4th Oct

Transcription

4th Oct

Tuesday 4 and Wednesday 5 October
The official newspaper of the EACTS Annual Meeting 2011
The beauty of the differences
In this issue
VATS in the 21st
century?
Jens Eckardt
questions
whether
VATS is still
an adequate
approach for
pulmonary
metastasectomy.
Entitled ‘The beauty of the differences’, this year’s Presidential Address was inspired
by a picture of Octavio Alfieri’s daughter, playing with children of different races.
Looking at the picture, one mother commented: ‘The beauty of the differences’. Ever
since, this spontaneous comment has remained impressed in Alfieri’s mind.
4
Prophylactic
annuloplasty
Manuel
Antunes
examines if
this treatment
paradigm is
still necessary
for less
than severe
functional tricuspid regurgitation.
10
Connective tissue
disease of the aorta
This special
Focus Session
will provide
insights into the
management of
cardiovascular
manifestations
of connective
tissue diseases.
12
Destination therapy
with MCS
Roland
Hetzer
reports on
his centre’s
25 year
experience
of implanting
1,848
devices.
W
“
hat does it mean? It
means appreciation,
respect, acceptance,
understanding, tolerance for different opinions, attitudes, cultures and
backgrounds. It means open mindedness, and therefore potential for
growth”, he explained.
Alfieri then discussed how this
concept is allied to the education
and training of cardio-thoracic surgeons – not only in the great value
of a formal, complete, structured
training programmes in a well-established institution, but also in the
importance of exposure to different
constituencies.
Alfieri said he has always been
looking for the opportunity to learn
from different teachers, gain different mentors, and work in different
countries, environments and healthcare systems. From Bergamo (under
Lucio Parenzan), and Buffalo (under
Dr Subramanian) to Alabama (John
Kirklin) and Nieuwegein, he explained how he took advantage of
all the diversities in his education.
“I think that you all agree that education and training should con-
tinue throughout our entire professional life and not be confined
within a temporary frame,” said Alfieri. “To travel around the world
He then outlined how the completion of the human genome has revolutionised perspectives to diagnose, treat and prevent a number
of diseases. Alfieri explained that
all patients are different and behave differently even if they have
the same disease, and that the genome of any given individual is
unique (with the exception of identical twins).
Accordingly, when patients have
the same disease, it can often be associated with different symptoms,
responses to treatment and outcomes. He therefore urged the audience to broaden the objectives of
their investigations, in line with a
better comprehension of the individual differences.
“For instance, to study the effect of a medical or surgical treatment in a population affected by
a certain disease, it is important to
document a reduction of adverse
events during follow-up (in this example from 30% to 15% after a
certain time),” he said. “But it is
equally or perhaps more relevant
to understand why 70% of the patients do not have adverse events
and find out what other people are without treatment and why 15%
doing differently, and why, is a very of the patients still have adverse
effective method to constantly learn events in spite of the treatment. If
and grow.”
we understand that, the treatment
Leonardo Da Vinci Award for
Training Excellence
16
Perfusion: problems
and opportunities
This special
Focus Session
will explore
the latest
developments in
extracorporeal
circulation.
23
Wednesday’s
Wednesday’s
Highlights
Highlights
27
Floorplan
36
Genome
can be avoided in 85% of the population!”
He said that the response to individual differences is patient-centred care, carried out in a multidisciplinary environment and should
be mandatory for a tailored patient
management. For many diseases
treated by cardiothoracic surgeons
the spectrum of therapeutic options has increased due to advances
in technology, and the response to
the individual differences can only
be improved by the wider choice of
possible solutions.
“Not only patients are different
and cardio-thoracic surgeons are
no exception. I am firmly convinced
that individual differences have to
be taken into account, and a sort of
‘genomic’ leadership has to be exerted. In the leadership repertoire,
there are many styles which can
be effectively applied to motivate,
guide, inspire, persuade people,
and to create resonance and emotional involvement in a group” concluded Alfieri.
The address finished with three
short speeches by Nicolo Piazza (via
video),
Joerg Seeburger, Francesco Maisano, who emphasised the importance of a varied education,
increased research and multidisciplinary cooperation.
Marko Turina receives Honorary
Membership from the EACTS
E
ACTS Daily News is delighted to announce
that the inaugural Leonardo Da Vinci Award
for Training Excellence was awarded to Alfred Kocher, of Vienna, Austria. The winner was
announced by Dr Rafael Sabada, who also acknowledged the tremendous teaching abilities of
the other two finalists, Mattia Glauber (Massa, Italy) and Samer Nashef (Cambridge, UK).
The Leonardo Da Vinci Award for Training Excellence is intended to recognise and reward excellence in training, establish a benchmark in the form
of a trainer role model, and define the attributes
that makes a good cardiothoracic surgical teacher.
The principle behind the award is for the trainee
to nominate the trainer, and all cardiothoracic
trainees in every country in Europe were invited to
nominate their trainer for the Leonardo Da Vinci
Award.
Dr Kocher will return to next year’s meeting in
Barcelona, in October 2012, to speak about his
teaching methods.
Alfred Kocher
P
rofessor Marko Turina (left), a co-founder and the first Secretary General of the
EACTS, yesterday received Honorary Membership from the Association. Current
Secretary General, Pieter Kappetein paid tribute to his outstanding contribution,
not only to the Association but to cardio-thoracic surgery around the world.
2 Tuesday 4 and Wednesday 5 October 2011 EACTS Daily News
Tuesday 4 October 2011
08:30 Professional Challenges
Auditorium 1
Total arterial grafting I
Learning objectives:
n
to gain insight into the reasons behind the disparity
between science and practice in total arterial grafting
Moderators: J. Gruenenfelder, Zürich; D. P. Taggart, Oxford
08:30
No touch all-arterial grafting
D. Glineur, Louvain
Keynote lecture:
08:45
Arterial grafting for everyone?
B. Buxton, Melbourne
09:05 Abstracts
Location ???
09:05
Propensity matched analysis of bilateral internal
mammary artery versus single left internal
mammary artery at 17 years follow-up: Validation
of a contemporary surgical experience J. B. Grau,
G. Ferrari, A. C. W. Mak, R. E. Shaw, M. E. Brizzio, B. Mindich, J. Strobeck, A. Zapolanski (United States)
Invited Discussant: D. P. Taggart, Oxford
09:20
Lessons learned from 2120 bilateral internal
mammary grafts: Early outcomes and long-term
survival
S. Mohammadi, F. Dagenais, E. Dumont,
E. Charbonneau, P. Mathieu, R. Baillot, J. Perron, P. Voisine (Canada)
Invited Discussant: D. Pagano, Birmingham
09:35
Survival benefit of multiple arterial grafting in
a 25-year single institutional experience: The
importance of the third arterial graft
D. Glineur, E. Navarra, N. Colina Manzano, P. Astarci, L. Dekerchove, P. Noirhomme, J. Price, G. El Khoury (Belgium)
Invited Discussant: M. Thielmann, Essen
09:50
Impact of total arterial grafting on long-term
clinical outcome after off-pump coronary artery
bypass grafting
G. Yi, Y. Youn, K. Yoo (Republic of Korea)
Invited Discussant: R. Yadav, London
08:30 Abstracts
Auditorium 2
Transcatheter aortic valve implantation II
Professional challenges – Total arterial grafting II Auditorium 1 10:30
The utility of FFR in the evaluation
of questionable coronary lesions:
Combining anatomic and functional
information to optimize the use of
arterial conduits prior to CABG
Juan Grau Columbia University
College of Physicians
and Surgeons
Christopher K
Johnson Valley Hospital Heart
and Vascular Institute
C
Juan Grau
oronary angiography remains the
most common method of determining the need for percutaneous coronary intervention (PCI). However, visual inspection of a lesion was
shown to be an inadequate method for
determining severity of disease as early
as 1984. Measuring Minimum lumen diameter (MLD) is an improved, quantified
form of coronary angiography that has
been shown to better predict the success of PCI and coronary artery bypass
grafts (CABG). FFR is an invasive method
of identifying hemodynamically compromised vessels by use of a pressure catheter. FFR is defined as the mean distal
pressure divided by the proximal pressure
in a vessel at maximum hyperemia; an
FFR of 1 would indicate no stenosis while
an FFR of 0.50 shows a 50% decrease in
blood flow after a lesion.
The benefits of using FFR-guided PCI
are well established. The DEFER trial
showed no significant differences in fiveyear outcomes between patients with
FFR >0.75 , regardless if treated medically or with PCI, The results of the FAME
trial suggested that the determination
of PCI indications by angiogram alone
resulted in significantly higher rates of
mortality and myocardial infarction when
compared to FFR-guided stenting. The
PHANTOM study analyzed small coronary arteries scheduled for PCI by angiogram and found only 35% of lesions
had significant coronary stenosis when
measured by FFR. Recently, a Functional
SYNTAX Score (FSS) that combines the
traditional SYNTAX score with FFR data
was developed. The use of these two
variables together better predicts adverse
events in patients with multivessel CAD
undergoing PCI.
We as cardiac surgeons are required
to provide full revascularization to our
CABG patients. Internal mammary arterial (IMA) conduits have been shown
to provide the most long term patency
when grafted to severely stenosed vessels and they are responsible for the
prolongation of survival observed after CABG. Given the limited availability of IMAs, it crucial to assure lesions to
be bypassed are severe enough to warrant their use
Our current ability to accurately predict,
through FFR, the functional impact of different coronary lesions amenable to surgical revascularization is likely being underutilized by cardiac surgeons worldwide.
This is likely secondary to the limited experience we as a group have had with this
technology when compared to our colleagues from Interventional cardiology
(PCI).It seems based on recent published
literature a more sophisticated analysis of
angiographic lesions on patients scheduled to undergo CABG is warranted.
n
to update knowledge of outcome and technical issues
in transcatheter aortic valve implantation
Moderators: V. Falk, Zürich; A.P. Kappetein, Rotterdam
08:30 Residual aortic and mitral regurgitation following
transcatheter aortic valve implantation
S. G. Jones, N. R. Abdulkareem, D. Roy, S. Brecker, M. Jahangiri (United Kingdom)
Invited Discussant: M. Thielmann, Essen
08:45
Transcatheter-based aortic valve implantation at
five years: What happened to our initial patients?
M. Doss, A. Zierer, S. Fichtlscherer, R. Lehman, S. Martens, A. Moritz (Germany)
Invited Discussant: F. Doguet, Rouen
09:00
Are there differences in clinical outcomes
between patients treated through a transaxillary
versus a transfemoral access route for
transcatheter aortic valve implantation?
S. Bleiziffer, A. Muensterer, N. Piazza, H. Ruge, A. Opitz, D. Mazzitelli, R. Lange (Germany)
Invited Discussant: M. Doss, Frankfurt
09:15
Worldwide experience with the 29mm Edwards
Sapien XT™ transcatheter heart valve in patients
with large aortic annulus
O. Wendler1, M. Thielmann2, H. Schroefel2, A. Rastan2,
H. Treede2, T. Wahlers2, W. Eichinger2, T. Walther2
(1 United Kingdom, 2 Germany)
09:30
Transapical aortic valve implantation: Two-year
outcomes from the SOURCE registry
O. Wendler1, T. Walther2, H. Schroefel2, R. Lange2,
H. Treede2, M. Fusari3, P. Rubino3, M. Thomas1
(1 United Kingdom, 2 Germany, 3 Italy)
Invited Discussant: A. Garsse, Maastricht
Invited Discussant: tba
09:45
A novel device for endovascular native aortic
valve resection for transapical transcatheter
aortic valve implantation
P. Astarci (Belgium)
Invited Discussant: M. Mack, Dallas
Continued on page 4
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We hope you enjoy the 25th Annual EACTS Meeting, in beautiful Lisbon, Portugal.
To learn more about HeartWare, please visit us at booth 1.34.
Coronary Angiogram of LAD
Intraoperative Doppler Flow Assement of LIMA to LAD at anastomosis
Abstracts Room 5A 08:30
Continued from page 2
Is VATS an adequate approach for pulmonary
metastasectomy in the 21st century?
08:30 Abstracts
Auditorium 7
Mitral valves
n
to gain insights into alternative techniques for
management of mitral valve disease
Moderators: R. Klautz, Leiden; P. Perier, Bad Neustadt
08:30
Enhancing departmental quality control in
minimally invasive mitral valve surgery: A single
institution experience
M. Murzi,
A. G. Cerillo, S. Bevilacqua, T. Gasbarri, E. Kallushi, P.
Farneti, M. Glauber (Italy)
Invited Discussant: I. Den Hamer, Groningen
08:45
Minimally invasive mitral valve surgery is a very
safe procedure with very low rates of conversion
to full sternotomy
M. Vollroth, J. Seeburger,
P. Kiefer, T. Noack, J. Garbade, M. Höbartner, M. Misfeld, F. Mohr (Germany)
09:00
Minimally invasive mitral valve repair for anterior
leaflet prolapse
B. Pfannmueller, J. Seeburger,
M. Misfeld, J. Garbade, M. A. Borger, F. Mohr (Germany)
Invited Discussant: J. Cremer, Kiel
Invited Discussant: Y. Van Belleghem, Gent
09:15
Percutaneous mitral valve repair using the
MitraClip system for treatment of highsurgicalrisk patients as an adjunct to a surgical mitral
valve programme: Single-centre experience in
>200 patients
J. Schirmer, S. Baldus,
H. Treede, O. Franzen, L. Conradi, M. Seiffert, T. Meinertz, H. Reichenspurner (Germany)
Invited Discussant: T. Sundt, Boston
09:30
Surgical versus percutaneous treatment of
functional mitral regurgitation
A. Giacomini, M. Taramasso, M. De Bonis, P. Denti, G. La Canna, A. Colombo, O. Alfieri, F. Maisano (Italy)
09:45
Impact of MitraClip therapy on secondary mitral
valve surgery: Does it preclude surgical repair?
L. Conradi, M. Seiffert, O. Franzen, S. Baldus, J. Schirmer, T. Meinertz, H. Treede, H. Reichenspurner (Germany)
Invited Discussant: V. Falk, Zürich
Auditorium 8
Antiplatelet therapy
n
to gain awareness of new developments in antiplatelet
treatment
Moderators: J. L. Pomar, Barcelona; D. P. Taggart, Oxford
08:35
08:45
08:55
09:05
09:15
09:25
09:35
09:45
09:55
Introduction
D. P. Taggart, Oxford
Platelet function
J. Carvalho de Sousa, Lisbon
Clopidogrel
N. van Mieghem, Rotterdam
Prasugrel
P. Smith, Durham
Ticagrelor
F. Verheugt, Amsterdam
Antiplatelet therapy in stable coronary artery
disease
A. Fernandez, Madrid
Antiplatelet therapy in unstable coronary artery
disease
A. P. Kappetein, Rotterdam
Operating under antiplatelet therapy – tips and
tricks
M. Sousa Uva, Lisbon
Postoperative use of antiplatelet therapy (mono,
double, triple …)
F. Verheugt, Amsterdam
Discussion
This programme is supported by an
unrestricted educational grant from
AstraZeneca, Daiichi Sankyo Europe and Eli
Lilly and Company
08:30 Abstracts
Room 5C
Assist devices II
n
to update knowledge of ventricular assist devices and
their application
Moderators: D. Loisance, Paris; C. Schmitz, Munich
08:30
Berlin heart paediatric assistance device: the
beginnings, the teachings and the cruising speed.
A monocentric experience with the same system
R. Henaine, S. Di Filippo, O. Bastien, M. Moutaouekkil, L. Berthomieu, J. Ninet (France)
Invited Discussant: F. Eckstein, Basel
08:45
T
Mechanical circulatory support after paediatric
heart transplantation G. Perri, J. Cassidy, R. Kirk,
S. Haynes, J. Smith, D. Crossland, A. Hasan, M. Griselli (United Kingdom)
Continued on page 6
Figure 1: Flowchart demonstrating
work-up and treatment of
patients referred for pulmonary
metastasectomy.
The transabdominal approach using
the right gastroepiploic artery in
redo coronary artery surgery
be a useful technique. This operation has been successfully
performed in 24 patients in a
10-year time frame, with low
in-hospital mortality and morbidity and favourable mid-term
eoperation for coronary
results. Some experience in usartery bypass grafting
(CABG) can be performed ing the GEA in redo CABG on
the beating heart is recomwith acceptable mortality and
mended.
morbidity, but is still a surgical
challenge. Repeat median sternotomy is associated with a sig- Surgical Technique
nificant risk of cardiovascular
The patients are placed in the
injury, which, in turn, carries a
standard supine position. Above
substantial risk of in-hospital
the xiphoid, an 8 to 10 cm medeath. When the right coronary dian incision is made on the
artery (RCA) or the right poste- scar of the previous sternotomy.
rior descending artery (PDA) is
This incision is long enough to
the only vessel involved, a small excise the xiphoid process, polaparotomy without any stersition a standard sternal retracnotomy and without cardiopul- tor, obtain adequate exposure
monary bypass using the right
of the inferior wall of the heart,
gastroepiploic artery (GEA) can and allow for easy access to the
Giuseppe Tavilla Department of
Cardio-thoracic Surgery, Radboud
University Nijmegen Medical Center,
The Netherlands
R
08:30 Focus Session
08:30
surgeons. Thirty-five of these were palpable during video-assisted thoracoscopic
surgery (87.5%) and all were identified
during thoracotomy. In addition, 26 new
and unexpected nodules were identified
he surgical approach for pulmonary
during thoracotomy: Five (19%) were
metastasectomy has become someunexpected metastases, 17 (65%) were
what controversial after the intrononclassified benign lesions, Three (12%)
duction of video-assisted thoracoscopic
were subpleural lymph nodes and one
surgery (VATS) in the early 1990´s bewas a primary lung cancer.
cause it has been questioned if radiologiIn conclusion, the present study demcally undetected parenchymal lesions are
Jens Eckardt
Peter Licht
onstrates that in the majority of patients
missed when bimanual palpation is reconsidered eligible for surgical resection who are referred for pulmonary metasstricted because of the portholes. Over
tasectomy an unexpected and radiologwere referred to our department. The
the years the VATS technology has improved and advanced surgical resections patients included 13 women, the median ically undetected nodule can be found
by bimanual palpation of the lung paare now performed routinely by VATS in age was 69 years.
renchyma during thoracotomy. The maTwo patients were excluded because
many centres but very little data on its
jority of these nodules are not palpable
mediastinal lymph node involvement or
efficacy for pulmonary metastasectomy
and consequently not resected and diagcarcinosis. In the remaining 28 patients
is available.
the primary cancers originated in the co- nosed during VATS. Because a substanAs a result, we conducted a prospectial proportion of these nodules are malon (n=24), GIST (n=1), kidney (n=1) or
tive observer-blinded study with modlignant we believe that VATS is an inferior
malignant melanoma (n=2). Forty nodern high-definition VATS. During a nine
ules suspicious of metastatic disease were approach for pulmonary metastasectomy
month period, 30 patients with suspected limited pulmonary metastatic dis- visible on the patient’s preoperative chest even in high-volume dedicated VATS-centres with high definition VATS equipment.
CT with no difference between the two
ease on a Computed Tomography (CT)
Jens Eckardt, Peter B Licht Department
of Cardiothoracic Surgery, Odense University
Hospital, Odense, Denmark
get coronary artery. The suction
device acts not only as a coronary stabilizer, but allows to
push back and to pull up the inferior wall of the heart for an
optimal surgical view. In patients with deep chests, exposure of the surgical field can be
upper abdomen for harvestimproved by either suturing the
ing of the GEA, making an addiaphragm to the caudal end
ditional lower sternotomy suof the skin incision or placing a
perfluous. The diaphragmatic
Giuseppe Tavilla
deep abdominal retractor, pullsurface of the heart is then dissected free from the diaphragm of the GEA; the graft is put in a ing caudally the diaphragm, the
to facilitate exposure of the in- warm gauze imbedded in dilute liver, and the other abdominal
organs.
nitroprusside and placed back
ferior wall of the heart. The
An incision of approximately
RCA and the PDA are identified into the abdominal cavity to4mm in the target coronary argether with the stomach.
to choose the target coronary
tery is made and an intracorNext, a hole in the right heartery for the anastomosis.
At this stage, the peritoneum midiaphragm is made to route onary shunt is placed whenever possible. The anastomosis
is opened, the stomach is pulled the GEA intrapericardially. The
is performed with a continuous
out gently of the abdomen, and site of the opening is chosen
dependent on the intended lo- 8/0 or 7/0 polypropylene suture
harvesting of the GEA is percation of the anastomosis. The on the beating heart. Heparin
formed in a skeletonized manGEA is always routed antegas- is antagonized with protamine
ner. After heparinization (1.5
trically and in front of the liver. (half the dose of the adminismg/kg), the distal part of the
tered heparin). At the end of
GEA is divided, and 3 to 4ml of Once the GEA is intrapericardially, a suction stabilizer is fixed the procedure, a small draina nitroprusside hydrochloride
age tube is placed into the pericranially on the retractor and
solution is injected intraluminally to relieve spasm. A hemo- the suction branches are placed cardium and the incision is routinely closed.
as close as possible to the tarclip is placed at the distal end
Sorin Group Freedom Solo Tissue Heart Valve
Providing Surgeons with New Treatment Options
S
ince 2004, Sorin Group has been
providing Freedom Solo, a biological aortic pericardial stentless
heart valve, to the medical community. Freedom Solo is the natural evolution of the Sorin Freedom
valve which has been on the market since 1991. Designed to maximize hemodynamic performance
and ease of implantation. Freedom
Solo behaves just like a healthy native valve restoring the quality of
life for patients.
Using a proven single-suture line
technique, the Freedom Solo can
be easily and safely implanted in
a shorter time than conventional
two-suture line stentless valves. Implanted in the supra-annular position, the Freedom Solo ensures
physiological blood flow through
the annulus providing excellent hemodynamics in terms of EOA and
mean and peak gradients which remain stable over time.. This leads
to a remarkable clinical improvement as well as to significant left
ventricular remodeling with fast
left ventricular function restoration. Freedom Solo is a totally biological heart valve with no synthetic material. The Freedom Solo’s
stentless design utilizes two pericardial sheets constructed to maximize
leaflet opening and closing.
Last March, Freedom Solo was
implanted for the first time in the
Canadian Investigational Testing
Authorization clinical study. Additional Canadian investigational
sites are scheduled to begin implanting the Freedom Solo pericardial aortic valve.
The first North American implant
of Freedom Solo was performed on
a 65-year male patient by Pierre Voi-
positioning, and Solo could be the
prosthesis of choice in the vast majority of patients”, said Dr. Voisine.
Sorin Group is very proud of the
first Freedom Solo valve implant in
North America, a next-generation
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its outstanding hemodynamic performance, durability, and ease of
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performance in Europe. Freedom
Solo valve with its unique technology provides an excellent alternative to physicians managing the
care of patients with aortic valve
disease. The Freedom Solo continues Sorin Group’s legacy of providsine, MD, Hopital Laval, Division of
Cardiac Surgery in Quebec City, Can- ing surgeons with market-leading
heart valve options.
ada. “The unique design and imFor further information on
plantation technique of the FreeFreedom Solo valve please come
dom Solo valve are very exciting.
Low gradients can be expected from and join us at The Sorin Group
a stentless valve with supra annular booth #2.22
One stitch too many: Transit-time flow predicts graft problem
Invited Discussant: G. Gerosa, Padova
09:00
Advanced heart failure in critical patients
(INTERMACS 1 and 2 levels): Ventricular
assistance devices or urgent transplant waiting
list? M. Attisani, P. Centofanti, M. Boffini, M. La Torre,
D. Ricci, M. Ribezzo, A. Baronetto, M. Rinaldi (Italy)
Invited Discussant: S. Westaby, Oxford
09:15
Paracorporeal biventricular assist device support
is superior to HeartMate II plus temporary
right ventricular assist device in patients with
cardiogenic shock
D. Schibilsky, E. Zimmer,
C. Benk, M. Siepe, C. Haller, M. Berchtold-Herz, F. Beyersdorf, C. Schlensak (Germany)
Invited Discussant: M. Pasic, Berlin
09:30
Established markers of renal and hepatic failure
are not appropriate in the acute stage before
extracorporeal life support implantation to predict
mortality
C. Heilmann, G. Trummer,
M. Berchtold-Herz, C. Benk, M. Siepe, C. Schlensak, F. Beyersdorf (Germany)
09:45
In vitro haemocompatibility of a novel
bioprosthetic total artificial heart
P. Jansen1, W. Van Oeveren2, A. Capel 1,
A. Carpentier 1 (1 France, 2 Netherlands)
Auditorium 1
Total arterial grafting II
n
to gain insight into the reasons behind the disparity
between science and practice in total arterial grafting
Moderators: J. Gruenenfelder, Zürich; D. P. Taggart, Oxford
10:30 Video
Arterial conduits in redo coronary artery surgery
G. Tavilla, Nijmegen
Learning from experience
Panel: D. Wendt, Essen; H. Reichenspurner, Hamburg
Left coronary fistula with origin of the circumflex
artery from the fistula: Treatment with coronary
artery bypass grafting
D. Schibilsky, K. Sarai, M. Siepe, C. Haller, F. Beyersdorf, C. Schlensak (Germany)
11:05 One stitch too many: Transit-time flow predicts
graft problem
T. M. Kieser, Calgary
11:20 How to use a SPY camera (fluorescent
indocyanine green) to predict problems in arterial grafts
D. P. Taggart, Oxford
11:35 The utility of fractional flow reserve in the
evaluation of questionable coronary lesions:
combining anatomic and functional information to
optimise the use of arterial conduits prior to CABG
J. B. Grau, New York
Teresa M Kieser and James
A Stone University of Calgary,
Foothills Medical Centre, Calgary,
Alberta, Canada
T
wo important points: 1)
When an extra stitch is
added to a distal anastomosis, recheck the transit-time
flow measurement (TTF) 2) If
the TTF value changes, it helps
if one pays attention to that
change.
This is a case of a patient
with an isolated 90% left main
stenosis and occluded right
coronary artery, who underwent emergency double coronary artery bypass surgery
with left internal thoracic artery (LITA) to left anterior descending (LAD) and right internal thoracic artery (RITA) to
a right coronary artery (RCA).
One extra stitch was placed at
the heel of the LITA for an anastomotic leak; TTF measurements
were made multiple times, (see
two of these below). On postop day one the patient developed lateral wall ischemia. Angiography showed patent RITA to
the RCA and patent LITA to the
LAD artery but no retrograde
flow to the proximal LAD or circumflex artery. At this point the
blinkers came off, and it was
obvious that the TTF values for
the LITA graft to the LAD had
changed after the extra stitch.
The patient underwent successful re-operation with placement
LITA to LAD before Protamine
left main stenosis, the left internal thoracic artery has capacity to fill the entire left coronary
artery system. 3) In 10-15% of
patients post CABG, Thallium
tests can be falsely positive.1
4) Bypass grafts may be imperfect without any other clinical
evidence: EKG changes, Echo
changes, hemodynamic compromise. 5) Vein grafts can become string signs – who knew?
Reference
1 Paolillo V, Iazzolino E, Varetto T, De Berardinis A, Rendine S, Marra S, Picciotto G, Baccega M, De Filippi PG,
Casaccia M. Myocardial scintigraphy with thallium-201
in the evaluation of aortocoronary bypass patients. G Ital
Cardiol. 1987 Nov;17(11):947-56
Teresa Kieser
LITA to LAD after Protamine, after extra stitch
of a saphenous vein to the lateral system and revision of the
LITA to the LAD artery.
The story gets better: four
months later a thallium test
shows a large volume of severe anterior wall ischemia. Angiography showed a still patent
RITA, a string sign of saphenous vein to the circumflex system and a very large left LITA
filling both the LAD artery anterograde and by retrograde
flow the whole circumflex system (see Angio picture right). A
repeat exercise Thallium at 19
months postoperatively showed
normal perfusion of the left
ventricle. At three years postoperatively, the patient is alive,
well and angina-free.
Lessons learned from this
case include: 1) repeated intraoperative TTF measurements
add diagnostic yield to graft patency assessment (as long as
one pays attention to them).
“Pre-stitch” flow down the LITA
graft was both anterograde and
retrograde, but “post stitch”
retrograde flow was lost. This
could have been uncovered by
measuring TTF using both proximal and distal snares to measure anterograde and retrograde
flow separately. 2) In isolated
Left Internal Thoracic Artery filling Left Coronary Artery
10:50
10:30 Abstracts
Auditorium 2
Aortic valve II
n
to enhance awareness and understanding of
techniques and outcomes in surgical management of
the aortic valve
Moderators: J. Pepper, London; G. Lutter, Kiel
10:30
Redo aortic valve surgery
M. Antunes, Coimbra
10:45 Aortic valve internal ring annuloplasty: In vitro
evaluation of a novel aortic valve annuloplasty
system L. De Kerchove1, A. Mangini 2, R.Vismara2,
G. Fiore2, M. Boodhwani3, P. Noirhomme1, C. Antona2,
G. El Khoury1 ( 1 Belgium, 2 Italy, 3 Canada)
Invited Discussant: H.-J. Schäfers, Homburg/Saar
11:00
Comparison between homograft and bioprothesis
for replacement of the right ventricular outflow
tract during the Ross procedure in adults
A. Miskovic, F. Özaslan, N. Monsefi, A. Karimian, M. Doss, A. Moritz (Germany)
Invited Discussant: A. Mangini, Milan
11:15
Mid-term outcomes of aortic valve replacement
after previous coronary artery bypass grafting
N. Dobrilovic, J. G. Fingleton, A. Maslow, W. Feng, F. Sellke, A. K. Singh (United States)
Invited Discussant: A. Maat, Rotterdam
11:30
Impact of residual regurgitation after aortic valve
replacement
S. Sponga, J. Perron, F. Dagenais, S. Mohammadi, P. Mathieu, R. Baillot, D. Doyle, P. Voisine (Canada)
Invited Discussant: W. Gomes, São Paulo
11:45
Film: Combined aortic valve and ascending aortic
replacement in symptomatic calcified aortic valve
Continued on page 8
Vivostat Co-delivery
®
S
Vivostat® Fibrin Sealant and Stem
ince the launch of the Vivostat®
system in 2001, the Copenhacells to develop biological heart
gen-based company Vivostat A/S
valve prostheses1
has had a strong focus on continn
At the Unfallklinik Murnau in
uously improving the user-friendGermany they are testing the coliness of the system as well as exdelivery system by using Vivostat®
panding the range of application
Fibrin Sealant and antibiotics to
devices.
minimize infections and re-infecThe most recent development for
tion.
Vivostat A/S is the Co-delivery sysn
At the University Hospital Zurich
tem. The Co-delivery system enain Switzerland they have tested
bles the surgeon to use the fibrin
matrix found in Vivostat® Fibrin
Sealant or Vivostat PRF® as a “delivery system” for topical application of any kind of compound
(liquid), for example drugs, antibiotics or even cells. A specially developed application system makes
it straightforward to embed your
own choice of drug or other solutions into the fibrin matrix for coapplication. Following application,
the fibrin matrix will be broken
down by fibrinolytic processes and
following this, the drug or cells are
gradually released to the surrounding tissue.
Vivostat A/S is currently in the
process of further developing the
co-delivery system so that the surgeon has the option of choosing between different sized syringes depending on the amount of
drug, antibiotics or cells that he/she
wants to co-deliver.
The Co-delivery system can be
used in a number of different procedures and settings. The past couple of years Vivostat A/S has tested
the Vivostat® Co-delivery system – in
a number of clinical environments
throughout Europe. A few of these
are listed below:
n
At the University Hospital of Rostock in Germany they have tested
Vivostat® Fibrin Sealant and cisplatin as chemotherapy by applying it directly on the tumor.2
The Vivostat® Co-delivery system
has time and time again shown its
potential, it allows the surgeon to
perform procedures in a way that
has not been possible until now. It
is a new way of thinking and acting
within surgery.
Using the Co-delivery system the
surgeon has the option to choose
between a number of different application devices:
The Vivostat® Spraypen®
The Vivostat® Spraypen® is a central
and unique component of the Vivostat® system. It enables the surgeon to apply Vivostat® Fibrin Sealant accurately and intermittently
throughout the entire procedure.
The Vivostat® Concorde
Spraypen®
With its carefully optimised angle on the spraytip, the Concorde
Spraypen® has been developed for
surgical procedures where fibrin
sealant must be applied in difficult
to reach areas, for example anastomosis on the backside of the heart
and sealing of the mammary bed.
Endoscopic Applicator
Spraypen®
Concorde Spraypen®
Endoscopic applicator
Spray Catheter
The Vivostat® Endoscopic Applicator is used in various types of Minimally Invasive Surgery. The singleuse endoscopic application catheter
is easily loaded into the endoscopic
handle, which is inserted via a 5mm
trocar. The pre-bent spraytip enables the surgeon to manipulate the
tip and spray in multiple directions.
Spray Catheter
The Vivostat® Spray Catheter is developed for the application of Vivostat PRF® in deep wounds and various kinds of fistulas. In combination
with specially designed spray
modes for the Applicator Unit, the
thin and flexible catheter enables
the surgeon to completely fill fistulas with fibrin sealant or PRF® without leaving any cavities behind.
For more information about the
Co-delivery system or the Vivostat®
system, visit www.vivostat.com or
stop by booth (2.12) at the EACTS
congress.
References
1 Tissue Engineering: Part C, 17 Issue 3: February 27, 2011
2 The Journal of Thoracic and Cardiovascular Surgery, Volume 141,
Number 1
Professional challenges – Mitral valve and beyond I Auditorium 1 14:00
Francesco Maisano Cardiochirurgia, Ospedale San Raffaele, Milano, Italy
10:30 Abstracts
Auditorium 7
Blood
n
to update knowledge of issues in blood conservation
in cardiac surgery
Moderators: D. P. Taggart, Oxford; M. Sousa Uva, Lisbon
10:30
Preoperative anaemia does not increase the
risks of early surgical revascularisation following
myocardial infarction
L. Zhang, B. Hiebert, R. C. Arora (Canada)
Invited Discussant: A. Fabbri, Verona
10:45
A case-controlled evaluation of the Medtronic
Resting Heart system compared to conventional
cardiopulmonary bypass in patients undergoing
isolated coronary artery bypass surgery
J. Nilsson, S. Nozohoor, S. Scicluna, P. Wallentin, E. Andell, P. Johnsson (Sweden)
Invited Discussant: A. Pavie, Paris
11:00
Isolated coronary artery bypass grafting with
minimal extracorporeal circulation, offpump,
and extracorporeal circulation: A prospective
comparison of haemodilution curves and
outcomes F. Rosato, C. Grossi, A. Capo, D. Bruzzone,
A. Verna, S. Rosano, F. Barili (Italy)
Invited Discussant: M. Versteegh, Leiden
11:15
Thromboelastography-guided blood component
therapy after cardiac surgery: A randomised study
J. Kempfert, M. Hänsig, P. Wobbe, E. Girdauskas, D. Schmitt, T. Walther, A. J. Rastan, F. Mohr (Germany)
Invited Discussant: J. J. Andreasen, Aalborg
11:30
Blood transfusions after on-pump coronary
artery bypass grafting: Focus on modifiable risk
factors
L. S. De Santo, C. Amarelli, A. Della
Corte, M. Scardone, C. Bancone, A. Carozza, G. Nappi,
G. Romano (Italy)
Invited Discussant: I. S. Modrau, Århus
11:45
Valve in ring: A method for mitral
revalving in patients with recurrent
MR following undersized anuloplasty
The impact of a multidisciplinary blood
conservation protocol on patient outcomes and
cost following cardiac surgery N. Ad, S. D. Holmes,
A. M. Speir, E. Choi, D. Fitzgerald, L. Halpin, L. Henry,
S. L. Hunt (United States)
Invited Discussant: J. Hörer, Munich
10:30 Focus Session
Auditorium 8
Functional tricuspid regurgitation:
State of the art and new perspectives
F
unctional mitral regurgitation
(FMR) is a challenging disease still
looking for the ideal treatment.
Following the pioneristic work of Steve
Bolling, surgeons have learned how to
treat it with undersized annuloplasty.
However, this technique is not always
effective and durable. For this reason,
the clinical value has been questioned
and alternative options have been suggested, including chordal sparing mitral
valve replacement and, more recently,
straightforward,
similar to TA-TAVI,
although echo
guidance was
mandatory for
proper positioning
transcatheter mitral valve repair with
the MitraClip system. Transcatheter mi- and implantation.
tral valve replacement is also under eval- Retrograde crossuation in preclinical studies and may being of the mitral
valve is a tricky
come another option in the future.
step of the proceToday, however, transcatheter valve
dure, where the
implantation is already available for
Francesco Maisano
operator should
those patients with recurrent MR folmake any effort to avoid the wires to be
lowing undersized anuloplasty or with
degenerated bioprosthesis. We describe entangled in the subvalvar apparatus.
We found this step to be facilitated
a case of valve in ring procedure, where
by the used of a balloon tipped cathea SAPIEN XT valve has been implanted
with a transapical approach, in a patient ter to cross the valve and by strict echowith recurrent MR following undersized guidance. The SAPIEN valve has been
implanted as usual under rapid pacing.
annuloplasty. The procedure was quite
Hemodynamic results were excellent as
the surgically implanted ring offered a
stable landing structure for the ballonexpandable stent and enabled adequate
sealing. The patient was discharged
home after few days.
