in-hospital mortality of 5.1%. Additionally, 30 (1.3%) patients died without having CABG. Finally 2028 (88.4%) were discharged with the intention of deferred CABG. After 12 months only 60% of them had undergone CABG with significantly better outcomes than non-operated ones. Conclusions: Only half of survivors of acute coronary syndrome destined for CABG after discharge had the procedure done by six months. Non-operated patients had twice the mortality of operated patients at 12 months. Probably the delay to CABG should not exceed three months. 033 TO GRAFT OR NOT TO GRAFT: TRANSIT TIME FLOW MEASUREMENT IN BYPASS SURGERY OF PREVIOUSLY STENTED VESSELS D.C. Reineke, D. Bircher, F.F. Immer, M. Stalder, L. Englberger, T.P. CarrelDepartment of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland Objectives: An increasing number of patients undergo CABG surgery after previous PCI. Preoperative angiography allows assessment of patency of the stents and quantification of in-stent restenosis. There are no recommendations available to aid the decision whether or not bypass grafting should be performed in a coronary vessel with a patent stent or with residual mild stenosis in situ. We assessed intraoperative bypass flows in patients after previous coronary stenting, and analysed the impact on stent patency. Methods: From 860 consecutive patients undergoing isolated CABG surgery, 95 (11.6%) had previous coronary stenting (101 treated coronary vessels). Of these, 41 (43.2%) received a bypass to a vessel with a patent stent in situ (group 1). At the end of surgery, the flow of these bypasses was compared to those obtained in 36 patients (37.9%) who received bypasses to vessels with >70% in-stent stenosis (group 2). Results: Average age was 63.2±10.0 years, with 81.1% of the patients suffering from 3-vessel disease. On average, 3.6±1.0 distal anastomoses were performed. Fifty-one stented vessels were bypassed with an arterial graft (50.5%). Average flow in patients from group 1 was 59.4±34.5 ml/min compared to 64.4±40.7 ml/min in group 2 (P=ns). Overall in-hospital mortality was 1.1% and one-year survival was 98.9%. Conclusions: Despite good angiographic results following stent placement, flow in the native coronary vessel does not seem to negatively affect the flow in the bypass graft. Therefore we recommend aggressive surgical revascularisation, to bypass all vessels regardless of the patency of a prior coronary stent.
034 NON-IMAGED PULMONARY NODULES FOR METASTASECTOMY DISCOVERED DURING THORACOTOMY WITH LUNG PALPATION R.J. Cerfolio, T. McCarty, A.S. Bryant University of Alabama at Birmingham, Birmingham, USA Objectives: Video-assisted thorascopic surgery (VATS) is an increasingly used technique to treat patients with pulmonary metastases, but it does not usually afford lung palpation. The objective of this study was to determine the incidence of nodules that would have been missed with VATS. Methods: A retrospective study on patients with VAT-able lesions who underwent open metastasectomy via thoracotomy. All patients underwent 64-slice helical CT with intravenous contrast at 5 mm intervals and most had integrated FDG-PET/CT. Unsuspected malignant pulmonary nodules that were palpated and removed and were not imaged preoperatively were defined as cancer that would have been missed by VATS metastasectomy. Results: From January 2004 to December 2005, 59 patients had VAT-able metastatic lesions that were resected via thoracotomy by one surgeon. Twenty-two (37%) patients had pulmonary nodules that would have been missed by VATS metastasectomy; 12 (20%) patients had missed malignant nodules. Three patients had malignant missed nodules in the same lobe as an imaged nodule, seven patients had malignant missed nodules in a lobe with no imaged nodules, and two patients had a malignant missed nodule in the same lobe, as well as a malignant missed nodule in a lobe with no imaged nodules. Six patients with malignant missed nodules had received adjuvant chemotherapy and/or radiation for the primary cancer. Renal cell carcinoma was the most commonly missed type of metastatic cancer 6 (50%). Conclusions: Open thoracotomy and metastasectomy, which affords palpation of the rest of the lung, may discover non-imaged malignant pulmonary metastases in 20% of patients with previously diagnosed and treated cancer, despite preoperative, fine-cut chest CT with contrast and integrated FDG-PET/CT scanning. The clinical impact of these findings is unknown. 035 LUNG METASTASES FROM COLORECTAL CANCER: SURGICAL RESECTION AND PROGNOSTIC FACTORS N. Rama, A. Monteiro, J. Bernardo, L. Eugénio, M.J. AntunesUniversity Hospital, Coimbra, Portugal Objectives: To analyse our experience with excision of lung metastases from colorectal carcinoma (CRC), and to evaluate clinically relevant prognostic factors, establishing the cluster of patients who would benefit from this procedure. Methods: Sixty-one patients, 42 men (69%), with primary CRC who underwent 94 curative resections of pulmonary metastases, were retrospectively reviewed. Age was 30–80 years (mean 61.2±14.9). Patients were evaluated for age, sex, location and histology of primary tumour, disease-free interval (DFI), number of lung lesions (and size of largest resected metastasis), prethoracotomy carcinoembryonic antigen (CEA) level, type of lung resection, nodal involvement (hilar/mediastinal), use of adjuvant treatment, morbidity-mortality and immediate and follow-up survival. Results: There was no mortality and significant morbidity occurred in five patients (8.2%). Mean DFI was 29.1±22.4 months (range 5.2–132 months), and mean follow-up was 38.7±3.9 months (range 4–173 months). Mean overall survival and disease-free survival were 66.9±16.0 months and 51.5±6.0 months, respectively. Three-, 5- and 10-year survival rates from date of primary colorectal resection were 83.4%, 71.0% and 43.2%, respectively. Three, 5- and 10-year survival rates from date of lung resection were 61.4%, 47.7% and 10.6%, respectively. Five-year survival was 57.0% in patients with normal pre-thoracotomy CEA levels and 18.4% for those with high levels (>5 ng/ml) (P=0.0389). Conclusions: Pulmonary metastasectomy has potential survival benefit for patients with metastatic colorectal carcinoma. Low morbidity and mortality rates, contrasting with the lack of any other effective therapy, justify aggressive surgical management. Single deposits, DFI>36 months and normal prethoracotomy serum CEA were significant independent prognostic factors. 036 WHICH FACTORS AFFECT PULMONARY FUNCTION AFTER LUNG METASTASECTOMY? F. Petrella, F. Leo, P. Chieco, P. Solli, G. Veronesi, A. Borri, D. Galetta, L. SpaggiariEuropean Institute of Oncology, Milan, Italy Objectives: Pulmonary metastasectomy is an accepted procedure in selected patients, very often requiring multiple non-anatomical resections. Although intuitive that functional loss is proportional to the number and the extent of pulmonary resections, this link has never been proved and it represents the hypothesis of the study. Methods: We retrospectively reviewed pulmonary function modifications after lung metastasectomy. Baseline and postoperative spirometric values were evaluated and their modifications were correlated with (a) number of resections, (b) extent of resections and (c) interval between surgeries. Results: Sixty-six patients were enrolled (31 males, mean age 56, range: 23–75). Mean interval time between surgery: 54.5 days; mean extent of resection: 11.45 cm; mean number of resections: 3. Mean modification of FEV 1, FCV and DLCO/VA were –13.4%, –12.4% and +1.2%, respectively. Patients receiving three or more non-anatomical resections had functional loss similar to those undergoing lobectomy. The extent of total resection (>11 cm, P<0.05) and the interval between surgeries (>90 days, P<0.0001) influenced FEV1 and FVC modifications. At three months none of these functional modifications was still detectable. Sex, age, side of the operation and histology of primary tumour did not affect spirometric modifications.
Conclusions: Spirometric modifications after pulmonary metastasectomy are affected by total volume of lung parenchyma resected within the first 90 days. Functional loss after three or more non-anatomical resections (n 037 THE CHANGE IN PATIENT POPULATION UNDERGOING PULMONARY METASTASECTOMY IN A TERTIARY REFERRAL UNIT OVER A 13-YEAR PERIOD RAISES CONCERN V. Dronavalli, B. Naidu, A. Harris, P.B. RajeshHeartlands Hospital, Birmingham, UK Objectives: Is there a change in the disease characteristics of patients undergoing pulmonary metastatectomy which may make historical registry data less relevant? Methods: Patients having pulmonary metastasectomies performed between 1995 and 2007 were retrospectively studied. Patient were divided into two groups, those prior to 2000 (group A, n=68) and those after (group B, n=172). Results: Mean age of patients was 55±19 in group A and 57±16 years in group B. There was no significant difference in the number or size of lung lesions excised in the two groups. However, in group B, 18 patients (10%) underwent associated liver resection for metastases but none in group A. There was a significant reduction in the disease-free interval from 31±15 months in group A to 21±20 months in group B (P<0.001). A significantly larger number of patients had colorectal primaries in group B, 31.4% (54) vs. 7.3% (5) in group A. Conclusions: There has been a significant growth in the number of lung metastasectomies predominantly in patients with colorectal primaries performed over a 13-year period in a regional thoracic centre. The patients tend to have a shorter disease-free interval and are more likely to have associated operated metastatic liver disease. The long-term benefit in patients with these poor prognostic markers is uncertain and may warrant further investigation. 038 EVALUATION OF PULMONARY METASTATIC LESIONS CAN PROVIDE A PROGNOSTIC FACTOR IN OSTEOSARCOMA PATIENTS I. Matsumoto, M. Oda, T. Yachi, M. Hada, T. Imagawa, G. WatanabeDepartment of General and Cardiothoracic Surgery, Kanazawa University, Kanazawa, Japan Objectives: This study aims to predict the prognosis of osteosarcoma patients with lung metastases, and determine more accurate indications for repeat pulmonary resection, using pulmonary metastatic lesion specimens. Methods: This retrospective study included 27 osteosarcoma patients with lung metastases (18 males, 9 females; age 21±10 years). The value of the expression of VEGF-A, VEGF-C, and MIB1 was evaluated in the pulmonary metastatic tumours. These factors were also evaluated in the primary tumours that were obtained before chemotherapy (n=13). Results: VEGF-A, VEGF-C and MIB1 expressions in the primary lesions did not correspond to those in the metastatic lesions. Evaluation of the metastatic lesions reflected the prognosis after pulmonary metastasectomy more than that of primary lesions. In the metastatic lesions, ‘positive’ expression of VEGF-A (n=17), VEGF-C (n=2) and MIB1 (n=14) was associated with a significantly poorer prognosis (P=0.020, P=0.0002, and P=0.013, respectively). The patient with ‘positive’ expression of VEGF-C succumbed within seven months after the initial pulmonary resection. No patients with ‘positive’ expression of both MIB1 and VEGF-A (n=9) survived more than five years after initial pulmonary resection. All patients who had ‘negative’ reactions to both MIB1 and VEGF-A (n=5) were alive at the end of the study. Conclusions: We conclude that combined evaluation of VEGF-A and MIB1 combination and VEGF-C using pulmonary metastatic lesion specimens in osteosarcoma patients clearly reflects long-term survival. We believe that our method can be useful to determine more accurate indications for repeat pulmonary metastasectomy in osteosarcoma patients even when a primary lesion specimen is not available. 039 VIDEO-ASSISTED VS. OPEN PULMONARY METASTASECTOMY: THE SURGEON'S FINGER OR THE RADIOLOGIST'S EYE? A. Nakas, M. Klimatsidas, A.E. Martin-Ucar, D.A. WallerGlenfield Hospital, Leicester, UK Objectives: The use of VATS metastasectomy remains controversial because of doubt surrounding its ability to remove palpable but CT occult lesions. We aim to evaluate our policy of elective VATS and compare it with our results with open metastasectomy. Methods: Metastasectomy was performed for metastatic colorectal adenocarcinoma in 52 cases: 27 open and 25 VATS. The age and sex distribution was similar: 66 for open and 69 years for VATS, P=0.67; 70% male in open and 64% male in VATS, P=0.42. Liver metastases were present in 37% in the open and 32% in the VATS group, P=0.46.The choice of surgical approach was dependent on the distance of the lesion from the surface of the lung. We examined the survival using the Kaplan–Meier method and we tested for differences in the incidence of missed lesions, pulmonary disease progression and repeat metastasectomy. Results: There was no in-hospital mortality and no difference in the incidence of missed lesions (1 in VATS, none in open, P=0.48) or pulmonary disease progression (11 in open, 9 in VATS, P=0.47). Median follow-up was 22 (1–70) months and there was no difference in the estimated actuarial survival (6–70, mean 47 months for open and 2–43, mean 37 months for VATS, P=0.93). The estimated 1- and 2-year survival was 90% and 80% for open and 90% and 75% for VATS. Conclusions: Selective use of VATS therapeutic metastasectomy in conjunction with multi-slice CT is justified in metastatic colorectal adenocarcinoma. The insertion of the surgical digit is not mandatory.
040 PAEDIATRIC TRACHEAL REPAIR WITH AUTOLOGOUS PERICARDIAL PATCH REINFORCED BY STRIPS OF CARTILAGE D.R. Koolbergen, A.M. Konig-Jung, J.A. Kersten, J.A.K. Peper, A.P. Bos, M.G. Hazekamp Academisch Medisch Centrum, Amsterdam, The Netherlands Objectives: To analyse the results of paediatric tracheal repair with autologous pericardium and cartilage. Methods: From 2003 to 2008, 14 non-consecutive patients were operated at median age of 5.75 (2.5–85.0) months. Patients had concomitant double aortic arch (8), pulmonary artery sling (2), aberrant anomalous artery (1), pulmonary agenesia with multiple VSDs (1) or pulmonary agenesia with AVSD (1) and isolated post intubation tracheal stenosis (1). All patients had severe respiratory symptoms, six were ventilated preoperatively. Operations were performed through a median sternotomy and with cardiopulmonary bypass. Pericardial patch plasty of the anteriorly or more laterally opened trachea was reinforced with 2–8 small hemicircular strips of autologous costal cartilage. Minimal internal diameters were recorded with endoscopic examination; preoperatively, intraoperatively and postoperatively at 3, 6, and 12 months. Intensive care stay and ventilation time were recorded and all patients had a recent interview. Results: Mean follow-up was 26.8 (±18.8) months. Late mortality occurred in one patient with pulmonary agenesia after reoperation for distal tracheal stenosis, whereas the second needed a tracheal cannula. For the other 12 patients mean postoperative ICU stay was 12.6 (±8.8) days and mean postoperative ventilation time was 6.9 (±2.7) days. One patient was reoperated for lateral compression by right aortic arch. Mean minimal tracheal diameter increased from 30% of age-average preoperatively to 60% postoperatively. At latest follow-up all patients were free of respiratory symptoms. Conclusions: Tracheal repair with autologous pericardium and cartilage strips results in an unobstructed and rigid trachea with short ventilation times and good functional results. 041 EARLY RESULTS OF BILATERAL PULMONARY ARTERY BANDING FOR HYPOPLASTIC LEFT HEART SYNDROME T. Sakurai1, T. Kado1, T. Nakano1, K. Hinokiyama1, A. Shiose1, M. Kajimoto1, K. Joo1, Y. Ueda21Fukuoka Children's Hospital, Fukuoka, Japan; 2Nagoya University School of Medicine, Nagoya, Japan Objectives: We compare the haemodynamics and perioperative course of initial palliation with bilateral pulmonary artery banding (PAB) and Norwood procedure. Methods: Between April 2004 and December 2007, a consecutive 39 children with hypoplastic left heart syndrome (HLHS) or variant underwent initial palliation (PAB, 14; Norwood, 25). Clinical perioperative data were analysed. Lipo-prostaglandin E1 administration was continued in PAB group with hospitalisation until stage two palliation. Bidirectional Glenn shunt with Norwood procedure was performed as stage two palliation for the PAB group. The median duration of follow-up was 16.1 months (range, 0–57 months). Results: There were no significant differences in the age and operative weight for stage 1 palliation (PAB, 12±10 days, 2.7±0.6 kg vs. Norwood: 12±8 days, 2.8±0.4 kg). There was increased early and intermediate mortality in the patients with Norwood procedure (early mortality; PAB: 7% vs. Norwood: 12%; P<0.0001, intermediate mortality; 8% vs. 27%; P<0.0001). The Kaplan–Meier survival estimate at 1 year was 71% for PAB and 64% for Norwood with no significant difference. Ductal stenosis was found in one patient in the PAB group during follow-up. Twenty six patients have undergone stage two reconstruction; the patients with PAB were younger at operation (109 days vs. 224 days; P=0.01). There were no significant differences in pulmonary artery index (177 mm2/BSA vs. 190 mm2/BSA) or the incidence of ventricular dysfunction after stage two construction (18% vs. 20%). Conclusions: Bilateral pulmonary artery banding with continuous lipo-prostaglandin E1 administration improves early and intermediate mortality. Intimate care with hospitalisation may contribute to the results. 042 COMMON ARTERIAL TRUNK REPAIR IN INFANCY: WITH CONDUIT OR WITHOUT? O. Raisky, W. Ben Ali, F. Roubertie, D. Tamisier, P. Pouard, D. Bonnet, D. Sidi, P.R. VouhéSick Children's Hospital, Paris, France Objectives: To compare the mid-term results of two techniques for reconstruction of the pulmonary outflow tract (POT) during common arterial trunk (CAT) repair, with special attention to reoperation rate and pulmonary artery (PA) growth. Methods: Between 2000 and 2006, 32 infants underwent CAT repair; in 15, POT was reconstructed using an extracardiac-valved conduit (conduit group); in 17, direct RV to PA connection was achieved (using the left atrial appendage and including a monocusp valve) (non-conduit group). The two groups were similar in terms of age, weight, type of CAT, truncal valve dysfunction and coronary abnormalities. Follow-up was complete and included echo-doppler evaluation, catheterisation and CT-scan. Results: Hospital mortality (5 patients, 15.6%) was increased by coronary abnormalities and preoperative ventilation but did not differ between the two groups (13.3% in conduit group vs. 17.6% in non-conduit group). Mean follow-up was 40±25 months. There were six late deaths (3 in each group). One was procedure-related (percutaneous dilatation for obstructive monocusp). Reoperations for POT obstruction were more frequent in the conduit group (5/10, 50%) than in the non-conduit group (2/11, 18%). At last follow-up, RV-PA gradient (83 mmHg vs. 38 mmHg) and RV/LV pressure ratio (1.02 vs. 0.62) were higher in the conduit group. At CT-scan evaluation, growth of the PAs was better in the non-conduit group. Conclusions: Repair of common arterial trunk without conduit for POT reconstruction (1) does not increase mortality and morbidity (2) decreases the need for reoperation and (3) promotes a better growth of the pulmonary arteries. 043 EXTRACORPOREAL LIFE SUPPORT FOLLOWING CARDIAC SURGERY IN CHILDREN: ANALYSIS OF RISK FACTORS AND SURVIVAL IN A SINGLE INSTITUTION B. Alsoufi1, O. Al-Radi2, C. Gruenwald2, L. Lean2, W.G. Williams2, J.G. Coles2, C.A. Caldarone2, G.S. Van Arsdell21King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; 2Hospital for Sick Children and University of Toronto, Toronto, Canada Objectives: Application of extracorporeal membrane oxygenator (ECMO) support following paediatric cardiac surgery varies between different institutions based on manpower availability and philosophy towards ECMO utilisation. We examined a large single institution experience aiming to identify significant outcome predictors. Methods: Patient demographics, cardiac morphology, timing of initiation and duration of ECMO were entered into a multivariable regression analysis to analyse factors associated with death. Results: Between 1990 and 2005, 148 consecutive children (age 1 day–17 years), required post-cardiotomy ECMO. Fifty-four (37%) had single-ventricle physiology. ECMO support was initiated in OR for failure to wean from cardiopulmonary bypass (n=80) or ICU for haemodynamic collapse (n=68). Thirty patients received rescue ECMO during cardiopulmonary resuscitation for cardiac arrest. While under ECMO support, 27 required surgical revision and 13 received heart transplantation. Eighty-seven patients (59%) survived >24 h after ECMO discontinuation and 55 (37%) were discharged alive. Mean ECMO duration was 5.2±4 days, not different for survivors and non-survivors (P=0.3). Survival occurred after up to 16-days of support and all patients requiring repeat ECMO runs (n=13) died (P=0.002). Survival for ECMO instituted in OR vs. ICU was similar (38% vs. 36%, P=0.86), and was not different for children with single vs. bi-ventricle physiology (43% vs. 34%, P=0.38). Fifty percent of rescue ECMO recipients survived. On multi-variable analysis, the only significant predictors of death were renal (P=0.03) and neurological complications (P=0.009). Overall, 5-year survival was 28±4%. Conclusions: ECMO plays a valuable role in children with low cardiac output state following cardiac surgery. Almost 40% including neonates, older children, patients with single-ventricle, or those requiring rescue ECMO can be salvaged. Outcome is not significantly influenced by timing of ECMO initiation and survival can be observed with prolonged support duration in selected cases. Patient survival could improve if renal and neurologic complications are avoided.
044 ON-PUMP CABG SURGERY: MINI VS. CONVENTIONAL EXTRACORPOREAL CIRCULATION. A PROSPECTIVE RANDOMISED STUDY J. Zeitani, S. Nardella, D. Colella, C. Del Giudice, M. Di Santo, M. Moresco, C. Giaccomini, L. Chiariello Tor Vergata University, Rome, Italy Objectives: To compare postoperative coagulation disorders, pulmonary function and adverse neurological outcome in patients under going CABG surgery using two different extracorporeal circulation systems. Methods: In a prospective randomised study, 40 consecutive CABG patients were assigned to mini ECC (group MECC) or to conventional ECC (group CECC). Coagulation disorders were evaluated by thromboelastography, thrombin-antithrombin complex (TaTc) and prothrombin fragment (PF1+2) to detect thrombin formation. Six blood samples were taken during and after operation. During ECC, cerebral oxygen saturation and emboli emission were monitored. Postoperative lung function was also evaluated considering gas exchange, extubation time and lung injury by Lung Injury Score. Results: In group MECC, TaTc and PF1+2 were significantly lower after 30–40 min and 3 h after surgery (P<0.002). Also thromboelastography analysis showed that clot time period R and K were lower (P<0.001 and <0.0001, respectively). During ECC, in group MECC, INVOS values were significantly higher (P<0.0001) and fewer emboli were detected by trans-cranial Echo Doppler (P<0.0001). Also, postoperative gas exchange values: DA-aO2 and PaO2/FiO2 were significantly better, consequently intubation time was shorter (P<0.001), and lung injury score was significantly lower on the second postoperative day (P=0.001). Conclusions: Our study suggests that the mini ECC induces less systemic response and thereby, less postoperative blood loss and better postoperative lung function. Optimal intraoperative cerebral oxygenation and less emboli emission might reduce the risk of postoperative neurological complications. Considering the aging population where the incidence of chronic pulmonary disease, diabetes, and peripheral artery disease are higher, MECC might be advantageous. 045 COMPARISON OF MINIMALLY INVASIVE CLOSED CIRCUIT VS. STANDARD EXTRACORPOREAL CIRCULATION FOR AORTIC VALVE REPLACEMENT: A RANDOMISED STUDY A. Castiglioni, A. Verzini, N. Colangelo, S. Nascimbene, G. Laino, O. AlfieriSan Raffaele Hospital, Milan, Italy Objectives: To evaluate the clinical results of aortic valve replacement performed with a miniaturised closed circuit extracorporeal circulation system (MECC) as compared to standard cardiopulmonary bypass. Methods: One hundred and twenty consecutive patients undergoing isolated aortic valve replacement were randomly assigned to either a miniaturised closed circuit CPB with the Maquet-Cardiopulmonary MECC System (Study group, n=60) or to a standard cardiopulmonary bypass (Control group, n=60). Results: Demographic characteristics and operative data were similar in the two groups. No hospital death occurred in either group and no differences in ICU stay or in hospital stay were observed. Patients in the study group showed lower chest tube drainage (212±62 ml vs. 420±219 ml, P<0.05) and lower need for blood products (6.1% vs. 40.4%, P<0.05) than patients in the control group. Platelet count at ICU arrival was significantly higher in the study group (139±40x109/l vs. 164±75x109/l, P=0.05). Peak postoperative c-Troponin I release was significantly lower in the MECC group (3.8±2.7 vs. 6.6±6.8 ng/dl, P<0.05). Conclusions: In this randomised study, the MECC system has demonstrated best postoperative clinical results in terms of need for transfusion, platelets consumption and myocardial damage, as compared to standard cardiopulmonary bypass. 046 CARDIOPULMONARY BYPASS WITH PHYSIOLOGICAL FLOW AND PRESSURE CURVES: PULSE IS UNNECESSARY! B. Voss, R. Bauernschmitt, M. Krane, G. Brockmann, R. LangeGerman Heart Center Munich, Munich, Germany Objectives: Advocates of pulsatile flow postulate that flow during ECC should be similar to physiological flow. However, the waveforms generated by clinically used ‘pulsatile pumps’ are still different. Therefore, we constructed a new computer-controlled pulsator which can provide nearly physiological perfusion during ECC. We compared its effect (group 1) with pulsatile (group 2) and non-pulsatile (group 3) perfusion induced by conventional roller-pump. Methods: Thirty pigs (10/group) underwent 180 min ECC with an aortic cross-clamp time of 120 min. The quality of perfusion mode was assessed by pulse pressure, peak aortic flow, dp/dtmax, and pulsatility index. We measured renal blood flow by fluorescent microspheres, the inflammatory response by interleukin 6/-1ra, the haemolysis by free haemoglobin, and the escape rate of plasma protein by the disappearance rate of Evans-blue dye. Results: Pulsatile waveforms during ECC compared to the preoperative curves were similar in group 1 and severely damped in group 2. Inflammatory response increased, with no significant differences between the groups. There were no differences in renal blood flow between groups. Free haemoglobin after ECC was higher in pulsatile groups (group 1=43±144 mg/dl, group 2=40±164 mg/dl, group 3=11±4 mg/dl, group 1 vs. 2 (ns); group 1 or 2 vs. 3 (P<0.001)). The escape rate of Evans-blue increased after ECC in group 1, 1.8-fold (P<0.05), in group 2, 1.45-fold (P<0.05) and in group 3, 1.27-fold (ns). Conclusions: Even when using physiologic waveforms, there is no advantage of pulsatile perfusion in relation to organ perfusion or inflammatory response. Moreover, the extent of haemolysis and capillary leak is higher compared to non-pulsatile perfusion. Efforts to optimise pulsatility are not justified. 047 INTRA-AORTIC BALLOON PUMP-INDUCED PULSATILE PERFUSION REDUCES ENDOTHELIAL ACTIVATION AND INFLAMMATORY RESPONSE FOLLOWING CARDIOPULMONARY BYPASS F. Onorati1, G. Santarpino1, G. Tancredi1, G. Palmieri2, C. Scalas1, D. Foti2, E. Gulletta2, A. Renzulli11Cardiac Surgery Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy; 2Biochemistry Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy Objectives: Intra-aortic balloon pump (IABP) induced pulsatile perfusion has been demonstrated to preserve organ function during cardiopulmonary bypass (CPB). We evaluated the role of IABP-pulsatile perfusion on endothelial response. Methods: Forty consecutive isolated CABG patients undergoing preoperative IABP were randomised to receive IABP-pulsatile CPB during aortic cross-clamping (group A, 20 patients) or standard linear CPB (group B, 20 patients) during cross-clamp time. Haemodynamic results were analysed by Swan-Ganz catheter [mean arterial pressure (MAP), cardiac index (CI), indexed systemic vascular resistance (ISVR), indexed pulmonary vascular resistance (IPVR), wedge pressure (PCWP)]. Inflammatory/endothelial response was analysed by pro-inflammatory (IL-2, IL-6, IL-8), anti-inflammatory cytokines (IL-10), and endothelial markers [vascular endothelial growth factor (VEGF) and monocyte chemotactic protein-1 (MCP-1)]. All measurements were recorded preoperatively (T0), before aortic declamping (T1), at the end of surgery (T2), 12 h (T3) and 24 h (T4) postoperatively. Two-way ANOVA was used to evaluate the differences of means. Results: Haemodynamic response was comparable except for higher MAP (P=0.01 at T1) and lower ISVR (P=0.001 at T1, P=0.003 at T2) in group A. No differences were found in perioperative leakage of IL-2, IL-6, and IL-8 between the two groups (within-group, P=0.0001 either in group A and group B; between-groups, P=NS at 2-ANOVA). Group A showed significantly lower VEGF (between-groups, P=0.001 at 2-ANOVA, P=0.001 at T1, T2) and MCP-1 (between-groups, P=0.001 at 2-ANOVA, P=0.001 at T1, T2) with higher IL-10 secretion (between-groups P=0.001 at 2-ANOVA, P=0.01 at T1, T2, T3). Conclusions: IABP-induced pulsatile perfusion allows lower endothelial activation during CPB and higher anti-inflammatory cytokines secretion.
