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Cardiac Track

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery: June 2016 - Volume 11 - Issue - p S31–S59
doi: 10.1097/IMI.0000000000000268
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C1 Aortic Valve Replacement With Sutureless Perceval Bioprosthesis: Single Center Experience With 517 Implants

Giovanni Concistrè, Francesca Chiaramonti, Giacomo Bianchi, Michele Murzi, Egidio Varone, Tommaso Gasbarri, Filippo Santarelli, Enkel Kallushi, Alfredo Cerillo, Pierandrea Farneti, Marco Solinas. Ospedale del cuore “G. Pasquinucci” - Fondazione G. Monasterio CNR, Massa, Italy.

Objective: Patients referred for aortic valve replacement (AVR) may benefit from sutureless technology to reduce mortality and morbidity and to facilitate minimally invasive approach. We describe our experience with sutureless Perceval (Sorin Group, Italy) aortic bioprosthesis.

Methods: Between March 2011 and January 2015, 517 patients underwent AVR with Perceval bioprosthesis. Mean age was 76±7 years, 331 patients were female (64%), and mean logistic EuroSCORE was 12.2±10.4%. Concomitant procedures were mitral valve surgery (n=74), tricuspid valve repair (n=21), CABG (n=41), myectomy (n=3) and ascending aorta replacement (n=2).

Results: In-hospital mortality was 1.5% (8/517). 385 (74.5%) patients underwent minimally invasive AVR with an upper ministernotomy (n=55) or right anterior minithoracotomy (n=330) approach. Cardiopulmonary bypass and aortic cross-clamp times were 81.2±36.7 and 50.8±25.1 minutes for isolated AVR and 138.2±56.3 and 91.1±34 minutes for combined procedures. At mean follow-up of 19.3 months (range: 0–52.7 months), survival was 91%, freedom from reoperation was 99%, and mean transvalvular pressure gradient was 11.4±5.4 mmHg.

Conclusions: Aortic valve replacement with Perceval bioprosthesis is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance.

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C2 Patients With Aortic Valve Disease and Coronary Artery Disease Can Benefit From a Hybrid Approach Combining Aortic Valve Replacement Through Right Minithoracotomy and Percutaneous Coronary Intervention

Jarosław Stoliński, Dariusz Plicner, Grzegorz Grudzień, Janusz Andres, Bogusław Kapelak. John Paul II Hospital, Jagiellonian University Cracow, Cracow, Poland.

Objective: The aim of the study was to report the results of hybrid aortic valve replacement through right anterior minithoracotomy (RAT-AVR)/PCI and conventional AVR/CABG surgery for patients with aortic valve and coronary artery disease.

Methods: Analysis of prospectively gathered data of 187 patients (86 hybrid and 101 conventional procedures) was performed. For 21 patients, RAT-AVR was followed by PCI during the same session; in 65 patients, RAT-AVR was performed within 90 days after PCI.

Results: Hospital mortality in the AVR/CABG and RAT-AVR/PCI group was 3.9% and 1.2%, respectively (P=0.237). Both hospital and intensive care unit stay were shorter in the RAT-AVR/PCI group (P<0.001). Complications occurred in 18.6% of patients in the RAT-AVR/PCI and 33.7% in the AVR/CABG group (P=0.020). There was a reduced rate of deep (4.9% vs. 0.0%, P=0.036) and superficial (9.9% vs. 2.3%, P=0.035) chest wound infections, less postoperative low-output syndrome (P=0.033), as well as reduced postoperative blood loss and blood requirements (P<0.001). There was no difference between groups regarding percentage of patients with postoperative renal failure, stroke, myocardial infarction, or pacemaker implantation. Increased postoperative blood drainage was less frequent (3.5% vs. 22.8%, P<0.001), and the mean volume of blood transfused was lower [342±326 mL vs. 166±181 mL] in the RAT-AVR/PCI group (P<0.001). Two-stage RAT-AVR/PCI was performed because of acute coronary syndrome (77.9%), one stage because of the intention to perform a minimal invasive procedure instead of conventional AVR/CABG (17.4%), or because of replacing CABG with PCI because of the lack of vascular grafts for CABG (4.6%). In 38.5% of patients from the two-stage subgroup, antiplatelet therapy was stopped before RAT-AVR, 32.3% of patients from thetwo-stage subgroup were on single and 29.2% on dual antiplatelet therapy until RAT-AVR, which had no influence on postoperative blood requirements or postoperative myocardial infarction (P<0.001 and P=0.050, respectively).

Conclusions: The hybrid procedure presented in our series favorable mortality and morbidity results may be an alternative to conventional AVR and CABG through full sternotomy in selected patients.

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C3 Transright Axillary Aortic Valve Replacement

Masayoshi Tokoro, Toshiaki Ito, Atsuo Maekawa, Sadanari Sawaki, Yasunari Hayashi, Junji Yanagisawa, Takahiro Ozeki, Maiko Tsuji, Mamoru Orii. Japanese Red Cross Nagoya Daiich Hospital, Nagoya City, Aich Prefecture, Japan.

Objective: Minimally invasive aortic valve replacement (AVR) is usually performed through partial sternotomy or thoracotomy in the anterior chest wall. We adopted right lateral thoracotomy through right axillary skin incision as an alternative access for minimally invasive AVR (TAX-AVR). The purpose of this study was to evaluate safety and less invasiveness of TAX-AVR compared with conventional AVR (C-AVR).

Methods: In surgery, the patient was set in partial left lateral position, and cardiopulmonary bypass was established through right femoral artery and vein. A small thoracotomy was made through right axillary skin incision. The ascending aorta was cross-clamped and AVR was performed. Endoscopic assist was used, and all sutures were tied using a knot pusher. In comparison with C-AVR, between January 2007 and October 2015, 324 patients underwent isolated AVR at our institution. Of 324 patients, 88 underwent TAX-AVR, 197 C-AVR, and 39 parasternum AVR. From C-AVR, emergency cases and patients with severely calcified ascending aorta were excluded, and 166 cases were enrolled as control group. Propensity matching between TAX-AVR and C-AVR patients generated 85 matched pairs. Early outcomes were compared in these 170 patients. Primary endpoints were major adverse cardiac events. Secondary endpoint was postoperative length of stay.

Results: No patient was converted to sternotomy from TAX-AVR. Hospital death (0.1) and major adverse cardiac events (4.6) were in TAX-AVR and C-AVR group, respectively (NS). Intensive care unit stay and postoperative hospitalization were significantly shorter in TAX-AVR group [TAX-AVR vs. C-AVR: 1.3±1.0 days vs. 2.4±3.6 days, P<0.001, and 9.7±6.2 days vs. 17.6±23.8 days, P<0.001, respectively]. There was no significant difference in implanted aortic valve size [TAX-AVR vs. C-AVR: 21.9±1.6 mm vs. 22.3±2.1 mm]; cardiopulmonary bypass time and cross-clamp time were significantly longer in TAX-AVR group [TAX-AVR vs. C-AVR: 138±33 minutes vs. 130±40 minutes, P=0.036, and 102±25 minutes vs. 94±30 minutes, P=0.013, respectively].

Conclusions: The TAX-AVR was as safe as C-AVR. The TAX-AVR was reproducible, cosmetically superior, and less invasive approach for AVR.

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C4 Traditional Sternotomy Versus Minimally Invasive Aortic Valve Replacement in Patients With Left Ventricular Dysfunction

Tom C. Nguyen 1, Vinod Thourani2, Yelin Zhao1, Justin Q. Pham1, Matthew D. Terwelp1, Prakash Balan1, Daniel Ocazionez1, Anthony Estrera1, Joseph Lamelas3. 1University of Texas, Memorial Hermann, Houston, TX USA; 2Emory University, Atlanta, GA USA; and 3Mount Sinai, Miami, FL USA.

Objective: Low ejection fraction (EF<40%) portends adverse outcomes in patients undergoing valvular heart surgery. The role of traditional median sternotomy (SAVR) compared with minimally invasive (MIAVR) aortic valve replacement in this cohort remains incompletely understood.

Methods: A multi-institutional retrospective review of 1503 patients undergoing SAVR (n=815) and MIAVR via right anterior thoracotomy (n=688) from 2011 to 2014 was performed. Patients were stratified into two groups (EF<40% and EF≥40%). In each EF group, MIAVR and SAVR patients were propensity matched by age, sex, body mass index, race, diabetes, hypertension, dyslipidemia, dialysis, cerebrovascular disease, cardiovascular disease, CVA, PVD, last creatinine level, EF, previous MI, and cardiogenic shock, and STS score. Continuous variables were compared using paired t test, and categorical variables were compared using the McNemar test.

Results: Among patients with an EF of 40% or more (377 pairs), patients undergoing MIAVR compared with SAVR had decreased intensive care unit hours (56.8 vs. 84.6, P<0.001), postoperative length of stay (7.1 vs. 7.9 days, P=0.04), bleeding (0.8% vs. 3.2%, P=0.04), and a trend toward decreased 30-day mortality (0.3% vs. 1.3%, P=0.22). STS scores were largely equivalent in patients undergoing MIAVR compared with SAVR (2.4 vs. 2.6, P=0.09). In patients with an EF of less than 40% (35 pairs), there was no difference in intensive care unit hours (69 vs. 72.6, P=0.80), postoperative length of stay (10.3 vs. 7.2, P=0.13), 30-day mortality (3.8% vs. 0.8%), or STS score (3.3 vs. 3.2, P=0.68).

Conclusions: Minimally invasive aortic valve replacement in patients with preserved EF was associated with improved short outcomes compared with SAVR. In patients with left ventricular dysfunction, short-term outcomes between MIAVR and SAVR are largely equivocal.

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CV1 A New Automated Minimally Invasive Aortic Valve Replacement Suturing Technique

Amber Melvin 1, Joshua Wong1, Devang Joshi1, Heather Gorea2, Angelo Martellaro2, Jude Sauer2, Peter Knight1. 1University of Rochester, Rochester, NY USA; and 2LSI Solutions, Victor, NY USA.

Objective: Despite the many potential therapeutic advantages of minimally invasive cardiac surgery aortic valve replacement (AVR), this promising procedure’s widespread adoption among cardiac surgeons has not yet occurred because of its complexity and technical challenges. Exposure of the valve and adequate placement of sutures in the annulus present a difficult barrier to ergonomic and reliable remote AVR surgery. This study evaluated a novel automated approach to minimally invasive AVR annular and prosthetic suturing through a right anterior minithoracotomy access site.

Methods: To develop and evaluate the functionality of this technique, nine minimally invasive AVR operations were sequentially performed in cadavers using two new automated technologies: an aortic annulus suturing device and a cardiac prosthetic valve sewing cuff suturing device. A right anterior minithoracotomy was made in the second intercostal space to access the aortic valve. After aortotomy, the native aortic valve was removed. A commercially available AVR bioprosthetic tissue valve was then implanted employing both devices. In addition to evaluating the devices’ functional mechanisms, factors such as operative angles, depth of bite in the annulus, apposition of the valve to the annulus, and surgeon ergonomics were investigated.

Results: All nine aortic valve prostheses were successfully implanted in study cadavers with satisfactory device function and prosthetic-annulus apposition.

Conclusions: This minimally invasive AVR technique using automated aortic annulus and cardiac prosthesis suturing devices is a feasible way to perform this beneficial but challenging surgery. The successful results of this research encourage further exploration of this technology and technique toward its future clinical use in minimally invasive AVR surgery.

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CMP1 Transcatheter Mechanical Aortic Valve Resection

Daniel S. A. Schilling, Saskia Pokorny, Irma Haben, Katharina Huenges, Jochen Cremer, Georg Lutter. University Hospital Schleswig-Holstein, Department of Cardiovascular Surgery, Kiel, Germany.

Objective: Transcatheter aortic valve implantation has become a widely used option for patients suffering of aortic stenosis. For transcatheter resection of calcified aortic valves before transcatheter aortic valve implantation, five different prototypes enabling mechanical resection have been developed and tested in vitro.

Methods: The handling qualities and cutting capabilities of five experimental transcatheter resection devices were assessed in vitro. General feasibility, positioning, and injuries arising from resection were examined in ten porcine aortic valves. Furthermore, punch experiments (n=50/device) were conducted in human aortic valves (reconstructed from several calcified human aortic semilunar cusps) and the resected areas were determined according to their size following a standardized protocol. In addition, the particles outside the resection chamber were recorded.

Results: Two of five resection devices showed inappropriate handling during the positioning procedure and inadequate resection properties, which were therefore classified as nonadequate. The remaining three devices showed adequate handling and resection properties throughout the experimental resection of the porcine valves. In the punch experiments of human calcified valves, these prototypes showed mean (SD) resection time of 9±1.2, 44±13.56, and 51.5±18.9 seconds with a respectively resected area of 62%, 7%, and 22%. The best positioning in terms of handling feasibility was performed by the second prototype in comparison with the other prototypes. Overall, a negative correlation with the total resected surface area was observed in relative to the degree of calcification in the aortic valves. Further findings were associated with injuries of the surrounding tissue, particles outside of the resection chamber, and damages recorded at the resection instruments.

Conclusions: Five transcatheter devices were designed, on the basis of different mechanical cutting techniques. Three of these five prototypes proved to be promising with regard to handling feasibility and cutting properties during this initial experimental study. However, the prototype with the best resection results showed marked deficiencies with regard to the risk of injury to the immediate surrounding surgical area. The advantages of individual punches thus need to be combined to optimize the existing resection instruments. The results of this study result in an optimized resection instrument.

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CMP2 Comparison of the Hemodynamic Performance of the Rapid Deployment Intuity Aortic Valve With the Conventional Valve Design Addressing Smaller Sizes and Patient Prosthesis Mismatch

Thorsten C. W. Wahlers 1, Francis Duhay2, Günther Laufer3, Axel Haverich4. 1Heartcent University Hospital Cologne, Cologne, Germany; 2Edwards Lifesciences, Irvine, CA USA; 3University Hospital Vienna, Vienna, Austria; and 4Hannover Medical School, Hannover, Germany.

Objective: Prosthesis-patient mismatch (PPM) especially in the small aortic root after aortic valve replacement leads to adverse outcomes. The newer generation of rapid deployment intuity aortic valve (RDAV) is designed to provide improved hemodynamics and may lessen PPM in small dimensions. Hemodynamic performance of RDAV’s was compared with the standard pericardial valves in smaller sizes (19, 21, 23 mm) to evaluate incidence of severe PPM.

Methods: Patient echocardiographic data from TRITON clinical report who received RDVAV in smaller sizes (19, 21, and 23 mm, group 1) were compared with patients who received similar size pericardial valves (group 2). Group 2 data were collected from postmarket approval database of the manufacturer of the pericardial valves. Prosthesis-patient mismatch is defined as severe when effective orifice area index of less than 0.65 cm2 and moderate PPM of less than 0.85 cm2/mt2.

Results: One hundred fifty-five patients with RDAV replacement (group 1) were compared with 123 patients who received aortic valve replacement with pericardial bioprosthesis (group 2). At 1 year, the echocardiographic data including mean transvalvular gradients, effective orifice area, effective orifice area index, left ventricular mass, and left ventricular mass index were compared between both groups (Table CMP2-1). Moderate PPM was noted in 42% of size 19- and 21-mm standard valve and none in RDAV.



Conclusions: In small size annulus, RDAV demonstrated superior hemodynamic performance and no incidence of moderate or severe PPM at 1 year in comparison with conventional pericardial bioprosthesis. This improvement may facilitate improved mid- and long-term survival. Replacement with RDAV should be considered in the presence of small aortic root.

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CMP3 Is There an Impact on Postoperative Morbidity and Long-Term Survival After Minimal Invasive Access? A Single Center Study of 7290 Patients With Aortic Valve Replacement

Sven Lehmann, Fabian Emrich, Christian D. Etz, Martin Misfeld, Anna Meyer, Anne K. Funkat, Jens Garbade, Friedrich W. Mohr. Heart Center Leipzig, Leipzig, Germany.

Objective: Minimally invasive techniques are progressively challenging traditional approaches in cardiothoracic surgery. The aim of this study was to compare outcomes in patients undergoing minimal (MIS) versus conventional (CON) access aortic valve replacement.

Methods: A total of 7290 consecutive patients undergoing primary aortic valve replacement at our institution from November 1994 to June 2015 were reviewed: 1776 patients had a MIS access and 5515 had a CON access.

Results: Patients in the CON group were significantly older than MIS patients [67±11 vs. 66±13 years, P<0.01] and had a lower EF [57±15% vs. 60±12%, P<0.01] and a higher log EuroSCORE [8.3±10 vs. 5.5±5.5, P<0.01]. There is no difference in cross-clamp time [50±23 vs. 52±23 minutes, P=0.15] between two groups. Thirty-day survival rate was 98.2±0.3 (MIS) and 94.4±0.3 (CON, P<0.01). The survival rate after 15 years was 70.9±1.8% (MIS) versus 53.1±1.0% (CON, p<0.01). The multivariate analysis revealed COPD [P<0.01, odds ratio (OR)=2.2], age older than 70 years (P<0.01, OR=1.8), preoperative intravenous inotropic (P<0.01, OR=6.5), dialysis (P<0.01, OR=3.7), emergency operation (P<0.01, OR=4.5), preoperative reanimation (P=0.02, OR= 3.2), preoperative cardiac shock (P<0.01, OR=4.1), previous cardiac surgery (P<0.01, OR=2.3), active endocarditis (P<0.01, OR=2.1), and female sex (P=0.01, OR=1.5) as independent risk factors for 30-day mortality.

Conclusions: Although patient selection may have influenced some of the observed differences between our patient groups, minimal access surgery seems to be associated with significantly lower postoperative morbidity and superior long-term survival.

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CMP4 Sutureless Technology and Minimal Invasive Approach: Are These Real Advantages for Patients Undergoing Aortic Valve Replacement?

Ferdinand Vogt, Steffen Pfeiffer, Joachim Sirch, Theodor Fischlein, Giuseppe Santarpino. Paracelsus Medical University, Nuremberg, Germany.

Objective: Minimal invasive aortic valve replacement (AVR) could cause less morbidity than conventional surgery, but up to now, strong clinical advantages are not yet demonstrated. Sutureless aortic valve prostheses could reduce the surgical time. However, whether shorter surgical time results in improved patient outcome remains to be determined.

Methods: From June 2007 to June 2015, 627 patients underwent elective isolated AVR through upper ministernotomy either with a sutureless valve (group A, n=206) or a stented aortic bioprosthesis (group B, n=247). One hundred seventy-four patients underwent isolated AVR through full sternotomy with a stented bioprosthesis (group C).

