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Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2013 - Volume 8 - Issue 2 - p 157–174
doi: 10.1097/IMI.0b013e3182978401
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D1 Minimally Invasive Transfusion: Rotational Thromboelastometry Based Coagulation Management in Cardiovascular Surgery

Masahito Minakawa, Takashi Ogasawara, Ikuo Fukuda, Yasuyuki Suzuki. Hirosaki University Graduate School of Medicine, Hirosaki, Japan.

Objective: Rotational thromboelastometry (ROTEM) has been developed in Germany and has been used in the world. In Japan it has become a clinical use. But unfortunately usefulness of ROTEM is not well known. We investigated the effect of ROTEM based coagulation management in cardiopulmonary bypass surgery.

Methods: A retrospective review was performed of 199 patients undergoing cardiopulmonary bypass surgery between January 2011 and October 2012. In a ROTEM group (group R, n = 82) patients treated with allogeneic blood products (fresh frozen plasma, followed by platelet concentrates) according to intraoperative ROTEM tests (FIBTEM A10 is aimed at the value of at least 10 mm; normal range 7-23 mm) and complete blood counts. In control group (group C, n = 117) patients were treated with allogeneic blood products (platelet concentrates, followed by fresh frozen plasma) according to activated coagulation time (ACT) and complete blood counts. Preoperative variables, intraoperative variables, perioperative blood loss, and amount of blood products were analyzed.

Results: Preoperative and intraoperative variables were similar between groups without rate of female patients (30.1% in group R vs. 50.4% in group C; P =0.016). There were significant differences about intraoperative blood loss between groups (1159 mL in group R vs. 1686 mL in group C; P = 0.014). Intraoperative transfusion of fresh-frozen plasma was not reduced in the group R (1097 mL in group R vs. 1241 mL in group C; P = 0.930). But the use of platelet concentrate and red blood cells were significantly decreased in the group R (RBC: 488 mL in group R vs. 713 mL in group C; P <0.05. PC: 148 mL in group R vs. 311 mL in group C; P <0.05).

Conclusions: By ROTEM we can frequently measure fibrinogen plasma levels and reduced unnecessary transfusions of platelet concentrate without increasing the perioperative bleeding.

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D2 If Minimally Invasive Aortic Valve Replacement is So Good, Why Aren’t We All Doing It? A UK Perspective

Justin Smyth, Gwyn Beattie, OC Nzewi. Royal Victoria Hospital, Belfast, United Kingdom.

Objective: Minimally invasive aortic valve replacement (MIAVR) was first described in 1996 as an alternative to the conventional median sternotomy for AVR. Its uptake has been sporadic in cardiac surgery units in the UK. It remains unclear and somewhat controversial whether it has superior patient outcomes over conventional sternotomy. This survey aims to explore the reason for the low uptake by consultant surgeons in the United Kingdom and assess current opinions regarding the benefits, evidence base and barriers to MIAVR.

Methods: An online survey was created with 20 questions designed to explore the reasons that the current consultant population uses to base its practice on MIAVR. The link was distributed by the UK Society of Cardiothoracic Surgeons to the consultant members. Opinions on benefits of MIAVR compared with conventional sternotomy were evaluated along with potential barriers and areas for future research. Information regarding use of MIAVR in clinical practice and experience was also obtained.

Results: Forty-nine consultants responded giving a response rate of approximately 30%. Three-quarters of respondents were from England, Northern Ireland and Scotland made up the remainder; no responses were received from Welsh surgeons. 67% of the consultants have performed MIAVR. 84% of the consultants identified that MIAVR was performed in their unit. 45% of the consultants who identified themselves as performing MIAVR have carried out less than 15 procedures. 22% have carried out more than 26 procedures. The most common barriers identified to a consultant practicing MIAVR were training of SpRs (both time taken to train in MIAVR and trainees ‘losing’ training in a conventional case) 9%, training of the consultant in the procedure 9%, equipment issues 9% (availability and expense), and objections from the anesthetic team 7%.

Conclusions: These results suggest that consultants’ opinions on the benefits and drawbacks of MIAVR remain divided. It has highlighted some perceived barriers and the desire for further evidence on which to base practice. Rigorous cost-benefit analysis would enable cardiac surgical units to make an informed decision on the most effective approach to patients requiring AVR.

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D3 Which Surgical Approach is Better for Minimally Invasive Aortic Valve Replacement? A Comparison of Outcomes between Right Anterior Minithoracotomy and Ministernotomy.

Kazuhiro Hisamoto, Marc P. Sakwa, Francis L. Shannon. William Beaumont Hospital, Royal Oak, MI USA.

Objective: The purpose of this study was to compare the safety, feasibility and benefits between the right anterior minithoracotomy (RAT) approach and the ministernotomy (MST) approach in patients with minimally invasive aortic replacement (mini-AVR).

Methods: We retrospectively reviewed 206 isolated mini-AVR cases from January 2008 to December 2011 in William Beaumont Hospital, Royal Oak, MI.

Results: Of the 206 patients, 117 patients underwent isolated mini-AVR via the RAT, 89 patients had the MST. The baseline characteristics were similar in both groups. There were no significant differences in the 30-day mortality (1.7% vs. 2.2%, p=0.78) and the incidence of permanent stroke (0% vs. 1.1%, p=0.25) between the RAT group and the MST group respectively. Cardiopulmonary bypass (CPB) time and an aortic cross-clamp (ACC) time in patients with the RAT approach both were significantly longer than that of the MST group (115±23 min vs. 94±17 min p<0.001, 85±13 min vs. 72±14 min p<0.001). Intraoperative blood products were less frequently used in the RAT group when compared to the MST group (21% vs. 44%, p=0.003). The length of hospital stay in patients with the RAT approach was significantly shorter than that in patients with the MST approach (7.8 days vs. 9.4 days, p=0.045).

Conclusions: Mini-AVR via both approaches can be safe and feasible with excellent outcomes. Despite longer CPB and ACC time, the RAT approach for mini-AVR has a less need for blood transfusion and results in shorter length of hospital stay when compared with the MST approach.

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D4 Enhancing Departmental Quality Control in Minimally Invasive Aortic Valve Surgery: A Single-Institution Experience

Michele Murzi, Alfredo G. Cerillo, Antonio Miceli, Stefano Bevilacqua, Marco Solinas, Pierandrea Farneti, Mattia Glauber. G. Pasquinucci Heart Hospital, Massa, Italy.

Objective: In recent years, there has been an increasing interest in monitoring the quality of cardiac surgical performance. The aim of the present study was to apply control charts (CUSUM curves) to monitor the performance of minimally invasive aortic valve procedures to enhance quality control for that operation.

Methods: A total of 586 minimally invasive aortic valve replacements (370 right minithoracotomy and 219 ministernotomy) were performed from 2006 to 2012 by six surgeons (range 31-294 procedures) at a single institution. Institutional and individual surgeons’ performances were monitored using descriptive statistics and control charts, with a predetermined acceptable failure rate of 10% and calculated 80% alert and 95% alarm lines. Perioperative death or one or more of seven adverse events constituted failure.

Results: The incidence of in-hospital mortality was 0.7% (4/586) and compared favorably with the predicted mortality (logistic EuroSCORE 5.3%). The incidence of stroke was 1.2% (7/586). Institutional CUSUM analysis revealed an initial learning curve and then the surgical process remained in control for all the study period. There were differences between surgeons with regard to the learning curves and perioperative complications (5.3–9.3%, P = 0.9). Five surgeons crossed the 95% reassurance boundary between operations 13 and 28 (Figure D4-1). One surgeon crossed the 95% reassurance boundary after 57 operations. No surgeon crossed the 95% alarm line, which indicates unacceptably high-failure rates.

Conclusions: Minimally invasive aortic valve surgery can be safely performed with low morbidity and mortality. CUSUM curve analysis is a simple statistical method to implement continuous individual and departmental performance monitoring.



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D5 Cardiac Surgery with Cardiopulmonary Bypass in Jehovah’s Witness Patients

Chan-Young Na. Dong-san Medical Center, Keimyung University, Daegu, Republic of Korea.

Objective: Cardiac surgery in Jehovah’s Witness patients has many limitations because of refusal of blood transfusion. We evaluated perioperative outcomes of cardiac surgery with cardiopulmonary bypass.

Methods: From January 1997 to July 2011, 118 Jehovah’s Witness patients underwent cardiac surgery with cardiopulmonary bypass without blood transfusion. From the earlier study period, we have conducted the blood conservative program including preoperative, intraoperative and postoperative management. We reviewed perioperative clinical outcomes, and various perioperative data were statistically analyzed to determine risk factors for postoperative complications.

Results: The median age was 40.5 years (interquartile range, 8.0 - 56.3). There were two emergent operations and 17 redo-operations. Cardiac surgeries included ASD (n = 19), VSD (n = 19), TOF total correction (n = 4), valve replacement (n = 36), valve repair (n = 11), CABG (n = 13), myxoma removal (n = 4), aortic root replacement (n = 3), and others. The operative mortality was 3.4% (n = 4). Postoperative values of hematocrit (34.7%) and hemoglobin (11.5g/dl) were significantly lower than preoperative values of hematocrit (39.4%) and hemoglobin (13.2g/dl) (p < 0.000). The mean value of lowest hematocrit during cardiopulmonary bypass was 22.3% ± 3.5%. Postoperative complications included acute renal insufficiency (n = 6), mediastinitis (n = 6), LV dysfunction (n = 3), thromboembolism (n = 2), intractable arrhythmia (n = 2), pericardiostomy (n = 2), and others. In multivariate logistic regression analysis, previous operation (odds ratio, 8.062; p = 0.007) and difference of preoperative and postoperative ejection fraction (odds ratio, 0.384; p = 0.017) were identified as significant independent risk factors for postoperative complications.

Conclusions: Perioperative hematologic diminution seems no longer a matter of grave concern regarding postoperative complications in Jehovah’s Witness patients under well-designed blood conservative program.

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D6 A Single-Center Propensity Analysis of Minimally Invasive versus Sternotomy Approach for Mitral Valve Surgery

Marian Urban, Tomas Martinca, Ivo Skalsky, Ondrej Szarszoi. Institute for Clinical and Expertimental Medicine, Prague, Czech Republic.

Objective: Over the last decade, minimally invasive mitral valve surgery has grown in popularity. The very low risk of mitral valve surgery performed through median-sternotomy must be reproducible when using minimally invasive approach to justify higher initial cost. Our goal was to compare outcome of mitral valve surgery through either standard sternotomy or right lateral minithoracotomy.

Methods: All 531 patients who received mitral valve surgery from June 2008 to June 2012, at our institution were analyzed for outcome differences due to surgical approach using propensity-score matching. Major outcome of interest included cardiopulmonary-bypass time, cross-clamp time, hospital length of stay, major in-hospital morbidity and 30-day mortality.

Results: Cardiopulmonary bypass time was 146 ± 57 minutes in minimally invasive and 102 ± 54 minutes in sternotomy group (p < 0.01). Cross-clamp time was 101 ±46 minutes in minimally invasive and 73 ± 43 minutes in sternotomy group (p < 0.01). There was no significant difference in the frequency of the major in-hospital complications between the groups (Table D6-1). Median hospital length of stay was 10.1 days in minimally invasive and 11.2 days in sternotomy group (p =0.96). There was no significant difference in mortality at 30 days (p = 0.75).

Conclusions: Although minimally invasive mitral valve surgery required longer cardiopulmonary bypass and cross-clamp time, there was no difference in morbidity and mortality at 30 days.



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D7 Robotic Ligation of Thoracic Duct and Pleurectomy for Chylothorax

Marian Urban, Tomas Martinca, Ivo Skalsky, Ondrej Szarszoi. Institute for Clinical and Experimental Medicine, Prague, Czech Republic.

Objective: We present a video of robotic ligation of thoracic duct and pleurectomy for chylothorax.

Methods: An 83-year-old male patient presented with recurrent bilateral chylothorax following a diagnosis of chronic lymphoid leukemia. Conservative treatment had been continued for 6 weeks and had failed. We performed a robotic ligation of thoracic duct with pleurectomy. The thoracic duct was identified and ligated by tying with a suture and clipping. The thoracic duct was then disconnected. A robotic pleurectomy was performed on the right side and a VATS pleurectomy was done on the left side.

Results: The drains were removed on the fourth-postoperative day. The patient was discharged home the following day.

Conclusions: Robotic ligation of thoracic duct is technically feasible. The robotic technique allows you good dexterity to dissect and tie the duct. In addition, a pleurectomy can also be performed easily.

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D8 Learning Curve of Robotic Anatomic Lung Resection in a VATS Center

Jennifer Hanna, Kimberly Howard, Mark Berry, Mark Onaitis. Duke University, Durham, NC USA.

Objective: Studies have reported a steep learning curve when a transition is made from open- to robotic-lung resection. We sought to examine the learning curve during a transition from VATS to robotic-lung resection.

Methods: Consecutive robotic lobectomies were identified from December 2010 until the present. Demographic, perioperative, and pathologic variables were collected and analyzed.

Results: Over this period, 32 robotic-anatomic lung resections were performed. Indications for resection included lung cancer (25), metastasis (6), and benign (1). Mean age was 66 years. Operations included lobectomy (23), bilobectomy (3), and segmentectomy (9). Median operative time was 152 minutes [135, 205]. In multivariable modeling, including case number (Figure D8-1), age, extent of resection, presence of nodal metastases, and induction chemotherapy, no variable significantly predicted operative time.

Conclusions: During the transition from VATS anatomic lung resection to robotic lung resection, the learning curve is flat. Operative time may be related to comfort performing minimally-invasive lung resections.



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D9 Minimally Invasive Aortic Valve Surgery Using St. Jude Medical Trifecta Aortic Bioprosthesis: An Assessment of Mid-term Hemodynamic Function

David J. McCormack, Amir H. Sepehripour, Kulvinder S. Lall. St. Bartholomew’s Hospital, London, United Kingdom.