This new option in our surgical armamentarium may stimulate a rethinking
in the field of FMR treatment. Now patients with recurrent MR following undersized annuloplasty may undergo a
less invasive procedure to restore normal
functionality of the mitral valve. Mitral
valve-in-ring is the demonstration that
transcatheter valve interventions are increasing our therapeutic options. Surgeons should be aware of the new possibilities and need to be fully involved in
these procedures to offer the best possible treatment to valve patients.
Focus session – The academic surgeon Room 3A 08:30
How to review a paper for a Journal
Friedhelm Beyersdorf Department of Cardiovascular
Surgery, University Medical Center Freiburg, Freiburg, Germany, and Editor-in-Chief EJCTS and ICVTS
T
he review process is an essential part of any scientific writing and publishing. In all major scientific Journals, a substantial number of submitted
papers are being sent to 2-4 reviewers, except those
submissions, which are rejected right away for various reasons (unsuitable paper, redundant paper, serious and unchangeable flaws in the paper, etc.). In addition the peer reviewed paper is usually seen also by
a very experienced Associate Editor and finally by the
Editor-in-Chief. Therefore there is a heavy burden on
the shoulders of the reviewers to perform an objective
and understandable review for the authors.
The peers who are performing the reviews for their
colleagues, will look for strengths and weaknesses in
the manuscripts. Usually the top strengths in accepted
papers are (a) timeliness of the problem studied, (b)
soundness of the study design, (c) excellence of writing (Bordage, 2001).
Therefore one of the main principles in scientific
writing is the fact that accepted papers have to have
both, a well designed and timely conducted study design and the ability of the authors to write a good
manuscript. If only one these two major prerequisites
is missing, the chance of being accepted for publication is low.
Whereas the importance of good scientific conductance of the study is easily understood, the importance
of good medical writing is often underestimated.
“Good medical writing” includes (1) a text that is easily read and is understandable also to those who are
not completely familiar with the special research field,
(2) clear outline of the problem (“Introduction”), (3)
statement of a hypothesis and questions which will be
answered by the study (“Introduction”), (4) description of the methods used and an explanation why
they have been used (“Material and Methods”), (5)
usage of the appropriate statistics – controlled and reviewed by an independent biostatistician before submission of the paper (“Material and Methods”), (6)
presentation of simple figures, tables and text – creating complicated figures/tables/text is easy, creating
easy to understand figures/tables/text is difficult!, (7)
objective presentation of the data (“Results”), (8) correct interpretation of the results (avoiding especially
overinterpretation) (“Results”), (9) balanced discussion
of the results (“Discussion”), (10) up-to-date citations
of relevant published papers.
The reviewer has to keep in mind that some deficiencies of a paper cannot be improved even by a
complete revision (e.g. lack of importance of the research topic, in appropriateness of the study design
(Bordage, 2001)), whereas others should be listed in
the review and send back to the authors asking for
a revision. In the “Comments of the Authors” there
should always be a list with major and minor weaknesses and strengths of the paper. This list should be
the basis for the final decision of the reviewer about
this paper, i.e. accept outright, send for revision, send
Image source: http://www4.stat.ncsu.edu/~stefanski/images/Peer%20review%20process%20improved.jpg
stenosis with calcified ascending aorta (porcelain
aorta) in a patient not suitable for transcatheter
M. Shrestha, N. Khaladj, C. Hagl, O. Teebken, M. Pichlmaier, A. Haverich (Germany)
for complete revision, or reject outright. It is also of
importance that this list in concert with the final decision. It is difficult to understand for the author, if the
reviewer lists only the strengths of the paper (or even
no comment at all) and his decision is to reject the
manuscript and vice versa.
It is known, that the level of agreement between
reviewers is highly variable (inter-rater variability =
0.25 range) (Chubin and Hackett, 1990), mainly because each reviewer focus on a different aspect of the
paper. Nevertheless, if the above mentioned factors
are being kept in mind, the reviewer very often helps
to improve the quality of the paper by the requested
revision and the quality is eventually better when the
article is printed as compared to its first submission.
References:
1 Bordage G: Reasons Reviewers Reject and Accept Manuscripts: The Strengths and Weaknesses in Medical Education Reports. Acad Med 2001; 76: 889-896
2 Chubin DE, Hackett EJ: Chapter 4. Peer review and the printed word. In: Chubin DE, Hacket
EJ (eds). Peerless Science: Peer Review and U.S. Science Policy. Albany, NY: State University of
New York Press, 1990: 83-122
n
to gain insight into new perspectives on diagnosis,
surgical indications and treatment of functional
tricuspid regurgitation
Moderators: O. Alfieri, Milan; G. Dreyfus, Monaco
Understanding functional TR: which implications?
10:30
10:40
10:50
11:00
11:10
11:20
11:30
11:40
Anatomy, pathophysiology and assessment of
functional TR
M. Sarano, Rochester
Implications in tricuspid annuloplasty rings
M. Jahangiri, London
Deciding about functional TR: timing of repair
Why so many MR patients with functional TR are
still not treated
R. Klautz, Leiden
Which patients should be treated?
L. A. Van Herwerden, Utrecht
Treating functional TR: beyond daily practice
How to prevent progression of functional TR?
S. Geidel, Hamburg
Is prophylactic annuloplasty for less than severe
functional TR really necessary?
M. J. Antunes, Coimbra
Tailoring the surgical approach to the stage of the
disease
G. Dreyfus, Monte Carlo
Discussion
G. Dreyfus, O. Alfieri
This session is supported by an unrestricted
educational grant from Edwards Lifesciences
10:30 Abstracts
Room 5C
Transplantation II
n
to increase awareness of risk factors, complications
and outcomes in cardiac transplantation
Moderators: F. Beyersdorf, Freiburg; P.Vouhé, Paris
Continued on page 10
Is it time for an interventional cardiac surgeon?
ments of surgical technique itself.
In the meantime, substantial
non-surgical innovations in the
asic surgical paradigms are
about to change these days un- treatment of cardiac and vascuder the influence of catheter based lar diseases, especially percutaneous techniques, have evolved and
cardiac and vascular technologies.
progressed to effective treatment
Since its early days cardiac surgery
strategies. Percutaneous coronary
changed from a high risk specialintervention has long replaced corized service to effective and reproducible surgery practiced with high onary surgery as the most common
treatment for coronary artery disquality at units all over the counease. However, not only since SYNtries. Driven by the success and
TAX we know that a tailored approbably also due to the fact that
proach to coronary heart disease
standard cardiac surgery significantly contributed to the economic including both surgical and interventional therapy options might be
well-being of the hospitals, the
willingness to implement technical the best for a distinct patient. Perinnovation into daily cardiac surgi- cutaneous catheter-based aortic
valve implantation became availcal practice was relatively modest
during a certain period of time. Un- able for an increasing population of patients, not only for those
til today “standard” coronary bywho were deemed “inoperable”
pass surgery in most centers is perfor several reasons. Multiple conformed only with small changes
cepts in the percutaneous treatfrom its origin in the late 1960s,
ment of mitral insufficiency are unmeaning an operation through a
dergoing pre-clinical and clinical
median sternotomy with the use
investigation including edge-toof open cardiopulmonary bypass.
Prostheses are still sutured into the edge repair, implantation of artificial chordae, and cinching techpatient and treatment of valvular
niques of the mitral annulus. Many
heart disease has benefited more
of the devices used are first generfrom improvements in prostheation devices and one can expect
sis design rather than from refineAndreas Liebold, MD
B
But who should perform this
new type of surgery in the future?
Will cardiac surgeons be trained in
catheter and imaging techniques
or will interventionalists take care
for the surgical access as well? Undoubtedly, the need for experienced surgeons, who are able
to perform complex surgery, will
continue. There is another view,
however, and that is that cardiothoracic surgeons are uniquely
Andreas Liebold qualified to adopt percutaneous
technologies in their armamentarthat after product refinements the ium. It is of vital interest for young
procedures will become more relia- trainees, skilled surgeons, and the
ble and competitive with open sur- whole specialty to be interested
gery. As a consequence to catheter- not only in the operating room
but also in the cath lab and angio
based valve procedures surgeons
try to keep the pace by performing suites. It is not difficult to imagine
a cardiac intervention room of the
classical operations through small
near future in which a combinaholes with the use of fluoro- or
videoscopy. Sutureless valves fitting tion of classic, small access,
through small holes are on the ho- videoscopic, and percutaneous
rizon. Hybrid procedures, meaning techniques are used simultaneously for the majority of patients.
the combination of a low risk surOne can argue about the opinion
gical access with a catheter based
of an anonymous discussant in an
cardiac or vascular intervention,
Internet blog “good surgeons will
became reality in many centers.
always have a good job”. The time
Risk splitting is the key word for
has come for an interventional carmany elderly patients presenting
diac surgeon.
with advanced disease.
Focus session – Functional TR: State of the art and new perspectives Auditorioum 8 10:30
10:30
Use of centrifugal left ventricular assist device
as bridge to candidacy in heart failure with
pulmonary hypertension
R. S. Kutty,
J. Parameshwar, C. Lewis, S. Nair, C. Sudarshan, D. P. Jenkins, J. Dunning, S. Tsui (United Kingdom)
10:45
Early graft failure after heart transplant: Risk
factors and implications for improved donor/
recipient matching
L. S. De Santo, C. Amarelli,
C. Marra, C. Maiello, C. Bancone, F. Grimaldi, G. Nappi, G. Romano (Italy)
Invited Discussant: F. Beyersdorf, Freiburg
Invited Discussant: J. B. Rich, Norfolk
11:00
Heart transplantation: 25-year single centre
experience G. Bruschi, T. Colombo, F. Oliva, L. Botta,
G. Pedrazzini, R. Paino, M. Frigerio, L. Martinelli (Italy)
Invited Discussant: H. Bittner, Leipzig
11:15
Is heart transplantation for complex congenital
heart disease a good option? A 25-year single
centre experience
N. Gorislavets, F. Seddio,
A. Iacovoni, A. Fontana, R. Sebastiani, A. Terzi, L. Galletti, P. Ferrazzi (Italy)
11:30
Risk factors for post-transplant low output
syndrome
T. Fujita, K. Toda, J. Kobayashi,
Y. Murata, O. Seguchi, H. Ueda, T. Nakatani (Japan)
Invited Discussant: G. Bruschi, Milan
Invited Discussant: A. Pavie, Paris
11:45
Rescue therapy with oral sildenafil decreases the
risk of early death due to right ventricular failure
in the transplanted heart
M. Maruszewski,
M. Zakliczynski, J. Nozynski, M. Zembala (Poland)
Invited Discussant: T. Carrel, Berne
Presentations:
12:00-12:10 Fontan Prize
Thoracic Prize Auditorium 1
Report: Fontan Prizewinner 2010
The Honoured Guest Lecture
Auditorium 1
12:15-12:45 Tissue-specific adult stem cells
Manuel J Antunes Cardiothoracic Surgery, University
Hospital, Coimbra, Portugal
T
ricuspid regurgitation
(TR) associated with
acquired left sided
valve disease is quite frequent, with a described
incidence varying from
8% to 35%. In 80% of
the cases the TR is “functional” and in 15–20%
the lesion is primarily rheumatic (organic).
Until fairly recently, it
was common belief that
tricuspid valve regurgitation ((TR) secondary to
left-side heart valve disease would revert with surgical correction of the left
heart pathology. This conservative management of
TR was based on the theory of the dispensable right
ventricle and was vindicated by some comparative series which showed
no difference in survival between patients who had
and those who did not
have tricuspid annuloplasty
during mitral and/or aor-
tic valve surgery1. It would
seem natural that by eliminating the “triggering”
factor, after adequate correction of left heart valvulopathy, the tricuspid regurgitation would regress, but
this does not always happen. This is in contrast with
organic tricuspid pathology
which, when significant, always requires correction.
Several factors may contribute to the complexity
of this problem: (i) Functional tricuspid regurgitation with severely dilated
annulus may produce an
irreversible deterioration
of right ventricular (RV)
function. (ii) RV dysfunction may affect postoperative prognosis. (iii) A longer
clinical course could result in a greater degree of
clinical and hemodynamic
deterioration and, thus,
greater surgical risk.
(iv) Associated right ventricular disease with severe
involvement of the tricuspid valve represents advanced disease which has
a decisive effect on natural
and post-surgical course.
(v) There is no reliable
method to judge how
much is reversible when
left-side problems are corrected. (vi) There is a lack
of reliable and repeatable methods for measuring
and quantifying the degree
of tricuspid regurgitation.
(vii) There is no satisfactory
method to assess true right
ventricular function.
In fact, the quality of
the “repair” of the left
sided valvulopathy appears
fundamental. Any incomplete or unsatisfactory repair will result in persistence of TR. Even with
long-term success of mitral valve surgery, in many
cases there is a progressive
increase in tricuspid regurgitation
The attitude towards
the management of the
functional TR has changed
dramatically in the last
decade, essentially as a result of a study published
by Dreyfus et al2, confirmed by other more recent studies which found
better longterm results in
patients with significant
TR subjected to tricuspid annuloplasty concomitantly with mitral (more
rarely with aortic) surgery.
Dreyfus et al went further
by concluding that “secondary tricuspid (annular) dilatation is present
in a significant number of
patients with severe mitral regurgitation without
tricuspid regurgitation. It
is a progressive disease
which does not resolve
with correction of the primary lesion alone. Tricuspid annuloplasty at the
time of mitral valve surgery in these patients results in improved functional capacity without any
increase in perioperative
morbidity or mortality”.
Since then, the majority of the surgeons have
adopted a more aggressive approach to the tricuspid valve. The group
o Calafiori3 have found
that “an aggressive strategy for functional TR correction, using systematic tricuspid annuloplasty,
was able to reduce the TR
grade one year after surgery, but mitral surgery
alone could not”.
Manuel Antunes
But the equation has
not been completely resolved. For many, it still is
difficult to decide to intervene on a functionally normal tricuspid valve
just based on a dilated
annulus. On the other
hand, these concepts
have evolved essentially
around rheumatic valve
disease and may not apply
to other pathologies. The
Mayo Clinic group4 has just
published a paper on functional TR at the time of mitral valve repair for degenerative leaflet prolapse
and concluded that “clinically silent nonsevere tricuspid valve regurgitation
in patients with degenerative mitral valve disease is
unlikely to progress after
mitral valve repair. Tricuspid valve surgery is rarely
necessary for most patients undergoing repair of
isolated mitral valve prolapse”, thus calling for a
“selective approach”.
The 2006 ACC/AHA
guidelines consider tricuspid annuloplasty for less
than severe TR in patients
undergoing mitral valve
surgery when there is tricuspid annular dilatation
as a class II indication but
only when there is severe
pulmonary hypertension,
and as a class III (not to be
done) in the absence of
pulmonary hypertension.
The next few years
should be able to better
define the equation.
References
1. Pellegrini A, Colombo T, Donatelli F, Lanfranchi M, Quaini E, Russo C, Vitali E. Evaluation and
treatment of secondary tricuspid insufficiency.
Eur J Cardiothorac Surg. 1992;6:288-96.
2. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T.
Secondary tricuspid regurgitation or dilatation:
which should be the criteria for surgical repair?
Ann Thorac Surg 2005;79:127-32.
3. Calafiore AM, Gallina S, Iacò AL, Contini M,
Bivona A, Gagliardi M, Bosco P, Di MauroM. Mitral valve surgery for functional mitral regurgitation: Should moderate-or-more tricuspid regurgitation be treated? A propensity score analysis.
Ann Thorac Surg 2009;87:698-70
4. Yilmaz O, Suri RM, Dearani JA et al. Functional tricuspid regurgitation at the time of mitral
valve repair for degenerative leaflet prolapse:
The case for a selective approach. J Thorac
Cardiovasc Surg 2011;142:608-613
Focus session – Functional TR: State of the art and new perspectives Auditorioum 8 10:30
P. Anversa, Boston
How to prevent progression of functional TR?
Auditorium 1
Mitral valve and beyond I
n
to become acquainted with new procedures performed
only a few times and to understand their potential
impact on the treatment of valvular heart disease
Moderators: O. Alfieri, Milan; J.L. Pomar, Barcelona
14:00
Videos: Valve-in-ring implantation R. Klautz, Leiden;
F. Maisano, Milan; H. Vanermen, Aalst
14:30 Discussion
14:45 Abstracts
14:45
Percutaneous transvenous Melody valve-in-ring
procedure for mitral valve replacement
T. Shuto, N. Kondo, Y. Dori, K. Koomalsingh, J. Gorman
3rd, R. C. Gorman, M. J. Gillespie (United States)
15:00
Direct access transcatheter mitral annuloplasty
with a sutureless and adjustable device
F. Maisano1, H. Vanermen2, J. Seeburger3, M. Mack4,
V. Falk5, P. Denti1, M. Taramasso1, O. Alfieri1
(1 Italy, 2 Belgium, 3 Germany, 4 USA, 5 Switzerland)
Invited Discussant: C. R. Smith, New York
Invited Discussant: G. Lutter, Kiel
15:15
Is prophylactic annuloplasty for less
than severe functional tricuspid
regurgitation really necessary?
Value of three-dimensional real-time
transoesophageal echocardiography in guiding
transapical beating heart mitral valve repair
J. Seeburger, T. Noack, S. Leontyev, M. Höbartner, H. Tschernich, J. Ender, M. A. Borger, F. Mohr (Germany)
Invited Discussant: S. Bleiziffer, Munich
14:00 Abstracts
Auditorium 2
Aortic valve III
n
to be informed about current status of techniques
of investigation and surgery, as well as risk factors,
complications and outcomes in aortic valve disease
Moderators: M. Glauber, Massa; M. Cikirikcioglu,
Geneva
14:00
Aortic valve repair: State of the art
G. El Khoury, Brussels
14:20 Improved risk-assessment in surgery for aortic
valve stenosis
C. Quarto, M. Dweck, S. Joshi,
G. Melina, E. Angeloni, R. Mohiaddin, S. K. Prasad, J. Pepper (United Kingdom)
Invited Discussant: M. Kolowca, Rzeszow
cific direct mechanisms regarding the TV
are then almost always annular dilatation, dilatation of the right atrium and
ventricle and more or less leaflet tethering. It therefore does not surprise that
TV surgery for functional TR has been
predominantly described concomitant to
MV procedures (in our patients 34 percent of ischemic MV cases and 43 percent of all mitral patients with persistent
AF have concomitant relevant functional
TV disease!).
Literature has identified some factors
of TR recurrence after prior surgery: increased myocardial remodelling, pulmonary hypertension and previous suture
annuloplasty (with a three-fold increase
of risk for TR recurrence when suture inStephan Geidel
stead of prosthetic ring annuloplasty had
been performed). It has been further
thetic ring annuloplasty for tricuspid dilademonstrated that remodelling prostation prevents progression of TR, which
is undoubtedly the essential part of every
surgical strategy to prevent TR progression and to eradicate existing severe TR,
particularly when there is annular dilatation and pulmonary hypertension.
In the past semi-rigid/rigid rings have
shown the highest benefit of TV repair – we worked over nine years with
Edwards MC³ Annuloplasty Ring -, for
the future three-dimensional configurated material combined with selective flexibility that preserves the natural movements might be an even more
physiologic alternative (Figure. 1). Our
strategy at AK St. Georg/Hamburg in
functional TV disease is that particularly “young” patients (<80 years) with
annular dilatation, ischemic cardiomyopathy and/or pulmonary hypertension
are treated generously with prosthetic
TV ring annuloplasty. Our concept to
prevent progression of functional TR is
to follow/use “accepted” indications
for TV surgery, a proven reconstructive technique with prosthetic ring annuloplasty, a reliable surgical concept in
general following the principles of reconstructive valve surgery and standardized AF ablation to induce/support a
Figure. 1: TV repair for functional TR and annular dilatation (45.8mm) using a Carpentier-Edwards Physio Tricuspid continuous reverse myocardial remodAnnuloplasty Ring (size 34). elling process.
progressive TR when the disease is not
treated adequately.
Carpentier has shown years ago how
perfectly the other atrioventricular valve
can be repaired and excellent long-term
hough the tricuspid valve (TV) is
results are achievable when some genstill known to be the forgotten
valve, functional TV disease has re- eral principles are followed, based on
cently deserved perceptible more atten- precise valvular analyses and of course
tion: relevant tricuspid regurgitation (TR) given, that proven techniques of reconhas been identified as an important and structive valve surgery are applied. For
independent predictor of reduced long- mitral valve (MV) disease this has meant
term survival and guidelines have been to understand it in its total complexity,
formulated to improve and standardize for the understanding of functional TR
the management of TR. However, there there are some parallels: myocardial dysfunction induced by some underlying
is still some uncertainty left, what indicates how really difficult it is to fully un- cause(s) brings out secondary changes
derstand the complex mechanisms par- of pulmonary artery pressure, tissue dilatation, mitral regurgitation (MR) and
ticularly of functional TR and therefore
atrial fibrillation (AF) in a sense of a fito give reliable general recommendanally complex heart failure syndrome,
tions. It is further believed that there is
a significant risk for residual and finally a circulus vitiosus has begun. The spe-
Stephan Geidel Abteilung für Herzchirurgie, Asklepios Klinik St Georg, Hamburg,
Germany
T
EACTS Daily News Tuesday 4 and Wednesday 5 October 2011 11
Abstracts – Aortic valve II Auditorium 2 10:30
T
he Sorin CP5, successor of the
SCP and SCP Plus, is the second
generation centrifugal pump incorporating the latest state-of-theart technology and design. The CP5
is an all-in-one-device suitable for
all centrifugal pump applications.
For maximum operating flexibility,
the user may selectively activate or
deactivate individual features and
functions.
It is possible to allocate the various alarms to the CP5.
The user has the choice of 3 different responses of the CP5 to the
alarms:
n
rampdown off: which means no
reaction from the pump. It simply displays the alarm condition.
n
rampdown on: which means that
the RPM’s of the CP5 are reduced
to the pre-assigned minimum
RPM’s setting. Once the alarm
is cleared, the user will have to
manually increase the speed to
the preferred operating value.
n
rampdown on + rampup: which
means that the RPM’s of the CP5
are reduced to the pre-assigned
minimum RPM’s setting while the
alarm is active. Once the alarm
is cleared the CP5 will automatically ramp up to the previous set
value.
In addition to the outlet pressure
an inlet pressure can be measured
or calculated at the CP5 display.
This is to avoid too negative pressure values at the inlet.
A flow controlled or auto mode
is available on the CP5. If the feature is selected in the CP5 menu,
the flow controlled mode key
along with the flow controlled
symbol appears on the screen of
the CP5. This key is used to activate
the flow controlled function and
the symbol indicates the status of
the mode.
A pulsatile flow mode is also
available on the CP5. If the feature is selected in the CP5 menu,
the pulsatile flow key along with
the pulsatile flow symbol appears
on the screen of the CP5. This key is
used to activate the pulsatile function and the symbol indicates the
status of the mode.
To utilize this feature, simply
press the pulsatile flow key on the
CP5 screen and pulsatile flow is
now active. The user can adjust the
frequency of pulse and set a peak
flow limit so that a predetermined
flow value will not be exceeded
while pulsing.
The CP5 is an all-in-one-device,
which allows the user to selectively
activate or deactivate each feature
and function independently. The
flexibility designed into the CP5 ensures a centrifugal pump option
that can be customized to meet
changing Perfusion and OR needs.
Modified Bentall
procedure in a
young patient with
symptomatic aortic
valve stenosis and
porcelain aorta
Malakh Shrestha Hanover Medical School, Hanover, Germany
A
ortic valve replacements in calcified
‘porcelain’ aorta
are technically demanding. It is more so when the
aortic annulus is small and
extremely calcified. We
present a video showing the replacement of the aortic valve and the ascending aorta in a case of symptomatic calcified aortic valve stenosis.
The aortic valve and the ascending aorta was replaced using a ‘home made’ mechanical valved conduit with 21mm prosthesis mechanical valve and
24mm Dacron prosthesis. As the ascending aorta was
completely calcified (porcelain aorta), the right subclavian artery was cannulated for the CPB. The aorta was
opened under moderate hypothermic circulatory arrest (HCA). For better organ protection, selective antegrade cerebral perfusion (SACP) was performed.
The peri-operative course was uneventful. X-clamp
and CPB times were 88 minutes and 163 minutes respectively. SACP and LFBP times were 41 minutes and
34 minutes respectively. The ICU stay was two days.
The further post-operative course was uneventful. Patient was discharged from the hospital on POD 12.
The surgical approach described here is an alternative method treatment of young patients with symptomatic aortic valve stenosis and porcelain aorta who
are not candidates for TAVI.
Focus session – Functional
TR Auditorioum 8 10:30
Implications
in tricuspid
annuloplasty rings
Marjan Jahangiri Professor of Cardiac Surgery,
St George’s Hospital, University of London
S
econdary tricuspid valve regurgitation (TR) is frequent in patients with chronic left-sided valve
disease, particularly associated with atrial fibrillation and pulmonary hypertention. Contrary to some
beliefs, TR does not disappear once the left-sided lesion is corrected. When the right ventricle becomes
impaired, the process of TR is progressive. The aim of
surgical correction for functional TR is to reduce annular diameter and improve leaflet coaptation.
Placement of an annuloplasty ring during TV repair
is associated with a decreased recurrence of TR and
with improved long-term and event free survival compared with repairs not using a ring. Rigid rings provide
superior results compared with flexible rings, however,
there has been some recent concerns that rigid rings
may increase risks of subsequent ring dehiscence.
For smaller tricuspid valve annuli, same size TV annuloplasty as used for concomitant mitral valve repair
procedures provides satisfactory functional results. For
larger annuli, down-sizing by 2 sizes provides satisfactory repair.
Some of the factors contributing to late TR following ring annuloplasty include greater left ventricular
dysfunction, presence of atrial fibrillation and permanent pacemaker implantation. As high as 50% of patients following successful TV repair with pacemaker
can develop recurrence of tricuspid regurgitation. Removing trans-tricuspid leads and replacing them with
an epicardial lead at the time of repair can reduce late
failure.
Any TR with annular dilatation cannot be ignored
when performing corrective surgical procedures for
mitral regurgitation or other cardiac procedures. Ring
annuloplasty should be the method of choice compared to suture-based or non-ring techniques.
14:35
Left ventricular mass regression is independent
of gradient and effective orifice area after aortic
valve replacement with a tissue prosthesis: A multicentre prospective corelab reviewed study
R. Sádaba1, W. Harringer2, M. C. Herregods3,
J. Bogaert3, G. Gerosa4
(1 Spain, 2 Germany,3 Belgium, 4 Italy)
Invited Discussant: H. Vetter, Wuppertal
14:50
Electrocardiogram-gated cardiac computed
tomography: A new imaging modality in the
diagnosis of aortic prosthetic valve endocarditis
E. Fagman, S. Perotta, O. Bech-Hanssen, A. Flinck, C. Lamm, L. Olaisson, G. Svensson (Sweden)
Invited Discussant: M. Siepe, Freiburg
15:05
Minimally invasive versus conventional surgery
for isolated aortic valve replacement: A propensity
score analysis
D. Gilmanov, S. Bevilacqua, M. Murzi, A. Miceli, A. G. Cerillo, T. Gasbarri, E. Kallushi, M. Glauber (Italy)
Invited Discussant: M. Zembala, Zabrze
14:00 Abstracts
Auditorium 7
Transcatheter aortic valve
implantation III
n
to update knowledge of issues in the developing field
of transcatheter aortic valve implantation
Moderators: J. Kempfert, Leipzig, T. Walther, Bad Nauheim
14:00
Aortic stenosis in high-risk patients presenting
coronary artery disease: conventional or
transcatheter strategy? A propensity score
analysis D. Wendt, P. Kahlert, M. Neuhäuser, T. Lenze,
T. Konorza, R. Erbel, H. Jakob, M. Thielmann (Germany)
Invited Discussant: L. Martinelli, Milan
14:15
Aortic valve calcium symmetry and distribution to
predict localisation of paravalvular leakage after
transcatheter aortic valve implantation
D. Wendt, B. Plicht, P. Kahlert, K. Hartmann, T. Konorza,
R. Erbel, H. Jakob, M. Thielmann (Germany)
14:30
Case load development of conventional aortic
valve surgery and transcatheter aortic valve
implantation in the era of new valve technologies
A. J. Rastan, D. Holzhey, M. Hänsig, J. Kempfert, T. Walther, A. Linke, G. Schuler (Germany)
14:45
Impact of preoperative mitral valve regurgitation
on outcomes after transcatheter aortic valve
implantation
A. D’Onofrio, V. Gasparetto,
M. Napodano, R. Bianco, G. Tarantini, V. Renier, G. Isabella, G. Gerosa (Italy)
Invited Discussant: O. Wendler, London
Invited Discussant: V. Bapat, London
Invited Discussant: S. Casselman, Aalst
15:00
Impact of previous cardiac operations on patients
undergoing transapical aortic valve implantation:
Results from the Italian registry of transapical
A. D’Onofrio,
P. Rubino, M. Fusari, F. Musumeci, M. Rinaldi, O. Alfieri, G. Gerosa (Italy)
Invited Discussant: M. Gorlitzer, Vienna
15:15
Aortic annulus sizing: transoesophageal
echocardiography versus computed tomographyderived measurements in comparison to direct
surgical sizing
J. Kempfert, A. Van Linden,
L. Lehmkuhl, A. J. Rastan, D. Holzhey, J. Blumenstein, F. Mohr, T. Walther (Germany)
Invited Discussant: C. R. Smith, New York
14:00 Focus Session
Focus session – Connective
tissue disease Auditoria 3&4 10:30
Hereditary aortic
syndromes
Alexander MJ Bernhardt,
Hermann Reichenspurner and
Yskert von Kodolitsch University
Heart Center Hamburg, Department of Cardiovascular Surgery,
Hamburg, Germany
A
Management of heart failure I
n
to be aware of new developments in the treatment of
advanced heart failure
Moderators: T. McDonagh, London; J. Pepper, London
14:00
Medical therapy: trial update; insight into new
guidelines
T. McDonagh, London
14:20 Resynchronisation therapy
F. Braunschwieg, Stockholm
14:40 Electrical treatment: cardiac resynchronisation
therapy; atrial fibrillation ablation; ventricular
tachycardia
M. Czesla, Stuttgart
15:00 Role of short-term support in acute heart failure:
extracorporeal membrane oxygenation
F. Beyersdorf, Freiburg
Connective tissue disease: Indications for
surgery of thoracic aorta and techniques
Thierry Carrel Clinic for Cardiovascular Surgery, University Hospital Berne, Switzerland
A
Alexander Yskert von
Bernhardt Kodolitsch
pproximately 80% of
thoracic aortic aneurysms and dissections are caused by arterial hypertension and arteriosclerosis, whereas hereditary diseases such as Marfan- or Loeys- Dietz- syndrome account
for 20% of aneurysms and dissections. Recently, various
genes have been identified, which are responsible for different phenotypes of thoracic aortic aneurysms and dissections. The diagnosis of Marfan syndrome relies on
defined clinical criteria of the recently revised Ghent nosology. This nosology stresses the diagnostic impact of
aortic root dilatation and ectopia lentis. FBN1 testing, although not mandatory, has now a greater impact in the
diagnostic assessment.
We have a Marfan outpatient clinic coordinating an
interdisciplinary team comprising cardiologists, heart surgeons, orthopaedic surgeons, ophthalmologists, paediatricians, geneticists and psychologists. We believe there are
three important rules in the diagnostic management for
patients with a suspected hereditary aortic disease:
First, because Marfan syndrome is the most often hereditary aortic syndrome we recommend evaluating the
Marfan syndrome according to the revised Ghent nosology first. In case of typical manifestations of the Marfan
syndrome sequencing of the FBN1 gene should be performed. If there are signs of Loeys- Dietz- syndrome or another hereditary syndrome TGFBR-1 and -2 or other genes
if appropriate should be investigated.
Second, the diagnosis of a syndrome should not be
based on presence of a mutation alone, but persons should
be evaluated for clinical features the respective aortic syndrome. As diagnostic alternatives of the Marfan syndrome,
Loeys- Dietz- syndrome, mitral valve prolapse syndrome,
MASS phenotype and ectopia lentis syndrome should also
be considered. The vascular type of Ehlers- Danlos- syndrome is diagnosed by the criteria described in the revised
Villefranche nosology. The Aneurysm- Osteoarthritis syndrome has only recently been described by van de Laar et al.
Third, since most hereditary aortic diseases present with
multi-organ involvement patients should only be diagnosed and treated in a specialized multidisciplinary centre,
with the capability also to perform genetic testing. Prognosis and therapy of aortic diseases depend on the genetic defect and therefore require a profound interdisciplinary diagnostic work- up.
ortic root disease is the hallmark of Marfan
syndrome (MFS) and, in the absence of aortic regurgitation, indications for surgery in
patients with MFS mainly follow established guidelines, such as the 2010 AHA guidelines: Surgical
repair in adults is recommended at an diameter of
50mm. In patients with a family history of dissection, symptomatic aneurysms or rapidly expanding aneurysm (> 5mm per year) intervention at a
diameter of 45mm is justified, since up to 20% of
patients may dissect below 50mm. If aortic regurgitation is present and aortic root size is less than
45mm, indication for surgery depends on the extent of regurgitation and hence left ventricular dimensions. The cross-sectional area in square centimeter divided by the patient’s height in meters
can be helpful as an indicator for surgery. If this ratio exceeds 10, surgery should be recommended.
In women with MFS who want to become pregnant, it is reasonable to consider prophylactic root
replacement if aortic root size exceeds 40mm.
The surgical approach to aortic root aneurysms largely depends on the state of the native
valve. Techniques for valve-sparing root replacement have matured over the past decade and
can be performed with excellent short- and medium term outcome. Whether patients with MFS
will benefit from a valve-sparing procedure in the
long-term remains controversial. As the experience
with this type of procedure grows and the operative risk for re-do surgery is declining, valve-sparing
root replacement has become a suitable alternative to the Bentall procedure. The Bentall procedure is a very safe procedure and the repair is very
durable. Long-term complications are mainly associated with the need for oral anticoagulation if a
mechanical valve is used. The risk for infective endocarditis is low. In a large series of patients with
MFS undergoing surgery, freedom from endocarditis at 20 years was 92% and freedom from thromboembolism 90%. Unfortunately, data obtained
on the results from valve-sparing surgery from different patient populations might not be applicable to patients with MFS since the valve itself has
an inherent structural deficiency. If the native valve
has several large fenestrations, most surgeons
chose to replace the valve, especially in patients
with MFS.
If the aneurysm extends into the aortic arch, we
attempt to remove all affected tissue using deep
Functional TR: From the treatment
of Regurgitation to the treatment of
Annular Dilatation
Thierry Carrel
hypothermic circulatory arrest and selective antegrade cerebral perfusion. In patients with MFS, we
recommend to perform separate implantation of
the supra-aortic branches rather than implanting
the head and neck vessels as an “island”. This approach minimizes the amount of left over aortic
tissue and the likelihood of aneurysm at the anastomosis. The most recent development of the elephant trunk technique is the combination of an
endovascular stent graft with a conventional surgical graft for hybrid procedures. This new option
was termed frozen elephant trunk. In patients with
MFS this should not be considered as a definitive
treatment but rather facilitates replacement of the
descending aorta in the future and avoids a second hypothermic circulatory arrest.
Patients with MFS frequently must undergo interventions on the distal aorta. The available data
suggest that aortic dissection is the main risk factor for re-intervention in downstream aortic segments. In our experience, nearly half of the patients (48%) with acute aortic dissections had to
undergo interventions on the distal aorta during a
mean follow-up of nine years, versus only 11% of
patients without dissection.
Reference
1 Schoenhoff F, Cameron DE, Matyas G, Carrel T. Cardiovascular surgery in Marfan syndrome: implications of new molecular concepts in thoracic aortic disease. Future Cardiol
2011;7:557-569.
ameter of 40mm has been
shown to be important as a
cut-off value above which
annuloplasty was useful.
This has been confirmed
by Van de Veire et al.4 who
has compared two groups
of severe TR that exists beof patients: in one group
Robert Klautz, M.D., Ph.D. Leionly pre-operative TR was
den University Medical Centre, The fore mitral valve surgery
has been clearly established
treated and in the other
Netherlands
and is a Class I indications in
group pre-operative TR and/
both European and Ameror annular dilatation was
unctional Tricuspid Retreated. From the analygurgitation (TR) is an un- ican Guidelines. The treatment exists of tricuspid ansis it appeared that annuderdiagnosed and undernuloplasty during mitral
loplasty in patients with an
treated condition in which
valve surgery. Untreated
annular dimension of 40mm
the tricuspid valve is inor more results in right vencompetent without a struc- this condition caries a poor
prognosis: the resolution aftricular reverse remodeling
tural defect of the valve itter successful left sided surand a reduction in TR at
self. It is caused by annular
mid-term follow-up. A ranand/or right ventricular dil- gery is unpredictable and
the dilated tricuspid annudomized trial from Italy has
atation. Due to its particlus does not reduce.1,2
confirmed these findings.5
ular functional behaviour
the right ventricle can dilate
Robert Klautz
The development of TR
It is likely that the underdue to various pathophysio- after mitral valve surgery
lying pathology is the inalogical conditions. This also has been shown to be inde- treat functional TR during
bility of the tricuspid annumakes TR a condition that
mitral valve surgery. Dreypendent of:
lus to reduce its dimension
varies over time and in dif1) left-sided valvular dys- fus et al.3 has shown us that as soon as it is stretched
ferent settings. It is, for infunction, 2) TR at initial sur- it is not just the mere presbeyond a certain dimenstance, very dependent on
gery, and 3) decrease in pul- ence or absence of regurgi- sion, probably for a certain
the volume status of the pa- monary artery pressure.
amount of time. More retation that is important in
tient. Volume overload is
Unfortunately, it occurs
search is necessary to prethe prognosis of TR, but it
probably the most prevafrequently at long-term fol- is the dilatation of the tricisely understand these
lent condition and mitral
low-up and has a poor out- cuspid annulus that demechanisms. Based on the
valve disease its underlying come. This poses a difficult
recommendations of the
termines outcome. In that
pathology. The treatment
dilemma: when should we
European Association of
study, tricuspid annular di-
F
Auditorium 8
Focus session – Connective tissue disease Auditoria 3&4 10:30
Echocardiography the tricuspid annulus is considered
dilated when it exceeds
35mm, or 21mm/m2. So
maybe we should even consider treating an annulus
smaller that 40mm. But the
most important advancement in our understanding of functional TR is the
fact that we should not focus on pre-operative TR, but
on the dimension of the tricuspid annulus and perform
an annuloplasty during mitral valve surgery as soon as
it is dilated.
