The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity....
Transcript of The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity....
Theofficialnewspaperofthe26thEACTSAnnualMeeting2012 Monday 29 October
In this issueMitral valve diseaseLenard Conradi asks which is the preferred treatment, surgery or intervention. 10
Aortic arch surgeryJean Bachet examines the current status of aortic arch surgery. 12
Tetralogy of fallotMark Hazekamp discusses how to minimize postoperative repair morbidity.26
Elephant TrunkMalakh Shrestha presents a single centre experience of the Elephant Trunk procedure.40
Heart rejuvenationCardioplegia and stem cells take centre stage as David Chambers and Philippe Menasche assess the latest evidence.41
Residents’ Luncheon 47
Floor plan 48
EACTS events 50
Monday’s highlights
Surgery following primary RVOT stenting in Fallot’s TetralogyRehabilitation of small pulmonary arteriesDavid Barron Birmingham Children’s Hospital UK
Fallot’sTetralogyisthecommonestcyanoticheartconditionandthespectrumofmorphologyleadstoavariabilityinthesymptoms(princi-
pallythedegreeofcyanosis)which,inturn,influencesthetimingandtechniqueofsur-gery.TheBlalock-Taussig(BT)shunthastra-ditionallybeenthemainstayofsecuringad-ditionalpulmonarybloodflowincyanosedneonatesandinfants–followedbystagedanatomicalrepairtypically6-9monthslater.However,theoverwhelmingshiftinsurgi-calpracticetoeffectanatomicalrepairatayoungeragehasdramaticallychangedman-agementstrategiesoverthepast15yearssuchthatcompleterepairhasbeenpro-motedatanincreasinglyyoungerage.However,eveninthemodernera,theBTshuntintheneonatecarriesasignificantmortality–partlyreflectingthefragilena-tureoftheshunt-dependentcirculationwithdiastolicstealphenomenonandtheriskofunpredictablecoronaryischaemia.Thissup-
portedthecaseforcompleteanatomicalre-pairinthecyanoticneonate.However,theresultsofcompleterepairinneonatescarryasimilarrisktoBTshunt,withfiveorsixtimestheoperativemortalitycomparedtothatof‘planned’repairperformedbetweenthreetoninemonthsofage.Afundamentalprobleminthecyanoticne-onatalFallotisthattherecanbeadegreeof
The TA PLUG is the first true-percutaneous self-expanding and self-centring device to successfully close a 39F left ventricular apex access in the experimental setting.
ChristophHuberdevelopedandpioneeredtheconceptandthemethodoftransapical(TA)TAVIin2004.OnlytwoyearslaterTho-
masWalterperformedthefirstsuccessfulclinicalimplant.Sincethenthemostprom-isingTATAVItechniquestarteditssteepas-censiontowardsbecomingthemostpopularsurgicalTAVIaccess.Significantadvantagesoverallotheraccesstechniquesincluding:A)Shorterworkingdistanceallowingforamoreprecisetargetsitedevicedelivery.B)Easedwirecrossingofthehighlystenosedaorticvalvedirectedbythenativebloodflowoftheejectingheart.C)Avoidedcrossingoftheaorticarchbythelargervalvedeliverysystems.D)Increasedaccessdiameterresult-inginlesstraumaticdevicecrimping,bene-ficiallydifferentiatetransapicalaccessfromotherTAVIaccessroutes.
Nevertheless,despitetheveryfavour-ableevidence,theenthusiasmforthe
transapicalaccessishamperedbythemerefactofrequiringasurgicalcut-downandsurgicalclosure.
Theauthor’sfocusistomovethetransapicalaccessplatformfurther.Thelasthurdletoovercome,toallowthetransapicalaccesstobecomethenumberoneTAVIroute,isareliableandsavetrue-percutaneousclosureoftheapex.Theen-couragingTAPLUGexperimentalresultsarebeingpresentedforthefirsttimeattheannualEACTSmeeting2012inBar-celona.
Thedeviceisself-expandingandmadefromfull-corebiocompatiblematerial.Ex-
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IntheProfessionalChallengesessions,specificproblemcases,inparticularcom-plicationcases,willbepresented.Thedesignofthesesessionsfacilitatesinter-
actionanddiscussiononcontroversialtopics.Topicsunderdiscussionincludehowto
optimisecoronaryrevascularization:plan-ningandexecution;whetherthereisaplaceforpalliationinthemanagementoffallotstetralogy;AorticarchdiseaseII:Videoses-siononallprovenapproachesforeffectivelytreatingthearch;and
Todaywillalsohostthefirst‘FocussedSessions’andwillincludeavideodemon-stration,followedbyakeynotelectureandconcludewithpresentationsthatallowdel-egatestoleavethesessionswithagreaterunderstandingofhowtosolveaparticularproblem.
ThiswillincludeanexaminationofAn-
tiplatelettherapyin2012-ImpactonCardi-ovascularsurgicalprocedures;Howtoopti-misetranscatheteraorticvalveimplantationoutcomes;TheFrontdoorapproach:theroleofthesurgeoninselectingthebestpatientspecificaccessroute;multiplevalves;andheartrejuvenation.
Asever,Mondaywillalsowitnessthisyear’sPresidentialAddressbyProfessorLud-wigKvonSegesser,entitled,“Thecontrain-dicationsoftodayaretheindicationsofto-morrow.”
TodaywillalsoseethefirstLateBreak-ingClinicalTrialssession,aswellasandthepresentationofabstractsfromallfourEACTSDomains.
TheVascularDomainwillhostaTEVARSimulationWorkshopandSimulationCourse,andtheGeneralInterestSessionwilllookatcurrent‘ResearchinCardiothoracicSurgery’. Ludwig von Segesser
David Barron
Christoph Huber
The TA PLUG
Congenital: Professional Challenges 08:15–09:45 Room 111
Cardiac: Abstract 08:15–09:45 Room 118/119
Satellite Symposia – Monday 12:45-14:00AbbottVascularScrub-inwithMitra-ClipBerlinHeartEXCOR®PediatricCoroneoAorticValveRepair:astand-ardizedapproachEdwardsLifesciences50yearsofAVRand10yearsofTAVIJOTECThefutureofAorticSurgeryMaquetCardiovascularAdvancesinLessInvasiveCABGMedistimClinicalandeconomicout-comes-qualityassessmentproceduresMedtronic3fEnablevalve–whathavewelearned?SorinGroupTheFutureofCardiacSurgeryisMICSStJudeMedicalAorticStenosis:Treat-mentOptionsandPerspectivesSymetisACURATETA:Self-PositioningTAVITechnologyVascutekInnovativeProductDesignsandEmergingImplantationTechniques
Welcome to Monday’s programme, which begin with ‘Professional Challenges’
2 Monday 29 October 2012 EACTS Daily News
Cardiac: Abstract 08:15–09:45 Room 118/119
Moritz Seiffert Klinik für Allgemeine und Interventionelle
Kardiologie; Universitäres Herzzentrum Hamburg, Hamburg,
Germany
Transcatheteraorticvalveimplantation(TAVI)hasemergedrapidly.Despiteunanimousrecommen-dationsandpotentiallyfatalintraoperativecom-
plications,theheart-teamapproachisnotcompre-hensivelyperformedbyallcenters.Evenmore,someauthorssuggestthatrareintraproceduralcomplica-tionsduringTAVIrequiringcomplexsurgicaltreatmentareassociatedwithdisproportionallyhighmortalityandratherfutileoutcomes,thereforequestioningtheprerequisiteofinstitutionalizeddepartmentsofcardi-ologyandcardiacsurgeryatsitesperformingTAVI.
AttheUniversityHeartCenterHamburg,TAVIisperformedasajointapproachofcardiologistsandcardiacsurgeonsinclosecollaborationwithanesthesi-ologistsandperfusioniststofacilitateappropriatebail-outoptionsincaseofcomplications.Inthisanalysis,
wesoughttocharacterizesevereintraproceduralcom-plicationsrequiringimmediatesurgicalorinterven-tionalbailoutmaneuversoutofacohortof458con-secutiveTAVIproceduresandevaluateoutcomes.
Overall,35of458patients(7.6%)experienced40majorintraproceduralcomplicationsduringTAVI,13(2.8%)requiringemergentconversiontosurgery.Complicationsincludedvalveembolization/migration(17%),severeaorticregurgitation(12%),androotrupture(5%),requiringimmediateimplantationofasecondvalveorconversiontosurgicalvalvereplace-ment(Figure).Sternotomyandsurgicalhemostasiswasperformedin5patients(13%)withleftventricu-larwireperforationandsubsequentcardiactampon-ade.Coronaryobstruction(15%)requiredemergentpercutaneouscoronaryinterventionin6patients.
At30days,all-causemortalitywas31.4%inpa-tientswithintraproceduralcomplicationsand38.5%inpatientsrequiringsurgicalconversion.However,mid-termsurvivalafter30daysandexercisetolerance
insurvivingpatientswerecomparabletopatientsun-dergoinguncomplicatedTAVI.
AninterdisciplinaryapproachtoTAVIfacilitatedbailoutproceduresaccomplishingacceptableout-comesdespitesevereintraproceduralcomplications.Despitesignificantearlymortalityinthesepatients,mid-termsurvivalafter30dayswascomparableto
theoverallTAVIpopulation.Amultidisciplinaryteamwithequalcontributionbycardiologistsandcardiacsurgeonsalikefacilitatedbailoutproceduresandac-complishedacceptableoutcomesinaheart-teamef-fort.Anexcellentcooperationwithanesthesiologists,perfusionists,andapreparedheart-lung-machineinthehybridsuiteisofparamountimportance.
Althoughafurtherdecreaseofintraproceduralcomplicationscanbeanticipatedwithgrowingexpe-rienceandimprovedtechnicalpreconditionsinthefu-ture,asurgicalandinterventionalsafetynetshouldbesustainedinallcentersperformingTAVIproceduresatthispointintime.ThesoleperformanceofTAVIbycardiologistsinacath-labwiththelackofappropriatebail-outoptionsincaseofcomplicationscontravenescurrentguidelinesandconstitutesadangerousap-proachinouropinion.
SevereintraproceduralcomplicationsduringTAVIandsubsequentbailoutmaneuvers
Severe intra-procedural complications after transcatheter aortic valve implantation: calling for a heart-team approach
Monday 29 October
08:00–17.00 Registration
Acquired Cardiac Disease 08:15 – 09:45
Professional Challenges
How to optimise coronary revascularization: planning and execution I
Rooms 116/117
Moderators: F. Mohr, Leipzig; J. Rich, Norfolk
08:15 Assessingthelesion N van Mieghem (Rotterdam)
08:30 Treatmentofcomplexcoronaryarterydiseaseinpatientswithdiabetes:Five-yearresultscomparingoutcomesofcoronaryarterybypassgraftingandpercutaneouscoronaryinterventionintheSYNTAXstudy A. P. Kappetein1, S. Head1, M. Morice2, A. Banning3, P. Serruys1, F. Mohr4, K. Dawkins5, M. Mack5 (1Netherlands, 2France, 3United Kingdom, 4Germany, 5United States)Discussant: D. Taggart (Oxford)
08:45 Five-yearfollow-upofdrug-elutingstentimplantationversusminimallyinvasivedirectcoronaryarterybypassforleftanteriordescendingarterydisease:apropensityscoreanalysis D. Glineur, C. Hanet, S. Papadatos, P. Noirhomme, G. El Khoury, P. Y. Etienne (Belgium)Discussant: P. Sergeant (Leuven)
09:00 PreoperativeSYNTAXscoreandgraftpatencyafteroff-pumpcoronarybypasssurgery T. Kinoshita, T. Asai, T. Suzuki (Japan)Discussant: V. Falk (Zürich)
09:15 Areal-worldcomparisonofsecond-generationdrug-elutingstentsversusoff-pumpcoronaryarterybypassgraftinginthree-vesseland/orleftmaincoronaryarterydisease G. Yi, H. Joo, K. Yoo (Republic of Korea)Discussant: F. Mohr (Leipzig)
09:30 DistalanastomosispatencyoftheCardicaC-Portsystemversusthehand-sewntechnique:aprospectiverandomizedcontrolledstudyinpatientsundergoingcoronaryarterybypassgrafting N. Verberkmoes, S. Wolters, J. Post, M. Soliman-Hamad, F. Ter Woorst, E. Berreklouw (Netherlands)Discussant: M. Glauber (Massa)
09:45 Sessionends
Abstracts
Surgical remodelling of the left ventricle
Room 115
Moderators: A. Calafiore, Riyadh; R. Lorusso, Brescia
08:15 Leftventriculoplastyforprogressivelydeterioratedleftventriclewithglobalakinesisduetoischaemiccardiomyopathy:Japanesesurgicalventricularreconstructiongroupexperience S. Wakasa, Y. Matsui (Japan)Discussant: L. Menicanti (Milan
08:30 Experience,outcomesandimpactofdelayedindicationforvideo-assistedwideseptalmyectomyin69consecutivepatientswithhypertrophiccardiomyopathy T. Heredia Cambra, L. Doñate Bertolín, A. M. Bel Minguez, M. Perez Guillen, F. J. Valera Martínez, J. A. Margarit Calabuig, F. Marín, J. A. Montero Argudo (Spain)Discussant: C. Simon (Bergamo)
08:45 Impactofsurgicalventricularrestorationoncardiacfunction,ischaemicmitralregurgitationandlong-termsurvival H. Fleming, R. Attia, J. Chambers, F. Shabbo (United Kingdom)Discussant: T. Isomura (Kanagawa)
09:00 Preoperativeregionalleftventricularwallthickeningwithquantitativegatedspectasapredictorofthemid-termsurgicalresultofischaemicandnon-ischaemiccardiomyopathy S. Kubota, S. Wakasa, Y. Shingu, T. Ooka, T. Tachibana, Y. Matsui (Japan)Discussant: R. Jeganathan (Belfast)
09:15 Durabilityofepicardialventricularrestorationwithoutventriculotomy A. Wechsler1, J. Sadowski2, B. Kapelak2, K. Bartus2, G. Kalinauskas3, K. Rucinskas3, R. Samalavicius3, L. Annest1 (1United States, 2Poland, 3Lithuania)Discussant: H. Reichenspurner (Hamburg)
09:30 ‘Onestep’subendocardialimplantofautologousstemcellsduringmodifiedleftventricularrestorationforischaemicheartfailure G. Stefanelli, F. Benassi, D. Gabbieri, G. D’Anniballe, D. Sarandria, C. Labia, G. Gioia (Italy)Discussant: J. Kluin (Utrecht)
09:45 Sessionends
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Based on interviews with Alec Va-hanian (Bichat Hospital, Paris) and Ottavio Alfieri (San Raffaele Hospi-tal, Milan)
New guidelines on the Manage-ment of Valvular Heart Disease
werereleasedattheESCinMunich,August2012.Theywerecreatedandendorsed by members of both theESCandEACTSandaretheresultofajointcollaborationspearheadedbyco-chairs Alec Vahanian and Ottav-ioAlfieri.Highlightswillbepresent-edonTuesdaymorningatEACTSat8:15 am. The new guidelines wereprompted by new evidence, diag-nosticmethods,improvedtherapeu-ticoptionsand,especially, theneedto reinforce the importance of theHeartTeamapproachbetweencardi-ologistsandsurgeons.
TAVI adoption has been swiftoverthepastfewyearsforhigh-risksurgical patients with severe aorticstenosis (AS), as well as non-surgi-calcandidates.Incertaincasesithasbeenperformedonpatientsconsid-ered tobe lower risk. Both Profes-sors Vahanian and Alfieri emphati-callystressthatTAVIshouldnotbeperformedinpatientsat intermedi-ate risk and that care needs to betakenatbothextremesofthespec-trum—casesthatmaybeconsideredfutile,aswellasthosethatmaystill
bebetterservedbysurgery.Therecommendedindicationsfor
TAVI in inoperable patients (Class I,LevelB)werebasedprimarilyontheresultsofThePARTNERBTrialintheUnited States, a randomized, con-trolled trial using the Edwards SAP-IEN balloon-expandable valve tech-nology.Inaddition,datafromsomelarge, non-randomized Europeanregistrieswerereviewed.Allthereg-istries includedpatientswithsevere,symptomaticASnotsuitableforaor-tic valve replacement (AVR) as as-sessed by a Heart Team and werelikely togain improvements to theirquality of life, and expected to livemorethanoneyear.1
Professors Vahanian and Alfi-eribelieveTAVIshouldalsobecon-sideredinhigh-riskpatientswithse-vere symptomatic AS who may stillbesuitableforsurgery,butinwhomTAVI is favored by a Heart Team,based on the individual risk profileandanatomicsuitability(Recommen-dationClassIIa,LevelB).HereagainthisrecommendationislargelybasedontheresultsofthePARTNERAran-domized trial and numerous otherlargeregistries
Includedintherecommendationsisaclearlistofabsoluteandrelativecontraindications to TAVI, includingan inadequate annulus size, throm-
busintheleftventricle,activeendo-carditis,plaqueswithmobilethrombiintheascendingaortaorarch,inade-quatevascularaccessforatransfem-oral/subclavian approach or a verylowleftventricularejectionfraction.2TheTaskForcebelievesAVRremainssuitable for patients with severesymptomatic AS, including thoseundergoing coronary artery bypasssurgeryor surgeryof theascendingaortaoranothervalve.Thiscouldin-cludethosewhoaresuitableforTAVI
aswell, but inwhom surgery is fa-vored by the Heart Team. Extremecareneedstobetakentoonlytreatsymptomaticpatientsifitissurethattheaorticdiseaseissevere.
StopbytheEdwardsLifesciencesboothforacopyofthenewguide-linesandaDVDofThePARTNERTri-alresults.1. Footnote: ESC/EACTS Guidelines on the the Management of Valvu-lar Heart Disease,Aug 2012 www.escardio.org/guidelines2. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events on transcatheter heart valves.
Severe intraprocedural complications (A) and subsequent bailout maneuvers (B), with the three indicated shares composing the conversion-to-surgery-group. AR, aortic regurgitation; EC, extracorporeal; LV, left ventricular; PVC, percutaneous vascular closure; TAVI, transcatheter aortic valve implantation; THV, transcatheter
heart valve.
European Society of Cardiology (ESC) and European Association of Cardio-Thoracic Surgeons (EACTS) joint guidelines make recommendations on TAVI
hypoplasiaofthecentralpulmonaryar-teriesthatincreasestheoperativeriskwithbothBTshuntorcompleterepair.Furthermore,thereareanatomicalvar-iantsofFallot’sTetralogythatincreasethecomplexityofsurgery–forexample,Fallot/AVSDoranomalousoriginoftheleftcoronary.AtBirminghamChildren’s
HospitalwehavepromotedaselectiveapproachtothesepatientswherewehaveusedRVOTstentingtosecurebet-terpulmonarybloodfowinpreferenceto‘conventional’surgery.Wereporttheoutcomesin32patientswhohadRVOTstentingintheset-tingofFallot’stetralogy.In20therea-sonwascyanoticneonates/smallinfantswithsmallpulmonaryarteriesandin12theindicationwascomplexanatomy
(egfallot/AVSD)orco-morbiditysuchaschroniclungdiseasethatmeriteddelayofcorrectivesurgery.Stentingwasnotalwayssuccessfulandfourpatientshadeitherfailedstentde-ploymentorhadpersistentcyanosisre-quiringearlysurgery.Overall,RVOTstentingimprovedarterialoxygensatu-rationfrom72%to92%.Furthermore,stentingresultedingrowthofthecen-tralpulmonaryarteriesfromaz-scoreof
-1.3to+0.1ontheleftand-2.0to-0.7ontheright.Todate,15oftheremaining28stentedpatientshaveundergonesubsequentcompleterepair,atamedianof210daysafterstentplacement.Theremain-ing13remainwellandareawaitingre-pair.Therehasbeennooperativemor-talityand,althoughremovingthestentslightlyincreasesoperativedurationand
RVOT stentingContinued from page 1
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4 Monday 29 October 2012 EACTS Daily News
Cardiac: Professional Challenges 08:15–09:45 Room 116/117
Takeshi Kinoshita Shiga University of
Medical Science, Otsu, Japan
Objective: We examined the association between preoperative SYNTAX score and graft patency after off-pump CABG.
Methods:Of912consecu-tivepatientsundergoingiso-latedCABG(906usingthe
off-pumptechnique)between2002and2011,217hadCTangiography.Ofthiscohort,westudied189patientsinwhompreoperativeSYNTAXscoreswereretrospectivelyobtained.Thepri-maryendpointwasgraftocclusiononfollow-upCTangiography.Graftocclu-sionwasdefinedasabsenceofcontrastagentalongthecourseofthegraft.Insequentialgrafts,eachsegmentwasan-alyzedasaseparategraft.Thesecond-aryendpointwasacompositeofma-joradversecardiacandcerebrovascularevent(MACCE),whichwasdefinedascerebrovascularaccident,non-fatalmy-ocardialinfarction,admissionduetopumpfailure,andrepeatedrevascular-ization.Allarterialconduits,exceptforoneright-sideITA,wereharvestedviatheskeletonizationtechniqueandusedasin-situgrafts.
ResultsThemeanintervalfromoperationtoangiogramwas4.7±2.4years(range0.8-10.0years).Estimated8-yeargraftpatencyofITA-LAD,ITA-CX,SV-CXand/orPDA,andGEA-PDAwere97.4±1.5%,89.3±4.2%,86.5±6.7%,and86.2±5.7%,respectively.Ofthetotal666distalanastomoses,27in21patientswereoccluded.Nosignificantdifferencewasfoundinthepreopera-tiveSYNTAXscoresbetweenthe21pa-tientswithgraftocclusion(mean35.7;range15.0-51.5)andthe168patientswithoutgraftocclusion(mean36.6;range17.0-54.5;unpairedttestp=0.87).Inunivariateandmultivariatelo-
gisticregressionmodels,nosignificantassociationwasfoundbetweengraftocclusionandindividualcomponentsoftheSYNTAXscore(Table).Therewasnosignificantdifferenceinpatientswithlow(≤22),intermediate(23-32),andhigh(≥33)SYNTAXscoresinthecumu-lativeratesofgraftocclusion(logranktest,p=0.88,Figure1)andMACCE(logranktest,p=0.86,Figure2).
ConclusionsPreoperativeSYNTAXscoreanditsin-dividualcomponentsarenotassoci-atedwithgraftocclusionafteroff-pumpCABG.
Abstracts
The search for sinus rhythm
Room 114
Moderators: S. Benussi, Milan; M. Castella, Barcelona
08:15 Effectivenessofbiatrialpacinginreducingearlypostoperativeatrialfibrillationafterthemazeprocedure W. Wang1, A. Hamzei1, X. Wang2 (1United States, 2China)Discussant: S. Salzberg (Zürich)
08:30 Minithoracotomyasaprimaryalternativeforleftventricularleadimplantationduringcardiacresynchronizationtherapy:canthecardiacsurgeonreducethenumberofnon-responders? S. Putnik, M. Matkovic, M. Velinovic, A. Mikic, V. Jovicic, I. Bilbija, M. Vraneš, G. Milašinovic (Serbia)Discussant: W. Wisser (Vienna)
08:45 Theassociationbetweenearlyatrialarrhythmiaandlong-termsuccessfollowingsurgicalablationforatrialfibrillation N. Ad, L. Henry, S. Holmes, S. Hunt (United States)Discussant: R. Almeida (Cascavel)
09:00 Pacemakerdependencyafterisolatedaorticvalvereplacement:doconductancedisordersrecoverovertime? H. Baraki, A. Ah Ahmad, S. Jeng-Singh, J. Schmitto, B. Fleischer, A. Martens, I. Kutschka, A. Haverich (Germany)Discussant: C. Vicol (Munich)
09:15 Transcutaneousleadimplantationconnectedtoanexternalizedpacemakerinpatientswithimplantablecardiacdefibrillator/pacemakerinfectionandpacemakerdependency S. Pecha, Y. Yildirim, B. Sill, A. Aydin, H. Reichenspurner, H. Treede (Germany)Discussant: A. Lahti (Turku)
09:30 Concomitantsurgicalatrialfibrillationablationandeventrecorderimplantation:bettermonitoring,betteroutcome? S. Pecha, T. Ahmadzade, T. Schäfer, H. Reichenspurner, F. Wagner (Germany)Discussant: B. Osswald (Bad Oeynhausen)
09:45 Sessionends
Abstracts
Mitral medley
Room 112
Moderators: K. Sarkar, Kolkata; F. Casselman, Aalst
08:15 Leafletextensioninrheumaticmitralvalvereconstruction J. Dillon, M. A. Yakub (Malaysia)Discussant: S. Livesey (Southampton)
08:30 Towardsanintegratedapproachtomitralvalvedisease:implementationofaninterventionalmitralvalveprogrammeanditsimpactonsurgicalactivity L. Conradi, M. Silaschi, H. Treede, S. Baldus, M. Seiffert, J. Schirmer, H. Reichenspurner, S. Blankenberg (Germany)Discussant: F. Maisano (Milan)
08:45 Intraoperativetransoesophagealechocardiographyforpredictingriskofsystolicanteriormotionaftermitralvalverepairfordegenerativedisease R. Varghese, S. Itagaki, P. Trigo, A. Anyanwu, G. Fischer, D. Adams (United States)Discussant: R. De Simone (Heidelberg)
09:00 Long-termechocardiographicfollow-upandqualityoflifeafterearlysurgeryinasymptomaticpatientswithseveremitralvalveregurgitation:asingle-centreexperience W. Van Leeuwen, S. Head, L. Van Herwerden, A. Bogers, A. P. Kappetein (Netherlands)Discussant: M. Borger (Leipzig)
09:15 Iscommissuralclosureforthetreatmentofmitralregurgitationdurable?Along-term(upto15years)clinicalandechocardiographicstudy M. De Bonis, E. Lapenna, M. Taramasso, M. C. Calabrese, N. Buzzatti, A. Pozzoli, T. Nisi, O. Alfieri (Italy)Discussant: L. Müller (Innsbruck)
09:30 Managementofmoderatefunctionalmitralregurgitationatthetimeofaorticvalvesurgery G. Freitas Coutinho, P. Correia, R. Pancas, M. Antunes (Portugal)Discussant: H. Vanermen (Aalst)
09:45 Sessionends
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Marco Ranucci, M.D., FESC, IRCCS
Policlinico San Donato, San Donato
Milanese (Milan) ITALY
Aortic cross-clamp time and car-diopulmonary bypass (CPB) du-
ration are well-known, independ-ent predictors of adverse outcomesin adult cardiac surgery. Their clin-ical meaning is different. CPB timeisamarkerofthecomplexityoftheoperation,andmayalsoaccountfordifficultweaning from theextracor-poreal support. From this point ofview, its association with bad out-comesisnotsurprising.Thisisespe-ciallytruewhenthepatientstaysonbypasstostabilizethehemodynam-icprofile,providetheadequatephar-macological supportandaccommo-date the insertion of a mechanicalassistdevice.
The aortic cross-clamp time alsorefers to the complexity of the op-eration.However,whenthesurgicaloperation is standardized (i.e.aortic
valvereplacement),aprolongedaor-ticcross-clamptimeispredominant-lyrelatedtothepaceofthesurgicalprocedure.Itisimpactedbyboththetechnical abilityof the surgeonandthe possible problems faced duringthenativevalveremoval,theprepa-rationoftheaorticvalveannulusandtheimplantoftheprostheticvalve.
New generation sutureless aor-tic valves arepresently entering themarket,andtheirmainadvantageisthe standardization of the surgicalprocedureandareductionofaorticcross-clamp time. Therefore, a cleardefinition of the role of the aorticcross-clamp time as a potential de-terminantofmorbidityandmortalityisofparamountimportance.
In a recent study1, the aorticcross-clamp time was analyzed asa determinant of major cardiovas-cular morbidity (low cardiac out-put, stroke, acute kidney injury ormortality).Thestudyincludedaret-rospective analysis of 979 consec-utivepatientswithaorticvalvesten-osiswhounderwentasurgicalaorticvalvereplacement.Theaorticcross-clamp timewas analyzedas an in-dependent predictor of severe car-diovascularmorbidity.Subgroupsofpatients who benefit more from areduction in the aortic cross-clamptimewereinvestigated.
In this analysis, the aortic cross-clamptimewasanindependentpre-dictor of severe cardiovascular mor-bidity,with an increased riskof 1.4percentperoneminuteincrease..Di-abetic patients and patients with aleftventricularejectionfraction≤40percent showed the most relevantclinical benefits froma reduction incross-clamptime.
These results stress the role ofaortic cross-clamp time in deteri-orating post-operative myocardialperformance, having a deleteriouseffectbothonsystolicand leftven-tricle diastolic function. Not surpris-ingly,thepatientsmorepronetothisinsultare thosewithapoorsystolicleft ventricular function anddiabet-icpatients,whohaveawell-knownsusceptibilitytodiastolicdysfunction.
In conclusion, reducing the aor-ticcross-clamptimeinselectpatientpopulationsmayresultinamorefa-vorablepost-operativeoutcome.1. M.Ranucci et al, J Heart Valve Dis, in press
Logistic regression for association between graft occlusion and components of SYNTAX score
Graft occlusion Yes No Univariate logistic regression Multivariate logistic regression
No. patients 21 168 Odd ratio(95% CI) p Odds ratio(95% CI) p
Total occlusion,% of patients 7(33.3) 81(48.2) 0.54(0.21-1.40) 0.20 0.50(0.18-1.37) 0.18
Trifurcation,% of patients 4(19.0) 35(20.8) 0.89(0.28-2.83) 0.85 0.52(0.11-2.50) 0.41
Bifurcation,% of patients 9(42.9) 78(46.4) 0.87(0.35-2.16) 0.76 0.67(0.22-2.08) 0.49
Aorto-ostial lesion,% of patients 1(4.8) 8(4.8) 1.00(0.12-8.42) 0.99 1.16(0.12-11.53) 0.90
Severe tortuosity,% of patients 7(33.3) 57(33.9) 0.97(0.37-2.55) 0.96 1.11(0.39-3.13) 0.85
Lesion length >20mm,% of patients 15(71.4) 105(62.5) 1.50(0.55-4.07) 0.43 2.02(0.62-6.57) 0.24
Heavy calcification,% of patients 7(33.3) 72(42.9) 0.59(0.23-1.54) 0.28 0.69(0.25-1.88) 0.46
Thrombus formation,% of patients* 0 4(2.4)
Diffuse disease,% of patients 6(28.6) 49(29.2) 0.97(0.36-2.65) 0.96 0.79(0.26-2.42) 0.68
Dataarenumberofpatients(%)*Thrombusformationnotenteredintologisticregressionmodelsasnotdetectedinpatientswithgraftocclusion
Title Preoperative SYNTAX score and graft patency after off-pump coronary bypass surgery
Takeshi Kinoshita
Figure 2 Cumulative rates of major adverse cardiac and cerebrovascular eventFigure 1 Cumulative rates of graft occlusion
Aortic cross-clamp time in aortic valve replacement: an independent risk factor for cardiovascular morbidity.
6 Monday 29 October 2012 EACTS Daily News
Abstracts
08:15 New ideas in transcatheter aortic valve replacement
Rooms 118/119
Moderators: T. Walther, Bad Nauheim; C. R. Smith, New York
08:15 Transapicalaccessclosure:thetapplugdevice C. Huber, H. Brinks, V. Göber, F. Nietlisbach, P. Wenaweser, B. Meier, L. Englberger, T. Carrel (Switzerland)Discussant: S. Bleiziffer (München)
08:30 Severeintra-proceduralcomplicationsaftertranscatheteraorticvalveimplantation:callingforaheart-teamapproach M. Seiffert, L. Conradi, R. Schnabel, J. Schirmer, S. Blankenberg, H. Reichenspurner, S. Baldus, H. Treede (Germany)Discussant: L. Harling (London)
08:45 Transapicalversustransfemoraltranscatheteraorticvalveimplantation:outcomeaccordingtostandardizedendpointdefinitionsbytheValveAcademicResearchConsortium S. Salizzoni, M. La Torre, F. Giordana, C. Moretti, P. Omede, G. Ferraro, M. D’Amico, M. Rinaldi (Italy)Discussant: N. M. D. A. van Mieghem (Rotterdam)
09:00 InitialclinicalresultsoftheBraileInovaretranscatheteraorticprosthesis J. H. Palma, D. Gaia, E. Buffolo, C. B. Ferreira, J. A. Souza, G. Agreli (Brazil)Discussant: H. Treede (Hamburg)
09:15 Systematictransaorticapproachfortranscatheteraorticvalveimplantation:avalidalternativetotransapicalaccessinpatientswithnoperipheralvascularoption.Oneyearsingle-centreexperience M. Romano, K. Hayashida, T. Lefèvre, T. Hovasse, B. Chevalier, D. Le Houérou, A. Farge, M. Morice (France)Discussant: J. Grünenfelder (Zürich)
09:30 Europeanexperienceofdirectaortictranscatheteraorticvalveimplantationwithaself-expandingprosthesis:evidenceofasignificantlearningcurve G. Bruschi1, M. Jahangiri2, U. Trivedi2, N. Moat2 (1Italy, 2United Kingdom)Discussant: H. Amrane (Leeuwarden
09:45 Sessionends
Professional Challenges
How to optimize coronary revascularization: planning and execution II
Rooms 116/117
Moderators: N. M. D. A. van Mieghem, Rotterdam; M. Mack, Dallas
10:15 DifferencebetweentheEuropeanandUSguidelines M. Mack (Dallas)
10:30 Impactofstatinuseonclinicaloutcomesaftercardiacsurgery:asystematicreviewofstudies,withmeta-analysisofover90,000patients O. Liakopoulos, S. Stange, E. Kuhn, A. Deppe, I. Slottosch, Y. Choi, T. Wahlers (Germany)Discussant: M. Thielmann (Essen)
10:45 Mortalityriskandcausesofdeathincoronaryarterybypasssurgerypatientswithpre-andpostoperativeatrialfibrillation:a12-yearfollow-up E. Fengsrud, A. Englund, A. Ahlsson (Sweden)Discussant: P.P. Paulista (Sao Paulo)
11:00 Comparisonofheart-typefattyacidbindingproteinandcardiactroponinIforearlydetectionofmyocardialinfarctionaftercoronarybypasssurgery S. Pasa, D. Wendt, M. Hösel, D. Dohle, K. Pilarczyk, H. Jakob, M. Thielmann (Germany)Discussant: M. Sousa Uva (Lisbon)
11:15 Shouldmoderateischaemicmitralregurgitationbecorrectedatthetimeofcoronaryarterybypassgrafting?Answerfroma10-yearfollow-up V. Shumavets, Y. Ostrovski, A. Shket, A. Janushko, S. Kurganovich, I. Grinchuk, N. Semenova, O. Jdanovich (Belarus)Discussant: A. Rastan (Rotenburg)
11:30 Intensivecareunitreadmissionaftercardiacsurgery:predictorsandconsequences U. Boeken, J.-P. Minol, A. Assmann, A. Mehdiani, P. Akhyari, A. Lichtenberg (Germany)Discussant: B. Rylski (Freiburg)
11:45 Sessionends
Continued from page 4
Continued on page 8
S. Salzberg, M. Emmert,
J. Grünenfelder, A. Plass and V. Falk
University Hospital Zurich, Switzerland
Surgical revascularization remainsthetreatmentofchoiceforcom-
plex 3-vessel coronary disease, leftmain coronary artery involvementordiabetesmellitus.However, coro-naryarterybypassgrafting(CABG)islimited by concern about the high-er stroke rate compared with PCI.Reports of inferior neurological out-comesforCABGvs.PCIhaveprimari-lyresultedfromstudiesinwhichcon-ventionalon-pumpCABGtechniqueswere used, rather than off-pumptechniques, aortic no-touch strate-giesoreventhecombinationofboth.
Agrowingbodyofevidencesup-portsclamplessoff-pumpapproach-es to surgical revascularization tominimizeneurologic injury.Byelimi-natingaorticcross-clampingrequiredfor cardiopulmonary bypass, off-pump coronary artery bypass (OP-CAB)results ina lower incidenceofstroke compared to conventionalCABG,particularlywhenperformedincombinationwithcompletein-situgrafting (double internal mammaryarteryand/orT-orY-Grafting).Whileoff-pump in situ grafting has beenproposedasthe‘standardofcare’toreduceneurologicalcomplications,itmaynotbeapplicableforeverypa-tient. Inmanycases toobtaincom-pleterevascularizationtheuseoffree
grafts (arterial or venous) requiringproximalanastomosisisnecessary.Inthesesituations,proximalanastomo-siscanbeenabledwithoutapartialclamp by using the HEARTSTRINGdevice(MAQUET,SanJose,CA,Unit-edStates).
In a propensity-matched analysisof4,314patientsundergoingsurgi-cal revascularizationat theUniversi-ty Hospital Zurich, stroke incidencewassignificantlylowerwhenHEART-STRING was used to perform prox-imal anastomoses during OPCABratherthanthepartialcamp.Ofnote,thestrokeratefortheHEARTSTRINGgroupwascomparabletothatofpa-tients who underwent completelyno-touchinsitugrafting(Figure1).
TheuseoftheHEARTSTRINGde-vicecanbesafelyimplementedintoroutine clinical practice with littlelearningcurveandsignificantlymin-imizestheoccurrenceofstrokeandother neurological complications
compared with partial- or side biteclamping. The combination of OP-CABandclampless strategieseitherusingcompleteinsitugraftingtech-niquesor clamplessdevices suchasHEARTSTRING for proximal anasto-mosis reduces stroke to levels com-parable to PCI, representing a sig-nificant advance over conventionalon-pumpCABG(Figure2)
While aortic cross clamping (A)during standard on-pumpCABG aswellaspartialclampingusingaside-biteclampduringOPCAB(B)arewellestablishedas importantriskfactors
forstroke,aclamplesstechniqueforproximal anastomosis (C) applyingtheHEARTSTRINGdeviceisaneffec-tive tool for stroke reduction. Onlyby these means can stroke rates ofCABGbecomesimilarorevenlowerthanforPCI.References
Emmert MY, Seifert B, Wilhelm M, Grünenfelder J, Falk V, Salzberg SP. Aortic no-touch technique makes the difference in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2011 Dec;142(6):1499-506.
Emmert MY, Salzberg SP, Seifert B, Scherman J, Plass A, Starck CT, Theusinger O, Hoerstrup SP, Grünenfelder J, Jacobs S, Falk V. Clampless off-pump surgery reduces stroke in patients with left main disease. Int J Cardiol. 2012 Jun 21. [Epub ahead of print].
CABG Comes with Comparable Stroke to PCI If the Aorta Is Not Clamped
Figure 2 – Alternative Approaches to Proximal Anastomosis
Figure 1 – Stroke Rate by Operative Procedure in 4314 CABG Patients
Thoracic: Abstract 08:15–09:45 Room 133/134
Ting Ye Chief, Department of Thoracic Surgery, Shanghai
Cancer Center, Fudan University,
Haiquan Chen Department of Oncology, Shanghai Medical
College, Fudan University, Shanghai, China
Moreandmoresinglepulmonarynod-ules(SPNs)especiallythosefeaturedwithgroundglassopacity(GGO)arede-tectednowadayswiththewideappli-
cationofhighresolutionCT.PersistentGGOnodulesalwaysindicatethemalignantorpremalignantdis-easeslikeatypicaladenoidhyperplasia(AAH),adeno-carcinomainsituorminimalinvasiveadenocarcinoma(MIA)whichneedsurgicalresection.However,pureorsubsolidGGOlesionsarehardtobepalpatedorrec-ognizedduringthoracoscopicresection.Ontheotherhand,preoperativeCT-guidedhook-wirelocalizationhasbeenwidelyusedinvideo-assistedthoracicsurgi-calresectionforSPNstheseyears.Sowedesignedthestudytoprospectivelyevaluatetheapplicationofpr-eoperativeCT-guidedhook-wirelocalizationfortho-racoscopicresectionofpureGGOnodulesandmixedGGOlesionswithasolidcomponentlessthan50%.
FromApril2008toJune2011,87patientsinclud-ing25malesand62femaleswithameanageof55.23±10.00yearoldand93GGOlesionsincluding
53pureGGOsand40subsolidGGOswereenrolled.Themeansizeofthesenoduleswas11.03±4.76*9.15±3.68mm.Andthemeandepthofthelesions(verticaldistancefromthenoduletopleuralsurface)was11.59±8.00mm.Weperformed93hook-wirelocalizationsforallthenodules.Themeandepthofneedleinsertionwas26.80±1.18mm.Andseventy-sixneedlelocalizationswerenearthelesionwhileseventeenprocedurespenetratedthelesion.Themeantimeoftheprocedurewas15.36±5.10min-utes.Allhook-wirelocalizationsweresuccessful.Thereweresixteenasymptomatichemorrhagesandfivepneumothoraxeswhichdidnotneedclinicalin-terventions.Thecomplicationratewas22.58%.Wesuccessfullydidninety-threewedgeresectionsandthirty-sevenlobectomies.Themeandurationofthewedgeresectionwas15.14±2.65minutes.Oneoperationwasconvertedtothoracotomybe-causeofthepleuraladhesion.Thereweretwocom-plicationsincludingonealveolarpleuralfistulacaseandonepost-operativeacatalepticthoracichemor-rhagecaseafterlobectomies,whichwerebothsuc-cessfullymanagedbyexpectanttreatment.Andthepatientwiththoracichemorrhagedischargedfromhospital22daysafteroperation.Themeanpostop-erativein-hospitaltimewas6.26days.Finalpatho-logicalresultsshowed29invasiveadenocarcinomas;
26adenocarcinomasinsitu;16minimalinvasivead-enocarcinomas,10atypicaladenoidhyperplasiaandsixalveolarepitheliumhyperplasiaandsixinflamma-tions.
Resultsinthisstudyshowedtheusefulnessandsu-periorityofthehook-wirelocalizationforpureandmixedGGOlesionsintermsofits100%successfullo-calizationandresectionrateandlowincidenceofre-latedcomplications.Wethinktheneedforpreopera-tivehook-wirelocalizationwillremainaslongastheapplicationofvideo-assistedthoracicsurgeryforpul-monarylesionswithdominantgroundglassopacityfeatures.
Ting Ye Haiquan Chen
Preoperative CT hook-wire localisation Thoracoscopic resection for ground-glass opacity pulmonary lesions: results from a prospective analysis
needfortrans-annularpatch(80%)thisisnotsignificantlydifferentfromourstandardpractice.WefeelthatselectiveuseofRVOTstentingcanbeausefuladjuncttothemanagementofcomplexvariantsofFal-lot’sTetralogy.Thetechniquereducestheneedforhighriskneonatalsurgeryandresultsinthegrowthofdiminutivepulmonaryarteries.
RVOT stentingContinued from page 2
8 Monday 29 October 2012 EACTS Daily News
William Wang Scripps Memorial
Hospital, La Jolla, California, USA
Earlypostoperativere-currentatrialfibrillation(AF)isthemostcom-monclinicallyencoun-
teredarrhythmiaaftermitralvalvesurgeryconcomitantwithMazeprocedure.Upto43%ofthecasespresentwithAFdur-ingpostoperativedaystwotofive.Thesetachyarrhythmiasarerecognizedasamajorcauseofperioperativemorbidity.
Themanagementofthese
arrhythmiashasbeenshowntosignificantlyextendthelengthofhospitalizationandasso-ciatedcost.Pharmacologicalcontrolisthefirstlineofther-apy,butAFmaybeassoci-atedwithlowsuccessrates,highrecurrencerates,orpa-tientintolerance.Thus,thereisconsiderableinterestinnon-pharmacologicaltherapyasawaytomaintainsinusrhythm.Continuousoverdrivebiatrialpacingwasfoundtobeeffec-tiveinpromotingsinusrhythmandinreducingtheincidence
ofAFafteropenheartsurgery.Between2002and2010,
240patientsundergoingmi-tral±tricuspidvalvesurgeryconcomitantwiththeMazeprocedurewererandomizedintothreeequalgroups:groupIusingoverdrivebiatrialpac-ing,groupIIutilizingsingleatrialpacingandgroupIIIwith-outpacing.Resultsshowthein-cidenceofrecurrentpostop-erativeatrialfibrillationwassignificantlylessinthegroupIwith9of80patients(11%)in-curringatrialfibrillationcom-
paredwith23of80patients(28%)inthegroupII(P<.01)and29of80patientsinthegroupIII(p<0.1).Thelengthofhospitalstayandthemeancostsofhospitalstayweresig-nificantlylowerinthebiatrial
pacinggroup(P<.05).Weconcludedthatbiatrial
overdrivepacingiswelltoler-atedandmoreeffectiveinpre-ventingtheearlyrecurrenceofatrialfibrillationaftertheMazeprocedure.
