P1 A Contemporary Approach to Reoperative Aortic Valve Surgery: When is Less More?
Deane E. Smith, III, Michael S. Koekert, David W. Yaffee, Patricia Ursomanno, Ramsey Abdallah, Eugene A. Grossi, Aubrey C. Galloway. New York University Langone Medical Center, New York, NY USA.
Objective: Although the benefits of minimally invasive valvular surgery are well established, the advantage of extending these techniques to reoperative aortic valve (AV) surgery is unknown. We evaluated our experience with a minimally invasive approach to this patient population.
Methods: From June 2010 through June 2015, 24 patients underwent reoperative isolated AV replacement via a minimally invasive approach by a single surgeon. We retrospectively reviewed our prospectively collected database. All patients underwent preoperative computed tomographic imaging and coronary catheterization. The mean age was 76.3 years (range, 53–92 years); 58% of the patients had previous coronary artery bypass grafting with patent internal mammary artery (IMA) grafts. Cold blood cardioplegia was administered antegrade (11/24), retrograde (12/24), or both (1/24), and systemic cooling, with a mean low temperature of 27.5. Surgical approach and cannulation strategies are presented in Table P1-1.
Results: All procedures were completed with a minimally invasive approach. The mean cross-clamp time was 54.8 minutes (32–101 minutes), and bypass time was 91.5 minutes (50–144 minutes). No IMA injuries occurred. There were no hospital deaths or occurrences of perioperative myocardial infarction, stroke, wound infection, renal failure, or endocarditis/sepsis. One patient required a reoperation for bleeding and subsequently met criteria for respiratory failure but ultimately recovered. Fifty-eight percent of the patients were discharged home; the mean (SD) length of stay was 6 (3) days.
Conclusions: Minimally invasive cardiac surgery techniques can be applied to reoperative AV surgery. Appropriate perfusion and cardioplegia strategies can protect the heart without the need for IMA graft dissection and potential injury. With appropriate preoperative evaluation and careful surgical planning, a minimally invasive approach to reoperative AV surgery can be performed in a safe and effective manner.
P2 Aortic Valve Repair
Oleg Orlov, Ioannis Paralikas, Carlos Padula, Alice Isidro, Konstadinos Plestis. Lankenau Heart Institute, Philadelphia, PA USA.
Objective: A 54-year-old woman presented with shortness of breath. She had a bicuspid aortic valve (right and noncoronary cusps were fused) with severe regurgitation and ascending aortic aneurysm.
Methods: An inverse T-type ministernotomy was performed, extending to the fourth intercostal space. The aortic arch was cannulated directly with the Seldinger technique, and an endopulmonary vent was used. The right atrium was cannulated via the right common femoral vein, under transesophageal echocardiographic guidance, using the Seldinger technique. Two liters of HTK Custodiol cardioplegia were administered in antegrade fashion to arrest the heart.
Results: The aorta was excised 1 cm above the sinotubular junction, and the aortic root was mobilized. The conjoined cusp of the bicuspid aortic valve was prolapsing. Free edge plication was used to repair the cusp. The Schaffer’s caliber was used to assess residual prolapse of the leaflets after the repair. Subcommissural annuloplasty was performed to reduce the annulus to 23 mm. A 24-mm graft was anastomosed to the sinotubular junction. Then, the distal anastomosis between the graft and the aorta was performed 1 cm proximal to the aortic clamp. The distal aorta was wrapped.
Conclusions: Postoperatively, the patient did well. Echocardiography revealed no regurgitation. She was discharged out of the hospital after 6 days of stay.
P5 Combined VV ECMO and Impella LVAD: An Alternative to VA ECMO
Louis Samuels, Eric Gnall, Elena Casanova-Ghosh. Lankenau Medical Center, Wynnewood, PA USA.
Objective: This study aimed to describe the configuration and advantages of combined venovenous extracorporeal membrane oxygenation (VV ECMO) with the Impella left ventricular assist device (LVAD).
Methods: The case of a 37-year-old man with ischemic cardiomyopathy who presented with acute decompensated heart failure requiring mechanical circulatory support is described. Initial cardiac support was provided with the Impella 5.0 LVAD. Thirty-six hours later, VV ECMO was added because of severe respiratory failure secondary to polymicrobial pneumonia. Device flows ranged between 4.5 and 5.0 L/min. Impella support was maintained for 13 days; VV ECMO was maintained for 20 days.
