STS46thAM Posters

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ADULT CARDIAC POSTERS P1-P36
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P1 Impact of Timing and Surgical Approach on Outcomes Following Mitral Valve Regurgitation Surgery L. Stevens1, E. Rodriguez2, L. Nifong2, E. Lehr2, T. Ferguson2, W. R. Chitwood2 1 Hospital of University of Montreal, Montral, Canada; 2East Carolina University, Greenville, NC
FINANCIAL DISCLOSURE W.R. Chitwood: Intuitive Surgical, Inc., speakers bureau/honoraria; Edwards Lifesciences, LLC, consultant/advisory board
P2 Do Short-Term Post-Transplant Outcomes Di er in Heart Transplant Recipients Bridged With Continuous and Pulsatile Flow Left Ventricular Assist Devices? M. J. Russo1, K. N. Hong2, H. Takayama1, K. Leitz1, R. Davies1, A. Iribarne1, A. S. Stewart1, M. R. Williams1, B. Ramlawi1, D. Ascheim2, A. Gelijns2, Y. Naka1 1 Columbia, New York, NY; 2Mount Sinai School of Medicine, New York, NY Purpose: e purpose of this study was to compare post-transplantation morbidity and mortality in orthotopic heart transplant (OHT) recipients bridged-to-transplant (BTT) with continuous and pulsatile- ow left ventricular assist device (LVAD) with those bridged with inotropic therapy. Methods: UNOS provided de-identi ed patient-level data. e study population included all UNOS Status 1A and 1B OHT recipients (n=6,709) aged 18 years old and transplanted between Jan. 1, 2001, and Dec. 31, 2007. Follow-up was through Feb. 7, 2009. Recipients were strati ed into 3 groups: inotropes (INO n= 4,790, 71.4%), continuous- ow LVAD (CVAD, n=376, 5.6%), and pulsatile ow LVAD (PVAD, 1,543, 23.0%). e primary outcome was 90-day post-transplant graft survival. Other outcomes of interest were risk-adjusted infection (INFX), stroke (STR), and dialysis (DIAL) during the transplant hospitalization; primary graft failure at 90 days (PGF); and length of stay (LOS). Multivariable logistic regression analysis (backward, p < 0.15) was used to determine the relationship between groups and outcome measures. For each variable, odds ratio (OR) and 95% con dence intervals were calculated. Results: Outcomes are summarized in Figure 1. Compared with recipients bridged with inotropes, post-transplant graft survival at 90 days did not di er for recipients bridged with either CVAD (OR=1.47, 0.77-2.82, p=0.247) or PVAD (OR=1.04, 0.731.48, p=0.829). Compared with INO, INFX, PGF, and LOS were signi cantly higher in PVAD and CVAD groups. Conclusions: Compared with recipients bridged with inotropes, post-transplant graft survival at 90 days did not di er for recipients bridged with either continuous or pulsatile- ow LVADs. Additional studies including longer-term follow-up are needed to determine if di erences exist in long-term survival and transplant-related complications.
Purpose: e purpose of this study was to determine if mitral valve (MV) repair timing and surgical approach a ect outcomes in patients with MV regurgitation. Methods: Between 1992 and 2008, 2,234 patients underwent MV surgery at a single institution. We included only patients with isolated MV regurgitation surgery (n = 1,289; MV repairs = 1,040, MV replacements = 249). e surgical approaches included sternotomy (n = 378) and right mini-thoracotomy video (n = 474) or robotically assisted (n = 437). Group di erences were assessed by ANOVA. Mean follow-up was 4.5 3.5 (SD) years. Results: Prevalence of sternotomy MV repair decreased from 66% (96/145; 19921998), to 20% (67/329; 1999-2003) and 8% (49/580; 2004-2008). At the same time, robotic MV repair increased from 0% (0/145) to 34% (113/329) and 57% (329/580). Robotic group patients were younger with fewer female, better ejection fractions and were more likely to have myxomatous degeneration (all p < .001). ese patients had a higher MV repair rate, use of lea et/chordal procedures but longer cardiopulmonary bypass. irty-day mortality for isolated MV repair was similar for all approaches (19/1040 (1.8%); p = 0.409). Five-year survival for isolated MV repair was 87 3% (sternotomy), 82 2% (videoscopic) and 95 2% (robotic; p < .001). After adjustment for age, NYHA class, renal failure, ejection fraction, and MV etiology, survival was similar for all approaches (p = 0.055). Patients in NYHA class I-II with myxomatous degeneration or annular dilatation had similar survival to an age and gender matched populations. However, survival was worse for those with NYHA class III-IV or having a MV replacement. Conclusions: MV repair in patients with severe MV regurgitation should be performed prior to patients developing NYHA Class III or IV symptoms. Minimally invasive MV repair techniques render similar excellent outcomes as the sternotomy approach.
Survival after isolated mitral valve repair in myxomatous degeneration or annular dilatation for patients in NYHA Class I-II vs. Class III-IV
310 The Society of Thoracic Surgeons 46th Annual Meeting 311
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Adult Cardiac Posters Continued P3 A Comparison of Aortic Root Enlargement Techniques and Stentless Valve Implantation for the Management of the Small Aortic Root J. M. Lyons, J. D. Puskas, P. Kilgo, K. T. Baio, E. R. Lyons, R. A. Guyton, E. P. Chen Emory University, Atlanta, GA Purpose: Patient-prosthesis mismatch (PPM) may be associated with poor clinical outcome following aortic valve replacement (AVR). Operative strategies to avoid PPM in the setting of a small aortic root include aortic root enlargement procedures (ARE) and use of stentless valves (SV). It is controversial as to which approach is associated with superior outcome. In this study, clinical outcomes in patients undergoing AVR with either ARE or SV were directly compared and evaluated. Methods: A single-institution retrospective review was performed for all patients undergoing AVR with a SV or ARE from 1998-2008. Redo and concomitant procedures were included, while patients undergoing aortic root replacement were excluded. Study endpoints included death, stroke, MI, major adverse cardiac events (MACE, a composite of death stroke, and MI), incidence of re-operation for bleeding, perfusion and cross clamp times, as well as ICU length of stay (LOS). To address potential selection bias, propensity scores (PS) were calculated for each patient based on 29 known covariates of acute risk. Surgery types were compared using multiple logistic regression models and odds ratios (AOR), adjusted for the PS. Results: Of 231 patients, 124 underwent ARE and 107 underwent SV. e SV group had lower perfusion (135.8 43.6 minutes vs. 161.9 51.9 minutes, p<0.001) and cross clamp times (104.3 27.1 minutes vs. 118.5 38.6 minutes, p=0.009) compared with the ARE group. No di erences were detected between groups for death, stroke, MI, MACE, or ICU parameters (Table 1). e incidence of mediastinal reexploration for hemorrhage was similar between groups. Conclusions: Use of both ARE and SV during AVR for the small aortic root are associated with acceptable operative risk. Clinical outcomes were similar between ARE and SV patients. SV were associated with shorter intraoperative ischemic times and may therefore be preferred to ARE during AVR in the setting of the small aortic root. Comparision of aortic root enlargement techniques and stentless valve outcomes
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P4 Reconsideration of Patient-Prosthesis Mismatch (PPM) De nition From the Valve E ective Ori ce Area Index Y. Sakamoto1, M. Yoshitake1, H. Naganuma1, K. Hashimoto1, K. Morita1, K. Kinouchi1, M. Yamazaki2 1 e Jikei University School of Medicine, Tokyo, Japan; 2Saitama Cardiovascular and Respiratory Center, Kumagaya, Japan Purpose: To prevent patient-prosthesis mismatch (PPM), we have routinely used the projected e ective ori ce area index (EOAI) to help select the most appropriate valve size preoperatively. However, we have encountered a higher residual transvalvular pressure gradient than expected in some patients with an aortic stented bioprosthesis. e aim of this study was to reassess the validity of PPM de nition and also to discuss the possible methods of preventing PPM for di erent valve types. Methods: From June 1996 to 2008, 342 patients who underwent aortic valve replacement with a stented bioprosthetic. e mean follow-up period was 2.41.8 (1~10) years. e mean age and body surface area at operation were 69.76.7 years and 1.540.17m2. Echocardiography was performed 1 to 2 years after surgery. From the data collected, the transvalvular pressure gradients were determined by using the modi ed Bernoulli equation and EOA was calculated with the standard continuity equation. PPM was de ned as an EOAI of less than 0.85 cm2/m2 on the basis of a previous study. Results: e correlation between mean PG and EOAI is shown in Figure 1. Our exponential curve was di erent from the original curve which was drawn from the data on the four di erent prostheses and de ned the criteria of PPM. e mean PG of the stented bioprosthetic demonstrated a higher gradient and smaller EOAI compared with the exponential curve described by Pibarot et al. Postoperative mPG(mmHg) were 17.45.6 and 14.55.6 in patients with the EOAI<0.85 and >0.85(p< 0.003). Most patients with the EOAI>0.85 showed the postoperative mPG beyond 10mmHg. Conclusions: Based on our data, an EOAI<2.0cm2/m2 might be the threshold for PPM in patients with the stented bioprosthetic. e practical implications of these ndings include the necessity to reconsider the hemodynamic performance of each prosthesis when seeking to de ne PPM, so as to avoid residual signi cant transvalvular PG and higher rates of morbidity and mortality.
p <0.05
Figure 1. Correlation between mPG and EOAI Solid line: Y=44.5exp(-X/0.52), only for data on the stented bioprosthetic valve Dotted line: Y=81.1exp(-X/0.40), described by Pibarot
46th Annual Meeting 313
312 The Society of Thoracic Surgeons
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Adult Cardiac Posters Continued P5 Clinical Results and Atrial Function Following Surgical Treatment of Lone Atrial Fibrillation G. Bisleri1, N. Berlinghieri1, A. Manzato2, P. Piccoli1, A. Repossini1, C. Muneretto1 1 University of Brescia Medical School, Brescia, Italy; 2Hospital Spedali Civili of Brescia, Brescia, Italy Purpose: Minimally invasive surgical treatment of lone atrial brillation(AF) is gaining popularity thanks to its encouraging results, albeit the atrial performance following surgical ablation in this speci c subset of patients has not been widely investigated so far. Methods: irty- ve patients with lone AF underwent closed-chest surgical ablation via a monolateral approach; a continuous linear epicardial encircling of the pulmonary veins (box lesion) was performed using a microwave or unipolar radiofrequency endoscopic probe; 63% (22/35) had paroxysmal AF while the remaining ones were in persistent AF. All patients received high-thoracic epidural anesthesia (T1-T2 level). Pre-operatively and at follow-up, echocardiographic evaluation of the atrial function was performed by means of the analysis of the LA diameter, EF, E/A waves ratio and deceleration time(Dt). Results: All procedures were successfully performed, and in 14 of them consciousness and spontaneous breathing was maintained throughout the operation. In the remaining patients, extubation was carried out in the OR. No ICU stay was required nor did any postoperative complications occur. Patients were discharged after 3.22.5 days. At a mean follow-up of 670 days (range 230-1233 days), 30/35 patients (85.8%) were in sinus rhythm. In 19 patients, an echocardiographic study was performed after 779283 days following ablation and compared to the pre-operative ndings; in 18/19 of those patients, sinus rhythm was detected. ere was a tendency toward a reduction of the LA diameter, improved EF, and normalization of the E/A ratio (p=NS); Moreover, there was a consistent reduction in the E wave deceleration time (p<0.05), as depicted in the table. Conclusions: Following surgical ablation (box lesion), patients with sinus rhythm showed a tendency toward normal atrial function, albeit further data are warranted to con rm our preliminary results. Echocardiographic data
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P6 Operative Strategy for Descending and Thoracoabdominal Aneurysm Repair with Preoperative Demonstration of the Adamkiewicz Artery Using Intra-arterial Computed Tomography K. Furukawa, S. Morita Saga University, Saga, Japan Purpose: Our study aimed to demonstrate the e cacy of preoperative intra-arterial CT angiography (IA-CTA) to identify the Adamkiewicz artery (AKA). We also aimed to show that accurate identi cation of the AKA may prevent spinal cord injury with the selective perfusion of AKA intra-operatively. Methods: irty-one patients were studied: 21 cases of descending aneurysms (DA) and 10 cases of thoracoabdominal aneurysms (TAA). Average age was 63.9 years old. A pigtail catheter was inserted into the descending aorta, and its tip was located immediately below the left subclavian artery. Subsequently, IA-CTA was performed and the segmental artery to the AKA (SA-AKA) was identi ed. Repairs were performed through a left thoracic or thoracoabdominal incision, using partial cardiopulmonary bypass. In cases where the aortic segment that supplied the AKA was cross-clamped, the identi ed SA-AKA was selectively perfused. In these cases, the SA-AKA was reconstructed with an interposition graft. Results: Preoperative IA-CTA successfully identi ed the SA-AKA in all patients. e numbers of AKA were 1 in 22 patients, 2 in 7 patients, and 3 in 2 patients, with the origin of the AKAs ranging between the level of the 5th thoracic vertebra and 3rd lumber vertebra. Selective perfusion of preoperatively identi ed SA-AKAs was performed in 12 cases. e average number of reconstructed segmental arteries was 0.4 in DA and 2.0 in TAA. e mean durations of cardiopulmonary bypass and cross clamping were 139 and 120 minutes, respectively. One hospital death (3%) occurred in a patient with chronic heart and renal failure. Although paraparesis occurred in one patient with a TAA (3%), the other patients survived without spinal cord injury. Conclusions: IA-CTA reliably identi ed the SA-AKA. Furthermore, selective perfusion of the SA-AKA, based on the accurate preoperative identi cation, is useful for preventing spinal cord injury.
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Adult Cardiac Posters Continued P7 Surgical Thoracic Sympathectomy Induces Structural and Biomechanical Remodeling of the Thoracic Aorta in Pigs D. C. Angouras1, T. J. Dosios1, N. G. Kostomitsopoulos2, C. A. Dimitriou2, T. Manos2, T. Chamogeorgakis1, C. K. Rokkas1, D. P. Sokolis2 1 Athens University School of Medicine, Athens, Greece; 2Academy of Athens, Athens, Greece Purpose: e e ect of sympathetic nervous system on aortic wall structure and function is poorly de ned. is study investigated chronic changes in aortic structural and biomechanical properties induced by thoracic sympathectomy. Methods: Six healthy Landrace pigs underwent bilateral thoracic sympathectomy from the stellate to T8 ganglion, while 10 pigs underwent sham-operation. Animals were sacri ced three months postoperatively. Histometrical examination was performed on specimens from the thoracic (TA) and abdominal aorta (AA) utilizing an imageprocessing system. Biomechanical evaluation was performed with a uniaxial tensile tester; parameters of extensibility, strength, and sti ness of aortic tissue were calculated. Results: Structural aortic remodeling of sympathectomized animals was observed, including increased inner aortic diameter in TA (15.30.4 vs. 10.40.2 mm, P<0.001) and AA (6.70.3 vs. 5.30.2 mm, P=0.002), and increased wall thickness in TA (2.00.1 vs. 1.60.1 mm, P<0.001) but not AA. Microscopic image analysis revealed increased elastin (TA: 50.11.1 vs. 29.70.6%, P<0.001; AA: 20.42.1 vs. 16.30.6%, P=0.03) and collagen density (only in TA: 22.00.9 vs. 15.40.5%, P<0.001), and decreased smooth muscle density (TA: 27.61.3 vs. 54.90.7%, P<0.001; AA: 57.21.5 vs. 63.40.8%, P<0.001). Sophisticated biomechanical analysis demonstrated that, in response to sympathectomy, the TA, although equally extensible, manifested augmented strength (134473 vs. 107152 kPa, P=0.004) and sti ness (6738478 vs. 5026273 kPa, P=0.003), in accordance with collagen accumulation in that region, while di erences in the AA were non-signi cant. Conclusions: Chronic thoracic sympathetic denervation causes signi cant structural and biomechanical remodeling of the thoracic aorta. Possible clinical implications for patients undergoing thoracic sympathectomy or chronically treated with sympathetic blockers require further investigation.
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P8 Short- and Mid-Term Outcomes of O -Pump Left Ventricular to Descending Aortic Conduit Bypass for the Relief of Aortic Stenosis in Adults V. H. ourani, A. B. Dara, W. B. Keeling, R. A. Guyton Emory University Hospital Midtown, Atlanta, GA
FINANCIAL DISCLOSURE V.H. Thourani: Maquet, research grant; Medtronic, Inc., research grant; Edwards Lifesciences, LLC, research grant; CardioMEMS, consultant/advisory board; Mitral Solutions, consultant/advisory board; Estech, consultant/ advisory board; Bayer, speakers bureau/honoraria; St. Jude Medical, speakers bureau/honoraria. R.A. Guyton: Edwards Lifesciences, LLC, research grant; Medtronic, Inc., research grant; On-X Life Technologies, research grant; Maquet, research grant; TCT, Inc., consultant/advisory board.
Purpose: Elderly patients with aortic stenosis (AS) presenting for an aortic valve replacement (AVR) with a hostile ascending aorta remain a challenging patient cohort. e purpose of this study was to assess outcomes following the use of an apical-aortic conduit (AAC) performed without cardiopulmonary bypass (CPB). Methods: A single U.S. institution retrospective review was performed on 20 high-risk patients who underwent primary, isolated AAC bypass from Sept. 2004 to June 2009. AAC was utilized for a porcelain aorta alone in 6 (30.0%) patients, previous coronary artery bypass grafting (CAB) in 4 (20.0%), or both in 9 (45.0%). One patient (5.0%) had an AAC for severe cirrhosis who was thought not to be a candidate for CPB. Results: Mean age was 74.36.9 years (median: 76 years) and 15 patients (75%) were male. Mean NYHA classi cation was 2.91.1 (median: 3) and preoperative EF was 46.816.3% (median: 53%). Preoperative co-morbidities included peripheral vascular disease (n=8, 40.0%), chronic lung disease (n=15, 75.0%), diabetes mellitus (n=9, 45.0%), heart failure (n=12, 60.0%), and dialysis-dependence (n=2, 10.0%). Either an 18 (n=11, 55%) or 20mm (n=9, 45%) conduit was utilized, with an interposed freestyle 21 porcine root in all patients. No patient experienced intraoperative complications or damage to previous coronary bypass grafts. ere was no postoperative stroke or renal failure. e mean ICU stay was 139.2163.5 hours (median: 89.1) and overall postoperative length of stay was 11.57.4 days (median: 9). In-hospital mortality was in 2 patients (10%): 1 of postoperative pulmonary embolus and the other of sudden ventricular brillation. Mid-term follow-up shows an additional 4 patients died at a mean of 301.3241.6 days (median: 258). Conclusions: AAC without the utilization of CPB is an innovative, feasible alternative for the treatment of severe AS with acceptable short-term morbidity and minimal mortality in this extremely high-risk surgical population.
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Adult Cardiac Posters Continued P9 Delivery of Combined Growth Factors by Genetically Engineered Myoblasts Improves Cardiac Function and Induces a Patent Vasculature in the Rat Failing Heart M. Gmeiner, P. Paulus, R. Schaefer, N. Sela, M. Grimm, S. Aharinejad Medical University of Vienna, Vienna, Austria Purpose: Re-constitution of blood supply is crucial to rescue myocardial tissue following infarction. Skeletal myoblast (MB) transplantation is an alternative to repair irreversibly damaged myocardium, however low MB survival and lack of patent blood vessels are limiting factors. erefore, we investigated whether genetic modi cation of MBs to overexpress a combination of growth factors ameliorates heart failure by inducing a patent vasculature. Methods: Rats developing ischemia-induced heart failure received intramyocardial injections of Ringers solution (control), unmodi ed autologous MBs or MBs transfected with colony-stimulating factor-1 (CSF-1), vascular endothelial growth factor-A (VEGF-A), basic broblast growth factor (bFGF) and angiopoietin-1 (Ang1) expression plasmids. Cardiac function was assessed by echocardiography over time up to 86 days following MB engraftment. Tissue vascular and macrophage density was analyzed by immunocytochemistry. An intravital video microscope imaging device captured in vivo images of the vasculature. Heart failure development was additionally monitored by measuring circulating brain natriuretic peptide (BNP). Results: Left ventricular function signi cantly improved over time and ejection fraction on day 86 was signi cantly enhanced in the transfected MB compared to control (p<0.01) and unmodi ed MB (p<0.05) groups. e density of a patent vasculature and macrophages recruited to the infarct zone increased in rats treated with modi ed MBs compared to other groups (p<0.001). BNP serum levels were signi cantly lower in the modi ed but not unmodi ed MB group compared to controls (p<0.05). Conclusions: Combination therapy with CSF-1, VEGF-A, bFGF and Ang-1 expression plasmids delivered by transplantation of autologous MBs may represent a novel strategy in treatment of ischemia-induced heart failure.