Abstracts
Mechanical support of the circulation
Room 115
Moderators: J. R. Pepper, London; G. Gerosa, Padua
10:15 Whobenefitsfromearlyventricularassistdeviceimplantation? T. Komoda, T. Drews, T. Krabatsch, H. Lehmkuhl, R. Hetzer (Germany)Discussant: L. Martinelli (Milan)
10:30 TheCardioWesttotalartificialheartasabridgetotransplantation:currentresultsatLaPitiéhospital M. Kirsch, A. Nguyen, C. Mastroinai, M. Pozzi, S. Varnous, P. Léger, A. Pavié, P. Leprince (France)Discussant: M. Iafrancesco (Birmingham)
10:45 Long-termresultswithatotalartificialheart:isitprimetimefordestinationtherapy? G. Gerosa1, G. Torregrossa1, P. Leprince2, F. Beyersdorf3, R. Hetzer3, J. Gummert3, D. Duveau2, J. Copeland4 (1Italy, 2France, 3Germany, 4United States)Discussant: J. B. Kim (Seoul)
11:00 Leftventricular/biventricularassistdevicesupportinchildrenwiththeBerlinHeartEXCOR:earlierindicationismandatory A. Bortolami, M. Padalino, A. Gambino, G. Toscano, G. Feltrin, V. Vida, G. Stellin, G. Gerosa (Italy)Discussant: V. Tsang (London)
11:15 CirculatorysupportinelderlychronicheartfailurepatientsusingtheCirculiteSynergysystem A. Barbone1, F. Rega2, D. Ornaghi1, E. Vitali1, B. Meyns2 (1Italy, 2Belgium)Discussant: A. Loforte (Bologna)
11:30 Survivalresultswithanintrapericardialthird-generationcentrifugalassistdevice:anINTERMACS-adjustedcomparisonanalysis A. Dell’Aquila, D. Schlarb, B. Ellger, A. Hoffmeier, S. Martens, J. Sindermann (Germany)Discussant: M. Grimm (Innsbruck)
11:45 Sessionends
Abstracts
10:15 The future of transcatheter mitral valve repair
Room 114
Moderators: R. Haaverstad, Bergen; H. Treede, Hamburg
10:15 State-of-the-artwiththeMitraClipprocedure F. Maisano (Milan)
10:22 ResidualmitralvalveregurgitationafterpercutaneousmitralvalverepairwiththeMitraClipsystem:impactonfollow-upoutcome G. D’Ancona, L. Paranskaya, S. Kische, H. Ince (Germany)Discussant: O. Alfieri (Milan)
10:37 MitralvalverepairusingmultipleMitraClips:perioperativeandshort-termresultsusingthe“zipping”technique S. Kische, G. D’Ancona, L. Paranskaya, I. Turan, H. Ince (Germany)Discussant: H. Vanermen (Aalst)
10:52 Percutaneousorsurgicalmitralvalverepairforfunctionalmitralregurgitation:comparisonofpatientcharacteristicsandclinicaloutcomes L. Conradi, H. Treede, E. Lubos, M. Seiffert, J. Schirmer, S. Blankenberg, S. Baldus, H. Reichenspurner (Germany)Discussant: A. Hensens (Enschede)
11:07 ClinicaloutcomesthroughsixmonthsinpatientswithdegenerativemitralregurgitationtreatedwiththeMitraClipdeviceintheACCESS-EuropephaseItrial F. Maisano1, O. Franzen2, S. Baldus3, J. Hausleiter3, C. Butter3, U. Schäefer3, G. Pedrazzini4, W. Schillinger3 (1Italy, 2Denmark, 3Germany, 4Switzerland)Discussant: H. Treede (Hamburg)
11:22 MitraCliptherapyinheartfailurepatientswithfunctionalmitralregurgitation:oneyearresultsin75high-riskpatientsinasingle-centreexperience M. Taramasso, P. Denti, M. Cioni, G. La Canna, N. Buzzatti, O. Alfieri, A. Colombo, F. Maisano (Italy)Discussant: M. Haensig (Leipzig)
11:30 MVARCGuidelines:howtoreportonoutcomesinmitralvalveinterventions S. Head (Rotterdam)
This session is supported with an unrestricted educational grant from Abbott Vascular International BVBA
11:45 Sessionends
Continued from page 6
Continued on page 10
Professor Ben Bridgewater Department of
Cardiothoracic Surgery, University Hospital of
South Manchester NHS Foundation Trust
Functional tricuspid regurgitationis typically secondary to left-sid-
ed valve dysfunction and is associat-ed with lower survival. The Europe-anguidelinesonvalvularheartdiseaserecommendthatpatientsundergoingleft sided valve interventions shouldundergotricuspidsurgeryiftheyhavesevere tricuspid regurgitation (TR) ormild/moderate TR with a dilated tri-cuspidannulus,≥40mm.
So does the surgical communi-tyfollowtheseguidelines?DatafromDreyfus and Van de Veire suggeststhat around half of the patients un-dergoingmitralrepairshouldundergoconcomitant tricuspid surgery. Anal-ysisof theSociety forCardiothoracic
Surgery of GreatBritainandIrelanddatabase showsthat an increas-ingnumberofpa-tients are under-going combined
mitralandtricuspidsurgery,butinthemostrecentyearofanalysislessthan20%ofpatientsundergoingmitralre-pairhadatricuspid intervention. It isunlikely that this ispurelyaUKphe-nomenon.
So why do surgeons not followthe guidelines? The data contribut-ingtotheguidancearesmall,single-centre studies. Some surgeons mayhave the view that successful mitralrepairsurgeryimprovesqualityof lifeandlifeexpectancytothatoftheage-matchedhealthypopulationandthattricuspidrepairmaynotbenecessary.
Does tricuspid repair increaseopera-tiverisk?Aswithanythinginsurgeryit is somewhat counter-intuitive thatadding extra procedures to any op-erationdoesnotincreaseriskbutthismaybetrueforfunctionaltricuspidre-pairaccordingtotherecentlyupdatedESC/EACTS Guidelines. Furthermore,around1/3rdofpatientsundergoingleftsidedsurgerywhohavenosignif-icant TR at the time of interventionwilldevelopimportantTRduringfol-low-up,andthesepatientshavepoorlong-termoutcomesandahighperi-operativemortalityinthecaseofsub-sequent tricuspid surgery. The diffi-cultyofassessmentandevaluationoftricuspidregurgitationmayalsobeim-portant: as a ventricular and valvulardisease,bothregurgitationandtricus-pidannulusdilationshouldbeconsid-eredtofullyassessthevalve.
Mitralrepairhaslongbeenasub-specialistinterestinsomepartsoftheworldwhereinothersitformspartofgeneral cardiac surgeon’s practice. If
only small volumes of mitral surgeryare undertaken we know that miti-gatesagainst the likelihoodof repairprocedures,anditislikelythatitalsodecreases the chance of appropriateinterventionon the tricuspidvalveatthe same time (and ‘appropriate’ in-cludes when to operate as well aswhat type of procedure to perform;contemporary litreature has demon-stratedsuperioroutcomesforringre-pairvs.sutureannuloplasty).
The tricuspidvalve is stillnotwellunderstood due to complex interac-tions with right ventricular function,pulmonaryarterypressureandcircula-tory loading.Tochangeclinicalprac-tice furtherwill requirebetterpatho-physiological understanding of therightheart,moreclinicalstudies(pref-erably randomized) demonstratingbeneficialeffectsof tricuspidannulo-plastyfordefinedgroups,furtheredu-cationforthesurgicalcommunity,andrigorousauditofpracticeagainstac-ceptedbestpracticestandards.
Monica Moz Department of Cardiac Surgery. Heart Centre,
University of Leipzig. Leipzig, Germany
Aorticarchreoperationfollowingpreviousas-cendingaortasurgery(AAR)±aorticarchisatechnicallycomplexprocedure.Longersurviv-
alsaftertheprimaryprocedure,anageingpopulation,improvedknowledgeinthemanagementofreoper-ationhavecontributedtoanincreaseofthesepro-cedures.Redo-surgeryofaorticarchcarriesahigherearlymortality-morbiditythanfirst-timeprocedures.WeretrospectivelyanalysedtheresultsatourInstitu-tion.
BetweenJanuary1995andDecember2011,1,022patientsunderwentAAR±aorticarchsurgeryatHZL.57patients(5.5%),whopreviouslyreceivedaorticsur-gery,underwentaorticarchsurgery.
Theindications:aorticarchaneurysm50%,resid-ualaorticdissection38%,vasculargraftinfection9%andapatientwithend-stageDCM.Themeaninter-valtimebetweentheprevioussurgery:7.6±7yearsforaorticaneurysm,4.4±4yearsfortypeAaorticdissec-tion(p=0.09).
Regardingcerebralprotection,SACPwithHCAwasusedin39patients(68%):UACPin11,BACPin28.In18patients(46%)HCAwasperformedwithameantemperatureof22°C.The30-daymortality:8.8%(n=5).Threepatientsdiedintabula(twobe-causeofLCO,oneduetomassiveIMA).Onepatientdiedduetomassivecerebraledemaaftersevendays,anotherafter23daysduetosepsis.IRAappearedinfive(9%),strokeinninepatients(16%)withperma-nentdeficitsinthree.Themeansurvivaltime:5.5±0.5years.Overallestimatedsurvival:77±0.3%,76±0.4%,75±0.6%atone,threeandfiveyears.Survivalforpa-tientswithaorticdissectionforoneoperationwassig-nificantworsecomparedwithaorticaneurysm(logrankp=0.016).
Univariateanalyzerevealedanassociationbetweenaorticdissection(OR9.2,p<0.01),emergencyindica-tions(OR8.2,p=0.02),PVD(OR5.5,p=0.02)andin-hospitalmortality:IntheCoxregressionmodel,aorticdissectionatthetimeofthefirstprocedurewasthesingleindependentriskfactor(OR3.7,p=0.01).
Manydifferentaspectsneedtobeconsideredforthesuccessoftheseprocedures.nPre-operativeevaluationwithCTscanimages,with
3Dreconstruction,allowsdevelopingasurgicalstrategy.
nTheselectionofarterialcannulationsite.Webelievethattheaxillarycannulationprovidesanexcellentvisibilityofthesurgicalfield,antegradeflowintotheaorticarchandrepresentsa“no-touch”tech-niqueandpreventsdislodgementofemboliintothebrain.
nTheincidenceofneurologicalevents.BACPpermitslongertimesofHCA.DuringSACPthereistheriskofcerebralembolismassociatedwitharch-vessel
cannulation.ThecontinuousmonitoringofcerebraloxygenationhasbeendevelopedforevaluationoftheadequacyofbloodsupplyduringtheHCA.WeroutinelyusetheSomaneticsInvosinaorticsurgery.
nThe“en-bloc”or“separategraft”techniquesforarchvesselsreimplantation.Weusetheseparateimplantationinaorticdissectionwhichinvolvesthearch-vesselsandinpresenceofcalcifiedplaquesthatmakedirectanastomosisproblematic.
nPatientswithMarfansyndromerequireacarefulfol-low-upafterthefirstoperation,importanttodeter-mineanylateaorticeventsandthecorrecttimingofreoperation.
Inconclusion,despitethecomplexityofthesepa-tients,thedifficultytoreoperationandmultipleintra-operativeaspectstoconsider,thissurgerycanbeper-formedwithalowmortality-morbidityrate.
Intra-operative data
CPB time minutes (mean ± SD) 251.2±84
Cross clamp time 99.4±60.4
Circulatory arrest time minutes (mean ± SD) 28±22
Cannulation method (n,%)
Femoral artery 27 (47%)
Axillary artery 30 (53%)
Surgery data
Hemi-arch replacement (n,%) 27 (47%)
Total arch replacement (n,%) 30 (53%)
Elephant Trunk 16
Frozen Elephant Trunk 6
(Jotec E-vita open plus, Jotec GmbH, Germany)
Reimplantation of arch vessel (n,%)
En-bloc technique 22 (73%)
Separate graft tecnique 8 (27%)
Bentall procedure (n,%) 20 (35%)
Homograft 4 (7%)
Thoracoabdominal aorta replacement (n,%) 9 (16%)
Vascular: Professional Challenges 08:15–09:45 Room 113
Aortic arch reoperation: a single centre experience of early and late outcome in 57 consecutive patients.
Monica Moz
Effectiveness of biatrial pacing in reducing early postoperative atrial fibrillation after the maze procedure
Cardiac: Abstract 08:15–09:45 Room 114
Functional Tricuspid regurgitation:Do we follow the guidelines?
10 Monday 29 October 2012 EACTS Daily News
Abstracts
Aortic valve repair at the crossroads
Room 112
Moderators: E. Lansac, Paris; H. Schäfers, Hamburg/Saar
10:15 Doesthegeometricorientationoftheaorticneorootinpatientswithraphedbicuspidaorticvalvediseaseundergoingvalverepairplusrootreimplantationaffectvalvefunction? P. Vallabhajosyula, T. Wallen, C. Komlo, W. Szeto, J. Bavaria (United States)Discussant: G. El Khoury (Brussels)
10:30 Long-termoutcomeofvalverepairforconcomitantaorticandmitralinsufficiency:settinganewstandardofcare H. Vohra1, R. Whistance2, L. Dekerchove1, D. Glineur1, P. Noirhomme1, G. El Khoury1 (1Belgium, 2United Kingdom)Discussant: M. Borger (Leipzig)
10:45 Impactofannuloplastyinbicuspidaorticvalverepair:valve-sparingreimplantationissuperiortosubcommissuralannuloplasty E. Navarra, L. De Kerchove, D. Glineur, P. Astarci, P. Noirhomme, G. El Khoury (Belgium)Discussant: M. Nosal (Bratislava)
11:00 Aorticvalvereconstructionwithautologouspericardiumfordialysispatients I. Kawase, S. Ozaki, H. Yamashita, Y. Nozawa, S. Uchida, T. Matsuyama, M. Takatoh, S. Hagiwara (Japan)Discussant: E. Lansac (Paris)
11:15 Functionalaorticannulusremodellingusingahandmadeprostheticringimprovesoutcomesinaorticvalverepair K. Fattouch, S. Castrovinci, G. Murana, G. Nasso, F. Guccione, P. Dioguardi, G. Bianco, G. Speziale (Italy)Discussant: E. Lansac (Paris)
11:30 Prospectiveanalysisoflong-termresultsofaorticvalverepairandassociatedrootreconstruction M. Jasinski, R. Gocol, M. Malinowski, D. Hudziak, M. Deja, S. Wos (Poland)Discussant: S. Leontyev (Leipzig)
11:45 Sessionends
Focus Session
10:15 Antiplatelet therapy in 2012: impact on cardiovascular surgical procedures
Rooms 118/119
Moderators: J. B. Grau, Ridgewood; D. Taggart, Oxford
10:15 Comparativeanalysisofavailableantiplatelettherapiesincurrentclinicalmanagement:whatagentstochoosefromandwhy H. Reichenspurner (Hamburg)
10:30 Applyingcurrentguidelinesonantiplatelettherapypriortocoronaryarterybypassgrafting:Whattodointhesettingofpreviouspercutaneouscoronaryintervention?Whatcanbeimproved? A. P. Kappetein (Rotterdam)
10:45 Shouldweplaceourpostcoronaryarterybypassgraftpatientsonantiplateletdrugs?Weighingthebenefitsandthecomplicationsthroughevidence-basedresearch I. George (Columbia)
11:00 Impactofpharmacogeneticsintheclinicalmanagementofantiplatelettherapy J. Quackenbush (Boston)
11:15 Antiplatelettherapyinhigh-riskpatientsandinthoseonwarfarintherapy E. Rodriguez (Greenville)
11:30 Newfrontiersinantiplatelettherapy:whereweareandwherewearegoingfromhere D. Glineur (Brussels)
This session is supported with an unrestricted educational grant from AstraZeneca
11:45 Sessionends
Abstracts
10:15 Heart transplants: the most effective treatment for end-stage heart failure
Rooms 120/12
Moderators: Ö. Friberg, Örebro; J.L. Pomar, Barcelona
10:15 Evolutionofrecipientanddonorprofilesincardiactransplantation:single-centreten-yearexperience C. D’Alessandro, M. Laali, E. Barreda, J. L. Golmard, J. Trouillet, P. Farahmand, P. Leprince, A. Pavié (France)Discussant: C. Knosalla (Berlin)
Continued from page 8
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Revolutionary unique technologycombines the benefits of a bi-
polar clampwith theflexibilityandminimally invasiveaccessofanen-doscopicallyguidedprobe.
Estech,aleadingproviderofmin-imally invasive cardiac ablation de-vices, launches its COBRA Fusion™Ablation System. This breakthroughtechnologyisthefirstofitskindde-viceutilizingauniquesuctionappli-cationandinnovativeelectrodecon-figuration to gently pull the tissuetargeted for ablation into the de-viceandoutofthepathofcirculat-ingblood.TheCOBRAFusionover-comesthemostsignificantchallengefacedinminimallyinvasiveepicardialablation,thecoolingeffectofbloodinside the heart, and reproducibly
createstransmurallesionsonabeat-ingheart.
The COBRA Fusion incorporatesproprietary Versapolar™ technology—anexclusiveinnovationthatdeliv-ersbothbipolarandmonopolar ra-diofrequency (RF) energy. The newdeviceispoweredbyEstech’spatent-ed temperature controlled radiofre-quency(TCRF)energywhichcontin-uouslymonitorsandmaintainstissuetemperatureattargetlevelsthrough-out theprocedure.TCRFavoids theneed for multiple applications thatothertechnologiesoftenrequireandensures that tissuetemperatures re-main within a safe and effectiverange.
JamesL.Cox,M.D.,thepioneerandcreatoroftheCox-Mazeproce-
durestated:“Ihavehadtherecentopportunity to observe the clinicaluseofthisnewdeviceinseveralpa-tients.Thehistoricalproblemofat-tainingatrialwalltransmuralityreli-ablyinabeating,workingheartbyapplying ablative energy from theepicardium only, appears to havebeensolvedwiththisnewdevice.”Dr.Coxadded:“Theabilitytoinvo-lutetheatrialwallintotheablationdevice itself using suction allowsfortheapplicationofradiofrequen-cyenergytobothsidesoftheinvo-lutedtissue,therebycreatingrepro-ducible transmural and contiguouslinear lesions for thefirst timeoff-pump.Moreover,thedeviceissmallenough to fit through a standardport, usinganendoscopicport-ac-
cess approach. I believe that thisdevicerepresentsasignificantaddi-tiontothesurgeon’sarmamentari-uminthefieldofcardiacablation.”
TheCOBRAFusion is theresultofseveralyearsofresearchandde-velopment and has been exten-sivelytestedinseveral labsinclud-ing theprestigious research labatWashington University in St. Lou-is. Ralph J. Damiano, M.D. stat-ed: “We have evaluated this newdevice inouranimal labandwerevery impressed with the results. Itisaninnovativedevicethathasthepotentialtofacilitateminimallyin-vasive surgical ablation. It is like-ly toadvance thefieldby improv-inglesionformationonthebeatingheart.”
Estech Launches Next Generation Technology, the COBRA Fusion™ System for Surgical Cardiac Ablation
Cardiac: Abstract 08:15–09:45 Room 112
Lenard Conradi Department of
Cardiovascular Surgery, University
Heart Center Hamburg, Germany
Surgicalmitralvalverepair(MVR)iscur-rentlythereferencetreatmentforsymp-
tomaticseveremitralregurgita-tion(MR).Duetolowperiop-erativemorbidityandmortality,MVRmayevenbeconsideredinasymptomaticpatients.Im-plementationofminimally-in-vasivesurgicaltechniqueshasdecreasedsurgicaltraumaandfurtherenhancedpostopera-tiverecovery.Inpatientswithventriculardysfunctionandsec-ondaryfunctionalMRhowever,themeritsofcorrectivemitralvalvesurgerymaybemoream-biguousandasurvivalbene-fithasnotbeendemonstratedtodate.Inaddition,asubstan-tialshareofpatientswithse-vereMRisnotbeingreferredforsurgeryduetoperceivedhighsurgicalrisk.Frequently,theseareelderlypatientswithrelevantcomorbidities,reducedleftventricularfunctionandfunctionalMR.Itisforthesepatientsthatpercutaneoustreatmentoptionsmaybeanadequatealternative.
Surgical or percutaneous mitral valve repair for functional mitral regurgitation – comparison of patient characteristics and clinical outcomesInthefirstoftwostudieswesoughttoretrospectivelyan-alyzeourprospectivehospitaldatabaseofpatientswithse-verefunctionalMRundergoingeithersurgicalMVRorpercuta-neoustreatmentusingtheMi-traClipdevice.Patientsunder-goingMitraCliptreatmentweresignificantlyolder(p<0.001),hadalowerleftventricularejectionfraction(p=0.014),andweregenerallymorehigh-risk,withasignificantlyhigher
meanlogEuroSCOREIcom-paredtosurgicalcandidates(p<0.001).30-daymortalitywas4.2%and2.6%(p=0.557)andmeangradeofresidualMRwas1.4±0.8and0.2±0.4(p<0.001)afterMitraCliptreat-mentandsurgicalMVRrespec-tively.Unadjustedsurvivalrateaftersixmonthswassignifi-cantlylowerinMitraClippa-tients.However,aftermulti-variateregressionanalysisandadjustmentforbaselinediffer-ences,survivaldifferenceswerenolongerstatisticallysignificant(p=0.358)underscorestheob-viousimpactoffundamentallydifferentpatientdemographicsonclinicaloutcomeamongthetwocohorts.
Towards an integrated approach to mitral valve disease – implementation of an interventional mitral valve program and
its impact on surgical activityInthissecondstudy,weas-sessedtheimpactofprovid-inganinterventionalmitralvalveprogramusingtheMitra-Clipdeviceonsurgicalmitralvalveactivity.Inthisanalysisweaimedtoanswerthefollowing
questions:1. What is the development of mitral valve surgical activ-ity after introduction of an interventional mitral valve program?From2007to2010,860con-secutivepatientsunderwentmi-tralvalvesurgeryforisolatedorcombinedproceduresatourcenter.Asteadyincreaseinthesurgicalcaseloadwasobservedovertheyearscontinuingde-spiteimplementationofanin-terventionalmitralvalvepro-graminMarch,2008(figure1a).Thisincreasewassignifi-cantlyhighercomparedtothenationalbackground(figure1b).2. Is there a change in the spectrum of surgical pa-tients regarding baseline de-mographics and risk factors?Eventhoughoverallriskpro-fileasestimatedbylogEuro-SCOREIwassimilarbeforecomparedtoafterimplementa-tionofaninterventionalmitral
valveprogram,thereweresev-eralimportantdifferencesbe-tweenthetwocohorts:theeti-ologyofMRindicatingsurgerychanged,especiallythepropor-tionofsurgicalcandidatespre-sentingwithfunctionalMRde-creasedsignificantly(p<0.001).Also,therewerefewerpatients
withcoronaryarterydiseaseandhistoryofmyocardialinf-arction(p<0.001).Finally,theshareofpatientsundergoingre-docardiacsurgerydecreasedsignificantly(p<0.001).3. How are surgical and in-terventional mitral valve pa-tients different?Regardingalmostallvaria-bles,interventionalmitralvalvepatientsweremorehighriskcomparedtosurgicalcandi-dates,culminatinginmeanlo-gEuroSCOREIof30.4±19.0%and9.6±10.7%respectively(p<0.001).Also,etiologiesofMRindicatingtreatmentweresignificantlydifferentbetweenthetwocohorts.Whileinter-ventionalpatientsweretreatedpredominantlyforfunctionalormixedMR,surgerywasper-formedfordegenerativedis-easeinapproximatelytwothirdsofcases(p<0.001).4. What is the outcome of surgical mitral valve pa-
tients before compared to after introduction of an in-terventional mitral valve program?Predictedperioperativemortal-ityofsurgicalpatientsasstrat-ifiedbylogEuroSCOREIre-mainedsimilarduringthestudyperiod.Crude30-daymortal-
ityhoweverdecreasedmark-edlyfrom7.2%to4.8%,eventhoughthistrenddidnotreachstatisticalsignificanceinthissingle-centerstudywithlim-itedpatientnumbers.30-daymortalityforpatientsunder-goingisolatedMVRwas1.7%(5/303)inallpatientsduringthestudyperiod.
AttheUniversityHeartCenterHamburgwestronglybelieveinaninterdisciplinaryapproachtovalvularheartdis-ease.Decision-makingshouldbeajointeffortbyadedicated‘HeartTeam’consistingofcar-
diologistsandcardiacsurgeons.Interdisciplinaryassessmentofpatients,selectionoftheap-propriatetypeoftreatment,performingtheprocedureandpost-proceduralcareshouldbeasharedtask.Forus,thispolicyiskeyforclinicalsuccessandoptimalpatientoutcomes.
Mitral valve disease: surgery or intervention?
Lenard Conradi
Development of surgical and interventional mitral valve acitivity (a) and comparison to the nationwide development (b). UHC University Heart Center Hamburg, GSTCVS German Society for Thoracic and Cardiovascular Surgery.
About EstechEstechdevelopsandmarketsaportfolioofinno-vativemedicaldevicesthatenablecardiacsur-geonstoperformavarietyofsurgicalprocedures,whilespecializinginminimallyinvasiveandhybrid
ablation.Thecompany’sCOBRAlinecomprisesanumberoffirst-evertechnologiesinvented,devel-oped,andbroughtexclusivelytothecardiacabla-tionmarketbyEstech.Theseincludetemperature-controlledRFenergydelivery,Versapolar™devices
thatprovidebothbipolarandmonopolarener-gy,suction-appliedtissuecontact,andinternally-cooleddeviceswhichprovidesuperiorablationper-formancecomparedtootherablationsystems.Formoreinformation,pleasevisitwww.estech.com
12 Monday 29 October 2012 EACTS Daily News
10:30 Doestheuseofolddonorgraftshaveaneffectonmorbidityandmortalityinhearttransplantation?practicalimplications P. Farahmand, C. D’Alessandro, P. Demondion, S. Varnous, M. Laali, P. Leprince, A. Pavié (France)Discussant: J. L. Pomar (Barcelona)
10:45 Six-yearoutcomesfollowinghearttransplantation:effectofpreservationsolutiononsurvivalandrejection A. Cannata, L. Botta, T. Colombo, F. Macera, G. Masciocco, F. Turazza, M. Frigerio, L. Martinelli (Italy)Discussant: A. Simon (Harefield)
11:00 Cardiactransplantationwithnon-heart-beatingdonors:haemodynamicandbiochemicalparametersatprocurementpredictrecoveryfollowingcardioplegicstorageinaratmodel. M. Dornbierer, J. Sourdon, S. Huber, B. Gahl, T. Carrel, S. Longnus, H. Tevaearai (Switzerland)Discussant: T. Wahlers (Cologne)
11:15 High-riskdonorsinhearttransplantation:arewepushingtoofar? A. Aliabadi, M. Groemmer, F. Eskandary, T. Haberl, O. Salameh, D. Wiedemann, G. Laufer, A. Zuckermann (Austria)Discussant: J. Dark (Newcastle upon Tyne)
11:30 Primarygraftdysfunctionversusprimarygraftfailure:areallgraftproblemscreatedequal? A. Zuckermann, A. Aliabadi, D. Wiedemann, T. Haberl, O. Salameh, M. Groemmer, F. Eskandary, G. Laufer (Austria)Discussant: A. Pavié (Paris)
11:45 Sessionends
Focus Session
How to optimize transcatheter aortic valve implantation outcomes
Rooms 122/123
Moderators: A. Vahanian, Paris; V. Falk, Zürich
10:15 Whichvalveforwhichannulussize N. M. D. A. van Mieghem (Rotterdam)
10:30 Valvepositioninganddeployment(TheBerlinaddition) M. Pasic (Berlin)
10:45 Percutaneousvalveleakassessment(withechocardiographynewValveResearchConsortiumdefinition) A. P. Kappetein (Rotterdam)
11:00 Analternativeaccessapproach P. Etienne (Brussels)
11:15 Apicalaccessandclosure T. Walther (Bad Nauheim)
This session is supported with an unrestricted educational grant from Edwards Lifesciences
11:45 Sessionends
The Presidential Address Rooms 116/117
11:50 Thecontraindicationsoftodayaretheindicationsoftomorrow L. Von Segesser, Lausanne
12:30 Lunch
Abstracts
14:15 Euroscore II: refining risk assessment
Rooms 116/117
Moderators: P. Sergeant, Leuven; W. Gomes, São Paulo
14:15 DevelopmentofEuroSCOREII S. Nashef (Cambridge)Discussant: D. Pagano (Birmingham)
14:30 ComparisonoftheEuroscoreIIandSocietyofThoracicSurgeons2008risktools B. Kirmani, K. Mazhar, M. Pullan, B. Fabri (United Kingdom)Discussant: M. Mack (Dallas)
14:45 EuroscoreIIdoesnotimprovepredictionofmortalityinhigh-riskpatients:astudyfromtwoEuropeancentres N. Howell1, S. Head2, E. Senanayake1, A. Menon1, N. Freemantle1, T. Van Der Meulen2, A. P. Kappetein2, D. Pagano1 (1United Kingdom, 2Netherlands)Discussant: J. J. M. Takkenberg (Rotterdam)
15:00 ComparisonoforiginalEuroscore,EuroscoreIIandSTSriskmodelsinanelderlycardiacsurgicalcohort A. Kunt1, M. Kurtcephe2, M. Hidiroglu1, L. Cetin1, A. Kucuker1, V. Bakuy1, A. R. Akar1, E. Sener1 (1Turkey, 2United States)Discussant: P. Sergeant (Leuven)
15:15 IsthenewEuroscoreIIabetterpredictorfortransapicalaorticvalveimplantation? M. Haensig, D. Holzhey, M. Borger, S. Subramanian, G. Schuler, W. Shi, A. Rastan, F. Mohr (Germany)Discussant: J. Obadia (Lyon-Bron)
15:30 Thefutureofriskscoring B. Bridgewater (Manchester)
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Jörg Kempfert
Kerckhoff Clinic, Bad Nauheim, Germany
IthasbeenoneyearsinceSymetisS.A.debuteditsnewly-approvedACURATETAAorticBioprosthesisandDeliverySystem.Theproduct
waslaunchedcommerciallyinLisbonduringtheEACTS2011AnnualMeet-ingandsincethenover200implanta-tionsofthemarketeddevicehavebeenperformedinEuropeandSouthAmer-ica.ACURATETAisdesignedspecifi-callyfortransapicalaccessandisavail-ableinthreesizestotreatannulusdiametersof21mmto27mm.Thebi-oprosthesisiscomposedofaself-ex-pandingnitinolstenthousingaregularporcinetissuevalve.AfullprofileofthedesignandfunctionoftheACURATETAwillbepresentedatEACTS2012duringtheSymetislunchsymposiumheldonMonday,October29at12:45inrooms129/130.
Today,theACURATETAhasestab-lisheditselfasanalternativetofirstgenerationTAVRsystemswithitscom-parablesafetyandefficacyprofileasshownintwoclinicaltrials.At12monthsfollow-up,pooleddatafromthepre-approvalstudies(n=90)showasurvivalrateof80.0%withnegligibleparavalvularleakrates(leakabove+1inonlytwopatients).
AnimportantcharacteristicoftheACURATETAthatsetsitapartfromthecompetitionisitseaseofuse.Forsec-ondgenerationTAVRsystemstobesuccessfultheymustbeeasiertousethanthefirstdevicesonthemarket.TheACURATETAisaverysimple-to-usedevice:atruesingle-operatorsys-temwithasmall,simplevalveloaderandafaciletwo-stepimplantationpro-cedurethatincludesnotonlyvisualmarkersbuttactilefeedbackguaran-teeingcorrectplacementinthenativeannulus.Itsself-seatingandconform-ablearchitectureallowsforperfectpo-
sitioningwithintheanatomyoncetheproductisdeployed.Thiseaseofuse,coupledwithashortoperatorlearningcurve,translatesintogoodresultsandsafeoutcomesforpatients.
Thetwo-stepimplantationsequencebeginsafterthedeliverysystemhascrossedthenativevalveandanatomicalandcommissuralalignmentisachievedusingtheradio-opaquemarkersandstentposts.
Steponestartsbyturningthereleaseknobuntilthestabilizationarchesanduppercrownareopened.TheoperatormaypullgentlytowardtheLVfortactilefeedbackthatcorrectpositionisachievedandthenativeannulusis“capped”.Atthispointthedevicecanberesheathedifrepositioningisrequired.
Steptwocommenceswithremovalofthesafetybutton(whichinhibitsprema-turedeployment)andtheoperatorcon-tinuestoturnthereleaseknobuntilthelowercrownisopenedandthebiopros-
thesisisfullydeployed.Retrievalofthedeliverysystemcanthenbeperformed.
Briefproceduretimes,onaveragefourminutesfromtransapicalintro-ductionofthedeliverysystemtore-trievalafterimplant,alsodistinguishestheACURATETAfromthecompetition.Proceduresuccessratesof94.4%inpre-marketclinicaltrialsand98.7%in
commercialimplants,attesttothede-vice’seaseofuse.
Withitssuccessfulfirstyearonthemarketandagrowingdemandforthedevicebythecardiovascularsurgicalcommunity,itsnosurprisetheACU-RATETAhasbecomeanattractive,al-ternativeoptionfortreatinghigh-riskpatientswithsevereaorticstenosis.
Ease of use and procedure success redefined
Vascular: Professional Challenges 08:15–09:45 Room 113
Jean Bachet Senior Consultant Surgeon, Zayed Military
Hospital, Abu Dhabi, UAE.
Surgeryoftheaorticarchhastodealwithseveralimportantissues:Theapproachofthearch,thetypeofcardiopulmonaryby-pass,theprotectionofthecerebralstruc-
turesandthereplacementofthediseasedaortaitself.So,duringseveraldecades,ithasbeenconsidered
asadifficultchallengeassociatedwithimportantmor-talityandmorbidityratesbeforeitbecamemuchsim-pler,muchsaferandmuchmorereliablethroughim-portantprogressesaccomplishedoneachofthosematters.
Forexample,cannulationofthefemoralarterywassystematicforallkindofaorticprocedures.Yet,someyearsago,itappearedthatthisissuecouldinfluencesignificantlythesurgicalresultsandthatthechoiceofaproperarterialcannulationsitewasanintegralpartofthesurgicalstrategy.Thistechniquehas,thus,lostitsmostprominenthegemonyandmanygroupshaveturnedtoothermodesofcannulation.
Conversely,cannulationoftherightaxillaryartery,althoughlesseasy,provedtohavenumerousadvan-tages.ItallowsfullantegradearterialinflowduringthewholedurationofCPBandselectiveantegradeperfusionofthebrainduringthearchrepairandcir-culatoryarrest.TheInnominatearterycannulationhasexactlythesameadvantages.
Cerebralprotectionappearedtobeakeyfactorinthequalityoftheresultsobtained.
Describedin1975byGriepp,theuseofprofoundhypothermiaassociatedwithtotalcirculatoryarresthadbecomerapidlyanduniversallyaccepted.Butgrowingevidencesofthelimitationsofthismethodalsorapidlycameout.Thiswasalsothecaseforthe“retrogradeperfusion”method.Itseemedtobeagoodidearapidlyadoptedbutmanyexperimentalstudiesandclinicalreportsdemonstratedthatitwas
notverysafeandreliable.Becauseofthosedisappointingexperiences,meth-
odsofSelectiveAntegradeCerebralPerfusion(SACP)weredescribed.Thosetechniquesrepresentedarealbreakthroughandwererapidlysupportedbyseveralundisputableexperimentalandclinicalstudiesprov-ingtheirsuperiorityovertheotherknownmethods.Inparticular,intheirmanyversions,theyallowedtogetridofthedrawbacksofprofoundhypothermiawhilekeepingtheadvantagesofcirculatoryarrestandpro-vidinganalmostunlimitedtimetoperformtheaor-ticrepair.
Similarly,thetechniquesforreplacingtheaorticarchitselfbecamenumerous.
Bloodtightdistalanastomoses,whenperformeddi-rectly,end-to-end,couldbeperformedsafelywiththeuseofreinforcingadjunctseventhoughinchronicle-sions,theaorticwallisgenerallysolidenoughtoallowtightsutureswithouttheaidofreinforcingartefacts.
The“Elephanttrunk”techniquedescribedbyBorstin1983representedanothergreatstepforwardal-lowingeasyandsafedistalanastomosisandmak-ingsecondstageoperationsonthedescendingaortaeasier.Itwasfollowedsomeyearsagobythetech-niqueof“Frozenelephanttrunk”whichseemsex-tremelypromising,inparticularinpatientswithacuteorchronicdissections.
Last,butnotleast,reimplantationofthethreeves-selsmaybeperformedinmanyways,either“enbloc”or“separately”usingindustriallypreparedprosthe-sesavailableonthemarketorwith“homemade”graftssuchasinthe“trifurcatedarchgraft”tech-nique.Complexmodesofreimplantationofthesupraaorticvesselslikethe“arch-first”techniquehavebeensuccessfullydescribed.Allhaveadvantagesanddraw-backs.Aswellasdependingonthelocation,typeandcauseoftheaneurysm,theydependonthepersonalpreferencesandhabitsofthesurgicalteam,thelocalsurgicalcultureandtheexperiencedeveloped.
Allthosemoreorless“conventional”techniquesarepresentlychallengedbynew“hybrid”approaches.Thosecombinetheimplantationofextra-anatomicbypassestothesupra-aorticvesselswithendovascu-larstent-graftingoftheaorticarch.Theymightmakeeasiersomeproceduresandallowbroadeningtheirin-dications.Yet,thosetechniquesof“debranching”arestillquestioned.AsstatedbyKarckinarecentreview:«thisnovelmodalitymightreduceoperativemortalityandmorbidityincludingmajorstroke.Atpresent,thesummarizedmortalityisnotlessthancalculatedaftertheconventionalorfrozenelephanttrunktechnique.Sofarthistechniquemightbecomeameaningfulal-ternativeafterfurthertechnicalevolution.Atpresenttheindicationofthismethodshouldbestronglylim-itedtootherwiseinoperablepatients.»Westronglyagreeandweremainconvincedthatthe“conven-tional”techniquesofreplacingthearchstillrepresentthe“goldstandard.”
State of the art in aortic arch surgery
Jean Bachet
Place loader (above) and delivery (below)
Step one: self alignment Step two: controlled deployment
14 Monday 29 October 2012 EACTS Daily News
Cardiac: Abstracts 08:15–09:45 Room 114
Ingo Kutschka Department of Cardio-Thoracic,
Transplantation and Vascular Surgery, Hannover Medical
School, Hannover, Germany
Theincidenceofearlypostoperativeperma-nentpacemaker(PPM)implantationafteriso-latedaorticvalvereplacement(AVR)is3-8.5%.Sofar,thereislittleevidenceabout
long-termPPMdependencyofpatientsthatrequiredPPMimplantationfollowingcardiacsurgery.
Inthisstudywefocusedonpatientswhoreceivedisolatedaorticvalvereplacementandearlypostopera-tivePPMimplantationduetoconductiondisturbancesinourinstitution.Weaimedtodeterminethelong-termoutcomeandPPMdependencyofthesepatients.
Furthermore,weaimedtoidentifypredictorsforlong-termpacemakerdependencyinordertoavoidunnecessaryPPMimplantationsandtodecideforearlyPPMimplantationinselectedpatients.LiberalPPMim-plantationmaybeinefficientandposespatientstoanavoidableriskofcomplications.Ontheotherhand,adelayedimplantationincreasesmorbiditybyimmobili-zationandtheriskforsuddendeathcausedbyunpre-dictableconductiondisorderswithoutsufficientven-tricularescaperhythm.Toourknowledgethecurrentstudyisthefirstonethatanalysedlong-termPPMde-pendencyafterisolatedAVR.
SinceJanuary1997atotalof2106consecutivepa-tientsunderwentisolatedAVRatourinstitution.Outofthese,138patients(6.6%,72female,meanage71±12years)developedsignificantconductiondisordersleadingtoPPMimplantationwithinthefirst30dayspostoperatively.PreoperativeECGshowednormalsi-nusrhythm(n=64),AVblockI°(n=19),leftbun-
dlebranchblock(LBBB,n=13),rightbundlebranchblock(RBBB,n=16),leftanteriorhemiblock(LAHB,n=14)andAVblockwithventricularescaperhythm(n=10).Atrialfibrillationwaspresentin23patients.Pacemakerswereimplantedafter7±6daysfollow-ingAVR.PPMdependencywasanalyzedbyECGandpacemakercheckduringfollow-up.
Atotalof45outof138AVRpatientswithpost-operativePPMimplantationdiedduringameanfol-low-uptimeof5.3±4.7years.Furtherninepatientswerelosttofollow-up.Long-termsurvivalat1-,5-,and10yearswas88%,79%and59%,respectively.Onlyeight(10%)outof84survivorswerenotpace-makerdependentanymore.Themajorityofpatients(n=66,87%)requiredpermanentventricularstim-ulation,theremaining10patients(13%)showedintermittentstimulationwithameanventricular
stimulationfractionof73±30%.Theunivariateanalysesdidnotidentifyanyassociationofpre-orperioperativeparameterswithlong-termPPMde-pendency.
SinceAVconductiondisordersafterAVRdidnotre-coverinthemajorityofourpatients,werecommendearlyimplantationofpermanentpacemakersinthesepatients.ThemainbenefitsofearlyPPMimplantationincludetimelymobilizationandrecovery,shorterICUstayaswellasearlierdischargefromhospital.Theriskofsuddendeathduetoasystole,AVblockordrugin-ducedarrhythmiascouldbesignificantlyreducedintheearlypostoperativeperiod.Furthermore,earlyPPMimplantationiseconomicallyreasonable,consideringthelowPPMassociatedcomplicationrates,fasterre-coveryrates,shorterhospitalstayandfallingpricesofpacemakerdevices.
Pacemaker dependency after isolated aortic valve replacement – do conductance disorders recover over time?
Ingo KutschkaCaption
15:45 Sessionends
Abstracts
14:15 Refining techniques in minimally invasive mitral valve surgery
Room 115
Moderators: T. Folliguet, Paris; M. Glauber, Massa
14:15 Minimallyinvasivemitralvalvesurgery:influenceofaorticclampingtechniqueonearlyoutcomes A. Mazine, D. Bouchard, H. Jeanmart, J. Lebon, M. Pellerin (Canada)Discussant: M. Kolowca (Rzeszow)
14:30 Mitralvalvepathologyinseverelyimpairedleftventriclescanbesuccessfullymanagedusingaright-sidedminimallyinvasivesurgicalapproach J. Garbade, J. Seeburger, M. Barten, S. Lehmann, B. Pfannmüller, M. Misfeld, M. Borger, F. Mohr (Germany)Discussant: E. Ferrari (Lausanne)
14:45 Non-inferiorityofminimallyinvasivemitralrepairversusmediansternotomyforBarlow’sdisease:three-yearclinicalresults G. Nasso, V. Romano, K. Fattouch, R. Bonifazi, G. Visicchio, N. Di Bari, G. Balducci, G. Speziale (Italy)Discussant: R. Stuklis (Adelaide)
15:00 Useofautomaticknot-tyingandcuttingdeviceisshorteningaorticcross-clamptimesinminimallyinvasivemitralvalvesurgery B. Gersak, B. Robic (Slovenia)Discussant: F Van Praet (Aalst)
15:15 Minimallyinvasivemitralvalvereconstructiononthefibrillatingheartisanattractivesurgicalstrategyforhigh-riskpatients J. Kilo, E. Ruttmann, H. Hangler, M. Grimm, L. Müller (Austria)Discussant: F. Siclari (Lugano)
15:30 Antegradeandretrogradearterialperfusionstrategiesinminimallyinvasivemitralvalvesurgery:apropensityscoreanalysison1280patients M. Murzi, A. G. Cerillo, A. Miceli, E. Kallushi, G. Bianchi, S. Bevilacqua, M. Solinas, M. Glauber (Italy)Discussant: G. Wimmer-Greinecker (Bad Bevensen)
15:45 Sessionends
Focus Session
14:15 The front door approach: the role of the surgeon in selecting the best patient-specific access route
Room 112
Moderators: F. Mohr, Leipzig; L. Van Garsse, Maastricht
14:15 Introductionandobjectives F. Mohr (Leipzig)
14:20 Thetransapicalapproach:asafetechnique M. Pasic (Berlin)
14:30 Newtransapicaldevicesinperspective H. Treede (Hamburg)
14:40 Willthetransapicalapproachbecomeapercutaneousprocedure?Outlookonnewtransapicalcompaniondevices J. Kempfert (Leipzig)
14:50 Acardiologistperformingtransapicalandtransfemoraltranscatheteraorticvalveimplantation H. Möllmann (Bad Nauheim)
15:00 Dispellingmythsaroundresultsofthetransapicalapproach:beyondthelearningcurveinthePARTNERtrial A. P. Kappetein (Rotterdam)
15:10 Alternativesurgicalaccess:transaorticandsubclavian V. Bapat (London)
15:20 Transapicaltranscatheteraorticvalveimplantationinperspective T. Walther (Bad Nauheim)
This session is supported with unrestricted educational grants from Edwards Lifesciences, JenaValve Technology GmbH, Medtronic International Trading Sàrl and Symetis S.A.
15:45 Sessionends
Abstracts
16:15 Late-breaking trials I
Rooms 116/117
Moderators: O. Alfieri, Milan; G. Laufer, Vienna
16:15 TheEngagertransapicalaorticvalveimplantationsystem:firstresultsfromthemulticentreEuropeanPivotalTrial H. Treede1, S. Baldus1, A. Linke1, D. Holzhey1, S. Bleiziffer1, J. Börgermann1, J.-L. Vanoverschelde2, V. Falk3 (1Germany, 2Belgium, 3Switzerland)Discussant: N. Moat (London)
16:30 Coronaryarterybypassgraftingversuspercutaneouscoronaryinterventionina“real-world”setting:insightsfromtheCooperation
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Alan Sihoe Queen Mary Hospital,
Hong Kong SAR, China.
Primum non nocere. First do no harm.
