Conclusions: Our study shows that there is no difference in pain scores after lobectomy via VATS versus NVBST. However, LOS is shorter for VATS. The establishment of VATS as a standard technique for lung resection has catalyzed the parallel evolution of improved thoracotomy techniques. Continued development of both techniques as part of enhanced recovery programs will ensure better outcomes for all patients undergoing lung cancer resection.
P65 Patient-Controlled Epidural Analgesia Provides Better Analgesia Than Intravenous Patient-Controlled Analgesia for Patients After Thoracotomy
Sanjay Kumar, Tarun K. Lahiri. Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
Objective: Intravenous patient-controlled analgesia (IVPCA) and patient-controlled epidural analgesia (PCEA) were studied in terms of analgesic efficacy, respiratory function, and adverse effects after thoracic surgery for 24 hours. Patient-controlled epidural analgesia using fentanyl and bupivacaine as compared with IVPCA using morphine provides better pain relief both at rest and during coughing and is associated with fewer adverse effects. This study compares IVPCA and PCEA in terms of analgesic efficacy, respiratory function, and adverse effects after thoracic surgery.
Methods: Thirty ASA I or II patients undergoing thoracotomy were assigned randomly to receive either IVPCA using morphine or PCEA using fentanyl and bupivacaine combination postoperatively. No background infusion was administered in either group. Postoperative evaluation included pain intensity both at rest and during coughing, degree of sedation, arterial blood gas, forced vital capacity, peak expiratory flow rate, presence of adverse effects (such as nausea/vomiting), and pruritus at 0, 2, 8, 12, and 24 hours. The primary outcome of the study was the percentage of patients with analgesia failure defined as a VAS score greater than 30 despite three consecutive PCA boluses requiring rescue analgesia with intravenous fentanyl. The data were analyzed using t test, χ2 test, and Mann-Whitney U test.
Results: Significantly fewer patients required rescue analgesia in the PCEA group (P<0.05). Pain relief was better both at rest and during coughing (P<0.05) in the PCEA group as compared with those in the IVPCA group. Patients in the PCEA group were less sedated and had fewer incidences of adverse effects, that is, nausea/vomiting and pruritus. Postoperative forced vital capacity and peak expiratory flow rate were reduced significantly compared with baseline only in the IVPCA group (P<0.05).
Conclusions: After thoracotomy, PCEA using fentanyl and bupivacaine as compared with IVPCA using morphine provides better pain relief both at rest and during coughing and associated with fewer adverse effects.
P66 The Role of Single-Photon Emission Computed Tomography–Computed Tomography to Predict Postoperative Pulmonary Function in Patients With Marginal Pulmonary Function
Samina Park, Gi Jeong Cheon, Yoohwa Hwang, Hyun Joo Lee, In Kyu Park, Chang Hyun Kang, Young Tae Kim. Seoul National University Hospital, Seoul, Republic of Korea.
Objective: In the current era of minimally invasive thoracic surgery, an accurate estimation of postoperative pulmonary function in a patient with marginal pulmonary reservoir is important because it can guide in the determination of the optimal extent of safe surgical resection at the segmental level. Integrated single-photon emission computed tomography–computed tomography (SPECT/CT) provides patient-specific three-dimensional images, which can overcome the limitations of planar images related to overlaps of anatomic segments and variability of lobar shape, which can vary according to patient’s underlying pulmonary conditions. We compared SPECT/CT with planar perfusion scintigraphy (PPS) in terms of predicting postoperative pulmonary function.
Methods: From March to October 2015, we selected 12 patients whose predicted forced expiratory volume in 1 second (FEV1) or diffusing capacity of the lung for carbon monoxide were less than 80% of normal. Single-photon emission computed tomography–computed tomography was performed using Technetium-99m–labeled macroaggregate of albumin, and PPS was conducted at the same time. We compared the predicted postoperative (ppo) values calculated from PPS and SPECT/CT and analyzed the differences of the two methods according to the underlying lung disease.
Results: The median age was 65 years (range, 53–82 years). Underlying lung diseases varied; bronchiectasis, obstructive lung disease, emphysematous lung, interstitial lung disease, and chronic empyema. The median preoperative predicted FEV1 and diffusing capacity of the lung for carbon monoxide were 76.5% (range, 28%–111%) and 65% (range, 31%–118%), respectively. The median estimated ppoFEV1 using PPS and SPEC/CT were 59.2% (28.0%–101.8%) and 60.2% (26.4%–101.2%), respectively. We found significant correlation between the two methods evaluating lobar perfusion (right upper lobe, r=0.663; right lower lobe, r=0.883; left upper lobe, r=0.734; left lower lobe, r=0.706) except for right middle lobe (P=0.339, r=0.303). We found that if the patient had localized destructive lesions (patients 1, 2, 3, and 8), the ppoFEV1 estimated by SPECT/CT and that measured by PPS were different by more than 5% points. On the other hand, if the patients had either diffuse parenchymal abnormality or obstructive lung disease without definite parenchymal lesions, the ppoFEV1 estimated both methods showed similar values (Table P66-1).
Conclusions: Single-photon emission computed tomography–computed tomography seems to be useful in estimating postoperative pulmonary function if patients have localized parenchymal destructive lesion. In patients with either diffuse parenchymal disease or normal lung, PPS can provide comparable postoperative lung function with SPECT/CT. In addition, SPECT/CT may guide surgeons to decide the extent of segmentectomy as it can visually display the amount of perfusion.
P67 Minimally-Invasive Sublobar Resection of Tiny Pulmonary Nodules With Real-Time Image Guidance in the Hybrid Theater
Sze Yuen Peter Yu, Wing Hung Rainbow Lau, Freddie G. Capili, Yuk Pui Innes Wan, Malcolm John Underwood, Cheuk Man Chu, Chun Ho Simon Yu, Sze Hang Calvin Ng. The Chinese University of Hong Kong, Hong Kong, China.
Objective: Localization of tiny lung nodules during video-assisted thoracic surgery (VATS) sublobar resection can be challenging. Real-time image-guided hook wire localization of target lesions immediately preceding lung resection in the hybrid operating theater setting is an emerging approach.
Methods: We retrospectively reviewed our experience with the real-time image guidance of hook wire insertion for lung nodules 1.5 cm or less using cone beam computer tomographic scan, followed immediately by VATS sublobar resection in the same operating suite and session.
Results: From February 2014 to October 2015, tiny lung nodules of indeterminate nature in 19 consecutive patients with mean nodule size 7.7±3.4 mm (range, 2–15 mm) underwent the procedure. All were localized accurately by hook wire and successfully resected. Five patients (26.3%) developed pneumothorax after hook wire insertion, but none required intervention. The mean operative time was 128.5±60.6 minutes, and the mean blood loss was 25.5±15.0 mL. The mean chest drain duration was 2.6±0.9 days, and the mean postoperative length of stay was 3.6±1.7 days. There were no postoperative complications or mortality. There were 14 malignant (73.7%) and 5 benign lesions, all with adequate resection margins.
Conclusions: Real-time image-guided hook wire localization in the hybrid theater setting is a safe and effective technique for VATS resection of tiny lung nodules. Its potential advantages over the traditional approach warrant further studies.
P68 Minimally Invasive Treatment of Metastatic Pleuritis
Severgin Vladislav. Odessa National Medical University, Odessa, Ukraine.
Objective: Metastatic pleuritis is one of the most frequent complications of malignancy. The course of the disease in more than half of the patients with disseminated forms of cancer is complicated with the development of metastatic pleuritis. One of the key moments in the treatment of metastatic pleuritis is the formation of pleurodesis. The most effective of the known methods is chemical pleurodesis with talc (90%). Suggested method allows us not only to create a pleurodesis but also to maximize the chance in the removal of metastases of the parietal pleura. The aim of the study was to assess the results of thoracoscopic treatment of metastatic lesions of the pleura.
Methods: This method is used by us in the treatment of 34 patients with metastatic pleuritis. Primarily, these patients had lung cancer (24 patients), breast cancer (8 patients), and ovarian cancer (2 patients). To create pleurodesis and destruction of metastases, we used a radiofrequency ablation device Fotek-150 with monopolar electrode. Under control of the thoracoscopy, the electrode was introduced through the thoracoport metastasis on the parietal pleura. Then, the current of high frequency was supplied with power of 60 W at an exposure time of 1 minute. Within a radius of 3 cm around the electrode, the coagulation zone with the destruction of metastatic node was formed. Operation was finished with pleural cavity drainage followed by 30 mg of bleomycin introduced into the pleural cavity.
Results: Recurrence of metastatic pleuritis appeared in three patients after 1 and 2 months after surgical intervention. In 91.2% of the patients, effective pleurodesis with the decrease in pleural exudation during 5 months was achieved.
Conclusions: (1) The use of radiofrequency ablation combined with the use of bleomycin not only allows to achieve stable pleurodesis but also liquidates metastasis on the parietal pleura. (2) This method requires additional clinical research.
P69 Use of Hybrid Techniques to Improve the Learning Curve for Video-Assisted Thoracoscopic Surgery
Narendra Agarwal, Shaiwal Khandelwal, Kamran Ali, Mohd Fauzi, Ali Zamir Khan, Ali Zamir Khan. Medanta the Medicity, Gurgaon, India.
Objective: Video-assisted thoracoscopic surgery (VATS) has been gaining importance as the criterion standard technique for various thoracic resections. This article presents the use of videoscope along with minithoracotomy to perform technically difficult VATS and improve the learning curve for performing VATS.
Methods: A series of 1043 VATS procedures were performed between 2011 and 2015. Of which, 103 cases were performed as a hybrid technique where minithoracotomy was made along with video-telescope at the thoracoscopic port. The advantages of this dual access were ease in instrumentation, visualization, lighting, retraction, and hand-eye coordination. In addition, this technique allows immediate access under direct vision for urgent control of bleeding, which can be difficult using a conventional thoracoscopic approach.
Results: Of 103 cases, 74 were males and 29 were females, with a mean age of 54 years (range, 22–82 years). The cases included anatomical anomaly, severe dense adhesions, identifications of very small/deep seated malignant lesions for biopsy, lobectomy, decortication, pneumonectomy, sleeve resections for carcinoid, and bronchoplasty. The mean operative time was 92 minutes. There were no conversions to conventional thoracotomy. Mean hospital stay was 3 to 4 days. Chest tube duration was 2 to 3 days. There was no mortality. The results were favorable compared with conventional VATS procedures and showed a feasibility of the hybrid technique.
Conclusions: The results suggest that every open thoracic surgery should have a thoracoscopic port for better visualization of anatomy, technique, and hand-eye coordination, which will further enhance the learning curve for VATS.
P70 A Uniportal Thoracoscopic Major Pulmonary Resection
Mitsuhiro Kamiyoshihara, Takashi Ibe, Natsuko Kawatani, Hitoshi Igai. Maebashi Red Cross Hospital, Maebashi, Japan.
Objective: The preferred thoracoscopic approach to lung resection varies among surgeons. Typically, three or four incisions are required. We have a fundamental commitment to a “reduced-port surgery,” and our approach has evolved from a three-incision method to use of a single incision 3 to 3.5 cm in length. Herein, we report our early experience (2 years) with uniportal thoracoscopic major pulmonary resections.
Methods: We analyzed the outcomes of successful uniportal thoracoscopic lobectomies and anatomical segmentectomies with special reference to the methodologies used and whether conventional instruments were used. However, we prefer the following techniques: the shaft-on-shaft approach, pulley method, one-hand encircling, one-hand exposure, extra vessel exposure, and “move-the-ground.”
Results: Of 14 attempted uniportal approaches to major lung resections (primary lung cancer in 11 patients and metastatic cancer in 3), 11 were successfully completed (in three patients, the operations were converted to three-port approaches). The procedures included eight lobectomies (right lower in five cases, left lower in one, right upper in one, and right middle in one) and three segmentectomies (one each in the right S6 region, the left basal, and the left lingular). The median surgical time was 180 minutes; the median duration of chest tube residence was 2 days; and the median hospital stay was 4 days. No major complication developed, and no hospital death was recorded.
Conclusions: Uniportal thoracoscopic anatomical resection is feasible, is safe, and affords good perioperative results. However, the selection criteria for the approach will limit the use thereof.
P71 Treatment Outcomes of Anatomical Lung Resection in Single-Port Video-Assisted Thoracoscopic Surgery for Stage I Lung Cancer
Kyoji Hirai. Nippon Medical School Chiba Hokusou Hospital, Chiba, Japan.
Objective: We have already reported the beneficial effects of single-port video-assisted thoracoscopic surgery (SPVATS) for patients with stage I lung cancer (Eur J Cardiothorac Surg 2016;49:i37–i41). So far today, the anatomical lung resection in SPVATS has been performed in 84 patients. We examine the effectiveness of SPVATS and elucidate on its technical knack.
Methods: In the SPVATS, an approximately 4-cm small incision was placed at the fourth or fifth intercostal space from the anterior to posterior axillary line.
Results: A total of 84 patients underwent anatomical lung resections, of whom 80 underwent lobectomy while 4 underwent segmentectomy. The ratio of sex (male to female) was 51:33, and the median age was 68.5±9.5 years. The mean forced expiratory volume in 1 second and maximum size of tumor were 1.85±0.31 L and 2.8±0.3 cm, respectively. The median operation time and blood loss were 175±35 minutes and 85±25 mL, respectively. The median drainage duration and postoperative hospital stay were 1.6±0.7 and 7.5±1.9 days, respectively, and the mean number of dissected lymph nodes was 14.8±3.5. The mean maximum of CPK showed 360±29 IU/mL. The mean of NRS on postoperative day 7 and 30 was 2.7±0.4 and 1.6±0.5, respectively. The number of days when analgesic agents were used within a month after surgery was 8.3±1.2. Two patients (2.4%) were required conversion to open thoracotomy.
Conclusions: Anatomical lung resection in SPVATS should be considered as a treatment option for stage I lung cancer. The knack of SPVATS is presented as follows. (1) To perform a safer operation, the operator should manipulate the forceps to raise the vascular sheath above the scissors, avoiding touching the tips. This creates a more three-dimensional view, prevents chances of damage, and provides an easier line of sight. (2) Dissecting the vessels and bronchus to the peripheral side is needed more than usual. (3) There is a need to master the ligation treatment including transfixing suture to the vessels via the single access at the fourth or fifth intercostal space. In SPVATS, the handling of forceps and scissors and the acquirement of the vessel ligation technique are difficult for the surgeon at first; however, I believe that practiced surgeons can master this operative procedure.
P72 Single-Port Video-Assisted Thoracoscopic Surgery for Primary Lung Cancer: A Single-Center Experience
Do Kyun Kang, InHa Kim, Woon Heo, Sung Kwang Lee, Ho-Ki Min, Hee Jae Jun, Youn-ho Hwang. Haeundae Paik Hospital, Busan, Republic of Korea.
Objective: As the technique of video-assisted thoracoscopic surgery (VATS) evolved, single-port VATS lobectomy became possible, and its advantages have been reported. We analyzed our experiences to evaluate the feasibility of single-port VATS lobectomy for primary lung cancer.
Methods: Single-port VATS lobectomy for primary lung cancer was attempted in 40 patients in Haeundae Paik Hospital from June 2012 to November 2015. In seven patients, the surgery was converted to open thoracotomy or three-port VATS lobectomy. Single-port VATS lobectomy was performed in 33 patients as planned. All patients underwent a lobectomy and systematic lymph node dissection using 5-mm 30-degree thoracoscope through 4- to 5-cm single incision. R0 resection was performed in all patients. We reviewed the medical records of these patients retrospectively.
