P1 Single-Center Early Experience in Frozen Elephant Trunk Surgery with New Thoraflex Hybrid Prosthesis
Vito Giovanni Ruggieri, Andrea Antonazzo, Giovanni Concistrè, Andrea Albertini, Bruno Madaffari, Alfonso Agnino. S. Anna Hospital, Catanzaro, Italy.
Objective: The frozen elephant trunk (FET) technique has been conceived to treat complex aortic pathologies (CAP) such as degenerative or dissecting aneurysms involving the aortic arch and descending aorta as a potential ‘single-stage’ procedure. Few different devices are available to perform the FET. We report our early experience with the new hybrid device Thoraflex (Vascutek, Ltd., Scotland, United Kingdom).
Methods: Since September, 2013, three patients (mean age 69±12.1 years) underwent one stage FET surgery for CAP. The first case was a redux chronic aortic dissection with aneurysmal evolution of the arch and descending aorta. The second was a double thoracic aortic aneurysm (ascending aorta/proximal arch and descending aorta). The third was an important descending aorta aneurysm (9 cm) with TEVAR contra-indication. During circulatory arrest and selective antegrade cerebral perfusion, the collapsed endoprosthesis was deployed into the descending aorta through the opened aortic arch. Ischemic and operative times as well as adverse events were monitored.
Results: The proximal 4-branched graft was appreciated for its sewing collar, which facilitates and makes safe the distal anastomosis. Moreover it allows a separate reimplantation of the arch vessels potentially reducing the ischemic time. The FET procedure was performed in all cases without technical problems. The CPB time was 231.6±10.5 min, aortic cross-clamp time was 131.6±28.5 min and circulatory arrest time was 95.5±33.2 min. Postoperative course was uneventful. Postoperative CT-scans confirmed the desired results.
Conclusions: The new hybrid device Thoraflex adds to the armament of the surgeon in the treatment of CAP. Its particular features can potentially make the FET procedure safer and easier.
P2 Off-Pump Debranching and TEVAR for Aortic Arch Pathology
Tamer Ghazy1, Ahmed Mashhour1, Ahmed Ouda1, Hans-Joachim Florek2, Klaus Matschke1, Utz Kappert1. 1Dresden Heart Center, Dresden University of Technology, Dresden, Germany, 2Weißeritztal-Kliniken GmbH Freital/Dippoldiswalde, Freital, Germany.
Objective: To analyze the feasibility and results of off-pump aortic arch debranching and stenting for treatment of aortic arch pathology, where a total circulatory arrest even with selective cerebral perfusion might be risky.
Methods: From June, 2012, through April, 2013, 7 patients with extensive aortic arch pathology, where an off-pump treatment strategy was preferred due to a past history of cerebrovascular accidents (CVA) in 3 patients and extensive renal insufficiency in the other 4. The aortic arch pathology included 4 aortic dissections and 3 aortic aneurysms. The patients underwent an off-pump arch debranching, followed by aortic arch stenting in the same setting. The aortic stent implantation was performed either via a standard transfemoral approach or in an antegrade manner via the ascending aorta.
Results: The mean operative time was 184 min. No conversion to cardiopulmonary bypass support was needed. Rethoracotomy for bleeding was necessary in one patient. Postoperative dialysis was needed in one patient. A new CVA was reported in one patient. The 30-day mortality was one patient.
Conclusions: Off-pump aortic debranching with arch stenting is a feasible procedure that could be considered in patients with arch pathology. This treatment concept should be especially considered in patients with a history of CVA or severe renal insufficiency, as it alleviates the risks associated with total circulatory arrest, lowering the procedural risk and yielding more favorable results.
P3 Minimal Access Surgery of the Ascending Aorta: Is This Procedure Safe?
Peter Lukas Haldenwang, Mahmoud Elghannam, Markus Schlömicher, Matthias Bechtel, Vadim Moustafine, Justus Strauch. BG University Hospital Bergmannsheil Bochum, Bochum, Germany.
Objective: Minimally invasive surgery (MIS) offers an alternative to the standard full-sternotomy access to the ascending aorta. We undertook this clinical study in order to evaluate the safety of MIS for ascending aorta replacement in terms of perioperative complication rate, hospitalization time and the occurrence of major adverse cerebral or cardiac events (MACCE).
Methods: 65 patients (75% male; age 67±12 years; BMI 30±6 kg/m2; EuroSCORE II 4.1±4.5; ejection fraction 55±9%) with ascending aortic aneurysm (diameter: 53.2±6.6 mm) underwent replacement of the ascending aorta via an upper partial “J”-shape sternotomy as follows: supra-coronary replacement 66%, concomitant aortic valve replacement 54%, Bentall-procedure 21%, aortic valve repair/reconstruction (David-procedure) 9%, and isolated aortic-root replacement 4%. Mean operation time was 229±84 min, CPB-time 129±62 min, aortic cross-clamp-time 97±48 min.
Results: Postoperative mean ICU-stay was 1.6±1.6 days with a ventilation-time of 12.3±5 hours. Through the entire cohort no re-thoracotomy for bleeding was needed; the mean chest-tube output was 528±333 ml/24h. During the ICU-stay an average of 3.5 erythrocytes concentrates, 1.1 g fibrinogen and 613 IE PPSB were needed. The overall stroke rate was 1.5%. The 30-day survival-rate was 100%. No cardiac infarction, septic event, wound disturbance or thorax instability occurred during the hospitalization period.
Conclusions: Replacement of the ascending aorta via a minimally invasive partial sternotomy requires longer operation, bypass and cross-clamp times than the standard access. Nevertheless, the MIS-strategy is less traumatic for the patient, providing a faster recovery, a reduced bleeding rate and a short ICU stay. Because of its excellent results and its low MACCE-rate in the hands of the experienced, we find the MIS-approach favorable for ascending aortic surgery.
P4 Design of a Fully Anatomic Aortic Root Graft
J. Scott Rankin1, Philip S. Crooke1, L. Alan Beavan2, Charles D. Griffin2. 1Vanderbilt University, Nashville, TN USA, 2BioStable Science and Engineering, Inc., Austin, TX USA.
Objective: Aortic root grafts have been developed that generally flare outward in the sinus region, and this feature has contributed importantly to technical procedural ease. However, current devices are not based on normal geometry, and a fully anatomic aortic root graft could facilitate valve-sparing root procedures.
Methods: High-resolution CT angiograms from 11 normal human aortic roots were used to generate high-density x, y, z coordinates of valve and root structures in Mathematica. Three-dimensional least squares regression analyses of leaflet-sinus coordinates precisely assessed geometry of the aortic valve and root. Shapes and dimensions of all root components were quantified, and minor variations were simplified.
Results: In 3-dimensional least square regression analyses, normal aortic root geometry was represented as 3 leaflet-sinus general ellipsoids nested within a funnel-shaped aorta. Sino-tubular junction diameter was uniformly 5 mm larger than the valve base, consistent with an observed 10-degree outward commissural flare. Thus, aortic diameter flared outward from the base to the mid-valve region, but was cylindrical above that. The base of the valve was elliptical (minor-major diameter ratio = 0.65), but the mid-aorta and sinotubular junction were circular above the mid-valve level. Commissural post location on the base circumference was symmetrical. Based on the average 3-dimensional diameters of the 3 sinus ellipsoids, 2 design variations in an aortic root graft were developed (Fig. P4-1). A partial root graft (left) represented the normal anatomy for a remodeling procedure (used in conjunction with a sub-annular aortic annuloplasty ring of the same design). Additionally, a full root graft (right) with incorporated annuloplasty ring could be used for reimplantation procedures or for RV outflow tract reconstruction using additional glutaraldehyde-fixed autologous pericardial leaflets.
Conclusions: An anatomic aortic root graft was designed based on mathematical analyses of CT angiograms. The design incorporated 3 fully anatomic sinuses, commissural symmetry, 10-degree outwardly flaring commissural posts, and modest outward lower aortic flare. These more anatomic grafts could prove useful for restoring aortic root geometry toward normal during reparative aortic valve and root surgery.
P5 Aortic Valve Reconstruction for Aortic Valve Insufficiency: A Single-Center Long-Term Experience
Stephan Jacobs, Simon H. Sündermann, Volkmar Falk. University Heartcenter Zürich, Zürich, Switzerland.
Objective: Aortic valve reconstruction following the Tirone David principle is a complex but efficient procedure for aortic valve insufficiency with good results. The objective of this study was to retrospectively investigate the short- and long-term results of this procedure in our center.
Methods: Data from 100 patients was retrospectively analyzed. Endpoints were long-term survival and reoperation rate. Continuous data is given as mean with standard deviation; linear data is given as parts.
Results: Mean age of patients was 47±15 years, 83% were female. 51% had aortic insufficiency (AI) grade 3 or 4 preoperatively and 22% had a bicuspid valve. 13 patients were operated as an emergency because of aortic dissection Stanford Type A. 29% were diagnosed with Marfan syndrome through histology. 43% had diagnosed hypertension, 4% had preoperative stroke and 1% had preoperative renal impairment. Mean ejection fraction preoperatively was 60±10%. The main part of the patients had no symptoms 72%. 4% were in NYHA class III. The rest were in class I or II. Mean diameter of the aortic root was 5.2 cm. The operation was performed as a redo procedure in 9% of cases. 10 patients had additionally a bypass operation; 5 patients an additional valve operation other than the aortic valve. In 7 patients, aortic arch surgery was performed additionally. Mean CPB time was 210±86 min. Mean cross-clamp time was 148±60 min. Postoperative echocardiography showed no AI in 24% of cases. 40% had trivial AI and 28% had mild AI. In 6% of cases moderate AI was seen. 2 patients showed persistent severe AI resulting in immediate conversion to valve replacement. 5 further patients had a reoperation due to new AI, aortic stenosis or endocarditis between 20 months to 124 months after the initial operation. Mean follow-up time was 42 months; median follow-up was 27 month (0-211 month). 5-year survival was 94.1±3% (1.1 death/100 patient years).
Conclusions: Short- and long-term outcomes of the Tirone David procedure shows good results with high survival and low reoperation rates; also, if performed in patients with aortic dissection and bicuspid valve.
P6 Mini-Sternotomy for Aortic Root Replacement: A Big Operation Through a Small Incision
Clare L. Burdett, Ignacio Bibiloni Lage, Enoch F. Akowuah, Ralph W. White, Khalid J. Khan, Andrew T. Goodwin, James Cook University Hospital, Middlesbrough, United Kingdom.
Objective: Minimally invasive AVR is an increasingly accepted technique. Aortic root replacement (ARR), however, is technically more challenging, meaning few centers perform it through a minimally invasive approach and with very little data published. After establishing a mini aortic valve program, we have extended this expertise to aortic root surgery. We sought to compare our full sternotomy (Standard-Root) and minimally invasive (Mini-Root) approaches.
Methods: One surgeon started performing Mini-Roots from April, 2012. We retrospectively analyzed our prospectively maintained database and reviewed the surgeon’s isolated ARR practice over an 18-month period (April, 2012 - September, 2013). Surgical approach was according to patient and surgeon choice. Surgery was performed through a mini-sternotomy via the 3rd intercostal space.
Results: Nine Standard-Roots and 7 Mini-Roots were performed. Pre-operative demographics and risk scores were similar. Mean additive UroScore Standard-Root 8.9 versus Mini-Root 7.7. Mean CPB time 108 versus 114 mins and cross-clamp time 75 versus 88mins were longer for the Mini-Roots. No Mini-Roots were converted. Post-operative blood loss was less for the Mini-Roots (436 versus 246ml) and fewer patients received blood transfusions (mean 56% versus 14%). Post-operative complications were similar in both groups with no deaths or strokes. Length of stay (8.4 versus 5.7days) was shorter in the Mini-Root group.
Conclusions: We have demonstrated that aortic root surgery through a mini-sternotomy is feasible with at least equivalent results to a full median sternotomy, permitting further cases to be performed for validation. Our experience has shown potential benefits of a Mini-Root include reduced blood loss, less transfusion and shorter hospital stays.
P7 Minimal Invasive Approach for Bentall de Bono Procedure: A Single-Center Experience
Radoslaw Smoczyński, Wojciech Sarnowski, Bartlomiej Szafron, Anna Witkowska, Dominik Drobinski, Zygmunt Kalicinski, Piotr Suwalski. Central Teaching Hospital MSW, Warsaw, Poland.
Objective: Ascending aortic aneurysm with a root extension and aortic valve dilatation is a rather more challenging procedure and usually full sternotomy is used. The aim of the study was presenting minimal invasive approach as possible access for the Bentall de Bono procedure.
Methods: 7 elective patients from 54 minimal invasive aneurysm operations prepared between 2011-2013 in our center were subanalyzed. Mean age was 54.14±13.17 (100% male). All patients had ascending aortic aneurysm with bicuspid aortic valve insufficiency amenable to repair. V-shape mini upper-sternotomy to 3rd intercostal space was done for the minimally invasive access. Additional 2 cm incision under xiphoid process was done for venous cannula and vent. Bio-conduits were prepared suturing latest generation biological valve to aortic graft during procedures. Aortic valve and ascending aorta were replaced in Bentall de Bono technique.
Results: Bio-conduits were implanted in 5 young patients aware of their own decision. Two patients had manufactured conduits with a mechanical valve. Overall valve size was 25.9 mm. Mean cross-clamp was 145.71±20.41 minutes, cardiopulmonary bypass time (CPB) was 199.57±45.25 minutes. Postoperatively, 1 patient required packing as consequence of tissue bleeding which were successfully removed after 2 days. 30-day mortality was zero. Postoperative echocardiography showed one digit mean gradient through biological aortic prosthesis. Mean follow-up was 14.4 months without Major Adverse Cardiac and Cerebrovascular Event (MACCE) and good echocardiographic parameters (mean gradients 7.4 mmHg, peak gradients 16.2 mmHg). All patients were in NYHA functional class I with stable sternum and good cosmetics effect of the surgical wound.
Conclusions: Mini upper-sternotomy can be expanded to ascending aorta and valve replacement using Bentall de Bono technique which is in our experience feasible, repeatable and safe.
P8 Minimally Invasive Approach for Anomalous Right Coronary Recover Faster than Full Sternotomy
Barbara Robinson1, Prem Shekar2, Frederick Chen2, Ann Burgess2, James Rawn2, Lawrence H. Cohn2. 1Division of Cardiothoracic Surgery, SUNY Medical Center, Syracuse, NY USA, 2Harvard, Brigham and Women’s Hospital, Boston, MA USA.
Objective: Adults with congenital heart disease (ACHD) have surpassed those with pediatric congenital heart disease (CHD). Minimally invasive surgery has expanded to ACHD but has not been previously described for anomalous coronaries (AC) in the adult. Anomalous right coronary from left coronary sinus (ARCA) undergoing reimplantation were addressed by either full sternotomy (FS) or partial upper hemi-sternotomy (PS). We hypothesized equipoise between PS and FS in ARCA reimplantation (ARCARI).
Methods: Patients underwent ARCARI. PS or FS was performed. Postoperative cardiopulmonary bypass (CPB) and cross-clamp times (CCT), creatinine phosphokinase myocardial band (CPKMB), intensive care (ICU) and length of stay (LOS) were determined. Values were expressed as a mean ± standard deviation. p values <=0.05 were considered significant.
Results: Of the 27 patients, 17 underwent repair of ARCA with 8 undergoing ARCARI and of those, 3 via FS and 5 PS. Mean age of FS was 55±12, significantly older than 42±4 for PS (p=0.04). FS was performed in 1 woman and 2 men, and PS in 5 men. CPB for PS (67±7 min) was shorter than FS (93±30 min) (p=0.04). Similarly, CCT for PS (33±9 min) was also significantly shorter than FS (60±20 min) (p=0.015). This resulted in CPKMB for PS of 8 and for FS 25 which trended to be significantly different (p=0.008). Likewise, mean ICU stay for PS was 1 day and 4 for FS due to one outlier (p=0.2). Mean LOS was shorter for PS at 3.6 days than 12 for FS (p=0.05). Operative mortality for the entire ARCARI group was 0%.
Conclusions: In conclusion, reimplantation of ARCA can be performed successfully through a partial upper hemi-sternotomy. This is the largest series in the literature of ARCA reimplantation and the first to describe ARCA reimplanted via a partial sternotomy. ARCARI unexpectedly had shorter CPB and CCT times, less CPKMB production, shorter ICU stay and total LOS than through full sternotomy. Partial upper hemi-sternotomy is feasible in ARCA and can be performed safely and efficiently with low morbidity and mortality.
P9 A Minimally Invasive, Algorithm-Based Surgical Approach for Anomalous Aortic Origin of a Coronary Artery
Nicholas S. Yerkes1, Brian D. Conway1, Sonali S. Patel2, Robert A. Hanfland2, Michael J. Bates1, Domenico Calcaterra3, Joseph W. Turek1. 1University of Iowa Children’s Hospital, Iowa City, IA USA, 2Children’s Hospital Colorado, Aurora, CO USA, 3Indiana University Health, Indianapolis, IN USA.
Objective: Operative repair for anomalous aortic origin of a coronary artery (AAOCA) has been described using various innovative techniques. Common to each report is the use of a full sternotomy. As demand for minimally invasive approaches to adult cardiac surgery has increased, the upper hemi-sternotomy has emerged as a safe and effective technique for aortic valve and root replacement. This study analyzes our early results in applying the upper hemi-sternotomy to an algorithm-based surgical approach for AAOCA.
Methods: From January, 2012, to March, 2013, the aortic root was approached via a 7 cm skin incision and upper hemi-sternotomy for all patients undergoing repair of an AAOCA (n=4; median age 29.5 years). The type of repair performed was in accordance with a pre-defined surgical algorithm (Fig. P9-1). Three patients were identified with a symptomatic anomalous right coronary artery (ARCA), while one patient presented with an asymptomatic anomalous left coronary artery (ALCA). The cohort was free of coronary artery disease. The anomalous vessel had a slit-like ostium and followed an intramural course above the commissure in the three patients with ARCA. These patients underwent coronary unroofing. In contrast, the patient with an ALCA presented without an intramural segment and underwent vessel translocation and reimplantation.
Results: All patients underwent AAOCA repair according to our surgical algorithm and via an upper hemi-sternotomy. The median length of stay was 4 days for the cohort. All patients had resolution of symptoms and there were no reported complications at a median follow-up of 11.15 months.
Conclusions: To our knowledge, this is the first series describing a minimally invasive approach to AAOCA repair. When used in conjunction with a defined surgical algorithm, this technique enables a safe and effective repair in all forms of AAOCA without concomitant coronary artery disease.
P10 One-Stage Off-Pump Coronary Artery Revascularization and Aorto-Femoral Bypass: Long-Term Results
Swapnil P. Deshpande, Purushottam K. Deshpande, Shrikrishna K. Deshpande. Dr. K. G. Deshpande Memorial Centre, Nagpur, India.
Objective: Single-stage coronary and lower limb revascularization.
Methods: 10 patients with longest follow-up of 10 years operated. Approach: median-sternotomy, off-pump coronary revascularization, subcutaneous tunnelling of tube grafts and lower limb revascularization. Post-operative evaluation by CT angiography. Figures P10-1A and P10-1B show the hand drawing and the CT angiography of one of the patients who underwent the procedure.
Results: All ten patients have reduction in claudication symptoms reduced by at least two grades. No patient had any wound complications, or sternal complications. No patient required any type of lower-limb amputation.
Conclusions: One-stage, off-pump coronary and lower limb revascularization is a viable and economically feasible and at the same time cosmetically and surgically less defiguring procedure with excellent long-term follow-up.
P11 Left Atrial Radiofrequency Ablation during Mitral Valve Surgery Improve Functional Capacity and the Clinical Outcome
Alessandro D’Alfonso1, Jacopo Alfonsi1, Filippo Capestro1, Carlo Zingaro1, Giovanna Patteri2, Romualdo Belardinbelli2, Lucia Torracca1. 1Cardiac Surgery Unit, Ancona, Italy, 2Cardiac Unit, Ancona, Italy.
Objective: The aims of this study were to report sinus rhythm restoration and to determinate functional capacity and clinical outcome at follow-up after concomitant left atrial radiofrequency ablation (RFA) during mitral valve surgery.
Methods: Between December, 2008, and December, 2011, 83 patients with AF underwent mitral valve surgery at our institution. Forty-five (54%) patients (Group A) received concomitant left atrium RFA and 38 (46%) patients did not (Group NA). All patients were evaluated 18±8.6 months after surgery. In each group clinical evaluation, cardiopulmonary exercise testing, two-dimensional echocardiography, 24 ECG Holter monitoring, and BNP level were compared during follow-up.
Results: Group A showed a significant improvement in SR rates at 6- and 18-months compared to group NA (29/45 versus 6/38 and 36/45 versus 5/38; p<0.01 respectively). Freedom from AF at follow-up was 83.92% versus 7.58% respectively and freedom from AF recurrence on group A was 56.12%. SR restoration joins an improvement in cardiopulmonary exercise testing, in ejection fraction and demonstrates a reduction in BNP level compared to AF patients. (VO2 peak 14.57 ml/kg/min vs. 12.11 ml/kg/min p=0.09, AT 8.98 ml/kg/min vs 7.75 ml/kg/min p=0.09; FE 56.23% vs. 49.82% p=0.007; BNP 117.78 fmol/mL vs. 219.17 fmol/mL p=0.08).
Conclusions: Concomitant left atrium RFA during mitral valve surgery significantly increases SR restoration and patient exercise capacity at follow-up. Our findings suggest that the use of left atrial RFA during mitral valve surgery is justified.
P12 Long-Term Follow-Up of Minimally Invasive Left Atrial Ablation Synchronous with Mitral Valve Surgery
Bastian Schneider, Julia Dumfarth, Herbert Hangler, Christoph Krapf, Anneliese Heinz, Juliane Kilo,Johannes Hohlfeld, Elfriede Ruttmann-Ulmer, Nikolaos Bonaros, Josef Fritz, Markus Stuehlinger, Michael Grimm, Ludwig Müller. Medical University of Innsbruck, Innsbruck, Austria.
Objective: The study investigates long-term efficacy of surgical left atrial ablation for atrial fibrillation (AF) synchronous with minimally invasive mitral valve surgery. The resulting data was collected for quality assurance and forms the basis for comparisons with other institutions.
Methods: The study is based on a single-center clinical trial with partly retrospective and partly prospective design. 54 patients, who underwent minimal invasive mitral valve surgery with additional radiofrequency left atrial ablation at our institution between October, 2006, and April, 2011, where examined in a long-term follow-up of 45±18 months. Cardiac rhythm, echocardiographic parameters and patient characteristics were assessed by single ECG, 24-hour Holter monitoring, prolonged continuous Holter monitoring, telephone interviews with patients, consultation of attending cardiologists or physicians and by retrieving data from the clinical information system. For statistical analysis of data, chi-square test, fisher’s exact test, student t-test, Kaplan Meier Analysis and log rank test were used. Assessment of quality of life was performed by means of SF-36 health survey.
Results: Freedom of AF after cardiac surgery over follow-up time is shown in Table P12-1. Binary logistic regression showed that age at time of surgery, episode of AF during hospitalization and preoperative arterial hypertension were predictors for the recurrence of AF.
Conclusions: Minimally invasive mitral valve surgery synchronous with surgical left atrial ablation results in high rates of sinus rhythm at discharge and in the long-term. Freedom from AF within the first year, however, is not predictive for long-term results. Evaluation and comparison of differing techniques may lead to improvement of long-term outcome in surgical patients with AF.
P13 A Single-Center Experience on Minimally Invasive Atrial Fibrillation Surgery
Jae Suk Yoo, Joon Bum Kim, Sung-Ho Jung, Suk Jung Choo, Cheol Hyun Chung, Jae Won Lee. University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
Objective: To review our experience on minimally invasive AF ablation surgery though a mini-thoracotomy assisted by AESOP (Automated Endoscopic System for Optimal Positioning) 3000 or da Vinci system.
Methods: Between July, 1997, and August, 2013, 335 patients underwent minimally invasive AF ablation using either AESOP 3000 (n = 279) or da Vinci system (n = 56), with or without other cardiac procedures. We retrospectively reviewed the postoperative clinical outcomes and rhythm outcomes. Rhythm outcomes were assessed by regular ECGs and Holter monitoring follow-up. AF recurrence was regarded as any AF or atrial flutter episodes after postoperative blanking period.
Results: Of 335 cases, 10 cases (3.0%) were isolated AF ablation, and concomitant cardiac surgeries were performed in 325 patients, which included mitral valve surgery in 291 patients (96.9%), tricuspid surgery in 173 patients (51.6%), and atrial septal defect closure in 26 patients (7.8%). Left atrial auricle resection was performed in 36 patients (10.7%). Preoperative paroxysmal AF was in 49 patients (14.6%) and persistent AF was in 286 patients (85.4%). AF ablation was successfully performed in 323 patients (96.4%) with sinus rhythm conversion immediate postoperatively. There were two in-hospital deaths (0.6%) and 7 surgical complications (2.1%) including low cardiac output syndrome in 3, stroke in 2, and complete atrioventricular block in 2. Regular rhythm follow-up (> 6 months) was possible in 291 patients (86.9%). At a median of 34.7 months (inter-quartile range: 21.3-92.6 months), freedom from AF at 5 years was 88.2±6.1% (Fig. P13-1).
Conclusions: Minimally invasive AF ablation is feasible and efficacious in terms of favorable mid-term AF free rate.
P14 Minimally Invasive Hybrid Sequential Approach to Persistent and Long-Standing Persistent Lone Atrial Fibrillation
Tommaso Gasbarri1, Giuseppe Arena2, Danyar Gilmanov1, Enkel Kallushi1, Stefano Bevilacqua1, Vincenzo Borrello2, Giacomo Bianchi1, Francesca Chiaramonti1, Mattia Glauber1. 1Ospedale del Cuore G. Pasquinucci - Fondazione Toscana Gabriele Monasterio, Massa, Italy, 2Ospedale Ss Giacomo e Cristoforo - ASL 1, Massa, Italy.
Objective: Aim of this study is to evaluate feasibility, safety and mid-term efficacy of a hybrid sequential approach to persistent and long-standing persistent AF consisting in a combination of thoracoscopic surgical ablation plus left appendage exclusion and a subsequent transcatheter EP ablation.
Methods: Between, April, 2010, and June, 2013, 24 patients (60.3±7.6 y.o.) with persistent or long-standing persistent AF (60.3±7.6 mo.), mean left atrial diameter 46.4±5.5 mm and mean LVEF 53.2±11.1% underwent to closed-chest, video-assisted thoracoscopic epicardial anatomical pulmonary veins isolation or box lesion performance with bipolar or unipolar radiofrequency and left appendage closure with external clip. No block was tested across the lines during surgical procedure. Subsequently, after a mean period of 2 months, we proceeded to transcatheter EP evaluation for electro-anatomical mapping, gaps touch-up, adjunctive substrate reduction and possible right side cavo-tricuspid isthmus line. Follow-up was prospectively conducted with clinical evaluation and 24-hour Holter ECG at 3-6, 9, 12, 18 and 24 months.
Results: There were no major complications, nor deaths. After a mean period of 15.4±8 mo. 18 (75%) patients were in stable SR and 13 (54.2%) were free from oral anti-coagulants drugs. Trans-catheter gaps touch-up of surgical lines was required in 8 (33.3%) patients. In 18 (75%) patients left appendage was successfully excluded. No stroke, nor TIA happened during follow-up period. At the end of the follow-up period significant improvement in LVEF was noticed (61.9%±9.2% vs. 53.2%±11.1% p 0.001).