Reference:
1 Song H, Kang DH, Kim JH, et al.Percutaneous mitral
valvuloplasty versus surgical treatment in mitral stenosis with severe tricuspid regurgitation.Circulation.
2007 Sep 11;116(11 Suppl):I246-50.
2 Sadeghi HM, Kimura BJ, Raisinghani A, et al.Does
lowering pulmonary arterial pressure eliminate severe
functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy.J Am Coll Cardiol. 2004
Jul 7;44(1):126-32
3 Gilles D. Dreyfus, Pierre J. Corbi, K. M. John Chan,
and Toufan Bahrami, Secondary Tricuspid Regurgitation
or Dilatation: Which Should Be the Criteria for Surgical
Repair? Ann Thorac Surg 2005;79:127–32.
4 Nico R. Van de Veire, Jerry Braun, Victoria Delgado,
et al.Tricuspid annuloplasty prevents right ventricular
dilatation and progression of tricuspid regurgitation in
patients with tricuspid annular dilatation undergoing
mitral valve repair. JTCS 2011;141:1431-1439.
5 Umberto Benedetto, Giovanni Melina, Emiliano
Angeloni,et al. Prophylactic Tricuspid Annuloplasty in
Patients with Dilated Tricuspid Annulus Undergoing
Mitral Valve Surgery. AATS Annual Scientific Meeting
2011.
Focus session – Connective tissue disease Auditoria 3&4 10:30
Connective tissue disease of the aorta:
prospects for drug treatment
Pathological correlates of
genetic aortic syndromes
John Pepper Department of Surgery, The Royal Brompton
Hospital, London, UK
Ornella Leone Pathology Institute, S Orsola-Malpighi
Hospital, Bologna, Italy
T
T
he discovery of the gene responsible responsible
for Marfan syndrome was the start of a revolution
in our understanding of aortopathy. Dietz and colleagues in elegant experiments using mouse models for
Marfan syndrome, showed that many of the pulmonary,
cardiovascular, skeletal, and skeletal muscle features of
Marfan syndrome are due to abnormal levels of activation of TGF-ß, which is a potent stimulator of inflammation, fibrosis, and activation, of certain matrix metalloproteinases (MMP), especiallymmP 2 and 9. Excess
TGF-ß activation in tissues correlates with failure of lung
septation, development of a myxomatous mitral valve
and aortic root dilatation in mice into which a human
mutation that causes Marfan syndrome was introduced.
This combination of structural microfibril matrix abnormalities, dysregulation of matrix homeostasis mediated by excess TGF-ß, and abnormal cell-matrix interactions is responsible for the phenotypic features of
the Marfan aorta. Superimposed on these abnormalities are the normal haemodynamic stresses on the proximal aorta during the cardiac cycle. The first randomised
open-label trial of ß-blockade in Marfan patients was reported in 1994. In this study 32 Marfan patients with
modest aortic dilatation were randomly assigned to propranolol and compared to 38 patients with similar untreated Marfan control patients. Over a decade, the rate
of growth of the proximal aortic segment in the treatment group (0.023/y) was significantly lower than that
seen in controls (0.84/y; P<0.001). This remains the largest randomised trial of in the Marfan population.
In a transgenic mouse model of Marfan, treatment
with antibodies against TGF-ß prevented the development of myxomatous mitral valve disease and aortic aneurysms. A similar effect occurred with losartan, a drug
that blocks angiotensin ll type 1 receptors. The effects
of stimulation of the type 1 receptor are mediated, at
least in part, by TGF-ß. Treatment of Marfan mice with
losartan prenatally and continuing until 10 months of
age resulted in preservation of proximal aortic elastic fi-
John Pepper
bre histology and overall aortic diameter similar to that
of wild-type mice. By contrast, mice with the same mutation treated with propranolol had disruption of elastic
lamellae and dilated aortic roots comparable to affected
mice treated with placebo.
A multi-centre, NIH-funded study of losartan versus atenolol in 600 children and young adults with Marfan is underway in North America. A similar study, AIMS,
has recently started in Europe involving 490 young adult
patients randomised to Irbesartan + normal treatment or
placebo (normal treatment). The latter trial is more pragmatic as ß-blockers are “allowed” in both experimental
and control groups. Both trials will continue for threefive years before reporting.
Other recently recognised molecules promoting aneurysm formation are being targeted in animal models. An
example is doxycycline which acts as anmmP inhibitor.
Likewise, genetic sequencing is a useful tool for screening of first-degree relatives of patients who are positive
for a mutation associated with aortic aneurysm formation, such as FBN1 and ACTA2. Overall, the prognosis
of patients with aortic root abnormalities has improved
substantially over the past decades, mainly as a result of
early diagnosis and timely intervention.
he aorta is an organ with a complex biology, able to perform sophisticated functions,
thanks to a structural organization finely regulated by numerous cellular and molecular systems.
The different expressions of this complex structure
in various aortic segments are the basis of the regional heterogeneity of the aorta, which conditions
susceptibility to and preferred localization of aortopathies in various segments.
Today, histopathological examination is an integral part of the pathological study of aortic diseases: its systematic application to aortic surgical
specimens has provided even more detailed information on aortopathies and their bio-pathological
mechanisms.
Syndromic or nonsyndromic genetic aortic diseases tend to prefer the thoracic aorta, with frequent aortic root involvement, and mainly concern inherited connective tissue disorders. Many
genes are involved in these diseases: those encoding for extracellular matrix (ECM) components or
cytoskeleton proteins, such as fibrillin, collagens,
alfa-smooth muscle actin, smooth muscle-beta-1myosin heavy chain, fibulin; the SLC2A10 gene influencing proteoglycan biosynthesis; genes active
in certain molecular signalling pathways affecting
the structure and composition of ECM, e.g TGFBR1
and TGFBR2. More rarely some inherited metabolic diseases (homozygous familial hypercholesterolemia, Menkes syndrome or alkaptonuria) may affect the aorta.
Among the main histopathological substrates of
aortopathies (inflammatory, degenerative/non-inflammatory, atherosclerotic or mixed/overlapping),
the most frequent and typical of aortic genetic diseases is degenerative, whose histopathological picture includes numerous elementary lesions related
to the main medial structural components, either
the cellular elements or the proteins of the fibril-
lary (elastin, collagens) and non-fibrillary (proteoglycans) ECM.
The principal elementary lesions are:
n
Elastic fibres: fragmentation and loss of elastic fibres, producing widening of intralamellar spaces
with localized or diffuse medial degeneration or
focal/multifocal interlamellar medial degeneration with glycosaminoglycan pooling.
n
Collagen fibres: increase to the point of organized fibrous tissue formation or altered distribution and composition of various collagens.
n
Smooth muscle cells: decrease or loss, altered
orientation, apoptosis. A particular lesion is laminar medial necrosis, characterized by band-like
smooth muscle cell loss with subsequent elastic
and collagen fibre collapse
n
Non fibrillary extracellular matrix
(glycosaminoglycans): mucoid material pooling
variable in size.
These elementary lesions, collectively referred to as
“medial degeneration”, are not sensitive to or specific for genetic syndromes or a particular aortopathy and can usually be found in the normal aging
process or as a consequence of altered hemodynamic forces: in various primary or secondary conditions, their differences are quantitative rather
than qualitative, so it is essential to grade them
quantitatively, in addition to listing, as in certain genetic aortic diseases their extent may be very severe.
Although a definitive diagnosis of a genetic aortic disease is not really possible on the basis of histopathology alone, the correlation of a detailed histopathological picture with the clinical situation
can limit the spectrum of possible aortopathies and
thus enable the pathologist to indicate the direction
for further diagnostic tests, including genetic tests.
In the presentation some recently recognized biopathological mechanisms related to degenerative
lesions will also be discussed, as well as some of the
rarer non degenerative histopathological pictures of
aortic genetic syndrome.
Focus session – Innovation in surgical training: Learning for the future Auditorium 6 10:30
14:00 Abstracts
High performing teams in the
operating theatre and NOTSS
Room 5C
Cardiopulmonary bypass
n
to update knowledge of progress in enhancing the
safety and efficacy of cardiopulmonary bypass
techniques
Moderators: A. Wahba, Trondheim; W. Harringer,
Braunschweig
14:00
Selective pulmonary pulsatile perfusion with
oxygenated blood during cardiopulmonary bypass
attenuates lung tissue inflammation but does not
affect circulating cytokine levels
F. Santini, F. Onorati, F. Patelli, M. Telesca, K. Pechlivanidis, G. Berton, G. Faggian, A. Mazzucco (Italy)
14:15
Circulating endothelial cells: A super-sensitive
marker of myocardial cell injury Y. Choi, K. Neef,
O. J. Liakopoulos, C. Stamm, E. W. Kuhn, I. Slottosch, T. Wittwer, T. Wahlers (Germany)
14:30
A closed phosphorylcholine-coated
cardiopulmonary bypass circuit reduces
inflammatory response and coagulopathy
following coronary artery bypass grafting
operation: A randomised controlled trial
D. Paparella, C. Rotunno, G. Cappabianca, G. Scrascia, M. De Palo, N. Marraudino, L. De Luca Tupputi Schinosa (Italy)
Invited Discussant: B. Bidstrup, Banora Point
Invited Discussant: R. Ascione, Bristol
Invited Discussant: G. Gerosa, Padova
14:45
Selective cerebral perfusion using moderate flow
in complex cardiac surgery provides sufficient
neuroprotection F. Emrich1, T. Walther 1, P. Muth1,
A. J. Rastan1, V. Falk2, S. Dhein1, F. Mohr 1,
M. Kostelka1 (1 Germany, 2 Switzerland)
Invited Discussant: R. Bonser, Birmingham
15:00
A novel aortic cannula to reduce intraoperative
embolic events: First in-vivo results
G. Bolotin,
L. Shani, O. Cohen, Z. Beckerman, B. Dilmoney, O.
Hirshorn, Y. Antebi (Israel)
15:15
Pulsatile perfusion accelerates recovery after
cardiac surgery: A propensity-matched analysis of
1959 patients
H. Baraki, B. Gohrbandt,
B. Del Bagno, A. Martens, S. V. Rojas, A. Haverich, D. Boethig, I. Kutschka (Germany)
Invited Discussant: H. Sievers, Lübeck
Invited Discussant: L. von Segesser, Lausanne
Auditorium 1
Mitral valve and beyond II
n
to become acquainted with new procedures performed
only a few times and to understand their potential
impact on the treatment of valvular heart disease
Moderators: O. Alfieri, Milan; J.L. Pomar, Barcelona
Video
16:00
Transfemoral mitral valve-in-valve procedure:
clinical experiences
A. Latib, Milan,
A. Vahanian, Paris
16:20 Off-pump transapical mitral valve replacement:
evaluation after one month J. Boldt 1, K. Iino1, L.
Lozonschi 2, A. Metzner 1, J. Schoettler 1, R. Petzina1,
J. Cremer 1, G. Lutter 1 ( 1Germany, 2United States)
Invited Discussant: M. Palmen, Leiden
16:35
Case report
Dysfunctional mitral bioprosthesis treated with
transapical mitral valve-in-valve implantation
T. Nolasco, S. Boshoff, R. Teles, J. Queiroz , E. Melo, J. Neves (Portugal)
Video
16:50
Percutaneous re-revalvulation of the tricuspid
valve
C. Dubois, Leuven
17:05 New perspectives for the tricuspid valve
H. Vanermen, Aalst
17:20 Discussion
16:00 Abstracts
Auditorium 2
Arrhythmia
n
to update knowledge of surgical arrhythmia
management
Moderators: S. Benussi, Milan, H. Vetter, Wuppertal
(Non-technical skills for surgeons)
come, there is increasing
evidence to show the importance of ‘non-technical skills’ and their role in
reducing adverse events in
surgery.
Research has now identified these non-technical
skills in surgery and metht is well accepted that a ods of assessing these skills
significant percentage of which are not covered in
formal training programs
surgical patients worldhave been developed. but
wide suffer from intra-opcan enable or hinder surgierative errors leading to
morbidity and mortality. Al- cal performance.
In the session on Tuesthough technical proficiency
day 4nd October titled ‘Inis essential to a good out-
Simon PatersonBrown Chairman, Patient
Safety Board, Royal College
of Surgeons of Edinburgh;
Consultant General and Upper
Gastro-intestinal Surgeon,
Royal Infirmary of Edinburgh,
Scotland, UK
I
novation in surgical education’ the NOTSS system will
be briefly outlined and discussed. In the 90 minute
workshop later the same
day on ‘High Performance Teams in the Operating Room: an introduction
to the NOTSS (Non-Technical Skills for Surgeons) programme’ this will be explored in more detail. This
interactive workshop will
be focused on the underlying human factors and
non-technical skills required for successful surgi-
cal outcomes.
The aim of this session
is to provide participants
with an understanding of
the essential non-technical skills for surgeons. The
workshop will be structured around the four categories of non-technical skills
in the NOTSS system (Situation Awareness, Decision
Making, Communication &
Teamwork and Leadership)
and involve short presentations, video simulation with
audience participation and
feedback. Structured methods of analyzing behaviour
will be used and participants
will leave the session with a
NOTSS handbook and some
initial understanding in identifying and discussing performance in surgery.
Focus session – Innovation in surgical training: Learning for the future Auditorium 6 10:30
“Training surgeons now to ensure
patient safety in twenty years time”
Chris Munsch Leeds General Infirmary,
Leeds, United Kingdom
S
o said Sir John Temple in his report into the impact of the
EWTR on medical education, and
probably no one would disagree with
him. But how seriously do you take
surgical training? Either as a surgeon
responsible for the delivery of training or as a trainee surgeon on the receiving end, are you doing everything
you can to make sure that the training is as effective as it should be? Or
do you still subscribe to the traditional apprenticeship model, of training ‘by osmosis’. My view is that, in
the present day, we can no longer defend traditional approaches to training; “See one, do one, teach one” no
longer stands up to either professional
or public scrutiny. We have an urgent
need to develop more robust training
they were. In other words, they had
strategies that are solidly grounded in
well-established principles of adult ed- certain behaviours or habits that anyone could learn and by doing so beucation and learning.
come great trainers themselves. An
Everyone knows and remembers
example would be giving approprigreat surgical teachers, in fact these
ate and timely feedback. Taking our
role models change our lives forlead from management guru Stephen
ever, but what is that they know, do
Covey, we were able to characterise
or say that makes them such inspiraseven such habits of highly effective
tional teachers? We attempted to ansurgical trainers.
swer that question by looking at a
The next stage was to translate this
very special group of proven surgiknowledge into a practical outcome,
cal trainers – the winners of the Silwith the objective
ver Scalpel prize,
of having a highly
awarded each
‘Leadership and learning are skilled training
year by the surindispensable to each other’ guru in every cargical trainees to
John Fitzgerald Kennedy
diothoracic surgithe individual concal unit in the UK.
sidered to be the
To this end we developed the Leader
best trainer in the UK. By analysing
as Educator programme*. The protheir personalities, attitudes and begramme was designed to help expehaviours we concluded that great
rienced surgeons develop the behavsurgical trainers were defined much
iours that provide a safe and dynamic
more by what they did than what
Chris Munsch
learning environment, thereby developing and inspiring the surgeons
of the future. The stimulating programme addressed many aspects of
surgical training and leadership and
we look forward to sharing it with
EACTS delegates in Lisbon this week.
If you do take training seriously and
would like to find out more please
come to our ‘Innovations in training’
session on Tuesday morning; we welcome all and any contribution.
Focus session – Management of heart failure I Auditorium 8 14:00
Role of short-term support
in acute heart failure:
extracorporeal life support
avoidance of limb ischemia by
insertion of a small (8 Fr), separate, distal limb perfusion cannula via the superficial femoral
artery, avoidance of hyperperfusion of limbs by omitting percute heart failure with
fusions through a T-graft anascardiogenic shock is a
tomosed to the femoral vessels,
rapidly evolving, lifethreatening disease. The causes etc), using alternate cannulation sites if necessary (e.g. jugfor acute heart failure may inular vein, subclavian vein, subclude acute myocardial infarcclavian artery), improvements in
tion, acute deterioration of
chronic heart failure, e.g. in pa- cardiosurgical intensive care of
these severely compromised patients awaiting cardiac transplantation, acute myocarditis,
failure to wean patients off car- Complication
diopulmonary bypass, etc.
* Reduced flow rates
Recent improvements in the
technology of extracorporeal circuits (pumps, tubing, oxygenators, filters, heparin coating),
increased surgical experience
* Cerebral and cardiac hypoxia
with peripheral cannulation
(most often femoro-atrial ve* LV dilatation
nous and femoro-arterial cannulation incl. guidance by trans- * Newly developed LV or LA
thrombi
esophageal echocardiography,
Friedhelm Beyersdorf Department of Cardiovascular Surgery,
University Medical Center Freiburg,
Freiburg, Germany
A
tients and the constant control,
supervision, and management
of these extracorporeal circuits
by perfusionists, have allowed
the development and clinical
application of “extracorporeal
life support systems” (ECLS) in
emergency situations. In recent
years, ECLS has evolved to a
very valuable short-term support
device in emergency situations.
The prerequites to use ECLS
safely have been recently summarized in a position paper,
published in The European Journal of Cardio-thoracic Surgery
(Beckmann et al. EJCTS 2011;
40:676-680). ECLS can be used
for several days up to a few
weeks, provided no severe complicatiosn occur, e.g. bleeding,
malperfusion, cerebral complications, etc. These systems are
most often used today either as
a “bridge-to-bridge” device or
Cause
Action
Inadequate venous return
Vacuum (10-40mmHg) repositioning of the venous cannula
Decreased volume
Volume replacement
Cardiac tamponade
Remove hematoma
LV ejection of hypoxemic blood
Delivery of oxygenated blood via
subclavian artery or vein
Aortic regurgitation
LV venting
Prolonged closure of the aortic
valve
Emergency surgery for removing
clots
for “bridge-to-recovery”, depending upon the underlying
disease of the patient.
However, many parameters
and details have to be monitored carefully during ECLS support and the adequate actions
have to be taken once either
complications or changes in the
hemodynamics of the patient
occur. There is a wide range of
potential problems, including
(to name just a few):
In summary, ECLS has
evolved as a reliable short-term
mechanical assist device in patients with acute heart failure.
However severe malfunctions
and complications may occur at
any time during this short-term
support. These problems can be
solved successfully by experienced cardio-thoracic surgeons
and perfusionists.
16:00
Post-acute electrophysiological efficacy of highintensity focused ultrasound in the clinical setting
A. Pozzoli, S. Benussi, Y. Privitera, D. Cianflone, P. Della
Bella, O. Alfieri (Italy)
RibLoc® Rib Fracture Plating System
Invited Discussant: A. Diegeler, Bad Neustadt
16:15
Does the outcome improve after radiofrequency
ablation for atrial fibrillation in patients
undergoing cardiac surgery? A propensitymatched comparison
S. Attaran, H. Z. Saleh,
M. Shaw, M. Pullan, B. Fabri (United Kingdom)
Invited Discussant: F. Wagner, Hamburg
16:30
Mid-term results of atrial fibrillation ablation
during mitral valve surgery through continuous
subcutaneous monitoring A. Bogachev-Prokophiev,
S. Zheleznev, E. Pokushalov, A. Romanov, A. Pivkin, A. Karaskov (Russian Federation)
16:45
Ablation of newly-discovered paroxysmal atrial
fibrillation during coronary artery bypass grafting:
Necessary?
A. Romanov, E. Pokushalov,
A. Cherniavskiy, I. Pak, Y. Kareva, A. Karaskov (Russian Federation)
Invited Discussant: S. Hunter, Middlesbrough
Invited Discussant: J. Braun, Leiden
17:00
Early and mid-term results of concomitant
cryoablation for atrial fibrillation in minimally
invasive mitral valve surgery
A. J. Rastan,
A. Simon, K. Badel, M. Misfeld, J. Garbade, M. A. Borger, J. Seeburger, F. Mohr (Germany)
Invited Discussant: A. Yilmaz, Nieuwegein
17:15
The outcome of the Cox maze III procedure for
atrial fibrillation: A propensity match analysis to
compare high-risk and low-risk patients
N. Ad, L. Henry, S. Hunt, S. D. Holmes (United States)
Invited Discussant: M. Castella, Barcelona
16:00 Focus Session
Auditorium 8
Management of heart failure II
n
to be aware of new developments in the treatment of
advanced heart failure
Moderators: A. Maat, Rotterdam; P. Leprince, Paris
A
blunt chest wall injury is a major
source of morbidity and mortality. Rib fractures are painful and can
lead to disability if left untreated.
Possible benefits of chest wall
stabilization are:
n
Wean the patient off the ventilator sooner, reducing risk of ventilator associated pneumonia.
n
Reduce chest wall instability,
leading to increasing lung function
n
Reduce risk of chronic pain associated with non-unions
The RibLoc® Rib Fracture Plating
System is indicated for flail chest,
multiple fractures, and non-union fractures. The plate’s unique ushape with locking screw technology provides superior fixation by
stabilizing the rib on three surfaces.
The precise targeting and instrumentation provide straightforward
and consistent insertion that may
reduce installation time when compared to other systems.
Stable Fixation:
The plate’s innovative U-shape and
locking screws allow fixation to be
independent of bone quality and/
or screw purchase in the bone. The
plate supports the fracture on three
surfaces and avoids the neurovascular bundle. This shorter U-shape
construct has shown to be biomechanically more stable when compared to a longer anterior plate.
Anterior plates require screw purchase into the bone for stability,
which may be difficult to achieve
due to the ribs weak and membranous quality.
Straightforward, Repeatable
Technique:
oped to decrease installation time.
ACUTE’s mission is to provide inThe plates are available in four
novative thoracic solutions that imwidths to match the anterior/poste- prove the quality of life for those in
Smaller Incision Sizes:
The plates in the RibLoc system are rior thickness of the rib. Color cod- need, by developing high quality
ing of the plates, screws and instru- products with a passion for problem
4.6 cm, 6.1cm and 7.6cm in length
mentation ensures that the correct solving, partnering with the healthand require four to six screws for
fixation. This reduces the necessary length of screw is used for the rib
care community, empathizing with
incision size, and speeds up the pro- while the innovative targeting
patients, and delivering outstandcedure (about 5 minutes per plate). guides aid the surgeon installing
ing service.
the plates in a straightforward, preIn contrast, anterior plates require
a much larger incision and at least 3 cise and repeatable manner. All of
screws on each side of the fracture. these features were carefully devel-
Focus session – Management of heart failure II Auditorium 8 16:00
16:00
16:20
16:40
17:00
Bridge-to-transplant and bridge-to-recovery:
complications and implications for further
treatment
Weaning from left ventricular assist device: How
and when?
E. Birks, London
Destination therapy with mechanical support
R. Hetzer, Berlin
Micropumps
A. Simon, London
Bridge to transplant M. Morshuis, Bad Oeynhausen
16:00 Focus Session
Room 5C
Perfusion: problems and opportunities
n
to gain an appreciation of new developments in
extracorporeal circulation
Moderators: F. Beyersdorf, Freiburg; A. Wahba, Trondheim
16:00
Mini cardiopulmonary bypassJ. Mulholland, London
Long-term oxygenators
F. De Somers, Gent
16:30 Portable systems
A. Philip, Regensburg
16:45 Extracorporeal membrane oxygenation –
guidelines
C. Benk, Freiburg
17:00 New ideas in myocardial protection
D. Chambers, London
16:15
08:30-10:00 Abstracts
Room 5A
Minimally invasive techniques
and risk factors
n
to extend knowledge of issues related to thoracic
maligancies
Moderators: L. Spaggiari, Milan; T. Folliguet, Paris
08:30
A propensity-matched comparison of survival
after lung resection in patients with high versus
low body mass index
S. Attaran, J. McShane,
I. Whittle, M. Poullis, M. Carr, N. Mediratta, M. Shackcloth (United Kingdom)
08:45
Lung cancer staging: A physiological update
M. Poullis, M. Shackcloth, R. Page, M. Carr, S. Woolley,
N. Mediratta (United Kingdom)
Invited Discussant: P. Rajesh, Birmingham
Invited Discussant: G. Cardillo, Rome
09:00
Increased number of skip mediastinal nodal
metastases in IIIA/N2 non-small cell lung cancer
detected using intraoperative ultrasound for
mediastinal lymphadenectomy
N. Ilic, J. Juricic, J. Banovic, D. Krnic, N. Frleta Ilic, S. Tanfara, D. Ilic (Croatia)
Invited Discussant: L. Spaggiari, Milan
09:15
Mediastinal lymph node dissection in early stage
non-small cell lung cancer: Totally thoracoscopic
versus thoracotomy
D. Gossot, R. Ramos, P. Girard, P. Validire (France)
09:30
Robotic extended thymectomy for clinical earlystage thymoma
O. Fanucchi, F. Melfi, A. Viti,
F. Davini, M. Lucchi, M. C. Ambrogi, A. Mussi (Italy)
Invited Discussant: M. S. Mulligan, Seattle
Invited Discussant: R. Schmid, Berne
09:45
Is video-assisted thoracoscopy an adequate
approach for pulmonary metastasectomy in the
21st century?
J. Eckardt, P. B. Licht (Denmark)
Invited Discussant: P. Van Schil, Antwerp
Destination therapy with
mechanical circulatory support
Roland Hetzer Deutsches
Herzzentrum Berlin, Berlin, Germany
E
nd-stage heart failure is a
growing world-wide problem for which there is no
definitive therapy. Although
heart transplantation remains
the gold standard treatment, it
is a limited resource that is not
attainable by a large number
of heart failure patients, both
young and old, but particularly
the elderly. It has been frustrating not to provide this group
with an optimal alternative to
ameliorate their symptoms. For
the past 14 years, however, the
Deutsches Herzzentrum Berlin has offered this expanding
group of advanced heart failure
patients who do not meet the
standard heart transplantation
criteria an alternative strategy:
destination (i.e. permanent) therapy with mechanical circulatory
support (MCS). With the development of the smaller and more
convenient continuous-flow
blood pumps for left ventricular assist devices (LVAD), destination therapy with these devices has become promising and
continues to be propitious. Patient selection and which type of
LVAD they receive are important
decisions.
In our institution, we implanted a total of 1848 LVADs
and total artificial hearts (TAH)
between April 1986 and August 2011 (137 in children), as
bridge to transplantation or to
allow myocardial recovery. Destination therapy was offered to
228 of these patients; 64 were
<65, 116 were >65-70 and 48
were >70 years old. Table 1
shows the devices implanted
for destination therapy in each
group and their outcome.
Destination therapy in patients <65 years old: Indications were malignancy (n=9),
amyloidosis (n=1), lack of compliance (drug and alcohol
abuse, n=3), obesity (n=12), peripheral arterial vascular disease
(n=2), pulmonary hypertension
(n=5), age >60 years with comorbidities (n=22) and others
(liver cirrhosis, patients’ wishes,
HIV and hepatitis C infections,
n= 9). Fifty-four had LVAD (pulsatile flow pumps, n=12; continuous flow rotary pumps,
n=42), while 9 had TAH.
Outcome: Causes of death
were multiorgan failure (n=10)
and sepsis (n=9). Forty-four patients survived >90 (median
297, range 105-1767) days.
Cumulative follow-up is 24,943
days, and the longest-term survivor is a 55-year-old female
with hypophysis tumor on Novacor LVAS for 5.2 years.
From among these 44 patients, VAD was explanted in
four (after 120, 676, 1,021 and
1,128 days), who finally underwent heart transplantation,
and in two (after 762 and 780
days), who had myocardial recovery. Complications encountered in remaining patients who
are still on MCS were cerebrovascular accident (CVA) in nine
(median support 212 days),
pump failure which required exchange in seven (median support of 1385 days) due to leaks
in air tubes and drivelines.
Destination therapy in patients 65-70 years old: These
are the patients with cardiomyopathy (idiopathic n=59; dilated
n=47; valvular n=2), acute myocardial infarction (n=4) and
myocarditis (n=4). Twenty-six
patients underwent MCS implantation via a left lateral thoracotomy approach.
Outcome: Causes of 90-day
mortality were multiorgan failure (n=20), CVA (n=10), right
ventricular failure (n=6), circulatory failure (n=6), lethal pneumonia (n=3), bleeding (n=3)
and sepsis (n=5). Twenty-four
patients survived >90 (median
316, range 95–1,914) days. The
longest survivor is a 67-year-old
female with idiopathic cardiomyopathy and severe peripheral
arterial vascular disease on DuraHeart LVAD for 1,914 days .
Pump driveline failure was
encountered after 657, 1,110
and 1,219 days. A patient on
Berlin Heart Excor and another
on Berlin Heart Incor committed suicide after 107 and 1,042
days of support, respectively.
Destination therapy in patients >70 years old: These
are patients with cardiomyopathy (dilated, restrictive), and
mostly with ischemic heart diseases. Thirteen patients underwent MCS implantation via
a left lateral thoracotomy approach. Forty-six patients were
in Intermacs level 1-3, while
two were in Intermacs level 4.
Outcome: The rate of implantation of MCS as destination therapy in the last two
aforementioned age groups
is shown in Figure 1. Figures.
2 and 3 show cumulative survival rate in patients >65 and
>70 years old, respectively. The
remaining patients (three are
>80 years old) are at home. The
longest survival time is 5.1 years
on Berlin Heart Excor.
apy. So far, our series is the largFurther directions: Our
est ever reported and our regroup has revolutionized the
use of MCS as destination ther- sults are satisfactory.We do not
Table 1. Mechanical circulatory devices implanted and outcome of destination therapy in 228 patients
<65 years old n=64 >65-70 years old n=116
>70 years old n=48
Median age (range), years
59 (20-64)
67 (65-69)
73 (71-82)
Devices
Berlin Heart Excor LVAD/BVAD
4/3
25
3/2
Berlin Heart Incor 10
30
11
SynCardia CardioWest TAH
3
7
1
Micromed De Bakey LVAD
9
7
3
Terumo DuraHeart
1
4
1
HeartWare LVAD/BVAD
12/3
15
14/2
Thoratec Heart Mate I
1
1
Thoratec Heart Mate II
8
16
9
Jarvik 2000
3
2
1
Novacor LVAS
5
6
Lion Heart
3
3
Outcome
30-day mortality, n (%)
10 (15.9)
39 (34)
17 (35.4)
90-day mortality, n (%)
9 (14.2)
53 (45)
Cumulative follow-up (patient-years)
68.3
80
36
Longest survival time (years)
5.2
5.2
5.1
Longest survivor (age at time of destination therapy)
55
67
75
refuse any patients with endstage heart failure who needs
destination therapy, who are still
intellectually capable of tolerating and handling their assist devices, who have a strong will to
live and who can comply with
the necessary follow-up care. In
the future, there will be newer
and safer implantable devices
with increased durability. With
improvements in patient selection, we foresee that many destination therapy patients will have
a life expectancy closer to that of
others in their age group, especially the elderly. Rather than dying from heart failure, these patients will live long enough to be
subject to other life-limiting disease processes. In one way or
another, they will still die, but it
is gratifying to offer them a reasonable option over the span of
their disease.
Room 5A
Abstracts – Acute type B aortic dissection Auditoria 3&4 14:00
Thoracic non-oncology
n
to update knowledge of techniques, complications
and outcomes of the management of pulmonary and
pleural disease
Moderators: D. Subotic, Belgrade; S. Margaritora, Rome
10:30
Bronchopleural fistula: surgical versus
endoscopic management. Analysis of 43 patients
treated in a single institution
G. Cardillo, L. Carbone, F. Carleo, B. Cali, G. Lucantoni,
R. Dello Iacono, G. Galluccio, M. Martelli (Italy)
10:45
Thoraco-mediastinal plication for
postpneumonectomy empyema: Experience with
30 consecutive cases
A. M. Botianu, P. V. Botianu (Romania)
Invited Discussant: G. Marulli, Padova
Invited Discussant: M. Jimenez, Salamanca
The location of the primary
entry tear in acute type B aortic
dissection affects early outcome
(convexity or concavity of the
distal aortic arch) using the referral CT scans at the time of
diagnosis. These findings were
correlated to clinical outcome
as well as to the need for interthe primary entry tear is not yet vention.
Gabriel Weiss Hospital Hietzing,
Twenty-five patients (48%)
taken into consideration during
Vienna, Austria
had the primary entry tear lothe course of determining the
cated at the convexity (group
treatment strategy.
n the current era, patients
A) of the distal aortic arch,
The goal of the retrospecwith uncomplicated type B
whereas twenty-seven patients
tive study was to correlate the
aortic dissections are usually
treated medically. However, de- site of the primary entry tear in (52%) had the primary entry tear located at the concavspite significant advances in di- acute type B aortic dissections
agnosis and treatment, the man- to the presence or development ity (group B) of the distal aortic
arch. Twenty percent of paof complications.
agement of acute type B aortic
tients with the primary entry
A consecutive series of 52
dissection remains controversial
tear at the convexity presented
and decision-making is based on patients referred with acute
type B aortic dissection was an- with or developed complicasubjective clinical judgment. To
alyzed with regard to the loca- tions, whereas 89% had or dedate in the overwhelming maveloped complications with the
tion of the primary entry tear
jority of cases, the location of
I
tor of the presence or the development of complicated type
B aortic dissection.
Summarizing, a primary entry
tear at the concavity of the aortic arch as well as a short distance between the primary entry tear and the left subclavian
artery are frequently associated
primary entry tear at the concavity (p < 0.001). Furthermore, with the presence or the development of complicated acute
in patients with complicated
type B aortic dissection, the dis- type B aortic dissection. Based
tance of the primary entry tear on these findings the localizato the left subclavian artery was tion of the primary entry should
be implemented in risk stratifisignificantly shorter as in uncomplicated patients (8mm vs. cation of acute type B dissection in addition to the common
21mm; p = 0.002). In Cox-regression analysis, a primary en- categorization in complicated
try tear at the concavity of the and uncomplicated. These findings may therefore also have an
distal aortic arch was identified as an independent predic- impact on primary treatment.
Advances in LVAD patient management: minimizing adverse events
Mark S. Slaughter, MD Professor of Surgery, Division of
Thoracic and Cardiovascular Surgery, University of Louisville, Kentucky
A
cross many cardiac centers of excellence,
there is rapid adoption of left ventricular assist device (LVAD) therapy and clinical outcomes
continue to improve. LVAD implantation is no
longer a niche treatment modality, destined for
only the sickest patients. Since being implanted
for the first time 25 years ago, the landscape for
the implantation of LVADs is vastly different today. Importantly, the devices have improved significantly, becoming more effective and more reliable over the years. The majority of implanted
LVADs are continuous-flow devices, based largely
on studies showing superiority of the device over
pulsatile-flow devices.1
In 2010, comprehensive guidelines for the clinical management of advanced heart failure patients treated with continuous-flow LVADs were
published.2 Use of the guidelines to optimize patient care has already yielded improved outcomes for both bridge-to-transplant (BTT) and
destination therapy (DT) patients. In the contemporary HeartMate II® DT access protocol, for example, investigators observed superior outcomes
compared with the primary cohort of the pivotal
trial, including a 50% reduction in stroke and a
trend toward improved survival (Figure 1). Similar trends were observed in the HeartMate II BTT
post-approval study.
The guidelines also highlight new understanding of effective anticoagulation. In some patients, heparin is not always needed in postoperative care. As a result, the evidence-based
INR recommendations for patients implanted
with the HeartMate II device have been reduced
to 1.5 to 2.5 (Figure 2). Patients are also required to take 81 mg to 325 mg of aspirin daily.2
Other published studies evaluated the effects of
heparin on thromboembolic and bleeding com-
plications after HeartMate II implantation. Individuals directly transitioned to warfarin and aspirin without postoperative intravenous heparin
had lower risks of bleeding without an increased
risk of pump thrombosis or ischemic stroke.3
Better blood pressure control is also important for minimizing adverse events. Continuousflow LVADs increase diastolic pressure and flow.4
Systolic blood pressure remains constant with the
devices, and as a result, pulse pressure is markedly reduced. Arterial blood pressure should be
controlled with vasoactive and inotropic medications and intravascular fluid volume man-
the desperately ill, but can be safely and effecagement, but not by adjusting the LVAD pump
tively used in a range of cardiac patients.
speed. Mean arterial blood pressure should be
View Dr. Slaughter’s full presentation at
maintained between 70mmHg and 80mmHg, and
VADParadigm.com.
is not to exceed 90mmHg.2 In the postoperative
management of LVAD patients, use of Doppler is References
1. Kirklin JK, Naftel DC, Kormos RL, et al. Third INTERMACS annual report: the evolution of destirecommended to obtain regular blood pressure
nation therapy in the United States. J Heart Lung Transplant. 2011;30:115-23.
measurements.