Results: There were 23 male and 10 female patients. Left upper lobectomy was the most frequent resection (11 patients). There was severe pleural adhesion in 10 patients. Twenty-two patients (66.7%) had an incomplete fissure. The mean number of the dissected lymph node was 29.3±13.3 (range, 10–63). The mean number of the explored nodal stations was 6.4±1.3 (range, 4–9). The mean size of tumor was 2.7±1.2 cm (range, 1.3–6.0). The mean operation time was 224.7±81.5 minutes (range, 100–495), and it was getting shorter gradually as our experience with the procedure grew. The operation time of the patients with complete fissure was shorter than that of the patients with incomplete fissure (P=0.003). However, pleural adhesion and tumor size was not associated with the operation time. The mean duration of the chest tube drainage was 6.5±3.9 days (range, 2–22). The mean duration of the hospital stay was 11.0±5.8 days (range, 6–34). There was no surgical mortality. There was a postoperative chylothorax in one patient.
Conclusions: In our experience, single-port VATS lobectomy for primary lung cancer was safe and feasible. To evaluate the feasibility of single-port VATS for primary lung cancer, more experiences and long-term follow-up would be required in well-selected patients.
P73 A Simplified Minimally Invasive Technique Operation for Mitral Valve Repair: Better With Less Risk
Marco Diena1, Gheorghe Cerin2, Philippe Caimmi3, Gabriele Musica3, Angelo Romano4, Edmond Stelian4, Eugenio Novelli5, Gian Luca Martinelli3, Ugo Tesler6. 1Cardioteam Foundation, Torino, Italy; 2Department of Cardiology; 3Department of Cardiac Surgery; 4Department of Cardiac Anaesthesia; 5Department of Statistics; and 6Department of Cardiac Surgery, San Guadenzio Clinic, Novara, Italy.
Objective: Mitral valve repair (MVR) has been proven to be the best treatment of mitral regurgitation in degenerative disease. Repair rate is high in dedicated centers through sternotomy. Right minithoracotomy is an appealing approach because of its minimal surgical trauma but entails greater technical difficulties. A simplified minimally invasive technique (SMIT) allows an easier approach with a smooth learning curve. Here, we analyze our experience with SMIT operation for elective MVR.
Methods: From January 2009 to January 2015 we operated on 262 patients (mean age, 55.7±12 years) for degenerative prolapse or flail with the SMIT procedure as follows: (1) chest opening in the third intercostal space, (2) insertion of a percutaneous venous cannula in the femoral vein, (3) direct cannulation of the ascending aorta, (4) a flexible aortic cross-clamp applied through the skin incision, and (5) antegrade cardioplegic arrest with crystalloid solution.
Results: There were no technical complications related to the perfusion technique and/or surgical access. Repair rate was 99.6% (261 patients); a second pump run was necessary in 2.67% of the patients (7 patients). Hospital mortality rate was 0.38% (one patient) but not related to the operative technique. We had three conversions to sternotomy (1.1%). No patient had a low output syndrome or a poor myocardial protection or wound infections. Mean follow-up was 3.6±1.6 years (range, 1.2–6.9). Actuarial freedom from reoperation at 6 years was 100%; actuarial freedom from greater than 2+ mitral regurgitation recurrence at 6 years was 96.8%; actuarial freedom from valve endocarditis was 100%; actuarial freedom from atrial fibrillation at 6 years was 82.1%; and global survival at 6 years was 97.9%. New York Heart Association class of 2 or lower at 6 years is present in 92.4% of the patients. Overall freedom from event was 77.7% at 6 years (95% confidence interval, 5.4–6.5).
Conclusions: The MVR with SMIT operation provides a less invasive and easier approach with a very high repair rate. We recommend the SMIT operation for every new program for minimally invasive MVR.
P74 Incremental Improvements in a Minimally Invasive Mitral Repair Program
Sion G. Jones, Kenneth Palmer, Omar Al-Rawi, Paul Modi. Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
Objective: The learning curve for minimally invasive mitral valve surgery is long. As our program continues to grow, we examine whether there are incremental improvements in patient outcomes.
Methods: We retrospectively examined a prospectively collected database of all patients in our minimally invasive mitral valve program. Patients were divided into tertiles according to the date of their procedure, and comparison was made between the first and third tertiles. Procedures were performed between March 2011 and November 2015.
Results: A total of 140 minimally invasive procedures were performed in total, of which 114 were minimally invasive mitral valve repairs with or without concomitant procedures. There were no differences between the two groups in terms of baseline characteristics: age (60.2 vs. 59.0 years, P=0.69); female sex (34% vs. 34%, P=1.0), baseline New York Heart Association class 3/4 (26% vs. 26%, P=1.0), body mass index (25.9 vs. 25.4, P=0.58), and left ventricular ejection fraction of less than 30% (0% vs. 2.6%, P=0.3141). There were no deaths or cerebrovascular complications in either group. Ten patients in the most recent tertile had concomitant procedures (one tricuspid annuloplasty, six cryoablations, three PFO closures, one myxoma excision), compared with four (one tricuspid repair, three cryoablations) in the earliest tertile (P=0.076). There was a reduction in cardiopulmonary bypass (210.7±33.2 vs. 171.4±32.9 minutes, P<0.0001) and aortic cross-clamp time (141.4±29.0 vs. 118.3±26.7 minutes, P=0.001) during this study. Postoperative bleeding was significantly less in the latter group (414±213 vs. 673±422 mL, P=0.002). Hospital stay (6.4±3.3 vs. 6.4±3.3 days, P=0.94) and intensive care unit stay (2.1±1.5 vs. 2.6±1.8 days, P=0.39) did not differ between groups.
Conclusions: Minimally invasive mitral valve repair is safe. We have seen a reduction in the cross-clamp and cardiopulmonary bypass times despite an increase in the number of concomitant procedures performed. The amount of postoperative blood loss has also decreased. Despite these changes, we are yet to see a reduction in the intensive care stay or the postoperative length of stay.
P75 Robotic Mitral Valve Repair: Midterm Follow-up Results
Changqing Gao, Huajun Zhang, Ming Yang, Cangsong Xiao, Yao Wang, Gang Wang. PLA General Hospital, Beijing, China.
Objective: This study aimed to summarize our surgical experience with robotic mitral valve repair and demonstrate the follow-up results out to 7 years.
Methods: From 2007 to 2014, 110 consecutive patients underwent robotic mitral valve repair with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA USA) in our center. The patients’ average age was 45±13 years (14–70 years), with a male-to-female ratio of 2.3:1. Mitral regurgitation (95.5%) or stenosis (4.5%) was diagnosed. The triangular or quadrangular resection was the most performed type of repair (63.3%). Nitinol U-clips (58.1%), running suture (31.1%), and COR-KNOT suture device (LSI Solutions, Victor, NY USA) (10.8%) were used to secure the annuloplasty ring. The operative data were collected, and patients were echocardiographically followed up regularly up to 7 years.
Results: All cases were performed by the same surgeon. One case of conversion to sternotomy was noted. The mean cardiopulmonary bypass time was 121±34.3 minutes (range, 70–152 minutes), and the mean cross-clamp time was 82.6±25.3 minutes (range, 47–122). After surgery, one death (0.91%) happened and two cases of transient neurocognitive defect (1.82%) occurred. Three cases of early prosthetic failure (2.73%) were noticed. All patients were successfully followed for a median of 4.1 years (range, 1 month to 7 years), and 94.5% had freedom from reoperation.
Conclusions: Robotic mitral valve repair is a safe and effective procedure with excellent intermediate-term outcomes.
P76 Minimally Invasive Mitral Surgery Versus Sternotomy Approach: A Meta-analysis of “Statistically Sound” Studies
Massimo Meco, Enrico Giustiniano, Paolo Panisi, Silvia Cirri, Antonio Miceli, Mattia Glauber. Icsa Milan, Milan, Italy.
Objective: The purpose of this study was to evaluate the postoperative, midterm, and long-term results of minimally invasive mitral surgery (MIMS) versus classical sternotomy approach (SMS).
Methods: To minimize possible bias, we decided to use for our meta-analysis only “statistically sound” studies in practice studies that had used at least one patient-matching technique. Potentially eligible trials were identified by searching the MEDLINE, EMBASE, Scopus, ISI Web of Knowledge, and The Cochrane Library. Searches were not restricted by language or publication status and were updated in October 2015. Statistically sound studies comparing MIMS and SMS were identified. The primary end points were postoperative mortality, postoperative renal failure, postoperative pulmonary failure, postoperative neurological complications, as well as cardiopulmonary bypass and cross-clamping times; secondary end points were midterm and long-term survival. Dichotomous data were summarized using risk ratio with a 95% confidence interval (CI). Heterogeneity was quantified with the I2 statistic. Publication bias was assessed using a funnel plot and Begg asymmetry test.
Results: Six trials met the inclusion criteria. A total of 4272 patients (2136 in MIMS group and 2136 in SMS group) were enrolled in this meta-analysis. We found no difference in 30-day mortality [1.07% vs. 1.07%; odds ratio (OR), 1.04; 95% CI, 0.56–1.91; P=0.91], in postoperative renal failure (1.63% vs. 1.96%; OR, 0.83; 95% CI, 0.52–1.31; P=0.42), in postoperative pulmonary complications (4.23% vs. 4.28%; OR, 1.02; 95% CI, 0.62–1.66; P=0.95), and in postoperative cerebrovascular complications (1.02% vs. 1.35%; OR, 0.78; 95% CI, 0.44–1.37; P=0.39). Both cardiopulmonary bypass and aortic cross-clamp times were longer in the MIMS group [MD, 30.13 (17.90–42.36), P<0.001; MD, 14.25 (6.14–22.37), P<0.001). Follow-up data were similar between the two groups (1-year survival: 96.3%±1.24% vs. 95.6%±1.24%; OR, 0.99; P=0.83; 3-year survival: 95.3%±0.62% vs. 94.3%±1.24%; OR, 1.23; P=0.42; 5-year survival: 93.6%±2.05% vs. 91%±1.41%; OR, 0.76; P=0.41; 7-year survival: 81.5%±4.5% vs. 81%±3%; OR, 1.07; P=0.85).
Conclusions: Minimally invasive mitral valve surgery is safe. In addition, midterm and long-term results are similar between minimally invasive and sternotomy approaches.
P77 Endoscopic Mitral Valve Surgery Following Basic Setting of Video-Assisted Thoracic Surgery
Toshiaki Ito, Masayoshi Tokoro, Jyunji Yanagisawa, Atsuo Maekawa. Japanese Red Cross Nagoya First Hospital, Nagoya, Japan.
Objective: Endoscopic surgery is a common technique in other surgical fields, but endoscopic cardiac surgery is not yet popular. We applied standard techniques of video-assisted thoracic surgery to mitral valve surgery and evaluated its feasibility and safety.
Methods: Femorofemoral cardiopulmonary bypass was established. Right fourth intercostal thoracotomy was made through a 3- to 6-cm of skin incision. An additional 5.5-mm trocar was inserted through the third intercostal space, for insertion of the forceps controlled by the surgeon’s left hand. Another trocar was inserted through sixth intercostal space for the endoscope. Rib spreader was not used. The endoscope was manually controlled by an assistant. From October 2010 to November 2015, 231 patients underwent endoscopic minimally invasive cardiac surgery for the mitral valve. Exclusion criteria were advanced peripheral vascular disease and calcification of the ascending aorta. Fifty patients were excluded from endoscopic minimally invasive cardiac surgery during that period. Average age was 63.3 years (range 22–88). A total of 104 were male. Etiologies were fibroelastic deficiency in 142, Barlow disease in 13, endocarditis in 14, rheumatic in 24, consolidating degeneration in 7, annular dilatation in 15, and others. Sixteen were redo cases. Regarding concomitant surgeries, 37 Maze procedures, 46 tricuspid annuloplasties, and 8 aortic valve replacements were performed. For the concomitant aortic valve replacement, a rib spreader was applied. Early results were evaluated.
Results: No in-hospital death occurred. Regarding complications, stroke occurred in two, reexploration for bleeding in three, superficial wound infection in one, and renal failure in one. Eight patients required mechanical ventilation longer than 24 hours. Mitral valve replacement was performed in 24, of these 23 as a scheduled procedure and 1 as conversion from attempted repair in active endocarditis. Two patients needed conversion to sternotomy because of bleeding. A total of 63% of the patients had no blood transfusion. Average operation, bypass, and aortic clamp times were, 258, 176, and 127 minutes, respectively. Average intensive care unit stay was 1.3 and postoperative hospital stay was 9.7 days. In patients who underwent mitral valve plasty, three had mild mitral regurgitation at discharge, and others had none or trivial.
Conclusions: Endoscopic mitral surgery with additional working port and handheld endoscope was reproducible and safe.
P78 Three-Port Thoracoscopic Techniques for Mitral Valve Replacement Without Robotically Assisted Surgical System: Technical Challenges and Solutions
Zengshan Ma, Sr, Hourong Sun. Shandong University, Ji’nan, China.
Objective: This study aimed to investigate the feasibility and safety of totally thoracoscopic mitral valve replacement (MVR) through three ports in the right chest.
Methods: A total of 262 patients with rheumatic heart disease were selected from cardiac surgery of our hospitals; 157 were males; mean age was 51.7±5.6 years; and mean body weight was 69.8±8.7 kg. An additional 36 patients undergoing open-chest MVR were selected as a control group. Using three-port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and MVR were performed by thoracoscopy without the aid of a robotically assisted surgical system.
Results: The cardiopulmonary bypass and aortic cross-clamp times were 62.2±9.8 and 46.5±7.3 minutes, respectively. There were no mortalities. The intensive care unit (14.1±4.5 vs. 24.5±5.6 hours, P<0.01) or postoperative hospital stays (6.5±1.8 vs. 8.6±2.1 days, P<0.05) in the thoracoscopic group were shorter than those in the control group. The percentage of patients who required postoperative opioid analgesics in the thoracoscopic group was lower than those in the control group (21.0% vs. 75.2%, P<0.01). Rate of blood transfusion during the operation was 17.6% vs. 69.8%, P=0.001. Transesophageal echocardiographic analysis 5.2±3.9 months after the operation showed that heart function improved and prosthesis was normal.
Conclusions: Three-port thoracoscopic technique for MVR by totally thoracoscopic is safe and effective. This technique is associated with reduced intensive care, rate of blood transfusion during the operation, and hospital stay in comparison with the conventional MVR.
P79 Mitral Valve Procedures Without Aortic Cross-Clamping via Right Minithoracotomy Using Titanium Fasteners
Rafik Margaryan, Giacomo Bianchi, Tommaso Gasbarri, Giovanni Concistrè, Pierandrea Farneti, Marco Solinas. Ospedale Del Cuore Fondazione ’G. Monasterio’, Massa, Italy.
Objective: We sought to review our experience with the use of new titanium knot fastener devices. We hypothesized that in selected cases, its use could importantly reduce the induced ventricular fibrillation (IVF) or beating heart procedure and cardiopulmonary bypass (CPB) time.