Objective: The St. Jude Medical Trifecta valve represents the next generation of aortic supra-annular bioprosthesis. No literature currently exists on the ‘real-world’ performance of this valve. The aim of this prospective observational study was to evaluate the hemodynamic performance following implantation using a minimally invasive approach over mid-term follow-up.

Methods: Ninety-nine consecutive patients undergoing minimally invasive aortic valve surgery (MIAVR) with partial J sternotomy using the St. Jude Medical Trifecta at a single UK centre were included in this study. Data was collected over a 24-month period. The subjects were evaluated pre-operatively, at end of operation (transesophageal echo), and prior to discharge (transthoracic echo). During this experience with the St. Jude Medical Trisect valve we have implanted 19, 21, 23, 25 and 27 mm valves.

Results: The mean subject age was 73.2 ±5.7 years. The mean post-operative pressure gradients were 8.78 ±3.6 mmHg, 8.13 ±2.3 mmHg, 8.26 ±3.5 mmHg, 7.01 ±3.8 mmHg, 7.27 ±2.7 mmHg, respectively, for valves sized 19 mm (n=6), 21 mm (n=26), 23 mm (n=47), 25 mm (n=16) and 27 mm (n=4). On echocardiography assessment of all valves were well seated. Moderate-severe paravalvular leak was observed in one patient and mild-moderate leak in another. Otherwise, there were only 14 patients with trivial regurgitation.

Conclusions: The results of our early experience with this new valve indicate that it offers excellent hemodynamic performance in the 19, 21, 23, 25 and 27 mm sizes using a minimally-invasive approach for implantation. The mean gradients compared favorably to other supra-annular aortic bioprostheses currently available.

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D10 Starting and Evaluating a Robot-Assisted VATS Program: Pilot Phase

Sandra M. Gelvez-Zapata, Priya Sastry, Aman S. Coonar. Papworth Hospital, Cambridge, United Kingdom.

Objective: The Freehand robot scope holder has been recently released and is being tested in various surgical specialties. We sought to assess the feasibility of implementing and using this robot-assisted telescope holder in VATS surgery, and to determine possible benefits/drawbacks for more detailed evaluation. To the best of our knowledge, this is the first use of this particular device in thoracic surgery.

Methods: Following dry-lab training of the consultant and theater team by an experienced trainer, we introduced the system into the operating room. Non-lobectomy patients were considered for robot-assisted VATS (R-VATS) if the system and trainer was available. Over 9 operating lists, 15 consecutive VATS patients were selected. The procedures were 7 wedge resections, 3 pneumothoraces, 3 lung volume resections (LVRS), 1 empyema drainage and 1 mediastinal cyst resection.

Results: 13/15 patients had 3 ports, and 2/15 patients had 4 ports (mean 3.1). In 1/15 patients (Case 2) we had a set-up problem and the robot was not used. 3/14 were early conversions to full or mini-thoracotomy (1 required apical segment sparing lower lobectomy, 2 due to adhesions), and the robot was not used. 2/3 were considered likely conversions, and thoracoscopy speculative. 14/15 procedures were elective and 1 was urgent (empyema drainage). We show data from the 11/14 patients who underwent R-VATS (Table D10-1).

Conclusions: Careful dry-lab preparation allowed robot position to be optimized for our pilot study. Implementation was rapid and safe. Consideration of robot placement and port position is critical. The robot gave a stable, non-wandering view. Scrubbed assistants observed the procedure, but were not required to participate. The number of scope removals for cleaning and number of scope/instrument clashes was much lower than usually occurs in this consultant’s practice. Positive feedback has been obtained from operating room staff.



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D11 Tracheobronchial Stenting Under Local Anesthesia for Acute Airway Emergencies

Mariam J. Almarashda, Mohammed A. Numairy, Anfal J. Almajidi, Amgad E. Elsherif. Tawam Hospital, Al Ain, United Arab Emirates.

Objective: Acute airway emergencies result from a wide variety of malignant and benign diseases. Advanced interventional endobronchial techniques can be lifesaving to achieve prompt relief of symptoms. Lack of expertise in these techniques can result in grave outcomes. Muscle relaxants with anesthesia may cause detrimental airway collapse. We report our experience using local anesthesia for these emergencies in a tertiary referral center in UAE.

Methods: Twelve patients (five females) with acute proximal airway emergencies were included between January 2008 and October 2012. Indications included thyroid cancer, synovial cell sarcoma, small-cell lung cancer, metastatic colon and breast, and endobronchial lesions from locally advanced esophageal cancer. All patients were treated in the operating room emergently with bronchoscopy and airway stenting. All patients underwent local anesthesia with intravenous sedation under fluroscopic guidance.

Results: There was no perioperative mortality or morbidity. The median age was 49 (range from 16 to 71). Immediate symptom relief was obtained after stenting in all patients. Median length of stay was 2 days. At median follow-up of 18 months, all patients were symptom-free; one patient with synovial cell sarcoma required restenting for recurrent occlusion proximal to the previous stent. Three patients died from malignant disease progression.

Conclusions: Stenting under local anesthesia is feasible. This reports the first cohort for this technique in UAE. Obstruction of the central airways by malignant tumor is associated with poor prognosis. The alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life, the primary goal rather than cure.

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D12 The Incidence of Postoperative Neurocognitive Deficits After Valve Surgery

Paul M. Menu, Laurent M. Soubiron, Jamil H. Hajj-Chahine, Hassan M. Houmaida, Pierre J. Corbi. C.H.U. de Poitiers, Poitiers, France.

Objective: The incidence of transient postoperative neurocognitive deficits (PND) after heart valve surgery varies between cardiothoracic centers. The effect on long-term cognitive decline secondary to transient PND remains a matter of ongoing debate. The primary objective was to assess the incidence of delirium state following cardiac valve surgery. The secondary objectives were to identify predictors of PND especially for the patients who are borderline between TAVI and conventional cardiac surgery.

Methods: We performed a prospective-descriptive study. Inclusion criteria were: all patients over 70 years undergoing valve surgery. Exclusion criteria were emergencies and endocarditis. The primary endpoint was the onset of a delirium state and at least one of the 12 criteria described by the NPI (Neuro-Psychatrie Inventory). Criteria for evaluation were made on scales HAD and MMS). We included 51 patients (30 men and 21 women); the average age was (74 +/-6.9 years) among these patients, 58% had hypertension, 18% had severe carotid artery disease and 11% had a history of cerebral vascular accidents. The operations were isolated aortic valve replacements (AVR) (32), AVR with coronary artery bypass (12) mitral valve repair (7).

Results: Twenty-five of 51 patients or 49.5% showed transient PND with a total of 57 acute delirium states (2.3 events per patient). The most common events were: delirium 7.1%, aggressiveness 13.3%, temporal-spatial disorientation in 50%. The mean time of occurrence of PND was 2.6 days. We observed a rapid regression of these deficits under medical treatment in the majority of cases; only 6.2% of patients had disorders more than 72 hours. Multivariate analysis revealed three predictors of PND: age≥ 70 × 2, use of anxiolytic drugs × 6 and history of agitation x 13.2 (p = 0.005). The hospital stay was increased by an average of 2 days.

Conclusions: The risk factors of the cognitive and psychological dysfunction have to be discussed and included in the decision-making for the best strategy for valve disease in the elderly.

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D13 Fibrin Sealant Patch for Temporary Intraoperative Hemostatic Control of Large Vessel Wounds: Feasibility Study

Scott Wadsworth1, Pullen Shnoda1, Julia Joyce2, Jerome Riebman 1, Richard Hutchinson1. 1Ethicon, Inc., Somerville, NJ USA, 2Charles River Laboratories, Wilmington, MA USA.

Objective: Injuries resulting in large blood vessel defects create a vexing surgical challenge. Optimal surgical management demands immediate control of bleeding from the defect to facilitate stabilization of the patient and execution of the surgical plan for vascular control and definitive repair of the defects. Fibrin sealant patch (FSP) device technology has hemostatic capability that may fulfill the needs for temporary hemostatic control of large blood vessel injuries. The feasibility of two different FSP technologies for this purpose was evaluated in a porcine aortic injury model.

Methods: The efficacies of two different FSP devices (FSP-1, FSP-2) were evaluated in an acute heparinized porcine aortic injury and repair model. Evaluations included: 1) achievement of hemostasis at a 4.4 mm aortic biopsy punch wound, 2) maintenance of hemostasis for a 3-hour period with a mean arterial pressure of ≥ 60 mmHg; 3) ability to be removed after 3 hours of hemostasis; and 4) allowance for subsequent repair of the vascular defect by suturing. Treatment sites were also examined histologically.

Results: FSP-1 achieved hemostasis in 3 out of 4 aortic injuries, and failed to achieve hemostasis at 1 test site due to adhesion failure. FSP-1 maintained hemostasis for the 3-hour period (3/3 injuries) and was successfully removed after 3 hours (3/3 injuries), allowing for repair of the aortic punch injuries by suturing (3/3 injuries). FSP-2 failed to achieve hemostasis after two sequential applications in 4 of 4 aortic injury test sites, with both cohesive and adhesive failures observed at each test site. No biologically significant adverse macroscopic or microscopic level findings (such as evidence of thrombus) were observed for either FSP-1 or FSP-2 treated sites.

Conclusions: In this preclinical model, FSP demonstrated immediate hemostatic capability in treatment of a punch defect in the aorta as well as acute maintenance of hemostasis, and could be removed to permit definitive surgical repair of the defect. Differences in FSP technologies may impact capability for this application, and require further investigation. FSP may be a new tool in the surgical management of large blood vessel defects to facilitate acute injury management and definitive repair.

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D14 Surgery of Primary Spontaneous Pneumothorax via Single Incision

Eun-Gu Hwang, Sun-Kyung Min, Yong-In Kim. Inje University Seoul Paik Hospital, Seoul, Republic of Korea.

Objective: Thoracoscopic operation is common in primary spontaneous pneumothorax. Recently, single incision approach is widely used. This study is aimed to evaluate the effectiveness of operation via single incision in primary spontaneous pneumothorax compare with conventional thoracoscopic operation.

Methods: We reviewed medical records of primary spontaneous pneumothorax operated by thoracoscopic approach from January 2011 to November 2012 retrospectively. Groups were divided into two groups according to approach as one camera port and another port on anterior chest wall (2-ports ) and single incision via 7th ICS- MXL (SITS). Operative method was common in two groups as wedge resection and reinforcement of stapled line with polyglycolic acid sheet and fibrin glue. Various parameters were compared with two groups including age, sex, operative time, numbers of staples, complications (wound infection, postop. CTD > 5 days, respiratory complication), postop. CTD days, postop. recurrence, and need of additional opioid. Statistical analysis was done by χ2-test, and statistical significance was p-value < 0.05.

Results: Thirty-two (32) cases were collected; 2-ports group were 16 cases, SITS were 16 cases. Men were 29, women were 3. Age mean was 24.75 yrs (15-66) (p=0.108). Operative time was mean 59.37 minutes (p=0.176); mean number of staples were 5.50 in 2-ports and 3.87 in SITS (p=0.163). Complications occurred in 12 cases, 6 cases (all postop. CTD > 5 days) in 2-ports and 6 cases (wound infection 2, postop. CTD > 5 days 3, respiratory cx. 1) in SITS (p=0.261). Mean postop. CTD were 4.69 in 2-ports and 3.38 in SITS (p=0.69). Postop. recurrence occurred in 4 cases (13.3%), 3 cases in 2-ports group (18.7%) and a case in SITS group (6.2%) (p=.600). Additional opioid needed in 19 cases, 11 cases needed in 2-ports group (69%) and 8 cases in SITS group (50%) (p=0.473)

Conclusions: There were no significant differences between 2-ports approach and single-incision approach. So, we could suggest that single-incision approach can be a substitute to conventional approach. Surgical technique and postoperative pain management should be refined to reduce postoperative pain. More cases and randomized controlled study are essential to evaluate the efficacy of single-incision approach.

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D15 Unanticipated Troubles in Video-Assisted Thoracic Surgery

Mitsuhiro Kamiyoshihara, Hitoshi Igai, Takashi Ibe, Natsuko Kawatani, Seshiru Nakazawa, Jun Atsumi, Yoichi Otak, Kai Obayashi, Toshiteru Nagahima, Seiichi Kakegawa, Masayuki Sugano, Osamu Kakegawa, Kimihiro Shimizu, Izumi Takeyoshi. Maebashi Red Cross Hospital, Maebashi, Japan.

Objective: Most thoracic surgeons encounter atypical cases or unexpected situations that usually lead them to convert minimally invasive surgery to open thoracotomy. Are there any other possibilities? We categorized video-assisted thoracic surgery (VATS) procedures for atypical cases or unexpected situations into two groups: the modification of techniques/instruments and the creation of additional access incisions. The purpose of this study was to suggest a VATS classification and present tips for the application of VATS to atypical cases or unexpected situations.

Methods: We retrospectively reviewed VATS with optional additional techniques.

Results: Twenty-seven patients had malignant lung disease and six had benign lung disease. All 33 patients underwent lobectomies including one or more of the following: bronchoplasty (n = 12), control of the main pulmonary artery (n = 9), total adhesiotomy (n = 7), combined resection with the diaphragm (n = 3), and separation of totally fused fissures (n = 2). The mean length of the skin incision was 8 cm, the mean total operating time was 208 min, and the mean blood loss was 173 g. No operative or hospital death occurred.

Conclusions: This idea may have educational benefits. Veteran surgeons can instinctively deal with intraoperative variance, but we frequently see inexperienced surgeons panic and stop their manipulations. Therefore, we believe that the creation of a categorized coping plan will help inexperienced surgeons cope with unanticipated problems.

