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Back to Annual Meeting Program
1:30 p.m. SIMULTANEOUS SCIENTIFIC SESSION A -ADULT CARDIAC SURGERY Ballroom, Ernest N. Morial Convention Center Moderators: Floyd D. Loop, M.D. Eric A. Rose, M.D.
7. Aortic Rupture after Aortic Valve Surgery in Women Monica L. McDonald*, Nicholas G. Smedira*, Bruce W. Lytle and Delos M. Cosgrove, Cleveland, Ohio Discussant: Robert J. Rizzo, M.D., Boston, MA
OBJECTIVE: To examine mortality in women after surgery for aortic regurgitarion (AR) and the contribution of aortic rupture to that mortality.
METHODS: 109 women underwent aortic valve replacement (AYR, n=92) or repair (n=17) for pure AR, 1985-96. In 59, concomitant aortic surgery (AOS) was performed by root replacement (n=31) or interposition graft (n=28). Of 50 undergoing isolated procedures, 31 had aortas >3.5 cm. The prevalence of larger aortas increased with age (P=.02). Mean follow-up was 5.7±2.6 yrs.
RESULTS: At 5 and 10 yrs, survival was 78% and 44%. 13 died of aortic rupture or sudden death and 3 underwent emergent operation for aortic rupture, 16 late aortic events (AE). Freedom from AE was 86% and 75% at 5 and 10 yrs. Risk factors for AE were older age (P=.07) and increasing ascending aorta diameter (P=.03) in women who had not undergone AOS. Rupture location was ascending aorta in 71% without AOS, and descending aorta in 56% with interposition grafts.
CONCLUSIONS: Late mortality following surgery for AR in women is due in part to aortic rupture. The figure depicts the risk of rupture according to AA size normalized to BSA and age, offering guidance for management of high-risk patients.
*By Invitation 8. Aortic Valve Replacement: Is Valve Size Important? Benjamin Medalion*, Eugene H. Blackstone, Bruce W. Lytle, Delos M. Cosgrove, and Jennifer White*, Cleveland, Ohio Discussant: Friedrich W Mohr, Leipzig, Germany
OBJECTIVE: To determine if patient-valve size mismatch affects long-term survival.
METHODS: We followed 892 patients (pts) up to 20 years (mean 5±3.9 years) after primary, isolated aortic valve replacement who had received either 1) a mechanical prosthesis (St. Jude, SJM, n=346); 2) a bovine pericardial valve (Carpentier-Edwards, CE, n=463); or 3) a cryopreserved allograft (ALLOG, n=83). Mean BSA was 1.86±0.23, range 1.15-2.57m2. 19mm prostheses were used in 19%. Multivariable analysis was focused on the Z-value for valve size, defined as the patient-specific number of standard deviations the internal prosthesis diameter departs from predicted normal aortic annulus size based on that individual's body surface area.
RESULTS: Internal Z-value ranged from -4.4 to +6.8, with 25% <-2. SJM valves had the smallest Z-value (-2.2±1.0), CE valves -0.5+0.99, and ALLOG the largest (0.2±1.4). Survival was 96%, 86%, 69%, and 49% at 1, 5, 10, and 15 years. Risk factors for death included older age, emergency surgery, endocarditis, coronary artery disease, and comorbidities, but no effect of valve size Z-value for any valve type (P>.2), in early, constant, and late hazard phases.
CONCLUSIONS: Survival after aortic valve replacement appears not to be adversely affected by mismatch between prosthesis valve size and body size down to at least -4 SDs below normal valve size.
*By Invitation 9. Minimally-Invasive Reoperative Aortic Valve Replacement Reduces Blood Loss and Transfusion Requirements John G. Byrne*, Sary F. Aranki, Gregory S. Couper* and Lawrence H. Cohn, Boston, Massachusetts Discussant: William A. Gay, Jr., M.D., St Louis, MO
OBJECTIVE: We developed techniques for minimally-invasive (min-inv) reoperative (reop) aortic valve replacement (AVR), using an upper hemi-re-sternotomy, and compared the results to reop AVR using conventional (conv) full re-sternotomy.
METHODS: We retrospectively analysed 19 conv & 20 min-inv isolated elective reop AVRs, performed between 11/96-9/98.
RESULTS: Age, sex, FC, EF, previous operations, and Aprotinin® use were not different between groups. Multivariate analysis determined that conv approach predicted greater blood loss, transfusion needs and longer operative (op) duration (Table).
CONCLUSIONS: Min-inv reop AVR avoids unnecessary lower mediastinal dissection, thereby reducing (1) blood loss, (2) transfusion needs and (3) total op duration. Patent CABGs may be less prone to injury. These beneficial effects, accomplished without compromising the valve procedure, make min-inv upper hemi-re-sternotomy superior to conv full re-sternotomy for reop AVR.
*By Invitation 10. Mitral Valve Repair and Replacement for Rheumatic Disease Terrence M. Yau*, Susan Armstrong*, Joan Ivanov*, Yasser A. Farag El-ghoneimi* and Tirone E. David, Toronto, Ontario, Canada Discussant: Alain F. Carpentier, M.D., Paris, France
OBJECTIVE: Repair of rheumatic mitral valves (MVs) has generally been associated with poor long-term results. We undertook this study to define the early and late results of surgery for rheumatic MVs.
METHODS: From 1978 to 1995, 575 patients (pts) underwent surgery for rheumatic MVs. Demographics and operative data were recorded prospectively. Followup was 97.7% complete (mean 67.5±45.7 mos). Survival and morbidity were evaluated univariately by Kaplan-Meier analysis and multivariately by Cox regression.
RESULTS: Mean age was 53.7±14.2 years, 80.5% of pts were female, 54.7% had congestive failure, 23.6% were undergoing redo MV surgery, and 9.7% also underwent coronary bypass. Mitral stenosis was present in 52.5%, regurgitation in 15.4%, and both in 32.1%. Valve repair (REP) was performed in 24.4%, 27.5% had replacement with a bioprosthesis (BIO) and 48.0% had a mechanical valve (MECH).
Operative mortality was 4.1%. Ten-year survival was: REP 88.2±0.04%, BIO 70.2±0.04%, MECH 73.4±0.06% (p=0.0002). Mortality was predicted by age, NYHA class, coronary disease, and reoperation.
Ten-year freedom from reoperation was: REP 72.0±0.05%, BIO 69.0±0.05%, MECH 95.3±0.02% (p=0.005). Type of prosthesis predicted reoperation after replacement. 23 pts underwent reoperation after initial repair, with no operative deaths.
Ten-year freedom from thromboembolic complications was: REP 92.5±0.02%, BIO 93.3±0.02%, MECH 71.6±0.07% (p<0.0001).
