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Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: June 2016 - Volume 11 - Issue - p S120–S147
doi: 10.1097/IMI.0000000000000270
Abstracts
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D1 Rapid Adoption of Transcatheter Aortic Valve Replacement in Florida Did Not Diminish Open Volumes

Lisa M. Soler1, Kalei Walker2, Julie A. Richter1, Anthony A. Bavry1, David R. Anderson1, John W. Petersen1, Charles Klodell1, Calvin Choi1, William B. Smith1, Kent Berg1, Thomas M. Beaver1. 1University of Florida, Gainesville, FL USA; and 2Dartmouth Hitchcock Medical Center, Lebanon, NH USA.

Objective: Transcatheter aortic valve replacement (TAVR) has been rapidly adopted internationally. We analyzed the TAVR use and open surgical aortic valve replacement (SAVR) trends within the state of Florida, which has a large elderly population.

Methods: The Florida Agency for Health Care Administration database was queried from 2009 to 2014 to identify all patients with primary International Classification of Diseases, Ninth Revision, procedure codes for SAVR (35.21, 35.22) and TAVR (35.05, 35.06). Annual use trends for TAVR and SAVR at the state and hospital level were analyzed including demographics, comorbidities, and hospital mortality.

Results: The annual volume of TAVR rose rapidly from 47 (2011) to 1206 (2014), whereas SAVR annual volume decreased only slightly during the 5-year study period (Fig. D1-1). Increasing number of centers offering TAVR, including several high-volume centers, drove this dramatic increase in TAVR volume. From 2011 to 2014, 61 hospitals performed TAVR: 36 were low-volume centers, performing fewer than 10 TAVRs during the study period, and 17 were high-volume centers, performing greater than 50 TAVRs during the study period. Concordant with guideline indications, TAVR patients were older than SAVR patients (mean age, 82±9 vs. 70±13 years; P<0.001) and had more comorbidities (chronic obstructive pulmonary disease, 17% vs. 6%, P<0.001; renal failure, 17% vs. 6%; P<0.001). Hospital mortality for TAVR did not change significantly from 2011 to 2014 (overall 4.6%). However, SAVR hospital mortality significantly decreased between 2009 and 2014, from 5.1% to 3.7% (P=0.02).

Conclusions: Transcatheter aortic valve replacement has been rapidly adopted within the state of Florida. This has not dramatically affected SAVR annual volume, which remained approximately fourfold higher than TAVR. However, SAVR hospital mortality decreased significantly during the study period, likely because of higher-risk patients receiving TAVR. Although maintaining surgical skill sets required to perform SAVR remains important, with an ever increasing demand for minimally invasive procedures, cardiothoracic surgeons should continue to pursue endovascular training because this skill set will be especially required for treating elderly frail patients with aortic valve pathology.

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D2 The AngioVac Device: Understanding the Failures on the Road to Success

Iosif Gulkarov1, Marcus D’Ayala2, Arash Salemi3, Robert J. Tranbaugh1, Regis Chang1, Berhane Worku1. 1Department of Cardiothoracic Surgery, New York Methodist Hospital, Brooklyn, NY USA; 2Division of Vascular Surgery, New York Methodist Hospital, Brooklyn, NY USA; and 3Departmemt of Cardiothoracic Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY USA.

Objective: Current percutaneous thromboembolectomy techniques may obviate surgical intervention in high-risk patients with iliocaval or right heart thrombus but typically require thrombus fragmentation and thrombolysis with associated bleeding and thromboembolic complications. The AngioVac (Angiodynamics, Latham, NY USA) device uses a percutaneous venovenous bypass circuit to aspirate intact thrombus. A review of the literature was performed with regard to the AngioVac device to determine the factors correlating with successful thrombus extraction.

Methods: A literature search was performed with regard to use of the AngioVac device using the PubMed database.

Results: Twenty-three reports describing 57 procedures in 56 patients were analyzed. Indications for thrombectomy included iliocaval thrombus in 53% (30), right heart thrombus in 49% (28), pulmonary embolus in 14% (8), and upper extremity venous/Glenn shunt thrombosis in 7% (4) (Table D2-1). The complete success rate, defined as removal of all thrombi, was 75% (43), with an 11% (6) partial success rate. In 14% (8) of the cases, minimal or no thrombus was retrieved. When analyzed by indication, iliocaval and right heart thrombus demonstrated 87% (26) and 82% (23) complete success rates, respectively. Pulmonary embolus demonstrated a significantly lower success rate at 12.5% (1; P<0.001). Complications occurred in 12% (7), including 6 hematomas and one retroperitoneal bleed (Table D2-2).

Conclusions: The AngioVac device offers an excellent alternative to surgical thrombectomy for patients presenting with iliocaval or intracardiac thrombus, with success rates of more than 80%, although it seems that pulmonary emboli are less amenable. Appropriate patient selection can lead to improved outcomes. Larger numbers are needed to make more definite conclusions.

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D3 Withdrawn.

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D4 Is Inflammation the Culprit Mechanism in Mitral Valve Prolapse?

Bastian Schneider, Johannes Holfeld, Cenk Özpeker, Can Tepeköylü, Michael Grabher, Günther Klima, Michael Grimm, Ludwig Müller. Medical University of Innsbruck, Innsbruck, Austria.

Objective: Mitral valve regurgitation due to a prolapse of leaflets is strongly associated with chordal rupture. Degeneration, inflammation, or genetic predisposition is thought to be the underlying mechanism of action. However, knowledge on the etiology of mitral valve regurgitation is limited. This pilot study aimed to elucidate the pathological process to achieve the ideal surgical strategy.

Methods: We performed histopathological and immunohistochemical analysis of the chordae tendineae of six patients, who underwent mitral valve surgery because of mitral valve regurgitation. Two samples of ruptured chordae, two samples of elongated fibrotic chordae, and two samples of macroscopically normal secondary restrictive chordae were collected during cardiac surgery. Tissues were prepared in frozen sections, stained with hematoxylin-eosin, and underwent electron microscope imaging. Immunofluorescence staining with DAPI and a cytokine profiler was performed to reveal a possible inflammatory process.

Results: Hematoxylin-eosin staining showed fibrotic thickening of elongated chordae and destruction of the chordal tissue of ruptured chordae. Electron micrograph imaging revealed disorganization of collagen fibers in ruptured chordae. Levels of CD40, IL-23, and IFN-γ inflammatory cytokines were significantly increased in ruptured chordae compared with healthy controls. Cell counting in DAPI staining showed cell infiltration in elongated chordae.

Conclusions: The detected increase of inflammatory cytokines in chordal tissue proves that an inflammatory process is present in chordal rupture. Cell infiltration in elongated nonruptured chordae may give an indication for inflammation as a cause for chordal rupture. Further investigation will show whether inflammation is the cause or the consequence of chordal rupture.

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D5 Thoracic Surgeons Prefer a 3D Camera to 2D During Simulation Tests

Gwyn Beattie, Cristiano Spadaccio, Jennifer Whiteley, John Butler. Golden Jubilee National Hospital, Glasgow, United Kingdom.

Objective: Three-dimensional (3D) camera systems are becoming more popular in surgery, and although 3D use in cinema and home entertainment is established, thoracic surgery is only beginning to explore its potential. This study explored the subjective and objective differences in a 3D camera compared with a two-dimensional (2D) camera system.

Methods: A 3D stack system was used for a wet laboratory training day with cardiothoracic surgeons. Five trainees and one consultant elected to take part in the trial. The system is capable of switching between 2D and 3D images without any change in the physical system. A laparoscopic simulator was fitted with a bead and peg simulation. One person throughout operated the camera. Half of the candidates used 2D and then 3D to complete the task, with the other candidates starting with 3D and then rerunning the simulation with 2D. Participants using the 3D camera were provided with polarizing passive glasses. All candidates took an online survey with the results collated in a spreadsheet.

Results: One candidate was an independent VATs operator, three had one to five cases as an operator, and two had experience manipulating the camera during VATs cases. The mean time for the bead transfer was 41 seconds for the 2D versus 18 seconds for the 3D. There were lower collisions and drops in the 3D tests and shorter time to acquire an object or move to a location. One hundred percent agreed or strongly agreed that they prefer the 3D camera, the 3D camera tests were easier than 2D during the simulations, and they felt more precise when using the 3D camera (Fig. D5-1).

Conclusions: Three-dimensional cameras reduce the time for the bead transfer test by 55%. Candidates were able to localize in space and directly pick up objects without searching, thereby reducing the time and looking more efficient with their movement. All surgeons indicated a subjective benefit in the economy of movement and precision and preferred a 3D camera system. Three-dimensional cameras with the natural haptic feedback and the economy of VATS instruments may be the next leap forward in thoracic surgery.

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D6 Off-Pump Minimally Invasive Treatment of Severe Degenerative Mitral Valve Disease and Concomitant Coronary Artery Disease: Hybrid Approach

Agne Drasutiene1, Kestutis Rucinskas1, Arturas Lipnevicius1, Vilius Janusauskas1, Diana Zakarkaite1, Rita Kramena1, Robertas Samalavicius2, Audrius Aidietis1. 1Department of Cardiovascular Medicine, Vilnius University, Vilnius, Lithuania; and 2Department of Intensive Care, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University, Vilnius, Lithuania.

Objective: This study aimed to present successful hybrid procedure for treating severe mitral valve regurgitation and concomitant coronary artery disease.

Methods: There were two patients treated with hybrid procedure. The first patient was a 79-year-old symptomatic [New York Heart Association (NYHA) III] man with severe mitral valve regurgitation and concomitant two–coronary artery disease (ROM, 90%; LAD, 75%). The second patient was an 86-year-old symptomatic (NYHA III) man with severe mitral valve regurgitation and concomitant single-vessel disease (LAD, 75%). The patients had degenerative mitral valve regurgitation with eccentric jet due to wide P2 prolapse. Both patients have undergone coronary stenting followed by off-pump transapical implantation of artificial chordae. The first patient had three chords implanted to the P2 segment. The second patient had four chords implanted to the P2 segment.

Results: None of the patients had any serious adverse events. Both patients had an improvement of symptoms (NYHA II) and had MR 1+ at 1-month follow-up.

Conclusions: Hybrid procedure (coronary artery stenting followed by off-pump transapical implantation of artificial chordae) is an option for treating patients with severe mitral valve regurgitation and concomitant coronary artery disease.

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D7 Extra-anatomical TAVI in a Patient With GUCH With a Rastelli Channel

Gry Dahle, Gunnar Eriksen, Jon Offstad, Anders Hervold, Kjell Arne Rein. Rikshospitalet, OUS, Oslo, Norway.

Objective: An increasing number of grownups with congenital heart defects are in need of secondary procedures. Sometimes, a third or fourth sternotomy is needed. These are very complex procedures with abnormal anatomy. The transcatheter valve technology as well as imaging is evolving, and “custom-made” extra-anatomical procedures may be an alternative. We present a 31-year-old man with atrial septal defect, ventricular septal defect, double-outlet right ventricle, transposition of the great arteries, and pulmonal atresia, gone through surgery three times before: Great Ormond Street modification of the Blalock-Taussig shunt, septalization of atrium and ventricle and rerouting of the left ventricle to aorta (am Rastelli) with a Gore-Tex patch, and last, reconstruction of the right ventricular outflow tract as well as the aortic root am Yacoub, now presenting with aortic regurgitation and left ventricular dilatation.

Methods: Computed tomographic images were segmented using the software from Materialise (Materialise, Leuven, Belgium). Images were discussed for best performance in the process. After a stereolitography file was generated from the CT data, a three-dimensional plaster model was printed (Fig. D7-1). The diameter of the native annulus was too large for a catheter valve on the market, but the subannular dimension was suitable for a catheter valve. The procedure was performed in a hybrid operation room under general anesthesia, with transesophageal echocardiography and fluoroscopy guidance. No predilatation was performed. An Edwards SAPIEN S3 #26 (Edwards Lifescience, Inc., Irvine, CA USA) was deployed transapically under rapid pacing. It was positioned below the anatomical aortic valve in the Rastelli channel. Apex was closed.

Results: The control angiogram and echocardiogram showed good position and performance and no leak in the valve. The patient was extubated in the operating room and discharged to a local hospital on day 6.

Conclusions: This technique can be useful in complex anatomy redo heat surgery, especially in the growing population of patients with grownups with congenital heart defect; three-dimensional printing can be useful for planning. It may also postpone the eventual need for heart transplantation in this group.

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D8 Blood Conservation in Minimally Invasive Aortic Valve Replacement

Umair Aslam, Joseph George, Jennifer Williams, Yasir Ahmed, Sobaran Sharma, Pankaj Kumar. ABM NHS Trust, Swansea, United Kingdom.

Objective: Minimally invasive aortic valve replacement (AVR) is becoming increasingly a routine. It helps in reducing the hospital stay, surgical wound infections, and above all, blood and blood product transfusions. We compare the blood transfusion between minimally invasive AVR and full-sternotomy AVR.

Methods: Patients’ details were taken from our national database, and blood transfusion details were taken from our blood bank. All were first-time isolated AVRs. Group 1 includes patients who underwent minimally invasive AVR performed by one surgeon. Group 2 includes patients who underwent full-sternotomy AVR undertaken by 5 surgeons. A retrospective analysis of the two cohorts was performed. Survival data were obtained from the national patient detail registry. SPSS version 22 (IBM, Armonk, NY USA) was used to undertake unpaired t test with 95% confidence interval. Logistic EuroSCORE was used to perform risk stratification. Patients were matched according to preoperative hemoglobin, age, sex, and creatinine values.

Results: There were 202 patients in group 1 and 600 patients in group 2. There was a significant reduction in blood transfusion requirement in group 1, which was 2.2 U as compared with group 2, which was 4.1 U (P<0.0001).

Conclusions: We demonstrated that blood transfusion is significantly lower in the minimally invasive group, which thus has an impact on the postoperative recovery and has financial implications.

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D9 Concomitant Tricuspid Annuloplasty in Patients With Minimally Invasive Mitral Valve Repair

Yuta Akamatsu, Kazuma Okamoto, Mikihiko Kudo, Akihiro Yoshitake, Mio Kasai, Akinori Hirano, Ichiro Kashima, Ryo Aeba, Hideyuki Shimizu. KEIO Hospital, Tokyo, Japan.

Objective: In recent years, we have actively performed concomitant tricuspid annuloplasty (TAP) in mitral valve plasty (MVP) via right minithoracotomy in case tricuspid regurgitation (TR) is moderate or severe; tricuspid annulus is enlarged, with atrial fibrillation; and/or there is pulmonary hypertension. The aim of this study was to investigate short-term outcomes of concomitant TAP in right minithoracotomy setting.

Methods: Between November 2011 and December 2015, 29 patients (mean age, 54.4±11.8 years; male, n=20) who underwent MVP and TAP via right minithoracotomy were retrospectively summarized. In the same period, 110 patients (mean age, 49.5±3.0 years, male n=80) underwent MVP without TAP. Annuloplasty ring was used for TAP.

Results: Thirty-day mortality for MVP with TAP was 0%, and the length of postoperative stay in the hospital was 13±8 days. Only one patient had major complications with reexpansion pulmonary edema that needed venovenous extracorporeal membrane oxygenation and tracheotomy. Thirteen patients (45%) required blood transfusion. Operative time, total pump time, and aortic cross-clamp time were 350.9±73.9, 245.0±68.4, and 172.6±50.9, respectively. On the other hand, 30-day mortality for MVP without TAP was 0%, and the length of postoperative stay in the hospital was 15±22 days. Forty-two patients (38%) required blood transfusion. Operative time, total pump time, and aortic occlusion time were 338.3±75.5, 239.1±67.1, and 167.4±54.2, respectively. Preoperative and postoperative TRs were 1.93±0.53 and 1±0.53 by transthoracic echocardiography.