Conclusions: Hybrid sequential ablation for persistent and LS persistent AF can be safely performed with satisfying success-rate at mid-term follow-up. Improvement in cardiac performance seems to characterize the clinical result. Adding an entrance/exit block test during surgery may help in improving thoracoscopic procedure success-rate. Left appendage exclusion can be safely performed in the setting of minimally invasive lone atrial fibrillation surgical ablation. In this context, adding such a procedure may help in maximizing immediate clinical result and improving long-term outcome.
P15 Catheter Ablation versus Thoracoscopic Surgical Ablation in Persistent Atrial Fibrillation
Anthony C. DeSouza1, Toufan Bahrami2, Rashmi Yadav1, Shouvik Haldar1, Vias Markides1, Wajid Hussain2, Tom Wong1. 1Royal Brompton Hospital, London, United Kingdom, 2Harefield Hospital, London, United Kingdom.
Objective: To evaluate the introduction of a closed chest standalone AF ablation program for persistent AF compared to established catheter ablation.
Methods: Patients with symptomatic persistent AF longer than a year in duration and refractory to pharmacological and electrical cardioversion, were recruited by patients’ choice to either surgical or catheter ablation. The surgical ablation technique involved a bilateral thoracoscopic approach for bilateral pulmonary vein isolation with dry bipolar radiofrequency clamps. Roof and inferior lines were created joining both sets of pulmonary veins using unipolar radiofrequency linear pen to form a box. Baseline pacing and conduction studies were performed before ablation on each pulmonary vein and the confluence. Bidirectional block was confirmed following ablation. High frequency stimulation of right sided ganglionic autonomic plexi was employed to guide subsequent ablation. On completion, a probe was also placed in the isolated box to confirm bidirectional block. Patients were left off antiarrhythmic drugs and monitored at 3, 6, and 12-month intervals with continuous monitoring. Failure was defined as any tachyarrhythmia longer than 30 seconds.
Results: 50 patients were recruited and 21 patients were ablated in an 18-month period under the mentorship of an experienced operator. At 3, 6 and 12-month follow-up, 14/17 (82%), 13/16 (81%) and 11/14 (78%) respectively of the surgical group were free from AF/AT. This compared to 11/19 (58%), 6/12 (50%) and 2/6 (33%) in the catheter ablation group. The long term follow-up was greater in the surgical group, but these initial results appear superior to catheter ablation supporting current literature.
Conclusions: Closed chest bilateral ablation can be safely introduced with mentorship achieving promising medium-term results at a year when compared to single intervention catheter ablation technique.
P16 Thoracoscopic Approach in the Treatment of Patients with Atrial Fibrillation: 1-Year Follow-Up through Continuous Subcutaneous Monitoring
Evgeny Pokushalov, Alexander Romanov, Dmitry Elesin, Alexander V. Bogachev-Prokophiev, Denis Losik, Sevda Bairamova. State Research Institute Circulation Pathology, Novosibirsk, Russian Federation.
Objective: The aim of this prospective observational study was to identify responders thoracoscopic ablation through continuous subcutaneous monitoring for 1-year after ablation.
Methods: Bilateral video-assisted thoracoscopy was performed to isolate both pairs of pulmonary veins, create box-lesion, to ablate the ganglionic plexus and amputate the left atrial appendage. Preoperative, in-hospital and follow-up data were collected for our first 60 patients. All patients were implanted with Reveal XT (Medtronic Inc.) for continuous AF monitoring and data collected every month during the 12-month follow-up. Paroxysmal AF was in 26%, persistent in 50% and permanent in 24% of cases. The mean (±SD) left atrial diameter was 48.1±7.4 mm and the mean duration of AF was 79.0±63.9 months.
Results: Mean operation time was 137.4±24.7 min. All patients were extubated in the operating room and left the recovery room within 12 h. The mean hospital stay was 6.1±1.8 days. Postoperative mortality was 0%. Freedom from AF was 84%, 75% and 33% for paroxysmal, persistent and permanent AF, respectively (p > 0.05), i.e., AF% < 0.5% according to subcutaneous continuous monitoring data at 12-month follow-up.
Conclusions: Thoracoscopic ablation is highly effective in treating AF, as assessed through detailed 1-year continuous monitoring: success rate is higher in PAF than in PersAF patients. The use of subcutaneous monitors is a valuable means of identifying responders and nonresponders, and can potentially guide antiarrhythmic and antithrombotic therapies.
P17 Safety and Feasibility of Use of Contact Force Catheter during Hybrid Procedure for Atrial Fibrillation Ablation
Narendra Kumar, Laurent Pison, Mark La Meir, Harry Crijns, Jos G. Maessen. Maastricht University Medical Center, CARIM, Maastricht, Netherlands.
Objective: Reconduction across an ablation line is the most common reason for arrhythmia recurrence over time, e.g., pulmonary vein (PV) and box lesion. Hybrid procedure combines the best of cardiac surgery (epicardial ablation of PVs and box lesion creation) and electrophysiologist (endocardial touchups if necessary to ensure any missed electrical gaps). This procedure is indicated for patients of longer duration of atrial fibrillation and with dilated left atrium. To create a transmural lesion, contact force (CF) between the ablation tip and cardiac tissue is one of the major determinant parameters for radiofrequency catheters. Low CF may lead to an inadequate lesion. However, if very high then is associated with increased risk of significant complications such as thrombus formation, catheter tip charring, steam pop formation and also cardiac perforation. Contact force monitoring is a significant new parameter for titration of the contact force for an adequate lesion creation.
Methods: All AADs were stopped 5 days before the procedure except for patients on Amiodarone. All 20 patients underwent PV isolation using epicardial bipolar radiofrequency clamps. Box lesion was made epicardially using bipolar radiofrequency isolator pen or cool rail. Then electrophysiologist checked for electrical isolation of the ablation lines by pacing maneuvers, voltage mapping (using electroanatomical mapping) and adenosine bolus administration. CF catheter was used for further ablation (if needed) to complete above lines, cavo-tricuspid isthmus line (CTI) and complex fractionated atrial electrogram (CFAE) ablation (Table P17-1).
Results: Endocardial touchup was needed for 1 PV and 4 box lesions. It was also used for creation of CTI line in 4 patients.
Conclusions: Use of TS catheters is safe and feasible and also complimentary to hybrid procedure setup for atrial fibrillation ablation.
P18 Minimally Invasive Exclusion of Left Atrial Appendage
Saqib Masroor. Florida Heart and Vascular Care, Miami, FL USA.
Objective: To demonstrate the technique of minimally invasive exclusion of left atrial appendage during concomitant surgery for atrial fibrillation as well as a stand-alone procedure in some patients.
Methods: This video is based on 4 patients who underwent the exclusion of left atrial appendage using an epicardial clip by a single surgeon using video-assistance.
Results: The left atrial appendage was successfully excluded in all patients with no significant morbidity or mortality.
Conclusions: The left atrial appendage can be safely and reliably excluded using an epicardial clip in patients undergoing concomitant surgery such as cryomaze, as well as some selected patients at high risk of stoke who are not candidates for anticoagulation.
P19 Novel Approach for a Robotic Cox-Maze IV
Mohammad Moslemi, Duy Nguyen, Mark Meyer, Barbara Tempesta, Keith Maas, Robert Poston, Farid Gharagozloo. University of Arizona, Tucson, AZ USA.
Objective: A complete Cox-Maze IV procedure is difficult to accomplish using current endoscopic and minimally invasive techniques. These techniques are hampered by inability to adequately dissect the posterior structures of the heart and place all necessary lesions. We present a novel approach using robotic technology that achieves placement of all the lesions of the complete Maze procedure.
Methods: In three cadaveric human models, the technical feasibility of using robotic instruments through the right chest to dissect the posterior structures of the heart and place all Cox-Maze lesions was performed.
Results: The entire posterior aspect of the heart was dissected in the cadaveric model facilitating successful placement of all Cox-Maze IV lesions with robotic assistance through minimally invasive incisions.
Conclusions: The robotic Cox-Maze IV procedure through the novel right thoracic approach is feasible. This obviates the need for sternotomy and avoids the associated morbidity of the conventional Cox-Maze procedure.
P20 Introducer Development for Cardiac Resynchronization via Right Parasternal Mediastinotomy
Henry M. Spotnitz, Keith J. Yeager, Santos E. Cabreriza, Gordana Vunjak-Novakovic, Daniel Y. Wang, Gregory D.N. Pearson. Columbia University, New York, NY USA.
Objective: Right parasternal mediastinotomy (RPMS) with right atriotomy has been utilized for pacemaker insertion. Although a similar approach might benefit patients with intrapericardial adhesions and technical barriers (8-13% of patients) to left ventricular lead insertion for cardiac resynchronization, appropriate introducers and techniques have not been described.
Methods: Anesthetized pigs underwent computerized axial thoracic tomography (CAT). Each digitized scan was used to define an introducer shape unique to the parent animal, using three-dimensional (3-D) modeling software. Each pig finally underwent RPMS demonstrating coronary sinus lead insertion using its custom configured introducer. With Institutional Review Board approval, 65 patients were identified who had undergone conventional endocardial coronary sinus lead insertion followed by CAT scanning. Scans were used to fabricate 3-D molds for introducer configuration via RPMS.
Results: Fifty-two introducer paths were defined following anatomic pathways and avoiding bends inconsistent with materials use for commercial strip away introducers. Each path was defined by a distance, bend, and twist relative to the long axis of the superior vena cava. The commonest dimensions were: distance 28.8 mm, bend angle 89.8 degrees, and twist 80 degrees. A prototype cannula was tested for fit in an appropriate postmortem human specimen, preserved by fresh freezing.
Conclusions: The RPMS approach to the coronary sinus for cardiac resynchronization is feasible. Human CAT scans can be used to define curvatures and dimensions for commercially produced introducers.
P21 New Strategy Using High Frequency Epicardial Ultrasound in Cardiac Surgery
Taiju Watanabe, Hirokuni Arai, Keiji Oi, Tsuyoshi Hachimaru, Hidehito Kuroki, Tatsuki Fujiwara, Tomohiro Mizuno. Tokyo Medical and Dental University, Tokyo, Japan.
Objective: High frequency epicardial ultrasound (ECUS) is a useful device to provide information about coronary artery, bypass graft function, and anastomosis configuration during coronary artery bypass grafting (CABG). Moreover, high frequency ECUS may also have potential for improved imaging in other area of cardiac surgery. In this study, we report the clinical applications of ECUS and the novel strategy using it in various cardiac procedures.
Methods: We introduced an approach using high frequency ECUS into the various cardiac procedures. We directly scanned the cardiac lesions and obtained the optimum images. On the basis of these images, we made the surgical decisions conclusively.
Results: High frequency ECUS could provide detailed images leading to successful surgical decision making. In the case with coronary artery fistula with coronary aneurysm, tortuous dilated left circumflex coronary artery (LCx) directly drained into the left ventricle (LV). It was difficult to determine the exact portion of the LCx drainage site into the LV by either palpation or direct vision. ECUS could detect the exact portion to ligate the drainage vessel. In the case with acute type A aortic dissection, emergent aortic arch replacement was performed without preoperative coronary angiography. Preoperative computed tomography showed left anterior descending artery (LAD) and right coronary artery (RCA) were calcified. ECUS could detect LAD stenosis, and thus we performed CABG to LAD. However, there was no stenosis in RCA so that CABG to RCA was not performed. In the case with ostial stenosis of RCA, the patient was scheduled to undergo aortic valve replacement (AVR). Preoperative angiography showed ostial stenosis of RCA was suspected, but uncertain. Intraoperative evaluation using ECUS revealed the mobile calcified plaque and restrictive color Doppler flow in right coronary ostium. Prior to AVR, CABG to RCA was performed for cardioplegia infusion. At the time of AVR, the calcified plaque in right coronary ostium was actually confirmed.
Conclusions: High frequency ECUS could provide accurate images and detailed information in various situations of cardiac surgery. It could assist successful surgical decision making and improve the safety and quality of cardiac surgery.
P22 A Simplified Method to Confirm Retrograde Cardioplegic Catheter Position in Coronary Sinus in Minimally Invasive Vale Surgery
Kenneth K. Liao, Ioanna Apostolidou, Richard Madlon-Kay, K.P. Madhu, Kevin Liao, Emil Missov. University of Minnesota, Minneapolis, MN USA.
Objective: Inserting retrograde cardioplegic catheter (RCC) into coronary sinus (CS) and confirming its position under transesophageal echocardiography (TEE) can be difficult in patients undergoing minimally invasive valve (MiniValve) surgery due to lack of contrast of RCC to the surrounding structure when its stylet is removed. We used agitated blood as contrast to enhance the visualization of RCC and CS under TEE to confirm the RCC position inside CS by injecting agitated blood via RCC. We studied the sensitivity and specificity of this method.
Methods: The TEE probe was positioned to visualize CS. During MiniValve surgery a RCC with stylet was inserted through a stab wound in the lateral wall of right atrium (RA) and advanced into the CS under TEE. The stylet was removed and a syringe of 10 cc agitated blood was injected into the CS via RCC. RCC position in CS was considered positive only when agitated blood filled CS first and leaked back into RA after 2 cardiac cycles. RCC position in CS was considered negative when agitated blood was not first visualized in CS or agitated blood immediately filled RA within 2 cardiac cycles.
Results: From April, 2011, to May, 2012, a total of 37 consecutive MiniValve surgery patients (26 aortic and 11 mitral valve) by a single surgeon underwent such study. There were 15 males. The average age was 69+/-13 years. CS was visualized by TEE in 33 patients. In the 33 patients with visualization of CS, 31 patients had RCC inserted into CS and had positive agitated blood test, with a sensitivity of 94% (31 out of 33). In 4 patients whose CS was not visualized and 2 patients whose CS was unable to be cannulated by RCC, the agitated blood test was negative in all of them, with a specificity of 100% (6 out of 6).
Conclusions: Injecting agitated blood as contrast via RCC is a simple, safe and cost-effective way to guide and confirm positioning of RCC in CS under TEE. Its high sensitivity and specificity make it a reliable method to confirm RCC position in CS in MiniValve surgery.
P23 The Proplege Peripheral Retrograde Cardioplegia Device in Minimally Invasive Cardiac Surgery: Single-Center Early Experience
Vito Giovanni Ruggieri, Alfonso Agnino, Andrea Antonazzo, Giovanni Concistrè, Andrea Albertini, Bruno Madaffari. S. Anna Hospital, Catanzaro, Italy.
Objective: During minimally invasive cardiac surgery (MICS) the myocardial protection can sometimes represent a challenge, especially when aortic insufficiency is associated. The Proplege Peripheral Retrograde Cardioplegia Device (PPRCD) (Edwards Lifesciences Inc., Irvine, CA USA) has been introduced as a new tool during MICS in order to safely administrate retrograde cardioplegia and to optimize myocardial protection. We present our single-center early experience with this device.
Methods: Since June, 2012, we performed retrograde cardioplegia using the PPRCD in 17 patients who underwent minimally invasive cardiac surgery (mitral, tricuspid and aortic) with associated aortic insufficiency. The device was introduced through the dedicated 11F sheath into the right internal jugular vein. Under the only transesophageal echocardiographic (TEE) control, the catheter was inserted into the coronary sinus and its position was confirmed by the pressure line. During CPB and aortic cross-clamping, the balloon at the top of the catheter was inflated and retrograde cold blood cardioplegia was administered (180-220 ml/min). Color duplex was used to visualize cardioplegia flow into the coronary sinus. After cardioplegia delivery and stable myocardial arrest, the balloon was deflated. Cardioplegia administration was repeated every 30 min. Both visualization and manipulation of the catheter into the right atrium under TEE were performed by the anesthesiologist alone.
Results: In 14 of 17 patients (82%) the coronary sinus cannulation was achieved and the cardioplegia delivery performed without any technical complication. The mean time for catheter positioning into the coronary sinus was 24±16 min. We registered no postoperative complications device or myocardial protection related. The 3 cases of technical failure were attributed to small coronary sinus ostium or difficulties in ostium echo-visualization.
Conclusions: We believe that the PPRCD should be considered as an important tool by minimally invasive heart teams in order to optimize myocardial protection, especially when aortic insufficiency is associated. A learning curve is necessary for a single-experienced operator that can perform both TEE visualization and safe catheter manipulation.
P24 Mitral Valve and Left Ventricular Reverse Remodeling after Surgical Repair of Submitral Left Ventricular Aneurysms Assessed with Multi-Slice Computed Tomography
Natalia Solowjowa, Adam Penkalla, Michael Dandel, Miralem Pasic, Yuguo Weng, Roland Hetzer, Christoph Knosalla. Deutsches Herzzentrum Berlin, Berlin, Germany.
Objective: Surgical repair of often life-threatening submitral aneurysms may present a technical challenge especially if the mitral valve (MV) apparatus is involved. We present the currently largest single-center surgical experience with the potential of multi-slice computed tomography (MSCT) in assessment of changes of MV and LV geometry and aneurysm morphology.
Methods: Between May, 2006, and August, 2013, 24 patients (m:w=20:4, ages 38-78, mean 62.3 years; mean NYHA class 2.91) with submitral LV aneurysm were operated upon. Echocardiography and MSCT were performed before and a short time after surgery. LV and aneurysm end-diastolic/end-systolic volume were measured and indexed to body surface area (LV-EDVI/LV-ESVI, A-EDVI/A-ESVI, respectively). LV ejection fraction (LVEF), cardiac output (CO) and cardiac index (CI) were calculated on the basis of MSCT data. MV geometry was characterized by intercommissural and anteroposterior MV annulus diameter (ICD and APD respectively), MV annulus area (MVAA), coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), interpapillary muscle distance (IMD) and coaptation-to-septum distance (CSD).
Results: Thirty-day and 5-year survival were 91.3% and 78.3%, respectively. Aneurysms were prevalently localized in myocardial segments 4/10/11. Preoperative A-EDVI showed a slight systolic increase, demonstrating adverse volume shift during systole (70.6±20.9 to 75.5±21.4 ml/sqm, p=0.001). There were reductions of LV-EDVI (160.9±21.6 to 86.5±7.8 ml/sqm, p=0.002) and LV-ESVI (121.4±26.3 to 51.2±6.4.9 ml/sqm, p=0.006) and LVEF improvement (29.9±4.2% to 42.5±3.1%, p=0.001) after surgical repair. Mitral repair and replacement was necessary in three patients in each case. Postoperative reduction of mitral regurgitation in the remaining 17 patients (1.26±0.23° to 0.21±0.08°, p=0.000) corresponded with improvement of MV geometry (ICD 38.8±1.4 mm to 35.0±1.6, p=003, APD 24.9±1.3 to 23.0±1.1 mm, p=0.103, MVAA 8.8±0.5 to 8.1±0.5 sqcm, p=0.011, CD 10.0±0.5 to 7.9±0.5, p=0.006, TA 1.8±0.1 to 1.5±0.1 sqcm, p=0.022, MVCA 104±3.6° to 114.5±2.2°, p=0.015) and reduction in MV tethering (IMD 35.18±1.88 to 28.23±0.98, p=0.000, CSD 31.9±1.4 to 28.7±1.7, p=0.012).
Conclusions: Surgical reconstruction of submitral LV aneurysms can be performed with good mid-term results. Advantages of MSCT, with possibilities to analyze the coherence of ventricular remodeling and subtle geometrical changes in mitral valve apparatus, make it a useful tool for analysis and planning of surgical restoration approaches.
P25 Using Cardiac MRI to Evaluate Cardiac Function and Predict Outcomes in Patients with Valvular Heart Disease
Dominic Emerson, Richard Amdur, Joshua Langert, Jason Morrisette, Frederico Mordini, Michael Greenberg, Gregory, Trachiotis. Veterans Affairs Medical Center, Washington, DC USA.
Objective: In patients with valvular heart disease, chronically elevated left atrial and pulmonary pressures may lead to right ventricular strain and ultimately right heart failure. Elevated pulmonary artery (PAP) and left ventricular end diastolic (LVEDP) pressures have been used as markers of right heart dysfunction and correlate with poor outcomes. Using cardiac MRI (cMRI), it is possible to directly quantify both left and right ventricular function (LVEF and RVEF), and here we compare cMRI to traditional markers as outcome predictors.
Methods: A retrospective review of prospectively collected data was performed for all patients undergoing valve surgery from January, 2004, to February, 2008, at a single-center (n=103). All patients underwent preoperative cardiac catheterization, with 56 additionally receiving cMRI. Patients were divided into two cohorts, those receiving cMRI, and those receiving only catheterization. Demographics were compared between groups and found to be similar. Univariate and multivariate logistic regression models were applied to determine predictors of mortality. Finally, predictive models for mortality using preoperative PAP, mean PAP (MPAPA), and LVEDP were compared to models using LVEF and RVEF obtained from cMRI.
Results: Overall, the two groups were generally similar. Average cMRI LVEF and RVEF were 57% and 46%, respectively. Of the risk factors analyzed, only age emerged as an isolated predictor of mortality (p=0.01) within the univariate models. Step-wise regression models were created using the catheterization or cMRI data. When compared, the cMRI model has a slightly better R^2, c (prediction accuracy), and sensitivity/specificity (0.22 v 0.28; 0.77 v 0.82; and 0.63/0.62 v 0.69/0.64, respectively).
Conclusions: In patients presenting for cardiac surgery, cMRI can accurately assess left and right heart function and morphology. Within our population, LVEF and RVEF were generally maintained and served as better predictors of mortality than traditional PAP values. Additionally, cMRI allows stratification of elevated PAPs into those caused by right heart dysfunction, and those due to other causes (such as OSA), allowing these other causes to be addressed preoperatively.
P26 Impact of Endoscopic Harvest on Saphenous Vein Graft Quality
Behrooz Dehdashti, Phat Le Tran, Badi Rawashdeh, Haudi Dehdashti, Abdulla Alabagi, Robert Poston. University of Arizona, Tucson, AZ USA.
Objective: Saphenous vein (SV) harvest for coronary bypass via endoscopic technique enables minimum invasive vessel harvest than open method but its impact on conduit quality remains to be determined. We used high-resolution optical coherence tomography (OCT) imaging intraoperatively to identify regions of harvested SV that appear injured and then confirmed this injury using scanning electron microscopy (SEM).
Methods: Prior to CABG, SV conduits were imaged with a sterile OCT (n=8) to identify intimal injuries. Biopsies were collected, sectioned, glutaraldehyde fixed en face, dehydrated, and prepared for SEM imaging.
Results: OCT and SEM images showed evidence of severe intimal injury on the conduit luminal surface (12.5%) (Figs. P26-1A, B). Minor intimal injuries were found in 4 of 8 (50%) of SV valve and ostia (Figs. P26-1C, E) as a result of distension. Further, SEM analysis revealed focal platelet presence (Fig. P26-1D). Branch ostia indicated crenated red blood cells (RBC) known as spheroechinocyte entrapped in fibrin mesh. Cautery thermal energy dispersion is most likely responsible for alteration in RBC morphology at vessel branches (Fig. P26-1F).
Conclusions: Our highly sensitive imaging protocol detected endoluminal injury in the main conduit, activated platelets and crenated RBC found near the ostia of SV branches indicating successful endoscopic vein harvest relies heavily on technician experience and expertise with minimum use of electrocautery.
P27 Immunohistochemistry Comparing Endoscopic Vein Extraction vs. Open Vein Harvesting on Saphenous Vein Endothelium
Mohammad H. Nezafati, Pouya Nezafati, Sakineh Amoueian, Armin Attaranzadeh, Hamid Reza Rahimi. Mashad University of Medical Sciences, Mashhad, Iran.
Objective: The present study attempts to compare the immunohistochemistry of vWf, e-cadherin, Caveolin and eNOS in VasoView endoscopic saphenous vein versus traditional open vein harvesting techniques for coronary artery bypass graft (CABG) surgery performed in Javad ol Aemeh Hospital of Mashhad, Iran in 2013.
Methods: Forty-seven patients were scheduled for CABG (30 EVH and 17 OVH) among whom patients with relatively same sex and similar age were selected. Three separate 2 cm vein samples were harvested from each patient’s saphenous vein. Each portion was collected from distal, middle and proximal zones of the saphenous vein. The tissues were deparaffinized, and antigen retrieval was done using EZ-retriever followed by an immunohistochemistry evaluation with vWf, e-cadherin, Caveolin and eNOS. Data analyses, including parametric and nonparametric tests were undertaken using the SPSS 16 software.
Results: The mean age of the EVH and OVH groups were 63.86±10.16 and 63.91±9.29 years respectively with no significant difference between them (p=0.989). In addition, there was no great difference between the EVH and OVH in lipid profile, DM, HTN, smoking history, CVA, and valvular dysfunction (p>0.05). Qualitative report of vWf, e-cadherin, Caveolin and eNOS reveals no significant difference between the EVH and OVH (p>0.05).
Conclusion: This study indicates that VasoView endoscopic saphenous EVH technique causes no endothelial damage in comparison with OVH. This study could be a molecular confirmation for the innocuous of EVH technique.
P28 Fluorescent Imaging for In-Vivo Visualization of Mesenchymal Stem Cells in a Myocardial Infarct Model in Pigs
Sabine Wipper, E. Sebastian Debus, Beate Reiter, Mandy Stubbendorf, Claudia Lange, Axel Larena-Avellaneda, Christian Detter. University Heart Center Hamburg Eppendorf, Hamburg, Germany.
Objective: Mesenchymal stem-cell (MSC) injection after infarction as regenerative therapy is under examination. The direct visualization by fluorescent imaging (FI) of these cells and localization during injection supervise the therapy concept.
Methods: For in-vivo visualization of indocyanine-green marced (ICG) MSCs by FI a previously established model of myocardial infarction in pigs was used. MSCs were isolated from male pigs. Isolation, purification and culture were carried out by standard protocol. MSCs were characterized using microscopy and flow-cytometry. The MSCs were dyed by incubation with ICG for 12 hours after passage 5. Further cultures of the remaining cells were performed for control in further passages. In an open-chest model acute transmural myocardial infraction was created in 11 female pigs by occlusion of the left anterior descending artery for one hour. During intracoronary or intramyocardial injection of the dyed cells, FI was performed to visualize and detect the distribution of the MSCs.
Results: After 5 passages of MSC, flow cytometry results showed CD45 (-), CD14 (-), CD90 (+), CD105 (+), MHCI (+), cells presented similar morphology and oteogenic, chondrocenic and adipogenic differentiation was successful. Incubation with ICG dyed the cells. Further culture and passage of the MSC were possible. Cultured MSCs could be visualized by FI. Intracoronary and intramuscular injection of dyed cells was possible and the visualization by FI presented excellent pictures for evaluation.
Conclusions: MSC can be successfully marked with ICG and visualized in-vivo by FI in a porcine myocardial infarct model. Therefore, it might be a good diagnostic tool and simple technology for investigation of therapeutic injection of MSCs.
P29 Intraoperative Indocyanine Green Fluorescence Lymphography to Detect Chylous Leakage Site after Congenital Heart Surgery
Te-I Chang, Yih-Sharng Chen, Shu-Chien Huang. National Taiwan University Hospital, Taipei, Taiwan.
Objective: To demonstrate a novel way of intraoperative fluorescence lymphography used for refractory chylothorax in a postoperative congenital heart disease patient.
Methods: Intraoperative indocyanine green fluorescence angiography has been proven in its usefulness in many fields of surgery such as ophthalmic chorioangiography, coronary angiography, and microscopic neurosurgery. We incorporated a novel intraoperative indocyanine green (ICG) fluorescence lymphography via subcutaneous injection of ICG at groin region to guide for the detection of chylous leakage during a resternotomy.