CONCLUSIONS: Mechanical valves minimize reoperation but limit survival and are prone to thromboembolism. Bioprostheses and repaired valves both have good freedom from thromboembolism and poor freedom from reoperation, but patients selected for valve repair had better late survival. Patients with rheumatic MVs should have repairs whenever technically feasible, accepting a risk of late reoperation, to maximize survival and reduce morbidity.
*By Invitation 11. Influence of Size 19mm Aortic Valve Replacement on Survival David H. Adams*, Raymond H. Chen*, Sary F. Aranki, Elizabeth N. Allied* and §Lawrence H. Cohn, Boston, Massachusetts Discussant: Donald B. Doty, M.D., Salt Lake City, UT
OBJECTIVE: Does valve size influence early and late clinical outcomes in patients ≥ 70 years of age undergoing aortic valve replacement?
METHODS: Between 12/91 and 7/98 408 patients ≥ 70 years of age (median age 77, range 70-97,50% male) underwent isolated AVR or AVR combined with CABG, utilizing either Carpentier-Edwards bovine pericardium valves (n=300) or St. Jude mechanical valves (n=108). Univariate methods were used to examine potential confounders (age ≥ 75, sex distribution, body mass index, CABG, re-operation, hypertension, myocardial infarction, renal failure, COPD, stroke, diabetes mellitus, congestive heart failure, aortic stenosis, prolonged ischemia/ bypass times) among patients receiving a small (19mm) or a large (≥ 21mm) aortic valve. Multivariate logistic regression methods were used to predict operative mortality and multivariate proportional hazards regression methods were used to predict late death (median follow-up 22 months) related to 19mm valve replacement after controlling for potential confounders.
RESULTS: Operative mortality was 16% (18/111) for size 19mm valve replacement, 5.8% (8/138) for 21mm valve replacement, and 2.5% (4/159) for ≥ 23mm valve replacement (p ≤.0005). The unadjusted odds ratio for operative death for 19mm vs. ≥ 21mm valves was 4.6 (95% CI:2.1,9.9; p ≤.0005). In the final multivariate model adjusted for potential confounders, small valve size remained a significant predictor of operative death (OR 4.2, 95% CI:1.8,9.8; p=.001). 19mm valve usage, however, did not predict late death in either the univariate analysis (HR 0.96,95% CI:0.5,1.9;p=.92) or the multivariate analysis (HR 0.6, 95% CI:0.3,1.4; p=.25).
CONCLUSIONS: Implantation of a 19mm aortic valve in a patient ≥ 70 years of age appears to be an independejnt risk factor for operative mortality, but does not impact on late death.
3:15 p.m. INTERMISSION - VISIT EXHIBITS
1992-94 AATS Research Scholar §Authors have a relationship with St. Jude Medical & Medtronic *By Invitation 4:00 p.m. SIMULTANEOUS SCIENTIFIC SESSION A -ADULT CARDIAC SURGERY Ballroom, Ernest N. Morial Convention Center Moderators: Floyd D. Loop, M.D. Eric A. Rose, M.D.
12. Hospital Readmission following Cardiac Surgery: Prevalence, Patterns and Predisposing Factors Richard S. D'Agostino*, Jerilynn P. Jacobson*, Lars G. Svensson*, Christina Williamson* and David M. Shahian, Burlington, Massachusetts Discussant: Timothy J. Gardner, M.D., Philadelphia, PA
OBJECTIVE: In this study, we examine the incidence of readmission within the 30-day period following hospital discharge after cardiac surgery, the reasons for readmission and pre-discharge factors that predispose to readmission.
METHODS: Pre, intra and postoperative clinical data were prosepctively collected for 1027 patients undergoing coronary bypass, valve replacement or combined bypass/valve surgery between 1/1/96 and 7/30/97. Thirty-day data was collected at the time of office visit or by telephone and/or written survey.
RESULTS: 163 (15.8%) patients were readmitted to a hospital within the 30-day period following discharge. The clinical problems that prompted read-mission were as follows: dysrhythmia=27 (16.5%), congestive heart failure/ dyspnea/pulmonary edema/pleural effusions=34 (20.8%), chest pain/rule out myocardial infarction=17 (10.4%), wound infection/problem=14 (8.5%), gastrointestinal problem=7 (4.3%), stroke/TIA=2 (1.25%), pneumonia or other non-wound infection=14 (8.5%), deep venous thrombosis or pulmonary embolus=8 (4.9%), peripheral vascular problem=7 (4.2%), anemia/hypotension/transfusion=12 (7.4%) and miscellaneous problems=22 (13.5%). Stepwise logistic regression analysis (Hosemer and Lemeshow Goodness-of-Fit chi square= -5.85; df=8; p=0.6631) showed that advancing age (p=0.04), increasing body mass index (p=0.0032), combined valve/bypass surgery (p=0.0003), longer cardiopulmonary bypass (p=0.0013) and crossclamp time (p=0.000), and longer postoperative length of stay (p=0.005) predispose to readmission.
CONCLUSIONS: Readmission within 30 days of discharge after cardiac surgery is a relatively common event. Some patients appear to be at greater risk for readmission and future efforts should focus on risk reduction strategies for these patients. Interestingly, shorter hospital stays do not appear to impact adversely on the risk of readmission.
*By Invitation 13. Mid-term Follow-up of Patients who had LVAD Removal following Cardiac Recovery in End-stage Dilated Cardiomyopathy Roland Hetzer, Johannes H. Mueller*, Yu-guo Weng*, Thorsten Drews*, Matthias Loebe* and Gert Wallukat*, Berlin, Germany Discussant: Eric A. Rose, M.D., New York, NY
OBJECTIVE: Cardiac recovery in end-stage dilated cardiomyopathy (DCM) was demonstrated after temporary LVAD support. However, the durability of such recovery has remained a matter of dispute. We report on our patients who had removal of LVAD up to 3-1/2 years ago.
METHODS: Since 3/1995, 21 patients with end-stage DCM who had been supported by LVAD (19 Novacor, 2 TCI) for periods of between 1 and 26 months (mean 6 months)had their LVAD removed following complete or near complete cardiac recovery as documented by echocardiography (LVEF, LVIDd) at time of pump-off trials.
RESULTS: Six patients (group A) suffered recurrence of cardiac failure after between 4 and 24 months. Transplantation was successfully performed in five, one died on the waiting list, four patients died from reasons unrelated to cardiac failure after between 3 days and 29 months. Stable cardiac recovery has been enjoyed by 11 patients (group B) for between 6 and 41 months (mean 20±6). At time of LVAD implant, there were no differences between groups A and B as to age, duration of heart failure, invasive hemodynamic values, LVEF, LVIDd, amount of apoptosis, TNF-u., b-receptor density, and level of autoanti-bodies. However, the degree of cardiac recovery at the time of pump explan-tation was significantly better in group B (A vs. B; LVEF 40±5 % vs. 48±4 % p < 0.01; mean LVIDd 62±6 mm vs. 53±5 mm, p<0.01).