Conclusions: There is no significant difference in operative time, length of postoperative stay, and blood transfusion, and there is significant difference in TR between before and after TAP. Concomitant TAP with MVP via minithoracotomy was safely added without significant increase of procedural time and additional risk. Even in minithoracotomy setting, concomitant TAP should be added aggressively, if it is indicated.

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D10 A Simple Approach to a New Technique for Correction of Posterior Mitral Leaflet Prolapse

Farouk M. Oueida1, Ibrahim M. Yassin2, Khalid Al Khamees1, Mustafa Al Refaei1, Hassan Ammar1, Khalid Eskander1. 1Saud al-Babtin Cardiac Center, Aldammam, Saudi Arabia; and 2Tanta University Hospitals, Tanta, Egypt.

Objective: One of the techniques that did not imply resection of any posterior leaflet (PL) scallop, or part of it, for the correction of PL prolapse is the U-technique, with provisional excellent short- to midterm results. Some have expressed concern, however, that minimally invasive (MI) techniques may lead to inferior results for mitral valve (MV) surgery.

Methods: From March 2012 to March 2015, 15 patients with a main MV pathology of PL prolapse underwent MI MV repair via a 5- to 7-cm right anterolateral thoracotomy with peripheral cannulation and external aortic clamping. Mean age, female-male ratio, left ventricular ejection fraction, and New York Heart Association class were 28±11 years, 2:1, 44%±7%, and 3.1±0.8, respectively. Custodiol cardioplegia via aortic root was used in all patients. The main finding of this technique is that PL prolapse can be corrected only by annular overreduction associated to scallop suturing and, if necessary, to longitudinal plication of the scallops to make their height uniform in nine cases (60%). Three-dimensional rings were implanted in all of the 15 cases (100%).

Results: All procedures were successfully performed with no/mild residual mitral regurgitation. Mean transmitral pressure gradient was 2.3±1.1. No systolic anterior motion. Mean aortic cross-clamp and bypass times were 108±23 and 141±31 minutes, respectively. There was no hospital mortality. At a mean follow-up of 6±8.2 months, all patients were alive with a freedom from 2+ or greater degree of mitral regurgitation of 100% and preserved left ventricular ejection fraction.

Conclusions: U-technique via MI approach is feasible and safe and provides comparable excellent early to midterm results.

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D11 Surgical Treatment of Prosthetic Valve Endocarditis: Is the Sutureless Technology a New Viable Option?

Antonio Lio, Antonio Miceli, Matteo Ferrarini, Mattia Glauber. Cardiac Surgery and Great Vessel Department, Istituto Clinico Sant’Ambrogio, Milan, Italy.

Objective: Prosthetic valve endocarditis (PVE) is a serious illness with significant mortality after cardiac surgery (20%–80%). The choice of the optimal prosthesis for aortic valve replacement is still debated. The objective of this study was to evaluate the results of the initial experience with sutureless valve implantation for active PVE.

Methods: A retrospective study was undertaken on six consecutive patients who underwent surgery for aortic PVE with sutureless bioprosthesis from October 2012 to December 2015. Follow-up was 100% complete. Relapse and reinfection were recorded.

Results: There were five men and one woman, with a mean age of 71.5±5.8 years (range, 65–79 years). Mean logistic EuroSCORE was 25.8%±16.6%. Mean cardiopulmonary bypass and aortic cross-clamp times were 158±47 and 92±19 minutes, respectively. Two patients (33%) underwent concomitant surgical procedures: one tricuspid valve replacement and one ventricular septal defect repair. There was one in-hospital death (16%). Median intensive care unit stay was 2 days. Echocardiography performed at discharge showed excellent hemodynamic performance of the bioprosthesis and no significant aortic regurgitation (Table D11-1). At the median follow-up of 18 months (range, 0–21 months), one late death occurred because of neoplastic disease. Freedom from reoperation, relapse, or reinfection was 100%.

Conclusions: Aortic valve replacement with sutureless valve in patient with PVE is a feasible and safe procedure, associated with low in-hospital mortality and good hemodynamic performance of the prosthesis.

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D12 Catheter-Based Mitral Valve Paravalvular Leak Closure: Early Results

Aleksejus Zorinas, Valdas Bilkis, Rokas Simakauskas, Vilius Janusauskas, Kestutis Rucinskas, Giedrius Davidavicius, Diana Zakarkaite, Audrius Aidietis. Vilnius University, Vilnius, Lithuania.

Objective: After mitral valve replacement, paravalvular leak may occur in up to 17% of patients. Patients with paravalvular leak present with symptoms of heart failure and/or anemia. Surgical closure is associated with increased morbidity and mortality. Alternative transcatheter closure has been developed and introduced into the clinical practice with a reasonable success. To the date, more evidence is needed to compare the efficacy and safety of catheter-based paravalvular mitral valve leak closure. Our objective was to present early results of efficacy and safety of catheter-based paravalvular mitral valve leak closure.

Methods: This is a retrospective analysis of patients’ medical records treated for mitral paravalvular leak at our institution in the years 2005 to 2015. Ten patients had catheter-based procedure (transapical approach). Patients’ data, operative variables, postoperative complications, as well as 1 and 4 months of postoperative results were analyzed.

Results: Patients in our analyzed group were 71±6 years old and had an incidence of essential hypertension of 80%. The average length of the procedure to close paravalvular leak was 86 minutes. Early after the treatment, mild/moderate regurgitation of a paravalvular leak was found more frequently in 50% of the patients.

Conclusions: Catheter-based closure of a paravalvular leak is reserved for older patients. The procedure of catheter-based paravalvular leak closure is quick; patients have high incidence of mild/moderate paravalvular leak after the procedure. With more clinical experience and development of special equipment, catheter-based paravalvular leak closure could be a possible alternative to the conventional operation.

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D13 The Use of B-type Natriuretic Peptide as a Predictor of Morbidity and Long-term Mortality in Coronary Artery Bypass Graft and Valve Surgery

Kendal Endicott, Richard Amdur, Michael Greenberg, Gregory Trachiotis. Veteran’s Affairs Medical Center, Washington, DC USA.

Objective: This study aimed to assess whether B-type natriuretic peptide (BNP) levels are a useful predictor of postoperative morbidity and mortality as well as long-term survival in coronary artery bypass graft (CABG) and valve surgery.

Methods: A retrospective review of patients undergoing CABG and/or valve surgery from 2012 to 2015 at a single center was conducted. A total of 432 patients were identified (295 CABG-only, 82 valve-only, and 55 CABG-and-valve cases). B-type natriuretic peptide levels were divided into quartiles (quartile 1, BNP<38.5; quartile 2, BNP of 38.5–88.5; quartile 3, BNP of 88.5–272; quartile 4, BNP>272), and preoperative, intraoperative, and postoperative variables were collected. Mortality data were available for up to 3.4 years after surgery.

Results: B-type natriuretic peptide quartile was independently associated with any complication on multivariate analysis with those in the highest quartile of BNP at highest risk (adjusted odds ratio, 3.81; P=0.047) versus those in the lowest BNP quartile. Thirty-day mortality was 0.9%, with 75% of the deaths occurring among those patients in the highest quartile of BNP (P=0.015 by Fisher exact test). There was a significant association between BNP quartile and time to death (log-rank χ2=8.30, P=0.04) with greatest association 9 months after surgery onward (Fig. D13-1). In a Cox regression model for long-term mortality stratified by BNP level, BNP quartile was significantly associated with the time to death after adjusting for ejection fraction, procedure (including on-pump vs. off pump cases), and other clinical variables in quartile 2 (HR, 3.73; 1.04–13.44; P=0.044) and quartile 4 (HR, 4.33; 1.14–16.44; P=0.031). Quartile 3 also had higher risk of death (HR, 3.5); however, this was only significant at a trend level (P=0.06).

Conclusions: B-type natriuretic peptide levels are an independent predictor of morbidity following CABG and/or valve surgery regardless of the type of procedure or on/off bypass use. B-type natriuretic peptide levels also correlate with the time to death, highlighting the need for sustained follow-up and heart failure management to attenuate survival in patients with elevated BNP levels presenting for all cardiac surgery.

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D14 The Expression and Clinical Significance of Nodal Protein in Non–Small Cell Lung Cancer

Jinyuan He, Jr, Yun Li, Jun An, Hongjie Zheng, Shaohong Huang, Junhang Zhang. The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.

Objective: This study aimed to detect and analyze the clonal significance of nodal expression in human non–small cell lung cancer.

Methods: Nodal protein was detected in 24 cases of squamous cell carcinoma and 70 cases of adenocarcinoma by immunohistochemical staining. Twenty cases of normal lung tissue were used as a control group, and we analyzed the correlation of nodal expression with clinical factors such as histological type and differentiation, clinical stage, lymph node, and distant metastasis.

Results: Immunohistochemical staining showed that nodal positive expression rates of squamous cell lung cancer and lung adenocarcinoma were 33.3% (8/24) and 84.3% (59/70), respectively. Nodal expression was significantly higher than in the control group whose positive expression rates were 10.0% (P=0.05). Nodal positive expression rate in high-differentiation lung adenocarcinoma (76.7%) was lower than in those with low differentiation (96.3%) (P<0.05). Nodal positive expression rates in clinical stages III to IV (94.7%) were higher than in stages I to II (71.9%) (P<0.05). For patients with lymph node metastasis, nodal positive expression rate was 92.8%, which was higher compared with those without lymph node metastasis (71.4%) (P<0.05). For patients with and without oligometastasis, nodal positive expression rates were 96.2% and 77.3%, respectively, and there was a statistically significant difference between them (P<0.05).

Conclusions: Nodal positive expression rate in lung adenocarcinoma was significantly higher than in normal lung tissue, but there is no significant difference between squamous cell carcinoma and normal lung tissue. In lung adenocarcinoma, nodal positive expression rate was detected higher in those patients with lower-differentiation degree, advanced clinical stage, lymph node metastasis, and distant metastasis.

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D15 Cervical Cannulation for Surgical Repair of Congenital Cardiac Defects in Infants and Small Children

Pankaj Garg, Arvind Kumar Bishnoi, Chandrasekaran Ananthanarayanan, Pranav Sharma, Amber Malhotra, Jigar Patel, Ritesh Shah, Sanjay Patel. U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, India.

Objective: Minimally invasive cardiac surgery has become an established technique for the correction of a wide variety of acquired and congenital cardiac lesions. However, it is yet to become an accepted technique in pediatric population. Among the hurdles faced in the conduct of minimally invasive cardiac surgery in pediatric population, one of the biggest challenges is peripheral vascular cannulation. We report our technique and results of the use of peripheral cannulation in infants and small children for repair of simple congenital cardiac defects.

Methods: From October 2014 to September 2015, 37 children (21 were male) with a mean age of 1.5 years (8 months to 6 years) and a mean weight of 8 kg (5.2–13.5 kg) were operated on for simple congenital cardiac defects through right lateral thoracotomy or transxiphoid incision [ventricular septal defect (VSD), 18 patients], ostium secundum atrial septal defect (ASD) (10 patients), sinus venosus ASD (4 patients), partial atrioventricular canal defects (4 patients), and ostium secundum ASD with pulmonary stenosis (1 patient). The length of thoracic or xiphoid incision ranged from 4 to 5 cm, and cervical incision was 1.5 to 2 cm. In all patients, the right common carotid artery, right internal jugular vein, and inferior vena cava were cannulated for the conduct of cardiopulmonary bypass and aorta cross-clamping through the right second intercostal space. Intracardiac defects were repaired as with full-sternotomy technique except that the anterior leaflet of tricuspid valve was detached routinely for the exposure of VSD. Perioperative and postoperative echocardiography was performed in all of the patients. Follow-up was complete.

Results: There was no mortality or significant surgical morbidity. There was vascular or no neck wound-related complications, and no patient had any neurological event. All patients were in sinus rhythm. Perioperative and postoperative echocardiography confirmed the absence of any residual defects in any patient. Two patients with VSD had tiny flow across patch. No patient had any significant tricuspid regurgitation.

Conclusions: Peripheral vascular cannulation using a graft on the right common carotid artery and direct cannulation of the right internal jugular vein is safe and easy to perform. It prevents the cluttering of the operative field and provides excellent exposure even in infants.

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D16 Single-Port Versus Multiport Video-Assisted Thoracoscopic Surgery Lobectomy: Perioperative Outcomes

JiHyong Yun. Kwangju Christian Hospital, GwangJu, Republic of Korea.

Objective: Single-port lobectomy is less traumatic and may provide lower postoperative pain compared with multiport video-assisted thoracoscopic surgery (VATS) lobectomy. In this study, we analyzed perioperative outcomes of single-port and multiport VATS lobectomies.

Methods: We retrospectively analyzed 19 consecutive patients undergoing VATS lobectomy for lung cancers (n=15) or inflammatory lungs (n=4) from December 2013 to November 2015. Variables included age, sex, operation time, intensity of pain [assessed by Visual Analog Scale (VAS) score], medication, and hospital stay.

Results: The operation types were 6 single-port lobectomies and 13 multiport lobectomies. Persistent air leak occurred in one patient who underwent multiport VATS. There were no significant differences in VAS score (single port, 1.83; multiport, 2.53), the median duration of intravenous patient-controlled analgesia (single port, 4 days; multiport, 4.2 days), and additional injection (single port, 2.8 times; multiport, 1.3 times). Mean hospital stay was 8.3 days (single port, 6.8 days; multiport, 9.0 days) (Table D16-1).

Conclusions: Single-port VATS lobectomy may be feasible for lung cancers and inflammatory lungs. However, further investigation is necessary.

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D17 Coronary Artery Bypass Grafting of the Left-Sided Thoracotomy in Patients With Coronary Artery Disease

Khudenkikh Elena. Federal State Institution, Kaliningrad, Russian Federation.

Objective: This study aimed to present our experience on coronary artery bypass grafting (CABG) from left thoracotomy.

Methods: From September 2012 to December 2015, our center treated 226 patients with coronary artery disease who underwent CABG from left thoracotomy: 141 were men (62.4%) and 85 were women (37.6%). The mean age was 68.6±17.4 years; the number of diseased coronary arteries was 2.2. Nineteen patients had a history of CABG, in seven cases using the left internal thoracic artery (LITA). Mean EuroSCORE II was 4.8±3.7. Comorbidities included chronic obstructive pulmonary disease, asthma, atherosclerosis, peripheral vascular disease, diabetes, obesity, chronic kidney disease. Angina functional class was II to III, CHF included New York Heart Association classes I to III, and ejection fraction was 38%±13.8%. All patients underwent CABG of anterior descending artery off pump: in 111 patients with isolated anterior descending artery lesion, the rest was a stage hybrid intervention. In 219 cases, the LITA was used; in 7, we performed autovenous subclavian artery bypass surgery (LITA used in the previous surgery).

Results: All patients were discharged from the hospital. The average time spent in the hospital was 5.8 days. There was no mortality. Angina functional class I was found in 12 patients, class II in 3 patients, class III in 2 patients. The mean intraoperative blood loss was 150.0 mL; there was bleeding in two patients (LITA bed). In three cases, there was urgent stenting OA in the early postoperative period because of acute ischemic changes. Two patients had thrombosis of the shunt. After surgery, there were atrial fibrillation episodes in 6 patients and anginal attacks in 3 -x; in 2 cases, there was a problem in wound healing.

Conclusions: Coronary artery bypass grafting from left thoracotomy can be performed at one-vessel and multivessel diseases as a stage hybrid intervention.

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D18 A Dual Dilemma: Management of Acute Aortic Dissection in the Setting of Preexisting Abdominal Aortic Aneurysm

Corbin Muetterties1, Steve DeBeer2, Grayson Wheatley, III1. 1Temple University School of Medicine, Philadelphia, PA USA; and 2Emory University, Atlanta, GA USA.

Objective: Acute aortic dissection (AAD) occurring in patients with a preexisting abdominal aortic aneurysm (AAA) presents a challenging treatment dilemma. Extension of the dissection flap into the lumen of the AAA can potentially change its suitability for endovascular repair. Limited knowledge exists about how best to approach this unique aortic pathology. In an attempt to address this question, we discuss our experience with this problem along with a comprehensive review of the literature.