Results: The group A was the eldest (Table CMP4-1). Aortic X-clamp, cardiopulmonary bypass, and operation times were shorter in group A than in B and C. As expected, X-clamp time in minimal invasive approach was prolonged (Table CMP4-1). MIC approach enables an advantage for bleeding complications in terms of postoperative drainage and transfusions (Table CMP4-1). MIC sutureless showed a protective effect on renal function but a higher incidence of permanent pacemaker implantation (Table CMP4-1). We recorded no difference in terms of postoperative cardiac enzymes and no difference in orotracheal intubation time as well hospital/intensive care unit stay (Table CMP4-1). There was no statistical difference in terms of mortality, stroke, and wound infection (Table CMP4-1).



Conclusions: MIC approach allowed a protective effect on bleeding complication, but it is time demanding. MIC-sutureless AVR was associated with significant shorter surgical times compared with stented bioprostheses. In addition, sutureless AVR showed same mortality and immediate outcome compared with stented AVR groups, which were significantly younger.

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C5 Hybrid Coronary Revascularization Is Associated With Improved Short-Term Outcomes but Worse Midterm Reintervention Rates Compared With Conventional CABG: A Propensity-Matched Analysis

Yu Xia, Abraham Katz, Stephen Forest, Robert Pyo, Mark Greenberg, Joseph DeRose, Jr. Montefiore Medical Center, Bronx, NY USA.

Objective: Hybrid coronary revascularization (HCR) using minimally invasive LIMA-LAD revascularization and PCI is an attractive alternative to conventional CABG, but data comparing the two are limited and may not adequately adjust for comorbidities. We evaluated outcomes after HCR and conventional CABG using a propensity-matched cohort.

Methods: We conducted retrospective review of CABG and HCR patients from 2007 to 2015 at a single institution. Patients were propensity matched 1:1 to receiving HCR versus CABG by multivariable logistic regression on age, sex, ejection fraction, peripheral vascular disease, cerebrovascular disease, COPD, diabetes, dialysis, and number of vessels requiring revascularization. In-hospital and 30-day outcomes were compared. Freedom from reintervention and death were assessed by the Kaplan-Meier method with log-rank test and univariable Cox proportional hazards regression.

Results: From an initial cohort of 91 HCR and 2601 conventional CABG patients, 91 patients in each group were selected after propensity score matching. Hybrid coronary revascularization was performed with surgery first in 56 patients (62%), PCI first in 32 patients (35%), and simultaneously in three patients (3%). Median interval between interventions was 3 [interquartile range (IQR), 3–6] and 36 (IQR, 30–50) days for surgery first and PCI first, respectively. HCR and conventional CABG patients had similar preoperative characteristics. HCR patients had shorter postoperative length of stay [median (IQR), 4 (3–6) vs. 5 (4–8), P<0.001] and lower incidence of postoperative transfusion (13.2% vs. 34.1%, P=0.001) and respiratory failure (0% vs 6.6%, P=0.03). HCR patients were more likely to be discharged home (93.4% vs. 71.4%, P<0.001). There was no significant difference in 30-day mortality (P=0.99) or readmission (P=0.23). HCR was significantly associated with more reintervention (log-rank P=0.02, Fig. C5-1), whereas overall survival was not significantly different (log-rank P=0.79). The hazard ratio for reintervention and patient mortality of HCR compared with CABG were 3.60 (95% confidence interval [CI], 1.16–11.20) and 1.17 (95% confidence interval, 0.37–3.72), respectively.



Conclusions: Despite having favorable short-term outcomes and similar survival compared with CABG, HCR may be associated with higher rates of repeat revascularization. Prospective studies to confirm these findings are warranted.

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C6 Is the Future of Coronary Arterial Revascularization a Hybrid Approach? The Canadian Experience across Three Centers

Vincenzo Giambruno 1, Ahmad Hafiz1, Stephanie Fox1, Hugues Jeanmart2, Richard Cook3, Feras Khaliel1, Patrick Teefy4, Kumar Sridhar4, Shahar Lavi4, Rodrigo Bagur4, Ivan Iglesias5, Philip Jones5, Christopher Harle5, Daniel Bainbridge5, Michael Chu1, Bob Kiaii1. 1Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON Canada; 2Division of Cardiac Surgery, University of Montreal, Montreal Heart Institute, Montreal, QC Canada; 3Division of Cardiac Surgery, University of British Columbia, St. Paul’s Hospital, Vancouver, BC Canada; 4Division of Cardiology, Department of Medicine, Western University, London Health Sciences Centre, London, ON Canada; and 5Department of Anesthesia and Perioperative Medicine, Western University, London Health Sciences Centre, London, ON Canada.

Objective: Hybrid coronary revascularization (HCR) offers and combines the advantages of both surgical and percutaneous revascularization eliminating at the same time the disadvantages of both procedures. In fact, this evolving revascularization technique uses the survival benefit conferred by the left internal thoracic artery (LITA) graft to the left anterior descending coronary artery (LAD) while providing the patients with complete and truly minimally invasive revascularization with PCI to the non-LAD vessels. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up.

Methods: From March 2004 to November 2015, a total of 203 patients [61.7±11.00 years, 160 males and 43 females] underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the LITA to the LAD and PCI in a non-LAD vessel in a single or two stage, in three different centres. Patients underwent 6-month angiographic follow-up. The mean (SD) clinical follow-up was 77.82±41.4 months.

Results: Successful HCR occurred in 196 of the 203 patients (seven patients required intraoperative conversion to conventional coronary bypass). One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patients underwent PCI after surgery. One hundred eighty-nine patients were treated with drug-eluting stents, whereas 14 patients were treated with bare metal stents. No in-hospital mortality occurred. The mean (SD) intensive care unit stay was 1±1 day, and the mean (SD) hospital stay was 5±2 days. Only 13.3% of patients required a blood transfusion. Six-month coronary angiogram follow-up has been performed in 95 patients. Angiographic evaluation demonstrated a LITA anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8±41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, 90.7% freedom from any form of coronary revascularization (PCI of LITA-to-LAD anastomosis was performed in five patients, in one case, the anastomosis was surgically revised, and PCI was repeated in 13 patients).

Conclusions: Hybrid revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

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CMP5 Fifteen-Year Experience of Endoscopic Robotic-Assisted Coronary Artery Bypass to LAD as Part of a Hybrid Approach With Percutaneous Intervention to Non-LAD Vessels: A Minimally Invasive Approach for Full Revascularization in Multivessels Coronary Artery Disease

Maria Cannoletta, Alan Soo, Rashmi Yadav, Richard Trimlett, Anthony De Souza. Royal Brompton Hospital, London, United Kingdom.

Objective: Endoscopic robotic-assisted coronary artery bypass is a relative new procedure performed only in specialist centers. In our institution, this technique is often combined with percutaneous intervention (PCI) to the non-left anterior descending coronary vessels as part of a “hybrid” coronary revascularization approach to achieve complete revascularization for multivessel coronary disease. This combined technique avoids cardiopulmonary bypass-related complications and aortic manipulation compared with conventional coronary revascularization surgery. Here, we report our single institution 15-year experience of employing this approach.

Methods: The hospital cardiac surgery database (PATS and EPR) was retrospectively reviewed for a 15-year period. Patient characteristics and outcome including mortality and postoperative complications are reported.

Results: Between January 2000 and August 2015, a total of 477 patients underwent EndoACAB in our institution. Of this cohort, 144 patients (30%) underwent the procedure as part of a hybrid procedure. During this period, there were 22 conversions (4.6%) to sternotomy and conventional coronary surgery. The most common reason (six patients, 1.2%) for conversion was pleural adhesions. In four patients (0.8%), there were problems related to LIMA harvesting. There were difficulty in identifying the LAD vessel in three patients (0.6%), and in another three patients, there were difficulty in achieving single-lung ventilation. Other reasons given for conversion include limited shoulder mobility (two patients, 0.4%), hemodynamical instability during the procedure in two patients, instrumental problem in two patients, and was unknown in one patient. Their in hospital mortality rate was 0.2%, and two mortality rates occur 6 months after discharge. The overall complication rate was low with the most common complication being atrial fibrillation (18 patients, 3.8%) and acute kidney injury (nine patients, 1.8%). Three patients (0.6%) were re-explored for bleeding. Otherwise, two patients developed pleural effusion requiring drainage, and three patients developed significant wound infection. Finally, two patients had occlusion of the LIMA graft requiring PCI to LAD.

Conclusions: Endoscopic robotic-assisted coronary artery bypass is a safe procedure with low complication rate and good results. Combined with PCI as part of a hybrid coronary revascularization strategy, EndoACAB offers a truly minimally invasive approach to achieve complete revascularization.

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CMP6 Midterm Follow-up of Minimally Invasive Multivessel Coronary Artery Bypass Grafting: Is the Learning Curve Detrimental?

Maria Lorena Rodriguez, Harry Lapierre, Benjamin Sohmer, David Glineur, Marc Ruel. University of Ottawa Heart Institute, Ottawa, ON Canada.

Objective: Multivessel small thoracotomy coronary artery bypass grafting (MVST-CABG) is a novel minimally invasive technique for surgical coronary revascularization, which is increasingly being adopted around the world. This study aims to describe the characteristics and medium-term outcomes of a series of minimally invasive cardiac surgery-coronary artery bypass grafting, to identify areas for improvement.

Methods: A prospective longitudinal study was performed on the 306 MICS-CABG patients operated by a single surgeon from 2005 to 2015. The MICS-CABG used a small left thoracotomy to enable coronary revascularization with a similar configuration to an open sternotomy technique, with left internal thoracic artery harvesting, and hand-sewn proximal radial/saphenous and distal anastomoses, under direct visualization. We compared patients who were operated during the first and second halves of the series to ascertain the impact of a learning curve on outcomes.

Results: The average age was 62±9 years, 87% were male, and 23% had 3-vessel disease. OPCAB was performed in 80%, and the median number of grafts was 2 (range, 1–4). Sternotomy conversion occurred in 3.3%, reoperation for bleeding in 2%, and unplanned, emergency CPB conversion in 1%. Superficial thoracotomy infection, atrial fibrillation, and left-sided pleural effusion requiring drainage were encountered in 2%, 4%, and 4%, respectively. There was no perioperative stroke, myocardial infarction, or death. At a mean follow-up of 1024 days, 97.4% of patients were free from major adverse coronary and cerebrovascular events. Between the first and latter half of the series, there was a decrease in the rate of conversion to sternotomy (5.2%–1.3%, P=0.05) and in the midterm need for repeat revascularization (11% vs. 2.6% at 3 years, P=0.03). The ICU and hospital lengths of stay (1.6±1.5 vs. 1.4±0.9, P=0.2, and 6.1±2.6 vs. 5.6±1.8, P=0.4) were not statistically different.

Conclusions: MICS-CABG can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization, with excellent midterm results. Learning curve effects were not observed with regard to overall procedural safety but rather in terms of improved freedom from conversion to sternotomy and from repeat revascularization.

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CMP7 Off-Pump Totally Endoscopic Coronary Artery Bypass Grafting: Seven-Year Single-Center Experience and Long-term Follow-up of Graft Patency

Changqing Gao, Huajun Zhang, Ming Yang, Yang Wu, Nan Cheng. PLA General Hospital, Beijing, China.

Objective: The aim of the study was to summarize the 7-year surgical experience with totally endoscopic coronary artery bypass grafting (TECAB) and demonstrate the long-term follow-up results of the graft patency.

Methods: Between March 2007 and November 2015, a total of 114 consecutive patients (96 male) at a mean age of 58 years (range, 36–78 years) and EuroSCORE of 1.1±1.3 underwent off-pump TECAB with da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA USA) in our institution. Skeletonized left internal mammary artery (LIMA) conduit was used to graft LAD, and the blood flow in LIMA graft was measured with Medistim VeriQC system (Medistim ASA, Oslo, Norway). The patients were followed-up after surgery, and the coronary angiography or computed tomography angiogram was performed to evaluate LIMA graft patency.

Results: All cases (n=114) were successfully performed by a single console surgeon with LIMA graft to LAD (100%). There was no operative death or conversion to median sternotomy. The mean (SD) operation duration was 219±58 minutes. The blood flow of LIMA graft was 36.8±18 mL/min after TECAB. No major complication was observed. The postoperative ventilation time was 13.9±4.0 hours. The chest draining volume was 417.4±274.8 mL. Coronary angiography or computed tomography angiogram showed 100% graft patency before discharge. During the follow-up, LIMA graft patency was 98.8% at 1 year, 97.8% at 2 years after surgery, and 97.1% at 3 to 5 years after surgery.

Conclusions: Off-pump TECAB using LIMA to graft LAD is safe and effective procedure, and the long-term graft patency is excellent.

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CMP8 Ten-Year Follow-up of Patients Undergoing Totally Endoscopic Coronary Artery Bypass Grafting

Markus Kofler 1, Sebastian Reinstadler2, Lukas Stastny3, Alim Basaran3, Thomas Schachner3, Guy Friedrich2, Dominik Wiedemann4, Johannes Bonatti5, Nikolaos Bonaros3. 1Medical University of Innsbruck, Innsbruck, Austria; 2Cardiology, Medical University of Innsbruck, Innsbruck, Austria; 3Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria; 4Cardiac Surgery, Medical University of Vienna, Vienna, Austria; and 5Cardiac Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.

Objective: Totally endoscopic coronary artery bypass grafting (TECAB) is an emerging and apparently a safe and feasible minimally invasive treatment option for surgical coronary artery disease in selected patients. Long-term results are still missing. Therefore, we aimed to investigate the clinical long-term outcome.

Methods: We analyzed 197 consecutive isolated TECAB patients at a median follow-up period of 78 (61–114) months, operated at a single center from 2001 to 2011. Median (range) age was 59.0 (53–67) years, and 143 (72.6%) were male patients. Arrested heart TECAB was performed in 93%, and 7% were beating heart TECAB. Single-vessel TECAB was performed in 82% and double vessel TECAB was performed in 18%. Clinical follow-up included death, stroke, myocardial infarction, re-CABG re-PCI, target vessel revascularization (TVR), and recurrence of angina as endpoints. The combined endpoint of major adverse cardiac and cerebral events was defined as a composite of death, stroke, myocardial infarction, and any form of repeat TVR.

Results: We observed no perioperative death and a stroke rate of 1.5%. After a median (range) follow-up of 78 (61–114) months, we report a survival rate of 96.4% (190/197), a freedom from myocardial infarction of 92.9% (183/197), freedom from stroke of 93.9% (185/197), freedom from re-CABG and re-PCI of 98.5% (195/197) and 87.3% (172/197), respectively, and freedom from TVR of 94.4% (186/197). Of the patients undergoing TVR, only three had a graft occlusion during the first year after operation. Long-term freedom from major adverse cardiac and cerebral events was 77.7% (153/197).

Conclusions: This is the first study providing results regarding clinical outcome of TECAB patients after such a long follow-up period. Despite that patients are highly selected with limited coronary artery disease, the long-term results reveal TECAB as an excellent treatment option for these patients.

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C7 Complexity of Coronary Artery Disease and Revascularization Quality in Off-Pump Versus On-Pump Surgery: Analysis From the GOPCABE Study

Konstantin Preindl 1, Nobuyuki Furukawa1, Diana Diaz1, Kavous Hakim-Meibodi1, Stephan Ensminger1, Armin Zittermann1, Arno Diegeler2, Jan-Fritz Gummert1, Jochen Börgermann1. 1Herz-und Diabeteszentrum NRW Ruhr University of Bochum, Bad Oeynhausen, Germany; and 2Cardiovascular Clinic Bad Neustadt, Bad Neustadt a.d. Saale, Germany.

Objective: Revascularization quality in off-pump versus on-pump coronary surgery is an ongoing and hotly debated issue. This is because some randomized studies have shown higher re-revascularization rates, a lower number of peripheral anastomoses, and more incomplete revascularizations in off-pump groups. In this single-center analysis from the German Off-Pump Coronary Artery Bypass in the Elderly study, revascularization quality is investigated in connection with the complexity of coronary artery disease.

Methods: Three hundred twenty-three patients 75 years or older who underwent isolated CABG at our center were randomized. The complexity of the CAD was quantified in the off-pump and on-pump groups using the SYNTAX score. The primary endpoints of the study were completeness of revascularization (number of grafts, index of completeness of revascularization), re-revascularization rates in the 4-year follow-up, and reangiography findings, the last being systematically analyzed according to the FitzGibbon and Thrombolysis in Myocardial Infarction Scoring systems.

Results: After 4 years, there was no difference between the groups regarding survival or MACCE (death, myocardial infarction, and stroke). The complexity of CAD according to the number of lesions and SYNTAX score was comparable in the off-pump and on-pump groups [4.21±1.51 vs. 5.05±7.96, P=0.330; 20.4±7.42 vs. 21.3±7.84, P=0.452, respectively]. Here, the number of peripheral anastomoses performed [2.71±0.68 vs. 2.68±0.74, P=0.570], index of completeness of revascularization [number of grafts performed/number of grafts intended, 0.89±0.23 vs. 0.90±0.22, P=0.723], and the re-revascularization rate (6.8% vs. 8.0%, P=0.734) in the 4-year follow-up were not significantly different. Twenty-nine patients (8.97%) underwent reangiography. In the off-pump group, one stenosed and 28 occluded grafts were found, compared with five stenosed and 18 occluded grafts in the on-pump group (Table C7-1).



Conclusions: In this single-center analysis from the German Off-Pump Coronary Artery Bypass in the Elderly study, there were no significant differences between off-pump and on-pump surgery regarding complexity of the coronary artery disease and revascularization quality.

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CMP9 Anaortic Versus Clampless Off-Pump Versus Conventional Coronary Artery Bypass Grafting: Midterm Analysis of 5422 Unselected Patients

Nobuyuki Furukawa 1, Konstantin Preindl1, Andre Renner1, Anas Aboud1, Kavous Hakim-Meibodi1, Michael Benzinger1, Thomas Pühler1, Stephan Ensminger1, Tobias Becker1, Oliver Kuss2, Jan-Fritz Gummert1, Jochen Börgermann1. 1Herz- und Diabeteszentrum NRW Ruhr University of Bochum, Bad Oeynhausen, Germany; and 2Inst. for Biometry and Epidemiology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.

Objective: Meta-analyses from observational studies and randomized studies have been able to demonstrate benefits of off-pump surgery for hard endpoints and surrogate endpoints. In some of these investigations, however, an increased re-revascularization rate was noted in the off-pump groups, which in turn could impact the long-term survival of these patients. Against this background, we analyzed the course of all patients undergoing isolated coronary surgery according to the major cardiac and cerebrovascular event criteria.

Methods: A prospective register was taken from a single high-volume off-pump center recording all anaortic off-pump (ANA, n=1233), clampless off-pump (PasPort, n=2310), and conventional (CONV, n=1879) coronary artery bypass operations during the period from July 2009 to June 2015. Propensity-score matching was performed on the basis of 28 preoperative risk factors, including the EuroSCORE II and German CABG score (KCH), to correct for selection bias between the three groups.