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P10 Transcatheter Aortic Valve Implantation (TAVI) Versus Conventional Aortic Valve Replacement: A Single-Center Experience M. Ghosh-Dastidar, S. Chaubey, R. Dworakowski, E. Kapetanakis, A. El Gamel, P. MacCarthy, M. Monaghan, O. Wendler Kings College Hospital, London, United Kingdom
FINANCIAL DISCLOSURE A. El Gamel: Edwards Lifesciences, LLC, consultant/advisory board. P. MacCarthy: Edwards Lifesciences, LLC, consultant/advisory board. M. Monaghan: Edwards Lifesciences, LLC, consultant/advisory board. O. Wendler, Edwards Lifesciences, LLC, consultant/advisory board.
Purpose: TAVI is considered in elderly and high-risk patients as an alternative to AVR. Currently there are only limited data on how demographics and postoperative results of AVR patients compare to patients undergoing TAVI. Methods: Retrospectively all data of patients who underwent isolated, primary AVR between April 1992 and Dec. 2008 were analyzed. ey were grouped according to age (70-79 years: Group-A n=416; 80years: Group-B n=157) and compared with patients who underwent TAVI between Aug. 2007 and March 2009 (n=53). Results: ere was no signi cant di erence between the mean age of Group-B (83.93.2 years) and TAVI (82.76.6 years). e logistic EuroSCORE was signi cantly higher in TAVI (21.510.4% vs. Group-B 16.210.7%; Group-A 8.67.3%; p<0.001). e comparison between Group-A and Group-B showed no signi cant di erence regarding left ventricular dysfunction, renal failure and respiratory disease. Interestingly a signi cantly lower incidence of diabetes mellitus (4.5%(n=7) vs. 10.3%(n=43)) and current smoking (2.6%(n=4) vs. 8.9%(n=37)) was found for Group-B.TAVI showed signi cantly higher incidence of diabetes mellitus (16.7%(n=9) vs. 4.5%(n=7)), renal failure (20.8%(n=11) vs. 1.3%(n=2)) and respiratory disease (39.6%(n=21) vs. 19.8%(n=31)) than Group-B. Postoperative outcome was not signi cantly di erent between Group-B and TAVI in terms of stroke (3.2%(n=5) vs. 3.7%(n=2)), AV-block (4.5%(n=7) vs. 1.9%(n=1)), length of hospital stay (86.1d vs. 87.1d), and in-hospital mortality (7.7%(n=12) vs. 9.4%(n=5)). Prolonged ventilation (7.7%(n=9) vs. 1.9%(n=1)) and intensive care stay >1d (25.5%(n=40) vs. 15.1%(n=8)) were less common after TAVI. Conclusions: Octogenarians who are considered for AVR present with fewer comorbidities than the cohort of patients 10 years younger. TAVI patients present with more co-morbidities and a higher predicted mortality than conventionally operated octogenarians. Post-operative results, however, for both groups are comparable.
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Adult Cardiac Posters Continued P11 Long-Term Survival for Bioprosthetic Valve Replacement is Similar to Mechanical Valve Replacement in Patients With Preoperative End Stage Renal Failure V. H. ourani, A. B. Dara, P. Kilgo, O. M. Lattouf, J. D. Puskas, E. P. Chen, W. A. Cooper, J. Vega, C. D. Morris, T. A. Vassiliades, R. A. Guyton Emory University Hospital Midtown, Atlanta, GA Unadjusted Outcomes
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FINANCIAL DISCLOSURE V.H. Thourani: Edwards Lifesciences, LLC, speakers bureau/honoraria; Medtronic Inc., speakers bureau/honoraria; St. Jude Medical Inc., speakers bureau/honoraria; Maquet, speakers bureau/honoraria; MitralSolutions, consultant/advisory board; Transcardiac Therapeutics, Inc., consultant/advisory board. O.M. Lattouf: On-X Life Technologies, research grant; Medtronic Inc., consultant/advisory board; Cardiogenesis, consultant/advisory board; Baxter, consultant/advisory board; Transcardiac Therapeutics, Inc., ownership interest. J.D. Puskas: Medtronic Inc., research grant; On-X Life Technologies, research grant; Maquet, research grant; Cardica Inc., research grant; Transcardiac Therapeutics, consultant/advisory board; Clear Catheter Systems, consultant/advisory board. E.P. Chen: Medtronic Inc., consultant/advisory board; Terumo Cardiovascular Systems Corporation, research grant; St. Jude Medical Inc., consultant/advisory board. W.A. Cooper: Maquet, consultant/advisory board. C.D. Morris: Maquet, speakers bureau/honoraria; T.A. Vassiliades, Maquet, consultant/advisory board; CorSynergy, Inc, ownership interest; Heart Lea et Technologies, consultant/advisory board. R.A. Guyton: Edwards Lifesciences, LLC, research grant; On-X Life Technologies, research grant; Medtronic Inc., research grant; Maquet, research grant; TCT, Inc., consultant/advisory board.
Purpose: e purpose of this study was to assess short- and long-term outcomes following valve replacement with biological or mechanical prostheses in patients with preoperative end stage renal disease (ESRD) on chronic dialysis. Methods: A retrospective review of patients with ESRD undergoing valve replacement from 1996-2007 at a U.S. academic center was performed. Outcomes were compared using chi-square tests and 2-sample t-tests, adjusted for 13 pre-operative covariates. Adjusted long-term survival up to 10 years was assessed with Kaplan-Meier plots and compared between biological and mechanical replacements using the Cox proportional hazards model. Results: A total of 202 patients underwent 211 valve replacement surgeries. Patient age was 20 to 83 years (mean age: 54.814.0); 115/211 (54.5%) were male. Surgeries included: 100/211 (47.4%) isolated aortic, 49/211 (23.2%) isolated mitral, 4/211 (1.9%) isolated tricuspid, and 58/211 (27.5%) combined replacements. irteen (6.2%) patients underwent reoperative valve replacements. Most patients received bioprosthetic valves (139/211, 65.9%), while 72/211 (34.1%) received mechanical valves. Concomitant coronary artery bypass was performed in 53/211 (25.1%) patients. irtyday mortality was in 42/211 patients (19.9%) and was not di erent between bioprosthetic and mechanical replacements (Table). Overall 10-year survival was 18.1% for all patients and was not in uenced by valve type implanted. Signi cant independent predictors for long-term mortality included age (HR 1.01) and peripheral vascular disease (HR 1.60). Conclusions: For patients with ESRD treated with dialysis, valve replacement carries acceptable operative mortality. Long-term survival is similar among patients receiving bioprosthetic versus mechanical valve replacement. Careful risk assessment and choice of valve prosthesis should be performed prior to surgical intervention in this high-risk patient population. Long-term survival of dialysis patients with bioprosthetic valves vs. mechanical valves
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Adult Cardiac Posters Continued P12 Marrow Stromal Cells Di erentiate Into Vasculature After Autologous Transplantation Into Ischemic Myocardium Y. Zhou, S. Wang, Z. Yu, R. F. Hoyt, K. A. Horvath National Heart Lung and Blood Institute, Bethesda, MD Purpose: Marrow stromal cells (MSCs) are reportedly able to improve ventricular function after MI through the paracrine e ect or regenerating myocytes. However, the evidence to prove that is scant. Methods: Following the harvest of adult pig bone marrow, the mononuclear cells were placed in DMEM (Dulbeccos modi ed eagles medium) supplemented with 10% FBS or in EGM2 (growth factor enriched medium) in a density of 106/cm2 at 37C with 5% CO2 in T-75 culture asks. After four passages, the phenotype of the cells in both media showed uniform broblast-like morphology. e FACS analysis at passage four revealed cells positive for CD44, CD90, and negative for CXCR4, CD34, C-kit, CD45, CD31 and CD54, suggesting MSC lineage. Further di erentiation studies of these cells revealed multi-mesenchymal lineages, such as adipocytes and osteocytes. Chronic ischemia via ameroid constriction of the circum ex artery was established and direct intramyocardial injection of 120 million autologous MSCs in the ischemic zone (25 inject sites) were performed on eight animals. Animals were then sacri ced for immunohistological studies at 1, 2, 4 and 6 weeks post-injection (2 animals at each time point). Results: At 1 week after injection, clusters of injected cells were noted. Higher magni cation revealed many immature capillaries inside the cell cluster. Over time, newly formed, more mature small vessels were found inside the clusters. ese cells stained negative for CD163 and CD68, but positive for CD90, factor VIII and smooth muscle actin. However, no new growth of myocytes was detected in the ischemic area as assessed by cell morphology or desmin immunostaining. Conclusions: ese results indicate direct injection of MSCs into ischemic myocardium leads to the cells di erentiation into vascular endothelial and smooth muscle instead of cardiomyocytes, suggesting that the bene ts of cell-based therapy are primarily due to angiogenesis not the regeneration of cardiomyocytes.
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P13 The Future of Cardiac Surgery in Canada: A Workforce Simulation Model C. Feindel1, S. Vanderby2, M. Carter2, T. Latham5, M. Ouzounian3, A. Hassan3, G. H. Tang2, C. Teng2, K. Kingsbury4 1 University Health Network, Toronto, Canada; 2University of Toronto, Toronto, Canada; 3 Dalhousie University, Halifax, Canada; 4Cardiac Care Network of Ontario, Toronto, Canada; 5 Royal Columbian Hospital, Vancouver, Canada Purpose: In Canada, because of the current lack of job opportunities, one-third of the 11 residency entry positions in cardiac surgery went un lled in 2009. is reduced interest in training, coupled with the aging of existing surgeons, as well as the population they serve, are causes for concern. We developed a workforce model that, under di erent scenarios, predicts the number of cardiac surgeons required to serve the Canadian population in the future. Methods: Using Systems Dynamics, the model simulates workforce needs for cardiac surgeons in Canada over time up to the year 2030. e variables considered in the model were: (1) Demand for cardiac surgery. (2) Supply of existing cardiac surgeons. (3) Average case volume per surgeon. (4) Supply of future cardiac surgeons. (5) Canadian population projections. Various scenarios were incorporated into the model in order to examine the interactions amongst changes in demand for cardiac surgery, surgeon productivity, resident enrollment rates and projected population growth rates. Results: While there is currently an over-supply of cardiac surgeons in Canada, this model showed that in the various scenarios tested, surgeon shortages are predicted to begin by 2015-2016 and by 2030 may be as high as one third of the required workforce. e predicted need for cardiac surgeons across Canada will only be met if the annual enrollment into residency training programs is maintained at 10 or more students per year. Conclusions: is model predicts that the current limited opportunities for cardiac surgeon employment will be short-lived, and, that unless enrollment is maintained at or above 10 trainees per year, signi cant and potentially critical shortages of cardiac surgeons can be expected in Canada after 2016. e ndings of this study should be helpful to those students considering a career in cardiac surgery, as well as to those organizations responsible for health care planning and health policy.
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Adult Cardiac Posters Continued P14 What is the Optimal Revascularization Strategy in Patients with Liver Cirrhosis? Insights from CREDO Kyoto Registry A. Marui, T. Kimura, S. Miwa, K. Yamazaki, K. Minakata, T. Nakata, T. Ikeda, T. Kita, R. Sakata Kyoto University Graduate School of Medicine, Kyoto, Japan
FINANCIAL DISCLOSURE T. Kimura: Research Institute, research grant. T. Kita: Research Institute, research grant.
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P15 Aortic Valve Repair With Ascending Aortic Aneurysms: Associated Lesions and Adjunctive Techniques M. Boodhwani, L. de Kerchove, D. Glineur, J. Rubay, R. Verhelst, M. Van Dyck, A. Pasquet, P. Noirhomme, G. El Khoury Private Universities Saint-Luc, Brussels, Belgium Purpose: Patients with supracoronary ascending aortic (AA) aneurysms can present with varying degrees of aortic insu ciency (AI) due to dilatation of the sinotubular junction (STJ) but may also have associated cusp pathology. In this patient population, the incidence and types of cusp lesions, as well as the e ect of AI severity and cusp repair on outcome, is not well de ned. Methods: Since 1996, 55 patients (mean age: 65 13 years, 17 [31%] bicuspid valves) presented with supracoronary AA aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated lea et pathology included cusp prolapse in 18 (33%), cusp restriction in 12 (22%), and both in 3 (5%). All patients underwent replacement of the supracoronary AA to reduce the size of the STJ. Adjunctive techniques included sub-commissural annuloplasty in 38 (69%) and cusp repair in 28 (51%). Clinical (mean: 61 28 months) and echocardiographic (mean: 40 21 months) follow-up was complete in 98% and 91% of patients respectively. Results: Severity of AI was not signi cantly associated with the presence of cusp pathology (p = 0.35). However, cusp disease was present in 100% of bicuspid aortic valves compared to only 34% of trilea et valves (p<0.001). ere was no hospital mortality and overall survival was 94 4% and 75 10% at 5 and 7 years. Freedom from aortic valve reoperation was 100% and freedom from recurrent AI (>2+) was 87 7% at 7 years. Neither the presence of preoperative severe AI (p=0.12), nor the need for cusp repair (p=0.93) was predictive of recurrent AI (>=2+) at follow-up. Conclusions: Cusp pathology is frequently encountered in patients with ascending aortic dilatation, particularly in bicuspid valves and does not correlate with the severity of AI. Severe AI is not a contraindication to valve preserving surgery but careful identi cation and repair of cusp pathology in addition to STJ reduction is critical for durable long-term outcome.
Purpose: Although liver cirrhosis (LC) is a major risk factor for cardiac surgery using cardiopulmonary bypass, only a few reports with small series have been available. Regarding coronary revascularization, percutaneous coronary intervention (PCI) or o -pump CABG (OPCAB) may be an alternative strategy in patients with LC. us, we investigated the optimal revascularization strategy in those patients. Methods: Between 2000 and 2002, a total of 9,877 Japanese patients from 30 institutions who received PCI or CABG were enrolled in CREDO-Kyoto Registry. Among them, 192 patients with multivessel disease with LC were enrolled in this study (699 years old, 142 male). e severity of LC was graded using the Child-Pugh classi cation. Results: 124 patients received PCI, 31 OPCAB, and 37 on-pump CABG (ONCAB), respectively. Median follow-up was 3.1 years. Age and preoperative left ventricular ejection fraction were not di erent among the 3 groups (p=0.93 and p=0.20). A number of diseased coronary vessels was lower in the PCI-treated group (p<0.001). e overall in-hospital mortality of patients who received PCI, OPCAB, and ONCAB were 1%, 0%, and 11%, respectively, which were not di erent by multivariate analysis. e overall mortality during the whole study period of PCI, OPCAB, and ONCAB was 26%, 23%, and 30%, respectively; whereas, the cardiovascular (CV) mortality was 13%, 3%, and 22%, respectively. Multivariate analysis showed that revascularization by OPCAB was only factor that reduced the incidence of the CV mortality (p=0.045). Furthermore, OPCAB also reduced the overall mortality (p=0.048). Both OPCAB and ONCAB reduced the incidence of any additional revascularization (p<0.0001) compared with PCI. Conclusions: Although the mortality was still high in patients with LC after coronary revascularization, OPCAB reduced the incidence of the overall and CV mortality as compared with PCI or ONCAB. OPCAB can be a favorable revascularization strategy in patients with LC.
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Adult Cardiac Posters Continued P16 Concomitant Septal Myectomy at the Time of Aortic Valve Replacement for Aortic Stenosis N. Kayalar, R. C. Daly, H. V. Scha , T. M. Sundt, J. Dearani, S. J. Park Mayo Clinic, Rochester, MN Purpose: Left ventricular out ow tract obstruction (LVOTO) may be unmasked following a successful aortic valve replacement for severe aortic stenosis in the setting of asymmetrical basal septal hypertrophy (BSH). We reviewed our experience of the patients who underwent concomitant septal myectomy at the time of aortic valve replacement for severe aortic stenosis. Methods: During the 10-year period ending Jan. 2009, 3,523 patients underwent aortic valve replacement (AVR) for severe aortic stenosis. Forty-seven of these patients underwent concomitant septal myectomy. Patients with the diagnosis of obstructive hypertrophic cardiomyopathy were excluded. Pre- and postoperative echocardiography, operative data, hospital course, morbidity and mortality were assessed. Preoperative risk factors associated with BSH requiring myectomy were also analyzed. Results: e mean age of the group was 7311 years. Only 27% of patients were suspected to have BSH of concern for a possible LVOTO on preoperative transthoracic echocardiography. e myectomy performed at AVR was not extensive with an excised mean muscle mass of 0.80.61 grams. e changes in left ventricular indices and hemodynamic data are summarized in the table. e operative mortality was 2%. Two patients (4.2%) required a permanent pacemaker for a complete heart block. No iatrogenic ventricular septal defect was noted. Conclusions: A quantitative assessment of the obstructive BSH in the setting of severe aortic stenosis may be di cult preoperatively. e presence of female gender, history of hypertension or high preoperative transaortic gradient may raise a suspicion for the obstructive BSH. Intraoperative inspection of the left ventricular out ow tract warranted a concomitant septal myectomy in a sizable fraction of patients undergoing AVR. e concomitant myectomy can be performed safely without increased risks of operative morbidity or mortality.
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LVM: Left ventricular mass, LVMI: Left ventricular mass index, IVS: interventricular septum, PW: posterior wall, LVEDD: Left ventricular end-diastolic dimension, LVESD: left ventricular end-systolic dimension, LVEF: Left ventricular ejection fraction. *p <0.05 before surgery vs. early after surgery p< 0.05 before surgery vs. at 1-year
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Adult Cardiac Posters Continued P17 Transapical Aortic Valve Replacements Under Real-Time MRI Guidance: Experimental Results With Balloon Expandable and Self-Expanding Stents K. A. Horvath, D. Mazilu, O. Kocaturk, M. Li National Heart Lung and Blood Institute, Bethesda, MD Purpose: Clinically, transapical aortic valves (tAVR) have been implanted on selfexpanding (SE) and balloon-expandable (BE) stents. Previously we have demonstrated the advantages of tAVR under real-time MRI guidance (rtMRI). Whether there are di erent advantages to SE or BE stents is unknown. Methods: irty-four domestic pigs (45-57 kgs.) underwent rtMRI guided tAVR without unloading by rapid ventricular pacing or cardiopulmonary bypass. Commercially available stentless bioprostheses (21-25mm) were mounted on either BE platinum iridium stents or SE nitinol stents and randomly implanted. Passive markers on both types of stents enhanced the orientation of the prosthesis in rtMRI. 1.5T MR imaging was used to precisely identify the anatomic landmarks of the aortic annulus, coronary artery ostia, and the mitral valve lea ets. e animals were allowed to survive and had follow-up MRI scans and echocardiography at 1, 3 and 6 months postoperatively. Results: rtMRI provided excellent visualization of the aortic prosthetic valve implantation mounted on either stent types. e implantation times were 7418 seconds (mean s.d.)(BE) and 6014s (SE). Total procedure time (mean) was 37 and 31 minutes, respectively. It was signi cantly easier to manipulate the SE stent during deployment without hemodynamic compromise. is was not always the case with BE and resulted in coronary obstruction or valve misalignment and death (n=4). Longterm results demonstrated stability of the implants with preservation of myocardial perfusion and function over time for both stents. Phase contrast MRI and echocardiography demonstrated minimal inter or paravalvular leaks immediately after implantation and at follow-up. Conclusions: Self-expanding stents were easier to position and deploy thus leading to fewer complications during transapical AVR. Future utilization of SE stent design should improve clinical results.
