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Poster Competition Abstracts

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2013 - Volume 8 - Issue 2 - p 121–156
doi: 10.1097/IMI.0b013e318297ea51
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P1 Experience of 600 Cases of Robotic Cardiac Surgery

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

Objective: The present study is to summarize the experience of 600 cases of various kinds of robotic heart surgery performed at a single-heart center.

Methods: Six-hundred patients underwent robotic cardiac surgery from January 2007 to December 2012. Of the 600 patients, 322 were male and 288 were female with a median age of 49-years-old (11 to 79 yrs). Left-port approaches were used in totally endoscopic coronary bypass grafting on beating heart (n=90) and direct coronary bypass grafting with minithorocotomy on beating heart (n=140). Right-port approaches were used in mitral valve repair (n=86), mitral valve replacement (n=40), atrial myxoma resection (n=45), atrial septal defect repair on arrest (n=54) or beating heart (n=90), ventricular septal defect repair (n=20), and other robotic cardiac surgery (n=35). With left-port approaches, patients were operated on via 3-port incisions in the left chest and 1 port in the left subcostal area of xiphoid process for endostabilizer on beating heart with da Vinci Si robot; the others were completed via left minithoracotomy after IMA was taken down robotically. With right-port approaches, patients were operated on via 3 ports in the right chest and a 1.5-2.0 cm working port, all the procedures were completed with the da Vinci Si robot on pump established through cannulation of femoral arteries.

Results: All procedures were accomplished by the same console surgeon. Operating time was shortened significantly for all procedures with considerable learning curve. For example, for TECAB procedure, the mean time of harvesting single ITA harvesting was 35.8±10.7 minutes (18 to 70 min). Harvesting time was decreased from 41 minutes in the first 30 cases to 29 minutes in the last 30 cases. All patients underwent coronary angiography or CTA scan before discharge. One patient was converted to median sternotomy due to aortic valve perforation, and one case had hemolyses after mitral valve repair. No patient died. There were no device-related and pro-related complications.

Conclusions: Our study shows that robotic cardiac surgery is a safe procedure, and the surgical results are excellent for selected patients.

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P2 Internet Marketing of Robotic Cardiac Surgery at Low Volume and Inactive Programs

Sugam A. Bhatnagar, Robert S. Poston Jr. University of Arizona, Tucson, AZ USA.

Objective: While internet marketing of robotic cardiac surgery is an appropriate response to growing demand for less invasive procedures, the value of this information to the public depends on transparency. We compared the content and quality of information on websites of hospitals with active, low volume and inactive robotic cardiac surgery programs.

Methods: A national database was queried for cardiac surgical volume of programs that performed at least one major robotic cardiac procedure (CABG, mitral valve repair) within the last 10 years. The websites of these hospitals were analyzed for the content and quality of data regarding these procedures.

Results: In the US, 372 programs have performed robotic cardiac surgery, distributed amongst programs that are active (i.e. >50 robotic cases in 2011, n=24), low volume (between 1-49 cases, n=136) and the remainder inactive (n=212). Out of 372 total programs, 195 (52%) have websites that specifically mention that they perform robotic cardiac surgery, including 100% (n=24) of active, 52% (n=71) low volume and 47% (n=100) of inactive programs. Regarding content, institutional superiority was claimed in 88% of active programs and 18% of low volume programs. In fact, there were 8 inactive programs (4%) that claimed to be the best in the region. Very few websites provided a description of limitations or a comparison group and almost all used stock images and text from the robotic manufacturer’s marketing toolkit. Only 3 evaluated websites met criteria for objective, balanced information and therefore eligible for certification by HONcode guidelines. Many contained egregious and obviously inaccurate claims (Table P2-1).



Conclusions: Internet marketing of robotics was noted to be widespread and often provides information of poor quality, rarely adhering to HONcode guidelines. There is a risk of patients being misdirected when information about robotics is provided on cardiac surgical websites that are not currently active.

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P3 Defining the Learning Curve for Robotic-Assisted Endoscopic Harvesting of the Left Internal Mammary Artery

Jonathan M. Hemli, Lucas W. Henn, Christopher R. Panetta, Jenny S. Suh, Scott R. Shukri, Joan Jennings, Gregory P. Fontana, Nirav C. Patel. Lenox Hill Hospital, New York, NY USA.

Objective: Robotic-assisted techniques are continuing to cement their role in coronary surgery, particularly in facilitating the endoscopic harvesting of the left internal mammary artery (LIMA), regardless of how the subsequent bypass grafting is performed. As more surgeons attempt to become trained in robotic-assisted procedures, we sought to better define the learning curve associated with robotic-assisted endoscopic LIMA harvest.

Methods: Between January 2011 and July 2012, 77 patients underwent robotic-assisted minimally-invasive direct coronary artery bypass (MIDCAB) surgery at our institution. The LIMA was harvested endoscopically in all patients, using standard robotic instruments, followed by direct grafting to anterior wall myocardial vessels via a small thoracotomy. Intraoperative times for various components of the procedure were collated and analyzed.

Results: The mean time taken to insert and position the ports for the robotic instruments was 3.9 +- 1.4 minutes. Mean LIMA harvest time was 31.8 +- 10.1 minutes, and mean total robotic time was 44.2 +- 12.9 minutes. All time variables consistently continued to decrease as the experience of the operating surgeon increased, with the greatest magnitude of improvement being evident within the first 15 cases (Figure P3-1). The logarithmic learning curves for LIMA harvest time and total robot time over our entire experience were both calculated as 90%, correlating to an expected 10% improvement in performance for each doubling of cases completed.

Conclusions: Coronary surgeons can rapidly become proficient in robotic-assisted endoscopic LIMA harvest, with significant improvement in operative times evident within the first 20 cases completed. This data may be useful in designing appropriate training programs for newer surgeons seeking to gain experience in robotic-assisted coronary surgery.



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P4 Assessing the Value of Anastomotic Connectors in Robotically Assisted Totally Endoscopic Coronary Artery Bypass Grafting

Stephanie L. Mick 1, Leonardo Canale1, Jeffrey D. Lee1, A. Marc Gillinov1, Tomislav Mihaljevic2, Johannes Bonatti2. 1Cleveland Clinic, Cleveland, OH USA, 2Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.

Objective: It is commonly believed that the use of automatic anastomotic devices holds the potential to simplify robotic totally endoscopic coronary artery bypass grafting and to decrease operative time. We compared robotically sewn distal anastomoses to device-created anastomoses in a porcine wet lab model.

Methods: In each case, the right coronary artery was dissected free from a cadaveric pig heart and then anastomosed to the LAD, simulating a LIMA to LAD anastomosis. In group A, a graft to coronary anastomosis was created using a running 7-0 Pronova suture with da Vinci Si robotic assistance. In group B, each anastomosis was performed using the C-Port Flex-A automatic anastomotic connector (Cardica, Redwood City, CA USA) with da Vinci Si robotic assistance. The anastomoses were inspected and probed to confirm patency.

Results: The anastomotic time was 294 +/-16 seconds in group A and 260 +/- 42 seconds in group B (p = 0.094). In the connector group, the times for device loading, positioning/firing and repair of the anvil hole were 116 +/-18, 53 +/-39, 90 +/-12 seconds respectively. All anastomoses in both groups were patent.

Conclusions: Both sewing and device construction produce simulated LIMA-LAD anastomoses of adequate quality. Use of an automatic anastomotic connector may slightly decrease anastomotic time; however, the clinical relevance of this is uncertain.

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P5 Early Experience of Minimally Invasive Totally Endoscopic Robotic-Enhanced Beating Heart and Hybrid Myocardial Revascularization

Vladimir Uspenskiy, Irina Belyaninova, Dmitry Zverev, Jean-Luc Jansens, Michael Gordeev. Almazov Federal Heart, Blood and Endocrinology Centre, St. Petersburg, Russian Federation.

Objective: Robotic-assisted coronary artery bypass grafting (CABG) in patients with ischemic heart disease was intended to improve post-operative recovery and cosmesis by minimizing surgical trauma. We report our early experience with beating heart robotic-enhanced totally endoscopic coronary artery bypass (TECAB) and hybrid minimally invasive myocardial revascularization.

Methods: Since November, 2011 we performed five robotic-assisted CABGs. All patients were males aged 57, 48, 50, 63 and 57 years. Four patients had single-artery lesion (significant stenosis or occlusion of LAD proximal segment). One patient had complex lesion of main LCA, proximal LAD and LCx segments. One patient underwent unsuccessful PCI LAD 3 days prior to TECAB. All patients had normal or slightly enlarged left ventricle, ejection fraction was normal or moderately decreased. No surgical post-infarction left ventricle aneurysm was diagnosed.

Results: Hospital mortality was 0%. One patient required conversion to sternotomy during LIMA harvesting due to inadequate visualization of its distal segment and risk of heart injury. The medium operation time in TECAB cases was 260.00 + 63.38 (165 - 295) minutes. The medium blood loss in ER was 80.00 + 57.15 ml (20 - 150) ml. All patients moved from ER to common ward the next day after surgery. Further post-operative period was uneventful. The patient with complex coronary lesion underwent PCI of left main LCA and proximal LCx on the post-operative day 5 (Figure P5-1). All patients were discharged in good condition on the post-operative day 8.

Conclusions: Robotic-enhanced totally endovascular beating-heart CABG and hybrid approach have potential advantages of providing an efficient myocardial revascularization. Obviously, the reason for conversion was suboptimal port placement. Further investigations, patient selection and gaining experience are needed.



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P6 Clinical Outcomes of Total Endoscopic Coronary Artery Bypass: A Single-Center Experience

Francis P. Sutter 1, MaryAnn A. Wertan1, Khawar Maqsood1, Wajeeha Saeed2, Trisha Senss1, Janet L. Reynolds1, Anny Luong1, Rizwan Sardar1. 1Lankenau Medical Center, Wynnewood, PA USA, 2Montefiore Medical Center, New York, NY USA.

Objective: Totally endoscopic coronary artery bypass (TECAB) is the least invasive form of coronary artery bypass grafting surgery. TECAB, its outcomes, exploring its potential use and selecting the appropriate patient population still need to be evaluated. This new minimally invasive technique has never been compared with robotic-assisted internal mammary takedown with direct visualization coronary artery bypass grafting.

Methods: We retrospectively reviewed consecutive single-vessel robotic coronary revascularization cases from the start of our TECAB experience January 1, 2011 through September 30, 2012; comparing all TECAB procedures with precision incision single-vessel small thoracotomy (SVST) procedures. Simple parametric testing Chi-square and 2 tailed t-test are employed.

Results: TECAB group n=54, have lower mean Society of Thoracic Surgery predicted risk of mortality score 0.01, p=<0.001, less intra and post-op blood transfusion, p=<0.001 and 0.002 respectively, shorter ICU stay 47:42±19:35 hours p=0.003 and more frequent extubation in the OR 92.6%, p=0.02. Fewer required readmission within 30 days of surgery 3.7%, p=0.015. There were comparable total OR duration, post-op atrial fibrillation, renal failure and operative mortality. TECAB was more frequently performed as an elective procedure. Precision incision SVST group n=117, have more patients with history of CHF p=<0.001 but LVEF< 40% was not significant and other baseline characteristics were similar between two cohorts.

Conclusions: Careful case selection and specialized plan of care permits improved outcomes and will further promote the acceptance of robotic-assisted technology in coronary revascularization. TECAB is found to be safe and when performed in the correct patient population will broaden the advantages of robotic technology.

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P7 Comparison of Endoscopic versus Conventional Internal Mammary Harvesting Regarding Unligated Side Branches

Mahmood Reza Sarzaeem, Saleh Sandoughdaran. Cardiac Surgery and Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Objective: In an effort to minimize access in cardiac surgery, endoscopic vessel harvesting has become more popular. The endoscopic approach, however, allows for only the harvest of the mid to distal internal mammary artery (IMA), leaving the more proximal branches of the conduit available for collateral flow away from the coronary bed. The aim of this study was to compare the number and anatomic variation of remaining side branches in thoracoscopic versus conventional internal mammary artery (IMA) harvesting.

Methods: 199 fresh cadavers were randomly divided into two groups. Group A (n=100) underwent endoscopic IMA harvesting. In group B (n=99) IMAs were harvested using an open conventional approach. In both groups during surgery side branches of the IMA were isolated and identified.

Results: The 2 groups were comparable with regard to mean age and age distribution, male sex (56% versus 63%, respectively), cause of death and coronary risk factors including smoking, diabetes, dyslipidemia and hypertension. 24 of 199 cadavers (12%) had a lateral costal branch. The LIMA arose from the third part of the subclavian artery in 6%, and from the thyrocervical trunk in 7% of the cadavers. There were a significantly higher number of unligated side branches in group B, compared with group A (14 branches versus 3 branches, P<0.01).the first intercostal artery and lateral costal artery were found unligated in 3% and 5% of cadavers in group B whereas no side branch remained unligated in group A. There was no subclavian artery or internal mammary artery injury in either group. Internal mammary vein was damaged in 2% of cadavers in group B.

Conclusions: The thoracoscopic LIMA harvesting is more accurate in finding and ligating the side branches of internal mammary artery.

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P8 Long-Term Outcome of Revascularization with Composite T grafts: Is Bilateral Mammary Grafting Better Than Single Mammary and Radial Artery?

Zvi Raviv 1, Rephael Mohr1, Dmitri Pevni1, Yosef Paz1, Amir Kramer1, Nachum Nesher1, Gideon Uretzky1, Yanai Ben-Gal1, Benjamin Medalion2. 1Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel, 2Rabin Medical Center, Petah Tikva, Israel.

Objective: Bilateral internal mammary (IMA) grafting is associated with improved survival. However, many surgeons are reluctant to use this revascularization technique due to the potentially increased risk of sternal infection. The composite T-graft with radial artery attached end-to-side to the left IMA provides complete arterial revascularization without the associated increased risk of sternal infection. The purpose of this study is to compare early- and long-term outcome of these two revascularization strategies.

Methods: Between 1996 and 2001, 1145 consecutive patients (1021 bilateral IMA and 124 single IMA and radial artery) underwent arterial revascularization using the composite T-graft technique.

Results: Occurrence of female sex (36.5% versus 23.8%, radial group versus bilateral IMA, respectively), patients older than 75 (28% versus 17.5%), diabetes (46% versus 34.3%) and COPD (18% versus 5.8%) was higher in the radial group. The radial group also had a higher EuroSCORE (6.64 versus 6.00, p=0.046). On the other hand, CHF (29% versus 15.6%) and recent MI (34.4% versus 16.4%) were more prevalent in the bilateral IMA group. Propensity-score matching was used to account for differences between groups in preoperative patients’ characteristics. The 113-matched pairs thus created had similar preoperative characteristics and similar EuroSCORE (6.57 versus 6.5). Operative mortality of the two groups was similar (0.9% versus 3.5% for the radial and bilateral IMA, respectively). There was a trend for higher occurrence of sternal infection in the bilateral IMA group (0% versus 3.5%, p=0.062). Mean follow-up was 12.5 years. Kaplan Meier 10-year survival (65% versus 73%, p=0.446 Log-Rank test), as well as Cox adjusted survival (p=0.429) of the two groups were similar. Age (HR 0.927, 95% Ci 0.900-0.956), diabetes (HR 2.160, 95% Ci 1.425-3.279) and PVD (HR 2.347, 95% Ci 1.508-3.650) were independent predictors of decreased survival.

Conclusions: This study suggests that long-term outcome of arterial revascularization with composite T-graft constructed using left IMA and radial artery is similar to that of bilateral IMA.

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P9 Minimally Invasive Coronary Bypass Angiographic Patency Study: Safety Results and Outcomes to One Year

Joseph T. McGinn 1, Harry Lapierre2, Masood Shariff1, Benjamin Sohmer2, Nikhil Goyal1, Marc Ruel2. 1Staten Island University Hospital, Staten Island, NY USA, 2University of Ottawa Heart Institute, Ottawa, ON Canada.

Objective: The Minimally Invasive Coronary Artery Bypass Grafting (MICS CABG) Patency Study prospectively evaluated angiographic bypass graft patency 6 months after MICS CABG. The study also assessed complications and outcomes during the first postoperative year.

Methods: The MICS CABG Patency Study was carried out at 2 centers and enrolled a total of 90 patients scheduled to undergo MICS CABG. Through a 4-7 cm left thoracotomy, the left internal thoracic artery (LITA), the ascending aorta for proximal anastomoses, and all distal coronary targets were accessed without endoscopic or robotic assistance. The study’s primary outcome was graft patency at 6 months using 64-slice CT angiography. Feasibility and safety outcomes including conversions to sternotomy and major adverse cardiovascular events (MACE) were prospectively recorded (Clinical Trial Registration Unique identifier: NCT01334866).

Results: Mean age was 64±8 years, and 80 patients (89%) were male. Twenty-seven patients (30%) had diabetes, 28 (31%) had a previous myocardial infarction, and mean ejection fraction was 51±11%. MICS CABG was completed in all patients without conversion to sternotomy, and using semi-elective pump assistance in 24 (27%). Complete revascularization was achieved in all patients, and the median number of grafts was 3 (mean 2.4±0.9). No perioperative mortality or stroke occurred. Transfusion was required in 17 patients (19%), and 2 (2%) were reopened for bleeding. Postoperative atrial fibrillation occurred in 9 patients (10%) and pleural effusions in 13 (14%). Two patients (2%) developed a superficial wound infection. The median length of hospital stay was 4 days, and follow-up to 1 year revealed no mortality or MACE. At 6 months, the overall CT angiographic graft patency was >93% for all grafts, and 100% for LITA grafts.

Conclusions: MICS CABG is feasible, safe, and reveals excellent outcomes in the first-year after surgery. Follow-up will continue in order to ascertain the procedure’s durability.

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P10 Influence of Radial Artery Grafting on Coronary Re-Intervention Rate during Thirteen-Year Follow-Up

Mojyan Safari, Eric Berreklouw, Ibrahim Ozdemir. Catharina Eeindhoven, Eindhoven, Netherlands.

Objective: This study was performed to evaluate coronary re-intervention rate after CABG in patients in whom radial artery graft (Radial Group, 597 patients) or saphenous vein graft (Vein Group, 6542 patients) were used.

Methods: Retrospectively, 7202 patients with triple coronary artery disease who underwent primary CABG with radial or veins were studied with a maximal follow-up of 13 years. The radial was intentionally used in younger patients. Subgroup analysis was done for different patient cohorts.

Results: Late all-cause-mortality was about twice (17.9% vs. 9%) as high in the Vein Group compared with the Radial Group (p < .0001), due to the higher mean age of the patients in the Vein Group; but after adjusting both study groups for age, late all-cause-mortality was similar in both study groups, and use of radial was not a predictor for late mortality. Rates of percutaneous coronary intervention (PCI) and re-CABG were about twice as high (respectively 8.4% vs. 4.6%, p < .0001, and 2.3% vs. 1.1%, p < .0001) in Radial compared to Vein Group. Multivariate analysis of unadjusted study groups, however, showed that use of Radial was not a predictor late coronary re-intervention, but age (p = 0.001), dialysis (p = 0.002), and aortic crossclamp time (p=0.021) were. The results of the study in different subgroups will be presented.

Conclusions: Coronary reintervention rate after CABG is mostly determined by age of the patients at surgery, resulting in significantly more re-interventions in younger patients, but not related to the graft being Radial or Vein.

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P11 Measuring Reperfusion of the Hand of Patients Undergoing Coronary Artery Bypass Surgery Using Laser Speckle Contrast Analysis: An Objective Allen’s Test

Stefan C. Sandker 1, Erwin Hondebrink2, Jan G. Grandjean1, Wiendelt Steenbergen2. 1Thoraxcenter Twente, Enschede, Netherlands, 2Department of Biomedical Photonic Imaging, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands.

Objective: The radial artery (RA) has become a routinely used conduit for coronary artery bypass graft surgery (CABG). Prior to surgery the Allen’s test is performed to test the patency of the ulnar artery (UA). The predictive value of a positive test is 0.53. In this pilot study we investigated if laser speckle contrast analysis (LASCA) provides a more objective determination of the reperfusion time compared to the conventional Allen’s test.

Methods: When the hand is illuminated with a coherent 660 nm 75mW continuous wave laser, the backscattered light will result in constructive and destructive interference consisting of bright and dark areas, speckles. This speckle pattern will change due to movement of red blood cells. LASCA uses these changes to visualize the perfusion during the Allen’s test at 30 frames/second. The average perfusion value of each frame of a 5x5cm2 area on the palmar side of the hand is calculated and set against time (blue line). The reperfusion time is calculated using the first derivative of a 6th order polynomial curve fit (red line). The reperfusion time of the hand of patients undergoing CABG (n=18) is calculated using LASCA and is compared to the conventional Allen’s test performed by the nurse practitioner.

Results: LASCA measurements showed a negative Allen’s test of both hands of eleven patients. Seven had a borderline reperfusion time of 5-6 seconds and/or a positive Allen’s test of one or both hands. These results were in agreement with the conventional Allen’s test. Furthermore, differences in reperfusion of different regions in the measured area were visible. The Figure shows an Allen’s test of a 56- year- old male patient (Figure P11-1)

Conclusions: LASCA is able to visualize perfusion of the hand and measure a quick, moderate, slow reperfusion response or no reperfusion. It is technically feasible to determine the reperfusion time of the hand. LASCA could be a useful and objective tool to assess UA patency prior to harvesting of the RA as a bypass graft.



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P12 Prospective, Randomized, Blinded Trial to Investigate Endothelial Dysfunction in Saphenous Vein Grafts subjected to a MAQUET® Vasoshield Pressure Limiting Syringe versus Non-Regulated Vessel Dilation in Patients Undergoing Coronary Artery Bypass Grafting

Vinod H. Thourani 1, Benjamin Predmore1, Christopher Nickum1, Keith Causey1, Michael Halkos1, John D. Puskas1, Robert A. Guyton1, Omar Lattouf1, Samantha Levine1, Kim Baio1, Pierluca Lombardi2, David Lefer1. 1Emory University School of Medicine, Atlanta, GA USA, 2Maquet Medical, Newark, NJ USA.

Objective: Endothelial damage during EVH of the saphenous vein (SV) may occur during the preparation of the graft secondary to the unregulated dilation of the vessel in order to isolate and clip branch vessels. The objective of this study was to evaluate a novel, pressure-regulated syringe compared to the currently utilized non-regulated syringe.

Methods: Twenty patients undergoing CABG requiring at least 2 SV were prospectively enrolled at an US academic institution from October 2011 to June 2012. EVH was performed by 2 experienced PAs. The harvested SV was transected into 3 pieces, one was used for a Control group and the remaining were randomized to: Vasoshield limiting syringe (Group 1, max pressure 150 mmHg) or non-regulated vessel dilation (Group 2). SV sections were collected in ice-cold K-H buffer and rings of 2-3 mm width were mounted on wires connected to a force transducer in a tissue bath at 37°C. The person performing these tests was blinded to the dilation method. Rings were stretched to a resting tension of 1.5 g over 1 hr. U-46619 (10-6M) was used to constrict the rings, and acetylcholine (Ach, 10-4M) and sodium nitroprusside (SNP, 10-4M) were used to relax the vessel segment. Percent relaxation was calculated based on the U-46619 constriction. A one-way ANOVA or nonparametric Kruskal-Wallis test were performed for statistical significance.



Results: There was a significant difference in the amount of tension generated following addition of U-46619 between Groups. While Control and Group 1 rings did not significantly differ, Group 2 rings generated significantly less tension than other rings indicating impaired function of vascular smooth muscle in those with the un-regulated syringe (Figure P12-1). There were no significant differences between Groups in percent relaxation to the endothelium-dependent vasodilator, Ach, or the endothelium-independent vasodilator, SNP (Figure P12-1).

Conclusions: In small cohort randomized trial, the Vasoshield pressure limiting syringe retains vascular contraction in those SV segments harvested endoscopically when compared to non-regulated vessel dilation. Further structural and morphologic characteristics will be important to ascertain vessel integrity.

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P13 Adventitial Dissection of the Radial Artery Graft: A New Surgical Approach to Reduce Graft Spasm

Stefan C. Sandker 1, Gianclaudio Mecozzi1, Sara C. Arrigoni2, Azuwerus van Buiten3, Massimo A. Mariani2, Hendrik Buikema2, Jan G. Grandjean1. 1Thoraxcenter Twente, Enschede, Netherlands, 2Department of Cardiothoracic Surgery, University Medical Center Groningen, Groningen, Netherlands, 3Department Clinical Pharmacology, University Medical Center Groningen, Groningen, Netherlands.

Objective: Over the last two decades, the radial artery (RA) has become a routinely used graft for coronary artery bypass graft surgery (CABG). A potential disadvantage of the RA is its higher susceptibility to vasospasm compared to other arterial grafts. This tendency to spasm, occurring in 5 to 10% of the patients, has been correlated to a significant proportion of early RA graft failures. It is generally accepted that the adventitia provides structural support to the vessel. Although, in the last decade, several studies have indicated that the adventitia also has an active role in vasomotor tone. In this study we investigated the effects of adventitial dissection of the RA for reducing vasospasm.

Methods: Following harvesting, adventitial dissection was carried out as longitudinal dissection of total adventitia and all bundles of circumferential collagen fibers on the ventral side of the RA using coronary scissors. Surplus radial artery segments (n=35) with and without adventitial dissection and left internal mammary artery segments (LIMA; n=11) of patients undergoing CABG were collected and pairwise assessment of vasoreactivity to potassium chloride, U-46619 and acetylcholine was performed in organ bath experiments.

