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Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: May/June 2014 - Volume 9 - Issue 3 - p 228–260
doi: 10.1097/IMI.0000000000000070
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D1 Minimally Invasive, Mini-Thoracotomy, Replacement of the Aortic Valve and Root with Reimplantation of the Coronaries, Ascending Aorta and Hemi Arch Utilizing Circulatory Arrest:

Joseph Lamelas. Mount Sinai Medical Center, Miami Beach, FL USA.

Objective: Replacement of the aortic valve with concomitant replacement of the ascending aorta performed via a minimally invasive right anterior thoracotomy approach has not been reported. We evaluated the feasibility, safety, and short-term outcomes of patients who underwent such procedure.

Methods: We retrospectively reviewed all the minimally invasive aortic valve replacements with concomitant replacement of the ascending aorta, performed at our institution between January 1, 2012, and December 30, 2012. The operative times, intensive care unit and hospital lengths of stay, post-operative outcomes, and mortality were analyzed.

Results: We identified a total of 20 consecutive patients with aortic valve disease and dilatation of the ascending aorta that underwent minimally invasive aortic valve replacement with concomitant replacement of the ascending aorta. There were 16 (80%) males, with a mean age of 61±13 years. The mean left ventricular ejection fraction was 58±8%. The aortic valve was bicuspid in 18 (80%) patients, with 14 (70%) being stenotic. The mean ascending aorta diameter was 4.5±0.4 cm. The median aortic cross-clamp and cardiopulmonary bypass times were 163 minutes (IQR 141-170) and 291 minutes (IQR 177-215), respectively. There were 19 (95%) patients who required hypothermic circulatory arrest, with a median hypothermic circulatory arrest time was 35 minutes (IQR 33-39.5). The median intensive care unit and post-operative length of stay were 24 hours (IQR 23-41), and 5 days (IQR 4-6), respectively. There were no strokes, reoperations for bleeding or conversions to sternotomy. The 30-day mortality was zero.

Conclusions: Minimally invasive aortic valve replacement with concomitant replacement of the ascending aorta, via a right anterior thoracotomy approach, can be performed safely with low morbidity and mortality. This technique can also be expanded to replacement of the aortic root with reimplantation of the coronaries.

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D2 Minimally Invasive Lateral Caval Flap Repair for Sinus Venosus Atrial Septal Defect with Partial Anomalous Pulmonary Venous Return:

Nicolas A. Brozzi, Elsy V. Navas, Tatiana Jamroz, Edward B. Savage. Cleveland Clinic Florida, Weston, FL USA.

Objective: Present a case of minimally invasive surgical repair of sinus venous atrial septal defect with partial anomalous pulmonary venous return through upper ministernotomy approach with a novel technique. Discuss technical pitfalls.

Methods: Our video presentation presents a clinical case, describes the surgical technique, and discusses the technical pitfalls of the novel technique.

Results: A 55-year-old patient, with diagnosis of sinus venous atrial septal defect with partial anomalous pulmonary venous return, received surgical repair with a lateral cabal flap technique through a mini-sternotomy approach. Patient recovered well after surgery and was discharged home within 5 days.

Conclusions: The lateral cabal flap repair creates a natural unobstructed tunnel with an endocardial surface, rerouting the anomalous veins to the left atrium. Attention to sinus node prevents atrial dysrhythmias. It is a simple technique that can be performed through a ministernotomy approach.

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D3 The Alternative Way to Reach to the Mitral Valve in Patients with Small Left Atrium: Superior Septal Approach:

Serkan Ketenciler 1, A.M. Ercisli2, Ertan Vuruskan3, Muslum Polat1, Murat ArN1, Abdurrahman Ekici4, Birol Yamak2. 1Dr. Ersin Arslan State Hospital Cardiovascular Surgery Clinic, Gaziantep, Turkey, 2Adiyaman University Medical Faculty Cardiovascular Surgery Department, Adiyaman, Turkey, 3Dr. Ersin Arslan State Hospital Cardiology Clinic, Gaziantep, Turkey, 4Dr. Ersin Arslan State Hospital Anesthesiology Clinic, Gaziantep, Turkey.

Objective: It is an important problem to reach the mitral valve for the patients that will be operated for the mitral valve pathology with small left atrium. In this study, we wanted to show superior septal approach is safe and alternative way to reach mitral valve for the cases that it is difficult to reach mitral valve by the standard way.

Methods: Totally 227 patients that performed mitral valve replacement and/or with additional procedures were added to study between 2001 and 2013. Isolated mitral valve replacement or concomitantly coronary artery bypass grafting, aortic valve replacement or tricuspid valve repair operation were performed to patients. The patients evaluated for transient or permanent rhythm disorders and early mortality.

Results: Transient rhythm disorders were seen in 10% of patients but permanent rhythm disorder was detected only in one patient. Hospital mortality was 3.6%. To reach the mitral valve by the way of superior septal approach extends cross-clamp time. When administered with caution, it does not cause permanent rhythm disorders.

Conclusions: We consider that superior septal approach for the patients that needed surgical mitral valve intervention with small left atrium is safe and alternative way.

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D4 Right Anterior Minithoracotomy AVR with Fast Deployment EDWARDS INTUITY Valve System

Marco Solinas, Francesca Chiaramonti, FedericaMarchi, PierAndrea Farneti, Filippo Santarelli, Enkel Kallushi, Tommaso Gasbarri, Giacomo Bianchi, Sergio Berti, Paolo Antonio Del Sarto, Mattia Glauber. Heart Hospital G. Pasquinucci FTGM, Massa, Italy.

Objective: In our center, the approach of choice for an isolated aortic valve replacement (AVR) is the right anterior minithoracotomy (RT). In this video, we want to show a minimally invasive AVR through a RT using a new fast-deployment bioprosthesis: the EDWARDS INTUITY Valve System.

Methods: A 6-7 cm incision is performed in the second intercostal space at the sternal edge. A soft tissue retraction is made to obtain a good exposure. Usually the aortic cannulation is made directly in the ascending aorta and the venous return is obtained with a multi-stage femoral cannula inserted percutaneously in the groin. The cardioplegia is administered antegradely in the aortic root. The aorta is directly cross-clamped. A standard aortotomy is performed. The three native valve leaflets are excised and the aortic annulus is completely decalcified. Three 2-0 Ethibond sutures are placed through the nadir of the aortic annulus. The sizing is performed and the right prosthesis is selected. The three sutures are passed on the prosthesis ring at the level of the three black marks. By using this sutures as guiding sutures, the valve with its delivery system are lowered into the annulus under direct vision. The correct position is accurately checked. The sutures are put tense. The balloon catheter is inflated to deploy the stent frame. The delivery system and valve holder are removed as a single unit. The three sutures are tied.

Results: Between June, 2012, and December, 2013, 47 patients with symptomatic aortic stenosis underwent AVR with EDWARDS INTUITY Valve System. Of these, 36 patients underwent isolated AVR. After the first cases performed through a median full sternotomy, 31 (66% of all patients and 86% of isolate aortic valve disease patients) patients received a minimally invasive approach (MIA): 21 (68%) patients through an upper J-type ministernotomy and 10 (32%) patients through a RT. In RT group implantation, success was 100% (10/10) without any complication related to the approach.

Conclusions: AVR with EDWARDS INTUITY Valve System using a RT is a safe and reproducible procedure in experienced centers. This sutureless bioprosthesis simplifying the valve implantation can be useful to increase MIA for AVR.

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D5 Minimally Invasive Valve Surgery Has Lower Morbidity in Obese Patients Compared to Median Sternotomy Approach:

Giacomo Bianchi, Marco Solinas, Rafik Margaryan, Pier Andrea Farneti, Matteo Ferrarini, Enkel Kallushi, Mattia Glauber Fondazione Toscana G. Monasterio– Ospedale del Cuore “G. Pasquinucci”, Massa, Italy.

Objective: To assess the potential of the minimally invasive approach to minimize the rate of in-hospital surgical complications in a population of morbid obese (BMI>35 kg/m^2) patients undergoing single or multiple valve surgery.

Methods: From January, 2003, to February, 2013, 73 consecutive patients (24 males, 33%) with BMI≥35 kg/m2 (38.7±4.4 kg/m2) underwent isolated mitral and (or) aortic valve surgery ± tricuspid valve repair by the means of median sternotomy (MS) or minimally invasive valve surgery (MIVS) approach. Both groups had no differences in preoperative variables.

Results: Thirty-nine patients underwent MIVS approach and 34 had valve surgery through MS. The mean age was 66.5±10 years (67±9 years vs. 65.8±11.8, p=0.81, MIVS vs. MS). Total cardiopulmonary bypass (CPB) time and cross-clamp (X-clamp) time were comparable (127±40 min vs. 132±60 min, p=0.83; and 87.6±33.5 min vs. 95±47 min, p=0.77 - MIVS vs. MS). Mechanical ventilation time and postoperative use of blood products did not differ in the two groups. Median intensive care unit (ICU) stay was 1 day for both groups (p=0.17). Composite complication rate was lower in the MIVS compared to MS group (10% vs. 38%, p<0.01) and was mainly driven by higher in-hospital surgical wound complication (3% vs. 18%, p=0.029; MIVS vs. MS) and occurrence of major post-operative arrhythmias (0% vs. 18%, p<0.01; MIVS. vs. MS). At multivariable analysis, the only risk factor for post-operative composite complications was the MS approach. Patients exhibited the same median hospital stay (7 days, p=0.88) and there was only one in-hospital death in the MS group (0% vs. 3%, p=0.2). We found a higher discharge-at-home rate in the MIVS group (44%) versus MS group (24%).

Conclusions: In morbidly obese patients the minimally invasive approach is not only safe and feasible, but also associated with fewer composite complications, mainly due to lower incidence of surgical site dehiscence and post-operative major arrhythmias. Furthermore, a higher proportion of MIVS patients were discharged at home compared to MS group.

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D6 A Three-Dimensional Evaluator for Mitral Valve Ring Size Selection:

Hiroyuki Tsukui1, Young Kwang Park2, Mitsuo Umezu2, Kenji Yamazaki1. 1Tokyo Women’s Medical University, Tokyo, Japan, 2Center for Advanced Biomedical Science, Waseda University, Tokyo, Japan.

Objective: In mitral valve repair, selection of the appropriate ring size is crucial to achieve excellent valve competence with sufficient coaptation, as well as to prevent residual regurgitation, stenosis, or systolic anterior motion. Two dimensional ring sizers provided by companies have limitations in determining the precise ring size and predicting post-implant valve competence. We developed three dimensional Evaluator of the mitral valve (EVAMITRA) functioning both measuring valve size and evaluating post-implant valve competence before ring implantation. The object of this study is to evaluate the efficiency of EVAMITRA.

Methods: The EVAMITRA consists of a metal wire covered with polyurethane, and its three-dimensional structure is identical to that of commercially available mitral valve rings. In a porcine model, sutures were placed on the mitral annulus and the EVAMITRA was fixed by placing a few sutures in the polyurethane portion without tying. Valve competence was evaluated by saline pressure test using each size of the EVAMITRA.

Results: The EVAMITRA was easily fixed on the annulus without tying within three minutes and functioned as a sizer and an evaluator of valve competence before ring implantation. In this porcine model, the 26-mm EVAMITRA predicted excellent valve competence, whereas the 28-mm EVAMITRA foresaw regurgitation after ring implantation because of insufficient downsizing of the annulus. After evaluation, the EVAMITRA was easily removed in seconds by tearing the polyurethane portion without any complications.

Conclusions: The three-dimensional structure of the EVAMITRA enables precise valve sizing and reproducible evaluation of valve competence before ring implantation in a short time. The EVAMITRA has potential to be an effective evaluator for mitral valve ring selection.

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D7 Concomitant Sutureless Aortic Valve Replacement and Mitral Valve Repair Through Right Anterior Minithoracotomy:

Mattia Glauber, Antonio Miceli, Daniyar Gilmanov, Rafik Margaryan, Antonio Lio, Tommaso Gasbarri, Michele Murzi, Pier A. Farneti, Matteo Ferrarini, Marco Solinas. Fondazione Toscana G. Monasterio, Massa, Italy.

Objective: Sutureless valve for minimally invasive aortic valve replacement (AVR) has shown good results in terms of mortality and morbidity, especially in high-risk patients. This device has allowed extending the minimally invasive approach even in double or multiple heart valve surgery. We show the feasibility of a concomitant sutureless AVR and mitral valve (MV) annuloplasty through a right minithoracotomy approach.

Methods: After careful patient selection, a right anterior minithoracotomy (6 cm) was performed in the second intercostal space. Cardiopulmonary bypass was achieved through direct aortic cannulation and percutaneous dual stage venous cannula. An external detachable aortic cross-clamp was applied through the skin incision and cardioplegic arrest was obtained.

Results: Type I mitral regurgitation was corrected through a MV annuloplasty using a semi-rigid ring and aortic valve stenosis was replaced with a sutureless collapsible prosthesis.

Conclusions: The surgical technique illustrated in this video allows concomitant AVR and mitral valve repair through minimally invasive access. Sutureless collapsible aortic prosthesis allows reducing cross-clamping time, facilitating the procedure in right anterior minithoracotomy approach. The choice of sutureless valve associated with a mitral procedure might be a good choice in aortic and mitral disease, especially in high-risk patients.

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D8 Minimally Invasive AVR: A Simplified Step-by-Step Approach

Ahmed Ouda, Klaus Matschke, Utz Kappert. Dresden Heart Center, Dresden, Germany.

Objective: Minimally invasive aortic valve replacement through right anterolateral mini-thoracotomy is considered by many surgeons as a challenging and time-consuming procedure. We believe that this problem emerges when surgeons try to apply the same surgical steps of conventional AVR despite using this limited access which has a complete different angle of view. In this video, we present a simplified step-by-step approach to enhance the safety and reproducibility of this procedure.

Methods: Beginning from skin incision and ending with skin closure, this video demonstrates in detail a case of minimally invasive AVR through right lateral mini-thoracotomy using a cascade of tailored synergetic steps aiming to maximize the exposure, shorten the operative time and make this procedure easy to be learned.

Results: Using this approach provides an optimized exposure of the aortic valve and enhances the reproducibility of the procedure.

Conclusions: From the surgical technical point of view, minimally invasive AVR through right lateral mini-thoracotomy can be easily performed and learned using this simplified approach.

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D9 Aortic Valve Replacement through Ministernotomy vs. Full Sternotomy:

Guillermo Reyes, Sara Badia, Juan Bustamante, Omer Leal, Eva Aguilar, Anas Sarraj. Hospital Universitario La Princesa, Madrid, Spain.

Objective: Aortic valve replacement (AVR) through ministernotomy has been claimed to have clinical advantages when compared with full sternotomy. However, this has not been supported by all authors. The aim of this study is to compare clinical and economic results of patients undergoing AVR through a ministernotomy and a full sternotomy.

Methods: All patients undergoing isolated AVR from January, 2011, to December, 2013, in our center were selected (n=259). Patients were divided in patients undergoing ministernotomy surgery (group M; n=40) and full sternotomy (group F, n=219). Baseline clinical characteristics and clinical outcomes were analyzed. Costs of both procedures were compared using the financial data from our hospital. In full sternotomy, pulmonary vent was used in all patients (37.26$). In ministernotomy a pulmonary vent catheter through internal jugular vein (651.32$) was used in 20% of patients. Peripheral retrograde cardioplegia (1,257$) was used in 12.5% of patients. The rest of surgical and anesthetic material was similar in both approaches. Intensive care unit (ICU) cost per day in our hospital is 1,223$. Cost of one day at ward is 815.4$.

Results: Baseline clinical characteristics were comparable in both groups. Patients undergoing ministernotomy surgery had similar logistic EuroSCORE risk (group M: 6.4% vs. group F: 8.3%; p=0.2). Cardiopulmonary bypass time and cross-clamp time were also similar (group M: 94 min. vs. group F: 85 min; p=0.07 and group M: 67 min. vs. group F: 62 min; p=0.11 respectively). Postoperatively 24 hours bleeding was less in group M (346 ml vs. 467 ml; p=0.03). ICU stay and total length of stay was shorter in ministernotomy group (2.1 vs. 3.6 days and 14.7 vs. 7.9 days respectively; p=0.01). Surgical mortality was 0% in group M and 3% in group F (p=0.29). Cost per patient in the ministernotomy group was 7,206.91$ cheaper than full sternotomy.

Conclusions: Patients undergoing AVR through ministernotomy had similar clinical results than those patients undergoing full sternotomy. Postoperative 24 hour bleeding, ICU length of stay and total length of stay were less in the ministernotomy group. Cost per patient was 7,206.91$ cheaper in patients undergoing ministernotomy.

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D10 Comparison of Minimally Invasive Coronary Bypass versus Conventional CABG Surgery Regarding Pain and Quality of Life:

Masood A. Shariff 1, Robert Silverman2, John P. Nabagiez1, Natasha Povar1, Christopher Aseervatham1, Wolf Karl von Waagner1, Kimberly Bowman1, Joseph T. McGinn, Jr.1. 1Staten Island University Hospital, Staten Island, NY USA, 2Long Island Jewish Medical Center, New Hyde Park, NY USA.

Objective: Pain and quality of life (QOL) after minimally invasive coronary artery bypass (MICS) grafting versus sternotomy coronary artery bypass grafting (CABG) were compared.

Methods: Seventy-two patients were consecutively enrolled who underwent CABG via MICS (n=32, left thoracotomy) and conventional sternotomy (n=42) incision. Pain was graded using the verbal rating scale (VRS), and QOL was evaluated using SF-12 Short-Form Health Survey (days 1, 2, 3, 4, and 5; 2 and 4 week; 6 months).

Results: Postoperative pain was higher after sternotomy on postoperative day (POD) 2, 3 and 4 (p < 0.01) in comparison to MICS. QOL was significantly better in the MICS group in the overall well being throughout the length of the study period, Item # 1 (In general, would you say your health is: excellent/very good/good/fair/poor), (p < 0.01: POD-1, 3, 4, 5; 2 and 4 weeks). Overall “energy” was also significantly better POD-2, 4, 5 and 2-weeks (p <0.05) in favor of the MICS group.

Conclusions: MICS patients express an overall improved well being postoperatively through improved QOL and manageable pain assessment allowing improved functional capacity.

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D11 Robot-Assisted Right Upper Lobectomy and Bronchoplasty

Raghav Murthy, Derek Williams, Kemp H. Kernstine. UT Southwestern Medical Center, Dallas, TX USA.

Objective: To demonstrate the technique of performing a robot-assisted right upper lobectomy and a bronchoplasty in a 62-year-old gentleman with squamous cell carcinoma of the right upper lobe.

Methods: NA

Results: NA

Conclusions: Robot-assisted right upper lobectomy and bronchoplasty is a feasible and oncologically sound procedure.

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D12 Is Surgical Aortic Valve Replacement Activity Really Stimulated by Trans-Catheter Alternatives in Active Centers?:

Mark A. Groh1, Steve W. Ely1, Oliver A. Binns1, Alan M. Johnson1, Wendy Westling2, Gerard L. Champsaur3. 1Asheville Heart, Asheville, NC USA, 2Mission Hospital, Asheville, NC USA, 3Mission Hospital, Asheville, NC USA.

Objective: Institutional support for transarterial aortic valve replacement (TAVR) is partly based on the “Halo effect” of increased surgical aortic valve replacement (SAVR) reported in centers participating in early US trials. We evaluated a mature regional program performing over 400 valve procedures annually to assess the reality of this purported effect on high-risk patients undergoing SAVR.

Methods: From January, 2008, through December, 2012, 154 octogenarians (36.6% female) underwent SAVR via sternotomy with cardiopulmonary bypass while a multidisciplinary valve clinic (MVC) was established in September, 2011. Global patient demographics are shown in Table D12-1, and have remained identical in both Groups: “I” before and “II” after establishing the valve clinic. A concomitant coronary bypass procedure (CABG) was performed in a total of 80 patients with the same frequency in both Groups.

Results: Early mortality was 5.8% and 7.6% in groups I and II, respectively (p=0.68) and between-groups differences did not reach statistical significance in STS risk scores, stroke rate, bleeding, renal failure, or arrhythmias. Number of high-risk patients undergoing SAVR averaged 3.2 and 3.4 per month, unchanged over time in Group II. Hospital length of stay remained stable although patients requiring concomitant CABG had similar significantly longer hospital stays in both groups (10.1 vs. 7.7 days, p<0.02). Global probability of survival is depicted in Figure D12-1 with 4-year survival at 71.36%.

Conclusions: So far, commitment of resources to a MVC has not increased the pool of patients referred for SAVR at our institution. This may be due to our history of aggressive management of older patients with aortic stenosis or to the short-term observation of the changes. Measuring the growth of SAVR from MVCs is mandatory to assess resource allocation afram.





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D13 Comparison of Different Resection Tools for Human Calcified Aortic Valves

Martin Marczynski-Buehlow, JustusGroQ, Rouven Berndt, Christoph Ro¨cken, Thilo Wedel, Martina Bo¨ttner, Jochen Cremer, Georg Lutter, Rainer Petzina. University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.

Objective: Symptomatic severe aortic valve stenosis is a disease primarily found in patients of advanced age. The standard therapy is the aortic valve replacement (AVR). Transcatheter aortic valve implantation (TAVI) is a treatment for patients ineligible for conventional AVR. To minimize the incidence of TAVI-related complications, such as paravalvular leakage, pacemaker necessity and ostial coronary occlusion, our research group works on the development of resection tools for aortic valves. The aim of the study was to investigate ex-vivo different resection tools for human calcified aortic valves concerning cross-section morphology.

Methods: Using twelve human calcified aortic leaflets, the effect of laser scalpel, punching device and scissors on cross-section morphology was investigated. Scanning electron microscopy and histological analyses were applied to evaluate the cutting surface area.

Results: The cross-section areas created by a laser scalpel were smooth, regular and uniform while these areas were rough, irregular and inhomogeneous when using the scissors or the punching device (see Fig. D13-1). Quantitative analysis of the cutting edges demonstrated significant differences between the three resection tools. The best results were obtained for the laser scalpel compared to the punching device (P<0.001) and for the laser scalpel compared to the scissors (P<0.05).



Conclusions: Laser cutting of human calcified aortic valves demonstrated the best results concerning homogeneous cross-section morphology compared to the punching device and scissors and seems to be a promising tool for aortic valve resection during TAVI procedures in future.

D14 Sutureless Aortic Valve Replacement with Minimal Invasive Access and Minimized Perfusion Circuit: A TAVI Alternative Approach?:

Carlo Savini, Giuliano Jafrancesco, Jacopo Alfonsi, Sofia Martin Suarez, Giacomo Murana, Irene Dotti, Davide Zardin, Roberto Di Bartolomeo. Ospedale S. Orsola, Bologna, Italy.

Objective: Conventional cardiac surgery in the last years progressed in three independent ways to improve its results: valve prosthesis improvement as design and deployment (sutureless prosthesis, SU-AVR); minimized cardiopulmonary bypass (MCPB) to reduce the systemic inflammatory response syndrome and minimal invasive surgical cardiac approach (MICS). The aim of this study is to evaluate the outcomes of the combination of these issues for aortic valve replacement (AVR) in high-risk patients.

Methods: We reviewed 10 SU-AVR performed in a population affected by severe aortic stenosis with average age of 78.8±8.7 from January, 2013, to November, 2013. The mean STS score (%) was 9.2±6.5. The mean basal glomerular filtration rate was 62.5±27.9 mL/min with baseline serum creatinine of 1.1±0.5 mg/dl. The end-points were defined as hospital mortality, perioperative myocardial infarction, cerebrovascular events and surgical procedure related complications. Furthermore, the renal function was investigated by glomerular filtration rate and serum creatinine level before surgery and at 1st, 3rd, and 5th, postoperative day.

Results: No hospital mortality was observed. The mean hospital stay was 8.6±1.2 days. No patient had major adverse events. Postoperative renal function curve reveals no increase of clinical/subclinical serum creatinine. The mean serum creatinine level (g/dl) and glomerular filtration rate (mL/min) were 1.1±0.5, 1.1±0.6, 0.97±0.46, 0.8±0.45 and 54.8, 54.1, 56.9 at 1st, 3rd, 5th postoperative day, respectively. The pre-discharge echocardiogram has shown satisfactory results with 1.6±0.5 cm2 of effective orifice area, 14.8±4.2 mmHg of mean aortic gradient

Conclusions: Surgical aortic valve replacement is still the treatment of choice in patients with aortic stenosis. To improve the advantages of conventional surgery for high-risk patients, we combined in a single approach the innovations available for AVR as SU-AVR, MCPB and MICS. To better analyze the quality of this idea, we observed the incidence of postoperative major events and some indicators of a good postoperative performance as the variation of serum creatinine, which has been demonstrated to be independently associated with 30-day all-cause mortality after cardiac surgery. Finally, this preliminary experience shows that an optimized approach for high-risk patients, including SU-AVR, MPCS and MICS, is safe and effective.