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P18 Transcatheter Aortic Valve Implantation as the Treatment of Choice in Patients With Previous Open Heart Surgery J. Strauch, P. Haldenwang, R. P ster, E. Kuhn, U. Hoppe, F. Baer, T. C. Wahlers University of Cologne, Cologne, Germany Purpose: e treatment option for symptomatic aortic stenosis even in the case of previous heart surgery is aortic valve replacement (AVR) with cardiopulmonary bypass (CPB) and median re-sternotomy. We determined whether transcatheter aortic valve implantation (TAVI) is a safe and gentle option of treatment in these often high-risk patients where the avoidance of median re-sternotomy and CPB is a major purpose. Methods: Since March 2008, 21 (82.43, 8 years, 16 female) out of 56 TAVI-patients with severe aortic stenosis underwent either transapical (n=47) or transfemoral (n=9) valve implantation under avoidance of CPB. All patients were scheduled for reoperations and rejected for open aortic valve replacement with an average log. EuroSCORE of 3810% and a STS Score of 154%. Mean ejection fraction was 4113% and mean aortic valve area was 0.580.16 cm2. Results: In 76% (16/21 patients) a CABG, in 19% (4/21 patients) biological AVR and in 5% (1/21 patients) mechanical MVR was previously operated. Device delivery was successful in 95% (20/21 patients). irty-day mortality was 7% (4/56 patients) resp. 5% (1/21 patients) (migration of the valve into LV-cavum) in the group of redoprocedures. Echocardiography at day 7 and week 10 revealed no paravalvular leakage graded higher than trace. Permanent neurological event occurred in 0% (0/21 patients), 10% (2/21 patients) required permanent pacemaker implantation. Conclusions: Results for TAVI following previous heart surgery, either previous CABG or valve replacement are excellent with signi cant lower mortality compared to the EuroSCORE estimated. To date in our series, TAVI should be automatically considered in patients undergoing AVR as a redo-procedure and may be the optimal treatment in these multiple compromised patients in the future.
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Adult Cardiac Posters Continued P19 Transapical Aortic Valve Implantation In Patients With Porcelain Aorta J. Kempfert, A. Van Linden, G. Schuler, A. Linke, S. Lehmann, L. Lehmkuhl, F. W. Mohr, T. Walther Heart Center University of Leipzig, Leipzig, Germany
REGUL ATORY DISCLOSURE Used within EU only, CE mark approved.
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P20 A Two-Stage Approach Reduces Risk of Paraplegia Following Repair of Extensive Thoracoabdominal Aneurysms S. Zoli, C. D. Etz, F. Roder, R. M. Brenner, C. A. Bodian, G. Kleinman, G. Di Luozzo, R. B. Griepp Mount Sinai School of Medicine, New York, NY Purpose: In a pig model, we compared spinal cord injury after extensive segmental artery (SA) sacri ce in a single stage with recovery after a 2-stage procedure: lumbar artery (LA) followed by thoracic SA sacri ce. Methods: Twenty juvenile Yorkshire pigs (mean weight 241.5 kg) were randomized to extensive craniocaudal SA sacri ce at 32C in a single operation (Group 1, N=10), or thoracic SA ligation 7 days after LA sacri ce (Group 2, N=10). 14.40.5 SAs were sacri ced in Group 1 and 14.30.5 in Group 2 (p=ns). Spinal cord perfusion pressure (SCPP) was monitored via a catheter placed in the distal stump of L1. Hind limb function was evaluated intraoperatively using motor-evoked potentials(MEP) and for 5 days postoperatively using a modi ed Tarlov score Results: MEPs were intact in all pigs until one hour after surgery. All pigs in Group 2 fully recovered hind limb function, while 40% in Group 1 developed paraplegia; median Tarlov scores at 5 days were 9 (range 8-9) in Group 2 vs. 7 (range 1-9) in Group 1 (p=.004). In contrast with the marked drop in SCPP in Group 1 after SA sacri ce (Figure), SCPP in Group 2 fell from 696 mmHg only to 448 mmHg(65% baseline) after 5.70.5 SAs were sacri ced (p<.0001), returning to baseline within 72 hours. After sacri ce of all residual SAs (8.60.5) one week later, SCPP in Group 2 remained consistently >80% of baseline, signi cantly higher than Group 1 SCPP from endclamping until 72 hours (p=.0002). Histopathological analysis showed more severe ischemic damage to the lower thoracic (p<.001) and lumbar spinal cord (p=.01) in Group 1 Conclusions: In contrast with the single-stage approach, a 2-stage procedure, starting with ligation of 6 lumbar SAs, leads to only a mild drop in SCPP and stimulates vascular remodeling, minimizing the impact of subsequent SA sacri ce on spinal cord function. e greater safety of extensive SA sacri ce when undertaken in 2 stages has important implications for endovascular/hybrid aneurysm repair
Purpose: Conventional aortic valve replacement (AVR) is technically demanding in patients with porcelain aorta and would be associated with an increased risk for stroke and mortality. We evaluated the results of those patients that received minimally invasive o -pump transapical aortic valve implantation (TA-AVI) in presence of a porcelain aorta during the past three years. Methods: From Feb. 2006 until March 2009, a total of 220 high-risk patients su ering symptomatic aortic stenosis (AS) received TA-AVI at our center. A subgroup of 29 patients (13.2%) presented with porcelain aorta, they form the study population. Mean age was 797.8 (64-93) years with 65.5% female. Logistic EuroSCORE and STSScore were 37.718.1% and 12.82.2%. Peripheral vascular disease (41.4%) and carotid stenosis (58.6%) were frequent comorbidities and 17.2% of patients had su ered a stroke previously. e majority of patients were re-do cases (51.2%) and 10.3% were dependent on chronic hemodialysis. 13.8% had undergone sternotomy for conventional AVR that was aborted because of intraoperatively detected porcelain aorta. Results: All valves were implanted successfully without embolisation or aortic dissection. All procedures were primarily performed o -pump but 4 patients required secondary CPB due to complications. Median procedure-time was 80 minutes and median ICU-stay was one day. Stroke occurred in one patient only. irty-day mortality was 17.2%. Mild paravalvular leak was seen in 31.0% and mild-to-moderate regurgitation in one patient. Conclusions: TA-AVI is a promising minimally invasive approach to treat elderly high-risk patients with porcelain aorta requiring AVR and is associated with acceptable outcome and low stroke rates.
Preoperative CT-scan demonstrating a porcelain aorta
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Adult Cardiac Posters Continued P21 Heliported ECMO for Cardiogenic Shock Expands Cardiac Assist Surgical Programs V. Gariboldi, D. Grisoli, N. Jaussaud, A. Riberi, V. Chalvignac, F. Kerbaul, F. Collart Hospital of Timone, Marseille, France Purpose: ECMO is an e ective technique to provide emergency mechanical circulatory assistance for patients with cardiogenic shock refractory to conventional medical therapies. For patients outside our institution we create a Heliported Remote Cardiac Assist unit to implant the ECMO and bring them back when stabilized in our ICU for follow-up. Our study was undertaken to evaluate the feasibility of the procedure and the results of our experience. Methods: Between March 2006 and June 2008, 38 consecutive patients in acute cardiogenic shock were implanted with percutaneous ECMO by our heliported team. We analyzed logistic concerns, indications, complications, and outcomes of these patients. Results: ere were no logistic or technical problems during round trip or ECMO implantation. Mean distance from our ICU was 42 miles (1-143). Maximal time limit between phone call and implantation was 90 min. Mean LVEF evaluated by TTE was 19%. Indications were fulminant myocarditis, pharmacologic suicide attempt, acute myocardial infarction, post-partum cardiopathy, end-stage dilated cardiomyopathy. ey received a percutaneous veno-arterial femoral ECMO with immediate reperfusion of the limb. Seventeen patients (45%) were successfully weaned from ECMO after 9.4 days. Four patients (11%) were transplanted. One patient (3%) was switched to a left ventricular assist device and successfully transplanted. Twenty-one patients (55%) survived to hospital discharge. Conclusions: e Heliported Cardiac Remote Assist unit allowed the emergent implant of ECMO support without logistic or technical problems and could rescue 55% of otherwise lethal cardiogenic shock patients in remote institutions or institutions without cardiac surgery department. P22 Safe Surgical Pacmeker Lead Extraction J. M. Kratz, J. M. Toole Medical University of South Carolina, Charleston, SC
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Purpose: With increasing use of electronic cardiac devices an increasing need for removal of chronically implanted leads has occurred. Removal can be dangerous, di cult, or unsuccessful. Methods: We retrospectively reviewed our results and techniques for removal of pacemaker and ICD leads in 365 consecutive patients. e eras before (1992-1999) and after the availability of laser sheath extraction (2000-2009) were compared. All infected pockets were closed primarily after debridement of all scar tissue. Results: Indications for lead removal were: infection 212, other indications 153. Staphylococcus aureus and coagulase negative staphylococcus occurred in 76% of infected cases. One-half of these organisms were methicillin resistant. e remaining organisms were varied. Pre-implant risk factors for infection in the 212 infected patients included more than one device implant 105 (47%), pre-implant warfarin 74 (31%), and hemodialysis 9 (4%). Before the year 2000, techniques employed for lead extraction included traction, locking stylets, dilating sheaths, jugular forceps, and femoral approach grasping tools. In year 2000, laser sheath extraction was added. e addition of the laser sheath was associated with a higher complete extraction rate (93% vs. 89.5%) and lower incidence of bleeding (1.9% vs. 3.1%). All deaths 4 (1%) were the result of severe systemic infection or stroke present pre-extraction. No deaths were associated with incomplete extractions or bleeding. Conclusions: A lead extraction protocol which includes procedures done by a cardiothoracic surgeon in an monitored operating room environment allowing rapid open intervention for bleeding, and a varied choice of extraction tools including laser sheaths, yielded complete extraction in over 90% of patients with a low complication rate and no deaths due to the extraction. Primary pocket closure in infected cases resulted in rare recurrent infection. Extraction Results
* Recurring pocket infection ** Preopeative sepsis cause of death *** Preoperative systemic sepsis in 2 and preoperative stroke in one cause of death
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Adult Cardiac Posters Continued P23 Saddle-Shaped Mitral Annuloplasty Increases Lea et Coaptation Area After Repair for Myxomatous Disease M. Vergnat, A. T. Cheung, S. J. Weiss, B. M. Jackson, M. A. Acker, J. H. Gorman, R. C. Gorman University of Pennsylvania, Philadelphia, PA Purpose: An adequate area of coaptation between the anterior and posterior mitral lea ets is important for ensuring a low-stress, durable valve repair in patients with mitral regurgitation due to myxomatous disease. We hypothesized that repair operations that employ saddle-shaped annuloplasty devices will improve lea et coaptation in these patients when compared to at annuloplasty devices. Methods: Eighteen patients with severe MR had valve repair using standard techniques. Nine patients received a saddle-shaped annuloplasty and nine received a at annuloplasty. Real-time 3D transesophageal echocardiography was performed before and after repair. Images were post-processed using a custom software algorithm to calculate mitral annular area (MAA), septolateral dimension (SL), Intercommissural width (CW), non-coaptated lea et area, and lea et coaptation area. Results: Complete data are presented in the table. All patients had severely dilated annuli and were treated with the same degree of annular reduction (saddle group=56.44.0%, at group=52.93.3%; p=0.52). e saddle-shaped annuloplasty group had a signi cantly greater lea et coaptation area (216.523.6mm2) compared to the at annuloplasty group (148.116.4mm2, p=0.03). Conclusions: Saddle-shaped annuloplasty improves lea et coaptation area after mitral valve repair for myxomatous disease when compared to at annuloplasty. Use of saddleshaped annuloplasty devices may, therefore, increase repair durability.
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P24 Radial Artery Conduits Improve Long-Term Survival After Coronary Artery Bypass Surgery R. F. Tranbaugh, K. R. Dimitrova, D. M. Ho man, C. M. Geller, L. J. Harris, P. Stelzer, B. Cohen, P. Friedmann Beth Israel Medical Center, New York, NY Purpose: e purpose of our study was to determine if the use of a second arterial conduit, the radial artery (RA), would improve long term survival after coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA) and saphenous vein (SV). Methods: We compared the 12-year outcomes in propensity matched patients undergoing isolated, primary CABG using the LITA, RA, and SV vs. CABG using the LITA and only SV. 903 patients from each group had essentially identical propensity matched demographics and multiple preoperative and operative variables. e average age was 59 years, 82% were male, 38% had diabetes and the average EF was 48%. Average grafts per patient was 3.7 and average arterial grafts per RA patient was 2.3. e primary endpoint was all cause mortality and the secondary endpoints were myocardial infarction, stroke, renal failure, sternal infection, and reoperation for bleeding. Results: e hospital mortality was 0.1% for the RA patients and 0.2% for the SV patients (NS). Kaplan Meier actuarial survival at 1, 5, and 10 years was 99%, 95%, and 87% for the RA group, respectively, vs. 98%, 86%, and 71% for the SV group (p<0.0001). Cox proportional hazards models showed a lower all cause mortality in the RA group compared to the SV group (Hazard ratio: 0.39, con dence interval: 0.30 to 0.52, p<0.0001). Ten-year survivals showed a 123% increased mortality in the SV patients (29%) versus the RA patients (13%), (p<0.0001). ere were no signi cant di erences in the postoperative secondary endpoints between the matched groups. Conclusions: CABG using the LITA, SV and a RA conduit results in signi cantly improved long-term survival compared to CABG using the LITA and SV. e use of two arterial conduits o ers a clear and lasting survival advantage, an important consideration when determining the initial revascularization strategy in patients with multivessel coronary artery disease.
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Adult Cardiac Posters Continued P25 Multi-Disciplinary Approach to Prevent Spinal Cord Injury After TEVAR For Distal Descending Aorta H. Matsuda, H. Ogino, T. Fukuda, K. Minatoya, H. Sasaki, H. Tanaka, S. Sato, O. Iritani, J. Kobayashi National Cardiovascular Center, Suita-Osaka, Japan Purpose: e preventive measures for spinal cord ischemia (SCI) after TEVAR were discussed based on the incidence according to the closure of the intercostal arteries which supplies the Adamkiewicz artery (ICA-AKA). Methods: During last 25 months, 43 patients (38 male, 57-85 years old) underwent TEVAR (TAG:32, MK:10, Talent:1) for distal descending aorta between 7 and L1. eir ICA-AKA identi ed by MRA/CTA were; 7:1, 8:7, 9:17, 10:10, 11:6, 12:1, L1:1 (one patient had double AKA). e history of descending, thoraco-abdominal and/or abdominal aortic graft replacement was observed in 18 patients. In 2 patients, the left subclavian artery was closed by TEVAR and the bypass surgeries had been performed before TEVAR. In all patients, motor evoked potentials were monitored during TEVAR and a CSFD tube was placed before TEVAR in 26 patients. Other current measures were the maintenance of mean blood pressure higher than 80mmHg to prevent SCI and CSFD and the infusion of corticosteroid and naloxone to treat SCI. e ICA-AKA was covered by stentgraft in 23 patients among whom the occlusion of ICA-AKA at its origin was con rmed before TEVAR in 2 patients. In 20 patients no ICA-AKA was covered by stentgraft including 5 patients whose ICA-AKA occluded. Results: e SCI was observed in 2 patients whose patent ICA-AKAs were covered. ey developed 10 hours and 24 hours after TEVAR. One patient could not ambulate and the other recovered to full ambulation within an hour. e estimated rate of SCI was 4.7% when TEVAR covered a part of distal aorta between 7 and L1 and 9.5% when the patent ICA-AKA was covered by TEVAR. No SCI was observed when ICA-AKA was not covered by TEVAR. Conclusions: Preservation of ICA-AKA is the key to prevent SCI. When the coverage of ICA-AKA is unavoidable, the maintenance of higher blood pressure is essential and CSFD, corticosteroid, and naloxone can be additive. P26 This poster has been withdrawn.
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Please visit the STS 46th Annual Meeting Scienti c Posters in Fort Lauderdale, Florida. Posters will be displayed in the 3rd oor concourse of the Greater Fort Lauderdale/Broward County Convention Center during the following times:
Sunday, January 24 Monday, January 25 Tuesday, January 26
12:00 pm 6:30 pm 7:00 am 5:30 pm 7:00 am 5:45 pm
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Adult Cardiac Posters Continued P27 Lea et Tethering Not Annular Dilation is Responsible for Load-Dependent Exacerbations of Ischemic Mitral Regurgitation M. Vergnat, M. Minakawa, J. D. Robb, M. Morita, R. C. Gorman, J. H. Gorman University of Pennsylvania, Philadelphia, PA Purpose: Ischemic mitral regurgitation (IMR) results from a combination of annular remodeling (dilatation) and subvalvular remodeling (lea et tethering) and is highly dependent on afterload. Annuloplasty only addresses the annular pathology. Recurrence of ischemic mitral regurgitation (IMR) after ring annuloplasty is often episodic and load dependent. Based on these facts we hypothesized that afterload accentuates IMR predominately by exacerbating lea et tethering and has a limited a ect on annular size. Methods: A posterobasal infarction involving 25% of the left ventricle was created in six pigs. Eight weeks after infarction, all pigs underwent 2D echocardiography and realtime 3D echocardiography at three afterloads (mean blood pressure = 80mmHg, 100mmHg and 120mmHg). Mitral regurgitation(MR) was quanti ed with 2D echocardiography using the standard 0 to 4 scale. 3D echocardiographic images were post-processed using a custom software algorithm to quantify annular size by measuring annular area (MAA), septolateral dimension (SL), intercommissural width (CW). Lea et tethering was assessed quantitatively by determining tenting volume (TV) and mitral valve tenting index (TI) de ned as TV/MAA. Results: All data are presented in the table. IMR increased from 2.51 to 2.70.8 and 3.30.8 with increasing afterload. MAA was not signi cantly a ected by afterload (909.376.3mm2, 899.772mm2 and 945.379.9mm2). SL and CW were also not signi cantly in uenced by loading. TI, however, increased signi cantly with increasing afterload (2.280.26mm, 2.750.22mm and 3.130.27mm). Conclusions: Lea et tethering not annular size is the dynamic (load-dependent) component of IMR. ese ndings may help to explain the high recurrence of IMR after ring annuloplasty alone for IMR.
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P28 Risk Factors Associated With Increased Mortality Following Tricuspid Valve Replacement: Mechanical Over Tissue Valves? Y. Jeon1, S. J. Park2, H. V. Scha 2, T. M. Sundt2, R. C. Daly2, J. Dearani2, H. M. Burkhart2, R. M. Suri2, K. Greason2, R. A. Nishimura2, Z. Li2 1 Gachon University Gil Hospital, Incheon, South Korea, 2Mayo Clinic, Rochester, MN Purpose: Tricuspid valve replacement (TVR) in patients with acquired heart disease is becoming more frequent, yet our understanding of risk factors that in uence late survival is poor. Also, there are few data to guide the choice of prosthetic valves (mechanical vs. tissue). erefore, we conducted this study to address these issues. Methods: We reviewed patients with acquired heart disease who underwent TVR from 1997 to 2007. Uni- and multi-variate analyses were performed on patient demographics, pre- and intra-operative variables and valve types to determine their impacts on the survival and valve related complications (VRC). We also speci cally examined the impact of valve type by propensity matching. Results: A total of 275 patients were identi ed. e mean age was 66 12 years, and 63.3% were female. Sixty-seven patients (24.4%) received mechanical valves, and the majority (68.4%) had prior cardiac surgery. Other cardiac procedures were performed concomitantly with TVR in 82.2% of the patients. In a multivariate analysis, survival was adversely a ected by the following variables (hazard ratio); tissue valve (2.55), urgent operation (2.09), male gender (1.82), elevated creatinine pre-op (1.65) and longer duration of CPB (1.01). We further compared propensity matched groups, comprised of 47 patients each, to study the impact of valve type. Although VRC were comparable (p=.94), survival was signi cantly worse in the tissue valve group (Figure 1, p = 0.034). Conclusions: We identi ed novel risk factors that adversely a ected the survival following TVR. e type of valve implanted had the strongest in uence on the survival. Patients with tissue valves had a worse survival even though they had a comparable VRC. Mechanical valves may be preferable for TVR in the acquired heart disease patients over tissue valves.
*p<0.05 compared to 80mmHg
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Adult Cardiac Posters Continued P29 Spinal Cord Ischemia After Thoracic Aortic Endovascular Repair: Is Simple Coverage of the Intercostal Arteries the Reason? B. Zipfel, S. Buz, R. Hammerschmidt, V. Dsterhft, R. Hetzer e German Heart Institute Berlin, Berlin, Germany Incidence of spinal cord ischemia
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FINANCIAL DISCLOSURE B. Zipfel: Jotec GmbH, consultant/advisory board; Nicolai (Bolton Medical), speakers bureau/ honoraria REGUL ATORY DISCLOSURE This presentation describes the use of the E-vita device whose FDA status is not approved. E-vita thoracic stent-graft is approved in the European Community. This presentation describes the use of the Relay device whose FDA status is investigational. Relay thoracic stent-graft is approved in the European Community.