Results: A male baby presented with endocardial cushion defect and severe coarctation of aorta received aortoplasty and pulmonary artery banding soon after birth. Massive chylothorax (800ml/day) developed after his corrective surgery at the age of 3 month. Low-fat diet and even total parenteral nutrition failed. Right-sided thoracic duct ligation, and later, left-sided thoracic duct ligation were performed but refractory chylothorax (∼300ml/day) remained. By incorporating novel intraoperative indocyanine green (ICG) fluorescence lymphography, we successfully detected and sutured a chylous leakage site through re-sternotomy (Fig. P29-1A, B). His chylous drainage stopped promptly after the operation.
Conclusions: The new application proved to be very sensitive for identifying even minor leakage sites with great precision and specificity. It could be a salvage option in treating patients with formidable chylothorax refractory to either conservative treatments or thoracic duct ligation.
P30 A Novel Heart Valve of Medical-Grade Ultra High Molecular Weight Polyethylene Fibers: In Vitro Bacteriological Experiments
Amir Basir, Paul F. Gründeman, Frans Moll, Joost van Herwaarden, Gerard Pasterkamp, Jolanda Kluin, Jos van Strijp, Reindert Nijland. University Medical Center Utrecht, Utrecht, Netherlands.
Objective: Current cardiovascular prosthesis materials carry drawbacks; some are not suitable for endovascular treatment by their inability to fold or have too large profile, other need strong anticoagulant drugs or have a moderate durability. These prostheses are also associated with bacterial infections. Prosthetic valve endocarditis (PVE) is a medical entity with potentially fatal outcome. In early PVE bacterium Staphylococcus aureus predominates with 36% prevalence. Medical-grade Ultra High Molecular Weight Polyethylene (UHMWPE) fibers are thin, flexible, fatigue- and abrasion-resistant and have high strength. Therefore, prostheses made of these fibers are attractive for construction of heart valves applied in transcatheter approaches. The aim of this study is to test the bacterial adherence on medical-grade UHMWPE patches.
Methods: Two different UHMWPE patches (one membrane patch and one fabric), and 4 patches currently used as cardiovascular patches; two different fabrics of polyester and two different membrane patches of ePTFE were used. All patches were contaminated with S. aureus bacteria in the presence of 20% human serum, and incubated for 10, 30 and 90 minutes. After incubation, the patches were rinsed to remove non-adherent bacteria. The remaining bacteria were released from patches, and counted by measuring the colony formed units (CFU) on plate.
Results: On fabric patches, there was less CFU for UHMWPE patches compared to the test patches at all 3 time points. On membrane patches, less CFU was observed on one PTFE patch after 10 minutes. At 30 and 90 minutes there was less CFU for UHMWPE patches compared to test patches.
Conclusions: UHMWPE patches are a potentially suitable material in blood for prosthetic valve and other low profile cardiovascular applications by their non-inferiority regarding bacterial adhesion. Yet, more extensive in vivo studies are needed to confirm if they are a suitable candidate for use in prosthetic heart valves and other vascular applications.
P31 Aortic Endoballoon: Use in Minimally Invasive Mitral Valve Surgery and Its Complications in the Early Post-Operative Period
Meeranghani M. Yusuf, Sanjay Chaubey, I. De Grieck, Bernard Stockman, Fillip Casselman, Frank Van Praet. OLV Hospital, Aalst, Belgium.
Objective: Minimally invasive mitral valve surgery through right minithoractomy using endovascular cardiopulmonary bypass via femoral vessels is widely practiced in the last decade. Increased rate of stroke amongst other complications was implicated with use of the aortic Endoballoon in the early studies. This study reports the early complications resulting from the use of the aortic Endoballoon catheter from a large series of patients.
Methods: Single-center data of patients who underwent primary, port access, mitral valve surgery with the use of Endoballoon (Edwards Lifesciences, Inc.) were reviewed. Data was collected from 2007 to mid-2013 and Endoballoon related groin and neurovascular complications within 6 weeks of surgery were recorded and analyzed.
Results: 1201 patients (male 52%; age 65±13yrs; BMI 25±4.5; BSA 1.86±0.22) underwent endoscopic mitral valve surgery [repair 1%, ring 28%, repair and ring 58%, replacement 13% (mechanical 34%, biological 66%)]. 26% of patients had concomitant tricuspid valve procedures. Total hospital stay was 11.2±5.9 days (pre-op 1.4±1.4 days; post-op 9.8±5.8 days). There were no aortic dissections; three groin hematomas (0.25%); two patients required embolectomy (0.2%); six groin infection (0.5%); two groin lymphocele (0.2%) and one groin pseudoaneurysm (0.1%). Neurovascular complications comprised of twelve strokes (1%) and two transient ischemia attacks (0.2%). The total six weeks mortality was 22 (1.8%).
Conclusions: Our experience suggests that with better understanding and frequent use, endovascular balloons can be safely used in patients undergoing minimally invasive mitral valve procedure with remarkably low peri-operative and early post-operative complications.
P32 Efficacy of Crystalloid Intracellular-Type Cardioplegia in Minimally Invasive Cardiac Surgery
Yoshitsugu Nakamura1, Yujiro Ito1, Hiroyuki Nakajima2, Hiroshi Niinami2, Shigehiko Yoshida3, Takaki Hori1, Takashi Murakami1. 1Chibanishi General Hospital, Chiba, Japan, 2Saitama Medical University International Medical Center, Saitama, Japan, 3IMS Katsushika Heart Center, Tokyo, Japan.
Objective: In minimally invasive cardiac surgery (MICS) via a right minithoracotomy approach, myocardial protection is relatively challenging because of technically demanding retrograde cardioplegia or troublesome changes of the mitral valve exposure for antegrade cardioplegia. Crystalloid intracellular-type cardioplegia is advantageous to decrease frequency of cardioplegia delivery in cardiac surgery. We aimed to investigate efficacy of crystalloid intracellular-type cardioplegia in MICS.
Methods: We retrospectively reviewed 42 MICSs performed from December, 2011, to November, 2013, and compared the outcomes of patients undergoing MICS using crystalloid intracellular-type cardioplegia (Group CR; n=26) with those who had blood cardioplegia (Group BL; n=16). Both cardioplegias were delivered antegradely through the aortic root cannula as cold solution. Selection of cardioplegia depended on surgeons’ preference. Warm terminal cardioplegia was given in group BL.
Results: Group CR included 25 mitral valve surgeries and 1 atrial septal defect closure while Group BL included 12 mitral valve surgeries, 1 atrial septal defect closure and 3 left atrial tumor resections. The baseline characteristics were similar between the groups. Cardiac arrest time was significantly longer in group CR (126 min versus 107 min (p=0.041). The mean volume of cardioplegia was smaller in group CR (2035 ml versus 6803 ml (p<0.001)). The mean frequency of cardioplegia delivery was fewer in group CR (1.1 versus 4.0 (p<0.001)). 25 patients (96%) in group CR needed only 1 delivery of cardioplegia. No hospital mortality was observed in either group. The mean intubation time and postoperative creatine kinase MB was similar in both groups (18.9 hours versus 19.1 hours and 30.1 ng/ml versus 37.1 ng/ml, respectively). There was 1 right ventricular failure in group BL. This might be related to myocardial protection.
Conclusions: Crystalloid intracellular-type cardioplegia was efficient and helpful to simplify management of myocardial protection, to minimize the procedural time, and consequently, to improve the safety of MICS.
P33 ASD Surgical Repair Using a Right Mid-axillary Minithoracotomy and Ventricular Fibrillation: Experience in Children Under 15 Kg
Alexey N. Arkhipov, Alexander Y. Omelchenko, Yuriy N. Gorbatykh, Alexey V. Zubritskiy, Timur S. Khapaev, Gregory S. Zaitsev, Alexander V. Bogachev-Prokophiev, Alexander M. Karaskov. Academician E. N. Meshalkin State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation.
Objective: The era of minimally invasive cardiac surgery has expanded the list of alternative surgical approaches for secundum atrial septal defect (ASD) repair. Currently, these procedures are commonly used for patients with weight above 15-30 kg. Safety and efficiency of this procedure for children less than 15 kg is still unclear.
Methods: From July, 2012, to October, 2013, 67 pediatric patients under 15 kg. of weight underwent surgical ASD closure using a right mid-axillary minithoracotomy and ventricular fibrillation. 65 patients had an isolated ASD with contraindications for catheter device closure. 2 patients had a sinus venosus ASD with partial anomalous pulmonary veins connection. Our surgical approach is a right mid-axillary thoracotomy in the 4th intercostal space with skin incision 3-4 cm. In all patients direct cannulation was performed for cardiopulmonary bypass.
Results: Mean age was 24.7±9.8 months (range, 7-60 months) and mean body weight was 11.3±1.9 kg (range, 6,7-15 kg), 23 patients (34%) were under 10 kg. Direct closure was carried out in 19 patients; the remaining 48 had pericardial patch closure. Average cardiopulmonary bypass time was 28.8±10.2 minutes (range, 12-57 minutes). Closure of the defect was carried out during ventricular fibrillation in all patients with the mean duration 13.0±9.6 minutes (range, 5-27 minutes). No patient required conversion to a sternotomy or incision enlargement to complete the repair. There was no mortality, bleeding or wound complications. Non-significant residual shunts have been revealed in 3 children. All patients were in good clinical condition with improved functional status at discharge from the hospital.
Conclusions: Surgical ASD repair in children under 15 kg. using a right mid-axillary minithoracotomy and ventricular fibrillation is safe and efficient. Moreover, the procedure is associated with low rate of complications and better cosmetic results.
P34 Perventricular Doubly Committed Subarterial VSD with New Saddle-Like Occluders
Quansheng Xing, Silin Pan. Children’s Hospital of Qingdao University, Qingdao, China.
Objective: Surgical repair of doubly-committed subarterial ventricular septal defect (VSD) under cardiopulmonary bypass (CPB) has been the gold standard. Perventricular device closure of muscular and then perimembranous VSD on beating heats with a small subxiphoid or inferior sternotomy has been attempted in the past few years with good results. We have tried perventricular closure of doubly committed subarterial VSD through a left anterior minithoracotomy as an alternative procedure with a modified occluder.
Methods: 21 selected patients with doubly committed subarterial VSD between January, 2008, and December, 2012, were recruited for modified device closure on beating hearts off-pump through left anterior minithoracotomy through a short incision in the third intercostal space. Their ages ranged from 13 to 61 months and their body weights from 11 to 27 kg. A single per-right ventricular “U” like suture under pulmonary annulus was established, and a delivery system was introduced, aided by an 18G trocar, including a guidewire, delivery sheath, and loading sheath. A proper device was selected according to the VSD size established by transesophageal echocardiography (TEE), and then the device was released under real-time monitoring of TEE if no residual shunt, increased aortic prolapse or regurgitation, abnormal atrioventricular valvular motion appeared.
Results: In 19 of the 21 children, a saddle-like occluder was successfully closed through a left minithoracotomy with satisfactory cosmetic effects. In the other two children, the procedure was converted to conventional open-heart repair because the relatively larger occluder induced significantly increased aortic regurgitation. There was no operative or late mortality or major morbidity. All children were followed longer than 10 months. No residual shunt, increased aortic prolapsed or regurgitation or serious atrioventricular block was recorded until the most recent follow-up.
Conclusions: Selected doubly committed subarterial VSD can be safely closed with a saddle-like occluder through left anterior minithoracotomy.
P35 Minimally Invasive ASD Surgical Repair with Robotic-Assistance in Adults: First Experience in Russia
Alexey N. Arkhipov, Yuriy N. Gorbatykh, Alexander Y. Omelchenko, Alexey V. Zubritskiy, Yuriy L. Naberukhin, Timur S. Khapaev, Alexander V. Bogachev-Prokophiev, Alexander M. Karaskov. Academician Meshalkin State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation.
Objective: Robotic enhancement had advantaged the evolution of minimally invasive cardiac surgery. This report describes the experience in the first step of learning curve –robot-assisted ASD closure via minithoracotomy in adults.
Methods: From March, 2012, to November, 2013, 37 patients underwent surgical ASD closure with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA USA). Mean age was 36.2±11.9 years (range, 15-61 years) and mean body weight was 65.1±12.5 kg (range, 43-95 kg). Thirty-two patients had an isolated ASD with contraindications for transcatheter device closure. In five patients an ASD closure with the concomitant tricuspid valve repair was performed. Our surgical approach is a right lateral minithoracotomy in 4th intercostal space with skin incision 4 cm and three 11-mm ports for robotic instruments. Cardiopulmonary bypass was established with peripheral cannulation. The aorta was cross-clamped with the Chitwood clamp and cardiac arrest was achieved by antegrade delivery of Custodiol solution.
Results: Direct closure was carried out in 4 patients; the remaining 33 had pericardial patch closure. In 5 (13.5%) patients with tricuspid valve insufficiency we used de Vega annuloplasty technique. Average cardiopulmonary bypass time was 78.9±25.1 minutes (range, 42-112 minutes), mean aortic cross-clamp time was 25.1±9.5 minutes (range, 14-47 minutes). No patient required conversion to a sternotomy or incision enlargement to complete the repair. There was no mortality, no residual shunts or postoperative bleeding. There was one case of sinus node dysfunction with a pacemaker implantation, one case of femoral lymphorrhea and two cases of right pneumothorax. All patients were in good clinical condition with improved functional status at discharge from the hospital.
Conclusions: Robotic technology can be utilized to perform open heart procedures safely and effectively via minithoracotomy approach. This technique could be used as an intermediate step with gaining experience to totally endoscopic procedures.
P36 Minimally Invasive Surgical Options for Treating Patients with Congenital Heart Disease
Vladimiro Vida, Chiara Tessari, Fabio Zucchetta, Massimo Padalino, Demetrio Pittarello, Ivo Tiberio, Giovanni Stellin. University of Padua, Padua, Italy.
Objective: We sought to present our experience with minimally invasive techniques (MIT) for surgical repair of various simple congenital heart diseases (CHD) in both pediatric and adult patients.
Methods: Between January, 1998, and December, 2013, 722 patients underwent MIT for treating CHD in our institution. Patients’ hospital outcome according to the type of MIT was evaluated.
Results: Minimally invasive techniques included: 1) mini-sternotomy (MS) (n=379, 52%), 2) right sub-mammary thoracotomy (RST) (n=304, 42%), and right axillary approach (RAA)(n=39, 6%). There 439 females (61%) and 283 males (49%). Median age at surgery was 4.5 years (range 1 month-70 years). Main diagnosis included: 1) atrial septal defect secundum type (n=443, 61%), ventricular septal defect (n=166, 23%), sinus venosus atrial septal defect ± partial anomalous pulmonary venous connection (n=51, 7%), partial atrio-ventricular septal defect (n=45, 6%), other CHDs (n=17, 3%). The majority of patients (n=468, 65%) underwent intra-cardiac repair using induced ventricular fibrillatory arrest; the remaining 254 patients (35%) had a standard cardioplegic arrest. We have recently introduced the routine use of peripheral cardiopulmonary bypass in patients above 15 kg of body weight (n=122) and a newer sternal retraction system. There were no hospital deaths. Fifty-two patients (7.2%) had postoperative complications which were higher in MS patients (n=37, 9.8%) and RAA patients (n=4, 10.3%) when compared to RST patients (n=11, 3.6%) (p=0.001). All patients were discharged home without residual defects. Mean hospitalization time was shorter during the last 2 years of our experience (p=0.01). Median follow-up time was 7 years (1 day - 15 years). There were no late deaths. The vast majority of patients (708/722, 98%) were in NYHA class I and 692/722 patients (96%) were satisfied with the cosmetic result of surgery. Reasons of dissatisfaction were the presence of a “too long/visible scar” (n=18), a cheloid at the incision level (n=10), asymmetric breast development (n=2).
Conclusions: The application of MIT for treating pediatric and adult patients with simple CHD proved safe and effective. The constant refinement of our MIT contributed to reduce patient’s surgical trauma, and combined a high standard of clinical outcome to an excellent cosmetic result.
P37 Perventricular Device Closure of Ventricular Septal Defect Using a Video-Assisted Thoracoscopic Approach
Alexander Y. Omelchenko, Yuriy N. Gorbatykh, Alexander M. Karaskov, Gregory S. Zaitsev, Marina A. Novikova, Alexey N. Arkhipov. Academician E. N. Meshalkin State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation.
Objective: To describe a new technique of perventricular closure of a perimembranous ventricular septal defect using transesophageal echocardiography guidance and video-assisted thoracoscopy.
Methods: The patient was in a 20° right lateral decubitus position. Trocars (3.5 and 3.9 mm) were set through punctures in the 3rd and 6th intercostal spaces along the midclavicular line, in the 4th intercostal space along the anterior axillary line to the left. The thoracoscopic ports were used: the right one for atraumatic forceps and a needle holder; the left one for micro scissors and exteriorization of the tourniquet using a purse-string suture. The central lower trocar was used for endoscopy. After the trocar for the endoscope was placed, insufflation of dioxide carbon (0.5 L/min) was started. The pericardium was opened widely. Using the Kelly forceps under TEE control, we detected the puncture site on the anterior wall of the right ventricle. The Prolene 4/0 purse-string suture was then placed. To close the defect, we used a tool, composed of a ventricular septal defect occlusion device, short occluder delivery system, and modified puncture needle. After direct puncture at the level of the sternocostal joint in the 4th intercostal space on the left, the delivery system was advanced into the anterior mediastinum. A puncture was then made in the anterior wall of the right ventricle through the purse-string suture. The VSD was closed using a standard perventricular device closure technique. A 3-mm drain was placed in the left pleural cavity through the lower puncture site. Extubation was performed in the operating room.
Results: Three patients were treated with this approach (ages 4, 5 and 6 years; weight, 15-17.5 kg; one had subaortic VSD and we used eccentric occluder). The first operation was performed on August 15, 2013. The 3-month follow-up examination revealed excellent cosmetic results in all patients with no shunts, conduction disturbances, or valve complications in any patient.
Conclusions: Applying this technique we expect to achieve high cost-efficiency since this procedure is off-pump, avoids incisions, is effective and safe, and reduces operating time and the patient’s length of stay.
P38 Comparison of Endoscopic Robotic versus Sternotomy Approach for the Resection of Left Atrial Tumors
Emmanuel Moss1, Michael E. Halkos1, Jeffrey S. Miller1, Patrick Kilgo2, Douglas A. Murphy1. 1Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA USA, 2Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA USA.
Objective: Primary cardiac tumors most commonly occur in the left atrium. The aim of this study was to compare outcomes among patients undergoing isolated left atrial tumor resection via a transsternal or robotic approach.
Methods: From 2003 to 2013, 69 patients underwent isolated left atrial tumor resection at three affiliated hospitals with either a transsternal (n=39) or robotic approach (n=30). A retrospective review of prospectively collected data was performed and outcomes were compared between the sternotomy and robotic-assisted groups. Univariate and multivariate analyses controlling for pertinent preoperative characteristics were performed.
Results: Patient characteristics in the 2 groups were similar with the exception of a history of chronic obstructive pulmonary disease (sternotomy = 12.8% vs. robotic = 0%, p<0.04) and elective surgical status (sternotomy = 64.1% vs. robotic = 93.3%, p<0.02). On univariate analysis, robotic-assisted surgery was associated with significantly shorter post-operative mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and a lower rate of perioperative blood transfusion (See Table P38-1). After controlling for patient comorbidity in a multiple logistic regression model, there remained a trend toward decreased blood transfusions (AOR 0.33, CI 0.09-1.20, p = 0.09), shorter ICU (16.3 fewer hours, p=0.11), and hospital LOS (1.1 fewer days, p=0.17) in the robotic group. There were two postoperative strokes in the sternotomy group and none in the robotic group (p=0.21).
Conclusions: Robotic-assisted left atrial tumor resection is safe and may be associated with a lower incidence of perioperative blood transfusion as well as shorter mechanical ventilation time, and shorter ICU and hospital length of stay.
P39 Comparison of Robotic Atrial Myxoma Excision and Conventional Approach
Changqing Gao, Ming Yang. PLA General Hospital, Beijing, China.
Objective: This study is to compare long-term clinical outcomes of robotic myxoma resection with those in conventional approach.
Methods: Between 2007 and 2013, 93 patients underwent robotic (ROBO group, n=49) or conventional sternotomy (STER group, n=44) atrial myxoma excision. In ROBO group, the mean tumor size was 43×52 mm (14×19 ∼ 44×74mm). Four tumors were in the right atrium and 45 tumors were in the left atrium, of which 39 tumors arose from the interatrial septum, 2 from the posterocaudal wall, 3 from the root of the anterior leaflet of the mitral valve, and 1 from the left atrial roof. Via 4 port incisions and a 1.5-cm working port, all the robotic procedures were completed with the da Vinci Surgical System. The exploration and excision were conducted through an oblique right atriotomy in STER group with conventional sternotomy. The clinical data were recorded and echocardiography was used as the diagnostic tool for follow-up. The Medical Outcomes Study Short Form Survey (SF-36) was administered to estimate the quality of life (QOL).
Results: All cases were accomplished successfully. Average amounts of postoperative drainage, intubation time, ICU and postoperative length of stay in ROBO group were less than the STER group (p<0.05). There was no death during the hospitalization or in the follow-up period. One patient in 1-year postoperatively and 1 patient in 3 years postoperatively required reoperation for recurrence in STER group. For the ROBO group, the mean follow-up was 29±16 (1∼60) months. No patient required reoperation for recurrence postoperatively. The quality of life scores in ROBO group were significantly higher than the STER group on postoperative day 30 (p<0.05). The patients in ROBO group appeared more satisfactory with their recovery and incision.
Conclusions: Compared with the conventional approach, robotic excision of atrial myxomas is efficacious, safe and with excellent long-term surgical result. And the patients that underwent robotic surgery lived a high quality of life after surgery.
P40 Subendothelial Excision of Left Atrial Myxoma: Efficacy in Robot-Assisted Cardiac Surgery
Cheong Lim, Dong Jung Kim, Dong Jin Kim, Yoon Cheol Shin, Jun Sung Kim, Kay-Hyun Park. Seoul National University, Seongnam-Shi, Republic of Korea.
Objective: Cardiac myxoma is the most common benign neoplasm in the heart, which shows good long-term result after surgical excision. Usually we use median sternotomy to excise all the tissues including the myxoma itself and adjacent endocardium and myocardium. Approach routes are various, such as bi-atrial, trans-septal, and left atrial, etc. Recently, the da Vinci robot is added to our surgical armamentarium. We analyzed our result of robot-assisted excision of myxoma using subendothelial excision through left atrial approach only.
Methods: From November, 2003, to May, 2013, we operated 39 patients with left atrial myxoma. One patient had recurred myxoma who received mass excision 3 years ago. Male vs. female ratio was 18:21 and mean age was 62.0±11.9 (40-86) years old. Among them, 30 patients received conventional operation (group C) and 9 patients received robot-assisted excision (group R). In robotic surgery, we performed bi-atrial approach in 3 and subendothelial approach with left atrial only in 6. Remaining stalk area was electrocauterized.
Results: In group C, cardiopulmonary bypass and aortic cross clamping times were 71±24 (31-125) and 48±17 (15-77) minutes, respectively. In group R, those were 136±32 (103-204) and 77±24 (54-132) minutes, respectively (p<0.05). Total operation time (from skin incision to sutures) was 182±39 (90-267) minutes in group C and 275±59 (218-386) minutes in group R (p<0.05). There is no operative mortality. One patient in group R received bleeding control for hepatic laceration. Hospital stay was 10.6±9.5 (4-44) days in group C and 6.7±2.7 (4-11) days in group R (p=0.23). During 30.9±26.1 (1-118) months follow-up, there were two follow-up losses. However, late mortality or recurrence have not occurred yet.
Conclusions: Excision of left atrial myxoma shows good long-term results. Endothelial excision through left atrial approach is feasible and effective in robot-assisted cardiac surgery. Further study is mandatory to prove long-term benefit in terms of recurrence.
P41 A New Suture for Distal Coronary Artery Anastomosis Which Eliminates Knot-Tying
Minoru Ono1, Yoshifumi Itoda1, Nirmal Panthee1, Takehiro Ando2, Ichiro Sakuma2. 1The University of Tokyo Hospital, Tokyo, Japan, 2School of Engineering, The University of Tokyo, Tokyo, Japan.
Objective: Traditional hand sewing and knot tying have been used for coronary artery bypass grafting (CABG). Although distal suture devices have been developed to facilitate an easier anastomosis in limited cases, such as endoscopic or robotically assisted CABG, almost all these devices were withdrawn from the market for various reasons. We developed a suture for coronary artery, which eliminates knot tying after continuous suture. We examined safety, feasibility and durability of this suture in swine CABG models.
Methods: A tiny anchoring mechanism (1.0 x 0.5 mm) made up with biocompatible stainless steel is attached to the tail of a regular 8-0 polypropylene suture (Fig. P41-1). This anchor works as a stop mechanism at the start point and as a hooking mechanism at completion of a continuous anastomosis. Suture is fixed by pinching the anchoring device by a needle driver, thus eliminating knot tying. Stability of anastomosis and tissue invasiveness of this new suture were examined in an off-pump CABG model using bilateral internal thoracic artery in miniature swine (acute, 1 month, 3 months and 6 months). All animals received humane care according to the guidelines of the University of Tokyo.
Results: Pigs were divided into two groups: new suture group and conventional suture group. Suture time and graft flow were not different between groups. Graft patency rate by angiography after 1 month (n = 5), 3 months (n =4) and 6 months (n = 2) was 100% in both groups. Histopathologic examination revealed only mild inflammatory responses at the anastomotic sites in both groups without any specific inflammatory change derived from the stainless steel anchor. Feasibility of this new suture is now being tested in an endoscopic situation.
Conclusions: Safety, feasibility and durability of this new suture device were shown in animal models. This may be a promising distal suture device for CABG in endoscopic and robotic assistance, as well as a regular open situation.
P42 MIDCAB in Hybrid Revascularization Strategy
Vadim Popov, Kirill Kozyrin, Egor Malyshenko, Vladimir Ganyukov, Olga Barbarash, Leonid Barbarash. Research Institute of Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation.
Objective: To analyze the results of LAD bypass in patients with isolated lesion who have undergone MIDCAB procedure and in patients with multivessel disease using the hybrid approach.
Methods: 85 patients were enrolled in the study: 52 of them (LAD lesion only) underwent MIDCAB LAD, and 33 patients (with multivessel disease) - hybrid revascularization (MIDCAB LAD with PCI of other coronary lesions). Indications for surgery were hemodynamically significant stenosis or LAD occlusion, high risk of PCI or a failed prior PCI attempt, contraindications to perform sternotomy (anatomical criteria). High-grade angina, a positive stress test in asymptomatic patients. Indications for the hybrid method were the availability to perform PCI of other affected arteries and the ones mentioned above. The average age of patients was 55.26±8.5 years. Male patients (90.5%) prevailed. 55% of patients demonstrated angina FC II, 25% - FC III, 9.5% - CVA, 4.7% - diabetes. The average left ventricular ejection fraction was 48.6±9.7%. Two-vessel CAD was found in 21 patients, three-vessel CAD - in 11 patients. One patient was presented with the lesion of the left main coronary artery with three-vessel CAD.
Results: All patients underwent off-pump LIMA-LAD grafting via minithoracotomy in the fifth intercostal space. There were no intraoperative complications. Blood loss was 270±160 ml; postop ventilation time was 5±2 hrs. ICU length of stay was 16±3.9 hrs. Good patency of the grafts was confirmed with flowmetry at the OR and then at the cath-lab (Fitz-Gibbon A). On day 1-3 PCI as a second stage of the hybrid method was performed with the further confirmation of CA patency (no complications, TIMI 3 grade flow). Average number of stents per patient was 1.36. There were no deaths, MACCE, repeated revascularization in the in-hospital period. There were no cases of incomplete myocardial revascularization, technical difficulties and other complications in our study. The average in-hospital stay was 9±1.9 days.