Results: We were able to find 937 triplets (n=2811) ANA versus PasPort versus CONV. Compared with the conventional group, the in-hospital mortality of the ANA group was significantly better {OR for ANA [95% confidence interval (CI)], 0.23 [0.05–0.75], P=0.01} and that of the PasPort group better, with a clearly noticeable trend [OR for PasPort (95% CI), 0.46 (0.16–1.20), P=0.12]. In the midterm course (median, 849 days), there were no longer any significant differences for mortality [HR for ANA (95% CI), 0.68 (0.48–1.03), P=0.07; HR for PasPort (95% CI), 0.83 (0.55–1.25), P=0.38; reference: CONV], stroke [HR for ANA (95% CI), 1.00 (0.54–1.86), P=0.99; HR for PasPort (95% CI), 1.06 (0.56–2.01), p=0.86], myocardial infarction [HR for ANA (95% CI), 0.50 (0.20–1.28), P=0.15; HR for PasPort (95% CI), 0.67 (0.29–1.53), P=0.34], or re-revascularization [HR for ANA (95% CI), 0.78 (0.53–1.14), P=0.19; HR for PasPort (95% CI), 0.86 (0.61–1.29), p=0.53].

Conclusions: These data show in the midterm course no difference with regard to the major cardiac and cerebrovascular events between anaortic off-pump, clampless off-pump using the PasPort device and conventional coronary artery bypass grafting.

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CMP10 A Comparison of Hospital Cost and Outcomes Between Minimally Invasive Techniques for Coronary Artery Bypass Surgery Using Robotic Technology

Zachary N. Kon 1, Chetan Pasrija1, Mehrdad Ghoreishi1, Eric Lehr2, James S. Gammie1, Bartley P. Griffith1, Johannes Bonatti3, Bradley Taylor1. 1University of Maryland School of Medicine, Baltimore, MD USA; 2University of Maryland School of Medicine, Baltimore, WA USA; and 3Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.

Objective: Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis and robotic-assisted minimally invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques.

Methods: Patients who underwent robotic minimally invasive single-vessel CABG between 2011 and 2014 were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (n=50) or RA-MIDCAB (n=50). The two groups were sequential and noncontemporaneous with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. All TECAB procedures were performed by an experienced surgeon (>200 cases), whereas all RA-MIDCAB procedures were performed by a surgeon still within a learning curve (<75 cases). Demographic and operative data, short-term outcomes, and hospital cost data were compared between the two groups.

Results: Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as were median operative {3.5 [interquartile range (IQR), 2.9–3.9] vs. 3.3 [IQR, 3.0–4.2] hours, P=NS} and total operating room times [5.2 (IQR, 4.5–5.7) vs. 5.2 (IQR, 4.6–5.8) hours, P=NS]. Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases (P<0.01). Hybrid revascularization was performed in 40% of TECAB and 28% of RA-MIDCAB patients (P=NS) and was nearly universally staged postoperatively during the same hospitalization. The duration of ventilation and lengths of ICU and hospital stay were similar between groups. Readmission rates were 12% and 14% for TECAB and MIDCAB (P=NS), respectively, and 30-day or in-hospital mortality was 2% in the TECAB and 0% in the RA-MDCAB group (P=NS). Total hospital cost was significantly higher with TECAB compared with RA-MIDCAB [33,769 (IQR, 28,237–41,505) vs. 22,679 (IQR, 19,293–30,106) dollars, P<0.01], which was primarily driven by operative costs [17,616 (IQR, 14,888–20,451) vs. 26,803 (IQR, 19,458–30,756) dollars, P<0.01].

Conclusions: TECAB and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction, and functional status, are needed to evaluate whether this additional cost is justified.

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CV2 Redo Coronary Artery Bypass Graft Surgery From the Descending Thoracic Aorta to the Lateral Wall of the Left Ventricle Via Left Minithoracotomy

Odeaa Al Jabbari, Walid K. Abu Saleh, Mahesh Ramchandani. Houston Methodist DeBakey Heart and Vascular Center, Houston, TX USA.

Objective: CABG today most commonly makes use of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) with saphenous vein grafts for the remaining vessels. Although the long-term patency of LIMA to LAD is excellent, the development of disease in the vein graft over time is all too common. This frequently results in recurrence of disabling symptoms. PCI for vein graft disease is often fraught with peril. We present a minimally invasive option for revascularization of the lateral wall of left ventricle.

Methods: Between 2011 and 2015, 11 patients (nine males, 82%) with a mean age of 71 (range, 37–81 years) years underwent minimally invasive redo CABG from the descending thoracic aorta to an obtuse marginal artery via a left minithoracotomy. All patients presented with disabling angina on maximal medical therapy, and PCI was considered unsafe option. All had a patent LIMA to LAD. All patients had advanced disease in the vein graft (Fig. CV2-1).



Results: None required conversion to sternotomy or the use of cardio pulmonary bypass. Mean surgery time was 4 (range, 3–5 hours) hours with a mean estimated blood loss of 550 mL (range, 400–1500 mL). Each patient had one graft anastomosis performed to the lateral wall. Proximal anastomoses were performed using Cardica Pas-Port device in 10 patients. All distal anastomoses were hand sewn. Graft flows were excellent with the mean flow being 52 mL/min (range, 20–110 mL/min), mean pulsatility index of 2.2 (range, 1.5–2.6), and mean diastolic filling of 70% (range, 60%–75%). The mean hospital stay was 7 days (range, 6–14 days). There was no in-hospital mortality, and at 6-month follow-up, all patients were alive, well, and symptom free.

Conclusions: In a select group of patients, redo CABG to the circumflex territory can be performed safely via left minithoracotomy using the descending thoracic aorta for the proximal anastomosis. This approach avoids the risk of injury to the patent LIMA that median sternotomy would carry. The use of the Cardica Pas-Port device facilitates this approach.

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CV3 No-Sternotomy Full Arterial Revascularization for Everyone

Boris Robic, Pascal Starinieri, Alaaddin Yilmaz. Jessa Hospital, Hasselt, Belgium.

Objective: Minimal invasive procedures emerge in cardiac surgery because of well-known drawbacks. Sternotomy is still mandatory for OPCAB surgery. MIDCAB surgery is limited to revascularization of anterior wall. Detrimental effects of conventional bypass systems and minimal access are not always minimally invasive. Endoscopic assisted port access approach for coronary artery bypass grafting (EndoCABG) combines full revascularization without sternotomy. Modular minimal invasive extracorporeal circulation (MiECC) reduces deleterious bypass effects and supports surgeon’s efforts in minimal invasive techniques.

Methods: Myocardial ischemic patients with multivessel disease are not suitable for hybrid approach. Possibility for remote access perfusion with MiECC is a low volume-small surface-full safety circuit, requiring lower heparin dosage. Ongoing dual antiplatelet therapy was no contraindication.

Results: From July 2014 to December 2015, 145 patients [mean age, 66.61 years (range, 36–90 years); 81% male, 19% female] underwent port access surgery EndoCABG. Full arterial revascularization was accomplished in 98% with the use of VATS unilateral/bilateral internal thoracic artery harvesting. In mean of 2.86 (range, 2–5), video-assisted direct anastomoses were accomplished via small left thoracotomy. Complete revascularization was achieved in 46% on empty beating heart and 54% on arrested heart (remote access perfusion with MiECC). Crossclamp time (when applied) was in a mean of 65.45 minutes with normal operation duration of 2.5 to 3 hours.

Conclusions: Minimal invasive surgery is a team approach. Use of MiECC flattens the steep learning curve in adapting port access techniques for coronary artery bypass grafting. Better outcome is caused by the possibility of full arterial revascularization. Maximum benefit is accomplished only through refinement of both surgical and perfusion techniques.

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CMP11 Laser-Assisted Coronary Anastomotic Connector (The Trinity Clip) in a Preclinical Safety Study

David Stecher 1, Glenn Bronkers2, Cornelis A. F. Tulleken1, Imo E. Hoefer1, Lex A. van Herwerden1, Gerard Pasterkamp1, Marc P. Buijsrogge1. 1University Medical Center Utrecht, Utrecht, the Netherlands; and 2Corvasco Medical b.v., Utrecht, the Netherlands.

Objective: A facilitated construction of a coronary anastomosis is a key toward expansion of less invasive bypass surgery. This preclinical safety study evaluated a laser-assisted, nonocclusive connector (the Trinity Clip) on small caliber coronary arteries in a porcine off-pump bypass model.

Methods: In 58 pigs, 33 left internal thoracic to left anterior descending coronary (1.6–1.9 mm outer diameter) artery anastomoses were facilitated by the connector, and 25 were hand-sutured. To assess anastomotic healing and patency, the anastomoses were evaluated at the short- (intraoperative and 4, 10, 14, and 35 days) and long-term (90 and 180 days) follow-up and were examined by flow measurements, angiography, histology, and scanning electron microscopy.

Results: A faster construction time was found (P<0.01), and hemostasis tended to be better (94% vs. 80%, respectively; P=0.11) in the connector compared with the hand-sutured group. Long-term follow-up showed 100% patency (14/14) in the hand-sutured compared with 82% (18/22) in the connector group [P=0.12, long-term patency was 92% (12/13) before a connector design change halfway the study]. The patent-facilitated anastomoses showed less intimal hyperplasia formation compared with the hand-sutured [0.08±0.06 vs. 0.26±0.07 mm, respectively; P<0.01].

Conclusions: This study demonstrated the feasibility of the connector to facilitate off-pump CABG on small caliber arteries. Patency rates were inferior but were related to a design change halfway the study. Provided that the technical limitations can be addressed, the presented concept of nonocclusive simplified anastomosis construction could fill the missing link toward expansion of minimally invasive CABG.

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CMP12 A New Suturing Device for Small Arteries

Ryoichi Kondo 1, Yoshifumi Itoda1, Hiroyuki Tsukihara1, Hiroshi Ashiba2, Etsuko Kobayashi2, Ichiro Sakuma2, Minoru Ono1. Departments of 1Cardiac Surgery and 2Precision Engineering, The University of Tokyo, Tokyo, Japan.

Objective: We developed a new suturing device that allows far easier performance of minimally invasive coronary artery bypass in comparison with conventional suturing methods (Fig. CMP12-1A–D). We have already showed no less efficacy and safety of this device than conventional suture in swine OPCAB model. In this experiment, we examined whether this device is superior to conventional suture under endoscopic environment.



Methods: A total of 18 rabbits were used in this study. The right carotid artery was bypassed using the jugular vein of the same side under endoscopic guidance. Of these, nine rabbits were operated on using the new devices (group D) and the other by using conventional polypropylene sutures (group C). Postoperative evaluations were performed at 1, 3, and 6 months after operations.

Results: The proximal anastomosis time was 14.9±3.6 minutes in group D and 21.3±7.0 minutes in group C (P<0.05). The distal suture time was 14.2±2.9 minutes in group D and 22.3±4.8 minutes in group C (P<0.05). The operation time was 106.6±12.1 minutes in group D and 136.6±11.8 minutes in group C (P<0.05). Graft flow was 21.8±4.8 mL/min in group D and 11.2±6.9 mL/min in group C (P<0.05). There are four occlusion cases in group D and three in group C. Graft flow at 1 month was 17.7±1.2 mL/min in group D and 5.3±5.3 mL/min in group C (P<0.05), but there were no significant differences at 3 and 6 months. Pathological findings revealed that there was no specific inflammatory reaction to the device.

Conclusions: The device that we developed was shown to be more effective than conventional suture under endoscopic environment. The device evoked no additional inflammatory change at the anastomoses.

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CMP13 Minimally Invasive CABG Is Safe and Durable: Ten-Year Results of the First Thousand Cases

Joseph T. McGinn, Jr 1, Masood A. Shariff1, Maria L. Rodriguez2, John P. Nabagiez1, Marc Ruel2. 1Staten Island University Hospital, Northwell Health, Staten Island, NY USA; and 2University of Ottawa Heart Institute, Ottawa, ON Canada.

Objective: Minimally invasive CABG (MICS CABG) is a nonrobotic, multivessel CABG performed via small left thoracotomy. Established in 2005, recent studies demonstrate recovery and freedom from infection advantages over OPCAB, a safe learning curve, and excellent graft patency. The purpose of this study was to evaluate the long-term outcomes from a combined two-center experience of the first thousand patients.

Methods: Patients (N=1078) underwent MICS CABG through a 4- to 7-cm thoracotomy in the left fourth or fifth intercostal space. The left internal thoracic artery was harvested under direct vision, proximal anastomoses were constructed on the ascending aorta, and all myocardial territories were accessed for distal anastomoses with an epicardial stabilizer and/or apical positioner. Patients were prospectively followed to evaluate overall survival, MACCE-free survival (cardiac death, nonfatal acute myocardial infarction, repeated target vessel revascularization, and stroke) and recurrence of angina.

Results: Patients were followed-up to a maximum of 10.5 years [mean (SD), 4.6±3.2]. At operation, mean (SD) patient age was 63.8±10.8 years and 253 patients (23.4%) were female. Diabetes was prevalent in 325 patients (30%), and 490 (45%) had significant triple vessel disease. A mean (SD) of 2.3±1.0 grafts were performed. Peripheral cardiopulmonary bypass without cardioplegic arrest was used in 124 patients (11%) with no major complication. There were 26 conversions (2.6%) to sternotomy. At mean follow-up, overall late survival after MICS CABG was 96.1%, MACCE-free survival was 93%, and 88% of patients were free from angina.

Conclusions: MICS CABG offers a safe and reproducible minimally invasive alternative in patients who require CABG. Survival and durability are comparable with conventional CABG with a low rate of complications and conversion to sternotomy.

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C8 Mei Mini Maze Procedure: Five-Year Experience of Consecutive 353 Patients in Single Center

Ju Mei, Nan Ma, Zhaolei Jiang, Hao Liu, Jiaquan Zhu. Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.

Objective: Mei mini maze procedure was a new thoracoscopic ablation procedure for atrial fibrillation (AF), which was performed on the beating heart through three ports in the left chest wall. Here, we reported the five-year experience of Mei mini maze procedure for AF.

Methods: Between June 2010 and May 2015, 353 patients (240 males, 59.7±8.5 years) of AF (paroxysmal 186, nonparoxysmal 167) received this therapy. The procedure was performed through three ports (10, 10, 25 mm) on left chest wall, included pulmonary vein isolation and ablations of the roof and posterior wall of left atrium, which were achieved by bipolar radiofrequency ablation. Ganglionic plexus ablation was made by the ablation pen. Left atrial appendage was excluded with surgical stapler. Twenty-four–hour Holter monitoring was performed at discharge and 3, 6, 12 months postoperatively as well as every year thereafter.

Results: The procedure was performed successfully for all patients. Average duration of procedure was 92.3±19.1 minutes. No conversion to sternotomy or thoracotomy. There was no early death and permanent pacemaker implantation in perioperation. Mean hospital stay was 8.5±2.1 days. The maintenance of sinus rhythm was 94.1% (332/353) at discharge. At a mean follow-up of 25.0±15.1 months, full follow-up was available for 342 patients (97.2%). There was no late death. Of 342 patients, 308 (90.1%) were in sinus rhythm. The maintenance of sinus rhythm was 93.3% (168/180) for paroxysmal AF, 87.9% (80/91) for persistent AF, and 84.5% (60/71) for long-standing persistent AF. Mean (SD) rate of cumulative maintenance of sinus rhythm at 2 years postoperatively was 92.4±2.4% for paroxysmal AF, which was significant higher than that of persistent AF [86.2±4.4%, P=0.036] or long-standing persistent AF [81.8±5.4%, P=0.014]. There was no significant difference of cumulative maintenance of sinus rhythm between persistent AF and long-standing persistent AF (P=0.645). Stroke, thrombus in the left atrium, and stenosis of pulmonary vein were not found after their procedures.

Conclusions: Our results demonstrate that Mei mini maze procedure is a safe, effective, and appropriate treatment for AF, which may be also associated with the prevention of AF-related stroke.

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C9 Minimally Invasive Cox-Maze Procedure Is as Effective as Median Sternotomy Approach

Matthew R. Schill, Laurie A. Sinn, Richard B. Schuessler, Hersh S. Maniar, Ralph J. Damiano, Jr. Washington University in St. Louis, Saint Louis, MO USA.

Objective: The Cox-Maze IV procedure (CMIV) has been shown to be an effective treatment for atrial fibrillation (AF) when performed concomitantly with other cardiac operations via median sternotomy (MS) or minimally invasive right minithoracotomy (RMT). Few studies have compared these approaches in patients with lone AF. This study examined short- and long-term outcomes with MS versus RMT in stand-alone CMIV at a single institution.

Methods: Between January 2002 and October 2015, 195 consecutive patients underwent stand-alone biatrial CMIV. Right minithoracotomy was used in 75 patients, MS in 120. Data were prospectively collected and retrospectively analyzed. Outcomes were evaluated using the χ2 test, Fisher exact test, and the Kruskal-Wallis test. Freedom from AF was ascertained using EKG, Holter, or pacemaker interrogation at 3, 6, 12, 24, 36, 48, and 60 months. Predictors of recurrence were determined using multivariable logistic regression.

Results: Of 17 preoperative variables examined, the only significant differences were that RMT patients had a higher rate of NYHA 3/4 symptoms and a lower rate of previous stroke. The RMT and MS patients had similar AF duration (84 vs. 67 months, P=NS) and AF type (26/75 vs. 29/120 paroxysmal, P=NS). The RMT patients had a slightly smaller LA diameter (4.5 vs. 4.8 cm, P=0.03). There was a higher rate of box lesion completion in RMT patients (73/75 vs. 100/120, P=0.002). The RMT patients had a shorter hospital stay (7 vs. 8 days, P=0.009) and a similar rate of major complications [3/75 (4%) vs. 7/120 (6%), P=0.74]. There were no differences in intensive care unit stay or 30-day mortality or in freedom from AF without antiarrhythmic drugs (Fig. C9-1). Significant predictors of AF recurrence at 12 months included a preoperative pacemaker, failure to isolate the posterior left atrium, and NYHA 3/4 symptoms.



Conclusions: In our experience, lone CMIV via RMT is as effective as MS with a shorter hospital stay. Expanded use of a minimally invasive approach is encouraged and is our procedure of choice for lone AF.

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C10 Clinical Results of Thoracoscopic Surgery in Nonvalvular Atrial Fibrillation

Toshiya Ohtsuka, Mikio Ninomiya, Takahiro Nonaka, Motoyuki Hisagi. Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.

Objective: We report stroke prevention and rhythm control by our thoracoscopic surgery in nonvalvular atrial fibrillation.

Methods: Four subaxillary thoracoscopic ports were made for the technique. The left atrial appendage was closed with an endoscopic cut-and-staple device; bilateral pulmonary veins and superior vena cava isolations were carried out with a bipolar radio-frequency epicardial ablation clamp. Anticoagulation immediately discontinued unless the patients had other thromboembolic risks. Periodical Holter electrocardiography and neurological checkups were conducted.