Results: Full curve and maximal vasoconstriction to potassium chloride (p=0.015 and p=0.001) and U-46619 (p=0.048 and p=0.001) was significantly reduced for adventitial dissected RA compared to non-adventitial dissected RA. Furthermore, vasoconstriction responses of the LIMA were significantly less compared to (non) adventitial dissected RA (p<0.05). Endothelium-dependent relaxation to acetylcholine of adventitial dissected RA was significantly increased (p=0.006) compared to non-adventitial dissected RA. Maximal vasorelaxation to acetylcholine was 33.1±4.6% for adventitial dissected RA compared to 20.9±3.5% for non-adventitial dissected RA (p=0.018) (Figure 1).

Conclusions: The adventitial dissected RA is less susceptible to vasoconstriction and more prone to vasorelaxation ex vivo. Therefore, we recommend to perform adventitial dissection of the RA graft to reduce vasospasm for arterial revascularization in CABG.



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P14 Minimally Invasive, Multivessel, Total Arterial, Off-Pump Coronary Artery Bypass Surgery Through Left Anterolateral Thoracotomy

Anvay Mulay, II, Ashish Gaur, Praveen Kulkarni, Sandeep Sinha. Kokilaben Dhirubhai Ambani Hospital, Mumbai, India.

Objective: Patients who are a long-standing diabetic, rheumatoid arthritis, on immunosuppressant, on steroids, and osteoporotic, in whom wound healing could be potential problem CABG through anterolateral thoracotomy can give them bilateral internal thoracic conduits or total arterial grafts. We evaluated 70 such selected patients who underwent minimally invasive multivessel total arterial off-pump CABG through left anterolateral thoracotomy.

Methods: The procedure was performed using 5-10 cm left anterolateral thoracotomy incision. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y, or LIMA-Radial Y was made to accomplish multivessel total arterial bypass grafting. In one patient saphenous vein was used to graft LAD and LIMA used to graft diagonal as LIMA length was not adequate.

Results: Multivessel, total arterial CABG was accomplished in all selected individuals. There was no mortality, no reexploration for bleeding and no wound dehiscence or wound infection. RIMA was harvested in long-standing diabetic patients with no concern for sternal wound healing. In one individual RSVG used to graft LAD and LIMA was used to graft diagonal as LIMA length was inadequate. In one individual conversion to sternotomy and CPB was required due to unstable hemodynamics. Muscle healing of anterolateral thoracotomy is faster as compared to bone healing of conventional sternotomy incision and patients were back to normal life earlier.

Conclusions: With local immobilization techniques and conventional instruments minimally invasive multivessel, total arterial off-pump CABG can be accomplished in selected individuals safely. RIMA can be harvested in long-standing diabetic patients with no concern for sternal wound healing. Muscle healing of anterolateral thoracotomy is faster as compared to bone healing of conventional sternotomy incision and patients are back to normal life earlier. Also MIDCAB can be salvage procedure for TECAB. So if we have to do TECABS tomorrow we have to do MIDCABS today.

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P15 Minimally Invasive Sternal-Sparing Direct Access Coronary Artery Bypass Grafting

Vikram Goyal 1, Alok Mathur1, Deepika Mishra2. 1Jaipur Heart Institute, Jaipur, India, 2SMS Medical College, Jaipur, India.

Objective: The morbidity of the conventional coronary artery bypass grafting (CABG) has been the major drawback in competing with other revascularization techniques. Over the last decade, attempts at robotic and endoscopic sternal-sparing approaches have met with limited success due to prohibitive cost and lack of reproducibility. We propose the middle path of a direct sternal-sparing approach through a small (3.5 inches) left thoracotomy for multi-vessel revascularization and present our experience of 100 cases.

Methods: Exclusion criteria were distal LAD disease, unstable patient and chronic obstructive pulmonary disease. Chest is entered through fourth intercostal space using a 3.5 inch incision. LIMA is dissected under direct vision using specially designed retractors. For CPB-assisted patients, femoral artery and vein are cannulated. Proximal anastomosis is next constructed under direct vision on the aorta.

Results: 100 patients underwent CABG through a small left thoracotomy between June 2010 and August 2012. 27 had single, 42 had double and 31 had triple vessel disease. Femoral cardiopulmonary bypass was used in 58 patients and the remaining patients had off-pump surgery. The mean age was 64±6 years. Fifty-eight percent were diabetic. The mean number of grafts was 2.4±0.7. The average blood transfusion requirement was 1.1±0.8 units. The mean intensive unit stay was 2.1±1.3 days. The mean hospital stay was 4.5±2.3 days. There were no deaths or wound infections.

Conclusions: Minimally invasive sternal-sparing direct-surgical revascularization combines the benefit of a direct vision good anastomosis with the morbidity of percutaneous intervention. It is safe, reproducible and cost-effective due to shortened intensive care and hospital stay.

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P16 Hemi-Sternotomy Approach for Off-Pump Coronary Artery Bypass Grafting: The New Minimally Invasive Direct Coronary Artery Bypass Grafting?

Gary S. Allen, David Corda, Michael Arizola, Tuwana Phelps-Keaton. Florida Hospital Waterman, Tavares, FL USA.

Objective: Minimally invasive direct coronary artery bypass grafting (MIDCAB) through a left thoracotomy has several shortcomings. Among them are significant wound pain, limited grafting targets, reduced graft patency, and poor adaptability. We report our early experience with OPCAB through a partial sternotomy for multivessel disease to assess safety and feasibility.

Methods: From March 2012 to June 2012 twenty-eight consecutive patients underwent OPCAB via an “L” shaped lower sternotomy incision through the third intercostal space. Tissue stabilization was achieved via port access and using the Medtronic Endooctopus system (Medtronic, Minneapolis, MN USA). Proximal anastomoses were performed with the Heartstring III proximal seal system (MAQUET, Wayne, NJ USA).

Results: The mean age was 68.3 years with 21 (75%) male patients. There were no conversions to full sternotomy or to an “on-pump” technique. Patients received an average of 2.7 grafts (range 1 to 5) of which one was single, 10 were double, and 17 were three or more grafts. Mean operating time was 194.6 min ± 59.1 (STDEV). All intended targets were successfully grafted. Three (10.7%) patients received a red blood cell transfusion. Seven (25%) patients required temporary inotropic support. Mean extubation time was 5.7 hr ± 4.1. There was no 30-day mortality. There were no postoperative myocardial infarctions, cerebrovascular accidents, or graft revisions.

Conclusions: Limited target access, graft inaccuracies and a slow learning curve have limited the adoption of MIDCAB. Our early experience with a partial sternotomy approach to OPCAB employs easily adaptable surgical techniques allows unobstructed visualization of all grafting territories while adding only a small increase to operating time. Hemi-sternotomy approach for off-pump CABG is safe, feasible and may offer similar benefits to other small incision approaches.

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P17 Off-Pump Technique Reduced Operative Mortality and the Incidence of Major Complications in Redo Coronary Artery Bypass Grafting: A Propensity-Score Analysis from a Japan Cardiovascular Surgery Database

Masahiro Dohi 1, Kiyoshi Doi1, Hiroaki Miyata2, Noboru Motomura3, Shuhei Fujita1, Suguru Ohira1, Hidetake Kawajiri1, Tsunehisa Yamamoto1, Taiji Watanabe1, Kazunari Okawa1, Shinichi Takamoto3, Hitoshi Yaku1. 1Department of Cardiovascular & Thoracic Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan, 2Department of Healthcare Quality Assessment Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, 3Department of Cardiac Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan.

Objective: The benefits of off-pump coronary artery grafting (OPCAB) have been demonstrated, especially in patients with high co-morbidity. Redo CABG is still a difficult entity of CABG, because patients are likely have multiple risk factors and often have diseased patent grafts in adhesion. The aim of the present study was to evaluate the effects of the OPCAB technique on mortality and morbidity of CABG from a Japan Cardiovascular Surgery Database (JCVSD).

Methods: We analyzed 46,576 patients who underwent isolated CABG through JCVSD between 2005 and 2011. Of these, we identified 892 (1.92%) patients who underwent redo CABG, including those who underwent OPCAB (n = 524; 58.7%) and on-pump CABG (n = 368; 41.3%). We used propensity-score (PS) matching with 13 preoperative risk factors to adjust for differences in baseline characteristics between the OPCAB and on-pump CABG groups. By one-to-one PS matching, we selected 200 pairs of OPCAB and on-pump CABG.

Results: There were no significant differences in patient background between the OPCAB and on-pump CABG groups after PS matching. The patients in the OPCAB group had a lower tendency in 30-day mortality although there were no significant difference between two groups (3.5% vs. 7.0%; P = .177). The OPCAB group had a significantly lower rate of composite mortality and major morbidities (11.0% vs. 21.5%; P = .006), prolonged ventilation (>24h) (7.0% vs. 15.0%; P = .016), shorter duration of intensive care unit (ICU) stay (the number of patients who stayed in the ICU for more than 8 days) (7.0% vs. 14.5% days; P = .023), and shorter mean operative time (353.7 min vs. 441.3 min; P < .0001) than the on-pump CABG group.

Conclusions: The off-pump technique reduced early operative mortality and the incidences of major complications in redo CABG.

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P18 Perioperative Outcomes of Minimally Invasive Coronary Artery Bypass Compared to Sternotomy Coronary Artery Bypass Grafting

Limael E. Rodriguez, Dewei Ren, Basel Ramlawi, Mahesh Ramchandani. Methodist DeBakey Heart and Vascular Center, Houston, TX USA.

Objective: Minimally invasive coronary artery bypass (MICS CAB) is a well established technique for revascularization. Studies have shown excellent long-term graft patency with these techniques. This study compares perioperative data of consecutive patients who underwent MICS CAB on the beating heart versus sternotomy coronary artery bypass grafting (CABG).

Methods: Sternotomy CABG was compared to mini-thoracotomy MICS CAB, which was performed both with and without cardiopulmonary bypass (CPB). Consecutive cases from May 2009 to April 2012 were reviewed from the STS database and analyzed for demographics, risk factors, and other covariates.

Results: Most MICS CAB procedures were ≤ 2 vessel bypass, while CABG procedures were primarily >2 vessels. MICS CAB patients had more previous percutaneous coronary intervention (PCI) and/or CABG. Sternotomy CABG used more blood products and had significantly longer total ventilator times. MICS CAB subjects had reduced operative time (22%), ICU time (26%), and length of stay (29%; p<0.001). There were no significant differences in complications, intraoperative mortality, or 30-day post-operative mortality between the two groups. The average total cost of hospital admission including surgical fees was $45,065 for MICS CAB versus $49,745 for sternotomy CABG.

Conclusions: Compared to sternotomy CABG, MICS CAB offers several perioperative benefits, including reductions in length of stay, need for hemodynamic supportive measures, postoperative recovery time, and total operating cost. MICS CAB can be performed safely with low perioperative morbidity or mortality comparable to CABG. Our data demonstrates significant clinical, logistical, and overall benefits of MICS CAB when employed in an experienced care center.

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P19 Long-Term Follow-Up of Off-Pump and On-Pump Coronary Artery Bypass Grafting

Shahzad G. Raja 1, Dimple Chudasama2, Siobhan Daley2, Mubassher Husain1, Mohamed Amrani1. 1Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom, 2Department of Quality & Safety, Harefield Hospital, London, United Kingdom.

Objective: Despite increasing recognition of the benefits of off-pump coronary artery bypass grafting concerns persist regarding its impact on long-term mortality and freedom from re-intervention. In this study we assessed the impact of off-pump coronary artery bypass grafting on long-term outcomes.

Methods: From January 2002 to December 2002, 307 consecutive patients that underwent isolated multi-vessel off-pump coronary artery bypass grafting at our institution were compared to a control group of 397 patients that underwent multi-vessel on-pump coronary artery bypass grafting during the same period. Peri-operative data was prospectively collected and compared. In-addition, univariate and risk-adjusted comparisons between the two groups were performed at 10 years.

Results: After adjusting for clinical covariates, off-pump coronary artery bypass grafting did not emerge as a significant independent predictor of long-term mortality (Hazard Ratio 0.91; 95% Confidence Interval 0.70-1.12), readmission to hospital for cardiac cause (Hazard Ratio 0.96; 95% Confidence Interval 0.78-1.10) or the need for re-intervention (Hazard Ratio 0.93; 95% Confidence Interval 0.87-1.05).

Conclusions: At long-term follow-up, off-pump coronary artery bypass grafting remains a safe and effective myocardial revascularization strategy with no adverse impact on survival or freedom from re-intervention.

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P20 Best Practice in Hybrid Coronary Revascularization

Stephan Jacobs, Simon Sündermann, Volkmar Falk. Department of Cardiovascular Surgery, University of Zürich, Zürich, Switzerland.

Objective: Here we report the results of 30 patients, scheduled for hybrid revascularization and PCI to non-LAD vessels.

Methods: From April 2011, revascularization of the left anterior descending artery was performed in 30 patients by minimally invasive direct coronary artery bypass grafting (MIDCAB) followed by percutaneous coronary intervention (PCI) of vessels other than the left anterior descending artery in a single procedure. All operations were performed in a surgical hybrid suite. MIDCAB was performed first followed by PCI using drug eluting stents (DES).

Results: MIDCAB and stenting were completed in all patients as planned. Mean age was 64.4 years. Preoperatively calculated mean EuroSCORE (European System for Cardiac Risk Evaluation) was 4.04%. 30% of the patients received coronary interventions at two non-LAD vessels. Angiography confirmed patency of all LIMA grafts. Mean intervention time was 120.35 minutes. No thoracotomy for bleeding was required, nor need for blood cell products obtained. Mean ICU stay was 0.83 days with an intubation time of 2.8 hours and hospitalization of 7.64 days. Kaplan-Meier survival was 100% (95% confidence interval [CI]: 93.8% to 98.4%) at 1-year. Freedom from major adverse cardiac and cerebral events (including reintervention) and angina was 100% (95% CI: 96.9% to 99.1%) at 1-year.

Conclusions: Minimally invasive hybrid coronary revascularization, combining MIDCAB and PCI to non-LAD vessels, is a safe approach with excellent short-term results.

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P21 Venoarterial Extracorporeal Membrane Oxygenation: Simplified Tunneled Technique Using Arterial Grafting and Saphenofemoral Cannulation

Keith B. Allen, A. Michael Borkon, Sanjeev Aggarwal, Michelle Haines, J. Russell Davis, Troy Sydzyik, Alex Pak, Jim Stewart, R. Scott Stuart, Kelsey E. Allen. St. Luke’s Hospital, Mid-America Heart and Vascular Institute, Kansas City, MO USA.

Objective: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has experienced resurgence; however, cannulation site morbidity including bleeding, infection, and limb ischemia remain problematic. We describe a novel approach using a tunneled graft sewn to the common femoral artery (CFA) and venous cannulation through the saphenofemoral junction (SFJ) that offers decreased morbidity and simplifies decannulation.

Methods: From June 2009 through Dec 2012, VA-ECMO was instituted in 26 patients using a Quadrox Oxygenator (Maquet, Wayne, NJ USA) and a Revolution Pump (Sorin, Arvada, CO USA). Salvage patients were emergently cannulated percutaneously; however, in our most recent 9 non-salvage patients VA-ECMO was established with a femoral cut down with these modifications. Venous cannulation was achieved by isolating the SFJ and placing a 0.35 guide wire from the anterior thigh into the saphenous vein approximately 2 cm distal to the SFJ. A 25 F Bio-Medicus (Medtronic, Minneapolis, MN USA) cannula was then advanced into the right atrium with echo guidance. Arterial cannulation was achieved by sewing an 8 mm Hemashield (Maquet, Wayne, NJ USA) graft to the CFA which was then tunneled to the anterior thigh. A 22 F Optisite Arterial Cannula (Edwards, Irvine, CA USA) was inserted into the graft with the tip of the cannula placed just outside the CFA to avoid distal limb ischemia (Figure P21-1).

Results: There were no (0/9) cannulation-related complications with this technique including no bleeding, infection, or limb ischemia. Average time required to establish VA-ECMO was 32 minutes. Average time on VA-ECMO was 10 days. Survival to discharge was 67% (6/9). Among survivors, decannulation was uneventfully completed at the bedside in three patients and in the operating room in three patients.



Conclusions: VA-ECMO can be safely established using a tunneled femoral approach with venous cannulation through the saphenofemoral junction and an arterial graft to the common femoral artery. This technique simplifies decannulation and may decrease common cannulation complications such as bleeding, infection, and limb ischemia.

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P22 Test Bench Results of a Novel Pediatric Biventricular Assist Device

Stéphanie F. Perrodin, Mathieu Van Steenberghe, Piergiorgio Tozzi. CHUV, Lausanne, Switzerland.

Objective: Ventricular assist devices (VAD) are widely used for the treatment of acute and chronic heart failure in children. Most pediatric devices are extracorporeal centrifugal pumps. Research currently focuses on miniaturizing axial pumps to make them entirely implantable. To suppress the need for extensive surgery and long-term anticoagulation we developed an external biventricular assist device for children made of Nitinol. The aim of this study is to evaluate the performance of this device in a test bench.

Methods: Coiled Nitinol wires were attached vertically between two discs at the apex and base of a heart model and powered by a generator. Ejection fraction, heart rate, cardiac output and generated systolic pressure were measured at various settings of preload and afterload.

Results: The test bench settings where the following: end-diastolic volume of heart model 26 ml, preload range 0 - 15 mmHg, afterload range 0 - 160 mmHg. The power supply was 35 V and 3.5 A during 1.5 seconds. With a diastole lasting 1.5 seconds, the maximal heart rate was 20 beats per second. The ejection fraction range was 1.2 - 34.4% depending on the afterload, and the cardiac output 6 - 180 ml/min.

Conclusions: External biventricular assistance in children is technically feasible. This device could be implanted through minimally invasive surgery and wouldn’t require anticoagulation therapy. It could support the failing heart once every third beat and significantly improve the patient’s symptoms and quality of life.

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P23 Combined Functional Mitral Valve Surgery and Coronary Artery Bypass Grafting in Patients With Severe Impaired Left Ventricles is Still a Challenge

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

Objective: The goal of this study was to analyze the outcome of complex mitral valve (MV) pathology and concomitant coronary arterial bypass graft (CABG) in patients with severe ischemic cardiomyopathy.

Methods: Within the last decade 380 patients (288 male) with severe functional MV pathology and systolic dysfunction (mean ejection fraction 24.84 ± 6.18%) underwent MV surgery combined with CABG. Mean logistic EuroSCORE was 19.1%. Of all patients 18.7% were in cardiac shock.10% were in a critical preoperative state and 12.1% were operated on as an emergency. Operative data, 30-day mortality and long-term outcome, MV related re-intervention and complications were retrospectively gathered. Follow-up was made with a mean time span of 1328 days (range 7-4198).

Results: MV repair could be done in 88% of patients successfully, mostly using Carpentier-Edwards Physio Ring Model 4450 and Carpentier-Edwards IMR Etilogix-Ring in 57.6% and 24.8%. Of the 45 patients with MV replacement, 32 received a biological and 13 a mechanical valve. Operation-, bypass- and cross-clamp time was 326.1 ± 77.5, 134.8 ± 47.0 and 80.7 ± 28.3 minutes respectively. Postoperatively 20% of the patients needed an IABP and 2.6% were obtained with an ECMO. Thirty-day mortality was 12.9% with a follow-up of 99.5%. Long-term mortality at 1, 5 and 10 years was 25%, 41.1% and 51.3% respectively. MV-related reoperation rate was 7.4%. MV replacement was done in 10 patients (2.6%) and MV repair in 2 patients (0.5%) with a mean postoperative reoperation time of 591 and 55 days respectively. A revision CABG was necessary in 4 patients (1.1%) at a median of 0.5 days postoperatively. 13 reoperations were done for other purposes such as aortic valve replacement, ventricular assist devices or heart transplantation.

Conclusions: Considering the impaired LV function and the clinical scenario of these patients, the combined complex MV surgery in addition to CABG is still challenging. However an appropriate early and long-term outcome can be obtained.

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P24 Early Outcomes in Minimally Invasive Mitral Valve Surgery and Depressed Ejection Fraction: An 8-Year Experience

Antonio Miceli, Michele Murzi, Matteo Ferrarini, Raffaele Fugà, Simone Simeoni, Alfredo G. Cerillo, Stefano Bevilacqua, Pier A. Farneti, Marco Solinas, Mattia Glauber. Fondazione Toscana G. Monasterio, Massa, Italy.

Objective: The beneficial effect of minimally invasive mitral valve surgery (MIMVS) has been well documented in patients with normal left ventricular ejection fraction (LVEF). However, few studies have examined outcomes of MIMVS in patients with depressed LVEF. The aim of our study was to evaluate our experience with MIMVS in patients with LVEF <35%.

Methods: From June 2004 to December 2012, 1240 patients underwent MIMVS. Of these, 63 patients had a LVEF <35%.

Results: Thirty-day mortality was 1.6% with a median predicted EuroSCORE of 14 (interquartile range [IQ] 8-18). Mean age was 69±10 years and mean LVEF was 32±3%. Seven patients (11%) had redo surgery. Functional mitral regurgitation (MR) was present in 30 patients (47%) and degenerative MR in 24 patients (38%). Two patients required surgery for active endocarditis and 3 patients had prostheses mitral valve dysfunction. Thirty-five patients (53%) underwent mitral valve replacement and 28 (44%) patients underwent mitral valve repair. Combined procedure was: tricuspid repair (n=6, 10%) and atrial fibrillation surgery (n=4, 6%). The median ventilation time was 10 hours (IQ range 6-20), as well as the median for intensive care unit and hospital stay was 2 days (IQ range 1-3) and 7 (IQ range 6-9). Two patients had a postoperative stroke, incidence of postoperative atrial fibrillation and blood transfusion was 30% (n=19) and 16% (n=10).

Conclusions: Minimally invasive mitral valve surgery in patients with depressed LVEF is a safe approach and can be achieved with low operative mortality and morbidity.

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P25 Adjunctive TMR with CABG: Does TMR as an Adjunct to CABG Impact on Outcomes of Operations

Ilia Berishvili, Leo Bokeria. Bakoulev Cardiovascular Scientific Center, Moscow, Russian Federation.

Objective: TMR as an adjunct to CABG is an effective procedure in patients with advanced CAD. However, the mechanisms that underlie these results remain controversial. The study was undertaken to evaluate perioperative and late efficacy of patients with CABG alone (I group) versus CABG plus TMR (2 group).

Methods: Between 1999 and 2009 we selected 172 patients for TMR+CABG for evident diffuse lesions of CA in patients with viable myocardium. Group I patients (n=18) underwent CABG alone. Other 154 patients (group 2) underwent TMR plus CABG. Hospital results and late outcomes (mean 62.6 +11.4 months) of the two groups were compared.

Results: A strong trend toward reduced operative mortality (22% vs. 4%) was observed after CABG+TMR compared with CABG alone. Significant difference was found between groups in terms of in postoperative variables (MI, low cardiac output and need in postoperative IABP support) (4.5% versus 11.1% and 2.6% versus 16.6%, respectively). Within the 5-year follow-up overall treatment success, defined as survival rate (94.2% vs. 72.2%) freedom from MI (98.1% vs. 85.7%) and recurrent angina (98.7% vs. 75.9%) was significantly better in the second group. In CABG alone group requirement in nitrates were also higher (2.3 vs. 1.16 and 30.0 vs. 2.15 respectively). On the contrary, LV EF and exercise tolerance were worse in group I (52.6 vs. 57.4; 84.1 vs. 85.6 respectively). We did not notice the improvement of perfusion in group I. Furthermore, the rates of psychoemotional condition were worse in group 1.

Conclusions: This study suggests that TMR performed adjunctively to CABG in patients not amenable to CABG alone has yielded significantly improved outcomes. Considering comparability of demographic and baseline variables and equal evidence of CAD (initially all patients were selected for TMR+CABG), we conclude that TMR allows to improve efficiency of surgery when used as adjunct to CABG in such category of patients. The mechanism for TMR is likely multifactorial with denervation and vasodilatation of CA responsible for the perioperative benefits and angiogenesis with improvement of perfusion for the long-term success.

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P26 Robotically-Assisted, Completely Endoscopic Transmyocardial Revascularization using an Optical Fiber-Based Laser Delivery System is Safe and Efficacious

Louis A. Brunsting, III 1, Averel B. Snyder2, Eric E. Espinal3, Sudhir P. Srivastava4. 1University of Alabama at Birmingham, Birmingham, AL USA, 2St. Joseph’s Hospital, Atlanta, GA USA, 3Summa Health System, Akron, OH USA, 4The International Centre for Robotic Surgery, New Delhi India.

Objective: Sole therapy transmyocardial revascularization (TMR) is effective treatment for refractory angina in patients who are not candidates for further direct coronary revascularization options, yielding improved survival over maximal medical therapy. The need for either sternotomy or thoracotomy incisions has limited application of TMR. The purpose of this study was to assess the procedural success and safety of an endoscopic, optical fiber-based, laser delivery system (LDS), developed to perform sole therapy TMR in a totally endoscopic, robotically-assisted operation.

Methods: Forty-two patients were enrolled in a multi-center, prospective, single-arm clinical trial conducted at 4 U.S. centers between 2005 and 2007. TMR was performed completely endoscopically with robotic assistance, introducing the Ho:YAG LDS via a 5 mm port. Completion of the operation endoscopically defined procedural success. Clinical data and adverse events were recorded before, during, and at least 30 days following the procedure.

Results: All patients had CCS angina Class IV at baseline. Average EF was 49% (R:28-71), mean age 59.1 year (R:36-80), 71% (30/42) were male, previous CABG surgery 86% (36/42), and prior coronary stenting in 76% (32/42). Procedural success was accomplished in 93% (39/42), with 3 conversions to thoracotomy: excessive adhesions (2) and obese body habitus (1). For the procedural successes, average number of TMR channels was 32 (R:16-50), mean operative time was 106 min (R:48-250 min), and mean length of stay postoperatively was 3.8 days (R:2-11). There was no operative or 30-day mortality. No patient required re-exploration for bleeding or transfusion. At 30 days, freedom from major adverse cardiac events was 95% (2 patients had transient congestive heart failure). At median six-month follow-up (single center data, n=12), mean CCS angina score was 1.3±0.05 (p<0.001 vs. baseline).