D15 Robotic Surgery Will Be Truly Minimally Invasive Cardiac Surgery in the Future: Changqing Gao. PLA General Hospital, Beijing, China.

Objective: To summarize the experience of 650 cases of various kinds of robotic heart surgery performed by a single surgeon in a single center.

Methods: Six hundred and fifty patients underwent robotic cardiac surgery from 2007 to 2013 in PLA General Hospital. There were 357 male and 293 female with a median age of 52.9±23.7 (11 to 80) years old. Left port approaches were used in totally endoscopic coronary bypass (TECAB) graft on beating heart (n=100) and direct coronary bypass grafting with minithoracotomy (MIDCAB) on beating heart (n=130). Right port approaches were used in mitral valve repair (n=100), mitral valve replacement (n=45), atrial myxoma resection (n=45), atrial septal defect repair on arrest (n=54) or on beating (n=121) heart, ventricular septal defect repair (n=20), hybrid revascularization (n=35), and other robotic cardiac surgery (n=35). Cardiopulmonary bypass (CPB) was established through peripheral vascular cannulation. The Chitwood clamp was used to occlude the ascending aorta. All the robotic coronary bypass graft surgeries were completed without CPB.

Results: No operative mortality or serious surgical complications were observed. For patients with atrial or ventricular septal defect, no residual shunt was detected at postoperative echocardiography. No patient required reoperation for recurrence in the follow-up of (31±14) months. Robotic mitral valve plasty included quadrangular resections, sliding-plasties, NeoChord insertion, and edge-to-edge annuloplasties. Postoperative echocardiograms showed that the patients had no mitral regurgitation (98%) or trace mitral regurgitation. The mean graft flow was 35.8±20.0 ml/min in TECAB group. All the patients accepted coronary angiography or CTA scan follow-up with 98.1% graft patency. One graft occlusion was found 1-year postoperatively. No more graft occlusion was found at 3 to 5 years. In MIDCAB group, single or double grafts were completed in “Y” type or sequence manner. The mean graft flow was 26.9±12.8 ml/min. Thirty-five patients with multiple vessel disease had off-pump robotic bypass surgery and stent placement using a staged approach without complications.

Conclusions: Our study shows that robotic cardiac surgery is a safe procedure in selected patients, and we believe that the robotic surgery will be truly minimally invasive cardiac surgery in the future.

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D16 Improved Outcomes with MICS CABG vs. Standard CABG:

Lance N. Blau, Mahesh K. Ramchandani. Houston Methodist Hospital, Houston, TX USA.

Objective: Debate still exists whether patient outcomes differ between MICS CABG and standard CABG. We compare our experience with these two procedures over the past 4 years.

Methods: In a large retrospective analysis at our institution, we analyzed data from 1,637 patients undergoing CABG from August, 2009, to June, 2013. Of these, 126 patients underwent MICS CABG vs. 1,511 patients who underwent a sternotomy approach. Outcome data including ICU stay, total length of stay, need for intraoperative blood products, morbidity (defined as significant bleeding, valve dysfunction, graft occlusion, TIA, stroke, ventilation dependence, or renal failure), and mortality were compared amongst the two groups. Case statistics were analyzed using a student t-test for continuous variables, a chi-squared test for categorical variables, and Cox regression analysis was employed.

Results: We have achieved excellent outcomes within the last 4 years performing both MICS and standard CABG. There were no deaths within 30 days of surgery in our MICS CABG group, compared to a 30-day mortality rate of 1.99% (30/1511) in our standard CABG group (p < 0.001). One-month postoperative morbidity (defined as significant bleeding, valve dysfunction, graft occlusion, TIA, stroke, ventilation dependence, or renal failure) was significantly lower in the MICS group (38.40% vs. 43.15% respectively, p < 0.001). Compared to standard CABG, MICS CABG patients spent less time in the ICU (58.42 hours vs. 90.66 hours, p < 0.001), less time in the hospital (7.08 days vs. 9.67 days, p < 0.001), and had less need for intraoperative blood products (14.29% vs. 41.1%, p < 0.001 ). There was no significant difference in average surgery duration between MICS and standard CABG (4.35 hours vs. 4.42 hours, p = 0.642), respectively.

Conclusions: MICS CABG is a safe and effective surgical approach for cardiac revascularization. Compared to standard CABG, MICS CABG patients had significantly lower 30-day morbidity and mortality, spent less time in the ICU and hospital, and required less intraoperative blood products. These data reinforce conclusions from other series. MICS CABG is a reproducible procedure.

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D17 A Case of Intralobar Pulmonary Sequestration Presenting as a Huge Mediastinal Mass:

Jae-Ik Lee, Kun Woo Kim. Gachon University Gil Hospital, Incheon, Republic of Korea.

Objective: Video-assisted thoracoscopic surgery (VATS) is a valid option in the surgical treatment of intralobar pulmonary sequestration (ILPS). However, adult cases pose a few additional difficulties in VATS resection. We present a case in which VATS for adult ILPS was successfully performed.

Methods: A 56-year-old woman was admitted to our hospital with the incidental finding of a huge mediastinal mass on routine examination. She denied any respiratory symptoms. Chest computed tomography (CT) showed a 14 cm sized round cystic mass, compressing the heart and diaphragm in the left lower hemithorax. Chest CT also revealed an anomalous artery arising from the descending thoracic aorta (See Fig. D17-1). Clinical impression was pulmonary sequestration (intralobar or extralobar).

Results: Three thoracic ports were placed for VATS. A 4 cm sized incision was made for working port at left 10th intercostal space (ICS) on middle axillary line. Two other 1 cm sized ports were placed at 5th ICS on anterior axillary line and 7th ICS on middle axillary line. After confirming the diagnosis of ILPS in left lower lobe by inspection through the camera port, 1.2 L of thick cystic fluid was evacuated in order to make room for the operating equipment. The anomalous artery was divided with an endostapler, and the left lower lobe including the sequestered segment was resected. The patient recovered uneventfully.

Conclusions: VATS is a safe and feasible option for the resection of adult ILPS, and can lower the threshold for surgery. Extremely low working port, the lower margin of which is a floating 11th rib, is helpful for the dissection of diaphragmatic adhesion and the retrieval of large specimen frequently encountered in adult cases, as well as controlling the anomalous aortic artery.



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D18 Influence of Experience on Mental Stress During Robotic Cardiac Surgery:

Saman Parvaneh, Badi Rawashdeh, Zain Khalpey, Sugam A. Bhatnagar, Abdulla Alabagi, Haudi Dehdashti, Robert Poston, Bijan Najafi. University of Arizona Medical Center, Tucson, AZ USA.

Objective: Technical challenges associated with robotic cardiac surgery can lead to mental stress in the surgeon. While moderate stress improves performance, severe stress has been shown to reduce surgical skill and lead to poor outcomes. The purpose of this study was to quantify the stress response (SR) in real-time as evidenced by reduced heart rate variability (HRV) in surgeons performing robotic cardiac surgery.

Methods: HRV was continuously monitored in an advanced and novice surgeon during robotic cardiac surgery using a wearable ECG monitoring sensor to measure the standard deviation of R-R intervals based on ECG signals. The 14 monitored cases included: (1) novice performing simulated robotic surgery on a cadaver (n=1), and (2) performing clinical robotic surgery (n=1), and (3) an advanced surgeon supervising a novice (n=5), and (4) performing clinical robotic surgery (n=7). Stress was quantified as severe (SRhigh) when HRV was below 60% of baseline HRV.

Results: Surgeons were monitored for an average duration of 240±137 minutes (range 85 to 525 min). Figure D18-1 illustrates the SR for each of the 4 categories of cases. For the advanced surgeon, SRhigh duration was 24±15% and 22±14% of the case when supervising and performing robotic surgery, respectively, which was significantly less than SRhigh for the resident at 51%. Real time analysis showed that episodes of SRhigh coincided with technical problems (e.g., camera clouding, bleeding) and when there was a switch between which surgeon was controlling the robotic console.

Conclusions: To our knowledge, this is the first study demonstrating that it is feasible to monitor spontaneous mental stress during cardiac robotic surgery. Preliminary results demonstrate that HRV <60% of baseline, a metric of severe stress, is more common in novice compared to advanced surgeons but simulated robotic surgery does not duplicate this same stress response.



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D19 Information and Technology Based Therapeutic Remote Monitoring of Patient After Assist Device Implantation: A Conceptual Study

Jens Garbade, Markus J. Barten, Sandra Eifert, Sven Lehmann, Martin Strueber, Michael A. Borger, Friedrich-Wilhlem Mohr. Herzzentrum Leipzig, Leipzig, Germany.

Objective: Left ventricular assist device (LVAD) implantation are increasing in prevalence to treat end-stage heart failure. Post-implantation follow-up is important for monitoring device function and patient condition to avoid anticoagulation related life-threatening side effects or VAD malfunction. However, practice is inconsistent, and according to physician preference. Thus, in this study we evaluated and described an intelligent e-health platform for wireless remote monitoring of cardiac performance and anticoagulation status in VAD patients to identify salient problems rapidly.

Methods: We designed and established a project pathway to conceptualize the deployment of this e-health service innovation. Using insights of technical and conceptual needs (status-quo process) and a patient survey (capture of willingness to apply modern information technology and demands related to e-health) were combined to develop step-by-step a full scope telemonitoring platform in VAD population.

Results: Cardiac implantable electronic devices (ICD) and anticoagulation management (CoaguCheck) are identified as potential enabler for health care process optimization and data flow. Using our e-health platform all data coming from the ICD or CoaguCheck are recorded, evaluated and stored in an electronic health record and periodically analyzed for 50 consecutive patients. For data transmission, no additional action is required. Potentially impaired health status, arrhythmias, disturbances or differences to define ranges of INR levels are highlighted automatically as alerts. Consequently, both the patient and the stakeholder are informed for further action. Most of the patients appreciate e-health technology, but they have concerns about the security of data transmission and data confidentiality.

Conclusions: A profound IT-support with continuous date exchange using implantable devices like monitoring VAD patients could impact the health care positively by avoiding life-threatening situations on a short-reaction time along the care pathway and between stakeholders. Additionally, such e-health monitoring will help to reduce hospitalization periods and rates and, therefore, decrease health insurance costs.

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D20 Minimally Invasive Total Aortic Arch Replacement Through Partial Sternotomy

Kenji Minatoya, Hiroaki Sasaki, Hiroshi Tanaka, Tatsuya Oda, Junjiro Kobayashi. National Cerebral and Cardiovascular Center, Osaka, Japan.

Objective: Total aortic arch replacement (TAR) through partial sternotomy was performed.

Methods: 74-year-old male had TAR through partial sternotomy with 12 cm skin incision.

Results: No major complications were found. Circulatory arrest time was 45 min., and cardiac ischemic time was 100 min.

Conclusions: TAR could be performed safely through partial sternotomy.

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D21 Totally Endoscopic Robotic Ventricular Septal Defect Repair in the Adult

Changqing Gao, Ming Yang PLA General Hospital, Beijing, China.

Objective: After 600 case of robotic cardiac surgery with the da Vinci Surgical System, the optimal results encouraged us to extend the use of this technology to more complicated patients with ventricular septal defect.

Methods: From January, 2009, to November, 2013, 25 patients underwent total endoscopic robotic ventricular septal defect repair. The average patient age was 29.0±9.8 years (range, 14∼45). Of the 20 patients, 9 were female and 16 were male. The echocardiogram demonstrated that the average diameter of the ventricular septal defect was 6.2±2.6 mm (range, 2∼15), and 4 patients had concomitant patent foramen ovale. Ventricular septal defect closure was directly secured with interrupted mattress sutures in 18 patients and patched in 7 patients. All the procedures were completed using the da Vinci robot by way of 3 port incisions and a 2.0- to 2.5-cm working port in the right side of the chest.

Results: All patients were operated on successfully. The mean cardiopulmonary bypass and mean cross-clamp time was 101.53±32.3 minutes (range, 66∼140) and 42.6±30.1 minutes (range, 22∼75), respectively. The mean operation time was 204.9±36.8 minutes (range, 180∼300). The postoperative transesophageal echocardiogram demonstrated an intact ventricular septum. No residual left-to-right shunting and no permanently complete atrioventricular dissociation was found postoperatively. The mean hospital stay was 5 days. No residual shunt was found during a mean follow-up of 28 months (range, 1∼49). The patients returned to normal function within 1 week without any complications.

Conclusions: Total endoscopic robotic ventricular septal defect repair in adult patients is feasible, safe, and efficacious.

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D22 Total Arterial Multi-Vessel Revascularization: Matched-Pairs Analysis of Wound Infection and Perioperative Results After Antero-Lateral Mini-Thoracotomy Compared to Sternotomy

Marc Albert, Hardy Baumbach, Adrian Ursulescu, Ulrich F. W. Franke. Robert-Bosch-Hospital, Stuttgart, Germany.

Objective: The total arterial multi-vessel coronary revascularization through a left-sided mini-thoracotomy is technically challenging and described only in a few cases, but has improved wound healing compared to median sternotomy due to the smaller skin incision and the untouched sternum. Through matched-pairs analysis the per-operative results of mini-thoracotomy surgery will be compared to those of patients with complete sternotomy.

Methods: Between September, 2008, and December, 2012, 157 patients underwent minimally invasive multi-vessel off-pump myocardial revascularization via left-sided mini-thoracotomy. In all patients the, left internal mammary artery was used. Additionally, the radial artery was harvested endoscopically in nearly all patients for the use as T-graft (group M). For every patient of group M we found a matching patient operated via a conventional sternotomy using both internal mammary arteries (group C). Intraoperative data were similar in both groups (see Table D22-1).

Results: There were no hospital, as well as 30-day, mortality, no postoperative myocardial infarction and no cerebrovascular stroke, respectively. The ventilation time (4.1±4.0h vs. 5.8±3.1h, p<0.001) and the over-all hospital stay (9.6±2.5d vs. 11.7±5.2d, p<0.001) were significantly shorter for patients of group M. Although the HbA1c showed no differences between the groups, there have been 1 (0.6%) wound infection in group M and 5 (3.2%) in group C (p=0.099).

Conclusions: The minimally invasive off-pump myocardial revascularization via left mini-thoracotomy is a feasible and safe procedure. Shorter ventilation time and shorter hospital stay demonstrate a faster recovery after mini-thoracotomy. Furthermore, the risk for a wound infection is reduced as well.



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D23 A Technique for Clipping the Left Atrial Appendage Using a Right Mini-Anterolateral Thoracotomy During Surgical Correction of Mitral Valve Regurgitation

Joseph A. Di Como 1, Walid M. Elzomor2, Mark W. Connolly2, Kourosh T. Asgarian2. 1St. George’s University School of Medicine, St. George’s, Grenada, 2St. Joseph’s Regional Medical Center, Paterson, NJ USA.

Objective: This manuscript aims to illustrate the accessibility of the left atrial appendage through a right mini-anterolateral thoracotomy and how to successfully place an atrial-clipping device when repairing the mitral valve through a combined surgical technique.

Methods: After accessing the mitral valve for replacement or repair using a right mini-anterolateral thoracotomy, the heart is assessed for mitral regurgitation and de-aired before the atriotomy is closed with two layers of continuous sutures. The left atrial appendage is identified posterior to the aorta through the coronal junction of the transverse sinus and an atrial-clipping device advanced through the coronal junction of the transverse sinus. Once placed securely on the base of the left atrial appendage, it is clipped using an appropriately sized clip. The clip is released after visual confirmation of adequate placement and the left atrium inspected for hemostasis.

Results: A right mini-anterolateral thoracotomy represents a less invasive option for mitral valve surgery without compromising the effectiveness of valve repair or patient safety. Atrial fibrillation is a risk factor for stroke and increases the lifetime risk in a patient, with 90% of embolic strokes originating from the left atrial appendage. Obliteration of the left atrial appendage in patients undergoing surgical treatment for atrial fibrillation or mitral valve regurgitation has been recommended. Conventional techniques of occlusion are not often utilized and possibly due to associated risks. The use of a clip device is preferred at our institution and has been implemented successfully using a right mini-anterolateral thoracotomy on multiple occasions.

Conclusions: When performing a right mini-anterolateral thoracotomy for mitral valve repair, clipping of the atrial appendage may prove beneficial to patients at risk for thromboembolic events. The accessibility of the left atrial appendage with a right mini-anterolateral thoracotomy and the relative ease of clip placement, make this approach a feasible surgical option that, to our knowledge, has never before been described in conjunction with mitral valve repair. When compared to other surgical techniques, clipping may decrease the risk of complications and obliteration failure. In patients undergoing a right mini-anterolateral thoracotomy for mitral valve repair, the benefits of clipping the left atrial appendage should be considered.

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D24 Computational Tool to Measure the Length of Artificial Chordae for Key-Hole Mitral Valve Repair

Abdullrazak Hossien Morriston University Hospital, Swansea, United Kingdom.

Objective: Non-resection technique is considered a valuable procedure in treatment of mitral valve (MV) incompetence using artificial chordae. The length of artificial chordae is a crucial step in the creation of optimal coaptation of leaflets. We propose a novel method to measure the height of chordae.

Methods: We processed the 3D images obtained from Phillips 3D Transesophageal Echocardiography (3D-TOE) for normal and prolapse mitral valve. The images were cropped by Qlab between the origin of chords on the papillary muscle and their insertion on the mitral leaflets in the mid- and late-systole phase of cardiac cycle. The cropped model was sliced and segmented computationally by using open source software program and mathematical equations to build a 3D chordae model.

Results: A high quality image set of the chords was retrieved from 3D-TOE. The slicing of images results in 7 images of 0.35 mm thickness. The reconstruction of the slices results in 3D anatomical segmentation of the chords. Binary STL file (STereoLithography) was built by processing the segmented MV model which was meshed as well. 3D segmentation of the chords results in understanding the geometry of leaflet coaptation, distribution of chords and variation of chordal length in relation to individual position. The length measurements were 2.43 cm±3.5 mm.

Conclusions: Computational measurement is a helpful and valuable tool in predicting chordae length for surgical planning of mitral valve repair and may play an important roll in key-hole techniques for mitral valve surgery.

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D25 Liposomal Bupivacaine in the Management of Early Peri-operative Pain in Robotic Cardiac Surgery: Impact of a Novel Longer Acting Local Anesthetic Agent

Husam H. Balkhy 1, Susan Arnsdorf2, Dorothy Krienbring2, John Urban2 . 1University of Chicago Medicine and Biological Sciences, Chicago, IL USA, 2The Wisconsin Heart Hospital, Milwaukee, WI USA.

Objective: Endoscopic robotic cardiac surgery (e.g., TECAB) is the least invasive of cardiac surgeries and provides benefits over sternotomy: faster recovery, quicker pain resolution, and shorter hospital stays. Patients have high expectations for significantly less pain, which is not always the case early postoperatively due to inter-costal incisions and chest tubes. We evaluated the impact of liposomal bupivacaine (LB) in the management of early postoperative pain after endoscopic procedures.

Methods: We compared LB to our standard of care (SOC) 0.25% bupivacaine HCL; both via local infiltration. A retrospective review was conducted involving 60 patients who underwent coronary, valve, and atrial fibrillation ablation surgeries between March 1, 2013, and June 1, 2013. Thirty patients received LB (1.3%, 266 mg in 20 mL, plus 20 mL 0.9% sterile normal saline) and 30 patients received SOC bupivacaine (0.25%, 100mg in 40 mL). Data points collected included numeric rating scale pain scores, opioid consumption, and postoperative nausea and vomiting.

Results: Patient demographics between the groups were similar. There were no major morbidities in either group. Surgery time and length of stay were similar; most patients were discharged postoperative day three. Pain scores were lower in LB group compared to SOC as was opioid consumption, 112mg SOC vs. 105mg LB; no outcome reached statistical significance, however, a trend in favor of LB was observed. We also noticed a trend of improved incentive spirometry volumes in LB group.

Conclusions: This study demonstrated safety and potentially improved efficacy of liposomal bupivacaine in robotic cardiac surgery. We are embarking on a larger prospective study to ascertain the benefits of this new local anesthetic in early peri-operative pain in robotic cardiac procedures.

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D26 Minimally Invasive Segmentectomy for Symptomatic Pryce’s Type I Sequestration

Jae Hyun Jeon, Yoohwa Hwang, Hye-seon Kim, In Kyu Park, Chang Hyun Kang, Young Tae Kim. Seoul National University Hospital, Seoul, Republic of Korea.

Objective: Pryce’s type I sequestration is one of the most rare congenital malformation characterized by an aberrant systemic arterial supply to a lung in the presence of a normal tracheobronchial communication, and atresia or hypoplasia of the pulmonary artery. Surgical treatment is indicated in patients with recurrent symptoms such as hemoptysis or infection. We herein report a case of Pryce’s type I sequestration which was treated with surgical resection.

Methods: The patient was placed in the right lateral decubitus position. The pleural cavity was explored by video-assisted thoracoscopic surgery (VATS), and the enlarged aberrant artery from descending thoracic aorta was identified. The aberrant artery was mobilized and securely ligated proximally using silk suture and Hem-o-lok clip, and divided using a vascular stapler. Subsequently, the involved basal segments were resected, conserving the superior segment of the left lung.

Results: A 20-year-old man was admitted with the complaints of progressive cough with blood tinged sputum of 2 months’ duration. A chest radiograph demonstrated a thickening of peripheral bronchovascular bundle. Subsequently, performed contrast-enhanced computed tomography (CT) showed that the normal basal segments of left lower lobe were supplied by a systemic tortuous artery directly originating from the descending thoracic aorta. Chest CT also revealed the absence of the basal segment pulmonary artery but with normal venous drainage, suggestive of Pryce’s type I sequestration. Left basal segmentectomy was performed by VATS, and the patient was discharged 4 days after operation without any complications.

Conclusions: Preoperative identification of the bronchial and vascular anatomy is essential to achieve good postoperative outcome for the treatment of pulmonary sequestration. VATS segmentectomy is a safe and effective choice for the treatment for Pryce’s type I sequestration.

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D27 Sternal Lift Retractor for Ministernotomy: A New Design

Thomas Mathew. Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, India.

Objective: To evaluate the use of a new sternal lift retractor system for lower ministernotomy in children undergoing repair of simple congenital heart disease.

Methods: Anterior and cranial retraction of the sternum is a crucial step while performing lower ministernotomy. The new retractor design was evaluated in children undergoing repair of simple congenital heart disease like ostium secundum ASD, sinus venosus ASD and partial AV canal. Weight range was 8 kg to 32 kg. The retractor was applied to the undivided part of the sternum to improve the exposure of aorta and SVC (Fig. D27-1). Repair of congenital heart defects were performed with central cannulation and through a right atriotomy.

Results: 52 cases were performed in total. Lower ministernotomy was performed for OSASD in 39 cases, VSD in 7 cases, SV ASD in 3 cases and PAVCD in 3 cases. Cases were performed with an incision length ranging from 4 to 8 cms. There were no re-operations for residual defects or any re- exploration. There were no emergency conversions to full sternotomy.

Conclusions: Lower ministernotomy provides a safe and cosmetic method for repair of simple congenital heart defects and the sternal lift retractor system provides excellent exposure of cardiac structures for this approach.



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D28 Short-Term Clinical Outcomes after Off-Pump Coronary Artery Bypass Graft at a Single VA Medical Center

Entela Lushaj, Athanasia Schreiner, Besa Jonuzi, Lucian Lozonschi. University of Wisconsin, Madison, WI USA.

Objective: Coronary artery bypass graft (CABG) procedure has been the most effective treatment for ischemic heart disease, traditionally done with cardiopulmonary bypass (CPB) and cardioplegic arrest. To avoid the side effects of CPB and reduce the risk of stroke, off-pump CABG technique has evolved as an alternative strategy to revascularize the ischemic heart.

Methods: We retrospectively studied 260 consecutive patients at our Veterans Hospital, between October, 2007, and September, 2010. Demographics, short-term clinical outcomes including 30-day operative mortality and perioperative morbidity were evaluated.

Results: One hundred seventy (170) patients underwent an off-pump CABG and 82 patients underwent an on-pump CABG procedure. There were more patients with COPD (p=0.04), LVEF of 35-44% (p<0.01) and smokers (p<0.01) in the off-pump group. None of the patients who underwent CABG off-pump required a new mechanical support device (p=0.01) or had a stroke (p=0.04). Off-pump CABG patients had a significant lower 30-day composite risk of morbidity and mortality (p<0.01). None of the off-pump CABG patients were converted to on-pump surgery (rate as high as 12.4% in ROOBY trial). Other short-term end points such as 30-day mortality, the number of bypass grafts, rate of infections or reoperations for bleeding were not significant between the 2 groups.

