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TUESDAY AFTERNOON, APRIL 27, 2004
2:00 p.m. SIMULTANEOUS SCIENTIFIC SESSION - ADULT CARDIAC SURGERY (8 minutes presentation, 12 minutes discussion) North Bldg., Hall C, Metro Toronto Convention Centre Moderators: Bruce W. LytleAxel Haverich
35. Current Prognosis of Ischemic Mitral Regurgitation Managed by Routine Mitral Valve Repair Donald Glower, Robert H. Turtle*, Linda K. Shaw*, Ricardo E. Orozco*, J. Scott Rankin; Durham, NC, Nashville, TN Discussant: David H. Adams
OBJECTIVE: Most studies have shown that surgical therapy for moderate-to-severe post-infarction, or ischemic (I), mitral regurgitation (MR) has been associated with diminished early and late survival, as compared to non-ischemic (N) forms of MR. Conversion from mitral valve (MV) replacement to valve repair (Rpr) seems to have improved prognosis somewhat, but it is not clear if IMR continues to be an independent predictor of outcome after routine surgical Rpr, especially if other risk factors are considered simultaneously.
METHODS: 535 patients undergoing MVRpr (primarily Carpentier ring annuloplasty) +/_ coronary bypass from 1993-2002 were reviewed retrospectively. Follow up was 99% complete, and a total of 93 deaths occurred over the 9 years of follow up. A Cox proportional hazards model evaluated long-term survival as a function of 10 simultaneous covariates: IMR vs NMR, age, gender, diabetes (DM), renal insufficiency (RI), pulmonary disease (PD), ejection fraction (EF), NYHA class, coronary disease (CD), and reoperation.
RESULTS: IMR patients (n=141) had greater age (69v59yrs), lower EF (.40v.50), more CD (100%vl6%), and higher comorbidity (DM, RI, and PD) (all p<0.001), as compared to NMR (n=394). Unadjusted 30-day mortality was: IMR=4.3%; NMR=1.0% (p=0.01), and unadjusted 5-year mortality was: IMR=44+/_5%; NMR=16+/_3% (p<0.001). In the full multivariable model, only advanced age and preoperative comorbidities (DM, RI, PD) were significant independent predictors of survival (all p<0.012), while IMR, EF, CD, NYHA class, gender, and reoperation did not achieve significance (all p>0.19). After adjusting for differences in these patient characteristics, long-term survival was not statistically different between IMR and NMR (Figure, p=0.39).
CONCLUSIONS: With routine application of modern surgical techniques for MVRpr, IMR is not an independent predictor of long-term outcome after adjusting for demographics, preexisting comorbidities, and clinical findings. Future surgical risk assessment and therapeutic decision making should be based on overall patient condition and should not be biased by ischemic etiology of MR.
*By Invitation
36. Recurrent Mitral Regurgitation after Anuloplasty for Functional Ischemic Mitral Regurgitation: Anuloplasty Type Makes a Difference Edwin C. McGee, Jr.*, A. Marc Gillinov, Gideon Cohen*, Eugene H. Blackstone, Jeevanantham Rajeswaran*, Farzad Najam*, Joseph F. Sabik*, Patrick M. McCarthy, Bruce W. Lytle, Delos M. Cosgrove; Cleveland, OH Discussant: D. Craig Miller
OBJECTIVE: The temporal course of return of mitral regurgitation (MR) after anuloplasty for functional ischemic MR and factors that accelerate the rate of return are unknown. Therefore, objectives of this study were to 1) characterize that temporal pattern and 2) identify its predictors, particularly with respect to anuloplasty type.
METHODS: From 1985 to 2003, 584 patients underwent anuloplasty alone for functional ischemic MR, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove-Edwards) was used in 68%, a semi-rigid ring (Carpentier-Edwards) in 21%, and bovine pericardium (Peri-Guard) in 11%. 685 echocardiograms assessing postoperative MR were available in 423 patients for longitudinal analysis. Median time to echocardiogram was 8 days; however, 10% were performed beyond 2 years.
RESULTS: The proportion of patients with 0-1 + MR decreased from 71 % early postoperatively to 41% at 1 year after repair, and the proportion with 3-4+ MR increased from 13% to 34% (P<.0001); MR was stable thereafter. This temporal pattern was similar for Cosgrove-Edwards and Carpentier-Edwards anuloplasties, but substantially worse for Peri-Guard anuloplasties (Fig). Risk factors for higher MR grade included greater degree of preoperative MR (P<.0001), complex MR jet (P=.02), more severe left ventricular dysfunction (P=.001), and use of Peri-Guard anuloplasty (P=.005). Small anuloplasty size was not associated with decreased postoperative MR (P=.2);however, Cosgrove-Edwards flexible bands were employed in most patients receiving 26- and 28-mm anuloplasties.
CONCLUSIONS: During the first year after anuloplasty for functional ischemic MR, important MR is present in 34% of patients. Pericardial anuloplasty is unsatisfactory, but equivalent results are obtained with Cosgrove-Edwards bands and classic Carpentier-Edwards rings. These results suggest the need to address additional mechanisms to prevent return of MR.
*By Invitation 37. Does the Left Internal Mammary Artery to the Left Anterior Descending Artery Confer any Benefit in Combined Coronary and Valve Operations? Shishir Karthik*, Arun K. Srinivasan*, Antony D. Grayson*, Brian M. Fabri*; Leeds, UK, Liverpool, UK Discussant: Bruce W. Lytle
OBJECTIVE: The benefits of Left Internal Mammary Artery (LIMA) to left anterior descending artery (LAD) in combined coronary artery bypass graft (CABG) and valve operations have not been fully investigated. We aimed to quantify the impact of LIMA to LAD on early- and mid-term outcomes in these patients.
METHODS: Data was collected prospectively as part of routine clinical practice on 630 consecutive patients who underwent revascularisation of the LAD with concomitant valve operations between April 1997 and March 2003. Multivariate logistic regression was used to adjust in-hospital outcomes for treatment selection bias. Deaths occurring over time were described using Kaplan-Meier techniques. Multivariate Cox proportional hazards analysis was used to calculate adjusted hazard ratios (HR) and to adjust the Kaplan-Meier survival curves. A propensity score for LIMA use was constructed to control selection bias. The variables included in the propensity score were as follows: age, sex, body mass index, priority, ejection fraction, aortic valve gradient, systolic pulmonary artery pressure, extent of coronary disease, diabetes, cerebrovascular disease, renal dysfunction, and respiratory disease (C statistic = 0.71). This was included along with the comparison variable in the multivariate analyses.