Results: The combination of Impella LVAD and VV ECMO was successful in providing acute cardiorespiratory support with preservation of end organs and ultimate survival. This unique configuration allowed for an uncoupling of the mechanical therapies, permitting differential timing of removal as each organ system (ie, cardiac and pulmonary) recovered independently.
Conclusions: The VV ECMO and Impella LVAD combination was successful in providing acute cardiorespiratory support in the most advanced decompensated state. This configuration has distinct advantages over venoarterial ECMO in allowing for superior left ventricular unloading, antegrade arterial blood flow, and the ability to uncouple the mechanical therapies depending on the timing of organ system (ie, cardiac and pulmonary) recovery. Consideration for similar clinical scenarios may be worthwhile.
P6 Contemporary Outcomes of Open Thoracoabdominal Aneurysm Repair Using a Multidisciplinary Approach
Harper Padolsky, Robert Moraca, Daniel Benckart, Bart Chess, Satish Muluk, George Magovern, Jr. Allegheny Health Network, Pittsburgh, PA USA.
Objective: Open thoracoabdominal aneurysm repair is reported to have a significant morbidity and mortality. As endovascular approaches to thoracic aneurysm repair are studied, it is important to have a contemporary analysis of open intervention to compare these results. This study evaluated the contemporary results of a multidisciplinary approach to elective thoracoabdominal aneurysm repair at a single institution.
Methods: Between March 2010 and January 2014, 46 patients underwent an elective open thoracoabdominal aneurysm repair at a single institution. Demographic, clinical, and outcome data were tabulated and analyzed. A literature review was performed to compare contemporary results.
Results: The mean (SD) age was 69.3 (11.1) years, and 54% (n=29) of the patients were male. Etiologies of disease were atherosclerotic aneurysm in 57% (n=26) and chronic type B dissection in 43% (n=20). Circulatory support was used in all cases, left atrial-femoral bypass in 65% (n=30) and cardiopulmonary bypass with circulatory arrest in 35% (n=16). The mean postoperative length of stay was 16.2 days. Postoperative paraplegia was found in 4% (n=2) of the patients, along with neurapraxia in 2% (n=1). The 30-day in-hospital mortality was 4% (n=2).
Conclusions: Thoracoabdominal aneurysms remain a complex problem requiring a multidisciplinary approach. Open repair remains an effective operation resulting in a reasonable outcome.
P7 Examining the Learning Curve of a First-Year Robotic Thoracic Surgeon in the Community Setting
John F. Lazar, Troy A. Moritz. Pinnacle Health CardioVascular Institute, Harrisburg, PA USA.
Objective: There are scant data in the literature regarding the experience of first-year thoracic attendings, their expected outcomes, and even less when combined with robotics. The purpose of this study was to examine the learning curve of a first-year robotic thoracic attending in a community health care system after a dedicated robotic fellowship.
Methods: Robotic thoracic cases from July 2014 to June 2015 were retrospectively analyzed and compared in two 6-month periods. Primary outcomes were length of stay, complications, morality, and operative time. Secondary outcomes included patient characteristics and operative outcomes. χ2 and Fisher exact tests were used for categorical variables and Student t test for numerical variables. Significance was defined as P<0.05.
Results: There were 65 cases: 28 lobectomies, 2 pneumonectomies, 1 segmentectomy, 22 wedges (11 diagnostic/therapeutic, 9 primary lung cancer, 2 metastasectomies), 6 foregut, and 6 others. Ten cases were converted to open or video-assisted thoracoscopic surgery; one emergently. There was no significant difference between the first or second 6 months except that patients were 7.9 years younger and major operating room time was 36 minutes shorter after corrected for complexity in the second period. There were no mortalities and nine perioperative complications.
Conclusions: The significant reduction in operating room time by 36 minutes in the second half of the year clearly shows a positive continuum in the attending’s learning curve. This improvement in resource use should continue as experience increases. The overall positive results infer that previous robotic training may be an important component for initiating a successful thoracic robotics program.
P8 Expanding the Field: Uniportal Video-Assisted Thoracic Surgery for Esophageal Surgery
David Zeltsman, Kyle Riggs, Bo Gu. Department of Cardiothoracic Surgery, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY USA.
