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Cardiac Track Abstracts

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2012 - Volume 7 - Issue 2 - p 95–117
doi: 10.1097/IMI.0b013e31825a58ca
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C1 Transcatheter Valve Replacement: New Concepts for Microsurgery Inside the Heart

M. Friedrich1, R. Brecht1, P. P. Heinisch1, K. Plonien1, B. Akra1, C. Hagl1, Rene Bombien 2. 1Clinic of Cardiac Surgery, University of Munich - Grosshadern, Munich, Germany, 2Department of Surgery, Vascular and Endovascular Surgery, University of Munich - Grosshadern, Munich, Germany.

Objective: The catheter-based valved stent implantation already became a part of clinical routine. But to refine these procedures and reduce complications, new concepts will be helpful. The aim of this study was to evaluate an intra-cardiac-corporeal circulatory support and a stapler-based concept for aortic valve replacement.

Methods: ActiveFlowModel: The transventricular valve isolation chamber (TVIC) was combined with an intra-cardiac pump (Impella), and the blood was directly bypassed from the right ventricle into the pulmonary artery. After in-vitro testing (porcine hearts, N = 10), the system was evaluated in a porcine beating-heart model (N = 1). Before isolation of the valve the intra-ventricular bypass was started. Time of bypassing, ECG, oxygen saturation and blood pressure were recorded. AorticValveReplacementModel: The stapler-based instrument for transapical aortic valve replacement (StapAVR) combines a removal section and an implantation section. The in-vitro evaluation was performed using artificial valves with fluorescent debris. During resection, black-light visualized the debris and their movements. A modified StapAVR was used in-situ in a porcine model (N = 4). The resection time and the occurrence of debris were documented.

Results: ActiveFlowModel: the TVIC deployment time in-vivo was 4.6 min ± 0.8min. Mean bypass flow of 1.2 ± 0.1 l/min during isolation was achieved. Oxygen saturation was a median of 94.4% (range 84–98). The median arterial blood pressure was 110 mmHg (systolic; range: 80–150) and 60 mmHg (diastolic; range: 20– 70) without use of inotropes or vasopressores. Sinus rhythm was observed. Isolation time with bypassing was 23 ± 0.7 min. AorticValveReplacementModel: The deployment of the StapAVR in the correct position was performed within 2.0min. The valve resection time was 4.2+/–1.6min. Fluorescent debris was found in the right coronary artery (7%), in the ascending aorta (11%), in the bulbus aortae (35%), and the left ventricle (24%). Valve implantation was performed successful in 3/4.

Conclusions: Active intra-cardiac bypassing during valve-isolation in a beating heart is possible. The next step is the isolation of the aortic valve in a beating heart cycle. The valve replacement with the StapAVR was also possible. Nevertheless, improvements of the prototypes are ongoing. The further development will bring the catheter-based intra-cardiac microsurgery closer to the surgical golden standard.

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C2 Transapical Aortic Valve Implantation at 5 Years

Martin Haensig 1, Ardawan J. Rastan1, David Holzhey1, Thomas Walther2, Jens Garbade1, Michael A. Borger1, Axel Linke1, Jörg Ender1, Gerhard Schuler1, Jörg Kempfert2, Friedrich W. Mohr1. 1Heart Center Leipzig, Leipzig, Germany, 2Kerkhoff-Clinic, Bad Nauheim, Germany.

Objective: The aim was to study the results of transapical aortic valve implantation in high-risk patients with aortic stenosis at up to 5 years after the procedure based on the newly established Valve Academic Research Consortium criterions.

Methods: A total of 439 patients underwent transapical aortic valve implantation from February 2006 until August 2011 using the Edwards SAPIEN prosthesis. Mean patient age was 81 ± 6 years and 64% were female. Logistic EuroSCORE and Society of Thoracic Surgeons score predicted risks for mortality were 30% ± 16% and 11% ± 8%, respectively. All patients were treated in a hybrid suite with advanced imaging modalities by a specialized TAVI team.

Results: Intraprocedural device success was 90.2% and the combined safety endpoint at 30 days occurred in 20.3%. Major vascular complications (3.4%), life-threatening or disabling bleeding (6.2%), and acute kidney injury using a modified RIFLE classification (stage 1: 8.3%, stage 2: 3.3% and stage 3: 16.3%) were further major adverse events. Periprocedural stroke/TIA was observed in 2.1% and further 2.1% of patients had a spontaneous stroke during their hospital stay (minor: 1.6% and major: 2.5%). Transapical aortic valve implantation was uneventful in 384 patients, whereas 55 patients (12.5%) required additional interventions. Such interventions included cardiopulmonary bypass support in 6.2%, implantation of a second SAPIEN valve in 5.5%, coronary intervention in 3.0%, conversion to conventional surgery in 2.5%, and annulus perforation in 0.7% patients (not mutually exclusive). Overall survival was 90% at 30 days, 73% at 1 year, 68% at 2 years, 58% at 3 years, 53% at 4 years and 44% at 5 years.

Conclusions: Transapical aortic valve implantation can be performed with good outcomes in high-risk patients with severe aortic stenosis. Perioperative complications occur in approximately 12.5% of patients. Standardized VARC definitions appear to facilitate outcome reporting beyond regulatory and clinical trials.

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CMP1 Acute Kidney Injury Following Transcatheter Aortic Valve Implantation: Incidence, Predictive Factors and Prognostic Effects

Aiman Alassar, Nada Abdulkareem, Oswaldo Valencia, Stephen Brecker, Marjan Jahangiri. St. George’s Hospital, London, United Kingdom.

Objective: Acute Kidney injury (AKI) is a common complication following surgical aortic valve replacement and is associated with increased mortality. Little is known about the occurrence of AKI after transcatheter aortic valve implantation (TAVI). The aim of the study was to establish the incidence predictive factors and prognostic value of AKI following TAVI.

Methods: Between January 2008 and January 2011, a total of 81 patients with severe aortic stenosis (AS) who underwent TAVI with the Medtronic CoreValve System or Edwards SAPIEN heart valve were included. Baseline characteristics and procedural complications were recorded. AKI was defined as an increase in creatinine levels more than 26.4 mol/L or more than 50% from baseline or more than 1.5 fold from baseline occurring within 48 hours.

Results: Postoperatively, 10 patients (12.3%) developed acute kidney injury which was completely resolved in 9 prior to hospital discharge. Predictive factors of acute kidney injury were diabetes (OR 6.722) and pre-renal dysfunction (OR 1.024). 11 patients (13.5%) died within one year following TAVI. 3 of the nonsurvivors (3.7%) had developed AKI postoperatively. AKI was not a predictive factor of one year mortality following TAVI.

Conclusions: Acute Kidney Injury occurred in 12.3% of the patients following TAVI and persisted in only one patient prior to hospital discharge. Diabetes and pre-renal dysfunction were found to be the main predictive factors of AKI after TAVI. AKI was not associated with increased one-year mortality.

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CMP2 Accuracy of New EuroSCORE II in Patients Undergoing Transcatheter Aortic Valve Implantation

Arnaud Van Linden, Serap Alkaya, Jörg Kempfert, Johannes Blumenstein, Won-Keun Kim, Markus Schönburg, Helge Möllmann, Christian Hamm, Thomas Walther. Kerckhoff Klinik, Bad Nauheim, Germany.

Objective: The patient selection for transcatheter aortic valve implantation (TAVI) is mainly based on risk score assessment, such as the logistic EuroSCORE (LES). It is well known that the LES overestimates the true risk after TAVI. Aim of this study was to evaluate the accuracy of the recently introduced EuroSCORE II (ES II) in patients undergoing TAVI.

Methods: Perioperative data of 138 patients receiving transfemoral or transapical aortic valve implantation between January and November 2011 were analyzed. Predicted mortality was calculated by LES and ES II. Median risk as well as 75th and 90th percentile for each predicted mortality were calculated and related to actual outcomes.

Results: Mean LES and ES II predicted mortality were 23.2 ± 13.2% and 8.1 ± 6.4% respectively (median 20.0% and 6.3%, respectively). Actual 30-day mortality was 11.6%. Subgroup analysis for both scores revealed a trend towards higher actual mortality in patients with predicted mortality above median, 75th or 90th percentile and the patients below without reaching significance (Table 1). The actual mortality for patients with a predicted mortality above the 90th percentile calculated with ES II was slightly lower without significance. Based on the 75th percentile ES II showed higher sensitivity than LES (93.75% vs. 25%), but worse specificity (11.5% vs. 75.4%).

Conclusions: The recently introduced EuroSCORE II seems to better predict overall 30-day mortality after TAVI than logistic EuroSCORE and should become the new golden-standard for risk profile assessment of TAVI patients. Other factors, such as patient frailty will have to be taken into account in addition.



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CMP3 Expanded Experience Using the Transaortic Approach for Transcatheter Valve Implantation Using the Edwards Sapien Valve

Rizwan Attia, Michael Sabetai, Martyn Thomas, Simon Redwood, Jane Hancock, Christopher P. Young, Vinnie N. Bapat. Guy’s and St. Thomas NHS Foundation Trust, London, United Kingdom.

Objective: We report our up-to date series for an alternative approach through the ascending aorta to implant Edwards SAPIEN THV valve in aortic position. We discuss in detail the technical aspects, the surgical advantages and future application of this novel approach. That might revolutionize surgical perspective on TAVI.

Methods: All patients were accepted through the multidisciplinary team. Conventional approach i.e. Transfemoral (TF) or Transapical (TA) was either not possible or desirable and ascending aorta was deemed suitable for cannulation. Procedure was performed under GA guided by fluoroscopy and 3-D transesophageal echo (TEE). We will describe the procedure in detail.

Results: 40/237 (17%) patients underwent the procedure. Median age was 86 (67-94years) with mean Logistic EuroSCORE of 27.2%. All patients had critical stenosis with mean AVA 0.67cm2, PG 72.5mmHg and LVEF 49%. Successful device implantation was achieved in all cases without any postoperative complications directly related to the approach. The incidence of chest sepsis, renal failure and stroke was 6.06%, 12.1% and no strokes compared to 12.2%, 12.8% and 4.85% compared to the TA and TF groups. This is despite higher incidence of co-morbidities (COPD, 17/40 (42.5%) vs. 23/204 (11.2%) p0.01; severe extra-cardiac arteriopathy, 10/40 (25%) vs. 25/204 (12.2%) p0.02 and >50% internal carotid artery occlusion 12/33 (34.3%) vs. 37/204 (18.1%) p0.001 in this cohort compared to the TA and TF routes. There were no procedure deaths. Kaplan-Meier analysis showed survival at 81.8%, 70%, 60% and 55% at 1-month, 6-months, 1-year and 2-years which followed the survival curve for TF patients with slightly higher overall survival in the TA group.

Conclusions: We have successfully used the trans-aortic route in patients deemed unsuitable for conventional approaches. TA approach is technically always feasible but not necessarily desirable in patients with severe chest deformity, poor lung function, previous pulmonary complications and extremely poor ventricular function. Thoracotomy is associated with pain and risk of pleural effusion which can complicate recovery. The advantages of partial sternotomy are the avoidance of these complications and preservation of respiratory dynamics, as the pleura remain intact. LV function is preserved by avoidance of ventricular purse-stings. Future modification of delivery devises might make this procedure more amiable as a default surgical route for TAVI.

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C3 Transapical Aortic Valve Implantation Using the SYMETIS ACURATE TA Device: Clinical Experience to Date

Joerg Kempfert 1, Hendrik Treede2, Ardawan Rastan3, David Holzhey3, Markus Schönburg1, Matthias Thielmann4, Holger Schroefel5, Arnaud van Linden1, Johannes Blumenstein1, Friedrich W. Mohr3, Thomas Walther1. 1Kerckhoff Clinic, Bad Nauheim, Germany, 2Heartcenter University of Hamburg, Hamburg, Germany, 3Heartcenter University of Leipzig, Leipzig, Germany, 4Heartcenter University of Essen, Essen, Germany, 5Clinic for Cardiac Surgery Karlsruhe, Karlsruhe, Germany.

Objective: Transapical aortic valve implantation (TA-AVI) is a standard approach for high-risk elderly patients using the balloon expandable Edwards SAPIEN prosthesis. As an alternative we are evaluating a new self-expanding transapical bioprosthesis in a high-risk patient population.

Methods: This novel device (SYMETIS ACURATE TA Transapical Aortic Bioprosthesis) composed of a porcine biologic valve attached to a self-expandable nitinol stent is designed for anatomical orientation of the commissures and for subcoronary implantation. A unique two-step implantation procedure with ventricular unsheathing provides simple positioning and tactile feedback during implant.

Results: 90 patients have been treated to date, patient age was 83.4 ± 4.1 years, 69% were female, all in NYHA Class III/IV, logistic EuroSCORE was 20.3 ± 8.7% and STS Score was 8.6 ± 6.4%. All implants were delivered successfully in the intra-annular and subcoronary position. Two patients required a valve-in-a-valve (SAPIEN) due to central leak after inadequate post-ballooning in one and after initial device misplacement in another patient. Three patients were converted to surgery, two after coronary obstruction and one following annular dissection post dilatation. Ten patients required a pacemaker post-implantation. 97% of patients had none or 1+ aortic incompetence only; 90% of patients had functional improvement to NYHA class I or II. At 30 days seven patients (7.8%) expired (respiratory complications = 4, right heart failure = 2, unclear = 1). Three patients suffered a secondary stroke.

Conclusions: The ACURATE TA has demonstrated promising results in this high-risk patient cohort, comparable to the SAPIEN experience. The Symetis valve proved good functional outcomes with relatively low rates of relevant aortic incompetence. CE approval has been granted recently.



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CMP4 Toward Direct Percutaneous LV Access: Healing Study of Porcine Heart Transapical Wounds Closed Using a Remote Automated Suturing Technology

Peter A. Knight1, Jude S. Sauer2, James W. Kaufer2, Candice L. Wilshire 1. 1University of Rochester Medical Center, Rochester, NY USA, 2LSI Solutions, Rochester, NY USA.

Objective: A safe and reliable direct percutaneous approach for transapical access to the left ventricle would be a significant advance toward decreasing the invasiveness of intra-cardiac interventions. This report presents initial results from an ongoing healing study in a survivor pig heart model where transapical wounds were closed using an automated suturing technique ultimately intended for percutaneous use.

Methods: A miniaturized automated suturing and mechanical knot placement technology, which simultaneously places two pledgeted horizontal mattress sutures concentrically around an apical access site, has been demonstrated to provide strong wound closures in previous porcine and human cadaver models. Through an approved protocol including general anesthesia, pig beating hearts were surgically exposed to permit transapical passage of a 0.035” guidewire and 5.5 Fr 0.9 ml Fogarty balloon catheter. With the balloon pulling the left ventricle anteriorly, the suturing device was passed over the guidewire and Fogarty onto the wound site. Both horizontal mattress sutures were simultaneously placed with a single squeeze of the device’s lever. Next, an 8.3 mm dilator was passed into the left ventricle over the guidewire and subsequently removed. The sutures were secured using pledgeted titanium knots. Skin wounds were closed. Pigs recovered from anesthesia and resumed a normal diet.



Results: Under general anesthesia, the transapical wound site of each pig was re-exposed via thoracotomy two weeks post surgery. Hemostasis was complete and all wounds healed well. Pigs were then sacrificed.

Conclusions: The evaluation of transapical wound closures in this survivor porcine heart model indicates complete hemostasis and excellent healing through use of this miniaturized automated remote suturing technology.

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CMP5 Experimental Evaluation of a New Apical Access and Closure Device

Johannes Blumenstein 1, Arnaud Van Linden1, Joerg Kempfert1, Mani Arsalan1, Helge Moellmann2, James Greene3, Jorge H. Jimenez3, Thomas Walther4. 1Department of Cardiac Surgery, Kerckhoff Heart-Center, Bad Nauheim, Germany, 2Department of Cardiology, Kerckhoff Heart-Center, Bad Nauheim, Germany, 3Apica Cardiovascular Limited, National University Ireland, Galway, Ireland, 4Department of Cardiac Surgery, Kerckhoff Heart-Center, Bad Nauheim, Germany.

Objective: Transapical (TA) access for aortic valve implantation (AVI) has evolved as a standard and safe procedure using a conventional purse-string suturing technique. The aim of this study was to evaluate a simplified approach using a TA access and closure device to eventually allow for percutaneous left ventricular TA approach.