Methods: We reviewed retrospectively our electronic records to identify patients who underwent mitral valve repair and replacement without aortic cross-clamping (on beating heart or induced ventricular fibrillation, mainly redo operations). Surgical approach was through right minithoracotomy with mainly femorofemoral arteriovenous cannulation. A portion of the group of patients have used fast knotting system (FK group; COR-KNOT Device; LSI Solutions Inc, Victor NY USA), and the remaining served as a control group (conventional hand knotting). We identified the FK patients and performed propensity-score matching to match 1:1 ratio from main population using FK versus hand knotting.
Results: A total of 55 underwent mitral valve repair or replacement on fibrillating or beating heart without aortic cross-clamping. A total of 13 patients (24%) underwent operation using FK. There were no statistical differences in total population while ignoring the procedure type and complexity on mitral valve. However, when subsetting procedures on native valve, there was an approximately 35-minute reduction of CPB time (P=0.06). Same pattern persisted when considering only IVF, and there was time reduction by 9 minutes (P=0.38). In the propensity-matched population, the effect of CPB and IVF reduction was consistent and repeated by an 18-minute (P=0.45) and a 15.5-minute (P=0.29) reduction, respectively.
Conclusions: Titanium fasteners are a useful tool to have in minimally invasive approaches, especially in complex cases and redo interventions. Titanium fasteners can reduce IVF time and overall CPB time in selected complex population. In matched group, the pattern of reduction of the two variables was consistent.
P80 Beating Heart Mitral Valve Surgery: Results in 120 Consecutive Patients Considered Nonsuitable Candidates for Conventional Mitral Valve Surgery
Stephan Jacobs, Simon Sündermann, Volkmar Falk. German Heart Center Berlin, Berlin, Germany.
Objective: This study aimed to assess whether beating heart mitral valve surgery is a valuable option in patients considered very high-risk candidates or inoperable for conventional mitral valve surgery.
Methods: One-hundred twenty patients (mean age, 63.7±12.1 years; range, 25.3–88.8 years; mean logistic EuroSCORE, 26.1%±20.6%; range 1.5%–84.3%) undergoing beating heart mitral valve surgery using normothermic cardiopulmonary bypass without aortic cross-clamping and without cardioplegia between September 2002 and April 2014 were included in this retrospective, single-center, observational cohort study. Preoperatively, 14 patients (11.7%) were in cardiogenic shock, 16 (13%) were on ventilator, 33 (27.5%) received inotropic support, 12 (10%) had dialysis, and 1 was on an extracorporeal membrane oxygenator. Sixty-five patients (54%) had at least one previous heart operation (range, 1–6). Mean follow-up was 920±973 days.
Results: Isolated mitral valve surgery was performed in 75 patients (62.5%). Combined mitral valve procedures were performed in 45 patients (37.5%). Fifty-eight patients (49%) had emergency or urgent procedures, and 62 (51%) were treated elective. Mean cardiopulmonary bypass time was 103±39 minutes (median, 94 minutes; range 45–252 minutes; interquartile range, 75–121.5 minutes). There were no conversions to conventional surgery. Overall 30-day mortality was 10% including patients in cardiogenic shock and 7.5% for patients without preoperative cardiogenic shock. Five patients (4.2%) had early rethoracotomy for bleeding, three (2.5%) had disabling stroke, and two (1.7%) had nondisabling stroke. Overall 6-month, 1-year, 2-year, and 5-year survival were 73.0%±4.2%, 63.5%±4.6%, 56.5%±4.8%, and 37.4%±5.0%, respectively (Fig. P80-1). Multivariate analysis revealed age (HR, 1.04; 95% confidence interval, 1.01–1.06; P=010) and creatinine (HR, 1.53; 95% confidence interval, 1.23–1.91; P<0.001) to be relevant for late survival.
Conclusions: Patients considered nonsuitable candidates for conventional mitral valve surgery had favorable postoperative course and survival if the operation was performed on the beating heart.
P81 Transapical Off-Pump Implantation of Artificial Cordae in Mitral Valve Regurgitation
Nalan Schnelle1, Horst Sievert2, Laura Vaskelyte2, Dilek Ister1, Christian F. Vahl1. 1University of Mainz, Mainz, Germany; and 2Cardiovascular Center Frankfurt, Frankfurt, Germany.
Objective: The present study describes the initial experience with the NeoChord DS System that allows transapical implantation of artificial neochordae in terms of periprocedural safety, clinical success, and short-term outcome in four patients.
Methods: Patients with dyspnea and New York Heart Association functional classes II to IV with severe mitral regurgitation (MR) that did not accept open heart mitral valve repair were included (female, 70 years old, MR III-IV due to P2-P3 prolapse; male, 88 years old, MR IV due to A1-A2 prolapse; male, 76 years old, MR III due to P2-P3 prolapse with previous mitral valve annuloplasty and chordae implantation at P2/P3; and female, 75 years old, MR IV due to P2-P3 prolapse). We decided in the heart team on transapical repair with NeoChord under general anesthesia. The NeoChord procedure was performed under two- and three-dimensional transesophageal guidance using a transapical access. After grasping the mitral valve leaflet with two grippers, valvular piercing and fixation and retraction of the neochordae were performed. In any patient, six neochordae were implanted (three pairs).
Results: The patients received multiple chordae. The procedures were uneventful with no hemodynamical instability. The perioperative results were excellent with no regurgitation left in three patients and MI I in one patient. There was no bleeding no infection. Discharge was performed within 7 to 10 days after the procedure. No cardiovascular or neurological complications were observed (no adverse event).
Conclusions: Despite the small patient population, off-pump transapical implantation of neochordae seems feasible, efficient, and safe without actual increase in the transvalvular gradient in comparison with mitral clip. It is even successful after previous mitral valve annuloplasty and chordae implantation. The dynamic physiological approach with stepwise resuspension of a leaflet without use of cardiopulmonary bypass has to be reserved for high-risk patients as long as long-term results are not available.
P82 Three-Dimensional Imaging in Minimally Invasive Mitral Valve Surgery: An 18-Month Single-Center Experience
Christoph Krapf, Bastian Schneider, Cenk Özpeker, Juliane Kilo, Michael Grimm, Ludwig Müller. Medical University of Innsbruck, Innsbruck, Austria.
Objective: Minimally invasive mitral valve surgery (MIMVS) through minithoracotomy is facilitated by video assistance. Because of difficult depth perception with two-dimensional (2D) video systems, most steps of the procedure by most surgeons are performed under direct vision. We report our results of an 18-month period using three-dimensional (3D) video endoscopy.
Methods: A continuous series of 65 patients who underwent totally endoscopic operations with 3D imaging is included. Perioperative and short-term results are analyzed retrospectively. Cross-clamping and cardiopulmonary bypass (CPB) times for isolated MIMVS in 45 patients were compared with those from 275 MIMVS patients operated on from 2001 to 2014 with 2D and direct vision. A total of eight surgeons either operated on their own or were assisted by the MIMVS program director.
Results: From June 2014 to December 2015, 65 patients (median age, 63 years), of whom 37 (56.9%) were male, underwent totally endoscopic MIMVS with 3D imaging. In 63 patients (96.9%), transthoracic aortic clamping with cardioplegic arrest median ischemic and CPB times were 123 minutes (SD, 32.2) and 222 minutes (SD, 65.1), respectively; in two patients (3.1%), a redo procedure was performed under ventricular fibrillation. In 59 patients (90.8%), mitral valve (MV) repair was possible; 5 received planned MV replacement. Additional tricuspid valve repair, ASD/PFO closure, and left atrial ablation were performed in 8 (12.3%), 13 (20%), and 6 (9.2%) cases, respectively. In two patients (3.1%), conversion to median sternotomy was necessary, one because of bleeding and another one because of unsuccessful reconstruction with final MV replacement. Thirty-day mortality was 0. In 45 patients with isolated MIMVS, CPB times were longer with 3D (221.0 minutes; SD, 63.9) compared with 275 patients with 2D imaging (194.5 minutes; SD, 64.6; P=0.011). Cross-clamp times were comparable [121.9 (SD, 28.9) vs. 110.4 (SD, 41.9) minutes, P=0.082].
Conclusions: Totally endoscopic MIMVS with 3D imaging is safe. Standard Carpentier techniques for repair or replacement can be performed without direct vision even in a training institution. Cross-clamping times using 3D imaging are not different; however, total CPB times are longer because preparative and final steps from pericardiotomy to cross-clamping and vice versa were performed mostly by surgeons less experienced with the MICS approach.
P83 Totally Thoracoscopic Mitral Valve Repair With Modified Loop Technique
Bin Xie. Cardiovascular Department, Guangzhou First People’s Hospital, Guangzhou, China.
Objective: This study aimed to summarize the experience of totally thoracoscopic mitral valve repair with modified loop technique.
Methods: From July 2011 to July 2015, only one surgeon performed 65 cases of totally thoracoscopic mitral valve repair with a modified loop technique. The whole group has 38 male and 27 female patients. Age was 19 to 79 years (48.9±24.3). Weight was 43 to 90 kg (51±15). Combined procedure involved TVP Ring in 16 patients. Twenty-one cases were anterior leaflet prolapse, 27 cases were posterior leaflet prolapse, 17 cases were bileaflet prolapse. All patients underwent right anterior minithoracotomy with three holes with double-lumen trachea cannula. The femoral artery, vein, and vena jugular external cannulae were used to set up cardiopulmonary bypass. Regarding Gore-Tex loop stitch point, one side was on the junction between papillary muscle and chordae, another side was on the edge of the prolapse leaflet. The number of chordae was 3.5±1.3. The lengths of artificial chordae were as follows: anterior leaflet, 1.65 to 1.88 cm (1.7±0.8); posterior leaflet, 1.5 to 1.7 cm (1.6±0.1). All cases used Carpentier-Edwards Physio I or II annuloplasty ring (Edwards Lifesciences, Inc., Irvine, CA USA). For bileaflet prolapse cases, we used a modified loop technique where a hand-made artificial chorda with a different length in one group of loop was used.
Results: There was no mortality. Two cases were converted to MVR. Cardiopulmonary bypass time was 123.24±38.22 minutes. Cross-clamp time was 79.83±29.48 minutes. Ventilation time was 14.2±8.8 hours. Drainage was 327.5±311.5 mL. Intensive care unit stay was 24.3±14.2 hours. Hospital stay was 6.4±3.9 days. Reoperation for bleeding occurred in two cases. There was pulmonary infection in six cases and wound infection in one case. Mitral insufficiency during the preoperative period was 12.6±5.09 cm2, 0.83±1.29 cm2 during discharge (P<0.001), and 1.58±2.01 cm2 at 3 months. Involution height was 0.5 to 1.5 cm (0.85±0.43).
Conclusions: Mitral valve repair with totally endoscopic is feasible, safe, and reproducible and has good clinical result. Modified Gore-Tex loop technique can simplify the request of implanting artificial chordae especially for bileaflet prolapse.
P84 A New Twist on an Old Problem: Robotic Septal Myectomy and Anterior Mitral Valve Leaflet Enlargement for Hypertrophic Obstructive Cardiomyopathy
Sarah L. Breves1, Thomas M. Kelley, Jr2, James McCarthy1, Mohammed Kashem1, G. William Moser1, Daniel L. Dries1, Clifton T. Lewis3, T. Sloane Guy4. 1Temple University School of Medicine, Philadelphia, PA USA; 2Dwight D. Eisenhower Army Medical Center, Augusta, GA USA; 3Princeton Baptist Medical Center, Birmingham, AL USA; and 4Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY USA.
Objective: Open transaortic myomectomy is the traditional treatment of hypertrophic obstructive cardiomyopathy (HOCM). Although the defining feature of HOCM is left ventricular hypertrophy, the condition is also characterized by anterior mitral valve leaflet enlargement. As a result, surgical treatment should simultaneously address the ventricular septum and the mitral valve. Our minimally invasive method uses robotic techniques and a transmitral approach to perform an extended septal myectomy along with anterior mitral valve leaflet augmentation. We reviewed our experience with this technique to understand the hemodynamic effects and outcomes of this novel robotic approach.
Methods: We conducted a retrospective review of 10 consecutive patients with HOCM who underwent robotic septal myectomy and anterior mitral valve leaflet augmentation from August 2012 to September 2015. We received institutional review board approval. Chart review was conducted to determine patient demographics and procedural outcomes. Data were analyzed using Microsoft Excel.
Results: Totally endoscopic robotic septal myectomy and anterior mitral valve leaflet augmentation was successfully completed in 10 patients (100%). The mean age of the patients undergoing the procedure was 53.6±9.0 years (42–66 years), and 40% (4/10) were male. The baseline mean left ventricular ejection fraction was 64.5%±7.6% (50%–80%). The patients had an average preoperative mitral valve regurgitation of 2.8±0.6, with 70% (7/10) of the patients presenting with 3+ or greater mitral regurgitation. The mean basal septal thickness was 22.3±5.3 mm (17–32 mm). All patients demonstrated systolic anterior motion of the mitral valve and left ventricular outflow tract (LVOT) obstruction. The average gradient across the LVOT was 128.2±38.9 mmHg (57–186 mmHg) with or without provocation. There were no mortalities, and no patients have required reoperation. Postoperative echocardiograms showed single-digit gradients and no mitral regurgitation or systolic anterior motion of the mitral valve. The mean follow-up was 8.9±13.2 months (2 weeks to 3 years), and follow-up transthoracic echocardiograms completed in 6/10 patients showed consistently low LVOT gradients.
Conclusions: Totally endoscopic robotic septal myectomy and anterior mitral leaflet augmentation is a safe and effective procedure for the treatment of HOCM. The totally endoscopic robotic approach increases visualization of the LVOT and expedites patient recovery. Continued evaluation and longer-term follow-up are needed.
P85 Sutureless Aortic Perceval Bioprosthesis: Single-Center Experience in Cardiac Reoperations
Giovanni Concistrè, Francesca Chiaramonti, Giacomo Bianchi, Michele Murzi, Egidio Varone, Tommaso Gasbarri, Filippo Santarelli, Enkel Kallushi, Alfredo Cerillo, Pierandrea Farneti, Marco Solinas. Ospedale del Cuore “G. Pasquinucci”—Fondazione G. Monasterio CNR, Massa, Italy.
Objective: Perceval sutureless aortic bioprosthesis (Sorin Group, now LivaNova, London, UK) represents an innovative approach for surgical aortic valve replacement (AVR), to reduce operative time and facilitate prosthesis implantation, especially in complex procedures. We described our experience with Perceval bioprosthesis in cardiac reoperations (REDO).
Methods: From March 2011 to January 2015, 517 patients underwent AVR with sutureless aortic Perceval bioprosthesis at our institution. Of these, 58 patients had previously undergone cardiac surgery. Mean age was 71±8.7 years, 27 patients were female (46.5%), and mean logistic EuroSCORE was 26.3%±6.9%. Preoperative, periprocedural, and echocardiographic parameters and clinical outcomes were analyzed.
Results: The primary procedure was aortic valve surgery (isolated or associated with concomitant procedures) in 41 patients (71%). Isolated REDO AVR was performed in 35 patients (60%). REDO surgery was performed via full sternotomy in 51 patients (88%) and via right minithoracotomy in 7 patients (12%). Cardiopulmonary bypass and aortic cross-clamp times were 97±42.1 and 53.5±28.4 minutes for isolated AVR and 155.8±82.7 and 95.4±43 minutes for combined procedures, respectively. In-hospital deaths occurred in three patients (5%), one patient had cardiac death, and all patients were alive at a mean follow-up of 19.3 months (range, 0–52.7 months). Events at follow-up included cerebral hemorrhage in one patient and the need of pacemaker implantation in three patients. On echocardiographic evaluation, no patient showed paraprosthetic leakages, and mean transprosthesis gradient was 10±5.2 mmHg.