Surgeryisinherentlytraumatictothepatientandhasthepotentialtocauseharm.Asstudentsand
trainees,wehaveallbeentaughtthattheremustbeastrongindicationforoperatingbeforesubmittingthepatienttomajorsurgery.
Whenoperatingonasolitarypulmo-narymasssuspiciousoflungcancer,thetraditionalsurgicalapproachwouldhavebeenviaanopenthoracotomy.Thisofcourseisnowrecognizedasaparticularlypainfulapproachwhichhasthecapacitytocauseconsiderablemorbidity.There-fore,establishedwisdomdictatesthateveryeffortshouldbemadetoconfirmadiagnosisofmalignancybeforetakingthepatienttotheoperatingroom.
However, the world is changing.Today,theincidenceofpatientsbe-ingfoundtohaveasuspiciouslungmassisrapidlyincreasing.Thishasbeenbroughtaboutbyacombinationofmanyfactors,including:increasingpub-licawarenessofhealthissues;unprece-dentedaccesstoscreeningservices;andmodernadvancesinradiologicalimag-ing(includingincreasinguseofPosi-tronEmissionTomography).Thepoten-tialbenefitintermsofdetectingearlierstageddiseaseis,however,counter-bal-ancedbyanincreasedburdenondi-agnosticservicestoinvestigatetheselesions–suchasbronchoscopyorimag-ing-guidedpercutaneousbiopsy.Thereisemergingevidencesuggestingthatpresentation-to-diagnosisandpresenta-tion-to-treatmentintervalsmayalreadybeincreasinginrecentyears.Moreo-ver,evenifpre-operativediagnosticin-vestigationsareperformed,theymay
notyieldapositivediagnosisinasignif-icantproportionofpatients.Forthesepatients,thewaitforthediagnostictestwouldhavebeeninvain,andsurgicalbiopsywillstillberequired.
Ontheotherhand,VideoAssistedThoracicSurgery(VATS)hasalreadybeenestablishedasasafe,low-mor-bidityapproachforthediagnosisofmanythoracicconditions,includingsolitarylungnodules.IfthetraumaofthoracotomyisnegatedbyVATS,canthethresholdsforbringingthepatienttotheoperatingroombesafelylow-ered?ThemodernsurgeonhastheoptionofperformingaVATSbiopsyofthesuspiciouslungmass,send-ingthetissueforfrozensectionanal-ysis,andthenproceedingtosurgeryiflungcancerisconfirmed.Byforegoingpre-operativediagnosticservicesalto-getherinthisway,willthishelpmini-mizepresentation-to-treatmentinter-
valsandbenefitthepatient?Thecounter-argumentisthatpro-
ceedingstraighttosurgeryasarou-tinestrategymayinvolveoperatingonalargenumberofpatientswithbenigndiseasethatwouldnothaverequiredsurgeryatall.Regardlessofhowmini-mallyinvasivethatsurgeryis,isitsafeorethicaltobesubjectingpatientstoapolicyofwantonsurgery?Inthiseraofincreasingincidenceofsuspiciouslunglesionsbeingfound,thethoracicsur-geonmustconfrontthisimportantclin-icalconundrum:isitstillworthwaitingforadiagnosisbeforeofferingsurgery?
IntheThoracicOncologyIsession(8:15AM-9:45AMonMonday,Octo-ber29),DrAlanSihoewillbepresent-ingastudyfromHongKonglookingattheprosandconsofoperatingforasuspiciouslungmasswithoutapre-operativelyconfirmedtissuediagnosis.Delegateswillbewelcometoshareex-periencesandopinionsonthisissueofrapidlygrowingclinicalrelevance.
Thoracic: Abstracts 08:15–09:45 Room 133/134
Diagnosis of a suspicious lung mass before operating: Is it worth waiting for ?
An increasingly common scenario: incidental finding of a small pulmonary nodule or ground-glass opacity suspicious of malignancy
Alan Sihoe
16 Monday 29 October 2012 EACTS Daily News
Paul P. Urbanski Cardiovascular Clinic,
Bad Neustadt, Germany
Althoughtheresultsofopenaorticarchsurgeryhaveimproveddra-maticallyinthelastdecade,thisprocedureisstillconsideredhigh-
risk.Unfortunately,theresultsfromthe90soreventhe80sarefrequentlyusedtosup-porttheargumentationthattheuseofex-tracorporealcirculationanddeephypother-miccirculatoryarrest,whichareneededforopenarchsurgery,leadtoincreasedmortal-ityandmorbidity.Hence,thoracicendovas-cularaorticrepair(TEVAR)ofaorticarchpathologies,whichiscombinedasahy-bridprocedurewithbypassingorre-routing(alsocalleddebranching)ofsupra-aorticar-teries,hasbeenproposedrecently.
Avoidingopensurgeryinpatientswithaorticarchpathologyisseldompossiblebe-causeitismostlycombinedwithpathol-ogyoftheascendingaortaanditisthere-forenotsurprisingthatinthelastreportfromtheTranscontinentalRegistryabouttotalarchre-routing,almost60%ofpa-tientsrequiredtheuseofCPB.Evenanaor-ticarchaneurysmthatseemstobeisolatedisfrequentlycombinedwithatherosclerosisandcalcificationsthatarespreadoutintheentireproximalaorta(Figure1).Giventhattheproximalaortaisamainsourceofcer-ebrovascularembolism,notonlyatangen-tialclampingoftheascendingaortashould
beavoidedinsuchcasesbutitscompletereplacementisevenindicated.Therefinedtechniqueofconventionalaorticarchre-pair,althoughmoreinvasiveinsomecases,providesdefinitiverepairwithexcellentclin-icalresultsandoffersthepossibilitytore-pairconcomitantcardiacpathologiessimul-taneously(Figure2).Aorticarchpathologyisveryfrequentlyassociatedwithanaorticvalvedefect,and,becauseitismostlypureinsufficiency,avalve-sparingsurgerycanbeperformed.Inourseries,87%ofthepa-tientsneededaorticvalveand/orrootsur-geryconcomitantlytoarchrepair,andthevalvecouldbepreservedinmorethanhalfofthem.EvenifthereisnodoubtthatdeephypothermiaaswellasCA,CPB,andsur-gerytimesaretheclearpredictorsofanin-creasedriskincardiovascularsurgery,theavoidanceofdeephypothermiaandcon-siderableshorteningofalltheseaspectsmentionedabovecouldbeachievedbytherecentimprovementsofsurgicalandper-fusionstrategies.Ourstudydemonstratesthatconventionalarchsurgeryoffersdefin-itiverepairand,ifperformedusingcurrentperfusionandoperativetechniques,leadstoexcellentresultswithverytolowmortal-ityandmorbidity.Opensurgeryensuressi-multaneousaorticvalverepair,whichisfre-quentlynecessary,andcanbeperformedbyreconstructioninmorethanhalfofthecases.Useofrefinedsurgicaltechniqueswithcerebralperfusionallowsavoidance
ofdeephypothermiawithallitsnegativesideeffectsandleadstoexcellentoutcomesagainstwhichtheresultsofalternativeap-proachesshouldbecompared.
Michele De Bonis
Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
Degenerativemitralregurgitation(MR)duetocommissuralchordalruptureorelongationhasbeencorrectedwithseveraldifferentsurgicalmethodsincludingneochordaeimplantation,chordaltransposition,extendedleafletslidingtechnique,papil-
larymusclerepositioning,replacementofthecommissuralareabyapar-tialmitralhomograftorbytheposteriorleafletofthetricuspidvalve.Theabsenceofauniqueandstandardizedapproachinthiscontextdemon-stratesthechallengingfeatureofcommissuralMR.Theedge-to-edgeap-proximationoftheanteriorandposteriormitralleafletsatthecommis-sure(commissuralclosure)hasbeenusedinthiscontextasa“functional”
ratherthan“anatomical”repair.Unlikethesurgicalproceduresmentionedabove,whichcanbedemandingforanumberofreasons,sutureclosureofthecommissurefollowedbyannuloplastyeliminatescommissuralmitralinsufficiencysimplyandrapidly.Asingle,standardizedandeasilyrepro-ducibleapproachwhichcanbeemployedtotreatanterior,posteriorandbileafletprolapseatthislevel.Inthisstudyweassessedthelongterm(upto15years)clinicalandechocardiographicresultsofthismethodin125patientswithdegenerativeorpost-endocarditisprolapseorflailofthean-terior-lateral(23.2%)orposterior-medial(76.8%)commissure.Hospitalmortalitywas1.6%.Athospitaldischarge,MRwasabsentormildin120(97.5%)patientsandmoderate(2+/4+)in3(2.4%).Clinicalandechocar-diographicfollow-upwas98.4%complete(meanlength7.1±3.0years,median6.7years,longestfollow-up15years).At11yearsfreedomfrom
reoperationwas97.4±1.4%andfreedomfromMR≥3+96.3±1.7%.Atthelastechocardiographicexam,MR≥3+wasdemonstratedinonlyfourpatients(4/121,3.3%).Meanmitralvalveareaandgradientwererespec-tively2.9±0.4cm2and3.4±1.1mmHg.NYHAfunctionalclassIorIIwasdocumentedinallcases.Suturingbothleafletstogetherseemstochal-lengefundamentalsurgicalconceptsinmitralrepairandraisesanumberofquestionsabouttheriskofinducingmitralstenosis,thedegreeofim-pairmentofmitralleafletmotionandtheoveralllong-termdurability.However,accordingtoourlong-termresults,thesupposeddrawbacksandrisksofthistechniquearemoretheoreticalthanpractical.Similarlytowhathasbeenreportedbyothergroups,wedidnotexperienceanysig-nificantrestriction,suturedehiscenceorrecurrentprolapseatthesiteofrepair.Theabsenceofmitralstenosiswasconfirmedbythelowtransval-vularpressuregradientsrecordedimmediatelyaftersurgeryandatthelastechocardiographicfollow-up.Long-termdurabilityoftherepairandclini-calconditionsofthepatientswerebothexcellentupto15yearsaftertheoperation.Becauseofitssimplicityanddurabilitycommissuralclosurere-mainsthemethodofchoicetocorrectisolatedcommissuralmitralvalveregurgitationinourInstitution.Thisreliableandeasilyreproducibletech-niquemighthopefullyincreasethenumberofreconstructiveproceduresperformedinthissetting.
Open aortic arch replacement in the era of endovascular techniques
Is commissural closure for the treatment of mitral regurgitation durable? A long-term (up to 15 years) clinical and echocardiographic study
Paul Urbanski
Figure 1
Figure 2
Vascular: Professional Challenges 08:15–09:45 Room 113
Cardiac: Abstracts 08:15–09:45 Room 112
The Hybrid Stent Graft System E-vita open plusTheE-vitaopenplushybridstentgraft
systemcombinessurgicalvascularre-constructionwithmodern,minimallyin-vasiveaorticstenting.Thisuniquepros-thesis simplifies previous therapeutictechniqueswhichimposeaseverestrainonthepatientswiththeirtwo-stagepro-cedureandinvasiveness.ByusingE-vitaopenplus, theoperativeprocedurecanbereducedtoasingleinterventionfromwhichbothpatientandsurgeon,benefitinequalmeasure.
E-vitaopenplusallowsthesocalledoptimized“FrozenElephantTechnique”technique.Thistechniqueenablestreat-mentofcomplex lesionsof thethorac-icaortaduringasingle-stageprocedurecombining the endovascular stentingof the descending thoracic aorta withconventional surgery using the con-ceptoftheelephanttrunk.Aftermedi-ansternotomyandundercirculatoryar-restthearchisopened.TheE-vitaopenplusstentgraft system is introduced inan antegrade fashion in the aorta de-scendensoverthepreviouslyplacedstiffguidewire.
By using of the safe and preciseSqueeze-to-Release deployment mech-anismthehybridstentgraftcanbede-ployed. After surgical fixation of thestent graft portion by a circumferentialsuturelinetheinfoldedsurgicalcuffcanbeeasilyevertedandsuturedtoanothervasculargraftorusedfortheaorticarchreconstruction.
The E-vita openplus stent graft sys-temisavailableindiametersfrom24to40mmaswellas indifferent lengthsofthesurgicalcuffportion(50,70mm)andstent graft portion (130mm, 150mmand170mm).Theone-piecehybridstentgraft is made of blood tight polyesterand supportedbynitinol springs in thestent graft section. Due to the specialweavingprocessthesurgicalcuff ispri-marily blood tight without any impreg-nationorpre-clotting.Theuniquedeliv-erysystemallowsprecisepositioningofthestentgraftandcontrollabledeploy-ment.Sinceafewmonthsanewdeliverysystem isavailablewhichoffersamorecompact size in order to ensure space-savinghandlingintheoperatingfield.
Joinourlunchsymposiumanddiscover“The Future of Aortic Surgery”!
Monday, 29th October 2012 12:45 –2:00p.m.Room120/121
Chair: Prof. Rüdiger Autschbach, MD,andCarlosMestres,MDLectures:n TheE-vitaopenhybridprosthesisforthe
treatmentoftheacutecomplicatedtypeBdissection
Prof. Martin Grabenwöger, MD, Heart Center Hietzing, Austrian Thefrozenelephanttrunktechnique:Bo-
lognaexperienceandtheinternationalregistry
Prof. Roberto Di Bartolomeo, MD, Bolo-gna University Hospital, Italyn SurgicalstrategiesfortypeAdissection–
theEssenapproachProf. Heinz Jakob, MD, West German Heart Center Essen, GermanynCombinedprocedureusingthehybridE-
vitaopenplusandE-vitathoracicendo-prosthesisinthoracicaorticdiseases.TheFrenchexperience
Prof. Jean-Philippe Verhoye, MD, Univer-sity Hospital Rennes, France
18 Monday 29 October 2012 EACTS Daily News
Gijong Yi Gangnam Severance Hospital,
Seoul, Korea
Coronaryarterybypassgraft-ing(CABG)hasbeenknownasthegoldstandardforthetreatmentoftriple-vesselor
leftmaincoronaryarterydisease.Re-centlyupdatedguidelinesfromEuro-peanSocietyofCardiologyandEuro-peanAssociationforCardio-ThoracicSurgeryandtheAmericanCollegeofCardiologyFoundationandAmericanHeartAssociationconfirmedCABGasClassIindicatedtherapyfortriple-ves-selandleftmaindisease.Butinrealpractice,percutaneouscoronaryinter-vention(PCI)hasincreasedinpatientswithtriplevesseland/orleftmaindis-easeespeciallyaftertheintroductionofdrug-elutingstent(DES).Recently,thesecondgenerationDEShasbeenintro-ducedandwidelyusedduetoitsbet-
terstentdesignandgreaterbiocompat-ibility.Coronaryarterybypassgrafting(CABG)hasshownsuperiorclinicalout-comescompadwithPCIthroughoutbare-metalstentand1stgenerationDESera,butthereislackofdatacom-paringCABGandthe2ndgenerationDES.Authorsaimedtoassesstheclin-icaloutcomesbetweenoff-pumpcor-onaryarterybypassgrafting(OPCAB)andPCIwith2ndgenerationDESintri-plevesseland/orleftmainpatients.
Inourcurrentstudy,1821consecutivepatientswhounderwentOPCABorPCIwith2ndgenerationDESastheirinitialrevascularizationtherapywereincluded.Wecomparedclinicaloutcomesfocusingonmajoradversecardiacandcerebrov-ascularevent(MACCE)inarealworldandinapropensityscore-basedmatchedpopulation(N-=902).Follow-updurationwas23.0±13.0months(0-56).
Inarealworldcomparison,theover-allMAACEratewas7.3%inthePCIgroupand3.8%intheOPCABgroup(p=0.001).The3-yearfreedomfromMACCEratewas88.4±1.5%inthePCIgroupand94.9±1.0%intheOP-CABgroup(p=0.002).Inmatchedpop-ulationcomparison,the3-yearfreedomfromMACCEratewas86.4%±2.3%inthePCIgroupand94.6±1.6%intheOPCABgroup(p=0.001).Thefree-domratesfromnonfatalmyocardialin-farctionandtargetvesselrevasculari-zationat3yearswere95.8±1.6%and92.4±2.0inthePCIgroupand98.7±0.8intheOPCABgroup(p=0.020,p=0.002,respectively).Thedeterminingfactorswerenonfatalmyocardialinfarctionandtargetvesselrevascularization.Inbothtriplevesselandleftmainsubsetanaly-sis,theOPCABgroupshowedsuperiorfreedomfromMACCErate(p=0.008,
p=0.001,respectively).Inourcurrentanalysis,theOPCAB
groupconsistentlyshowedsuperiormid-termclinicaloutcomesintripleves-seland/orleftmaindiseaseinthesec-ondgenerationDESerabothinarealworldandinamatchedpopulation.Nonfatalmyocardialinfarctionandtar-getvesselrevascularizationwerethedeterminingfactors.Surgicalbypassshouldbethefirsttreatmentoptioninpatientswithtripleand/orleftmainpa-tientsinthesecondgenerationDESera.Longerfollow-upwithrandomizationwillclarifyourcurrentresults.
Mauro Romano Italy
Therecentlyintroducedtransaorticapproachseemstobetheappropriateanswertotheproblemoftheaccessrouteinpatientswithpoorperipheralvesselsand/orhostilechest.
Thistechniqueoftranscatheteraorticvalveimplan-tationwassystematicallyadoptedatourInstitutionsinceJanuary2011.Tothebestofourknowledge,with94patients,wepresentatthismeetingthelarg-estsinglecenterexperienceintheworld.
Thechoiceofthetransaorticapproachliesmainlyinthesurgeon’sfamiliaritywithuppermanubriotomyandcanulationoftheascendingaortawicharedailypracticeincardiacsurgery(Figures1and2)withouttheneedofnewspecifictraining,theabsenceofapi-calcomplicationssuchasbleeding,pseudoanurysmordelayedrupture,theabsenceofmyocardialdamageresultingindecreasedejectionfraction,theavoidanceofintercostalpainandpleuralcomplicationswichareimportantlimitationsofthetransapicalapproachandabettersubjectivetolerance.
Besidesthis,theshortdistancebetweenthesheathandaorticannulusallowincreasedcoaxialityandsta-bilityleadingtoeasypositioninganddeploymentofthedevicepotentiallyreducingX-rayexposureandcontrastmediumadministration.
Ontheotherhand,theabsenceof“navigation”ofguidewiresandcathetersintheaorticarchcouldde-creasetheriskofdistalembolizationinpatientswithaorticdebrisinthehorizontalordescendingaorta.In-deedtheincidenceofcerebrovascular,procedurere-lated,accidents(3.2%)waslowerthanthatobservedinPARTNERB(6.7%)andA(5.5%).
Inpatientswithcomplexcoronaryarterydiseasesuchdistalleftmain,bifurcationlesionsormultivesseldiseasenotsuitableforPCI,offpumpcoronaryarteybypasscanbeperformedinthesamesessionwithfullsternotomyimmediatelybeforethetranscatheteraor-ticvalveimplantation.
Moreoverthetransaorticapproachispotentiallymoreeffectivethanthetransapicalaccessrouteinmanagingcomplicationsbyallowingquickandeasyconversiontoopenchestsurgery.
Inourexperiencetheonlylimitationwastheocca-sionaldifficultyincrossingthenativeaorticvalvewith
theAscendradeliverysystemcurrentlyavailablewhenwestartedourexperiencepromptingustoadopta”sheath-dilator“manoeuvernomorenecessarynowwiththenewAscendra+deviceequippedwithanosecone(Figures3and4).
Ourresultsshowadevicesuccessrateof92.6%and30-daymortalityandcombinedsafetypointin7.4%and14.9%ofpatientsrespectivelyaccordingtotheVARCcriteria;thiscomparesfavorablywiththetransapicalapproachorconventionalaorticvalvere-placementinhighriskpopulations.
Cardiac: Abstracts 08:15–09:45 Room 116/117
Cardiac: Abstracts 08:15–09:45 Room 118/119
Gijong Yi
Mauro Romano
Study F. Nicolini, D. Fortuna, P. Guastaroba, D. Pacini, S. Di Bartolomeo, R. De Palma, R. Grilli, T. Gherli (Italy)Discussant: T. Graham (Birmingham)
16:45 Myocardialrevascularizationintheeraofdrug-elutingstent/off-pumpcoronarysurgery:fromtheCREDO-Kyotopercutaneouscoronaryintervention/coronaryarterybypassgraftRegistryCohort-2 A. Marui, T. Kimura, T. Komiya, T. Kita, R. Sakata (Japan)Discussant: D. Pagano (Birmingham)
17:00 Off-pumptransapicalimplantationofartificialchordaetocorrectmitralregurgitation(TACTtrial):proofofconcept J. Seeburger1, M. Rinaldi2, R. Lange1, M. Schoenburg1, S. Nielsen3, O. Alfieri2, F. W. Mohr1, K. Aiditeis4 (1Germany, 2Italy, 3Denmark, 4Lithuania)Discussant: G. Lutter (Kiel)
17:15 First-in-manevaluationofthenewApicaASC™transapicalaccessandclosuredevice J. Blumenstein1, J Kempfert1, A Van Linden1, WK Kim1, H Moellmann1, V Thourani2, T Walther1
(1Germany, 2United States)Discussant: V. Subramanian (New York)
17:45 Sessionends
Focus Session
16:15 Multiple valves
Room 115
Moderators: M. J. Antunes, Coimbra; A. Colli, Padua
16:15 Aorticstenosisandmitralregurgitation R. Rosenhek (Vienna)
16:30 Tricuspidregurgitationandmitralregurgitation J. Kluin (Utrecht)
16:45 Carcinoidsyndrome S. Rooney (Birmingham)
17:00 Outcomesinmultiplevalves J. J. M. Takkenberg (Rotterdam)
17:15 Doublevalvereplacement:biologicalversusmechanicalprostheses E. Elmistekawy, V. Chan, B. Lam, T. Mesana, M. Ruel (Canada)Discussant: L. De Kerchove (Brussels)
17:30 Associationsbetweenvalverepairandreducedoperativemortalityinmitral/tricuspiddoublevalvesurgery J. S. Rankin, V. Thourani, R. Suri, X. He, S. O’Brien, C. Vassileva, M. Williams (United States)Discussant: T. Doenst (Jena)
17:45 Sessionends
Focus Session
16:15 Minimally invasive aortic valve repair
Room 114
Moderators: A. Haverich, Hannover; A. Repossini, Brescia
16:15 Theevidencebaseforminimallyinvasiveaorticvalverepair M. Borger (Leipzig)
16:30 Suturelessvalves M. Shrestha (Hanover)Discussant: L. Von Segesser (Lausanne)
16:45 Differentapproaches M. Glauber (Massa)Discussant: M Palmen (Leiden)
17:00 AorticvalvereplacementwiththePercevalSsuturelessprosthesis:clinicaloutcomesin140patients K. Zannis, T. Folliguet, G. Ghorayeb, M. Noghin, D. Czitrom, L. Mitchell-Heggs, F. Laborde (France)Discussant: J. O. Solem (Lund)
17:15 Aorticvalvereplacementingeriatricpatientswithsmallaorticroots:aresuturelessvalvesthefuture? M. Shrestha, K. Hoeffler, I. Maeding, H Laue. B. Borchert, C Barra S. Sarikouch, A. Haverich (Germany)Discussant: U. Lockowandt (Stockholm)
17:30 Developingapractice C. Young (London)Discussant: N. Howell (Birmingham)
This session is supported with an unrestricted educational grant from the Sorin Group
17:45 Sessionends
Focus Session
16:15 Is there a limit in the repair of mitral & tricuspid regurgitation?
Room 112
Moderators: M.Castella Barcelona; J L Pomar, Barcelona
16:15 Functionalregurgitationinmitralandtricuspidvalvedisease M Sitges (Barcelona)
16:30 Whatarethedifferencesintheleftventricleandrightventriclehemodynamic?Similaritiesanddifferences B Bijnens (Barcelona)
16:45 Surgicaltechniquesandlongtermresultsin
Continued from page 14
Continued on page 20
A real-world comparison of second-generation drug-eluting stents versus off-pump coronary artery bypass grafting in three-vessel and/or left main coronary artery disease
The transaortic approach for TAVIA valid alternative to the transapical access for patients with hostile vascular anatomy
Figure.1: Purse string sutures on the ascending aorta
Figure 2: Aortic access closed Figure 3: Nose cone
Figure 4: Ascendra +
20 Monday 29 October 2012 EACTS Daily News
Cardiac: Abstracts 08:15–09:45 Room 114
Cardiac: Abstracts 08:15–09:45 Room 114
Simon Pecha1, Muhammed Ali Aydin2, Yalin Yildirim1,
Björn Sill1, Beate Reiter1, Iris Wilke2, Hermann
Reichenspurner1, Hendrik Treede1 1DepartmentofCardiovascularSurgery,UniversityHeartCenterHamburg,Germany:2DepartmentofCardiology,Electrophysiology,UniversityHeartCenterHamburg,Germany
A newtherapyoptioninpatientswithpace-makerinfection-andpacemakerdepend-encyisremovaloftheinfecteddeviceandimplantationofanewtemporaryactivefix-
ationRVleadontheipsilateralsidewhichisthencon-nectedextracorporallytotheoldpacemakerdeviceprogrammedforbipolarstimulation.
Weusedthisapproachin12patientswithpace-maker/ICDinfectionandpacemakerdependency.La-serleadextractionwasperformedandsimultaneousimplantationofanewRVleadwithactivefixation,connectedextracorporallytotheoldpacemaker/ICDdevice,wasconducted.Antibiotictherapywasiniti-ated.Afternormalizationofinfectionparametersandwoundconditionsanewpacemaker/ICDsystemwasimplantedonthecontralateralsideandtemporaryRVleadwasremoved.
Meanpatient´sagewas71.3+/-9years.Labora-toryinfectionparameterswereelevatedinallpatients(MeanCRP79mg/dl,meanLeukocytescounts12.4).AfterLaserleadextraction,temporarypacingwasnec-essaryinallpatientsduetoseverebradycardia(<30bpm).Temporarypacingwasachievedbyipsilateralimplantationofanewactivefixationlead.Meantimeofantibiotictreatmentwas14.3+/-3daysandmeandurationoftemporarypacing11.2days.Whenlabo-ratoryinfectionparameterswereinnormalrangeandbloodculturesamplesshowednegativeresults,anewsystemwasimplantedsuccessfullyoncontralateral
sideinallpatients.Nomajorprocedurerelatedperi-orpostoperativeadverseeventsoccurred.Meantimeofhospitalizationwas19days.Follow-upaftertwelvemonthshowedfreedomfromreinfectionof100%.
ImplantationofatemporaryactivefixationRVlead
connectedtoanexternalizedpacemakerandpursuedantibiotictherapyseemstobeagoodoptionforpa-tientswithdeviceinfectionandpacemakerdepend-ency.Thetechniquehelpstoavoidunsecuretempo-rarypacingbyfloatingballooncatheters.
Simon Pecha1, Timm Schäfer1, Friederike
Hartel2, Teymour Ahmadzade1, Irina
Subbotina1, Hermann Reichenspurner1,
Florian Wagner1 1Department of
Cardiovascular Surgery, University Heart
Center Hamburg, Germany; 2 Department
of Cardiology, Electrophysiology, University
Heart Center Hamburg, Germany
Concomitantablationisanestablishedtherapyincar-diacsurgicalpatientswithatrialfibrillation(AF).Post-
dischargecareseemstobeanessen-tialfactorforclinicaloutcome.Wean-
alyzedtheinfluenceofEventrecorder(ER)implantationandconsecutivepost-operativefollow-upbyourdepartmentofelectrophysiology.
Between07/2003and08/2010401cardiacsurgicalpatientsunderwentconcomitantsurgicalAFablationther-apy.Since08/2009anEventrecorder(REVEALXT,MedtronicInc.,Minne-apolis,Minnesota)wasimplantedin98patientsintraoperatively.ERinter-rogationwasperformedbyourde-partmentofelectrophysiologythree,sixand12monthspostoperative.Re-sultandoutcomewascomparedto
amatchedcohortofpatientswithablationandnoERmonitoring.Pri-maryendpointofthestudywassinusrhythmrateafter12months.
Meanpatient’sagewas67.0±9.7years,68.4%weremale.Noma-jorablationrelatedcomplicationsoc-curred.Overallsinusrhythmconver-sionratewas65.3%afteroneyearfollow-up.Sinusrhythmrateoffan-tiarrhythmicdrugswas60.3%re-spectively.Conversionratetendedtobehigherinpatientswithanim-plantedER(69.3%vs.60.1%,re-spectively;p=0,098).Sinusrhythm
rateoffantiarrhythmicdrugswasalsohigherinERgroup(64.3%vs.56.2).PatientswithERwereseenmoreof-tenbyacardiologistinthefirstyearpostoperative(3.1+/-0.8vs.1.5+/-0.9p<0.05)andreceivedsignificantlymoreadditionalprocedureslikeelec-tricalcardioversionoradditionalcath-eterbasedablation(16.1%vs.4.3%;p<0.001;11.2%vs.3.1%;p<0.001).
ImplantationofanEvent-Recorderwithlink-uptoacardiologyand/orelectrophysiologyprovidesoptimizedantiarrhythmicdrugmanagementandhigherratesofconsecutiveproce-dureslikecardioversionoradditionalcatheter-basedablation.Asaresultatrendtohighersinusrhythmconver-sionratewasobservedafteroneyear.
Transcutaneous lead implantationConnected to an externalized pacemaker in patients with implantable cardiac defibrillator/pacemaker infection and
pacemaker dependency
Better monitoring – better outcome? Concomitant surgical atrial fibrillation ablation and Eventrecorder implantation
mitralregurgitation:Wheredowestand? R. De Paulis (Rome)
17:00 OperativeTechniquesandoutcomesinfunctionaltricuspidregurgitation G. Dreyfus (Monte Carlo)
17:15 Whatarethefactorsinthedevelopmentofrecurrenttricuspidregurgitation? F. Casselman (Aalst)
17:30 Discussion
This session is supported by an unrestricted educational grant from Edwards Lifesciences
Focus Session
16:15 Heart rejuvenation
Room 111
Moderators: W. Brawn, Birmingham; J. R. Pepper, London; D. J. Chambers, London; M. Kanani, London
16:15 Cardioplegia D. Chambers (London)
16:35 Stemcells P. Menasche (Paris)
16:55 Exvivoheartandlungpreservation A. Simon (Harefield)
17:15 Preconditioninganditsfuture V. Venugopal (London)
17:45 Sessionends
Thoracic Disease
Abstracts
08:15 Thoracic oncology I
Rooms 133/134
Moderators: M. E. Dusmet, London; P. Van Schil, Antwerp
08:15 Theroleofpreoperativecomputedtomography-guidedhook-wirelocalizationinthoracoscopicresectionforground-glassopacitypulmonarylesions:aprospectiveanalysis T. Ye, J. Zhou, H. Hu, G. Li, W. Li, L. Shen, H. Chen (China)Discussant: M. Jimenez (Salamanca)
08:30 Surgicalresultsofnon-small-celllungcancerwiththeappearanceofground-glassopacity S. Cho, S. Jheon (Republic of Korea)Discussant: P. Van Schil (Antwerp)
08:45 Innateimmunefunctionfollowingmajorlungresectionforbronchogeniccarcinomaviavideo-assistedthoracoscopicsurgeryandthoracotomy R. Jones, N. Anderson, J. Murchison, M. Britton, W. Walker, A. J. Simpson (United Kingdom)Discussant: S. Margaritora (Rome)
09:00 Operatingonasuspiciouslungmasswithoutapreoperativetissuediagnosis:prosandcons A. Sihoe, R. Hiranandani, H. Wong, E. Yeung (Hong Kong)Discussant: R. Rami-Porta (Barcelona)
09:15 Islobectomyreallymoreeffectivethansublobarresectioninsurgicaltreatmentofsecondprimarylungcancer? A. Zuin, L. Andriolo, G. Marulli, M. Schiavon, S. Nicotra, F. Calabrese, P. Romanello, F. Rea (Italy)Discussant: P. De Leyn (Leuven)
09:30 Whichisthemostimportantprognosticfactorinneuroendocrinetumoursofthelung?Asingle-centreexperience A. Sandri, F. Guerrera, G. Bora, A. Oliaro, L. Delsedime, P. Lausi, S. Olivetti, P. L. Filosso (Italy)Discussant: P. B. Licht (Odense C)
09:45 Coffee
10:15 Thoracic oncology II
Moderators: P. G. Dartevelle, Le Plessis Robinson; P. De Leyn, Leuven
10:15 PrognosticstratificationofstageIIIapn2non-small-celllungcancerbyhierarchicalclusteringanalysisoftissuemicroarrayimmunostainingdata:anAlpeAdriaThoracicOncologyMultidisciplinaryGroupstudy(ATOM014) G. Aresu, G. Masullo, E. Baracchini, A. Follador, F. Grossi, A. Morelli (Italy)Discussant: P. G. Dartevelle (Le Plessis Robinson)
10:30 Enzyme-linkedimmunosorbentspotformonitoringofpostoperativeimmununosupressionofpatientswithlungcancer P. Rybojad, A. Jabłonka, B. Wilczyñska, J. Tabarkiewicz (Poland)Discussant: M. Lucchi (Pisa)
10:45 Surgicalmanagementofmalignanttumoursinvadingtheinferiorvenacava D. Fabre, P. Bucur, R. Houballah, E. Fadel, S. Mussot, O. Mercier, P. Dartevelle (France)Discussant: L. Spaggiari (Milan)
Continued from page 18
Caption
Figure 1: Externalized lead and pacemaker device for temporary pacing
Simon Pecha
Continued on page 22
Cardiac: Focus Session 14:15–15:45 Room 112
Thomas Walther Klinik für
Herzchirurgie,
Bad Nauheim, Germany
Transcatheteraor-ticvalveimplantation(TAVI)hasevolvedasaroutineprocedureto
treatelderlyhigh-riskpatientssufferingfromseveresympto-maticaorticvalvestenosis.T-AVIisbeingperformedus-ingdifferentaccessoptions,eitherbyimplantedusingaretrogradeendovascularap-proach(transfemoralTF,trans-subclavianTS,transaorticTAo)oranantegradetransapicalap-proach(TA).
ManyphysiciansconsidertheTFapproachbeinglessin-vasivethantheTAapproach,
leadingtopatientselectionandhigherTFversusTAim-plantationratesinmanycoun-tries.Inaddition,sickerpa-tientswithperipheralvasculardiseasearethenbeingtreatedusingtheTAapproach.Differ-encesinoutcomesarethencompared.Suchcomparisonsarenotvalid.
FromascientificstandpointthereisnoevidencethattheTFapproachleadstobetterre-sultsthantheTFapproachandthereisnoprospectiverand-omizedtrialexaminingthisas-pect(atpresent).Thereforecurrentassumptions,whicharebeingtakenfromselectedse-riesorfromregistrydata,arenotvalid.InsimilarpatientstheTAapproachclearlyisasgood
orevenbetterthantheTFap-proach.TherearemanyquiteobviousadvantagesofTA-AVI:Accesstotheaorticvalveisrelativelyshortandstraight,thusallowingforeasyandpre-cisemanipulations.Thepros-theticvalveisbeinginsertedantegradely,thesystemcanbeplacedquitecoaxiallybymeansofaguidewireandverycon-trolledimplantationcanbeperformed.Obviousdatafromthemedicalliterature(Sourceregistry,PrevailTAstudy)indi-catethelowestaccessrelatedcomplicationrate,whichisbe-low1%,fortheTAapproach.Thisisclearlylowerthanwithanyotheroftheavailableac-cessmodalities.Inadditionthereisclearevidencefrom
ametaanalysisonmorethan10,000patientsindicatingthattheTAapproachisassociatedwiththeloweststrokerate.
TheTAapproach,offcourse,requiresananterolateralmi-nithoracotomyatpresent.Thisaccess,however,isverysafeandpatientsusuallytolerateitquiteeasily.Atpresentsev-eralaccessandclosuresystems(APICA;PERMASEAL;ENTOU-RAGE,CARDIOAPEX)areen-teringclinicaltrialswhichmayleadtoanevenmorestandard-izedandsafeapicalaccessandclosureinduecourse.Otheroptions,suchasrelativelysim-pleaccesstothemitralvalve,willbefeasiblewiththeTAap-proachaswell.Inthefutureapercutaneousapicalaccessandclosuremaygetintoreachwiththesenewaccessandclo-suresystems,thusallowingforacompletelypercutaneousap-
proach,guidedbyadvancedimagingmodalities.
Severaltechnicaloptionswillbecomeavailablewithcur-rentandfuturegenerationsoftransapicaltranscathetervalvesystems.Someofthemareso-lutionstopreventparavalvularleakagesuchaswiththeSAP-IEN3(Edwards)valveorsomeassistanceduringpositioningtogetherwithpartialretrieva-bilitysuchaswiththeEngager,Jenavalve,Symetisdevices.Fu-tureiterationsofthesesystemswillhelpphysicianstoobtainimprovedoutcomesfortheirpatients.CardiacsurgeonsshouldbeencouragedtobeactivelyinvolvedinthefieldofT-AVIasanactivepartnerintheheartteam.Thetransapicalapproach,duetoitsexcellentfeaturesandoutcomes,shouldbeusedfrequentlytosafelytreatelderlyhighriskpatients.
Transapical TAVI in perspective
EACTS Daily News Monday 29 October 2012 21
Advert
Two years ago, in September 2010, SorinXtra® was launched at the EACTS in Gene-
va. XTRA®combines 30 years of experience inautotransfusion with the latest technology, toachieveexcellentclinicalperformanceinanintu-itive,easy-to-useand innovativedevice.Xtra® isbeingused ineachcontinentandthecustomerresponse indicates thedevicesuccessfullymeetsclinician’sneedsinvarioussurgicalsettings.
Twointerestingarticleshavebeenpublishedshar-ingexperiencesandclinicalresultsachievedwiththeXtra®.
In“Evaluatingthenextgenerationofcellsalvage–Willitmakeadifference?”(Yarhametal.–Per-fusion1-8,2011)thetechnologicalinnovationsin-troducedinthesystemareevaluated.ItisshownhowXtra®iscapableofmeetingthedemandingneedsofmodernbloodmanagementofferingan“…easy,robustandconciseuserinterface…”andanintegrateddatamanagementsystemthat“pro-videsseveraloptionstoexportandrecordthelevelofdatarequiredforgoodelectronicperfusiondatamanagement”.Alsothedisposablesetupiseval-uated:thedesignoftheproductallowsforeasierandsubsequentlyfastermounting,beneficialdur-ingemergencysituationsaswellashighdemandar-easlikecardiacsurgery.Nonetheless,duringthetrialXtra®hasshowntobeapowerfuldevicedeliveringexcellentclinicalresults,especiallywhenusingthefactoryprotocolPoptand“…achievingahigherendproducthaematocritthanourperfusionteam’sbestpractice”.
Alsothearticle“ClinicalevaluationoftheSorinXtra®autotransfusionsystem”(EPOverdevestetal.Perfusion1-6,2012)stressesthepowerfulper-formanceofthedeviceandshowshowthetwo-stepsbowlfillingofthefactoryprotocolPoptandthenewbuilt-intechnologicalinnovation,thedualRBCdetector,candriveverygoodendresults.Sor-inXtra®isdescribedas“…excellentwithregardtotheachievedhematocritlevelsintheRBCreinfu-sionvolume(Ed.63%using225mlbowlwithfac-toryPoptprotocol)”whilekeepingRBCrecoveryratesatanadequatelevelandeliminatingplasmacontaminants,proteinsandheparinaccordingtoex-pectations.
Thesetwopublicationssupporttheconclusionthatwhetheryouarestrivingfortechnologicalin-novation,intuitivenessofsetupanduserinterfaceorpowerfultopperformance,SorinXtra®isreadytoserveyourneeds.SorinGrouphasalwaysbeencommittedtoofferingproductsthateffectivelyfacethenewchallengesofperfusionandbloodrecovery.Forthisreasonweareverygladtoseetheenthusi-asmthatSorinXtra®generatesamongthemedicalcommunity.
Andwhataboutyou?HaveyoualreadyhadachancetoexperiencetheextraordinaryfeaturesofSorinXtra®?
PleasecometoboothNo.85andshareyourex-periencewithus!Orifyouareinterestedinevalu-atingthedevice,comeandvisitusandwewillputyouincontactwithyourlocalSorinGrouprepre-sentative
Sharing the Xtra®experience
Akaira Marui Kyoto University, Japan
Severalstudiescomparingpercutaneouscoro-naryinterventions(PCIs)withcoronaryarterybypassgrafting(CABG)demonstratedsimi-larlong-termsurvivaloutcomesforPCIand
CABG.However,thecurrentincreaseofPCIwithdrug-elutingstent(DES)oroff-pumpCABG(OPCAB)maychangethepowerrelationshipintheareaofmyocar-dialrevascularization.ParticularlyinJapan,OPCABisemployedmorefrequently(>60%)thanitisintheUSorEurope,whichmayenableamorereliablecompari-sonbetweenPCIwithDESandOPCAB.Inaddition,riskstratificationsuchasbySYNTAXscoremayalsoenablemoreaccuratecomparison.
TheCREDOKyotoCohort-1and-2arelargemulti-
centerregistriesinJapanenrollingover25,000patientsundergoingfirstPCIorCABG.IntheCREDO-KyotoRegis-tryCohort-1,wehavereportedtheoutcomescomparingPCIwithCABGintheeraofbare-metalstent.Nowinthepresentstudy,weidentified3986patientswithtriple-ves-seland/orleftmaindiseaseof15,939patientswithfirstmyocardialrevascularizationenrolledintheCREDO-KyotoRegistryCohort-2.Therewere2,190patientsreceivedPCImainlywithDES,655on-pumpCABG(ONCAB),and1141OPCAB.Weusedpropensity-scoreanalysistoadjustthedifferencesinbaselinecharacteristicsofpatientsun-dergoingPCIorCABG.
Asaresult,cumulative4-yearincidenceofdeathwashigherafterPCIthanCABG(15.7%vs.12.4%,p<0.01).AdjustedmortalityafterPCIwasalsohigherthanCABG.(hazardratio[95%confidenceinterval]:1.36[1.02-1.81],
p=0.03),whereasadjustedmortalitywassimilarbetweenONCABandOPCAB(1.00[0.65-1.52],p=0.98).Strati-fiedanalysisusingtheSYNTAXscoredemonstratedthatriskfordeathwasnotdifferentbetweenPCIandOPCABinpatientswithlow(<23)andintermediate(23to33)SYNTAXscore(1.00[0.52-1.91],p=0.36and1.05[0.59-1.85],p=0.88),whereasthosewithhigh(≥33)SYNTAX
score,theyweresignificantlyhigherafterPCIthanthatafterOPCAB(2.51[1.33-4.74],p<0.01).Ontheotherhand,adjustedmortalitywasnotdifferentbetweenON-CABandOPCABregardlessoftheSYNTAXscore.Theseresultsindicatethatinpatientswithtriple-vesseland/orleftmaindisease,bothOPCABandONCABareassoci-atedwithbetterlong-termsurvivalthanPCIusingDESinpatientswithhigherSYNTAXscore.SurvivaloutcomesaresimilarbetweenONCABandOPCABregardlessofthecomplexityofcoronarylesions.
Inconclusion,CABGshouldbeselectedinthosepatientswithmorecomplexcoronarylesionsduetobettersurvivalthanPCI.SelectionofONCABorOPCABshouldbeprop-erlydeterminedaccordingaspatients’comorbiditiesbe-causeofsimilarsurvivaloutcome.
Cardiac: Abstracts 16:15–17:45 Room 116/117
Myocardial revascularization in the era of drug-eluting stent/off-pump coronary surgery: From the CREDO-Kyoto PCI/CABG Registry Cohort-2
Akaira Marui
22 Monday 29 October 2012 EACTS Daily News
Cardiac: Abstracts 08:15–09:45 Room 115
Caption
G.Stefanelli, F. Benassi, D.Gabbieri,
G.Danniballe, D.Sarandria, C.Labia, and
G.Gioia Hesperia Hospital, Modena ITALY,
AtlantiCare, Heart Institute, NJ, USA°
Theauthorsreportinthispa-perasingleinstitution,sin-glesurgeon,10yearsexperi-ence,withpatientsaffected
byischemicdilatationofleftventricleandmeanejectionfraction<30%,andsubmittedtosurgicalventricularresto-ration(SVR)since2002.Theoperativetechniquehaschangedwithtime,mov-ingfromtheconceptof‘volumere-ductionsurgery‘totheideaofreshap-ingtheventricularchambertoamoreellipticalgeometry.Thereforethelast28patients,outof59treatedbySVR(groupB)underwentamodifiedsurgi-caltechniquedifferentfromtheclassi-calDORoperationadoptedinthefirstcases(groupA)(Figure1).Anaggres-siveapproachtothemitralvalve,oftenincompetentinthesecases,hasbeenassociatedin61%ofpatients,andcon-sistedofannularundersizingand,inse-lectedcases,ofpapillarymusclesap-proximation.
Asadjuncttothesurgicaltreatment,since2007,arandomizedclinicaltrialwasinitiated,withtheaimofverifytheimpactonleftventricularfunctionofdirectsubendocardialimplantofautol-ogousbonemarrowderivedmononu-clearcells(BMMNCs)intothescarredmyocardium,asaconcomitantproce-dureduringSVR.80to100cc.ofbonemarrowwereharvestedfromthester-numbeforeskinincision,treatedinasterilemini-labasidetheoperatingroomtoobtain5–8cc.ofconcentratedBMMNCs,andinjectedbydirectpunc-tureintheinfarctedareasbeforeclo-sureofventriculotomy.