Purpose: Despite extensive sacri ce of segmental arteries the incidence of spinal cord ischemia (SCI) in stent-grafting is unexpectedly low. Individual analysis may give new insights into the mechanisms. Methods: In a 10-year period, stent-grafts were implanted in 326 patients for various aortic pathologies. Mean age was 62 (16-89) years and 241 (73.5 %) patients were male; 45 patients underwent staged thoracic stent-graft procedures. e aorta was covered between 90 and 490 (mean 194) mm in length. No adenosine-induced cardiac arrest or rapid ventricular pacing was used for the moment of deployment; the mean arterial pressure was adjusted to 60 mmHg. Prophylactic cerebral spinal uid (CSF) drainage was used selectively in 3 cases, no neuromonitoring was used. All new onset spinal cord events (paraplegia, paraparesis, mild anterior spinal artery syndrome) were analyzed per patient including all individual stent-graft procedures. Nine cases with sustained paraplegia prior to stent-graft implantation induced by trauma or dissection were excluded. Results: Incidence of spinal cord ischemia was 2.1% (n = 7). All occurred during postoperative hospitalization, 1 after a secondary procedure. No delayed onset of paraplegia was observed. Secondary CSF drainage was performed in 2 cases without e ect. Four patients su ered a major permanent de cit. Conditions with a potential in uence on spinal cord ischemia were analyzed (table). Individual case analysis revealed signi cant intraluminal thrombus at the landing zones in 2 of 7 patients. Conclusions: e incidence of spinal cord ischemia is low even in extended covering of the thoracic aorta and implantation in the thoraco-abdominal segment. Previous abdominal aortic repair was found as a signi cant risk factor. An underestimated mechanism may be embolization of thrombus or debris into the segmental arteries by expansion of the stent-graft. A bene t of CSF drainage in thoracic aortic stent grafting is questionable.
AAA = abdominal aortic aneurysm; DTA = descending thoracic aorta; n.s. = not signi cant; SCI = spinal cord ischemia; oraco-abdominal segment = stent-graft extending below diaphragm; Entire DTA = stent-graft from left subcalvian artery extending below diaphragm
Mobile atheroma (a) in a 78-year-old female, who su ered unilateral paraplegia after implantation of a short stent-graft (b). Spinal cord ischemia may have been caused by embolization of debris into the segmental arteries by expansion of the stent-graft.
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Adult Cardiac Posters Continued P30 Echo-Endoscope Biplane Navigation System for Endovascular Aneurysm Repair Y. Inoue1, R. Yozu2 1 Siaseikai Utsunomiya Hospital, Utsunomiya, Japan; 2 Keio University School of Medicine, Tokyo, Japan
REGUL ATORY DISCLOSURE This presentation describes the o -label use of the Nove Echo-Endoscope device.
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Please visit the STS 46th Annual Meeting Scienti c Posters in Fort Lauderdale, Florida. Posters will be displayed in the 3rd oor concourse of the Greater Fort Lauderdale/Broward County Convention Center during the following times:
Sunday, January 24 Monday, January 25 Tuesday, January 26
12:00 pm 6:30 pm 7:00 am 5:30 pm 7:00 am 5:45 pm
Purpose: Requirement of contrast medium during transluminal delivery of aortic stents under uoroscopy limits the indication of endovascular aneurysm repair (EVAR) to the patients with renal insu ciency and allergic reaction. Furthermore, landmarks under uoroscopic guidance do not necessarily encompass the local anatomy of branched aortic lesions of atherosclerotic aneurysm and dissection. We evaluated the feasibility of the biplane monitoring system consisting of echo and endoscopy as a more accurate anatomical navigation system for EVAR. Methods: Seven domestic swines underwent dual intravascular monitoring of ascending, transverse arch and descending aorta by intraluminal echo-endoscopic device that was delivered through right femoral artery. is device consisted of a exible endoscope with an optical latex balloon attached to create bloodless visual elds, and of 1.6-mm-diameter thin echo probe inserted through the channel of the endoscopy for cross-sectional view. e latex balloon could be lled with contrast medium to provide rapid positioning under uoroscopy. Results: Anatomical landmarks of thoracic and abdominal aorta, conditions of the aortic intima and the location of aortic branches and lumbar arteries were readily visualized by endoscopic direct vision. Simultaneously, subintimal anatomies and angles of the branches relevant to stent graft implantation were also monitored by the ultrasonographic cross-sectional view. Precise anatomical information of the potential landing zone could be obtained by this technique, which would be also useful to con rm the post-procedural stent-tissue contact. Conclusions: e echo-endoscope biplane navigation system may facilitate the precise launch of the stent graft to the target location, and may help to reduce the dose of contrast medium. Combined with carbon dioxide digital subtraction angiography, this device may have a potential to enable EVAR without using contrast medium.
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Adult Cardiac Posters Continued P31 Application of a Hemispherical Annuloplasty Frame to Repair of Experimental Aortic Valve Insu ciency J. S. Rankin, L. Beavan Vanderbilt University, Nashville, TN Table
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FINANCIAL DISCLOSURE J.S. Rankin: BioStable Science and Engineering, Inc., consultant/advisory board; HAART Inc., ownership interest. L. Beavan: BioStable Science and Engineering, Inc., employment; HAART Inc., ownership interest REGUL ATORY DISCLOSURE This presentation describes the use of the HAART Aortic Annuloplasty device. The FDA status is investigational. This abstract describes the animal studies being done on the device, and has no clinical data.
Purpose: A need exists for a stable method of annuloplasty for aortic valve repair. Based on a hemispherical model of aortic valve geometry in which valve lea ets were represented as 3 hemispheres nested within a cylindrical aorta ( JHVD 2008;17:179186), a prototype annuloplasty frame was developed (Figure) and tested in a porcine aortic root preparation. Methods: Eight isolated porcine aortic roots were perfused from a water reservoir at a constant pressure of 100 mmHg, and valve leak was measured by timed collection in a beaker. Baseline leak was negligible, and then the 2 commissures adjacent to the right coronary lea et were incised vertically to create gross valve insu ciency. rough a transverse aortotomy, a hemispherical annuloplasty frame (sized according to lea et free-edge length) was sutured to the aortic valve annulus with horizontal mattress sutures (Figure). e valve otherwise was repaired using clinical-grade techniques, including lea et plication stitches to correct minor degrees of prolapse. e aortotomy then was closed, and post-repair leak again was measured at 100 mmHg aortic pressure. Signi cance of the change in valve leakage after annuloplasty was assessed with a twotailed paired t-test. Results: Data from each study are shown in the Table. Subcommissural incision disrupted annular geometry and created a valve leak of 1400847 ml/min (meanSD). Suturing the 3-dimensional hemispherical annuloplasty frame into the aortic valve annulus re-established appropriate geometry of lea et coaptation and restored valve competence (Figure). Post-repair valve leak decreased to 10286 ml/min (Table; p=0.004). Conclusions: Insertion of a hemispherical annuloplasty frame into severely disrupted and insu cient porcine aortic valves routinely and e ectively restored valve competence. ese data support the continued development and testing of this device as a stable method of annuloplasty during aortic valve repair.
Figure
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Adult Cardiac Posters Continued P32 Perioperative Risks of Patients With Recent ST-Elevation Myocardial Infarction: A Comparison With Non-ST-Elevation Myocardial Infarction L. Zhang, K. Kumar, B. Hiebert, M. Moon, R. Arora University of Manitoba, Winnipeg, Canada Purpose: Compared with non-ST-elevation myocardial infarction (NSTEMI), STelevation myocardial infarction (STEMI) has been associated with increased mortality following medical treatment and percutaneous coronary intervention (PCI). e aim of our study was to investigate the prognostic value of myocardial infarction (MI) classi cation in the setting of early surgical revascularization. Methods: We studied 2,412 consecutive patients between 1995 and 2007, who underwent an isolated coronary artery bypass grafting (CABG) procedure within 21 days after MI. e outcomes of interest were in-hospital mortality and major adverse events (MAEs), which included death, MI, stroke, and hemodialysis. Results: STEMI patients were more likely to have preoperative left ventricle (LV) systolic dysfunction, cardiogenic shock, and perioperative intra-aortic balloon pump (IABP) insertion than NSTEMI patients. STEMI patients were also more likely to receive thrombolysis or PCI preoperatively. Crude in-hospital mortality and MAEs were higher in STEMI patients (6.4% vs. 3.6%, P = 0.006; 13.3% vs. 8.3%, P = 0.0009; respectively). Stepwise regression analysis revealed that age, preoperative congestive heart failure (CHF), cardiogenic shock, stroke, pulmonary hypertension, New York Heart Association (NYHA) classi cation, and CABG within 7 days after MI were associated with increased in-hospital mortality. Similarly, age, preoperative CHF, cardiogenic shock, stroke, pulmonary hypertension, LV systolic dysfunction, NYHA classi cation, renal insu ciency, and CABG within 7 days after MI were independent predictors of MAEs. However, after adjustment for covariates, MI category, STEMI vs. NSTEMI, did not predict in-hospital mortality or MAEs. Conclusions: Surgical risks of patients with recent MI are independent of MI category. Distinguishing STEMI and NSTEMI is of limited value in the decisionmaking process of early surgical intervention.
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P33 ST2 Biomarker Predicts One-Year Mortality Among High-Risk Patients Undergoing Coronary Artery Bypass Surgery S. Henkin, P. Desai, A. Brown, P. Ziu, R. Poston Boston University School of Medicine, Boston, MA Purpose: High-risk patients have shown improving operative mortality rates after coronary artery bypass surgery (CABG) but suboptimal 1-year survival. Soluble ST2 (sST2), a biomarker released from myocytes in response to mechanical overload, predicts poor outcome in heart failure and myocardial infarction. We hypothesized that sST2 would predict death during the rst year after CABG in patients at high risk for operative mortality Methods: We analyzed 210 CABG patients with an STS predicted mortality risk >3% for the relationship of sST2 levels at baseline (BL), immediately after CABG (post), 24 hours and 72 hours to all-cause mortality at one year. Serum was frozen until analysis of sST2, NT-proBNP, CKMB and cTn I levels using ELISA. Results: Of the 210 patients enrolled, death occurred in 3 (1.5%) within 30 days and 20 (9.5%) by 1 year. e sST2 levels did not change immediately post-CABG (BL: 0.16, post: 0.23 ng/ml) but became signi cantly elevated at 24 hours and 72 hours (2.12, 0.57 ng/ml; P<0.001). Patients that were living vs. deceased at 1 year showed a signi cant di erence in carotid disease (12.7% vs. 35.0%; p = 0.008) and previous MI (21.1% vs. 50.9%, p = 0.014) at baseline and pBNP (2491 2105 vs. 3850 2113; p=0.007), CKMB (8.5 10 mEq/L vs. 14.4 9.2 mEq/L; p = 0.014), Tn-I (2.3 3.5 vs. 4.1 3.3; p = 0.034), ST2 (2.8 2.6 ng/mL vs. 7.7 3.2 ng/mL; p < 0.001) levels at 24 hours. Binary logistic regression analysis showed that ST2 level (p = 0.001) and STS score (p = 0.047) were associated with 1-year mortality. In multinomial regression analysis controlling for clinical risk factors, only ST2 (p=0.017) remained correlated with 1-year mortality. Conclusions: sST2 rises after CABG in high-risk patients and independently predicts 1-year mortality. sST2 assessment after CABG may help improve the strati cation of mortality risk after hospital discharge in order to guide appropriate follow-up.
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Adult Cardiac Posters Continued P34 Late Stroke/TIA and Major Bleeding Events Following the Cox-Maze Procedure: Does the CHADS Score Have Any Predictive Value? N. Ad, L. Henry, S. Hunt, K. Schlauch Inova Heart and Vascular Institute, Falls Church, VA
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P35 Fully Echo-Guided Transapical Aortic Valve Replacements E. Ferrari, C. Sulzer, L. von Segesser University Hospital of Vaud Lausanne (CHUV), Lausanne, Switzerland Purpose: e transcatheter aortic valve replacement (TAVI) is traditionally based on speci c landmarks for the stent-valve positioning and implantation, identi ed preoperatively by cardiac CT-scan and con rmed intraoperatively by TEE and uoroscopy with contrast medium injection. To diminish the risk of acute postoperative renal failure, we developed a fully echo-guided technique to perform transapical TAVI procedures. Methods: From Nov. 2008 and May 2009, 17 consecutive high-risk patients su ering from severe and symptomatic aortic valve stenosis underwent a transapical AVR with a transcatheter stent-valve system. e procedures were based on low-dose contrast medium injections ( rst 5 patients) or fully echo-guided stent-valve implantation without contrast medium (12 patients). Results: e mean age was 78.315.8 years (range 72-90 years) and there were 10 females. e mean logistic Euroscore was 30.7%10.3 (range 18-46%). e mean aortic valve gradient was 58.322.3 mmHg, the mean aortic surface area was 0.730.17 cm2 and the mean left ventricle ejection fraction was 59.4%9.2. Risk factors: severe pulmonary hypertension (8/17 patients), severe peripheral vascular disease (14/17 patients, 82.3%), severe COPD (5/17 patients, 29.4%) and chronic renal insu ciency 41.2% (7/17 patients) with a mean serum creatinine level of 116.7692.2 g/dL. All 17 implants were performed under low-dose contrast medium (mean of 12.99.8 mL), and 12 implants without contrast injection at all. In one patient, a valve embolisation in the ascending aorta required a second successful implant. e mean procedural time was 135.829.6 minutes. Patients did not experience acute postoperative renal failure, and the mean creatinine level at day 1 was 94.872.2 g/dL. Conclusions: TAVI under uoroscopy control without contrast medium injection is feasible and can o er a bene t to the old high-risk patients requiring a transcatheter procedure and su ering from chronic renal insu ciency.
FINANCIAL DISCLOSURE N. Ad: ATS Medical, Inc., speakers bureau/honoraria; AtriCure, consultant/advisory board
Purpose: e HRS guidelines recommend continuing warfarin after ablation when a patients CHADS Score (CHADS2) is 2. Managing anticoagulation is challenging especially when NSR has been restored and the left atrial appendage (LAA) has been removed. e purpose of this study was to quantify the applicability of the CHADS2 in anticoagulation strategies following the Cox-Maze procedure. Methods: In a prospective, longitudinal study, CHADS2 were calculated preoperatively (N=366). Follow-up clinical information on rhythm, anticoagulation medication, major bleeding, and embolic stroke/TIA was obtained every 3 months. Results: 16.1% of patients presented with history of Stroke/TIA. In a mean follow-up of 27.75 (15.2) months, only 4 patients had an embolic stroke/TIA (5.16 events per 1000 patient years; event group) and 13 patients had a major bleeding event (16.8 events per 1000 patient years, event bleed group). ere was no signi cant di erence in the mean CHADS2 between the event and non-event group (1.25 vs. 1.45, p=0.72). ere was a signi cant di erence in the CHADS2 between the event bleed group and the non-event group (2.38 vs. 1.41, p=.008) with 81% on warfarin at the time of event (Figure 1). Linear models were used to determine whether age, hypertension (HTN), diabetes, CVA, CHF, CHADS2, rhythm, and warfarin were predictors of either event. None were predictive of Stroke/TIA. e interactive term CHF/HTN (p<0.014), was the most signi cant predictor of a major bleed increasing the odds of bleeding > 10 fold. Conclusions: e number of stroke/TIA events following the Cox-Maze procedure is very low and unrelated to the CHADS2 or rhythm status. is together with the higher rate of bleeding in CHADS2 2 group raises questions regarding the applicability of the HRS guidelines for patients following the maze procedure. A large randomized study is required to rede ne the risks and anticoagulation strategies for this group of patients especially when the LAA was excluded.
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Adult Cardiac Posters Continued P36 Midterm Results After Endovascular Treatment of Acute, Complicated Type B Aortic Dissection M. P. Ehrlich, J. Dumfarth, R. Gottardi, J. Holfeld, A. Juraszek, T. Dziodzio, G. Sodeck, M. Funovics, M. Schoder, M. Grimm, M. Czerny General Hospital Vienna, Vienna, Austria Purpose: To assess the e cacy and midterm results of endovascular treatment of acute complicated type B dissection. Methods: Between Jan. 2001 and Feb. 2009, 25 patients (5 female, 20 male) with acute complicated aortic type B dissections (mean age 58, range 35-86 years), de ned as either aortic rupture, malperfusion, intractable pain or uncontrolled hypertension underwent endovascular stent graft placement with either the Gore Excluder/TAG device (n=12) or Medtronic Talent /Valiant device (n=13). Follow-up was 100% complete and averaged 23 24 months. Mean numeric and logistic Euroscore was 11 and 32%, respectively. Results: Technical feasibility and success with deployment proximal to the entry tear was 100%, requiring partial or total coverage of the left subclavian artery in two patients (8%). Hospital mortality was 16% 7% (70% con dence limit) with 2 late deaths (17 and 18 months post-implant). Causes of hospital death included rupture in 3 and cardiac arrest in one patient. None of the patients who survived the procedure developed any neurological complications. Two patients with malperfusion required branch vessel stenting. Furthermore, three patients developed a Type Ia Endoleak. Actuarial survival at 1 and 5 years was 84% and 76%, respectively. Freedom from treatment failure at 5 years (including reintervention, aortic rupture, device related complication, aortic related death, or sudden, unexplained late death) was 58% 11%. Conclusions: Endovascular stent-graft placement in acute complicated type B aortic dissection proves to be a promising alternative therapeutic treatment modality in this relatively di cult patient cohort. Re nements, especially in stent design and application, may further improve the prognosis of patients in this life-threatening situation.
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CONGENITAL POSTERS P37-P55
FINANCIAL DISCLOSURE B. Zipfel: Jotec GmbH , consultant/advisory board; Nicolai (Bolton Medical), speakers bureau/ honoraria REGUL ATORY DISCLOSURE This presentation describes the use of the E-vita device whose FDA status is not approved. E-vita thoracic stent-graft is approved in the European Community. This presentation describes the use of the Relay device whose FDA status is investigational. Relay thoracic stent-graft is approved in the European Community.
P37 Endovascular Stent-Graft Repair of Late Complications After Surgery for Aortic Coarctation B. Zipfel, P. Ewert, S. Buz, V. Dsterhft, R. Hetzer e German Heart Institute Berlin, Berlin, Germany
Purpose: We analyzed the potential of endovascular stent-grafts to treat late aortic aneurysms after coarctation repair. Methods: Seven patients (6 male; age 28-59, median 52 years) presented with aortic aneurysms following primary patch aortoplasties performed at the age of 7-28 (median 10) years, 2 of them with rupture in hemorrhagic shock. e mean interval between the procedures was 31 (19- 42) years; one patient had 3 previous operations. oracic endografts were implanted in transfemoral retrograde technique: 1 Talent, 2 E-vita, 4 Relay. Custom-made reverse tapered stent-grafts were used in 4 cases. e left subclavian artery (LSA) was covered in 5 patients. Protective transposition of the left subclavian artery was performed in 4 cases. Results: Hospital mortality was 14%. One patient died from secondary rupture after emergency repair. Primary complete exclusion of the aneurysm was achieved in 5 patients, secondary exclusion after implantation of a second stent-graft in the second rupture patient. No endoleak was present at discharge. All discharged patients are alive after 9-51 (median 21) months. Follow-up computed tomography or transesophageal echocardiography revealed no secondary endoleaks or late expansion. e aneurysms had shrunk completely in 3 cases, had reduced in size in one case and remained unchanged in 2 cases. No late secondary interventions were noted. Conclusions: e failure in the rst case was due to an inappropriately sized stentgraft in an emergency situation. Single piece reversed tapered stent-grafts adapt better to the special anatomy of the hypoplastic aortic arch. Mid-term results are excellent: complete shrinkage in 50% is remarkable. However, the long-term behavior of these implants in young patients requires further evaluation and life-long surveillance.
a: Endovascular repair of a patch aneurysm after coarctation repair in childhood. b: Completion angiogram shows complete exclusion of the aneurysm by a reverse tapered stent-graft, a left carotid-subclavian transposition and a bare metal stent in the left common carotid artery.