Results: Starting in 2008, 522 patients [men, 292 (56%)] were operated by a single surgeon. A total of 352 [paroxysmal, 218; nonparoxysmal, 134; mean (SD) age, 65 (9) years; mean CHA2DS2-Vasc score, 2.1; mean HAS-BLED score, 1.5] chose appendectomy plus ablation, whereas 170 [paroxysmal, 28; nonparoxysmal, 142; mean (SD) age, 74 (5) years; mean CHA2DS2-Vasc score, 4.6; mean HAS-BLED score, 3.3] chose appendectomy alone. The mean operative time was 77 minutes for the appendectomy plus ablation and 28 minutes for the appendectomy alone. In 12 patients (23%), thoracoscopy was switched to minithoracotomy approach. Cardio-pulmonary bypass was prepared and used in one case with complicated heart anomaly. Blood loss was less than 50 mL in all except five (1%); none underwent blood transfusion. The mean hospital stay was 5.8 days after the appendectomy plus ablation and 3.9 days after the appendectomy alone. There was no hospital death and no major complications, such as stroke, phrenic nerve palsy, and serious pneumonia. Cardiotomy-associated pericarditis was observed in 24 patients (4.6%). Three patients (0.6%) underwent pace-maker implantation. During the follow-up period [mean (SD), 35 (25) months], seven patients (1.3%) died and two (0.4%) suffered coronary artery ischemia. Only nine (1.7%) continued oral anticoagulation. All-cause neurological symptom occurred in 12 patients, but only three patients suffered cardiogenic stroke (Fig. C10-1). Five years after surgery, Holter electrocardiography documented continuous sinus rhythm in 90% of the paroxysmal and 71% of the nonparoxysmal cases.



Conclusions: Our thoracoscopic surgery is safely achievable and provides satisfactory anticoagulation-free brain protection and acceptable rhythm-control in nonvalvular atrial fibrillation.

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CMP14 Redo VATS Epicardial Atrial Fibrillation Ablation in Patients With Previous Cardiac Surgery

Gansevoort H. Dunnington, Jr, Carolyn Pierce. St Helena Hospital, St Helena, CA USA.

Objective: Previous cardiac surgery is considered a contraindication to VATS epicardial atrial fibrillation (afib) ablation by most surgeons. It may be a feasible option for some patients with challenging afib as part of a hybrid ablation strategy.

Methods: A retrospective review of 186 VATS afib ablation patients at our institution, from April 13, 2013, to November 4, 2015, revealed 12 patients who have had previous cardiac surgery. Patients underwent bilateral VATS epicardial ablations as planned first phase procedures of a hybrid Maze, where endocardial ablation would be performed at a later stage. Rhythm monitoring was performed by 1- to 2-week long-term monitors at 3-month, 1-year, and 2-year time points.

Results: Of 186 VATS afib ablations done at our institution since April 2013, 12 patients have had previous cardiac surgery (Table CMP14-1). Six of these patients have had previous CABG, whereas the other six have had noncoronary surgery. All patients were restored to normal sinus rhythm (NSR) at the conclusion of the procedure. Of 12 patients, eight have had second stage endocardial ablation to complete hybrid Maze, and all eight of these are currently in NSR at mean follow-up of 424 days. All patients had their left atrial appendage closed during the procedure. There was one mortality in the perioperative period because of multiorgan failure. There have been no strokes or TIA’s in the postoperative period, despite all patients being off anticoagulation. None of the patients required blood transfusion nor conversion to open sternotomy or thoracotomy.



Conclusions: Redo VATS afib ablation after previous cardiac surgery is feasible in the hands of experienced surgeons. Results can be excellent when combined with endocardial ablation for a hybrid approach. Patients should be carefully selected, because these cases are more technically challenging than nonredo cases.

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CMP15 Long-term Follow-up After Minimally Invasive Surgical Ablation for Stand-alone Atrial Fibrillation

Gianluigi Bisleri, Fabrizio Rosati, Lorenzo Di Bacco, Laura Giroletti, Claudio Muneretto. University of Brescia Medical School, Brescia, Italy.

Objective: Minimally invasive surgical treatment of atrial fibrillation (AF) has gained popularity during the past decade; however, there is paucity of data about the long-term outcomes of this novel approach.

Methods: Study population included 125 consecutive patients undergoing standalone surgical treatment of AF via a closed-chest, right-sided monolateral thoracoscopic approach (box lesion set) by means of a versapolar (combining unipolar/bipolar) radiofrequency ablation device. Mean (SD) age was 62.5±10.4 years, and the prevalence of paroxysmal, persistent, and long-standing (LS-persistent) AF was 37.6%, 11.2%, and 51.2%, respectively, with a median AF duration of 60 months. Mean (SD) left atrial anteroposterior diameter was 48.6±8.6 mm.

Results: The procedure was successfully accomplished via an endoscopic approach in all patients except one requiring conversion to ministernotomy. Hospital mortality was 0%, and no major complications occurred during the postoperative hospital stay except for a thromboembolic event occurring in two patients (1.6%). Multivariate Cox regression analysis identified LS-persistent AF [odds ratio (OR), 9.5; confidence interval (CI), 2.5–35.4; P=0.001] and female sex (OR, 3.03; CI, 1.06–8.7; P=0.039) as independent risk factors for AF recurrence; instead, paroxysmal AF was associated with improved rhythm outcomes (OR, 0.12; CI, 0.04–0.36; P<0.001). At a median follow-up of 60 months, overall stable sinus rhythm was achieved in 79.2% (99/125 pts; paroxysmal 91.5%, 43/47 pts; persistent 78.6%, 11/14 pts; LS-persistent 70.3%, 45/64 pts). Finally, there was a trend toward the stabilization of rhythm over the follow-up time, as depicted by Spearman analysis showing a positive correlation among sinus rhythm restoration and follow-up duration (ρ=0.82).

Conclusions: Totally endoscopic AF surgical ablation (box lesion) is a safe and effective procedure providing excellent and stable results over time at long-term follow-up. Rhythm outcomes in patients with LS-persistent AF may be further improved with an integrated hybrid approach.

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CMP16 Early Operative Comparison of Two Epicardial Left Atrial Appendage Occluding Systems Applied During Off-Pump Coronary Revascularization

Grzegorz Suwalski 1, Robert Emery2, Leszek Gryszko3, Kamil Kaczejko3, Emilia Frankowska3, Arkadiusz Zegadlo3, Andrzej Skrobowski3. 1Military Institute of Health Service, Warsaw, Poland; 2Department of Cardiac Surgery, Saint Joseph’s Hospital, Minnesota, MN USA; and 3Military Institute of Medicine, Warsaw, Poland.

Objective: Atrial fibrillation (AF) increases long-term mortality and stroke rate in patients having coronary artery bypass grafting (CABG). Because oral anticoagulation (OAC) is associated with both a significant incidence of discontinuation and well-known complication rates, left atrial appendage occlusion might be beneficial for stroke prevention. This study compares two epicardial left appendage occluders accruing experience in application during off-pump coronary revascularization in patients with persistent AF.

Methods: Twenty-two consecutive patients with persistent AF were assigned to intraoperative LAA occlusion with either Tiger Paw System II (n=11) or AtriClip (n=11) device during off-pump CABG and concomitant left atrial epicardial ablation. Both systems were analyzed in terms of ease and safety of application along with intraoperative LAA occlusion success.

Results: Surgical risk was increased in the study population [mean (SD) EuroSCORE II, 3.2±0.3%]. In all patients in AtriClip group, successful off-pump LAA occlusion confirmed by intraoperative transesophageal echocardiography was achieved. Tiger Paw application was generally quicker and easier; however, in two patients, application was not successful. During the hospital stay, there were no bleeding or thromboembolic events recorded.

Conclusions: Epicardial LAAC during off-pump CABG in patients with persistent AF can be easily, safely, and successfully performed with both presented devices, but it seems that Tiger Paw system requires technological improvement. It might be useful to adapt the use of the type of occluding device to LAA morphologic type and target revascularization vessels to avoid the additional use of a heart positioner use or obviate coronary compression.

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CMP17 Caval Occlusion Improves Performance of Beating Heart Epicardial Radiofrequency Ablation

Yoshiyuke Watanabe1, Matthew R. Schill 2, Toshinobu Kazui3, Richard B. Schuessler2, Ralph J. Damiano, Jr2. 1Nippon Medical School, Tokyo, Japan; 2Washington University in St. Louis, Saint Louis, MO USA; and 3University of Arizona, Tucson, AZ USA.

Objective: Reliably creating transmural linear lesions on the beating heart using an epicardial approach is an important component of minimally invasive surgical ablation for atrial fibrillation. However, previous studies have shown this to be extremely difficult, primarily because of the heat sink effect of the circulating intracavitary blood. The purpose of this study was to evaluate the effect of vena caval occlusion on the efficacy of linear surface bipolar radiofrequency ablation on the beating heart.

Methods: Six pigs were anesthetized. Median sternotomy was performed. With the use of a surface bipolar ablation device and an epicardial approach, two 40-second ablations were performed on the right atrium of each pig. Ablations were performed with the normal caval blood flow and with vena caval occlusion (VCO). Ultrasonic flow probes were used to verify occlusion. The animals were then killed. The hearts were removed and stained with 2,3,5-triphenyl-tetrazolium chloride. Each section was examined for lesion depth and transmurality using digital photography and custom software. Student t test, Fisher exact test, and χ2 test were used for statistical analysis.

Results: With VCO, 42 (81%) of 52 lesions were transmural; however, without caval occlusion, only 12 (24%) of 50 lesions were transmural (P<0.01, Fig. CMP17-1). In thick (>2 mm) tissue, 10 (59%) of 17 VCO sections were transmural compared with only 2 (8%) of 24 with normal caval blood flow. In thin (<2 mm) tissue, 32 (91%) of 35 VCO lesions were transmural compared with 10 (42%) of 24 without VCO.



Conclusions: In an acute animal model, caval occlusion improved the efficacy of linear surface bipolar ablation on the beating heart. Maneuvers that lower intracavitary blood flow such as caval occlusion and cardiopulmonary bypass should improve the efficacy of beating heart epicardial RF ablation and thus improve outcomes in minimally invasive atrial fibrillation ablation.

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CMP18 Initial Results of a Two-Staged Hybrid Procedure in Patients With Long-standing Persistent Atrial Fibrillation

Niels Verberkmoes, Khibar Salah, Daily Krijnen, Sabine Eijsbouts, Pepijn van de Voort, Bart van Straten. Catharina Hospital, Eindhoven, the Netherlands.

Objective: Two-staged hybrid procedure combines a bilateral totally thoracoscopic maze procedure (TT-maze), followed by endocardial transcatheter ablation if required. We present our initial results with this treatment strategy in patients with long-standing persistent atrial fibrillation (LSPAF).

Methods: Study population consisted of patients with symptomatic LSPAF (mean duration 3.6±2.8 years) who underwent a TT-maze procedure between August 2013 and July 2015. Totally thoracoscopic maze procedure consisted of bilateral pulmonary vein isolation, roof and floor lesions, trigone line, ganglionated plexi ablation, and left atrial appendage amputation. Endocardial transcatheter ablation was performed within 90 days in patients with recurrent arrhythmias. Primary endpoints were sinus rhythm and freedom from symptoms at 90 and 180 days post–TT-maze. Follow-up was performed by electrocardiogram and Holter monitoring.

Results: From 51 patients, 33 were male, median age 63 years (IQR 56–70), mean BMI 29.5±4.0 kg/m2 and mean left atrial volume index 41.8±11.5. Seventeen patients (33.3%) had a history of previous endocardial ablation. Surgical complications were perioperative bleeding (n=2, 3.9%), pacemaker (PM) implantation (n=1, 2.0%), pulmonary vein stenosis (n=1, 2.0%), and pneumothorax (n=4, 7.8%). No deaths or thromboembolic events occurred. Subsequently, 7 patients (13.7%) underwent endocardial ablation as part of the treatment strategy. Complete follow-up at 90 and 180 days were respectively 98% and 76% with respectively 80% (n=40/50) and 85% (n=33/39) of patients in sinus rhythm.

Conclusions: The collaborative approach to the treatment of atrial fibrillation between cardiac surgeons and electrophysiologists showed excellent initial results at 90 and 180 days for patients with LSPAF. This strategy has the advantage that endocardial ablation is not required in all patients.

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CV4 Concomitant Cox Maze IV Ablation Procedure Performed Entirely by Bipolar Clamp Through Right Lateral Minithoracotomy

Ju Mei, Zhaolei Jiang, Nan Ma, Hao Liu, Fangbao Ding, Chunrong Bao. Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.

Objective: The aim of the study was to introduce the technique of performing concomitant Cox Maze IV ablation procedure entirely by bipolar clamp through right lateral minithoracotomy for patients with atrial fibrillation associated with mitral valve diseases.

Methods: Ablation procedure was performed through right lateral minithoracotomy entirely by bipolar radiofrequency clamp as follows: a 6-cm right lateral incision was made over the fourth intercostal space. After peripheral cardiopulmonary bypass was established, tissues between pericardial transverse and oblique sinuses were bluntly dissected. Then, one 16-Fr catheter was placed inferior to the left pulmonary veins (PVs), and another catheter was placed superior to the left PVs. Both of the two catheters were connected to the upper and lower jaws of the bipolar clamp and used to guide the clamp to clamp and ablate the left PVs. Then, ablation line around right PVs, ablation line from the right superior PV to the left superior PV; ablation line from the right inferior PV to the left inferior PV; ablation line from the right inferior PV to the mitral valve annulus; excision of the left atrial appendage; ablation line from the base of left atrial appendage to the left superior PV, and right atrial ablation were performed.

Results: All patients successfully underwent this minimally invasive concomitant Maze IV ablation procedure and mitral valve surgery. The mean cardiopulmonary bypass time was 130.3±17.7 minutes. The mean aortic crossclamp time was 91.8±12.7 minutes. No patient needed conversion to sternotomy during the surgery. There was no early death or pacemaker implantation in the perioperation. The average length of hospital stay was 9.8±3.3 days. At discharge, 65 patients (65/69, 94.2%) maintained sinus rhythm. At a mean follow-up time of 21.0±8.6 months, sinus rhythm was restored in 62 patients (62/69, 89.9%). Cumulative maintenance of normal sinus rhythm without atrial fibrillation recurrence at 2 years postoperatively was 85.1±5.8%.

Conclusions: This procedure is safe, feasible, and effective. This procedure did not require an additional unipolar or cryothermal energy device for completing all ablation lines, which may reduce costs. Therefore, this technique deserves further usage and implementation.

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CMP19 Hybrid Approach in Transvenous Laser-Assisted Extraction of Pacemaker and Defibrillator Leads: The Alliance Between Cardiac Surgeon and Electrophysiologist

Alberto Repossini, Laura Giroletti, Gianluigi Bisleri, Lorenzo Di Bacco, Fabrizio Rosati, Luca Bontempi, Antonio Curnis, Claudio Muneretto. University of Brescia Medical School, Brescia, Italy.

Objective: The laser-assisted extraction of chronically implanted pacemaker (PM)/defibrillator leads have reduced the necessity of surgical open removal of devices, minimizing the invasiveness of the procedure. However, major complications included right atrial injury, vena cava laceration, or disruption could be life-threatening requiring emergent surgery with high risk of mortality. A hybrid approach to leads extraction has been developed by associating of right minithoracotomy/thoracoscopic access to visualized cardiac structure during the transvenous procedure. The aim of this study was to evaluate safety and efficacy of this strategy to reduce perioperative complications.

Methods: Between January and December 2015, 16 patients (44% males, mean age 72±11 years) underwent hybrid leads laser-assisted extraction procedure for pocket/system infection (11 patients) or leads malfunctioning (five patients). For each patient, a Lead Extraction Difficulty (LED) index has been assessed with the following criteria: age of the oldest and number of leads, presence of coil defibrillator, and absence of vegetations. In case of LED index of greater than 10, the procedures were considered as a high risk and a hybrid approach was performed. A right anterior minithoracotomic/ thoracoscopic access was performed in hybrid room, and lead extraction was conducted under direct control. In case of pacemaker dependency (12 patients), previous transvenous PM implantation was performed in five patients. Permanent epicardial PM was placed on left ventricle through left minithoracotomy during leads extraction in three patients or before in four patients.

Results: Complete lead removal was achieved in all patients. Superior vena cava laceration at level of right atrial junction occurred in two patients. Bleeding was immediately controlled, and injury was repaired under direct vision without emergency sternotomy and cardiopulmonary bypass. Hospital mortality was 0%. A mild pericardial effusion without hemodynamic significance was reported in three patients but did not require pericardial drainage. No wound complication was reported.

Conclusions: In our early experience, hybrid approach to laser-assisted leads extraction has been proven a safe and efficacy strategy to prevent emergent treatment of any major complications, mainly in patients with high LED index. A very small minithoracotomy or thoracoscopic access avoids the need of full sternotomy, minimizing postoperative complications and hospitalization period.

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CMP20 Minimally Invasive Lead Extraction Post Heart Transplant: Avoiding Abandoned Lead Fragments

Samer Hakmi, Simon Pecha, Osamh Noor, Alexander Bernhardt, Markus Barten, Florian Wagner, Hermann Reichenspurner. University Heart Center Hamburg, Hamburg, Germany.

Objective: Most of the heart failure patients are waiting for heart transplant (HTX) and have a cardiac implantable electronic device (CIED). Device and lead removal are still a part of the HTX procedure. This study sought to assess the incidence of complete lead removal in HTX patients. Abandoned lead fragments carry a high risk for infections and prohibit magnetic resonance imaging. We therefore propose an appropriate minimally invasive lead management algorithm.

Methods: Between February 2009 and September 2015, 90 consecutive patients underwent HTX at our center. The study population included 80 patients (88.9%) with previously implanted cardiac implantable electronic devices. Lead removal was performed by simple traction during HTX. To achieve complete lead removal, abandoned lead fragments were removed in some cases electively under fluoroscopic guidance using extraction sheath at a later time.

Results: Patients were 50.8±12.1 years of age (range 17–68), and 85% were men. Eighty-two devices (VVI-PM: 3, DDD-PM: 2, CRT-P: 3, VVI-ICD: 25, DDD-ICD: 13, CRT-D: 34, CCM: 2) were removed. One hundred ninety-one leads were attempted with a mean implant duration of 33.2±39.2 months (range 0.9–268.3). The rate of dual coil ICD leads was 75%. Complete lead removal was only achieved in 48 patients (60%). Postoperative x-ray revealed abandoned intravascular lead fragments in 24 patients (30%). Later on, in five cases, the abandoned lead fragments were completely removed using lead locking devices and excimer laser sheaths. No lead removal related vascular complication occurred.

Conclusions: The results indicate that pacing and defibrillation leads should be removed after HTX using appropriate minimally invasive lead extraction techniques. Moreover, the use of extraction tools during HTX under fluoroscopic guidance is not always possible. The removal of all lead material is obvious because of infection risk due to lifelong immunosuppressive therapy. In addition, abandoned lead fragments limit magnetic resonance imaging application.

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C11 Mitral Bridge Implantation Eliminates and Prevents Early Recurrence of Mitral Regurgitation in Patients With Ischemic Mitral Regurgitation

Stepan Cerny 1, Valavanur A. Subramanian2, Nirav Patel3, Miroslava Benesova1, Ivo Skalsky1, Katerina Mzourkova1. 1Na Homolce Hospital, Prague, Czech Republic; 2Heart Repair Technologies Inc, Morgan Hill, CA USA; and 3NSHS - Lenox Hill Hospital, New York, NY USA.

Objective: Indirect reduction of septolateral diameter (SLD) by circumferential cinching with ring annuloplasty results in high early recurrence of mitral regurgitation (MR) in patients with ischemic MR (IMR). A novel, dynamic, nitinol mitral bridge (MB) across the mitral annulus, which achieves a nonplanar direct reduction of SLD with preservation of the leaflet curvature, is currently under clinical CE Mark trial, which includes 34 patients with type 1 and 3 MR. This study examines the effect of this device in a subgroup of eight patients with moderately severe (3+) and severe (4+) IMR.

Methods: Implantation of mitral bridge as an exclusive mitral valve repair technique was done in all patients under cardiopulmonary bypass with arrested heart. Concomitant procedures included coronary artery bypass (7), tricuspid valve repair (2), and CryoMAZE procedure (3). Implantation was rapid with three sutures at each midpoints of anterior and posterior mitral annulus. Serial clinical and echocardiographic follow-up (F/U) was done at baseline, 1 month, 3 months, and 6 months. Mean (SD) age of patients was 67.5±5.52 years, mean (SD) left ventricular ejection fraction was 44.4±10.4%, and mean (SD) left ventricular end diastolic diameter was 55.37±7.55 mm.

Results: All patients had freedom from MACE (death, myocardial infarction, stroke, reoperation, and device related adverse events) at 6-month F/U. Echocardiographic F/U showed a significant reduction of the mean (SD) grade of MR from 3.5±0.5 to 0.0±0.0 (P<0.0001), SLD from 39.5±2.7 mm to 29.1±2.1 mm (P<0.0001), increase in coaptation height from 4.0±1.3 mm to 7.9±1.1 mm (P<0.0001), and reduction in coaptation depth from 6.25±2.25 mm to 2.38±1.8 mm (P=0.004) at 6-month F/U (Fig. C11-1).



Conclusions: Mitral bridge implantation as the exclusive repair technique eliminates and prevents early recurrence in IMR at 6-month F/U. This is achieved by direct SLD reduction, normalization of coaptation depth, increasing the coaptation height, preservation of leaflet curvature, and annular function without any progressive annular dilatation. These encouraging results are in direct contrast to the results of ring annuloplasty in IMR patients, and this thus warrants further studies in a larger group of patients.

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CV5 Preclinical Evaluation of an Automated Minimally Invasive Mitral Valve Repair Technique

Joshua K. Wong 1, Amber L. Melvin1, Devang J. Joshi1, Heather R. Gorea2, Angelo J. Martellaro2, Jude S. Sauer2, Peter A. Knight1. 1University of Rochester Medical Center, Rochester, NY USA; and 2LSI Solutions, Victor, NY USA.

Objective: Mitral valve (MV) repairs remain technically challenging, particularly during minimally invasive cardiac surgery procedures. Technologies that enable the rapid, reliable, and complete surgical repair of a diseased MV without causing significant trauma to the chest wall may enable improved surgical outcomes. This preclinical study evaluates an automated minimally invasive cardiac surgery MV repair technique, employing new technologies for placing and securing artificial chordae and mitral annuloplasty suture.

Methods: This automated technique incorporates a dual curved needle suturing device for placing artificial chordae using expanded polytetrafluoroethylene suture through the mitral leaflet and subsequently through the papillary muscle. A specialized titanium fastener (TF) crimped at the base of the papillary muscle reliably secures the replacement chordae at a desired length that can be determined during real-time infusion testing. A 2-0 polyester suture is then remotely placed around the mitral annulus using a single curved needle suturing device to secure an annuloplasty ring or band. The feasibility of this MV repair technique was studied in multiple bench-top and cadaver models. In accordance with institutional guidelines, chordae replacements and TF healing were also evaluated in sheep. Mitral regurgitation was induced in both the animal and cadaver models by the transection of one to two native chordae. Repairs were directly assessed using saline infusion testing for MV competence and in sheep, via epicardial echocardiography.

Results: The repair technique was evaluated in 10 ex vivo porcine hearts and proved feasible. Artificial chordae were successfully placed in two male sheep. One animal was survived for healing analysis; trace mitral regurgitation was noted using saline infusion and on intraoperative echocardiography. Reoperation at 6 weeks noted an intact and partially endothelialized artificial chord and TF without damage to surrounding structures. Effective and ergonomic automated MV repairs were also demonstrated in two cadavers.

Conclusions: This automated MV repair technique was successfully tested and demonstrated in a variety of preclinical surgical models. It reliably places and remotely secures artificial mitral chordae and annuloplasty suture and can minimize the technical difficulties frequently associated with less-invasive mitral surgery. This research encourages further development and potential investigation in human clinical trials.

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C12 Redo Mitral and Tricuspid Valve Surgery: Comparison of Robotic Endoscopic Approach to Redo Sternotomy and Right Thoracotomy

Emmanuel Moss 1, Michael E. Halkos2, Jose N. Binongo2, Douglas A. Murphy2. 1Jewish General Hospital, McGill University, Montreal, QC Canada; and 2Emory University, Atlanta, GA USA.

Objective: The aim of the study was to compare perioperative outcomes in patients with previous sternotomy undergoing mitral valve surgery via redo sternotomy, right thoracotomy, or lateral endoscopic approach using robotics (LEAR).

Methods: From 2006 to 2013, 291 patients with a history of previous sternotomy surgery underwent reoperative isolated mitral ± tricuspid valve surgery at a single US academic institution. Propensity scoring was used to compare in-hospital and 30-day outcomes between the LEAR technique and sternotomy or thoracotomy approaches.

Results: Of 291 patients, 151 (51.9%) had a repeat sternotomy, 71(24.4%) had a right thoracotomy approach, and 69 (23.7%) had a LEAR approach. Composite outcome of death or stroke was 5.8% (n=4) with the LEAR technique, compared with 6.6% (P=0.9) and 11.3% (P=0.3) in the sternotomy and thoracotomy groups, respectively. Cardiopulmonary bypass and aortic occlusion times in the LEAR group [139.8±53.3 and 87.8±37.0 minutes, respectively] were similar to the sternotomy group [131.1±49.3 and 97.2±39.9 minutes, respectively] but were significantly shorter compared with the thoracotomy group [163.6±54.7 minutes, P=0.01, and 129.1±60.7 minutes, P<0.001, respectively]. After propensity adjustment, the LEAR technique was associated with a shorter hospital and intensive care unit length of stay (P<0.01) compared with sternotomy and fewer perioperative blood transfusions compared with both sternotomy and thoracotomy (37.7% vs. 83.4% and 77.5%, P<0.01, respectively) (Table C12-1). Mitral valve repair rates were significantly higher with the LEAR technique (66.7%) compared with sternotomy (11.3%, P<0.001) and thoracotomy (5.6%, P<0.001).



Conclusions: Mitral valve repair or replacement after a previous sternotomy can be performed effectively using the LEAR technique with low morbidity and mortality and is associated with fewer transfusion requirements and a higher repair rate compared with sternotomy and thoracotomy techniques.

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CMP21 Novel Direct Annuloplasty Fixation System for Minimally Invasive Mitral Valve Repair

Joshua L. Chan, Ming Li, Dumitru Mazilu, Justin G. Miller, Keith A. Horvath. National Institutes of Health, Bethesda, MD USA.

Objective: Mitral valve repair is an effective therapeutic option for mitral regurgitation. The development of less invasive approaches that additionally avoid the need for cardiopulmonary bypass and cardioplegia remains an important objective, particularly in patients with multiple comorbidities. Here, we describe a novel method and system to deploy strap fixators to affix a commercially available mitral valve annuloplasty ring in a minimally invasive manner.

Methods: A delivery apparatus for an annuloplasty fixator system was designed. Two channels were created, one for advancing the mitral annuloplasty ring, with the second channel designed to hold the fixator device. U-shaped strap fixators were primed within the fixator device, and automatic alignment of these fixators was achieved to allow accurate firing of the fasteners securing the ring. The delivery apparatus was constructed to be deployed within a trocar through a left atrial approach.

Results: With the use of swine heart as an ex vivo model, access to the mitral valve from the left atrium was obtained. The delivery apparatus was advanced, and placement of six strap fixators equidistant along the annular plane was performed for each annuloplasty ring. Subsequent postprocedural testing revealed that the use of the strap fixator system achieved significant fixation force; a considerable magnitude of force was required to detach the ring (mean force, 420.83 g; 95% confidence interval (CI), 319.29–522.37 g). The annuloplasty ring remained intact and did not experience any structural deformity during fixation process.

Conclusions: The use of a novel strap fixator system was successful in deploying and securing a mitral valve annuloplasty ring. These promising results may have further application for minimally invasive mitral valve repairs. Further evaluation of this procedure with in vivo animal studies is necessary.

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CMP22 Shifting From Minimally Invasive to Periareolar Endoscopic Access for Mitral Valve Surgery

Giacomo Bianchi, Rafik Margaryan, Marco Solinas. Ospedale del Cuore - Fondazione Toscana “G. Monasterio,” Massa, Italy.

Objective: The aim of the study was to evaluate performance of a well-established minimally invasive cardiac surgery program using single-incision minimally invasive mitral valve surgery (sMIMVS) shifting to endoscopic mitral surgery with periareolar access.

Methods: In July 2015, 23 patients (male, 86%) underwent endoscopic mitral surgery with periareolar access in men or a 2-cm incision in the submammary groove in women. We evaluated the timing of surgical steps of endoscopic approach and compared retrospectively with 38 patients (male, 47%) who underwent sMIMVS in May 2015 from the same surgical team.

Results: Time from skin incision to heparin was significantly lower in endoscopic approach [18.3±6.1 vs. 23.1±8.5, P=0.03], whereas no differences were found in cannulation time (P=0.65); interestingly, time to cross-clamp was higher in endoscopic approach [27±10.6 vs. 13.3±6.7, P<0.01]. Cardiopulmonary bypass and aortic cross-clamp were significantly longer in endoscopic approach [154±36 vs. 117±40, P<0.01, and 98±25 vs. 74±26, P<0.01]. No differences were found in mechanical ventilation time (6 hours vs. 5 hours, P=0.42) and intensive care unit stay [1.3±0.7 days vs. 1.4±1.1 days, P=0.67], whereas hospital length of stay equal or less than 6 days is in favor of endoscopic access (78% vs. 58%, P<0.01). Conversion to sternotomy occurred in one patient in the endoscopy group and in two patients in the sMIMVS group (P=NS); no conversion occurred because of poor exposition or difficulties in mitral valve repair. There was one in-hospital death in the sMIMVS group (P=NS).

Conclusions: Although initial experience with endoscopic mitral valve surgery is associated with prolonged CPB and cross-clamp time, these did not affect the outcome, reducing the hospital length of stay and ensuring equal repair rate of a well-established sMIMVS.

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CMP23 Robotic Mitral Valve Replacement: Six-Year Single-Center Experience and Follow-up Results

Changqing Gao, Ming Yang, Huajun Zhang, Cangsong Xiao, Yang Wu, Gang Wang, Yao Wang, Jiali Wang. PLA General Hospital, Beijing, China.

Objective: The aim of the study was to summarize the surgical experience with robotic mitral valve replacement (MVR) for the last 6 years and demonstrate the clinical follow-up results.

Methods: From 2008 to 2014, a total of 44 patients underwent robotic mitral MVR with da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA USA) in our center. Mean (SD) age of the patients was 45±13 years with male to female ratio of 0:9. Median heart function was NYHA class II and 46.5% had atrial fibrillation. Rheumatic mitral stenosis was diagnosed in 74.3% of the patients. Mechanical or bioprosthetic valve was replaced via left atriotomy. Radiopaque titan clips were applied by Cor-Knot knot-tying device (LSI Solutions, Inc, Victor, NY USA) to anchor the valve. The patients were followed-up at outpatient clinic regularly up to 6 years.

Results: All cases were performed successfully by the same surgeon. No conversion to median sternotomy or operative mortality occurred. The operation time was 292±62 minutes (ranged, 140–450 minutes) with CPB time of 125±27 minutes and aorta cross-clamping time of 88±21 minutes. The mechanical ventilation was continued for 15±6 hours postoperatively. No myocardial infarction, ventricular tachycardia, or excessive bleeding was complicated. All patients were successfully followed for a median of 4 years (range, 1 month–6 years). No death, stroke, and reoperation were reported, and 39.5% of the patients still had atrial fibrillation.

Conclusions: Robotic MVR is a safe and effective procedure with excellent long-term surgical outcome.

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CMP24 Two-Year Follow-up After 3D Ring Annuloplasty for Surgical Tricuspid Valve Reconstruction: Early and Midterm Experience in a Matched Pairs Analysis

Sumi Westhofen, Christian Detter, Hermann Reichenspurner, Florian Wagner. University Heart Center Hamburg, Hamburg, Germany.

Objective: Recurrent tricuspid regurgitation (TR) of more than 30% even in the early follow-up period after tricuspid valve annuloplasty (TVR) has been the impulse for further development of reconstructive agents. Three-dimensional (3D), recently introduced anatomically shaped 3D remodeling rings shall improve functional and hemodynamic results of TVR. We analyzed results achieved with a 3D ring and compared them with those of a 2D ring.

Methods: Since February 2013, 3D Contour rings were implanted in 100 patients with high-grade functional TR. We compared this group with an age, sex, and preoperative diagnoses matched group of 100 patients who received a 2D Physio Tricuspid ring focusing on functional and echocardiographic results at discharge 1- and 2-year follow-up. Tricuspid valve annuloplasty was combined with mitral valve surgery in 62% versus 72%; isolated TVR was performed in 32% versus 23%.

Results: Postoperative echo at discharge showed competent valves without any TR in 83% of patients in group 1, with all other patients with TR of 1 or less, and 75% without any TR in group 2, with 19% of patients with TR of 1 or less and 6% with TR of 2 or less (P=0.15). At 2-year follow-up, mean (SD) TR was 0.43±0.65 versus 0.62±0.92 (P=0.119) with 4% versus 12% of patients showing recurrent TR of 2 or greater in group 1 versus group 2 (P=0.008). Mean (SD) NYHA score after 1 year was 1.4±0.5 versus 1.7±0.5 (P=0.006) in group 1 versus group 2 and 1.4±0.6 vs. 1.9±0.4 (P=0.003) after 2 years, respectively. In group 1, RV function improved significantly from preoperative 37% with a moderate dysfunction to 24% after 2 years (P=0.04). In group 2, no significant improvement was seen (preoperative, 34%; 2 years, 33%). Concomitant atrial ablation was performed significantly more often in group 2 (60% vs. 37% in group 1, P<0.05); incidence of postoperative permanent pacemaker implantation was not significantly different between groups (26% vs. 23%, group 1 vs. group 2) nor was overall MACE at 1- and 2-year follow-up. Mortality after 2 years was 6% versus 5%.

Conclusions: Both tricuspid rings showed excellent repair results at discharge. At 1-year follow-up, patients in the 3D Contour ring group showed less significant recurrent TR, better RV function, and lower NYHA scoring.

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CMP25 Early Results of Minimally Invasive Aortic and Mitral Valve Surgery Through a Minithoracotomy

Antonio Lio, Antonio Miceli, Matteo Ferrarini, Mattia Glauber. Cardiac Surgery and Great Vessel Department, Istituto Clinico Sant’ Ambrogio, Milan, Italy.

Objective: Benefits of minimally invasive cardiac surgery have been recognized when compared with a median sternotomy approach. However, few experiences exist in minimally invasive mitral and aortic valve surgery (MIMAVS). We describe our experience with 69 patients who underwent aortic and mitral valve surgery through a right minithoracotomy.

Methods: A retrospective study was undertaken on 69 patients scheduled for MIMAVS through a right minithoracotomy from October 2012 to December 2014. A 5-cm incision was performed in the third intercostal space. Cardiopulmonary bypass (CPB) was established with central cannulation of the ascending aorta and a double-stage venous return cannula placed percutaneously into the right femoral vein.

Results: The most frequent type of MIMAVS was the replacement of aortic valve with mitral valve repair (35 patients, 50%). A sutureless aortic prosthesis was implanted in 48 patients (70%). Concomitant procedures were performed in the following 22 patients (32%): 12 tricuspid valve annuloplasty, eight atrial fibrillation ablation, and two septal myectomy. Mean (SD) CPB and cross-clamp times were 135±41 and 95±32 minutes, respectively. Introduction of sutureless aortic prostheses has increased the number of patients treated with a minimally invasive approach, with a significant reduction of CPB [120±23 minutes vs. 160±67 minutes in stented prosthesis, P<0.05] and cross-clamp times [85±19 minutes vs. 110±40 minutes in stented prosthesis, P<0.05]. Postoperatively, no patient died in hospital. A stroke occurred in two patients. Three patients required permanent pacemaker for heart block. Conversion to full sternotomy was required in one patient. Median intensive care unit and in-hospital stay were 1 and 6 days, respectively. No paravalvular leakage or prosthesis displacement was reported. (Table CMP25-1).



Conclusions: Minimally invasive mitral and aortic valve surgery is a feasible approach that could be implemented with the use of sutureless devices. Need for concomitant mitral valve surgery is not contraindication for sutureless valve implantation.

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C13 Endovascular Management of Acute Ascending Aortic Pathology Using Transapical and Transcarotid Vascular Access

Keith B. Allen, A. Michael Borkon, Sanjeev Aggarwal, J. Russell Davis, Karthik Vamanan, Alex F. Pak, Eric Thompson. St. Luke’s Mid America Heart Institute, Kansas City, MO USA.

Objective: Thoracic endovascular aortic repair (TEVAR) of ascending aortic pathology is feasible; however, the unique features of this aortic segment in addition to access challenges restrict its use to a high-risk subset of patients. We describe transcarotid and transapical vascular access for the endovascular management of acute ascending aortic pathology.

Methods: Five patients with acute ascending aortic pathology at extreme risk for conventional surgery were managed with endovascular stent grafts using either transcarotid or transapical vascular access. Transapical ascending aortic TEVAR used a similar technique to transapical TAVR, and both modified and unmodified thoracic stents were used. During transcarotid access, surgical technique included delivery of abdominal aortic cuffs through direct exposure of the left common carotid artery with and without a conduit, modification/shortening of the delivery sheath, and intraoperative EEG to guide the need for femoral to carotid shunting during device delivery. In addition to demographics, endpoints in this retrospective review included operative details, procedural complications, and follow-up.

Results: Pathology included four patients with penetrating ascending aortic ulcers and one patient with a pseudoaneurysm in a previously grafted ascending aorta. Mean age was 86 years (range, 81–92 years). Vascular access was transapical (n=3) and left transcarotid (n=2); concomitant procedures included transapical TAVR for associated aortic stenosis (n=1) and transfemoral TEVAR for descending dissection/aneurysm (n=1). Procedural success was 100% without deaths or strokes. No transcarotid patient required femoral to carotid shunting. Median length of stay was 4 days (range, 3–8 days); all patients were discharged to home. With a median follow-up of 12 months (range, 2–20 months), survival remains 100% with no late carotid access complications and stable endografts without endoleaks by computed tomography (Fig. C13-1).



Conclusions: Endovascular management of ascending aortic pathology is feasible using both transapical and transcarotid vascular access. To our knowledge, these are the first reported cases using transcarotid access in the successful endovascular management of ascending aortic pathology.

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CMP26 Brachiofemoral Through-and-Through Wire Technique for Hybrid Arch Repair

Hidetake Kawajiri, Katsuhiko Oka, Osamu Sakai, Keiichi Kanda, Hitoshi Yaku. Kyoto Prefectural University of Medicine, Kyoto, Japan.

Objective: Retrograde endograft insertion from iliofemoral access is a standard maneuver during thoracic endovascular aortic repair. However, retrograde endograft insertion is still quite challenging when the aortic shape is “Gothic type” or when the elephant trunk is severely collapsed. In such cases, a brachiofemoral through-and-through wire technique is used.

Methods: Between June 2008 and October 2015, 55 patients underwent hybrid arch repair at Kyoto Prefectural University of Medicine and at four associated institutes. Of the 55 patients, the brachiofemoral through-and-through wire technique was used for 11 patients. Their mean age at procedure was 74.0±7.2 years, eight males, and three Kommerell diverticulum cases. Hybrid procedures were either type 1 (n=4) or type 2 (n=8). Gore TAG (W. L. Gore & Associates, Inc, Flagstaff, AZ USA) was used in all cases.

Results: Endografts were placed accurately in all patients. There were no 30-day mortality, symptomatic cerebral infarction, and paraplegia. No endoleaks were observed on postoperative CT scan. There was one in hospital death (cerebral hemorrhage), which was not associated with the procedure.

Conclusions: The brachiofemoral through-and-through wire technique is a simple and safe method when the retrograde endograft insertion is challenging. To avoid major postoperative cerebrovascular events, precise preoperative evaluation of the innominate artery is mandatory.

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CMP27 Open Elephant Trunk Versus Hybrid Technique for Complicated Type B Aortic Dissection Without Enough Landing Zone

Xin Chen. Nanjing First Hospital, Nanjing, Jiangsu, China.

Objective: The aim of the study was to compare the short- and mid-term results of open surgery and hybrid technique for the treatment of complex type B aortic dissection (AD) without enough landing zone.

Methods: A total of 38 cases of complex type B AD without enough landing zone were admitted. All cases were confirmed by CTA and were divided into two groups: open surgery group (OS group, 25 cases, antegrade stent-graft implantation under circulation arrest, and bypass LSCA to LCA) and hybrid group (HT group, 13 cases, LCA to CSLA bypass, and then transfemoral endovascular stent repair). Compare the short- and mid-term results of these two groups for complex type B AD.

Results: There was no death or any neurological complications in both groups. In the OS group, one patient with AKF needs CRRT, and his renal function was returned to normal before discharge; one patient underwent debridement surgery because of postoperative sternal dehiscence. In the HT group, two patients had recurrent chest pain, which CTA showed aortic arch and ascending aorta hematoma formation caused by dissected tear, and underwent frozen elephant trunk procedure immediately. CTA three months postoperatively showed that in OS group, the tear of AD was closed well by stent-graft, no leakage or shunt was detected in CTA, and the rate of thrombosis formation of the false lumen in descending thoracic aortic was 100%. However, in the HT group, one case had type 1 leakage, and the rate of thrombosis formation of false lumen in the descending thoracic aortic was only 76.92%.

Conclusions: For complicated type B AD, either open surgery or hybrid technique can achieve satisfactory short- and mid-term results. However, there are more advantages by open surgery than by hybrid technique.

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CMP28 Early Results of Thoracic Aortic Surgery Under Partial Sternotomy

Yosuke Inoue, Kenji Minatoya, Tatsuya Itonaga, Tatsuya Oda, Yoshimasa Seike, Hiroshi Tanaka, Hiroaki Sasaki, Junjiro Kobayashi. National Cerebral and Cardiovascular Center, Suita, Japan.

Objective: Partial sternotomy with limited skin incision has been used for cardiac surgery. With the establishment of the strategy for aortic arch surgery, the operative results have been remarkably improved in recent years. We, therefore, started to apply the partial sternotomy for aortic arch surgery since 2013 in selected cases. The aim of this study was to report the results of our early experiences.

Methods: Between July 2013 and December 2015, we retrospectively reviewed 23 cases [median (range) age, 70 (38–84), 16 males] who underwent aortic arch surgery through partial sternotomy. All aortic pathology was degenerative disease except for one chronic dissection. Nine patients added the inguinal incision to establish the cardiopulmonary bypass. Main procedures consist of eight case of hemiarch replacement and 15 cases of total arch replacements. As concomitant procedures, two cases had aortic valve surgery. All procedures were performed under moderate hypothermic circulatory arrest with selective cerebral perfusion.

Results: Median (range) skin incision was 8 (range, 7–15) cm (4.9% of height) and partial sternotomy consisted of 21 upper and 2 lower partial sternotomy (L shape, 11 cases; T shape, 12 cases). Median (range) operation time, cardiopulmonary bypass time, ischemic heart time, selective cerebral perfusion time, and hypothermic circulatory arrest time were 406 (274–770), 218 (140–270), 135 (88–154), 134 (23–169), and 62 (25–90) minutes, respectively. Median (range) duration of ventilator dependent time was 12 (5–38) hours. Median (range) length of intensive care unit stay and hospital stay were 2 (1–7), and 16 (10–55) days, respectively. Thirty days and in-hospital mortality were 0% without any neurological complications. There are two aorta-related reoperations due to graft inducing hemolytic anemia and no aorta–related death during follow-up [median (range), 360 (31–867) days].

Conclusions: The early results of aortic arch surgery through partial sternotomy were satisfactory. We need long-term follow-up data to try to establish the standardization of surgical strategy.

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CMP29 Minimally Invasive Aortic Arch Surgery

Nora Goebel, Daniel Bonte, Schahriar Salehi-Gilani, Ragi Nagib, Hardy Baumbach, Adrian Ursulescu, Ulrich F. W. Franke. Robert-Bosch-Hospital, Stuttgart, Germany.

Objective: Median sternotomy is still the standard approach for surgery including the aortic arch. Minimally invasive surgery promises faster reconvalescence and shorter hospital stay plus better cosmetic results. However, safety is a concern in complex aortic surgery. The aim of the study was to investigate whether aortic arch surgery via partial upper sternotomy can compare with standard procedure in terms of safety and major adverse cardiac and cerebrovascular events.

Methods: We interrogated our prospectively collected database and identified a total of 21 nonemergent patients operated on at our center between October 2008 and February 2015. Indication for operation was aneurysmatic disease in 18 and aortic dissection in three patients. Data were analyzed for in-hospital mortality, stroke, bleeding complications, acute kidney injury, and rhythm disturbances (pacemaker implantation).

Results: Mean (SD) age of patients was 69.3±14.4 years, 57.1% were female, and mean (SD) logistic EuroSCORE was 17.0±7.2%. Surgery on the aortic arch comprised proximal arch in nine patients, hemiarch in nine patients, and total arch replacement in three patients, including two patients receiving a frozen elephant trunk. Concomitant procedures were aortic root repair in 10 patients, aortic root replacement in two patients, and aortic valve replacement in three patients. We lost one patient because of septic shock. We did not see any stroke but a transient neurologic deficit in three patients and a postoperative delirium in four patients. Re-exploration for bleeding was necessary in two patients, pacemaker implantation in two patients, and acute kidney injury occurred in one patient.

Conclusions: Minimally invasive aortic arch surgery via partial upper sternotomy does not increase the risk of mortality or major adverse cardiac and cerebrovascular events. Thus, in experienced hands, it is safe, feasible, and therefore favorable and should be offered to more patients.

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C14 Transcatheter Versus Surgical Aortic Valve Replacement: Propensity Score Matched Comparison of 3751 Patients

Jochen Börgermann 1, Eric Emmel1, Nobuyuki Furukawa1, Smita Scholtz1, Stephan Ensminger1, Buntaro Fujita1, Werner Scholtz1, Marios Vlachojannis1, Tobias Becker1, Dieter Horstkotte1, Oliver Kuss2, Jan-Fritz Gummert1. 1Herz- und Diabeteszentrum NRW Ruhr University of Bochum, Bad Oeynhausen, Germany; and 2Institute for Biometry and Epidemiology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.

Objective: Transcatheter aortic valve replacement (TAVR) is an established method in high-risk patients. Two aspects of this procedure are currently under discussion: (1) do the data acquired from randomized studies and registers justify expansion of the procedure to include younger and healthier patients? and (2) is the transfemoral approach superior to the transapical approach with regard to mortality and periprocedural complications? Against this background, we examined the mortality and morbidity of all patients who received an isolated conventional, transapical, or transfemoral aortic valve replacement in accordance with the criteria of the Valve Academic Research Consortium-2.

Methods: A prospective register was taken from a single center recording all conventional (CONV, n=2881), transapical (TAVR-TA, n=363), and transfemoral (TAVR-TF, n=570) aortic valve implantations during the period from July 2009 to October 2014. With the use of propensity-score matching, first CONV and TAVRall (TA+TF) and then TAVR-TA and TAVR-TF were paired on the basis of 21 risk variables, creating comparable groups.

Results: A total of 393 pairs CONV versus TAVRall within a moderate risk could be created (EuroSCORE, 18.7 vs. 18.5; STS, 5.0 vs. 5.4). Comparison revealed no difference for 30-day mortality (4.6% CONV vs. 5.1% TAVRall, P=0.74), stroke (2.8% vs. 2.0%, P=0.48), or myocardial infarction (0.0% vs. 0.3%, P=0.50). Bleeding complications were significantly more frequent in the CONV, SM implantations and vascular complications in the TAVRall group. In the propensity score–adjusted comparison TAVR-TA versus TAVR-TF (289 pairs; EuroSCORE, 25.1 vs. 22.1; STS, 6.8 vs. 6.7), there was also no difference in the hard endpoints (30-day mortality, 4.9% TA vs. 4.2% TF, P=0.70; stroke, 3.1% vs. 2.8%, P=0.81; myocardial infarction, 0.4% vs. 0.4%, P=1.00). Here, bleeding complications were significantly more frequent in the TA group, SM implantations, and vascular complications in the TF group. Subgroup analysis showed an advantage of the TAVR procedure in octogenarians.

Conclusions: These data show that (1) conventional aortic valve replacement and TAVR are comparable in the moderate risk group and (2) the two approaches, transapical and transfemoral, produce comparable results.

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C15 Treatment of Pure Aortic Regurgitation Using a Novel Second-Generation Transcatheter Aortic Valve Implantation System (J-Valve System): Initial Clinical Experience

Da Zhu, Yingqiang Guo, Bengui Zhang, Yingkang Shi. West China Hospital of Sichuan University, Chengdu, China.

Objective: Experience with transcatheter aortic valve implantation (TAVI) for pure aortic regurgitation (AR) is limited because of the risk of insufficient anchoring of the valve stent within the noncalcified aortic annulus. The aim of this study was to report the clinical experience with a novel transcatheter aortic valve implantation system, the J-Valve system for the treatment of pure AR.

Methods: Transapical TAVI with the J-Valve system was performed in 28 patients with pure AR in our center with a mean (SD) age of 74.1±4.6 years (Fig. C15-1). All patients were considered high risk for open-heart surgery with a mean (SD) logistic EuroSCORE 23.2±3.3%. Clinical and echocardiographic evaluations were performed at baseline, postprocedure, and follow-up. Procedural success and complications were reported according to Valve Academic Research Consortium-2 definitions.



Results: Implantation was successful in 26 of 28 cases (success rate, 93%). All-cause in-hospital mortality was 0% and 6-month survival was 100%. Two patients were converted to surgical valve replacement because of moderate-degree paravalvular AR after valve implantation and valve embolism into the aortic arch. Pacemaker implantation for new-onset conduction disorders was necessary in two patients (7.1%). Minor access complication was noted in one patient (3.6%). Postprocedural paravalvular AR was none/trace in 20 of 26, and mild in 6 of 26 patients at 6-months follow-up. Mean (SD) transvalvular gradient was favorable after valve implantation during follow-up at 10.2±3.5 mmHg.

Conclusions: Pure AR remains a challenging pathology for TAVI. The J-Valve system demonstrated feasibility, safety, and effectiveness in the treatment of patients with pure AR.

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CMP30 Frailty Assessment Using the FORECAST Is a Valid Tool to Predict Mortality After Transcatheter Aortic Valve Implantation: Results From the “Comprehensive Assessment of Frailty” Validation Study

Simon H. Sündermann 1, Alexander Meyer1, Adrian Kobe2, Hassan Elmubarak3, Thomas Walther3, Jörg Kempfert1, Volkmar Falk1. 1Deutsches Herzzentrum Berlin, Berlin, Germany; 2University Hospital Zurich, Zurich, Switzerland; and 3Kerkhoff Clinic, Bad Nauheim, Germany.

Objective: The term “frailty” is used frequently during decision making in transcatheter heart valve procedures. Nevertheless, frailty is still measured by eyeballing rather than by using frailty assessments. In a previous study, we developed a frailty assessment in a cardiac surgical patient population including patients who underwent transcatheter heart valve replacement. Here, we present the results from the validation study focusing on the TAVI cohort.

Methods: One hundred thirty patients underwent a TAVI procedure in a center in Switzerland and in Germany. Frailty assessment using the FORECAST (frailty predicts death 1 year after elective cardiac surgery test) was performed for every patient before the procedure. EuroSCORE and STS score were assessed as well. Follow-up included assessment of in-hospital mortality, mortality after 30 days, and quality of life at follow-up using the SF-36 assessment.

Results: Mean age of the patients was 83.3 years, and 50% were female. LogEuroSCORE was 15±8.7% and STS score was 5.1±3.4%. More than 80% of the patients lived at home before the procedure, either alone or with their spouse. Mean (SD) FORECAST score was 4.8±3.3 points of 15. In-hospital and 30-day mortality was 1%. Stroke rate was 0.3% in-hospital and 0.2% at 30-day follow-up. With regard to the SF-36, quality of life decreased significantly in 4 of 10 items (role emotion, general health, social functioning, and the mental health component summary score) after the intervention. Kruskas-Wallis test showed that the FORECAST is a valid tool to predict in-hospital mortality and 30-day mortality after TAVI. By combining the FORECAST and the STS score, this effect was even higher. The area under the receiver operating characteristics curve was 0.7 for in-hospital mortality and 0.76 for 30-day mortality, summing up both scores. Stratifying the patients according to their FORECAST score showed highest probability of mortality in the highest frailty group (Fig. CMP30-1).



Conclusions: The FORECAST is a valid tool to assess frailty in TAVI patients, which is relevant to predict short-term outcome.

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CMP31 Transpical Implantation of Neochords for Mitral Valve Repair: The Double-Helix Knot

Mehrdad Ghoreishi, Chetan Pasrija, Brody Wehman, Pete Wilson, James Gammie. University of Maryland School of Medicine, Baltimore, MD USA.

Objective: Mitral valve repair using ePTFE neochords is effective and durable. We have developed a new technique to anchor ePTFE neochords to the mitral leaflet on the beating heart using transapical cardiac access and have investigated the force required to pull the implanted suture out of the leaflet.

Methods: An ePTFE-wrapped needle configured in a preformed knot configuration is positioned on the ventricular side of the targeted mitral leaflet. The needle is advanced across the leaflet, and a preformed “double-helix” ePTFE knot is formed on the atrial surface of the leaflet (Fig. CMP31-1). The ePTFE suture pair is titrated to an optimal length and secured on the epicardium. The perpendicular tension required to pull the neochords out of the leaflet was measured with a digital force gauge (in newton). Normal in vivo forces on marginal mitral valve chordae tendineae are 0.1 to 0.3 N.



Results: Eleven porcine hearts were studied. In seven hearts, the sutures were implanted with the described technique. In four hearts, the neochords were secured to the leaflet edge using conventional technique. In seven hearts, we implanted 11 double-helix knots in anterior leaflets and six knots in posterior leaflets. The mean (SD) distance from the knots to the edge of the leaflets was 11±6.25 mm in anterior leaflets and 5±1.67 mm in posterior leaflets. The mean anterior leaflet thickness was 1.4 mm, and the mean posterior leaflet thickness was 1.7 mm. The mean (SD) pull-out force was 8.58±3.34 N for double-helix–anchored neochords and 8.34±3.29 N for conventional neochords (P=0.93). The mean (SD) pull-out force for sutures implanted with double-helix technique in anterior leaflets was 8.22±3.64 N and 9.23±2.91 N in posterior leaflets (P=0.58).

Conclusions: Transapical neochord implantation with the double-helix preformed knot technique enables rapid and secure anchoring of ePTFE neochords on the beating mitral leaflet. Anchoring security is equivalent to conventional suturing techniques, and pull-out forces are 25 to 80 times greater than physiologic forces on marginal chords.

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CMP32 Transcervical Transcatheter Mitral Valve Replacement: A Proof of Principle

Cristiano Spadaccio 1, Piotr Sonecki1, Ying Sutherland2, Fraser Sutherland1. 1Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom; and 2CardioPrecision Ltd, Glasgow, United Kingdom.

Objective: Transcatheter mitral valve replacement (TMVR) is emerging as an attractive alternative to mitral surgery. Existing approaches TA and TF have major limitations and pertain to the much larger size of mitral devices and delivery systems in comparison with “equivalent” TAVR devices. We recently developed a device system to provide a transcervical access to cardiac structures through a short incision in the neck and successfully performed first-in-man cases of aortic valve replacement via both transcatheter and standard surgical approaches. We now sought to demonstrate the feasibility of this route for TMVR as the transcervical system allows for visualization and exposure of the dome of the left atrium (LA) similar to routinely used open approaches for MV surgery.

Methods: Thiel-embalmed human cadavers were used. Transcervical access was obtained with the developed system, LA exposed, and purse string suture in the dome of the LA readily placed. A steerable catheter was used to insert a guidewire from the LA into the left ventricle (LV), and a delivery catheter was introduced and manipulated through the MV under echocardiographic guidance. The catheter was removed and atrium closed.