Conclusions: The on-pump conversion rate in our study is the lowest reported in a consecutive patient series or randomized controlled trial. VA patients may benefit from an off-pump approach, including a lower stroke risk when they face higher risks with on-pump CABG approach.

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D29 Upper J-Hemisternotomy Compared to Full Sternotomy in Elective Isolated Aortic Valve Replacement: a Single-Center Experience

Bruno K. Podesser, Wolfgang Dietl, Karola Trescher, Andreas Milchrahm, David Santer, Konrad Binder, Hermann Kassal, Christoph Holzinger. Landesklinikum St. Poelten, St. Poelten, Austria.

Objective: We compare clinical outcome of upper J-hemisternotomy (JHS) with full sternotomy (FS) in elective isolated aortic valve patients.

Methods: Between January, 2007, and January, 2012, a total of 505 patients underwent isolated aortic valve surgery using a pericardial bioprosthesis. Ninety patients were operated via upper JHS and 415 via FS. Perioperative outcome was compared between groups. Data presented as mean±SEM.

Results: There was no difference in age, body mass index, gradient, EF and NYHA classes between JHS and FS patients. Logistic EuroSCORE was 7.5±2.7 vs. 7.4±4.1 (n.s.). Operative data showed that 75% vs. 72% of patients received a bioprosthesis of size #23 or #25. ACC (64±19min vs. 56±15min) and ECC (79±22min vs. 76±20min) were slightly higher in JHS compared to FS (n.s.). Operative mortality was 0% in both; 30d mortality was 2.7 % vs. 3.4% (n.s.). Postoperative complications (de novo) were as follows: myocardial infarction 0.9% vs. 0.5%, deep sternal infection 0.9% vs. 0.8%, stroke 0.9% vs. 1.9% (all n.s.), transient neurologic deficit 6.3% vs. 11.1% (p<0.05), prolonged ventilation 4.5% vs. 8.2% (p<0.05), renal failure and dialysis 1.8% vs. 3.9% (p<0.05), and atrial fibrillation 17.1% vs. 33.8% (p<0.05) in JHS vs. FS.

Conclusions: In patients with comparable EuroSCORE JHS can be performed safely as compared to FS. Postoperative ventilation was significantly prolonged and the incidences of transient neurologic deficits, renal complications and atrial fibrillation were significantly higher in patients with FS. In the advent of sutureless valves JHS may be a valuable approach for increasingly frail patients.

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D30 Paravertebral Blockade and Immediate Extubation for Totally Endoscopic Robotic Mitral Valve Repair Surgery: An Impact Study

Peter J. Neuburger, M. Megan Chacon, Brent J. Luria, Ana Maria Manrique-Espinel, Jennie Y. Ngai, Eugene A. Grossi. NYU Langone Medical Center, New York, NY USA.

Objective: Immediate extubation of select patients in the operating room following cardiac surgery has been shown to be safe and may result in improved hemodynamics and decreased resource utilization perioperatively. The addition of paravertebral blockade (PVB) to a general anesthetic has been shown to decrease pain and improve respiratory dynamics in thoracic surgery. The aim of this study was to evaluate the impact of adding PVB to general anesthesia upon immediate extubation (operating room) in patients undergoing totally endoscopic robotic mitral valve repair (TERMR).

Methods: The records of 65 consecutive patients who underwent TERMR between January, 2012, and June, 2013, at a single-institution were reviewed retrospectively. Patients were divided into two groups, one that received PVB and general anesthesia, and a second group that received general anesthesia alone. PVB was performed on ipsilateral side of surgical incisions with bupivacaine 0.5%. Extubation data was collected along with intraoperative fentanyl administration.

Results: A total of 34 patients received PVB and general anesthesia while 31 received general anesthesia alone. The two groups had similar demographic and surgical data. Patients in the PVB and general anesthesia group were more likely to be extubated in the operating room (23/34, 67.6% versus 13/31, 41.9%, p=0.05) and require less intraoperative fentanyl (3.41μg/kg versus 4.90μg/kg, p<0.01) than patients in the general anesthesia alone group (Table D30-1). There were no adverse perioperative events in either group related to PVB or extubation.

Conclusions: A significant percentage of patients undergoing TERMR are safe candidates for immediate extubation in the operating room after surgery, and this was facilitated by the addition of PVB to a general anesthetic. PVB allowed for decreased intraoperative narcotic administration, which was associated with an increase in immediate extubation following TERMR. PVB may have similar benefits in patients undergoing other types of minimally invasive cardiac surgery including robotic coronary revascularization and port access mitral valve repair; additional research is warranted.



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D31 Apical Occluder for Percutaneous Transapical TAVR

Enrico Ferrari, Didier Locca, Siniscalchi Giuseppe, Denis Berdajs, René Prêtre, Piergiorgio Tozzi. University Hospital CHUV, Lausanne, Switzerland.

Objective: Transcatheter aortic valve replacement (TAVR) is an established technique for high-risk patients with aortic valve stenosis. The transapical approach is dedicated to patients with concomitant peripheral vascular disease. The development of valid apical occluder is the most important step towards full percutaneous transapical TAVR.

Methods: We employed an existing myocardial occluder and we modified its shape and its anchoring system to adapt the device to the new role: myocardial occluder for the apex in transcatheter TAVR. First-in-human of the non-modified device (to confirm the feasibility) followed by animal tests with modified devices (2 designs).

Results: The first-in-human use of the non-modified VSD occluder after a TAVR using the SAPIEN platform was a successful case and confirmed that the procedure can be performed without purse-string sutures (Fig. D31-1). Animal tests are ongoing and preliminary results with the 2 different designs are promising. Data will be available beginning 2014.

Conclusions: Following the first human implant of an apical occluder for TAVR, and after the first animal experiences with modified devices, results appear very promising. This is a first step towards full-percutaneous TAVR.



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D32 Aortic Valve and Ascending Aorta Replacement Through a J Mini-Sternotomy

Marco Di Eusanio, Giacomo Murana, Mariano Cefarelli, Paolo Berretta, Sebastiano Castrovinci, Gianluca Folesani, Roberto Di Bartolomeo. Ospedale S. Orsola-Malpighi, Bologna, Italy.

Objective: Mini-sternotomy is infrequently used during combined aortic valve and ascending aorta interventions. In fact, this adds complexity when compared to a standard median sternotomy approach. This video shows in detail a simplified technique for aortic valve and ascending aorta replacement through a J-ministernotomy.

Methods: The patient was a 51-year-old female with a 47 mm ascending aortic aneurysm and a bicuspid aortic valve with severe aortic stenosis/insufficiency. Through a 5 cm skin incision and mini-sternotomy, the patient was centrally cannulated. The ascending aorta was replaced with a 24 mm Dacron graft and the aortic valve with a 22 mm mechanical valve. The total cross-clamp time was 68 minutes.

Results: The patient was uneventfully discharged on post-operative day 6, with no need for red blood cell transfusion. Pre-discharge echocardiogram and angio CT scan showed a satisfactory result.

Conclusions: Ascending aorta and aortic valve replacement can be safely performed through a mini-sternotomy with acceptable ischemic times. This approach requires minor modifications in standard techniques that can be readily learned by most surgeons having experience with conventional ascending aortic and valvular surgery.

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D33 An Interdisciplinary Approach: Latissimus Dorsi Myocutaneous Flap Surgery in Patients with Mediastinitis and Sternal Resection after Cardiac Surgery with Internal Thoracic Artery Grafting

Friederike Schlingloff 1, Martin Oberhoffer1, Jochen von Freyhold-Hünecken2, Jörg Elsner2, Michael Schmoeckel1. 1Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany, 2Plastic Surgery, Asklepios Klinik St. Georg, Hamburg, Germany.

Objective: Chest wall reconstruction after mediastinitis and sternal resection remains a difficult task. In current practice, mostly pectoralis major muscle advancement or turnover flaps with omentum transposition are used. These techniques seem not well suited for patients with internal thoracic artery (ITA) grafting, where blood supply to the muscle is further reduced. We use latissimus dorsi myocutaneous flaps for chest wall reconstruction in these patients and report on long-term follow-up in our series.

Methods: We used latissimus dorsi myocutaneous flaps for chest wall reconstruction in patients with mediastinitis after cardiac surgery with ITA grafting and retrospectively analyzed patient data with follow-up at 12 and 24 months.

Results: From January, 2009, until October, 2013, we performed latissimus dorsi myocutaneous flap surgery in 31 patients. 28/31 (90%) patients had bilateral or unilateral ITA grafting. 4/31 (10%) patients had aortic or valve surgery. Mean age was 68±8 years. Mean EuroSCORE II was 3.8±5.4% before cardiac surgery. On average, flap surgery took place 2.5±5.5 months after cardiac surgery. There was one (1/31; 3%) in-hospital death due to multi-organ failure 45 days after flap surgery. All-cause-mortality at 12-month follow-up was 16% (5/31 patients). Mean follow-up was 27.1±8.4 months. At follow-up, 29/31 patients (93%) had no limitation of movement measured with the neutral zero method. 21/31 patients (68%) had no pain at all. 7/31 patients (23%) complained of constant, light pain measuring 1/10 points on the visual analogue scale (VAS) while resting or only while coughing or lying on the side. 3/31 patients (10%) complained of intermittent strong pain (VAS 8/10).

Conclusions: Flap surgery using the latissimus dorsi myocutaneous flap seems to be a good option for patients with mediastinitis and sternal resection after ITA grafting. The latissimus dorsi muscle flap is not used widely because the impact on quality of life is feared. These results show that loss of mobility and chronic pain are rare after these procedures.

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D34 Use of the AngioVac Device for Percutaneous Treatment of Thrombosed, Migrated Inferior Vena Cava Filters

Berhane Worku 1, Kyle Blake2, Iosif Gulkarov1, Anthony Tortolani1, Andrew Sticco3, Akhilesh Sista2, Marcus D’Ayala 3, Arash Salemi2. 1New York Methodist Hospital and Weill Cornell Medical College/New York Presbyterian Hospital, Brooklyn, NY USA, 2Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA, 3New York Methodist Hospital, Brooklyn, NY USA.

Objective: Inferior vena cava filter (IVCf) migration and IVC thrombosis are known complications of IVCf placement. Most percutaneous mechanical thrombectomy devices utilize some method of thrombus fragmentation and/or thrombolysis for subsequent aspiration, with a risk of inadvertent embolization. The AngioVac device consists of a venovenous bypass circuit in which blood is drained via a 22 french cannula placed in a central vein and advanced under fluoroscopic guidance into the thrombus. Drained blood is returned via a second reinfusion cannula, placed in a separate central vein. A filter spliced into the circuit separates thrombus from blood to be returned.

Methods: We describe two cases of IVCf migration and thrombosis treated with percutaneous thrombectomy with the AngioVac device and percutaneous IVCf removal.

Results: A 60-year old male underwent permanent IVCf placement for deep venous thrombosis after a stroke and subsequently developed severe lower extremity swelling and acute renal failure. Magnetic resonance venography revealed a migrated suprarenal IVC with extensive IVC thrombosis. A 56-year old female presented with severe right-sided chest pain, shortness of breath, and acute renal failure. She had undergone permanent IVCf placement several months prior for recurrent pulmonary embolism. Cardiac magnetic resonance imaging revealed a migrated right atrial IVCf with extensive IVC thrombosis. In both patients renal vein thrombosis was believed to be the etiology of acute renal failure. Both patients underwent percutaneous thrombectomy utilizing the AngioVac system and percutaneous IVCf removal and were discharged uneventfully with resolution of all symptoms and renal failure.

Conclusions: To our knowledge, these are the first reports describing use of the AngioVac system for thrombectomy of migrated, thrombosed IVCfs. Extensive thrombus was extracted whole allowing for subsequent IVCf removal and resolution of symptoms of venous insufficiency and renal failure. The device requires heparinization and is not an option in some cases. However, in appropriate patients, its use obviates the need for thrombolytics and allows for removal of larger, more chronic clot. The AngioVac system is a significant addition to the surgeons’ armamentarium and should be considered early in this scenario.

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D35 Video-Assisted Right Mini-Thoracotomy Cardiac Surgery as a Routine Approach

Kazuma Okamoto, Mikihiko Kudo, Mio Kasai, Akinori Hirano, Takahito Ito, Shinji Kawaguchi, Ryohei Yozu, Hiroto Kitahara. Keio University Tokyo, Japan.

Objective: Cardiac surgery with small incision is collecting global attention from patients and surgeons. We have applied right mini-thoracotomy approach for cardiac surgery since 1998. Currently, for mitral valve surgery, ASD closure and cardiac tumor resection, a video-assisted mini-thoracotomy approach is routinely used.

Methods: Consecutive 661 cardiac surgeries via mini-thoracotomy (mitral valve plasty (MVP) 359, mitral valve replacement (MVR) 49, ASD closure 230, cardiac tumor 13, partial ECD repair 6, others 4), performed between August, 1998, and December, 2013, were reviewed. The mean age was 47.8±15.6 (11 - 83) years. 323 (48.9%) were female patients. In a current surgical setting, a right mini-thoracotomy, 5 to 7 cm in length, was done in the right fourth intercostal space and a high-definition video scope was placed at the lateral side of the mini-thoracotomy through the same intercostal space. CPB was established with femoral artery, femoral vein and right internal jugular vein cannulations. All cannulations were done under guidance with transesophageal echocardiography. The heart was arrested with antegrade cold blood cardioplegia under direct cross-clamping with a modified Cosgrove flexible clamp placed through a surgical working port. Additional cardioplegia was given in antegrade and retrograde fashion. To gain an optimal exposure of the mitral valve and other cardiac anatomy, a left atrial retractor with a flexible arm integrated to a mini-thoracotomy rib retractor.

Results: Aortic cross-clamping time in MVP, MVR, and ASD closure were 171.7, 151.2 and 50.7 minutes, respectively. Total perfusion time in MVP, MVR, and ASD closure were 255.3, 239.1 and 105.1 minutes, respectively. Conversion to full sternotomy happened in five cases (0.76%) due to retrograde aortic dissection, bleeding and severe heart failure. There were four surgical mortalities (0.61%).

Conclusions: Video-assisted right minithoracotomy approach for cardiac surgery is well established as a routine technique with a good result. Careful patient selection, well established surgical setting, and well trained team approach realize good outcomes.

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D36 Robotics Changes the Approach to Diagnosis and Management of Mediastinal Masses

Mohammad Moslemi, Duy Nguyen, Mark Meyer, Barbara Tempesta, Keith Maas, Robert Poston, Farad Gharagozloo. University of Arizona, Tucson, AZ USA.

Objective: Traditional approaches to diagnosis of mediastinal masses is often inaccurate and requires repeated interventions for diagnosis and, if needed, resection. The robotic approach offers multiple advantages over previous techniques allowing high accuracy in diagnosis and improved management of mediastinal masses.

Methods: From September, 2005, to July, 2013, we reviewed patients diagnosed with a mediastinal mass and underwent transthoracic robotic biopsy for definitive diagnosis and, if necessary, robotic resection.

Results: 73 patients underwent robotic mediastinal mass biopsy or resection. There were 39 anterior, 23 middle, and 10 posterior mediastinal masses. Of the anterior mediastinal masses, 29 were thymic in origin, 6 lymphomas, and 1 germ cell. Of the middle mediastinal masses: 9 lymphatic in origin and 12 aerodigestive cysts. Of the posterior mediastinal masses, 3 were neurogenic, 3 thyroid origin, and 2 lymphoid. The transthoracic robotic approach was from the right side in 46 patients and from the left side in 23 patients. Complications were 2 air leaks/pneumothorax, 1 hemothorax, 1 AFib, and 1 ileus. This approach had a sensitivity of 100% and specificity of 100%. Subsequently, 51 patients underwent robotic resection of the mass during the same operation. 2 patients required conversion to an open procedure.

Conclusions: The robotic surgical approach to the diagnosis of mediastinal masses is associated with high sensitivity and specificity. Furthermore, in patients in whom resection of the mass is indicated, the robot can be used for resection in the same operative setting in a safe and definitive manner.

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D37 A Novel Heart Valve of Medical-Grade Ultra-High Molecular Weight Polyethylene Fibers: In Vitro Blood Cell Adhesion Experiments

Amir Basir 1, Mark Roest1, Wally Müller2, Joost van Herwaarden1 , Frans Moll1, Gerard Pasterkamp1, Jolanda Kluin1, Paul F. Gründeman1, Philip de Groot1. 1University Medical Center Utrecht, Utrecht, Netherlands, 2Utrecht University, Utrecht, Netherlands.

Objective: Different prostheses materials are available for vascular- and heart-valve replacement. All of them carry more or less serious drawbacks; some are not suitable for endovascular treatment by their inability to fold or have too large profile, other need strong anticoagulant drugs or have a moderate durability. Medical-grade Ultra High Molecular Weight Polyethylene (UHMWPE) fibers are very thin, flexible, fatigue- and abrasion-resistant and have high strength. Therefore, prostheses made of these fibers might be attractive for construction of heart valves applied in transcatheter approaches. The aim of this study is to test the blood cell adhesion on woven patch of UHMWPE and to compare this with the most common cardiovascular patches.

Methods: A UHMWPE patch and five commonly used patches of ePTFE and polyester were perfused with human blood of three healthy donors in a double flat rectangular perfusion chamber connected to a roller pump. The perfusion was performed six times per donor. During each perfusion session, two different patches were perfused with 15 ml whole blood during three minutes. After the perfusion, nine different pictures of selected areas were taken from the middle, the top, and the bottom of each patch using scanning electron microscopy; they were assessed for different types of cell adhesion (see Fig. D37-1).

Results: Less platelet-aggregates were seen per field on UHMWPE patch compared to the woven polyester patch (P=0.01). Compared to the other polyester and ePTFE patches there was not a significantly difference for UHMWPE patch regarding adherence of platelet-aggregation. For red blood cell adherence, there was no significant difference for this patch compared to the five patches.

Conclusions: UHMWPE patch hold promise to be a potentially suitable material in blood for prosthetic valve and other low-profile cardiovascular applications by their non-inferiority regarding platelet aggregation compared to test materials. Yet, more extensive in vivo studies are needed to confirm if medical-grade UHMWPE is a suitable candidate for use in prosthetic heart valves and other vascular applications.



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D38 Uniportal VATS Lobectomy in Childhood

Jae Ho Chung, Yong Soo Choi. Samsung Medical Center, Seoul, Republic of Korea.

Objective: VATS lobectomy is a challenging procedure in childhood even using 3 to 4 ports. We report our case of uniportal VATS lobectomy in childhood patients.

Methods: A 3-year-old male child diagnosed with congenital cystic adenomatoid malformation of his right lower lobe was admitted for recurrent pneumonia. His height was 99.5 cm and weight was 15.75 kg. Under general anesthesia with single-lumen endotracheal tube, uniportal VATS right lower lobectomy was performed through a single incision of 3 cm at 5th intercostal space. Operation was performed under double-lung ventilation, and endoscopic staplers and clips were used for division of vessels and bronchus.

Results: Total operative time was 129 minutes, and intraoperative blood loss was 30 ml. The operation was successfully performed without any specific event. Chest tube was removed on postoperative day 3, and the patient was discharged without any complication.

Conclusions: Uniportal VATS lobectomy could be performed in childhood pulmonary lobectomy.

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D39 Is Unilateral Pulmonary Edema Exclusive to the Minimally Invasive Right Thoracotomy Mitral Valve Approach?

Joseph M. ArcidiJr. McLaren Regional Medical Center, Flint, MI USA.

Objective: Right lung edema has been observed in minimally invasive right thoracotomy mitral valve procedures, requiring extracorporeal membrane oxygenation in some patients. Proposed mechanisms have included right lung manipulation, ischemia/reperfusion, and reexpansion edema. It has been regarded as specific to the right minithoracotomy approach, but we recently managed a patient with this complication following sternotomy.

Methods: This 74-year-old man had NYHA Class IV congestive failure from severe mitral and tricuspid regurgitation with P1 segment prolapse. The ejection fraction was 60%, but PA pressures (mmHg) were 77/45 (systemic 112/67), CVP was 26, and CO was 1.6 L/min. After sternotomy, he underwent 1-vessel coronary bypass, limited resection repair of P1 fibroelastic deficiency through the left atrial dome, and tricuspid repair after aortic unclamping. He weaned from bypass without transfusions on 5 mcg/kg/min dobutamine and norepinephrine, with no mitral or tricuspid regurgitation, normal biventricular function, PA pressures of 36/19, and a CVP of 8. Within minutes, however, 600 ml frothy endotracheal secretions developed with hypoxemia, treated with pressure control ventilation and positive end-expiratory pressure.

Results: The initial chest x-ray showed right lung edema which progressed (Fig. D39-1). During the first 8 hrs, 2000 ml of blood-tinged endotracheal secretions were aspirated. WBC was 25K, but cultures were negative. The patient was extubated after 18 hrs, catecholamines were discontinued after 30 hrs, and a diuretic infusion was started on day 2. The sputum continued to be bloody until discharge on day 9.

Conclusions: This patient’s complicated recovery demonstrates that unilateral pulmonary edema can develop after successful mitral repair through sternotomy and is not related to right lung manipulation or differential management of right and left lungs on bypass. The relationship to severe preoperative pulmonary hypertension is suspected, although asymmetric injury developed with minimally elevated post-bypass PA pressures.



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D40 Robotic Endoscopic Excision of Mitral Valve Fibroelastoma

Faisal H. Cheema 1, Muhammad J. Younus2, Muhammad S. Khan3, Muhammad A. Younus4, Harold G. Roberts4. 1Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD USA, 2Geisinger Medical Center, Danville, PA USA, 3Dow University of Health Sciences, Karachi, Pakistan, 4Aventura Hospital & Medical Centre, Aventura, FL USA.

Objective: Isolated mitral valve fibroelastomas are rare, non-neoplastic tumors with great potential for embolization making early surgical excision critical. Here we describe resection of mitral valve fibroelastoma using a robotic endoscopic approach, a minimally invasive technique.

Methods: A 50-year-old male, with a history of hypertension, presented with atypical chest pain. Stress echocardiography revealed a mass associated with subvalvular apparatus of the posterior leaflet of the mitral valve that was subsequently confirmed by transesophageal echocardiography (TEE) to be a 1.1x1.4 cm mobile mass on the P3 portion of the posterior leaflet of mitral valve. Based on the position and nature of the mass, mitral valve fibroelastoma was suspected. Considering the high possibility of embolic complications, surgical excision was advised. We utilized femoral perfusion with Endoballoon for aortic occlusion and antegrade cardioplegia. Mass was excised via the robotic endoscopic approach through an 18 mm service port in the right chest. Standard mitral valve reconstructive techniques were utilized after resecting the mass.

Results: Final TEE revealed trace mitral regurgitation and ejection fraction of 60%. Histological examination of the specimen confirmed the diagnosis of papillary fibroelastoma. Other than transient atrial fibrillation, the postoperative course was uneventful, and the patient was discharged on postoperative day 6. The patient was asymptomatic at the last follow-up.

Conclusions: Compared with traditional techniques, robotic endoscopic approach has great potential to resect dangerous friable tumors such as mitral valve fibroelastomas with excellent surgical outcomes.

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D41 Robotic-Assisted Surgery: Proposed Credentialing Guidelines

Faiz Yahya Bhora 1, Adnan M. Al-Ayoubi1AbdulBadee Bogis1, Michael Barsky1, George Todd1, Martin Karpeh2, Cliff P. Connery2, Scott Belsley1. 1Mount Sinai Health System, St. Luke’s-Roosevelt Hospital, New York, NY USA, 2Mount Sinai Health System, Beth Israel Medical Center, New York, NY USA.

Objective: With increasing use of the robotics in the operating room, a need for effective credentialing guidelines has become necessary. We propose an algorithm that is robust and takes into account volume, outcomes, and appropriateness of robotic usage.

Methods: We reviewed the literature (MEDLINE) for ways of introducing and credentialing robotic use among surgeons. The following terms were queried: robot, robotic, surgery and credentialing. We provide our recommendations based on review of the literature, our institutional experience, as well as the experience of other medical centers around the US.