Conclusions: Perceval sutureless AVR is a fast and safe procedure, even in high-risk REDO surgery, providing a good hemodynamic performance with excellent clinical results.
P86 Single-Center Experience of Aortic Valve Replacement with Rapid-Deployment Bioprosthesis: One Hundred Fourteen Implantations
Francesca Chiaramonti, Giovanni Concistrè, Federica Marchi, Egidio Varone, Giacomo Bianchi, Tommaso Gasbarri, Pierandrea Farneti, Marco Solinas. Heart Hospital G.Pasquinucci FTGM, Massa, Italy.
Objective: The growing elderly population increases the number of patients with aortic valve stenosis and multiple comorbidities. In this patient population, the sutureless and rapid-deployment bioprosthesis can represent a good option to reduce surgical risk. We report our experience with a fast-deployment bioprosthesis, the EDWARDS INTUITY Valve System (Edwards Lifesciences, Inc., Irvine, CA USA).
Methods: Between June 2012 and December 2015, 114 patients with symptomatic aortic stenosis were scheduled for aortic valve replacement with EDWARDS INTUITY Valve System. Mean age was 74.9±6.6 years, and mean logistic EuroSCORE was 8.6±6.5. Eighty-five patients were male (75%). Sixty-eight patients underwent isolated aortic valve replacement. Concomitant procedure were coronary artery bypass graft (n=32), mitral valve procedures (n=6), mitral valve procedure combined with coronary artery bypass graft (n=6), and tricuspid annuloplasty (n=2). Three-month and 1-year follow-up were performed.
Results: Implantation success was 99% (113/114). Prosthesis size were 19 (n=7), 21 (n=23), 23 (n=35), 25 (n=34), and 27 (n=14). In 66 patients (58% of all patients and 97% of patients with isolated aortic valve disease), a minimally invasive approach was performed. Deployment time was 13.7±4.5 minutes. Cardiopulmonary bypass and aortic cross-clamp times were 86.9±20.5 and 50.3±15 minutes, respectively, for standalone procedures. Two patients who underwent a ministernotomy approach needed a conversion to full sternotomy because of aortic wall tear after weaning from cardiopulmonary bypass. Median mechanical ventilation time was 6 hours (range, 2–63). Median intensive care unit stay was 1 day (range, 1–27). Median length of stay was 5 days (range, 0–14). The mean transvalvular gradient was 10.3±3.9 mmHg at discharge, 8.3±4.3 mmHg at 3-month follow-up, and 8.9±4.2 mmHg at 1-year follow-up. A trivial paravalvular leakage in six patients and a moderate paravalvular leakage in one patient were accepted at discharge and were stable at follow-up. Survival was 98% at discharge, 98% at 3-month follow-up, and 97% at 1-year follow-up.
Conclusions: Aortic valve replacement using the EDWARDS INTUITY Valve System in our experience is a feasible and reproducible procedure associated with excellent results in terms of survival and hemodynamic performance. However, experience with a larger number of patients and longer-term follow-up are necessary to validate these data.
P87 Sutureless Prosthesis Option in Patients Undergoing Concomitant Aortic Valve and Ascending Aorta Replacement: First Experience in 13 Cases
Mattia Glauber, Antonio Lio, Matteo Ferrarini, Antonio Miceli. Cardiac Surgery and Great Vessel Department, Istituto Clinico Sant’Ambrogio, Milan, Italy.
Objective: A significant proportion of patients undergoing aortic valve replacement (AVR) have a dilated ascending aorta that needs concomitant surgical replacement. The objective of this study was to report our first experience on 13 patients undergoing AVR and concomitant ascending aorta replacement (AAR), with implantation of a sutureless prosthesis.
Methods: A retrospective study was undertaken on 189 consecutive patients undergoing AVR and AAR between January 2001 and December 2015. Propensity-score matching was used to reduce selection bias. Thirteen patients treated with a sutureless prosthesis implantation (study group) were compared with a control group of 13 patients undergoing AVR and AAR with conventional mechanical/biological prosthesis.
Results: Both patients with aortic stenosis and patients with aortic regurgitation were treated with sutureless valve implantation. In the sutureless group, patients were more likely treated with a minimally invasive approach. Only one patient died in the hospital. No paravalvular leakage or prosthesis dislodgment was reported. Permanent pacemaker implantation was needed only in one patient. The sutureless group has shown shorter cardiopulmonary bypass (142±52 vs. 167±38 minutes, P=0.01) and cross-clamp times (85±18 vs. 101±29 minutes, P=0.01) (Table P87-1).
Conclusions: In patients undergoing AVR and AAR, sutureless valve implantation is a safe and reproducible procedure associated with good postoperative results (Table P87-1).
P88 Minimally Invasive Aortic Valve Replacement via Right Anterior Minithoracotomy and Central Aortic Cannulation: A 13-Year Experience
Daniel M. Bethencourt1, Jennifer Le2, Gabriela Rodriguez3, Robert W. Kalayjian3, Gregory S. Thomas3. 1MemorialCare Heart & Vascular Institute at Long Beach and Orange Coast Memorial, Long Beach, CA USA; 2University of California San Diego Skaggs School of Pharmacy, La Jolla, CA USA; and 3MemorialCare Heart & Vascular Institute at Long Beach Memorial, Long Beach, CA USA.
Objective: The study objective was to evaluate the clinical outcomes of a minimally invasive aortic valve replacement (mini-AVR) technique by a right anterior minithoracotomy approach with central aortic cannulation using a 5- to 6-cm second intercostal incision and transection of one (or two) ribs.
Methods: In this observational, two-hospital cohort study from 2003 to 2015, demographic and operative outcomes were evaluated, including surgical and ventilator times, length of stay, stroke, reoperation, and mortality. Statistical analyses were performed using two-tailed analyses.
Results: A total of 202 patients underwent mini-AVR over 13 years, divided into two periods, 2003 to 2009 (n=65, “early”) and 2010 to 2015 (n=137, “late”). Mean age was 72.5±12.9 years; 60% were male. Beginning in 2006, mean cardiopulmonary bypass and aortic cross-clamp times decreased significantly each year with Bonferroni adjustment (Fig. P88-1). Demographic data were similar, except for weight, 75.3±14.7 kg for the early versus 80.9±20.8 kg for the late period (P=0.03). Compared with the early study period patients, those from the late study period were more often extubated intraoperatively (52% vs. 12%, P<0.001), had less prolonged ventilator use postoperatively (6% vs. 16%, P=0.018), required less blood transfusions (mean, 2.0±2.3 vs. 3.6±3.0 U, P=0.011), and had shorter postoperative stay (6.3±4.5 vs. 8.0±5.9 days, P=0.026). Numerically, fewer postoperative strokes (1% vs. 6%, P=0.09) and fewer reoperations for bleeding (3% vs. 6%, P=0.3) occurred in the late period. In-hospital mortality did not differ (1/65 early vs. 3/137 late).
Conclusions: Minimally invasive AVR intraoperative and postoperative clinical outcomes improved over a 13-year experience.
P89 Full or Partial Sternotomy Rather Than Right Minithoracotomy: Tailoring the Best Approach for Each Patient in Aortic Valve Replacement
Elisa Mikus, Simone Calvi, Marco Panzavolta, Marco Paris, Mauro Del Giglio. Maria Cecilia Hospital, GVM for Care & Research, Cotignola (Ra), Italy.
Objective: During the past decade, minimally invasive cardiac surgery has emerged as a valid approach to treat aortic valve disease. Various techniques have been developed: partial sternotomy (V-shaped, Z-shaped, inverse-T, J reverse-C, and reverse-L partial) and right minithoracotomy at the second or third intercostal space. We describe our 6-year, single-center experience, using either standard full sternotomy or upper J hemisternotomy or right minithoracotomy.
Methods: From January 2010 to October 2015, 1550 isolated, aortic valve operations were performed at our institution. Surgical approach included standard sternotomy (509, 32.8%), minimally invasive technique using upper J hemisternotomy (695, 44.8%), or right anterior minithoracotomy (346, 22.4%). Aortic clamping was direct in all patients. Total central cannulation was used whenever possible.
Results: Bivariate and multivariate regression analyses revealed that preoperative renal insufficiency is a common independent risk factor for death. In addition, in case of minimally invasive approach with upper hemisternotomy, obesity results as an independent risk factor (P=0.05; adjusted odds ratio, 5.06; confidence interval, 1.01–25.28) as well as peripheral extracardiac vascular disease for the full sternotomy group (P=0.02; adjusted odds ratio, 4.42; confidence interval, 1.27–15.34). Hospital mortality rate in minimally invasive approach (right minithoracotomy, 1.7%; upper hemisternotomy, 2.9%) was at least comparable with that in the standard full sternotomy (3.5%).
Conclusions: Minimally invasive surgery must be considered as a safe option for aortic valve replacement. Our experience shows that in case of high body mass index or peripheral vascular disease, the right minithoracotomy could have some advantages over other surgical approaches.
P90 Mini-Bentall: An Attractive Approach for Elective Patients
Elisa Mikus, Marco Pagliaro, Alberto Tripodi, Diego Magnano, Mauro Del Giglio. Maria Cecilia Hospital, GVM for Care & Research, Cotignola, Italy.
Objective: Minimally invasive surgery through an upper J sternotomy for aortic valve replacement has become routine approach with excellent results. Complex ascending aortic procedures are performed through the same minimally invasive access only in few centers. We describe our experience using either standard full sternotomy or minimally invasive approach for Bentall operation.
Methods: From January 2010 to October 2015, 240 patients received elective ascending aorta and aortic valve replacement using Bentall De Bono procedure at our institution. Of 240 patients operated on, 53 had minimally invasive ministernotomy and 187 had full median sternotomy. Median age was 63 years (25th percentile, 51; 75th percentile, 73) for the minimally invasive group and 68 years (25th percentile, 54; 75th percentile, 73) for the full sternotomy group (P=0.365). No statistically significant differences in terms of body mass index (P=0.678), left ventricular ejection fraction (P=0.319), diabetes mellitus (P=0.988), chronic obstructive pulmonary disease (P=0.5), and renal insufficiency (P=0.198) have been found between the two groups.
Results: The partial sternotomy was performed from the notch to the third right intercostal space. A Bentall De Bono procedure, using a pericardial Mitroflow bioprosthesis implanted in a Valsalva graft or a standard mechanical conduit, was performed in all patients. Median cardiopulmonary bypass time and median cross-clamp time were 84 (74.25–103) and 73 (64–89) minutes, respectively, for the minimally invasive group and 101 (80–133) and 81 (67–112.5), respectively, for the full sternotomy group, with significant difference (P=0.007 and P=0.029, respectively). Postoperative ventilation time resulted lower in patients treated with ministernotomy (median, 8 vs. 8.5 hours without statistically difference; P=0.069) as well intensive care unit stay (P=0.281), incidence of atrial fibrillation (P=0.62), and hospital mortality (P=0.126).
Conclusions: Our experience confirms that a minimally invasive approach using a partial upper J-shaped sternotomy could be an attractive and safe alternative approach to the standard one also in selective patients affected by complex aortic root pathology.
P91 Feasibility of Minimally Invasive Aortic Root Surgery
Alon Aharon1, Oleg Orlov1, Ioannis Paralikas1, Matthew Thomas1, Joshua Wong2, Amber Melvin2, Konstadinos Plestis1. 1Lankenau Medical Center, Philadelphia, PA USA; and 2Division of Cardiac Surgery University of Rochester Medical Center, Rochester, NY USA.
Objective: Traditionally, proximal aortic surgery has been performed through a midline sternotomy. We describe our outcomes in patients who underwent aortic root surgery via an upper hemisternotomy (mini-Root).
Methods: This is a retrospective analysis of 13 mini-Roots performed from June 2014 to October 2015 at our institution. A minimally invasive approach was achieved through a standard hemisternotomy with lateral extension to the fourth intercostal space. Central aortic and femoral venous cannulations were used using the Seldinger technique with transesophageal echocardiography guidance. Antegrade HTK-Custodial (Essential Pharmaceuticals, LLC, Ewing, NJ USA) cardioplegia was used in all patients. There were 10 Bentall and 3 David procedures.
Results: There was no in-hospital mortality or postoperative strokes. Median ICU stay was 2 days, and median hospital stay was 5 days. Ventilatory support was 7.5±16 hours. Three patients (23%) had postoperative atrial fibrillation, and five (38%) required transfusion.
Conclusions: A minimally invasive approach can be safely applied in proximal aortic surgery with excellent outcomes.
P92 Intermediate-Term Evaluation of Hemodynamic Behavior and Patient Prosthesis Mismatch at Rest and Under Stress After Aortic Valve Replacement With Sorin Freedom Pericardial Stentless Prosthesis
Guglielmo Stefanelli, Fabrizio Pirro, Alina Olaru, Clorinda Labia, Massimo Longo. Marco Meli, Hesperia Hospital, Modena, Italy.
Objective: This study aimed to evaluate the hemodynamic behavior of Sorin Freedom stentless valve under stress conditions and to encourage the choice of an aortic prosthesis in relation to a better quality of life of the patient.
Methods: Between March 2003 and April 2010, 184 patients who received a Pericarbon Sorin Freedom stentless aortic prosthesis (Sorin Group; now LivaNova, London, UK) at our unit underwent an echocardiographic evaluation at rest and under stress conditions at a mean follow-up time of 6.8 years. The mean age of the patients was 69.7±10.9 years. Mean Log EuroSCORE was 7.73±7.03. Concomitant procedures were performed in 41.3% of the cases. The stress protocol consisted of a maximum exercise of 100 w for 6 minutes at cycle-ergometer. Assessment of maximum-mean aortic gradient, effective orifice area, effective orifice area index were obtained by echocardiographic examination, along with the assessment of patient-prosthesis mismatch, New York Heart Association functional class, and percentage of reduction in ventricular mass.
Results: A low increase of mean (from 7.8±3.3 to 11.6±4.0 mmHg) and peak (from 14.9±5.2 to 21.6±6.5 mmHg) gradients even under maximum exercise was observed. Interestingly, there was an increase in the effective orifice areas related to a possible dynamical valve adaption to the changes of a patient’s hemodynamics. The patient-prosthesis mismatch was virtually absent. The clinical conditions were excellent for the majority of the patients.
Conclusions: The hemodynamic evaluation of Sorin Pericarbon Freedom at rest and under stress showed excellent performances. A good capability of valve adaption to changes in cardiac output has been observed. Therefore, the Sorin Pericarbon Freedom can be considered a good option within the aortic valve substitutes in the younger, active population and an excellent prosthesis in cases of bacterial endocarditis.
P93 Minimally Invasive Aortic Valve Replacement in Patients With Concomitant Coronary Artery Disease
Alon Aharon1, Matthew Thomas1, Oleg Orlov1, Ioannis Paralikas1, Djamila Abjigitova2, Joshua Wong1, Amber Melvin3, Konstadinos Plestis1. 1lankenau Medical Center, Philadelphia, PA USA; 2Erasmus Medical Center, Rotterdam, the Netherlands; and 3Division of Cardiac Surgery University of Rochester Medical Center, Rochester, NY USA.
Objective: Minimally invasive aortic valve replacement (mAVR) has become the standard of care for isolated aortic valve disease. In patients with asymptomatic one- or two-vessel coronary artery disease (CAD) not involving the left main or the ostial left anterior descending coronary artery, isolated mAVR may be a viable option. We compared the outcomes of mAVR patients with concomitant CAD with those of the mAVR patients without concomitant CAD.