Methods: The Apica access system (Apica Cardiovascular Ltd., Ireland) consists of an introducer system, which delivers a sealing coil and postprocedural sealing cap. The system accommodates multiple TA-AVI systems. In this study the Edwards Ascendra II system was used in an experimental pig model. Two different types of access coils (with or without a silicon flange for sealing) were evaluated. After partial sternotomy, apical puncture and positioning of the guide wire, the TA delivery sheath was inserted through the Apica introducer system. The introducer system engaged the myocardium by turning the access coil. At the end, the sealing device was inserted through the introducer into the access coil. Integrity of the closure was evaluated under high blood pressure conditions. Post mortem position of the coil was examined.

Results: Eight different access sites were evaluated in 3 male, adult pigs (67 ± 2.5kg). The Apical access site could be safely secured in all cases with the use of the coil without silicon flange. In all cases the access coil stabilized and created an effective seal around the device. Discreet blood loss was documented in all animals during insertion of the sealing cap. The access sites were sealed successfully in all cases. Minor seepage occurred at the edge of the access coil in two procedures which subsided after protamine was administered. Integrity of access site closure was demonstrated while heart was pressurized to 200mm/Hg in all cases. Post mortem examination showed a uniformed depth of the large coil extending to the endocardium and thus providing safe anchoring of the devices.

Conclusions: Apical access, stabilization and closure using the Apica access and closure system is feasible. The use of this system will lead to even easier and standardized apical access and could eventually allow for a percutaneous non rib-spreading TA-AVI procedure in the future.

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CMP6 How Does Etiology of Mitral Regurgitation (MR) Influence Outcome of Interventional Mitral Valve Repair Using the MitraClip System in High-Surgical-Risk Patients

Johannes Schirmer, Stephan Baldus, Hendrik Treede, Volker Rudolph, Olaf Franzen, Malgorzata Knap, Lenard Conradi, Moritz Seiffert, Stefan Blankenberg, Hermann Reichenspurner. University Heart Center Hamburg, Hamburg, Germany.

Objective: Various transcatheter approaches to mitral valve disease have been clinically employed for patients carrying a high risk for surgery. We sought to assess the impact of etiology of MR on functional and clinical results after MitraClip therapy in a cohort of symptomatic patients with severe MR not amenable to surgery.

Methods: Between 9/2008 and 04/2011, a total of 226 consecutive patients underwent MitraClip implantation for either functional MR (group A; n = 143; 63%) or degenerative/mixed MR (group B; n = 83; 37%). Risk for mitral valve surgery was considered high by means of a logistic EuroScore of 31 ± 19% and 28 ± 19% (p = 0.2536), respectively. Preprocedural left ventricular ejection fraction was reduced to 38 ± 14% and 54 ± 12% (p<0.0001), respectively.

Results: MitraClip implantation was successful in 138 (97%) patients with functional and 69 (83%) patients with degenerative/mixed MR (p = 0.0008), respectively. Most of these patients (group A: n = 96 (70%); group B: n = 37 (54%); p = 0.0311) were treated with a single clip, whereas 42 (30%) patients in group A and 32 (46%) patients in group B received ≥2 clips. Preprocedural MR severity was gade 3+ (group A: n = 86 (62%); group B: n = 36 (52%)) or grade 4+ (group A: n = 52 (38%); group B: n = 33 (48%)) (p = 0.1792), whilst MR severity at discharge was grade 1+ (group A: n = 62 (45%); group B: n = 22 (32%)) or grade 2+ (group A: 76 (55%), group B: n = 47 (68%)) (p = 0.0744). NYHA functional class at baseline and at time of discharge did not differ between both groups. Thirty-day mortality was 4.8% in group A and 2.4% in group B (p = 0.358), respectively.

Conclusions: MR of functional origin is associated with significantly higher technical success and requires a significantly lower number of clips for successful procedure as opposed to degenerative/mixed MR. Interventional mitral valve repair is probably more likely to be successful in functional MR compared to degenerative/mixed MR, which is still a domain of surgical mitral valve reconstruction.

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CMP7 Update on Mitral Valved-Stent Implantation with an Apically Tethered Valve

Saskia Pokorny1, Katharina Huenges1, Martin Marczynski-Bühlow1, Telse M. Bähr1, Huangdong Dai1, Jan-Paul Gundlach1, Lucian Lozonschi2, Georg Lutter 1. 1Department of Cardiovascular Surgery, Christian-Albrechts-University of Kiel, School of Medicine, Kiel, Germany, 2Department of Cardiothoracic Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI USA.

Objective: To date, minimally invasive off-pump treatment of mitral valve disease is limited to repair techniques. This study investigates the outcomes of a novel mitral valved-stent using the off-pump technique one and two months after implantation.

Methods: Eight pigs received a self-expanding nitinol valved-stent into the mitral position via a transapical approach. Hemodynamic stability, stent function and positioning were assessed before (n = 8) and 1h after implantation (n = 7), at one month (n = 6) and two months (n=1) using transesophageal echocardiography (TEE), ventriculography and cardiac computed tomography.

Results: One animal died of cardiac fibrillation during the implantation procedure and one animal died due to unrecognized inadequate valved stent positioning 4 days after implantation. Reliable stent stability and good positioning was achieved in all other animals. No arrhythmias were sustained in the six remaining pigs. TEE examination showed no significant mitral regurgitation, no left ventricular outflow tract (LVOT) obstruction and minimal gradients across the new valve and the LVOT. Gross evaluation of the six pigs demonstrated correct stent positioning and no thrombus formation. The atrial elements were covered with 50%/70% tissue ingrowths within the anatomically structures of the left atrium 4 weeks and 8 weeks after implantation, respectively.

Conclusions: Reliable stent stability, minimal gradients and adequate stent function were seen throughout the study at a high degree of reproducibility, over a post-operative period of up to two months. The prospective focus will pertain to stent design, aiming at enhanced durability of the valved-stent components and studying the effects of anchorage to native heart tissue.

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CMP8 First in Man Implantation of Transapical 29 mm Edwards SAPIEN Aortic Valve in a Failed Mitral Valve Repair with a 34 mm Annuloplasty Ring

Gry Dahle, Arnt Fiane, Hilde Korslund, Kjell Arne Rein. Rikshospitalet, OUS, Oslo, Norway.

Objective: Mitral valve repair with annuloplasty ring is the treatment of choice for mitral regurgitation, but recurrency may occur, necessitating re-intervention. The operative risk at re-operation is significantly higher than in the primary operation. It is previously demonstrated that a transcatheter valve-in-valve technique reduces the operative risk. Though, the experience with valve-in-ring procedure is limited, we demonstrate the use of a transapical 29 mm Edwards SAPIEN aortic valve in a failed mitral valve repair with a 34 mm Edwards Physio semi-rigid ring.

Methods: A 71-year-old female underwent both mitral and tricuspid valve repair with implantation of annuloplasty rings three years before referral. The operative result was initially good, but she developed residual mitral regurgitation and heart failure (EF17), NYHA III-IV and declive oedema. She was deemed to have too high operative risk for conventional redo surgery. We measured the Physio-ring inner diameter on 3D-transoesophageal echo and CT scan and correlated this to the company specifications. We tried the 34 mm Physio-ring on different Carbomedics aortic sizers, fitting the 27 mm sizer. In a “bench-test” we expanded a 29 mm Edwards SAPIEN valve into a 34 mm Physio-ring. Following these tests, the patient underwent a transapical mital valve-in-ring implantation on partial cardio-pulmonary bypass. She got electrodes for planned cardiac re-synchronization therapy.

Results: The 29 mm Edwards SAPIEN valve fitted well into the 34 mm Physio-ring. Postoperative the patient had only a small paravalvular leak, otherwise the valve functioned well. IABP was used for 24 hrs, otherwise the postoperative period was uneventful.

Conclusions: The valve-in-ring concept may play an important role in the future to reduce the redo-mortality in patients with failed mitral valve repair. The 26 mm Edwards SAPIEN valve has previously been used in a 28 mm Physio-ring. We have shown that it is feasible to put a 29 mm Edwards SAPIEN valve in a 34 mm Physio-ring. This is of great importance as many Pysio-semirigid rings of the size 30 – 34 mm are used in repairing degenerative mitral valve disease.

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C4 Age Modifies the Comparative Early Outcomes of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting

Arman Kilic 1, David D. Yuh2, Ashish S. Shah1, William A. Baumgartner1, John V. Conte1. 1Johns Hopkins Hospital, Baltimore, MD USA, 2Yale University School of Medicine, New Haven, CT USA.

Objective: To evaluate the effect of age on comparative early outcomes of off-pump (OPCAB) versus on-pump coronary artery bypass grafting (CABG).

Methods: The Nationwide Inpatient Sample registry was utilized to identify patients undergoing isolated OPCAB or on-pump CABG between 2003–2008. Patients were stratified into 4 cohorts according to age: 50–59.9 years, 60–69.9 years, 70–79.9 years, and 80 years of age or older. Outcomes were compared within each age group between OPCAB and on-pump CABG. These outcomes included operative mortality, defined as occurring during the same admission as CABG, postoperative stroke, postoperative major cardiac complication, and hospital cost.

Results: A total of 107,777 OPCAB and 1,165,996 on-pump CABG patients were identified. OPCAB and on-pump CABG patients had similar comorbidities and operative acuity within each age cohort (each p>0.05). Within each age cohort, females were more prevalent in OPCAB compared to on-pump CABG by 2-3% (each p<0.001). For patients under the age of 80 years, the operative mortality was significantly higher in OPCAB (Figure). For those 80 years or older, operative mortality was comparable between OPCAB and on-pump CABG (p = 0.57). Postoperative cardiac complication rates were similar between approaches for each age group (each p>0.05). For patients younger than 70 years, postoperative stroke rates were comparable (Figure). OPCAB was associated with reduced postoperative stroke in patients 70-79.9 years (p<0.001) and patients 80 years or older (p = 0.02). Although hospital costs were higher with OPCAB compared to on-pump CABG in patients younger than 80 years, costs were comparable in those 80 years or older (OPCAB $45,009 versus on-pump $43,617, p = 0.18).

Conclusions: In this analysis of over 1.2 million CABG patients in the United States, patient age modified the comparative outcomes of OPCAB versus on-pump CABG. Moreover, with increasing age, operative mortality rates and hospital costs equalized between surgical approaches, and postoperative stroke rates became significantly lower with OPCAB compared to on-pump CABG. These data collectively suggest that elderly patients may derive greater short-term benefit with OPCAB than younger patients.

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C5 Superior Outcomes in Patients Undergoing Surgery With a Minimized Extracorporeal Circulation Compared to Off-Pump Revascularization

Thorsten Wittwer, Anton Sabashnikov, Yeong-Hoon Choi, Parwis Rahmanian, Mohammed Zeriouh, Thorsten Wahlers. Heart Center, University Hospital of Cologne, Cologne, Germany.

Objective: Conventional coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC) is associated with adverse effects as systemic inflammatory response (SIRS) leading to decreased systemic vascular resistance (SVR) and hemodynamic instability. Owing to the technical improvements in the past decades modern “less invasive” methods of minimized on-pump approaches and off-pump-coronary-artery-bypass (OPCAB) procedures have been established who can potentially avoid the negative side effects of ECC. The aim of this study was to compare both "less invasive" approaches focusing on perioperative outcome particularly with regard to hemodynamic characteristics.

Methods: In this prospective randomized clinical trial 120 patients referred for CABG were assigned either to OPCAB- or to ECC-procedure with utilization of a minimized circuit (Mini-HLM, ROCsafe). Patient demographics, preoperative characteristics and postoperative outcome were analyzed. Hemodynamic data (cardiac index, central venous saturation, central venous pressure, pulmonary capillary wedge pressure, pulmonary and systemic vascular resistance and arterial pressure) were measured at seven time points perioperatively.

Results: Mean age was 65.6 ± 10.8 years, and 18.3 % of patients were female. There were no differences regarding preoperative morbidities between the two groups. The operating time was significantly longer in the Mini-HLM group (178.3 ± 32.9) compared to the OPCAB group (133.2 ± 32.7, p< 0.001) with a significant higher number of grafts in the Mini-HLM group (3.11 ± 0.7 vs. 1.78 ± 0.7, p< 0.001). There were no significant differences in perioperative hemodynamic criteria inotropic support, hospital (p = 0.534) and intensive care unit stay (p = 0.88), ventilation time (p = 0.113), blood loss (p = 0.57), transfusion requirements, postoperative atrial fibrillation rate (p = 0.706) and neurocognitive disturbance (p = 0.297). There were no deaths and no myocardial infarctions observed in both groups.

Conclusions: Conceptional advantages of minimized ECC systems result in perioperative hemodynamics and clinical outcome completely comparable to OPCAB procedures. As an advantage, Mini-HLM combines all OPCAB-benefits with low morbidity and mortality while allowing for more complete revascularization. Therefore, particularly in patients with complex multivessel disease the use of the Mini-HLM may help to improve functional outcome. However, larger clinical series are necessary to validate these preliminary results.

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C6 Hybrid Coronary Revascularization: A Game Changer

Francis P. Sutter 1, Timothy A. Shapiro1, MaryAnn Wertan1, Francis D. Ferdinand1, Janet L. Reynolds1, Anny Luong2, Vanessa J. Cambria-Mengel1, Li Zhang3. 1Lankenau Medical Center, Wynnewood, PA USA, 2Lankenau Hospital, Wynnewood, PA USA, 3Lankenau Institute for Medical Research, Wynnewood, PA USA.

Objective: Hybrid Revascularization, combining survival benefit of left internal mammary artery (LIMA) to left anterior descending (LAD) artery with advances of coronary stents, holds promise as a valuable option in treatment of complex coronary disease (CAD). 2011 AHA/ACC listed: Heart Team Approach - collaboration between interventional cardiology and cardiac surgeon for decision making in patients with complex CAD - a Class I, LOE C recommendation. Maintaining patient anonymity, we report our experience in this retrospective consecutive cohort of 275 patients - pre-planned staged hybrid coronary revascularization procedures - using beating heart, sternal sparing, robotic assisted coronary revascularization with percutaneous coronary intervention (PCI).

Methods: Since May 2005, over 700 robotic assisted procedures were performed, 275 patients underwent staged hybrid revascularization from September 2005-October 31, 2011, 200 patients had surgery first, 75 underwent PCI first. Hybrid candidates include patients with complex CAD; those with ostial LAD disease, bifurcating disease, long lesions, chronic occlusion; left main with small circumflex amenable to later PCI; it is especially considered for patients at high risk for sternotomy; elderly, frail, obese, other co-morbidities; and for young who may require future surgery.

Results: Preoperative risks / co-morbidities for hybrids mirrored our institutional data. 44% with double vessel disease, 55% triple vessel and 10.7% left main disease. 45.4% had greater than one distal graft; 34% had bilateral IMA grafts placed. 18% had COPD, posing no difficulty to single lung ventilation; 87.1% were extubated in OR; 1.5% required reintubation and 1.9% remained ventilated > 24hours. 12% were taking Clopidogrel or Prasugrel; which were not deterrents to scheduling surgery. 56 patients required transfusions; 4.5% intra-operatively, 16% postoperatively. Noteworthy, no patients returned to OR. STS predicted risk of mortality was 2.3%, observed mortality 1.09%.

Conclusions: Hybrid coronary revascularization enhances collaboration and team approach to patient care; maximizing the advantages of PCI and surgery; while decreasing complications associated with sternotomy. Precise robotic movements and meticulous attention avert the need for re-exploration. Full cardiology adoption, institutional outcomes, program growth, and patient satisfaction emphasize potential for greater adoption of available technology and minimally invasive functional revascularization - offering patients promising alternatives with individualized treatment plans.

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C7 Totally Endoscopic Coronary Artery Bypass Grafting on Beating Heart

Changqing Gao. PLA General Hospital, Beijing, China.

Objective: Despite the early introduction of totally endoscopic coronary artery bypass on beating heart (BH TECAB), only a limited number of cases have been performed. The limiting factor has been the concern about safety and graft patency of the anastomosis. This study describes our experience with BH TECAB with robotic assistance and its early and midterm results.

Methods: In 500 cases of robotic cardiac operations, 225 patients underwent robotic CABG on beating heart, in which 80 patients (59/M, 21/F) underwent BH TECAB. Mean age was 66.87 ± 7.7 (33 to 79) years. LIMA to LAD anastomosis was performed using U-CLIP.