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D16 Peri-Xiphoid Process Minimal Incision for Surgical Repair of Simple Congenital Heart Diseases Under One-Year of Age

Zhongdong Hua, Shoujun Li, Shengshou Hu. Fuwai Hospital Beijing, Bejing, China.

Objective: To introduce a minimal peri-xiphoid process incision for the surgery of patients with congenital heart disease under one-year of age.

Methods: From May 2011 to December 2012, 126 patients under one year of age with simple congenital heart disease underwent complete surgical repair with cardiopulmonary bypass. A 3-4 cm incision was made with the top at one-centimeter-below nipples level. Partial sternotomy was performed. Regular cannulation was performed under cardiopulmonary bypass. The surgeries included isolated ventricular septum defect (VSD) repair in 92 patients, VSD with mitral valve repair in 5, VSD with right ventricular obstruction repair in 6, VSD repair with patent ductus arteriosus lightation in 4, VSD with ASD repair in 10, VSD with other anomaly repair in 9.

Results: All the surgeries went smoothly. The mean bypass time was 63 minutes and mean cross-clamp time was 43 minutes. There was no mortality and no major complication in all the patients. Two patients had trivial leak from VSD patch. Two had mild residual mitral regurgitation. One patient developed subcutaneous hematoma which relieved after discharge. One patient had postoperative pneumonia which was cured two weeks after.

Conclusions: Minimally invasive approach through peri-xiphoid process incision for the surgery of congenital heart disease is a safe procedure and provides a very cosmetic effect.

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D17 OPCAB Without Transfusion

Weon-Yong Lee1, Ho-Hyun Ko 1, Sung Jun Kim1, Kun-Il Kim1, Hyoung-Soo Kim2, Sung-Woo Cho3. 1Hallym University Sacred Heart Hospital, Anyang-si, Gyeonggi-do, Republic of Korea, 2Chuncheon Sacred Heart Hospital, Chin-cheon, Kang-won do, Republic of Korea, 3Kangdong Sacred Heart Hospital, Seoul, Republic of Korea.

Objective: Transfusion is strictly limited in USA, but generous in Korea. Also there is lack of interest for open heart surgery without transfusion. In this study, we estimate success rate according to hemoglobin (Hb) level for OPCAB without transfusion, cut-off point of Hb and risk factors of transfusion.

Methods: Among 112 consecutive patients who had underdone OPCAB from 2007 to 2011, we excluded 10 CRF and 3 deaths. We estimate success rate by pre-operative Hb in 99 patients. In patients with pre-op. Hb >11, we performed retrospective study between transfusion and non-transfusion group to evaluate the risk factors for transfusion. Trigger points of transfusion are Hb < 8.0, and < 10.0 in the presence of bleeding or unstable vital signs. We have used blood saving protocols such as intraoperative autologous donation (IAD), frequent infusion of cell saver reservoirs, etc.

Results: 75 of 99 (75.8%) patients had undergone OPCAB without transfusion. Especially in patients with Hb 11 or more, significantly higher success rate (85.0%) has been observed and the reasons of transfusion are mainly bleeding or unstable vital signs. Risk factors of transfusion are age, diagnosis of AMI, clopidegrel, pre op. platelet, albumin, post op. CTD drain and ventilator time.

Conclusions: The patients with pre op. Hb > 11.0 improve chances of OPCAB without transfusion. The risk factors of transfusion are age, AMI, clopidogrel, platelet, and albumin. Also, the causes of transfusion are correctable (mainly unstable vital signs, bleeding). OPCAB without transfusion can be performed safely with proper patient selection, various blood salvage methods, and meticulous bleeding control.

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D18 New Mediastinal Drain after Cardiac Procedures

Francisco T. Nobre 1, Vera Lucia2, Marcelo Pochini2, José Menegolli1, Marcos Cesar2, Carlos Gonelli2, Mauro Machado3, Noedir Stolf2. 1Hospital Beneficencia Portuguesa São Paulo e São Caetano do Sul, São Paulo, Brazil, 2Hospital Beneficencia Portuguesa São Paulo, São Paulo, Brazil, 3Hospital Beneficencia Portuguesa São Paulo l, São Paulo, Brazil.

Objective: The aim of the present study demonstrate the effectiveness of drain mediastinal with balloon, with respect to permeability, blood drainage postoperatively and observation of cardiac tamponade.

Methods: From November 2011 to May 2012, drain mediastinal balloon was used in 101 patients (68 men, 33 women, mean age 60.2 years), underwent surgery for myocardial revascularization in 72 patients, the other patients the mitral valve replacement surgery in 17.1 patients to aortic valve replacement surgery. Patients with pleural drainage and bronchopleural fistula were excluded. All patients underwent extracorporeal circulation, the mediastinal drain with the balloon system was placed in the mediastinum prior to closure of the sternum, positioned at the longitudinal position, as usual in most cases above the pericardium. The patients at the conclusion of surgery were transferred to the intensive care unit for postoperative care, draining blood were calculated. The drains were removed only if there was less than 100 ml of blood in the period up to 12 hours. Total amount of blood drainage, days spent with the drains, days in the ICU and hospital were documented. Radiography was taken from routine in the immediate postoperative period, in the second post operative day and a day before the hospital discharge. After the radiographs were analyzed, if verified presence of increased mediastinal area or signs of tamponade, a transthoracic echocardiogram was performed.

Results: A total of 101 patients undergoing balloon drainage system for a period of 6 months with the majority undergoing CABG surgery. The drainage blood was documented at each time, observing if excessive bleeding happened. The protocol of balloon inflation was each hour, with 10 ml of air through an external syringe. On the day of postoperative drains were removed, were observed in this analysis that all drains were patent. There were no cases of cardiac tamponade.

Conclusions: The mediastinal drain balloon demonstrated safe and effective for promoting blood drainage in postoperative period due to facilitating the removal of clots thus offering a new tool and alternative to the mediastinal drainage in cardiac surgery.

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D19 Elective Implementation of Pump-Assisted CABG With or Without Arrested Heart as an Alternative to OPCABG Reduces Complications and the Incidence of Emergency Conversions: A Retrospective Review of 1319 Consecutive Cases

Alex Zapolanski 1, Christopher K. Johnson1, Giovanni Ferrari2, Mariano E. Brizzio1, Richard E. Shaw1, Jason S. Sperling1, Juan B. Grau1. 1Valley-Columbia Heart Center, Ridgewood, NJ USA, 2University of Pennsylvania School of Medicine, Glenolden, PA USA.

Objective: Off-pump cardiopulmonary bypass surgery (OPCABG) has not been widely adopted, due to its technical demands and heavy reliance on practitioner experience. In some situations, emergency conversion (EC) from off-pump to on-pump becomes unavoidable. Several series have demonstrated an increase in morbidity and mortality when conversions occur. No established algorithms exist to guide surgeons through the decision to utilize cardiopulmonary bypass in order to reduce the risk for EC. The purpose of the current study was to analyze the influence of implementing a flexible approach in decision making to CABG. This includes all alternatives available to the surgeon in order to minimize EC. Additionally, we also assessed the extent of perioperative complications associated with EC.

Methods: Using our STS database, we retrospectively analyzed our most recent series of coronary revascularization procedures from January 2006 to December 2011. 1319 patients were scheduled for isolated CABG. We divided them into three groups: off-pump (Group A; N=1087, 82%), on-pump with cardioplegic arrest (Group B; N=195, 15%), and on-pump beating (Group C; N=37, 3%). We analyzed the in-hospital and 30-day complications for each group, as well as for those patients who underwent EC.

Results: In-hospital and 30-day mortality was 0.65% for Group A, 1.5% for Group B, and 0% for Group C. Overall mortality for the entire series was 0.76%. Five patients (0.46%) were converted emergently from off- to on-pump. The mortality in this group was 0% without any perioperative complications. Indications for conversion were inadequate size and/or diffuse disease of distal vessels, hemodynamic instability, and/or inadequate visualization/exposure.

Conclusions: Appropriate decision-making following pericardiotomy at the time of CABG prevents unnecessary ECs. When EC becomes unavoidable, CPB should be instituted expeditiously without persistence to finish the operation off pump in order to avoid prolonged hemodynamic instability and/or ischemia. Implementing elective on-pump beating as a viable and safe alternative to some challenging OPCABG cases reduces complications and may reduce the need for EC. Our flexible approach to CABG does not compromise a high percentage of off-pump cases. Contrary to other published results, this series had a low complication rate associated with ECs.

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D20 Endovascular Repair versus Open Repair for Blunt Traumatic Aortic Injury

Ohchoon Kwon 1, Sub Lee1, Jun Woo Cho1, Nam Hee Park2, Keun Jik Kim3. 1Daegu Catholic University Hospital, Daegu, Republic of Korea, 2Dongsan Medical Center, Daegu, Republic of Korea, 3Kyungbuk National University Hospital, Daegu, Republic of Korea.

Objective: Blunt traumatic aortic injury (BTAI) is a rare disease, but its mortality has been reported to be as high as over 80%. Open repair has been established as the standard treatment for BTAI, however, endovascular repair is preferred in many medical centers after the introduction of endovascular stent grafting.

Methods: The retrospective study was performed from March 2003 to August 2012 for the patients with BTAI. The endovascular repair was started from 2008 in our center. We analyzed the differences between the open repair group and endovascular repair group in terms of age, sex, time to procedure, injury severity score (ISS), dosage of heparin, bleeding volume, transfusion volume, period of ICU stay, period of hospital stay, and mortality.

Results: A total of 30 patients (17 male) with the descending thoracic aorta injured by blunt trauma were treated. Among them, 11 patients were treated by open repair (OR) and, 19 patients were treated by endovascular repair (ER). The mean ages of the open repair group and endovascular repair group were 43.19 and 49.47, respectively (p=0.374). There was no statistical difference between the two groups in time to procedure (OR 95.9 hr vs. ER 74.89 hr) or ISS (OR 26.27 vs. ER 26.11). Dosage of heparin (OR 22181.82 units vs. ER 2894.74 units, p<0.000), bleeding volume (OR 2045.45 ml vs. ER 252.63 ml, p<0.000), and transfusion volume (OR 14 units vs. ER 2.42 units, p<0.000) were statistically different between the two groups, but the period of ICU stay and hospital stay were not different. The endovascular repair group showed better results for mortality (open repair 18.8% vs. endovascular repair 0%), but there was no statistical difference.

Conclusions: Although statistically no significant different mortality existed between the two groups, there was a tendency toward lower mortality in the endovascular group. Endovascular repair with lesser blood loss and transfusion volume can be used in BTAI over open repair, but the conformational changes of endovascular stent must be followed with these relatively younger-aged patients.

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D21 Hybrid and Endovascular Management of Complex Aortic Arch and Descending Thoracic Aortic Pathology

Vasilios D. Kollias, Vasilios Lozos, Dimitrios Angouras, John Toumpoulis, Christos Rokkas. University Hospital of Athens “Attikon”, Athens, Greece.

Objective: To assess the feasibility and safety of hybrid and endovascular techniques in the treatment of complex diseases of the aortic arch (AA) and the descending thoracic aorta (DTA) in patients at high surgical risk.

Methods: We retrospectively studied all high-risk patients with complex AA and DTA pathology who received endovascular or hybrid therapies without the use of cardiopulmonary bypass over the past 2 years.

Results: Nine patients, aged 70.7 ± 13 years, having a logistic EuroSCORE of 19.9 ± 6.9 were included. The patients were divided in two groups, according to aortic pathology: AA±DTA aneurysm (4 patients-group A) and proximal DTA penetrating atherosclerotic ulcer or intramural hematoma (5 patients - group B). In group A patients a “hybrid” repair was implemented, with off-pump surgical debranching and revascularization of the aortic arch vessels and concomitant endovascular deployment of stented endografts reaching into the ascending aorta, in a single stage (Figures D21-1, D21-2). In 3 of 4 patients a left carotid-subclavian bypass was also performed. Patients in group B were treated solely by endovascular placement of stented endografts. In 4 of 5 patients the left subclavian artery was excluded. In one of these patients a carotid-subclavian bypass was required in a second stage. Complications included one type I endoleak in group A and one type V local dissection of distal ascending aorta in group B. One patient (group A) died postoperatively due to low cardiac output syndrome.

Conclusions: Off-pump hybrid and endovascular techniques can be successfully used in the management of high surgical risk patients with complex disorders of the aortic arch and the descending thoracic aorta. New grafts designed to conform to the anatomy of the aortic arch are being developed.



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D22 Minimally Invasive Endoscopic Graft Harvesting Procedure With Reusable Devices

Toshimi Ujiie, Hisato Ito. Shi-Yurigaoka General Hospital, Kawasaki City, Kanagawa, Japan.

Objective: We improve the less invasive graft harvesting (SVG and radial artery) procedure with the endoscopic device and the ultrasonic scalpel which can do re-sterilization. This procedure enables to have not only less invasive result but economical advantage. This method may give the great impact to the surgeons who are interesting in minimally invasive graft harvesting procedures.

Methods: Only 2 cm skin incision was made on two positions. Then Harmonic Scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH USA) and KARL STORZ-Endoskope system Bisleri endoscopic radial artery retractor (KARL STORZ GmbH & Co. Tuttlingen, Germany) were used for RA harvesting. To acquire a further less invasiveness result, we selected the skin incision position 2 cm proximal side from the wrist as harvesting radial artery. In addition, shaking or rubbing move with scalpel was possible to ultrasonically skeletonize SVG or radial artery harvesting. 79 CABG cases were indicated this endoscopic RA harvesting method with above procedure.

Results: 76 CABG cases were performed by off-pump CABG. Three cases were performed by on-pump beating CABG. Male:female = 49:30. Two skin incisions (1 cm or 2 cm) were made on the patient’s arm. SVG harvesting: 59 CABG cases were indicated the same endoscopic method. A single surgeon performed all cases. Mean harvest time was 32.1±8.6 minutes. Mean RA harvested length was 20.1±3.1 cm. 71 cases had postoperative angiography; all grafts were patent and there were no anastomotic stenosis. There were no significant nerves parentheses’ with all patients’ arm that RA was harvested. There was no conversion from the endoscopic graft harvesting technique to the conventional method.