Results: 43 manuscripts were identified in the published English language literature through December, 2013. Two pathways for robotic training exist: residency- and non-residency-trained. In the US, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals to credential and privilege physicians on their medical staff. Below we present our suggested guidelines for granting robotic privileges in a graduated fashion. A credentialing designee (CD) is appointed by the surgery department to oversee and review all requests. Residency trained surgeons must fulfill 20 cases with program directors’ attestation to obtain Full privileges. Non-residency trained surgeons are required to fulfill the following: simulation, didactics including online modules, wet labs (cadaver or animal) and observation of at least 2 cases for Provisional privileges. To serve as a proctor, a robotic surgeon with Full privileges must complete 25 cases in the same specialty with good outcomes and be approved by the CD and the department chair. A minimum number of cases (10 suggested) is required to maintain competency. Cases are monitored via department quality assurance committee review. Investigational uses of the robot require IRB approval. Complex operations (e.g., lobectomy) may require additional proctoring and quality improvement review (See Table D41-1).

Conclusions: Safety concerns regarding use of the robot in the operating room must be paramount. Our privileging recommendations also take into account concerns regarding appropriate utilization, restraint of trade and state reporting ramifications. Our algorithm for granting privileges may serve as a basic guideline for institutions that wish to implement a robotic program.

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D42 Facile Implantation of Neochordae for Complex Mitral Valve Repair with the Minimally Invasive Right Thoracotomy Approach: 2-Year Follow-Up

Michael J. del Rio, Steven Jin, Cynthia Jovanov, Houshang Karimi. Riverside Community Hospital, Riverside, CA USA.

Objective: To evaluate the efficacy and durability of titanium suture fasteners for facilitation of neochordal implantation for mitral valve repair with the minimally invasive approach.

Methods: 2 patients with severe complex mitral valve regurgitation were implanted with neochordae utilizing a titanium suture fastener on 2-0 polyester suture along with other repair techniques in a minimally invasive right minithoracotomy approach. The first patient was a 47-year-old male who had severe cardiomyopathy with a 20% ejection fraction and severe mitral valve regurgitation. At surgery, he underwent repair with a posteromedial commissuroplasty and implantation of a #28 annuloplasty ring as well as neochordal implantation at A2 using the titanium fastener and 2-0 polyester suture. The second patient was a 46-year-old male with severe mitral valve regurgitation due to Barlow’s pathology. At surgery, he underwent implantation of a #32 annuloplasty ring and formation of a revised line of apposition along the posterior leaflet by neochordal implantation along a created rolled edge of the redundant posterior leaflet at P1, P2 and P3 using the titanium suture fastener onto 2-0 polyester suture.

Results: Both patients were discharged on post operative day #5 with no significant mitral valve regurgitation. Both patients returned to their blue collar jobs within 1 month of surgery. One- and two-year followup of these patients by echocardiogram has shown intact mitral valve repairs with no significant regurgitation.

Conclusions: The titanium suture fasteners feature the unique capability to secure knots without slippage at precise designated lengths. The implantation of these chordae took minutes and lengths were easily measured. The durability of the neochordae has now been demonstrated at 2-year follow-up. To our knowledge, this is the first report to show the use of this type of device to facilitate neochordal implantation; now this is the first report that shows its long term efficacy. This preliminary data further reinforces the need for a larger multicenter study.



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D43 Improved Technique for Totally Endoscopic Antegrade Cardioplegia Delivery in Robotic Surgery

Louis A. Brunsting III, Robert L. Reed, Charles M. Tyndal CCP . University of Alabama in Birmingham, Birmingham, AL USA.

Objective: Delivery of antegrade cardioplegia in totally endoscopic, robotic cardiac surgery has been characterized by compromise between hydrodynamics (cardioplegia delivery flow rate and adequate venting) and invasiveness (a larger cannula needs a bigger hole). We hypothesized a pediatric ECMO cannula would provide comparable hydrodynamics to open cardioplegia cannulae, with a minimal additional incision.

Methods: An 8 Fr. pediatric arterial ECMO cannula was adapted for transthoracic placement into the aortic root using robotically controlled Seldinger technique. Cardioplegia delivery flow rates and line pressures were measured. Our video completely describes the procedure.

Results: In 17 patients, the described technique resulted in antegrade cardioplegia flow rates (319.0+17.4 ml/min) and line pressures (200.7+22.3 mmHg) similar to those experienced in open chest procedures (319.2+23.9 ml/min and 199.5+45.5 mmHg, respectively). Good aortic venting was accomplished, with minimal intracardiac air on transesophageal echocardiography and no instance of transient ST elevation suggestive of intracoronary air embolism. The additional incision ranged from 3 to 5 mm in length.

Conclusions: In totally endoscopic robotic cardiac surgery, the technique demonstrated in our video resulted in hydrodynamics comparable to open chest cardioplegia delivery, with a minimal additional incision.

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D44 Direct Aortic Cannulation for Robotic Totally Endoscopic Coronary Artery Bypass Grafting

Eric J. Lehr 1, Juan A. Millan2, Samuel J. Youssef1 , Amanda Earnhart1, Peter Demoulos1, David Bruck1, Glenn R. Barnhart 1. 1Swedish Heart and Vascular Institute, Seattle, WA USA, 2RADIA, Inc., Seattle, WA USA.

Objective: Cardiopulmonary bypass and cardioplegic arrest for robotic totally endoscopic coronary artery bypass grafting (TECAB) is typically achieved via femoral arterial and venous cannulation. Many patients are excluded from this technique because of aortoiliac or femoral atherosclerotic disease. We present a case in which single-vessel TECAB was safely performed in a patient with moderately-severe aortoiliac atherosclerosis using direct aortic cannulation and endoaortic balloon occlusion for cardioplegic arrest.

Methods: A 60-year-old gentleman was found to have 80% left anterior descending (LAD) disease and reduced left ventricular function. Computed-tomographic angiography identified atheroma in the aortic arch, proximal-descending thoracic aorta and bilateral iliac arteries with a short dissection in the right common iliac artery. After harvesting the left internal mammary artery (LIMA) robotically, the patient was heparinized and percutaneous femoral venous cannulation was performed. The robot was undocked and a small right-anterior thoracotomy was made in the first intercostal space. The pericardium was opened and retracted. An aortic cannula with side arm was deployed and an endoaortic occlusion balloon catheter was inserted into the ascending aorta. The skin was closed to maintain the pressurized capnothorax (Fig. D44-1). After redocking the robot, cardiopulmonary bypass was established, the heart was arrested and the LIMA was anastomosed to the LAD in a totally endoscopic fashion. Following cardiopulmonary bypass, the robot was undocked. The aortic cannula was removed and the cannulation site controlled directly.

Results: Care should be taken not to injure the RIMA. Operative time is increased as cannulation cannot be performed during mammary harvest. Ensuring an airtight closure of the skin around the cannula secures the cannula and maintains the pressurized capnothorax.

Conclusions: Diffuse peripheral arterial disease and aortic atherosclerosis is a prohibitive risk for arrested-heart TECAB. Direct aortic cannulation with endoaortic balloon occlusion is feasible in TECAB and may extend the benefits of TECAB to patients with advanced vascular disease while minimizing the risks of embolism and retrograde aortic dissection while providing a dry, stable operative field.

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D45 Impact of a Right Mini-Thoracotomy Approach using a Three-Dimensional Endoscopy in Redo Mitral Valve Replacement

Masahiko Kuinose. Tokyo Medical University, Tokyo, Japan.

Objective: Conventional mitral valve surgery through a re-sternotomy after previous cardiac surgeries has several technical difficulties in the dissection of broad adhesions to the cardiac apex, the prevention of injury of the right ventricle and, if any, previous coronary bypass grafts, the aortic cross-clamping and the myocardial protection. To avoid these problems, we have performed redo mitral valve replacement after previous cardiac surgeries (redo MVR) under ventricular fibrillation (VF) through a right mini-thoracotomy with a three-dimensional (3D) endoscope (Shinko Optical Co., Ltd, Tokyo, Japan) since 2009. In this study, we clarify the impact of this minimally invasive cardiac surgery (MICS) approach in redo MVR.

Methods: From 2006 to October, 2013, 262 patients underwent MVR at Sakakibara Heart Institute in Okayama and Tokyo Medical University by one surgeon (MK). Of them, 39 patients required redo MVR and 11 patients (28.2%) underwent this MICS redo MVR (Group 1). The outcome was compared with that of the other 28 patients undergoing conventional redo MVR through a median sternotomy (Group 2).

Results: In the Group 1, preoperative EuroSCORE was significantly higher (4.8±1.8 vs. 3.9±2.4; p=0.039) and left ventricular ejection fraction (LVEF) was significantly lower (52.3±17.8% vs. 62.8±11.2%; p=0.048). Although the Group 1 required more core-cooling and rewarming time, the operative time was significantly shorter (254±43 min vs. 375±68 min; p=0.035), while the duration of cardiopulmonary bypass was equivalent to that of Group 2. There was no significant difference in postoperative maximum creatine kinase (CK)-MB. The hospital mortality rate was 0% and 3.6% (n= 1). The incidence of postoperative paravalvular leakage and stroke was 0% vs. 3.6% and 9.1% vs. 3.6%, respectively. Two patients underwent reoperation for bleeding in Group 2. Intensive care unit stay in Group 1 was also significantly shorter than that in Group 2 (1.7±0.5 days vs. 3.6±2.2 days; p= 0.022)

Conclusions: MICS redo MVR under VF through a right mini-thoracotomy using a 3D endoscopy can be a less-invasive and safe alternative approach in redo MVR after various cardiac surgeries.



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D46 Ministernotomy versus Median Sternotomy for Isolated Aortic Valve Replacement: Is it Time to Define a New Gold Standard?:

Laurence Carole Ngo Yon, Pasquale Totaro, Alessandro Mazzola. Cardiothoracic Surgery, IRCCS Foundation San Matteo, Pavia, Italy.

Objective: Minimally invasive cardiac surgery (MICS) is not considered yet as gold standard for cardiac surgery procedures. Based on our extensive experience using MICS procedures (>1500 patients) here we try to elucidate if mini-sternotomy (MI) can be considered as gold standard for isolated AVR compared to median sternotomy (MS).

Methods: Out of a general population of >2000 patients undergone isolated AVR, 62 patients were randomized to receive MI or MS approach. Patients were homogeneous in terms of preoperative parameters including EuroSCORE. Intraoperative data (extracorporeal circulation and cross-clamp times, pH, BE, TC°) were analyzed and compared using unpaired t-test. Early post-operative outcomes were analyzed using both SOFA and SAPS II ICU admission risk scores plus standard clinical parameters.

Results: Analysis of intraoperative parameters (Fig. D46-1A) showed no differences in terms of mean extracorporeal circulation and cross-clamp times between two groups. Furthermore, analysis of metabolic intraoperative parameters showed a significant better preservation of metabolic status (Ph analysis) in MI group (Fig. D46-1B). Early postoperative outcome in terms of ICU admission risk score was also no significantly different (SOFA and SAPS II 3.80 ± 2.39 and 20 ± 8 for MI and 3.58 ± 2.71 and 24 ± 8 for MS respectively). As far as clinical postoperative parameters were concerned, despite mean postoperative ventilation time, incidence of prolonged ventilation and ICU stay and total length of stay were all in favor of MI, the difference did not reached statistical significance.

Conclusions: Our experience shows that ministernotomy is a reproducible, effective approach who can be performed safely, compared with sternotomy approach for an aortic valve surgery without surgical time differences. Despite the difficulties in showing statistical differences in early clinical outcome, due to the low incidence of complications, the advantages in terms of reduced invasively and preservation of physiological status combined with psychological advantages which become relevant in the long-term follow-up, make this approach, in our mind, the gold standard for isolated AVR.

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D47 Improved Outcome of Minimally Invasive Mitral Surgery with IntraClude Aortic Balloon Occlusion Compared to Transthoracic Clamping

Andreas Liebold, Hagen Gorki, Ramiz Emini, Mohamed Quader, Christian A. Skrabal. Ulm University, Ulm, Germany.

Objective: Damage to the ascending aorta caused by the transthoracic clamp and/or cardioplegia needle during minimally invasive mitral procedures belongs to the specific drawbacks of this technique and hampers its adoption among surgeons. The introduction of a novel type of intraaortic balloon occlusion catheter (IntraClude, Edwards Lifesciences, Inc., Irvine, CA USA) aims in preserving aortic integrity and thus reducing specific complications.

Methods: In a series of 100 consecutive patients (61.8±14 years) operated on by a single surgeon for video-assisted port access mitral valve repair the last 50 patients using a transthoracic clamp (Chitwood) were compared to the first 50 patients in whom the IntraClude balloon occlusion catheter was used. The catheter features atraumatic aortic occlusion as well as antegrade cardioplegia delivery and aortic root pressure monitoring. Besides the type of aortic occlusion patients were equally treated. Intra- and post-operative data as well as clinical events were analyzed.

Results: The groups were comparable regarding demographics, co-morbidities, hemodynamics and valve pathologies. Patients in the IntraClude group experienced significantly shorter CPB time (136±37 vs. 158±28 min) and aortic occlusion time (76±19 vs. 88±17 min), less blood drainage (642±312 vs. 298±144 ml), fewer blood transfusions (1.1±2 vs. 4.0±6 units) and fewer neurologic events (1/50 vs. 5/50). Re-exploration for bleeding was only necessary in the Chitwood group (10/50 patients). In 8 patients the aorta was identified as the bleeding site, two of them developed aortic dissection. Conversion to full sternotomy was needed in 5/50 patients in the Chitwood group and in none of the IntraClude patients. Two mortalities occurred in the Chitwood group and one in the IntraClude group.

Conclusions: The use of intra-aortic balloon occlusion instead of transthoracic clamping in minimal invasive mitral surgery is safe and may help reducing specific procedural complications.



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D48 Robotic Resection of a Superior Sulcus Neurogenic Tumor

Duy Nguyen, Mohammad Moslemi, Mark Meyer, Barbara Tempesta, Keith Maas, Robert Poston, Farid Gharagozloo. The University of Arizona Medical Center, Tucson, AZ USA.

Objective: Neurogenic tumors in the superior sulcus are rare and traditionally difficult to resect via thoracotomy or even conventional VATS approaches. We present a video of resecting such a mass via the robotic approach.

Methods: We evaluated a single patient with a superior sulcus neurogenic tumor and proceeded with a robotic-assisted resection.

Results: Resection was completed successfully with no complications with preservation of all nearby vital structures.

Conclusions: Robotic resection of superior sulcus neurogenic tumors is feasible and safe due to enhanced visualization and precise dissection in a narrow space.

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D49 Totally Endovascular Repair of a Symptomatic Thoraco-Abdominal Aneurysm

Burkhart Zipfel, Semih Buz, Roland Hetzer. Deutsches Herzzentrum Berlin, Berlin, Germany.

Objective: To demonstrate the implantation technique of a branched thoraco-abdominal stent-graft in a video.

Methods: An 83-year old woman with a 60 mm thoraco-abdominal aneurysm and a shrunken right kidney was admitted with acute aortic syndrome and a periaortic hematoma. The patient remained stable in hospital. A custom made branched E-vita stent-graft (JOTEC, Hechingen, Germany) with only 3 branches was produced to celiac artery, superior mesenteric artery and left renal artery. The stent-graft was implanted 4 weeks after admission in a hybrid operation room through an open right transfemoral approach and the bridging stent-grafts for the side branches (Advanta, Atrium Medical, Hudson, NH USA) through an open left transaxillary approach. The procedure time was 400 min, fluoroscopy time 91 min with 180 ml of contrast. Aspirin and Clopidogrel was administered postoperatively.

Results: The procedure was successful without endoleak. All branches were connected to the target vessels. The patient recovered uneventfully and was already mobilized on the ward, until she suffered massive spontaneous intracranial bleeding and died on postoperative day 5.

Conclusions: Totally endovascular repair is a reasonable and feasible option for TAAA in patients deemed unfit for open surgery. Antiplatelet prophylaxis should be less aggressive in octogenarians.

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D50 Robotic Approach to the Ascending Aorta: Proof of Concept

Leonardo S. Canale, Johannes Bonatti. Cleveland Clinic Foundation, Cleveland, OH USA.

Objective: To develop a cadaveric model for surgery in the ascending aorta.

Methods: Two fresh cold cadavers were used. A 3 cm mini thoracotomy was performed in the third intercostal space in the anterior axillary line and used as camera port and working port. The left and right robotic arms were inserted in the adjacent intercostal spaces. The third robotic arm, used for the retractor, was inserted in the third intercostal space, just adjacent to the sternum. The da Vinci SI patient cart approached the cadaver from the left perpendicularly. A tableside surgeon assisted with suctioning and handling needles inside the cavity.

Results: The pericardium was opened 3 cm anterior to the phrenic nerve. The ascending aorta was dissected free from the right pulmonary artery and from the main pulmonary artery. The head vessels were dissected individually. In one cadaver the ascending aorta was wrapped with a piece of #26 Hemashield graft. In the second cadaver the ascending aorta was resected (from the sino-tubular junction to just below the origin of the innominate artery) and a segment of #26 Hemashield graft was sewed in successfully.

Conclusions: In this proof-of-concept cadaver experiment, we were able to approach the ascending aorta and head vessels in a robotically assisted fashion. Wrapping and replacement of the ascending aorta were feasible.

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D51 Laparoscopic Direct Morgagni Hernia Repair With and Without Excision of the Sac:

Conor Hynes, Marc Margolis, M. Blair Marshall. Georgetown University Medical Center, Washington, DC USA.

Objective: Morgagni hernias are repaired through a variety of approaches and with a variety of techniques: thoracic, abdominal, either with or without excision of the sac, and primary or patch repair. Currently, there is not universal agreement of ideal approach or repair. We use this video to demonstrate the technical aspects of the laparoscopic direct repair of Morgagni hernia, with and without excision of the hernia sac. Although some report injury of the phrenic nerve to be more likely in patients who undergo removal of the sac, we demonstrate how to avoid nerve injury with complete reduction of the sac prior to excision.

Methods: Two patients were evaluated with symptomatic Morgagni hernias. Bother underwent direct laparoscopic repair. Direct repair without removal of the sac is demonstrated in the first video and direct repair with sac removal is demonstrated in the second.

Results: The laparoscopic procedure was performed with two 5 mm ports, and 1 10/12 mm port. A 5 mm 30 degree laparoscope was used. The edges of the defect were defined and primary repair performed. The sac was not removed in the first patient and the persistent sac is demonstrated on follow-up imaging. In the second patient, the sac was removed. The right pleural space was also entered during this procedure and the management of this demonstrated. Both patients are well without recurrence at 4 years and 1 year follow-up respectively.

Conclusions: Laparoscopic repair of Morgagni hernia with and without excision of the sac is associated with minimal morbidity. Complete reduction of the sac is advised when planning to excise the sac. One may be more likely to enter the pleural space with excision of the sac and this is easily managed with a few maneuvers. Both techniques are a reasonable option in the management of these patients.

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D52 Transapical or Minimally Invasive Aortic Valve Replacement? A Propensity-Score Analysis in High-Risk Operable Patients

Alejandro Vazquez, Tomas Heredia, Lucia Donate, Carlos Hernandez, Mona Schuler, Alberto Berbel, Ana Bel, Manuel Perez, Francisco Valera, Salvador Torregrosa, Anastasio Montero. Hospital Universitari i Politecnic La Fe, Valencia, Spain.

Objective: Transcatheter techniques offer a therapeutic surgical possibility in selected inoperable patients; however, its potential benefit in high-risk operable patients remain controversial.

Methods: We retrospectively selected 11 transapical procedures based in operative risk (logistic EuroSCORE>15) and operability (absence of frailty or anatomical contraindications for conventional surgery) from a single-center transcatheter cohort (n=53) during a 3-year period. Patients were matched 1-to-1 with 11 minimally invasive conventional aortic valve replacement procedures (“J” shaped partial upper sternotomy) from a database of n=415, by means of propensity-score matching based on age, main comorbidities and preoperative risk profile during the same period.

Results: Both groups were comparable in terms of age (79.18±5.60 vs. 76.45±5.28 years) and operative risk (logistic EuroSCORE 19.67±10.35 vs. 16.68±5.46) after matching. Thirty-day mortality was higher in the transapical group: 18% (n= 2) versus 9% (n= 1) in the surgical group, although non-statistically significant. There was 1 intraoperative death and 1 reexploration for bleeding in the transcatheter group versus none in the surgical group. Major neurologic adverse events were also higher in the transapical group: 18% (n=2) versus none in the surgical group (p=ns) as well as postoperative atrial fibrillation (36% vs. 9%) and permanent pacemaker implant (9% vs. 0%) rates. Mean intensive care unit stay (2.60±1.34 vs. 3.45±2.34 days) and total hospital stay (7.33±3.08 vs. 7.64±9.66 days) were comparable between groups. Severe preoperative pulmonary hypertension was found to be the only independent predictor for operative mortality in the logistic regression analysis.

Conclusions: Transcatheter techniques have opened the span of surgical indications for calcific aortic stenosis. However, they remain complex surgical procedures with inherent morbidity and mortality. Conventional surgery remains as the gold standard for non-frail and anatomically operable patients, even when considering a high-risk operative profile. Minimally invasive techniques could offer certain clinical and cosmetic advantages in selected patients.

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D53 Direct Iliac Artery Puncture Without A Conduit During TAVR

Keith B. Allen 1, Marc Gerdisch2, A. Michael Borkon1, Sanjeev Aggarwal1, J. Russell Davis1, David J. Cohen1, James A. Grantham1, Adnan K. Chhatriwalla1. 1St. Luke’s Mid-America Heart & Vascular Institute, Kansas City, MO USA, 2St. Francis Medical Center, Indianapolis, IN USA.

Objective: Transcatheter aortic valve replacement (TAVR) is sometimes precluded due to iliac tortuosity or femoral occlusive disease and alternative transapical or direct aortic approaches may be limited in patients with comorbidities such as emphysema or prior sternotomy. We describe a technique in which device delivery in patients with inadequate femoral access is facilitated by direct common iliac artery puncture without the construction of an iliac conduit.

Methods: From January, 2012, through October, 2013, 12 TAVR patients were identified at two hospitals that had inadequate femoral access and were not considered good transapical or direct aortic candidates. Six patients had severe obstructive pulmonary disease including one patient receiving TAVR in anticipation of lung transplantation. The common iliac artery was exposed through a retroperitoneal incision and concentric double purse-string sutures (Fig. D53-1A) were used to secure the sheath and repair the artery without the use of vascular clamps at the conclusion of the case. Devices were delivered through a 24 French sheath inserted over a guidewire directly into the common iliac artery without the use of a graft conduit. Orthogonal deployment of the device was maintained by passing the delivery sheath through a separate stab incision in the groin (Fig. D53-1B).

Results: Device delivery was achieved in all patients without complications including arterial dissection, occlusion, or bleeding. There were no respiratory complications and all patients were extubated at the conclusion of the case. One patient required re-exploration on post-operative day three for retroperitoneal bleeding unrelated to the arterial puncture after beginning anticoagulation. Average length of stay was 6 days (range 4-9).

Conclusions: When transfemoral TAVR is not feasible and patient comorbidities such as severe obstructive lung disease preclude thoracic access, a direct common iliac puncture without a graft conduit is a safe and effective option for device delivery.



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D54 Repair of Bicuspid Aortic Valve and Ascending Aortic Aneurysm Through Ministernotomy Approach

Nicolas A. Brozzi, Edward B. Savag. Cleveland Clinic Florida, Weston, FL USA.

Objective: Describe a minimally invasive surgical technique employed for repair of a bicuspid aortic valve and ascending aortic aneurysm.

Methods: We present a clinical case of a 45-year-old female patient with bicuspid aortic valve, symptomatic moderate aortic insufficiency, and ascending aortic aneurysm, who received surgical repair of both the aortic aneurysm and aortic valve through a ministernotomy approach.

Results: The presentation illustrates the technical challenges of such an approach, and we discuss pitfalls to perform a safe operation.

Conclusions: In recent years, we have seen and increased application of techniques to repair insufficient aortic valves, and an expansion of the indications of upper ministernotomy approach. These techniques are used complementary to perform minimally invasive simultaneous repair of bicuspid aortic valve and ascending aortic aneurysm.

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D55 A Prospective Study to Evaluate Minimally Invasive Right Thoracotomy versus Conventional Sternotomy Approach for Mitral Valve Repair in Rheumatic Patients:

Shamsher S. Lohchab, Ashok Chahal. PGIMS, Rohtak, India.

Objective: This study was planned to evaluate the feasibility of mitral valve repair through minimally invasive right anterolateral thoracotomy approach and compare the outcomes with conventional sternotomy approach in patients suffering from rheumatic valvular heart disease.