2. Slaughter MS, Pagani FD, Rogers JG, et al. Clinical management of continuous-flow left venOverall, the newest LVAD devices are adtricular assist devices in advanced heart failure. J Heart Lung Transplant. 2010;29: S1-S39.
3. Slaughter MS, Naka Y, John R, et al. Postoperative heparin may not be required for transitionvanced, sophisticated, reliable, and safe. Best
ing patients with a HeartMate II left ventricular assist system to long-term warfarin therapy. J
practices can guide patient selection and longHeart Lung Transplant. 2010;29:616-24.
4. Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuousterm postoperative care within clearly defined
flow left ventricular assist device. N Engl J Med. 2009;361:2241-51.
parameters. As a result, the devices no longer
provide care only for
Figure 1.
Figure 2. Events per patient per year versus INR range at time of thrombotic and
hemorrhagic events.
Abstracts – Cardiopulmonary bypass Room 5C 14:00
11:00
Accuracy of transthoracic ultrasound for the
detection of pleural adhesions N. Cassanelli (Italy)
Invited Discussant: F. Rea, Padova
11:15
A prospective randomised trial comparing stapler
and laser techniques for interlobar fissure
completion during pulmonary lobectomyG. Marulli,
A. Droghetti, F. Di Chiara, F. Calabrese, A. Rebusso, E.
Perissinotto, G. Muriana, F. Rea (Italy)
Invited Discussant: M. Yuksel, Istanbul
11:30
Surgical treatment of bronchiectasis: Impact on
quality of life and results A. Aquino, W. Schimidt,
L. Londero, F. A. Perin, S. Camargo, J. Felicetti, J. Camargo, S. Filho (Brazil)
Invited Discussant: D. Subotic, Belgrade
11:45
Cysteinyl-leukotriene receptor antagonist
montelukast ameliorates acute lung injury
following haemorrhagic shock in rats
F. G. Alamran, N. R. Hadi (Iraq)
Invited Discussant: S. Margaritora, Rome
12:00 Presentations and report
Auditorium 1
Fontan Prize; Thoracic Prize; Fontan Prizewinner 2010
12:15 The Honoured Guest Lecture
Auditorium 1
Tissue-specific adult stem cells P. Anversa, Boston
Room 5A
Special topics – Thoracic
n
to increase knowledge of newer methods for managing
difficult thoracic surgical problems
Moderators: F. Rea, Padova; M. Yuksel, Istanbul
14:00
Spray cryotherapy: a novel treatment modality for
minimally invasive surgery in the thorax
J. T. Au, J. Carson, T. J. Song, W. Krimsky, S. Monette, V. W. Rusch, D. J. Finley (United States)
Invited Discussant: C. Deschamps, Rochester
14:15
Development and validation of a clinical
prediction model to estimate the probability of
malignancy in solitary pulmonary nodules in
Chinese people
Y. Li, K. Chen, J. Wang (China)
Invited Discussant: F. Rea, Padova
14:30
A real change in postoperative course after
sternectomy: Chest wall reconstruction using a
titanium rib bridge system
D. Fabre, S. El Batti,
E. Fadel, S. Mussot, O. Mercier, B. Petkova, F. Kolb, P. Dartevelle (France)
14:45
Outpatient endobronchial laser ablation of
symptomatic airway obstruction is costeffective
and safe
M. Scarci, X. Allison, K. Piggott,
Y. Shargall, C. Finley, J. Miller (Canada)
Invited Discussant: K. Athanassiadi, Athens
Invited Discussant: K. Moghissi, Hull
15:00
How early can we repair pectus excavatum: The
earlier the better?
H. J. Park, S. Sung, J. Park,
J. J. Kim, Y. Wang (Republic of Korea)
15:15
Case Report:
The use of a suction cup as an adjunct in the
Nuss procedure for severe asymmetric pectus
excavatum: interesting/challenging case report M. Goretsky, R. Obermeyer, R. Kelly (United States)
Invited Discussant: M. Yuksel, Istanbul
16:00-17:30 Focus Session
Room 5A
Chest wall
n
to gain an appreciation of the latest advances in chest
wall surgery
n
to be aware of specific new techniques in chest wall
repair and reconstruction
Moderators: J. M. Wihlm, Strasbourg; J. Ribas Milanez,
Buenos Aires
16:00
16:15
16:30
16:45
17:00
17:15
Sternal reconstruction with cadaver bone (video)
F. Rea, Padova
Minimally invasive pectus excavatum repair
H. Pilegaard, Copenhagen
Minimally invasive pectus carinatum repair
M. Yuksel, Istanbul
Minimally invasive first rib resection
M. C. Ghefter, São Paolo
Chest wall resection and reconstruction
C. Deschamps, Rochester
Sternal dehiscence
M. Tocco, Rome
Lung protection by selective pulmonary
pulsatile perfusion in cardiac surgery
60 bpm. Compared to a control
group managed conventionally
with a CPB-induced non-physiologic linear sole systemic perfusion, these patients showed a
mans, a better preservation of
he etiology of pulmonary lung function, in terms of both protective effect of PPP on CPB
induced lung damage, clinically
functional respiratory indices
dysfunction after cardiac
manifested by better preserved
and pulmonary hemodynamic
surgery is multifactorial
respiratory indices (alveolo—arparameters, when utilizing seand includes extra- cardiopullective pulsatile pulmonary per- terial oxygen gradient, oxygenmonary bypass (CPB) factors
ation index, lung compliance),
fusion (PPP) with the patient’s
(general anesthesia, sternotown oxygenated blood during and pulmonary hemodynamic
omy, postoperative pain with
CPB and aortic cross-clamping. parameters (indexed pulmonary
hypoventilation, breach of the
vascular resistances, mean pulpleura, surgical wound-related Indeed, in patients prospecmonary arterial pressure, pultively randomized to pulsatile
inflammatory response, etc.)
perfusion, PPP at a flow rate of monary capillary wedge presand intra-CPB factors (blood
sure, and cardiac index [CI].
contact with artificial materials, 7ml kg-1 min-1 was initiated
Post-CPB lung injury has
loss of arterial physiologic pul- at the start of CPB, and termibeen demonstrated to be the
sation replaced by a non-phys- nated at the beginning of the
weaning period. The pulmonary consequence of a cytokine/
iologic linear perfusions, lung
flow was infused into the main chemokine-mediated inflammaischemia/reperfusion, pulmotion, predominantly triggered
pulmonary artery via a 14-Fr
nary air and/or fat embolism,
cannula (Edwards Fem-Flex, Ed- by an ischemia-reperfusion
hypothermia, lung ventilatory
mechanism of injury, which rewards Lifesciences, Irvine, CA,
arrest, etc.). The combination
sults from the sequestration of
of all these variables result in a USA) and drained out the left
activated leukocytes and plateatrium through a vent, to selocal (lung) and a systemic inlets in lung parenchyma, with
flammatory response, mediated cure a bloodless surgical field
consequential lung damage by
by endothelial cells, leukocytes, and a decompressed left venseveral molecules including oxycomplement, cytokines, chem- tricle. Pulsatility was achieved
gen-derived free radicals. In this
okines, and other soluble mole- by a pulsatile pump (Jostra,
cules, all of which contribute to Maquet Cardiopulmonary, Hir- second investigational trial, we
perioperative lung damage and rlingen, Germany) integrated in aimed at assessing the systemic
and local (alveolar) inflammathe CPB machine, at a rate of
respiratory dysfunction.
In the setting of isolated elecFrancesco Santini Professor of
Cardiovascular Surgery, Department tive coronary artery bypass
grafting (CABG), we demonof Surgery, University of Verona
strated, for the first time in huMedical School, Verona, italy
T
tory response in humans undergoing selective PPP. In particular, the primary endpoint of the
study was to evaluate the role
of PPP on alveolar inflammation and the neutrophil count
in bronchoalveolar fluid lavage (BAL) samples was considered the primary outcome variable. Beside the neutrophil
count, absolute number of
white blood cells (WBC), monocytes/macrophages and lymphocytes were also collected.
Proinflammatory cytokine (IL-1,
IL-8, TNF-alpha), chemokine assay (GRO, MCP-1), and anti-inflammatory cytokine assay (IFNgamma) were similarly collected
from BAL-samples and central
venous blood, and considered
as secondary endpoints.
Patients undergoing selective PPP demonstrated at BAL
analysis a significantly lower
number of absolute WBC count
when compared to the control
Group. In particular, the higher
WBC alveolar infiltrates after
standard CPB resulted from a
significantly higher sequestration in alveolar spaces of both
neutrophils and lymphocytes
(vs monocytes/macrophages in
the PPP Group). When pro-inflammatory and anti-inflammatory mediators were considered in BAL, selective PPP
Francesco Santini
resulted in a higher anti-inflammatory with lower pro-inflammatory lung activation. On the
other hand, serum pro-inflammatory cytokines and chemokines, as well as anti-inflammatory IFN-gamma demonstrated
an evident systemic response in
both Groups, although with no
significant differences.
In conclusion, selective PPP
seems to attenuate CPB-induced lung inflammation as
shown by a lower sequestration in alveolar spaces of WBC
and a reduced alveolar leakage
of pro-inflammatory mediators.
These data appear to support
the better clinical outcome, in
term of preserved respiratory indices and pulmonary hemodynamic parameters, as previously
reported.
Abstracts – Mixed congenital Room 5B 16:00
Long-term surgical outcome of mitral valve repair
in infants and children with Shone’s anomaly
72.0±8.3% and 52.8±11.8%, at 30
days, one, five, 10 and 15 years postoperatively, respectively. In the <one year
olds, freedom from reoperation was
95.56 % at one year and was sustained
Eva Maria Delmo Walter,1 Takeshi Kountil the late follow-up period. Repeat
moda,1 Henryk Siniawski,1 Richard van
MV repair was performed mostly in the
Praagh,2 Roland Hetzer1 1 Department of
1-5 year old groups until 10 year folCardiothoracic and Vascular Surgery, Deutlow-up. In the ≥10 year-old group it was
sches Herzzentrum Berlin, Berlin, Germany 2
noted that there was no repeat MV surChildren’s Hospital Boston/Harvard Medical
gery five years after the initial MV repair.
School, Boston, Massachusetts, USA
We performed only one MV replacement, and this was on a two year-old
orty-eight years after Shone and
patient with parachute valve at the time
colleagues1 described the develof the initial MV repair. He underwent
opmental complex of four potenrepeat repair five years postoperatively.
tially obstructive lesions, consisting of
Two years later, he underwent MV reparachute mitral valve, supravalvar miplacement but died eight years postoptral ring, subaortic stenosis and coarceratively. Mortality unrelated to valve retation of aorta (Figure. 1), there have
been only three other published studEva Maria Delmo Walter
Figure 1 pair accounted for nine (20%) deaths.
The formidable surgical challenge
ies2,3,4 reporting their long-term operapresented by these patients is amplitive outcomes, while others are sporadic subaortic stenosis due to fibromuscuously corrected or concomitant correccase reports describing the anomaly.5,6,7 lar hypertrophy in 71.1% and subvalvar tion of the left-sided obstructive lesions, fied by the coexistence of restrictive and
often surgically unfavorable morpholThere has been a tremendous paucity of membrane in 51.6%. Forty-five patients MV repair was performed using comunderwent a total of 367 procedures to missurotomy, division of chordae tend- ogy of the MV,. especially in hypoplasinformation, probably because pediattic valves in infants. An aggressive funcric patients with Shone’s anomaly are a repair the left ventricular inflow and out- inae, papillary muscle splitting and
fenestration,11 and resection of suprav- tional MV repair approach and relief of
rare occurrence in clinical practice and, flow tract obstructive lesions including
the LVOT obstruction lead to long-term
repair of associated cardiac anomalies.
to date, only a total of 84 cases operalvular mitral ring.
event-free survival in these children. DeMV involvement seen in this series
ated on with long-term outcomes have
Outcome of MV repair. There was a
does not entirely encompass the feabeen specifically reported in the literasignificant improvement in NYHA func- spite high surgical risk, late outcomes
are favorable and are related to the deture. The finding in Shone’s original de- tures of Shone’s anomaly, as Shone1
tional class postoperatively, and this
gree to which MS can be relieved.
scription that the extent of mitral valve originally described. MV morphology
was sustained until the late follow-up
(MV) involvement seems to be the pre- conforms to the gamut of congeniperiod. There was a marked absence
References:
1 Shone JD, Sellers RD, Anderson RC, Aadms P, Lillihei CW, Edwards JE.
dominant factor determining outcome
tal MV anomalies reported by the path- of MS (mean MV orifice area 5.2±0.8
The developmental complex of “parachute mitral valve“, supravalvular
is supported by the review of 30 cases
cm2 with mean resting end-diastoological studies of Ruckman and Van
ring of left atrium, subaortic stenosis, and coarctation of aorta. Am J
by Bolling and colleagues2 which repPraagh8 and that of others9,10 as well as lic pressure gradient 2.3mm Hg)) afCardiol 1963;11:714-725.
ter MV repair. During follow-up, 14 pa- 2 Bolling SF, Iannettoni MD, Dick M II, Rosenthal A, Bove EL. Shone’s
resents the most comprehensive report by Shone1 himself. In our series, supanomaly: operative results and late outcome. Ann Thorac Surg
to date, and comprises patients with a
ravalvular mitral ring was present in all; tients have developed significant MS
1990;49:887-893.
2
(mean MV orifice area 3.3±0.5cm and 3 Brauner R, Laks H, Drinkwater DC Jr, Scholl F, McCaffery S. Multiple
multitude of anatomic variants and dif- parachute valves, however, comprise
ferent management approaches That
only 17.7%. In this lesion, all chordae
mean resting end-diastolic pressure gra- left heart obstruction (Shones’s anomaly with mital valve involvement:
long-term surgical outcome. Ann Thorac Surg1997;64:721-729.
outcome is related to the severity of the tendinae, which were short and thickdient 5.7±1.3mm Hg) warranting re4 Brown J, Ruzmetov M, Vijay P, Hoyer MH, Girod D, Rodefeld MD, Turrentine MW. Operative results and outcomes in children with Shone’s
mitral component of the disease has
ened, were attached to just one papilpeat intervention. Twelve (26.7%) paanomaly. Ann Thorac Surg 2005;79:1358-1365.
also been suggested by Brauner et al.3
lary muscle. which was mostly centrally tients who underwent primary resection 5 Prunier F, Furber AP, Laporte J, Geslin P. Discovery of a parachute
mitral valve complex (Shone’s anomaly) in an adult. Echocardiography
of supravalvular mitral ring had to unin their study of 19 cases, and Brown et located. We did not see both papillary
muscles with attachment of chordae
dergo repeat resection. These were also 2011;18:179-182.
al.4 with their reported 27 cases.
6 Joffe D, Gurvitz M, Oxorn D. An unusual presentation in a patient with
Having collected the largest series of tendinae to only one.4 The other MV le- the ten patients with type I congenShone’s anomaly. Anesthesia and analgesia 2008;107:1825-1827.
7 Moustafa SE, Lesperance J, Rouleau JL, Gosselin G. A forme fruste of
Shone’s anomaly so far, we analyzed
sions encountered were mostly the typ- ital MS with fused commissures and
Shone’s anomaly in a 65 year-old patient. McGill J Med 2008;11:19-21.
the operative results and long-term out- ical congenital MS (Type I) described as thickened leaflets and two with hypo8 Ruckman R, Van Praagh R. Anatomic types of congenital mitral stenosis: report of 49 autopsy cases with consideration of diagnosis and
come of mitral valve (MV) repair techsmall annulus, thickened and rolled leaf- plastic MV (Type II). Aside from resecniques performed to correct this conlets with short and fused chordae, untion of the membranous ring, commis- surgical implications. Am J Cardiol 1978;42:592-601.
9 Oosthoek PW, Wenink AC, Macedo AJ, Gittenberg-de Groot AC. The
genital anomaly.
derdeveloped papillary muscles, and
surotomy, chordal division and papillary parachute-like assymetric calve and its two papillary muscles. J Thorac
Xardiovasc
Surg 1997;114:9-15.
Between 1986 and 2011, 45 children commissural fusion seen in 53.3% and muscle splitting. were also performed.
(median age 4.7, range 0-15 years) un- hypoplastic MV (Type II), the miniature
Their latest echocardiogram showed ab- 10 Rosenquist GC. Congenital mitral valve disease associated with coarctation of the aorta. A spectrum that includes parchute deformity of
derwent surgical correction of Shone’s
of a normal MV, seen in 11.1% .
sence of MS. Mean duration of follow- the mitral valve. Circulation 1974;49:985-993.
anomaly. Left ventricular outflow tract
For obstructive lesions on the MV,
up was 17.5±1.5 years (range 6.4-22.7 11 Hetzer R, Delmo Walter EMB, Huebler M, Alexi-Meskishvili V, Weng
Y, Nagdyman N, Berger F. Modified surgical techniques and long term
(LVOT) obstructive lesions consisted of
a total of 141 procedures were peryears). Freedom from reoperation was
outcome of mitral valve reconstruction in 111 children. Ann Thorac
coarctation of the aorta found in 88.8%, formed. On patients with either previ97.6±2.4%, 89.3±5.1%, 77.1±7.2%,
Surg. 2008;86:604-613.
F
Abstracts – TAVI III Auditorium 7 14:00
Impact of previous cardiac operations on patients
undergoing trans-apical aortic valve implantation:
results from the Italian Registry of trans-apical
aortic valve implantation (I-TA)
Augusto D’Onofrio1, Paolo Rubino2, Melissa Fusari3, Francesco Musumeci4, Mauro Rinaldi5,
Ottavio Alfieri6 and Gino Gerosa1 on behalf of the I-TA investigators 1 Division of Cardiac
Surgery, University of Padova, Padova, Italy; 2 Invasive Cardiology Laboratory, Cardiology Division, Clinica Montevergine, Mercogliano, Italy; 3 Department of Cardiovascular Sciences, Centro
Cardiologico Monzino, IRCCS, University of Milan, Milan, Italy; 4 Department of Cardiac Surgery, San
Camillo Hospital, Rome, Italy; 5 Division of Cardiac Surgery, University of Turin, Turin, Italy; 6 Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
A
lthough conventional surgical aortic valve replacement (SAVR) is still
the treatment of choice for patients
suffering from severe degenerative aortic valve stenosis (AS), transcatheter aortic
valve implantation (TAVI) has shown good
early and mid-term results in patients with
severe comorbidities and in inoperable patients. High-risk or inoperable patients with
severe symptomatic degenerative AS who
had previously undergone at least one major cardiac operation represent a particularly
challenging group that could benefit from a
minimally invasive transcatheter approach.
In redo patients, the potential advantages
of TAVI derive from the minimally invasive
approach that requires a small mediastinal
reentry and dissection (in case of transapical
[TA]-TAVI and transaortic) or no dissection
at all (transfemoral [TF]-TAVI and trans-subclavian) and consequently reduces the risk
related to chest reopening such as massive
hemorrhage or graft injury. Advantages also
derive from the beating heart technique
that eliminates myocardial protection issues
in patients with previous CABG. The aim of
this prospective multicenter study from the
Italian Registry of Trans-Apical aortic valve
implantation (I-TA) was to evaluate the impact of a previous cardiac operation in high
risk or inoperable patients undergoing TATAVI, on early and mid-term clinical outcomes in terms of mortality, morbidity and
operative complications.
The I-TA registry is an independent prospective multicentre registry that includes
the great majority of TA-TAVI performed in
Italy since this procedure became commer-
Augusto D’Onofrio
cially available in 2008.
The I-TA registry includes the TA-TAVI experience of 20 Italian cardiac surgery centers since April 2008. We divided patients
into two groups: Group F with patients
who underwent TA-TAVI as the first cardiac
operation and Group R with patients who
had already undergone at least one cardiac
operation before TA-TAVI. From April 2008
through May 2011, 566 patients were en-
rolled in the I-TA registry. Group F included
456 patients (80.6%) while Group R included 110 patients (19.4%). Group R patients were younger (76.3 vs. 81.6 years,
p<0.001) and more likely to suffer from diabetes, porcelain aorta and peripheral vascular disease. Furthermore, Group R patients
had higher logistic Euroscore (35±18.6%
vs. 23.5±11.9%, p<0.001) and STS mortality score (14±9.2 vs. 8.9±6.7%, p<0.05)
than Group F patients. All-cause 30-day
mortality in the overall population was
7.8% (44 patients). All-cause 30-day mortality in Group R and F was 7.2% (8 patients) and 7.9% (36 patients), respectively (p=0.8). Overall 30-day cardiovascular
mortality was 6.4% (36 patients). Thirtyday cardiovascular mortality occurred in 8
(7.2%) and in 28 (6.1%) patients in group
R and F, respectively (p=0.21). We did not
find significant differences in the incidence
of operative complications between groups.
In particular, intraoperative life-threatening
or disabling hemorrhage due to the apical access occurred in 3 patients of Group
F (0.7%) and only one patient of Group R
(0.9%) (p=0.77). There were no significant
differences between groups in terms of
postoperative complications.
At the multivariate analysis porcelain aorta (OR: 3.48; 95%CI:1.04-11.68;
p<0.05) and LVEF (OR:0.94; 95%CI:0.890.99; p<0.05) were independent predictors
of 30-day mortality in group R.
Mean follow-up (100% complete) was
10.4±7.9 months (Range: 1-34 months).
All-cause 1-year Kaplan-Meier survival in group F and R was 83.6±2% and
82.7±4.2%, respectively and 2-year survival was 75.4±3.5% and 64.2±9.8%, respectively (p=0.69) (Fig. 1). In conclusion,
according to our data, TA-TAVI in patients
with previous cardiac operations can be carried-out with good outcomes in terms of
mortality, morbidity and complications, that
result similar to those of patients with no
history of cardiac surgery. In particular, the
transapical approach is not associated with
a higher incidence of access-related complications. Therefore TA-TAVI should be considered as a reasonable therapeutic option
in this patient population. The choice of
the reoperative approach, whether TAVI or
SAVR, should be made taking into consideration age, comorbidities and type of previous operation and the final decision should
be tailored on each single patient and
shared by the “TAVI-team”.
Figure 1: Survival in groups F and R
Impact of preoperative mitral valve regurgitation on outcomes after trans-catheter aortic valve implantation
Augusto D’Onofrio1, Valeria Gasparetto2, Massimo
Napodano2, Roberto Bianco1, Giuseppe Tarantini2, Vera
Renier1, Giambattista Isabella2 and Gino Gerosa1 1
Division of Cardiac Surgery, Department of Cardiac Thoracic
and Vascular Sciences, University of Padova Medical School,
Padova, Italy 2 Cardiology Clinic, Department of Cardiac
Thoracic and Vascular Sciences, University of Padova Medical School, Padova, Italy
M
itral regurgitation is often associated with aortic valve stenosis. Double valve replacement
is indicated in case of concomitant severe MR
and AS but the mortality rate associated with this procedure is significantly higher than isolated aortic valve
replacement. TAVI is indicated in patients with severe
symptomatic AS who are inoperable or have a high-risk
for conventional surgery. In these patients, the presence
of moderate-severe MR represents a therapeutic challenge and there are few data about patient outcomes.
The aims of this prospective single-center study
were to assess the impact of preoperative MR on the
outcomes of patients undergoing TAVI and to evaluate MR changes after TAVI. We analyzed all TAVI patients performed at our institution. We included transapical, trans-femoral and trans-subclavian approaches
and we divided patients into two groups according to
the presence and the degree of MR. From June 2007
to January 2011, 176 consecutive patients underwent
TAVI at our department. Trans-apical and trans-femoral
TAVI were performed in 52 (29.5%) and 119 (67.6%)
patients, respectively and 5 patients(2.9%) underwent
trans-subclavian implantation.
Patients were divided into two groups according
to the degree of preoperative mitral insufficiency: MR
<2+=NoMR group (133 patients, 75.6%), MR≥2+=MR
group (43 patients, 24.4%). Mean follow up was
10.4±7.7 months (Range 1-36 months) and was 100%
complete. Patients in the NoMR group were more likely
to have lower logistic Euroscore (19.6% vs 26.9%,
p<0.001) and less atrial fibrillation (16.5% vs 34.9%,
p=0.004). MR patients had larger left atrium, higher
systolic and diastolic left ventricular volumes and worse
E
dwards offers a wide range
of arterial cannulae that
are specifically designed to
help you protect your patients
during on-pump cardiac surgery by minimizing trauma to
the aorta and by enabling less
invasive surgical techniques.
The Embol-X Glide protection system is the only arterial
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ejection fraction if compared to NoMR patients. Furthermore patients belonging to NoMR group had
higher pulmonary and wedge pressures and lower cardiac output values. The analysis of TAVI procedures did
not show significant differences in terms of anesthesia,
TA or TF approach, implanted device, procedural success and postoperative aortic regurgitation. Overall allcause hospital mortality was 4.5% (8 patients). In particular all-cause hospital mortality in NoMR and MR
group was 3% (4 patients) and 9.3% (4 patients), respectively (p=0.06). Kaplan-Meier survival 20 months
after TAVI was 78±8% in MR group and 75±6% in
NoMR group (p=0.2) (Figure 1). At echocardiographic
follow-up we observed in the MR group, but not in the
NoMR group, a significant improvement of left ventricular ejection fraction, a significant reduction of left
ventricular volumes and a significant reduction of right
ventricular systolic pressure . Out of the 43 patients of
the MR group, at follow-up 12 patients (27.9%) experienced a significant reduction of MR degree that resulted <2+. Multivariate analysis identified as independent predictors for hospital mortality: logistic Euroscore
(OR: 1,089, 95%CI: 0.993-1.195; p<0.05) and procedural success (OR: 0.032; 95%CI: 0.001-0.873;
p<0.001). Preoperative MR was not found to be an inFigure. 1 Kaplan-Meier survival after TAVI of
the two groups
n
A dispersion tip that allows a
low trauma outflow path
n
An advanced filter technology
n
All integrated into a conventional cannula design
n
Available in kits or as individual components
The EMBOL-X intra-aortic filter
has been demonstrated to provide safe and effective emboli
capture hence reducing certain
adverse events and end-organ
damage.
The highly evolved EMBOLX Glide protection system is the
only device that combines a
low-trauma outflow path with
advanced filter technology – all
integrated into a conventional
cannula design.
dependent predictor for hospital mortality. At follow-up
we observed a significant reduction of New York Hear
Association (NYHA) functional class in both groups.
In conclusion, our data show that inoperable or
high-risk patients with severe AS and concomitant
moderate-severe MR undergoing TAVI have a higher
surgical risk profile and a trend towards higher hospi-
tal mortality. However MR was not identified as an independent risk factor for mortality. At follow up a reduction of MR, an improvement of left ventricular
echocardiographic parameters and a significant improvement of NYHA class were observed. Therefore,
these data justify a “TAVI-only” procedure even in the
presence of moderate-severe MR.
Focus session – Chest wall Room 5A 16:00
Congenital
Minimal invasive repair of PE
08:30-10:20 Focus Session
Room 5B
Fontan controversies:
EACTS-AEPC joint session
n
understand current controversies in the management
of patients undergoing Fontan operation
n
obtain clinical insight and management plan for
Fontan-related complications
Moderators: C. Schreiber, Munich; S. Qureshi, London
08:30
Surgical view of controversies
W. Brawn, Birmingham
08:40: Cardiological view of controversies
O. Milanesi, Padova
08:50 Panel Discussion
Surgeons: B. Maruszewski, Warsaw; J. Fragata, Lisbon; M. Reddy, Stanford
Cardiologists: D. Schranz, Giessen; J. Pihkala, Helsinki; J. L. Zunzunegui, Madrid
Controversies:
Optimal age
Management of pulmonary pulsative flow
Management of AV-valve regurgitation
Fenestration
Anticoagulation
Arrhythmia
09:35 Bidirectional cavopulmonary shunt with additional
pulmonary blood flow: Failed or successful
strategy?
C. Boulitrop, S. Gerelli, D. Maldonado,
M. Van Steenberghe, D. Bonnet, O. Raisky, D. Sidi, P. R. Vouhe (France)
Invited Discussant: F. Hanley, Stanford
09:50
Natural and modified history of single ventricle
physiology in adult patients
E. Angeli, C. Pace Napoleone, A. Balducci, R. Formigari, G. Oppido, S. Turci, L. Ragni, G. Gargiulo (Italy)
Invited Discussant: H. Sairanen, Helsinki
10:05
Current outcomes of the Glenn bidirectional
cavopulmonary connection for single ventricle
palliation
B. Alsoufi 1, C. Manlhiot 1, A. Awan1,
M. Al-Ahmadi 1, A. Al-Omrani 1,
B. McCrindle2, A. Al-Wadei 1, Z. Al-Halees1
(1 Saudi Arabia, 2 Canada)
Invited Discussant: E. Austin, Louisville
10:40 Congenital Domain abstracts
and initiatives
Room 5B
Congenital initiatives and best papers
n
to gain insight into some important challenges in the
management of congenital heart disease
Moderators: J. V. Comas, Madrid; P. Vouhé, Paris
secondary to correction1. Recently, we
have shown that patients with PE are
less capable of increasing cardiac index
(CI) during exercise than age matched
controls2.
In the last 60 years it has been possible
to correct this anomaly. First by an open
ectus excavatum
procedure which has been considered
(PE) is the most
frequent congenital chest wall de- very traumatic with resection of cartilage,
formation. It is found in one out of 300- osteotomy and different ways of fixa400 male births and represents around tion of the sternum. Dr. Nuss published
the first paper of the minimal invasive
90% of congenital chest wall deformmethod in 1998 with 10-years of expeities.
rience3. Since then several thousand paThe indication for surgery has been
debated but is predominantly cosmetic tients have undergone minimally invasive
(90%). Changes in lung- or cardiac
pectus correction. From the beginning it
function have only recently been demwas thought that the minimally invasive
onstrated, even though it is well recog- technique might only be used in children
nized that patients complain of breath- and adolescents but with growing expelessness, dypnea and fatigue. In contrast rience it has been shown that it also can
several papers have documented rebe used in adults with equivalent results
duced quality of life and improvement
compared to young patients4,5.
the gold standard in primary correction
of PE in all patients.
My experience is based on more than
1,000 operations which more than 950
have been done at Aarhus University
Hospital, Skejby, Denmark in the time
period 2001-2011. Result have been
published in several papers and at the
session an overview will be given4,5,8.
Hans K. Pilegaard Department of Cardiothoracic & Vascular Surgery,
Aarhus University Hospital, Skejby, Denmark
P
References
The learning curve can be kept at an
acceptable level when trained by an experienced surgeon and beginning with
young patients with moderate PE. Experience can probably be gained and
maintained by doing 20-30 cases a year.
Many modifications6,7 have been proposed to reduce complications as rotation, dislocation, heart injuries and
problems concerning correction of very
deep excavated patients. Taking all
these advices into account the complications can be minimized and today the
minimal invasive technique is considered
1 Jacobsen EB, Thastum M, Jeppesen JH, Pilegaard HK. Health-related
quality of life in children and adolescents undergoing surgery for pectus
excavatum. Eur J Pediatr Surg 2010;20:85-91.
2 Lesbo M, Tang M, Nielsen HH, Frokiaer J, Lundorf E, Pilegaard HK,
Hjortdal VE. Compromised cardiac function in exercising teenagers with
pectus excavatum. Interact Cardiovasc Thorac Surg 2011.
3 Nuss D, Kelly RE, Jr., Croitoru DP, Katz ME. A 10-year review of a
minimally invasive technique for the correction of pectus excavatum. J
Pediatr Surg 1998;33:545-552.
4 Pilegaard HK, Licht PB. Routine use of minimally invasive surgery for
pectus excavatum in adults. Ann Thorac Surg 2008;86:952-956.
5 Pilegaard HK. Extending the use of Nuss procedure in patients older
than 30 years. Eur J Cardiothorac Surg 2011;40:334-337.
6 de Campos JR, Das-Neves-Pereira JC, Lopes KM, Jatene FB. Technical modifications in stabilisers and in bar removal in the Nuss procedure. Eur J Cardiothorac Surg 2009;36:410-412.
7 Pilegaard HK, Licht PB. Can absorbable stabilizers be used routinely
in the Nuss procedure? Eur J Cardiothorac Surg 2009;35:561-564.
8 Pilegaard HK, Licht PB. Early results following the Nuss operation for
pectus excavatum--a single-institution experience of 383 patients. Interact Cardiovasc Thorac Surg 2008;7:54-57.
Abstracts – Special topics: Thoracic Room 5A 14:00
YAG-Laser: Outpatient
bronchoscopic palliative
tumour ablation for
advanced lung cancer –
a cost analysis
ciated with this palliative procedure.
Endobronchial laser debridement of cancer is particularly
beneficial in that it restores airway patency immediately and
therefore provide immediate
palliation of symptoms. TreatMarco Scarci
ment with the YAG laser can
be performed using the flexiMarco Scarci, K Piggott, Carmine Barnett, Yaron Shar- ble bronchoscope under local
gall, Christian Finley, John Miller Department of Thoracic anesthesia, the rigid bronchoscope under general anestheSurgery, St Joseph’s Healthcare, Hamilton, Ontario Canada.
sia, or a combination of the
ndobronchial symptoms of malignancies include two under general anesthesia.
The flexible instrument allows
cough, hemoptysis, dyspnea, and bronchial inJohn Miller
greater maneuverability and alfections, which can be both distressing to the
lows treatment of more peripheral lesions not accespatient and imminently threatening to their life.
sible by the rigid scopes. In addition, by allowing it
Endoscopic palliative relief has therefore become
important tool in the armamentarium of the Thoracic to be performed under conscious sedation, it avoids
some of the potential respiratory complications assoSurgeon. Several studies have reported on the safety
and effectiveness of the Nd:YAG laser, and its use has ciated with bronchoscopic therapy and general anbecome common practice. There is, however, still con- esthesia.
There was a minimum of complications experienced
siderable debate regarding optimal safety practices,
specifically with regard to the use of rigid versus flex- by patients in our sample undergoing the endobronchial laser procedure without the use of general anible bronchoscopy, and inpatient versus outpatient
esthesia. Both anesthetic complications as well as laser
treatments.
Considerable attempts to find ways to reduce over- -specific complications, such as fistulation, perforaall health care costs, while maintaining optimal care of tion, hemorrhage, endobronchial fire, respiratory aciour patient population have also been described. Our dosis, hypoxemia, cardiac arrhythmia and arrest which
presentation describes our effort to develop an outpa- had been reported earlier were avoided. In fact, our
tient program that would reduce the usual costs asso- documented minor complication rate of 10% is quite
E
favourable when compared to other published results.
In our sample, only one patient of 48 experienced
significant bleeding leading to abortion of the procedure, there were no intra-procedure deaths or iatrogenic complications, and only 1.8% of patients had
documented agitation or bleeding leading to procedure prolongation. In addition 89.5% of our patients
had a successful outcome. Overall, our experience
with the Nd:YAG laser used with flexible bronchoscopy and conscious sedation has confirmed it to be a
safe and highly effective palliative treatment.
Finally, when cost is considered, patients who undergo outpatient flexible bronchoscopy with the use
of the Nd:YAG laser clearly have an advantage over
those who undergo similar treatment using a rigid
bronchoscope and general anesthetic. For the procedure to be carried out in our endoscopy suites, there
is significantly less preparation, personnel, equipment, and medication required. While this would be
a concern if it altered patient safety or treatment outcomes, our study does not show there is any compromise being made at the expense of cost when results
are compared to rigid bronchoscopy under general
anesthetic in the literature. At our institution, when
the two procedures were compared, outpatient flexible bronchoscopy conferred a cost savings of $1,242
per case compared to rigid bronchoscopy under general anesthetic. For the 167 cases performed over our
10-year study period, it resulted in a cost savings of
$207,414, something that is quite notable in an era of
ever increasing healthcare costs and medical budget
constraints.
10:40 Abstracts
10:40
Long-term prognosis of double-switch operation
for congenitally corrected transposition of the
great arteries
T. Hiramatsu, G. Matsumura,
T. Konuma, K. Yamazaki, T. Nakanishi (Japan)
Invited Discussant: W. Brawn, Birmingham
10:55
Results of reparative surgery for tetralogy of
Fallot: Public data from the European Association
for Cardio-Thoracic Surgery Congenital Database
G. E. Sarris1, J. V. Comas2, Z. Tobota3,
B. Maruszewski3 (1 Greece, 2 Spain, 3 Poland)
Invited Discussant: J. Jacobs, St. Petersburg
11:10
Outcomes and surgical approach of aortic arch
repair over two decades
T. Sakurai, J. Stickly,
N. Khan, T. Jones, D. Barron, W. Brawn (United Kingdom)
Invited Discussant: T. Spray, Philadelphia
11:25
Historic lecture
J. Monro, Bristol
Past EACTS Congenital Domain Chairs
J. Monro, F. Lacour-Gayet, B. Maruszewski, P. Vouhé
11:45 The future: next steps
J. V. Comas, Madrid
11:40
Presentations and Report
Auditorium 1
Fontan Prize
Thoracic Prize
Fontan Prizewinner 2010
Sternal reconstruction with cadaver bone (video)
Federico Rea Department of CardioThoracic and Vascular
Sciences, Padova, Italy
S
urgical excision
with a safety
margin is the
cornerstone of treatment of malignant sternal tumors. After
sternal resection, the primary goals of
chest wall reconstruction are to prevent
flail chest with ventilatory impairment,
protect the underlying mediastinal structures, and avoid chest deformity. Various
techniques and several materials have
been used over the years for this purpose. Prosthetic materials are the most
commonly used technique for chest wall
reconstruction. Although these materials are widely available and easy to use,
they suffer from excessive rigidity (methylmethacrylate) with risk of erosion of
adjacent structures or insufficient support (Prolene mesh); moreover, incorporation into the host tissue never occurs. Search for the ideal material for
chest wall reconstruction is still a challenge for thoracic surgeons. Bone grafts
nal replacement by using an allogenic
cryopreserved sternum and costal cartilages in three cases of condrosarcoma
and in two cases of sternal metastasis (one from mammary cancer and the
other from hepatocellular carcinoma).