Conclusions: Robotically-assisted TMR can safely be performed using an endoscopic, optical fiber-based LDS, with high-procedural success, avoidance of adverse clinical events, and successful angina relief.

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P27 Atrial Septal Defect Closure in Adults Through a Right Thoracotomy

Narihiro Ishida, Katsuya Shimabukuro, Yukihiro Matsuno, Hiroki Ogura, Toshiya Higashi, Hirofumi Takemura. Graduate School of Medicine, Gifu University, Gifu City, Japan.

Objective: Minimally invasive approaches have become a feature of cardiac surgery. We compared the outcomes of atrial septal defect (ASD) closure in adults through either a right thoracotomy (RT) or a median sternotomy (MS).

Methods: We compared the characteristics, perioperative factors and early outcomes of patients who underwent ASD closure to repair ostium secundum defects through either an RT (n = 11) or an MS (n = 7). Cardiopulmonary bypass (CPB) was established in the RT group via unilateral or bilateral femoral arterial cannulation. The ASD was closed directly or with an autologous pericardial patch in both groups.

Results: Age, sex, body mass index and mean pulmonary arterial pressure did not significantly differ between the two groups, whereas preoperative Qp/Qs was significantly higher in the RT than in the MS group (2.95 ± 0.52 vs. 2.21 ± 0.75, p = 0.03). The perioperative durations of CPB and of cardiac arrest were longer in the RT than in the MS group (98 ± 32 vs. 45 ± 16 min, p = 0.001 and 42 ± 14 vs. 23 ± 9 min, p = 0.02, respectively), but the amount of intraoperative blood loss was lower in the RT than in the MS group (96 ± 53 vs. 209 ± 142 mL, p = 0.03). All patients underwent autologous blood transfusion. Early mortality rates, intubation time, length of ICU stay or hospitalization, and both total amount and duration of blood drainage did not significantly differ between the two groups. Laboratory findings revealed no significant differences in white blood cell counts and levels of C-reactive protein. Postoperative paroxysmal atrial fibrillation occurred in one and two patients in the RT and MS groups, respectively, but this was not a significant difference.

Conclusions: The outcomes of ASD closure through an RT were comparable with outcomes achieved with an MS, suggesting that the RT method is a safe and effective alternative to an MS for safe ASD closure in adults.

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P28 Transmitral Septal Myectomy for Subvalvular Aortic Stenosis: Minimally Invasive Solution

Daniyar Gilmanov, Stefano Bevilacqua, Marco Solinas, Matteo Ferrarini, Enkel Kallushi, Pier Andrea Farneti, Mattia Glauber. G. Monasterio Tuscany Foundation, G. Pasquinucci Heart Hospital, Massa, Italy.

Objective: Transaortic left ventricular septal myectomy described by Morrow is classical procedure for the treatment of systolic anterior motion of the mitral apparatus associated with hypertrophic obstructive cardiomyopathy (HOCM). We reviewed our results of transmitral septal myectomy and mitral valve repair/replacement in minimally invasive setting.

Methods: Between 2005 and 2012, 16 patients (37.5% men, mean age 68.1±14.2 years) were treated with minimally invasive approach for degenerative mitral regurgitation (MR) and HOCM. Preoperative peak left ventricular outflow tract gradient was 61.4±23 mm Hg. Severe MR was diagnosed in 13 cases (81%). New York Heart Association functional class III-IV heart failure was present in 11 patients (69%). 2 patients of this series were previously operated on for septal myectomy and 1 for aortic valve disease (reintervention cohort - n=3; 19%).

Results: 14 patients (87.5%) underwent mitral valve replacement and 2 patients for mitral valve repair. Video-assisted right anterolateral minithoracotomy, central arterial cannulation into the ascending aorta and transfemoral venous cannulation were standard setups for procedure. LVOT obstruction was corrected directly in all patients via the mitral valve with septal myectomy/myotomy, avoiding aortotomy in majority of the patients (n=15, 94%). No significant prolongation of extracorporeal circulation/aortic cross clamping times was observed (p=0.36) when compared with similar population without HOCM. No iatrogenic ventricular septal defect developed in treated patients (0%). No hospital mortality occurred (0%). Resting LVOT gradient reduced at discharge to 15±23 mm Hg (p<0.03). Median hospital stay length was 7 days.

Conclusions: Transmitral left ventricular septal myectomy in patients with degenerative mitral valve disease is quite simple, feasible and effective technique and does not require aortotomy in the most of cases. It can be performed with low early mortality and satisfactory resolution of LVOT obstruction in minimally invasive setting.

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P29 Adverse Effect of Manipulation of the Ascending Aorta on Stroke after Off-Pump Coronary Artery Bypass Surgery

Takeshi Kinoshita, Tohru Asai, Tomoaki Suzuki. Shiga University of Medical Science, Otsu, Japan.

Objective: We retrospectively examined the adverse effect of manipulation of the ascending aorta on stroke after off-pump CABG.

Methods: Of 1006 consecutive patients underwent isolated CABG between January 2002 and August 2012, we studied 1000 patients who underwent off-pump CABG without conversion to cardiopulmonary bypass during surgery. We excluded the remaining 6 patients who required emergent PCPS support at other hospitals for cardiac arrest caused by AMI and were then transferred to our hospital, where they underwent emergent CABG with PCPS support. Stroke was defined as a postoperative central neurological deficit lasting >24 hours confirmed by MR scan that resulted in irreversible body impairment. Vein-to-aorta anastomosis was performed using partial clamping or an anastomotic device after assessing the severity and location of atherosclerosis of the ascending aorta using CT scan and epiaortic ultrasonography. Propensity score was created to quantify the likelihood that manipulation of the aorta would be performed in a given patient using a multivariate logistic regression based on the following even variables with a significant level of < 0.05 in bivariate analyses: age, female gender, body mass index, smoking, hyperlipidemia, chronic kidney disease, previous myocardial infarction, and preoperative intra-aortic balloon pumping (C statistics, 0.74; Hosmer-Lemeshow goodness of fit chi square, 5.92, p=0.657).

Results: The incidence of stroke was 1.1% of all patients (11/1000), 2.0% of patients who did receive the manipulation of the ascending aorta (8/414), and 0.5% of patients who did not (3/586). The risk factors statistically significant in a multivariate logistic regression model were manipulation of the ascending aorta (odds ratio, 2.22; 95% CI, 1.55 to 5.55; p=0.001), history of stroke (odds ratio, 3.59; 95% CI, 1.75 to 7.12; p=0.001), and estimated glomerular filtration rate <60 mL/min/1.73 m2 (odds ratio, 4.76; 95% CI, 2.15 to 7.31; p=0.001). Propensity score-adjusted odds ratio (95% CI) of manipulation of the ascending aorta for the association with postoperative stroke was 2.73 (1.44 to 5.82).

Conclusions: Manipulation of the ascending aorta needs to be avoided to further reduce the risk of stroke after off-pump CABG.

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P30 Short-Term Results of Enclose II in Off-Pump CABG: Comparison with the Conventional Aortic Clamping Technique

Susumu Manabe, Kenji Sakai, Chieko Shibuya, Shogo Sakurai, Shuhei Fujita, Tatsuki Fujiwara, Taiju Watanabe, Hideto Kuroki, Tsuyoshi Hachimaru, Satoru Kawaguchi, Tomohiro Mizuno, Hirokuni Arai. Tokyo Medical and Dental University, Tokyo, Japan.

Objective: Stroke is a devastating complication after CABG, and its major cause is considered a cerebral embolization mostly due to aortic-clamping. The clampless proximal anastomosis device Enclose II is expected to minimize the aortic manipulation, but its impact on the short-term results is yet to be determined.

Methods: Medical records of 303 patients who underwent off-pump CABG were retrospectively reviewed. Enclose II was used in 217 patients and aortic-clamping was performed in 86 patients.

Results: There were no differences in in-hospital mortality rate (Enclose: 0.5% vs. clamp: 0%, p=1.00) and in stroke rate (Enclose: 0.5% vs. clamp: 1.2%, p=0.49). The etiologies of strokes in Enclose group and in clamp group were due to postoperative cerebral emboli due to atrial fibrillation and intraoperative emboli due to aortic-clamping, respectively. There was no difference in patency rate between the grafts anastomosed with Enclose II (Overall: 94.8%; SV: 94.7%, RA: 94.4%, GEA: 100%) and those with aortic-clamping (Overall: 94.1%; SV: 89.0%, RA: 100%).



Conclusions: After the introduction of Enclose II, the incidence of intraoperative cerebral emboli has decreased. Enclose II is considered an effective tool which can minimize aortic manipulation without compromising the quality of the anastomosis.

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P31 Left Ventricular Remodeling after Minimal Mitral Valve Reconstruction: A Prospective cMRI and 3D TEE Study

Inna Kammerer, Armin Vomend, Bernd Cornelius, Günther Layer, Falk-Udo Sack. Academic City Hospital Ludwigshafen, Ludwigshafen, Germany.

Objective: The aim of this prospective study is the evaluation of the postoperative remodeling of the left ventricle (LV) after mitral valve reconstruction (MVR) in patients with isolated mitral valve disease.

Methods: Since 2011 36 patients were enrolled. In a prospective trial, LV geometry was assessed by the cardio magnetic resonance imaging (cMRI) and the real-time 3-dimensional echocardiography (3D TEE) pre- and postoperatively. Of these, 27 (75%) were men, the mean age was 60 + 16 years. Minimal invasive operation technique (MIC) was done in more than 86% of MVR.

Results: One patient died 4 months after MVR due to an aortic dissection Stanford A. The 1-year freedom from reoperation or severe recurrent insufficiency was 86% (n=31). The mean ischemia time observed 77 + 20 min, the mean hospital duration was 9 + 3 days. The mean ring size was 34 mm by 83% (n=30) of posterior leaflet correction with ring, 14% (n=5) only ring without leaflet surgery and 3% (n=1) anterior leaflet rectification. The end-systolic and -diastolic volumes in cMRI measurement observed incurred levels in hospital history: EDV 161 + 37 ml (preOP) vs. 124 + 24 ml (postOP), ESV 61 + 16 ml vs. 56 + 18 ml. Other remodeling parameters from 3D TEE and cMRI showed no differences in methods and in early postoperatively results (Table P31-1).

Conclusions: Measurements of ventricular geometry with 3D TEE and cMRI proved to be important imaging tools in assessing reverse LV remodeling. There is a clear tendency for postoperative remodeling. Long-term follow-up (1 year) will provide more information of the dynamics of this process.

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P32 Preoperative Computerized Tomographic Angiograpy Prevents Stroke in Minimally Invasive Cardiac Surgery

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

Objective: Stroke is one of the most devastating complications of cardiac surgery. We proceeded to evaluate the role of computerized tomographic angiography (CTA) in patients undergoing minimally invasive cardiac surgery (MICS).

Methods: Retrospective review of 213 MICS performed by a single surgeon at a single institution over a period of 36 months and evaluation for cerebral events with a permanent deficit. A protocol has been developed at our institution whereby all patients undergoing MICS, i.e., minimally invasive aortic or mitral valve surgery or robotic-assisted valvular or coronary artery bypass surgery will have a CTA performed to rule extensive arterial calcification and the assessment of caliber of the vessels.

Results: In this series of 213 patients, there were 72 minimally invasive aortic valves (mAVR), 73 minimally invasive mitral valves (mMVR), 47 robotic-assisted CABG performed and the rest of the 21 patients were miscellaneous including minimally invasive pulmonary valve replacement, removal of tricuspid valve fibroelastoma, etc., 40% of these patients were ≥ 75 years of age. In every case, when there were extensive calcifications identified on CTA, we would change the arterial inflow site from femoral to right axillary approach (10% cases). There was only one single major stroke in an 84-year-old with permanent right-sided hemiplegia. There were two other patients with a transient neurologic deficit but with full recovery.

Conclusions: Preoperative CTA helps identify patients at high risk for stroke, especially in the elderly population. It should be an essential part of the work-up of all patients undergoing MICS.

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P33 Mitral Valve Overlay Facilitates Beating Heart Transatrial Annuloplasty in an Acute Animal Trial

Philipp Kiefer, Thilo Noack, Marcel Vollroth, Joerg Ender, Friedrich W. Mohr, Joerg Seeburger. Heart Center Leipzig, Leipzig, Germany.

Objective: Transcatheter mitral valve (MV) interventions are of great interest. However, optimal imaging modalities are lacking. We, therefore, aimed to evaluate 3D rotational angiography (Dyna-CT) for MV imaging and navigation of a transcatheter mitral annuloplasty device.

Methods: An acute animal swine model (n=6) was established. Pigs were anesthetized and operated using a 3 cm left-sided mini-thoracotomy through the 4th or 5th intercostal space. 3D rotational angiography using rapid ventricular pacing was performed. A 3D-overlay of the left atrium (LA), the MV-annulus and the MV-leaflets was implemented in the fluoroscopic screen. Additionally, the coronary sinus was marked using a standard pacemaker wire. A transcatheter sutureless annuloplasty band (Cardioband, Valtech-Cardio Ltd) was introduced through an 18F sheath in the left atrium and sequentially anchored to the annulus under 3D model guidance only. After size adjustment, the device was removed and the atrium closed by purse-string suture. Postprocedural Dyna-CT and sacrifice of all pigs where then performed for validation of device-positioning.

Results: All annuloplasty implants could be placed successfully on the posterior MV annulus. In two the band was also attached directly to the hinge of the leaflet, however, without functional impairment. There was no intraoperative death or iatrogenic damage caused by the flexible delivery system. Postprocedural Dyna-CT and necropsy showed optimal positioning of the annuloplasty device.

Conclusions: This study highlights the feasibility and further potential of Dyna-CT technology for MV-imaging and guidance of transcatheter mitral valve repair.

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P34 Mechanical Valve Evaluation with Four-Dimensional Computed Tomography

Satoshi Numata, Yasushi Tsutsumi, Osamu Monta, Sachiko Yamazaki, Hiroyuki Seo, Shohei Yoshida, Takaaki Samura, Hirokazu Ohashi. Fukui Cardiovascular Center, Fukui, Japan.

Objective: The objective of this study was to evaluate the validity of “four-dimensional” computed tomography (4D-CT) in the morphological and functional evaluation of mechanical prosthetic valves.

Methods: Thirty-seven patients with forty-five implanted mechanical valves were studied with electrocardiogram gated multi-detector (16 or 256 rows) computed tomography (MDCT). Volume-rendering three-dimensional and multiplanar reformation were obtained. Valve leaflet movement was evaluated using reformatted images in a cine mode (four-dimensional images). Patient age was 65.1 ± 10.1 (0.5-85) years old. The series included 18 aortic and 27 mitral mechanical valves and 36 bileaflet valves and nine mono-leaflet valves. Fifteen patients had atrial fibrillation. Seven patients had permanent pacemaker implantation. The quality of mechanical valve leaflet visualization was scored on a four-grade scale (leaflet index). The level of artifact was also scored (artifact index).



Results: There were two stuck valve patients who required emergency surgery. Stuck mechanical leaflet could be visualized by 4D-CT. With all bileaflet mechanical valves, valve leaflet motions were visualized with four-dimensional images (Figure P34-1). On the contrary, in four out of nine valves with mono-leaflet valves, opening and closing angle could not be visualized, because of radiopacity of the leaflet. Leaflet index and artifact index were significantly lower in monoleaflet valve (p<0.0001, p=0.0037). By 256-row MD-CT, artifact index was better than by 16-row without statistical difference (p=0.0654).

Conclusions: Functional and morphological evaluation of mechanical valve with four-dimensional multi-detector computed tomography is promising in patients with bileaflet mechanical valve. However, the evaluation of mono-leaflet valve is limited.

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P35 Computational Fluid Dynamics Analysis for Automated Distal Anastomosis in Coronary Bypass Grafting: Need of In-Vitro Training with Quantitative Anastomotic Quality Assessment

Young Kwang Park 1, Tadashi Motomura2, Daisuke Ogawa1, Naohiko Kanemitsu1, Gustavo G. Salinas2, Basel Ramlawi2, Limael Rodriguez2, Mitsuo Umezu1, Mahesh Ramchandani2. 1Waseda University, Tokyo, Japan, 2Methodist DeBakey Heart and Vascular Center, Houston, TX USA.

Objective: Proximal automated suture devices are clinically used for off-pump coronary bypass grafting (OPCAB). Beyond standard OPCAB methods, an even less invasive approach has been applied, the so-called minimally invasive coronary artery bypass (MICS-CAB). Due to the small surgical field in MICS-CAB, distal anastomoses in the circumflex or right coronary artery territory are technically challenging. Distal coronary automated anastomosis devices are clinically available and offer a promising option for the MICS-CAB operation. However, in vitro imaging analysis and the need for device deployment training are not well investigated. This study aims to clarify characteristics of automated sutures in comparison with hand-sewn anastomoses using rapid computational fluid dynamics (CFD) analysis.

Methods: A tissue-mimicking silicone-rubber coronary model was used by a cardiac surgeon to create 2 hand-sewn models and 2 automated suture models each. For morphological assessment, minimum cross-sectional area (CSA) was measured by Micro CT using a special 50 μm resolution. Energy loss value was calculated using CFD techniques to assess the degree of anastomotic stenosis (where high energy loss represents high stenosis). These parameters were compared for the first and second automated suture models.



Results: Inadequate installation of automated device encompassed poor anastomosis with high energy loss (489.8 μW) and a narrowed anastomosis (1.64 mm2), as opposed to hand-suture group (mean energy loss of 87.5 μW and mean CAS of 9.4 mm2). In contrast, properly installed graft to the automated device significantly improved energy loss (93.1 μW, 81% improvement) and a CSA (7.80 mm2, 475% improvement). This result was comparable with hand-sewn group and suggested importance of graft installation training as well as final deployment techniques (Figure P35-1).

Conclusions: Automated suturing of distal anastomoses showed equivalent anastomotic qualities compared with conventional hand-suture anastomosis. As well as hand sewing skills, it is equally important to maintain consistent anastomosis quality for automated device. Particularly, graft installation and automated clip deployment maneuvering may require systematic in-vitro training and imaging/quantitative assessment prior to device clinical implementation.

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P36 Impact of Epicardial Ultrasound in Patient with Embedded Coronary Artery in Off-Pump Coronary Bypass Surgery

Masato Hayakawa, Tohru Asai, Takeshi Kinoshita, Tomoaki Suzuki. Shiga University of Medical Science, Otsu City, Japan.

Objective: We have focused on off-pump coronary artery bypass (CABG) with skeletonized ITA and GEA for over 10 years. During this period, over 1000 patients underwent complete functional revascularization by the off-pump technique without conversion to cardiopulmonary bypass. However, it is often difficult to detect embedded coronary arteries on beating heart. From June 2010, we routinely use a high-frequency epicardial ultrasound (ECUS) for assessing embedded arteries. The purposes of the present study were to report the clinical outcomes in patients before or after introduction of ECUS and to assess its impact in patients with embedded target vessels.

Methods: Between June 2008 and June 2012, 364 consecutive patients underwent isolated CABG in our institution. In 34 patients (including 28 (82.4%) patients with three-vessel disease and 5 (14.7%) patients with emergency operation), the target sites could not be identified either visually or on palpation. We divided them into two groups, pre-introduction group (non-ECUS group, 15 patients including 15 anastomotic sites) or post-introduction group (ECUS group, 19 patients including 25 anastomotic sites).

Results: The preoperative profiles and surgical data of the two groups were not significantly different. The embedded target sites were located in LAD (7 anastomotic sites in non-ECUS group vs. 16 in ECUS group), LCX (6 in non-ECUS group vs. 6 in ECUS group) and RCA (2 in non-ECUS group vs. 3 in ECUS group). ECUS facilitated finding the best target sites and constructing anastomoses even with embedded targets. All patients underwent complete functional revascularization by the off-pump technique without conversion to cardiopulmonary bypass. The 30-day mortality was 0% and no significant difference was found in postoperative complications between the two groups. All grafts were confirmed to be patent by postoperative angiogram.

Conclusions: ECUS is extremely useful in detecting and assessing embedded coronary arteries especially in off-pump coronary bypass surgery.

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P37 Evaluation of Peripheral Arterial Cannulation Techniques in Minimally Invasive Valve Surgery

Juan S. Jaramillo, Bob Kiaii, Daniel Bainbridge, Ivan Iglesias, Michael Chu. London Health Science Centre, London, ON Canada.

Objective: Minimally invasive valve surgery can be achieved through a minithoracotomy but has known risks and limitations of peripheral cannulation including retrograde perfusion, aortic dissection and leg ischemia. Regional oxygen saturation measured by means of near-infrared spectroscopy (NIRS) may be a useful noninvasive tool to continuously monitor and detect lower limb ischemia. We sought to evaluate the differences between direct femoral arterial cannulation and an 8 mm Dacron graft in minimally invasive valve surgery.

Methods: We evaluated 26 patients who underwent peripheral cardiopulmonary bypass (CPB) by direct femoral arterial cannulation (n=11) or 8 mm Dacron graft (n=15) for minimally invasive valve or ASD surgery between May 2011 and December 2012. A 4 cm right minithoracotomy was employed in all cases. Operations performed included mitral valve repair/replacement (22 cases), aortic valve replacement (1 case), ASD and tricuspid repair (3 cases).

Results: Patient demographics were similar between the two groups. Overall, there was only one mortality which occurred in the cannula group. In the cannulae and graft groups, no patients experienced perioperative stroke or aortic dissection, respectively. The median NIRS value in the cannula group during the cross clamp time was 58.45+/-10.57 and in the graft group was 71.60+/-12.19 (p value = 0.008). The mean CPB and cross-clamp times were 176.36+/-53.11 and 117.89+/-33.43 in the cannulae group and 209.87+/-72.48 and 130.92+/-48.41 in the graft group (p= 0.207 and 0.498), respectively. There were no differences in complications between the two groups. Median ICU and hospital lengths of stay were 1 and 5 in the cannulae group, and 1 and 7 days in the graft group (p=0.402 and p=0.088).

Conclusions: Peripheral cannulation with an 8 mm Dacron side-graft appears to have improved lower limb perfusion compared to cannulation alone for minimally invasive valve surgery. Continuous lower limb NIRS monitoring provides excellent real-time assessment for lower limb perfusion and should be considered in all cases requiring peripheral cannulation. Further investigation with a randomized trial is warranted.

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P38 Imaging and Assessment During Experimental Mitral Valved Stent Implantation

Katharina Huenges 1, Saskia Pokorny1, Telse Bähr1, Huang D. Dai1, Florian Bönke1, Lucian Lozonschi2, Jochen Cremer1, Georg Lutter1. 1University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany, 2University of Wisconsin, School of Medicine and Public Health, Madison, WI USA.

Objective: In the course of the recent developments of various catheter-based technologies, the demands on imaging techniques become more critical. In this study we report our experiences in experimental off-pump mitral valved stent implantation focused on guidance and assessment using a combination of different imaging techniques.

Methods: Transapical mitral valved stent implantation in the beating heart was performed in 10 pigs under 3DTEE and 2DTEE guidance. TEE was conducted to evaluate the heart function before, and the valved stent position and performance after implantation. After one month cardiac CT was performed to evaluate stent formation and position. Cardiac catheterization was utilized to evaluate performance and paravalvular leakage (PVL).

Results: Ten animals were implanted successfully and were followed-up for one month. 3DTEE provided dependable spatial visualization of the left heart, mitral apparatus, delivery system, and valved stent (Figure P38-1A). It was an adequate method for correct positioning of the stent. Disadvantage of this technique were the strong artifacts caused by the metal frame, shadowing the structures beyond the stent. Cardiac catheterization and contrast angiography proved to be of explicit value to evaluate global pump function, regurgitation, PVL and hemodynamics (Figure P38-1B). It provided more reliable results on the impact of the stent on the heart function compared to the TEE, in particular judging the combined central and PVL. Cardiac CT provided quantitative information on the stent positioning and shaping in the beating heart (Figure P38-1C). These results are of great value to optimize the prototypes. In the future, CT-based evaluation of the mitral valve apparatus will be important for preoperative stent sizing.



Conclusions: The development of real time 3DTEE is of great value and 2DTEE enables an accurate and quantitative evaluation. The drawback is the sound cancellation beyond the valved stent. Angiography is very beneficial for an overall judgment of heart function. This is of particular importance in the follow-up examinations. Choosing the optimal imaging technique and particularly a combination optimizes the results, not solely in experimental developments.

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P39 Management of Peri-Operative Myocardial Ischemia-Role of Angiography?

Pradeep Narayan, Kunal Sarkar, D. Das, M. Das. RTIICS, Kolkata, India.

Objective: Peri-operative MI is a relatively rare but potentially fatal complication following CABG and is due to graft related problems in a significant proportion of cases. Angiography, the gold standard for pre-operative angina remains extremely under-utilized for evaluation of peri-operative ischemia. The aim of this study was to evaluate the role of angiography in the management of peri-operative ischemia.

Methods: Between January 2011 until September 2012, we performed 2,312 isolated primary coronary artery bypass grafts. 26 (0.01%) of these patients needed peri-operative angiography. The patients for angiography were identified based on our institutional algorithm. In the presence of ST changes, recurrent VT/VF or increase in inotropic support, TnI and CPK-MB levels were measured and TEE performed. In the presence of above signs and new regional wall dysfunction, the patient was taken for angiography.