Conclusions: MIDCAB in isolated LAD stenosis as well as MIDCAB + PCI in multivessel disease patients have demonstrated high efficacy and safety.
P43 Off-Pump Minimally Invasive Coronary Artery Bypass Grafting with a Multisuction Cardiac Positioner: A Better Exposure of Target Vessels without Additional Incisions
Keita Kikuchi1, Yoshiki Endo1, Kotaro Suzuki1, Takayoshi Matsuyama1, Shinnichi Osaka1, Dai Une2, Marc Ruel2. 1Yamato Seiwa Hospital, Yamato-city, Japan, 2Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON Canada.
Objective: Off-pump minimally invasive coronary artery bypass grafting (MICS CABG) for multivessel disease via a small left thoracotomy requires extensive surgical experience and skill. Lateral and inferior territories are difficult to expose; consequently, requiring the use of cardiopulmonary bypass at times. Maximizing exposure may help surgeons complete off-pump multivessel MICS CABG safely. As a result, more surgeons may perform this operation with comfort so that patients will benefit from this less invasive strategy. For a better exposure, we initiated a stepwise approach with a multisuction cardiac positioner.
Methods: A 6-9 cm left thoracotomy is made in the fifth intercostal space. After the left internal thoracic artery is taken down, proximal anastomoses are made onto the ascending aorta with a side-clamp. For distal anastomoses, a stepwise approach is performed. Firstly, a rib-retractor is placed in the small thoracotomy and pulled cephalad and leftward. Secondly, several retraction sutures attached to the lateral pericardial edge are held on the skin for optimizing exposure of the lateral and inferior area. Thirdly, two of three suction cups of a multisuction cardiac positioner are put on the sides of the target vessel through the same thoracotomy, and pulled directly towards the incision (Fig. P43-1). Finally, a distal anastomosis is performed with an epicardial stabilizer via the thoracotomy as in standard off-pump CABG.
Results: We recently initiated a MICS CABG program, and completed 20 cases, including 9 multivessel MICS CABG with a multisuction cardiac positioner. In these cases, the average number of distal anastomoses was 2.8±0.9. Two cases were off-pump quadruple bypass grafting. All patients were discharged, and remain well to this day.
Conclusions: Despite the time of initiation, off-pump multivessel MICS CABG is feasible with the use of a multisuction cardiac positioner. Thus, this approach is easy and helpful in providing good exposure of target vessels during MICS CABG without additional incisions for an epicardial stabilizer or apical positioner.
P44 Functional Angiographic Evaluation of Arterial Composite Grafts with Skeletonized Bilateral Mammary Arteries
Mahmood Reza Sarzaeem, Amirsina Sharifi, Alireza Karimi Damavandi, Jamshid Bagheri, Mohammad Jebelli, Mohammad Hossein Mandegar. Tehran University of Medical Sciences (TUMS), Tehran, Iran.
Objective: Many studies suggest better outcomes after coronary artery bypass surgery (CABG) using arterial grafts, especially bilateral internal mammary arteries (BIMA). Using composite arterial grafts with bilateral internal mammaries provide the optimal technique. In this study, we evaluate the efficacy of multiple composite grafts with BIMA to bypass coronary arteries without sequential technique which is supposed to induce flow disturbance in graft.
Methods: From April, 2006, to May, 2007, 23 patients younger than 55 years old with ejection fraction (EF) ≥40% underwent CABG using SKT-BIMA. Both mammary arteries were harvested with skeletonization technique. Right-IMA (RIMA) was harvested in its full length and was cut in different lengths, and anastomosed to left-IMA (LIMA) which was connected to its pedicle. We used the radial artery to incorporate more branches if necessary. Graft patency and flow abnormalities were examined with functional angiography in all of the patients in 8-12 weeks interval.
Results: Short-term clinical outcomes were excellent and there was no mortality. Echocardiographic evaluations of the patients, showed 3.4% increase in EF (p-value <0.05). Among 94 distal anastomoses in all patients, 66 of which (70.2%) were with mammary arteries, the most common performed patterns were ϰ (kappa) (11 patients), ≙ (lambda) (3 patients) and double mini-composite (3 patients). Post operative functional angiography showed angiography-defined string sign in 1 mammary graft (1.5%), total graft occlusion in 1 mammary graft (1.5%) and competitive blood flow in 4 mammary grafts (6%).
Conclusions: Short-term patency of multiple composite arterial grafts using SKT-BIMA technique in CABG was excellent, proved to have low-flow disturbances and acceptable clinical results.
P45 A Randomized Comparison of Coronary Flow Reserve Following Coronary Bypass with Multiple Grafts vs. Single (T-Graft) Influx
Arndt H. Kiessling1, Nadia El Hadouchi1, T. Voigtländer2, Andreas Zierer1, Anton Moritz1. 1Goethe University, Frankfurt am Main, Germany, 2CCB, Frankfurt am Main, Germany.
Objective: T-graft technique is often used to achieve a complete arterial revascularization with two arterial conduits. Avoidance of aortic trauma is also cited as an advantage. There are works in the literature that show a normal coronary flow reserve of the single influx via an internal mammary artery, but there is increasing evidence that a complete flow reserve cannot be achieved. The aim of the present study poses is whether the T-graft bypass technique can achieve a myocardial flow reserve analogous to that achieved after conventional supply employing individual grafts.
Methods: From March, 2011, through July, 2013, a total of 24 patients (96% male, aged 65±9 years), were included in the prospective, randomized study (NCT01170988). Inclusion criteria were: three-vessel coronary disease (degree of stenosis at least 70%), good LV function, IMA bypass capability, and willingness to undergo an MRT follow-up study 6-12 weeks after surgery. The MRT myocardial perfusion analysis was initially performed visually, at rest, under adenosine. In the semi-quantitative analysis of the 16 sectors that followed, a perfusion reserve below 1.5 was assessed positively. Tissue differentiation occurred by means of contrast imaging (Late Enhancement).
Results: 5 patients could not be considered for the evaluation (lost to follow up, MRT contraindication). Contrary to the randomization, one patient was treated with a conventional bypass technique (n=8 conventional technique/n=11 T-graft technique). The magnetic resonance imaging study revealed normal ventricular function for both arms of the study (Table P45-1). Non-transmural posterior wall scarring was demonstrated among 50% of the patients in each case. Among n=4/8 (50%) of the patients in the T-graft group and n=6/11 (54%) of the conventional bypass group, the perfusion measurement, which was supported by adenosine, exhibited a diminished perfusion reserve.
Conclusions: Given the small number of cases, no distinction could be drawn between the two groups. In each case, the high proportion of patients with perfusion deficits and non-transmural posterior wall scars with clinically unremarkable post-operative courses is striking.
P46 Total Arterial Multi-vessel Revascularization: Matched-Pairs Analysis of Results and Quality of Life after Antero-lateral Mini-thoracotomy Compared to Sternotomy
Marc Albert, Astrid Schlegel, Hardy Baumbach, Adrian Ursulescu, Ulrich F.W. Franke. Robert-Bosch-Hospital, Stuttgart, Germany.
Objective: Off-pump myocardial revascularization allows improved results of coronary artery revascularization regarding mortality and neurological outcome. Total arterial multi-vessel coronary revascularization through a left-sided mini-thoracotomy is technically challenging and described only in few cases. This study presents the results of this new technique of off-pump myocardial revascularization. Using the matched-pairs analysis these results will be compared to those of patients with complete sternotomy for total arterial off-pump revascularization.
Methods: Between September, 2008, and December, 2012, 153 patients underwent minimally invasive multi-vessel off-pump myocardial revascularization via left-sided mini-thoracotomy. In all patients the left internal mammary artery was used. Additionally, the radial artery was harvested endoscopically in all patients for the use as T-graft (group M). For every patient of group M we found a matching patient operated via a conventional sternotomy using both internal mammary arteries (group C). Intraoperative data were similar in both groups (See Table P46-1). A SF-36 questionnaire was given to the patients on average of 9 months post-operatively.
Results: There were no hospital, as well as 30-day-mortality; no post-operative myocardial infarction and no cerebrovascular stroke, respectively. The ventilation time (4.2±3.9h vs. 5.9±3.2h, p=0.001) and the over-all hospital stay (9.4±2.4d vs. 11.4±5.3d, p<0.001) were significantly shorter for patients of group M. In the SF-36 survey, the patients showed a significant improvement regarding physical role functioning (p=0.038) and bodily pain (p=0.010). No patient reported a myocardial infarction or a cerebro-vascular stroke within the follow-up period.
Conclusions: The minimally invasive off-pump myocardial revascularization via left mini-thoracotomy is a feasible and safe procedure. It is equivalent to conventional sternotomy. Shorter ventilation time and shorter hospital stay demonstrate a faster recovery after mini-thoracotomy. Furthermore, this minimally invasive access allows an improvement of postoperative quality of life.
P47 Anaortic Coronary Bypass through Left Minithoracotomy: Comparison between Single and Multivessel Coronary Disease
Massimo Lemma1, Monica Contino1, Claudia Romagnoni1, Andrea Mangini1, Antonietta Delle Fave1, Matteo Munari1, Carlo Antona2. 1Luigi Sacco University General Hospital, Milan, Italy, 2Università degli Studi di Milano, Milan, Italy.
Objective: Anaortic coronary artery bypass graft (CABG) has proved to be safe and effective through sternotomy. Aim of this study was to evaluate the clinical outcome of single and multivessel CABG using an off-pump “no touch aorta” technique through a left minithoracotomy.
Methods: From July, 2008, to July, 2013, 169 consecutive patients were prospectively enrolled to undergo off-pump CABG through a left minithoracotomy: 84 had single-vessel coronary artery disease and underwent minimally invasive direct coronary artery bypass (MIDCAB) using only the left internal thoracic artery (LITA); 85 had multi-vessel coronary artery disease and underwent minimally invasive cardiac surgery - CABG (MICS-CABG) using the LITA and the right radial artery as composite Y-graft. All the patients were operated on by the same surgeon.
Results: Female sex was more frequent in MIDCAB group (15.4% vs. 0%; p=0.002). Age (61±10 yrs. MIDCAB vs. 64±9 yrs. MICS-CABG; p=0.11) and body mass index (25.7±4 MIDCAB vs 25.8±4 MICS-CABG; p=0.92) were similar, ejection fraction was greater in MICS-CABG group (51.5±7.1% vs. 54.4±7.5%; p=0.01). There was no conversion to sternotomy in both groups. Thirty-day mortality occurred in 1 MIDCAB patient (1.1% vs. 0%; p=0.99). There was neither perioperative myocardial infarction nor neurological complication in both groups. The average number of distal anastomosis was 1 in MIDCAB and 2.4±0.4 in MICS-CABG. Reoperation for bleeding (1.1% MIDCAB vs. 3.5% MICS-CABG; p=0.62), blood transfusion (21% MIDCAB vs. 27% MICS-CABG; p=0.49), intensive care unit length of stay (1.5±1 days MIDCAB vs. 1.5 days MICS-CABG; p=0.39) and ventilation time (14.2±34.8 hrs. MIDCAB vs. 15±26.7 hrs. MICS-CABG; p=0.73) were similar. The incidence of postoperative atrial fibrillation was greater in MICS-CABG group (15.2% vs. 31.7%; p=0.021).
Conclusions: Anaortic CABG through a minithoracotomy approach confirms its safety and efficacy. MICS-CABG and MIDCAB are both safe and feasible and associated with excellent postoperative outcome.
P48 Long-term Experience with Radial Artery as Y-Graft to Internal Mammary Artery in No-Touch Aorta Off-Pump Coronary Artery Bypass Surgery
Stefan C. Sandker, Gianclaudio Mecozzi, Jan G. Grandjean. Thoraxcenter Twente, Enschede, Netherlands.
Objective: Over the past two decades the radial artery has regained its popularity in complementing the left internal mammary in CABG. Furthermore, it has been proven that the main stem of the LIMA allows sufficient flow reserve to achieve full-arterial revascularization with a Y-graft construction for three vessel disease. The main advantage of this technique is to avoid aortic manipulation during off-pump CABG surgery, thereby, minimizing the chance of cerebrovascular accidents and myocardial damage due to cardioplegic arrest. The aim of this study was to analyze the clinical long-term follow-up of patients who underwent off-pump CABG surgery using total arterial grafting and no-touch technique at our institution.
Methods: The study cohort consisted of 293 consecutive patients enrolled as all-comers undergoing no-touch aorta off-pump CABG surgery with a radial artery as Y-graft to the LIMA. End points were defined as in-hospital and at maximum follow-up major adverse cardiovascular or cerebrovascular events, defined as all-cause death, stroke, myocardial infarction, and any repeat revascularization. Data was collected from patient charts of the last visit to the cardiologist and mortality was checked at the National Civil Registry.
Results: The median length of follow-up was 5.2 years, range 1.0 to 8.8 years. The number of distal anastomosis per patient was 3.6±0.8 with a median of 4. In hospital mortality was 1.0%, stroke 0.0%, percutaneous coronary intervention 0.0%, and reoperation for graft occlusion 0.7%. At maximum follow-up overall mortality was 9.6%, stroke 4.8%, percutaneous coronary intervention 9.6%, and redo-CABG 0.0%. 18.1% of the patients had recurrent angina pectoris complaints and 4.4% had a myocardial infarction (See Table P48-1).
Conclusions: Total arterial off-pump CABG surgery can be safely performed with low in hospital mortality, overall mortality, need for repeat revascularization and stroke rate. The no-touch aorta technique with the radial artery as Y-graft to the internal mammary artery provides excellent long-term results and we suggest it as treatment of choice for patients with three-vessel disease.
P49 Off Pump Plication of Post MI Left Ventricular Aneurysm: Improve Cardiac Function and Mitral Regurgitation
Ajeet Bana. Fortis Hospital, Jaipur, India.
Objective: Post MI LV aneurysm results into dilatation of ventricle, reduced ejection fraction and appearance of mitral regurgitation. LV aneurysm repair was done using CPB by endovascular patch or linear plication. Advantage of aneurysmorrhaphy and off-pump CABG may be extended to patient by linear plication of LV aneurysm without CPB.
Methods: From January, 2010, to August, 2013, 9 patients were operated on for post-infarction antero-apical aneurysm during off-pump CABG. Repair was completed on the beating heart with help of two tissue stabilizer (ACROBAT – I, MAQUET) applied around the LVA after spreading the suction pods. All patients presented with symptoms of angina or congestive heart failure. Mean pre-operative ejection fraction was 27±8%. The mean left ventricular end diastolic diameter was 52.5±9.6 cm. Three patients were having moderate to severe MR. Pre- and post-operative ejection fraction, left ventricular end diastolic dimension and grade of MR were compared and reassessment was done at 6-month post-operatively.
Results: There was no in-hospital mortality. Coronary artery bypass was performed with an average 3.2 grafts per patient. At the time of discharge, all patients were asymptomatic. There was significant improvement in LV ejection fraction and left ventricular end diastolic dimension. Mitral regurgitation was significantly reduced. All these parameters were maintained at 6-month follow-up.
Conclusions: Surgical closure of left ventricular aneurysm especially in antero-apical region can easily be performed during off-pump coronary artery bypass and stabilization of area with two tissue stabilization facilitate this procedure.
P50 Minimally Invasive Coronary Artery Bypass Surgery Maintains Pulmonary Function Postoperatively
Masood A. Shariff, Rami Michael, Edward Daniele, Natasha Povar, Simon Esthappan, Juan Ariel, John P. Nabagiez, Joseph T. McGinn, Jr. Staten Island University Hospital, Staten Island, NY USA.
Objective: Minimally invasive coronary artery bypass (MICS) is performed through a small left lateral thoracotomy. Surgical approaches (sternotomy versus small thoracotomy) on postoperative pulmonary function were evaluated.
Methods: Preoperative and postoperative (days 1- 6; 2 and 4 week; 6 months) pulmonary function were assessed in 49 patients undergoing MICS and were compared with 55 patients undergoing sternotomy for CABG.
Results: The MICS group compared to sternotomy group did not show significance in surgical time, intubation period, and length of stay (Table P50-1). Pulmonary function test results were higher in MICS group for Forced Vital Capacity (FVC) compared to sternotomy and showed significance on postoperative day (POD) 1, 3, and 6 (POD1: 1.4L versus 1.0L, p=0.0081; POD3: 1.6L vs. 1.2L, p= 0.0009; and POD6: 2.1L vs. 1.4L p=0.049) MICS versus sternotomy: FEV1 (forced expiratory volume in 1 second) was significant on POD 1, 3, and 6 (p=0.0398, 0.008, and 0.0191, respectively). Both groups have similar volumes at 2 and 4 weeks and returned to baseline at 6 months.
Conclusions: MICS CABG procedure leads to better preservation of pulmonary function postoperatively compared with sternotomy CABG.
P51 Multivessel Minimally Invasive Coronary Artery Bypass Grafting: Learning Curve
Masood A. Shariff, Basem Azab, Natasha Povar, Carmen Chan, Peter A. Abotaga, John P. Nabagiez, Joseph T. McGinn, Jr. Staten Island University Hospital, Staten Island, NY, USA.
Objective: Minimally invasive coronary artery bypass grafting (MICS CABG) is a safe and widely applicable procedure for coronary artery disease. We reviewed a single surgeon’s experience with MICS CABG, noting operative time, number of bypasses performed and rate of conversion to sternotomy.
Methods: A prospectively accumulated database of 720 MICS CABG performed by one surgeon between January, 2005, and December, 2012, was reviewed. MICS CABG is performed through a 4-5 cm thoracotomy in the left 5th intercostal space with harvesting of left internal thoracic artery; proximal anastomoses on the ascending aorta and distal anastomoses are done in a stepwise fashion.
Results: A total of 700 consecutive cases were distributed into equal sized chronological 7 groups. (Table 51-1) Number of triple vessel disease referrals has increased significantly (1st vs. 5th Group: p=0.0001; 1st vs. 6th Group: p=0.007). Number of bypasses was significantly increased between the first 100 cases and the successive 600 patients (p<0.001). We observed significant decreased in operative time index after the first 200 cases (p<0.0001) (Fig. P51-1 and Table P51-2).
Conclusions: With experience in MICS CABG number of bypassed vessels increases and operative time and conversion to sternotomy decreases. Additional analyses showed statistical significant difference in operative time was noted after the first 200 cases (between 2nd and 3rd group).
P52 MICS CABG: The Learning Curve: Lessons Learned
Lance N. Blau, Mahesh K. Ramchandani. Houston Methodist Hospital, Houston, TX USA.
Objective: Minimally invasive cardiac surgery (MICS) for coronary artery bypass grafting (CABG) can achieve durable revascularization without the need for a conventional sternotomy. We describe our early and recent experiences with MICS CABG. The differences in outcomes reflect lessons from the learning curve.
Methods: In a large retrospective analysis at our institution, we analyzed data from 174 patients who underwent MICS CABG from March, 2005, to June, 2013. Early cases (before August, 2009) and late cases (from August, 2009, onward) were sub-stratified and analyzed for postoperative outcome using a student t test for continuous variables, chi squared test for categorical variables, and Cox regression.
Results: We have seen significant improvement in our operative proficiency as well as post-operative outcomes in our MICS CABG patients over the past 4 years compared to our first 4 years. From March, 2005, to August, 2009, one-month mortality was 3.45% compared to 0% from August 2009, onwards (p=0.013). There was also a significant reduction in the need for intraoperative blood products (30.61% vs. 14.4%, p = 0.026).The following variables showed no significant difference between early and late groups. Postoperative morbidity at one month - defined as significant bleeding, valve dysfunction, graft occlusion, TIA, stroke, ventilation dependence, or renal failure (36.73% vs. 38.40% respectively, p=0.943). Postoperative length of stay (10.31 days vs. 7.10 days, p=0.081). Surgery duration (4.95 hrs. vs. 4.36 hrs., p=0.099). Average hours in the ICU (137.18 hrs. vs. 58.7 hours, p=0.078) and readmission rate to the ICU (8.16% vs. 3.2%, p=0.238).
Conclusions: MICS CABG is a surgical approach that can be performed safely and effectively. In the second half of our experience, we were able to achieve significantly better mortality rates at one month and require less intraoperative blood products when compared to the first half of our experience. Valuable lessons were learned in technique, patient selection, and teamwork that could help to shorten the learning curve for others embarking on such a program.
P53 Impact of the Interplay among Number of Grafts, Pump Status and Conduit Selection on 15-Year Survival in Patients Undergoing CABG: A Propensity-Matched Study in 2012 Patients
Juan B. Grau1, Christopher K. Johnson1, Giovanni Ferrari2, Richard E. Shaw1, Mariano E. Brizzio1, Daniel J. Flores1, Bruce Mindich1, Alex Zapolanski1. 1Valley-Columbia Heart Center, Ridgewood, NJ USA, 2University of Pennsylvania, Philadelphia, PA USA.
Objective: We have shown that optimal survival after CABG is achieved when bilateral internal mammary arteries (BIMAs) are used as conduits. However, the effect of number of grafts and pump status on the long-term outcomes of BIMA use remains unknown. To determine the impact of these variables on 15-year survival after CABG, we analyzed a cohort of 2012 propensity-matched patients.
Methods: From 1994-2013, 6,666 patients had CABG at our institution. These patients were matched by developing a propensity-score for having BIMA using 22 preoperative factors and the nearest-neighbor-matching algorithm with Greedy 5-1 Digit Matching. This resulted in two patient cohorts (BIMA and Single IMA (SIMA)) of 1,006 patients each. These groups were further stratified by the number of grafts (<4 vs. ≥4) performed and pump status (off- vs. on-pump) to form 8 groups. Late mortality was determined using the Social Security Death Index. Cox Proportional Hazards Regression analysis was used to control for baseline factors.
Results: Table 53-1 demonstrates that the highest survival was found in patients who had BIMA off-pump when ≥4 grafts used (86%). For patients having BIMA with <4 grafts placed, survival was higher when the operation was performed on-pump (78% vs. 69%). Secondary analysis of BIMA off-pump <4 grafts patients demonstrated that the majority of those patients were under-revascularized and off-pump may have not been the best strategy for these patients. On the other hand, patients with SIMA and <4 grafts used demonstrated higher survival when the off-pump strategy was used (75% vs. 67%).
Conclusions: If patients require ≥4 grafts, survival is highest if the BIMAs are utilized via the off-pump approach. For SIMA with ≥4 grafts, survival is significantly lower than for BIMA and pump status has no survival advantage. Therefore, 15-year survival after CABG is influenced by not only conduit selection, but also by the interplay between the number of grafts used and pump status. These findings provide guidance in determining the ideal surgical approach for isolated CABG.
P54 Should Bilateral Internal Thoracic Artery Grafting be used in Patients with Peripheral Vascular Disease?
Yanai Ben-Gal1, Rephael Mohr1, Zvi Raviv1, Amir Kramer1, Nahum Nesher1, Nadav Teich1, Yossi Teich1, Dimitri Pevni1, Benjamin Medalion2. 1Tel Aviv Sorasky Medical Center, Tel Aviv, Israel, 2Rabin Medical Center, Petach Tiqva, Israel.
Objective: Peripheral vascular disease (PVD) is known to be a significant risk factor for early as well as long-term mortality after coronary artery bypass grafting (CABG). Potential survival benefit of using bilateral internal thoracic artery (BITA) grafting in this subset of patients is questionable due to their short life expectancy and the increased risk of sternal infection compared to operations incorporating single internal thoracic artery (SITA). The purpose of this study is to compare early- and long-term outcome of patients with PVD undergoing BITA grafting, to that of patients with PVD undergoing CABG with SITA and other conduits such as saphenous vein graft (SVG) or radial artery (RA).
Methods: Four-hundred-seventy-one patients with PVD who underwent BITA grafting between 1996 and 2003 were compared with 268 patients who underwent CABG with SITA.
Results: Occurrence of female gender (22.9% vs. 31.7%, P= 0.000, in the BITA and SITA groups, respectively), diabetes (38.2% vs. 48.9%, P=0.003), emergency operation (15.1% vs. 22%, p=0.012), chronic obstructive pulmonary disease (11% vs.24.3%, p=0.000) and chronic renal failure (10.6% vs. 19.5%, p=0.001) was lower in the BITA group. On the other hand, congestive heart failure (33.1% vs.19.4%, P=0.000), and recent myocardial infarction (29.9% vs. 18.7%, P=0.000) were more prevalent among BITA patients. EuroSCORE of SITA patients was significantly higher (9.45±3.1 vs. 7.68±3.6, p=0.000). Operative mortality (7% vs. 8.6%, BITA vs. SITA), post operative stroke (5.3% vs. 4.1%) and sternal wound infections (3.2% vs. 3.4%) were not significantly different between groups. Mean follow-up was 8.85±4.95 years. Ten-year survival (Kaplan-Meier) of the SITA group was not significantly lower. (47.4% vs. 54.5%, log rank test p=0.168). Assignment to the SITA group was also associated with similar adjusted survival (p<0.001, compared to the BITA group, COX model).
Conclusions: This large cohort study shows that, with selective use of BITA and SITA, long-term outcome of SITA patients with PVD is not inferior than that of BITA patients.
P55 Long-Term Outcome of GEA Graft
Makoto Hibino, Kazuyoshi Tajima, Keisuke Tanaka, Wataru Kato, Yoshimasa Sakai. Nagoya Daini Red Cross Hospital, Nagoya, Japan.
Objective: In OPCAB, aorta no touch strategy is employed to reduce operative complication and in situ right gastroepiploic artery (RGEA) would be useful graft to accomplish this strategy. In this study, we evaluated the result of in situ GEA used in CABG.
Methods: From January, 2000, to December, 2005, 543 consecutive patients underwent isolated CABG with full sternotomy. Of these, we retrospectively reviewed 305 patients who underwent CABG with in situ GEA harvested in semi-skeletonize fashion.
Results: The average age was 64.3±8.5 years, and 242 patients were male. 267 patients received elective surgery and 6 patients had previous cardiac surgery. 153 patients had diabetes mellitus and 23 patients had hemodialysis. There were 79 OPCAB, 39 on-pump beating CABG, 187 conventional CABG. The average number of anastomosis was 3.5±1.1. Single ITA was used in 92 cases, and bilateral ITA was used in 204 cases. 290 patients received CABG with all arterial graft. Postoperative complication included 2 pneumonia, 6 stroke, and 10 mediastinitis. 30-day mortality was 2 (0.66%). The survival rate and the cardiac death free rate at 1, 5, 10 years were 97.2%, 94.0% 79.8% and 99.3%, 98.4%, 97.3%, respectively. A total 409 GEA anastomoses included 344 RCA anastomoses, 64 circumflex anastomoses and 93 sequential anastomoses. There were 11 early occlusions (2.7%). The cumulative patency rate of the GEA at 1, 5, 10 years were 94.8%, 83.7%, 75.1%, respectively. The cumulative patency rate of the GEA to RCA and circumflex at 10 years were 73.2% and 82.4%, which was not significant (log-rank p=0.75; see Fig. P55-1). Multivariate Cox proportional hazard regression analysis showed severe target vessel stenosis as the only risk factor for late GEA occlusion. (HR 1.85, 95% CI 0.19-0.92, p=0.031).
Conclusions: The patency rate of GEA graft in semi-skeletonize fashion was excellent. This result would promote aorta no touch CABG with all arterial graft.
P56 Cost-Effectiveness and Length of Stay: A Comparison between TECAB, MIDCAB and Conventional CABG
Radoslaw A. Rippel1, Marcus Kofler2, Kathrine Klingler2, Margareta Rammer2, Thomas Schachner2, Johannes Bonatti2, Nikolaos Bonaros2. 1University College London, London, United Kingdom, 2Innsbruck Medical University, Innsbruck, Austria.