Methods: From January 2006 to May 2015, 517 patients underwent mAVR at our institution. Sixty-nine patients (70% male) had concurrent CAD (>50% stenosis, CAD group), and 448 patients (58% male) had no CAD (nCAD group). Mean age was 74.1 years (in the CAD group vs. 68.5 years in the nCAD group; P<0.05). There was a higher incidence of hypertension (82.6% vs. 71%, P=0.041) and hypercholesterolemia (88.4% vs. 62%, P<0.05) in the CAD group.
Results: The mean cardiopulmonary bypass and cross-clamp times were 114.9 versus 125 and 86.9 versus 96 minutes for the CAD group versus the nCAD group, respectively. There was no difference in the use of packed red blood cell (2.3 vs. 2.1), fresh frozen plasma (0.77 vs. 0.43), platelets (1 vs. 1), and cryoprecipitate (1.2 vs. 1.2 U) in the CAD group versus the nCAD group, respectively. There was no difference in postoperative stroke [2 (2.9%) vs. 5 (1%)], new onset renal insufficiency [5 (7.2%) vs. 18 (4%)], and atrial fibrillation [29 (33.3%) vs. 126 (28%)] in the CAD group versus the nCAD group, respectively. In-hospital mortality was higher (5.8% vs. 2%) in the CAD group (P<0.05). The actuarial survival at 1, 3, and 5 years was 90.87% versus 96.88%, 87.36% versus 93.45%, and 74.27% versus 89.57% in the CAD group versus nCAD group, respectively (P<0.05).
Conclusions: Although CAD did not directly contribute to postoperative mortality, the presence of CAD had a negative impact both on short- and on long-term survival.
P94 Reduced Length of Hospital Stay for Minimally Invasive Aortic Valve Replacements After Implementation of an Enhanced Recovery After Surgery Program
Pierre Oses, Sr, Cedrick Zaouter, Jocelyn Duchateau, Alexandre Ouattara, Louis Labrousse. Bordeaux University Hospital, Bordeaux, France.
Objective: There is presently a warm enthusiasm for enhanced recovery after surgery (ERAS) program. A recent review indicates that length of hospital stay and postoperative complication could be reduced by 30% and 50%, respectively. However, most of the studies analyzed encompassed solely colorectal and orthopedic surgeries. Only one retrospective ERAS program has been described for minimally invasive cardiac surgery. Thus, in an effort to provide more evidence to the literature, we have investigated prospectively the feasibility and clinical effectiveness of a dedicated ERAS program for minimally invasive aortic valve replacements (AVRs).
Methods: Data were collected prospectively from consecutive patients scheduled for an AVR via a ministernotomy during two periods, before (PRE-AVRERAS group) and after application of a dedicated ERAS pathway specifically designed for this minimally invasive cardiac procedure (AVRERAS group). Operative data, postoperative morphine consumption, postoperative data of interest, postoperative infection rates, types and rate of complications, 30-day type and rates of readmission were collected.
Results: There were 22 patients in the PRE-AVRERAS group and 14 in the AVRERAS group. The median length of hospital stay was 9 days in the PRE-AVRERAS group compared with 5 days in the AVRERAS group (P<0.05). The results of postoperative interest are described in Table P94-1. An ERAS pathway envisioned for minimally invasive AVR seems feasible and associated with a shorter hospital stay.
Conclusions: Our study indicates that an ERAS pathway could be implemented effectively with interesting results when a minimally invasive AVR is planned.
P95 Aortic Valve Replacement Using a Rapid Deployment Valve Through Anterior Right Thoracotomy: A Single-Center Study
Stephane Mahr, Martin Andreas, Andreas Habertheuer, Martin Schauperl, Dominik Wiedemann, Alfred Kocher, Gunther Laufer. Medical University of Vienna, Vienna, Austria.
Objective: Aortic valve replacement through anterior right thoracotomy (ART) using a rapid-deployment valve combines two surgical innovations that despite technical challenge might have a beneficial effect on patients with severe aortic stenosis. In this study, we revised our experience.
Methods: Between April 2011 and November 2015, 76 patients (39 male, 51.3%) with a mean age of 73±10 years underwent aortic valve replacement for severe aortic stenosis through ART with an 8-cm skin incision using direct cannulation of the aorta and the right atrium. Mean logistic EuroSCORE and EuroSCORE II were 6.9±5.3 and 2.3±2.1, respectively.
Results: Implantation of the rapid-deployment valve was successful in all patients using ART. Mean cross-clamp time and perfusion time were 86.8 and 123.6 minutes, respectively. A total of 30 patients (39.4%) had an annulus of 21 mm or less, with the most common implanted prosthesis size being 21 mm (n=22, 28.9%). One major bleeding event (1.3%) necessitating rethoracotomy occurred immediately after the patient was transferred to the intensive care unit postoperatively. In one patient (1.3%), a stroke occurred, whereas no transient ischemic attack was observed. No other valve-related complications were observed such as valve thrombosis, valve endocarditis, or reoperation due to structural and nonstructural valve deterioration. Mean and peak prosthesis gradients at discharge were 14.1±4.8 and 25.5±8.5 mmHg, respectively. Permanent pacemaker dependency with postoperative implantation of a pacemaker was 13.2% (n=10). Thirty-day mortality was 1.3% (n=1), whereas overall mortality was 2.7% (n=2).
Conclusions: Despite a higher-than-expected permanent pacemaker rate, overall results show a safe and feasible implantation technique using ART with a rapid-deployment valve with a remarkably low complication and mortality rate.
P96 The Use of Rapid Deployment Valves in Combined Aortic and Mitral Valve Surgery: One-Year Clinical and Echocardiographic Outcomes
Markus Schloemicher, Peter Lukas Haldenwang, Vadim Moustafine, Matthias Bechtel, Justus Thomas Strauch. Ruhr-University Hospital Bergmannsheil, Bochum, Germany.
Objective: Patients undergoing multiple-valve surgery represent a high-risk group who could potentially benefit from a reduction of cross-clamp and cardiopulmonary bypass times because prolonged bypass and cross-clamp times are considered independent risk factors for increased morbidity and mortality after cardiac surgery.
Methods: Between July 2013 and November 2014, 16 patients underwent rapid-deployment aortic valve replacement with the EDWARDS INTUITY Valve System (Edwards Lifesciences, Inc., Irvine, CA USA) in the setting of concomitant mitral disease. Fifteen patients showed mitral regurgitation, whereas one patient had severe mitral stenosis. Fourteen patients received mitral valve repair, and two patients biological mitral valve replacement. Tricuspid valve repair was performed additionally in two patients. The mean age was 72.8±8.4 years, and the mean logistic EuroSCORE II was 8.7%±3.4%.
Results: Within a 30-day perioperative period, no patient was lost (n=0). The mean follow-up time was 11±2 months. At 1 year, the overall survival was 81% (n=13). A mean transaortic gradient of 10.7±2.3 mmHg and a mean effective orifice area of 1.7±0.3 cm2 were measured echocardiographically. No higher grade paravalvular leak (AI>1+) occurred. Eight patients (61%) had no residual mitral regurgitation, four patients (30%) showed trivial regurgitation (1/4), and one patient (7.3%) had moderate mitral regurgitation (2/4). No interference of the subannular stent frame with the reconstructed valve or the biological mitral prosthesis was seen.
Conclusions: Rapid-deployment aortic valve replacement with the EDWARDS INTUITY Valve System in combined aortic and mitral valve surgery can be performed safely with reproducible results. One-year follow-up data of this small series show encouraging results potentially justifying the extension of the indication for rapid deployment valves to patients with concomitant mitral disease. Especially elderly patients undergoing multiple valve surgery may benefit from a reduction of cardiopulmonary bypass und myocardial ischemic times.
P97 The Influence of Left Ventricular Hypertrophy on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement
Danielle D. Spragan, Fenton McCarthy, Katherine McDermott, Saif Anwaruddin, Jay Giri, Wilson Szeto, Howard Herrmann, Joseph Bavaria, Nimesh Desai. Hospital of the University of Pennsylvania, Philadelphia, PA USA.
Objective: Severe left ventricular hypertrophy (LVH) is known to increase mortality risk in patients undergoing surgical aortic valve replacement. It is unknown whether severe LVH also increases the risk of mortality after transcatheter aortic valve replacement (TAVR). This study aimed to determine the effect of LVH (as indicated by increased relative wall thickness on preoperative echocardiogram) on 30-day and late mortality in patients undergoing TAVR.
Methods: A retrospective review of a single-institution TAVR database from 2007 to 2014 was conducted to review preoperative echocardiograms. Six hundred thirty-three patients were identified. Severe LVH is defined in this study as a relative wall thickness (RWT) greater than 0.45, a validated measure of concentric LVH. Patients were stratified into groups with severe LVH (RWT>0.45) and those without severe LVH (RWT<0.45). Logistic regression analysis was used to examine the effect of RWT on 30-day mortality after TAVR, and Kaplan-Meier curves were created to plot the effects of RWT on late mortality.
Results: Echocardiograms were reviewed from 633 patients, and these individuals were stratified into those without severe LVH as measured by an RWT of 0.45 (RWT, 0.64±0.18, n=411). Logistic regression analysis revealed similar 30-day mortality in patients with and without LVH [n=18 (8%) vs. n=23 (6%); P=0.24]. However, late mortality was increased in patients with preoperative evidence of LVH at 12 months (log-rank P<0.001, Fig. P97-1). Patients with severe LVH were noted to be slightly older (84.1±7.1 vs. 82.0±7.88 years, P=0.001) and more likely to be female (56% vs. 39%, P<0.001). The Society of Thoracic Surgeons score was similar for both groups of patients (10.6±4.3 vs. 10.5±4.3, P=0.84).
Conclusions: Preoperative LVH is predictive of increased mortality risk in patients planning to undergo transcatheter aortic valve replacement. Preoperative risk stratification should include elevated RWT on echocardiogram to help inform surgical management.
P98 Reduced Ejection Fraction: Is There an Improvement After Transcatheter Aortic Valve Replacement?
Mahim Malik, Muhammad Shareef, Juan A. Crestanello, Barry S. George, Gregory D. Rushing. Ohio State University, Columbus, OH USA.
Objective: Transcatheter aortic valve replacement has expanded the treatment of aortic stenosis to patients who are too sick for traditional open procedures. Transcatheter aortic valve replacement in low-gradient, low ejection fraction (EF) patients has been an area of controversy. We sought to examine if there is an improvement in the EF of this cohort of patients after undergoing transcatheter aortic valve replacement.
Methods: Patients undergoing transcatheter aortic valve replacement at our institution between January 2012 and 2015 were reviewed. Those with EF less than 35% were included in the study. These were substratified into those with severely depressed EF (<20%) and EF of 20% to 35%. Primary end points were EF measured on echocardiography at immediate postoperative, 1-month, and 1-year follow-up.
Results: Forty-seven patients with preoperative EF of less than 35% underwent transcatheter aortic valve replacement procedure. Sixty-six percent of the patients were male (n=31), with a mean age of 78.4 years (range, 52–93 years). Forty-one patients (n=19) had undergone previous sternotomy. There was a statistically significant improvement in EF in postoperative echocardiograms performed within 24 hours postoperatively (25% vs. 33%, P=0.003), at 1 month (25% vs. 33.7%, P=0.0043), and at 1 year (25% vs. 34.5%; P=0.00036) (Fig. P98-1). When substratified to two groups, that is, to EF less than 20% versus 20% to 35%, there was still a statistically significant improvement in EF between the two groups.
Conclusions: Transcatheter aortic valve replacement in low-EF patients is safe and effective. It may also help improve EF in these patients, both in the immediate postoperative period as well as at 1-year follow-up. Whether this confers an improvement in overall survival or heart failure symptoms and readmissions remains to be seen.
P99 Outcome After Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis With Poor Contractile Reserve on Dobutamine Stress Echocardiography
Sanjay Kumar1, Tarun K. Lahiri2. 1Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT USA; and 2Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
Objective: Few data are available on risk stratification for valve replacement in patients with aortic stenosis (AS), left ventricular (LV) dysfunction and low transvalvular gradients. We assessed risk stratification by using dobutamine stress echocardiography (DSE) in patients with AS and severe LV dysfunction.
Methods: Low-dose DSE was performed in 10 patients [3 women and 7 men; median (quartile range) age in years, 47 (32–78); left ventricular ejection fraction, 0.29 (0.23–0.32); aortic valve area (in cm2): 0.7 (0.5–0.8); mean transaortic gradient (in mmHg): 26 (21–33)]. Patients were classified into two groups as follows: group I (n=6, LV contractile reserve on DSE) and group II (n=4, poor contractile reserve). Valve replacement was performed in six and three patients in groups I and II, respectively.
Results: Perioperative mortality was 0% in group I and 0% in group II. Survival at 2 years after the operation was 100% in group I. The effect of valve surgery on survival remained significant in both groups after adjustment for age, diabetes, respiratory disease, and hypertension. Medical therapy had the same effect in both groups.
Conclusions: In patients with AS, LV dysfunction and low transvalvular gradients, contractile reserve on DSE is associated with a low operative risk and good long-term prognosis after valve surgery. In contrast, operative mortality may be high in the absence of contractile reserve. Light premedication, thermodilution cardiac output pulmonary artery catheters, and omniplanar transesophageal echocardiography remains essential armamentariums for perioperative anesthetic managements in this high-risk group of the patients.
P100 Perioperative Outcome of Low-Flow Low-Gradient Aortic Stenosis in Transcatheter Aortic Valve Implantation: Insights From a Two-Center Study With More Than 700 Patients
Markus Kofler1, Nikolaos Bonaros1, Sebastian Reinstadler2, Samir Ahad3, Tim Schäufele4, Lukas Stastny1, Gudrun Feuchtner5, Silvana Müller2, Ludwig Müller1, Guy Friedrich2, Michael Franz2, Michael Grimm1, Ulrich Franke3, Hardy Baumbach3. 1Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria; 2Cardiology, Medical University of Innsbruck, Innsbruck, Austria; 3Cardiac Surgery, Robert Bosch Klinikum, Stuttgart, Germany; 4Cardiology, Robert Bosch Klinikum, Stuttgart, Germany; and 5Radiology, Medical University of Innsbruck, Innsbruck, Austria.
Objective: Our aim was to investigate the outcome of low-flow low-gradient aortic stenosis (LFLG-AS) after transcatheter aortic valve implantation (TAVI). Furthermore, we analyzed the impact of the ejection fraction (EF) on the outcome of patients with LFLG-AS after TAVI.
Methods: From 2008 to 2015, a total of 747 consecutive patients underwent TAVI for severe AS in this two-center study. We compared patients with LFLG-AS (stroke volume index>35 mL/m2 and mean gradient<40 mmHg, n=113) with patients showing typical characteristics of severe AS (n=514). To further elucidate the impact of left ventricular EF (LVEF) on the perioperative outcome of patients with LFLG-AS, we divided LFLG patients into two subgroups according to the LVEF, with a cutoff of 50% to distinguish between reduced and preserved LVEF. Overall, mean age was 81.7±5.7 years, and the overall mean Society of Thoracic Surgeons score was 7.0%±5.5%. Valve Academic Research Consortium (VARC)-2 criteria were used to define clinical end points.