Methods: We reviewed our institutional aortic database for patients with preexisting AAA and AAD treated at our institution. In addition, we performed multiple PubMed queries for peer-reviewed publications using the search term AAA with concurrent dissection and the terms repair, aortic dissection, aortic aneurysm, and thoracoabdominal. Articles that described surgical or endovascular management of patients with coexisting AAA and AAD in native aortas were included.

Results: Three patients with preexisting AAA and subsequent AAD were treated at our institution (1 endovascularly and 2 medically). There were no strokes, paraplegia, or deaths within 30 days of follow-up. Figure D18-1 shows a concurrent AAA and AAD with a thrombosed false lumen treated at our institution. The PubMed query revealed a total of six articles describing the surgical management of patients with coexistent AAA and AAD. Sixteen patients were treated with open surgery, whereas two patients were treated endovascularly. In two patients (one open and one endovascular), fenestration of the aortic septum was completed at the time of intervention. Type II endoleak was reported in 100% (2/2) of the cases treated endovascularly; however, neither required reintervention. Overall mortality was 37.5% (6/16) and 0% (0/2) for open and endovascular surgeries, respectively. Of the patients who perished, two died intraoperatively, three because of aortic rupture, and one because of acute renal failure.

Conclusions: Acute aortic dissection and AAA presenting as coexistent conditions are rare, and clinical experience is limited with regard to optimal therapy. We propose that endovascular therapy, when feasible, may provide a safe and effective intervention; however, further study is needed.

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D19 Endovascular Repair of Peripheral Arterial Disease: Midterm Results From a Single Center

Kemal Korkmaz1, Hikmet Selcuk Gedik1, Ali Baran Budak1, Serdar Gunaydin1, Kerim Cagli2. 1Numune Training & Research Hospital, Ankara, Turkey; and 2Yuksek Ihtisas Training & Research Hospital, Ankara, Turkey.

Objective: One thousand patients who underwent endovascular repair in a 5-year period were studied retrospectively to evaluate technical success, freedom from reinterventions, and early clinical outcome.

Methods: Mean Rutherford class was 4.086±0.8. A total of 755 patients experienced claudication, 423 from rest pain and 169 from ischemic ulceration. Angiographic lesions are listed in Table D19-1.

Results: A total of 552 men and 448 women (mean, 69.8±8 years; range, 19–89 years) underwent endovascular repair. A total of 698 patients received local anesthesia and 302 received general anesthesia. Interventions were as follows: 210 predilatations, 294 single atherectomies, 116 atherectomy+surgery, 132 atherectomy+PTA+surgery, 129 atherectomy+PTA+stent+surgery, and 121 postdilatations. Mean additional PTA rate was 3.6±2.2; 144 wired and 448 drug-eluting balloons were used. A total of 155 self-expandable, 67 balloon expandable, 33 bare stents, 110 stent grafts were placed. The procedure was successful in 847 patients (84%). There was no early death. There were 151 early occlusions (95 underwent surgery, 56 received stents), 121 dissections (39 underwent surgery, 56 received stents, and 26 received medical treatment), 32 hematomas, and 13 early leaks. Mean Rutherford class improved to 3.02±0.9. Rate of freedom from reintervention at 5 years was 76%. Sixty-three patients underwent surgery, and 59 underwent cellular therapy. A total of 134 finger, 142 below-knee, and 29 above-knee amputations were reported.

Conclusions: Endovascular interventions can be performed with high technical success and low complication rates; however, nonfatal complications and catheter-based reinterventions are frequent.

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D20 A Comprehensive Animal Model to Evaluate Novel Sternal Closure Devices

Lishan Aklog1, Jaishankar Raman2, Edward Garrett3, Jeremy London4, Brian deGuzman5, John Pirris6, Kenneth Burkus7, Kyle Icke8, Brian Hatcher8. 1PAVmed Inc, New York, NY USA; 2Rush University, Chicago, IL USA; 3University of Tennessee Medical Center, Memphis, TN USA; 4Savannah Vascular and Cardiac Institute, Savannah, GA USA; 5Kaleidoscope Medical, Phoenix, AZ USA; 6University of Florida, Jacksonville, FL USA; 7The Hughston Clinic, Columbus, GA USA; and 8Zimmer Biomet, Jacksonville, FL USA.

Objective: Increased attention to sternal healing dictates the need for a useful model to compare new sternal closure devices (SCDs). We report a model for evaluating sternal healing, biomechanical stability, biocompatibility, and device removal with a novel titanium plate with integrated cerclage band SCD.

Methods: Three skeletally mature sheep underwent median sternotomy followed by sternal closure with a combination of three SCDs and two cerclage wires. Animals underwent sternal computed tomographic (CT) CT scanning at 6 weeks as well as device removal force analysis, postnecropsy micro-CT scanning, and biomechanical and histopathological analysis at 3 months. Computed tomographic scans were scored on a 6-point scale at seven locations according to a validated method by an independent core laboratory (Fig. D20-1). Sterna were sectioned into three dog bone–shaped segments and tested in lateral distraction until failure. Identical segments from intact sterna served as controls. Biocompatibility was characterized by independent histopathological assessment of 13 inflammatory and healing markers at 16 peri-implant sites.

Results: Mean CT scan scores increased significantly from 6 weeks (3.4±1.1) to 3 months (4.3±0.9, P=0.003), confirming moderate-to-complete sternal healing at 3 months. Biomechanical properties of fixated sterna at 3 months approached those of intact controls with no significant difference in peak force (675±327 N, fixated; 880±287 N, intact; P=0.224) or stiffness (781±210 N/mm, fixated; 893 ± 204 N/mm, intact; P=0.317). Histopathological assessment confirmed biocompatibility of the SCD with a relatively mild inflammatory response that did not differ from wire controls (P=0.23). The average force for SCD band removal (24.0±15.1 N) was significantly less than for wire removal (52.0±22.2 N, P=0.014).

Conclusions: A comprehensive animal model for assessing sternal healing, biomechanical stability, biocompatibility, and device removal performance of SCDs has been established. At 3 months, the SCD device showed sternal healing by CT scan, biomechanical stability approaching intact bone, biocompatibility, and ease of removal. This model may be used to evaluate performance of sternal fixation devices outside of a clinical setting.

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D21 Photodynamic Therapy Modalities in the Thorax for the Kaposiform Hemangioendotheliomas With Kasabach-Merritt Syndrome

Rasul Sadykov. Tashkent Medical Academy, Tashkent, Uzbekistan.

Objective: The vascular anomalies are the most frequent pathology in childhood. Vascular anomalies include different types of pathology such as vascular tumor and vascular malformations. In rare cases, Kaposiform hemangioendotheliomas can be noted, sometimes with Kasabach-Merritt syndrome. Such cases make the surgical approach for the bleeding complication difficult. For this reason, the development of laser technologies such as photodynamic therapy (PDT) is helpful.

Methods: This research includes five patients with Kaposiform hemangioendotheliomas on the thorax region. After general investigation, PDT procedure was performed. For the PDT, we used AFT-1 (Uzbekistan) device with a power of 5 W. Before the treatment, we performed 5-ala local injection 1 mg/mL; after 3-hour exposition was done, irradiation was performed using 635 laser light 50 J/cm2. Photodynamic therapy procedure was queued with ultrasound control during the session and every month.

Results: During the time of treatment, two of the five patients who presented with long-term pain reported improvement after the treatment. In addition, four of the five patients reported significant reduction of bleeding related to their hemangioendothelioma. Improvement of swelling was reported by five of the five patients. Clinical assessment showed that PDT had “good response” to the treatment. Radiological and ultrasound assessments comparing imaging results 6 weeks after laser and PDT with those taken at the baseline showed significant response in five patients.

Conclusions: The management of Kaposiform hemangioendotheliomas continues to be extremely challenging. Although several modalities have been developed and the literature reports successful treatment in many, data from long-term studies report relapse in many and the need for retreatment or another intervention. Photodynamic therapy is not superior to other modalities, but it is one of the least invasive, being repeatable with no residual toxicity and with a minimal bystander effect on the overall tissue architect and integrity as well as the nerves. The growing body of evidence regarding its efficacy, the increasing use of image-guided PDT, and its innate minimally invasive characteristics suggest that it should become an important addition to the various techniques used in the management of vascular anomalies.

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D22 Midterm Outcome of Mitral Valve Repair in 351 Patients From a Single Team in Turkey

Kerim Cagli1, Ersin Kadirogullari1, Omer Faruk Cicek1, Emre Yasar1, Serkan Mola1, Ibrahim Erkengel1, Eren Gunertem1, Ferhat Ikbaliafsar1, Sabit Kocabeyoglu1, Ali Baran Budak2, Adnan Yalcinkaya1, Adem Diken3, Gokhan Lafci1, Serdar Gunaydin2. 1Yuksek Ihtisas Training & Research Hospital, Ankara, Turkey; 2Numune Training & Research Hospital, Ankara, Turkey; and 3Hitit University, School of Medicine, Corum, Turkey.

Objective: Mitral valve repair is feasible for all patients with mitral regurgitation (MR) and/or mitral stenosis, and its advantages are well documented; however, there is general agreement that it is technically demanding and that success rates are related to volume/experience of the centers. The aim of this study was to evaluate the clinical and echocardiographic outcome of patients who underwent mitral repair by a single team.

Methods: We retrospectively evaluated 351 patients who underwent mitral valve repair for MR and/or mitral stenosis from May 2009 to December 2013. A total of 192 patients were male (54.7%), and mean age was 50.8±16.5 years. A total of 222 patients (63.3%) had degenerative disease, 71 (20.2%) had congenital, 26 (7.4%) had ischemic, and 32 (9.1%) had rheumatic origin. Seven patients (2%) had previous valve surgery and recurrent regurgitation. The mean EuroSCORE was 8.2±2.4, and two thirds of the patients were in New York Heart Association class III/IV. Repair procedures included mitral ring annuloplasty, quadrangular resection, chordal replacement, and commissuroplasty.

Results: According to control postoperative echocardiography (mean, 23.4±17.2 months), 309 patients (88%) had no MR. Four patients (1.1%) underwent valve replacement intraoperatively because of lack of coaptation after repair. Short-term (<30 days) mortality was 2%, and long-term mortality was 2.6%. Eight patients (2.4%) had trivial MR, and seven (2.1%) of them are still under follow-up. Seven patients (2%) had severe MR and underwent second surgery. Mechanical valve replacement was preferred in six patients (1.7%), and valve repair was performed in one (0.3%) of them. Postoperative complications included atrial fibrillation in 15.4%, check bleeding in 3.1%, and wound infection in 1.6%.

Conclusions: Mitral valve repair techniques should be considered as the first choice in surgical treatment of mitral valve disease when it is possible and can be used as a safe and an effective choice with its superiority to mechanical valve replacement in experienced centers.

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D23 Unilateral Carotid Cannulation Using a Side Graft Facilitates Minimally Invasive Surgery of the Ascending Aorta and Aortic Arch

Rainer Leyh, Constanze Bening, Dejan Radakovic, Christoph Schimmer, Mehmet Oezkur, Ivan Aleksic, Khaled Hamouda. Medical University Wuerzburg, Wuerzburg, Germany.

Objective: The impact of arterial cannulation of the right carotid artery using a side graft in combined aortic valve–ascending aortic surgery with and without arch surgery using a minimally invasive upper hemisternotomy has not yet been evaluated. This study evaluated the clinical outcome of this technique.

Methods: Between July 2012 and December 2015, 33 patients underwent aortic valve and replacement of the ascending aorta with and without arch surgery in a minimally invasive technique with an upper hemisternotomy at our institution. Arterial return of the cardiopulmonary bypass was performed in all patients via cannulation of the right carotid artery using a side graft. In patients requiring aortic arch surgery, unilateral cerebral perfusion was performed using this side graft.

Results: A total of 27.3% (9/33) of the patients required aortic root replacement, and 58% (19/33) required aortic arch surgery. The cardiopulmonary bypass time and aortic cross-clamp time were 131±44 minutes and 83±34 minutes, respectively. The duration of circulatory arrest with unilateral cerebral perfusion in patients with aortic arch surgery was 14±4 minutes. Brain perfusion was performed at a blood temperature of 25°C and a flow rate of 0.7±0.2 L/min. Median ventilation time and intensive care unit stay were 15 hours and 1 day, respectively. Prolonged ventilation time (>24 hours) was necessary in 9.1% (3/33), and 51% (17/33) required red blood cell transfusion with a median of 1 U each. Rethoracotomy for bleeding was performed in 6.1% (2/33). According to Acute Kidney Injury Network classification, stage I acute kidney injury developed in 21.2% (7/33), and stage III, requiring temporal renal replacement therapy, developed in 3% (1/33). There was no 30-day mortality. One patient with severe calcification of the aortic valve experienced a minor embolic stroke.

Conclusions: These preliminary data indicate that arterial cannulation of the right carotid artery using a side graft is an efficient and safe method for combined surgery of the aortic valve, ascending aorta, and aortic arch in a minimally invasive technique using upper hemisternotomy.

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D24 Three-Dimensional Thoracoscopic Cardiac Surgery: An Analysis of 160 Cases

Huiming Guo, Jian Liu, Bin Xie, Xiaosheng Zhang, Xin Zang, Wenda Gu, Bo Chen, Jian Zhuang. Guangdong General Hospital, Guangzhou, China.

Objective: The aim of this study was to evaluate the efficacy and safety of cardiac surgery assisted by three-dimensional (3D) thoracoscopy.

Methods: Retrospective analysis was performed on 160 cardiac surgery cases (76 male patients, 48%; 84 female patients, 52%) assisted by 3D thoracoscopy from March 2014 to May 2015. The mean age was 48.3±14.95 years (range, 15–79 years). Among the total 160 cases, there were 56 MVR (concomitant TVP, 16 cases) and 7 TVR cases; MVP performed in 36 cases (concomitant TVP, 9 cases; 3 cases were transitioned to MVR because of repair failure), left atrial myxoma resection 12 cases, surgical ablation for atrial fibrillation in 2 cases, and 23 MID-CAB cases using 3D thoracoscopy to harvest the LIMA; meanwhile, congenital cardiac surgeries included 20 ASD repair, 1 VSD repair, 1 cor triatriatum correction, 1 unroofed coronary sinus syndrome correction, and 1 PAVC repair. Eleven cases had received cardiac surgery before. All cases were performed using a 30-degree 3D thoracoscopy, 3D high-definition display screen. CPB was established via femoral artery, femoral vein, and internal jugular vein.

Results: Two re-TVR patients died; in-hospital mortality was 1.3%.Two cases were transitioned to median sternotomy because of severe pericardium adhesion and LIMA injury. Total mechanical ventilation time was 16.1±25.4 hours (range, 2–227), hospital stay after surgery was 6.9±7.9 days (range, 1–36), and intensive care unit stay was 50.4±78.2 hours (range, 12–777). Chest drainage volume in the first 24 hours was 170.7±175.46 mL. Other complications included reoperation for bleeding (5 cases, 3.1%), pneumonia (12 cases, 7.5%), poor wound healing (6 cases, 3.7%), pneumothorax (3 cases, 1.8%), hypoxemia (1 case, 0.6%), and stroke (1 case, 0.6%).

Conclusions: Three-dimensional thoracoscopy could be used in various cardiac surgeries safely. It can also be used in high risk reoperation patients under critical assessment.

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D25 Active Clearance Technology: An Effective Drainage System to Prevent Postoperative Atrial Fibrillation

Samuel St-Onge, Philippe Demers, Walid Ben Ali, Ismail Bouhout, Louis Perrault. University de Montréal, Montreal, Quebec, Canada.

Objective: Postoperative atrial fibrillation (POAF) is one of the most frequent complications after heart surgery and significantly increases morbidity. An obstructed chest tube, leaving unevacuated blood around the heart and lung, therefore driving inflammation, may be a contributing factor for this complication. The aims of this study were to assess the effectiveness of chest drainage using active tube clearance (ATC) system in reducing the rate of POAF and to evaluate the impact of ATC on retained blood syndrome (RBS).