048 PRESYSTOLIC MITRAL ANNULAR SEPTAL-LATERAL SHORTENING IS INDEPENDENT OF LEFT ATRIAL AND LEFT VENTRICULAR CONTRACTION DURING ACUTE VOLUME DEPLETION W. Bothe1, T.C. Nguyen1, T. Timek1, N.B. Ingels2, D.C. Miller1 1Stanford University School of Medicine, Stanford, USA; 2Research Institute of the Palo Alto Medical Foundation, Palo Alto, USA Objectives: Mitral annular septal-lateral (S-L) shortening occurs mainly during late diastole following atrial contraction (‘pre-systolic’) and is absent during atrial fibrillation. It has therefore been speculated that the left atrium (LA) and mitral annulus (MA) are functionally coupled. Whether the MA can shorten independently of LA contraction during normal sinus rhythm is, however, unknown. We investigated MA dynamics in hearts in sinus rhythm and varied LA dynamics using acute volume depletion. Methods: In ten sheep, radio-opaque markers were placed in the LA, MA and LV base (LV-base). Twelve weeks postoperatively, 4-D marker coordinates were obtained by biplane-videofluoroscopy (60 frames/s) before (CTRL) and during acute inferior vena caval occlusion (VCO). S-L dimensions were calculated as distances between corresponding markers in the LA, MA and LV-base five frames before end-diastole (ED-5) and at end-diastole (ED). Dynamic geometry during late diastole is described as changes from ED-5 vs. ED. Results: During late diastole in CTRL, the LA and MA both shortened along the S-L dimension, (32.9±6.6 vs. 31.0±5.5 mm*, 27.3±3.7 vs. 24.6±4.1 mm*, respectively), whereas the LV-base lengthened (56.2±9.3 vs. 57.3±9.3 mm*). VCO abolished S-L dynamics of LA and LV-base during late diastole (27.8±4.3 vs. 27.4±3.9 mm and 49.4±7.7 vs. 49.5±7.5 mm, respectively) while the MA still shortened (19.0±2.9 vs. 18.0±2.8 mm*) *P<0.05. Conclusions: Whereas MA and LA dynamics are coupled during late diastole in normovolemic hearts, pre-systolic mitral annular S-L shortening is independent of LA and LV dynamics during acute volume depletion. A better understanding of mitral annular dynamics and functional coupling may ultimately help to improve mitral valve repair strategies. 049 COMPARISON OF OUTCOMES OF MINIMALLY INVASIVE MITRAL VALVE SURGERY FOR POSTERIOR, ANTERIOR, AND BILEAFLET PROLAPSE: EXPERIENCE IN 1230 PATIENTS J. Seeburger, V. Falk, N. Doll, M.A. Borger, T. Kuntze, M. Czesla, T. Walther, F.W. MohrHeartcenter, Leipzig, Germany Objectives: We sought to compare the outcome of minimally invasive mitral valve (MV) surgery for anterior (AML), posterior (PML), and bileaflet prolapse. Methods: Between May 1999 and January 2008, 1230 patients who presented either with isolated AML (n=156), isolated PML (n=672), or bileaflet prolapse (n=402) underwent minimally invasive MV surgery. Preoperative mitral regurgitation was 3.3±0.8, LVEF was 62±12%, mean age was 58.9±13 years and 836 were male. Results: For PML prolapse MV repair was accomplished in 651 (96.9%) patients, for AML in 142 (91%), and for bileaflet in 363 (90.3%). Seventy-four patients received MV replacement. Repair consisted mainly of resection (AML, n=40/PML, n=445), implantation of neochordae (AML, n=327/PML, n=536), and ring annuloplasty (n=1142). Concomitant procedures were tricuspid valve surgery (n=56), atrial ablation (n=286), and ASD closure (n=89). Duration of CPB was 127±40 min and aortic clamp-time was 78±33 min. Mean hospital stay was 11.6±9.7 days for the overall group. Early and mid-term echocardiographic follow-up revealed excellent valve function in the vast majority of patients regardless of the repair technique with mitral regurgitation 0.3±0.5 mean. Mean follow-up time was 2.7±2.1 years, and follow-up was 100% complete. For the overall group 8-year survival was 84.6% (95% CI: 79.5–88.6) and freedom from reoperation was 94.9% (95% CI: 92.8–96.4). The log rank test revealed no significant differences between the groups regarding long-term survival and freedom from reoperation. Conclusions: Minimally invasive MVR shows excellent results. Long-term outcome for AML prolapse is equal to that for PML and bileaflet prolapse. The use of neochordae was especially valuable for AML prolapse. 050 LONG-TERM SURVIVAL IN ASYMPTOMATIC PATIENTS WITH SEVERE DEGENERATIVE MITRAL REGURGITATION P. Montant, F. Chenot, D. Vancraeynest, A. Pasquet, B. Gerber, P. Noirhomme, G. El Khoury, J.L.J. VanoverscheldeUniversite Catholique de Louvain, Brussels, Belgium Objectives: The management of asymptomatic severe mitral regurgitation (MR) remains controversial. The aim of the study was to assess the long-term survival, the incidence of cardiac complications, the factors that predict outcome, and the effect of mitral surgery on the long-term prognosis of patients with asymptomatic severe MR amenable to valve repair. Methods: One hundred and ninty-nine asymptomatic patients (mean age 63±13 years, 68% males) with severe degenerative MR diagnosed by 2D-echocardiography between 1990 and 2001 were prospectively followed-up for a median of 8.5 years. Overall, cardiovascular and event-free survival was evaluated in two groups of patients: ‘conservative approach’ group (n=67), ‘early surgery’ group (n=132). Outcomes were also analysed in patients with atrial fibrillation (AF), pulmonary hypertension (PHT), or both, as well as in patients free of any MR complications. Results: In the whole population, 10-year overall survival was significantly lower in the ‘conservative approach’ than in the ‘early surgery’ group (50±7 vs. 84±4%, log rank <0.0001). Similar results were obtained in the subgroups with AF and/or PHT (10-year overall survival of 8±8% vs. 76±8% in the ‘conservative approach’ and the ‘early surgery’ groups, respectively (log rank <0.0001), or without any MR complication (10-year overall survival of 62±7 vs. 88±4% in the ‘conservative approach’ and the ‘early surgery’ groups, respectively (log rank <0.0001). Conclusions: Our results show that the outcome of asymptomatic patients with severe degenerative MR is better when opting for an ‘early surgical’ rather than for a more ‘conservative’ treatment strategy. 051 MID-TERM ECHOCARDIOGRAPHIC RESULTS WITH DIFFERENT RINGS FOLLOWING RESTRICTIVE MITRAL ANNULOPLASTY FOR ISCHAEMIC CARDIOMYOPATHY F. Onorati1, G. Santarpino1, D. Marturano1, E. Pasceri2, G. Mascaro2, S. Zinzi2, C. Indolfi2, A. Renzulli11Cardiac Surgery Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy; 2Cardiology Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy Objectives: Although restrictive mitral annuloplasty (RMA) is considered effective for chronic ischaemic mitral regurgitation (CIMR), few data exist on mid-term echocardiographic results with different prosthetic rings. Therefore, comparative echocardiographic analysis has been performed. Methods: Sixty-four consecutive CABG+RMA (downsizing by two-ring sizes; median size 26) for CIMR with at least 6-months follow-up were prospectively followed-up with serial echocardiograms (preoperative, discharge, 6-months, follow-up ending). Hospital mortality, follow-up clinical and echocardiographic results were analysed and compared between three groups (group A: incomplete semi-rigid ring, 17 patients; group B: complete symmetric semi-rigid, 22 patients; group C: complete asymmetric semi-rigid, 25 patients). Results: Hospital mortality was 6.3%. At a mean of 21.6±1.9 S.E. months (range 6–55), survival was 96.5±2.5%; freedom from reintervention 94.2±4.2%, from re-revascularisation 87.5±11.7%, from grade-2 mitral regurgitation 58.2±9.8%, from heart failure (CHF) 71.6±10.5%. CIMR recurrence (grade 2) correlated with worse freedom from CHF (P=0.0001), NYHA (P=0.0001) and LVEF (P=0.024), higher diuretics (P=0.0001), absence of reverse remodeling of left ventricular end-diastolic diameter (LVEDD, P=0.004), systolic diameter (LVEDS, P=0.014), indexed mass (LVMi, P=0.005), coaptation depth (P=0.0001). Group A showed significantly worse freedom from acute decompensation (42.8±19.5% vs. group B: 88.9±10.5% vs. group C: 92.3±7.5%; P=0.049) and from grade 2 mitral regurgitation (17.4±13.8% vs. 82.1±11.7% vs. 94.1±5.7%, respectively; P=0.0001). Group A correlated with higher grade of CIMR at follow-up (P=0.031 vs. group B; P=0.023 vs. group C), higher NYHA (P=0.002 and P=0.001, respectively) and diuretics (P=0.036 and P=0.034), less trans-mitral mean gradient (P=0.0001), reverse remodeling of LVEDD (P=0.009 and P=0.010), coaptation depth (P=0.040 and P=0.002). Conclusions: Recurrence of CIMR avoids ventricular reverse remodeling. Despite a higher trans-mitral gradient, complete rings achieve better results in the treatment of CIMR with RMA. 052 MITRAL VALVE SURGERY FOR FUNCTIONAL MITRAL REGURGITATION: PROGNOSTIC ROLE OF MODERATE-OR-MORE FUNCTIONAL TRICUSPID REGURGITATION A.M. Calafiore1, A. Bivona1, A.L. Lacò1, M. Contini1, M. Gagliardi1, S. Gallina2, M. Di Mauro11Department of Cardiac Surgery, University of Catania, Catania, Italy; 2Department of Cardiology, University of Chieti, Chieti, Italy Objectives: The purpose of this study was to evaluate the impact of untreated moderate-or-more functional tricuspid regurgitation (FTR) on mid-term outcome of patients with functional mitral regurgitation (FMR) undergoing mitral valve surgery (MVS). Methods: From January 1988 to April 2003, 165 patients having FMR underwent MVS with untreated FTR. Patients with residual moderate FMR until hospital discharge, as well as patients having organic mitral or tricuspid valve disease, were excluded. The entire population was divided into two groups, group A: 102 patients (FTR 0/1+), group B: 63 patients (FTR 2+/3+). No statistical difference was found between the two groups concerning preoperative and operative variables. The MV was repaired in 137 and replaced in 28 patients; the impact of untreated moderate-or-more FTR was estimated by Cox analysis. The results were reported as hazard ratio (HR), 95% confidence interval (CI) and P-value. The final model was validated in 500 bootstrap samples. Results: Thirty-day mortality was 6.7% (5.9% group A vs. 7.9% group B, P=0.607). Five-year actuarial survival was 73.5±3.5% (88.2±3.2 group A vs. 46.0±6.3 group B, P<0.001); survival in NYHA class I–II was 65.8±3.8% (78.4±4.1 group A vs. 41.2±6.2 group B, P<0.001). Cox analysis confirmed the impact of untreated moderate-or-more FTR on mid-term survival (HR=3.1, 95% CI=1.8–5.1, P<0.001) and survival in NYHA Class I–II (HR=3.0, 95% CI=1.8–4.9, P<0.001). Conclusions: Patients with untreated moderate-or-more FTR had poorer survival and quality of life than patients with untreated less-than-moderate FTR at mid-term follow-up. 053 QUALITY OF LIFE OF ELDERLY PATIENTS FOLLOWING VALVE SURGERY FOR CHRONIC ORGANIC MITRAL REGURGITATION G. Viganò, A. Blasio, A. Giacomini, P. Denti, F. Maisano, O. AlfieriSan Raffaele Hospital, Milan, Italy Objectives: Mitral surgery for organic regurgitation (MR) in the elderly is debated. Quality of life is a better indicator of success than survival. We assessed this in elderly patients submitted to surgery for MR using the Minnesota Living with Heart Failure (MLHF) questionnaire. Methods: Between August 2003 and August 2006, 242 consecutive patients >70 years underwent surgical treatment of organic MR. Mean age was 77±3.3 years (71–87), EF 50±11%, degenerative disease 77%, associated CABG 25%, Charlson score 4.3±1.4 and 110 patients (45%) in NYHA class III/IV. Hospital survivors were followed-up and quality of life by MLHF score was assessed. Results: Mitral repair and replacement were equally distributed. Hospital mortality was 2.9%, late survival 92±1.8% and freedom from heart failure 78±4% at three years. MLHF was obtained from 208 patients at a distance of 2±1 years. MLHF score was 40±19; 90 (43%) patients with MLHF>40. Univariable preoperative predictors of MLHF were age (P=0.0004), preoperative AF (P=0.0005), diabetes (P=0.04), serum creatinine (P<0.0001), COPD (P=0.02), EuroSCORE (P<0.0001), Charlson score (P=0.002), tricuspid regurgitation degree (P=0.01). Surgical treatment (repair vs. replacement and prosthesis choice) did not predict MLHF at follow-up. MLHF increases with time (P=0.0035) and was related to EF%, EDD and pulmonary pressure at follow-up (all P>0.0001). Residual/recurrent MR was strongly related to MLHF (r2=0.10, P<0.0001). Conclusions: Quality of life following mitral valve surgery is suboptimal in almost half of elderly patients. MLHF score at follow-up is mostly related to preoperative conditions. Type of surgery did not influence MLHF score; however, quality of life is worse in patients with recurrent/residual MR following repair.
054 SURGICAL REPAIR OF PECTUS EXCAVATUM NOT REQUIRING EXOGENOUS IMPLANTS IN 113 PATIENTS H. Lida1, A. Doi1, T. Sunazawa1, Y. Sudo2, H. Ukita2 1Narita Red Cross Hospital, Narita, Japan; 2Kimitsu Central Hospital, Tisarazu, Japan Objectives: To review our experience of non-prosthetic repairs of pectus excavatum. Methods: Since 1993, 113 patients underwent repair of pectus excavatum. Sterno-costal elevation was adopted for 102 patients (12.8±8.8 years). A part of the third or fourth to the seventh costal cartilages and the lower tip of the sternum were resected. All of the stumps were pulled and resutured with the sternum. Osteotomy of the upper sternum was not employed. Eleven adult patients (24.1±7.5 years) with severe asymmetric deformities underwent sternal turnover. The sternum was cut at the level of the second or third intercostal space and the lower part of the sternum was turned over and secured in a position such that it overlapped with the upper sternum. The stumps of cartilages were reattached to the plastron. In these procedures, exogenous plates or bars were not used, and the tension generated by the patient's ribs was sufficient to elevate and fix the sternum. Results: There were no operative deaths. Mechanical ventilation was not required after recovery from anaesthesia. None of the patients experienced threatening complications or required reoperation. The length of the anterior chest wound was 4.4±0.7 cm in patients <7 years, 6.8±2.0 cm in those 7–15 years, and 8.5±2.4 cm in those >15 years. Ninety-eight patients (87%) were graded as excellent, and 15 patients (13%) were graded as good at one month after surgery. Conclusions: The procedures described here can be performed with low morbidity and no mortality, and produced high patient satisfaction. 055 MINIMALLY INVASIVE REPAIR OF PECTUS EXCAVATUM IN ADULT PATIENTS: THE NUSS PROCEDURE. MULTICENTRE FRENCH STUDY OF 76 CASES J.-M. Wihlm1, G. Grosdidier21Thoracic Surgery Department, University Hospital, Strasbourg, France; 2Thoracic Surgery Department, University Hospital, Nancy, France Objectives: Minimally invasive repair of pectus excavatum (MIRPE or NUSS procedure) is well established in paediatric surgery. Often used in Europe, it is still uncommon in France and its application in adult patients is questionable. Our study analyses the efficacy of, and indications for MIRPE in a multicentre coordinated series. Methods: From August 2004 to March 2008, we performed 76 MIRPE procedures in adult patients (68 men, 8 women, mean age 19.9 years) in France using a uniform technique. The deformation was mild to moderate and the indication for surgery was cosmetic only. A ‘Pectus-Bar’ (MedXpert) was inserted in the retrosternal position, under videothoracoscopic control. Twenty patients (26%) required 2 bars. Postoperative pain control was provided by patient-controlled epidural analgesia (PCEA). Clinical and X-ray checks were performed one week, one month, three months and then annually after discharge. Results: Mean operating time was 70 min (range 30–120 min); hospital stay was 5–7 days. Mid-term complications included one chronic inferior bar infection, one early bar displacement and two prolonged pain syndrome. Two long-term chronic infections developed after 24 and 30 months. Cosmetic results were good or excellent in 68/76 cases, fair in two cases (inferior costal flaring) and incomplete in 6 deep asymmetrical cases (four patients were reoperated using an open Ravitch procedure). Conclusions: This multicentre French coordinated series indicates the feasibility of MIRPE using the NUSS procedure in teenagers and young adult patients, with good results if precise inclusion criteria are observed: age under 30 years, still compliant chest wall (positive auto-correction test mandatory), moderately deep pectus, only mild asymmetry, and no inferior costal flaring. 056 A 27-YEAR EXPERIENCE WITH STERNAL CLEFT REPAIR J.R.M. De Campos, A. Fernandez, M.C.P. Velhote, S.J.G. Pereira, J.C.N. Pereira, F.B. JateneThoracic Surgery Department, Heart Institute do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil Objectives: Congenital sternal cleft is a rare condition and is usually reported as an isolated case presentation. Primary repair in the neonatal period is the best management but only a few patients were referred to us at that age. We reported our initial experience in 1998 and presented an option of a surgical technique for selected patients. Our latest results are now presented. Methods: A review of fifteen cases of sternal cleft not associated with ectopia cordis presented from October 1979 to December 2007. Surgical repair consisted of: 3 sliding chondrotomies; 10 building a ‘posterior sternal wall’; 1 combining repair with Ravitch technique for pectus excavatum; and 1 associated with total repair of Cantrell's pentalogy. Results: Follow-up ranged from four months to 27 years. All patients submitted to surgical correction had a good aesthetic and structural result. Neither postoperative mortality nor major complication was observed. Two patients developed subcutaneous fluid collection that prolonged the drainage time. The mean hospital stay was six days. Conclusions: Whether dealing with older children or young adults, the technique of reconstructing a new sternum with a ‘posterior periosteal flap from sternal bars and chondral graft’ is an effective option with good aesthetic and long-term structural results. 057 SURGICAL CORRECTION OF PECTUS EXCAVATUM AND ASSOCIATED HYPOMASTIA J.-M. Wihlm1, C. Bruant-Rodier2, F. Bodin2, A. Wilk21Thoracic Surgery Department, University Hospital, Strasbourg, France; 2Plastic and Reconstructive Surgery Department, University Hospital, Strasbourg, France Objectives: Major pectus excavatum deformity can be associated with hypomastia in female patients. Correction by mammary prostheses only, without prior correction of the pectus excavatum, shows unsatisfactory cosmetic results. This study investigates the clinical and radiological outcome of female patients after a combined surgical correction of a double deformity. Methods: Since 1990, 18 female patients (age 17–47, median 27 years) underwent a two-stage correction: (1) Modified Ravitch procedure with steel or STRATOS(TM) titanium osteosynthesis; (2) One year after, material removal and mammary prostheses implantation. The following criteria were studied: function (questionnaire and PFT), morphology (CT Haller index), cosmesis (evaluation on a scale of 1–10 by both surgeons and patients) and psychology (questionnaire). Results: Although there was little change in spirometry, patients reported better exercise tolerance. The sterno-vertebral distance increased by mean 3.2 cm (range 1.5–5.5) resulting in cardio-pulmonary decompression. The CT (Haller) index decreased from mean 6.4 (range 3.2–12.5) to mean 3.1 (range 2.4–4.0). The cosmetic result was scored grade 8.7/10 by the patients, while only graded 7.6/10 by the surgeons. The patients experienced considerable psychological benefit. Conclusions: Repair of both pectus excavatum and severe hypomastia is feasible using a combined two-stage procedure merging thoracic and plastic surgery. These techniques lead to excellent cosmetic and psychological results with a low complication-rate, in female patients suffering from a double deformity. In opposition to silicon presternal prosthesis implantation only, the modelling sterno-costo-chondroplasty leads to definitive results, may correct functional cardio-pulmonary disorders and allows secondary placement of breast implants. However, this invasive double intervention should only be indicated in patients with major funnel chest deformity.
058 LATE ROUTINE MRI SURVEILLANCE AFTER AORTIC COARCTATION REPAIR DETECTS SIGNIFICANT RATES OF RE-COARCTATION R. Puranik, V. Tsang, S. Puranik, R. Jones, P. Bonhoeffer, M. Hughes, A.M. Taylor Great Ormond Street Hospital for Children, London, UK Objectives: Late follow-up after repair of coarctation of the aorta (CoA) is associated with re-stenosis, hypertension and aneurysm formation. We aimed to examine the impact of routine MRI surveillance of repaired CoA. Methods: We investigated 47 consecutive subjects (17.2±8.1 years post repair) where initial repair was performed <2 years of age and who were referred for routine follow-up MRI scanning. There were 42 cases of end-to-end repair and five cases of subclavian flap repair. Early re-intervention with balloon angioplasty post-surgical repair was required in 12 cases. Results: Amongst the 47 subjects, 17 (36%) had a bicuspid aortic valve (BAV) and 15 (32%) were hypertensive at rest. The mean indexed LV mass and EF was normal for the group (71±16 g/m2 and 68±7%, respectively). Late re-coarctation was considered at least moderate in 36%, mild in 32% and none was identified in 32%. Mild post-stenotic dilatation was found in 23% and no cases of aneurysm formation were identified. Amongst those with BAV, there were higher rates of moderate or severe re-coarctation (58% vs. 33%), larger aortic sinus (31±2 mm vs. 27±1 mm, P<0.05) and ascending aortic (28±1 mm vs. 23±1, P<0.01) dimensions when compared to subjects with morphologically tricuspid aortic valves. Normotensive subjects had similar rates of moderate or severe re-coarctation (37% vs. 33%) and mean indexed LV mass (69±3 vs. 74±4 g/m2, respectively, P=NS) as subjects with hypertension. Conclusions: Long-term routine MRI surveillance of repaired CoA detects significant rates of re-coarctation. BAV disease confers a worse prognosis and may warrant more frequent non-invasive monitoring. 059 ANOMALOUS LEFT CORONARY ARTERY FROM PULMONARY ARTERY: IS MITRAL VALVE FATE AN ISSUE? O. Raisky, W. Ben Ali, F. Roubertie, D. Tamisier, P. Pouard, D. Bonnet, D. Sidi, P.R. VouhéSick Children's Hospital, Paris, France Objectives: To evaluate the outcome of patients operated upon for anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), with special attention to left ventricular (LV) and mitral valve (MV) functional recovery. Methods: Between 1986 and 2006, 62 patients were operated upon for ALCAPA. Six patients (10%) were in critical preoperative clinical condition and 30 (48%) had poor LV function (LV ejection fraction <30%) with moderate to severe mitral regurgitation. Mean age at operation was 16 months (10 days–11 years). All patients underwent direct aortic re-implantation of the anomalous coronary artery; only 3 (5%) had concomitant MV repair. Results: Hospital mortality was 9.7% (6 patients). LV assist device was used in four patients for a mean duration of 6.7 days. One patient was lost to follow-up. Mean follow-up was 116±80 months. There were two late deaths. Five patients (9%) underwent reoperation (obstruction of the re-implanted coronary artery in 2, severe residual mitral regurgitation in 3). LV function recovered to normal in all survivors but one. Moderate to severe mitral regurgitation persisted in seven patients (13%); three had MV repair. Conclusions: Direct aortic re-implantation provides satisfactory results in ALCAPA, even in patients with poor LV function. LV function always recovers. Mitral regurgitation improves along with LV function, but recovery may be incomplete. MV repair is usually not indicated at the time of initial operation. MV repair should be considered only in patients with massive regurgitation or when regurgitation is associated with preserved LV function (without potential recovery). 060 IMPLICATIONS OF INCISING THE VENTRICULAR SEPTUM IN DOUBLE OUTLET RIGHT VENTRICLE REPAIR AND IN THE ROSS-KONNO OPERATION F. Lacour-Gayet, S.P. Goldberg, A.C. McCanta, D.N. Campbell, M.B. Mitchell, D.R. Clarke, E. da Cruz, D.D. IvyThe Children's Hospital, Denver, USA Objectives: Incision into the ventricular septum in complex biventricular repair is controversial, and has been blamed for impairing left ventricular function. This retrospective study evaluates the risk of a ventricular septal incision in patients undergoing double outlet right ventricle (DORV) repair and Ross-Konno procedure. Methods: From January 2003 to September 2007, 11 patients with DORV had a ventricular septum (VS) incision and 12 DORV patients did not. Sixteen patients had a Ross-Konno and 16 had an isolated Ross procedure. The ventricular septal incision was made to match at least the diameter of a normal aortic annulus. In DORV, the VSD was enlarged superiorly and to the left. In the Ross-Konno, the aortic annulus was enlarged towards the septum posteriorly and to the left. Results: The median follow-up for the study is 19 months (1 month–4 years). For DORV, there were no significant differences in discharge mortality (P=0.22), late mortality (P=0.48), or late mortality plus heart transplant (P=0.09). Although patients with DORV and VSD enlargement have a more complex postoperative course, there were no differences in ECMO use, occurrence of permanent AV block, left ventricular ejection fraction (LVEF), or shortening fraction (LVSF). Similarly, for the Ross-Konno there were no significant differences in discharge mortality (P=0.30), late mortality (P=NS), AV block, LVEF, and LVSF compared to the Ross, even though the Ross-Konno patients were significantly younger (P<0.0001). Conclusions: Doing a ventricular septal incision in DORV repair and in the Ross-Konno operation does not increase mortality and does not impair LV function. 061 LONG-TERM FOLLOW-UP OF ARTERIAL SWITCH OPERATION WITH AN EMPHASIS ON FUNCTION AND DIMENSIONS OF LEFT VENTRICLE AND AORTA K.D. Vandekerckhove, N.A. Blom, S. Lalezari, M.G. HazekampLeiden University Medical Centre, Leiden, The Netherlands Objectives: To analyse size and function of aortic root and left ventricle (LV) in patients 20 years after arterial switch procedure (ASO). Methods: Thirty-nine patients who underwent ASO between 1977 and 1989 were examined. Perioperative and follow-up data were analysed. Evaluation included clinical assessment, ECG, echocardiography and quality of life (QOL) questionnaire. Results: Patients had simple TGA (24), TGA with VSD (7), Taussig-Bing anomaly (4) or TGA/VSD with aortic arch obstruction (4). Age at evaluation was 19.9±2.6 years. Seven patients required reinterventions for pulmonary stenosis (4), coarctation (2) and subaortic stenosis, followed by valve replacement 10 years later (1). Arrhythmia occurred in four patients. Patients were in NYHA functional class I (38) or II (1). QOL scores were normal. Diameters of aortic annulus, sinus of Valsalva (SV) and sinotubular junction (STJ) were 26.5±4.1, 36.5±5.6 and 29.2±6.6 mm, respectively. Sixty-five per cent of SV and 38% of STJ diameters indexed to BSA fell outside the 95% normal confidence limit. Aortic insufficiency was absent in 72%, grade I in 13% and grade II in 15%. Patients without insufficiency had smaller diameters of annulus (P=0.005) and SV (P=0.01). LV end-diastolic and end-systolic diameters were 51±7 mm and 34±6 mm, respectively. LV fractional shortening was 34±5%, no regional wall motion abnormalities. Mild LV dysfunction was present in five patients. Conclusions: Clinical outcome is excellent 20 years after ASO and aortic valve function remains preserved in most patients. However, aortic root dilatation is present in two thirds of patients emphasising the need for careful follow-up. 062 SUSTAINED IMPROVEMENT AFTER COMBINED ANTERIOR MITRAL VALVE LEAFLET RETENTION PLASTY AND MYECTOMY IN PREVENTING SYSTOLIC ANTERIOR MOTION IN HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY IN CHILDREN E.M.B. Delmo Walter, H. Siniawski, R. HetzerDeutsches Herzzentrum Berlin, Berlin, Germany Objectives: Anatomic alterations of the mitral valve such as increased mitral leaflet area, length and laxity, and anterior displacement of the papillary muscles in hypertrophic obstructive cardiomyopathy predispose patients to residual systolic anterior motion and persistence of outflow obstruction and mitral regurgitation after myectomy. We investigate the long-term results of anterior mitral leaflet retention plasty and myectomy in children with hypertrophic obstructive cardiomyopathy. Methods: Anterior mitral leaflet retention plasty and subaortic septal myectomy were performed in 12 children (mean age 10.8±1.7 years) with hypertrophic obstructive cardiomyopathy. Mean preoperative left ventricular outflow tract pressure gradient was 49±11 mmHg. After careful assessment of the mobility of the anterior leaflet and subvalvular apparatus, segments of the anterior leaflet nearest the trigones were sutured to the corresponding posterior annulus with polypropylene reinforced with untreated autologous pericardial pledgets. Intraoperative valve orifice measurement based on age-related valve diameter ensures that no mitral stenosis is produced. Mean intraoperative pre- and post-septal myectomy pressure gradient was 60±25 mmHg and 5±6 mmHg, respectively. Results: Post-myectomy mitral insufficiency was reduced to a regurgitant fraction of 0–10%. Mean follow-up was 13.18±1.22 years. Mean left ventricular outflow tract pressure gradient was 6.2±3.95 mmHg. No mortality, no repeat myectomy or repeat mitral valve repair or replacement, no mitral stenosis and no SAM occurred. Conclusions: Long-term follow-up shows sustained absence of systolic anterior motion, attenuation of mitral regurgitation, sustained improvement in functional status, and reduction of outflow tract obstruction. 063 DEVELOPMENT OF NOVEL DRUG-ELUTING BIODEGRADABLE NANO-FIBRE FOR PREVENTION OF POSTOPERATIVE PULMONARY VENOUS OBSTRUCTION M. Mutsuga1, Y. Narita2, A. Yamawaki2, H. Oshima1, A. Usui1, Y. Ueda11Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Department of Clinical Cell Therapy and Tissue Engineering, Nagoya University School of Medicine, Nagoya, Japan Objectives: Pulmonary venous obstruction (PVO) following correction of total anomalous pulmonary venous connection (TAPVC) due to intimal-hyperplasia is infrequently encountered and requires re-operation, with associated high mortality. Therefore, an innovative surgical strategy is needed to prevent recurrent PVO. We developed a novel, sustained-release drug delivery system, a Tacrolimus-eluting biodegradable nano-fibre (TEBN), which can prevent post-anastomotic arterial stenosis. It consists of nano-scaled fibre, which is composed of biodegradable polymer and Tacrolimus. This study demonstrated the effects of TEBN for prevention of venous anastomotic stricture in a rat model which could be applied to PVO operation. Methods: TEBN was fabricated by an electrospinning technique. Tacrolimus was incorporated into poly (L-lactide-co-glycolide) with L:G molar ratio of 50:50. The venous stricture model was made by rat inferior vena cava anastomosis. Four rats with TEBN (1.0 wt% of Tacrolimus) placed at the anastomotic site, and four rats without TEBN at the anastomotic site, were evaluated histologically at one week after the operation. Results: The intimal size and the ratio of intimal width were significantly reduced in the TEBN group compared with control group (size: 90.0 vs. 9.5 µm P<0.05, ratio: 0.74 vs. 0.34 P<0.05, control vs. TEBN, respectively). It was also observed that thrombus formation rate was significantly lower in the TEBN-treated group (control 75%, TEBN 25%, P<0.05). Histological findings showed endothelisation along the inner surface of the vein. Conclusions: TEBN reduced intimal hyperplasia and preserved endothelialisation in a venous stricture model. These results suggest that this strategy might be useful for prevention of recurrent PVO after TAPVC correction.