Results: Device success, early safety, and clinical efficacy were not significantly different in patients with LFLG-AS (all P>0.05). The stroke rate [LFLG-AS, 0.9% vs. high gradient (HG) AS, 3.7%; P=0.148] was similar between the groups. Incidence of stage 2 acute kidney injury (LFLG-AS, 20.4% vs. HG-AS, 11.5%; P=0.012) and renal replacement therapy (LFLG-AS, 15.9% vs. HG-AS, 9.3%; P=0.039) were significantly higher in the LFLG group. Perioperative mortality was significantly higher in LFLG-AS (LFLG-AS, 13.3% vs. HG-AS, 7.4%; P=0.042). The EF had no impact on perioperative mortality of patients with LFLG-AS (LFLG-reduced EF, 10.9% vs. LFLG-preserved EF, 14.0%; P=0.765).
Conclusions: Patients with LFLG-AS showed a worse outcome regarding VARC II end points. In our cohort, reduced EF did not impact the outcome of LFLG-AS patients undergoing TAVI.
P101 Impact of Gradient and Flow on Perioperative Renal Function After Transcatheter Aortic Valve Implantation
Markus Kofler1, Hardy Baumbach2, Sebastian Reinstadler1, Samir Ahad2, Stephan Hill3, Lukas Stastny1, Gudrun Feuchtner4, Silvana Müller5, Ludwig Müller1, Guy Friedrich5, Wolfgang Franz5, Michael Grimm1, Nikolaos Bonaros1. 1Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria; 2Cardiac Surgery, Robert Bosch Klinikum, Stuttgart, Germany; 3Cardiology, Robert Bosch Klinikum, Stuttgart, Germany; 4Radiology, Medical University of Innsbruck, Innsbruck, Austria; and 5Cardiology, Medical University of Innsbruck, Innsbruck, Austria.
Objective: Postoperative acute kidney injury was shown to be associated with an increased mortality after transcatheter aortic valve implantation (TAVI). In this analysis, we aimed to investigate the impact of preoperative gradient and flow on kidney function after TAVI.
Methods: From 2008 to 2015, a total of 717 consecutive patients underwent TAVI for severe aortic stenosis (AS) in this two-center study. We divided our study population into four groups and compared patients with high-gradient AS (n=520; mean gradient≥40 mmHg; HG-AS) to those with low-gradient AS (n=197; mean gradient, 35 mL/m2; HF-AS) to those with low-flow AS (n=314, stroke volume index<35ml/m2; LF-AS). Overall mean age was 81.7±5.6 years, and the overall mean Society of Thoracic Surgeons score was 6.9%±5.5%. VARC II criteria were used as clinical end point.
Results: Perioperative mortality did not differ between patients with low- versus high-gradient AS (LG-AS, 10.0% vs. HG-AS, 7.9%; P=0.368). Device success, early safety, and clinical efficacy were similar between the groups (all P>0.05). Acute kidney injury of stage 2 or higher was detected significantly more often in the low-gradient group (LG-AS, 16.8% vs. HG-AS, 10.8%; P=0.032). With regard to the impact of flow, no difference was seen on mortality between patients with low- versus high-flow AS P=0.322). Device success, early safety, and clinical efficacy were also similar between the two groups (all P>0.05). The incidence of acute kidney injury of stage 2 or higher was higher in the low-flow group (LF-AS, 18.2%), as compared with the high-flow group (HF-AS, 7.6%; P<0.001). Time-related valve safety was not different between all four groups.
Conclusions: Although we were able to show very good results regarding clinical outcome, we identified low flow and low gradient to have an impact on renal function in patients undergoing TAVI.
P102 Transcatheter Aortic Valve Implantation in Redo Patients With Native Aortic Valve Stenosis: A Meta-analysis
Alexander Meyer, Simon Sündermann, Axel Unbehaun, Semih Buz, Volkmar Falk, Jörg Kempfert. German Heart Institute Berlin, Berlin, Germany.
Objective: Redo surgical aortic valve replacement (SAVR) is technically challenging especially in the presence of a patent ITA graft. We investigated whether transcatheter aortic valve implantation (TAVI) is advantageous in the redo setting.
Methods: We performed a systematic review comparing SAVR with TAVI in redo cases with native aortic valve stenosis. Defined end points were 30-day mortality, postprocedural stroke, necessity for pacemaker implantation, occurrence of a relevant paravalvular leakage (PVL), and in-hospital length of stay. Case-control studies and case series reports were not considered for analysis.
Results: The PubMed query on September 27, 2015, retrieved 337 records. After screening, 328 were excluded: 251 hits did not address the research question, 1 article was not retrievable, and 76 studies were performed with a study design not eligible for inclusion. Overall, we pooled 9 studies with 1095 patients (TAVI, n=548; SAVR, n=547). Thirty-day mortality did not differ between TAVI and SAVR (Fig. P102-1). In the TAVI cohort, stroke rate was markedly reduced. The difference was significant in the fixed-effects (FE) model, but not in the random-effects (RE) model (FE: risk ratio, 0.51; 95% CI, 0.28–0.94, P=0.032; RE: risk ratio, 0.58; 95% CI, 0.28–1.18, P=0.13). Necessity for pacemaker implantation was almost double in TAVI patients compared with SAVR patients (FE: risk ratio, 1.95; 95% CI, 1.28–2.97, P=0.0018; RE: risk ratio, 2.08; 95% CI, 0.85–5.07, P=0.11). Only four of the nine studies reported data on PVL. Pooling these data showed no significant difference in relevant PVL (FE, P=0.12; RE, P=0.45). Similarly, length of stay was only reported in five studies, and pooled results did not differ (FE, P=0.78; RE, P=0.20).
Conclusions: For redo patients with native aortic valve stenosis, TAVI can be considered a safe alternative with similar short-term outcomes compared with SAVR in high-risk patients. Transcatheter aortic valve implantation offers a safe and effective treatment option in a challenging patient cohort. A randomized controlled trial in a lower-risk redo population seems warranted.
P103 Transcatheter Aortic Valve Implantation Versus Minimally Invasive Aortic Valve Replacement With Sutureless Valve: A Single-Center Matching Study
Francesca Chiaramonti1, Giovanni Concistrè1, Tommaso Gasbarri1, Federica Marchi1, Giacomo Bianchi1, Danyar Gilmanov1, Pierandrea Farneti1, Sergio Berti1, Mattia Glauber2, Alfredo Giuseppe Cerillo1, Marco Solinas1. 1Heart Hospital G. Pasquinucci FTGM, Massa, Italy; and 2Istituto Clinico Sant1Ambrogio, Milano, Italy.
Objective: Surgical aortic valve replacement is still the treatment of choice for patients with severe symptomatic aortic valve stenosis (SSAVS). During the last few years, novel technologies such as transcatheter [transcatheter aortic valve implantation (TAVI)] and sutureless bioprosthesis (whether or not with minimally invasive approaches) have shown early good results. The aim of this study was to compare early and midterm outcomes of high-risk patients undergoing TAVI procedures versus patients undergoing minimally invasive aortic valve replacement (MIAVR) with sutureless or rapid-deployment bioprosthesis.
Methods: From January 2011 to December 2013, 69 patients with SSAVS underwent TAVI procedure at our center (TAVI group). This prospective cohort of patients was matched by four categories of risk profile and three categories of age, to a prospective cohort of patients undergoing MIAVR with a sutureless/rapid-deployment bioprosthesis from January 2011 and December 2013 (sutureless group, n=73 patients) at our center. We created a group of 40 pairs of patients with comparable preoperative risk profile and age.
Results: Major/minor vascular complications were significantly more frequent in the TAVI group than in the sutureless group (15.0% vs. 0%, P=0.0255). Median mechanical ventilation time and median intensive care unit stay were significantly lower in the TAVI group compared with the sutureless group. In the sutureless group, the rate of new onset of atrial fibrillation was higher with respect to the TAVI group [38.5% (n=15) vs. 10.8% (n=4), respectively; P=0.0083]. At discharge and at 1-year follow-up, mean transvalvular gradient was comparable between the two groups, whereas paravalvular regurgitation was more frequent after TAVI (P<0.001), but paravalvular regurgitation was not associated with increased 1-year mortality (P>0.001). At discharge, mortality rate was higher in the TAVI group compared with sutureless group (7.5% vs. 2.5%; P=0.6153), but 1-year mortality rate was 5.6% (n=2) in the TAVI group and 13.2% (n=5) in the sutureless group (P=0.4310), and the 1-year cumulative mortality was not significantly different between the two cohorts.
Conclusions: In high-risk patients with SSAVS, transcatheter procedures and MIAVR with sutureless/rapid-deployment bioprosthesis were associated with similar rates of survival at 1 year, although 30-day mortality was considerably lower in the sutureless group. Moreover, there were some differences in periprocedural complications and midterm outcomes.
P104 Transapical Aortic Valve Implantation in Dialysis-Dependent Patients
Sergey Leontyev, Philip Kiefer, Norman Mangner, Axel Linke, Gerhard Schuler, Friedrich W. Mohr, David Holzhey. Heart Center Leipzig, Leipzig, Germany.
Objective: The treatment of dialysis-dependent patients is associated with increased postoperative morbidity and in-hospital mortality. The purpose of this study was to evaluate outcome in those patients who underwent transapical aortic valve implantation for severe aortic valve stenosis.
Methods: A total of 47 dialysis-dependent patients underwent transapical aortic valve implantation between 2008 and 2015. The mean age was 75±8 years, and 66% were male. The mean Society of Thoracic Surgeons score and EuroSCORE logistic II score were 14.5±10.6 (range, 30.4–2.1) and 8.4±6 (range, 48.5–2.8), respectively. The most common comorbidities were diabetes (38.3%), chronic obstructive pulmonary disease (39.1%), peripheral vascular disease (40.4%), and pulmonary hypertension (36.2%).
Results: In-hospital mortality was 25.5% (n=12) for all patients. Sternotomy and conventional aortic valve replacement were necessary in one patient (2.1%) because of annulus rupture. The most common reasons for death were sepsis, heart insufficiency, and multiorgan failure. Other postoperative complications were pneumonia (15.2%), low cardiac output (10.9%), bleeding (6.5%), atrioventricular block with pacemaker implantation (17.4%), stroke (6.3%), and sepsis (8.7%). Wound healing complication was observed in one patient (2.2%). One-year survival was 44%±1% with estimated mean survival time of 2.5±0.5 years.
Conclusions: Transapical aortic valve implantation in dialysis-dependent patients was associated with low rate of intraoperative complication. However, the early and midterm mortality were significantly increased because of high-risk profile of the patient. The most common postoperative complications were pneumonia and low-cardiac output.
P105 Right Thoracotomy: The Access of Choice for Transaortic Transcatheter Aortic Valve Replacement
Julius I. Ejiofor1, Morgan T. Harloff1, Marko T. Boskovski1, Siobhan McGurk1, Prem S. Shekar1, Lawrence H. Cohn1, Pinak Shah2, Tsuyoshi Kaneko1. 1Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA USA; and 2Division of Cardiology, Brigham and Women’s Hospital, Boston, MA USA.
Objective: Transcatheter aortic valve replacement (TAVR) is now a well-established option in high-risk patients with aortic stenosis. In cases unsuitable for the transfemoral approach, transaortic access offers an alternative approach. A right thoracotomy offers a better technical coaxial angle for transaortic TAVR implantation compared with a median sternotomy, which may lead to less paravalvular leak. We report a series of transaortic TAVRs performed via right thoracotomy incisions with emphasis on technical success, morbidity, and mortality.
Methods: All TAVR patients in our cardiac surgery database from November 2011 to May 2015 were queried. Of 353 TAVRs, 42 cases of transaortic performed via right thoracotomy were identified for analysis. Median follow-up time was 1.5 years [interquartile range (IQR), 0.8–2.2].
Results: Mean age of the cohort was 80.7±8.4 years, and 26/42 (61.9%) were women. At baseline, 31% were diabetic, 9.5% had renal failure, 7.1% had previous strokes, and 11.9% had previous myocardial infarctions. Mean ejection fraction was 55±10.1, and 61.9% were in class III/IV New York Heart Association heart failure. A total of 47.6% had previous cardiac surgery, and mean Society of Thoracic Surgeons PROM score was 7.85.7. Balloon expandable valves were used in 40 patients (95%) and self-expandable valves in the rest. Technical success rate was 97.6% (41/42). One patient required open conversion and cardiopulmonary bypass. Operative mortality was 7.2% (3/42). There were no reoperations for bleeding and no postoperative stroke, and 7.1% (3/42) had new-onset renal failure. No patient required permanent pacemaker postoperatively. Six patients (14.3%) had mild paravalvular leaks, and none had more-than-moderate paravalvular leak. Median intensive care unit and hospital lengths of stay were 45 hours (IQR, 26–68 hours) and 7 days (IQR, 5–8 days), respectively. One- and 2-year survival rate were 73.7% (95% confidence interval, 60.3%–87.1%) and 67.8% (95% confidence interval, 53.5%–82%), respectively.
Conclusions: Transaortic TAVR via a right thoracotomy allows accurate positioning and low rate of paravalvular leak. Right thoracotomy should be the access of choice for transaortic TAVR.
P106 Improved Outcomes in Transcatheter Aortic Valve Replacement Using a Minimalist Approach: A Single-Center Experience
Kendra J. Grubb, Tyler Fields, Mary Jo Noon, Michael Flaherty, Jaimin Trivedi. University of Louisville, Louisville, KY USA.
Objective: Transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis (AS). A minimalist approach (MA) to TAVR, relying on local anesthesia and conscious sedation (MAC) has been used and has a reported benefit of improved outcomes.
Methods: This is a single-center, prospective, study of 50 consecutive MA-TAVR patients compared with 50 patients who underwent TAVR under general anesthesia (GA-TAVR). The MA-TAVR protocol included intraoperative MAC and transthoracic echocardiogram guidance and a postoperative protocol including no narcotics, mobilization within 4 hours of intensive care unit arrival, and the goal of discharge directly from the intensive care unit on postoperative day 1. Patients were treated with balloon expandable or self-expanding valves. Preoperative, intraoperative, and postoperative data were collected.
Results: Fifty consecutive patients with appropriate anatomy for a percutaneous approach were assigned to the MA-TAVR protocol. Preoperative variables and comorbidities were not significantly different between the MA-TAVR and GA-TAVR cohorts, with the exception of fewer female patients undergoing MA-TAVR [26% (13) vs. 56% (28), P=0.002] and higher Society of Thoracic Surgeons PROM (10.7±3.3 vs. 9.1±5.5, P=0.002) in the MA-TAVR group. Intraoperative variables were similar with the exception of a lower volume of contrast used during the MA-TAVR (126.9 vs. 207.7 mL, P<0.0001). Postoperatively, there was no difference in in-hospital mortality, mortality at 30 days, major vascular complication, need for permanent pacemaker, or stroke. There was a clinical increase in the number of patients who developed renal failure and required dialysis in the GA-TAVR group [6% (3) vs. 0 in MA-TAVR, P=0.07]. A higher proportion of MA-TAVR patients were discharged home [78% (39) vs. 58% (29), P=0.05] with a significantly shorter postoperative length of stay [2.5±3.3 (median. 1) vs. 5.1±3.8 (median, 4) days, P<0.0001].
Conclusions: Minimalist approach TAVR is safe and associated with low morbidity and mortality. Implementation of an MA-TAVR protocol resulted in shorter length of hospitalization with the majority of patients being discharged home. The improved outcomes associated with MA-TAVR illustrate increased efficiency and potential cost savings.