Objective: Minimally invasive surgical techniques have revolutionized most surgical fields, and esophageal surgery is no exception. As more experience with standard three-incision video-assisted thoracic surgery (VATS) was gained, we gradually decreased the number of VATS incisions to one and use this approach for all aspects of thoracic surgery. It has become our preferred method of performing esophageal surgery as well. The following video demonstrates the use of uniportal VATS for esophageal mobilization, long Heller myotomy, and resection of an esophageal duplication cyst and is representative of the technique.
Methods: Video-assisted thoracic esophageal surgery is performed through a single 1- to 2-cm incision performed in the seventh intercostal space. No trocars are used, and the instruments are inserted into the chest directly through the incision. We use a 5-mm 30-degree telescope, standard VATS instruments, ultrasonic coagulation shears and/or electrocautery, and surgical staplers to accomplish the intraoperative goals with intraoperative steps closely mimicking those of the open procedures.
Results: We successfully used uniportal VATS for esophageal mobilization during modified McKeown esophagectomy, extended esophageal myotomy for esophageal dysmotility disorders, and resection of esophageal wall masses. No complications related to the technique occurred, and all the cases were completed as planned.
Conclusions: Uniportal VATS is a truly minimally invasive approach to a variety of esophageal operations, is safe, and is feasible for complex thoracic interventions. Extensive VATS experience is a prerequisite to successful outcomes. As surgeons become more familiar with uniportal VATS, there are very few limitations to its application in the thorax.
P9 Humanitarian Cardiac Surgery: A Trainee’s Perspective
Tyler J. Wallen. Mercy Catholic Medical Center, Darby, PA USA.
Objective: Cardiothoracic surgeons have a long and storied history of humanitarian aid. Although several reports have described this practice, none has documented it from the perspective of the surgical trainee.
Methods: This report provides an account of a surgical trainee’s experience within the practice of humanitarian congenital cardiac surgery and provides reports of both the trainee’s experience as well as the barriers faced in attaining that experience.
Results: Serving with the International Children’s Heart Foundation, the author was able to participate in more than 30 congenital cardiac procedures as a general surgery resident, which is significantly more than required by the American Board of Thoracic Surgery for a cardiac surgery fellowship. Furthermore, the experience provided education from practitioners from several continents and provided a much-needed service to underprivileged children. Unfortunately, there were barriers to this experience. These included challenges at the financial, institutional, and regulatory level. There are no standardized pathways for incorporating trainees into humanitarian surgery. Furthermore, there is little funding available. Finally, the Accreditation Council for Graduate Medical Education process of granting operative credit is lengthy and uses antiquated methods.
Conclusions: Incorporating humanitarian efforts into the surgical trainee’s education allows for early and significant exposure to the practice of cardiac surgery. It provides a great service to the less fortunate and trains residents to grow into humanitarians. Streamlining the Accreditation Council for Graduate Medical Education’s approval process for international experiences by incorporating digital resources, coupled with the establishment of scholarship opportunities, would likely increase the involvement of trainees in humanitarian experiences. Surgical societies are in excellent position to assist with facilitating these changes.
P10 Hybrid Treatment of Aortic Arch Disease
Daniel Watson, Nirvana Siraswat. Riverside Methodist Hospital, Columbus, OH USA.
Objective: This study aimed to summarize the experience of treating aortic arch disease with ascending aorta–to–carotid artery revascularization and subsequent endovascular repair.
Methods: From January 2002 to June 2015, 12 high-risk patients with aortic arch disease were treated with ascending aorta–to–carotid artery revascularization with subsequent endovascular repair. There were nine male and three female patients, with a mean age of 64 (14) years (range, 54–71 years). Of the 12 patients, 3 had aortic dissection, and 9 had thoracic aortic aneurysm. All aortic arch debranching was performed with midsternotomy, including seven ascending aorta–to–innominate artery and left common carotid artery bypass and five ascending aorta–to–left common carotid artery and left subclavian artery bypass. Subsequently, simultaneous (n=9) and staged [n=3; mean (SD) interval, 7 (4) days] endovascular repairs were performed via femoral artery.
Results: Technical success rate was 100%. The 30-day mortality was 3/12, including 1 brain stem infarction, 1 circulatory failure, and 1 aortotracheal fistula. Complication included one type II endoleak. The median time of follow-up was 24 (14) months. Computed tomographic scanning was performed at 1 month, 3 months, and annually thereafter. There was no death and no occlusion of bypass during follow-up. No complication occurred except one existing type II endoleak.