Theresultsofourexperienceseemencouraging.Thetotalearlymortal-ityfortheentiregroupwas3.4%(0%forgroupB).Duringameanfollow-uptimeof7.4years(10years–8months)
17patientsdied(28.8%).Ifweexcludethenoncardiacdeaths,mortalityrateforheartfailurewas3.5%,(Figure2),withafreedomfromhospitalizationof78%.AmultivariedanalysishasfailedtoidentifyriskfactorsforearlynorlatemortalityWhilenostatisticaldifferenceexistformortalityandclinicaloutcomebetweenthetwogroupsofpatients,impactofsurgicaltechniqueonleftventricularenddiastolicdiameterandHYHAclassisremarkable(Figure3),infavorofthemodifiedone,evenmoreinthegroupofpatientimplantedwithBMMNCs.Sixpatientstreatedwithcelltherapyhavedemonstratedatpet-scancontrolapartialrecruitmentofinf-arctedareas(p<0,05)(Figure4).
SVRisanpromisingandevolvingtechnicalsolutionforheartfailurepa-tients.Ithastobeconsideredasapartofamorecomplexandarticulateap-
proach.Cardiacregenerativemedicinerepresentaninnovative,adjunctivetoolforthetreatmentofthisseveredisease.
11:00 Pneumonectomywithenblocchestwallresection:isitworthwhile?Reporton34patientsfromtwoinstitutionsG.Cardillo,L.Spaggiari,D.Galetta,F.Carleo,L.Carbone,G.NgomeEnang,M.Martelli(Italy)Discussant: P. Van Schil (Antwerp)
11:15 Sleeveresectionsofthebronchuswithoutpulmonaryresectionforendobronchialcarcinoidtumours K. Nowak1, W. Karenovics2, A. Nicholson2, S. Jordan2, M. Dusmet2 (1Germany, 2United Kingdom)Discussant: P. De Leyn (Leuven)
11:30 Robot-assistedversusthoracotomylymphadenectomyforearlystagenon-small-celllungcancer:preliminaryresults F. Allidi, F. Melfi, O. Fanucchi, A. Picchi, F. Davini, A. Mussi (Italy)Discussant: R. Schmid (Bern)
11:50 Presidentialaddress
12:30 Lunch
Abstracts
14:15 Thoracic oncology III
Rooms 113/114
Moderators: L. Spaggiari, Milan; P. B. Licht, Odense
14:15 Dynamic4-dimensionalcomputedtomographyforpreoperativeassessmentoflungcancerinvasionintoadjacentstructures C. K. C. Choong, S. Pasricha, S. Stuckey, J. Smith, J. Troupis (Australia)Discussant: A. Zuin (Padua)
14:30 Outcomeafterfull-thicknesschestwallresectionforisolatedbreastcancerrecurrence E. Fadel, D. Levy Faber, F. Kolb, S. Delaloge, P. Dartevelle (France)Discussant: G. Cardillo (Rome)
14:45 Occultpleuraldisseminationofcancercellsdetectedusingthetouchprintcytologymethodduringsurgeryshowssurvivalimpact D. Kim, Y. Kim, Y. Park (Republic of Korea)Discussant: M. Dusmet (London)
15:00 PreoperativeserumICTPlevelsasapredictorofrecurrenceinpatientswithnon-small-celllungcancer Y. Tanaka, S. Oura, T. Yoshimasu, F. Ota, K. Naito, Y. Hirai, M. Ikeda, Y. Okamura (Japan)Discussant: L. Spaggiari (Milan)
15:15 Dothehistologicalsubtypesofnon-small-celllungcancercorrelatewiththeclottingdisorderspresentinpatientssubmittedtoradicalsurgicalresection? N. Theakos, G. Athanassiadis, S. Pispirigou, L. Zoganas, P. Behrakis (Greece)Discussant: P. B. Licht (Odense)
15:30 Predictionofin-hospitalmortalityfollowingpulmonaryresections:improvingontheThoracoscoreriskmodel M. Poullis, R. Page, M. Shackcloth, N. Mediratta (United Kingdom)Discussant: D. Wood (Seattle)
Abstracts
16:15 Thoracic non-oncology I
Rooms 133/134
Moderators: J. Wihlm, Strasbourg; A. D. L. Sihoe, Hong Kong
16:15 NormalizedcardiopulmonaryfunctionfollowingtheNussprocedureforpectusexcavatum:3-yearfollow-up.Aprospective,controlledstudy M. Maagaard, M. Tang, H. H. Nielsen, J. Frøkiær, S. Ringgaard, M. Lesbo, H. Pilegaard, V. Hjortdal (Denmark)Discussant: J. Wihlm (Strasbourg)
16:30 Omittingchesttubedrainageafterthoracoscopicmajorlungresection K. Ueda, M. Hayashi, K. Hamano (Japan)Discussant: P. Sardari Nia (Breda)
16:45 Earlyandlateoutcomeaftersurgicaltreatmentofbenigntracheo-oesophagealfistulas G. Marulli, M. Loizzi, G. Cardillo, L. Battistella, A. De Palma, G. Ngome Enang, D. Zampieri, F. Rea (Italy)Discussant: A. Lerut (Leuven)
17:00 Paincontrolofthoracoscopicmajorpulmonaryresection:ispre-emptivelocalbupivacaineinjectionabletoreplaceintravenouspatient-controlledanalgesia? H. C. Yang, J. Lee, I. Song, J. Lee, W. Choi, S. Cho, K. Kim, S. Jheon (Republic of Korea)Discussant: N. Novoa (Salamanca)
17:15 Long-termresultsofpectoralismuscleflap
Continued from page 20
Continued on page 24
‘One step’ subendocardial implant of autologous stem cells during modified left ventricular restoration for ischemic heart failure
Figure 1: Operative details: Technique A (DOR) versus technique B (modified CABROL)
Figure 3: SVR: TE echo at surgery. Pre-op (left) and post-opFigure 2: Survival function for the entire group (death for all
causes and cardiac)
Benassi
Figure 4: PET-scan preoperative and at six-months after implant of BMMCS and SVR. Pre (left) and post (>six months)
Gonçalo F. Coutinho
University Hospital of Coimbra,
Portugal Secondarymitralregurgi-tation(MR)ofvaryingde-greeshasbeenreported
inuptotwothirdsofpatientsundergoingAVR(aorticvalvere-placement),thisoftenraisesthequestionofwhetheradditionalmitralvalvesurgeryisneces-sary1,2.WhileseveresecondaryMRobviouslyrequiresinterven-tion,non-severeMRisoftenleftunaddressedatthetimeofAVR,becauseitisexpectedtode-creaseaftersurgery.
Relativelyfewstudiestodatehaveexaminedtheclinicalim-pactofsecondaryMRinpa-tientsundergoingAVR3,5andthemajorityofpriorreportshaveinvolvedsmallsamplesizesandareconfoundedbythein-clusionofpatientswithorganicorischemicmitralvalvedisease.Furthermore,anevensmallernumberhaveevaluatedtheper-sistenceofMRinthelong-termanditsimpactonsurvival.
Theaimofourpresentstudywastoexamine:1-thepreva-lenceofsecondaryMRinourpopulation;2-thesurgicalop-tions(tointerveneornotonthemitralvalve)andtheirimpact
Management of moderate secondary mitral regurgitation at the time of aortic valve surgery
Cardiac: Abstracts 08:15–09:45 Room 112
Table 1 – Preoperative Characteristics
Baseline characteristics Group A Group B P- Value
Age (years) 64.4±10.5 68.6±12.1 0.006
Male Sex 71(75.5%) 90 (55.9%) 0.002
Body surface area (m²) 1.72±0.16 1.67±0.21 0.081
NYHA III-IV 67 (71.3%) 98 (60.9%) 0.093
Chronic atrial fibrillation/flutter 30 (31.9%) 31 (19.3%) 0.022
Hypertension 40 (42.6%) 103 (64.0%) 0.001
Diabetes mellitus 13 (13.8%) 21 (13.0%) 0.859
COPD 13 (13.8%) 20 (12.4%) 0.747
Coronary disease 78 (83.0%) 48 (29.8%) 0.023
Previous myocardial infarction 4 (4.3%) 12 (7.5%) 0.310
Previous stroke/TIA 3 (3.2%) 10 (6.2%) 0.290
Carotid artery disease 5 (5.3%) 21 (13.0%) 0.049
Renal Failure 11 (11.7%) 11 (6.8%) 0.181
Aortic stenosis 48 (51.1%) 131 (81.4%) 0.001
Echocardiographic findings
Mitral Regurgitation (grade) 3.3±0.5 2.8±0.3 0.001
LA diameter (mm) 49.4±7.7 46.7±7.5 0.008
LV end-diastolic dimension (mm) 66.9±9.5 58.9±8.6 0.001
LV end-systolic dimension (mm) 47.9±9.7 40.1±9.6 0.001
IVS (mm) 11.5±2.2 12.4±2.9 0.041
LVPWT (mm) 10.1±1.9 10.8±2.4 0.066
Ejection Fraction (%) 47.6±16.7 56.2±18.4 0.004
Shortening Fraction (%) 28.3±8.0 32.1±9.6 0.002
LV dysfunction (EF<45%) 42 (44.7%) 36 (22.4%) 0.001
Peak aortic gradient (mmHg) 70.2±30.0 82.1±32.7 0.015
Mean aortic gradient (mmHg) 50.5±21.1 54.7±24.1 0.259
Pulmonary hypertension 26 (27.7%) 27 (16.8%) 0.039NYHA–NewYorkHeartAssociation;COPD–chronicobstructivepulmonarydisease;TIA–Transientischemicattack;LA–Leftatrium;LV–leftventricle;IVS.–interventricularseptum;LVPWT–leftventricularposteriorwallthicknessContinued on page 23
EACTS Daily News Monday 29 October 2012 23
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onsurvival,adversevalve-re-latedeventsandclinicalsta-tus;and3-theevolutionofMRovertimeandpossiblepredictorsofpersistence.
FromJan-99toDec-09,3,339patientsunderwentAVRforaorticvalvedisease.Ofthese,255wereconsid-eredtohavesecondaryMRgreaterthan2+,whichwasdefinedasdysfunctionwith-outstructuralabnormalitiesofthemitralapparatus,suchasvalveprolapse,signifi-cantcalcificationofleafletsorannulus,rupturedchor-daeandconcomitantmitralstenosis.Patientswerestrat-ifiedintotwogroups(table1),thosewithconcomitantmitralvalvesurgery(groupA,n=94,36.8%)andthosewithout(groupB,n=161,
63.2%).Therewasnodifferencein
hospitalmortalityandmor-biditybetweengroups,al-thoughECCandaorticclampingtimeswereappre-ciablylongerinthemitralsurgerygroup.
Overallsurvivalat1-,5-and10-yearswas93.0±2.8%,84.2±4.2%and76.7±5.7%,respectively,forgroupA,and98.7±0.9%,79.6±4.2%and66.6±8.9%,respectively,forgroupB(P=NS).OnlyCAD,historyofCVA,permanentAF,CRFandMRpersistenceemergedasindependentpredictorsforoverallmortality(Table2).Patientswhoshowedper-sistentMRearlyaftersurgeryhadseverelycompromisedlong-termsurvival(Figure1).Thiswasthemostpower-
fulindependentpredictorforlatemortality(hazardratio[HR]:4.9;P=0.001).
Eightpatientswerereop-erated,thoughonly2un-derwentmitralvalvesurgeryandbothwerefromgroupA(earlymitro-aorticendocardi-tisandlatemitralrepairfail-urenineyearsaftersurgery).
Earlyechocardiogramre-vealedimprovementoftheMRgradeinnearly82%ofpatientsfromgroupB(vs.99%fromgroupA).Over-time,therewasanincreaseintheseverityofMR,with32.6%fromgroupBshow-ingpersistentMRduringlatefollow-upagainst17.7%fromgroupA(P=0.045).Ta-ble3showstheindependentpredictorsofpersistentMRatearlyandmediumtolong-termfollow-up.
SecondaryMRinthecon-textofAVRcanbetreatedwithahighrateofmitralre-pairandwithlowmortalityandmorbidity.
Thegreatmajorityofpa-tientswithsecondaryMRcanexpecttoimprovetheirMRdegreeearlyafteriso-latedAVRandapproximately67%maintaintheirimprove-mentinthemediumtolong-term.Patientswhodonotimproveorhaveanimpor-tantdegreeofMRbythefirstmonthafterAVRareatriskofhavingsignificantper-sistentMRinthefutureandhaveseverelycompromisedsurvival,henceshouldbecloselyfollowedandreferredtomitralvalvesurgeryearly.
PatientsinAFarealsoatriskfordecreasedsurvivalandofpersistentMRover-
time,thereforetheyshouldhavetheirmitralvalvere-pairedsimultaneouslyduringAVRprocedureandhaveAFablation,ifindicated.References
1. Sabbah HN, Rosman H, Kono T, Alam M, Khaja F, Goldstein S. On the mechanism of secondary mitral regurgitation. Am J Cardiol 1993;72:1074-1076.2. Moazami N, diodato MD, Moon MR, Lawton JS, Pasque MK, Herren RL, Guthrie TJ, Damiano RJ. Does secondary mitral regurgitation improve with isolated aortic valve replacement? J card Sur. 2004;19:444-448.
3. Wan CKN, Suri RM, Li Z, Orsulak TA, Daly RC,
Schaff HV, Sundt TM. Management of moder-
ate secondary mitral regurgitation at the time of
aortic valve replacement: is concomitant mitral
valve repair necessary? J Thorac Cardiovasc Surg
2009;137:635-640.
4. Ruel M, Kapila V, Price J, Kulik A, Burwash IG,
Mesana TG. Natural history and predictors of out-
come in patients with concomitant secondary mitral
regurgitation at the time of aortic valve replace-
ment. Circulation 2006;114[suppl I]:I541-546.
5. Absil B, Dagenais F, Mathieu P, Metras J, Perron
J, Baillot R, Bause R, Doyle D. Does mitral regurgita-
tion impact early or mid-term clinical outcome in
patients undergoing isolated aortic valve replace-
ment for aortic stenosis? Eur J Cardiothorac Surg
2003;24:217-222.
The Rapid Evolution of a Transcatheter Hybrid Procedure for Heart FailureInterestindevelopingmoreminimallyinvasivetherapiescon-
tinuestogrowinthemedicalcommunity.Inthefieldofcar-diaccare,thishasbeendemonstratedbytheemergenceofcatheter-basedproceduresforatrialfibrillation,aorticvalvere-placement,closureofcongenitalandacquiredseptaldefects,mitralvalverepair,coronaryarterydiseaseandnowrenalden-ervationforhypertension.BioVentrix,Inc.(SanRamon,Calif.,EACTSbooth92/93)haslaunchedauniqueproductcalledtheRevivantMyocardialAnchoringSystemTMatEACTSthisyear.
Thisproduct isdesignedforLess InvasiveVentricularEn-hancementTMorLIVETMprocedures,enablingeffective treat-mentofpatientssufferingfromischemiccardiomyopathyduetopostanteriormyocardialinfarction(AMI)scarring.Withtheongoinggrowthof theheart failurepopulationworldwide,thistechnologyappearstobeextremelypromising.
AsthecompanyisshowcasingitsflagshipReviventsys-tem at this meeting, the company’s next generation tran-scatheterdevicetherapyisnearinghumanclinicaltrials.Thisminimallyinvasiveapproachemploysacombinedendovas-cularandtransthoracicdeliverysystemthatallowsforaster-nalsparingplicationoftheinfarctedtissue. Intendedforacombinedhybridsurgicalandcardiologyteam,itutilizestheidenticalimplanttechnologyastheoriginalReviventdevice.The resulting exclusion of acontractile scar should renderthesamepromisingresults.Transeptalpunctureisachievedunderfluoroscopywith17Gneedlestofacilitateadvance-mentofaguidewire.Theanchorsaredeliveredretrogradethroughtherightinternaljugularveinandretrievedontheleftsideoftheheartviaathoracoscopicport.
To date, BioVentrix has tested this concept in over 40ovine models with impressive outcomes. The first humanclinicalexperiencesareexpectedtobereportedatthismeet-ingnextyear.
Table 2 – Independent predictors for late mortality
Variable HR 95% CI P- value
CAD 2.97 1.32-6.70 0.009
Previous stroke/TIA 3.25 1.04-10.10 0.041
Permanent AF 2.74 1.24-6.06 0.013
CRF 3.01 1.22-7.40 0.016
MR persistence 4.90 1.92-12.60 0.001
CAD–Coronaryarterydisease;TIA–Transientischemicattack;AF–Atrial
fibrillation;CRF–Chronicrenalfailure;MR–Mitralregurgitation;HR–Hazard
ratio;CI–confidenceinterval
Table 3 – Independent predictors for persistent MR at early and late follow-up
Variable OR 95% CI P value
At early FU (discharge)
Aortic root enlargement 1.53 0.13-3.11 0.006
Inotropic support 1.34 0.20-2.83 0.012
No mitral surgery 2.81 1.16-20.30 0.009
At medium-long-term FU
Atrial fibrillation 2.65 1.02-6.88 0.044
MR degree at discharge 1.92 1.19-3.09 0.007
FU–Follow-up;OR–Oddsratio;CI–confidenceinterval
Continued from page 22
24 Monday 29 October 2012 EACTS Daily News
Vascular: Professional Challenges 08:15–09:45 Room 113
Vascular: Professional Challenges 08:15–09:45 Room 113
Vassil Papantchev University
hospital “St. Ekaterina”, Medical
University, Sofia, Bulgaria
Duringunilateralse-lectivecerebralper-fusion(uSCP)withcannulationof
rightaxillaryarteryorbrachi-ocephalictrunk,thebrainre-ceivesbloodonlyviarightcommoncarotidarteryandrightvertebralartery.Theas-sumptionforprotectiveeffectofuSCPisbasedontheun-derstandingthatcollateralcir-culation,mainlythroughar-terialcircleofWillis(CW),issufficienttomaintainade-quateperfusioninthecon-tralateral(left)hemisphere(figure1).However,varia-tionsofCWexistinatleast50%ofthepeople.Itisalsoknownthatthesevariationsusuallyaffectmorethanonesegmentofthecircle.
InthisrespecttheaimofourworkwastostudythevariationsofCW,whichcouldhaveanimpactonhemody-namicsduringuSCP.
BetweenMay2005andMarch2012atotalnumberof500CWswerecollected.TwohundredandfiftyCWwereexaminedduringroutinemedico-legalautopsy,whileother250circleswerestudiedwithCTangiography.
WeobservedsevendistincttypeofCW,thatcouldcausehypoperfusionduringuSCPandthustovitiateitsprotec-tiveeffect.Resultsaresum-marizedonfigure2,wherehypo/aplasticvesselsarepresentasmissingsegments,vesselsatriskofhypoper-fusionduringuSCParepre-sentedinblackandcerebralzoneatriskofhypoperfusionispresenthatched.Briefly:nAsTypeIAwereclassi-
fiedallCWswithhypo-oraplasiaoftheleftposte-riorcommunicatingartery(PcomA;foundin35.6%ofallcases);
nAsTypeIBwereclassifiedallCWswithhypo-orapla-siaofoftheanteriorcom-municatingartery(AcomA;foundin2%ofallcases);
nAsTypeIIAwereclassifiedallCWswithhypo-orapla-siaofboththeleftPComAandAComA(foundin4.8%ofallcases);
nAsTypeIIBwereclassifiedallCWswithhypo-orapla-siaoftheleftP1orrightvertebralartery(VA;foundin9.2%ofallcases);
nAsTypeIIIAwereclassifiedallCWswithhypo-orapla-siaoftherightA1(foundin6%ofallcases);
nAsTypeIIIBwereclassifiedallCWswithhypo-orapla-siaofboththerightVAandAComA(foundinonly0.2%ofallcases);
nAsTypeIVwereclassifiedallCWswithhypo-orapla-siaofbothrightA1andrightVAorbothrightA1andleftP1(foundin0.8%ofallcases);
ThesesevenvariantCWtypeswerepresentin58.6%ofallexaminedcircles.Thepres-enceofoneofvariantcircles’types,reportedhere,couldexplaintheunfavorablepost-operativepsychical,sensor,and/ormotordeficits,whichoccursinsomepatientsaf-teruSCP.
Ourcurrentfindingssup-porttheneedofextensivepreoperativeexamination(includingCTangio)andme-ticulousintraoperativemon-itoringofcerebralperfusionduringuSCP(NIROetc).
Finally,ourpresentdatasupportthesuperiorityofbi-lateralSCP(rightaxillary+leftcarotidperfusion)overuSCP,becausemostofvariationsdescribedbyusdonothavehemodynamicsignificanceduringbilateralSCP.Reference
1 This work is supported under Grand 2011 program of Medical University, Sofia with Contract No 19/Project 20
Alexander Bernhardt and Hermann
Reichenspurner University Heart Center
Hamburg/ Germany
Plateletsplayamajorroleinthehistoryandprogressionofcoronaryarterydisease.Theseplateletsrapidlyadhere
totheexposedsubendothelialarea,wheretheybecomeactivatedbycon-tactingwithstimulants.Basedonthemoleculartargets,antiplateletdrugsareclassifiedasThromboxaneA2path-wayblockers,ADPreceptorantago-nists,GPIIa/IIIbantagonists,adenosinereuptakeinhibitors,phosphodiesteraseinhibitors,thrombinreceptorinhibitors,andothers.Coronaryarterybypassgraft(CABG)surgeryisanimportanttherapeuticapproachtotreatcoro-naryarterydisease.Long-termsuccessafterCABGdependsonthepatencyofthebypassvessels.Sinceplateletsplayacrucialroleinthepathogenesisofthrombosisinthebloodvessels,ex-
periencewithnewantiplateletdrugsismainlybasedontrialsonPCI.Af-tertheCUREtrialaspirinandclopidog-relwerethegold-standardforpatientswithacutecoronarysyndrome(ACS).IntheTRITONTIMI-38trial,aspirinwas
givenwitheitherprasugrelorclopi-dogrel.Prasugrelhadfavourablemor-tality,despiteanincreaseinobservedbleeding,platelettransfusion,andsur-gicalre-explorationforbleeding.Cau-tiousindicationshouldbemadeinpa-
tientswithahistoryofstroke.Recently,theTRILOGYtrialfoundnodifferenceinoutcomesbetweenclopidogrelandprasugrel.InthePLATOtrialaspirinwasgivenwitheitherticagrelororclopidog-rel.Ticagrelorshowedareductioninprimaryend-pointwithnosignificantincreaseinbleedingrates.AV-Block-ageisacontraindicationforticagre-lorduetoventricularbreaks,whichwereobservedinsomepatients.Cur-rentguidelinesrecommendticagrelorforNSTEMIpatients.Prasugrelandas-pirinarethefavourablecombinationinSTEMIanddiabetics.Administrationofclopidogrelisonlyrecommendedinpa-tientswithcontraindicationsforotherantiplateletdrugs.Todate,large,pro-spectivetrialsonantiplatelettherapyinCABGpatientsarelacking.Resultsareonlyavailableforretrospectivesub-groupanalysisinhigh-riskpatients(STEMI).Both,prasugrelandticagrelorshowedasignificantreductioninmor-talitycomparedtoclopidogrel.
The role of Willis circle variations during unilateral selective cerebral perfusion: a study of 500 circles1
Comparative analysis of available antiplatelet therapies in current clinical management. What agents to choose from and why
Caption
reconstructionversussternalrewiringfollowingfailedsternalclosure J. Zeitani, E. Pompeo, M. Scognamiglio, C. Arganini, G. Simonetti, L. Chiariello (Italy)Discussant: P. Rajesh (Birmingham)
17:30 Two-stageunilateralversusone-stagebilateralsingle-portsympathectomyforpalmarandaxillaryhyperhidrosis C. Menna, M. Ibrahim, C. Andreetti, A. M. Ciccone, A. D’Andrilli, C. Poggi, F. Venuta, E. Rendina (Italy)Discussant: A. Sihoe (Hong Kong)
17:45 Sessionends
Congenital heart disease
Professional Challenges
08:15 Is there a place for palliation in the management of Fallot’s tetralogy?
Room 111
Moderators: V. Hraska, Sankt Augustin; D. Barron, Birmingham
08:15 Introduction:Videorepair V. Hraska (Sankt Augustin)
08:30 Methodsofpalliation D. Barron (Birmingham)
08:45 SurgeryfollowingprimaryrightventricularoutflowtractstentingforFallot’stetralogy:rehabilitationofsmallpulmonaryarteries D. Barron, B. Ramchandani, J. Murala, O. Stumper, J. De Giovanni, T. Jones, J. Stickley, W. Brawn (United Kingdom)Discussant: A.J.J.C. Bogers (Rotterdam)
09:00 IsthereanyneedfortheshuntinthetreatmentoftetralogyofFallot? C. Arenz, A. Laumeier, S. Lutter, H. Blaschczok, N. Sinzobahamvya, C. Haun, B. Asfour, V. Hraska (Germany)Discussant: G. Stellin (Padua)
09:15 WhatistherelationshipbetweenageandoutcomeintetralogyofFallotrepair? B. Mimic, K. Brown, S. Khambadkone, T. Hsia, V. Tsang, M. Kostolny (United Kingdom)Discussant: G. Sarris (Athens)
09:30 NeonatalrightventricletopulmonaryconnectionwithautologoustissueaspalliativeprocedureforpulmonaryatresiawithventricularseptaldefectorseveretetralogyofFallot S. Gerelli, M. Van Steenberghe, D. Bonnet, M. Bojan, P. Vouhé, O. Raisky (France)Discussant: F. Fynn-Thompson (Boston)
09:45 Coffee
10:15 Is there a place for palliation in the management of Fallot’s tetralogy?
Moderators: J Comas, Madrid, G Sarris, Athens; M. Lo Rito, Birmingham
10:15 Howtopromotegrowthoftherightventricularoutflowtractandpulmonaryartery V. M. Reddy (Stanford)
10:30 Howtominimizepostoperativerepairmorbidity M. Hazekamp (Leiden)
10:45 Howtojudgequalityofrepairintheoperatingroom M. Vogt (Munich)
11:00 Impactofdifferentmanagementprotocolsonlong-termoutcome C. Caldarone (Toronto)
11:20 Discussion
11:50 Presidentialaddress
12:30 Lunch
Abstracts
14:15 Aspects of valve repair
Room 111
Moderators: B. Kreitmann, Marseille; B. Asfour, Sankt Augustin
14:15 Repairofincompetenttruncalvalve:earlyandmid-termresults G. Perri, S. Filippelli, A. Polito, D. Di Carlo, S. Albanese, A. Carotti (Italy)Discussant: B. Asfour (Sankt Augustin)
14:30 Reoperationforleftatrioventricularvalvedysfunctionafterrepairofatrioventricularseptaldefect E. Belli, M. Pontailler D. Kalfa, M. Ly, E. Garcia, E. Le Bret, R. Roussin, V. Lambert (France)Discussant: C. Margarita (Marseille)
14:45 RepairofEbstein’sanomalyinneonatesandsmallinfants:impactofrightventricleexclusion S. Sano, S. Kasahara, Y. Fujii, S. Arai (Japan)Discussant: O. Ghez (London)
15:00 A17-yearexperiencewithmitralvalverepairwithartificialchordaeininfantsandchildren S. Oda, T. Nakano, K. Hinokiyama, D. Machida, H. Kado (Japan)Discussant: V. Tsang (London)
Continued from page 22
Continued on page 26
Vassil Papantchev Alexander Bernhardt
Figure 1
Figure 2
EACTS Daily News Monday 29 October 2012 25
Cardiac: Abstracts 10:15–11:45 Room 115
Takeshi Komoda
Deutsches Herzzentrum Berlin, Berlin Germany
InGermany,thereisadilemmainthetherapyforhearttransplant(HTx)candidateswithend-stageheartfailure.Earlierventricularassistde-vice(VAD)implantationmayreducetheriskof
dyingfromheartfailure;however,oncethepatientreceivesaVAD,thepossibilityofreceivingHTxre-cedes.
IfapatientwhowasstableoninotropicsupportaftercardiacdecompensationandreceivedaVADaf-terurgencylistingforHTx,unfortunatelydied,theimplantationofaVADatanearlierstagewouldhaverescuedthepatient(plan#1inFigure1).However,earlierVADimplantationmaydeprivethepatientofachanceforHTxafterurgencylisting.InGermany,mostHTxcandidatesreceiveHTxinurgentstatus,andpatientswhoreceiveaVADareawardedurgentstatusonlyaftertheoccurrenceoflife-threateningdevice-relatedcomplications.Weinvestigatedtheva-lidityofearlyVADimplantationfromtheviewpointofheartallocationinaretrospectivecohortstudy.
Among576adultcandidatesfordenovoHTxwhowerenewlylistedasT(transplantable)byEuro-transplantwithoutVADsupportinourcenter,310progressedtoacriticallyillstatus,i.e.,primarilyur-gencylisting(GroupU,n=208)orprimarilyVADim-plantation(GroupVAD,n=102).Inthelattergroup,patientswhoreceivedacontinuousflowLVAD(leftventricularassistdevice)atINTERMACSlevel3(i.e.,stableoninotropicsupport)wereassignedtoGroupcLVAD3(n=50).
SurvivalonthewaitinglistinGroupUwassig-nificantlybetterthaninGroupcLVAD3.FreedomfromHTxinGroupUwassignificantlylowerthaninGroupcLVAD3.Accordingly,thesurvivalrateatthemedianwaitingtimeforHTxinGroupcLVAD3(43.7%at24.9months)wasmuchlowerthanthatinGroupU(95.0%at1.7months).
OverallsurvivalofGroupUwassignificantlybetterthanthatofcLVAD3(57.3%vs.35.8%for5-yearsurvival,p=0.026).Eveniftheoverallsurvivalrates
weretobeequalbetweenthetwogroups,thequal-ityoflifeandriskofdevice-relatedcomplicationsmaybedifferentbecausepatientsinGroupUre-ceiveHTxmuchearlierthanthoseinGroupcLVAD3andpatientsinthelattergrouphavetowaitforHTxundermechanicalcirculatorysupportuntillife-threateningdevice-relatedcomplicationsoccur.
Intheabove-mentionedcircumstances,wecannotrecommendearlierVADimplantationinHTxcandi-datesatINTERMACSlevel3ingoodclinicalcondi-tion,whoaregoodcandidatesforurgencylisting.AsanalternativetoearlyVADimplantationinthepatientsatINTERMACSlevel3,wepostulateVADimplantationpriortocardiacdecompensation(plan#2inFigure1).WhenaVADisimplantedinHTxcandidateswhoareinstablestatusandwithoutino-tropicsupport,thismaypreventpotentialdeathfol-lowingVADimplantationatINTERMACSlevels1,2,and3(asshowninthecasesa,b,andcinFig-ure1).However,thevalidityofVADimplantationinthesepatientsshouldbeinvestigatedfurtherinfu-turestudies.
Who benefits from early VAD implantation?
Acute and chronic results us-ing NeoChord’s sternal-sparing, beating-heart, mitral valve repair system to implant artificial chor-dae tendinae are encouraging.
NeoChord,amedicaldevicecom-panyfocusedonminimallyinva-
sivemitralvalverepair,hascomplet-edenrollmentforitsongoing‘TACT’(TransapicalArtificialChordaeTendi-nae)clinicaltrialinEurope.
“The 30-patient TACT trial nowhasnumerouspatientsshowingone-andeventwo-yeardurabilityofrepairwithclini-callysignificantreductionsinmitralregurgitation.Acuteproceduresuccessratesinthesecondhalfof thetrialwere94%withexcellentearlydura-bilityresults.ThesecombinedresultssuggestthatNeoChordwillmakeastrongcontributionintheevolvingfieldofmitralrepair,”saidJohnSeaberg,ChairmanandCEO,NeoChord.
“WeareverypleasedthatwehavesuccessfullyconcludedenrollmentintoourTACTtrial,asthesepatients suffering from mitral regurgitation arepotentially avoiding the complications and trau-maassociatedwithtraditionalopen-chestsurgeryperformedonastoppedheart,”addedJohnZent-graf,VPof R&D (vicepresident of research anddevelopment)atNeoChord.Headdedthat“WelookforwardtoconductingadditionalstudiesviatheTACTRegistryinEuropecommencinginear-ly2013.”
“Follow-up visits at 12and24monthspost-opconfirmthatthevastmajorityofpatientsop-erated on using the NeoChord technology con-tinuetoshowresolutionorsignificantreductionofmitralregurgitationuptotwoyearsaftertheprocedure,”saidGiovanniSpeziali,M.D.,acardi-acsurgeonwhoistheprimaryinventoroftheNe-oChorddevice.“Theseresultscomparefavorably
to thoseobtainedwith tradi-tionalsurgicalrepairofseveremitralregurgitation,”saidDr.Speziali.Headdedthat“Iamverypleasedwiththeprogresswe have made in both pa-tient selectionandproceduremethodology.”
The NeoChord procedurewasdevelopedtotreatmitralprolapse caused by rupturedor elongated chordae tendi-nae — the primary cause ofdegenerativemitral regurgita-
tion–—viaminimallyinvasiveimplantationofar-tificialchordaetendinae.Thetechnologywasde-veloped by Dr. Speziali, University of PittsburghMedical Center, along with Richard Daly, M.D.,acardiacsurgeonfromMayoClinic,andCharlesBruce,M.D.,cardiologist,alsoofMayoClinic.ThetechnologyislicensedexclusivelytoNeoChordInc.
Based in Eden Prairie, Minn., NeoChord is aprivately held medical technology company fo-cusedonadvancingthetreatmentofmitralregur-gitation. The Company expects to commercial-izeasurgicaldeviceforminimallyinvasivemitralvalve repairvia surgical implantationofartificialchordaetendinae.Degenerativemitralregurgita-tionoccurswhentheleafletsoftheheart’smitralvalvedonotcloseproperly,usuallyduetoruptureor elongation of the chordae tendinae (chords)that control the leaflets’motion.Duringpump-ing, the“leak” in themitralvalvecausesbloodtoflowbackwards(mitralregurgitation)intotheleftatrium,therebydecreasingbloodflowtothebody.Mitralregurgitationisaprogressivediseasethatleftuntreatedcanresultinatrialfibrillation,congestiveheartfailure,anddeath.Formorein-formation,visit:www.NeoChord.com.TheNeo-Chorddevice is an investigational device and isnotavailableforcommercialuse.
NeoChord completes enrollment for ‘TACT’ clinical trial
Figure 1: Graphic of early VAD implantation plans #1 and #2. CD: cardiac decompensation, HU: high
urgency status
John Seaberg
26 Monday 29 October 2012 EACTS Daily News
Congenital: Professional Challenges 10:15–11:45 Room 111
Thoracic: Abstracts 10:15–11:45 Room 133/134
Thoracic: Abstracts 10:15–11:45 Room 133/134
Mark Hazekamp Leiden University Centre and
Amsterdam Academic Medical Centre, The Netherlands
TetralogyofFallot(TOF)isthebeststudiedcongenitalheartdefectworldwide.TOFre-pairstartedearlyinthe1950’iesandmortal-ityhasdramaticallydecreasedto1-2%inthe
currentera.Althoughpostoperativemortalityisverylow,mor-
bidityremainssignificant.Themajordeterminantsofpost-repairmorbidityaredurationofmechanicalven-tilation,lengthofICUandhospitalstay.Pleuralfluiddrainagemaybenecessaryanddelaysdischargefromhospital.
DiastolicdysfunctionoftheRVresultsinhighRApressureandprolongedpleuralfluidproduction.SomedegreeofLVimpairmentiscommonandhemodynam-icsmaybecompromisedaftersurgery.Volumead-ministrationisfrequentlyneededandprolongspleuralfluiddrainageandICUstay.
Theacutechangefromapressure-loadedtoamainlyvolume-loadedRVfollowingrepairisanim-portantreasonforpostoperativemorbidity.RVhyper-trophyincreaseswithtimeandresultsindiastolicdysfunction.Transannularpatchaugmentationisnec-essaryinamajorityandincisingintotheRVaddstofunctionalloss,especiallyifthisisusedfortransven-tricularVSDclosure.Transannularpatchingresultsinpulmonaryvalveinsufficiencyandaccountsforan-otherinsulttoRVfunction.
AsecondcauseforRVfailureafterTOFrepairisin-creasedpulmonaryvascularresistance.Pulmonaryar-
teries(PA’s)matureinthefirstfewmonthsoflife.Later,theymayremainsmallorshowobstructionafterprevious(Blalock)shuntplacement.
TominimizepostoperativemorbiditywethusneedtofocusonbothRVandpulmonaryarteries.IfTOFrepairisperformedlate,theRVwillbehypertrophicwithdiastolicdysfunction.IfTOFrepairisperformedinthefirstthreemonthsoflife,PAvasculaturehasnotfullymaturedanddiametersmaybeonthesmallside.Bothsituationsleadtopostoperativemorbidity.Tim-ingisimportantandalthoughTOFrepaircanbedoneinthefirstthreemonthswithoutincreasedmortality,morbidityismoresevereandprolongedthanwhenre-pairisperformedlater.Furthermore,symptomsareuncommoninthefirstmonthsandveryearlyrepairisusuallynotnecessary.WaitinglongerthanoneyearincreasesRVhypertrophyanddoesnotcarryfurtherbenefits.
SurgicaltechniquesshouldbedesignedtominimizeRVdamage:TransatrialVSDclosureisalwayspossi-bleandresectionofRVOTmuscletissuecanbeper-formedeffectivelybytranspulmonary-transatrialap-proach.Pulmonaryinsufficiencyfromtransannularpatchingcanbereducedbymakingthepatchnottoowide,bypreservingthenativepulmonaryvalvewhen-everpossibleandbyaddingamonocusp.
InLeidenthepolicyistorepairTOFpreferablyat5to10months.Ifsymptomsoccurearlier,amodifiedBlalock-shuntisplaced.Transpulmonary-transatrialap-proachisusedtominimizetheRVOTincision.WhentheRVOTisnarrowoveralongerdistance,itcanbenecessarytoextendtheincisionfurtherintotheRV.In
thesecasesweuseatransannularpatchwith(Gore-tex)monocuspvalvetoprotecttheRVasmuchaswecan.Sincelongwehavestoppeddoingveryearly(un-derthreemonthsofage)TOFrepairwhenweob-servedthatthisledtolongerandmorecomplicatedICUstays.
An Alpe Adria Thoracic Oncology Multidisciplinary Group Study (ATOM 014)G. Aresu, G. Masullo, E.Baracchini, A.
Follador, F. Grossi, A. Morelli
PatientswithstageIIIAnon-smallcelllungcancer(NSCLC)involvingipsilateralmedias-tinalnodes(pN2)represent
aheterogeneouspopulationwithdif-feringclinicalpresentationsandprog-noses.
TreatmentguidelinesforstageIIIApN2NSCLCareevolving,andtheman-agementofthesepatientsremainschallenging.
Subclassificationofthisheterogene-ouspopulation,andtheidentificationofdistinctprognosticsubgroups,mayallowtheoptimizationofclinicaltrialdesign,withthepotentialtoimprovetreatmentoutcomes.
Molecularmarkers,includingthoseinvolvedintheregulationofcellprolif-eration,differentiation,apoptosis,andininvasion,angiogenesis,andmetasta-sis,havethepotentialtofurtherrefinethisprocess.
Inthisstudy,weusedimmunohisto-chemistryontissuemicroarray(TMA)toevaluatetheexpressionandprognosticsignificanceofapanelof10molecular
markersinpatientswithstageIIIApN2NSCLCtreatedsurgicallywithcura-tiveintentwhodidnotreceiveadjuvantchemotherapyorbiologictherapies.
Thepanelofmarkersincludedcellcy-cleregulators(cyclinD1andcyclinB1),growthfactorreceptors(c-erbB-1andc-erbB-2,c-kit),antiapoptoticfactors(bcl-2andsurvivin),anenzymeinvolvedinthearachidonicacidcascadewithan-giogenicproperties(cyclooxygenase-2[COX-2]),andproteinsinvolvedinthedegradationoftheextracellularmatrixmetalloproteinases(MMPs)-2and-9.
MethodsPrimarytumourtissuemicroarrays(TMAs)wereconstructedandsectionsusedforimmuno-histochemicalanaly-sisofepidermalgrowthfactorreceptor,ErbB-2,c-kit,cyclo-oxygenase-2,sur-vivin,bcl-2,cyclinD1,cyclinB1,metal-loproteinase(MMP)-2,andmmP-9.Uni-variateandmultivariateanalysesandunsupervisedhierarchicalclusteringanalysisofclinicalpathologicandim-mune-stainingdatawereperformed.
ResultsBcl-2(P<0.0001)andcyclinD1(P=0.015)weremorehighlyexpressedinsquamouscellcarcinoma(SCC),whereasmmP-2(P=0.009),mmP-9
(P=0.005),andsurvivin(P=0.032)hadincreasedexpressioninotherhisto-logicsubtypes.Inunivariateanalysis,SCChistologyandcyclinD1expres-sionswerefavourableprognosticfac-tors(P=0.015andP<0.0001,respec-tively);bycontrast,mmP-9expressionwasassociatedwithworseprogno-sis(P=0.042).Inmultivariateanalysis,cyclinD1wastheonlypositiveprog-nosticfactor(P<0.0001).Unsuper-visedhierarchicalclusteringanalysisofTMAimmune-stainingdataidentifiedfivedistinctclusters.Theyformedtwosubsetsofpatientswithbetter(clus-ters1and2)andworse(clusters3,4,and5)prognoses,andmediansur-vivalof51and10months,respectively
(P<0.0001).Fig1.ThebetterprognosissubsetmainlycomprisedpatientswithSCC(80%).
ConclusionHierarchicalclusteringofTMAimmune-stainingdatausingalimitedsetofmarkersidentifiespatientswithstageIIIA-pN2-NSCLCathighriskofrecur-rence.
Theintegrationofclinicalparame-terswithmolecularprofilingdatawillbecomeincreasinglyimportantinthemanagementofpatientswithNSCLC,tomakeanaccuratediagnosisandtotailortreatmentdecisiontotheindivid-ualpatient.