064 DOES PRETRANSPLANT LVAD THERAPY IMPROVE RESULTS AFTER HEART TRANSPLANTATION IN PATIENTS WITH ELEVATED PVR? H. Liden, Å. Haraldsson, U. Kjellman, L. Wiklund Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Göteborg, Sweden Objectives: Pulmonary hypertension (PHT), defined as a pulmonary vascular resistance (PVR) of 2.5 Wood units or greater, and/or a trans-pulmonary gradient (TPG) of 12 mmHg or greater, is a risk factor for mortality in heart transplantation due to risk of perioperative right heart failure. It has recently been shown that PHT in heart transplant candidates can be lowered using a left ventricular assist device (LVAD) and it has been proposed to be the treatment of choice for transplant candidates with PHT. In this study we determined the effect and outcome of the pretransplant heart recipients treated with LVAD due to PHT. Methods: All heart transplant recipients during the period 1988–2007 with pretransplant PHT were divided into two groups. Group 1 were patients without LVAD treatment (n=58) and group 2 patients treated with LVAD prior to transplant (n=11). Results: Group 1 had a mean pretransplant PVR of 3.2±0.7. Group 2 had a mean pretransplant PVR of 3.2±0.9 that was reduced to 2.1±0.6 after LVAD treatment. We observed two patients with acute right heart failure after transplantation requiring mechanical support in group 1, in contrast to none in group 2. The incidence of other perioperative complications was comparable between the two groups. Four-year survival in group 1 and 2 was 70% and 63%, respectively. Conclusions: Pretransplant LVAD treatment reduces the pulmonary pressure in heart transplant recipients with PHT but there was no statistically significant difference in survival in patients treated with or without LVAD. 065 CAVO-PULMONARY ANASTOMOSIS IMPROVES LEFT VENTRICULAR ASSIST DEVICE SUPPORT IN ACUTE BIVENTRICULAR FAILURE G.M. Succi, L.F. Moreira, A.A. Leirner, R.S. Silva, N.A.G. StolfHeart Institute of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil Objectives: Right ventricular failure during left ventricular assist device (LVAD) support can result in severe haemodynamic compromise with high mortality. This study investigated the acute effects of cavo-pulmonary anastomosis on right ventricular unloading and LVAD performance in a model of severe biventricular failure. Methods: LVAD support was performed by means of centrifugal pump implantation in 14 anaesthetised dogs (20–25 kg) with severe biventricular failure obtained by ventricular fibrillation induction. Animals were randomised to be submitted to classical cavo-pulmonary anastomosis (Glenn shunt) or to control group and were maintained under LVAD support for 2 h. Left and right atrial, right ventricular and systemic pressures were monitored, while total pulmonary flow was simultaneously recorded by transonic flow meters located on the superior vena cava and pulmonary trunk. Blood gas and venous lactate determinations were also obtained. Results: Ventricular fibrillation maintenance resulted in acute LVAD performance impairment after 90 min in the control group, while animals with Glenn circuit maintained normal LVAD pump flow (1.2±0.4 vs. 0.5±0.1 l/min, P<0.001) and better peripheral perfusion (blood lactate of 29±10 vs. 46±9 pg/ml, P<0.001). Left and right atrial pressures did not change significantly, while right ventricular pressure was lower in animals with the Glenn circuit (13±3 vs. 22±8 mmHg, P=0.005). Right ventricular unloading with Glenn shunt also resulted in superior total pulmonary flow (1.2±0.3 vs. 0.4±0.1 l/min, P<0.001). Conclusions: The concomitant use of cavo-pulmonary anastomosis during LVAD support in a model of severe biventricular failure resulted in limited right ventricular overloading and better LVAD performance. 066 LEVITRONIX CENTRIFUGAL PUMP AS SHORT-TERM CARDIAC ASSIST DEVICE IN DIFFERENT CLINICAL SCENARIOS: A SINGLE-CENTRE EXPERIENCE G. Bruschi, A. Cannata, M. Lanfranconi, F. Milazzo, E. Catena, M. Frigerio, C.F. RussoA De Gasperis Cardiology and Cardiac Surgery Department, Niguarda Ca Granda Hospital, Milan, Italy Objectives: We review our clinical experience with the Levitronix CentriMag, magnetically levitated bearing-less centrifugal pump, for refractory heart failure. Methods: Since February 2005, we supported 15 patients using the Levitronix CentriMag pump. Ten patients (73.3%) were male. Mean age was 46 years (range 2–77). Indications for support were: bridge to heart transplantation in six patients with acute decompensation of chronic heart failure (five patients), one with thrombosis of implantable assist device (group A); and bridge to recovery in nine patients, affected by myocarditis in three cases, post-cardiotomy in three, cardiac graft failure in two, and cardiogenic shock in acute myocardial infarction in one (group B). The Levitronix was implanted as veno-arterial extracorporeal membrane oxygenation in 12 cases (80%), with peripheral cannulation in six cases. Results: Mean support time was 12 days (range 3–30) for all patients. In group A, four patients were transplanted and discharged home; one was bridged to implantable long-term ventricular assist device, but died because of multi-organ failure; the remaining patient died on ECMO because of multi-organ failure. In group B, four patients (44.4%) were weaned from Levitronix; only two patients with myocarditis were discharged home. We did not observe any device failure or device-related complications. Conclusions: Our experience suggests that Levitronix is effective, reliable and versatile in the treatment of refractory cardiac failure. Because of straightforward implantation and management, it is a valuable option to await recovery and evaluate bridge to other therapeutic options in severely ill patients. The results are encouraging in patients affected by myocarditis or awaiting heart transplantation. 067 BIVENTRICULAR PULSATILE VENTRICULAR ASSIST DEVICE SUPPORT: THE GOLD STANDARD FOR PATIENTS IN CARDIOGENIC SHOCK? D. Loisance, M.E.W. Kirsch, E. Vermes, K. Nakashima, M.-L. HillionHopital Henri Mondor, Créteil, France Objectives: We observe an increasing use of extracorporeal membrane oxygenation (ECMO) for bridging patients to transplantation (BTT). The purpose of this study was to evaluate outcomes in cardiogenic shock (CS) patients managed by primary use of paracorporeal ventricular assist devices (pVADs) for BTT. Methods: A retrospective analysis was performed of demographics, clinical characteristics and survival outcomes of patients treated at time of admission for cardiogenic shock with Thoratec pVADs. Results: pVADs were used in 73 patients with acute CS secondary to AMI (32%), idiopathic (45%) or ischaemic (12%) cardiomyopathy, myocarditis and other (11%). Prior to implant, 22% had cardiac arrest, 37% were on ventilator, 32% on IABP. Cardiac index was 1.6±0.5 l/min/m2 and bilirubin 36±53 (µmol/l). Following pVAD implantation, 20 patients (27%) died in ICU (mean duration of support 17±16.8 days) and 7 (10%) died after leaving the ICU (mean duration of support 146.7±162.7 days). Forty-six patients (63%) were weaned or successfully transplanted (mean duration of support 84.5±87.9 days). Actuarial estimates for 1-year survival after transplantation were 76%±4%. Conclusions: Our experience supports the proven concept of immediate VAD support for cardiogenic shock patients. In contrast to ECMO, where there is risk of organ wasting with premature transplantation, VADs provide in a single procedure safe support for extended durations, if required, and effective rehabilitation of the patient. pVADs provide immediate ventricular unloading and good organ perfusion thereby improving long-term outcomes for bridging to transplantation or recovery. 068 EUROPEAN RESULTS WITH A CONTINUOUS FLOW VENTRICULAR ASSIST DEVICE FOR ADVANCED HEART FAILURE PATIENTS J.R. Lahpor1, A. Khaghani2, R. Hetzer3, A.J. Pavie4, I. Friedrich5, K. Sander6, M.H. Yacoub2, M. Strüber71University Medical Center Utrecht, Utrecht, The Netherlands; 2Harefield Hospital, Harefield, UK; 3German Heart Institute, Berlin, Germany; 4Heart Institute Pitie Salpetriere, Paris, France; 5Martin Luther University, Halle, Germany; 6University Hospital Copenhagen, Copenhagen, Denmark; 7University Medical Center Hannover, Hannover, Germany Objectives: The HeartMate II LVAD (HM II) is a small, quiet, continuous flow left ventricular assist device (LVAD) for circulatory support in advanced heart failure patients, with over 1200 implants worldwide. We report on the European experience with this device. Methods: The HM II was implanted in 398 patients at 46 European institutions. Patients (19% female, 49% ischaemic aetiology) were on maximum medical therapy including inotrope support. Body surface area ranged from 1.30 to 2.50 m2 and age from 14 to 75 years (median 53 years; n=111 over age 60). The intentions of support were bridge to transplant (74%), destination therapy (23%) and bridge to recovery (3%). Adverse events were documented in the first 54 patients for obtaining CE Mark (received November 2005); outcomes were determined in all patients. Results: Mean support duration was 192 days (62 patients >1 year, six patients >2 years; total support time: 208 patient-years). Of 264 patients implanted >6 months ago, 75.4% survived, with 12% undergoing transplantation, 2% recovery with device removal, and 61% ongoing device support at six months. Survival was 78.6% in patients with ischaemic and 72.5% with non-ischaemic aetiologies. Adverse events included bleeding (0.61), percutaneous lead infection (0.22), local non-device infections (0.30) and stroke (0.09) (events/patient-year). Conclusions: These results support the use of the HM II continuous flow LVAD for long-term support as a bridge to transplant and possibly for destination therapy. Future emphasis should focus on minimising adverse events such as infections, bleeding, and neurologic events. 069 EUROPEAN CLINICAL EXPERIENCE OF DURAHEART MAG-LEV CENTRIFUGAL LEFT VENTRICULAR ASSIST SYSTEM M. Morshuis1, A. El-Banayosy1, R. Koerfer1, R. Hetzer2, G. Wieselthaler3, A.J. Pavie4, C. Nojiri51Heart and Diabetes Center, North Rhine-Westphalia, Bad Oeynhausen, Germany; 2German Heart Center Berlin, Berlin, Germany; 3University of Vienna, Vienna, Austria; 4Pitie Salpetriere Hospital, Paris, France, 5Terumo Heart, Inc., Ann Arbor, Michigan, USA Objectives: The DuraHeart (DH) is the world's first approved Mag-Lev centrifugal LVAS designed for long-term circulatory support. We report the clinical outcomes of 55 patients in Europe.
Methods: Fifty-five patients with advanced heart failure (6 females), who were eligible for transplant were implanted with DH between January 2004 and March 2008. Median age was 58 (29–74) with 27% Results: Mean support duration was 213±226 (16–1000) days with a cumulative duration of 32 years. Twenty-seven patients remain ongoing, 18 transplanted and one explanted. Ten died during support with a median time to death of 33 days. Kaplan–Meier survival was 86% at six months and 77% at one year. Of the 13 patients supported for >1 year (2 supported for >2 years) two were transplanted, one died and 10 are ongoing with a mean duration of 585±207 days. Major adverse event rate per patient-year for the 33 trial patients were driveline/pocket infection: 0.4, stroke (mainly haemorrhagic stroke): 0.28, TIA: 0.28, bleeding requiring surgery: 0.22, RHF requiring RVAD: 0.06. After implementing a less intensive anticoagulation regimen, there was no stroke in the last 22 patients. There was no incidence of pump mechanical failure, pump thrombosis, or haemolysis. Conclusions: DH was able to provide safe and reliable circulatory support with an improved survival in advanced heart failure patients who are eligible for transplant. The high device reliability and low adverse event rate of DH is promising for its broader indication of destination therapy. 070 SENSITISATION AND POST-TRANSPLANT COURSE AFTER THE IMPLANTATION OF A VENTRICULAR ASSIST DEVICE R. Malickaite, K. Rucinskas, A. Staneviciene, S. Miniauskas, V. Maneikiene, G. Zuoziene, V. SirvydisVilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania Objectives: The role of anti-HLA sensitisation after ventricular assist device (VAD) use in cardiac transplantation is still controversial. This study was designed to compare sensitisation and post-transplant rejection rate in groups of patients bridged to transplantation with VAD and non-bridged patients. Methods: Sensitisation using standard complement-dependent cytotoxicity was tested in 16 patients awaiting cardiac transplantation before VAD placement and one month post-implantation. Post-transplant course was compared with 19 non-bridged recipients of the same age (41±16 vs. 39±15 years) and immunosuppression. Results: 62.5% (10/16) VAD recipients with long-term support had not produced anti-HLA antibodies despite receiving blood products; in six patients (37.5%) sensitisation was revealed. Sixteen non-bridged patients were not immunised, three had low level sensitisation. Eleven VAD patients were transplanted after 72–1097 days of support (transplantation rate 68.8%); six of them were eligible for long-term post-transplant follow-up. All sensitised patients independent of VAD placement underwent graft rejection. Three patients underwent moderate grade (2R) cellular rejection episodes one month after the Tx without anti-HLA antibody production. Overall post-transplantation course was similar: 83.3% (5/6) VAD recipients vs. 42.1% (8/19) non-bridged (P=0.16) experienced early biopsy-proven rejection episodes, but only one (16.7%) sensitised VAD recipient was treated because of grade 2R rejection, compared to 26.3% (6/19) in the non-bridged group, P=0.63. None of the patients had failed because of early graft rejection. Conclusions: Patients with VAD could be at risk for development of anti-HLA antibodies and increased risk of acute rejection after transplantation. Correlation exists between post VAD implant sensitisation and cellular rejection episodes. 071 LONG-TERM THERAPY WITH AN AXIAL FLOW PUMP AND NOVEL POWER DELIVERY S. Westaby1, M.E. Siegenthaler2, F. Beyersdorf6, J. Pepper3, A. Khayat7, R. Hetzer4, O.H. Frazier51Oxford Heart Centre, Oxford, UK; 2University of Pittsburgh Medical Center, Pittsburgh, USA; 3Royal Brompton Hospital, London, UK; 4German Heart Institute, Berlin, Germany; 5Texas Heart Institute, Houston, USA; 6University of Freiburg, Freiburg, Germany; 7University of Caen, Caen, France Objectives: The study tested the hypothesis that a miniaturised axial flow pump with infection-resistant power delivery could improve longevity and quality of life (QOL) in advanced heart failure patients deemed unsuitable for transplantation. Methods: The study included all non-United States Jarvik 2000 patients (33), where a skull pedestal based power line was used for long-term support. Age ranged from 27 to 73 years. All were NYHA IV with predominantly idiopathic dilated (19) or ischaemic (12) cardiomyopathy. Kaplan–Meier (KM) survival analysis was done. Results: The internal components are imperceptible for the patient. The power/control system is user-friendly, allowing excellent QOL including international air travel. There has been no pump malfunction. Longest event-free survival is 7.25 years. Support exceeded three years in five cases. Cumulative experience exceeds 40 years. Two patients were transplanted and one explanted at 90 days. Twelve are ongoing on the pump (mean 663 days). Eighteen died during support (mean survival 322 days), five from non-device-related diseases. Temporary local infection occurred in two pedestals and one needed repair for pin fracture. There has been one pump infection. Reduced early mortality in the 12 patients treated since CE mark approval is an encouraging trend with 80% KM survival at 1.8 years. Conclusions: Both LVAD and post-auricular power delivery are reliable and promising for long-term therapy. Early mortality parallels other studies and reflects the severity of illness. There is a trend to improvement in recent cases. Pump infection is extremely low and prolonged event-free survival is clearly possible.
F1 SURGICAL REPAIR OF TRUNCUS ARTERIOSUS COMMUNIS TYPE 1–2 IN A 2.6 KG NEWBORN M. Nosal, P. Valentik, I.C. Omeje, M. Sagat, R. Poruban Children's Heart Centre, Slovak Republic, Bratislava, Slovak Republic Objectives: We present an HDV video of surgical repair of a truncus arteriosus communis type A1–2 in a 2.6 kg newborn. The view is from the patient's head. Methods: A hypotrophic and premature baby girl was admitted to the Children's Heart Centre with signs of congestive heart failure and failure to thrive. On echo a truncus arteriosus communis type A1, A2 (Van Praagh), associated with a patent foramen ovale with near confluent pulmonary arteries, was diagnosed. The patient was referred for complete repair. During the operation the cono-ventricular defect was closed through a right ventriculotomy with a dacron patch by continuous suture. The common trunk was incised longitudinally and, after identifying the coronary ostia, the origin of the pulmonary arteries was excised with a button of surrounding tissue. The ascending aorta was sutured longitudinally. Both pulmonary arteries were mobilised. The button with the origin of the pulmonary arteries was directly anastomosed to the right ventriculotomy. The right ventricular outflow tract was reconstructed with a pericardial patch, connecting the right ventricle to the pulmonary arteries. The foramen ovale was left patent. Results: The postoperative course was uneventful; the patient was extubated after 32 h. The patient was discharged home on the 10th postoperative day with a patent left ventricular outflow tract and a 30 mmHg gradient over the right ventricular outflow tract. Conclusions: Good functional result can be achieved by complete surgical repair of truncus arteriosus even in small neonates. F2 INTRAPULMONARY ARTERY SEPTATION FOR A COMPLICATED FONTAN CANDIDATE WITH NON-CONFLUENT PULMONARY ARTERIES AND SEVERELY HYPOPLASTIC LEFT PULMONARY ARTERY K. SakamotoShizuoka Children Hospital, Shizuoka, Japan Objectives: It is difficult to manage patients with single ventricular physiology and unbalanced pulmonary arteries. We have previously reported intrapulmonary artery septation (IPAS: ICVTS 2007) to improve results. IPAS consists of a bidirectional Glenn shunt (BGS), a systemic-pulmonary artery shunt (SPS) and a septation patch. Both BGS and SPS are joined to a well-grown pulmonary artery, and a septation patch is placed between BGS and SPS. We show this new approach by video. Methods: Original diagnosis was single ventricle with pulmonary atresia, PDA, common atrioventricular valve and pulmonary coarctation. BGS with plasty of the left pulmonary artery (LPA) was performed at seven months. Re-plasty for obstructed LPA was performed at 18 month, but in vain. She was presented to us at 28 month, with BGS, non-confluent pulmonary artery made by long LPA obstruction, severely hypoplastic (absent?) LPA and massive collateral arteries. We selected IPAS with LPA reconstruction, to secure a reliable blood source to LPA and to prevent wasteful volume load caused by left massive collateral arteries. The LPA from the hilum of left lung to BGS was made mainly by autologous pericardium. An SPS 4 mm in diameter to the right pulmonary artery was made and a septation patch was placed between BGS and SPS. Results: Acceptable growth of LPA was seen 13 months later. She came to Fontan circulation with a CVP of 11 mmHg, which was easily made by removal of the septation patch and setting of extracardiac conduit for IVC re-routing, at 48 months. Conclusions: IPAS can pilot more complicated cases to the Fontan circulation. F3 VATS BI-LOBECTOMY OF RIGHT UPPER AND MIDDLE LOBE IN LUNG CANCER: TIPS FOR APPROACHING HILAR STRUCTURES M.K. Bae, J.G. Lee, S.H. Cho, I.K. ParkYonsei University College of Medicine, Seoul, Korea (South) Objectives: This film is prepared to present technical tips for managing hilar structures in VATS bi-lobectomy of right upper lobe (RUL) and right middle lobe (RML) in lung cancer. Methods: A 57 year-old male had adenocarcinoma in the RUL. The 3x3x5 cm sized mass invaded RML across the minor fissure. PET-CT revealed no lymph node or distant metastasis. Operation was performed in left lateral decubitus position. Three 5 mm ports were inserted – 1st at 7th ICS along the anterior axillary line, 2nd at 8th ICS along the posterior axillary line and 3rd at auscultation triangle. A 6 cm working window was made at the anterior portion of 4th ICS. The length of severed intercostal muscle was 8 cm. A 30° 5 mm video-thoracoscope was used. An ultrasonic scalpel was used for tissue dissection. Large vessels and bronchi were divided by endo-staplers. A 12 mm trocar was introduced through the 2nd port (postero-inferior port) hole intermittently to apply staplers to sever vessels and bronchus. Small vessels were divided after clipping. Systematic lymph node dissection was performed. A 28 Fr chest tube was inserted through 2nd port hole. Results: Operation time was 210 min. One hundred and five minutes were taken for pulmonary resection and 50 min for node dissection. No aberrant event occurred during operation. The patient was extubated in the operating room. Chest tube was removed on the 4th day and the patient discharged on the 6th day. Pathologic stage was T2N0. Conclusions: VATS bi-lobectomy of RUL and RML is technically feasible for lung cancer crossing the fissure. Hilar structures can be severed easily and safely by advancing staplers through the postero-inferior port. F4 A NEW METHOD FOR IDENTIFICATION OF THE INTERSEGMENTAL PLANE WITH PHYSIOLOGICAL FUNCTION OF OXYGEN ABSORPTION IN SEGMENTAL LUNG RESECTION H. Iwata, K. Shirahashi, S. Matsumoto, T. Marui, Y. Mizuno, H. TakemuraDepartment of General and Cardiothoracic Surgery, Graduate School of Medicine, Gifu University, Gifu, Japan Objectives: It is important to identify the intersegmental plane in lung segmentectomy. We present a new and easy method for identification of the intersegmental plane using physiological function. Methods: Our surgical procedure: we cut the segmental pulmonary artery and vein, then inflate the segment with pure oxygen for 5 min. Immediately after oxygen inflation, we deflate the lung and staple the segmental bronchus. After a couple of minutes, we can easily detect the intersegmental plane. The logic of this method is speculated to be the following. Lung tissue with intact pulmonary artery and vein contributes to gas exchange. The alveoli have high oxygen concentration within during oxygen inflation. The alveoli retaining the pulmonary circulation can perform gas exchange and absorb oxygen. Conversely, the alveoli without pulmonary circulation cannot contribute to gas exchange and oxygen remains inside them. The parts of the lung with alveoli, with or without oxygen inside them, define the intersegmental plane. We use a stapler along this plane or ultrasonic sizzlers. We also use fibrin sealant and absorbable felt for the prevention of air leakage. Results: We used this method in 23 cases of 27 segmentectomy during four years. Of the 23 patients studied, 18 were male and five were female. We performed VATS segmentectomy in 13 cases. In all cases except one with severe emphysema we could detect the intersegmental plane easily. Delayed air leakage was observed in one case (9 days). Average drainage duration was 3.4±1.0 days. Conclusions: Our procedure was useful for detecting the intersegmental plane for segmentectomy. F5 STERNAL RECONSTRUCTION WITH PLATES AND CABLES IN COMPLICATED STERNAL DEHISCENCE B. Voss, P. Libera, R. Bauernschmitt, M. Krane, G. Brockmann, R. LangeGerman Heart Center Munich, Munich, Germany Objectives: Sternal dehiscence after median sternotomy can be a challenging problem in the case of multiple fractures or infection. To treat such patients, the principles of rigid plate and screw osteosynthesis gained from orthopaedic surgery have been recommended by several authors for sternal refixation. We present our closure technique for dehiscent infected sternum with a new sternal closure system (Synthes, Switzerland) consisting of cannulated screws, steel cables and reconstruction plates. Methods: The system can be applied once the wound is germ-free. First, the remaining sternum is delivered after pectoralis muscle mobilisation. Two steel plates (10–24 holes) are fitted individually to the complete sternal halves in a longitudinal fashion. Every plate is fixed with 5–9 cannulated screws (8–26 mm length, 4.5 mm diameter), which are placed in solid osseous areas. Bicortical screw insertion is necessary for maximum effectiveness. A depth gauge is used to select the appropriate screw length. After approximating the sternal halves with two or three sternal cerclages, the sternum is finally closed with 5–9 transverse cables (1 mm diameter), which are guided through the cannulated screws and plates. The cables are tensioned, crimped and cut in one step by a special device. Results: The video demonstrates in detail the successful application of the new system in a 75-year-old obese patient (103 kg/174 cm, body mass index: 34) with sternal non-union after infection. Conclusions: This new sternal fixation system is easy to handle and broadens the spectrum of techniques for closure of complicated sternal dehiscence. F6 CHEST WALL AND DIAPHRAGM RESECTION AND RECONSTRUCTION FOR CHONDROSARCOMA A. Oliaro, C. Mossetti, P.L. Filosso, R. Cristofori, P. Lyberis, R. Giobbe, E. Pizzato, E. RuffiniDepartment of Thoracic Surgery, University of Torino, Torino, Italy Objectives: The curative treatment of primary chest wall tumours sometimes also includes diaphragmatic resection. Methods: We present an extensive chest wall and diaphragmatic resection for chest wall chondrosarcoma. Gore-Tex dual mesh was used for diaphragmatic reconstruction and the patch was fixed to the thoracic wall to restore the costo-diaphragmatic angle. A latissimus dorsi flap was interposed between the Gore-Tex mesh and the skin. Results: This approach can be performed safely and can be curative. Conclusions: The benefits to the patient in terms of comfort and survival justify an aggressive approach. F7 COMBINED CHEST WALL AND SPINE RESECTION AND RECONSTRUCTION B. Naidu, F. CollinsHeart of England NHS Trust, Birmingham, UK Objectives: Demonstration of our surgical approach to posterior chest wall resection and reconstruction with combined vertebral excision and stabilisation as a single-stage procedure for cancer. Methods: Our favoured chest wall prosthesis is a moulded plate made from orthopaedic cement (methyl methacrylate), sandwiched between two layers of prolene mesh. The medial fixation of this is complicated by the resection and fixation of the vertebrae. Results: We present two such cases: one with oncological clearance, the other with palliation of symptoms, and both with excellent cosmetic/functional results. Conclusions: Posterior chest wall resection and reconstruction with combined vertebral excision and stabilisation as a single-stage procedure for cancer requires good coordination and cooperation between specialist surgeons.