The bone graft was harvested from a
suitable donor under a complete aseptic technique and treated with antibiotic
solution for 72 hours at -4°C and then
submitted to cryopreservation at -80°C.
These processes guarantee the sterility
Figure 1. (A) Preoperative computed tomography scan ) showing the extent of of the graft and the absence of immuthe tumor (involving only the body). (B) The sternal allograft ready to be used nogenic capacity. Fixation of the graft
before tailoring. (C) Intraoperative view showing the tailored sternal allograft to the recipient was carried out with tifixed in place to cover the defect after sternectomy. tanium plates and screws and this easily permitted a perfect coupling to the
bone of the host. Reconstruction of the
form. Previous experimental and clinihave been proposed as an effective alchest wall was completed with muscuternative to synthetic materials. The use cal experiences demonstrated that the
lar transposition: in all cases the funcof bone autograft (ribs or iliac bone) or cryopreserved bone graft retains some
tional and aesthetic result was excellent.
properties, such as osteoconductive
allograft has been reported as a valid
This technique was effective for geoand osteoinductive capacity. The graft
solution to cover small chest wall demetrically covering the entire large antefects. The advantages of autografts are: acts as a scaffold for new bone forrior chest wall defect by using the same
mation, allowing the ingrowth of capeasy incorporation into the recipient
amount of bone and cartilages removed
illaries and perivascular tissue into its
bone, low risk of infection, and absent
risk of rejection. However, there is a lim- structure. Moreover, recruitment of unin the recipient. We had a single complication consisting in the displacement
differentiated mesenchymal cells from
itation regarding the amount of bone
three months after the operation of one
adjacent tissue with subsequent differthat can be harvested and transferred
entiation into osteoprogenitor cells un- screw that was removed; after that graft
to the new site, in addition to the postability was good. In conclusion we
der inductive stimulus of bone growth
tential complications at the donor site.
factors has been proved. Up to date, we consider this procedure safe and techniMoreover, harvesting and grafting of
have performed five partial or total ster- cally sound.
vascularized bone are not easy to per-
Abstracts arrhythmia Auditorium 2 16:00
Sternal dehiscence
greater omentum.
Once the sternum is in a good
condition and direct resynthesis is
ternal dehiscence is amongst feasible, it is preferred to use Nitinol clips instead of steel wires.
the most serious complications which can occur follow- These clips made of a nickel and titanium alloy (Nitinol) have thermoing open-heart surgery.
reactive properties whereby coolIn many patients, the sternum
can be damaged due to the aggres- ing allows the clips to behave as a
sive debridement or the presence of malleable material, whilst heating
restores the material to its original
several transversal fractures. Thus,
undeformed shape. Cooling before
performing a successful chest cloimplantation, allows the clips to be
sure surgery can be very difficult
deformed easily which facilitates
(Figure 1).
insertion. Heating with a warm
The decision to perform such a
surgery under these circumstances gauze, allow the clips to contract
and to return to the original shape
should thus go hand in hand with
thus pulling the sternum edges toa clean sternal wound as well as
gether (Figure 3)
healthy sternal margins. In light
This clips are easy and quick to
of this, the Vacuum Assisted Cloapply, safe, and can be easily resure (VAC) treatment is an excelmoved. Moreover, the clips have
lent method for achieving the latthe advantage to be non-invasive as
ter (Figure 2)
The advantage of the VAC treat- it is not necessary to free the posterior face of the sternum from the
ment is the application of a conmediastinal structures.
tinuous negative pressure which
When the sternum is in a bad
stimulates tissue granulation and
condition due to the extensive defacilitates wound healing after reconstruction. Furthermore, wound bridement or to the multiple transdepth reduction, following the use versal fractures, the use of muscle
flaps seems to be a good solution
of the VAC, allows the use of the
to close the chest.
pectoralis major muscles without
The pectoralis major flaps are
the need of harvesting other flaps
such as the rectus abdominis or the considered as a first line method
Ablation for atrial fibrillation during mitral
valve surgery: One-year results through
continuous subcutaneous monitoring
Maria Pia Tocco San Filippo Neri
Hospital, Rome, Italy
Alexandr Bogachev-Prokophiev Heart Valves Surgery
Department, State Research
Institute of Circulation Pathology, Novosibirsk, Russia
S
Figure 1: Sternal dehiscence
dwards ThruPort systems is
proud to offer the broadest range of products designed
specifically for small incisions.
With peripheral cannulation,
intra-aortic occlusion, specialized techniques for myocardial
protection, and long-shafted
instruments, ThruPort systems
provides you with all necessary
devices for minimal incision
valve surgery.
Minimal incision valve surgery (MIVS) approaches provide excellent outcomes,
comparable to traditional sternotomy, as well as significant surgeon and patient benefits. With fewer products in
the incision site, providing surgeons with excellent visualiza-
Maria Pia Tocco
for the chest closure procedure.
The surgical harvesting technique is
easy and feasible without the need
of more skin incisions. In this procedure, the muscle fibres are dissected from the sternal edges, the
cartilages and from the ribs. The
dissection stops at the clavicle, taking care not to damage the thoracoacromial pedicle. No dissection of
the humeral insertion is done. The
flaps can then be advanced to the
midline without tension, and transposed into the mediastinum where
they are fixed with absorbable sutures. Six closed suction drains are
then placed (Figure 4 and Figure 5).
It is worth mentioning that the use
of the musculocutaneous flaps was
not needed for this procedure.
Figure 2 The VAC
Figure 4: Pectoralis flaps
E
N
Figure 3: Nitinol Clips
Figure 5: Reconstruction with Pectoralis flaps
tion and a virtually bloodless,
unobstructed operative ¬field,
Edwards ThruPort systems is
rede¬fining MIVS.
Through peripheral cannulation, Edwards Lifesciences MIVS
approach, enabled by ThruPort
systems, offers excellent visualization of cardiac structures
through a virtually bloodless,
unobstructed operative field so
you can repair or replace the
valve through the smallest incision possible*. With this approach, you can consider all isolated valve patients—including
reoperations and those contraindicated for traditional sternotomy—because it provides
safe and reproducible options
for cardiopulmonary bypass,
global myocardial protection
and intra-aortic occlusion
Patient satisfaction is improved and outcomes are enhanced when the least invasive approach possible is used
in heart valve surgery. Patient
benefits of MIVS include:
n
Shorter hospital stays
n
Less time in the ICU and on a
ventilator
n
Faster return to work or routine activities
n
Less discomfort and pain
n
Reduced blood loss
n
Less surgical trauma and risk
of complications
n
Improved cosmesis
* When compared to median sternotomy
owadays, surgical ablation of
atrial fibrillation
(AF) is the standard recommended concomitant
procedure during valve
surgery, which leads to
improving quality of life,
reducing the risk of stroke
and heart failure and improving survival. Electrocardiograms and Holter
monitoring are commonly
used to assess cardiac
rhythm after surgical therapy of AF. However, this
“snapshot” in time and
has limited ability to detect those patients that
may have transient atrial
arrhythmias in the followup period. In this study,
we used implantable direct cardiac rhythm monitor device for precise evaluation the incidence of
atrial arrhythmias in patients who underwent mitral valve surgery and AF
ablation procedure.
Forty seven patients
with mitral valve lesion
and long standing persistent AF underwent mitral valve surgery and
concomitant left atrial
corded 279 episodes palpitations activated the
patient assistant device
during all follow-up. From
all subjective symptoms,
only in 27.6% cases was
AF recurrence according ILR dates (Figure 2). In
two (4.3%) patients, AF
recorded by the ILR was
completely asymptomatic.
In conclusion, concomitant bipolar maze procedure during mitral valve
surgery is effective for the
treatment of long standing
persistent, as proven by
scheduled at 3, 6, and 12 detailed one year monitormaze procedure with biing. Continuous long-term
months postoperatively.
polar radiofrequency. At
monitoring after surgical
At the first follow-up
the end of the operation
AF ablation in mitral valve
(end of the blanking pethe implantable loop recorder (ILR) for continuous riod) 25 (53.2%) patients patients is safe method to
obtain accurately informamonitoring was implanted were AF-free, according
to all the patients. Patients to ILR data AF < 0.5%. At tion about cardiac rhythm
development as indicated
12 month follow-up 30
with an AF <0.5% were
(65.2%) patients were re- by daily AF burden.
considered AF-free (RePerhaps in the near fusponders and had no any
sponders).
atrial arrhythmias (AF bur- ture use of continuous
No procedure-related
monitoring will be fundacomplications occurred ei- den <0.5%) (Figure 1).
ther for ablation or for the Three (6.5%) patients out mental in antithrombotic
of 16 non-responders had and antiarrhythmic thermonitoring device. Four
atrial flutter (1 (2.1%) left apy in patients after valve
(8.5%) patients required
atrial flutter and 2 (4.3%) surgery and concomitant
a pacemaker implantamaze and using ILR will be
tion before discharge due typical flutter) and 13
included in Guidelines for
to sinus node dysfunction. (27.7%) had AF (AF burAF management.
den >0.5%). Patients rePatient follow-up was
279
symptom
episodes
Figure1: Kaplan-Meier estimates of AF
freedom survival
SR – sinus
rhythm;
ST – sinus
tachycardia;
PC – premature
contractions;
AF – atrial fibrillation
Figure.2 Cardiac rhythm by ILR during
symptomatic episodes
Abstracts arrhythmia Auditorium 2 16:00
Room 5B
Transposition of the great arteries
Electrophysiologic efficacy of Epicor
high intensity focused ultrasound
n
to improve knowledge of techniques in arterial switch
surgery and its applications
Moderators: O. Raisky, Paris; F. Lacour-Gayet, New York
14:00
Arterial switch in the first hours of life: No need
for Rashkind septostomy?
T. Nevvazhay,
A. Chernogrivov, L. Biktasheva, K. Karchevskaya, T. Rybakova, L. Ekimenko, E. Birukov, S. Sulejmanov (Russian Federation)
Invited Discussant: D. Barron, Birmingham
14:15
The importance of neo-aortic root geometry in
the arterial switch operation with the trap-door
technique
D. M. Seo, W. K. Jhang, H. J. Shin,
J. J. Park, T. J. Yun, Y. H. Kim, J. K. Ko, I. Park (Republic of Korea)
14:30
Risk factors after arterial switch operation
and aortic arch reconstruction in complex
transposition of the great arteries
T. Tlaskal, R. Gebauer, J. Gilik, O. Reich, P. Vojtovič, V. Kučera (Czech Republic)
Invited Discussant: K. Sakamoto, Shizuoka
Invited Discussant: E. Da Cruz, Denver
14:45
Twenty-eight years experience with arterial
switch operation for transposition of the great
arteries in a single institution
S. Oda, T. Nakano, J. Sugiura, H. Kado (Japan)
15:00
Outcomes following a predominantly one-stage
approach for Taussig-Bing malformation
S. Mussa, J. Stickley, D. Barron, T. Jones, W. Brawn
(United Kingdom)
15:15
Mid-term results of modified atrial switch
procedure as part of anatomic correction of
congenitally corrected transposition of the great
arteries
V. Sojak, I. M. Kuipers, M. E. Rijlaarsdam,
J. Hruda, N. A. Blom, M. Hazekamp (Netherlands)
Invited Discussant: R. Di Donato, Riyadh
Invited Discussant: J. V. Comas, Madrid
Invited Discussant: V. Hraska, Sankt Augustin
Room 5B
Mixed congenital
n
to gain further understanding of wider management
issues in congenital heart disease surgery
Moderators: E. Da Cruz, Denver; M. Reddy, Stanford
16:00
Initial application in the STS Congenital Database
of an empirically-derived methodology of
complexity adjustment to evaluate surgical case
mix and results
J. P. Jacobs1, M. Jacobs1,
F. Lacour-Gayet1, C. I. Tchervenkov2,
B. Maruszewski 3, G. Stellin 4, E. Austin1, C. Mavroudis1
(1 United States, 2 Canada, 3 Poland, 4 Italy)
Invited Discussant: Z. Al-Halees, Riyadh
16:15
Characterisation of non-technical skills in
paediatric cardiac surgery: communication
patterns
J. Fragata, R. Santos, L. Baquero,
P. Franco, C. Alves, I. Fragata (Portugal)
Invited Discussant: R. Neirotti, Cambridge
16:30
Evaluation of the Aristotle complexity models in
grown-up patients with congenital heart disease
J. Hoerer, M. Vogt, M. Wottke, Z. Prodan, J. Kasnar-Samprec, J. Cleuziou, R. Lange, C. Schreiber (Germany)
16:45
Long-term surgical outcome of mitral valve repair
in infants and children with Shone’s anomaly
E. M. Delmo Walter, T. Komoda, H. Siniawski, V. Alexi-Meskishvili, R. Hetzer (Germany)
Invited Discussant: F. Lacour-Gayet, New York
Invited Discussant: E. Belli, Le Plessis-Robinson
17:00
Surgical correction of hypertrophic obstructive
cardiomyopathy in patients with simultaneous left
ventricular, mid-ventricular and right ventricular
outflow tract obstruction
K. V. Borisov (Russian Federation)
Invited Discussant: S. Cicek, Istanbul
17:15
Comparison of long-term clinical outcomes and
costs between video-assisted thoracoscopic
surgery and transcatheter AMPLATZER® occlusion
of patent ductus arteriosus
G. X. Weng, J. Bao, H. Chen, Z. Chen (China)
Invited Discussant: R. Mair, Linz
17:30
Patient-specific cardiac progenitor cells and
regenerative medicine: production of autologous
cardiac prior to birth
PJ Gruber, D Juhr, N Khalek, AE King (United States)
Invited Discussant: C. Tchervenkov, Montreal
Alberto Pozzoli San Raffaele
University Hospital, Cardiothoracic
Surgery Department, Milan, Italy
D
urable transmurality of
the ablation lines is instrumental to the successful cure of atrial fibrillation
(AF). One of the key aspects of
AF treatment consists in ablating the pulmonary veins ostia,
obtaining their electrical disconnection and transmurality
of the lesions.
Despite the significant advances which characterized ablation technology during the
past decade, linear uninterrupted lesions proved difficult
to obtain epicardially with unipolar devices. In particular, only
bipolar radiofrequency appears
to be reproducibly transmural from the epicardium, on the
beating heart.
Epicor is an unipolar ablative
platform which uses high intensity focused ultrasound (HIFU),
to create a box lesion around
the four pulmonary veins (PVs)
and a mitral connecting line epicardially, on the beating heart.
While the clinical value of
HIFU has been investigated in a
number of studies, with variable results, its electrophysiologic
(EP) efficacy has never been
systematically studied. We assessed the evolution of the conduction across the PV box ablation performed with HIFU, by
pacing from additional strategically positioned atrial temporary wires (Figure 1). Furthermore, to investigate a possible
modulating effect on the autonomic nervous system (ANS) induced by HIFU lesions, we analyzed heart rate variability (HRV)
changes over time.
With this purpose, 10 con-
secutive mitral patients have
been enrolled (mean age: 57 ±
10 years) with paroxysmal atrial
fibrillation undergoing concomitant ablation with the EPICOR
ablation system, in order to perform the electrophysiological
assessment.
The additional temporary
wires were fixed on the right
PVs (RPV) and on the roof of
the left atrium (RLA), before the
epicardial ablation. Exit block
(defined as no capture under
pacing at 20 mA) of RPV and
of RLA was assessed systematically for every patient before,
after ablating and immediately
after chest’s closure. Electrophysiologic assessment was repeated before discharge and at
three weeks.
The results of EP analysis
stated as follow: during surgery, the mean PTs considered as baseline were 3.5 ± 2
mA (range 1.5÷8 mA) on the
RPV and 1.73±1.1 mA (range
0.7÷4.3 mA) on the RLA. Absence of isolation persisted in
all patients till the third week
analysis, in which the mean PTs
were 6.8 ± 5.8 mA from the
RPV and 6.4 ± 5.3 mA from
the RLA (range 2÷16 mA and
1÷19, respectively). Complete
isolation, as identified by simultaneous absence of capture
from both the RPVs and the
RLA leads in the same patients,
was never obtained (Figure 2).
Regarding the HRV analysis, the comparison of the variations of the time domain parameters correlated to vagal
influence (SDNN, rMSSD and
pNN50) showed a statistically
significant decrease (p<0.05)
of all the HRV parameters, for
all the time periods considered. On the side of the frequency domain parameters (LF
and HF, indicating respectively
the sympathetic and the vagal tone), over the 24 hours the
PSD in the HF band reduced by
-78.6,4±11.8% while in the LF
band the reduction was -74.2
± 24.2%, showing close relative variations for both the frequency bands.
Despite absent PVI, our clinical results were consistent with
Figure 1: Circumferential PVs ablation line and positioning
of the two pairs of epicardial temporary wires (RPV, Right
pulmonary veins; RLA, Roof of the left atrium).
a fair freedom from arrhythmia in most patients. This topic
must be pondered considering the small size of our study
group and that all of our patients had paroxysmal AF, which
may be easier to cure. Furthermore, correction of the mitral
valve disease and modulation
of the ANS induced by HIFU ablation on the left atrium epi-
Pacing thresholds measured from the atrial
wires before and after HIFU ablation, before
discharge, and at 3 weeks (RPV, Right
Pulmonary Veins; RLA, Roof of the Left Atrium;
RA, Right Atrium).
cardium might have played a
role in abating the AF burden.
If confirmed by larger studies,
this ANS modulatory effect of
HIFU can, at least partly, explain
the satisfactory success rates reported.
In conclusion, pulmonary
veins isolation was not achieved
after Epicor HIFU ablations, up
to three weeks after surgery.
Figure 3: Over the 24 hours the PSD of HF
and LF components showed a reduction of
respectively 78.6% and 74.2% at one year
follow up (p<0.01).
Minimally invasive pectus carinatum repair
Mustafa Yüksel Marmara University
Hospital, Istanbul, Turkey
P
ectus carinatum (PC) is a common
chest wall deformity characterized
by the protrusion of the sternum.
Most of the patients have no objective
cardiovascular or respiratory symptoms.
Pscho-social problems are prominent in
these paitents, therefore the most common indication for surgical repair is cosmetic disfigurement. The classical open
surgical technique for the repair of PC is
Ravitch sternoplasty and its modifications.
Minimally invasive repair of pectus excavatum (PE), known as the Nuss procedure,
has become the treatment of choice in recent years. A modified technique of Nuss
procedure for minimally invasive PC repair
was defined by Abramson, mainly consisting of a presternally placed metal bar
compressing the sternum, fixed on both
sides of the chest wall on metal plates.
Having been inspired by Abramson
technique we have been performing
minimally invasive pectus carinatum repair since the beginning of 2006. In our
first three PC cases in 2006 and 2007,
standard bars and stabilizers for the
Nuss procedure were used presternally.
At the beginning of 2008, in search of
a higher degree of success and stamina, a new bar and stabilizing system for
the minimally invasive surgical correction of PC were designed by us, to get a
Mustafa Yüksel
better result in compressing the sternum
and stabilizing the bar on both sides of
the chest wall on the ribs. Since then
we have operated 50 patients with PC
between the ages of 10 and 28 at the
Marmara University Hospital, and the results have been very satisfactory both
for the patients and us (Figures 1-3).
Our PC bar has a diagonal edge on
one side to fit in the stabilizer with
the same manner and several notches
on the other side for the screw to settle in and secure the bar at the desired
level. The stabilizer has a curve on both
sides to fit on the costae better than
the standard stabilizers. The seat of the
bar has a diagonal groove on one side
and one screw hole on the other side to
hold a stronger grip of the bar.
Figure 1: Preoperative
Figure 2: Postoperative
lateral view of a patient. lateral X-ray of a patient.
Our minimally invasive surgical technique is based on the principles defined
by Abramson, but with some modifications. The ribs for placement of the stabilizers are chosen and encircled subperiostally with steel wires. The stabilizers
are placed perpendicular on the ribs and
secured with the steel wires. The appropriate sized bar is selected using templates and then bent into a convex configuration as needed. Using clamps, a
subcutaneous tunnel is prepared and a
polyvinyl chloride tube with a trocar is
passed presternally from one incision to
the other. The trocar is removed from
the lumen of the tube, and the bar is inserted in it with concavity facing posteriorly, to withdraw it through the presternal tunnel.
Figure 3: Postoperative
lateral view of a patient.
Compressing the bar over the sternum, both edges are placed into the
stabilizers at appropriate level and secured with one screw each on both
sides. This bar and stabilizing system
enables extra grip with the fit-in diagonal groove on one side and with the
easy-to-place screw on the other, making the bar almost impossible to disengage. In addition, it can be adjusted for
the patient very precisely with the use of
its notches. It is a safe and easy-to-use
prosthesis for minimally invasive surgical
correction of PC deformities.
We think that, just like the Nuss procedure for PE, minimally invasive PC repair
is becoming a treatment of choice for
the short operating time, low morbidity
and high levels of patient satisfaction.
Abstracts – TAVI III Auditorium 7 14:00
General Interest
08:30 Focus Session
Room 3A
The academic surgeon
n
to gain insight into critical reading and reviewing of
articles
Moderators: L. von Segesser, Lausanne; M. L. Kaljusto, Oslo
08:30
How to review a paper for a journal
F. Beyersdorf, Freiburg
09:00 Critical reading of an article P. Sergeant, Leuven
09:30 Fraud and plagiarism in biomedical research
J. Vaage, Oslo
10:30 Focus Session
Auditorium 6
Innovation in surgical education: learning for the
future
n
To gain knowledge of recent innovations in training
in cardiothoracic surgery, which will enhance the
understanding and the delivery of training
Moderators: L. Hamilton, Newcastle; J. R. Sádaba,
Pamploma
10:30
Good trainer: born or made?
C. Munsch, Leeds
The cardiothoracic surgical Brain and Hand 2011
P. Sergeant, Leuven
11:10 Teaching in the operating room E. Verrier, Seattle
11:30 Non-technical skills for surgeons
S. Paterson-Brown, Edinburgh
11:50 Discussion
10:50
14:00 Focus Session
Room 1.08
High-performance teams in the operating room:
an introduction to the NOTSS (non-technical skills
for surgeons) programme
n
to improve communication, understanding and
performance
Moderators: S. Paterson-Brown, Edinburgh; C. Munsch, Leeds
Aortic stenosis combined with
coronary artery disease – total
percutaneous or surgical treatment?
cedure only targeting patients presenting with isolated aortic valve stenosis
deemed at highest operative risk for conventional surgery and it was primarily
not intended to treat patients presenturgical aortic valve replacement
ing with concomitant coronary artery disand coronary artery bypass graftease. The recently published randomized
ing is the current proven standard therapy for patients presenting with controlled PARTNER trial (PARTNER cohort A) suggested TAVI to be as good as
aortic stenosis and concomitant corsurgery. However, in daily practice, more
onary artery disease. It is actually anand more patients are presenting with
ticipated that coronary artery disease
pre-exists in about 25% of patients pre- coronary artery disease, which is often
treated in the forefront or even during
senting with aortic valve stenosis and
transcatheter aortic valve implantation.
may increase up to 50% in selected
This group of patients should therefore
cases presenting typical angina. Coexisting coronary artery disease clearly in- be compared to those who undergo concreases operative morbidity and mortal- comitant aortic valve replacement with
CABG surgery rather than those who
ity in such concomitant operations.
Moreover, increasing patient age and have isolated aortic valve replacement.
Our aim was therefore to compare the
various pre-existing comorbidities may
outcome of patients treated completely
further increase mortality in such papercutaneously (TAVI+PCI) with those
tients. Therefore, new transcatheterwho underwent a complete surgical
based techniques have been emerged
concomitant operation (AVR+CABG) in
to treat such high-risk patients durour center by propensity score analysis.
ing the last years. Transcatheter aortic
A total of 243 high-risk patients (STSvalve implantation (TAVI), as an alternative to conventional aortic valve replace- Score >10% and/or EuroSCORE >15%)
presenting aortic valve stenosis with
ment, has currently changed the paraconcomitant coronary disease were
digms in the treatment of aortic valve
therefore studied, treated either by surstenosis. This technique has been inigical AVR combined with CABG (n=184)
tially considered as a `stand-alone´ pro-
Daniel Wendt, Heinz G Jakob, Matthias
Thielmann Westgerman Heart Center Essen, University Hospital Essen, Germany
S
New ideas for myocardial protection
David J Chambers Cardiac Surgical Research/
Cardiothoracic Surgery,
The Rayne Institute (King’s
College London), Guy’s and
St Thomas’ NHS Foundation
Trust, St Thomas’ Hospital,
London UK.
16:00 Residents’ Meeting
he current gold
standard for myocardial protection during cardiac surgery is hyperkalemic cardioplegia,
to induce rapid cardiac arrest by cell membrane depolarization. The cardioplegia can be used both
as a crystalloid or bloodbased solution, and at
temperatures varying from
4°C to ~34°C; these characteristics have essentially
remained unchanged for
around 35 years. However, the patient population undergoing cardiac
surgery has changed considerably over that period;
patients are now older,
sicker and with more diffuse and severe cardiac
disease. Despite an overall
improvement in mortality
over recent years, the evi-
The future of cardiothoracic surgery: how to be
trained and master minimally invasive techniques
n
to update knowledge of minimally invasive techniques
in cardiothoracic procedures
n
to gain insight into the impact of minimally invasive
techniques on the training and future of the
cardiothoracic specialty
Moderators: P. Sardari Nia, Nieuwegein; M Siepe,
Freiburg
16:00
16:15
16:30
16:45
17:00
History of minimally invasive techniques in
cardiothoracic surgery
R. Lorusso, Brescia
Future perspectives and new developments in
minimally invasive techniques
V. Falk, Zürich
Cardiothoracic training and the place of minimally
invasive techniques
A. P. Kappetein, Rotterdam
Survival of the cardiothoracic specialty: training
and innovation
J. R. Sádaba, Pamplona
Discussion
Vascular
Auditoria 3+4
Complex aortic arch pathology
n
to gain insight into problems and issues associated
with management of complex aortic disease
Moderators: P. Urbanski, Bad Neustadt; M. Karck, Heidelberg
08:30
Film: Single-stage replacement of the thoracic
aorta using mild hypothermia
P. Urbanski, S. C. Frank (Germany)
or by PCI within 12 months prior to
transapical or transfemoral TAVI (n=59).
A propensity score adjusted regression
analysis was used to compare 30-day
mortality as the primary study endpoint
between the groups.
The mean age, EuroSCORE and STSScore differed significantly between
both groups. Thirty-day mortality was
12.5% in group 1 compared to 11.9%
in group 2 (OR 0.94, 95% CI 0.38-2.32,
P=0.89). Univariate analysis revealed
left ventricular ejection fraction (LVEF),
pulmonary hypertension, renal insufficiency, STS-Score, EuroSCORE and previous cardiac surgery as predictors for
30-day mortality (P<0.05). Risk-adjusted
multivariate regression analysis showed
only LVEF to be strongly associated with
30-day mortality and confirmed no significant difference between the groups
(P=0.44). To further control for study
bias, a 10-layer propensity score model
based on the univariate analysis again
confirmed equivalence regarding the
primary endpoint (P=0.33).
Focus session – Perfusion: Problems and opportunities Room 5C 16:00
n
90 minute interactive workshop which will focus on
the underlying human factors and non-technical skills
required for successful surgical outcomes.
The workshop will involve short presentations, video
simulations from the operating room and audience
participation. Structured methods of analysing
behaviour will be introduced and participants will leave
the session with a NOTSS handbook and some initial
training in identifying and discussing performance in
surgery
Room 3A
Matthias Thielmann, Heinz G Jakob
and Daniel Wendt
The present descriptive study is the
first to clearly demonstrate that TAVI
combined with PCI produces at least
equivalent results for in-hospital mortality in high-risk patients presenting with
aortic valve stenosis and concomitant
coronary artery disease compared with
high-risk patients undergoing surgical
aortic valve replacement with CABG surgery. Finally, despite the fact that patients in the TAVI+PCI group showed
a higher risk profile and comorbidities,
the results showed the total percutaneous approach as an equivalent and acceptable alternative treatment option
compared to surgery. It should be emphasized however, that to date, surgical aortic valve replacement with combined coronary artery bypass grafting
still represents the golden standard therapy. In fact, modern aortic tissue valves
show durability of 15 years or even
longer, especially in such elderly patients, whereas the durability of transcatheter heart valves have to be investigated in the long-term. In addition, a
multidisciplinary heart team approach
is recommended for decision making in
these patients.
To what extent the increasing number
of PCIs combined with TAVI will have an
influence on decision making between
the two treatment options has to be investigated in the near future. Further
work needs to be done to determine
the clinical significance of these findings
in a larger patient population.
T
dence in the more elderly
patients shows relatively
high operative mortality. In
addition, there is increasing evidence that poor intraoperative myocardial
protection correlates with
worse long-term survival.
Over the past 10-15
years, many clinical and
basic science researchers
have been examining new
ideas for potential improvements in myocardial
protection. Ischemic preconditioning is an endogenous adaptive protective
mechanism, utilizing short
periods of ischemia (or
pharmacological stimulation) before a longer and
more damaging ischemia,
which stimulates a signaling cascade to initiate the
protective adaptation of
the tissue and reduce the
eventual damage. Experimentally, this has been
shown to be very effective; however, it remains
controversial whether it
is efficacious when used
during cardiac surgery,
particularly in conjunction
with cardioplegia (as well
as the anesthesia and bypass procedures). There
are also practical aspects
of feasibility. An interesting development has been
‘remote’ preconditioning;
a preconditioning protocol on a ‘remote’ organ
(such as an arm or leg)
was shown to initiate protection in the heart. This
is a more feasible technique for use during surgery, and is currently undergoing investigation in
a multicentre trial to determine efficacy. Another
recent protective technique is ischemic postconditioning, where short
episodes of ischemia
and reperfusion are in-
duced immediately after
the start of reperfusion.
This technique would appear to be ideal for cardiac surgery, but (as with
preconditioning) it is controversial whether it is efficacious following cardioplegic protection.
A potentially more beneficial way of improving
myocardial protection is
to examine the concept of
‘polarized’ arrest (in contrast to depolarized arrest),
whereby the heart is arrested at a membrane potential closer to the normal
cellular resting potential.
This involves using agents
that interact with mechanisms involved in the action potential, such as the
fast sodium channel, the
potassium channel or the
L-type calcium channel. Experimentally, cardioplegic solutions containing
agents such as lidocaine (a
sodium channel blocker)
and adenosine (a potassium channel opener) have
shown improved protection compared to hyperkalemic solutions. However,
the high concentrations of
lidocaine required to induce arrest, together with
the prolonged efficacy of
its action (with potential
systemic toxicity), could
be a clinical problem. We
have recently developed
and characterized a new
cardioplegic solution using
high concentrations of esmolol (an ultra-short-acting β-blocker) and adenosine; this solution induces
a polarized arrest since esmolol was shown to have
both sodium channel and
calcium channel blocking effects (independent
of its β-blocking properties), and provides significantly improved protection
(Figure 1) compared to hyperkalemic solutions in rat
hearts (with these agents
having the benefit of short
half-lives independent of
liver and kidney metabolism). Further studies are
planned in pigs undergoing cardiopulmonary bypass, before translation
into the clinical arena.
The potential of these
new ideas for improved
myocardial protection is
high, and may introduce
a further advance in postoperative outcomes for
the increasingly elderly
population of patients currently undergoing cardiac
surgery; however, further
research is essential.
Focus session – Perfusion: Problems and opportunities Room 5C 16:00
08:45 Keynote lecture:
Decision algorithms in choosing conventional,
hybrid and total endovascular approaches for
arch repair
J. Bavaria, Philadelphia
09:05 Long-term outcomes and risk factor analysis
of aortic arch repair by thoracic endovascular
aneurysm repair with debranching arch vessels
K. Shimamura, T. Kuratani (Japan)
Invited Discussant: D. Pacini, Bologna
09:20
Surgery for extensive aortic aneurysm:
Replacement from the ascending aorta to the
descending aorta focusing on left thoracotomy
Y. Okita, K. Okada, H. Minami, T. Oka, T. Inoue, S. Miyahara, A. Tanaka, A. Omura (Japan)
Invited Discussant: P. Urbanski, Bad Neustadt
09:35
Undersized graft diameter and optimal location
reduce peri-graft perfusion and further dilation
of descending aorta after long elephant trunk
technique for arch aneurysm
H. Kondoh, T. Funatsu, M. Kainuma, K. Taniguch (Japan)
Invited Discussant: M. Shrestha, Hannover
09:50
Six years experience with a hybrid stent graft
prosthesis for extensive thoracic aortic disease:
An interim balance
H. Jakob, D. S. Dohle,
J. Piotrowski, J. Benedik, M. Thielmann, G. Marggraf, R. Erbel, K. Tsagakis (Germany)
Auditoria 3+4
Connective tissue disease
n
to gain insight into the management of cardiovascular
manifestations of connective tissue diseases
Moderators: M. Funovics, Vienna; W. Harringer, Braunschweig
10:45
11:00
11:15
11:30
11:45
Hereditary aortic syndromes
Y. von Kodolitsch, Hamburg
Pathological correlates of genetic aortic
syndromes
O. Leone, Bologna
Indications for open surgery and surgical
techniques
T. Carrel, Berne
The thoraco-abdominal aorta in Marfan syndrome
M. Schepens, Brugge
Pharmacological treatment in connective tissue
disease
J. Pepper, London
TEVAR in hereditary aortopathy
M. Funovics, Vienna
12:00 Presentations and report
Auditorium 1
Fontan Prize
Thoracic Prize
Fontan Prizewinner 2010
12:15 The Honoured Guest Lecture
Auditorium 1
John Mulholland Lead Clinical Perfusionist, Department of Clinical Perfusion Science,
Essex Cardiothoracic Centre, UK: Honorary
Member, Department of Clinical Perfusion
Research, Imperial College Health Science
Centre, London, UK
G
iven the current patient population we as a cardiac team need
to move toward better artificial
heart and lung support. We should be
very clear about the fact that we “get
away” with Cardiopulmonary Bypass
(CPB) in the majority of our patients.
The ‘miniature CPB’ literature to date is
flawed in as much as the miniature systems are never described well enough
to understand what aspect of the system is improving or in some cases impairing the standard of care. Unfortu-
nately a good definition of the system
is only the starting point, how the end
user manages that system is an enormous variable that also requires adequate definition. Unlike conventional
CPB there is a significant amount of variability in both these aspects of miniature technology.
Oddly the answer for miniature bypass moving forward lies in this variability. A good understanding of all the
strengths and weaknesses of miniature CPB allow the Perfusionist and the
cardiac team to fit the correct benefits around specific patients or operations, whilst avoiding any potential disadvantages.
This hybrid system sits somewhere
between conventional and extreme miniature (one pipe out, pump, heat ex-
John Mulholland Left: Well managed suction/vent blood (no air interface
mixing). Right: Poorly managed suction/vent blood (air
interface mixing)
changer, oxy, one pipe in). Whether the
system is ‘more’ conventional or ‘more’
miniature depends on the complexity of
the operation. This philosophy is hardly
a revelation; a Surgeon takes a standard
procedure and tailors it to the patient.
The presentation discusses getting
the balance correct as well as the advantages of miniature CPB, which extend far beyond reduced haemodilution:
1.More control over venous drainage
2.Superior micro air management and
air removal
3.Smaller non-physiological surface
4.Better vent and suction blood management (see figure 1)
5.Improved volume and prime management
6.Promotion of good practice and communication
Abstracts – Transplantation II Room 5C 10:30
Heart transplantation 25 years experience
at Niguarda Ca’ Granda Hospital
10:30 Focus Session
10:30
Mini cardiopulmonary bypass
Tissue-specific adult stem cells P. Anversa, Boston
14:00 Abstracts
Auditoria 3+4
Acute type B aortic dissection
n
to gain further insight into the management and
outcome of Type B aortic dissection
Moderators: M. Czerny, Berne; R. Di Bartolomeo,
Bologna
14:00
Can we predict risk for acute type B aortic
dissection in hypertensive patients using
anatomic variables? A. S. Shirali, M. S. Bischoff, H.
Lin, I. Oyfe, R. A. Lookstein, R. B. Griepp, G. Di Luozzo
(United States)
14:15
What makes the difference between the natural
course of a remaining type B dissection after type
A repair and a primary type B aortic dissection?
E. S. Roost-Krähenbühl, S. Maksimovic, M. Czerny, D. Reineke, F. Schönhoff, J. Schmidli, T. Carrel, M. Stalder (Switzerland)
14:30
Predictors of aortic events after thoracic
endovascular aortic repair for type B aortic
dissection: Impact of aortic remodelling on the
late results T. Yoshida, T. Kuratani, K. Shimamura,
Y. Shirakawa, K. Torikai, K. Kin, Y. Sawa (Japan)
Giuseppe Bruschi Cardiology & Cardiac Surgery
Department, Niguarda Ca’ Granda
Hospital, Milan,. Italy
O
ver the past four decades the field of heart
transplantation has
evolved considerably, with improvements in surgical techniques and post-operative
care, and with the introduction of potent immunosuppressive medications and effective
drugs to prevent and treat infections and still in 2011 heart
transplantation remains the
gold standard in the treatment
of end-stage heart failure in appropriate candidates.
From 28th November 1985
to 31st December 2010, 905
orthotopic heart transplants
have been performed at our
centre. We considered in the
present analysis 878 primary
adult orthotopic heart transplants because we exclude 13
patients who underwent retransplantation and 14 pediatric cases (age at HTx <15 years).
Patients’ characteristics are reported in Table I.
The total number of heart
transplantations performed at
our center per year showed a
plateau since the late ‘90s and
then progressively decreased,
mean donor age increased
constantly over years, from a
low of 25 years at the beginning of our experience to 37
years by the 1990s and reached
45.3 years in 2010 as shown
in Figure 1. The primary indication for heart transplantation were substantially equally
split between ischemic and
non-ischemic patients. Ten patients, with end-stage heart disease associated with severely
impaired renal function, underwent combined simultaneous heart and kidney transplantation with allografts harvested
from the same donor.
Mean heart ischemic time
was 173.5±63.8 minutes, 45
patients required post-transplantation intra aortic balloon
pump support, 155 patient experienced severe right ventricular failure, successfully pharmacological treated in 120 patients,
post-HTx 30-days mortality was
11.6% (102 patients), early graft
failure unresponsive to any pharmacologic and mechanical support was the principal cause
of death for 58 patients followed by infections in 18 cases
and acute rejection in seven patients. Overall actuarial sur-
culopathy (CAV) in 78 patients
(30.3%). During follow-up 137
patients (17.6%) experience severe renal dysfunctions and 59
vival was 78.1% at 5 years and patients required haemodialy63.8% and 47.5% respectively sis; 75% of cases of severe renal failure occurred after three
at 10 and 15 years from HTx,
years from transplantation,
mean survival was 10.74 years
mean time to severe renal dys(see Figure 2). Mean follow-up
time of the 776 discharged pa- function 8.5±5.5 years. Freedom
tients was 11.3±6.2 years (range from any infection at five years
1 month to 25.1 years). During was 52.2%, with 65% of all the
infection occurred in the first
follow-up 80% of patients developed hypertension and 12% three months. Freedom from redeveloped insulin dependant di- jection at five years was 36.2%,
abetes. Two hundred fifty-seven with 493 patients experienced
at last one episode of rejection,
late deaths were reported and
the majority occurred during
main causes of late mortality
the first two months after transwere neoplasm in 83 patients
plantation. The long-term sur(32.3%) and cardiac causes invival of HTx recipients is limited
cluded coronary allograft vasTable I: Donors and recipients’ characteristics at heart transplant
Categorical Variables
Number
%
Recipient Male
715
81.4
Donor Male
567
64.6
Recipient Male/Donor Female
203
23.1
NYHA Class IV
512
58.3
Idiopathic cardiomyopathy
376
42.8
Ischemic cardiomyopathy
353
40.2
Diabetics
99
11.3
Severe Vasculopathy
52
5.9
Status I
358
40.8
Previous Sternotomy
345
39.3
LVAD Implanted
52
5.9
Continuous Variables
Mean value Standard Deviation
Recipient Age (years)
49.6
11.6
Donors Age (years)
36.9
14.8
Cardiac Output
3.6
1.1
Cardiac Index
2.0
0.6
PVR-i (Wood Unit)
4.2
2.6
Creatinine at HTx
1.3
0.8
Bilirubine at HTx
1.1
0.9
Ischemic time (minutes)
173.5
63.8
Cardiopulmonary bypass time (minutes) 175.4
101.8
LVAD: Left Ventricular Assist Device; PVR-i: Index Pulmonary Vascular Resistance; TPG:
Transpulmonary pressure gradient.
in large part by the development
of coronary artery vasculopathy
and malignancies. In our experience freedom from coronary allograft vasculopathy at 10 years
was 66.9%, and 85 patients
underwent percutaneous coronary revascularization. In our
study population 44 patients experienced post-transplant lymphoproliferative disorder and 91
patients experienced a solid neoplasm, mean survival free from
neoplasm was 12.23 years.
Our experience confirms that
heart transplant, as unanimously
reported by Literature, offers excellent short and long term results with an half life posttransplant survival of 10 years;
unfortunately, the number of
donors is, and will remain, much
lower than the number of the
patients who could benefit from
HTx, making optimal use of this
rare resource mandatory in the
view of both ethics and economics. We believe that one of
the primary key points to obtain
these successful results, are patients’ selection and treatment
of candidates for transplantation as well as accurate clinical
follow-up. Only a real multidisciplinary team work that involved, different heart failure
specialist including cardiologist
transplant specialists, cardiac
surgeons, anesthesiologists, internists, nurses, fellows, psychologists and other referring doctors, with the skills to manage
the team and with the ability to
reevaluate patients periodically
and monitoring and adjusting
therapy allowed us to obtain our
excellent long-term results.
Invited Discussant: L. Conzelmann, Mainz
Invited Discussant: C. Mestres, Barcelona
Invited Discussant: K. Tsagakis, Essen
14:45 The location of the primary entry tear in acute
type B aortic dissection affects early outcome
G. Weiss 1, I. Wolner 1, S. Folkmann 1,
D. Reineke 2, J. Schmidli 2, M. Grabenwöger 1,
T. Carrel 2, M. Czerny 2 (1 Austria, 2 Switzerland)
Figure 1: Number of heart transplantation performed each ear in our 25 years single center
experience and mean donor age.
HTx: Heart Transplant
Figure 2: Kaplan-Meier actuarial survival curve at 15 years
from heart transplantation in our single center 25 years
experience of 878 primary adult heart transplant patients.
Residents’ Meeting Room 3A 16:00
Invited Discussant: M. Grimm, Vienna
15:00
Long-term outcomes of acute type B aortic
dissection T. Minami, K. Imoto, K. Uchida, S. Yasuda,
T. Sugiura, J. Shirai, K. Kazama, M. Masuda (Japan)
Invited Discussant: S. Trimarchi, Milan
15:15
Evaluation of the use of lower body perfusion
during selective cerebral perfusion at 28°C in
aortic arch surgery
P. Haldenwang, T. Wahlers,
T. Klein, A. Sterner-Kock, H. Christ, J. Strauch (Germany)
16:00 Abstracts
Auditoria 3+4
Descending aorta
n
to gain further insight into experimental and clinical
efforts in the management of descending aortic
disease
Moderator: H. Jakob, Essen
16:00
Eighteen years experience and treatment
strategy of endovascular repair of thoracic aortic
aneurysmsT. Kuratani, K. Shimamura, Y. Sirakawa, K.
Torikai, K. Kin, T. Yoshida, Y. Sawa (Japan)
16:15
Estimation of cumulative radiation dose exposure
during thoracic endovascular aneurysm repair
and subsequent computed tomography follow-up
S. Zoli, P. Trabattoni, L. Dainese, C. Saccu, R. Spirito, P. Biglioli (Italy)
Invited Discussant: C. Etz, Leipzig
16:30
Surgical outcome of cryopreserved aortic
allografts for aorto-oesophageal fistula
A. Saito, N. Motomura, O. Hattori, O. Kinoshita, S. Shimada, N. Oda, M. Ono (Japan)
Invited Discussant: M. Thompson, London
16:45
Repair of retrograde type A dissection after
endovascular treatment of acute complicated
type B dissection
M. Gorlitzer 1, G. Weiss 1,
R. Moidl 1, S. Folkmann 1, F. Waldenberger 1,
M. Czerny 2, M. Grabenwöger 1
(1 Austria, 2 Switzerland)
Invited Discussant: C. Schachner, Innsbruck
17:00
Erythropoietin attenuates ischaemic spinal cord
injury with enhanced recruitment of CD34+ cells
in mice K. Hirano, K. Wagner, P. Mark, E. Pittermann,
R. Gäbel, N. Ma, G. Steinhoff (Germany)
Invited Discussant: M. Shrestha, Hannover
17:15
Selective perfusion of intercostal arteries
for preoperative detection of the artery of
Adamkiewicz during repair of descending and
thoraco-abdominal aortic aneurysm
N. Kawaharada, T. Ito, T. Maeda, T. Koyanagi, H. Hyodoh, Y. Kurimoto, A. Watanabe, T. Higami (Japan)
Invited Discussant: M. Schepens, Brugge
Survival of cardio-thoracic
surgery: Training and innovation
scatheter valve implantation in
2002, its used in Europe has
increased exponentially. The
“catheter” represents the only
new and disruptive technolIn just over 50 years, cardiac
Justo Rafael Sádaba Department
ogy in treating cardiac strucsurgery flourished thanks to piof Cardiac Surgery, Hospital de
tural disease in the last decade,
oneers such as Dr Charles BaiNavarra, Pamplona, Spain
and it is here to stay and to inley and others, who despite inexorably expand. On the other
itial failures persevered in their
he Dodo was a flightless
hand, traditional cardiac surbird which existed for only efforts to find cure for congery may have reached its limit
100 years since it was first ditions which were fatal unof performance.
til then. Based on the principles
discovered in 1598. The Dodo
Change is hard; change is
evolved in the island of Mauri- of efficacy and reproducibilharder on those caught by surity, the expansion of heart valve
tus without any natural predand coronary artery bypass surator. It wasn’t even hunted as
Justo Rafael Sádaba prised. But change is harder
for those who have difficulty in
gery gave us the opportunity to
food, because it tasted horrichanging too. There is a need
successfully treat the common- the necessary means to treat
ble. Pigs, dogs and rats introthese patients until… the cath- for a culture of change in carest life-threatening conditions
duced by humans in the early
diac surgery; otherwise doom is
eter arrived.
XVII century, destroyed the Do- in the West. All this led to an
in the horizon
In 1977, Dr Andreas
outburst in the number of cardo’s forest habitat, it was not
So what are the implications
able to adapt and so it became diac operations performed and Gruentzig performed the first
expanded cardiac surgery from coronary artery angioplasty in for training? Success derives
extinct.
Will cardiac surgeons be the a few specialized centres to re- a human being. By 1997, angi- from three factors: knowledge,
oplasty had become one of the competencies and attitudes. Of
gional hospitals. Cardiac surDodo bird of the XXI century?
the three, attitude is the main
most common medical intergeons lived in an environment
Are new species invading our
ventions in the world. Since Dr one. Today’s trainees must have
with increasing number of panatural habitat? Will we bean attitude of open mindedtients to treat, easily obtaining Alain Cribier introduced trancome extinct?
T
ness towards less invasive and
percutaneous techniques and
also, towards joining forces
with allied specialties.
New competencies will be
necessary in order to survive.
Cardiac surgeons will have
to acquire skills in less invasive approaches and the ability to perform specific tasks
such as transcatherter procedures, which have traditionally thought to belong to
other specialties. Training programmes must be tailored to
meet these needs.
Knowledge in structural heart
disease is natural to surgeons.
We should take advantage of
this and lead the efforts to advance in the treatment of these
conditions.
A new era in the management of heart diseases is in the
making. There is an imperative
need for a culture of change in
cardio-thoracic surgical training.
Abstracts – Mixed congenital Room 5B 16:00
The role of communication and
non technical skills in the practice
of paediatric cardiac surgery
ied by a behaviour observer, that directly
observed, inquired and tape recorded
ten complex paediatric cardiac surgical
cases, performed by the same chief surgeon and involving a variable team of 21
different staff members – anaesthesioloraditionally, performance in exigent activities, as it is the case for gists, circulating and scrub nurses, surgipaediatric cardiac surgery, has re- cal assistants and perfusionists.
An average of over 1,000 commulied mostly on the technical skills of the
nications occurred per procedure, that
surgical team, with a strong emphasis
on leading surgeon’s decision and dex- lasted an average of 136 minutes (operterity capabilities. Lessons from disasters ating time). Communication was mostly
involving other equally demanding and from surgeon to scrub nurse (16 %), followed by surgeon to first assistant (13,8
dangerous activities, where team performance is deemed to be crucial, high- %) and surgeon to perfusionist (12,4 %),
being less frequent to the anaesthesiololighted the role of non technical skills,
gist (5 %) – figure 1. Structured commuas one of the major factors for both,
performance, reproducibility and safety. nications (closed-loop type, with formal
Non technical skills comprise cognitive answer – response) occurred only between
(namely self) and social (team) capabilithe surgeon and the perfusionist, being
ties and, among the last, communication mostly open and non structured in nais determinant, as it allows efficient flow ture, among all other members of the
of information among team members, al- team. More formal communications oclowing for decision and action; commucurred during the procedure itself and
nication deficits were identified as remore informal, even not case related,
sponsible for over 65 % of all health care dominated during waiting times, as for
accidents !
the re warming period.
Communication patterns (flows and
Regarding the factors influencing or
negative influencing factors) were studdisturbing communications, noise related
J Fragata, L Baquero, P Franco, C Alves,
I Fragata and Raquel Santos Cardiothoracic Surgical Department, Santa Marta
Hospital, Lisbon
T
José Fragata
Figure 1: Distribution of team members in the
OR and communication frequency
to environment, interruptions due
to side questions, namely directed
to the surgical leader, repetitive
entry / exits, by staff members performing tasks, (average of 100 per procedure
!), contributed to frequent distraction and
disruption of the communication flows.
How did these communication patterns affect other non – technical skills,
namely teamwork and leadership?. Team
work levels were found to be low, each
staff member was doing, mostly, his own
job, without showing significant mutual
performance monitoring and cooperation
relationship among different disciplines.
This has, equally, affected leadership patterns, namely the situation awareness
component for nurses and perfusion-
Note: communications surgeon – perfusionist are
“closed-loop”, all others are mostly unidirectional.
ists, due to lack of information, by the
chief surgeon, about the surgery developments.
Surgery is a high risk and most complex activity, therefore one would expect
that there would be a higher level of control, a higher level of reliability and low interference levels in OR’s. This study shows
that there is still a great role for improvement; no major uncompensated errors or
accidents occurred in this limited series,
but one gets the feeling that non technical skills clearly need to be developed and
greatly improved in the surgical domain,
on the sake of safety and to improve
overall performance.
Professional challenges – Mitral valve and beyond II Auditorium 1 16:00
Dysfunctional mitral bioprosthesis treated with transapical mitral valve-in-valve implantation
T Nolasco, S Boshoff, R Teles, J Queiroz e Melo,
J Neves Hospital de Santa Cruz, Lisboa
T
he incidence of structural bioprosthesis deterioration with need for reoperative surgery is becoming more common, as the world’s population
ages. Reoperation of degenerated bioprosthesis has a
high mortality risk that also increases with age and is
correlated with the patients co-morbidities, and therefore more patients are deemed high risk or unsuitable
for the standard of care, which continues to be surgical
replacement. The valve-in-valve concept is an emerging therapeutic option for these high-risk patients with
dysfunctional bioprosthesis, with reduced operative risk
and good outcomes.
We present the case of a 87-year-old caucasian
male with heart failure (NYHA IV/IV) due to a dysfunctional 27mm Carpentier-Edwards porcine mitral
valve (Edwards Lifescience) implanted at the age of
75-years-old due to mitral insufficiency, who had previously undergone coronary artery bypass grafting x
4 at the age of 69-years-old, still with three patent
grafts. Other co-morbidities included atrial fibrillation
and stroke with minor sequelae, and severe hypertension due to renal artery stenosis, with implantation of
a Genesis stent in the left renal artery.
Considered “too high risk” patient for regular mitral
surgery. Still independent and active, he was selected
for mitral transcatheter valve implantation.
Pre-operative transthoracic echocardiography confirmed severe mitral regurgitation due to flail, noncoapting bioprosthetic leaflets. Computed tomography
of the mitral Carpentier-Edwards bioprosthetic valve revealed an internal diameter of 21mm, and therefore
chosen a 23mm Edwards Sapien transcatether valve.
A transapical approach was established with a
standard 26F Ascendra® delivery system and extrastiff guidewire was placed in a stable position in the
left atrium. Under fluoroscopy and transoesophageal
echocardiography monitoring the aortic 23mm Edwards
Sapien valve in reverse position was positioned inside
the mitral bioprosthesis and deployed under rapid pacing. No radiopac contrast was used, due to age and renal function. There were no surgical complications, no
Figure 1: Positioning the transcatheter valve inside
porcine valve
need for cardiopulmonary bypass or reinterventions
The post-procedure echocardiography revealed deon a eight months follow-up maintains clinical stable
crease in maximal gradient from 37 to 15mmHg, and
in mean gradient from 21 to 8mmHg, with no transval- NYHA I-II/IV.
As a conclusion, transcatheter transapical valve-invular or paravalvular leak.
valve implantation into a dysfunctional mitral bioprosThe patient was discharged home on day six, and
Figure 2: Balloon valvuloplasty and deployment of
23mm Edwards Sapien transcatheter valve
thesis is a viable approach for “high risk” patients, with
good outcome and reduced mortality and morbidity.
It’s exact place in the surgical armamentarium is still
under determination.
Wednesday 5 October 2011
09:30 Transcatheter aortic valve implantation:
the gold standard for the treatment of
aortic valve stenosis
Organiser: J. R. Sádaba, Pamplona
Session 1: Traditional AVR vs TAVI:
A head-to-head comparison
Auditorium 2
n
to update knowledge of the good results of TAVI in the
treatment of calcific aortic stenosis
n
to be aware of the evidence for the possible
advantages of TAVI over traditional AVR
Moderators: A. P. Kappetein, Rotterdam; J. R. Sádaba, Pamplona
09:30
Implantability and short-term complications
J. Goiti, Bilbao
10:00 Haemodynamics and the relevance of aortic
regurgitation
N. Moat, London
10:30 Mid-term results: insights from the PARTNER trial
C.R. Smith, New York
11:00 Coffee
Session 2: Transcatheter aortic valve
implantation in 2020:
The role of the surgeon in
a transcatheter era
n
to be informed about the trends and future
developments of TAVI, particularly new technologies
and markets, and the implications for surgeons
Moderators: J. R. Sádaba, Pamplona; I. George, New York
11:30
Next developments in technology: surgical
implications
V. Falk, Zürich
12:00 Indications and patterns of referral for
transcatheter aortic valve implantation in 2020
A. Vahanian, Paris
12:30 The future market for transcatheter aortic valve
implantation
Philip Ebeling,
VP, Research & Development, St Jude Medical
13:00 Adjourn
Abstracts – Mitral valves Auditorium 7 08:30
Enhancing departmental quality control
in minimally invasive mitral valve
surgery: A single institution experience
failure was reoperaration for bleeding
(44 patients; 4.7%) which accounted
for the 55% of all surgical failures. Institutional cusum curve (Figure 2) shows a
sharp positive slope for the firsts 70 patients reflecting the learning curve assoplied to operators with both a high vol- ciated with this new procedure. In the
Michele Murzi ume and a low volume of cases. In our initial phase the curve gravitated around
Ospedale del Cuore
the alert boundaries two times at opstudy, CUSUM is defined as: Sn=(Xi –
Fondazione Monasterio
eration 41 number and 48. During this
p0), where Xi=0 for success and Xi=1
CNR, Massa, Italy
period we recognized an elevated incifor failure. The graph starts at 0, but is
dence of reoperation for bleeding and
incremented by 1-p0 for a failure and
his evolution
stroke. For this reason, in order to simdecremented by p0 for a success. For
towards less
the purpose of this study p0, or the “ac- plify the procedure and reduce the ininvasive mitral
cidence of complications, we decided
ceptable failure rate” was set at 10%.
valve surgery proto avoid the use of femoral artery perBetween 2003 and 2011, 936 MIMVS
cedures (MIMVS)
has been characterised by the develop- procedures were performed at our insti- fusion and endo-aortic cross clamp and
ment of dedicated surgical tools, modi- tution. During the seven years study pe- we shifted to central aortic cannulation
fied perfusion methods and visualization riod there has been a constant increase with transthoracic cross-clamp whenever
possible. Subsequently, the curve started
in the number of MIMVS procedures
techniques. However some concerns
to run horizontally and the process came
(Figure 1).
about the safety and reproducibility of
in control on operation number 91. FiThe overall failure rates were 8.5%
such interventions have been raised up.
nally the curve presents a slow but con(80/936). The incidence of in-hospital
Importantly, it is universally accepted
stant downward inflection reflecting
mortality was 1.8% (17/936) and comamong cardiac surgeons to keep efpared favorably with the predicted mor- positive results. Seven surgeons were inficacy and safety competitive in relavolved in the MIMVS program, achieving
tion to standard surgery. In other words tality calculated by the logistic Euroa different level of experience ranging
SCORE of 7.3%. The most frequent
the benefits of minimally invasive approach must be reached without compromise the quality of the operation and
Figure 1
increasing the morbidity and mortality of standard open procedure. Within
this paradigm, performance monitoring
and learning effect surveillance of minimally invasive mitral procedure have
become two mandatory responsibilities
of individual cardiac surgeons and institutions.
In this study we used control charts
to monitor our institutional and individual surgeons performance over time.
Specifically we adopted the CUSUM
charts that report of changes in outcome rates over time. They can be ap-
T
from 401 to 21 operations. Three surgeons performed more than 100 operations. Cusum failure graphs for each surgeons were plotted. There was a great
variability among surgeons in their Cusum failure curves. However our results
show that MIMVS presents a learning
curve that is quickly mitigated with experience. Interestingly we observed that
while the institution increased the volume of MIMVS procedures and became
proficient in this technique, the learning
cuve of surgeons introduced to MIMVS
were less steep.
In conclusion our study shows that it
is relatively simple to implement control
charts for continuous individual and
departmental performance monitoring. The great strength of this type of
analysis is that it can easily and quickly
identifying the trend. If the trend suggests that the process is going out of
control it is mandatory to closely analyze the process. On the other hand if
the trend is steadily improving, it is also
interesting to identify the reasons for
this changes.
Figure 2
09:30 Master of valve repair
Focus session – Fontan controversies: EACTS - AEPC joint session Room 5B 08:30
Auditorium 7
Programme to be announced
09:30 Minimally invasive therapies for
atrial fibrillation
Auditorium 8
Organiser: M Castella, Barcelona
n
to update knowledge of efforts in minimising
approaches for surgical ablation for arrhythmias
Moderator: M. Castella, Barcelona
09:30
Surgical atrial fibrillation therapy in port-access
surgery
M. Czesla, Stuttgart
10:00 Isolated lone atrial fibrillation ablation through
right mini-thoracotomy
G. Nasso, Bari
10:30 Two-stage hybrid procedure for long-standing
lone atrial fibrillation
B.Gersak, Ljubljana
11:00 Coffee
11:30
One-stage hybrid procedure for long-standing
lone atrial fibrillation
M. La Meir, Brussels
12:00 Minimally invasive left appendage management
in patients with atrial fibrillationS. Salzberg, Zürich
12:30 Adjourn
This programme is supported by an
unrestricted educational grant from Atricure
and Estech
09:30 Controversies in aortic valve
and root surgery
n
to gain an overview of current status and anticipated
developments in surgery of the aortic valve and aorta
Moderators: M Shrestha, Hannover; S. Kendall,
Middlesbrough; R. Haaverstad, Bergen
09:45
10:00
10:15
10:30
gle ventricle pathologies who
underwent BCPC at our institution between 2002-2007.
There were 139 males (61%).
Median age at time of BCPC
was 7.6 months (inter-quartile
Bahaaldin Alsoufi King Faisal
range IQR 5.6–10.7) and meSpecialist Hospital and Research
dian weight was 6.2 Kg (IQR
Center, Riyadh, Saudi Arabia.
5.2–7.4 Kg). Forty-three patients (19%) had no prior opn the recent decades, there
eration while 184 (81%) had
has been a remarkable imprior palliation such as aortoprovement in the outcomes
pulmonary shunt (n=83), Norof children born with various
wood operation (n=55), PA
single ventricle cardiac anomalies. Multi-stage palliation is the single ventricle anomalies. Sev- band (n=48), atrial septeccurrent mainstay in the treateral selection criteria have been tomy (n=25), PA reconstruction (n=14), anomalous pulmoment of those complex chiladopted worldwide to help
dren, in addition to orthotopic choosing proper candidates for nary venous connection repair
heart transplantation in sethe Glenn procedure. In the cur- (n=7) and other procedures
lected group of patients. The
rent study, we aimed to exam- (n=8). Predominant ventricle
morphology was left (n=122,
Glenn bidirectional cavopulmo- ine contemporary results fol54%), right (n= 95, 42%) and
lowing BCPC.
nary connection (BCPC) is an
We identified 227 consecu- equally developed (n=10, 4%).
established procedure in this
multi-stage palliation of various tive children with variable sin- Twenty-six patients (11%)
I
had bilateral SVC. Concomitant surgery included preparation for percutaneous Fontan
(n=34), atrio-ventricular valve
repair (n=18), PA augmentation (n=80) and other surgery
(n=24).
Competing risks analysis showed that five years following BCPC, approximately
15% have died, 81% have undergone the Fontan operation and 4% were alive awaiting or not qualifying to receive
the Fontan operation. Competing risks analysis showed that
three years following the Fontan operation, approximately
10% have died, 7% have undergone further cardiac surgery and 83% were alive and
free from reoperation. Survival
and unplanned reoperation
were not significantly influ-
enced by diagnosis, concomitant surgery, pre-operative PA
pressure, bilateral SVC or other
tested demographic, hemodynamic, anatomic and operative
variables.
We concluded that despite
established selection criteria
and improved surgical techniques and medical management, there is a continuous
failure and attrition risk following BCPC. This highlights the
continuous disadvantage that
patients with Fontan physiology have and the wealth of
single ventricle-related long
term complications. This also
emphasizes the need for continuous research to improve
the physiology which could decrease interim and long-term
morbidity and mortality in
those difficult patients.
EACTS meeting on Monday
First experiences with a second generation transapical TAVI system – The JenaValve
Auditorium 5C
09:30
Current outcomes of the Glenn
bidirectional cavopulmonary connection
for single ventricle palliation
New technologies in aortic valve replacement: the
cardiologist’s view
A. Vahanian, Paris
Classical aortic valve replacement: surgery, still
the gold standard
G. Berg, Glasgow
Aortic valve endocarditis: what to do
C.
Mestres, Barcelona
Aortic root in bicuspid valves: what to do
R. De Paulis, Rome
Discussion
10:45 Coffee
Hendrik Treede Oberarzt,
Universitäres Herzzentrum
Hamburg, Klinik und Poliklinik
für Herz- und Gefäßchirurgie,
Hamburg, Germany
T
ranscatheter aortic valve implantation has become a viable treatment option for
patients with severe aortic stenosis at high risk for
open heart surgery. More
than 15,000 TAVI procedures have been performed to date worldwide
with promising results and
acceptable safety. Nevertheless paravalvular leakage, conduction disorders,
coronary obstruction and
valve displacement represent problems that occur frequently in TAVI procedures amongst others.
Next generation devices
hold promise to overcome
or reduce at least some of
these problems by novel
stent designs and implant
techniques.
One of these new devices is the JenaValve system developed by two
cardiologists from Jena
University, Prof. Figulla
and Prof. Ferrari. It consists of a porcine root
valve mounted on a low
profile self-expanding Niti-
nol stent and achieves anatomical correct positioning by feeler guided active
clip fixation on the native
valve leaflets. This special
technique is designed to
reduce the amount of paravalvular leakage and precludes obstruction of the
coronary ostia. The valve
is implanted transapical
through a mini-thoracotomy without rapid pacing
at the beating heart.
A successful first-inman series was conducted
at the Heart Centre Leipzig showing good results
and no mortality despite
one case of aortic dissec-
tion. The delivery catheter was refined to solve
this problem before the
multi-centre CE-Mark pilot study was started
with Prof. Mohr as principle investigator. Sixtyseven patients underwent
transapical aortic valve
implantation in seven German centres. The majority of patients were
treated at the University
Heart Centre Hamburg by
Dr Treede who presented
acute and 30 day results
of the multi-centre trial
at the EACTS conference
yesterday.
The transapical deliv-
ery route now allows surgeons as members of the
heart team to be in control of the implant procedure and to prove that
transapical procedures
do not carry higher risks
compared to transfemoral approaches. Longterm performance of porcine root valves as used in
the JenaValve are known
to be very good in surgical
aortic valve replacement.
Longevity should not be
influenced by transapical
transcatheter delivery because the valve leaflets are
not crimped by force but
only folded into the delivery catheter. In addition
flexible stent posts of the
JenaValve allow for stress
reduction on the leaflets. The JenaValve system is available in three
sizes (23mm, 25mm and
27mm) serving aortic annuli of 21 to 27mm. CE
Mark approval is expected
for October 2011.
Wednesday’s Highlights Wednesday’s Highlights
Room5B 10:40
EACTS
Congenital
Domain Chair
Francois Lacour-Gayet Head Pediatric Cardiac Surgery, Montefiore Children’s Hospital; Professor of Surgery, Einstein College of Medicine,
New York, NY, USA
T
he Congenital
Domain has contributed in good
place to the excellent
development of the
EACTS. The unique structure of the Society, organized in three different domains, is
specific to the EACTS compared to the STS
and AATS. I personally believe that adult cardiac, thoracic and congenital surgeons feel
really at home at the EACTS and that securing their independence continues to be inspiring.
The quality of the publications is improving year after year, as shown by the excellent
scientific impact of the EJCTS journal. Evaluation of quality of care has been a permanent focus of the congenital domain. The remarkable success of the congenital database
required the creation of the STS-EACTS congenital nomenclature as well as the introduction of the Aristotle score. Developing a scientific method to evaluate quality of care in
CHS is a continuous effort that is best undertaken in partnering with sister organizations.
The collaboration between the EACTS congenital domain and the STS congenital work
force is a good example.
Finally, the spirit of camaraderie and respect between congenital surgeons at the
EACTS is quite unique. The European Congenital Heart Surgeons Society has contributed to this harmony in working at the side
of the EACTS to help improving the quality
of care of our congenital patients.
I thank Dr Juan Comas and the EACTS
Council for recognizing the past contribution
of the EACTS Congenital Domain Chairs and
wish them a great future.
Abstracts – Descending aorta Auditoria 3&4 16:00
Learning from experience Room 5A 09:00
Repair of stent graft-induced
retrograde type A aortic dissection
using the E-vita open prosthesis
Surgical treatment of advanced right upper
lobe tumour invading left atrium and left
ventricle via right superior pulmonary vein
and partially occluding mitral valve
dovascular repair using a specially designed
hybrid prosthesis (Jotec E-vita open) were
performed.
Replacement of the ascending aorta, the
aortic arch, and the proximal descending
horacic endovasaorta can be performed simultaneously by
cular aortic repair
this combined single-session procedure.
(TEVAR) is used inAll patients survived the surgical procecreasingly often as a less
invasive treatment option than open surgery dure. No stroke, paraplegia, or other major
for patients with acute complicated Stanford neurological complications occurred. Posttype B thoracic aortic dissections. The poten- operative CT scans revealed perigraft thrombus formation and stable aortic dimensions
tial benefits of TEVAR, such as avoidance of
in all patients after six months.
thoracotomy, extracorporeal circulation, carThis single-stage hybrid approach perdiac ischemia, have to be weighed against
the considerable risk of acute or delayed ret- mits safe, effective and simultaneous treatrograde type A dissection, stroke, paraplegia ment of the ascending aorta, the aortic
or access-related complications at the femoral arch, and the descending aorta in patients
or iliac arteries. Another major concern asso- with acute complicated type B aortic dissecciated with this minimally invasive procedure tion who undergo TEVAR and develop retis whether the stiff stent graft or endovascu- rograde type A dissection. The procedure is
lar manipulation would injure the aorta. This associated with a good clinical outcome in
patients with this potentially lethal complimay lead to the potentially lethal complication of retrograde ascending aorta dissection. cation. Based on theses findings the frozen
The aim of this retrospective analysis is to elephant trunk procedure should be condescribe a bailout strategy using the frozen sidered as first line therapy in patients with
elephant trunk technique to counteract this acute complicated type B aortic dissection if
associated with dilatation of the ascending
potentially lethal complication.
aorta or possible potential components for
In three cases of retrograde aortic type
retrograde type A dissection.
A dissection a combined surgical and en-
Mehmood A Jadoon,
Alsir Ahmed
and Pushpinder
Sidhu Royal Victoria
Hospital, Belfast,
Northern Ireland.
Michael Gorlitzer Lainz Hospital, Vienna, Austria
T
signs of any recurrent disease or distant
metastasis.
We conclude that if carefully evaluated in selected patients with lung tumours having polypoidal extension into
the left atrium and left ventricle with no
attachment or invasion of endocardium
or heart valves need not be considered
an absolute contraindication to surgical
resection. In fact, in highly selected patients, pneumonectomy with retrieval of
tumour from left atrium on bypass can
provide excellent control of the disease,
and even may lead to a definitive cure.
W
e present
a challenging
Mehmood
Jadoon
yet interesting case
of a 51 year old lady
who presented to a peripheral hospital with dry cough and night sweats. CT
scan showed tumour in right upper lobe
(Figure 1) tracking via right superior pulmonary vein into left atrium and then
through mitral valve in diastole into left
ventricle partially occluding mitral valve.
Transoesophageal ECHO (Echocardiography) ruled out any attachment of
tumour to any part of heart (Figure 2).
Intracardiac polypoidal tumour measured 6 cm x 1.6 cm. The patient had
good Pulmonary function tests with
FEV1 (Forced expiratory volume in one
second) of 2.30 L (97%), FVC (Forced vital capacity) of 2.71 (97%) and DLCO
Figure 1: Computed tomography view
of a large tumour with satellite nodules
(Diffusion lung capacity for carbon
involving right upper lobe.
monoxide) 1.37 (67%).
Patient underwent excision of left
atrial extension of tumour on bypass via
median sternotomy. Immediately afterwards right pneumonectomy was performed via posterolateral thoracotomy.
This tumour was moderately differentiated adenocarcinoma and it was staged
pT4N2 (stage 3b) (6th Edition of the
AJCC staging system). There was no evidence of distant disease on PET (Positron emission tomography) scan.
Post-operatively she received four cycles of cisplatin and vinorelbine based
chemotherapy. A year and half afFigure 2: Transeosophageal
echocardiography view of large
ter her operation patient is doing
pedunculated tumour (a) crossing across
very well. A follow-up CT scan at 18
mitral valve (b) into left ventricle.
months post-operatively shows no
An inside look at the Edwards SAPIEN and Edwards SAPIEN XT Transcatheter Heart Valves (THVs)
Expanded treatment options:
Laksen Sirimanne Vice-President, Research & Development, THV, Edwards Lifesciences
Valve diameters
T
he results of The PARTNER Trial Cohorts A and B support the balloon-expandable Edwards SAPIEN transcatheter heart valve (THV) released in Europe in late 2007. Since its release, our team of
engineers has continued to advance the design of the Edwards’ line of balloon-expandable valves.
Utilising clinical feedback and R&D advancements, the Edwards SAPIEN XT THV was released in early 2010. The Edwards
SAPIEN THV product line is based upon four key design elements: proven leaflet design, optimal frame height, high radial
strength, and predictable valve deployment. These elements
went into the original design of the Edwards SAPIEN THV, and
were also the core criteria evolving the Edwards SAPIEN XT THV.
The Edwards SAPIEN XT
THV treats an annulus size
range of 18 to 27mm
Proven leaflet design
Optimal frame height
High radial strength
Predictable valve deployment
he Edwards line of transcatheter heart valves
shares many features that are core to Edwards’ long history of
tissue valve design. The
leaflets are made of
bovine pericardial tissue, which has clinically
proven longterm durability. The leaflets undergo the CarpentierEdwards ThermaFix
treatment process which
is intended to minimise
the risk of calcification. All leaflets are matched
for thickness and elasticity to promote consistent
leaflet function and coaptation.
One new feature of the Edwards SAPIEN XT
transcatheter heart valve, compared to the original Edwards SAPIEN THV, is the new leaflet design. This design features a proprietary surgical leaflet shape based upon Edwards’ surgical
valves and has been enhanced for stress distribution, to support valve durability.
significant design criterion for the Edwards
transcatheter heart valves is to have a frame
height that is designed for proper
placement and
non-interference
with the surrounding
anatomy. The
Edwards SAPIEN THV frame
is 14mm (in the
23mm valve), or 16mm (26mm valve) tall. It is designed to fit within the native annulus, minimising the risk of atrioventricular (AV) block and
disruption of mitral leaflet function. It is also designed for placement below coronary arteries, allowing clear access for future percutaneous coronary interventions (PCIs). The Edwards SAPIEN
XT THV frame had the same design requirement.