P.Rybojad, A.Jabłonka, B.Wilczyńska,
J.Tabarkiewicz Medical University of Lublin, Poland
Despiteextensiveresearch,theroleoftheindivid-ualcomponentsoftheimmunesysteminhost-neo-plasminteractionsisnotfullyspecified.Theanti-can-cerresponseisofteninefficientbecauseoftumorcells’contraction.Howeverifpatientistreatedwith
surgery,chemotherapyorradiotherapy,changesofimmunologicalparametersareverydifficulttobeinterpreted,becausetoomanyvariablescaninflu-encethecurrentimmunologicalstatus.Inthecan-cerbearingpatientswecanobservetwoantagonis-ticphenomena:anti-cancerimmuneresponseandcancerinducedimmunosuppression.Eradicationoftumourshallstopthenegativeinfluenceofneoplas-
ticcellsandboostimmuneresponseeliminatingre-sidualcancercells.Unfortunatelypossibleseveretrauma,associatedwithinvasivesurgicalproceduresmayinducedown-regulationofimmunereactionandpromoterecurrenceofdisease.Thephenom-enonofimmunosuppressioninducedbysurgeryiswidelydescribedastheadverseeffectofsurgicalin-
Tetralogy of Fallot: How to minimize postoperative repair morbidity
Prognostic Stratification of Stage IIIA pN2 Non-small Cell Lung Cancer by Hierarchical Clustering Analysis of Tissue Microarray Immunostaining Data
Enzyme-linked immunosorbent spot for postoperative immununosupression monitoring of patients with lung cancer
Mark Hazekamp
Figure 1: overall survival by cluster based on hierarchical clustering analysis
15:15 PreliminaryresultsoftheRossprocedureassociatedwithautograftreinforcementusingareimplantationtechnique M. Ly, D. Kalfa, A. Serraf, E. Garcia, A. Lipey, A. Baruteau, E. Belli (France)Discussant: J. Hörer (Munich)
15:30 Outcomeofavalverepair-orientedstrategyfortheaorticvalveinchildren A. Abousteit, N. Prior, G. Soda, P. Reddy, R. Dhannapuneni, P. Venugopal, J. Lim, N. Alphonso (United Kingdom)Discussant: R. Prêtre (Zürich)
Focus Session
16:15 Heart rejuvenation
Room 111
Moderators: W. Brawn, Birmingham; J. R. Pepper, London; D. J. Chambers, London; M. Kanani, London
16:15 Cardioplegia D. Chambers (London)
16:35 Stemcells P. Menasche (Paris)
16:55 Exvivoheartandlungpreservation A. Simon (Harefield)
17:15 PreconditioninganditsfutureV. Venugopal (London)
17:45 Session ends
Vascular disease
Professional Challenges
08:15 Aortic arch disease I
Room 113
Moderators: C. A. Mestres, Barcelona; P. P. Urbanski, Bad Neustadt
08:15 Stateoftheartinaorticarchsurgery J. Bachet (Abu Dhabi)
08:30 Mid-tolong-termresultsafteraorticarchrepairusingafour-branchedgraftwithantegradeselectivecerebralperfusion S. Numata, Y. Tsutsumi, O. Monta, S. Yamazaki, H. Seo, R. Sugita, S. Yoshida, H. Ohashi (Japan)Discussant: M. Pasic (Berlin)
08:45 Isthebranchedgrafttechniquebetterthantheenbloctechniquefortotalaorticarchreplacement? M. Shrestha, A. Martens, S. Behrend, I. Maeding, A. Haverich (Germany)Discussant: D. Loisance (Paris)
09:00 Aorticarchreoperation:asingle-centreexperienceofearlyandlateoutcomein57consecutivepatients M. Moz, S. Leontyev, M. Borger, M. Misfeld, F. Mohr (Germany)Discussant: B. Mochtar (Maastricht)
09:15 Openaorticarchreplacementintheeraofendovasculartechniques P. Urbanski, M. Raad, A. Lenos, P. Bougioukakis, M. Zacher, A. Diegeler (Germany)Discussant: H. Jakob (Essen)
09:30 TheroleofWilliscirclevariationsduringunilateralselectivecerebralperfusion:astudyof500circles V. Papantchev, V. Stoinova, A. Alexandrov, D. Todorova-Papantcheva, S. Hristov, D. Petkov, G. Nachev, V. Ovtscharoff (Bulgaria)Discussant: T. Sioris (Tampere
09:45 Sessionends
Simulation Workshop
08:30 TEVAR Simulation Workshop
Room Vallvidrera, Hotel AC Barcelona Forum
Objectives:
nAfter the course, participants will be able to describe the rationale for doing TEVAR and list the procedural steps of the implantation of a Valiant Captivia stent graft for a thoracic aortic aneurysm and/or rupture
Participant Profile:
nSurgeons interested in understanding the endovascular treatment of the thoracic aorta with the Medtronic Valiant Captivia stent graft with no/limited experience in this field
Logistics:
nSlots of 1 hour for two registered Annual Meeting delegates at a time. Registration on a first-come, first-served basis via the Information Desk in the main registration foyer area
Note: This programme is repeated on Tuesday 30 October at the same time and in the same venue
16:30 Sessionends
Simulation Workshop
08:30 Mentice Simulation Course
Room Tres Torres, Hotel AC Barcelona Forum
Objectives:
Continued from page 24
Continued on page 28
Continued on page 27
EACTS Daily News Monday 29 October 2012 27
terventionsonleukocytesandse-cretionofseveralcytokines.Threetypesoflaboratoryassays:tetram-ers,intracellularflowcytometryandenzyme-linkedimmunosorbentspot(ELISPOT)assayhaveemergedasfirst-linemethodsformonitoringofspecificimmuneresponse.TheELIS-POTmethodpermitsenumerationofindividualantigen-specificcellsthroughdetectionofantigen-trig-geredsecretionofcytokines.Incon-trasttosupernatant-basedassays(ELISAorbeadsarrays),thepro-teinsareimmediatelycaptured,be-foretheyevadedetectionbybind-ingtoreceptors,dilutinginthesupernatant,ordegradingbypro-teases.Recentclinicaltrialsfocusedoncancervaccines,testedinavari-etyofneoplasms,haveprovedthatELISPOTcanbetreatedasagoldenmethodformonitoringofspecificanti-tumourimmuneresponse.Theaimofourstudywasmonitoringof
changesinspecificandnon-spe-cificimmuneresponseinpost-op-
erativeperiodin30patientswithresectedlungcancer.WeusedELIS-POTforenumerationofcellsse-cretingpro-andanti-inflammatorymediators(IFN-y,granzymeB,per-forines,IL-4,IL-5,IL-10,IL-17a).Bestofourknowledgewepresentthefirstreportassessingtheimpactofsurgicaltreatmentonthespecificimmuneresponseagainsttumourantigens.
Ourresultssuggestanimmuno-suppressiveeffectofsurgeryonthespecificandnonspecificimmunestimulation.ThiseffectisparticularlyexpressedinrelationtoTh1-typeim-munecalresponsewhichisassoci-atedwithdirecteliminationofcan-cercells.Anothernegativefactistheincreaseofthesecretionofimmuno-suppressiveIL-10inresponsetocan-cerantigens.
Thepostoperativeimmunosup-pressionisthemostnoticeableon
thefirstdayaftersurgery.Itreturnstopre-operativelevelafterapproxi-matelyfourweeks.Thisoccurrenceisextremelyunfavorable,consider-ingthepossibilitythatsurgicalma-nipulationmayresultinintroducingtumorcellsintothebloodstream.Thesephenomenacanbeassoci-atedwithanincreasedriskofme-tastasisandrecurrenceofthedis-ease.Additionally,theweakeningofnon-specificsecretionofIFN-γ,granzymeBandperforinesmayel-evatetheriskofinfectiouscompli-cationsaftersurgery.Theresultsobtainedbyourteammayhavesignificantimplicationsforbothplanningandpreventingofperi-operativeoncologicalandbacterio-logicaltreatment.Additionallyourresultsopenthegatesforinten-siveresearchonpre-andpostop-erativeimmunostimulation,whichwillbeabletopreventsurgeryin-duceddown-regulationofimmuneresponse.
J. TabarkiewiczP. Rybojad
Continued from page 26
Cardiac: Abstracts 10:15–11:45 Room 114
Perioperative and short-term results using the “zipping” techniqueStephan Kische institute
MitraCliphasbeenre-centlyproposedtotreatmitralvalvere-gurgitation(MVR).
Inpatientswithextremeventricu-lardilatationandcoaptationteth-ering,placementofasingleclipinthemiddleoftheanteriorandposteriorleafletsofthemitralvalvemaynotbetechnicallypos-sibleand/ormayleadtoincom-pleteMVRcorrection.
Insuchpatientswehavede-velopeda´zipping´technique.Multipleclipsareplacedstart-ingfromthepostero-medialto-wardstheantero-lateralcom-missure(seepicture).Inthiswayleaflets“grasping”isfacilitatedandtensionhomogeneouslydis-tributedalongthenewcoapta-tionline.Fourteenpatientswith
severeMVRsecondarytoexten-siveleaflettetheringweretreatedby´zipping´.LogisticEuro-SCOREwas27.7±8.7.
Aminimumof3clipsperpa-tientwasplaced.AttheendoftheprocedureMVRpassedfrom3.6±0.5to0.9±0.4(p<0.0001).Dobutamineechocardiography
wasperformedbeforedischarge.AlthoughMVRremainedsta-ble,transmitralgradients(Rest3.4±0.6vs.Stress4.0±0.5mmHg;p<0.0001)andMVorificearea(Rest2.9±0.2vs.Stress3.9±0.4cm2;p<0.0001)increasedsignificantly.At6-monthMVRde-greewasunchanged.OnepatientdiedforcardiaccausesandallthesurvivingpatientsareinNYHAI-II.Ourpreliminarydatainalim-itednumberofpatientessuggeststhat´Zipping´usingmultipleMi-traClipscanbeperformedsafelyinpatientsconsidereduntreatablefollowingthestandardclippingtechnique.Progressiveapproxi-mationoftheMVleafletsstartingfromthemedialcommissureandusingmultipleMitraClipscanleadtosignificantreductionofMVR.Applicationofthe´zipping´tech-niquedoesnotseemtoleadtopathologicalincreaseinMVgra-dientsduringmidtermfollow-up.
Mitral valve repair using multiple MitraClips
Stephan Kische
28 Monday 29 October 2012 EACTS Daily News
Continued on page 28
Cardiac: Focus Session 10:15–11:45 Room 122/123
Cardiac: Abstracts 10:15–11:45 Room 112
Hunaid A Vohra, Robert N Whistance, Laurent
deKerchove, Jawad Hechadi, David Glineur, Phillipe
Noirhomme, Gebrine El Khoury Department of
Cardiovascular and Thoracic Surgery, Cliniques Universitaires
Saint-Luc, Brussels, Belgium.
Traditionally,concomitantaortic(AI)andmi-tralvalveinsufficiency(MI)hasbeentreatedwithdoublevalvereplacement(DVR).Al-thoughmitralvalverepair(MVr)forMIisthe
standardofcare,theoutcomesofaorticvalverepair(AVr)areimproving.Thisisduetobetterunderstand-ingofthefunctionalanatomyofAV,AImechanismsanddevelopmentofaclassificationsystem.DrVohraperformedthisresearchduringhisfellowshipatBrus-sels.HeevaluatedoutcomesofconcomitantAVr/MVrinaspecialistcentreperformedovera13-yearpe-riod.Sixtyfivepatientswereidentified.Meanagewas56.4±15.8yearsand70%weremales.Therewere8bicuspidAV(12%).IndicationsforAVrwereAI>2+(n=30,46%),AI≥2+withaorticdilatation(n=20,30%)andaorticdilatationonly(n=4,6%).Allpa-tientshadMIpreoperatively.Twelvepatients(18%)hadevidenceofimpairedLVEF(<50%).Sixpatients(9%)hadpreviouslyundergonecardiacsurgery.Un-derlyingAVpathologyincludeddegeneration(n=46;70%),bicuspidAV(n=8;12%),Marfan’sdisease(n=4;6%),rheumatic(n=5;8%)andendocarditis(n=2;3%).AetiologyofMVdiseasewasdegenerative(n=33;50%),rheumatic(n=12;18%),endocarditis(n=4;6%),functional(n=10,15%),ischaemic(n=2,3%)andother(n=4;6%).Themostfrequentlyper-formedAVprocedureswerecusprepair+annuloplasty(n=28,43%),AV-sparingprocedure+cusprepair(n=9,14%),AV-sparingprocedurealone(n=8,12%)
andannuloplastyonly(n=8,12%).SixteenDavid(25%)andfiveYacoub(8%)procedureswereper-formed.MVproceduresincludedannuloplastyonly(n=52,80%),cuspresection(n=18,28%)andneo-chordaeformation(n=10,15%).Concomitantpro-cedureswereperformedin21patients(32%).Theseincludedtricuspidannuloplasty(n=10),CABG(n=7),CABG+Dor(n=1),tricuspidannuloplasty+Maze(n=1),Maze(n=1)andleftatrialmyxomaexcision(n=1).
Therewasonehospitalmortality(1.5%).Twopa-tients(3%)requiredpermanentpacemakerinser-tionwhileonepatient(1.5%)requiredearlyAVre-operation.Atdischarge,nopatienthadAI>2+ascomparedto30patientspre-operatively(p<0.001).PeakAVgradientwas13.6±12.4mmHg.Atdis-charge,meanLVEDDwas48±7mmcomparedto59±9mmpre-operatively(p<0.007).Meanfollow-upwas62±45months.Atlatestfollow-up17pa-tientswereNYHA≥2ascomparedto52patentspre-operatively(p<0.001).At1,5and10years,freedomfromcardiacdeathwas100%,93.4±3.7%and88.5±5.9%,respectively.Therewere8valvere-interventionsandfreedomfromvalvere-inter-ventionsat1,5and10yearswas95.3±2.6%,91.6±3.6%and78.4±8.0%,respectively(fig-ure).At1,5and10years,freedomfromAI2+was98.2±1.7%,93.4±3.7%and88.3±5.8%whilefree-domfromMI2+was96.4±2.4%,93.3±3.8%and93.3±3.8%.AVr/MVrissafeandhasexcellentover-allsurvivalandfreedomfromvalve-relatedeventsupto10yearspost-surgery.ThissuggeststhatAVr/MVrisaneffectivealternativetoDVRorAVRplusMVrinpatientswithconcomitantAIandMI.AVr/MVrmayalsobeanattractiveoptioninrelativelyyoungpatientswhowishtoavoidwarfarinwhere
therateofstructuralvalvefailurewouldberela-tivelyhigh.AlearningcurveexistsforAVr/MVrandwidertraininginternationallyis,therefore,war-ranted.FuturestudiesarerequiredtoconfirmtheeffectivenessofAVr/MVragainstproceduresinvolv-ingvalvereplacement.
Long-term outcome of valve repair for concomitant aortic and mitral insufficiency
Hunaid Vohra (left) and Gebrine El Khoury
nUtilizing the endovascular Mentice VIST-Lab simulator for an introduction to EVAR. You will perform a variety of different EVAR focused anatomies utilising the real devices in a safe and controlled environment.
Participant Profile:
nIdeally the participants will have at least a basic knowledge of wire and catheterisation skills. The participants will be able to perform an EVAR on a variety of different anatomies with 2 or 3 part graft systems.
Logistics:
nSlots of 1 hour for three registered Annual Meeting delegates at a time. Registration on a first-come, first-served basis via the Information Desk in the main registration foyer area.
Note: This programme is repeated on Tuesday 30 October at the same time and in the same venue
17:00 Sessionends
Simulation Workshop
08:30 TEVAR pre-case planning course with OsiriX
Room Montjuic, Hotel AC Barcelona Forum
Objectives:
The objective of the course is to teach the participants how to:
nimport images from a CT scan
nview one or multiple series of images from a study
nnavigate through the most important commands and toolbars
ncustomize toolbars
nuse the main analysis and measurement tools
nprecisely perform the measurements with the MultiPlanar Reconstruction Display (MPR) and 3D volume rendering
nexport images, videos or DICOM files
In TEVAR, pre-case planning is key for achieving clinical success – failing to plan is planning to fail. Before entering the operating room, an analysis of the case is mandatory to properly understand the pathology and choose the optimal treatment. This course aims to provide an understanding of the use of OsiriX for the analysis of the pathologies of the thoracic aorta and the planning of potential treatments. OsiriX is becoming a reference in the endovascular market because it is easy to use, it includes all the tools needed for analysis and pre-case planning such as multiplanar reconstruction, 3D reconstruction, centerline and sizing tools; more, a free version is available. The course aims to be predominantly practical. After a brief introduction, the participants will be using individual Mac computers to go through the course and practise all the concepts explained.
Logistics:
The course is restricted to 25 registered Annual Meeting delegates.
Registration:
Fee 80 Euros including VAT. Registration on a first-come, first-served basis via the EACTS User area
17:00 Sessionends
Professional Challenges
10:15 Aortic arch disease II: Video session on all proven approaches for effectively treating the arch
Room 113
Moderators: W. Harringer, Braunschweig; T. Carrel, Berne
10:15 Archrerouting–single M. Czerny (Berne)
10:25 Archrerouting–double M. Grimm (Vienna)
10:35 Archrerouting–triple E. Weigang (Mainz)
10:45 Conventionalarch–island R. De Paulis (Rome)
10:55 Conventionalarch–branched P. Urbanski (Bad Neustadt)
11:05 Conventionalelephanttrunk Y. Okita (Kobe)
11:15 Frozenelephanttrunk G. Weiss (Vienna)
11:25 ShouldaorticarchreplacementbeperformedduringinitialsurgeryforaorticrootaneurysminpatientswithMarfansyndrome? F. Schoenhoff, A. Kadner, M. Czerny, J. Schmidli, T. Carrel (Switzerland)Discussant: T. Dessing (Nieuwegen)
11:40 Discussion
11:50 Presidentialaddress
12:30 Lunch
Abstracts
14:15 Elephant trunk: conventional and frozen
Room 113
Moderators: C. Hagl (Munich); M. Karck, Heidelberg
14:15 Thirtyyearsofclassicalelephanttrunk:single-centreexperience M. Shrestha, H. Krueger, A. Martens, F. Fleissner, F. Ius, A. Haverich (Germany)Discussant: M. A. A. M. Schepens (Brugge)
Continued from page 26
Continued on page 30
Berlin-TAVI-Team Deutsches Herzzentrum
Berlin, Berlin, Germany
Simultaneousangiographiccontrolduringslowandgrad-ualvalvedeploymentsignif-icantlyimprovedthecrucial
partofthetranscatheteraorticvalveimplantationprocess.Thepositionofthevalvecanbepreciselydeterminedduringvalvedeploymentbypushingorpullingthecatheterwiththemountedprostheticvalve.Angiographyenabledperfectvisualizationofthepositionoftheprostheticvalveanditsrelationshiptothecoronaryarteriesthroughoutthevalvedeployment.Contrastmediumre-mainsintheproximalpartoftheas-cendingaorta(aorticroot)dueto“noflow”throughtheaorticvalveduringrapidpacing.Inthismannerthepro-cedureiscompletelyundercontrolandundervisualization.
ModifiedImplantationTechnique:Theproperpositionofthevalveisde-terminedaccordingtotheannularplane.Thetubusisdisconnectedfromtherespirator,rapidpacingisstartedandtheballoonisinitiallyexpandedbyabout30%–40%andinthismomentangiographyisperformed(either10mlor20mlofcontrastmedium)viaapig-tailcatheterthatispreviouslypulledbackfromthesinusofValsalva2-3cmdistallyintothemid-partoftheas-cendingaortajustabovethesinotubu-larjunction.Thepositionofthevalveiscorrectedifnecessary.Thentheballoonisfurtherinflatedtoabout60%–70%
andthevalveisopenedabout50-60%sothatsecondfinecorrectionofthevalvepositionisstillpossible.Theidealpositionofthevalveisobtainedbypre-cisecorrectionofthepositionrelat-ingtothecoronaryarteryostia,nativevalve,andnativeaorticvalveannulus,whichinthiswayareperfectlyvisual-ized.Finally,forcedcompleteinflationoftheballoonisperformedandthevalvedeployedinthedesiredposition.
Usually,onlyoneshotofcontrastme-diumintotheascendingaortaforang-iographyisnecessaryduringvalvede-ployment.Rarely,especiallyinpatientswithahighriskforocclusionoftherightcoronaryartery,suchasinpatients
withabulkyleafletorshortdistancetooneofthecoronaryarteries,precisepo-sitioninganddeploymentofthevalveareveryslowandasecondinjectionofthecontrastmediumintotheascendingaortaisrequired.Althoughtheinflationoftheballoonduringvalvedeploymentisperformedslowly,thevalvedeploy-mentremainsaveryshortprocedure,lastingonlybetween5and10seconds.
Angiographicvisualizationimprovesthesafetyoftransapicalaorticvalveim-plantationandsimplifiesvalveposition-ingandthevalvedeployingtechnique.Ittransformstheprocedurefromapar-tiallyuncertainand“halfblind”pro-ceduretoahighlycontrollabletech-
niquethatismorecongruentwiththe“surgicalwayofthinking”tobeableto“controlallpartsofaprocedure.”Wehighlyrecommendthatthissimplebutveryeffectiveandhelpfulmodifica-tionbeusedforalltranscathetervalveimplantations,asforthetransfemo-ralapproachforaorticvalveimplan-tation.Wehavebeenusingthemod-ifiedtechniquesince2008inalmost800ourTAVIpatients.ThetechniquewaspublishedintheAnnalsofTho-racicSurgeryin2010.(PasicM,DreysseS,DrewsT,etal.Improvedtechniqueoftransapicalaorticvalveimplantation:“TheBerlinaddition”.Ann Thorac Surg2010;89:2058-60.)
Slow valve deployment during angiographic visualization of the aortic root during TAVI – the “Berlin addition”
Berlin-TAVI-Team
EACTS Daily News Monday 29 October 2012 29
Advert
Cardic: Professional Challenges 10:15–11:45 Room 116/117 Cardiac: Abstracts 10:15–11:45 Room 115
Espen Fengsrud Sweden
Atrialfibrilla-tion(AF)isthemostcom-montypeof
arrhythmiaamongpa-tientsundergoingaor-tocoronarybypasssur-gery(CABG).Upto9%ofthepatientspresentthemselveswithpre-operative
AFaccompanyingtheircoronaryarterydis-easeandapproximatelyone-thirdofCABGpatientswithpreoperativesinusrhythmsus-tainanepisodeofpostoperativeAF.
Atrialfibrillationisassociatedwithadou-bledmortalityriskandafivefoldincreasedriskofstroke.Incardiacsurgerypatients,pre-operativeAFisanindependentriskfactorforshort-andlong-termmortality.Moresurpris-ingly,anepisodeofpostoperativeAFisalsoassociatedwithdecreasedlong-termsurvival,whichismainlyexplainedbyanincreasedriskofcardiovasculardeath.
TheincreasedmorbidityandmortalityriskinCABGpatientswithAFofanykindisama-jorchallengetoourprofession.
Dr.EspenFengsrudisworkingasanar-rhythmiacardiologistatOrebroUniversityHospital,Sweden,andhastogetherwithcar-diacsurgeonAndersAhlssonbeeninvolvedinpreviousepidemiologicalstudiesofAFincar-diacsurgerypatients.
Theyhavefoundthatanepisodeofpost-operativeAFisariskindicatoroffutureAFandatleast25%ofthesepatientsdevelopAFduringsixyearsfollow-up.Managementofthesepatientswithregardtoanticoag-ulationandanti-arrhythmicmedicationre-
mainscontroversial.Theaimofthepresentstudywastoeval-
uatepre-andpostoperativeAFasriskfac-torsforlong-termmortalityamongCABGpa-tients.Byidentifyingspecificassociatedriskfactorsandcausesofdeathinthispatientco-hort,ourintentionwastogeneratefurtherhypotheseswhichcanbeevaluatedinclini-calstudies.
Sixhundredandfifteenpatientsundergo-ingaortocoronarybypasssurgeryattheDe-partmentofThoracicandCardiovascularSur-gery,ÖrebroUniversityHospital,Örebro,Swedenintheyears1999-2000werestud-iedandcausesofdeathwereobtainedfordeceasedpatients.Themeanfollow-uptime
wastwelveyears.Themainfindinginthestudyisthatpre-or
postoperativeAFisanindependentriskfactorforlatemortality,andtheincreasedmortalityislinkedtospecificdeathcausesascerebralischemicdeath,suddendeathanddeathduetoheartfailure.
ThespecificdeathcausesinbothAFgroupsindicatethatAFisthemainfactorin-creasingthelong-termmortality.
Thesefindingssupportabetterfollow-upstrategyinpatientswithpostoperativeAF,thepotentialbeneficialroleofconcomitantAFablationsurgeryandbettercompliancetoex-istingguidelinesofanticoagulanttherapyinpatientswithpreoperativeAF.
Atrial fibrillation of any kind in patients undergoing coronary artery bypass surgery affects survival-what are the options?
Left ventricular/biventricular for assist device support in children
Figure 1: Kaplan-Meier survival curve for all patients with No atrial fibrillation (AF), Preoperative, AF and Postoperative AF undergoing coronary artery bypass graft
(CABG) surgery, 1999–2000. Survival curves for all patients. Log rank test p<0.001.
Massimo Padalino
University of Padova, Italy
Ourpresentstudyisanob-jectiveandcriticalevalu-ationofourinitialexpe-riencewithVADtherapy,
inwhichwesoughttoevaluateifaprecociousVADimplant(i.e.beforeMOFoccurs)canleadtoimprove-mentinclinicaloutcomes.
Hearttransplantationiscurrentlyahighlyeffectivetherapyforpa-tientswithend-stageheartfailure.However,duetothelimitednumberofdonors,onlyasmallpercent-ageofpatientscanbenefitfromthisoperation,especiallyinthepediat-ricage,wheremortalityratewhileawaitingtransplantationcanexceed20%.Duetothelimitedsupplyoforgandonors,long-termsupportisneededforchronicheartfailure.Lim-itedexperienceisreportedamonginfantsandchildren.Wehavere-viewedourinitialexperiencewithBerlinHeartEXCORventricularas-sistdevice(VAD)inchildrenandad-olescentswithend-stageheartfail-uresinceourveryfirstcasein1996.Startingfrom2007,wechangedourapproachandphilosophyofVADtherapy,andwestartedtoevaluatepatientsforanearlierimplant.Thus,wesoughttoanalizeourexperi-encebeforeandafterthischangeofVADtherapymanagement,inordertoevaluateappropriatenessofsur-gicalindicationandclinicalmanage-mentissues,withthefinalaimofde-
termininginstitutionalguidelinesandimprovingouroutcomes.
BetweenJanuary1992andJune2011,11patientsagedlessthan18yearsunderwentBerlinHeart(BH)im-plantationinourinstitution(M/F:9/2,meanage4±5yrs).IndicationstoVADimplantationwerecardiogenicshockindilatedcardiomyopathy(4patients),congenitalheartdisease(4pts),myo-carditis(2patients),andothercausesin1.Sixpatientsrequiredemergencyextracorporealmembraneoxygen-ationbeforeBHimplantation.Me-dianBHsupportwas79days(range1d-9.7mths).Complicationsoc-curredinmostpatients.Overallsur-vivaltodischargewas27%.However,after2007resultsimprovedsubstan-tially,since60%ofpatientsweresuc-cessfullybridgedtohearttransplant.Currently,includingpatientsoutofthisseries,ourresultsaresatisfactory,withan87,5%ofsuccessfulbridgetotransplant.Inconclusion,theven-tricularassistdevicetherapywithBer-linHeartExcorhasprovedtobeanef-fectivesupportinend-stagepediatricheartfailureusedasbridgetotrans-plantationwhenindicationisearly.Thepreoperatorycomorbiditiesmayhaveanimportantnegativeimpactonearlysurvival,whilepostoperativesignsofinadequatetissueperfusionsuchasrenalandmultiorganfailurecanpredictunsuccessfuloutcomesforthesechildren.WerecommendanearlyindicationtoBHimplantinor-dertoimproveoutcomeofourpedi-atricpatients.
30 Monday 29 October 2012 EACTS Daily News
Aldo Cannata Niguarda Ca’ Granda Hospital, Milan, Italy
Manydifferentsolutionsfororganpres-ervationareroutinelyadoptedinclini-calhearttransplantation(HT).However,itisstillcontroversialwhichsolutionof-
fersthebestresultsintermsofallograftfunctionandpatientsurvival.Moreover,mostofstudiescomparingdifferentpreservationsolutionsfocusedonin-hospitalresults,withlongestfollow-updurationnotextendingbeyondoneyearaftertransplantation.WereviewedourexperienceinHTinordertotestthehypothesisifthepreservationsolutionhasaneffectonpatientsix-yearsurvivalandfreedomfromrejection.One-hundredsixtypatientsunderwentHTatourhospitalfromJanuary2006toMarch2012.Theyweredividedinthreegroups,accordingtothesolutionadoptedinthedonor:HTK-Custodiol(n=78),Celsior(n=45)andStThomas(n=37).Foreachpatientsolutionwaschosenaccordingtosurgeonpreference.Thethreegroupsdidnotdiffersignificantlyintermsofpre-operativefeatures.Overallin-hospitalmortalitywas15%andwedidnotobservesignificantdifferencesofmortalitybetweengroups(HTK15.4%,Celsior11.1%,StThomas18.9%,p.61).Atsixyearssurvivaldidnotdiffersignificantlybetweenthethreegroups(HTK76.4%,Celsior74.3%,StThomas73.2%,logrank0.68).Alsofreedomfromgrade<2Rrejec-
tionwassimilarbetweenthethreegroups.However,weobservedasignificantlyhigherincidenceofgrade≥2RrejectioninCelsiorgroup(20.1%)ascomparedtoothersolutions(HTK6.8%,StThomas2.7%;logrank.008;Figure1).Freedomfromgrade≥2Rrejec-tionremainedlowerinCelsiorgroupevenaftersplit-tingthegroupsaccordingtotheoccurrenceofpreop-erativeand/orpostoperativerenalfailure(logrank.01;Figure2).Theresultspresentedhereinconfirmtheconclusionsofanourpreviousstudyperformedonasmallersubsetoftransplantedpatients,namelythatHTK,CelsiorandStThomassolutionsdonotdiffersignificantlyintermsofin-hospitalincidenceofbiven-tricularfailureanddeath.Itshouldbenotedthatthelowerincidenceofbiventricularfailureandin-hospi-taldeathinCelsiorgroupisnonsignificantanditisassociatedtoalowerneedofpreoperativemechani-calcirculatorysupportascomparedtoothergroups.
Moreover,datafromthisstudyshowedthatpreser-vationsolutionsdidnotdiffersignificantlyintermsof6-yearsurvivalandearlyandlategraftfunction.How-ever,freedomfromgrade≥2RacutecellularrejectionwassignificantlylowerinCelsiorgroupascomparedtoHTKandStThomas,evenfollowingadjustmentforthepreoperativeorpostoperativerenalfunction.Thereasonofsuchdifferenceremainsstillunexplained.Itcouldberelatedtosomecomponentofthesolu-tions,butfurtherinvestigationsareneededtoclar-ifysuchissue.StThomassolutionshowedthehigh-estfreedomfromgrade≥2Rrejection.Moreover,alsoperioperativereleaseofcreatinekinaseMB,leftven-tricularejectionfractionandtricuspidregurgitationdidnotshowsignificantdifferencesbetweenthethreeso-lutions.Satisfactoryallograftfunctionhasbeenmain-tainedduringfollow-upindependentlyfromthetypeofpreservationsolution.
Paul P. Urbanski
Cardiovascular
Clinic Bad Neustadt,
Germany
Antegradecerebralperfusionmakes
deephypothermianon-essentialforneu-roprotection.However,performingdis-talarchanastomosisand/oranastomo-seswithsupra-aorticarter-iescanbedifficultandtimeconsuminginpartic-ulararchpathologies.Werecommend,forsuchcases,atechniqueofgradualreperfusionforshorteningboththecir-culatoryarrestandunilateralcerebralperfusiontimesbyusingabifurcatedar-teriallineandabranchedprosthesis(Fig-ure1).Anarteriallineisbifurcatedus-ingY-shapedconnectors.Thefirstlineisusedforcannulationoftherightcom-
moncarotidarteryforestablishmentofcardiopulmo-narybypassanduni-lateralcerebralperfusionduringthearchreplacement.Aftercross-clamp-ingthesupra-aorticarteries,theper-fusionofthelowerbodyisinterruptedattherectaltemperatureofabout30-32°C.Theunilateralcerebralperfusionismaintainedbysimplyreducingtheflowratetoabout1.5litresaminuteatthebloodtemperatureof28°C.Theaorticarchisresectedandthesupra-aorticarteriesaresevereddistallyfromtheirorigins.First,theend-to-endanas-tomosisbetweenthegraftandthede-scendingaortaisperformedusinga5-0sutureandthenoneofthefourside-branchesiscannulatedwiththesecondbranchofthearterialline.Afterclamp-ingremainingside-grafts,perfusionofthelowerbodyisreestablished.Forper-fusionofthebifurcatedline,separatepumpsarenotnecessarybecausethe
peripheralresistanceismuchlowerintheaorta,andtheflowratesaredis-tributedautomatically.Then,thesidebranchesofthegraftareanastomo-sedtothearchvessels.ThenumbersinFigure1indicatethesequenceofanas-tomoses.Cere-bralperfusionisre-es-tablished,step-by-stepaftercompletingeachfurtheranastomosis,startingwiththeleftcarotidarteryorwiththeleftsub-clavianarterywhenthelatterislocat-edverydeeplyinthechest.Consequently,
cerebralperfusionisre-establishedgradu-allyensuringshorteningofunilateralcer-ebralperfusion.Incomparisontoare-routingofthesupra-aorticarteriesandimplantationoftheendograft,onlyoneadditionalanastomosis,namelythedistalone,hadtobeperformed;however,con-ventionalsurgeryoffersanatom-icalanddefinitiverepairwhileavoidingtheside-clampingoftheascendingaortaandriskofcerebralembolism.
Thetechniquepresentedisverysuit-ableforaorticarchsurgery.Itoffersavoidanceofdeephypothermiawithallitsnegativesideeffectsandshorteningofthecardiopulmonarybypasstime,evenincasesofcomplexarchrepairforwhichprolongedtimeofsurgeryisnecessary.Italsoenablescompletearchreplacementwithoutaconsidera-blylongertimeoflowerbodyischemiainsituationswhenelectivehemiarchre-placementwasplannedandanunex-pectedsituation(e.g.,severeulcerousorexophyticatherosclerosischangeswithintheaorticarch)demandsanex-tensionofrepair.
Six-year outcomes following heart transplantation: effect of preservation solution on survival and rejection
Cardiac: Abstracts 10:15–11:45 Room 120/121
Vascular: Profeesional Challenges 10:15–11:45 Room 113
Figure 1: Freedom from grade ≥2R rejection, log rank .008 Figure 2: …and log rank .01
Figure 1
Daniel Wendt, MD and
Matthias Thielmann, MD
Conventional surgical aorticvalve replacement with bio-
prostheses is a well establishedprocedure, and the advantagesanddisadvantagesofthesevalvesarewellknown.Incontrasttome-chanicalvales,biologicalvalvesdonotneedanticoagulationtherapy,butontheotherhandtheyhavealim-ited life-span due to potential structur-alvalvedeterioration,andcomparedtomechanicalvalves,theyhavetocompetewiththeirlargeaorticvalveareas(AVA).
Conventional bioprostheses are cur-rentlygainingpopularityduetoincreaseddurabilityandimprovedhemodynamics,resultingintheincreasedimplantationofthesevalvesinyoungerpatients.
In this editorial we want to focusprimarily on two new-generation su-pra-annular prostheses that have beenintroduced–theCarpentier-EdwardsPE-RIMOUNTMagnaEase™(EdwardsLifes-ciences, Irvine, CA, USA) and the Tri-
fecta™(St. JudeMedical, Inc.,St.Paul,MN,USA)bioprosthesis.TheCEMagnaEase™prosthesis isbasedon theorigi-nalCEPERIMOUNT™design,whichwaslaunchedin1981,andactuallyrepresentsits3rdgeneration.Itconsistsofaflexiblewire-form cobalt-chromium stent withthree independentandsymmetricalbo-vinepericardial leafletsmountedunder-neaththestent-frametominimizetissueabrasion and reduce stress on commis-sures.Inordertominimizethecalcifica-tion-process in the long-term, the pro-prietarydual-modeThermaFix™processextractsphospholipids and residualglu-taraldehydemolecules.
The Trifecta™ bioprosthesis repre-sentsoneofthecompany’slatestdevel-opments goingback to the concept ofexternallymounted leaflet-issue. It con-sists of a high-strength titanium stent,which is covered with porcine pericar-dium. The leaflets are made from onesheet of bovine pericardium, which isseweddirectlyaroundthestent.LiketheEdwardsvalves,theTrifecta™isfixedun-derlow-pressureconditions,andthepro-prietaryLinxAC™anticalcification-tech-nology isalso incorporatedtoeliminatecalcification-bindingsites.
Recently,greatemphasisisplacedonvarious determinants of valve perform-ance,includingAVA,pressuregradientsanddurabilitybybothcompanies.How-ever, there are currently no publishedstudiespresentingdataontheTrifecta™bioprosthesis,whereasanumberofhe-modynamicanddurabilitystudiesoftheCEPERIMOUNT™platformareavailable.Inanycase,regardlessofwhichprosthe-sis isbeingassessed,dataonvalvehe-modynamicsshouldbeobtainedatleast6-monthspostoperativelyinordertolim-
itthebiasofhemodynamicinstabilityintheimmediatepostoperativecourse.
Therefore, we decided to analyzevalveperformanceof theTrifecta™,CEPERIMOUNT Magna™ and CE PERI-MOUNTMagnaEase™bioprosthesesinaprospectivestudy, including6-monthsfollow-up echocardiographic data. Theresultsofthestudywillbepresentedatthisyear’sannualmeetingoftheAmeri-canHeartAssociation,howeverwewereabletopresentabriefpreviewofthere-sultshere.
Inastudyofalmost350patientstheunadjustedAVAandmeanpressuregra-dientwere initially slightly favorable fortheTrifecta™bioprosthesis,howeveraf-termultivariatecovarianceanalysisnoin-fluence of the prosthesis type on AVAoronmeanpressuregradient couldbeidentified(detaileddataatAHA2012).
Inour view, it isnotonly importantto evaluate valve prostheses clinical-ly,butalsotoinvestigatetheirhemody-namics in-vitro. In a recently publishedstudy, we showed superior hemody-namics,asevidencedbylowervelocities,
shearstrengthandvorticities,fortheCEMagna Ease™ bioprosthesis comparedto CE Magna™1. Such improved flowcharacteristics, as the two valves sharenearlythesamedesign,suggestthattheoverall lower profile of the CE MagnaEase™prosthesishasapositive impacton flow dynamics, a fact that mighttranslate into improveddurability,how-everthisremainstobeverified.
Finally,wewouldliketostatethatinouropinion,thereisnovalve,whichcancurrently be considered superior to theother,especiallyinrespectofshorttermhemodynamic follow-up. However, theCarpentier-EdwardsPERIMOUNT™plat-formcomeswiththeadvantageofase-ries of peer-reviewed studies confirm-ing long-term durability, which has yettobeinvestigatedintheTrifecta™valve.Therefore,furtherstudiesevaluatingthelong-term durability performance andvalve-relatedmorbidityareneeded,andthey should definitely include detailedechocardiographicdata.1 Wendt D, Stühle S, Piotrowski JA, Wendt H, Thielmann M, Jakob H, Kowalczyk W. Comparison of flow dynamics of PERIMOUNT Magna and Magna Ease aortic valve prostheses. Biomed. Tech. 2012;57:97-106.
Stented Pericardial Aortic Bioprostheses – A Look Inside
14:30 Conventionalelephanttrunkversusfrozenelephanttrunktechniqueinthetreatmentofpatientswiththoracicaorticdisease:effectonneurologicalcomplications S. Leontyev, M. Borger, C. Etz, M. Moz, J. Seeburger, F. Bakhtiary, M. Misfeld, F. Mohr (Germany)Discussant: R. Di Bartolomeo (Bologna)
14:45 Hybridrepairofmegaaorticsyndromewiththelupiaetechnique G. Esposito, S. Bichi, D. Patrini, P. Tartara, P. Gerometta, V. Arena (Italy)Discussant: M. Grabenwöger (Vienna)
15:00 Totalaorticarchreplacementwithfrozenelephanttrunk:10-yearsinglecentreexperience M. Shrestha, F. Fleissner, F. Ius, M. Karck, A. Martens, M. Pichlmaier, A. Haverich (Germany)Discussant: A. Saito (Tokyo)
15:15 One-stagerepairincomplexmultisegmentalthoracicaneurysmaldisease:resultsofamulticentrestudy C. Mestres1, K. Tsagakis2, D. Pacini3, R. Di Bartolomeo3, M. Grabenwöger4, M. Borger2, R. Bonser5, H. Jakob2 (1Spain, 2Germany, 3Italy, 4Austria, 5United Kingdom)Discussant: S. Numata (Fukui)
15:45 Coffee
Abstracts
16:15 Contemporary approaches in acute and chronic type B aortic dissection
Room 113
Moderators: A. Martens, Hannover; R. Di Bartolomeo, Bologna
16:15 OutcomeofopensurgeryfortypeBaorticdissection M. Nozdrzykowski, J. Garbade, C. Etz, M. Misfeld, M. Borger, F. Mohr (Germany)Discussant: C. Hagl (Munich)
16:30 Openaorticrepairofdistalarchanddescendingaorticaneurysm:contemporaryoutcomesin250patients T. Fujikawa (Japan)Discussant: B. Pfannmüller (Leipzig)
16:45 ClinicaloutcomeofemergencysurgeryforacutetypeBaorticdissectionwithrupture T. Minami, K. Imoto, K. Uchida, N. Karube, T. Yasutsune, T. Cho, E. Umeda, M. Masuda (Japan)Discussant: W. Schiller (Bonn)
17:00 Incidenceandriskfactoranalysisofaorticerosionafterendovascularthoracicaorticrepairforaorticdissection K. Shimamura, T. Kuratani, Y. Shirakawa, K. Torikai, J. Yunoki, T. Sakamoto, Y. Watanabe, Y. Sawa (Japan)Discussant: S. Folkmann (Vienna)
17:15 Fateofthedistaltruelumenafterstent-graftingfortypeIIIbaorticdissection:awordofcaution F. Dagenais, P. Voisine, S. Mohammadi, E. Dumont (Canada)Discussant: W. Morshuis (Nieuwegein)
17:30 AssessmentofdurationfromonsettothoracicendovascularaorticrepairintypeBaorticdissection:impactofaorticremodellingasthepredictivefactorforaorticevents Y. Watanabe, T. Kuratani, K. Shimamura, Y. Shirakawa, K. Torikai, J. Yunoki, T. Ueno, Y. Sawa (Japan)Discussant: K. Tsagakis (Essen)
17:45 Sessionends
Complete arch replacement using branched prosthesis and gradual re-perfusion technique
Continued from page 28
32 Monday 29 October 2012 EACTS Daily News
Emiliano Navarra Institute
Bicuspidaorticvalve(BAV)re-pairforaorticregurgitation(AR)andoraorticaneurysmisanat-tractivealternativetoprosthetic
valvereplacementintheadolescentandyoungadult.However,moststudiesre-portareoperationrateof20%ormoreaf-teronedecademainlyduetorecurrenceofAR.Wehaverecentlyshownthatvalvesparingreimplantation(VSR)improvesdu-rabilityofBAVrepairincomparisontosub-commissuralannuloplasty(SCA).Theaimofthisstudywastoassessthedegreeofannularreductionprovidedbythesetech-niquesandcorrelatethatwithrepairdu-rability.From1995to2010,161patientsunderwentBAVrepair.Forthisstudy,weincludedonlythepatientswithSCAorVSR
havingintra-operativepre-andpost-repairtrans-esophagealechocardiographystoredinourechocardiographicimagesdatabase.Pre-andpost-repairVAJdiameterwasmeasuredonthelongaxisviews.Inclusioncriteriaweremetby53patientswithSCAand65patientswithVSR.Medianfollow-upwas42months.Follow-upwas100%completeinSCAgroupand94%completeinVSRgroup.
Therewasnooperativeorlatemortal-ityinthispopulationofpatients.Meanpre-operativeVAJwassimilarinbothgroups(VSR:28.3±3.5mmvsSCA:27.5±3.3,p=0.16).PreoperativeVAJwaslargerinpatients<40yearsandinpa-tientwithaorticregurgitation(AR)≥3+(p<0.001).Meanpost-operativeVAJwassmallerinVSRincomparisontoSCA(21.4±0.22mmvs23.6±0.36mm,p<0.001).
Inunivariateanalyzes,SCA,preoperativeVAJ≥30mm,postoperativeVAJ≥25mmandpericardialpatchforcusprepairwerepredictiveofrecurrentAR>1+.IntheSCAgroup,preoperativeVAJ≥30mmandpostoperativeVAJ≥25mmwereas-sociatedwithdecreased6yearsfreedomfromrecurrentAR>1+(<30mm:74.4%vs
≥30mm:39.2%,p=0.01;<25mm:80.1%vs≥25mm30.8%,p=0.002)IntheVSRgroup,preoperativeVAJ≥30mmhadnoeffectonrecurrentAR>1+(<30mm:92.8%vs≥30mm:93.8%,p=0.93)andpostoperativeVAJ≥25mmwasobservedinonlythreepatientshavingVSR.Incon-clusion,inBAVrepair,thecircumferen-
tialannuloplastyprovidedbyVSRoffersgreaterreductionoftheVAJcomparedtothenon-circumferentialannuloplastypro-videdbytheSCA.ThedegreeandextendofVAJreductionintheVSRseemstobeonefactorsamongothersthatpositivelyinfluencetherepairdurabilityespeciallyinpatientwithlargeVAJ(≥30mm).
Monika Dornbierer, Joevin Sourdon, Simon Huber,
Brigitta Gahl, Thierry Carrel, Hendrik Tevaearai, Sarah
Longnus Department of Cardiovascular Surgery, Inselspital,
Berne University Hospital and University of Berne, Switzerland
Heartfailureisaprogressivediseaseandcountsamongtheleadingcausesofmor-bidityandmortalityinwesterncountries.Inthemostadvancedstage,cardiactrans-
plantationremainstheonlyreasonablepossibilityforimprovingqualityoflifeandsurvival.Unfortunately,thislife-savingtherapyisavailabletoonlyafractionofthosewhoneeditbecauseoftheconstantshortageofavailabledonors.
Non-heart-beatingdonors(NHBDs)representacur-rentlyuntappedsourceofheartsthatcouldsignifi-cantlyincreasedonoravailability.Althoughthefirsthumancardiactransplantationswereperformedwiththesedonors,NHBDcardiacdonationwasrapidly
abandonedwiththesubsequentdefinitionofbraindeath.Morerecently,however,oneclinicalreportde-scribedthreesuccessfulpediatrichearttransplanta-
tionswithNHBDhearts,providingnewevidencetosupportthisapproach1.Notably,ithasbeenestimatedthatthepoolofcardiacgraftscouldincreaseby17%foradultsand42%forchildren,ifuseofNHBDsweretobecomewidespread2,3.
DespitetheconsiderablepotentialofNHDBs,thisdonorpopulationhasnotbeenadoptedforhearttransplantation,mainlybecauseofconcernsregardingdamagesustainedasaresultoftheunavoidablepe-riodofwarmischemia.Importantly,severalpre-clinicalreportshaveprovidedevidencethatheartsdotoleratewarmischemia,iflimitedtoaperiodof20-30min,andmaythusmaintainsufficientintegrityfortrans-plantation4–7.Fromaclinicalperspective,however,us-
inganischemicheartremainsquestionable,especiallyasrecognizedmeanstopredicttherecoveryoffreshlyexplantedheartsarenotcurrentlyavailable.
Wehaveinvestigatedmeanstoevaluatecardiacgraftsuitabilityfortransplantationusinganisolated,working,NHBDratheartmodel.Todoso,weas-sessedthepotentialofseveralparametersmeasuredimmediatelyafteraperiodofwarm,insituischemia,atthetimeofheartprocurement,toeffectivelypre-dictcontractilerecoveryfollowingsubsequentcardio-plegicstorageandreperfusion.