Objective: To compare cost-effectiveness and length of hospitalization between TECAB, MIDCAB, and conventional sternotomy CABG.
Methods: Preoperative and postoperative data of patients undergoing TECAB, MIDCAB and conventional sternotomy CABG were collected in a prospective database. Health quality adjusted life years (QALY) were calculated from SF-36 questionnaires collected at 0, 1, 3, and 6 months. Cost data was obtained from previous published manuscripts. Incremental cost effectiveness ratio (ICER) was calculated by diving increment of cost of TECAB by increment in QALY when compared to CABG. Mann-Whitney U test was used and results are compared by median and range values with statistical significance at p<0.05.
Results: There was a significant benefit of totally endoscopic procedures among conventional CABG in length of primary (8 days (5-25 days) vs. 7 (2-33), p<0.001) and secondary hospitalization (7 (1-14) vs. 0 (0-49), p<0.001). Length of stay at rehabilitation (21 (0-29) vs. 28 (0-42), p=0.691) as well as total institutionalization (39 (10-50) vs. 34 (4-83), p=0.350) were not significant between the groups. TECAB group had a significantly higher QALY gained at 6 months after procedure when compared to MIDCAB (0.370 (±0.041) vs. 0.358 (±0.030), p=0.029) and a trend towards higher QALY gained when ± compared to CABG (0.370 (±0.041) vs. 0.357 (±0.036), p=0.068). For conventional CABG, the cost per QALY gained was $333,840 and for TECAB it was $263,849. In addition, we calculated incremental cost effectiveness ratio (ICER) comparing conventional CABG to TECAB. The TECAB had higher QALY and lower cost of the procedure resulting in the ICER of $-1,658,231.
Conclusions: All in all, we demonstrated a reduction in hospitalization time with a trend in QALY gained at 6 months after procedure using totally endoscopic techniques when compared to CABG. TECAB was associated with a significant reduction in costs per QALY gained.
P57 Assessment of ST2 Levels in Patients Undergoing Coronary Artery Bypass Surgery via Conventional vs. Robotic Techniques
Phat L. Tran, Badi Rawashdeh, Sugam A. Bhatnagar, Behrooz Dehdashti, Abdulla Alabagi, Robert Poston. University of Arizona, Tucson, AZ USA.
Objective: Myocardial injury occurs in patients that undergo coronary artery bypass grafting (CABG). The remodeling process is usually self-limiting. Some would ultimately enjoy preserved cardiac function and prolonged survival while others develop secondary ventricular remodeling where the myocardial strain exceeds the pathological threshold and releases a soluble biomarker ST2 (sST2), a member of the interleukin receptor family. Previous studies have shown that ST2 level after admission for heart failure and myocardial infarction is a potent predictor of adverse outcome. Here, we serially tested and compared sST2 levels among patients undergoing CABG by sternotomy (sCABG) vs. minimally invasive robotic technique (rCABG). We hypothesize that the intraoperative myocardial strain is a patho-physiologically important predictor of mortality within the first post-operative year.
Methods: Blood was collected from 410 patients at: 1) Preop (preoperatively prior to skin incision), 2) Postop (30 minutes after surgery), 3) 24 hour, and 4) 72 hour. Serum was stored at -80OC until analysis for the concentration of sST2 using an enzyme-linked immunosorbent assay with single freeze-thaw cycle.
Results: Death occurred in 9 patients (2.2%) at 30 days and 32 patients (7.8%) at 1-year after CABG. 58 rCABG and 58 sCABG patients with matching clinical and biochemical risk factors have similar mean level of sST2 (ng/ml) at preop, postop and 72 hours but significantly different at 24 hours (2.95±0.46 vs. 4.32±0.61, P=0.05), respectively. Mean sST2 level at 24 hours was significantly elevated in decedents vs. survivors (7.33 vs. 2.68, P<0.001). Length of stay was also shorter for rCABG patients in comparison to sCABG.
Conclusions: After stratifying for clinical predictors and biomarkers, sST2 elevation after CABG was an independent predictor of 1-year mortality. Assessment of this novel biomarker after CABG may improve mortalities associated with conventional cases and prolong survival after CABG.
P58 Equivalent Medium-Term Survival with Open and Endoscopic Vein Harvesting in Coronary Revascularization
Rashmi Yadav, Saina Attaran, Richard Trimlett, Ganesh Sobhun, Philip Kimberley, Eleanor Dunnett, John Pepper, Anthony C. DeSouza. Royal Brompton Hospital, London, United Kingdom.
Objective: Coronary artery bypass surgery performed through median sternotomy remains an invasive operation. Efforts to reduce invasiveness include minimally invasive conduit harvest, already widely practiced in the USA. Despite initial concerns regarding long-term vein graft patency, several studies have now demonstrated the safety of endoscopic vein harvesting (EVH). We present the process of introduction of EVH at our center, leading to near total adoption of the technique at the present time.
Methods: After a period of training, EVH was started in November, 2009. In 2010 and 2011 over 50% of saphenous vein harvests were EVH, which rose to 73% in 2012 and 90% in 2013. Mid-term data was collected using patient telephone survey and national outcome databases.
Results: Overall, of 2262 CABG ± other, EVH=1105 compared with 1157 cases of open vein harvest (OVH) for this period. There were no differences between the two groups with regard to preoperative characteristics, number of diseased vessels, ventricular function or other co-morbidities. EVH did not influence the duration of operation, bypass or cross-clamp time. Postoperatively, there were no statistical differences in the rate of complications between the groups. Leg wound infection was three times higher in the OVH group compared to EVH (2.7% versus 0.7%, p=0.004). In-hospital mortality (p=0.31) and reoperation for graft problems (p=0.49) were similar between the groups. Mortality data was collected from the UK Personal Demographics Service and showed no difference in survival at 3 years between the EVH and OVH groups (97.8 vs. 97.5, p=0.3).
Conclusions: Our initial results of EVH in over 1000 patients demonstrated comparable results with OVH but lesser degree of wound infection rates. Medium-term follow-up showed equivalent survival in the two groups.
P59 Results of Proximal Anastomosis Devices for CABG: HEARTSTRING vs. Enclose II
Akira Yamada. Teine Keijinkai Hospital, Sapporo, Japan.
Objective: We used two different kinds of proximal anastomosis devices for off-pump CABG: HEARTSTRING and Enclose II. We sought the usefulness and short-term patency of the devices.
Methods: From 2004 to 2005, we used 17 HEARTSTRING in 15 cases and 14 Enclose II in 14 cases for off-pump CABG. All grafts were SVG for HEARTSTRING while 14 SVG and 3 RA (radial artery) for Enclose II. For concomitant bypass, we used LITA and RITA for LAD or LCX. We use 6-0 polypropylene sutures for all proximal anastomosis. Post-operative graft gram was performed in all cases on day 1 to day 40 to evaluate early patency.
Results: We have no hospital mortality and no neurological complications in the present cases. Distal target vessels were as follows: 13 RCA, 2 LAD and 2 D1 for HEARTSTRING, 13 RCA and 4 LCX for Enclose II. In the post-operative graft gram, patency rates were 17/17 (100%) with HEARTSTRING and 15/17 (88.2%) with Enclose II.
Conclusions: Both HEARTSTRING and Enclose II were safe and useful devices for proximal anastomosis in off-pump CABG.
P60 Novel Sternum Lifting Technique for Robotic Internal Mammary Artery Graft Harvesting
Ishikawa Norihiko, Isao Matsumoto, Go Watanabe. Kanazawa University, Kanazawa, Japan.
Objective: Internal mammary artery (IMA) harvesting using the robotic system usually requires artificially induced capnothorax to provide visualization and working space, but this procedure has the disadvantage of deteriorating the hemodynamics.
Methods: We developed an electrical sternum lifting system (ESLS) for robotic IMA harvesting, which is robust and can be finely adjusted, capable of lifting the sternum for a maximum of 5 to 10 cm (Fig. P60-1).
Results: Using a mechanical sternum lifting device significantly (p<0.01) shortened the time of IMA harvesting from a mean ± SD of 55.5±24.1 minutes to 33.0±15.7 minutes. No patient using the ESLS required induced capnothorax.
Conclusions: Our novel ESLS provides a good operative field of view and allows IMA harvesting without inducing capnothorax.
P61 One Year’s Experience with Lung Cancer Screening in Brazil: BRELT1 Preliminary Results
Juliana P. Franceschini1, José R. Pereira1, Fernando U. Kay1, Rodrigo C. Chate1, Altair S. Costa Júnior2, André Luiz C. Trajano3, Jose Ernesto Succi2, Roberto Saad, Júnior4, Mário C. Ghefter1, Ricardo S. Santos1. 1Hospital Israelita Albert Einstein, São Paulo, Brazil, 2Federal University of São Paulo, São Paulo, Brazil, 3Instituto Cardiopulmonar, Salvador, Brazil, 4Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil.
Objective: Low dose computed tomography (LDCT) is becoming part of the standard of care for lung cancer (LC) detection in high-risk individuals. Little is known about incidence of screening detected lung nodules or LC in Brazil. Our objective is to evaluate the value of LDCT on detection of benign or malignant thoracic diseases in asymptomatic smokers in Brazil.
Methods: The 1st Brazilian Early Lung Cancer Detection Program (BRELT1) was designed to provide free care and monitoring of 1000 smokers. The current accrual was initiated on March, 2013. All included individuals underwent baseline LDCT and were invited to participate in smoking cessation programs. LDCT results were evaluated by a multidisciplinary team consisted of radiologists, pulmonologists, oncologists and thoracic surgeons. Studies with 4 mm or above nodules were classified as “positive”. The inclusion and exclusion criteria were similar to National Lung Screening Trial: 55-74 years, current or former smoking history of at least 30-pack years, smoking cessation of less than 15 years, excluding candidates with suggestive symptoms of LC or serious illness.
Results: From March to November, 292 participants were recruited. Initial results are depicted in Table P61-1. Following the NCCN guidelines, individuals with positive studies underwent: PET-CT (7), bronchoscopy (5), transthoracic needle aspiration (3), robotic or VATS (4). Three patients were diagnosed with LC, all stage I disease. One schwannoma and 2 active tuberculosis infections were found. Recommendations for 3-6 months LDCT were given to 116 individuals (39.7%). In despite of a “positive study”, 11 individuals will repeat LDCT in one year due to suggestive findings of previous granulomatous disease.
Conclusions: Preliminary data indicate a similar incidence of lung cancer in high-risk smokers living in Brazil. A large number of lung nodules suggestive of tuberculosis exposure were seen; nevertheless, invasive diagnostic assessment should not be recommended on asymptomatic individuals with benign findings. Further assessment of all nodules with serial LDCT will add significative information for the development of a local lung cancer CT screening protocol.
P62 The Role of Intra-operative Frozen Pathology with Embedding Medium Inflation Technique for the Optimal Guidance of Surgical Methods for Pulmonary Ground Glass Nodules
Yoohwa Hwang1, Jae Moon Koh1, Yong Won Sung2, Jae Hyun Jeon1, In Kyu Park1, Chang Hyun Kang1, Doo Hyun Chung1, Jin Mo Goo1, Young Tae Kim1. 1Seoul National University Hospital, Seoul, Republic of Korea, 2SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.
Objective: Increasing number of lung cancer screening program frequently detects pulmonary ground glass nodules (GGN), which often require surgical resection. However, the guideline how to decide optimal surgical resection method is not well established. We applied intra-operative frozen section diagnosis using embedding medium inflation technique (EMIT) and compared its usefulness to that of convention method in terms of guiding an optimal surgical resection.
Methods: We prospectively set up 41 GGN patients and applied EMIP method. For comparison, 154 consecutive GGN cases where the conventional frozen diagnosis was used were set. The diagnostic accuracy as well as its role to guide optimal surgical methods was compared between two groups with a gold standard being that of final pathologic diagnosis. Optimal surgical method was defined as wedge resection if the final pathologies were benign, AAH, adenocarcinoma in situ (AIS) or microinvasive adenocarcinoma (MIA) and as anatomic resection if the lesions were invasive adenocarcinoma.
Results: There were no differences in nodule sizes between the conventional group and EMIT group (1.45±0.6 versus 1.51±0.5, p=0.63). In conventional group, 138 nodules were correctly classified as to either malignant or benign lesion (sensitivity 95.6%, specificity 53.8%). Anatomic resections should have been applied in 5 patients. Actually, one patient underwent a second round of anatomic operation. In EMIT group, 38 of 41 nodules were correctly classified (sensitivity100%, specificity 66.7%). In five patients, anatomic resections were performed despite the diagnosis of MIA or AIS: in one, because gross finding suggested visceral pleural dimpling, in four, because the lesions were centrally located. In one patient among those four, the diagnosis changed from MIA to invasive adenocarcinoma. However, as the invasive portion was only 7mm, he did not require a second operation. As a consequence, none of the patients received inadequate, non-anatomic resection because of erroneous frozen diagnosis in EMIT group (Fig. P62-1).
Conclusions: The diagnostic accuracy of EMIT in GGO nodules was superior to that of conventional method. Furthermore, EMIT could accurately guide surgeons to decide optimal surgical resection by providing accurate size estimation of the invasive components of the GGN intraoperatively.
P63 Is Lobe Specific Nodal Dissection an Alternative to Systematic Dissection in Early Lung Cancer?
Khalid Amer1, Ali Zamir Khan2, Sanjay Jogai1, Neeta Singh1. 1University Hospital Southampton, Southampton, United Kingdom, 2Medanta, The Medicity, Gurgaon, New Delhi, India.
Objective: To identify stage migration in patients with non small cell lung cancer (NSCLC) operated by VATS major pulmonary resection (VMPR) and systematic nodal dissection (SND) if they were to receive lobe specific nodal dissection (LSND) instead.
Methods: Patients undergoing first time VMPR + SND for NSCLC with a negative mediastinum on CT and PET. SND was defined as at least 2 nodes from at least 3 stations including subcarinal #7, and 90% of patients had at least 10 nodes harvested. LSND was defined as at least 6 nodes in total, harvesting for right upper lobe or right middle lobe: 2R, 4R and 7, for right lower lobe: 4R, 7, 8, 9, for left upper lobe: 5, 6, 7 and for left lower lobe 7, 8, 9. Cancer staging was recalculated for patients who underwent SND, excluding nodes harvested in excess of LSND. Stage migration is the main outcome of this study.
Results: Between April, 2005, and March, 2011, 101 consecutive patients met the criteria. 98.9% of these patients had six or more nodes harvested from three stations and always including #7. Median number of harvested nodes (right = 12, range 5-33; left = 10, range 7-21. Recalculating the pathological staging after disregard to nodes beyond LSND did not change the staging in a single station. SND failed to migrate the staging from LSND.
Conclusions: There is strong evidence that evaluating mediastinal N2 node by LSND is as good as SND. It follows that N2 metastases are predictable and can be covered by LSND without compromise to staging.
P64 Robotic Mediastinal Nodal Exenteration is Safe and Increases Upstaging for Early Stage Lung Cancer
Duy Nguyen, Farid Gharagozloo, Barbara Tempesta, Keith Maas, Robert Poston, Mark Meyer, Mohammad Moslemi. The University of Arizona Medical Center, Tucson, AZ USA.
Objective: One advantage of the application of robotics for lobectomy in patients with lung cancer may be the ability to provide greater mediastinal lymph node exenteration (MLNE) with robotic instruments. Large series have shown upstaging after robotic MLNE is up to 21%, compared to 11.6% in VATS groups and 14.3% in open groups. We reviewed our experience with upstaging in patients who underwent robotic lobectomy.
Methods: Patients with clinical stage I or II lung cancer who underwent robotic lobectomy and MLNE were included in this retrospective study.
Results: 228 patients underwent robotic segmentectomy or lobectomy and MLNE. Lobectomies were right upper 44, middle 24, lower 32; left upper 49, lower 27. Mean operating time was 186±60 minutes. Tumor type included adenocarcinoma 135, squamous cell carcinoma 50, adenosquamous carcinoma 16, bronchoalveolar 17, large cell 4, poorly differentiated 2, carcinoid 7. Overall pathologic upstaging was noted in 32 patients (32/228, 14%). Segmentectomies had 10% upstaging and lobectomies had 16.7% upstaging. Median hospitalization was 6 days. Complications included atrial fibrillation, prolonged air leak, atelectasis, and pneumonia. Mortality was 1.7%. At median follow-up of 41 months 4/228 patients died from lung cancer, 8 from metastatic disease, and 2 had a second lung primary cancer. There was no local recurrence.
Conclusions: Robotic lobectomy is safe and efficacious by virtue of a thorough removal of lymph nodes. This may increase the oncologic efficacy of video-assisted thorascopic surgery and allows patients to receive adjuvant chemotherapy for microscopic disease.
P65 Video-Assisted Thoracoscopic Lobectomy: Incisions and Feasibility
Vinh H. Vu, Sr. Choray Hospital Vietnam, Hochiminh, Viet Nam.
Objective: Video-assisted thoracoscopic surgery (VATS) lobectomy is not a new issue but the technique to perform it is still controversial especially the access incisions. The trend is getting smaller incisions and lesser entrance ports but enable surgeon to perform anatomical lobectomy. We present our experience using three entrance ports in which the maximum one is 2.5 cm.
Methods: We reviewed patients who underwent VATS lobectomy by the same surgeons during the time of 4 years (from August, 2009 to May, 2013). We accessed the lung by a 2.5 cm working incision and two other 10 mm ports for scope and endoscopic instruments using exchangeable. Resected lobe(s) was (were) put in a plastic bag and taken out via working incision (without further incision).
Results: The described incision and ports could access all aspects of the lung, enable surgeon to perform total endoscopic lobectomy and lymph nodes resection in 97 cases of VATS lobectomy (Fig. P65-1). Of them, 2 had trivial bleeding that required chest tube for 4 days. No mortality. The main operation time is 150 minutes and the main post-op hospitalization is 6 days.
Conclusions: The above described incision and ports enabled to perform total VATS lobectomy for lung tumor sized up to 7 cm and complete lymph node resection in lung cancer staging up to 2B.
P66 Robotic-Assisted Lobectomy for Early Stage Lung Cancer: Mid-Term Follow-up in 168 Consecutive Cases
Mohammad Moslemi, Duy Nguyen, Mark Meyer, Barbara Tempesta, Keith Maas, Robert Poston, Farid Gharagozloo. University of Arizona, Tucson, AZ USA.
Objective: Lobectomy for early stage lung cancer can be performed by open thoracotomy, thorascopy, or robotic surgery. Robotic lobectomy has developed over the past decade, and is a feasible and safe technique. We report the largest series to date of patients who underwent robotic lobectomy.
Methods: From January, 2004, to July, 2013, we reviewed patients that underwent robotic lobectomy. From this cohort, patients who had early stage lung cancer were included.
Results: 168 patients underwent robotic lobectomy for early stage lung cancer. There were 76 men and 92 women, mean age 66±10 years. Lobectomies were right upper 44, middle 24, and lower 32; left upper 49 and lower 27; lingulectomies 11, and bi-lobectomies 11. Mean operating time was 201±58 minutes. Tumor type was adenocarcinoma 108, squamous cell carcinoma 33, adenosquamous carcinoma 9, bronchoalveolar 14, large cell 4, poorly differentiated 2, carcinoid 7. Pathologic upstaging was noted in 29/168 (17%). There was no emergent conversion to open and no intraoperative death. Postoperative mortality was 1.2%. There was one death among the last 128 patients. Total morbidity was 23%. Median hospital stay was 6 days. At median follow-up 41 months, 4/168 (2.3%) patients died from lung cancer, 8/168 (4.7%) had metastatic disease, and 2/168 (1.2%) had a second primary lung cancer. There was no local recurrence.
Conclusions: Robotic lobectomy is feasible and safe with comparable morbidity to thoracotomy and VATS approaches. The oncological efficacy of robotic lobectomy may be due to enhanced bronchovascular.
P67 VATS Lobectomy for Lung Cancer without Preoperative Histological Diagnosis: Is It Justified?
Khalid Amer1, Ali Zamir Khan2, Sanjay Jogai1, Neeta Singh1. 1University Hospital Southampton, Southampton, United Kingdom, 2Medanta, The Medicity, Gurgaon, New Delhi, India.
Objective: To explore the safety and efficacy of a 2-staged approach to VATS major pulmonary resection (VMPR) for presumed lung cancer in highly selected patients presenting with previous extra-thoracic adenocarcinoma and a fresh lung lesion. There is a tendency for interventional radiologist to omit the CT-guided needle biopsy and intraoperative frozen section could be non-contributory.
Methods: Patients undergoing first time VMPR for lung cancer were assessed within 2 groups: (A) patients with spiculate lesion, positive computed tomography and or positron emission tomography and without preoperative histological diagnosis going straight to lobectomy or had intraoperative frozen section and Group (B) patients who had 2-stage VMPR, i.e., initial VATS wide-margin wedge resection followed 2-4 weeks later by VMPR ± systematic nodal dissection (SND). Lobectomy was considered inappropriate if final histology was benign or metastatic, and sublobar excision was possible.
Results: Between April, 2005, and March, 2010, 196 consecutive patients were considered for VMPR ± SND for presumed lung cancer in a multidisciplinary setting. Group II had significantly more patients with another extra-thoracic cancer by design. There is no difference in outcomes between the two groups. There was unacceptably high rate 74/169 (44%) of patients in Group I going straight to lobectomy without histological confirmation of malignancy. There were 10 (5.9%) unnecessary lobectomies in Group I, compared to none in Group II. There was no survival difference between the two groups.
Conclusions: Every endeavor should be made to obtain preoperative histological diagnosis before VMPR to avoid unnecessary lobectomy, nodal dissection and to improve theatre-time utilization. The two staged approach in selected cases is justified in a unit with a high throughput of VATS lobectomy. There is no additional morbidity or mortality to this approach. Principles of curative resection should not be compromised in this cohort of patients.
P68 Discrepancy between Preoperative Plan and Intraoperative Decision for Thoracoscopic Segmentectomy in cT1a Lung Cancer Patients
In Kya Park, Yoohwa Hwang, Hye-Seon Kim, Jae Hyun Jeon, Chang Hyun Kang, Young Tae Kim. Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
Objective: Planned segmentectomy in cT1a lung cancer patients can be converted to lobectomy intraoperatively by various factors. We investigated the pattern and indication of conversion to lobectomy from planned segmentectomy in cT1a lung cancer.
Methods: Data of 43 patients with cT1a lung cancer and was indicated for thoracoscopic segmentectomy from 2011 to 2013 were retrospectively reviewed. Indication of thoracoscopic segmentectomy was clinical Ia lung cancer with tumor size 2 cm or less. Patients who underwent segmentectomy due to pulmonary dysfunction were excluded.
Results: Thirty-nine patients had no preoperative histologic diagnosis. Radiologic nodule characteristics were pure GGN in 22 (51%), part-solid nodule in 13 (30%) and solid nodule in 8 (19%). Histology was adenocarcinoma in 22, adenocarcinoma in situ (AIS) in 19 and other in 2. Mean tumor size was 1.1±0.4mm radiologically and 1.2±0.6mm pathologically. Pathologic T stage was T1b in 1 due to tumor size and T2a in 3 due to tumor size or visceral pleura invasion. One lobectomy patient had lymph node metastasis at N1 and N2 nodes. Pathologic stages were Ia in 39, Ib in 3 and IIIa in 1. Segmentectomy was completed in 16 (37.2%) patients. Wedge resection with curative intent was performed in 4 (9%) because frozen examination result was AIS. Lobectomy was performed in 23 (53%) patients. The most common indication for conversion to lobectomy was invasive adenocarcinoma by frozen examination in 12 (52%). Close resection margin by intraoperative assessment was indication in 7 (30%) patients. One patient had both indication factors. Small volume of residual lung parenchyma after segmentectomy was indication in 3 (13%) patients. Lobectomy was performed in 2 Ib and 1 IIIa patients. One stage Ib patient underwent segmentectomy eventually. Radiologic tumor size of this patient was 1 cm. There was no conversion to thoracotomy.
Conclusions: Although segmentectomy is indicated in cT1N0M0 lung cancer, conversion to lobectomy is necessary in some patients based on pathologic finding of frozen examination, intraoperative assessment of resection margin and volume of residual lung parenchyma to avoid compromised oncologic surgery. Thoracic surgeons should be prepared for conversion of planned segmentectomy to lobectomy intraoperatively based on these findings.
P69 VATS Lobectomy of Pulmonary Sequestration
Muhtar Sundetov, Temur Eshmuratov, Nurlan Zharilkapov, Nurhat Zhunisov, Askar Eleusizov, Bekdaulet Akimniyazova, Ruslan Kasenbaev. National Scientific Center of Surgery, Almaty, Kazakhstan.
Objective: Improvement of diagnosis and treatment of pulmonary sequestration.
Methods: In our thoracic department from 1998 to 2013, we examined and operated on 18 patients with pulmonary sequestration; 4 of them were performed videothoracoscopic lobectomy. In diagnostics we used radiography, computed tomography, endoscopy, and aortography angiopulmonography.
Results: Clinical examination in 8 patients in the preoperative period allowed suspected lung sequestration, which was confirmed by aortography. 2 patients during aortography due to pulmonary hemorrhage was performed endovascular occlusion of the aberrant artery. It allowed it to stop the bleeding and prepare patients for elective surgery. In the remaining patients, lung sequestration was detected during surgery, at 3 patients during videothoracoscopic lobectomy. Due to high-resolution optics we succeeded in allocating pulmonary ligament to identify additional blood vessels extending from the thoracic aorta and going to the lower lobe. The number of aberrant arterial vessels ranged from 1 to 7. Only 1 patient had extrapulmonary sequestration, and the rest was easy intrapulmonary sequestration. In the postoperative period there were no complications.
Conclusions: At suspicion of congenital malformation of lung, aortography and angiopulmonography should be carried out. Endovascular occlusion of the aberrant artery allows to stop bleeding and to prepare the patient for elective surgery.
P70 Robotic Extrapleural Pneumonectomy
Mohammad Moslemi, Duy Nguyen, Mark Meyer, Barbara Tempesta, Keith Maas, Robert Poston, Farid Gharagozloo. University of Arizona, Tucson, AZ USA.
Objective: The pleurectomy phase of the extrapleural pneumonectomy is associated with significant blood loss and difficulty in clearing tumor from the apex as well as the costophrenic recess. This intrinsic blood loss results in increased transfusion rates with increased risk for the remaining lung to have post transfusion injury. We hypothesize that robotic technology, due to its ability to provide magnified high definition three dimensional visualization, and greater instrument maneuverability in confined spaces, could potentially obviate these difficulties.
Methods: Over a six-month period, we reviewed patients planned for extrapleural pneumonectomies with robotic-assisted pleurectomy. Blood loss was measured by transfusion requirement. Tumor clearance was subjectively graded by the surgeon.
Results: 6 patients were planned for robotic-assisted extrapleural pneumonectomy. Two of these patients were deemed unresectable after robotic exploration. Of the remaining 4 that completed this procedure, there were 3 men and 1 woman. Three cases were for mesothelioma and one case was for lung cancer (T4 with pleural involvement). There were no intraoperative transfusion requirements, though two patients required 2 units of packed red blood cells for drift hematocrit. Surgeon grading of tumor clearance was R0 in all four patients, R1 or R2 in no patients. Median operative time was 7 hours, 17 minutes. Median hospitalization days were 13 days. Thirty-day survival was 100%.
Conclusions: Robotic technology allows for pleurectomy with decreased blood loss and increased clearance of tumor from areas too difficult to remove otherwise. This may improve outcomes for extrapleural pneumonectomy.