CONCLUSIONS: In a selective group of patients with end-stage DCM complete and lasting cardiac recovery may be achieved after ventricular unloading with LVAD. At present, no reliable pre-LVAD-implant indices have been recognized that would allow prediction of the degree of recovery after implant. However, lasting cardiac recovery seems to be related to complete normalization of cardiac function during the unloading period.
*By Invitation 14. Choice of Non-transplant Cardiac Surgical Procedures for End-stage Cardiomyopathy Hisayoshi Suma, Tadashi Isomura*, Taiko Horii*, Toru Sato* and Norio Kikuchi*, Kamakura, Kanagawa, Japan Discussant: Steven F. Bolling, M.D., Ann Arbor, MI
OBJECTIVE: To treat end-stage cardiomyopathy, endoventricular circular patch plasty (EVCPP), partial left ventriculectomy (PLV) and solo-valvular reconstruction (VR) have been proposed. To find a proper choice of those non-transplant cardiac procedures, we evaluated our 2 years results of those procedures and introduce echo-guided volume reduction test.
METHODS: From December 1996 to September 1998, 68 patients with end-stage cardiomyopathy (27 ischemic and 41 non-ischemic) underwent EVCPP±CABG/VR, PLV1VR or Solo±VR. Preoperative characteristics is shown in Table. For ischemic cardiomyopathy, EVCPP(Dor procedure) was used for all patients. In non-ischemic group, Group I indicates early 24 patients treated with PLV±VR (mostly replacement) and Group II includes recent 17 patients treated with different types of procedures depends on intraoperative volume reduction test which observes changes of LV size, wall motion and thickness before and after CPB by echography. When the LV became smaller and the wall increased thickness entirely with LV decompression, solo-VR (mostly annuloplasty) was chosen and if akinetic thin wall remained, PLV or EVCPP was added according to the site of akinesis.
RESULTS: Hospital mortality was acceptably low in elective operations in each group whereas the risk was high inongoing shock patients needed emergency operation (Table). With colume reduction test, mortaily reduced from 12% to 0% in non-ischemic group.
CONCLUSIONS: EVCPP is favorable for ischemic cardiomyopathy because septal exclusion is effective. Volume redution test is useful to choose an optimal procedure for non-ischemic cardiomyopathy to avoid excessive LV excision.
*By Invitation 15. Passive Ventricular Constraint With the Acorn Prosthetic Jacket Prevents Progressive Left Ventricular Remodeling and Functional Mitral Regurgitation in Dogs With Moderate Heart Failure Pervaiz A. Chaudhry*, Gaetano Paone*, Victor G. Sharov*, Takayuki Mishima*, James Hawkins*, §Clif Alferness* and §Hani N. Sabbah*, Detroit, Michigan Sponsored By: Norman A. Sttverman, Detroit, Michigan Discussant: Gerald D. Buckberg, M.D., Los Angeles, CA
OBJECTIVE: The purpose of this study was to determine if passive mechanical constraint of the cardiac ventricles with a surgically placed prosthetic jacket prevents progressive left ventricular (LV) remodeling and attenuates functional mitral regurgitation (MR) in dogs with moderate heart failure (HP).
METHODS: HF (LV ejection fraction 30-40%) was produced in 12 dogs by multiple sequential intracoronary microembolizations. Six dogs underwent mid-sternotomy and pericardiotomy followed by placement of the prosthetic jacket (a preformed-knitted polyester mesh, Acorn Cardiovascular, Inc.) snugly around the ventricles and anchored at the AV groove. Six untreated HF dogs served as controls (CON). LV end-diastolic (EDV) and end-systolic (ESV) volumes and the presence and severity of functional MR were determined angiographically before (PRE) and 3 months after (POST) treatment. Cardiomyocyte cross-sectional area (CCSA), a measure of myocyte hypertrophy, was assessed histomorphometrically.
RESULTS: In CON dogs, EDV increased 15±5 ml between PRE and POST but decreased 7±1 ml in dogs treated with the Acorn prosthetic jacket (P=0.002). Similarly, ESV increased 17±5 ml in CON dogs but decreased 9±1 ml in dogs treated with the jacket (P=0.001). In CON dogs, 4 of 6 had 1+ to 2+ MR that persisted and/or increased after 3 months of follow-up. In contrast, 4 of 6 surgically treated dogs had 1+ to 2+ MR that was completely abolished after 3 months. In dogs treated with the prosthetic jacket, the average CCSA area was smaller than in CON (791+51 vs. 987±37 mm2, p=0.011).
CONCLUSIONS: Passive ventricular constraint with the Acorn prosthetic jacket prevents progressive LV remodeling and abolishes functional MR in dogs with moderate HF.
§Authors have a relationship with Acor Cardiovascular, Inc. *By Invitation 1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION B - GENERAL THORACIC SURGERY Room 211-213, Ernest N. Morial Convention Center Moderators: Thomas R. J. Todd, M.D. Steven J. Mentzer, M.D.
16. Secondary Pulmonary Hypertension Does Not Adversely Affect Outcome After Single Lung Transplant. Scott Huerd*, Frederick L. Grover, James R. Mault*, Max B. Mitchell*, David N. Campbell, Fernando Torres*, Paul Chetham*, Tony Hodges* and Martin Zamora*, Denver, Colorado Discussant: Vaughn A. Starnes, M.D., Los Angeles, CA
OBJECTIVE(s): Elevated pulmonary artery pressures (PAP) have been associated with poor outcomes in patients undergoing SLT. Some groups advocate double lung transplant or the routine use of cardiopulmonary bypass (CBP) for SLT in this population. These recommendations remain controversial. The goal of our study was to determine whether secondary PHTN requires CPB and adversely affects outcomes following SLT.
METHODS: We retrospectively reviewed 76 consecutive SLT performed from 1992-98. Patients with primary PHTN and Eisenmenger's syndrome were excluded. Recipients were stratified according to preoperative PAP (PA systolic pressure > 40mm Hg); 58 had low PAP and 18 high PAP (13 with COPD or A1AT deficiency, 5 with idiopathic pulmonary fibrosis).
RESULTS: No patient in the high PAP group required CPB or inhaled nitric oxide (iNO) intraoperatively. Postoperatively, no significant differences were seen in length of stay (LOS, 14.6 ±.9 vs.ll.9±1.5 days), 30 day survival (95 vs 89%) or lung injury as measured by CXR score or PaO2/FiO2 or the need for iNO (5(8.6%) in the low and 2(11.1%) in the high group) in the low versus high groups respectively (p=NS). There were also no differences in FEV1 or six minute walk at 1 and 2 yrs or in the incidence of acute rejection, infection or BOS>grade 2. Survival at 1, 2, and 4 yrs posttransplant was 85,79, and 71% in the low group and 78, 78, and 67% in the high group (p=NS).