Methods: This is a retrospective analysis based on 344 consecutive patients admitted for heart surgery. We compared 158 patients allocated to an ATC chest drainage protocol from June to August 2014 to 186 consecutive controls who were managed with standard chest drainage from August to September 2014. The primary end point was new onset of POAF. Secondary end point was the occurrence of RBS, a composite including reexploration for bleeding or tamponade, and interventions for hemothorax, pericardial effusion, and pleural effusion.

Results: Patients undergoing ATC chest drainage protocol had an absolute reduction of 39% in their POAF rate compared with those managed with standard drains (20% vs. 33%, P=0.007). After a propensity-score matching based on 15 primary end point–related variables, ATC drainage showed a protective effect on new onset of POAF with odds ratio of 0.52 (95% confidence interval, 0.31–0.86; P=0.010). On the other hand, there was no difference in the RBS rate (6% vs. 5%, P=0.722), even after propensity-score matching (odds ratio, 1.24; 95% confidence interval, 0.47–3.29; P=0.670).

Conclusions: The use of an ATC chest drainage protocol effectively reduced POAF but failed to show a protective effect on interventions for RBS.

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D26 Off-Pump Mitral Valve Stent Implantation: A Histological Evaluation

Sinje Haasler, Saskia Pokorny, Irma Haben, Katharina Huenges, Jochen Cremer, Georg Lutter. Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany.

Objective: The aim of this study was the histological evaluation of mitral valve stents in an experimental in vivo porcine model 4 to 12 weeks after implantation with a focus on inflammatory reactions.

Methods: The self-expanding mitral valve stents were implanted in the healthy porcine model via transapical approach in the beating heart. In this study, a histological evaluation of five animals is presented. The stents were implanted in vivo for a period of 4 weeks or longer. Posthumously, samples of the native mitral annulus and the atrial stent’s bed were taken and histologically analyzed (hematoxylin and eosin, Masson’s trichrome, Elastica van Gieson, Movat’s Pentachrome, and von Kossa). Furthermore, CD45+ leukocytes, CD20+ B cells, CD3+ T cells. and CD68+ macrophages were detected by specific immunohistochemical staining.

Results: The tissue’s architecture not only showed largely physiological regular structure (Fig. D26-1A) but also presented local areas in which the integrity of the tissue was damaged to different extents. In four of the five animals, the formation of fibrin was detected (Fig. D26-1C). In all but one animal, partly mild (n=2) or no (n=2) accumulations of calcium carbonate were shown (Fig. D26-1B). Some inflammation in the surrounding tissue was detectable (Fig. D26-1D). In three of the five animals, a strong presence of leucocytes was found; in one animal, a locally restricted presence of leucocytes was found; and in one animal, only a sporadic presence of leucocytes was found. A moderate (n=4) or strong (n=1) distribution of macrophages was detectable. Only low numbers of T cells and B cells were found in all animals but one. These results indicate an innate immune response but only low adaptive immune response after up to 12 weeks after implantation. No differences between annulus and the atrial stent’s bed were visible.

Conclusions: The histological evaluation of five mitral valve stents showed widely a good integration into the native heart’s tissue. The stent surrounding tissue was classified and characterized for the first time. However, signs for inflammation and the slight presence of calcification show potential risks. This has to be evaluated in greater detail in a future study including a larger number of cases.

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D27 High Prevalence of Undetected Permanent Foramen Ovale, as an Underestimated Risk Factor for Cerebral Embolism

Cenk U. Oezpeker, Christoph Krapf, Bastian Schneider, Elfriede Ruttmann, Juliane Kilo, Michael Grimm, Ludwig Mueller. University of Innsbruck, Innsbruck, Austria.

Objective: The overall incidence of patent foramen ovale or atrial septal defect (PFO/ASDII) is reported to be 27.3%. During mitral or tricuspid valve surgery, sometimes, a PFO is encountered, which is not detected by transthoracic and transesophageal echocardiography (TTE/TEE). Untreated PFO, however, may be of clinical relevance in occult cerebral embolism. The aim of this investigation was to analyze the prevalence of undetected PFO in patients undergoing minimally invasive mitral/tricuspid valve surgery.

Methods: From 2001 to 2015, 657 patients underwent mitral and/or tricuspid valve surgery via mini lateral thoracotomy. In 93 patients, a PFO/ASD was closed during the procedure. In 80 patients a mitral valve repair, with concomitant tricuspid valve repair (TVRep) in 16 of these patients, was performed. In seven patients, a mitral valve replacement with additional TVRep in three patients was the surgical intervention. In six patients, isolated TVRep was performed. In all patients, the existence of PFO had been examined preoperatively and intraoperatively by TTE and TEE.

Results: The incidence of surgically proven and closed PFO in the total cohort of 657 patients was 93 (14.2%). However, in 65 (69.9%) of these patients, no echocardiographic signs for PFO/ASD had been diagnosed preoperatively.

Conclusions: These data indicate that 70% of PFOs may be not diagnosed by TTE and TEE. Consequently, a high prevalence of PFOs in the population remains untreated and may be a potential risk factor for cerebral embolization. This should be taken into account if embolic stroke occurs and source of embolization remains unclear.

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D28 The Choice of Surgical Procedure for the Correction of Anomalous Aortic Origin of the Coronary Artery Does Not Affect Early Results

Modesto J. Colon, Farzan Filsoufi, Khan Nguyen, Paul Stelzer, Ramachandra C. Reddy. Mount Sinai Medical Center, New York, NY USA.

Objective: Anomalous aortic origin of the coronary artery (AAOCA) is an uncommon condition occurring in 0.1% to 0.3% of the population but may be associated with sudden death and myocardial ischemia. Surgical correction including unroofing, reimplantation, and coronary artery bypass grafting is required in the latter groups. The choice of the optimal surgical intervention and their outcomes remain undetermined. Here, we report our contemporary experience in a large cohort of patients with AAOCA.

Methods: We retrospectively analyzed prospectively collected data of 42 patients with AAOCA who underwent surgical correction at Mount Sinai Hospital between 2007 and 2015. Outcomes measured included hospital mortality and postoperative complications.

Results: Twenty-nine patients were male, and 13 were female. The age ranged from 7 to 82 years. Sixteen patients had anomalous left coronary artery, and 26 presented with anomalous right coronary artery. Indications for surgery included symptoms, positive stress test result, and other concomitant cardiac operations. The procedure performed was determined by surgeons’ preference and included unroofing (n=15), reimplantation (n=6), minimally invasive coronary artery bypass grafting (CABG) (n=8), and CABG (n=13). Nine patients with anomalous right coronary artery who underwent CABG had proximal ligation of the proximal artery but none in the anomalous left coronary artery group. There were no mortalities. One patient developed a hemothorax, and one needed a reexploration for bleeding.

Conclusions: A variety of techniques can be applied to correct AAOCA with excellent results. The choice of procedures does not affect early surgical outcomes. Long-term follow-up is necessary to better determine the exact role of each surgical intervention in the correction of AAOCA.

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D29 Nickel Immersion From Nitinol Thin-Film Heart Valves

Constantin Fuehner, Saskia Pokorny, Irma Haben, Katharina Huenges, Jochen Cremer, Georg Lutter. Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany.

Objective: The development of heart valve leaflets manufactured from a thin-film nitinol is the focus of recent research. A nitinol heart valve would be an efficient, durable, very thin heart valve with low thrombogenicity and would hence be able to decrease the minimal implantation diameter of valve stents. However, nickel has a high allergic potential, and heart valves are exposed to permanent deformation. In this study, the release of nickel from nitinol valves within a permanent pulsatile flow was evaluated.

Methods: An in vitro test setup was developed, simulating the dynamic blood flow in vivo and enabling the analysis of nickel release. The experimental setup was a closed system composed of a roll pump, causing a continuous, pulsatile flow; a specimen mounting; and a reservoir. Ultrapure water was used as a test medium. Five heart valve specimens were tested following a standardized protocol. Samples of the test medium were taken at defined points of time (1, 72, 144, 216, 288, and 360 hours), and the nickel concentration was determined with a mass spectrometer. Within this testing period, the specimens were loaded with 70 beats per minute, resulting in 1.515.000 cycles in total. Furthermore, the surface of the heart valves was analyzed using a scanning electron microscope, to detect corrosion and abrasion.

Results: The amount of nickel released was determined by a mass spectrometer and normalized to the surface area and the number of hours within the test setup. The released nickel was highest within the first 72 hours with 2.9±1.2 ng/cm2/d after 1 hour and 2.1±0.5 ng/cm2/d after 72 hours and decreased thereafter to 1.0±0.5 ng/cm2/d after 12 days (288 hours). After 15 days, the nickel immersion slightly increased to 1.8±0.8 ng/cm2/d. The scanning electron microscope showed signs for kinks in restricted areas.

Conclusions: A test setup was developed to evaluate the nickel immersion from nitinol thin-film heart valves within pulsatile flow conditions. The nickel immersion in six specimens was analyzed over a period of 15 days under pulsatile flow loading. A very low nickel immersion was detected, below the level associated with allergic responses.

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D30 How Reliable Is Radial Artery Pressure in Minimally Invasive Cardiac Surgery Using Peripheral Perfusion?

Yoshitsugu Nakamura, Miho Kuroda, Yohei Kawatani, Yujiro Hayashi, Tetsuyoshi Taneichi, Yujiro Ito, Yuji Suda, Takaki Hori, Chihiro Shirai, Naoya Yamauchi. Chibanishi General Hospital, Chiba, Japan.

Objective: It has been reported that radial artery pressure (RAP) can become lower than the central (aortic) perfusion pressure in cardiac surgery with cardiopulmonary bypass (CPB) via central cannulation. However, it is unknown if the same phenomenon occurs and to what extent in minimally invasive cardiac surgery (MICS) using CPB with peripheral perfusion via femorofemoral cannulation. This study assessed how well RAP tracked central perfusion pressure during MICS.

Methods: Fifty-two consecutive patients undergoing MICS were prospectively included in this study. Mean age was 65±14 years, and male-female ratio was 29:23. Types of surgeries included 23 aortic valve replacements, 22 mitral valve surgeries with or without maze procedure, and 5 double-valve surgeries. Cardiopulmonary bypass was established via a femoral artery cannulation and femoral vein with or without internal jugular cannulation. Mean CPB and cross-clamp times were 153±31 and 118±30 minutes, respectively. The lowest blood temperature during CPB was 32°C. Radial artery pressure was monitored via a 5-cm-long 20-gauge catheter. Central perfusion pressure was approximated by femoral artery pressure, which was measured via a 15-cm-long 3F catheter.

Results: Mean systolic femoral artery pressure was higher than RAP throughout surgery (P<0.01), and the pressure gradient (PG) between them varied with time (Fig. D30-1). The PG was level at approximately 5±8 mmHg until declamping of the aorta then increased to a peak of 24±16 mmHg at CPB termination. After the CPB, the PG decreased gradually. Twenty patients (54%) and 21 patients (40%) had maximum PG of more than 20 mmHg and 30 mmHg, respectively. Univariate analysis showed that longer CPB time and intraoperative use of vasodilator were predictors of PG greater than 20 mmHg. In multivariate analysis, the latter remained a predictor of PG greater than 20 mmHg.

Conclusions: In MICS, RAP does not reflect central perfusion pressure, especially after declamping. Intraoperative arterial pressure management based solely on RAP should be avoided.

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D31 Does a Lipid Nanoparticle Carrying Methotrexate, This Nanoparticle Carrying Paclitaxel, or a Combination of Both Particles, Decrease Graft Vascular Disease in Rabbit Heterotopic Transplanted Hearts?

Noedir Stolf, Sr, Lucas Regatieri Barbieri, Domingos Filho Lourenco, Paulo Guitierriz, Elaine Tavares, Raul Maranhao. Heart Institute University Sao Paulo, Sao Paulo, Brazil.

Objective: This study aimed to evaluate the effect of a lipid nanoparticle LDE-methotrexate, LDE-paclitaxel, and a combination of both particles in graft vascular disease (GVD) and to evaluate the influence of this treatment in the expression of genes involved in inflammatory response in a model of rabbit heart transplantation.

Methods: Twenty-eight rabbits were submitted to heterotopic heart transplantation in the neck. All of them received cyclosporine and a diet enriched with cholesterol. The preparation of a modified LDL lipid nanoparticle called LDE and the incorporation of methotrexate and paclitaxel to LDE were previously described. The recipient rabbits were divided in four groups of seven animals: group I, LDE-methotrexate; group II, LDE-paclitaxel; group III, both particles; group IV, control; the animals were killed after 6 weeks. Ischemic transplantation time, basal and at-the-moment-of-sacrifice lipid profile, hematologic count, weight, and ration ingestion were analyzed. Immunohistochemistry was performed for macrophage. Morphometry of coronary arteries of the native and transplanted hearts were performed including the area of internal elastic lamina, lumen area, and calculation of percentage of stenosis. Expression of genes of inflammation cellular receptors and metalloproteinase in the myocardium was determined.

Results: Weight variation, increase of cholesterol ischemic time, and ration ingestion were similar in all groups. The immunohistochemistry for macrophage showed significantly lower percentage of macrophage in the three treatment groups compared with the control group. In morphometry, there was no stenosis of coronary arteries in the native hearts. The mean stenosis of coronary arteries is higher in group IV and lowest in group II and intermediate in group I and group III. The difference is significant between group II and the control group as well as between group II and group I and group III. The analysis of genes of inflammatory response, cellular receptors, and metalloproteinase showed variable results not consistent with an influence of the treatment in decreasing inflammatory response.

Conclusions: In a model of heterotopic heart transplantation in rabbits, the treatment with group II decreases significantly GVD. The treatment with group II and treatment with the combination of groups I and II had a nonsignificant decrease of GVD. The treatment with groups III and l had no toxic effect. The treatment had a variable effect in the expression of genes of inflammatory response.

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D32 Prevention of Lower Limb Ischemia with Near-Infrared Spectroscopy Monitoring in Minithoracotomy Cardiac Surgery Under Femoral Artery Cannulation

Kazuma Okamoto, Noriyuki Hirabyashi, Mikihiko Kudo, Akihiro Yoshitake, Yuta Akamatsu, Hidetoshi Oka, Takayuki Kawashima, Mio Kasai, Akinori Hirano, Hiroto Kitahara, Shinji Kawaguchi, Ichiro Kashima, Ryo Aeba, Hideyuki Shimizu. Keio University, Tokyo, Japan.

Objective: Efficacy of near-infrared spectroscopy monitoring for the prevention of lower limb ischemia in minithoracotomy cardiac surgery under femoral artery cannulation was verified.

Methods: Near-infrared spectroscopy monitoring using INVOS Cerebral/Somatic Oximeter (Medtronic, Inc., Minneapolis, MN USA) was applied to monitor regional oxygen saturation (rSO2) of blood in the lower legs in 62 cases of minithoracotomy cardiac surgery [mitral valve repair (36), mitral valve replacement (6), atrial septal defect closure (17), and tumor (3) with/without tricuspid valve repair] with femoral artery cannulation.

Results: In 22 cases, depression of rSO2 greater than 30% from the baseline was observed. In nine cases, distal perfusion of cannulated femoral artery was added in reference to the rSO2 depression. An apparent compartment syndrome of the lower leg occurred in a case without distal perfusion despite depression of rSO2. In the comparison of the two groups (A, rSO2 depression; B, without depression), body height (1.69 vs. 1.64 m, P=0.027), total perfusion time (225.6 vs. 166.0 minutes, P=0.031), and aortic cross-clamping time (154.2 vs. 107.3 minutes, P=0.036) were significantly greater in group A (Fig. D32-1).

Conclusions: Monitoring of rSO2 and distal perfusion in a case with rSO2 depression was an efficient prevention of lower limb ischemia during minithoracotomy cardiac surgery using femoral artery cannulation.