Conclusions: Ascending aorta–to–carotid artery revascularization with subsequent endovascular repair is suitable for high-risk aortic arch pathology patients in poor general condition with little tolerance to aortic arch replacement.
P11 Improving the Odds: Intercostal Metal Coils Mark the Area for Resection of Rib Lesions
David Zeltsman1, Bo Gu1, Kyle Riggs1, Chris Sung2, Igor Lobko2. 1Department of Cardiothoracic Surgery, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY USA; and 2Hofstra North Shore-LIJ School of Medicine, Great Neck, NY USA.
Objective: Precise localization of a rib lesion for its resection remains a challenge because of multiple factors including nonpalpable pathology, unfavorable body habitus, inaccurate clinical examination and unreliable rib count on physical examination, unfavorable lesion location within a rib (its posterior aspect), and presence of sclerotic lesions with grossly intact rib cortex. We describe a novel rib localization technique that eliminates potential mistakes and avoids resection of an inappropriate rib.
Methods: Our method of rib localization includes placement of metallic coils by interventional radiologists under computed tomographic guidance where two coils are deployed within the intercostal spaces, one superior to the rib lesion and one inferior. Intraoperative use of fluoroscopy results in the precise localization of rib lesions even in cases where the pathology is not grossly apparent.
Results: We implemented this approach in 2014 and have since performed it in five patients for both lytic and sclerotic lesions. Placement of markers superficial to the intercostal spaces resulted in their displacement in one case. Successfully, we removed the correct ribs in each patient without technical difficulties or complications.
Conclusions: Our series demonstrates a novel strategy for the most accurate and relatively easy way to identify the exact portion of the rib for surgical resection. Intercostal space positioning of the coil markers superior and inferior to the lesion prevents their dislodgement during patient transport and positioning on the operating room table and improves rib identification accuracy and reliability. When combined with intraoperative fluoroscopy, it could virtually eliminate resection of an incorrect rib.
P12 Initial 3-Year Review of TAVR Program Launch at a Tertiary Academic Community Hospital
Raymond L. Singer1, Tara C. Stansbury2, James K. Wu1, Sanjay M. Mehta1, Joseph P. Kleaveland1, William G. Combs1, David A. Cox1, Rhonda J. Moore1. 1Lehigh Valley Health Network, Allentown, PA USA; and 2Lehigh University, Allentown, PA USA.
Objective: Transcatheter aortic valve replacement (TAVR) is a transformative procedure that avoids the need for conventional open heart aortic valve replacement in high-risk patients. This review was aimed to assess the outcomes for the launch of a TAVR program at a tertiary academic community hospital.
Methods: A retrospective chart review was performed with approval of the Lehigh Valley Health Network Department of Surgery as a quality/performance improvement project.
Results: A review of the first 3 years shows that 225 TAVR procedures were performed, 134 transfemoral and 91 transapical. The patient population was 120 men and 105 women; age ranges were 50 to 99 years [41 (<75 years), 96 (75–84 years), 81 (85–94 years), and 1 (>95 years)]. Overall in-hospital mortality was 4 (1.78%); 30-day mortality was 7 (3.11%); 60-day mortality was 8 (3.56%); and 1-year mortality was 27 (12%). Complications included stroke in 11 (4.89%) and need for pacemaker in 41 (21.81%). The four in-hospital deaths were caused by stroke (1), liver failure (1), cardiac failure (1), and hemorrhage (1). These results compared favorably to the PARTNER trials and other commercial rollout studies.
Conclusions: Our results confirm that TAVR procedures can be performed safely at a tertiary academic community hospital with excellent outcomes compared with the PARTNER trials and commercial rollout studies. Factors predicting success include an existing high volume of interventional cardiology and cardiac surgical program, documented quality outcomes, a hybrid operating room, and the ability for the interventional cardiologists and cardiac surgeons to work as a collaborative team.
P13 Left VATS Resection of an Esophageal Duplication Cyst
Mark Crye, Lana Schumacher, Mathew VanDeusen, Toshi Hoppo, Blair Jobe, Rodney Landreneau. Allegheny Health Network, Pittsburgh, PA USA.