072 PERCUTANEOUS AORTIC VALVE REPLACEMENT: GROSS ANATOMY AND HISTOLOGICAL FINDINGS AFTER TRANSAPICAL AND ENDOLUMINAL RESECTION OF THE AORTIC VALVE IN HUMAN PREPARATIONS R. Quaden1, M. Appel1, T. Attmann1, R. Klaws2, M. Schünke2, C. Haß1, J. Cremer1, G. Lutter1 1Department of Cardiovascular Surgery, University Hospital of Schleswig Holstein Campus Kiel, Kiel, Germany; 2Institute of Anatomy, Christian Albrechts University of Kiel, Kiel, Germany Objectives: Transluminal resection of the aortic valve has already been described by our group. The aim of this study was to analyse the gross anatomy and histology of the surrounding tissue after resection. Methods: Aortic valve resection was performed in human post mortem preparations (transluminal [TL] n=9, transapical [TA] n=4). After deployment of the aortic valve isolation chamber the leaflets were resected with a thullium/YAG laser scalpel (cw, 20 Watts). After resection, the hearts were examined for lesions caused by the resection procedure and the resection tools. As well as gross anatomy, an additional histological analysis was performed (HE staining). Results: Lesions of the aortic annulus were seen in 3/9 (TL) and 2/4 (TA), lesions of the aorta (ascending-arch-descending) in 6-9-0/9 (TL) and 0-0-0/4 (TA), lesions of the mitral valve in 0/9 (TL) and 0/4 (TL), lesions of the papillary muscle in 0/9 (TL) and 2/4 (TA), lesions of the endomyocardium in 0/9 (TL) and 4/4 (TA), and the coronary ostia remained unaffected. The depth of histological lesions ranged from 250 to 500 µm up to one complete perforation into the aortic annulus. Conclusions: This study demonstrates less invasiveness of the transapical aortic valve resection method (antegrade approach) compared to the endovascular method (retrograde approach). In particular, the aortic arch remains unaffected with the transapical procedure. Transferred to actual transapical and percutaneous aortic valve replacement procedures, the transapical approach seems to be safer. 073 IN VITRO RESULTS OF A NEW MINIMALLY INVASIVE AORTIC VALVE RESECTING TOOL D. Wendt1, W. Müller1, F. Hauck2, M. Thielmann1, H. Wendt1, B. Kipfmüller3, B. Vogel2, H. Jakob11Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Essen, Germany; 2 Endosmart GmbH, Stutensee, Germany; 3Department of Physical Engineering, Fachhochschule Gelsenkirchen, Gelsenkirchen, Germany Objectives: Aortic valve replacement (AVR) using extracorporeal circulation is currently the treatment of choice for symptomatic aortic stenosis. However, patients with multiple high-risk comorbid conditions may benefit from reduced ECC-time by a simplified and faster resection in conjunction with quick, sutureless valve implantation. Methods: A prototype of a new minimally-invasive aortic valve resection tool equipped with rotating and foldable Nitinol cutting edges was designed. Commercially available aortic valve bioprostheses were artificially calcified (group 1: moderately calcified, n=8; group 2: severely calcified, n=8). In vitro resection was performed using a 21 mm cutting blade. Resection time (RT), maximum turning moment (MTM) and number of required rotations (NR) were measured. Furthermore, particle generation during the process of cutting was obtained and quantified. Results: Aortic valve cutting could be obtained without any complications in all cases. The cutting process resulted in an RT of 15.5±3 s in group 1, compared to 34.9±15 s in group 2 (P=0.005), MTM was 3±0.6 Nm in group 1 compared to 3.5±0.6 Nm in group 2 (P=0.068) and NR were 30.6±2.3 in group 1 compared to 48.1±15.5 in group 2 (P=0.007). Particle generation was 1.77±0.17 g (group 1) compared to 1.41±0.44 g (group 2, P=0.047). Conclusions: These first in vitro results confirm the feasibility of accelerated aortic valve resection within 30 s. This new concept holds promise for very fast AVR in combination with insertion of a sutureless aortic valve prosthesis, targeting for ischaemic times <10 min in the open heart situation. Finally, resection and percutaneous AVR within one minute in the beating heart situation is envisioned. 074 THE LEFT AXILLARY ARTERY: A NEW APPROACH FOR TRANSCATHETER AORTIC VALVE IMPLANTATION F. De Robertis, A. Asgar, S. Davies, M. Dalby, A. Kelleher, M. Petrou, M. Mullen, N. MoatRoyal Brompton and Harefield NHS Trust, London, UK Objectives: Transcatheter aortic valve replacement implantation (TAVI) is an alternative treatment for aortic stenosis in selected cases but requires suitable vascular access. We describe a novel endovascular access for patients with contraindications to the use of the more common trans-femoral approach. Methods: Between 01 April 2007 and 31 March 2008, 108 patients were referred for consideration of TAVI and individually assessed by a multi-disciplinary team to determine their clinical and anatomical suitability. Anatomical suitability included angiographic assessment of the ileo-femoral arterial system. Twenty-seven TAVIs were performed. Five patients (3 female, median age 84 years) had access problems precluding the use of the trans-femoral route (too small, two patients; diseased, two patients; AAA, one patient) and underwent TAVI through the left axillary artery approach. Results: Thirty-day mortality was 0%. There was one localised dissection at the entry point in the axillary artery. The surgeons perceived the positioning of the prosthesis as being easier through this approach because of the shorter distance between the endovascular entry point and the target area. In all cases there was only trace paravalvular regurgitation on TOE at the end of the procedure. The median hospital length of stay was 10 days. Conclusions: TAVI can be performed through a left axillary artery approach with satisfactory early results. Prosthesis positioning may be facilitated by the short distance between the entry point and the target area and the greater control over the device that this affords. 075 TRANSAPICAL AORTIC VALVE IMPLANTATION IN PATIENTS REQUIRING REDO SURGERY T. Walther, V. Falk, M.A. Borger, J. Kempfert, J. Ender, A. Linke, G. Schuler, F.W. MohrHerzzentrum Leipzig, Leipzig, Germany Objectives: To evaluate the results of minimally invasive transapical aortic valve implantation (TA-AVI) in patients requiring redo surgery. Methods: Since February 2006, 25 high-risk patients with symptomatic aortic valve stenosis and previous cardiac surgical interventions received TA-AVI using a pericardial xenograft fixed within a stainless steel, balloon-expandable stent (Edwards Sapien) as a redo procedure. All valves were implanted in a hybrid operative theatre. Patient age was 79±6 years, 58.3% were female, logistic EuroSCORE and STS score risk for mortality were 40±15% and 19±10%, respectively. Previous cardiac surgery was CABG in 17, valve surgery in five and other procedures in three patients. Results: TA-AVI was performed successfully in 24 (96%) of the patients; one patient required early conversion to sternotomy, another patient required temporary ECMO support. Twenty-one patients (84%) were treated completely off-pump, one early patient was treated on-pump by intention and three patients required secondary cardiopulmonary bypass support. Echocardiography revealed good valve function in all but the converted patient with trivial to mild (1+) paravalvular incompetence in 44%. By 30 days, three patients had died and during subsequent follow-up two patients died, all demonstrating good valve function at most recent echo. Thirty-day survival was 87.5±7% and 1-year survival 76.5±9%, respectively. There were no new onset neurological events. Conclusions: TA-AVI can be performed with excellent results and minimal stroke risk in high-risk patients requiring redo cardiac surgery. TA-AVI represents an important alternative to conventional surgery in elderly high-risk patients requiring reoperative procedures. 076 RESULTS OF PERCUTANEOUS AND TRANSAPICAL TRANSCATHETER AORTIC VALVE IMPLANTATION PERFORMED BY A SURGICAL TEAM S. Bleiziffer, H. Ruge, D. Mazzitelli, C. Schreiber, A. Hutter, J.-C. Laborde, R. Bauernschmitt, R. LangeClinic for Cardiovascular Surgery at the German Heart Center Munich, Munich, Germany Objectives: Transcatheter aortic valve implantation has been performed by several groups, most of them either specialising in the transapical (surgeons) or the percutaneous femoral transarterial approach (cardiologists). We established both, transapical and percutaneous transcatheter valve implantation by a surgical team in a hybrid OR. Methods: Since June 2007, 78 patients (n=36 female, mean age 81±8 years) underwent transcatheter aortic valve implantation (n=71 transfemoral, n=2 via subclavian artery, n=5 transapical) with the CoreValve (n=74) or the Edwards Sapien (n=4) prosthesis. Results: Thirty-day mortality was 9.0% in this patient cohort with a logistic EuroSCORE mortality risk of 25.4±15.2%. Sixty-six patients (84.6%) are alive at a mean follow-up of 53±42 days. Pacemaker implantation due to postoperative AV block was performed in 20 patients (26%), and six patients (8%) sustained neurological events. Patients improved in NYHA class (from 3.1±0.3 to 1.7±0.6, P<0.001) and in self-assessed health state (from 55±19% to 66±18%, P=0.013) at one month follow-up. Echocardiographic assessment revealed excellent haemodynamic function of the prostheses with a mean aortic gradient (MAG) of 11.4±4.5 mmHg, an effective orifice area (EOA) of 1.7±0.5 cm2 at discharge, an MAG of 12.0±3.6 mmHg and an EOA of 1.8±0.3 cm2 at six months FU. Conclusions: Transcatheter aortic valve implantation has become a routine alternative technique for the treatment of aortic stenosis with reasonable short- and mid-term results at our institution. With the opportunity to perform conventional surgical valve replacement and transapical and percutaneous transcatheter procedures by one team, the technique of lowest risk can be chosen for the individual patient. 077 PERCUTANEOUS AORTIC VALVE IMPLANTATION ACUTELY AFFECTS LV DIASTOLIC FUNCTION F. Guarracino, V. Di Bello, S. Petronio, E. Talini, L. Doroni, R. Baldassarri, F. LapollaAzienda Ospedaliera Universitaria Pisana, Cardiothoracic Department, Pisa, Italy Objectives: Percutaneous aortic valve replacement (pAVR) has been proposed as an option for high-risk patients with severe symptomatic AVS. We aimed to compare the acute effect of pAVR and surgical AVR on LV diastolic function. Methods: Twelve patients with symptomatic severe AVS (area <1 cm2), age >75 years with a logistic EuroSCORE >20%, scheduled to undergo pAVR were included. LV diastole was evaluated basally (T1) and after valve implantation (T2) with TEE by LV flow propagation velocity (vp), mitral annulus velocities, and BNP measurement. An age-matched control group of 12 patients undergoing surgical AVR for AVS was evaluated intraoperatively in the same way before (T1) and after AVR (T2). Student's t-test (P<0.05) was performed. Results: The pAVR group showed an acute change in diastolic phase consisting of significant change of vp (31 cm/s at T1 vs. 43 cm/s at T2, P<0.05), and of mitral annular E (3.9 cm/s at T1 vs. 5.3 cm/s at T2, P<0.05). BNP did not change significantly (358 pg/ml at T1 vs. 381 pg/ml at T2, P>NS). The control group showed a significant reduction of vp (34 cm/s at T1 vs. 27 cm/s at T2, P<0.05) and E (4.1 cm/s at T1 vs. 2.9 cm/s at T2, P<0.05), and increase of BNP (364 pg/ml at T1 vs. 678 pg/ml at T2, P<0.05). Conclusions: pAVR acutely improves LV diastolic phase when compared to surgical AVR, as demonstrated by vp and E increase and BNP profile. Preservation of diastolic function during percutaneous AVR may play a major role in lowering morbidity and mortality. 078 A NEW SELF-EXPANDING AORTIC STENT-VALVE WITH ANNULAR FIXATION: IN VITRO HAEMODYNAMIC ASSESSMENT M. Vergnat, S. Bommeli, M. Kalejs, E. Ferrari, L. Von SegesserCentre Hospitalier Universitaire Vaudois, Lausanne, Switzerland Objectives: Balloon-expandable stent-valves require flow reduction during implantation (rapid pacing). The present study was designed to compare a self-expanding stent-valve with annular fixation versus a balloon-expandable stent-valve. Methods: Implantation of a new self-expanding stent-valve with annular fixation (Symetis®, Lausanne, Switzerland) was assessed vs. balloon-expandable stent-valve, in a modified Dynatek Dalta® pulse duplicator (sealed port access to the ventricle for trans-apical route simulation), interfaced with a computer for digital readout, carrying a 25-mm porcine aortic valve. The cardio-vascular simulator was programmed to mimic an elderly woman with aortic stenosis: 120/85 mmHg aortic pressure, 60 strokes/min (66.5 ml), 35% systole (2.8 l/min). Results: A total of 450 cardiac cycles were analysed. Stepwise expansion of the self-expanding stent-valve with annular fixation (balloon-expandable stent-valve) resulted in systolic ventricular increase from 120 to 121.6+0.6 mmHg (126–830+76 mmHg)*, and left ventricular outflow obstruction with mean transvalvular gradient of 11+1.5 mmHg (366+202 mmHg)*, systolic aortic pressure dropped distal to the valve from 121 to 64.5+2.3 mmHg (123–55+30 mmHg) N.S., and output collapsed to 1.9+0.06 l/min (0.71+0.37 l/min (before complete obstruction)*). No valve migration occurred in either group. *=P<0.05. Conclusions: Implantation of this new self-expanding stent-valve with annular fixation has little impact on haemodynamics and has the potential for working heart implantation in vivo. Flow reduction (rapid pacing) is not necessary. 079 TRANSAPICAL ENDOVASCULAR IMPLANTATION OF NEOCHORDAE USING A SUCTION AND SUTURE DEVICE F. Maisano1, G. Viganò1, A. Giacomini1, P. Denti1, A. Guidotti1, S. Rowe2, O. Alfieri11IRCCS San Raffaele University Hospital, Milan, Italy; 2Edwards Lifesciences, Irvine, USA Objectives: Neochordae implantation is a standard method for treatment of mitral valve prolapse. We describe a transcatheter technology enabling transapical endovascular chordal implantation. Methods: Six adult pigs were anaesthetised. Two 10F sheaths were introduced in the femoral vessels for monitoring and intracardiac echo. After midline sternotomy, the pericardium was opened, the apex was punctured inside two 3-0 polypropylene purse-strings. A 0.035-in J tipped guidewire was introduced in the left ventricle and an ultrastiff 14F sheath (guide catheter) inserted through the apex. A suction-and-suture device was introduced in the left ventricle. The mitral valve was crossed under echo guidance. Using suction, either the anterior (2 cases) or posterior (4 cases) leaflet was captured and a loop of 4-0 polypropylene was thrown at the edge of the leaflet. The loop, with a pledget, was exteriorised through the introducer. The introducer was removed and the purse-string tied. Under echo guidance, the neochordae suture was pulled and tied over a pledget to evoke leaflet tethering. The animals were sacrificed and gross anatomy reviewed. Results: Leaflet capture was feasible in the intended location in all cases. Following suture tethering, variable degrees of MR were obtained. At gross anatomy, the neochordae were positioned at 1–4 mm from the leaflet free edge, and were firmly attached to the leaflets. Conclusions: Transcatheter endovascular neochordae implantation is feasible. A prolapse model is needed to further demonstrate feasibility under pathologic conditions. The apical approach allows easy and direct route to transcatheter beating heart minimally invasive mitral repair.
080 PET-CT DOES NOT ASSESS THE EXTENT OF THORACIC DISEASE IN LUNG CANCER PATIENTS F.M. Carnochan Royal Infirmary of Edinburgh, Edinburgh, UK Objectives: The aim of the study was to assess the accuracy of PET-CT in staging thoracic disease in lung cancer patients. Methods: Two hundred patients referred for surgery between June 2006 and January 2008 underwent PET-CT followed by staging mediastinoscopy and resection if appropriate. Results of scans and histopathology were analysed. Results: PET-CT correctly staged 103/200 patients (52%), under-staged 60/200 (30%), and over-staged 36/200 (18%). 15/186 (8%) mediastinoscopies revealed metastatic disease not detected on PET-CT, and 20 (11%) had negative histology despite a positive scan. Sixty-two (10.8%) out of the 572 node stations taken at resection were involved by cancer though negative on PET-CT. Five (2.5%) resections were benign despite avid FDG uptake, and 6 ((3%) were malignant despite a negative scan. PET-CT had false positive rates of 6.5%, 5.5%, 4.5% and 3.5%, respectively for hilar, station 2, 7 and 5 nodes. False negative rate was 12.5%, 10.5% and 8%, respectively for hilar, intrapulmonary and station 4 nodes. Twelve (6%) patients were under-staged regarding chest wall and mediastinal invasion, and 10 (5%) patients had metastatic nodules in the lung (T4). Thirty-five (17.5%) stage 1 on PET-CT were higher stage at histology. Conclusions: PET-CT fails to fully assess the extent of thoracic disease in lung cancer patients, and supports the need to continue with other means of staging. 081 CLINICAL UPSTAGING OF NON-SMALL CELL LUNG CANCER THAT EXTENDS ACROSS THE FISSURE: IMPLICATIONS FOR THE CURRENT TNM CLASSIFICATION SYSTEM V. Joshi, J. McShane, A. Soorae, R. Page, M. Carr, N. Mediratta, M. Shackcloth, M. PoullisThe Cardiothoracic Centre, Liverpool, UK Objectives: To determine the effect of extension of a non-small cell lung cancer (NSCLC) across a fissure into an adjacent lobe. The current TNM staging system does not take extension across the fissure into account. We examined the experience at our centre. Methods: Data were collected prospectively on all patients undergoing lung resection for NSCLC between 2001 and 2007 (1020 patients underwent a lobectomy). One hundred and eighty patients were identified as having lesions extending between two lobes and underwent bi-lobectomy or lobectomy and wedge resection. (Histopathological Stage 1(a)=11.7%, 1(b)=51.1%, 2(a)=1.7%, 2(b)=21.1%, 3(a)=10.0%, 3(b)=2.8% and 4=1.7%). These were matched for stage with 420 patients who underwent lobectomy for a tumour confined to a single lobe. Sub-group analyses were conducted in a similar manner. Survival data were obtained using the National Strategic Tracing Service and a Kaplan–Meier analysis performed. Results: For stage 1 NSCLC, our data appears to show a difference in survival developing after 1-year with a significant reduction in 5-year survival of between 10 and 15%. Log Rank Test=0.037. For stage 2(a) and above, there was no difference in survival in our sample. Conclusions: Our data suggests there is a significant difference in survival for patients with resected stage 1 lung cancer crossing the fissure vs. those confined to a single lobe. These findings differ from those recently published in a smaller study in the EJCTS. If our sample is representative of the wider population, should the TNM staging system be revised to accommodate these lesions? 082 RECOMMENDED CHANGES FOR T AND N DESCRIPTORS PROPOSED BY THE IASLC LUNG CANCER STAGING PROJECT: A VALIDATION STUDY FROM A SINGLE CENTRE E. Ruffini, P.L. Filosso, M. Molinatti, C. Mossetti, R.C. Cristofori, P. Lyberis, E. Pizzato, A. OliaroDepartment of Thoracic Surgery, University of Torino, Torino, Italy Objectives: The International Association for the Study of Lung Cancer (IASLC) recently recommended changes for T and N descriptors for the next TNM edition. We reclassified our operated patients to evaluate the effectiveness of the IASLC suggestions.