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Congenital Posters Continued P38 Mid-Term Follow-Up of Porcine Xenografts for Redo Right Ventricular Out ow Tract Reconstruction in Young Adults J. W. Brown, M. Ruzmetov, O. Yurdakok, M. D. Rodefeld, M. W. Turrentine Indiana University School of Medicine, Indianapolis, IN Purpose: A variety of valve substitutes are used for right ventricular out ow tract (RVOT) reconstruction in children and young adults after previous RVOT surgery that has led to signi cant pulmonary insu ciency and/or stenosis. e authors experience with pulmonary valve replacement (PVR) using a porcine xenografts late after previous RVOT surgery was reviewed. Methods: Between 1993 and 2009, 60 patients (mean age 24.013.8 years; range: 5-59 years) underwent PVR using the stented porcine aortic bioprostheses. All patients except 2 had prior RVOT reconstruction. ese patients averaged two prior operations (range: 1-5) for the following diagnoses: tetralogy of Fallot + pulmonary atresia (n=42); transposition of the great arteries (n=6); truncus arteriosus (n=4); double-outlet right ventricle (n=3); and others (n=5). Of these patients, 29 (64%) underwent additional procedures at the time of pulmonary valve insertion. Results: ere was one early and one late death. Overall survival rate was 96% at 10 years. All survival patients were well at a mean follow-up of 6.43.8 years (range: 0.513). Echocardiography showed trivial or no pulmonary insu ciency in 38 patients (88%). e calculated mean peak systolic RVOT gradient by echocardiography was 22.46.6 mmHg. ere have been no valve related complications or reoperation and one patient death from an arrhythmia. Conclusions: e porcine aortic bioprostheses demonstrated excellent intermediateterm results for repeat RVOT reconstruction. is valves hemodynamic characteristics are comparable to those of homografts, and it is an attractive alternative given the limited availability of homograft valves. e porcine aortic bioprosthesis remains an ideal valve choice for teenagers and young adults with congenital abnormalities of the RVOT especially for redo as a second or third choice.
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P39 The E ects of Basic-FGF in an Animal Model of Acute Mechanically Induced Right Ventricular Hypertrophy V. L. Vida, S. Speggiorin, E. Faggin, A. Dedja, M. A. Padalino, G. Boccuzzo, P. Pauletto, A. Angelini, O. Milanesi, G. iene, G. Stellin University of Padua, Padua, Italy Purpose: e right ventricle seems to have a maladaptive response under systemic pressure conditions. e aim of this study is to evaluate the e ects of continuous basic Fibroblastic Growth Factor (bFGF) infusion on the adaptive potential of the right ventricular myocardium after 30 days of mechanical-induced overload in rats. Methods: We banded the pulmonary trunk, so as to increase the systolic work load of the right ventricle (PAB), in 12 adult Lewis/HanHsd rats at the age of 10 weeks, using 6 adults as controls. Some of the rats had also an additional implantation of an osmotic subcutaneous pump that released bFGF at the time of banding (6 PAB-bFGF rats and 3 controls-bFGF rats). We analyzed the functional adaptation and structural changes of the right ventricular myocardium, blood vessels and interstitial tissue after 30 days of increased afterload. Results: e right ventricle free wall thickness was signi cantly increased in banded rats (both PAB and PAB-bFGF rats) if compared to controls (Table 1). e myocyte diameter was signi cantly higher in PAB rats if compared to PAB-bFGF and controls. e percentage of interstitial brosis was signi cantly higher in PAB rats if compared to controls and it is also signi cantly higher in PAB vs. PAB-bFGF rats. e capillary network was more extensive in PAB-bFGF rats if compared to PAB rats. However the capillary density in PAB-bFGF was still lower than in controls (Table 1). Conclusions: e subcutaneous infusion with osmotic pumps is a valid and reproducible method to deliver bFGF to heart tissue. e use of bFGF showed a higher adaptive capillary growth, which hampered the development of brosis and reduced the degree of compensatory hyperthrophy. Table 1.
BW: body weight, BFGF: basic- broblastic growth factor, IQR: inter-quartile range, LV: left ventricle, PAB :pulmonary artery banded, RV: right ventricle, SD: standard deviation.
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Congenital Posters Continued P40 Age is a Risk Factor for Maladaptive Changes of the Pulmonary Root in Rats Exposed to Increased Pressure Loading V. L. Vida, N. Maschietto, S. Rizzo, G. Boccuzzo, O. Milanesi, G. iene, G. Stellin, C. Basso University of Padua, Padua, Italy Purpose: Neo-aortic root dilation has been proposed to be the main mechanism for failure of the pulmonary autograft in systemic position. Aim of this study is to evaluate, in an animal model, the age related-histological changes of the pulmonary root under increase pressure load. Methods: We banded the pulmonary trunk, so as to increase the systolic pressure in the pulmonary root, in 10 adult Sprague-Dawley rats at the age of 10 weeks, and 10 weanlings when they were 3 weeks old, using 7 adults and 8 weanlings as controls. We analyzed the functional adaptation and structural changes of the pulmonary root after 30 days of increased workload focusing on pulmonary wall thickness, number of elastic bers and quantifying the degree of elastic bers disarray and fragmentation, interstitial brosis, mucoid degeneration, medionecrosis and apoptosis. Results: e mean pressure gradient across the banded pulmonary trunk was 53.57 mmHg (SD 10.90 mmHg) in the adult rats, and 86.73 mmHg (SD 15.02 mmHg) in the weanlings. Both age groups of pulmonary banded rats had increased pulmonary vascular wall thickness and signi cantly higher degree of elastic bers fragmentation, interstitial brosis, mucoid degeneration and medionecrosis if compared to age-related controls (Table 1). Adult banded rats had signi cantly higher degree of elastic bers disarray (p=0.006) if compared to weanling rats. Conclusions: e pulmonary root reacts with signi cant changes in its vascular wall structure to increase pressure load. Elastic bers disarray, however, is present in adult pulmonary banded rats only. ese data suggests a worst adaptation of the pulmonary root to increased pressure load in adult rats. Table 1. Structural changes of the pulmonary root
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PAB: pulmonary artery banded
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Congenital Posters Continued P41 The UltraMag Ventricular Assist Device Provides Hemodynamic Stability in a Strategy of Single Ventricle Palliation M. P. Schiralli, A. N. Winterborn, R. Angona, K. Belmont, K. Jones, H. Wang, G. M. Al eris, J. J. Gangemi University of Rochester, Rochester, NY Purpose: Newborns with single ventricle physiology often require extensive surgical intervention during the neonatal period. e parallel circulation following Stage I palliation contributes to an unstable physiology which leads to considerable morbidity and mortality. Separating the pulmonary and systemic circulations using a ventricular assist device (VAD) could decrease the deleterious e ects of single ventricle physiology. We hypothesize that hemodynamic stability and adequate pulmonary gas exchange can be achieved in an acute neonatal model of complete, pump-assisted cavopulmonary diversion (CPD) using a portable VAD. Methods: An acute newborn lamb model (n=9) of complete, pump-assisted CPD was performed using a Levitronix UltraMag VAD (a preclinical, portable magnetically levitated centrifugal pump) following bicaval venous (in ow) cannulation, distal main pulmonary artery (out ow) cannulation, and complete occlusion of the proximal main pulmonary artery. Extensive hemodynamic data and assessment of pulmonary gas exchange were taken at baseline (Hour 0) and at hourly intervals for 8 hours. Repeated measure ANOVA was used to compare the measured variables throughout the experiment. Results: Hemodynamic measures including mean arterial pressure, heart rate, lactate levels, and cardiac index were not signi cantly di erent during the experimental time period compared to baseline. Arterial blood gasses, pulmonary artery pressures and pulmonary vascular resistance were also not signi cantly di erent during this time period. Hematocrit was the only variable shown to have a statistically signi cant change in the study. Conclusions: In conclusion, complete, pump-assisted CPD using a Levitronix UltraMag provides stable hemodynamics and maintains pulmonary gas exchange in an acute newborn lamb model. is device provides a platform for chronic studies in a survival model of complete, pump-assisted CPD.
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Congenital Posters Continued P42 Impact of Primary Sutureless Repair on Survival and Reintervention in Neonates and Infants With Mixed Total Anomalous Pulmonary Venous Drainage O. Honjo, C. R. Atlin, B. C. Hamilton, N. Viola, J. G. Coles, G. S. Van Arsdell, C. A. Caldarone e Hospital for Sick Children, Toronto, Canada Purpose: Mixed type total anomalous pulmonary venous drainage (TAPVD) poses technical challenges and high risk of postoperative pulmonary vein (PV) stenosis due to diminutive size and remote location of the PV con uences. We hypothesized that primary application of sutureless repair may better incorporate small and remote con uences, thereby minimizing PV stenosis and improving clinical outcomes. Methods: Twenty consecutive infants (1985-2008, median age 27 days, body weight 3.7kg) with mixed TAPVD were retrospectively reviewed. Survival and reintervention were compared between sutureless group (n=6) and conventional group (n=14). Risk factors for death and reintervention were analyzed by the multiple regression model. Results: No di erences were noted on pre- and intraoperative variables including subtypes of mixed TAPVD between the groups (p=NS). ere were trends toward improved survival (100% vs. 57% at 1 year, p=0.07) (Figure) and freedom from reintervention (100% vs. 67% at 1 year, p=0.09). In the regression model, univariate analysis showed that preoperative PV stenosis (p=0.02), non-sutureless (conventional) repair (p=0.05), palliative surgery (PV repair with a shunt or a band) (p=0.001), circulatory arrest (p=0.05), and PV stenosis on intraoperative echo (p=0.009) were the risk factors for death. Multivariate analysis showed that preoperative PV stenosis (p=0.02) and palliative surgery (p=0.001) were the risk factors for deaths. e risk factors for reinterventions by uni- and multivariate analyses included preoperative PV stenosis (p=0.03), palliative surgery (p=0.03), and PV stenosis on intraoperative echo (p=0.001). Conclusions: Primary sutureless repair for mixed TAPVD improved survival and may reduce reintervention for postoperative PV stenosis. No patients in sutureless group had mortality or reinterventions. Further analysis with a larger cohort is essential to determine the impact of this strategy on reintervention.
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P43 Use of Bosentan in Children With Single Ventricle Physiology and Elevated Pulmonary Pressures to Improve Fontan Candidacy S. Seltzer, J. C. Alejos, B. L. Reemtsen University of California Los Angeles, Los Angeles, CA Purpose: To determine outcomes in children with elevated pulmonary pressures in whom bosentan was used to improve candidacy for Fontan completion. Methods: A retrospective review was performed of all pediatric patients previously deemed to high-risk for Fontan due to unfavorable hemodynamics. ese patients were subsequently treated with bosentan and later underwent total cavopulmonary connection. Hemodynamics were recorded pre- and post-bosentan therapy as well as in the post-operative period. In addition surgical outcome data and quality of life assessment data were observed. Results: Five consecutive patients (4 male) with mean age 5.7 3.5 years underwent extracardiac Fontan following bosentan therapy for a mean of 18.8 12.9 months. Following bosentan therapy, all hemodynamics demonstrated improvement, including mean pulmonary artery pressure (17 to 12mmHg, p=0.14), pulmonary capillary wedge pressure (11.3 to 9.2mmHg, p=0.13) and transpulmonary gradient (5.9 to 2.9mmHg, p=0.13). Pulmonary artery z score improved in all children (-1.2 to +0.26, p=0.18). All children reported improvement in quality of life as assessed by WHO classi cation. ere were no side e ects from the medication. ree of the ve patients had fenestrated extracardiac Fontans and two were non-fenestrated. Postoperatively, all ve patients continued to show favorable hemodynamics with immediate mean postoperative Fontan pressure of 16mmHg and saturations >95% on room air. All patients were extubated on the operative day. Patients had chest tubes removed within a mean of 2 days and were discharged home at a mean of 5.5 days. No signi cant morbidity was observed. Conclusions: Bosentan therapy in children with single ventricle physiology and elevated pulmonary pressures improves Fontan candidacy in previously ineligible patients and has shown promising early surgical outcomes in patients following total cavopulmonary connection.
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Congenital Posters Continued P44 Cardiac Surgery After PDA Stenting In Duct-Depending Pulmonary Circulation S. Speggiorin, V. L. Vida, M. A. Padalino, M. Lo Rito, N. Maschietto, R. Bi anti, A. Cerutti, O. Milanesi, G. Stellin University of Padua, Padua, Italy Purpose: Stenting of the patent ductus arteriosus (PDA) has been recently introduced to palliate patients with ductus-dependent pulmonary circulation. Since no data are currently available, we sought to evaluate the surgical outcome of patients who had a previous PDA stent, focusing on their pulmonary arteries status. Methods: Between Aug. 2004 and April 2009, all patients who underwent cardiac surgery after PDA stenting were included. Outcomes included hospital mortality, morbidity and the need for reoperation or re-intervention on pulmonary artery branches. Results: Fifteen patients (11 males, 4 females) were included. irteen patients underwent elective cardiac surgery after a median time of 11 months (range 0.3 months-3.7 years) from PDA stenting. Two patients underwent emergent surgery due to stent migration during percutaneous positioning. Four patients required preoperative interventional cardiology procedure including PDA stent dilatation (3 patients) and multiple LPA dilatations (1 patient). During elective correction, PDA stents were completely retrieved in 5 patients (38%), and partially removed in 10 (62%) due to the fusion of the stent to the vascular wall. Pulmonary artery plasty was deemed necessary in 7 patients (47%). Eleven postoperative complications occurred in 6 patients (40%). One patient died in hospital (6%) after emergent surgery. Median follow-up time was 16.7 months (range 1 months-2.5 years). Two patients died suddenly at home (14%), 4 and 8 months after surgery. ree patients (25%) required further interventional procedures for LPA stenosis, 43, 56, and 61 days after surgery. e 12 survivors are doing well on stable clinical conditions. Conclusions: Surgery after PDA stenting is safe and low-risk. e presence of PDA stents requires additional surgical manoeuvres on pulmonary arteries in near half of the patients. Furthermore, postoperative repeated interventions can be required. Table 1
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LPA= left pulmonary artery; PA= pulmonary artery; RPA = right pulmonary artery, m: months, y: years, d: days.
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Congenital Posters Continued P45 Contemporary Treatment of Isolated VSD in Children: Percutaneous VSD Device Closure Versus Surgical Closure P. Oses1, G. Brugada1, N. Hugues1, S. Vobecky1, N. Dahdah1, M. Pellerin2, J. Miro1, N. Poirier1 1 St. Justine Hospital, Montreal, Canada; 2Heart Institute of Montreal, Montreal, Canada Purpose: Isolated hemodynamically signi cant ventricular septal defects (VSD) were once solely surgical lesions. Since the introduction of percutaneous (PC) devices, the management of isolated VSD has evolved. In our center, nitinol self centering devices have been implanted since 1998 and for selected isolated perimembranous (PMb) and muscular VSD since 2002. Methods: We retrospectively reviewed charts of all isolated PC VSD closures since 2002, in addition to all the surgical closures performed during the same period. Clinical, electrocardiographic, and echocardiographic data were analyzed. Pre-operative, immediate post-operative, 1-month, 6-month, and annual postop results were studied. Results: e following table summarizes demographic data in addition to results of 37 patients who underwent PC closures and 34 other patients who treated surgically with a mean follow-up 42 months. e PC group was signi cantly older (p < 0.01) and bigger (p < 0.001). e VSD gradient preop was signi cantly lower in the surgical group (p < 0.004), thus patients were in greater clinical heart failure. ere was no mortality in either group. At follow-up there were no di erences in the incidence of residual VSD (p = 0.34). Two patients with PMb VSD and pre-existing aortic valve insu ciency increased its level to moderate post-Amplatzer implantation versus none in the surgical group (p = 0.45). A permanent pacemaker was implanted for complete heart block following post-device closure of a PMb VSD in one patient and none in the surgical group. Conclusions: e surgical results are excellent in this sicker patient population. Patient selection remains a challenge to avoid post-percutaneous intervention complications such as heart block and aortic insu ciency in the perimembranous VSD patients. Percutaneous closure of isolated VSD, which avoids some morbidity of open-heart surgery should however remain part of the therapeutic armamentarium.
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P46 Impact of Inspired Oxygen Concentration on Cerebral Blood Flow in Univentricular Circulation S. Haydar1, B. Willis1, D. H. Frakes2, E. K. Rhee1, J. J. Nigro1 1 St. Josephs Hospital and Medical Center, Phoenix, AZ, 2Arizona State University, Phoenix, AZ Purpose: e pulmonary and systemic circulations are parallel in univentricular circulation with a systemic to pulmonary shunt, and a careful balance is required to ensure survival. Optimal organ function and long-term survival quality may depend on regional blood ows, which might be a ected by fraction of inspired oxygen (FiO2). e purpose of this study was to assess the e ects of FiO2 on cerebral blood ow in a piglet model of univentricular circulation. Methods: Univentricular circulation was established in 10 neonatal piglets by performing a systemic to pulmonary shunt, atrial septostomy, tricuspid avulsion and pulmonary artery occlusion. Transit-time ultrasound measurement of cardiac output (CO), pulmonary blood ow (Qp), carotid blood ow (Qc), and blood gas analysis were performed in all 10 piglets at steady state with FiO2 of 21% and 100%. Systemic blood ow (Qs), Qp/Qs ratio, oxygen delivery (D02) and oxygen extraction (O2ER) were calculated. Results: Increasing FiO2 from 21% to 100% was associated with a signi cant increase in Qp, Qp/Qs, and O2ER; and with signi cant reduction in Qc, Qs, and D02 (table 1). Mean reduction in Qc was 23% (median 26%, 0.10) while that for Qs was 17% (median 19%, 0.09). Conclusions: Increased fraction of inspired oxygen decreases carotid blood ow in a univentricular model. is study suggests that increasing FiO2 reduces cerebral perfusion and oxygen delivery, and may consequently impact neurologic outcome in children with univentricular circulation and a systemic to pulmonary shunt. Table 1
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Congenital Posters Continued P47 In Vivo Implantation of a Functional Tissue Engineered Stentless Pulmonary Valve Using Bone-Marrow-Derived Mesenchymal Stem Cells and Circulating Endothelial Progenitor Cells E. B. Delmo Walter1, V. L. Sales1, B. Sill1, D. Martin2, E. Rusk2, S. Emani1, C. Estrada1, R. Hetzer3, J. E. Mayer1 1 Childrens Hospital Boston/Harvard Medical School, Boston, MA; 2TEPHA, Inc., Cambridge, MA; 3 e German Heart Institute Berlin, Berlin, Germany Purpose: We investigated the functional potential of poly-4-hydroxybutyrate (P4HB) sca olds as tissue-engineered (TE) stentless pulmonary valve (PV) by determining the most suitable thickness and ratio of co-cultured progenitor cells for construction of pulmonary lea ets and annular sewing ring. Methods: Melt-blown bronectin (FN)-coated P4HB sca olds (varying thickness 100-, 220-, 440-, 660 M) were seeded with di erent percentages of characterized ovine bone marrow-derived mesenchymal stem cells (MSC) and peripheral bloodderived endothelial progenitor cells(EPC) in a laminar uid ow system. Results: H&E of FN-coated sca olds (100M and 220M) seeded with 40% MSC and 60% EPC demonstrated enhanced cellularity, extracellular matrix formation, and cellular ingrowth into the interstitial layer, con rmed by scanning electron microscopy. Both pre-coated and uncoated sca olds demonstrated primary surface expression of CD31+, vWF+ and VEGF-R2 + cells; -SMA+ cells were found both on the surface and in the interstitium evidenced by IHC. Immunoblotting revealed increased expression of -SMA+ in 100 M and 220 M sca old thickness seeded with 40% MSC and 60% EPC. Mechanical testing demonstrated increased tensile strength over strain in 100M and 220M seeded with 40% MSC and 60% EPC. Autologous TE stentless PV using 220M for PV lea ets covered with 100M for annular sewing ring was successfully placed in PV position. e neo-tissue integrity allowed secure anastomosis with adequate tensile strength. Echocardiography demonstrated normal biventricular function, absence of anastomotic dilatation and aneurysm, good lea et coaptation with trivial central regurgitation. Conclusions: is demonstrates the successful creation of an anatomically functional, autologous TE stentless PV using sequentially seeded progenitor cell sources. is suggests the importance of sca old thickness and ratio of seeded cells in the suturability of TE stentless PV.