Objective: Esophageal duplication cysts are an uncommon source of swallowing-related symptoms and pain in adults. As they grow, compression of adjacent structures results in symptoms corresponding to their location within the thoracic cavity. Resection is recommended when the diagnosis is made, and historically, this was performed via open thoracotomy. With the advancement of minimally invasive technique, a video-assisted thoracoscopic surgery (VATS) approach is a viable option for curative resection.
Methods: A 22-year-old man had been experiencing recurrent cough when eating, in addition to nausea and emesis when eating quickly. A computed tomography of the chest was performed when the patient was involved in a motor vehicle crash, revealing a 4.9×6.8-cm cystic lesion abutting and causing compression on the esophagus. Preoperative evaluation was completed, and the patient underwent left VATS resection. Five ports were used, and complete resection was performed. Intraoperative esophago-gastro-duodenoscopy showed no evidence of full-thickness esophageal injury.
Results: The patient’s operative and postoperative course was uneventful. His chest tube was removed on postoperative day 1, and he was discharged home on postoperative day 2. Postprocedure gastrografin swallow evaluation showed no evidence of leak or stricture.
Conclusions: Thoracoscopic resection of esophageal cysts is a viable alternative to more invasive open procedures. Postoperative morbidity is lower with a VATS approach compared with an open thoracotomy and should be attempted when possible.
P14 Outcomes of Open Repair of Mycotic Descending Thoracic and Thoracoabdominal Aortic Aneurysms
Erin Mills, Christopher Lau, Mario Gaudino, Monica Munjal, Leonard Girardi. Weill Cornell Medical College, New York, NY USA.
Objective: This study aimed to evaluate the outcomes of open repair of mycotic thoracic and thoracoabdominal aneurysms.
Methods: From November 1997 to May 2015, 16 consecutive patients underwent open repair of descending thoracic (n=11, 68.8%) and thoracoabdominal (n=5, 31.3%) mycotic aortic aneurysms. Soft tissue coverage of the prosthesis was performed when anatomy and patient condition permitted. Perioperative outcomes, intermediate-term survival, and reinfection rates were examined.
Results: Preoperative patient characteristics are shown in the Table P14-1. A majority of the patients underwent repair using a clamp-and-sew technique (n=12, 75%). After radical debridement of the infected tissue, grafts were placed in the normal anatomic position; eight patients (50%) had additional soft tissue coverage, five (31.3%) used an omental flap, and three (18.8%) used a serratus muscle flap. There was one (6.3%) in-hospital mortality. Four patients (25%) required tracheostomy, and one (6.3%) had recurrent nerve injury. After surgery, all patients were given 6 weeks of intravenous antibiotics. Life-long suppression was maintained with oral antibiotics. The mean follow-up time was 23 months (median, 3.6 months; range, 1–142 months). Actuarial 5-year survival was 71%. There were no episodes of prosthetic graft infection on follow-up. Univariate analysis revealed that New York Heart Association functional class, diabetes, and preoperative renal dysfunction were preoperative risk factors for major in-hospital adverse events.
Conclusions: Open repair of mycotic descending thoracic and thoracoabdominal aortic aneurysms permits a high rate of success in this very high-risk cohort of patients.
P15 Patients With Infectious Endocarditis and Drug Dependence Have Worse Clinical Outcomes After Valvular Surgery
Anthony Lemaire, Viktor Dombrovskiy, George Batsides, Aziz Ghaly, Takashi Nishimura, Lindsay Volk, Alan Spotnitz, Leonard Y. Lee. Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ USA.
Objective: Patients with infectious endocarditis (IE) are at high risk for postoperative morbidity and mortality, which might be increased by drug abuse. The purpose of this study was to evaluate the impact of drug dependence on outcomes in patients who have IE and undergo valvular surgery (VS).
Methods: The National Inpatient Sample (2001–2012) was queried to select patients with IE who had elective VS using International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis and procedure codes. Among them, patients with drug dependence (PDDs) were identified, and their health status and postoperative outcomes were compared with those patients without drug dependence (controls). χ2 and Wilcoxon rank sum tests and multivariable regression analysis were used.