P71 Robot-Assisted Laparoscopic Gastroesophageal Valvuloplasty as an Alternative Anti-Reflux Procedure Which More Closely Replicates the Physiologic Anti-Reflux Mechanism
Duy Nguyen, Mark Meyer, Mohammad Moslemi, Barbara Tempesta, Keith Maas, Robert Poston, Farid Gharagozloo. The University of Arizona Medical Center, Tucson, AZ USA.
Objective: The Nissen fundoplication is the most common procedure performed for gastroesophageal reflux disease. This operation is associated with dysphagia and gas bloat in some patients. The normal antireflux barrier consists of a valve formed by intussusception of the esophagus into the stomach at the gastroesophageal (GE) junction. Creation of a GE valve using the surgical robot may enable a more physiologic anti-reflux procedure associated with a lower incidence of dysphagia and gas bloat.
Methods: All patients who underwent robot-assisted GE valvuloplasty were reviewed retrospectively. Operations were performed by a single surgeon (FG) through five ports, and included robotic dissection of the esophageal hiatus, anterior and posterior closure of the hiatus, followed by intussusception of a 2-cm segment of esophagus into the stomach for 270 degrees in order to create a GE valve. Results were assessed by preoperative and postoperative endoscopy, manometry, 24 hour pH study, UGI study, subjective symptom questionnaire, and objective Viscik grading.
Results: There were 68 patients (38 men, 30 women), mean age 52±9 years. Mean operative time was 175+56.7 minutes. There were 4 minor complications and no mortality. Mean hospitalization was 3.42+3.52 days (median 1 day). 65 patients (95%) had transient postoperative dysphagia which resolved within 3 weeks. Mean follow-up was 46 months. On follow-up, 94% patients had a Viscik I grading and the remaining patients had a Visick II grading. Additionally, there was no gas bloat or long-term dysphagia. There was no recurrence of the hiatal hernia.
Conclusions: Robot-assisted GE valvuloplasty recreates the normal anti-reflux barrier, and is associated with a low incidence of long-term untoward affects. These results appear to be sustained over medium-term follow-up. Although greater experience is necessary, robot-assisted GE valvuloplasty may represent a more physiologic alternative to the Nissen fundoplication.
P72 Robot-Assisted Ivor Lewis Esophagectomy with Intrathoracic Hand-Sewn Anastomosis for Esophageal Cancer
Mark Meyer, Duy Nguyen, Mohammad Moslemi, Julia Samame, Barbara Tempesta, Keith Maas, Carlos Galvani, Robert Poston, Farid Gharagozloo. The University of Arizona Medical Center, Tucson, AZ USA.
Objective: Ivor Lewis esophagectomy is associated with significant morbidity and mortality rates ranging from 2 to 10%. Robotics has been applied to minimally invasive esophagectomy to varying degrees with promising results. However, totally robotic Ivor Lewis has not been described to date and remains the ultimate goal. We report our initial experience in robotic esophagectomy.
Methods: All patients who underwent robotic-assisted esophagectomy between January, 2004, and July, 2013, were included. Robotic, laparoscopic, or open gastric/esophageal mobilization were performed followed by robotic thoracoscopic esophageal dissection, mediastinal nodal dissection and intrathoracic anastomosis.
Results: Robotic-assisted esophagectomy was performed in 48 patients (39 men, 9 women. Avg age was 71.2±9.3 years). Esophageal cancer was present in 39 patients, achalasia in 1, and high-grade dysplasia in 8. Neoadjuvant chemotherapy was given in 17 patients. Avg operating time was 9±1 hr 25 min. Median hospitalization was 10 days. Pathology showed Barrett’s esophagus in 6.7%, squamous cell carcinoma in 6.7%, adenocarcinoma in 53% and no residual tumor in 18%. Stapled anastomosis was performed in 24 of the last 30 patients while robotic hand sewn was performed in the remaining 6. Conversion to thoracotomy for completion of anastomosis occurred in 8 patients. The most common complications were atrial fibrillation (6), and anastomotic stricture (7). There were 2 anastomotic leaks (1 hand sewn, 1 stapled anastomosis. 30-day mortality was 3/45 (6%).
Conclusions: Ivor Lewis esophagectomy for esophageal cancer can be performed safely with robotic assistance with mortality rates similar to recent literature. Intrathoracic anastomotic technique is continuing to evolve and requires further data to assess outcomes.
P73 Use of Digital Suction Drainage for VATS and Robotic Surgery
Kamran Ali, Shaiwal Khandelwal, Narendra Agarwal, Sangeeta Khanna, Ali Zamir Khan. Medanta, The Medicity, Gurgaon, India.
Objective: We present outcomes of use of Medela digital suction drainage for complex VATS and robotic surgery cases.
Methods: Between January and December, 2012, 115 patients had Medela digital suction device following complex VATS and robotic thoracic surgery. Suction was set at 2 Kpas and daily recordings were maintained. Drains were removed at 20 mls. Early mobilization was encouraged with yoga and vigorous chest physiotherapy.
Results: Age group was between 4 to 88 years (mean 56 years). Average drainage was 458 mls. 2 patients drained 1.5 liters needing change of bottle. Mobilization along with yoga was started on day one. Good radiological outcomes were experienced in all patients. Mean drain dwell time was 2 days for all cases except for decortication where the drain dwell time was 5 days. No patient needed conversion to regular chest drain. All staff demonstrated a high level of comprehension and satisfaction with management of digital drain. One night call out was noted due to bleeping of device.
Conclusions: Use of Medela digital suction devices allows early mobilization, early removal of drains and shorter hospital stay. It aids good clinical outcomes in complex VATS and robotic thoracic surgery.
P74 Fluoroscopy Plus Rigid and Fiberoptic Bronchoscopy and Balloon Dilatation for Benign Tracheal Strictures: An Alternative to Tracheal Resection
Muhammad A. Nawaz, Alan Kirk, Ali Jilaihawi. Golden Jubilee National Hospital, Glasgow, United Kingdom.
Objective: The surgical resection used to be the mainstay therapeutic approach for benign tracheal stricture (BTS). Bronchoscopic balloon dilatation (BBD) is a valuable tool in the management of benign tracheal strictures. This retrospective study aims to assess its usefulness and the long-term outcome following minimally invasive BBD.
Methods: 56 balloon dilatation procedures (repeat range 2-14 times) were performed for 11 patients for benign tracheal strictures between 2001 and 2013 using the fluoroscopic contrast Cordis tracheal balloon 18 – 25 mm using 4 - 6 atm pressures.
Results: The main indication for intervention was severe stridor in almost all of these cases. The etiology for stricture in 3 cases was post-intubation, 2 Wegener’s granulomatosis, 1 post radiotherapy, 1 Good’s syndrome, 1 inflammatory, 1 post tracheostomy, 1 severe inhalational burns and 1 secondary to panniculitis and trachea-esophageal fistula who needed 14 dilatation sessions. The patients were oxygenated well at the start of procedure using the venturi ventilation and balloon would be inflated for 1-2 minutes. Procedure was performed as a day case in majority (82%) apart from 2 complicated cases of stricture (severe burns and trachea-esophageal fistula) following prolonged ventilation. None of the patients we described mandated further surgical tracheal resection.
Conclusions: This is a technique we used for several years, has proved to be effective in virtually all types of BTS. The results are extremely encouraging and gratifying and we do recommend this as a first line treatment for BTS, which are very likely to obviate the need for surgery.
P75 Re-expansion Pulmonary Edema after Minimally Invasive Cardiac Surgery
Yusuke Irisawa, Toshinori Totsugawa, Arudo Hiraoka, Genta Chikazawa, Kentaro Tamura, Hidenori Yoshitaka, Taichi Sakaguchi. The Sakakibara Heart Institute of Okayama, Okayama, Japan.
Objective: Re-expansion pulmonary edema (RPE) may sometimes occur after minimally invasive cardiac surgery (MICS) conducted by single-lung ventilation. However, it has not been widely recognized as one of the serious complications after MICS. The aim of this study is to seek the occurrence rate and risk factors of RPE.
Methods: The study enrolled 381 consecutive patients who underwent MICS with right mini-thoracotomy from March, 2005, to October, 2013. We retrospectively compared the data between patients with and without RPE, and evaluated the risk factors.
Results: RPE after MICS was observed in 8 patients (2.1%). In preoperative data, greater percentage of an internal use of steroid or immunosuppressant was found in patients with RPE (25% [2/8] vs. 1% [4/373]; P=.0056). In operative data, significantly longer operation and cardiopulmonary bypass (CPB) time were found in patients with RPE (388±80 vs. 272±61; P<.0002 and 253±79 vs. 158±50; P=.0009). Additionally, significantly greater percentage of second CPB run was observed in patients with RPE (38% [3/8] vs. 1.3% [5/373]; P<.0001). In postoperative data, prolonged ICU and postoperative hospital stay were found in patients with RPE (9.5±8.5 vs. 1.5±0.9; P< .0001 and 41±21 vs. 20±9.8; P=.0003). The overall 30-day mortality was 0.8% (3/381), and 30-day mortality of patients with RPE was 12.5% (1/8). By multivariate analysis, preoperative use of steroid or immunosuppressant, longer CPB time (>181 min) and second CPB run were detected as independent risk factors for RPE after MICS (p=.0014, .0302 and .0410, respectively).
Conclusions: RPE was one of the serious complications after MICS with right mini-thoracotomy, and preoperative use of immunosuppressant and prolonged use of CPB were identified as risk factors for RPE.
P76 Videothoracoscopic Lung Biopsy in the Diagnosis of Interstitial Lung Disease: How Many Biopsies?
Francesco Quarantotto, Pio Maniscalco, Nicola Tamburini, Elena Garelli, William Grossi, Giorgio Cavallesco. Department General and Thoracic Surgery, Ferrara, Italy.
Objective: Interstitial lung disease (ILD) is a generic term representing a heterogeneous group of lung disease sharing clinical, roentgenographic, and physiologic features. Surgery may still be needed to establish an accurate diagnosis, to identify potential treatable causes and to rule out other process. Video-assisted thoracoscopic surgery (VATS) has been recently adopted as a safe and effective approach in obtaining biopsies of parenchymal lung disease. It is not clear the number of biopsies required to obtain a diagnosis of certainty. This study tests the diagnostic accuracy and safety of the videothoracoscopic lung biopsy in the diagnosis of ILD.
Methods: A retrospective study was conducted of 47 consecutive patients with suspected interstitial lung disease (ILD) on clinical and radiological grounds referred for VATS biopsy during a 5-year period (from January, 2005, to December, 2010). The mean age was 59.3±12.0 years (range 27-80). Pulmonary function tests, chest high resolution computer tomography scan, bronchoscopy and bronchoalveolar lavage (BAL) were carried out in all patients. A suitable biopsy site was chosen using chest HRCT-scan abnormalities and intraoperative findings. All the specimens were sent to the microbiology and pathology department for microbiological and histopathological diagnosis. One chest-tube (28F) was positioned and connected to a drainage-system and placed on suction.
Results: Twenty-three 23 patients (49%) one biopsy was performed; multiple biopsies (two or three) were carried out in 24 patients (51%). The histopathological diagnosis was obtained for all patients and therefore the diagnostic accuracy of the procedure was 100%. Postoperative mortality rate was 0%. The mean and median post-operative stay was 3.1 days. The postoperative complications were very rare. Two patients (4%) experienced a prolonged air-leak.
Conclusions: Videothoracoscopic lung biopsy provides adequate specimen volume for histopathologic diagnosis and achieves a very high diagnostic yield. A very high diagnostic accuracy can be achieved also in case of single biopsy by targeting the site using chest HRCT-scan.
P77 Small Single-Incision Thoracoscopic Surgery Using Wound Protector and Anchoring Suture of the Lung Parenchyma for Two-Directional Traction in Primary Spontaneous Pneumothorax
Dohyung Kim, Bong Soo Son. Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
Objective: Currently, single-incision thoracoscopic surgery, SITS, is a potential alternative procedure in primary spontaneous pneumothorax compared with conventional multi-ports thoracoscopic surgery. But SITS is not yet a widespread procedure for primary spontaneous pneumothorax because of an increased likelihood of collision between the instruments during surgery, and the use of all instruments through one incision means that a relatively large incision is required, leading to less satisfactory cosmetic outcomes. The purpose of this study is to confirm that our surgical method can be safe and an alternative procedure for the treatment of primary spontaneous pneumothorax.
Methods: From October 1, 2012, to August 31, 2013, a total of 33 patients were enrolled and had surgery for primary spontaneous pneumothorax. Total 35 surgeries were performed because 2 patients had a contralateral recurrence of pneumothorax. Our surgical technique is illustrated in Figures P77-1, 2, 3, 4. All of the clinical data were analyzed retrospectively.
Results: The mean age of the 33 patients was 22.9±7.5 years. 32 patients were men and 1 patient was woman. The mean operative time was 52.3±11.4 minutes. The mean duration of thoracic catheter insertion was 3.1±1.3 days. The patients with the postoperative air leak were 19 and the mean duration of the air leak was 1.6±1.2 days. No complications were recorded. The Wong-baker pain scale of the postoperative day 0, 1, 2, discharge were 3.2±1.5, 2.6±1.3, 1.7±0.9, 1.2±0.8 respectively. The mean duration of the hospital stay and the postoperative hospital stay were 7.8±2.9 and 4.9±2.5 days respectively. The mean follow-up period was 5.9±2.9 months. There were 2 ipsilateral recurrent pneumothorax cases during this period.
Conclusions: Small single-incision (less than 2 cm) thoracoscopic surgery using wound protector and bidirectional anchoring suture is safe and feasible; the method has acceptable outcomes for primary spontaneous pneumothorax. Our operative technique can be an alternative method of the treatment for primary spontaneous pneumothorax.
P78 Outcomes of Minimally Invasive Nuss Procedure for Correction of Pectus Excavatum in Adults: Case Series
Shyam Kolvekar, Alexandra Bartnik, Jeremy Felderhof. UCLH The Heart Hospital, London, United Kingdom.
Objective: Pectus excavatum (PE) is a congenital condition characterized by inward depression of the chest wall. Significant PE can lead to heart compression and can affect exercise tolerance. Minimally invasive Nuss procedure is now replacing the open surgery (Ravitch). We present the outcomes of this novel technique.
Methods: We retrospectively followed a series of 47 patients, mean age 38 (15-68, mode and median 27), 4% female, who underwent Nuss procedure at the Heart Hospital, London, UK, between February, 2010, and July, 2013. We recorded the reasons for the operation, history of cardio-respiratory symptoms, results of echocardiogram, pre- and post-surgery chest radiographs and CT chest images, the length of hospital stay, need for analgesia, complications, and planned completion bar removal.
Results: Reasons for the procedure: 72% cosmetic reasons alone, 19% breathlessness on exertion, 4% palpitations, 4% chest pain on exertion and 9% other chest pain. 4 patients had evidence of right ventricular compression on CT with normal function on echocardiography. Bar number and size: 50% 1 bar, 50% 2 bars, 42% size 10 and 35% size 11. The mean length of hospital stay was 4.7 days (3-21). Requirement for analgesia: mean 17 days (5-28), 45% required opiate analgesia, 38% tramadol, 62% required 3 or more types of analgesia. Complications (patient number): 5 incision site cellulitis (2 requiring intravenous antibiotics), 14 pleural effusions (12 resolved spontaneously, 2 required drainage), 16 small pneumothoraxes which resolved spontaneously, 4 bar displacements requiring re-do Nuss. Completion bar removal was performed in 2 patients at 2 and 3 years post-insertion respectively.
Conclusions: Minimally invasive Nuss procedure is a safe and effective alternative to the open correction of PE. It is successfully used in different age groups and in both genders. Longer follow-up is needed to assess how long-lasting its effects are following bar removal.
P79 Minimally Invasive Repair of Pectus Excavatum: A Single-Institution Experience
Constantin Grozavu, Sr., Mihai Ilias, Dragos Marin, Daniel Pantile. Spitalul Universitar de Urgenta Militar Central, Bucharest, Romania.
Objective: The Nuss procedure is a minimally invasive alternative to the traditional “Ravitch-type” operation for pectus excavatum. This relatively new procedure has gained enough ground among thoracic surgeons to recommend it. We conducted this study to evaluate our experience.
Methods: With the largest number of patients treated using this procedure (65 patients who underwent pectus excavatum minimally invasive repair between October, 2007, and December, 2013), our center is the biggest in Romania. This study brings information about demographics, operative course, complication and patients’ degree of satisfaction.
Results: With an average of 58 minutes per intervention, minimal blood loss and 3.8 days of postoperative hospitalization time, we consider this approach to pectus excavatum more suitable than any other surgical intervention aiming to correct this deformation (Ravitch-type procedure, silicone implants, etc.). We also analyze the pre- and postoperative respiratory and cardiac function for these patients. Last, but not least, we will analyze the psychological aspect of this deformation.
Conclusions: The minimally invasive repair for pectus excavatum can be performed with minimal blood loss and reduced operative time. The quality of repair, the absence of postoperative symptoms, patients’ satisfaction degree and cosmetic appearance encourage us to recommend this procedure for most of the patients with pectus excavatum.
P80 Videothoracoscopic Intervention in Chest Trauma
Temur Eshmuratov, Muhtar Sundetov, Nurlan Zharilkapov, Nurhat Zhunisov, Askar Eleusizov, Bekdaulet Akimniyazova, Ruslan Kasenbaev. National Scientific Center of Surgery, Almaty, Kazakhstan.
Objective Based on the development and use of minimally invasive endovideothoracoscopic interventions improve the results of treatment of complicated chest injury.
Methods: Study is based on a comparative evaluation of the results of diagnosis and treatment of complicated injuries to the chest at 342 patients with and without the use videothoracoscopy. Among them were 303 men and 39 women, aged from 16 and up to 83 years (mean age 33.3±9.5 years). Videothoracoscopy always perform in the operating room, fully equipped, if necessary conversion. Found that the use of videoendoscopic technology in complicated chest injuries was effective in 113 (88.9%) patients. It is allowed to reduce frequency of unnecessary thoracotomy duration of drainage of the pleural cavity, the frequency of complications and duration of hospital treatment. The mortality has decreased in 2 times, and was 3.14%. Found that at floating rib fractures are always complications: clotted hemothorax, lung laceration, various sizes subpleural and intrapulmonary chest wall hematoma. A comparative evaluation of various methods of fixation of floating rib fractures and found clear advantages of minimally invasive fixation under control of videothoracoscopy. Already next day after fixation, there is noted improvement in vital capacity of the lung and blood oxygen saturation.
Results: In 66 (90.4%) patients using videoendoscopic technologies made the full amount of surgeries. Conversion required in 7 (9.6%) patients. Comparative studies have shown that the use of minimally invasive interventions in penetrating wounds of the chest allowed to reduce the frequency of thoracotomies in 2.1 times, the duration of drainage of the pleural cavity 2 times, the frequency of complications in 3.3 times, length of hospital treatment in 2 times and mortality in 2 times.
Conclusions: Videothoracoscopy is an effective diagnostic and therapeutic method in complicated closed chest trauma. Chest carcass recovery under control of videothoracoscopy allows to securely stabilize the chest wall, avoiding wide dissection of injured soft tissue.
P81 Our Experience: Minimally Invasive Aortic Valve Replacements
Siavash Saadat, Anthony Azzolini, Viktor Dombrovskiy, Karen Odroniec, Peter Scholz, Anthony Lemaire, George Batsides, Leonard Lee. Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ USA.
Objective: The small incisions of minimally invasive surgery have the proposed benefit of less trauma, pain, and improved cosmetic outcome; all of which correspond to faster postoperative recovery. Opponents claim smaller incisions lead to poor exposure, making the operation longer, more difficult and dangerous. Here, we report our experience performing minimally invasive aortic valve replacements (AVRs), via minimally invasive anterior thoracotomy or mini-sternotomy approach, compared to conventional sternotomy.
Methods: All data were collected from the Robert Wood Johnson University Hospital Cardiac Surgery Database. A total of 189 AVRs were completed from January, 2012, to December, 2013, using one of three techniques: (1) mini-thoracotomy, (2) mini-sternotomy, (3) conventional sternotomy. Preoperative comorbidities and aortic valve dysfunction were compared, along with operative morbidity and mortality, length of hospitalization, and postoperative complications.
Results: Of the 189 cases, 82 (43.4%) were mini-thoracotomy, 44 (23.3%) mini-sternotomy, and 63 (33.3%) conventional sternotomy. Analysis of postoperative complications revealed that the mini-thoracotomy approach, compared to the mini-sternotomy and conventional sternotomy, had a lower incidence of prolonged ventilator support [2.4% vs. 11.4% and 11.1%, respectively (p = 0.054)]. Further, the mini-thoracotomy approach, compared to the mini-sternotomy and conventional sternotomy, required a shorter ICU stay [38.3 vs. 62.8 and 92.7 hours, respectively (p<0.05)] and shorter postoperative length of stay [6.5 vs. 9.4 and 9.3 days, respectively (p<0.05)], resulting in an overall shorter hospitalization [8.8 vs. 12.8 and 14.7 days, respectively (p<0.05)]. Incidence of stroke [1.2% vs. 2.3% and 1.6%, respectively(p=1.0)], reoperation for bleeding [4.8% vs. 6.8% and 4.8%, respectively (p=0.84)], renal failure [6.1% vs. 9.1% and 6.4%, respectively (p=0.82)], and atrial fibrillation [21.9% vs. 34.1% and 23.8%, respectively (p=0.34)], were lower in the mini-thoracotomy group compared to the mini-sternotomy and conventional sternotomy; however, these differences were not statistically significant. Overall, minimally invasive techniques demonstrated a trend towards better survival [mini-thoracotomy 2.4%, mini-sternotomy 2.3%, and conventional sternotomy 4.8 % (p=0.77)].
Conclusions: Minimally invasive AVR is a safe and effective alternative to conventional sternotomy. The mini-thoracotomy approach showed a decrease in postoperative ventilation time, a decrease in length of ICU stay, and a decrease in overall duration of hospitalization. Finally, postoperative morbidity and mortality trended towards being lower following mini-thoracotomy when compared to mini-sternotomy and conventional sternotomy.
P82 Risk Factors for Acute Kidney Injury in Elderly Patients Undergoing TA-TAVI or Minimally Invasive Aortic Valve Replacement
Peter Lukas Haldenwang1, Markus Schlömicher1, Matthias Trampisch2, Matthias Bechtel1, Justus Strauch1. 1BG University Hospital Bergmannsheil Bochum, Bochum, Germany, 2Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University of Bochum, Bochum, Germany, Bochum, Germany.
Objective: Acute kidney injury (AKI) represents a major complication following aortic valve replacement in elderly high-risk patients. The aim of this study was to determine the ideal strategy, minimal invasive valve replacement (MIS-AVR) or transapical valve implementation (TA-TAVI), regarding the postoperative renal function.
Methods: 133 patients (67 male) with severe aortic stenosis and age ≥75 years were included over two years: 42% were treated with MIS-AVR, 58% underwent TA-TAVI-procedure. AKI was considered as a post-procedural 1.5x increase in creatinine or an increase of >0.3 mg/dl over 48h. Group differences were tested with chi-square or t-test. Risk assumption for AKI was analyzed in multiple multivariate logistic regression models.
Results: EuroSCORE II risk assumption was 8.7±6.9 for TA-TAVI and 4.5±5.7 for MIS-AVR (p<0.001). The overall 30-day survival rate was 93%. 58 patients developed a risk for AKI and 13 a manifest renal injury/failure. Multiple multivariate regression models revealed a higher risk of AKI for the TA-TAVI (OR 2.82; 95%CI [1.33, 5.98], p=0.007). Neither the EuroSCORE II (OR 0.99; 95%CI [0.94, 1.05], p=0.722) nor the pre-operative creatinine level (OR 2.05; 95%CI [0.93, 4.56], p=0.076) had any impact on AKI. The regression model adjusting for the variables age, gender, BMI, diabetes and the procedure-type revealed a higher AKI-rate for male gender (OR 2.41; 95%CI [1.13, 5.11], p=0.022). The operation time and the amount of radio-contrast media had no influence on the occurrence of AKI. There was no correlation between AKI and early mortality.
Conclusions: A higher risk for AKI after TA-TAVI should be considered in the therapy decision, especially in elderly male patients, since MIS-AVR still yields excellent results.
P83 EDWARDS INTUITY Valve System: A New Useful Tool for Minimally Invasive Aortic Valve Replacement
Marco Solinas, Francesca Chiaramonti, Pier Andrea Farneti, Federica Marchi, Tommaso Gasbarri, Giacomo Bianchi, Paolo Antonio Del Sarto, Sergio Berti, Mattia Glauber. Heart Hospital G. Pasquinucci FTGM, Massa, Italy.
Objective: The sutureless bioprosthesis are designed to allow faster and easier valve implantation reducing the cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times. These characteristics make it especially useful for minimally invasive approaches (MIA). We present our initial experience with a new class of rapid-deployment aortic valves, the EDWARDS INTUITY Valve System (Edwards Lifesciences, Inc., Irvine, CA USA) implanted in MIA.
Methods: Between June, 2012, and December, 2013, 47 patients with symptomatic aortic stenosis underwent aortic valve replacement (AVR) with EDWARDS INTUITY Valve System. Of these, 36 patients underwent isolated AVR. In 31 (66% of all patients and 86% of isolate aortic valve disease patients) patients were performed an AVR in MIA: 21 (68%) patients received an upper J-type ministernotomy and 10 (32%) patients received a right anterior minithoracotomy. One-month follow-up (phone call) and three months follow-up (echocardiographic evaluation) were completed.
Results: Implantation success was 100% (30/30). In 1 patient it was decided to not implant the sutureless bioprosthesis for evidence of bicuspid aortic valve. Deployment time was 15.3±4.1 minutes. CPB and ACC time were respectively 85.8±17.5 and 52.2±13.8 minutes. These times are significantly lower then observed in our previous experience using sutured bioprosthesis during MIA. Mechanical ventilation time was 5.7±2.4 hours, ICU stay was 1.7±0.5 days and ward stay was 5.7±1.4 days. The transvalvular gradient at discharge was 10.2±4.1 mmHg (mean) and 16.6±6.4 mmHg (peak). At three-month follow-up the mean transvalvular gradient was 8.3±4.6 mmHg and the peak transvalvular gradient was 13.7±7.2 mmHg. Three months survival was 100%.
Conclusions: AVR with EDWARDS INTUITY Valve System is feasible and reproducible and it is associated, in our experience, with excellent results in terms of survival and hemodynamic performance at short-term follow-up. This bioprosthesis represents a new tool that promises to reduce technical difficulties and operative times during AVR in MIA compared to sutured bioprosthesis. However, experience with a larger number of patients and a longer follow-up are necessary to validate these preliminary data.
P84 Sutureless Aortic Valve Replacement Does Not Impair Surgical Key Times and Outcome
Harald C. Eichstaedt, Oto Dapunt. Klinik für Herzchirurgie, Oldenburg, Germany.
Objective: To evaluate surgical feasibility and clinical outcome of sutureless aortic valve replacement (SAVR) in patients (pts) using a minimally-invasive approach via anterolateral thoracotomy.
Methods: In pts with severe and isolated aortic valve stenosis cardiopulmonary bypass (CPB) was installed by femoral cannulation. After right-sided anterolateral minithoracotomy, AVR was performed using two different types of sutureless aortic valves prostheses. Surgical key times and clinical outcome were assessed. Echocardiography was performed during surgery, before discharge, and during follow-up exams each year.