Methods: Proposals for the T descriptor were: T1a ( Results: Staging by T descriptor was: T1a (366 patients), T1b (298), T2a (605), T2b (178), T3 (203), non-multifocal T4 (52), non-multifocal M1 (22); MF1 (49), MF2 (32). Staging by N descriptor was: N0 (1146 patients), N1a (289), N1b-N2a (200), N2b (67). Five-year survival showed significant differences among the T (T1a 68%, T1b 55%, T2a 45%, T2b 38%, T3 30%, T4 12%, M1 12%, P=0.000001) and the N groups (N0 55%, N1a 35%, N1b-N2a 20%, N2b 8%, P=0.000001). Five-year survival by the current N descriptor were: N0 55%, N1 32%, N2 15%. Five-year survival in MF1 and MF2 were 28% and 8%, respectively. Conclusions: The IASLC recommended changes for the T and N descriptors in TNM staging of NSCLC are appropriate and provide excellent survival stratification. 083 MULTIFOCAL (MF) T4 NON-SMALL CELL LUNG CANCER: A SUBSET WITH FAVOURABLE PROGNOSIS P.L. Filosso, E. Ruffini, E. Pizzato, P. Lyberis, R. Giobbe, A. OliaroDepartment of Thoracic Surgery, University of Torino, Torino, Italy Objectives: The current international staging system for lung cancer designates intralobar satellites as multifocal (MF) T4 disease. The aim of this study was to compare MF with other T4 lung cancers, to identify factors influencing prognosis. Methods: A retrospective review of our thoracic cancer surgical database between 1993 and 2007 was conducted, and 119 T4 patients were included; of these, 46 patients (38.6%) had an MF cancer. Patients with multifocal bronchoalveolar carcinomas or carcinoids were excluded. Results: There were 35 males (76%) and 11 females; mean age was 61.7 years (range 42–76 years). Radical resection with lymphadenectomy was accomplished in all. There were 27 (58.7%) adenocarcinoma, 14 (30.4%) squamous cell carcinoma and five other neoplasms. Twenty-six (56.5%) patients had more than one satellite lesion. Provisional staging, disregarding the presence of the satellite lesion, includes: 20 stage I, 9 stage II and 17 stage III patients. Median survival was 48 months (15 months in non-MF T4 cancers). Three- and 5-year survival rates were 33% and 29%, respectively. Even if not statistically significant, a trend towards a better survival in MF T4 lung cancers as compared to other T4 cancers was observed. Cox regression identified visceral pleura invasion and the presence of metastatic lymph nodes as negative prognostic variables. Conclusions: The presence of MF (T4) in primary lung cancers is a rare occurrence. Patients with N0 MF disease show a more favourable prognosis than might be predicted by their stage T4 designation. They should be down-staged in the next lung cancer staging. 084 MANAGEMENT OF GROUND-GLASS OPACITY ACCOMPANIED BY OTHERWISE OPERABLE NON-SMALL CELL LUNG CANCER H.K. Kim, Y.S. Choi, K. Kim, Y.M. Shim, K. Lee, J. KimSamsung Medical Center, Seoul, Korea (South) Objectives: There are no definite guidelines as to whether ground-glass opacity (GGO) should be resected simultaneously with primary tumour or merely followed-up when detected in patients with otherwise operable non-small cell lung cancer (NSCLC). We evaluated the relationship between radiologic features and pathologic diagnoses of accompanying GGO in NSCLC. Methods: Between 1994 and 2006, 23 patients had 40 pure GGOs in the non-primary lobe accompanied by NSCLC. Twelve GGOs were resected simultaneously with NSCLC (n=8) or resected later because their size increased during follow-up (n=4). The remaining 28 GGOs were considered benign since their size did not change (n=20) or decreased (n=8) during follow-up. All the GGOs were divided into benign (n=32) and malignant groups (n=8), and their clinical and radiologic features were compared between the two groups. Results: No significant differences were observed between the two groups in clinicopathologic characteristics. The mean size of the GGOs in the benign group (6.13±3.9 mm) was significantly smaller than that in the malignant group (11.25±3.1 mm) (P=0.001). We attempted to predict whether an accompanying GGO is benign or malignant based on its size in CT images, and when 10 mm was determined as the cut-off value, sensitivity, specificity and accuracy was 75%, 90.6%, and 90.9%, respectively. Conclusions: When an accompanying pure GGO is detected in the non-primary lobe in patients with otherwise operable NSCLC, we believe that the GGO should be resected to rule out the possibility of malignancy if the size is >10 mm. However, if the size is <10 mm, we suggest that close follow-up of the lesion with CT-scans would be sufficient. 085 THE VALUE OF MEDIASTINAL STAGING WITH ENDOBRONCHIAL ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION (EBUS-TBNA) IN PATIENTS WITH LUNG CANCER H. ØmarkDepartment of CardioThoracic Surgery, Odense University Hospital, Odense, Denmark Objectives: To access the value of EBUS-TBNA in mediastinal staging of patients with lung cancer. Methods: Patients with biopsy-verified lung cancer were included in the study. The first patient was included in January, 2006 when EBUS-TBNA was introduced in the department. The study period ended in December, 2007. All EBUS-TBNA examinations were done with a linear scanner (BF-UC160F, Olympus) and aspiration was done with a 22G needle (NA-201SX-4022, Olympus). None of the four examiners had any previous experience with EBUS-TBNA or ultrasound when the study began. Two or more aspirations were taken from all lesions visualised. Aspirated material was expelled onto glass slides and smeared for cytological examination or expelled into saline and prepared for histological examination. All examinations were done under general anaesthesia. Results: A total of 159 patients were included in the study. N2-3 disease was found in 67 patients (42.1%). EBUS-TBNA missed the mediastinal spread in 11 patients-i.e. EBUS-TBNA had a sensitivity of 0.84 and a negative predictive value of 0.89. No complications occurred from EBUS-TBNA. Conclusions: The results of this study suggest that staging of the mediastinum with EBUS/TBNA is safe and accurate and at least as good as mediastinoscopy. The method is furthermore less invasive and allows for easier restaging. 086 USE OF THE NEW PROPOSED IASLC CLASSIFICATION OF NON-SMALL CELL LUNG CANCER IN PREDICTING LONG-TERM PROGNOSIS O. Rena1, F. Massera1, M. Robustellini2, E. Papalia1, D. Turello1, E. Lisi1, R. Delfanti2, C. Casadio11Thoracic Surgery Unit, University of Novara, Novara, Italy; 2Thoracic Surgery Unit, E Morelli Regional Hospital, Sondalo, Italy Objectives: To evaluate the use of the proposed seventh classification of the International Association for the Study of Lung Cancer (IASLC) in staging patients submitted to radical surgical resection of non-small cell lung cancer and to compare its value in predicting long-term prognosis with the existing classification of the 6th American Joint Committee on Cancer (AJCC) 2002. Methods: Nine hundred and twenty-one patients received anatomical resection and hilar-mediastinal dissection for primary non-small cell lung cancer during the period 1990–2005. Histopathological staging following the AJCC classification were: 209, T1, 561, T2, 148, T3, 4, T4; 570, N0, 149, N1, 199, N2, 4, N3; 163 stage Ia, 340, stage Ib, 25, stage Ia, 159, stage IIb, 222, stage IIIa, 8, stage IIb. Stages reclassified using the new proposed IASLC classification were: 111, T1a, 123, T1b, 386, T2a, 131, T2b, 107, T3 and 4, T4; 227, stage Ia, 227, stage Ib, 173, stage IIa, 71, stage IIb, 215, stage IIIa, 4, stage IIIb. Results: Follow-up was obtained for 836 patients. Mean follow-up was 46.5±48.9 months. N-status (unchanged between the two classifications) was confirmed a significant prognostic factor. Significant differences in 10-year disease-related survival were demonstrated between stages IIb and IIIa only (37% vs. 15%; P=0.0001) of the AJCC classification and between stages Ib and IIa (61.6% vs. 40.2%; P=0.00002) and stages IIb and IIIa (37% vs. 13.8%; P=0.0043) of the proposed IASLC classification. Conclusions: The new proposed classification of IASLC demonstrated a better utility in predicting long-term prognosis of patients operated for non-small cell lung cancer than the accepted existing one of 6th AJCC. 087 PROSPECTIVE PREOPERATIVE MEDIASTINAL LYMPH NODE STAGING BY INTEGRATED 18FDG PET-CT IN PATIENTS WITH NON-SMALL CELL LUNG CANCER C. Perigaud1, B. Bridji2, J.C. Roussel1, C. Sagan3, A. Mugniot1, D. Duveau1, O. Baron1, P. Despins11Department of Thoracic and Cardiovascular Surgery, Hospital GR Laennec, Nantes, France; 2Department of Nuclear Medicine, Rene Gauducheau Cancer Center, Nantes-Saint Herblain, France; 3Department of Pathological Anatomy, Hospital GR Laennec, Nantes, France Objectives: Mediastinal lymph node staging determines the choice of non-small cell lung cancer treatment. The aim of this study was to evaluate prospectively, preoperatively, the integrated 18FDG PET-CT accuracy for mediastinal lymph node staging. Methods: Preoperatively, integrated 18FDG PET-CT analysed mediastinal lymph nodes from patients with non-small cell lung cancer. Nodal stations were identified according to the mapping system of the American Thoracic Society. Nodal uptake with a standardised uptake value (SUVmax) >3 was considered positive. Mediastinal lymph nodes were harvested during pulmonary resection. The integrated 18FDG PET-CT results were compared with mediastinal lymph node pathological results. Results: Fifty-one patients were enrolled in this study. Mean period between integrated 18FDG PET/CT and surgery was 31±15.8 days (range 2–78). Mean mediastinal lymph nodes and station number per patient harvested during surgery were 11.8±5.6 (range 2–27) and 3.8±1 (range 2–6), respectively. The incidence of disease in mediastinal lymph nodes station was 8.7%. Integrated 18FDG PET-CT sensibility and specificity were 47±0.25% and 95±0.03%, respectively. Positive and negative predictive values were 44% and 96%. False positive (9 cases), was mainly due to inflammatory lymph nodes. False negative (8 cases) was due to infracentrimetric malignant lymph node invasion. Conclusions: Integrated 18FDG PET-CT sensibility in mediastinal lymph node staging for patients selected for surgery is low. In the case of positive mediastinal lymph nodes, invasive mediastinal staging must be done. On the other hand, specificity is very high: patients with negative integrated 18FDG PET-CT can be operated on without invasive mediastinal staging. 088 COMPARISON OF LONG-TERM RESULTS BASED ON INITIAL TREATMENT IN PATHOLOGIC N2 NON-SMALL CELL LUNG CANCER S.W. Chang, H.K. Kim, Y.S. Choi, K. Kim, Y.M. Shim, J. KimSamsung Medical Center, Seoul, Korea (South) Objectives: Preoperative chemotherapy has been adopted as a standard treatment for non-small cell lung cancer (NSCLC) patients with mediastinal lymph node metastases (N2 disease). However, the incompleteness of staging modalities could inevitably result in false-negative cases, in which pathologic N2 diseases are detected after curative-intent surgical resection. We performed a retrospective analysis in NSCLC patients with pathologic N2 diseases to compare the long-term results between patients initially undergoing surgical resection and those initially undergoing induction therapies. Methods: Between January 1995 and June 2007, a total of 464 patients with pathologic N2 disease were enrolled in this study. Of those, 226 patients underwent curative-intent pulmonary resection, which revealed pathologic N2 diseases (Initial Resection group). Conversely, 238 patients received induction treatment based on positive results of mediastinoscopic biopsy (Initial Induction group). Their medical records were retrospectively reviewed to compare the long-term results between the two groups. Results: No significant differences were observed in overall 5-year survival rates between the two groups (Initial Resection, 43.43% vs. Initial Induction, 35.39%, P=0.26). Subgroup analysis showed that there were no significant differences in clinical T1 stage (P=0.2), clinical T2 stage (P=0.6), single station N2 disease (P=0.7), and multi-station N2 disease (P=0.14) between the two groups. Conclusions: This study showed that the long-term results in patients who initially underwent curative-intent pulmonary resection despite pathologic N2 disease were no worse than those in patients who initially underwent induction treatment for pathologic N2 disease.
089 FUNCTIONAL SINGLE VENTRICLE WITH EXTRACARDIAC TAPVC T. Nakata, Y. Fujimoto, K. Hirose, M. Osaki, Y. Tosaka, Y. Ide, M. Tachi, K. Sakamoto Shizuoka Children's Hospital, Shizuoka, Japan Objectives: To evaluate the surgical repair of functional single ventricle (fSV) and extracardiac total anomalous pulmonary venous connection (TAPVC). Methods: Retrospective chart review from 1998 to 2007 at a tertiary paediatric cardiac centre. Results: Twenty-six patients (males, 17; median age, 34 days; range, 0–744 days) with fSV and TAPVC underwent surgical intervention. Eleven patients had supracardiac TAPVC; 5, infracardiac; 10, mixed. Twenty-four patients had heterotaxy; 16, pulmonary atresia; 17, obstructed TAPVC. TAPVC was repaired at initial palliation in 16 patients, at Glenn in 9 and at Fontan in 1. The overall survival after TAPVC repair was 57.2% and 52.0% at one and five years, respectively. Of the 14 survivors (supracardiac, 9; infracardiac, 4; mixed, 1), 11 underwent Fontan completion; 2, Glenn; and 1 is awaiting Glenn. There were no cases with anastomotic stenosis, but recurrent pulmonary venous ostial stenosis (PVS) was observed in nine patients. Freedom from recurrent PVS was 55.8% at both one and five years. Reoperation for recurrent PVS was performed in six patients and two patients underwent Fontan completion, but three patients with bilateral and multiple PVS declined. Univariate and multivariate analyses revealed mixed type TAPVC as a risk factor for mortality and atrioventricular valve regurgitation, which required surgical intervention at the palliative stage, as a risk factor for recurrent PVS. Conclusions: Mid-term results of the surgical repair of fSV with supracardiac or infracardiac TAPVC are acceptable. The surgical treatment of patients with mixed type TAPVC and with severe atrioventricular valve regurgitation can be improved. 090 PULMONARY ARTERIOVENOUS MALFORMATIONS AFTER FONTAN OPERATION IN LEFT ISOMERISM WITH ABSENT INFERIOR VENA CAVA Y. Nakamura, T. Yagihara, K. Kagisaki, I. Hagino, J. KobayashiNational Cardiovascular Center, Suita, Osaka, Japan Objectives: We evaluated the occurrence of pulmonary arteriovenous malformations (PAVM) after Fontan operation in left isomerism (LI) with absent inferior vena cava (IVC) concerning the type of superior vena cava (SVC). Methods: We retrospectively reviewed 19 patients with LI and absent IVC who underwent Fontan operation at our institution. They were divided into two groups: bilateral SVCs (group A, n=9), and single SVC (group B, n=10). Median age at Fontan operation was 6.2 years (1.0–24.1). Diagnosis of PAVM was made by pulmonary angiography and bubble contrast echocardiography. Results: Median follow-up was 5.3 years (0.2–17.3) with one hospital death. Six patients suffered from PAVM, three in each group. Pulmonary coarctation was recognised in four patients: One of group A with PAVM, two of group B with PAVM, and one without PAVM. In group A, the ratio of the distance between the hepatic venous channel and the dominant SVC (where azygos vein and hemi-azygos vein connected) to the distance of bilateral SVCs was higher in patients with PAVM than without PAVM (0.78±0.68 vs. 0.49±0.26, P=0.071). In group B, there was no significant correlation between PAVM and the offset from the hepatic venous channel to the SVC (P=0.905). Conclusions: It may be important for the hepatic vein to be connected close to the dominant SVC in patients with bilateral SVCs, and pulmonary coarctation should be avoided to prevent PAVM. 091 INTRACARDIAC FONTAN OPERATION FOR HETEROTAXY SYNDROME WITH COMPLEX SYSTEMIC AND PULMONARY VENOUS ANOMALY Y. Naito, M. Aoki, K. Agematsu, K. Sughimoto, T. FujiwaraChiba Children's Hospital, Chiba, Japan Objectives: In patients with heterotaxy syndrome with complex systemic and pulmonary venous anomalies, the extracardiac Fontan procedure has gained wide acceptance; however, it lacks growth potential and requires long-term anticoagulation. We present the long-term outcome of intracardiac Fontan procedure in which the disadvantages of extracardiac Fontan procedure were eliminated. Methods: Twenty-four patients (mean age, 4.1 years; weight 13.0 kg) with heterotaxy syndrome underwent intracardiac-Fontan operations between March 1995 and March 2008. In each patient, anomalous systemic venous return with isolated hepatic vein was redirected to pulmonary artery using intra-atrial baffle without obstructing the pulmonary venous pathway. Redirection of systemic venous return was accomplished by anterior (n=5), lateral (n=15), and posterior tunnel method (n=4), respectively, according to the anatomical relationship of systemic and pulmonary venous pathway. Results: There was one (4.1%) hospital and one (4.1%) late death overall, respectively. Five (20.8%) patients underwent reoperation for either pulmonary venous obstruction or supraventricular tachycardia. Actuarial survival at 10 years was 91.5% by Kaplan–Meier survival plot. Freedom from reoperation at 10 years was 77.3%. Only two patients (8.3%) who had prosthetic valve and coagulation disorder, respectively, required anticoagulation. No patient showed obstruction of systemic venous pathway. However, 9 (37.5%) patients had postoperative arrhythmias. At final follow-up all survivors presented in New York Heart Association class I. Conclusions: With detailed preoperative anatomical and physiological diagnosis, unobstructed systemic and pulmonary venous pathway could be made by intracardiac Fontan procedures in selected patients with complex systemic and pulmonary venous anomaly with acceptable long-term results except for postoperative arrhythmia. 092 IMPROVED CURRENT ERA OUTCOMES IN PATIENTS WITH HETEROTAXY SYNDROMES P.V. Anagnostopoulos, J.M. Pearl, C. Octave, M. Cohen, A. Gruessner, E. Wintering, M.F. TeodoriPhoenix Children's Hospital Heart Center, Phoenix, USA Objectives: Patients with heterotaxy syndrome and, in particular, right atrial isomerism (RAI) have a myriad of visceral and cardiac malformations historically resulting in significant morbidity. We sought to assess whether current era management strategies have improved outcome. Methods: A retrospective review (1994–2007) of our database identified 41 consecutive patients [28 RAI; 13 left atrial isomerism (LAI)] who underwent surgical palliation. Functional single ventricle (SV) was present in 26 patients and 19 had total anomalous pulmonary venous return (TAPVR), of which seven were obstructed. An initial neonatal surgical approach was performed in 25/41 (61%). Twenty-eight patients (68%) required systemic-pulmonary artery shunt. Results: There were four hospital deaths, all after the first operation, and three interstage deaths (6 RAI; 1 LAI). A multivariate Cox-regression identified greater than moderate atrioventricular valve regurgitation (AVVR) (Hazard Ratio (HR) 9.4, P=0.02) and obstructed TAPVR (HR 16.7, P=0.006) as factors associated with increased RAI mortality. In contrast SV palliation, BT shunt and need for neonatal operation were not predictors of increased mortality. Patient survival at 1, 3, 5 years was 78%, 74%, 74% in RAI and 92%, 92%, 92% in LAI patients (P=0.18). All survivors are doing well without cardiovascular-related symptoms. LAI patients have a higher incidence of sinus node dysfunction than RAI patients (45% vs. 13%, P=0.04). Conclusions: Surgical outcomes in heterotaxy patients are improving in the current era. Significant AVVR and obstructed TAPVR remain risk factors for RAI mortality. Survivors are doing well with no activity restrictions, although LAI patients maintain a higher proclivity of sinus node dysfunction. 093 BRAIN PRESERVATION WITH SELECTIVE CEREBRAL PERFUSION FOR OPERATIONS REQUIRING CIRCULATORY ARREST: PROTECTION AT 25 °C IS SIMILAR TO 18 °C WITH SHORTER OPERATING TIMES J.D. Salazar1, J. McNeil1, S. Griffith1, R. Coleman1, H. Young1, J. Hensler1, J.H. Calhoon1, R. DiGeronimo21University of Texas Health Science Center, San Antonio, USA; 2Wilford Hall Medical Center, San Antonio, USA Objectives: Hypothermic circulatory arrest (HCA) is employed for aortic arch and other complex operations, often with selective cerebral perfusion (SCP). Our previous work has demonstrated real-time evidence of brain preservation using SCP at 18 °C. The purpose of this study was to evaluate the utility of SCP at warmer temperatures (25 °C) and its impact of operating times. Methods: Piglets undergoing cardiopulmonary bypass and 60 min of HCA were assigned to three groups: 18 °C without SCP, 18 °C with SCP and 25 °C with SCP. Bypass flows were 150 ml/kg/min utilising pH-stat management. SCP flows were 10 ml/kg/min via the innominate artery. A microdialysis probe placed into the cerebral cortex was sampled every 15 min. Microdialysate levels at baseline were compared to post-HCA. All data are presented as mean±SEM and were analysed using one-way ANOVA (n=6 animals/group). Results: Without SCP, HCA at 18 °C had significantly elevated brain lactate (4.1±0.4 RU)* and glycerol (3.1±0.4 RU)* levels, while energy substrates glucose (0.1±0.1 RU)** and pyruvate (0.1±0.1 RU)* were profoundly diminished. With SCP at 18 °C and 25 °C, significant changes in cerebral metabolites were not observed. Mean operating times were 162.5 min for 18 °C without SCP, 155.7 min for 18 °C with SCP, and 114.0 min for 25 °C with SCP.** (RU=units relative to baseline of 1.0, *P<0.01, **P<0.001). Conclusions: HCA results in acute cerebral energy depletion and ischaemic injury that are attenuated with the use of SCP, at 18 °C and 25 °C. Procedures performed at 25 °C had significantly shorter operating times. 094 NEUROPROTECTIVE EFFECTS OF ERYTHROPOETIN DURING DEEP HYPOTHERMIC CIRCULATORY ARREST AFTER DIRECT ADMINISTRATION INTO CEREBROSPINAL FLUID – A PIGLET MODEL M.-Y. Cho, J. Kempfert, T. Walther, S. Dhein, P. Pritzwald-Stegmann, M. Kostelka, F.W. MohrDepartment of Cardiac Surgery, Heartcenter, University of Leipzig, Leipzig, Germany Objectives: Current research suggests that erythropoetin (Epo) protects the brain from ischaemic injury. However, intravenously administered Epo enters cerebrospinal fluid (CSF) in significant amounts only if administered in extreme doses or in case of disrupted blood brain barrier. We investigated the neuroprotective effects of Epo administered directly into the CSF, during deep hypothermic arrest (DHCA) in a piglet model. Methods: Seven piglets received a single dose of Epo (500 IU/kg) into the lumbar CSF before cardiopulmonary bypass and underwent DHCA (18 °C) for 60 min. Another seven piglets underwent DHCA without Epo (DHCA-group). Five further piglets were used as healthy controls. After 4 h reperfusion neuronal injury was assessed by immunostaining for apoptosis inducing factor (AIF) of hippocampus CA1 (early stage apoptosis), brain tissue malondialdehyde (MDA) levels (oxidative stress) and brain tissue wet-dry (WD) ratio (tissue oedema). CSF and serum Epo levels were measured using ELISA. Results: The Epo-group showed significantly fewer neurons AIF-positive (control 4.1±0.2%, Epo 8.6±0.8%, DHCA 13.9±0.9%; P<0.001 Epo vs. DHCA). Brain tissue MDA levels (control 0.52±0.07 Cmol/g, Epo 0.53±0.07 Cmol/g, DHCA 0.75±0.15 Cmol/g; P=0.223 Epo vs. DHCA) and WD ratio (control 48±3.2%, Epo 51.8±1.6%, DHCA 54.8±2.4%; P=0.319 Epo vs. DHCA) suggested possible benefit. CSF Epo levels prior to DHCA (baseline 3.7±1.7 IU/l, pre-DHCA 427.5±99.7 IU/l, post-reperfusion 237.4±79.4 IU/l) were significantly higher (P<0.004) than serum levels (baseline 1.2±0.4 IU/l, pre-DHCA 63.2±18.2 IU/l, post-reperfusion 168.5±17.6 IU/l). Conclusions: Epo administered directly into the CSF results in significant Epo concentrations during DHCA and is associated with significantly less visible neuronal apoptosis. 095 EFFECT OF HYPOTHERMIA ON REGULATORY PATHWAYS TO NEURONAL INJURY OR SURVIVAL FOLLOWING CARDIOPULMONARY BYPASS AND CIRCULATORY ARREST IN BRAIN OF NEWBORN PIGLETS P. Pastuszko1, A. Pirzadeh2, E. Reade2, J. Kubin3, A. Mendoza-Paredes3, G.J. Schears4, W.J. Greeley2, A. Pastuszko31The University of Oklahoma, Oklahoma City, USA; 2The Children's Hospital of Philadelphia, Philadelphia, USA; 3The University of Pennsylvania, Philadelphia, USA; 4The Mayo Clinic, Rochester, USA Objectives: To determine the effect of recovery with mild hypothermia after cardiopulmonary bypass and deep hypothermic circulatory arrest on the activity of selected key proteins involved in initiation (Bax, Caspase-3) or inhibition (Bcl-2, increased Bcl-2/Bax ratio) of apoptotic injury in the brain of newborn piglets. Methods: The piglets were placed on CPB, cooled to 18 °C, subjected to 30 min of DHCA followed by 1 h of LF at 20 ml/kg/min, rewarmed to 37 °C (normothermia) or to 33 °C (hypothermia), separated from CPB, and monitored for 6 h. Expression of the above proteins was measured in striatum, hippocampus and frontal cortex by Western blots. The results are means for six experiments±SEM. Results: There were no significant differences in Bcl-2 level between the normothermic and hypothermic groups. The Bax levels in the normothermic group in cortex, hippocampus and striatum were 94±9, 137±22 and 125±34 and decreased in the hypothermic group to 59±17 (P<0.05), 70±6 (P<0.05) and 48±8 (P<0.05). In cortex, hippocampus and striatum Bcl-2/Bax ratio increased from 1.23, 0.79 and 0.88 in normothermia to 1.97, 1.28 and 2.92 in hypothermia. Expression of Caspase-3 was 244±3, 202±74 and 224±31 in cortex, hippocampus and striatum in the normothermic group and decreased to 146±41 (P<0.05), 44±16 (P<0.01) and 81±16 (P<0.05) in the hypothermic group. Conclusions: In the neonatal piglet model of cardiopulmonary bypass with circulatory arrest, mild hypothermia during post bypass recovery provides significant protection from cellular apoptosis, as indicated by lower expression of Bax and Caspase-3 and an increased Bcl-2/Bax ratio. Supported by NIH grants HL-58669 and NS-31465. 096 PREDICTORS OF IMPAIRED NEURODEVELOPMENTAL OUTCOMES AT ONE YEAR OF AGE AFTER INFANT CARDIAC SURGERY S. Fuller1, M. Gerdes1, A. Nord2, G. Wernovsky1, G. Jarvik2, J. Bernbaum1, E. Zackai1, J. Gaynor11Children's Hospital of Philadelphia, Philadelphia, USA; 2University of Washington, Seattle, USA Objectives: For most newborns, CHD appears to be an isolated anomaly and the brain is presumed to have normal developmental potential. This study assessed patient, perioperative and operative factors which may affect neurodevelopmental outcomes. Methods: Infants with complex CHD and no identified syndromes other than 22q11 microdeletions enrolled in a study of apolipoprotein-E (APOE) polymorphisms and developmental outcome underwent evaluation at one year of age including assessment by a geneticist and the Bayley Scales of Infant Development-II [Mental (MDI) and psychomotor Developmental Indices (PDI)]. Results: Of 550 infants enrolled, 359/501 survivors (72%) returned including 20 with known 22q11 microdeletions. Genetic syndromes not previously identified were confirmed in 28 (8.1%) and suspected in an additional 51 (15.0%). Mean MDI was 90±15 and PDI was 78±18. By multivariable analysis, suspected/confirmed genetic syndromes and the APOE e2 allele predicted lower MDI and PDI (all P<0.04). Lower birth weight (P<0.001) and preoperative intubation (P=0.012) predicted lower MDI. Higher haematocrit at surgery correlated with higher MDI (P=0.007). Longer postoperative length of stay was predictive of lower PDI (P=0.002). Additional operations with cardiopulmonary bypass were associated with lower MDI and PDI (both P<0.002); use of deep hypothermic circulatory arrest was not. Conclusions: Patient factors (birth weight, genetic syndromes and preoperative status) and operative management strategies are significant determinants of neurodevelopmental outcomes after infant cardiac surgery. In this cohort, a large number of genetic syndromes were diagnosed after the newborn period and correlated with poor neurodevelopmental outcomes. Genetic evaluation should be considered in all infants with CHD, even in the absence of additional anomalies.