The Edwards SAPIEN XT THV frame is 14mm
(23mm valve),17mm (26mm valve) and 19mm
(29mm valve) tall.
he Edwards transcatheter heart valves established a new paradigm in valve delivery; one
key feature of this was the fact they possess a strong supportive frame with high
radial strength. The Edwards SAPIEN THV
frame strength has shown, throughout
its high volume of implants, to result in a
large effective orifice area, even in heavily calcified annuli. It was designed for
reliable deployment with nominal diameter which is necessary for proper leaflet
coaptation. This high radial strength results in proper haemodynamics and valve
durability. The Edwards SAPIEN XT THV
frame offers comparable radial strength to the
original Edwards SAPIEN THV frame. This was
one of the key design criteria. The new feature
of this frame is that it also allows for low profile crimping. In order to combine radial strength
with low profile crimping, the Edwards SAPIEN
XT frame geometry features fewer rows than the
Edwards SAPIEN frame and is made from cobalt
chromium rather than stainless steel.
he Edwards SAPIEN THV is delivered transapically with the Ascendra delivery system and
transfemorally with the
RetroFlex 3 delivery system. The delivery systems
were designed for their
means of access and featured balloon-expandable
delivery engineered for
predictably accurate valve
placement. These are
the products used in The
PARTNER and The PARTNER II Trials. The Edwards
SAPIEN XT THV is delivered transapically with the
Ascendra2 delivery system and transfemorally
with the NovaFlex+ delivery system. Both systems
were designed to take advantage of the lowprofile crimping frame design to decrease their
sheath sizes while maintaining predictable valve
placement, which represent significant steps forward in design evolution.
T
A
T
T
Wednesday’s Highligh
11:15
11:30
11:45
12:00
12:15
12:30
12:45
Aortic valve in acute aortic dissection type A:
what to do
M. Shrestha, Hannover
Minimally invasive aortic valve replacement
M. Glauber, Massa
New technologies in aortic valve replacement:
positive trend
T. Folliguet, Paris
View from the medical industry: Aortic valve
replacement
J. McKenna,
Vascutek Ltd, United Kingdom
View from the researchers: aortic valve
replacement; tissue engineered valves, the
future?
A. Haverich, Hannover
Discussion
Adjourn
09:00 The role of the Ross operation on
the surgical menu
Room 3A
n
to gain an overview of the worldwide experience
with the Ross operation detailing different surgical
techniques
n
to understand the indications and contraindications for
the Ross procedure
n
to be able to compare the Ross procedure with other
options on the surgical menu
n
to appreciate the requirements for optimal clinical
application of the Ross procedure
Moderators: J. J. M. Takkenberg, Rotterdam; W. F.
Northrup III, Kennesaw
09:00
Introduction
J. J. M. Takkenberg, Rotterdam
Ross root replacement: indications,
contraindications and results
I. El-Hamamsy, Montreal
09:25 Video: Ross procedure root replacement
I. El-Hamamsy, Montreal
Controversies in aortic valve and root surgery Auditorium 5C 09:30
Surgery of the aortic root in acute aortic dissection: Type A
Malakh Shrestha, Axel Haverich Hanover Medical School, Hanover, Germany
T
he standard approach for repair of acute aortic dissection type A (AADA) involving the aortic root is the so called ‘Bentall Procedure’ where
the aortic root is replaced with a composite graft carrying a mechanical or biological prosthesis. Reimplantation (David) or remodeling (Yacoub) procedures have
become valve-sparing alternatives. However, both
techniques are more demanding than the Bentall procedure. Supra-commisural replacement of the ascending aorta with repair of the dissected root is another
alternative, but it bears the risk of root aneurysm formation or late necrosis, especially when surgical glue
is used. The third alternative is the valve-sparing aortic
root stabilizing technique.
The aortic root is dissected below the level of the
aortic annulus and measured. The graft is implanted
outside the native aorta by using 10-12 braided polyester mattress sutures placed in the left ventricular outflow tract in a horizontal plane just below the
lowest level of the valve leaflets. The Dacron graft is
incised twice vertically to create an opening in the
prosthesis to correspond with the right and left coronary ostia. Thereby, the entire graft covers the native aortic root cylinder from the outside. Distal aortic reconstruction is done as usual. There is no need
to re-implant the native aortic valve and the coronary ostia.
The approach described here is a technically simpler alternative to other aortic valve sparing operation in patients with AADA with involvement of the
aortic root.
09:05
Video
09:40
Ross subcoronary implantation technique
Hans Sievers, Lübeck
09:50: Training requirements for the Ross procedure
W. F. Northrup III, Kennesaw
10:10 Coffee
10:25
10:45
11:05
11:25
11:35
12:00
Mechanical AVR: indications, contraindications
and results
H. Körtke, Bad Oeynhausen
Stentless bioprosthetic AVR: indications,
contraindications and resultsR. J. M. Klautz, Leiden
Aortic valve repair: indications, contraindications
and results
H.-J. Schäfers, Homburg/Saar
Optimised decision-making for prosthetic AV
selection
J. J. M. Takkenberg, Rotterdam
Discussion: The surgical menu for aortic valve
disease in (young) adults
All
Adjourn
WETLAB TRAINING
08:30 Strategies to deal with the
small aortic root
Room 3B
08:30-10:30 and 11:00-13:00
n
At the end of this wetlab, the candidate will be able to
describe the commonlyused techniques to perform
aortic root enlargement in the adult, and:
n
1. Explain the reasons why one technique might be
used in place of another
n
2. Perform the techniques in a wetlab environment
Co-ordinator: D. Pagano, Birmingham Lead convenor: M. Lewis, Brighton
Faculty: S. Rooney, Birmingham; T. Jones, Birmingham;
A. Chukwuemeka, London
08:30
08:35
08:45
08:50
08:55
10:25
Introduction
M. Lewis, Brighton
Anatomy of the aortic root T Jones, Birmingham
Lecture: Use of low-profile valves
A. Chukwuemeka, London
Outline of the wetlab
M. Lewis, Brighton
Aortic root enlargement wetlab
All faculty
i. Nicks ii. Manoughian iii. Use of sutureless valves (demonstrator only on a fresh heart)
tba
Summary, feedback and close M. Lewis, Brighton
10:30 Coffee
11:00-13:00 Programme repeated
n
Target audience: Senior Residents
n
Attendance at these interactive sessions is restricted:
pre-registration is required on-site
n
educational grant from the Sorin Group
New technologies in
AVR: Positive trend
require a longer bypass and aortic cross clamp time compared
with stented valve which can be
detrimental for older patients.
Therefore to simplify surgical
implantation Sutureless Bioprosthesis were designed. These are
the 3f Enable (ATS, Minneapolis, MN), the Perceval S (Sorin,
ortic valve replacement
with biological valves is Saluggia, Italy), and the Intuthe treatment of choice ity (Edwards Lifesciences, Irvine,
for severe aortic stenosis (≤ 0.6 CA, USA).
The 3f Enable consists of a tucm2/m2) when symptomatic,
or with left ventricular dysfunc- bular structure assembled from
three equal sections of equine
tion in older patients. Pericarpericardial tissue mounted on
dial valves have a lower rate
a self-expanding nitinol frame,
of structural valve deterioration compared with porcine bi- which contributes to the fixation
oprosthesis, however since they of the device in the deployed loare all mounted on a stent, this cation by virtue of outward racan lead to residual gradient in dial forces inherent in the Nitinol
small aortic annulus. In order to material. There are currently four
sizes available 21mm, 23mm,
improve hemodynamics stentless bioprosthesis have been de- 25mm, and 27mm.
Perceval S is a prosthetic valve
veloped. These valves provide a
greater effective orifice area for comprising a functional compothe same annular diameter, but nent in bovine pericardium fixed
Thierry Folliguet Department
of Cardiovascular Surgery,
Institut Mutualiste
Montsouris, Paris,
France
A
3f Enable
Perceval S
Intuity
in a metal cage made of nitinol.
The cage design is characterised
by two ring segments, on the
proximal and distal end, and a
number of connecting elements
designed to support the valve
and to allow the prosthesis anchoring to the aortic root, in the
sinuses of valsalva.
Therefore the cage can be
compressed for the implantation and is then released to
reach its final diameter. Three
valve sizes (21mm, 23mm,
25mm) are available for annulus size 19mm to 24mm.
The Intuity valve is a pericardial valve with a balloon expandable frame, placed supra annularly, with valve sizes ranges
from 19 to 27mm. This device is
neither folded nor crimped prior
to implementation. mAll these
valves are implanted with cardiopulmonary bypass through a
surgical incision under general
anesthesia. The diseased native
aortic valve is removed and the
valve is implanted after being
sized surgically.
The Sutureless Bioprosthesis have been tested in 5 multicenters trials enrolling approximately 700 high risk patients.
Early results are encouraging and positive. Compared
to stented bioprosthesis these
valves offer an increase effective orifice area with low gradient. They can be inserted with
increase speed even in small
calcified aortic annulus, reduc-
ing bypass time. The complications are similar to stented
bioprostheses with a slightly
increased rate of paravalvular leaks (4-7%) leading to a
higher rate of reoperation rate
at three years. No migration,
thrombosis or coronary obstructions have been reported.
Presently due to the lack of
long term follow up, these
valves should be reserved for
older patients.
In conclusion the Sutureless
Bioprostheses may offer some
advantage in patients with severe calcification of the aortic root and/or patients requiring concomitant procedures in
whom a reduce bypass time is
preferable.
View from the research: Aortic
valve replacement: tissue
engineered valves the future?
preserved allografts undergo degenerative processes, the leading cause for reoperation of patients after 10 years.
As a result, implantation of acellular or reseeded heart valves with patients’ own cells may solve the immune
response problems and facilitate in-vivo
common treatment in advanced aortic
Axel Haverich valve (AV) disease. Accelerated degener- graft remodeling.
Hannover Medical
Over the last decade, tissue engineeration of biological allo- and xenovalves
School, Germany
is partially attributed to remaining cells ing (TE) has become a promising strategy by which to obtain such valves.
within the valve tissue. Preserved antis the number
genicity induces a chronic inflammatory Initial clinical experience with decellularof humans
response with subsequent valve failure. ized homografts, proceeded by methods
with conof TE prior to implantation in pulmonary
In addition, all described grafts have a
genital heart defects
position, showed in contrast to convenlimited acceptance in patients that are
is growing and the
tional homografts and xenografts, imstill growing. Immunological responses
population in the EU is ageing in genproved freedom from explantation, proare avoided by the use of the patient’s
eral, thereby leading to higher health
costs, reduction of costs for heart valve own pulmonary valve in replacement of vided low gradients in follow-up and
exhibited adaptive growth.1
replacement could compensate for this diseased AV, as in the Ross operation.
to some extent. A reduction of one per- The pulmonary autograft is also advanIn sheep, a model considered to be
cent of total costs for cardiovascular dis- tageous, as it has been shown to grow
standard in predicting calcification of
along with a child, resulting in fewer re- biological heart valves, decellularized
eases, which seems realistic given the
operations. Factors contributing to a
high numbers of heart valve operaAV demonstrated superior durability as
tions (60,000 per year, EACTS-database) limited acceptance of this procedure in- compared to unprocessed conventional
clude operation complexity and the rewould represent savings about more
allografts in long-term experiments.2
placement requirement of both aortic
than one billion Euros.
As a consequence, AV replacements
and pulmonary valves. Moreover, cryoBiological valve replacement is the
with TE grafts now have reached clinical
A
level and we have implanted several decellularized homografts in selected complicated cases.
The future of tissue engineered valves
in aortic position therefore already has
begun.
References
1 Cebotari, Haverich et al. The Use of Fresh Decellularized Allografts
for Pulmonary Valve Replacement May Reduce the Reoperation Rate
in Children and Young Adults – Early Report. Circulation 2011, in Press
2 Baraki , Haverich et al. Orthotopic replacement of the aortic valve
with decellularized allograft in a sheep model. Biomaterials 2009;
30:6240–6246.
hts Wednesday’s Highlights
Aortic root in bicuspid valves: what to do
vent further dilatation. It is not well
established the maximal dimension
at which the sinuses might be left
untreated.
will have an influence on the differthe normally functioning BAV is as- family history of early dissection,
Ruggero De Paulis Cardiac Surgery
There is some recent evidence
ent surgical techniques, whether a
syndrome-associated aortopathy
sociated with abnormal flow patDepartment, European Hospital, Rome,
that the phenotype of the root
terns and asymmetrically increased gene mutations, younger age, diam- Bentall operation or a separate valve
Italy
whether with a preserved or efand graft replacements. In the last
eter in relation to body size or aorwall stress in the proximal aorta.
faced ST junction, might help the
There is still considerable contro- tic cross-sectional area/height ratio, decade the aortic root has been reicuspid aortic valve (BAV) is a
decision making process. As more
ceiving increasing attention with the
progression of diameter, anatomic
common congenital heart ab- versy as to whether the BAV aordata are collected and the interacaim of preserving as much as possisite of dilatation according to BAV
topathy is caused by genes or henormality affecting 0.5% to
tion between the underlying geble a proper function of the natural
modynamics. The risk of rupture or phenotypes, severity of aortic ste2% of the population. It is associaortic valve.
nosis or regurgitation, mechanical
ated with an increased lifelong risk dissection is individual and general
Ruggero De Paulis netics with the altered hemodynamic flow will be unveiled, it will
In BAV patients presenting a
guidelines are difficult to be drawn. properties, biomarkers. While the
of aortic valve dysfunction and en(usually the non coronary with the probably become more evident
progressive ascending aortic dilata- symmetrical aortic root aneurysm
It is generally accepted that in the
docarditis requiring surgery. Cenwhat segments of the aorta are
raphe between the left and right
tral to the pathology of a BAV is the presence of a bicuspid valve the aor- tion in bicuspid valve disease is well a valve sparing operation, in case
diseased and prone to dissection
cusp), its sole replacement using a
tic diameter indicating the need for documented, the progressive dilata- of a functioning valve, or a Benmalformation of the commissures
and need to be excised. At that
tion of sinuses of Valsava is not ev- tall operation, in case of a diseased Dacron patch or a tongue extensurgery is smaller than in the presand the adjacent parts of the two
sion of the Dacron graft needed for point the surgical technique can be
and calcified valve, both can guarence of a tricuspid valve. In this re- ident or probably proceeds with a
corresponding cusps forming a raantee stable and long-term results. the ascending aorta is a satisfactory better tailored to each individual
phe. Besides the peculiar valve mor- gard, various factors should also be slower rate of enlargement. This is
anatomical condition.
of major clinical relevance because it In the case of single enlarged sinus way to stabilize the root and prephology, there is evidence that also included for decision making, like
B
Minimally invasive aortic valve replacement
Mattia Glauber Fondazione G Monasterio
CNR-Regione Toscana, Italy
C
linical outcomes after aortic valve
replacement (AVR) have improved dramatically in the last
decade despite gradual increases in patient age and overall risk profile. Data
reported from STS database show an
overall operative mortality for isolated
AVR of 2.6 %. Despite these results,
the development of new cardiothoracic
technologies has spurred interest into
the realization of alternative approaches
in order to reduce the invasiveness of
the surgical procedure. Minimal invasive refers to a small chest wall incision
that does not include a full sternotomy.
Compared with conventional surgery,
minimally invasive AVR has shown to reduce postoperative mortality and morbidities, shorten hospital stays with
faster recovery, provide less pain with
better cosmetic results and consequently
reduce costs. However, most of these
studies on minimally invasive AVR focus on upper ministernotomy and few
reports have described outcomes after
RT. The most common minimally invasive AVR approaches at our institution
are the right anterior minithoracotomy
(RT) and the upper V-shaped ministernotomy (MS).
Since January 2005 we performed
363 minimally invasive AVR procedures,
of which 226 were done through RT
and 150 through MS access. Cardiopulmonary bypass was established under direct aortic cannulation and venous
drainage was obtained through percutaneous femoral venous cannulas with
the Seldinger guidewire–transesophageal echocardiographic technique. Patients were suitable for RT approach if,
at the level of main pulmonary artery,
more than half of ascending aorta was
positioned on the right respect to the
right sternal border and the distance
from the ascending aorta from the sternum was less than 10 cm. Previously
we reported excellent results with minimally invasive AVR through RT. Specifically, we found 1.5% overall mortality, (lower than the recent mortality rate
reported from STS), low incidence of
postoperative stroke, renal failure, atrial
fibrillation, blood transfusions in intensive care unit as well as short ventilation
time and hospital stay.
At a median follow-up of 24 months,
freedom from reoperation was 99%.
Moreover, when the RT procedure was
compared to the conventional surgery
in a propensity matched study, we demonstrated that patients undergoing
minimally invasive AVR via RT had lower
incidence of postoperative atrial fibrillation, blood transfusions in ICU, shorter
ventilation time and length of hospital stay, although cardiopulmonary bypass and cross clamp time were higher.
These results were still confirmed when
compared to the ministernotomy approach. Furthermore, the proportion of
patients discharged home was higher in
Classical AVR
Surgery, still the
gold standard
A trial show that TAVI was found to be non inferior
to aortic valve replacement for all cause mortality at
one year (24.2% versus 26.8%) in a group of elderly
high risk candidates suitable for conventional surgery. Whilst there is limited published data on TAVI
outcomes beyond one year of follow up and on the
quality of life compared with other interventions,
the early results in high-risk patients are encouraging and there is likely to be a high patient driven demand. However, there are currently no published
Geoffrey Berg West of Scotland Heart and Lung Centre,
evaluations of the cost effectiveness of TAVI. Multi
Golden Jubilee National Hospital, Glasgow, Scotland
disciplinary team meetings have stimulated interest
in high-risk aortic valve replacements with some reince the first aortic valve replacement over
50 years ago the procedure has remained the ports of excellent results in patients who are unsuitable for TAVI.
treatment of choice for patients with sympCaution has been expressed about transferring the
tomatic aortic stenosis who are thought to be fit
results of the one published randomised study to difenough to tolerate surgery. The PARTNER Cohort B
ferent patient groups and concern has been expressed
trial of medical management versus TAVI included
regarding “TAVI creep” into lower risk populations.
358 patients whom were assessed and found to
Over the past ten years hospital outcomes for convenbe unsuitable for conventional aortic valve replacetional surgery have also improved. In the United Kingment due to either a predicted high mortality or
dom in-hospital mortality rates have nearly halved
the risk of serious irreversible complications. Defrom 3.1% in 2001 to 1.7% in 2010 for first time aorspite a higher incidence of major strokes and vascular complications associated with TAVI, there was tic valve replacements. At the same time stroke rates
decreased from 2% to 1% with a mean logistic Euroa reduction in mortality from 50.7% with medical
score values increasing from 6.2 to 6.9.
treatment to 30.7%. Although experienced operConventional aortic valve replacements in octogeators working in a team in hybrid operating rooms
narians can produce survival rates the same as a norachieved these results, the implication is that TAVI
mal age-adjusted population and structural valve dewill become the gold standard of management for
terioration in the elderly is rare in long-term follow
patients who are not suitable for conventional surgery. Porcelain aortas and elderly patients with pat- up. Compared with TAVI, conventional surgery will
remain the gold standard for acute endocarditis, aorent grafts also look to benefit from TAVI compared
tic root replacement and all but high-risk aortic valve
with conventional surgery.
For patients who are deemed suitable for conven- replacements until the problems with paravalve leak,
tional aortic valve replacement, there is now a choice permanent pacemaker requirements and the stroke
rate are improved and long-term durability is known.
of intervention. The results of the PARTNER Cohort
S
References
the RT group. In conclusion, minimally
invasive AVR is associated with lower incidence of postoperative mortality, morbidities and excellent midterm survival. If
the aorta ascending aorta is rightward,
surgeons should perform RT. Sutureless bioprostheses will reduce operative
times, standardizing the approach and
high risk patients will definitively benefit
of these procedures.
1 Murtuza B, Pepper JR,
Stanbridge RD, Jones C,
Rao C, Darzi A, Athanasiou T. Minimal access
aortic valve replacement: is it worth it? Ann
2008;85:1121-31
2 Brown ML, McKellar
SH, Sundt TM, Schaff
HV. Ministernotomy
versus conventional
sternotomy for aortic
valve replacement: a
systematic review and
meta-analysis. J Thorac
Cardiovasc ular Surg
2009;137:670-9.
3 Glauber M, Miceli a,
Bevilacqua S, Farneti
PA. Minimally invasive
aortic valve replacement
via right anterior
minithoracotomy: early
outcomes and midterm
outcomes. J Thorac
Cardiovasc Surg 2011,
in press. Doi:10.1016/j.
jtcvs.2011.05.011.
4 Karimov JH,
Cerillo AG, Gasbarri T,
Solinas M, Bevilacqua
S, Glauber M. Stentless
though an upper manubrium limited V type
ministernotomy. Innovation 2010;5:378-380.
Advanced techniques in vascular surgery Auditoria 3&4 09:30
Preventing paraplegia in
thoracic endovascular aortic
repair – EUREC II
pothesis is not valid and
the mechanism of paraplegia remains unclear. As
such this report is not the
answer to all questions.
espite being a story
Furthermore, institutional
of success from
factors will always have a
the very beginnon-measurable influence
ning, thoracic endovascuon such reports.
lar aortic repair (TEVAR)
Summarizing, extenwas associated with rare,
sive coverage of interbut when present, disascostal arteries by TEVAR
trous and challenging clinalone is not associated
ical situations such as retwith symptomatic spirograde type A dissection,
nal cord ischemia as sacparaplegia and infection.
rifice of one spinal cord
As these events are fortublood supplying vascular
nately the exception and
territory is irrelevant. Sinot the rule, knowledge
multaneous closure of at
regarding these issues is
least two supplying vasmerely based on casuistics finally, identifying patterns systematic approach to
cular territories is highly
of these rare complications implement a clear and
even in large aortic centrelevant, especially in the
traceable algorithm to
ers. As a consequence, the in order to prevent them
combination with proEuropean Registry on En- in the future. As such, the understand and prevent
longed intraoperative hysymptomatic spinal cord
aim of this study was to
dovascular Aortic Repair
injury. Nevertheless, limita- potension. As such, these
identify mechanisms of
Complications (EuREC)
tions are numerous. With- results further emphasize
was founded with the aim symptomatic spinal cord
preservation of the left
out doubt, there remain
ischemia after TEVAR.
of collecting these rare
subclavian artery.
patients where our hyThis study is the first
events, merging them and
Martin Czerny Inselspital,
University Hospital Berne,
Berne, Switzerland
D
Redo operations of the aortic root
08:30-10:30 Aortic root remodelling
Room 3C
n
This course is aimed at surgeons wishing to
incorporate aortic valve and root repair into their
cardiac surgical practice.
n
Participants should expect to learn precise aortic root
anatomy and understand the pathologic processes
that are amenable to surgical repair techniques
n
The evolution of the Yacoub and David techniques that
have yielded the current state-of-the-art repairs will
be covered, and participants can expect to be able to
perform both of these techniques on completion of the
course
Co-ordinator: D. Pagano, Birmingham
Lead convenor: M. Redmond, Dublin
Faculty: M. Redmond, Dublin; H.-J. Schäfers,
Homburg/Saar; L. Nolke, Dublin; E. Lansac, Paris
08:30
08:35
08:45
09:35
10:20
10:30
Introduction
M. Redmond, Dublin
Aortic valve and root anatomy
E. Lansac, Paris
Root remodelling: Yacoub technique and results
H.-J. Schäfers, Homburg/Saar
All faculty
Root remodelling wetlab
David techniques: evolution to current status
(David 5)
M. Redmond, Dublin
Wetlab
All faculty
Discussion
All faculty
Adjourn
n
Target audience: Independent surgeons in early years
of career path
n
n
educational grant from the Sorin Group and Vascutek
the native aortic root (45mm),
moderate aortic regurgitation
with preserved left ventricular function. Pre-operative coronarography documented a
severe stenosis of the proximal
LAD. Comorbidities included
renal insufficiency and hyper69 year old man, who
underwent a supra-cor- tension.
Before skin incision and reonary ascending aorta
sternotomy, CPB was estaband partial arch replacement
lished by means of right axilwith separate re-implantation of the innominate and left lary artery and right femoral
common carotid arteries for an vein cannulation. A vent was
acute type A aortic dissection in positioned into the left ventri2005, was recently admitted to cle through the cardiac apex
our hospital for reoperative sur- by mean of a right mini-thoracotomy at the 5th intercosgery on the aortic root.
tal space. Cooling was initiated
Pre-operative angio-CT
while the innominate artery,
showed a huge pseudoaneuproximal to the origin of the
rysm (85mm) originating from
a dehiscent proximal aortic su- left carotid artery, was isolated
and passed below the clavicula.
ture line, involving the origin
At the nasopharyngeal temof the arch vessels, eroding the
sternum and extending into the perature of 25°C, CPB flow
peri-sternum subcutaneous tis- was reduced to 700ml/min, the
innominate artery was clamped
sue (Fig.1). In addition, transand, under unilateral right
oesophageal echocardiogram
revealed moderate dilatation of brain perfusion, skin incision
Marco di Eusanio Cardiac Surgery
Dept. Sant’orsola
Malpighi Hospital,
University of Bologna, Bologna; Italy
A
and re-sternotomy were performed. The pseudo-aneurysm
was entered and isolation of
the aortic graft was promptly
obtained. The clamp was removed from the innominate
artery and placed on the aortic graft proximal to the origin
of the innominate artery. Accordingly, CPB full flow was instituted and, after opening the
aortic graft, cardioplegia was
selectively administrated into
the coronary ostia.
Final aortic repair contem-
plated aortic valve replacement
with a 25mm tissue-valve, replacement of the dilated non
coronary sinus, and re-inforcement of the dehiscent proximal
aortic suture-line. A vein graft
was used to re-vascularize the
LAD, with a proximal anastomosis performed on the main
aortic graft.
The patient was uneventfully discharged nine days after surgery.
Due to the ageing population and the increased frequency of procedures on the
proximal thoracic aorta with an
expanding use of biologic con-
duits, tissue valves, and aortic valve sparing procedures, reoperative surgery on the aortic
root is expected to rise and,
eventually, to account for 10%
of all ascending aorta surgery
procedures.
This surgery represents a great
challenge for the cardiac surgeon with early mortality rates
mostly influenced by underlying
disease, surgical technique and
type of re-intervention.
Indications for re-operative
root surgery, pitfall, tricks, and
results from most recent literature will be presented and
commented.
SVC = Superior Vena Cava; * = Pseudo-aneurysm
08:30-12:30 Dry lab training
Room 1.08
Coronary artery bypass
anastomotic techniques
n
to gain “hands-on” experience of techniques and skills
involved in coronary anastomoses
Introduction to anastomotic techniques and low
fidelity simulation
Anastomoses/shunting in a horizontal plane
Anastomoses/shunting in a vertical plane
Sequential anastomoses in a vertical plane
Anastomoses/shunting in a reduced space
Target Audience: junior or senior scholars
P. Sergeant, Leuven
n
n
educational grant from Ethicon
09:30-12:30 Mitral valve replacement
Room 1.07
Programme to be announced
n
n
educational grant from St Jude Medical
Novel surgical techniques
in acute complicated type B
aortic dissection
tal access, an acute angled aortic arch
or a very close relationship of the primary entry tear to the left subclavian artery. The second option is the open opn acute comeration via a left thoracotomy in deep
plicated type
hypothermic circulatory arrest. Due to
B aortic disthe close relation to the aortic arch left
section is defined
heart bypass techniques can be applied
by the presence of
infrequently. Reported results of the
malperfusion, conconventional operation are associated
tained rupture and persistent or recurwith high mortality and morbidity.
rent pain. Treatment options include
In patients with an acute complicated
endovascular stent-grafting of the proxtype B dissection open antegrade enimal descending aorta with the goal
dovascular treatment using the E-vitato close the primary entry tear into the
false lumen. Decompression of the true open stent graft prosthesis (Jotec, Gerlumen followed by improved distal per- many) exhibit a novel surgical strategy for
this indication. In the period of moderfusion and stabilization of the aortic
ate hypothermic circulatory arrest and anwall are achieved by this interventional
technique. In some patients stent graft- tegrade bilateral cerebral perfusion the
ing is not possible due to the lack of dis- stent graft is placed in the true lumen of
Martin Grabenwöger Vienna, Austria
A
the proximal descending aorta closing
the primary entry tear. Positioning of the
stent-graft in the true lumen can be controlled by an angioscope. A running suture line at the offspring of the left subclavian artery guarantees closure of the
primary entry tear. Furthermore, treatment
of the ascending aorta and aortic arch
can be performed in this one-stage procedure. Complications of the retrograde
approach, such as retrograde type A aortic dissection, distal vascular complications
and incomplete closure of the primary en-
try tear can be avoided by this technique.
Endovascular stent graft placement in
patients with acute complicated type B
aortic dissection still represents the first
line therapy. However, in patients with a
significant retrograde component of the
dissection into the aortic arch, a dilated
ascending aorta or aortic arch, an acute
angled aortic arch or the absence of an
adequate distal access, the frozen elephant trunk procedure offers a valid and
promising alternative in the treatment
of this serious aortic disease.
09:00-12:35 Learning from experience
Room 5A
Challenging issues in general thoracic surgery
n
to gain insight into a variety of unusual surgical
challenges in thoracic surgery
Moderators: P. Dartevelle, Le Plessis-Robinson; P. Sardari Nia, Nieuwegein; A. Maat, Rotterdam; M. Dusmet, London
09:00
Film: Video-assisted thoracoscopic removal of
hydatid cysts
L. Alpay, T. Lacin, C. Atinkaya,
H. Kiral, M. Demir, V. Baysungur, E. Okur, I (Turkey)
09:15 Keynote lecture
09:35
09:50
10:05
10:20
Challenging issues with regard to oesophageal
fistulas
D. Mathisen, Boston
Surgical treatment of oesophago-tracheal fistula
caused by oesophageal foreign body
T. Moroga, S. Yamamoto, S. Takeno, S. Yamashita, K. Kawahara (Japan)
Iatrogenic oesophageal rupture due to anterior
cervical spine surgery
K. Athanassiadi, M. Fratzoglou, E. Chatzidakis, S. K.
Pispirigkou, E. Papadopoulos, M. Gerazounis (Greece)
Asymptomatic trachea-oesophageal fistula
coincidental with tracheal stenosis
H. R. Davari (Iran)
Film: Thoracoscopic bi-segmentectomy with
vessel sealing system A. Watanabe, J. Nakazawa,
M. Uehara, M. Miyajima, S. Nakashima, Y. Kurimoto, N. Kawaharada, T. Higami (Japan)
Introduction to the European
Registry of Aortic Disease (EuRADa)
Ernst Weigang University
Medical Center
Mainz, Mainz,
Germany
M
ost aortic diseases are lifethreatening,
requiring surgical, interventional or medical therapies. Most of the information on the management
and treatment of these patients reflects retrospective
single-centre experience.
Many questions are unanswered regarding what
constitutes the best treatment, and controversy remains about what the best
acute medical care, including diagnostics, peri-operative management and optimal surgical technique,
interventional or medical
treatment and long-term
therapy are. The main
goal of clinicians is to reduce the morbidity and
mortality rate of these diseases.
Current studies do not
adequately define the best
treatment options for aortic diseases. The decision
as to which treatment is
best is highly individual
and depends on the underlying aortic pathology,
extent of aortic disease,
and each patient’s anatomy and co-morbidities.
Further studies are necessary to ensure that individual decisions regarding
the best medical care are
based on a high level of
evidence.
The aim of the European
Registry of Aortic Disease
(EuRADa) is, by collecting
standardised data on patients with aortic diseases,
to enhance our knowledge about these diseases via intensive data
analysis. With this knowledge we hope to improve treatment in the
future and identify key
parameters affecting patient survival rates. EuRADa
(Figure 1) is designed to
collect specific information
about patient clinical status, diagnostics, treatment
options, complications,
cause of death, and follow-up data. The mid- and
long-term aim of EuRADa
is to continuously improve
therapy by analysing and
interpreting these data.
The key aspect is the database itself for collecting
anonymous patient data.
EuRADa collects param-
Figure 1
eters addressing all aortic
diseases and all potential
treatment options (conservative/pharmaceutical, interventional/endovascular,
and open surgical). Each
set of data is closed by the
user when all the data have
been included and the data
has been validated. Those
data can no longer be
changed and are then included in the analysis. Thus
incomplete data sets cannot be subject to analy-
sis. Follow-up data, which
must also be validated, can
be included at regular intervals. Postoperative followup data will be collected at
30 days, six months, one
year and then once annually for up to 10 years.
EuRADa is a long-term
project. After a test phase
of EuRADa, the centres will be connected to
the registry step by step.
Achieving a high level of
evidence in the treatment
of patients with aortic disease is this register’s primary goal. To
successfully translate
into action the evidencebased knowledge gained
through EuRADa, it is important that as many European centres and other
medical societies treating aortic diseases as possible participate in this
ambitious project. Other
medical societies, centres
or institutes and potential sponsors who are interested in participating in
or supporting this registry
should contact us at the email address below.
EuRADa is being developed under the leadership
of Prof. Dr. Ernst Weigang
(Department for Cardiothoracic and Vascular Surgery of the University Medical Center, Mainz), and is
supported by the Vascular
Domain of the EACTS and
the EACTS Council.
EUROMACS Registry to collect mechanical circulatory support data
E
UROMACS is delighted to announce that the
organisation will soon launch the EUROMACS
Registry, a web-based registry that will collect procedural and outcomes data for patients receiving mechanical circulatory support (MCS). The
EUROMACS association was founded in December
2009, on the initiative of the two European hospitals with the largest clinical programmes in the field
of MCS (Deutsches Herzzentrum Berlin and the Herzund Diabeteszentrum NRW Bad Oeynhausen). Since
then, the Association has grown from the original 14
founding members to 52 (as of 2011). The Association was established to create a European registry for
data collection from patients with MCS systems.
rofessor Jan Gummert (Herz- und Diabeteszentrum NRW Bad Oeynhausen), explained that
although there is a MCS database in the US
called INTERMACS (a national registry for patients
who are receiving MSC device therapy to treat ad-
vanced heart failure), this registry only collects data
on FDA-approved devices and therefore many devices used in Europe are not eligible for inclusion in
the INTERMACS database. He added that there are
also issues regarding patient consent and data ownership to establish a truly ‘international’ database.
“As a result, Professor Roland Hetzer and I felt it
was necessary to form a European Registry on the basis that most of the leading centres in Europe agree
to share their data. Our goal is to get the data from
each centre directly, as it is very difficult to collect the
data on a national (by country) basis,” said Gummert.
The aim is to get a picture of how MCS is performed in Europe. The data collected by the registry will record how many procedures are being performed and what the outcomes are. Currently, there
is no information about MCS systems in Europe, although there is some single centre experience, there
is no database recording multi-centre information on
MCS systems.
“We know for sure that there are approximately
800 MSC procedures in Germany per annum, but we
do not know the figure for the whole of Europe. The
registry will also collect data on devices so we can
P
Web-based clinical software solutions
for the international healthcare sector
John Gummert
see the number of individual devices used, the outcomes and complication rates,” he added. “In Europe, there are probably ten or more devices with
the CE Mark, compared to only a handful that are
FDA-approved in the US. So hopefully, we will be
able to collect a lot of data on many devices.”
Registration
Hospital and database installations
Our innovative system has become the preferred clinical governance tool at over 250 major
hospitals throughout the world.
National and international databases and registries
Our registries are empowering professional societies, hospitals, clinical departments and
clinicians with their own data, allowing them to make informed decisions leading to improved
outcomes for patients.
reveal • interpret • improve
To learn m
ore
our produc about
ts and
services, a
nd to be giv
en
a demonstr
a
software p tion of our
lease visit
Dendrite a
t
Stand 1.01
Station Road - Henley-on-Thames - RG9 1AY - United Kingdom
Phone: +44 1491 411 288 - e-mail: [email protected] - www.e-dendrite.com
To record your data onto the registry, centres must
become a member of EUROMACS and enter into a
contract with the Association. This is to ensure that
each party knows their responsibilities and obligations, and centres are obliged to enter complete patient data, which will allow EUROMACS to produce a comprehensive report in the next few years.
The web-based registry (powered by Dendrite Clinical Systems) will be ready to begin collecting data in
October this year. The aim is to have an annual outcomes report, once the registry has collected a sufficient number of records and has complete datasets.
The reports will be made freely available to all members who contribute data.
“At the moment we have received very encouraging responses from European countries and we
would like to expand the registry beyond Europe.
Already, we have had enquiries from Turkey and Israel. So we would welcome registrants from beyond
Europe.
All EUROMACS members will be provided with
a unique password to access and enter information
into this intuitive, web-based database. The database is designed to allow each member immediate
access to data that they have entered, and to obtain specific reports in real time (e.g. demographics and outcomes) for their own records and practices. Each member will be able to download their
data and obtain reminders for pending follow-ups
of their patients.
The Registry can be accessed using a standards
web browser, allowing registrants to enter data
without the need to install additional software or
perform any complex system configurations. This
web-based system allows the individual clinician to
enter patient information onto a database whether
at in hospital from an office-based practice or even
at home.
“As an organisation, EUROMACS is proud to
have accomplished so much in very little time. We
believe that the EUROMACS Registry will be a very
important database for MCS, as we hope it will facilitate improved decision-making for physicians and
healthcare providers by providing much needed clinical data. It is important that we establish the EUROMAC registry to determine current practice and
to guide future practice.”
The EuroMACS Registry is funded with the generous support of educational research grants from
industry.