CONCLUSIONS: Our data demonstrate that secondary PHTN is not associatied with significantly increased morbidity, mortality, or LOS after SLT and that double lung transplant or the routine use of CPB are not necessary for patients with pulmonary parenchymal disease and secondary PHTN.
*By Invitation 17. Hyperthermic Pleural Perfusion with Cisplatinum -Preliminary and Midterm Results Yael Refaely*, David A. Simansky*, Michael Paley* and Alon Yellin*, Tel Hashomer, Israel Sponsored By: John R. Benfield, Los Angeles, California Discussant: TBA
OBJECTIVE: Intrapleural chemotherapy and hyperthermia have been investigated separately for the treatment of pleural tumors or rumors with pleural extension . The aim of this study is to conduct a phase I and n study of operation, chemotherapy and hyperthermia in one session for the treatment of pleural cancers.
METHODS: Since 1994, 26 pts with the following underlying conditions had intraoperative HPF:Thymoma-11, Mesothelioma-8, others-6. Technique of per-fusion was: Use extracorporal circuit and heat exchanger, circulating the pleural space with 1000-2500 ml/min of Ringer lactate. Cisplatinum (60mg-2 pts, 100mg-2,120mg-1,150mg-18,200mg-3 pts) was added when the inrrapleural temperature stabilized (mean- 40.8ºc). The associated operations were: extended extrapleural pneumonectomy-8, resection of rumor with pleurectomy -10, resection of rumor without pleurectomy -4, exploration and HPF only -4( Thora-cotomy-2, VATS-2).
RESULTS: There were no technical problems during the perfusion period. The maximal systemic temperature reached 38ºc. There were no renal or hematological toxicity except one case of thrombocytopenia. One pt died from complications developing after herniation of the stomach through the sutured diaphragm. Additional complications were: bleeding which required re-thoracotomy-1 pt;empyema-3(early-2, late-1); prolonged air leak -2; atrial fibrillation -1. Median postoperative stay was 7 days (range 2-50). four pts died 6-15 months following HPF from systemic disease progression. Two of them had contralateral or peritoneal spread without local reccurence. 20 are alive 1-47 months after surgery. 1-year survival is 81%. 2 and 3-years survival is 70%.
CONCLUSIONS: Intraoperative HPF including cisplatinum was adequately safe. Finding to date show that this method offers excellent local control for pleural cancers.
*By Invitation 18. Surgical Treatment of Lung Cancer with Synchronous Brain Metastasis Peter S. Billing*, Daniel L. Miller*, Mark S. Allen, Claude Deschamps, Victor F. Trastek, and Peter C. Pairolero, Rochester, Minnesota Discussant: Joseph I. Miller, Jr., M.D., Atlanta, GA
OBJECTIVE: Although resection of primary lung cancer and metachronous brain metastasis is superior to other treatment modalities in prolonging survival, resection of primary lung cancer and synchronous brain metastasis is controversial.
METHODS: From January 1975 to December 1997, 220 patients received treatment at our institution for synchronous brain metastasis and primary non-small cell lung cancer. Twenty-seven of these patients (12.3%) underwent staged surgical resection of solitary synchronous brain metastasis and primary non-small cell lung cancer.
RESULTS: There were 18 men and 9 women. Median age was 56 years (range, 35-71). Twenty-four patients (88.9%) presented with neurological symptoms. Craniotomy was performed first in all 27 patients. Median time between craniotomy and thoracotomy was 13 days (range, 4-67 days). Lobectomy was performed in 21 patients, bilobectomy in 3, and pneumonectomy in 3. There were no operative deaths. Cell type was adenocarcinoma in 11 patients, squamous cell in 8, and large cell in 8. At the time of the pulmonary resection, 14 patients had no evidence of lymph node metastases, 6 had hilar metastases and 7 had mediastinal metastases. Twenty-two patients (81.5%) received adjuvant therapy: whole brain radiation (WBR) alone in 15; WBR/systemic chemotherapy in 4; and WBR, chest radiation and systemic chemotherapy in 3. Follow-up was complete in all patients for a median of 22 months (range, 2-104 months). Median survival was 18.5 months (range, 2-104). Actuarial survival at 1, 2 and 5 years was 60%, 36% and 20%, respectively.
CONCLUSIONS: The survival for patients who present with brain metastasis from lung cancer is poor. However, a therapeutic plan including staged resection of synchronous solitary brain metastasis followed by pulmonary resection can be beneficial in a select group of patients.
*By Invitation 19. Chest Wall Resection for Recurrent Breast Carcinoma Robert J. Downey*, Valerie Rusch, F. Ida Hsu*, David Linehan*, Manjit S. Bains, and Robert J. Ginsberg, New York, New York Discussant: Mark S. Allen, M.D., Rochester, MN
OBJECTIVE: To define safety and efficacy of resection of bony thorax for recurrent breast carcinoma
METHODS: Retrospective chart review. Survival by Kaplan-Meier, prognostic factors by log rank/Cox regression, p significant if ≤0.05
RESULTS: During 10/87-4/97, 41 women (med age 56yrs) underwent resection of sternum (2), ribs (17), or sternum/ribs (22). Operative mortality 0%, resection rate 80%. Skeletal reconstruction: MMMM(35), MM(2), Gore-tex (1), other/no material(3). Median skin defect 110 cm2 (range 0-448). Soft tissue closure: primary(10), pedicled flap(26), microvascular flap(4), combination(l). At last FU, 24 patients were without local recurrence, 14 with local recurrence, and 3 status unknown. Synch mets, + margins, + lymph nodes, size largest nodule, # nodules, or bony invasion did not correlate with local recurrence. Synch mets, + margins, + lymph nodes, (but not size largest nodule, no. nodules, or bony invasion) correlated with survival.
CONCLUSIONS: 1. Resection/reconstruction of the bony thorax for recurrent breast carcinoma is safe 2. Survival and local control following resection are favorable, even if distant metastases present
3:05 p.m. INTERMISSION - VISIT EXHIBITS
*By Invitation 3:50 p.m. SIMULTANEOUS SCIENTIFIC SESSION B - GENERAL THORACIC SURGERY Room 211-213, Ernest N. Morial Convention Center Moderators: Thomas R. J. Todd, M.D. Steven J. Mentzer, M.D.