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D33 Minimally Invasive Resection of Atrial Tumors via Mini Anterolateral Thoracotomy

Anke-Susann Sprengel, Mirko Doss, Ayse Cetinkaya, Schönburg Markus, Thomas Walther. Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Germany.

Objective: Reports of minimally invasive treatment of atrial tumors are rare. We present our single-center experience with minimally invasive resection of left and right atrial tumors.

Methods: From June 2009, minimally invasive resection of atrial tumors was performed in 34 patients (9 were male) via a right minithoracotomy. Tumor location was left atrial in 28 and right atrial in 6 patients. Surgical access was performed via left atrial approach in 18 patients, right atrial in 6 patients, and transseptal in 10 patients.

Results: There was no operative mortality. Mean age at the time of operation was 61 years (range, 40–80 years). Mean cardiopulmonary bypass time was 98±26 minutes (median, 98 minutes). Cross-clamp time was 52±16 minutes (median, 55 minutes). Five patients were operated with induced fibrillation. There were no conversions to open sternotomy. Fourteen patients required closure of an atrial septal defect (patch closure in 11). Histological examination showed typical atrial myxoma (n=31), endocardial hemangioma (n=1), papillary elastoma of the tricuspid valve (n=1), and malignant melanoma (n=1). No postoperative neurological impairment was observed in any patient. Two patients required femoral access site revision because of seroma.

Conclusions: Minimally invasive resection of left and right atrial tumors is feasible with excellent clinical outcomes. Major neurological complications are rare, and patient acceptance is high.

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D34 Prospective Analysis of 50 Oligosymptomatic Patients With Severe, Structural Mitral Regurgitation Who Underwent a Procedure of Minimally Invasive Mitral Valve Repair

Witold Gerber1, Agnieszka Drzewiecka-Gerber1, Krzysztof Sanetra1, Małgorzata Świątkiewicz1, Katarzyna Czarnecka2, Justyna Jankowska-Sanetra1, Marek Cisowski1. 1American Heart of Poland, Bielsko-Biała, Poland; and 2Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland.

Objective: The objective of this study was to determine whether patients with oligosymptomatic, structural mitral valve insufficiency may benefit from minimally invasive mitral valve repair with right thoracotomy approach.

Methods: A group of 50 patients, who underwent minimally invasive mitral valve repair with right thoracotomy approach, was included in this prospective study. The European Society of Cardiology (ESC) and the European Association of Cardio-Thoracic Surgery (EACTS) 2012 echocardiographic criteria for the definition of severe mitral valve regurgitation were met in all cases; clinically, patients were in New York Heart Association (NYHA) classes I and II. Detailed echocardiography examination was performed, and an assessment of certain clinical parameters was performed during 1- and 6-month observation.

Results: At baseline, 74% patients were in NYHA class I, and 26% patients were in NYHA class II. EuroSCORE was 3.2±2.2. The patients underwent mitral valve repair with annuloplasty ring and other interventions such as implantation of artificial chordae (76%), resection of P2 (18%), correction of clefts (8%), additional radiofrequency ablation (8%), closure of left atrial appendage (14%), and closure of patent foramen ovale (10%). Mean aortic cross-clamp time was 83±17.6 minutes, and mean extracorporeal circulation time was 120.8±25 minutes. None of patients died during the entire observation time. During the perioperative period, 12% patients had arrhythmia that resolved spontaneously or after pharmacotherapy. One patient required electrical cardioversion. Six patients had thoracentesis, and three underwent surgical thorax revision because of surgical bleeding. Mean total in-hospital stay was 7.5±1.7 days. Six-month observation complications were thoracentesis in four patients, mild cerebral infarction in one patient, reoperation because of endocarditis in one patient, and pericarditis in one patient. At six-month follow-up, nine patients maintained without pharmacotherapy; nine required only a small dose of β-blocker. Clinically, 98% of the patients were in NYHA classes I and II. Mild mitral regurgitation was observed in three patients; in two cases, total regression of regurgitant jet was observed after correction of hypertensive therapy. Details of the echocardiographic evaluation are presented in Table D34-1.

Conclusions: Minimally invasive mitral valve surgery should be considered in oligosymptomatic patients because it is a safe, highly successful method that significantly improves echocardiographic and clinical parameters in 6-month observation.

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D35 Minithoracotomy Approach for Repair of Mitral, Tricuspid Valves, Atrial Septal Defects, and Atrial Tumor Removal in Octogenarians

Jakub Piotr Staromłyński, Radosław Smoczyński, Anna Witkowska, Paweł Stachurski, Wojciech Sarnowski, Jarosław Świstowski, Dominik Drobiński, Piotr Suwalski. Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland.

Objective: Minimally invasive cardiac surgery is becoming more and more popular. Because of decreased tissue traumatization, it provides better hemostasis. Small incision and untouched shoulder girdle enable fast recovery. The minimally invasive procedure may be an excellent choice for high-risk patients. Of 235 all-comers, 20 patients 80 years and older were analyzed. All octogenarians were operated on through right minithoracotomy.

Methods: Between November 2011 and December 2015, 20 consecutive patients 80 years and older of 235 all-comers were operated on through right minithoracotomy. We performed mitral valve and tricuspid valve repair or replacement. In two cases, atrial myxomas were removed. The surgical access was made through right lateral minithoracotomy with the use of extracorporeal circulation via femoral vessels. In one case, cannulation via cervical vessels was provided. When tricuspid valve was involved additionally, the right internal jugular vein was cannulated.

Results: Preoperative comorbidities included insulin-dependent diabetes mellitus in 31.25% and chronic obstructive pulmonary disease in 32.25%; the mean left ventricular ejection fraction was 57%±13.1%. Mean EuroSCORE II was 3.32%±3.53%. Postoperatively, one patient required rethoracotomy because of bleeding (5%). During first 24 hours, we observed a mean drainage of 371.25±208.2 mL. Blood transfusion rate was low at 1.8±2.7 U. Time of total ventilation/intubation was 16.21 hours, which was driven by tricuspid patients. Early appropriate rehabilitation had been implemented during the first day in the postoperative period. No mortality was observed in 30 days. We did not observe conversion to full sternotomy, vascular complication, and wound infection.

Conclusions: Our consecutive all-comer patients showed that right minithoracotomy is a safe and feasible approach in octogenarians, referred to mitral and tricuspid surgery.

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D36 Bronchobiliary Fistula Due to Bevacizumab: A Method of Palliation

Kendal Hervert, Jacob Mahaffey, Daniel Nader, Peter Baik. Southwestern Regional Medical Center, Cancer Treatment Centers of America, Tulsa, OK USA.

Objective: Acquired bronchobiliary fistula is an uncommon but highly morbid complication of hepatocellular carcinoma treatment. We report a case of a bronchobiliary fistula in a patient being treated for hepatocellular carcinoma with bevacizumab, its sequelae, and treatment.

Methods: A 57-year-old woman initially diagnosed with stage I (cT1N0M0) hepatocellular carcinoma in 2011 underwent a right hepatic lobectomy. She was diagnosed with recurrence to the left lobe of her liver and was started on multiple cycles of chemotherapy. Bevacizumab was added in April 2013. She experienced recurrent pneumonias beginning in October 2013 and hemoptysis followed by bilioptysis in November 2013. A hydroxy iminodiacetic acid scan revealed an acquired bronchobiliary fistula (Fig. D36-1). She continued to have worsening bilioptysis, even after discontinuing bevacizumab and undergoing multiple intrahepatic drainage procedures. To treat this highly morbid complication, the patient underwent a robotically assisted resection of bronchobiliary fistula.

Results: The patient underwent right robotically assisted resection of bronchobiliary fistula along with intercostal muscle flap closure of the diaphragm tract. Bilioptysis resolved. However, she began having bilious drainage from her 24F Blake drain on postoperative day 6 and continued to have biliocutaneous fistula drainage with a drain after discharge. She continued to report no episodes of bilioptysis at 2-month follow-up.

Conclusions: The majority of bronchobiliary cases are described because of trauma, hepatic abscess, hydatid disease, liver surgery, hepatocellular malignancy, or radiofrequency ablation of hepatic mass. Patients may present with a number of conditions including bilioptysis, respiratory distress, and aspiration. In instances where bronchobiliary fistula persists after hepatic drainage procedures, surgical intervention should be considered to palliate bilioptysis. Minimally invasive technique using robotic assistance decreases the morbidity associated with thoracotomy and allows excellent palliation.

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D37 Minimally Invasive Lower Hemisternotomy for Valvular Heart Surgery After Previous Coronary Artery Bypass Grafting With Patent Internal Mammary Graft

Amit Pawale, Anelechi C. Anyanwu, David H. Adams. Mount Sinai Medical Center, New York, NY USA.

Objective: Patients needing mitral or aortic valve surgery after previous coronary artery bypass grafting with patent internal mammary artery (IMA) grafts are a technically challenging subset of reoperations because of the potential for IMA injury during reentry. In reoperative sternotomy without dissecting or clamping the IMA, right thoracotomy approach has been used to avoid IMA injury. We present our technique of lower hemisternotomy approach for such patients.

Methods: A contrast computed tomographic scan is performed as preoperative workup. Patients with an ascending aorta relatively lower in relation to the sternum and IMA graft close to the manubrium are selected for this approach. Cardiopulmonary bypass is established using right axillary artery graft, direct cannulation of right axillary vein, and percutaneous cannulation of inferior vena cava through femoral vein. Lower hemisternotomy is performed with a Stryker saw, and lower sternal table is dissected off the heart. The sternal retractor is gradually opened in stages. After the ascending aorta has been dissected, moderate systemic hypothermia is used, and the aorta is cross-clamped (Fig. D37-1D). Antegrade and then retrograde blood cardioplegia is used every 20 minutes. Internal mammary artery is not looked for in the following cases: case 1, a 73-year-old man with patent LIMA behind the manubrium (Fig. D37-1A), and case 2, a 63-year-old man with patent RIMA to the LAD, crossing the midline (Fig. D37-1B)—both underwent MV repair (Fig. D37-1E, F) with transseptal approach for severe mitral regurgitation along with tricuspid valve repair. In case 3, a 77-year-old man with patent LIMA-to-LAD graft close behind the manubrium (Fig. D37-1C) underwent AVR for severe symptomatic aortic stenosis.

Results: All three patients had uneventful recovery and were discharged home within a week.

Conclusions: Minimally invasive lower hemisternotomy is a viable approach to avoid patent IMA graft injury. This technique has potential advantages over the right thoracotomy in terms of its ability to cross-clamp the aorta safely, less potential for ventricular distension, better deairing, and avoiding thoracotomy when there is hostile pleural space. It is more likely to avoid IMA injury than full sternotomy.

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D38 Three-Port Thoracoscopic Techniques for Redo-MVR Without Thoracotomy: A Short-term Clinical Observation on Safety and Feasibility

Zengshan Ma, Sr, Hourong Sun. Shandong University, Ji’nan, China.

Objective: This study aimed to investigate the feasibility and safety of totally thoracoscopic redo-MVR through three right chest incisions without thoracotomy.

Methods: The redo-MVR through a right chest incision under totally thoracoscopy was performed in 32 patients (19 were male; mean age, 56.8±7.1 years) without thoracotomy in the observer group. An additional 36 patients undergoing conventional median thoracotomy redo-MVR were selected as a control group. All patients in the observer group had mitral valve and prosthetic valve dysfunction after MVR, repair of mitral valve and for from 2 years to 19 years. Under totally thoracoscopic, pericardial adhesions right atrial incision at the same time and atrial septal was opened in longitudinal axis of fossa ovalis, three stay sutures were placed on the incision to expose the left atrial structure and mitral valve. Cooling to ventricular fibrillation and carbon dioxide gas filling intrathoracic. The mitral valves were ablated, and a prosthesis was placed on home position. After mitral valve replacement, the atrial septal and right atrium or the incision of the interatrial groove was closed.

Results: No patient died; the operation time and cardiopulmonary bypass time were 188.5±33.6 and 68.1±16.7 minutes as well as 381.1±48.5 and 89.7±19.8 minutes between the observer group and control group, respectively. There were no mortalities. The intensive care unit stay (24.9±12.1 vs. 41.9±15.3 hours, P<0.01) and postoperative hospital stay (8.7±2.8 vs. 11.4±2.5 days, P<0.05) in the observer group were shorter than in the control group. The rate of blood transfusion during the operation in the thoracoscopic group was also lower than in the control group (21.6% vs. 100%, P=0.001). The volumes of drainage were 115±22 and 892±221 mL. Transesophageal echocardiographic analysis 6.3±3.4 months after the operation showed improved heart function and normal prosthesis.

Conclusions: Three-port thoracoscopic techniques for redo-MVR without thoracotomy are safe and effective.

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D39 New Minimally Invasive Surgical Approach for Excision of Left Atrial Myxoma

Cristiano Spadaccio, Karim Elkasrawy, Fraser Sutherland. Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom.

Objective: The current approaches for left myxoma excision, that is, interatrial groove incision (Sondergaard groove) or transseptal approach through the right atrium, present a number of shortcomings. The former requires an extensive dissection of the heart and penalizes visualization of the septum and the site of tumor attachment; the latter, commencing the incision in the inferior margin of the septum, the site of the tumor’s pedicle in the majority of the cases, carries the risk of traumatic injury and embolization of the mass and of the division of the sinus node artery with conduction disturbances. In accordance to the recent trend in revisiting the left dome approach for mitral surgery, we propose a minimally invasive strategy restricted to the left atrium (LA) for myxoma excision. The rationale underlying this approach relies in its advantage in terms of surgical exposure and limited invasiveness on cardiac structures considering the benign nature of the disease.

Methods: Three patients underwent excision of left atrial myxoma through the dome of the atrium, two of them by a mini J-sternotomy approach at the fourth intercostal space. Standard aortic and two-stage right atrial cannulation was performed. The dome of the LA was incised in the angle between the superior vena cava and the aorta, and the tumor was exposed and excised with its base en bloc from the interatrial septum (Fig. D39-1). Atriotomy was closed with a running Prolene suture.

Results: This technique provided optimal visualization of both the mass and the interatrial septum, allowing for a rapid, safe, and uncomplicated excision of the mass. After a single overnight stay in critical care, patients were discharged to the floor on the first postoperative morning with mild analgesic requirements and left the hospital on the fourth postoperative day.

Conclusions: The avoidance of wide incisions in the heart chambers and risks associated to the classical approaches combined with the clinical benefit deriving from the limited invasiveness of mini J-sternotomy might render this restricted left atrial dome approach a useful strategy in the surgical armamentarium for left-sided cardiac masses.

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D40 Partial Everting Mattress Method for Easy and Secure Placing of Annular Sutures During Minimally Invasive Aortic Valve Replacement

Toshinori Totsugawa, Taichi Sakaguchi, Arudo Hiraoka, Kentaro Tamura, Hidenori Yoshitaka. The Sakakibara Heart Institute of Okayama, Okayama, Japan.

Objective: In minimally invasive aortic valve replacement (MIAVR), it is usually hard to obtain good exposure of the annulus of the right coronary cusp (RCC) because of the leaning aortic sinus wall. Here, we present the efficacy of partial everting mattress (PEM) technique for easier approach to the RCC annulus.

Methods: From October 2012 to September 2014, a single surgeon performed MIAVR through right anterolateral minithoracotomy for 48 patients having aortic stenosis. Among these patients, 20 patients underwent MIAVR with PEM method because of poor exposure of the RCC annulus (group P). Patients’ characteristics, surgical data, and postoperative echocardiographic data were compared with those of remaining 28 patients in which prosthetic valve was placed in a supra-annular position (group S). In PEM method, noneverting mattress sutures with pledgets in the left ventricular side are placed at the annulus of the left coronary cusp and the noncoronary cusp; everting mattress sutures with pledgets in the aortic side are for the RCC annulus. Needles can be grasped in forehand at all three coronary cusps. Exposure of the RCC annulus is secured by pushing the leaning right coronary sinus away by a minimally invasive needle holder when placing the needle down into the annulus. Finally, a prosthetic valve is implanted in a supra-annular position for the left coronary cusp and noncoronary cusp and in an intra-annular position only for the RCC.