RESULTS: 478 (75.9%) had LIMA to the LAD. Patients who received LIMA were significantly younger but less likely to be female, or have poor ejection fraction, renal dysfunction, respiratory disease or have emergency surgery. Both LIMA and non-LIMA patients had a median of 3 distal anastomoses (p=0.92), and median of 1 valve either repaired or replaced (p=0.83). On the univariate analyses, LIMA patients had significantly lower in-hospital mortality (6.3% (n=30) versus 13.2% (n=20); p<0.01) and postoperative renal failure (8.2% (n=39) versus 13.8% (n=21); p=0.038). There were no significant differences with regards to stroke, re-exploration for bleeding, myocardial infarction, sternal wound infection, and length of hospital stay. After adjusting for treatment selection bias (with the propensity score), in-hospital mortality (adjusted odds ratio (OR) 0.74 [95% confidence intervals (CI) 0.37 to 1.45]; p=0.37) and renal failure (adjusted OR 0.93 [95% CI 0.49 to 1.77]; p=0.82) were no longer significantly different. A total of 127 (20.2%) deaths occurred during the follow-up, with a total follow-up of 1,736 patient-years. The crude HR for LIMA was 0.64 (p=0.02). After adjusting for the propensity score, the adjusted HR was 0.86 (p=0.47).
CONCLUSIONS: LIMA to the LAD does not seem to affect the short- and medium-term outcomes adversely in patients undergoing concomitant CABG and valve operations.
3:00 p.m. INTERMISSION - VISIT EXHIBITS North Bldg., Exhibit HallMetro Toronto Convention Centre
*By Invitation
3:40 p.m. SIMULTANEOUS SCIENTIFIC SESSION - ADULT CARDIAC SURGERY North Bldg., Hall C, Metro Toronto Convention CentreModerators: Bruce W. LytleAxel Haverich
38. Should the Ascending Aorta be Routinely Replaced in Patients with Bicuspid Aortic Valve Disease? Michael A. Borger*, Mark Preston*, Joan Ivanov*, Paul W. Fedak*, Piroze Davierwala*, Susan Armstrong*, Tirone E. David; Toronto, ON, Canada Discussant: Ludwig K. von Segesser
OBJECTIVE: Patients with bicuspid aortic valve (BAY) disease often have associated dilation of the ascending aorta. Controversy exists regarding the optimal diameter at which replacement of the ascending aorta should be performed.
METHODS: We reviewed all BAY patients undergoing aortic valve replacement at our institution from 1979 to 1993 (n = 201). BAY patients operated on after 1993 were excluded to allow for adequate long-term follow up. Patients undergoing concomitant replacement of the ascending aorta were also excluded. Follow up was obtained on 100% of patients.
RESULTS: Mean (+/_ SD) length of follow up was 10.2 +/_ 3.7 years. Average patient age was 56 +/_ 14 years, and 76% were male. The ascending aorta was normal in 111 patients (55%), mildly dilated (40 - 45 mm) in 66 patients (33%), and moderately dilated (45 - 50 mm) in 24 patients (12%). (All BAY patients with marked dilation (> 50 mm) underwent replacement of the ascending aorta and were therefore not part of this study.) Fifteen year survival was 63%. During follow up, 4] patients (20%) required reoperation, predominantly for aortic valve prosthesis failure. Thirteen patients (6.5%) had long-term complications related to the ascending aorta: 9 developed ascending aortic aneurysm (> 50 mm), 1 patient suffered from aortic dissection, and 3 patients died of sudden cardiac death. Importantly, 10 of these 13 patients (77%) had an aortic diameter equal to or greater than 40 mm at the time of initial surgery. Fifteen-year freedom from ascending aorta-related complications was 92% in patients with an aortic size of < 40 mm versus 80% for patients with an aortic size of 40 mm or greater (p = 0.02).
CONCLUSIONS: Patients undergoing surgery for bicuspid aortic valve disease should undergo concomitant replacement of the ascending aorta if the diameter is 40 mm or greater.
*By Invitation 39. Map-Guided Surgery for Atrial Fibrillation Takashi Nitta*, Takashi Sasaki, Hiroya Ohmori*, Shun-Ichiro Sakamoto*, Yoshiaki Saji, Kazuhiro Hinokiyama*, Yasuo Miyagi*, Shigeto Kanno*, Kazuo Shimizu*; Tokyo, Japan Discussant: James L. Cox
OBJECTIVE: Although current surgical procedures result in a high success rate for AF, they are not guided by electrophysiologic findings in individual patients, and thus may include unnecessary incisions in some patients or be inappropriate for other patients. Map-guided AF surgery can avoid unnecessary incisions, reduce the surgical mortality and morbidity, and preserve a greater atrial transport function.
METHODS: A 256-channel three-dimensional dynamic mapping system with custom-made epicardial patch electrodes was used to examine the atrial activation during AF and to determine the optimal procedure in 34 permanent and 8 paroxysmal AF patients intraoperatively. Underlying heart disease consisted of valvular heart disease and congenital heart disease in 33 and 5 patients, respectively, while 4 patients had no associated heart disease. The mapping system successfully displayed the activation wavelets during AF as a movie using three-dimensional computer constructed atrial models.
RESULTS: Concurrent multiple repetitive activations arising from the pulmonary veins or LA appendage were observed in all patients except for one who exhibited LA macroreentry. The fastest activation of the repetitive activations propagated toward the RA, conducting through Bachmann's bundle with a progressive conduction delay or block in the pathway, resulting in an irregular and desynchronized RA activation. Surgery for AF was not indicated in 3 patients in whom the atrial electrograms had a low voltage over a broad area. A simple procedure, consisting of pulmonary vein isolation and LA incisions without any RA incisions, was performed in 6 patients in whom the RA activation was passive, and all were cured of AF with a significant atrial contraction. The radial procedure was performed in the remaining 33 patients in whom the RA activation exhibited focal or reentrant activation, and 30 of the patients (91%) were cured of AF. In this subset of patients, 10 exhibited reentrant or focal activation in the posterior LA between the right and left pulmonary veins and required an additional linear ablation on the posterior LA.
CONCLUSIONS: Intraoperative mapping facilitates determining the optimal procedure for AF in each patient.
*By Invitation 40. Hypertrophic Obstructive Cardiomyopathy: Outcomes by Propensity Score after Myectomy or Alcohol Ablation Anthony Ralph-Edwards*, Anna Woo*, Brian W. McCrindle*, Jonathan L. Shapero*, Leonard Schwartz*, Harry Rakowski*, Douglas Wigle*, William G. Williams; Toronto, ON, Canada Discussant: Marko I. Turina
INTRODUCTION: In November 1998, our centre began offering alcohol ablation (AA) as an alternative to surgical myectomy (M) for patients with hypertrophic obstructive cardiomyopathy (HOCM). Patients with concomitant lesions were referred for surgery and the others were offered either treatment option. We sought to review the early outcomes for both protocols.
METHODS: 147 patients had intervention for HOCM. to June 30, 2003. Sixty pts. elected to have alcohol ablation, 4 crossed over to surgery. A total of 91 pts had a myectomy. Hospital records were reviewed and follow-up contact (mean 1.6 years) with the pt or referring cardiologist and recent echo reports were obtained. Differences in clinical and hemodynamic outcomes between achieved treatment groups were compared after adjustment for differing baseline patient characteristics, including use of a propensity score, in order to adjust for the non-randomization.