Conclusions: Current endoscopic procedure for SVG or radial artery harvesting needed a high cost, because these are single-use devices. On the other hand, we do not use the single-use device. Our procedure could have great economical advantages. We suspect that this harvesting procedure may have endoscopic method spread to cardiac surgery field because of economical and less invasive advantages.

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D23 Single-Vessel Revascularization Using Robotically Enhanced Minimally Invasive Direct Coronary Artery Bypass Compared to Open Off-Pump Coronary Artery Bypass Surgery

Christian Detter, Katarina Felkel, Tobias Deuse, Hermann Reichenspurner, Hendrik Treede. University Heart Center Hamburg, Hamburg, Germany.

Objective: Robotically enhanced surgery allows for minimally invasive harvest of the left internal mammary artery (LIMA) without rib spreading. Here we describe our experiences using the robotic da Vinci system for coronary artery bypass surgery with limited incision (ENDO-MIDCAB) in comparison to off-pump coronary artery bypass surgery using median sternotomy (OPCAB) for single-vessel revascularization.

Methods: From January 2004 to May 2012, 269 patients underwent single-vessel revascularization on the beating heart using a LIMA-LAD bypass. Of these patients, 58 underwent ENDO-MIDCAB (84.5% men, age 60.9 +/- 9 years) and 211 patients (65.4% men, age 67.9 +/- 11.5 years) conventional OPCAB revascularization. Preoperative, intraoperative, and early postoperative data were retrospectively analyzed and were 100% complete.

Results: Mean total operating time for ENDO-MIDCAB was 259 +/-69 minutes compared to 150 +/- 49 minutes using OPCAB surgery (p<0.001). Hospital length of stay was 7.3 +/-3.3 days in OPCAB and 6.1 +/- 1.6 days in MIDCAB surgery (p<0.005). The postoperative ventilation time for patients requiring MIDCAB was shorter than for patients requiring OPCAB surgery (6.6±5.0 h vs. 7.3±5.3 h, p<0.05). There were no deaths or strokes but 2 early re-intervention due to bleeding in the MIDCAB group (3.4%), whereas 5 strokes, 3 deaths and 7 re-intervention due to bleeding could be seen in the OPCAB surgery (7.1%; p<0.05)). In the ENDO-MIDCAB group, 62.1% of patients had single-vessel coronary disease compared to 35.5% of the OPCAB group. More patients in the ENDO-MIDCAB group had good left ventricular function compared to patients requiring OPCAB surgery (89.7% vs. 66.2%).

Conclusions: Although there is a selection bias between the two groups of patients in terms of pre-operative morbidity, age and LV function, MIDCAB surgery was accomplished with no mortality and low morbidity. Time in intensive care unit, post-operative ventilation time as well as hospital length of stay were shorter compared to OPCAB surgery. Although mean operating time while using the robotic system was longer than using the open technique for bypass surgery, this experience shows the advantage of this technique in carefully selected patients.

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D24 Right Lateral Minithoracotomy Thoracotomy Approach for ASD Closure

Durgaprasad B. Reddy. Vydehi Institute of Medical Sciences, Bangalore, India.

Objective: Surgical closure of secundum atrial septal defect (ASD) is a standard procedure associated with very low mortality and morbidity. We evaluated outcomes in the era of catheter-based interventional closure and minimally invasive techniques.

Methods: From June 2011 to November 2012, 115 patients with a body weight of more than 30 kg underwent surgical ASD closure. A right lateral minithoracotomy (RLMT) was used in 105 patients and a conventional approach, in 10. Diagnoses included secundum ASD in 103 patients in the minithoracotomy group and 8 in the conventional group, sinus venosus ASD in 2 patients in each group respectively. Mean age was 37± 17 years in the minithoracotomy group and 43±20 years, in the conventional group; mean body weight was 66±17 kg and 70±16 kg respectively. In the minithoracotomy group, femoral cannulation was performed for cardiopulmonary bypass.

Results: Direct ASD closure was carried out in 67.2% of patients in the RLMT group and 58.2% of those in the conventional group. The remaining patients had pericardial patch closure. There was no death. Average stay in the intensive care unit was 1.2±0.5 days. Two patients required reoperation for residual ASD after direct closure, 1 sustained a temporary neurological deficit that resolved completely. On postoperative echocardiography, a minimal residual shunt was seen in only 3 patients. All patients were in good clinical condition with improved functional status at discharge from the hospital.

Conclusions: Secundum ASD closure by minithoracotomy has become as standard and safe operation as the conventional technique and achieves good perioperative results and satisfactory long-term outcomes. Thus, right lateral minithoracotomy is an attractive option for patients who are not suitable for closure using catheter-based devices.

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D25 Modified Cabrol Shunt After Complex Redo-Aortic Root Surgery

Chan-Young Na. Dongsan Medical Center, Keimyung University, Daegu, Republic of Korea.

Objective: Bleeding after redo-aortic root replacement may be impossible to control in a certain situation. Perigraft to right atrial shunt for hemorrhage control after aortic surgery was first described by Cabrol and colleagues. We report another modification of the Cabrol shunt.

Methods: A 45-year-old male patient with Behcet disease had a history of aortic valve replacement with mechanical valve and transvenous permanent pacemaker implantation 8 years ago; he then had replaced aortic root with aortic homograft due to severe aortic regurgitation and aortic prosthetic valve annular dehiscence 7 years ago. He presented with severe aortic regurgitation and severe homograft calcification due to aortic homograft failure (Figure D25-1). Patient was replaced with aortic root using button Bentall technique with St. Jude composite graft (St. Jude Medical, St. Paul, MN USA). On-going bleeding from many operative sites occurred, including bleeding from aortic annular and both coronary button anastomosis sites due to aortic homograft calcification. Bleeding continued despite conventional maneuvers, including application of sutures, topical hemostatic agents, and recombinant factor VII. As a result, a bovine pericardial patch (approximately 8 x 10 cm) was tailored to isolate the area of bleeding from aortic root. Suturing the patch proceeded from the superior vena cava laterally on the patient’s right side along the right atrium inferiorly, and the border of the heart and pulmonary artery on the patient’s left side. After aortic root exclusion with bovine pericardial patch, bovine patch was bulging due to bleeding and hypotension was noticed. We decided to connect the cavity covered by bovine pericardial patch to superior vena caval cannulation sites using Gore-Tex tube graft 6 mm (Figure D25-2).





Results: Bleeding was controlled, as blood from aortic root suture line and adjacent tissue was redirected to superior vena cava creating autotransfusion of shed bloods as described originally by Cabrol and colleagues.

Conclusions: Modified Cabrol shunt allows an option for dealing with severe bleeding in redo complex aortic root surgery.

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D26 Minimally Invasive Repair for Pectus Excavatum (Nuss Procedure): Five-Year Experience

Constantin Grozavu, Mihai Ilias, Dragos Marin, Daniel Pantile. Spitalul Universitar de Urgenta Militar Central, Bucharest, Romania.

Objective: Pectus excavatum is the most frequent anterior thoracic wall congenital malformation. Among teenagers, when the esthetics and clinical symptoms become more important, pectus excavatum becomes a real psychological problem. During the time, many treatment techniques have been proposed, conservative or surgical. The minimally invasive repair technique of pectus excavatum, “Nuss technique”, developed after 1986, is now the most used technique worldwide. Our study aimed to analyze the degree of patients’ satisfaction regarding the esthetic results after the minimally invasive repair of pectus excavatum, as well as the improvement of respiratory functional parameters.

Methods: We will present some historical data related to surgical repair of pectus excavatum, advantages and disadvantages of open surgery; also we will present clinical and paraclinical evaluations, including anthropometric indexes, as well as indications and contraindications of Nuss technique and possible intraoperative and postoperative complications (recent and late). Our study was carried out on a group of 60 patients with pectus excavatum, who have been submitted to Nuss technique, during a timeframe of 5 years (2007 - 2012), ages 8 to 38 years. Prior to surgery the patients were submitted to a standard protocol of investigations.

Results: We present the benefits of Nuss technique and the improvements of the functional and aesthetic indexes. The patients who have been treated with Nuss technique are following a strict and specific postoperative protocol recommended by the physician.

Conclusions: Nuss technique is an efficient method, with very good aesthetical and functional results, allowing quick social and professional patients’ reintegration, as well as an improved self-image and self confidence.

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D27 The Role of LeGoo Polymer in Thoracoscopic Pulmonary Hydatid Cyst Surgery

Fadhil Ghaly Al-Amran, Sr. Kufa Medical College, Najaf, Iraq.

Objective: Hydatid disease is caused by the tapeworm Echinococcus granulosus. It is the most severe helminthic zoonosis, with a major medical, social, and economic burden in endemic areas. Postoperative hydatid cyst recurrence is mainly due to intraoperative spillage of scolisis. Until now there is no specific technique or agent that can perfectly prevent intraoperative spillage of scolisis. In this study we used a polymer to test its advantage in intraoperative spillage of scolisis during surgery, this polymer is LeGoo.

Methods: This study was done to test ability of LeGoo polymer to prevent spillage of fluid contained scolisis in vivo in animals and in vitro hydatid cyst from human beings. In each time, the fluid will undergo microscopic examination for scolisis.

Results: Microscopic examination of spilled fluid from human being hydatid cyst shows numerous alive scolisis. All sheep lung hydatid cyst with LeGoo injection transformed into solid gelatinous mass; microscopic examination for the swab from content shows no scolisis. LeGoo polymer injection into hydatid cyst from human being in vitro transformed into solid mass that can be mobilized easily; opening of the cyst after injection will revealed gelatinous solid content and swab from it yield no scolisis.

Conclusions: LeGoo injection into the cyst would facilitate its removal with less risk of rupture, and without likelihood of scolisis spillage both in vivo animal hydatid cyst and in vitro human being cyst. Upon the results of this study, we recommend: 1) thoracoscopic hydatid cyst removal with the new approach for hydatid cyst surgery, so it is important to start implication of LeGoo in this scopic surgery, 2) ultrasound guided percutaneous injection of LeGoo especially for inoperable cases of hydatid cyst is an important future proposed plan, and need to prove the efficacy of LeGoo in regression of the cyst, prevention of spontaneous rupture, and stop further cyst growing.

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D28 Whether Off- or On-Pump, Arteries Are Not in Vain: Mid-Term Follow-Up of Total Arterial Off- vs. On-Pump Surgery in 899 Consecutive “All-Comer” Patients

Teresa M. Kieser, M. Sarah Rose, Mouhieddin Traboulsi, Kishan Narine. University of Calgary, Calgary, AB Canada.

Objective: Off-pump coronary artery bypass graft (CABG) surgery benefits higher risk patients early. Arterial grafting benefits patients long-term. We sought to compare mid-term (up to 3 years) outcomes in total arterial CABG patients undergoing off- and on-pump surgery.

Methods: Outcomes were compared between off- and on-pump patients in a prospective cohort of all consecutive CABG patients from July 2003 to September 2011 using Kaplan-Meier survival curves and Cox regression.

Results: A cohort of 899 consecutive CABG patients received 98% arterial grafts, 72% BIMA and 37% of these CABG procedures were performed off-pump. On-pump was the principal procedure of choice for the first 529 patients (6% of patients in this group went off-pump for single-vessel disease or prohibitive ascending aortic calcification). Thereafter, off-pump was performed in 78% of CABG procedures. Demographics for the whole group included: mean age 65+/-10.4, diabetes mellitus in 33%, males 78%, urgent in-patients 46%, emergent 11%, and mean logistic EuroSCORE for all patients was 5.88. Total operative mortality was 3.4%/4.3% (p=0.605) for off-pump vs. on-pump patients. Thirty-four out-of-province patients were unavailable for follow-up, leaving 828 patients with a median follow-up of 4.8 years (IQR 2.6, 7.0). At three years post-surgery, after controlling for EuroSCORE at time of surgery, there was no significant difference between on-pump and off-pump patients for overall survival (HR=1.39, p=0.274), post-operative angioplasty (HR=0.96 p=0.948), and new angina (HR=0.94 p=0.870). At 3 years post-surgery overall survival (95% CI) was 92.8% (87.4, 96.0) for off-pump and 95.5% (93.2, 97.0) for on-pump patients, rates of post-operative angioplasty were 1.8% (0.76, 4.36) for off-pump and 1.8% (0.93, 2.9) for on-pump patients, angina occurred in 4.1% (2.2, 7.6) of off-pump and 3.2% (1.9, 5.1) of on-pump patients. Transit-time flow for assessment of intra-operative graft function was used equally in both off- and on-pump groups since April 2004 (86% of all CABG patients).

Conclusions: At 3 years post-operatively, both off- and on-pump patients with 98% arterial grafts have similar survival, development of angina and need for angioplasty. Arterial grafting can benefit even those in whom off-pump is mandated.

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D29 Previous Coronary Stents Do Not Increase Early and Mid-Term Adverse Outcomes in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Toshihiro Fukui, Minoru Tabatha, Shuichiro Takanashi. Sakakibara Heart Institute, Tokyo, Japan.

Objective: The aim of this study was to compare the early and mid-term outcomes of patients undergoing off-pump coronary artery bypass grafting with and without previous coronary stents.

Methods: Between September 2004 and September 2011, there were 269 patients with previous stents who underwent first-time isolated off-pump coronary artery bypass grafting. Those patients were compared with 897 patients without previous stents. Mean follow-up time was 43.4 months after the operation.