P107 The Surgical Experience of Transcatheter Aortic Valve Replacement for Bicuspid Aortic Valve
Kizuku Yamashita, Yusuke Shimahara, Tomoyuki Fujita, Hiroki Hata, Yuta Kume, Yorihiko Matsumoto, Junjiro Kobayashi. National Cerebral and Cardiovascular Center, Suita City, Japan.
Objective: Bicuspid aortic valve (BAV) remains a challenging structural valve disease of transcatheter aortic valve replacement (TAVR). The aim of this study was to evaluate the efficacy and safety of TAVR in patients with severe aortic stenosis described as BAV.
Methods: Between October 2013 and December 2015, 104 consecutive patients underwent TAVR for severe aortic stenosis in our institute. Of those, BAV was diagnosed based on transesophageal echocardiography and multidetector computed tomography in four patients (3.9%; median age, 85.4 year; range; 69.0–88.5; three female patients). Transcatheter aortic valve replacement with balloon-expandable prosthetic valve was performed in each patient. The median Society of Thoracic Surgeons Predicted Risk of Mortality (STS) score was 5.5% (range, 2.7%–5.9%). We examined clinical outcomes as well as intraoperative and postoperative complications.
Results: The median aortic annulus diameter was 25.8 mm (range, 23.1–28.1) by 20.1 mm (range, 16.2–21.5), and the median aortic valve area was 448 mm2 (range, 404–465) detected by preoperative multidetector computed tomography during end-systolic phase. Each BAV had a raphe between the right and left coronary cusp in three patients and left coronary cusp in one patient. Transaortic approach and transfemoral approach were performed in one patient and three patients, respectively. Annulus rupture occurred in one patient who had a bulky calcification of the raphe and was cured by immediate subxiphoid pericardial drainage. The patient required permanent pacemaker implantation after TAVR. Stroke of the cerebellum occurred in another patient. Although the postoperative rehabilitation was required, neurologic symptoms were improved. There were no other major complications and conversions to surgical aortic valve replacement. Transcatheter aortic valve replacement except annulus rupture was accomplished without blood transfusion. The median operation time was 2.4 hours (range, 1.8–2.7); median intensive care unit stay was 2.5 days (range, 1–6). Postoperative paravalvular leak was less than mild in all patients, and severe aortic stenosis disappeared by transthoracic echocardiographic follow-up. There were no rehospitalizations due to cardiac events including heart failure and no early or late mortality.
Conclusions: Transcatheter aortic valve replacement for BAV is feasible in selected patients with low to intermediate STS score. Understanding of the aortic valve anatomy and preparation for major adverse complications such as annulus rupture or valve malposition are crucial to achieve successful outcomes.
P108 Transcatheter Transapical Mitral Valve-in-Valve Implantation: The Singapore Experience
Zameer Aziz, Jia Lin Soon. National Heart Centre, Singapore, Singapore.
Objective: This study reports the results of transcatheter mitral valve-in-valve implantations in our center to review the safety and efficacy as a complementary approach to reoperative mitral valve surgery.
Methods: We present a prospective study of six patients (age, 59–85 years) who received transapical implantation of a transcatheter prosthesis in the mitral position at our institution over 4 years. All patients were considered to be at an increased risk after evaluation by an interdisciplinary heart team. We analyzed the outcomes with up to 2-year follow-up.
Results: The average Society of Thoracic Surgeons score for the cohort was 11.85% (range, 5.46–22.32). The average EuroSCORE was 12.66 (range, 5.62–27.80). Implantation was successful in all patients. All patients were implanted with SAPIEN XT transcatheter valves: one #29, one #23, and four #26 size valves. Five patients underwent implantations into previous mitral valves, and one patient who had a previous mitral ring repair had a transcatheter valve implanted. One patient experienced intraoperative hypotension requiring hemodynamic support. There were no other clinically significant complications encountered. Mean reduction in transvalvular gradients from 12.26 to 6.25 at 1 year was shown, with a corresponding decrease in mean New York Heart Association scores. The mean duration of hospital stay was 7.5 days (range, 6–13).
Conclusions: Transapical mitral valve-in-valve implantation provides a promising complementary approach to reoperative mitral valve surgery in carefully selected patients with satisfactory clinical outcomes.
P109 Efficacy of Intraoperative Monitoring of Limb Perfusion With Near-Infrared Spectroscopy in the Prevention of Lower-Limb Neuropathy After Minimally Invasive Cardiac Surgery
Kosuke Nakajima, Kazuyuki Nagata, Toshinori Totsugawa, Arudo Hiraoka, Tomoya Oshita, Ryosuke Muraki, Masahisa Arimichi, Hidenori Yoshitaka, Taichi Sakaguchi. The Sakakibara Heart Institute of Okayama, Okayama, Japan.
Objective: Lower-limb neuropathy (LLN) sometimes occurs after minimally invasive cardiac surgery with peripheral perfusion access. As insufficient distal perfusion is a possible cause of this complication, aggressive intraoperative management including alternative perfusion strategies by monitoring lower-limb perfusion with near-infrared spectroscopy (NIRS) may be useful.
Methods: Minimally invasive cardiac surgery via right minithoracotomy was performed in 487 patients between 2009 and 2015. Surgical procedures included mitral valve surgery in 310 patients, aortic valve surgery in 131, and the other procedures in 36. Near-infrared spectroscopy was used in the recent 227 patients (NIRS group). Occurrence of LLN was retrospectively compared between the NIRS group and the remaining 260 patients (control group). In most patients, cardiopulmonary bypass (CPB) was established with single femoral arterial access. The size of the femoral arterial cannula was selected based on necessary flow dynamics and the diameter of the femoral artery measured by preoperative contrast-enhanced computed tomography. When the femoral artery was too small, alternative perfusion access was considered, including bilateral femoral artery, the right axillary artery, and central aortic cannulation. In the NIRS group, perfusion status of lower-limbs was continuously monitored during the period of CPB, and further alternative strategies were considered when tissue oxygen saturation decreased by more than 30% of the preoperative values.
Results: The duration of CPB was similar between the two groups (NIRS vs. control: 170±52 vs. 167±52 minutes). More patients received intraoperative change of perfusion access in the NIRS group, including additional distal limb perfusion using a small catheter in five patients (Table P109-1). As a consequence, the incidence of LLN was significantly lower in the NIRS group than the control group (0.4% vs. 5.5%, P=0.0014).
Conclusions: Intraoperative monitoring of tissue-oxygen saturation with NIRS is useful for optimal lower-limb perfusion to prevent LLN after minimally invasive cardiac surgery.
P110 Low Incidence of Cerebral Microembolization During Convergent Procedure for Atrial Fibrillation
Borut Gersak1, Katarina Surlan Popovic2, Marta Cvijic3, Bor Antolic3, Tine Prolic Kalinsek4, Matevz Jan4. 1University of Ljubljana, Department of Cardiovascular Surgery, UMC Ljubljana, Ljubljana, Slovenia; 2Department of Interventional Radiology, UMC Ljubljana, Ljubljana, Slovenia; 3Department of Cardiology, UMC Ljubljana, Ljubljana, Slovenia; and 4Department of Cardiovascular Surgery, UMC Ljubljana, Ljubljana, Slovenia.
Objective: This study aimed to assess the rate of cerebral microembolization during the convergent procedure (CP) for the treatment of atrial fibrillation.
Methods: A prospective study included 22 consecutive patients [age 58.9±6 years; 68.2% (15/22) male] who underwent hybrid CP for the treatment of paroxysmal atrial fibrillation. Patients received intravenous heparin to reach the ACT of at least 300 seconds before the transseptal punctures. Magnetic resonance scans (diffusion-weighted and FLAIR) were performed the day before and the day after the procedure. Presence of new cerebral ischemic lesions was assessed.
Results: Only one patient (4.5%, 1/22) had two new ischemic cerebral lesions (diameter, 1–2 mm) and was without any clinically detectable neurologic deficit.
Conclusions: The incidence of periprocedural cerebral microembolization in patients with paroxysmal atrial fibrillation undergoing CP is low.
P111 Impacts of Size and Viability of Revascularized Area on Graft Flow and Patency in Off-Pump Coronary Artery Bypass Grafting
Hiroyuki Nakajima, Tabata Mimiko, Masaru Kambe, Masahiro Ikeda, Kazuhiko Uwabe, Toshihisa Asakura, Atsushi Iguchi, Hiroshi Niinami. Saitama International Medical Center, Saitama, Japan.
Objective: Graft flow is an important predictor of patency of arterial and vein graft and is determined by balance against native coronary flow and flow demand. Although evaluation of native coronary stenosis has been improved, the impact of flow demand has not yet been fully discussed. We examined the impact of flow demand in the grafted region on the graft flow and patency.
Methods: We examined 692 bypass grafts in 376 patients who underwent off-pump coronary artery bypass grafting and postoperative angiography between 2007 and September 2014. They consisted of 310 in situ internal thoracic artery (ITA)–to left anterior descending, 121 in situ ITA and 63 aortocoronary saphenous vein graft (SVG)–to–left circumflex (LCX), and 135 in situ gastroepiploic artery and 63 aortocoronary SVG–to–right coronary artery (RCA). Only bypass grafts, which were individual, and created as the sole bypass graft for each vascular region were selected. Flow insufficiency (FI) was defined as 20 mL/min or less in intraoperative flowmetry, and graft failure was defined as occlusion or string sign in postoperative angiography. MLD was measured at the narrowest portion of the target vessel. Proximal lesion was defined as stenosis at #1 to 3, 5, 6, and 11, whereas distal lesion was defined as stenosis at #4, 7, and 12 to 14.
Results: There were 120/692 (17.3%) FIs and 46/692 (6.6%) failures. Flow insufficiency significantly correlated with graft failure of ITA (x3.1), gastroepiploic artery (x2.8), and SVG (x5.8) (P<0.001). By multivariate logistic regression analysis, distal lesion [odds ratio (OR), 3.45; P<0.001], RCA (OR, 13.3; P<0.001) and LCX (OR, 2.23; P=0.01) region, previous myocardial infarction in the grafted region (OR, 3.72; P=0.02), and large MLD (OR, 3.72; P<0.001) were identified as significant predictors of FI. For RCA, there were 52/198 (26.3%) FIs and 26/198 (13.1%) failures. The causes of FI were competitive flow in 23.1% (11/52), small revascularized area due to hypoplastic RCA or stenosis at midportion of posterior descending branch at 34.7% (17/52), history of myocardial infarction at 34.7% (17/52), and LCX ectasia providing abundant collaterals at 5.8% (3/52).
Conclusions: Since graft selection based on the severity of native coronary stenosis has been introduced, the incidence of competitive flow decreased, whereas the influence of flow demand and collateral circulation became evident. The size and viability of revascularized area should be taken into account for surgical decision-making to achieve sufficient graft flow and patency.
P112 IntraClude Device: How to Predict the Balloon Volume Inflation From Previous Experience Analysis
Monica Contino1, Massimo Giovanni Lemma1, Claudia Romagnoni1, Andrea Mangini1, Antonietta Delle Fave1, Simone Colombo1, Carlo Antona2. 1Ospedale Luigi Sacco, Milan, Italy; and 2Universitá degli Studi di Milano, Milan, Italy.
Objective: The heart-port procedure is performed using the endo-balloon for aortic cross-clamping. The new IntraClude (Edwards Lifesciences, Inc., Irvine, CA USA) features a new design of both catheter and balloon, resulting in an easier clamping technique. A balloon filling strategy based on an initial volume of 10 mL of saline, followed by additional injections of 2 mL up to complete aortic occlusion, is suggested by the producer. We report a simpler and faster filling procedure based on a relationship between balloon pressure and volume and the size of the ascending aorta.
Methods: From August 2012 to November 2015, 33 patients (20 were male) underwent minimally invasive valve surgery with the use of IntraClude (22 had repair, 11 had replacement, 2 had redo); mean age was 58±9.2 years. All 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. During the first four surgeries, we observed that the aortic occlusion was complete and stable when the balloon pressure was kept between 300 and 350 mmHg; an additional 2-mL volume was injected whenever this value got close to 300 mmHg. We analyzed the final balloon volume and the aortic diameter of each patient within a balloon pressure between 300 and 350 mmHg.
Results: Mean ascending aorta diameter was 31.45±2.12 mm, mean cross-clamping time was 120.73±41.01 minutes, mean saline volume inflated was 27.73±4.24 mL, and mean balloon pressure was 340.94±53.74 mmHg. There is a significant relationship between ascending aorta diameter and total balloon inflation volume calculated by linear regression (Fig. P112-1) (inflation volume=1.54× ascending aorta diameter−20.81). The Pearson product moment correlation showed an R=0.84 (P<0.001), R2=0.7 with an adjusted R2=0.69, and an SE of estimate=4.06.
Conclusions: The presence of a relationship well correlating ascending aorta dimensions and the saline volume necessary to reach an effective aortic cross-clamp is important to guarantee a stable occlusion throughout the operation. Additional saline volume can be required to keep the balloon pressure between 300 and 350 mmHg.
P113 Risk Stratification and Care Bundle Approach Including Endoscopic Vein Harvesting Reduces Sternal and Donor Site Infection Rates to 0%
Rashmi Yadav, Melissa Rochon, Terri Ann Russell, Cesare Quarto, Richard Trimlett, Anthony De Souza. Royal Brompton Hospital, London, United Kingdom.
Objective: Surgical site infection (SSI) after coronary artery bypass surgery causes significant morbidity, but to date, there is a lack of risk stratification tool to identify patients at high risk of SSI. We report a risk stratification model developed at our institution and externally validated at three additional institutions. The risk stratification model was used to focus our efforts at reduction of SSI at the highest-risk group.
Methods: The Brompton Harefield Infection Score (BHIS) was developed using binary logistic regression analysis to identify independent predictors of SSI in coronary artery bypass grafting patients. Area under the receiver operating characteristic curve for the model was 0.727. A series of “care bundle” interventions were targeted at patients identified by the BHIS as high risk. These included extended preoperative antibacterial wash, endoscopic vein harvesting, modified sternal closure, extended antibiotic prophylaxis, negative pressure wound therapy (PICO), and patient involvement in self-care using wound photographs at hospital discharge.
Results: Diabetes, HbA1c greater than 7.5%, body mass index greater than 3, female sex, left ventricular ejection fraction of less than 45%, and emergency surgery were identified as independent risk factors for SSI. Patients with a score of 4 or higher were identified as high risk with a predicted SSI risk in excess of 16%. Concerted effort was made to implement the care bundle approach for high-risk patients belonging to two consultant firms. The remaining patients in the institution were treated routinely. Between October 2013 and October 2015, in the high-risk group (n=29) treated with the care bundle approach, the SSI rate was reduced to 0%. In the same period, SSI rate in high-risk patients not treated with the care bundle approach was 12.5% (7 of 56). The difference between the two groups did not reach statistical significance (P=0.08 by Fisher exact test).
Conclusions: The BHIS identified high-risk patients for SSI, in whom a targeted multidisciplinary care bundle approach was successfully implemented. Although the data were not statistically significant, the abolition of sternal and leg wound infections in the highest-risk group had a great impact on quality improvement for our patients. This model and treatment approach warrant further validation because of its potential to have significant impact on SSI after coronary artery bypass grafting.