Results: Regarding patients’ demographic characteristics, the mean age of the group S was significantly higher than that of the group P (77.1±8.8 vs. 71.1±10.1, P=0.03). Regarding surgical data, there were no significant differences between the two groups in operative time (270±42 vs. 265±29 minutes, P=0.60), aortic cross-clamping time (104±19 vs. 106±13 minutes, P=0.61), and prosthetic valve size (20.3±1.8 vs. 21.1±1.7 mm, P=0.15). Postoperative echocardiographic data including mean aortic valve pressure gradient and effective orifice area index were almost the same between the two groups (12.5±3.5 vs. 12.1±2.7 mmHg, P=0.69; 0.94±0.13 vs. 0.93±0.14 cm2/m2, P=0.70, respectively).

Conclusions: Our PEM technique can lead to easy and secure placement of annular sutures under poor exposure of the RCC annulus, without adverse influences on prosthetic hemodynamic performances.

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D41 Minimally Invasive Aortic Valve Replacement via Right Minithoracotomy for Elderly Patients With Aortic Stenosis

Toshinori Totsugawa1, Masahiko Kuinose2, Taichi Sakaguchi1, Arudo Hiraoka1, Kentaro Tamura1, Hidenori Yoshitaka1. 1The Sakakibara Heart Institute of Okayama, Okayama, Japan; and 2Kawasaki Medical School, Kurashiki, Japan.

Objective: Because of the concerns about increased risk of perioperative complications, minimally invasive aortic valve replacement (MIAVR) for elderly patients with aortic stenosis (AS) remains controversial. Here, we reviewed our results of MIAVR in elderly patients with AS.

Methods: From May 2007 to July 2015, 88 patients with AS underwent MIAVR via right minithoracotomy. Seven cases in which concomitant mitral valve surgery and/or arrhythmic surgery were performed via left atriotomy were excluded. Among 81 patients, 41 patients were older than 75 years (group E). Perioperative outcomes of these patients were compared with those of the remaining 40 patients who were younger than 75 years (group Y). Contrast-enhanced computed tomographic scan is important in preoperative evaluation of MIAVR especially for elderly patients. If there are any atheromatous plaques in the aorta, we consider additional right axillary cannulation to prevent stroke.

Results: The age of group E ranged from 75 to 89 years, and the ratio of bicuspid aortic valve was significantly higher in group Y (55% vs. 12%, P<0.0001) (Table D41-1). There were no significant differences between the two groups in cardiopulmonary bypass time and aortic cross-clamping time. There were no cases of in-hospital mortality and morbidity including stroke in group E. The ratios of blood transfusion were almost the same (38% vs. 44%, P=0.56); only the length of intensive care unit stay in group E was longer than that in group Y (1.4±0.7 vs. 1.8±0.7 days, P=0.02).

Conclusions: Perioperative outcomes in group E were almost the same as those in group Y, except for intensive care unit stay. Careful preoperative evaluation and appropriate patient selection make MIAVR a safe and secure option even in elderly patients.

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D42 Sutureless Aortic Valve Implantation for Pure Severe Native Aortic Valve Regurgitation

Anthony Nguyen, Laurence Carmant, Ismail Bouhout, Denis Bouchard, Michel Carrier, Philippe Demers. Montreal Heart Institute, Montreal, Quebec, Canada.

Objective: This study focused on data collection and evaluation of sutureless Perceval implantation for pure native aortic valve regurgitation (NAVR). Data and experience with sutureless valves in the treatment of patients with pure severe NAVR are limited and usually considered as a contraindication.

Methods: From July 2011 to November 2015, we retrospectively collected data on patient characteristics, preoperative and echocardiographic parameters, and outcomes in patients undergoing sutureless valve replacement for NAVR.

Results: During this time frame, 341 patients received a Perceval valve for AVR or combined procedures at the Montreal Heart Institute. Among those, we identified seven patients who received the Perceval for NAVR (mean age, 74.8±6.5 years; 85% were male; mean EuroSCORE II, 6.8%±5.3%). All patients had greater than 2+ NAVR on echocardiography without aortic stenosis. Surgical access was right minithoracotomy (n=3), partial sternotomy (n=1), and full sternotomy (n=3). Implantation of the Perceval could be successfully performed in all patients, and one patient (14.3%) required valve redeployment for residual aortic regurgitation preoperatively. Mean cross-clamp time was 63.7±28.1 minutes, and mean cardiopulmonary bypass time was 79.3±36.3 minutes. Mean implanted prosthesis size was 26.1±1.1 mm (median, 27 mm). Concomitant procedures included two plications of the native annulus (28.6%), two coronary artery bypass grafting procedures (28.6%), three mitral valve repairs (42.8%), one septal myectomy (14.3%), and one tricuspid valvuloplasty (14.3%). No paravalvular leak occurred at discharge echography. The mean transprosthetic gradient was 15±2.6 mmHg, and the mean effective orifice area was 1.68±0.39 cm2 at discharge. Permanent pacemaker implantation was required in three patients (42.8%) for complete atrioventricular block. At 30 days, no major stroke or mortality occurred.

Conclusions: This study demonstrates the feasibility and potential procedure difficulties when using sutureless valve for severe NAVR. Acceptable results may be achieved in carefully selected high-risk patients, but the possibility of valve redeployment and the need for permanent pacemaker implantation remain a major concern.

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D43 Microvascular Clip for Mitral Valve Repair

Taishi Fujii. Nagano Red Cross Hospital, Nagano, Japan.

Objective: This study was performed to evaluate potential benefits of Micro vascular clip (BEAR Medic, Ibaraki, Japan) in minimally invasive mitral surgery.

Methods: Micro vascular clip is a small artery and vein clamp, which is globally used for hemostasis in plastic surgery. Its length is 14.5 mm and weight is 0.051 g. From February to November 2015, the Micro vascular clip was used during mitral valve repair in six patients (female, 4; male, 2). The age was 67.7±16 years and ranged from 39 to 81 years. Ejection fraction was 67.2%±12% (35%–62%). All patients had severe mitral regurgitation due to leaflet prolapse (anterior leaflet, 2; posterior leaflet, 4). All operations were performed by mini right thoracotomy and loop-in-loop technique with CV-4 (GORE Medical, Flagstaff, AZ USA). We used the Micro vascular clip to hold the artificial chordae height for regurgitation test with normal serine injection into the left ventricle and to keep a knot in position during tying the CV-4. Physio ring II (Carpentier Edwards, Irvine, CA USA) was applied for annuloplasty in all patients.

Results: No hospital death occurred. No major complication was observed, although three patients experienced paroxysmal atrial fibrillation. The number of artificial chordae was 2.0±0.9 couples, and the mean ring size was 29.3±1.6 mm. Postoperative echocardiography showed no regurgitation in three, mild in two, and moderate in one patient.

Conclusions: This initial study suggests that the Micro vascular clip is useful for the adjustment of the artificial chordae height in mitral valve repair. The clip weighs only 0.051 g and applies no impediment force on the artificial chordae during the leak test.

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D44 Minimally Invasive Reoperative Valve Surgery in a Developing Country: A New Paradigm

Tamer Ayed1, Ayman Sabry1, Sherrif Orieby1, Walid Ragab1, Wael Mobkhet1, Mark Anderson2. 1Galaa Family Hospital, Cairo, Egypt; and 2Einstein Healthcare Network, Philadelphia, PA USA.

Objective: Rheumatic heart disease remains prevalent in developing countries. Often, patients are denied reoperation because of the historically high perioperative morbidity and mortality. We initiated a minimally invasive cardiac surgical program in Cairo, Egypt, in 2012. As part of this effort, we encountered patients in need of reoperative valve surgery who were subsequently approached with a minimally invasive surgery technique. The objectives of this report were to detail the outcomes of these patients and to compare them with those having had a conventional sternotomy technique.

Methods: All patients who underwent a reoperative MIS procedure had their charts retrospectively reviewed for individual characteristics with emphasis on intraoperative details and postoperative outcomes. These patients were then compared with a similar group having had a conventional sternotomy approach.

Results: Fourteen reoperative MIS patients were identified since the program was initiated (8 were male, 6 were female; mean age, 54±9 years). The procedures included 13 reoperative MVRs and 1 MVR/AVR. One procedure was a second reoperation. All procedures were completed via a small right lateral thoracotomy with peripheral cannulation. During this same period, 15 conventional sternotomy cases were identified. The baseline demographics were similar. The cases included 6 MVRs and 9 MVR/TVRs. There were no intraoperative or postoperative (30 days) deaths in the MIS group, and there was one (6.5%) in the conventional group. There was one reoperation (6.5%) for bleeding in the conventional group and none in the MIS group. Mean computed tomographic drainage was 931±390 versus 690±280 mL in the conventional and MIS groups, respectively (P=<0.05). There were no other significant differences in terms of postoperative morbidity between the groups. Intensive care unit and total lengths of stay were less for the MIS group, having a mean of 60 hours 6 days versus 72 hours 8 days for the conventional cases, which trended toward significance.

Conclusions: Despite the increased complexity, the less invasive cases trended toward having superior outcomes. Routinely using an MIS approach should allow a greater number of challenging patients to undergo surgical intervention and represents a new paradigm for cardiac surgery in a developing country.

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D45 Left Ventricular Reconstruction in Cases of Ischemic Dilated Cardiomyopathy: Long-term (13 Years) Results

Guglielmo Stefanelli1, Fabrizio Pirro1, Paolo Giovanardi2, Alina Olaru1, Davide Trevisan1, Marco Meli1. 1Hesperia Hospital, Modena, Italy; and 2Ospedale Policlinico, Modena, Italy.

Objective: The aims of the study were to analyze the long-term results (13 years) after left ventricular restoration (SVR) in cases of dilated ischemic cardiomyopathy and to emphasize the importance of reshaping the cavity in addition to reducing the left ventricular volume.

Methods: Between March 2003 and September 2014, 60 patients affected by ischemic dilated cardiomyopathy received an SVR at our institution, along with surgical myocardial revascularization. The STICH trial criteria have been used as indication to SVR. The patients underwent SVR using a typical Dor operation or more recently adopting a different surgical technique, with the aim of reshaping the left ventricle also at the dilated equatorial level. A mean reduction of left ventricular and systolic volume of greater than 50% was achieved in all cases. Follow-up time ranged between 6 months and 13 years (mean, 8.4 years)

Results: Total early in-hospital mortality was 3.4%, (0% in the last 31 cases). Reduction of left ventricle end-diastolic diameter, improvement of ejection fraction, and New York Heart Association class after surgery and at last follow-up were statistically significant (P<0.05). Residual mitral incompetence at discharge was absent in 34 patients (59.6%) and mild in 2 (3.5%). Late mortality was 44% (25 patients), with a cardiac mortality of 20%. Freedom from rehospitalization for heart failure was 87% for the entire group of patients.

Conclusions: Patients affected by ischemic dilative cardiomyopathy, in our experience, have a satisfactory short- and intermediate-term outcome after SVR, particularly if accomplished by using a surgical protocol addressing both the volume and the shape of the left ventricle.

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D46 Short-term Outcomes After Minimally Invasive Repair of Both Atrioventricular Valves in 51 Patients

Marc Albert, Ragi Nagib, Hardy Baumbach, Ulrich F. W. Franke. Robert-Bosch-Hospital, Stuttgart, Germany.

Objective: The minimally invasive access via right-sided minithoracotomy has become the standard technique for the repair of the atrioventricular valves. However, many patients experience regurgitation of both atrioventricular valves, and because of the concomitant right-sided heart failure with subsequent secondary organ dysfunctions, the perioperative risk may be higher when reconstructing both valves simultaneously. In this study, we demonstrate the short-term outcome after combined repair of both valves.

Methods: Between November 2008 and August 2015, 46 patients underwent minimally invasive simultaneous reconstruction of both atrioventricular valves. Patients with endocarditis, redo procedures, or conversion to median sternotomy were excluded. Patient demographics and intraoperative data are shown in Table D46-1.

Results: Seven patients (15.2%) died in the perioperative course. There was no perioperative infarction requiring intervention and two postoperative strokes (4.3%). A total of six patients (13.0%) required a pacemaker implantation because of atrioventricular lock and four patients after ablation of atrial fibrillation. The length of hospital stay was 15.4±9.1 days, and the length of intensive care unit stay was 3.4±3.5 days.

Conclusions: Not surprisingly, in the early postoperative course, the simultaneous reconstruction of both atrioventricular valves has a higher risk regarding major complications and a longer intensive care unit and hospital compared with an isolated mitral valve repair reported in the literature. To limit the ischemia of the heart, more that 40% of all tricuspid repairs were performed during the reperfusion period using the beating heart technique. Further investigation about the long-term results should follow.

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D47 The Efficacy of Rigid Plate Fixation in Off-Pump Coronary Artery Bypass Grafting

Yohei Kawatani, Yoshitsugu Nakamura, Yujiro Hayashi, Tetsuyoshi Taneichi, Yujiro Ito, Hirotsugu Kurobe, Yuji Suda, Takaki Hori. Chiba-Nishi General Hospital, Matsudo-shi, Japan.

Objective: Cerclage wire fixation is a standard technique of sternal fixation after median sternotomy in cardiovascular surgery. However, the efficacy of plate fixation has been reported these days. We evaluated the early outcome of plate fixation in off-pump coronary artery bypass grafting (OPCABG), and, we compared the outcome with that of wire fixation.

Methods: A retrospective study of patients who underwent rigid sternal fixation with plate and cerclage wire fixation in OPCABG between June 2014 and March 2015 at Chiba-Nishi General Hospital was performed. Outcomes including surgical site infection, sternal instability, postoperative drain output, the day of the chest drain removal, the postoperative day, and the distance of the first walk after surgery were assessed. We performed plate fixation in patients with bilateral internal thoracic artery use, insulin-dependent diabetes mellitus, or chronic hemodialysis, and patients without history of these underwent wire fixation. The all plating system used was SternaLock Blu (Biomet, Warsaw, IN USA).

Results: Seventy-three patients (male-female ratio, 59:14; age, 67.8±11.1 years) were engaged. In 41 patients (male-female ratio, 35:6; age, 75.0±10.4 years), plate fixation was performed (P group). In 32 patients (male-female ratio, 24:8; age, 70.3±11.3 years), wire fixation was performed (W group). There was significant difference in the number of the grafts (W group, 2.6±0.7 vs. P group, 3.4±0.9; P<0.001) and intraoperative bleeding (W group, 1069±594 vs. P group, 1517±881 mL; P=0.019). Drain output in postoperative day 1 (W group, 255±240 vs. P group, 148±108 mL; P=0.013) and day 2 (W group, 127±180 vs. P group, 27.6±55.3 mL; P=0.001) as well as total drain output was significantly less in the P group. The day of walk for the first time after operation did not show significant difference (P group, 2.6±2.0 vs. W group, 2.1±1.2 postoperative day; P=0.201), but the distance of walk in the day was significantly longer in the P group (P group, 57.1±29.5 vs. W group, 42.5±30.0 m; P=0.041). The intensive care unit and hospital lengths of stay were almost the same. We observed surgical site infection in one patient in each group.

Conclusions: Plate fixation with SternaLock Blu was effective in OPCABG. The difference can be caused by the better reduction of sternum in plate fixation. It can also be a reason why fewer wires penetrate the sternum in plate fixation.

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D48 Mitral Valve Repair Through Minithoracotomy as a First Choice Approach

Kazuma Okamoto, Mikihiko Kudos, Akihiro Yoshitake, Yuta Akamatsu, Hidetoshi Oka, Takayuki Kawashima, Mio Kasai, Akinori Hirano, Hiroto Kitahara, Shinji Kawaguchi, Ichiro Kashima, Ryo Aeba, Hideyuki Shimizu. Keio University, Tokyo, Japan.