Results: There was no difference in age (68.0 ± 9.4 versus 68.2 ± 10.5; p = 0.7858) and left ventricular ejection fraction (55.8 ± 11.3 % versus 56.1 ± 11.8 %; p = 0.7496) between patients with and without stents. Patients with previous stents were more likely to be male (85.9% vs. 79.4%; p = 0.0221) and more likely to have prior myocardial infarction (60.2% vs. 36.8%; p < 0.0001). The number of anastomoses per patient was lower in patients with previous stents than patients without previous stents (4.0 ± 1.3 versus 4.2 ± 1.2; p = 0.0370). There was no difference in the use of bilateral internal thoracic artery graft between the groups (88.8% versus 89.1%; p > 0.9999). The operative death rates did not differ between the groups (0.7% versus 0.9%; p > 0.9999) and neither did the major complications rates (7.8% versus 7.7%; p > 0.9999). There were no differences in freedom from all death (87.3 ± 3.2% versus 84.3 ± 2.0%; p = 0.3805), cardiac death (98.8 ± 0.7% versus 95.5 ± 1.0%; p = 0.1290), and major adverse cardiac and cerebrovascular events (79.1 ± 3.7% versus 76.2 ± 2.2%; p = 0.4376) at 7 years after the operations between patients with and without previous stents.

Conclusions: Previous coronary stents do not increase early and mid-term morbidity or mortality in patients undergoing off-pump coronary artery bypass grafting.

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D30 A New Method of a Totally Endoscopic Repair of Pectus Excavatum: A VATS Approach Using the Ravitch Principles

Michael Klimatsidas. Thoracic Surgery Department, 424 Military Hospital Greece, Thessaloniki, Greece.

Objective: To present the concept of a completely VATS approach for selected patients with pectus excavatum.

Methods: All the principles of the classic open (Ravitch) approach just before 70 years were analyzed. Today’s technology and VATS experience provide us with all the necessary tools so as to achieve exactly the same result with a completely minimally invasive approach and fantastic cosmetic results.

Results: A completely new and totally VATS operation is designed. This method needs to go to the next phase with clinical implementation.

Conclusions: Today’s technology and VATS experience provide us all the necessary help so as to design the “Perfect” approach for congenital thoracic deformities. A new approach is designed. A business case has to be presented and laboratory research has to be done so as to have clinical implementation.

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D31 Graft Patency on Symptom Directed Cardiac Catheterization and Leg Complications in Patients with “No Touch” versus Endoscopically Harvested Saphenous Veins After CABG

John D. Mannion, Daniel Marelli, Jeffrey Cirks, Debbie Warshawsky, Todd Brandt, Megan Stallings. Bayhealth Medical Center, Dover, DE USA.

Objective: “No Touch” (NT) saphenous vein harvesting preserves adventitial vasa-vasorum, prevents medial ischemia, and is associated with an improved short-term and long-term graft patency, in comparison with conventional vein harvesting. Because NT harvesting requires an open technique, it is associated with higher wound complication rates. There has not been a comparison between NT harvesting and endoscopically harvested saphenous veins (endo-vein) harvesting for CABG.

Methods: Over a one and one-half year period, we compared the vein graft patency, at symptom directed cardiac catheterization, and wound complication rates at follow-up in 166 contemporaneously treated patients who received NT (77 patients) or endo-vein (89) harvesting. The follow-up period was short-term at 285 days. The symptom directed catheterization patency was also compared with all patients operated on by the endo-vein surgeon (216 patients) over a 3.5-year period.

Results: In the contemporaneous groups, 6 of 77 (7.8%) of NT patients were recatheterized, and 10 of 11 (91%) NT veins at risk were patent; 7 of 89 (7.9%) of endo-vein patients were recatheterized, and only 3 of 13 (23%) of endo-vein grafts at risk were patent (P<0.01 NT versus endo, Fisher’s exact test). The NT vein graft patency was significantly better than the accumulated patency of all endo-veins harvested by the endo-vein surgeon over a 3.5-year period. Only 11 of 39 endo-vein grafts were patent (28%) in the 17 of 216 (7.8%) patients recatheterized (P<0.01 NT versus endo-vein). However, the harvest site complications over a similar time period were significantly higher with open vein harvest required by NT in comparison with endo harvest. 14 of 83 (16.9%) of open harvest patients required intervention (wound-vac or IV antibiotics) versus 3 of 97 (3.1%) of patients with endo-vein harvest.

Conclusions: These results confirm that NT vein harvesting is associated with improved vein graft patency, but suggest that methods have to be developed to lower wound complication rates.

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D32 Antegrade Thoracic Endovascular Aortic Repair via the Ascending Aorta

Kosuke Fujii, Toshihiko Saga, Hitoshi Kitayama. Kinki University, Osaka, Japan.

Objective: Adequate access is important during thoracic endovascular aortic repair (TEVAR) because of the necessity of inserting a large sheath. We performed antegrade TEVAR from the ascending aorta in six patients whose femoral arteries were too small or due to other extenuating circumstances. This approach can be useful and less invasive in certain situations. We report here the early results of our experience with antegrade TEVAR from the ascending aorta.

Methods: From December 2010 to date, we performed antegrade TEVAR from the ascending aorta on six patients. Rupture had occurred in one case and impending rupture in two. The median patient age was 79.5 years (range, 70-83). Median follow-up was 4.5 months. Previous open or endovascular aortic surgery had been performed in four patients. The femoral artery diameter was inadequate in five patients. In one patient, sheath insertion through the abdominal aorta was difficult because this patient had undergone endovascular aortic repair (EVAR) for an abdominal aortic aneurysm by Endologix Powerlink two years previously and the device had snagged the TEVAR sheath. Concomitant surgery, consisting of total arch replacement in two cases and debranching of three neck vessels in two cases, was performed in four patients. The other two patients underwent TEVAR alone.

Results: Early mortality occurred in one patient due to multiple organ failure on postoperative day six, and late mortality occurred in one patient four months postoperatively due to mediastinitis. A total of two patients suffered embolic events.

Conclusions: Antegrade TEVAR can be a useful approach in patients with inadequate access. However, we experienced a high embolic event rate. Thus, this problem must be considered in future cases.

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D33 The Safety and Cost Effectiveness of Low Dose Recombinant Activated Factor VII in High-Risk Cardiac Surgery

Aman Garsa 1, Clint R. Irvin1, David M. Haybron2, Darrell J. Triulzi2, Margaret Kennedy1. 1West Penn Allegheny Health System, Pittsburgh, PA USA, 2University of Pittsburgh Medical Center, Pittsburgh, PA USA.

Objective: The efficacy of the recombinant Factor VIIa in cardiac surgery has been previously described. We studied the use of low-dose rFVIIa relatively early in the postoperative course for safety and cost effectiveness.

Methods: The study included 142 patients who underwent cardiac surgery at a tertiary care center between May 2004 and May 2010 and were given rFVIIa. In the beginning, the administration of rFVIIa followed FDA approved dosage guidelines and was restricted for use only after at least two doses each of platelets and FFP. The institutional evolution of a strategy for rFVIIa use involved using the smallest packaged dose (1-1.2 mg) as well as its early utilization, in lieu of blood products, for post-op bleeding. Data was collected from charts, blood bank records and STS database.

Results: The patient population was at high-risk for mortality and morbidity. Ninety-five (67%) patients received one dose of rFVIIa. Total median dose was 31.2 mcg/kg, given at a median time of 143 +/- 77 minutes from the end of CPB. Median number of blood transfusions before and after rFVIIa was 6 (PRBC 3u, FFP 2u, platelets 1 dose) and 5 (PRBC 2u, FFP 2u, platelets 1 dose) respectively. For ICU patients, median chest tube drainage was noted to be decreased. PT/INR, aPTT, platelet count and ACT improved after rFVIIa use. Total of 13 patients (9.1%) died. The number of thrombotic events were: CVA/TIA 6 (4%), DVT 5 (4%), acute limb ischemia 1 (<1%). No postoperative AMI or PE were reported in 28 days follow-up.

Conclusions: Our study is second largest study in US highlighting the role of earlier administration of low dose rFVIIa in cardiac surgery in reducing total blood product transfusions, while maintaining safety and efficacy. The use of low-dose rFVIIa with an associated reduction in transfusion-related morbidity and cost suggests it may have a role as initial treatment for excessive bleeding in this setting. Prospective study of early, possibly first line use of low dose rFVIIa in cardiac surgery is needed to explore this option.

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D34 Anterograde Thoracic Endovascular Aortic Repair With Mini-Thoracotomy

Chi Hyeong Yun, Sang Gi Oh. Department of Thoracic and Cardiovascular Surgery Chonnam National University Hospital, GwangJu, Republic of Korea.

Objective: Thoracic endovascular aortic repair (TEVAR) is an accepted alternative to conventional surgery in selected patients. However, TEVAR is impossible with severe iliac disease or a tortuous aorta. We report on anterograde TEVAR combined with video-assisted thoracic surgery (VATS).

Methods: From January 2002 to May 2002, we performed anterograde TEVAR with VATS on 2 patients with a diseased aortic or iliac artery. The supra-aortic branch needed to be revascularized to create the landing zone for the stent-graft in 1 patient.

Results: There were no operative deaths. In 1 patient, the stent graft remains collapsed, but seals the aortic aneurysm completely.

Conclusions: The anterograde TEVAR may be effective for thoracic aortic aneurysm with a diseased aortic or iliac artery. But further investigation is necessary.

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D35 Efficacy of Off-Pump Coronary Artery Bypass Grafting in Patients with Chronic Kidney Disease

Masahito Minakawa, Norihiro Kondo, Kazuyuki Daitoku, Wakako Fukuda, Kaoru Hattori, Yoshiaki Saito, Anan Nomura, Takashi Ogasawara, Yasuyuki Suzuki, Kozo Fukui, Ikuo Fukuda. Hirosaki University School of Medicine, Hirosaki, Japan.

Objective: Complication of chronic kidney disease (CKD) is a risk factor for postoperative morbidity and mortality in coronary revascularization surgery. The purpose of this study was to assess early and long-term outcomes of off-pump coronary artery bypass grafting in patients with chronic kidney disease.

Methods: From 2003 to 2011, 71 isolated CABG cases for the patients with chronic kidney disease (serum creatinine level >1.1mg/ml) were enrolled in this study. We compared two groups: patients who required pre-operative hemodialysis (HD Group, 19 cases) vs. non-hemodialysis (non-HD Group, 52 cases). Patients background of non-HD vs. HD groups were the following: men/female, 37/15 vs. 17/2; age, 68.6±0.9 vs. 65.2±10.5; emergency, 13% vs. 25%; DM, 76% vs. 45%; serum creatinine, 2.0±1.2 mg/dl vs. 10.1±3.2 mg/dl; coronary lesion, 2.7±0.4 vs. 2.9±0.3; LMT lesion, 27% vs. 35%; severe atherosclerosis on the thoracic aorta, 24% vs. 25%.

Results: Off-pump CABG was carried out in 88% in non-HD and 95% in HD. In non-HD group, anastomotic number was 3.2±1.2 grafted using LITA in 96%, RITA in 54%, SVG in 62% and BITA in 48%. Early graft patency of LITA, RITA and SVG were 100%, 96% and 100%, respectively. In HD group, anastomotic number was 3.1±0.8 grafted using LITA in 74%, RITA in 68%, SVG in 84% and BITA in 42%. Early graft patency of LITA, RITA and SVG were 94%, 96% and 96%, respectively. Postoperative stroke was found in 3 patients who had bilateral carotid lesion in 2 and unilateral carotid lesion in one. Mediastinitis was found in 3 patients. Hospital death was one who underwent emergency OPCAB for AMI in non-HD. Five-year survival of HD and non-HD were 90.9% vs. 88.4%, respectively (Log rank P=0.189). Freedom from MACE in 5-year of HD and non-HD were 75.4% vs. 97.6%, respectively (Log rank P=0.018).

Conclusions: Early and long-term outcome of OPCAB in patients with CKD were satisfactory.

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D36 Graft Patency of Saphenous Vein Grafts in the Prosperity of Arterial Grafts on Coronary Revascularization

Akitoshi Takazawa, Jr, Hiroyuki Nakajima, Hiroshi Niinami. Saitama Medical University International Medical Center, Hidaka City, Japan.

Objective: Arterial grafts should be firstly considered in current coronary artery bypass grafting (CABG) However, saphenous vein graft (SVG) are frequently needed to achieve complete revascularization, especially for high-risk patients with multi-vessel disease. We sought to delineate factors affecting early patency of SVG.

Methods: We reviewed pre- and postoperative coronary angiograms of 182 patients who underwent coronary artery bypass grafting using at least one SVG between May 2007 and May 2012. Total distal anastomoses were 474. Since total arterial grafting has been our standard strategy, SVG was used only for patients with some reasons for avoidance of bilateral internal thoracic artery or gastroepiploic artery. The assessment of anastomoses was functional graft occlusion by catheter or multi-detector computed tomography.

Results: The early graft patency rate was 255/282(90.4%). There was no stroke during operation. We analyzed 283 distal anastomoses for detailed preoperative and operative factors. There was no significant difference according to sex, diabetes mellitus, hypertension, hyperlipidemia, past history of stroke and myocardial infarction, calcification of ascending aorta, left ventricular contraction, and diastolic dimension of left ventricular. Additionally, history of percutaneous coronary intervention, severity of native coronary lesions chronic kidney disease requiring artificial hemodialysis, and sequential grafting were not associated with the outcomes.

Conclusions: Patency of SVG could be safely utilized regardless of sex, comorbidities low left ventricular function and size, coronary territories and severity of native coronary stenosis. SVG still have important roles of current CABG.

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D37 An Economic Training Tool for Teaching VATS: Sheep Carcass

Shaiwal Khandelwal, Ali Zamir Khan. Medanta The Medicity, Gurgaon, India.

Objective: We describe the sheep carcass to be used as a model to provide surgeons hands-on training to learn VATS.