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P48 Does a Biodegradable Ring Enable Growth of the Native Tricuspid Annulus? W. Mrowczynski1, B. Mrozinski1, B. H. Walpoth2, M. Pawelec-Wojtalik1, A. Kalangos2, M. Wojtalik1 1 Poznan University of Medical Sciences, Poznan, Poland; 2University Hospitals of Geneva, Geneva, Switzerland
FINANCIAL DISCLOSURE A. Kalangos: Bioring, SA, consultant/advisory board
Purpose: e aim of this study was to assess the growth potential of the tricuspid valve (TV) annulus after annuloplasty with the intratissular biodegradable ring in children. Methods: Twenty-four children were operated for severe congenital TV regurgitation with the use of a biodegradable annuloplasty ring. eir median age was 12.2 years (0.2-18.8). Patients were followed regularly by trans-thoracic echocardiography; the TV annulus lateral diameter (TVALD) and valve function were monitored. e rates of growth were derived from the slope of regression equations relating TVALD to the natural logarithm of BSA. Results: Childrens somatic growth was harmonious throughout the whole follow-up period - 594366 days (68-1227). TVALD di ered signi cantly at 6 months, 1 and 2 years in comparison to discharge value. It raised from -3.6Z(range: -4.9 to +0.3) and to -1.4Z(range: -3.9 to +3.8) at the last control(p=0.0001). A signi cant linear correlation between TVALD and lnBSA was found in 46% of patients. Rate of growth was exceeding tenfold the norm in 23% of children who were signi cantly older. e median TV insu ciency fraction of 11% (9-13%) remained constant during the follow-up. Discharge TV maximal pressure gradient was 5.2mmHg(3-15) and did not increase over time. Conclusions: e implantation of a biodegradable ring does not restrict the growth of the native TV annulus which is proportional to the somatic growth in almost half of the children. e rate of growth is faster than in normal population especially among older children. TV annulus begins to change its dimensions 6 months postoperatively which coincides with complete biodegradation of the annuloplasty ring and does not in uence the results of valve repair.
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Congenital Posters Continued P49 Viscous Impeller Pump (VIP) for Cavopulmonary Assist in a Univentricular Fontan Circulation: Performance Predictions and Analysis G. Giridharan2, S. Koenig2, J. Graham2, B. Coats3, J. Chen3, S. Frankel3, M. D. Rodefeld1 1 Indiana University School of Medicine, Indianapolis, IN; 2University of Louisville, Louisville, KY; 3 Purdue University, West Lafayette, IN Purpose: In a univentricular Fontan circulation, augmentation of existing cavopulmonary ow will reduce systemic venous pressure, increase ventricular lling, and thus, improve circulatory status. e performance expectations and limitations for a pump to operate in this unique low pressure environment are undetermined. We tested the e cacy of a catheter-based viscous pump with an expandable bi-conical impeller (VIP) using computer simulation and mock circulatory system models. Methods: A lumped parameter model of a four-year-old with a univentricular Fontan circulation was created. Resistance, compliance, and volumes were adjusted to match Fontan physiology. e VIP was integrated into the model at the cavopulmonary junction. Simulations were conducted to predict acute hemodynamic response to 0%, 50%, 75%, and 100% VIP support. Simulation results were veri ed in a mock circulatory loop. Results: Without support, the Fontan circulation is associated with diminished cardiac output, and aortic systolic and diastolic pressures. With VIP support, systemic venous pressure, pulmonary arterial pressure, cardiac output, ventricular end-diastolic pressure, and aortic systolic and diastolic pressure normalize to biventricular values. VIP support also increases ventricular end-systolic and end-diastolic volumes from Fontan values. Negative pressure was not observed in the cavopulmonary junction inlets. In vitro ndings correlate strongly with computational estimates. Conclusions: A modest shift of cavopulmonary pressure (6 mmHg) in the direction of the single ventricle restores the Fontan circulation to normal biventricular values. Risk of negative pressure suction collapse of the vena cavae is low. VIP cavopulmonary assist may improve circulatory status in Fontan patients by restoring normal 2-ventricle physiology, and may permit Fontan conversion without intermediary surgical staging or use of a systemic arterial shunt.
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P50 Blood Arginine-Vasopressin Concentration in Patients Undergoing Pediatric Cardiac Surgery V. Chirumamilla, A. Vivencio, A. DeAnda, S. Weinstein Monte ore Medical Center - Albert Einstein College of Medicine, Bronx, NY Purpose: Cardiopulmonary bypass (CPB) is presumed to alter the normal production of endogenous vasopressin. Vasopressin is increasingly used in children to increase vascular tone. We attempt to evaluate speci c response of endogenous Vasopressin in pediatric patients undergoing CPB. Methods: Between Oct. 2007 and Nov. 2008, 24 pediatric patients requiring CPB for cardiac repair/palliation was studied. Approval from Internal Review Board was obtained. Blood was collected at ve intervals during the operation: 1) after induction, 2) post heparin, 3) 30 minutes on CPB, 4) post protamine and 5) following skin closure. Arginine vasopressin (AVP) concentrations were determined from plasma samples using the Assay Design (Ann Arbor, Mich.) human AVP enzyme-linked immunosorbent assay (ELISA) kit. Results: Mean age was 5.7+6 years; 62.5% were males. Cyanotic heart disease was seen in 41.7%. Mean CPB time 142.8+77 minutes. A signi cant increase in AVP concentration was seen from periods 1 to 3 (p=0.001) and a signi cant decrease in AVP concentration from periods 3 to 5 (p=0.001).[graph 1] ere was no signi cant di erence in AVP concentration from induction (interval 1) to following skin closure (interval 5) p = 0.113. Vasopressor use was increased in patients with CPB >150 minutes (p=0.004). ere was no di erence in postoperative vasopressor requirement between cyanotic and acyanotic heart disease patients. Conclusions: ere is a signi cant increase in AVP during pediatric cardiac surgery which returns to baseline following bypass. CPB >150 minutes may be a more important indicator for the need of postoperative vasopressor support than preoperative diagnosis. ere was no di erence in production of Vasopressin between cyanotic and acyanotic patients.
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Congenital Posters Continued P51 Fetal Right Ventricular Myocardial Function is Better Preserved by Fibrillatory Arrest During Fetal Cardiac Bypass O. Petrucci1, R. Baker2, C. Lam2, C. Reed2, J. Du y2, P. Eghtesady2 1 State University of Campinas, Campinas, Brazil; 2Cincinnati Childrens Hospital Medical Center, Cincinnati, OH Purpose: Protection and preservation of fetal myocardial function are important for successful fetal intracardiac repair. Our objective was to determine fetal biventricular cardiac performance with fetal bypass and compared two cardiac arrest techniques for myocardial protection and function. Methods: ree groups of ovine fetuses (100-109 GD) underwent 90-minute bypass. A control group (no arrest shams, n=3), and two groups that included 20 minutes of arrest, using either brillatory (Fib, n=3) or blood cardioplegia (Plg, n=3), were compared. Blood cardioplegia consisted of 4:1 blood to crystalloid solution with cold induction followed by warm shot terminal dose prior to clamp removal. Myocardial function parameters with biventricular intracardiac pressure catheters and 3-axes cardiac sonomicrometry, fetal hemodynamics, and arterial blood gases were continuously recorded. Fetal myocardium was collected from all animals for troponin-I analysis at 90 minutes. Statistical analysis was by ANOVA with repeated measures. Results: Compared to sham, myocardial contractility was reduced in Plg but not Fib by 90 minutes post-arrest as measured by dP/dt max (511 347 vs. 1208 239, P< 0.01) and pre-recruitable stroke work,(7.28.5 vs. 32.314.6, P< 0.01). End diastolic pressure-volume relationship (ventricular sti ness), worsened by 90 minutes post-arrest for Plg compared to Fib, (0.84 0.18 vs. 0.25 0.16, p<0.05). ere was no di erence in left myocardial performance between groups. Fetal heart rate was reduced in both arrest groups at 30 and 60 minutes post-arrest compared to Sham, (p<0.05). Right ventricular-troponin-I degradation increased with Plegia, but not Fib arrest compared to Sham, (p=0.04). Conclusions: Fetal right myocardial contractile function deteriorates with blood plegia-based cardiac arrest. Fibrillatory arrest better preserves right myocardial function, the dominant ventricle in fetal life, for short periods of arrest.
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P52 Posterior Lea et Obliteration: A Simple, Reproducible, and E ective Technique for Tricuspid Valve Repair in Hypoplastic Left Heart Syndrome D. C. Dinh, J. G. Gurney, J. E. Donohue, E. L. Bove, J. C. Hirsch, E. J. Devaney, R. G. Ohye University of Michigan, Ann Arbor, MI Purpose: Signi cant progress has been made in the care of patients with hypoplastic left heart syndrome (HLHS). However, tricuspid regurgitation (TR) remains a considerable obstacle in advancing through the stages of palliation. Since a previous study from our institution suggested that posterior lea et obliteration (PLO, Figure 1) was a simple and e ective technique for TR repair, we have preferentially utilized that method. We sought to analyze the e ect of this policy on repair success and patient survival. Methods: Twenty-six HLHS patients with 3-4+ preoperative TR underwent tricuspid valve repair between April 2002 and November 2007. Clinical and echocardiographic data were used to determine the success of repair and patient outcome. Patients with 0-2+ TR were categorized as successes, whereas 3-4+ constituted failure. Results: Follow-up was 92% complete (24/26) at a median 21 months (range, 1-71). Of the 24 patients, 18 (75%) underwent repair with PLO; 71% (17/24) of patients had success at early outcome while the remaining 7 experienced failure of repair; and 63% (15/24) demonstrated continued success at late outcome. Early outcome status was found to be a predictor of late outcome status (P = 0.0037) with an odds ratio of 22.9. Overall survival was 71% (17/24). Survival could not be shown to be associated with early or late outcome status (OR = 0.96). Conclusions: A policy of preferentially utilizing PLO for tricuspid valve repair was found to be an e ective and long-lasting means of treating TR in HLHS patients. Success at immediate outcome was predictive of success over time. Survival was not found to be associated with TR status. e use of PLO has the advantage over other techniques of being simple and reproducible, and produces very good results in this challenging group of patients.
Figure 1. Posterior Lea et Obliteration (PLO)
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Congenital Posters Continued P53 Hypothermic Circulatory Arrest Increases Permeability of the Blood Brain Barrier in Watershed Areas T. Okamura, N. Ishibashi, Y. Iwata, K. Susheel, H. Lidov, D. Zurakowski, R. A. Jonas Childrens National Medical Center, Washington, DC Purpose: Integrity of the blood brain barrier (BBB) after cardiopulmonary bypass (CPB) with hypothermic circulatory arrest HCA) is controversial, especially in children. Using acute and subacute experiments, we tested the hypothesis that BBB is disrupted by HCA. Methods: Twenty- ve piglets (mean weight 11kg) were randomly assigned to either acute (n=15) or subacute experiments (n=10). Experiments included 5 groups (5 per group): anesthesia alone (control) without heparin or surgery, CPB at 25C with low ow (LF), surgery with CPB, and HCA at 25C.1) Acute (three groups); Evans blue dye (EBD) was infused two hours after end of CPB. Brains were perfused and removed after one hour observation. EBD extravasation in brain tissue was measured using: i) macroscopic imaging of whole brain and ii) immunohistochemistry of cortex, caudate nucleus, thalamus, hippocampus, and cerebellum measuring density of EBD in each area and colocalization study between albumin antibody and EBD. 2)Subacute (two groups); brains of piglets were removed for histological analysis 4 days after surgery. Brains were analyzed by H&E staining. Groups were compared by ANOVA and nonparametric Kruskal-Wallis test. Results: Macroscopically, BBB disruption was obviously greater around watershed areas in 25C HCA than in control. Microscopic data showed that leakage of EBD in 25C HCA compared to control was signi cantly more severe in cortex, caudate nucleus, thalamus, hippocampus, and cerebellum (p<0.01). EBD and albumin showed colocalization. Histologic scores in watershed areas were higher in 25C HCA compared with 25C LF (p=0.01). Conclusions: BBB is impaired around watershed areas by 25C HCA for one hour, and 25C LF (very low ow bypass) is more e ective in maintaining BBB integrity than 25C HCA. Both macro and microscopic data show clear evidence of BBB leakage with 25C HCA. e increase in permeability of BBB may lead to or increase the risk of brain damage. Further investigation is needed to understand mechanisms of brain damage after HCA.
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P54 Perioperative Blood Conservation Strategies in Pediatric Patients Undergoing Open Heart Surgery: Impact of Nonautologous Blood Transfusion and Surface Coated Extracorporeal Circuits S. Gunaydin1, K. McCusker2, V. Vijay3 1 University of Kirikkale, Ankara, Turkey; 2Portsmouth Regional Hospital, Portsmouth, NH; 3 Hudson Cardiothoracic Surgeons, New York, NY Purpose: Blood transfusion in adults is associated with increased mortality and morbidity after cardiac operations. e aim of this study was to explore the relative clinical and biomaterial e ects of blood transfusion (Tx) and surface coated circuitry on perioperative outcome in pediatric patients undergoing surgery with cardiopulmonary bypass (CPB). Methods: Over a 6-month period, 80 consecutive patients, weighing 5-10 kg, underwent surgery with CPB in a tertiary pediatric cardiac center. Patients were prospectively randomized to four equal groups (N=20): Group 1- Tx-free procedures on low prime surface-coated circuitry (FX05, Terumo); Group 2- Procedures requiring Tx on coated circuitry; Group 3- Tx-free procedures with standard identical uncoated circuitry, Group 4 (Control): Procedures requiring Tx on uncoated circuitry. Tx criteria were hematocrit <20%, mixed venous oxygen saturation <70%, regional cerebral oxygenation (rSO2) <50%, and plasma lactate level >4.0 mmol/L during CPB. Serum lactate, interleukin-6 (IL-6) and TNF-alpha levels were measured. CD11b/CD18 expressions were determined by ow cytometry. Blood samples were collected at baseline (T1); at the end of the CPB (T2) and 24 h (T3), postoperatively. rSO2 desaturation risk score (Invos, Somanetics) was calculated by multiplying rSO2 below 50% by time (sec). Blood cell adhesion on circuit bers was analyzed by scanning electron microscopy. Desorbed protein amount on bers (microalbumin) was evaluated by spectrophotometer. Results: Perioperative data are demonstrated in Table. ere was a signi cant positive correlation between hospital stay and the amount of transfused blood (r=0.74). Conclusions: Allogenic blood Tx ampli es CPB related in ammatory response and increases the surface protein adsorption on circuits. It is feasible to do congenital procedures safely without Tx for patients weighing more than 5 kg by using combined blood management strategies. Perioperative Outcome
*p<0.05 vs. control
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Congenital Posters Continued P55 A Congenital Heart Surgery Failure-to-Rescue Measure J. H. Silber, S. Smith-Simone, S. Fuller, C. Ravishankar, A. T. Kennedy, Y. Teng, O. Even-Shoshan, J. W. Gaynor e Childrens Hospital of Philadelphia, Philadelphia, PA
FINANCIAL DISCLOSURE J.W. Gaynor: Aristotle Committee, consultant/advisory board
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GENERAL THORACIC POSTERS P56-P76
P56 Sub-Lobar Resection With Absorbable Mesh I-125 Brachytherapy for Early Stage Non-Small Cell Lung Cancer (NSCLC) M. A. Manning1, C. Bryant2, M. K. Mohamed1, D. Burney1 1 Moses Cone Health System, Greensboro, NC; 2University of Florida, Gainesville, FL
FINANCIAL DISCLOSURE M.A. Manning: GE Healthcare, consultant/advisory board
Purpose: Failure-to-Rescue (FTR) is an outcome that describes the probability of death after a patient develops a complication. For adults, FTR has been adopted as a quality of care metric by AHRQ and NQF. FTR has generally proven to be strongly related to hospital characteristics such as nursing mix and volume when using administrative data with or without clinical data. An advantage in using FTR as an outcome measure in addition to mortality rests in severity adjustment, as all analyzed patients in an FTR analysis must have developed a complication and thus are generally more uniformly ill than those who did not develop complications. is study reports on a pilot algorithm for de ning FTR in Congenital Heart Surgery (CHS) with the hope of ultimately improving CHS quality assessment. Methods: We merged all patients eligible for RACHS evaluation from the pilot hospitals STS National Database between 2002 and 2007 (excluding patients with cardiac malignancies) with hospital discharge claims to create a working le that included ICD9-CM principal and secondary diagnoses and procedures obtained from CPT codes. Complications (N=45 types) were aggregated into 7 clinical groups (CGs) for presentation. Results: ere were 1,568 patients, of which 844 (53.83%) had complications and 55 died (3.51%). All deaths displayed at least one preceding complication and of those with complications, the death rate (= FTR rate) was 55/844 or 6.52%. FTR rates for speci c complications will be reported. A Respiratory CG occurred in 43% of patients, FTR = 7%; Surgical/bleeding CG occurred in 26%, FTR = 10%; Infection CG in14%, FTR = 14%; Neurological CG in 2%, FTR=17%; Renal CG in 2%, FTR = 55%. Conclusions: FTR can be applied to CHS with a set of complications that precedes all deaths. Studying variations in FTR across institutions and across speci c complications may allow for a better understanding of the determinants of mortality and a better ability to compare outcomes and quality.
Purpose: For patients with early stage NSCLC and pulmonary dysfunction, there are many emerging treatment options. is study describes results from sub-lobar resection with brachytherapy (SLR-B) in a clinical series characterizing the overall survival (OS), the progression free survival (PFS), local control (LC) rates, and complications associated with this lung-sparing surgical approach. Methods: Between July 2006 and Feb. 2009, 74 patients with peripheral clinical stage IA NSCLC based on PET-CT, underwent SLR-B. Intraoperatively, histology/margins were veri ed and lymph nodes were sampled. I-125 seeds embedded in vicryl mesh were applied to the site of resection to deliver 100-120 Gy at a depth of 5 mm. Patients were restaged pathologically post surgery. Results: At surgery, only 47/74 (64%) of subjects were con rmed to have stage IA disease. Stage IB disease was discovered in 13/74 (17%). e average FEV1 was 1.49 liters. One- and two-year PFS for stage IA were 92.6% and 84.5%, respectively. LC was 96.8% at 2 years. Regional and distant failure accounted for 70% of recurrences. OS was 85.2% and 60.3% at 1 and 2 years. Acute complications occurred in 30% including post-operative pneumonia, atrial brillation, and air leak which occurred in 4, 5, and, 6 patients, respectively. Late complications occurred in 4.1% with one patient each experiencing bronchopleural stula, an air cavity, and/or prolonged supplemental oxygen requirement. Conclusions: For patients with Stage IA NSCLC and signi cant pulmonary dysfunction, SLR-B o ers excellent local control rates and progression free survival. Acute complications occurred at comparable rates to lobectomy and late complications were rare even for patients with signi cant pulmonary dysfunction. Additionally, SLR-B led to the recognition of more advanced subclinical disease that would have been overlooked by non-invasive stereotactic body radiotherapy.
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General oracic Posters Continued
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P57 Winning the Battle, Losing the War: The Non-Curative Curative Resection for Stage I Adenocarcinoma of the Lung S. C. Murthy, U. Ogwudu, S. I. Reznik, T. W. Rice, D. P. Mason, P. L. Houghtaling, E. R. Nowicki, E. H. Blackstone Cleveland Clinic, Cleveland, OH Purpose: To determine the risk of recurrence of cancer following anatomic resection of stage I adenocarcinoma of the lung, and to identify associated risk factors. Methods: From 1991 to 2001, 287 patients underwent anatomic resection of stage I adenocarcinoma (pathologic) of the lung. ey were followed cross-sectionally for evidence of lung cancer recurrence (any subsequent cancer of similar cell type, regardless of how remote from index resection). Mean follow-up among survivors was 9.73.5 years, 10% were followed more than 14 years, and 1,961 patient-years of data were available for analysis. Risk factors for recurrence were sought among demographic, medical history, surgical procedure, and detailed tumor pathology data. Results: Cancer recurrence was recognized in 99 patients. Freedom from recurrence was 92%, 72%, and 60% at 1, 5, and 10 years (Figure). Two phases of risk were found: an early hazard phase and an essentially constant late phase, with recurrences equally distributed in each. Early recurrence was associated with larger tumor size (P=.0002; 61% pT1 and 39% pT2). Late recurrence was more common in patients with higher pack-years of smoking (P=.001) and less common in patients with a history of other cancers (26% of patients, P=.006) and if mediastinal lymphadenectomy had been performed (31% of patients, P=.001; Figure). Conclusions: Risk of recurrence after anatomic resection of stage 1 adenocarcinoma is adversely a ected by absolute tumor size and a higher pack-year smoking history; however, routine mediastinal lymphadenectomy at the time of resection may be protective.