Wedemonstratethatseveralhemodynamicandbi-ochemicalparameters,assessedduringabrief,un-loadedperfusionatprocurement,arehighlycorre-latedwithcontractilerecoveryfollowingcardioplegiaandreperfusion.Althoughourexperienceislimitedtosmallanimalmodel,webelievethatthisapproachmaybeofclinicalrelevance,especiallyinthesettingofcardiactransplantationwithNHBDs,toaidinthedevelopmentofprotocolsforevaluatingcardiacgraftsuitabilityfortransplantationatthetimeoforganprocurement.
MoredetailedresultswillbepresentedthisweekbyMsDornbierer.References
1. Boucekmm, et al. N Engl J Med 2008;359: 709-714.2. Osaki S, et al. Eur J Cardiothorac Surg 2010;37(1):74-9.3. Koogler T, et al. Pediatrics 1998;101(6):1049-52.4. Illes RW, et al. J Heart Lung Transplant 1995;14:553-61.5. Koike N, et al. Transplantation 2004;77:286-92.6. Scheule AM, et al. J Invest Surg 2002;15:125-35.7. Koike N, et al. J Heart Lung Transplant 2003;22:810-7.
Effect of annulus dimension and annuloplasty in bicuspid aortic valve repair
Evaluation of cardiac grafts from non-heart-beating donors: hemodynamic and biochemical measures at procurement predict contractile recovery
An alternative access approach
Cardiac: Abstracts 10:15–11:45 Room 112
Cardiac: Abstracts 10:15–11:45 Room 120/121
Cardiac: Focus Session 10:15–11:45 Room 122/123
Figure 1: A. Kaplan-Meier actuarial survival curves comparing freedom from recurrent aortic regurgitation >1+ on basis of preoperative ventriculoaortic junction (VAJ) diameter ≥30mm in the entire cohort (p=0.03).
B. Idem a. in subcommissuralannuloplasty (SCA) and valve sparing reimplantion (VSR) groups (SCA <30mm vs SCA ≥30mm, p= 0.01; VSR <30mm vs VSR ≥30mm, p= 0.93; SCA ≥30mm vsVSR ≥30mm, p= 0.01; SCA <30mm vsVSR <30mm, p= 0.16).
Monika Dornbierer (left) and Sarah Longnus Isolated Heart Preparation
Pierre-Yves Etienne
Brussels, Belgium
Transcatheteraorticvalveim-plantationisarapidlygrowing
technologywithcon-tinuousnewdevelop-ments.InthePartnerstudy,survivaladvan-tageshavebeenshownfortransfemoralap-proachininoperablepatientsbutinhighriskpatients,resultsofsurgicalapproacharebal-ancedbydeleteriouseffectsofpreoperativeriskfactorsofthepatients,complicationsdirectlyassociatedtothetechniqueincludingstrokeandparavalvularleakbutalsobyspecificeventsrelatedtothetransapicalroute.Trans-Aorticappproachofferstothesurgeonsnewperspec-tivesthankstoawell-knownaccesstotheas-cendingaortaandasimplifiedapproachtotheaorticvalve.Easinessoftheprocedure,perfectstabilityofthedeliverysystemallowedbythe
proximitytotheaorticannulus,andpromptac-cesstoconventionalsurgicalprocedurecouldofferadditionaladvantageswhencomparedtootheraccessroutes.Anti-embolicdevicedeploy-mentintheascendingaortacouldalsolowertherateofneurologicalcomplicationduringtheprocedure.
Anyway,thisapproachhasuntilnowbeper-formedthroughuppersternotomyorsecondin-tercostalspacethoracotomyassociatedinsomecaseswithpartialribresection.
Wepresentinthismeetingthefirstcaseofpuretotallypercutaneousvideo-assistedthora-coscopicdeploymentofaSapienvalvethroughthetrans-Aorticroute.Theinterventionwastechnicallyuneventfullandthepatientwasim-mediatelyextubatedaftertheprocedure.Thistechniquecouldminimizethesideeffectsofthesurgicalapproachinsomeselectedcases.Theeffortsoftheindustrytodevelopnewac-cessclosuredevicesfortheascendingaortaandanti-embolicdevicescouldeveninthefu-turereallysimplifytheprocedureandincreasehissafety.
EACTS Daily News Monday 29 October 2012 33
Cardiac: Abstracts 10:15–11:45 Room 118/119 Cardiac: Professional Challenges 10:15–11:45 Room 116/117
Alessandro Barbone
Istituto Clinico Humanitas Rozzano, Italy
InChronicheartfailure,de-spitemanypatientsmightnotbenefitfrominterventionslikecardiacresynchronizationwith
pacemakersanddefibrillators,yethearttransplantationisavailabletoonlyalimitednumberofpa-tientsperyear.TheCircuLiteSYN-ERGYCirculatorySupportSys-tem,whichrecentlyreceivedCEMarkapprovalinEurope,isamin-iaturemechanicalcirculatorysup-portsystemthatrepresentsanewoptionfortheearlytreatmentofambulatoryheartfailure.Despiteitssmallsize,theSYNERGYMi-cro-Pump(Figure1)iscapableofprovidingupto4.25L/minofbloodflowandisintendedfortreatmentofpatientswithsignif-icantlycompromisedleftheartfunction.Can-didatesforSYNERGYtherapyaretypicallyclas-sifiedasINTERMACS4-6(i.e.,non-inotropedependent)andareambulatorybutexperiencerelativelyfrequenthospitalizationsforheartfail-uredecompensation.(SeeFigure1)
Inthecurrentparadigm,mechanicalcircula-torysupportsystemshavelargelybeenlimitedtotreatingend-stageheartfailurepatientsduetothehighlyinvasivenatureoftheimplantationprocedureandassociatedcomplications.
TheSYNERGYSystem(Figure2)iscomprisedofCircuLite’sproprietarymicro-pump,inflowcannulaandoutflowgraft,apercutaneousleadthatisconnectedtoawearableexternalcontrol-lerandalightweight,rechargeabledualbatterypacksystem.TheSYNERGYmicro-pumpisim-plantedinasubclavicularpocketwithouttheuseofcardiopulmonarybypass,andpreliminarydatafromanongoingstudyinEUsuggestthatitisas-sociatedwithfewerperioperativeadverseeventsthancurrentfullsupportdevices.
In2007,CircuLiteinitiatedamulti-centerclini-caltrialinEuropetoevaluatedsafetyandpatientqualityoflifeimprovementsassociatedwithde-vicesupport.DatafromtheEuropeantrialhaveshownthatsupplementalcirculatorysupportwithSYNERGYcanprovidestatisticallysignifi-cant,sustainedimprovementsinhemodynamicsandareductionofsymptomsofheartfailure.
Inasub-analysis,CircuLiteinvestigatorscom-paredsafetyandefficacydatainyounger(<70years)versusolder(≥70years)patients.Thein-itialexperiencehassuggestedthattheminimalinvasiveimplantproceduremightbewelltoler-atedbyolderandmorefragilepatients;specif-ically,moretolerablethanafullsternotomyoncardiopulmonarybypassprocedure.
Clinically,olderpatientshavecertaincharacter-isticsthatdifferfromtheyoungerpatients:they
havelongerhistoryofheartfail-ure,arenoteligiblefortrans-plant,andthushavealreadyun-dergonemoreintensiveeffortstoexhaustallconventionalther-apies.Furthermoreelderlypa-tientstendtorecoverandreha-bilitatemoreslowlyfromsurgery,aremorepronetoinfectionandothercomplications.Bleedingmightbeanissueduetoparticu-lartissuefrailtyoftheelderlypa-tient.
Despiteitslimitedexperi-enceforthisclassofpatient,thelesserinvasivenatureofthissys-tem(smallsize,nosternotomy,andnocardiopulmonarybypass)canbeconsideredtobeassoci-atedwithlessadverseeventsin
theshort-andlongterm,especiallyinthemorefragilepatients.Thisstrategymaybeparticularlyusefulinelderlypatientslesslikelytobeabletotoleratemoreinvasiveprocedures.
ForadditionalinformationaboutCircuLiteortoseetheSYNERGYSystem,pleasevisitEACTSbooth4orvisitwww.CircuLite.net.
Circulatory support in elderly chronic heart failure patients using Circulite’s SYNERGY circulatory support system
Thoracic: Abstracts 10:15–11:45 Room 133/134
Figure 2: SYNERGY System
Figure 1: CircuLite SYNERGY Micro-Pump
Alessandro Barbone
Vadim Shumavets, Alexander
Shket, Andrey Janushko, Svetlana
Kurganovich, Irina Grinchuk, Natalia
Semenova, Oksana Jdanovich, Youry
Ostrovski Belarus Cardiology Centre
Ischemicfunctionalmitralregurgi-tation(IMR)developsin20-25%ofpatientsaftermyocardialin-farctionandisstronglyassoci-
atedwithpooroutcomesinpatientswithadvancedcoronaryarterydis-ease.However,theevidencetosup-portmitralvalvesurgeryatthetimeofCABGinthepresenceofmoder-atemitralregurgitationisstillweak.EveninrecentlypublishedbyESCandEACTStheEuropeanGuidelinesonthemanagementofvalvularheartdisease(version2012)declaredthatthereiscontinuingdebateregardingthemanagementofmoderateIMRinpatientsundergoingCABG.
Whethercorrectingofmitralre-gurgitationatthetimeofcoronaryarterysurgeryimproveslong-termsurvivalandfunctionalclasswastheaimofourstudy.
Atotalof1,296patientsfrompro-spectivelymaintainedclinicalall-in-comersdatabasepresentingmod-eratetosevereischemicMRwerethereforestudied,treatedeitherbyisolatedCABG(n=509)orcom-binedCABG+mitralvalve(MV)repair(n=787).Wefocusedourinterestonmorethanfive-yearslong-termsur-vival(n=541)withmeanfollow-up5.2±1.84years(range,0–11.4years).Usingpropensityscorematchinginanattempttocontroltheselectionbias,wewasabletoovercomeinitialheterogeneityofourstudygroupandreceivedanabsolutelyhomogenouscohortof190patientswithmoder-ateMR,moderateLVdilatationandmoderateLVdepression,exceptingdifferenceinsurgicalmanagementonMV.10%ofsurvivorswerefol-lowedmorethannineyears.Wecon-sideredestimatesofoutcomereliableto10years.
Keyfindingsofourstudywerethat:1)CABG+MVRsignificantlyre-ducedMRcomparetoCABGalone,butevenafterisolatedmyocar-dialrevascularizationMRgradede-creasedin49.2%ofpatients;2)additionofMVannuloplastytoCABGconsiderablyimprovedsymp-tomsduringfollow-up,buttheper-centageofseveresymptomaticpa-
tientsremainsathighlevel(30.6–41.2%);3)additionofMVannulo-plastytoCABGhadnoevidentsur-vivalbenefitinhomogenouspropen-sity-matchedcohortofpatientswithmoderateMRandmoderateLVdys-functionover10-yearsfollow-up(HR(95%CI)1.07;0.54-2.1;p–0.82).;4)riskfactorsbasedonmultivariateCox’sregressionanalysesforlatesur-vivaloftheseischemicpatientswithmoderateIMRandmoderateen-
largedLVwasmostlybasedonthepresenceofseverelydepressedLVfunction(LVEF<40%HR1.91;p–0.025),,LVdilation(EDDHR1.05;p–0.027),ageandadditivesumofEuroscoreI,alsoassessedthenon-cardiaccomorbidities.
WewereenabletoassessdoesrecurrentMRdirectlyaffectsurvivalduetoincompletenessofEchofol-low-uptodate.Buttheendpointsofthisstudywereverystrongpre-dictorsofdeathduringlong-termfollow-upandwenotfoundanysignificantdifferencebetweengroupsinentireunadjustedcohortintermsofallanothercomponentofMACE.
Inconclusion,thepresentstudydemonstratesthatthefactofper-formingMVprocedureduringCABGsignificantlyreducedMRgradebutseemsdidnotimprovethelatesur-vival.ModerateIMRdecreasedaftersuccessfulrevascularizationaloneinnearhalfofpatientsandweascar-diacsurgeonsarerequiredtopro-videfullrevascularizationtoourCABG+IMRpatients.Ourdatestillemphasizestheimportanceofleftventricleinresolvingproblemofischemicmitralregurgitation.
Should moderate ischaemic mitral regurgitation be corrected at the time of coronary artery bypass grafting? answer from a 10-year follow-up
Vadim Shumavets
Figure 2
Figure 1
Pneumonectomy with en bloc chest wall resection: is it worthwhile? report on 34 patients from two institutionsGiuseppe Cardillo Carlo
Forlanini Hospital, Rome, Italy
I amveryproudtopresentthisstudy“Pneumonec-tomywithen-blocchestwallresection:isitworth-
while?reporton34pa-tientsfromtwoinstitutions“comingfromtwohigh-volumeItalianinstitutions,theaziendaospedalierasancamilloforlaniniinRomeandtheEuropeanInstituteofOn-cologyinMilan.,addressingtheproblemofpneumonec-tomywithen-blocchestwallresection,aprocedurewhichisoftendeniedbecauseof
theprocedure-relatedhigh-risk.
AsfarasIknowthisrepre-sentsauniquestudyonsuchtopics.Theshortandlong-termoutcomeofthisproce-durewerecarefullyevaluated.
From1/1995to10/2011,34patients(30male,fourfe-male;meanage:61.8yrs)un-derwentpneumonectomywithen-blocchestwallresec-tionfor33NSCLCandonemetastaticosteosarcomaintwoinstitutions.Datawereretrospectivelyreviewed.
TheOperative(30-days)mortalitywas2.94%(1/34).Morbiditywas38.23%
(13/34).Therewere14(41.17%)rightsidepro-ceduresand20(58.82%)leftsideprocedures.Threepatients(8.82%)devel-opedbronchopleuralfis-tulas.Themeannumberofresectedribsperpa-tientwas2.7.In13patients(38.23%)aprostheticrecon-structionofthechestwallwasneeded.Inthreecases(8.82%)thebronchialstepwasbuttressed.Preoperativepainwasstatisticallysignif-icantlyrelatedtothedepthofchestwallinvasion(p:0.026).TheNstatuswasN0in18cases(52.94%),N1in
ninwcases(26.47%),N2in6cases(17.64%),andNxinonecase(metastaticoste-osarcoma).Patientswerefol-lowed-upforatotalof979months.Themediansur-vivalwas40months.Theoverallfive-yearsurvivalwas46.87%:45.27%forrightand48.46%forleftproce-duresrespectively.AccordingtoNstatus,five-yearsurvivalwas59.76inN0,55.56%inN1,and16.67%inN2.ThesubgroupN0plusN1(27pts)showeda58.08%five-yearsurvivalcomparedto16.67%inN2(Chi-Square3.74;p:0.05).
Inconclusion,Pneumonec-tomywithen-blocchestwallreconstructioncanbesafelyofferedtoselectedpatients.TheadditionofenblocchestwallresectiontoPneumon-ectomydoesnotsignificantlyaffectoperativemortalityandmorbiditycomparedtostand-ardpneumonectomy.
Thepivotaladditionalef-fectofthechestwallresec-tionshouldnotbeconsideredacontraindicationforsuchprocedure.Survivalisrelatedtonodalstatuswithhistolog-icallyprovenN2diseasetobethesinglenegativeprognos-ticfactor. Giuseppe Cardillo
34 Monday 29 October 2012 EACTS Daily News
Cardiac: Abstracts 10:15–11:45 Room 114 Vascular: Professional Challenges 10:15–11:45 Room 113
Maurizio Taramasso
Cardiac Surgery Department,
San Raffaele Scientific Institute, Milan, Italy
Perioperativemortalityaftersurgeryforfunctionalmitralregurgitation(FMR)isnotnegligibleandalargenumberof
patientswithFMRisnotreferredforopenheartsurgerybecauseofhighsurgicalriskorcomorbidities.Newpercutaneoustech-niqueshavebeenrecentlydevelopedtotreatMRwithlessinvasiveapproaches.TheMi-traClipTM(AbbottVascularInc.MenloPark,CA,USA)isadevicereproducingtheAlfi-erisurgicaltechniquewithapercutaneousapproachwhichhasbeenusedtodecreasetheinvasivenessforthehighriskpatientstotreatbothdegenerativeandfunctionalMR.Theaimofthisstudyistoreporttheclini-caloutcomesofMitraCliptherapytotreatsymptomatichigh-riskpatientswithsevereFMRandsevereLVdysfunctioninoursinglecentreexperience.
FromOctober2008,85consecutivehigh-riskpatientswithFMRunderwentMitraClipimplantation(meanage68±9.5years).FMRwasischemicin55pts(73%);78.8%ptswereinNYHAclassIII-IV,whileaverageLo-gisticEuroScorewas21.8±16%,withabout
50%ofthepatientshavingLogisticEuro-Score≥20%.
Preoperativeechoparametersincluded:EF27±9.8%andLVEDD69.8±7.8mm.Qual-ityoflifequestionnairerevealedanimpor-tantimpairmentinperceivedqualityoflifeinallthepatients.
In-hospitalmortalitywas1.1%.Globally,60%ofthepatientshadanintensivecareunitstaylessthan24hours.Medianpost-operativelength-of-staywas4.8daysThemajorityofthein-hospitalsurvivorswasdischargedhome(67.8%ofthetotal).Pre-dischargeechocardiographyshowedresidualMR≤2+in87%ofthepatients.
Overallactuarialsurvivalwas87.7±4.1atone-year.ActuarialfreedomfromMR≥3+was79.3±5.3%atone-year.Atone-yearfollow-up,asignificantimprovementinEFwasdocumented(from27±9.8%to34.7±10.4%-p=0.003)and86%ofthepa-tientswereinNYHAclassI-II.Asignificantimprovementwasdocumentedwithallthequalityoflifeassessments.
TheresultsofthepresentstudyconfirmsafetyofMitraCliptherapyinend-stagepa-tientswithFMRwhoarenotamenableforsurgery,suggestingthatinpresenceofex-tremelyhighsurgicalriskalessinvasiveap-
proach,likeMitraCliptherapy,shouldbeconsidered.MitraCliptherapywasassoci-atedwithlowhospitalmortality,shortpost-operativeLOSandthepostoperativecoursewassmoothinthemajorityofthepatients,inspiteofthehigh-riskprofileatbaseline.
Mid-termfollow-upconfirmedtheclinicalbenefitofMitraCliptherapyinthissetting:86%ofthepatientswereinNYHAclassI-IIandasignificantimprovementinperceivedqualityoflifeandfunctionalcapacitywasdocumented.
Predictorofmortalityatone-yearfollow-upinourexperiencewerepreoperativeLo-gisticEuroScore≥20%(Figure1),needforpostoperativeIABPandoccurrenceofnewonsetacuterenalfailure(Figure2).However,longerfollow-upwouldberequiredtode-terminetheclinicalimpactofresidualMRaf-terMitraclipimplantation.
Inconclusions,thisstudyshowsthatMi-traCliptherapyinselectedhighriskpatientswithFMRisasafeprocedureandcanbeac-complishedwithlowmorbidityandmortal-ity.Moreover,MitraCliptreatmentisassoci-atedtofunctionalstatusandqualityoflifeimprovementsatone-yearandtosignificantLVreverseremodelling.
Mitraclip therapy in heart failure patients with functional Mitral RegurgitationSingle centre experience in 85 consecutive high-risk patients with severe systolic dysfunction
Cardiac: Abstracts 10:15–11:45 Room 112
Fattouch K1, Castrovinci S2, Murana G2, Nasso G3, Guccione F1, Dioguardi
P1, Bianco G1, Ballo E1, Speziale G3 1 Department of Cardiovascular Surgery,
GVM Care and Research, Maria Eleonora Hospital, Palermo, Italy; 2 Department
of Cardiac Surgery, University of Palermo, Palermo, Italy; 3 Department of
Cardiovascular Surgery, GVM Care and Research, Anthea Hospital, Bari,Italy
Thenormalfunctionandcompetencyoftheaorticvalvedependontheintegrityofallstructuralaorticrootcomponents:theaor-ticvalve,thenadiroftheannulus,thesinusesofValsalva,thesino-tubularjunctionandthetubularpartofascendingaorta.
Thefunctionalaorticvalveannulus(FAVA)isacomplexunitwithproxi-mal(aorto-ventricularjunction)anddistal(sino-tubularjunction)compo-nents.Thesetwoanatomicalstructures,apparentlyseparate,arestrictlyincontactbythecommissures.So,anypathologyaffecteachofaorticrootcomponentsmayleadtoaorticvalvedysfunctionandinsufficiency.Understandingthemechanismsofaorticvalvedysfunctionandtheeti-ologyoflesionshasdeeplyaidedsurgeonsintechniquesadvancetore-pairtheaorticvalveandrootandtoavoidvalvereplacement.AimofourstudywastoevaluatetheimpactofthetotalFAVAremodeling,usinganewhandmadeprostheticring(Figure.1),onlongtermresultsafteraor-ticvalverepair(AVR).
SinceFebruary2003,250patientswithtricuspidaorticvalveregurgi-tation(AR)underwentAVRinourinstitutions.Themechanismsofvalvedysfunctionaccordingtofunctionalclassificationwerethefollowing:TypeIin79(31.6%)patients,TypeIIin138(55.2%)andTypeIIIin33(13.2%).Concomitantaorticrootorascendingaortareplacementwereperformedin166patients(66.4%).FAVAdilatationwascorrectedbyourringin42patients,subcommissuralplastyin77,subcommissuralplastyplusascendingaorticreplacementin57,David’sprocedurein89.Leafletprolapsewascorrectedineachpatients.Themeanfollow-upwas48±14months.Long-termsurvivalandfreedomfromrecurrentAR≥moderate
wasevaluatedbyKaplan-Meier.Therewas6(2.4%)in-hospitaldeaths.Asecondpump-runwasre-
quiredin14(5.6%)patientstocorrectresidualAR.Mechanismsofre-sidualARwereuncorrectedcuspprolapseinninepatientsandresidualannulusdilatationinfive.Overalllatesurvivalwas90.4%.Latecardiac-relateddeathsoccurredin15patients.Atfollow-up,36(16%)patientshadrecurrentAR≥thanmoderate(cuspre-prolapseand/orFAVAdilata-tion).FAVAdilatationoccurredonlyinisolatedAVRwithorwithoutas-cendingaorticreplacement.FreedomfromrecurrentARwassignificantlyhigherforAVRplusDavid’sprocedureorFAVAremodelingbyprostheticringcomparedwithisolatedAVR(p<0.01)orAVRplusascendingaortareplacement(p=0.02).Therewasn’tstatisticaldifferencebetweenDavid’sprocedureorprostheticringannuloplasty(p=0.26).
Inconclusion,FAVAannuloplastybyourprostheticringisasafeandgoodprocedurefortreatmentofARandFAVAlongtermstabilization.Thistechniquemaybeusedinallpatientswithslightrootdilatationtoavoidaggressiverootreimplantation.WerecommendedtotalFAVAannu-loplastyinallpatientsunderwentAVRtoimprovelongtermrepairresults.
Functional aortic annulus remodelling using a handmade prosthetic ring improves outcomes in aortic valve repair.
Fig 1.(A) Circular ring for subvalvular aortic annuloplasty: (1) the commissural zone and (2) the intercommissural zone. (B) The three
crown-like shaped ring for the sinotubular junction annuloplasty. (C) The circular ring is sutured into the left ventricular outflow tract just
under the aortic valve cusps. (D) The sinotubular junction ring is sutured from outside the ascending aorta at the level of the sinotubular
junction. The three vertical arms of the sinotubular junction ring were fixed to the underlying circular ring to stabilize the continuity between
the two structures and to reshape the functional annulus.
Khalil Fattouch
Gabriel Weiss Vienna, Austria
Thefrozenelephanttrunktech-niqueisasingle-stagehybridprocedure,whichenablessi-multaneoustreatmentofthe
ascendingaorta,theaorticarchandthedescendingaorta.ThemainindicationsforthefrozenelephanttrunkrepairareaorticdissectionstypeA(DeBakeytypeI),oraneurysmsinvolvingtheaor-ticarchanddescendingaorta.Incaseofcompli-catedaorticdissectiontypeB,notamenableforendovascularther-apy,thefrozenelephanttrunktechniqueseemstoofferavalidtreat-mentstrategyfordeal-ingtheselife-threaten-ingaorticpathologies.
Prosthesis.ThemostfrequentlyusedprosthesisistheJotecE-vitaopenhy-bridgraft(Hechingen,Germany).It’savailableinvarioussizesandlengthsanditcon-sistsofapolyestergraftencapsulatingcircumferentialZ-shapednitinolstentsalongitslengthandawovenpolyes-tergraftattheproximalend.AnothercommerciallyavailablehybridprosthesisismanufacturedbyVascutec,Scotland.
Surgical technique.Thesurgicalaccessisacompleteme-diansternotomy.Inourdepartmentwemainlyusetherightaxillaryarteryforthearteriallineofthecardiopulmonarybypass(CPB).Oncetheextracorpo-ralcirculationisestablishedthecoolingprocessisinitiated.Thereconstructionoftheaorticarchcanbeperformedindeepormoderatehypothermicarrest.Dependingontheextentoftheaor-ticpathologyandtheexpectedcircu-latoryarresttimeitissafetoperformtheprocedureinmoderatehypother-miawithacoretemperature(bladderorrectal)of26-28°Celsius.Forbrainprotectionweuseselectiveantegradebilateralcerebralperfusion(10ml/kg
bodyweight).Theleftsubclavianarteryistypicallyblockedwitha6-FFoga-rtycathetertopreventastealphenom-enon.Afterresectionofthediseasedaortictissuethehybridprosthesisisplacedintothedescendingaortainanantegrademannerthroughtheopenaorticarch.Incaseofaorticdissection,itisrecommendedtouseaguidewireforthismaneuvertopreventaccidentalfalselumenintubation.Thestentgraft
isthendeployedinthedescendingaortawiththeproximalstentlevelapproximately2cmdis-taltheoffspringofleftsubclavianartery.Thereplacementoftheaor-ticarchcanbedonewiththeintegratedtu-bulargraftofthehy-bridprosthesisorwithaseparatevasculargraft.Headvesselre-implan-tationisthenperformedaccordingtoanatomyandsurgeonprefer-ence.Ifanatomicallypossiblewepreferto
maintaina2-3cmjunctionbetweentheleftsubclavianarteryandthedescend-ingaorta.(Fig.1)TheDacronofthehy-bridprosthesisistrimmedtoa1cmrimandfixedtothewalloftheproximaldescendingaortawitha4-0prolenerunningsuture.Oncethearchreplace-mentisaccomplished,thegraftpros-thesisisclamped,andfullperfusionandrewarmingisrestarted.Inthere-warmingperiodtheproximalanasto-mosisiscompletedandconcomitantprocedurescanbeperformedifnec-essary.
Thissinglestagehybridapproachen-ablessimultaneoustreatmentoftheas-cendingaorta,theaorticarchandthedescendingaortainordertoreducethenecessityforadditionaloperationsonthedescendingaortaandtoimprovelong-termsurvival.However,ifanaddi-tionalinterventionshouldbenecessary,thestentgraftofthehybridprosthe-sisoffersagoodlandingzoneforasec-ondaryTEVARprocedureorevenforanopenthoracoabdmoninalrepair.
Frozen elephant trunk
Figure 1
Figure 1 Figure 2
EACTS Daily News Monday 29 October 2012 35
Thoracic: Abstracts 10:15–11:45 Room 133/134
Udo Boeken
Heinrich Heine University, Dusseldorf, Germany
Itiswellknownthatpatientswhosuf-ferfromreadmissiontointensivecareunit(ICU)aftercardiacsurgeryfaceanincreasedriskofmorbidityandmortal-
ity.Itwasouraimtoanalysetheimpactofrecentoperativestrategiesontheincidenceofreadmission.Itshouldbeevaluatedwhetherlessinvasiveprocedures(i.e.MIC,OPCAB)maybeassociatedwithareduction
ofthiseconomicallyimportantproblem.TheroleofthequantityofICU-bedsaswellastheproportionofICU-tointermediate-care-bedsshouldalsobeinvestigated.
Altogether,wereviewed5,333patientsundergoingcardiacsurgeryinourdepart-mentbetween2005and2010.Theinci-denceandreasonsofreadmissionweredeterminedwithregardtoindividualsub-groups,particularlycomparingminimallyin-vasiveprocedureswithconventionalstrate-gies.Wetriedtofindoutperioperativerisk
factorsformorbidityandanalysedtheim-pactofthetotalamountofICU-andinter-mediate-care-bedsontherateofreadmis-sionsindifferenttimeintervals.
Inthegroupof5,333patientsbetween2005and2010,therewere5132pa-tientswhichcouldbeprimarilydischargedfromICU.Outofthisgroup,293patientsneededatleastoneadditionalICU-stayaf-terrequiredreadmission(5.7%,groupre).Accordingtothat,groupcoconsistedof4839patients.Afterreadmission,themean
lengthofstayinhospitalwas21.9±11.3dayscomparedto12.8±5.0daysinallotherpatients(p<0.05).
Comparingthereadmissionrateinsep-arateyears,itisobviousthatthisratede-creaseswithagrowingcapacityofICUandintermediate-carewards.
Inpatientswithlessinvasivecardiacsur-gery(i.e.MIC,OPCAB),thereadmissionratesweresignificantlylowerthaninthetotalofpatients.Therewerealsoremarka-bledifferencesregardingthereasonsforre-
admission,amongstotherssignificantlyres-piratoryproblemsafterminimallyinvasiveprocedures.
ReadmissiontoICUaftercardiacsurgeryiscorrelatedtoanimpairedoutcome.GrowingresourceswithregardtoICU-andintermedi-atecare-capacitymaypositivelyinfluencethisproblemresultinginadecreasingnumberofreadmissions.Recentsurgicalstrategieswithlessinvasiveprocedurescouldalsobeassoci-atedwithareducedincidenceofreadmissionbasedonlessrespiratoryproblems.
Readmission to intensive care unit as predictor of impaired outcome in times of minimally invasive cardiac surgery
Cardiac: Professional Challenges 10:15–11:45 Room 116/117
Bronchoplastic resection without pulmonary resection for endobronchial carcinoid tumoursKai Nowak1,3, Wolfram Karenovics1,
Andrew G. Nicholson2, Simon
Jordan1, Michael Dusmet1
1 Department of Thoracic Surgery,
Royal Brompton Hospital, London,
UK; 2 Department of Pathology,
Royal Brompton Hospital, London,
UK; 3 Division of Surgical Oncology
and Thoracic Surgery, Mannheim
University Medical Center, University of
Heidelberg, Germany
Bronchialcarcinoidsarerareneuroendocrinetumours,accountingforlessthan5%ofall
bronchopulmonarytumours.Theyarecategorizedaseithertypicaloratypicalandhavedistinctlydif-ferentprognosesandtherapeuticoptions.Roughly20%ofallcar-cinoidtumourspresentaspurelyintraluminalpolyp-likebronchiallesionswithoutgrossradiologi-caldetectableinvolvementofthebronchialwallandlung.Untilre-cently,thetreatmentofchoicere-mainedbronchoplasticsurgery.However,someauthorshavede-scribedtheirexperienceusingdif-ferentendoscopictechniquessuchasNd-YAGlaser,diathermyandcryosurgery.Itisamatterofdis-cussionwhetheritisnecessarytoprovidesomeadditionallo-caltherapybeyondsim-pleexcisionoftheairwaycomponentinordertode-creasetheriskoflocalre-currence.Long-termfol-low-updataforbothapproachesisscant.
Wepresentourexperiencewithallpatientswithpurelyendobron-chialcarcinoidswhounderwentparenchymaspar-ingbronchoplasticresectionwithsys-tematicnodaldis-sectionoverthelast10yearsandgeneratedare-viewofliterature.
Thirteenpa-tients(age45±16years,10male)underwentbronchoplas-ticresectionwithsystematicnodaldissectionforendobronchialcarci-noidtumours.Nolymphnodein-vasionwasobserved.Therewasnosignificantoperativemorbid-ityormortality.Medianfollow-
upwas6.3±3.3years.Onele-sionwasanatypicalcarcinoidandatfiveyearsatinyendobronchialtumourletwasseeninthecontra-lateralairway,whichwasresectedendoscopically.
Wereviewedtheliteratureofthelast15years.Thepathologiestreatedarebenignorlow-grademalignanttumors,mostcom-monlytypicalcarcinoidandotherbenignconditionssuchasstrictureortrauma.Parenchymasparingbronchoplasticresectionofferedadefinitesolutionforendobronchialcarcinoidswithverylowmorbid-ityandmortality(nilinthisseriesofcarcinoids,andupto25%mor-bidityandwithacomplicationratearound5%).
Aswecouldshowinourse-ries,surgeryremainsagoodandsafetreatmentoption.Ithastheadvantageofdealingwiththeproblemonceandforallandinadditiongivesacompletelymphnodestaging.Endoscopictreat-mentsareemergingasavalidal-ternativeorcomplementinthetreatmentofthesetumours.En-doscopycouldserveeitherasastandalonetreatmentincaseofcompletelyrespectabletumoursorasafirststepincaseofin-
completeendoscopicresectionorrecurrence.Endoscopictreat-mentwillhowevernotyieldalymphnodestagingandlargertumourscanberemovedonlyinapiecemealtechnique.Thepiecemealtechniqueandme-chanicalmanipulationdur-ingendoscopicresectionimpairpathologicalassessment.Also,althoughlessinvasive,itisinawaymorecumbersomeforthepatient,asseveralsessionsmaybenecessaryinordertoachieveresection.
InConclusionwefeelthatfitpatientsshouldbeofferedsurgicalresection,reservingendoscopicre-sectionforthosethatareunfitforsurgeryordeclineit.
Kai Nowak
Minimalincisionvalvesurgery(MIVS)providesexcellentoutcomesandsignificantbenefits
forpatientsandsurgicalteamsalike.Throughpe-ripheralcannulation,EdwardsThruPortsystems’allowsforfewerproductswithintheincisionsite.Thisoffersexcellentvisualizationandavirtuallybloodless,unobstructedoperativefield,enablingvalverepairorreplacementthroughthesmallestpossibleincision.*
MIVSenabledbyThruPort systems,providessignificantpatientbenefits,including:n ShorterhospitalstaysandtimeintheICUn Fasterreturntoworkorroutineactivitiesn LessdiscomfortandpainnReducedbloodlossn Lesssurgicaltraumaandriskofinfectionor
complicationsn ImprovedcosmesisEdwards ThruPort Systems offers the ProPlegeperipheral retrogradecardioplegiadeviceastheonlyretrogradecardioplegiadevicethatisperiph-erallyplaced–soyoucanrepairor replacethevalvethroughthesmallestpossibleincision.*The
ProPlegedevicecanbeusedincardiopulmonarybypass procedures such as in minimal incisionaortic valve replacement (MIAVR) and minimalincisionmitralvalverepair/replacement(MIMVR)for:nDeliveryofretrogradecardioplegiasolution,out-
sideoftheincisionnGentleocclusionofthecoronarysinusnMonitoringofcoronarysinuspressureThe ProPlege device provides global myocar-dial protection, in conjunction with antegrade,through the least obstructive cannulation tech-nique—andbestoutcomesfor thepatient.TheProPlegedevicecanbeusedincardiopulmonarybypassproceduressuchasminimalincisionaorticvalvereplacement,mitralvalverepairorreplace-ment procedures, re-operations, tricuspid valveprocedures,intracardiacmyxomaresection,pat-entforamenovalerepairs,atrialseptaldefectre-pairs,andablativemazeproceduresforatrialfi-brillation.* When compared to median sternotomy** In conjunction with antegrade cardioplegia
Right sided parenchyma sparing bronchial sleeve resection types for endobronchial carcinoids.
A: upper lobe division bronchial sleeve resectionB: central carinal and right main bronchial sleeve
C: bronchus intermedius sleeve resectionD: sleeve resection of the middle lobe bronchus
36 Monday 29 October 2012 EACTS Daily News
Angelo Maria Dell’aquila Genova, Italy
Reportsonthird-generationcen-trifugalintrapericardialpumps(HVADHeartware)areencour-aging;howeverthepreopera-
tivelevelofstabilityseemstoremainthemoreimportantpredictingfactorofmor-tality.InthepresentstudywesoughttocomparethesurvivalresultsofthisnovelpumpwithotherLVADsystemstakinginaccountthepreoperativeINTERMACSlevel.Forthispurposeasurvivalanaly-siswasperformedinaretrospectiveseriesof287(INTERMACSLevel1-2=158pa-tients,INTERMACSLevel3-4-5=129pa-tients)consecutivepatientsreceivingVADimplantationinouruniversityhospitalbe-tweenFebruary1993andMarch2012.Assistdevicesimplantedwere:groupA(HVADHeartWaren=52)groupB(previ-ousContinous-flowLVAD,INCORn=37,VENTRASSISTn=7,DEBAKEYn=32)and
groupC(pulsatilesystemsn=159).Af-tercumulativesupportdurationof54,436daysandmeanfollow-upof6.21±7.46months(range0to45.21months)ato-talof185pts.wassuccessfullybridgedtotransplantation,fivepatientscouldbeweanedfromthedevice.Log-rankanaly-sisrevealedasurvivalof82.0%,70.4%,70.4%forgroupA,84.0%,48.2%,33.7%forgroupBand71.6%,46.1%,33.8%forgroupCat1,12and24monthsrespectivelywithasignificantly(p=0.013)betteroutcomeforgroupA.Whenstrat-ifyingthesurvivalonthebasisofINTER-MACSlevel,nosignificantsurvivalim-provementwasobservedamongallpatientswhounderwentLVADimplanta-tioninINTERMACS1-2(p=0.47).Inthosepatients,MOFfollowedbyneurologicaleventswerethemostfrequentcauseofmortality(24.05%and13.92%respec-tively).Weconcludethatdespitepumpin-novations,prognosisofthosehigh-risk
patientsafterVADimplantationremainspoorandseemsnottobeenhancedbyadvancementoftechnology.
Ontheotherhand,amongpatients,whounderwentelectiveLVADimplan-tation,groupAexhibitsasignificantly(p=0.005)betteroutcomewhencom-paredwiththeotherINTERMACSmatchedgroups(B-C)withasurvivalrateof(88.8%groupAversus34.2%groupBand45.6%groupCat24months).AmongpatientswhounderwentelectiveVADimplantation(INTERMACSlevelof3-4-5)similarlytopa-tientsinINTERMACS1-2,MOFfollowedbyneurologicaleventswerethemostfre-quentcauseofmortality(10.08%and9.3%respectively).However,Log-Rankanalysisshowedasignificantlylowerinci-denceofneurologicaleventscausingdeathingroupAwithafreedomfromneuro-logicaleventscausingdeathof97%forthe3rdgenerationpumpsversus83%and78%fortheoldercontinuousdevices
andpulsatilesystemsatoneyearrespec-tively.Thisdifferencemightbeexplainedbythebetterbiocompatibilityofmate-rialsandlowermechanicalbearingsbe-tweentheimpellerandthepumphousingoftheHVADminimizingtheoccurrenceof
thromboembolicevents.Inconclusionelec-tiveHeartWareHVADsystemimplantationshowsnotablesurvivaloutcomes.Moreo-verpreoperativeunstablehemodynamicsresultsinapoorprognosisindependentofpumpgeneration.
Survival results of intrapericardial third-generation centrifugal assist divice: an intermacs-adjusted comparison analysis
Caption
Cardiac: Abstracts 10:15–11:45 Room 115
Cardiac: Abstracts 10:15–11:45 Room 112 Cardiac: Focus Session 14:15–15:45 Room 112
Marek Jasinski Dept Cardiac Surgery, Katowice, Poland
Thereisanincreasinginterestinaorticvalveandaorticrootrepair.ValvesparingoperationswereintroducedbyDrT.DavidandSirM.YacoobAn-
othersteptowardssystemicapproachwasstandariza-tionofleafletmanagementandintroductionofaor-ticregurgitation(AR)classification.proposedbyProfG.El-Khoury
Atotal150patientswithsevereARunderwentaor-ticvalverepairwithorwithoutaorticroot,ascendingaortaanddifferentconcomitantprocedures.Inhospi-talmortalitywas2,7%(n=4).Causesweremultiorganfailure(n=2)andcongestiveheartfailure(n=2).Meancardiacischemictimewas88,1minandCPBtimewas126,8min..Therewerefiveconversionsorredooper-ationsduringthesameadmission.Overallsurvivalat105monthswas95+/-1,9%.
Thecuspanatomywastricuspidin.117andbicus-pidin33ofpatients.Leafletrepairmanagementconsistedof:free-edgeremodellingwithGoretex7/0-16,leafletplication-.18,triangularresectionwithorwithoutpatchandrapheshaving-17.Techniquesappliedforannularstabilizationwere:subcomis-suralannuloplasty-78,andSTJremodellingin.26.Rootmanagementwasperformedasreimplanta-tion-46andremodelling-41includingfullrootremod-ellingin16.
100patientsbetween2003and2009,werepro-spectivelyfollowed,withclosingf-updataattheendof2011.Thereweresixlateredooperations.Thereweretwonotvalve-relatedredooprerations:acutedissectionofaorticarchanddescendingaorta(n=1)andchronicdissectionofdescendingaortainMarfanpatient.dissectionOtherreoperationswerecausedby:VSDatthelevelofperimembranousseptum(n=1),BAVcomplexrepairfailureafterrapheexcision+/-patchandgoretexstabilization.Meantiemwas107+/-2,7mths.Overall6yearsfreedomfromredoop-erationswas.91,37%.
Therewerefivepatientswithdevelopmentofmod-erate-severeAR.Meantime-107+/-2,5mths.Over-all5yearstreedomfromARgrade2+was93+/-3,2%.Therewasonedeath,lateafteremergencyredosur-geryfortypeBdissection.
Riskfactorsoflongtermsurvivalwere:NYHAclass,creatyninelevel,concomitantaortareplacementwithvalvereimplantation.Riskfactorsforredooperationwereleafletresectionwithandwithoutpatchandgoretexforfreeedgeremodelling.RiskfactorsforAR2+(aorticrepairfailure)werebicuspidaorticvalve,goretexleafletedgeremodellingandlefletresectionwithandwithoutpatch.
Aorticvalverepairoritssparingisaminorityascomparedtovalvereplacement.Probably,thereasonbeinglackofwidelyacceptedsystemicapproachal-lowingforclearlyreproducibleapproach.Weprospec-tivelyfollowedallpatientssuitableforrepairwiththe
strictprotocolsclassifingythetypeofregurgritationandappropriatetreatment.Asaresulttherewere:typeIa/b-remodelling-42;typeIb+Ic-reimplantation-48;TypeIc-78,TypeII-45.
105monthsfollow-updatafromprospectivelyana-lyzedcohortofpatientsshowsthataorticvalverepairassociatedwithaorticrootreconstructioncanbeper-
formedwithsatisfactoryresultsandprovenitsdurability.However,theresultscanbeimprovedwithmore
aggressiverootstabilizationduringbicuspidaor-ticvalverepair.Thismaybeachievedby:morelib-eraluseofreimplantationstrategy,probablyeasierwithValsalvaprosthesis,andplicationduringleaf-letrepair.
Prospective analysis of long-term results of aortic valve repair and associated root reconstruction
Legend: Stratified survival comparison among the three groups that undergoing elective VAD implantation (INTERAMACS
3-4-5)
Legend: Stratified survival comparison among the three groups undergoing
VAD implantation in cardiogenic shock (INTERMACS 1-2)
Berlin-TAVI-Team Deutsches Herzzentrum Berlin, Germany
TransapicalTAVIisasafeprocedure:Inourfirst500consecutivepatientswithahighrisk-pro-file(meanlogisticEuroSCORE36±21%,mean
STSPROMscore16.7%±14%),weobservedanoverall30-daymortalityrateof4.6%(4.0%forpa-tientswithoutcardiogenicshock).Access-siderelatedcomplicationswererare:surgicalrevisionforbleed-ingin1.4%,andsurgicalrevisionforapicalpseu-doaneurysmin0.4%,annularrupturein1.2%.Therewasonlyoneiatrogenicaorticdissection(0.2%)ina91-yearoldpatient;treatedbytransapicalplacementofanuncoveredaorticendostentwithgoodout-come.Neurologicalcomplicationswererare(majorstroke,1.0%;minorstrokerate,1.0%).Weobservedaverylowrateofpost-proceduralparavalvularorval-vularregurgitation:79%ofpatientswerewithoutoronlywithtraceregurgitationandonlythreepatients(0.6%)hadregurgitationofgradetwo.
Itisfrequentlyaskedwhatthecriteriaareinde-cidingbetweenatransapicalandatransfemoralap-proach.Thesimplestwayistodecideaccordingtotheconditionofthevascularaccess(state,presenceorabsenceofperipheralarterialdisease,calcifications,diameterofthearteries).Thecriticalvascularstatusforcestousethetransapicalapproach.Butshouldwesimplydecideaccordingtothevascularaccesscondi-tion?Transapicalimplantationhasseveraladvantagesoverthetransfemoral(ortransaxillary)route.Thetransapicalapproachisadirectprocedureandinde-pendentofthedegreeofthepatient’speripheralarte-rialdisease.Furthermoretheadvancingofthewireinanantegradedirectionthroughthevalveisveryeasy,rapid,andsimpleincomparisontotheretrogradeap-proachusedwithtransfemoralimplantation.Itmayreduceoreliminatecerebralembolizationduringthisphaseoftheprocedure.Wealsoexpectalowerrateofneurologiccomplicationsbecausethedangerofembolizationduringmanipulationintheaorticarchisreducedoreliminatedbythetransapicalroute.