20. The Current Role of Mediastinoscopy in the Evaluation of Thoracic Diseases Zane T. Hammoud*, Bryan F. Meyers*, Tracey J. Guthrie*, Joel D. Cooper, Charles L. Roper and G. Alexander Patterson, St. Louis, Missouri Discussant: Douglas E. Wood, M.D., Seattle, WA
OBJECTIVE: Mediastinoscopy(med) is a commonly employed procedure utilized for the diagnosis of thoracic disease and the staging of lung cancer. We sought to re-evaluate the safety and efficacy of med in an academic thoracic surgical program.
METHODS: We conducted a retrospective review of all patients undergoing med on our service between 1/88 and 8/98.
RESULTS: We performed med on 2069 patients during the study period, including 1909 cervical meds, 62 anterior mediastinotomies, and 98 combined procedures. A total of 1668 patients underwent med for known or suspected lung cancer. In 427(26%) of these, N2 or N3 disease was identified; only 29(7%) of these patients underwent resection, with a 5 yr. survival of 25%. In 1241(74%) of patients with suspected lung cancer, med was negative; all of these patients underwent exploration. In these patients, 954(77%) had lung cancer. Only 74(8%) of the lung cancer patients were found to have N2 disease at exploration; the 5 yr. survival in this group was 24%. Among the 1241 patients with a negative med, 71(6%) had a non-bronchogenic malignancy and 216(17%) had resection of what proved to be a benign lesion. In 156 patients, the med proved positive for a non-bronchogenic malignancy. Evaluation of mediastinal aden-opathy in the absence of any identifiable intrathoracic tumor in 245 patients led to a definitive diagnosis in 218(89%). In the entire group of 2069 patients, we observed 4(0.2%) perioperative deaths and 10(0.5%) complications. Only one death was attributed to med(tumor invading the aorta). No deaths or complications occurred in patients undergoing med for benign disease.
CONCLUSIONS: Mediastinoscopy is a highly effective and safe procedure. We believe that mediastinoscopy should currently be used routinely in the diagnosis and staging of thoracic diseases.
*By Invitation 21. Bronchoplastic Procedures in Malignant and Non-Malignant Disease - Results of 144 Cases Adelheid End*, Peter Hollaus*, Andreas Pentsch*, Michael Mueller*, Ernst Wolner and Franz Eckersberger*, Vienna, Austria Discussant: Thomas R. J. Todd, MD., Toronto, Ontario, Canada
OBJECTIVE(s): We present our experience with bronchoplastic procedures in a seven year period.
METHODS: Data from 144 patients who underwent bronchoplastic surgery between 1991 and 1997 were collected retrospectively. There were 110 men and 34 women, mean age was 59±9 years (range, 26 - 79 years). Indication for surgery was primary lung cancer (n=130), metastases (n=4) and carcinoid tumors (n=10). Full bronchial sleeve resections were performed in 108 cases, bronchial wedge resections in 28 and sleeve pneumonectomies in 8 cases; 103 procedures were done on the right (72 %) and 41 on the left side (28%). In 15% (n=21) an angioplasty and in 3, 5% (n=5) resection of the thoracic wall was performed. In 3 extended resections cardiopulmonary bypass was used. 61% of patients presented with cardiovascular risk factors, 62% were smokers and 64% had chronic pulmonary obstruction.
RESULTS: 30-day mortality was 8 %. Causes of death were cardiac failure and myocardial infarction (n=3), pulmonary embolism (n=2), hepatorenal failure (n=1), stroke (n=1), pneumonia (n=3), gastrointestinal bleeding (n=1) and mesenteric infarction (n=1). Major complications consisted of anastomotic dehiscence in 5 cases beyond the 30th postoperative day, 4 of them died, rethoracotomy for bleeding (n=3) and empyema (n=3). The presence of cardiac risk factors, chronic obstructive disease, N2-disease, R1-resection and performance of sleeve pneumonectomy had an adverse influence on survival (p<0.05).
CONCLUSIONS: Bronchoplastic procedures have evolved as an alternative to pneumonectomy in high-risk patients with centrally located tumors or in non-malignant disease. However, our mortality rate of 8 % demonstrates that patients should be selected carefully assessing their preoperative risk profile.
*By Invitation 22. M1a/M1b Esophageal Carcinoma: Surgical Relevance Neil A. Christie*, Thomas W. Rice, Malcolm M. DeCamp *, John R. Goldblum*, David J. Adelstein*, Lisa A. Rybicki* and Eugene H. Blackstone, Cleveland, Ohio Discussant: Mark J. Krasna, M.D., Baltimore, MD
OBJECTIVE: The 1997 staging system for esophageal carcinoma subdivides distant metastatic disease (M1) into M1a (non-regional lymph node metastases) and M1b (visceral metastases). This study evaluates the clinical relevance of this classification.
METHODS: From our prospective esophageal database, 141 patients (pts) were identified with M1 disease, 37 (26%) with M1a and 104 (74%) with M1b. Histology was adenocarcinoma in 119 (84%) pts, squamous cell in 18 (13%) and adenosquamous in 4 (3%), with a similar distribution for Mia and M1b (P=.3). Forty-seven pts underwent surgery. Of these, 29 (78%) were M1a and 18 (17%) M1b (P<.001). Medical therapy (chemotherapy and/or radiation therapy) was given to 99 (70%) pts; 31 (84%) Mia and 68 (65%) M1b (P=.04).
RESULTS: Median and 5-year survival were 11 months and 6% for Mia pts, and 5 months and 2% for M1b pts (P=.002). Surgery provided no evident advantage in M1b and a small benefit after 12 months in Mia. Multivariable analysis demonstrated that M1b pts had 1.7 times the risk of death of M1a pts (CI 1.1-2.5, P=.009), and pts without medical therapy had 2.2 times the risk of those with medical therapy (CI 1.5-3.2, P<.001). Despite the high prevalence of surgery for M1a disease, the analysis suggests that M1a and use of medical therapy, rather than surgery per se, account for the small and clinically unimportant differences in survival.
CONCLUSIONS: We conclude that: 1) although there are statistically significant survival differences between M1a and M1b pts, these differences are not clinically important; 2) medical therapy is associated with a modest survival benefit; and 3) surgery offers no advantage in the treatment of these pts.
*By Invitation 23. The Role of Positron Emission Tomography in Evaluating the Mediastinum in Patients with Non-Small Cell Lung Cancer Tracey L. Weigel*, Carolyn C. Meltzer*, David Friedman*, Robert J. Keenan, Peter F. Person* and James D. Luketich*, Pittsburgh, Pennsylvania Discussant: Kemp H. Kernstine, M.D., Iowa City, IA
OBJECTIVE: Currently, mediastinoscopy with histologic nodal examination is the gold standard for preoperative assessment of the mediastinum. Positron Emission Tomography (PET) is a new, noninvasive tool that differentiates malignant from benign processes based upon metabolic status rather than anatomic structure. This study compares the accuracy of PET and CT scanning, as compared to histology, in staging the mediastinum in patients with NSCLC.