RESULTS: The AA pts (N = 60) were older (58 vs 48 years), had fewer associated lesions (1 vs. 39 pts), lower pressure gradients (67 vs. 73 torr), and had similar symptomatic status and degrees of mitral regurgitation compared to the M group.
AA was abandoned in 7 pts, 3 of whom underwent M. Among the completed AA, there are 2 late deaths, and 1 other pt. was referred for M. One late death occurred after M.
At latest follow-up (3 year survival 97%), 92 % of the pts are in NYHA II or 1.
Adjusted comparisons showed significantly lower post-intervention LV outflow gradients at rest in the M group (7 vs. 27 torr; p=0.008), with provocation (11 vs. 51mmHG; p = 0.0001), mitral regurgitation (none or trivial in 69% vs. 23%; p=0.0002), and NYHA (p=0.0002). No significant difference was present in post-intervention septal thickness or freedom from post-intervention pacing, although in time-related analysis, the 3 year freedom from pacing is 83% vs. 59% (p = 0.004).
CONCLUSIONS: Either AA or M offer substantial clinical improvement for pts with HOCM. Hemodynamic resolution of the obstruction and its sequelae is more complete with M. Residual lesions after AA may affect longer-term outcomes.
*By Invitation 41. Value Of Autopsy Examination For Quality Control After Cardiac Surgery Ardawan J. Rastan*, Jan F. Gummert*, Nicole Lachmann*, Thomas Walther*, Dierk V. Schmitt*, Volkmar Falk*, Nicolas Doll*, Paul Caffier*, Markus Richter*, Christian Wittekind*, Friedrich W. Mohr; Leipzig, Germany Discussant: Edward D. Verrier
OBJECTIVE: To assess the impact of autopsy on quality control in the current era of advanced diagnostic technology.
METHODS: From 01/2000 to 09/2003 779/13.402 (5.8%) patients who underwent elective or urgent cardiac surgery died in hospital. Autopsy rate was 408/779 (52.4%) forming the study population. Clinical and pathological findings were evaluated prospectively and independently by clinicians and pathologists. The data were compared concerning causes of death, postoperative complications, concomitant diseases and pathologies of operative procedures.
RESULTS: Patients died after a mean of 14.2 days postoperatively. 65.9% were male, mean age was 68.6y. 59.4% had urgent surgical indication with acute coronary syndrome in 30.2% at the time of operation.
Causes of death are shown on table 1, they were unexpected in 65 pat. (15.9%). These included pulmonary embolism (7), acute myocardial infarction (29), low output syndrome (8), respiratory (7), technical failure (6), gastrointestinal bleeding (3), cerebal stroke (1) and multi-organ-failure (4). 80% (24/30) of clinically unclear causes of death could be determined by autopsy, including 9/15 sudden cardiac deaths.
Clinically unrecognized postoperative complications were found in 293 (71.8%) patients. These were nonfatal pulmonary embolism (54), deep vein thrombosis (41), acute cerebral ischemia (16), acute pancreatitis (12), gastrointestinal ischemia (11), pneumonia (43) and others (116).
Unknown concomitant diseases were found in 318 patients (77.9%), which might have been relevant for therapy in 67 patients (21.1%), including 24 unknown malignant tumours.
In 84 patients (20.6%) pathological findings of operative situs were recognized at autopsy with 31 known premortem. These included significant CABG stenosis/occlusion in 28 (21 known), bleeding in 11 (8), valve endocarditis in 1 (0), valve thrombosis in 9 (2), aortic rupture in 1 (0), left ventricle rupture in 2 (0) and tamponade in 2 (0) patients.
CONCLUSIONS: A significant part of autopsies reveals major discrepancies between clinical and postmortem examinations. Autopsy remains of great importance for quality control of perioperative treatment and education in cardiac surgery.
5:00 p.m. EXECUTIVE SESSION (Members Only) North Bldg., Hall C, Metro Toronto Convention Centre
*By Invitation
TUESDAY AFTERNOON, APRIL 27, 2004
2:00 p.m. SIMULTANEOUS SCIENTIFIC SESSION - GENERAL THORACIC SURGERY (8 minutes presentation, 12 minutes discussion) North Bldg., Rm 105, Metro Toronto Convention Centre Moderators: Alec PattersonDavid J. Sugarbaker
42. High-Dose Radiation in Tri-Modality Treatment of Pancoast Tumors Improves Pathologic Complete Response Rates and Confers Survival Advantage 1King F. Kwong*, Lindsay B. Cooper*, Martin J. Edelman*, Mohan Suntharalingam*, Ziv Gamliel*, Whitney Burrows*, Petr Hausner*, L. Austin Doyle*, Mark J. Krasna; Baltimore, MD Discussant: Valerie W. Ruscb
OBJECTIVE: To study the clinical characteristics and outcomes of patients treated with a surgery inclusive multi-modality approach for Pancoast tumors over a 10-year period.
METHODS: Clinical records of all patients who completed neoadjuvant chemoradiation followed by surgery between 1993-2003 at our institution were reviewed retrospectively.
RESULTS: Thirty-six patients completed treatment of their Pancoast tumors with neodjuvant chemoradiation followed by en bloc lung and chest wall resection during this period. Study population included 22 men (mean age 54, range 31-76) and 14 women (mean age 56, range 36-74). Pulmonary resections included lobectomies (n=33) and pneumonectomies (n=3). Operative approaches included standard posterior-lateral, anterior-superior, and anterior hemi-clamshell thoracotomies. Pre-treatment clinical stages were IIB, IIIA, IIIB, and IV (presenting with single isolated brain metastasis) in 18 cases, 7 cases, 6 cases, and 5 cases, respectively. Complete surgical resection with negative margins was achieved in 35 patients (97.2%). Operative mortality was 2.7% (n=1). Radiotherapy was successfully tolerated in all patients and mean total radiation dose was 56.7 Gy. Pathologic complete response (p-CR) was found in 41.7% patients (n=15). Recurrences were found in 50% of all treated patients (n=18). Distant recurrences were most commonly found as brain metastases (n=9,50% total recurrences, 25% all patients). Other distant recurrences accounted for 4 patients (22.2% total recurrences, 11.1% all patients) while local recurrences included 5 patients (27.7% total recurrences, 13.8% all patients). Median survival time (MST) for entire cohort is 31-6 months (2.6 years). However, MST for patients with p-CR was 93.1 months (7.8 years). Interestingly, the MST of patients with positive pre-treatment lymph nodes (n=12 patients) remains undefined (not reached). Log rank comparisons of survivals were performed. Statistical significance was limited by sample size, however, encouraging trends are evident.
CONCLUSIONS: Surgical resection of Pancoast tumors after neoadjuvant high-dose radiation and chemotherapy can be safely performed and with improved clinical outcomes. High-dose radiation as part of a tri-modality treatment regimen can be successfully tolerated and may confer a survival advantage. Pre-treatment lymph node metastasis should not necessarily exclude patients from tri-modality treatment. Local cancer control of Pancoast tumors can be accomplished by aggressive tri-modality therapy, but the high number of distant metastasis to the brain suggests that adjuvant prophylactic cranial irradiation (PCI) may play an integral part of a cohesive multi-modality treatment regimen for this disease.