Transapicalandtransfermoralapproachesaretwodifferenttherapeuticoptionsfortreatingthesameclinicalproblem,namelysevereaorticstenosisinpa-tientswithincreasedriskfromconventionalproce-dures.Bothproceduresarecompetitivewithconserv-ativetherapyorstandardaorticvalvereplacementbuttheyarealsocompetitivebetweenthemselves(transfemoralversustransapicalortransaxillary).Thebesttreatmentoptionevaluatedineachpatientshouldbechosen.Inourinstitutionweareabletoofferalltheseoptions.Our“TAVIteam”usesallap-proachesoftranscatheteraorticvalveimplantation(transfemoral,transapical,transaortic,rightandlefttransaxillary).Inthiswaythesameteamwasabletoperformtheprocedurethatisassessedtobereallythebestforthepatient(pleasedistinctbetween“thebestforthepatient”and“thebestfortheteam”).
The transapical approach:
A safe technique
EACTS Daily News Monday 29 October 2012 37
Congenital: Abstracts 14:15–15:45 Room 111
Cardiac: Abstracts 14:15–15:45 Room 116/117
Gianluigi Perri*a, Sergio Filippellia, Angelo Politob, Duccio Di Carloa, Sonia
B. Albanesea, Adriano Carottia Bambino Gesù Children’s Hospital IRCCS,
Rome, Italy.
Truncusarteriosusisacongenitalheartdiseaseoccurringinap-proximately0.04%of1,000livebirths.Truncalvalveincompe-tenceisachallengingcomplicationassociatedwithahighrateofearlyandlatemortality.Wereportourexperiencewithtruncal
valverepairandanalyzethefactorsassociatedwithin-hospitalmortalityandmid-termsignificantneo-aorticregurgitation.
Elevenchildrenunderwenttruncalvalverepairatourinstitutionduringthestudyperiod.Techniquesforrepairincludedbicuspidalizationthroughleafletapproximationassociatedwithtriangularresectionintwopatients(18%)andeitherbicuspidalizationortricuspidalizationoftruncalvalvethroughexcisionofoneleafletandrelatedsinusofValsalvainninecases(82%).Moreoverthreeofthelatterpatientsunderwentcoronarydetach-mentbeforecuspremovalfollowedbycoronaryreimplantation,duetocoronaryarterialimpediment.Thereweretwoearlyin-hospitaldeaths(18%),inonecaserelatedtothetechniqueofvalverepair(cuspremovalwithoutcoronaryreimplantationcausingcoronarydistorsion).Freedomfromsignificant(moderateorsevere)neo-aorticregurgitationwas76.2%and60.9%atoneandtwoyearsrespectively(Fig.1).
Freedomfromreinterventionattwoyearswas91%.Severeneo-aor-ticregurgitationwaspresentintwochildren:inonechildwhounderwentleafletapproximationandtriangularresectionwithoutcuspremovalandinonewhounderwentbicuspidalizationthroughleafletandsinusofVal-salvaexcisionfollowedbycoronaryreimplantation.Thelatterpatientde-velopedsevereneo-aorticregurgitationfourmonthslater,despiteasatis-
factoryearlypostoperativeresult.Statisticalanalysisshowedagelessthen1year(p=0.05),weightlessthen3kg(p=0.02),andlongercrossclampingtime(p=0.008)asriskfactorsforhospitalmortality.Furthermore,therewasatrendtowardsassociationbetweendevelopmentofsignificantaor-ticinsufficiencyandabsenceofcuspremovalattimeofrepair(Fig.2).
Ourinstitutionalpolicyisbasedonaggressiveapproachtotruncalvalverepairatthetimeofneonatalprimarycorrectionwhensignificantaorticregurgitationispresenttoavoidtheriskofprolongedmyocardialischemia.Inthemajorityofcasesweperformedthecuspremovaltech-niqueandselectforexcisionthesmallestleafletandrelatedsinusofVal-salva.Thebenefitofthisannulovalvuloplastyistoremodeltheneo-aorticvalvewithoutsuturingontheleaflets,avoidingexcessivesysto-diastolic
stressontherepairandrelatedriskofleafletsuturedisruption.Also,de-spitethefactthatcuspremovaltechniquewouldallowtosacrificethesmallestcusp,wesuggesttoavoidtheexcisionofthecuspoverridingtheareaofVSDclosureinordertoavoidbloodflowturbulencecausingin-creasedstressontheventricularsideoftheneo-commissureandeventu-allyitsearlydisruption.
Ourexperiencesuggeststhatthecorrectapplicationofthecuspreduc-tiontechniquemightdecreasetherateofpost-operativesignificantneo-aorticregurgitation.Aslongasleafletexcisionisperformed,coronaryde-tachmentbeforecuspremovalfollowedbycoronaryrelocationmightreducetheriskofmyocardialischemiabyavoidingtractiontothecoro-naryarteries.
Bil Kirmani UK
“What are my chances?” vs “Am I going to die?”
SuccessiveiterationsoftheEuro-SCOREandSocietyofThoracicSurgeonscalculatorshaveestab-lishedthetrendforincrementally
refiningtheanswertotheformerquestion.Ultimately,however,thesearchfortheper-fectriskcalculatorisasfutileastryingtoanswerthelatter.
Theoriginalriskstratificationtoolshadgooddiscrimination,ortheabilitytodis-tinguishbetweenlowest,higherandhigh-estrisks–infact,muchthesameasweseewiththenewcalculators.Butthede-mandforgoodcalibration,theabilitytomeanfourinahundredpatientswhentheriskis4%,putsthetoolsundernewscru-tiny.TheAreaUndertheROCcurvehasbeenjoinedbytheHosmer-Lemeshowtestindeterminingwhetherornotarisktoolisaccurateornot.Itbreaksthetestpopula-
tionintotenequallysizeddecilesandcom-parestheobservedandexpectedmortalityinthosedeciles.Expectedmortalityof,forexample,1%,2%,3%,4%etc.mustbeapproximatelythosevaluesandnotcon-sistentratiosthereof.Anobservedmortal-ityof0.5%,1%,1.5%,2%wouldthere-forefailthetestasthegroupsareclearlynotthesame.
TherationalebehindtheHosmer-Leme-showtestissound:anindividualpatientwillalwayshaveamortalityofeither0%or100%,whichmakeseveryindividualpredictionalwayswrong.Atestbasedonthiscomparisonwouldshowpoorcalibra-tion.However,ontheotherendofthespectrum,iftheoutcomefortheentiretestpopulationisaveragedandthepre-dictedmortalityequalstheobservedmor-tality,thisdoesnotmeanthatthecalcula-toriswellcalibrated.Somewherebetweenthesetwodichotomies,existsanappro-priatedivisionofthepopulationtoassesscalibration.TheHosmer-Lemeshowtypi-
callyutilisestengroupsofequalsize,butcouldequallyusethree(low,mediumandhighrisk,forexample)orfiveoronehun-dred.Wedemonstratetheeffectofusingapercentileratherthandeciledivisionofgroups.Whilethisstillgivesahighlysignif-icantP-value(variationinanyonegroup
meansthetestfails),thegraphicalrepre-sentationgivesaclearerideaofhowthecalculatorfails.
Inourretrospectiveseriesofnearly15,000patients,weexaminedtheexter-nalvalidityEuroSCOREIIandtheSTSRiskScorefrom2008.Neitherisa“backoftheenvelope”calculationanymore,andbothdemonstrateequivalentdiscriminationforawiderangeofprocedures,includingmanythattheSTSscoreneverintendedtopre-dictfor.C-statisticswereconsistentlyinthe
0.8region,suggestionmoderatelygooddiscriminationofbothtools.TheHosmer-Lemeshowtestwasfailedbybothcalcula-tors(p<0.0001inallcases)but,asabove,wequestionthereliabilityofthistestasitcurrentlyexistsinlargetestgroups.
Overseveraldecades,ourtoolsforriskstratificationhavebecomeincreasinglywell-adjusted,allowingustonotonlyes-timatetheoutcomesforourpatients,buttobenchmarkourresultsandstandard-isecare.
Repair of incompetent truncal valve: early and mid-term results
Comparison of the euroSCORE II and Society of Thoracic Surgeons 2008 risk tools
Gianluigi Perri Figure 1 Figure 2
Isamu Kawase Toho University Ohashi Medical
Center, Tokyo, JAPAN
Inthepast,chronichemodialysisforend-stagerenaldisease(ESRD)wascon-sideredacontraindicationtomajorcar-diacsurgery.Nowadays,manypatients
onhemodialysisundergoheartsurger-ies.Thelongerthelifeexpectancyofdialy-sispatientsisbecoming,themorepatientsmaybecomecandidatesformajorcardiacsurgery.Majorreasonsfordeathofthepa-tientsondialysiswereheartfailure,cerebralinfarction,cerebralhemorrhage,gastro-in-testinalbleeding,andinfection.Forthepre-ventionofthesefactors,weneedthebetterheartvalvesurgerywithgoodhemodynam-icsandpost-operativewarfarin-freecon-dition,andtoavoidforeignbodyimplan-tationasmuchaspossible.Tosearchtheidealsurgicaltreatmentofaorticvalvedis-ease,ouroriginalaorticvalvereconstruc-tionusingglutaraldehyde-treatedautolo-gouspericardiumfordialysispatientswasreviewed.Ouroriginalaorticvalverecon-
structionwasinventedbyProfessorOzaki.And,Prof.OzakiandIhavebeenperform-ingthisoperationformorethanfiveyears.SomesurgeonsarecallingthisprocedureasOzakioperation.
Aorticvalvereconstructionhasbeenperformedfor404casesfromApril2007throughSeptember2011.Amongthem,54casesonhemodialysiswereretrospec-tivelystudied.Forty-sevenpatientshadAS,5hadAR,andtwohadinfectiveendocar-ditis.Meanagewas70.2±8.5yearsold.Therewere35malesand19females.Therewere27primaryaorticvalvereconstruc-tions,11withCABG,sixwithascendingaorticreplacement,fivewithmitralvalvere-pair,andfourwithMaze.Firstintheproce-dure,harvestedpericardiumistreatedwith0.6%glutaraldehydesolution.Afterre-sectingcusps,wemeasurethedistancebe-tweencommissureswithoriginalsizingin-strument.Then,pericardiumistrimmedwithoriginaltemplate.Threecuspsaresu-turedtoeachannulus(Figure1).Peakpres-suregradientwasaveraged66.0±28.2
mmHgpreoperatively,anddecreasedto23.4±10.7,13.8±5.5,and13.3±2.3respec-tivelyoneweek,oneyear,andthreeyearsaftertheoperation.Nocalcificationwasde-tectedwithechocardiographicfollow-up.RecurrenceofARwasnotrecordedwiththemeanfollow-upof847daysexceptforonecasere-operatedforinfectiveendocar-ditis2.5yearsaftertheoperation.Three
hospitaldeathswererecordedduetonon-cardiaccause.Otherpatientshadbeeningoodconditions.Therewasnothrom-boembolicevent.Survivalrateof79.6%andfreedomfromreoperationrateof95.2%ataboutfiveyearsfollow-upwerecalculatedbyKaplan-Meiermethod.
Medium-termresultswereexcellent.Sincewarfarinforthedialysispatientsbe-
comesproblematic,post-operativewarfa-rin-freestatusisdesirable.Aorticvalvere-constructioncangivethebetterqualityoflifeforthepatientsondialysiswithgoodhemodynamicsandwarfarin-freecondi-tion.Thisoperationmighthavethepossibil-itytobecomeoneofthestandardsurgicaltreatmentsforaorticvalvediseaseindialy-sispatients.
Cardiac: Abstracts 10:15–11:45 Room 112
Aortic valve reconstruction with autologous pericardium for dialysis patients
Isamu Kawase (left) and Professor Ozak Figure1: Completion of aortic valve reconstruction
38 Monday 29 October 2012 EACTS Daily News
Leontyev S., Borger M.A., Etz C.D., Moz M.,
Seeburger J, Bakhtiary F., Misfeld M, Mohr
F.W. University of Leipzig, Leipzig, Germany.
Theconventionalelephanttrunkprocedure,developedbyBorstinthe1980s1,becamethestandardapproachforpatientswithexten-
sivepathologyofthethoracicaortainvolv-ingthearchandthedescending/thoraco-abdominalaorta.Thisprocedure,however,remainsasurgicalchallengeassociatedwithasignificantoperativeandintervalmortal-ity,andahighincidenceofneurologicalcomplications2,3.Inthecurrentendovascu-larera,newtechnicalsolutionshavebeendevelopedtotreatthesepatients.Sincethemid–90s,endovascularorhybridopera-tionssuchasdebranchingprocedures4orthefrozenelephanttrunktechnique5wereintroducedintoclinicalpractice.
Wecomparedtheclinicalresultsaf-teraconventionalelephanttrunk(cET)ap-proachtothenewfrozenelephanttrunk(FET)techniqueinordertodeterminetheef-fectsonneurologicaloutcome,mostimpor-tantlyischemicspinalcordinjury.Atotalof
171consecutivepatientsunderwentaorticarch/descendingaortareplacementwithacET(n=125)orFET(n=46)procedureoveran8yearperiod.Themajorityofpatientspre-sentedwitheitheracuteorchronicaorticdis-section,andacETprocedurewasperformedsignificantlymoreofteninpatientswithacuteTypeAaorticdissection.Theintraoper-ativevariablesweresimilarbetweenthetwopatientgroups,withtheonlydifferencebe-ingthatthatthemeannasopharyngealtem-peraturewashigherinpatientsundergoingFETsurgery.The30-daymortalityandover-alloccurrenceofpermanentneurologicaldef-icitwasnotstatisticallysignificantdifferentbetweenstudygroups.Themultivariateanal-ysisidentifiedacutetypeAaorticdissectionastheonlyindependentpredictorfor30-daymortalityandpermanentneurologicaldeficit.
Wefoundasignificantlyhigherincidenceofparaplegiainpatientswhounderwentaone-stageFETprocedure(21.7%vs4%,p<0.01).Furthermore,FETwasidentifiedasanindependentriskfactorforpermanentparaplegia.AmongFETpatients,multivar-iateanalysisidentifiedanasopharyngealtemperatureduringcirculatoryarrestof28
degreesorhigherincombinationwithdu-rationofcirculatoryarrestmorethan40minutesastheonlyindependentpredictorforpermanentspinalcordinjury.
Paraplegiaisoneofthemostdreaded—buthistoricallyrare—complicationsofele-phanttrunksurgery.Thereportedincidenceofspinalcordinjuryinpatientsundergo-ingFETappearstobesignificantlyhigherthanforconventionalETprocedures6.Inouropinion,theoccurrenceofspinalcordinjuryismultifactorialandmostlyinfluencedbyacombinationofacuteischemicinjuryduringdistalcirculatoryarrestatmildtomoderatehypothermia,andpostoperativehemody-namicfluctuationsafterextensivesegmentalarteryocclusion.FETprocedures,however,havethepotentialtoimpactonbothinflowpathwayssimultaneously:segmentalarteryperfusionandupperinflowtotheCollateralNetworkviathevertebralartery.Thismightbethereasonfortheincreasedoccurrenceofparaplegiaandthesignificantlyhigherin-cidenceascomparedtocETprocedures.
Inconclusion,thefrozenelephanttrunkimplantationprocedurecanbeperformedwitharelativelylowmortalityrate,butis
associatedwithanincreasedincidenceofpermanentparaplegiaduetoischemicspi-nalcordinjury.Aprolongeddistalarresttimeofmorethan40minutes,particu-larlyincombinationwithacorebodytem-peratureofmorethan28degrees,isanin-dependentpredictorofparaplegiainFETpatients.MorepronouncedhypothermiashouldbeusedduringFETsurgery,partic-ularlyinpatientswithexpectedprolongedcirculatoryarresttimes.References
1 Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement us-ing “elephant trunk” prosthesis. The Thoracic and cardiovascular surgeon 1983;31:37-40.2 Khaladj N, Shrestha M, Meck S, Peterss S, Kamiya H, Kallenbach K, Winter-halter M, Hoy L, Haverich A, Hagl C. Hypothermic circulatory arrest with selec-tive antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. The Journal of thoracic and cardiovascular surgery 2008;135:908-914.3 Misfeld M, Leontyev S, Borger MA, Gindensperger O, Lehmann S, Legare JF, Mohr FW. What is the best strategy for brain protection in patients undergoing aortic arch surgery? A single center experience of 636 patients. The Annals of thoracic surgery;93:1502-1508.4 Buth J, Penn O, Tielbeek A, Mersman M. Combined approach to stent-graft treatment of an aortic arch aneurysm. J Endovasc Surg 1998;5:329-332.5 Kato M, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, Matsuda H. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94:II188-193.6 Jakob H, Tsagakis K, Pacini D, Di Bartolomeo R, Mestres C, Mohr F, Bonser R, Cerny S, Oberwalder P, Grabenwoger M. The International E-vita Open Registry: data sets of 274 patients. The Journal of cardiovascular sur-gery;52:717-723.
Jörg Kempfert
Kerckhoff Clinic, Bad Nauheim,
Germany
Overthelastyearsthetechniqueoftran-scatheteraorticvalveimplantation(TAVI)has
evolvedtoaroutineprocedureinmanycenterstotreatelderlyhigh-riskpatientssufferingfromseveresymptomaticaorticstenosis.Thetransapicalapproach(TA-AVI)of-ferstheadvantageofatrulymin-imally-invasivedirectandaxialac-cesstotheaorticvalvethathasbeenproventobeextremelysafewithverylowratesofaccesssiterelatedcomplications(<1%)whileatthesametimefacilitatingun-matcheddevicecontrol(shortdis-tance)anda“notouch”approachinregardtotheascendingaortaandaorticarch(strokerisk).
AlthoughtheTAapproachhastobeconsideredatrulyminimally-invasiveprocedurealreadyitstillinvolvesasurgicalcut-downusing
a5cmskinincisionandanantero-lateralmini-thoracotomy.Tofur-therreducetheinvasivenessoftheapproachandtofurtherstandard-izeventricularaccessseveralsocalled“apicalclosuredevices”areunderdevelopment.Suchdevicesmightfacilitatethetransitiontoafullypercutaneoustransapicalap-proachsoon.
Thepresentationfocusesonthedifferentemergingdevicecon-ceptsandwillgiveanupdateoneachdevicestatus.
Atpresent,fourdifferentde-viceconceptsarejustabouttostartclinicaltrialsorhavealreadybeensuccessfullyusedwithin“FIM”trials:
TheApicaASCdevice(Fig-ure1)reliesoncircularmyocar-dialcompressionusinga“sealingcoil”meanttosealpara-sheathbleedingduringtheactualTAVIimplantation(Figure2left)fol-lowedbysecuresealingoftheventricularaccessbyusinga“clo-surecap”afterremovalofthe
TAVI-sheath(Figure2right).Sev-eralsuccessfulcaseshavebeenal-readyperformedwithinamulti-centerCE-marktrialwithoverallverypromisingresults.
Theseconddeviceconceptthathasbeenusedwithinfirstclinicalcasesjustrecentlyappliesmyocar-dialanchorsthatcreatean“oper-atingwindow”whichisthenusedtoinsertTAVIdevices.AftervalvedeploymentthePermasealdevice(MicroInterventionalDevices)fa-cilitatesimmediateself-closure(Figure3).
Otherpromisingconceptsin-cludetheEnTouragesystemwhichreliesonhelicaltransmuralsuturesandtheCardiApex™approachwhichnotonlyoffersapicalclosurebutpercutaneouspuncturingfromthe“inside”.Bothdeviceshavedemonstratedproofofconceptwithinanimaltrialsandarejustabouttoenterfirstclinicaltrials.
Insummary,thefieldoftransapi-calclosuredevicesisemergingrap-idlysuggestingthatfullypercuta-neousTA-AVIproceduresmightbecomerealityverysoon.
Conventional elephant trunk vs frozen elephant trunk technique in treatment of patients with thoracic aortic disease – effect on neurological complications
Will the transapical approach become a percutaneous procedure? Outlook on new transapical companion devices
Figure 1: Apica ASC™: transapical access and closure device
Figure 2: Apica ASC left: Step1 “sealing coil”, right: Step2 “closure cap”
Vascular: Abstracts 14:15–15:45 Room 113
Cardiac: Focus Session 14:15–15:45 Room 112
Sergey Leontyev
ThatisthecalltoactionattheAbbottVascularbooththroughouttheEACTScongressthisyear.InanefforttoraiseawarenessofthedebilitatingburdenofMitralRegurgitation,physicianshavetheopportunitytowriteonadedicatedwallofAbbott’sboothabouthowtheirpatientsfeel.
MitralRegurgitationisadeadlyandpervasivediseasethatoftengoesuncheckeduntilitistoolate.Nearlyhalfofpatientsreferredforsurgeryaredeclinedsurgicalrepairorreplacementbecauseofmulti-pleco-morbiditiesandadvancedage.Visuallyrepresentingthesevereclinicalimpactofthediseaseisapow-erfulreminderofhowmuchmorewecandoforthesepatients.Themore–andsooner-themedicalcom-munityscreensforMRandreferspatients,thebettertheoutcome.Afterthecongress,asummaryofyournoteswillbemadeavailableandsharedwithotherspecialtiesacrossEurope.Taketheopportunityforyouropinionstobeseenandyourpatient’sfeelingstobeheard.
Express yourself through completion of the sentence: “patients with severe MR feel like …!”
Express yourself through completion of the sentence: “patients with severe MR feel like …!”
“Express yourself!”Figure 3: Permaseal apical closure device facilitating immediate “self-closure”
EACTS Daily News Monday 29 October 2012 39
Cardiac: Abstracts 10:15–11:45 Room 116/117 Residents’ Session 14:15–15:45 Room 118/119
Martin Haensig University of
Leipzig, Germany
Conventionalsurgi-calrisk-scoresareusedtoidentifysuit-ablecandidatesfor
transapicalaorticvalveimplan-tation(TA-AVI)atpresent.Thetwomostcommonlyusedrisk-scoresaretheEuropeanSys-temforCardiacOperativeRiskEvaluation(EuroSCORE)andtheSocietyofThoracicSurgeonsPredictedRiskofMortality(STS-PROM).Both,developedtoas-sessmortalityriskforcardiacsurgicalprocedures.WhereastheEuroSCOREwasinitiallyconductedin1995andfirstpublishedin1999,theSTS-Scorewasinitiallydevelopedinthelate1980sanditscurrentmodelforsolelyisolatedaorticvalvere-placement(AVR)introducedin2007.
Inasmuchasbothmodelswerebasedonpa-tientswhohaveactuallyundergonesurgicalAVR,theiraccuracyinselectedhigh-riskpatientsisnec-essarilyspeculative.Still,theyarethebesttoolswecurrentlyhavetohelpselectpatientsandas-sessoutcomes.
Whileadvancesinsurgicaltechniquesandperi-operativecarehavesteadilyreducedtheproce-duralriskofAVR,thechangingriskprofileofsurgicalpatientsoverthelastdecadeledtheEu-roSCOREinvestigatorstodeveloparevisedver-sion,theEuroSCOREII.Theaimofthisstudywastocomparethepredictiveabilityandproperties,aswellasthecorrelationofthenewEuroSCOREIItothesurgicalrisk-scorescurrentlyinuse.
FromFeb/2006toMay/2011,360consecu-
tivehigh-riskpatients,age81.6±6.4years,64.4%female,werein-cludedusingtheEdwardsSapi-enTMprosthesisandatransapi-calapproach.TheSTS-ScoreandEuroSCOREII(r=0.504,p<0.001)showedagoodcorrela-tion,whereasastrongcorrelationwasfoundbetweenthelogisticEu-roSCOREandEuroSCOREII(r=0.717,p<0.001).30-dayandin-hospitalmortalityratewere10.6%(38/360)and11.4%(41/360).In-hospitalmortalityratewasesti-matedbythelogisticEuroSCORE:30.0±15.7%,theSTS-Score:11.7
±7.8%,andtheEuroSCOREII:6.7±5.1%.TheprognosticvalueoftheSTS-Score,logisticEuro-SCOREandtherecentEuroSCOREIIsystemswasanalyzedinROCcurveanalysisforthepredictionof30-day(AUC:0.64vs.0.55vs.0.50)andin-hospitalmortality(AUC:0.65vs.0.54vs.0.49).Evenintheabsenceofahighpreoperativesurgi-calriskmany‘extreme’orrareconditions(porce-lainaorta,frailtyorpreviouschestradiationetc.)willjustifyaTAVIprocedure.
ToshedlightontheperformanceofthenewEuroSCOREII,wepresentasingle-centeranal-ysisin360transapicalpatients.Inpatientsun-dergoingTA-AVI,thenewEuroSCOREIIcorre-latesstronglywiththelogisticEuroSCORE,butisapoorerpredictorof30-dayandin-hospitalmor-talitythantheSTS-Score.ThenewEuroSCOREIImayactuallyunderestimate30-dayandin-hospi-talmortalityriskinhigh-riskpatients.AtrueTAVIrisk-scorewouldbedesirablebeyondtheestab-lishedscores.Theresultswillbepresentedsepa-ratelyduringthemeeting.
Doosang Kim
Seoul Veterans Hospital,
Seoul, South Korea
A retrospec-tiveclinicalstudyfromSeoulre-
portedsurvivaldiffer-encesbetweenTouchPrintCytologysub-groupswhenTouchPrintCytologytestwasperformedduringNSCLCasurgeryforde-tectingoccultpleuraldisseminationofcan-cercells.Thestudyenrolled256patientswhohavebeenconductedbothTouchPrintCytologyandPleuralLavageCytologyus-ingglassslidesandsaline1.TheglassslideswereexaminedandgradedasnegativeTPC,positiveTPC1+(afewcells,lessthan10cells),2+(cellnests,morethan10cellsaggregated),3+(clusters,morethanfiftycellsaggregated),and4+(diffuse).Inthisstudy,negativeTPC,positiveTPC1+,andpositiveTPC2+aredesignatedasGroupI,3+asGroupIIand4+asGroupIII.Thepa-tientswhohashighgradesTPCshowpoorsurvivalresults(RecurrenceFree5YSRandMedianSurvivalTimeofeachgroupare43.6%,30.8%,0%and32.03m,10.50m,0.03m(p=0.0169),respectively.)
ThisstudyresultsareconsistentwithIn-ternationalPleuralLavageCytologyCollab-orators’2010reports,whichshowedsur-vivaldifferenceofPLCresultfrom8,763individualdataof11institutesinternation-allywithstatisticalsignificance[2].Clinical
relevancesofTouchPrintCytologywerere-portedpreviouslybyothergroups[3,4].
Pleuralcavityisapotentialspacewhichcancercellscouldbedisseminated.Malig-nantpleuraleffusionisclassifiedasM1a,accordingtotherevisedTNM-7stagingin2009,whichwasdesignatedpreviouslyasT4atTNM-6in1997.However,occultpleuraldisseminationofcancercells,whichhasnodefiniteeffusion,isnotclassified
yet,becauseitisdifficulttodetectusingpleurallavagecytologyduringsurgeryduetoitslowsensitivityrangeof4-14%andnotsufficientevidence-basedresults.Touchprintcytologywasadoptedandusedtode-tectoccultpleuraldisseminationofcancercellseasilybySeoulgroup.Thesurvivalim-pactofthisfindingwasremainedtobeelu-cidatedbeforethisreport.
Fromthisstudy,twofindingsaremade
evidently.Oneisthepresenceofoccultpleuralmicrometastasisandtheotherisitsclinicalrelevanceofpleuralmicrometasta-sis.ThestudygroupsuggeststhatonlyTPCgradesover3+shouldbeconsideredasclinicalrelevancetopleuralmicrometasta-sis.Obviouslynottheappearanceitselfbuttheamountofmalignantcellsseenisofimportanceinpleuralmicrometastasis.References
1 Kim D, Ryu W, Cho SJ, Kim J, Park S. Touch print cytology shows higher sensitivity than pleural lavage cytology for pleural micro-metastasis in lung cancer. Interact CardioVasc Thorac Surg 2005;4:70-74.2 International Pleural Lavage Cytology Collaborators. Impact of positive pleural lavage cytology on survival in patients having lung resection for non small-cell lung cancer: An international individual patient data meta-analysis. J Thorac Cardiovasc Surg 2010;139:1441-1446.3 Safai A, Razeghi A, Monabati A, Azarpira N, Talei A. Comparing touch imprint cytology, frozen section analysis, and cytokeratin immunostaining for intraop-erative evaluation of axillary sentinel lymph nodes in breast cancer. Indian J Pathol Microbiol; 2012 Apr-Jun;55(2):183-6.4 Alayouty HD, Aminmm, Aloukda AW, Bafakeer SS, Sulieman DD. Should three slide-touch print cytology replace pleural lavage cytology for detection of pleural micrometastasis in cases of bronchogenic carcinoma? Interact Car-dioVasc Thorac Surg 2011;12:728-732.
Is the new euroSCORE II a better predictor for transapical aortic valve implantation?
Tissue engineering of the right heart outflow tract by a cell-seeded bioabsorbable poly-L-lactic acid valved tube
Occult pleural dissemination of cancer cells detected using touch print cytology method during surgery shows survival impact
Thoracic: Abstracts 14:15–15:45 Room 113/114
David Kalfa University Paris Descartes
Sorbonne Paris Cité, Paris, France.
Currentdevicesusedinclini-calpracticeforthesurgicalrepairoftherightventricu-laroutflowtract(RVOT)in
congenitalcardiacdiseasesareinertmaterialswithoutgrowthpotentialandrequiremultiplereoperations1-3.
Theprimaryobjectiveofourstudyistorestoreanautologous,liv-ingvalvedRVOTinagrowinglambmodel,usingatri-leafletvalvedtubemadeofbioabsorbablepoly-L-lacticacidseededwithautologousmesen-chymalstemcells(MSC).Secondaryaimsaretoprovethegrowthpoten-tial,absenceofdegenerationandthevalvularcompetenceatmid-andlong-termofthisdevice.
Theproofofconceptwasmadein vivobyimplantingbioresorba-blevalvedpatchesmadeofpolydiox-anoneandseededwithautologousperipheralblood-derivedMSCintotheRVOTofsixthree-month-oldlambsandevaluatedbyMRIandimmuno-histochemistryuptoeightmonthsaf-tersurgery4.Tissue-engineeredRVOTwereneitherstenoticnoraneuris-malanddisplayedagrowthpotential,withlessfibrosis,lesscalcificationsandnothrombuscomparedwithcon-trolpolytetrafluoroethylene/pericardialpatches.Thepolydioxanonescaffoldwascompletelydegradedandcolo-nizedbyhostcells,leadingtoaviable,
three-layered,endothelializedtissueandanextracellularmatrixwithelasticfiberssimilartothatofnativetissue4.Thenon-optimalmechanicalcharac-teristicsofpolydioxanoneledustoconsiderpoly-L-lacticacidforfurtherexperiments5.
Firstgenerationsoftubesandvalveswereperformed,usingwo-venpoly-L-lacticacidandacopoly-merof{poly-L-lacticacidandpolyes-ter}respectively.Acomputer-assistedmodelingdefinedthegeometryofthetri-leafletvalveanditsinsertionwithintheconduit.Invitromechan-icaltestsdemonstratedahighburststrengthperformanceofthetube(mean:303±43N).Anexcellentwa-terpermeability(0.01mL/min/cm²)wasobtainedbyimprovingthecolla-gencoatingandthesurfacedesignofasecond-generationcrimpedtube.A
dynamicbiphasicbioreactorwascus-tomizedtoperformefficientinvitrocell-seeding(3,5x106MSC/cm²for10days)andmaturationofthepol-ymerictube.Thefirstin vivoimplan-tationofpoly-L-lacticacidbioabsorb-abletube(unvalved–unseeded)ina12-kg-lambdisplayedatafour-monthfollow-uptheabsenceofstenosis,aneurysm,thrombus,andhistologicalevidenceforanendothelialliningbutahighcollagendensity.
Thecompetence,dynamicsandfa-tigueofthevalvewillbetestedinvitro.Threetypesofvalvedtubesareplannedtobeimplantedingrowinglambswitha12-monthfollow-up:PLLA+autologousMSC(n=8);PLLA+allogenicMSC(n=4)insex-mis-matchedrecipients(toidentifytheor-iginofthecellspresentinthetube);and“standard-of-care”controltubesmadeofpolyethyleneterephtalate(Dacron)associatedwithaporcinebi-ologicalvalve(n=3).Themechanicalresultsandhistologicaloutcomesoftheexplantedconduitswillultimatelydictatethechoiceofthepolymerandthewaysofoptimizingitsmanufac-turability.References
1. D Kalfa, et al. J Thorac Cardiovasc Surg 2011 Octo-ber;142(4):950-3.2. D Kalfa, et al. Eur J Cardiothorac Surg, 2012, doi: 10.1093/ejcts/ezs248.
3. D Kalfa, et al. Eur J Cardiothorac Surg, 2012, doi:10.1093/
ejcts/ezs367.
4. D Kalfa, et al. Biomaterials. 2010 May;31(14):1056-63.
5. D Kalfa, et al. Journal de Chirurgie Thoracique et Cardio-
Vasculaire, 2012 March;16(1):20-32.
40 Monday 29 October 2012 EACTS Daily News
Malakh Shrestha, Andreas Martens, Felix Fleissner,
Fabio Ius and Axel Haverich Hannover Medical School.
Objective
Combinedpathologyoftheaorticarchandthedescendingaorta(aneurysmsandDis-section)remainsasurgicalchallenge.Dif-ferenttechniqueshavebeenproposed.Ina
twostageoperation,atthefirststage,theaorticarchisreplacedthroughamedianstenotomyandduringthesecondstage,thedescendingthoracicaortaisreplacedthroughalateraltho-racotomy.ProfessorHansBorstandcol-leaguesintroducedsocalled‘Elephanttrunk’techniquein1982atourcenter,greatlysimplifyingthistwostagetech-nique.However,amajordisadvantageofthisapproachwastheneedfortwoop-erationswithitsassociatedmortalityandmorbidityaswellasthefactthatatleastsomemortalityintheintervalbetweenthetwooperationsduetotheruptureoftheuntreatedsegmentofaorta.
Withthe‘frozenelephanttechnique’(FET),theaor-ticarchisreplacedconventionallyandanendovascularstent-graftisplacedintothedescendingaortainan-tegrademannerthroughtheopenaorticarch,therebypotentiallyallowingfora‘single–stage’operation,es-peciallyinpathologieslimitedtotheproximaldescend-ingaorta.PublicationswithLongtermfollow-upresultsaresparse.Wepresentour10yearresults.
MethodsBetween2001-01/2012,FETwasim-plantedin131patients(95males,61±13years).Theindicationsincluded91aorticdissections(TypeA(acuteandChronic):n=78,typeB(acuteandchronic):n=13)andaorticaneurysms(n=40),respectively.Medianfollow-upwas42±37months.40patientshadundergonepreviouscar-diacoperations.Concomitantproceduresincluded25Bentall,26CABG,17David,5Yacouband8aorticrootrepairs,re-spectively.
ThreedifferentFETprostheses,cus-
tom-made(n=66),Jotec-E®-vita(n=30)andVascutek(n=35)prosthesiswereused.Thecerebralprotec-tionwasdonemoderatehypothermiccirculatoryar-rest(MHCA)andselectiveantegradecerebralperfusion(SACP).
Results Intra-operativemortalitywas1.6%(n=2)andin-hos-pitalmortalitywas14.17%(n=20).CPB,X-clamp,MHCAandSACPtimeswere238±70,137±51,58±24,and69±31minutesrespectively.Complica-tionsincludedre-thoracotomies18%(n=24),acutere-nalfailureleadingtoDialysis16%(n=21),paraparesis3.1%(4)andstroke14.7%(n=19).
Thirty-sixpatientsunderwentfollow-upprocedureonthedownstreamaorta,eitherendovascular(n=16),
opensurgery(n=20),respectively.One,fiveandten-yearsurvivalwas82±3,72±5and
58±8years,respectively.
ConclusionFETconceptaddstothearmamentofthesurgeoninthetreatmentofcomplexanddiverseaorticarchpa-thology.Theinitiallearningcurve,acutedissections,re-doandconcomitantprocedurespartiallyexplainsthehighermortalityrate.Nevertheless,ourexperiencedemonstratesacceptableshortandlong-termresultsintreatingthiscomplexdiseasecohort.Ourseriesshowsthatincarefullyselectedpatientswithcombinedpa-thologyoftheaorticarchandtheproximaldescend-ingaorta,theFETprocedureallowsfora‘single-stage’procedure.
Ahmed Abousteit UK
Overthepastthreedecadesasignifi-cantprogresshasbeenachievedin
themanagementofaorticvalvediseaseinpaediatrics,mostlyasaconsequenceoftheoverallimprovementsincardiacsurgerymethodsandoutcomes.
BackgroundManagementoftheaorticvalvediseaseinpaediatricpopulationhasanongoingcontroversyofwhichisthebesttreatmentoptionforthisagegroup.Theoptionsavailablearereplacementwithavalvesubstitute[me-chanical,bioprosthesis,homograft,orautograft(Rossprocedure)],orvarioustechniquesofvalverepair.
Centresandsurgeonsvaryintheirapproachandallaretryingtosupporttheirpredilection;andastimepasses,dataarecompilinggivingusmorechancetoanalyse,compareandprefer.
ObjectiveInourcentre,wehaveatrendtowardsrepairandweaimedatevaluatingthemid-termresultsofourinter-ventions.
Weperformedthirtynineaorticvalverepairsinchil-drenbetweenFebruary2007andNovember2011.
Twentysixpatients(67%)weremalesand13(33%)werefemales.Themedianageatsurgerywas5.5years(3days–18years)Fig.1.Medianweightwas16.7kg(2.7-83.5kg).Fourteenpatients(36%)werediagnosedwithaorticregurgitation,13(33%)hadaorticsteno-sisand12(31%)hadmixeddisease.Fourteenpatients(36%)hadonlyleafletaugmentationwithacombina-tionoftechniquesandtheremaining25patients(64%)hadadditionalcardiacprocedures.
ResultsEarlyandlatemortality,cardiaccomplications,IntensiveCareUnit(ICU)andhospitalstay,reinterventionrates(catheterandsurgery)andhaemodynamicperform-
ancewerereviewed.Medianbypassandcross-clamptimeswere132(34-
444)minand92(25-236)minrespectively.MedianICUandhospitalstayweretwo(1-96)andfive(3-96)daysrespectively.Postoperativecardiaccomplicationsoccurredintwopatients(5%).Therewerenoearlydeathsandthree(7.7%)latedeaths,nonedirectlyre-latedtotheaorticvalve.
Atamaximumfollow-upof39monthsandacumu-lativefollowupof30.9years,twopatients(5%)haverequiredsurgicalreintervention.Atlastfollow-up,in25patientswithaorticstenosis(pure/mixed),theme-diangradienthadreducedfrom3.8m/sec(2.5-6)to2m/sec(1.25-3.6)(Pvalue=0.02).Inthe26patientswith
aorticregurgitation(pure/mixed),only3patients7.7%hadmildtomoderateregurgitation(Pvalue=0.02).Ka-plan-Meierfreedomfromreinterventionwas95%atthreeyears(Figure2).
Earlyandlatemortality,cardiaccomplications,Inten-siveCareUnit(ICU)andhospitalstay,reinterventionrates(catheterandsurgery)andhaemodynamicper-formancewerereviewed.
ConclusionArepair-orientedstrategyforaorticvalvediseasehassatisfactoryearlytomid-termresultsandisapromis-ingmanagementoptioninchildrenwithaorticvalvedisease.
Malakh Shrestha, Axel Haverich
Hannover Medical School, Germany.
Objective
Combineddiseaseoftheaor-ticarchandthedescendingaorta(aneurysmsandDissec-tion)remainsasurgicalchal-
lenge.Variousapproacheshavebeenusedtotreatthiscomplexpathology.Asinglestageoperationisperformedei-therthroughaclam-shellincisionoracombinedmediansternotomyandalat-eralthoracotomy.
Inthetwo-stageoperation,atthefirststage,theaorticarchisreplacedthroughamedianstenotomy.Later,atthesecondstageoperation,thede-scendingthoracicaortaisreplacedthroughalateralthoracotomy.Socalled‘Elephanttrunk(ET)technique’
wasintroducedbyProfessorHansBorstandcolleaguesatourcenterinMarch1982,greatlysimplifyingthesecondphaseofthethistwostagetechnique.Wepresentour30yearsexperience.
MethodsFrom03/1982to03/2012,179pa-tients(112male,age56,4±12,6years)receivedan‘Elephanttrunk’procedureforcombineddiseaseoftheaorticarchandthedescendingaorta(91aneu-rysms,88dissections(47acute)).55ofthesepatientshadundergonepre-viouscardiacoperations.Concomitantprocedureswereperformedifneces-sary.Thecerebralprotectionwasdoneeitherbydeep(till1999)ormoder-atehypothermiccirculatoryarrest&se-lectiveantegradecerebralperfusion(SACP,after1999).
ResultsCardio-pulmonarybypass(CPB)andX-clamptimeswere208,5±76,5min-utesand123,7±54,8minutes,respec-tively.Theintra-operativemortalityand30day-mortalityduringtheIststageoperationwere1.7%(3/179)and17,3%(31/179,15withAADA),re-spectively.Peri-operativeStrokewas8,9%(n=16/176)Postoperativerecur-rentnervepalsywaspresentin16,2%(29/176),Paraplegia5,6%(10/176)
Thesecondstagecompletionopera-tionwasperformedasearlyaspossible.
Fifty-onesecondstagecompletionprocedureswereperformed,eithersur-gically(n=46)orinterventionally(n=5).
Theintra-operativeand30-day-mor-talityafterthesecondstagecomple-tionprocedureswere5.8%(3/51)and7.8%(4/51),respectively.Thestroke,
recurrentnervepalsyandparaplegiarateswere0%,9.8%(5/51)and7.8%(4/51),respectively.
Conclusion‘Elephanttrunk’techniquehasgreatlyfacilitatedthetwostagetechniqueforsurgicaltreatmentofthecombineddiseasesoftheaorticarch&descend-ingaorta.Theinitiallearningcurve,acutedissections,re-do&concomitantprocedurespartiallyexplainsthehighermortalityrate.Despitethedevelop-mentofnewhybridtechniques,thereisstillarolefortheclassicalelephanttrunkinselectedpatients,especiallyincontextofprovenlongtermresultsandcosteffectiveness.
Total aortic arch replacement with frozen elephant trunk: 10-year single center experience
Outcome of a valve-repair oriented strategy for the aortic valve in children
Vascular: Abstracts 16:15–17:45 Room 113
Congenital: Abstracts 14:15–15:45 Room 111
Vascular: Abstracts 16:15–17:45 Room 113
Figure 1: Age Distribution of operated patients Figure 2: Freedom from re-intervention at three years
Professor Hans Borst
Thirty years of elephant trunk: single center experience
EACTS Daily News Monday 29 October 2012 41
Vascular: Abstracts 16:15–17:45 Room 113
Cardiac: Focus Session 16:15–17:45 Room 111
Nozdrzykowski M, Garbade
Jww, Lehmkuhl L, Misfeld
M, Borger, and Mohr FW
Heart Center Leipzig, University
of Leipzig, Germany
Abstract Background
Generally,pa-tientswithchronicuncom-plicatedStan-
fordtypeBaorticdissection(TBAD)aretreatedmedi-cally,butsomeoftheaf-fectedaortasprogresstoaneurysmaldilatationandruptureduringthechronicphase.Thepurposeofthisstudyistoevaluatethesur-vivalandoutcomeofpa-tientswithTBADwithafo-cusedonopensurgeryasfirstorsecondprocedureafterthoracicendovascularaorticrepair(TEVAR).
MethodsBetween2000andMay2010,weidentified80con-secutivepatients(59male,medianage63,interquar-tilerange(IQR)55-69)sub-mittedwithchronicTBADwhoweretreatedatourin-stitution.Ofthesepatients,41weretreatedmedi-cally(groupA,medianage:64,IQR:57-70.5),17re-ceivedTEVAR(groupB,me-dianage:66,IQR:56-71.5)and22patientsunder-wentopensurgery(groupC,medianage:60,IQR:53-64).Medianfollow-upwas
1,235daysandforallofpa-tientscompletelyavailable.
ResultsTherewerenosignificantdifferenceingenderandco-morbidities.ThepatientsingroupAweresignifi-cantlyolder(p=0.03).Theindicationsforopensurgery(groupC)wereprogressiveenlargementofthediam-eterofthedissectedseg-mentoftheaorta(n=12,median:59mm,range:51-65mm),freerupture(n=2),impendingrupture(n=1).Insevenoutoftheprima-rily24patientstreatedwithTEVARbychronicTBADen-dovasculartherapyfailedorresultedinaseverecompli-cation.Theindicationsforsecondaryconventionalsur-gicalproceduresafterTE-VARwereindetail:typeIendolaek(n=2),coveredrupturewithprolongedneurologicaldysfunction(paraplegia)(n=1),infec-tionoftheendoprosthe-sis(n=1),migrationofstent(n=1),aortobronchialfis-tula(n=1),andanenlarge-mentoftheaneurysmasac(n=1).Twentyfivepatients(31.2%)hadacomplicatedTBADandtenofthemre-quiredopensurgery.Theoverallmortalityratewas20%(n=16).Indetail,themortalityforgroupAwas12.2%,forgroupB29.4andforgroupC27.3%.