Results: ECG changes were seen in 19 (79.1%) cases. arrhythmias in 8 (33.3%) and ST changes in 11 (45.8%). Eight (33.3%) patients had hemodynamic compromise. CK/ CK-MB ratio appeared elevated above the threshold of 10% set as significant was found only in 4 (16.6%) patients. Troponin (TnI) was raised in 6 patients (25%). TEE revealed regional wall dysfunction in 6 out of 24 (25%) patients undergoing angiography. Mean time between operation and angiography was 24.58±6.71 hours. Of the 6 patients undergoing angiography, 18 (69 %) had graft issues and needed re-operation. The overall mortality in the group re-operated for graft issues was 2 out of 18 (11.1%). In the group where angiography was carried out within 48 hours no mortality was seen.

Conclusions: In conclusion, angiography remains an extremely useful tool in identifying graft related causes and to discriminate them from non-graft related ischemia thus allowing appropriate management. Based on our findings we would recommend a more liberal and early application of this diagnostic modality in this setting.

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P40 Off-Pump Coronary Artery Bypass Grafting for Acute Myocardial Infarction

Tomoya Uchimuro, Toshihiro Fukui, Yasuyuki Katou, Minoru Tabata, Shuichiro Takanashi. Sakakibara Heart Institute, Tokyo, Japan.

Objective: High mortality has been reported in conventional coronary artery bypass grafting (CABG) for patients with acute myocardial infarction (AMI). Recently, off-pump CABG is widely accepted to be safe and effective for myocardial revascularization. We assessed the outcome of off-pump CABG for patients with AMI.

Methods: Between September 2004 and April 2012, 1,506 patients underwent off-pump CABG; of these patients, 97 consecutive patients (6.4%) with AMI were assessed. Postoperative coronary angiography was performed in 66 patients (68.0%) at 1 week after surgery. Forty-nine patients (50.5%) had coronary angiography at 1 year after surgery. The mean follow-up time was 4.0±2.3 years. Long-term survival was analyzed using Kaplan-Meier survival curves. Cox proportional hazard analysis was performed to identify independent predictors of mortality.



Results: Mean age at operation was 70.8 years, and 76 (78.4%) patients were male. Anterior, inferior, and lateral infarctions were observed in 61 (62.9%), 28 (28.9%), and 8 (8.2%), respectively. The time from AMI to operation was <24 hours in 25 patients (25.8%), 1-7 days in 27 (27.8%), 8-21 days in 32 (33%), and >22 days in 13 (13.4%). Intra-aortic balloon pumping was used in 48 patients (49.5%). The mean number of anastomoses per patient was 4.0±1.2. There was no in-hospital mortality. Low-output syndrome was observed in 7 patients (7.2%), stroke in 5 patients (5.2%), and respiratory failure in 7 patients (7.2%). The early graft patency rate was 98.5% (270/274 anastomoses), and 1-year patency rate was 90.5% (183/202 anastomoses). Ten patients (10.3%) underwent percutaneous coronary intervention, and the revascularization free-survival rate was 86.9% at 7 years. Twenty patients (20.6%) died during follow-up, and actuarial survival rate was 68.5% at 7 years. Major adverse cardiovascular and cerebrovascular event free-survival rate was 60.9% at 7 years. Cox proportional hazard analysis revealed that octogenarian and time from AMI to operation >=24 hours were independent predictors of mortality (Table P40-1).

Conclusions: Off-pump CABG is a safe and effective procedure in patients with AMI.

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P41 Combined Aortic Valve Replacement and Coronary Artery Bypass Graft without a Sternotomy: Early Experience with Eleven Cases

Zhandong Zhou 1, Michael Hodell1, Ahmed Nazem1, Gary R. Green1, Charles Lutz1, Feng Gao2. 1St. Joseph Hospital, Syracuse, NY USA, 2An Zheng Hospital, Beijing, China.

Objective: Patients with aortic valve stenosis who need coronary artery bypass graft (CABG) were not candidates for minimally invasive approach in the past. With the development of new technologies, we were able to perform combined aortic valve replacement (AVR) and single-vessel CABG without a sternotomy in selected patients.

Methods: Patients who need AVR and single-vessel CABG were selected for either a mini-right thoracotomy or bilateral mini-thoracotomy approach depending on the location of the graft. For patients with left anterior descending coronary artery (LAD) disease, the da Vinci robot was used to takedown the left internal mammary artery (LIMA) first. Then AVR was performed through a right mini-thoracotomy. With aorta still clamped, the LIMA to LAD anastomosis was performed through a mini left thoracotomy. For patients with circumflex or diagonal artery disease, a small left thoracotomy was performed after AVR was completed. A saphenous vein/radial artery graft was then anastomosed to the target artery with the aorta still clamped. The graft was then tunneled to the right side for anastomosis to the aorta. For patients with right coronary artery disease, the distal and proximal anastomosis can usually be performed through the same incision.

Results: Total eleven patients had combined AVR and CABG through a right thoracotomy or bilateral mini-thoracotomy approach. Average age was 74±2.6 year, with 6 male and 5 female patients. Other demographics include 3 patients with COPD, 10 patients with diabetes, and 2 patients had previous congestive heart failure. All patients successfully completed the surgery without conversion to sternotomy and stay alive in 30 days. Average aortic clamp time was 127±11 minutes and cardiopulmonary bypass time was 169 ± 12 minutes. No early post operative complications were noticed. One patient developed endocarditis and died three months later. All patients are in class I or II in follow-up.

Conclusions: To our knowledge, this is the first reported series that combined AVR and single-vessel CABG were performed without a sternotomy to all territories of the coronary artery distribution. It is especially valuable in patients who need to return to full activity sooner with little restrictions.

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P42 Outcome of Isolated, Open Aortic Valve Replacement via Right Mini-Thoracotomy versus Median Sternotomy in 1,371 Patients

Donald Glower, Bhargavi Desai, G. Chad Hughes, Carmelo A. Milano, Jeffrey G. Gaca. Duke University Medical Center, Durham, NC USA.

Objective: To define the relative role, advantages and disadvantages of a right mini-thoracotomy (RT) versus standard median sternotomy (ST) for open aortic valve replacement (AVR).

Methods: A retrospective analysis was performed of all 1,371 patients undergoing isolated, open aortic valve replacement at single institution over a 14-year period. Because relatively few patients were technically suitable for redo AVR with the RT approach (n=21), all redo patients (n=211) were excluded, leaving 1,160 patients available for analysis. Patients were selected for RT versus ST approach by patient or surgeon choice.

Results: Relative to ST (N=700), patients undergoing RT AVR (N=460) were older (67±13 v 63±14, p<0.0001) with more stenosis (88% v 76%, p<0.0001) and less regurgitation (31% v 42%, p<0.0001) but with more recent operation year (2008 v 2003, p<0.0001), less CHF (NYHA Class II v III, p<0.0001), higher EF (55±9 v 52±13, p<0.0001), less endocarditis (2% v 9%, p<0.0001), and less renal disease (8% v 18%, p<0.001) than ST AVR patients. Conversion to ST occurred in 16 (1.36%) of RT patients. RT AVR was associated with longer cardiopulmonary bypass times (156±25 v 134±40, p<0.0001) and clamp times (101±21 v 86±28, p<0.0001), but less transfusion (1.4 v 3.7U, p<0.0001), less chest tube output (404 v 992ml, p<0.0001), less reoperation for bleeding (0.4% v 4%, p<0.0001), shorter length of stay (6 v 8 day, p<0.0001), less sternal infection (0% v 2%, p=0.001), and less atrial fibrillation (14% v 21%, p<0.01). Operative mortality, stroke, and pneumonia and long-term multivariable survival were not significantly different between groups. With experience, one surgeon ultimately performed 446/463 (96%) of selected, isolated, first time AVR using RT approach.

Conclusions: Given the biases of a retrospective analysis, these data suggest that RT AVR is a safe alternative to ST AVR in selected patients. RT AVR may have advantages of avoiding sternotomy with associated bleeding, transfusion, and delayed wound healing, at the expense of longer pump and clamp times. These results suggest that the RT platform may have value in TAVR and sutureless AVR.

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P43 A 16-Year Experience in Minimally Invasive Aortic Valve Replacement: Context for the Changing Management of Aortic Valve Disease

Igor Gosev, Tsuyoshi Kaneko, Siobhan McGurk, Scott R. McClure, Ann Maloney, Lawrence H. Cohn. Brigham and Women’s Hospital, Boston, MA, USA.

Objective: Aim of this study was to evaluate short- and long-term morbidity and mortality in patients with aortic valve disease that had minimally invasive aortic valve replacement through upper hemisternotomy.

Methods: From July 1996 to June 2012, 1,639 patients underwent minimally invasive aortic valve surgery. Patient data was extracted from hospital electronic records after IRB approval. Outcomes of interest included postoperative complications and survival with separate evaluation of patients that underwent reoperations and patients over 80 years of age.

Results: The average age was 67.03 years (range 22-95 years). There were 363 (22.2%) octogenarians and 211 (12.9%) of the patients underwent reoperative procedures. Postoperatively, 2.3% (37/1639) had reoperations to correct bleeding, 2.7% (44/1639) had strokes 20.4% (334/1639) had new onset atrial fibrillation and 1.5% (24/1639) required permanent pacemakers. Only 34% (571/1639) of patients received packed red cells. The median discharge was on day 6 (5-8), and 72.2% of patients (1184/1639), were discharged home. Overall unadjusted operative mortality was 2.9% (48/1639). Operative mortality for the octogenarian group was 5.2% (19/363) and 5.7% (12/208) for reoperative patients. Long-term survival overall at 1 year was 94% (+/-1), 83% (+/-1) at 5 years, and 66% (+/-3) 10 years postoperatively. For reoperative patients, 1-year survival was estimated to be 89% (+/-4), 70% (+/-6) at 5 years, and 41% (+/-9) at 10 years. Long-term survival in octogenarians was 87% (+/-4) at 1 year, 64% (+/-6) at 5 years, and 48% (+/-7) at 7 years.

Conclusions: The upper hemisternotomy approach for aortic valve replacement is safe and reliable. Patients older then 80 years and patients undergoing reoperations benefit the most with decreased mortality and morbidity. These data provide a benchmark against which outcomes of percutaneous/transapical aortic valve replacements should be compared.

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P44 Right Mini-Thoracotomy Approach for Isolated Aortic Valve Replacement with Total Central Cannulation: Is It the Way to a New Standard?

Mauro Del Giglio 1, Simone Turci1, Corrado Bentini1, Simone Calvi2, Elisa Mikus2. 1Villa Torri Hospital, Bologna, Italy, 2Maria Cecilia Hospital, Cotignola, Italy.

Objective: Minimally invasive surgical techniques have been developed for treating many cardiac diseases. Minimally invasive aortic valve replacement (MIAVR) through a right mini-thoracotomy is not widespread because it is limited by the very tiny operating field, the need for a peripheral cannulation and the longer cardiopulmonary bypass time compared to the standard approach. The purpose of this study is to review our initial experience with MIAVR through a right mini-thoracotomy with total central cannulation.

Methods: Between January 2010 and December 2012, 116 patients underwent MIAVR through a 4- to 6-cm skin incision at the third intercostal space without rib resection. In the last 70 consecutive patients, mean age 72.7 ± 10.3 years; the cardiopulmonary bypass was instituted through the same surgical access. The aortic cross-clamp has been placed trancutaneously just above the main skin incision and cold blood antegrade cardioplegia has been used in all cases.

Results: All patients received an isolated aortic valve replacement with a median prosthesis size of 25 mm. Mean cardiopulmonary bypass time and cross-clamp time were respectively 62.5 ± 13.5 min and 49.8 ± 12.1 min. Skin-to-skin time was 178.2 ± 35.4 minutes. Median post-operative ventilation time was 7 hours and intensive care and hospital stay were respectively 1.7 days and 8 days. No deaths have been recorded. One patient has been revised for wound complication and in one case a pacemaker implantation was needed for complete atrio-ventricular block.

Conclusions: Our experience confirms that MIAVR achieved through a right mini-thoracotomy with central cannulation is safe and it can be easily performed without increasing the surgical time if compared with the standard full sternotomy approach at our department and avoiding groin incisions. The advantages of this technique include early mobilization and rehabilitation, excellent aesthetic result and lower risk of wound complications.

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P45 Aortic Valve Replacement with Sutureless EDWARDS INTUITY Valve System: Early Single-Center Experience

Francesca Chiaramonti, Marco Solinas, Simone Simeoni, Federica Marchi, Danyar Gilmanov, Giacomo Bianchi, Tommaso Gasbarri, Antonio Miceli, Mattia Glauber. Heart Hospital G. Pasquinucci FTGM, Massa, Italy.

Objective: High-risk patients referred for aortic valve replacement (AVR) may benefit from sutureless technology in order to reduce mortality and morbidity. We describe our initial experience with a new class of rapid-deployment sutureless aortic valves: the EDWARDS INTUITY Valve System (Edwards Lifesciences, Irvine, CA USA).

Methods: Between June and November 2012, 14 patients with symptomatic aortic stenosis underwent AVR with EDWARDS INTUITY Valve System. Mean age was 74.8 ± 6.6 (range: 63 to 83) and mean logistic EuroSCORE was 6.9 ± 3.8. Twelve patients were male (80%). Concomitant procedure were coronary artery bypass graft (n=3), mitral valve replacement (n=1) and tricuspid annuloplasty (n=1).

Results: Implantation was successful in 12/15 (80%). Prosthesis size were 19 (n=1), 21 (n=4), 23 (n=4), 25 (n=1) e 27 (n=1). In 5 (56% of isolated aortic valve replacement) patients was performed a minimally invasive approach with an Upper J-type ministernotomy in the third intercostal space. Deployment time was 14.8 ± 3.5 minutes. CPB and ACC time were respectively 71.5 ± 13.3 and 43, 3 ± 4 minutes for stand-alone procedures. Combined procedures required 155 ± 71.7 and 103 ± 44.6 minutes, respectively. There were no complications related to the minimally invasive approach. The 3 procedural failures were prosthesis sizing related in 2 cases and in one case due to a tearing of the aortic wall after CBP weaning. Mean mechanical ventilation time was 8.9 ± 3.5 hours, mean ICU stay was 1.5 ± 0.9 days and mean hospital stay was 6.6 ± 2.2 days. The transvalvular gradient at discharge was 11.3 ± 4.9 mmHg (mean) and 16.6 ± 5.9 mmHg (peak). Trivial paravalvular leakage was observed in 1 patient. One month survival was 100%.

Conclusions: AVR with EDWARDS INTUITY in high-risk patients is a feasible and efficacious procedure associated with low in-hospital mortality and excellent hemodynamic performance. Upper J-type ministernotomy in the third intercostal space is a safe and reproducible approach. The new sutureless valve system combines the safety and efficacy of the bioprosthesis Carpentier-Edwards Perimount with the simplicity of implantation. However, longer-term follow-up is necessary to confirm these first results.

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P46 Minimally Invasive versus Standard Approach Aortic Valve Replacement: A Propensity-Score Analysis of 808 Patients

Jochen Börgermann 1, Nobuyuki Furukawa1, Anas Aboud1, André Renner1, Michael Benzinger1, Kavous Hakim-Meibodi1, Oliver Kuss2, Jan F. Gummert1. 1Heart and Diabetes Center NRW, Bad Oeynhausen, Germany, 2Martin-Luther-University Halle, Halle/Saale, Germany.

Objective: The proportion of minimal-invasive approaches is rising in cardiac surgery, in part driven by increasing patient demand. This study aimed to perform a risk-adjusted comparison of mortality, rate of stroke, and perioperative morbidity of aortic valve replacement conducted through either partial ministernotomy (MIC-AVR) or through conventional sternotomy (CONV-AVR).

Methods: Between July 2009 and July 2012, data from 984 consecutive patients undergoing isolated aortic valve replacement were prospectively recorded. In 44.3% (n=436), the less invasive partial ministernotomy was used. Propensity Score matching was performed based on 15 preoperative risk factors to correct for selection bias. In-hospital mortality, stroke rate, as well as other major complications of MIC-AVR and CONV-AVR were compared in 404 matched patient pairs (total: 808).

Results: Both death and rate of stroke, as well as the rates of all other complications were similar between groups (Table 46-1). Likewise, neither resource utilization (OR time, duration of stay in the intensive care unit, in-hospital stay) nor valve selection (type and size) was affected by the surgical approach.

Conclusions: Aortic valve replacement can be safely conducted through a partial ministernotomy. This approach is not associated with an increased rate of complications. Prospective studies with special emphasis on endpoints such as postoperative pain, duration of postoperative recovery, and quality of life during follow-up are needed to further clarify the role of MIC-AVR.



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P47 Minimally Invasive Aortic Valve Replacement: Comparative Study of Three Different Approaches

Lai Wei, Chunsheng Wang, Jinqiang Shen, Limin Xia, Huan Liu, Jiasi Zhu, Yiwei Xu, Wenjun Ding. Zhongshan Hospital, Fudan University, Shanghai, China.

Objective: Minimally invasive aortic valve replacement (AVR) has been supposed to reduce surgery trauma, decrease postoperative pain, blood loss, and shorten hospital stay. Previous study compared outcomes of partial and complete sternotomy for AVR, but there was no article compared thoracotomy to partial or complete sternotomy for AVR. This retrospective study compared outcomes of AVR with a 5 cm anterolateral thoracotomy with those of partial and complete sternotomy.

Methods: From July 10, 2009 to October 30, 2012, 260 patients with aortic valve disease underwent primary isolated AVR via complete sternotomy (N=96), partial sternotomy (n=78), or an anterolateral thoracotomy in the third intercostal space (ICS) with a groin incision for femoral connection of cardiopulmonary bypass (n=86). Outcomes of three groups were compared of in-hospital morbidity and mortality, mediastinal drainage, transfusion requirement, pain, and mid-term survival.

Results: In-hospital mortality was similar in three groups: no mortality in complete sternotomy, 1.3% in the partial sternotomy group and 1.2% in the thoracotomy group (p=0.6). The thoracotomy group had longest cardiopulmonary bypass time: 25 minutes longer than complete sternotomy group and 15 minutes longer than partial sternotomy (P<0.001); myocardial ischemic time was 16 minutes longer for the thoracotomy group than complete sternotomy and 12 minutes longer than partial sternotomy(P<0.001). Neurologic, pulmonary, and renal complications were similar among three groups (P>0.1). Median hours to extubation were 4.5 hours longer for the thoracotomy group than complete sternotomy and 2.6 hours longer than partial sternotomy. The thoracotomy group had the least drainage and lowest ratio of the patient required postoperative blood transfusion contributing to shortest length of postoperative hospital stay (mean 6.3 days), 1.6 and 0.9 days shorter than for complete and partial sternotomy (p<0.01).

Conclusions: Minimally invasive aortic valve replacement through the anterolateral thoracotomy is safe and feasible as partial and complete sternotomy, with good cosmetic results and rapid postoperative recovery, and is worthy of clinical selective application.

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P48 Minimally Invasive Aortic Valve Replacement with Sutureless Valves by J-Sternotomy or Right Thoracotomy Approach

Giuseppe Santarpino, Steffen Pfeiffer, Giovanni Concistré, Ferdinand Vogt, Martin Hinzmann, Theodor Fischlein. Klinikum Nürnberg, Nuremberg, Germany.

Objective: Although minimally invasive aortic valve replacement (AVR) has been shown to cause less morbidity than conventional surgery, it has not yet received broad application. The purpose of this study was to evaluate sutureless implantation using a pericardial aortic valve bioprosthesis mounted in a nitinol stent in minimally invasive approach.

Methods: Ninety patients (51 females, 39 males; mean age 77.5 ± 4.6 years) with aortic valve stenosis (mean gradient of 52 ± 14 mmHg) underwent aortic valve implantation with the sutureless bioprosthesis, following cardiopulmonary bypass (CPB), aortic cross-clamping (ACC), cardioplegic arrest, and removal of the calcified native valve. Surgical approach was a mini “J”-sternotomy in 85 and an anterior right thoracotomy in 5. The mean logistic EuroSCORE was 9.6 ± 5.7%.

Results: The prosthetic valve was successfully deployed in all patients. Thirty-day mortality was 2.2% (n = 2). Associated procedures were performed in 9 (10%). Mean CPB, ACC and implantation times were 68 ± 19 min, 38.7 ± 12.7 min, and 9.1 ± 4.2 min, respectively. Perioperative echocardiography revealed a paravalvular leakage in two patients. Postoperative mean gradient was 11.6 ± 5.1 mmHg. At a mean follow-up of 14 ± 8.8 months, 3 no cardiac deaths were recorded. No significant paravalvular leakage or valvular regurgitation was observed, and no migration or dislodgement of the prosthesis occurred.

Conclusions: This study shows that sutureless implantation of this aortic valve bioprosthesis provides a simple and reproducible alternative for minimally invasive AVR. As the valve does not need to be sutured, it may also result in reduced ACC and CPB times, especially in mini-approach. Therefore, this self-anchoring valve may also allow the application of minimally invasive AVR to a broader spectrum of patients.

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P49 Redo Minimally Invasive Aortic Valve Replacement Shortens Hospital Stay Compared to Redo Conventional Aortic Valve Replacement

Kayven Farshad, Stephen J. Kaplan, Christopher Piercecchi, Samata R. Paidy, Robert S. Poston, Sreekumar Subramanian. University of Arizona Medical Center, Tucson, AZ USA.

Objective: In recent years, redo minimally invasive (partial upper) sternotomy has been increasingly used. However, the approach is technically more challenging and may be associated with longer operative times. The purpose of this study was to determine whether the redo minimally invasive approach confers any advantages over conventional redo sternotomy for isolated aortic valve replacement.

Methods: Between March 2011 and October 2012, 27 consecutive patients underwent redo procedures for isolated aortic valve replacement and were divided into 2 groups. Surgical approach for Group 1 patients was conventional redo sternotomy and a redo mini-sternotomy for Group 2 patients. Retrospective chart review was used to analyze indications, techniques and outcomes. Statistical comparison was performed using t-test, Mann- Whitney and Fischer’s exact test, where appropriate.

Results: Group 1 patients (12/27, 44%) received a full sternotomy, while Group 2 patients (15/27, 56%) were treated via mini-sternotomy. Demographics, operative details and outcome data are presented in Table P49-1. Despite being much older, Group 2 patients (redo mini-sternotomy) had a significantly lower post-procedure length of stay (p=0.02) than Group 1 patients, a difference which persisted after exclusion of infective endocarditis cases. In-hospital and 30-day mortality was 0% for both groups.

Conclusions: Compared to conventional redo sternotomy, the redo minimally invasive (partial upper) sternotomy shortens the post-procedure hospital stay, and should be considered for patients ineligible for transcatheter aortic valve implantation.



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P50 Minimally Invasive Mitral and Aortic Valve Surgery Through Right Anterior Minithoracotomy: First-Results

Antonio Miceli, Michele Murzi, Danyiar Gilmanov, Raffaele Fugà, Stefano Bevilacqua, Matteo Ferrarini, Simone Simeoni, Alfredo G. Cerillo, Pier A. Farneti, Marco Solinas, Mattia Glauber. Fondazione Toscana G. Monasterio, Massa, Italy.

Objective: Minimally invasive surgery for either mitral or aortic valve surgery through right anterior minithoracotomy (RT) has shown excellent results in terms of mortality, morbidity and patient’s satisfaction. However, no study has described the combined minimally invasive mitral and aortic surgery (MIMAS) through RT. The aim of our study was to report early outcomes in patients undergoing MIMAS through RT.

Methods: From October 2005 to December 2012, 18 patients underwent MIMAS through RT. Additional procedures were: tricuspid valve repair (n=5) patients, atrial fibrillation surgery (n=5) and myectomy (n=1). A 7-8 cm skin incision was performed through the third intercostal space. Cardiopulmonary bypass was achieved by direct ascending aortic cannulation and percutaneous femoral vein drainage into right atrium.

Results: No death occurred. Mean age was 66±12, 12 patients (70%) were female and the median EuroSCORE was 7 (interquartile [IQ] range 3-12). The mean cardiopulmonary bypass and cross-clamp time were 166±41 min and 126±29 min respectively. No patient required a conversion to standard sternotomy. The median ventilation time was 7 hours (IQ range 5-16), as well as the median for intensive care unit and hospital stay was 1 day (IQ range 1-1) and 6 (IQ range 5-9). One patient had a postoperative stroke, another patient required blood transfusion and incidence of postoperative atrial fibrillation was 22% (n=4).

Conclusions: Minimally invasive mitral and aortic surgery through RT is a safe procedure associated with excellent early outcomes. More studies are required to validate our data.

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P51 Computed Tomographic Comparison of Different Prototype Designs for Off-Pump Mitral Valved Stent Implantation

Saskia Pokorny 1, Holger Hettich1, Alin Heinig1, Telse Bähr1, Benjamin Sattler1, Michael M. Morlock2, Jochen Cremer1, Georg Lutter1. 1University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany, 2Hamburg University of Technology, Hamburg, Germany.

Objective: Implantation of a mitral valved stent using an off-pump technique is a novel approach for treatment of mitral regurgitation. This study compares the in vivo performance of two different prototypes using cardiac CT.

Methods: Eight pigs received a self-expanding mitral valved stent, consisting of an atrial element connected to a ventricular body accommodating a bioprosthetic heart valve at a preset angle. The angle in between atrial element and ventricular body was modified from 45° in the first design (n=4) to 90° in the second design (n=4). Cardiac CT was performed 10 days (45° n=4; 90° n=2) and one month after implantation (90° n=2). Focus of this study was the evaluation of stent design related parameters such as the obstruction of the LVOT and the shaping of the valved stent (oval deformation, angular deflection). To evaluate the angular deflection, the annulus was divided into four zones.