Results: 78 TECAB procedures were completed, in which 26 patients received hybrid procedures. Two patients were converted to minithoracotomy. The average LIMA harvesting and anastomosis times were 25.3 ± 11.5 (15∼55) min and 10.3 ± 4.7 (5∼21) min respectively. The mean operating room and operation times were 306.1 ± 53.5 (198∼580) min and 244.8 ± 55.6 (130∼420) min respectively. The drainage was 154.9 ± 53.2 (70∼450) ml. Before discharge, 68 patients underwent angiography and 12 patients underwent CTA scan, and the study showed that graft potency was 100% and unexpectedly, LIMA graft had a collateral branch in 2 patients. After discharge, all patients were followed up by CTA scan, average follow-up time was 18.67 ± 9.43 (1 to 51 months). One patient had gastric bleeding after surgery.

Conclusions: BH TECAB is a safe procedure in selected patients and produces excellent early and midterm patency of anastomosis.

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CV1 Minimally Invasive Direct Right Internal Thoracic Artery Harvesting and Multivessel Total Arterial CABG Using BITAS Through a Left Minithoracotomy without Robotic or Thoracoscopic Assistance

Pradeep Nambiar, Chandermohan Mittal. Dr. B. L. Kapur Hospital, New Delhi, India.

Objective: BITAS in CABG have shown greater survival and freedom from reintervention. Our aim was to develop a multivessel MIDCABG technique, where the RITA was directly harvested and complete revascularization of the myocardium done by OPCAB using only BITAS (LITA – RITA Y) through a 2.5” left minithoracotomy incision without any robotic or thoracoscopic assistance.

Methods: Using a 2.5” left inframammary incision the thoracic cavity was entered through the fifth intercostal space. The fatty attachments between the pericardium and the sternum were divided and on dissecting the pleura from the endothoracic fascia of the right chest wall, the RITA was visualized and directly harvested followed by the LITA. Where the RITA length was inadequate for complete revascularization, it was extended with a segment of radial artery. A LITA-RITA Y was constructed and complete revascularization of the myocardium was done followed by flow study of the grafts. We have carried out 49 cases of total arterial coronary revascularization using the left mini thoracotomy approach.

Results: We have had no mortality, recurrence of angina, myocardial infarction or any other complication during this short period of follow up. Inotropic usage was very minimal and the hospital stay was 2-3 days. Post operative Coronary angiograms done showed widely patent grafts.

Conclusions: Direct harvesting of the RITA and Minimally invasive direct multivessel total arterial CABG, using BITAS as a Y conduit through a left minithoracotomy without robotic or thoracoscopic assistance and using the OPCAB technique is technically feasible and reproducible. The short term results have been excellent but a longer follow up is required.



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CMP9 Increasing Surgical Experience with Off-Pump Coronary Surgery Does Not Mitigate the Morbidity of Emergency Conversion to Cardiopulmonary Bypass

Jonathan M. Hemli, Nirav C. Patel, Valavanur A. Subramanian. Lenox Hill Hospital, New York, NY USA.

Objective: Emergency conversion during off-pump coronary artery bypass (OPCAB) confers significant morbidity and mortality. We sought to determine whether the outcomes in these patients have changed over time as our experience with off-pump techniques has increased.

Methods: Between January 1999 and December 2010, 4763 consecutive patients underwent isolated coronary artery surgery. A primary off-pump strategy was attempted in 4415 cases (92.7%). The results of the most recent 50 patients who required emergency conversion were compared with the preceding 50 emergency conversions, and also with patients who underwent either successful OPCAB (n = 2737) or on-pump coronary artery bypass grafting (CABG) (n = 268) during the same time period.

Results: The overall emergency conversion rate was 2.3% (n = 100), being 2.97% for the first 50 cases, and 1.77% for the subsequent 50 patients. The 2 sequential groups of emergency conversions had similar indications for conversion, timing of conversion, and comparable morbidity and mortality (Table 1). When compared with patients who underwent successful OPCAB (Table 1), the more recent group of 50 conversions had higher mortality (p = 0.002), greater postoperative complications (p<0.0001), and more frequent deep sternal wound infection (p = 0.036), hemorrhage requiring reoperation (p = 0.003), respiratory failure (p<0.0001), and sepsis of any cause (p = 0.001). Compared with the on-pump group (Table 1), the more recent conversions had higher mortality (p = 0.055), and a greater rate of postoperative sepsis (p = 0.002).

Conclusions: Emergency conversion during OPCAB has decreased with increasing surgical experience, however, the morbidity and mortality in these patients is unchanged. The outcomes in these patients remain significantly worse than those in non-converted patients, be they off-pump or on-pump. Safer and more consistent bail-out strategies during OPCAB are thus still warranted.



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CMP10 Application of a Transthoracic Aortic Crossclamp from the Left for Totally Endoscopic Coronary Artery Bypass Grafting

Eric Lehr 1, Kimberly Schwartz2, Alina Grigore2, Johannes Bonatti2. 1Swedish Heart and Vascular Institute, Seattle, WA USA, 2University of Maryland School of Medicine, Baltimore, MD USA.

Objective: Atherosclerotic disease often prohibits the use of an endoaortic occlusion balloon in patients undergoing robotically assisted totally endoscopic coronary artery bypass grafting (TECAB). Although a transthoracic clamp is easily applied from the right side through the transverse sinus, application from the left is more challenging. Use of a transthoracic clamp generally necessitates the delivery of antegrade cardioplegia, which poses additional challenges in the totally endoscopic setting as compared to a small thoracotomy.

Methods: Between January and June 2011, 6 patients (age 65 [26 - 81], 33.3% male) underwent arrested heart TECAB (3 single, 3 double vessel bypasses) with application of a transthoracic aortic crossclamp from the left. The aorta and pulmonary artery were separated and an antegrade cardioplegia was administered via a cardioplegia catheter inserted totally endoscopically through a double 4-0 Goretex pursestring suture using a modified Seldinger technique under echocardiographic guidance. Cardiopulmonary bypass was established with left axillary and percutaneous femoral venous cannulation.

Results: Cardiac arrest was successfully induced in all six patients although in one case the cardioplegia catheter required repositioning after the crossclamp had been applied as it had turned distally in the aorta. In another patient, an additional stitch was required in one case to attain hemostasis at the cardioplegia site. No patients required conversion to an open incision and there were no 30-day mortalities.

Conclusions: Application of a transthoracic crossclamp from the left side in patients undergoing TECAB is feasible when the use of an endoaortic occlusion balloon is contraindicated.

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CMP11 Robotic TECAB and PCI in Integrated Coronary Revascularization: Initial Experience using a Planned Staged Approach

Husam H. Balkhy 1, John Manley1, Richard Wakefield2, Krishna Kumar1, David Ashpole1, Amanda Allen1, Susan Arnsdorf1, Dorothy Krienbring1. 1The Wisconsin Heart Hospital, Milwaukee, WI USA, 2Community Memorial Hospital, Milwaukee, WI USA.

Objective: Recent advances in minimally invasive/ robotic coronary bypass procedures and percutaneous interventions with DES have allowed surgeons and interventional cardiologists to justify hybrid revascularization strategies in patients with mulitvessel CAD. In the absence of a Hybrid OR this approach can present challenges. We report on our initial experience with hybrid coronary revascularization in mulitvessel CAD using an elective staged approach.

Methods: Between 5/2008 and 11/2011, 41 patients with multi-vessel CAD were scheduled for elective staged hybrid revascularization. Mean age was 65+/-12, and 86% percent were men. The order of procedures was dictated by the clinical presentation. Twenty-nine patients (71%) had TECAB first and 12 patients (29%) had PCI first. TECAB procedures were performed using a da Vinci off pump beating heart approach with anastomotic connectors (Flex A, Cardica). Seventeen (41%) were single-vessel and 24 (59%) were multivessel procedures (23 double vessel and 1 triple vessel TECAB). The PCI procedures were to branches of the RCA and distal circumflex artery. A mean of 1.7+/-1.0 stents was deployed per patient. Of the 29 patients who had surgery first, 5 elected not to undergo the second stage of the hybrid procedure because they had negative postoperative stress tests and/or were asymptomatic.

Results: There was no peri-procedural mortality, stroke, MI, wound infection or conversion to sternotomy. Median length of stay after surgery was 3 days. The average length of time between procedures was 69+/-70 days. In patients who had PCI first, anti-platelet therapy was continued through surgery. There were no re explorations for bleeding. One patient in the surgery first group was converted to femoro-femoral CPB because of RCA distribution ischemia. Patency in 41 grafts evaluated in 25 patients (24 at time of PCI and 1 with CT angiography) was 94% at a mean of 65+/–80 days.

Conclusions: Staged integrated coronary revascularization is feasible in patients with multivessel CAD with excellent early outcomes. In the absence of a hybrid OR, clinical presentation should dictate the order of procedures. Continuation of anti-platelet therapy did not result in increased peri-operative bleeding. Early graft patency was excellent. Further follow-up is necessary.

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CMP12 Does Body Mass Index Affect Intra-Operative and Post-Operative Outcomes in Robotic-Assisted Minimally Invasive Direct Coronary Artery Bypass Procedures?

Nirav Patel, Lincoln Darla, Christopher Panetta, Jonathan Hemli, Joan Jennings, Valavanur A. Subramanian. Lenox Hill Hospital, New York, NY USA.

Objective: Obesity poses technical challenges for minimally invasive direct coronary bypass surgery. The aim of this study was to examine effect of body mass index (BMI) on short term outcomes in robotic assisted minimally invasive direct coronary bypass grafting (MIDCAB).

Methods: From January 2010 to November 2011, 109 patients underwent robotic assisted MIDCAB at single institution. All patients had robotic assisted internal mammary artery mobilization followed by direct bypass to left anterior descending artery via small anterior thoracotomy. The intraoperative and postoperative outcomes were collected in prospectively and were analyzed retrospectively. Spearman analysis was used to determine correlation between BMI and outcomes.

Results: Average left internal artery (LIMA) mobilization and operative room time was significantly higher in patients with BMI >30 compared to patients with BMI <30. (Average time: LIMA mobilization 40.1 vs 51.3 mins; p = 0.008, operating room time: 187.7 vs 218.3 mins; p = 0.04). All other postoperative outcomes (Re-op for bleeding, stroke, renal failure, respiratory failure, periop MI) were not significantly different between both groups. The outcomes and their correlation with BMI are shown in the table.

Conclusions: Patients with obesity (BMI>30) have similar post-operative outcomes compared to patients with lower BMI. LIMA harvest time and operative times are longer in obese patients in our experience. Robotic MIDCAB can be performed safely in obese patients.



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CMP13 Robotic Reoperative Coronary Artery Bypass

Adam J. Hansen, Robert S. Poston, Michael Simmons. The University of Arizona College of Medicine, Tucson, AZ USA.

Objective: Reoperative coronary surgery using an internal mammary artery (IMA) conduit has a well established symptomatic and survival benefit. Given that most of these reoperative cases have a prior history of left IMA usage, the right IMA (RIMA) is commonly intact and available for harvest. Minimal access revascularization procedures offer distinct advantages over standard coronary artery bypass grafting (CABG), including avoidance of reoperative sternotomy and providing the longevity benefits of a RIMA conduit without the risk of sternal healing difficulties in the setting of bilateral IMA procurement.

Methods: We performed reoperative CABG using robot assistance in 18 patients, harvesting the RIMA through three right chest port sites. The distal left anterior descending coronary target was accessed through a left chest minithoracotomy. Patient outcomes were analyzed based on retrospective chart review.

Results: Average total operative time was 232 min (range 135-306). Cardiopulmonary bypass via femoral artery and vein access was utilized in 2 patients. Average volume of donor red blood cell transfusion was 1.83 units. Average length of hospitalization was 5 days (range 3-10) and average ventilator time was 18 hrs (range 0-105). There was 0% incidence of reoperation, perioperative stroke, myocardial infarction, or renal failure at 30 days. One patient was ventilated longer than 24 hrs. There was one in-hospital death. Patency of the bypass grafts was 100% as measured by computed tomographic angiography prior to discharge.

Conclusions: Robotic-assisted reoperative CABG is beneficial for patients requiring IMA grafting to the LAD after prior failed revascularization. Complications associated with reoperative sternotomy are avoided. The technique can be safely applied to selected patients with low risk of blood transfusion and perioperative complications that often accompany reoperation.

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CMP14 Continued Experience with Robotically Enhanced Minimally Invasive Bypass Surgery (Endo MIDCAB) Using the da Vinci System in Germany

Christian Detter, Tobias Deuse, Lenard Conradi, Hermann Reichenspurner, Hendrik Treede. University Heart Center Hamburg, Hamburg, Germany.

Objective: Minimally invasive off-pump coronary bypass surgery through anterolateral minithoracotomy (MIDCAB) is a well established procedure for single vessel disease. Surgical trauma is even more reduced by robotically enhanced endoscopic LIMA harvest (Endo-MIDCAB). Here we report about a consecutive series of Endo-MIDCAB procedures at our center.

Methods: Between 2004 and 2011, 63 patients underwent Endo-MIDCAB surgery for single vessel (n = 58, 92%) or multi-vessel (n = 5, 8%) bypass grafting. Mean patient age was 60 ± 7.9 years (84% male). After port placement LIMA preparation was performed using the da Vinci Telemanipulator system under 3-D endoscopic control from a workstation in the operating room. After opening of the pericardium the target vessel was located and access site determined. After minimally invasive small anterolateral minithoracotomy LIMA to LAD bypass was achieved in off-pump technique by stabilization of the coronary vessel, shunt insertion, and hand sewn anastomosis followed by flow-measurement.

Results: Endo-MIDCAB could successfully be performed in 95.2% of patients through anterolateral mini-thoracotomy with robotically enhanced endoscopic LIMA harvest. Three patients were converted to median sternotomy, one due to deep intra-myocardial LAD position, 2 multi-vessel patients due to LIMA dissection. Two patients underwent re-operation for bleeding from the chest wall and another patient developed a wound infection. In hospital mortality was 0%. Two patients underwent planned hybrid procedures with consecutive PCI and coronary stent implantations. Flow measurements showed sufficient bypass flow in all patients (mean flow 37.7 ± 14.9 ml/min). All patients were discharged from hospital in good conditions.

Conclusions: Endo MIDCAB can be successfully performed in patients with single or even multi-vessel disease. Robotically enhanced endoscopic LIMA preparation using the da Vinci system allows for atraumatic and safe preparation of the complete length of the vessel and for exact determination of the access site. Anastomosis can then safely be performed hand-sewn through an anterolateral MIDCAB incision thereby favorably reducing surgical trauma.

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CMP15 Endoscopic Vessel Harvest Using Current Techniques: Analysis of Thermal Spread, Conduit Quality and Adverse Events

Brian J. deGuzman 1, Dixie Patterson1, Lishan Aklog1, J Papson2, J Luber2. 1St. Joseph’s Hospital and Medical Center, Phoenix AZ USA, 2St. Joseph Medical Center, Tacoma, WA USA.

Objective: Endoscopic vessel harvest (EVH) is now the most prevalent technique used when the greater saphenous vein (GSV) is procured for use as a coronary artery bypass graft. Although vein quality has been assessed by various methods, little is know about thermal injury and endothelial damage to the vein when the latest generation cautery tools are utilized. This study aims to define GSV quality when harvested utilizing current endoscopic technology.

Methods: 30 prospective, non-randomized patients undergoing EVH of the GSV for bypass using the VASOVIEW HemoPro system were enrolled in this prospective, multi-center study. Histologic analysis (H&E staining and CD31) was performed on vein segments (N = 41) where a side branch or the vein itself was divided with the HemoPro device. Secondarily intra-operative vessel interventions (simple suture closure of vein leaks other than typical ligation of side branches), vein harvest complications (thrombosis, thrombophlebitis, vein/graft injury, wound infection, nerve injury, bleeding, excessive hematoma/edema) and adverse events were recorded.

Results: Endothelial damage measured by thermal spread was minimal (range 0-845um, mean 202.9um, SD 184.3um). 27/30 patients’ veins required 0-1 interventions, one patient required 2 and one patient required 10. No complications or adverse events were observed prior to discharge or between 10(+/- 2) and 28 days post-operatively.

Conclusions: EVH of the GSV utilizing the VASOVIEW HemoPro system results in minimal thermal spread and endothelial damage, acceptable macroscopic vein quality and a low post-operative complication rate. Because lateral thermal spread beyond the device jaws is extremely low (<1.0mm), the risk of endothelial damage to the main conduit when dividing side branches during harvest is minimized and graft quality optimized. This data supports the safety of this widely used technique.

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C8 An Endovascular Approach to Stanford Type B Aortic Dissections Mitigates the Adverse Impact of Increasing Age or Comorbidity Burden on Operative Mortality

Arman Kilic 1, John V. Conte1, Ashish S. Shah1, Duke E. Cameron1, David D. Yuh2. 1Johns Hopkins Hospital, Baltimore, MD USA, 2Yale University School of Medicine, New Haven, CT USA.

