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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.