Results: All animals were successfully implanted and were in good health at the time of CT examination. Correct position of the stents within the mitral annulus and full expansion of the ventricular element were observed in all cases. Minor deformation of 1.6±1.3 mm of the ventricular body (45° n=3, 90° n=2) were detected in five of eight cases. At the atrioventricular junction, large deformations of the stent structure were observed in all cases. The 45° stents revealed a greater deflection of the preset stent geometry, even though the overall angle was larger in the group of 90° stents (Table P51-1). No obstruction of the LVOT through the stent body was observed in five of eight animals. An obstruction of 20±8% was found in the remaining three animals (45° n=2; 90° n=1).

Conclusions: Good in vivo performance of the novel mitral valved stents was demonstrated and critical areas within the stent design were identified. The results indicate that larger preset angles lead to less stent deflection and hence could reduce the mechanical loading and the risk of stent fractures.



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P52 A Novel Heart Valve of Medical-Grade Ultra High Molecular Weight Polyethylene Fibers: In Vitro Biocompatibility Testing

Amir Basir, Mark Roest, Paul Gründeman, Claudia Tersteeg, Coen Maas, Arjan Barendrecht, Wally Müller, Irene Rademaker, Joost van Herwaarden, Jolanda Kluin, Frans Moll, Gerard Pasterkamp, Philip de Groot. University Medical Center Utrecht, Utrecht, Netherlands.

Objective: Different materials have been used for heart valves and vascular prostheses. Major drawbacks of current implanted valves are either the need for strong anticoagulants or moderate durability and low resistance to fatigue and tear. Ultra high molecular weight polyethylene (UHMWPE) fibers are flexible, fatigue- and tear-resistant and have high strength. Therefore, prostheses made of medical-grade UHMWPE fibers might be attractive for construction of heart valves applied in transcatheter approaches. The aim of this study is to test the biocompatibility of medical-grade UHMWPE fibers in vitro in blood contact.

Methods: Blood of three randomly chosen donors was subjected to three different experiments. First, platelet adhesion on filaments (Ø 15μm) of medical-grade UHMWPE fibers and polyester (gold standard) were tested in Polydimethylsiloxane (PDMS) perfusion chambers and visualized by light microscopy. Secondly, woven patches of medical-grade UHMWPE fibers were compared with the 5 most commonly used commercially available vascular patch prostheses, i.e., a knitted and a woven polyester fabric and 3 different ePTFE patches. Commercially available patches were tested as they are, meaning that they may contain a coating and that the construction and surface characteristics of these patches are different from the patch of UHMWPE fibers. Coagulation activation was tested by measuring the thrombin formation caused by the patches over time. Thirdly, platelet adhesion, activation and aggregation on the patches were studied in a flow chamber and thereafter visualized by the use of scanning electron microscopy.

Results: The platelet adhesion on medical-grade UHMWPE filaments was significantly lower compared with polyester filaments in the PDMS perfusion chamber experiment (P=0.03). The time to peak and total formed thrombin in the coagulation experiment was non-inferior for patches of UHMWPE fibers, compared to the reference materials. Currently, the scanning electron microscopic results of the patch perfusion tests are being analyzed.

Conclusions: These experiments support the idea that medical-grade UHMWPE fibers hold promise to be a potentially suitable material in blood for prosthetic valves and other vascular purposes. Yet, more extensive (in vivo) hemocompatibility studies are needed to confirm if UHMWPE is a suitable candidate for use in prosthetic heart valves and other vascular applications.

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P53 Design Characteristics of a Three-Dimensional Geometric Aortic Valve Annuloplasty Ring

Philip S. Crooke, L. Alan Beavan, J. Scott Rankin. Vanderbilt University, Nashville, TN USA.

Objective: A full geometric annuloplasty ring that restores three-dimensional aortic valve geometry toward normal could facilitate aortic valve repair. This study performed mathematical analyses of normal human aortic valve CT angiograms, in order to design such a ring.

Methods: Using 1 mm axial slices, high-resolution CT angiograms from 11 normal aortic roots were used to generate high-density x, y, z coordinates of valve structures in Mathematica. Three-dimensional least squares regression analyses of leaflet-sinus coordinates assessed geometry of aortic valve and root structures. Shapes and dimensions of all valve components were quantified, and attention was given to evaluating structural symmetry and root expansion during systole.

Results: Normal valve geometry could be represented as 3 leaflet-sinus hemispheres nested within an elliptical aortic root. The base of the valve was quite elliptical (minor-major diameter ratio = 0.65), which extended vertically up the commissures. In contrast, leaflet-sinus circumferences were fairly circular (minor-major diameter ratios = 0.82-0.87), and the commissural post between left and non-coronary leaflets was located at the posterior minor diameter-circumference junction; the center of the right coronary leaflet was located opposite. Commissural post location on the circumference was symmetrical, with only a +/-1-2% deviation from 33.3% symmetry on average. The commissural posts flared outward by 5-10 degrees, and the 3 leaflets were of equivalent area and volume (p=0.42). From end-diastole to mid-systole, the aortic root became less elliptical (minor-major diameter ratio increased by 0.15), but area of the aortic root expanded minimally (+4.6%). A one-piece rigid Titanium annuloplasty ring, covered with a thin layer of Dacron, was designed to mimic normal diastolic geometry, with 2:3 base ellipticality and three 10-degree outwardly flaring subcommissural posts positioned symmetrically on the circumference (Figure P53-3).



Conclusions: A hemispherical model of normal aortic valve geometry was used to design a three-dimensional aortic annuloplasty ring. The design incorporated 2:3 diastolic base ellipticality, commissural symmetry, and 10-degree outwardly flaring subcommissural posts. This device may prove useful for restoring annular geometry toward normal during aortic valve repair.

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P54 In Vitro Evaluation of a New Percutaneous Mitral Valved Stent Delivery System

Huangdong Dai, Martin Marczynski-Buehlow, Gunther Fischer, Traudel Hansen, Beke Sarrahs, Anja Metzner, Jochen Cremer, Georg Lutter. University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.

Objective: The complete replacement of the native mitral valve by implantation of a valved stent via catheter technique in an off-pump procedure is still challenging. Though, the outcome will presumably exceed today’s percutaneous repair techniques. Here, a newly developed, less-invasive transcatheter mitral valved stent delivery system will be presented.

Methods: The new stent delivery system combines a percutaneous transapical access with an optional left-transatrial, right-transatrial/transseptal or transfemoral/transseptal access. It consists of three functional units: (1) the first unit establishes the connection line between both accesses with a stiff guide-wire. (2) From antegrade the stent delivery catheter with a Nitinol mitral stent is introduced. (3) An atrial septal occluder system serves as apical stent fixation as well as apical occlusion system. In vitro system testing was performed on eleven porcine hearts under endoscopic view from atrial side and eleven porcine hearts under x-ray visualization. The hearts were continuously flushed with 37° C warm water throughout the implantation procedure. The new prototype was evaluated with regard to general operability and duration of the implantation procedure from apical puncture to completed stent implantation. In separated in vitro experiments, tensile tests were conducted on the fixation unit in order to evaluate its suitability to hold the stent in position.

Results: This study showed good operability of the prototype. The overall procedure time took in average 18:59 minutes (range: 13:38 to 22:58 minutes) under endoscopic view and 10:47 minutes (range: 8:00 to 20:25) under x-ray visualization. Both studies revealed a steep learning curve of the physician. In all the 22 hearts, the stent as well as the occluder were precisely positioned. The tensile tests on the fixation unit revealed forces of 9.4 N ± 3.4 N in order to remove it from the myocardium. For the used mitral stent design, this force is estimated to be sufficient holding the stent in position.

Conclusions: These first in vitro prototype tests showed good results in terms of operability and mitral stent fixation. The procedure has a great potential to develop to an alternative and less-invasive implantation procedure in contrast to transapical mitral valved stent implantation.

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P55 In-Vitro Hemodynamic Assessment of Newly Developed Stentless Mitral Valve (NORMO Valve)

Susumu Manabe 1, Hitoshi Kasegawa2, Moon Sojung3, Takahiro Okada3, Tetsuya Doi3, Kiyotaka Iwasaki3, Tetsuo Fujimoto3, Mitsuo Umezu3, Hirokuni Arai1. 1Department of Cardiovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan, 2Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan, 3Advanced Research Institute for Science and Engineering, Waseda University, Tokyo, Japan.

Objective: We have developed a new stentless mitral valve (NORMO valve) made with a pericardium and a flexible artificial ring. The valve can be made by hand-sewing at the time of surgery. The purpose of this study is to compare the hemodynamic performance between NORMO valve and bioprosthesis.

Methods: The hemodynamic performance of NORMO valve was analyzed using a pulsatile in-vitro mitral valve simulator. The simulator is driven by LVAD. We measured the transvalvular flow volume and regurgitant volume at each heartbeat. NORMO valve (n=8) was compared with commercially available bioprosthetic valve (MOSAIC, Medtronic, Inc, Minneapolis, MN USA) (n=8).

Results: The simulator was preset at 70 beats/minute under systolic fraction of 35%. The aortic pressure and the atrial pressure were adjusted to 100 (120/80) mmHg and 10mmHg, respectively. There was no difference in cardiac output between the two groups (NORMO: 4.7 ± 0.4L/min, vs. bioprosthesis: 4.5 ± 0.3 L/min, p=0.28). The forward flow volume per beat was similar between the two groups (NORMO: 72.5 ± 6.8 mL/beat, vs. bioprosthesis: 68.7 ± 3.9 mL/beat, p=0.19), but the regurgitant volume was lower in NORMO valve than that in bioprosthesis (NORMO: 8.7 ± 1.6 mL/beat, vs. bioprosthesis: 13.1 ± 3.3 mL/beat, p<0.01).

Conclusions: NORMO valve possesses an equivalent flow capacity with less regurgitation, compared with bioprosthetic valve of the same size. The results of this study suggested that NORMO valve can be an alternative to the bioprosthetic valve in short-term.

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P56 Comparison of Strength, Consistency and Speed of Manually-Tied Knots vs. Automated Titanium Fasteners in an Ex-vivo Minimally Invasive Mitral Ring Model Using a New Micro-Transducer Pressure Analysis System

Candice Y. Lee 1, Jude S. Sauer2, Heather R. Gorea2, Angelo J. Martellaro2, Peter A. Knight1. 1University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY USA, 2LSI SOLUTIONS, INC., Victor, NY USA.

Objective: To better understand cardiac prosthetic valve attachment suture strength and consistency, a micro-transducer system was developed to quantify the pressures between sutured prostheses and underlying heart tissue. The compression forces within and adjacent to attachment sutures were measured for comparative analyses. Sutures through a flexible prosthetic mitral ring were secured in an ex-vivo porcine heart model simulating a minimally invasive mitral annuloplasty to evaluate sutures knotted with an extracorporeal knot pusher versus an automated titanium fastener.



Methods: Using standard suture placement techniques, 16 mitral annuloplasty rings were sewn into pig hearts with 8 sutures per ring. Eight rings were secured with hand-tied knots and 8 secured with automated fasteners via a thoracotomy trainer by either a senior cardiac surgeon or a general surgery resident; each operator completed 4 manually-tied rings and 4 automated rings. Six throws were placed per manually-tied knot. The total time to tie and cut each ring’s 8 sutures was recorded. Suture attachment pressures were promptly measured within (intra-suture) and between (extra-suture) each suture loop using the computerized 0.5 x 2.0 mm micro-transducer probe.

Results: The median suture holding pressure for the mitral rings attached with automated knots was significantly greater than that for manually-tied knots (1008.9 vs. 415.8 mmHg, p < 0.001). Fourteen percent of the hand-tied knots had attachment pressures of less than 75 mmHg and 43% were less than 375 mmHg, while none of the automated fasteners measured that low (Figure P56-1 A). There was also less variation in the pressures of automated knots than those of hand-tied knots (SD: 401.6 vs. 499.3 mmHg, p = 0.04) (Figure P56-1 B, C). Significant time savings occurred with use of automated knots compared to manual tying (13.0 vs. 68.8 sec/knot, p = 0.0012).

Conclusions: The new micro-transducer technology proved useful for measuring the attachment pressures between cardiac prostheses sutured to heart tissue. Mitral annuloplasty ring sutures knotted with automated titanium fasteners were stronger, more consistent and faster than manually-tied knots.

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P57 Training Surgeons in Mitral Valve Repair Directly Through Minimally Invasive Approaches

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

Objective: We aimed to study the results of minimally invasive mitral valve repair performed by a consultant who introduced the technique at our institution and five young surgeons who were trained in mitral valve repair directly through a video-assisted right chest approach.

Methods: Data were analyzed for consecutive patients undergoing minimally invasive mitral valve repair that were operated on by one consultant or one of five trainees. Conversions were analyzed by intention to treat. Perioperative death or one or more of 6 adverse events constituted failure. Predicted risks of failure for individual patients were derived from the study population. Risk-adjusted control charts were plotted for each surgeon in an effort to monitor the individual performance. In addition, consultant and trainee operations were compared using standard tests.

Results: The consultant operated on 355 patients and the trainees on 240 (81, 77, 39, 33 and 15, respectively for trainees 1-5). In hospital-mortalities were 1.3% in the trainees group and 0.8% in the senior surgeon group. Crude postoperative outcomes were similar between trainees and consultant. There were 17 conversions (consultant 11, trainees 6). The overall failure rate was 11% (12% for consultant’s operations and 11% for trainees’ operations), including 3 deaths (0.75%). Predicted and observed risks of failure were similar for all five surgeons. Risk adjusted control charts revealed that performance was the same or better for the trainees as for the consultant (Figure P57-1).

Conclusions: Minimally invasive mitral valve repair can be safely taught to cardiac surgery trainees. Implementation of continuous performance monitoring for surgeons exposed to this technique is practicable.



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P58 Complete Tricuspid Valve Regeneration: A Novel Minimally Invasive Surgical Technique and New Surgical Paradigm

Walter D. Boyd 1, James L. Cox2, Anna M. Fallon3, J. N. Young1, Robert G. Matheny3. 1University of California Davis, Sacramento, CA USA, 2Washington University, Saint Louis, MO USA, 3Cormatrix Cardiovascular, Alpharetta, GA USA.

Objective: Preliminary clinical experience with valve repair using matrix bioscaffolds (Cormatrix) has demonstrated that this material can remodel into the patients own tissue. Valves currently available for tricuspid valve replacement were not designed for the tricuspid position and do not provide annular to ventricular continuity resulting in suboptimal hemodynamics and physiology after implantation. The objective of the current study was to determine if complete valvular regeneration could be accomplished in a chronic ovine model using a uniquely designed matrix bioscaffold valve implanted via a new surgical technique.

Methods: A chronic study using an ovine model (n=4) evaluated valve function up to one year after implantation. The heart was approached through a small thoracotomy cardiopulmonary bypass established and the native tricuspid valve, including chordae excised. Based on annular size and annulus-papillary muscle depth, a Matrix sleeve valve was constructed. The ventricular end of the construct was first attached to the three papillary muscles and the annular end of the construct sutured to the annulus in a running fashion. Serial post-operative echocardiography was performed at 1 week, bimonthly, and at termination to evaluate in vivo valve function. Study animals were sacrificed at 3, 5, 8, and 12 months. Histological evaluation and scanning electron microscopy (SEM) were performed.

Results: Echocardiography intraoperatively demonstrated immediate valve competence in all animals. Throughout the study, the leaflets maintained their compliance and did not calcify or thicken. After 3 months, the explanted valves had the trileaflet structure of native valves and histological examination showed diffuse cellular infiltration with a confluent endothelial lining as shown by eNOS staining and SEM demonstrating remodeling. By 5 months, papillary muscle attachment sites were beginning to resemble native chordae. By 8 months, the leaflets demonstrated collagen glycosaminoglycan and elastin distribution similar to native leaflets.

Conclusions: These results demonstrate tricuspid valve regeneration is possible using a novel matrix bioscaffold constructed in a unique design and implanted using a minimally-invasive approach. ECM material recruits host stem cells and remodels into endothelialized tissue indistinguishable from the host’s native valve both grossly and histologically. Preliminary human implantation has been performed with excellent results at one year.

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P59 Performance Increase in Venous Drainage for Mini-Invasive Heart Surgery

Saad Abdel-Sayed, Mhedi Belkoniene, Steven Taub, Ludwig Karl von Segesser. Research Laboratory, Lausanne, Switzerland.

Objective: Originally, the Smartcanula principle (collapsed insertion and expansion in situ) was developed for venous drainage by gravity. However, in minimally invasive surgery, augmentation with either constrained force vortex pumps or vacuum is often used. The current study was set up to assess whether smaller diameters of self-expanding venous cannulas are sufficient in conjunction with venous drainage augmentation resulting in smaller access orifices.

Methods: To evaluate cannulas intended for CPB, an in-vitro circuit was set-up with silicone tubing between the test cannula encased in a lower reservoir, the centrifugal pump, and after upper reservoir. Afterload was set arbitrarily at 60 mmHg using a centrifuge pump. The pressure value (P) was measured using high fidelity Millar pressure transducers taking in account the level of the test fluid. Flow rate (Q) was measured using an ultrasonic flow meter calibrated with volume tank and timer. RPM of the centrifugal pump were calibrated with a stroboscope. Data display and data recording were controlled using a Lab View application custom made particularly for our application. Self-expanding (Smartcanula 24 F) and control (Biomedicus 25 F) were used.

Results: 60 measurements were recorded. At 1500, 1570, 2000, 2500, and 3000 rpm pump speed, the Q values were 3.6, 5.2, 6.6, 9.3, and 11.8 l/min for the 24 F self-expanding Smartcanula respectively. The P values were 3.6, -5.4, -15.9, -45.3, and 80.6 mmHg. Biomedicus 25 F showed Q values from 16 to 19% times less as compared to 24 F Smartcanula. The Q values were 3, 4.3, 5.4, 7.5, and 9.3 l/min. The P values were 6, 7, 4, 2, and 2 times more as compared to 24 F Smartcanula.

Conclusions: Our experimental evaluation demonstrated that the self-expanding cannula outperforms the commercially available control cannula. The self-expanding Smartcanula provides superior flow despite the small access diameter.

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P60 Percutaneous Superior Vena Cava Drainage Improves Outcomes during Minimally Invasive Mitral Valve Surgery: A Randomized, Cross-Over Study

Michael W. Chu, Bob Kiaii, Andrew Cleland, John Murkin, Daniel T. Bainbridge. University of Western Ontario, London, ON Canada.

Objective: Minimally invasive mitral valve surgery relies upon optimal venous drainage and perfusion strategies to prevent cardiac distension and allow adequate perfusion. Controversy exists as to whether a percutaneous superior vena cava drainage cannulae (PSVC) is necessary during these operations. We therefore sought to determine the effect of using a PSVC on brain near infrared spectroscopy (BNIRS), blood lactate levels, as well as hemodynamic and surgical parameters.

Methods: Using a randomized cross-over study design, patients undergoing minimally invasive mitral valve surgery were allocated to 20 minutes of PSVC line unclamped and 20 minutes of PSVC line clamped during minimally invasive mitral valve repair. Both perfusion and surgery were blinded to the intervention. Inclusion criteria included any patients between the age of 18 and 80, undergoing elective mitral valve surgery through right mini-thoracotomy with at least 40 minutes of cardiopulmonary bypass time.

Results: Of the 40 patients approached to participate in the trial, a total of 35 underwent randomization. Mean patient age was 67±14 and 36% were female. Mitral valve repair and replacement were performed in 77% and 23% of patients, respectively. Concomitant procedures were performed in 25.6% of patients and included mostly Cryomaze and tricuspid valve repair. Comprehensive outcomes data are shown in Table P60-1. For the primary outcome of BNIRs there were no differences between the two groups (PSVC clamped 55.0 ± 11.6 versus control 56.1 ± 10.2; p= 0.283). The secondary outcomes were similar except for pH, surgical score and CVP, which were statistically significantly different, all favoring the use of the PSVC line (unclamped). No patients experienced any complications as a result of PSVC line clamping.

Conclusions: The use of the PSVC cannula improves venous drainage and surgical visualization during minimally invasive mitral valve surgery. BNIRs do not appear to be affected over the short 20 minutes trial period of the study; however, without a PSVC line, the effects on brain perfusion are unknown at longer durations.



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P61 Video-Assisted Minimally Invasive Cardiac Surgery: A 10-Year, Single-Center Experience

Jae Suk Yoo, Joon Bum Kim, Sung Ho Jung, Suk Jung Choo, Cheol Hyun Chung, Jae Won Lee. University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.

Objective: To review a 10-year, single-center experience with video-assisted minimally-invasive cardiac surgery (MICS).

Methods: A retrospective analysis was performed on all patients who underwent video-assisted MICS between December 2002 and October 2012.

Results: A total of 826 patients included 583 (70.6%) mitral valve surgeries and other cardiac surgeries (Table P61-1), of which 90 (10.9%) had underwent previous sternotomy. MICS approach involved a 4- or 6-cm right thoracotomy (except for MIDCABs and some VSD closures via left thoracotomy) and cardiopulmonary bypass conducted through femoral vessels and/or jugular vein. Mean bypass and cross-clamping time was 130.5±50.2 and 80.0±34.6 hours. There were 5 (0.6%) 30-day deaths (4 from mitral valve replacement and 1 from myxoma excision). Post-operative complications included 32 (3.9%) post-operative bleeding, 11 (1.3%) newly-required dialysis, 6 (0.7%) permanent stoke, 4 (0.5%) low cardiac output, 5 (0.6%) pneumonia, and 8 (1.0%) minor wound problem. There was only one (0.1%) intraoperative conversion to sternotomy, which was due to bleeding. Among patients who underwent mitral valve repair, mid- and long-term follow-up was possible in 314 patients (MR in 96.8%, MS in 3.1%, anterior leaflet involvement in 36.0%, rheumatic etiology in 10.8%). Of them, various repair techniques including annuloplasty (95.9%), commissuroplasty (23.2%), neochordae formation (33.1%), leaflet resection (40.8%), leaflet plication/extension (7.6%), chordal transfer/shortening (4.1%), edge-to-edge (3.5%) were utilized, with no/trivial or mild residual MR in 95.2% of patients. The median follow-up was 50.2 months, during which freedom from MR (>mild) at 5 years was 84.3%, and freedom from major adverse event or death at 5 years was 92.5%. Reoperation for mitral valve problem occurred in 8 (2.5%) patients (6 recurred MR, 1 MS, 1 infective endocarditis) (Figure P61-1).

Conclusions: A video-assisted MICS is safe with low mortality and morbidity. It is also feasible in mitral valve repair in terms of utilizing various types of repair techniques and the efficacy of repair.





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P62 Minimally Invasive Redo Surgery for Late Isolated Tricuspid Valve Regurgitation

Giacomo Bianchi, Marco Solinas, Pierandrea Farneti, Matteo Ferrarini, Mattia Glauber. Hospital & Research Institute CREAS IFC CNR – Massa, G. Pasquinucci Heart Hospital, Massa, Italy.

Objective: Tricuspid valve (TV) regurgitation after left-sided-valve surgery is likely to occur and progress over time, requiring surgical intervention and negatively affect survival and prognosis. We analyzed the outcome of a consecutive series of patients at our institution that underwent isolated redo isolated tricuspid valve procedure.

Methods: Between January 2005 and January 2012, a total of 59 patients underwent isolated tricuspid valve surgery; of those 13 (22%) patients (2 males, 11 females; mean age 65.5±7.7 years) underwent redo procedure for new-onset tricuspid regurgitation (TR) through right lateral mini-thoracotomy approach. The preoperative left ventricular ejection fraction was 56%±12%; the thirteen patients underwent a total of 19 previous cardiac operations for left-sided valve pathology. Tricuspid regurgitation progressed from grade ≤2+/4+ to 4+/4+ until surgery in 204±134 months. Preoperative NYHA class was grade ≥III in 9 (69%) patients.

Results: Ten patients (77%) had TV repair and three patients had TV replacement. TR decreased from grade 3.85±0.55 to 0.92±0.7 (p≤0.001) as well as pulmonary artery pressure (PAPs; 51.5±18.9 mmHg vs. 37.9±10.2 mmHg, p=0.02) postoperatively. One patient (7.7%) died in-hospital for low cardiac output syndrome. The mean follow-up was 15±13 months and was 100% complete. Survival and freedom from HF symptoms were 91.7% 92.5% (Figure). CI: 30-43) and 83.3% (95% CI: 26-41) at 40 months, respectively; NYHA class ≤IIb was found in 81.8% of patients were in. At follow-up the PAPs remained as low as at post-operative assessment (p=0.6).

Conclusions: Redo procedure for isolated TR is a feasible and effective procedure with acceptable in-hospital mortality. High survival rate and freedom from symptoms are associated with stable decrease of PAPs, TR grade and improvement of NYHA class.

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P63 Stand-Alone Mitral Valve Repair: What are the Predictors for Minimally Invasive Approach?

Niv Ad, Sari D. Holmes, Graciela Pritchard, Anthony J. Rongione, Linda Halpin, Paul S. Massimiano. Inova Heart and Vascular Institute, Falls Church, VA USA.

Objective: The surgical approach for isolated mitral valve surgery is dependent on the mitral valve pathology and the surgeon’s experience. The purpose of this study was to determine which clinical variables are associated with the decision to perform isolated mitral valve repair (MVR) using minimally-invasive (MI) approach and the effect of these factors on perioperative outcomes.

Methods: All consecutive patients with stand-alone mitral valve repair from 2005-November 2012 were followed prospectively (N=373). Perioperative morbidity was captured according to STS definitions. Predictors for mid-sternotomy (MS) MVR were examined via logistic regression.