Theincidenceofemer-gencyprocedureswassig-nificantlyhigheringroupsBandC(p<0.05).Themaxi-malaorticdiameterwassig-nificantlyhigheringroupC(median:65mm,IQR:56-70;p<0.05)asinanothertwogroups.There-inter-ventionratewasrequiredin26.8%ingroupA(n=11)and11.7%ingroupB(n=2).NopatientsingroupCrequiredre-intervention.Strokeoccurredpostoper-ativelymoreofteningroupC(18.2%,p=0.01).Therateofanothermajorcom-plications(e.g.paraplegia,malperfusion)didnotdiffersignificantlybetweenthetreatmentsgroup.InCoxregressionanalysis,aorticdiameter,emergency,Mar-fan’ssyndromeandcoro-naryarterydiseasewereidentifiedasindependentpredictorsofdeath.
ConclusionsDespiteoptimalmedicaltherapy,31.2%ofpatientswithchronicTBADdevel-opedduringthenaturalcourseofdissectioncompli-cationsand40%ofthemrequiredopensurgery,asfirstorsecondaryproce-dureafterTEVAR.Theef-ficacyofopenrepairforchronicTBADishighlightedbynormalsurvivalafterthefirstyear,andalowreinter-ventionrate.
Malakh Shrestha and Axel Haverich
Hannover Medical School, Germany
Objective
Aorticvalvereplacement(AVR)ingeriatricpatients(>75years)withsmallaorticrootsisasurgi-calchallenge.Toavoid‘Patient-
prosthesismismatch’longX-clamptimesnecessaryforstentlessvalvesorrooten-largementaremattersofconcern.WecomparedresultsofAVRwithsuture-less(SorinPerceval)againstthosewithconven-tionalbiologicalvalvesperformedatourcenter.
MethodsBetween4/2007and12/2012,120iso-latedAVRwereperformedinpatientswithsmallannulus(<22mm)atourcenter.In70patients(68females,age77.4±5.5years)conventionalvalves(C-Group)andin50patients(47females,age79.8±4.5years)suturelessvalves(P-Group)wereim-planted.TheLogisticEuroSCROREofCgroupwas16.7±10.4andthatofPgroup20.4±10.7respectively.Minimallyaccesssurgerywasperformedin4.3%(3/70)patientsinCgroup&72%(36/50)pa-tientsinPgroup,respec-tively.
ResultsThecardio-pulmonaryby-pass(CPB)andX-ClamptimesofCgroupwere75.3±23and50.3±14.2minutesand58.7±20.9and30.1±9minutesinPgroup,respectively.InCgroup,twoannulusen-largementswereper-formed.
Thirty-daymortalitywas4.3%(n=3)inCgroupand0inPgrouprespectively.Infollow-up(uptofiveyears),mortalitywas17.4%(n=12)inCgroup&14%(n=7)inPgroup,respectively.
ConclusionsThisstudyhighlightstheadvantagesofthesuture-lessvalvesforgeriatricpatientswithsmallaorticroots.ThisisreflectedinshorterX-clampandCPBtimeseventhoughmostofthesepatientswereoperatedviaamin-
imallyinvasiveaccess.Moreo-ver,duetotheabsenceofsew-ing-ring,thesevalvesarealsoalmost‘stent-less’withgreatervalveeffectiveorificearea(EOA)foranygivensize.Thismaypotentiallyresultinbet-terhemodynamicsevenwith-outtherootenlargement.Thisisofadvantageasseveralstud-ieshaveshownthataorticrootenlargementcansignificantlyincreasetherisksofAVR.
Moreover,asseeninthisseries,thesevalvesmayalsoenablebroaderapplicationofminimallyinvasiveAVR.
Outcome of open surgery for chronic type B aortic dissection
Aortic valve replacement in geriatric patients with small aortic roots: are suture-less valves the future?
Cardiac: Focus Session 16:15–17:45 Room 114
David Chambers St Thomas’
Hospital, London, UK.
TheOxfordEnglishDictionarydefinitionof‘rejuvenation’is–“make(someoneor
something)lookorfeelbetter,younger,ormorevi-tal”.Cardioplegiadoesnoneofthesethings!Anal-ternativedefinitionisto‘restoretoanoriginalornewcondition’.Thisismoreinlinewiththepoten-tialofcardioplegia;thus,cardioplegiacanprevent(ordelay)theimpactofischemicinjurytomaketheheartworse(ie.maintaintheoriginalcondition).
However,currentpotassium-basedcardiople-gicsolutionsmaynotdoeventhisverywell,espe-ciallyinthemoreelderlyandsickerpatientsthatarenowseenbycardiacsurgeons.Itwouldappeartobetimetothink‘outofthebox’,andtointroduceanewconceptformyocardialprotectionthathasthepotentialtoprovideoptimalprotectionforallcar-diacsurgerypatients.Thisconceptinvolvesarrestingtheheartina‘polarized’manner,ratherthanbyde-polarization(asoccurswithpotassiumasthearrestagent).Polarizedarrestmeansthattheheartisar-restedatamembranepotentialclosertothenormalrestingpotentialofthemyocyte.
Thiswillleadtomorebalancedionicgradients,fewchannelsorpumpsbeingactivatedandre-ducedmetabolicdemand,therebyimprovingcellu-larprotection.Polarizedarrestinvolvesusingagentsthatinteractwithmechanismsinvolvedintheac-tionpotential,suchasthefastsodiumchannel,thepotassiumchannelortheL-typecalciumchannel.Experimentally,cardioplegicsolutionscontainingagentssuchaslidocaine(asodiumchannelblocker)
andadenosine(apotassiumchannelopener)haveshownimprovedprotectioncomparedtohyperka-lemicsolutions.However,thehighconcentrationsoflidocainerequiredtoinducearrest,togetherwiththeprolongedefficacyofitsaction(withpotentialsystemictoxicity),couldbeaclinicalproblem.Ourrecentstudieshavedemonstratedthesignificantim-provementsthatcanbeachievedusingpolarizedar-rest,andhaveleadtothedevelopmentandcharac-terizationofanewcardioplegicsolutionusinghighconcentrationsofesmolol(anultra-short-actingγ-blocker)andadenosine;thissolutioninducesapo-larizedarrestsinceesmololwasshowntohavebothsodiumchannelandcalciumchannelblockingef-fects(independentofitsγ-blockingproperties),andprovidessignificantlyimprovedprotectioncomparedtohyperkalemicsolutionsinrathearts(withtheseagentshavingthebenefitofshorthalf-livesinde-pendentofliverandkidneymetabolism).
Currentstudiesareexaminingthepotentialofthisnewsolution(theStThomas’Hospitalpolariz-ingsolution)inpigsundergoingcardiopulmonarybypass,andpreliminaryresultshaveshownthisso-lutiontobeatleastequivalenttothepotassium-basedStThomas’Hospitalcardioplegia.Wehopethatthisnewsolutionwillsoonbeavailablefortranslationintotheclinicalarena.
Thepotentialofthesenewideasforimprovedmyocardialprotectionishigh,andmayintroduceafurtheradvanceinpost-operativeoutcomesfortheincreasinglyelderlypopulationofpatientscurrentlyundergoingcardiacsurgery.Furtherresearchises-sential,however,andwehopetowidenthescopeofthesolutionbyexaminingitseffectsasapreser-vationsolution,andforuseinimmatureheartsforpediatriccardiacsurgery.
Philippe Menasché Hôpital Européen Georges Pompidou,
Paris, France.
Alongwithwholeorganreplacement(hearttransplantation)andcelltherapy,heartre-juvenationisanotherstrategywhichaimsatrestoringapoolofcontractilecellsbutin
contrasttothetwootherapproaches,itisbasedonharnessingtheself-repairendogenousmechanismsoftheheart.Theoretically,thiscouldbeaccomplishedbymobilizingthreemaincelltypes.Thefirstcom-prisestheputativecardiacstemcellswhichmaybehar-bouredinnichesintheheartandcouldbeeitherre-cruitedpharmacologically(forexamplebydrugslikeneuregulin,whichisthesubjectofanongoingclini-caltrial)orharvestedduringacardiacprocedure,cul-ture-expandedandthenintracoronarilyreinjected,likeintheSCIPIOtrialwhoseenthusiasticresultsneedtobecautiouslyinterpreted.Thereasonforthiscautionisthatthesecardiacstemcellsraiseseveralissues,pri-marilytheidentificationoftheirphenotypeandtheirpersistenceintheadult,diseasedhumanheart.Thesecondcelltypeofinterestinthecontextofself-rejuve-nationcomprisestheepicardialcells,knowntoplayanimportantroleinembryoniccardiopoiesis.Thesecellsmightundergoanepithelial-to-mesenchymaltransitionandgenerateapoolofcellswithacardiomyogenicandvasculardifferentiationpotentialundertheinflu-enceofappropriatecues,amongwhichthymosinγ-4whichisplannedtobetestedclinicallyinpatientswithanacutemyocardialinfarction.Ofnote,however,thisapproachisplaguedwiththepossibilitythatepicardialcellsintheadultischemically-diseasedheartmayhavelostthisphenotypicplasticity.Thethirdcelltypetocon-sidercomprisesthecardiacfibroblastsasithasbeenproposedtoreprogramthemtodrivetheirphenotype
directlytowardsacardiomyogeniclineage,withoutgo-ingbacktoanembryonic-likestate,butthisconversioniscurrentlyachievedbyusingcompoundswhichmakerealisticallyunlikelyclinicalapplications,atleastinanearfuture.Insummary,thestudyoftheendogenousself-repairmechanismsiscertainlyimportanttobetterunderstandsignallingpathwaysinvolvedinheartdevel-opmentandpossiblyusethesedatafordevelopingef-fectivetherapiesbutitisstilluncertainwhether,inthefuture,self-supportedrejuvenationcanchallengetrans-plantationofexogenousstemcellsendowed,regard-lessoftheirtissuesource,withanangiogenicand/oracardiomyogenicdifferentiationpotential.
Heart rejuvenation: Cardioplegia Heart rejuvenation. Stem cells
Philippe Menasché
Malakh ShresthaAxel Haverich
42 Monday 29 October 2012 EACTS Daily News
Konstantinos Zannis
Insititut Matualise Montsouris, Paris, France
TheexperiencewithsuturelessvalvesstartedattheIMMcentrein2007.Sincethenwehaveim-plantedthePercevalSvalveon
143patients,whichwewereabletofol-lowupyearlywithamaximumfollowupoffiveyears.
ThePercevalSvalveisapericardialtrileafletvalvemountedinasuperelas-ticalloystentwhichcanbecollapsedbe-foreimplantationandthenreleasedintheaorticroot.Itssinusoidalandflared-outdesignallowsitsanchoringintheValsalvasinuses.
Thevalveprovedtobeeasytoimplant,showinga99.3%ofimplantsuccess,andlooksstableinthefirstfiveyears:duringtheentirefollowuptherewasnovalvemigrationorSVD.ThePercevalSvalvecanbeimplantedthroughaMISap-proach,andthisadvantagehasallowedamoreintensiveshifttowardsminimallyin-vasiveapproaches.
Intermsofsurgicaltechniquesuture-lessvalvesreducebothcrossclampandbypasstimewhencomparedtotradition-allyimplantedsurgicalvalvessincesu-turepositioningandknottingaretimeconsumingprocedures.AcomparisonofouroverallmeanpumpandcrossclamptimewiththeSTSdatabaseresultsdem-onstratedareductionofsurgicaltimesof50-60%.Myocardialtolerancetohy-poxiaandischemiaarereducedinolderpatientswecouldthereforesupposethatolderpatientscouldbenefitfromthesekindofdevice,advantagecouldevenbegreaterforthesubgroupofthoseneces-sitatingassociatedby-passsurgeryand
thereforeexposedatevenlongermyocar-dialischemia.
Theprofileofpatientsselectedfortheimplantwasquitecritical,asthemeanagewas79.4±5.9yearsandtheMedianpreoperativelogisticEuroSCOREwas12.04±10.7,onethirdhavingconcomi-tantprocedures.
Thevalvehemodynamicswasgoodinallsizes,showingsingledigitgradientsaf-teroneyearoffollowup.Thehemody-namicprofileobservedinthisstudyispar-ticularlyinterestingforsizeS,specificallydesignedforsmallaorticannulus.Itisreachingalevelclosetotheoneobservedwithstentlessvalveratherthantotheonecommonlyfoundinotherstentedvalves.TheinterestingPercevalShemodynamicperformancestranslateinimprovementofpatients’clinicalstatusassessedbyNYHA
classpostoperatively.Infact,withinthefirstyearfollowingtheimplantation,aclearimprovementinNYHAclasswasob-served.Whilehalfofthepatientswereclassifiedasseverelyimpairedatinclusion,64.6%ofthepatientswereinNYHAclassIIIorIVpreoperatively,whileatoneyear,94.4%ofthepatientswereinNYHAclassIandII.
Intermsofclinicaloutcomesthemor-talityrateintheearlyperiodwas3.5%,whileatfiveyearstheoverallsurvivalratedat85.5%.
Theresultsatfiveyearsrepresent,atthebestofourknowledge,thelongestexperienceeverreportedwithasuture-lessdevice,andshowthatthePercevalSsuturelessbioprosthesisoffersanattrac-tivealternativetoAVR,especiallyintheolderandfrailpatients.
Aortic valve replacement with the Perceval S sutureless prosthesis: clinical outcomes
Jolanda Kluin UMC,
Utrecht, Netherlands
Significantmitralvalveregurgita-tionisprev-
alentin2%oftheadultpopulationSeveralsafeandeffectivesurgicalap-proachestotreatmitralvalveregurgitationhavebeende-velopedoverthepastdec-ades.Whileoutcomesofsur-gicallycorrectedmitralvalvediseaseareexcellent,asignif-icantamountofpatientsarehamperedbylatetricuspidregurgitation(TR).
TRisnotabenigndisease:five-yearssurvivalformoder-atetosevereTRis74%.TRispresentinupto70%ofpa-tientswithmitralvalvedis-easeanditprogressesin20-50%withinfiveyearsaftermitralvalvesurgery,evenwithoutleft-sideddysfunc-tion.ReoperationtocorrectTRinthissettingcarriesahighoperativemortality(upto20-50%in-hospitalmor-tality)andpoorfunctionalre-sults.BecausethepersistenceorprogressionofTRbadlyaf-fectsthelong-termmortal-ityandmorbidity,itwouldseemlogicalthatduringmi-tralvalverepairsurgery,peo-plemayatthesametime
undergotricuspidvalverepair.How-ever,tricuspidvalverepaircurrentlyap-pearsseverelyun-derutilized.Thecur-rentsurgicalvolumeoftricuspidvalve
repairrepresentsonlyone-tenthofthe>40.000mitralvalveoperationsperformedyearlyintheUS.
TheoccurrenceoflateTRseemsunrelatedtoresid-ualorrecurrenceofleftsidedvalvediseaseandoftenalsounrelatedtotheamountofpre-operativeTR.Somestud-ieshavepointedoutthatnotTRshouldbetreatedbuttri-cuspidannulardilatation.Ifatricuspidannulusofmorethan40mmwouldbeusedasacut-offvalueabovewhichtricuspidannuloplastywouldbeperformed,somehavees-timatedthatabout50%ofmitralsurgerypatientsshouldalsoundergoconcomitanttri-cuspidannuloplasty
Duetothedifferencesinindication(degreeofTRver-susannulusdilatation)andimagingmodalities,thether-apeuticprocedureinpatientswithseveremitralregurgita-tionandlessthansevereTRvarieswidely:thepercent-ageofpatientsundergo-ingconcomitanttricuspidre-
pairvariesbetween<10%to>70%amongstinstitu-tionsandcountries.System-aticevidenceregardinghowthecurrentlyavailableimag-ingandtechnicalprocedurescomparewithoneanotherislacking.Giventhegrowinghealthburden,optimaluti-lizationofhealthresourcestotreatpatientswithmitralvalveregurgitationisessen-tialtobothoptimizepatientoutcomeandminimizecostsoftreatment.
Intheguidelines,noneoftherecommendationsde-riveevidencefromrand-omizedstudies.Unlesslarge-scalerandomizedtrialsareundertaken,itislikelythatexpertopinion,extrapola-tion,andindirectcorrelates,ratherthandirectevidence,willcontinuetoformtheba-sisofmostpracticerecom-mendationsformanagementoffunctionalTR.
Wethereforedesignedaprospectiverandomizedcontrolledmulticentretrial(CONSUMERtrial)thataimstoquantifytheeffective-nessandcosteffectivenessofconcomitanttricuspidvalverepaircomparedtomi-tralvalverepairaloneinthetreatmentofpatientswithseveremitralregurgitationandlessthansevereTR.
Tricuspid regurgitation and mitral regurgitation
Cardiac: Focus Session 16:15–17:45 Room 115
Cardiac: Abstracts 16:15–17:45 Room 118/119 Cardiac: Focus Session 16:15–17:45 Room 115
Konstantinos Zannis
Pierre-Yves Litzler and Hassiba Smail Rouen
University Hospital Charles Nicolle, Rouen, France
Thetreatmentofrefractoryheartfailurewithaleftventricularas-sistdevice(LVAD)isnowawide-spreadmethodforbridgetotrans-
plant(BTT)ordestinationtherapy(DT).EarlyaftertheEuropeanexperienceintheHeartMateIIdevice(HMII)(Thoratec,Pleasanton,CA)implantation,thefirstresultsrevealedahigherincidenceofbleedingeventsthanthethromboticcomplications.
Thereisnoconsensusofantithromboticprocedureanddifferentprotocolsareused,includingVitaminKantagonistwithorwithoutaspirinandclopidogrel.
Inordertominimizehemorrhagiccom-plications,mostofexperiencedcentresin-tendtoreducetheanticoagulationtherapy.Atthebeginningofourexperience,aspirinwasadministered,butduetoseverebleed-ingwediscontinuedit.Weaimtoreportthesafetyandeffectivenessofourantico-agulationprotocolusingvitaminKantag-onistwithoutAspirininpatientssupportedwithHMIIdevice.
Weretrospectivelyreviewedtheclini-calandbiologicaldataof27patientswiththeHMIIbetweenFebruary2006andSep-tember2011,(26men),meanagewas55,7±9.9years.Mostpatients16(59,3%)hadischemiccardiomyopathyandmeandurationofsupportwas479±436(1-1555)dayswith35.4patientyearsonsupport.Sixpatientswereimplantedfordestinationtherapy.
Theanticoagulationtherapywasfluin-dioneforallpatients,andAspirinwasad-ministeredonlyto4patientsfor6,15,60,
460days.Duetogastro-intestinalbleedingandepistaxis,Aspirinwasdiscontinued,andsinceAugust2006,nopatientshavere-ceivedantiplatelettherapy.
Atthreeyearsthesurvivalrateduringsupportwas75%.Themostcommonpost-operativeadverseeventwasgastrointes-tinalbleeding(19%)andepistaxis(30%)(Mediantime:26days)forpatientsreceiv-ingfluindioneandaspirin.MeanINRwas2.59±0.73duringsupport.FifteenpatientshavebeentestedforacquiredVonWille-branddisease.Weobservedareducedra-tioofcollagenbindingcapacityandristoce-tincofactoractivitytoVWFantigeninsixpatients.Inthepostoperativeperiod,twopatientshadanischemicstrokeatoneandeightmonths.Oneofthemhadahistoryofcarotidstenosiswithischemicstroke.Therewerenopatientswithhemorrhagicstrokeortransientischemicattack.Amongthepatientstreatedonlywithfluindione,theeventrateofstrokeperpatient-year
was0,059.Themeanincidenceofanytypeofstrokeinliteratureis0,17(mean;range0,06-0,29)strokesperpatient-yearinpa-tientswithHMIIandaregimenofpostop-erativeheparinconvertedtowarfarinandaspirin.
Thelowriskofthromboemboliceventwithouttheuseofantiplatelettherapyinourexperiencemaybeexplainedbythesubstantialalterationoftheplateletfunc-tioninpatientswithaxialflowLVAD.
AntiplatelettherapywithaspirinisgiventopatientswithHMIILVAD,buttheefficacyofthispracticehasnotbeendetermined;plateletfunctionstudiesandthromboelas-togrammayhelpinassessingtheneedofantiplatelettherapy.
Inconclusion,Fluindioneregimenwith-outAspirininHMIIsupportseemsdonotincreasethromboemboliceventsandcouldreducetheriskofhemorrhagicevents.Fur-thercontrolledstudiesareneededtocon-firmthesefindings.
Elsayed Elmistekawy,
Vincent Chan, Buu Khanh
Lam, Thierry G. Mesana, and
Marc Ruel* Division of Cardiac
Surgery, University of Ottawa
Heart Institute, Ottawa, Canada
Concomitantaor-ticandmitralvalvediseasemayoccursecondarytorheu-maticdisease,bacterialendo-
carditis,ordegenerativechanges.WhileCurrentguidelinesserveasaguidetoaidpatientsandtheirsurgeonsse-lecttheoptimalprosthesisinsinglepo-sitioneithertheaortaormitral;how-everTodate,therearenoguidelinesorlargepublisheddatatohelpwithpros-thesesselectionindoublevalvereplace-ment(DVR)procedures.Westudiedthelongtermoutcomesofpatientswhoun-derwentdoublevalveprocedures(AorticandMitralvalvereplacement)
Thisstudyincluded319patientswhohadfirsttimeDVRafter1980.PatientswerefollowedinadedicatedvalveclinicatOttawaHeartInstitute.
Wefoundthatpatientswhounder-wentdoublebiologicalvalvereplace-menthadworselong-termsurvivalcomparedtopatientswhounderwentdoublemechanicalvalvereplacement,aftercorrectingforageandgender.Mostnotably,wefoundthatthediffer-enceinlong-termsurvivalwasapparentinpatients71yearsofageorless.
Wealsofoundthatthehazardratio
forreoperationisstatisticallymoreinbiologicaldoublevalvecomparedwithme-chanicaldoublevalveandat10yearsaftersurgery97%ofpatientswhohadtwomechanicalprostheseswerefreefromreoperationcom-
paredwith66%ofpatientswhohadtwobiologicalprostheses.
Inthecurrentstudy,theperioperativemortalityfollowingdoublevalvesurgerywasingenerallowerthanreportedinotherstudiesandtherewasasignificantdifferenceforthosewhoreceivedtwobiologicalvalves(21patients(14%)ver-sus13patients(7.7%);P=0.04).
Theuseoftwomechanicalvalvesisassociatedwithalowerrateofreopera-tion.Notably,DVRreoperationsarenotlowrisk.Itwasestimatedthatmortalityrateofredosurgeryrangesfrom11%-25%.
Atpresent,somebiologicalvalvesmaybereplacedwithpercutaneousvalve-in-valvetechnology;however,thefeasibilityanddurabilityofthistechniqueisnotyetestablishedanditisnotwithoutarisk,especiallyinDVRscenarios
Theseresultsconstituteasinglecenterexperienceandtheresultsmaybenotgeneralizable;furthermore,thecutoffageatwhichmechanicalversusbiolog-icalvalveselectionprevailsmayneedtobereaddressedduetotheincreasinglongevityofpopulations.
Is anti-platelet therapy needed in continuous flow LVAD Patients? A single center experience Double valve replacement:
Biological versus mechanical prostheses
Pierre-Yves Litzler Hassiba Smail
EACTS Daily News Monday 29 October 2012 43
Thoracic: Abstracts 16:15–17:45 Room 133/134 Cardiac: Abstracts 14:15–15:45 Room 116/117
Cecilia Menna
University of L’Aquila,
Teramo, Italy;
Severaleffortshavebeenmadetorecog-nizedsurgical
therapyasthetreatmentofchoiceforpatientswithprimarypalmarandaxillaryhyperhidrosis,adisordercharacterizedbyexcessiveperspirationbeyondthermoregula-toryneeds,particularlyinresponsetotempera-tureoremotionalstim-uli.Todateamongallthedifferentsurgicalap-proaches,video-assistedthoracoscopicsympathec-tomyhasbeenshownassafeandminimallyinva-siveprocedure.Numer-ouscriticalissueshavestilltobeovercometoobtainmoredetailedre-portsonlong-termresults
aftervideo-assistedthora-coscopicsympathectomy.Althoughvideo-assistedthoracoscopicsympathec-tomyisastandardtech-nique,howevertoourbestknowledgeaproperinvestigationonnewcriti-calaspectsunderlyingthemainsideeffects,ascom-pensatorysweating,af-tersurgicalprocedurehasneverbeenshown.
Compensatoryhyper-hidrosis(postoperativein-creaseofsweatinginre-gionsofthebodywhereithadnotbeenprevi-ouslyobserved)isthe
mostcommonlatecom-plication,withdiffer-entincidencereportedinpreviousstudies,rang-ingfrom33%to85%.Howeverthemechanismofcompensatoryhyper-hidrosisisstillunclear.Analternativetoreducecompensatorysweatingconsistsinapplyingmetalclipstointerruptthesym-patheticchainbycom-pression.
Inourstudyone-hun-dredandthirtypatientsreceivedone-stagebilat-eral,singleportvideo-as-sistedthoracoscopicsym-pathectomy(one-stagegroup)andone-hundredandfortypatientstwo-stageunilateral,single-portvideo-assistedthora-coscopicsympathectomy(two-stagegroup).Single-portthoracoscopicsym-pathectomywasassoci-
atedwithalowrateofcompensatoryhyperhid-rosis.However,compen-satorysweatingoccurredmorefrequentlyinone-stagegrouppatients.
Ourfinalandnovelaimwastoidentifyvaria-blesrelatedtotheoccur-renceofcompensatorysweatingandpneumoth-oraxaftersurgicalproce-dure.Specifically,inourstudyinlinewithotherreports,weconfirmedthatbilateralanduni-lateralsingle-portsym-pathectomyforprimaryhyperhidrosisareeffec-tive,safeandfeasiblesurgicaltechniques.Moreinterestingly,wedemon-strateforthefirsttimethattwo-stagesurgicalapproachcouldbeapos-siblestrategytoavoidcompensatorysweatingoccurrence.
Two-stage unilateral versus one-stage bilateral single-port sympathectomy for palmar and axillary hyperhidrosis
Cardiac: Focus Session 14:15–15:45 Rooms 115/117
Vinod Bapat Department of
Cardiothroacic Surgery & Cardiology,
Guy’s and St. Thomas’ Hospital,
London, UK.
AorticStenosis(AS)isamajorcauseofcardio-vascularmorbidityandmortalityintheeld-
erly.TherehasbeenamarkedgrowthinTAVIespeciallyoverthelasttwoyears,2011-2012withitnowbeingapprovedinaround50countriesincludingtheUnitedStatesofAmerica.
TAVIisperformedviatwoapproaches,Transapaical(TA)andTransfemoral(TF)route.MedtronicCoreValvecanonlybeimplantedthroughtheTFapproachwhilstEdwardsSpaienvalvecanbeimplantedthrougheithertheTAortheTFroute.AsthelatterislessinvasiveitispreferredovertheTAapproach.
Despitetheshort-termresultsofbothTAandTFap-proachesbeingcomparableincentresperformingalargenumberofsuchcases,theTAapproachhasbeenfoundtobemoreinvasiveinnature.IncomparisontotheTFapproach,theTAapproachhas3maindraw-backs,whichmaycontributetotheincreasedmorbid-ityandmortalityinthesepatients1.Complicationoftheaccesssite:Apicalruptureand
Delayedpseudoaneurysmformation
2.Complicationofthoracotomy:Interferencewithpostoperativerespiratorydynamics
3.Complicationofpursestringsuture:Effectsonleftventricularfunction
Apicalruptureremainsadreadedcomplicationbeingassociatedwithahighermortalityandalowerone-yearsurvivalrate.Despiteincreasingexperienceandavailabilityofsmallerdeliverysystems(22-26French),apicaltearandrupturestilloccurandaremainlyduetothepoorqualityofthecardiactissuewherethepursestringisplaced.Intra-operativeandorimmedi-atepostoperativeleftventricularapicalrupture/bleed-ingarenotuncommonbeingassociatedwithpooreroutcome.TAapproachandapicalventingcanalsoleadtolatepseudoaneurysmformation.FurthermoreTAapproachcannotbeusedforimplantingCoreValve.
Thisledtodevelopmentoftwoalternativeaccessrouteswiththeaimofreducingmorbidityandmor-tality;Transaortic(TAo)approachandSubclavianap-proach.
TAoapproachcanpotentiallyovercomeissuesasso-ciatedwithTAapproachasitentailspurse-stringsontheaortaasopposedtotheleftventricle.Aorticcan-nulationisperformedonnearlyeveryopenheartsur-geryandhasproventobesafe.TheAortaisanelas-ticstructureandhencethechancesofimmediateordelayedcomplicationsareless.Inadditionitisatech-niquewithwhichsurgeonsarefamiliarandhencewill
haveashorterlearningcurve.Furthermore,TAoroutecanalsobeusedforimplantingCoreValve.AlthoughtheTAoapproachwasinitiallyusedtotreatpatientsnotsuitableforTAapproachithasslowlygrowninpopularityandisnowpreferredoverTAinmanycen-tres.Thisisreflectedinthedevelopmentofadedi-cateddeliverysystemforTAo,AscendraplusforEd-wardsSapienXTvalveandadedicateddeliverysystemforMedtronicCorevalvetobereleasedsoon.ItisnowconceivablethatTAomaybecomethepreferredap-proachoverTA,especiallyifthereisashiftinusingthistechnologyinlowerriskpatientsthusenablingthemtolivelongerfollowingtheprocedure.
AlthoughtheSubclavianroutewasexploredfor
CoreValveimplantationasearlyas2007itwasonlyusedwhentheTFapproachwasnotpossible.Increas-ingexperienceinthisapproachhasseenitspopular-itygrowcomparablewiththatoftheTFapproachinsomecentressuchasItaly.Improvementsindeliverysystemssuchassmallercalibreandimprovedmanoeu-vrabilitywillindeedincreaseitsapplicationinfuture.
SinceperformingthefirstsuccessfulcasewithSap-ienvalvethroughTAoapproachourefforthasbeentostandardisetheproceduralstepsinordertomaketheprocedureeasilyreproducible.
Iwillbedemonstratingacaseattechno-collegeus-ingthenewAscendraplussystemandwillalsodiscusstheoperativestepsindetail.
Alternative Surgical Access for TAVI – Transaortic and Subcalvian
Ayse Gul Kunt Ankara Ataturk
Education and Research Hospital,
Bilkent, Ankara, Turkey
Scoringsystemsareessen-tialpartofcurrentcardiacsurgicalpracticeinassess-ingoperativemortality
andmorbidity.EuropeanSystemforCardiacOperativeRiskEvaluation(EuroSCORE)andTheSocietyofThoracicSurgeons(STS)databasearepopularcardiacriskmodelsintheworld.Moreover,theuseofEu-roSCOREmodelinadultTurkishcardiacsurgicalpopulationisob-ligatorypracticedbythenationalhealthauthorityandTurkishSocialSecurityAgency.
We,therefore,aimedtocomparethesethreeriskmodelsonapro-spectivelycollecteddatafromTurk-ishelderlycardiacsurgicalpopu-lationstoredintheTurkoSCOREdatabase.Themeanpatientagewas74.5±3.9yearsatthetimeofsurgery,and35%werefemale.Fortheentirecohort,actualhospi-
talmortalitywas7.9%(n=34;95%confidenceinterval[CI]5.4-10.5).
However,additiveEuroSCOREpredictedmortalitywas6.4%(P>0.05vsobserved;95%CI,6.2-6.6),logisticEuroSCOREpredictedmortalitywas7.9%(P>0.05vsob-served;95%CI,7.3-8.6),Euro-SCOREIIpredictedmortalitywas1.7%(P<0.001vsobserved;95%CI,1.6-1.8),andSTSpredictedmortalitywas5.8%(P>0.05vsob-
served;95%CI,5.4-6.2).Themeanpredictiveperformanceoftheana-lyzedmodelsfortheentirecohortwasfairwith0.7(95%CI,0.60-0.79).AUCvaluesforadditiveEu-roSCORE,logisticEuroSCORE,Eu-roSCOREII,andSTSriskcalculatorwere0.70(95%CI,0.60-0.79),0.70(95%CI,0.59-0.80),0.72(95%CI,0.62-0.81),0.62(95%CI,0.51-0.73),respectively.
TheresultsofourstudysuggestthatEuroSCOREIIsignificantlyun-derestimatedmortalityriskforTurk-ishelderlycardiacpatientswhereasadditiveandlogisticEuroSCOREandSTSriskcalculatorswerewellcalibratedinthiscohort.Ethnic-ity,seasonalvariationsandsin-glecenterstudyshouldbekeptinmind.Subsequently,thesecondpartofthestudyisbeingconsid-eredforthepostoperativecompli-cationsinthesamepopulation.
Now,wewillcompleteandcheckthedatabaseofthecurrentpopulationandthenwewillsharewithyou.
Comparison of original euroscore, EUROScore II and STS risk models in an elderly cardiac surgical cohort
Ayse Gul Kunt
44 Monday 29 October 2012 EACTS Daily News
Kazuhiro Ueda Yamaguchi
University Graduate School of
Medicine, Yamaguchi, Japan
Background
Wepreviouslyre-portedtheex-cellenteffectoffibringlue
whenitwasusedincombinationwithabioabsorba-blemesh:thechesttubecouldberemovedthedayaf-tertheoperationin90%ofpatientsundergoinglunglobectomyforcancer[1,2].Inaddition,comparedwiththeconventionalprocedureusingfibringluealone,ourtechniqueledtoareductionintherateofpostoper-ativepulmonarycomplicationsandthelengthofthepostoperativehospitalstay[2],whichinturnacceler-atedthepostoperativephysiologicalrehabilitation[3].Consideringthesefavorableresults,ournextgoalwas
toomitpostoperativechesttubeplacementinselectedpatientsundergoingthoracoscopicmajorlungresec-tion.Toidentifythepatientswhodidnotneedpostop-erativechesttubedrainage,wedefinedoriginalcriteriatoconfirmpneumostasisduringtheintraoperativeairleaktestbasedonourpreviousobservationalstudy.Byreferringtotheintraoperativeairleaktestresults,wewereabletoremovethechesttubeintheoperatingroomineligiblepatients.Thisstudywasconductedtoclarifythefeasibilityofomittingchesttubeplacementafterthoracoscopicmajorlungresection.
MethodsIntraoperativeairleaksweresealedwithfibringlueandabsorbablemeshinpatientsundergoingthoracoscopicmajorlungresection.Thechesttubewasremovedjustaftertrachealextubationifnoairleaksweredetectedinasuction-inducedairleaktest,whichisanoriginaltech-niquetoconfirmpneumostasis.Patientswithbleeding
tendencyorextensivethoracicadhesionswereexcluded.
ResultsChesttubedrainagewasomittedin29(58%)of50eligiblepatients,andwasusedin21(42%)patients,basedonthesuction-inducedairleaktestresults.Malegenderandcompromisedpulmonaryfunctionweresignificantlyassociatedwiththefailuretoomitchesttubedrainage(both,P<0.05).Regardlessofomittingthechesttubedrainage,therewerenoadverseeventsduringhospitalization,suchassubcutaneousemphy-sema,pneumothorax,pleuraleffusion,orhemothorax,requiringsubsequentdrainage.Furthermore,therewasnoprolongedairleakageinanypatients:Themeanlengthofchesttubedrainagewasonly0.9days.Omit-tingthechesttubedrainagewasassociatedwithre-ducedpainonthedayoftheoperation(P<0.05).
ConclusionTherefinedstrategyforpneumostasisallowedtheomissionofchesttubedrainageinthemajorityofpa-tientsundergoingthoracoscopicmajorlungresectionwithoutincreasingtheriskofadverseevents,whichmaycontributetoafast-tracksurgery.
References:
1. Ueda K, et al. Sutureless pneumostasis using polyglycolic acid mesh as artificial pleura during video-assisted major pulmonary resection. Ann Thorac Surg 2007; 84: 1858-61.2. Ueda K, et al. Sutureless pneumostasis using bioabsorbable mesh and glue during major lung resection for cancer: Who are the best candidate? J Thorac Cardiovasc Surg 2010; 139: 600-5.3. Ueda K, et al. Mesh-based pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection. J Surg Res 2011; 167: e71-e75.
Pero Curcic, I Knez, I Ovcina, J Krumnikl,
T Marko, H Suppan, H Mächler, D
Dacar Medical University of Graz, Austria
Closedperfusionsystems,whencomparedwithconventionalopencardiopulmonarybypass(CPB)systems,haveshownsu-
periorperformanceintheadultpopula-tionresultinginreducedprimingvolumes,transfusionrequirementsandinflammatoryresponseactivation.Wehaveestablishedastepwise,closed-circuitanimalmodelwhichenabledsimultaneousmeasurementsofor-ganspecificcontinuous,parenchymalpO2/pCO2changesandmetabolicvariablesde-
tectedfromtheparieto-temporallobeofcerebrum,theLVmyocardiumandtherighthepaticlobeusingopto-chemicalprobes.
Ourprojectcommencedin2009attheMedicalUniversityofGraz,Austria.Dur-ingthefirstphase,wetested14testingan-imals(pigs,30.7±2.5kg)inarandomisedstudycomparingCPBwithP-MEC.Wefoundsignificantlyhigherneedforprimingbloodtransfusion(1000±823mlsvs.50±36mls)andhigherperioperativelactatelevelsingroupCPB(p<0.000001).ANOVAatdifferenttime-pointsofsurgeryemphasizedsignificantlyhigherpositivecerebralpO2levels(p=0.007)ingroupP-MEC.Incontrast,bothhepaticandmyocardialnegativepCO2levelswere
significantlyhigheringroupCPB(p=0.004).Inthesecondphase,werepeatedtheex-
perimentwithminimizedclosedcircuitandlighteranimals(10.7±2.8kg).Experimentalresultsshowedconsistentlythesamesignifi-cantdifferences.
Intheclinicalphase,betweenAugust2011andJune2012,weoperatedon11patientswithcongenitalheartdefects(ex-tracardiacTCPC4pts,ASDpatchclosures5pts,ASDprimumclosure+RVOTproce-dure1pt,atrioseptectomy+ap-shunt1pt)withmeanweight8.3-18.7kg,meanage4±1.7yrs;usingthein-housedevelopedandnewlynamedMedtronicP-MEC.Thesystemischaracterizedbyareductionof
primingvolumeofupto50%,anovelmin-iaturizedoxygenatorandthepossibilityofimmediatesafety-conversiontoopenex-tracorporealcirculation.MeanCPBdura-tiontimewas57±30min.Themeanpreop-erativehaematocritwas39±9%,on-pump30±6%andpostoperatively33±7%.Nobloodtransfusionswererequiredduringtheprocedures.In8outoftotal11pa-tients,packedred-bloodcellunitswouldhavebeenprimedusinganyconventionalCPB.Postoperativelactatelevelswerebe-low1.2mmol/l.Noneofthepatientshadanembolicevent.
WeconcludethattheP-MEC®maypro-videanalternativetoroutinelyusedCPBinpaediatricpopulation.Prospectivemul-ticentrestudiesareneededtoconfirmourfindingsindifferentsettingsandtopro-videfurtherevidenceofsafetyandefficacy.Wewouldwelcomeanopportunitytocol-laborateonsuchprojectswithinterestcol-leaguesworld-wide.
Thoracic: Abstracts 16:15–17:45 Room 133/134
Residents’ Session 14:15–15:45 Room 118/119
Omitting chest tube drainage after thoracoscopic major lung resection
P-MEC – a novel closed-circuit minimally invasive pediatric extracorporeal circulation: from conception to clinical conduction
Bioabsorbable mesh, used in the study, is exhibited at booth No: 23 (GUNZE LIMITED).
Pero Curcic
Haveyoueverthoughtthateachtimeyouattendascientificmeet-ing,itdoesn’tmatterwherethemeetingisbeingheldorwhichso-
cietyorinstitutionistheorganizer,thatitjustfeels“thesame?”Thatthemeetingcouldbeanywhereintheworld,butthesamepeo-plearetalkingaboutthesamething?Ifyouhave,thenyouhaven’tyetparticipatedinanISMICSMeeting.ForISMICSis a society like no other.
ISMICScelebratesinnovation,embracesnewideas,andwelcomessurgeonsfromaroundtheworld.Firsttimeattendeesal-wayscommentonthefactthatISMICSisanopen,collegial,andwarmsocietywherecardiac,thoracic,andcardiovascularsur-geonscometogethertosharetheirideasandtheirlatestchallengesandsuccessesintheevery-changingcardiothoracicandcar-diovascularspecialty.
ISMICSmembersareinnovators–whethertheyarepursuinglessinvasivesur-gicaltechniques,embracingthenewesttechnologies,orpushingtheboundariesofmedicalscience.Theyallshareapassionfortheirworkandacommondesiretoimprovethelivesoftheirpatients.
ScientificsessionsatISMICSarelively,withspiriteddiscussionperiodsandvariedformatsdesignedtoallowpresentationofworkinmanyways,includinganinterac-tivepostercompetition.AndeachISMICSmeetingisdesignedtoprovideattendeeslargeamountsoftimetomeetwithourin-dustrypartners,totestdrivetheirlatesttechnologiesandlearnmoreabouttheirproducts.ISMICSmembersareearlyadop-ters–theywanttoknowwhatisthelat-est,thebest,andwhatiscomingnext.Theyhaveneverlosttheirsenseofcurios-ity,andtheynever,everrepresentthesta-tusquo.
Are you an ISMICS member? Or better yet – should you be?
From12to15June2013,ISMICSismeetingintheelegantold-worldcityofPrague,inthePragueHilton,intheCzechRepublic.Weinviteyoutojoinusfor4daysofcutting-edgescience,livelyinteractionwithcolleaguesfromallovertheworld,ex-tendedtimetovisitindustrypartners,andopportunitiesforsocialinteractioninoneoftheworld’smoststunningvenues.
Visitourbooth-#38intheExhibitHall,andlearnmoreaboutISMICS!
TheEuropeanPerfusionRegistry(EPR)hasbeenformallyestab-lishedsinceOctober2011byagroupofperfusionistsbased
acrossEurope.TheaimoftheEPRistoprovideaplatformformeasuringandimprovingthequalityofpracticeinper-fusion.Aregistrywillservetocollectdatafromextracorporealproceduresduringcardiacsurgery.Wehavebeenpresentingourideasatanumberofin-ternationalperfusionconferencesandreceivedfavourablefeedbackvalidatingouraims.
Therearemanymethods,modelsandprinciplestochoosefromtodoim-provementresearchandtoimprovepracticeperformance,butnomatterwhichmethod(s)youuse,allmethodsrequiremeasurementofpractice.Car-diacsurgerybeingateameffort,wesoughtcooperationwithothermem-bersofthecardiacsurgeryteam.Sinceahighqualitydatabaseofcardiacsur-geryalreadyexistsinEurope,TheEACTSAdultCardiacSurgerydatabase,itwasconsideredsensibletoadheretothisex-tensiveregistrytobeabletomatchsur-gicalandperfusiondatafromthesamepatients.Thisfitsinneatlywithprevi-ouslypublishedaims,“TheEACTSisthustoestablishaQualityImprovementProgramTaskforceandhaschosenqual-ityimprovementasthemainthemeofthe26thannualEACTSmeetinginBar-celona”.
Notinterestedinbeinganotherex-erciseinmerelynumbercrunching,weratherstrivetoformthebasisofapro-gramthatwillenableparticipantsto
measurequalityofpracticeandim-proveonthis,inanever-endingcy-cleofevaluationandamelioration.ItisthereforewithgreatenthusiasmthatwecanannounceourparticipationintheEACTSQualityImprovementPro-gramme(QUIP).TheQUIP,whichisinitsinitialphaseofgatheringspecialistsandprogrammesexperiencedinqual-ityimprovement,hasthesamemissionandvisiononqualityassessmentandimprovementandisthusidealforco-operationbetweensurgeonsandper-fusionists.
Inordertoestablishadataset,whichisdeemedsuitablebyandformostper-fusionprogrammes,theEPRwillun-dertakeaninternationalsurveyonper-fusionpractice.Thesurveyisaimedto
detectvariabilityinpractice,andtode-terminewhichquestionsmustlikelybeansweredtotargetdatacollectiontofindtheanswerstothosequestions.
Theresultsachievedfromthecol-lectionandprocessingofextracorpor-ealproceduresdata,combinedwiththesurgicaldatawillbeusedtoidentifyriskfactorsforoutcomeassessmentsuchasbloodtransfusion,lengthofstay,mor-bidityandmortalityandcomplications.Furthermorepre,per-andpost-oper-ativequalityindicatorswillprovideustoolstomeasurethequalityofcareandhelpusinimprovingit.Thisinformationcanbeintegratedintoclinicalpathwaystoprovidethebestperfusioncareforgeneralandspecificpatientsundergo-ingextracorporealprocedures.
An update from the EPR
Luc Puis
Specialists in clinical database software for hospitals and national/international registries• Installations in 250+ hospitals worldwide• 90+ national and international databases• Systems in 40+ countries
Station Road - Henley-on-Thames - RG9 1AY - United KingdomPhone: +44 1491 411 288 - e-mail: [email protected] - www.e-dendrite.com
reveal interpret improve
EACTS 2012To learn more aboutour products andservices, and to be given a demonstration of oursoftware please visitStands 98–99