Objective: To evaluate the relationship between operative mortality and increasing patient age or comorbidity burden in open versus endovascular repair of Stanford type B aortic dissections (TBAD).

Methods: Patients undergoing open or endovascular repair of thoracic or thoracoabdominal TBAD between 2005-2008 were identified in the Nationwide Inpatient Sample. Patients with aortic aneurysms or with procedure codes for cardioplegia, or operations on coronary vessels or valves were excluded from analysis. The primary outcome was operative mortality. The relationships between operative mortality and increasing patient age or Charlson comorbidity index were compared between approaches.

Results: A total of 8,202 patients underwent TBAD repair, with 1,522 (18.6%) being endovascular. The overall operative mortality rate was 16.6%. In both elective and urgent/emergent cases, an endovascular approach was associated with reduced operative mortality compared to open repair (elective: 1.1% versus 10.2%, p = 0.01; urgent/emergent: 10.0% versus 21.1%, p = 0.006). In elective cases, there was a strong association between increasing patient age and increasing operative mortality with open repair (p = 0.008) (Figure 1). There was no such association with elective endovascular cases (p = 0.68). Similarly, in urgent/emergent cases, the risk of operative mortality increased significantly with increasing age in open (p<0.001), but not endovascular cases (p = 0.89). The same relationships were observed with Charlson index, where an increasing comorbidity burden was associated with a significantly increased risk of operative mortality in elective open cases (p = 0.004) and a strong trend towards increased mortality in urgent/emergent open cases (p = 0.06) (Figure 2). The endovascular approach was associated with similar mortality despite increasing comorbidity burden (elective: p = 0.49; urgent/emergent: p = 0.99).

Conclusions: This large-cohort analysis demonstrates that an endovascular, but not an open approach, to TBAD mitigates the adverse impact of increasing age or comorbidity burden on operative mortality risk. These data strongly support the use of endovascular TBAD repair in older patients and/or those with significant comorbidities.





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C9 Transapical Access for Endograft Treatment of Acute Type A Aortic Dissection

Tilo Kölbel1, Jens Brickwedel 2, Lenard Conradi2, Sabine Wipper1, Eike Sebastian Debus1, Hermann Reichenspurner2. 1Department of Vascular Surgery, University Heart Center Hamburg, Hamburg, Germany, 2Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany.

Objective: Standard management for treatment of acute type A aortic dissection is open surgical repair. This technique is known to be associated with high mortality and morbidity rates, especially in octogenarians and patients with severe comorbidities.

Methods: Two male patients, both diagnosed with an acute type A aortic dissection (DeBakey II) and pericardiac tamponade, were treated with an endovascular stent graft through transapical access. Both patients were not considered candidates for open surgical repair: the first, 83 years old, due to his poor general condition, and the second, due to his comorbidities such as COPD (Gold IV), chronic renal failure, peripheral artery disease, and disabling ankylosing spondylitis. Transapical access through a mini-thoracotomy was used to decompress the pericardiac tamponade and to place the endograft securely into the true lumen of the ascending aorta under repeated angiographies. Rapid ventricular pacing was used to reduce cardiac output during endograft-deployment.

Results: Both patients were transferred to ICU postoperatively and were hemodynamically stable through the entire treatment period. Following stent graft placement false lumen perfusion occluded and the entry tear was securely covered in both cases. Both patients survived. There were no malperfusion syndromes or cerebrovascular events. Postoperative CT scans showed the stent graft in ideal position with no signs of persistent false lumen perfusion. Both patients could be discharged to rehab facilities 10 and 13 days respectively, after intervention.

Conclusions: Stent graft placement for limited dissection of the ascending aorta (DeBakey II) is feasible in patients unfit for open treatment with promising short term results. This novel treatment option may play a gaining role in the future. However, long-term follow-up is requested to demonstrate durable results.

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C10 Early Clinical Outcomes of the Debranching Thoracic Endovascular Aortic Repair without Sternotomy nor Thoracotomy in High Risk Patients with Distal Aortic Arch Disease

Kazuya Kobayashi, Hideki Ueda, Toshihiro Ohata. KKR Sapporo Medical Center, Sapporo, Japan.

Objective: Thoracic endovascular aortic repair (TEVAR) combined with supra-aortic debranching and revascularization emerged as a promising approach for the patients with distal aortic arch disease, especially for an aged population with multiple comorbidities. We evaluate the early outcomes of debranching TEVAR without sternotomy or thoracotomy in these high risk patients.

Methods: This study was a retrospective analysis of clinical records. From March 2009 to November 2011, 20 high risk patients with distal aortic arch disease underwent debranching TEVAR without sternotomy or thoracotomy. The mean age was 76 ± 11 years at operation, and there were 14 male and 6 female. Aortic pathology included 16 true aneurysms and 4 aortic dissections. The average size of aneurysm was 59 ± 9 mm. As to proximal landing zone, Z0 was involved in 4, Z1 in 8 and Z2 in 8 cases. The bypass of right axillary artery-left axillary artery was performed in 9 cases, and right axillary artery-left common carotid artery and left axillary artery with bifurcated graft in 11 cases. All bypasses were placed outside the thoracic wall. Fenestrated stent graft was used in two cases. Chimney technique was applied in 5 cases. The Excluder TAG device was used in 16 cases, Najuta in 2 cases, Talent in one case, and hand-made device in one case. Urgent operation was performed in two cases. The mean logistic EuroSCORE was 26.6 ± 19.7%. The mean follow-up period was 10.4 months.

Results: Primary technical success was achieved in all cases. There was one 30-day mortality (5%) due to low cardiac output syndrome. Perioperative morbidities were found in two cases (10%), and both are stroke caused during the procedure. No endoleak or graft migration was observed by postoperative computed tomography scans, and all bypass grafts remained patent during the follow-up period. We had no experience of paraplegia, new aortic event, or surgical site infection.

Conclusions: The early outcomes of the debranching TEVAR without sternotomy or thoracotomy are satisfactory and encouraging. This procedure has the advantage of simpleness, less invasiveness, and no possibility of sternal infection compared with sternotomical approach especially in high risk patients with distal aortic arch disease.

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C11 Frozen or Fixed Elephant Trunk? Mid-Term Results of Two Different Hybrid Approaches to Extensive Thoracic Aortic Aneurysms

Giampiero Esposito, Giangiuseppe Cappabianca, Samuele Bichi, Nicola Troisi. Department of Cardiovascular Disease, Cliniche Humanitas Gavazzeni, Bergamo, Italy.

Objective: to compare the outcome of one-stage frozen elephant trunk (FET) technique to two stages “Lupiae” technique (surgical “fixed” elephant trunk) performed in hybrid repair of extensive thoracic aortic disease involving the ascending aorta, arch and proximal descending aorta with different etiologies.

Methods: Fifty-six consecutive patients with extensive thoracic aortic aneurysms were treated with one stage (FET) or two stage (Lupiae) hybrid approach between 2004 and 2008: eighteen patients underwent FET and 38 Lupiae repair. All the procedures were performed by a single surgeon on cardiopulmonary bypass (CPB), antegrade selective cerebral perfusion (ASCP) and distal circulatory arrest (DCA).

Results: CPB was 194 ± 41 min vs. 122.6 ± 35 min (p < 0.0001) X-clamp time was 101 ± 22 min vs. 61,3 ± 22,4 min (p<0.0001), ASCP was 92 ± 15 min vs. 75 ± 12 min (p<0.0001) and DCA was 73 ± 14 vs. 28.1 ± 6.7 (p<0.0001) in the FET and Lupiae group respectively. 30-days mortality was 11.1% vs. 7.7% (p = 0.65) and spinal cord ischemia 16.6% vs. 0% (p = 0.03) in FET and Lupiae group respectively. The second endovascular stage in the Lupiae group was performed in all (35/38) the survived patients. During the three-year follow-up one patient died in the Lupiae group and 5 in the FET group (p = 0.009). The incidence of Type Ia endovascular leaks was 31.2% and 2.8% for FET and Lupiae group respectively (p = 0.009).

Conclusions: The hybrid fixed elephant trunk “Lupiae” technique in comparison with FET technique achieves superior results in term of avoidance of secondary endovascular procedures due to distal endoleaks and 3-year survival. Additional studies will be needed to validate the hybrid thoracic aortic aneurysm repair paradigm.



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CMP16 Hybrid Aortic Repair Using a Custom Quadfurcated Graft: Mid-Term Outcomes

Ali Khoynezhad 1, Carlos Donayre2, Rod White2. 1Cedars-Sinai Medical Center, Los Angeles, CA USA, 2Harbor-UCLA Medical Center, Torrance, CA USA.

Objective: A significant portion of patients with thoracic and thoracoabdominal aortic pathologies are not candidates for open or endovascular repair due to physiological or anatomical constrains. A combination of both approaches; hybrid endovascular repair has demonstrated promising early results in experienced hands. The aim of this study is to review the utility and mid-term results of hybrid endovascular aortic using custom quadfurcated graft: the same graft design is used for the visceral/renal or brachiocephalic vessels during hybrid thoracoabdominal or transverse aortic repair.

Methods: Between September 2005 and November 2011, 342 patients underwent thoracic endovascular aortic repair. 195 of these patients required a combined open and endovascular approach. A total of 52 patients from this cohort required hybrid aortic repair using custom quadfurcated graft. Indications were aneurysm in 31, chronic dissection in 15, and acute dissection in 6 patients. 18 (35%) patients had extra-anatomic revascularization to the visceral and renal arteries; 34 (65%) patients underwent zone 0 hybrid arch reconstruction.

Results: Mean age was 68 ± 11 years (range 59-83 years). 15 (29%) patients had prior aortic operation or procedure. Operative procedures were urgent or emergent in 12 (23%). In 12 (23%) patients, endovascular exclusion was performed sequentially. Early mortality was 6% (n = 3), two (4%) patients developed permanent stroke perioperatively. Postoperatively, no patient suffered spinal cord injury or type I or III endoleak. One patient required re-intervention. Mean follow-up was 34 ± 11 months. One-year and four-year survival rates according to Kaplan Meier were 90% and 79%. All debranching bypass grafts have remained patent.

Conclusions: Hybrid aortic repair using custom quadfurcated graft appears to be feasible, safe and effective at mid-term follow-up, and it represents a feasible alternative in high-risk patients. Long-term surveillance requiring repeated contrast administration and radiation exposure remains an unresolved issue that requires to be addressed in future. More extensive follow-up is needed to substantiate the durability of hybrid repair using the quadfurcated aortic graft.

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CMP17 Matrix-Based Repair of Acute Type-A Aortic Dissections as an Alternative to Conventional Glue Repair

Tobias Kruger, Milan Lisy, Mahmud Kalhil, Czold Nagy, Ulrich A. Stock, Stephen M. Wildhirt. University of Tuebingen, Tuebingen, Germany.

Objective: The use of glues to repair intimal and medial disrupted layers during surgical repair of acute Type-A aortic dissections (AAD) is often discontinuous, may not achieve sufficient reinforcement and is costly. We report a highly effective method of matrix based repair (MBR) of dissected aortic tissue with a collagen matrix double layer coated with fibrinogen/thrombin on either side (TachoSil; Nycomed). It is known to be converted into autologous collagen within 3 months thereby creating an autologous neo-media.

Methods: In 12 subsequent patients (7 male, 66.9 ± 11.7 years) with acute AAD we performed MBR of the intima-media disruption at the proximal and distal anastomosis site intending to create an autologous collagen “neo media”. Care was taken that the MBR covered 1) at least 2-2.5 cm in depth and 2) the whole dissected aortic circumference on either anastomosis thereby respecting the geometry of the tissue to be repaired. Clinical outcome parameters, blood products used and CT-scans were analyzed. No glue was used to repair the dissected aortic wall in all patients.

Results: Mortality was 0%, recovery was satisfactory, mean ICU stay was 13.6 ± 6.0 d, mean hospital stay was 20.7 ± 4.4 d. A total of 7.0 ± 2.6 RBC, 3.4 ± 1.5 platelets and 8.0 ± 4.3 FFP were transfused. CT follow-up: In 7/7 DeBakey II dissections the intimal tear was completely resected, in 3/5 DeBakey I dissections the false lumen in the descending aorta was completely collapsed. No re-dissections and no aortic valve insufficiencies were seen during follow-up.

Conclusions: The present early analysis shows that MBR intended to create an autologous collagen “neo-media” of the dissected aortic tissue is safe and effective. The matrix based double layer collagen matrix coated with thrombin/fibrinogen results in continuous reinforcement of aortic tissue and completely avoids the need for conventional glues. The present early analysis shows that MBR intended to create an autologous collagen “neo-media” of the dissected aortic tissue is safe and effective. The matrix based double layer collagen matrix coated with thrombin/fibrinogen results in continuous reinforcement of aortic tissue and completely avoids the need for conventional glues.

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CMP18 Traumatic Aortic Disruptions Managed Endovascularly with Short Abdominal Aortic Cuffs

Keith Allen, Michael Borkon, Steve Laster, Sanjeev Aggarwal. St. Luke’s Mid-America Heart Institute, Kansas City, MO USA.

Objective: Traumatic aortic disruption management has shifted from open repair to endovascular stent grafts. Thoracic stent grafts designed to treat aneurysmal disease, however, may have disadvantages including size mismatch in younger trauma patients and current lengths which necessitate coverage of 10 cm of thoracic aorta which may increase the risk of spinal cord ischemia. The use of abdominal aortic cuffs to treat traumatic aortic disruptions, however, may provide an advantage regarding better size match in the younger trauma patient, reduced thoracic aortic coverage and less cost to the institution.

Methods: From 2008-2011, sixteen traumatic aortic disruptions were evaluated and managed. The last six were managed with abdominal aortic cuffs (Excluder, Gore, Newark, DE) rather than traditional thoracic stent grafts. In addition to demographics and trauma-related data, additional endpoints evaluated in this retrospective review included operative time, number of cuffs utilized, stent cost data, procedural complications and follow up.

Results: In the six patients (5 males/1 female) with traumatic aortic disruption treated with abdominal aortic cuffs, the average age was 27 (range 18–44). The number of cuffs utilized to cover the traumatic tear averaged 2.6 per patient (range 2–3 cuffs per patient) covering an average of 5.3 cm of thoracic aorta (range 4–6cm). Procedure times averaged 70 minutes and were without complications including death or spinal cord ischemia. Hospital cost for each cuff was $2200 (average total stent cost per patient $5720). For comparison, a single 10 cm TAG graft (Gore) costs $12,500. Average follow up of two years demonstrates no complications or migration of the stent grafts. The following case illustrates a typical patient.

Conclusions: Traumatic aortic disruptions can be safely managed with aortic cuffs traditionally used during AAA stent grafting. These may provide advantages over traditional thoracic stents including better size match in a younger trauma patient, less aortic coverage and reduced cost.





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CMP19 Percutaneous Access for Thoracic Aortic Endografts: No Advantage versus Femoral Artery Cut-Down

Burkhart Zipfel, Semih Buz, Robert Hammerschmidt, Volker Düsterhöft, Roland Hetzer. Deutsches Herzzentrum Berlin, Berlin, Germany.

Objective: To evaluate whether percutaneous access reduces local complications of thoracic endografting related to surgical access to the femoral artery.

Methods: Out of 581 thoracic aortic endograft procedures 147 (25 %) were performed through percutaneous access to the common femoral artery (CFA) and 374 (64 %) through CFA cut-down. Exclusion criteria for percutaneous access were (1) external iliac artery diameter less than 7 mm in, (2) calcification of the anterior wall of the CFA, (3) poorly palpable pulses due to obesity and (4) acute Type-B-dissections. Two U-sutures were placed in the femoral artery using a single Prostar percutaneous suture device, before the delivery sheaths of the endografts with outer diameters of median 24 F were advanced into the artery. The U-sutures were tied at the end of the procedure. All procedures were performed in the operation room.

Results: All stent-grafts were successfully deployed through the percutaneous approach. In 34 cases (23 %) the femoral artery had to be exposed and repaired because of incomplete sealing by the percutaneous sutures. The table compares femoral access site complications of percutaneous (conversions included) vs. conventional approach. Reoperations through the same femoral artery are included in both groups.

Conclusions: In relation to the large delivery catheters the primary effectiveness of the percutaneous technique is impressive, but the results of this retrospective analysis are disappointing. Despite proper selection of the cases and liberal conversion to open repair the need for secondary surgery outweighs the reduction of lymph and nerve complications. Thus overall the technique fails to improve patient comfort of the thoracic endograft procedure.



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CMP20 Does Cryomaze Injure the Circumflex Artery? A Preliminary Search for Occult Post-Procedure Stenoses

Faisal H. Cheema 1, Mohammad B. Pervez2, Mansoor Mahmood2, Muhammad J. Younus2, Mohammad B. Munir2, Gianluigi Bisleri2, Fabio Barili2, Ivan L. Ayala3, Niv Ad4, James L. Cox5, Harold G. Roberts, Jr6. 1College of Physicians & Surgeons of Columbia University - New York Presbyterian Hospital, New York, NY USA, 2Aegis Cardiovascular Research Foundation, Fort Lauderdale, FL USA, 3Atlantic Coast Radiology, Sunrise, FL USA, 4Fairfax Hospital, Falls Church, VA USA, 5Washington University School of Medicine, St. Louis, MO USA, 6Aegis Cardiovascular Research Foundation & Holy Cross Hospital, Fort Lauderdale, FL USA.

Objective: Concerns of circumflex artery injury have been expressed during the epicardial application of the cryoprobe over the coronary sinus as the artery courses on the posterior surface of the sinus in the atrioventricular (AV) groove. The objective of this study was to analyze the incidence of significant injury to the circumflex artery in patients undergoing the cryomaze procedure.

Methods: Between Sep. 2004 and Dec. 2009, 223 patients underwent argon based cryoablation [120 sec application at -150°C]. After WIRB approval, 20 consecutive patients with normal preoperative coronary angiograms [coronary artery disease: none; right dominance: 75%, left: 15% and 10% co-dominant circulation] were enrolled. Mean age was 60.7 years, 35% were male and 50% had NYHA III/IV. Average AF duration was 23 months (65% were paroxysmal). Ten percent (n = 2) had primary cryomaze, 40% (n = 8) had cryomaze plus mitral valve repair and 50 (n = 10) had 2 or more concomitant valvular procedures. Sixteen patients underwent biatrial and four had left-sided only cryomaze. All consented patients prospectively underwent a 24-hour Holter monitor, ECG stress test and a CT angiogram.

Results: At discharge, 75% had normal sinus rhythm while 25% patients were paced. On follow up at 19.5 months Holter showed AV synchrony (18 in sinus rhythm, 1 paced) in all patients save an incidental finding of junctional rhythm in 1 patient who converted to AV synchrony after subsequent pacemaker implantation. Stress test (n = 18) was negative in all patients. On CT angiogram 95% patients had completely patent circumflex artery. Significant stenosis was seen in only 1 patient (right dominant circulation) with a 30–40% tubular stenosis of circumflex artery. However, this lesion corresponded to the P1 area of the mitral annulus, and was significantly proximal to the P3 area where the cryoprobe was applied during the cryomaze procedure.

Conclusions: Barring one case of partial circumflex stenosis, likely due to the on-going normal progression of coronary artery disease, these data derived from a limited prospective trial suggest that epicardial application during the cryomaze procedure does not cause any anatomic or physiological compromise of the circumflex artery.

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CMP21 Completely Thoracoscopic Ablation of Left Atrium via Left Chest for Treatment of Lone Atrial Fibrillation

Ju Mei, Nan Ma, Fangbao Ding, Haibo Xiao. Xinhua Hospital, Shanghai, China.

Objective: We have recently developed a new completely thoracoscopic procedure (modified mini Maze) via left chest with the use of RF-energy for treatment of lone AF. This study was to assess the feasibility, safety and effectiveness of the completely thoracoscopic procedure via unilateral approach to cure alone AF.

Methods: Forty-five patients with symptomatic, drug-refractory, lone AF, including 37 male and 8 female between the ages of 31 and 81 years (mean age 63.4), underwent this therapy from October 2010 through October 2011. Thirty-two patients were with paroxysmal, 9 with persistent, and 4 with long-standing AF. The procedure was performed on the beating heart, avoiding the need for cardiopulmonary bypass, through three thoracoports on left chest wall after general anesthesia. The incision was made on the pericardium a few centimeters anterior to and parallel to descending aorta, exposing both sides of pulmonary vein and the posterior portion of left atrium. Isolation of the PVs was achieved by bipolar radiofrequency ablation with the AtriCure Isolator Synergy ablation clamp. Linear lesion of left atrium (between the left PVs to right PVs with the addition of linear lesions extending to the mitral annulus and left atrial appendage) and the ablation of GPs and the ligament of Marshall was made by the AtriCure Isolator Synergy ablation pen. The left atrial appendage was excluded by using an Autosuture Endo Gia stapler.

Results: The procedure was performed in all 45 cases successfully. The operation duration was 104 ± 37 min. Patients were extubated after 152 ± 38 min. No cardiovascular accidents or pacemaker implantation were identified and none of the patients died. The hospital stay was 4-8 (mean 5.7) days. Follow-up was done between 1 and 12 months (mean 6.1 months) postoperatively. 91.1% (41/45) of all patients were in sinus rhythm during follow-up, and freedom from AF was 93.8 % 30/32) and 84.6% (11/13) for paroxysmal and persistent/longstanding AF, respectively.

Conclusions: This new completely thoracoscopic procedure (modified mini Maze) via unilateral approach presents optimistic medium-term outcomes and proves to be feasible, safe and effective for the treatment of lone AF.

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CMP22 Plasma Homocysteine Levels in Patients with and without Recurrence of Atrial Fibrillation after Successful Minimally Invasive Epicardial Ablation via Right Minithoracotomy

Giuseppe Nasso 1, Vito Romano1, Khalil Fattouch2, Raffaele Bonifazi1, Giuseppe Visicchio1, Pietro Dioguardi2, Flavio Fiore1, Giuseppe Speziale1. 1Division of Cardiac Surgery, GVM Care & Research, Bari, Italy, 2Division of Cardiac Surgery, University of Palermo, Palermo, Italy.

Objective: The minimally invasive, epicardial off-pump ablation has been reported as a feasible option in selected patients with drug-resistant lone atrial fibrillation (AF). It is important to stratify the patients on the basis of their risk of recurrence. We addressed whether increased plasma Homocysteine is associated with recurrent AF after successful minimally invasive epicardial ablation, and whether it could be useful as a preoperative predictor of outcome.

Methods: In the setting of a prospective observational study, we enrolled patients subjected to minimally invasive epicardial ablation of lone AF who leaved the hospital in stable sinus rhythm. Blood samples were obtained on day before surgery and at the six months follow-up visit. Plasma Homocysteine levels were determined in both samples and expressed as µmol/L. The recurrence of AF was demonstrated by scheduled 24-hours ECG monitoring.

Results: A total of 104 patients were enrolled. The rate of freedom from AF was 88.5% (92 patients) at an average 17-months follow-up. In patients with at the least one episode of recurrent AF, the average preoperative Homocysteine was 16.9 µmol/L vs. 13.1 µmol/L in patients without recurrence (p = 0.032). Patients having preoperative persisting-type AF had average preoperative Homocysteine = 15.4 µmol/L vs. 12.1 µmol/L in patients with paroxysmal-type AF (p = 0.002). Patients having with preoperative enlarged left atrium (defined as left atrial size ≥22 mm/m2) displayed higher average preoperative Homocysteine levels (p<0.01). Similar results were obtained with the Homocysteine levels measured at 6 months. Cox proportional hazards regression evidenced increased preoperative and 6-months homocysteine levels (continuous variable) as an independent predictor of recurrent AF. The cutoff value of 15.1 µmol/L for preoperative Homocysteine level displayed the best diagnostic performance in predicting the recurrence of AF during the follow-up (area under the Receiver Operating Characteristic curve = 0.89).

Conclusions: Higher preoperative Homocysteine levels are significantly associated with the recurrence of lone AF after minimally invasive epicardial ablation. This factor should be weighted in conjunction with other predictors of recurrence (persisting type of AF, advanced left atrial remodeling) in the establishment of surgical indication for lone AF.

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CMP23 Role of Video-Assisted Thoracoscopy in the Management of Stroke

Magdi Ibrahim Ahmad Muhammad. King Fahd Hospital, Al Madina Almunawara, Saudi Arabia.

Objective: We evaluated the role of surgery (anterior thoracotomy versus video-assisted thoracoscopy) in the management of stroke by obliteration of left atrial appendage in patients with chronic or intermittent nonrheumatic atrial fibrillation.

Methods: We conducted a prospective study from January 2008 through January 2010. All patients with chronic or intermittent nonrheumatic atrial fibrillation were identified from routine clinical practice who attended the cardiothoracic department in King Fahd Hospital are included in this study. They were 58 patients [35 male, 23 female; aged 62 ± 13.2 years]. Patients were subdivided into 2 groups; Group [A] 29 patients underwent anterior thoracotomy for obliteration of left atrial appendage and Group [B] 29 patients underwent the video-assisted thoracoscopic obliteration of left atrial appendage. Preoperative, intraoperative and postoperative variables, morbidity, occurrence or recurrence of stroke and survival are compared in both groups. All patients were followed for at least 1 year.

Results: Preoperative variables were well matched for age, sex and co morbidities between both groups. No occurrence or recurrence of stroke was observed in both groups. Operative time was statistically highly significant [p < 0.001]; it was longer in Group [B]. There was no intraoperative complication in both groups. There was no postoperative complication in both groups except two cases of superficial wound infection in group [A]. There was no any significance difference between both groups as regard duration of chest tube drainage and length of hospital stay. There was no in-hospital mortality in both groups.

Conclusions: In chronic or intermittent atrial fibrillation patients, prophylactic left atrial appendage exclusion is suggested as a method to prevent occurrence or recurrence of stroke. The left atrial appendage obliteration can be done through either surgical approach or thoracoscopic approach but video-assisted thoracoscopy approach is effective, less invasive and it avoids complications of surgical approach.

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C12 Augmented Reality Echocardiographic Navigation and Guidance for Beating Heart Transapical Mitral Valve Repair

Michael W. Chu 1, John Moore1, Terry Peters1, Daniel Bainbridge1, Pencilla Lang1, Gerard Guiraudon1, Richard Daly2, Bob Kiaii1. 1University of Western Ontario, Robarts Research Institute, London, ON Canada, 2Mayo Clinic, Rochester, MN USA.

Objective: Emerging off-pump, beating heart valve repair techniques offer patients less invasive mitral valve repair alternatives. Neochord DS is a novel transapical tool that delivers PTFE neochords from the left ventricular apex to the mitral valve leaflets on the beating heart, relying upon conventional transesophageal echocardiography for tool navigation and guidance. However, echocardiographic guidance alone can be problematic as limited spatial and temporal resolution can make tool visualization challenging.

Methods: Utilizing a magnetic tracking system and integrated sensors, we created a virtual reality environment displaying important intracardiac landmarks that is registered real-time to biplane TEE imaging. Two fixed views were constructed to assist with surgical navigation and guidance, including the apical ‘bulls-eye’ view to help navigate the tool from the apex to the mitral annulus and the mitral annular view to assist engaging the tool to the appropriate mitral valve leaflet. In a porcine model, we evaluated the efficacy of tool navigation from apex to the appropriate mitral leaflet with TEE guidance alone versus augmented reality navigation in 5 surgeons.

Results: Magnetically tracked tool paths for TEE only and augmented reality navigation are displayed in Figure 1. TEE guidance alone resulted in multiple erroneous tool passes into the left ventricular outflow tract, aorta and undersurface of the anterior and posterior leaflets of the mitral valve. Augmented reality assistance greatly facilitated a more linear path through the mitral coaptation line without transgressing other structures. Mean time required for TEE guidance alone versus augmented reality guidance was 124 ± 94 seconds versus 21 ± 8 seconds, respectively.

Conclusions: Augmented reality enhanced TEE greatly facilitates more direct and safe intracardiac navigation of the Neochord DS tool from left ventricular apex to mitral valve leaflet. Tracked too path results demonstrate improved safety and shorter operative times required.



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C13 Value of 3D-Real-Time Transesophageal Echocardiography for Guiding of Transapical Beating Heart Mitral Valve Repair

Philipp Kiefer, Joerg Seeburger, Thilo Noack, Sergey Leontyev, Michael Höbartner, Heinz Tschernich, Jörg Ender, Michael A. Borger, Friedrich W. Mohr. Heart Center Leipzig, Leipzig, Germany.

Objective: Transapical beating heart mitral valve repair (MV) is a novel surgical technique to correct mitral regurgitation (MR) due to prolapse. It facilitates the implantation of neo-chordae to the prolapsing segment of the MV. We herein assess the feasibility/ effectiveness of 3D-real-time transesophageal echocardiography to guide the procedure in men.

Methods: A standard transapical access is installed and the NeoChord DS-1000 device (Neochord, Minnetonka, MN USA) is introduced through the LV apex. The device is identified within the LV cavum and advanced through the MV into the LA exclusively under echocardiographic guidance using the X-plane view (MV commissural/midesophageal long-axis view). The alignment of the grippers towards the prolapsing segment of the leaflet is then accomplished under 3D-zoom view. Subsequent grasping of the leaflet is conducted under X-plane. Functional neochordae length adjustment is carried out under 3D-zoom and X-plane view. Final assessment of the repair before definite fixation of neochordae to the apex is done using color-flow full volume mode.

Results: 3D-real-time transesophageal echocardiography successfully guided the implantation of neo-chordae in six patients to re-suspend prolapsing MV leaflets in a transapical beating heart approach. It was highly applicable in terms of adequate intracardiac orientation, verification of the prolapsing segment, alignment of grippers, grasping of MV leaflets, length adjustment and final assessment of the intraoperative result.

Conclusions: Transapical beating heart MV repair is feasible and corrects MR due to MV prolapse. This initial experience highlights the feasibility and value of 3D-real-time transesophageal echocardiography to effectively guide the procedure.

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C14 Dual-Source Computertomography and Magnetic Resonance Perfusion Imaging: How Good Do We Revascularize?

Andre Plass, Maximilian Emmert, Robert Goetti, Jurg Grunenfelder, Hatem Alkadhi, Volkmar Falk. University Hospital Zurich, Zurich, Switzerland.

Objective: Coronary artery bypass grafting (CABG) is routinely based on invasive coronary angiography (ICA) without information on myocardial perfusion. This study evaluates the outcome of CABG as well as patency rate of bypass anastomoses in relation to pre- and postoperative myocardial perfusion.

Methods: CABG was performed in 19 patients (18M/1F; age 65 ± 8y) based on ICA data with a total of 62 bypass anastomoses (mean 3.1 bypass anastomoses/patient). Perfusion MRI assessed the myocardium for ischemia and scars preoperatively in a 16-segment heart model. These data were compared to postoperative values in follow-up exam (mean follow-up 13 ± 3 months). Coronaries were preoperatively evaluated in Dual-Source CT (DSCT) for significant stenosis and postoperatively for bypass anastomoses patency.

Results: Of 304 assessed heart segments 39% (88/304) showed ischemic myocardium under stress/rest preoperatively. CABG was successful in treating 94% (83/88) of all ischemic segments with no signs of residual ischemia postoperatively. In 6% (5/88) of segments persistent ischemia was present postoperatively in 3 of 19 patients (one patient with 5 patent bypass anastomoses, 2 patients with each one occluded bypass anastomosis).79% of all bypass anastomoses (49/62) were optimally placed to supply ischemic regions. 21% (13/62) of all bypass anastomoses were placed either into non-ischemic myocardium (9) or into scar tissue (4). 10% (6/62) of all bypass anastomoses were occluded: 3 anastomoses to non-ischemic regions (potential competitive flow), 1 anastomosis was placed into scar-tissue, 2 anastomoses to ischemic regions that therefore remained ischemic postoperatively.

Conclusions: Even if 94% of ischemic segments were successfully revascularized, the outcome of CABG may be improved by myocardial perfusion imaging allowing for better preoperative planning with regards to the number and location of bypass graft anastomoses.

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CMP24 Anatomic Measurements in Preoperative CT Scans Predict Operative Times in Robotic Totally Endoscopic Coronary Artery Bypass Surgery

Brody Wehman, Kian Lahiji, Jeffrey D. Lee, Zachary N. Kon, Patricia Hong, Marc Gibber, Eric J. Lehr, Jean Jeudy, Bartley P. Griffith, Johannes Bonatti. University of Maryland School of Medicine, Baltimore, MD USA.

Objective: Endoscopic procedures require accurate preoperative planning. Computed tomography (CT) provides anatomic information which can support this planning process. The aim of the study was to determine if patient anatomy as determined by preoperative CT scan correlates with intra-operative time requirements for different procedural steps and overall operative time in robotic total endoscopic coronary artery bypass (TECAB).

Methods: Preoperative CT scans were retrospectively reviewed for 108 consecutive patients who underwent single vessel TECAB from 8/2008 to 8/2011. Anatomic measurements included dimensions of the heart and chest cavity, angle of cardiac rotation, left internal mammary artery (LIMA) to left anterior descending (LAD) distance, depth of thoracic subcutaneous tissue, distance from left heart border to chest wall, and thickness of pericardial fat. Findings were correlated with time to complete various intra-operative procedural steps as well as overall operative time.

Results: Of 108 procedures there were 63 performed on the arrested heart (AH) and 45 on the beating heart (BH). There was a significant correlation between LIMA harvest time and depth of subcutaneous tissue at the level of the nipple (r = 0.24,0 p = 0.018). Pericardial fat pad thickness was associated with longer resection times (r = 0.266, p = 0.008). LIMA to LAD anastomotic time was inversely correlated with distance from left heart border to chest wall (r = -0.241, p = 0.016). Total operative time was also inversely correlated to this distance (r = -0.275, p = 0.005) (Figure 1).

Conclusions: Preoperative CT measurements in patients undergoing robotic totally endoscopic coronary artery bypass grafting can predict time requirements for various procedural steps. Patients with greater amounts of subcutaneous tissue require longer LIMA harvesting times. A large pericardial fat pad requires more time for removal. Short distance between the chest wall and the heart predicts longer LIMA to LAD anastomotic times and total operative times.



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CMP25 Ventricular Function Assessed by MRI after Transapical Aortic Valve implantation: Apical Trauma or Simple and Safe Access?

Joerg Kempfert, Arnaud van Linden, Won-Keun Kim, Johannes Blumenstein, Andreas Rolf, Helge Möllmann, Markus Schönburg, Mani Arsalan, Christian Hamm, Thomas Walther. Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.

Objective: Transcatheter aortic valve implantation (TAVI) using the antegrade transapical ventricular access has evolved to a safe and simple alternative approach to transfemoral (TF) valve implantation. The potential impact on left ventricular function after the apical access has not been evaluated yet. Aim of the prospective study was to access changes in left ventricular ejection fraction (EF) by pre- and postoperative echocardiography (echo) and cardiac MRI-scanning.

Methods: A total of 35 patients scheduled for TAVI underwent pre- and postoperative echocardiography and cardiac MRI-scan. 15 patients received TA-AVI (age: 83 ± 5 years; logistic EuroSCORE 27 ± 13%; STS-Score: 7 ± 4%). The other 20 patients underwent TF-AVI (age: 82 ± 5 years; logistic EuroSCORE 22 ± 9%; STS-Score: 5 ± 4%) and served as the control group. Transapical access was established using routine techniques (left mini-thoracotomy, two apical pledged purse-string sutures).

Results: Baseline EF derived from echo and MRI was comparable between both groups (TA: echo 55.4 ± 8.4%, MRI 55.3 ± 9.4% TF: echo 56.7 ± 13.2%, MRI 54.2 ± 13.2%; p = n.s.). Median time interval between the procedure and postoperative MRI/echo was similar between groups (TA: 7 days, TF: 6 days; p = 0.494). Postoperatively echo revealed no significant changes in EF compared to baseline (deltaEF TA: 3 ± 7.5%, p = 0.159; deltaEF TF:-0.6 ± 3.8%, p = 0.547) and no differences between groups. In all patients receiving TA-AVI, MRI demonstrated small localized areas of late-enhancement. However, apical scars had no impact on ventricular function. Changes in EF between pre- and postoperative MRI showed no significant differences between TF and TA patients (TA deltaEF -4.2 ± 8.6%; TF deltaEF 2.2 ± 13.1%; p = 0.113).

Conclusions: Limited apical scaring can be detected by cardiac MRI after transapical access (transmural late-enhancement). However, the ventricular access has no negative impact on postoperative EF compared to TF-AVI patients.



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CMP26 A Simple Method for Grading Aortic Atherosclerosis Which has Prognostic Value in Robotic Totally Endoscopic Coronary Artery Bypass

Jeffrey D. Lee, Patrick G. Chan, Gregory Bittle, Patricia Y. Hong, Brody Wehman, MD, Bartley P. Griffith, Johannes Bonatti. University of Maryland School of Medicine, Baltimore, MD USA.

Objective: Minimally invasive and robotic cardiac surgical procedures commonly utilize remote access peripheral perfusion. Although CT scanning has been commonly used in preoperative planning, its prognostic value has not been fully investigated.

Methods: 244 consecutive robotic totally endoscopic coronary artery bypass (TECAB) patients who underwent preoperative contrast enhanced CT scanning of the chest, abdomen and pelvis were evaluated. Each patient was given an aortic disease grade (ADG) based on the number of atherosclerotic lesions seen. All distinct lesions measuring greater than 4 millimeters were counted starting from the subclavian artery down to the femoral arteries. Below the bifurcation of the aorta the side with the greater number of lesions was counted. The cumulative number of lesions was the ADG given to each patient and was correlated with intraoperative and postoperative clinical parameters. 169(69.3%) male and 75(30.7%) females, aged 61 + 10 years were studied. 121(49.5%) single, 104 (42.6%) double, 18 (7.3%) triple and 1(0.4%) quadruple TECAB procedures were performed using the DaVinci S and Si robotic systems.

Results: Average ADG was 4.1 + 4.6. The following parameters were positively correlated with ADG; operative time (r = .201, p = 0.002), ventilation time (r = .141, p = .034), and postoperative length of stay (r = .266, p < 0.001) (Fig 1). The ADG in successfully completed TECAB patients was 3.9 + 4.6 whereas those requiring conversion to sternotomy or requiring on table graft revision was 6.3 + 5.3 (p = 0.02).

Conclusions: We conclude that preoperative CT scanning has prognostic value for robotic totally endoscopic coronary artery bypass. Although elementary in concept, the number of distinct lesions seen on CT had a direct correlation to operative time, ventilation time, need for conversion to sternotomy or on table graft revision, and postoperative length of stay. This simple method may be useful in the selection and prognostic forecasting for patients being considered for TECAB and other minimally invasive surgical procedures that use remote access peripheral perfusion.



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C15 Paving the Way to 500 TECAB Cases: Insights From a Comparison of Five Eras

Nikolaos Bonaros 1, Thomas Schachner1, Eric Lehr2, Felix Weidinger1, Dominik Wiedemann1, Andreas De Biasi2, Brody Weheman2, Guy Friedrich2, David Zimrin2, Johannes Bonatti2. 1Innsbruck Medical University, Innsbruck, Austria, 2University of Maryland, Baltimore, MD USA.

Objective: Totally endoscopic coronary artery bypass grafting (TECAB) using robotic technology is the only coronary procedure combining the respect of the integrity of the thoracic cavity and the excellent long-term results of using mammary arteries for bypass grafting. However this procedure remains technically challenging and involves two types of learning curves: one surgeon-related and one procedure-related. The aim of the study is to describe and compare the course of 5 different eras after 500 TECAB cases, in terms of indications, perioperative outcome and technical difficulties.

Methods: Five hundred patients, who underwent TECAB at the Universities of Innsbruck and Maryland over a period of 10-years, were chronologically divided into 5 quintiles. The groups were compared in terms of procedure selection, indications, perioperative outcome, as well as occurrence of technical difficulties using one-way ANOVA.

Results: The incidence of beating heart TECAB versus arrested heart TECAB (1st quintile- 5th quintile: 10 vs 24% and 90 vs 76%, p<0.001, respectively), as well as multivessel TECAB (1st quintile- 5th quintile 10 vs 56%, p<0.001, respectively) increased steadily throughout the observation period indicating an increase in procedure complexity. Hybrid revascularization accounted for 29%in the first and 46% in the last 100 cases (p = 0.006). Operative times decreased significantly overtime (1st quintile - 5th quintile 376 ± 129 vs 307 ± 132 p = 0.009). The rate of conversions or on-table repair for anastomotic problems was significantly lower in fifth quintile as compared to the first one (12 vs 6%, p = 0.006 and 6 vs 1%, p = 0.011). The observed increase of patients’ and procedure complexity had no negative impact on the incidence of perioperative complications and outcome (Table).

Conclusions: TECAB has been developed and differentiated overtime. Technical aspects have improved and the clinical outcome has not been compromised by the increase of complex procedures.



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C16 Minimally Invasive Coronary Artery Bypass Surgery: A Single Surgeon Series of 335 Patients

Mohammed R. Sayeed 1, Vivek Jawali2, Dharmesh Agrawal2, Murali Chakravorthy2. 1Cardiovascular & Thoracic Surgery, Fortis Hospitals, Bangalore, India, 2Fortis Hospitals, Bangalore, India.

Objective: Many approaches for minimally invasive off-pump coronary artery bypass grafting (CABG) have gained widespread interest in the last decade. To expand the indications for MIDCAB from single-vessel disease to multi-vessel disease, we have used a partial inferior sternotomy which decreases the invasiveness by avoiding splitting of the manubrium sternii and preservation of the stability of the superior thoracic aperture which is the main factor of chest stability. The purpose of this study was to demonstrate the feasibility and safety of this technique.

Methods: Between March 2007 till date, a total of 335 patients, 226 males and 109 females with age ranging from 32 to 86 years, underwent OPCABG through a lower midline skin incision from the fourth intercostal space to the xiphoid process with longitudinal division of the lower half sternum up to the 3rd rib, with a reversed-J shaped division of the sternum. 73 patients (21.79%) had total arterial revascularization; LIMA and RIMA in 32 patients, LIMA and Lt Radial Artery (Y graft) in 41 patients. 15 patients (4.47%) had critical left main stem disease, 47 (14.02%) had single-vessel disease, 63 (18.8%) had double vessel disease and the rest 225 (67.16%) had triple-vessel disease.

Results: The mean length of the skin incision was 6 cms. The mean number of grafts per patient was 3.3 (range 1 to 5). Average ICU stay was 12 hours with average ventilator time of 2.25 hours. Average 24 hour drainage was 370ml. Rate of blood transfusion was extremely low. Average length of stay in hospital was 4 days. There were 2 conversions to full sternotomy. No major wound complications were seen. Postoperative pain score was 5. Five LIMA’s were damaged during harvest, 1 hospital death due to graft failure was observed.

Conclusions: Our experience demonstrates that the partial inferior sternotomy approach is technically feasible for revascularizing multi-vessel disease in this era of minimally invasive surgeries with excellent cosmetic results and safety. Hence we conclude that this minimally invasive surgical technique can be used as an approach for multi-vessel beating heart surgeries.

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CV2 Endoscopic, Non-Robotic U-Clip Anastomosis in a Beating Heart Model

Hagen Gorki 1, Nirav C. Patel2, Andreas Liebold1. 1University of Ulm, Ulm, Germany, 2Lenox Hill Hospital, New York, NY USA.

Objective: An endoscopic, port access coronary anastomosis without robotic support is regarded commonly as technically too difficult.

Methods: The video presents an endoscopic, handsewn vein-to- coronary artery anastomosis using U-clips in an isolated, mechanically actuated porcine heart positioned in a human chest model.

Results: The endocast and endovascular view proof the appropriateness of the anastomosis.

Conclusions: A handsewn coronary anastomosis under endoscopic vision is well possible and improved instruments and vision could lead to wider acceptance of this technique and finally to clinical application.

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CMP27 A New Sutureless Coronary Anastomotic Device - Excimer Laser Assisted Non-occlusive Anastomosis (ELANA) - in an Off-Pump Porcine Bypass Model

David Stecher, Gerard Pasterkamp, Lex A. van Herwerden, Marc P. Buijsrogge. University Medical Centre Utrecht, Utrecht, Netherlands.

Objective: To further facilitate minimal access coronary artery bypass surgery, a reliable and simplified alternative for hand-sutured coronary anastomosis has to be developed. The ELANA (Excimer Laser Assisted Non-occlusive Anastomosis) technique is a non-occlusive, facilitated bypass technique that is FDA-approved for clinical application in neurosurgery. This study evaluates a new sutureless ELANA-based prototype coronary anastomotic connector. Patency, anastomotic healing, remodeling and hemodynamic function were assessed in the acute and mid-term follow-up in a pig coronary bypass model.

Methods: In the porcine model (n = 12 animals), left internal thoracic artery (LITA) to left anterior descending (LAD, outer diameter 3 mm) coronary bypasses were evaluated intraoperatively (n = 12 anastomoses) and at 4 hours, 4 days, 10 days, 2 weeks, 3 weeks and 5 weeks (each subgroup n = 2 anastomoses). The anastomoses were examined by flow measurement, angiography and histology.

Results: The ELANA-connector enabled fast (mean 7.6 ± 2.4 minutes) anastomosis construction. In all anastomoses (n = 12) complete hemostasis was demonstrated and all anastomoses (n = 12) were fully patent (FitzGibbon grade A) at follow-up. Mean peak hyperemic flow response was 4.4 (see Table). In all anastomoses the intima of the LITA was opposed to the adventitia of the LAD. At 5-week follow-up, a streamlined cover of endothelium was observed along the full circumference of the anastomosis.

Conclusions: The ELANA coronary connector is easy-to-use, safe and feasible in the porcine off-pump bypass model. Safety and quality on the long-term still have to be assessed. Hence, this facilitated non-occlusive coronary bypass technique might have potential for minimally invasive coronary bypass surgery.



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CMP28 Lessons Learned from Robotic-Assisted Coronary Artery Bypass Surgery: Risk Factors for Conversion to Median Sternotomy

Michael E. Halkos, Kim Baio, Chandan Devireddy, Henry A. Liberman, Aloke Finn, John D. Puskas. Emory University, Atlanta, GA USA.

Objective: Robotic-assisted coronary artery bypass is a minimally-invasive alternative to traditional coronary artery bypass surgery (CABG) via median sternotomy. However, this minimally-invasive, sternal-sparing technique is associated with a learning curve. The purpose of this study was to investigate the reasons for conversion to sternotomy and to determine if the conversion rate varied with surgeon experience.

Methods: From 10/09 to 12/11, 213 consecutive robotic-assisted CABG procedures were performed at US academic institution by two surgeons. In all cases, isolated, off-pump, left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) grafting was planned via a 3-4 cm sternal-sparing thoracotomy after robotic LIMA harvest and pericardiotomy.

Results: Conversion to sternotomy occurred in 14/213 (6.6%) patients. The most common reason for conversion was technical difficulty with the LIMA-LAD anastomosis, which occurred in 6/14 (42.9%) patients. Other reasons included the following: LIMA dissection, 2 (14.3%); wrong vessel grafted 2 (14.3%); ventricular fibrillation and cardiac arrest, 1 (7.1%); right ventricular injury during port placement, 1 (7.1%); technical problems with robotic system, 1 (7.1%); and left chest adhesions, 1 (7.1%). Two patients underwent emergent conversion. Three patients underwent conversion based on results of intraoperative completion angiography. Six patients were planned hybrid coronary revascularization procedures and underwent multivessel CABG after conversion. There was no mortality among patients that required conversion to sternotomy. However, 2 patients had postoperative myocardial infarction and 1 had a superficial sternal wound infection. The conversion rate was not significantly different among the 4 different time quartiles of the study (Figure).

Conclusions: Conversion to sternotomy is a relatively infrequent complication of robotic-assisted CABG, most commonly due to technical difficulties during the LIMA-LAD anastomosis. Conversions should be expected in a portion of these procedures due to anatomic and patient variables as well as inherent technical problems with minimally-invasive procedures. Based on these data, conversion may be more related to anatomic and patient-specific variables than surgeon experience.



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CMP29 Effects of the Novel Polymer Gel LeGoo on Human Internal Thoracic Arteries

Bernhard Winkler 1, Else Müller Schweinitzer2, Faik Elezi3, Thomas Grussenmeyer4, Florian Rueter3, Matt Peter3, Moritz Konerding5, Martin Grapow3, Friedrich Eckstein3. 1University Hospital Basel, Basel, Switzerland, 2University Hospital Basel DBM Cardiac Surgery, Basel, Switzerland, 3University Hospital Basel Cardiac Surgery, Basel, Switzerland, 4University Hospital Basel DBM, Basel, Switzerland, 5University Mainz Anatomy, Mainz, Germany.

Objective: Several established hemostatic devices enable performing vascular anastomosis in a blood free environment but existing methods can harm the vessel integrity leading to endothelial denudation or plaque rupture. LeGoo (Pluromed, Woburn, MA USA), is a novel poloxamer gel with reverse thermo-sensitive properties that can be used for temporary occlusion of blood vessels and facilitating anastomoses during bypass surgery. Aim of the present study was to investigate the effect of LeGoo on vascular function and integrity of the human endothelium.