P114 Preoperative Eligibility for Minimally Invasive Coronary Artery Bypass Grafting: An Examination of Epicardial Adipose Using Computed Tomography
Kate Dillon1, Marjorie Johnson1, Ian Chan2, Bob Kiaii3. 1Western University, London, ON, Canada; and 2Department of Radiology and 3Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, ON, Canada.
Objective: One of the primary concerns necessitating conversion to a conventional full sternotomy coronary artery bypass procedure from a robot-assisted endoscopic single-vessel small thoracotomy (endo-SVST) is the inability to visualize the left anterior descending (LAD) coronary artery within the surrounding epicardial adipose tissue using the endoscopic camera. The purpose of this study was to determine whether the analysis of anatomical properties of the epicardial adipose tissue, along with anthropometric parameters examined using patient data and preoperative computed tomographic (CT) images, is able to predict and thus reduce the need for intraoperative conversion based on effective preoperative exclusion criteria.
Methods: A retrospective analysis of patient preoperative CT angiographic scans from both converted (n=13) and successful robot-assisted (n=13) procedures was performed. Where possible, measurements of thoracic cavity dimensions and epicardial adipose tissue thickness were acquired from axial slices, at the most accessible segment of the LAD, in the fourth anterior intercostal space. An independent-samples Student t test (α=0.05) was performed using IBM SPSS Statistics 22 (IBM, Armonk, NY USA).
Results: Results indicate that patients who successfully underwent the endo-SVST procedure (mean thickness, 5.0±2.0 mm) had significantly less epicardial adipose tissue (34%, P=0.03) overlying the LAD in the transverse [Fig. P114-1, LAD to pericardium (II)] measurement than those who were converted to the full sternotomy approach intraoperatively (mean thickness, 7.6±3.3 mm). Using this mean thickness as the baseline for exclusion reduces the conversion rate for this group by 46%. Preliminary data suggest that no significant differences exist between the two groups with respect to the remaining epicardial adipose tissue and anthropometric data.
Conclusions: The addition of CT measurements of the epicardial adipose tissue overlying the LAD may enhance preoperative surgical planning for the endo-SVST procedure, thereby reducing the instances of procedural changes, which have been shown to lead to higher patient morbidity, along with increased operative time and costs.
P115 Minimally Invasive Aortic Valve Replacement: No Groin, A New Perfusion Technique: The “R-R India Method”
Ravi K. Singh, Rajneesh Malhotra. Max Heart and Vascular Institute, New Delhi, India.
Objective: The main objective of our study was to develop a technique for performing minimally invasive aortic valve replacement (MIAVR) that should avoid all complications of the groin incision involved in femoral cannulation and cannula traffic in central cannulation.
Methods: For MIAVR, the most popular cannulation technique among surgeons worldwide is still total femoral cannulation, and few surgeons adopt direct ascending aorta cannulation and femoral vein cannulation for venous drainage. Both techniques are associated with groin incision’s complications. Some adopt totally central arterial and venous cannulation technique but reluctant for the same because of the crowding of cannulae in the surgical field of interest. We have developed our direct technique of perfusion to avoid all complications related to retrograde perfusion, groin exposures, and cannula traffic. In our technique, we can avoid extra incision in the groin for femoral cannulation, and the three-stage venous cannula comes out from the midaxillary line through the fifth intercostal space (the site is used for pleural chest tube insertion after the completion of procedure). Venous cannula completely avoids the surgical field, so that there is no crowding by the venous cannula (Fig. P115-1).
Results: We have just used this technique in our practice, and now, we are performing all our MIAVRs with this technique successfully. To date, we have performed this technique in five cases with 100% success rate, no mortality, no morbidity, involving four female and one male patient. Mean age was 51.8 years (27–63 years), mean weight was 66.6 kg (37–95 kg), mean cardiopulmonary bypass time was 216.8 minutes (169–241 minutes), and mean aortic cross-clamp time was 143.2 minute (123–168 minutes).
Conclusions: Our technique can be used for MIAVR with good success results without involving any complications of groin incision and retrograde perfusion.
P116 Single-Stage Hybrid Coronary Intervention With Concomitant Minimal Invasive Valve Surgery
Andreas Habertheuer, Arminder Jassar, Bill Matthai, Prashanth Vallabhajosyula, Clark Hargrove, Jacob Gutsche, William Vernick, Wilson Y. Szeto. Hospital of the University of Pennsylvania, Philadelphia, PA USA.
Objective: In high-risk patients requiring open heart surgery, hybrid procedures offer less invasive methods of addressing patient cardiac pathology. We report our single-institution outcomes of a single-stage hybrid strategy for high-risk patients with concomitant valvular and coronary artery disease.
Methods: From 2010 to 2015, 24 patients underwent single-stage hybrid surgery consisting of percutaneous coronary intervention (PCI) followed by minimally invasive valve replacement/repair. In all cases, a loading dose of 300-mg clopidogrel was given before induction of anesthesia and PCI. Aortic valve replacement (n=21) was performed via a partial sternotomy approach, and mitral valve repair (n=3) was performed through a right minithoracotomy approach. Patient records were retrospectively reviewed.
Results: Mean patient age was 71.2±10.3 years (29.2% female), with the majority of patients presenting with one vessel disease (n=18). Aortic valvular pathology was severe aortic stenosis in all cases (mean aortic valve area, 0.8±0.2 cm2; mean gradient, 41.6±9.5 mmHg). Mitral valvular pathology was severe mitral regurgitation (functional, n=1; leaflet prolapse, n=2). There were no intraoperative conversions to full sternotomy. Percutaneous coronary intervention was successfully performed in 96% (n=23) of the cases, with successful minimally invasive surgery in all cases. Mean cardiopulmonary bypass time was 97±24 minutes, and mean aortic cross-clamp time was 69±19 minutes. Intraoperative transfusion requirement was zero. In-hospital and 30-day mortality was 4% (n=1). Stroke rate, reoperation for bleeding, and renal failure rate were zero. Ten patients (42%) required blood product transfusion postoperatively, with a mean transfusion rate of 0.8±1.6 U per patient for the entire group. On discharge echocardiography, paravalvular leak rate was zero in patients undergoing aortic valve replacement, and mitral regurgitation rate was also zero.
Conclusions: This study demonstrates the feasibility and early safety of single-stage hybrid strategy with PCI followed by valvular surgery in high-risk patients (Table P116-1). This strategy enables the use of minimally invasive surgical approaches to treat combined valvular and coronary artery pathology, which may have decreased operative morbidity in high-risk patients.
P117 Comparison of COR-KNOT Device Suture-Fastening System Versus Hand Tying In Conventional Open Cardiac Surgery: A Retrospective Study
Sudeep Das De, Paschalis Kapsomenakis, Susan Dewar, Hussein El-Shafei. Aberdeen Royal Infirmary, Aberdeen, United Kingdom.
Objective: The COR-KNOT device is an automated suture-fastening system, which enables the operator to secure the knot as well as to trim and cut the suture without the need for hand tying and cutting the sutures. The COR-KNOT device is used mainly in minimally invasive valve surgery to facilitate easier access and remote suture tensioning. In this study, our aim was to evaluate the safety and speed of the COR-KNOT device compared with hand tying in conventional open surgery.
Methods: This is a retrospective study on patients who underwent cardiac surgery by a single surgeon in one center between October 2013 and June 2014. Procedures included conventional aortic valve replacement with or without concomitant coronary artery bypass graft and major aortic surgery. The cohort of patients was divided into two groups based on the suturing technique used; the COR-KNOT device was used in patients between December 2014 and June 2015. The outcomes were compared to a historical control of patients between October 2013 and December 2014 where conventional hand tying and cutting with scissors was used. The primary outcome measure in each group was the cross-clamp time. We performed multivariate linear regression analyses to compare differences in means of cross-clamp times between the two groups.
Results: In the analysis of the entire cohort, the mean cross-clamp time in the hand tying group was 15.6 minutes longer compared with the COR-KNOT group [95% confidence interval (CI), 8.6–22.6; P<0.05]. In the subgroup of patients who underwent isolated aortic valve surgery, the mean cross-clamp time was 15.96 minutes longer in the hand tying group compared with the COR-KNOT group after adjustment (95% CI, 7.55–24.37; P<0.05). The mean cross-clamp time in patients who underwent aortic valve replacement and concomitant coronary artery bypass graft using hand tying was 15.5 minutes longer compared with the COR-KNOT group (95% CI, 5.85–25.1; P<0.05).
Conclusions: Our study has demonstrated that the COR-KNOT device is a safe suture-fastening system and reduces the cross-clamp times significantly in conventional surgery. Larger randomized controlled trials with longer follow-up times are necessary to further evaluate the safety and efficacy of this device compared with conventional hand tying, especially in the context of concomitant aortic and multiple valve procedures.
P118 Robotic Assistance in Reoperative Cardiac Surgery: Feasibility and Early Outcomes
Husam H. Balkhy, Zewditu Asfaw, Brooke Wilkey, Mackenzie Reupert, Dorothy Krienbring, Susan Arnsdorf. University of Chicago Medicine, Chicago, IL USA.
Objective: Robotic cardiac surgery is well established in the literature and can improve outcomes by eliminating the potential complications of sternotomy, decreasing hospital length of stay, and improving recovery times. These benefits are enhanced in patients who have had previous cardiac surgical procedures by eliminating the added risk of redo sternotomy. We reviewed our robot-assisted reoperative cardiac surgical procedures
Methods: We performed a retrospective chart review of our robotic redo cardiac surgical procedures from 2008 to 2015. The surgical approach was to introduce a 5-mm scope into the appropriate pleural space away from previous incisions. A limited video-assisted thoracoscopic surgery dissection was then performed as necessary to create a space for the robotic camera and arms after which the robot was docked and the rest of the redo dissection was performed. Valve and intracardiac procedures were performed with peripheral cannulation and endoballoon cardiac arrest. Totally endoscopic coronary artery bypass was performed on the beating heart with anastomotic devices.
Results: From 2008 to 2015, 851 patients underwent robot-assisted cardiac surgery. Forty-four patients had one or more previous cardiac surgical procedures. Forty patients had one previous cardiac surgical procedure, and four patients had two previous cardiac surgeries. Demographics are shown in Table P118-1. Ten patients underwent robotic beating heart totally endoscopic coronary artery bypass, 10 patients underwent epicardial left ventricular lead placements, one patient underwent atrial myxoma removal, and 23 patients underwent valve procedures (15 mitral valve, 5 combined mitral and tricuspid valve, and 3 isolated tricuspid valve). Of the 20 mitral valve procedures, 14 were repairs and 6 were replacements; of the 8 tricuspid valve procedures, 7 were repairs and 1 was a replacement. There were eight concomitant Cryomaze procedures for atrial fibrillation. Median length of stay was 4 days. One patient was converted to sternotomy. Perioperative mortality was 2.3%.
Conclusions: Robot-assisted reoperative cardiac surgery is feasible with excellent clinical outcomes. A large experience in robotic cardiac surgery is necessary. Initial careful thoracoscopic dissection allows for safe placement of robotic ports and instruments. Further studies of robotic reoperative cardiac surgery are needed.
P119 Alteration of Echocardiographic Findings and Analysis of the Long-term Survival Factors After Pericardiectomy
Min Soo Kim, Jongbae Son, Dong Seop Jeong, Kiick Sung, Pyo Won Park. Seoul Samsung Medical Center, Seoul, Republic of Korea.
Objective: Echocardiographic findings before pericardiectomy of constrictive pericarditis are well documented. However, there were only few reports on sequential alteration of echocardiogram after pericardiectomy. The purpose of this study was to analyze alteration of echocardiographic findings after pericardiectomy and to uncover the long-term perioperative survival factors for constrictive pericarditis.
Methods: A total of 90 consecutive patients who underwent pericardiectomy from 1995 to 2015 in Seoul Samsung Medical Center were analyzed retrospectively. Patients were categorized into the conventional group and the extended group according to the extent of removal of pericardium based on the relative position to the phrenic nerve. Echocardiographic findings were sorted into three groups: preoperative, immediate postoperative, and the most recent. The median follow-up period was 37.6 months.
Results: The early mortality rate was 4.4%, and the late mortality rate was 4.4% as well. The 10-year survival rates were 70.3%±12.3% for the conventional group and 95.0%±4.9% for the extended group, which were calculated by the Kaplan-Meier method (P=0.021). When multivariate analysis was applied to analyze the long-term survival factors, the odd of survival was 24.9 times greater for the extended group (P=0.021), and the odd of survival was 17.8 times greater when cardiopulmonary bypass was used (P=0.008). When the predictive factors for major adverse cardiocerebral events (MACCEs) were analyzed, patients who had atrial fibrillation before the surgery had 29.3 times greater chance of MACCE (P=0.015), and the patients with early morbidity had 13.6 times higher chance of MACCE (P=0.015). On echocardiographic findings of the immediate postoperative and the most recent examination for both groups, the medial mitral annulus velocity during diastole was significantly decreased, and the ratio of the lateral mitral annulus velocity to the medial mitral annulus velocity during diastole was significantly reduced as well.
Conclusions: Although the postoperative echocardiography may show diminished clinical findings of constrictive physiology regardless of the extent of pericardiectomy, using cardiopulmonary bypass and removal of pericardium beyond the phrenic nerve posteriorly significantly increased the long-term survival rate. Atrial fibrillation before the surgery and early morbidity were the predictive factors for MACCE.
P120 Evaluation of the Efficacy of a Novel Medial Adhesive, MAR VIVO-107, in a Vessel Burst Pressure Study
Pramod Kadaba Srinivasan, Kerstin Pawlowsky, Babette Koegel, René Tolba. University Hospital RWTH Aachen, Aachen, Germany.
Objective: Invasive surgical procedures carry a high risk of bleeding. One of the main causes of bleeding is vascular damage. Our aim was to test the efficacy and adhesive properties of novel synthetic glue, MAR VIVO-107 (Adhesys Medical, Aachen, Germany), in comparison with ligation, coagulation, and TachoSil (Baxter Healthcare, Deerfield, IL USA) (a fibrin patch).
Methods: Arteries and veins were freshly explanted from a porcine. The vessels were sectioned into a desired length of 1 cm. The cuts were sealed with MAR VIVO-107, ligation, coagulation, or TachoSil. The vessels were then connected to an infusion pump. Physiological saline was pumped into the vessels at a constant flow (99 mL/h), and the opposite ends of the vessels were ligated. The maximum pressure at which the vessels burst was recorded using a digital pressure meter. The results were documented and statistically analyzed using one-way analysis of variance and Tukey post hoc test.
Results: MAR VIVO-107 showed superior sealing performance in comparison with TachoSil. The results of MAR VIVO-107 were comparable with those of coagulation, which is the clinical standard for hemostasis during laparoscopic surgery. The mean venous pressure was assumed to be 20 to 25 mmHg, whereas, MAR VIVO-107 (150±56.14 mmHg) showed numerically higher values compared with TachoSil (19±4.07 mmHg); however, ligation (620±136 mmHg) was significantly stronger compared with the other groups. Meanwhile, the mean systolic arterial pressure is 120 mmHg; MAR VIVO-107 (334±130.63 mmHg) provided sufficient and safe sealing for a pressure, which is two-fold higher than the normal. TachoSil (21±3 mmHg) and MAR VIVO-107 were significantly lower compared with ligation (1196±173 mmHg).
Conclusions: MAR VIVO-107 showed an efficient, strong, and reliable sealing under high pressure in comparison with TachoSil.©2016 by the International Society for Minimally Invasive Cardiothoracic Surgery