Results: There were 212 patients with MI MVR and 161 with MS MVR surgery. The percent of patients with MI MVR has steadily increased during this time-frame from 35% in 2005 to 76% in 2012 (through November). The significant predictors for MS MVR were older age (OR=1.20, 95% CI: 1.09-1.32, p<0.001), higher BMI (OR=1.06, 95% CI: 1.004-1.11, p=0.03) and CHF (OR=3.19, 95% CI: 1.80-5.65, p<0.001). For every 5 years increase in age, there was 20% greater odds for MS MVR; for each 1 point increase in BMI, there was 6% greater odds for MS MVR; and patients with CHF had 3 times greater odds for MS MVR. In CHF patients (16% vs. 39%, p=0.04), older age patients (12% vs. 47%, p<0.001) and higher BMI patients (3% vs. 24%, p<0.001) the percentage of patients with any STS defined perioperative morbidity was significantly lower in those with MI MVR vs. MS MVR, median length of stay was shorter for MI vs. MS (2 vs. 5 days, p=0.001; 3 vs. 5 days, p<0.001; 2 vs. 4 days, p<0.001, respectively) and there were no differences in operative mortality (0% vs. 3.6%, p=1.00; 0% vs. 4%, p=0.28; 0% vs. 1%, p=1.00, respectively).

Conclusions: The data from our center indicate that age, BMI and CHF are the most important factors predicting which patients receive MI MVR or MS MVR. However, within patients with these factors, outcomes are similar or improved using the MI approach.

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P64 Chasing One-Hundred-Percent Repair Rate in Endoscopic-Guided Mitral Valve Surgery Using Different Patho-Anatomical Shaped Annuloplasty Devices

Markus Liebrich, Deter Riser, Vladimir Vote, Julia Gotten, Ulrike Wale, Timo Weimar, Wolfgang Hemmer, Nicolas Doll, Markus Cesar. SANA Cardiac Surgery, Stuttgart, Germany.

Objective: Although mitral valve (MV) repair is the recommended treatment for severe mitral regurgitation (MR) of primary/secondary etiology, valve replacement remains common, particularly for complex lesions or anterior leaflet (AML) involvement. We sought to characterize the feasibility and outcomes of an “all comers” repair strategy applied systematically in all cases of mitral valve disease using various annuloplasty devices, regardless of complexity, leaflet involvement or age.

Methods: Between November 2008 and August 2012, 646 patients who presented with primary MR (n=455, 70%) or secondary MR (n=191, 30%) underwent endoscopic-guided MV surgery. Specific cusp pathology was isolated posterior mitral leaflet (PML) (n=353, 54.6%), isolated AML (n=41, 6.3%), and bileaflet (BL) prolapse (n=57, 8.9%). The preoperative MR grade was 3.2+/-0.6, left ventricular ejection fraction was >50% in 513 patients (79.9%), 30-50% in 112 patients (17.4%), and <30% in 17 patients (2.6%). Mean age was 64.6+/-12.7 years; 400 patients (62%) were male.

Results: Overall, the MV repair rate was 98% (631 patients). Forty-eight (48) patients (7.4%) had previous cardiac surgery. Eleven (11) patients (1.7%) were suffering from endocarditis of the MV. Repair techniques consisted predominantly of leaflet reconstruction (n=443, 69%) with/without implantation of neochordae and leaflet resection (n=28, 4.4%), combined with ring annuloplasty. According to the MV pathology 9 different annuloplasty devices were used. Concomitant procedures were tricuspid valve surgery (n=59, 9.2%), atrial fibrillation ablation (n=203, 31.4%), closure of an atrial septal defect (n=69, 10.7%), and closure of the left atrial appendage (n=231, 35.7%). Cardiopulmonary bypass time was 154+/-47 min. and aortic cross-clamp time was 91+/-32 min. The mean postoperative hospital stay was 8.6+/-5.7 days. Early echocardiographic follow-up revealed excellent valve function in the vast majority of patients, regardless of the repair technique, with a mean MR grade of 0.3+/-0.6.

Conclusions: A systematic strategy of endoscopic mitral valve repair that uses a variety of techniques and annuloplasty devices allows repair of primary and secondary MR in a reference center, with good short-term outcomes and mid-term durability.

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P65 Robotic Mitral Valve Replacement for Severe Rheumatic Mitral Disease: Perioperative Technique, Outcomes and Early Results

Sahin Senay 1, Ahmet Umit Gullu1, Muharrem Kocyigit2, Aleks Degirmencioglu2, Hasan Karabulut1, Cem Alhan1. 1Acibadem University School of Medicine, Istanbul, Turkey, 2Acibadem Maslak Hospital, Istanbul, Turkey.

Objective: Recent advances in technology have made robotic totally endoscopic mitral valve repair feasible. However, robotic technique may be challenging when the valve pathology is not suitable for repair and replacement is inevitable. We report a case series of robotic mitral valve replacement in patients with severe rheumatic mitral disease.

Methods: From March 2010 to December 2012, a total of 43 patients underwent robotic cardiac procedures. Robotic procedures were performed using the da Vinci Si surgical telemanipulation systems (Intuitive Surgical, Inc, Sunnyvale, CA USA). Twelve of the patients (27.9%) underwent robotic mitral valve replacement with or without additional cardiac procedure (tricuspid valve replacement/ tricuspid valve repair/ left atrial radiofrequency ablation). Rheumatic disease was the underlying pathology in all patients. Mean follow-up period was 13±12 months.

Results: Mean age and EuroSCORE (%) of the patients were 52±11 and 4.3±7. Six patients (50%) had an additional cardiac procedure. No operative and hospital mortality was observed. Mean cross-clamp time and cardiopulmonary-bypass time were 131±40 and 191±60 minutes. Ten of the patients (83.3%) were discharged from the intensive care unit within the postoperative first 24 hours. During the intensive care unit stay, one patient (8.3%) needed prolonged ventilatory support and one patient (8.3%) needed inotropic support. There was one (8.3%) intensive care unit readmission and one (8.3%) hospital readmission observed. During the follow-up, there was no mortality and no need for reoperation or reintervention.

Conclusions: Robotic mitral valve replacement for severe rheumatic mitral disease is technically feasible. Early results are encouraging.

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P66 First Experience with Adjustable Annuloplasty in Degenerative MR Patients

Markus Czesla. Sana Herzchirurgie Stuttgart, Stuttgart, Germany.

Objective: The use of an adjustable, semi-rigid annuloplasty ring in patients with degenerative MR allows post-pump adjustment for optimal results in valve repair.

Methods: Participating in a post-market study to evaluate clinical outcome using this novel device currently 20 patients have been enrolled at our institution. All patients were scheduled for mitral valve repair and experienced post-pump ring adjustment for optimization of coaptation under real-time echocardiography guidance.

Results: All patients presented with anterior, posterior, bileaflet prolapse or even Barlow disease were treated with implantation of neochordae following annuloplasty. Postoperative off-pump adjustment by a mechanical rotating cable attached to the ring leads to an increase in coaptation length up to 4 mm and a disappearance of residual MR.

Conclusions: Postoperative results in all patients were satisfying without any residual MR. The repair of anterior or bileaflet prolapse proves sometimes to be difficult in terms of the correct length of the neocardae. Using postoperative adjustment of the ring diameter may compensate any inaccuracy and prevent SAM phenomenon. In our experience the adjustable annuloplasty device may have the potential for regular use in patients with degenerative mitral valve disease.

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P67 Universal Repair Technique for Bileaflet- and Posterior-Leaflet Myxomatous Mitral Valve Regurgitation

Hugh D. Wolfenden, Levi Bassin, Beatrix Weiss. Prince of Wales Hospital, Randwick, Australia.

Objective: We present our results with a repair technique that is objective, simple and reproducible, based on three measurements: normal posterior chord height, size of the anterior leaflet, and set distance from the posterior annulus.

Methods: This technique was progressively introduced since 2008, with all patients with posterior and bileaflet myxomatous mitral valve disease treated with a standard approach since 2011. Multi (2-5)-headed PTFE neochordal loops were attached to the papillary muscle head(s). The length of the loops was determined by the length of the normal posterior primary chords and attached to the atrial aspect of the posterior leaflet at a standard distance of 1.5 cm from the annulus (Figure P67-1). The neochordae were separated by 6-8 mm along the leaflet surface, and attached to any segment taller than 2 cm and/or with ruptured/elongated primary chords. The repair was supported with a rigid annuloplasty sized on the anterior leaflet. No leaflet resections were performed. Patients with chordal elongation/rupture to the anterior leaflet were not part of this study.

Results: Eighty-seven (87) patients were operated on between 2008 and 2012, 71% male, mean age 67 (38-88 yrs). Isolated posterior leaflet disease was present in 68 and 19 had bileaflet disease. Concomitant procedures included: CABG (n=18), AVR (6), tricuspid repair (10), and AF surgery (14). In the 30-day post-operative period there was no mortality and one stroke. Post-procedure MR grade was ≤mild in all and ≤trivial in 90%. Pre-discharge MR was ≤mild in all and ≤trivial in 86%. Recent echocardiographic follow-up was available in 71/87 patients with a mean follow-up period of 17.1±12.8 months. At follow-up MR was ≤mild in 90%, ≤trivial in 62%, and >moderate in one.

Conclusions: This technique offers a reliable mitral valve repair operation for posterior and bileaflet myxomatous mitral valve regurgitation based on objective measurements, with a standardized and reproducible technique, which is easy to teach. This should allow for more widespread uptake of MV repair, and facilitate minimal access surgery.



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P68 One-Single Antegrade Dose of Cold HTK Cardioplegia is a Safe and Easy Cardioprotective Strategy in Minimally-Invasive Mitral Valve Surgery

Carlo Savini, Giacomo Murana, Marco Di Eusanio, Sofia Martin Suarez, Sebastiano Castrovinci, Giuliano Jafrancesco, Andrea Castelli, Roberto Di Bartolomeo. Ospedale S. Orsola-Malpighi, Bologna, Italy.

Objective: Minimally-invasive cardiac surgery (MICS) sometimes can be technically demanding, especially during some mitral valve surgical procedures. Particularly in these situations, a single-dose cardioplegia seems attractive especially when an endoaortic clamp is used. We retrospectively analyzed our early outcomes using one-single dose of histidine-triptophane-ketoglutarate (HTK-Custodiol) solution for myocardial protection in minimally-invasive mitral valve surgery.

Methods: From February 2003 to October 2012, 49 consecutive patients underwent minimally-invasive mitral valve surgery using an endo-cardiopulmonary bypass (CPB) system and a single-dose of HTK solution as myocardial protection. The mean patient age was 61.1 ± 9.3 years, and the preoperative ejection fraction was normal in all patients. Mean CPB time was 142.2 ± 21.4 minutes, and aortic cross-clamp duration was 92.5 ± 16.2 minutes.

Results: The heart restarted spontaneously after cross-clamp removal in 37 patients (75.5%). Only 7 (14.3%) patients needed inotropic drug support after CPB discharge, and no patients required intraoperative anti-arrhythmic infusion. No significant modifications in myocardial cytonecrosis enzymes during the postoperative period was found (mean CK-MB 75.5 ± 4.2 μg/L at 6 hours, 63.7 ± 4.7 μg/L at 12 hours, and 48.2 ± 3.8 μg/L at 24 hours). There was no ischemic ECG modification in all patients (100%) prior to hospital discharge.

Conclusions: HTK solution allows excellent myocardial protection and a safe long cardioplegic arrest time during elective and urgent minimally-invasive mitral valve surgery. It also reduces the risk of inadequate coronary perfusion due to dislodgement of the endoaortic clamp, and increases the comfort of the surgeon during the procedure. Further randomized studies will be needed to demonstrate its effectiveness compared to repeated blood cardioplegia infusion.

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P69 Myocardial Protection in Minimally-Invasive Mitral Surgery, Using the Endovascular Coronary Sinus Catheter Alone, is at Least Equivalent to Open-Mitral Surgery

Jean-Sébastien Lebon, Pierre Couture, Christian Ayoub, Antoine Rochon, Alain Deschamps, Baqir Qizilbash, Éric Laliberté, Michel Pellerin, Denis Bouchard. Montreal Heart Institute, Montréal, QC Canada.

Objective: One of the most important challenges in minimally-invasive mitral surgery (MIMS) remains to provide optimal endoscopic myocardial protection. We hypothesize that the quality of myocardial protection offered by an endoscopic retrograde cardioplegia alone in MIMS when a transthoracic aortic clamp is used could be equivalent to the combined antegrade and retrograde strategy in open-mitral surgery (OMS).

Methods: After institutional approval, charts of patients admitted for MIMS were reviewed. Patients without coronary artery disease undergoing isolated elective OMS were used as a control group. Our primary end-point was to compare myocardial protection as illustrated by myocardial enzymes (troponin and CK-MB). We also gathered statistics regarding myocardial function, hemodynamic stability and complications. MIMS requires retrograde cardioplegia to be administered through an endovascular coronary sinus (CS) catheter. After aortic transthoracic clamping, cardioplegia was administered at a variable rate to generate a CS pressure ≥ 30 mmHg. If after 5 minutes asystole was not attained, a needle was inserted in the aortic root for antegrade cardioplegia. Adequate retrograde cardioplegia administration was monitored by CS pressure (≥ 30 mm Hg) and asystole during CBP.

Results: Data was collected from 98 MIMS files and 118 OMS files. Adequate intra-operative cardioplegia administration was attained in 73 patients (74%) with retrograde alone and 23 patients (23%) needed the addition of an antegrade cardioplegia needle. Failure to adequately position the CS catheter was observed in only 2 patients (3%). Significantly less MIMS patients required administration of a second inotropic agent. No statistically significant difference was found for maximal CK-MB and number of patients with CK-MB levels > 50 or >100 UI/L. However, mean troponin and lactate levels in MIMS were significantly lower. In the MIMS group, mean troponins were even significantly lower in patients receiving retrograde alone.

Conclusions: A cardioplegia strategy based on the endovascular CS catheter alone, with or without the addition of an antegrade needle, in MIMS provides at least equivalent myocardial protection when compared to OMS.

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P70 The Effects of Evacuation of Custodiol in Minimally-Invasive Cardiac Surgery

Hyung-Gon Je 1, Pil Je Kang1, Sang Kwon Lee1, Hyung Tae Kim1, Si Chan Sung1, Sang-Pil Kim2. 1Pusan National University, Yangsan Hospital, Yangsan, Republic of Korea, 2Pusan National University Hospital, Busan, Republic of Korea.

Objective: Although Custodiol has been widely used in cardiac surgery, there are some concerns on Custodiol-induced hyponatremia and following neurologic complications. Herein, we investigate the effects of Custodiol evacuation during minimally-invasive cardiac surgery (MICS).

Methods: From December 2008 to August 2012, 223 patients underwent MICS. After exclusion (blood cardioplegia, fibrillation, multiple cardioplegia), 142 patients were enrolled in this study. The control group (group 1, n=103) was compared to Custodiol-evacuated patients (group 2, n=39). Changes of sodium (ΔNa), potassium (ΔK), and hematocrit (ΔHct) before and after Custodiol-infusion was investigated and postoperative neurologic complication of two groups were also compared. Custodiol was evacuated through right atriotomy or venting-catheter insertion at right atrium.

Results: There was one mortality in group 2. Mean dosage of Custodiol-infusion was 2000 cc, and mean dosage of Custodiol-evacuation was 1450 cc. There was no significant difference in mean of cardiopulmonary-bypass time and aortic cross-clamp time between two groups. The concentration of Na and Hct after Custodiol-infusion in group 1 were lower than in group 2 (p<0.01). ΔNa and ΔHct were lower in group 2 than in group 1. Need of transfusion (group 1; 81.6%, group 2; 38.5%, p<0.01) and postoperative delirium (group 1; 15.5%, group 2; 0, p<0.01) was more common in group 1 (Table P70-1).

Conclusions: Our experience shows the evacuation of Custodiol reduces risk of postoperative delirium and the need of transfusion by reducing hemodilution during CPB.



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P71 The Results of Single-Port Video-Assisted Thoracic Surgery for Primary Spontaneous Pneumothorax

Do Kyun Kang, Ho-ki Min, Youn Ho Hwang, Hee Jae Jun. Haeundae Paik Hospital, Busan, Republic of Korea.

Objective: Recently, single-port video-assisted thoracic surgery (VATS) has been proposed as an alternative to conventional three-port VATS for bullectomy/blebectomy for primary spontaneous pneumothorax. The aim of this study is to evaluate the feasibility of single-port VATS for primary spontaneous pneumothorax.

Methods: VATS was performed for primary spontaneous pneumothorax in 40 patients from March 2011 to June 2012. We reviewed the medical records of these 40 patients, retrospectively.

Results: Eighteen patients underwent conventional three-port VATS (three-port group) and 22 patients underwent single-port VATS (single-port group). The mean age of patients was 19.8 years in three-port group and 21.6 years in single-port group. The mean operation time was 40.3 minutes in three-port group and 42.5 minutes in single-port group. There was no difference in number of wedge resection, amount of chest tube drainage, operation time and postoperative pain between both groups. The mean length of chest tube drainage and hospital stay were shorter in single-port group than three-port group. These differences were statistically significant. There were less postoperative paresthesias in single-port group than three port group (p=0.04). There was postoperative recurrence of pneumothorax in one patient in three-port group and two patients in three-port group. There was no significant difference between two groups, statistically. The median size of surgical wound was 2.0 cm (range, 1.5-2.5) in single-port group.

Conclusions: In our study, single-port VATS and three-port VATS for primary spontaneous pneumothorax offered a similar result. There were many advantages in length of drainage, hospital stay, postoperative paresthesia and cosmetic result in single-port group compared to three-port group. In well-selected patients, single-port VATS would be considered for primary spontaneous pneumothorax.

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P72 Single-Incision VATS Bullectomy with Suture-Lift Method in Primary Spontaneous Pneumothorax

Chun Sung Byun 1, Jung Joo Hwang2, Jin Ho Choi2. 1Wonju Severance Christian Hospital, Yonsei University College of Medicine, Wonju-si, Kangwon-do, Republic of Korea, 2Eulji University Hospital, Daejeon, Republic of Korea.

Objective: VATS using the baseball-diamond concept is currently the technique of choice for three-port VATS bullectomy of primary spontaneous pneumothorax. However, the procedure has been shown to have neurological paresthesia and pain related to the port sites. Single-incision VATS (SITS) has been proposed as an alternative to three-port VATS for anticipating lower incidence of neurological complications and less wound. Also, SITS needs specific single-port instrument for ergonomic technique application. But, without SITS equipment, we had performed SITS bullectomy using suture-lift method with the conventional VATS instrument.

Methods: We evaluate our initial experience of suture-lift SITS bullectomy (n=12), with randomly assigned three-port VATS bullectomy (n=12) provide a comparison of post-operative result and pain in the same period.

Results: All pneumothorax was primary spontaneously occurred and diagnosed by chest X-ray and chest CT. All surgical procedures during three-port VATS was performed adequately in suture-lift SITS such as endo-stapling, mechanical pleurodesis, air-leak test and cover a polyglycolic acid sheet with fibrin glue (P72-1). There was no difference between the groups in terms of age, resected tissue number, operation time, drainage time and in-hospital stay. However, a difference between post-operative pain scores was noted. The suture-lift SITS group had a lower median score of 2.6 (visual analogue range 1∼10) while the three-port technique reported 4.2 (P<0.05, Paired T-test). During one-month follow-up for single-incision and three-port VATS, no patient had a pneumothorax recurrence in both groups.



Conclusions: Suture-lift SITS bullectomy appears to be easily applicable, safe and efficient in treating primary spontaneous pneumothorax; in hospital did not prepare single-port equipment. Moreover, post-operative pain incidence was lower than three-port VATS.

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P73 The Single-Port Thoracoscopic Surgery Using Anchoring Suture of Lung Parenchyma to Chest Wall Instead of Using Grasping Instrument

Hyo Yeong Ahn1, Do Hyung Kim1, Bongsoo Son1, Yeong Dae Kim2, Hoseok I2, Jeong Su Cho2. 1Pusan National University, Yangsan Hospital, Yangsan-si, Gyeongnam, Republic of Korea, 2Pusan National University Hospital, Busan, Republic of Korea.

Objective: Since single-port thoracoscopic surgery has been developed, there is still difficulty in manipulation of the lung by three thoracoscopic instruments (grasping instrument-thoracoscope-staple) through a single-incision which would cause postoperative paresthesia and wound dehiscence. In our hospital, to decrease limitation of movement of thoracoscopic instruments, the authors used anchoring suture to tag lung parenchyma to the chest wall instead of grasping instrument.

Methods: From September 2012 to December 2012, 25 patients underwent single-port thoracoscopic surgery for lung biopsy of nodule or interstitial lung disease and pneumothorax. Under lateral decubitus position, a 2 cm single-incision was made at an effective area to manipulate and placed by a wound protector (Figure P73-1A). After detecting lung lesion to be resected under a guidance of 5 mm straight-viewing thoracoscope, penetrated prolene 1-0 through chest wall was used (Figure P73-1B) to tag around lung lesion (Figure P73-1C) and anchored to the chest wall. As pulling anchoring suture, the staple was introduced to be settled (Figure P73-1D) and fired (Figure P73-1E, P73-1F).



Results: Performing single-port thoracoscopic surgery using just two thoracoscopic instruments (thoracoscope-staple) was an easy way for a surgeon to manipulate the lung without any difficulty. The median hospital stay was 4.5 days (range, 0.5 to 1 day) and the median day of chest tube placement was 1.5 days (range, 1 to 2 days). The mean postoperative pain measured by Wong-Baker Scale was 0.48 ± 0.65 and the wound dehiscence was not found.

Conclusions: The single-port thoracoscopic surgery using anchoring suture of lung parenchyma to chest wall instead of using grasping instrument would be an effective surgical technique to overcome the obstacles of handling thoracoscopic instruments through small incisions and secure a clear surgical view.

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P74 Single-Incision VATS with Aid of Spinal Needle for Pulmonary Wedge Resection

Dae Hyun Kim 1, Sang Ho Cho1, Young Tae Kwak1, Hyo Chul Yoon2, Soo-Cheol Kim2. 1Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea, 2Kyung Hee University Hospital, Seoul, Republic of Korea.

Objective: A few publications describing the single-incision VATS for wedge resection of lung have been reported. We introduce the single-incision VATS technique with aid of spinal needle for wedge resection of lung.

Methods: Between March 2011 and December 2012, 109 patients were enrolled. A 1.5∼2.0 cm hole in anterior or mid-axillary line of the 5th∼8th intercostal space was created according to the location of the target lesion. A 5 mm 30° scope and a 5 mm grasper were inserted into pleural cavity through the hole without guidance of a trocar. The target lesion was picked up by a grasper and then a spinal needle (20 gauge, 9 cm) bended approximately 90° was inserted into pleural cavity through the most appropriate intercostal space. The target lesion was hooked by the needle and the grasper was taken out of the pleural cavity. A reticulating stapler was inserted into the pleural cavity through the hole and wedge resection of lung was performed. Additionally, the stapled line was covered with Neoveil sheet and fibrin glue in the pneumothorax patients.

Results: Patients included 78 men and 31 women with the mean age of 37.5 years (range 15∼75). There were 69 patients with spontaneous pneumothorax patients and 40 patients with pulmonary mass or disease (primary lung cancer 13, metastatic lung cancer 3, hamartoma 3, organizing pneumonia 4, granuloma 3, interstitial lung disease 5, tuberculosis 4, sarcoidosis 2, and others 3). The mean operative times were 33 minutes (20∼60) in the 69 pneumothorax patients and 41 minutes (20∼70) in the other 32 patients. Neither mortality nor major morbidity was observed in all the 109 patients. The median chest drain duration and median hospital stay were 2 days (1∼5) and 3 days (2∼7) in the pneumothorax patients. There was no recurrence of pneumothorax during mean 9 months follow-up period in the pneumothorax patients.

Conclusions: Single-incision VATS technique with aid of spinal needle for pulmonary wedge resection is simple and easy to perform and may be applicable to both spontaneous pneumothorax and peripheral lung lesions.

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P75 Feasibility of Video-Assisted Thoracoscopic Anatomic Pulmonary Resection in Patients with Central Lung Cancer

Hyeong Ryul Kim 1, Yong Jik Lee2, Geun Dong Lee1, Yong-Hee Kim1, Dong Kwan Kim1, Seung-il Park1. 1Seoul Asan Medical Center, University of Ulsan Medical College, Seoul, Republic of Korea, 2University of Ulsan Medical College, Ulsan, Republic of Korea.

Objective: To evaluate the feasibility and efficacy of video-assisted thoracoscopic (VATS) anatomical pulmonary resection in patients with central lung cancer.

Methods: Between July 2004 to December 2011, 1,123 patients underwent VATS anatomical pulmonary resection and systematic mediastinal lymph node sampling or dissection (MLND) for lung cancer. A subsegmental, segmental or lobar endobronchial tumor was found in 80 patients and confirmed as cancer by bronchoscopic biopsy or brushing. Eighty (80) patients were followed-up until June 2012 and medical records were reviewed retrospectively.

Results: Median age of 80 patients (64 men) was 61 years (range 24, 80). A VATS lobectomy was attempted in 55 patients, a bilobectomy in 22 patients and a segmentectomy in 3 patients. Additional VATS bronchoplasty was completed in 2 patients. Conversion to thoracotomy (5%) was occurred in 3 patients for lobectomy with bronchoplasty and in one patient for bilobectomy with bronchoplasty. Complete resection (R0) was not possible in 5 patients (6.3%). Among theses, 4 had positive bronchial resection margin and 1 had remnant tumor around paratracheal tissue with extranodal invasion. Of 4 patients with positive RM, 3 were intraoperative R1 resection and 1 was intraoperative R0 resection. Pathologic stage IA was reported in 31 patients (38.8%), IB in 18 (22.5%), IIA in 15 (18.8%), IIB in 3, IIIA in 7 and IV in 6 patients. There was one operative mortality due to small bowel infarction. Prolonged air-leakage (> 1 week) occurred in 5 patients, pneumonia in 4, vocal cord palsy in 2, chylothorax in 2, atrial fibrillation in 1 and bleeding requiring reoperation in 1 patient. Median hospital stay after operation was 6 days (range 2, 26). Median follow-up duration was 28.8 months (range 0.1, 93.8). Recurrence after complete resection was observed in 13 patients (disease-free survival time 79.1±3.8 months). Among total 9 observed deaths, cancer-related death occurred in 5 patients (overall survival time 82.9±3.4 months).