*By Invitation 12004-06 Research Scholar 43. Does Esophagogastric Anastomotic Technique Influence Outcomes in Patients with Esophageal Cancer? Sina Ercan*, Thomas W. Rice, Sudish C. Murthy, Lisa A. Rybicki*, Eugene H. Blackstone; Cleveland, OH Discussant: Mark B. Orringer
OBJECTIVE: To compare outcomes of patients with esophageal cancer who had either standard hand-sewn or simplified hybrid stapled cervical esophagogastric anastomosis following esophagectomy.
METHODS: From March 1996 to October 2002, 274 patients with esophageal cancer underwent esophagectomy with gastric replacement and cervical esophagogastric anastomosis. For the most recent cohort of patients (March 2001 to October 2002, n=86), a simplified hybrid stapled technique (stapled) was used to construct the cervical esophagogastric anastomosis (Fig); standard hand-sewn technique (sewn) was used on all others (n=188). Using a propensity score based on 8 variables (age, sex, race, surgeon, type of operation, pathologic stage, histologic cell type, induction chemoradiotherapy), 85 patient pairs were matched. All patients were followed for tune-related events. Outcomes compared were cervical wound infection, cervical anastomotic leak, postoperative hospital stay, need for dilatation, and overall survival.
RESULTS: At 30 days, freedom from cervical wound infection was 92% for stapled vs. 71% for sewn anastomoses (P=.001), and freedom from cervical anastomotic leak was 96% vs. 89% (p=.09), respectively. Postoperative hospital stay was similar for both groups (P>.2).At 2 years, freedom from dilatation was 34% for stapled vs. 10% for sewn anastomoses (P<.0001), and mean number of dilatations per patient was 2.4 vs. 4.1 (P=.0001), respectively. Survival at 30 days, 6 months, and 24 months was 98%, 91%, and 77% for stapled anastomoses and 98%, 88%, and 69% for sewn anastomoses (P=3).
CONCLUSIONS: The simplified hybrid stapled anastomotic technique dramatically improves outcomes after esophagectomy and should become the preferred technique for cervical esophagogastric anastomosis.
*By Invitation 44. Large Cell Neuroendocrine Carcinoma: An Aggressive Form of Non-Small Cell Lung Cancer 1Richard J. Battafarano*, John Ritter*, Felix Fenandez*, Bryan F. Meyers, Tracey J. Guthrie*, Joel D. Cooper, G. Alexander Patterson; St. Louis, MO Discussant: William H. Warren
OBJECTIVE: Large cell neuroendocrine carcinomas (LCNEC) of the lung display morphologic and immunohistochemical characteristics common to neuroendocrine tumors and the morphologic features of large cell carcinomas (LCC). Surgical resection of LCNEC in many series has been described with 5 year actuarial survival rates ranging from 13-47%. Considerable debate has emerged as to whether these tumors should be classified and treated as non-small cell lung cancers (NSCLC) or small cell carcinoma (SCC). The objective of this study was to report the outcome of surgical resection in patients with LCNEC.
METHODS: An analysis of our tumor registry was identified all patients undergoing surgical resection of lung cancer between July 1, 1998 and December 31, 2002 for large cell tumors. Cases were then segregated into LCNEC, Mixed LCNEC (in which at least one portion of the tumor was LCNEC), or LCC on the basis of morphology and differentiation. Follow-up was complete on all patients with a mean follow-up of 48 months. Type of resection, mortality, and survival by stage were analyzed. Kaplan Meier survival was determined for all patients from the date of surgery. Cox Proportional Hazards model analysis incorporating the variables of age, gender, histology, and stage estimated the impact of LCNEC and Mixed LCNEC on recurrence and death. All patients were staged according to the 1997 AJCC guidelines.
RESULTS: Of the 2,089 patients that underwent resection, 82 (3.9%) had large cell lung cancers. Perioperative mortality was 2.4%. Overall survival and freedom from recurrence at 5 years for the entire group was 47.1% and 58.4% respectively. Survival by histologic subtype is presented below. The presence of LCNEC in the specimen (groups LCNEC and Mixed LCNEC combined) was significantly associated with decreased freedom from recurrence (Relative Risk (RR) 2.96, 95% Confidence Interval (CI) 1.12-7.81, P=0.015).
*p=0.03 compared to LCC
CONCLUSIONS: Patients with LCNEC have a worse survival after resection than patients with LCC, even in stage I disease. Accurate differentiation of LCNEC from LCC is important because it identifies those patients at highest risk for developing recurrent lung cancer.
*By Invitation 12001-03 Research Scholar 45. Value of Positron Emission Tomography Following Induction Therapy of Locally Advanced Bronchogenic Carcinoma Thomas Peter Graeter*, Dirk Hellwig*, Dieter Ukena*, Carl-Martin Kirsch*, Hans-Joachim Schafers*; Homburg/ Saar, Germany Discussant: Robert J. Cerfolio*
OBJECTIVE: Induction therapy is a promising modality in patients with locally advanced bronchogenic carcinoma. Following induction therapy it is unclear, whether tracer accumulation on positron-emission-tomography with 18F-fluorodeoxyglucose (FDG-PET) in restaging predicts tumor viability. We compared FDG-PET results following induction therapy with histology obtained at subsequent surgery.
METHODS: From 7/98 to 2/03, 45 patients (age: 58±9 years) with advanced bronchogenic carcinoma (stage IIIA and B) and induction therapy (chemo- and/or radiation therapy) were evaluated by FDG-PET before planned pulmonary resection. FDG-PET interpretation was visual, in addition tracer accumulation was quantified measuring standardized uptake values (SUV). By conventional staging 4 patients were in complete remission (CR), 33 were in partial remission (PR) and 8 had no change (NC).
RESULTS: In 9 patients unexpected distant metastases were found by PET and verified histologically in 8 cases; these patients did not undergo resection. In the assessment of the primary tumor all patients with CR had non-viable tumor cells (SUV:1.9±0.4) whereas all NC patients had viable tumor cells (SUV:9±5.9). In patients with PR 8 had non-viable cells (SUV:3±1.9) and 23 had residual tumor cells (SUV:5.9±5).Overall, viable tumor cells were seen in the specimen in 25 of 36 surgical patients (SUV:6.4±5.2; range 1.9-21.6). In 11 patients there was no of viable tumor (SUV:2.9±1.6; range 1.2-6.3; p< 0.01). All patients with a SUV of >5.8 had residual tumor cells. Using a SUV level of 3.25 to differentiate between viable or non-viable tumor, sensitivity was 80% and specificity 64% (positive predictive value (PPV) :80%; negative predictive value(NPV) :44%). In the evaluation of mediastinal lymph node disease after induction therapy, PET had a sensitivity of 50% and a specificity of 83% (PPV:72.7%; NPV:92%). Survival at 36 months was significantly higher in patients with a SUV of less than 4 (SUV<4:78±11%, n=17; SUV>4:22±13%, n=15; p<0.0008).