Results: A total of 809 PDDs (12.9%) of the 6264 patients who underwent VS were evaluated. They were younger compared with controls [39.0 (10.8) vs. 54.4 (14.8) years; P<0.0001] and had less age-related comorbidities such as hypertension, diabetes, congestive heart failure, and renal failure. Despite the younger age and fewer comorbidities, PDDs compared with controls were more likely to develop postoperative complications overall [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.34–2.01], including infectious complications (OR, 1.5; 95% CI, 1.27–1.78), specifically pneumonia (OR, 1.4; 95% CI, 1.14–1.74) and sepsis (OR, 1.4; 95% CI, 1.16–1.63); renal complications (OR, 1.5; 95% CI, 1.23–1.77); and pulmonary embolism (OR, 1.9; 95% CI, 1.44–2.52). Furthermore, PDDs had 11% longer hospital stay compared with controls (P<0.0001). However, we did not find significant difference in hospital mortality between these groups.
Conclusions: Drug dependence significantly worsens postoperative outcomes in patients with IE who underwent VS and lengthens their hospital stay.
P16 Perioperative Use of Systemic Thrombolytics in Patients Undergoing Cardiothoracic Surgical Procedures
Frank Manetta1, Sean McCarney2, David Zeltsman2, L. Michael Graver2, Pey-Jen Yu2. 1Hofstra-North Shore LIJ School of Medicine, Bay Shore, NY USA; and 2Hofstra-North Shore LIJ School of Medicine, Manhasset, NY USA.
Objective: Systemic administration of thrombolytics such as tissue plasminogen activator is used to treat disease processes such as embolic cerebral vascular accidents and massive or submassive pulmonary embolisms. Their use is generally contraindicated in the perioperative period, especially in patients undergoing cardiothoracic procedures. The purpose of this study was to evaluate the outcomes of patients who received systemic thrombolytic administration perioperative to a major cardiothoracic surgery procedure.
Methods: A retrospective chart review was performed. Six patients who received thrombolytics in the perioperative period were identified. Indications for surgery and thrombolytic administration were identified, and outcomes were assessed.
Results: The administration of thrombolytics was within 6 hours of surgery preoperatively in three patients who had massive pulmonary embolisms (two pulmonary embolectomies, one peripheral extracorporeal membrane oxygenation placement). Thrombolytics were administered at 4, 17, and 91 hours postoperatively in three patients who experienced a pulmonary embolism (1) and acute stroke (2), after subxiphoid pericardial window, video-assisted thoracoscopic surgical left upper lobectomy, and aortic valve replacement, respectively. Thrombolytics were administered within 6 hours of the strokes. There were no major bleeding complications in patients who received preoperative thrombolytics. Resuscitation and transfusion were required in two patients who received thrombolytics postoperatively. Reoperation was required in one of these patients. All patients survived without major neurologic deficits.
Conclusions: Administration of systemic tissue plasminogen activator in the perioperative period should be considered “relatively” rather than “absolutely” contraindicated and therefore may be considered in life-critical situations where benefit is deemed to outweigh the risks.
P17 Primary Intrapulmonary Thymoma: A Case Report and Literature Review of This Rare Entity
Dustin J. Manchester, Ned Carp. Lankenau Medical Center, Wynnewood, PA USA.
Objective: This study aimed to present an interesting, rare intrapulmonary mass and to review the literature on primary intrapulmonary thymomas.
Methods: A comprehensive literature search was performed using OVID, PubMed, and Cochrane databases. Search terms used included primary intrapulmonary thymoma and pulmonary thymoma. Previous major review articles were analyzed for further case reports.
Results: Including this report, 32 cases of primary intrapulmonary thymomas have been reported since 1951. Our patient is an 82-year-old woman with a 20–pack-year remote smoking history who presented to our emergency department with a productive cough. Imaging (Fig. P17-1) showed a suspicious, calcified intrapulmonary mass, prompting further workup and thoracic surgery evaluation. Computed tomography–guided biopsy of the mass was nondiagnostic. The patient underwent surgical resection via right anterolateral thoracotomy and right middle lobectomy. Final pathology showed a 9×6.5×6.0-cm type BI thymoma (lymphocyte rich) with negative margins. Her operative and postoperative courses were uneventful, and she is recovering nicely.
Conclusions: Although uncommon, primary intrapulmonary thymomas are described entities that must be considered when evaluating abnormal lung masses. Most patients present with a cough or shortness of breath or are incidentally diagnosed on imaging. In contrast to mediastinal thymomas, primary intrapulmonary thymomas rarely cause myasthenia gravis. Complete surgical resection is the treatment of choice and is curative in most patients. Adjuvant radiation is of little benefit, and patients should be closely followed up because of the risk of delayed local recurrence.