Results: The system provided exposure of LA dome similar to the standard surgical view (Fig. CMP32-1A–C). Insertion of guidewire across the MV freely mobile within the LV (Fig. CMP32-1D) was confirmed. Transcatheter mitral valve replacement delivery catheter passed easily through MV orifice into the LV and seemed to follow a smooth curve from neck to valve with ease of manipulation through the MV, catheter removal, and atrial closure under HD screen visualization (Fig. CMP32-1E–F).



Conclusions: Although preliminary, the results of this study prove the feasibility of TMVR through a transcervical access. The approach overcomes problems with TA and TF access routes, facilitating delivery of large devices to the MV. The procedure could be performed through a minor incision in the neck avoiding chest disruption and promises significant future benefits in terms of rapid recovery, reduction in complications, and early discharge, similar to experience with transcervical aortic valve replacement.

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CMP33 Proximal Arterial Access in Transcatheter Aortic Valve Replacement: The Case for the Innominate Artery

Mark A. Groh 1, William B. Abernethy2, Joshua P. Leitner2, Gerard L. Champsaur2. 1Asheville Heart, Asheville, NC USA; and 2Mission Hospital, Asheville, NC USA.

Objective: We initiated a systematic approach of proximal arterial access (PAA) over transapical implantation (TA) for alternative access transcatheter aortic valve replacement (TAVR). Early in our PAA experience, we favored transaortic (TAo) approach, but we have increasingly employed the innominate artery (TI), offering a less invasive alternative. We review here our current experience.

Methods: Between February 7, 2012, and October 10, 2015, we performed a continuous series of 168 TAVR procedures. Because of safety concerns with TA (n=8) and our familiarity with aortic cannulation, we began performing all alternative access procedures via TAo. In the second year, for the sake of minimal invasiveness, we initiated TI access through incision limited to the manubrium without the need for a “J” incision. Proximal and distal control is gained on the innominate artery, and wire access is gained through direct puncture. After crossing the valve, the introducer and sheath are advanced across the valve and the introducer is removed, allowing the valve to be placed into the outflow tract without balloon valvuloplasty. After valve deployment, the sheath is removed with rapid pacing and the arteriotomy is closed in transverse fashion.

Results: Proximal arterial access has been employed in 90 patients (56 TAo and 34 TI) with increasing TI share as shown in Figure CMP33-1. Our PAA patients have higher STS risk scores than TF patients (8.93 vs. 6.58, P=0.002). Compared with TF (n=70), PAA is significantly shorter procedures, has less radiation exposure, and requires less contrast, with no significant difference between TI and TAo. There were no differences in stroke or early mortality (4.0% vs. 4.44%, P=0.96) between PAA and TF. Device success was 85.71% for TF and 95.55% for PAA (P=0.002), with no difference between TAo and TI.



Conclusions: The TI approach, similar to TAo, offers highly reliable valve implant success rates and short procedure times with a less invasive approach. The added proximity of the aortic valve may make TI the access of choice for PAA TAVR.

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CMP34 The Valve-in-Valve Procedure: Does Patient-Prosthesis Mismatch Matter?

Philipp Kiefer, Alexandro Hoyer, Thilo Noack, Eric Nerger, Axel Linke, Joerg Seeburger, Friedrich W. Mohr, David Holzhey. Heart Center Leipzig, Leipzig, Germany.

Objective: Transcatheter aortic valve implantation used as a valve-in-valve (ViV) procedure is well established. We herein investigate the role of the surgical valve sizes and their initial gradients compared with the hemodynamic functions after ViV procedure.

Methods: The ViV procedure was performed in 99 patients in our institution. Of this cohort, 62 patients were identified with full hemodynamic assessment after initial surgical aortic valve implantation (SAVR) and after transcatheter ViV implantation. Patient-prosthesis mismatch (PPM) was calculated within four groups related to initial surgical valve size (19, 21, 23≥25). Mean (SD) age was 77.4±7.1 years (59% male) with a log EuroSCORE of 27.5±16.4%. Transfemoral, transapical, and transaortal access was used in 45 (73%), 14 (22%), and 3 (5%) patients, respectively. We used 30 SAPIEN valves (Edwards Lifesciences, Irvine, CA USA), 30 CoreValve (Medtronic Inc., Minneapolis, MN USA), and two others.

Results: Valve-in-valve procedure was successful in 100% (n=62) of the cases with a mean (SD) procedural time of 66.1±43.5 minutes. Thirty-day, 1-year, and 2-year mortality was 6.4%, 8.1%, and 12.9%, respectively. Group 1 (size 19, n=1) showed severe PPM. Group 2 (size 21, n=14) showed moderate PPM in 11 patients (78%) but with no significant changes in hemodynamics after ViV compared with initial SAVR (mean Pmax, 27>24 mmHg; P=0.29). Group 3 (size 23, n=29) showed moderate PPM in 22 patients (76%) with significant changes in hemodynamics after ViV compared with initial SAVR (mean Pmax, 42>22 mmHg; P=0.02). No PPM was detected in group 4 (size ≥25, n=18), but hemodynamic improvement after ViV compared with SAVR (mean Pmax, 20>22 mmHg; P=0.65).

Conclusions: Transcatheter ViV procedure is associated with good results. Patient-prosthesis mismatch and the initial surgical valve size have a significant influence on hemodynamic function after ViV.

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CMP35 Single Surgical Center Experience With Transcatheter Mitral Valve Therapies

Rashmi Yadav, Alison Duncan, Cesare Quarto, Ulrich Rosendahl, Simon Davies, Neil Moat. Royal Brompton Hospital, London, United Kingdom.

Objective: In our cardiac surgical practice of complex mitral valve patients, we are faced with a small cohort of prohibitively high-risk patients. We have treated these patients with catheter-based interventions using a heart-team approach led by cardiac surgeons. Broadly, two generic types of devices have been used for mitral valve pathologies: devices designed specifically for the mitral valve or those devised originally for the aortic position but adapted to the mitral. Our experience with these therapies include first-in-man transapical mitral valve implants (TMVIs) of an apically tethered device (Tendyne, Tendyne Holdings, Inc., Roseville, MN USA) and transcatheter valve implant of aortic prostheses (Edwards Lifesciences, Irvine, CA USA; SAPIEN; Direct Flow, Direct Flow Medical, Inc., Santa Rosa, CA USA) in the mitral position. We report our initial experience.

Methods: Between March 2013 and December 2015, a total of 13 patients were treated with novel TCV therapies. Of these, four patients had native mitral valve disease and underwent TMVI with the Tendyne prosthesis. Nine patients more had undergone previous mitral valve surgery of whom four had failing mitral bioprostheses and five had recurrent mitral regurgitation (MR) after mitral repair. All patients had MR grade 4 and severe pulmonary hypertension. In this group, valve-in-valve or valve-in-ring (ViR) implantation was carried out in six patients with the Edwards SAPIEN system, two with Direct Flow and one with Tendyne TMVI (Table CMP35-1).



Results: Device success was achieved in all patients. There were no procedural complications, no valve malpositioning or embolization, and no access site complications. No patient had residual significant MR or significant mitral gradient. There was no 30-day mortality or cerebrovascular accident. All patients were discharged to their own home. At 6-month follow-up, all patients (n=7) were alive and with significant improvement of their functional capacity.

Conclusions: An armamentarium of TCV options is required in surgical centers to be able to treat the full range of mitral valve pathologies. In our experience, a high-risk group of patients can be treated successfully with low morbidity and mortality using these novel therapies.

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C16 Antegrade and Retrograde Arterial Perfusion Strategy in Minimally Invasive Valve Surgery Performed Through the Right Chest: A Propensity-Score Analysis on 2379 Patients

Michele Murzi, Alfredo G. Cerillo, Pierandrea Farneti, Enkel Kallushi, Marco Solinas. Fondazione Toscana Gabriele Monasterio, Massa, Italy.

Objective: Recent studies have suggested a link between postoperative stroke and retrograde perfusion in minimally invasive valve surgery. The aim of the present study was therefore to evaluate the impact on early outcome of retrograde arterial perfusion strategy versus antegrade arterial perfusion strategy in a consecutive large cohort of patients who underwent minimally invasive mitral and aortic valve surgery through a right minithoracotomy.

Methods: Between 2003 and 2015, 2379 consecutive patients underwent first-time minimally invasive mitral (1621 patients, 69.7%) and aortic (751 patients, 30.3%) valve surgery at our institution. Two hundred twenty-seven (9.5%) of these patients received a retrograde perfusion, whereas 2152 (90.5%) received an antegrade perfusion. Logistic analysis was used to evaluate outcomes and risk factors for stroke. Treatment selection bias was controlled by a propensity score from core patient characteristics. The propensity score was the probability of receiving retrograde perfusion and was included along with the comparison variable in the multivariable analyses of outcome.

Results: The overall frequency of in-hospital mortality was 0.8% (21/2379) and postoperative stroke was 1.8% (43/2379). After adjusting for the propensity score, retrograde arterial perfusion was associated with a higher incidence of stroke (3.8% vs. 0.9%, P=0.02), postoperative delirium (13% vs. 4%, P=0.001), and aortic dissection (1.2% vs. 0%, P=0.01). The multivariable regression analysis revealed that the use of retrograde perfusion was an independent risk factor for stroke [OR, 3.57; P=0.02] and postoperative delirium (OR, 2.96; P=0.001). Finally, the bootstrapping interaction model revealed that the use of retrograde arterial perfusion in patients with atheriosclerotic burden disease was the only significant risk factor for stroke (OR, 4.38; P=0.03).

Conclusions: Minimally invasive valve procedure through the right chest can be performed with low morbidity and mortality. Retrograde perfusion is associated with a higher incidence of neurologic complications and aortic dissection when compared with antegrade perfusion. Central aortic cannulation avoids complications associated with retrograde perfusion while extends the suitability of minimally invasive procedures also to those patients who have an absolute contraindication to femoral artery cannulation.

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CMP36 Minimally Invasive Mitral Valve Surgery: Why Do You Take the Risks?

Farouk M. Oueida, Ahmed Attia, Khalid Al Khamees, Khalid Eskander, Hassan Ammar, Mustafa Al Refaie. Saud Albabtain Cardiac Center, Dammam, Saudia Arabia.

Objective: During recent years, minimally invasive mitral valve surgery (MIMVS) has become the preferred method of mitral valve repair and replacement in many institutions worldwide with excellent results. However, there are no efficient studies about the risks of MIMVS compared with conventional mitral valve surgery. We presented early and mid-term outcomes of patients undergoing MIMVS in our institution.

Methods: The patient’s demographic profile, intraoperative data, and postoperative outcomes of patients undergoing MIMVS were retrospectively collected from our database from May 2011 to April 2014.

Results: Seventy consecutive patients [45 males and 25 females; mean (SD) age, 35±12 years] underwent MIMVS surgery. Mean (SD) preoperative NYHA function class was 2.6±0.7. Mean (SD) ejection fraction was 50±8. Cardiopulmonary bypass was instituted through femoral cannulation (28/70, 40%), direct aortic cannulation (42/70, 25%), and use of aortic cross-clamp (66/70, 94.2%).Without aortic cross-clamp in 4 (5.7%) of 70 patients, mitral valve repair has been done in 52 (74.2%) of 70 patients and mitral valve replacement in 18 (25.7 %) of 70 patients. Concomitant procedures included atrial fibrillation ablation (24/70, 34.2%) and tricuspid valve repair (33/70, 47.1%). No mortality was recorded, and residual mitral regurge was found in 6 (8.5%) of 70 patients during 1-year follow-up. Cardiopulmonary bypass and “skin-to-skin” surgery were 95±35 and 250±74 minutes, respectively. Four patients (5.7%) underwent re-exploration for bleeding, and 57 (81.4%) of 70 patients did not receive any blood transfusions. Six patients (8.5%) sustained face edema. Mean (SD) length of hospital stay was 7±3.8 days. Eighteen patients (25.7%) did not feel any interest regarding cosmetic advantage over conventional surgery.

Conclusions: Minimally invasive mitral valve surgery is an excellent alternative to conventional mitral valve surgery in most cases; however, compared with conventional mitral surgery, it shows long bypass time, long cross-clamp time, need for re-exploration for bleeding, and multiple body incisions.

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CMP37 Use of Del Nido Cardioplegia in Minimal Invasive Cardiac Surgery Cases: Four Years of Surgical Experience and Follow-up

Ashwani Bansal, Milind P. Hote, Velayoudam Devagourou, Balram Airan. AIIMS, New Delhi, India.

Objective: Minimal invasive cardiac surgery (MICS) requires adequate visualization of operative field through small incisions, and the expected clamp times are higher. To avoid repeated manipulations, it is desirable to use single-dose cardioplegia with good myocardial protection. The aim of the present study was to determine whether del Nido cardioplegia could be used safely and effectively in MICS.

Methods: Minimal invasive cardiac surgery requires adequate visualization of operative field through small incisions, and the expected clamp times are higher. To avoid repeated manipulations, it is desirable to use single-dose cardioplegia with good myocardial protection. The aim of the present study was to determine whether del Nido cardioplegia could be used safely and effectively in MICS.

Results: Minimal invasive cardiac surgery was performed for 41 ASD (73%), 10 MR (17.8%), 2 MS (3.5%), 1 AR, 1 AVSD and 1 SV ASD patients. Mean age was 19.4 years (range, 4–39 years), and the mean weight of patients was 42.9 kg. Minithoracotomy approach (5-cm incision) was used in 26 patients (46.4%) and ministernotomy approach was used in seven patients (12.5%), whereas right thoracotomy was performed in the rest 23 patients (41%). Surgical procedure could be completed with a single dose of del Nido cardioplegia in 90% of cases (50/56) with a mean cross-clamp time of 44.2 minutes. No patient required retrograde cardioplegia and stable rhythm was achieved in 53 of 56 patients. In intensive care unit, three patients (5.3%) required temporary pacing, all reverting to sinus rhythm after mean interval of 12.6 hours. Postoperative recovery was smooth with mean inotropic score being 1.6 (at 1 hour) and 0.26 (at 24 hours). Early extubation was achieved for all patients, with mean ventilation time of 6.6 hours leading to short intensive care unit (mean, 1.2 days) and hospital stays (mean, 5.4 days). With a mean follow-up duration of 29.3 months, all patients are asymptomatic with normal LV function.

Conclusions: Del Nido cardioplegia is safe and convenient alternative for MICS.

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CMP38 Is a Bicaval Cannulation Strategy Advantageous in Minimally Invasive Mitral Valve Surgery?

Christopher L. Tarola 1, Daniel J. P. Burns1, Stephanie A. Fox1, Sankar Balasubramanian1, Rakesh Gudimella1, Jill J. Gelinas1, Stuart Swinamer1, Michael W. A. Chu1, Linrui R. Guo1, Alan Menkis2, Bob Kiaii1. 1London Health Sciences Center, Western University, London, ON Canada; and 2Winnipeg Regional Health Authority, University of Manitoba, Winnipeg, MB Canada.

Objective: Minimally invasive mitral valve surgery (MIMVS) is a common approach to treating mitral valve (MV) pathology, and outcomes are comparable with conventional median sternotomy techniques. Given the anatomic constraints during MIMVS, adequate venous drainage is critical to ensure optimal surgical exposure. The conventional MIMVS venous cannulation strategy uses a single 2-staged femoral venous cannula placed in the right atrium or superior vena cava. We compared operative and clinical outcomes between patients who underwent femoral and bicaval venous cannulation strategies to investigate whether increased venous drainage affected patient outcomes.

Methods: All patients who underwent MIMVS (245 MV repair, 11 MV replacement) at our institution were retrospectively identified and stratified by cannulation strategy. The primary outcomes of interest were intensive care and in-hospital length of stay. Secondary outcomes were operative times as well as postoperative clinical outcomes.

Results: Between August 2002 and November 2014, 256 patients underwent MIMVS through a right lateral thoracotomy approach. Sixty underwent single femoral cannulation, whereas 194 underwent a bicaval approach. There were no significant differences in demographics or comorbidities between the two groups, with the exception of left ventricular grade (Table CMP38-1). Cardiopulmonary bypass and aortic cross-clamp times were significantly reduced in the bicaval group (189.6 vs. 214.6 minutes, P=0.001, and 128.1 vs. 146.9 minutes P<0.001, respectively). There were no differences in postoperative myocardial infarction, renal failure, wound infection, or in-hospital mortality between groups. However, there was a significant reduction in neurologic complications (3 vs. 1, P=0.043) and reoperation for bleeding (5 vs. 2, P=0.009) in the bicaval group. Length of intensive care (P=0.302) and hospital (P=0.163) stays were not affected by cannulation strategy.



Conclusions: The addition of a superior vena cava venous drainage cannula in MIMVS was associated with significantly reduced cardiopulmonary bypass and aortic cross-clamp times. Although there were no differences in length of stay, a bicaval cannulation strategy resulted in fewer adverse neurological outcomes and reoperations for bleeding.

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CMP39 Double Versus Single Double-Stage Venous Cannula in Minimally Invasive Mitral Valve Repair

Alberto Repossini, Lorenzo Di Bacco, Laura Giroletti, Fabrizio Rosati, Gianluigi Bisleri, Claudio Muneretto. University of Brescia Medical School, Brescia, Italy.

Objective: We investigate outcomes of patients who underwent minimally invasive mitral valve repair through anterolateral right thoracotomy, by venous drainage via single femoral double-stage cannula versus venous drainage via femoral vein plus percutaneous right jugular vein.

Methods: From 2012 to 2015, 290 patients underwent minimally invasive mitral valve repair at our institution. Venous drainage was assured by percutaneous right jugular vein and right femoral vein cannule in the first group (167 patients, G1) and by single femoral vein cannula in the second group (123 patients, G2). We analyzed how the efficacy of cardiopulmonary bypass, and the early postoperative outcomes were influenced by the different type of venous drainage.