Results: Overall, 21 pts underwent SAVR via minimally-invasive approach (m:w = 10:11), mean age 76.1 ys (range 68-88 ys). Mean EuroSCORE was 11.1 (range 4.3 - 24.2). Mean cross-clamp time was 46.2 mins (range 29-70 mins), mean CPB time was 82.4 mins (range 58 - 113 mins). Prostheses sizes of 23 and 25 mm were used in most pts (n=7 and 5, respectively). In a comparable cohort of isolated SAVR pts with full sternotomy approach, aortic cross-clamp time was lower (mean X clamp time 40.1 mins (19-63 mins; statistically n.s.). Echocardiographic examinations did reveal no paravalvular leakage (lvl) in all pts and low pressure gradients (overall mean 10.1 mmHg). There was one postoperative death due to respiratory failure (day 19). Postoperative pacemaker implantation due to new-onset bradycardia was necessary in 1 pt. During mean follow-up time of 355 days (range 13 to 693 days) no further significant complication was observed. Follow-up echocardiographic examination did not reveal any new onset of pvL. Mean pressure gradient was 7.9 mmHg (5-11.5 mmHg) on average and remained low over time.
Conclusions: In our preliminary experience with minimally-invasive SAVR via minithoracotomy, surgical key times, hemodynamic and clinical outcome did not differ from patients with SAVR via full sternotomy. The unique properties of sutureless aortic valves facilitate minimally-invasive access to the aortic valve resulting in safe and faster SAVR compared to conventional heart valves.
P85 Sutureless Aortic Valve Size Estimation and Prediction Using Multidetector Row Computed Tomography
Rafik Margaryan, Alfredo Giuseppe Cerillo, Enkel Kallushi, Daniyar Gilmanov, Antonio Micelli, Michele Murzi, Marco Solinas, Mattia Glauber. Ospedale Del Cuore Fondazione ’G. Monasterio’, Massa, Italy.
Objective: Sutureless prostheses facilitate aortic valve replacement (AVR) through a right anterior minithoracotomy (RAMT). However, correct valve sizing remains a crucial step of this procedure. We analyzed contrast-enhanced preoperative multidetector row computed tomography (cMDCT) for aortic annulus measurement and valve size prediction in patients undergoing AVR.
Methods: From January, 2011, to September, 2013, 201 patients underwent aortic valve surgery as sole procedure with implantation of Sorin Perceval S (SPS) in RAMT. Inclusion criteria for this study were presence of preoperative cMDCT and echocardiography. cMDCT was used to measure the aortic annulus as the diameter derived either from the area (aD) or the circumference (cD) of the virtual basal ring, left ventricular outflow tract (LVOT) diameters either from the area (aLVOT) or the circumference (cLVOT). cMDCT was reviewed with single operator who was blind to implanted valve size. Aortic annular diameter and LVOT diameter were retrieved from echocardiographic records. Predictive models were built based on ordered logistic regression with single covariates.
Results: We identified 54 patients who had preoperative cMDCT. Seven patients received an S, 21 received an M and 26 received an L size SPS. Mean age of the patients at the time of intervention was 76.3±6.8 years, mean logistic EuroSCORE 10.4±8.7%. Echocardiographic measurements showed lower accuracy to predict valve size compared to cMDCT measurements. Echocardiographic LVOT measurements were 61.1% to predict the valve size whereas annulus measurement was 53.7%. aLVOT from cMDCT had around 63% and cLVOT had 64.8% predictive accuracy. cD had highest accuracy to predict the valve size (81.5%, AUC 0.77) following by aD having accuracy around 79.6%. Multivariate models fail to increase the predictive accuracy. Classification tree models, after pruning with 4 nodes, increased the accuracy (83.3%) and it was easy to interred and possibly easy to implement for clinical use.
Conclusions: cMDCT measured estimates seem to have higher predictive value for valve size determination in patients undergoing RAMT with SPS. In clinical conditions, cMDCT is preferable over echocardiography for precise aortic annulus diameter estimation.
P86 Minimizing the Learning Curve in Minimal Invasive Aortic Valve Replacement by Usage Low-Fidelity Trainer
Abdullrazak Hossien. Morriston University Hospital, Swansea, United Kingdom.
Objective: Nowadays the aortic valve replacement (AVR) in minimal invasive technique is used increasingly because quick postoperative recovery and cosmetic results. Therefore, we propose low-fidelity trainer for cardiac trainees and junior surgeons to reduce the learning curve in key-hole surgery.
Methods: Low-fidelity trainer is designed from a box in which we inserted aortic root models. The models were made from self-moulded Silicon. The diameters and measurements are made to simulate the real work environment. The design steps are described in this study. 6 cardiothoracic surgery trainees used the simulator for 3 days. The procedures were performed according multimedia guideline. The results were reviewed by a senior surgeon.
Results: The usage of the simulator results in cannulation of the aorta and right atrium in key-hole circumstances. Providing the simulator with aortic substitute lead to performing of all AVR techniques involving interrupted, semi-continuous, continuous and sutureless AVR. The time taken to perform the procedures improved by 30-40% after 3 days. The needle direction and angle were scored according an assessment sheet. Closure of the aortotomy was done successfully in single- and double-layer fashion.
Conclusions: The low-fidelity trainer may improve the surgical skills in minimal invasive aortic valve replacement. The familiarity and repetition in performing of surgical procedures results in shortening the learning curve and in reducing the time consumed in the operation room.
P87 Perceval S Sutureless Valve Choice in High-Risk Patients Undergoing Multiple Valve Surgery
Antonio Miceli, Michele Murzi, Daniyar Gilmanov, Antonio Lio, Matteo Ferrarini, Marco Solinas, Mattia Glauber. Fondazione Toscana G. Monasterio, Massa, Italy.
Objective: Perceval S sutureless valve has shown excellent outcomes after isolated aortic valve replacement (AVR). However, no experience is reported on Perceval S in multiple valve surgery. The aim of our study is to report our single-center experience in high-risk patients undergoing AVR combined with mitral and/or tricuspid valve surgery.
Methods: This is a retrospective, observational study of prospectively collected data on 35 consecutive high-risk patients undergoing AVR with Perceval S valve and other valve procedures. Of these, 8 had previous cardiac surgery.
Results: Twenty-seven patients underwent AVR+ mitral valve surgery (15 replacements and 12 repairs), of which 2 had also tricuspid valve repair. Of the 8 redo patients, 5 had AVR after previous mitral valve surgery (3 replacement and 2 repairs) and 3 had AVR re-replacement associated with tricuspid surgery (1 replacement and 2 repairs). The mean cross-clamp and cardiopulmonary bypass times were 93±32 min and 140±45 min, respectively. In hospital mortality was 2.8% (1/35) with an expected median logistic EuroSCORE I of 16% (range 4-74%). Postoperative stroke and need of pacemaker implantation occurred in 2 patients, respectively. At median follow-up of 6 months, survival was 83%; freedom from reoperation was 100%. No paravalvular leakage occurred and the mean gradient at follow-up was 11±4 mmHg.
Conclusions: Aortic valve replacement with Perceval S sutureless valve in combined multiple valve surgery is a feasible and safe procedure associated with good early and 6-month outcomes.
P88 Concomitant Valve Surgery and Coronary Artery Bypass Grafting Via Right Thoracotomy
Rami Michael, Masood A. Shariff, Jonathan Davila, Robert Carlucci, John P. Nabagiez, Joseph T. McGinn, Jr. Staten Island University Hospital, Staten Island, NY USA.
Objective: Coronary artery bypass grafting (CABG) with aortic valve replacement (AVR) or mitral valve replacement (MVR) is traditionally performed via sternotomy. Minimally invasive coronary artery bypass grafting (MICS) and minimally invasive valve surgery (MIVS) have been successfully performed independently. We present our series of 6 patients who underwent a combined MICS-MIVS via right anterior thoracotomy.
Methods: Between January, 2011, and June, 2012, six patients underwent MICS-MIVS (four AVRs and two MVRs) via right anterior mini-thoracotomy for valve replacement and single-vessel bypass. The surgeries were evaluated perioperatively for overall outcomes.
Results: Six patients with an average age of 74±5 years underwent single-vessel grafting using reversed saphenous vein graft to the right coronary artery with either AVR or MVR. Two patients were elective and 4 were emergent. Average cardiopulmonary bypass time was 170.5±30.3 minutes in the MICS-AVR group and 169.0±7.1 minutes for MICS-MVR; average aortic cross-clamp time was 121.8±35.9 minutes for MICS-AVR and 111.50±2.1 minutes for MICS-MVR. Three patients were discharged home in 5±0 days, one patient went to nursing home, and two were admitted to rehab. No patients required conversion to sternotomy or reoperation; one patient developed atrial fibrillation in the AVR group; one was complicated by sepsis.
Conclusions: Concomitant valve replacement and single-bypass grafting via right anterior mini-thoracotomy is a feasible surgical choice, particularly when a non-stentable lesion exists in a high-risk patient. In the appropriate patient population, combined CABG and valve surgery can be safely performed via right anterior thoracotomy.
P89 Titanium Fasteners in Open Aortic Valve Replacement Surgery: Effective and Significant Savings
Candice Y. Lee, Juan M. Lehoux, Peter A. Knight. University of Rochester Medical Center, Rochester, NY USA.
Objective: While titanium fastener technology is gaining acceptance in cardiac surgery, no publications address its use in aortic valve replacement (AVR). This study evaluates the effectiveness, time savings and cost of titanium fasteners used to secure prosthetic aortic valve suture in open cardiac surgery.
Methods: An ongoing IRB-approved prospective randomized clinical trial was conducted by a single surgeon at one institution. Open AVR surgery patients were randomized to receive either conventional hand-tied knots (HT) or titanium fasteners (TF) to secure prosthetic sutures.
Results: Analyses of 51 subjects (48 completed, 3 withdrawn) demonstrated the groups did not differ significantly in preoperative morbidity, concomitant surgery, AVR size or number of sutures. On average, TF use was faster than HT (23.0 vs. 39.5 sec/knot, p<0.001; 42% reduction) with 21.0 minutes less in aortic cross-clamp (69.0 vs. 90.0 min, p=0.01; 23%), 26.0 minutes less in cardiopulmonary bypass (87.5 vs. 113.5 min, p=0.01; 23%) and 42.5 minutes less in overall operative times (235.5 vs. 278.0 min, p=0.04; 15%). No intraoperative complications occurred with use of TF. No paravalvular leaks, valve dehiscence or fastener embolization occurred. Perioperative complications included: 3 reoperations for bleeding, 4 prolonged ventilator dependence, 1 pneumonia, 2 strokes (HT at 7 days post-op, TF at 12 days) and 1 30-day mortality (TF). Transesophageal echo in both stroke patients confirmed fully functional prosthetic valves and no evidence of thrombus. On cost analysis, the higher average TF operating room (OR) supply costs ($7,857 vs. $7,034; p=0.01), but lower average OR time costs ($1,927 vs. $2,230; p=0.05), resulted in no significant difference between the estimated total OR costs for each group ($10,412 vs. $9,892; p=0.22) (See Table P89-1).
Conclusions: In this study of open AVR surgery, titanium fastener use is demonstrated as safe, effective as and significantly faster than hand-tying. These data also suggest that use of this technology provides operative-time savings without significantly increasing OR costs.
P90 Mid-Term Results of Off-Pump Aortic Valve Bypass Using a Novel Automated Device in Severe Aortic Valve Stenosis
Gabriele Di Giammarco, Massimiliano Foschi, Daniele Marinelli, Carlo Canosa. University G. D’Annunzio, Chieti, Italy.
Objective: High-risk patients affected by severe aortic stenosis represent an increasing population. Aortic valve bypass may be considered as an additional option for treatment. We report on mid-term results of a novel device incorporating a bioprosthetic stentless valve and designed to perform off-pump aortic valve bypass.
Methods: From March, 2012, to August, 2013, 15 patients were submitted to aortic-valve bypass (AVB) to treat a severe aortic valve stenosis using a composite conduit incorporating a bioprosthetic valve deployed by an automated system. Patients mean age was 77±7.2 years (33% males). Mean ejection fraction (EF) was 52±13%. Mean preoperative NYHA class was 2.6±0.89. The mean Log EuroSCORE was 16.45±13.6%; mean STS risk of morbidity/mortality was 26.6±16.5%. All the patients received AVB through a mid-lateral thoracotomy. In two patients an LIMA-to-LAD anastomosis was performed off-pump. In one of these two, a lung tumor resection was added along with a lymphadenectomy. In two patients lung function was supported by CPB.
Results: No intraoperative deaths occurred. Median ICU stay and intubation time were 42 (25-75° perc:22-59.5) and 17 (25-75° perc:16-19.7) hours respectively. The mean hospital stay duration was 10±6.8 days. No cerebrovascular events occurred. There were four in-hospital deaths due to MOF (2), myocardial ischemia (1) acute gastrointestinal bleeding (1). Two patients died during follow-up; one for silent hepatocarcinoma (2 months) and one for necrotic pancreatitis (6 months). Nine patients (median follow-up:14.7 months; 9.58-18.31) are alive; 8 patients are in NYHA class 1; one patient switched from NYHA 4 to 3. The longest survival is 21.6 months. Actuarial survival and event-free survival including in-hospital mortality is 59.25% at a median follow-up of 11.2 months (25-75perc 1.76-17.21); actuarial survival and event-free survival out of in-hospital mortality is 80.8% at a median follow-up of 14.7 months; (25-75perc:9.58-18.31).
Conclusions: AVB with automated ventricular coring system is an alternative to conventional aortic valve replacement in high-risk patients. It stays besides transcatheter aortic valve implantation (TAVI) procedures or as alternative in case TAVI is not possible for technical or clinical reasons. To the best of our knowledge, this is the largest single-center experience until now using this novel device.
P91 Full Sternotomy Has More Significant Impact than the Cardiopulmonary Bypass Time in Patients of Mitral Valve Surgery: A Propensity-Score Matched Study
Chen Xin, Qiu Zhibing, Xu Ming, Wang Liming, Jiang Yinshuo, Huang Fuhuang. Nanjing First Hospital, Nanjing, China.
Objective: We sought to compare the minimally invasive mitral valve surgery through a right anterolateral minithoracotomy fairly with conventional full sternotomy approaches by using propensity-score matching methods. The study assess if the incision methods has more significant impact for patients than the cardiopulmonary bypass time.
Methods: From January, 2011, to October, 2013, a total of 320 isolated mitral valve operations were performed at our institution. Data were retrospectively collected on all patients, and a logistic regression model was created to predict selection to minimally invasive approach versus conventional sternotomy approach. Propensity scores were then generated based on the regression model and matched pairs created using 1:1 nearest neighbor matching. There were 50 matched pairs in the analysis for a total sample size of 320 (sternotomy, n=50; minimally invasive, n=50). Clinical outcomes included bypass and cross-clamp time, morbidity, and mortality.
Results: The minimally invasive approach led to longer cardiopulmonary bypass time (128±56 vs. 86±21 minutes, p<.01), and cross-clamp time (78±24 vs. 55±12 minutes, p<.01). There were no differences between the matched groups in 30-day mortality (2% vs. 2%, p>0.05). However, mediastinal drainage was lower at 6 and 24 hours after a minimally invasive approach (100 ml [CL, 50-175 ml] and 240 ml [CL,150-320 ml]) than after conventional sternotomy (425 ml [CL, 320-650ml] and 680 ml [CL, 560-850 ml]) at these times (p<.001). Transfusion was less frequent after minimally invasive surgery than after conventional surgery (26% vs. 58%, p=.01). Volume of RBCs transfused was reduced by nearly two units for minimally invasive versus sternotomy group. Early after operation, pain scores were lower (p<.001) after minimally invasive surgery. There was 1 sternal wound infection (4.0%) in the sternotomy group compared with none in the minimally invasive group.
Conclusions: Despite minimally invasive mitral valve surgery required a longer cardiopulmonary bypass time and cross-clamp time, less postoperative chest drainage, fewer need for perioperative blood transfusion and absence of sternal wound infection are the main advantages over conventional surgery. The full sternotomy has more significant impact than the cardiopulmonary bypass time.
P92 Mitral Valve Surgery: Right Lateral Minithoracotomy or Sternotomy? A Systematic Review and Meta-Analysis
Stephan Jacobs, Simon H. Sündermann, Volkmar Falk. University Heartcenter Zürich, Zürich, Switzerland.
Objective: To update the current evidence of mitral valve surgery through a lateral minithoracotomy versus median sternotomy.
Methods: We performed a comprehensive literature research regarding studies comparing mitral valve surgery through a right-lateral minithoracotomy and median sternotomy in MEDLINE, EMBASE, Cochrane Central, CTSNet and Google Scholar for the most recent literature up to April, 2013. From the studies found in the literature we performed a systematic review and meta-analysis.
Results: 20,000 patients out of 46 studies were included in this study. Stroke rate and all-cause mortality up to 30 days was similar in both groups. The length of stay in the ICU, respirator dependence and hospital stay were significantly shorter in the minimally invasive (MIVS)-group. Furthermore, blood drainage volume and blood transfusions were decreased in the MIVS-group. On the contrary, cardiopulmonary bypass time, cross-clamp time and procedure’s length were longer in the MIVS-group. Postoperative new atrial fibrillation was less in the MIV-group. Aortic dissections occurred more in the MIVS-group. The rate of re-thoracotomies and postoperative renal failure was similar in both groups.
Conclusions: MIVS and conventional mitral valve surgery show a similar perioperative outcome. Minimally invasive mitral valve surgery seems to be favorable in regards of resource related outcome.
P93 Using the Endoclamp for Cardiac Surgery Improves Patient Outcomes: A Propensity-Matched Comparison with Sternotomy Patients
Vivek Srivastava, Abdul Nasir, David Rose, Laura Howell, P. Saravanan, Andrew Knowles, Joseph Zacharias. Victoria Hospital, Blackpool, United Kingdom.
Objective: Cardiac surgery with right anterior mini-thoracotomy and use of an Endoclamp (ThruPORT approach) is now an established procedure in many developed centers. However, given its added costs, it is difficult to justify in a nationalized health service. Our objective for the present study was to evaluate if the ThruPORT approach has advantages over conventional median sternotomy approach by comparing propensity-matched cohorts.
Methods: ThruPORT patients between June, 2007, and September, 2013, were identified from the departmental database. Using propensity-matching (MatchIt software package), a comparable group was identified for similar cardiac surgery by median sternotomy approach over the same period. Outcomes for the two groups were compared using a two sample t-test or Mann-Whitney U test for continuous variables and chi-square test for categorical variables.
Results: There were 134 patients in each group with the ThruPORT group consisting of 57 (42.5%) females and the sternotomy group having 54 (40.3%) females. Mean age was 60.1 years for the ThruPORT approach and 62.4 years in the sternotomy group (p=0.15). Comorbidities and other preoperative characteristics including ventricular function and operative priority were not different between the two groups. There were 3 deaths (2.2%) in each group. Mean postoperative stay was 8.4±5.9 days in the ThruPORT group while in the sternotomy group, it was 10.3±8.3 days (p=0.032). Despite more redo surgery in the ThruPORT group, blood loss, incidence of reopening and blood usage were higher in the sternotomy group (p<0.001). Other outcomes were not statistically different between the two groups (Table P93-1).
Conclusions: The present study demonstrates that minimally invasive surgery using the Endoclamp is associated with a shorter postoperative stay and reduced blood loss translating into less blood usage. Despite the possibility of a learning curve, other complication rates were not significantly different between the two groups even though the ThruPORT cohort had longer CPB and cross-clamp times.
P94 First Short-Term Outcome after Folding Plication with Gore-Tex Neochordae in Prolapsing Posterior Mitral Leaflet
Devdas T. Inderbitzin1, Babu A. Chiran2, Vineet Mahajan2, Yopie A. Habibie3, Venkat Rao Parachuri2. 1Clinic for Cardiac Surgery Basel-Bern, University Hospital Basel, Basel, Switzerland, 2Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, India, 3Department of Cardiac Surgery, The Zainoel Abidin General Hospital, Aceh, Indonesia.
Objective: Among many surgical techniques to address excessive myxomateous posterior mitral leaflet prolapse we describe a simplified, safe and reproducible resection, and annular-plication-free technique to fold the posterior mitral leaflet (PML) utilizing Gore-Tex neochordae with minimal risk of postoperative SAM. The first short-term outcome is presented.
Methods: We provide an illustrative insight in our new mitral folding plication technique and present intra-operative and short-term echocardiographic results at discharge and 6 weeks postoperatively (see Fig. P94-1).
Results: 50 patients (12 female, mean age 46.8±15.3 years) were included (32 for 6 week follow-up only). Intraoperative trans-esophageal echocardiography showed a good mitral leaflet coaptation (minimum 5 mm coaptation length) and transthoracic echocardiograpy at discharge (n=50) and 6 weeks postoperatively revealed absent to mild residual regurgitation without SAM.
Conclusions: The mitral leaflet folding plication utilizing Gore-Tex neochordae is a simple, reproducible and safe method to repair isolated PML prolapse omitting leaflet resection, annular plication and complex measuring and reconstruction at a minimal risk of developing SAM. Further mid- and long-term results are needed to evaluate durable repair by this simple technique.
P95 Minimally Invasive Late Adjustment of a Dynamic Mitral Ring: Developing a Clinical Pathway Toward a New Treatment Concept
Martin Andreas, Michelle Uy, Claus Rath, Andreas Habertheuer, Dominik Wiedemann, Guenther Laufer, Alfred Kocher. Medical University of Vienna, Vienna, Austria.
Objective: Mitral valve repair developed to the first-line therapy in patients suffering from mitral valve regurgitation (MR). A clinically relevant number of patients return due to recurrent MR. We investigated a novel mitral ring which allows for a reduction of the anterior-posterior diameter through remote adjustment at any time point after surgery. Herein, we present our clinical experience and considerations for device handling and patient selection.
Methods: Twenty-four patients (71±9 years; 16m/8f) received the adjustable ring between 2011 and 2013. The mean logistic EuroSCORE was 14. All but two patients underwent concomitant procedures. The activation lead of the mitral ring was run through a small puncture in the left atrial wall and placed subcutaneously above the rectus sheath.
Results: Ring implantation was safe and did not result in prolonged aortic cross-clamp times. Twenty-two patients are alive with a mean follow-up of 13 months. One patient was successfully adjusted applying a minimally invasive approach 13 months post implantation. He had a recurrent MR II-III, deterioration of his cardiac function and an increase in ventricular dimensions. Following adjustment, MR was reduced to grade I. In one patient with ischemic MR, the ring, which was deliberately downsized, became partially dehiscent and the valve was replaced. One ring could not be adjusted due to technical problems.
Conclusions: Implantation of this adjustable mitral ring is safe and feasible. Late adjustment can be performed by a minimally invasive approach. The clinical benefit of this device remains to be revealed. We changed our implantation strategy to use this device in ischemic MR and annular dilatation, because these patients are at a higher risk for recurrent MR. Our experience with the new device led to the development of a white paper regarding optimal lead placement. Furthermore, an expert statement on the optimal time point of activation was developed (recurrent MR 2+).
P96 Off-Pump Minimal Invasive Mitral Valve Repair in Mitral Valve Prolapse with NeoChord
Abdul-Hakim Dayeh, Andreas Moka, Aris Argyroulis, Sabine H. Daebritz. Heartcenter Duisburg, Duisburg, Germany.
Objective: On-pump mitral valve repair is well established. Off-pump mitral valve repair has so far not been feasible. Improved online cardiac imaging techniques like 3D echocardiography enable an improved visualization of the underlying pathology and the development of a technique for closed application of neochordae on the prolapsed leaflet segments with a newly developed device, the NeoChord DS 1000. We present our experience with the first three patients repaired with this technique for prolapse of P2.
Methods: Three pts., mean age (57±3.46 years), 2 male, presented in NYHA I-II with moderate-severe MV regurgitation with P2-prolapse, with excentric jets and vena contracta >8 mm. EF was 55%, 50% and 40%; one patient had moderate pulmonary hypertension and paroxysmal AF, LA-diameter was 47.3±3.5mm, LVEDD: 62±10mm, no severe annulus dilatation. Surgery was performed via left minithoracotomy (5th intercostal space, medioclavicular line). The chordal implantation tool was inserted under heparin (ACT 300s) through the lateral ventricular wall under 2D/3D guide with consecutive artificial chordae placement (Gore-Tex 4.0) with the NeoChord DS 1000 System. The number of neochordae inserted was 3, 3 and 4. Adjustment was done under sophisticated 2D/3D echo-control.
Results: There was no operative mortality, residual MI was trace in one and zero in two. Pts. were extubated within 3 hours; there were no blood transfusions or other complications. Echo at discharge showed trace or no MR as p.o.
Conclusions: Off-pump minimally invasive mitral valve repair with artificial chordae is feasible with excellent short-time results. Long-term observation is necessary to prove long-term durability.
P97 Evaluation of a Novel Automated ePTFE Suturing and Coaxial Fastener System for Mitral Chordae Tendineae Replacement: Strength, Feasibility and Healing
Candice Y. Lee1, Jude S. Sauer2, Heather R. Gorea2, Angelo J. Martellaro2, Andrew Sifain1, Peter A. Knight1. 1University of Rochester Medical Center, Rochester, NY USA, 2LSI SOLUTIONS, Victor, NY USA.
Objective: Mitral valve (MV) chordal replacement remains technically challenging. Automated technology that remotely delivers and accurately secures ePTFE suture could shorten the learning curve and improve the reliability of surgical MV repairs.
Methods: An IACUC-approved sheep survivor model was developed to perform open MV repairs on the fibrillated hearts of 8 rams; 4 demonstrated feasibility and 4 evaluated healing integrity after 6 months. Cutting 1-2 native chords produced intraoperative mitral regurgitation (MR). An automated suturing device placed a pledgeted ePTFE suture through the papillary muscle. Another ePTFE suture was placed through the leaflet. Both sutures were threaded coaxially in opposite directions through a hollow titanium fastener in the shaft of a hand-activated device. With the fastener positioned against the papillary muscle, saline was infused through the device into the left ventricle, enabling real-time suture length adjustment. When MV competence was observed, a squeeze of the device lever crimped the fastener and trimmed suture tails (Fig. P97-1A). Echocardiography and pathologic evaluation confirmed MV competence, repair integrity and healing. Multiple ex vivo animal hearts and two in situ cadaver hearts also had artificial chords successfully placed. A customized fixture simulating intracardiac chordal tensioning quantified the durability of 120 coaxial fastened ePTFE sutures (80 tensioning cycles/minute up to 3 months).
Results: Three sheep were survived for an average of 6.7 months; a fourth died at 6.5 months from unknown causes. At reoperation, epicardial echocardiography demonstrated trace or no MR (Fig. P97-1C). The hearts healed well with suture and fasteners nearly completely endothelialized (Fig. P97-1B). Study ex vivo, cadaver and survivor heart repairs illustrated MV competence. Simulator testing of fastened ePTFE suture demonstrated no degradation of knot holding forces for a total of over 440 million cycles.
Conclusions: Using ex vivo, cadaver and survivor sheep hearts, this study demonstrated a new technology enabling easier papillary suture placement, real-time adjustment of chordal suture length during infusion testing and durability of automated fasteners to secure ePTFE sutures for MV repairs. These successful results encourage further exploration.
P98 Totally Thoracoscopic Replacement of Mitral Valve Through Three Ports of Right Chest: A Preliminary Report
Zeng-Shan Ma1,2, Chang-Yong Yang1, Ming-Feng Dong3, Shou-Dong Chai3, Shu-Ming Wu1, Le-Xin Wang2. 1Department of Cardiac Surgery, Qilu Hospital, Shandong University, Jinan, P.R.China; 2School of Biomedical Sciences, Charles Sturt University, Wagga, NSW, Australia; 3Department of Cardiac Surgery, Liaocheng People’s Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong, P.R.China.