097 PERCUTANEOUS CORONARY INTERVENTIONS IN CARDIAC TRANSPLANT RECIPIENTS: 10 YEAR SINGLE CENTRE EXPERIENCE G. Bruschi, P. Colombo, A. Sacco, P.L. Silva, F. Turazza, M. Frigerio, S. Klugmann A De Gasperis Cardiology and Cardiac Surgery Department, Niguarda Hospital, Milan, Italy Objectives: Cardiac allograft vasculopathy (CAV) remains a major cause of long-term morbidity and mortality among heart transplant (HTx) recipients. Percutaneous transluminal coronary angioplasty (PCI) should be used as the treatment of choice, but the restenosis rate in HTx recipients is in some experiences discouraging. Methods: We analysed the role of PCI in CAV, particularly restenosis, morbidity and mortality in bare metal stents (BMS) and drug-eluting stents (DES). At our Institution from 1985, 790 patients have had heart transplantation. To date 58 patients have undergone 69 PCI, resulting in 104 treated lesions. Mean age 54.3±12.2 years, 48 male, 23% diabetics, 85% with multi-vessel disease. Results: The indication for PCI was asymptomatic CAV in 29 cases, angina/dyspnoea in 16 patients and acute coronary syndrome in 11. Mean time from HTx to first PCI was 116.2±62.5 months. Multivessel procedures were 38.2%, primary success (<50% residual stenosis) was obtained in 95.1% of lesions. We had no peri-procedural mortality, no acute thrombosis, no bleeding complications; one patient experienced peri-procedural myocardial infarction. Sixteen per cent of lesions were treated with POBA, 49% with direct stenting, 54 lesions were treated with DES. Angiographic follow-up was obtained in 63 lesions (61.2%) at 18±27 months. Restenosis was observed in 24% of lesions (15/63). Subacute and late stent thrombosis was not observed. All patients obtained clinical follow-up at 42.3±39.3 months. There were 16 deaths (11 cardiac) after a mean time from PCI of 38.5±29.2 months. Conclusions: In HTx recipients, PCI can be performed safely with high rates of primary success. Restenosis rates are higher compared with PCI in native coronary arteries. The clinical benefit from PCI may be reduced, due to disease progression in untreated segments. 098 LUNG TRANSPLANTATION FOR RECIPIENTS AGED 65 AND OLDER Y. Toyoda, C. Bermudez, K. McCurry, M. Zenati, B. Johnson, M. Crespo, J. Pilewski, B. HattlerUniversity of Pittsburgh Medical Center, Pittsburgh, USA Objectives: Age 65 is considered the upper limit for lung transplantation. Its outcome for patients aged 65 years or older is unknown. Methods: Retrospective analysis was performed for 83 consecutive lung transplant recipients operated by a single surgeon (YT) from January 2006 to September 2007. Patients aged 65 years or older at the time of lung transplantation (group A) were compared with those who were younger than 65 years (group B). Results: Group A had 27 patients (age 69±1, range 65–81, 19 male and 8 female); group B had 56 patients (age 52±1, range 21–64, 32 male and 24 female). Idiopathic pulmonary fibrosis was the more (P<0.01) common diagnosis in group A (63%) vs. B (25%). Double lung transplantation was less (P<0.01) frequently performed in group A (37%) vs. B (73%). There were no significant differences between group A vs. B in donor age (40±3 vs. 38±2 years), ischaemic time (322±15 vs. 337±10 min), use of cardiopulmonary bypass (22 vs. 36%), cardiopulmonary bypass time (238±45 vs. 239±10 min), use of postoperative ECMO (4 vs. 5%), extubation within 48 h (63 vs. 52%) and extubation beyond postoperative day 5 (22 vs. 30%). The 30-day and 1-year survival was 100% and 78% in group A vs. 93% and 88% in group B (P=0.621, Log Rank). Conclusions: Lung transplantation can be performed for patients aged 65 years or older with acceptable morbidity and mortality that is similar to younger recipients. Patients in this age group should not be declined based on age as the sole reason. 099 DONOR CARDIAC TROPONIN-I: A BIOCHEMICAL SURROGATE OF HEART FUNCTION BUT NOT A PREDICTOR OF OUTCOME R.V. Venkateswaran, V. Dronavalli, R.P. Steeds, J.S. Ganesh, I.C. Wilson, J.G. Mascaro, R.D. Thompson, R.S. BonserUniversity Hospital, Birmingham NHS Foundation Trust, Birmingham, UK Objectives: Measurement of cardiac troponin-I (cTnI) in the potential heart donor may be a marker of donor heart dysfunction and predictive of recipient outcome. We studied the prevalence of cTnI elevation and its association with function and donor heart usability. Methods: In a prospective study, cTnI measurement, Swan-Ganz catheterisation and transthoracic echocardiography were performed at initial assessment in 80 potential cardiac donors (mean age 43±13.1). All donors were then managed according to a strict algorithm to optimise cardiac function and received hormonal therapy as part of a randomised trial. Donor heart suitability for transplantation was assessed after 7 h of management. The association of cTnI with initial functional indices was assessed and outcome compared for donors categorised according to cTnI level <1 µg/l or >1 µg/l. Results: cTnI levels strongly correlated with initial cardiac index (CI) (P=0.003), right (P<0.001) and left ventricular ejection fraction (P=0.001) and LV-Tei index (P=0.003). Serum cTnI was elevated in 29/80 donors. Higher CVP (10±5.1 vs. 7.9±2.9; P=0.026) and PAWP (12±5.4 vs. 8.1±3.1; P=0.002), lower cardiac index (2.7±1.1 vs. 3.6±0.9; P=0.001) and fractional shortening (P<0.01) and worse wall motion score index (P<0.01) and RV-Tei index (P=0.012) were observed in the cTnI >1 µg/l group. Despite these differences, the number of hearts ultimately suitable for transplantation post-optimisation, was not different (P=0.137) and post-transplant 30-day and 1-year survival were similar. Conclusions: Donor cTnI level represents a biochemical correlate of functional donor heart assessment. Although, high cTnI is associated with worse donor heart function, this does not preclude successful optimisation or recipient outcome following transplantation. 100 ECMO TEMPORARY SUPPORT FOR EARLY GRAFT FAILURE AFTER CARDIAC TRANSPLANTATION C. D'Alessandro1, S. Aubert1, B.L. Praschker1, R. Makris2, A. Combes3, C.E. Luyt3, A. Pavie1, P. Leprince11Thoracic and Cardiovascular Surgery Unit, La Pitie Salpetriere Hospital, Paris, France; 2Anesthesiology Department, La Pitie Salpetriere Hospital, Paris, France; 3General Intensive Care Unit, La Pitie Salpetriere Hospital, Paris, France Objectives: Early graft failure (EGF) is a major risk for death after heart transplantation. We studied the impact of ECMO temporary support on the operative mortality and the mean-term survival after EGF. Methods: Between January 2000 and December 2006, 398 patients underwent orthotopic heart transplantation at our Institution. EGF was observed in 76 (19%) patients. Fifty-three patients (13%) were treated with ECMO support (group 1), 8 (2%) with other assist devices (group 2), and 15 (4%) received maximal inotropic drug support only (group 3). Results: Overall mortality was 22% (89 patients). EGF was a major risk for death: 13% (41 patients) without EGF vs. 63% (48 patients) with EGF, P<0.001. Among these patients, operative mortality was lower in group 1 (53%, 28/53 patients) than in group 2 (75%, 6/8 patients) or group 3 (93%, 14/15 patients), P<0.01. Overall survival was 72% at 1 year and 64% at five years. Absence of EGF improved long-term survival: 78% at one year and 69% at five years without EGF vs. 29% at 1 year and 27% at 5 years with EGF. Patients treated with ECMO have the same one-year conditional survival than patients not having suffered EGF: 94% at three years. Conclusions: ECMO support for EGF seems to have a significant impact on operative mortality. Patients treated with ECMO have the same one year conditional survival as patients not having suffered EGF. 101 SURFACTANT PRETREATMENT DIMINISHES LUNG ISCHAEMIA-REPERFUSION INJURY UP TO 3 MONTHS AFTER REPERFUSION N.P. van der Kaaij1, J. Kluin1, J.J. Haitsma2, M.A. den Bakker3, B.N. Lambrecht4, B. Lachmann2, R.W.F. de Bruin5, A.J.J.C. Bogers11Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands; 2Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands; 3Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands; 4Department of Pulmonary Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands; 5Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands Objectives: Lung ischaemia-reperfusion-injury (LIRI) contributes to both early and late morbidity and mortality after lung transplantation. The objective was to investigate whether surfactant treatment before ischaemia provides lung protection up to months after reperfusion. Methods: Male Sprague-Dawley rats (n=63) were randomised to receive intra-tracheally administered surfactant or no pretreatment. One hour thereafter, animals underwent 2 h of warm ischaemia by clamping the bronchus, pulmonary artery and vein of the left lung. A third and fourth group were sham operated or served as healthy controls. Rats were killed 30 or 90 days after surgery. Lung compliance was determined and broncho-alveolar-lavage-fluid (BALf) was collected to assess surfactant function and alveolar protein content. Leukocyte infiltration, measured by flow cytometry, was determined in BALf and lung tissue. Lungs of three animals per group were used for histological assessment. Results: Thirty and 90 days after LIRI, lung compliance was significantly decreased and the level of left lung tissue B/T-lymphocytes was diminished compared to control groups. HE slides of LIRI animals showed diffuse alveolar damage with atelectasis and pre-stages of fibrosis. No changes were found in surfactant phospholipids or amount of alveolar protein in the BALf of the left lung. Surfactant pretreatment improved lung compliance, preserved lung architecture, and normalised the number of lung tissue B/T-lymphocytes. However, more macrophages were present in the pretreated lung compared to other groups. Conclusions: Two hours of warm ischaemia caused lung damage up to three months postoperatively. Surfactant pretreatment prevented long-term LIRI and may be a promising strategy to ameliorate LIRI in lung transplant recipients. 102 DUAL SCAN TOMOGRAPHY IN DIAGNOSIS OF VASCULOPATHY: A PILOT STUDY P. Przybylowski, K. Wierzbicki, P. Klimeczek, I. Milaniak, P. Wegrzyn, J. Konstanty-Kalandyk, M. Pasowicz, J. SadowskiDepartment of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland Objectives: Dual scan computer tomography (DSCT) is a promising method for diagnosis of vasculopathy in the transplanted heart. The aim of the study was comparison of the acquired data from classical angiography and from DSCT. Methods: We included 12 patients with previously diagnosed vasculopathy at average age 60.4±7.3 years, and the post transplant follow-up time was 11.1±4.0 years. In all patients angiography and DSCT were done. We used 128 slides technique with time interval 83 ms. Results: The vasculopathy diagnosed previously by angiography was confirmed by the DSCT. DSCT revealed abnormalities in vascular wall thickening in all epicardial coronary arteries. We observed the concentric, non-calcified changes in arterial wall of the same characteristic spreading out towards the vessel length. Moreover the eccentric changes typical for classical atherosclerosis were identified in all patients. Due to resolution of 0.6 mm, accurate description of the wall changes is limited. But the patency of implanted stents and the lumen diameter could be visualised. Conclusions: 1) Dual-source computer tomography is a useful method in the group of patients without the necessity of pharmacological bradycardia; 2) The current technology makes DSCT a potent tool for diagnosis of the vasculopathy of the transplanted heart; 3) The artery lumen diameter and patency of previously implanted intracoronary stents could be described. 4) There is only limited data of the severity of the intimal thickening and morphology of vascular changes. 103 REPAIR OF BRAIN DEATH INDUCED DONOR LUNG DAMAGE IN AN EX VIVO RECONDITIONING CIRCUIT: FICTION OR REALITY? S. Wipper, A. Dupree, J. Lindner, C. Pahrmann, H. Reichenspurner, F.M. WagnerUniversity Heart Center, Hamburg, Germany Objectives: The aim of the study was to investigate whether our previously established model for ex vivo reconditioning of pulmonary grafts allows reversion of brain death induced injury. Methods: Brain death was induced by rapid intracranial balloon inflation (n=6) or not induced (control, n=6). Four hours after brain death induction, the heart-lung-block was explanted after Perfadex preservation, to be reperfused for 6 h. The perfusion circuit consisted of a rotary-blood-pump, leukocyte filter, heparin-coated oxygenator, tubing and reservoir. The system was primed with washed erythrocytes and Steen solution (1:1; Hb 5.5 mg/dl). Reperfusion started at 21 °C to reach 37 °C within 30 min, ventilation at 32 °C (FiO2=0.3). Respiratory and haemodynamic parameters were monitored pre-harvest and hourly during reperfusion. Wet-dry ratios were calculated pre- and post-reperfusion; semi-quantitative histological assessment was performed by light microscopy. Results: All lungs were perfused for 6 h. Control lungs showed no significant change throughout the study. Brain death led to significant reduction (vs. control) of pulmonary compliance (35±4.3 vs. 47±2.9 ml/cmH2O; P<0.05), increase of PVR (322±73 vs. 193±97 dynes; P<0.05), while gas exchange remained unchanged (PartO2index 277±73 vs. 269±57 mmHg; P=NS). Further deterioration occurred during the first hour of reperfusion (brain-death vs. control: compliance 22±4.6 vs. 35±7.1 ml/cm H2O; PVR 1356±626 vs. 718±176 dynes). However, lungs recovered after 3–4 h to control values, remaining stable until study end-point. Histologically, brain-death induced diffuse interalveolar oedema with massive cellular infiltration in all lobes which completely normalised by the end of reperfusion. Conclusions: Brain death led to severe pulmonary injury with only mild impact on gas exchange. Extended in vitro reperfusion in our circuit allowed reconditioning, reversal of damage and optimisation of graft function. 104 CARDIOTHORACIC SURGERY AFTER HEART TRANSPLANTATION: A SAFE AND EFFECTIVE THERAPEUTIC OPTION H. Görler, C. Kühn, A. Meyer, G. Warnecke, B. Gohrbandt, A. Haverich, M. Strüber, A. SimonDepartment of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany Objectives: Because of the critical shortage of donor organs, non-retransplant surgical options have become the first choice in patients suffering from cardiac allograft vasculopathy (CAV) or valvular disease late after heart transplantation (HTX). However, there are few reports of long-term results after this therapeutic approach. Therefore, we evaluated our results of non-retransplant cardiac surgery in these patients and compared them to those after retransplantation. Methods: Since 1983 a total of 859 heart transplantations have been performed at our institution. Among them, 28 patients underwent non-retransplant cardiac surgery, three of them repeatedly. The procedures included 18 coronary artery revascularisations, 10 valvular procedures and three aortic operations. Long-term results of these patients were compared to those after cardiac retransplantation. Results: Early mortality was 3.6% (1/28) in the non-retransplant group. Three patients died late after surgery. Indications for surgery included CAV, tricuspid regurgitation, aortic and mitral valve insufficiency, as well as aortic root dilatation and acute type A dissection. Mean follow-up was 6.2 years (range: 29 days–17 years). Actuarial survival rates in the non-retransplant group at 1, 3, 5 and 7 years were 96%, 92%, 82% and 82%, respectively. In comparison, survival after retransplantation was 53%, 50%, 47% and 36%, respectively. Causes of death were intracerebral bleeding, biventricular heart failure, lymphoma and cardiac arrhythmias. Conclusions: According to these results we consider organ-sparing surgical procedures for cardiac allograft vasculopathy and valvular disease after HTX a safe and effective therapeutic approach with good long-term results.
105 HOMOGRAFT AORTIC ROOT REPLACEMENT IN NATIVE OR PROSTHETIC ACTIVE INFECTIVE ENDOCARDITIS WITH PERIANNULAR ABSCESS: 20-YEAR SINGLE CENTRE EXPERIENCE M. Musci, C.A. Yankah, M. Pasic, S. Kosky, J. Stein, Y. Weng, H. Siniawski, R. Hetzer Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany Objectives: To compare early and long-term results of cryopreserved homograft aortic root replacement (ARR) in native (NVE) or prosthetic valve endocarditis (PVE) associated with periannular abscess. Methods: Between May 1986 and December 2007, 1163 endocarditis patients were operated upon. Of these, 221 patients (n=185 men, median age 55 years) underwent homograft ARR due to 99 cases of NVE (45%) and 122 of PVE (55%); 189 patients (86%) developed perinannular abscess formation. Perioperative characteristics, probability of survival, freedom from recurrence and reoperation and valve-related events were analysed. Follow-up (median 3.49 years) was completed in all survivors, with a total of 1109 patient years. Results: Overall survival at 30 days, 1, 5, 10 and 15 years was 78.6%±2.8%, 71.3%±3.0%, 56.8%±3.5%, 40.7%±3.9% and 29.8%±4.8% with significantly better survival of NVE than PVE patients (P=0.0293) and a greater tendency towards abscess formation. Thirty-one (14.0%) required reoperation either for SVD (n=19, 8.6%, mean 1062 days) with a high-risk in patients <40 years or for endocarditis of the homograft (n=12, 5.4%, median 98 days) with a tendency towards PVE. Mortality for reoperation was 38.7% (n=12). Conclusions: Radical resection, reconstruction of LVOT and homograft ARR for infected aortic root with periannular abscess has improved patient survival for primary and secondary operations, significantly better in NVE. It is associated with a low recurrence rate of most valve-related events although the risk of SVD increases over time, especially in young patients. Reoperations for homograft endocarditis show a high mortality rate. In our institution homograft ARR remains the preferred valve substitute in periannular abscess formation. 106 EVALUATION OF CORONARY FLOW RESERVE BY TRANSTHORACIC ECHOCARDIOGRAPHY IN PATIENTS AFTER THE ROSS PROCEDURE AND MECHANICAL AORTIC VALVE REPLACEMENT: LONG-TERM RESULTS FROM A RANDOMISED TRIAL T. Wittlinger, F. Bakhtiray, O. Dzemali, P. Kleine, M. Doss, S. Martens, A. MoritzDepartment of Thoracic and Cardiovascular Surgery, University Hospital, Frankfurt, Germany Objectives: Coronary flow reserve (CFR) may be an important parameter of long-term survival after aortic valve replacement (AVR) in patients with aortic stenosis. We hypothesised that CFR after Ross procedure is increased compared to patients with mechanical AVR and may be one factor for the better long-term results. This study investigated the long-term effect of AVR on CFR. Patients were randomised between 1999 and 2001 to mechanical AVR or Ross procedure. Methods: CFR by transthoracic Doppler echocardiography (TTDE) (GE Vivid 5) was assessed in 36 patients at mean 6.6 years after the operation. Eighteen patients each were randomised to mechanical AVR (group A) or Ross procedure (group B). Ten healthy volunteers were examined for control (group C). After adequate images of resting LAD diameter and flow had been obtained, a 5-min intravenous infusion of adenosin (140 µg/kg/min) was started. Assessment of stress flow velocity was performed after 4 min. Results: CFR was significantly reduced compared to normal healthy volunteers. The peak and mean diastolic coronary flow velocities at baseline did not differ between groups A and B (21.6±8.5 vs. 23.6±9.5 and 14.6±6.5 vs. 17.3±8.5). However, the peak and mean diastolic coronary flow velocities during hyperaemia in group A were significantly smaller than those in group B (34.4±16.5 vs. 55.7±16.5 and 23.2±12.5 vs. 36.3±12.5). The CFR was significantly reduced in group A (1.5±0.3 vs. 2.5±0.5). Conclusions: CFR determined by TTDE is feasible and useful in patients after aortic valve operation. Patients after Ross procedures show increased CFR compared with patients after mechanical valve replacement. Further long-term studies are mandatory to evaluate the effect on the better outcome of this patient group. 107 ISOLATED AORTIC VALVE REPLACEMENT AFTER PREVIOUS CABG WITH PATENT GRAFTS: IS THE ‘OLD FASHIONED’ WAY OBSOLETE FOR THE FUTURE? N. Khaladj, C. Hagl, S. Peterss, I. Kutschka, A. Pichlmaier, M. Strüber, A. Haverich, M. ShresthaHannover Medical School, Hannover, Germany Objectives: High–risk patients are currently under evaluation for alternative catheter-based aortic valve replacement (AVR) techniques. To identify the individual patient's risk, scores such as the EuroSCORE or STS risk calculator are used. The aim of the present study was to evaluate patients who needed isolated AVR via a median re-sternotomy after prior CABG, all potentially suitable for the newer less invasive techniques. Methods: Between January 1996 and January 2008, 349 patients underwent AVR as a redo procedure. One hundred and thirty patients had previous CABG, in 39 patients (29 male, median age 75 (60–84)) preoperative coronary angiography revealed open grafts with no need for additional revascularisation (30 LIMA grafts). These patients underwent isolated AVR. Operative mortality was calculated using (logistic) EuroSCORE and STS risk calculator. Results: Operative (30-day mortality) was 5% (2 patients). Estimated mortality was 12% using EuroSCORE (32% logistic) and 10% according to the STS risk calculator, respectively. Scores were significantly overestimated for all three methods used (P<0.001). Conclusions: Conventional AVR as a redo procedure after CABG with patent grafts can be performed with excellent results and significant lower mortality as estimated. Results of newer catheter-based AVR approaches should not to be compared with artificial scores to justify high morbidity rates. To date, the ‘old fashioned’ way of high-risk AVR has still to be considered as the gold standard in experienced hands. 108 PATIENT-PROSTHESIS MISMATCH IN ELDERLY PATIENTS UNDERGOING AORTIC VALVE REPLACEMENT: IMPACT ON QUALITY OF LIFE AND SURVIVAL S. Urso, R. Sadaba, M. Vives, J. Trujillo, S. Beltrame, B. Soriano, L. Piqueras, G. AldamizClinica Capio, Albacete, Spain Objectives: The consequences of patient-prosthesis mismatch (PPM) following aortic valve replacement (AVR) continues to be a matter of debate. Also, because of the ageing of the western population, AVR is being performed in elderly patients with increasing frequency. The aim of the study was to evaluate the impact of PPM on quality of life and survival of elderly patients undergoing AVR by a propensity score adjustment.
Methods: A total of 163 patients aged Results: Patient-prosthesis mismatch was present in 43% of our population. In multivariable analysis, patients with mismatch were more often female, more often operated on for aortic degenerative calcification, had a larger body surface area and more often received a bioprosthesis than those in the control group. According to multivariable analysis, the SF-12 physical component score of the mismatch group was significantly inferior to that of the control group (P=0.001). The SF-12 mental component score and early and mid-term survival data did not show any significant difference between mismatch and control groups. Conclusions: Patient-prosthesis mismatch in elderly patients appears to have a negative effect on physical quality of life. Nevertheless, we were unable to show a significant difference in early and mid-term mortality between mismatch and control groups. 109 IS WARFARIN NECESSARY AFTER TISSUE AORTIC VALVE REPLACEMENT? Z. Makhija, M. Baghai, R. Deshpande, L. John, J. Desai, A. El-Gamel, O. WendlerKing's College Hospital, London, UK Objectives: Current ACC guidelines for postoperative management of patients who have undergone tissue aortic valve replacement indicate a course of warfarin therapy for three months. There appears to be increasing acceptance of anti-platelet therapy as being equally effective in preventing postoperative thromboembolic complications. This study verifies the reliability of anti-platelet therapy in this cohort of patients. Methods: Between 1998 and 2007, data were prospectively collected on 1346 consecutive patients who underwent isolated tissue aortic valve replacement. Sixty-six percent (n=890) were males, with a mean age of 74 years and 16% (n=143) of the implanted valves were stentless. All patients received low molecular weight heparin until discharge. Bleeding and thromboembolic events were monitored during the first three postoperative months. All patients were discharged on 75 mg aspirin/day for six weeks. Results: Early mortality was 2.9%. 18.6% (n=166) of the patients developed early postoperative atrial fibrillation, of which 85% were cardioverted to sinus rhythm prior to discharge while the rest (n=30) of the patients required warfarin and so were excluded from the analysis. Follow-up at three months was 98% complete with the rate of bleeding and thromboembolic events being 0.38% and 0.46%, respectively. Conclusions: Postoperative warfarin therapy after tissue aortic valve replacement seems to be unnecessary as anti-platelet treatment for six weeks appears to be safe and effective. It may also decrease the length of stay, cost of care, and complications. 110 LONG-TERM FOLLOW-UP OF ELDERLY PATIENTS SUBJECTED TO AVR WITH MECHANICAL PROSTHESES R. Pancas, G.E. Coutinho, P.E. Antunes, J. Ferrão de Oliveira, M.J. AntunesUniversity Hospital, Coimbra, Portugal Objectives: The current tendency to use biological prostheses in the aortic position in younger patients raises the dilemma of using mechanical prostheses in patients older than 65 years of age. This cohort study analyses prospectively the long-term follow-up of this group of patients, using death and prosthetic-related complications as endpoints. Methods: From April 1988 to December 1995, 144 patients aged 65–75 years (mean 67.7±2.5) were subjected to AVR with a mechanical prosthesis. The majority were in NYHA class II–III. Thirty-six patients (25%) were submitted to combined surgery (CABG, mitral/tricuspid valvuloplasty and replacement, ascending aorta surgery). Follow-up was conducted by personal/telephonic interview and letter, and was complete for 99% of the patients (mean 14.2 years; range 12–19 years). Results: Thirty-day mortality was 1.4% (n=2). Five- and 10-year actuarial survival was 81.7% (21 deaths) and 61.0% (36 deaths), respectively, approaching that of the normal population. Cardiac-related mortality was 14.8% (1.04%/patient/year), non-cardiac 25.3% (1.78%/patient/year) and unknown 4.9% (0.34%/patient/year). Valve-related complications occurred at a rate of 2.71%/patient/year: CVA/TIA (19.7%; 1.38%/patient/year), haemorrhagic accidents (10.0%; 0.74%/patient/year), endocarditis (5.6%; 0.39%/patient/year) and reoperation (2.8%; 0.20%/patient/year). Mean age of patients alive was 79.8±1.4 (77–87). Conclusions: With increased life expectancy, considerations regarding prosthetic durability tend to gain importance with regard to the choice of the type of prosthesis to implant in elderly patients. After 12 years of follow-up, about two-thirds of our patients were alive. Hence, we consider implantation of a mechanical prosthesis in elderly patients safe and appropriate; the choice must be tailored for each specific patient.
111 PULMONARY RESECTION AFTER CONCURRENT CHEMOTHERAPY AND HIGH DOSE (60 GY) RADIATION FOR NON-SMALL CELL LUNG CANCER IS SAFE AND PROVIDES HIGH SURVIVAL R.J. Cerfolio, A.S. Bryant University of Alabama at Birmingham, Birmingham, USA Objectives: To evaluate the use of 60 Gy or higher for neoadjuvant chemo-radiotherapy for patients with stage IIIA non-small cell lung cancer (NSCLC) from N2 disease. Methods: A retrospective cohort study using a prospective database of patients with NSCLC who underwent thoracotomy with intent to cure after 60 Gy of preoperative radiation. Patients underwent initial staging with CT, PET-CT and mediastinoscopy and/or EUS-FNA. Results: Between January 1998 and December 2007, 210 patients underwent thoracotomy with intent to cure after 60 Gy of radiation. Median dose of radiotherapy was 60 Gy (range 60–72 Gy) and an intercostal muscle flap was used. Median hospital stay was 4.2 days, (range 2–41). Morbidity occurred in 53 (25%). There were five (2.3%) deaths. There were no bronchopleural fistulas (BPFs) after lobectomy, but there were two after right pneumonectomy. Predictors of morbidity were low FEV1% and DLCO% (P<0.001) and older age (>75 years) (P=0.006). Complete pathologic response occurred in 66 patients (31%). The overall 5-year Kaplan–Meier survival was 34% for the 210 patients, 42% for those who underwent R0 resection, 38% for those with initial N2 disease and 34% for those with Pancoast tumours. Conclusions: Pulmonary resection after high dose (>60 Gy) neo-adjuvant radiotherapy is safe. BPFs can be prevented. Older patients and those with poor PFTs are more likely to have complications. Complete response rates and survival rates may be higher using 60 Gy of preoperative radiotherapy than the standard dose of 45 Gy. Since subsequent pulmonary resection appears safe, its use should be further studied. 112 ROLE OF 18FDG-PET-CT IN PATIENT SURVEILLANCE AFTER MULTIMODALITY THERAPY FOR MALIGNANT PLEURAL MESOTHELIOMA C. Tan, S. Barrington, S. Rankin, D. Landau, J. Pilling, L. Lang-LazdunskiGuy's and St Thomas’ Hospital, London, UK Objectives: To investigate the role of 18FDG-PET-CT in patient surveillance after multimodality therapy of malignant pleural mesothelioma. Methods: Retrospective study of patients having had chemotherapy, radical surgery and radiotherapy for mesothelioma in our unit. Radical surgery included extrapleural pneumonectomy (EPP) or radical pleurectomy/decortication (P/D). 18FDG-PET-CT was performed at least six months postoperatively to evaluate response to treatment or when disease recurrence was suspected. 18FDG-PET scans were acquired from skull base to upper thighs together with low dose CT-scans for attenuation correction and image fusion. Results: Thirty-two patients had EPP (21) or P/D (11) between January 2004 and August 2007. Seven symptomatic patients had 18FDG-PET-CT done for suspicion of disease recurrence at a median of nine months (6–16) postoperatively. Five asymptomatic patients had a surveillance 18FDG-PET-CT done at a median of 11 months (7–13) postoperatively. 18FDG-PET-CT correctly diagnosed mesothelioma recurrence in five out of seven symptomatic patients and missed microscopic recurrence in one. 18FDG-PET-CT showed unsuspected recurrences in three out of five asymptomatic patients. Recurrent mesotheliomas had a mean SUVmax measured at 10.3±3.7 (4–18.6). Globally, 18FDG-PET-CT had a sensitivity of 88.9%, specificity of 75% and accuracy of 91.6%. Eight patients were started on a second-line chemotherapy based on 18FDG-PET-CT findings. Conclusions: 18FDG-PET-CT is useful in diagnosing or ruling out disease recurrence in symptomatic and asymptomatic patients following multimodality therapy of malignant pleural mesothelioma. We recommend that 18FDG-PET-CT is performed in all symptomatic patients and we suggest that asymptomatic patients have a surveillance 18FDG-PET-CT at 12 months postoperatively and then yearly. 113 ROLE OF DIFFUSION-WEIGHTED IMAGING IN ESTIMATING TUMOUR INVASIVENESS FOR CLINICAL STAGE IA NON-SMALL CELL LUNG CANCER N. Kanauchi, H. Oizumi, H. Kato, M. EndoYamagata University School of Medicine, Yamagata, Japan Objectives: Recently, diffusion-weighted imaging (DWI) has become available for clinical use in lung cancer, the same as for the central nervous system. The purpose of this study was to assess the role of DWI in evaluating tumour invasiveness of non-small cell lung cancers, especially for clinical stage IA patients. Methods: From January 2006 to September 2007, preoperative DWI and 18F-FDG PET-CT were performed on 42 patients (45 lesions) with clinical stage IA non-small cell lung cancer who had undergone curative operations. From their pathological findings, lung cancers that exhibited nodal, lymphovascular or pleural invasion were defined as invasive lung cancers. Hypo-intense nodules, as observed by DWI in spinal cords, were defined as DWI positive. We analysed the association between the pathological findings and the following preoperative clinical factors: age, sex, smoking history, preoperative CEA levels (<5.0 or >5.0 ng/ml), tumour size, SUV max on PET-CT (<5.0 or >5.0) and DWI (positive or negative). Results: The histological subtypes were: 35 (78%) adenocarcinomas, 9 (20%) squamous cell carcinomas, 1 (2%) typical carcinoid. There were 12 (27%) invasive lung cancer cases and 18 (33%) DWI-positive cases. On univariate analysis, DWI (P<0.01), SUV max (P<0.01), and preoperative CEA level (P<0.01) correlated with invasive lung cancer. On multivariate analysis, DWI (P=0.03) and preoperative CEA levels (P=0.04) were independent predictive factors of invasive lung cancer. Conclusions: Our results suggest that DWI might be a useful method for estimating tumour invasiveness for clinical stage IA non-small cell lung cancers. 114 EXPRESSION PROFILE OF SMALL HEAT SHOCK PROTEIN ALPHA-B CRYSTALLIN IN OPERATED NSCLC PATIENTS: CLINICAL IMPLICATION R.V. Cherneva1, D.B. Petrov2, Y. Slavova3, N.L. Trifonova4, M.I. Stamenova41Department of Internal Medicine at Medical University, Sofia, Bulgaria; 2Department of Thoracic Surgery at Medical University, Sofia, Bulgaria; 3Department of Pathology at Medical University, Sofia, Bulgaria; 4Department of Immunology and Biology at Medical University, Sofia, Bulgaria Objectives: To evaluate the expression profile of the small heat shock protein alpha-B crystallin in NSCLC and to analyse the correlation with clinico-pathological data.