Objective: The feasibility and current setup of mitral valve repair through minithoracotomy were verified, and the suitable repair technique for thoracotomy setting was clarified.

Methods: A total of 437 cases with mitral valve insufficiency treated through minithoracotomy between 1998 and 2015 were reviewed retrospectively. Cases with mitral stenosis were excluded.

Results: Mitral repair was applied in 417 cases (95.4%). In this population, age was 51±13.6 years. Two conversions to median sternotomy occurred. The average aortic cross-clamp time, total perfusion time, and operative time were 168.5±47.2, 250.1±60.2, and 368.2±75.0 minutes, respectively. Hospital mortality was zero. Prolapse in the anterior leaflet was found in 181 cases (43.4%). Neochordae creations were used in 313 cases [average, 3.9 neochordae (1–10)]. Loop technique was used in 300 cases.

Conclusions: The surgical result of mitral valve repair through minithoracotomy was excellent. Neochordae creations with loop technique facilitated complicated repair including anterior leaflet lesion.

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D49 Aortic Valve Repair and Ascending Aortic Replacement Performed via a Ministernotomy

Oleg Orlov1, Alon Aharon1, Ioannis Paralikas1, Matthew Thomas1, Konstadinos Plestis2. 1Lankenau Medical Center, Philadelphia, PA USA; and 2Lankenau Medical Center, Wynnewood, NY USA.

Objective: This study aimed to demonstrate the feasibility of performing aortic valve repair and ascending aortic replacement via a mini upper sternotomy in a patient with an ascending aortic aneurysm, bicuspid aortic valve, and severe aortic regurgitation.

Methods: A 54-year-old woman presented with a bicuspid aortic valve (right and noncoronary cusp fusion), severe regurgitation, and a 5-cm ascending aortic aneurysm. An inverse 5-cm J-type ministernotomy was performed, extending to the right third intercostal space. The aortic arch was cannulated directly with the Seldinger technique. An endopulmonary vent was used. The right atrium was cannulated via the right common femoral vein, under transesophageal echocardiographic guidance, using the Seldinger technique. Two liters of Custodiol HTK (Essential Pharmaceuticals, LLC, Ewing, NJ USA) cardioplegia were administered in an antegrade fashion to arrest the heart. The aorta was excised 1 cm above the sinotubular junction, and the aortic root was mobilized. The conjoined cusp of the bicuspid aortic valve was prolapsing. Free edge plication was used to repair the cusp. The Schäfers caliber was used to assess residual prolapse of the leaflets after the repair. Subcommissural annuloplasty was performed to reduce the annulus to 23 mm in diameter. A 24-mm graft was anastomosed to the sinotubular junction, and the distal anastomosis between the graft and aorta was performed 1 cm proximal to the aortic clamp. The distal aorta was wrapped with the residual graft, and the patient was separated from cardiopulmonary bypass without difficulty.

Results: The patient had an uneventful hospital course and was discharged home on the sixth postoperative day. Transthoracic echocardiography revealed no aortic insufficiency.

Conclusions: This video demonstrates that aortic valve repair and concomitant ascending aortic replacement can be safely performed using a minimally invasive approach.

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D50 Minimally Invasive Reoperative Surgery Is the Preferred Approach After Previous Sternotomy

Anthony Lemaire, Madonna Lee, George Batsides, Aziz Ghaly, Leonard Y. Lee. Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ USA.

Objective: This study aimed to determine the effectiveness of minimally invasive surgery for patients with previous sternotomy. The primary end points include operative mortality and complication rate.

Methods: This is a retrospective review of prospectively collected data from a single institution from July 1, 2011, to December 31, 2013. The patients underwent aortic valve replacement, mitral valve repair or replacement, and other procedures. Charts were evaluated for demographics, operative details, and postoperative outcomes. Operative mortality was defined as death within 30 days of surgery.

Results: The average age of the patients was 71.83±14.60 years, and the majority of the patients were male (n=28). We identified 43 patients who underwent previous sternotomy for open heart surgery and now underwent a ministernotomy (n=23) or right thoracotomy (n=20) for surgery. Of the patients, 27 had an aortic valve replacement, 11 had a mitral valve procedure, and 5 had other procedures including an aneurysm repair. The mortality rate was 0% for the entire group, and there were no complications. The average length of stay was 12.41±8.93 for the entire group.

Conclusions: Repeat sternotomy has increased risk for patients undergoing adult cardiac surgery. Our study shows that patients who underwent a minimally invasive approach for open heart surgery after previous sternotomy have great outcomes with no mortality and no complications. Although the risks are enhanced, with proper preparation, patients can have successful outcomes.

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D51 IntraClude Device: Tips and Tricks in the Presence of a Particular Aortic Configuration

Monica Contino1, Massimo Giovanni Lemma1, Andrea Mangini1, Claudia Romagnoni1, Simone Colombo1, Antonietta Delle Fave1, Carlo Antona2. 1Ospedale Luigi Sacco, Milan, Italy; and 2Università degli Studi di Milano, Milan, Italy.

Objective: Minimally invasive valve surgery was first introduced into clinical practice during the mid-1990s; this technique is nowadays getting a growing diffusion especially because of the significant improvement in patients’ quality of life in the postoperative course. The more recent introduction of an intra-aortic balloon for aortic clamping is further facilitating this kind of surgery. In this case report, we explain how to manage aortic balloon positioning in the presence of a particular aortic configuration.

Methods: From August 2012 to November 2015, 33 patients (20 were male) underwent minimally invasive valve surgery with the use of IntraClude (Edwards Lifesciences, Irvine, CA USA); mean age was 58±9.2 years. Twenty-two were repair, 11 were replacement, 2 were redo surgeries. All of these patients have been selected based on the analysis of a preoperative thoracic and abdominal computed tomographic scan performed to analyze aortic course and diameters. In three cases, the radiological examination analysis detected some particular aspects: two patients had a bovine aortic arch associated to a very narrow curving at this level, whereas in the last case, the aorta showed only a very close curving at the level of the arch. All of these patients were young, with a wide aortic compliance, and we experienced some problems during balloon positioning.

Results: After starting femorofemoral extracorporeal circulation, under transesophageal control, we began the IntraClude positioning by advancing the guide, but we did not succeed in visualizing it at the level of the ascending aorta because the wire went straight into the supra-aortic vessels due to the particular aortic arch configuration. At that moment, we thought of using the kite effect: we inflated the balloon with 5 mL of saline solution, and we advanced it alone without the wire, taking advantage of the femorofemoral flow directed toward the ascending aorta; this tip worked well, and we proceeded with surgery.

Conclusions: Intra-aortic balloon for aortic clamping represents an important tool in minimally invasive valve surgery. In the presence of a particular aortic configuration, we may experience some problems, but this should not be considered a reason for exclusion because, thanks to some tricks, it is possible to easily overcome the positioning difficulty.

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D52 Minithoracotomy Approach for Repair of Mitral, Tricuspid Valves, Atrial Septal Defects, and Cardiac Tumors Removal in High-Risk Patients

Jakub Piotr Staromłyński, Radosław Smoczyński, Anna Witkowska, Wojciech Sarnowski, Jarosław Świstowski, Dominik Drobiński, Paweł Stachurski, Zygmunt Kaliciński, Piotr Suwalski. Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland.

Objective: Minimally invasive surgery is becoming more popular. Because of the proven advantages of minimally invasive procedures such as decreased tissue traumatization, better hemostasis, untouched shoulder girdle, fast recovery, most cases described in literature involve well-selected, low- and medium-risk patients. It raises the question whether minithoracotomy approach may be a choice for high-risk patients? We analyzed 64 consecutive high-risk patients of 235 all-comers who were operated on via right minithoracotomy.

Methods: Between November 2011 and December 2015, 64 high-risk patients of 235 all-comers underwent minimally invasive surgery. Three different groups of high-risk patients were selected: patients older than 80 years (20 patients), those with an ejection fraction of less than 35% (15 patients), and those with a EuroSCORE of greater than 6 (29 patients). The surgical access was via right lateral minithoracotomy with the use of cardiopulmonary bypass via femoral vessels with a jugular vein cannulation in the case of a right atrial procedure. In one case, cannulation was provided through both cervical vessels.

Results: Twenty-nine patients underwent repair of the mitral valve, and 14 underwent repair of the tricuspid valve. Because of the lack of possible repair, 16 mitral valves were replaced; isolated tricuspid plastic was made in two patients, and one tricuspid valve was replaced; and atrial myxoma was removed in four patients. We performed 16 ablation and 20 closures of left atrial appendage, 1 atrial septal defect, and 2 patent foramen ovale. Mean age was 72.12±10.62 years. Preoperative comorbidities included insulin-dependent diabetes mellitus in 29.68%, chronic obstructive pulmonary disease in 15.625%, chronic renal failure in 31.25%, and active endocarditis in 6.25%. The mean ejection fraction was 41.52%±16.91%. The mean EuroSCORE II was 7.9%±6.76 %. Postoperatively, we did not observe conversion to full sternotomy. During first 24 hours, we observed a mean drainage of 352.85±298.02 mL. In this particular group of patients, blood transfusion rate was low at 2.34±2.08 U. Thirty-day mortality was observed in two patients (3.1%). In five patients, we observed postoperative bleeding (2.12%). We did not observe any stroke or neurological incidents. Time of intubation was 8.26 hours. Early appropriate rehabilitation had been implemented.

Conclusions: Minimally invasive procedures through minithoracotomy are safe and feasible methods in high-risk patients. In the most difficult group of patients, the greatest benefits were observed in terms of early extubation and low rate of transfusion.

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D53 Minithoracotomy Approach for Repair of Mitral, Tricuspid Valves, Atrial Septal Defects, and Cardiac Tumors Removal in 235 Consecutive Patients

Jakub Piotr Staromłyński, Radosław Smoczyński, Anna Witkowska, Paweł Stachurski, Jarosław Świstowski, Zygmunt Kaliciński, Wojciech Sarnowski, Dominik Drobiński, Piotr Suwalski. Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland.

Objective: Minimally invasive cardiac surgery is becoming more and more popular because of the proven advantages of minimally invasive procedures such as decreased tissue traumatization, which provides better hemostasis and untouched shoulder girdle that enables fast recovery. We analyzed 235 consecutive all-comers who were operated on via right minithoracotomy.

Methods: Between November 2011 and December 2015, we performed right minithoracotomy in 235 consecutive patients. The surgical access was made through right lateral minithoracotomy with the use of extracorporeal circulation via femoral vessels. In one case, cannulation was provided via cervical vessels. When the tricuspid valve was involved additionally, the right internal jugular vein was cannulated.

Results: Mean±SD age was 63.9±12.8 years; 11 patients underwent previous sternotomy. Mitral valve was replaced in 21 and repaired in 72 patients. Tricuspid valve repair was performed in 11 patients. Tricuspid valve was replaced in four patients. Preoperative comorbidities included insulin-dependent diabetes mellitus in 12.7%, chronic obstructive pulmonary disease in 5.53%, chronic renal failure in 10.63%, and active endocarditis in 2.5%. The mean left ventricular ejection fraction was 54.78%±12.06%. The mean EuroSCORE II was 6.9%±7.01%. Three different groups of patients were selected according to the most common “high risk” definitions: patients older than 80 years (20 patients), patients with an ejection fraction of less than 35% (15 patients), and patients with a EuroSCORE of greater than 6 points (29 patients). Median cardiopulmonary bypass time was 166.23±71.7 minutes, and cross-clamp time was 87.06±49.5 minutes. We did not observe conversion to full median sternotomy. Reopening for bleeding was necessary in nine patients (3.8%). Acute kidney injury was reported in six patients (2.55%). Four patients had neurological complications (1.7%). The average stay in the intensive care unit was 2.41±1.61 days. During the first 24 hours, we observed a mean drainage of 395.25±332.01 mL. Blood transfusion rate was low at 1.72±2.88. Thirty-day mortality was 2.97%. Patients who underwent minimally invasive procedures did not have a deep wound infection or vascular complication.

Conclusions: Minimally invasive procedures via minithoracotomy are safe and feasible methods in consecutive all-comers. Because of decreased tissue traumatization, it provides better hemostasis. Small incision and untouched shoulder girdle enable fast recovery.

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D54 Totally Thoracoscopic Resection of Idiopathic Hypertrophic Subaortic Stenosis and Mitral Valve Plasty Through Paramammary Access

Radoslaw Smoczynski, Jakub Starolynski, Anna Witkowska, Domink Drobinski, Piotr Suwalski. Central Teaching Hospital MSW, Warsaw, Poland.

Objective: Idiopathic hypertrophic subaortic stenosis (IHSS) is type of hypertrophic obstructive cardiomyopathy that causes obstruction in the outflow track from the left ventricle (LV), and it usual coexists with systolic anterior motion (SAM) of mitral valve anterior leaflet. Both pathologies create severe obstruction and lead to LV hypertrophy, low LV diastolic volume, ventricular arrhythmias, and sudden cardiac death. Resection of hypertrophic ventricular septum and mitral valve pasty is a surgical strategy as an alternative to percutaneous alcoholic ablation. We present a totally thoracoscopic treatment of HSS and SAM as an alternative to full sternotomy or percutaneous methods.

Methods: Two male patients (56 and 73 years old) with coexisting symptomatic IHSS and SAM were qualified for a totally thoracoscopic resection of the hypertrophic ventricular septum and mitral valve plasty. Surgical access was performed through paramammary incision around the right nipple, and a small silicone retractor was used. Additional port was performed for a two-dimensional variable angle thoracoscope. Extracorporeal circulation by peripheral cannulation of femoral vessels was performed, and crystal cardioplegia for heart protection was perfused into the aortic bulb. Preoperative transthoracic and intraoperative transesophageal echocardiographies were performed. Clinical follow-up at 1 and 6 months were performed in the postoperative period, and wound satisfaction score was measured.

Results: Totally thoracoscopic resection of a hypertrophic subaortic stenosis was performed in two cases. Additional anterior leaflet of the mitral valve was reimplanted and stabilized by ring annuloplasty. Cross-clamp time was less than 120 minutes in both patients. Postoperative echocardiogram showed normal gradients in outflow track from the LV. Histopathology sample from the resected septum confirmed IHSS. In-hospital and late major adverse cardiac events did not occur in the follow-up period. Patient wound satisfaction scores were optimal.

Conclusions: Totally thoracoscopic resection of IHSS and mitral valve plasty through paramammary access is a possible surgical treatment. The use of a thoracoscope provided excellent view into the LV and helped provide a better visualization of hypertrophic obstructive area. Resection of the ventricular septum and correction of the mitral valve anterior leaflet seem to be important for the good final results of the operation. Paramammary incision around the nipple in follow-up observation provided a “scar-free” cosmetic effect and optimal wound satisfaction score.

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D55 Comparing Between Thoracoscopic Limited T2 to T3 Sympathectomy and Open T1 to T4 Sympathetic Chain Resection in the Treatment of Primary Palmar Hyperhidrosis

Reza Bagheri, Sr1, Seyed Ziaollah Haghi1, Maryam Salehi2, Rozita Moradpoor1. 1Cardio-Thoracic Surgery & Transplant Research Center, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran; and 2Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran.

Objective: Primary hyperhidrosis, which is focal oversweating in specific areas of the body including the palms, soles, armpits, face, and scalp, interferes with social activities and requires an effective and safe treatment. This study aimed to compare the therapeutic outcome of unilateral single-port sympathectomy with open surgery.

Methods: In this historical clinical trial study, patients with primary palmar hyperhidrosis were divided into two groups based on the surgical approach: open surgery and video-assisted thoracic surgery (VATS). Complete resection of T1 to T4 ganglia was performed in open surgery, and cutting and cauterization of the sympathetic chain between T2 and T3 ganglia in the dominant hand side was performed in VATS. Complications of procedure, length of hospitalization, operation time, and therapeutic results were recorded in prepared forms. Patients were followed up at 1, 3, 6, and 12 months after surgery.