Objective: To investigate the feasibility and safety of totally thoracoscopic replacement of mitral valve through three ports in right chest (Fig. P98-1).
Methods: Totally thoracoscopic mitral valve replacement (MVR) was performed in 62 patients (27 males; mean age 51.7±5.6 years). An additional 36 patients undergoing open-chest MVR were selected as a control group. Through three-port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, MVR were performed by a thoracoscopy without the aid of a robotically assisted surgical system (See Fig. P98-1B, C).
Results: The cardiopulmonary bypass and aortic cross-clamp times were 62.2±9.8 and 41.5±7.3 min, respectively. There were no mortalities. The intensive care unit (14.1±4.5 vs. 24.5±5.6 hours, P<0.01) or postoperative hospital stays (6.5±1.8 vs. 8.6± 2.1 days, P<0.05) in the thoracoscopic group were shorter than in the control group. The percentage of patients who required postoperative opioid analgesics in the thoracoscopic group was lower than in the control group (21.0% vs. 75.0%, P<0.01). Rate of blood transfusion during the operation in the thoracoscopic group was also lower than in the control group (17.7% vs. 69.4%, P=0.001). Transesophageal echocardiographic analysis 5.2±3.9 months after the operation showed improved heart function and normal prosthesis.
Conclusions: Totally thoracoscopic MVR through a 3-port entry without the aid of a robotically assisted surgical system appears to be safe and effective.
P99 Minimally Invasive Correction of Degenerative Mitral Valve Regurgitation and Hypertrophic Obstructive Left Ventricular Cardiomyopathy
Tommaso Hinna Danesi, Giovanni Domenico Cresce, Loris Salvador. Ospedale San Bortolo Vicenza, Vicenza, Italy.
Objective: Most of mitral valve regurgitation (MVR) is due to degenerative pathology. When a hypertrophic obstructive left ventricular outflow cardiomyopathy (HOLVC) is associated, the risk of systolic anterior motion (SAM) of the anterior leaflet of the mitral valve after its repair is high. The presence of SAM should determine a residual MVR and the valvuloplasty failure.
Methods: From January, 2010, to November, 2013, 409 patients underwent mitral valve repair for mitral valve regurgitation using a totally video-guided port-access approach. Among them, 6 (1.4%) patients presented a hypertrophic subaortic cardiomyopathy; mean diastolic thickness was 20.8±12 mm with an increased LVOT velocity. In all patients a subaortic myomectomy was performed after the detachment of the anterior mitral valve leaflet. The anterior leaflet was then reconstructed with a bovine pericardial patch. The MVR was finally corrected: in 2 cases only with neochordae implantation on posterior leaflet, in 2 cases with a modified Paneth posterior stabilization annuloplasty, in 1 case with an edge-to-edge stitch and in 1 patient with a posterior open ring and neochorade implantation.
Results: Mean pump and cross-clamp time were 177±76.1 and 127±52.3 min respectively. Postoperative complication were: new onset of AFib in 2 patients, major ventricular arrhythmia in one patient, three patients presented at discharge 1+/4 of residual MR, one of them still presented a residual SAM. No aortic regurgitation was noted. One patient died in II pod for a major cerebral event due to massive left atrial thrombosis.
Conclusions: Degenerative mitral valve repair in the presence of HOLVC is difficult. SAM should contribute to MVR genesis and should determine the failure of the repair. In our experience, the MVR should be corrected with the subaortic myomectomy associated to a lone neochordae implantation and a non-restrictive annular stabilization. This technique is suitable for minimally-invasive approach.
P100 A “Robot-First” Approach to Mitral Valve Surgery
Thomas Kelley1, Mohammed A. Kashem2, Grayson Wheatley III3, Yoshiya Toyoda1, James McCarthy3, Sheila Pai1, Vishnu V. Ambur3, Yanfu Shao1, T. Sloane Guy. 1. 1Temple University School of Medicine, Philadelphia, PA USA, 2Cardiovascular Surgery, Temple University School of Medicine, Philadelphia, PA USA, 3Temple University Hospital, Philadelphia, PA USA.
Objective: We studied the results of our first 120 cases during a period where totally endoscopic robotic mitral valve surgery became our standard approach for nearly all patients requiring mitral valve procedures. We define totally endoscopic robotic mitral valve surgery as that in which no portion of the procedure can be performed through direct visualization through any incision (working port 15 mm for repair, 30 mm for replacement). Our relative exclusion criteria were minimal: extreme high-risk patients, severe mitral annular calcification, severe right chest adhesions, ascending aortic aneurysm > 4 cm, and concomitant disease requiring an open approach. There were no absolute exclusion criteria other than inoperability.
Methods: Our group conducted a retrospective chart review of all patients during the study period that underwent robotic mitral valve surgery at our institution. Procedures included a broad spectrum of surgical management including leaflet repairs, augmentations, mitral replacements, and concomitant procedures including concurrent tricuspid repair, MAZE procedures and atrial septal defects.
Results: The average age of the patients was 61±13 years. The ejection fractions were >50% EF- 61%; 35-50% EF- 25%; and <35% - 14%. Average operative time was 254±44 min, CPB was 129±39 min and cross-clamp time was 82±32 min. 8 (6%) patients were converted to an open procedure (either thoracotomy or sternotomy) primarily for unanticipated right chest adhesions. 94% of patients underwent repair and 6% replacement. 20% had concomitant intracardiac procedures. Our average length of stay was 6.9±4.4 days. 1 patient had permanent stroke who also died. During the study period at our institution, there were only 3 patients who underwent primary sternotomy for mitral surgery due to previous lung surgery, severe mitral annular calcification, and preoperative acute cardiogenic shock requiring ECMO.
Conclusions: We demonstrate that totally endoscopic robotic mitral surgery can be used as the first choice for treatment of nearly all isolated mitral valve disease requiring surgery rather than only for select patients.
P101 Which TAVI Device is Best Suited for the Bicuspid Valve?
Jürg Grünenfelder1, Sacha Salzberg1, Tim Aeppli2, Patric Biaggi1, Roberto Corti1. 1Heart Clinic, Zurich, Switzerland, 2University Hospital Zurich, Zurich, Switzerland.
Objective: The aim of this study was to compare two commercially available devices in regard to all valvular leaks after transcatheter aortic valve implantation (TAVI) in patients with a bicuspid aortic valve (BAV) stenosis. BAV has long been considered as a contraindication to TAVI, but recent studies have demonstrated good clinical outcome after TAVI for these patients. No comparative study has yet been conducted evaluating the two commercially available devices.
Methods: TAVI was performed in 12 individuals with BAV at our institution from May, 2008, to December, 2012. The Edwards SAPIEN (n=4) and the Medtronic CoreValve (n=8) prostheses were implanted by either transfemoral or transapical access. Clinical outcomes and echocardiography are reported according to the Valve Academic Research Consortium (VARC) criteria and assessed using the latest documented visit within one year of intervention in our dedicated core lab.
Results: A symptomatic and hemodynamic improvement was seen in all but one patient, who died of a gastro-intestinal catastrophy 2 days after successful SAPHIEN implantation (STS score 5.9%). A reduction of the mean valvular gradient after TAVI intervention was noticed and in both patient groups. All patients were in NYHA class I or II after the procedure, compared to NYHA-class III (50%) and IV (25%) before. The left ventricular ejection fraction was improved or unchanged in 75% of the patients with no difference between the two groups. Paravalvular regurgitation was trivial or mild except for two (one CoreValve and one SAPIEN), both having moderate paravalvular regurgitation. One patient with CoreValve required a pacemaker, while two SAPIEN patients had a significant central leakage.
Conclusions: In our experience, both types of valves can safely be used in BAV patients. Hemodynamics are improved after TAVI in the BAV setting. From our limited results, and the current literature, we conclude that BAV is no longer a contraindication to TAVI. Further data is necessary to substantiate our conclusions.
P102 Immediate and Mid-Term Quality of Life Improvement Comparison between Transapical and Transaortic, Transcatheter Aortic Valve Implantation
R. Haris Bilal, Jessica Maycock, Mahvash Zaman, D. Fraser, Vaikom Mahadevan, Ragheb Hasan. Manchester Royal Infirmary, Manchester, United Kingdom.
Objective: Transcatheter aortic valve implantation (TAVI) is a standard approach for severe aortic stenosis in high-risk surgical candidates. Transaortic route (TAo) is gaining popularity as an approach for TAVI. The aim of this study was to assess the impact on the quality of life (QoL), pain control, functional status and mid-term survival after this procedure.
Methods: Twenty-five consecutive patients (84.5±6.4. years, 21 men and 15 women) with a logistic EuroSCORE of 29.7±13.7 underwent TAVI using the Edwards SAPIEN Valve (Edwards Lifesciences, Irvine, CA USA). Aortic valve was implanted via transapical route in 19 patients via mini-thoracotomy. Six patients had direct TAo implantation via hemi-sternotomy. Post-operative pain was analyzed with numeric rating scale (NRS-11). QoL was evaluated by administering the Short Form 36 (SF-36) tool and the shorter SF-12 version 2 (SF-12v2) questionnaires before and 1 year after TAVI.
Results: TAVI was successfully performed in all patients. The estimated 1-year survival was 72%. Mean follow-up was 14±8 months. There was significant improvement in echocardiographic parameters (peak gradient 54.2±26.1 vs. 18.4±7.8 mm Hg, P< .001; aortic valve area 0.8±0.1 vs. 2.4±1.7 cm2, P < .001) with a significant change in New York Heart Association class (4±0.7 vs. 1.2±0.4, P < .001). There was a significant improvement in physical and mental scores on SF-12v12 and SF-36. There was no difference in quality of life improvement in the transaortic vs. transapical groups respectively, SF-36 (56.2 vs.54.5, P=0.78) at 1 year. Results for physical component summary (PCS, SF-12v12) was similar in transaortic vs. transapical group (44.1 vs. 45.2 p=0.53). There was no difference in (MCS) mental quality summary (38.2 vs. 39.4, p=0.51). Mean pain score was higher in the transapical group on day 1, (7.4 vs. 4.1, p=0.02), but was similar on day 4 (3.2 vs. 3.8, p=0.50). There was no difference in analgesia requirements.
Conclusions: There was physical and mental improvement in quality of life in transaortic and transapical group of patients; patients in transapical group experienced more pain in the immediate post-procedural period.
P103 Retrograde Contrast Echocardiography for Assessment of Aortic Regurgitation after TAVI
Marian Kukucka, Semih Buz, Alexander Mladenow, Axel Unbehaun, Thorsten Drews, Miralem Pasic. Deutsches Herzzentrum Berlin, Berlin, Germany.
Objective: Aortic regurgitation (AR) is a possible complication following transcatheter aortic valve implantation (TAVI) which is associated with less-favorable outcome. Quantification of total regurgitation caused by multiple, multidirectional jets remain controversial. The purpose of this study is to assess the usefulness of retrograde contrast echocardiography in quantification of total AR following TAVI and to evaluate its prognostic significance.
Methods: In 245 patients following Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA USA) implantation, we performed retrograde contrast transesophageal echocardiography to quantify AR immediately after TAVI. The contrast (20 mL agitated gelatine polysuccinate, Gelafundin 4%, Braun, Melsungen, Germany) was injected as a bolus into the sinotubular junction of the aorta through a pigtail catheter. We measured the area of the regurgitant cloud during mid- to end-diastole. A regurgitant area ≥ 3.8 cm2 was determined as an indicator of less favorable outcome. To assess whether AR identified by this novel method independently determined survival, a multivariate model was applied.
Results: Contrast echocardiography recognized 56 patients with relevant regurgitation. Multivariate analysis including regurgitant area ≥ 3.8 cm2, NYHA class IV, age, and creatinine concentration identified regurgitant area ≥ 3.8 cm2 (p=0.027) as independent risk factor for 2-year survival (See Fig. P103-1).
Conclusions: Contrast echocardiography is a simple method for quantification of total AR following TAVI and could serve in the future as objective method to compare AR after implantation of different valves. Its clinical relevance is demonstrated by the impact of the AR detected by contrast echocardiography on survival.
P104 Aborted Sternotomy Due to Unexpected Porcelain Aorta: Does TAVR Offer an Alternative Choice?
Jahanzaib Idrees, Eric E. Roselli. Cleveland Clinic Foundation, Cleveland, OH USA.
Objective: Aortic valve replacement (AVR) is challenging in patients with porcelain aorta, but transcatheter aortic valve replacement (TAVR) offers a clampless option. With the advent of TAVR, more patients have been referred after sternotomy and aborted procedure due to intraoperative discovery of severe aortic calcification. Objectives are to characterize these patients and describe outcomes.
Methods: From 2001 to 2012, 17 patients were referred after a prior aborted attempt at an outside facility for surgical AVR due to unexpected intraoperative findings of porcelain aorta (Fig. P104-1). Procedures performed at the time of aborted AVR included off-pump coronary bypass in 9 and isolated exploratory sternotomy in 8. These patients were then treated with open AVR (n=6) or TAVR (n=11) for severe aortic stenosis (n=14), regurgitation (n=1) or both (n=2) at our institution. Median interval between prior aborted AVR and definitive AVR was 9.6 months. Mean age was 74±11 years, preoperative gradients were 53±18mm Hg, and valve area was 0.6cm2. In surgical AVR group the approach was via redo sternotomy in 5 and mini-sternotomy in 1. Hypothermic circulatory arrest was used in 4 and axillary artery cannulation was used in 2. Additional procedures included ascending repair (n= 4), coronary bypass (n=3) other valve repair (n=1). In TAVR group, the approach was transfemoral (n=6), or transapical (n=5).
Results: Proximal aorta was severely calcified in all patients. Mean post-operative gradient was 13±4 mmHg. Patients in surgical AVR group had multiple cardiac co-morbidities, whereas in TAVR group patients were older (mean age 79±3 years) and high risk (STS score 8-13). There was no operative mortality, stroke, renal or respiratory failure, but in TAVR group, one patient required valve-in-valve implantation for paravalvular leak, another required intra-aortic balloon pump for hemodynamic instability. Median hospital length of stay was 8 days. Three late deaths occurred at median follow-up of 2.5 years.
Conclusions: Open and transcatheter AVR at a tertiary care center are safe and effective. TAVR expands options in high-risk patients with aortic stenosis and porcelain aorta. Open approach may be preferred when multiple cardiac co-morbidities are present.
P105 Predictors of Mortality in Inoperable Patients Undergoing Transcatheter Aortic Valve Implantation for Severe Aortic Valve Stenosis
Ghulam Murtaza1, Suhail Allaqaband2, Rayan Yousefzai2, Amanda Kirby2, Christopher Koblosky2, Tanvir Bajwa2, Daniel O’Hair2. 1Medical College of Wisconsin, Milwaukee, WI USA, 2St Luke’s Hospital, Milwaukee, WI USA.
Objective: Severe aortic stenosis in patients deemed too high-risk for surgical therapy benefit from transcatheter aortic valve implantation (TAVI). We review our two-year experience with TAVI to identify risk factors associated with increased mortality.
Methods: Forty-six patients with severe aortic stenosis underwent TAVI at our institution in the past 24 months. Demographics, comorbidities, echocardiographic characteristics, technical approach and postoperative complications were recorded for comparison. P-value of <0.05 was considered significant.
Results: Of forty-six patients with mean age of 84.5 years 45% (n=21) were females. 35% had diabetes mellitus and 91% had hypertension; 41%, 37% and 22% of the patients had COPD, renal insufficiency and prior stroke, respectively. 76% of the patients had coronary artery disease of which 28% had prior coronary artery bypass and 37% underwent PCI. 91% patients were NYHA class III or higher. One-third of patients had a second valve pathology of at least moderate severity. Mean pulmonary systolic pressure was 48.6 mmHg with 39% patients with severe pulmonary hypertension (>50 mm Hg). Edwards SAPIEN valve was used in all patients. Transfemoral (26%), transapical (61%) as well as direct aortic (13%) approach was used. Rapid pacing and pre-implantation balloon dilation was carried out in all patients. 30-day mortality and 1-year mortality was 9% and 28% patients respectively.
Conclusions: Prior ischemic heart disease and stroke, degree of tricuspid regurgitation and pulmonary systolic hypertension and left ventricular dysfunction were associated with higher early mortality following TAVI.
P106 Localization of Aortic Annulus with Transesophageal Echocardiography for Transcatheter Aortic Valve Implantation
Maria E. Currie1, A. Jonathan McLeod2, Rajni Patel3, Terry M. Peters4, Bob Kiaii1. 1London Heath Sciences Centre, London, ON Canada, 2Western University, London, ON Canada, 3Canadian Surgical Technologies & Advanced Robotics, London, ON Canada, 4Robarts Research Institute, London, ON Canada.
Objective: Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective treatment for aortic stenosis. However, valve deployment still relies on fluoroscopy that requires nephrotoxic contrast. We have developed a guidance system for TAVI that magnetically tracks the TAVI catheter in an augmented reality environment (Fig. P106-1). This method uses only transesophageal echocardiography (TEE) to define the aortic valve annulus and eliminates the need for nephrotoxic contrast. Accurate identification of the aortic annulus is essential for TAVI deployment using this system. Since the commissures of the aortic valve are stationary hinge points visible in echocardiography, these points can be used to define the aortic valve annulus. Other image guidance systems have employed the lowest point of the aortic valve leaflets, the nadirs, to guide TAVI deployment. This study was conducted to determine how consistently the aortic valve annulus could be defined using either aortic valve commissures or nadirs from full volume TEE images.
Methods: Inter-operator variability in identifying aortic valve commissures and nadirs was assessed between five subjects. Each subject identified the three commissures and leaflet nadirs in full volume TEE images of the aortic root in diastole acquired from eight patients. The nadir and commissure points were used to define a valve plane. The inter-operator variability in defining this plane was obtained by calculating the standard deviation of the valve centroid and orientation.
Results: Using the commissural points, mean interoperator variability of 1.8 mm and 9.1° were obtained over all 8 images. Similarly, using the nadir points resulted in an interoperator variability of 2.5 mm and 7.8°.
Conclusions: Our results indicate that while both aortic valve commissures and aortic leaflet nadirs can be localized reliably, there is lower interoperator variability in the localization of aortic valve commissures. The increased variability in identifying valve orientation is unlikely to contribute to a significant error in valve deployment. This suggests that an accurate TEE guidance system is realizable using the commissures to define the valve plane.
P107 Computed Tomography for Planning and Postoperative Imaging of Transvenous Mitral Annuloplasty: First Experience in an Animal Model
Simon H. Sündermann1, Sonja Gordic2, Robert Manka3, Nikola Cesarovic4, Hatem Alkadhi2, Volkmar Falk1, Francesco Maisano1. 1Division of Cardiovascular Surgery, 2Institute of Diagnostic and Interventional Radiology, 3Clinic of Cardiology, 4Department of Surgical Research, University Hospital Zurich, Zurich, Switzerland.
Objective: To investigate the use of computed tomography (CT) to measure the mitral valve annulus size before implantation of a percutaneous mitral valve annuloplasty device in an animal trial.
Methods: Five domestic pigs were included. Under general anesthesia animals underwent CT before and after the implantation of a CardioBand (percutaneously implantable mitral valve annuloplasty device) with a second-generation 128-section dual-source CT machine. Posterior mitral annular circumference, shortest distance from posterior annular circumference to the circumflex artery was measured before and device length and shortest distance from anchor to RCx were measured after the implantation of the CardioBand. After sacrifice of the animals, the hearts were explanted and the length of the CardioBand was measured manually.
Results: Implantation of the CardioBand could be performed successfully. Gross examination found the CardioBand adequately implanted in all animals, with no anchor dehiscence and no damage of the circumflex artery. The CardioBand device did not result in a metal artifact-related degradation of image quality in any of the animals. Both the implant and the surrounding structures could be visualized on post-interventional CT with high quality; measurements of the length of the CardioBand could be successfully performed. The average posterior mitral annular circumference prior to intervention measured 99.5±3.8 mm (Fig. P107-1); the average length of the CardioBand measured in CT after intervention was 86.9±9.3 mm, and direct measurements after explantation revealed an average length of the implant of 97.2±6.1 mm. The distance from the posterior mitral annulus to the CX was 3.0±0.9 mm (range 3 - 5 mm). The closest distance from the closest anchor to the CX was 2.0±0.8 mm (range 1 - 3 mm).
Conclusions: CT visualization and measurement of the mitral valve annulus dimensions is feasible and could become the imaging method of choice for procedure planning before implantation of a CardioBand or other transcatheter mitral annuloplasty devices that are already available or will be available in the future.
P108 Off-Pump Mitral Valved Stent Implantation: Evaluation of Apical, Sub-Annular and Supra-Annular Fixation Technologies
Saskia Pokorny1, Katharina Huenges1, Telse Bähr1, Lennart Bax1, Martin Marczynski-Bühlow2, Michael M. Morlock3, Jochen Cremer1, Georg Lutter1. 1Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany, 2University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany, 3Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany.
Objective: In this study, three different fixation designs of a mitral valved stent are presented: apical fixation, sub-annular fixation and supra-annular fixation.
Methods: Mitral valved stents were implanted in the porcine model via transapical approach in the beating heart. The stents were comprised of an atrial element and a tubular body accommodating a bioprosthetic heart valve. The first prototype was solely anchored apically with neo-chords attached to the ventricular rim of the stent (AP; n=10). Additional sub-annular fixation elements were included in the body of the second design (Sun=10). In the third design (SUPRA), hook-shaped fixation elements were attached to the atrial element to achieve a supra-annular fixation (n=6). 2D and 3D transesophageal echocardiographic (TEE) and hemodynamic evaluations following standardized protocols were conducted pre- (n=26) and post implantation (n=24) and at monthly intervals during the follow-up.
Results: Three animals were excluded due to ventricular fibrillation prior to stent deployment (SUB:n=2, SUPRA:n=1). Secure deployment and stent positioning was reproducibly achieved in all remaining cases. The mean gradients across the mitral valved stent and the LVOT were slightly increased in group AP and SUB (p≤0.018), but remained within a physiological range in all groups. The mitral-annular-plane-systolic-excursion remained within physiological ranges. The pulmonary capillary wedge pressure was higher in group SUPRA (p=0.043). No paravalvular regurgitation (PVL) was detected in the group of design AP following implantation. In group SUPRA the fixation elements caused shunts in 2/5 and multiple stent fractures in all cases. The concept was hence abandoned. The overall well-being was best in the group AP.
Conclusions: Three prototypes following different fixation technologies were successfully tested in vivo. Low gradients and a normal longitudinal LV function were achieved. Improvement potential (e.g., sizing of fixation elements) has been identified for the sub-annular design. Stents with sole apical fixation showed the most promising outcome so far with no PVL, normal longitudinal function and good health of the animals for up to three months.
P109 Circulating Endothelial Cells: A Predictive and Diagnostic Marker in Transcatheter Aortic Valve Replacement
Yeong-Hoon Choi, Klaus Neef, Anton Sabashnikov, Vera Chesnokova, Maximilian Scherner, Navid Madershahian, Thorsten Wittwer, Thorsten Wahlers. Heart Center of the University of Cologne, Cologne, Germany.
Objective: Cardiovascular risk factors as well as the surgical trauma affect the endothelial integrity resulting in the detachment of endothelial cells into the blood stream. Here, we introduce a novel, automated method for the enumeration of circulating endothelial cells (CEC) in order to determine the preoperative risk and the procedural invasiveness in patients undergoing either transcatheter (TAVR) or conventional aortic valve replacement (CAVR).
Methods: 22 consecutive patients with severe aortic stenosis were enrolled assigned to either CAVR or TAVR by heart team decision. Patient demographics, preoperative characteristics and postoperative outcome were analyzed. CECs were enumerated applying isotype controlled flow cytometry, including automated pre-enrichment of CD34+ blood cells.
Results: TAVR-patients were older (81.0±4.8 yrs. vs. 69.1±11.2 yrs, p=0.004), with higher Euro-/STS-score (9.6±2.9 vs. 5.2±1.8, p<0.001), higher serum creatinine levels (1.5±0.9 mg/dl vs. 0.9±0.3 mg/dl, p=0.042), higher rate of preoperative cardiac failure (0% vs. 36.4%, p=0.045), and lower hemoglobin (11.6±1.5 g/dl vs. 13.81±1.29 g/dl, p=0.001). CEC frequencies were significantly higher in the TAVR-group preoperatively (9.8 ±4.1 /ml vs. 5.5±2.2 /ml, p=0.019) and 1h postoperatively (13.4±5.1 /ml vs. 8.2±4.1/ml, p=0.03). 5d postop. CEC-frequency was significantly increased in the AVR group (39.0±13.0 /ml vs. 14.3±4.4 /ml, p<0.001). There was a significant correlation between preoperative Euro- and STS score (9.55±2.98 (TAVI) vs. 5.18±1.78 (AVR), p<0.001) and CEC (9.8±4.1/ml (TAVR) vs. 5.5±2.2/ml (CAVR), p=0.019). Additionally, all patients with preoperative CEC>10/ml developed postoperative atrial-fibrillation, more transfusion requirements, prolonged ICU-stay, higher rate of transitory psychotic disorder and paravalvular leakage.
Conclusions: Initial results show that the frequency of CEC is a predictive clinical marker for assessment of preoperative risk, surgical invasiveness and clinical outcome. However, further studies are necessary to validate practical clinical usefulness and potential superiority compared to conventional markers.
P110 Is There a Difference Between Balloon-Expandable and Self-Expanding Stents for Transapical Aortic Valve Replacement?
Bogdan Kindzelski, Ming Li, Dumitru Mazilu, Keith Horvath. National Heart, Lung and Blood Institute, NIH, Bethesda, MD USA.
Objective: While both balloon expandable (BE) and self-expanding (SE) prostheses are used for transapical aortic valve replacement (TAVR), differences between these types of devices are unknown. Histopathology, aortic insufficiency (AI) assessment, and structural integrity of BE and SE stents in a preclinical model were analyzed up to 6-months post-TAVR.
Methods: Real-time MRI guided TAVR was performed in 22 Yucatan Swine using BE (10) or SE (12) prostheses. Follow-up echocardiography and MRIs were performed at 1, 3, and 6-month intervals. Additionally, high contrast radiographs were used to assess for any strut fractures. Pigs were sacrificed at 6 months for histopathologic analysis. Transverse sections of the aortic root and stent/valve assembly were examined by light microscopy for the presence of inflammation, calcification, thrombus and neointimal formation, endothelialization, aortic wall integrity, patency of coronary ostia, and valve apposition. AI was assessed by echocardiography and correlated with left ventricular hypertrophy or dilatation.
Results: No statistically significant differences were noted in leaflet thrombus and fibrin deposition, pannus formation, neointimal formation, calcification, or hemorrhage between BE and SE groups. Stent malposition was found in 7 BE (70%) and 3 SE (25%) prostheses (p=0.046). There were 3 (25%) specimens with partial coronary ostia obstruction in the SE group. In the BE group, 2 (20%) specimens had partially collapsed prosthetic leaflets. The incidence and severity of AI along with the mean heart weight upon fixation were similar between BE and SE groups. 3 BE (30%) and 1 SE (8.3%) prostheses had a gap between the stent frame and aorta. Strut fractures were 6.1±3.45 and 1.17±2.32 (mean ± SD) in the BE and SE groups, respectively (p=0.002). Additionally, 2 (20%) implanted BE prostheses had a compressed stent frame appearance as a result of the strut fractures.
Conclusions: Long-term pathology results from necropsy specimens in a preclinical model of rtMRI guided TAVR demonstrate that SE are superior to BE stent prostheses in terms of proper valve apposition and durability. These results may be attributed to differing deployment methods and associated expansion forces employed by BE and SE stents.