Methods: Tissue microarray technology for analysis of immunohistochemical expression of alpha-B crystallin was applied in 155 operated on lung cancer patients between 2005 and 2006. The correlation between clinico-pathological data (TNM-stage, grade, metastatic potential and survival) and the grade of the staining was analysed using Results: Sixty percent of the tumours showed moderate and 34% intensive staining. For the first time a nuclear staining was observed. There was a stable significance between adenocarcinoma histology and nuclear staining in 88% of patients. The same is true for bronchoalveolar histology (75%), while in squamous cell histology the nuclear staining is positive in only 56% of the cases. The intensive cytoplasmic staining corresponds to the grade of dedifferentiation of the tumours (P<0.05). We could not find a statistical significance between the grade of staining and the mediastinal lymph node metastases. The moderate and weak cytoplasmic staining correlated with haematogenic metastases with P=0.011 and P=0.016, respectively. The grade of cytoplasmic staining was not associated with the stage of the disease (P=0.39) or with the survival rate (P=0.07). Conclusions: The small heat shock protein alpha-B crystallin is a novel biomarker that could be applied for stratifying patients in risk groups for disease recurrence. As it is largely expressed in non-small cell lung cancer, it could also be used in a diagnostic panel for early detection. 115 PLEOMORPHIC CARCINOMA OF THE LUNG: PROGNOSTIC FACTORS AND SURVIVAL D. Galetta, A. Borri, R. Gasparri, F. Petrella, P. Solli, G. Veronesi, F. Leo, L. SpaggiariDivision of Thoracic Surgery, European Institute of Oncology, Milan, Italy Objectives: Pleomorphic carcinoma of the lung is rare and presents unpredictable clinical behaviour. We investigate clinical outcome and prognostic factors of these tumours. Methods: Records of patients undergoing pulmonary resection for pulmonary pleomorphic carcinoma between January 1999 and November 2007 were retrospectively analysed; survival was calculated using the Kaplan-Meier method. Results: There were 73 patients (58 men and 15 women). Median age was 64 years (range 39–85). Sixty-five patients (89%) were smokers. Median tumour size was 4.5 cm (range 0.6–19 cm). Twenty-four patients (32.8%) received induction chemotherapy. Operative resections included lobectomy in 42 patients (57.5%), pneumonectomy in 16 (22%), wedge resection in 10 (13.7%), and segmentectomy in 5 (6.8%). Four patients (5.4%) had an incomplete resection. Postoperative staging included 18 stage I (24.6%), 31 stage II (42.4%), and 24 stage III (33%). Five-year overall survival and disease-free survival were 31% and 38%, respectively (median, 18 and 12.5 months, respectively). Recurrences occurred in 33 patients (44.6%) most of them at distant sites (22/33 [66.6%]). Factors associated with increased survival included right side disease (P=0.01); pathological stage I (P=0.01), no metastatic lymph nodes (P=0.001), and no induction treatment (P=0.04). Conclusions: Pulmonary pleomorphic carcinomas are aggressive tumours usually presenting as a large lesion in male smokers. Prognosis is poor, and distant recurrence rate is high. In our study induction therapy is associated with a worse prognosis. Long-term survival can be achieved by means of lung resection combined with complete lymph node dissection. 116 OCT4 EXPRESSION IN NON-SMALL CELL LUNG CANCER: IMPLICATIONS FOR THERAPEUTIC INTERVENTION G. Karoubi, C.-D. Lourdes, I. Breyer, R.A. Schmid, A.E. DutlyDivision of General Thoracic Surgery, University Hospital Bern, CH-3010 Bern, Switzerland Objectives: The OCT4, transcription factor, is a robust marker of pluripotency for both mouse and human embryonic stem cells. Expression of OCT4 is rarely seen in normal somatic tissues but can be detected in some human tumours such as breast, testis and pancreas. These findings illustrate a potentially critical role for OCT4 in tumourigenesis. The objective of our study was to investigate OCT4 expression in primary cultures of adenocarcinoma and bronchoalveolar carcinoma. Methods: We have isolated and characterised primary pulmonary cells from human lung. Biopsies were taken intraoperatively from patients diagnosed with adenocarcinoma and/or bronchoalveolar carcinoma undergoing major lung resection. Cultures were obtained from both the tumour tissues as well as the respective (normal) tissues and cells were characterised for OCT4 expression. Results: We found expression of OCT4 in cells cultured from both the adenocarcinoma and bronchoalveolar carcinoma. In the adenocarcinoma, the tumour samples illustrate a significantly higher amount of OCT4 expression than their normal counterparts. Interestingly, this is not true in bronchoalveolar carcinoma where OCT4 expression is lower in both tumour and normal tissue with no visible difference between normal and tumour OCT4 expression levels. Conclusions: The expression of OCT4 in adenocarcinoma and bronchoalveolar carcinoma has great implications in cancer therapy as OCT4 represents an attractive target for therapeutic intervention in both. In addition, the aberrant expression and distribution of OCT4 may provide some important clues concerning the differences between the two peripheral non-small cell lung cancer subtypes.
117 DO WE NEED FENESTRATION WHEN PERFORMING 2-STAGE TOTAL CAVOPULMONARY CONNECTION (TCPC) USING AN EXTRACARDIAC CONDUIT? Y. Harada, S. Uchita, M. Kimura, Y. Toyoda, T. Nishino Department of Cardiovascular Surgery, Nagano Children's Hospital, Azumino, Japan Objectives: We have performed a modified Fontan procedure by 2-stage TCPC using an extracardiac conduit without fenestration. The purpose of this study is to evaluate our clinical experience with a modified Fontan procedure without fenestration. Methods: Between August 1999 and December 2007, 70 consecutive patients with single ventricle physiology underwent a modified Fontan procedure after a bidirectional Glenn shunt using an extracardiac PTFE conduit without fenestration. Age at TCPC ranged from 2 to 9 years (average 3 years) and body weight from 9 to 24 kg (average 13 kg). Preoperative catheterisation showed mean PAP of 9.9±3.0 mmHg, Nakata index of 247±110 mm2/m2, and Rp of 2.1±0.8 unit m2. Nitric oxide gas inhalation started just after cardiopulmonary bypass together with intravenous PD III inhibitor administration. After oral intake started, a pulmonary vascular dilator such as beraprost, sildenafil, bosentan was given orally according to the amount of chest drainage and the patient's condition. After discharge, oxygen therapy was continued at home for three months. Results: No hospital death occurred after surgery. All patients were followed by our institute and no patient died during the follow-up period (average 43 months). Cardiac catheterisation 1–2 years after a modified Fontan procedure showed central venous pressure of 10.9±2.7 mmHg, and systemic output of 3.4±2.1 l/min.m2. SpO2 at catheterisation was 94.4±2.9%. Conclusions: According to our clinical experience with 2-stage TCPC using an extracardiac conduit, we conclude that we do not need fenestration. A modified Fontan procedure without fenestration can be satisfactorily completed with the aid of pulmonary vasodilation therapy. 118 LONG-TERM PATENCY OF THE ‘KISSING’ TECHNIQUE OF FENESTRATION FOR EXTRACARDIAC FONTAN E. Ruiz, R. Guerrero, C. Salih, T. Nguyen, Y. d'Udekem, C. BrizardRoyal Children's Hospital, Melbourne, Australia Objectives: A fenestration in the Fontan circulation will, in the long-term, increase the preload of the ventricle. Thus, reliability of long-term patency is essential. The ‘kissing’ technique of extracardiac conduit fenestration was devised. We assess the long-term patency and clinical outcome. Methods: From 2001 to 2007, 65 patients (median age, 65 months; 33–228) underwent a fenestrated extracardiac Fontan procedure using the ‘kissing’ technique. Hence, the atrial end of the divided inferior vena cava (IVC) was sutured in an end-to-side fashion to the leftward aspect of the conduit away from the edge of the fenestration. All patients received oral anticoagulation. The clinical outcome and the echocardiographic follow-up were reviewed retrospectively. Concurrent follow-up was 100%. Results: The majority of patients (n=60) received an 18 or 20 mm conduit with a 4-mm fenestration. There was one early death (mortality: 1.5%). The median hospital stay was 11 days (5–81). The fenestration was patent in 60 patients at a median follow-up of 11 months (1–91). The mean velocity across the fenestration was 1.6 m/s±0.55. None of these patients required reintervention related to the fenestration. Failure of the Fontan circulation occurred in two patients, requiring Fontan takedown during hospital stay. Two patients required heart transplantation. One patient had percutaneous fenestration closure. All patients remained in sinus rhythm. Conclusions: The ‘kissing’ technique gives reliable long-term patency, is easily reproducible and has low incidence of major complications. The use of the IVC orifice and remote suture line explains the non-thrombogenic and non-arrhythmogenic features. 119 MID-TERM FOLLOW-UP OF THE STATUS OF GORE-TEX GRAFT AFTER EXTRACARDIAC CONDUIT FONTAN PROCEDURE Y. Ochiai, Y. Imoto, M. Sakamoto, T. Kajiwara, A. Sese, M. Watanabe, T. Oono, K. JooKyushu Koseinenkin Hospital, Kitakyushu, Japan Objectives: The extracardiac conduit Fontan (ECF) procedure has some theoretical advantages over other types of Fontan procedures, such as optimised flow dynamics, a lower frequency of arrhythmias, and technical ease of procedure. The main concern is a lack of growth potential, which possibly leads to reoperation for conduit stenosis. In this study, we investigated the change and the status of the Gore-Tex graft used in the ECF procedure by comparing with the patients inferior vena cava (IVC) size. Methods: Between November 1987 and December 2007, 79 patients underwent ECF procedure using Gore-Tex graft. Of these, 36 patients underwent cardiac catheterisation during follow-up period (5.4 years after the ECF procedure). We measured the internal diameter of the conduit and IVC angiographically. Results: Mean follow-up duration was 103±19 months. The conduit diameter used was 14 mm in 1 patient, 16 mm in 17, 18 mm in 10, 20 mm in 7 and 22 mm in 1. The mean conduit-to-IVC cross-sectional area ratio was 0.87±0.29. According to the conduit size, this ratio was 0.82, 0.94 and 0.94 in 16 mm, 18 mm and 20 mm, respectively, which did not differ significantly according to the conduit size. There were no reoperations due to conduit stenosis, kinking, or pulmonary artery distortions. Conclusions: During follow-up of about 5.4 years, conduit cross-sectional area remained stable even with the 16-mm graft. However, careful follow-up is warranted for conduit length, as well as diameter, especially in small children after completion of the Fontan circulation. 120 CLINICAL OUTCOME OF FONTAN OPERATION IN PATIENTS WITH POOR CARDIAC FUNCTION Y. Kotani, S. Kasahara, Y. Fujii, K. Yoshizumi, Y. Oshima, S. Otsuki, T. Akagi, S. SanoOkayama University Hospital, Okayama, Japan Objectives: Although staged Fontan strategy achieves excellent outcome in high-risk patients, low cardiac function has been an increasing factor in early and late mortality. We evaluated the clinical outcome of Fontan operation in patients with low cardiac function. Methods: A retrospective review was performed on 217 patients who had undergone Fontan operation between 1991 and 2007. Results: Twenty-nine (13%) patients had low cardiac function (EF of <50%). Median age at operation was 3 (range 1–31) years. There were five adult patients. Ventricular morphology was right in 20 patients (including 5 HLHS) and left or biventricle in nine patients. Heterotaxy syndrome was present in eight patients. Previous palliation included bidirectional Glenn anastomosis in 24, BT shunt in 2 and pulmonary artery banding in 2. Preoperative EF was 42.8±5.6 (range 30–50)%. Significant atrioventricular valve regurgitation was noted in four patients. Percutaneous oxygen saturation (SaO2) was 82.1±5.2%. Pulmonary artery index and mean pulmonary artery resistance were 296±102 mm2/m3 and 11.1±3.2 mmHg, respectively. All 29 patients tolerated the Fontan operation without early death. There were two late deaths and two reoperations. At median follow-up of 7.5 (1–19) years, EF was 59±15 (35–82)%. SaO2 increased to 92±2%. Cardiothoracic ratio and BNP were 51±8% and 22 (9–382)%, respectively. Three patients had heart failure, seven had arrhythmia, and two developed protein-losing enteropathy. Conclusions: Acceptable clinical outcomes have been achieved at intermediate follow-up of the Fontan operation in patients with low cardiac function. 121 NO-PATCH REPAIR OF AV CANAL J.I. Aramendi1, G. Hamzeh1, A. Crespo1, R. Voces1, M. Luis2, M.A. Rodriguez1, L. Lizama11Division of Cardiac Surgery, Hospital de Cruces, Barakaldo, Spain; 2Division of Pediatric Cardiology, Hospital de Cruces, Barakaldo, Spain Objectives: To describe our technique of no-patch repair of AV canal. Methods: Since 2002, 41 patients were operated upon with the no-patch technique. Thirty-one patients showed complete or intermediate canal: intermediate 7, Rastelli Type A 19, Rastelli Type B 1, Rastelli Type C 3 and AV canal+Fallot 1. Mean age at operation was nine months. In 18 a pericardial patch was used to close the ostium primum. In 13 patients no patch was used to close either the VSD or the ostium primum. Ten patients with partial AV canal were repaired with direct suture of the ostium primum, mean age 13 years. Four of them were operated upon with Heart-Port. No-Patch Technique: the VSD was closed directly, anchoring the common bridging leaflets to the crest of the septum with interrupted stitches. The cleft was closed completely. The atrial defect was closed primarily with running suture anchoring the free edge of the ostium primum to the annulus of the AV valve. Results: Mortality was one patient in the complete AV canal group (3%) and no mortality in the partial AV canal. Mean ischaemic and pump times were 54 and 82 min for the complete AV canal and 31 and 58 min for the partial AV canal respectively. Mean follow-up was 33 months. There were three reoperations in the complete AV canal group (3.7/100 patient/year): 1 subaortic stenosis, 2 residual VSDs. These two patients were re-repaired without patch. Conclusions: AV canal can be repaired without the need of any septal patch. This technique is fast, safe and reproducible. 122 SURGICAL OUTCOMES OF THE MODIFIED SINGLE PATCH TECHNIQUE IN COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT I.S. Jeong, C.-H. Lee, C. Lee, H.G. Lim, J.G. Kwak, I.S. Kim, H. Ch YounSejong General Hospital, Bucheon, Korea (South) Objectives: For the surgical management of complete atrioventricular septal defect, diverse methods have been developed and surgical results have been improved. We compared the surgical results of the modified single patch technique with the conventional 1 or 2 patch technique and examined the usefulness of the modified single patch technique. Methods: From January 1997 to December 2006, 61 patients undergoing total correction for complete atrioventricular septal defect were classified to the modified single patch technique group (group A: n=18) and the conventional 1 or 2 patch technique group (group B: n=43). Median age was 3.5 months in group A vs. 5 months in group B. Results: There was no statistical significance between groups except for aortic cross clamp time. Aortic cross clamp times were shorter in group A (110.8±27.5 vs. 134.4±42.5 min, P=0.03). During the follow-up period, one patient required reoperation for severe right atrioventricular valve insufficiency in group A vs. one patient for severe left atrioventricular valve insufficiency in group B. There was one late death (heart failure) in group A vs. one hospital death (low cardiac output syndrome) and two late deaths (arrhythmia, heart failure) in group B. There were no patients with complete atrioventricular block or left ventricular outflow tract obstruction in either group. Conclusions: The modified single patch technique has the advantage of relatively simple surgical technique and shorter operation time, and thus it is thought to be a potent alternative surgical technique for the correction of complete atrioventicular septal defect.
123 DOES SODIUM NITROPRUSSIDE DECREASE THE INCIDENCE OF ATRIAL FIBRILLATION AFTER MYOCARDIAL REVASCULARISATION? A PILOT STUDY R. Cavolli1, K. Kaya1, A. Aslan2, O. Emiroglu2, S. Erturk1, R. Tasoz3, U. Ozyurda3 1Ulus Hospital, Ankara, Turkey; 2Kavaklidere Umut Hospital, Ankara, Turkey; 3Ankara University Medical School, Ankara, Turkey Objectives: Atrial fibrillation (AF) often occurs following coronary artery bypass grafting (CABG) and can result in increased morbidity and mortality. In this pilot study our aim was to investigate whether sodium nitroprusside, as nitric oxide donor, can reduce the frequency of post-CABG AF. Methods: To investigate the effectiveness of sodium nitroprusside in the prophylaxis of AF, we conducted a prospective, randomised, placebo-controlled clinical study on 100 consecutive patients in whom we performed elective, initial CABG operations. The control group (50 patients) were treated with placebo (dextrose 5% in water), whereas the sodium nitroprusside group (50 patients) were treated with sodium nitroprusside (0.5 µg/kg/min) at the rewarming periods. High sensitivity C-reactive protein levels were measured before surgery and five days postoperatively. All patients were monitored postoperatively with telemetry. Results: The baseline characteristics were similar in both treatment groups. AF in sodium nitroprusside and control groups was 12% and 27%, respectively. The occurrence of AF was significantly lower in the sodium nitroprusside group (P=0.005). The duration of AF in the sodium nitroprusside group was significantly shorter than that in the control group (5.33±1.86 h and 7.55±1.94 h; P=0.023). C-reactive protein levels were higher postoperatively in the control group than in the sodium nitroprusside group (P<0.05). Postoperative AF significantly prolonged postoperative hospital stay (P<0.05). Conclusions: The incidence of postoperative AF in the sodium nitroprusside group was significantly reduced. Further studies are needed to better delineate the anti-AF properties of sodium nitroprusside. 124 PREVENTION OF ATRIAL FIBRILLATION AFTER CORONARY ARTERY BYPASS GRAFTING USING ATRIAL ELECTROMECHANICAL INTERVAL AND AMIODARONE PROPHYLAXIS F. Roshanali, M.H. Mandegar, M.A. Yousefnia, B. SaidiDay General Hospital, Tehran, Iran Objectives: In our previous study on the validity of the atrial electromechanical interval (AEMi), as measured by transthoracic tissue Doppler echocardiography, in determining patients at risk of atrial fibrillation (AF) in the wake of coronary artery bypass grafting (CABG) (post-CABG AF), we defined a cut-off point for the AEMi and chose 120 ms for categorisation, which yielded 100% sensitivity and 94.8% specificity. Accordingly, the present study sought to investigate whether or not prophylactic perioperative administration of amiodarone could reduce the incidence of AF in this high-risk group undergoing CABG. Methods: In this prospective, double-blinded, placebo-controlled, randomised study, 100 patients with AEMi more than 120 ms received either amiodarone (n=50) or placebo (n=50). The endpoints were the occurrence of AF after CABG and the hospitalisation length of stay after CABG. Results: The incidence of postoperative AF was significantly higher in the placebo group than in the amiodarone group (92 vs. 14% of patients, P<0.0001). Prophylactic therapy with amiodarone significantly reduced the intensive care length of stay (1.5±0.3 vs. 2.6±1.8 days, P<0.001) and hospitalisation length of stay (6.1±1.4 vs. 9.0±2.2 days, P<0.001). Conclusions: AEMi could be a valuable method for identifying patients vulnerable to post-CABG AF. The incidence of postoperative AF among patients with high AEMi was significantly reduced by prophylactic amiodarone treatment, resulting in shorter intensive care unit and hospital stays. 125 PROPHYLACTIC INTRAVENOUS MAGNESIUM SULPHATE IN ADDITION TO ORAL BETA BLOCKADE DOES NOT PREVENT ATRIAL ARRHYTHMIAS AFTER CABG: A RANDOMISED CONTROLLED TRIAL R.C. Cook, K.H. Humphries, K. Gin, M.T. Janusz, R. Slavick, V. Bernstein, M. Tholin, M.K. LeeUniversity of British Columbia, Vancouver, Canada Objectives: Atrial arrhythmias (AA) may affect up to 40% of patients following CABG. The best strategy for prevention of AA remains undetermined. However, beta blocker (BB) administration is the standard of care at many centres. Although magnesium sulphate (MgSO4) has been demonstrated to be effective for the treatment of atrial fibrillation, the effectiveness of MgSO4 for prophylaxis of AA after cardiac surgery remains controversial. This study is the largest randomised, placebo-controlled trial of intravenous (IV) MgSO4 for the prevention of AA following CABG. Methods: Eligible patients were consented and randomised to receive either 5 g IV MgSO4, or placebo upon removal of the cross-clamp, followed by daily infusions of MgSO4 or placebo over 4 h, from the day of surgery until postoperative day 4. Approximately 85% of the patients tolerated an increasing dose of oral atenolol, administered according to an established protocol. The primary endpoint was an AA lasting >30 min, or requiring treatment because of haemodynamic compromise. Results: A total of 694 patients undergoing elective CABG were enrolled in the study. There was no difference in the incidence of AA between patients who received IV MgSO4 or those who received placebo. Of the 347 patients in the MgSO4 arm, 89 (25.7%) experienced an AA, compared to 80 of 347 patients (23.1%) in the control arm (P=0.43). Conclusions: In patients proactively treated with oral BB following CABG, the addition of prophylactic daily IV MgSO4 infusions for five days postoperatively did not reduce the incidence of AA. 126 MITRAL VALVE SURGERY PLUS CONCOMITANT ATRIAL FIBRILLATION ABLATION IS SUPERIOR TO MITRAL VALVE SURGERY ALONE WITH AN INTENSIVE RHYTHM CONTROL STRATEGY U.O. Von Oppell1, N. Masani1, P. O'Callaghan1, R. Wheeler1, G. Dimitrakakis1, S.L.H. Schiffelers21University Hospital of Wales, Cardiff, UK; 2Medtronic Bakken Research Center, Maastricht, The Netherlands Objectives: Prospective randomised study comparing patients with atrial fibrillation (AF) (>6 months duration) after MV surgery plus biatrial modified radiofrequency MAZE procedure using the Medtronic Cardioblate system (n=24) vs. MV surgery plus intensive rhythm control strategy (n=25). Methods: Patients were blinded to randomisation. Postoperative echocardiograms, quality of life assessments and ECGs were performed preoperatively, at discharge, and at 3 months and 1–year postoperatively. In both groups, SR restoration was attempted by intra- and postoperative DC cardioversion and class III anti-arrhythmic medication. All patients received warfarin. Amiodarone and warfarin were discontinued after 3 months SR, 24-h Holter or event monitor excluding AF. Results: Both groups underwent MV replacement or repair (16:8 vs. 10:15), had similar gender (male: 33% vs. 56%), age (66±8 years vs. 68±9 years), additional AVR (7 vs. 6), TA (13 vs. 13), and CABG (10 vs. 16). There was 0% operative mortality, 0% postoperative CVA, but two late deaths in the control group. At discharge, 3 and 12 months follow-up, more MAZE patients returned to SR compared to control (29%, 57% and 75% vs. 20%, 43% and 39%; P<0.05). Amiodarone treatment decreased more in MAZE patients over time (92%, 55% and 29% vs. 52%, 52% and 21%; P<0.01), whereas warfarin decrease was comparable (100%, 100% and 71% vs. 100%, 95% and 82%; P=NS). Atrial contribution to LV filling improved equally in both MAZE and control patients in SR at one year (3–24% vs. 11–39%; P=NS).