CONCLUSIONS: Tumor cell viability can be detected by FDG-PET following induction therapy. Due to the high negative predictive value of PET in lymph node staging repeated mediastinos copy may be omitted. The SUV level in the tumor region after induction therapy is a prognostic factor.
3:20 p.m. INTERMISSION - VISIT EXHIBITS North Bldg., Exhibit HallMetro Toronto Convention Centre 4:00 p.m. SIMULTANEOUS SCIENTIFIC SESSION - GENERAL THORACIC SURGERY North Bldg., Rm 105, Metro Toronto Convention Centre Moderators: Alec Patterson David J. Sugarbaker
*By Invitation
46. Surgical Resection of Limited Disease Small Cell Lung Cancer in the New Era of Platinum Chemotherapy: Its Time Has Come Malcolm V. Brock*, Craig Hooker*, James Syphard*, William Westra*, Li Xu*, Anthony Alberg*, David Mason*, Stephen Baylin*, James Herman*, David Ettinger*, Stephen Yang*; Baltimore, MD Discussant: Frances Shepard
OBJECTIVE: Although surgery has almost always been excluded from the treatment of limited-disease small cell lung cancer (LD-SCLC), new platinum drugs and modern staging techniques have allowed re-evaluating the role of surgery in this disease.
METHODS: We reviewed our experience from 1976-2002 of 1415 patients with SCLC of whom 84/1415 (6%) underwent surgery with curative intent. All long-term survivors were re-examined by a single pathologist to ensure accuracy with modern histological classifications.
RESULTS: Median age at surgery was 62 years old with most patients undergoing lobectomy or greater resection. Mixed morphology SCLC/Large Cell occurred in 15% (13/84), while other mixed tumors represented 12% (10/84). Treatment consisted of surgery alone in 22% of cases (19/84), neoadjuvant therapy in 10% (8/84), adjuvant therapy in 55% (46/84), and 13% (11/84) of patients received combined neoadjuvant and adjuvant therapy. Prophylactic cranial irradiation was given to 33% (28/84) of patients while platinum and non-platinum based chemotherapy (85% cyclophosphamide, adriamycin, vincristine) was administered to 26% (22/ 84) and 39% (33/84) of patients, respectively. The 5-year and 10-year survival rates for the entire cohort were 41% and 33% respectively. Patients receiving platinum based chemotherapy had significantly longer 5-year survival rates than patients who did not (48% vs.13%, p=0.02). Survival rates differed significantly before and after 1987 (p=0.003), the first year of widespread platinum use at our institution. The overall 5-year and 10-year survival rates for the 43 patients with very limited disease (T1-2 NO) were 55% and 44% respectively. Of those with very limited disease who received chemotherapy, the 5-year survival rates for platinum and non-platinum based chemotherapy were 76% and 39%, respectively. Survival outcomes also differed by gender with females having a statistically significant 5-year and 10-year survival advantage over males (58% vs. 28% and 49% vs. 22%, respectively; p=0.03). Stage, pack year tobacco history, age at surgery, administration of platinum-based chemotherapy, and presence of mixed morphology SCLC did not differ between genders.
Survival Curves of Patients With Resected Small Cell Lung Cancer Who Received Platinum or Non-Platinum Chemotherapy (N=55)
CONCLUSIONS: Our favorable long term survival in selected patients with ID-SCLC supports a re-evaluation of the multimodality therapeutic approach to ID-SCLC that now only includes radiotherapy and chemotherapy. Surgery may play a significant role in the treatment paradigm of this disease.
*By Invitation
47. Sublobar Resection with 125 Iodine Intraoperative Brachytherapy for Peripheral Small Stage IA Non-Small Cell Lung Cancers Hiran C. Fernando*, Ricardo S. Snatos*, John R. Benfield, Frederic W. Grannis, Jr.*, Robert J. Keenan, James D. Luketich, Rodney J. Landreneau; Pittsburgh, PA, Los Angeles, CA, Duarte, CA Discussant: 1Joseph P. Shrager
OBJECTIVE: Aggressive CT screening programs are identifying small peripheral NSCLC amenable to sublobar resection (SR) with clear margins; however, popular belief among thoracic surgeons is that SR should be only used as "compromise therapy" for physiologically impaired patients when lobar resection (LR) may be hazardous. Recent results in the literature demonstrating good results with sublobar resection (SR) lead us to review our experience with SR compared to lobar resection (LR) for stage IA NSCLC. We also evaluated the effect of 125 Iodine intraoperative brachytherapy (Brachy) on local recurrence following SR.
METHODS: Three hundred patients (149 men) undergoing either SR (n= 128) or lobectomy (LR n=172) for peripheral stage IA NSCLC were analyzed. Brachy was utilized in 63 SR patients. Patients were stratified by tumor diameter (<2cm; n=l41) or (2-3cm; n=159) and type of resection. Chi square and Kaplan-Meier survival were used for statistical analysis.
RESULTS: SR patients were older (69 versus 66 years; p=0.017); with poorer pulmonary function (FEV1% 53% versus 78%; p=0.001). The general results of our analyses are seen in the table below. In the <2cm SR patients local recurrence was 1/22 (4.5%) with Brachy compared to 9 / 35 (25.7%) without Brachy*. SR of 2-3cm lesions was associated with a local recurrence in 1/41 patients (2.2%) with Brachy and 2/30 patients (6.7%) without Brachy**. Overall, Brachy decreased local recurrence from 16.9% to 3.2% among all SR patients (p=0.010). Survival was similar between SR and LR for stage 1A patients with <2 cm tumors. Patients with 2-3cm tumors had lower survival with SR vs. LR; however, cancer deaths were not different between groups (LR-15% versus SR-21%; p=0.296).
CONCLUSIONS: Sublobar resection of peripheral stage IA NSCLC <2cm diameter appears reasonable. Intraoperative brachytherapy may reduce local recurrence following SR. For tumors >2cm, differential survival between SR and LR may be related to impaired functional status in our patient selected for SR. Prospective study is recommended to confirm these findings.
*By Invitation 11999-01 Research Scholar 48. Pain and Return of Physical Function are no Different Following Auxiliary Muscle-sparing versus Modified Posterolateral Thoracotomy E. Andrew Ochroch*, Allan Gottschalk, John G. Augoustides*, Larry R. Kaiser, 1Joseph B. Shrager; Philadelphia, PA, Baltimore, MD Discussant: Steven J. Mentzer
OBJECTIVE: We hypothesized that pain and impairment of physical function during hospitalization and the first postoperative year would be less in patients undergoing the vertical, auxiliary, wholly muscle-sparing thoracotomy (MT) vs. serratus-sparing, posterolateral thoracotomy (PT).
METHODS: Prospective data collected for a randomized, double-blinded study comparing two modes of intraoperative epidural drug administration were analyzed with respect to MT and PT incisions for segmentectomy, lobectomy, or bilobectomy without chest wall resection. Incision type was determined by the surgeon. Pain, physical activity, and the extent that incision pain interferes with several activities were assessed with standard questionnaires (Brief Pain Inventory and SF-36) on postop days l-5,and at postop weeks 4, 8, 12, 24, 36, and 48 by a blinded research assistant. Postoperative pain management was standardized for all subjects, and included epidural analgesia until after thoracostomy tube removal.