Results: The mean hospitalization periods were 2.2±0.41 and 3.3±0.47 days in the VATS and open surgery groups, respectively (P=0.02). The average operation times were 39.6±1.46 and 79.8±1.53 minutes in the VATS and open surgery groups, respectively (P<0.001). Complications were as follows: delayed hemothorax (one patient, VATS), compensatory hyperhidrosis (two, open surgery), and wound infection (one patient, open surgery). The mean blood loss during surgery and time to return to work were significantly less in the VATS group (P<0.001). Oversweating was completely alleviated in the dominant hand in all patients. Alleviation was achieved in the opposite hand in 60% and 65% of the VATS and open surgery groups, respectively. (P=0.74)

Conclusions: Single-port ipsilateral to dominant hand sympathectomy between T2 and T3 ganglia is a safe, minimally invasive, and effective method in the treatment of primary palmar hyperhidrosis. Moreover, alleviation of the opposite hand’s oversweating is achieved in a large group of patients.

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D56 Totally Three-Dimensional Endoscopic Mitral Valve Repair

Hirokazu Niitsu, Takahiro Takemura, Takahito Yokoyama, Yujirou Kawai, Yasuyuki Toyota, Yasutoshi Tsuda. Saku Central Hospital, Saku, Japan.

Objective: Minimally invasive mitral valve surgery has significant advantages of minimizing surgical trauma. This procedure is a widely used technique with endoscopic assist. However, robotic assist is used for totally endoscopic procedure in many institutions. We performed a full three-dimensional (3D) endoscopic procedure through 5- to 7-cm right minithoracotomy without rib spreading and robotic assist from January 2013. We present the results of our early experience.

Methods: From January 2013 to December 2015, a total of 27 patients underwent full 3D endoscopic mitral repair for severe degenerative mitral regurgitation or functional mitral regurgitation. The procedure was performed through a 5-cm skin incision in male patients and 7- to 8-cm inframammary skin incision in female patients using a soft tissue retractor. An 11-mm endoscopic port, a 5-mm thoracic port, and a transthoracic aortic clamp were used.

Results: Pulmonary bypass time and cross-clamp time were 152±40 and 99±23 minutes, respectively. Resection techniques were performed in 10 patients, and chordal replacement was performed in 10 patients. Combined procedure for both leaflets was performed in three patients. Ring annuloplasty was combined with those procedures in all patients. Two patients underwent annuloplasty alone. Endocardial surgical Cox-Maze ablation for the left atrium using a pen-type radiofrequency device was performed in six patients with persistent atrial fibrillation. No patients required conversion to sternotomy. There was no mortality and no reexploration due to bleeding. All patients had no severe operative pain. Twenty-three patients had no or trivial mitral regurgitation, and two patients had mild regurgitation at discharge. One patient required reoperation because of the recurrence of moderate regurgitation, and one patient required reoperation because of hemolysis 2 months after the operation.

Conclusions: We performed standard mitral valve repair techniques using 3D endoscope with good visualization. This procedure is a safe and cost-effective technique compared with robotic mitral surgery.

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D57 Clinical Outcomes of Minimally Invasive Surgery for Pectus Excavatum Deformity: A Beginner-Level Center Experience

Serdar Evman, Talha Dogruyol, Levent Alpay, Hakan Kiral, Serda Kanbur, Aysun Kosif Misirlioglu, Cansel Atinkaya, Cagatay Tezel, Volkan Baysungur, Irfan Yalcinkaya. Sureyyapasa Training and Research Hospital, Istanbul, Turkey.

Objective: Pectus excavatum is the most common congenital chest wall deformity. The aim of this study was to share the initial outcomes with minimally invasive repair of pectus excavatum, which has recently been gaining popularity worldwide.

Methods: The medical files of all patients undergoing minimally invasive repair of pectus excavatum between August 2007 and December 2015 were reviewed retrospectively in terms of patient demographics and postoperative complications.

Results: A total of 65 patients (14 were female, 51 were male), with a mean age of 18.2 (range, 9–35), underwent 73 operations. Two patients required longer bar placement after 8 and 14 months, respectively. Five patients necessitated revision because of bar flipping/dislocation, and one patient underwent exploratory video thoracoscopy for bleeding, originating from an intercostal artery. Small-bore (8 Fr) pleural catheter was placed in eight patients with postoperative pneumothorax. Pneumonia and local incision dehiscence were the other morbidities seen in one patient each. Only one pneumothorax requiring drainage and one of the five malposition cases occurred during the last 3 years in 34 patients. No mortality was seen in the group.

Conclusions: Despite relatively high redo and complication rates, these trends have shown great improvement, especially in the last few years. As an apprentice clinic for this minimally invasive and cosmetic technique, we believe that the learning curve has been passed with reasonable results and will surely obtain better clinical outcomes with gained experience.

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D58 Aortic Valve Replacement With Sutureless or Rapid Deployment Valves Through Minimal or Conventional Access: Propensity Score Analysis of Early Outcomes

Marco Diena1, Philippe Caimmi2, Gheorghe Cerin3, Attilio Cotroneo2, Gabriele Musica2, Angelo Romano4, Gian Luca Martinelli2. 1Department of Cardiac Surgery, San Gaudenzio Clinic, Cardioteam Foundation, Novara, Italy; and 2Department of Cardiac Surgery, 3Department of Cardiology, San Gaudenzio Clinic, and 4Department of Cardiac Anaesthesia, San Gaudenzio Clinic.

Objective: Minimally invasive aortic valve replacement (AVR) is a safe and effective treatment option, but it has not been widely adopted until sutureless or rapid deployment valves (S/RDVs) have been recently available. We report here our experience with the Perceval sutureless valve (Sorin, Italy) and the Intuity rapid deployment valve (Edward Lifesciences, Irvine, CA USA) either in minimal or in conventional access.

Methods: Between November 2013 and November 2015, data from 112 consecutive patients with aortic stenosis undergoing isolated AVR with S/RDV [Perceval group (PG) and Intuity group (IG)] by means of J-ministernotomy or full sternotomy were prospectively recorded. Propensity-score matching was performed on 15 preoperative risk factors to correct selection bias.

Results: Clinical outcomes were not significantly affected by the surgical approaches or prosthesis except for transfusions, which were significantly lower in the ministernotomy group than in the full sternotomy group (P<0.034). The improvement of sizing between annulus (by echocardiography) and S/RDV was significantly higher in the PG than in the IG (+3.75±1.65 vs. 1.88±1.64 mm, P<0.012). After AVR, the decrease of maximal and mean gradients was similar in both prosthetic group (PG, 69.13±25.68 vs. IG, 60±24.51 mmHg, P<0.21; PG, 40.89±17.22 vs. IG, 43.12±14.023 mmHg, P<0.34).

Conclusions: As previously reported for stented bioprosthesis, the ministernotomy group showed a significant advantage for blood consumption also in AVR with S/RDV. The PG presents a greater mean sizing than did the IG despite similar hemodynamic performances, but this observation needs more detailed imaging investigations to be confirmed.

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D59 Tumor Recurrence of the Chest Wall After Percutaneous Hook Wire Localization: A Case Report (Needle Tract Implantation)

Hee Jong Baek. Korea Cancer Center Hospital, Seoul, Republic of Korea.

Objective: Increasingly, localization of small lung nodule (solid or ground glass) is needed for thoracoscopic resection of accurate diagnostic and/or curative intent. Hook wire implantation is one of the important localization techniques. Meanwhile, tumor recurrence in the chest wall of the percutaneous fine-needle aspiration (FNA) tract is well-known in thoracic malignancy, particularly lung cancer.

Methods: We report the case of a 64-year-old man with tumor recurrence of the chest wall. Eight months earlier, he underwent hook wire–guided thoracoscopic resection of an RUL nodule and further anterior segmentectomy because of an intraoperative diagnosis of NSCLC (squamous cell carcinoma, pT1aN0M0 IA). Location of the chest wall tumor was coincident with the hook wire tract. The tumor was resected en bloc and reported as a metastatic squamous cell carcinoma.

Results: If a small lung nodule (solid or ground glass) is suspected to be malignant on computed tomographic and/or positron emission tomographic scan but is neither visualized nor palpable on thoracoscopic exploration, preoperative or intraoperative localization techniques are mandatory for its detection. Hook wire implantation is one of the important localization techniques, and its procedure is similar to transthoracic FNA techniques, except for keeping the hook wire after pulling the needle back. Meanwhile, tumor recurrence in the chest wall of the percutaneous FNA tract (needle tract implantation or seeding) is well-known in thoracic malignancy, particularly lung cancer. Aspiration biopsy of the lung tumor has resulted in implantation metastasis in pleura, skeletal muscles, and subcutaneous tissue along the needle tract. This is the first report of tumor recurrence related to hook wire localization in our PubMed search.

Conclusions: To reduce the risk of tumor recurrence related to localization techniques, thoracic surgeons should have a better knowledge of the topographical anatomy of the lung. Unnecessary localization can be avoided by careful visual examination of the corresponding segment containing the ground glass density nodule as well as a digital or instrumental palpation after complete lung atelectasis, occasionally wide wedge or segmentectomy. In addition, the hook wire is recommended to be withdrawn through the VATS port rather than percutaneously.

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D60 Valve Sizing for Pure Aortic Regurgitation Underwent Transcatheter Aortic Valve Implantation: Deep Insight Into Deformation Dynamic of Aortic Annulus in Pure Aortic Regurgitation

Simeng Wang, Wei Cheng, Da Zhu, Yingqiang Guo. West China Hospital of Sichuan University, Chengdu, China.

Objective: Indication of transcatheter aortic valve implantation (TAVI) has been expended to high-risk patients with pure aortic regurgitation (AR). Understanding dynamic aspects of functional aortic valve anatomy is important for this type of beating heart procedure. Unlike aortic stenosis, the dynamic aspect of aortic annulus in pure AR may be quite different. The purpose of this study was to assess the deformation dynamics of the aortic annulus throughout the cardiac cycle for patients with pure AR.

Methods: During the study period, 15 high-risk patients (mean age, 74.2±5.2 years; 5 were female) underwent TAVI procedure in our institution because of noncalcified pure AR. All patients received dual-source three-dimensional computed tomography. The aortic annulus plane “virtual ring” was reconstructed in 10% increments over the cardiac cycle. For each phase, the minimum diameter, maximum diameter, cross-sectional area, and perimeter were measured.

Results: For patients with pure AR, the maximum diameter of the aortic annulus significantly increased in the systole phase compared with the diastolic phase (2.83±0.42 vs. 2.51±0.41 cm, P<0.05), whereas the minimum diameter remained consistent during the cardiac cycle (2.24±0.12 vs. 2.0±0.31 cm, P=0.11). However, both the cross-sectional area and the perimeter were significantly larger in the systolic phase than in the diastolic phase (4.99±0.21 vs. 4.01±0.40 cm2 and 7.99±0.79 vs. 7.41±0.60 cm, respectively; P<0.05), which was quite different from patients with aortic stenosis reported in the literature. In some cases, the functional aortic valve annulus even became irregularly shaped during the diastolic phase (Fig. D60-1).

Conclusions: In contrast to aortic stenosis, deformation dynamic of the aortic valve annulus may be totally different in patients with pure AR. Caution should be applied to annular sizing in patients with pure AR who underwent TAVI procedure.

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D61 Isolated Minimally Invasive Valve Surgery Outcomes Comparable With Standard Approach

Masood A. Shariff, Rawan Sharma, Juan A. Abreu, Peter Andrawes, Miriam Sedrak, Mohammed Mustafa, John P. Nabagiez, Joseph T. McGinn, Jr. Staten Island University Hospital, Northwell Health, Staten Island, NY USA.

Objective: Minimally invasive surgery is a sought-out approach for isolated valve procedure. In light of the evidence that minimally invasive approach adds operating room time compared with sternotomy, the overall outcomes are comparable between approaches. This study assessed comparative outcomes between minimally invasive versus traditional sternotomy valve surgery.

Methods: From January 2005 to November 2012, 402 patients underwent isolated valve surgery at our institution (sternotomy, n=164; minimally invasive, n=238), mitral or aortic. Clinical outcomes included bypass and cross-clamp times, length of hospitalization, morbidity, and mortality.

Results: Of the 402 patients, 164 underwent the minimally invasive approach (aortic valve replacement, 144; mitral valve repair or replacement, 95), and 164 had a sternotomy (aortic valve replacement, 105; mitral valve repair or replacement, 59). The mean age was 67.6±12.8 years for the minimally invasive group and 66.3±11.9 years for the sternotomy group (P=0.298). The minimally invasive approach was associated with a 2.2-minute longer cross-clamp time (89.2±26.3 vs. 87.0±30.3, P=0.433) and also a 2.2-minute longer bypass time (121.0±33.8 vs. 118.7±40.4, P=0.547). Surgical time was not significant but comparable (minimally invasive, 246±55 minutes vs. sternotomy, 253±82 minutes, P=0.321). Access to cardiopulmonary bypass was mainly femoral artery and vein cannulation in minimally invasive procedures compared with aorta and atrium in sternotomy. Intraoperative blood product used was significantly less in minimally invasive compared with sternotomy (38% vs. 52%, P=0.004). There were no significant differences in the rate of major postoperative complications, except that atrial fibrillation was higher in the minimally invasive group (33% vs. 24%, P=0.045). Minimally invasive surgery was associated with a relatively shorter hospitalization (6.4±3.5 vs. 6.9±4.5, P=0.144).

Conclusions: Minimally invasive valve surgery was comparable with sternotomy approach, with advantages of having reduced intraoperative need for blood products and shorter hospitalization. The comparable bypass time and surgical time without overt complications with either approach allow for the integration of technique into an established institution with trained surgeons.

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D62 Incidence and Risk Factor of Vascular Complication in Transcatheter Aortic Valve Replacement via a Transfemoral Approach

Takayuki Kawashima, Sr1, Akihiro Yoshitake1, Kazuma Okamoto1, Shiji Kawaguchi1, Akinori Hirano1, Mio Kasai1, Yuta Akamatsu1, Hidetoshi Oka1, Kentaro Hayashida1, Shinji Miyamoto2, Keiichi Fukuda1, Hideyuki Shimizu1. 1Keio University Hospital, Tokyo, Japan; and 2Oita University Hospital, Oita, Japan.

Objective: In transcatheter aortic valve replacement (TAVR) via a transfemoral approach, vascular complications have been associated with increased morbidity and mortality. This study sought to evaluate the incidence and risk factors of vascular complications in TAVR.

Methods: We performed a retrospective review of 120 patients who received transfemoral TAVR between October 2013 and July 2015 at our institution. The predictor for vascular complication, including risk factors for arteriosclerosis (age, smoking history, diabetes, and dyslipidemia), ankle-brachial index, the minimal iliofemoral artery luminal diameter (MLD), sheath and valve size, as well as procedure (puncture or cut down), were analyzed.

Results: Vascular complications occurred in 16 (13%) of 120 patients. Vascular complication included type A aortic dissection in 2 patients, iliofemoral artery dissection or perforation in 11 patients, and bleeding of the puncture site in 3 patients. On univariate analysis, there was no predictor associated with all vascular complication, whereas only MLD was associated with iliofemoral artery dissection or perforation (P=0.022). By receiver operating characteristic (ROC) analysis, an MLD cutoff value of 6.05 mm had 76.1% sensitivity and 81.8% specificity in iliofemoral artery dissection or perforation (area under the curve, 0.77). An MLD of 6.0 mm or less was thought to be a strong predictor for iliofemoral artery injury (odds ratio, 14.37; 95% confidence interval, 3.34–61.87; P<0.0001) on univariate analysis.

Conclusions: The incidence of vascular complication was 13% in transfemoral TAVR. In small iliofemoral case, particularly an MLD of 6.0 mm or less, transfemoral approach should be avoided.

©2016 by the International Society for Minimally Invasive Cardiothoracic Surgery