Methods: We have used the chest of sheep carcass to teach surgeons to teach VATS. The trainees included both general and cardiothoracic surgeons. The basic VATS procedures included pleural biopsies, drainage of multiloculated pleural effusions, wedge lung resection, pericardial window, bullectomy/pleurectomy. The advanced VATS procedures included esophagectomy and lobectomies. We also taught pulmonary physicians to do local anesthesia thoracoscopy.

Results: This animal model was very well accepted by the surgeons and physicians. About 20% of our trainees have started performing basic VATS procedures following attending our courses.

Conclusions: The sheep carcass replicates the human chest and proved to be an excellent tool to teach surgeons about the principles of VATS. However, the surgeon should be competent with open thoracic surgery before attempting doing any VATS procedure.

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D38 Robotic-Assisted CABG: A Single-Surgeon Experience

Atiq Rehman. Sarasota Memorial Hospital, Sarasota, FL USA.

Objective: Coronary artery bypass surgery (CABG) through a sternotomy is standard of care. We wanted to observe outcomes of robotic assisted CABG (rCABG) at our institution.

Methods: Retrospective review of rCABG performed at our institution over the past 36 months, evaluating outcomes including rate of conversion to sternotomy, major adverse cardiovascular and cerebral events (MACCE) and mortality.

Results: There were 47 patients who underwent rCABG at our institution. The mean age was 67 (range 45-85); 12% were octogenarians. There was one totally endoscopic CAB (TECAB) performed and the rest of them had a robotically assisted left internal mammary (LIMA) take down, the distal and proximal anastomosis (in case of multivessel rCABG) performed through a 6 cm left minithoracotomy. Thirty (30) patients had a single-vessel rCABG and 17 had multivessel (3 patients had three grafts and the rest had 2 grafts). All the multivessels grafts were separately taken off the proximal ascending aorta except one which had the LIMA sequenced to the diagonal and the left anterior descending (LAD) arteries. Two patients had RIMA to right coronary artery anastomosis. One LAD was completely intramyocardial. One patient undergoing a multivessel rCABG had a breast implant removed at the beginning of the procedure and reinserted after the distal anastomosis. One patient had a distal LAD stent inserted for distal plaque disruption. Two patients were converted to full sternotomy (one due to hemodynamic instability and the other had a presumed LV wall injury). There were no MACCE and there was no death.

Conclusions: The rCABG has minimal MACCE and mortality, even in octogenarians and thus may be considered as an option in a select group of patients undergoing CABG.

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D39 Operative Outcomes of On-Pump and Off-Pump Coronary Artery Bypass Surgery in Hemodialysis Patients

Tae Sik Kim, Sam Sae Oh, Gwang Ree Cho, Gil Soo Yie. Sejong General Hospital, Bucheon, Republic of Korea.

Objective: On-pump or off-pump coronary artery bypass surgery can be performed in patients requiring hemodialysis. We retrospectively evaluated the operative outcomes of these techniques in hemodialysis-dependent patients.

Methods: From January 2001 to December 2012, 27 patients requiring hemodialysis underwent coronary artery bypass surgery at our center. In our series, on-pump coronary artery bypass surgery was used in 13 patients, and off-pump coronary artery bypass surgery in 14 patients. The demographics and operative results were compared between two groups.

Results: The mean age was 64.0 ± 6.9 and 63.1 ± 9.9 years in on-pump and off-pump group (p = 0.769), respectively. There were four operative deaths (30.8%) in on-pump group, and no patient died postoperatively in off-pump group (p = 0.041). Causes of deaths were low cardiac output syndrome (n =1), myocardial infarction (n = 1), and intractable ventricular arrhythmia (n = 1). Preoperative ejection fraction was 42.6 ± 14.0 in on-pump group, and 55.5 ± 14.4 in off-pump group (p = 0.033).

Conclusions: In hemodialysis-dependent patients with moderate left ventricular dysfunction, off-pump coronary bypass surgery seems to have better perioperative outcomes than on-pump surgery in small hospital volume of procedures.

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D40 Mortality Meetings: Analysis of 12 years of Functioning in an Intensive Care Unit of Cardiac Surgery

Paul M. Menu, Jamil H. Hajj-Chahine, Hassan M. Houmaida, Hassan M. Houmaida, Laurent Soubiron, Claire Biderman, Pierre J. Corbi. C.H.U. de Poitiers, Poitiers, France.

Objective: Mortality meetings (MM) became a modern approach in improving the quality and the safety of the cardiac patient care. It is also a collective approach of learning favoring the dialogue between surgeon and anesthesia caregivers and gives us instructive argumentation for the choice of the strategy for the best surgical management. The MM is a global analysis of a situation estimating the organizational, technical and human parameters.

Methods: All our mortality and morbidity files considered instructive were reviewed. Every case is presented by a member of the team according to a well established plan, and then comes an opened discussion with analysis of every element between all the participants. The objective is to answer the questions: how arrived the event? Why did it happen? What it is necessary to implement to avoid that in the future?

Results: All the cases were analyzed, with the issue of the methodological guidelines of the HAS “the not making guilty of the people having participated in the taking care is indispensable to the objectivity and to the success of the research of the causes”. This has allowed to federate the team around a common objective, in a constructive state of mind. Numerous decisions were taken; the identification of improvement actions and the individualized follow-up of these actions were very fertile. The analysis of the hemorrhagic complications made us establish a predictive score of the patients at risk and an algorithm for the decision-making. The study of the infectious complications made us bring to light markers by following the method ALARM. The integration of the paramedical teams is enriching to analyze the organizational parameters. The analysis of outcomes of valve replacement in the high-risk patients helps us to decide between TAVI and conventional valve surgery.

Conclusions: Our MM were validated by the Medical committee of our Establishment. Our MM of cardiac surgery are now considered in the certification and in the accreditation of the surgeons and the anesthetists.

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D41 Early Outcomes of Off- and On-Pump Total Arterial Bypass Graft Surgery: Analysis of 937 Consecutive “All-Comer” Patients

Teresa Kieser 1, M Sarah Rose1, Mouhieddin Traboulsi2, Kishan Narine1. 1University of Calgary, Calgary, AB Canada, 2Llibin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB Canada.

Objective: Off-pump coronary artery bypass graft (CABG) surgery and total arterial grafting (TAG) are not commonly coincident. This study compares the early safety and efficacy of total arterial CABG in off- and on-pump surgery.

Methods: A prospective cohort of all consecutive CABG-only patients from 2003-2012 was analyzed to compare short-term outcomes of off-pump with on-pump patients.

Results: From July 2003 to March 2012, 937 patients underwent CABG with 98% arterial grafts (2727/2782). From April 2008 onward, 79% (322/408) of CABG was performed off-pump. Prior to this only 6% (31/529) of CABG was done off-pump and was mainly for single-vessel disease or ascending aortic calcification. For off-pump/on-pump respectively TAG was performed in 94% (333/353)/96% (561/584) patients and 98% (913/934)/98% (1814/1848) bypasses. Excluding single-vessel disease, 71%/74% patients received bilateral mammary arteries and an average of 2.8/3.2 grafts/patient. Incomplete revascularization occurred in 16% of off-pump and 12% of on-pump surgeries (p=0.172). Conversion rate from off-to on-pump was 4.3% (15/353). No significant differences were observed for gender (78% male, p=0.872), obesity (33%, p=0.086) and admission status (43% elective, 46% urgent and 11% emergency, p=0.420) but off-pump patients were older (66.8 vs. 64.1 years, p=0.0001), less likely to have diabetes (29.5% vs. 36%, p=0.046) and were more likely to be high-risk with a logistic EuroSCORE ≥6 (31.2% vs. 23.5%, p=0.020). After controlling for EuroSCORE risk and admission status, off-pump patients had a lower (but not significantly) risk of MACCE (OR=0.70, 95% CI 0.39, 1.23, p=0.214). Unadjusted rates of MACCE for off- and on-pump groups were: peri-operative myocardial infarction 1.4%/2.2% (p=0.467), deep sternal wound infection 1.1%/2.1% (p=0.436), stroke in 0.9%/0.9% (p=1.0), overall operative mortality 3.4%/4.3% (p=0.605), operative mortality for emergency patients 8.5%/22% (P=0.112), for urgent-in patients 4.5%/3.65 (P=0.671), and for elective patients: 0.7%/0.8% (p=0.871). Transit time flow was used to measure graft flow intra-operatively from April 2004 on and was therefore used in 91% of both off- and on-pump patients.

Conclusions: TAG can be performed off- or on-pump with low morbidity and mortality. Patients undergoing off-pump need not be deprived of arterial grafts.

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D42 Comparison of Lower Ministernotomy with Limited Skin Incision and Conventional Sternotomy Approach for Surgical Closure of Atrial Septal Defect in Children

Rudolf Poruban, Michal Chalupka, Pavel Valentík, Matej Nosál’. National Institute of Cardiovascular Disease, Bratislava, Slovakia.

Objective: From December 2007 to November 2012 overall 98 secundum atrial septal defect (ASD) surgical closures were performed. A lower L-ministernotomy (MS) was used in 47 patients and 49 patients had conventional sternotomy (CS) approach. In this study we compared the outcome between both groups with a focus on complications and effectiveness.

Methods: After minimal skin incision and mobilization of subcutaneous tissue the MS was performed through a partial lower L-sternotomy up to the second or third intercostal space towards the right side. Standard extracorporeal circulation (ECC) with cold blood cardioplegia or induced ventricular fibrillation (VF) was used in both groups. There were no significant demographic differences between both groups. There was no difference between both groups in median age (MS 3.37 years, CS 3.16 years, p=NS), median weight (MS 15.5 kg, CS 13 kg, p=NS) and height (MS 104 cm, CS 92 cm, p=NS). Direct suture of ASD was more frequently used in MS group than pericardial patch (MS 30 pts direct ASD suture vs. CS with 21 pts, p=0.015).

Results: There was no significant difference between both groups in operation time (120 min MS vs. 117 min. CS, p=NS), ECC time (33 min equally for both MS and CS), cross-clamp time (15 min MS vs. 14 min CS) and ICU stay (1 day). There was significant difference in ventilation time (0.5 h MS vs. 2.6 h CS, P < 0.0001) and postoperative stay (MS median 4 days vs. 5 days CS, P = 0.0003). There were no significant differences in postoperative complications in both groups. In the MS group the skin incision length ranged from 3 cm to 7 cm and there was no sternal deformity recorded during the median follow-up of 3.04 years.

Conclusions: Surgical closure of ASD through partial ministernotomy with small skin incision has a superior cosmetic result, shorter postoperative ventilation time and shorter postoperative hospital stay in comparison with conventional sternotomy approach.

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D43 Off-Pump Coronary Artery Bypass Grafting in Very High-Risk Acute Coronary Syndromes

Lakshmi Srinivasan, Adam Lea, Lognathen Balacumaraswami. University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, United Kingdom.

Objective: Off-pump coronary artery bypass grafting (OPCABG) is associated with reduced early mortality and morbidity in high-risk patients with EuroSCORE >6 (Lemma, et al., J Thorac Cardiovasc Surg). We present clinical outcomes following OPCABG in a very high-risk cohort of patients who had presented with preoperative acute coronary syndromes with or without unstable hemodynamics.

Methods: OPCABG was offered to all consecutive patients on an all-comers basis. All patients operated by a single surgeon in a cardiothoracic unit in UK between April 2010 to November 2012 were included. Of the 218 patients who underwent OPCABG, 16 patients had acute coronary syndrome preoperatively with or without stable hemodynamics. The coronary disease pattern was deemed unsuitable for PCI or ischemia was ongoing despite primary PCI. The average age was 62 (range 42-83) and six were obese (BMI >30). All 16 patients were on intravenous nitrates and/or heparin. IABP was placed (12 out of 16 patients) in the cardiac catheterization laboratory and the patients were transferred for surgery.

Results: Five out of sixteen patients were operated as urgent, ten were operated as an emergency and one was operated under salvage conditions. Three patients had poor ejection fraction (EF< 30%), one was in cardiogenic shock and three had failed primary PCI; two of the latter had dissected coronary arteries. The patients tolerated OPCABG well and made an excellent recovery with no mortality or any major adverse cardiac, renal or cerebrovascular events. Only two patients needed inotropic support postoperatively and there were no reoperations.

Conclusions: OPCABG has fewer incidences of major adverse events in high-risk patients in acute settings when a specific high-risk strategy is tailored to suit the individual patient hemodynamics.

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D44 A Potential Utilization of Human Thymus Fat in Coronary Artery Bypass Grafting

Julian Salas 1, Rajaa El Bekay2, Sergio Gonzalez1, Jose Valderrama1, Julio Gutierrez1, Leticia Coin2, Wilfredo Oliva2, Francisco Tinahones2. 1Hospital Carlos Haya, Malaga, Spain, 2Fundacion Imabis, Malaga, Spain.

Objective: Regeneration of ischemic myocardium is a challenge nowadays. Actually, we are performing coronary artery bypass grafting (CABG) in worst patients, because they are elderly, with worst coronary artery, metabolic diseases, previous IAM, etc. In these patients, to dispose a complementary technique to the conventional CABG may be a great solution. Our group has obtained excellent results showing the angiogenic capacity of thymus fat. This is the aim of our study.

Methods: Study was carried out in patients who underwent cardiac surgery by ECC (n=20) aged (45-80 years old), to whom thymus fat and subcutaneous adipose tissue were extracted and used for protein and mRNA expression analysis of angiogenic markers, including VEGF isoforms, Angiopoeitin and Tie2.

Results: Expression of VEGF-A, VEGF-B, VEGF-C and VEGF-D mRNA and protein expression in thymus fat (n=20) were at similar levels than in subcutaneous adipose tissue (SAT n=20) (Figure D44-1). At elderly age (>75 years) angiogenic factor expression levels were increased significantly in thymus fat compared to younger age (∼45 years old), while in subcutaneous fat these levels declined significantly at elder age.