P18 Retrospective Review of the Use of Facilitating Technologies in Minimally Invasive Aortic Valve Replacement
Oleg Orlov1, Ioannis Paralikas1, Grace Kim2, Jessica Grippaldi2, Alice Isidro1, Scott Goldman1, Konstadinos Plestis1. 1Lankenau Heart Institute, Philadelphia, PA USA; and 2Villanova University, Villanova, PA USA.
Objective: Aortic valve replacement via upper sternotomy [minimally invasive aortic valve surgery (MIAVR)] has emerged as an alternative treatment to full sternotomy for patients with isolated aortic valve disease. The MIAVR is, however, technically demanding. We evaluated the impact of using an automated suture fastening system (Cor-Knot) and one 2-L dose of HTK cardioplegia (facilitating technologies) as facilitators in MIAVR procedures.
Methods: This is a retrospective review of prospectively collected data from two groups of patients who underwent MIAVR between 2008 and 2015. In one group (n=56), we used two facilitating technologies (Cor-Knot and HTK cardioplegia) (FT group), whereas in the other group (n=112), we used blood cardioplegia and hand tying of the surgical knots (non-FT group).
Results: There were 33 men (mean age, 70.5 years) in the FT group and 55 men (mean age, 73.5 years) in the non-FT group (P>0.05). Severe aortic stenosis was present in 55 patients (98.21%) in the FT group and 105 (93.75%) in the non-FT group (P>0.05). The mean (SD) cross-clamp time was 82.18 (18.25) versus 88.11 (19.73) minutes (P=0.0225), and the mean pump time was 107.02 (22.69) versus 114.78 (27.6) minutes (P=0.053) for the FT and non-FT groups, respectively. The mortality, stroke, new-onset renal insufficiency, and atrial fibrillation were 1 (1.85%), 1 (1.78%), 1 (1.78%), and 18 (32.14%) versus 3 (2.68%), 2 (1.78%), 6 (5.36%), and 39 (34.82%) for the FT and non-FT group, respectively (P>0.05). The average intubation time was 0.77 (1.1) versus 2.26 (9.38) days (P<0.00017). The hospital stay was 6.03 (2.42) versus 10.56 (11.53) days (P<0. 000076). The early [mean (SD) follow-up, 103.4 (205) days] paravalvular leak was 0 (0%) versus 5 (4.5%) for the FT versus non-FT group, respectively (P=0.051).
Conclusions: The use of the facilitating technologies simplifies the MIAVR without affecting outcomes. It is also associated with a decrease in the hospital stay and, importantly, early paravalvular leak rates.
P19 The Development of a Survivor Ovine Model for Advancing Minimally Invasive Mitral Valve Surgery
Joshua K. Wong, Amber L. Melvin, Candice Y. Lee, Devang J. Joshi, Louis DiVincenti, Jr, Peter A. Knight. University of Rochester Medical Center, Rochester, NY USA.
Objective: Critical steps in minimally invasive mitral valve (MI-MV) surgery can be technically challenging because of limited access. In our research of technology to overcome these challenges, we have developed an ovine animal model for investigational MI-MV surgery and described our experience and techniques in this report.
Methods: The animal model was developed in accordance with institutional guidelines. The operative approach, techniques for cardiopulmonary bypass (CPB), aortic cross-clamping, options for myocardial protection, and anatomical differences between sheep and humans are described.
Results: Ten male Dorsett sheep were operated on. Left anterolateral thoracotomies in the fifth intercostal space provided optimal exposure of the left atrium and aortopulmonary trunk for CPB and cross-clamping. Cardiopulmonary bypass was instituted via cannulation of the thoracic aorta and the main pulmonary artery. Intermittent aortic cross-clamping with moderate hypothermia was performed in six sheep because cardioplegia was not administered, with a mean (SD) total cross-clamp time of 23.4 (8.6) minutes. All 10 sheep were successfully weaned from CPB and returned to sinus rhythm after completion of the MV procedure; there were no intraoperative deaths. Six sheep survived and were reoperated on at a mean duration of 141 days (range, 7–203 days) to determine the long-term outcome of the MV procedure (Table P19-1).