RESULTS: 82 underwent MT and 39 underwent PT during the 16 month accrual period. There were no significant differences in demographics, tumor stage or size between the two groups. The mode of epidural analgesia had no impact as a covariate, and there was no difference in the amount of any type of analgesics received by the 2 groups. Early postoperative pain (averaged over days 1-5) was similar in both groups (Table). At 4 weeks, PT trended towards more pain, but this trend was not statistically significant, and at week 12 the pain scores were nearly identical (Table). The number of patients with pain > 3 out of 10 at 48 weeks was also not different between groups. Physical activity levels showed a significant drop from preop to 4 weeks postop, but with no difference between MT and PT (p=0.28). Incision type did not predict complications, morbidity or mortality. Women suffered more pain than men regardless of incision type.
Pain scores are means. Influence of Pain: 0= does not affect, 10= completely inhibits, scores are means. Activity scores are medians. No statistically significant differences were found using p<0 05 as a cutoff.
CONCLUSIONS: In this study with prospectively acquired pain data on a large cohort of patients, we failed to find a significant difference in early or late pain or recovery of function comparing MT vs PT. One might choose muscle sparing incisions in particular patients for purposes of cosmesis or preservation of arm strength, but it does not appear that one should anticipate reduced pain or more rapid overall recovery of function following this incision, at least when epidural analgesia is used aggressively for perioperative pain control.
5:00 p.m. EXECUTIVE SESSION (Members Only) North Bldg., Hall C, Metro Toronto Convention Centre
*By Invitation 11999-01 Research Scholar
TUESDAY AFTERNOON, APRIL 27, 2004
2:00 p.m. SIMULTANEOUS SCIENTIFIC SESSION - CONGENITAL HEART DISEASE (8 minutes presentation, 12 minutes discussion) North Bldg., Rm 107, Metro Toronto Convention Centre Moderators: Richard A. Jonas Scott M. Bradley
49. Does Duration of Donor Brain Injury Affect Outcome After Orthotropic Pediatric Heart Transplantation? Jonah Odim*, Hillel Laks, Chris Vincent*, Charles Murphy*, Caron Burch*, Kausik Mukherjee*, Anamika Banerji*, David Gjertson*; Los Angeles, CA Discussant: Leonard L. Bailey
OBJECTIVE: There are scarce data relating donor brain injury to outcomes after heart transplantation. We tested the hypothesis that the duration of donor brain injury had an adverse effect on recipient rejection and mortality in pediatric heart transplantation.
METHODS: Ninety-three pediatric patients from 1997 to 2003 underwent orthotropic heart transplantation at our center. The donor and recipient medical records were reviewed. The primary outcomes were the number of rejection episodes and the time to first rejection. Secondary outcome was mortality.
RESULTS: Of the 93 recipients of cardiac allografts, 8 (9%) and 2 (2%) received second and third allografts respectively. Overall mortality for the group was 7% (6/93). Median time duration of donor brain injury to declaration of death, death to organ removal, and graft ischemia time were 38, 24, and 3.3 hours respectively. Cox regression analysis (adjusting for UNOS status, ventilator dependence, ECMO/VAD status, diagnosis of congenital heart disease, gender and CMV mismatches, and type of immunosuppression) demonstrated that recipients of donor hearts with relatively long periods from brain injury to death declaration (96 hours) or from death to organ removal (34 hours) had significantly lower rejection rates [HRs = 0.3 (p=0.01) and 0.5 (p=0.05) for injury and death times, respectively]. In this series, prolonged donor heart ischemia (4.6 hours) did not impact rejection rates.
CONCLUSIONS: The longer duration of neurohormonal discharge and stress related to donor brain injury and death, may attenuate factors in the recipient associated with rejection. Further study of these phenomena are warranted.
*By Invitation 50. Repair of Congenital Heart Lesions Combined with Lung Transplantation for the Treatment of Severe Pulmonary Hypertension: A Thirteen-Year Experience Charles B. Huddleston, 1Cliff K. Choong*, Eric N. Mendeloff, Stuart C. Sweet*, Tracey J. Guthrie*, Fabio J. Haddad*, Pam Schuler*, Maite De La Morena*; St Louis, MO Discussant: Vaughn A. Starnes
OBJECTIVE: Treatment options of patients with severe pulmonary hypertension associated with congenital heart disease include a combined repair of the underlying congenital heart lesion and lung transplantation (CCII) or alternatively a heart-lung transplant (HET). We prefer to perform lung transplantation (LT) with repair of the cardiac lesion so as to augment the donor pool and to avoid the cardiac complications associated with heart transplant. We report our experience with CCLT and compare the results to patients who had HIT during the same time period.
METHODS: Patients who had CCLT (n=35) and HIT (n=16) performed between 7/90 and 9/ 03 were reviewed retrospectively and shown in table.
RESULTS: Underlying congenital heart disease (CHD) in the CCLT patients included transposition of great vessels (n=2), atrioventricular canal defect (n=2), ventricular septal defect (n=9), pulmonary venous obstruction (n=7), Scimitar syndrome (n=2), pulmonary artery atresia or stenosis (n=5) and others (n=8). Thirteen (37.1%) of the CCLT patients had their CHD repair prior to LT, while the remaining CHD repairs were performed concomitantly with LT. Causes of hospital mortality in the CCLT group were graft failure (n=5), severe intraoperative hemorrhage (SIH) (n=2) and infection (n=2). Causes of late mortality were bronchiolitis obliterans (BO) (n=3), infection (n=5) and malignancy (n=2). Sixteen patients underwent HLT because of poor LV function or single ventricle anatomy associated with severe pulmonary hypertension. Causes of hospital mortality in the HLT group were graft failure (n=2),SIH (n=2) and infection (n=1). Causes of late mortality were cardiac arrest related to coronary arteriopathy (n=1) and infection (n=1). Kaplan-Meier (KM) freedom from BO at 1, 3, 5 years were 72.9%, 54.7%, 54.7% for CCLT group and 77.8%, 51.9%, 38.9% for HLT group respectively. KM survival at 1,3,5 years were 62.9%, 51.4%, 51.4% for CCLT group and 66.5%, 66.5%, 60% for HLT group respectively.
CONCLUSIONS: CCLT is a feasible surgical treatment option and hospital mortality has markedly improved over the course of time. Long term outcome is determined by associated complications related to lung transplantation. Despite the complexity of performing a combined CHD repair with lung transplant and the resulting increased perioperative morbidity, the patients experienced a similar hospital mortality and long-term outcomes as compared to patients who had HLT.