Results: After propensity matching, two cohorts of 93 patients were obtained. Every patient received antegrade HTK cold solution (Custodiol, Essential Pharmaceuticals, LLC, Ewing, NJ USA) for myocardial protection. Conversion to median sternotomy was reported in two cases in G1 (2.15%) and one case in G2 (1.07%) due to bad exposure (P=0.574). Some differences among the two groups were reported in cardiopulmonary bypass (CPB) management: CPB time was significantly longer in G1 [G1: 154±16.2 minutes vs. G2: 122±10.1 minutes, P<0.001] but aortic cross-clamp time was similar [G1: 115±17.8 minutes vs. G2: 104±6.8, P=0.121]. Blood flow during CPB was similar among two groups and adequate to the body surface area for each patient [G1: 4.1±0.55 L/min vs. G2: 4.2±0.6 L/min, P=0.693] as well as mean (SD) arterial pressure [G1: 74.8±5.2 mmHg vs. G2: 75.3±5.1 mmHg, P=0.818]. Acid-base equilibrium was monitored through emogas analysis during CPB: pH [G1: 7.41±0.45 vs. G2: 7.41±0.32, P=0.951], base excess [G1: 2.3±0.45 vs. G2: 1.9±0.32, P=0.671], blood lactate [G1: 1.05±0.25 vs. G2: 0.89±0.25, P=0.851], and bicarbontes [G1: 27.1±2.41 vs. G2: 26.2±1.6, P=0.428] concentration were similar among groups. No death within 30 days from surgery was reported among the two groups. Only one in G1 early reoperation for repair failure. During postoperative period, no major epatic injuries was reported, only three temporary bilirubin values rising (G1: 1.07% vs. G2: 2.15%, P=0.574), and mean (SD) bilirubin values were similar among groups [G1: 1.15±2.41 vs. G2: 26.2±1.6, P=0.428]. Mean day 1 postoperative CK-MB was not significantly but higher in G2 [G1: 30.9±3.2 vs. G2: 35.2±4.6, P=0.378].

Conclusions: Both strategies guarantee optimal venous drainage during minimally invasive mitral valve repair with surgical visualization with excellent results and low grade of postoperative complications.

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CMP40 Thirteen-Year Experience of Intraoperative Graft Validation Using SPY 2000 System and Brand-New SPY 3000

Masao Takahashi 1, Keisuke Miyajima1, Toshihiro Ishikawa2, Kazuyoshi Hatada2. 1Hiratsuka Kyosai Hospital, Hiratsuka, Japan; and 2Odawara Municipal Hospital, Odawara, Japan.

Objective: The SPY system has been developed for fluorescence graft validation during CABG. We are the first site in Asia-Oceania region to use SPY Intraoperative Imaging System since 2002. Based on the 13-year experience using SPY 2000 system, useful technique using brand-new SPY 3000 will be demonstrated.

Methods: From March 2002 to November 2015, off-pump CABG surgery was performed in 697 cases (147 MIDCAB, 550 OPCAB). The SPY System (SPY 2000) has been used routinely for intraoperative graft validation of all 2329 distal anastomoses. Since July 2015, the brand-new SPY 3000 system was introduced in our institute for further examination. It has color contrast mode as the figure.

Results: Clear SPY images could be obtained in all 2329 distal anastomoses. Almost all patients without cardiac failure could be awake from general anesthesia and extubated in the operation room, because the graft patency could be guaranteed visually by SPY system. Thirty anastomoses (1.3%) had to be revised intraoperatively, because of unfavorable SPY images. Post-CABG catheter angiography or MD-CT was performed in 91.4% patients except borderline chronic kidney disease. Early graft patency rate was satisfactory as 98.7%. All 30 revised grafts also revealed patent, including critical cases. Several interesting examination using SP 3000 will be shown (Fig. CMP40-1).



Conclusions: Intraoperative graft validation using SPY system will be criterion standard for CABG surgery.

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CMP41 Noninvasive Quantification of Blood Flow in Epicardial Coronary Arteries, Coronary Artery Bypass Grafts, and Anastomoses

Thomas B. Ferguson, Jr 1, Cheng Chen1, Kenneth Jacobs1, Zhiyong Peng1, Jeffery Basham2. 1East Carolina Heart Institute, Greenville, NC USA; and 2RFPi, LLC, Greenville, NC USA.

Objective: Clinical and experimental approaches to directly measure flow in epicardial coronary arteries, coronary bypass grafts, and anastomoses are severely limited by the invasiveness and inaccuracy of existing technologies. As a result, less than 25% of patients undergoing CABG worldwide have any intraoperative evaluation performed. The advent of a simple, accurate, and noninvasive technology to directly quantify blood flow in conduits and rheology at anastomotic sites would provide intraoperative quality documentation and new physiologic information that would improve outcomes.

Methods: The fact that existing technologies are unable to meet this demand necessitated a different technology solution. With the use of an optical physics approach, flow in conduits and tissue can be quantified in real time with nonionizing broad-spectrum imaging and temporal and spatial analyses. In particular, cardiac motion must be addressed so that flow can be quantified at any point throughout the cardiac cycle.

Results: This new, proprietary, and patented technology is demonstrated in the Figure CMP41-1 in an established porcine cardiac experimental model. Flow velocities and flow in the mid-distal left anterior descending coronary artery (white box) vary with the cardiac cycle. The quantified change in flow velocity in the mid-distal LAD is shown by the blue curve within each cardiac cycle and at end-systole (middle panel) and end-diastole (right panel). These imaging data are captured, analyzed, and displayed in real time as a video from a viewing distance of 30 cm. The field of view is 9×9 cm, large enough to capture flow in the proximal and distal epicardial coronary, the conduit, and at the anastomosis simultaneously.



Conclusions: The rheologic interaction between conduit flow and native coronary flow at the anastomosis remains the most poorly understood aspect of coronary artery bypass grafting. A noninvasive, noncontact, nonrisk imaging technology as simple as a snapshot can provide this critical physiologic information, validate and document intraoperative quality, and improve even further CABG outcomes.

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CMP42 Feasibility of a New Automatic Imaging Tool Prototype for Interventional Mitral Valve Therapy

Arnaud Van Linden, Mani Arsalan, Claudia Walther, Won-Keun Kim, Christoph Liebetrau, Ulrich Fischer-Rasokat, Mirko Doss, Thomas Walther. Kerckhoff Klinik, Bad Nauheim, Germany.

Objective: Precise imaging is a prerequisite for interventional mitral valve procedures such as MitraClip or transcatheter mitral valve implantation. This includes evaluation of the left atrium (LA), the interatrial septum, the mitral valve, the left ventricle, and the left ventricular outflow tract. Mitral Valve Guidance (MVG; Siemens Healthcare GmbH, Erlangen, Germany) is a new software prototype that allows for automatic segmentation of these relevant landmarks from multislice computed tomography (MSCT) datasets. This is a preliminary feasibility study of the first clinical experience using the MVG.

Methods: Multislice computed tomography scans of 10 patients were imported into the MVG workstation and processed automatically.

Results: Three-dimensional reconstruction of the LA, followed by segmentation and landmark detection, was automatically started by the MVG prototype (Fig. CMP42-1). Pulmonary veins are colored in purple, the LA red, the LA appendage in dark blue, and the mitral valve leaflets in green and light blue. The mitral valve annulus and the coaptation line are presented as yellow lines, and a centerline is derived through the middle of the coaptation line. A virtual septum model for transseptal crossing is calculated, and the distance between this virtual septum and the LA appendage can be measured. The automatic segmentation and landmark detection worked well in all MSCT datasets from 10 patients.



Conclusions: The Mitral Valve Guidance prototype offers a new tool for interventional mitral valve therapy planning. Automatic segmentation may lead to reproducible and examiner-independent results. Intraprocedural registration based on data acquisition using a DynaCT spin is possible and may lead to direct procedural guidance. Further and larger investigational studies are ongoing.

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CMP43 Preoperative Simulation and Surgical Navigation in Minimally Invasive Cardiac Surgery Using Virtual Reality and Individualized Three-Dimensional Model

Takashi Murakami, Mitsuharu Hosono, Masanori Sakaguchi, Akimasa Morisaki, Yasuo Suehiro, Shinsuke Nishimura, Yoshito Sakon, Daisuke Yasumizu, Takumi Kawase, Toshihiko Shibata. Osaka City University Graduate School of Medicine, Osaka, Japan.

Objective: Operative field is limited in minimally invasive cardiac surgery (MICS). To increase the safety and quality of the operative procedure, we developed the virtual reality of the patient’s anatomy for preoperative and intraoperative navigation. Furthermore, three-dimensional (3D) model of the patient’s heart valve is made, and simulation of the procedure was conducted.

Methods: Form the cardiac computed tomography data, segmentation of the tissues or organs were made separately, such as a skin, a bone, a heart, coronary arteries, epicardial fat, and so on, and virtual realistic anatomy was made using 3D computer graphics software. Assessment and simulation were made using this 3D computer graphics, in terms of the incision site for best exposure, intracardiac view for valve surgery, coronary artery anatomy in relation to other cardiac anatomy and fatty tissue for MICS coronary bypass surgery, and papillary muscle anatomy for anchoring the artificial chordae for mitral valve repair. With the use of 3D model of the diseased aortic valve, simulation of aortic valve replacement was performed before the aortic valve replacement.

Results: Virtual reality model was made by 3D computer graphics software, and 3D model was useful for the planning of the surgical procedure. It was also used as a navigation during surgery. When the orifice of the right coronary artery could not be recognized, preoperative graphics guided the tip of coronary cannula. During MICS CABG, anastomosis site was easily recognized by the graphics guide. Details of the surgical procedure were considered during the simulation operation on the 3D model.

Conclusions: Our navigation method was useful in MICS in increasing the safety and quality of the surgical procedures.

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CMP44 Minimally Invasive Axial Flow to Centrifugal Flow Left Ventricular Assist Device Exchange: First-in-Man

Amit K. Taggarse, David Lyle Joyce. Mayo Clinic, Rochester, MN USA.

Objective: Left ventricular assist device (LVAD) thrombosis represents an increasingly frequent problem in patients with axial flow devices. In some cases, exchange to a centrifugal flow device is required. Redo sternotomy has been described in all of the previously reports for this technique. We developed a minimally invasive strategy for axial to centrifugal flow device exchange using a limited subcostal incision.

Methods: Cannulation for CPB is performed via the right groin. A limited left subcostal incision is made to facilitate removal of the axial flow device from the silastic sheath, which is trimmed to accommodate the centrifugal flow device. After securing the centrifugal flow LVAD, an end-to-end anastomosis is performed to the existing outflow graft (Fig. CMP44-1).



Results: We employed this technique in a critically ill 50-year-old woman who had a difficult course after axial flow device implantation complicated by LVAD thrombosis 66 days after her LVAD implantation. After minimally invasive device exchange, her LDH levels improved from 2820 to 290 U/L.

Conclusions: Application of minimally invasive approaches to LVAD exchange represents an appealing alternative to redo sternotomy, particularly among patients who are unlikely to tolerate a major surgical procedure. By minimizing dissection through a subcostal approach with retention of the inflow cannula sleeve, device exchange can be accomplished with minimal morbidity.

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CMP45 Axial to Centrifugal Continuous Flow Left Ventricular Assist Device Pump Exchange Using Minimally Invasive Technique

Amit Pawale, Dimosthenis Pandis, Ariel Farkash, Anelechi C. Anyanwu. Mount Sinai Medical Center, New York, NY USA.

Objective: Device infection with extensive soft-tissue abdominal wall destruction may complicate axial flow left ventricular assist device (AFLVAD) implants, and only curative option may be pump exchange. Replacement with similar device is liable to reinfection, as pump configuration is such that the new device may partly lie within infected tissue. We describe treatment of severe AFLVAD infection by minimally invasive exchange to an intrapericardial centrifugal flow left ventricular assist device (CFLVAD).

Methods: A 53-year-old man with an AFLVAD developed refractory device infection with multiple sinuses discharging pus via the abdominal wall, despite antibiotics and repeat surgical debridement. We decided to switch to a CFLVAD to allow abdominal wall healing. We performed a fifth intercostal space left minithoracotomy and a vertical midline epigastric incision. Peripheral cardiopulmonary bypass was instituted. We clamped the outflow graft of AFLVAD through the epigastric incision. We then divided the device inflow via the minithoracotomy and through the two incisions dissected and explanted the pump. The existing apical cuff was excised. A tunnel was dissected anterior to the right ventricle, connecting the two incisions, for later passage of the outflow graft. The CFLVAD was then implanted in the apex and secured. The outflow graft was tunneled to the epigastric incision and anastomosed to the transected AFLVAD outflow graft. The driveline was exteriorized away from the infected abdomen. Left ventricular assist device support was initiated and CPB weaned. After the incisions were closed, we debrided the abdominal wall and placed a drain in the abscess cavity.

Results: Patient had uneventful recovery. After 6 weeks, the abdomen had healed completely and antibiotics had been stopped without recurrence of infection.

Conclusions: Axial to centrifugal continuous flow LVAD pump exchange for extensive driveline/pocket infection is possible using nonsternotomy approach and may reduce the morbidity of what would otherwise be a very invasive reoperation.

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CMP46 Minimally Invasive Left Ventricular Assist Device Implantation: A Comparative Study

Prashant N. Mohite, Diana Garcia-Saez, Bartlomiej Zcyh, Anton Sabashnikov, Rachel Hards, Michael Hedger, Kristine Kiff, Gemma Edwards, Olga Ananiadou, Ashok Padukone, Levente Fazekas, Aron Popov, Binu Raj, Christopher Bowles, Fabio DeRobertis, Toufan Bahrami, Mohamed Amrani, Nicholas Banner, Aida Suarez, Andre Simon. Royal Brompton and Harefield NHS Foundation Trust, Harefield, Uxbridge, United Kingdom.

Objective: Left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. Thoracotomy approach for LVAD implantation is getting popular because of its advantage over conventional sternotomy approach in terms of reduced risk at reoperation due to sternal sparing.

Methods: Thoracotomy approach involved fitting of LVAD inflow cannula into left ventricle apex via left anterior thoracotomy and anastomosis of outflow graft to ascending aorta via right anterior thoracotomy. In sternotomy approach, both the procedures were performed via sternotomy. Outcomes in patients after LVAD implantation were compared depending on the approach for the surgery.

Results: Two hundred five continuous flow LVAD implantations performed between July 2006 and June 2015 at a single center were divided into sternotomy (n=180) and thoracotomy (n=25) groups. There was no significant difference between the groups in relation to patient demographics, preoperative hemodynamic parameters, laboratory markers, or risk factors. HeartWare (HeartWare, Miami Lakes, FL, USA) and HeartMateII (Thoratec, Pleasanton, CA USA) were used in sternotomy approach, whereas only HeartWare was used in thoracotomy approach. There was no significant difference between the groups in terms of postoperative hemodynamic parameters, laboratory markers, bleeding, requirement of blood products, intensive care unit and hospital stay, or complications of LVAD surgery. Thoracotomy compared with sternotomy approach incurred significantly less requirement of temporary right ventricular assist (4% vs. 19.4%).

Conclusions: Minimally invasive thoracotomy approach for LAVD implantation in addition to benefits of sparing sternum avoids dilatation of right ventricle and reduces chances of right ventricular failure requiring temporary right ventricular assist.

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CMP47 Left Ventricle Assist Device Minimally Invasive Implantation: The Evolution of Surgical Technique in a Single-Center Experience

Jonida Bejko, Alvise Guariento, Marina Comisso, Massimiliano Carrozzini, Maurizio Rubino, Vincenzo Tarzia, Gino Gerosa, Tomaso Bottio. Padua University, Padova, Italy.

Objective: The aim of the study was evaluate our surgical experience with continuous-flow left ventricular assist devices (LVADs), from the original full-thoracotomy approach to less invasive surgical strategies comprehending ministernotomy and/or minithoracotomies. We analyze the evolution of our LVAD surgical experience.

Methods: We enrolled patients undergoing surgical implantation of one of the two LVAD types used in our center (both are small, intrapericardially positioned, continuous-flow centrifugal), to reduce possible bias related to the device. Of a total of 93 LVADs implanted in our center, we retrospectively reviewed 52 (55.9%) who received the specific LVAD examined from December 2008 to November 2015. In this analysis, we focused on the surgical implantation technique. Most of the patients (63.5%) were affected of end-stage heart failure because of postischemia or dilative cardiomyopathy, receiving the LVAD in INTERMACS class score of I to II. Mean age, left ventricular ejection fraction, and New York Heart Association class were 59.9 years, 19.23%, and 3.77, respectively.

Results: The implantation of LVAD was performed via full left thoracotomy in 17 patients (32.69%) and full sternotomy in four patients (7.69%), whereas it was conducted throughout a mini-invasive procedure in the remaining 31 patients (59.6%). Mini-invasive approaches were combined upper ministernotomy with left minithoracotomy (nine patients, 17.3%) and combined bi-minithoracotomy (22 patients, 42.3%). The most common postoperative complications were acute right ventricular failure (RVF, 21.15%) and revision for bleeding (32.69%). Revision for bleeding was significantly related to both full sternotomy (75% of the sternotomies) and full thoracotomy (47% of the thoracotomies) with a total of 52.4% versus 22.58% of incidence for the mini-invasive approaches (P=0.026). Regarding the RVF, it was recorded in 50% of the sternotomies and 11.7% of the thoracotomies for a total of 19%, versus 22.6% of incidence in the mini-invasive approach (P=0.76). The most frequent cause of death was stroke (ischemic or hemorrhagic, 11.5%). Nine patients were successfully transplanted.

Conclusions: Satisfactory mid-term survival in severely compromised patients was recorded in our series. Trend versus a decrease in postoperative bleeding, mechanical ventilation, and additionally reduced postoperative in-hospital stay was observed during time-technique evolution toward mini-invasive surgical technique, whereas regarding RVF, the mini-invasive approach is not diriment for the LVAD model analyzed.

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CMP48 Minimal Posterior Axillary Thoracotomy and Muscle-Spare Technique for Female Infants With Congenital Heart Diseases

Zhongdong Hua. Fuwai Hospital Beijing, Beijing, China.

Objective: The aim of the study was to evaluate the surgical outcomes of minimal posterior axillary thoracotomy and muscle-spare technique on female infants with simple congenital heart diseases.

Methods: From April 2008 to October 2015, 586 female infants underwent surgical repair for simple congenital heart diseases by one surgeon with the approach of posterior axillary thoracotomy. The approaches of all the surgery were through thoracotomy with minimal right posterior axillary incisions and muscle-spare technique to avoid breast development issues. The age of the patients ranged from 7 months to 6 years (mean, 14 months), with body weight 7 to 30 kg (mean, 13 kg). The cohort of the patients consists of 156 atrial septal defects, 388 ventricular septal defects, eight partial atrioventricular septal defects, two cor triatriatum, nine partial anomalous pulmonary vein connection, and 23 ventricular septal defects with anomalous muscle bundle in right ventricles. The associated anomalies include left superior vena cava, patent ductus arteriosus, mitral insufficiency, and tricuspid insufficiency. The cardiopulmonary bypass time ranges from 25 to 81 minutes (mean, 45 minutes), and the cross-clamp time ranges from 6 to 51 minutes. The length of incision ranges from 2 to 4.5 cm.

Results: There was no mortality and no major complication. Three patients needed repump run for residual lesion. Eight patients had minimal residual ventricular septal defects, did not need intervention, had pneumothorax, and recovered soon after surgery. All the patients are doing well during follow-up period.

Conclusions: Minimal right posterior axillary thoracotomy with muscle spare technique is a very safe and reliable approach for female infants with congenital heart diseases. The more posterior incision is anticipated to have less concern of breast development issue as well as provides a cosmetic effect.

©2016 by the International Society for Minimally Invasive Cardiothoracic Surgery