Conclusions: An ovine animal model is a valuable platform for the development of technology for MI-MV surgery. Because of anatomical differences, cannulation of the thoracic aorta and pulmonary artery provides an alternative method for CPB, whereas intermittent aortic cross-clamping with hypothermic cooling adequately protects the myocardium and maintains a bloodless field.
P20 The Diagnostic Yield of Electromagnetic Navigational Bronchoscopy: Are We Getting Everything?
William K. Childers, John F. Lazar, Steve Ballinger, Troy A. Moritz. Pinnacle Health System, Harrisburg, PA USA.
Objective: Electromagnetic navigational bronchoscopy (NB) combines the minimally invasive benefits of flexible bronchoscopy and direct visualization of the central airways with three-dimensional planning to accurately and safely guide the probe to the periphery, thus potentially increasing the accuracy of the desired diagnostic yield. The purpose of this study was to evaluate our NB experience in the diagnosis of other noncancerous nodule pathology.
Methods: This is a retrospective single-center study from March 2013 to June 2015 to determine what our overall diagnostic efficacy was using the superDimension system (Covidien, Inc, Minneapolis, MN USA) especially noncancerous pathology. Data from two attending physicians were analyzed. Data points included patient demographics, final pathology, cytology, acid-fast bacilli culture, fungal culture, and lower respiratory growth. Additional data points included those who went on for computed tomography–guided biopsy and/or surgery.
Results: Forty patients underwent an NB with a biopsy. A diagnosis from pathology, cytology, or microbiology was obtained for 31 (77.5%) of the bronchoscopies; 25 (80.6%) obtained diagnosis from pathology, and 6 (19.4%) obtained diagnosis from fungal cultures. Of the nine NBs with no diagnosis, three underwent computed tomography–guided biopsy with two returning as malignancy, and one returned as inflammation. Three patients underwent surgery with the diagnosis of a fungal abscess and two malignancies. Three patients did not pursue further diagnostic tests. Zero patient had a complication after NB.
Conclusions: Electromagnetic NB is a safe and effective diagnostic modality to gather not just oncological specimen but also infectious etiology in patients with suspicious lesions in the peripheral and mediastinal locations.
P22 The Use of a Negative-Pressure Dressing for Delayed Sternal Closure and Rates of Mediastinitis: A Single-Institution Experience Using the Wound VAC
Mark Joseph1, Timothy Brand2, Richard Helton2, Amish Parikh2, Virginia Guerro2, William Stansfield2, Benjamin E. Haithcock2, Brett C. Sheridan2, Andy C. Kiser2. 1Carilion Clinic, Roanoke, VA USA; and 2University of North Carolina, Chapel Hill, NC USA.
Objective: Open chest management with delayed sternal closure (DSC) is used in poststernotomy patients for hemodynamic compromise, uncontrolled bleeding, refractory arrhythmias, cardiac edema, and tamponade physiology. The current literature states that incidence of mediastinitis is between 0.5% and 2.7% in poststernotomy patients, with mortality rates of up to 27%. We reviewed our experience with DSC versus primary sternal closure (PSC) to determine mediastinitis rates.
Methods: Patients undergoing complex cardiac surgical procedures were selected on the likelihood of postoperative bleeding, cardiac edema, and emergent or urgent surgical status from 2008 to 2013. A total of 325 patients were divided into two cohorts of PSC or DSC using negative-pressure dressing. A total of 149 patients were identified as DSC and 176 patients were identified as PSC. Primary end point included the rate of mediastinitis between both groups with secondary variables affecting outcome (Table P22-1).
Results: Patients who had DSC had higher body mass index (28.91 vs. 27.46, P=0.025), higher average total intensive care unit stay (14.2 vs. 9.2 days), and longer operative time. They also had a higher rate of blood transfusions with increased need for mechanical ventilation. The rate of mediastinitis overall was 0.7%. The rate of reoperation for bleeding was lower in the DSC group (4.7% vs. 6.3%, P=0.631); however, the rate of pneumonia was higher (9.4% vs. 4.0%, P=0.068), with comparable mortality rates between the two groups (12.6% vs. 16.8%, P=0.343).
Conclusions: Delayed sternal closure with the use of negative-pressure dressing does not significantly increase the rate of mediastinitis but may decrease the rate of emergent reoperation for bleeding compared with PSC. Patients who undergo DSC are likely to be more critically ill compared with patients who undergo PSC.