Methods: About 3 cm of the distal end of the internal thoracic artery was separated by a clamp, 1 cm was taken as control and LeGoo injected into the remaining part to be dissolved 10 minutes later by applying ice directly to the artery. Vascular function of both control and LeGoo -applied segments was determined in organ bath experiments. Further samples were stored to be investigated using scanning electron microscopy.

Results: Following LeGoo application both maximal contractile responses to noradrenaline and endothelium-dependent relaxant responses to acetylcholine were significantly reduced. Elimination of endogenous relaxant mechanisms (i.e., noradrenaline uptake, beta-adrenoceptors and endogenous prostaglandin synthesis) reversed these changes partially. Scanning electron microscopic findings were in line with the functional changes.

Conclusions: The present data suggests that application of LeGoo induced mild endothelial injury and certain functional deterioration to the smooth muscle in human ITA.

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C17 ASD Closure Surgery by Sub-Xiphoid Approach: As Day-Care Procedure?

Arumugam Chandrasekaran, Ranjith Karthikeyan, Mahesh Vakamudi, Shiva Muthukumar, Richard Saldanha, Periyasamy Tangavelu. Sri Ramachandra Medical College & Research Center, Chennai, India.

Objective: The aim of this study was to justify and analyze the result of ASD closure surgery by sub-xiphoid (3 cm skin incision) approach as day care procedure.

Methods: All of the 35 ASD patients were evaluated on out-patient basis; the type of ASD was confirmed. The patients were advised to get admit NPO on early hours of the posted day of surgery (NPO for last 6 hours). They were prepared and taken for surgery in the morning. ASD closure surgery was performed by our technique of sub-xiphoid (3 cm skin incision) approach. The accuracy of ASD closure was confirmed using TEE before shifting the patient to ICU. The patients were extubated with in 1 - 2 hours in ICU. Later in the day the ICD is removed and a routine post ICD removal chest x-ray is done. After 2 hrs the patient is shifted to the ward. Next morning a post op ECHO is done and patients are discharged by noon. 1 week later the patients are followed up as out patients.

Results: The age group of the patients was from 3 yrs to 18 yrs. the weight of the patients was from 14 kg to 42 kg. The sub-xiphoid approach skin incision was 2cm to 3cm. No inotrope was required and no rhythmic disturbances or neurological complication were encountered.

Conclusions: The closure of ASD can be performed through a sub-xiphoid approach as day care procedure, conferring a good cosmetic result without compromising the safety or accuracy of the repair.



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C18 Totally Thoracoscopic Surgical Closure of Atrial Septal Defect in Children

Zhao-Yun CHENG, Feng WANG, De-Guang FENG. Institute of Cardiovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou, Henan, China.

Objective: This study assesses the approaches and the advantages of totally thoracoscopic cardiac surgery as an emerging alternative to the traditional median sternotomy procedure in children with low body weight.

Methods: From March 2009 to October 2011, 39 pediatric patients (31 females) with a mean age of 5.8 ± 2.1 (4.5∼8) years and body weight of 15.0 ± 4.65 (13.5∼22) Kg underwent totally thoracoscopic atrial septal defect (ASD) closure. There were 31 ostium secundum defects and 8 sinus venosus defects with partial anomalous pulmonary venous connection. Mean defect sizes were 18 ± 11.6 (range,12∼42 )mm. Patients with aortic regurgitation, small femoral arteries or veins, arteriosclerotic diseases of the aorta or the femoral arteries, and body weight less than 13 kg were excluded from the operation as a contraindication to the technique. The operation was undertaken under video assistance and direct vision without opening the chest. Double lumen endotracheal intubation ventilation was applied, with the patient supinely positioned and the right hemithorax slightly elevated (∼ 30°). Femoral artery was cannulated with 10F or 12F cannula whereas the femoral vein and the superior vena cava with 19F and 20F cannula, respectively. Intraoperative TOE where applied for every patient. Three skin incisions of 1.0∼2.5 cm each were made on the right chest wall. Direct suture closure were made in 25 patients, whereas Dacron patches repair were performed in the remaining 14 cases.

Results: No operative death or major intraoperative complication including significant residual shunts was observed. All patients had a regular hospital course with minimal chest pain and discomfort.

Conclusions: Totally thoracoscopic surgical ASD closure in low body weight children is feasible, minimally invasive, safe, with good cosmetic effects. Routine use of this technique can be reached by careful selection of indicated patients and fundamental understanding of the thoracoscopic approach.

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C19 Totally Endoscopic Robotic Ventricular Septal Defect Repair in the Adult

Changqing Gao, Ming Yang, Cangsong Xiao, Gang Wang. PLA General Hospital, Beijing, China.

Objective: We have previously reported totally endoscopic ventricular septal defect (VSD) repair in the adult using da Vinci S Surgical System. The optimal results encouraged us to extend the use of this technology for more complicated cases with VSD.

Methods: From January 2009 to July 2010, twenty patients underwent totally endoscopic robotic VSD repair. The average age was 29.0 ± 9.5 (range 16 to 45) years old. Nine patients were female and 11, male. The echocardiography demonstrated that the average diameter of VSD was 6.1 ± 2.8 (range 2 to 15) mm, and 4 patients had concomitant patent foramen ovale. The VSD closure was directly secured with interrupted mattress sutures in 14 patients, and patched in 6 patients. All the procedures were completed using da Vinci robot via 3 port incisions and 2.0 to 2.5 cm working port in the right chest.

Results: All patients were operated on successfully. The mean CPB and mean cross-clamp times were 94.3 ± 26.3 (range 70 to 140) minutes and 39.1 ± 12.9 (range 22 to 75) minutes, respectively. The mean operation time was 225.0 ± 34.8 (range 180 to 300) minutes. The postoperative transesophageal echocardiography demonstrated intact ventricular septum. There were no residual left-to-right shunting and no permanently complete AV dissociation after operation. The mean hospital stay was 5 days. No residual shunt was found in the follow-up of mean 7 (range 1 to 22) months. The patients returned to normal function in one week without any complications.

Conclusions: The totally endoscopic robotic VSD repair in adult patients is feasible, safe and efficacious.

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C20 The Application of Robotic Surgery in Vascular Medicine

Petr Stadler, Libor Dvoracek, Petr Vitasek, Pavel Matous. Na Homolce Hospital, Praha, Czech Republic.

Objective: The feasibility of robotically-assisted laparoscopic aortic surgery has been adequately demonstrated. Our clinical experience with robot-assisted aortoiliac reconstruction for occlusive diseases, aneurysms, and hybrid procedures performed using the da Vinci system is herein described.

Methods: Between November 2005 and November 2011, we performed 225 robot-assisted laparoscopic aortoiliac procedures. 174 patients were prospectively evaluated for occlusive diseases, 43 patients for abdominal aortic aneurysm, two for a common iliac artery aneurysm, two for a splenic artery aneurysm, three for hybrid procedures, and one for endoleak II treatment post EVAR.The robotic system was applied to construct the vascular anastomosis, for the thromboendarterectomy, for the aorto-iliac reconstruction with a closure patch, for dissection of the splenic artery, and for the posterior peritoneal suture. A combination of conventional laparoscopic surgeries and robotic surgeries were routinely included. A modified, fully-robotic approach without laparoscopic surgery was used in the last 55 cases in our series.

Results: 217 cases (96%) were successfully completed robotically; one patient’s surgery was discontinued during laparoscopy due to heavy aortic calcification. In seven patients (3%) conversion was necessary. The thirty-day mortality rate was 0.4%, and non-lethal postoperative complications were observed in ten patients (4.4%).

Conclusions: Our experience with robot-assisted laparoscopic surgery has demonstrated the feasibility of this technique for aortoiliac vascular and hybrid procedures. The da Vinci robotic system facilitated the creation of the aortic anastomosis, and shortened the aortic clamping time as compared to purely laparoscopic techniques.



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C21 First Clinical Experience with a Novel Percutaneous Short-Term Right Ventricular Assist Device: The Impella RP

Anson Cheung 1, Pascal Leprince2, Dan Raess3, Darren Freed4. 1St. Paul’s Hospital, Vancouver, BC Canada, 2Pitie-Salpetriere Hospital, Paris, France, 3Abiomed Inc, Danver, MA USA, 4St. Paul’s Hospital St. Boniface Hospital, Winnipeg, MB Canada.

Objective: Right ventricular (RV) failure is a clinical problem associated with a high mortality in the setting of post-cardiotomy cardiogenic shock, cardiac transplant, right ventricular infarction, pulmonary embolism and after left ventricular assist device (LVAD) implantation. Temporary mechanical right ventricular support could be a reasonable option in these patients. We report the initial first clinical evaluation of a novel minimally invasive percutaneous right ventricular assist device, Impella RP.

Methods: Impella RP is a new, minimally invasive, 3D catheter-based percutaneous microaxial pump that is designed for short-term right ventricular support. The device is inserted percutaneously via the femoral vein using Seldinger techniques. The device (22 Fr microaxial pump mounted on an 11 Fr catheter) is positioned under fluoroscopic and echocardiographic guidance. It delivers up to 4.4 liters/min of blood flow from the inferior vena cava into the pulmonary artery transversing the tricuspid and pulmonary valve. A First in Man pre-market clinical feasibility evaluation has been initiated at several sites in Canada and Europe.

Results: Five patients received the device for cardiogenic shock primary from RV failure (2 post-cardiac transplant, 2 post LVAD and 1 RV infarct) in three centers. Successful implantation occurred in all patients. The support time ranged from 1 to 7 days with a median of 6 days. The average flow was 3.7 L/min. Three patients were successfully weaned and had the device explanted. There was no major device-related morbidity. Overall thirty-day survival was 80%.

Conclusions: Impella RP is a novel percutaneous right ventricular assist device. The design was enhanced after the first human implant to improve torque-ability and push-ability, resulting in ease of placement for the subsequent patients. It delivers sufficient flow and allows RV recovery in cardiogenic shock patients with RV failure. The preliminary clinical experience is very encouraging and further evaluation is ongoing.

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C22 Injectable Matrix Bioscaffolds Improve LV Function and Stimulate Cardiomyocyte Regeneration in Infarcted Hearts

W. Douglas Boyd 1, Robert G. Matheny2, Anna M. Fallon2, Dongming Hou3, Stephen Frohwein4, Marc Gerdisch5. 1University of California, Sacramento, CA USA, 2CorMatrix Cardiovascular, Atlanta, GA USA, 3St. Joseph Translational Research Institute, Atlanta, GA USA, 4St. Josephs Hospital, Atlanta, C, USA, 5St. Francis Hospital, Indianapolis, IN USA.

Objective: After myocardial infarction (MI), necrosis in the ischemic region causes negative remodeling that leads to left ventricular dysfunction, arrhythmias and subsequent congestive heart failure (CHF). Regenerative therapies to treat CHF must provide mechanical support, limit apoptosis, promote angiogenesis and restore cardiomyocytes. CorMatrix injectable extracellular matrix (I-ECM) is manufactured from decellularized porcine small intestine submucosa (SIS) containing glycoproteins, glycosaminoglycans, and growth factors. SIS scaffolds have demonstrated chemotactic properties, and in a rat MI model, I-ECM recruited c-kit+ cells to sites of ischemic damage resulting in improved functional endpoints including ejection fraction (EF). The synergistic effects of I-ECM include mechanically maintaining normal myocardial physiology while recruiting c-kit+ cells to the site to become cardiomyocytes. The objective of the current study was to determine if injectable extracellular matrix bioscaffolds can improve LV function and regenerate myocytes in a large-animal model of chronic ischemic CH.

Methods: A chronic study using a porcine MI model (n = 9, 5 test, 4 control) evaluated therapeutic effects of I-ECM injected 2-3 months after negative remodelling had occurred. The left anterior descending coronary artery was occluded with collagen to induce ischemic damage to the left ventricle and septum. An MRI was performed 60–81 days post infarction. The animals then underwent either a sham procedure or therapeutic I-ECM injections. Restudy was performed at 5 and 8 months post-injection. Ventricular function was assessed via MRI, and the infarct area was evaluated histologically to show collagen distribution and demonstrate the presence of cardiomyocytes.

Results: EF was significantly improved (p<0.05) compared to untreated controls 5 and 8 months post I-ECM, and end systolic volume (ESV) was significantly improved (p<0.05) compared to untreated controls 8 months post I-ECM. Control EFs were 37.9 ± 2.6% and 42.1 ± 5.4% compared to 46.8 ± 6.5% and 49.3 ± 3.8% after I-ECM therapy, at 5 and 8 mos post treatment, respectively. Control ESV was 40.2 ± 8.2ml compared to 27.4 ± 7.9ml 8 mos post I-ECM Histology demonstrated arteriogenesis and cells surrounding the degrading I-ECM. Cardiomyocytes were seen in the I-ECM suggesting regeneration of new cardiac muscle.

Conclusions: Surgical delivery of injectable ECM bioscaffolds significantly improves chronic CHF by positive remodeling and may facilitate cardiac regeneration.

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C23 Early In Vivo Results of the Ax-Tide VAD

Noedir A. G. Stolf 1, Alessandro Verona2, Regina Salum2, Rui Barbosa3, Juan Mejia4, Idágene A. Cestari1. 1InCor Heart Institute of the University of São Paulo Medical School, São Paulo, Brazil, 2Studheart Medical Technologies Inc., Fortaleza, Brazil, 3Department of Mechanical Engineering of University of Fortaleza (UNIFOR), Fortaleza, Brazil, 4Heart Transplant and Mechanical Circulatory Assistance Division, Messejana Hospital, Fortaleza, Brazil.

Objective: There is growing evidence of the use of continuous flow ventricular assist systems to treat severe heart failure patients on a temporary or permanent basis. We evaluated the in vivo performance of a novel miniaturized, fully implantable axial-flow blood pump, the Ax-Tide VAD.

Methods: The intraventricular pump (20 mm in diameter, 7 cm in length, 86 g in weight) is based on an impeller magnetically coupled to a brushless dc motor sealed in the rear diffuser. The electronic controller powered by lithium-ion batteries is connected to the pump through a 3 mm diameter cable. The titanium pump is coated in diamond-like carbon to improve hemocompatibility and has a sintered microsphere coated shell to favor progressive endocardial overgrowth. A ePTFE vascular graft offloads to the descending thoracic aorta. Six pumps were implanted in 2 calves (70 - 108 Kg) and 4 sheep (48 to 57 kg) under general anesthesia. Blood pressure was measured in the femoral artery and cardiac output measured by thermodilution. A left lateral thoracotomy was performed at the 5th intercostal space to expose the heart. A catheter tip pressure transducer was inserted into the left atrium and the pump outflow graft was sutured to the partially clamped aorta. A sewing cuff was attached to the LV apex with pledgeted 2-0 polyester sutures and the inner myocardium was cored using a cylindrical knife. The Ax-Tide was inserted into the left ventricle and secured in place. An ultrasonic flow probe was connected to the outflow graft and a second probe was placed around the aorta distal to the graft anastomosis. After deairing, pumping was initiated and pump speed was increased.

Results: Maximum average flows were in the range of ∼5 to 6 L/min and a reduction of native cardiac output was observed as pump flow increased. Mean arterial blood pressure was maintained within a narrow range with a large increase in diastolic pressure.

Conclusions: This study demonstrates the adequate performance of the Ax-Tide pump and its applicability in the cardiac assistance arena.

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C24 Minimally Invasive Off-Pump LVAD Explantation

Anson Cheung, Jennifer Higgins, John Bowering, Andrew Ignazweski. St. Paul’s Hospital, Vancouver, BC Canada.

Objective: Patients who successfully demonstrate the ability to wean from LVAD are candidates for LVAD explant, which is conventionally performed through a median sternotomy, with cardiopulmonary bypass. In this video, we describe the technical aspect of explantation of a HeartWare HVAD centrifugal device, through a small anterior thoracotomy, without cardiopulmonary bypass.

Methods: A 41-year-old male with previous aortic replacement with a homograft for endocarditis at age 19. At age 21, a redo AVR with a bioprosthesis was performed. He presented with CHF and depressed EF of 20%, secondary to severe prosthetic AS and AI. He underwent transapical aortic valve-in-valve implantation. Unfortunately, ventricular valve embolization occurred, requiring emergent conversion. He developed post-cardiotomy shock requiring ECMO support and was bridged to a HeartWare HVAD. Myocardial recovery occurred and explantation was performed. A small left thoracotomy was performed, outflow graft was stapled and divided, pump explanted and apical inflow plugged with a titanium plug. No blood product were used and patient was extubated in OR and discharged home on day 3.

Conclusions: In complex patients with multiple previous surgery, a minimally invasive off-pump approach to LVAD explant may reduce peri-operative morbidity and mortality.

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C25 Trans Apical Device Implantation for Diastolic Heart Failure

Amir Elami. Hebrew University Hadassah School of Medicine, Jerusalem, Israel.

Objective: Diastolic heart failure (DHF) accounts for 40-54% of HF cases. Patients with advanced DHF (NYHA class III and IV) have poor quality of life and high mortality. There are no guidelines for the use of either drugs or devices in these patients. Treatment is based on controlling co-morbidities and conditions that may exacerbate the disease, such as hypertension, diabetes, rapid atrial fibrillation and congestion. A novel mechanical principle of transferring energy exerted by the left ventricle (LV) during systole to diastole to enhance diastolic performance was realized.

Methods: a transapically delivered three-arm elastic device, leaning on the internal surface of the LV wall was developed and evaluated in a large-scale preclinical safety study in more than 60 sheep.

Results: After screening, guided by fluoroscopy and echocardiography, the device is positioned inside the LV, with one arm located between the papillary muscles, another arm on the septum and the third arm on the free wall, avoiding the mitral valve and subvalvar apparatus. Bail-out is possible, if necessary. There were no safety events up to 12-month follow-up.

Conclusions: Previous clinical experience with an extra-ventricular device, using the same principle and implanted as an add-on to aortic valve replacement for aortic valve stenosis, revealed signs of efficacy. This was demonstrated by greater decrease in left-atrial area, regression of LV mass and of BNP levels compared to control group (aortic valve replacement only without device). Clinical study with the intra-ventricular device is to be initiated during 2012.

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CMP30 Results of the C-Pulse Prospective Feasibility Study for the Treatment of Ambulatory Heart Failure Utilizing a Minimally Invasive Thoracotomy Implantation Technique

Sanjeev Aggarwal, Keith B. Allen, Jacqueline Smith, Andrew Kao, Michael Borkon. Mid-America Heart Institute, Kansas City, MO USA.

Objective: The C-Pulse System (Sunshine Heart, Inc) is an implantable, non-blood contacting device designed to provide long-term counterpulsation therapy for advanced heart failure patients. Results from a recently completed 20 patient FDA-approved feasibility study demonstrated improvements in NYHA class and quality of life with a low incidence of adverse events. We describe our single center experience in a subgroup of patients undergoing implantation of the C-pulse system utilizing the first minimally invasive thoracotomy approach.

Methods: Between July 2010 and March 2011, five patients underwent implantation of the C-Pulse device at a single institution under an FDA approved IDE prospective feasibility study. Safety endpoints included death, aortic injury, neurologic events, and major infection at 6 months. Quality of life was assessed using Minnesota Living with Heart Failure (MLWHF) and the Kansas City Cardiomyopathy Questionnaire (KCCQ). One patient underwent implantation using a hemisternotomy approach. Four patients underwent placement using a limited right parasternal thoracotomy incision, leaving the sternum intact.

Results: Mean age was 53 years (range 34–71) and 80% were male. All patients were NYHA class III at baseline, with non-ischemic etiology in 80% (4/5). Two patients were inotrope dependent. Mean follow up was 351 days (range 64 – 498) with 1754 total patient days. There were no deaths. There were no neurologic events, aortic disruptions, or mediastinal infections. One patient was re-explored for mediastinal bleeding. One patient developed a driveline exit site infection prior to 6 months. One patient was transitioned to an LVAD at 64 days for worsening heart failure symptoms. Improvement in NYHA class was seen in 80% (4/5 patients). Significant improvements were seen at 6 months in MLWHF scores [baseline mean 50 (range 20–71) vs. mean 31 (range 5–49) at 6 months] and in KCCQ scores [baseline mean 56 (range 37–81) vs. mean 69 (range 52–92)].

Conclusions: The results of the C-pulse cardiac assist system study have demonstrated feasibility and preliminary safety and efficacy in patients with moderate to severe ambulatory heart failure. The system can be safely implanted utilizing a minimally invasive non-sternotomy approach. These findings warrant further study with a prospective, randomized control trial.

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CMP31 Outcome of the Impella Device for Acute Mechanical Circulatory Support

Anthony Lemaire, George Batsides, Thomas Prendergast, Neil Stockmaster, Amin Medjamia, Ann Marie Lozane, Mark B. Anderson. University of Medicine and Dentistry of New Jersey, New Brunswick, NJ USA.

Objective: Acute cardiogenic shock is associated with high mortality rates. Mechanical circulatory devices have been increasingly used in this setting for hemodynamic support. The Impella device (Abiomed Inc., Danvers, MA USA) is a microaxial LVAD that can be inserted using a less invasive technique. The purpose of this study is to determine the outcome of patients who have undergone the placement of the Impella device for acute cardiogenic shock in our institution.

Methods: A retrospective chart review of 36 patients who underwent placement of the Impella device was performed from January 1, 2006 to December 31, 2010. Charts were evaluated for demographics, operative details and postoperative outcomes. Operative mortality was defined as death within 30-days of surgery.

Results: The average age of the patients was 60.27 ± 13 and the majority of the patients were male (N = 25). The indication for placement of the Impella device include cardiogenic shock in 19 (52%), acute myocardial infarction in 4 (11%), ischemic cardiomyopathy in 3 (8%), and other indications in 10 (28%). Twenty-eight patients of the 36 total patients (78%) had the Impella 5.0 and the rest the 2.5 device. The majority of the patients, 25 of 36 (69%), recovered ventricular function and had the device removed with 3 patients (8%) transitioned to long-term ventricular assist devices. The 30-day mortality was 25%. Complications occurred in 14 of the 36 patients (38%) and consisted of device malfunction, high purge pressures, tube fracture, and groin hematoma.

Conclusions: This is the largest series of patients undergoing placement of the Impella device for acute cardiogenic shock. The outcomes from our study have results which are improved over historical data. Myocardial recovery was accomplished in the majority of the patients. Finally the 30-day mortality and complication rate was acceptable in these critical patients. These benefits were all achieved with the Impella device in a less invasive method.

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C26 Minimally Invasive Mitral Valve Surgery via Right Minithoracotomy: An 8-year, Single-Center Experience in 1155 Patients

Mattia Glauber, Antonio Miceli, Daniyar Gilmanov, Matteo Ferrarini, Filippo Santarelli, Enkel Kallushi, Alfredo G. Cerillo, Stefano Bevilacqua, Tommaso Gasbarri, Francesca Chiaramonti, Michele Murzi, Giacomo Bianchi, Egidio Varone, Pier A. Farneti, Marco Solinas. Fondazione Toscana G. Monasterio, Massa, Italy.

Objective: To review a single center experience with minimally invasive mitral valve surgery (MIMVS) over an 8-year period.

Methods: A retrospective study was undertaken of prospectively collected data on consecutive patients undergoing MIMVS via right minithoracotomy by six surgeons between January 2003 and October 2011.

Results: A total of 1155 patients underwent MIMVS via right minithoracotomy, of whom 859 (74.3%) patients had mitral valve repair and 296 (25.7 %) patients received mitral valve replacement. The mean age was 62.3 ± 13.4 years, 569 (49.2%) patients were female, mean ejection fraction was 59.1 ± 10%, 120 patients (10.3%) had previous cardiac operations and 57 (5%) patients had active endocarditis. Direct aortic cannulation was achieved in 1114 (98%) patients. Overall in-hospital mortality was 1.3% (15 patients). Mortality for mitral valve repair and replacement were 0.5% (4 patients, predicted median EuroSCORE 4%, range interquartile 2-6) and 3.7% (11 patients, predicted median EuroSCORE 7%, range interquartile 4-14,8 %), respectively. In the mitral valve repair group, 661 (76.9%) patients received mitral valve repair (leaflet resection, sliding, neochordae placement) with either annuloplasty (n = 629, 95.1%) or without annuloplasty (n = 32, 4.9%) and 198 (23%) patients received only a mitral valve annuloplasty. In patients who had mitral valve replacement, a mechanical and biological valves were implanted in 130 (43.9%) and 166 (56.1%), respectively. Twenty-six (2.2%) patients had conversion to sternotomy. Concomitant tricuspid valve repair was performed in 153 patients (13.25) and concomitant ablation of atrial fibrillation was performed in 120 patients (10.4%). At discharge, 98% of patients showed no or trivial residual mitral regurgitation.

Conclusions: Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and high rate of mitral valve repair.

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C27 Aortic Valve Replacement in Intermediate-Risk Patients: Two Alternative Sutureless Strategies

Giovanni Concistrè 1, Steffen Pfeiffer1, Giuseppe Santarpino1, Pierandrea Farneti2, Antonio Miceli2, Francesca Chiaramonti2, Alfredo Giuseppe Cerillo2, Mattia Glauber2, Theodor Fischlein1. 1Klinikum, Nuremberg, Germany, 2Ospedale del cuore "G.Pasquinucci" - Fondazione Monasterio - CNR, Massa, Italy.

Objective: Important comorbid conditions in intermediate-risk patients referred for aortic valve replacement (AVR) require less invasive strategies. We describe our initial experience with Perceval S (Sorin Group, Saluggia, Italy) (“P”) and 3f Enable (ATS Medical, Minneapolis, MN USA) (“E”) sutureless aortic bioprostheses.

Methods: Patients undergoing sutureless AVR in 2 cardiac surgery departments between March 2009 and August 2011 were enrolled. We compared intraoperative data, postoperative clinical outcomes, and echocardiographic results from patients receiving a “P” (n = 94) or “E” (N = 32) prosthesis, respectively.

Results: Baseline patient characteristics were similar in both groups, “P” and “E”. Mean logistic EuroSCORE was 11.2% ± 8.5%. From 126 patients, 78 underwent minimally invasive AVR with either an upper partial ministernotomy (n = 66) or right anterior minithoracotomy (n = 12) approach. Concomitant procedures were performed in 27 (28.7% of “P”) and 9 (28.1% of “E”) patients (p = 0.56). In-hospital mortality was 2.4% (“P”: n = 2, “E”: n = 1). Mean prosthesis diameter was 23.5 ± 1.4 mm (“P”) compared to 22.1 ± 2 mm (“E”) (p = <0.001). Aortic cross-clamp (ACC) time was 70.5 ± 20.5 minutes in “P” and 76.4 ± 16.7 minutes in “E” (p = 0.58). At a mean follow-up of 8.3 ± 4.5 months, survival was 96.8% (one death after 11 months in “P”), and freedom from reoperation was 99.2% (one reoperation in “E”). In 5 patients (“P”: n = 1, “E”: n = 4), a moderate paravalvular leak was present (p = 0.013). Mean transvalvular gradient was 13.9 ± 4.1 mmHg with Perceval S and 11.2 ± 5.2 mmHg with 3f-Enable (p = 0.012).

Conclusions: AVR with sutureless aortic bioprosthesis in intermediate-risk patients is safe and feasible, also with a minimally invasive approach. It is associated with good outcomes and a low mortality rate. The implants perform hemodynamically excellent. The 3f-Enable shows lower mean transvalvular gradients but a higher rate of paravalvular leaks. This new technology needs long-term follow-up.

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CV3 Cardiac Reoperation with da Vinci Surgical System: Repair of Systolic Anterior Motion (SAM) in Hypertrophic Obstructive Cardiomyopathy (HOCM)

Daniel Tai-Leung Chan, Hazaim Alwair, Amber Melvin, Evelio Rodriguez, Wiley L. Nifong, Randolph W. Chitwood, Jr. East Carolina University, Greenville, NC USA.

Objective: To demonstrate the technique and approach of robotic repair of SAM in a patient after previous septal myomectomy for symptomatic HOCM.

Methods: A 65-year-old lady with a previous history of septal myomectomy (Morrow Procedure) via median sternotomy presented with increasing shortness of breath. Echocardiogram showed SAM with moderate mitral regurgitation and increased left ventricular out flow tract gradient.

Results: Robot assisted mitral valve repair was performed in this patient. The reparative procedure consisted of resection of hypertrophic chords, reposition of the antero-lateral papillary muscle followed by annuloplasty. The post-operative TEE showed no mitral regurgitation and no LVOT gradient. Her post-operative course was uneventful.

Conclusions: Re-operations using robotic-assisted techniques are possible. In this video we present a successful repair of SAM in a patient after previous septal myomectomy for HOCM. Repair techniques included chordal resections and papillary muscle repositioning to treat papillary muscle hypertrophy and malposition. Robotic assisted surgery provides superior visualization and dexterity allowing improved access to the subvalvular apparatus.

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C28 Outcomes of Transaortic Edge-to-Edge Repair of the Mitral Valve in Patients Undergoing Minimally Invasive Aortic Valve Replacement

Christos G. Mihos, Orlando Santana, Juan C. Brenes, Joseph Lamelas. Mount Sinai Heart Institute, Miami Beach, FL USA.

Objective: We evaluated the safety and durability of a transaortic edge-to-edge mitral valve repair in patients undergoing minimally invasive aortic valve replacement.

Methods: We retrospectively analyzed all patients who underwent concomitant aortic valve replacement and transaortic edge-to-edge mitral valve repair via a right mini-thoracotomy (minimally invasive) at our institution between September 2008 and September 2011. Intra-operative transesophageal and follow-up transthoracic echocardiograms were performed to evaluate the adequacy of the repair, and assess for any post-operative recurrence of mitral regurgitation (MR).

Results: There were 24 patients identified (16 males and 8 females), with 8 patients having a history of prior heart surgery. The median EuroSCORE was 12.5 (IQR 6-23). The mitral valve lesion was classified as functional (n = 11), degenerative calcification (n = 10), or rheumatic (n = 3). The median aortic cross clamp and cardiopulmonary bypass times were 101 minutes (IQR 86-116) and 127 minutes (IQR 109-149), respectively. There was one (4%) in-hospital death. The median total hospital length of stay was 8 days (IQR 7-12). Median pre-operative versus post-operative MR grade was 3 (IQR 3-4) versus 0 (IQR 0-1), P<0.001. Median time to follow-up echocardiogram was 13 days (IQR 5-93). Median preoperative versus follow-up MR grade was 3 (IQR 3-4) versus 1 (IQR 0-2), P<0.001, and postoperative versus follow-up MR was 0 (IQR 0-1) versus 1 (IQR 0-2), P = 0.01, respectively.

Conclusions: In patients undergoing minimally invasive aortic valve replacement with at least moderate mitral valve regurgitation, a transaortic edge-to-edge mitral valve repair is a safe and effective alternative to conventional double valve surgery.



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CMP32 Minimally Invasive Mitral Valve Surgery for Severe Impaired Left Ventricular Function: Experience in 177 Patients

Jens Garbade, Jörg Seeburger, Markus J. Barten, Bettina Pfannmüller, Sven Lehmann, Martin Misfeld, Michael A. Borger, Friedrich-Wilhelm Mohr. Heart Surgery, Heart Center, University of Leipzig, Leipzig, Germany.

Objective: We sought to review our experience in patients with severely impaired left ventricular function (ejection fraction ≤ 30%) who underwent minimally invasive mitral valve (MV) surgery.

Methods: Between 1999 and 2010 a total of 3450 patients underwent minimally invasive MV surgery. Of these patients, 177 suffered from severely impaired left ventricular function (EF < 30%, including ischemic and non-ischemic cardiomyopathy). Primary indication for surgery was MV regurgitation in all patients, whereas five patients were diagnosed with additional stenosis. Mean age of patients was 67 ± 11 years and 110 were male. Mean EUROScore was 13.6 ± 11.

Results: MV repair was accomplished in 86.4% of patients (n = 153) and MV replacement was necessary in 13.6% (n = 24). Primary MV repair included the implantation of an annuloplasty ring in all patients (complete rings including amongst others the Physio and ETLogix ring in 146 patients, with mean size of 29.5 ± 2.2) and additional procedures like chordae replacement in several patients. Concomitant procedures were tricuspid valve surgery in n = 27, atrial ablation in n = 48, and ASD closure in n = 10. Duration of CPB was 123 ± 64 min and aortic-clamp-time was 54 ± 36 min. Thirty-day mortality was 7.9 %. Mean follow-up time was 3 ± 2.5 years, and follow-up was 92 % complete. For the overall group ten year survival was 45.5 % (95% CI: 35.2 - 55.9). The over-all rate of MV-related re-intervention was 4% and heart transplantation in 6%.

Conclusions: Minimally invasive MV repair in patients with significantly impaired left ventricular function can be performed with a reasonable operative mortality and acceptable long-term survival for this sick patient cohort.

Copyright © 2012 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.