Methods: From May, 2012, to October, 2013, 25 patients underwent mitral valve repair through limited right anterolateral thoracotomy (Group 1). Various clinical outcome parameters were compared with a 25-patient (Group 2) sternotomy. The age and sex distribution in two groups were comparable. All patients in both groups were having similar spectrum of RHD and functional status. Different repair techniques were used with rigid ring annuloplasty. TEE was used perioperatively to evaluate the mitral valve.

Results: There was no operative mortality. Clinical parameters were better with Group1compared to Group 2, like ICU stay (68.84 hrs vs. 88.82 hrs), hospital stay (5.4 days vs. 9.5 days), chest tube drainage (375.60 ml vs. 536.5 ml), chest tube removal (55.96 hrs vs 65.78 hrs), incision length 7.4 cm vs. 14.2 cm). Cross-clamp time and bypass time were higher in Group 1. Superficial groin wound discharge was in one in Group 1. Outcome in terms of mitral valve function was comparable (significant MS, MR 4%, 0% Group 1 vs. 4%, 4% Group 2 at maximum follow-up of 18 months.

Conclusions: Mitral valve repair is feasible and safe with minimally invasive thoracotomy approach in patients suffering from rheumatic valvularheart disease with equivalent functional results and is better with respect to cosmesis, incision length, ICU stay, hospital stay, early mobility and patient satisfaction compared to sternotomy.

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D56 Minimally Invasive Video-Assisted Mitral Valve Repair: Single-Center Experience in 153 Patients

Giovanni Concistrè, Vito Giovanni Ruggieri, Luca Bellieni, Andrea Antonazzo, Elvira Gerbasi, Mario Portolan, Alfonso Sciangula, Alessandro Testa, Domenico Vuoto, Bruno Madaffari, Alfonso Agnino. S. Anna Hospital, Catanzaro, Italy.

Objective: Minimally invasive video-assisted mitral valve repair (MIMVR) has become an alternative to the conventional median sternotomy approach. We report a single-center experience with MIMVR and analyze mid-term results.

Methods: Between October, 2009, and October, 2013, 153 patients underwent Port-Access mitral valve repair. Mean age was 61.6±12.6 years (range: 24 to 84 years), 61 patients were female (40%), and mean logistic EuroSCORE was 4.6±5.4%. Concomitant procedures were tricuspid valve repair (n = 19), Maze procedure (n = 3), interatrial defect closure (n = 3). Mitral ring was implanted in all patients; in 8 patients Goretex neo-chordae were inserted for anterior leaflet prolapse. A total of 52 patients (34%) were in New York Heart Association functional class III/IV.

Results: Hospital mortality was 0.6% (n = 1). This patient had aortic dissection caused by retrograde CPB flow through the Endoreturn cannula in the femoral artery. Mean aortic cross-clamp and cardiopulmonary bypass times were 93.75±33.7 min and 138.7±40.8 min, respectively. Aortic cross-clamp was performed with Endo-Aortic Clamp in 97 patients (63%) and external aortic clamp in 56 patients (37%). Mean hospital stay was 8.3±4.2 days (range: 4-22 days). During follow-up (mean 25 months; range: 2-49 months) all patients improved their NYHA class; fourteen (9%) remained in class II. One hundred and thirty-two patients (88%) had no or trivial MR, and 18 (12%) had moderate MR (2+). There were two late deaths.

Conclusions: Minimally invasive video-assisted mitral valve repair appears to be safe and reproducible. This approach constitutes a valid alternative to the standard procedure, and has good mid-term results.

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D57 CABG During Acute Coronary Syndrome: Outcomes and Comparison of Off-Pump to Conventional CABG at a Veteran Affairs Hospital

Dominic Emerson, Michael Greenberg, Gregory Trachiotis. Veterans Affairs Medical Center, Washington, DC USA.

Objective: The management of acute coronary syndrome (ACS) has evolved dramatically over the last 50 years. Currently, management includes a multidisciplinary approach involving internal medicine, interventional cardiology, and surgery, with the optimal treatment for an individual potentially including catheter-based therapy, surgery, or purely medical management. Where surgical therapy is indicated, data regarding long-term outcomes within the Veteran population is lacking. In particular, little data exists regarding on-pump (cCABG) versus off pump (OPCABG) outcomes for this specific group.

Methods: A retrospective review of prospectively collected data was undertaken using an in-house database. All patients who underwent isolated CABG from January, 2000, to December, 2011, (n=1125) were included. From this cohort, patients who had ACS were identified (n=271). The remainder (n=854) were established as a control. Demographics and outcome data were compared between groups. The primary endpoints examined were 30-day and long-term mortality.

Results: Demographics between the ACS and control groups were generally similar, as was 30-day mortality; however, long-term mortality was worse for the ACS group (p=0.032, median follow-up 5.5 years). Additionally, length of stay (LOS) was higher in the ACS group (p<0.0001), as was composite morbidity (p=0.01). Subgroup analysis of ACS patients (OPVABG vs. cCABG) demonstrated significantly worse renal function (p=0.006) and ASA scores (p<0.001) in the OPCABG group, but both 30-day and long-term mortality were similar. However, the cCABG group had higher rates of reoperation for bleeding (p=0.034), and longer LOS (p=0.017) and operative time (p<0.0001). Finally, a Cox proportional hazards model was applied. Within the entire cohort, age, diabetes, OPCABG, and ACS were risk-factors (all p<0.05). Among the ACS cohort, only age remained a statistically significant factor (p<0.0001).

Conclusions: At this center, patients with ACS who are managed operatively tend to have similar short-term mortality compared to non-ACS controls. Long-term mortality appears worse for those presenting with ACS, as anticipated. In patients undergoing CABG for ACS, mortality is similar between off-pump and conventional CABG, however there does seem to be some benefits to OPCABG in terms of LOS and morbidity.

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D58The Descending Thoracic Aorta: The Forgotten Vascular Access for Endovascular Device Delivery

Keith B. Allen, A. Michael Borkon, Sanjeev Aggarwall, J. Russell Davis, David J. Cohen, Adnan K. Chhatriwalla, Aaron Grantham. St. Luke’s Mid-America Heart & Vascular Institute, Kansas City, MO USA.

Objective: Vascular access for delivery of large endovascular devices has evolved as patients have become more complicated and device indications have expanded. We describe direct descending thoracic aortic access during endovascular aortic repair (EVAR) and transcatheter aortic valve replacement (TAVR).

Methods: Transfemoral access has typically been utilized for device delivery during endovascular aortic repair for abdominal/thoracic aortic pathology. With the advent of TAVR, additional vascular access options such as direct aortic, subclavian, iliac and transapical expand the options for endovascular management. We describe using the descending thoracic aorta as access in complicated EVAR/TAVR cases in which more traditional access could not be utilized.

Results: Case 1: A 66-year old male presents three years following successful EVAR of abdominal aortic aneurysm with type III endoleak, sac expansion and severe angulation of components (Fig. D58-1A). Iliofemoral access inadequate for 17 French delivery sheath and component angulation would prevent retrograde device delivery. Descending thoracic aorta directly accessed utilizing a 7th interspace thoracotomy (Fig. D58-1B), and endoleak successfully repaired with stent graft (Fig. D58-1C) deployed antegrade.

Case 2: An 88-year old female with critical aortic stenosis and a porcelain ascending aorta presented with class IV CHF. Iliofemoral access inadequate (5 mm/calcified) for transfemoral TAVR. Prior left radical mastectomy and high dose chest wall cobalt radiation complicated by wound necrosis requiring skin grafting prevented a transapical access incision. Direct descending thoracic aortic access was achieved through a 6th interspace thoracotomy. A separate 8th interspace port was utilized to successfully deliver a SAPIEN 26 mm percutaneous aortic valve. Recovery in both cases was uncomplicated. Length of stay was three and six days respectively.

Conclusions: The descending thoracic aorta provides excellent vascular access for endovascular device deployment when less invasive alternatives are not available.



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D59 Minimally Invasive Surgery for Congenital Atrial Septum Defects in Adults

Yonne Schneeberger, Jens Brickwedel, Tobias Deuse, Hendrik Treede, Christian Detter, Hermann Reichenspurner. University Heart Center Hamburg, Hamburg, Germany.

Objective: To evaluate the outcome after minimally invasive surgery for congenital atrial septum defects (ASD) in adults.

Methods: Between March, 2004, and April, 2010, 52 patients underwent minimally invasive surgery for congenital ASD. Mean patient age was 40.79±13.0 years, 34 (65.4%) were female. Indications for surgery were sinus venosus defect, shunt-volume >30% or ASD >2 cm as well as persistent ASD after catheter based device-occlusion. Surgery was performed through a small right lateral mini-thoracotomy with cannulation of the peripheral vessels and video-assistance. ASD closure was conducted through the right atrium by either direct closure or pericardial patch. In the cohort, 2 (3.8%) patients suffered from a persistent foramen ovale, ASD II was present in 41 (78.8%) cases. A sinus venosus defect was found in 9 (17.3%) patients. All patients were in sinus rhythm preoperatively. Mean follow-up time was 42.3±22 months. Perioperative parameters were analyzed including stroke, arrhythmia, death and remaining ASD.

Results: In all patients no remaining ASD was found in the postoperative echocardiography. No major peri-operative complications, such as stroke, cardiac ischemia or death were found. Overall minor complication rate was 17.9%. Two (2.8%) patients with additional intervention of the superior vena cava required permanent pacemaker insertion. One (1.9%) patient suffered from an inguinal seroma, another one from inguinal paresthesia. In one case rethoracotomy due to hemorrhage had to be performed. Embolic occlusion of the femoral artery was reported in one case, two patients (3.8%) required drainage of a pneumothorax. All patients were in sinus rhythm postoperatively, except the two with the new permanent pacemaker.

Conclusions: In our cohort minimally invasive surgery for ASD could be performed safe and feasible without major complications. Lack of remaining ASD and long-term freedom from neurological complications are the major advantages of this procedure. Due to these favorable results, minimally invasive surgery for atrial septal defects should be standard of care for patients with contraindications for or failed catheter based device-occlusion.

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D60 Long-Term Outcomes Following Off-Pump or Conventional Coronary Artery Bypass Grafting Within a Veteran Population

Dominic Emerson 1, Gregory Trachiotis2. 1Georgetown University Hospital, Bethesda, MD USA, 2Veteran’s Affairs Medical Center, Washington, DC USA.

Objective: Recently published data indicates that outcomes for off-pump coronary revascularization (OPCABG) may be inferior to conventional techniques (cCABG) within the veteran population, but this has yet to be examined specifically within high-volume off-pump centers. Here we seek to examine the long-term outcomes for these patients within the Veteran population at a single institution well-experienced with OPCABG.

Methods: Utilizing a pre-existing in-house database, all patients who had undergone isolated CABG from 2000-2011 (n=1125) were identified. From this data, 18 demographic and risk factors were compared and utilized to create a propensity-score, which was used for matching between groups (OPCABG vs. cCABG). The primary endpoint examined was death. Survival was analyzed using the Kaplan-Meier method and the log-rank test. Groups were compared using a student’s t-test, or Fisher’s exact test, where appropriate.

Results: Unmatched OPCABG and cCABG groups were found to have significant differences in risk factors, with the OPCABG being a higher-risk population by EF, COPD status, age, and renal function, among others (all p<0.05). Kaplan-Meier analysis of the unmatched groups demonstrated an increased mortality rate within the higher-risk OPCABG group (p=0.0002). Using propensity-score matching, 335 OPCABG patients were then matched to 334 cCABG controls. Comparison of demographic and risk factors between these matched groups did not demonstrate any statistically significant difference. When Kaplan-Meier analysis was performed for the matched groups, there was no statistically significant difference in survival. Additionally, in the matched dataset, OPCABG patients had a shorter average length of stay (LOS) (10.5 vs. 12.3 days, p=0.017), shorter operative time (205 vs. 270 minutes, p<0.0001), and lower rate of composite morbidity (7% vs. 11%, p=0.041).

Conclusions: In this high-volume off-pump center, matched OPCABG survival is similar to cCABG. Though recent data indicates OPCABG survival may be worse than cCABG within the entire Veteran population, in centers well experienced with OPCABG this does not appear to hold true. Additionally, the benefit of decreased LOS and lower morbidity rates appears to be significant. Further study of the long-term outcomes of OPCABG in high-volume Veteran’s centers is warranted.

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D61 Marketing of Low Volume Robotic Cardiac Surgery Programs via the Internet and Public Reporting Avenues

Sugam A. Bhatnagar, Abdulla Alabagi, Robert Poston. University of Arizona, Tucson, AZ USA.

Objective: Marketing of robotic cardiac surgery via the internet and voluntary public reporting is an appropriate response to growing demand for less invasive procedures. However, the value of this information to the public depends on transparency. For robotic cardiac surgery programs defined as active vs. inactive, we compared the content and quality of information on websites and the % programs that publically report their results to the The Society of Thoracic Surgeons (STS).

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: Within the last 10 years, 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 currently inactive (n=212). Out of 372 total programs, 100% (n=24) of active, 52% (n=71) low volume, and 47% (n=100) of inactive programs contain information about robotic cardiac surgery. Institutional superiority was claimed in 88% of active programs, 18% of low volume programs. Eight inactive programs (4%) contained egregious and inaccurate claims about superiority. The percentage of active programs that volunteered to report to STS website was significantly higher than those that were inactive (30 vs. 40% reporting, Fisher test, P=0.018) and showed a trend towards increased overall composite score (96.16±1.138 vs. 96.62±1.138, P=0.16).

Conclusions: Internet marketing of robotics was noted to be widespread and often provides information of poor quality. Inaccurate or incomplete information about robotics increases the risk that patients are misdirected about this procedure.

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D62 High Rates of Mitral Valve Repair are Achievable with Minimally Invasive Surgery Even at the Start of a New Program

Sion G. Jones, Susannah Love, Kenneth Palmer, Omar Al-Rawi, Paul Modi. Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.

Objective: Minimally invasive mitral valve (MIMV) surgery is technically challenging with a long-learning curve. Concern exists that repair rates may be lower than with sternotomy. We reviewed our initial experience to ascertain if this is justified.

Methods: From March, 2011, to October, 2013, 63 MIMV procedures were performed through a 6 cm right anterior minithoracotomy by a single surgeon (repair, n=55; replacement, n=8). Types I, II and IIIa dysfunction were present in 6 (10%), 50 (79%) and 7 (11%) patients respectively. Exclusion criteria included bileaflet prolapse, body mass index >35 and >1+ aortic regurgitation. Data are presented as medians (interquartile range).

Results: Median age was 61 (56-69) years, 35% were female, and 2 were reoperations. Nine patients had concomitant procedures: tricuspid valve repair (n=1), cryomaze (n=6), and patent foramen ovale closure (n=3). There was no mortality and no strokes. For primary degenerative and functional disease, the repair rate was 100% with no/trivial residual MR (n=53, 96%) or mild MR (n=2, 4%) on the intra-operative echo. All rheumatic valves were replaced. Bypass and clamp times were 205 (189-230) and 137 (126-156) minutes respectively. There were no conversions to sternotomy. Duration of ventilation, ITU and hospital stay were 8 (6-10) hours, 2 (1-3) and 6 (5-8) days respectively. Two patients needed reoperation, one for endocarditis following an E. coli urinary tract infection and one for early failure of the anterior leaflet repair.

Conclusions: High rates of valve repair with minimally invasive mitral surgery are achievable with appropriate training and in appropriately selected patients even at the start of a new program.

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D63 Neurological Tests and Quality of Life Measurements in Patients after Minimal-Invasive Mitral Valve Surgery

Inna Kammerer 1, Armin Vomend1, Arndt-H. Kiessling2, Falk-Udo Sack1. 1Academic City Hospital Ludwigshafen, Ludwisghafen, Germany, 2Head Cardiovascular Research, Academic Hospital of Johann-Wolfgang-Goethe University, Frankfurt, Germany.

Objective: Clinical benefit of mitral valve reconstruction (MVR) is well documented, but comparative data of long-term follow-up (> 12 months period) in postoperative quality of life (QoL) and mental power are missing. We hypothesized that mitral valve reconstruction with isolated mitral valve disease have neuropsychological benefits in 1-year follow-up.

Methods: Since 2011, 40 patients (mean 60 years, 75% male) after non-emergent MVR were enrolled. In a prospective trial, psychological measurements like SF-36 with 8 scaled scores about physical and mental health, depressive analysis (BDI), neuropsychological tests like Mini-Mental test (KMS), Trial A, B tests and 6-minute-walk (6 MWT) for exercise tolerance was assessed before (n=38), 9 days (n=34) and 12 months (n=19) after surgical intervention.

Results: In a paired t-test model correcting for physical function SF-36 headings were detected significant lower scores, especially in period before vs. 9 days after the operation (p>0.001) and vs. after 12 months (p>0.001) without significances in mental power scores during the time. The 6-minute-walk measure decreased to hospital discharge date: 516 m preop vs. 438 m postop (p>0.038) vs. 526 m 12 months later (n.s.). Significant differences showed Part B in postoperatively period: 88 min pre OP vs. 111 min post OP (p>0.001) vs. 100 min 12 months after OP (p>0.01).

Conclusions: The differences of QoL and neurological testing in patients with MVR in 1-year period outcome showed significant improvement as well in physical fitness (6MWT) as in SF-36 measures.

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D64 Transapical Transcatheter Aortic Valve-in-Valve Implantation for Aortic Regurgitation with a Self-Expandable Device in a Stentless Supra-Annular Bioprosthesis

Gry Dahle 1, David Holzhey2, Bjørn Bendz1, Jon T. Offstad1, Jan Fredrik Bugge1, Kjell Arne Rein1. 1Rikshospitalet, OUS, Oslo, Norway, 2Heart Center, Leipzig, Leipzig, Germany.

Objective: Transcatheter aortic valve implantation (TAVI) has initially been considered as an alternative for high-risk patients with aortic stenosis. Also valve-in-valve (VIV) technique for degenerated bioprosthesis is performed for stented as well as for calcified stentless bioprosthesis. With a new generation of self-expandable devices, VIV for aortic regurgitation (AR) in a stentless bioprosthesis may be an option.

Methods: An 83-year-old woman operated with aortic valve replacement with a stentless supra-annular 25 mm CryoLife O’Brien (CLOB) (CryoLife International, Atlanta, GA USA) prosthesis ten years ago, was referred. Initially, the result of the aortic valve implantation was good, but progressively she developed a severe aortic regurgitation due to degeneration of the prosthesis. VIV was considered and CT measurements were done to evaluate the size of the valve and the implantation angle. A major concern was the short distance between the bioprosthesis and the coronary ostia.

Results: Via a mini left thoracotomy and transapical access, a self-expandable 26 mm Engager (Medtronic Inc., Minneapolis, MN USA) with control arms was implanted in good position. The preoperative angiography showed contrast in both coronary arteries. There were only trace of paravalvular leak (PVL) intraoperatively that ceased upon the echo control two days later. The patient was extubated in the operation room and mobilized the following day.

Conclusions: This case report demonstrates the feasibility of transapical transcatheter aortic VIV implantation of the Engager valve in a degenerated stentless supra-annular CLOB bioprosthesis with aortic regurgitation. This may expand the use of the VIV implantation technique, applicable also in a situation with pure AR.



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D65 Decision Making in the OR: Seeking for Excellence in Mitral and Tricuspid Valve Repair through Right Minithoracotomy

Antonio Miceli, Matteo Ferrarini, Daniyar Gilmanov, Michele Murzi, Pier A. Farneti, Marco Solinas, Mattia Glauber. Fondazione Toscana G. Monasterio, Massa, Italy.

Objective: Minimally invasive mitral valve repair (MIMVR) is becoming the gold standard approach for the management of degenerative mitral regurgitation (MR) with or without concomitant tricuspid annuloplasty (TVR). Irregardless of the access, we believe that suboptimal intraoperative results should not be accepted as this may translate in earlier failure of the repair and worse long-term outcome. In mitral valve repair, we should always seek for excellence to guarantee the best patient outcome. In this video, we show how to handle a suboptimal result in a case of a concomitant complex mitral and tricuspid repair to hunt for an ideal result.

Methods: Our approach consists of femoral venous cannulation and direct ascending aorta cannulation with trans-thoracic aortic clamping.

Results: The present video reports a case of Typi MR with extensive P2 prolapse due to chordal rupture and moderate tricuspid insufficiency. MR was corrected with triangular resection, chordal replacement and semirigid annuloplasty ring while the tricuspid was corrected with a flexible annuloplasty ring. Suboptimal result with 1+ residual MR was considered not acceptable and MV was re-accessed to achieve the optimal result.

Conclusions: The surgical technique illustrated by the video is routinely applied in our center to address both mitral and tricuspid valve repair with low morbidity and mortality rates. Central aortic cannulation allows the avoidance of complications associated with retrograde perfusion while extending the suitability of MIMV surgery also to those patients who have an absolute contraindication to femoral artery cannulation. Nonetheless, a minimally invasive approach should not discourage one from seeking an excellent result from mitral repair procedures. Good quality TEE is mandatory to check the quality of the repair and guide the surgeon to the repair strategy. With this video, we strongly advise to always hunt for the optimal result of MVR as this will lead to better patient outcome and long-term results.

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D66 Robotic Cardiac Surgery Is a Safe and Effective Option for Elderly Patients

Edward T. Murphy, Charles Willekes. Meijer Heart Center, Grand Rapids, MI USA.

Objective: Minimally invasive robotic surgery is not offered to elderly patients in many cardiac centers because of concerns that the risk of morbidity and mortality would be prohibitive in this population. We examined our experience with robotic surgery in this population to determine if these concerns are warranted.

Methods: All patients undergoing robotic cardiac surgery at our institution during the previous 6 years (2008-2013) were retrospectively reviewed. Patients 70 years of age and older at the time of surgery were compared to their younger cohorts with regard to mortality and major surgical morbidity.

Results: A total of 182 patients, ages 20 to 84 years underwent surgery during the study period. 34 (18.7%) were >70 years old. Of these, 27 patients had isolated mitral repair (79.4%), 2 had repair combined with a maze procedure (5.9%) and 5 had atrial myxoma excisions (14.7%). No deaths occurred in the elderly group; 1 death occurred in the younger group during the postoperative phase (0.7%). 4 patients in the elderly group required conversion to an open procedure for valve replacement because of persistent mitral regurgitation. One patient with a satisfactory repair required sternotomy for repair of an aortic dissection seen upon removal of the cross-clamp. CVA, renal failure, and re-exploration for bleeding were not statistically different between the two groups.

Conclusions: Robotic cardiac surgery was accomplished in this group of elderly patients with zero mortality and an incidence of morbidity similar to that seen in the younger cohort. These findings suggest that robotic minimally invasive cardiac surgery should be offered to carefully screened candidates regardless of their age.

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D67 Comparative Analysis of the Results of MICS-CABG

Aliaksandr Ziankou 1, Uriy Ostrovskij2. 1Vitebsk State Medical University, Vitebsk, Belarus, 2Republic Research-Practical Center “Cardiology”, Minsk, Belarus.

Objective: To carry out the comparative analysis of immediate results of minimally invasive coronary surgery (MICS-CABG), conventional off-pump (OPCABG) and on-pump coronary artery bypass grafting (ONCABG) for optimization of the surgical treatment of the patients with coronary heart disease (CHD).

Methods: From 2008 to 2013 at the Cardiac Surgery Department of ME Vitebsk Regional Clinical Hospital 183 patients with the CHD underwent MICS-CABG (Group I), 156 patients - OPCABG via sternotomy (Group II) and 99 patients - ONCABG via sternotomy (Group III). In Group I MICS strategy was directed to avoid cardiopulmonary bypass with cardioplegia and manipulations of the ascending aorta, usage of the left minithoracotomy access and tendency to perform complete or functionally reasonable composite-sequential arterial myocardial revascularization. 14 patients of this group underwent hybrid procedure with full arterial revascularization of the left ventricle. Clinical characteristics of patients in all groups did not differ significantly.

Results: MICS-CABG with aortic no-touch technique is attended by the lower index of revascularization (2.33) in comparison with OPCABG (2.79) and ONCABG (3.17), higher rate of arterial revascularization (80.9%, 54.5% and 43.4% respectively), functionally reasonable revascularization (37.2%, 12.2% and 10.1% respectively) and lower rate (62.8%, 87.8% and 89.9% respectively) of complete myocardial revascularization (p<0.05). Immediate surgery results were found satisfactory (complete angina retrogression and absence of the MACCE) in 98.9% of patients of the MICS-CABG group, in 96.8% of patients of the OPCABG group and 95.0% of patients of the ONCABG group (Table D67-1) and were comparable (p>0.05).

Conclusions: Application of the MICS-CABG leads to the reduction of the perioperative complications rate (intra- and post-operative blood loss, superficial and deep wound infection) and also decreases postoperative hospital length of stay, saving the effectiveness of the coronary procedures. Further comparative trials of MICS-CABG results are necessary with respect to survival, quality of life, major adverse cardiovascular events rate, and conduit patency.



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D68 Uniportal VATS Lobectomy after Neoadjuvant Chemoradiation for N2 Lung Cancer

Jae Ho Chung, Yong Soo Choi. Samsung Medical Center, Seoul, Republic of Korea.

Objective: We report our case of uniportal VATS lobectomy in advanced lung cancer.

Methods: A 53-year-old male patient was diagnosed with N2-positive advanced lung cancer in his right lower lobe. Considering the tumor in paraesophagel lymph node confirmed on EBUS-TBNA, neoadjuvant chemoradiation therapy (weekly Paclitaxel/cisplatin and RT 38Gy) was performed. After partial response of chemoradiation therapy, uniportal VATS right lower lobectomy was planned. Operation was performed through a single incision of 4 cm at 5th intercostal space, and usual lobectomy with mediastinal lymph node dissection was performed.

Results: Total operative time was 195 minutes, and intraoperative blood loss was 200 ml. The operation was successfully performed without specific events. A total of 20 mediastinal lymph nodes were removed from stations of right lower paratracheal, subcarinal, paraesophageal, hilar, interlobar, right upper lobar, right middle lobar area. The pathologic report confirmed TNM stage of ypT1aN0M0. Chest tube was removed on postoperative day 6, and the patient was discharged without any complication.

Conclusions: Uniportal VATS lobectomy seems to be a feasible and acceptable method in some patients after neoadjuvant chemoradiation for N2 lung cancer.

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D69 Aortic Valve Replacement Through Ministernotomy: Factors Related to Longer Cardiopulmonary Bypass and Cross-Clamp Time

Guillermo Reyes, Juan Bustamante, Sara Badia, Eva Aguilar, Omer Leal, Anas Sarraj. Hospital Universitario La Princesa, Madrid, Spain.

Objective: In most papers, longer cardiopulmonary bypass time and longer cross-clamp time are associated with aortic valve replacement (AVR) through ministernotomy. The aim of this study is to analyze those factors related to cardiopulmonary bypass and cross-clamp in patients undergoing AVR through a ministernotomy.

Methods: All patients undergoing AVR using an upper ministernotomy from January, 2011, to December, 2013, in our center were selected (n=40). According to surgeon preferences, in some patients a pulmonary vent catheter through the internal jugular vein was used. In others, a peripheral retrograde cardioplegia device was employed. All baseline clinical characteristics and surgical data were analyzed. Mean cardiopulmonary bypass (CPB) time and cross-clamp time was 94±30 and 67±21 minutes respectively. Therefore, patients were divided in Group A (CPB time > 94/cross-clamp time > 67 minutes) and Group B (CPB time < 94/cross-clamp time < 67 minutes).

Results: Mean age was 73±14.5 years old with 40% female patients. Logistic EuroSCORE (%) was 6.4±4.3. Post-operative morbidity was: atrial fibrillation in 7 patients, pneumothorax in 3 patients and early endocarditis in 1 patient. There was no mortality. There were no differences between groups regarding age, logistic EuroSCORE, preoperative creatinine, aortic annulus diameter and length of stay. Group A (CPB time > 94 or cross-clamp time > 67 minutes) was associated to male patients (78.6% vs. 50%; p=0.07 and 76.5% vs 47.8%; p=0.06). Also in Group A an aortic valve double lesion was more frequent than isolated aortic stenosis or insufficiency (71.4% vs. 19.2% and 70.6% vs. 13%, p<0.001). Shorter cross-clamp time (<67 minutes) was more frequent in those patients operated in 2013 than those operated previously (69.6% vs. 29.4%; p=0.01) and in patients in which a pulmonary vent catheter was used (26.1 vs. 5.9%; p=0.09).

Conclusions: In patients undergoing AVR through ministernotomy, longer CBP and cross-clamp time were more frequent in male patients and in patients with an aortic valve double lesion. Shorter cross-clamp time was more frequent in patients operated in the last period and in patients in which a pulmonary vent catheter was used.

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D70 VATS/Thoracoscopic Laser Metastasectomy

Narendra Agarwal, Shaiwal Khandelwal, Kamran Ali, Sangeeta Khanna, Jyotirmoy Das, Ali Zamir Khan. Medanta, The Medicity, Gurgaon, India.

Objective: We present a video of video-assisted thoracoscopic resection of sarcoma metastases using 1318 nm laser.

Methods: 22-year-old patient presented with evidence of six metastases to lung following resection of primary sarcoma from left femur eight years ago. Surgery was the only way forward as these metastases are resistant to chemotherapy. Patient underwent VATS resection using a 1318 nm Laser to complete the surgery.

Results: Eight metastases were resected. There was no air leak on table on testing underwater. The largest metastasis was 4 cm large. Digital suction device showed a measurement of 10 ml/min within 5 minutes of finishing the surgery. The chest drain was removed the following day. The patient was discharged the next day.

Conclusions: Use of laser during VATS metastasectomy reduces the incidence of air leak, reduces cost by reducing use of staplers. This is a major advantage in the third world where economic constraints play an important role. Early removal of drain and early discharge was possible due to the use of VATS and laser.

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D71 Endoscopic Vein Harvest in Elderly Patients (More than 70 years of Age) Does Not Reduce Postoperative Stay: Propensity-Matched Comparison with Open Vein Harvest

Vivek Srivastava, Manoj Purohit, Steven Power, Laura Howell, Amal K. Bose, Mohamad Nidal Bittar, Joseph Zacharias. Victoria Hospital, Blackpool, United Kingdom.

Objective: Endoscopic vein harvest (EVH) is cosmetically advantageous but involves additional cost difficult to justify with increasing budgetary restrictions. One perceived advantage would be reduced postoperative stay (POS), saving on bed costs. Our objective was to compare length of POS between EVH and open vein harvest (OVH). We chose patients more than 70 years of age as they potentially stand to benefit most from early mobilization afforded by EVH.

Methods: Patients having EVH between November, 2008, and September, 2013, were identified from departmental database. Propensity-matching (MatchIT software package) was used to identify patients having similar surgery with OVH. POS was derived from date of physiotherapy discharge as other factors including social circumstances may artificially prolong actual POS. Outcomes for the two groups were compared using two sample t-test or Mann-Whitney U test for continuous variables and chi-square test for categorical variables.

Results: There were 176 patients in each group with similar age distribution (mean 76.8±4.8 vs. 76.5±4.5, p=0.545). EVH group had 57 (32.4%) females and OVH group had 59 (33.5%). Comorbidities and other preoperative characteristics were not statistically different between the two groups although there was higher incidence of diabetes, renal dysfunction and poor LV function in the EVH group. Mean additive EuroSCORE I was higher in EVH group (6.55±2.5 vs. 6.01±3.2) but not statistically significant (p=0.082).There were 6 deaths (3.4%) in each group. Median stay was 7 days in each group (p=0.267). Amongst 128 isolated CABGs in each group, mean stay was 9.46 days in EVH and 7.14 days in OVH (p=0.076). Other outcomes are presented in Table D71-1.

Conclusions: Despite slightly higher risk profile, EVH group had comparable POS. Unfortunately, in this relatively small cohort, we have been unable to demonstrate a cost benefit in terms of reduced postoperative bed usage. However, patient satisfaction and wound care costs have not been included in the present analysis which may be additional factors in favor of EVH.



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D72 Robotic-Assisted Lung Resections: Our Initial Experience in a Community Hospital

Sudhan Nagarajan 1, Richard S. Chang2. 1Drexel University College of Medicine, Philadelphia, PA USA, 2Department of Thoracic Surgery, ARIA Health/Jefferson Medical College, Philadelphia, PA USA.

Objective: To evaluate our experience and assess our learning curve over the last three years in robotic-assisted lung resections.

Methods: We retrospectively reviewed the patients who have undergone robotic-assisted lung resections at our hospital. All procedures were done in the same health system by a single surgeon with basic video-assisted thoracoscopic surgery (VATS) experience. We also analyzed our modified operative technique with regards to port placement and dissection.

Results: There were a total of 100 patients, 51 men and 49 women, with an age range from 17 to 88 years. The lung resections included 49 lobectomies, 1 bilobectomy, 2 pneumonectomies, 38 wedge resections and 10 segmentectomies. The mean duration of hospital stay was 5.8±4.6 days and the trend favored a shorter hospital stay as our experience with these procedures increased. The docking times and physician console operative times became shorter with more cases reflecting the team and the surgeon’s adaptation to the robotic-assisted procedures. The mean number of nodes retrieved in patients who also underwent mediastinal node dissection was 9.3±5.4. The learning curve is around 15 to 20 cases and similar to the existing literature. Major complications were seen in 20% of patients and included significant atelectasis, pneumonia, atrial fibrillation, middle lobe torsion and persistent air leaks. There were two conversions and one mortality in our series.

Conclusions: Robotic-assisted lung resections have been increasingly adapted by more thoracic surgeons across the country. We have seen that it is feasible in community hospitals like ours. The surgeons and the team with even little VATS experience can adapt to this technology, which makes minimally invasive approaches to the lungs more precise and safe.

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D73 Hemodynamic Performance of the St. Jude Medical Trifecta Aortic Bioprosthesis Following Minimally Invasive Aortic Valve Replacement (MIAVR)

Amir Sepehripour, Jacob Chacko, Kulvinder Lall. St. Bartholomew’s Hospital, London, United Kingdom.

Objective: The St. Jude Medical Trifecta aortic supra-annular bioprosthesis is regarded as the next generation in pericardial stented tissue valves. The unique design of tissue leaflets attached to the exterior of the valve stent provides unrivalled in-vivo mean gradients and hemodynamics. The aim of this prospective study was to evaluate mid-term hemodynamic performance.

Methods: One hundred and thirty five consecutive patients undergoing MIAVR (partial J sternotomy) using the St. Jude Medical Trifecta valve at a single UK center over a 36-month period were included in this study. All implanted valves were 19, 21, 23, 25 and 27 mm in size. Assessment of hemodynamic function was carried out using transthoracic echocardiography pre-operatively and at follow-up, as well as transesophageal echocardiography intra-operatively.

Results: The study population consisted of 135 patients (73 male, 62 female). Mean age was 77.5±5.2 years. Implanted valve sizes were 19 mm (n=13), 21 mm (n=35), 23 mm (n=57), 25 mm (n=23) and 27 mm (n=7). Overall mean post-operative pressure gradients were 7.46±3.7mmHg (mean) and 15.36±4.9mmHg (peak). Subgroup mean post-operative pressure gradients were 7.26±7.2mmHg, 7.56±2.9mmHg, 8.67±4.3mmHg, 7.41±3.9mmHg, 7.36±2.9mmHg, for the 19, 21, 23, 25 and 27 mm cohort respectively. Overall mean post-operative left ventricular ejection fraction was 61±3.1%. Overall mean effective orifice area was 1.81±0.5cm2. Moderate-severe paravalvular leak was observed in one patient and mild-moderate leak in another. Otherwise there were only 17 patients with trivial regurgitation.

Conclusions: These results of our experience demonstrate excellent hemodynamic performance of the Trifecta bioprosthetic valve using a minimally invasive approach for implantation.

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D74 Hemodynamic Performance of the St. Jude Medical Trifecta Aortic Bioprosthesis in Octogenarians Following Minimally Invasive Aortic Valve Replacement (MIAVR)

Amir Sepehripour, Jacob Chacko, Kulvinder Lall. St. Bartholomew’s Hospital, London, United Kingdom.

Objective: The St. Jude Medical Trifecta aortic supra-annular bioprosthesis is regarded as the next generation in pericardial stented tissue valves. The unique design of tissue leaflets attached to the exterior of the valve stent provides unrivalled in-vivo mean gradients and hemodynamics. The aim of this prospective study was to evaluate mid-term hemodynamic performance of valve implanted into patients over 80.

Methods: Thirty-nine consecutive patients undergoing MIAVR (partial J sternotomy) using the St. Jude Medical Trifecta valve at a single UK center over a 36-month period were included in this study. All implanted valves were 19, 21, 23, 25 and 27 mm in size. Assessment of hemodynamic function was carried out using transthoracic echocardiography pre-operatively and at follow-up, as well as transesophageal echocardiography intra-operatively.

Results: The study population consisted of 39 patients (23 male, 16 female). Mean age was 82.3±1.2 years. Implanted valve sizes were 19 mm (n=7), 21 mm (n=12), 23 mm (n=13), 25 mm (n=5) and 27 mm (n=2). Overall mean post-operative pressure gradients were 8.12±3.5mmHg (mean) and 14.27±5.7mmHg (peak). Subgroup mean post-operative pressure gradients were 8.23±5.1mmHg, 7.83±1.5mmHg, 8.15±2.6mmHg, 7.38±2.4mmHg, 7.14±2.3mmHg, for the 19, 21, 23, 25 and 27 mm cohort respectively. Overall mean post-operative left ventricular ejection fraction was 57±2.4%. Overall mean effective orifice area was 1.73±0.9cm2. There were only 4 patients with trivial regurgitation.

Conclusions: These results of our experience demonstrate excellent hemodynamic performance of the Trifecta bioprosthetic valve in octogenarians using a minimally invasive approach for implantation.

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D75 Early True Post-Infarctional Left Ventricle Free Wall Rupture Treated with Extracellular Matrix Patch in the “Off-Pump” Technique

Tomas Holubec, Ibrahim E. Caliskan, Simon H. Sündermann, André Plass, Dominique Bettex, Volkmar Falk, Francesco Maisano. University Hospital Zurich, Zurich, Switzerland.

Objective: The aim is to present a case report showing a successful closure of ventricular free wall rupture with epicardially placed patch using a new material on the beating heart.

Methods: A 50-year-old male has been referred to our department presenting with cardiogenic shock due to transmural myocardial infarction of the inferior wall which has been treated by PCI of the circumflex artery. Additionally, a rupture of the left ventricle free wall was suspected and pericardium was partially drained. An urgent operation was indicated and an IABP was placed. After median-sternotomy, the heart has been elevated using a LIMA stitch without cardiopulmonary bypass and the true rupture of the inferior left ventricle wall has been identified (Fig. D75-1A). An extracellular matrix patch (CorMatrix ECM) has been sutured with a running polypropylene suture around the rupture creating a pouch, which has been filled with gelatin-resorcinol-formaldehyde glue (Fig. D75-1B). Additionally, a venous graft has been anastomosed to the posterior descending artery.

Results: The patient recovered well from the operation, could be easily weaned from IABP and was extubated on the 3rd post-operative day. The post-operative course was then complicated by perforation of sigmoid colon diverticula requiring a resection of the sigmoid colon via median laparotomy.

Conclusions: This case report demonstrates the extracellular matrix patch as a feasible material alternative for epicardial patch technique to treat a ventricular free wall rupture, even when performed in “off-pump” technique. The advantage of this material is better pliability than conventional pericardial patches and, therefore, less risk of tearing. To the best of our knowledge, this is the first use of this particular material in this technique.



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D76 Full Arterial Revascularization for Multivessel Critical Disease with Fully Skeletonized and T-Grafts: More Than a Decade of Experience (2002 – 2013)

R. Pradeep Kumas, Balachandran Nair, Y. A. Nazer. Travancore Heart Institute, Tranvancore Medical College Kerala, PRS & KIMS Group of Hospitals, Kerala, India.

Objective: Full arterial CABG is the optimal surgical option for best long-term results in multivessel critical coronary artery disease (CAD). Use of full arterial revascularization using fully skeletonized arterial grafts and T-grafts is associated with prolonged operating times, but with best long-term results and no additional morbidity. We present our experience in the use of these techniques on a routine basis in patients with multivessel critical occlusion.

Methods: Between November, 2002, and November, 2013, 890 patients (aged 51±9 year) underwent full arterial CABG. Left ventricular ejection fraction ranged from 15% to 85% (mean 59±15%); triple-vessel disease was present in 100% of the patients. The incidence of diabetes mellitus was 44.9% (14% insulin dependent). Either both fully skeletonized internal thoracic arteries (ITAs) (800) or the left ITA and fully skeletonized radial artery (90) were used as conduits. Bilateral radial artery was used in 160 patients. In 865 of the patients, a T-graft was created. Mean operating time was 188±46 minutes; bypass time, 92±25 minutes; and ischemic time, 56±22 minutes. 4 to 8 (mean 4.1±1.9) anastomoses were performed per patient.

Results: Perioperative intra-aortic balloon pump was necessary in 12 patients. Endarterectomy was required in 12 patients. Sternal complications occurred in 4, and in-hospital mortality was in 2 patients with sepsis. Postoperative coronary angiography in 180 patients documented excellent patency rates 98.3% in up to 11 years follow-up.

Conclusions: Full arterial revascularization in critical multivessel CAD is possible with the use of fully skeletonized arterial grafts and T-grafts with excellent immediate and late results.

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D77 Collared Graft for Hybrid Repair of Extensive Thoracic Aortic Aneurysm

Kenji Aoki, Takeshi Okamoto, Hiroki Sato, Osamu Namura, Kazuhiko Hanzawa, Masanori Tsuchida. Niigata University, Niigata, Japan.

Objective: Hybrid procedure of graft replacement with elephant trunk (ET) and endovascular repair with stent graft has been an optimal treatment for extensive thoracic aortic aneurysm (eTAA). However, such a hybrid repair (HR) is limited when the aneurysm is extended to the ascending aorta. Size discrepancy in the anastomotic site becomes a great problem. In Japan, the maximum diameter of commercially available grafts for aortic reconstruction is 30 mm. When the aorta is 50 mm or more, the difference in size cannot be resolved by simple plication of the aorta. We developed a new graft to correct the mismatch.

Methods: We created a collared graft for HR. It has a donut of Dacron tube graft. The donut functions as a collar to correct the mismatch in the anastomotic site.

Results: We used a collared graft for HR of eTAA. [Case] An 80-year-old woman was referred to our department for asymptomatic aneurysm of the thoracic aorta. Computed tomography (CT) showed an extensive aneurysm of ascending arch and descending thoracic aorta extending to the diaphragm level. The aneurysm was over 70 mm at its arch and descending segment. The ascending aorta was 62 mm. To complete an anastomosis in the ascending aorta, a collared graft was made by a combination of 30 mm branched aortic graft and 12 mm straight graft. The collar was about 60 mm in diameter (See Fig. D77-1). Under cardiopulmonary bypass, the collared graft with ET was anastomosed to the aneurysmal ascending aorta with continuous suture of 4-0 polypropylene. After arch branches were reconstructed, the residual aneurysm was excluded with 36 mm and 34 mm stent grafts by connecting to ET. She experienced consumption coagulopathy early after surgery and tolerated by transfusion. Postoperative CT showed complete exclusion of the aneurysm.

Conclusions: A collared graft can be an option to complete HR for extensive aneurysm including ascending aorta.



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D78 Robot-Assistance Enhances Laparoscopic Dissection and Primary Closure of the Hiatus in Patients with Giant Hiatal Hernias

Barbara Tempesta, Duy Nguyen, Mark Meyer, Mohammad Moslemi, Keith Maas, Robert Poston, Farid Gharagozloo. University of Arizona Medical Center, Tucson, AZ USA.

Objective: Giant hiatal hernia with intrathoracic stomach is often not amenable to laparoscopic repair, conventionally requiring thoracotomy or laparotomy to address these defects. The results of surgical repair for these defects have been disappointing, independent of approach. We describe our experience in application of robot-assisted laparoscopic surgery to the treatment of this difficult problem.

Methods: All patients who underwent robot-assisted laparoscopic repair for incarcerated giant hiatal hernia over a 10-month period were included in the study. The operation was performed by a single surgeon (FH) through four ports. Mediastinal dissection was accomplished with robot-assistance and hiatal closure was performed using a traditional laparoscopic approach. Success was assessed by intraoperative endoscopy and postoperative esophagography. Symptoms were assessed subjectively and objectively by a validated metric.

Results: There were two men, three women, with a mean age of 56 years. The procedure was deemed successful in all patients based on the return of normal anatomy, endoscopically, and on postoperative esophagram. All patients were asymptomatic and were graded as Viscik I at one day, two weeks, and 10-months, with no recurrences to date.

Conclusions: Robotics enables a complete dissection of the hernia sac and reduction of the intrathoracic stomach in patients with giant hiatal hernias. Although greater experience is necessary, robotics may represent a more viable minimally invasive approach with primary closure of the hiatus in patients with giant hiatal hernias. By virtue of three-dimensional visualization and greater instrument maneuverability, the robot can facilitate a laparoscopic mobilization of incarcerated organs, allowing for successful, minimal, and primary repair of the giant hiatal hernia.

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D79 A Bubble-Mixture Method to Improve Dynamic Image of Carbon Dioxide Angiography

Te-I Chang, Sr., I-Hui Wu, Sr.,Chih-Yang Chan, Sr. National Taiwan University Hospital, Taipei, Taiwan.

Objective: To demonstrate a novel way of preparing carbon dioxide (CO2) used for angiography by bubble-mixture of blood and CO2 gas before injection.

Methods: CO2 angiography has provided a valuable option for patients with kidney diseases in endovascular procedures. Due to the buoyancy of CO2 gas, it preferentially fills nondependent vessels. The force of buoyancy may exceed the kinetic force of blood flow in vessels, especially in smaller distal vessels, causing transient gas trapping and poor dissemination to distal vessels. By premixture of blood and CO2 with a bubble-creating technique, it allows a single CO2 volume to be dispersed into numerous tiny bubbles. In this way, the vapor-lock phenomenon can be dramatically reduced and the distribution of CO2 inside target vessels is more even, thus creating a more contrast-like image during digital subtraction angiography. The bubble-mixing technique was very simple and safe by just adding one three-way lock and a syringe into previous closed CO2 delivery system. The proteins in the blood act as natural foaming agents. The blood was withdrawn from the patient by the same delivery catheter and by acting piston motions of two parallel syringes, we create bubble mixtures of CO2 and blood (Fig. D79-1). The risk of air contamination was minimized because no parts of closed system were disconnected during preparation.

Results: A patient with left superficial femoral artery occlusive lesion was presented. We delivered pure CO2 and bubble-mixed CO2 during angiographies for comparison. The pure CO2 subtraction images showed strolling of CO2 back and forth and poor enhancement of distal femoral artery due to low distal runoff before angioplasty; comparing to that, the bubble-mixed CO2 images showed smooth progression of CO2 and better visualization of distal arteries. After balloon angioplasty, the distal run off improved.

Conclusions: The dynamic image quality change for CO2 digital subtraction angiography was promising. It solves uneven distribution of CO2 toward antigravity side of vessels and provides more smooth “contrast-like” dynamic images of CO2 angiography.



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D80 Establishing a Novel Protocol for Cardiac Decellularization

Courtney Hemphill 1, Ning Qu1, Anthony V. Louis2, Tiffany Son1, Zain Khalpey2. 1University of Arizona, Tucson, AZ USA, 2University of Arizona, University of Arizona Medical Center, Tucson, AZ USA.

Objective: Cardiac disease is one of the leading causes of mortality in Western countries. Regeneration of cardiac tissue remains an elusive goal, making transplantation the only viable option to improve quality of life for chronic end-stage patients. Use of a decellularized bioscaffold for ex-vivo tissue engineering provides future application for clinical cardiac transplantation. By optimizing the decellularization procedure, we established a new protocol for producing cardiac bioscaffolds using porcine hearts as a bridge-to-transplantation.

Methods: Using a system consisting of regulated pulsatile pumps, hearts were completely decellularized. The system was modified by gradual flow rates (up to 2200 ml/min) with gradual pressures (up to 400 mmHg) to decellularize porcine hearts (n=10). Decellularization involved perfusion of 1-2% sodium dodecyl sulfate (SDS) and 1-3% Triton detergents. Native and decellularized hearts were analyzed via DNA assessment, hematoxylin and eosin (H&E) staining and transmission electron microscopy (TEM). Forward-looking infrared (FLIR) cameras were used to record reliable temperature measurements through thermographic images.

Results: Compared to a native heart, a heart decellularized in slightly less than five hours appears translucent, indicating loss of cellular components. Histology and TEM data of decellularized bioscaffolds indicated removal of nuclear material with the maintenance of key extracellular matrix architecture such as collagen. Quantitative (99.9%) analysis of DNA concentrations of the decellularized heart showed a significant decrease in the presence of DNA as compared to the native control. FLIR imaging verified a homogenous decellularization.

Conclusions: Pressures greater than those found physiologically are necessary for cardiac decellularization. Gradual increases in flow rates play an important role in decellularization. Monitoring pressures and flow rates throughout the decellularization process combined with our modified decellularization protocol has resulted in a shorter cardiac decellularization method. To our knowledge, a cardiac decellularization protocol that produces bioscaffolds in less than five hours does not exist, making this clinically applicable work novel. This efficient method significantly revitalizes the field of transplantation by providing an improved model that can ultimately be translated to the clinical setting.

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D81 Push-Pull Technique for Mechanical Vacuum-Assisted IVC and Bilateral Iliac Thrombectomy

Eric J. Lehr, Glenn R. Barnhart, Samuel J. Youssef, Mai T. Pham. Swedish Heart and Vascular Institute, Seattle, WA USA.

Objective: Management of the thrombosed inferior vena cava (IVC) often involves anticoagulation and thrombolysis. A large-bore thrombectomy cannula has previously been described for mechanical aspiration in conjunction with veno-veno extracorporeal bypass (VVECB), but can be challenging to steer. We describe using bilateral femoral venous balloon catheters to direct the aspiration cannula from the IVC sequentially into each iliac and proximal femoral vein.

Methods: A 58-year-old gentleman with non-resectable glioblastoma multiforme presented with worsening bilateral lower extremity edema. Duplex ultrasound showed the completely occluded IVC with thrombosis extending bilaterally into the ilio-femoral veins and was confirmed by computed-tomographic venogram. Lytic therapy was contraindicated because of previous intracranial bleeding after anticoagulation for a pulmonary embolism. Under general anesthesia, bilateral internal jugular veins (IJ) were accessed. Following heparinization, an 18F return cannula was positioned in the left IJ and a 26F sheath was placed in the right IJ. The aspiration cannula was directed through the right IJ sheath and VVECB was established. Thrombus was extracted from the IVC. The cannula was advanced past an IVC filter but could not be directed beyond the proximal iliac veins. While pausing VVECB, access to the right and left common femoral veins was obtained. A 12mmx20mm balloon catheter was directed over a hydrophilic guidewire through the right femoral vein and into the aspiration cannula (Fig. D81-1). With the balloon inflated, the aspiration cannula was pushed from the right IJ and pulled with the balloon catheter into the proximal right femoral vein. VVECB was reestablished and iliac thrombectomy was performed with multiple passes. The technique was repeated on the left side. Sheaths were removed and hemostasis obtained.

Results: Follow-up venograms from the femoral veins showed recanalized bilateral iliac veins and IVC.

Conclusions: A “push-pull” technique with right IJ aspiration cannulation and femoral venous balloon catheter intubation of the aspiration cannula can effectively guide a large-bore thrombectomy aspiration cannula into the femoral veins for percutaneous mechanical thrombectomy of thrombosed IVC and iliac veins.



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D82 Hemodynamic Performance of the St. Jude Medical Trifecta Aortic Bioprosthesis in Young Patients under 65 Following Minimally Invasive Aortic Valve Replacement (MIAVR)

Amir Sepehripour, Jacob Chacko, Kulvinder Lall. St. Bartholomew’s Hospital, London, United Kingdom.

Objective: The St. Jude Medical Trifecta aortic supra-annular bioprosthesis is regarded as the next generation in pericardial stented tissue valves. The unique design of tissue leaflets attached to the exterior of the valve stent provides unrivalled in-vivo mean gradients and hemodynamics. The aim of this prospective study was to evaluate mid-term hemodynamic performance of valves implanted into patients under 65.

Methods: Twenty-three consecutive patients undergoing MIAVR (partial J sternotomy) using the St. Jude Medical Trifecta valve at a single UK center over a 36-month period were included in this study. All implanted valves were 19, 21, 23, 25 and 27 mm in size. Assessment of hemodynamic function was carried out using transthoracic echocardiography pre-operatively and at follow-up, as well as transesophageal echocardiography intra-operatively.

Results: The study population consisted of 23 patients (12 male, 11 female). Mean age was 60.7±2.1 years. Implanted valve sizes were 19 mm (n=3), 21 mm (n=6), 23 mm (n=7), 25mm (n=4) and 27mm (n=3). Overall mean post-operative pressure gradients were 7.34±4.2 mmHg (mean) and 14.31±4.8 mmHg (peak). Subgroup mean post-operative pressure gradients were 7.35±2.8 mmHg, 7.62±2.1 mmHg, 7.94±3.7 mmHg, 7.61±2.7 mmHg, 7.21±2.8 mmHg, for the 19, 21, 23, 25 and 27 mm cohort respectively. Overall mean post-operative left ventricular ejection fraction was 62±1.7%. Overall mean effective orifice area was 1.86±0.4 cm2. There were only 2 patients with trivial regurgitation.

Conclusions: These results of our experience demonstrate excellent hemodynamic performance of the Trifecta bioprosthetic valve in young patients under 65 using a minimally invasive approach for implantation.

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D83 Comparison of Off-Pump Coronary Artery Bypass Grafting versus On-Pump Bypass Grafting Concomitant with Maze Procedure in Treatment for Patients with Coronary Disease and Atrial Fibrillation

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

Objective: We compared our clinical results of off-pump CABG concomitant with left atrial appendage plication (LAAp) for patients with coronary disease and AF in contrast with conventional CABG concomitant with maze procedure.

Methods: Thirty-two patients who had coronary disease and AF were enrolled in this study. All underwent CABG in one institution. Twenty-three who underwent off-pump CABG concomitant with LAAp were set as off-pump group, and 9 who underwent conventional CABG with maze procedure using cryoablation were set as maze group. Warfarin was prescribed for patients who had atrial fibrillation after operation. Off-pump group were older (71±5 years old versus 64±6 years old, p=0.002) and had less paroxysmal AF (0% versus 33%, p<0.01). Follow-up period was 49±46 months.

Results: Freedom from AF recurrence after maze procedure was 100% at 1 year. Survival rate was 100% in off-pump group and 95% in maze group at 5 years. Freedom from cardiac and cerebrovascular event was 88% in off-pump group and 91% in maze group at 5 years. There was no significant difference between groups in both survival rate and freedom from cardiac and cerebrovascular event curve.

Conclusions: Both operations showed satisfactory results. There was no significant difference between the results of off-pump CABG with LAAp and conventional CABG with maze procedure.

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D84 Extrapleural Robot-Assisted Thymectomy With Contralateral Phrenic Nerve Protection

Faiz Y. Bhora Muhammad Farhan Nadeem, Sadiq Rehmani, Michael Barsky, Jalal Abuhalimah, Cliff P. Connery, Scott Belsley. St. Luke’s-Roosevelt Hospital, New York, NY USA.

Objective: A subset of thymic tumors is well-suited for resection by minimally invasive approaches. The robotic platform with distal articulation and magnification provides significant advantages in thymic operations. There remains concern regarding visualization and protection of the contralateral phrenic nerve during transthoracic minimally invasive thymic surgery. We describe a technique where we perform a complete thymectomy using a minimally invasive transthoracic approach without the need for direct visualization of the contralateral phrenic nerve by keeping the mediastinal pleura intact.

Methods: A 32-year-old patient was found to have a 5 x 3 cm complex anterior mediastinal mass. Percutaneous CT-guided biopsy was non-diagnostic. We performed a right VATS exploration and felt that this mass was completely resectable. Our operative technique for most mediastinal tumors includes a right-sided approach with identification of the confluence of the innominate vein and superior vena cava (SVC) as an important landmark. We performed a complete anterior mediastinal exenteration of all soft tissues anterior to the pericardium from the diaphragm up to the individual thymic horns which are divided as high as possible. The right phrenic nerve is directly visualized during the entire course of the operation. The left phrenic nerve, however, is not directly visualized. We utilize blunt dissection to lift the left mediastinal pleura off the mediastinum, with care taken to leave the pleura intact. This technique allows us to lift the phrenic nerve off the mediastinum with no risk of injury to the nerve during the course of mediastinal dissection. If there is an inadvertent entry into the pleura, we are also able to directly visualize the nerve by advancement of the camera into the left pleural cavity.

Results: The video highlights the technique that we have described in our abstract.

Conclusions: Extrapleural robot-assisted thymectomy is a straight-forward technique that allows protection of the contralateral phrenic nerve during minimally invasive thymic surgery without need for direct visualization of the nerve. In particular, it avoids opening the contralateral pleural cavity and risk of post-operative pleural effusion or pneumothorax.

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D85 Is There a Gender-Dependent Negative Inotropic Effect of Methylene Blue on the Contractile Performance on the Level of Myofilaments?

Constanze Bening, Helge Weiler, Christian-Friedrich Vahl. Department of Cardiothoracic and Vascular Surgery, Mainz, Germany.

Objective: Methylene blue is a rescue therapy especially in patients with septic shock; the arterial blood pressure and SVR is increased, while cardiac output, oxygen delivery and oxygen consumption does not show any significant change. Therefore, we underwent the current study to observe, if MB has a direct impact on cardiac performance on level of the contractile apparatus.

Methods: Right auricle tissue from 12 patients (6 male and 6 female patients) undergoing cardiac surgery was obtained prior to right atrial cannulation. The tissue was skinned with Triton-X. The fibers were exposed to a gradual increase of calcium concentration and the corresponding force was measured and recorded. We performed 3 experiments with different fibers in each cycle and each patient (n=30 in each patient with and without MB).

Results: (1) Male patients without MB developed a maximal force of 2.5 mN±0.7mN, whereas samples, which were exposed to MB achieved 2.1 mN±0.2 mN. This difference was significant (p= 0.0002). (2) Female fibers with MB achieved 2.3 mN±0.2 mN whereas fibers without MB developed 2.7±0.7 mN. This was not statistical significant. (3) Focusing the different steps of calcium concentration, male and female fibers with MB different significant to those without MB (p=0.04).

Conclusions: Our data suggest, that MB has a negative inotropic effect on contractile performance of skinned human atrial fibers. We observed reduced absolute forces; additionally, there is some evidence for a gender-dependent effect on the contractile apparatus.

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D86 Robotic and VATS Lobectomy for Post Tuberculosis Aspergilloma

Ali Zamir Khan, Narendra Agarwal, Shaiwal Khandelwal, Kamran Ali, Sangeeta Khanna. Medanta, The Medicity, Gurgaon, India.

Objective: We present a video of our experience of robotic and VATS resection of aspergilloma using a da Vinci 4 arm robot. We also demonstrate a novel intraoperative technique to prevent spillage of aspergilloma into the normal lung.

Methods: Between January, 2012, to September, 2013, 15 patients underwent surgical resection of aspergilloma; CT scan demonstrated an aspergilloma. 4 arm da Vinci robot was used to perform the surgery. Intubation was done with double-lumen tube into the non-operative bronchus with the patient in a lateral position with the affected side down to prevent spillage. A Fogarty catheter was also introduced into the affected side (operative side). Fissure and hilum were exposed and structures were stapled with endostaplers.

Results: Age group was 35 to 78 years (mean 48 years); 8 males and 4 females. Patients received antituberculous drugs for at least 6 weeks. Voriconazole was given 2 weeks prior and continued for 3 months postop. 3 cases of robotics needed completion by VATS. 2 needed conversion to open due to bleeding and frozen hilum. Mean operative time was 188 minutes. Mean blood loss was 558 mls. 6 patients received blood transfusion. Chest X-ray showed complete lung expansion. One patient died with multi-organ failure and fungal septicemia on day 25.

Conclusions: Robotic and VATS resection of lung is technically possible with good clinical outcomes. Robotics allows 3D visualization and 360 degree movement of EndoWrist. It gives good and accurate mobilization of adhesions. Addition of anesthetic techniques like lateral double lumen intubation, Fogarty catheter prevents spillage of aspergilloma into normal lung.

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D87 Hybrid Procedure for Patient with Aortoectasia and Aortic Coarctation: Case Report:

Zan Mitrev, Anguseva N. Tanja, Sr. Special Hospital of Cardiosurgery, Skopje, Macedonia.

Objective: Aortoectasia with a severe aortic regurgitation and coarctation of the descending aorta can be successfully treated with a hybrid strategy. Balloon expandable stents have been used to manage coarctation of the aorta, and in a second step Tirone David reconstruction has been performed for reconstruction of the ascending aorta into the normal morphology.

Methods: I. T. 22-year-old patient with a history for a hypertensive disease, and a frequent chest pain and fatigue had been diagnosed for aortoectasia (7 cm ascending aorta) with a severe aortic regurgitation and aortic coarctation by echocardiography and multislice computer tomography.

Results: In a first step, the patient got primary stenting with an immediate relief of the gradient. All antihypertensive medications were discontinued immediately. After 5 months, the patient got a surgery in a second step, preserving nature aortic leaflets into the Dacron graft and with reimplantation of both coronary arteries. Control transesophageal echocardiography and CT scan showed normal morphology of the ascending aorta, no regurgitant jet through the aortic valvula, and no pressure gradient on the descending aorta.

Conclusions: In patients with coarctation of the aorta and aortoectasia, stent implantation may be a feasible and improved option to relieve the stenosis in a first step, allowing for surgical reconstruction of the aortic root. Patient had a normal quality of life after surgery; follow-up period 2.5 years.

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D88 Minimally Invasive Aortic Valve Replacement: Early Outcome and Results

Udgeath Dhir, Ramesh Kumar Bapana, Surinder Bazaz, Harpreet Wasir, Deepak Agarwal, Manisha Mishra, Naresh Trehan. Medanta Heart Institute, Gurgaon, India.

Objective: In the era of catheter-based aortic valve replacement, we intend to share our institutional experience of minimally invasive AVR through right anterior thoracotomy of 50 patients aged between 16 to 70 years.

Methods: All patients admitted June, 2012, to October, 2013, for isolated aortic valve pathology were primarily evaluated for minimally invasive AVR. Our exclusion criteria were (1) small aortic root less than 19 mm, (2) aneurysmal dilatation of aorta and/or sinuses, (3) inadequate femoral vessel size, and (4) ejection fraction less than 30%. Preoperative CT was done for evaluation of aortic anatomy. After evaluation, standard protocols for anesthesia were followed with double-lumen tube for intubation. TEE was placed in all patients. External defibrillation pads were placed. After draping, femoral vessels were exposed, and size of vessels assessed visually. Once sure of the size, anterior thoracotomy was done through 2nd intercostal space with cutting of costochondral junction of the lower rib with clipping of right internal mammary artery. After femoral cannulation, TEE-guided retrograde coronary sinus cardioplegia catheter was inserted. Chitwood aortic clamp was used for cross-clamping aorta. Antegrade blood cardioplegia with intermittent retrograde cardioplegia was used for myocardial protection. Standard interrupted pledgeted sutures used after proper sizing of the valve. Costochondral junction was restored and intrapleural catheter placed for postoperative pain control.

Results: All 50 patients are on 100% follow-up. Average CPB time was 85 with ACC time of 63. Average ventilation time was 5.5 hours. Average drain was 210 ml; average hospital stay was 5 days. In one patient, with severe concentric hypertrophy, median sternotomy was done while coming off CPB due to inability to defibrillate the heart. In one patient, VATS was done for right pleural hematoma.

Conclusions: Minimally invasive is a safe procedure when performed after careful preoperative evaluation. No doubt the CPB time was more as compared to conventional AVR but the hospital stay and early recurrence are its major advantages.

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D89 Would Any Mitral Annuloplasty Ring and Band Be Suitable for Valve-in-Ring Technique?

Gry Dahle, Kjell Arne Rein. Rikshospitalet, OUS, Oslo, Norway.

Objective: Mitral annuloplasty rings may be complete or incomplete and rigid, semi-rigid or flexible. Mitral valve repairs may fail and valve-in-ring (VIR) may be an option. So far there are a few reports for the Melody valve (Medtronic, Minneapolis, MN USA) and more frequently the Edwards SAPIEN/Edwards SAPIEN XT (Edwards Lifesciences, Irvine, CA USA). The question is whether the valve will fit into and how it will function in a failed ring repair.

Methods: A bench test was done with selected annuloplasty rings with the Edwards SAPIEN XT deployed. Video and photos documented the procedure. The CE Edwards Classic rigid annuloplasty ring (Edwards Lifesciences, Irvine, CA USA), Edwards semi-rigid Physio ring (Edwards Lifesciences, Irvine, CA USA), CG future band/ring (Medtronic, Minneapolis, MN USA) and the Profil 3D (Medtronic, Minneapolis, MN USA) were tested.

Results: The CE Classic rigid ring was opened by the valve deployment and the SAPIEN XT was deformed; hence, the leaflets were not sealing completely. For the complete semi-rigid rings, the rings turn out circular and the valve leaflets were sealing. The incomplete semi-rigid CG future band was dislocated on the valve by deployment and not sealing. The complete semi-rigid CG future ring was not sealing complete the Edwards SAPIEN XT valve. The rigid Profil 3D ring was deforming the Edwards SAPIEN XT and the leaflets were not sealing (Fig. D89-1).

Conclusions: The incomplete rings will dislocate and may cause annulus rupture in real life. The rigid rings will deform the catheter valve causing paravalvular leak and dysfunction of the valve leaflets. VIR is feasible for semi-rigid annuloplasty rings, though the right size must be selected to fit the valve to prevent dislocation or paravalvular leak.



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D90 Hemodynamic Performance of the St. Jude Medical Trifecta Aortic Bioprosthesis Following Minimally Invasive Aortic Valve Replacement (MIAVR): The Training Perspective

Amir Sepehripour, Jacob Chacko, Kulvinder Lall. St. Bartholomew’s Hospital, London, United Kingdom.

Objective: The Trifecta aortic bioprosthesis provides exceptional hemodynamic performance, durability and implantability. The unique design, encompassing a contoured silicone insert within a unique cuff is specifically designed to conform to the native annulus shape for proper seating and minimal risk of paravalvular leak. The aim of this prospective study was to evaluate hemodynamic performance of valves implanted by cardiothoracic trainees at a single UK center.

Methods: Twenty-one consecutive patients undergoing MIAVR (partial J sternotomy) using the Trifecta valve performed by trainees at a single UK center over a 36-month period were included. Assessment of hemodynamic function was carried out using transthoracic echocardiography pre-operatively and at follow-up, as well as transesophageal echocardiography intra-operatively.

Results: The study population consisted of 21 patients (14 male, 7 female). Mean age was 72.4±7.6 years. Implanted valve sizes were 19 mm (n=1), 21 mm (n=7), 23 mm (n=9), 25 mm (n=3) and 29 mm (n=1). Overall mean post-operative pressure gradients were 6.47±1.7 mmHg (mean) and 13.42±5.3 mmHg (peak). Subgroup mean post-operative pressure gradients were 7.21±3.1 mmHg, 7.51±3.1 mmHg, 7.63±2.4 mmHg, 7.31±4.6 mmHg, 7.46±4.9 mmHg, for the 19, 21, 23, 25 and 27 mm cohort respectively. Overall mean post-operative left ventricular ejection fraction was 56±0.12%. Overall mean effective orifice area was 1.63±0.7cm2. All valves were well-seated and only 2 exhibited trivial regurgitation.

Conclusions: Our experience demonstrates the excellent hemodynamic performance of the Trifecta bioprosthesis in minimally invasive implantations performed by surgical trainees resulting from the innate superior hemodynamic properties of the Trifecta valve as well as the simple yet faultless implantability of the valve.

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D91 Heart Luxation After Totally Thoracoscopic Ablation

Anna Witkowska, Radosław Smoczyński, Dominik Drobinski, Dariusz Kosior, Krzysztof Jaworski, Sławomir Sypuła, Monika Niewinska, Zygmunt Kalicinski, Bartlomiej Szafron, Jaroslaw Swistowski, Piotr Suwalski. Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland.

Objective: Thoracoscopic access is gaining growing interest in cardiothoracic surgery. Despite it demands greater skills and attention, minimal injury correlates with lower complication rate and faster recovery of the patient. During thoracoscopic surgery, it is necessary to create working space with insufflation of carbon dioxide (CO2). Here we describe a case of iatrogenic heart luxation caused by excessive CO2 tension during thoracoscopic ablation of atrial fibrillation (Afib).

Methods: A 65-year-old man with symptomatic resistant persistent AFib was referred to our institution for surgical ablation. His medical history involved kidney transplantation for end-stage nephropathy, diabetes mellitus and stable coronary artery disease treated with bear metal stent implantation to left anterior descending coronary artery (LAD). Patient underwent totally thoracoscopic bilateral ablation of arrhythmia substrate with CO2 insufflation. As the first step from right port access isolation of right pulmonary veins (PVI) with connective lines and autonomic ganglia ablation was performed. As the second step from left port access left PVI with left atrial appendage stapling was performed.

Results: Patient was extubated 6 hours after operation. Although stable condition mild hypotension requiring minor inotropic support with increasing renal markers and changes in electrocardiogram were observed. Based on unexpected postoperative chest x-ray examination suggesting dextrocardia in a patient with previous normocardia and inappropriate course, we decided to perform computed tomography of the chest on the first postoperative day. It revealed distortion of the heart on the right side of the chest with stretch of the pulmonary trunk. Decision of immediate thoracoscopic revision was made. In right pleural cavity left ventricle and LAD were visible and tear in thin and flabby pericardium. Heart was replaced to pericardial sack. The patient was extubated immediately after reoperation. We observed rapid improvement in his condition with decrease in creatinine and troponin level. Patient in good condition with stable sinus rhythm was discharged 10 days later.

Conclusions: Although totally thoracoscopic bilateral ablation of AFib is repeatable and a safe procedure with promising results, to our knowledge, this firstly described benign complication shows the need of closure of the pericardial sack, cautious use of CO2, and watchful following a patient after operation.

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D92 Analysis of Pulmonary Bullae and Spontaneous Pneumothorax Among Hyperhidrosis Patients

Yun Li, Shaohong Huang, Jun An, Junhang Zhang. The 3rd Affiliated Hospital of SUN Yat-sen University, Guangzhou, Guangdong, China.

Objective: To explore the incidence of pulmonary bullae and spontaneous pneumothorax in hyperhidrosis patients; data was provided for clinic.

Methods: Four hundred and twenty-six patients with hyperhidrosis received T3-4 sympathectomy using needle thoracoscopy. No patients had pulmonary or pleural diseases. According to the status of pulmonary bullae observed during thoracoscopy, the patients were divided into bullae positive group and bullae negative group. The relationship between pulmonary bullae and BMI or smoking index was analyzed. All patients were followed up after operation to make sure if they suffered from spontaneous pneumothorax.

Results: There were 24 (5.6%) patients in bullae positive group. Bullae positive group had a significantly lower BMI when compared with bullae negative group [(20.9±2.2) kg/m2 vs. (22.2±2.7) kg/m2, P=0.025)]. The smoking ratio of two groups had no statistical significance, but the smoking index of bullae positive group was obviously higher than that of bullae negative group (172.0±67.2 vs. 75.7±50.9, P=0.000). Smoking index was the risk factor of pulmonary bullae (OR 1.01,95%CI 1.003∼1.018), while BMI was the protect factor (OR 0.81,95%CI 0.665∼0.985). Bullae were most prevalent among slim individuals (BMI≤18.5kg/m2) who are smoking (OR 2.185, 95%CI 1.144∼33.198). All patients were followed up from 6 months to 7.5 years; no spontaneous pneumothorax occurred.

Conclusions: Low BMI and high smoking index may have an important role in the development of pulmonary bullae in patients with hyperhidrosis. However, pulmonary bullae may not be responsible for future spontaneous pneumothorax.

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D93 Role of 3D-CT Scan in VATS Major Pulmonary Resection in a Patient with Complete Situs Inversus

Adnan Raza1, Khalid Amer 1, Lukacs Veres2, Stephen Harden1, Stuart Jenkins1. 1Southampton General Hospital, Southampton, United Kingdom, 2Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom.

We present a case of presumed lung cancer in a patient with complete situs inversus which was successfully treated by VATS lobectomy, with the help of pre-operative multi-detector 3D-CT scan assessment. The patient previously had sternotomy and mitral valve repair. Bronchoscopy revealed mirror image of the normal bronchial arrangement and no endo-bronchial lesion was seen. A three-port right anterior VATS approach was used. The nodule was too deep in the lobe to permit safe wedge biopsy, due to proximity of branch of pulmonary artery. 3D-CT images were invaluable in pre-op assessment of the lesion, anatomy identification and were key to safe completion of the right VATS lower lobectomy. Sectioning the lung after retrieval of the specimen suggested a chondroid hamartoma; therefore, no systemic lymph node dissection (SND) was contemplated. Histology of the specimen confirmed this diagnosis. Pre-operative imaging with 3D-CT scan plays a vital role in identifying important anatomy during VATS lobectomy in patients with unfamiliar anatomy such as situs inversus. In future application, the 3D image manipulation intra-operatively may be common practice to assist in all VMPR, thus helping in identification of possible vascular or bronchial anomalies to prevent iatrogenic injury during surgery.