P58 Lung Cancer and Lung Transplantation: A Single Center Perspective J. K. Bhama, D. Zaldonis, M. Crespo, J. M. Pilewski, B. A. Johnson, S. Dacic, C. Bermudez, S. Gilbert, Y. Toyoda University of Pittsburgh Medical Center, Pittsburgh, PA Purpose: Expansion of donor/recipient selection criteria has increased the number of lung transplants with an expected increase in the number of native lung cancers. Simultaneously, outcomes of transplants for bronchoalveolar carcinoma (BAC) remain unde ned. is study evaluates our experience with lung cancer in patients undergoing lung transplant. Methods: A retrospective review of lung transplant recipients who were either found to have native lung cancer (Group A, n=13) or underwent transplant for BAC (Group B, n=4). Outcomes were compared to separate case-matched controls. Results: Group A received double (n=9) or single (n=4) lung transplant based on diagnosis. e indication was emphysema in 10/13 cases with a mean age of 60 years. Induction therapy was used in 10/13 cases. Cancers found were non-small cell lung cancer (n=8), BAC (n=2), sarcoma (n=1), lymphoma (n=1), and thyroid (n=1). Cancer stages were I (n=3), IIA (n=8), IIB (n=1), and IV (n=1). Cancer recurred in 4 patients at days 881, 863, 241, and 40. Among cases of primary lung cancer (n=10), the recurrence rate was 40%. Causes of death were recurrent lung cancer (n=2), disseminated infection (n=1) and bronchiolitis obliterans (n=2). Overall 30-day, 1, 2, and 3-year survival rates were 100%, 100%, 100%, and 52% versus 100%, 84%, 75%, and 52% for a case-matched control group (p=0.93). Group B received double lung (n=3) or single lung (n=1) transplant based on location of disease. All had a pathologic diagnosis of BAC and the mean age was 50 years. Overall 30-day, 1, 2, and 3-year survival rates were 100%, 75%, 75%, and 75% versus 100%, 75%, 75%, and 75% for a case-matched control group (p=0.96). Conclusions: Native lung cancer found at the time of lung transplant does not impact early to midterm survival. Risk for cancer recurrence is high thus frequent radiographic surveillance is indicated. Patients with BAC may experience similar early to midterm survival after lung transplant as patients with other diagnoses.
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General oracic Posters Continued Figure
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P59 Argatroban Inhibition of Osteopontin Modulates Isoform Speci c Malignant Properties in Non-Small Cell Lung Cancer (NSCLC) J. D. Blasberg, C. M. Goparaju, H. I. Pass, J. S. Donington New York University Medical Center, New York, NY Purpose: Osteopontin (OPN) is a ubiquitous protein central to NSCLC pathogenesis. e three human OPN isoforms have di erential expression and function in NSCLC. OPNa, the full-length protein, is selectively expressed in NSCLC and confers a malignant phenotype, while OPNc, which lacks exon 4, confers an indolent phenotype. rombin cleavage of OPN increases its biologic activity by exposure of a central integrin binding site. We hypothesize that thrombin inhibition of OPN will alter malignant behavior of NSCLC cell lines in an isoform speci c manner. Methods: rombin inhibition of individual OPN isoforms was evaluated by transfecting cDNA plasmids speci c to OPNa, OPNc, and empty vector controls into four NSCLC cell lines and performing MatrigelTM invasion and in vitro angiogenesis assays in the presence and absence of Argatroban (25ug/ml), a thrombin inhibitor. Results: OPNa overexpression in H153 and H358 (cell lines with low native OPN) and A549 and H460 (high native OPN) resulted in signi cantly increased invasion and angiogenesis compared to controls. OPNc overexpression signi cantly decreased invasion and angiogenesis compared to controls. Argatroban treatment decreased invasion and angiogenesis in control cell lines with high native OPN (A549 and H460), but had no e ect on control cells with low native OPN (H153 and H358). Argatroban signi cantly decreased invasion and angiogenesis in cells with forced overexpression of OPNa, and increased invasion and angiogenesis in cells with forced overexpression of OPNc, negating the isoform speci c e ects. (Figure) Conclusions: We have demonstrated that Argatroban treatment signi cantly reduces the isoform speci c malignant impact of OPN in NSCLC by interfering with thrombin cleavage. ese data may lead to therapeutic strategies which selectively inhibit OPN isoforms and alter the metastatic potential of NSCLC.
A) OPN isoforms have divergent impact in all cell lines on invasion; treatment with Argatroban (Ar) selectively reduces isoform speci c behavior. B) OPN isoforms also have divergent impact in all cell lines on angiogenesis; Ar reduces isoform speci c behavior.
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P60 A Sublobar Resection Due to a Compromised Medical Condition has an Equivalent Long-Term Outcome to That of a Standard Lobectomy in Elderly Patients With Stage IA Non-Small Lung Cancer (NSCLC) J. Okami, M. Higashiyama, J. Maeda, K. Oda, A. Fujiwara, R. Kanzaki, K. Kodama Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan Purpose: A sublobar resection is indicated for the treatment of early stage NSCLC in patients associated with impaired medical conditions in order to reduce the perioperative risk. e long-term outcomes of sublobar resections are still unclear. Methods: All patients (N=777) who underwent a pulmonary resection for peripheral stage IA NSCLC from 1990 and 2007 were enrolled. Any patients undergoing sublobar resections with a radical intent for the treatment of non-invasive carcinoma, which was identi ed as a shadow containing a ground-glass opacity on CT scans (N=220), were excluded in advance. Primary variables included perioperative mortality and morbidity, survival, cause of deaths, and reasons for selecting a sublobar resection. e outcomes were compared between a sublobar resection and a lobectomy according to age. Results: Patient characteristics were summarized in the table. In the lobectomy group, the patient was younger, the tumor was larger in size and more adenocarcinomas were observed. No perioperative mortality was recorded. e principal reasons for performing sublobar resections were a poor pulmonary function in 53 patients, a poor cardiac function in 34, a history of cancer treatment in 21, and others. ere was a signi cant di erence in the 5-year overall survival rates between the sublobar and lobectomy groups (66.1% in sublobar resection and 88.4% in lobectomy) but not in the elderly patients (75 or older) (Figure). No signi cant di erence in postoperative complications was observed according to the type of surgery in the elderly patients. Conclusions: A sublobar resection for stage IA NSCLC is associated with an inferior overall survival in comparison to a standard lobectomy in the general population. In contrast, this procedure is nevertheless considered to be an appropriate treatment strategy in the elderly since a sublobar resection provides an equivalent long-term outcome. Patient characteristics
P61 Results of Superior Vena Cava Reconstruction With Externally StentedPolytetra uoroethylene Vascular Prostheses I. C. Okereke, K. A. Kesler, K. M. Rieger, T. Birdas, D. Mi, M. W. Turrentine, J. W. Brown Indiana University School of Medicine, Indianapolis, IN Purpose: Resection and reconstruction of the superior vena cava (SVC) is occasionally required in the surgical treatment of intra-thoracic neoplasms or symptomatic occlusion secondary to benign etiologies. We reviewed our institutional experience with SVC reconstruction using externally stented-polytetra uoroethylene (ES-PTFE) vascular prostheses. Methods: From 1991 to 2009, 38 patients who underwent SVC resection and reconstruction with ES-PTFE vascular prostheses were reviewed. Indications for surgery were malignancy in 34 (89%) patients (germ cell = 13, thymoma = 10, lung cancer = 9, sarcoma = 2) and benign symptomatic occlusion in 4 (11%) patients. Results: Eighteen patients (47%) underwent right innominate vein to SVC interposition graft reconstruction, which became the favored approach over the study interval when resection of the innominate con uence was necessary. Eight patients (21%) had left innominate vein to SVC interposition grafts, earlier in the series or when the right innominate vein was unavailable. Nine patients (24%) received graft interposition of the proximal to distal SVC. e remaining three patients had a Y reconstruction. ere were two peri-operative mortalities. Follow-up averaged 15 months (1-113 months), including 11 (29%) patients who died of disease. All patients demonstrated minimal to no symptoms of SVC occlusion at last follow-up. Twenty (53%) patients underwent imaging after an average of 24 months, with only two grafts demonstrating complete occlusion. Conclusions: Although several SVC reconstructive techniques have been described, ES-PTFE vascular prostheses are readily available for o -the-shelf use. In our experience, patency rates are high and patients who do demonstrate graft thrombosis have remained asymptomatic.
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P62 Oropharyngeal Dsyphagia Increases Mortality After Orthotopic Lung Transplantation B. Z. Atkins1, R. Prince-Petersen2, S. S. Lin2, R. Davis2 1 Durham VA Medical Center, Durham, NC; 2Duke University Medical Center, Durham, NC Purpose: Few modi able risk factors for lung transplantion (LT)-related mortality have been recognized, although development of bronchiolitis obliterans (BOS) reduces graft function and longevity. We recently demonstrated the frequent occurrence of oropharyngeal dysphagia with tracheal aspiration after LT and other thoracic surgical procedures, which increases perioperative morbidity. We hypothesized that postoperative dysphagia is associated with worse survival and increased rates of BOS after LT. Methods: After local IRB approval, records of 263 consecutive LT patients from a single institution were retrospectively reviewed ( Jan. 2001- July 2005). All patients underwent clinical swallowing evaluation in the early postoperative period; 149 patients underwent additional beroptic or video uoroscopic swallowing evaluation (SE). Results of SE were correlated with BOS and mortality using Kaplan Meier survival curves, and Cox proportional hazard modeling assessed factors associated with BOS and mortality. Results: Mean follow-up time was 920 560 days. SE was positive in well over twothirds of patients (n = 105). Results of SE did not impact the combined end-point of BOS/death. However, patients with normal/negative postoperative SE had signi cantly improved postoperative survival relative to those with positive/failed SE (Figure 1). Postoperative ventilator dependence independently predicted mortality as well as the combined endpoint of BOS/death, while normal SE was protective of both mortality and BOS/death (Table 1). Conclusions: Oropharyngeal dysphagia is surprisingly common after LT and often overlooked when relying solely on clinical assessment of deglutition. Preserved/normal swallowing mechanisms appears protective of survival after LT, but the presence of dysphagia does not increase the presence of BOS. Mechanisms underlying post-LT dysphagia are unclear, but pre-transplant SE may distinguish patients at increased risk for dysphagia after LT. Table 1. Figure 1
P63 Is Pulmonary Ablation More E ective With Single Lung Ventilation? R. S. Santos2, M. Ebright1, G. Steiner1, M. DeSimone1, B. D. Daly1, H. C. Fernando1 1 Boston Medical Center, Boston, MA; 2Albert Einstein Institute for Research and Education, So Paulo, Brazil
FINANCIAL DISCLOSURE H.C. Fernando: Covidien, research grant
Purpose: ermal ablation is increasingly used to treat pulmonary tumors in high-risk patients. Most procedures are performed with sedation in the radiology suite. Ideally, the ablation should encompass the entire tumor volume with a surrounding margin of necrosis; however, ablation may not be as e ective in normal lung surrounding the tumor compared to denser tumor tissue. Inducing atelectasis of the lung may potentially increase ablation volumes. is study examines the e ect of single-lung ventilation on ablation size. Methods: Twenty microwave ablation procedures were performed in the lungs of 10 swine. Bilateral thoracotomies using a clamshell approach were used. In one lung, ablation was performed with continuous ventilation. In the other lung, single-lung ventilation was achieved by clamping the bronchus prior to ablation. e ablated lobes were resected and sent for pathological analysis. Routine and supra-vital staining was performed. Results: e ablation zone was clearly demarcated on gross examination; and in all cases 100% ablation occurred, without skip areas of viability. e ablation zones were eliptical with the long axis parallel to the axis of the ablation probes (active tip 3.7cm). Ablation diameters (cm) and volume (cm^3) were compared between ventilated and non-ventilated lungs (Table). Ablation volume was superior in non-ventilated lungs, primarily due to di erences in the short axis of the ablation zone. Conclusions: Microwave energy can e ectively ablate normal pulmonary parenchyma without skip areas of viable tissue. e volume of necrosis is increased in non-ventilated lungs, suggesting that ablation results may be improved in patients by using general anesthesia with single lung ventilation. Future studies will be required to con rm this hypothesis. Ablation Dimensions in Ventilated vs. Non-ventilated Lungs
Cox Proportional Hazard Model
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P64 The Intrathoracic Vacuum Assisted Closure (VAC) Device to Control Thoracic Sepsis J. Y. Perentes, A. Saadi, A. Tempia, N. Demartines, H. Ris, T. Krueger University Hospital of Vaud Lausanne (CHUV), Lausanne, Switzerland Purpose: We evaluated the VAC device for the treatment of intrathoracic infections following lung resections, necrotizing pneumonia, or esophageal surgery. Methods: All patients treated with an intrathoracic VAC device between Jan. 2005 and Dec. 2008 were reviewed. Surgical debridement and pleural decortication were performed in all cases and the underlying cause of infection was treated (i.e., bronchus stump insu ciency correction, necrotic lung resection, and esophageal leak closure). is was followed by repeated intrathoracic VAC dressings under general anesthesia until the infection was controlled. e chest wall was temporarily closed after each VAC replacement procedure. All patients had systemic antibiotherapy. Results: Twenty-seven patients underwent VAC dressings to control thoracic sepsis (16 male, 9 females, median age 64, range 37-77 years). Intrathoracic infections were related to postresectional empyema (pneumonectomy, n=3; lobectomy, n=8), intrathoracic infection following necrotizing pneumonia (n=5) and intrathoracic gastrointestinal leaks (spontaneous esophageal perforations, n=3; esophageal anastomotic leaks, n=7, and small bowel perforation, n=1). e intrathoracic VAC therapy lasted 233 days with a mean interval of 41 days between VAC changes. Infection control was achieved after 62 VAC changes. e in-hospital mortality was 15% (n=4). De nitive thorax closure was achieved in 100% of surviving patients. Conclusions: e application of the VAC device for intrathoracic infections is e cient and safe and may replace open window thoracostomy (Clagett) in selected cases. Time intervals in between VAC changes are longer than those reported in the literature for the open window procedure.
P65 Impact of Awake Thoracoscopic Surgery on Postoperative Lymphocyte Responses G. Vanni, E. Pompeo, F. Tacconi, T. C. Mineo University of Rome Tor Vergata, Rome, Italy Purpose: Surgical stress and general anesthesia can have detrimental e ects on postoperative immune function. We sought to evaluate comparatively postoperative lymphocytes response in patients undergoing video-assisted thoracoscopic surgery (VATS) under general anesthesia or sole thoracic epidural anesthesia. Methods: Between Oct. 2008 and June 2009, 50 patients with non-malignant pulmonary conditions were randomized by computer to undergo VATS through epidural anesthesia with spontaneous ventilation (awake group, N=25) or general anesthesia with one-lung ventilation (control group, N=25). In both groups, assessment of total lymphocytes count and changes in proportion of speci c lymphocyte-subsets including CD19+, CD3+, CD4+, CD8+, CD4+/CD8+ ratio, and CD16+CD56+ (Natural-Killer) were evaluated at baseline and on postoperative day 1, 2, and 3. Results: Study groups were well-matched in baseline and surgical data. On postoperative day 1, a signi cantly higher amount of Natural-Killer was found in the awake group versus the control group (median: 12 [QR: 8-14] vs. 5 [QR: 3-8], P=0.003); this di erence was still signi cant on postoperative day 2 (median: 11 [QR: 8-21] vs. 7 [QR: 4-10], P=0.02). Yet, in awake group there was a higher CD4+/CD8+ ratio on postoperative day 1 (median: 2.8 [QR: 1.6-3.5] vs. 1.7 [QR: 1.1-2.6], P=0.05). No di erence was found amongst groups in the remaining lymphocyte subsets. On postoperative day 3, total lymphocyte count was signi cantly decreased from baseline value in the control group only (median-: 410/mm3 [QR: -1030/+80 mm3], P=0.02) while it remained unchanged in the awake group (median-: 70 mm3 [QR: -300/+80 mm3], P=0.6). Conclusions: In this study, awake VATS resulted in a lesser impact on postoperative lymphocyte responses when compared to the equivalent procedure performed under general anesthesia.
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P66 Adenosine A2B Receptor Signaling is Important in Bronchiolitis Obliterans Development Y. Zhao, J. Steidle, H. Zhao, I. L. Kron, G. Ailawadi, J. M. Linden, C. L. Lau University of Virginia, Charlottesville, VA Purpose: Adenosine A2B receptor (A2BR) activation has been reported to enhance bleomycin-induced pulmonary brosis. In this study we investigated the e ect of A2BR deletion on bronchiolitis obliterans using a heterotopic tracheal transplant model. Methods: A non-revascularized hetereotopic tracheal model across a total alloantigeneic mismatch was used to study A2BR signaling in a mouse model of bronchiolitis obliterans. Balb/c donor tracheas were transplanted into congenic wildtype or A2BR knockout C57BL/6 recipients. Transplanted tracheas were removed 3, 7, 12, and 21 days after transplantation (n=64). e luminal obliteration was evaluated through hematoxylin and eosin staining and the cellular in ltration (macrophage, neutrophil and CD3+ T cell) was detected by immunohistochemical staining. Results: In comparison to allografts in wild type recipients, tracheas transplanted into A2BR knockout mice displayed signi cantly less bronchiolitis obliterans development on day 21(P=0.029) (time when bro-obliteration is seen in this model). Neutrophil and macrophage in ltration were not signi cantly di erent in the A2BR knockout recipients at the early time-points (when ischemia-reperfusion is seen in this model). A2BR knockout mice had signi cant decreased CD3+ T-cell in ltration on day 12 (P=0.001) (when acute rejection is seen in this model). Conclusions: A2BR deletion diminishes bronchiolitis obliterans and this e ect is associated with a reduction in lymphocyte, but not granulocyte in ltration. ese data suggest that blockade of A2BRs might be a useful therapeutic approach for the treatment of bronchiolitis obliterans.
P67 The Ravitch Versus Nuss Procedure for Treatment of Funnel Chest: Mid-Term Surveillance of the Degree of Satisfaction With the Surgical Result C. Kang1, H. Lee3, Y. Kim1, S. Jheon2, S. Sung2, J. Kim1 1 Seoul National University Hospital, Seoul, South Korea; 2Seoul National University Bundang Hospital, Bundang, South Korea; 3Asan Medical Center, Seoul, South Korea Purpose: e Nuss procedure is increasingly being performed due to several advantages as a minimally invasive surgery. However, a comparative study between the Nuss and Ravitch procedures with respect to patient satisfaction has not been performed. Methods: One hundred patients who underwent surgical correction of funnel chest between 2001 and 2004 and a follow-up period 2 years were included. Surveillance regarding the degree of satisfaction was determined using a 5-point Likert scale. Seventy-nine families participated in the surveillance. Results: e Nuss and Ravitch procedures were performed in 63 and 37 patients, respectively. e mean age of the Nuss group was younger than the mean age of the Ravitch group (4.8 2.5 years vs. 6.7 3.0 years; p=0.001); however, gender, the Haller index, the depression index, and the asymmetry index did not di er between the two groups. e Nuss procedure required less operative time and the patients had a shorter hospital stay than the Ravitch procedure (p<0.001). e surveillance results demonstrated that 17.6% of the Nuss group and 35.7% of the Ravitch group were not satis ed with the outcome of surgery (p=0.072). e most common causes of dissatisfaction were recurrence after bar removal (n=5) and reoperation by the Ravitch procedure due to a failed Nuss procedure (n=2) in the Nuss group, incomplete correction of the defect compared to what was expected (n=6), and a larger operative wound (n=3) in the Ravitch group. e pre-operative depression index was related to the level of satisfaction, which was 2.1 0.5 in the satisfaction group and 2.4 0.6 in the dissatisfaction group (p=0.030). Conclusions: e Nuss procedure had several advantages over the Ravitch procedure in the immediate post-operative period. However, the mid-term satisfaction was determined by complete correction without recurrence or re-intervention and in uenced by the pre-operative severity of the funnel chest.
Figure 1. E ect of A2BR KO on luminal obliteration and T cell in ltration in mouse hetereotopic tracheal model. A: A2BR KO decreased luminal obliteration on day 21. Top panel, H&E staining of allografts; bottom panel, bar graph of luminal obliteration. B: CD3+ T cell in ltration in the day 12 allografts. Top panel, immunohistochemical staining, brown indicates the T cell staining signals; bottom panel, bargraph of the in ltrated T cells per slide.
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P68 Management of Delayed Gastric Emptying After Esophagectomy With Endoscopic Balloon Dilatation of The Pylorus M. Lanuti, P. E. de Delva, J. C. Wain, H. Gaissert, C. D. Wright, D. M. Donahue, D. J. Mathisen Massachusetts General Hospital, Boston, MA Purpose: is study seeks to evaluate the use of postoperative pyloric balloon dilatation for delayed gastric emptying after esophageal substitution with gastric conduit. Methods: 436 patients underwent esophagectomy with gastric conduit from 20022008. All approaches to esophagectomy were included except patients with alternative reconstruction or emergent esophagectomy. Gastric conduit diameter and anastomotic location on the conduit were variable. Gastric outlet obstruction (GOO) was strictly de ned to include patients with clinical and radiographic delayed gastric emptying requiring intervention. Results: GOO was found in 17% (76/436) of patients who underwent esophagectomy. Pyloromyotomy was performed on 50% (38/76) of these patients and employed in 41% (180/436) of patients in the entire cohort. GOO was present in 21% (38/180) of patients who underwent a pyloric drainage procedure compared to 15% (38/256) of patients with no pyloric intervention (p=0.09). Endoscopic balloon dilatation of the pylorus was used to treat 59% (45/76) of patients with delayed gastric emptying yielding a 96% success rate. Pyloric dilatations were performed with controlled radial expansion esophageal balloon dilators ranging from 12-18 mm. e remainder of patients were treated conservatively with prokinetics, nasogastric drainage or observation. Nasogastric drainage was employed for 7.5 4.2 days in patients with GOO (reinserted in 8 patients) and 6.7 3.7 days in asymptomatic patients (p=0.41). Neoadjuvant chemoradiotherapy did not contribute to increased incidence of GOO. ere was no signi cant di erence in post-operative pneumonia (11.8 vs. 14.4%) or length of hospital stay (15.3 vs. 13.5 days) in patients with GOO versus normal emptying. Conclusions: Delayed gastric emptying after esophageal substitution with gastric conduit can be adequately treated with balloon dilatation of the pylorus regardless of an operative pyloric drainage procedure.
P69 Patterns of Presentation of Primary Adenosquamous Carcinoma of the Lung Compared to Primary Adenocarcinoma and Squamous Cell Carcinoma, and Early Stage Post-Lobectomy Survival D. T. Cooke, N. V. Danh, Y. Yang, S. L. Chen, R. F. Calhoun University of California, Sacramento, CA Purpose: Primary adenosquamous carcinoma of the lung (ASC) is a rare tumor that may carry a poor prognosis. Using a large national database we examined if ASC exhibited distinct clinical behavior from squamous cell (SC) and adenocarcinoma of the lung (AC). Methods: is is a retrospective study querying the Surveillance, Epidemiology, and End Results database to identify 872 surgical patients diagnosed with ASC, 7,888 with SC and 12,601 with AC of the lung from 1998 to 2002. Our analysis consists of two parts. e rst characterizes demographic and clinical variables in all patients identi ed to determine patterns of presentation. e second focuses on a comparison of survival among the above three histologic groups after lobectomy for stage I disease. Results: Of the 21,361 patients examined, 4.1% had the diagnosis of ASC of the lung. ASC tended toward right sided (56.9%) laterality and upper lobe (60.0%) location. Compared to AC, patients with ASC and SC were more likely to be male (48.8% vs. 54.9% and 65.3%, p < 0.0001). ASC patients were less likely to be of white ethnicity compared to AC and SC (77.3% vs. 81.7% and 82.6% respectively, p < 0.0001), had worse histologic grade (p < 0.0001) and greater incidence of histologic positive lymph nodes (p < 0.0001). Survival after lobectomy for stage I disease was signi cantly reduced in both ASC and SC compared to AC (p < 0.0001, Figure 1). ASC had a signi cantly increased hazard of 1.34 (95% CI, 1.07 to 1.68; p = 0.012). Other signi cant negative predictors of survival include tumor grade of III and IV, increasing tumor size, patient age, male gender, and black ethnicity. Conclusions: is is the largest review of ASC to date. Our study demonstrates that ASC is an uncommon tumor with distinct clinical behavior and worse prognosis than AC and SC. Further insight into the molecular pro le of ASC is needed to determine the cause of its biologic aggressiveness.
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P70 Acute Changes in Right Ventricular Function After Lung Isolation Predict Postoperative Arrhythmias R. Matyal, F. Mahmood, P. Hess, J. Mitchell, J. Pawlowski, S. Karthik, A. Maslow, S. P. Gangadharan, M. S. Kent, M. M. DeCamp Beth Israel Deaconess Medical Center, Boston, MA Purpose: Acute changes in the loading conditions have been shown to a ect right ventricular (RV) function in animal studies. We used myocardial performance index (MPI), which is an echocardiographic index of global ventricular function, to assess changes in RV function with lung isolation. We hypothesized that changes in MPI with lung isolation may be related to the incidence of immediate postoperative supraventricular tachycardia (SVT). Methods: Transesophageal echo examinations were performed after induction of general anesthesia in patients undergoing elective lung resections. We used Doppler tissue imaging of the lateral tricuspid annulus to calculate MPI. MPI was calculated at baseline without lung isolation, and 10 minutes after institution of one-lung ventilation (OLV). An MPI value of >0.40 was considered abnormal. Arrhythmias occurring within the rst ve postoperative days were recorded. Results: Fifty-nine patients completed the study. 19/59 patients with a normal baseline MPI had a higher incidence of SVT as compared to patients with an abnormal baseline MPI (42% vs. 10%; P=0.012). e MPI increased during OLV in 46 patients; an increase in MPI with lung isolation which was normal at baseline, was associated with higher incidence of SVT (57% vs. 0%; P=0.045), compared to an increase in MPI in patients with an abnormal baseline MPI (13% vs. 6%; P=0.62)(Table 1). Logistic regression identi ed increased MPI from normal baseline and left atrial dilation as independent predictors of SVT. Advanced age was also identi ed as a predictor of SVT, with lower predictive value than change in MPI or a normal baseline MPI. Conclusions: Acute lung isolation is associated with global changes in RV function as assessed by MPI. A normal baseline MPI which worsens after lung isolation is a better predictor of postoperative SVT as compared to baseline abnormal MPI which does not worsen after lung isolation.
P71 The Impact of Number of Evaluated N1 Nodes on the Survival of Resected Patients With Non-Small Cell Lung Cancer A. Turna, A. Celikten, N. Urer, M. Metin, A. Gurses Yedikule Teaching Hospital for Chest Diseases and oracic Surgery, Istanbul, Turkey Purpose: Mediastinal lymph node dissection has been proven to be essential in surgery of non-small cell lung cancer. However, the minimal requirement for N1 node dissection remains largely unknown. We aimed to analyze the impact of number of resected and evaluated N1 nodes in patients who underwent resectional surgery for non-small cell lung cancer. Methods: We analyzed 979 consecutive patients who were operated for non-small cell lung cancer between Jan. 1998 and Aug. 2008. A systematic mediastinal lymph node dissection along with hilar/interlobar lymph nodes were performed. Patients were followed-up at a mean of 26 months (ranging from 8-125 months). Results: e overall survival rate was 54.7% in all patients. e mean number of resected mediastinal lymph node 8.1 (ranging from 3-26) whereas mean number of evaluated N1 nodes were 10.2 (ranging from 0 to 49). e survival of patients in whom fewer than 21 N1 nodes were evaluated was lower than patients who had more than 20 N1 node analyzed; however, the di erence was not statistically signi cant (5-year survival was 56% vs. 83%; p=0.36). In patients who had undergone lobectomy, the impact of number of evaluated N1 node was prominent (p=0.03). Multivariate analysis demonstrated a hazard rate of 1.24 (p=0.03) for evaluation of fewer than 20 N1 nodes controlling for stage, histology, gender. ere appeared to be no incremental improvement after evaluating >21 lymph nodes. On the other hand, patients with at least 10 mediastinal lymph nodes dissected during surgery had a modest but statistically signi cantly longer survival compared to survival of patients in whom fewer than 5 lymph nodes were evaluated(p=0.04) . Conclusions: Our results indicate that patient survival following resection for nonsmall cell lung cancer is associated with the number of N2 and N1 lymph nodes evaluated during surgery.
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General oracic Posters Continued Radical pleurectomy vs extrapleural pneumonectomy
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P72 Photodynamic Therapy (PDT) and the Evolution of a Lung Sparing Surgical Treatment for Malignant Pleural Mesothelioma J. S. Friedberg, A. Fernandes, M. J. Culligan, R. Mick, D. Smith, J. Stevenson, S. M. Hahn, K. Cengel University of Pennsylvania, Philadelphia, PA
REGUL ATORY DISCLOSURE This presentation describes the o -label use of Photofrin.
Purpose: Photodynamic therapy (PDT) is a light-based cancer treatment that acts to a depth of penetration several mm into tissue. e purpose of this study was to review the results of patients who underwent a macroscopic complete resection and intraoperative PDT as a treatment for mesothelioma. Methods: From 2004 to 2008, 28 patients with mesothelioma underwent macroscopic complete resection, by either extrapleural pneumonectomy (EPP) or radical pleurectomy (RP), and intraoperative PDT (por mer sodium injection 2 mg/kg, 630 nm light to 60 J/cm2). e breakdown was 14 EPP and 14 RP, but the use of PDT allowed the technique to evolve such that the 14 most recent patients all underwent lung sparing RP, even in the setting of large bulk tumors (Figure). Results: e table describes the characteristics and clinical outcomes of patients treated with either RP+PDT or EPP+PDT. Patients in both groups had similar characteristics with respect to age, sex, histology, adjuvant treatments and stage (the majority being stage 3 or 4). Patients treated with RP+PDT had zero 30-day operative mortality and signi cantly improved overall survival when compared to patients treated with EPP+PDT. Conclusions: Capitalizing upon the depth of penetration property of PDT allowed for the evolution of a debulking procedure where the lung and, commonly, the phrenic nerve, pericardium and/or diaphragm could be predictably spared even in the setting of heavy bulk disease. In addition to the inherent advantages of sparing the lung, preserving natural barriers and limiting prosthetic reconstruction, RP+PDT yielded superior results to EP+PDT in this series. ese results compare favorably with many reported surgical series, especially in light of the advanced stage of the majority of these patients. Given these results, and the lack of any long-term PDT toxicity, we feel RP+PDT is a reasonable option for patients pursuing a surgical treatment for mesothelioma and that this procedure can serve as the backbone of surgery-based multimodal treatment protocols.
Comparison of radical pleurectomy (RP) + PDT and extrapleural pneumonectomy (EPP) + PDT for malignant pleural mesothelioma
Left side shows surgeon holding massive RP specimen. Right side shows skeletonized PA in ssure after RP.
POSTER ABSTRACTS
POSTER ABSTRACTS
P73 Neurogenic Thoracic Outlet Syndrome (N-TOS): Predictive Value of Ultrasound-Guided Muscle Injections (U/S-MI) D. M. Donahue, G. R. Veillette, E. Collins, R. Gupta, M. Torriani Harvard Medical School, Boston, MA Purpose: e diagnosis of N-TOS is often made on history and physical examination. Imaging and nerve conduction studies are not consistently reliable in either the diagnosis or in predicting the response to treatment. One proposed mechanism causing N-TOS is increased muscle activity resulting in narrowing of the thoracic outlet. is study was designed to determine if clinical response to U/S-MI can predict successful treatment of N-TOS. Methods: Between Aug. 2007 and Nov. 2008 a total of 70 patients with chronic cervicobrachial pain had an evaluation for possible N-TOS. Of this group, 33 patients underwent U/S-MI. ere were 27 female and 6 male patients, aged 18-69 (mean 41) years. ree patients were referred with persistent N-TOS following rst rib resection. Based on clinical ndings, injections were performed into the anterior scalene (n=22), the pectoralis minor (n=3) or both (n=8) using ultrasound to con rm placement of the needle into the center of the muscle. A local anesthetic was injected in 13 patients (2-4 cc of 1% Lidocaine in 4 patients, 2 cc of 0.5% Bupivicaine in 9 patients). Botulinum toxin A (12-15 units) was used in 20 patients. Results: 21/33 patients (64%) had temporary symptomatic improvement following injection. Of these 19/21 (90%) had signi cant long-term improvement with either physical therapy (PT) alone (n=11), or with surgery (n=8) involving either rst rib resection (n=5) or pectoralis minor tenotomy (n=3). 12/33 (36%) did not improve with injection. ese patients continue with PT with only 2 of 12 (17%) improving (p< 0.001). Conclusions: Patients with temporary improvement in their N-TOS symptoms following U/S-MI had signi cantly better longer-term results with de nitive therapy (PT or surgery) compared to those who did not. Response to U/S-MI is a useful tool in predicting outcomes in selected patients with N-TOS.
P74 Treatment of Acute Severe Pulmonary Hypertension With Right to Left Atrial Shunting and Veno-Venous Extracorporeal Life Support D. Camboni, B. Akay, J. Toomasian, J. W. Haft, K. Cook, R. Bartlett University of Michigan, Ann Arbor, MI Purpose: Lung transplantation is the only treatment for refractory severe pulmonary hypertension. However, most patients die of right ventricular (RV) failure before a donor can be found. An atrial septostomy (AS) can be performed relieving RV failure, but this causes perilous hypoxemia. An AS combined with veno-venous extracorporeal gas exchange life support (VV ECLS) could be a novel bridge to transplant for critically ill patients. In previous experiments we demonstrated that extracardiac right to left atrial shunting with VV oxygenation was feasible in severe acute pulmonary hypertension. Methods: In 7 adult sheep a thoracotomy was performed and monitors placed to measure cardiac output (CO) and all relevant pressures. A 1cm atrial septal defect was created under cardiopulmonary bypass. e pulmonary artery (PA) was banded to allow progressive PA occlusion leading to acute pulmonary hypertension. Catheters were placed for veno-venous (VV) gas exchange. After baseline data with normal lung function and blood ow, data were collected for 30 minutes at 60, 30, and 0% PA ow relative to baseline ow. Results: Baseline CO was maintained during progressive PA banding resulting in decreasing PA ow (Figure 1). However, right ventricular, right atrial, and pulmonary artery pressures remained moderately elevated. VV ECLS preserved excellent blood gases with mean oxygen saturations of 99% even during complete PA occlusion (Figure 2). Conclusions: Right to left atrial shunting is capable of eliminating RV failure and maintaining normal CO, while ECLS preserves physiologic arterial blood gases. is concept might o er a novel bridge to lung transplantation in severe pulmonary hypertension.
Figure 1: e relationship between cardiac output (CO) and pulmonary artery ow (qPA) during the course of the experiment. Note, that even with complete pulmonary artery banding CO remained stable. Figure 2 shows the arterial blood gases during the course of the experiment. With increasing pulmonary artery banding resulting in augmented right to left atrial shunting a decrease in pO2 occurs while pCO2 remains una ected. e x-axis indicates the di erent degrees of pulmonary artery banding resulting in 60%, 40% and 0% pulmonary artery ow relatively to baseline pulmonary artery ow.
POSTER ABSTRACTS
POSTER ABSTRACTS
P75 Video-Assisted Versus Open Lobectomy for Lung Cancer in the U.S. Mid-Atlantic Region (2007-2008): Signi cant Variations in Practice Patterns and Measured Outcomes K. Stitzenberg, W. J. Scott, A. Lebenthal Fox Chase Cancer Center, Philadelphia, PA
FINANCIAL DISCLOSURE W.J. Scott: Celgene Corporation, ownership interest; Biogen Idec, ownership interest
P76 A Novel Tissue-Engineered Solution for the Post-Pneumonectomy Space N. Tsunooka1, S. Hirayama1, J. A. Medin2, M. Liu1, S. H. Keshavjee1, T. K. Waddell1 1 University Health Network, Toronto, Canada; 2Ontario Cancer Institute, Toronto, Canada
REGUL ATORY DISCLOSURE This presentation describes the off-label use of Gelfoam Sponge.
Purpose: Although video-assisted (VATS) lobectomy for the treatment of lung cancer was described over 15 years ago, adoption remains limited. is study documents current practice and outcomes for VATS versus open lobectomy. Methods: Inpatient discharge claims data were queried for all lobectomies performed for cancer in the mid-Atlantic United States (New Jersey, New York, and Pennsylvania) between Oct. 2007 and June 2008. Patients <18 years old were excluded. We analyzed sociodemographic factors related to use of VATS with logistic regression. Outcomes were compared using t-tests. Results: 2,895 lobectomies met criteria for inclusion. 48% of patients were men, and 58% of patients were 65 years old. 29% (839/2895) were VATS lobectomies. On multivariate analysis, men were less likely to undergo VATS than women (OR 0.84, p=0.031). ere was no di erence in use of VATS vs. open techniques based on age, race, payer, or socioeconomic status. Although patients from rural areas were less likely to undergo VATS (OR 0.62, p=0.002), travel distances for the groups (VATS vs. open) were equivalent. 47% of hospitals performing lobectomies (120/255) performed at least 1 VATS lobectomy. Only 16% of hospitals (41/255) performed 5 VATS lobectomies. In general, the odds of VATS technique increased as hospital overall lobectomy volume increased (Table). VATS cases had a shorter mean length of stay (6 vs. 8, p<0.001) and a higher rate of discharge to home (93% vs. 89%, p=0.001) than open cases. Mean total hospital charges were less for the VATS cases ($65,000 vs. $74,000, p=0.004). Inhospital mortality did not di er signi cantly (VATS 1.1% vs. open 2.0%, p=0.084). Conclusions: A minority of mid-Atlantic United States centers performed VATS lobectomy in 2007-2008. Patients in rural or low-volume hospitals were less likely to undergo VATS lobectomy. Outcomes were similar to open cases but clinical stage was not evaluable. ese data have implications for health care policy and the adoption of new technology.
Purpose: Pleural space complications after pneumonectomy (PN) can be devastating. Standard treatment consists of transfer of viable tissue as aps from elsewhere on the body, but the volume of the tissue isnt always adequate. e aim of this study is to explore the possibility that engineered-tissue can be e ective in lling the thoracic cavity after PN. Methods: Cells were embedded in denatured collagen matrices by co-culture for 1 week. A left PN was performed in Bl/6 mice and the cavity lled with the engineered tissue constructs. Lentiviral transduction of mesenchymal stem cells with luciferase was used to evaluate cell viability and vascular perfusion of the constructs, and long-term viability of the cells, using bioluminescence imaging (BLI) in vivo. Histologic evaluation and immunohistochemistry for von Willebrand Factor (vWF) were performed on explanted constructs. Controls consisted of acellular matrix implants. ActGFP mice were used as a source for bone marrow cells (BMC). Flow cytometry was used to characterize the cellular content over time. Results: Embedded cells proliferated within the matrices cultured ex vivo. After implantation, the early slope of BLI activity (suggesting rate of perfusion with luciferin substrate) and the maximum BLI activity increased with time up to Day 6, and decreased after Day 7. Adhesion of construct to naive tissue was increased when embedded with adherent BMC. Cellularity within the constructs and number of vessels stained by vWF increased over time, augmented by pre-implantation of cells ex vivo. Conclusions: Cells within denatured collagen matrices proliferate ex vivo and survive in the thoracic cavity during early time points. Cellularized matrices quickly become vascularised. Further research is required to develop strategies to enhance long term survival of the implanted cells. is study indicates the potential feasibility of a novel, tissue engineering approach to problems of the post-PN space. e slope of bioluminescent imaging activity after implantation of engineered tissue
Immunohistochemistry for von Willebrand Factor


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ADULT CARDIAC POSTERS P1-P36

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Preoperative CT-scan demonstrating a porcelain aorta

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*p<0.05 compared to 80mmHg

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PAB: pulmonary artery banded

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Figure 1. Posterior Lea et Obliteration (PLO)

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*p<0.05 vs. control

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