METHODS: Histologic examination of mediastinal lymph nodes (MLNs) was performed on 34 patients with NSCLC by multi-station lymph node sampling at mediastinoscopy and/or mediastinal lymph node dissection at surgical resection. PET scans were read by a single radiologist, blinded to histologic assessment, using CT scans for anatomic localization. CT scans were independently assessed for mediastinal lymphadenopathy.
RESULTS: The overall accuracy, sensitivity, and specificity for PET in the determination of metastases to the mediastinum was better than CT when compared to histologic findings (see table). PET scan staging, however, correlated poorly with histologic MLN staging; R=0.553, (p=0.001).
CONCLUSIONS: PET scanning appears to be more accurate than CT for staging the mediastinum in patients with NSCLC. However, PET imaging still fails to identify 20% of histologically-proven MLN metastases. At present, mediastinoscopy should remain the standard of care for pre-operative staging of the mediastinum in patients with NSCLC.
*By Invitation 24. Primary Mediastinal Nonseminomatous Germ Cell Tumors: The Influence of Postchemotherapy Pathology On Long-Term Survival After Surgery Kenneth A. Kesler*, Karen M. Rieger*, Kristen N. Ganjoo*, Matt Sharma*, Naomi S. Fineberg*, Lawrence H. Einhorn* and John W. Brown, Indianapolis, Indiana Discussant: Scott J. Swanson, M.D., Boston, MA
OBJECTIVE(s): Treatment of nonseminomatous germ cell tumors (NSGCT) with cisplatin based chemotherapy (CT) followed by surgical resection of residual disease, represents a successful model for multimodaliry cancer therapy. We reviewed 104 Pts from 1981 to 1997 with primary mediastinal NSGCT to evaluate variables which may influence survival following surgery.
METHODS: 27 (26%) Pts did not undergo post-CT resection due to progression during CT (n=25) or had a complete response after CT (n=2). 77 Pts (74%) underwent 80 resections and were further analyzed with respect to multiple variables including pre and post CT pathology and serum tumor markers (STM). All were male between 12 and 49 yrs (mean=28). The majority (95%, 69/73) had elevated STM, 44 of which (64%) demonstrated normalization after primary or secondary CT. 21 Pts (27%) had extra-mediastinal disease at presentation.
RESULTS: The finding of tumor necrosis in the resected specimen (n=16) predicted excellent survival which was significant compared to teratoma (n=26), sarcomatous degeneration (n=6) or persistant NSGCT pathologies (n=44). The finding of teratoma predicted significantly better survival than persistent NSGCT. No other variable was significantly predictive.
CONCLUSIONS: Primary NSGCT of the mediastinum can be cured with a multimodality approach. Post-CT pathologic findings of tumor necrosis and teratoma predict excellent and intermediate long-term survival respectively. Survival is poor but possible in patients suspected of unfavorable pathology following CT, justifying an aggressive surgical approach.
ADJOURN
*By Invitation 1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION C - CONGENITAL HEART DISEASE Room 208-210, Ernest N. Mortal Convention Center Moderators: John J. Lamberti, M.D. John A. Waldhausen, M.D.
25. Revision of Previous Fontan Connections to Total Extracardiac Cavopulmonary Anastomosis: a Multicenter Study Carlo F. Marcelletti, Frank L. Hanley, Constantine Mavroudis, Mohan V. Reddy*, Raul F. Abella*, Stefano M. Marianeschi*, Francesco Seddio*, Marco Meli*, Fiore S. lorio* and Francis Fontan, Bordeaux, France, Chicago, Illinois, Modena, Italy and San Francisco, California Discussant: John E. Mayer, M.D., Boston, MA
OBJECTIVE: Conversion of modified Fontan procedure to a total extracardiaccavopulmonary connection (TECPC)has been proposed as an alternative surgical treatment of pts who showed manifestation of surgical failure. The aim of the present multicenter study is to evaluate the midterm outcome after conversion.
METHODS: Between Oct'92 and Sept'98, 24 pts (mean age 21, 1 yrs; range 10-39) underwent revision of the atriopulmonary connection to TECPC in 4 different Institutions. In these pts who have received previously an atriopulmonary connection, complications due to right atrial enlargement were: Fontan pathway obstruction(10), progressive CHF(16), atrial dysrhythmias(19), RA thrombus(2),obstruction of right pulmonary veins(6), subAo stenosis(1), protein losing enteropathy(PLE)(2)and effusions(6). Conversion to a TECPC was carried out with a non-valved conduit from the IVC to RPA.PTFE tube graft was used in 18 pts, homograft conduit in 3 pts and Dacron tube in 3 pts.
RESULTS: Three deaths occurred: 1 pt with severe cachexia, in whom transplantation was controindicated for social reasons, died in the early postoperative period of massive effusions. The second patient died for irreversible heart failure during the operation and the third pt died at home 8 months postop for arrhythmia. All surviving pts have improved to NYHA class I (16 pts)or II (4 pts) except 1 pt in NYHA class IV who underwent OHTX. Postop arrhythmias occurred in 10 pts:4 pts underwent PMK implantation and in 6 pts medical therapy was sufficient to manage the symptoms. Two pts with PLE improved within 30 days.
CONCLUSIONS: Conversion of failing previous Fontan procedure to TECPC can be accomplished with a low mortality and it appears to be a viable option. However the revision should be undertaken early in symptomatic pts before irreversible ventricular failure ensues.
*By Invitation 26. Repair of the Truncal Valve and Associated Interrupted Arch in Neonates with Truncus Arteriosus Marjan Jahangiri*, David Zurakowski*, Pedro J. Del Nido, John E. Mayer and Richard A. Jonas, Boston, Massachusetts Discussant: Edward L. Bove, M.D., Ann Arbor, MI
OBJECTIVE: Truncal valve regurgitation and interrupted aortic arch have frequently been identified as risk factors in the repair of truncus asteriosus. We wished to examine these factors in the current era including the impact of truncal valve repair.
METHODS: Between 1992 and August 1998, 50 patients underwent surgical repair of truncus asteriosus. Their ages ranged from 2 days to 6 months (median, 2 weeks). Nine patients had associated interrupted aortic arch. Of the 14 patients (28%) who were diagnosed to have truncal valve regurgitation pre-operatively, five underwent truncal valve repaid and one underwent homograft replacement of the truncal valve with coronary reimplantation.
RESULTS: The acturial survival was 96% at 30 days, 1 year and 3 years. There were no deaths in patients with associated interrupted aortic arch. The two deaths in the series occurred in patients with truncal valve regurgitation, neither of whom underwent repair. Postoperative transthoracic echocardiography in patients who underwent valve repair showed minimal residual valvar regurgitation. None of the patients have required reoperation for truncal valve problems or aortic arch stenosis at a mean follow-up of 22 months. Conduit replacement has been performed in 17 patients (34%) after a mean duration of 2 years. The freedom from reoperation for those who had an aortic homograft was 4 years and for those who had pulmonary homograft was 3 years.
CONCLUSIONS: Despite the magnitude of surgery, excellent results can be achieved in complex forms of truncus arteriosus. In the current era interrupted aortic arch is no longer a risk factor for repair of truncus. Aggressive application of truncal valvuloplasty methods neutralize the traditional risk factors of truncal valve regurgitation.
*By Invitation 27. Five To Fifteen Year Follow-Up of Fresh Autologous Pericardial Valved Conduits Andres J. Schlichter*, Christian Kreutzer, Rita C. Mayorquim*, Jorge L. Simon*, Maria I. Roman*, Haydee Vazquez*, Eduardo A. Kreutzer* and Guillermo O. Kreutzer*, Buenos Aires, Argentina Sponsored by: Richard A Jonas, Boston, Massachustts Discussant: William G. Williams, M.D., Toronto, Ontario, Canada
OBJECTIVE: To evaluate the long term results of an autologous pericardial valved conduit (APVC) in the venous ventricle outflow tract.
METHODS: Between 1983 and 1993, 82 conduits were placed in the subpulmonary position. Patients receiving homografts(n=2), heterografts(n=3) or valveless conduits(n=19) and dying within 90 days were excluded. Thus, 54 late survivors of venous ventricle outflow reconstruction with a fresh bicuspid APVC were followed from 5 to 15 years with a median of 7 years. Yearly evaluations by two dimensional echo Doppler were made and 9 patients had cardiac catheterization. Diagnosis include D-transposition of the great arteries (n=16), L-transposition of the great arteries(n=14), Tetralogy of Fallot(n=11), Truncus arteriousus(n=10) and double outlet right ventricle(n=3). Mean age at implantation was 2.9 ± 6.3 years(2 months to 24 years). Cath or surgical intervention was indicated when the gradient exceed 50 mm Hg.
RESULTS: In 27 patients the APVC increased its diameter (1 to 7 mm), in 20 it remained unchanged and a reduction of 1 mm was noted in 4. Median conduit diameter at implantation was 16 mm and was 17.5 mm at last evaluation.(p=0.0001) Freedom from reintervention at 5, and 10, years was 89% and 80%. Freedom from reintervention was 100% at 10 years for conduits larger than 16 mm at the time of implantation and it was 85% at 5 years and 72% at 10 years for those 16 mm or less. The valve had good function in the first six months but late failure without obstruction. Conduit related reoperation was required only in 6 cases between 4.5 and 10 years after implantation and 2 patients underwent balloon dilation of APVC. There were 3 late deaths caused by arrhythmia, sepsis and brain tumor.
CONCLUSIONS: Pericardial valved conduits show excellent results and compare favorably to those of other conduits.
2:45 p.m. INTERMISSION - VISIT EXHIBITS
1998-99 AATS Graham Fellow *By Invitation 3:30 p.m. SIMULTANEOUS SCIENTIFIC SESSION C - CONGENITAL HEART DISEASE Room 208-210, Ernest N. Morial Convention Center Moderators: John J. Lamberti, M.D. John A. Waldhausen, M.D.
28. Pre-Surgical Risk-of-Death Prediction Model in Neonatal Repair of Congenital Heart Disease Robert R. Clancy*, Susan A. McGaurn*, James E. Coin*, Gil Wernovsky*, Thomas L. Spray, William I. Norwood, Marshall L. Jacobs*, John D. Murphy*, Deboral G. Hirtz* and J. William Gaynor*, Bethesda, Maryland, Browns Mills, New Jersey, Media, Pennsylvania, Philadelphia, Pennsylvania and Wilmington, Delaware Discussant: Marc R. de Leval, M.D., London, U.K.
OBJECTIVE: To generate a pre-surgical risk-of-death prediction model in a population of neonates with congenital heart disease (CHD) undergoing surgery with deep hypothermic circulatory arrest (DHCA).
METHODS: We completed a single-center, prospective, randomized, double-blind, placebo-controlled neuroprotection trial in a population of neonates with CHD requiring surgical repair or palliation utilizing DHCA. An extensive 5,500 item database was generated and included pre-surgical, intra- and post-operative variables. Stepwise logistic regression evaluated 49 presurgical variables (delivery, maternal & infant related factors) producing a risk prediction model.
RESULTS: Between 7/92 and 9/97, 350 of 481 eligible infants were enrolled of whom 317 were deemed evaluable cases. The overall mortality was 52 of 317 (16.4%), unaffected by the investigational drug. The resulting model contained information on 4 presurgical categories: (i) cardiac anatomical classification (two vs single ventricle, with/without arch obstruction), (ii) 1 min. Apgar score (≤5 vs >5), (iii) presence of named genetic syndrome or chromosomal abnormality and (iv) age at hospital admission for surgery (≤5 or >5 days). Mortality for two ventricle repair was 4 of 129 (3.1%). Mortality for single ventricle palliation was 48 of 188 (25.5%) but this rate was significantly increased by the presence of low Apgar score, genetic diagnosis and older age at admission. The logistic regression model based on the 4 categories resulted in a prediction accuracy of 81%.
CONCLUSIONS: In this population, much of the force of mortality is determined by conditions that exist pre-operatively. The identification of high risk subgroups may impact family counseling, therapeutic intervention and risk stratification for future study designs, (funded by NIH contract NS-NO1-2315)
*By Invitation 29. Simplified Single Patch Technique for the Repair of Atrioventricular Septal Defect Ian A. Nicholson*, Graham R. Nunn*, Gary F. Sholler*, Richard E. Hawker*, Stephen G. Cooper* and Kai C. Lau*, Westmead, Australia Sponsored By: Lawrence H. Cohn, M.D., Boston, Massachusetts Discussant: John W. Brown, M.D., Indianapolis, IN
OBJECTIVE: Due to the complexity of traditional one and two patch techniques for the repair of complete atrioventricular septal defect we modified our repair technique to avoid the use of any ventricular septal patch material. We report our prospective experience with this simplified one patch technique.
METHODS: Forty seven consecutive patients between September 1995 and August 1998 underwent repair using this technique without modification. All patients were repaired by direct suturing of the common atrioventricular valve leaflets to the crest of the ventricular septum . No division of valve leaflets was necessary. A single pericardial patch was used to close the defect in the atrial septal component. Follow-up included electrocardiography and echocardiographic assessment of ventricular function, AV valve function and the adequacy the left ventricular outflow tract.
RESULTS: There were two deaths (4%), only one cardiac related, in the series. There were 17 males and 30 females. Mean age at repair was 5.6 months (median 3.4 months). Associated lesions were repaired in 19 patients (40%). Mean follow-up was 1.85 years ( median 1.9 years). There was no heart block. There were no significant residual ventricular septal defects detected and no left ventricular outflow tract obstruction seen on echocardiography in any patient to date. Mitral valve status post-operatively was assessed as no incompetence in 13 (28%) patients , minimal in 19 (40%), mild in 12 (26%) and moderate in 3 (6%).
CONCLUSIONS: Therepair of complete atrioventricular septal defect by direct suturing of the atrioventricular valve leaflets to the crest of the ventricular septum using a single patch technique greatly simplifies the repair and does not lead to left ventricular outflow tract obstruction nor interfere with valve function.
*By Invitation 30. Lung Transplantation in Very Young Infants Charles Burford Huddleston, George B. Mallory*, Stuart C. Sweet*, Aaron Hamvas* and Eric N. Mendeloff*, St. Louis, Missouri Discussant: Thomas L, Spray, M.D., Philadelphia, PA
OBJECTIVE(s): There are rare congenital pulmonary parenchymal and pulmonary vascular diseases that occur in infants resulting in the death of these otherwise normal infants even with aggressive medical therapy. In these circumstances, lung transplantation (LTX) offers the only effective treatment.
METHODS: We reviewed our experience with LTX in infants presenting at less than 6 months of age with either end-stage pulmonary parenchymal or pulmonary vascular disease. 25 infants were listed for LTX at an average age of 67 ± 52 days (range = 8-169 days). All were mechanically ventilated and 18 had been so since birth; 12 infants required ECMO and 5 others required high frequency oscillating ventilator prior to transplantation. 7 patients died while awaiting donor organs and thus 18 were transplanted, forming the basis for this review.
RESULTS: The average age at transplant was 104 ± 44 days; the average weight was 4.9 ± 1.6 kg. There were 6 early deaths. The 12 surviving hospitalization were ventilated 24 ± 21 days and had an average post-LTX hospital stay of 58 ± 33 days. The followup for these survivors is 2.6 ±1.8 years (range = 0.5-5 years). Transbronchial biopsies as part of a surveillance protocol or due to clinical indications revealed only 2 episodes of acute rejection (A2 or greater) and only one patient out of the 12 early survivors (8%) has developed bronchiolitis obliterans over an average followup of 2.6 ± 1.8 years. One required re-transplantation for severe respiratory failure following sepsis. Somatic growth has been at eh 20th percentile for length and 25th percentile for weight. There have been 2 late deaths for an overall survival of 56%.
CONCLUSIONS: Although high risk, LTX for infants with end-stage pulmonary parenchymal and pulmonary vascular disease is feasible. Acute rejection and bronchiolitis obliterans have not posed significant problems in early followup.
*By Invitation 31. Improved Results with Selective Management in Pulmonary Atresia with Intact Ventricular Septum Marjan Jahangiri*, David Zurakowski*, David P. Bichell*, John E. Mayer, Pedro J. Del Nido and Richard A. Jonas, Boston, Massachusetts Discussant: Frank L. Hartley, M.D., San Francisco, CA
OBJECTIVE: Late outcome of neonatal pulmonary atresia with intact ventricular septum remains poor in most reported series. We have followed a selective approach towards either single ventricle repair versus complete or partial biventricular repair based on the presence of right ventricular dependent coronary circulation (RVDCC) and growth of the RV.
METHODS: Forty seven patients underwent surgery between January 1991 and September 1998.
RESULTS: Sixteen (34%) patients had RVDCC with a tricuspid valve Z score of -3.0+.66 versus -2.0+.95 (p=0.002) for those without RVDCC. A systemic to pulmonary artery shunt only was performed in all patients with RVDCC with one death. Thirteen of the sixteen patients with RVDCC underwent a bidirectional Glenn at a median time of 9 months after their first operation, nine of whom have had a Fontan procedure (no death). One patient has had a 1.5-ventricle repair. In the 31 (66%) patients without RVDCC, 6 patients underwent a systemic to pulmonary artery shunt only, 23 had a shunt and right ventricular decompression and 2 had only a transannular patch. In this group, 10 patients received a 2-ventricle repair, 6 a 1.5-ventricle repair and 8 patients had a Fontan procedure. The overall actuarial survival was 97.7% at 1 month, 1 year, 5 years and 7 years.
CONCLUSIONS: If stratified well, excellent survival can be achieved in the treatment of pulmonary atresia with intact ventricular septum. This may be at the price of achieving a 1-ventricle as opposed to a 2-ventricle repair.
*By Invitation 32. Repair of Ebstein's Anomaly Associated with Bidirectional Cavopulmonary Shunt in High Risk Patients Sylvain Chauvaud*, Jean Francois Fuzellier*, Alain Berrebi* and Alain Carpentier, Paris, France Discussant: Jan M. Quaegebeur, M.D., New York, NY
OBJECTIVE: Patients suffering from Ebstein's anomaly and severely impaired right ventricular (RV) function often present with difficult postoperative course. The aim of this study is to report the use of bidirectional Cavopulmonary shunt (BCPS) associated with intracardiac repair in this high risk group.
METHODS: Since 1980, 125 patients (pts) have been operated on for Ebstein's anomaly. Only 3 pts had a tricuspid valve (TV) replacement and 122 had an intracardiac repair (ICR) using Carpenrier's technique. Among the later group, 67 pts were classified as high risk because of severe RV dysfunction and/or severe arrhythmia. This cohort was divided into 2 groups: GI (45 pts) had isolated ICR and Gil (22 pts) had ICR associated with BCPS. All pts had the same preoperative clinical pattern and age (mean 22y). The ICR was identical in all patients (TV repair and RV plication). The a trial septal defect when present was closed.
RESULTS: Operative mortality was 9.8% in the whole group, 24.4% in GI (CL 95%: 13-43) and 0% in Gil (CL 95%: 0-18) p<0.05. The main cause of mortality in GI was RV failure (5/11 deaths). Significant residual or recurrent TV insufficiency was present in 12% of both groups. However, the need for a reoperation was more frequent in GI: 11% (5/45) than in Gil: 0%, due to RV preload reduction. No deleterious effect of the BCPS was observed.
CONCLUSIONS: Bidirectional Cavopulmonary shunt associated with intracardiac repair decreased the operative mortality in high risk patients suffering from Ebstein's anomaly. It improved clinical tolerance of occasional residual TV insufficiency.
*By Invitation |
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