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The official newspaper of the 26th EACTS Annual Meeting 2012 Monday 29 October In this issue Mitral valve disease Lenard Conradi asks which is the preferred treatment, surgery or intervention. 10 Aortic arch surgery Jean Bachet examines the current status of aortic arch surgery. 12 Tetralogy of fallot Mark Hazekamp discusses how to minimize postoperative repair morbidity. 26 Elephant Trunk Malakh Shrestha presents a single centre experience of the Elephant Trunk procedure. 40 Heart rejuvenation Cardioplegia 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 Tetralogy Rehabilitation of small pulmonary arteries David Barron Birmingham Children’s Hospital UK F allot’s Tetralogy is the commonest cyanotic heart condition and the spectrum of morpholo gy leads to a variability in the symptoms (princi- pally the degree of cyanosis) which, in turn, influences the timing and technique of sur- gery. The Blalock -Taussig (BT) shunt has tra- ditionally been the mainstay of securing ad- ditional pulmonary blood flow in cyanosed neonates and infants – followed by staged anatomical repair typically 6-9 months later. However, the overwhelming shift in surgi- cal practice to effect anatomical repair at a younger age has dramatically changed man- agement strategies over the past 15 years such that complete repair has been pro- moted at an increasingly younger age. However, even in the modern era, the BT shunt in the neonate carries a significant mortality – partly reflecting the fragile na- ture of the shunt-dependent circulation with diastolic steal phenomenon and the risk of unpredictable coronary ischaemia. This sup- ported the case for complete anatomical re- pair in the cyanotic neonate. However, the results of complete repair in neonates carry a similar risk to BT shunt, with five or six times the operative mortality compared to that of ‘planned’ repair performed between three to nine months of age. A fundamental problem in the cyanotic ne- onatal Fallot is that there can be a degree of 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. C hristoph Huber developed and pioneered the concept and the method of transapical (TA) TAVI in 2004. Only two years later Tho- mas Walter performed the first successful clinical implant. Since then the most prom- ising TA TAVI technique started its steep as- cension towards becoming the most popular surgical TAVI access. Significant advantages over all other access techniques including: A) Shorter working distance allowing for a more precise target site device delivery. B) Eased wire crossing of the highly stenosed aortic valve directed by the native blood flow of the ejecting heart. C) Avoided crossing of the aortic arch by the larger valve delivery systems. D) Increased access diameter result- ing in less traumatic device crimping, bene- ficially differentiate transapical access from other TAVI access routes. Nevertheless, despite the very favour- able evidence, the enthusiasm for the transapical access is hampered by the mere fact of requiring a surgical cut-down and surgical closure. The author’s focus is to move the transapical access platform further. The last hurdle to overcome, to allow the transapical access to become the number one TAVI route, is a reliable and save true- percutaneous closure of the apex. The en- couraging TA PLUG experimental results are being presented for the first time at the annual EACTS meeting 2012 in Bar- celona. The device is self-expanding and made from full-core biocompatible material. Ex- Continued on page 2 Continued on page PB I n the Professional Challenge sessions, specific problem cases, in particular com- plication cases, will be presented. The design of these sessions facilitates inter- action and discussion on controversial topics. Topics under discussion include how to optimise coronary revascularization: plan- ning and execution; whether there is a place for palliation in the management of fallots tetralogy; Aortic arch disease II: Video ses- sion on all proven approaches for effectively treating the arch; and Today will also host the first ‘Focussed Sessions’ and will include a video demon- stration, followed by a keynote lecture and conclude with presentations that allow del- egates to leave the sessions with a greater understanding of how to solve a particular problem. This will include an examination of An- tiplatelet therapy in 2012 - Impact on Cardi- ovascular surgical procedures; How to opti- mise transcatheter aortic valve implantation outcomes; The Front door approach: the role of the surgeon in selecting the best patient specific access route; multiple valves; and heart rejuvenation. As ever, Monday will also witness this year’s Presidential Address by Professor Lud- wig K von Segesser, entitled, “The contrain- dications of today are the indications of to- morrow.” Today will also see the first Late Break- ing Clinical Trials session, as well as and the presentation of abstracts from all four EACTS Domains. The Vascular Domain will host a TEVAR Simulation Workshop and Simulation Course, and the General Interest Session will look at current ‘Research in Cardiothoracic Surgery’. 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 12:45-14:00 Abbott Vascular Scrub-in with Mitra- Clip Berlin Heart EXCOR® Pediatric Coroneo Aortic Valve Repair: a stand- ardized approach Edwards Lifesciences 50 years of AVR and 10 years of TAVI JOTEC The future of Aortic Surgery Maquet Cardiovascular Advances in Less Invasive CABG Medistim Clinical and economic out- comes - quality assessment procedures Medtronic 3f Enable valve – what have we learned? Sorin Group The Future of Cardiac Surgery is MICS St Jude Medical Aortic Stenosis: Treat- ment Options and Perspectives Symetis ACURATE TA: Self-Positioning TAVI Technology Vascutek Innovative Product Designs and Emerging Implantation Techniques Welcome to Monday’s programme, which begin with ‘Professional Challenges’

The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

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Page 1: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

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-

Continued on page 2 Continued on page PB

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’

Page 2: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

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

Continued on page 4

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

Continued on page 6

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Page 4: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

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

Continued from page 2

Continued on page 6

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.

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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

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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?

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Caption

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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

Continued on page 12

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

Page 11: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

Advert

Page 12: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

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)

Continued from page 10

Continued on page 14

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

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Advert

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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

Continued from page 12

Continued on page 18

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

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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

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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 +

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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

Page 21: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

EACTS Daily News  Monday 29 October 2012  21

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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”.

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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

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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

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EACTS Daily News  Monday 29 October 2012  23

Advert

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

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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

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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

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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

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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

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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

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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.

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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

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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.

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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

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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

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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

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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

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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

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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”

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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.

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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

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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

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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

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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

Page 44: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

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

Page 45: The official newspaper of the 26th EACTS Annual Meeting ...€¦ · postoperative repair morbidity. 26 ... cardiologists in a cath-lab with the lack of ... transcatheter aortic valve

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


24th EACTS Annual Meeting Management (EACTS)

24th EACTS Annual Meeting Management (EACTS)

Documents
EACTS Association Activities (EACTS)

EACTS Association Activities (EACTS)

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2018ESC/EACTS Guidelines on myocardial revascularization · 2018ESC/EACTS Guidelines on myocardial revascularization The Task Force on myocardial revascularization of the European

2018ESC/EACTS Guidelines on myocardial revascularization · 2018ESC/EACTS Guidelines on myocardial revascularization The Task Force on myocardial revascularization of the European

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Transcatheter LAA Occlusion

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