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D94 A Patient with MCA Stroke and ACOM Aneurysm Detected with Type-A Dissection: A Decision Dilemma

Rajneesh Malhotra, Kewal Krishan, Ravi Kumar Singh, Ratna Malika Kumar, Arvind Goyal, Biju Shivam Pillai, Sanjay Goel, Sanjoy Kumar Majhi. Max Superspeciality Hospital, New Delhi, India.

Objective: Aortic dissection with neurological deficit is not uncommon. Fourteen to 30% of Type-A dissection patients have pre-operative neurological involvement and that 32-48% of all patients develops post-op neurological deficits of varying penetration. Our patient had massive cerebral acute insult with 100% occlusion of right common carotid artery and accompanying anterior communicating artery (ACOM) aneurysm. Dissection in these patients should be aggressively managed to improve outcome. This case is a rare combination of dissection, ACOM aneurysm and complete shut-off of common carotid artery.

Methods: 65-year-old hypertensive female admitted with sudden onset headache/altered sensorium and 3 episodes of vomiting. Clinical examination revealed evolving left hemiparesis. CT scan showed right MCA/PCA infarct with large berry aneurysm of the anterior communicating artery, Type-A dissection with involvement of the arch vessels and near total occlusion of the brachio-cephalic trunk with 100% occlusion of common carotid artery. Deteriorating neurological situation prompted emergency right fronto-tempero-parieto-occipital craniectomy with augmentation duroplasty. Our case was complicated by a large berry aneurysm in the ACOM yet unaddressed. It was a decision-dilemma as to what to fix first, whether dissection or ACOM aneurysm. Manipulations of the ascending aorta and arch vessels would produce significant pressure swings in the cerebral circulation. This would increase the possibility of an inadvertent aneurysm rupture and/or worsening the neurological insult. So, coil embolization of ACOM aneurysm was done before fixing the dissection. Dissection was repaired with interposition Dacron graft as aortic valve was found spared of dissection.

Results: Patient was extubated on day 2 and was discharged home on day 10 with reasonable neurological recovery. There was residual left hemiparesis at the time of discharge.

Conclusions: Type-A dissection should be aggressively managed to improve outcome despite major preoperative neurological insult. According to international registry of aortic dissection, overall mortality is around 18-20% and does not significantly differ between patients with and without initial neurological symptoms or complications.

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D95 Reducing Sternal Wound Infections with Increased Use of Bilateral Internal Thoracic Arteries in Cardiac Surgery: A Multi-Modality and Interdisciplinary Challenge

Martin Oberhoffer 1, Friederike Schlingloff1, Marieke Huelskoetter1, Nicolai Bayer1, Jochen von Freyhold-Huenecken2, Joerg Elsner2, Borck Hans-Ulrich3, Michael Schmoeckel1. 1Cardiac Surgery, Asklepios Hospital St. Georg, Hamburg, Germany, 2Plastic/Hand and Reconstructive Surgery, Asklepios Hospital St. Georg, Hamburg, Germany, 3Labatory Medicine /Microbiology, Asklepios Hospital Altona, Hamburg, Germany.

Objective: Sternal wound infections (SWi) following cardiac surgery carry a high morbidity and mortality risk, especially when using bilateral internal thoracic arteries (BITA). Data on the impact of modifying perioperative, non-patient-related factors, are lacking. With increasing the use of BITA-grafting in our patients we introduced new perioperative preventive strategies in a multimodality interdisciplinary team approach and assessed the influence on SWI’s over a period of 2-years.

Methods: We stepwise changed pre-/intra-/postoperative standard operating procedures and analyzed our prospective database in half-year intervals (Period 1 - 4) between January, 2011, and December, 2012, with respect to the occurrence, treatment and results of SWI following cardiac surgery. Sternal swab results over the last 6 years (n=2315) were reviewed.

Results: A total of 1752 cardiac procedures were included. From period 1 through period 4 SWI occurred in 5.2 % (23/540), 6.3% (24/382), 4.4% (21/480) and 4.2% (19/450) of the patients. During that time period, BITA use increased from 50% to 90%. Plastic surgical intervention including partial/total sternectomy for osteomyelitis was necessary in 32/1752 (1.8%) decreasing from 2.7% (22/822) of the patients in the year 2011 (period 1 and 2) to 1.1% (10/930) of the patients in 2012 (period 3 and 4). Myocutaneous flaps used were: latissimus muscle in 56% (18/32), pectoral muscle in 38% (12/32) and rectus muscle in 6% (2/32) of the patients. In-hospital mortality for myocutaneous flap patients was 9.4% (3/32), overall 1-year mortality was 18.8% (6/32), respectively. Reviewing 2315 sternal swabs resulted in a change of initial antibiotic therapy to Vancomycin and Ceftazidime.

Conclusions: When introducing perioperative preventive multimodality strategies and treatment guidelines in cardiac surgery, the strict adherence to and surveillance of measures resulted in a stepwise reduction of sternal wound infections, even in high-risk BITA patients. Continuous data analysis and discussion in an interdisciplinary team is crucial in achieving low in-hospital and late-mortality rates in patients undergoing sternectomy for osteomyelitis.

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D96 Utility of Cardiopulmonary Bypass with Bicaval Venous Cannulation for Minimally Invasive Mitral Valve Repair

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

Objective: We evaluated the utility of bicaval venous cannulation to achieve sufficient cardiopulmonary bypass (CPB) and provide clear view during mitral valve repair by minimally invasive cardiac surgery (MICS) approach.

Methods: Since August, 2011, 50 (average age; 54±10 year-old, 15 female) patients with type II mitral valve dysfunction underwent mitral valve repair by MICS approach in which procedures were done either by minithoracotomy in 41 patients or by robotically assisted procedure using da Vinci S surgical system (Intuitive Surgical, Sunnyvale, CA USA) in 9 patients. Cardiopulmonary bypass was established with retrograde arterial perfusion from femoral artery and vacuum-assisted venous drainage from jugular vein and femoral vein. Jugular vein cannulation was done by anesthetists preoperatively. Sizes of cannulae were modified according to the body surface area (BSA). Target flow/BSA and temperature during CPB were 2.4 liter/minute/m2 and 32 degree. Surgical procedure comprised resection and suture for posterior lesion (n=47) and chordal replacement using PTFE sutures for anterior lesion (n=3) in combination with ring annuloplasty. Concomitant procedures included Cryo-Maze procedure in 3 patients. Flow, temperature and other parameters were recorded during cardiopulmonary bypass. The drainages from jugular vein and femoral vein were measured individually every 10 minutes in 8 patients.

Results: There was no death recorded. One patient required re-mitral valve repair due to hemolysis; otherwise, all patients discharged home at day 8 on an average without any major complications. Pre-discharge echocardiography revealed 1 or less residual mitral regurgitation (graded 0-4) in all patients. The average CPB time and cross-clamp time were 133±45 minutes and 100±35 minutes, respectively. All patients achieved target flow and temperature during CPB. The jugular vein/femoral vein drainage ratio was 0.35/0.65 on an average and those have not been changed through the CPB (before, middle of, and after left atrial retraction) in the measurable 8 patients.

Conclusions: Jugular vein cannulation is appreciated to achieve undemanding minimally invasive mitral valve repair by maintaining secure CPB with sufficient venous drainage.

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D97 Early and Mid-Term Clinical Outcome in Elderly Patients Undergoing Mitral Valve Repair

Jochen Börgermann, Kavous Hakim-Meibodi, Anas Aboud, Armin Zittermann, André Renner, Jan F. Gummert. Heart and Diabetes Center NRW, Bad Oeynhausen, Germany.

Objective: There is on-going debate about whether or not mitral valve (MK) repair should be recommended to elderly patients with MK defects.

Methods: In a retrospective data analysis, we assessed intensive care unit (ICU) stay, clinical complications until discharge and in-hospital and mid-term mortality in younger (< 75 years: n= 417) and older (≥ 75 years: n=74) patients undergoing MK repair between September, 2009, and August, 2012.

Results: As expected, EuroSCORE was significantly higher in older patients compared to younger patients (median and IQR: 9.9 [6.8-14.9] vs. 2.2 [1.5-4.5]; P<0.001), and so was ICU stay (25h [21h-90h] vs. 22h [18h-30h]; P<0.001). Compared to younger patients, older patients also had a higher incidence of low output syndrome (8.2% vs. 2.9%; P=0.041), whereas the incidence of perioperative myocardial infarction (1.4% vs. 0.0%; P=0.152), postoperative stroke (1.4% vs. 0.5%; P=0.547) and infections (2.7% vs. 2.2%; P=0.677) were similar between the two age groups. Moreover, 30-day mortality did not differ between groups (0.0% vs. 0.8%; P=0.999). Likewise, 6-month-mortality was comparable between groups (1.9% vs. 1.3%; P=0.565).

Conclusions: Our data demonstrate excellent early postoperative mortality rates in older patients undergoing MK repair. Consequently, even in older patients with MK defects, MK repair should be considered a suitable surgical method.

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D98 Medial End of the Major Skin Crease of Knee Joint: A New Absolute Land Mark of Long Saphenous Vein

Kawryshanker Rajaratnam, Jurgen Passage. Sir Charles Gairdner Hospital, Nedlands, Australia.

Objective: Understanding of long saphenous vein (LSV) landmark at the knee level is very essential for the cardiac surgeon. The long saphenous vein originates on the medial border of foot ascends anterior to medial malleolus, easiest location to identify the LSV and the commonest site vein harvesting starts. Passes upwards over the distal third of the tibia and proximally along the medial margin of the tibia to the knee level; lays superficial posteriorly.

Methods: Traditional land marks of LSV at knee joint 10 cm from front of patella, one hand breath from border of patella, two fingers breath from the medial condyle of femur. Not precise due to ”spatial heterogeneity”. Be applicable for the average built, lean patients, not for obese. Because subcutaneous structure deviates from bony land mark, deposits of fat deviates superficial structure well away from bone. Many CABG patients are obese, often landmarks not applicable and calf region LSV not usable due to varicosity. Even with preoperative identification may be challenging than expected, envisioned preoperatively with digital palpation won’t be identical after anesthesia. Preoperatively marked our new landmark of LSV at the knee level where the major skin crease ends. Done 125 patients. Made the incision at marked site and identified the vein at that spot.

Results: At the site, identified the vein in all.

Conclusions: Understanding embryological origin of superficial marginal vein pre- and post-axial veins running along respective borders. Pre-axial superficial veins of limb join to the deep vein at proximal (hip joint) post axial vein join deep system at distal (knee joint) lower limb pre axial is LSV, post axial is short saphenous vein, closely related to the skin. Deep system alongside artery and related to bone. So better land mark for LSV is skin than bone. Observation from practice on harvesting. Easy detection of LSV at knee joint, where major skin crease of knee joint ends.

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D99 Robotic Mitral Valve Replacement: Istanbul Experience

Sahin Senay, Ahmet U. Gullu, Muharrem Kocyigit, Aleks Degirmencioglu, Cem Alhan. Acibadem University, School of Medicine, Istanbul, Turkey.

Objective: In this video, we present the details of our technique in robotic-assisted mitral valve replacement.

Methods: A fifty-two-year old women with a body mass index of 36.6 kg/m2 underwent mitral valve replacement with a 29 mm bioprosthetic valve using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA USA) through an incision of 3 cm.

Results: The total operative time starting from anesthetic induction to skin closure was 230 minutes. Transesophageal echocardiography revealed competent prosthetic mitral valve without residual gradient. The patient was discharged from the hospital at fourth postoperative day without any complication.

Conclusions: Robotic-assisted mitral valve replacement may be performed as precise and fast as an open procedure. The described method may find broader application with the continuing evolution in this technology.

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D100 Ascending Aorta and Hemi-Arch Repair without Circulatory Arrest and with Brain Perfusion by the Left Carotid Artery in a Patient with Chronic Renal Failure: A New Technique of Brain and Renal Protection in a Selected Case

Flavio D. Camurca, Paulo R. Medeiros, Jocerlano S. Sousa, Sebastiao N. Martins, Lusypaula B. Alencar, Patricia Lorenna A. L. Costa, Jose Itamar A. Costa. Itacor Hospital, Teresina, Brazil.

Objective: The most commonly used strategy of brain protection for ascending aorta and hemi-arch aneurysm repair consists of selective cerebral perfusion by the right carotid artery, with temporary systemic circulatory arrest, which may adversely affect renal function, especially in patients with chronic renal failure. This report describes a new strategy of brain and renal protection used during ascending aorta and hemi-arch repair without systemic circulatory arrest and with cerebral perfusion by the left carotid artery (LCA).

Methods: A 67-year-old man with hypertension and chronic renal failure presented with a 67.6 mm ascending aortic aneurysm involving the proximal arch, being referred for surgical treatment. During surgery, the aortic arch was cannulated after the origin of the LCA and cardiopulmonary bypass was established. Body temperature was lowered to 30°C. After distal ascending aortic clamping and aortotomy, cardioplegia was established in the coronary ostia. The aortic valve and the ascending aorta were replaced by a valved polyester tube with reinsertion of the coronary ostia. The aortic clamp was repositioned obliquely between the brachiocephalic trunk and LCA, enabling replacement of the hemi-arch without total circulatory arrest. Cerebral blood flow was maintained through the LCA. Cardiopulmonary bypass time was 150 min and aortic clamping time was 116 min.

Results: The postoperative period was uneventful, with no need for renal replacement therapy and with gradual improvement of renal function. Furthermore, the technique proved to be easy, avoiding manipulation of the brachiocephalic trunk. However, it requires ideal anatomic conditions, mainly an elongated aortic arch.

Conclusions: The new technique described is a safe option for the replacement of the ascending aorta and hemi-arch without circulatory arrest and with mild hypothermia in selected patients.

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D101 Collaborative Lead Management Increases Volume and Case Complexity

Rebekah Macfie, Anil Gehi, Eugene Chung, Paul Mounsey, Andy C. Kiser. University of North Carolina at Chapel Hill, Chapel Hill, NC USA.

Objective: This study examines a novel collaborative approach to cardiovascular implantable electronic device (CIED) lead extraction in which the cardiac surgeon and electrophysiologist (EP) work together to extract and re-implant leads. We compared this new protocol with EP-only and surgeon-only extraction.

Methods: Lead extraction records from 2007- 2013 were reviewed. In the standard and surgeon-only approaches the respective EP or surgeon performs the entire procedure. In the collaborative approach the cardiac surgeon does the lead extraction and the EP completes the re-implantation; both physicians are engaged for the entire case.

Results: Forty-nine patients underwent collaborative extraction, 34 underwent standard EP-only extraction and 20 patients underwent surgeon-only extraction. In the hybrid approach, infection was the indication for extraction in 20% of cases (10/49); in the surgeon-only approach, infection was the indication for extraction in 85% of the cases (17/20); in the EP-only cases, infection was the indication in 15% of the extractions. For cases with a surgeon involved (hybrid and EP-only), there were significantly more leads removed due to infection than in EP-only cases (p=0.0099). There was no significant difference in the average number of leads extracted in the EP vs. collaborative techniques (1.26 vs 1.48 p=0.11). There were, however, a significantly greater average number of leads extracted in the surgeon-only group (2.315) as compared to the collaborative (p<0.05) and EP only group (p<0.05). Procedures with a surgeon involved (collaborative and surgeon-only) were significantly more likely to use the laser than EP-only cases (p <0.005) suggesting increased complexity of these cases. There was a trend toward decreased post-operative complications in patients undergoing hybrid extractions. The institution of hybrid lead management has contributed to four-fold case growth in lead extractions and a three-fold increase in device reimplantations since the initiation of the collaborative technique in 2011 (Fig. D101-1).

Conclusions: This review suggests that a collaborative approach to intravenous CIED lead management allows for safe management of complicated lead extraction can provide excellent patient outcomes and practice growth.



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D102 Catastrophic Complications Regarding Management of Extracorporeal Circulation during Minimally Invasive Cardiac Surgery

Takeo Tedoriya, Ryoi Okano, Masaomi Fukuzumi. Ageo Central General Hospital, Ageo, Saitama, Japan.

Objective: Since 2007, we have MICS for mitral and aortic valve surgery. Although we have been satisfied with surgical results for intra-cardiac performance, we had catastrophic complications regarding extracorporeal circulation (ECC) management. We reviewed the details of complications in order to clarify problems to solve.

Methods: In 148 cases (2007 to 2013) with MICS, we had 5 (3.4%) catastrophic complications with ECC (one death), 4 of mitral valve surgery (4/92), and one of aortic valve replacement (1/56).

Case 1: A 39-year-old male of MVR with severe pulmonary hypertension and obesity had the left side lung expanding injury immediately after discontinuing from ECC. He had suffered from serious brain damage of hypotension with desaturation. He died from brain edema on 21POD.

Case 2: A 42-year-old male of MVP had iliac vein injury resulting retroperitoneal hematoma, which required surgical drainage and long-time ventilation management.

Case 3: A 72-year-old female of MVP with severe atherosclerotic change on the descending aorta and bilateral carotid arteries, had cerebral infarction.

Case 4: A 38-year-old male of MVP with no risk of atherosclerosis, had cerebral infarction of small and solitary vertebral artery. He suffered from irreversible visual problem.

Case 5: A 63-year-old male of AVR required additional left mini-thoracotomy in order to discontinue ECC, because of failure of the left ventricular venting. Postoperative course was stable without any arrhythmia and LV dysfunction.

Results: Our careless failure may have caused complications in Case 2 and 5. In Case 3 and 4, perfusion flow was maintained with high pressure using central perfusion technique. With conventional approach, cross-clamping and ECC times should be shorter so that complication might not have occurred or milder. In Case 1, lung injury developed only on the right, although re-expansion was induced simultaneously on both sides after a 15-minute one-lung ventilation. Preoperative pulmonary hypertension may have been the cause of the lung injury.

Conclusions: We have to recognize disadvantage of MICS like management of ECC, prolonged operation time. In case we required central perfusion with complicated situations and lung problems, we have to consider the indication of MICS more seriously.

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D103 Risk Factors of Blood Transfusion in Patients Undergoing CABG

Hideki Teshima, Masahiko Ikebuchi, Toshikazu Sano, Ryuta Tai, Hiroyuki Irie. Chikamori Hospital, Kochi, Japan.

Objective: We investigated the rate of peri-operative blood transfusion in patients undergoing CABG.

Methods: Isolated CABG was performed in 367 consecutive patients between 2007 and 2012. Among them, non-elective surgery (51 patients) and chronic renal failure (21 patients) with hemodialysis were excluded. Total 295 patients were enrolled in this study. Off-pump CABG was done in 109 patients (37%) mainly because of plaque lesions in the ascending aorta. We have used intra-operative blood saving protocols. Trigger points of blood transfusion are defined as Hb ≤ 7.0 g/dl and the presence of bleeding or unstable vital sign. Logistic regression analysis was conducted using peri-operative factors (age, female gender, pre-operative hemoglobin, EuroSCORE-II, re-operation, chronic obstructive pulmonary disease, ejection fraction, history of percutaneous coronary intervention, cerebral vascular disease, diabetes mellitus, intra-aortic balloon pump assist, surgical procedure; off-pump CABG and on-pump CABG, and operation time) in relation to the blood transfusion.

Results: No blood was transfused in 243 of 295 (82%) patients: 98 of 109 (90%) off-pump CABG patients and 145 of 186 (80%) on-pump CABG ones. There was significant difference in peri-operative blood transfusion between off-pump CABG and on-pump CABG (P=0.0093). Significant difference in other pre-operative factors was not seen between off-pump CABG and on-pump CABG. “Surgical procedure; off-pump CABG and on-pump CABG” was identified as an independent risk factor in the logistic regression analysis (P=0.003, odds ratio=3.280, 95% confidence interval (CI): 1.495-7.197). Female gender (P=0.022, odds ratio=2.237, 95% CI: 1.122-4.460), EuroSCORE-II (P<0.001, odds ratio=1.137, 95% CI: 1.064-1.214) and pre-operative Hb (P<0.001, odds ratio=0.538, 95% CI: 0.424-0.683) were also identified as second, third and fourth independent risk factors in the logistic regression analysis.

Conclusions: This study suggested that off-pump CABG can be performed by avoiding blood transfusion safely rather than on-pump CABG.

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D104 Transaortic Approach for Transcatheter Aortic Valve Implantation, A Valid Alternative: A Single-Center Experience

R. Haris Bilal, Jessica Maycock, Mahvash Zaman, S. Hampshaw, D. Fraser, Ragheb Hasan, Vaikom Mahadevan. Manchester Royal Infirmary, Manchester, United Kingdom.

Objective: Transaortic (TAo) route for transcatheter aortic valve implantation (TAVI) is a novel approach. It is a feasible alternative for patients with unfavorable transfemoral (TF) access. We evaluated our early experience and quality of life improvement following TAo-TAVI approach using Edwards SAPIEN platform (Edwards Lifesciences, Inc., Irvine, CA USA).

Methods: 92 patients February, 2009, to January, 2014, underwent TAVI. Tao-TAVI was performed in 6 patients with unfavorable access for TF approach. Aortic valve, root and annular size were carefully assessed by computed tomography (CT angiography), transesophageal echocardiography (TOE) and coronary angiography. The aorta was exposed through a hemi-sternotomy. Early results and functional improvement were assessed. In addition, pain assessment (NRS-11) and quality of life evaluation were performed via SF-36 and SF-12v2.

Results: Mean age was 79.1±5 year. Mean logistic EuroSCORE 18.2±10. All patients had grade III-IV descending aortic calcification. Mean preoperative valve area and mean gradient was 0.7±0.4 cm2 and 70±26.2 mm of Hg respectively. Mean annular diameter was 2.4±0.2 cm2. Edwards SAPIEN XT was used in all cases. Hemi-sternotomy was performed in all patients. Mean size of implanted device was 2.6±0.2cm2. Device was successfully implanted in all cases. Mild-moderate paravalvular leak was observed in one patient (6%). There was no in-hospital mortality or stroke. Mean hospital stay was 11.6±5.1 days. All patients remain well on follow-up. There was marked improvement in functional status, New York Heart Association (NYHA) to 1.7±1.2 vs. 3.4±1.1 preprocedural (p=0.02). In addition, quality of life, SF-36 evaluation showed an improvement of 56.2 vs. 24.8 preprocedural (p<0.01). Mean pain score was 4.1 and 3.8 on day 1 and 4 respectively (NRS-11).

Conclusions: The TAo approach for SAPIEN XT is a clinically safe approach with satisfactory early results in our experience and provides an alternative to TF with difficult peripheral access.

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D105 Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction: Off-Pump versus On-Pump Strategies

Sung Jun Park 1, Seok Won Yun2, Joon Bum Kim1, Sung-Ho Jung1, Suk Jung Choo1, Jae Won Lee1, Cheol Hyun Chung1. 1Asan Medical Center, Seoul, Republic of Korea, 2Dajeong Chest Surgery Clinic, Seoul, Republic of Korea.

Objective: The optimal surgical strategy during coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) dysfunction has not been well established. This study compared the surgical outcomes between off-pump and on-pump CABG to determine the optimal strategy in patients with severe LV dysfunction.

Methods: From 1989 to 2012, we evaluated consecutive 308 patients (age 62.4±9.0, 61 females) with preoperative severe LV dysfunction (ejection fraction ≤35%) who underwent elective isolated CABG (off-pump, n=124; on-pump, n=188). The rates of adverse outcomes were compared with the use of propensity scores.

Results: 30-day mortality rates were 2.5% (n=3) in off-pump group and 4.3% (n=8) in on-pump group (P=0.54). During follow-up period (median, 5.2 years; inter-quartile range, 2.9-8.6 years), 67 patients (21.2%) experienced major adverse cardiovascular events (MACE; myocardial infarction, repeat-revascularization, stroke and hospitalization for cardiovascular causes) and 117 patients (37.0%) died. Survival and MACE-free survival rate at 5 years were 75.6±2.6% and 65.7±2.8%, respectively, and these rates were not significantly different between the two groups (P=0.38 and 0.58, respectively). After adjustment, both groups showed similar risks of 30-day mortality (odds ratio, 1.39; 95% CI, 0.34-5.69; P=0.65), overall death (hazard ratio [HR], 0.75; 95% CI, 0.49-1.14; P=0.17), and the composite of death and MACE (HR, 1.11; 95% CI 0.76-1.62; P=0.61).

Conclusions: Both the short-term and long-term outcomes of CABG in patients with severe LV dysfunction were not affected by pump-strategy. Therefore, off-pump CABG can be performed as a reasonable and safe option even in patients with severe LV dysfunction.

©2014 by the International Society for Minimally Invasive Cardiothoracic Surgery