Conclusions: VATS anatomical pulmonary resection is a safe procedure providing a low-operative mortality and a low probability for conversion to open thoracotomy. VATS anatomical pulmonary resection is feasible for central lung cancer providing comparable outcomes. More experiences and long-term data are needed.

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P76 Comparison of Surgical Outcome of Lung Cancer between Video-Assisted Thoracic Surgery and Open Thoracotomy in Patients Aged 80 or Over

Taichiro Ishizumi 1, Yasufumi Kato2, Tatsuya Inoue1, Norihiko Ikeda2, Jitsuo Usuda1. 1Nippon Medical School, Tokyo, Japan, 2Tokyo Medical University, Tokyo, Japan.

Objective: The effectiveness of video-assisted thoracic surgery (VATS) for elderly patients with lung cancer is unclear. We compared the postoperative course of VATS and thoracotomy in patients aged 80 or over who underwent lobectomy for lung cancer.

Methods: We retrospectively reviewed the charts of 72 patients aged 80 or over who underwent lobectomy and systematic lymph node dissection for previously untreated lung cancer between January 2007 and October 2012.

Results: The mean age was 81.6 (range 80-88). The pathological stages were IA in 25, IB in 33, IIA in 6, IIB in 3, and III A in 5 cases. We performed thoracotomy in 52 patients and attempted VATS lobectomy in 20 patients, but 1 case converted to thoracotomy due to pulmonary artery injury. The median operative duration was 207 minutes for the thoracotomy group and 213 minutes for the VATS group (p=0.821). The median blood loss was 82.0 ml for thoracotomy group and 74.5 ml for VATS group (p=0.544). The median chest tube indwelling duration was 3.8 days for the thoracotomy group and 4.2 days for the VATS group (p=0.271). The median hospital stay was 10.5 days for the thoracotomy group and 10.2 days for the VATS group (p=0.496). Postoperative complications occurred in 14 patients (19.4%); prolonged air leak in 7, pneumonia in 5, atrial arrhythmias in 3, delirium in 3, and bronchopleural fistula in 1. There were no significant differences in the occurrence of complications between the two groups. However, these groups had a significantly higher incidence of complications than patients younger than 80.

Conclusions: VATS lobectomy for elderly patients can be performed relatively safely without severe complications. However, as shorter hospitalization associated with minimally-invasive procedures was unattainable due to mild complications, pre-and post-operative management in elderly patient requires considerable attention.

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P77 Comparison of Energy-Based Vascular Instruments for VATS Lobectomy

Yoshio Tsunezuka. Ishikawa Prefectural Central Hospital, Kanazawa, Japan.

Objective: During complete VATS lobectomy (c-VATS), suture ligation of pulmonary artery (PA) and treatment of intraoperative bleeding can be more stressful and challenging than during standard thoracotomy. We consider that energy-based instruments (EBIs) are useful clinical tools for dividing the PA in c-VATS. We investigated whether several EBIs, the LigaSure (LS), Enseal (ES) as vessel sealing systems (VSS), and ultrasonic energy device (HS) were experimentally and clinically safe and effective for ligation of PA.

Methods: Experimental study: The burst pressures (BP) of resected porcine common carotid arteries (diameter about 5 mm) with each EBI were measured and histopathologically analyzed. The angiocatheter was attached to a digital pressure monitor to record maximal intraluminal pressure (mmHg). Samples were histologically analyzed. Using ES, sealing time was changed from 2 sec to 8. Clinical study: a total of 180 cases were analyzed. We performed c-VATS with 2-ports and one 3 cm utility window. Thick segmental PA (diameter >10mm) were divided with staplers. PA with 5 mm and larger in diameter were ligated with a suture and the peripheral site was ligated with the EBIs.

Results: Experimental study: There was no significant difference in the BP among two VSS (458/452mmHg) but higher with VSS compared to HS (199 mmHg). Sorter sealing time with ES was insufficient for sealing arteries, their BP is lower (211-265mmHg) than LS and ES with standard sealing time (8s). Histopathologically, the cut ends of arteries were completely sealed and degenerated by the VSS, the lengths of the weldings were longer than HS. However, the welding shape was destroyed at some point in ES; the cause was suspected to be the cutter systems. Clinically, there were some intraoperative bleeding cases from the peripheral sites; their PA was sealed with ES or HS resulted from moving of lung specimens.

Conclusions: These studies demonstrated the safety and the efficacy of the LS to seal and ligate pulmonary arteries in c-VATS. While ES and HS are not suit for dealing several PA because of clinical bleeding and histological imperfect welding constructions.

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P78 Video-Assisted Thoracoscopic versus Open Surgery for Early-Stage Thymoma: A Comparative Analysis of Surgical Outcomes

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: Video-assisted thoracoscopic surgery (VATS) may be used for resection of various mediastinal tumors. However, a VATS approach for thymoma is still controversial. The objective of this study was to compare the VATS and open surgery to see whether VATS thymectomy could be used as successfully to treat early-stage thymoma.

Methods: Between 2002 and 2011, we retrospectively reviewed 58 patients (29 males and 29 females) with early-stage (Masaoka stage I, II) thymoma who underwent thymectomy in our institution. All of the patients had no associated myasthenia gravis. Of these, VATS was performed in 30 patients (the VATS group) and open (trans-sternal) surgery was performed in 28 patients (the open group). Demographic and clinical features, surgical outcomes were analyzed.

Results: Mean age was 53.0 ± 13.9 years (range, 11 to 77 years). Among the VATS group, 17 patients were operated by right-sided (56.7%), and the others were operated by left-sided (43.3%). One patient in the VATS group required conversion to posterolateral thoracotomy because of severe adhesion between the tumor and the mediastinal pleura which mimicked invasion to the lung. There was no in-hospital mortality. The difference between the VATS and open groups in mean age (51.7 ± 14.1 years vs. 54.5 ± 13.9, p=0.456); male:female ratio (13:17 vs. 16:12, p=0.431); morbidity (3.4% vs. 10.3%, p=0.138) were not statistically significant. However, mean tumor size (4.7 ± 1.5 cm vs. 7.1 ± 2.5 cm, p < 0.001), mean operation time (79.7 ± 29.8 min vs. 129.8 ± 35.9 min, p < 0.001) and mean duration of postoperative hospital stay (3.7 ± 2.4 days vs. 9.3 ± 3.2 days, p < 0.001) were significantly different. During the follow-up period, none of the patients died from thymoma-related causes. There was no difference in recurrence rate between the two groups (10.0% vs. 10.7%, p=1.000).

Conclusions: Our data indicate that VATS thymectomy for early-stage thymoma is technically feasible and can produce satisfactory surgical outcomes. But, further investigation with long-term follow-up is needed.

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P79 Prognosis After Enucleation of Esophageal Gastrointestinal Stromal Tumor

Hyo Yeong Ahn, Hoseok I, Jeong Su Cho, Do Youn Park, Gwang Ha Kim, Yeong Dae Kim. Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea.

Objective: Of gastrointestinal stromal tumors (GIST), esophageal GIST is extremely rare neoplasm, arising from mesodermal tissue in esophagus. Although new chemotherapeutic agents have emerged, radical surgical removal is still one of optimal treatment. Among various approach methods, we tried to perform video-assisted thoracoscopic mass removal, excluding a large-sized mass. Here, we reviewed long-term surgical results of patients with esophageal GIST.

Methods: From January 2002 to June 2008, six patients (two male and four female, mean age 54.3±14.7 years, range 34-71) diagnosed with esophageal GIST in our hospital underwent surgical resection, excluding one patient who had a concomitant malignancy. All patients’ data, tumor characteristics, surgical procedure and recurrence data were analyzed retrospectively.

Results: Of them, three patents had preoperative significant symptom, two patients had tumor size > 3cm diameter, one patient was suffered from increasing mass size and two were already suspicious of GIST under preoperative endoscopic ultrasound. The location of tumors were three cases in upper thoracic, two in mid-thoracic and one in lower thoracic esophagus. All patients underwent macroscopically complete surgical resection: video-assisted thoracoscopic surgery (VATS) for five patients and thoracotomy for one; right-side approach for five patients and left-side approach for one. The mean tumor size was 4.6±1.8cm (range 2.8-7.9cm). Based on National Institutes of Health (NIH) consensus classification system, tumors were identified as an intermediate risk of malignant potential for five (83.3%) and low risk for one (16.7%). There were no perioperative mortality, complication and recurrence during long-term follow-up (mean follow-up 52 months, range 37-60 months).

Conclusions: Although surgical resection of esophageal GIST remains the mainstay of treatment, macroscopically complete surgical resection using VATS, especially in suspicious low malignant risk esophageal GIST, could be a feasible choice and make better chance for long-term free-recurrence.

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P80 Surgical Enucleation of Submucosal Esophageal Tumors: Feasibility of Minimally Invasive Approach and Comparison with Open Approach

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: Surgical enucleation is the treatment of choice for submucosal esophageal tumors (SMTs) in symptomatic, larger, or ill-defined lesions. Enucleation of SMTs has traditionally been performed via thoracotomy. However, recently minimally-invasive approaches (thoracoscopic and laparoscopic techniques) have been introduced and successfully applied. We present here our experiences with the thoracotomy and thoracoscopic approach to SMTs.

Methods: Between August 1996 and May 2012, we retrospectively reviewed 47 patients with SMTs who underwent surgical enucleation. All (n=34) patients underwent the thoracoscopic enucleation as the initial approach. Since 2006 it has been first introduced to SMTs in our institution. Demographic and clinical features, tumor-related factors, surgical outcomes were analyzed.

Results: There were 30 males (63.8%) and 17 females (36.2%); mean age was 50.0 ± 12.2 years (range, 16 to 79 years). Histology revealed leiomyoma in 45 patients, GIST in 1 patient and schwannoma in 1 patient. Seventeen (17) patients (36.2%) were symptomatic. The tumors were located in the upper (n=17), middle (n=18), and lower (n=12) thirds of the esophagus. Thirteen (13) patients underwent planned thoracotomy enucleation. Of 34 patients planned for thoracoscopic approach, 5 patients required conversion to thoracotomy because of too small tumors or poor visualization in 4 patients and accidental mucosal injury in 1 patient. There was no mortality. There were no major postoperative complications including postoperative leakage. Compared to thoracotomy, thoracoscopic approach had a little shorter operation time but without significance (thoracoscopy vs. thoracotomy = 131.8 ± 48.1 vs. 168.8 ± 73.7 minutes, p=0.128). There was a significant difference in the length of hospital stay (thoracoscopy vs. thoracotomy = 9.5 ± 3.0 vs. 17.0 ± 4.9 days, p<0.001).

Conclusions: Thoracoscopic enucleation of submucosal esophageal tumors is technically safe and associated with a shorter length of hospital stay compared with thoracotomy approaches. Thoracoscopic approach is recommended as a standard procedure in experienced centers.

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P81 Primary Aortic Coarctation Diagnosed in the Older Patient: Endovascular Treatment with Thoracic Covered Stents

Keith B. Allen 1, A. Michael Borkon1, John Forman2, Sanjay G. Khicha3, Alessandra Puggioni4, Chandrahas Patel4, Steve Laster1, Sanjeev Aggarwal1, J. Russell Davis1, Kelsey E. Allen1. 1St. Luke’s Hospital, Mid-America Heart & Vascular Institute, Kansas City, MO USA, 2Freeman Health System, Joplin, MO USA, 3Wichita Surgical Specialists, Wichita, KS USA, 4Scottsdale Healthcare System, Scottsdale, AZ USA.

Objective: Primary aortic coarctation (PAC) has been managed in younger patients with uncovered stents; however, in older adults this may be associated with an increased incidence of complications, particularly aortic dissection or rupture. We describe the use of covered thoracic stents to successfully manage previously undiagnosed PAC in older adults.

Methods: From 2011-2012, PAC was identified in five adult patients at four centers (Figure P81-1). Endovascular management included covered thoracic stents (CTAG, WL Gore and Associates, Flagstaff, AZ USA) by themselves or in combination with abdominal aortic extension cuffs (Excluder Cuffs, WL Gore and Associates, Flagstaff, AZ USA). Demographics, operative details, procedural complications and follow-up were retrospectively reviewed.

Results: Covered stents were successfully deployed in all patients (4 females/1 male). Average age was 62 (range 44-76). Two patients were asymptomatic while three patients presented with ischemia (cerebral, colonic, and lower extremity). Covered thoracic stents were delivered through open femoral exposure; two patients required additional abdominal aortic extension cuffs. Left subclavian artery was preserved in all patients. Graft deployment was facilitated using 30 mg of adenosine to obtain transient asystole in four patients. Balloon dilatation was not performed prior to graft placement, however, grafts were dilated post deployment. There were no deaths, spinal cord ischemia, or vascular access morbidity. Following treatment, pressure gradient across the PAC was zero in all patients (Figure P81-2). Average length of stay was 4 days (range 2-5). With follow up of 6 to 25 months, all patients are alive and well with stable endografts by computed tomography (Figure P81-3).

Conclusions: The treatment of primary aortic coarctation in adults using covered stents is feasible and may reduce the risk of aortic disruption, particularly in older patients, when compared to uncovered stents.







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P82 Less Invasive Approach to the Patients Undergoing AVR with Moderately Enlarged Ascending Aorta: PTFE Felt Wrapping Surgery

Makoto Hibino, Kazuyoshi Tajima, Ken-ichiro Uchida, Hisaaki Munakata, Kei Fujii, Wataru Kato, Yoshiyuki Takami, Yoshimasa Sakai. Nagoya Daini Red Cross Hospital, Nagoya, Japan.

Objective: To prevent the post AVR aortic event, the concomitant ascending aortic surgery is recommend to the patient with more than 50 mm in tricuspid aortic valve. There are dilemmas about the increase of the operative risk by the replacement of ascending aorta and the future risk of ascending aortic enlargement by leaving the moderately enlarged ascending aorta untreated. There are many reports of less invasive ascending aortic surgery to reduce the risk of the operation and future enlargement, such as ascending aortoplasty and ascending aortic wrapping with kinds of materials. For this purpose, we have performed ascending aortic PTFE felt wrapping to the patients undergoing AVR with moderately enlarged ascending aorta. To testify the efficacy of our approach, we hereby report our long-term results.

Methods: Between January 2005 and September 2011 at our single institute, we performed ascending aortic PTFE felt-wrapping surgery to 9 patients from 312 patients undergoing cardiac surgery including AVR. Computed tomography scan of the ascending aorta was performed in the preoperative, early and late postoperative term. Dates were analyzed retrospectively. PTFE felt wrapping was performed after AVR was performed and the hemostasis of the ascending aorta was confirmed. PTFE felt (15×15 cm) was trimmed into a butterfly shape to fit the ascending aortic curvature.

Results: The mean age was 68.7±7.6 years (range, 57 to 77). The overall aortic valvular diseases we treated were: 2 aortic insufficiency, 6 aortic stenosis, 1 aortic stenosis and insufficiency and 6 bicuspid aortic valves. There was no hospital death, no morbidity and no postoperative aortic events. The mean interval of the follow-up CT scans was 2.4 years (range, 0.03 to 5.69). The diameters of the ascending aorta were significantly reduced from mean 46.9±3.3mm (range, 43 to 54) to mean 39.6±5.6mm (range, 29 to 46) in late term (P=0.0077). There was no enlargement in the proximal and distal portion of the felt wrapping.

Conclusions: The PTFE felt-wrapping surgery given to the patients undergoing AVR with moderately enlarged ascending aorta is useful to reduce the diameter, and to prevent future enlargement less invasively.

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P83 Employment of Extracellular Matrix Scaffold as a Tubular Graft for Ascending Aorta Aneurysm Repair

Mahesh Ramchandani, Tadashi Motomura, Dewei Ren, Limael E. Rodriguez, Luis J. Garcia-Morales, Bagrat Grigoryan, Brandi Scully, Jane Grande-Allen. Methodist DeBakey Heart and Vascular Center, Houston, TX USA.

Objective: While extracellular xenograft repair has produced encouraging results when applied to cardiac, valvular, and specific aortic defects, its employment as a tube graft to replace the ascending aorta has not been reported. We describe a patient who underwent resection and replacement of an infected ascending aortic graft with an extracellular matrix (ECM) conduit. The patient did well, but 14 months later developed a pseudoaneurysm from the staple line used to construct the ECM conduit. The ECM graft was subsequently explanted and replaced with Dacron. There was no residual infection. We present histological and mechanical properties of the explanted ECM material.

Methods: Explanted ECM material was examined and compared with unused control material. Histological examination included Annexin V, c-Kit (C-19), elastin, and CD45. Mechanical testing utilized the Enduratec 3200 Tensile system (Bose Corporation, Eden Prairie, MN USA). ECM segments were preconditioned for 10 cycles, then pulled in tension, at a rate of 0.15 mm/sec, until failure while recording time, load, and displacement (Figure P83-1).



Results: We observed no remarkable histological differences between explanted and control specimens; both had similar cellular components. There was a lack of infiltrating or repopulating cells within the explanted matrix. No dissection, delamination, or breakdown of material was noted. Mechanical testing of control ECM demonstrated an elastic modulus of 42.9±11.6 MPa (n=5). Elastic modules of the explanted sample was 6.6 MPa in the circumferential direction and 13.0 MPa in the longitudinal direction (native ascending thoracic aorta range: 2.0-6.5 MPa).

Conclusions: Our experience suggests that its superior strength, handling characteristics, and resistance to infection make ECM scaffold a possible alternative conduit to cryopreserved homografts. We were surprised the explanted sample did not show endothelialization, which is inconsistent with reports of post-implant ECM transformation. Applicability as an aortic conduit merits further investigation to better understand behavior of ECM in this situation. Long-term durability data is also needed, especially for shear stress and ideal securing techniques when implanted as primary grafts in high-pressure vascular systems.

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P84 Less Invasive Surgery of the Proximal Aorta

Petar Risteski, Nadejda Monsefi, Tanja Josic, Sherife Bala, Ali Al-Sayed, Anton Moritz, Andreas Zierer. Johann Wolfgang Goethe University, Frankfurt am Main, Germany.

Objective: Partial upper sternotomy (PUS) is established less invasive approach for single- and double-valve surgery. Reports of aortic surgery performed through PUS are rare.

Methods: The records of 52 patients undergoing primary elective surgery on the proximal aorta through PUS between 2005 and 2011 were reviewed. Patients mean age was 57±16 years, 35% were in New York Heart Association Class III or IV, 59% had recent cardiac decompensation, and 17% had pulmonary hypertension. The PUS was taken down to either the 4th (44 patients; 85%) or 5th (8 patients; 15%) left intercostal space as appropriate.

Results: No conversion to full sternotomy was necessary. The aortic cross-clamp, cardiopulmonary bypass and operative times averaged 136 ± 20 min., 186 ± 36 min. and 327 ± 83 min., respectively. In eight patients, the right axillary artery was cannulated for establishing cardiopulmonary bypass; the other 44 patients were cannulated centrally. All patients except one received a procedure on the ascending aorta, either replacement in 30 (58%) or reduction aortoplasty in 21 (40%). Aortic root replacement was additionally performed in 31 patients (60%), including David procedure in 20 (38%) and Ross procedure in 6 (11.5%). Furthermore, the aortic arch was replaced either partially in 5 (10%) or totally in 3 (6%) patients, in moderate hypothermia employing antegrade cerebral perfusion. Additional procedures, among others, included mitral valve repair in 15 (29%) patients and coronary grafting with the left internal thoracic artery to left anterior descending in 3 (6%) patients. Ventilation time, intensive care unit and hospital stay averaged 17 ± 12 hours, 2 ± 1, and 11 ± 9 days. Myocardial infarction was not observed. Chest drainage was 470 ± 380 ml/24 hours. Permanent neurologic deficit did not occur. Wound dehiscence was observed in a single patient (2%). Thirty-day and hospital mortality were not observed.

Conclusions: Less invasive surgery on the aortic root, ascending aorta and aortic arch can be performed safely and reproducibly. Potential benefits include a minimized risk of wound dehiscence and reduced postoperative bleeding. The PUS does not compromise the quality of the operation.

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P85 Repair of Regurgitant Biscuspid Aortic Valves According to Functional Classification of Aortic Insufficiency: Long-Term Results

Khalil Fattouch 1, Giuseppe Bianco1, Giuseppe Nasso2, Giacomo Murana3, Sebastiano Castrovinci3, Massimo Salardino1, Emanuela Clara Bertolino4, Giuseppa Caccamo4, Giuseppe Speziale2. 1Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Palermo, Italy, 2Department of Cardiovascular Surgery, GVM Care and Research, Anthea Hospital, Bari, Bari, Italy, 3Department of Cardiovascular Surgery, University of Bologna, Bologna, Italy, 4Department of Cardiovascular Disease, University of Palermo, Palermo, Italy.

Objective: Bicuspid aortic valve (BAV) is frequently associated with aortic insufficiency (AI) due to cusps disease or aortic root dilatation. Starting from the functional classification of AI, we used a reconstructive systematic approach.

Methods: From February 2003 to January 2012, 92 consecutive patients (mean age 55±15 years; 78% male) underwent aortic valve repair (AVR) for regurgitant BAV with or without aortic root surgery. We identified Type I lesions in 23.9% of patients, Type II in 61.9% and Type III in 14.2%. Cusp pathology was treated with central plication (n=35), free-edge reinforcement (n=31), triangular resection (n=14), pericardial patch (n=10) and our approach “the chordae technique” (n=30). Root dilatation was corrected with subcommissural plasty (n= 25), supracommissural aortic replacement (n=29), or valve reimplantation (n=47). Mean follow-up was 50±18 months.

Results: The severity of aortic insufficiency, as assessed by Doppler echocardiography (graded from 0 to 4) preoperatively and at late follow-up, was 3.5 ± 0.6, and 0.7 ± 0.9, respectively, and freedom from recurrence of AI ≥ grade II of 92.5%. There have been no operative and postoperative deaths. Freedom from reoperation was significantly different between Type I+II and type III (p<0.01), and between “the chordae technique” and plication compared to free-edge reinforcement (p<0.01). Significant difference was found between AVR and valve reimplantation compared with isolated AVR (p=0.02). Aortic root diameter between 40 to 45 mm in patients underwent AVR alone is more likely associated with reintervention.

Conclusions: Type I and II BAV can be ease reproducibly repaired and is associated with long-term low incidence of recurrent insufficiency. Valve reimplantation had better outcomes compared with isolated AVR. Aortic size larger than 40 mm should be considered triggers for concurrent aortic root repair.

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P86 David I Reimplantation Procedure and Bentall-De Bono Operation through Partial Upper J Ministernotomy: A Safe Option

Mauro Del Giglio 1, Elisa Mikus2, Simone Calvi2. 1Villa Torri Hospital, Bologna, Italy, 2Maria Cecilia Hospital, Cotignola, Italy.

Objective: Combined surgery of both the aortic valve and the ascending aorta through an upper “J” sternotomy approach has not been widely described in literature. We describe our experience using a minimally invasive approach for aortic valve (AV) and ascending aorta replacement using either David I (reimplantation) or Bentall technique.

Methods: 34 patients who received both an ascending aorta and aortic valve replacement at our institution between January 2009 and September 2012 were retrospectively reviewed. 16 of them underwent an aortic valve-sparing surgery and the other 18 a Bentall operation. There were 29 male (85.3%) and the mean age was 57.6±12.1 years (range: 35-79 years). Median aortic root diameter was 54.3 mm. In case of AV-sparing procedure the ascending aorta has been replaced with a Vascutek Gelweave Valsalva - Terumo graft up to the origin of the brachiocephalic artery.

Results: The hospital mortality was 2/34 (5.8%); median cardiopulmonary-bypass time and mean cross-clamp time were respectively 136.3 ±48.7 min and 118.9±39.4 min. Median intensive care unit stay was 2.4 days and total length-of-stay was 10.2 days. Two patients needed to be revisited for mediastinal bleeding. There were no sternal or wound complications

Conclusions: A partial upper sternotomy is considered a safe option for aortic valve replacement. Our experience confirms that a partial upper “J”-shaped sternotomy can be chosen also for complex aortic root surgery like David-I reimplantation and Bentall technique without affecting the patient’s outcome and proving to be as safe as standard procedure in terms of hospital morbidity and mortality rates.

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P87 Hybrid Repair of Thoracic and Thoraco-Abdominal Aortic Aneurysms: Ten- Year, Single-Surgeon Experience in 158 Patients

Giampiero Esposito, Davide Patrini, Samuele Bichi, Camillo Poloni, Pasquale Pellegrino, Marianna Redaelli, Giuseppe Nicola Valerio, Vincenzo Arena. Humanitas Gavazzeni Hospital - Bergamo, Bergamo, Italy.

Objective: Hybrid approach to thoracic and thoracoabdominal aortic aneurysm may improve the morbidity and mortality in patients who are suboptimal candidates for conventional open surgery. The aim of this study was to analyze retrospectively a 10-year single-surgeon experience in the hybrid treatment of aneurysmal aortic disease of different extent and etiology.

Methods: We carried out a retrospective review of 158 patients treated from November 2002 to November 2012 by a single surgeon (Dr. G. Esposito) requiring off-pump surgical rerouting of supraaortic vessels +/- visceral vessels from the undiseased ascending aorta (36 pts) or an on-pump rerouting of supraaortic vessels +/- visceral vessels from a replaced ascending aorta (108 pts). In 15 patients with mega-aortic syndrome involving also the abdominal aorta a surgical two-stage approach was performed firstly with on-pump ascending aorta replacement plus epiaortic vessels rerouting; secondly, an off-pump abdominal aorta replacement plus visceral vessels rerouting was done to create a proximal and distal landing zone for subsequent endograft implantation. The endovascular procedure has been performed in 130 of 145 survived patients (89.6%) in order to cover the remaining diseased aorta. The etiology of the aortic aneurysm was type A acute dissection in 68 patients, chronic dissection in 39 patients, degenerative aneurysmal dilatation in 51 patients.