*By Invitation 12002-03 Graham Fellow 51. Long Segment Congenital Trachea! Stenosis: Slide Tracheoplasty and a Multi-disciplinary Approach Improve Outcomes and Reduce Costs Ergin Kocyildirim*, Catherine Dunne*, Ben Hartley*, Clare McLaren*, Quen Mok*, Clair Noctor*, Nick Pigott*, Derek Roebuck*, Savjeet Uppal*, Colin Wallis*, Martin Elliott; London, UK Discussant: Hermes C. Grillo
OBJECTIVE: Long segment congenital trachea! stenosis (LSCTS) is rare, life-threatening, difficult and expensive to treat. Management remains controversial. A Multi-Disciplinary Tracheal Team (MDTT) (Cardiothoracic Surgeon, ENT Surgeon, Interventional Radiologist, Intensivist, Respiratory Physician, Specialist Nurses, etc.) was formed in 2000 to deal with a large number of children with airway problems referred for management. We review the impact of that service and a simultaneous shift to slide tracheoplasty (ST) as the preferred treatment option.
METHODS: From 1997 to 2003,33 patients with LSCTS (19 patients had cardiovascular anomalies) had surgery. Prior to MDTT, pericardia! patch tracheoplasty (PPT), +/_ auto graft was the preferred method of repair. After MDDT, an integrated care plan preferring slide tracheoplasty was initiated. Cardiac lesions were corrected simultaneously.
RESULTS: Treatment strategies overlapped eras. PPT was performed (1997 - 2001) on 15 infants. 12 patients had a suspended' PPT, of whom 2 pts (17%) died late. Three patients had a simple, unsuspended patch, 2 (67%) died in early post-operative period. Four patients underwent trachea! autograft repair with 2 (50%) early deaths. All patients in this group required additional stent insertion.
14 pts underwent ST, with 1 early death (7.14%) and no late deaths. Only 1 ST patient has required stenting. Postoperative length of stay was halved.
CONCLUSIONS: Despite the heterogeneity of this group, the combination of slide tracheoplasty and MDTT management has resulted in a dramatic improvement in outcome for the patients with LCTS, and surrogate measures of cost reveal savings.
*By Invitation
52. Trends in Vascular Ring Surgery Carl L. Backer, Lauren D. Holinger*, Constantine Mavroudis; Chicago, IL Discussant: Mark W. Turrentine
OBJECTIVE: Review our clinical experience with infants and children with anatomically complete vascular rings (VR), ie, double aortic arch (DM) and right aortic arch with left ligamentum (RAA), and define trends in diagnostic and surgical strategies and clinical outcomes.
METHODS: From 1946 through 2003, 209 patients (113 DAA, 96 RAA) have had surgical repair of their VR. Mean and median ages at operation were: DAA 1.4±2.4 years and 0.75 years, RAA 2.7±3.9 years and 0.9 years, respectively. Male: female ratios for DAA and RAA patients were 1.3:1 and 1.8:1, respectively. Fourteen patients with an RAA had an associated Kommerell's diverticulum (KD). Associated cardiac diagnoses were present in 18 RAA patients (19%): VSD (8), TOF (3), LTGA (2), PDA (3), absent left pulmonary artery (1), and dextrocardia (1). In 8 DAA patients (8%), associated cardiac diagnoses were: left superior vena cava (2), pulmonary atresia (1), LTGA (1), VSD (1), PDA (1), absent left pulmonary artery (1), and dextrocardia (l).
RESULTS: There has been no operative mortality after repair of a VR since 1959- Mean and median hospital stay was: DAA 6.9± 17.1 and 3 days, and RAA 5.8±6.1 and 4 days, respectively. The primary means of diagnosis has shifted in the past 10 years from barium swallow and angiography (66% of patients through 1991 to 44% of patients 1992-2003) to CT scan or MRI (29% to 80%). In the past 10 years 52% have had a pre- or intraoperative bronchoscopy. For DAA patients the right arch was dominant in 85 patients (75%), left arch was dominant in 20 patients (18%), and the arches were equal in 8 patients (7%). Arch division strategy is guided by the preoperative CT scan. In RAA patients, 45 (47%) had a retroesophageal LSA, 15 (16%) had mirror image branching. The technique of operation has shifted to a muscle-sparing left thoracotomy without routine chest drainage (n=55). This has reduced the median hospital stay to 2 days for DAA and 3 days for RAA patients. In 5 earlier RAA patients the KD was pexed to the chest wall, in 7 recent RAA patients the KD was resected and the left subclavian artery (LSA) was transferred to the left carotid artery as a primary procedure. All patients undergoing LSA transfer have a patent anastomosis. In patients without cardiac anomalies, 2 DAA patients were repaired via a right thoracotomy; and 1 RAA was repaired via median sternotomy. Two DAA patients and 2 RAA patients underwent late reoperation (4/209, 2%) for aortopexy1.
CONCLUSIONS: At our institution, CT scan has replaced barium swallow as the diagnostic procedure of choice for VR evaluation. All VR patients should have pre- or intraoperative bronchoscopy, and a preoperative echocardiogram to rule out cardiac pathology. RAA with an associated KD is an indication for KD resection with LSA transfer to the left carotid artery. Use of a muscle-sparing thoracotomy incision without routine chest drainage has improved the median hospital stay.
3:20 p.m. INTERMISSION - VISIT EXHIBITS North Bldg., Exhibit Hall A & B Metro Toronto Convention Centre
*By Invitation 4:00 p.m. SIMULTANEOUS SCIENTIFIC SESSION - CONGENITAL HEART DISEASE North Bldg., Room 107 Metro Toronto Convention Centre Moderators: Richard A. JonasScott M. Bradley
53. Preoperative Cerebral Blood Flow is Diminished in Neonates with Severe Congenital Heart Defects Daniel J. Licht*, Jiongjiong Wang*, David W. Silvestre*, Susan C. Nicolson*, Lisa M. Montenegro*, Sarah Tabbutt*, Suzanne M. Burning*, Mayadah Shabbout*, David M. Shera*, J. William Gaynor, Thomas L. Spray, Robert R. Clancy*, Robert A. Zimmerman*, John A. Detre*; Philadelphia, PA Discussant: Erie H. Austin, III
OBJECTIVE: Impaired neurological outcome represents a major morbidity for survivors of neonatal surgery for congenital heart defects (CHD). Previous studies in these neonates have reported preoperative microcephaly and periventricular leukomalacia (PVL). The hypothesis of this study is that cerebral blood flow (CBF) is significantly diminished in neonates with severe forms of CHD, and may be an underlying etiology for the microcephaly and PVL seen.
METHODS: We measured CBF in infants with CHD utilizing a novel non-invasive MRI technique termed pulsed arterial spin label perfusion MRI (PASL-pMRI). CBF measurements were made immediately before surgery, under standard ventilator settings (PaC02 mean=40.7±5.4) and repeated under conditions of increased inspired carbon dioxide (PaCO2 mean= 61.6+7.0). Structural MR imaging of the brain was also obtained.
RESULTS: Of the 25 term preoperative infants studied, 13 were female, average weight was 3.1±0.4 kg (range 2.4-4), average age was 4.4±4.6 days (1-25 days), and all patients were intubated and received similar sedation and muscle relaxation. CHD lesions included hypoplastic left heart syndrome (10), transposition of the great arteries (6), tetralogy of Fallot (2) and others (7). Head circumference (HC) mean was 33.2±1.2cm (normal=35cm). Microcephaly, defined as HC < 2nd percentile, was seen in 24% (6/25). Baseline CBF was 19.7+9.2 ml/l00g/min (range 8.0-42.2) with normal values reported by "133Xe clearance as 50+3.4 ml/100g/min for term infants. Five patients had CBF below 10ml/100g/min. With hypercarbia, CBF increased in all patients to a mean of 40.1+20.3 (range 11.4-94.0, p<0.001) and percent change above baseline was 99.1+50% (range 11.6 to 224.8%). Univariate analysis found a lower hemoglobin was associated with higher baseline CBF (p=0.04) and microcephaly trended toward an association with lower CBF (p=0.13). A larger CBF percent change above baseline with hypercapnia was associated with a lower hemoglobin (p=0.012) and higher mean arterial pressure (p=0.004). Structural imaging showed PVL in 28% (7/25). The presence of PVL was associated with both decreased resting CBF (p=0.05) and a smaller change in CBF with hypercarbia (p=0.003).
CONCLUSIONS: When compared to published normative data, the mean CBF for this cohort was low, and drastically low in some. Chronic cerebral hypo perfusion in these preoperative neonates is associated with structural brain injury and may contribute to the adverse neurodevelopmental outcomes seen in some survivors of neonatal heart surgery. With hypercarbia, CBF increased to levels considered normal for this age group. PASL-pMRI is a novel technique with broad pediatric application. The accuracy of severely low CBF measurements and their physiologic significance requires continued investigation.
*By Invitation 54. Replacement of Stage I Norwood by Ductal Stenting and Bilateral Pulmonary Artery Banding Paul R. Vogt*; Hakan Ismail Akinturk*, Ina Michel-Behnke*, Klaus Valeske*, Matthias Muller*, Josef Thul*, Dietmar Schranz*, Giessen, Germany Discussant: Thomas L. Spray
OBJECTIVE: The classical Norwood pathway is associated with an important inter stage mortality. Interventional ductal stenting + surgical bilateral pulmonary artery banding followed by aortic arch reconstruction + bidirectional Glenn anastomosis, later completed by total cavopulmonary connection (TCPC), replaces stage I Norwood and decreases the overall mortality along the Norwood pathway.
METHODS: Between 1998 and 2003,27 patients with hypoplastic left heart syndrome (HLHS) (n=20; 74%) or hypoplastic left heart complex (HLHC) (n=7; 26%) underwent interventional ductal stenting, balloon dilatation atrial septectomy, if indicated, and bilateral pulmonary artery banding. Out of 20 HLHS patients, 12 (60%) had arch reconstruction + bidirectional Glenn after a mean of 4±1 months (3.5 to 6 months), followed by TCPC in 5 patients after a mean of 3 years (2 to 3.5 years) after arch reconstruction and bidirectional Glenn. None had deep hypothermic circulatory arrest along this pathway. After ductal stenting + bilateral pulmonary artery banding, 4 children not eligible for the Norwood pathway underwent cardiac transplantation (HTX) after a mean waiting time of 55 days (23 to 364 days). After ductal stenting + bilateral pulmonary artery banding, left ventricular growth was observed in 7 children (26%), 6 subsequently undergoing biventricular repair after a mean 4.5 months (3.5 to 7 months).
RESULTS: Out of 27 children, 3 (11 %) had ductal stenting + bilateral pulmonary artery banding, now awaiting the next stage; 12 (44%) had aortic arch reconstruction + bidirectional Glenn, and, 5 (18.5%) had TCPC. 30-day mortality was 7% for ductal stent + bilateral pulmonary artery banding; 8% for aortic arch reconstruction + bidirectional Glenn, and, 0% for TCPC. Up to now, 5 out of 20 patients (25%), undergoing ductal stenting + bilateral pulmonary artery banding, finally completed the Norwood pathway. Overall, 5 patients died (18%) during the study period: 2 (7%) died from ductal stent displacement early in this series in 1999, 2 (7%) died on the waiting list for HTx and 1 child (4%), for whom parents refused proposed HTx for religious reasons, died after arch reconstruction + bidirectional Glenn. Operative mortality was 0% for both group of patients, for those undergoing HTx, and for those receiving biventricular reconstruction.
CONCLUSIONS: For children with HLHS and HLHC, early postnatal ductal stenting + bilateral pulmonary artery banding replaces stage I Norwood in selected children undergoing the Norwood pathway, decreasing its overall mortality rate. In addition, ductal stenting + pulmonary artery banding extends the safe period on the waiting list for those children with HLHS undergoing HTx, and allows observation of left ventricular growth to identify children with HLHC suitable for biventricular repair.
*By Invitation 55. The Contegra Conduit in the Right Ventricular Outflow Tract Induces Supravalvular Stenosis Leen Van Garsse*, Bart Meyns*, Benedicte Eyskens*, Luc Mertens*, Derize Boshoff*, Marc Gewillig*, Willem Daenen*; Leuven, Belgium Discussant: John W. Brown
OBJECTIVE: To evaluate the incidence and nature of pulmonary stenosis after implantation of the bovine jugular vein graft (Contegra) in the right ventricular outflow tract (RVOT).
METHODS: Between May 2000 and September 2002, 58 Contegra conduits (12 to 22 mm) were implanted in the RVOT during primary repair (n=27) or redo surgery (n=31) in 57 patients. The ages ranged from 2 days to 48 years (mean 9 years).
Indications were truncus arteriosus (17), tetralogy of Pallet (27), pulmonary replacement in the Ross operation (10) and Rastelli type repair for double outlet right ventricle (4). Echocardiography was prospectively performed by a fixed team of investigators during follow-up (mean 19.08+14.67 months, 98% complete). An instantaneous peak gradient > 50mmHg was considered as a severe stenosis.
RESULTS: Two patients died from staphylococcus aureus septicemia and enterococcal endocarditis after 12 days and 12 weeks respectively.
Freedom of severe stenosis was 91±3% at 3 months, 68±6% at 12 months and 49±8% at 24 months. The incidence of pulmonary stenosis increases linearly in time. Younger age and its derivatives (graft size, indication) are signifantly related to the occurrence of severe stenosis (p=0.0004).
All stenoses were located at the distal anastomosis. Seventeen conduits (29%) required an endovascular intervention (balloon dilatation or stent). Seven conduits (12%) were explanted (2 because of endocarditis, 5 because of stenosis). Histological analysis of the explanted conduits showed important proliferation of neo-intima at the level of the distal anastomosis. Severe valve regurgitation was observed in 6 conduits (10%) and was always secondary to dilatation in the presence of severe graft stenosis.
CONCLUSIONS: The Contegra conduit induces a neo-intima proliferation at the level of the pulmonary anastomosis. This leads to a high incidence of severe stenosis at intermediate-term follow-up.
5:00 p.m. EXECUTIVE SESSION (Members Only) North Bldg., Hall C, Metro Toronto Convention Centre
*By Invitation
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