Conclusions: Radiofrequency MAZE ablation additional to MV surgery resulted in a higher SR conversion rate (75%), despite control group with intensive rhythm control strategy having a higher SR conversion rate (39%) compared to literature ( 127 RISK FACTOR ANALYSIS IN FAILURE OF MAZE PROCEDURE: MID-TERM RESULTS H.-G. Je, J.-W. Lee, S.H. Jung, S.J. Choo, H. Song, C.H. ChungAsan Medical Center, University of Ulsan, Seoul, Korea (South) Objectives: The aim of this study was to evaluate our results of the MAZE procedure in the last decade and analyse the risk factors of AF recurrence after the MAZE procedure. Methods: Between July 1997 and July 2007, 560 consecutive patients underwent MAZE procedures for AF by a single surgeon. The surgical ablation data were prospectively collected and thorough electrocardiogram follow-up was performed by a cardiologist from our institute. Univariate and multivariate analysis for risk factors of AF recurrence were evaluated with comparison between patients who have maintained sinus rhythm and those with recurrent atrial fibrillation. Kaplan–Meier survival curve with Log-rank test was conducted to evaluate survival benefit of sinus rhythm conversion. Results: The mean follow-up period was 37.2±30.8 months (0.1–113.3). Despite 99.3% of MAZE procedures being combined with cardiac surgery, the in-hospital mortality (1.6%) and late mortality (1.8%) rates were acceptable. During follow-up, permanent pacemaker insertion for sick-sinus syndrome was necessary in 12 patients (2.1%). At the last follow-up, restoration of normal sinus rhythm was shown in 83.4% (467/560) of our patients and effective left atrial contraction was identified in 97.6% (456/467) of these patients. In multivariate analysis, older than 60, fine fibrillation wave in preoperative ECG, cardiothoracic ratio over 60%, preoperative left atrial size over 60 mm and failure to revert to sinus rhythm within a day of operation were found as independent predictors of AF recurrence after MAZE procedure. In addition, patients with restored sinus rhythm show better long-term survival. Conclusions: Surgical ablation of AF shows an acceptable success rate. Since we identified the risk factors of AF recurrence from the present study, we have performed thorough ablation technique in high-risk patients. 128 LONG-TERM RESULTS AND RELIABILITY OF CRYOTHERMIC ABLATION BASED MAZE PROCEDURE FOR ATRIAL FIBRILLATION CONCOMITANT WITH MITRAL VALVE SURGERY T. Funatsu, J. Kobayashi, H. Nakajima, Y. Iba, Y. Shimahara, T. YagiharaNational Cardiovascular Center, Osaka, Japan Objectives: In 1998, we introduced cryothermic surgical ablation to treat atrial fibrillation (AF) to reduce operative risk. In this paper, we retrospectively reviewed our clinical results of cryothermic ablation based MAZE procedure concomitant with mitral valve (MV) surgery. Methods: Between June 1998 and December 2005, 268 patients (mean age 61 years) with MV disease and AF underwent cryothermic ablation based MAZE procedure. Surgical procedures for MV were valve replacement in 170 patients, valvuloplasty in 94 and commissurotomy in 4. As concomitant procedure, 70 patients underwent aortic valve surgery and 110 tricuspid valve surgery. Mean follow-up period was 3.8 years. Results: There were 3 (1.1%) in-hospital deaths and 5 (1.9%) late deaths. Actuarial survival rate was 93% at 5 years. Sinus rhythm conversion was obtained on discharge in 92% of patients. Freedom from AF was 84% and 80% at 3 and 5 years after operation, respectively. Larger size of left atrium (>80 mm) and long duration of AF (>10 years) were independent risk factors for failure to convert to sinus rhythm. Conclusions: MAZE procedure utilising cryothermic ablation was a safer, more reliable and also economical procedure for treating AF.
129 WALL MOTION SCORE INDEX PREDICTS MORTALITY AND FUNCTIONAL RESULT AFTER SURGICAL VENTRICULAR RESTORATION FOR ADVANCED ISCHAEMIC HEART FAILURE P. Klein1, E.R. Holman1, M.I.M. Versteegh1, E. Boersma2, H.F. Verwey1, J.J. Bax1, R.A.E. Dion1, R.J.M. Klautz1 1Leiden University Medical Center, Leiden, The Netherlands; 2Erasmus University Medical Center, Rotterdam, The Netherlands Objectives: Advanced ischaemic heart failure (HF) can be treated with surgical ventricular restoration (SVR). While numerous risk factors for mortality and recurrent HF have been identified, no single risk variable for identifying SVR patients with left ventricular (LV) damage beyond recovery is yet available. We tested echocardiographic Wall Motion Score Index (WMSI) as a predictor for mortality or poor functional result. Methods: One hundred and one patients electively operated between April 2002 and April 2007, were included for analysis. All patients had advanced ischaemic HF (NYHA class >II and LVEF <35%). Mean logistic EuroSCORE was 14±12. Mean follow-up was 25±17 months. Preoperatively, a 16-segment echocardiographic WMSI was calculated and receiver-operating characteristic analysis was used to identify cut-off values for WMSI in predicting combined early and late mortality or poor functional result (NYHA-class >II). Results: Operative mortality was 9.9%, late mortality 6.6%. NYHA class improved from 2.9±0.5 to 1.4±0.6. At follow-up until 2 years, 11 patients (13%) were in NYHA class III and the remainder in NYHA class I/II (74 patients, 87%). The optimal cut-off value for WMSI in predicting mortality or poor functional result was 2.19 (sensitivity and specificity, 82%, area under the curve, 0.93). Positive and negative predictive value was 67% and 92%, respectively. Conclusions: Sufficient residual remote myocardium is necessary to recover from an SVR procedure and to translate the surgically-induced morphologic changes into a functional improvement. Preoperative WMSI is a surrogate measure of residual remote myocardial function and is a promising tool for better patient selection to improve results after SVR procedures for advanced ischaemic HF. 130 EFFECTS OF SURGICAL VENTRICULAR RESTORATION ON DIASTOLIC FUNCTION IN PATIENTS WITH ISCHAEMIC DILATED CARDIOMYOPATHY L. Menicanti, S. Castelvecchio, C. de Vincentiis, A. Frigiola, M. Di DonatoSan Donato Hospital, San Donato Milanese, Milano, Italy Objectives: To assess changes in diastolic function (DF) induced by surgical ventricular restoration (SVR) in patients with ischaemic cardiomyopathy and symptoms of angina and heart failure. Methods: One hundred and one patients (14 F, 65±9 years) operated for SVR at our centre received a complete echocardiographic study before SVR, at discharge and at follow-up. DF was explored using the transmitral flow velocity curve and diastolic pattern (DP) was graded from 0 (normal) to 3 (restrictive). Patients with mitral regurgitation were excluded. SVR was conducted on the arrested heart using an intraventricular device to re-size and re-shape the LV chamber. Results: Median time from operation to follow-up was 6 months. DP and E/A did not change significantly. Five patients had restrictive pattern before operation that improved in 4 at late control. Eighteen patients developed a restrictive pattern at follow-up. Compared to patients who did not have restriction after surgery, they were younger (61±7 vs. 66±9, P=0.018), had greater preoperative LV dimensions, P=0.022, lower EF (29±7 vs. 35±8, P=0.008), more spherical ventricle (sphericity index, 0.58±0.7 vs. 0.51±0.1, P=0.03). EF improved from 33±9 to 40±9 to 40±9%, P=0.001; end diastolic and end systolic volumes decreased significantly (195±64 to 132±42 to 160±62, P=0.001 and 133±59 to 81±33 to 98±49 ml, respectively, P=0.001). NYHA class improved (2.4±0.8–1.6±0.6, P=0.001). Conclusions: Systolic function improves in all patients. Diastolic function does not change significantly. Diastolic restriction after SVR occurs in 18% of the patients. 131 SHORT-TERM SYSTOLIC AND DIASTOLIC VENTRICULAR PERFORMANCE AFTER SURGICAL VENTRICULAR RESTORATION FOR DILATED ISCHAEMIC CARDIOMYOPATHY T. Bove, Y. Van Belleghem, G. Vandenplas, F. Caes, K. François, J. De Backer, M. De Pauw, G. Van NootenUniversity Hospital of Ghent, Ghent, Belgium Objectives: To report on the early results of surgical ventricular restoration (SVR) as adjunct therapy for dilated ischaemic cardiomyopathy. Methods: Using LV volume determination as primary indication for SVR, 21 patients with SVR/CABG/MVP (group 1) were compared to 54 patients undergoing solely CABG/MVP (group 2). Analysis focused on clinical outcome and short-term echocardiographic assessment of systolic and diastolic LV performance. Results: Thirty-day mortality was 14% (group 1) vs. 7% (group 2) (P=0.05). Within a mean follow-up of 18±7 months, Group 1 included 2 late deaths and 3 re-hospitalisations compared to 1 late death and 8 re-hospitalisations in group 2. Echocardiography revealed a greater improvement of LVEF (27–38% vs. 37–43%) and wall motion score index (2.21–1.79 vs. 1.77–1.61) within 1 year, correlating with the greater LV volume reduction after SVR (LVEDVI 19% vs. 6%, LVESVI 12% vs. 7%; P=0.001). Diastolic LV dysfunction worsened progressively during the first year after SVR, indicated by E/A ratio increase (1.29–1.84; P=0.05) and shortened deceleration time (167 >150 ms). This correlated with secondary increase of LV volumes, recurrent mitral regurgitation and withdrawal of diuretic therapy. Conclusions: SVR in addition to CABG and MV annuloplasty results in early improvement of systolic LV function, whereas this occurs more progressively after isolated CABG and MVP. However, it entails a time-dependent impairment of the diastolic LV function related to secondary remodelling within the first year. Further study is required to define whether this diastolic dysfunction is reversible or is a subtle precursor of subsequent systolic dysfunction. 132 SURGICAL VENTRICULAR RESTORATION FOR ENDSTAGE ISCHAEMIC CARDIOMYOPATHY H. Suma1, H. Tanabe1, T. Isomura2, T. Horii31The Cardiovascular Institute, Tokyo, Japan; 2Hayama Heart Center, Kanagawa, Japan; 3Kagawa University, Kagawa, Japan Objectives: A poorly functioning, dilated left ventricle with mitral regurgitation is an ominous condition in chronic ischaemic heart failure. Our seven years experience of combined mitral valve and left ventricular reconstruction was evaluated. Methods: In 246 patients who had undergone left ventriculoplasty for postinfarction left ventricular dysfunction, operative mortality was 5.6% and 5-year survival rate was 71%. There were 76 patients with advanced heart failure due to dilated ischaemic cardiomyopathy with mitral regurgitation (70 men and 6 women with a mean age of 60 years). All patients had NYHA class III (n=41) or IV (n=35) heart failure including 26 patients (34%) on inotropic support before the operation. All patients had mitral regurgitation more than 2+ and 46 patients (61%) had 3+ or more. Mitral reconstruction (repair 61, replacement 15) and LV plasty (Dor 34, SAVE 36, PLV 6) were performed in combination with CABG (74%). Results: Operative mortality was 7.9% (5.0% in 60 elective and 18.8% in 16 emergency operations). EF and cardiac index increased from 24.9±7.0% to 33.3±8.7%, and 2.0±0.4 l/m2/min to 2.6±0.4 l/m2/min, respectively (P<0.001). EDVI, ESVI and diastolic dimension decreased from 165.9±43.2 ml/m2 to 121.2±31.1 ml/m2, 123.3±38.9 ml/m2 to 84.0±27.5 ml/m2, and 69.5±7.7 mm to 61.2±7.1 mm, respectively (P<0.001). There were 13 late deaths (17.1%) with 10 cardiac deaths. One- and 5-year survival was 81.3% and 65.6%, respectively. Mean NYHA class was improved from 3.5–1.4 in the survivors. Conclusions: Combined mitral and left ventricular reconstruction is effective in treating advanced heart failure with endstage ischaemic cardiomyopathy.
133 THE ROLE OF THORACOSCOPY FOR THE DIAGNOSIS OF HIDDEN DIAPHRAGMATIC INJURIES IN PENETRATING THORACOABDOMINAL TRAUMA R. Bagheri, A. Tavassoli Mashhad University of Medical Science, Mashhad, Iran Objectives: Penetrating thoracoabdominal stab wounds may cause diaphragmatic and abdominal organs laceration and 15–20% of these patients may have hidden diaphragmatic injuries that would ultimately lead to chronic diaphragmatic hernia. In this study we have assessed accurate diagnostic value of thoracoscopy in diagnosing occult diaphragmatic injuries in penetrating thoracoabdominal stab wounds. Methods: Thirty patients with penetrating thoracoabdominal injuries who were stable haemodynamically and did not need emergency exploration were enrolled in this study. They underwent thoracoscopy to evaluate probable diaphragmatic injury, from March 2005 to October 2007. Diaphragmatic injuries were repaired via thoracoscopy or laparatomy and all patients were evaluated for chronic diaphragmatic hernia by CT-scan, six months later. Results: Mean age was 26.2 years and M/F was 5:1. We observed 5 hidden diaphragmatic injuries (16.7%) in thoracoscopic evaluations; 3 cases (9.9%) were repaired through thoracoscopic approach and laparatomy was inevitable in 2 (6.6%) patients. Lung parenchymal laceration was seen in two patients (6.6%), where repair was performed with thoracoscopy, and intra-abdominal injury was seen in one patient (3.3%), where repair was performed with laparotomy. No complication was reported after thoraco-scopy. There was no evidence of chronic diaphragmatic hernia on chest and abdominal CT-scan performed 6 months later. The diagnostic accuracy of thoracoscopy in occult diaphragmatic injuries in our study was 100%. Conclusions: Because of its high diagnostic accuracy rate, minimal invasiveness and diagnostic treatment ability, we recommend that thoracoscopy be performed in all clinically stable patients with penetrating thoracoabdominal stab wounds. 134 FEASIBILITY OF VIDEO-ASSISTED THORACOSCOPIC SURGICAL SEGMENTECTOMY FOR SELECTED PERIPHERAL LUNG CARCINOMAS A. Watanabe, S. Nakashima, S. Ohori, T. Mawatari, T. HigamiDepartment of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan Objectives: Segmentectomy for non-small cell lung cancer (NSCLC) is believed to increase the rates of recurrence and postoperative air leak. We sought to present our clinical data and outcome of VATS segmentecomies (VSs) with systematic node dissection for selected NSCLC patients. Methods: Inclusion criteria are clinical T1N0M0 peripheral NSCLC 2 cm or smaller (n=38) and NSCLC with interlobar invasion, which causes positive surgical margin with malignancy after partial resection of invasion site (n=3). Outcome variables include hospital course, complications, mortality, recurrence patterns and survival. The intersegmental border was identified using the intersegmental veins as landmarks and the demarcation between the resected (inflated) and preserved (collapsed) lungs. The intersegmental plane was divided by an endoscopic stapler and electrocautery. Results: The median operative time and intraoperative bleeding were 210 min (range 100–310) and 100 ml (30–730), respectively. The number of stapler cartridges used for intersegmental division was 2 (1–5). Postoperative air leak (>7 days) occurred in two patients. The chest tube drainage duration was 3 days. There were no in-hospital deaths. The numbers of resected subsegments and reserved subsegments in comparison with lobectomy were 5 (2–9) and 5 (3–11), respectively. The FEV1.0 after VS was higher than predictive FEV1.0 after lobectomy, if the latter was performed as standard procedure. We experienced four cases of distant metastasis after segmentectomy, but there was no case of local recurrence. The 5-year survival and recurrence-free survival in pathological stage IA NSCLC was 89.9% and 93.3%, respectively. Conclusions: VS with systematic node dissection is a reasonable treatment option for selected peripheral NSCLC. 135 VATS LOBECTOMY PRESERVES MORE CHEST WALL MUSCLE THAN CONVENTIONAL SURGERY T. Karasaki, J. Nakajima, M. Kusakabe, Y. Yoshida, Y. Suka, S. Takamoto, M. Taguri, H. OhtsuThe University of Tokyo Graduate School of Medicine, Tokyo, Japan Objectives: Video-assisted thoracic surgery (VATS) lobectomy for early lung cancer is technically feasible. Comparative studies of VATS and conventional thoracotomy have indicated that VATS may reduce inflammatory reactions, wound pain, and impaired respiratory function postoperatively. We sought to determine if VATS preserved chest wall muscle volume postoperatively better than thoracotomy. Methods: Consecutive patients who underwent lobectomy between 2004 and 2006 for Stage IA non-small cell lung cancer through VATS (VATS group) or posterolateral thoracotomy (PLT group) at our institution were eligible for the study. Cross-section areas of bilateral latissimus dorsi muscle (LDM) at the lower end of the scapula were obtained by computed tomography preoperatively and one year after the surgery. These were quantified with image analysis by two researchers in a blinded manner. Results: Sixteen patients in the VATS group (mean age=69 years, 10 male patients) and 28 patients in the PLT group (mean age=62 years, 16 male patients) were assessed. Postoperative/preoperative rates of LDM cross-section area of surgical side were 87±21% (mean±S.D.) in the VATS group and 57±15% in the PLT group (P<0.001, t-test). Those of the non-surgical side were 86±24% in the VATS group and 97±17% in the PLT group (P=0.08, t-test). Conclusions: We suggest that VATS may prevent atrophy of chest muscles and contribute to preserved quality of life postoperatively in comparison with conventional PLT for lobectomy in lung cancer. 136 TOTALLY THORACOSCOPIC PULMONARY SEGMENTECTOMY H. Oizumi, N. Kanauchi, H. Kato, M. Endoh, J. Suzuki, K. Fukaya, M. Chiba, M. SadahiroYamagata University School of Medicine, Yamagata, Japan Objectives: Only a few reports of totally thoracoscopic pulmonary segmentectomy are currently available. The safety and feasibility of the procedure was evaluated. Methods: During 2004, 30 patients underwent totally thoracoscopic segmentectomy. Median age was 69 years (range, 16–81 years). Operative procedures are detailed as follows: One 20- or 15-mm sized flexible port, a 10-mm port and two 5-mm ports were used. Vessel and bronchus were mainly dissected using a ligation technique and a stapler, respectively. Parenchymal dissection was done with an electrocautery along the intersegmental pulmonary veins or inflation-deflation line. Stapler was used to dissect the peripheral lung. In anatomically complex cases, intersegmental pulmonary veins were identified preoperatively and individual operative dissections were simulated with the aid of 3-dimensional volume-rendering method of contrast CT. Results: Indications for pulmonary resection included lung cancer (n=25), metastatic disease (n=1), and other diagnoses (n=4). One case required conversion to mini-thoracotomy procedure because of arterial bleeding and another one required conversion to open lobectomy because of an oncological issue. Operating times ranged from 146–425 min (median, 216 min) and bleeding ranged from 3 to 305 g (median, 100 g). Chest tubes were left in place for 1–7 days (median, 1 day). One patient showed postoperative subcutaneous emphysema. No patients suffered 30-day mortality. Local recurrence or metastases have not been observed in malignant cases. Conclusions: Although thoracoscopic segmentectomy is a time-consuming and as yet unexplored procedure, it is considered to be a good option for sublobar anatomical pulmonary resection. 137 CERVICAL APPROACH TO INVESTIGATING PLEURAL DISEASE L. Fowkes, N. Shah, K. Lau, M.H. Chamberlain, E.A. BlackDepartment of Thoracic Surgery, Nottingham City Hospital, Nottingham, UK Objectives: In pleural disease, investigation is typically performed using intercostal thoracoscopy/pleuroscopy. This may precede or be combined with cervical mediastinoscopy to study lymphadenopathy and stage malignancy. A cervical approach to the pleural space permits performance of both investigations simultaneously. However, information regarding its practice is scarce. Methods: Over 18 months, 14 patients underwent the procedure. Indications were staging (n=10) and diagnosis of pleural thickening with associated lymphadenopathy (n=4). The technique comprised cervical mediastinoscopy, lymph node sampling, pleural biopsy and irrigation (following thoracoscope entry to the hemithorax through the neck). Talc poudrage was performed in 2 cases. Finally, an intercostal drain was brought out through the neck. Results: Thirteen patients (93%) were male. Median age: 63 years (52–73). Seven right- and 7 left-sided thoracoscopic biopsies were performed. Histopathology revealed benign disease (n=3), lymphoma (n=1) and mesothelioma (n=10). In mesothelioma cases, all with the exception of 1 (sarcomatoid) were of epithelioid cell type with no evidence of lymph node metastasis. Median in-patient stay (excluding the lymphoma case) was 2.5 days (1–5). The lymphoma patient was complicated by preoperative renal failure, developing acute lung injury necessitating a 22-day stay. There were no mortalities, bleeding complications, mediastinal infections or evidence of tumour seeding in the remaining cases. Conclusions: Cervical pleuroscopy may be used to diagnose pleural disease and stage thoracic malignancy. It appears a safe method, utilises a small incision and is well tolerated. Longer-term follow-up is necessary to determine mediastinal contamination risk. 138 INTENTIONALLY LIMITED VATS RESECTION FOR SMALL SIZED NON-SMALL CELL LUNG CANCER M. Oda, I. Matsumoto, T. Yachi, T. Imagawa, M. Hada, T. Itoh, G. WatanabeDepartment of General and Cardiothoracic Surgery, Kanazawa University Hospital, Kanazawa, Japan Objectives: Small sized resectable lung cancers are found more frequently with widespread use of HRCT and PET in Japan. We evaluated our results of intentional limited VATS resection for small sized non-small cell lung cancer. Methods: The indication of intentional VATS limited resection is clinical stage IA lung cancer <2 cm in tumour diameter. Wedge resection was performed if tumour showed pure or nearly pure ground glass opacity (GGO) on CT-scan. Segmentectomy was performed if tumour did not show pure or nearly pure GGO on CT-scan. Between January 2000 and March 2008, among 830 resected lung cancer patients, 91 patients (11%) underwent segmentectomy and 112 (14%) underwent wedge resection. Results: There were 99 men and 104 women with a median age of 64 years. Histology was adenocarcinoma in 191 patients (94%). Postoperative stage was IA in 191 patients, IB in 4, IIA in 4, IIIA in 2, and IIIB in 2. Median tumour diameter was 11.3 mm in the wedge resection group and 16.6 mm in the segmentectomy group. There were no hospital deaths and no severe morbidity. Four cases in the segmentectomy group had distant metastasis (lung in 1, bone in 2, liver in 1), but there was no local recurrence. Cause-specific and overall 5-year survival was 100% and 97.5% in the wedge resection group, and 100% and 98.5% in the segmentectomy group with median follow-up of 27 months. Conclusions: Intentional limited VATS resection is a safe procedure and can be an alternative standard operation for selected patients with small sized non-small cell lung cancer.
139 MINIMALLY INVASIVE MITRAL VALVE SURGERY VIA RIGHT MINITHORACOTOMY: EXPERIENCE WITH 750 PATIENTS M. Glauber, M. Murzi, S. Bevilacqua, A.G. Cerillo, E. Kallushi, M. Ferrarini, P. Farneti, M. Solinas Ospedale del Cuore Monasterio Foundation IFC CNR, Massa, Italy Objectives: We report our institutional experience with minimally invasive mitral valve operations, reviewing short-term morbidity and mortality and echocardiographic follow-up. Methods: Since February 2003, 750 consecutive patients had video-assisted minimally invasive mitral valve operations via right mini-thoracotomy (4–7 cm). Mean age was 61±13 years and 10% (n=75) of patients had previous cardiac operations. Mean EuroSCORE was 8.6 (range 2–54). Urgent operation was performed in 81 patients (10.8%). Arterial cannulation was central in 85.7% (n=643) and femoral in 14.3% (n=107). Transthoracic aortic clamp was used in 84.2% (n=632), port access endoclamp in 91 patients (12.1%) and hypothermic ventricular fibrillation in 27 patients (3.7%). Results: Procedures performed were: mitral valve repair, n=588 (78.4%), replacement n=164 (21.6%) and associated tricuspid valve repair n=89 (11.8%). Hospital mortality was 1.7% (13/702). Mean cross-clamp time was 92±25 min and cardiopulmonary bypass time was 129±44 min. Fourteen patients (1.8%) had conversion to sternotomy. Twenty patients (2.6%) underwent re-exploration for bleeding. Mean intensive care unit and hospital stay were 20 h and 7.4 days, respectively. Perioperative morbidity included permanent neurologic deficit in five patients (0.6%), acute renal failure in nine patients (1.2%) and aortic dissection in one patient (0.1%). Post-discharge echocardiographic follow-up (26±11 months) demonstrated 90.1% of the repair patients had only trace or no residual mitral insufficiency. Conclusions: Our experience demonstrates that video-assisted minimally invasive approach to mitral valve operations is reproducible with low perioperative morbidity, mortality and with late outcomes similar to conventional surgery. 140 MECHANISM OF CARDIOPROTECTIVE PROPERTIES OF ERYTHROPOIETIN DURING COLD GLOBAL ISCHAEMIA AND REPERFUSION A. Bogdanova3, D. Mihov3, G. Zünd2, M. Gassmann4, R. Tavakoli11Department of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland; 2Department of Surgical Research, University Hospital Zurich, Zurich, Switzerland; 3Institute for Veterinary Physiology, Vetsuisse Faculty, Zurich, Switzerland; 4Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland Objectives: Human recombinant erythropoietin (hrEpo) efficiently reduces myocardial ischaemia-reperfusion injury in experimental settings. The mechanism of cardioprotective properties of hrEpo is unknown. Methods: Hearts of donor rats were arrested with cold crystalloid cardioplegia and after 45 min of cold ischaemia grafted heterotopically into the abdomen of recipient rats. Recipients were randomly assigned to control non-treated or Epo-treated group receiving 5000 U/kg of hrEpo intravenously 20 min prior to reperfusion. At 5 time points 5–1440 min after reperfusion the recipients (n=6–8 at each point) were sacrificed, and blood and grafted hearts harvested. Results: Myocardial damage assessed by plasma Troponin T was significantly reduced in the Epo-treated group (0.38±0.05 vs. 1.80±0.59 pg/ml, P<0.01). hrEpo treatment abolished reperfusion-induced depletion of reduced glutathione observed in non-treated hearts (baseline 2.29±0.06, non-treated 1.60±0.31, Epo 2.28±0.30 mmol/kg wet tissue, P<0.05). NO production assessed by plasma NO2- was up-regulated by Epo (1348±193 vs. 860±57 nmol/l, P<0.05). Apoptosis assayed by caspase 3 activity was minimal in both non-treated and Epo-treated heart grafts (1.71±0.44 vs. 1.19±0.33% of maximal caspase 3 activity, induced by staurosporin in endothelial cell culture, P=ns). Correspondingly cleaved PARP and Tunel staining did not reveal significant apoptosis in grafted hearts of either group. Epo did not activate protein kinase B-depending signaling cascade in grafted hearts of either group. Conclusions: Administration of Epo protected ischaemic hearts against reperfusion-induced oxidative stress and necrosis. Our data indicate minor involvement of apoptosis in the reperfusion injury. Cardioprotective properties of hrEpo are mediated by up-regulation of NO production in vascular endothelium rather than by its interaction with myocardial Epo-receptors. 141 MINIMALLY INVASIVE OFF-PUMP VALVE-IN-A-RING IMPLANTATION: THE ATRIAL TRANSCATHETER APPROACH FOR REOPERATIVE MITRAL VALVE REPLACEMENT AFTER FAILED REPAIR J. Kempfert, J. Blumenstein, M.A. Chu, S. Lehmann, T. Kobilke, V. Falk, F.W. Mohr, T. WaltherDepartment of Cardiac Surgery, Heartcenter, University of Leipzig, Leipzig, Germany Objectives: Based upon recent developments in transcatheter technology, this study was designed to evaluate the feasibility and haemodynamic performance of transcatheter valve-in-a-ring (VinR) implantation for potentially failed mitral repair using a minimally invasive, trans-atrial, off-pump approach. Methods: Seven adult sheep (54.3±3.0 kg) underwent mitral< |
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2 segments in RV [14 (61%) TOF vs. 1 (13%) control; P=0.02] and septum [7 (44%) TOF vs. none control; P=0.04]. Multivariable analysis identified transannular patch as predictive of greater segmental dyssynchrony (P=0.003). In TOF, PR grading (9-absent, 6-mild, 5-moderate, 3-severe) by itself was not predictive of RV end-diastolic area index (RVEDAI) or early outcome. In the presence of PR, the magnitude of RV dyssynchrony correlated with increased RVEDAI (r=0.73, P=0.004), longer ventilation (r=0.64; P=0.01), ITU time (r=0.68; P=0.008), and pleural/pericardial effusion (P=0.007); but not with CI, SVO2, or lactate. This relationship was not seen in the absence of PR. 
2, P>0.05). However, patients requiring one or multiple reoperations showed significantly poorer psychological functioning (P=0.035) and QoL (P=0.015, Mann–Whitney-Test) scores than non-reoperated ones. The additional questionnaire revealed that 5% of patients underwent no further education, 14.4% received a disability pension (no significant difference among diagnosis groups), 20.6% declared having had problems with health or life insurance acquisition. 7.7% of women admitted renouncing their pregnancy because of the CHD. 
2 cm), T1b (>2 to 
20%). MAZE ablation resulted in normalisation of atrial function in patients converted to SR.