If you or a colleague are interested
in registering your interest please
visit: www.euromacs.org
or email: [email protected]
or phone: +49 (0) 30-45 93 2000
Advanced techniques in congenital surgery Room 5B 08:30
10:35 Coffee
11:00 Film: Resection of a mediastinal paraganglioma
with cardiopulmonary bypass
T. Hoppert, I. Aleksic, R. G. Leyh (Germany)
Intracorporeal mechanical
circulatory support for children
11:15 Keynote lecture
11:35
11:50
12:05
12:20
12:35
Extensive resection of thoracic tumours with
cardiopulmonary bypass
P. Dartevelle, Le Plessis-Robinson
Pulmonary artery obstruction due to recurrent
extranodal Rosai-Dorfman disease
A. S. Jassar, N. D. Desai, W. G. Moser, W. Y. Szeto, J. Bavaria (United States)
Surgical resection of an advanced right upper
lobe adenocarcinoma invading the heart and
partially occluding the mitral valve
M. A. Jadoon, A. Ahmad, P. Sidhu (United Kingdom)
Progressive bilateral pleural fibrosis: suffocating
benign
A. Maat, M. Schnater, D. Cheung,
I. Hartmann, M. Den Bakker, A. Bogers (Netherlands)
Pleuro-pulmonary complications in a patient
affected by rheumathoid arthritis: a real challenge
for the thoracic surgeon
S. Sanna, D. Argnani,
M. Monteverde, M. Mengozzi, M. Taurchini, D. Dell’Amore (Italy)
Adjourn
08:30 Advanced techniques in
congenital surgery
Room 5B
Extracorporeal life-support workshop
Organiser: E. Da Cruz, Denver
Ventricular assist devices for neonates, infants,
children and grown-ups with congenital heart
disease. An interactive demonstration
n
to update knowledge and information and gain
hands-on exposure to currently used ventricular assist
devices in congenital and paediatric cardiac patients
Moderator: E. Da Cruz, Denver
Lectures:Theoretical background
08:30
Indications and contraindications for VADs
D. L. S. Morales, Houston
08:50 Review of centrifugal and roller pump
technologies
C. Haun, St. Augustin
09:10 Developing ventricular assist devices
P. Wearden, Pittsburgh
09:30 Hands-on practice and troubleshooting
There will be five stations with different devices.
The attendees will be in five groups which will
rotate for a total of 30 minutes per station. Each
station will offer a short lecture (five minutes)
about the device, followed by 25 minutes practice.
Station 1Levitronix
R. Firmin, Leicester
Station 2Berlin Heart
R. Henaine, Lyon
Station 3Medtronic M. Van Driel;
C. Matheve Bio-Console and Spectrum Medical
patient monitoring system
Station 4Thoratec
D. L. S. Morales
Station 5Jarvik
S. McConchie
12:30 Wrap-up and evaluation
Attendance at this workshop is restricted to 10 persons per station:
pre-registration is required on site
This workshop is supported by unrestricted educational grants from
Berlin Heart, Jarvik, Levitronix, Medtronic and Thoratec
09:30 Advanced techniques in
vascular surgery
Auditorium 3+4
Novel strategies for the treatment of the thoracic aorta
n
to update knowledge of techniques for investigation
and management of thoracic aortic disease and its
complications
Moderators: J. Bachet, Abu Dhabi; C. Mestres, Barcelona
09:30
Functional imaging of the aorta
M. Czerny, Berne; E. Weigang, Mainz
09:50 Redo operations on the aortic root
M. Di Eusanio, Bologna
10:10 One, two or three vessel perfusion during
selective antegrade cerebral perfusion
J. Bachet, Abu Dhabi
10:30 Coffee
11:00
11:20
11:40
12:00
12:30
Novel surgical techniques in acute complicated
type B aortic dissection M. Grabenwöger, Vienna
Preventing paraplegia in thoracic endovascular
aortic repair – EUREC II
M. Czerny, Berne
Thoracic endovascular aortic repair in
thoracoabdominal aneurysm – Risk of endoleaks
M. Funovics, Vienna
Introduction to EURADA
E. Weigang, Mainz
Adjourn
Iki Adachi1, Jordan Merecka2, David L.S.
Morales3 and Andres X. Samayoa4 1
Pediatric Cardiovascular Surgery Instructor*.
2 First pediatric patient transplanted with
the SynCardia Total Artificial Heart(TAH) in a
pediatric hospital in the United States. 3 Associate Professor, Congenital Heart Surgery,
Transplant Surgeon (TAH)* 4 Research
Associate*
Ventricular Assist Device (VAD)
We most often use the HeartMate II®
LVAD for patients with a body surface
area (BSA) ≥ 1.3 m2. Besides its use for
bridge-to-transplantation for those with
cardiomyopathy, we successfully supported an adolescent as an out patient
with failing Fontan physiology primarily due to systemic ventricular failure
(JTCVS 2011). We termed this usage as
* Michael E. DeBakey Department of Surgery, Division “systemic VAD (SVAD)”. We also experiof Congenital Heart Surgery, Baylor College of
Medicine, Houston, TX
enced a successful application of this device for bridge-to-recovery, which is the
he number of children with heart only reported application for this purpose in a pediatric program. Our indicafailure has been increasing extion for an intracorporeal VAD has been
ponentially. Recently we reported the number of children hospi- further expanded with the emergence of
talized for heart failure in the U.S. has the HeartWare® VAD, that we have used
increased by 25% between 2003 and and hope will allow us to support chil2006. This big wave of pediatric heart dren with a BSA as small as 1.0m2.
failure patients cannot be fully addressed by heart transplantation only
Total Artificial Heart (TAH)
because of the invariable limitation
We consider the SynCardia TAH for
in donor organ supply. Indeed, the
some specific conditions where a VAD
number of pediatric heart transplants is not an ideal solution. These include
worldwide has remained stagnant for chronic transplant graft failure and late
the last 10 years.
sequel of previous complex congenital
Unlike adult patients, where durable heart surgery. A total replacement of an
intracorporeal devices for mechanical
implanted graft eliminates the need of
circulatory support (MCS) are available, immunosuppression, which has a great
extracorporeal membrane oxygenation advantage over VAD support. A VAD
has been the most common form of
implantation late after congenital heart
MCS for the pediatric population. With surgery often requires multiple, concomthe improvement in technology and
itant procedures depending on the anatthe maturation of pediatric heart failomy and previous surgeries. We have reure programs, however, relatively older placed valves, closed ventricular septal
children can benefit from adult-size in- defects and repaired pseudoaneurysms
tracorporeal devices.
in individual patients and then placed
T
Left to right: Iki Adachi, Jordan Merecka, David Morales and Andres Samayoa at
Texas Children’s Hospital
a VAD. These additional procedures require prolonged pump-run and crossclamp time and certainly affect an inherently dysfunctional right ventricle. This
may result in the need for biventricular VAD support, which is proven to be
suboptimal by several studies. In this circumstance, a TAH provides a much simpler solution. Our recent experience of
TAH in an adolescent with congenitally
corrected transposition of great arteries
has reinforced this belief. If supported
with a VAD, we would have had to perform multiple additional procedures for
his severe aortic insufficiency and obstruction of his conduit between the
morphologically left ventricle and the
pulmonary artery through a 5th median
sternotomy. He tolerated the implantation of a TAH well despite some technical challenges and modifications necessary for his unusual relationship of great
arteries. He has done well since the TAH
placement and currently at home in the
Freedom® Driver awaiting for a suitable
donor heart to become available.
Even though still an infrequent therapy
for most pediatric programs, the field of
pediatric MCS has begun and is growing
rapidly owing to the significantly increasing number of children with heart failure.
An increasing demand for pediatric MCS
will certainly make congenital heart surgeons consider initiating their own MCS
programs with multiple devices. Also, acquired heart surgeons will not be free
from this phenomenon as they may have
more referral of adults with congenital
heart disease for consideration of MCS
support. In either scenario, a thorough
understanding of the unique pathology,
physiology and clinical features of pediatric heart failure is an absolute key to
success.
Berlin heart pediatric assistance
device: The beginnings, the
teachings and the cruising speed
- A monocentric experience with
the same system
Roland Henaine, Jean
Ninet Department of Cardiothoracic Surgery, Hôpital Louis
Pradel, Centre HospitaloUniversitaire Lyon, France
H
eart failure is a reality in children. In
a 2003 study of
children less than 16 years
old in all pediatric cardiac
centers in the United Kingdom and Ireland, incidence
of new onset heart failure was 0.87 per 100,000,
with the highest incidence
occurring in the first year
of life. In European tertiary care facilities , children
with heart failure represented 10% to 33% of all
cardiac admissions.
Cardiac transplantation
has been the most effective long-term therapy for
children with intractable
heart failure. However, it
is not unusual for a child
listed as a status 1A heart
transplant candidate to
wait several months before an organ becomes
available. The imbalance
between donor heart
availability and number of
pediatric recipients may
result in some children dying while on in the emergency wait list for cardiac
transplantation.
Options for mechanical
circulatory support (MCS)
in children include extracorporeal membrane oxygenation (ECMO), centrifugal pumps, and,
more recently, pulsatile ventricular assist devices (VAD). In the scenario of extended waiting
list, a long-term support,
such as the Berlin Heart
(BH) VAD, seems a better choice than extracorporeal membrane oxygenation and since 1999
and the pioneering work
of Hetzer and colleagues,
this option provides reliable and satisfactory outcomes .
All mechanical circulatory assist systems are
associated with a wide
range of possible complications, of which bleeding and thromboembolic
complications are the
most frequent and most
serious. Infections, hemolysis have also been reported. Learning curve
of this technique can affect initial results. Organizing a MCS program requires a multidisciplinary
involvement to minimize
this effect.
To date the largest
French experience is being
conducted in Lyon. The
Program for long-term
VAD support in the pediatric population was initiated in 2005 at the University of Lyon Medical
Center (France).
The aims of this study
are to: 1) report the largest monocentric French
experience with VAD in
children, 2) assess short
and mid-term outcomes
after VAD implantation,
and 3) report challenges
(mainly anticoagulation,
infection, organ shortage) faced at initiation of a
MCS program.
Eighteen patients (8 females, 10 males) underwent VAD implantation
from April 2005 to April
2011. Median age at surgery was 1.83 (3 months
to 13 years). Median
weight at onset of VAD
was 10.5 kg (4.5 to 34).
Five patients underwent
left-VAD support, 13 required bi-VAD support.
Throughout presentation of our six year experience with VAD support,
we report evolution of our
practice in establishing a
MCS program. Learning
Dr R.Henaine (in blue) , Pr. J.Ninet (in white) and Titouan having a left
ventricular assistance Berlin Heart device.
curve revealed key points
in perioperative management of the supported
child. Using multidisciplinary approach, three levels have been identified:
optimization of indication and timing; choice
of mechanical circulatory support type (preceding ECMO or VAD) and
its good technical execution and finally, ICU close
monitoring and management (anticoagulation,
external ventricles for
thrombo-embolic prophylaxis, long term central
venous catheter).
After the first four years
long acquisition of experience, the use of the Berlin Heart EXCOR VAD in
children as bridge to heart
Figure: Outcome after Mechanical Circulatory
Support
transplantation or myocardial recovery is now considered, in our institution,
as reliable and safe.
NB: An interactive
demonstration will
be presented by Dr
R.HENAINE on Wednesday October 5th, 2011
within the workshop
EACTS Advanced Techniques: Extracorporeal life-support with the
Berlin Heart System.
The role of the Ross operation on the surgical menu Room 3A 09:00
Optimized decision making for
prosthetic AV selection
criticize its complexity (“treat single valve
disease with double prosthetic valve disease”), high operative mortality risk, and
limited durability. During the session the indications, contraindications and results of
the Ross procedure will be addressed, and
n Wednesday morning October
the same will be done for three other op5 the Advanced Techniques session on the role of the Ross proce- tions that are available on the surgical
dure on the surgical menu will address the menu, namely: aortic valve repair, stentless
bioprosthetic valve replacement, and reavailable options for young adult patients
who require surgical treatment of their aor- placement with a mechanical prosthesis.
Aortic valve repair used to be a surgical
tic valve disease, and discuss how an opoption open to very few patients. However,
timal choice can be made for the individthere is a growing movement of young exual patient.
cellent and creative surgeons who are testFocus will be on the Ross procedure, a
ing these boundaries. Preservation of the
controversial operation as is evidenced by
the lively discussions in the literature in the patient’s valve removes the need for anticopast few years. Some claim it to be the best agulation, but may not be a durable solusolution in particular in children and young tion. Stentless bioprosthetic aortic valve readults with a hemodynamically superior liv- placement is another alternative for adult
patients who wish to avoid anticoagulation,
ing valve substitute, excellent late survival,
although at the cost of a limited durability.
and no need for anticoagulation. Others
Johanna JM Takkenberg Epidemiologist,
Department of Cardio-Thoracic Surgery, Erasmus
University Medical Center, Rotterdam, The
Netherlands
O
There is relatively little evidence of the performance of these valves in younger adults.
Finally, mechanical aortic valve replacement
provides the patient with a valve that is designed to last a lifetime but requires lifelong
anticoagulation. In recent years the burden
of anticoagulation has been addressed by
the introduction of self-management of anticoagulation (and even telemedicine), and
there are new promising thrombin inhibitors on the horizon.
A balanced choice between all these surgical options is usually made by weighing
the technical pros and cons of the surgical
options in relation to the patient’s clinical
profile. Besides that, there is a need to take
into account the desire of the informed patient, as is stated in the ESC Guidelines.
This proves to be a difficult task, since not
only does the physician need to translate
the general knowledge on valve performance to the specific clinical patient profile, it
Johanna JM Takkenberg
is also necessary that the patient is well in- highlighted and suggestions for addressing
them will be made.
formed and that patient’s preferences are
elicited. During the session all three aspects of the decision making process will be
The role of the Ross operation on the surgical menu Room 3A 09:00
Training requirements for the Ross procedure:
The mentored simulation imperative
The obvious weakness in this
model is the inability to engage
in deliberate repetitive practice of the numerous technical steps required in more complex procedures such as mitral
he performance of cardiac surgery requires the valve repair and the Ross procedure. Learning the Ross procedevelopment of psychodure within the old apprenticemotor skill-sets. The Ross procedure requires some skill-sets ship model was very difficult
unless the ideal clinical condicommon to other operations
and some that are unique. Pro- tions were met: the master surficiency with these brain/mus- geon was a true mentor with a
large case-load and the mentee
cle interactions in surgery is
had protected time for concenacquired in the same way extrated involvement with every
pertise is achieved in speech,
bicycle riding, athletics and the case. Even then, it was difficult to achieve timely mastery
performing arts. The two esof the procedure, sometimes
sential ingredients for the deresulting in dangerous early
velopment of all psychomotor skill-sets are mentoring and learning curves after completion of the mentoring period.
practice.
For many decades, the aviIn the previous generation,
ation industry has trained airwhen there was less to learn
and more time to learn it, pro- plane pilots on simulators, long
ficiency in cardiac surgery was before they actually fly a plane
usually achievable within a clas- with passengers. It is now apsical apprenticeship model, par- parent that simulators can offset the disadvantages and comticularly with simpler operapliment the advantages of the
tions requiring fewer steps.
William F Northrup III Cardiovascular, Thoracic Surgeon, Vice
President, Physician Relations and
Education, CryoLife
T
operating room as the sole forum for acquiring surgical skillset mastery. Because of the
opportunity for deliberate repetitive practice, mistakes and
early learning curves can now
happen risk-free in a simulation lab instead of the operating room. This narrowed focus on the specific component
steps of any cardiac surgical
procedure should result in an
accelerated (and safe) learning
curve with a much shorter path
to mastery.
The need to learn all the
steps of the Ross procedure
exclusively on a living human
heart can be supplemented
with an inexpensive pig heart—
a true high-fidelity biological
“simulator” in three-dimensions with normal tissue feel
and tactile feedback. All the
technical steps of the operation
can be carefully reproduced:
the pulmonary autograft harvest, coronary button development, autograft implant, coronary artery reimplantation and
pulmonary homograft replacement. Immediate feedback of
the quality of all suture-lines
and both valves is then possible
with a simple autopsy of the
pig heart at the end of each
procedure.
Mastery of any psychomotor skill-set has always required
deliberate repetitive practice
and deliberate repetitive mentoring. In some respects the
apprenticeship model hasn’t
really changed. Mentored simulation on pig hearts is now
the equivalent of multiple
sketches on paper by the Renaissance artist and the operation on the patient’s living
heart in the operating room
becomes the equivalent of the
final painted canvas. The use
of high-fidelity biological “simulators” under the nurturing
eye of a master surgeon/mentor should much more rapidly
and thoroughly facilitate the
availability of more master surgeons proficient in the Ross
procedure.
Aortic valve repair – State of the art
bleeding complications essentially absent.
Ongoing research has also identified remaining
problems as well as criteria for better patient selection. Dilatation of the aortoventricular junction has rethology. It was found that the combined application
of root and cusp repair expanded the applicability and cently been identified as an important pathogenetic
risk factor in recurrent aortic regurgitation. Currently
improved the durability of aortic valve repair procedures. It is now understood that root and cusp defor- several concepts are studied that attempt to eliminate
this problem on a routine basis. The treatment of cusp
mation frequently coexist.
restriction, e.g. as a consequence of rheumatic heart
Valve-preserving root replacement has by now bedisease, or cusp calcification currently remain uncome routine both for tricuspid and bicuspid aortic
valves. Reproducible cusp repair techniques already ex- solved challenges. Many patients with these pathologies at this time are better treated by replacement
ist that allow the correction of prolapse due to cusp
rather than repair.
stretching or the presence of fenestrations. Strategies
Aortic valve repair is possible in the majority of
have been developed for clinical application in unicuspid and quadricuspid aortic valves. In the experience of patients with aortic regurgitation. Since the incithe Department of Cardiovascular Surgery in Homburg/ dence of valve-related complications is lower than
Saar which constitutes the largest European series with what has been reported for aortic valve replacement, aortic repair procedures are becoming a true
more than 1,400 aortic repair procedures, a low risk
of valve-related complications could be confirmed. En- and increasingly attractive alternative to convendocarditis and thromboembolic complications are rare, tional treatment strategies.
valve was achieved.
Hans-Joachim Schäfers Department of Thoracic and CarIn the past 15 years techniques have been develdiovascular Surgery, University Hospital of Saarland, Homburg/
oped for correction of congenital or acquired cusp paSaar, Germany
B
ackground: Aortic valve replacement is a standardized treatment of aortic regurgitation, but
continues to be associated with a relevant risk
of prosthesis-related complications. In the treatment
of mitral valve disease repair has become the preferred
treatment due to superior survival and fewer valve-related complications.
In the past 20 years efforts have been made to develop and establish reconstructive approaches also for
the regurgitant aortic valve with the intention to minimize the long-term complications.
Initially the concept of aortic valve repair was introduced as valve-preserving aortic replacement for aortic aneurysm without concomitant cusp deformation.
In several large series excellent clinical results could
be demonstrated if normal configuration of the aortic
Pulmonary autograft“Simulated” harvest in pig heart
EACTS Membership Applications for 2011
We are pleased to confirm that we have received 289 complete EACTS membership applications for 2011.
These applications were formally accepted by the General Assembly on Monday 3 October.
The EACTS is happy to receive new EACTS Membership Applications for the year 2012. Please, spread the word amongst
your colleagues. EACTS Membership provides access to a network of knowledge and the opportunity to develop your
own expertise and share this with fellow professionals – www.eacts.org/content/membership-application
Osamah Ahmed Abdulqader Abdullah Yemen
Marcus Abreu Brazil
Zargham Hossein Ahmadi Iran
Toshiaki Akita Japan
Fadhil Alamran Iraq
Ibrahim Halil Algin Turkey
Levent Alpay Turkey
Hassan Alsisi Egypt
Sergey Alsov Russian Federation
Gokalp Altun Turkey
Dario Andrade Colombia
Hendrik Jan Ankersmit Austria
Omid Assar Iran
Alessandro Barbone Italy
Aureliu Batrinac Moldova
Vladlen Bazylev Russian Federation
Usman Shehu Bello Nigeria
Alessandro Bertani Italy
Stefano Bevilacqua Italy
Akhlaque Bhat Qatar
Christopher Blauth UK
Frank Boos Germany
Johan Brink South Africa
Keith Buchan UK
Domenico Calcaterra USA
Aldo Cannata Italy
Giuseppe Capotorto Italy
Giuseppe Cardillo Italy
Manuel Castella Spain
Pisanuwach Chareonpacharaporn Thailand
Serafeim Chlapoutakis Greece
Se Hoon Choi Korea (South)
Ian Colquhoun UK
Cesar Conforti Brazil
Donald Cristell Italy
Edgar Daeter Netherlands
Per Erling Dahl Norway
Arijit Datta India
Hamid Reza Davari Iran
Ryan Davies USA
Andrea Anneliese Reichmuth Day Brazil
Antonio De Bellis Italy
Patricio Delgado Chile
Martin Devoto Argentina
Marco Di Eusano Italy
Marco Diena Italy
Vincent Doisy France
Polyvios Drosos Greece
Peter Julius Ekmedzic Germany
Hossam El Shahawy Egypt
Jamil Esfahani Zadeh Iran
Mario Fabbrocini Italy
Miklos Fabri Serbia
Martin Farrando Argentina
Leonardo Flausino Brazil
Godehard Friedel Germany
Arul Furtado India
Mohammad Ghafarinejad Iran
Mohammad Ghazinour Iran
Maziar Gholampour Dehaki Iran
Jose Luis Godia Argentina
Mikhail Gordeev Russian Federation
Franc Gregorcic Slovenia
Martin Haensig Germany
Abd Elrahman Hammad audi Arabia
Ashutosh Hardikar Australia
Joost Hartman Netherlands
Ahmed Hassouna Egypt
Mohamed Helmy Egypt
Hossein Hossein Nejad Iran
Po-yuan Hu Taiwan
Nenad Ilic Croatia
Vlad Anton Iliescu Romania
Hikaru Ishii Japan
Hussan Jabbad Saudi Arabia
Povilas Jakuska Lithuania
Juan Jaramillo Colombia
Fuad Jindan Qatar
Naser Kachoueian Javadi Iran
David Kalfa France
Pei-leun Kang Taiwan
Saziye Karaca Switzerland
Imre Kassai Hungary
Nabil Kharma United Arab Emirates
Boonton Khorprasert Thailand
Joon Bum Kim Korea (South)
Dong Kwan Kim Korea (South)
Matthias Kirsch France
Kazuya Kobayashi Japan
Vadim Kotowicz Argentina
Hiroshi Kubota Japan
Tk Susheel Kumar USA
Henry Kuper Netherlands
Vladimir Kuzmichev Russian Federation
Tunc Lacin Turkey
Mauro Lamarra Italy
Michael Lass Germany
Katrin Leadley Germany
Hyun-sung Lee Korea (South)
Luiz Lisboa Brazil
Zhongmin Liu China
Attilio Lotto UK
Hekmat Manoochehr Iran
Rita Daniela Marasco Italy
Luis Carlos Maroto Spain
Graham McCrystal New Zealand
Milan Mijovic Montenegro
Vladimir Mironenko Russian Federation
Bekkouche Mohamed Oman
Hossein Montazerghaem Iran
Behrooz Mottahedi Iran
Mohammad Hassan Nezafati Iran
Ayman Nosair Egypt
Satoshi Numata Japan
Shinichiro Oda Japan
Takanori Oka Japan
Humberto Oliveira Brazil
John Were Onundu Germany
Aree Othman Iraq
Babu Packirisamy India
Domenico Paparella Italy
Francesco Parisi Italy
Hyung Joo Park Korea (South)
Pyo Won Park Korea (South)
Jashvant Patel India
Kiew-kong Pau Malaysia
Vereshchagin Pavel Russian Federation
Charles Peniston Canada
Juan Ignacio Perez Moreiras Lopez Spain
Ramon Perez-Caballero Martinez Spain
Fausto Pina Brazil
Pavan Kumar Pipada India
Vitoon Pitiguagool Thailand
Nancy Poirier Canada
Vadim Popov Russian Federation
Jagdish Prasad India
Nenad Protrka Croatia
Roman Przybylski Poland
Igor Pyaterichenko Russian Federation
Saji Radhakrishnan Nair India
Ahmad Rajaii-khorasani Iran
Jai Raman USA
Darius Rassoulian Germany
Peter Raudkivi New Zealand
Karl Reyes Philippines
Anilton Rodrigues Junior Brazil
Felice Rosapepe Italy
Alireza Rostami Iran
Roger Rutsaert Belgium
Mahmood Saeidi Iran
Gholam Reza Safar Poor Iran
Marat Sagirov Russian Federation
Aya Saito Japan
Genichi Sakaguchi Japan
Schahriar Salehi-gilani Germany
Kunal Sarkar India
Fabrizio Sbraga Spain
Wolfgang Schiller Germany
Egil Seem Norway
Enrique Seguel Chile
Francesco Sellitri Italy
Masih Shafa Iran
Ashok Sharma Oman
Hesham Shawky Egypt
Takeshi Shimamoto Japan
Hideto Shimpo Japan
Mahesh Singh India
Franjo Siric Croatia
Teerasak Srichalerm Thailand
Ivan Stojanovic Serbia
Robert Stuklis Australia
Sandor Szabados Hungary
Sandeep Tadas India
Shuichiro Takanashi Japan
Hiroshi Tanaka Japan
Marco Taurchini Italy
Tomasz Timek USA
Francesco Tizzano France
Borys Todurov Ukraine
Bjarni Torfason Iceland
Alexander Troitskiy Russian Federation
Willem Van Boven Netherlands
Paolo Vanelli Italy
Dmitry Vetchinkin Russian Federation
Robert Von Wattenwyl Germany
Vaidas Vysockas Lithuania
Shoei-shen Wang Taiwan
Alberto Weber Switzerland
Guo Xing Weng China
Hermann Wiedensohler Germany
Resit Yaman Turkey
Kazuo Yamanaka Japan
Erdal Yekeler Turkey
NEW TRAINEE MEMBERS LIST 2011 Henrik Aamodt Norway
Udo Abah UK
Hassane Abdallah France
Hamdi Abu Ali USA
Amjed Ahmed Iraq
Alassal Ahmed Alkodami Saudi Arabia
Saleh Alshehri France
Oezge Altas Turkey
Jaime Arroyo Spain
Athanasios Athanasiou Greece
Christopher Austin UK
Anil Bhattarai Italy
Rody Boon Netherlands
Abdelghani Bouhiouf Germany
Lucio Careddu Italy
Nicola Cassanelli Italy
Ali Cej Germany
Songhe Chen Germany
Thabbta De O Nassif S Vianna Brazil
Maximilian Emmert Switzerland
Diana Fajardo Colombia
Fernando Figueira Brazil
Petr Fila Czech Republic
Elizabeth Fonseca Escalante Germany
Vugar Gapagov Azerbaijan
Marco Gennari Italy
Robert George UK
Radu Gheta UK
Daniyar Gilmanov Italy
Christoph Haller Germany
Ilias Iakovakis Greece
Michaela Innerhuber Austria
Reubendra Jeganathan UK
Feras Kabbesh Germany
Meletios Kanakis Greece
Carlos Karigyo Brazil
Samuil Kazakov Bulgaria
Assen Keltchev Bulgaria
Hazem Khairat UK
Feras Khaliel Canada
Espeed Khoshbin UK
Janusz Konstanty Kalandyk Poland
Ruslan Lazarev Russian Federation
Markus Liebrich Germany
Geicu Lucian Romania
Maximilian Luehr Germany
Yuri Malinovsky Russian Federation
Rebeca Manrique Spain
Jakub Marczak Poland
Thomas Martens Belgium
Van Steenberghe Mathieu Switzerland
Kavitha Mattam UK
Pavlo Melnychenko Ukraine
Victor Mendes Germany
Miraziz Mirsaidov Uzbekistan
Ishaq Muhammad Belgium
Masakazu Nakao Singapore
Mate Petricevic Croatia
Till Ploenes Germany
Tomasz Plonek Poland
Muhammad Umar Rafiq UK
Antonios Roussakis Greece
Igor Rychlik UK
Hester Schenk Netherlands
David Schibilsky Germany
Stefan Rudolf Bertram Schneider Germany
Sebastian - Patrick Sommer Germany
Thamar Stollman Netherlands
Thomas J. Van Brakel Netherlands
Abraham Van Wijk Netherlands
Sona Vanekova Czech Republic
Dominik Wiedemann Austria
Edem Ziadinov Uzbekistan
Alexey Zyryanov Russian Federation
NEW STS MEMBERS JOINING EACTS 2011 Marlos Coelho Brazil
Walid Dajer-Fadel Mexico
Jayesh Dhareshwar India
Afshin Ehsan USA
Chawki Elzein USA
Mario Gasparri USA
Joe Helou Canada
Akio Ikai Japan
Kemp Kernstine USA
Suresh Keshavamurthy USA
Thomas Klikovits Austria
Eric Lehr USA
Tomislav Mihaljevic USA
Thomas Molloy USA
Andrew Newcomb Australia
Noritaka Ota Japan
Louis Perrault Canada
Evelio Rodriguez USA
Manoj Kumar S.p. India
Takahiko Sakamoto Japan
Edward Savage USA
Hisham Sherif USA
1.36
1.59
1.40
1.63
1.39A
1.37
1.39B
1.45
1.62
1.60
1.11
1.35
1.58
1.68
1.10
1.22
1.15
1.13
1.12
1.08
1.34
1.26
1.57
1.32
1.70
1.49
1.56
1.07
1.06
1.05
1.71
1.27
1.28
1.29
1.55
1.31
MDD
1.30
1.72
1.50
1.51
1.54
Catering
1.52
1.73
1.53
1.16
L.05
L.04
1.01
1.03
L.03
L.02
ENTRANCE
Pavillion 1
Pavillion 1
Floor plan
2.49 Geister Medizintechnik GmbH
1.57 Genesee BioMedical Inc
2.03 Covidien Deutschland GmbH
2.20 & 2.26 Cryolife Europa Ltd
1.37 CardiaMed BV
2.14 Cardia Innovation AB
2.43 Estech Inc
1.22 ESCVS
1.73 Elsevier
2.37 California Medical
Laboratories Inc
1.50 Hamamatsu Photonics
Main Foyer EACTS – The European Association for
Cardio-Thoracic Surgery
2.39 Edwards Lifesciences
1.71 Gunze Ltd
2.09 Doctors Research Group Inc
L.05 ISMICS – International Society for
Minimally Invasive Cardiothoracic
Surgery
2.48 Integra
1.34 HeartWare Inc
1.32 Heart Hugger / General Cardiac
Technology
1.06 Gore & Associates
1.35 Geomed Medizin-Technik GmbH & Co.
KG
1.01 Dendrite Clinical Systems
2.46 BracePlus/Slimstones BV
1.51 Biomet Microfixation
2.38 Berlin Heart GmbH
1.63 Baxter Healthcare SA
2.42 B Braun Surgical SA
1.40 Atrium Europe BV
1.62 AtriCure Inc
2.23 AstraZeneca R&D Mölndal
1.11 Asanus Medizintechnik GmbH
L.03 CTSNet
2.47 Fuji Systems Corporation
2.11 Coroneo Inc
1.72 Andocor NV
1.45 Acute Innovations LLC
2.07 & 2.08 Fehling Instruments GmbH & Co KG
1.52 & 1.53 CorMatrix Cardiovascular Inc
1.26 EUSA Pharma
2.19 Eurosets SRL
2.45 Abbott Vascular
2.39
2.22
2.11
2.04 & 2.05 Cook Medical
2.44 Ethicon –
Johnson & Johnson
2.12
L.04 AATS – American Association for
Thoracic Surgery
2.49
2.43
2.38
2.13
1.27 CircuLite Inc
2.48
2.44
2.33
2.21
2.14
1.07 Chase Medical
2.45
2.34
2.31
2.26
2.15
2.02 A&E Medical Corporation
2.35
2.30
2.19
2.20
2.16
StandCompany Name
2.47
2.46
2.37
2.36
2.29
2.28
2.27
2.18
2.17
2.09
2.08
2.07
2.40
2.23
2.06
2.05
1.49 MiCardia Corporation
1.08 Medxpert GmbH
2.40 Medtronic International Trading SÁRL
1.10 Medos Medizintechnik AG
2.32 Medistim ASA
1.12 Medex Research Ltd
1.31 MDD Medical Device Development
GmbH
2.01 & 2.24 Maquet Cardiovascular
1.16 Levitronix GmbH
2.29 Lepu Medical Technology (Beijing) Co
Ltd
1.13 Landanger/Delacroix-Chevalier
1.55 Labcor Laboratorios Ltda
1.39A KLS Martin Group
1.39B Karl Storz GmbH & Co KG
2.34 JOTEC GmbH
2.31 Jena Valve Technology GmbH
2.13 Jarvik Heart Inc
2.10
2.03
2.41
2.02
2.24
2.01
2.30 Starch Medical Inc
2.41 St Jude Medical
2.22 Sorin Group
2.10 Smartcanula LLC
1.59 & 1.60 & 1.68 Siemens AG
2.06 Sciencity Co Ltd
1.15 Scanlan International Inc
2.15 Redax SRL
2.16 Qualiteam SRL
2.36 PulseCath BV
1.70 Praesidia SRL
1.36 Pioneer Surgical
1.58 Peters Surgical
1.30 PCR
2.33 On-X Life Technologies Inc
2.18 NeoChord Inc
1.56 Micromed CV Inc
2.04
and foyer
ENTRANCE
Pavillion 2
1.05 & 1.29 Wisepress Online Bookshop
2.17 Wexler Surgical Inc
2.12 Vivostat
1.54 Transonic Systems Europe
1.28 Tianjin Plastics Research Institute
2.25 Thoratec Corporation
2.21 Terumo Europe NV
1.03 Synthes GmbH
2.35 SynCardia Systems Inc
2.27 & 2.28 Symetis SA
L.02 STS –
The Society of Thoracic Surgeons
2.42
2.32
2.25
Pavillion 2
The European Valve Repair Group (EVRG) Symposium
Tuesday October 4th:
aortic valve.
Top experts will present advanced latest
Valve Repair. How You Can Do It.
and current surgical techniques, approaches
and challenges during today’s session, entitled
Interactive Video Session.
“Advanced Leaflet Restoration in Aortic and
Mitral Repair”.
Advanced Leaflet Restoration in Aortic
Based on interactive videos, the EVRG symand Mitral Repair.
posium will present an educational review focusing on experiences in leaflet restoration
Sponsored by St. Jude Medical
techniques for various cases and pathologies
(endocardits, rheumatic, calcification etc.).
or the 6th consecutive year, the European
Cases will be shown on aortic cusp restoration
Valve Repair Group (EVRG) will once again
procedures, commissural reconstruction techhost their ever-popular lunch symposium on
niques, mitral leaflet augmentation,… Tips,
heart valve repair techniques. Over the previtricks, pitfalls and a systematic approach to
ous years, the EVRG members have presented
valve assessment will figure prominently in
a range of techniques for mitral and aortic
valve repair. This year, the group of 14 valve re- the discussions.
“Education in a how-to-do-it format is carpair experts will focus on different techniques
dinal in the process of adopting new surgical
of leaflet restoration in both the mitral and
F
cessful and delegates benefited from a diversified learning opportunity, a full spectrum
techniques and improving the quality of heart of surgical techniques presentation and amvalve repair. Formed eight years ago, the Euple opportunity for debate with the attendees
ropean Valve Repair Group aims to stimuand faculty.
late and promote the professional and educaJoin the European Valve Repair Group, Tuestional development in the field of valve repair day October 4th at 12.45h in auditorium F.
surgery”, says Prakash P. Punjabi, member of
The European Valve Repair Group (EVRG):
the EVRG and Consultant Cardiothoracic Sur- R. Benetis (Lithuania), G. El-Khoury (Belgium),
geon at the Imperial College Healthcare’s
W. Harringer (Germany), S. Hunter (UK), K.
Hammersmith Hospital in London. “With viKhargi (Netherlands), P-O. Kimblad (Sweden),
tal industry support, different educational in- F. Maisano (Italy), J.F. Nistal (Spain), J-F. Obadia
itiatives in this domain can be developed. St.
(France), R. Prêtre (Switzerland), P.P. Punjabi
Jude Medical is partner, collaborating with
(UK), H-J. Schäfers (Germany), J.J. Thiis (Denthe EVRG in all of the group’s initiatives and
mark), C. Zussa (Italy)
supporting us to accomplish our primary obEuropean Valve Repair Group – Lunch
jective. We wish to encourage surgeons want- Symposium
ing to specialize in heart valve reparative
surgery and provide a forum for scientific
Auditorium F
presentations and discussions”.
Previous EVRG symposia have been very suc- Tuesday October 4th, 12.45 – 14.00h
Come and
join the party!
TONIGHT!
at the Convento do Beato,
19:30–24:00
W
e shall
be celebrating
our 25th Anniversary at one of
Lisbon’s most remarkable and historical buildings – the
Convento do Beato. Within the various wings
of this 15th Century convent, recognized over
the years for its magnificient construction, we
will provide you with a variety of culinary and
musical delights!
In the main Cloiser Hall we will celebrate the
decade in which the Association was founded
– the 80’s – by showcasing some of the most
famous stage musicals from that period. Our
performers will sing and dance their way
through internationally renowned hit stage
musicals such as Les Miserables and Cats. The
programme on the main stage will culminate
in a performance by our EACTS ‘house’ band,
made up of our own group of surgeons. The
band will perform some well known cover
songs, enticing everyone onto the dance floor.
In the more tranquil setting of the Library,
our soloists will perform a range of classical
music and operatic arias written by European
composers, and in the Upper Foyer area we
will celebrate the best traditional and folk music and dance that Europe has to offer.
For those of you seeking even more excitement, we plan to run an EACTS casino where
you will have the opportunity to join your colleagues for a flutter on the gaming tables.
Finally, if you just want to sit and take in the
beautiful surroundings of this wonderful building, we will provide an area where you can relax and enjoy a quiet drink and a bite to eat in
the company of friends and colleagues.
Visit
Symetris on
stands
2.27 & 2.28

4th Oct

Transcription

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