Results: The 30-day mortality rates was 13/158 (8.2%), the incidence of temporary renal failure was 5.2%. None of the patients had stroke or spinal chord injury. Mean follow-up was 72 months (range 2-120) and the survival rate was 87%. The endoleak’s rate was 3/145 (2%).

Conclusions: Hybrid staged surgical and endovascular therapy represent a good alternative option in the treatment of diffuse aneurysmal dilatation involving the thoracic and thoraco-abdominal aorta at different extent especially in high-risk patients and urgent/emergent cases. The outcome of these patients is strictly dependent from aortic anatomy, comorbid status and age. In this single-surgeon experience the hybrid staged aortic repair seems to offer a safe alternative treatment to conventional surgery showing good long-term results.

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P88 Minimal-Invasive Preconditioning of the Spinal Cord Collateral Network by Preoperative Segmental Artery Coil Embolization for Extended Thoracoabdominal Aneurysm Repair

Christian D. Etz, Maximilian Luehr, Aida Salameh, Alexandro Hoyer, Felix F. Girrbach, Konstantin von Aspern, Stefan Dhein, Friedrich Wilhelm Mohr. Leipzig Heart Center, Leipzig, Germany.

Objective: Paraplegia remains the most devastating complication following extensive descending and thoracoabdominal aortic aneurysm repair (TAA/A). The Collateral Network (CN) concept of spinal cord perfusion suggests segmental artery (SA) occlusion to trigger arteriogenesis leading to the restoration of spinal cord blood flow from alternative arterial sources within 96-120h. A “two-staged” approach to TAA/A-repair–which has been shown to significantly reduce paraplegia–is challenging, particularly in the absence of an appropriate vascular segment for the “staged” anastomosis or an endovascular landing zone. Selective, transarterial “Minimally Invasive SA-Coil Embolization” (MISACE) provides a solution to endovascularly trigger arteriogenic CN preconditioning. MISACE–prior to conventional open or endovascular repair–may enable safe “single-stage”-repair of extensive TAA/A.

Methods: An experimental study was undertaken to explore the feasibility of MISACE. A 6F sheet was introduced via the groin in the sedated animal and a 4F right Judkins catheter allowed for selective angiography and coil insertion. All thoracic and lumbar aortic SAs (T3-L5) were successfully identified by dye injection. Pediatric platinum endovascular coils (Trufill Pushable Coils, 3x20mm, Cordis, Germany) were used to serially occlude the segmental arteries mimicking a “first-stage” preconditioning procedure.

Results: Successful SA coil deployment was verified intraoperatively: MISACE achieved successful coil occlusion (100%) with a coil-to-occlusion and cath-positioning time of 30-45 seconds and 15-30 seconds per SA, respectively. The total MISACE procedure time was less than 45 minutes. Intra- and post-operative hemodynamics were much more stable than after conventional open “first-stage” procedure, thus preventing acute CN-pressure fluctuations during the most vulnerable period in the first 48h postoperatively. No intraoperative coil dislodgement occurred. Autopsy revealed complete occlusion of all embolized SAs enhanced by early local thrombus formation. No SA dissection was observed.

Conclusions: A two-staged approach has been suggested to dramatically reduce paraplegia after open or hybrid TAA/A-repair. MISACE allows for rapid serial endovascular selective occlusion of thoracic/lumbar aortic SAs to trigger preconditioning of the paraspinous arterial CN and may be performed in any cath lab or hybrid theater without the daunting side-effects of an open surgical procedure. After successful endovascular MISACE preconditioning conventional open or complete endovascular TAA/A-repair might be feasible in one-single step with zero paraplegia.

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P89 Thoracic Aortic Diseases Treated With Modified Sutureless Endoluminal Anastomotic Rigid Ring Technique: Initial Experience of Ten-Consecutive Cases

Ricardo B. Corso, Isaac Azevedo Silva, Elson Borges Lima. Cardiovascular Associados, Brasília, Brazil.

Objective: Many surgical advances have been recently added to the surgical treatment of thoracic aortic diseases to minimize peroperative morbidity and mortality. The use of sutureless rigid endoluminal anastomotic ring techniques with regular dacron grafts has long been described, but hardly ever used routinely due to previous published failures, like anastomotic pseudoaneurysm formation. A ring modification described by RC Bernardes, at al., has shown easy and reproducible application, excellent long-term results, with no pseudoaneurysm formation. We describe the surgical technique, immediate- and short-term results of the first ten operated cases with the modified Castro Bernardes sutureless rigid endoluminal anastomotic ring.

Methods: All the patients have been operated through midsternotomy and with extracorporeal circulation. Right axillary or carotid arteries were used as preferred perfusion return site. The modified endoluminal rigid anastomotic ring is made of Polyoxymethylene in different sizes (Figure P89-1). The sutureless grafting anastomosis to the aorta is made exclusively with triple polyester threads encircling the entire aorta wall. Ten consecutive patients were operated between October 2011 and September 2012. Eight patients were male. Average age was 57.1 years. Eight patients presented acute aortic dissection and two proximal aortic aneurysms. One patient had a previous cardiac surgery. Every patient received one endoluminal ring anastomosis except one who has received two rings.

Results: There was no need for reintervention because of bleeding or any other cause. There was no operative death. One patient died (10%) in hospital due to anticoagulation complication (cardiac tamponade) and respiratory failure. One Marfan-like patient needed early descending aortic endografting due to distal residual dissection complication after discharge. The same patient needed surgical re-intervention due to aortic arch expansion in one-year follow-up. There was no anastomotic pseudoaneurysm formation during this early follow-up period.

Conclusions: The Castro Bernandes modified sutureless endoluminal rigid ring anastomosis has shown to be technically easy and reproducible in thoracic aorta disease treatment. This surgical technical option seems to reduce intraoperative and pump-times and perioperative blood loss.



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P90 The Fate of the Visceral Arteries after Stent-Graft Implantation in Patients with Acute Type B Dissection

Marie-Elisabeth Stelzmueller 1, Vera Leonhard2, Dominik Wiedemann1, Stephane Mahr1, Alfred Kocher1, Marek Ehrlich1, Günther Laufer1, Johannes Lammer2, Christian Loewe2, Florian Wolf2, Maria Schoder2, Martin Funovics2. 1Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria, 2Department of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria.

Objective: Endovascular stent-graft implantation represents an established treatment option for patients with acute type B-dissection, with satisfying postinterventional results. The aim of this study was to analyze the mid-term results of visceral artery stenosis, after stent-graft implantation.

Methods: Patients undergoing stent-graft implantation for type-B dissection between January 2005 and December 2010 were included in this study. Post-interventional and latest follow-up CT scans were examined. The visceral arteries (VA) were characterized by departure from true/false/both lumen, degree of stenosis (<50%, 50-75%, 75-100%) and the length of the monitoring period.

Results: A total of 144 VA were investigated, 125 VA were supplied from the true lumen (VATL), whereby in 10 cases (8%) a deterioration in the degree of stenosis could be observed at the end of the observation period (mean 42 months). 19 VA departed completely or partially from the false lumen (VAFL/VAPL); 4 (21%) of which showed a progression of stenosis. The mean freedom of increasing stenosis in the VATL was 95.4 month, compared to the VAFL/VAPL group with 61.5 months (p=0.018, log rank).

Conclusions: In conclusion, visceral arteries after stent-graft implantation in patients with acute type-B dissection, supplied completely or partially from the false lumen are more likely for progression in stenosis. Therefore, a closer observation as well as careful evaluation for reinterventions are indispensable.

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P91 Attrition of Sinus Rhythm in Mid-Term and Long Follow-Up after Surgical Ablation of Atrial Fibrillation

Leonid Sternik, Alexander Kogan, David Luria, Michael Glikson, Ateret Malachy, Shany Levin, Ehud Raanani. Sheba Medical Center, Ramat-Gan, Israel.

Objective: Atrial fibrillation (AF) surgical ablation is a widely used procedure. It’s positive early and mid post-operative effect seem to decline in the late follow-up. We describe late follow-up of the surgical AF ablation and factors influencing the AF recurrence years after the ablation.

Methods: Between February 2004 and December 2009, we performed AF ablation with the same technique using bipolar radiofrequency ablator and cryoprobe as a part of another cardiac surgery in 212 patients. Patients were 63±11 years of age. 79 (39%) patients had permanent and 86 (42%) persistent atrial fibrillation. 25 (14%) had left atrial volume >200 cc. 75% of patients underwent mitral valve surgery. 79% had left atrial ablation and 21% biatrial ablation.

Results: Mean follow-up was 39 months (range 26-70 months). The follow-up was performed by electrophysiologists and surgeons. Sinus rhythm was found in 83%, 81%, 72%, and 72% of patients at 6-months, 1, 3, and 5-years after the ablation correspondently. The attrition of sinus rhythm was insignificant (p>0.005). 38%, 43%, 35%, and 41% of patients were free from antiarrhythmic medications at 6-months, 1, 3, and 5-years after the ablation correspondently. The only patient factor related to ablation failure in the late follow-up was pre-operative permanent AF (p=0.001). The duration of AF pre-ablation, left atrial size, age and other demographic parameters were not found to be related to AF recurrence.

Conclusions: The efficacy of AF ablation seems to decline not significantly in the late follow-up. Patients with permanent AF can be expected to have a high rate of AF recurrence in the late follow-up.

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P92 Heart Rhythm Early After Surgical Ablation of Atrial Fibrillation

Leonid Sternik, Alexander Kogan, David Luria, Michael Glikson, Ateret Malachy, Shany Levin, Ehud Raanani. Sheba Medical Center, Ramat-Gan, Israel.

Objective: While surgical ablation of atrial fibrillation (AF) is currently a well established procedure, several issues remain unsolved; one of them is a heart rhythm during the first days after the procedure.

Methods: Between February 2004 and December 2009 we performed AF ablation using the same technique with a bipolar radiofrequency ablator and cryoprobe as part of other cardiac interventional procedures in 212 patients. Of them, 88 patients were in sinus rhythm and 60 in nodal rhythm during the first 3 days post surgery. Patients in both groups were 63±11 years of age; of them, 79 (39%) had permanent and 86 (42%) persistent AF, and 25 (14%) had left atrial volume >200 cc. Mitral valve surgery was performed in 75%, left atrial ablation in 79% and biatrial ablation in 21% of patients.

Results: Mean follow-up, performed by electrophysiologists and surgeons, was 39 months (range 26-70 months). Type and length of AF before surgery, left atrial size and left ventricle function were the same in both groups. However, patients with nodal rhythm were older (p=0.002) and in lower functional class (p=0.044). At 6 months, 1, 3 and 5 years after ablation there was no statistical difference between groups in ablation results concerning sinus rhythm, antiarrhythmic drug use and anticoagulation.

Conclusions: While patients in nodal compared with those in sinus rhythm during the first 3 days after ablation were older and had lower functional class, sinus rhythm, antiarrhythmic drug use and anticoagulation results were similar in both groups.

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P93 Thoracoscopic Radiofrequency Ablation for Lone-Atrial Fibrillation: Box-Lesion Set Experience

Marek Pojar 1, Jan Vojacek1, Ludek Haman2, Petr Parizek2, Jan Harrer1. 1Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic, 21st Department of Cardiovascular Medicine, Charles University in Prague, Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic.

Objective: Atrial fibrillation is the most common arrhythmia. We report the feasibility and results of totally thoracoscopic box-lesion ablation technique to treat stand-alone atrial fibrillation.

Methods: Between May 2009 and November 2012, 32 patients (25 male), mean age 57.2±8.9 years (range, 44-73 years) with lone-atrial fibrillation refractory for antiarrhythmic drugs underwent the procedure. Twenty patients (62.5%) had symptomatic paroxysmal atrial fibrillation, while five (15.6%) had persistent and seven (21.9%) long-standing persistent atrial fibrillation. The median duration of atrial fibrillation was 50 months (7-240). The approach included two 11 mm ports and one 5 mm port. Box-lesion set ablation procedure included bilateral pulmonary vein ablation together with the posterior wall of the left atrium using irrigated bipolar radiofrequency with the documentation of exit block. Closure of the left atrial appendage was performed in 2 patients. All patients were followed-up after the ablation including Holter ECG monitoring.

Results: There was no intra- or perioperative ablation related complication. There were also no operative mortality, no myocardial infarction, and no stroke. Skin-to-skin procedure time was 119.4±25.8 minutes and the postoperative average hospital stay was 7.3±2.7 days. Sinus rhythm was restored in 29 (90%) patients while 10% remained in paroxysmal atrial fibrillation at discharge. After a mean follow-up of 107±23 days, the single-procedure success rate was 76%. In the next period 21% patients underwent catheter re-ablation. At the last postoperative control, median follow-up 280 (86-1112) days, 90% patients were in sinus rhythm. Pleural effusions occurred in one patient postoperatively.

Conclusions: Thoracoscopic box-lesion ablation procedure is a safe and effective, less invasive method for treatment of isolated (lone) atrial fibrillation. The operation provides excellent short-term freedom from atrial fibrillation.

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P94 Long-Term Follow-Up after Aortic Valve Replacement for Patients with Aortic Valve Lesion and Atrial Fibrillation

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

Objective: Treatment for patients having non-mitral disease with atrial fibrillation is controversial. Now, we report our clinical results of aortic valve replacement (AVR) for patients with aortic valve lesion and atrial fibrillation in contrast with AVR concomitant with maze procedure.

Methods: Eighty-eight patients who had atrial fibrillation and aortic valve disease were enrolled in this study. All underwent AVR in one institution. Thirty-five were performed AVR with left atrial appendage plication (LAAp) and 53 were performed AVR with maze procedure using cryoablation. Warfarin was prescribed for patients who had atrial fibrillation after operation or used mechanical valve.

Results: The conversion rate from atrial fibrillation after maze procedure was 94% at 6 months. There were 2 hospital deaths (6%) in AVR with LAA plication group, and 3 (6%) in AVR with maze procedure. Survival rate was 82% in AVR with LAAp versus 92% in AVR with maze procedure at 5 years and 73% versus 83% at 10 years (p=0.322). There were no significant differences of freedom from embolism (p=0.356), hospitalization for heart failure (p=0.129) and cerebral breeding (p=0.159) between groups.

Conclusions: There was no difference between the results of AVR with LAAp and AVR with maze procedure. The atrial fibrillation conversion rate was good after AVR with maze procedure using cryoablation.

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P95 Totally Thoracoscopic Ablation and Post-Procedural Confirmation: Early Results of a Surgical-Electrophysiological Approach for Long-Standing Atrial Fibrillation

Dong Seop Jeong, Kiick Sung, Ji-Hyuk Yang, Tae-Gook Jun, Young Tak Lee, Pyo Won Park. Samsung Medical Center, Seoul, Republic of Korea.

Objective: Totally thoracoscopic ablation is a new approach in the treatment of atrial fibrillation (AF). We report the early results of a totally thoracoscopic ablation following post-procedural electrophysiological (EP) back-up in patients with long-standing AF.

Methods: Between February 2012 and November 2012, 22 patients underwent totally thoracoscopic ablation for AF. We enrolled the 16 patients who underwent post-procedural EP study after thoracoscopic ablation for long-standing AF. Totally thoracoscopic ablation included pulmonary vein isolation, division of ligament of Marshall, ganglionated plexus ablation, creation of roof line and posterior lines, resection of left atrial appendage and verification of conduction block. Post-procedural EP study was conducted at 4th postoperative day after chest tube removal. Freedom AF was assessed by ECGs and Holter monitoring at postoperative 6 months.

Results: There was no early mortality and no surgical complication except one prolonged pleural effusion due to chronic lung disease. Stroke occurred in one patient at postoperative 5th day who recovered completely despite sinus conversion. All patients showed no residual potentials around pulmonary veins in endocardial mapping except one patient who needed additional endocardial touch-up to remove small potential around pulmonary veins. Post-procedural CTI ablation was performed for atrial tachycardia in one patient and then CTI ablations were routinely performed to prevent atrial tachyarrhythmias. One patient required permanent pacemaker due to sinus node dysfunction despite sinus conversion. All patients showed sinus rhythm in ECGs during follow up. Ten patients who underwent Holter monitoring showed normal sinus rhythm.

Conclusions: Totally thoracoscopic ablation following post-procedural EP study is a safe and successful procedure. Post-procedural CTI ablation may be effective in preventing atrial tachyarrhythmia during follow-up.

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P96 Box Lesion in the Open Left Atrium for Surgical Ablation of Atrial Fibrillation

Leonid Sternik, Alexander Kogan, David Luria, Michael Glikson, Ateret Malachy, Shany Levin, Ehud Raanani. Sheba Medical Center, Ramat-Gan, Israel.

Objective: Maze with a “box lesion” around the pulmonary veins is currently the gold standard procedure. Recently, we changed our surgical ablation of atrial fibrillation technique from standard bilateral epicardial pulmonary vein isolation with interconnecting lesions, to a “box lesion” procedure with a bipolar radiofrequency ablator. Our study describes this new technique.

Methods: Between March 2009 and June 2012, we performed 90 ablations by the “box” technique, using a bipolar radiofrequency device. Fifty-five (61%) patients had persistent and 21 (23%) long-standing persistent atrial fibrillation. The left atriotomy was performed along the interatrial septum. Left atrial appendage was amputated. The “box” was made by connecting the left atriotomy to the base of the amputated appendage with lines along the transverse and oblique sinuses by epi- and endocardial application of a bipolar radiofrequency ablator. Left atrial isthmus was ablated by cryoprobe.

Results: The mean follow-up was 13±11 months. The follow-up was performed by electrophysiologists and surgeons. There were no ablation-related complications. The “box” was easy to perform, with no dissection around the pulmonary veins. The “box” technique was found especially useful when surgery was performed through the right minithoracotomy incision (5 patients). At 6-months, 1-year and 2-years follow-up; 80 (94%), 69 (93%) and 47 (91%) patients were in sinus rhythm correspondently. The freedom from antiarrhythmic medications in patients with sinus rhythm at 6 months, 1-year and 2-years follow-up was 78%, 88% and 85% correspondently.

Conclusions: “Box lesion” provided excellent freedom from atrial fibrillation. “Box lesion” may improve transmurality due to ablation of one rather than two layers of atrial wall, as in epicardial pulmonary vein isolation. “Box lesion” deems dissection around the pulmonary veins unnecessary. This technique was found especially useful when surgery was performed through the right minithoracotomy incision.

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P97 First Report of Minimally-Invasive Total-Endoscopic Robotic Surgery for the Treatment of Inappropriate Sinus Tachycardia

Eric M. Hoenicke 1, Jeff Nitzsche2, Kevin Daly3, Andrea Natale4, John David Burkhardt4. 1Cardiothoracic and Vascular Surgeons, St. David’s South Austin Medical Center, Austin, TX USA, 2Austin Anesthesiology Group, Austin, TX USA, 3Atricure, Westchester, OH USA, 4Texas Cardiac Arrhythmia Institute, Austin, TX USA.

Objective: Surgical treatment for inappropriate sinus tachycardia (IST) has been described for patients who have been refractory to standard pharmacologic or catheter-based approaches (CBA). CBA for IST is additionally challenging because ablation targets are often adjacent to the phrenic nerve, which may cause phrenic nerve injury. Although no consensus exists on the optimal surgical approach, sternotomy, thoracotomy, and thoracoscopy have been described. We describe the first report in the literature of a minimally-invasive total-endoscopic robotic surgery (MITERS) where a migrating focus of IST was surgically ablated.

Methods: A 32-year-old woman was referred for a surgical opinion for symptomatic IST. Pharmacologic and CBA were unable to successfully control her symptoms of exercise intolerance, palpitations, and chest pain. MITERS was recommended for her treatment-refractory IST. A robotic approach was pursued because of enhanced surgical precision negotiating a potentially hostile and adhesed right atrium (RA). Four robotic ports were placed into the second, fourth, sixth, and eighth intercostal spaces in the right anterior chest. Dense intrapericardial adhesions were robotically dissected, completely freeing the RA. An isoproterenol infusion was initiated to achieve target heart rate (HR). Epicardial activation mapping was performed on the RA utilizing a specialized thoracoscopic bipolar pen. A migrating focus of IST was identified and ablated utilizing the thoracoscopic bipolar radiofrequency ablation (RFA) device.

Results: Prior to general anesthesia, the baseline HR was approximately 95 which increased to 115 after induction. With isoproterenol infusion at 20 micrograms/minute, HR increased greater than 155. Epicardial mapping revealed multiple sites of early activation. During RFA of this migrating focus, HR briskly increased to 175 followed by a dramatic drop below 120 with concomitant p-wave inversion. This focus migrated caudally during the procedure. Post-operatively, HR was maintained below 80. There was no IST evident during her entire post-operative in-hospital stay. She was discharged home on post-operative day five.

Conclusions: This study presents preliminary successful surgical results utilizing MITERS for treatment-refractory IST. This unique combination of minimally-invasive robotic and thoracoscopic RFA may serve as a platform for approaching other challenging treatment-refractory arrhythmias surgically.

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P98 Five-Year Long-Term Results of MCG Map-Guide Minimal AF Surgery in Long-Standing Persistent AF Patients

Doosang Kim. Seoul Veterans Hospital, Seoul, Republic of Korea.

Objective: Map-guided AF surgery will be a good help to treat AF successfully. We introduced the magnetocardiography action potential activity mapping, non-contact and higher sensitive method to detect atrial F-wave for tracing abnormal conduction route than conventional EKG. Using this method, we conducted the MCG map-guide minimal AF surgery and report their 5-year long-term results.





Methods: To detect weak atrial excitation, we utilized a high sensitive low-Tc 64-channel MCG system with application software KRISSMCG64 to make a MCG map on the three-dimensional atrial surface. From the information of MCG map, from June 2006 to June 2008, we conducted the minimal AF surgery in 8 long-standing persistent AF patients having concomitant structural heart disease, such as valvular or coronary disease. Their mean age is 63 years old, AF duration is 17 months, AF burden is 1.0, LA size is 60 mm, and LVEF is 54%. Monthly-based standard 12-lead ECG was used for follow-up examination.

Results: Among the 8 long-standing persistent AF patients who had undergone MCG map-guide minimal AF surgery, there are two early-loss patients due to CRF sepsis and CVA stroke (at 21 and 15 postoperative days, respectively) and two follow-up loss patients because of pneumonia (at 25.3 and 5.7 months, respectively). The remaining 4 patients show 100% (4/4) regular QRS rhythm with varying atrial contraction activities at 72.2, 68.0, 61.4 and 59.5 months follow-up period (mean follow-up 65.3 months, 5.4 years). Their final atrial contraction activities are normal sinus P, AT 2:1 conduction, and atrial irregular contraction. There are no thrombo-embolic episode, sick sinus syndrome, and no permanent pacemaker insertion cases. Figures P98-1 and P98-2 show the pre-follow-up and the last follow-up EKG example of a 48-year-old female patient who underwent a MVR+AVP+TAP and MCG map-guide minimal AF surgery for severe MSR+AR+TR and long-standing persistent AF.

Conclusions: Using MCG map-guide, we conducted minimal AF surgery in the patients who had long-standing persistent AF, and their 5-year long-term rhythms converted all regular AF-free rhythm successfully with drug-off status. It is a good method to treat AF with long-term feasible results.

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P99 LA Flutter as a Complication of the Maze Procedure Using Cryoablation for Treatment of Paroxysmal and Permanent AF in Patients Undergoing Concomitant Cardiac Surgery

Samir Redzepagic, Alexander Rosalion. St. Vincent’s Hospital Melbourne, Australia.

Objective: The objective of this study was to evaluate the incidence of LA flutter as one of the complications of the Maze procedure using cryoablation for treatment of paroxysmal and permanent atrial fibrillation (AF) in patients undergoing concomitant cardiac surgery. We sought to identify the predictors of failure for this particular tachyarrhythmia and recognize the patterns in order to avoid this complication in the Maze procedure.

Methods: From July 2003 to December 2010, 227 consecutive patients (mean age 73.1 years) who underwent cryoablation for AF were evaluated and divided into 2 groups. Group A the left-sided CryoMaze for paroxysmal AF (n=119) and Group biatrial CryoMaze for permanent AF (n=108). Seventeen (6.74%) patients out of 227 presented with symptomatic LA flutter and 10 (5.1%) of them were from Group A while 7 (8.75%) from Group B. EP studies were conducted in all of them.

Results: Success rate with freedom from AF after the Maze procedure for Group A at 12 months was 85.5% and for Group B 73.2%. On EP studies in 3 patients from Group A one had micro-reentry circuit around LA appendage while the other two had lesions at the roof of PV and the MV annulus. All of them were successfully ablated. In 6 patients from Group B we identified foci around LA in each of them and 2 had additional foci in the isthmus. All of them had incomplete lesion around MV annulus. Five out of 6 from Group B were ablated with success. We analyzed if other risk factors and predictors of failure played a role in atrial tachyarrhythmias.

Conclusions: The cryoablation for paroxysmal and permanent AF in patients undergoing concomitant cardiac surgery is safe and effective but certain subset experience symptomatic atrial arrhythmias which must be addressed and treated in EP lab. We were able to demonstrate that in some patients with paroxysmal AF presenting with LA flutter incomplete lesion set or additional ablation lines may be responsible for success or failure, while in patients with permanent AF mitral valve annulus ablation line and size of the left atrium (consider reducing) are the two factors most likely to impact on LA flutter. The combination of two modalities, catheter and surgical ablation, can improve the outcome even in complex patients.

©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery