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Back to Annual Meeting Program
MONDAY AFTERNOON, APRIL 26, 2004
1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION - ADULT CARDIAC SURGERY (8 minutes presentation, 12 minutes discussion) North Bldg., Hall C, Metro Toronto Convention Centre Moderators: David A. FullertonR. Scott Mitchell
8. Early and Midterm Patency of Vein Grafts Performed with Symmetry ConnectonAControlled Angiographic Study Jacob Bergsland*, Runar Lundblad*, Kjell Arne Rein*, Per Snorre Ling˚as*, Rune Andersen*, Per Kristian Hoi*, Steinar Halvorsen*, Bjørn Erik Mørk*, Erik Fosse*; Oslo, Norway Discussant: John D. Puskas
OBJECTIVE: This study compared patency of vein grafts in two groups undergoing off pump coronary bypass. In "Symmetry" group proximal anastomosis were performed with "Symmetry" proximal connector and in "Sutured" group with partial occlusion and polypropylene suture.
METHODS: Two consecutive groups (total n= 46) were included. All patients had off pump bypass surgery through sternotomy by experienced surgeons. Patients received one LIMA and at least one vein graft. Proximal anastomosis were done first. Intraoperative patency was examined by flowmetry and angiogram. Postoperative angiogram was performed in most cases. Radiologists evaluated angiograms and graded graft quality : 0 ( normal graft), 1 (50-99% stenosis), 2 (occluded graft). Stenosis in the proximal part of the vein-grafts was noted.
RESULTS: 66% of LIMA - and SV -grafts were angiographically studied at the surgery. Postoperative angiograms were done in 86% of LIMA- and 80% of vein grafts after a median time of 4 months. All LIMA grafts studied were patent intra and postoperatively.
Intraoperatively 88% of "Symmetry grafts were patent and 100 % of "Sutured" grafts. The difference was not significant.
Postoperative patency was reduced in "Symmetry" group. 8% of "Sutured" grafts were totally occluded while 50% of "Symmetry" grafts were Grade 2 (p<0.01). No "Sutured" grafts were Grade 1 while 25 % of "Symmetry" had 50-99% obstruction (p< 0.01). Changes in vein grafts were localized in or close to the device. Several "Symmetry" patients underwent percutanous interventions. 25% of "Symmetry" grafts were graded 0 compared to 92% of" Sutured"(p< 0.01).
CONCLUSIONS: The introduction of "Symmetry" was met with enthusiasm because it promised less manipulation of the aorta during proximal anastomosis. This was attractive in high risk and off pump surgery and early patency rates were encouraging. In our prospective, controlled study pre- and postoperative angiograms were obtained in a high percentage of patients. LIMA graft patency was identical in both groups. While vein grafts in the control group showed only slight detoriation over time, "Symmetry" grafts frequently occluded over the first 3-6 months. In addition 25% of the open "Symmetry" grafts had significant abnormalities related to the device. These results points out that new anastomotic devices should not be introduced in routine coronary surgery until controlled studies including serial angiography have been performed.
*By Invitation 9. Surgical Treatment of Atrial Fibrillation: Predictors of Late Recurrence Sydney L. Gaynor*, Richard B. Schuessler*, Marti S. Bailey*, John P Boineau*, Marye J. Gleva*, Yosuke Ishii*, Ralph J. Damiano, Jr.; St. Louis, MO Discussant: A. Marc Gillinov
OBJECTIVE: The Cox-Maze CM) procedure was introduced 16 years ago for the treatment of atrial fibrillation (AF). Since then, four versions of this procedure have been performed, yet there has been no report comparing the long-term results of these different modifications. This study evaluates the results and predictors of late AF recurrence in 276 consecutive patients who underwent a CM procedure at our institution.
METHODS: From 1987 through June 2003, 276 patients (79 female and 197 male) underwent the CM procedure, with a mean age of 55 ± 11 years. Thirty-three patients had a CM 1,16 patients had CM II, and 197 patients had the CM III procedure. The last 30 patients underwent a modified procedure (CM IV) using bipolar radiofrequency ablation to replace a number of the surgical incisions. There were 113 patients (41%) who had a concomitant cardiac operation with the most common being a mitral valve procedure (19%) or coronary artery bypass grafting (20%). Data were analyzed by stepwise Cox-Regression analysis with pre- and postoperative variables used as covariates. Patient follow-up was conducted by questionnaire, physician examination, and electrocardiographic documentation. All patients had a minimum of 3-month follow-up following their procedure.
RESULTS: There was a significant difference in the freedom from AF recurrence between CM versions (p=0.036) (see Table). Risk factors for late AF recurrence were age at time of surgery (p=0.03), duration of preoperative AF (p=0.001), and CM version (p=0.048). There was no difference in operative mortality between the groups. Patient follow-up was achieved in 92.4% of cases with a mean follow-up time of 5.6 ± 3.6 years. There was no difference in actuarial ten-year survival between the CM I, II, and III groups being 92%, 93%, and 94%, respectively.
CONCLUSIONS: The CM procedure remains the gold standard for the treatment of AF, and has evolved over time into a procedure with high long-term efficacy and a low morbidity and mortality. The most significant predictor of late recurrence was duration of preoperative AF suggesting that earlier surgical intervention would further increase the efficacy of the procedure.
*By Invitation 10. Changes in Microvascular Perfusion Measured With OPS- Imaging Correlate With Neuropsychologic Outcome After CPB Frank Christ*, Behin Dadasch*, Sandra Eifert*, Bruno Reichart*; Munich, Germany Discussant: John W. Mammon, Jr.
OBJECTIVE: Minor neuropsychological deficits after cardio-pulmonary bypass (CPB) occur in up to 80% of patients undergoing heart surgery and are mostly due to hypoperfusion, macro- and microemboli. The purpose of our study was to see whether there is a correlation between changes in microvascular perfusion during CPB, detectable with OPS (Orthogonal Polarization Spectral) -imaging, and the severity of the patients postope.
METHODS: We visualized the microcirculation using OPS-Imaging in 29 patients undergoing open-heart surgery to examine the changes in microvascular perfusion during CPB. Microvascular diameter (DIA [pm], red cell velocity (VEL [mm/s]) and functional capillary density (FCD [cm/cm2]) were measured. Images were taken from the sublingual mucosa immediately after induction of anaesthesia (T1), at the beginning of CPB (T2), during me last 30 minutes of CPB (T3), during decanulation of the aorta (T4) and one hour after reperfusion.
Pre-and postoperatively we evaluated the patients neuropsychologic status with 4 standartised tests.
RESULTS: None of the patients showed severe neuropsychologic injury, however, all had some minor or moderate deficits. Thus we divided them into 2 groups according to the severity of the neurocognitive changes; group 1 (n=22) with minor and group 2 (n=7) with moderate deficits. DIA was significantly increased in both groups at T2 (42,3 ± 20,0 and 47,l ± 21,6) compared to T1 (39,5 ± 21,3 and 40,4 ± 19,7), VEL was significantly decreased in group 1 at T2 (0,57 ± 0,2) compared to T1 (0,75 ± 3,9) and FCD was significantly decreased in both sub-populations at T3 (133,1 ± 10,0 and 116,8± 7,5) compared to T1 (144,9 ± 13,7 and 143,0 ± 12,8), recovering to preoperative values at T5 (148,9 ± 14,3 and 141,5 ± 5,7).
CONCLUSIONS: Microvascular blood flow was well maintained during CPB. However, since the decrease in FCD was more pronounced in group 2, we suggest a correlation between impaired microvascular blood flow and neuropsychological deficits detectable with OPS-Imaging.
2:45p.m. INTERMISSION - VISIT EXHIBITS North Bldg., Exhibit Hall Metro Toronto Convention Centre
*By Invitation 3:20 p.m. SIMULTANEOUS SCIENTIFIC SESSION - ADULT CARDIAC SURGERY North Bldg., Hall C, Metro Toronto Convention CentreModerators: David A. FullertonR. Scott Mitchell
11. Results of Aortic Valve Replacement with the Toronto SPY Bioprosthesis at 10 Years Tirone E. David, Christopher M. Feindel*, Joanne Bos, Susan Armstrong*, Joan Ivanov*; Toronto, ON, Canada Discussant: John G. Byrne
OBJECTIVE: To examine the clinical outcomes of aortic valve replacement (AYR) with the Toronto SPY bioprosthesis at 10 years.
METHODS: The Toronto SPV was used for AYR in 332 patients from July 1991 to December 2001. There were 231 men and 101 women whose mean age was 64.5±10.3 years. Aortic stenosis was present in 78% of patients, coronary artery disease in 37%, and left ventricular ejection fraction (EF) <40% in 13%. Patients were interviewed annually and had a Doppler echocardiographic study. The mean follow-up was 6.3±2.9 years and was complete.
RESULTS: The table below shows the freedom from morbid events at 5 and 10 years of follow-up. There were one operative, 7 valve-related, 14 cardiac and 29 non-cardiac deaths. Sixteen patients developed echocardiographic evidence of bioprosthetic dysfunction and 15 were re-operated on. Cox regression analysis revealed that age/5-year increment had a risk ratio of 0.73,95% CI 0.6-0.9. At the latest follow-up, the mean systolic gradient across the valve (6.8±4.4 mmHg) and the effective orifice area (2.0±0.6 cm_) and remained unchanged throughout the observation. Aortic insufficiency was progressive in 14% of patients and absent in 86% during the follow-up. Most patients were in NYHA functional classes 1 and II and only 7% were in class III at the latest follow-up.
CONCLUSIONS: This bioprosthesis has provided excellent symptomatic improvement and survival during the first decade after implantation, and is durable in patients >65 years of age. *By Invitation 12. Does Reporting of Coronary Artery Bypass Grafting Outcomes from Administrative Databases Accurately AssessActual Clinical Outcomes? Michael J. Mack, Morley A. Herbert*, Syma L. Prince*, April Simon*, Todd M. Dewey*, Mitchell J. Magee*; Dallas, TX, Zionsville, IN Discussant: T. Bruce Ferguson, Jr.
OBJECTIVE: Quality assessment of coronary artery bypass grafting (CABG) surgery has traditionally been performed using data from clinical databases. Increasingly, administrative databases relying primarily on billing data have been employed as tools for public reporting of number of procedures and mortality rates, implying an assessment of quality. The accuracy of these sources and their usage has not been confirmed.
METHODS: We analyzed the data of all patients undergoing CABG surgery in one hospital between 1999 and 2001. This information is collected before, during and after the surgery and hospital stay by designated people involved with the patient care and then entered into a clinical database (STS National Database). This data was compared for the hard endpoints of number of procedures and mortality with administrative data as reported by the federal government (MEDPAR), state government (Texas Health Care Information Council (THCIC)), hospital system (HCA Casemix Database), and an internet web site (Healthgrades.com). Data was analyzed based upon population reported, definitions used, risk assessment algorithms, and case volumes.
RESULTS: The table compares procedure volume and mortality rates on the same group of patients as reported by the different groups. Using the audited STS database as standard, case volumes varied by as much as 46% and mortality by as much as 76% depending upon the reporting agency. The disparate risk adjusting algorithms used produced different variances between the data sets. Despite the sources labeling the results as 1999-2001, they use different reporting periods either calendar years or Oct-Sept. time periods.
CONCLUSIONS: Wide variability of reported outcomes is seen in various data sets in the hard endpoints of number of procedures performed and mortality making it impossible for the non-clinician to make an informed decision. Definition of quality as defined by these data sets is questionable.
*By Invitation 13. Valve Sparing Aortic Root Replacement (Yacoub Remodeling) in Bicuspid Aortic Valves - A Reasonable Option? Diana Aicher*, Frank Longer*, Anke Kissinger*, Henning Lausberg*, Hans-Joachim Schafers; Homburg, Germany Discussant: Christopher M. Feindel
OBJECTIVE: Aortic dilatation occurs in many patients with bicuspid aortic valves (BAY) and may have an adverse impact on the results of valve repair. We added aortic root replacement using the remodeling technique of Yacoub- originally designed for tricuspid valves (TAV) - to BAY repair for treatment of the dilated root. We compared our results of root remodeling in BAY with those achieved in TAV.
METHODS: From 10/1995 to 8/2003, 175 patients underwent remodeling of the aortic root for aortic regurgitation and proximal aortic dilatation. A BAY (group A) was seen in 56 patients, a TAV in 119 patients (group B). Patients were younger in group A (A 53±11 years; B 64±13 years p<0,001). There were more emergency procedures for acute dissection in group B (A 4/56=7%; B 27/119=23% p=0,012). Sinu-tubular and aorto-ventricular diameters were identical in both groups (A: 40mm ± 0,58; 27mm ± 0,17; B: 4lmm ± 0,64; 26mm ± 0,16). Correction of cusp prolapse by suture plication (A 36/56=64%; B 41/119= 35% p=0,0003) or triangular resection (A 20/56=36%; B 1/119= 0,8% p<0,0001) was significantly more often performed in group A. Concomitant procedures were proximal arch (A 13/56=23%; B 65/119=55%; p< 0,001) or total arch replacement (A 0/56; B 13/119= 11%;p=0,010) and coronary bypass (A 8/56=14%; B 35/119=29%; p=0,048). Transthoracic echocardiography was performed at 1 week, 6 and 12 months and every 12 months thereafter. Cumulative follow-up was 5669 patients months (mean 34±23).
RESULTS: Mortality in group B was 5,4% (5/92; 1,7%- 12%/ 95% CL) after elective and 11,1% (3/27; 2,3%-29%/ 95% CL) after emergency operations. No patient died in group A. Mean systolic gradients at 1 year were 4,8mmHg ± 2,1 (group A) versus 4,OmmHg ± 2 (group B) and at 5 years 4,5mmHg ± 2,3 (group A) versus 3,9mmHg ±2,2 (group B). Actuarial freedom from aortic regurgitation grade 2 or higher after 1/ 5/ 8 years was 98%/ 95%/ 95% in group A and 95%/ 83%/ 78% in group B (p=0,10). Freedom from reoperation at 1/5/8 years was 98% in group A and 98%/ 98%/ 90% in group B (p=0,86).
CONCLUSIONS: Valve-sparing aortic replacement using root remodeling can be applied for the combination of aortic dilatation and regurgitant BAY The hemodynamic function of a repaired BAY is almost identical to tricuspid anatomy. Up to 8 years valve stability is at least identical to that of TAV, and freedom from repair failure and reoperation is better than results published for isolated BAY repair.
*By Invitation 14. Does the Risk of Repeat Aortic Valve Replacement Justify the Use of Tissue Prostheses in Younger Patients? D Dean Potter, Jr.*, Thoralf M. Sundt III, Kenton J. Zehr*, Joseph A. Dearani, Richard C. Daly, Charles J. Mullany, Christopher G.A. McGregor, Fransico J. Puga, HartzeU V. Schaff, Thomas A. Orszulak; Rochester, MN Discussant: Robert W. Emery
OBJECTIVE: The choice between mechanical and bioprosthetic valves must balance the risks of thromboembolism and anticoagulant associated hemorrhage against the risk of reoperation for prosthetic valve deterioration. Improved durability of bioprosthetic valves has encouraged their use in younger patients. Our objective was to examine the risk of repeat aortic valve replacement (AYR) in the current era.
METHODS: Between 1/1993 and 1/2001, 162 patients underwent repeat AYR ± coronary artery bypass (CAB) while 2290 underwent primary AVR±CAB. The repeat and primary groups were similar in gender (women 37% versus 37%), preoperative functional class (2.8±1 versus 2.8±1), and ejection fraction (58%±15% versus 57%±15%). Prior prostheses were bioprosthetic in 75 (46%), mechanical in 61 (38%), homograft in 24 (15%), and autograft in 2(1%). Mean time to reoperation was 9-7±6.8 years.
RESULTS: Early mortality for repeat AVR±CAB (8/162, 5%) was not statistically different from primary AVR±CAB (71/2290,3%, P=0.20). Patients undergoing repeat AVR±CAB were younger than primary AVR±CAB (64±15 years versus 70±13, P<0.001). Endocarditis was more common in the repeat group (22% versus 3%, P<0.001); when endocarditis was excluded from the analysis, early mortality for repeat and primary AVR±CAB was 4/126 (3.0%) and 70/2231 (3.0%), respectively. For all patients, multivariate predictors for early mortality were advanced preoperative functional class (P<0.001, odds ratio 2.3), prosthetic valve endocarditis (P=0.005, odds ratio 8.9), and peripheral vascular disease (P=0.008, odds ratio 2.0). Neither reoperation nor advanced age were independent predictors of early mortality. After adjusting for the significant predictors identified by the multivariate model, there was no difference in early mortality between the groups (P=0.94).
CONCLUSIONS: The risk of repeat AYR is low, and similar to primary AYR. These data support the expanded use of bioprosthetic valves in younger patients.
*By Invitation 15. Repair of Functional Tricuspid Valve Insufficiency Using a Partial Prosthetic Ring Annuloplasty or a Partial Suture Annuloplasty: 15-Year Experience of Two Reconstructive Techniques Rainald Seitelberger*, Jan Bialy*, Roman Gottardi*, Ernst Wolner; Vienna, Austria Discussant: Neal D. Kon
OBJECTIVE: Surgical repair for funtional tricuspid insufficiency (FTI) is associated with a high perioperative mortality and poor long-term survival, especially in combination with additional cardiac procedures. Although several basic types of tricuspid annuloplasty have been introduced over the last decades, little is known about possible differences in their influence on long-term outcome and their efficacy to prevent recurrence of insufficiency. This study retrospectively compares perioperative and long-term outcome of the two most common reconstructive techniques for FTI: partial prosthetic ring annuloplasty (PPRA) and partial suture annuloplasty (De Vega, PSA).
METHODS: The study population includes 194 adult patients, who underwent repair of FTI of at least functional Grade II between November 1984 and August 2003. 144 patients (mean age:63±16 years, male/female:50/94) received a PPRA and 50 patients (mean age: 65±15 years, male/female: 16/34) received a PSA. Additional cardiac procedures were performed in all patients. The mean follow-up was 8,23±4,25 years for the PPRA (range: 0,1-15,6 years) and 7,84±4,1 years for the PSA-group (range: 0,1-12,84 years).
RESULTS: According to preoperative anamnestic data, patients receiving a PSA had a slightly higher operative risk than those with a PPRA (Euroscore: 9,36±2,4% vs 8,4±3,5%). Accordingly, the in-hospital mortality was higher in the PSA- than in the PPRA-group (16% vs 9,7%). Recurrence of tricuspid insufficiency of at least Grade II at latest follow up was substantially higher in the PSA as compared to the PPRA-group (36 vs 4,9%, p<0,001). In addition, 1- and 10-year survival was significantly lower in patients receiving a PPRA (82% and 66%) as compared to those receiving a PSA (75% and 32%). Clinical evaluation at latest follow up revealed that more patients with a PPRA were in NYHA-functional Class I and II (83%) than those undergoing a PSA (66%, p<0.05).
CONCLUSIONS: The results of this retrospective study clearly demonstrates that in patients with functional tricuspid insufficiency, PPRA is superior to PSA with regard to early- and late mortality, recurrence of insufficiency and functional status. It is therefore recommended as the method of choice in patients with FTI.
5:00 p.m. ADJOURN
7:00 p.m. ATTENDEE RECEPTION Eternal Egypt: Masterworks of Ancient Art from the British Museum Royal Ontario Museum (separate subscription)
*By Invitation MONDAY AFTERNOON, APRIL 26, 2004
1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION - GENERAL THORACIC SURGERY (8 minutes presentation, 12 minutes discussion) North Bldg., Rm 105, Metro Toronto Convention Centre Moderators: Larry R. KaiserCarolyn E. Reed
16. The Impact of Chemoradiotherapy on Pulmonary Morbidity After Esophagectomy Ara A. Vaporciyan*, Boon K. Lee*, James D. Cox*, Stephen G. Swisher*, Ritsuko Komaki*, W. Roy Smythe*, Garrett L. Walsh*, David C. Rice*, Jack A. Roth, Joe B. Putnam, Jr.; Houston, TX Discussant: Thomas W. Rice
OBJECTIVE: Esophagectomy for esophageal cancer remains a high risk procedure with perioperative mortality, mostly due to pulmonary morbidity, reported between 2% and 10%. Improved long-term survival with preoperative Chemoradiotherapy (pCRT) has been reported in a subset of esophageal cancer patients who achieve a pathologic response. However, an increase in pulmonary morbidity after esophagectomy in patients who received pCRT, may offset any potential oncologic benefit. We examined the impact of pCRT, and other pre and perioperative factors, on the incidence of postoperative major pulmonary events (MPE: pneumonia or acute respiratory distress syndrome) after esophagectomy.
METHODS: A prospectively collected database identified all patients undergoing esophagectomy for primary esophageal cancer from 1/97 to 6/03. Only patients who received all their therapy at our institution were included. The influence of pCRT, the total radiotherapy dose, an estimate of the radiation dose to the lung, and common pre and perioperative factors on the incidence of MPE were examined using univariate analysis. Any significant factors (defined as p<0.25) were included in a multivariable analysis.
RESULTS: A total of 245 patients met inclusion criteria. 141 received pCRT. The overall incidence of MPE was 20.8% (51). Mortality was significantly increased in patients who developed a MPE (18.6% versus .6%, p<0.01). Use of pCRT, the total dose of radiotherapy (as a continuous or categorical variable), or the estimated dose of radiotherapy delivered to the lung (the "off-cord dose"; as a continuous or categorical variable) were not associated with MPE by univariate analysis. The factors that were associated with an increased risk of MPE by univariate and subsequent multivariable analysis are shown in the table below.
CONCLUSIONS: The use of pCRT was not associated with an increased risk of MPE after esophagectomy at our institution. In addition, the dose of radiotherapy or the delivery technique did not increase the risk of MPE using conventional measurements of radiation dosing. Factors that were associated with MPE in this population include the timing of smoking cessation, length of surgery and use of intraoperative transfusions.
*By Inviation 17. Do Combined PET/CT Scans Reliably Predict Pathologic Staging in Resectable Primary Non-Small Cell Lung Cancer? Stephen C. Yang*, Kristin M. Yang*, Malcolm V. Brock*, David P. Mason*, Carmen M. Roig*, Richard L. Wahl*, Rex C. Yung*, Julie Brahmer*, David S. Ettinger*; Baltimore, MD Discussant: Bryan F. Meyers
OBJECTIVE: Isolated PET scanning is widely utilized to evaluate and stage lung nodules suspicious for cancer. However, its exact role and ability to supplant surgical staging remains to be defined. Since the technology and sensitivity of these scanners have advanced, this study sought to determine the accuracy of combined PET/CT in staging patients with potentially resectable NSCLC.
METHODS: This was a single institution study of prospectively collected data from 133 patients between July 2001 and October 2003. All patients had proven or suspected NSCLC that was potentially resectable initially, and underwent combined PET/CT at this Institution's scanner (GE Corp.).
PET/CT identified 19 (14%) patients with potentially advanced disease. Five (4%) had biopsy proven distant metastatic disease and excluded. Tissue confirmation of N2 disease by medias-tinoscopy precluded surgical resection in 10 (8%); 4 were later resected after induction chemotherapy and included in this study. Also included were the remaining 4 patients who had negative mediastinoscopy despite PET/CT findings. All patients with a final diagnosis of NSCLC had lymph node sampling/dissection at the time of surgery.
RESULTS: There were 122 subjects in the study population (median age 68, 66 men). Based on pathology after surgery, PET/CT correctly identified 94 of 100 malignant lesions, but only 8 of the 22 benign masses.
For the 100 cancer patients, PET/CT was correct regarding pathologic nodal (N) status in 61 patients (56 with NO, 2 with N1, and 3 with N2 disease). However, 18 patients had pathologically positive nodes (9 each N1 and N2) that were not seen on PET/CT (false negative). Interestingly, PET/CT findings overstaged pathologic N status in 20 patients (5 N1_NO, 8 N2_NO, 2 N3_NO, and 5 N2_N1), while understaging 19 (9 NO_N1, 9 NO_N2, and 1 N1_N2). Tumor and N status data analysis are tabulated below.
CONCLUSIONS: These results show that integrated PET/CT is highly sensitive in identifying malignant lesions, but less accurate for benign nodules. It is good in predicting NO disease, but overall N staging remains extremely difficult, especially distinguishing N1 from N2 disease. It has proven useful in detecting distant metastatic disease which obviates surgical resection. Although our results may be comparable to PET scan alone, we feel that combination PET/CT has imaging advantages and should be included in the preoperative staging of potential patients with NSCLC, but not replace surgical staging of mediastinal nodal disease.
*By Invitation 18. Improved Survival After Living-Donor Lobar Lung Transplantation Hiroshi Date*, Motoi Aoe*, Yoshifumi Sano*, Itaru Nagahiro*, Kalsumasa Miyaji*, Keiji Goto*, Masaaki Kawada*, Shunji Sano*, Nobuyoshi Shimizu*; Okayama, Japan Discussant: John C. Wain, Jr.
OBJECTIVE: The survival after living-donor lobar lung transplantation (IDLLT) has been reported to be similar to that after cadaveric lung transplantation. The purpose of this study was to summarize our 5-year experience of LDLLT for critically ill patients.
METHODS: From October 1998 to August 2003, LDUT was performed in 5 children and 19 adults. Mean age was 29.0 years (range 8 to 53 years). Diagnoses included primary pulmonary hypertension (n = 9), idiopathic interstitial pneumonia (n = 5), bronchiolitis obliterans (n = 3), bronchiectasis (n = 3), lymphangioleiomyomatosis (n = 2), cystic fibrosis (n = 1), Eisenmenger's syndrome (n = 1). All recipients were oxygen dependent, 17 were unable to walk and 4 were on a ventilator. Intensive postoperative management included slow weaning from mechanical ventilator, relatively low dose immunosuppressant, careful clinical rejection monitoring with no transbronchial lung biopsy, routine use of inhaled nitric oxide, aggressive physiotherapy and frequent fiberoptic bronchoscopy.
RESULTS: The average duration of mechanical ventilator was 14.6 days, ICU stay was 23.1 days and hospital stay was 61.0 days. Clinically judged acute rejection occurred 1.45 episodes/ patient during the first month, but no infection was encountered. Their mean vital capacity (1920 ml or 68.7% of predicted) and arterial oxygen tension on room air (99-7 mmHg) were excellent at one year. Three patients (12.5%) developed unilateral bronchiolitis obliterans 10, 12, 42 months after LDLLT. Their FEV1 significantly decreased (2250 ml to 1250 ml, 1650 ml to 780 ml, 1250 ml to 800 ml) but reached plateau within 6 months. All 24 recipients are currently alive with a follow-up period of 2-60 months (mean 21.3 months, Figure). All donors have returned to their previous life styles.
CONCLUSIONS: LDLLT can be applied to both pediatric and adult patients with various lung diseases. With intensive postoperative care, it may provide better survival than conventional cadaveric lung transplantation.
*By Invitation 19. Esophageal Adenocarcinoma in African-Americans: A Clinicopathological Variant of Esophageal Cancer? Pierre Theodore*, Craig Hooker*, Eric Syphard*, Leonard Sowah*, Arlene Forastiere*, Elizabeth Montgomery*, David Mason*, Stephen Baylin*, James Herman*, Stephen Yang*, Malcolm V. Brock*; Baltimore, MD Discussant: Carolyn E. Reed
OBJECTIVE: Recent increases in the incidence rates of esophageal adenocarcinoma in the U.S. have largely been confined to Caucasian males. Among African-Americans (AA), esophageal cancer is most commonly of squamous cell histology. There are only a few reports comparing the Clinicopathological characteristics of AA and Caucasian patients with adenocarcinoma.
METHODS: From 1984 to 2002, 574 patients with esophageal adenocarcinoma presented to a single institution in a metropolitan area with a large AA population. Of these, only 3.5% (20/574) were AA which represents one of the largest experiences of AA with adenocarcinoma reported. Clinical and pathological data as well as overall survival were compared between AA and Caucasian esophageal adenocarcinoma patients.
RESULTS: Median age was 62 years in AA (range 36-83) and 64 years in Caucasians (range 19-94) with a male:female ratio of 3:1 and 7:1 respectively. Compared to Caucasians, AA were significantly less likely to have endoscopically proven Barrett's metaplasia (57% (317/554) vs. 20% (4/20); p=0.001) and did not have as strong a history of gastroesophageal reflux disease (GERD) (54% (301/554) vs. 35% (7/20);p=0.09). The rates of cigarette smoking did not differ significantly between the two groups. AA were significantly more likely to present with more advanced stage disease with 45% (9/20) of patients presenting in stage IV versus 22.2% (123/554) of Caucasians (p=0.05). AA were also significantly less likely to have surgical resection than their Caucasian counterparts (30%(6/20) vs. 63%(351/554);p<0.01). Overall survival rates in AA were significandy worse than Caucasians with no AA patient surviving more than 3 years.
CONCLUSIONS: Esophageal Adenocarcinoma in AA is rare, less male-sex predominant, less likely to be associated with GERD and Barretts metaplasia, but is associated with worse survival compared to esophageal adenocarcinoma in Caucasians. The pathological features and demographics of adenocarcinoma in AA suggest an etiology separate from the Barrett's esophagus-dysplasia-carcinoma sequence,
3:05 p.m. INTERMISSION - VISIT EXHIBITS North Bldg., Exhibit Hall Metro Toronto Convention Centre
*By Invitation MONDAY AFTERNOON, APRIL 26, 2004
3:40 p.m. SIMULTANEOUS SCIENTIFIC SESSION -GENERAL THORACIC SURGERY North Bldg., Rm 105, Metro Toronto Convention CentreModerators: Larry R. KaiserCarolyn E. Reed
20. Resectional Surgery Combined with Chemotherapy Remains the Treatment of Choice for Multidrug Resistant Tuberculosis Yuji Shiraishi*, Naoya Katsuragi*, Makoto Kurai*, Nobumasa Takahashi*, Yutsuki Nakajima*; Tokyo, Japan Discussant: Andrew A. Conlan
OBJECTIVE: Multidrug resistant tuberculosis remains a significant health problem. The best available treatment of multidrug resistant tuberculosis has been the combination of pulmonary resection and antituberculous chemotherapy. This study was aimed to evaluate the results of resectional surgery combined with chemotherapy for multidrug resistant tuberculosis in the current century.
METHODS: Between 1983 and 2002, 87 patients underwent 95 pulmonary resections for multidrug resistant tuberculosis. Of these patients, 30 patients (34%) were operated on from 2000 to 2002, which were reviewed in this study. All patients shed strains resistant at least to isoniazid and rifampin upon admission, and were treated with multidrug regimens for at least three months prior to operation. Indications for surgery were persistent positive sputum despite chemotherapy and high risk of relapse even though sputum conversion was achieved by chemotherapy. There were 33 pulmonary resections because three patients underwent staged multiple resections. Procedures included completion pneumonectomy (n=1), pneumonec-tomy (n=11), lobectomy (n=17), and segmentectomy (n=4). The bronchial stump was reinforced with a latissimus dorsi muscle flap in 29 resections. All patients were kept on multidrug regimens for at least one year postoperatively.
RESULTS: Operating time ranged from 140 to 623 minutes (median, 270 minutes). The median intraoperative blood loss was 180 ml (range, 10 to 1330 ml). There was no operative mortality. All patients attained negative sputum status after the operation. Major complication occurred in seven patients. Bronchopleural fistula with empyema, which resulted from recurrent disease at the bronchial stump, occurred in two patients. A space problem occurred in five patients, being treated by thoracoplasty. Relapse of multidrug resistant tuberculosis occurred in three patients. Of these, two patients had a relapse at the bronchial stump and underwent open window dioracostomy. The remaining one had a relapse in the post-lobectomy space, being successfully treated by completion pneumonectomy following open window thoracostomy. Twenty-eight patients (93%) were free from disease with a median follow-up of 26 months (range, 9 to 44 months).
CONCLUSIONS: An increasing number of patients with multidrug resistant tuberculosis are requiring resectional surgery in the 21st century. Pulmonary resection combined with chemotherapy achieves high cure rates with acceptable morbidity, and remains the treatment of choice for multidrug resistant tuberculosis.
*By Invitation 21. Surveillance CT Scans Following Complete Resection for Non-small Cell Lung Cancer: Analysis of Results and Costs Robert J. Korst*, Heather T. Gold*, Jeffrey L. Port*, Paul C. Lee*, Nasser K. Altorki; New York, NY Discussant: Keith S. Naunheim
OBJECTIVE: Patients with completely resected nonsmall cell lung cancer (NSCLC) are at risk for developing recurrent or new primary lung cancer. We sought to determine the utility of and costs associated with surveillance computed tomography of the chest and upper abdomen (CT) for the detection of recurrent or new primary lung cancer in patients with previously resected NSCLC.
METHODS: We reviewed the records of all patients who presented for followup in 2002 with completely resected NSCLC. To be included in the cohort, patients had to be disease-free with no signs/symptoms suggestive of recurrent or new primary disease at the beginning of 2002. Data collected included demographics, initial tumor stage, the radiologists' and surgeons' impressions of any surveillance CT scans performed in 2002, and the results of any further tests instigated by CT results. Surveillance CT scans were defined as only those performed in patients with no signs/symptoms of lung cancer. The cost associated with surveillance CT scans combined with any resulting studies/therapies for the entire cohort was then calculated using Medicare fee schedules.
RESULTS: 213 patients met the criteria for entry into the study cohort, including 141 undergoing a total of 168 surveillance scans. 105 scans were interpreted as abnormal (nodules, adenopathy or pleural fluid) by the radiologist, but in only 32 was the surgeon suspicious for recurrent or new primary lung cancer. 43 additional diagnostic tests/procedures were performed in these 32 patients, including biopsy attempts in 18. Recurrent or new primary lung cancer was diagnosed in 16/32 patients with suspicious scans, with 6 undergoing a second complete resection. 9 patients developed recurrence in 2002 which was detected independent of surveillance CT scans (interval cancers). The total cost associated with the performance of surveillance scanning for the entire cohort combined with subsequent testing/therapies was $602,328. If surveillance CT scans were not performed in these patients and all new lung cancer was allowed to progress to stage IV prior to detection, the total cost of treatment for the 16 patients with new primary or recurrent lung cancer would have been $789,008.
CONCLUSIONS: From these data, we conclude that (1) Postoperative surveillance CT scans are read as abnormal by the radiologist in nearly 2/3 of patients after complete resection for NSCLC. (2) The surgeon's impression of suspicious findings on the CT scan is only 50% specific for recurrent or new primary lung cancer. (3) Resectable lung cancer can be detected using surveillance CT scans after previous resection for NSCLC, and, (4) The total costs associated with surveillance CT scanning may compare favorably with the alternative of no postoperative surveillance.
*By Invitation 22. Selective Management of Intrathoracic Anastomotic Leak After Esophagectomy Juan A. Crestanello*, Claude Deschamps, Stephen D. Cassivi*, Francis C. Nichols III*, Mark S. Allen, Peter C. Pairolero; Rochester, MN Discussant: Richard E Heitmiller
OBJECTIVE: To analyze our experience with management of intrathoracic anastomotic leak after esophagectomy
METHODS: All patients who had intrathoracic anastomotic leakage after esophagectomy were reviewed. Management and factors affecting outcome were analyzed.
RESULTS: Between March 1993 and March 2003, 761 patients had esophagectomy with intrathoracic anastomosis at our institution. Forty-eight patients (6.3%) developed an anastomotic leak. Twenty-four patients (50%) had a contained leak on contrast studies. Twenty-seven patients (56%) were managed non-operatively. The remaining 21 patients (44%) required surgical intervention that included primary anastomotic repair in 19 and esophageal diversion in 2. A single reoperation was done in 16 patients, 2 in 4, and 4 in 1. Median hospitalization was 31 days (range, 11 to 97 days) in die surgical group and 21 (range 10 to 42 days) in die non-operative group. Four patients died (8.5%), 3 in the surgical group (15%) and one in die non-operative group (3.7%). Cause of death was sepsis in 3 patients and congestive heart failure in one. At last follow up (median, 13 months; range, 1-122 months), 15 patients in the surgical group (83%) were eating a normal diet; 5 (28%), however, required at least one dilatation. Similarly, 22 patients in the non-operative group (85%) were eating a normal diet and 9(35%) required at least one dilatation.
CONCLUSIONS: Intrathoracic anastomotic leaks after esophagectomy are associated with significant mortality. Contained leaks can often be managed non-operatively. Long- term functional results are satisfactory and similar for both non-operative and operative management. Total diversion is unnecessary in the majority of patients.
*By Invitation 23. The U.S. Experience with Lung Transplantation for Pulmonary Lymphangioleiomyomatosis Jacques Kpodonu*, Malek G. Massad, John C. Lee*, Rabih Chaer*, Alexander N. Evans*, Amitra Caines*, Michael Fitzgerald*, Norman Snow, Alexander Geha; Chicago, IL Discussant: Walter Weder
OBJECTIVE: Pulmonary Lynphangioleiomyomatosis (LAM) is a rare disease of unknown origin that predominantly affects women in their reproductive years as well as patients of both sexes with tuberous sclerosis. The disease leads to progressive deterioration of lung function and ultimately death. Lung transplantation has been utilized as a therapeutic option that may improve survival. In this study, we tapped the United Network for Organ Sharing (UNOS) database to analyze the pooled data from 20 U.S. lung transplant centers. Our aim was to evaluate the outcome of patients with LAM who underwent lung transplantation with the aim of making some recommendations regarding patient management.
METHODS: We conducted a retrospective review of 84 patients who underwent lung transplantation for end stage pulmonary LAM between 1987-2003 and were reported to UNOS.
RESULTS: All patients were women with a mean age of 42 years (range 24-65 years). Forty-seven patients (56%) received double-lung and 37 (44%) received single lung transplants. The mean cold ischemia time was 4.7 hours. The 30-day mortality was 5%. There were 2 intra-operative deaths. The cause of death among the 4 patients who died within the first 30 postoperative days was acute lung injury in 3 patients and a cardiovascular event in 1. There were 20 late deaths (>30 days post-transplant). Of those, 5 were from multi-system organ failure, 4 from pulmonary complications and 3 from aspergillus infection. Chronic rejection and bronchiolitis obliterans accounted for two deaths each. Four patients (5%) were re-transplanted. Follow up was complete on all 84 patients. The mean follow up was 37 months (range 0-128 months). The actuarial Kaplan-Meier survival at 1-year was 85.2%, at 3-vears 78.3% and at 5-years 65.4%. There was a statistically significant difference in survival among patients with organ ischemia time 4 hours compared to those with > 4 hours (70% vs. 62%, p<0.05). Survival was also affected by the recipients' age; those 40 years had a 76% survival vs. 65% for those > 40 years (p<0.05), but not by transplant eras (1987-1994 vs. 1995-2003).
CONCLUSIONS: Lung transplantation is a valuable therapeutic option for patients with end-stage pulmonary LAM, and should be considered in patients who demonstrate deteriorating lung functions and poor work effort. The operative mortality among patients who undergo lung transplantation is low, and recurrence of the disease in the lung allograft has not been reported. Lung transplantation offers survival rates that are equivalent to, if not better than, those of patients who receive lung transplantation for other pulmonary indications.
5:00 p.m. ADJOURN
7:00 p.m. ATTENDEE RECEPTION Eternal Egypt: Masterworks of Ancient Art from the British Museum Royal Ontario Museum(separate subscription)
*By Invitation MONDAY AFTERNOON, APRIL 26, 2004
1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION - CONGENITAL HEART DISEASE (8 minutes presentation, 12 minutes discussion) North Bldg., Rm 107, Metro Toronto Convention CentreModerators: Thomas L. Spray Ross M. Ungerleider
24. Outcomes of Mitral Valve Replacement in Children: A Competing Risks Analysis Fatima Kojori*, Rui Chen*, Christopher A. Caldarone*, Sandra L. Merklinger*, Anthony Azakie*, William G. Williams, Glen S. Van Arsdell*, John Coles, Brian W. McCrindle*; Toronto, ON, Canada Discussant: Vincent Tarn*
OBJECTIVE: Mitral valve replacement (MVR) in children is associated with important ongoing morbidity, risk of valve failure and death. We sought to determine factors associated with these outcomes in children after MVR.
METHODS: Demographic, anatomic, procedural and outcome data were collected for all MVR from 1973 to 2003. Competing risks analysis for each valve was used to determine time-related redo MVR (valve longevity) and death without redo MVR, and associated factors.
RESULTS: MVR was performed 138 times in 104 patients (50% male). Initial MV disease was congenital in 65%, rheumatic 13%, Shones 6%, Marians 3%, endocarditis 2%, and other in 11%. Prior MV repair had been performed in 58%. Median age at initial MVR was 5.9 years (range, birth to 19 years), with 26 patients having at least one redo MVR. Overall, there were 18 deaths after initial and 9 after a redo MVR. Of the 138 MVRs, the median ratio of valve size to body weight was 1.2 mm/kg (range, 0.4 to 6.4). Valve type was St. Jude in 37%, Bjork-Shiley 25%, Carbomedics 20%, Ionescu-Shiley 10%, Hancock 4% and other in 4%. Post-operative complications included arrhythmia in 25%, bleeding 10%, pacemaker implantation 10%, perivalvar leak 5%, and stroke 3%, with 20% requiring reoperations before discharge. Complications during follow-up of each valve included a bleeding episode in 6%, valve thrombosis 3%, TIAs 3% (no strokes), arrhythmia 16%, endocarditis 6%, and perivalvar leak in 17%. In competing risks analysis, at 10 years after MVR 30% of valves were in survivors without redo, 45% of valves had been replaced, and 25% were in patients who had died without redo MVR. Time-related mortality after any MVR was characterized by an early hazard phase superimposed on a low level of constant risk, while time-related risk of redo MVR (valve longevity) was characterized by a high immediate hazard rapidly falling to low levels which then rose progressively during follow-up. Incremental risk factors for mortality included MVR for endocarditis, presence of subaortic stenosis before MVR, longer duration of cardiopulmonary bypass, larger size of valve relative to patient weight and use of valve type other than Carbomedks valves. Incremental risk factors for redo MVR included the presence of associated aortic stenosis or regurgitation, smaller absolute size of implant, and use of Hancock or lonescu-Shiley valves. Age at MVR and initial vs. redo MVR were not significantly associated with mortality or valve longevity.
CONCLUSIONS: MVR in children is associated with important morbidity and mortality. After failed valve repair, MVR options (type and size) are often limited. High risk patients (eg. unavoidably high ratio of valve size to patient weight, preoperative subaortic stenosis) may be better managed with alternative strategies such as transplantation or single ventricle palliation.
*By Invitation 25. Mid-Term Results of Mitral Valve Repair Using Artificial Chordae in Children Kazu Minami*, Hideaki Kado*; Fukuoka, Japan Discussant: Joseph A. Dearani
OBJECTIVE: Artificial chordal replacement using expanded polytetrafluoroethylene (ePTFE) sutures has become an established component in the technique for mitral valve repair. We have applied this procedure in children and reported favorable clinical results. However, the long-term durability of this procedure following patients' growth is a great concern. Therefore, we present our series during the last 8 years to evaluate the efficacy of the mitral valve repair using artificial chordae in children.
METHODS: From April 1995 to September 2003, 40 children underwent mitral valve repair with chordal replacement using ePTFE. In all patients, the grade of mitral regurgitation (MR) was more than moderate mainly as the result of prolapse of the anterior mitral leaflet. Isolated MR was diagnosed in 26 patients. The mean age and body weight at the time of operation was 4.9 years (1 month to 17.8 years) and 15.2 kg (3.9 to 35.5 kg), respectively. The cause of prolapse was as follows; elongation of the chordae in 21, torn chordae in 14, and absence of the chordae in 5 patients. We placed 4-0, 5-0, or 6-0 ePTFE sutures as artificial chordae. According to the width of the prolapsed leaflet portion and length of chordae in opposite normal leaflet, we decided the number and length of the ePTFE sutures. The mean number and length of ePTFE was 1.4 sutures (1 to 3 sutures) and 19.2 mm/BSA (8.3 to 31.9 mm/BSA), respectively. In addition to the chordal replacement, we performed unilateral or bilateral Kay-Reed annuloplasty to correct annular dilatation in all patients. The mean follow-up period and body weight at the latest follow-up was 4.7 years (10 months to 8.2 years) and 23.8 kg (6.9 to 50 Kg), respectively.
RESULTS: There was no operative or late death. During the follow-up period, one patient required mitral valve replacement due to recurrent MR at 17 days after the initial repair. In two patients, re-mitral valve plasty was required at 2 and 5 years after the initial repair. The actuarial reoperation free rate at 5 and 10 years were 94.8% and 89.5%, respectively. Less than trivial MR measured by trans-thoracic echo was observed in 34 (85.0%) patients. The mean flow velocity, diameter of mitral annuls, and diastolic descent rate of anterior leaflet before discharge and the latest follow-up period was 106.3cm/s vs. 110 cm/s, 102% vs. 104%, and 64.2 mm/s vs. 62.4mm/s, respectively. We also measured the ratio of diameter of mitral annuls to depth of coaptation. In all cases, this ration has been unchanged. All patients were NYHA class I at the latest follow-up.
CONCLUSIONS: Although continued surveillance is required to watch the mitral valve reconstructed with ePTFE, this procedure demonstrated favorable mid-term outcome. The mitral valve repair using artificial chordae in children would be safe and effective procedure with adaptability of patients' growth.
*By Invitation 26. An Approach to Two Ventricle Repair in Infants with Pulmonary Atresia and Intact Ventricular Septum John E. Foker, James Berry*, Lee A. Pytes*; Minneapolis, MN Discussant: Frank L. Hanley
OBJECTIVE: Infants with pulmonary atresia and intact ventricular septum (PA/IVS) have a severe group of lesions. As a result, the mortality remains high and only about 30% end up with a two ventricle repair. We have shown that flow across the AV valve will provide the signal for ventricular growth. Moreover, the response is relatively rapid and, within days to weeks, the ventricles will enlarge dramatically. Our hypothesis was that growth could be induced in these infants, however, the ultimate success would depend on addressing the other significant lesions. Important connections between the right ventricle and the coronary arteries (CA) may occur, for example, and coronary blood flow may be predominantly retrograde.
METHODS: The treatment of infants with PA/IVS has evolved over 15 years as the individual components have been better understood. From 1990-1998,26 infants with PA/IVS were treated to achieve a two-ventricle repair. No patients were turned down because of RV hypoplasia and only those with Ebstein's anomaly are excluded from this study. RV and tricuspid valve (TV) analysis was done by echo measurements in two orthogonal planes, avoiding the falsely low 4-chamber estimates. The Z-scores of the RVs and TVs were calculated from standard nomo-grams. Our approach to achieve a two-ventricle repair includes (1) ligation of RV-CA connections off bypass to prevent a steal phenomenon (2) RV decompression with an outflow patch (3) snared control of an ASD to ensure systemic output and increase tricuspid valve flow and (4) either reduction of the PDA with more favorable RVs or the placement of a central shunt if the RVs are very small (Z = -7.0).
RESULTS: All had an RVOT patch and the RV-CA connections, (up to 7/pt) were ligated when significant (in 36%). The 21 (81%) longer term survivors formed the basis of this study and the measurements of RV and TV size were assessed serially by echo. All had two-ventricle repairs, none were on a palliative course, and all shunts were closed. The RV size initially was Z=-7.0 +/_ 2.1 (range -2.8.to -11.0). Six months later, the range was +0.8 to -3.2 with all normal in function The tricuspid valves were more complicated. Preoperatively: Z=-3.5 +/_ 0.9 (range -2.3 to -5.8). Six months later, Z=-1.1 +/_ 2.5 (range 2.0 to -2.4). Of 10 studied in detail, 7 were normal and 3 stenotic requiring dilation. There were no discernible effects from the RV/ CA ligations either acutely or long term. Ah" survivors had a two-ventricle repair with no residual shunts.
CONCLUSIONS: (1) Two ventricle repairs can be reliably achieved in PA/IVS patients with improved longer term survival. (2) Rapid catch-up growth of RV and TV size has been demonstrated. (3) Growth enhanced RVs will have normal function. The benefits of the two-ventricle repair should increase with time.
*By Invitation 27. Left Ventricular Performance of Pulmonary Atresia With Intact Ventricular Septum AfteraRight Heart Bypass Surgery Yoshihisa Tanoue*, Hideaki Kado*, Taketoshi Maeda*, Yuichi Shiokawa*, Naoki Fusazaki*, Shiro Ishikawa*; Fukuoka, Japan Discussant: David Bichell*
OBJECTIVE: Left ventricular performance of pulmonary atresia with intact ventricular septum (PA/IVS) before and after the bidirectional Glenn procedure and a staged total cavopulmonary connection was compared with that of tricuspid atresia (TA).
METHODS: Contractility (end-systolic elastance; Ees), afterload (effective arterial elastance; Ea), and ventricular efficiency (ventriculoarterial coupling; Ea/Ees, and the ratio of stroke work and pressure-volume area; SW/PVA) were approximated on the basis of the cardiac catheterization data before the bidirectional Glenn procedure (PreG), before and after the staged total cavopulmonary connection (PreT, PostT0), and around 1 year after the total cavopulmonary connection completion (PostT1) in 20 patients of PA/IVS and 21 patients of TA.
RESULTS: Contractility and ventricular efficiency in PA/IVS patients is inferior to those in TA patients after the total cavopulmonary connection.
CONCLUSIONS: The high-pressure residual right might impair the left ventricular performance of PA/TVS after the right heart bypass surgery.
3:05 p.m. INTERMISSION - VISIT EXHIBITS North Bldg., Exhibit Hall Metro Toronto Convention Centre
*By Invitation 3:40 SIMULTANEOUS SCIENTIFIC SESSION - CONGENITAL HEART DISEASE North Bldg., Rm 107, Metro Toronto Convention CentreModerators: Thomas L. SprayRoss M. Ungerleider
28. Surgical Management of Transposition of the Great Arteries with Intact Ventricular Septum in Infants Older Than 21 Days Emre Belli*, Dominique Piot*, Anita Touchot*, Regine Roussin*, Emir Mokhfi*, Claude Planche*, 1Alain Serraf; Le Plessis-Robinson, France Discussant: 2Marc de Leval
OBJECTIVE: Rapid 2-stage arterial switch operation (ASO) following left ventricular (LV) retraining has become a safe alternative to the primary ASO for the treatment of transposition of the great arteries with intact ventricular septum (TGATVS) in infants older than 21 days. However, criteria predicting post-operative LV performance remains controversial.
METHODS: Between 1993 and 2002,49/538 patients who underwent ASO for TGAIVS were > 21 (median 44; 22 to 367) days old. Primary ASO was performed in 28 (group I) (median age 32,22 to 172) while 21 (group II) underwent a rapid 2-stage (median delay 11 days) management with initial pulmonary artery banding, this associated with a systemic-to-pulmonary shunt in all but 1. At preoperative echocardiography, LV geometry as well as the LV mass index, mass/ volume ratio and LV diastolic posterior wall tickness/LV diastolic diameter ratio and also the patency of arterial duct were considered. Post-operative LV function and outcome measurements were recorded. In early experience, indications were based on the LV mass only (< 35 g/ m2). The decision criteria for initial left ventricle retraining has evolved with time.
RESULTS: There were 3 (6%; 70% CI 2-11%) hospital deaths : 2 after primary ASO and one because of mediastinitis between the 2 stages. Three patients required ECMO support: 1 after first stage procedure and 2 after primary ASO. The indexed LV mass/volume ratio appeared to be the principal parameter predicting postoperative LV failure (p<.05).
CONCLUSIONS: A preoperative mass/volume ratio > 1.2 allowed to perform an uneventful primary ASO until 6 months of age. The outcome after rapid 2-stage ASO remains encouraging.
*By Invitation 11993-94 Graham Fellow 21973-74 Graham Fellow 29. Biventricular Repair in Atrioventricular Septal Defects with a Small Right Ventricle: Anatomical and Surgical Considerations Nilto Carias de Oliveira*, Rekwan Sittiwangkul*, Brian W. McCrindle*, Anne Dipchand*, John G. Coles, William G. Williams, Glen S. Van Arsdell*; Toronto, ON, Canada Discussant: Giovanni Stettin
OBJECTIVE: Single ventricle palliation (SVP) in children with a small right ventricle and AVSD (sRV/AVSD) in the presence of trisomy 21 has suboptimal results. We have therefore adopted a strategy of pushing the limits for biventricular repair (BVR), with or without an atrial fenestration.
METHODS: From January 1989 to July 2003, 32 children (median age 6 mo, 1 - 47 mo) with a sRV/AVSD underwent a BVR (sRV/AVSD/BVR). A sRV was identified by echocardiographic impression and defined for this analysis by detailed measurements of complete atrioventricu-lar valve (CAW) area and diameter, and annulus to RV and LV apex. A theoretic partitioning plane for the AVSD on the right side of the septum allowed for calculations of left and right atrioventricular valve (LAW, RAW) dimensions and ratio. Measurements of the sRV patients were validated against case match controls of balanced AVSD. Seven other children having sRV/ AVSD with SVP were studied. Downs syndrome was present in 37 patients.
RESULTS: By case match control sRV/AVSD/BVR children had lower RAW/CAW area ratio (mean 0.41 ± 0.1 vs control 0.52 ± 0.1, p < .0001); lower RV/LV length ratio (0.78 ± 0.1 vs control 0.99 ± 0.17, p < .0001); and lower median RAW/CAW diameter ratio (0.48 ± 0.12 vs control 0.55 ± 0.1, p < .03). SVP children had the smallest RV dimensions: compared to sRV/AVSD/BVR they were: RV/LV length ratio (0.64 ± 0.13 vs 0.78 ± 0.1, p = .002) and lower median RAW/CAW diameter ratio (0.36 ± 0.1 vs 0.48 ± 0.12, p = .03); however, there was no difference in RAW/CAW ratio suggesting that RV volume was smaller in the SVP group. There were 5 operative deaths (3 in sRV/AVSD/BVR and 2 in SVP). Kaplan Meyer estimates of survival were 90 % at 10 years for sRV/AVSD/BVR vs. 69 % for SVP patients (p=0.23). Compared to the SVP, patients after sRV/AVSD/BVR had lower CVP on arrival to the ICU (11.2 ± 2.6mmHg vs 17 ± 6.3 mm Hg, p=.003) and 24 hours later (13.2 m ± 6.3 mmHg vs 22 ± 12.8 mmHg, p= .04). In the sRV/AVSD/BVR group, 02 sat at 24 hours correlated with right AW annulus size (r=0.47, p=0.02). 02 saturations at 24 hours were not different between the sRV/AVSD/BVR and the SVP in contrast to last follow-up, being higher in the BVR group (0.93 ± 0.06 vs 0.83 ± 0.14, p=0.04). A restrictive atrial fenestration was left in 9 patients after BVR. Absolute RAW dimension was smaller in the fenestrated group (1.04 vs 1.48, p= 0.03) Patients with a fenestration had a lower 02 saturations at 24 hours (91 % vs 97 %, p= 0.003).
CONCLUSIONS: These findings suggest that an aggressive strategy towards BVR in patients having sRV/AVSD is beneficial. BVR was successful in infants having a RAVV/CAVV ratio as small as 0.32 and an RV/LV ratio as small as 0.66. An atrial fenestration extends the anatomical limits for BVR and was not detrimental to oxygen saturation as compared to the SVP cohort.
*By Invitation 30. Evolving Techniques in the Repair of Truncus Arteriosus 1990-2003 Jonathan M. Chen*, Julie S. Glickstein*, Ryan R. Davies*, Michelle L. Mercando*, Ralph S. Mosca, Jan M. Quaegebeur; New York, NY Discussant: Constantine Mavroudis
OBJECTIVE: While previous methods of truncus arteriosus (TA) repair have employed various conduits to establish right ventricle (RV) to pulmonary artery (PA) continuity, recent techniques using direct RV-PA anastomosis with anterior patch augmentation have been promoted to delay or avoid later RVOT reconstruction. Whether these measures postpone reoperation (REOP), or instead replace it with catheter-based interventions (CBI, e.g., stent placement, balloon angioplasty) remains unclear. To address this, we evaluated our experience with primary repair of TA.
METHODS: Records were reviewed of all patients undergoing repair of TA from 6/90 - 6/03. Functional and demographic parameters were evaluated and patients divided according to type of primary TA repair: homograft, or non-valved direct anastomosis with anterior patch materials. Postoperative outcomes, including the need for CBI or REOP were evaluated by univariate and multivariate analysis.
RESULTS: 51 patients underwent primary repair of TA during the 13 year period; 4 patients first operated elsewhere who had reoperative homograft replacements were excluded from the analysis. Median age at repair was 14 days. RV-PA connections used a homograft in 16, and direct connection with autologous pericardial (6), bovine pericardial (8), cryopreserved pericardial (7), Cortex (13) and other (1) hoods. Mean follow-up was 86.9 months (range 0-161 months). One patient died postoperatively. Of the remaining 50 patients, 26 required no further interventions.
The number of patients requiring any intervention (CBI or REOP) was comparable in both homograft and direct connection cohorts (40.0% vs 46.7%). The number of patients requiring REOP was higher for homograft (46.7% vs. 20.0%, p = 0.054), and the number requiring CBI was higher for direct connection (31.4% vs. 13.3%, p = 0.181) patients. No patients with Cortex hoods required reoperation, (0% vs 38.9%, p = 0.001) and only 3 (23.1% vs. 52.78%, p = 0.039) required CBI.
Median time to any intervention was 103.3 months for direct connection and 108.1 months for homograft recipients. Nonparametric analysis of survival free from any intervention demonstrated a significant difference (p<0.007) according to anterior hood type: autologous pericardial (5.6 months), cryopreserved pericardial (7.5 months), bovine pericardial (64.1 months) and Cortex (97.3 months).
CONCLUSIONS: When compared to homograft recipients, patients undergoing direct connection for primary repair of TA require fewer reoperations but more CBI, and appear to require intervention according to the type of patch material used for hood augmentation, likely due to hood dilatation or branch PA distortion. Despite the need for CBI, direct connection repair may allow for patient growth, thereby either eliminating or postponing the need for later reoperation.
*By Invitation 31. The Sutureless Technique for Repair of Pulmonary Veins: Extension from Post-Repair Pulmonary Vein Stenosis to Primary Repair of Pulmonary Venous Anomalies Tae-Jin Yun*, John G. Coles, Wald M. Rachel*, Glen S. Van Arsdell*, William G. Williams, Jeffrey Smallhorn*, Christopher A. Caldarone*; Toronto, ON, Canada Discussant: Francois Lacour-Gayet
OBJECTIVE: We have previously reported a limited but favorable experience with a novel sutureless technique for surgical management of postoperative pulmonary vein stenosis (PVS) occurring after repair of total anomalous pulmonary venous drainage (post-repair pulmonary vein stenosis). Because this technique requires integrity of the retro-cardiac space for hemostasis, extension of the technique to the primary repair of pulmonary vein anomalies requires evaluation. This analysis reviews our experience with the sutureless technique in patients with post-repair PVS as well our extension of the technique into primary repair of pulmonary vein anomalies.
METHODS: Retrospective univariable/multivariable analysis of all pulmonary vein stenosis procedures and sutureless pulmonary vein procedures over a 20 year period (1983-2003) was performed.
RESULTS: Sixty patients underwent 73 procedures. PVS was present in 65 procedures. The sutureless technique was used in 40 procedures (32 with PVS, 7 with PR-PVS, 24 with no prior surgery). Conventional' management, including direct pulmonary vein-to-atrial anastomoses and stenting procedures, was used in 33 procedures. Mean followup: 2.9 yrs. Mean age: 1.1yrs.
Using the entire cohort, freedom from reoperation or death at 5 years after initial procedure was 49%. Variables associated with increased risk of reoperation or death included bilateral stenosis (hazard ratio 7.22), right atrial isomerism (HR 11.04), and the use of stents (HR 3.59). After controlling for identified risk factors, the use of the sutureless technique was associated with decreased but not statistically significant risk of reoperation or death (HR 0.64, p=0.34).
The sutureless technique was used as a primary procedure in 24 patients with PVS (n = 19) or at increased risk of PVS (n=5). Despite the absence of a retrocardiac adhesions, operative mortality was not increased (p=0.64). In 4 patients, dissection through the pleural reflection resulted in bleeding into the pleural cavity which was easily controlled with a straightforward trans-pleura! approach to the pulmonary hilum.
24 patients had post-repair pulmonary vein stenosis of whom 7 underwent a sutureless repair and 17 underwent conventional management. The sutureless technique was associated with decreased risk of re-operation or death (univariable p=0.03) with no reoperations or death in the sutureless group (mean followup: 3.lyrs).
CONCLUSIONS: The sutureless technique for post-repair pulmonary vein stenosis is associated with excellent mid-term results. Extension of the indications for the technique to primary repair appears safe with development of simple hemostatic maneuvers and offers potential for improved freedom from postoperative PVS.
5:00 p.m. ADJOURN
7:00 p.m. ATTENDEE RECEPTION Eternal Egypt: Masterworks of Ancient Art from the British Museum Royal Ontario Museum (separate subscription)
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