Conclusions: Thymus fat is an adipose tissue physiologically similar to white adipose tissue. Moreover, thymus fat is more enriched of angiogenic factor than subcutaneous adipose tissue, especially in elderly subjects (with age >75 years old). The use of this fat by injection in the myocardium in the areas where the surgeon cannot apply the normal technique of CABG could be a great solution. It would be necessary to find a method for obtaining thymic extract ready in 1 to 3 hours, time necessary between tissue extraction and final processing of a normal CABG.



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D45 Video-Assisted Thoracoscopic Surgery in the Treatment of Postoperative Chylothorax

Sang Gi Oh 1, Ju Sik Yun1, Kook Joo Na2, Sang Yun Song2. 1Chonnam National University Hospital, Gwangju, Republic of Korea, 2Chonnam National University Hwasun Hospital, Jeollanamdo, Republic of Korea.

Objective: Chylothorax is an uncommon but well-known complication following thoracic surgery. Chylothorax is usually treated conservatively, but a surgical procedure is required for cases refractory to conservative treatment. Recently, video-assisted thoracoscopic surgery (VATS) has gained popularity in the treatment of chylothorax.

Methods: We describe 3 patients treated successfully by VATS, using 3 ports. There were 2 men aged 56 (patient 1) and 76 years (patient 2) and 1 women aged 19 years (patient 3). Bilobectomies have been performed by thoracotomy due to lung cancers in patient 1, 2. Resection of posterior mediastinal tumor has been performed by VATS in patient 3.

Results: All patients were initially treated conservatively. To identify the leakage exactly, patients undergoing VATS received olive oil through a nasogastric tube 1 hour preoperatively. Patient 1 underwent direct suture of mediastinal pleura. Patient 2 underwent clipping of lymphatic vessel and ligation of thoracic duct. And Patient 3 underwent clipping of lymphatic vessel and spray of fibrin glue. All patients were discharged without recurrent chylothorax.

Conclusions: In postoperative chylothorax patients, VATS could be considered as an effective method.

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D46 Endoscopic Epicardial Lead Implantation as a Primary Alternative for Repeated Failure of Endovascular Insertion for Cardiac Pacing and Re-Synchronization Therapy

Nachum Nesher, Yosef Paz. Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Objective: Numerous anomalies or post-procedural stricture of the central venous system prevent the optimal endovascular implantation of left ventricle lead in more than 10% of patients indicated for either permanent pacing or cardiac resynchronization therapy. The endovenous approach may be one of the reasons for the large number of the non-responders reported in the literature. The purpose of our report is to analyse the thoracoscopic technique and the immediate postoperative results of the lesser invasive epicardial approach as the first alternative to the traditional failed endovascular lead insertion.

Methods: From January 2008 to November 2012 nine epicardial leads were introduced thoracoscopically at our center. Patients were placed in a supine position and were ventilated using a double-lumen endotracheal intubation. A 5 mm 30 degree lance thoracoscope was inserted into the fifth intercostal mid-axillary line. A second 10 mm port was created in the seventh intercostal anterior axillary line. The pericardium was opened interiorly to the phrenic nerve. A screw-in pacing lead (Medtronic Model 5071 Pacing lead, Minneapolis, MN USA) was inserted into the apical portion of the left ventricle. A third 5 mm port was needed for suturing when a non-screw pacing lead was used (first 5 cases). After the lead was placed and assessment made with pacing system analyzer for threshold less than 1 V, they were brought to the chest wall and tunneled to the pacemaker generator pocket. A size 10 Jackson Pratt drain was placed into the pocket. Another small flexible drain was left inside the pleural cavity for the next 24 hours.

Results: There were no deaths or any major surgical complication among these patients. All patients responded to the epicardial lead implantation in terms of appropriate pacing and conductivity. No clinical failure was observed and none needed another attempt.

Conclusions: Thoracoscopic lead insertion is safe and easy to perform and should be offered as the first choice for failed endovascular implantation. Improving the cooperation between cardiologists and cardiothoracic surgeons will probably attenuate the non-responder rate.

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D47 Is the Outcome of Ventricular Assist Device or Heart Transplantation After Initial Coronary Artery Bypass Graft and Mitral Valve Surgery in Patients With Severe Ischemic Cardiomyopathy a Feasible Option in Well Selected Patients?

Jens Garbade, Rahel Kluttig, Joerg Seeburger, Markus J. Barten, Sven Lehmann, Denis R. Merk, Michael A. Borger, Friedrich-Wilhelm Mohr. Cardiac Surgery, Heart Center University of Leipzig, Leipzig, Germany.

Objective: Left ventricular assist device (LVAD) and heart transplantation (HTX) are end-stage therapies in patients with severe ischemic cardiomyopathy (ICM) following complex mitral valve surgery (MVS) and coronary artery bypass grafting (CABG). However, the incidence and outcome of this worse clinical scenario is completely unknown.

Methods: During the last decade 475 patients with ICM (mean ejection fraction (EF) 25.0 ± 6.0%) underwent MVS additional to CABG. Within this cohort 8 high-risk patients (6 male) at a mean age of 61.9 ± 5.6 years and with a mean EF of 20.6 ± 4.3% presented with impaired left ventricular (LV) function and further surgical therapy was needed. Patients treated by LVAD had an intermacs level 1 or 2, and the procedure was performed urgently, whereas the others were listed as high urgent for transplantation during follow-up. Clinical data and information on complications, re-intervention and mortality were retrospectively gathered. Follow-up was made with a mean-time span of 1210 days (range 13-3709 days).

Results: Five patients received a LVAD at a mean postoperative time of 50.6 days (range 6-184 days). For one patient the device was a bridge-to-transplant therapy. All others were final destination therapy. Three patients received a HTX at a mean postoperative time of 1633 days (range 252-3470 days). Thirty-day mortality of all LVAD patients was 20% with a follow-up of 100%. Mortality at 60, 90 and 365 days was 40%, 80% and 80% respectively with a follow-up of 100%. Mean support time was 57.8 days (range 0-146 days). The patient who survived received his HTX 146 days post LVAD surgery and is still alive at day 1977 post surgically. After HTX no patient died within 30 days. The long-term mortality at 180 days, 1 and 5 years was 0%, 33.3% and 33.3% respectively with a follow-up of 100%.

Conclusions: VAD and HTX are the last options in patients with impaired LV function after CABG with additional MV surgery. However, patients who needed an assist device had a poor outcome but heart transplantation may offer the best alternative to these patients.

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D48 The Role of VATS in Treatment of Primary Spontaneous Pneumothorax

Reza Bagheri 1, Seyed Ziaollah Haghi1, Davood Attaran2, Fatemeh Ebadi1. 1Cardio- Thoracic Surgery & Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran, 2Pulmonary Medicine, Lung Diseases and Tuberculosis Research Center, Mashhad University of Medical Science, Mashhad, Iran.

Objective: Spontaneous pneumothorax is a relatively common problem that occurs frequently in young and tall adults without underlying history of previous illness. Treatment in case of recurrence or developing complications is surgery. In the past, the surgical technique used for these patients was thoracotomy which was associated with higher morbidity. The aim of this study is to investigate the results of utilizing VATS in treatment of this clinical condition.

Methods: All patients with primary spontaneous pneumothorax, between 2010 to 2012, underwent VATS and were followed up for 1 year after the operation and were evaluated according to age, sex, diagnosis, indication of surgery, postoperative complications, and recurrence rate.

Results: Twenty patients were recruited, mean age was 28.6 years and male to female ratio was 16:4. The problem mostly occurred on the right side (16 patients) and its recurrence was the most common indication of surgery (14 patients). Two patients developed postoperative complications (residual space) that were recovered by means of negative pressure suction. No mortality was recorded and there was only one case of relapse at 6 months of follow-up that underwent thoracotomy.

Conclusions: Considering that postoperative complications of thoracoscopy is quite acceptable and this surgical technique is associated with less morbidity and the results are agreeable and satisfying, using this technique, as an appropriate method of surgical treatment in these patients, is recommended.

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D49 Treatment of Atrial Fibrillation with the Wolf Mini-Maze Procedure: Intermediate-Term Results

Leonardo S. Canale, Inderjit Gill, Lon Castle, Christine Tanaka-Esposito, Allison Kocsis. Cleveland Clinic Foundation, Cleveland, OH USA.

Objective: The Wolf mini-maze procedure is a novel minimally invasive approach for atrial fibrillation treatment. We report our initial experience with this treatment and intermediate-term results.

Methods: Between July 2006 and December 2011, 34 patients underwent a Wolf mini-maze procedure (video-assisted bilateral minithoracotomies) with left atrium appendage occlusion as a stand alone procedure for atrial fibrillation treatment. Age varied from 35 to 76 years old (mean: 59, 6+-8.8 years), 9 (26%) were women. Comorbidities included arterial hypertension in 17 (50%), diabetes mellitus in 2 (5.8%), previous stroke/TIA in 3 (8.8%). Four patients (11.7%) had history of previous arrhythmia ablation. Atrial fibrillation was classified as: paroxysmal in 25 (73.5%), persistent in 7 (20.5%) and long-term persistent in 2 (5.8%). Duration of atrial fibrillation varied from 4 to 360 months (mean: 97+-91 months).

Results: Two patients (5.8%) had a conversion to full sternotomy due to pericardial adhesions. Mean length of surgery was 393+-107min. Lesions performed were: bilateral PVI in 34 (100%), left atrium communicating lesions in 26 (76.4%), line to aortic annulus in 19 (55.8%), Ligament of Marshall division in 34 (100%); right and left ganglionic plexus denervention were necessary in 29 (85.2%) and 12 (35.2%) respectively. LAA occlusion was possible to be performed in all but one patient (97%). Length of ICU stay varied from 1 to 3 days (mean: 1.3 +- 0.7, median: 1), total hospital stay varied from 3 to 12 days (mean: 5.7+-1.9 days). Complications of the procedure included reintubation in 1 (2.9%), pericardial effusion with tamponade in 2 (5.8%) and hemidiaphragm paralysis in 1 (2.9%). Follow-up varied from 1 to 67 months (16.4+-15.6 months) with serial EKGs and Holter 24-hour. Thirty patients (88%) had at least 3-month follow-up and were considered for procedure success X failure. At last follow-up 23/30 patients were in sinus rhythm (76.6%). Sixteen patients (53%) were free from arrhythmia and off AAD and anticoagulants. There were no procedure-related deaths. There were 2 late deaths not related to the procedure.

Conclusions: The Wolf mini-maze procedure is a safe and effective treatment for atrial fibrillation.

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D50 Influence of Cardiac Surgery on Electromagnetic QRS Fragmentation Index in Patients Undergoing Elective On-Pump Cardiac Surgery Due to Aortic Valve or Coronary Artery Disease?

Inna Kammerer, Helena Garcia Jordan, Thomas Kleemann, Ralf Zahn, Falk-Udo Sack. Academic City Hospital Ludwigshafen, Ludwisghafen, Germany.

Objective: High-resolution magnetocardiography with electromagnetic QRS fragmentation is suggested to have the propensity to detect myocardial ischemia, arrhythmic events and increased mortality in postmyocardial infarction (MI) with left ventricular dysfunction. The aim of our prospective study was to compare the electromagnetic QRS fragmentation index (eQFI) in elective cardiac patients before and after undergoing cardiac surgery.

Methods: A prospective study (03-09/2012) was performed in 35 patients (66 years, 65% male, 9% with EF 30-50%) undergoing elective coronary artery bypass graft (CABG, n=23) or aortic valve replacement (AVR, n=12) at the Heart Center Ludwigshafen, Germany. The measurement of eQFI was done before and 7 days after extracorporeal circulation. A QRS fragmentation index > 1.2 was defined as an increased eQFI and an eQFI change of > 0.1 before and after intervention as a significant change.

Results: The mean ischemia time accounted 47+17min. The demographic dates of elective cardiac surgery patients undergoing CABG or AVR were not significantly different. No hospital death was observed. The comparison of eQFI did not show significant differences before and 1 week after the cardiac procedure: 1.07 + 0.386 vs. 1.06 + 0.267 without differences in both groups.

Conclusions: Our study could not show an acute effect of cardiac surgery on the eQFI. Further eQFI measurements are needed to evaluate if an effect of cardiac surgery can be observed during a longer follow-up period.

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D51 Endoscopically Unilateral Left Atrial Ablation Technology is the Surgical Therapy of Choice for Patients with Isolated Persistent Atrial Fibrillation

Ralf Krakor, Pavol Kopriva, Ingolf Eichler. Klinikum Dortmund, Dortmund, Germany.

Objective: Monopolar and bipolar unilateral atrial ablation technology was used endoscopically to create a box lesion in patients with persistent isolated atrial fibrillation. Effectiveness, safety and ablation results were analyzed.

Methods: Between June 2010 and December 2012 a box lesion was created around all pulmonary veins in 19 patients with isolated atrial fibrillation (Table D51-1). All procedures were performed using right thoracoscopic access. Exit block was defined as the intraoperative success end-point. A loop recorder was implanted in all patients. The mean follow-up time was 8.3 ± 4.7 months. Amiodarone and Warfarin were given postoperatively for 6 months.

Results: There were no in-hospital deaths. No perioperative complications such as conversion to open chest procedure, bleeding, esophagus damage, need for pacemaker or stroke were observed. The primary success rate (exit block) was 94.7% (18/19 pts). At discharge 18 of 19 patients were free of atrial fibrillation (94.7%). Success rate at 3, 6, and 12-month follow-up was 94.1% (16/17), 85.7% (12/14), and 85.7% (6/7), respectively.

Conclusions: Unilateral monopolar and bipolar thoracoscopic atrial ablation to create a box lesion is a safe and effective procedure. Minimal trauma and high safety and efficacy make this technology the surgical therapy of choice in patients with persistent and long-standing persistent atrial fibrillation.



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D52 Thymectomy Between Video-Assisted Thoracoscopy and Different Open Surgical Techniques

Magdi Ibrahim Ahmad Muhammad. Department of Cardio-Thoracic Surgery, Faculty of Medicine, Suez Canal University, Ismaïlia, Egypt, Department of Cardio-Thoracic Surgery, King Fahd Hospital, Al-Madina Al-Munawara, Saudi Arabia.

Objective: Thymectomy is well established in the treatment of myasthenia gravis. Numerous techniques for performance of thymectomy have been described and published. We conducted this study to compare the outcomes of the three distinctly different operative techniques which are thymectomy through total median sternotomy, partial median sternotomy and video-assisted thoracoscopy.

Methods: Between January 2008 and December 2011, thirty patients (9 male and 21 female) aged 20-65 years were included in this study. Patients were subdivided into three groups: group (A) 10 patients underwent thymectomy through total median sternotomy, group (B) 10 patients underwent thymectomy through partial median sternotomy and group (C) 10 patients underwent thymectomy through video-assisted thoracoscopy. Preoperative, intra-operative, postoperative variables and mortality are compared in all groups.

Results: In all groups, preoperative variables were well matched for age, sex and preoperative clinical staging according to the MGFA clinical classification. Operative time was statistically highly significant; it was longer in Group [C]. There was no intra-operative complication in all groups. Also, postoperative length of hospital stay was statistically highly significant; it was shorter in Group [C]. Postoperative complications occurred in three patients (10%) mostly in group [A] and group [B]. There was no perioperative mortality in all groups.

Conclusions: We conclude that video-assisted thymectomy is effective as the traditional open surgical approaches for performance of thymectomy in the management of patients with myasthenia gravis. In addition, the improved cosmesis of the video-assisted approach ideally will lead to earlier thymectomy in patients with myasthenia gravis.

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D53 Minimally Invasive Thoracoscopic Esophagectomy in Esophageal Cancer: Analysis of 20 Cases

Reza Bagheri 1, Seyed Ziaollah Haghi1, Hazrati Nazanin2. 1Cardio-Thoracic Surgery & Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran, 2Endoscopic & Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

Objective: Esophageal cancer is a common cancer of the digestive system that our country is one of the common areas. The foundation of surgical treatment of esophageal cancer is surgery. Due to the development of minimal invasive techniques in our study we found that the results of this technique in patients with esophageal cancer surgery.

Methods: Twenty patients with middle and lower thirds of esophageal cancer who had good general conditions and operated with this technique, enrolled in this study. Patients were evaluated based on the following criteria: age, sex, tumor location, pathology. Intraoperative complications leading to minimal invasive esophagectomy technique to open surgery–early postoperative complications after surgery.

Results: Twenty patients enrolled in the study, 15 patients in middle part of esophagus, and 5 patients in lower part of esophagus. There were M/F = 15/5 with an average age of 58 years. In pathological examination 18 patients had SCC and 2 patients had AC. Five patients had a history of neo-adjuvant therapy. Surgery was performed without complications in 18 patients with proper technique. In two patients with severe pleural adhesion VATS could not be completed and patients were operated with open surgery. Early postoperative complications were seen in 2 patients (atelectasis and inferior MI) that both patients recovered with conservative treatment. We had no mortality.

Conclusions: We recommended this technique in patients with esophageal cancer in centers that have experience in this technique because of the proper results and low-grade invasion.

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D54 An Interdisciplinary Approach for Minimal Invasive Pacemaker Lead Extraction and Epicardial Pacemaker Implantation

Hessian Baraka, Thomas Rod, Bernhard Meyer, Axel Haverich, Ingo Kutschka. Hannover Medical School, Hannover, Germany.

Objective: A growing number of patients require surgery for pacemaker infection. Minimal invasive, interdisciplinary approaches should be preferred, especially in multimorbid patients. Here, we present an innovative approach for a complex redo-case with severe device infection and biventricular heart failure.

Methods: A 59-year-old pacemaker-dependent man presented with severe sepsis and renal failure due to an infected CRTD-system. The patient was listed for heart transplantation since 2007. Ejection fraction was 10-15%. In 1987 he underwent replacement of the aortic valve and the ascending aorta. He underwent ICD (via left subclavian vein) implantation followed by CRTD (via right subclavian vein) implantation in 2003 for AV-block III°. Replacement of the aortic valve prosthesis and the mitral valve was performed in 2005. Blood cultures turned positive for Staphylococcus aureus and 4 pacing leads had to be extracted.

Results: First, we implanted a temporary percutaneous VVI pacing lead via the right jugular vein. Then, 3 out of four leads were successfully extracted using Excimer laser technique. Unfortunately, the dual coil ICD electrode ruptured in the vena cava superior. The critical clinical status of the patient did not allow for surgical lead removal by re-re-sternotomy. Therefore, we extracted this remaining lead, with the help of our interventional radiologists, using a transvenous femoral approach. The free segment of the lead was looped with a pig-tail catheter and a guide-wire, pulled inside a 20F sheath and was completely removed using gentle continuous traction. The clinical status of the patient improved. However, single chamber VVI-pacing did not allow for mobilization of the patient. Therefore, after two weeks of antibiotic therapy, we implanted a left ventricular epicardial lead via a left lateral mini-thoracotomy and a right ventricular epicardial lead via a small subxiphoid incision. Under biventricular pacing, cardiac and renal function improved and the patient was finally dismissed from the hospital.

Conclusions: The transfemoral wire loop technique represents a suitable bail-out approach to remove lead parts after failing complete Excimer laser lead extraction. Epicardial leads can be implanted by small lateral and subxiphoid accesses, to avoid (re-)sternotomy in multimorbid patients.

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D55 Interventional Procedures for Congenital Heart Disease

Zan Mitrev, Tanja Anguseva. Special Hospital for Surgery Fillip II, Skopje, Macedonia.

Objective: Interventional techniques available for use in treating congenital heart disease include balloon dilation of valves and vessels, stent placement and coil embolization of collaterals, patent ductus and other arterial fistulae. In addition, a variety of devices for closure of atrial and ventricular septal defects and patent ductus currently are under investigation. Radiofrequency ablation of arrhythmias also is applicable to the pediatric population.

Methods: During the last 8 years 253 patients with congenital heart disease had been treated with interventional procedures in our hospital. All of them had been diagnosed by transthoracic and transesophageal echocardiography. All patients had one-day hospitalization.

Results: 123 patients with atrial septal defect had been occluded with amplatzer septal occluder, 43 patients had interventional closure of the persistent arterial channel between the aorta and pulmonary artery by amplatzer AGA vascular plug et coil. Eight patients got ventricular septal defect occlusion by amplatzer septal occluder. Balloon valvuloplasty of the congenital aortic valve stenosis was performed in 5 patients and balloon valvuloplasty for pulmonary valve stenosis was performed in 52 patients. Aortic stent for treatment of the aortic coarctation was implanted in 19 patients. With an amplatzer AGA vascular plug coronary AV fistula was occluded in 3 patients. No mortality and no complications were noted. Follow-up period is up to 8 years.

Conclusions: Interventional catheterization has become solidified as an integral component of the comprehensive management of patients with essentially all forms of congenital heart disease. Patients are getting permanent solution with minimum side-effects of their health.

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D56 Minimally Invasive Direct Coronary Artery Bypass with Robotically Assisted Intra-Mammary Artery Harvesting

Tomoyuki Fujita, Hiroki Hata, Yusuke Shimahara, Shunsuke Sato, Junjiro Kobayashi. National Cerebral and Cardiovascular Center, Suita, Japan.

Objective: We evaluated the feasibility of off-pump minimally invasive direct coronary artery bypass (MIDCAB) in combination with robotically assisted left internal mammary artery (LIMA) harvesting.

Methods: Since 2004, 33 patients (average 64 years old, 27 (82%) males) underwent MIDCAB with LIMA harvesting using the da Vinci Surgical System. All were indicated for single-vessel grafting at the internal coronary conference and provided consent for the procedure. Sixteen (48%) had single-vessel disease, and percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) was previously performed in 14 (42%). Target arteries were the left anterior descending (LAD) in 31, diagonal branch in 1 and high lateral branch in 1. The LIMA was harvested in a pedicle manner in 21 cases and a skeletonized manner in 12. Off-pump MIDCAB was performed through the 4th or 5th intercostal space with guidance by enhanced computed tomography (CT). Graft flow was measured intra-operatively using a transit time blood flow meter, while graft patency was evaluated 1 week postoperatively by coronary angiogram or coronary CT.

Results: There were no deaths or major adverse cardiac events observed. Robotically assisted LIMA harvesting was completed in 30 (91%) of the patients, while 3 (9%) were converted to a median sternotomy due to bleeding from the LIMA. Right internal mammary artery (RIMA) was anastomosed to LAD in 2 and LIMA was repaired using RIMA patch to be utilized as a conduit in 1. Among the 30 successful cases, the average time for harvest was 67 minutes, the average amount of bleeding was 200 ml and only 2 (7%) required transfusion. Graft flow was measurable in all cases and the average was 35 ml/minute. All grafts were patent at the postoperative evaluation, though CT revealed that the LIMA was anastomosed to an untargeted artery in 1.

Conclusions: Off-pump MIDCAB in combination with robotically assisted LIMA harvesting is a feasible and less invasive procedure. Potential problems include difficulty in controlling bleeding from the graft and proper identification of the target artery.

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D57 Urgent Thoracic EndoVascular Aortic Repair of Acute Aortic Syndrome in Patients with Comorbidities

Mitsuhiro Kawata 1, Tsuyoshi Taketani2, Sei Morizumi1, Yoshihiro Suematsu1. 1Tsukuba Memorial Hospital, Tsukuba, Japan, 2Mitsui Memorial Hospital, Tokyo, Japan.

Objective: Acute aortic syndrome (AAS) is associated with high mortality and morbidity. Furthermore, AAS in patients with comorbidities may be judged by the age or its comorbidities that a conventional open surgery is impossible. Thoracic endovascular aortic repair (TEVAR) using a commercially available device has emerged as an alternative to open surgery. We report four successful TEVAR performed for AAS detailing our experience.

Methods: From April to December 2012, in our hospital, there were four urgent TEVAR for AAS. All of them have survived.

Results: [CASE 1] A 93-year-old woman with renal dysfunction was taken to the emergency room due to severe back pain that was diagnosed as 5.7 g/dl of hemoglobin level and ruptured TAAA (Crawford V). Urgent visceral debranching TEVAR (Celiac a., SMA) was performed after making a general condition improve. On day 15, she was discharged to home (Figure D57-1).

[CASE 2] A 75-year-old man with a history of CABG (patent LITA-LAD and SVG-OM), TEVAR for distal aortic arch, and cerebral infarction, who presented to the emergency room as massive hemoptysis. It was diagnosed as the stent graft dislodgement, 80 mm of saccular ruptured TAA. Urgent debranching (LtCCA, LtSCA) TEVAR was performed. On day 17, he was discharged to home (Figure D57-1).

[CASE 3] An 87-year-old man with vomiting by esophageal transit obstacle and aspiration pneumonia were repeated from one-month before. He was taken to the emergency room by diagnosis of impending ruptured TAA (descending, 90 mm, saccular). Urgent TEVAR was performed. On day 2, he could walk. Feeding-tube was endoscopically inserted on day 3, and a tube feeding started. On day 36, he was discharged to home.

[CASE 4] A 63-year-old woman with aortoiliac occlusive disease who was diagnosed ruptured TAA (descending, 70 mm). After sternotomy, antegrade TEVAR was performed from the ascending aorta. On day 14, she was discharged to home.



Conclusions: TEVAR is safe and an effective option for life-threatening AAS in patients with comorbidities. Regular follow-up is mandatory.

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D58 A Safe Strategy for Peripheral Cannulation in Minimally Invasive Valve Surgeries Without Pre-Operative CT Angiogram

Zhandong Zhou, Michael Hodell, Ahmad Nazem, Gary R. Green, Joel Rosenberg, Feng Gao. St. Joseph Hospital, Syracuse, NY USA.

Objective: Pre-operative CT angiogram (CTA) before minimally invasive valve surgeries is gaining popularity in recent years. Although it provides valuable information for choosing peripheral cannulation site, CTA increases the risk of renal dysfunction, radiation exposure and the cost of the healthcare. We developed a stepwise cannulation strategy for minimally invasive valve surgeries without a routine pre-operative CTA.

Methods: Data were collected from hospital database used for New York state and STS reporting purpose. All patients from January 2007 to June 2012 had peripheral cannulation were identified. Only patients with minimally invasive valve surgeries first time were choosen for analysis. None of the patients had pre-operative CTA for the purpose of peripheral arteries. Right femoral artery is the site of choice for peripheral cannulation. Alternative sites were used only if the right femoral artery could not be used.

Results: Total 276 consecutive patients underwent minimally invasive valve surgery in our institution had peripheral artery cannulation during this period. Average age is 65-years-old. Patient demographics include 27 (8%) patients with peripheral vascular disease, 13 (5%) patients with cerebral vascular disease, 55 (20%) patients with chronic obstructive pulmonary disease, 42 (15%) patients with diabetes and 7 (2.5%) patients on dialysis. Minimally invasive valve surgeries were successfully performed in all patients. Average aortic clamp time is 93 minutes and perfusion time is 132 minutes. None of the patients died at discharge (0%). Permanent stroke occurred in two patients (0.7%). Three patients required change to different cannulation sites during surgery due to high perfusion pressure.

Conclusions: With our stepwise peripheral cannulation strategy, peripheral cannulation can be safely performed in minimally invasive valve surgeries without a routine CTA. It may help to save the health care cost, reduce the radiation exposure and the contrast related renal dysfunction in those patients.

©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery