Abstracts: Suppl. 1 to Vol. 12 (May 20, 2011) (2024)

1st Cardiac Surgery Session – Congenital I May 20, 2011 14:00–15:30

C1–1 RISK FACTORS IN NEONATAL CARDIAC SURGERY

I.I. Trunina, M.R. Tumanyan, O.V. Filaretova, A.G. Anderson, A.V. Kharkin, M.A. Abramyan

Bakoulev Scientific Centre for Cardiovascular Surgery RAMS, Moscow, Russian Federation

Objective: In recent years more researches of leading hospitals are devoted to analysis of different factors, which augment mortality risk in newborns with congenital heart disease. Risk factors differentiation helps to analyse outcome and quality of life after cardiac surgery in newborns.

Methods: From 2005 to 2010 we have treated 7558 children in first year of life, including 1193 (16%) newborns (average 3.6 days, average weight 2.9 kg). Congenital heart defects were the following: TGA, LHHS, coarctation of the aorta, PA atresia, critical aortic or pulmonary valve stenosis, etc. As to the structure of surgical interventions for the whole group, 54% (4065 operations) were made under artificial circulation (283 of which were operations for newborns, 40% were urgent, with survival rate of 86.9%) and 46% under closed.

Results: The statistical analysis of the factors influencing the outcomes of the surgical treatment (P<0.01) in confunction with the expert estimate of anamnestic, clinical, laboratory results of the newborns study led to the conclusions on the risk factors. In the newborns group the risk factors are: prematurity and low birth weight (339 children – 31.6%), hypotrophy (82 children – 7.6%), early neonatal period (468 – 39.2%), TORCH infections (56 children – 5.2%), concomitant somatic pathology and mechanical ventilation while entering hospital (216 children – 20.1%), multiple disembriogenetic stigmas and syndromic forms of CHD (94 children – 8.8%). Severity of condition was characterized by the presence of the risk factors in each child (from zero to six). The increase in the quantity of risk factors lead to the increase (P<0.05) of the mortality risk. Analysis of the risk factors enabled to elaborate particular dynamic steps of clinical treatment for each group in order to improve the outcomes. As a result in a period from 2005 to 2010 the number of newborns significantly (P<0.03) increased and the survival rate after urgent operations improved to 94.2%, including premature and low-birth-weight children (average weight 1.6 kg).

Conclusions: Optimization of preoperative care in children with CHD and risk factors exert positive influence on quality of treatment and improve outcome for newborns and infants with CHD.

C1-2 INTRAOPERATIVE FINDINGS OF MORPHOLOGIC DIFFERENCES IN HOCM

Y. Chudinovskikh, M. Eremeeva, D. Malenkov, M. Berseneva, T. Sukhachova, R. Serov, L. Bockeria

Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Science, Moscow, Russian Federation

Objective: To investigate into clinical features and cell mechanisms which play an important role in the cardiac hypertrophy in different age groups with hypertrophic obstructive cardiomyopathy (HOCM).

Methods: In our study we involved 38 patients suffering from the HOCM (mean age 39.3±12.6). The mean echocardiographical parameters were: LVEDV=80.5±24.4 ml, LVESV=3.6±10.2 ml, LVEF=74.2±7.4%, LVOT peak gradient=90.8±34.1 mmHg, IVS=23.9±5.1 mm. Endomyocardial biopsies were obtained by the IVS during the surgical myectomy. Proliferate active cardiomyocytes were determined by confocal immunohistochemistry by means of double staining by antibodies to the Ki67 (proliferation marker) and α-sarcomeric-actin (marker of cardiomyogenic differentiation). Resident cardiac stem cells (RCSC) were determined by means of the evaluation of the stem cell marker c-kit and α-sarcomeric-actin. Light and electron microscopy was also used to determine morphological features of HOCM.

Results: We divided 38 patients in two age groups, 27 patients of 18–45 years (mean age 33.1±8.8) and 11 patients of 46–61 years (mean age 54.5±5.5) according to morphologic features and their correlation with clinical and functional parameters. Patients of first group had significantly lower LVOT peak gradient than patients of second group (79.6±29.7 mmHg vs. 111. 6± 37.8 mmHg, P<0.01), lower LVEDD (4.0±0.5 mm vs. 4.4±0.7 mm, P<0.05), higher mean cell diameters (25.1±4.4 mm vs. 21.0±5.5 mm, P<0.05). In both groups we found small low differentiated and adult Ki67±cardiomyocytes, but the difference of number of those cells between the two groups was insignificant. Proliferation activity in adult cardiomyocytes correlated with the thickness of IVS, LVOT gradient and amount of fibrosis in both groups. We also found RCSC in two groups without significant differences between them. The diameter of cardiomyocytes in the younger group increased with the decreasing of LVESD (r=0.45, P=0.02) but cell diameter in the elder group decreased with the decreasing of LVESV (r=0.68, P=0.02). The number of small Ki67±α-sarcomeric±cells increased in the younger group with the decreasing of LVEDV (r=–0.49, P=0.01) and LVESV (r=–0.53, P=0.005) but in the elder group the number of these cells decreased significantly with the decreasing of LVESD (r=0.78, P=0.01).

Conclusions: Proliferation activity in adult cardiomyocytes correlates with the thickness of IVS, LVOT peak gradient and the degree of fibrosis in adult and young patients. The relatively high degree of cell hypertrophy and active proliferation of small progenitors could be associated with a more aggressive form of HOCM on the cell level in the younger group. In elder patients we found the mean degree of cell hypertrophy and high proliferation activity.

C1-3 MID-TERM RESULTS OF HEMODYNAMIC CORRECTION OF COMPLEX CONGENITAL HEART DEFECTS IN ADULTS

I.A. Yurlov, V.P. Podzolkov, M.M. Zelenikin, D.V. Kovalev, K.A. Mchedlishvili, N.A. Putiato, S.B. Zaets

Bakoulev Scientific Centre for Cardiovascular Surgery RAMS, Moscow, Russian Federation

Objective: The influence of age on results of hemodynamic correction of complex congenital heart defects remains disputable. This retrospective study is objective to analyse mid-term results of hemodynamic correction in adults.

Methods: During the years 1983–2010, 394 patients underwent Fontan operation. Twenty-four of 394 patients were older than 18 years. The age procedure ranged from 18 to 38 years (23.9±4.7 years at mean). The most frequent diagnoses were single ventricle, tricuspid atresia and complete atrioventricular canal with pulmonary stenosis. The majority of patients (79.1%) previously underwent various palliative interventions. The most frequent palliation was BCPA (84.2%). Three patients were subjected to two palliations prior to Fontan operation. In all patients, one of these palliations was subclavian-to-pulmonary artery shunt. Interval between palliative procedure and Fontan operation ranged from two to 18 years (mean – 8.4±6.0, median – seven years). Mean pulmonary artery pressure was 15.2±3.9 mmHg, SO₂ 79.8±6.8%, single ventricle ejection fraction 58.3±7.3%, Hb 174.1±26.1 g/l. Fontan operation was performed in modifications: atrio-pulmonary anastomosis – five, total cavopulmonary connection – two, extracardiac conduit – in 17 cases. Mid-term results of surgical treatment were followed from one to 14 years (3.7 years at mean).

Results: Twenty patients survived and were discharged from the hospital. Twelve of them are in the I-II class NYHA. The most frequent non-lethal complication was congestive heart failure. Lethal outcomes in four patients were caused by pulmonary thromboembolism on the first year after surgery in one, and in three remaining in one, five and 14 years as a result of progressing congestive heart failure and protein-losing enteropathy. Pre and postoperative clinical and hemodynamic parameters have been compared between groups of patients with complicated and non-complicated follow-up period. The Student’s t-test or ANOVA was used to compare continuous variables (e.g. pre or postoperative hemodynamics), as appropriate. χ² analysis was used to test for differences in proportions between groups (e.g. proportions of non-compliant selection criteria or incidence of postoperative complications). Logistic regression model was used to determine risk factors for hospital mortality and morbidity. P-values <0.05 were considered statistically significant. The analysis was conducted with the SPSS statistical package (version 16.0), Chicago, IL, USA.

Conclusions: Hemodynamic correction of complex congenital heart defects in adults is accompanied by good mid-term results and significantly improves condition of patients.

C1-4 REINTERVENTIONS LATE AFTER COMPLETE REPAIR OF TETRALOGY OF FALLOT

T.Yu. Danilov

Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Complications late after complete TOF repair are not rare. The objective of the study was to evaluate the reasons and estimate results of reoperation in late follow-up after complete repair of Tetralogy of Fallot (TOF).

Methods: Between 1990 and 2010, 71 patients at late follow-up after complete repair of Tetralogy of Fallot underwent reoperations. At the time of reoperation mean age was 17.6±7.4 (from three to 41 years). Interval between complete TOF repair and reoperation was 8.4±4.7 years (from one to 35 years). The most frequent consequences for the surgery were: ventricular septal defect (VSD) recanalization in 45 patients, tricuspid regurgitation – 27, aortic insufficiency – 14, pulmonary regurgitation – eight and residual right ventricular outflow tract (RVOT) obstruction in 19 patients.

Results: Hospital mortality reached 4.2% (three patients). In cases of RVOT obstruction transannular patching was used in 10 patients, RVOT patching was performed in five patients. Conduit replacements have been done in four patients. In all patients RV/LV pressure ratio decreased from 0.75±0.13 to 0.47±0.12; P<0.0001. Tricuspid valve regurgitation (TVR) was caused by annular dilation, infective endocarditis, severe deformation of leaflets and subvalvular structures. Tricuspid valve was replaced in 13 patients, and reconstructive surgery was performed in 14 patients. At discharge, according to TEE TVR was minimal or absent. The average cause of aortic valve insufficiency was leaflet perforation and (or) deformation, due to improper VSD patching during complete TOF repair. Twelve patients underwent aortic valve replacement, and in two patients aortic valvuloplasty was performed. At discharge, in all patients, left ventricle end-diastolic volume decreased from 115.9±17.3 ml/m² (at admission) to 103.9±15.4 ml/m². In patients with aortic valve replaced valve function was tolerable, and in those with valvuloplasty mild regurgitation was noted. In two cases, in order to eliminate severe pulmonic regurgitation caused by monocusp dysfunction, framed xenopericardial valve had being implanted, and stentless valve was used in six cases. After surgery, right ventricle end-diastolic volume decreased from 114 ml/m² to 98 ml/m², right ventricle ejection fraction grew up from 44±4% to 49±4%. Residual VSD was found in 28 patients, and repatching was performed in 17, TEE examination showed no left-to-right shunt.

Conclusions: The necessity of reoperation after complete TOF repair is the result of surgical inaccuracy during first operation, pulmonic regurgitation leading to RV dysfunction, and infective endocarditis. Early mortality is low, and functional outcome is good.

C1-5 CONTEGRA BOVINE JUGULAR VEIN AND MATRIX DECELLULARIZED PORCINE PULMONARY VALVE CONDUITS FOR RIGHT VENTRICULAR OUTFLOW TRACT RECONSTRUCTION IN PEDIATRIC PATIENTS

G. Oppido, C. Pace Napoleone, S. Turci, C. D’Andrea, V. Gesuete, E. Angeli, G. Gargiulo

S. Orsola Malpighi Hospital Bologna, Bologna, Italy

Objective: hom*ograft is still considered the conduit of choice for the right ventricular outflow tract reconstruction. Nevertheless, its lack of availability particularly in pediatric patients, prompts surgeons to identify an ideal alternative. The present study evaluates the outcome of Contegra bovine jugular veins and Matrix decellularized porcine pulmonary conduits implanted to reconstruct the right ventricular outflow tract in pediatric patients.

Methods: From April 2000 to October 2010, 52 patients (mean age, 18±29 months) underwent 56 conduit implants (38 Contegra and 18 Matrix). Diagnoses were: truncus arteriosus (21), ToF/PA (21), ToF/PS (5), PAIVS (2), PS (2), TGA/VSD/PS (1). End points were: reintervention, reoperation and onset of severe dysfunction meant as severe incompetence or severe stenosis of the valved conduit.

Results: Six patients died (one only in the Matrix group), four early (7.7%) and two late (4.2%), none for conduit-related cause. Mean conduit sizes were 13±2 and 15±3 for Contegra and Matrix, respectively. The rate of overall conduit replacement was 17.1% for the Contegra vs. 17.6% for the Matrix at a mean time of 50±31 and 34±10, respectively. Causes of replacement were: conduit stenosis (4), dilatation (1) and endocarditis (1) in the Contegra group; stenosis (2) and dilatation (1) in the Matrix group. Nineteen balloon dilatation procedures were required, seven on the pulmonary arteries and so not conduit-related. The remaining 12 procedures were done in eight (22.9%) in the Contegra group (mean time 24±15 months) and four (23.5%) in the Matrix group (mean time 20±17 months). In 11 cases, the stenosis was at the distal anastomosis. All the survivors were followed up with three months intervals, echocardiograms and severe incompetence of the conduit valve was detected in 29% and 17.6% of the patients of the Contegra and Matrix groups, respectively, at a mean time of 21±14 and 25±20. Five years freedom from replacement was 90±5 and 77±14 (P=0.58) and freedom from dysfunction was 47±10 and 38±16 (P=0.83), in the Contegra vs. Matrix group, respectively. Age of <1 year, body surface area, pulmonary branches stenosis, and conduit size <14 mm were not identified as risk factors of premature failure.

Conclusions: Contegra and Matrix conduits can be considered valid to reconstruct the right ventricular outflow tract of pediatric patients although both similarly show a not negligible rate of early dysfunction, need for catheter intervention and replacement.

C1-6 EARLY AND LONG-TERM RESULTS OF MITRAL VALVE REPLACEMENT IN CHILDREN

Y.N. Gorbatykh, Y.L. Naberukhin, A.Y. Omelchenko, E.V. Zhalnina, E.V. Lenko, V.G. Stenin, L.G. Knyazkova, O.V. Kamenskaya

Federal State Institution Academician E.N. Meshalkin Novosibirsk State Research Institute of Circulation Pathology Rosmed Technology, Novosibirsk, Russian Federation

Objective: Analysis of early and long-term results of mitral valve replacement in children.

Methods: Between 1995 and 2009, 121 children from three months to 17 years have undergone mitral valve replacement. The study group consisted of 62 male and 59 female patients. The mean age was 9±5.2 years. All patients were divided into three subgroups based on subvalvular apparatus preservation degree. Complete chordal cutting was performed in 49 patients (group I), one cut-off chordae tendineae was done in 53 patients (group II), and no chordial cutting at all was in 19 patients (group III).

Results: The hospital mortality was 11.6% (14 patients, mean age 4.7±3.9 years). Right after the surgery there was a decrease left ventricular ejection fraction (EFLV) from 68.5±7.2% to 63.2±6.1% in group I, up to 65.9±5.9% in group II and 68.4±3.4% in group III. Comparing all the groups in long-term period, the higher EFLV was registered in the group with preserved annular attachments (after three years – 60.1±3.5% in group I; 66.8±4.6% in group II; 70.3±1.1% in group III; after five years – 58.5±2.9% in group I, 65.1±2.4% – group II, 68.8±0.9% – group III). Faster and significant reduction in the linear dimensions of left chambers of the heart was observed in the third group. Early-aged patients faced the problem of ‘fixed-size valve for the growing organism’ in a long-term period. Eleven patients required re-replacement later on because of small size of prosthesis and pannus overgrowth. Five–year survival was 85.1%. Fifty-six patients were completely examined after sometime, they received echocardiography, X-ray, step-test. BNP and pro-ANP level was determined. Patients were evaluated using Nottingham questionnaire. The best tolerance to physical activities, the lowest level pro-ANP and BNP were recorded in patients with preservation of both anterior and posterior chordae tendinea in the late postoperative period.

Conclusions: Mitral valve replacement in children with preservation of both anterior and posterior chordae tendinea allows us to consider this as the surgery of choice. Preservation of anterior and posterior chordae tendinea of mitral valve provides the best contractile function of LV not only directly after the operation, but also in the late postoperative period. Quality of life and physical working capacity in the long-term period is higher among the patients with preserved all chordae tendinea.

C1-7 RIGHT VENTRICULAR OUTFLOW TRACT STENTING IN THE SYMPTOMATIC PATIENTS WITH TETRALOGY OF FALLOT

Y. Chesnov, A. Savchuk, N. Shevchenko, A. Bashkevich, T. Bashkevich, L. Evgrafova

Children’s Cardiosurgery Center, Minsk, Belarus

Objective: Debate continues regarding the initial management of cyanotic or duct-dependent infants with Tetralogy of Fallot (TOF). Total repair in these patients associates with increased morbidity. Palliation may be required before the total correction.

Methods: Seven patients with TOF with critical right ventricle outflow tract (RVOT) obstruction who underwent eight RVOT stent implantation from January to December 2010 were reviewed. Due to anatomical and somatic conditions the patients were not qualified for Blalock–Taussig shunt (BTS) or radical correction. Prostaglandin dependency or hypercyanotic spells in infants were the most common indications. Mean age of infants was 6.1 months (from 16 days to three years). The median oxygen saturation on 100% oxygen was 65% (range 30–75%). The stents (cordis, genesis) with diameters from 6 to 10 mm and 12 to 39 mm long were implanted in the infundibulum. Then pulmonary valvuloplasty was performed with the same balloon. One infant required a second stent implant six months after the initial implantation. The whole procedures were performed under fluoroscopy, echocardiography, and pressure monitoring.

Results: All patients became acyanotic in the cathlab with oxygen saturations of 89–100% in room air. Control echocardiography revealed mild residual stenosis with 30 mmHg gradients. There were no procedural complications. Pulmonary over-perfusion was not problematic in any cases. Median time to discharge was four days. One child had surgical correction. Surgery was elective in eight months after stenting. The remainder are awaiting elective repair with oxygen saturations more than 90% with no further hypercyanotic episodes. Patient underwent standard repair with stent removal and a transannular RVOT patch reconstruction. Stent removal was easy and without any complication.

Conclusions: Successful stent implantation into the RVOT in critical patients with TOF, which are not suitable for total repair, improves their clinical condition, increases pulmonary blood flow by physiological means and leads to an improvement of pulmonary artery and left ventricle development before surgical treatment. Stenting of the RVOT provides a safe and effective management strategy and is a good alternative to BTS.

C1-8 OUTCOME AFTER BALLOON AORTIC VALVULOPLASTY OF CRITICAL AORTIC STENOSIS IN NEWBORNS

Y.L. Kuzmenko

Ukrainian Children’s Cardiac Center, Kiev, Ukraine

Objective: We present a review of our experience in primary interventional treatment and in surgical treatment of residual aortic valve disease after BAV of critical aortic stenosis in newborns.

Methods: Between 1996 and 2010 balloon dilatation of critical aortic stenosis was performed in 73 newborns with biventricular circulation. Mean age at the BAV procedure was 13.5 days (range 1–30 days), weight was 3.38 kg (range 2.2–4.45 kg), ratio balloon/aortic annulus=0.9, ejection fraction <55% (mean 40.4+11.9%; P<0.001). All patients presented with variant degrees of congestive failure as evidenced by tachypnoea, cardiomegaly and hepatomegaly. Prostaglandin infusion was initiated in 48 patients (66%), 21 patients (43%) required assisted ventilation, 45 (62%) needed an inotropic infusion or hospital transfer. The mean Doppler gradient was reduced from 52.8+23.8 to 21.5+11.5 (P<0.001). Hospital mortality 2.7% (two patients), three patients died during one year after initial BAV, one patient – 2.5 years after initial BAV. During a median follow-up was 4.7 years ranging up to 14.1 years, there were 14 reinterventions on the LV outflow tract in 11 (15.5%). Mean time interval between the initial dilation and reintervention was 45.5+27.7 months (range 2–77 months); three patients required balloon procedure, 11 a Ross operation and two an open valvulotomy.

Conclusions: Transcatheter BAV offers effective immediate reduction of gradient in critical aortic stenosis with biventricular circulation resulting in the relief of heart failure and the need for continued ventilation and inotropic support.

C1-9 TEN-YEAR INSTITUTIONAL EXPERIENCE OF THE COMMON ATRIOVENTRICULAR SEPTAL DEFECT REPAIR IN INFANTS

D.S. Akatov, A.I. Kim, T.V. Rogova, S.A. Kotov, D.V. Ryabtsev, T.R. Grigoryants, S.S. Kharitonova

Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Between 2000 and 2010, 198 infants underwent the repair of a complete atrioventricular canal defect (CAVCD) with modified two-patch and modified single-patch technique.

Methods: From 2000 to 2010, 198 (72 males, 126 females) consecutive patients underwent repair of CAVCD. There were 122 patients with Down’s syndrome. Mean age was 192 days and the mean weight was 5.8 (range 3.4–8.5) kg. Concomitant cardiac defects were presented in 177 patients: PDA (59 patients), PFO (118 patients). All patients were examined with echocardiography to evaluate AV valve and ventricular function. There were 69% of patients with balanced ventricles. Depending on the morphology of the superior leaflet of the common atrioventricular valve, three types of CAVC have been delineated (type A, B and C, according to Rastelli’s classification). One hundred and forty-six (74%) patients had moderate and 52 (26%) – severe left atrioventricular valve regurgitation. One hundred and fifty-four (78%) patients had moderate and 44 (22%) – severe right atrioventricular valve regurgitation. In all patients, the ventricular septal defect was repaired with an individualized approach according to each patient’s specific anatomy: 176 patients had a modified two-patch and 22 patients – a modified single-patch technique – in cases when VSD height did not exceed 20% of inlet part in patients with balanced ventricles.

Results: ICU length of stay was 43 h (16–149 h) and the hospital stay was 24 days (range 7–98 days). Reoperation for postoperative left A-V incompetence occurred in five patients in the modified two-patch group. At the early follow-up, left atrioventricular valve regurgitation was absent or trace in 174 patients (80%), mild to moderate in 15 patients (17.5%), and moderate to severe in five patients (2.5%). Right AV valve regurgitation was none or trace in 184 patients (93%), mild to moderate in 12 patients (7%). Early postoperative mortality was 13 patients (6.5%).

Conclusions: A modified double-patch technique is applicable in all types of CAVSD including patients with unbalanced ventricles. With a strict patient selection modified single-patch technique gives good early results, but long-term results need to be analysed.

1st Vascular Surgery Session – AAA May 20, 2011 14:00–15:30

V1-1 RUPTURED INFRARENAL AAA TREATED BY EVAR AS AN EMERGENCY PROCEDURE: FIVE-YEAR EXPERIENCE

M.A. Cairols, R. Vila-Coll

Hospital Universtari de Bellvitge, Bellvitge, Spain

Objective: Despite improvements in perioperative care, open repair for ruptured infrarenal aortic aneurysms (rAAA) remains high. The introduction endovascular repair of (rAAA) may have had a real impact in their management. The aim is to analyze the results at five years after implantation of emergency endovascular repair (eEVAR) as compared to the open repair (OR).

Methods: This is a retrospective study of 103 patients who presented consecutively to the emergency department from 2004 to 2009 with rAAA. Of them 39 (38%) were rejected for treatment (refractory shock and yuxta or suprarenal). Inclusions criteria: evidence of retroperitoneal hematoma or free blood in the abdominal cavity were included. Symptomatic AAA were excluded. The anatomical characteristics were used to indicate eEVAR (same anatomical limitations as the conventional EVAR). If anatomical incompatibility OR was carried out. Patient’s monitoring was clinical, CT and plain abdominal X-ray (dual projection) per month and by echo-Doppler by the semester. The statistical analysis was carried out using the SPSS v 13.0, comparing the complications, mortality and survival in both treatment groups.

Results: Of the 64 patients operated (62%), 33 (51%) were treated by eEVAR and 31 (48%) were OR. Both treatment groups showed no statistical differences except for higher renal insufficiency in the eEVAR group. The most common early complications in the EVAR group was renal (n=36) and respiratory failure (n=39). In the OR group, an association (P<0.005) between the onset of respiratory failure and multiple organ failure with anaemia (Hb <9.1), hemodynamic instability, and age over 72 years was found. The abdominal compartment syndrome and postoperative renal failure was associated (P<0.005) with the polytransfusion and longer surgical time. Mortality at 30 days was 39% in the EVAR group and 64% (P=0.015) in the CA group, achieving over five years, a mortality curve downward.

Conclusions: We experienced a significant decrease in overall mortality, reduction of postoperative complications and better outcome at five years follow-up, with a low number of complications after eEVAR as compared to OR. In our department eEVAR is now the first therapeutic option for rAAA.

V1-2 POSTOPERATIVE ACUTE KIDNEY INJURY AFTER ABDOMINAL AORTIC ANEURYSM REPAIR: A COMPARATIVE STUDY BETWEEN OPEN AND ENDOVASCULAR ANEURYSM REPAIR

M. Yamanami, K. Kanda, K. Oka, O. Sakai, K. Okawa, M. Dohi, K. Kitani, H. Yaku

Kyoto Prefectural University of Medicine, Kyoto, Japan

Objective: In recent years, endovascular aneurysm repair (EVAR) has been widely used for the treatment of abdominal aortic aneurysms. Although EVAR is less invasive compared to open repair, the burden on the kidneys is concerned due to the intraoperative use of contrast media. We retrospectively compared the incidence rates of postoperative acute kidney injury (AKI) between patients who underwent open repair and those who underwent EVAR at our hospital.

Methods: Of the 70 consecutive patients who underwent elective infrarenal abdominal aortic aneurysm repair between January 2009 and October 2010, 59 had preoperative serum creatinine (Cre) values of <1.5 mg/dl; we compared the incidence rates of postoperative AKI in these 59 patients.

Results: The subjects consisted of 27 patients who had undergone open repair (OR group) and 32 patients who had undergone EVAR (EVAR group). The male to female ratio was 26:1 in the OR group and 25:7 in the EVAR group; the percentage of females was significantly higher in the EVAR group (P<0.05). There was no significant difference in the average age between both the groups [69.3±6.90 years in the OR group and 73.5±10.7 years in the EVAR group, P=0.08]. Preoperative renal function test showed no significant difference between both the groups (serum Cre: 0.90±0.23 mg/ml in the OR group and 0.81±0.24 mg/dl in the EVAR group, P=0.13; eGFR: 67.0±16.3 ml/min/1.73 m² in the OR group and 75.0±26.6 ml/min/1.73 m² in the EVAR group, P=0.18). Acute kidney injury network (AKIN) criteria (increase of 0.3 mg/dl in serum Cre or of 50% in serum Cre’s basal value) were used for the diagnosis of postoperative AKI. Postoperative AKI occurred in 11 patients (19%) [nine in the OR group (33%) and two in the EVAR group (6.3%)], and its incidence was significantly higher in the OR group than in the EVAR group (P<0.05). None of the patients required postoperative dialysis.

Conclusions: We found that the incidence of AKI was significantly higher in the OR group than in the EVAR group. In this series, the level of invasiveness of open surgery surpassed the influence of contrast media use in the EVAR group. In abdominal aortic aneurysm repair, EVAR could be less invasive also in the renal function compared with open repair even though the aorta were clumped infrarenally.

V1-3 ASYMPTOMATIC SMALL ABDOMINAL AORTIC ANEURYSMS AND RISK OF RUPTURE: A POSITRON EMISSION/COMPUTED TOMOGRAPHY (PET/CT) EVALUATION

N. Rousas, B. Pane, G. Spinella, C. Marini, M. Massello, S. Morbelli, G. Sambuceti, D. Palombo

San Martino University Hospital, Genoa, Italy

Objective: The present study we planned to verify the prevalence of visible FDG uptake in aneurysmatic walls, adopting a case-control approach in a large population of asymptomatic patients with relatively small AAA (<5.5 cm) and potential risk of rupture.

Methods: This study included 42 males (mean age 74 years, range 59–93 years), consecutive, white Caucasian patients, with asymptomatic infrarenal AAA. The mean diameter of AAA was 49 mm (range 34–54), detected by CT-scan. Control subjects: 44 age-matched controls subjects (mean age 71 years, range 59–85 years, 24 males, 20 females) who were selected according to a case-control criterion among a population of patients without any clinical evidence of atherosclerotic disease. Patients and controls underwent simultaneous FDG-PET and CT imaging from the skull base to the femoral neck using an integrated PET/CT scanner. FDG uptake was quantified by calculating the mean standardized uptake value (SUV) within each VROI, for bilateral arteries mean value was considered. To take into account the contribution of circulating FDG, VROI SUVs were normalized for the blood-pool SUV value.

Results: Metabolic activity in the aneurysmatic aortic segment was even lower with respect to both the adjacent – non-aneurysmatic – sample of the same patient and the corresponding arterial segments of control subjects (0.7±0.2, 1±0.3 and 0.9±0.3, respectively; P<0.001 vs. non-aneurysmatic segment of the same patient and P<0.01 vs. the same segment of control subjects). No patient showed an increased focal uptake of degree adequate to identify the aneurysmatic arterial wall. No correlation was observed between AAA uptake and its diameter.

Conclusions: Our results suggested that FDG-PET/CT cannot be considered a reliable technique to identify a subgroup of asymptomatic patients with AAA sizing just more than the threshold usually considered for surgical indications.

V1-4 THE FUNCTIONAL CONDITIONS OF RESPIRATORY, GAS EXCHANGE AND NEUROREGULATORY SYSTEMS IN ABDOMINAL AORTA ANEURYSM RUPTURES IN THE EARLY POSTOPERATiVE PERIOD

O.V. Nikitina

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: The studies of ventilation, gas exchange, and neuroregulatory system functions in 73 patients with abdominal aorta aneurysm (AAA) ruptures complicated by a massive blood loss of more than 2500–3000 ml have allowed a differentiated approach to the treatment tactics in an early postoperative period.

Methods: Investigation of the external respiratory function revealed an abrupt decrease of the forced vital capacity (FVC) of the lungs, vital capacity (VC), and the maximal voluntary ventilation (MVV) (21.3%, 23.5%, 24.4% of due values, respectively), the respiration reserves were decreased to 22.7%, that was accompanied by the increased minute respiratory volume up to 126.28% of due values. The reduced respiratory volume (69.20% of due value) was compensated by tachypnea (26–34/min). The decreases of external respiration volumetric values were accompanied by the decreased respiration rates. Tiffno index made 73±22% that was indicative of respiratory disorders having predominantly restrictive nature. From the third day, the fine distal bronchi patency deteriorated (53.17% of the due value). The disorders were mainly attributed to the blood loss volume and the infusion load.

Results: The total infusion rate above 4000 ml resulted in the decreased volume-and-rate characteristics of the external respiration, the increasing obstructive disorders. Changes of neuroregulatory system activity associated with various blood loss volumes characterized the body adaptation power in the process of treatment. Adrenaline concentration rose. After blood loss above 2500 ml, the blood content of noradrenaline increased to 2.34±0.49 pcmol/ml that was the evidence of the activated both hormonal and mediatory components of sympathoadrenal system. Acetylcholinesterase and cholinesterase activities tended to increase, as was observed. Meanwhile, the serotonin levels significantly dropped to 0.96±0.20 nmol/ml. Thus, the depressed activity of serotonin-histaminergic system was compensated by such factors as the increased activity of the cholinergic system and the additional activation of the mediatory component of sympathoadrenal system.

Conclusions: Thus, the patients with AAA rupture complicated by a massive hemorrhage have significant gas exchange impairments in an early postoperative period and need a respiratory support, using various ventilation modes that allow improving the respiratory function, reducing the manifestations of restrictive disorders and providing the conditions for patients’ transfer to spontaneous respiration. Abnormal activities of neuroregulatory systems in massive hemorrhage indicated a significant depression of human body adaptation power and dictated the necessity of their correction.

V1-5 AN ANALYSIS OF SENSITIVITY, SPECIFICITY, POSITIVE PREDICTIVE VALUE And NEGATIVE PREDICTIVE VALUE OF LEFT VENTRICULAR EJECTION FRACTION IN PATIENTS UNDERGOING ABDOMINAL AORTIC ANEURYSM REPAIR

J. Khan, H. Barakat, G. Smith, N. Samuel, R. Gohil, F.A.K. Mazari, I.C. Chetter, P.T. McCollum

Academic Vascular Surgical Unit, University of Hull, Hull, UK

Objective: Preoperative risk assessment is important in patients undergoing major vascular surgery in the current era of evidence based medicine. Identification of individuals at increased risk may allow important alterations in perioperative management. There has always been a debate as to which test is best in risk stratification. This study was performed to assess the sensitivity, specificity, positive and negative predictive value (PPV and NPV) of left ventricular ejection fraction (LVEF) to predict cardiac complications and 30-day mortality in patients undergoing abdominal aortic aneurysm (AAA) repair.

Methods: The study was designed as a retrospective analysis of prospectively collected data. List of patients who underwent elective open AAA repair between October 2006 and December 2009 was obtained from departmental database. All patients who underwent assessment of LVEF by means of multi-gated acquisition (MUGA) scan were identified and included in the study. LVEF of 40% or more was labelled as normal as per protocol and was used as cut-off for inter-group analysis. Perioperative parameters and outcomes were recorded for all patients. Statistical analysis was performed using SPSS v16.0.

Results: Seventy-three patients [62 male; median age: 75 years (IQR: 71–79)] were included in the study. Median hospital stay was nine days (IQR: 7–12). LVEF was <40% in 37% (n=27) and >40% in 63% (n=46) of patients. Postoperative cardiac complications were observed in 6.8% (n=5) patients. Thirty-day mortality was 9.5% (n=7). Sensitivity, specificity, PPV and NPV of LVEF for prediction of cardiac complications were 40%, 63%, 28% and 93%, respectively. Similar results were seen for prediction of 30-day mortality (sensitivity 43%, specificity 68%, PPV 14%, NPV 90%). Inter-group analysis: there was no statistically significant difference between the two groups for basic demographics, co-morbidities and preoperative medications. Also no statistically significant difference was observed in the length of hospital stay (P=0.249).

Conclusions: LVEF is not an appropriate indicator of cardiac complications or 30-day mortality in patients undergoing AAA repair. Further studies are required to assess the role of surrogate markers like cardiopulmonary exercise testing in addition to LVEF for prediction of morbidity and mortality in these patients.

V1-6 HAVE WE CLOSED THE GAP ON GENDER DIFFERENCES IN AAA?

H. Sekhar, S.W. Grant, M. Welch, C.N. McCollum, M.S. Baguneid

University Hospital of South Manchester, Manchester, UK

Objective: Despite women accounting for a quarter of all cases of abdominal aortic aneurysms (AAA), it is considered a male condition. Previous studies suggest that women with AAA have unfavourable outcomes, with higher rupture rates and poorer postoperative survival. Major advances have occurred in the overall detection, timing of intervention and treatment of AAAs. It is currently recommended that women should be considered for treatment when the AAA diameter reached 5.0 cm and endovascular repair has become popular in most vascular centres. With this in mind, we aim to evaluate the current presentation, treatment and outcomes of female patients with AAA enrolled into a surveillance programme compared with that of men.

Methods: A single-centre prospectively collected database of patients under AAA surveillance was interrogated. AAA scan intervals followed unit protocol. Decision to treat was based on patients’ perceived surgical risk. Thirty-day and one-year mortality rates were calculated.

Results: From May 1997 to April 2010 a total of 1112 patients with AAA were entered into the surveillance programme, out of which 263 (23.7%) were female. Women presented with smaller aneurysms compared to men (4.06 cm vs. 4.23 cm, P<0.05) with no significant difference in growth rate (0.27 cm/year vs. 0.25 cm/year, P=0.433). Women were older when entering surveillance compared to men (mean 75.3 years vs. 73.3, P<0.001). Women received fewer elective procedures [32 (12.1%) vs. 156 (18.4%), P<0.005] and had higher rupture rates [15 (5.7%) vs. 13 (1.5%), P<0.001]. Women who undergo surgery do so at a smaller AAA size when compared to men (5.58 cm vs. 5.91 cm, P<0.05). Thirty-day elective mortality was comparable between women and men [1 (3.1%) vs. 3 (1.9%), P=1.8]. One-year mortality, however, was significantly higher in women [2 (7.1%) vs. 9 (6.5%), P=0.02].

Conclusions: Women represent a significant proportion of those in AAA surveillance. They present at older age with smaller aneurysms than men. Thirty-day mortality rates following elective surgery are comparable to men. However, female patients were still less likely to receive elective surgery for detected AAA for as yet unclear reason. Also, when performed, the mean diameter of AAA for women at surgery was 5.58 cm, not the recommended 5.0 cm. These two factors may contribute to the higher rate of rupture demonstrated. A significantly higher one-year mortality is demonstrated for unknown reasons and could reflect an older group or a greater co-morbidity load.

V1-7 SCREENING FOR INFLAMMATORY ABDOMINAL AORTIC ANEURYSM – AN OPTION TO IMPROVE PROGNOSIS?

T.U. Cohnert, S. Koter, S. Schweiger, J. Fruhmann, A. Baumann

Graz Medical University, Graz, Austria

Objective: Inflammatory abdominal aortic aneurysm (iAAA) accounts for 3–10% of patients (pts.) treated for AAA. Aim of this study was to analyze treatment results with special focus on gender aspects and influence of treatment timing as well as long-term prognosis for iAAA patients.

Methods: Prospectively collected data of all consecutive patients undergoing surgery for AAA between October 1996 and April 2010 were analyzed retrospectively. Long-term follow-up data were obtained up to 15 years postoperatively. Statistical analysis was performed by Mann–Whitney U-test and survival assessed by Kaplan–Meier method.

Results: Nine hundred and thirty-one patients underwent treatment for AAA. Open AAA surgery was performed in 760 patients (611 men, 149 women) (760/931=81.6%) and EVAR in 171 elective patients (171/931=18.4%). In 46 patients (42 men, four women, mean age 68.2+9.4 years) (46/931=4.9%) the intraoperatively confirmed diagnosis was iAAA. Mean aneurysm diameter was 6.5+1.7 cm. Twenty-three iAAA patients were treated by elective surgery, 17 urgently for symptomatic iAAA and six as emergency for iAAA rupture. With 2.7% (4/149) less women were treated for iAAA than men with 6.9% (42/611 patients). All female iAAA patients survived surgery. Twenty-three of 46 iAAA patients (50%) underwent urgent or emergent surgery compared to 177 non-iAAA patients (177/760=23.3%). Two of six patients with iAAA rupture (2/6=33%) and one elective iAAA patient died during the early postoperative course (1/23=4.3%). Mortality in non-iAAA emergency patients was 13.6% (24/177 patients). Long-term follow-up in 42 iAAA patients showed a five-year survival rate of 88%.

Conclusions: During a 13-year period with 931 operative procedures for AAA a total of 46 patients underwent surgery for inflammatory AAA. 91.7% of the iAAA patients were male. In this study, a high percentage of iAAA patients underwent urgent or emergent treatment for symptomatic or ruptured aneurysms. Mortality for iAAA patients presenting with rupture was 33% and therefore significantly higher than in non-iAAA patients with rupture with 16.3%. Long-term survival after open repair for iAAA was good with a five-year survival rate of 88%. Early diagnosis and prevention of emergency surgery is important especially in iAAA to reduce postoperative morbidity and mortality. AAA screening programs for risk groups are a valuable tool to improve patient’s prognosis.

V1-8 ASSESSMENT OF THE ACCURACY OF AORTASCAN FOR DETECTION OF ABDOMINAL AORTIC ANEURYSM (AAA) IN A SCREENING PROGRAMME

A. Abbas, A. Smith, M. Cecelja, M. Waltham

Kings College London, Cardiovascular Division, British Heart Foundation Centre of Excellence, NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College Hospital, London, UK

Objective: AortaScan AMI 9700 is a portable 3D ultrasound device that automatically measures the maximum diameter of the abdominal aorta without the need for a trained sonographer. It is designed to rapidly diagnose or exclude an AAA and may have particular use in screening programs. The accuracy of the device has previously been compared with conventional ultrasound and found to have 90% sensitivity. Our objective was to determine its accuracy against definitive imaging with CT.

Methods: Seventy-five subjects from our AAA screening and surveillance programs were examined (34 AAA on conventional ultrasound and 41 controls). The aorta was scanned using the AortaScan AMI 9700 as per the instructions for use. An operator blinded to the aortic size placed the probe at four positions along the midline from xiphisternum to umbilicus. Subjects then underwent CT of the aorta. The largest measurement obtained by AortaScan was compared against the CT aortic measurement.

Results: The CT-scan confirmed the diagnosis of AAA in 33 subjects. There was one false-positive measurement on conventional ultrasound. The average age of subjects was 68.7 years and the mean aortic diameter was 2.8 cm (1.5–5.5 cm). The average body mass index (BMI) of subjects was 25.9. AortaScan missed the diagnosis of AAA in seven subjects and of these five had a BMI >28. The largest diameter missed was 4.4 cm. There were 11 false-positive measurements by AortaScan and of these six had a BMI <25. The sensitivity, specificity, positive and negative predictive values were 78%, 73%, 70% and 81%, respectively.

Conclusions: The AortaScan AMI 9700 can detect AAA without the need for a trained operator and has potential in a community-based screening programme. It would, however, need further technical improvement in order to increase sensitivity before it could be considered as a replacement for trained screening personnel.

V1-9 SURGERY OF INFLAMMATORY ABDOMINAL AORTA ANEURYSMS

A.V. Pokrovsky, V.N. Dan, A.F. Kkarazov, V.M. Aleksanyan, I.A. Badretdinov

The A.V. Vishnevsky Institute of Surgery of Ministry of Health and Social, Moscow, Russian Federation

Objective: To assess the detection frequency of inflammatory abdominal aorta aneurysms (AAA); to estimate the results of surgical treatment of patients with inflammatory AAA.

Methods: From 1983 to 2010, 750 patients with AAA were operated at the Vishnevsky Institute of Surgery. An inflammatory AAA was detected in 47 (6.2%) patients. The mean age of the patients was 61 years. Sex ratio was nine men to one woman. We used the following criteria for detection of inflammatory AAA: 1. thickening of the aneurysmal wall more than 6 mm; 2. retroperitoneal fibrosis; 3. an increase of erythrocyte sedimentation rate (ESR) and an increase of C-reactive protein (CRP). Thirty-three (70%) patients had abdominal pain syndrome, seven (15%) patients suffered from a prolonged subfebrile temperature rise. The increase of ESR was detected in 35 (75%) patients. An ureteric stricture was diagnosed in five (11%) patients. Local involvement of left renal vein and postcava into the inflammation zone of retroperitoneal space was found in eight (17%) patients. On the basis of intraoperative data the patients were divided into groups by the thickness of the aneurysmal wall. In the first group the thickness of the aneurysmal wall was from 6 mm to 1 cm (17 patients), in the second group – 1–2 cm (23 patients), in the third group – more than 2 cm (seven patients). CT of aorta and abdomen was made to all patients before surgery, and in 24 (51%) patients the diagnosis was verified by CT. Complication of diagnosing on the basis of CT is that the aneurysmal wall often may not be differentiated from thrombotic mass. MRI allows clearly differentiate the aneurysmal wall from thrombotic mass. Retroperitoneal fibrosis was diagnosed in 24 (51%) patients (CT), and significant correlation between the thickness of aortic wall and the presence of retroperitoneal fibrosis was not found.

Results: Twenty-seven (57%) patients were performed a resection of aneurysm with linear replacement, 16 (34%) patients – with aorta-iliac replacement, and four (9%) patients – with aorta-bifemoral replacement. During postoperative period three (6.3%) patients died.

Conclusions: According to our data, the detection frequency of inflammatory AAA was about 6.2%. The most effective technique for inflammatory AAA diagnosing is MRI. The surgical treatment of such patients is associated with advanced technical difficulties and accompanied with large loss of blood, but these have no influence on early postsurgical mortality.

2nd Cardiac Surgery Session – TAVI May 20, 2011 15:30–16:30

C2-1 SATISFACTORY RESULTS OF TRANSCATHETER AORTIC VALVE IMPLANTATION IN ELDERLY PATIENTS ARE NOT ALWAYS CONNECTED WITH PERIOPERATIVE NT-PROBNP DECREASE

M. Krason

Silesian Centre for Heart Disease, Zabrze, Poland

Objective: N-terminal-pro-B-type natriuretic peptide (NT-proBNP) is an accepted diagnostic and a prognostic marker of aortic stenosis severity. The objective of this study was to establish whether perioperative change in NT-proBNP plasma level can be a good predictor of the aortic transvalvular gradient drop after TAVI in high-risk patients with symptomatic stenosis of the aortic valve.

Methods: Between November 2008 and December 2010, 42 patients underwent TAVI in our center (mean age 78±6 years, EuroSCORE logistic 24.76±11.3%, hospital mortality 9.5%, total mortality 11.9%). Thirty-four patients in this group had perioperative monitoring of NT-proBNP plasma levels, with at least two measurements performed. Data were collected preoperatively (one sample) and at least one sample postoperatively (on mean 20±24.9 postoperative day). A retrospective data analysis was performed in correlation with procedure results and patients’ clinical status. Due to the small number of cases in the groups, non-parametric statistical tests were performed.

Results: Two patterns of change in the NT-proBNP plasma level were observed in the study. Twenty-one patients (61%) presented a significant (P=0.000013) decrease in the NT-proBNP plasma level: from 4941.9±4377.7 pg/ml preoperatively to 2640.2±2834 pg/ml postoperatively, whilst in 13 patients (39%) a significant (P=0.00087) increase in the measured NT-proBNP levels was noted – before TAVI: 1601.3±1099 and after: 4085.8±6606 pg/ml. In order to reveal the background of this observation, additional factors were analysed. COPD, FA, CAD, previous CABG, cardiac pacemaker were more frequently seen in the group with increased NT-proBNP (respectively: 53.85%, 61.54%, 84.62%, 46.15% and 69.23% of the patients in this group); however, these differences were not significant. Moreover, BMI, patients’ age, EuroSCORE logistic and creatinine plasma levels before and after the procedure, as well as LVEF before and after the procedure, were not statistically different between the groups. The peak transvalvular aortic gradient dropped significantly in both groups: from 102.5±33.4 to 25.1±7.7 mmHg in the group with decreased NT-proBNP (P=0.00002) and from 81.6±20.9 to 22.1±9.3 mmHg in the group with increased NT-proBNP (P=0.0008). There were no significant differences in the peak and mean gradients before and after the procedure between the groups. Postoperative mean gradients were: 12.2±4 mmHg (decrease of NT-proBNP) and 11.3±4 mmHg (increase of NT-proBNP).

Conclusions: Despite good echographic results in each analysed patient, both a significant perioperative increase and a significant perioperative decrease in the NT-proBNP plasma level have been observed in the study, NT-proBNP was not a good predictor of postoperative decrease of mean and peak gradient in TAVI patients.

C2-2 CEREBRAL ISCHEMIA AND COGNITIVE FUNCTIONING AFTER TRANSAPICAL MINIMALLY INVASIVE AORTIC VALVE IMPLANTATION

S.C. Knipp, P. Kahlert, D. Jokisch, J. Fritsch, S. Luck, D. Wendt, H. Jacob, M. Thielmann

Klinik für Thorax- und Kardiovaskuläre Chirurgie Universitätsklinikum, Essen, Germany

Objective: With dislodgement of debris from native usually heavily calcified aortic valve during ballon aortic valvuloplasty and deployment of the stent valve bioprosthesis, transapical aortic valve implantation (TAVI) inheres the risk of cerebral embolism. We prospectively studied neurological and cognitive outcome after TAVI and conventional aortic valve replacement (AVR).

Methods: Patients with severe aortic stenosis undergoing either TAVI (n=27, 82.2±4.7 years, logES 36.4%) or AVR (n=21, 67.4±7.6 years, logES 2.5%) were examined at baseline, before discharge and after three months. Cognitive function was assessed by a comprehensive battery of tests to various cognitive domains, and ischemic brain injury was detected by DW-MRI.

Results: There was one stroke in each group. On individual level, cognitive decline relative to baseline (decline in z-score ≥1 S.D.) was found in 61% vs. 48% at discharge, and 28% vs. 24% by three months after TAVI and AVR, respectively. On group level, early postoperative decline was observed in 1/6 tests after TAVI and 6/11 tests after AVR. At discharge, DWI revealed new brain lesions in 58% vs. 48% of patients after TAVI and AVR, respectively. Number of lesions/patient was similar in both groups but lesions were smaller after TAVI (mean, 90 vs. 224 μl, P<0.05). A correlation between cognitive decline and cerebral lesions, procedural or demographic parameters was not found in each group.

Conclusions: Although TAVI patients were elder and at higher surgical risk, neurological and cognitive outcome were comparable to AVR patients at normal risk. Cerebral embolic lesions were more frequent after TAVI, but this was not related to cognitive impairment.

C2-3 TRANSCATHETER AORTIC VALVE ORIENTATION HAS NO IMPACT ON VALVE-IN-VALVE HEMODYNAMICS

E.E. Tseng, A. Azadani, N. Jaussaud, L. Ge, S. Chitsaz, T.A. Chuter

University of California at San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA

Objective: Transcatheter aortic valve implantation (TAVI) for selected degenerated bioprostheses has yielded acceptable valve-in-valve (VIV) hemodynamics. However, while current transcatheter aortic valves (TAVs) are aligned in the annulus with respect to the axial direction to avoid coronary impingement and allow secure fixation, no effort has been made to align rotationally TAV and degenerated valve commissures. Whether rotational malalignment of TAV and degenerated bioprosthetic commissures has an impact on VIV hemodynamics is unknown. Thus, we studied the impact of TAV orientation on VIV hemodynamics.

Methods: Twenty millimeter TAVs were created based on Edwards SAPIEN valve design using stainless steel stents with trileaflet pericardial valve. Bioprosthetic degeneration of pericardial valves was simulated using BioGlue to achieve a mean pressure gradient of 50 mmHg, while porcine degeneration was simulated using BioGlue on two leaflets and cutting the third leaflet to yield stenosis and regurgitation. Degenerated bioprostheses were sutured in situ into human hom*ograft roots of matched sizes. TAVI within degenerated Carpentier–Edwards 19 mm pericardial and porcine bioprostheses was performed as VIV in standard orientation where TAV and bioprosthetic commissures were aligned and later with 60º rotation where TAV commissures were situated in the middle of bioprosthetic leaflets. VIV hemodynamics were studied in a custom-built pulse duplicator.

Results: No differences in mean pressure gradient were seen with 20 mm TAVI in 19 mm pericardial valves with standard orientation vs. 60° rotation (23.5±3.9 vs. 25.2±5.4 mmHg). No significant differences between standard orientation and 60° rotation was seen with respect to effective orifice area (1.07±0.10 vs. 1.04±0.14 cm²) or energy loss (582.3±27.5 vs. 610.0±74.7 mJ/stroke). Twenty millimeter TAVI in 19 mm porcine valves did not yield acceptable VIV hemodynamics irrespective of orientation. In both standard and 60° rotated orientation, mean pressure gradient was unacceptably high (43.9±7.5 vs. 41.2±2.6 mmHg); effective orifice was not improved (0.78±0.07 vs. 0.80±0.04 cm²), and energy loss was not reduced (726.3±79.6 vs. 689.0±35.4 mJ/stroke). Furthermore, orientation had no effect on coronary blood flow in standard or 60° rotated orientation (right coronary: 36.6±0.6 vs. 36.3±0.6 ml/min; left coronary: 57.0±1.0 vs. 57.6±0.6 ml/min).

Conclusions: Orientation of TAV commissures to align with bioprosthetic leaflet commissures had no effect on VIV hemodynamics when compared to placement of TAV commissures in the middle of degenerated leaflets. Surprisingly, TAV orientation had no impact on ostial coronary flow. New devices which have TAV rotational alignment to match diseased leaflets may have little impact on TAV hemodynamics.

C2-4 TRANSCATHETER IMPLANTATION OF AORTIC VALVE PROSTHESIS IN HIGH ESTIMATED SURGICAL RISK PATIENTS WITH CRITICAL AORTIC STENOSIS

R.S. Akchurin, T.E. Imaev, A.E. Komlev, M.R. Osmanov, P.M. Lepilin, A.A. Margolina, E.V. Dzibinskaya

Cardiology Research Center, Moscow, Russian Federation

Objective: Transcatheter aortic valve implantation (TAVI) has recently become a method of choice to repair valvular aortic stenosis, especially in a group of patients with high surgical risk. The objective of the study was to evaluate the immediate results of applying transcatheter aortic valve implantation in aortic valve surgery. Twenty-two patients underwent transcatheter aortic valve implantations (including one patient with previous mitral valve replacement and coronary bypass surgery) at the division of cardiovascular surgery of Russian Cardiology Research and Production Complex from February 2010 to December 2010.

Methods: Twenty-two patients with a mean age of 78 years were included. All patients had severe aortic stenosis. According to the echocardiograms an average gradient of systolic pressure on the aortic valve before the operation was 76.3±22.5 mmHg (102–62 mmHg). All patients were in III-IV functional class by NYHA. The risk of conventional open repair was >20% by EuroSCORE and >10% by STS. All patients underwent implantation of biological Edwards Sapien valves (Edwards Life Sciences, USA). In 10 cases implantation was performed through transfemoral access and in 12 cases transapical access was used due to severe atherosclerotic changes of iliac and femoral arteries.

Results: Intraoperative mortality was 4.5%: one patient (woman) died with symptoms of acute heart failure. One patient died on the fourth day from myocardial infarction. Total 30-day mortality rate was 9%. Other 20 patients had no complications. The average pressure gradient on the implanted aortic valve was 9.6±5.5 mmHg after the surgery. Average blood loss was 250 ml. All patients in the group with transapical implantation of aortic valves were extubated within 12 h after surgery. Length of hospital stay did not exceed over seven days.

Conclusions: Transcatheter aortic valve implantation can be successfully applied for surgical correction of critical aortic stenosis in patients with high estimated surgical risk for open-heart surgery as a real alternative to traditional aortic valve replacement in operations with artificial blood circulation.

C2-5 ECHOCARDIOGRAPHIC ASSESSMENT OF PATIENT PROSTHESIS MISMATCH AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)

T. Niklewski, M. Krason, K. Wilczek, R. Przybylski, P. Chodor, T. Kukulski, M. Zembala

Silesian Center for Heart Diseases, Zabrze, Poland

Objective: Echocardiography is one of the most important instruments used for qualification and monitoring of high-risk patients with severe aortic stenosis (AS) for transapical, transfemoral or through subclavian artery valve implantation (TAVI). We objectiveed to explore the echocardiographic, hemodynamic and clinical results of TAVI procedures performed in end-stage elderly AS patients.

Methods: Using transthoracic and transoesophageal echocardiography (TTE and TEE) 38 TAVI patients were analysed (32 females and six males) with mean age 79.6 years, BSA 1.83 m², mean logistic EuroSCORE 22.3% and STS score 14.26% who survived a period of three months observation. All TAVI procedures were uneventful. In 18 THVI patients with annulus 20–21 mm we used 23 mm valves and in 20 patients with annulus larger than 22 mm – valves 26 and 29 mm. We implanted 13 SAPIEN and 25 Core Valve prostheses.

Results: Mean gradient decreased from 68+22 to 14 mmHg (P=0.0001), EOA increased from mean 0.72 to 1.55 cm² (P<0.05), EOA index of all our group was 0.86 cm²/m² (0.73 cm²/m² for 23 mm and 1.08 cm²/m² for 26–29 mm prostheses, respectively). After valve implantation mean prosthesis annulus relaxation using the 23 mm and 26 mm prosthesis were 20 mm and 23 mm measured in long axis view of TTE and TEE echocardiography we observed trivial perivalvular leakage in 12 and moderate in four patients.

Conclusions: Our echocardiography data have shown that despite of THVI significant improvement of mean AVA and decreased transvalvular gradient, implanted valves expanded only to preoperatively measured annular diameter, what may result in moderate patient prosthesis mismatch (0.85–0.60 cm²/m²), which could influence on left ventricular function and mass reduction in the future. However, this hypothesis needs further clarifications.

3rd Cardiac Surgery Session – Miscellaneous I May 20, 2011 15:30-16:30

C3-1 CORRELATION BETWEEN MICROALBUMINURIA AND GLOMERULAR FILTRATED RATE AT CARDIOSURGICAL PATIENTS

M.A. Charnaya, Yu.A. Morozov, I.I. Dementieva, V.G. Gladisheva

Petrovsky National Research Center of Surgery RAMS, Moscow, Russian Federation

Objective: The objective of the study is to find an interrelation between glomerular filtrated rate and microalbuminuria at cardiosurgical patients.

Methods: On 209 cardiosurgical patients undergoing CPB, were done tests of blood and urine in order to levels of urea, creatinine, ions of sodium and potassium with calculation of glomerular filtrated rate (GFR, ml/min), transtubular potassium gradient (TTPG, %), fractional excretions of urea (FEUr, %) and sodium (FENa, %), in urine investigated microalbuminuria (MAU, mg/min) before operation, one and three postoperative days. Renal dysfunction (RD) considered as decrease GFR on 33% and more by preoperative value.

Results: Patients have been allocated in four groups, depending on preoperation GFR: group 1 (n=30) – GFR <60, group 2 (n=38) – GFR 60–80, group 3 (n=87) – GFR 80–120, group 4 (n=54) – GFR over 120 ml/min. The tendency on reduction of patient age in groups 1–4 was revealed. In groups 1 and 2 parity of men and women makes 1.5–1.7: 1, and in groups 3 and 4 – 6.9-4.4: 1. initial hyperfiltration was associated with tubulopathya signs – increase TTPG, decrease FEUr, FENa, and initial hypofiltration – with decrease in renal water secretory function. In one postoperative day it is revealed that the maximum quantity of patients with RD was in group 1 – 50%, and minimum – in group 2 – 3.4%. In groups 2 and 4 patients with RD was 21.1 and 22.2%, respectively. For three postoperative days in all groups the number of patients with RD was approximately identical. After coronary arteries bypass grafting, following equations of regress for decrease GFR=–31.4x+171.2, r²=0.9555 and MAU=3.07x+20.3, r²=0.8583 have been received. At patients with valve replacements of the equation of regress are presented as GFR=–28.21x+159.0, r²=0.9775 and MAU=4.72x+36.0, r²=0.983. At after surgical aortic aneurysms correction of the equation of regress represent GFR=–33.08x+175.35, r²=0.9546 and MAU=10.567x³–74.2x²+151.63x–40.8, r²=0.956.

Conclusions: Women older than 55 years had a sharp and progressing decrease in renal function. Initial hyperfiltration associated with tubular dysfunction, and a hypofiltration – with decrease in renal water secretory function. The increase MAU at 1 mg/min in the early postoperative period testified to decrease GFR on 4.5 ml/min after coronary arteries bypass grafting, on 3.8 ml/min – after valves replacement and on 5.4 ml/min – after surgical treatment of aortic aneurysms. It can be used for an estimation renal functions on MAU level at cardiosurgical patients.

C3-2 RESULTS OF BADALONA ULTRA FAST-TRACK PROTOCOL

A. Colli, C. Fernandez Gallego, B. Romero-Ferrer, L. Delgado-Ramis, M.L. Camara-Rosell, X. Ruyra-Baliarda

Hospital Universitari Germans Trias i Pujol, Badalona, Spain

Objective: Recent objective of minimally invasive adult cardiac surgical techniques and transcatheter valve procedures has emphasized the advantage of early hospital discharge. However, we compare the safety, efficacy, and feasibility of ultrafast-track protocol while retaining standard cardiac surgery procedure.

Methods: From May 2009 to January 2010 a total of 408 consecutive patients underwent cardiac surgery procedures at our institution and were treated with an ultra fast-track protocol including the extubation directly in the operating room, normothermic surgery, and use of sternal continuous local anesthetic infusion. These patients were retrospectively compared with a historical control group of patients who underwent cardiac surgery prior to the ultra fast-track implementation by the same surgical team.

Results: The two groups of patients were preoperatively similar with similar age, co-pathologies and EuroSCOREs. Ultra fast-track patients extubated in the operating room were significantly higher than in historical cohort (66% vs. 4%, P<0.0002), as well as the number of the patients having <24 h length of stay in the intensive care (37% vs. 7%, P<0.0002), and a reduced overall hospital length of stay (10±0.6 days vs. 13±0.8, P<0.05). The number of ultra fast-track patients also had a lower risk of urinary infections (4% vs. 7%, P<0.05), lower risk of postoperative renal failure (2% vs. 5%, P=0.01) and lower need of prolonged inotropic drug support (2% vs. 7%, P=0.0009).

Conclusions: The Badalona ultra fast-track protocol is a safe and effective method to manage cardiac surgery patients. Early extubation is suitable as routine procedure in the vast majority of patients.

C3-3 SUCCESSFUL REPLACEMENT OF BEAGLE PULMONARY VALVES BY IN VIVO TISSUE-ENGINEERED VALVED-CONDUITS WITH THE SINUS OF VALSALVA ‘BIOVALVES’

M. Yamanami, M. Uechi, H. Ishibashi-Ueda, T. Tajikawa, K. Ohba, K. Kanda, H. Yaku, Y. Nakayama

Kyoto Prefectural University of Medicine, Kyoto, Japan

Objective: We developed autologous prosthetic implants by simple and safe in-body tissue architecture technology, which is a practical concept of regenerative medicine, without using special sterile conditions or complicated in vitro cell treatment processes. We present the development of autologous valved conduit with the sinus of Valsalva (BIOVALVE) by using this unique technology, and its subsequent implantation in the pulmonary valves in a beagle model.

Methods: A mold of BIOVALVE organization was assembled using two types of specially designed silicone rods with a small aperture in a trileaflet shape between them. The concave rods had three projections that resembled the protrusions of the sinus of Valsalva. The molds were placed in the dorsal subcutaneous spaces of beagle dogs. After four weeks of implantation, autologous connective tissues completely covered the surface of the molds and migrated into their apertures. BIOVALVEs with three leaflets in the inner side of the conduit with the sinus of Valsalva, and consisting only of autologous tissues, were obtained after removing the molds. These BIOVALVEs were implanted to the main pulmonary arteries as allogenic conduit valves under cardiopulmonary bypass (n=3).

Results: The BIOVALVEs had three separated leaflets in the luminal surface of the conduit with the sinus of Valsalva. They were composed only by autologous connective tissues without any support of synthetic methods, and had adequate mechanical properties similar to those of native valves. These valves had adequate burst strength, similar to that of native valves. Tight valvular coaptation and sufficient open orifice area were observed under the flow circuit in vitro. In implantation experiment, postoperative echocardiography demonstrated smooth movement of the leaflets with trivial regurgitation in the observation period of up to 84 days. Histological examination of specimens obtained at 84 days showed that the surface of the leaflet was covered by endothelial cells and neointima, including an elastin fiber network, was formed at the anastomosis sides on the luminal surface of the conduit.

Conclusions: We developed the completely autologous BIOVALVEs with the sinus of Valsalva by using a living body as the bioreactor for tissue organization and successfully implanted these BIOVALVEs in a beagle model in a preliminary study. Completely autologous BIOVALVEs with no synthetic support methods have excellent biological compatibilities which could be applied to growing children and patients with infective endocarditis.

C3-4 MECHANICAL RESISTANCE OF CRYOPRESERVED AORTIC VALVE LEAFLETS IS NOT AFFECTED BY DECELLULARIZATION

M. Pesce¹, A. Guarino¹, E. Penza¹, M. Soncino², B. Fiore², B. Micheli¹, L. Dainese¹, G.L. Polvani¹

¹Centro Cardiologico Monzino, Milan, Italy; ²Politecnico di Milano, Dipartimento Bioingegneria, Milan, Italy

Objective: The use of decellularization protocols may be an useful approach for the development of bio-compatible aortic valves as alternative to currently used biological valves. The objective of the study was therefore to evaluate whether mechanical differences exist between decellularized and non-decellularized heart valve leaflets.

Methods: Between July 2009 and May 2010 heart valve leaflets mechanical characterization was performed. This study analysed mechanical resistance of valve leaflet tissue cryopreserved in vapor nitrogen ranging from four to 14 years. Fourteen specimens were obtained from non-decellularized (PRE), while 15 specimens were derived from decellularized valves (POST). PRE and POST specimens were morphologically analysed by hematoxylin and eosin staining. Decellularization was performed by a proteolytic enzyme (trypsin)-based protocol, followed by RNA digestion. Mechanical testing was performed at room temperature immediately after thawing. Before performing mechanical tests, width, length and depth of the samples were measured. Before applying test tractions, samples were mechanically pre-conditioned by serial load and unload cycles until reaching steady relaxation conditions. Mechanical characterization protocol consisted in: relaxation tests, allowing tissue stress variation measurement upon traction at a defined load value (200 kPa) over a fixed time period (500 s). Traction test, enabling tissue deformation calculation under an increasing traction force. This test permits to obtain load-deformation curve from which elastic modulus, maximum length and maximum load after breaking values are estimated.

Results: Histological staining showed that decellularization was complete, as observed by absence of nuclei in transverse sections. Mechanical testing allowed the derivation of parameters describing resistance of native and decellularized valve leaflets to traction: maximum load value (the parameter describing maximum load before tissue rupture) was 2.011±1.298 Mpa (mean±S.D.) vs. 1.452±1.206 Mpa (PRE vs. POST-decellularization protocol); maximal tension at rupture was 2008.167±1492.628 N/m vs. 1133.855±627.989 N/m (PRE vs. POST); finally, maximal deformation at breaking was 0.15±0.073 mm/mm vs. 0.142±0.072 mm/mm (PRE vs. POST). Analysis by unpaired t-test showed that all parameters did not statistically differ in PRE vs. POST conditions.

Conclusions: Our results show the feasibility of enzyme-based decellularization protocols for the derivation of cell-free aortic valve leaflets. They further suggest that no major modifications of the mechano-elastic properties occur as a consequence of decellularization protocol.

C3-5 NOVEL TECHNIQUE OF INDUCING ISCHEMIC PRECONDITIONING DURING CARDIAC SURGERY

D.I. Kurapeev, M.M. Galagudza, V.O. Kabanov, V.K. Grebennik, V.V. Dorofeykov, A.P. Mikhailov

Almazov Heart, Blood and Endocrinology Center, Saint Petersburg, Russian Federation

Objective: Ischemic preconditioning (IPC) commonly regarded in having a powerful internal protective effect on the organs. Studies of IPC in cardiac surgery provide conflicting results, but the majority of studies show that IPC is an effective adjunct to myocardial protection in cardiac surgery. The aim of this study was to develop a novel technique of inducing IPC during cardiac surgery with no-touch aorta technique. This work was supported by a research grant from the Ministry of Education and Science of the Russian Federation No 16.512.11.2043.

Methods: From May 2010 to December 2010, 50 patients with three-vessel coronary artery disease (CAD) and stable angina, receiving first-time elective coronary artery bypass grafting (CABG), were randomly divided into two equal groups: IPC plus intermittent isothermal blood cardioplegia (IIBC) (IPC+IIBC group, n=25); and IIBC (IIBC group, n=25). Exclusion criteria: age >65 years, ejection fraction <50%, unstable angina, STEMI or non-STEMI <3 months before surgery, confirmed by ECG and cardiac markers, diabetes mellitus, severe extracardiac pathology, inotropes before cardiopulmonary bypass (CPB). Cannulation of the heart and venting were performed in typical manner, according to the operation type or surgeon preference. Antegrade cardioplegia cannula is placed into the aortic root proximal to the aortic cross-clamp. After aortic cross-clamp, left vent decompressed the heart. Decompressed heart was performed for 3 min in global ischemia conditions. After this, 3 min reperfusion through the antegrade cannula with normothermic blood was performed. Two cycles of ischemia/reperfusion were performed for induction of IPC. After the second reperfusion, typical IIBC protocol was initiated. The study was registered and approved by Local Ethical Committee.

Results: There were no complications and in-hospital death cases in both groups. We have collected blood samples during perioperative period for biochemical (troponin I, CK-MB mass, myoglobin, blood gas testing) analyses. Thin needle biopsy for histology, immmunohistochemistry and Western blotting were taken in both groups. Currently, we are continuing data collection and analyses and will publish it in the near future.

Conclusions: Thus, IPC during cardiac surgery can be safe and readily induced without additional use of the aortic cross-clamp, avoiding possible embolic complications.

C3-6 SURGICAL STRATEGY IN ASSOCIATED LESIONS OF CORONARY AND CAROTID ARTERIES

L.A. Bockeria, I.Yu. Sigaev, Z.K. Pirtskhalaishvili, M.M. Alshibaya, V.Yu. Merzlyakov, N.A. Darvish, O.L. Bockeria, I.V. Klyuchnikov, T.N. Serguladze, D.G. Tsirikhova, A.A. Ozolinsh

Bakoulev SCCVS, Moscow, Russian Federation

Objective: To analyse the results of surgical treatment of coronary artery disease (CAD) in patients with combined cerebral atherosclerosis.

Methods: The study included 504 patients [428 men (84.9%), 76 women (15.1%) with mean age 56.4±5.3 years] with combined lesions of coronary and carotid arteries. In dependence on surgical treatment all patients (n=504) were divided into three groups: first group of patients underwent one-stage operation (n=196); second group included patients with first- stage carotid endarterectomy (n=215), third group included patients with first-stage coronary artery bypass grafting (n=93). Division of patients on types of chronic cerebrovascular failure was performed according to the classification of Bakoulev Scientific Center: 1 stage – 28%, 2 stage – 31%, 3 stage – 41%. Division by CCS (Canadian Cardiology Society): painless ischemia – 3.2%, Angina I functional class – 4.5%, Angina II functional class – 16%, III-IV functional class – 76.3%. MI in history ln 51.3%. Cardioneurological examination included ECG, Holter, ECHO, stress ECHO, ultrasound of the brachiocephalic vessels with functional stress tests which has been performed in all patients. All patients underwent angiocoronarography, angiography of the brachiocephalic arteries (25 patients underwent MR angiography). MRI or CT of the brain have been carried out in 42 patients after stroke to determine the size of the lesion. CT with cerebral perfusion has been performed in 21 cases to define the risk of cerebral ischemia during surgery.

Results: Overall mortality was 2%, neurological complications – 2.2%, cardiac complications (including arrhythmia) – 4.2%.

Conclusions: A comprehensive assessment of anatomical features of lesions and functional status, as well as perfusion and functional reserve of the heart and brain makes it possible to choose the appropriate surgical treatment in patients with combined lesions of coronary and carotid arteries and reduce the probability of intra- and postoperative cerebral and cardiac complications.

4th Cardiac Surgery Session – Miscellaneous II May 20, 2011 15:30–16:30

C4-1 IMPLANTATION OF CAVA FILTER AS A PREVENTIVE METHOD OF PULMONARY THROMBOEMBOLISM IN PATIENTS WITH EMBOLEGENIC DEEP VEIN THROMBOSIS OF LOWER EXTREMITIES

A.V. Bocharov

Novgorod Regional Clinical Hospital, Velikiy Novgorod, Russian Federation

Objective: To evaluate the results of implantation of cava filter in the inferior vena cava as a method of prevention of pulmonary embolism in patients with embologenic deep vein thrombosis of lower extremities.

Methods: An analysis of implantation of cava filter to the inferior vena cava has been carried out in 39 patients with thrombosis of deep veins of the lower extremities. All cases had and a high risk of pulmonary embolism. The patients’ age varied from 20 to 70 years. All patients underwent implantation of cava filter ‘OptEase’ of company ‘Cordis’ in the infrarenal portion of inferior vena cava. Preoperatively, and 48 h after surgery, patients underwent ultrasound angioscanning of veins of lower extremities was carried out. The results were evaluated in the first five days and 1.3 months after implantation of cava filter. All patients received warfarin in dose adjusted to international normalized ratio. Implantation of cava filter on an emergency basis was performed in 33 patients (91%). It was performed in cases of flotation of a blood clot above safeno-femoral junction (44%), recurrent pulmonary embolism (22%), progression of deep vein thrombosis of lower limbs, despite ongoing therapy (34%). In 22 patients (57%) pulmonary embolism of varying severity was presented on admission to the hospital. Localization of deep-vein thrombosis was in ileofemoral (60%) and femoral-popliteal (23%) segments. Flotation of a blood clot was detected in 17 patients (49%). Cause of deep vein thrombosis in the majority of cases was malignant neoplasms (51%).

Results: The death caused by pulmonary embolism during the observation period was not recorded. Three patients died from progression of cancer process. According to the ultrasound angioscanning in the postoperative period in 29 patients (83%) in the cava filter there were trapped thrombi. In one patient with malignant tumors developed the inferior vena cava syndrome in the period 2.5 months after the implantation of cava – the filter. The cause of syndrome was the compression of the inferior vena cava by enlarged lymph nodes. The possibility of cava filter was preserved.

Conclusions: Surgical prophylaxis of pulmonary embolism using cava filter in patients with embologenic deep vein thrombosis of lower extremities can significantly reduce mortality caused by this complication.

C4-2 EFFICACY OF LEVOSiMeNDAN PRETREATMENT IN HIGH-RISK CARDIAC SURGERY PATIENTS

A. Bautin

Almazov Federal Heart, Blood and Endocrinology Center, Saint Petersburg, Russian Federation

Objective: To estimate efficacy of levosimendan pretreatment in high-risk cardiac surgery patients.

Methods: Sixty-four patients have been included to prospective randomized study. All patients were operated because of combined valves pathologies and had injection fractions <40%. Patients have been divided in two groups: 33 patients of the first group receive levosimendan (Simdax Orion corporation) infusion after induction to anesthesia, before incision. For patients of control group we used standard anesthesiology management. There were no differences between patients of main and control groups. All patients of main group receive bolus of levosimendan 12 μg/kg followed by infusion 0.2 μg/kg/min. If required, patients received acute heart failure therapy, included inotropes.

Results: There were significant differences in postoperative course between the two groups. ICU stay duration was 97.2±16.6 h in main group and 138±20.2 h in control group (P<0.05). Respiratory support duration in main group was 27.05±3.1 h, in control group – 38.25±3.6 h (P<0.05). Mortality rate was 11% in main group and 33% in control group (P<0.05). There were no significant increase of adverse effects in main group. So, atrial fibrillations paroxysm rate in main group was 12%, in control group – 14% (NS). Vazopressor agents were used in 4/12.1% in main group and 3/9.7% in control group (NS).

Conclusions: We found out that levosimendan pretreatment in high-risk cardiac surgery patients improved postoperative period and decreased mortality rate.

C4-3 MORTALITY RISK STRATIFICATION AND TREATMENT MONITORING IN JEHOVAH’S WITNESS PATIENTS WITH SEVERE ANAEMIA

A.M. Beliaev, R.J. Marshall, W. Smith, J.A. Windsor

Department of General Surgery, Auckland City Hospital, Auckland, New Zealand

Objective: The management of severe anemic Jehovah’s Witness (JW) patients, who refuse blood transfusion on religious grounds, is challenging. In the published literature there are a few cohort studies, which consider patient- and treatment-related risk factors of mortality in isolation and are lacking in their predictive power. This does not allow clinicians to stratify severe anaemic JW patients into different mortality risk groups, to monitor and alter patients’ management. The objective of this study was to identify patient- and treatment-related risk factors of mortality and develop predictive mortality risk stratification and treatment monitoring instruments for severe anaemic JW patients.

Methods: This retrospective cohort study evaluated predictors of mortality for severely anaemic JW patients who refused allogeneic red blood cell transfusion on religious grounds. JW patients, including cardiothoracic, vascular and interventional radiology patients, were identified from the records of four major public hospitals of New Zealand for the period from 1998 to 2007 inclusive. The inclusion criteria were 15 years and older and severe anaemia (haemoglobin concentration is ≤80 g/l). Palliative care patients were excluded from the study.

Results: Patient-related and treatment-related risk factors of mortality for severe anaemic JW patients were identified and used to construct a combined mortality predictive scores, Auckland Anaemia Mortality Risk Score (Auckland MRS) and Hamilton Anaemia Mortality Risk Score (Hamilton MRS), respectively. This allowed stratification of severely anaemic JW patients into groups according to the Auckland MRS. It has been shown that JW patients with Auckland MRS of 0–3 had 5% mortality, Auckland MRS 4–5 (23%), Auckland MRS 6–7 (46%) and Auckland MRS eight and above (86%). Hamilton MRS was calculated on the basis of patients’ treatment-related risk factors each patient had. It has been demonstrated that the JW patients with Hamilton MRS of 0 had 4% mortality, Hamilton MRS 1 (19%), Hamilton MRS 2 (40%) and Hamilton MRS 3 and above (64%).

Conclusions: Mortality of severe anaemic JW patients was predictable for patients’ Auckland and Hamilton Anaemia Mortality Risk Scores, which allowed JW patients’ stratification and monitoring treatment progress.

C4-4 HIGH-RISK PULMONARY THROmBOEMBOLISM: PRACTICAL APPROACH TO COMPLEX TREATMENT

A. Medvedev¹, V. Pichugin¹, S. Nemirova¹, S. Jourko², N. Melnikov², A. Bogush², V. Prytkov²

¹Nizhny Novgorod State Medical Academy, Nizhny Novgorod, Russian Federation; ²Cardiac Surgery Centre, Nizhny Novgorod, Russian Federation

Objective: The objective of this study is to evaluate possibilities of surgical desobstruction of pulmonary blood flow in high-risk patients with massive pulmonary thromboembolism.

Methods: Forty-five patients with acute total or subtotal thromboembolic obstruction of the pulmonary artery or main branches were operated. Mean age was 40.60±9.17 (from 17 to 82) years; males – 20, females – 25. Complex preoperative diagnostic investigation was performed to all patients. Pulmonary embolism was evaluated as massive and high-risk in all patients (three patients were operated after cardiac arrest and cardio-pulmonary resuscitation; 22 patients were taken in operation room with severe shock; 20 patients had severe right ventricle dysfunction). All patients were in IV functional class (NYHA); 32 patients had pulmonary infarction. Indications for surgery were as follows: pulmonary thromboembolism with right ventricle dysfunction and pulmonary hypertension more than 50 mmHg, if patient had contraindications for thrombolytic therapy; ineffectiveness of thrombolytic therapy; intracardiac thrombi or emboli; central or mixed (central+peripheral) localization of pulmonary thromboemboli. Nine patients were operated after unsuccessful thrombolytic therapy and 21 patients had absolute contraindication for thrombolytic therapy. Thromboembolectomy using off-pump technique was performed in seven patients, thromboembolectomy using cardiopulmonary bypass was performed in 38 patients. Retrograde pulmonary perfusion was supplemented to conventional embolectomy in eight patients.

Results: Mean stay in ICU was 72.00±12.83 h. Early postoperative complications included: two patients with lung reperfusion syndrome and four patients with acute respiratory failure and prolonged artificial ventilation of the lungs. Hospital mortality rate was 6.6%, three patients died, the causes of death were severe right ventricle failure (2) and multiorgan failure (1). All these patients were operated later than 14 days after thromboembolic event. Recurrence of deep veins thrombosis of lower extremities was registered in seven patients as result of anticoagulant therapy failure in 2–3 months after surgery. Recurrence of deep veins thrombosis with following non-massive pulmonary embolism of small pulmonary vessels was registered in two patients. One patient died after complicated hemicolectomy (cancer) in six months. Thirty-seven patients were in good stable condition, pulmonary artery mean pressure was 27.05±3.11 mmHg.

Conclusions: Adequate surgical desobstruction of pulmonary vessels performed in central and mixed (central+peripheral) types of pulmonary embolism is low-risk and effective operation that can cause the complete regress of cardiopulmonary pathology.

C4-5 A NOVEL SURGICAL-PERFUSIOnAL TECHNIQUE FOR TREATMENT OF RENAL CANCER EXTENDING INTO THE HEART

G. Bisleri¹, A. Moggi¹, S. Cosciani¹, A. Antonelli¹, F.H. Cheema², C. Muneretto¹

¹University of Brescia Medical School, Brescia, Italy; ²Columbia College of Physicians and Surgeons, New York, USA

Objective: Renal carcinoma extending into the inferior vena cava (IVC) and right atrium (RA) occurs in 4–25% of cases. In such instances, it is mandatory to perform a concomitant nephrectomy and thrombus excision by means of a combined approach utilizing cardiopulmonary bypass (CPB) and circulatory arrest. We evaluated the outcome of a novel surgical and perfusional technique for such type of procedures.

Methods: Ten patients (five males) underwent nephrectomy and thrombus removal; mean age was 68.5±10.8 years. In all cases the thrombus extended above the supra-hepatic veins into the RA. This novel approach was developed to allow cerebral perfusion during circulatory arrest: following conventional median sternotomy, the ascending aorta as well as cannulation of both the RA and the superior vena cava (SVC) was performed. Once moderate hypothermic (30 °C) was achieved, the aorta was cross-clamped and crystalloid cardioplegia administered; then, an additional clamp was placed in the aortic arch, between the left common carotid artery and the left subclavian artery; following opening of the RA, venous drainage was ensured exclusively by the cannula in SVC; therefore, a continuous cerebral perfusion was delivered from the SVC to the aortic arch during the circulatory arrest. Following concomitant right atriotomy and IVC opening (form the abdominal side), the neoplastic mass was completely removed. Finally, the RA was sutured, the cannula in RA reinserted, either clamps released and full normothermic CBP was re-established.

Results: All procedures were successfully performed without any intraoperative complications. Mean time for aortic arch isolation was 4±3 min; one patient underwent concomitant aortic valve replacement. Mean CPB time was 75.4±18.5 min, mean circulatory arrest with cerebral perfusion time was 15.6±5.3 min. Postoperative ICU stay was 2.7 days (mean). There were no early major postoperative complications, nor there were any neurological injuries. One patient with severe COPD died due to respiratory failure and sepsis on 27th POD. The remaining nine patients were successfully discharged after a mean hospital stay of 19.4±5.5 days. At the mean follow-up of two years, 44.4% (4/9 patients) are alive; all postoperative deaths were not cardiac-related.

Conclusions: This novel surgical perfusion technique allows avoidance of deep hypothermic circulatory arrest and related complications. This approach provided a physiologic cerebral perfusion under moderate hypothermia during body circulatory arrest with no evidence of neurological injury and impairment and should be considered the technique of choice for the treatment of renal tumor extending into the supra diaphragmatic vena cava or into the heart.

C4-6 IS A SINGLE-STEP SURGICAL TREATMENT OF CORONARY ARTERY DISEASE AND ANEURySMAL DISEASE OF THORACOABDOMINAL AORTA JUSTIFIED?

R.N. Komarov, Yu.V. Belov, A.B. Stepanenko, A.P. Gens, N.Yu. Stogny

Russian Academy of Medical Sciences, National Research Center for Surgery named by academician B.V. Petrovsky, Moscow, Russian Federation

Objective: To substantiate the advisability of single step surgical treatment of coronary artery disease and aneurysmal disease of thoracoabdominal aorta.

Methods: Our experience summarizes 10 single-step operations of myocardial revascularization in combination with prosthesis of descending thoracic and thoracoabdominal aorta. Mammary coronary anastomosis was made in four patients ‘without perfusion’ in combination with prosthesis of descending thoracic aorta. Various modifications of perfusion, such as left heart bypass with the stage of myocardial revascularization on a beating heart (n=1), peripheral extracorporeal circulation/circulatory arrest with the stage of myocardial revascularization on stopped heart/parallel extracorporeal circulation (n=5) also have been used. No lethal cases, perioperative myocardial infarctions were observed in studied group of patients.

Results: The indications to correction of concomitant coronary insufficiency in each specific case require the individual approach (the approach, extent of operation and organs’ protective technique). In case of focal lesion of anterior interventricular artery/diagonal branch and planned ‘local prosthesis’ of descending aorta, it is advisable to accomplish mammary coronary bypass graft as a single-step from the left-sided thoracotomy on a beating heart and the stage of aorta prosthesis – from the same approach under conditions of left heart bypass. In similar circ*mstances, it is possible to perform the modification of atypical autovenous bypass graft of posterior-lateral branch of the first order. In forced cases, such as ischemic changes in ECG at aorta mobilization it is possible to perform multiple CABG (posterior interventricular branch, posterior-lateral branches) under conditions of complete peripheral extracorporeal circulation both with cardioplegia and parallel extracorporeal circulation followed by prosthesis of thoracoabdominal aneurysm under conditions of circulatory arrest.

Conclusions: The pursuit to complete patients’ rehabilitation within short time, economic expediency, experience of the surgical team offer the possibility to expand indications to the single-step operations. The surgical risk associated with performing CABG in patients with aneurysms of descending thoracic and thoracoabdominal aorta, is absolutely justified, and coronary revascularization allows to decrease the rate of coronary complications.

C4-7 THREE YEARS AFTER APROTININ’S WITHDRAWAL. WAS IT A CORRECT DECISION?

A. Paschalis, S. Datta, A.A. Steit, Y.A. Nasher, F. Hashmi, B. O’Neill, T. Velissaris, R. Hasan

Manchester Royal Infirmary, Manchester, UK

Objective: It has been three years since the use of aprotinin was discontinued in cardiac surgery following the results of the BART study. The objective of our study was to compare the outcome of patients before and after aprotinin’s withdrawal at our center.

Methods: One thousand six hundred and sixty-four patients who had first time, isolated on-pump CABG from November 2005 to October 2009 were evaluated. Patients who had preoperative renal impairment and previous stroke were excluded from the study. Logistic regression analysis and Cox proportional regression analysis were used to evaluate whether aprotonin was a risk factor for postoperative renal failure, blood usage, re-exploration, stroke and increased in-hospital mortality.

Results: Among 1664 patients, 795 received full dose aprotinin and 869 patients did not. Blood usage was less in the aprotinin group but was not statistically significant (P<0.075) (n=16 vs. n=29). Re-exploration for bleeding was significantly less in the aprotinin group (P<0.056) (n=30 vs. n=49). The aprotinin was not a risk factor for developing postoperative renal failure requiring dialysis (P<0.108) (n=20 vs. n=12) and stroke (P<0.524) (n=2 vs. n=1). There was no difference in postoperative worst creatinine (P<0.204) (112±63 vs. 108±61) and worst eGFR (P<0.176) (77±35 vs. 80±36) between the two groups. Re-intubation rates were higher in the aprotinin group (P<0.005, OR 2.8, 95% CI: 1.3–3.8) (n=36 vs. n=18). There was no difference in the in-hospital mortality (P<0.66) (n=19 vs. n=16) between the two groups.

Conclusions: Contrary to what has been reported earlier, aprotinin usage did not affect renal function, stroke rates and in-hospital mortality rates in our experience. Re-exploration for bleeding rates has risen since the discontinuation of aprotinin. We claim that a larger multi-institutional study may be required to validate our findings.

5th Cardiac Surgery Session – Video May 20, 2011 15:30–16:30

C5-1 METHOD OF POSTANEURYsMECTOMY LEFT VENTRICLE PLAStY AND SIMULTANEOUS INTERVENTRICULAR SEPTUM PLICATION USING two- STOREY STITCH

V.I. Ursulenko, A.V. Rudenko, L.S. Dzakhoieva, S.V. Salo

National Institute of Cardiovascular Surgery, AMS of Ukraine, Kiev, Ukraine

Objective: To evaluate efficiency of the method of left ventricle (LV) plasty with the use of a two-storey stitch and simultaneouse plication (goffering) of interventricular septum (IVS) elaborated by us according to the data of a control ventriculography and ECHO cardiohemodynamic indices.

Methods: Seven thousand five hundred and twenty-nine patients with ischemic heart disease were operated between 2001 and 2010, the course of the disease in 1193 (18.8%) of them was complicated by the development of left ventricular aneurysms (LVA). Postoperative mortality after LVA resection composed 2.9% during 2001–2007, it decreased to 1.4% in 2008–2009. There were no lethal events in 145 consecutive LVA aneurysm resections in 2010. Our method of postinfarction LVA surgical treatment included off-pump coronary arteries bypass grafting (in separate cases heart–lung bypass machine worked in parallel) but resection of the dome of an aneurysm and two-layer stitch plasty with simultaneous goffering of IVS was fulfilled with artificial heart fibrillation.

Results: Postinfarction LV aneurysms caused total deformation and enlargement of LV cavity. The use of patches for LV cavity decrease entails forming big zones of ischemia, which has negative impact on immediate and remote results. The use of our method (n=274) showed that after resection of big aneurysms and LV cavity reconstruction signification decrease of EDLVV (from 224.4±45.5 to 165.5±37.3 ml) ESLVV (from 143.5±18.4 to 91.9±15.4 ml) increase of EF (from 36.2±6.3% to 47.4±3.8%) decrease of LVEDP (from 21.1±5.1 to 12.3±3.7 mmHg), decrease of PA hypertension (from 57.3±9.3 to 36.4±3.8 mmHg), are observed. This was evidenced by ventriculography and ECHO data.

Conclusions: Postoperative study [ECHOCG and ventriculography (n=27)] after resection of big, typical LVA showed, that our method of LV plasty permits to form geometrically adequate LV chamber, it is an effective method of LV plasty after resection of middle and big aneurysms. This method permits to obtain improvement of LV contractile function already in the hospital postoperative period, which is evidenced by significant increase of EF, decrease of LVEDP, decrease of PA pressure, decrease of LV volume.

C5-2 RIGHT ANTERIOR MINITHORACOTOMY: A NEW PATH FOR MINIMALLY-INVASIVE AORTIC VALVE REPLACEMENT

E. Penza

Centro Cardiologico Monzino, Milan, Italy

Objective: Less invasive approaches for aortic valve replacement have been developed in the last 10 years. We describe our approach through a right anterior minithoracotomy.

Methods: Patients selection plays a pivotal role in successful minimally-invasive aortic valve replacement. Our criteria are: BMI £ 25, £ 70 age £ 85 years old, COPD, neither previous cardiac surgery nor concomitant CABG – mitral valve surgery or ascending aorta aneurysm. Surgery is performed under general anaesthesia. The patient is positioned supine with an air sack under the right scapulae in order to put the right chest upward or downward if deinflated. For intubation is recommended a carlens tube for single left lung ventilation when necessary. Endocardial pace leads are positioned percutaneosly and defibrillator pads are placed across chest wall. Transesophageal echocardiography is mandatory. A right straight incision is performed (mean length 7 cm), through third intercostals space. A soft tissue retractor allows a good exposure of the pericardium. Once opened the sierosa stay sutures allow a good access to the mediastinum. Cardiopulmonary bypass is settled with an arterial line in right common femoral artery and venous drainage throughout the right atrium. Vent is positioned in right upper pulmonary vein. A single purse is put in ascending aorta for anterograde perfusion and final dearing. CO₂ gas insufflation minimizes the risk of air embolism. The aorta and pulmonary artery are dissected, a linen stitch is placed in transverse sinus. Cardioplegia is delivered as a single dose of crystalloid solution (Custodiol) into the aortic root, or selectively into both coronary ostia if there is significant regurgitation.

Results: From May 2009 to December 2010, 21 minimally-invasive aortic valve replacement were performed using this technique in our centre. Two cases were converted to conventional sternotomy because of bleeding and aortic root discontinuity. There was no mortality and no complication related to this procedure. According to patient’s anatomic features, incision can be done also in 2nd–4th intercostal space. At the beginning of our experience both lines for cardiopulmonary bypass’s installation were placed in femoral vessels; atrium cannulation allows a better exposition of the aortic root by pulling down the venous cannula.

Conclusions: Minimally-invasive cardiac surgery offers the benefits of open heart operations with decrease pain and limited skin incision. With its several recognized advantages this technique certainly requires some dedicated skills and experience of surgeons, anesthesist and perfusionist for a successful result.

C5-3 NEW SIGNS OF MYOCARDIAL DYSFUNCTION IN PATIENTS WITH SEVERE AORTIC VALVE STENOSIS

N. Maroz-Vadalazhskaya

Scientific-Practical Center ‘Cardiology’, Minsk, Belarus

Objective: The impairment of myocardial deformation is revealed in patients with hypertrophic or dilated cardiomyopathy. Nevertheless, patients with normal or wide QRS and significant left ventricular (LV) myocardial wall hypertrophy due to aortic valve stenosis had myocardial dyssinchrony and myocardial dysfunction, which are not clearly understandable. The objective was the estimation of myocardial Doppler velocities and myocardial longitudinal deformation patterns in patients with significant rheumatic aortic valve stenosis and LV dyssinchrony.

Methods: Thirty-six patients (10 females, 26 males, mean age 41.7 years LVEF 44.5±15.5%, 15 patients with LVEF <35%, mean peak aortic valve pressure gradient 80.8±31.3 mmHg, effective aortic orifice area 0.80 cm², LV mass I 162.5±49.8 g/m², NYHA class 2.8) were enrolled in the study in 2007–2008. Whole cohort was undergone aortic valve replacement with mechanical bileaflet artificial valve immediately after enrolling. Intra- and interventricular dyssinchrony as well as chamber sizes and volumes were estimated by mode and TDI techniques via SONOS 5500 echo-machine. Myocardial Doppler velocities of basal segment interventricular septum (IVS) and basal segment of lateral wall (lateral wall) were measured in apical four-chamber position. Intraventricular delay (IVD)=80 ms was used as a cut- point (LV dyssinchrony) for groups dividing: 1 group – 22 patients with IVD<80 ms and group 2 – 14 patients with IVD>80 ms. Groups were comparable in aortic valve parameters, LV size and volume, NYHA class, but patients of group 1 had more significant LV hypertrophy (LV mass I 143.4±22.3 g/m² vs. 173.6±38.8 g/m², P=0.02).

Results: Patients of both groups had significantly decreased systolic and diastolic myocardial velocities of IVS and lateral wall, but patients with IVD>80 ms are characterized by higher systolic myocardial velocity of lateral wall (S: 4.1±1.8 cm/s vs. 7.0±1.5, P=0.0005).

Conclusions: Severe decrease of subendocardial velocities is common in patients with significant aortic valve stenosis. In contrast of diastolic velocities, slightly high but abnormal lateral wall systolic velocity may be a sign of adaptations in patients with rheumatic aortic stenosis and intraventricular dyssinchrony.

C5-4 INTRA-THORACIC SUBCLAVIAN ARTERY CANNULATION FOR AORTIC ARCH SURGERY

A. Panza, S. Lesu, P. Masiello, A. Longobardi, F. Cafarelli, G. Di Benedetto

Cardiac Surgery Division, ‘San Giovanni e Ruggi’ University Hospital, Salerno, Italy

Objective: The selection of the arterial cannulation site for institution of cardiopulmonary bypass is a critical point during aortic arch surgery. Historically, in these patients the femoral artery has been adopted as primary site for arterial access. Recently, axillary artery cannulation is largely accepted as valid alternative. Benefits of this procedure are: secures continuous antegrade, no surgical extra step in order to have an antegrade aortic perfusion after completion of distal anastomosis and ready arterial inflow for selective cerebral perfusion. However, it can be small, friable and deeply placed. In this video we present the cannulation of the intra-thoracic right subclavian artery as a safe and effective access for arterial inflow during aortic arch surgery.

Methods: After a median sternotomy, we extend the incision with a supraclavicular transverse cervicotomy (about 5–6 cm) to access to the prescalene portion of the right subclavian artery. The fibers of the sternal head of the sternocleidomastoideus, the sternohyoideus and sternothyreoideus muscles are separated and retracted laterally. During the dissection in this area it must be careful to avoid injury to the recurrent laryngeal and vagus nerves. A longitudinal incision is made and an 8 mm polytetrafluoroethylene vascular graft is sewn to the subclavian artery with a continuous 5–0 polypropylene suture. The prosthesis is cannulated with a 20 straight arterial cannula, that is connected to the arterial line. After cardiopulmonary bypass is terminated, decannulation is accomplished simply by transecting the vascular graft and over-sewing the stump.

Results: Right subclavian artery cannulation has been used in 17 patients (seven for acute type A dissection and 10 for aortic arch aneurysms). Cannulation through an 8 mm polytetrafluoroethylene vascular graft has been applied in all patients. There were no complications related in this technique. One patient suffered transient confusion postoperatively, that resolved spontaneously within 12 h. No focal neurologic deficits were detected in the remaining patients. Hospital mortality occurred in one patient (5.8%) due to respiratory insufficiency. No lesions to the vagus and recurrent nerve have been reported, neither movement deficit of the neck.

Conclusions: Intra-thoracic subclavian artery, as alternative arterial cannulation site, is safe and effective. Its major advantages are: ready arterial inflow for selective cerebral perfusion, no manipulation-related injury to the head vessels and comfortable incision.

C5-5 RECONSTRUCTIVE SURGERY OF EXTENDED THORACIC ANEURYSMS USING TRANSVERSAL THORACOSTERNOTOMY: OUR EXPERIENCE

R.N. Komarov, Yu.V. Belov, A.B. Stepanenko, A.P. Gens, N.Yu. Stogny

Russian Academy of Medical Sciences, National Research Center for Surgery named by academician B.V. Petrovsky, Moscow, Russian Federation

Objective: To value the first experience of surgical treatment of extended thoracic aneurysms using transversal thoracosternotomy.

Methods: Eight operations of prosthesis of the whole thoracic aorta using transversal through two-pleural thoracosternotomy.

Results: Total replacement of the whole thoracic aorta may be accomplished by single-step or by stages. The ‘elephant trunk’ operation, proposed by H. Borst, is usually performed at the first stage. The prosthesis or stenting of descending thoracic or thoracoabdominal section of the aorta is performed at the second stage. According to N. Kouchuokos the mortality at single-step replacement of thoracic aorta amounts to 7.2% (n=69), that may be comparable with the results of staging aorta prosthesis. Thus, according to various authors the mortality at staging aorta prosthesis amounts 6.3–16.0% after I stage and 4.0–9.7% after II stage of operation. In the period between operations 2.9–13% of patients died because of complications. Comparable figures of mortality at staging and single-step approach, the possibility of disease recovery in one stage, as well as the possibility to decrease the risk of aortic rupture between stages of operation have determined the necessity of performing single-step replacement of the whole thoracic aorta through transversal two-pleural approach in our patients. After using the all-possible modifications of perfusion and protection of the brain, at present time we give preference to antegrade be hemispheral cerebral perfusion with complete perfusion of the body under conditions of moderate hypothermia. Average time of operation for replacement of the whole thoracic aorta constituted 558 min, intraoperative blood loss – 4200 ml, mortality – 12.5%.

Conclusions: The abnormality of the thoracic aorta determines in some cases the necessity and the only possibility of its single-step replacement. Such reconstructive operations are accompanied by significant blood loss (on average 4200 ml), they are long-lasting (on average 558 min), and the mortality in these circ*mstances amounts to 12.5%.

C5-6 RESECTION AND PROSTHESIS OF THE AORTA COMBINED WITH RADICAL OPERATION ON ACCOUNT OF ADVANCED LUNG CANCER

R.N. Komarov, V.D. Parshin, Yu.V. Belov

Russian Academy of Medical Sciences, National Research Center for Surgery named by academician B.V. Petrovsky, Moscow, Russian Federation

Objective: To value the first experience of resection and prosthesis of the aorta combined with radical operation on account of advanced lung cancer.

Methods: Three patients with advanced lung cancer and its invasion in the thoracic part of the aorta have been operated. Combined operations with resection and aorta prosthesis have been accomplished. There were no lethal outcomes. All patients were discharged and referred to chemo- and radiation therapy.

Results: So far, our experience is extremely small in order to make any long-term conclusions. Surgical approach depends on the level of aorta involvement in tumoral process, on invasion the heart and on the other mediastinum structures. The determination of tactics concerning the modification of organs’ blood circulation support underneath the aorta resection zone is also important. The resection and aorta prosthesis in two of our patients were accomplished under ‘off-pump’ conditions with the time of aorta clamping amounting to 26 and 22 min. One patient was operated under conditions of left heart bypass. Whether such operations are justified from oncologic point of view? The data available at present time are controversial.

Conclusions: Single-step extended and combined operations at lung cancer, when it is necessary to perform the resection and aorta prosthesis, are possible. In order to achieve the results that are more exact these studies should be continued.

C5-7 MULTI-BRANCH AORTA BYPASS GRAFT BY COSELLI IN A 14-YEAR-old CHILD

R.N. Komarov, Yu.V. Belov, A.B. Stepanenko, A.P. Gens, N.Yu. Stogny, V.I. Kaleda

Russian Academy of Medical Sciences, National Research Center for Surgery named by academician B.V. Petrovsky, Moscow, Russian Federation

Objective: To present the modification of surgical treatment of middle aorta syndrome in a 14-year-old child.

Methods: We present the modification of surgical treatment of middle aorta syndrome, associated by congenital hypoplasia of descending aorta at the level of visceral branches origin in a 14-year-old girl. Estuarial hemodynamically significant stenoses of visceral branches have indicated its revascularization, for that the bypass graft of thoracoabdominal aorta with prosthesis of celiac trunk, upper mesenteric and both renal arteries by Coselli’ multi-branch prosthesis was performed.

Results: The main problem in surgical treatment of middle aorta syndrome is a choice of technique. The stenoses of all visceral branches’ entrances in a young girl with potential growth and possible worsening of visceral branches’ stenoses indicated the complete revascularization of internal organs. In our case the application of left heart bypass was impossible because of small diameter of infrarenal section of the aorta and femoral arteries (impossibility of distal cannulation), that virtually always takes place at stenotic abnormality of descending thoracic and thoracoabdominal aorta. Selective perfusion of visceral branches of the aorta was also impossible due to extremely small size of the latter (aorta diameter at the level of visceral branches amounted to 2–3 mm). The only correct decision in this case became the application of ‘old’ by-passing technique by M. DeBakey. This technique has allowed to minimize visceral ischemia in the girl (ischemia of the superior mesenteric artery was 20 min).

Conclusions: Thus, the application of Coselli’ multi-branch prosthesis using by-passing technique had predetermined the success and radicalism of this operations in the child.

6th Cardiac Surgery Session – Moderated Posters May 20, 2011 15:30-16:30

C6-1 OFF-PUMP MYOCARDIAL REVASCULARIZATION ATTENUATES ENDOTHELIN-1 EXPRESSION IN ARTERIAL VASCULAR COMPARTMENTS

D. Unic, D. Baric, M. Planinc, D. Jonjic, K. Brkic, I. Rudez, Z. Sutlic

Dubrava University Hospital, Zagreb, Croatia

Objective: To evaluate the influence of cardiopulmonary bypass on endothelin-1 (ET-1) expression in various circulation compartments in patients undergoing myocardial revascularization.

Methods: Thirty patients were randomized to undergo myocardial revascularization with (CABG, n=15) or without (OPCAB, n=15) cardiopulmonary bypass (CPB). Endothelin-1 (ET-1) levels were determined in arterial (ART), pulmonary (SG) and coronary (CS) circulation compartments. Samples were taken preoperatively (T0-in both groups), after establishing CPB (T1-CABG), prior to revascularization (T1-OPCAB), after CPB (T2-CABG), after revascularization (T2-OPCAB), and six and 24 h postoperatively (T3, T4-both groups). Values of ET-1 were compared between groups at all time points and correlated to postoperative cardioselective enzyme values and clinical parameters.

Results: In OPCAB group ET-1 levels did not significantly vary between time points. In CABG group ET-1 levels were significantly elevated vs. baseline in arterial – ART-T2 vs. ART-T0 (1.83±1.81 fmol/ml vs. 0.76±1.07 fmol/ml, P=0.05), pulmonary – SG-T2 vs. SG-T0 (2.70±2.75 fmol/ml vs. 0.39±0.28 fmol/ml, P<0.001), SG-T3 vs. SG-T0 (1.56±0.28 fmol/ml vs. 0.39±0.28 fmol/ml, P<0.001) and coronary circulation CS-T2 vs. CS-T1 (1.12±0.49 fmol/ml vs. 0.27±0.09 fmol/ml, P=0.01). ET-1 levels were significantly higher in CABG group in all vascular compartments: ART-T2 (1.83±1.81 fmol/ml vs. 0.17±0.16 fmol/ml, P=0.02); ART-T4 (0.99±0.56 fmol/ml vs. 0.24±0.12 fmol/ml, P=0.01); SG-T1 (0.59±0.15 fmol/ml vs. 0.25±0.13 fmol/ml, P=0.01); SG-T2 (2.70±2.75 fmol/ml vs. 0.30±0.24 fmol/ml, P=0.004); SG-T3 (1.56±0.28 fmol/ml vs. 0.35±0.31 fmol/ml, P<0.001); SG-T4 (1.34±0.11 fmol/ml vs. 0.34±0.16 fmol/ml, P<0.001); CS-T2 (1.12±0.49 fmol/ml vs. 0.12±0.12 fmol/ml, P=0.004). Coronary sinus ET-1 level after CPB (CS-T2) in CABG group correlated positively with troponin-I level 24 h postoperatively (r²=0.802, P=0.02).

Conclusions: Off-pump myocardial revascularization attenuates ET-1 expression in arterial vascular compartments. Elevated coronary ET-1 levels after CPB in CABG group correlate with Tn-I levels 24 h postoperatively.

C6-2 CHOICE OF A CONDUIT FOR THE RIGHT CORONARY SYSTEM

Y.Y. Vechersky, S.L. Andreev, V.M. Shipulin, V.V. Zatolokin, Y.A. Arsenjeva

Tomsk Institute of Cardiology, Tomsk, Russian Federation

Objective: Since the optimal conduit for the right coronary system still remains to be established the objective of our study was to compare the performance of different conduits used for shunting the right coronary artery or its branches during a five-year period after primary CABG.

Methods: A grafts’ patency and clinical outcomes were evaluated in a controlled trial with 192 enrolled patients comparing radial artery (RA), saphenous vein (SV), pedicled right internal thoracic artery (RITA) and composite grafts (pedicled RITA+RA). One hundred and twelve patients received different arterial grafts and 80 patients – SV grafts to the right coronary artery or its branches. A simple technique for the assessment of the length of RITA prior to harvesting required as an individual bypass for the distal right coronary was used. In the case of insufficient length the novel surgical technique was introduced using the proximal stump of the right internal thoracic artery as an intrathoracic arterial source of flow for RA composite graft, avoiding direct aorta manipulation. A retrospectively compiled database was used to establish patency rates of the grafts and clinical events among these patients.

Results: Absolute graft patency rates were as follows: composite grafts 92.3%, radial artery 81%, saphenous vein 79.2%, RITA in situ 71.6%. The overall mortality showed no difference between the group of arterial grafts and SV group (P=0.451 and P=0.389, respectively). Major cardiac and cerebrovascular events (MACE) occurred in the arterial grafts group in 2.1% of the cases vs. 5.1% of the cases (P=0.3) in the saphenous vein group. Five-year freedom from RCA reintervention rate was 92.3±1.8% in the arterial grafts group and 88.3±0.7% in the SV group (P=0.06).

Conclusions: Composite grafts (RITA+RA) showed favorable patency rate to the right coronary artery or its branches. The radial artery patency is at least comparable to that of the saphenous vein. The SV graft showed better patency in patients with moderate stenosis of RCA compared with RITA in situ. The rate of MACE is significantly smaller in arterial grafts group. Composite grafts (RITA+RA) сan be as long as required, and their proximal anastomoses guarantee a better match of the two conduits, undergo a lower peak pressure and save a completely free ascending aorta for any further cardiac procedure.

C6-3 ANALYSIS OF MULTIVESSEL CORONARY BYPASS SURGERY RESULTS (FIVE AND MORE DISTAL ANASTOMOSeS) THROUGH CONTROL CORONAROGRAPHY AT PATIENTS DISCHARGE FROM HOSPITAL

M.G. Tayursky, M.P. Shatakhyan, S.G. Sukhanov

Perm Heart Institute, Perm, Russian Federation

Objective: To assess results and effectiveness of multivessel CABG with five or more distal anastomoses with coronary artery disease through control coronary angiography at patient’s discharge from the hospital.

Methods: Between 2005 and 2010 at the Heart Institute 1562 patients underwent isolated coronary artery bypass grafting with five or more distal anastomoses. During the period from January to April 2010, 83 patients with multivessel disease successively underwent control angiography at discharge from hospital. Mean age of patients was 64±7 (35–78) years, 72.3% – males, 27.7% – females. All patients had exertional angina at level III-IY FC or unstable angina. All operations were performed using cardiopulmonary bypass. The total number of distal anastomoses was 508, an average of 6.12 anastomoses per patient. All patients underwent complete myocardial revascularization (size of bypassed arteries 1 mm³). Endarterectomy was performed in 52 (9%) cases. LIMA was used for 79 anastomoses, radial artery for three, venous autografts – in the other cases. The average ischemic time for one anastomosis was 8.04 min.

Results: Two (2.5%) patients died in intrahospital period (polyorgan failure, arrhythmia). Re-interventions were performed in four patients (bleeding – two, graft occlusion – two). Control angiography was performed at hospital discharge in 81 survived patients. Number of occluded and stenosed (>50%) anastomoses was 60 (12%) or 0.71 anastomosis per a patient. Forty-three anastomoses were occluded or narrowed in sequential grafts, 17 – in simple ones. All affected grafts were autovenous. Most often in sequential grafts were occluded anastomoses with distal circumflex branch (OM 1.2) – 11 cases, postero-lateral artery – eight cases and DA – six cases. In cases with simple shunts: PDA – eight cases, DA – six cases. Perioperative infarction (with or without Q deflection) was observed in seven (8.7%) patients. Other complications: syndrome of low cardiac output – one patient (connection of IABP), respiratory failure – five patients, stroke – one patient, atrial fibrillation – 20 patients.

Conclusions: Multiple CABG may be priority for multi-vessel coronary artery disease for an experienced and skilled surgeon. Analysis of the angiography data proves inappropriateness of including, as possible, the anastomosis with OM in the sequential shunt with DA or postero-lateral artery, and when performing single shunts to PDA and DA attention should be given to choose the place of the anastomosis, implantation technique and quality of graft. Long-term clinical and radiological studies are needed to draw final conclusions from received results.

C6-4 COMPARISON OF ANTI-ARRHYTHMIC AGENTS IN THE PREVENTION OF ATRIAL FIBRILLATION RECURRENCE FOLLOWING CORONARY ARTERY BYPASS GRAFTING

T. Doulias, S. Attaran, S. Amarantidis, G. Priona, D. Chung, B.M. Fabri

Liverpool Heart and Chest Hospital, Liverpool, UK

Objective: Atrial fibrillation (AF) after CABG is common. Different anti-arrhythmic agents are used to treat AF and prevent its recurrence. However, a treatment that minimises AF recurrence has not yet been identified. The objective of this study was to compare the common medications used for the treatment of AF and to investigate their abilities to minimise AF recurrence within six weeks after CABG.

Methods: In this study, data were reviewed for a three-year period. It included a total of 598 patients who underwent CABG and developed AF, but were cardioverted on medications prior to discharge. Patients were discharged on either amiodarone (n=88), digoxin (n=48), sotalol (n=186), other β-blockers (n=72), or a combination of a β-blocker with either digoxin/amiodarone/sotalol (n=203). We reviewed each patient’s ECG and history of readmission for AF in six weeks.

Results: The recurrence of AF was observed in 67 (11.2%) cases: 8.6% of patients on sotalol, 25% of patients on amiodarone, 29.1% of patients on digoxin, 5.5% of patients on β-blockers, and only 5.4% of patients on a combination therapy. The recurrence of AF depended on the type of the treatment (P<0.001). A greater AF recurrence was observed in patients treated with digoxin/ amiodarone, whereas a lower AF recurrence was observed with combination therapy. There was no statistically significant difference in AF recurrence between sotalol/β-blockers/combination therapy.

Conclusions: Despite successful postoperative, in-hospital cardioversion in most AF cases, AF recurrence after discharge can result in readmission and other complications. Therefore, treatments should also objective to maintain sinus rhythm, postoperatively. In our study, we observed that the use of amiodarone or digoxin as the sole anti-arrhythmic agent for the treatment of AF was associated with a higher incidence of AF recurrence compared with β-blockers, sotalol and the combination therapy.

C6-5 ENDOSCOPIC TECHNIQUE HARVESTING OF THE GREAT SAPHENOUS VEIN IN BYPASS SURGERY

O.V. Lavrenyuk, A.M. Chernyavskiy, Yu.E. Kareva, D.A. Sirota

E.N. Meshalkin Novosibirsk State Research Institute, Novosibirsk, Russian Federation

Objective: To study the results of the endoscopic venous graft harvesting technique (the great saphenous vein) for bypass surgery.

Methods: From January 2006 to December 2010, 4475 operations of CABG have been performed at the clinic. In 839 (18.7%) patients satisfied the harvesting of the great saphenous vein using an endoscopic set VasoView six Guidant. Among them there were 579 men (69%) and 260 women (31%). Mean age was 58±7.1 years. Diabetes was in 223 (26.5%) patients, obesity in 137 (16.3%), lesions of peripheral arteries of the lower extremities in 107 (12.7%).

Results: The average time for allocation of venous graft was 25±6 min. Conversion in harvesting of the veins in the other lower limb or to the open technique has been performed in 25 cases (2.97%): the small diameter of the veins – in five (0.59%) patients, loose type of vein structure – in 12 (1.43%), poor quality of the conduit for bypass surgery – in eight (0.95%) patients. On histological examination of venous grafts used to bypass the integrity of the endothelium is not violated, infiltration wall veins formed elements, including platelets, as well as areas of thermal damage to the venous wall were observed. In the postoperative infectious complications in the lower limb were observed. Complications in the immediate postoperative period include the appearance of lymphorrhea in three (0.35%) patients from the surgical wound on the leg, the formation of a hematoma in the course of the great saphenous vein in 12 (1.43%) patients. All complications were treated with non-surgical method.

Conclusions: The use of endoscopic techniques for the harvesting of venous graft on operations of myocardial revascularization can be successfully accomplished with a decrease injury surgery. This leads to a rapid restoration of function of the lower extremity and reduces period of hospitalization. This is especially true if there are concomitant diseases such as diabetes, obesity, chronic lower limb ischemia.

C6-6 EFFICIENCY AND SUITABILITY OF COMBINED OPERATIONS ON BRACHIOCEPHALIC ARTERIES AND OFF-PUMP CORONARY ARTERY BYPASS GRAFTING

Y. Schneider, G. Sokurenko, G. Gorbunov, M. De Tsoi, A. Krasikov, D. Kandyba

Medical Academy of Postgraduate Studies, Saint Petersburg, Russian Federation

Objective: The objective is to evaluate the efficiency and suitability of combined operations on brachiocephalic arteries and off-pump coronary artery bypass grafting.

Methods: For last six years 46 patients underwent combined operations on brachiocephalic arteries and off-pump coronary artery bypass grafting. In all cases operation on brachiocephalic arteries provided firstly with parallel harvesting of conduits for CABG (radial artery, vein or mammary artery). CABG was the second stage. Three (6.5%) patients were asymptomatic, 13 (28.5%) patients were with transitory ischemic attacks, seven (15.2%) patients were with chronic insufficiency of cerebral blood flow, 23 (49.9%) patients were after ischemic stroke. Fifteen (32.5%) patients had bilateral injury of inner carotid arteries and in three (6.5%) patients stenosis of brachiocephalic artery combined with it. In 28 (60.7%) patients three-vessel coronary artery disease was found. Myocardial infarction was in 35 (75.9%) patients. Ejection fraction lower than 30% was diagnosed in eight (17.4%) patients, from 30 to 50% was found in 29 (62.9%) patients. Everything for endarterectomy from inner brachiocephalic artery was performed in 44 (95.5%) cases, in two (4.5%) cases classical endarterectomy with autovenous plasty was performed. Mean number of distal anastomoses was 3.2. In 27 (58.6%) operations CABG with mammary artery and radial artery was performed. In eight (17.4%) cases we used bilateral mammary arteries.

Results: There were no perioperational myocardial infarctions and impairment of cerebral circulation in operation dependent area. All patients underwent total myocardial revascularization. In majority of patients a positive effect from operation has been observed, characterized by avoidance of angina, better myocardial contractility. Postoperational mortality was 2.17% (one patient) as a result of stroke in collateral brachiocephalic artery area. Follow-up results were observed in 32 patients in terms from one to three years. There were no myocardial infarctions and impairment of cerebral circulation.

Conclusions: The use of modern surgical techniques and anestesiologic allowance and methods of postoperational patient treatment permit to provide operations on brachiocephalic arteries combined with off-pump CABG with good results similar to isolated CABG.

C6-7 OFF-PUMP CABG: HAS CORONARY ARTERY BYPASS GRAFTING ON A BEATING HEART ANY ADVANTAGES?

A.V. Rudenko, V.I. Ursulenko, A.V. Kupchinskiy, S.A. Rudenko, E.K. Gogaeva, N.M. Verich, M.M. Amosov

National Institute of Cardiovascular Surgery, AMS of Ukraine, Kiev, Ukraine

Objective: To evaluate the immediate results of CABG on a beating heart using compression type stabilizers.

Methods: From 1 January 2000 to 31 December 2010, the M.M. Amosov Government Facility National Institute of Cardiovascular Surgery AMS of Ukraine was performed 6.321 CABG on a beating heart using a compression type stabilizers (Genzyme, USA). Exposition of the coronary arteries was carried out by imposing two pericardial traction sutures and using silicone lopes. Indications for operation on a beating heart were similar to that one used for CABG operations with extracorporeal circulation: the presence of coronary disease with stenotic or occlusive lesions of the coronary arteries.

Results: Hospital mortality was 0.8% for the entire group of patients (predicted mortality by EuroSCORE scale – 3.4%). Mean age was 59.6±8.5 years, of which 38.6% of patients were over 60 years (mortality in this group – 1.2%, in patients younger than 60 years – 0.4%, P<0.05). 14.8% of patients were female (mortality – 0.7%, in men – 0.6%, P>0.05). 17.1% of patients had diabetes history. 66.2% of patients were in III-IV functional class according to CCA. Multivessel coronary arteries disease was identified in 72.6% of patients, the left main stenosis was diagnosed in 10.8% patients. LVEF <40% was detected in 11.6% of patients (mortality in this group – 1.2%, in the group with EF>40–0.6%, P>0.05). Average number of grafts per patient was 3.1. LIMA sinistra was used in 85.5% of patients for anterior interventricular artery bypass. Eight percent of patients required emergency and urgent operations (mortality – 3.6%, in the group of elective operations – 0.5%, P<0.05). Low output syndrome was diagnosed after the operation in 3.3% of patients. Stroke and acute MI was diagnosed in 0.3%, respectively. No significant risk factor effecting on mortality, except elderly age of patients and emergency and urgent status of operations, was detected.

Conclusions: Immediate results of beating heart CABG using compression type stabilizers testify that the operations provide insignificant number of complications and are accompanied by a low hospital mortality. This technique allows to minimize the effect of standard risk factors on the results of operations.

C6-8 LONG-TERM RESULTS OF CORRECTION OF ISCHEMIC MITRAL REGURGITATION IN PATIENTS WITH SEVERE LEFT VENTRICULAR DYSFUNCTION

A.M. Chernyavsky, A.V. Marchenko, V.U. Efendiev, T.M. Ruzmatov, D.S. Prohorova, O.S. Efanova

Federal Research Institute of Circulation Pathology, Novosibirsk, Russian Federation

Objective: To evaluate the effectiveness of methods of surgical correction of mitral regurgitation (MR) in patients with ischemic heart failure.

Methods: In this study, we have included 200 patients (178 men), mean age 56±8 years with ischemic heart failure and severe left ventricular (LV) dysfunction. All patients had heart failure NYHA III and IV functional class, EF <35%. Myocardial revascularization (CABG) was performed in all patients. In addition to coronary artery bypass grafting 57 patients underwent correction of MR with moderate and severe degree, and 61 patients underwent the reconstruction of the). The method of echocardiography was used to assess mitral regurgitation and dysfunction LV.

Results: The dynamics of the degree of MR according to the method of surgical treatment was assessed in terms ranging from 4 to 36 months. With isolated CABG was initially MR 1.4±0.6. However, in the late period the progression of MR was marked – 1.6±0.7 in four months, 1.6±0.9 in 12 months and 1.8±0.5 in 36 months. In the group of patients after reconstruction of LV MR initially was 1.4±0.6, in terms of four months – 1.1±0.5 and in terms of 12 months – 1.2±0.6, the statistically-valid positive trend was shown (P=0.08), but in terms of 36 the degree of progression of MR was also indicated 1.7±0.3. Patients with CABG and mitral valve plasty the dynamics of the degree of MR was the following: initially 2.4±0.8, in the late period the statistically-valid positive trend of the degree of MR was shown; 1.4±0.6 in four months and 1.6±0.8 (P=0.04) in 12 months, and in 36 months MR has progressed to 1.7±0.3. Thus, the negative dynamics was found in 7% after CABG and mitral valve plasty, and 28% and 22% after CABG and LV reconstruction with CABG, respectively.

Conclusions: In case of severe LV dysfunction the correction of MR is necessary with moderate and severe degree, as an isolated CABG does not decrease the degree of MR. In all patients with ERO >30 mm² the negative dynamics of the mitral valve function was shown in the late postoperative period, and this may be regarded as indication for mitral valve replacement.

C6-9 CABG – COMPARED STUDY WITH THE 4TH EACTS ADULT CARDIAC DATABASE REPORT

G. Tinica¹, M. Enache², D. Anghel¹, O. Bartos¹, V. Prisacari¹, I. Nedelciuc¹, A. Ciucu¹, L. Stoica¹

¹Cardiovascular Institute, Iasi, Romania; ²University of Medicine and Pharmacy ‘Gr. T. Popa’, Iasi, Romania

Objective: Regarding the fact that our country has never reported its results to the EACTS, we evaluated our perioperative results by comparing them with the 4th EACTS Cardiac Database Report (ACDR), in order to evaluate our clinic’s performance in patients undergoing CABG.

Methods: From 2000 to 2010, we treated a total of 1148 patients addressing our clinic for CABG. We retrospectively studied the operative conduit and perioperative management of these patients, as well as the short-term outcomes. In order to compare our results with the 4th EACTS ACDR, we divided our patients into three groups: group A (830 patients undergoing CABG alone), group B (106 patients undergoing CABG+aortic valve procedures) and group C (38 patients undergoing CABG+mitral valve procedures).

Results: The overall mortality was 0.84% in group A, 0% in group B and 2.63% in group C vs. 2.24%, 5.51% and 8.60%, respectively in EACTS. The female mortality was 0% in all three groups vs. 3.1%, 7.5% and 10.4%, respectively in EACTS. The male mortality was 1.02% in group A, 0% in group B and 3.03% in group C vs. 2%, 4.6% and 7.7%, respectively in EACTS. The mortality rate among patients with diabetes was 0.40% in group A, 0% in group B and C vs. 2.90%, 6.8% and 12.3%, respectively in EACTS. The mortality rate within CCS 3–4 angina was 0.95% in group A and 0% in group B and C vs. 8.20%, 7.22% and 13.83%, respectively in EACTS. The mortality rate of patients with NYHA III-IV dyspnoea was 0% in group A and B and 3.22% in group C vs. 11.70%, 6.67% and 11.58%, respectively in EACTS. The mortality rate among patients with >50% LM stenosis was 1.42% in group A and 0% in group B and C vs. 3.10%, 7.6% and 13.0%, respectively in EACTS. The mortality rate of patients with various stages of chronic renal failure was 0% in all three groups vs. 9%, 12.9% and 22.7%, respectively in EACTS.

Conclusions: The average age in all three study groups was lower than that documented in the 4th EACTS ACDR. Our patients had considerably lower mortality rates compared with the 4th EACTS ACDR in all the associated comorbidities (diabetes, chronic renal failure, extracardiac arteriopathy, arterial hypertension, congestive heart failure, CCS 3–4 angina). The overall mortality rate was lower than that reported by the EACTS in all three groups studied.

C6-10 PET – 18F-FDG AND SPECT – 99mTc-TECHNETRIL IN EVALUATION OF PREDICTION OF LEFT VENTRICULAR FUNCTION RECOVERY AFTER REVASCULARIZATIoN IN PATIENTS WITH CORONARY ARTERY DISEASE

I.V. Shurupova, I.P. Aslanidis, T.A. Trifonova, O.V. Moukhortova, E.P. Derevyanko, T.A. Katunina

Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: To evaluate the predicting capabilities of the combination of gated single-photon emission computed tomography with 99mTc-technetril (99mTc-tn SPECT) and positron emission tomography (PET) with 18F-FDG methods in evaluation of LV function improvement after revascularization.

Methods: Twenty-one patients with coronary artery disease (mean age 56.7±2.8 years) were studied. Nineteen of them (90%) had history of myocardial infarction, 16 patients had heart failure, 9/16 of them had functional class III as per NYHA. Average left ventricular ejection fraction (LVEF) was 44.9±9.6% (from 25 to 50%). The results of rest 99mTc-tn SPECT and 18F-FDG-PET were analysed. Using 20 segments model, myocardial perfusion was estimated for all segments (comparing to normal data pool). Based on results of comparison between the non-attenuation corrected gated-SPECT and 18F-FDG-PET images (tomographic slice and polar diagrams) the perfusion/metabolic (P/M) match (scar) and mismatch (hibernation) regions of LV were identified. LVEF was calculated out of gated-SPECT using ‘QGS’ software. To evaluate LVEF changes in dynamics, myocardial perfusion gated-SPECT was repeated in all patients within 127±56 days after revascularization.

Results: Resting hypoperfusion was detected in 193 LV segments, P/M mismatch was found in 88/193 (45%), P/M match – in 105/193 (55%). Hibernation myocardium in two and more segments was diagnosed in 11/21 patients (group 1), <2 segments – in 10/21 patients (group 2). After revascularization LVEF increased by 35% in 8/11 patients of group 1 (positive predicted value 73%) and only in 1/10 patients of group 2 (negative predicted value 90%). Sensitivity and specificity of the combination of 18F-FDG-PET and 99mTc-tn SPECT in LVEF improvement prediction was 89% and 70%, respectively, diagnostic accuracy – 77%. Left ventricular EF increase was noted in group 1 (55±5.8% compared to 45.4±7.6%, Р<0.05), in group 2 LVEF increased from 43.7±7.8% to 49.7±4.0% (Р=NS).

Conclusions: The combination of 18F-FDG-PET and 99mTc-tn SPECT methods demonstrates high accuracy of hibernation myocardium diagnostics in patients with LV ischemic dysfunction. Besides, the availability of hibernation myocardium of more than 10% of LV (2 segments) allows to predict considerable LVEF increase after revascularization.

C6-11 THE RADIAL ARTERY – AN OPTIMAL ARTERIAL CONDUIT FOR THE REVASCULARIZATION OF THE RIGHT CORONARY ARTERY

G. Tinica¹, M. Enache², D.Anghel¹, O. Bartos¹, V. Prisacari¹

¹Cardiovascular Institute, Iasi, Romania; ²University of Medicine and Pharmacy ‘Gr. T. Popa’, Iasi, Romania

Objective: Controversy still exists concerning the optimal conduit for the right ventricle revascularization. Through this study we analysed the use of the radial artery as a proper arterial conduit for the revascularization of the right coronary artery.

Methods: We retrospectively studied 188 patients that underwent CABG with a radial artery graft mounted on the right coronary artery and one or two ITA on the left coronary system (group A) in comparison with a control group of 177 patients receiving a saphenous vein graft mounted on the right coronary artery and one or two ITA on the left coronary system (group B), during the period from 2000 to 2010, investigating the perioperative events and short-term outcomes. Our perioperative protocol in harvesting the radial artery consists of Allen’s test preoperatively, careful harvesting of the radial artery alongside the comitant veins, intraluminal washing and storing the artery in a blood and papaverine solution, calcium blockers administered three months postoperatively (in order to prevent arterial spasm). The radial artery is usually mounted on the second or third segment of the right coronary artery, as well as on the posterior interventricular artery, only when the degree of coronary stenosis exceeds 75%.

Results: The average age was 58.9 years±8.82 in group A vs. 61.5 years±8.33 in group B. There were 16.48% women in group A vs. 18.6% in group B. The mean number of grafts was 3.39±0.96 vs. 2.88±0.93, 18.08% vs. 22.59% had additional cardiac surgical procedures, 28.72% vs. 28.24% had diabetes, 11.17% vs. 29.37% had peripheral arterial disease. Preoperatively 31.91% vs. 24.29% of patients had a low LVEF (<50%) and postoperatively the %ages were 10.81% vs. 20.8%. The morality in group A was 0% and in group B was 1.12%. The average time spent in ICU was 3.01 days±1.26 vs. 3.5 days±1.59.

Conclusions: The radial artery is an excellent arterial conduit for the revascularization of the right coronary artery. Good early postoperative outcomes in group A recommend the use of the radial artery in diabetic patients. Our clinic promotes the use of one or two internal thoracic arteries as bypass grafts for the revascularization of the left ventricle and the use of the radial artery as the method of choice for the revascularization of the right ventricle.

C6-12 MID-TERM RESULTS AFTER TRANSMYOCARDIAL REVASCULARIZATION COMBINED WITH AUTOLOGOUS STEM CELLS TO TREAT DIFFUSE CORONARY ARTERY DISEASE: ANGINA AND SURVIVAL STATUS

P. Alvarez Navarro, G. Reyes, J. Bustamante, A. Sarraj, O. Leal Fernandez, S. Badia Gamarra, J. Duarte, J. Nuche

Hospital Universitario La Princesa, Madrid, Spain

Objective: Transmyocardial laser revascularization (TMR) is an option for patients with medically refractory angina not amenable to conventional revascularization. The injection of autologous stem cells is also helpful in treating these patients. Combination of both therapies may have a synergetic effect in these patients. We described the mid-term results of patients with medically refractory angina treated with TMR in combination with autologous stem cell injection.

Methods: Twenty patients (17 males and three females) with diffuse coronary artery disease and medically refractory Canadian Cardiovascular class angina III (12 patients) or IV (seven patients) were evaluated. A single device performed holmium:YAG TMR channels through a small anterior thoracotomy with injection of 1 cc of concentrated stem cells through three needles into the border zone around each laser channel. Survival and clinical status of patients was analysed.

Results: Mean age was 65 years. Seventy-nine percent of patients had at least one PTCI procedure (range 1–7). CABG surgery was present in eight patients. There were not perioperative adverse events including arrhythmias. There has not been any surgical mortalities. Mean number of laser channels was 19 and the mean number of injected cells per patient were: total mononuclear cells (1660×106), CD34+ (9.8×106), and CD133+ (4.6×106). Median length of stay was six days. Mean follow-up was 19 months (range 1–30). One patient died 24 months after the procedure due to heart failure. At last follow-up patient angina was class I in 13 patients, class II in five patients, and class III-IV in two patients. Two patients required coronariography due to angina one year after the procedure showing new coronary lesions in one of them.

Conclusions: TMR in combination with stem cell injection is safe and effective in patients with severe angina and no conventional options in a short and medium follow-up. Coronary disease is a progressive disease and patients may need to be revaluated in a long-term follow-up.

C6-13 SURGICAL TREATMENT OF ISCHEMIC MITRAL REGURGITATION COMBINED WITH CABG

Y. Schneider, C. Kouznetsov, A. Krasikov, N. Aleshkin

Medical Academy of Postgraduate Studies, Saint Petersburg, Russian Federation

Objective: Chronic ischemic mitral regurgitation remains one of the most complex problems in surgical treatment of ischemic heart disease. It appears approximately in 20–25% of the patients with myocardial infarction and in 50% in patients with chronic heart failure. Indications to surgical treatment of mitral insufficiency of I-II degree are still discussable. The objective of the study was to analyse the results of isolated CABG and mitral valve plasty and replacement.

Methods: In this study 308 patients with ischemic heart disease and ischemic mitral regurgitation were included. In 212 patients CABG with mitral valve plasty was performed. In 32 patients we performed CABG with mitral valve replacement. In 64 patients with mitral regurgitation of I-II degree isolated CABG was performed. Sixty-seven (21.8%) patients underwent papillary muscle plication. In 53 (17.2%) patients we made left ventricle restoration due to postinfarction aneurysm.

Results: Hospital mortality in CABG with mitral valve plasty group was nine (4.2%). Three (9.4%) patients died in group CABG with mitral valve replacement. In isolated CABG group 1 (1.6%) patient died. Follow-up mortality in terms up to seven years was 43 (28.9%) of 149 observed patients in first group. Twenty-two patients of second group were investigated, seven (31.8%) patients died. In isolated CABG group 6 (11.0%) patients died of 48 investigated. In this group in 32 (76.2%) patients mitral regurgitation not increased and in 10 (23.8%) mitral regurgitation increased in seven years follow-up.

Conclusions: Modern methods of surgical correction of ischemic mitral insufficiency let to improve the outcome and survival rate in these patients.

C6-14 ASSESSMENT OF THE HAND COLLATERAL BLOOD FLOW BY THE LASER-DOPPLER FLOWMETRY METHOD IN SMOKING PATIENTS WITH CORONARY ARTERY DISEASE PRIOR TO THE CORONARY ARTERY BYPASS GRAFTING

O.V. Kamenskaya, L.M. Bulatetskaya, A.S. Klinkova, A.M. Chernyavsky, S.A. Alsov, D.S. Khvan

Federal State Institution Academican E.N. Meshalkin Novosibirsks State, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation

Objective: To evaluate hand collateral blood flow (CBF) in patients with coronary heart disease (CHD) considering smoking factor with laser-Doppler flowmetry method during vascular tests prior to the coronary artery bypass surgery.

Methods: The study was performed on two groups: 56 non-smoking patients – 112 upper limbs (UL) and 55 smoking patients – 110 UL. Peripheral microcirculatory blood flow (MBF) check of the UL was performed with the laser-Doppler flowmeter BLF-21D (US). The test included simultaneous occlusion of both radial (RA) and ulnar (UA) arteries at the wrist during 1 min, and then open UA blood flow with the RA being obstructed. After 2 min, the occlusion of the RA was released and the recovery of MBF was assessed and recorded within 2 min. On each site of the MBF record M±a was defined and the following assessed: indicators of collateral blood flow (ICBF) – MBF in % against the baseline and indicators of the deficiency (ID=100%–ICBF) collateral blood flow and indicators of the recovery (IR) blood flow in % against the baseline.

Results: ID level was adjusted as a criteria for the possibility to safely harvesting RA as a conduit for coronary artery bypass grafting – less or 30% against the baseline level. According to the findings, the level of MBF baseline between the groups practically was not different. However, differences were observed in dynamics of indicators of the collateral blood flow at the test stages. ID level at the end of 1 min RA occlusion in both groups on average was significantly lower than the baseline. At the same time non-smokers’ ID was 11.4±2.9%, but smokers’ two times more – 22.7±3.0% (P<0.007), that indicates significant reduction of hand collateral blood flow in smoking patients with CHD. During the 2 min of RA occlusion the difference between the groups in the studied parameters decreased: 12.7±2.5% and 17.6±2.6%, accordingly (P>0.05).

Conclusions: Thus, we have established a significant increase in deficit of collateral circulation during RA occlusion in smoking patients. It appears necessary to take into account the smoking status during the cardiovascular tests prior to the coronary bypass surgery.

C6-15 OPTIMIZATION OF MYOCARDIAL PROTECTION BY INTERMITTENT ISOTHERMIC BLOOD CARDIOpLEGIA IN PATIENTS WITH MYOCARDIAL HYPERTROPHY

D.A. Botkin, M.L. Gordeev, D.I. Kurapeev

Almazov Federal Heart, Blood and Endocrinology Centre, Saint Petersburg, Russian Federation

Objective: The purpose of this study was to optimize myocardial protection by intermittent blood cardioplegia isothermal in patients with myocardial hypertrophy.

Methods: The study examined 700 samples of transmyocardial blood taken from 100 patients, divided into two groups: research, with left ventricular hypertrophy (n=50, LVPW 11 mm³) and a control without left ventricular hypertrophy (n=50, LVPW <11 mm³). In each group, the statistical analysis of transmyocardial blood gases and metabolites depending on the temporal and volumetric parameters of cardioplegia have been performed. Between the groups was not statistically significant difference in anthropometric indices, the basic parameters of cardiopulmonary bypass and cardioplegia. Cardiopulmonary bypass was performed on standard techniques accepted in our center

Results: Biochemical profile in both groups had similar features: an initially pronounced metabolic acidosis, hypoxemia, hypercapnia, hyperlactatemia. At the end of the cardioplegia session, improved biochemical changes took place with the approach of the indicators of arterial (fed) blood. In this study, the markers of the adequacy of myocardial reperfusion have been taken transmyocardial lactate levels, venous saturation, pH, oxygen extraction, pvCO₂, as well as the degree of change in these indicators by the end of each cardioplegia session and the dynamics of change throughout the ischemic period. If the intervals between cardioplegia sessions were 12–15 min the average transmyocardial lactate level was significantly higher in research group (2.2±1.7 and 1.6±1.1 mmol/l; P<0.05), if the intervals were more than 15 min the changes had even more expressed character (2.5±1.9 and 1.7±0.9 mmol/l; P<0.05). In cases of maintenance coronary sinus lactate level <2.2 mmol/l in both groups, average time between cardioplegia sessions was 11.3±5.9 min and was significantly lower, than in group with compromised myocardium metabolism.

Conclusions: In patients with myocardial hypertrophy with an increase in lactate levels ischemia time grew to a greater extent. In both groups, the duration of the ischemic interval, not exceeding 12 min does not lead to a significant increase in lactate levels at the beginning of each subsequent session cardioplegia measurements of blood lactate transmyocardial we successfully used as an indicator of the adequacy of myocardial protection during anoxia, as opposed to markers of myocardial damage, these data are available for research in real time and are in general use, routine. Made repeatedly, they help to characterize the dynamics of changes in metabolic rate infarction during the operation.

C6-16 PLICATION OF LEFT VENTRICULAR ANEURYSM ON BEATING HEART

D.L. Yurchenko¹, A.A. Payvin¹, D.O. Denisyuk¹, G.G. Khubulava², A.M. Volkov², A.I. Lyubimov², V.N. Kravchuk², N.N. Yakovlev¹

¹40th Municipal Hospital, Saint Petersburg, Russian Federation; ²Military Medical Academy, Saint Petersburg, Russian Federation

Objective: To evaluate the short-term outcome after small left ventricular (LV) aneurysm plication on beating heart.

Methods: Between July 2004 and December 2010, 47 consecutive patients underwent LV restoring due to postinfarction aneurysm. The aneurysms plication on beating heart has been performed in 19 patients (18 males, one female) have been subjected. The indication for operation were: small size of LV postinfarction scar (the area <20–25 cm²), the absence of LV thrombosis on ultrasound and radiologically, and the absence of concomitant valve pathology. The manipulation was represented by enucleation of the heart and an aneurysm exposition by means of vacuum stabilization system. After heart enucleation the postinfarction scar looked as a thinning zone which was sinking down in a diastole. After that 2/0–3/0 polypropylene U-stitches with pledgets (as a rule, from three to five) were used for aneurysm plication on beating heart without cutting LV. The objectives of this procedure are: to eliminate an aneurysmatic diverticulum and to exclude of thrombogenic endocardial surface from LV cavity.

Results: Seventeen operations were performed off-pump, and two operations – with on-pump beating heart technology. All interventions were combined with CABG (mean revascularization value was 2.3±1.1). The median operation time was 205.0±25.1 min, ICU stay was 1.2±0.6 days, and hospital stay was 8.1±2.9 days. In investigated group there were no perioperative death and myocardial infarctions. Early postoperative cardiac complications which have demanded short-term inotropic therapy were marked at two patients (10.5%). Postoperative median LV ejection fraction (Simpson) was 48.5±4.3%, in comparison with 44.6±5.9%, preoperatively.

Conclusions: Plication of small LV aneurysm on beating heart is minimally- invasive procedure, which provides low operative complications rate and satisfactory short-term results. This manipulation allows to avoid cardiopulmonary bypass use and cardiac arrest at certain indications, and expands possibilities of surgery of an ischemic heart disease.

C6-17 REPAIR OF POSTINFARCTION LV ANEURYSM; COMPARISON BETWEEN TWO TECHNIQUES

R. Tenchurin, A. Duzhikov

Rostov Cardiovascular Surgery Center, Rostov, Russian Federation

Objective: Controversy still exists regarding the optimal surgical technique for postinfarction dyskinetic left ventricular aneurysm (LVA) repair. We compared the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LVA.

Methods: From 2006 to 2010, 111 (19 women, 92 men) consecutive patients underwent repair of LV aneurysms. Seventy-six (68.5%) patients underwent remodeling patch and 35 (31.5%) linear repair. Mean age was 60.1±8.3 years. Coronary surgery was performed in all patients (mean no. of grafts/patient, 3.2±0.8). Forty-four (40.5%) patients had angina CCS class III/IV (linear 43.4%, patch 32.4%, NS) and the majority was in NYHA class I/II (88.4% in both groups). Left ventricular dysfunction (EF>40%) was present in 72 (65.9%) patients (linear 61.8%, patch 73.5%, NS). Thirty-six patients had a history of congestive heart failure.

Results: There was no perioperative mortality, and major morbidity was not significantly different between linear repair and patch repair groups. There was no significant difference in late survival between the patch and the linear groups. At late follow-up, the mean angina and NYHA class were, 1.3 (preoperative 2.4, P<0.001) and 1.5 (preoperative 1.7, NS), respectively, with no difference between the groups.

Conclusions: The technique of repair of postinfarction dyskinetic LV aneurysms should be adapted in each patient to the cavity size and shape, and the dimension of the scar. Applying these considerations to the choice of the technique of repair, both techniques achieved good results with respect to perioperative mortality, late functional status and survival.

C6-18 QUALITY OF LIFE IS IMPROVED AFTER CORONARY ARTERY BYPASS GRAFTING – A 10-YEAR FOLLOW-UP STUDY

B. O’Neill, F. Taylor, A. Vohra

University of Manchester, Manchester, UK

Objective: To determine the effect of coronary artery bypass grafting on long-term quality of life.

Methods: Eighty patients (mean age 62.4 years; 67 males, 13 females) undergoing on-pump CABG between September 1999 and June 2000 completed perioperative questionnaires. They were followed-up via telephone interview at set intervals from six weeks to 10 years after CABG. Main outcome measures: mortality, disease specific symptoms [chest pain (CCS), breathlessness (NYHA), myocardial infarctions, heart failure], patient satisfaction, health related quality of life (shortform-12), functional status (Barthel’s score, Duke Activity score, working hours) and neurocognitive function (mini mental score, strokes). The analysis was made by using basic descriptive, Mann–Whitney U-test, Pearson correlation and Wilcoxon matched pairs using SPSS 16.

Results: 91.3% of patients was survival at five years and 70% at 10 years. Causes of deaths of 24 patients were: cardiac (7), cancer (5), stroke (4) respiratory (2), old age (1) and unknown (5). At 10 years: 6.2% of patients had had an MI and 17.5% a stroke. There was a significant reduction in prevalence and severity of angina – 2.5% angina free preoperatively compared with 86% of survivors angina free at 10 years (P<0.001). CCS scores reduced from 2.46 preoperative to <1 postoperatively (P<0.001). Ninety-five percent of patients were satisfied about their surgery. Patients experienced an improved functional status (P<0.05) and cognitive function returned to normal within a year in all patients. Preoperative SF-12 scores, which were significantly lower than an age-matched UK population (P<0.001), improved following CABG to become comparable with the population. Patients that restarted smoking did not show a sustained improvement in functional status or health related quality of life and had a more variable mental state score compared with non-smokers.

Conclusions: Quality of life is improved by coronary artery bypass grafting but not in patients who restart smoking.

C6-19 CLINICAL, POSITRON EMISSION TOMOGRAPHY IMAGING, STRESS ECHOCARDIOGRAPHY AND PROCEDURAL ANGIOGRAPHIC CHARACTERISTICS OF MYOCARDIAL VIABILITY BEFORE AND AFTER PERCUTANEOUS RECANALIZATION OF CHRONIC TOTAL CORONARY OCCLUSIONS

O.G. Zverev¹, A.B. Volkov¹, D.V. Rygkova²

¹I. Pavlov Medical University, Saint Petersburg, Russian Federation; ²Research Institute of Radiology and Surgery, Saint Petersburg, Russian Federation

Objective: Percutaneous coronary intervention for chronic total occlusion lesions is technically difficult despite equipment advances. The identification of dysfunctional myocardial segments that can improve after revascularization is pivotal for further patient management.

Methods: Patients (1760) who underwent coronary angiography at our university hospital were identified using a dedicated database. Total occlusion lesions were revealed in 189 patients. Percutaneous coronary interventions were attempted in 172 total occlusion lesions. Seventeen patients were referred to surgery (n=14) or were treated medically (n=3). We analysed viability from clinical data, positron emission tomography imaging (PET) with 18F-fluorodeoxyglucose and procedural angiographic characteristics (significant retrograde flow) before and after recanalization. 18F-fluorodeoxyglucose (FDG) uptake was classified in groups of % uptake using the segment with maximum tracer.

Results: Percutaneous coronary interventions were attempted in 172 total occlusion lesions. Successful recanalization with stent implantation was accomplished in 144 lesions, with a procedural success rate of 84%. Inability to cross the stenosis with a guide wire was the most common cause of procedural failure. Statistically significant predictors of procedural success include older occlusions (86% <12 months old vs. 37% ≥12 months old), angiographically abrupt-appearing occlusions (72% vs. 93% with tapered occlusions), presence of bridging collateral vessels (23% with vs. 88% without) and lesions >15 mm.

Conclusions: These findings suggest that clinical, procedural characteristics and PET imaging may be useful for assessing myocardial viability and the degree of myocardial salvage. In some cases we overestimate or underestimate the degree of viability. This reduces prognostic benefits of coronary revascularization in such patients. Further clinical investigation is warranted.

C6-20 ENDOSCOPIC RADIAL ARTERY HARVESTING FOR CORONARY ARTERY BYPASS GRAFTING EARLY AND MID-TERM RESULTS

N. Ito, T. Tashiro, M. Nishimi, N. Minematsu, G. Kuwahara, Y. Sukehiro, H. Teratani

f*ckuoka University School of Medicine, f*ckuoka, Japan

Objective: The radial artery (RA) is a commonly used arterial conduit in coronary artery bypass grafting (CABG). Traditional open-vessel harvest often leads to postoperative wound complications and cosmetic problems. Endoscopic radial artery harvesting (ERAH) is used to prevent these problems. However, the mid-term results of ERAH are still unknown. The purpose of this study was therefore to assess the efficacy of ERAH regarding the early- and mid-term results after CABG.

Methods: Off-pump technique has been the standard method for isolating CABG since April 1999. Therefore, this study compared the outcomes of 247 patients that underwent isolated off-pump CABG using RA in this institution from April 1999 to December 2009. One hundred and nine patients underwent ERAH (excluding cases requiring conversion to open technique), and 138 underwent traditional open-RA harvesting (ORAH).

Results: The mean age was significantly higher in the ORAH group than in the ERAH group. The other baseline characteristics, excluding hyperlipidemia, body surface area and peripheral vascular disease, were similar between the two groups. All RAs were successfully harvested and used. The mean harvesting time (forearm ischemic time) was 30.6 min. The mean length of RA was 18.2 cm in the ERAH group and 16.2 cm in the ORAH group (P<0.001). Neither wound complications, such as wound infection and skin necrosis, nor severe neurological complications were recorded in the ERAH group. The early patency rate was 97.5% (157/161 anastomoses) in the ERAH group and 95.6% (132/138) in the ORAH group. The three-year patency of RA in the ERAH group was higher than in the ORAH group (96.4% vs. 88.5%, P=0.546). A Cox regression analysis demonstrated that ERAH was not associated with death, cardiac death or cardiac events.

Conclusions: ERAH can be performed safely and the early- and mid-term – results are similar and satisfactory. Endoscopic vessel harvesting is therefore recommended as the technique of choice for RA harvesting.

C6-21 CARDIAC HERNIATION THROUGH AN IATROGENIC PERICARDIAL BREACH

F.G. Arlati, E. Penza, M. Agrifoglio, M. Gennari, G.L. Polvani

Centro Cardiologico Monzino, Milan, Italy

Objective: Dyspnea and chest pain sometimes can deceive also the most experienced physician, especially in young patients. A good anamnesis still plays a pivotal role in the diagnostic path. In November 2009, a 47-year-old woman was admitted at our hospital with a diagnosis of heart dislocation in left hemithorax. She underwent left inferior lobectomy for bronchiectasis in 2003, moreover she had a history of hypertension, dyslipidemia, renal lithiasis, frequent pneumonia and bronchitis. In 2006, she was hospitalized because of acute myocardial infarction. Coronary catheterization showed a milking of the left anterior descending artery with no other significant stenosis upon the principal coronary vessels. From that moment the patient complained of dyspnea for mild to moderate stress. Finally, in 2009 a cardiac CT showed a partial herniation of the heart through a pericardial breach with a ring shaped incisura on the basal portion of the ventricular chambers causing ab extrinseco compression on LAD and first diagonal branch and a 90° right rotation of heart’s axis.

Methods: Once the diagnosis was made, the patient was enlisted for cardiac surgery. Preoperative chest X-rays showed a mild left basal pleural effusion, echocardiography and blood examinations were normal, a right axis deviation was evident at the EKG. Through a median sternotomy we performed a pericardiectomy without extracorporeal circulation. As the CT clearly showed, the ventricular chambers, from their basal portion to the apex, were herniated through a pericardial breach located on the left infero-lateral portion of the pericardial sac. An evident rotation of the heart axis towards right was appreciable.

Results: The patient recovered fast and well from cardiac surgery. Two years after operation she is in good clinical condition and completely asymptomatic. A recent CT-scan made in February 2011, shows no signs of ab extrinseco compression.

Conclusions: This case report wants to point the attention of the physician on the patient’s history. A cardiac surgeon should always consider the possibility of a iatrogenic lesion of the pericardium in a patient with previous thoracic surgery.

C6-22 TRANS-VENTRICULAR MITRAL VALVE RING ANNULoPLASTY (MVRA) DURING LV GEOMETRY RECONSTRUCTION (GR) AND CABG IN PATIENTS WITH ISCHEMIC DILATED CARDIOMYOPATHY (IDCM)

L.A. Bockeria, M.D. Alshibaya, O.A. Kovalenko, D.E. Musin, K.V. Krymov, E.P. Golubev

Bakoulev Scientific Centre for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Moderate or severe ischemic mitral regurgitation (IMR) is the main reason of unsatisfied results of LVGR in IDCM. The new method of trans-ventricular MVRA allows to avoid additional atrial incision and to reduce the time of procedure.

Methods: Thirty-six patients with IDCM, severe heart failure and moderate to severe IMR were operated upon between March 2006 and October 2009. All patients were in NYHA class IV, mean LVEF was 28+6%, mean IMR degree 2.5+0.4. MVRA was performed during LVGR through the left ventriculotomy. The mean bypass number was 3.1+0.4/patients.

Results: Three patients (8.3%) died in hospital period due to profound postoperative heart failure. Mean LV end-diastolic volume decreased postoperatively from 304+31 to 148+14 ml (P<0.001), mean LVEF aroused to 42+4% (P<0.01), mean MR degree dropped after correction to 0.6+0.3 (P<0.001). One patient was successfully re-operated three weeks after primary intervention for partial ring dislocation. In mid-term postoperative period (11+3 months) all patients but one were in NYHA class I and II, mean LVEF was 43+5%, mean MR degree 0.6+0.2 in comparison with 68 LVGR patients with moderate IMR without MVRA where mean degree of postoperative MR was 1.5+0.7 (P<0.05 in contrast with MVRA group). In two patients of the last group MV replacement was performed through 11 and 14 months after the first operation.

Conclusions: Trans-ventricular MVRA is an effective method of surgical correction in patients with IDCM, severe heart failure and IMR. The indication to MVRA during LVGR is moderate to severe IMR due to LV distension and mitral annulus dilatation.

C6-23 CLOPIDOGREL AND BLEEDING IN CARDIAC SURGERY

P. Borsani, G. Mariscalco, S. Tenconi, M. Cottini, V.D. Bruno, G. Piffaretti, C. Dominici, A. Sala

Ospedale di Circolo, Varese, Italy

Objective: Clopidogrel administration in the treatment of acute coronary syndromes has been shown to reduce mortality and morbidity for both STEMI and NSTEMI and to reduce early thrombosis after coronary angioplasty. As a consequence, more and more patients undergoing a cardiac surgery procedure are currently in clopidogrel treatment. The objective of our study is to find out the relationship between clopidogrel therapy and the risk of transfusion and hemorrhagic complications after myocardial surgical revascularization.

Methods: Between 1 January 2005 and 30 June 2010, 1392 patients underwent isolated myocardial surgical revascularization in our centre. After propensity score matching, a group of 248 clopidogrel-treated patients and a group of 248 non-clopidogrel-treated patients were analysed. Considered parameters were blood loss during the operation day and the day after, the number of transfused red blood cell, plasma and platelet units during hospital stay and chest re-exploration for bleeding.

Results: Overall mortality was 1.8%; patients requiring transfusions were 56.9%; patients requiring chest re-exploration for bleeding were 4.2%. No differences in perioperative and early outcome were observed between the two groups. Patients in clopidogrel treatment until 24–48 h before surgery required more transfusions compared to control group (P=0.001). The same difference was observed when different blood elements transfusions were analysed (P=0.026, P=0.037 and P<0.001). Clopidogrel treatment during the first 24–72 postoperative hours was an independent predictor of transfusion and chest re-exploration need.

Conclusions: Clopidogrel treatment in surgical revascularization candidates should be interrupted, according to the clinical conditions, at least five days before surgery. Early postsurgical treatment is a risk factor for transfusion need and chest re-exploration for bleeding.

C6-24 APPLICATION OF BRAIN NATRIURETIC PEPTIDE IN ESTIMATION OF eFFICIENCY OF SURGICAL RECONSTRUCTION POSTINFARCTION LEFT VENTRICULAR ANEURYSM

N.S. Paskar, I.V. Sukhova, I.I. Ivanov, V.V. Dorofeykov, M.L. Gordeev

Federal Centre of Heart, Blood and Endocrinology named after V.A. Almazov, Saint Petersburg, Russian Federation

Objective: Level of brain natriuretic peptide (BNP) is a significant indicator for patients with decrease ejection fraction. The objective of this study was to estimate the level BNP after surgical ventricular restoration (SVR).

Methods: Twenty-one male patients have been involved in the study, mean age at the moment of operation was 56.4±8.3 years. Fifteen (71.4%) patients were in NYHA functional class III or IV. Multi-vessel disease was present in 14 patients. Functional status, left ventricular volumes, ejection fraction (Simpson’s method) and BNP were analysed at baseline, postoperative days and after six months.

Results: Twenty-one patients underwent CABG and SVR. There was no early mortality. Depending on a type of LV reconstruction, patients were divided into two groups. The first group included eight patients after endoventricular reconstruction according Dor technique and the second group included 13 patients after linear LV repair. Initially in 1 group level of BNP has made 297.5 pg/ml, in second group 127.3 pg/ml. For the first day after operation at patients of two groups level BNP exceeded normal value 828.1 – in 1 group, in 2 – 444.1. During seven days after operation the tendency to the decrease was marked in the first group. Ejection fraction improved from 31.8% to 39.4% (P<0.05) in first group and from 41.7% to 45.2% – second group. End-diastolic volume were reduced from 263.7 ml to 184.1 ml – 1 group and second group – from 205.2 ml to 168.3 ml. Six months postoperatively 8/8 patients in first group were in NYHA class I or II and 12/13 patients had the same class NYHA. Level of BNP after six months was 181.2 pg/ml in first; 197.8 pg/ml in second group. That happened because patients of the second group initially were more different to the functional status of LV and the majority of them had lowered as global and Theiholz ejection fraction.

Conclusions: Improvement in patients first group was associated with reduced levels of BNP six months after surgery. Use of surgical ventricular reconstruction allows to improve LV function and functional state in the patients of both groups. The most expressed dynamics of parameters at patients of the first group. Change of a level BNP after surgical correction demands the further studying in more long-term period after operation.

C6-25 CORONARY AND CAROTID ARTERY OCCLUSIVE DISEASE: A SINGLE CENTER EXPERIENCE

P. Kovacevic, L. Velicki, B. Mihajlovic, S. Nicin, A. Redzek, M. Fabri, N. Komazec

Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia

Objective: Due to increased life expectancy, the risk profile of the patients undergoing cardiac surgery changed dramatically. This is especially important in case of concomitant coronary artery disease and carotid artery stenosis (CAS). Controversy about relationship between staged and concomitant carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) still exists. The objective of the study was to evaluate the results of surgical treatment of patients with concomitant carotid artery stenosis and coronary artery disease.

Methods: The study included 835 patients operated of occlusive coronary and carotid artery disease during the period 1 January 1982 to 31 December 2010. There were 558 (66.8%) male patients and 277 (33.2%) female patients, and the mean age was 62.6±8.7 years. As for the operative approach, three modalities were used in our hospital. Two-stage operation – patients with unilateral CAS and coronary artery disease (CAD) – CEA followed by CABG in the second act. Three-stage operation – patients with bilateral CAS and CAD – CEA followed by another CEA of the opposite carotid artery followed by CABG afterwards. Simultaneous operation – patients with unilateral CAS and CAD – CEA and CABG at the same time.

Results: Echocardiography revealed that 28% of the patients had poor left ventricle ejection fraction (<30%). Coronarography demonstrated that 21.4% of the operated patients had significant left main coronary artery stenosis (>60%). In terms of neurological status, majority of patients (88.3%) were neurologically asymptomatic. The overall mortality regardless the sequence of procedures was 2.3% (19 patients). In the group of concomitantly treated patients 44.6% (50 patients) required triple coronary bypass while the mean number of coronary bypasses was 2.6. Postoperative neurologic complications were present in 102 patients (12.2%). Eighty-four patients (10.0%) have had TIA, while 18 patients (2.2%) have had permanent neurologic deficit while four patients (0.5%) died as a result of it.

Conclusions: It is imperative that every patient being considered for CABG should undergo ultrasonic evaluation of the carotid arteries regardless the neurological symptomatology. It may be considered concomitant surgical treatment only in patients with unstable angina and significant carotid artery stenosis, in whom it is expected higher morbidity and mortality.

2nd Vascular Surgery Session – Moderated Posters I May 20, 2011 15:30–16:30

V2-1 THE PATENCY OF CONDUCTED THERAPY IN ACUTE ARTERIAL THROMBOSIS OF LOWER EXTREMITY

I.P. Mikhailov, N.E. Kudryashova, A.S. Siluyanova, O.A. Chernyshova

Scientific Research Institution named after N.V. Sklifosofskiy, Moscow, Russian Federation

Objective: The goal of our study was assessment of tissue viability in acute ischemia of lower extremity due to an acute arterial thrombosis.

Methods: Within the period from 2005 to 2010, 725 patients with acute arterial thrombosis of the lower extremity, not embolic genesis, have been treated. The reason of thrombosis in 103 patients (14.2%) was arterial agilities, in 72 patients (9.9%) coagulopathy were diagnosed (polycythemia, anti-phospholipid syndrome, deficiency of proteins C and S, etc.), in 550 patients (75.8%) the reason of thrombosis was the atherosclerosis, bypasses thrombosis, injury, iatrogenic damages in endovascular interventions. An average age of patients varied from 18 up to 99 years. The degree of an acute leg ischemia has been estimated based on classification of an acute ischemia named after I.I. Zatevakhin. The basic diagnostic methods were: ultrasonic duplex scanning of arteries and veins with measurement ankle-brachial index, angiography, three-phase isotope scanning a tissual blood flow, laboratory analyses (myoglobin, creatine phosphokinase, etc.).

Results: One hundred and three patients (14.2%) with arterial angitises complicate thrombosis and patients with coagulopathy have been treated by conservative therapy which included infusions of 60 μg of alprostadil, anti-inflammatory and anticoagulant therapy, 12 patients (1.6%) have been treated with thrombolytic therapy. Efficacy of therapy has been evaluated according to isotope scanning of tissual blood flow and indicators of creatine phosphokinase and myoglobin. Five hundred and fifty patients (75.8%) were operated. Reconstructive operations were carried out using synthetic vascular prosthesis and autovenous prosthetic repair. In 43 patients (5.9%) fasciotomy was added to this operation. The choice of tactics of surgical treatment has been estimated by tissue viability, clinical finding, degree of an ischemia and three-phase isotope scanning of tissual blood flow. The three-phase isotope scanning of tissual blood flow gives the greatest objective estimation of efficacy of surgical treatment. The presence of muscular necrosis and changes of peripheral blood circulation can be diagnosed via reduction or increasing of drug activity in artery segments.

Conclusions: In acute arterial thrombosis of lower extremity, three-phase isotope scanning of tissual blood flow allows to estimate pathophysiological changes with the exact and quantitative characteristic of changes of a blood-groove in each certain site of an extremity that allows to choose tactics of treatment and can be used in control over efficacy of conducted therapy.

V2-2 CLINICAL EVALUATION OF THE EFFECTIVENESS OF AUTOLOGOUS IMPLANTATION OF BONE MARROW MONONUCLEARS IN LOWER LIMB ISCHEMIA

O.V. Maslyanyuk, G.G. Khubulava, A.B. Sazonov

Surgery Clinic of Excellence No 1, Military Medical Academy, Saint Petersburg, Russian Federation

Objective: To evaluate safety and efficacy of transplantation of autologous mononuclear cell fraction of bone marrow in lower limb ischemia.

Methods: The study included 26 patients suffering from obliterative atherosclerosis of lower limb diabetic angiopathy of lower extremities vessels with IIb–IV stage ischemia treated in the period from February 2009 to October 2010 (nine patients with IV stage, 10 patients with III stage, seven patients with IIb stage). In all patients, reconstructive operations on arteries of lower limbs were considered impossible; lumbar sympathectomy was previously performed in 19 patients. Depending on the mode of administration, all patients were divided into three groups: the first group received intramuscular, the second group intra-arterial, and the third group combined intramuscular and intra-arterial injection. Treatment outcomes in 26 patients with similar topical lesion of lower limb arteries and the degree of lower limb ischemia treated with the same therapy as patients of the experimental groups (except for the implantation of bone marrow mononuclear cells) were analyzed as a control group. Evaluating the effectiveness of the therapy consisted of: – assessing the intensity of pain, dosage decrease and analgesics withdrawl; – changes in pain-free walking distance (treadmill test); – the dynamics of wound healing process in the presence of ulcer or necrosis; – dynamics of peripheral blood flow according to Doppler ultrasound, transcutaneous oximetry; – frequency and level of lower limb amputation; – estimate the total mortality.

Results: There were no side effects and deterioration in patients after the introduction of suspension of autologous mononuclear cells. Of nine patients with IV stage limb ischemia and trophical ulcers, necrosis and initial limb gangrene, five patients as a result of the treatment achieved positive changes of the wound healing process, with subsequent healing of ulcers. There were no deaths during hospitalization and a follow-up of patients up to 10 months after discharge. Upon further observation period of 10 months return to a level of critical ischemia was observed in three patients from the main group and six in the control group. The best result was obtained in patients with three and two stage ischemia; pain at rest disappeared, walking distance significantly increased.

V2-3 ANGIOPLASTY OF DISTAL ANASTOMOSIS AFTER INFRAINGUINAL BY-PASS GRAFTING

J. Kesik, P. Terlecki, A. Paluszkiewicz, T. Zubilewicz

Department of Vascular Surgery and Angiology, Lublin, Poland

Objective: Acute lower limb ischemia caused by graft thrombosis may occur in the patients who underwent infrainguinal by-pass grafting. The efficiency of surgical thrombectomy depends on adequate in- and out-flow. The aim of this study was to assess the efficacy of endovascular treatment of distal anastomotic intimal hyperplasia simultaneously with surgical thrombectomy.

Methods: From January 2006 to December 2010 data from 314 surgically treated patients with acute lower limb ischemia caused by infrainguinal by-pass graft thrombosis were retrospectively analysed. The time from graft thrombosis to surgical intervention ranged from 3 h to 61 days. After Fogarty catheter thrombectomy, all patients had intraoperative control angiography. Thirty-two cases underwent open surgical angioplasty of proximal anastomosis. Seventy-seven required angioplasty of distal anastomosis. In that group everyone underwent balloon angioplasty of distal anastomosis, 16 required also stent placement in the place of anastomosis due to presence of residual stenosis and other 13 required angioplasty of tibial arteries.

Results: In the group who had undergone angioplasty of distal anastomosis early technical success was obtained in 72 (93.5%) cases. In one patient, recurrent graft thrombosis during first 24 h after intervention was observed. During six-month follow-up graft thrombosis was observed in 11 (14.3%) patients, four (5.2%) required repeated angioplasty.

Conclusions: Every surgical thrombectomy of infrainguinal graft requires intraoperative control angiography to assess patency of anastomosis and tibial arteries. The observing of stenosis in the place of anastomosis requires angioplasty. The use of endovascular techniques reduces traumatic of intervention and allows prolonging graft patency rate.

V2-4 CHYLOTHORAX AFTER SURGERY OF RUPTURED THORACAL AORTIC ANEURYSM AND AORTA COARCTATION: EFFICACY OF SOMATOSTATIN

N. Gormus, Z.I.S. Gormus, C. Guven, I. Yilmaz, O. Koc, T. Yuksek

University of Selcuk, Meram Medical School, Selcuk, Turkey

Objective: Chylothorax after surgical treatment of thoracal aortic aneurysm is a rare complication and may prolong the hospitalization.

Methods: A 34-year-old male patient admitted to our department with back pain and dyspnea. Chest X-ray showed a consolidation at the upper lobe of left lung just closed to descending aorta. Computerized tomography angiography showed a ruptured huge thoracal aortic aneurysm below the enlarged left subclavian artery. Between the aneurysm and left subclavian artery the aorta was seen as coarctated. Active atrio-femoral shunt was created with centrifugal pump aid. The thoracal aortic aneurysm and coarctated aorta were cut and an 18-mm dacron graft was interposed between the left subclavian artery and thoracal aorta.

Results: In the first postoperative day, he was stable without any neurological defect. However, he had a significant drainage (1500 ml/daily). The analysis of the drainage fluid revealed that this was a chylous drainage. Therefore, oral food in-take stopped, total parenteral nutrition started (containing less fat) and a somatostatin infusion was started with an initial dose of 3.5 μg/kg/h. Everyday a dose of 2 μg/kg/h was added to infusion rate until reaching to 12 μg/kg/h, whereas the drainage was decreased to 100 ml/daily. At the postoperative 33rd day the drainage was <50 ml/daily and chest tube removed. Oral food intake was started and control chest X-ray did not show any fluid accumulation. He was discharged.

Conclusions: Active atrio-femoral shunt provides an excellent postoperative outcome in surgical treatment of thoracal aortic aneurysms. Severe adhesions may cause difficult dissection which may result with ductus thoracicus injury and chylothorax. Somatostatin infusion provides successful treatment of chylothorax after thoracal aortic surgery.

V2-5 SURGICAL TREATMENT OF MASSIVE PULMONARY EMBOLISM

V. Kertsman, O. Cohen, Z. Beckerman, E. Kisselman, E. Saig, Z. Adler, S. Diab, G. Bolotin

Cardiac Surgery Department, RAMBAM Medical Center, Haifa, Israel

Objective: Massive pulmonary embolism (PE) is an infrequent but a devastating clinical scenario which carries high morbidity and mortality. The treatment of massive PE is debatable in the clinical literature. Surgical pulmonary embolectomy is one of the possible treatments available for this dramatic and urgent entity. The purpose of this study is to evaluate our early-, mid-, and long-term results after pulmonary embolectomy.

Methods: Between November 1999 and December 2010, 14 patients (mean age of 55.3±18.02 years) diagnosed with massive PE were emergently operated at our department. All patients were followed up and reported their medical condition on a telephone survey. Among them, 12 had a surgical procedure performed prior to the PE event. The indications for surgical intervention were: hemodynamic instability, right heart failure (per echocardiography), respiratory failure, and massive PE diagnosed by CT angiography. All 14 patients had embolism involving the main pulmonary branches. Nine of the patients arrived after cardiopulmonary resuscitation (CPR) and eight were intubated and ventilated prior entering the operating room. All procedures were performed using extracorporeal circulation, four of them were done on beating-heart (without aortic cross-clamping).

Results: Average bypass and cross-clamp time were 80.06±35.62 (40–158), and 36.42±28.2 (20–91) min, respectively. Time period between diagnosis and beginning of operation was 12±13.02 (2–62) h. Postoperative length of stay was averaged to be 11 days. Short-term mortality occurred in three of the patients (23%), causes of death were: anoxic brain damage (1), AMI (1), and right heart failure (1). Long-term mortality occurred in three patients, one from heart failure, and the two from oncologic disease. The remaining patients were found in a good general condition. Six are treated with anticoagulation for life (Warfarin), and two with aspirin only.

Conclusions: Emergent pulmonary embolectomy proved to carry a relatively good short- and long-term survival (even in high-risk patients).

V2-6 FUNNEL TECHNIQUE FOR EVAR: ‘A WAY OUT’ FOR ABDOMINAL AORTIC ANEURySMS WITH ECTATIC PROXIMAL NECKS

S. Ronsivalle, F. Faresin, F. Franz, C. Rettore, L. Zonta, M. Zanchetta

Department of Cardiovascular Disease, Vascular Surgery and Diagnostic, Cittadella Hospital, Padua, Italy

Objective: To describe an endovascular technique for proximal stent graft fixation in patients with an abdominal aortic aneurysm and an ectatic aortic neck.

Methods: We describe a method for stent graft fixation in ectatic aortic necks in patients with abdominal aortic aneurysm, in which using currently available devices in a hybrid assembly offers another option for circumventing the limitations of problematic proximal fixation. We use four clinical cases to illustrate the feasibility of placing a straight thoracic endograft as a proximal extension of a bifurcated aortic or aorto-uni-iliac endograft in patients with an abdominal aortic aneurysm and a dilated proximal aortic neck.

Results: Through four examples we illustrate the feasibility of placing a straight endograft as proximal extension of a bifurcated or aorto-uni-iliac graft in patients with a dilated proximal aortic neck. This endograft configuration appears secure and effective, with no type I endoleak or migration over a mid-term follow-up.

Conclusions: This endograft configuration appears secure and effective, with no type I endoleak or migration over a mid-term follow-up.

V2-7 HYBRID TREATMENT FOR THORACIC AND THORACOABDOMINAL AORTIC ANEURYSM IN HIGH-RISK PATIENTS UNFIT FOR OPEN SURGERY – OUR FIRST EXPeRIENCE

I. Marjanović, M. Jevtić, S. Mišović, S. Rusović, A. Tomić, M. Šarac, U. Zoranović

Military Medical Academy, Belgrade, Serbia

Objective: Hybrid repairs of aorta refer to procedures combining both open surgical and endovascular techniques. By bypassing vital aortic side branches first, it is possible to cover their origins with a stent-graft and thus achieve total aneurysm exclusion.

Methods: We want to report our first experience with hybrid vascular procedures in two high-risk patients. First patient was a 74-year-old male with type V thoracoabdominal aortic aneurysm (Safi’s classification) with maximum diameter of aorta 9 cm. In previous medical history patient had diabetes, chronic renal failure and chronic pulmonary obstructive disease. Second one was a 68 years male, with aneurysm of descending thoracic aorta (diameter 8.3 cm) and abdominal aortic aneurysm (diameter 5.5 cm), and stenosis of 80% of the left internal carotid artery and hypotrophy of the right vertebral artery. Level of the thoracic aneurysm was at the origin of left subclavian artery (proximal lending zone two-Ishimiura classification). In previous medical history the patient had diabetes, congestive heart failure and stroke two years before with good recovery.

Results: Case 1: We performed elective visceral hybrid reconstruction of TAAA. Open vascular procedure included the retrograde revascularization from the distal part of aorta with bypass procedure of all visceral artery (celiac trunk, superior mesenteric artery and both renal arteries). Endovascular technique performed complete exclusion of aneurysm with two TAG (Gore–Tex) stent-grafts. Patient left the hospital on the 21 postoperative day. Control computed tomography, performed six months after hybrid procedure showed functional all visceral branches and no sign of endoleak. Case 2: We decided for reconstruction of aorta in three stage. First stage was endarterectomy of the left internal carotid artery and at the same time we performed left carotico-subclavian bypass. Two weeks later, we performed endovascular procedure for thoracic aorta. We have placed TAG stent graft through the temporary iliac conduit, up to the origin of the left common carotid artery. Two months after second procedure we performed open vascular repair of abdominal aortic aneurysm. Control CT aortography, performed six months after last procedure showed normal flow rates through all branches of the aortic arch, and no evidence of endoleak.

Conclusions: The hybrid approach of combining endovascular repairs with appropriate open surgical techniques may provide a valuable alternative for high-risk patients with thoracic and thoracoabdominal aneurysm. Our first results of hybrid procedures in the thoracic arch and thoracoabdominal aorta in selected high-risk patients are encouraging.

V2-8 MORPHOGENETIC SCREENING OF ABDOMINAL AORTIC ANEURYSMS

K. Andreychuk, E. Kechaeva, V. Soroka, P. Kagachev

Emergency Medicine Research Institute, St. Petersburg, Russian Federation

Objective: Prevalence of abdominal aortic aneurysms impels us to tackle preventive health care and early detection of that pathology. In accordance to present notion, aortic involvement and character of its clinical course is considered as multiple-factor disease, significant factor of which development is genetic constituent. Many of genetic disorders affecting a connective tissue show themselves in various morphological signs. Early detection of these morphogenetic markers can be a significant component of screening protocol for abdominal aortic aneurysms, because prerequisite for the aneurysm origin would be detected earlier, before an aortic dilatation. We analyzed genetic disorders and associated with them significant phenotypic markers of the patients with abdominal aortic aneurysms for the purpose of the screening criteria definition.

Methods: One hundred and fifteen patients (age 69.7±9.1 years) with abdominal aortic aneurysm were examined. Genetic part of study was based on exposure of most informative for this disease gene disorders, namely – 5G-allele of plasminogen activator inhibitor (PAI-1), hom*ozygotes for the deletion allele of angiotensin converting enzyme (ACE), polymorphism of the NO-synthase (eNOS) gene (G894), etc. – by the use of polymerase chain reaction (PCR). Phenotypic markers were evaluated by means of stock checklist.

Results: Among the phenotypic markers, most frequently revealed in the study group and closest interrelated to genetic disorders, the following were extremely significant: myopia (P=0.002), joint hypermobility (P=0.035), abdomen hernias (P=0.033), platypodia (P=0.024), existence of epicanthi for Caucasians (P=0.037), saddle nose or wide nose bridge (P=0.030). Such assessment is available for every physician. Presence of three and more among these stigmas should be an indication for abdominal aorta examination. If a patient does not have an aortic dilatation, advanced genetic study must be performed. In the event of genetic corroboration such patients are subject to regular ultrasound examination, because of the high risk of aneurysm’s development.

Conclusions: Morphogenetic screening is a method of early detection of abdominal aortic aneurysms and prevention of disease complications.

V2-9 OUTCOME OF SURGICAL MANAGEMENT IN STAGE IV ISCHEMIC DISEASE OF LOWER LIMBS DEPENDING ON BACTERIAL FLORA IN NECROTIC DEFECT AND TYPE OF SURGICAL PROCEDURES

S.V. Kochetov, A.V. Gavrilenko, A.E. Kotov, S. Meyo

Russian Scientific Centre of Surgery named after academician B.V. Petrovsky, Moscow, Russian Federation

Objective: To verify the outcome of direct or indirect reconstructive treatment in patients with critical ischemic lower limbs depending on the types of surgical procedures and type of bacterial flora in the wounds.

Methods: Observation of 60 patients with critical ischemia of lower limbs (CILL). Among them 32 patients (53.3%) have atherosclerosis, arteritis in 11 (18.3%); diabetes in 17 (28.3%) patients. Duration of ulcer was from one month to three years, mean duration was seven months. Bacteriological investigations were done two times with standard bacterial inoculation method in elective environment. Group I consists of 48 (80%) who were treated with direct revascularization procedures. Group II consists of 12 (20%) patients who underwent indirect revascularization in combination with necrectomy. All patients had ulcers with the size from 2 mm to 5 cm and one or many digital gangrenes.

Results: We analyzed the results of postoperative period in both groups according to surgical intervention and range of bacterial flora of wound. There was 48% and 6.3% of wound healing in I group (n=48) in association with detection of monoculture or bacterial association in the wound, respectively. Wound healing was 21.7% (n=13) in subgroup in which no flora was detected. CILL remained in 12.5% (n=6), 6.3% (n=3), and there was no patient who had no bacterial flora. High amputation was performed in 1 case associated with bacteria flora in the wound (2.1%), and there was no patients in other subgroups. There was 25% (n=3) and 8.3% (n=1) of wound healing in II group (n=12) in association with detection of monoculture or bacterial association in the wound, respectively. CILL remained in 8.3% (n=1), 25% (n=3), but patients in third subgroup 0. High amputation was performed in one patient with monoculture in wound (8.3%) and four patients with bacterial association in wound (33.3%). There was no patients in subgroup 3.

Conclusions: Within six months postoperative period, the signs of CILL was ceased and the incidence of limb saving in group I was 77.2%. But digital amputations were performed in patients who had microbial flora in wound. In group II CILL ceased in 33.3% and majority of digital amputations were also associated with microbial flora in the wound.

V2-10 HYBRID TECHNIQUES FOR TREATMENT OF VARICOSE VEINS: COMBINED NEW AND CONVENTIONAL TECHNOLOGIES

Ch. Baraldi¹, M. CarellI¹, F. Rinaldi²

¹Tricarico Clinic, Belvedere Marittimo, Italy; ²Carmona Clinic, Messina, Italy

Objective: We assessed the safety and efficacy of combined endovenous laser treatment (ELT) and traditional techniques for treatment of the saphenous veins insufficiency, based on experience, increasing endolaser procedure in patient often treated with stripping.

Methods: Since September 2007–June 2010, 704 ELT procedures have been performed (great and small saphenous vein) using a diode laser 980 nm wavelength (LASEmaR1000-Eufoton, Italy) by a kit that includes optical fibers of 600 µ (KIT INVE, Eufoton, Italy). Local echo-guided anesthesia were performed in all cases. Laser power is variable regarding veins diameter from six to 12 watts settled in semi-continuous mode and the energy supplied is personalized to morphologic vein characteristics. Power is always personalized to echography vein patterns (diameter, wall thickness, anatomic deep). In 94% of all patients other techniques have been associated: microflebectomy (86%), varicectomy (12%), perforator vein closure (4%), stripping of lower extremity of great saphenous vein (GSV) (7%). This last procedure (stripping) combined to ELT is performed when tortuosity of GSV prevent laser endovenous treatment.

Results: In all cases (100%) has been detected the subjective symptomatology’s fading, with an objective improvement of symptomatology after one month of the operation and of aesthetic profile. At three months after operation, in 99.9% of all cases has been detected a complete occlusion of vein treated, and in 0.01% of cases has been detected an early recanalization of saphenous vein (initial learning curve only). At six months after operation has been detected a recanalization of saphenous vein in the 1.5% of 145 operated patients. At 12 months after operation has been detected a long-regurgitation without usual relapses in 0.46% of 32 operated patients. No major complications occurred. One DVT (0.0012%) occurred. Local transient paraesthesia at the ankle and midcalf level occurred in five patients (0.006%). In 74% of patients we observed that vein treated disappear after six months.

Conclusions: In all (100%) patients treated with combined technique ELT-stripping we assessed a total improvement of aesthetical and functional aspects. The endovenous laser treatment (ELT) of saphenous veins is a minimally-invasive surgical intervention, that often can be combined to other techniques performable by a one-day surgery always under ultra-sound guide and by a topical anesthesia. It can ensure good clinical and aesthetic results avoiding invasive procedures like stripping. Combined techniques personalized to the patient’s vein situation permit to obtain the best results and the best satisfaction of patients.

V2-11 A MINI-INVASIVE TECHNIQUE FOR TREATING THROMBOPHlEBITIS OF SUPERFICIAL VEINS OF LOWER EXTREMITY

P.G. Shvalb, A.E. Kachinksky, I.A. Suchkov, R.E. Kalinin, A.S. Pshennikov, N.D. Mzhavanadze, M.V. Narizhny

Ryazan State Vascular Surgery Center, Ryazan, Russian Federation

Objective: To evaluate the efficacy of phlebocentesis in treatment of thrombophlebitis of superficial veins of lower extremity.

Methods: We performed 504 surgeries for acute ascending thrombophlebitis in Ryazan State Vascular Surgery Center between 2005 and 2010. In 147 (29.1%) cases the surgeries were supplemented with phlebocentesis. The indication for phlebocentesis was the presence of the thrombosed veins along with extended infiltration regardless of its localization, thigh or leg. The procedure involves crossectomy as the first obligatory step and then skin punctures over the thrombosed veins performed with a sharp-pointed scalpel under local anesthesia. The depth of the punctures should be sufficient to access the thrombosed veins. The distance between the punctures varies from 2 to 4 cm. As a rule the semi-fluid dark thrombotic masses fill the surgical wound. After the moderate pressure put upon the vein the thrombus is completely evacuated. The extent of thrombotic mass evacuation depends on the number of skin punctures. Mini-incisions do not require stitches. The tight bandages are placed on the surgical wounds. The original dressing is soaked with blood following the first day after procedure. The surgical wound dressing is replaced after 24 h, then the operated extremity is firmly wrapped with an elastic bandage giving pressure of 20–25 mmHg.

Results: Short-term results were evaluated upon the physical examination, palpation of the infiltration sites as well as patient survey performed on the first, third, fifth, and seventh days after procedure. After the evacuation of thrombotic masses the infiltrates quickly regress. Hyperemia and local hyperthermia regress within 1–3 days, along with the reduction of edema. Following the first day after surgery the patients show significant decrease in rest pain and skin itching. Such symptoms completely regress within 2–3 days. Pain on palpation is completely reduced within 3–5 days in 87% of patients. Phlebectomy was performed in 22 (14.9%) patients within one year following the primary surgery. Throughout the years of using such a technique we have never experienced the progression of superficial thrombosis to deep vein thrombosis or pulmonary embolism. Long-term results show reduction of symptoms of chronic venous insufficiency in such patients.

Conclusions: Phlebocentesis is indicated in patients with acute ascending thrombophlebitis in presence of a massive cluster of thrombosed superficial veins on leg and thigh. The described mini-invasive technique for treating thrombophlebitis of superficial veins does not require general anesthesia or additional facilities and allows a faster rehabilitation of patients.

V2-12 CAROTID ENDARTERECTOMY UNDER REGIONAL ANAESTHESIA IN HIGH-RISK PATIENTS

D.D. Sultanov, A.K. Baratov

Republican Scientific Center for Cardiovascular and Thoracic Surgery, Dushanbe, Tajikistan

Objective: To analyze the short-term outcomes of carotid endarterectomy (CEA) under regional anesthesia.

Methods: Eighty males and seven females aged 46–74 years with internal carotid artery stenosis were observed during the period 1986–2006. Estimated risk factors were: contralateral lesion – 32 (36.8%), hypertension – 61 (70.1%), diabetes – 22 (25.3%), history of stroke – 10 (11.5%), coronary artery disease – 60 (69%), smoking – 74 (85.1%). Eighteen patients were asymptomatic. Preoperatively, antianginal and hypotensive agents were administered to those who suffered from coronary artery disease and hypertension. Less frequent occurrence or complete disappearance of angina pectoris attacks, palpitation, dyspnea on the one hand and stabilization of blood pressure and positive ECG dynamics, on the other hand, were regarded as criteria for the patients’ preparedness for operation.

Results: One hundred and five CEA were performed under regional anesthesia in 87 patients. Prior carotid artery cross-clamping all the operated patients were subject to the occlusion test of the artery, lasting for 3 min. The patients’ consciousness monitored during these 3 min. Thus, high brain tolerance to ischemia was identified in majority of cases. The internal shunt for brain protection was applied only to six patients under the surgery. Normotensive condition of patients during CEA was controlled by additional medication, especially at the moment of carotid artery clamping. Mortality rate was 0.95%. In the early postoperative period one patient developed ischemic stroke and six patients had transient ischemic attacks. Fourteen patients had different cardiac complications: transient myocardial ischemia, hyper- or hypotension, extrasystolia. No cases of myocardial infarction were recorded under this study.

Conclusions: CEA under regional anaesthesia seems to be a safe approach for high-risk patients and may significantly reduce the use of internal shunt and perioperative both cardiac and neurological complications.

V2-13 THE EFFECT OF A CAROTID REVASCULARIZATION ON COGNITIVE FUNCTION IN PATIENTS WITH SEVERE STENOSIS: A PROSPECTIVE, nine MONTHS FOLLOW-UP STUDY

T.P. Evdokimova, Y.V. Rodionova, M.N. Guryev, N.M. Lobova, L.A. Geraskina, S.I. Skrylev

Neurology Research Center of RAMS, Moscow, Russian Federation

Objective: The effects of carotid revascularization on cognitive function have not been fully definite. Furthermore, global anesthesia in time CEA performed may result in adverse neuropsychological consequences. We aimed to assess the influence of carotid stenting (CAS) or carotid surgery (CEA) on cognitive function from baseline to nine months in patients with severe carotid artery stenosis using neuropsychological test.

Methods: We consecutively recruited 38 patients (28 males; mean age 60±9 years) with high grade carotid artery stenosis (370%) at baseline. Ten patients underwent CAS and other 28 ones – CEA. Cognitive measure was composed of MMSE and neuropsychological tests which containing subcategories for testing of attention, language, calculating, operative and delayed memory and executive function (Arnold–Colman test, Wexler test, Shoulte tables, Kraepelin test). We evaluated the changes of cognitive outcome measures from baseline to nine months follow-up period.

Results: The baseline findings (sex, age, education level, cerebrovascular and cardiac disorders, and cognitive status assessment) in patients undergone CAS or CEA were not different. Total MMSE score was 27 [27; 28] points referred to mild cognitive decline. After nine months follow-up, patients underwent either CAS or CEA showing moderate improvement in cognitive function on the score of MMSE compared baseline state – 28 [27; 28] points (=0.03). The other cognitive outcome measures showing significant improvements (P<0.05) were the Arnold–Colman test, Wexler test, Shoulte tables which indicated moderate positive changes of active attention level, diminishing aural and operative memory disturbances especially in part of selecting and stability link. Neuropsychological testing results did not differ in patients one and two groups.

Conclusions: Thus, there was a positive effect of carotid revascularization on cognitive function from baseline to nine months in patients with severe stenosis using neuropsychological test. Either CAS or CEA resulted in cognitive improving regardless of operative intervention type likely due to the beneficial effect of carotid revascularization on cerebral hemodynamics.

V2-14 ‘BACK-TABLE’ SURGERY IN ORGAN TRANSPLANTATION

A. Tomic¹, M. Jevtic², S. Misovic¹, U. Zoranovic¹, M. Draskovic¹, Z. Bjelanovic¹, I. Lekovic¹, P. Djoric³

¹Military Medical Academy, Clinic for Vascular Surgery, Belgrade, Serbia; ²Head of Military Medical Academy, Belgrade, Serbia; ³Clinic Centre of Serbia, Clinic for Vascular Surgery, Belgrade, Serbia

Objective: In this paper, we reflect on the different techniques of vessel reconstruction during kidney transplantation including important steps during organ harvesting, preparation and implantation. Donor kidneys with multiple renal arteries represent a surgical challenge with by the difficulty in performing the anastomoses, bleeding and stenosis.

Methods: During living donor nephrectomy or deceased donor harvesting of the kidneys, multiple arteries should be preserved and special attention should be paid to accessory polar arteries. In deceased donor all arteries should be located on a single aortal patch. For technical reasons living donor kidneys were procured without an aortal patch for transplantation. After explantation kidney vessels should be free from perivascular tissue. Cannulation of every single artery and perfusion was performed ex situ immediately. End to end anastomosis to the recipient internal iliac artery was the standard procedure in MMA.

Results: In MMA for 15 years experience in kidney transplantation we performed 311 living donor and 24 deceased donor kidney transplantations. Around 7% of all kidneys had two or more renal arteries. We repaired 19 cases of donor kidneys with two arteries, four cases with three renal arteries, one case with three arteries and additional PTFE graft reconstruction, and five cases of iatrogenic injuries of kidney vessels during organ harvesting. Except four cases with thrombosis of polar branch and three cases with intraoperative bleeding, the surgery was without other major complications. At a minimum follow-up of one year, all patients showed normal renal function, and color Doppler ultrasonography indicated no thrombus formation or obstruction in the main renal artery. Further follow-up was not enabling because patients scattered in all directions. We also present one interesting case of living liver transplantation with three hepatic veins in right liver lobe and their reconstruction with saphenous graft.

Conclusions: The ‘back table’ reconstruction of the donor renal artery is a feasible and effective surgical procedure for the transplantation of donor kidneys with multiple renal arteries. By reconstruction of the multiple donor renal arteries we showed that two or more kidney arteries are not contraindication for transplantation. If a common patch is impossible to preserve in cadaveric kidney, we suggest own patches for each artery.

V2-15 EXTERNAL VALVULOPLASTY IN PATIENTS WITH PRIMARY VARICOSE VEINS

N.G. Xorev¹, V.M. Kuzmichev²

¹Medical University, Railway Hospital, Barnaul, Russian Federation; ²Railway Hospital, Barnaul, Russian Federation

Objective: To study the effects of deep venous reflux in the degree of chronic venous insufficiency (CVI) in patients with primary disease of lower extremity veins. Determine the clinical and hemodynamic efficiency of the operation external valvuloplasty (EV).

Methods: Trends in the number of operations carried out over the correction of deep venous reflux has been studied over the time 1990–2008. Effect of EV on the disease carried out by conducting a retrospective study in 133 patients undergoing surgery for varicose veins with detected signs of deep venous reflux. The basic group included 64 patients, who completed EV in the form extravasal correction of deep vein valve coil of PTFE. The comparison group – 69 patients without interference from the deep veins. Samples were obtained randomly in comparable proportions among 1086 operated patients. Patients in both groups are C3–C6. Results of operations are studied in period of observation 12 years.

Results: The need for EV was <1% among all patients undergoing surgery for primary varicose veins. Comparing the groups using the scale of point scoring of clinical signs of CVI statistically significant difference (P<0.05) on the intensity of pain (1.9±0.10 – basic, 1.4±0.08 – comparison), edema (1.9±0.10; 1.4±0.13), varicose veins (2.0±0.08; 1.5±0.04), lipodermatosklerosis (2.1±0.1927; 1.5±0.14), inflammation (2.0±0.20; 1.5±0.14) and compression (1.6±0.09; 1.1±0.05). In patients of the basic group (more ‘severe’ one) after surgery reduction in pain, swelling, varicose veins, pigmentation, duration and number of ulcers, inflammation and the need for compression (P<0.05) were observed. The total area of the histogram of clinical signs of CVI up operation was 1.89±0.16 points, and after the operation it decreased to 0.76±0.15 points (P<0.05). Hemodynamic effects of EV the long-term elimination of reflux disease (<0.5 s) was observed in 42 (65.6%) patients, a small reflux (0.5–1.5 s) – six (9.4%) and preservation of reflux (1.5 s) remained in 16 (25%) patients.

Conclusions: The presence of valvular insufficiency of deep veins in patients with varicose disease aggravates the disease. External valvuloplasty deep veins reduces the majority of clinical symptoms and syndromes of CVI. Complete disappearance of reflux after surgery external valvuloplasty observed in 65.6% of patients.

3rd Vascular Surgery Session – Moderated Posters II May 20, 2011 15:30-16:30

V3-1 THE PECULARITIES OF AORTIC MORPHOLOGY IN CONNECTIVE TISSUE DISORDERS

V. Rumbesht¹, A. Duzhikov¹, A. Matsionis³, S. Amelina²

¹Cardiovascular Surgery Centre of Regional Hospital; ²Regional Medical and Genetic Counseling of Regional Hospital; ³Regional Institute of Pathology, Rostov-on-Don, Russian Federation

Objective: Connective tissue disorders (CTD) is widespread in population in form of hereditary CTD and undifferentiated CTD with marfanoid, Ehlers like or unclassifiable phenotypes. The vascular syndrome with possible dissection and rupture of aorta is one of the manifestations of CTD. The aim of study was to reveal morphological pecularities of CTD in etiology of aneurysms of ascending aorta (AAA), possible differences in aortic morphology in hereditary and undifferentiated CTD.

Methods: From 2005 to December 2010, 61 patients with AAA were operated, 13% among them for emergency indications because of acute dissection or rupture of ascending aorta. one patient died in preparation for emergency operation. Histological analysis of intraoperative and autopsy material (aortic samples) was carried out using hematoxylin and eosin staining, MASSON staining for collagen, stainings for elastic and reticular fibers and immunohistochemical staining for type IV collagen. For suspected CTD genetic consultation was made for typing of hereditary forms.

Results: CTD was the leading cause of AAA (61%). The mean age of patients was 39.83±9.67 years (18–65 years). For gender analysis revealed two-fold predominance of males was found. During medical and genetic consulting hereditary CTD were revealed in 42%: Marfan’s syndrome (six patients), Ehlers–Danlos syndrome (three cases), osteogenesis imperfecta (one case) and polycystic kidney disease (one case). In all patients with AAA on the background of CTD the signs of CTD were found in relatives. Undifferentiated CTD were predominated (58%). The aorta is characterized by elastic fiber fragmentation and disarray, paucity of smooth muscle cells and deposition of collagen and mucopolysaccharide between the cells of media. We did not find any difference in hereditary and undifferentiated forms of CTD.

Conclusions: In identifying of patient with AAA on the background of CTD medical and genetic counseling with survey of patients’ families. The absence of significant differences in aortic morphology in patients with CTD requires aiming phenotypic diagnosis in patients with CTD in the preoperative stage. It is expedient to create a survey protocol patient with CTD of the proposed scoring small anomalies and use it in patients with congenital and acquired heart diseases and AAA to assess proposed aortic morphology before operation. The dynamic survey of patients with CTD families will reveal the first signs of AAA and perform planned surgery.

V3-2 OPTIMIZING THE TACTICS OF THE SURGICAL TREATMENT OF PATIENTS WITH COMPLICATED FORMS OF ABDOMINAL AORTIC ANEURYSMS

J.I. Kazakov, S.A. Mihalev, D.V. Federyakin

Tver State Medical Academy, Tver, Russian Federation

Objective: The operative mortality rates of the patients with abdominal aortic aneurysm ruptures remain high and fluctuate between 38% and 80%. The results of the surgery depend on how much time has passed since the abdominal aortic aneurysm rupture. The aim of the study is to improve the results of the surgical treatment of patients with complicated forms of abdominal aortic aneurysms.

Methods: The results of the treatment of 106 patients with abdominal aortic aneurysm ruptures have been studied. Mistakes in making the primary diagnosis have been analyzed. Much attention has been given to the clinical significance of the instrumental methods of diagnosing complicated forms of aneurysms – USS, CT, more seldom – angiography. The diagnostic significance of the developed method of infrared spectrometry (IRS) has been analyzed using two groups of patients – one of the groups had the IRS method in the examination algorythm and the other did not.

Results: Mistakes in making the right diagnosis on the basis of the clinical assessments took place in 75 cases (70.7%). 54.7% of the patients were diagnosed with the abdominal aortic aneurysm rupture by USS, 73% – by CT, 34.3% – by angiography, 90.7% – by IRS. Forty-four patients examined without the IRS were operated on their aneurysms 24.6+3.6 h after being admitted to hospital, for 46 patients who had IRS the surgery time was 11+2 h after hospitalization. Surgery was performed on 90 patients with aneurysm ruptures. The mortality rates in the groups were 25 patients (56.8%) (group I) and 17 patients (36.9%) (group II), respectively.

Conclusions: To summarize, diagnosing and surgical treatment of the abdominal aortic aneurysm rupture remains a hard problem to solve. The time factor (i.e. how much time is between the abdominal aortic aneurysm rupture and the surgery) is vital for the surgical treatment to be successful. The findings provide strong evidence in favor of the developed method of infrared spectrometry which reduces the time to correctly diagnose the abdominal aortic aneurysm rupture.

V3-3 PREDICTING PERIOPERATIVE MORTALITY AFTER OPEN ABDOMINAL AORTIC ANEURYSM REPAIR: A CASE CONTROL STUDY

J. Khan, F.A.K. Mazari, N. Samuel, G. Smith, R. Gohil, I.C. Chetter, P.T. McCollum

Academic Vascular Surgical Unit, University of Hull, Hull, UK

Objective: Preoperative risk assessment is important in patients undergoing major vascular surgery as open aortic aneurysm repair carries significant morbidity and mortality. This assessment allows further stratification of patients, so individuals at increased risk may be identified early, allowing important alterations in perioperative management to prevent morbidity and mortality. The aim of this study was to identify factors affecting 30 days mortality in patients undergoing open AAA repair.

Methods: A retrospective case control study was performed using patients identified from the vascular database. All patients who underwent elective open AAA repair between January 2005 and December 2009 with a 30-day mortality were included. These individuals were matched in 1:3 ratio with alive patients. Perioperative parameters and outcomes were recorded for all patients. Statistical analysis was performed using SPSS 16.0.

Results: Twenty patients [19 males; mean age: 74 (S.D.: 6.33)] with 30-day mortality were identified and matched to 60 live consecutive controls [52 males; mean age: 73(S.D.: 6.11)]. Risk factors associated with 30-day mortality were: previous MI [OR: 3.33 (95% CI: 0.91–11.70)]; diabetes [OR: 3.5 (95% CI: 0.89–13.26)]; chronic renal failure [OR: 19.67 (95% CI: 1.9–945)]. Preoperative investigations associated with mortality were: abnormal ECG [OR: 4.45 (95% CI: 1.29–15.20)]; raised creatinine [OR: 4.85 (95% CI: 1.15–20.30)]. AAA AP diameter on CT-scan; median 6.25 cm (IQR: 5.8–6.8) compared to control 5.6 cm (IQR: 5.5–6.2) [P=0.009]. Perioperatively supra-renal clamping, had a significant associated mortality [OR: 4.33 (95% CI: 1.14–16.12)].

Conclusions: Preoperative optimisation should be performed in patients who are identified to have risk factors to reduce 30-day mortality after open AAA repair.

V3-4 ENDOVASCULAR REPAIR OF THORACIC AORTA IN PATIENTS WITH CONCOMITANT ABDOMINAL AORTIC DISEASES

I. Koncar, M. Marković, N. Jakovljević, P. Ćorić, M. Ćolić, L.B. Davidović

Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia

Objective: Endovascular techniques are expanding our possibilities to treat high-risk patients with complex pathology. Aim of the study is to present the experience of treatment of concomitant thoracic and abdominal aortic aneurysms.

Methods: From March 2007 to November 2010, 75 patients were operated due to thoracic (TAA) and thoracoabdominal aortic aneurysm (AhAA) at the Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Center. Out of them 25 were treated with implantation of thoracic endograft. We retrospectively analysed this group where 10 (40%) patients had concomitant disease of distal thoracic or abdominal aorta that needed previous reconstruction. Two patients had THAA (type IV), one had supravisceral saccular aneurysm, one had juxtarenal aortic thrombosis and penetrating aortic ulcer of the distal thoracic aorta, two patients had already repaired abdominal part due to rupture and four patients had isolated thoracic aneurysm and infrarenal abdominal aortic aneurysm (AAA) revealed in the same time. One of these patients was admitted with ruptured TAA with history of previous ruptured AAA repair.

Results: Average age of the treated patients was 76.4 years. Treatment plan was made by individual approach. All distal segments were repaired by open surgery whenever possible. In one case we used visceral debranching as a first step procedure. The proximal segments were treated by endograft implantation (nine Medtronic^® Valiant and one Bolton^®, Relay). In two patients we used two stent grafts to cover more than 250 mm of thoracic aorta. Early mortality rate was 0% in elective cases. There were no signs of spinal ischemia. After mid-term follow-up of 17.9 months (range 2–40 months) there is no aneurysm related death, no aneurysm diameter increase.

Conclusions: Thoracic endografting is convenient solution for patient with concomitant pathology of thoracic and abdominal aorta if anatomical conditions allow. Previous abdominal aortic reconstruction provides safe access to thoracic aorta, however, individual approach should be considered in these patients.

V3-5 IMMEDIATE RESULTS OF OPEN AND ENDOVASCULAR REPAIR IN AORTIC DISSECTION

V. Papitashvili, L. Bockeria, V. Arakelyan

Bakoulev Scientific Center of Cardiovascular Surgery, Moscow, Russian Federation

Objective: The traditional approach for B-type aortic dissection repair is open surgery. The endovascular treatment of type B aortic dissection is an acceptable therapeutic procedure for patients who have favorable anatomy, in the acute and in the chronic stages of the disease; initial success rates are high regarding exclusion and thrombosis of the false lumen. Compared to the classic surgical treatment, the reduction of mortality and paraplegia rates with thoracic endovascular aortic repair has encouraged its use, often indiscriminately.

Methods: Thirty-four patients with B-type aortic dissection underwent surgical treatment. Endovascular repair was performed in eight patients. Twenty- six patients underwent open reconstruction. Indications for treatment were symptomatic or complicated B-type aortic dissection (defined by persistent pain, diagnosed or imminent rupture, and organ or limb ischemia), total aortic diameter >40 mm, or high flow in the false lumen.

Results: Technical success was achieved for 99% of patients with endovascular and open repair. In-hospital death occurred in two patients with open repair. Early postoperative complications occurred in 11.5% patients with open reconstructions and 12.5% patients with endovascular repair. Paraplegia occurred in one patient with open repair.

Conclusions: Patients with chronic type B aortic dissection had excellent initial results with thoracic endovascular aortic repair. Although event-free survival rates decreased gradually with time owing to the frequent need for new interventions, survival curves were comparable to those for less complex patients undergoing clinical or surgical treatment.

V3-6 SURGICAL AND ENDOVASCULAR TREATMENT OF THE TRAUMA OF THORACIC AORTA AND ITS BRANCHES AND POST-TRAUMATIC COMPLICATIONS

S. Tkhor, E. Lietuvietis, D. Krievins, V. Aleksandrovics, A. Lacis, G. Mednis, M. Gedins, J. Savlovskis

Stradins Hospital, Vascular Surgery Centre, Riga, Latvia

Objective: We have reviewed the records of our centre for the last 30 years period for the comparison of surgical and endovascular approaches in the treatment of thoracic aorta and its branches trauma and post-traumatic complications.

Methods: There has been a total of 16 blunt and 41 penetrating trauma cases (16 iatrogenic). Localisation of trauma or aneurysm (emergency/elective) was as follows: aorta 6/16, aortic arch–left brachiocephalic vein fistula with an aneurysm 0/2, innominate artery 2/0, subclavian artery 14/2, carotid artery 8/4 and vertebral artery 3/0. The following approaches for intervention were used: 14 thoracotomies, five sternotomies, 26 extrathoracic; 12 patients via trans-femoral or trans-iliac access (seven for descending aorta, two for right subclavian artery, one for carotid artery branches). Revascularisations were performed for two carotid and two subclavian arteries.

Results: Revascularisation was achieved in 53 patients. In another four cases ligation was performed on the common carotid artery for gigantic aneurysm owing to internal carotid occlusion and in two cases vertebral artery occlusion by wax. Three carotid artery branches were embolised for profuse bleeding. In emergency patients treated surgically five have died: two after post-traumatic repair of carotid artery; one post-haemorrhagic complication owing to iatrogenic injury of ascending aorta, one iatrogenic injury of the right subclavian artery (cardiogenic shock owing to myocardial infarction) and one as a result of the third degree burns on substantial body area. In elective surgically treated patients for aortic aneurysm repair we used hypothermia (7), CPB (6) and left subclavian to descending aorta temporary by-pass (5). Conventional resections of post-traumatic aneurysms were performed in six patients and in one patient we used ring-graft implantation, all seven patients with uneventful recovery. Complications: one light paraparesis resolved in six months after elective descending aorta aneurysm resection and another emergency patient with innominate artery graft implantation for injury complicated by the permanent ipsilateral blindness. Seven elective patients after stent-graft implantation for post-traumatic aneurysm of descending aorta and one patient for the right subclavian artery aneurysm have had an uneventful recovery.

Conclusions: There are undisputable benefits of endovascular interventions for complicated injuries of the thoracic aorta and its branches. However, in real life circ*mstances district hospitals do not always have access to modern technologies or skilled staff that university multidisciplinary hospitals have for relatively rare admission of such patients. Therefore, today open surgery is still the method of choice for thoracic aorta branch injuries.

V3-7 ENDOVASCULAR AND OPEN SURGERY FOR PENETRAtING ATHEROSCLEROTIC ULCERS

J. Szmidt, L. Romanowski, G. Szostek, O. Rowinski

Medical University of Warsaw, Warsaw, Poland

Objective: Penetrating atherosclerotic ulceration (PAU) is rare but potentially life-threatening disease. It is characterized by ulceration of atheromatous plaque disrupting the internal elastic lamina. PAU is increasingly encountered in patients with acute aortic syndromes according to improved vascular imaging techniques. In this study we present results of surgical treatment of 22 patients who were operated on for penetrating atherosclerotic ulcer.

Methods: Between January 2006 and December 2010, there were 22 patients treated for penetrating atherosclerotic ulcer in the Department of General, Vascular and Transplant Surgery of Medical University of Warsaw. In this group there were 18 males and four females. Mean age was 67 years (range 53–84). All atherosclerotic ulcerations were confirmed by preoperative computed tomography scans. Five ulcers were located in the descending thoracic aorta, another 15 in the abdominal aorta, one in the left common iliac artery and one patient had two concomitant ulcerations of both thoracic and abdominal aorta. Twenty-one patients were suitable for endovascular intervention. There were 10 straight and 12 bifurcated stentgrafts implanted under DSA guidance. In one patient an open repair with aortic replacement and conventional tube graft positioning was performed. The patient with concomitant thoracic and abdominal PAU underwent simultaneous thoracic stentgraft implantation and infrarenal aortic replacement. Follow-up scheme for patients who received stentgraft included postoperative computed tomography prior to discharge, at three, six, and 12 months, and yearly thereafter. Mean follow-up was 20.4 months (range 1–60).

Results: There were no endoleaks observed prior to discharge. One endoleak (type IA) occurred three months after endovascular operation and the patient was successfully treated by implantation of proximal stentgraft extension. Other patient underwent two sessions of endovascular embolization of endoleak type II. There were no other complications or aortic related deaths. During the follow-up period there was no aortic rupture observed.

Conclusions: Endovascular treatment seems to be an effective and safe method to prevent aortic rupture in patients presenting with penetrating atherosclerotic ulcer.

V3-8 MULTISTAGE HYBRID SURGICAL TREATMENT OF PATIENTS WITH AORTIC DISSECTION

T.E. Imaev, R.S. Akchurin, A.E. Komlev, M.R. Osmanov, P.M. Lepilin, S.A. Terechin, I.S. Fedotenkov

Russian Cardiology Research Centre, Moscow, Russian Federation

Objective: Surgical treatment of aortic dissections is the most difficult and actual problem of modern vascular surgery. The level of complications after traditional operations remains rather high despite considerable success achieved in recent years. So great attention should be paid to alternative surgical techniques that are considered to reduce complication rate and mortality. To evaluate the preliminary results of multistage hybrid surgical treatment of patients with aortic dissection type 3 compared with traditional surgery.

Methods: Since May 2009 nine patients (seven men, two women; mean age 47.2±5.5; range 25–57 years) with aortic dissection type 3a were treated with the two-stage hybrid technology: endografting of thoracic aorta combined with reimplantation of left subclavia artery in left carotid artery. Etiology of aortic dissections was as follows: atherosclerosis, Marfan syndrome, cystic medionecrosis (60%, 30% and 10%, respectively).

Results: Neither intraoperative nor early postoperative complications common for the traditional approach in group of hybrid treatment. No one patient has developed clinical presentation of spinal cord injury or other neurological confuses. In each case the absence of endoleak was obtained. Duration of hospitalization did not exceed five days. There was no in-hospital mortality in this group.

Conclusions: The use of hybrid technology in treating patients with aortic dissection type 3 allows to decrease risk of neurological injury and reduces the rate of endoleak by means of over-stenting the ostia of branchiocephalic arteries.

V3-9 OPERATING INJURY DEPENDING ON LAPAROTOMY SIZE IN AORTOFEMORAL RECONSTRUCTIONS

A.V. Maximov¹, A.K. Feyskhanov¹, E.A. Gaysina²

¹Republican Clinical Hospital, Kazan, Russian Federation; ²State Medical Academy, Kazan, Russian Federation

Objective: Estimation of operation injury at the aortofemoral reconstructions depending on the size of operative access.

Methods: Thirty-seven men have been included in research at the age from 45 up to 80 years (average – 57.5±7.5 years), suffering from atherosclerosis of aortofemoral segment. The body mass index has made from 19.9 to 29.1 (average – 22.9±0.4). It has been executed the aortobifemoral bypass to all of the patients. They have been randomized in three groups. In I group reconstruction is made through standard, in II group – through transperitoneal miniaccess in the size of 5–7 mm, in III group – through transperitoneal miniaccess in length of 8–10 mm. The research report included definition of function of external breath, level of a cortisol, level of a painful syndrome (defined on a visual analog scale). The vegetative status was estimated by cardiointervalography.

Results: The analysis of heart rhythm made by a cardiointervalography has shown different changes of indicators during the various moments of an operative measure and in the early postoperative period. Cardiointervalography, registered on the eve of operation (‘outcome’) has shown a high sympathicotonia, at all patients. During the various moments of operation all these parameters had different changes, which are difficult for systematizing and interpreting. Authentic differences between groups during the intraoperative period have not been taped. In the postoperative period the vegetative status was normalized in II group of patients with a mini-laparotomy authentically faster. Pulmonary function tests demonstrated the worst results in first group. Cortisol level increased at the end of operation in all groups and became 1440.0±147.5 nmol/l in I group, 925.6±216.3 nmol/l and 447.9±93.0 nmol/l in II and III groups. For the second day, cortisol level decreased in all groups and more expressed in group with standard laparotomy. Degree of a painful syndrome (visual analog scale) in the postoperative period in I group has made for the second day 78.8±17.2, for the third day 49.7±15.9, on fourth day 42.8±19.5, in II group accordingly – 55.2±20.1, 40.2±21.9, 20.5±6.7, in III group accordingly – 62.07±16.1; 50.43±17.17; 39.5±18.39.

Conclusions: Reconstruction of infrarenal aorta through miniaccess is characterized by a rather invasiveless, than the standard.

V3-10 THE AORFIX STENT-GRAFT TREATMENT in PATIENTS WITH DIFFICULT ABDOMINAL AORTIC ANEURYSMS ANATOMY: FIRST EXPERIENCE

M. Generalov, D. Maystrenko, P. Tarazov, V. Osovskikh, F. Zherebtsov, E. Yakovleva, A. Polikarpov, J. Suvorova

Russian Research Center for Radiology and Surgical Technologies, St. Petersburg, Russian Federation

Objective: To evaluate preliminary results of Aorfix stenting in patients with difficult infrarenal abdominal aortic aneurysm (AAA) anatomy.

Methods: Between May 2007 and September 2010, 79 patients with AAA were examined. Six patients (five men and one woman, mean age 68 years, range 63–79) have at least one of the following risk factors: short proximal neck (mean length was 5 mm, range 5–9 mm), proximal neck angulation between 60º and 90º (mean angulation was 74.6º), and/or severe iliac artery angulation/tortuosity. These patients were selected for endovascular repair with Aorfix (Lombard Medical) bifurcated stent-graft.

Results: Endovascular operation was technically successful and uncomplicated in all six cases. Occlusion of an internal iliac artery was necessary in two patients. There were no conversions to open repair. The length of hospital stay was 7–12 days. All patients returned to their preoperative activity within a three-week interval and are alive at 11–26 months. Control CT-scan and duplex ultrasound show excluded aneurysms with no endoleaks in all cases.

Conclusions: The Aorfix device seems to be safe and reliable in difficult complex infrarenal AAA anatomy, demonstrating good mid-term clinical outcomes.

V3-11 MULTI-SLICE COMPUTER TOMOGRAPHY IN ASSESSMENT OF ENDOVASCULAR THORACIC AORTIC ANEURYSMS REPAIR RESULTS

V.V. Khovrin, Yu.A. Kalmykova, Yu.V. Belov, E.R. Chatchyan, S.A. Abugov, M.V. Strutcenko

National Center of Surgery named after academician B.V. Petrovsky Russian Academy of Medical Sciences, Moscow, Russian Federation

Objective: Increasing of rate of endovascular thoracic aortic aneurysms repair technique application caused, on one hand, by pathology revealing in persons of young age, in other cases – by indications to endovascular repair in persons of high surgical risk. Crucial importance at planning of endovascular repair intervention volume and dynamic supervision in postoperative period remains behind methods of computer tomography. The estimation of efficiency of endovascular method of thoracic aortic aneurysms treatment with application of sizing and postoperative control according to multi-slice computer tomography became an objective research.

Methods: During six years since 2004, 42 patients of age from 23 to 80 years (middle age 53.5±5.4 years) underwent endovascular repair of thoracic aortic aneurysm. Thirty-four patients (80.9%) were men and eight patients (19.1%) were women. The post-traumatic thoracic aortic aneurysm was revealed at 16 patients (38%) according to multi-slice computer tomography, at 14 patients (33.3%) – thoracic aortic dissection, at 10 patients (23.8%) aneurysm was caused by atherosclerosis, at two patients (4.9%) – postcoarctational false aneurysm. The standardized sizing report is applied in all supervision.

Results: Reimplantation of the left subclavial artery before stenting has been executed in two cases (4.9%) at an estimation of results of preoperative sizing and revealing of absence or shortening of a proximal aneurysm’s neck. The stents fixing with overlapping of the left subclavial artery is proved at absence or insufficiency of a aneurysm’s proximal neck length in 10 cases. Thus, clinically in one case (2.4%) was marked the ischemia of the left upper extremity, which has not demanded reimplantation of subclavial artery. According to multi-slice computer tomography in one case (2.4%) with distal aortic dissection in postoperative period the proximal leakage of type I without dynamics of increasing aneurysms sizes was defined, as a result of stent dislocation. Deformation and destruction of stents were not revealed in all of supervisions. Dynamic control in the early postoperative period in two cases (4.9%) showed that the leakage of type III into the cavity of switched- off aneurysm was thrombosed.

Conclusions: The favorable result of endovascular thoracic aortic aneurysms repair is predetermined by a complex of accurately well-founded indications and algorithm of treatment in this group of patients, on the basis of detailed pre-surgical morphometrical thoracic aortic aneurysms assessment and postoperative multi-slice computer tomography.

V3-12 ENDOVASCULAR REPAIR OF MYCOTIC ANEURYSM OF THE DESCENDING THORACIC AORTA: DIAGNOSTIC AND THERAPEUTIC DILEMMAS – TWO CASE REPORTs WITH ONE-YEAR FOLLOW-UP

U. Zoranovic, M. Jevtic, I. Marjanovic, S. Mišovic, S. Rusovic, M. Šarac, M. Mihajlovic, J. Obradovic

Military Medical Academy, Belgrade, Serbia

Objective: A mycotic aneurysm of the aorta is a rare diagnosis with high mortality. Worse outcome is predicted by delayed diagnosis and rupture at time of surgery. Mycotic aneurysms have a relative incidence of 1–3% in large aneurysm aortic series, and represent one of the most challenging clinical problems for the vascular surgeon. The classical symptoms of septic fever, chest pain, hemoptysis and leucocytosis are non-specific, and this often leads to late diagnosis and treatment. The traditional open vascular treatment of infected aneurysms is excision of the aneurysm with debridement of the surrounding infected inflammatory tissue followed by either in situ repair or extra-anatomical bypass. However, in the largest recent series the mortality for open mycotic aneurysm repair was almost 40%.

Methods: We presented two cases of endovascular repair of mycotic aneurysm of descending thoracic aorta, with discussion of the preoperative and postoperative treatment with six months follow-up. The both patients were not optimal for an open reconstruction of the thoracic aorta, so we decided for endovascular treatment. First patient was a 67-year-old female with all signs of sepsis, chest pain and massive hemoptysis. A second one was a 63-year-old male, with hemoptysis, fever and back pain. Computed scan (CT) angiography showed the mycotic aneurysm of descending thoracic aorta in both cases, with maximum diameters 7 cm in female and 4 cm in male.

Results: In both cases we made endovascular repair of mycotic descending thoracic aorta with TAG (Gore–Tex) stent graft. Our therapeutic dilemma of antibiotic treatment after surgery was made on the type of antibiotics and duration of antibiotic therapy. Specific or non-specific bacterial or other infectious agent in serial samples of blood, urine, cerebrospinal fluid and pleural puncture was not detected at both cases. We empirically started, preoperatively with broad spectrum intravenous antibiotics, imipenem in combination with vancomycin one week before endovascular repair, and continue with the same medication for four weeks after endovascular repair. After that, patient continued taking per os antibiotic for next two months (ciprofloxacin 1000 mg/day for four weeks and after that doxycycline 100 mg/day for another four weeks). Control CT six months after reconstruction showed no endoleak and complete thrombosis of aneurysm at both patients.

Conclusions: Repair of mycotic descending thoracic aortic aneurysms by endoluminal stent-graft is alternative treatment to open surgical intervention especially in high-risk patients. Long-term postoperative antibiotic therapy and regular follow-up are crucial.

V3-13 METHOD FOR PATIENT-SPECIFIC CLINICAL ASSESSMENT OF ABDOMINAL AORTIC ANEURYSM RUPTURE RISK BASED ON ITS GEOMETRIC PARAMETERS

C. Vaquero¹, G. Vilalta², F. Nieto², J. Vilalta³

¹University Hospital Valladolid, Spain; ²Cartif. Robotic Center, Valladolid, Spain; ³Industrial Engineering Department, Havana University, Cuba

Objective: Abdominal aortic aneurysms (AAAs) rupture is one of the main causes of death in the world. This is a very complex phenomenon, that usually occurs ‘without previous warning’. Currently, criteria to assess the aneurysm rupture risk (peak diameter and growth rate) cannot be considered as reliable indicators.

Methods: In order to improve the predicting of AAA rupture risk, the theoretical foundation of a simple method, where the main geometric parameters of aneurysms have been linked into six biomechanical factors, which have been combined to obtain a dimensionless rupture risk index, RI(t), is presented in this work. This quantitative indicator, which has been implemented in a tool, is easy to understand, it allows estimating the aneurysms rupture risks, it is expected to be able to identify the one that ruptures even when its peak diameter is less than the threshold value and identify those cases where the rupture should not occur and according to the maximum diameter, the patient is submitted to surgical procedure. The method was validated, preliminarily, with a clinical case and other three cases from the literature.

Results: Based on these initial results of the validation test, a broader prospective randomised control study has been carried out with 201 patients at the Clinic Hospital of Valladolid–Spain, which were submitted to surgical repair treatment (EVAR).

Conclusions: The results of this study show that it is possible to carry out a clinical assessment of the AAA rupture risk through its geometric parameters and that the most important geometric biomechanical factors are the deformation rate and saccular index.

V3-14 FOUNDATIONS FOR THE DESIGN OF A TOOL TO PREDICT THE ABDOMINAL AORTIC ANEURYSM RUPTURE RISK, BASED ON A MULTISCALE MODEL

A. Vaquero¹, G. Vilalta², F. Nieto², L. Mihai³

¹University Hospital Valladolid, Spain; ²Cartif. Robotic Center, Valladolid, Spain; ³Industrial Engineering Department, Havana University, Cuba

Objective: The rupture of abdominal aortic aneurysm (AAA) represents an important clinical event due to its high mortality rate. Currently, the criteria to decide on the treatment of AAA patients are the peak transverse diameter and the growth rate which can be considered insufficient because they have not a reasonable physical base.

Methods: The foundations for the design of a PC tool to predict, with sufficient accuracy to be clinically relevant, the risk of AAA rupture on patient-specific basis are defined in this paper.

Results: The algorithms and the functions of the three modules of the tool, which are designed for processing all patient-specific information (as input data will be used the patient information and the CT image set of each revision) and integrate them through a multiscale model that incorporates the interrelation of the different nature factors (biological, structural and geometric), dimensional and temporal scale from the lowest level (molecular) to higher (organ), in older to calculate a numerical and patient-specific indicator of the rupture risk, are described.

Conclusions: This tool should constitute an auxiliary information to physician in making a decision on appropriate treatment for patients with aneurysm.

V3-15 DELAYED CLOSURE OF ABDOMINAL CAVITY OF THE PATIENTS WITH RUPTURED ABDOMINAL AORTIC ANEURYSMS

K. Andreychuk, A. Postnov, P. Kagachev, V. Soroka, E. Kechaeva

Emergency Medicine Research Institute, St. Petersburg, Russian Federation

Objective: Mortality among the patients operated on ruptured abdominal aortic aneurysms remains very high today. Abdominal compartment syndrome that is shown by the progressive increase of intraabdominal pressure is being attached great importance in bad outcomes in ruptured abdominal aortic aneurysm patients at present. Delayed closure of abdominal cavity is used as a method of abdominal compartment syndrome prevention in the event of huge retroperitoneal hematoma, obesity and other predisposing factors. We studied efficacy of delayed closure in the management of ruptured abdominal aortic aneurysms from the aspect of intra-abdominal hypertension prophylaxis. This study is based on retrospective and prospective analysis of 41 cases in two groups. These patients (average age 69.1±7.8 years) with ruptured abdominal aortic aneurysms had undergone open repair. Huge retroperitoneal hematoma (>2 l) was found. Intra-abdominal pressure was monitored and adjusted in the postoperative period with the further estimation of the results through the bladder, according to the recommendations of WSACS (2004). All of these patients had predictors for development of abdominal compartment. An abdominal cavity was closed directly after procedure in I group (n=27) or deferred in group II (n=14). By the delayed closure an abdominal wall was covered with the skin only or with special ‘sandwich’ technique.

Results: Clinical indications of intra-abdominal hypertension, such as increase of the airways resistance, cardiac output decrease and oliguria were evaluated. In group I abdominal compartment syndrome was defined in most patients (78.5%), while in group II – only in 11.9% (P=0.007). Difference in frequency of multiple organ dysfunction development and postoperative mortality in groups was equal to 84.2% and 43.7%, accordingly (P=0.009). In group I postoperative manifestation of compartment syndrome required urgent laparostomy performance in 87.2%. The closure of abdominal wall defect war performed in a period from two weeks until six months (mean period 4.2±0.7 months).

Conclusions: The use of delayed closure methods can reduce a frequency of development of an abdominal compartment syndrome by ruptured abdominal aortic aneurysms and can have an influence on the improvement of treatment results.

7th Cardiac Surgery Session – Congenital II May 21, 2011 9:00–11:00

C7-1 RESULTS OF SURGICAL TREATMENT OF CHILDREN WITH CONGENITAL AORTIC VALVE FAILURE IN THE PERM HEART INSTITUTE

O. Ivanova, S. Sukhanov, S. Sazonova, I. Naumenko

Perm Heart Institute, Perm, Russian Federation

Objective: To analyse the results of surgical treatment of children with congenital aortic valve (AV) failure.

Methods: Thirty-eight patients (0–18 y.o.), operated during 2003–2009 were included in the study. Average age – 8.4±3.5 years. Twenty-one percent were young children (0–3 years), two of them – newborns.

Results: Operated patients were divided into three groups depending on nosology of AV disease: I – isolated stenosis of AV (22 patients), II – isolated deficiency of AV (10 patients), III – AV stenosis and insufficiency (six patients). Mortality was six patients. In the first group average gradient of AV was 77.5±25.3 mmHg. Bicuspid valve was in 81%. Open commissurotomy of AV was performed in 10 patients, gradient dropped from 88 to 22 mmHg. Insufficiency of AV II-III degree developed in three patients, one patient needed AV replacement after five years. In four cases transluminal balloon valvuloplasty of AV was performed, gradient decreased from 116 to 17 mmHg. In one case insufficiency of AV III developed. In another case gradient on AV dropped from 86 to 74 mmHg. And two months later prosthetics of AV with mechanical valve was made. In five cases prosthetics of AV with mechanical valve was made, in one case of those prosthetics replacement of the valve was required within three years due to thrombosis of AV. Ross procedure was performed in four patients. After four years one patient underwent AV prosthetics due to severe compression of autograft by extended pulmonary hom*ograft. The indication for surgical treatment in the second group of patients was significant insufficiency of AV of III degree. All patients underwent AV prosthetics: six cases with mechanical valves, three cases with hom*ografts, one case with autograft (Ross procedure). One patient required re-prosthetics of mechanical valve within two years due to increased gradient on valve to 65 mmHg. In group III moderate stenosis of AV – from 16 to 30 mmHg was registered, together with insufficiency of AV of II-III degree. Following AV prosthetics were made: one case of mechanical valve, one case of autograft (Ross procedure), three cases of open commissurotomy and valvuloplasty. In one case re-prosthetics of mechanical valve after five months was required due to development of paraprosthesis fistula against bacendocarditis.

Conclusions: Bicuspid AV was the main cause of hemodynamic disturbances. The choice of surgical treatment type depends on anatomy of AV and the patient’s age.

C7-2 ENDOVASCULAR TREATMENT OF CRITICALLY ILL NEWBORNS WITH AORTIC VALVE AND PULMONARY VALVE STENOSIS

V.L. Baldin, B.G. Alekyan, M.G. Pursanov, A.I. Kim, M.R. Tumanyaan, S.M. Krupianko, H.G. Agasyan

Bakoulev SCCS, RAMS, Moscow, Russian Federation

Objective: The analysis of the results of balloon valvuloplasty of aortic and pulmonary valve stenosis in critically ill newborns.

Methods: From 1998 to 2010 we have operated on 64 newborns with valvular aortic stenosis (AS) and 45 newborns with pulmonary valve stenosis (PS) aged from 2 h to 30 days old. Mean weight of patients was 3.21±0.52 kg. All patients were critically ill. Preoperative left ventricular-aortic peak systolic pressure gradient in patients with AS was 80.8±13.34 mmHg. Peak pulmonary transvalvular gradient in patients with PS was 95.97±18.9 mmHg, arterial blood saturation varied from 21 to 88%. We preferred to use Tyshak-mini (Nu Med, Canada) balloons for balloon valvuloplasty (BVP) of the aortic valve and pulmonal artery valve.

Results: Survival after transluminal balloon valvuloplasty for AS was 87.5% (n=56), the procedure efficacy was 96.5%. Peak systolic pressure gradient on the aortic valve decreased by 69% on the average and was 23.9±10.2 mmHg (P<0.05). Complications were registered in 29.8% (n=17) of all patients. Mortality was 12.3% (n=7). After BVP for PS survival was 97.8% (n=44), the procedure efficacy – 87.2% (n=39). Peak systolic pressure gradient on the pulmonary valve decreased by 75.8% on the average and was 23.6±16 mmHg (P<0.05). Arterial blood saturation with oxygen increased on the average from 59.7±17.5% to 79.6±11.5% (P<0.05). Complications after procedure were registered in 6.7% (n=3) of patients with PS. Long-term follow-up was obtained in 41 (72.1%) patients after BVP for AS and in 37 (84.1%) – after BVP for PS. The follow-up duration ranged from two months to 10 years. The survival was 100%. Good long-term results were obtained in 41.5% (n=17) patients with AS and in 89.2% (n=33) with PS. Aortic valve restenosis was registered in 26.8% (n=11) (P<0.05), aortic valve insufficiency of ≥2 degree – in 12.2% (n=5) (P<0.05), restenosis and insufficiency of the aortic valve were revealed in 14.6% (n=6) (P<0.05). Reoperations were necessary in 13 (31.7%) patients (P<0.05). After BVP for PS valvular restenosis was registered in only one patient (3%).

Conclusions: Balloon valvuloplasty for critical aortic valve and pulmonary valve stenosis in newborns is an effective procedure. In the long-term follow-up 68.3% of newborns after BVP for AS did not require reoperations, after BVP for PS restenosis developed in only 3% of newborns.

C7-3 EARLY AND INTERMEDIATE RESULTS OF RECONSTRUCTION OF RVOT WITH VIABLE AND DEVITALIZED ALLOGRAFTS DURING ROSS PROCEDURE

F. Khammoud, L. Bockeria, R. Muratov, D. Britikov, A. Sachkov, N. Soboleva

Bakoulev Scientific Center for Cardiovasclar Surgery, RAMS, Moscow, Russian Federation

Objective: The cryopreserved pulmonary allografts may tend to become stenotic or incompetent, especially in young patients. There is an experimental and clinical evidence suggesting an immunological basis for the failure of allograft structure and function. Recently, in a chronic canine model, we described a new devitalizing allograft treatment with digitonine and EDTA. In this study we compare the clinical, echocardiographic and MRI data of devitalised vs. viable allograft used for RVOT reconstruction during Ross operation.

Methods: In our institution from 2001 to 2009, 50 Ross operations were performed. Patients were divided into two groups. In the first group of 32 patients devitalised allografts were used, and second group of 18 patients received the viable allografts. Mean follow-up was 37.5 months (15–66 months) and 77 months (64–90 months) correspondingly. Patients were analysed for survival, reintervention and echocardiographic findings. Fifteen patients were investigated by MRI (eight from first group and seven from second) at mid-term follow-up. MRI was used to assay allografts diameter and the degree of regurgitation.

Results: There were no significant differences between the two groups in age and sex. No patient was lost from the follow-up. There was one early death in each group by non-valve reason. One reoperation was performed in the first group (5.8%) for infective endocarditis of pulmonary allograft, developed 18 months after operation. There was no reinterventions in the second group and late mortality in both groups. On echocardiogram there were no differences in initial degree of allograft insufficiency or systolic gradient. There was no significant differences in peak gradient and insufficiency between groups at 1.3 and five years after operations. Slight increase in peak gradient was observed in both groups during follow-up period. The degree of regurgitation was stable. With MRI slight stenosis of allografts at the part of proximal anastomosis was observed in both groups. The degree of stenosis was higher in the second group, but these differences were not statistically significant.

Conclusions: At early- and mid-term follow-up, the devitalized valve did not demonstrate advantages over viable one. However, long-term effects on survival, reintervention and hemodynamic characteristics remain unknown and requires longer follow-up.

C7-4 CARDIOSURGICAL INTERVENTION RISK FACTORS IN THE NEONATAL PERIOD

I.I. Trunina, M.R. Tumanyan, O.V. Filaretova, A.G. Anderson, A.V. Kharkin, M.A. Abramyan

Bakoulev Scientific Centre for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: In recent years more researches of leading hospitals are devoted to analysis of different factors, which augment mortality risk in newborns with congenital heart disease. Risk factors differentiation helps to analyse outcome and quality of life after cardiac surgery in newborns.

Methods: From 2005 up to 2010 we have treated 7558 children in first year of life, including 1193 (16%) newborns (average age 3.6 days, average weight 2.9 kg). Congenital heart defects were the following: TGA, LHHS, coarctation of the aorta, PA atresia, critical aortic or pulmonary valve stenosis, etc. As to the structure of surgical interventions for the whole group, 54% (4065 operations) were made under artificial circulation (283 of which were operations for newborns, 40% were urgent, with survival rate of 86.9%) and 46% under closed method.

Results: Statistical analysis of factors influencing the outcomes of the surgical treatment (P<0.01) in conjunction with the expert estimate of anamnestic, clinical, laboratory results of the newborns study led to the conclusions on the risk factors. In the newborns group they are: prematurity and low birth weight (339 children – 31.6%), hypotrophy (82 children – 7.6%), early neonatal period (468 children – 39.2%), TORCH infections (56 children – 5.2%), concomitant somatic pathology and mechanical ventilation while entering hospital (216 children – 20.1%), multiple disembryogenetic stigmas and syndromic forms of CHD (94 children – 8.8%). Severity of condition was characterized by the presence of the risk factors in each child (from zero to six). The increase of quantity of risk factors led to the increase (P<0.05) of the mortality risk. Analysis of risk factors enabled to elaborate particular dynamic steps of clinical treatment for each group in order to improve the outcomes. As a result, in a period from 2005 to 2010 the number of newborns significantly (P<0.03) increased and the survival rate after urgent operations improved to 94.2%, including premature and low-birth-weight children (average weight 1.6 kg).

Conclusions: Optimization of preoperative care in children with CHD and risk factors exerts positive influence on quality of treatment and improves outcome for newborns and infants with CHD.

C7-5 RVOT RECONSTRUCTION IN INFANTS WITH PULMONARY ATRESIA

R.T. Grigoryants, A.I. Kim, R.R. Khamitov, T.V. Rogova, D.V. Ryabtsev

Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Pulmonary atresia with ventricular septal defect is a complex pathology featured by the hypoplasia of the pulmonary trunk and arteries, with associated left ventricle volume reduction in some patients. Traditional management has involved systemic-pulmonary shunt placement with frequent pulmonary artery grow inefficiency. The objective of this study is to evaluate the applicability and specialties of RVOT reconstruction in infants with pulmonary atresia.

Methods: Since July 2007 a total of 12 infants (four males and eight females) with a mean age of 11.3±3.3 months (range 6–23 months) underwent RVOT reconstruction. Nine patients had previously placed systemic-pulmonary shunt. All operations have been completed through median sternotomy with cardiopulmonary bypass and cold cardioplegic arrest. Bovine pericardium patch was used in seven patients, monocusp bovine pericardial patch was placed in two patients, bovine pericardial valve conduit – in two patients and one patient underwent PTFE graft implantation.

Results: Cardiopulmonary bypass mean time was 103.7±59 min (range 45–243 min), and aortic cross-clamp time was 55±48.6 min (range 21–196 min). Mean pressure in pulmonary artery after the reconstruction was 31±12 mmHg (range 14–55 mmHg). ICU length of stay was 46±30 h (range 17–124 h) and the hospital stay was 12±2 days (range 7–19 days). There was one early death in a previously shunted patient with RVOT reconstruction. There were no late deaths up to now.

Conclusions: During this study we observed good early and short-term results of RVOT reconstruction in infants with pulmonary atresia. Low postoperative mortality and morbidity rate make this procedure possible in newborns and infants. Significant increase and physiologic pulsatile pulmonary artery blood flow demonstrate benefits of RVOT reconstruction in early age.

C7-6 EXPERIENCE WITH CAVOPULMONARY ANASTOMOSIS AFTER NORWOOD PROCEDURE IN SURGICAL TREATMENT OF LEFT HEART HYPOPLASIA

A.A. Shikhranov¹, V.G. Lubomudrov², A.L. Tzytko¹, E.V. Mikhaylova¹, D.R. Yamgurov¹, L.S. Sulkovskaya¹, V.V. Molchanov¹, R.R. Movsesian¹

¹Children’s Hospital #1, St. Petersburg, Russian Federation; ²Chest Disease Hospital, Al-Kuwait, Kuwait

Objective: The treatment of left heart hypoplasia syndrome and other congenital heart defects accompanied by similar hemodynamics consists of consecutive performance of Norwood procedure, bidirectional cavapulmonary anastomosis and Fontan procedure. The objective of the study was to study the results of the second stage of surgical treatment – the operation for the creation of bidirectional cavopulmonary anastomosis after Norwood procedure.

Methods: From 2000 to 2010 in Children’s Hospital No. 1 the operation for the creation of bidirectional cavopulmonary anastomosis after Norwood procedure was performed in 26 patients. Their age varied from four to 15 months, mean age – nine months. Norwood procedure was performed in accordance with the standard technique with patch aortic arch reconstruction in 16 (61%) patients, and using R. Mee modification (direct aortic anastomosis) – in 10 (30%). Central shunt was used for pulmonary blood flow creation in 12 patients (46%), the Sano shunt – in 14 (54%). In most cases bidirectional cavopulmonary anastomosis was created under cardiopulmonary bypass on beating heart (21 patients – 80%). Some operations in patients with previously created Sano shunt was performed without extracorporeal circulation. Two children required cardioplegia for the correction of associated pathology (mitral valve reconstruction in one and recoractation correction in another). Pulmonary artery reconstruction for bifurcation stenosis was necessary in six patients (23%).

Results: No early deaths occurred. Two patients (7.7%) died in the long-term follow-up: one with meningococcal infection and one with heart failure due to tricuspid valve insufficiency. The remaining patients are in satisfactory condition.

Conclusions: Survival improvement after Norwood procedure leads to the increase of the number of patients in need for the next stage of treatment – the creation of bidirectional cavopulmonary anastomosis. Immediate results can be considered as satisfactory. We noted a high need of concomitant procedures.

C7-7 EXPERIENCE WITH SURGICAL TREATMENT OF CORRECTED TRANSPOSITION OF THE GREAT ARTERIES USING DOUBLE SWITCH TECHNIQUE

N.V. Fedorova, V.G. Lubomudrov, A.L. Tsytko, E.V. Mikhaylova, A.A. Shikhranov, N.V. Antsygin, V.V. Molchanov, D.R. Yamguro, A.V. Kagan, V.G. Lubomudrov, A.L. Tsytko, E.V. Mikhaylova, A.A. Shikhranov, N.V. Antsygin, V.V. Molchanov, D.R. Yamgurov

Children’s Hospital #1, St. Petersburg, Russian Federation

Objective: Corrected transposition of the great arteries (CTGA) is a rare congenital anomaly characterized by atrioventricular and ventriculoarterial discordance, in which morphologically right ventricle is a systemic ventricle. The rate of CTGA is 0.7% of all CHD or 0.02 per 1000 of live-born children. CTGA often is associated with other heart anomalies: tricuspid valve pathology (insufficiency, Ebstein’s anomaly), ventricular outflow tracts obstruction (more commonly – of the left ventricle and pulmonary arterial valve), VSD, dextrocardia, as well as conducting system the anomalies (mainly of AV node and peripheral pathways). Physiological problems in CTGA are caused by the fact that right ventricle assumes morphologically the systemic functions decreasing with age, as well as by associated heart anomalies. Up to 50% of patients develop complete AV block. In cases with two balanced ventricles it is possible to correct associated anomalies (traditional method), of to perform the ‘anatomical correction’ of the defect, after which morphologically left ventricle became systemic (‘double switch’). This method is used in some foreign clinics from the mid-1990s. Purpose of study to analyse initial experience with surgical correction of CTGA using ‘double switch’ technique. Patients’ characteristics and

Methods: In 2005-2009 in the department of cardiac surgery of Children’s hospital No. 1 the ‘double switch’ for CYGA was performed on 7 patients. Two patients underwent atrial switch and Rastelli procedure, in the remaining cases arterial and atrial switch were carried out.

Results: Despite long duration of extracorporeal circulation and technical complexity of the operations, early postoperative course was uneventful in five patients. This fact can probably be explained by ‘anatomical’ correction of the defects and absence of serious complications, such as heart rhythm disturbances, marked ventricular dysfunction and significant residual anatomical problems. In one child the severity of early postoperative course was caused by cardiac (mainly, right ventricular) failure due to hypoplastic RV cavity, as well as heart rhythm disturbances necessitating temporary heart pacing. One patient died in early postoperative period. In long-term two patients had residual problems in the form of intraatrial tunnels’ stenoses and small residual atrial septal defect.

Conclusions: ‘Anatomical correction’ of the defect leading to the creation of systemic anatomically left ventricle is preferable in children with CTGA and associated heart anomalies. Taking into account the high risk of residual problems such patients need prolonged follow-up. The long-term results require further study.

4th Vascular Surgery Session – Carotid Artery Disease May 21, 2011 09:00–11:00

V4-1 URGENT CAROTID ENDARTERECTOMY IS A SAFE AND EFFECTIVE TREATMENT IN PATIENTS WITH ‘CRESCENDO’ TRANSIENT ISCHEMIC ATTACK

P. Gajin, C. Radak, D. Nenezic, N. Ilijevski, S. Tanaskovic, P. Popov, S. Babic

Dedinje Cardiovascular Institute, Belgrade, Serbia

Objective: The aim of this study was to analyze the outcome of urgent carotid endarterectomy (CEA) with respect to the type of preoperative acute neurogical deficit.

Methods: From January 1998 to December 2008, 5133 eversion CEAs were performed at our clinic. In 59 patients urgent CEA was performed because of acute neurological deficit in progression. All procedures were performed within a few hours after symptoms appeared. The patients were divided into three groups. Group I consisted of 42 patients with ‘crescendo’ transient ischemic attack (TIA), group II consisted of 12 patients with stroke in progression, while group III consisted of five patients with stroke and loss of consciousness. Recovery of neurogical deficit, complications and total hospital stay were noted. Follow-up was at one month and at 12 months.

Results: All patients in ‘crescendo TIA’ group recovered without any neurogical deficit following urgent CEA (100%). In ‘stroke in evolution’ group one patient died, two patients improved and nine had a dramatic recovery. Four patients died in group III following urgent CEA (80%) and one remained hemiplegic. Comparing the outcome of urgent CEA between the ‘crescendo TIA’ group and both remaining groups, we found very significant statistical difference (P<0.01) X.

Conclusions: Our results suggested that the outcome of urgent CEA depended on the type of preoperative acute neurogical deficit in progression. Urgent CEA is a safe and effective treatment in patients with ‘crescendo’ TIA. Stroke in evolution may be acceptable indication for urgent CEA.

V4-2 URGENT CEA IN PATIENTS WITH ‘STROKE IN EVOLUTION’

V. Popovic

Clinical Center of Vojvodina, Novi Sad, Serbia

Objective: Evaluation of the therapeutical efficacy of urgent CEA in patients with clinical sign of ‘stroke in evolution’.

Methods: Retrospective analysis of 24 patients operated in two years (2009, 2010) within one week after onset of symptoms of stroke in evolution. Patients were presented by neurologist having mild neurological deficit (modified Rankin scale 0–3) and no significant comorbidity – assessed by ASA class (I–II). All were examined by duplex US, and MRA, MRI of the brain (diffusion-perfusion mismatch). For surgery were accepted only patients with symptomatic carotid stenosis and/or unstable plaque, without coliquation of the brain. Two groups were formed according neurological state. I Rankin score 0–2 and II Rankin score 3.

Results: All patients in first group (18 patients) were recovered and had no worsening of symptoms. In second group (six patients) two have had worsening of symptoms developing hemorragic insult. No mortality.

Conclusions: CEA is a safe and useful procedure in treating urgent patients with symptoms of stroke in evolution presenting by mild neurological deficit.

V4-3 CLINICAL DIAGNOSTICS AND TREATMENT OF PATHOLOGICAL TORTUOSITY OF INTERNAL CAROTID ARTERY IN CHILDREN

N.G. Xorev, Y.N. Choicet, A.V. Beller, N.I. Kulicova

Medical University, Railway Hospital, Barnaul, Russian Federation

Objective: Refine and formalize clinical signs syndrome pathological tortuosity of the internal carotid artery (PTICA) in children, and to assess long-term results of different options for surgical correction of the distorted internal carotid artery (ICA).

Methods: The studies were performed in 88 children. The first group (comparison) includes 45 not operated children. The second group (basic) – 43 children who had conducted 46 different operations (resection of the ICA with replantation of old mouth – 30, arterioliz – 16). Sex and age composition of the groups, the frequency of single and bilateral lesions, as well as the nature of stroke in the studied groups did not differ (P>0.05).

Results: The manifestations (headache, epileptiform seizures, enuresis, hyperkinetic disorders, the local compression of the caudal cranial nerves), vascular brain disease in children with PTICA, statistically significant differences were observed. Efficiency of operations in the late period (from one year to 12 years) was studied from the perspective of the degree of regression of clinical signs of cerebral vascular insufficiency of the standard procedure of the proposed program. The incidence (%) extinction, reduction, and the lack of dynamics symptom or syndrome. The operation resulted in more decrease or disappearance of the frequency of headache (74.4%), including the manifestations of intracranial hypertension (60.5%), as well as a decrease in stem disorders (30.3%), improve the development of higher cortical functions in a child (27.8%). Less pronounced effects were observed operations in the regulation of suprasegmental levels of the autonomic nervous system (25.2%), the disappearance of epileptiform seizures (23.2%), including forms of epilepsy resistant to anticonvulsant therapy (11.6%), normalization of the limbic system (23.2%). In 90.0% of patients with resection of the ICA with replantation of the old mouth of regressing the studied clinical symptoms and syndromes. Arterioliz possible to achieve regression of symptoms PTICA in 75% of patients. Reconstruction of internal carotid artery with resection of the method allowed in 83% cases to achieve the elimination of local and regional hemodynamic disorders. Operation arterioliza had only a 25% efficiency.

Conclusions: The syndrome PTICA in operated and not operated children detected through ultrasound examination of neck vessels. Clinical implications for determining the indications for surgical treatment is the frequency of headache, including manifestations of intracranial hypertension, stem dysfunction and developmental disorders of higher cortical functions in the child. Operation allows you to achieve regression of neurologic symptoms in different clinical signs from 27.8 to 74.4%.

V4-4 RARE, BUT CLINICALLY SIGNIFICANT CASES OF ABNORMALITIES OF CAROTID ARTERIES: ‘PATHOLOGICAL VALVES’

D.I. Alekhin, A.V. Koudrina, J.A. Goloshschapova, M.A. Kokorishvili

Clinical of Chelyabinsk Medical Academy, Chelyabinsk, Russian Federation

Objective: Study of features of a morphological structure of carotid artery (CCA) at the patients with non-atherosclerotic pathology of carotid arteries at presence at them neurologic semiology.

Methods: The presented work is dedicated to studying the author-revealed rare, yet clinically significant pathology of carotid arteries. There are rare structural abnormalities of CAs which descriptions in the available literature devoted to ultrasonic, radiological diagnostics and surgical treatment we have not met. We called such abnormalities ‘pathological valves’ of carotid arteries. Ultrasonographic triplex scanning and transcranial duplex scanning was employed as a primary method of diagnosis of that pathology. We revealed a total of 30 subjects presenting with circulatory disorders in the CAs associated with local intimal dysplasia in the zone of the CCA bifurcation. Ten of these patients were operated on. All of them had a history of clinical symptomatology (TIAs, degree I-II cerebral infarction in the ipsilateral basin).

Results: The incidence of PVs amounted to 0.37% of the cases of CCA’s lesions. Circulatory disorders secondary to local intimal dysplasia in the CCA’s bifurcation zone were revealed in 30 patients [18 (60.0%) men, 12 (40.0%) women]. Of these, USDS showed that six (20%) subjects had isoechogenic, mobile, thin and elastic ‘valvular leaflets’, and in 24 (80%) patients the latter appeared as immobile ‘pocket-valve’ in the form of an ‘intimal duplicature’. Macroscopically, all the resected PVs appeared as non-transparent, whitish, 1–1.5-mm-thick semilunar leaflets localizing near the entry to the ICA. In four cases in the subclavian space, there were varying-age thrombotic masses. Histological examination demonstrated that the valve’s leaflet appeared as an endothelium-lined protrusion. Its subepithelial layer contained bundles of coarse collagenous fibres and interrupted bundles of elastic fibres. No smooth muscular layer in the ‘valvular leaflet’ was observed. The CCA’s wall in the vicinity of the ‘VP’s leaflet’ was typically represented by three membranes. Feature of diagnostics of this pathology consists in its rare occurrence and complexity of differential diagnostics.

Conclusions: 1. ‘Pathological valves’ in the carotid arteries are rarely encountered, yet clinically meaningful pathological conditions, with an incidence rate of 0.37% on ultra-sonography. 2. Based on the findings of both histological and morphological examinations it was proved that ‘pathological valves’ have a structure similar to that of the internal membrane of the vessel and constitute a duplicature of the arterial intimal. 3. The main method of diagnosis of ‘pathological valves’ in the carotid arteries is triplex scanning transcranial duplex scanning.

V4-5 IS THERE REALLY RELATIONSHIP BETWEEN THYROID FUNCTION AND CAROTID ARTERY STENOSIS?

U. Sevuk, B. Erdolu, E. Kubat, F. Cicekcioglu, T. Ulus, U. Tutun, A. Saritas, C. Levent Birincioglu

Turkiye Yuksek Ihtisas Hospital, Ankara,Turkey

Objective: Thyroid dysfunction has been known to be closely associated with increased cardiovascular events. This study was carried out to determine the prevalence of thyroid dysfunction in patients with internal carotid artery stenosis and relationships between normal ranges of thyroid function and internal carotid artery stenosis.

Methods: From January 2009 to October 2010, 113 consecutive patients with internal carotid artery stenosis referred to our institution were analyzed. Internal carotid artery stenosis was defined as >50% luminal narrowing or complete obstruction in at least one internal carotid artery. Thyroid disease was determined by free thyroxine (fT4) and thyroid stimulating hormone (TSH) measurements. After the exclusion of patients with abnormal levels of thyroid hormones, normal ranges of fT4 were classified into three groups: low-normal, mid-normal, and high-normal thyroid groups. Comparison was made with a similar group of consecutive 100 patients undergoing coronary artery bypass grafting who were free of any carotid artery lesions.

Results: Both groups were similar for demographic properties, diabetes mellitus, hyperlipidemia and hypertension. There were 31 patients (27.4%) with thyroid dysfunction in the carotid stenosis group and 11 patients (11%) in the control group. There was a significantly higher percentage of thyroid dysfunction in the carotid artery stenosis group (P<0.05). There were 82 patients (72.6%) with normal fT4 and TSH levels in the carotid artery stenosis group. Low-normal and high-normal thyroid function was significantly associated with carotid artery stenosis when compared to control group (P<0.05).

Conclusions: In patients with carotid artery stenosis, the prevalence of thyroid dysfunction was higher than general population. Low-normal and high-normal thyroid function was independently associated with a higher percentage of internal carotid artery stenosis in euthyroid patients. We conclude that thyroid function is associated with the presence of carotid artery stenosis. Periodical screening and early treatment of atherosclerotic risk factors should be performed in these group of patients.

V4-6 HYPOXIC PRECONDITIONING AS A NEUROPROTECTIVE METHOD DURING SURGERIES ON CAROTID ARTERIES

A.S. Gorohov, Y.K. Podoksenov, M.S. Kuznetsov, E.V. Lebedeva, B.N. Kozlov, V.M. Shipulin

Tomsk Institute of Cardiology, Tomsk, Russian Federation

Objective: The objective of the study was to develop safe and efficient method of hypoxic preconditioning for neuroprotection during carotid endarterectomy.

Methods: Seventy-two male patients (mean age 61.8±7.4) were subjected to carotid endarterectomy for atherosclerotic lesion of internal carotid artery (ICA) in conditions of general anesthesia with BIS-monitoring. The patients were assigned to two comparable groups: 36 patients treated with hypoxic preconditioning (group 1) and 36 patients treated without it (group 2). Two episodes of hypoxic preconditioning were performed intraoperatively (before ICA occlusion) by introduction of a gas mixture with 10% oxygen into the contour of a respiratory apparatus for 5–6 min. To identify necessity for intra-arterial shunt placement EEG-monitoring was performed when retrograde arterial pressure was lower than 40% of systemic pressure. To evaluate an immediate effect of hypoxic preconditioning on the oxygen brain homeostasis and on the level of S-100b protein there were assessed SaO₂, regional brain homeostasis (rSO₂) and oxygenation of the blood from the internal jugular vein (SjO₂); cognitive functions were assessed in the postoperative period.

Results: During hypoxic preconditioning in the first group decrease of SaO₂ level lower 75% and rSO₂ lower 40% was not noticed. During ICA occlusion and after it in the first group of patients SjO₂ was 65.6±9.3% and 64.0±6.9%, in the second group of patients – 63.0±10.1% and 68.2±9.6%, correspondingly. The necessity for intra-arterial shunt appeared in four patients of the first group and in seven patients of the second group. The phenomenon of cerebral hyperemia (SjO₂>75%) was observed in 16% of the cases in the first group of patients and in 30% of the cases in the second group of patients. The level of S-100b protein was lower in the first group during ICA occlusion periods and after it (P<0.07). In the postoperative period recovery time in the first group was 1.8±1.2 h and in the second – 2.4±1.2 h. Improvement of cognitive functions in comparison with their preoperative level was noticed in 63% of the patients of the first group, no changes were noticed in 37% of the cases while in the second group improvement was observed in 28% of the cases, no changes – in 60% and worsening – in 12% of the cases.

Conclusions: The offered method of intraoperative hypoxic preconditioning as an additional component of anesthetic support of carotid endarterectomy is safe and associated with lesser occurrence of intra-arterial shunt placement and better surgical outcome.

V4-7 CAROTID ENDARTERECTOMY VERSUS STENTING FOR CAROTID ARTERY STENOSIS

V.N. Vavilov, K.K. Tokarevich, V.M. Sedov, V.A. Kreyl, R.A. Azovtsev, V.A. Kovalev, V.M. Lapina, P.S. Kuryanov

I.P. Pavlov Medical University of Saint Petersburg, Russian Federation

Objective: To compare the outcomes of open and endovascular interventions in patients with carotid stenosis.

Methods: The study involved two comparable groups of patients: group I – open reconstructions, which included various types of carotid endarterectomy (CEA) (59 patients with 62 arteries, three bilateral procedures) and group II – stenting (61 patients with 65 arteries, four bilateral procedures). All interventions were done within the last three years and the follow-up was six months to three years. A detailed examination including cerebral angiography and duplex ultrasound was conducted prior to surgery. The groups were comparable, however, patients who underwent stenting tended to be older, have more severe cerebrovascular ischemia and more significant comorbidities. Postoperative follow-up included duplex ultrasound with measurement of the arterial intima-media thickness (IMT) and cross-sectional area (IMA) at the center of the endarterectomized zone or stent, its proximal and distal edges.

Results: There were no intraoperative events. Three patients in group I had transient ischemic attack (TIA) with complete regression of symptoms during (n=2) or within 24 h after the intervention. In group I (open surgery) two patients had cranial nerve palsy and another one had TIA involving the contralateral carotid artery bed. There were no residual stenoses one week after surgery in either group. Subsequently, we found two types of changes involving the intima-media complex (IMC) in group I: diffuse thickening of the IMC, which developed gradually and resulted in no significant stenosis in the long-term. Another type (27% of cases) included a more severe diffuse thickening of the IMC with simultaneous step-like local IMC thickening occurring on the proximal and/or distal edge of CEA. The latter caused significant stenosis in four out of 17 arteries. At the same time, there were no significant intimal hyperplasia in the stented arteries. Only a mild restenosis was found in a female patient six months after the procedure. Subsequently, it did not result in any significant narrowing.

Conclusions: The tapered shape of the arterial lumen occurring due to stenting seems to prevent any significant flow disturbance. Carotid artery stenting may be successfully used to treat carotid artery stenosis in elderly patients with severe cardiovascular disease, particularly in those with contralateral occlusion of the internal carotid artery or insufficient compensation via the Circle of Willis, and, far more, in patients awaiting coronary revascularization, interventions on the abdominal aorta or lower limb arteries.

V4-8 TEN YEARS OUTCOMES OF CAROTID ARTERY STENTING (CAS): A MONOCENTRIC EXPERIENCE IN 582 PATIENTS

D. Mazzaccaro, A.M. Settembrini, G. Malacrida, M.T. Occhiuto, S. Stegher, M. Caldana, D. Giuseppe Tealdi, G. Nano

Università degli Studi di Milano, Ist Unit of Vascular Surgery, IRCCS Policlinico S. Donato, San Donato Milanese, Italy

Objective: Even if carotid endarterectomy (CEA) still remains the gold standard treatment for carotid artery stenosis, carotid artery stenting (CAS) has emerged as a therapeutic alternative for high-risk patients, with good early and long-term results. Arranging a randomized clinical trial (RCT) which compares CAS to CEA is a hard matter, as different standards of care exist for CAS. Multicenter prospective registries and single-centres experience are thus essential to validate the technique, however they all have some limitations. We report early and long-term results of our experience in CAS.

Methods: From January 1999 to June 2010, 1612 patients were admitted to our department for a significant carotid stenosis. Of them, 582 patients (36.1%) were proposed for CAS according to our ‘intention to treat’. Indications for CAS included 88 patients (15.1%) who had restenosis after endarterectomy and 12 patients who presented (2.1%) in-stent restenosis; in these patients, the previous endovascular procedure had been performed at a median of 20.4 months before (range: 15.8–23.4 months). In remaining patients CAS was considered for high surgical risk, because of patients’ comorbidities or difficult anatomy. Symptoms had occurred in 205 patients (35.2%). Most of CAS were performed in males (409 patients, 70.3%). Patients’ median age was 73.6 years (range 49.4–99.7 years), while 102 (17.5%) were aged more than 80. Carotid stenosis were right-sided in 277 (47.6%) cases. In 505 patients CAS was performed using EPD. Five hundred and forty-nine stents were used (428 closed-cells, 101 open-cells and 20 hybrid stents).

Results: The procedure was successfully ended in 573 patients (98.4%): in six selective catheterization of vessels was not possible, and three required an immediate conversion to surgery for acute stent thrombosis. At 30-day results we observed three deaths (0.5%), one of them following a severe stroke, four ipsilateral invalidant strokes (0.7%), three minor strokes (0.5%), five TIA (0.9%) and one MI (0.2%). At a median follow-up of 90.3 months (range 1–136 months), 46.3+5.4% of patients were free from any adverse event, 55.6+5.8% were alive, 97+0.9% were free from any neurological event and 91+4.3% were free from restenosis.

Conclusions: CAS has emerged as a therapeutic alternative to endarterectomy for high-risk patients, with good early and long-term results. As arranging a (RCTs) for CAS is difficult, multicenter prospective registries and single-centres experience are essential to validate the technique, however, they have some limitations. In our experience CAS is both a safe and effective procedure, with good long-term results.

V4-9 CAROTID STENTING IN PATIENTS WITH SIGNIFICANT INTERNAL CAROTID ARTERY STENOSIS: SAFE AND EFFECTIVE METHOD

S.V. Volkov, I.V. Mostovoy, A.E. Udovichenko, V.V. Chapilin, K.V. Lyadov

State Institution ‘Medical and Rehabilitation Center’, Moscow, Russian Federation

Objective: To expect the safety and efficacy of internal carotid artery stenting (ICAS) in the patients with significant internal carotid artery stenosis.

Methods: From 2001 to 2009, 215 carotid stenting were performed in 202 patients. All patients were treated with the standard therapy before, during and after the procedure. Complex assessment of brain perfusion and cognitive tests was carried out. All studies were performed before procedure (24–48 h) and after one month. The cerebral protective devices were used in all cases. In 28 patients was performed with IVUS control. One hundred and eighty-eight males and 14 females with middle age 63.2 (47–81) years were treated. Middle carotid stenosis was 85.9%. In 183 patients (90.5%) the carotid atherosclerosis was associated with significant coronary artery disease required future treatment (92 patients – stenting and 91 – bypass surgery).

Results: Right carotid stenting was done in 98 cases, left – in 116 cases and common carotid artery stenting – in one case. Immediate angiographic success was achieved in 100% of the cases. The middle in-hospital period was 5.7 days (2–30 days). In 13 patients the bilateral stenting was performed. Ischemic complications were registered in 1.4%. One case (0.5%) was intraoperative embolic stroke (the embolism of medial cerebral artery on target side with following persistent neurological defect); two cases (0.9%) were transient ischemic attacks in the early postoperative period (with following full regress of the symptoms). In two patients early postoperative period was complicated with unstable angina and required urgent PCI. In patients with previous ischemic strokes and carotid occlusion the contra-lateral stenting was done. Before stenting perfusion in distal part of the middle cerebral artery was 60–70%; after stenting significant 15–20% increase of cerebral perfusion was found. In asymptomatic patients with significant carotid stenosis hypo perfusion zones were found in target side in combination with symmetric general hypo perfusion. After the procedure 15–25% increasing of cortex perfusion was registered. Also the improvement of cognitive function was found.

Conclusions: Carotid stenting is safe and effective method in the treatment of carotid stenosis (and, hopefully, in the prevention of the future stroke). Single photon emission tomography (SPECT) could be used for the assessment of carotid stenting efficacy. Also SPECT could be used in the treatment strategy choice for the patients with ‘silent stenosis’.

V4-10 SURGICAL MANAGEMENT OF CAROTID BODY TUMORS

A.A. Fokin, V.V. Vladimirsky, E.V. Babkin

Urals Postgraduate Medical Academy, Cheliabinsk, Russian Federation

Objective: The aim of this study has been to evaluate the experience of carotid body tumors (CBT) surgery from 1985 to 2010.

Methods: During this period, we operated on 20 patients with CBT (malignancy – 3), eight males and 12 females, only one had bilateral tumors. Mean age 39 years (26–62 years). All patients had a palpable neck mass. The operations were performed under general anesthesia. Significant alterations in systolic and diastolic blood pressure and heart rate were not documented. The tumors were surgically resected, included 11 (55.0%) reconstruction (replacement or direct anasthom*osis) of internal carotid artery. No one of the patients underwent radiotherapy or chemotherapy and preoperative embolisation.

Results: No perioperative mortality. One stroke was observed. Five patients, with a grade according to Shamblin had temporal cranial nerve damage that resolved within four months. No reoperations in the following 20-year follow-up.

Conclusions: Surgical treatment is recommended for all patients with CBT. We had good postoperative and follow-up results. Preoperative embolisation of the tumor does need to be a routine procedure. Cranial nerve injuries deteriorate the results of operations and temporary decrease quality of life.

8th Cardiac Surgery Session – Coronary I May 21, 2011 12:15–13:30

C8-1 CLINICAL EFFICACY OF EPTIFIBATIDE ADMINISTRATION IN PATIENTS WITH NSTE ACS REQUIRING URGENT CABG. A SINGLE CENTER RANDOMIZED STUDY. twelve MONTHS FOLLOW-UP

W.I. Miroslaw, K. Lukasz, W. Krystian, T. Zbigniew, B. Krzysztof, B. Andrzej

Medical University of Silesia, Katowice, Poland

Objective: Aggressive anti-aggregative treatment with aspirin, fractionated heparin and platelet GP IIb/IIIa inhibitors is an important strategy which preserves myocardial microcirculation during mechanical reperfusion for myocardial ischemia, particularly in patients undergoing CABG for NSTE-ACS, where the period of ischemia and subsequent reperfusion is relatively longer. However, patients exposed to eptifibatide in the setting of urgent or emergency CABG may be at risk of increased bleeding. The objective of this randomised study was to evaluate the efficacy and safety of eptifibatide administration in the high-risk group of patients with NSTE ACS, requiring CABG. The primary end point was MACCE defined as cardiac related death, myocardial infarction, stroke and recurrence of angina pectoris symptoms in 12 months follow-up observation. The assessment of eptifibatide administration safety was based on the occurrence of bleeding complications.

Methods: In our study 140 patients with NSTE ACS qualified for surgical revascularization were prospectively randomized into two groups. Seventy-two patients in the study group apart from routinely administered enoxaparine and aspirin received additionally eptifibatide (180 µg/kg bolus+2 µg/kg/min infusion) 24 h prior to surgery. The control group consisted of 68 patients who received only enoxaparine and aspirin before surgery. The CABG was performed in all patients 4 h after discontinuation of eptifibatide infusion.

Results: The MACCE rate in 12 months follow-up was statistically higher in the control group than in the study group (8.3% vs. 3.3%, P<0.05). There were two deaths (2.8%) in study group with eptifibatide and seven deaths (10.3%) in control group in 12 months follow-up. There was also a difference between both groups regarding perioperative MI (25.0% vs. 11.1%, P<0.05). There was no difference regarding stroke incidence (2.9% vs. 2.8%, P=NS). Also there was no difference regarding blood loss and blood products transfusion (920 ml vs. 750 ml, P=NS).

Conclusions: This prospective randomized study proved that eptifibatide administration in patients with NSTE-ACS required CABG, reduced significantly MACCE rate on 12 months follow-up observation. The use of eptifibatide just before coronary artery bypass grafting is safe and does not increase postoperative bleeding.

C8-2 PREDICTORS OF PROLONGED MECHANICAL VENTILATION IN PATIENTS UNDERGOING ELECTIVE CORONARY BYPASS SURGERY

H.Z. Saleh, H. Elsayed, J. Yates, D.M. Pullan, J.A. Chalmers, B.M. Fabri

Liverpool Heart and Chest Hospital, Liverpool, UK

Objective: Postoperative prolonged mechanical ventilation is a serious complication associated with poor outcomes. In addition to pulmonary variables, the risk of prolonged ventilation is known to be impacted by various factors, including operative and postoperative events. The purpose of this study was to identify perioperative variables associated with prolonged mechanical ventilation in patients undergoing elective first time CABG.

Methods: Between January 1999 and March 2009, 7630 consecutive patients were retrospectively identified and evaluated for perioperative predictors of prolonged mechanical ventilation which was defined as postoperative ventilation longer than 72 h.

Results: The mean age was 64.04±8.69 years. Six thousand one hundred and eight patients (81%) were male. Mean FEV₁% was 86.85±25.22. There were 113 (1.48%) deaths and 174 (2.28%) patients had prolonged ventilation. At a multivariate analysis preoperative predictors of prolonged ventilation included NYHA (per increase in class) [odds ratio (95% CI) 1.27 (1.09, 1.48)] P<0.001, FEV₁ (per 10% increase) [odds ratio (95% CI) 0.92 (0.86, 0.98)] P=0.02 and peripheral vascular disease [odds ratio (95% CI) 1.54 (1.15, 2.09)] P=0.01. Among analysed postoperative variables stroke [odds ratio (95% CI) 21.1 (13.11, 33.94)] P<0.001 and re-exploration for bleeding [odds ratio (95% CI) 2.69 (1.63, 4.44)] P<0.001 were also predictors of prolonged ventilation.

Conclusions: Postoperative prolonged ventilation is related to both preoperative and postoperative variables. Preoperative FEV₁ was an independent predictor of prolonged ventilation. This underlines the value of preoperative spirometry in enhancing morbidity risk stratification.

C8-3 THE MEANING OF THE INTRAOPERATIVE ANGIOGRAPHY IN THE ASSESSMENT OF THE CORONARY BYPASS GRAFTING ADEQUACY

L.A. Bockeria, N.A. Chigogidze, M.K. Musaev, A.A. Magomedov, P.B. Pysetckiy, T.M. Djincharadze, I.D. Skhirtladze, A.Y. Musalov

Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Intraoperative estimation of bypass consistency and the possibility of timely correction.

Methods: Three hundred and twenty patients who were grafted 807 bypasses were included in the research. The mean age of patients was 59.8±4.2 years and was fluctuating from 42 to 79 years. The majority of them were men and estimated at 291 (91%) and the rest 29 (9%) were women. According to NYHA stenocardia tension of functional class II was recorded in 66 patients (20.5%), of functional class III – in 182 patients (57%), of functional class IV – in 72 patients (22.5%). The general fraction ejection of aortic ventricle fluctuated from 32% to 65%, estimating at 48.5±3.8% at the average. Cardiopulmonary bypass surgery was performed in 229 cases (72%) and off-pump surgery was performed in 91 cases (28%). The operation access was made by midline sternotomy. Revascularization of bypass grafting arteries was the following: 286 (35.5%) conduits from 807 were grafted in LAD, 252 (88%) of them were conduits of the left internal mammary artery, 203 (25.2%) of them were the system AC, 25 (3%) – a.intermedia, 180 (22.3%) – the system RCA. There were 252 (31.2%) autoarterial conduits from 807 conduits and 555 (68.8%) were autovenous. The average number of bypasses was 2.5 per one patient.

Results: The sanguimotor interception to blood flow was observed in 258 cases (32%) from 807 grafted bypasses. The interception in 185 cases (71.7%) of that number overcame after the selective objective of anticonvulsive drug of nitroglycerin and in 73 cases (28.3%) the surgery correction was needed. Discovered problems were observed in bypass grafting artery the following way: by LAD in 41 cases (56.2%), by AC in 21 cases (28.8%), by a.intermedia in two cases (2.7%), by RCA in nine cases (12.3%). The ventricles’ fibrillation which was stopped by defibrillation appeared in six cases from 320 after the selective tight bypass opacification.

Conclusions: The inconsistency of bypasses may lead to state instability of patient both in early periods and distant periods after the coronary bypass graft surgery. Intraoperative angiography of the coronary bypasses allows directly to detect the technical problems concerned bypass grafting during the operation and to perform the correction if it is necessary.

C8-4 TRANSMYOCARDIAL LASER REVASCULARIZATION. DIFFERENT LASERS – DIFFERENT RESULTS

L.A. Bockeria, I.I. Berishvili, M.T. Kozaeva, M.H. sem*nov

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: Transmyocardial laser revascularization (TMR) has emerged as an alternative therapeutic option for patients with severe diffuse coronary artery disease refractory to conventional modes of therapy. However, only in patients treated with CO₂ laser results are explained by improvement of perfusion. We presented results of 692 TMR operations, performed with different lasers.

Methods: From April 1997 to September 2010, 692 patients underwent TMR. Isolated TMR was performed in 243 patients, 443 patients underwent combined CABG with TMR. In 152 of these cases TMR was used in combination with CABG on a beating heart. In 642 cases TMR was performed with high power CO₂ laser, 30 – with XeCl laser and 22 – with low energy laser ‘LASON’.

Results: Hospital mortality was – 1.7%, on the last 500 operations there was only two hospital deaths (0.4%). There was seven late deaths. Overall mortality rate was 2.8%. Mortality rate after operations with CO₂ laser was 1.5%, after low power lasers – 17%. Postoperative thallium scan controls (SPECT) after lasing with CO₂ laser demonstrated significant improvement in stress-induced ishemia in majority of patients. PET study revealed restoration of segments with hibernating myocardium. The same improvement was not seen in cases with XeCl and ‘LASON’ lasers. A comparative assessment of the available rates of postoperative congestive heart failure, myocardial infarction, and arrhythmias demonstrated a higher rate of all of these complications for patients treated with low energy lasers.

Conclusions: The distinction in wavelengths of light between low energy and CO₂ lasers has increasing importance in the results. Operations performed with low energy lasers demonstrated significant mortality and morbidity. TMR created with CO₂ laser is a safe and effective procedure. At seven-year follow–up in patients with end-stage CAD that precluded conventional modes of therapy TMR showed significant functional improvement as well as improvement of quality of life.

C8-5 THE EARLY AND LATE RESULTS OF OFF-PUMP CORONARY BYPASS SURGERY. PROPENSITY CASE-MaTCHED STUDY

M.A. Deja, T. Sticel, W. Mazur, T. Kargul, W. Domaradzki, M. Jasiiski, R. Bachowski, S. Woi

Medical University of Silesia, Katowice, Poland

Objective: To compare the early and late outcome of elective off-pump and on-pump CABG.

Methods: Of 783 consecutive patients subjected within two years to elective CABG for chronic stable coronary artery disease in our institution, 146 (19%) were operated off-pump. Basing on preoperative patients characteristics, we calculate the propensity to off-pump surgery. The operating surgeon and anesthetist were included into model. After we propensity matched and analysed early and late outcome of 100 pairs of patients.

Results: Patients did not differ with relation to demographics and clinical characteristics. In OPCAB group 55 patients had three-vessel disease and 36 two-vessel disease compared to 54 and 34 in on-pump group (P=0.6). Median two grafts (interquartile range 1–3) were performed in OPCAB and three grafts (2–4) in on-pump group (P<0.001). OPCAB patients received full arterial revascularization in 53% and on-pump patients in 6% of cases (P<0.001). The number of deaths did not differ one vs. two patients (P=1.0 off vs. on-pump), as did the number of perioperative MIs: two vs. six (P=0.3 off vs. on-pump). Median maximal CKMB was higher in on-pump group as was maximal troponin I: 31.0 IU (21.3–65.5) vs. 26.0 IU (19.0–45.5) (P=0.04) and 0.90 ng/ml (0.56–2.06) vs. 0.23 ng/ml (0.09–0.74) (P<0.001), respectively. Eight on-pump patients and five off-pump patients (P=0.4) experienced postoperative low output requiring inotropes or IABP. Postoperative drainage was higher in OPCAB group 880 ml (700–1120) vs. 740 ml (550–1070) (P=0.01), however they received packed red blood cells transfusion less often 18% vs. 41% (P<0.001) and had smaller postoperative hematocrit drop 11.85% (9.20–14.05) vs. 13.85% (11.35–15.75) (P<0.001). The WBC increased by 3.8 G/l (2.4–5.3) vs. 4.5 G/l (2.8–6.7) (P=0.03) and platelets dropped by 51 G/l (34–67) vs. 68 G/l (50–89) (P<0.001) in off and on-pump group, respectively. Long-term survival (95.6±2.2% vs. 93.3±2.7% at five-year; P=0.5) and survival free of repeated revascularization did not differ between the groups. Five-year survival free of cardiac hospitalization equaled 74.8±4.8% vs. 74.6±5.2% (P=0.7).

Conclusions: Both methods of surgical revascularization seem to yield equivalent long-term results. OPCAB is associated with tendency to using less grafts, although arterial conduits are more often employed.

C8-6 Four-YEAR OUTCOMES OF DRUG-ELUTING STENT IMPLANTATION VERSUS CORONARY ARTERY BYPASS GRAFT FOR UNPROTECTED LEFT MAIN CORONARY ARTERY LESIONS

A. Omarov¹, T. Batyraliev², I. Lazarev³, D. Fettser⁴, E. Merkulov⁵, I. Pershukov³, T. Sadykov⁵, B. Sidorenko³

¹A.N. Syzganov’s National Scientific Center for Surgery, Almaty, Kazakhstan; ²Sani Konukoglu Medical Center, Gaziantep, Turkey; ³Presidential Medical Center, Moscow, Russian Federation; ⁴Regional Clinical Hospital, Lipetsk, Russian Federation; ⁵Cardiology Research Center, Moscow, Russian Federation

Objective: We evaluated at four years the major adverse cardiac events [cardiac death; myocardial infarction (MI); target vessel revascularization (TVR)] following real clinical practice of percutaneous coronary intervention (PCI) with drug-eluting stent (DES) vs. coronary artery bypass graft (CABG) in unprotected left main coronary artery lesions. Preliminary results at one year showed comparable occurrence of major adverse cardiac events in our centers between PCI and CABG.

Methods: All consecutive patients with an unprotected left main coronary artery stenosis treated with DES implantation vs. CABG between 2002 and 2006 were analysed. A propensity analysis was performed to adjust for baseline differences between the two groups.

Results: We included 498 patients in the study, 215 were treated with PCI and DES implantation and 283 with CABG. At four-year clinical follow-up no difference was found between PCI and CABG in the occurrence of cardiac death [adjusted odds ratio (OR): 0.57; 95% confidence interval (CI): 0.19–1.55; P=0.21]. The PCI group showed a trend toward a lower occurrence of the composite end point of cardiac death and MI (adjusted OR: 0.48; 95% CI: 0.21–1.27; P=0.07). Indeed, CABG was correlated with lower target vessel revascularization (adjusted OR: 5.1; 95% CI: 1.74–13.19; P<0.001). No difference was detected in the rate of major adverse cardiac events (adjusted OR: 1.63; 95% CI: 0.79–3.66; P=0.13).

Conclusions: At four-year clinical follow-up there was still no difference in the occurrence of major adverse cardiac events between PCI with DES implantation and CABG in unprotected left main coronary artery lesions in real clinical practice. There was an advantage of PCI in the composite end point of death, MI, whereas a benefit in the need for reintervention was found in CABG.

C8-7 LATE OUTCOME IN PATIENTS WITH OBESITY UNDERGOING CABG

I.Y. Sigaev, M.A. Keren, N.A. Chigogidze, L.A. Bockeria

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: The objective of this study was to investigate the impact of obesity on the long-term clinical outcome in adult patients undergoing coronary artery revascularization.

Methods: We prospectively examined 205 adult patients undergoing isolated coronary revascularization. Patients were divided into two groups based on body weight; Group 1 consisting of 118 (57.6%) obese patients [body mass index (BMI) 30 kg/m²] and Group 2 of 87 (42.4%) non-obese patients (BMI <30 kg/m²). Nineteen percentage of patients were women and 81% men. Long-term follow-up time was 48.0±11.2 months. The use of internal mammary arteries (95.5% in Group 1 vs. 92.9% in Group 2), the use of saphenous vein grafts (94.9% in Group 1 vs. 95.8% in Group 2) and the mean number of distal anastomoses (2.8±0.7 in Group 1 vs. 2.7±0.8 in Group 2) were similar. Seventy-eight patients had late postoperative angiography.

Results: There were 18 late deaths 13 with obesity (11.0%) and five without obesity (5.7%), whereas only 10 (4.9%) of these patients died due to a cardiac reason, such as acute myocardial infarction (n=6) and heart failure (n=4). The other eight patients (4.1%) died for non-cardiac reasons including stroke, renal failure and infection. Myocardial infarction occurred in nine patients (4.3%). In five of these patients (2.4%) this was a re-infarction. The cumulative survival rate among patients with obesity was in one year – 97.7% (S.E.=0.018), in two years – 94.7% (S.E.=0.033) and in three years – 90.2% (S.E.=0.048). Among patients of group of control (without obesity) cumulative level of survival rate has made in one year of 97.3% (S.E.=0.001), in two years – 94.5% (S.E.=0.039) and in three years – 93.5% (S.E.=0.044). Seventy-eight patients had late postoperative angiography: 37 with obesity and 41 without obesity (control). Arterial graft patency was 96.4% and vein graft patency was 82.3% in Group 1 (P=0.02), arterial graft patency was 96.4% and vein graft patency was 92.3% in Group 2 (P=0.1).

Conclusions: Obesity is a risk factor for vein graft patency in long-term follow-up time. No differences arterial graft patency in this group of patients with obesity and without obesity.

C8-8 IDENTIFICATION OF THE INDEPENDENT PREDICTORS OF ISCHEMIC BOWEL FOLLOWING CARDIAC SURGERY

S. Attaran, J. McShane, L. Bond, M. Pullan, B.M. Fabri

Liverpool Heart and Chest Hospital, Liverpool, UK

Objective: Ischemic bowel (IB) is one of the most lethal complications after cardiac surgery. Despite its poor prognosis, early diagnosis and treatment can prevent its devastating outcome. Several risk factors have been associated with this condition. We objective to investigate the main predictors of IB postcardiac surgery.

Methods: For a period of 10 years, from 2000 to 2010, of 19,625 patients that underwent cardiac operations, 112 (0.57%, group A) who developed IB were analysed. Stepwise multivariate logistic regression analysis was used to identify independent risk factors predicting postoperative IB. These 112 cases were then propensity matched with their preoperative and operative characteristics, to 112 cases that did not result in IB. Postoperative complications were then compared between the two groups.

Results: In-hospital mortality for the patients with IB was 87.2%. Age, peripheral vascular disease, respiratory disease, ejection fraction <30% and preoperative renal impairment were the main preoperative predictors of IB (P<0.001). After adjusting for the preoperative and operative characteristics, arrhythmia, postoperative myocardial infarction, prolonged ventilation time, re-exploration, acute renal failure, inotropic support and use of intra-aortic balloon pump were found to be significantly higher in the group with IB compared to those without IB (P<0.0001).

Conclusions: Due to the low incidence and unspecific clinical signs, IB remains undiagnosed. Despite the propensity matching for both preoperative and operative characteristics, patients with IB also suffered from other complications. This may be due to perioperative events resulting in different morbid consequences. Therefore, high-risk patients should be identified pre and postoperatively, and any changes in patient status should raise the suspicion and prompt us to investigate for a possible IB.

5th Vascular Surgery Session – Endovascular Procedures May 21, 2011 12:15–13:30

V5-1 LONG-TERM RESULTS OF STENT-GRAFT VERSUS ANGIOPLASTY IN THE FEMORO-POPLITEAL ARTERY LESIONS

E. Scudieri, A. Matarazzo, V. De Blasio, S. Pecoraro, C. Lusi, A. Polichetti, A. Florio

Second University of Study of Naples School of Vascular Surgery, Naples, Italy

Objective: The aim of this study is to compare the long-term results in patients with steno-obstructive lesions of femoro-popliteal artery treated with PTA alone and/or PTA and stenting.

Methods: Our study included 30 patients with associated diseases, such as hypertension, diabetes mellitus and hypercholesterolemia with claudicatio intermittens or rest pain, treated with PTA alone (n=17) and PTA and stenting (n=13). Of these patients, we considered the equivalent parameters, such as the ABI (Ankle-brachial index), the criteria for classification of Leriche–Fontaine, the runoff, the extent of fibro-calcified lesions, and the characters thereof. The follow-up postoperative evaluation included clinical status (restoration of posterior tibial pulses, and increased distance of travel in the absence of pain) and Doppler ultrasound examination for a period of approximately 24 months.

Results: In 17 patients treated with PTA alone there was a surgical success rate of 92% (16 out of 17), whereas in those with PTA and stenting it was 100%. The only PTA lesions below 5 cm (TASC A and B) showed a patency at two years of 59–93%. This percentage is variable in relation to the factors listed first, especially as regards the runoff score, a value of 78% with two or three patent tibial vessels and 25% in the presence of one or any patent tibial vessel. In lesions >5 cm (TASC C and D) the only PTA showed a high rate of restenosis (65% primary patency at six months, 23% at 24 months). Among the complications in the group of patients treated with endoprosthesis we include stent thrombosis (n-1) successfully treated with thrombolytics and pain relief (n-5) at the limb that required the use of painkillers. On the evaluation of A.B.I. it showed after two years in patients with PTA alone an increase of 0.39 in approximately 93% of them while there was an increase of 0.51 in 93% in patients treated with PTA and stenting.

Conclusions: Long-term results have proved better in patients treated with PTA and stenting (82%) than those treated with PTA alone (43%).

V5-2 THE RATIONAL USE OF RENAL ARTERY STENTING IN RENOVASCULAR HYPERTENSION THERAPY: A SINGLE-CENTER EXPERIENCE

R. Gattuso, L. Irace, M.M.G. Felli, A. Alunno, A. Castiglione

Policlinico Umberto 1, Rome, Italy

Objective: Endovascular surgery in renal artery stenosis is now the treatment of choice. Our aim is to evaluate the improvement in blood pressure and renal function in patients undergoing renal stenting.

Methods: Fifty-two patients were submitted to renal stenting for steno-obstructive lesions. Preoperative study consisted of contrast-enhanced ultrasound, dynamic renal scintigraphy and computed tomography angiography. Fifty-five stents were implanted in 52 patients (three bilateral). In all cases, renal artery stenosis was hemodinamically significant and >75%. All patients received 300 mg clopidogrel the day before the procedure, followed by clopidogrel 75 mg/day associated with ASA 100 mg/day for 6–12 months, then ASA 100 mg indefinitely. The follow-up (six and 60 months) was performed by means of sontrasted-enhanced ultrasound and if a restenosis was discovered, an angio-CT-scan was performed.

Results: Reduction in blood pressure in the early stages (3–6 months) was observed in 31 patients (59.6%). In 25 of this group (80.6%), a return to preoperative values of blood pressure within 12 months was registered. A reduction in creatinine values <1.4 mg/dl was reached in 36 patients (69.2%), while in 10 (19.2%) remained unchanged and in the remaining six (11.6%) worsened. The primary patency was 84.6% at two years and assisted at primary level of 94.2% at five years.

Conclusions: Renal stenting is a safe procedure with a low rate of perioperative complications and with an assisted primary patency rate close to 95% in our experience. In this study, there was no immediate deterioration of renal function during follow-up but there was a 69.2% improvement in itself. In our opinion, the poor results obtained for the improvement of blood pressure need to be investigated with controlled prospective trials. In this experience, there is a good result concerning the recovery and/or improvement in renal function; while there is only a temporary benefit in blood pressure control.

V5-3 SUPERFICIAL FEMORAL ARTERY STENTING: A RETROSPECTIVE REVIEW OF A SINGLE-CENTER EXPERIENCE

H. Nasr

City Hospital, Birmingham, UK

Objective: The treatment of superficial femoral artery (SFA) disease remains controversial. There are several treatment options including percutaneous transluminal angioplasty, surgical bypass and stenting. This study aimed to evaluate the safety, efficacy and clinical outcomes of SFA stenting.

Methods: This was a retrospective, single centre review of all patients who underwent recanalisation of the SFA with self expanding nitinol stent between February 2008 and December 2009. Procedural success was evaluated clinically and defined as resolution of symptoms and/or ulcer healing. Patients did not undergo further investigations/interventions unless clinically warranted.

Results: Twenty patients’ notes were reviewed. Mean age was 75.4 years; there were 14 men (70%) and six women (30%), with a mean follow-up period of 23 months (range 14–32 months). Four patients (20%) were treated for activity limiting (<100 yards) claudication and 16 patients (80%) were treated for critical limb ischaemia (CLI). The Trans-Atlantic Inter-Society Consensus (TASC) distribution for SFA disease was A, 0%; B, 45%; C, 45%; D, 10%. The procedural success rate was 80% with one mortality (NSTEMI) and three in hospital morbidities. Symptomatic resolution was achieved in 50% of patients (TASC B, 56%; TASC C, 44%; TASC D, 50%) and 45% required re-intervention (TASC B, 33%; TASC C, 56%; TASC D, 50%). The rate of symptomatic in-stent stenosis/occlusion at six, 12 and 18 months was 30%, 40% and 45%, respectively.

Conclusions: In our centre SFA stenting was confined to those with multiple comorbidities, deemed unfit for surgical reconstruction, which could explain the inferiority of our results compared to the large SFA stent trials. Nonetheless, we feel that SFA stenting may be considered for palliation in those with severe peripheral vascular disease who are unfit for surgical intervention.

V5-4 HYBRID PROCEDURES IN PATIENTS WITH COMBINED ATHEROScLEROSIS OF LOWER EXTREMITIES

I.P. Mikhaylov

Research Institution named after N.V. Sklifosofkiy, Moscow, Russian Federation

Objective: Improvement of surgical treatment results in patients with arterial atherosclerosis of lower extremities combined with stenosis and occlusion.

Materials: We performed 53 hybrid surgeries in patients with widespread arterial atherosclerosis of lower extremities; 37 patients (70%) with acute thrombosis and 16 (30%) with chronic critical ischaemia, six patients (11%) had trophic disturbances. Average age was 64.5 years. Concomitant diseases hypertensive disease – 82% of patients; postinfarction cardiosclerosis – 28%; diabetes – 13%; affect of brachiocephalic arteries and stroke – 9%. Thirty-seven patients (70%) had occlusion of femoral artery with critical stenosis of iliac arteries; 16 patients (30%) had occlusion and stenosis of femoral, popliteal and tibial arteries. Perfomed surgery: the single-stage stent procedure of iliac arteries and reconstruction of femoral arteries was performed to 10 patients (19%), among them, six patients (60%) had the prosthetics of femoral-popliteal arteries and four patients (40%) had endarterectomy from the femoral artery. Forty-three patients (81%) at first stage had dilatation and stent procedure. At second stage an corrective surgery have been performed. Fifteen patients (35%) had prosthetics of iliac-femoral arteries. From the contralateral part, 17 patients (39.6%) had femoral-popliteal prosthetics (six of them – autovenous, 11 – using polyester prosthesis), eight patients (19%) had endarterectomy from the external iliac artery and femoral artery, three patients (7%) had femoral-tibial shunting.

Results: Forty-nine patients (92%) had decrease of level of ischemia of extremities; three patients (6%) had remained ischemia of foot due to thrombosis of distal arteries, one patient (2%) had necrosis of second and third fingers of the foot. There were no any amputations and lethal outcomes.

Conclusions: Performing hybrid surgery in patients with combined atherosclerosis of lower extremities significantly improves the results of treatment: due to minimal invasiveness and as a result due to decreasing the amount of further complications. The hybrid surgery allows to perform surgeries in patients with severe concomitant pathology, who are at very high risks, connected with other methods of surgical treatment.

V5-5 OPEN AND ENDOVASCULAR OPERATION IN PATIENTS WITH CHRONIC LIMB ISCHEMIA

O.A. Demidova, V.S. Arakelyan, N.A. Chigogidse, B.G. Alekyan

Bakoulev’ Scientific Center of Cardiovascular Surgery, Moscow, Russian Federation

Objective: The purpose of the study was to improve the outcome of patients with chronic lower limb ischemia.

Methods: Six hundred and thirty patients (mean age 53.8±7.1 years) with Leriche syndrome were treated in our clinic during the last 15 years. Open surgery procedures were performed in 424 (I group), and endovascular interventions in 206 cases (II group). The number of percutaneous interventions rising progressively from 8 to 23%, while number of conventional surgery remains unchangeable. Comorbidity was significantly higher and more severe in group II, which was one of the reasons for the percutaneous method choice. The presence of poor outflow tract and critical lower limb ischemia was twice higher in patients who underwent surgery.

Results: Hospital mortality in group I was 1.3% and there was no early mortality in group II. Early thrombosis occurred in 4.3% and 6% of cases, the mean hospital stay length was 10 and 3 days, significant and moderate clinical improvement after treatment was achieved in 97% and 83% of cases in group I and II, respectively. Cumulative patency of reconstruction zone after one, three and five years was 94%, 84% and 76% in group I and 94%, 77% and 69% in group II. Reintervention rate at different times after the surgery/intervention was 13.5% in group I and 36% in group II.

Conclusions: Endovascular operation is method of choice for patients with less extensive lesions of lower extremity arteries but with more difficult concomitant pathology. Early and late results of open and endovascular operation is comparable.

V5-6 SHORT- AND LONG-TERM OUTCOMES OF OPEN SURGICAL AND ENDOVASCULAR REVASCULARIZATION IN PATIENTS WITH CHRONIC MESENTERIC ISCHEMIA

R. Bukatsello, L.A. Bockeria, V. Arakelyan, B. Alekyan, S. Pryadko, N. Chigogidze

Bakoulev Scientific Center of CardioVarcular Surgery, Moscow, Russian Federation

Objective: We lead the retrospective analysis of short- and long-term results of open surgical and endovascular treatment in patients with a chronic mesenteric ischemia (CMI).

Methods: Between 1990 and 2010 in BSCCVS are operated 84 patients with CMI. To all patients the diagnostic complex including physical survey, laboratory diagnostics and various methods of definition a lesion of an aorta and its branches (duplex ultrasound, multiplanar digital subtraction angiography and multidetector computed tomography). For a revascularization we considered as indications the patients with a classic history of CMI (postprandial abdominal pain, weight loss, signs of ischemic gastroenteropathy) and/or hemodynamically significant (50% and more) a stenosis/occlusion of the visceral arteries. Patients have been paired into two groups: traditional surgical repair (group A) – 68 patients and endovascular repair (group B) – 16 patients. Among patients treated with open surgical revascularization, operative strategies included resection with interposition PTFE grafts (n=20, 29.4%); transaortic eversion endarterectomy (TAE) (n=16, 23.5%); vein patch angioplasty (n=2, 2.9%) or reimplantation mesenteric arteries in abdominal aorta (n=9, 13.2%). Decompression interventions were performed in 21 (30.1%) cases. A total of 16 stents (all balloon expandable) were successfully implanted in 16 mesenteric arteries, six in celiac trunk and 10 in superior mesenteric artery. Short-term and late clinical outcomes were analyzed between the two groups. Follow-up data were collected for recurrent stenosis/occlusion, recurrent symptoms or deaths. In all cases recurrent stenosis or occlusion was documented with a duplex ultrasound.

Results: At comparison of two groups frequency of postoperative complications was above in group of traditional surgical treatment and has made 27.9%. On a share of respiratory complications in group A was necessary 19.1%, on intestinal – 4.4%, on cardial and hemorrhagic – 2.9%, neurologic and thrombotic complications are noted in 1.47% of cases, respectively. Local infection complications are taped at 7.3% of patients. The common postoperative 30-day mortality in group A has made 1.47% (one patient). In endovascular group the complicated current of the postoperative period was met in one patient (6.26%), lethal outcomes were not. There was no survival difference at three-year between the groups (100% [B] vs. 98.1% [A]). At three-year, occlusion and recurrent stenosis were documented in 18.8% of the group B compared with 14.5% of the group A. Cumulative recurrent symptoms at three-year were more common in the endovascular group (31.3%) compared with the traditional surgical repair (12.5%).

Conclusions: Comparative analysis shows that endovascular method has the best short-term results, a zero mortality and can be alternative to a surgery intervention at specially selected group of patients. A principal cause of postoperative complications and unsatisfactory results is the degree of intervention and patients co-morbidity. Although the results of group A and group B were similar with respect to recurrent stenosis and death, endovascular repair was associated with a significantly higher incidence of recurrent symptoms.

V5-7 MANGLED EXTREMITY SEVERITY SCORES ARE NOT PREDICTIVE OF LIMB SALVAGE AFTER ARTERIAL RECONSTRUCTION

M.A. Elsharawy

University of Dammam, Al-Khober, Saudi Arabia

Objective: Over the past two decades, few guidelines were available for the decision-making process for primary amputation. These guidelines were based on application of severity grading systems. However, these systems derived from retrospective data and a small number of patients. The aim of this study is to assess these systems for prediction of limb salvage after arterial reconstruction.

Methods: Between December 2000 and August 2010, a prospective study on all patients with arterial injuries in mangled extremities was undertaken. All patients were scored using the Mangled Extremity Severity Score (MESS) and the Mangled Extremity Severity Index (MESI).

Results: During the study period, arterial reconstruction was performed in 112 patients with mangled extremity. Primary patency, secondary patency, and limb salvage rates were 81%, 85.5%, and 93.5%, respectively. The only factor affecting limb salvage (statistical trend) was the site of trauma (upper limb 100% vs. lower limb 89%; P=0.08%). There was no significant effect related to the mechanism of trauma (blunt 90% vs. stab 100%; P=0.125), MESS (<7, 100% vs. >7, 91%; P=0.22), and MESI (<20, 100% vs. >20, 90.5%; P=0.154).

Conclusions: Upper limb injuries were the least likely to lead to amputation. We recommend that all injuries, whatever their score, should be surgically explored before treatment decisions are made.

9th Cardiac Surgery Session – Coronary II May 21, 2011 14:30–16:00

C9-1 INTRAOPERATIVE SHUNTOGRAPHY FOR IMMEDIATE CONTROL OF CORONARY BYPASS SURGERY

N.V. Zakarian, L.A. Bockeria, B.G. Alekyan, A.V. Staferov, K.V. Petrosian, A.V. Abrosimov

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: To analyse our experience with intraoperative shuntography for immediate evaluation of coronary shunts condition in patients after CABG.

Methods: The study comprised 863 patients who received 2166 coronary shunts during the period from February 2009 to December 2010. Patients’ age varied from 41 to 69 years (mean 59.1+4.1), there were 804 (93%) men and 59 (7%) women. Mean number of shunts per patient was 2.5. All 2166 shunts were distributed as follows: 823 (38%) autoarterial shunts using internal mammary artery to the system of the left coronary artery (LAD and DB); 731 (34%) autovenous shunts to the system of the left coronary artery (CxB, OMB, Intermedia, DB, LAD); 612 (28%) autovenous shunts to the system of the right coronary artery. Thus, autoarterial shunts were used in 38% and autovenous shunts – in 62% of cases. In 24 cases an arterial shunt to the LAD and the DB using the left internal mammary artery was performed with the use of ‘snake’ technique. In 651 (75%) cases the operations were performed under extracorporeal circulation, and in 212 (25%) cases – on the beating heart. In all cases shuntography was performed before the sternum closure to provide the possibility of shunts correction. In 103 (12%) cases with unstable hemodynamics and signs of myocardial ischemia urgent shuntography was performed.

Results: The problems in shunts or in shunted arteries were revealed in 291 (33%) patients, hence, the rate of complications as calculated for the totality of shunts is 13%. In 155 (53%) cases the stenoses were revealed in the site of distal anastomosis or the native artery beyond it the degree of stenosis varied from 50 to 90%. In 56 (19%) cases the stenoses of mammaro-coronary shunt were revealed, in 40 (14%) – venous shunt occlusions, in 24 (8%) – native artery occlusions and in 16 (6%) – mammaro-coronary shunt occlusions. In 94 (32%) repeated interventions with subsequent control shuntography were performed: in 32 (34%) the revealed lesion was corrected by stenting, in 62 (66%) cases surgery was applied.

Conclusions: Intraoperative shuntography can reveal certain technical problems related to immediate shunts performance, which can lead to early angina recurrence and shunts occlusion in early postoperative period. Intraoperative solution of these problems contributes to the improvement of immediate as well as of long-term results of aortocoronary bypass surgery.

C9-2 THE ROLE OF STENT LENGTH IN DEVELOPMENT OF STENT THROMBOSIS AFTER DRUG-ELUTING STENT IMPLANTATION

A. Omarov¹, T. Batyraliev², I. Pershukov³, D. Fettser⁴, E. Merkulov⁵, J. Ramazanov², D. Salnikov³, B. Sidorenko³

¹A.N.Syzganov’s National Scientific Center for Surgery, Almaty, Kazakhstan; ²Sani Konukoglu Medical Center, Gaziantep, Turkey; ³Presidential Medical Center, Moscow, Russian Federation; ⁴Regional Clinical Hospital, Lipetsk, Russian Federation; ⁵Cardiology Research Center, Moscow, Russian Federation

Objective: The objective of this study was to evaluate the association between the length of stented segment and the risk of stent thrombosis (ST) after drug-eluting stent (DES) implantation and to determine the cut-off value of stent length in higher risk of ST in real clinical practice. Despite the recommendations of full lesion coverage to prevent angiographic restenosis, the length of the stented segment has been a risk factor for DES-related ST.

Methods: A total of 4403 consecutive patients (6534 lesions) who underwent DES implantation from 2004 to 2008 were analysed. The independent association of stent length with ST and its predictive value were evaluated for a median 27.1 months (interquartile range 20.3–36.8 months).

Results: Stent thrombosis occurred in 96 patients (2.2%) at three years. The stent length/lesion was an independent predictor of ST (hazard ratio: 1.22 95% confidence interval: 1.08–1.45, P<0.001). The threshold of stent length for predicting ST was 33 mm (area under the receiver-operating characteristic curve: 0.731, 95% confidence interval: 0.677–0.782, P<0.001), which had a sensitivity and specificity of 83.4% and 56.7%, respectively. Stent lengths >33 mm were associated with higher rates of ST (4.6% vs. 0.6%, P<0.001), death (5.8% vs. 2.4%, P<0.004), and myocardial infarction (3.3% vs. 0.8%, P<0.001) at three years, as compared with stent lengths ≤33 mm.

Conclusions: Length of the stented segment was independently associated with the incidence of ST and death or myocardial infarction after DES implantation. The value of stent length >33 mm is a threshold for the prediction of ST.

C9-3 EFFECTIVE COMBINED OFF-PUMP SURGICAL TREATMENT AND AUTOLOGOUS BONE-MARROW TRANSPLANTATION FOR END-STAGE ISCHEMIC CARDIOMYOPATHY: FIVE YEARS EXPERIENCE

S. Prapas, D. Protogeros, I.P.F. Danou, V. Kotsis, J. Linardakis, E. Chandrinou

Henry Dunant Hospital, Athens, Greece

Objective: To evaluate the mid-term results of an alternative method for the treatment of end-stage ischemic cardiomyopathy consisting of off-pump revascualization of ischemic areas, external reshaping of the LV and autologous bone marrow-derived mononuclear cell (BM-MNC) implantation.

Methods: Sixty-eight patients (mean age 58±8.9 years) underwent the above procedure between July 2005 and November 2010. All patients were NYHA III-IV, whereas four of them were transplantation candidates. They underwent standard laboratory evaluation, transthoracic echocardiography, dipyridamole thallium scintigraphy (DTS) and cardiac MRI, preoperatively. After revascularization and external LV reshaping, BM-MNCs were injected into predetermined peri-infarct areas.

Results: Sixty-three patients survived during a follow-up period of 3–65 months. Ejection fraction improved from 21.7±7.4% to 30.6±6.9%, 36.5±4.3% and 37.7±4.2% at three, six and 12 months, respectively. Left ventricular end-diastolic diameter was reduced from 66.1+4.9 mm to 62.6±3.9 mm, 60.5±2.9 mm and 59.3±4.2 mm, respectively. Previously non-viable areas on DTS were found to contain viable tissue and MRI showed hypokinesia in previously akinetic areas. NYHA class improved to I-II. No significant arhythmias were noted during the follow-up period. Three patients died due to cardiac and one patient due to non-cardiac reason. One patient suffered stroke and two patients underwent additional PCI.

Conclusions: Combined off-pump surgical treatment and autologous bone-marrow mononuclear cell transplantation for end-stage ischemic cardiomyopathy is safe and feasible and appears to improve the patients’ functional status.

C9-4 MIDCAB EXPERIENCE AND ITS EXTENSION IN MULTi-VESSEL CORONARY ARTERY DISEASE WITH OR WITHOUT HYBRID REVASCULARIZATION

I. Kotelnikov, A. Costetti, A. Moggi, A. Repossini

University of Brescia, Hospital of Brescia, Italy

Objective: Minimally invasive direct revascularization of LAD by left mammary artery (MIDCAB) via small left minithoracotomy is an alternative of conventional CABG through sternotomy. MIDCAB can be used for isolated revascularization or as a part of an hybrid strategy in combination with PCI. The purpose of this study was to evaluate retrospectively long-term outcome following MIDCAB.

Methods: Since May 1997 up to January 2011, 810 MIDCAB (LIMA-LAD) have been performed by the same surgical group as isolated revascularization in 644 patients.

Results: The overall mortality was 0.12%, perioperative acute myocardial infarction – 1.6%, early reoperation – 0.74%, reopening for bleeding – 1.2%, cases with hemotransfusion – 3.1%, with a mean hospital postoperative stay of 4±2.5 days. Postoperative angiographic control in the first consequent 149 patients showed that the left internal mammary artery patency in 100% of cases. One hundred and sixty-six patients were treated by MIDCAB with following PCI (2–60 days). At the mean follow-up of 8.4±3.2 years freedom from related cardiac death was 93% with freedom from cardiac reintervention of 83%.

Conclusions: Our 13 years’ experience of MIDCAB demonstrates that the operation is safe and associated with a very low incidence of early and late complications. Hybrid approach provided excellent long-term outcome in terms of freedom from cardiac death and reoperation. Accurate patient selection as well the timing of the hybrid procedure is mandatory to optimize surgical and PCI results.

C9-5 IDENTIFICATION OF THE INDEPENDENT PREDICTORS OF STERNAL WOUND INFECTION FOLLOWING ISOLATED CABG

S. Attaran, J. Mcshane, L. Bond, M. Pullan, B.M. Fabri

Liverpool Heart and Chest Hospital, Liverpool, UK

Objective: Sternal wound infection (SWI) following cardiac surgery has been reported to be associated with high body mass index (BMI), diabetes, bilateral internal mammary artery (BIMA) harvest, and re-exploration for bleeding. The objective of this study was to investigate the main predictors of SWI post CABG and compare them to our previously published data.

Methods: Data were prospectively collected from 8439 patients who underwent isolated CABG between 2001 and 2009 (group A). Logistic regression models were used to identify independent risk factors predicting SWI and Cox proportional hazards analysis calculated the adjusted hazard ratios (HR). Results were compared with the predictors of SWI in 4228 CABG patients operated between 1997 and 2001 (Group B).

Results: The incidence of SWI was 3.4% (0.8% deep and 2.6% superficial SWI). Age, insulin-dependent diabetes, peripheral vascular disease, BMI>30, duration of ventilation, history of renal impairment and the use of BIMA were the main predictors of SWI (P<0.001). In this series (A), compared to the patients in the previous time cohort (B), reopening was no longer a risk factor for SWI (P=0.39) even after adjusting for the preoperative characteristics.

Conclusions: In our experience, reopening for bleeding is no longer a risk factor for SWI. We believe that a low threshold for reopening for bleeding/tamponade has resulted in a reduction of SWI rate, comparable to first time sternotomies. We recommend that risk factors, such as high BMI, diabetes and respiratory problems to be identified and optimised preoperatively to minimise SWI.

C9-6 COMPARING THE OUTCOME OF ON-PUMP VERSUS OFF-PUMP CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH PREOPERATIVE ATRIAL FIBRILLATION

S. Attaran, J. Mcshane, L. Bond, M. Pullan, B.M. Fabri

Liverpool Heart and Chest Hospital, Liverpool, UK

Objective: About 3–5% of patients undergoing CABG suffer from persistent atrial fibrillation (PAF). This is a benign arrhythmia but can affect the outcome. The objective of this study was to assess the effect of PAF on the immediate postoperative course of the patients undergoing on-pump (ONCAB) vs. off-pump (OPCAB) CABG.

Methods: For a 10-year period, data were prospectively entered into the database of our institution; a total of 9259 patients undergoing CABG were included; 8838 (95.3%) patients were in sinus rhythm (SR) preoperatively and 421 (4.7%) were in PAF. Other arrhythmias were excluded. After propensity matching and adjusting for the preoperative and operative characteristics, 410 patients with PAF were compared with 410 patients in SR.

Results: Before propensity matching the patients, all the complications were significantly higher with PAF. After adjusting the preoperative characteristics as well as the procedure type, in patients who had ONCAB, postoperative complications, such as renal failure, ventilation time, inotropic support, ICU and hospital stay, as well as in-hospital mortality were significantly higher with PAF compared to those in SR (P<0.001). Also in ONCAB cases, the higher stroke rate in the PAF group (5.1%) was observed compared to those in SR (2.3%), but the difference did not reach the statistical significance (P=0.09). In OPCAB patients, on the other hand, there was no statistically significant difference in the postoperative complications between the patients with preoperative SR or PAF.

Conclusions: PAF is associated with a higher incidence of postoperative complications. Our results have demonstrated that, patients in PAF undergoing ONCAB are more susceptible to the postoperative complications compared to those in SR. However, postoperative complications were similar between PAF and SR groups undergoing OPCAB. OPCAB may be the procedure of choice in persistent AF.

C9-7 EFFECT OF SURGICAL TECHNIQUE ON EARLY AND LATE RESULTS OF SURGICAL TREATMENT OF ISCHEMIC HEART DISEASE IN ELDERLY PATIENTS

J. Pacholewicz, I. Jaworska, D. Ciela, M. Zembala

Silesian University Center for Heart Disease, Zabrze, Poland

Objective: To compare early and late results of coronary artery bypass grafting with and without cardiopulmonary bypass - OPCAB vs. CABG in elderly patients.

Methods: One thousand one hundred and twenty-eight consecutive patients over 65 years old, underwent surgical myocardial revascularisation in the Silesian Center for Heart Diseases in Zabrze, from January 2003 to December 2007. Patients were divided into two groups: I - 669 patients undergoing CABG technique, II - 459 patients undergoing OPCAB technique. Preoperatively demographic data, risk factors for coronary heart disease, cardiovascular fitness, and comorbidities were compared. Postoperatively the mortality and the nature and incidence of complications, total postoperative drainage and the frequency of blood transfusion, duration: hospital, hospital stay, and postoperative mechanical ventilation were compared. In the five-year follow-up, the influence of surgical technique used for survival and survival free of major cardiovascular events were compared.

Results: Both groups were comparable in preoperative assessment, with the exception of the incidence of carotid artery disease: 50 (7.5%) in group I vs. 56 (12.2%) in group II, P<0.01. Vascular analysed groups: 90% vs. 88% and 60% vs. 65%. The observed mortality was similar and amounted to: 12 (2.6%) in group I and 19 (2.8%) in group II, as well as postoperative myocardial infarction, which was found in 16 (3.5%) in group I and 26 (3.9%) in group II. In group I it had significantly higher incidence: use of inotropic drugs: 242 (36.2%) vs. 102 (22.2%) P<0.001, use of IABP: 45 (6.7%) vs. 15 (3.3%) P<0.05, serious neurological complications – stroke: 21 (3.1%) vs. 7 (1.5%) P<0.01, reoperation due to bleeding: 28 (4.2%%) vs. 7 (1.5%) P<0.05 and the proportion of patients requiring transfusion 334 (49.9%) vs. 121 (26.4%) P<0.001. In group I observed a prolonged hospitalization of 7.29 vs. 6.84, P<0.001. Multivariate analysis showed that the use of cardiopulmonary bypass increases more than twice the risk of stroke (OR=2.26: 95% CI=1.44–3.55) in the early postoperative period.

Conclusions: The use of minimally invasive techniques for coronary artery bypass – OPCAB, in elderly patients reduces the incidence of complications in the early postoperative period, and shortens the time of hospitalization. Long-term results of treatment using minimally invasive techniques of OPCAB are comparable to classical CABG.

C9-8 POSTOPERATIVE BLEEDING RISK PREDICTION WITH THE PLATELET FUNCTION TEST IN BYPASS SURGERY PATIENTS ON ASPIRIN

W. Kuliczkowski¹, J. Sliwka¹, J. Kaczmarski¹, M. Zembala¹, D. Zysko², T. Hrapkowicz¹, D. Steter¹, M. Zembala¹

¹Silesian Center for Heart Diseases, Zabrze, Poland; ²Wroclaw Medical University, Wroclaw, Poland

Objective: Preoperative aspirin can influence the risk of postoperative bleeding. Nowadays, there is a tendency to proceed with the bypass surgery in elective patients while on aspirin. A tool predicting the risk of bleeding in such patients would be useful to avoid subsequent transfusion-related complications.

Methods: The study consisted of 350 patients (mean age 64.3±9.2 years; 84 women) who underwent cardiac surgery, including patients on aspirin 75 mg until <5 days before operation. Patients who received platelet concentrate during hospital stay were excluded from the study. Platelet testing was performed with the multiplate aggregometer 24 h before the operation. The ASPI test with arachidonic acid as aggregation agonist was used to assess the response to aspirin. Postoperative bleeding was estimated by blood transfusion, drainage volume and necessity for reoperation.

Results: One hundred and ninety-one of 350 patients were operated with the classic CABG and 159 with OPCAB. In the ROC analysis of the entire group and the OPCAB group, the ASPI test result (area under curve, AUC) showed no statistically significant cut-off value for any bleeding risk estimates. In the CABG group, ASPI test below 389 with 77% sensitivity and 49% specificity, predicted the need for postoperative red blood cell concentrate (RBC) (95% CI 0.54-0.70; P<0.01). There was a significant negative correlation between the ASPI test result before operation and postoperative drainage in the CABG group (correlation coefficient=–0.14; P<0.05).

Conclusions: In CABG patients operated on aspirin, the ASPI test below 389 AUC predicts the need for postoperative RBC transfusion. The ASPI test is not useful for bleeding risk prediction in OPCAB patients.

C9-9 MORPHOLOGICAL AND BIOPHYSICAL PROPERTIES OF RADIAL ARTERY USED AS CONDUITS FOR MYOCARDIAL REVASCULARIZATION

Y.Y. Vechersky, S.L. Andreev, M.L. Dyakova, V.V. Zatolokin, K.V. Eremenko

Tomsk Institute of Cardiology, Tomsk, Russian Federation

Objective: As soon as the choice of the right drug for vasospasm prevention is still a matter of controversy the objective of this work was to study RA morphological and biophysical properties and to investigate the effects of ‘in vitro’ topical vasodilatators in a human RA to improve performance of arterial grafts.

Methods: The objects of the study were distal rings segments of a radial artery (n=120) that were taken intraoperatively. Each vessel was carefully dissected from surrounding fat tissue and cut into several rings of 3–4 mm. Morphological and morphometrical methods were used to study intimal and medial areas. Relaxation studies were performed after the vessels were contracted with hyperpotassium solution and phenylephrine. Vessel segments were then exposed to incremental doses of ‘nitromixture’ (5 mg verapamil hydrochloride; 2.5 mg nitroglycerine; 500 UN heparin; 300 ml isoosmotic crebs solution), nifedipine, papaverine. The ability to prevent RA spasm was assessed by dose-response curves.

Results: The adding of ‘nitromixture’ solution caused the reduction of basic mechanical voltage of RA smooth muscle for 22.5% (Р<0.05). Hyperpotassium solution (30 mmol KH) resulted in development of supported contraction. Adding the ‘nitromixture’ caused long relaxation of RA smooth muscle 100±2% (Р<0.05). Adding phenylephrine (10 µmol) into KH solution led to the development of supporting contraction with the amplitude of 36.6±8.6% (Р<0.05) from the basic hyperpotassium contraction. Contractile ability of RA segments was not restored during 30–60 min after laundering ‘nitromixture’ and impacting hyperpotassium or phenylephrine solutions. Adding nifedipine into KH solution (in different concentrations – 3 µmol, 30 µmol, 300 µmol, 3 mmol) led to relaxion of RA smooth muscle to the values of 81.0±10.5%, 39.0±7.2%, 22.0±5.0%, 5.0±6.1% (Р<0.05) respectively. Contractile ability of RA segments was not restored during 60-90 min after nifedipine removal. Papaverine (10 µmol) induced relaxation of RA segments for 53.0±6.1% (Р<0.05). Papaverine (100 µmol) relaxed RA segments completely. Increasing concentration up to 1 mM caused a complete suppression of contractile response. The average of intimal thickness was 8.8±3.8 µmol, medial thickness – 128.5±18.7. One case of atherosclerotic changes (2.1%) was noticed. There was found a high occurrence of intimal thickening of RA (10.6%).

Conclusions: All segments showed from minor to moderate atherosclerotic changes without severe intimal thickening or luminal narrowing. This study strongly supports the use of the ‘nitromixture’ and nifedipine to relieve spasm of radial artery to reduce the incidence of angina after CABG.

C9-10 LEFT VENTRICULAR ANEURYSM REPAIR: AN ASSESSMENT OF TWO TYPEs OF ENDOVENTRICULAR PLASTY

A.V. Rudenko, L.S. Dzakhoieva, S.A. Rudenko, V.V. Gutovskiy, A.V. Kupchinskiy, L.V. Yakob

M. Amosov National Institute of Cardiovascular Surgery, Kiev, Ukraine

Objective: A large transmural myocardial infarction often results in a dyskinetic or akinetic left ventricular aneurysm (LVA), which may in turn cause congestive heart failure, ventricular arrhythmia and thromboembolic events. Endoventricularplasty of left ventricular without patch and endoventricular patch plasty are alternative techniques to repair large postinfarction left ventricular aneurysm. The objective of the study was to compare these two methods of surgical treatment.

Methods: Between January 2000 and December 2010, 1084 consecutive patients underwent repair of LV aneurysms. Six hundred and eighty patients were operated with the conventional technique and 404 with the endoventricular plasty. Three hundred and eight patients (76.2%) were submitted to endoventricularplasty without patch (Group 1) and 96 (25.8%) to patch remodeling (Group 2). There were 368 (91.1%) men and 36 women, mean age 53.9±9.1 years. Two hundred and forty (59.4%) patients had angina CCS class III/IV and 164 were in NYHA class I/II (40.6%).

Results: Coronary artery bypass was performed with an average of (2.3±1.2) grafts per patient. Hospital mortality in Group 1 was 1.0% and 2.1% in Group 2. The mean NYHA class and ejection fraction increased significantly (P<0.001). The mean left ventricular, end diastolic diameter decreased significantly (P<0.001).

Conclusions: Ventricular function in patients with left ventricular aneurysm improved after both techniques. In many cases we can use endoventricular plasty of left ventricular without patch. Using endoventricular plasty with patch is necessary only when aneurysm injury all walls of LV.

C9-11 CABG AND MITRAL VALVE RESTRICTIVE ANNULOPLASTY IN PATIENTS WITH ISCHEMIC MITRAL REGURGITATION

M. Aleksanyan, G. Khubulava, S. Marchenko, N. Shikhverdiev

Kuprianov CVS Clinic, Saint Petersburg, Russian Federation

Objective: To study the results of surgical treatment of patients with ischemic mitral regurgitation (IMR), who were underwent CABG and mitral valve restrictive annuloplasty.

Methods: From April 2005 to December 2010, 38 patients with IMR were operated. All patients had two or more degree of MR. LV EF was 0.21–0.57. All patients were in NYHA class III. Two patients had severe tricuspid regurgitation, and underwent DeVega’s annuloplasty. Twenty-three patients (60.5%) had LV EF <26%. Intraaortic balloon pump was inserted before procedure.

Results: Mitral regurgitation in 94.7% cases has disappeared after restrictive mitral ring annuloplasty, in 5.3% (two patients) – has decreased from 3 to 2º. LV EF increased mean 6.4% after surgery. Mortality 5.3% (two patients) in early postoperation period (acute renal failure).

Conclusions: Intraaortic ballon pump in patients with ischemic mitral regurgitation is performed before procedure.

10th Cardiac Surgery Session – Coronary III May 21, 2011 14:30–16:00

C10-1 DOES THE PREVIOUS PERCUTANEOUS CORONARY INTERVENTION INFLUENCE THE OUTCOME OF SURGICAL REVASCULARIZATION?

L. Velicki, B. Mihajlovic, N. Cemerlic-Adjic, S. Nicin, R. Jung, M. Fabri

Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia

Objective: The growing number of percutaneous coronary intervention (PCI) patients is referred to coronary artery bypass grafting (CABG) without standing profound advancements in PCI techniques and patient selection. It was unclear to what extent PCI influences the outcome of subsequent CABG especially in cases with multivessel disease. The aim of this study was to determine whether there is an association between previous PCI and results of the following CABG.

Methods: Between January and December 2010, 624 consecutive patients at our clinic underwent for the first-time isolated CABG. Five hundred and sixty-four patients of them (90.4%) underwent CABG as a primary revascularization procedure, while 60 patients (9.6%) have had prior PCI. These two groups were evaluated and compared for 30-day mortality rate, major adverse cardiac events (MACE) and other important characteristics.

Results: All causes of mortality in next 30 days did not differ significantly between the two groups (no prior PCI: 1.60% vs. prior PCI: 0%; P=0.61), as for MACE (no prior PCI: 3.9% vs. prior PCI: 5%, P=0.72). Mean value of logistic EuroSCORE in patients without prior PCI was 3.48%, while in patients with prior PCI it was 3.41% (P=0.43). Mean number of distal anastomoses was significantly lower in patients with prior PCI, 2.38 compared to patients without prior PCI 2.64 (P=0.04). Cardiopulmonary bypass time did not differ significantly (68.23 min vs. 58.20 min, P=0.45). The number of patients with left main coronary artery stenosis >50% was significantly lower in prior PCI group (odds ratio 2.94, 95% confidence interval 1.15–7.51, P=0.03). There was no significant difference in number of patients treated as non-elective (odds ratio 0.63, 95% confidence interval 0.14–2.89, P>0.05). Number of patients with unstable angina symptoms was significantly higher in the prior-PCI group (odds ratio 0.49, 95% confidence interval 0.28–0.87, P=0.01). Mean ejection fraction of the left ventricle was comparable between the groups (53.47% vs. 52.33%, P=0.88). In patients in the prior-PCI group, the average time between the last PCI and CABG, was 12.77 months, average number of stents per patient was 1.8 while average number of percutaneously treated arteries was 1.15.

Conclusions: Previous PCI has no influence in terms of mortality and morbidity on the outcome of subsequent surgical revascularization. The following CABG in patients with prior PCI can be carried out safely, although prior PCI reduces the number of distal anastomoses.

C10-2 COMPLICATIONS IN CARDIAC SURGERY: STERNAL DEHISCENCE AFTER MEDIAN STERNOTOMY. ANALYSIS OF 14,173 CASES OPERATED BETWEEN 1990 AND 2009

M.J. Listewnik, P. Sielicki, A. Biskupski, P. Slozowski, M. Brykczynski

Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland

Objective: Dehiscence of the sternum is one of the most serious complications after median sternotomy and it may occur in 0.2–5% of cases. The objective of this study was the evaluation of the factors that can influence the frequency of this complication.

Methods: A retrospective review of all patients undergoing median sternotomy for cardiac surgery between years 1990 and 2009 was performed at The Cardiac Surgery Department of Pomeranian Medical University in Szczecin (Poland). A total of 14,173 median sternotomies were performed during this period, and 309 patients (2.2%) required surgery to treat sternal dehiscence. In the researched group there were 3999 (28.2%) women and 10,174 (71.6%) men aged 11–87 (mean age 59.8) years.

Results: The coexistence of diabetes, chronic obturative lung disease or a high body mass index (BMI) did not influence the frequency of occurrence of sternal dehiscence. The significant independent factors turned out to be age and sex. In the group with complications the average age was 63.8 years, compared to 59.7 years in the group without them (P<0.00001). Also, in the group of patients younger and older than 65 years the differences in frequency of sternal dehiscence occurrence was significant (1.72% vs. 3.17%; P<0.0001). Sex was also a very important factor. In men, sternal dehiscence occurred nearly two times more often that in women (2.48% vs. 1.42%; P<0.0001). The highest rate of sternal dehiscence was observed in the group of patients after operations of aortic aneurysm (2.46%) and CABG (2.42%). The lowest rate was noticed after short operations on and off ECC, such as ASD closure, pulmonary embolectomy, surgery of heart injuries (0.62%), yet these differences between the groups were not statistically significant. The use of at least one mammary artery during surgery (1.59% vs. 2.25%; P<0.03) doubled the risk of sternal dehiscence, the use of two IMAs increased its three-fold (1.59% vs. 4.6%; P<0.0001 and 2.25% vs. 4.6%; P<0.001).

Conclusions: The factors which significantly heighten the risk of sternal dehiscence are advanced age of the patient, male sex and the use of one, and especially two IMAs during surgery.

C10-3 IMMEDIATE POSTOPERATIVE PERIOD HYPERLACTATEMIA AFTER SURGICAL INTERVENTION UTILIZING CARDIOPULMONARY BYPASS

V.E. Rubinchik, A.P. Mikhailov, A.O. Marichev, A.V. Najmushin, A.E. Bautin, D.A. Laletin

Almazov Federal Heart, Blood and Endocrinology Centre, Saint Petersburg, Russian Federation

Objective: The aim of the study was to determine interdependence of lactate level with hemodynamics and oxygen transport indices after cardiac surgery utilizing cardiopulmonary bypass (CPB).

Methods: The survey included 210 patients having undergone CABG operation, with an LVEF ≥50% and comparable gender, age and CPB duration separated into three groups in accordance with peak lactate level during the whole follow-up period. CPB and anesthesia was performed on standard techniques accepted in our center. Peak lactate level was: <2.2 mmol/l (first group), 2–5 mmol/l (second group), more than 5 mmol/l (third group).

Results: The peak lactate level has been reached within 6.1±2.3 h in the first group, within 7.2±2.2 h in the second group, within 7.4±2.5 h in the third group (Р>0.05). Oxygen delivery index DO₂I (ml/min/m²) was 397±89 ml/min/m² in the first group, 369±83 ml/min/m² in the second group, 446±90 ml/min/m² in the third group. DO₂I indices were lower in the first and second groups than in the third (Р<0.05). Stroke volume index SVI (ml/m²/ beat) did not differentiate in groups and amounted 38±2 ml/m²/beat in the first group, 36±2 ml/m²/beat in the second group and 37±2 ml/m²/beat (Р>0.05). Cardiac output CI (l/min/m²) measurements indicated 2.8±0.65 l/min/m² in the first group, 2.71±0.63 l/min/m² in the second group, 3.24±0.85 l/min/m² in the third group. CI figures in the first and second groups were lower than in the third one (Р<0.05). Mixed oxygen saturation level SVO₂ (%) amounted 74±8% in the first group, 73±9% in the second group and 76±8% in the third group (Р>0.05). Oxygen extraction level (O_2extr) (%) amounted 25±8% in the first group, 26±9% in the second group and 23±8% in the third group. O_2extr indices in the third group were lower than in the first and second groups (Р<0.05). The CI/O_2extr ratio amounted 11±2 in the first group, 11±3 in the second group and 15±3 in the third group. The CI/O_2extr ratio measurements in the third group were higher than in the first and in the second groups (Р<0.05).

Conclusions: 1. The peak of lactate level was reached 7 h after the end of CPB and did not depend on its duration. 2. Patients with the peak lactate level more than 5 mmol/l demonstrated an increased haemodynamics level as compared to patients with a lower lactate level. Lactate level was independent from oxygen transport. 3. An inverse dependence of lactate level from oxygen extraction and CI/O_2extr ratio has been detected.

C10-4 THE EuroSCORE – STILL HELPFUL TO PREDICT OPERATIVE RISK IN PATIENTS UNDERGOING CARDIAC SURGERY?

D. Nezic, M. Borzanovic, T. Spasic, M. Balevic, A. Knezevic, I. Petrovic, D. Kosevic, M. Jovic

‘Dedinje’ Cardiovascular Institute, Belgrade, Serbia

Objective: The EuroSCORE risk model is widely used as cardiac surgery risk model and it is used in two versions: an additive and a full logistic version. The objective of the study was to analyse the additive and logistic EuroSCORE for its accuracy in patients undergoing cardiac surgery, as well as to test EuroSCORE for prediction of prolonged ICU and postoperative hospital stay.

Methods: From January to September 2009, 1500 patients operated on in a single institution, were prospectively assigned expected risk of dying calculated by the additive and the logistic EuroSCORE algorithms. The discriminating ability of the two models was tested by receiver operating characteristic (ROC) curves. The area under the curves (AUC) of the additive and logistic model was compared with the Hanley-McNeil test. Calibration was assessed by the Hosmer-Lemeshow (H-T) test.

Results: Overall mortality was 3.67%. Predicted mortalities were 4.86±2.99% (additive) and 5.95±7.54% (logistic). Both models satisfactorily discriminated outcomes (ROC areas of 0.83 and 0.84 for the additive and the logistic model, respectively), without statistically significant difference between AUCs (Hanley-McNeil test, P=0.11). The H-L test showed that calibration was good for both models (P-value of 0.95 and 0.12 for the additive and the logistic model, respectively). Actual mortality was 0.3% in the low risk (additive EuroSCORE 0–2; predicted mortality of 1.28±0.71% and 1.35±0.29% for the additive and the logistic model, respectively), 1.13% in the medium risk (EuroSCORE 3–5; predicted mortality of 3.93±0.82% and 3.04±0.86% for the additive and the logistic model, respectively) and 8.5% in the high-risk groups (EuroSCORE 6; predicted mortality of 8.04±2.12% and 11.93±9.77% for the additive and the logistic model, respectively). Although calibration was good for all risk groups, both models unsatisfactorily discriminated outcomes in medium risk group (both AUC <0.65). Although both variants showed very good discriminatory power (AUCs ≈0.79) to predict prolonged ICU stay (>5 days), as well as to predict (AUCs ≈0.72) prolonged postoperative hospital stay (>12 days), only additive model confirmed good calibration in both cases.

Conclusions: Although overall observed to expected mortality ratio was 0.62, both EuroSCORE variants showed excellent discrimination and calibration applied to the whole group. Discriminatory power was unsatisfactory (overprediction) for both models in medium risk group. Additive EuroSCORE confirmed good predictive value for prolonged ICU and postoperative hospital stay.

C10-5 LONG-TERM (10–YEAR) OUTCOMES IN SURGICAL VENTRICULAR RESTORATION FOR CONGESTIVE HEART FAILURE

D.V. Kuznetsov, A.P. Semagin, S.M. Khokhlunov, P.V. Polyakov, V.P. Polyakov

Regional Cardiovascular Center, Samara, Russian Federation

Objective: Congestive heart failure (CHF) is one of the main causes of hospitalization in Europe and the USA which is associated with significant morbidity and mortality. We reviewed experience of the SVR in combination with coronary artery bypass grafting in patients with coronary heart disease (CHD), CHF and enlarged left ventricle.

Methods: Retrospectively, we reviewed the SVR patients (who had undergone SVR with CABG in 1996–2009 years and have been followed–up until December 2010). The survival and CHF freedom were analysed using Kaplan–Meier method. Cardiac function was evaluated with contrast ventriculography end 2D or 3D echocardiography.

Results: One hundred and thirty-six patients with CHD, CHF and enlarged left ventricle who underwent SVR and CABG were included in study. The mean rate of ejection fraction has improved from 32%±3% to 40%±1.5% (P<0.05). Left ventricular end-systolic volume index decreased from 108±8 ml/m² to 71±11 ml/m² (P<0.05). Five-year survival amounted to 80%, 10-year survival – 56.5%. The freedom from high functional class (III–IV NYHA) was 68% totally.

Conclusions: SVR with CABG in patients with coronary heart disease, CHF and enlarged left ventricle, results in increasing of postoperative left ventricular ejection fraction and improving long-term clinical outcomes significantly.

C10-6 NON-INVASIVE VENTILATION TO PREVENT POSTOPERATIVE PULMONARY COMPLICATIONS AFTER CARDIAC SURGERY

E. Golukhova, A. Medressova, M. Luckashkin, G. Lobacheva, K. Shumkov, V. Merzlyakov

Bakoulev Center, Moscow, Russian Federation

Objective: To assess the efficacy of non-invasive ventilation (NIV) in prevention of postoperative pulmonary complications after cardiac surgery in patients at increased risk.

Methods: Forty-two patients with the following preoperative risk factors – body mass index >30 kg/m², chronic obstructive pulmonary disease, history of smoking, diabetes – after extubation were randomly assigned to receive either NIV plus respiratory exercises (n=12) or usual care (oxygen therapy plus respiratory exercises) (n=30). Clinical state of patients, spirometry variables, arterial blood gas tensions and chest X-ray examination were analysed.

Results: After cardiac surgery atelectasis was present in three (25%) of 12 patients in the NIV group and 14 (47%) of 30 patients in the usual care group. Pneumonia occurred in three (10%) of 30 patients in the usual care group and did not occur in the NIV group.

Conclusions: NIV was superior to conventional treatment regarding the reducing of incidence of postoperative pulmonary complications after cardiac surgery in high-risk patients.

C10-7 LONG-TERM RESULTS OF SURGICAL VENTRICULAR RECONSTRUCTION IN CAD PATIENTS WITH LEFT VENTRICULAR ANEURySM

R.S. Akchurin

Cardiology Research Center, Moscow, Russian Federation

Objective: Ischemic heart disease is very frequently complicated by transmural myocardial lesions. Most of these scars become left ventricular aneurysms. A recent STICH study exposed a large number of questions and discussions in this attractive problem of coronary surgery. Thus, nowadays, this area of cardiac surgery is very disputable.

Methods: One hundred patients were included in this study. Sixty-five had dyskinetic, and 35 – akinetic scar. All of them underwent the left ventricular aneurysmectomy with modified endoventriculoplasty with PTFE-patch concomitantly with CABG. LVEDV was 284±101 ml and LVESV 181±66 ml, EF – 38±7% before operation. Urgent patients and patients with significant valvular lesions were excluded from this study. Follow-up period varied from 2 to 9 years.

Results: Hospital mortality was 2%. Dynamic of LVEF was from 38 to 45±4% (P<0.05), LVEDV decreased to 154±55, LVESV to 84±25. NYHA-class was slightly lower than preoperative results. Long-term outcome: long-term survival was: one year 98%, 3–94%, 5–81%, 7–72%, 9–65%. Five patients underwent ICD-implantation for the secondary prevention from six months to two years after SVR. Two of them had appropriate shocks, and one died from heart failure progression. Despite excellent survival, we found very high rate of mortality in patients with episodes of ventricular tachycardia, and in patients with EF <35%. After seven-year follow-up all patients with VT died, and patients with low EF died even after four years after operation.

Conclusions: Modified LV-reconstruction in patients with left ventricular aneurysm is very effective and safe operation. Long-term survival in whole population is very good. Low ejection fraction and episodes of ventricular tachycardia is a significant predictor of high-rate mortality after five-year follow-up. The EP-procedure and/or ICD implantation should be used probably in such patients in addition to LV reconstruction.

C10-8 RITA TO LAD – AN ALTERNATIVE GRAFT CONFIGURATION IN CORONARY ARTERY SURGERY

T. Hrapkowicz, M. Krasov, T. Styn, K. Kubacki, R. Przybylski, M. Zembala

Silesian Center for Heart Disease, Zabrze, Poland

Objective: The excellent patency rate and better long-term outcomes after total arterial coronary revascularization were confirmed in many studies. This allows to certify that in the modern era the use of only one arterial bypass seems to be insufficient. The application of radial artery as a second arterial graft remains still controversial, the right internal thoracic artery (RITA) should be used alongside with LITA. In some cases the configuration of coronary bypass requires cutting off and attaching right to the left ITA as a composite graft. In some cases to avoid this additional anastomosis RITA can be used as an in situ graft to LAD and LITA as a graft to circumflex and/or other vessels like IM, OM, Cx, PDA. We present short-term outcomes in the group of patients in whom RITA to LAD anastomosis was applied in both off- and on-pump coronary surgery.

Methods: In the years 2005–2009 we performed 3725 coronary operations. In this cohort there were 82 patients in whom right ITA was attached to LAD. The grafts configurations, intraoperative flow through the grafts, early complications and mortality in this group of patients were analysed. Additionally, the results in off-pump and on-pump subgroups were compared.

Results: In the overall group of 3725 coronary patients apart from on-pump surgery, OPCAB (41%) and MIDCAB (3.8%) operations were performed. The mean age was 62.3±8.8 years, EuroSCORE – 3.8±2.6 and mortality rate 1.1%. The mean age among the patients with RITA-LAD anastomosis was 54.3±7.2 years and EuroSCORE 2.1±1.9. The mean number of anastomosis was 2.5±0.6. Both ITAs were applied in 76 (92.7%) patients. Left ITA was used as a graft to diagonal (two patients). The flow parameters in RITA to LAD grafts (Flow, PI, DF) were proper. The most important complications were reoperation (bleeding) in one patient (1.2%), MI in one patient (1.2%) and the need of IABP in one patient (1.2%). There were no neurological complications in this group. In-hospital mortality was 1.2% (one patient). There were no significant differences in results in off-pump compared to on-pump patients.

Conclusions: The alternative graft configuration RITA to LAD is a safe method which allows to use both ITAs without the necessity of additional anastomosis (RITA to LITA). Moreover, in some patients no-touch aorta operation is possible even in multivessel coronary artery.

6th Vascular Surgery Session – ESCVS Young Vascular Surgeon Prize May 21, 2011 14:30–16:00

V6-1 PENETRATING AORTIC ULCER DATABASE: THE WAY TO KNOW MORE

I. Koncar¹, A. Robaldo², A. Zekovic³, L. Davidovic¹, D. Palombo²

¹Clinic for Vascular and Endovascular Surgery of Serbian Clinical Center, Belgrade, Serbia; ²Division of Vascular and Endovascular Surgery, ‘San Martino’ University Hospital, University of Genoa, Genoa, Italy; ³Faculty of Mathematics, University of Belgrade, Belgrade, Serbia

Objective: The development of modern diagnostic procedures contributed to more frequent, easier and precise detection of aortic disease like ‘penetrating aortic ulcer’ (PAU). Although firstly described in 1929, this disease is still unknown to us, and the question that is still actual is its natural outcome and indications to treat. Aim of this study was to investigate PAU in its presentation, complication rates, and efficacy of the treatment modalities.

Methods: An easy to use internet database (Penetrating Aortic Ulcer Database – PAUD) was created in order to collect and analyze data connected to PAU development and long-term follow-up after surgical (open or endovascular) repair as well as during conservative treatment in patients unsuitable for former. PAUD website capable of collecting data from all around the world was developed in cooperation of Clinic for Vascular and Endovascular Surgery of Serbian Clinical Center and, Division of Vascular and Endovascular Surgery, ‘San Martino’ University Hospital, University of Genoa. All participants are able to register on the website and to submit data of the patient with PAU by filling questionnaire, and to upload diagnostic images. Patients were submitted prospectively in the moment of admission, or partly retrospectively during their follow-up examinations. Every six and 12 months participant will receive reminder about necessary follow-up.

Results: Since January 2009–2010, 41 patients were submitted to PAUD, with PAU of different locations, from ascending aorta, aortic arch and descending aorta to abdominal infrarenal segment, and different clinical presentation from asymptomatic to acute aortic syndrome. They were treated with open (15 patients), endovascular (20 patients) and conservative treatment (six patients), and prospectively followed. Early mortality rate was 7.5%, while long-term follow-up is still to be announced.

Conclusions: This kind of database will contribute to better knowledge concerning presentation, risk factors and results of open, endovascular and conservative treatment of PAU, giving us milestones for further investigations in the future.

V6-2 ROLE OF TEMPORARY REPERFUSION FOR KIDNEY ISCHEMIA DAMAGE PREVENTION IN A RAT MODEL

M. Piazza, S. Bonvini, M. Menegolo, M. Antonello, L. Ferretto, E. Molon, G. Deriu, F. Grego

Clinic of Vascular and Endovascular Surgery, Padua University, Padua, Italy

Objectives: Renal insufficiency after thoraco-abdominal surgery significantly increases morbidity and mortality. During thoraco-abdominal surgery, blood flow to renal arteries must be interrupted for a period of time longer than the threshold for irreversible renal ischemic injury. The aim of the study was to analyse the results of temporarily re-established blood flow into the renal arteries for 3′ after varying intervals of occlusion in prevention of RI and ischemic-reperfusion injury using an animal model.

Methods: In Sprague-Dawley male rats, both renal arteries were selectively cross-clamped producing the complete tissue ischemia, using microsurgical techniques. In the Group A, continuous ischemia for control group was made from 30′ to 90′; in the Group B – two ischemia periods (30′ interrupted by one 3′ reperfusion); in Group C – three ischemia periods (30′ interrupted by two 3′ reperfusion); in Group D – two ischemia periods (45′ interrupted by one 3′ reperfusion). Renal function was assessed by plasma creatinine and urea level at 24 h and 48 h after surgery. After sacrifice, histological and electronic microscopy analysis were performed in all rats for both kidney.

Results: In Group A irreversible renal tissue lesions appear after 60′ ischemia. In Group B irreversible lesions did not appear after 60′ ischemia. In Group C a total ischemia time of 90′ showed irreversible ischemic lesions. Group D showed less ischemic-reperfusion lesions than group C.

Conclusions: Kidney reperfusion of 3′ can protect renal tissue from warm clamping ischemia (until 60′) without irreversible lesions evidence. Prolonged clamping ischemia (until 90′), seems to be safer in case of a single 3′ reperfusion period after 45′ ischemic time, than in cases of multiple reperfusion with shorter ischemic time.

V6-3 DOES STENTGRAFT IMPLANTATION IMPROVE THE PERFUSION OF LOWER LIMBS?

B. Solonynko, Z. Galazka, T. Jakimowicz, J. Szmidt

Medical University of Warsaw, Warsaw, Poland

Objective: Stentgraft implantation is the method of choice in treatment of abdominal aortic aneurysm (AAA) in patients with high operative risk. In some of them coexisting atherosclerotic lesions of iliac arteries and lower extremity ischemia are observed. The aim of this study was to assess the influence of stentgraft implantation on the lower limb perfusion in patients with AAA and coexisting atherosclerosis in the ilio-femoral segment.

Methods: Since 1998 in the Department of General, Vascular and Transplant Surgery of Medical University of Warsaw, 928 patients were treated endovascularly for abdominal aortic aneurysm. The study group consisted of 100 consecutive patients with AAA and preoperative ankle-brachial index (ABI) below 1.0. Patients with inflammatory, ruptured and false aneurysms as well as those who required additional intraoperative procedures (e.g. endartherectomy, stenting, vascular bypass) or uniiliac devices were excluded from the study. Perfusion disorders occurred in 154 lower extremities. The atherosclerosis was considered to be the cause of ischemia in all cases.

Results: ABI was estimated at the first week and after six months postoperatively. The significant increase of ABI (for at least 0.1) in the first week after stentgraft implantation was observed in 57 of 154 limbs (37.0%). In 31 (20.1%) of them it reached 1.0 and in the remaining 26 (16.9%) extremities the improvement ranged from 0.1 to 0.3. A durable increase was found in 49 of 57 (86.0%) lower limbs at the sixth month. In 8/154 (5.2%) cases the decrease of ABI value was observed, but only in three of them it reached the preoperative level.

Conclusions: Endovascular repair of AAA in patients with atherosclerosis in the ilio-femoral segment may improve the perfusion of lower limb. The probable reason of this phenomenon is the dilatation of the iliac arteries by means of the introducer sheet and stentgraft itself.

V6-4 ENDOVASCULAR ANEURYSM REPAIR: EXPERIENCE OF 12 YEARS IN A SINGLE INSTITUTION

D. Mazzaccaro, A.M. Settembrini, G. Malacrida, S. Stegher, M.T. Occhiuto, F. Sorba, D.G. Tealdi, G. Nano

Università degli Studi di Milano, Ist Unit of Vascular Surgery, IRCCS Policlinico S. Donato, San Donato Milanese, Italy

Objective: In the last 10 years endovascular repair has proved to be an alternative to open surgery for the treatment of abdominal aortic aneurysms. Early and mid-term results for EVAR are known throughout the literature, otherwise long-term results have been published recently. We report our experience in the last 12 years evaluating early and long-term results of applying this technique.

Methods: From January 1998 to June 2010, 494 of 1237 patients (39.9%) underwent EVAR in our centre for an abdominal aortic aneurysm. Most EVARs were performed on males (92.9%). Patients’ median age was 73 years (range 49–91 years). All procedures were performed by experienced Vascular Surgeons in Operatory Room with anesthesiological assistance. After the procedure, patients were routinely followed-up at two months with a duplex ultrasound, at six months with a contrast-enhanced CT-scan, then at 12 months and every year with a duplex ultrasound. Median follow-up was 68 months (range 1–144 months). Data were collected about perioperative and long-term cardiac and renal complications, thrombosis, surgical conversions, endoleaks, death and death from aortic rupture. All data were analysed using Sigma Stat 3.0.

Results: The procedure was successfully ended in 488 patients (98.8%). Immediate surgical conversion was necessary in six patients (1.2%) for acute thrombosis of the graft (one patient), rupture of iliac artery (2), incomplete opening of the graft (3). At 30 days we observed six deaths (1.2%), 12 acute renal failures (2.4%), three graft thrombosis (0.6%) and six (1.2%) myocardial infarction (MI). Long-term results were collected on 391 patients (81.1%). We observed five MI (1.2%), 10 chronic renal failures (2.5%), eight graft thrombosis (2.0%), 77 deaths (19.7%), 31 type I endoleaks (7.9%), 12 type II endoleaks (3.0%), three type III endoleaks (0.7%). There were not any type IV, V nor VI endoleaks. Reintervention was necessary in 45 patients (11.5%); eight of them (2.0%) were late surgical conversion, all within 60 months from the first intervention. Aortic rupture occurred in five patients (1.2%), three of them were fatal. At 144 months 32.8%+4.4% of patients were alive and free from any major adverse events, 5.2%+5.6% of patients were alive, 97.5%+1.1% were free from aortic rupture and 65.4%+5.4% were free from graft-related complications.

Conclusions: In our experience EVAR was safe and effective both at early and at long-term results, especially in relation to the prevention of late aortic rupture and aneurysm-related mortality, which are the main outcomes of endovascular treatment.

V6-5 ARTERIOVENOUS FISTULAS FOR PERMANENT VASCULAR ACCESS IN CHILDREN WITH RENAL INSUFFICIENCY

I. Nurmeev, D. Osipov, L. Mirolubov

Kazan State Medical University, Kazan, Russian Federation

Objective: Chronic hemodialysis treatment is indicated in case of renal insufficiency. Hemodialysis procedure requires permanent vascular access usually. Arteriovenous fistulas can increase venous blood flow volume velocity, up to necessary level. Study of our long-term experience of permanent vascular access in children with renal insufficiency.

Methods: From 1997 to 2010 years, 43 arterial-venous shunting procedures were performed in 32 patients with renal insufficiency. Seventeen boys and 15 girls from 3 years to 21 years (on average 14±0.47 years). Computer program in QuickBasic4.5 enabled us to perform experiments routinely with the use of special designed algorithm for each patient.

Results: Initial arterial-venous fistulas were formed on lower third of forearm. Cephalic vein and radial artery end-to-side anastomoses in forearm were performed in 14 cases on left side and in nine cases on right side. Cephalic vein and radial artery end-to-end anastomoses in forearm were performed in eight cases on left side and in three cases on right side. Second potential level for a shunting was in cubital fossa. Anastomoses between cephalic vein and brachial artery and between basilic vein and brachial artery were performed in seven cases on the left side and in three cases on the right side. It is known that cephalic vein and radial artery end-to-side and end-to-end anastomoses on non-dominant hand are the most favourable variants. Fistula care in early and late postoperative period is very important. Adequate haemodynamic surgical procedures were theoretically substantiated based on results of computing experiments. Routine estimations were done for each patient since the year 2010. Anastomoted vessels diameters were: veins – from 1.5 to 4 mm (average 1.8±0.2 mm) and arteries – from 1.5 mm tо 4 mm (average 2.8±0.13 mm). Typical causes of permanent vascular access function termination were early or late intravascular thrombosis usually. Incidence of reinterventions is in inverse correlation with diameter of vessels. Reinterventions in case of early shunt thromboses were performed in three cases. Reconstructions of fistulas were performed in three cases. Fistula constriction – one case.

Conclusions: The main difficulty of arteriovenous shunting procedures in children is minor diameter of vessels. Maximal rate of successful results was in proximal shunts group. Results of arteriovenous shunting procedures also depend of age and fistula care in early postoperative period. Mathematical simulation with computer programs make it possible to calculate hemodynamic effect of operation routine, individually for each patient.

V6-6 METHODS OF MODELING OF TRANSABDOMINAL MINI-ACCESS TO AORTA WITH HELP OF MULTISPIRAL COMPUTER TOMOGRAPHY

R.V. Sultanov¹, G.K. Zaloev², A.M. Putintsev¹, S.V. Moshneguts³, V.A. Lutsenko¹, V.N. Sergeev¹

¹Department of Vascular Surgery of Kemerovo Regional Clinical Hospital, Kemerovo, Russia; ²The Center of After Treatment of Invalids, Novokuznetsk, Russia; ³Department of Computer Tomography of Kemerovo Regional Clinical Hospital, Kemerovo, Russian Federation

Objective: In the literature there is only some information about orientation of mini-access to aorta with help of an ultrasonic method of research and a computer tomography. In this situation additional methods of research become an important part of operative treatment. However, the methodology of modeling of access was not found in the studied literature. The objective of the research is to work out the method of modeling of mini-access to aorta, to study the possibility of usage of computer tomography for modeling mini-access to aorta.

Methods: Since 2005 until 2010 in Department of Vascular Surgery of Kemerovo Regional Clinical Hospital 57 reconstructive operations in aorta-femoral zone were performed with help of a hardware complex ‘mini-assistant’. The analysis of results showed high percent of conversion (15%). The main cause of conversions was inadequate length or position of skin incision, inappropriate to a level of the basic object of the operation, namely to the site of aorta which is suitable to form proximal anastomosis. In 2009–2010 in connection with high percent of conversion, there was developed methodology of modeling of mini-access and successfully introduced in 13 cases. This procedure is technically simple and does not require any additional equipment. Localization and the size of the skin incision was defined by results of preoperative measurements of MS-CT. Besides, there was possibility not only to detect aorta’s involvement, but also to predict possibility of mobilization of the left renal artery and aorta’s bifurcation from a certain skin incision of the concrete patient.

Results: In the group with preoperative MSCT-angiography operative treatment passed according the beforehand generated plan, without dilatation and conversion of access. The usage of three-dimensional reconstruction according to MSCT-angiography allows to model and optimize the access depending on a degree of atherosclerotic variations and individual anatomic features of the patient. Also it is possible not only to correct the lengths, but also a position of an incision of a front abdominal wall that is necessary for comfortable manipulations on the certain site of aorta. Thus, this methodology helps to reduce the number of cases of conversions and so traumatism of interventions.

V6-7 THE COMBINATION OF MOBILIZATION AORTA BY ‘SUITCASE HANDLE’ TECHNIQUE AND THE OPERATION OF PROXIMAL ‘LOCAL PROSTHESIS’ IN SURGERY OF TYPE B AORTIC DISSECTION

N.Yu. Stognii

Russian Academy of Medical Sciences National Research Center for Surgery named by academician B.V. Petrovsky, Moscow, Russian Federation

Objective: To appraise the results of treatment at the operation of aorta proximal ‘local prosthesis’ in combination with ‘suitcase handle’ technique in surgery of B type aortic dissection.

Methods: Sixty-five patients which underwent the operation since 1995 until 2010. The patients of first group (n=34) were accomplished prosthesis of the aorta from isthmus up to Th 5–10 with suturing or ligation of spinal arteries at the level of reconstruction – proximal aortas ‘local prosthesis’. The approach: thoracotomy by 3–5 intercostal space. The following aorta mobilization techniques were used: 1. suturing of the spinal arteries from the inside of aorta after aortotomy; 2. suturing or ligation the spinal arteries by the clips before aortotomy using ‘suitcase handle’ technique; 3. coagulation of the spinal arteries by ‘LigaSure’ apparatus. The second group included the patients (n=31), which were performed the operations: prosthesis of the aorta from distal section of descending thoracic part up to bifurcation of the aorta with proximal cobra-shaped anastomosis at the level of visceral arteries and total prosthesis of thoracoabdominal aorta.

Results: The patients of the first group were noted significantly less operation duration (342.0±12.7 min) in comparison with second group (411.2±25.8 min). Both intraoperative blood loss and blood loss by drains in the first days after operation in the first group were significantly smaller than in the second group (intraoperative blood loss 2731.8±200.2 ml vs. 5067.6±976.3 ml, P=0.016, t=2.76; blood loss by drains in the first days after operation 417.2±35.0 ml vs. 608.9±80.5 ml, P=0.015, t=2.52). The amount of postoperative bed-days in the first group of patients was far less than in the second one (19.2±2.2 vs. 27.7±6.4). The aorta mobilization by ‘LigaSure’ apparatus reduces intraoperative blood loss up to 2311.4±17.5 ml. In the patients with B type aortic dissection the mortality when using proximal ‘local prosthesis’ of the aorta in combination with ‘suitcase handle’ technique amounts to 5.7±3.9% in comparison with the same in second group equal to 22.6±7.5% (t=1.99, P=0.0508).

Conclusions: The aorta mobilization using ‘suitcase handle’ technique in combination with proximal ‘local prosthesis’ of the aorta in surgery of distal aortic dissections has the significant advantage compared to prosthesis of the whole thoracoabdominal section of aorta.

V6-8 RESVERATROL MODULATES SYSTEMIC AND PERIVASCULAR INFLAMMATION IN EXPERIMENTAL ABDOMINAL AORTIC ANEURYSM

N. Rousas, B. Pane, G. Spinella, D. Palmieri, C. Barisione, S. Garibaldi, G. Ghigliotti, D. Palombo

San Martino University Hospital, Genoa, Italy

Objective: Abdominal aortic aneurysm (AAA) is related to chronic mural inflammation in which activation of the Renin-Angiotensin system (RAS), infiltration of mononuclear phagocytes and other leukocytes contribute to proteolytic activity, aortic tissue damage and AAA expansion. Resveratrol is a natural antioxidant polyphenol with vasoprotective properties. In this study, we evaluated the effects of Resveratrol on the inflammatory response in an experimental model of elastase-induced AAA.

Methods: Out of 30 male Sprague-Dawley rats subjected to elastase infusion AAA induction, 15 received Resveratrol (seven days before and 14 days after elastase-induced damage) and 15 received vehicle alone. At the time of sacrifice, blood was collected for monocytes and serum protein analysis. Aortas were removed and subjected to histology and immunohistochemistry for morphological analysis.

Results: Circulating levels of CD143 (ACE) monocyte surface expression, which promote local RAS activity, and of CD62L-monocyte subset, which is involved in the innate immune response, decreased in Resveratrol-treated rats, when compared to untreated animals. MMP-9 plasma activity and TNF serum levels, which showed a positive correlation, respectively, with CD143 monocyte expression and circulating CD62L-monocytes, were lower in Resveratrol-treated than in untreated rats. Similarly, vessel wall of Resveratrol-treated rats displayed fewer macrophages and a reduction of MMP-9 expression.

Conclusions: Resveratrol is an anti-inflammatory compound acting at both circulating and tissue level in the experimental model of elastase-induced aortic lesion; Resveratrol ability in reducing immune response and proteolysis could be of great relevance to improve inflammation in AAA patients, both for patients with small aortic aneurysms, to limit the aneurysm progression, as well as for the management of large aneurysms, which require surgical repair, to modulate the inflammatory response.

7th Vascular Surgery Session – Moderated Posters III May 21, 2011 14:30-16:00

V7-1 STRATEGY OF TREATMENT of THE CONGENITAL ARTERIO-VENOUS FISTULAS

A.D. Gaibov, A.N. Safarova, A.N. Kamolov

National Scientific Centre of Cardiovascular and Thoracic Surgery, Cathedra of Surgical Diseases of the Medical State University, named Abualy ibn Sino X Dushanbe, Tajikistan

Objective: Choose the optimal surgical method for patients with congenital arterio-venous fistulas of the limbs.

Methods: Data were collected from 18 patients with Parks-Veber-Rubashev disease from 2005 to 2009 at the department of vascular surgery. There were three cases with macrofistular form of the lower limbs and 15 with macrofistular. The age of the patients varied from 9 to 28 years. The investigation of the patients included clinical symptoms, ultrasound dopplerography (18), duplex scanning (13), rentgenography (8), computer tomography (2), magnetic-resonance tomography (1), angiography (18).

Results: Surgical treatment in congenital vascular malformations depended on the area of affected limb, on the stage at which closed anatomic structures of involving, the form of the malformation (venous, arterial, lymphatic, combined) and the angiographic image of pathology. In four cases of the macrofistular form combining with gigantism syndrome, counting up the hypervascularisation (owing to the multitude arterial branches), endovascular embolisation pathologic arterial branches were made in the first stage and skeletisation of another arterial segments in the second. Eleven patients undertook the two-stage embolisation: in the first stage the branches of femoral artery, while in the second stage the branches of poplitea and tibialis were embolised. The ligation of arterio-venous fistulas over the extent and in the area, their connection with veins was shown under the macrofistular forms (3). In one case macrofistular form was presented with angiomatose of the knee joint, therefore the ligation of arterio-venous fistulas with the dissection of aneurysmaticallly increased vessels of this area was conducted. Postoperative period followed without complications. The development of the pathology was not commended. Decrease of swallowing and muscular tension was recorded in 15 cases, liquidation of systolic tremble and sound in all patients.

Conclusions: The selection of the method the surgical treatment of congenital vascular malformations depended on the form of pathology and angioarchitectonic of affected area. Endovascular embolisation of supplementary sources of vascularisation of the limb was the alternative method of the protracted operations, that allowed successfully enough and traumaticless treat the patients with congenital vascular malformations. Combination of this method with the traditional skeletisation of magistral arteries rather improve the treatment.

V7-2 SURGICAL TREATMENT OF IATROGENIC LESIONS OF GREAT VESSELS DURING THE PLACEMENT OF HAEMODIALYSIS CATHETERS

Z. Galazka, T. Jakimowicz, J. Szmidt

Medical University of Warsaw, Warsaw, Poland

Objective: Important indication for percutaneous great vessels cannulation is vascular access for haemodialysis. But this kind of treatment can be associated with the risk of iatrogenic vessels lesions. The aim of the study is presenting the experience with the treatment of great vessels lesions done during the placement of vascular access catheters.

Methods: During the last two years in our department there were three dialysis dependent patients (two female and one male) age 51–70 years, who had during implantation of the haemodialysis catheters in another hospital lesions of: internal jugular vein (one patient); subclavian vein (one patient); origin of the common carotid artery (one patient).

Results: The diagnosis was confirmed with angio-CT-scan. Operative access has been achieved by sternotomy and destroyed vessel was primarily sutured after previous catheter removal. In addition in two cases mediastinal hematoma was drained. No patient had postoperative complications. Temporal haemodialysis access was achieved by femoral vein cannulation.

Conclusions: Lesion of the great vessels during haemodialysis catheter placement is a serious complication, the treatment can require sternotomy. Catheter placement under ultrasound guidance could probably avoid such complication.

V7-3 VASCULAR COMPLICATIONS IN RENAL TRANSPLANTATION: DIAGNOSIS AND TREATMENT. RETROSPECTIVE ANALySIS OF DATA FROM THE FOLLOW-UP OF 650 RENAL TRANSPLANTATIONS

M. Martelli, D. Moniaci, P. Stratta, R. Cassatella, A. Renghi, M. Aronici, P. Brustia

Ospedale Maggiore della Carita, Novara, Italy

Objective: The aim of this study was to evaluate the incidence of vascular complications in kidney transplant patients, to describe the diagnostic methods, the treatments performed and possible treatment complications.

Methods: We decided to include all 650 patients who had undergone a renal transplantation at our Centre (1998–2008); thus, we enrolled the recipients of single/double cadaveric transplantation (632) and the recipients of transplantation from living donors (18).

Results: In the analysis of the results we divided the complications in premature (<30 days) and delayed (>30 days). Among the premature complications there were 35 cases of perirenal hematoma, seven post-biopsy arteriovenous fistulae (AVFs), 30 cases of lymphocele, five cases of renal artery stenosis, four cases of renal vein thrombosis, one case of ipsilateral external iliac artery thrombosis, two cases of ipsilateral deep vein thrombosis (DVT), and one case of polar artery obstruction. Among the delayed complications there was one case of post-biopsy AVF treated by endovascular embolization, 11 cases of renal artery stenosis, and two cases of claudicatio intermittens.

Conclusions: Overall, an incidence of steno-obstructive complications (considered as serious and which possibly put patients’ life at risk) of 3% was emphasized. If we add less serious complications (lymphocele, post-biopsy AVF, DVT), a complication rate of about 10% was found out. In concordance with data from literature, we can conclude that kidney transplant is a safe therapeutic procedure for the treatment of end-stage chronic renal failure; however, vascular complications can still cause significant clinical problems.

V7-4 IMMEDIATE AND LATE RESULTS OF SURGICAL TREATMENT OF JUGULAR VEIN ANEURYSMS

S.I. Pryadko, A.A. Malinin, A.S. Rimsha

Bakoulev Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: The purpose of the study is to estimate efficiency of surgical interventions in patients with jugular vein aneurysms.

Methods: From 1970 to 2010, 159 patients with aneurysms of an internal jugular vein were observed, 113 of the patients were treated surgically. Among 21 patients diagnosed with aneurysms of the external jugular vein, seven patients were operated. The age of patients ranged from 2.2 to 61 years old. Diameter of jugular vein aneurysms was from 26 to 78 mm. The main clinical manifestation of jugular vein aneurysms was the presence of tumor like formation which increases in size when laughing, coughing in the projection of the great veins of the neck. Preoperative diagnostics was conducted with Ultrasound Duplex Scanning, Transcranial Dopplerography, phlebography, magnetic resonance and computer tomography. The indication for surgical treatment was the presence of an aneurysm, the diameter of which exceeded that of an unchanged vein segment twice. Ultrasound scanning and CT angiography were performed afterwards, this allowed the estimation of the character of blood flow, condition of the reconstruction site and function of the venous valve.

Results: The method of operation depended on aneurysms localization, sizes, condition of jugular vein valves and patient’s age. Type of operations performed in patients with internal jugular vein aneurysm: in 47 cases, circular resection, in 59 cases, resection of the aneurysm with the strengthening of the walls of vein-type ‘clutch’ (duplication of the walls of the aneurysm), aneurysmoraphy with side grafting and in four cases, aneurysms resection with reconstruction of the venous valve. In external jugular vein aneurysms resection, a ‘end-to-end’ anastomosis was used in four cases, resection with ligation in two cases. All patients after operation had laminar type of venous blood flow. Long-term results from one year until 25 years were investigated in 87 operated patients. There was no recurrence of jugular vein aneurysm or thrombosis, cyanosis and swelling of the face, increasing venous pattern of the neck established. No death and significant complications occurred.

Conclusions: Surgical treatment of jugular vein aneurysms improves venous outflow from a brain, prevents thrombotic and other significant complications.

V7-5 LONG-TERM RESULTS EVALUATION OF OPERATIVE TREATMENT OF PATIENTS WITH CHRONIC VENOUS INSUFFICIENCY OF LOWER EXTREMITIES

S. Katorkin

State Medical University, Samara, Russian Federation

Objective: To improve long-term results of operative treatment of patients with chronic venous insufficiency of lower extremities by use of biomechanical methods of functional diagnostic.

Methods: With the aim of complex functional diagnostic of venous and musculoskeletal system conditions were used: Dopplerography and Doppler mapping, podometry, goniometry, plantography, X-ray and optical projecting computer investigation of bearing, functional electromyography. Four hundred and twelve patients aged 18–85 years (mean age – 51.5±12.5 years) with chronic venous insufficiency C3–C6 class of CEAR were examined. One hundred and sixty-four of them (36.3%) are men and 288 (63.7%) are women. Most of them have been ill for more than five years. The life quality of patients in long-term postoperation period was analyzed with the help of questionnaire ‘SF36 Health Status Survey’.

Results: The results of examination of patients (C3-C6) showed that 56% have scoliosis, 28% – osteohondrosis, 89% – dysfunction of foot configuration, 45% – osteoarthritis. The most evident pathology of musculoskeletal system have patients with active trophic changes of soft tissues of lower extremities. Were noted pathological changes of internal temporary structure of step cycle and lowering locomotion, especially in ankle joint. There is a physiological reaction of unloading of affected extremity with pathological displacement of gravity (C3-C4a) projection centre. In C4b-C6 – there is an overwork of affected extremity. In early term postoperation period was noted the increase of life quality coefficient. Were also increased physical functioning and role-physical functioning, general health and vitality. But 6.24% patients remained with pain which was before operation, and also convulsive syndrome. In long-term period the amount of patients with pain syndrome was decreased, and was only 2.3%. The sense of heaviness, which appears during heavy physical activity, had 3.85% patients. Edema of distant part of lower extremities had 2.8% of patients, and 4.9% kept convulsive syndrome. In long-term postoperation period index of life quality is staying rather low in comparison with healthy people. From our point of view, the appearance of complaints and low life quality coefficient of part patients in long-term postoperative period is thought to be because of concomitant pathology musculoskeletal system. An absence of adequate treatment is the main reason of life quality decrease.

Conclusions: Rehabilitation programs before and after operation should be used to stimulate muscle system of lower extremities, recovery amplitude locomotion, liquidation of pathological walk and work on feedback principle.

V7-6 NEAR INFRARED SPECTROSCOPY AS AN INDEX OF CEREBRAL PERFUSION DURING HYBRID REPAIR OF A COMPLEX AORTIC ARCH ANEURYSM

L. Biasi, T. Tecchio, B. Salamousas, M. Azzarone, A. DeTroia, P.F. Salcuni

University of Parma, Parma, Italy

Objective: Traditional surgical repair of thoracic arch aneurysms carries an attendant risk of significant morbidity and mortality precluding certain patients from undergoing open surgery. Hybrid open and endovascular repair has evolved as a less invasive treatment option for high-risk patients but stroke and spinal cord ischemia remain frequent complications (up to 25% and 4%, respectively). The brain is the primary target of general anesthetics but is still the least monitored organ in clinical anesthesiology. Near infrared spectroscopy provides non-invasive continuous real-time monitoring of the adequacy of cerebral perfusion. We present a case-report and an extensive review of the current use, limitations and confounders of NIRS devices.

Methods: A 77-year-old man was admitted with a large aortic arch aneurysm <1.5 cm distal to the innominate artery. He had previously undergone a successful open repair for ruptured AAA complicated by cardiac arrest and bilateral pulmonary embolia. Simultaneous surgical-endovascular procedures were performed, with endograft deployment in Proximal Landing Zone-O (two overlapped Valiant-Medtronic-stent grafts) proceeding immediately after supra-aortic-debranching (16-8 mm Dacron graft to the innominate artery and left CCA). Cerebral oxygen saturation was monitored by Somanetics INVOS 4100 during surgery and for two postoperative days until discharge from intensive care unit.

Results: Final biplanar completion angiography documented the successful exclusion of the TAA with secure proximal and distal fixation. Basal right-INVOS values ranged from rSO₂ 68 (left) to 60 (right), defining values lower than 55 as index of hemispheric desaturation. INVOS parameters correlated with consecutive vascular clamp: partial occlusion clamp of the innominate artery determined a drop of the right-INVOS values from 60 to 54; left-CCA clamping determined a drop of left-INVOS values from 60 to 45. Values turned promptly normal after declamping. Endovascular graft deployment in PLZ-0 made the left-INVOS values drop from 64 to. Discrepancy in the final values between right and left were observed (58–60 vs. 64–68) seemingly due to the left-subclavian stealing syndrome. No neurological deficit has been recorded.

Conclusions: Continuous monitoring of cerebral oxygenation using NIRS can guide optimal perfusion strategies in aortic arch surgery. It allows detection of clinically significant modification of regional cerebral blood flow preventing neurologic sequelae. Brain damage is related to both the extent and the duration of the drop in rSO₂. Cerebral oximetry sensors have also been demonstrated to detect progressive spinal cord ischemia. Limits are the relative sensitivity and specificity of such devices vs. other monitoring modalities.

V7-7 HYBRID SURGICAL INTERVENTIONS IN THE CASE OF MULTILEVEL DAMAGES OF BRACHIOCEPHALIC ARTERIES

V. Starodubtsev

Novosibirsk Research Institute of Circulation Pathology named by Meshalkin, Novosibirsk, Russian Federation

Objective: To clear out the question about the prescriptions of the hybrid surgical interventions and to value their effectiveness for brachiocephalic arteries when patients suffer from the cerebrovascular insufficiency.

Methods: In our investigation 14 patients, who came through the hybrid surgical interventions on brachiocephalic arteries in 2008–2010, have been included. Among them there were 10 men and four women. The average age of the patients is 59±6.5 years. In all cases the reason of the occlusive damages of the arteries is atherosclerosis.

Results: In 10 cases the stenting of the stenosis of the left common carotid artery in the combination with the carotid endarterectomy (in eight cases with the use of the eversion technique because of the presence of the pathologically kinking left internal carotid artery) was performed. In three cases the carotid endarterectomy of the right internal carotid artery in the combination with the stenting of the critical stenosis of the brachiocephal trunk was performed. One patient with the multilevel stenosis of the left internal carotid artery in the combination of the pathological kinking was made the stenting of the distal stenosis in the combination with the eversion carotid endarterectomy. In one case the patient who had a stroke, after stenting left common carotid artery had mixed conscience and the weakness of the right side of the body (the index of the retrograde pressure was 0.4) during the carotid endarterectomy. The operation was performed according to the ‘classical’ technique, Pruitt-Inahara carotid shunt was used and neurologic problem was solved. During the early postoperative period neurologic problems were not registered. Local neurologic complications, such as damages of the hypoglossal nerve were registered in one case because of the high-level of the pathological kinking. Other complications after hybrid surgical interventions were not registered.

Conclusions: 1. The critical stenosis of the brachiocephalic trunk and common carotid artery in the combination with the critical ipsilateral stenosis of the internal carotid artery can be regarded as a prescription for hybrid surgical interventions. 2. The usage of hybrid surgical methods give more wide possibilities for effective elimination of multilevel critical stenosis of brachiocephal arteries by means of standard operative access to the bifurcations of common carotid artery.

V7-8 SURGERY IN ATHEROSCLEROTIC LESIONS OF THE RENAL ARTERIES

A. Mamyrbaev, V. Arakelyan, E. Tutov

Bakoulev National Center for Cardio-Vascular Surgery, Moscow, Russian Federation

Objective: To evaluate the results of the surgical reconstruction of renal arteries with atherosclerotic lesions.

Methods: One hundred and fifty procedures for atherosclerotic lesions of renal arteries were analyzed. In 95 cases (63.3%) transaortic endarterectomy was performed, in 32 cases (21.3%) – resection with renal arterioplasty and bypass was carried out. Seven (4.7%) patients underwent renal artery decompression and nine (6%) had nephrectomy. Epinephrectomy was performed in seven (4.7%) patients. Seventy-three (48.7%) superior/inferior diaphragmal splanchganglionectomies as individual surgery or in addition to other reconstructive operations were carried out. In 15 (10.2%) patients concomitant aortofemoral bypass was performed.

Results: Positive clinical effect was observed in 139 (92.7%) patients. In 10 (6.7%) patients arterial hypertension remained, but signs of renal failure significantly decreased. One patient (0.7%) died of acute left ventricular failure.

Conclusions: Timely performed surgical reconstruction allows to decrease significantly blood pressure and signs of renal failure in patients with atherosclerotic renovascular disease.

V7-9 ENDOVASCULAR TREATMENT OF PATIENTS WITH RENOVASCULAR HYPERTENSION

A. Mamyrbaev, V. Arakelyan, K. Petrosyan

Bakoulev National Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Assessment of outcomes of endovascular intervention in patients with renovascular hypertension.

Methods: Results of 114 consecutive endovascular interventions performed in 101 patients with renovascular hypertension were evaluated: 60 angioplasties with stent implantation and 54 angioplasties without stenting. Seventy-six patients (75.2%) were male and 25 patients (24.8%) – female. Mean age was 55±9.7 years. Ninety-three patients (92%) had atherosclerotic origin of the renal artery stenosis, six patients (5.9%) had aortoarteritis, and two (2%) patients had fibromuscular dysplasia. All patients underwent diagnostic aortography prior and up to one month after the intervention.

Results: According to aortography, there were revealed significant decrease of intraaortic systolic BP from 182.12±36.2 mmHg to 134±15.87 mmHg (P<0.0005) and diastolic BP from 125±33.21 mmHg to 80.54±14.68 mmHg (P<0.0005). Renal artery residual stenosis was 14.45±5.89% after stenting and 20±10.02% after the angioplasty. Immediate angiographic success was 100%. Positive clinical effect was demonstrated in 98 (97%) patients.

Conclusions: Endovascular interventions are an effective treatment of patients with renovascular hypertension.

V7-10 ANALYSIS OF HEMODYNAMIC CHANGES AND CLINICAL SYMPTOMS IN PATIENTS WITH PATHOLOGICAL CAROTID ARTERY KINKING

A.V. Gavrilenko, A.V. Abramyan, A.V. Kuklin, I.I. Omaryanova, E.F. Dutikova, S. Myo, S.E. Savchenko

Russian Scientific Centre of Surgery named after Academician B.V. Petrovskii, Moscow, Russian Federation

Objective: To study the hemodynamic important of pathological carotid artery kinking (PCAK) and detection of indication for surgical treatment for the patients who have pathology.

Methods: Observation of 75 patients with PCAK within the period from 1996 to 2009. Age from 35 to 80 years, men – 56 (74.7%) and women 19 (25.3%). Asymptomatic – 24 (32%) patients, symptomatic – 51 (68%). TIA in 38 (74.5%) patients, from them with C- and S-shaped bending – 27, with kinking 11. Encephalopathy – in eight (15.7%) with C- and S-shaped bending. Stroke – in five (9.8%) patients. Operations were performed in 53.2%: resection of ICA with auto vein graft – 27.3%, resection with anastomosis – 14.3%, arteriolis – 5.2%. Detection of dynamical character of blood flow with Colour Doppler and spiral CT.

Results: In intermediate postoperative period in symptomatic patients: Vps of ICA in the tortuous zone 1.6±0.05./s before operation, 0.75±0.03./s (P<0.05) after operation; blood flow in ICA was turbulent flow before operation and after operation - laminar flow; index of resistance (IR) in tortuous ICA was 0.89±0.07, postoperation – 0.61±0.03 (P<0.05). In asymptomatic patients: Vps in the tortuous ICA preoperational period 1.45±0.05./s, after operation – 0.67±0.03./s (P<0.05); blood flow in ICA was turbulent flow before operation and after operation - laminar flow; index of resistance (IR) in tortuous ICA was 0.87±0.07, after operation – 0.58±0.03 (P<0.05). In long-term period (after operation five years), symptomatic and asymptomatic patients maintain normal blood flow and IR in ICA compared with preoperative period. Clinical analysis after operation show positive dynamic effect in neurological status in intermediate and long-term period. In intermediate period of symptomatic patients group, 84.2% become asymptomatic, cessation of symptoms of patients who had II and III stage CVI, in asymptomatic group 95.2% maintain asymptomatic period. In long-term period positive dynamic was maintained – 79.9% asymptomatic patients in group of before operative symptomatic patients and in preopetative asymptomatic patients group, symptoms were not observed in 81.8% of patients.

Conclusions: Indications for surgical treatment in patients with PCAK depend on the symptoms of patients who have hemodynamic changes. Surgical correction of pathological carotid artery kinking is prevention for ischemic stroke.

V7-11 THE ROLE OF ACUPUNCTURE IN PREPARATION FOR CAROTID INTIMECTOMY (CASE SERIES)

Y.E. Shnaider¹, M.G. Tutova¹, M.V. Tardov²

¹Hospital #15, Moscow, Russian Federation; ²MNPCO, Moscow, Russian Federation

Objective: Cerebral accidents take now one of the first places as a reason of persistent disability. Main accent in primary and secondary prophylaxis of the stroke is made on antiplatelet and anticholesterol therapy, but in case of clinically significant artery narrowing carotid intimectomy becomes the most important ischemic prevention measure. Possibility of surgical procedure depends on the degree of vascular compensation, which often cannot be restored up to the safe level. Potential of acupuncture in improving the intracranial blood flow has not been estimated yet and that warranted the goal of our work: determining of acupuncture influence on cerebral ischemia tolerance in patients with significant cerebral arteries stenosis before intimectomy.

Methods: Ultrasound study of extra- and intracranial arteries with carotid compression test was managed in 13 patients of 49–59 years old. All of them were in-patients before carotid intimectomy because of significant narrowing in both carotid systems. Included in the study were persons, who could not stand compression test for more then 60 s – critical index for decision-making about surgery opportunity – before course of traditional medicinal therapy and after it. After that part of treatment acupuncture procedures on the author’s method were conducted with subsequent ultrasound investigation of cerebral flow. Linear velocities of blood flow in medial cerebral artery were measured before and after compression of ipsilateral common carotid artery, as well as compression tolerance duration.

Results: After the course of acupuncture nine patients tolerated carotid compression for more than 60 s and were successfully operated with fast rehabilitation; growth of collateral cerebral flow velocity for 1.5–2.7 times after acupuncture was registered. In the other three patients two-time flow increment was noted with 1.5–2.0 time gain of compression test tolerance. The only one man with atrial fibrillation, untreated before hospitalization, had no changes in cerebral flow. This phenomenon can be related to multifocal cerebral lesion, involving all the main vascular systems and causing low tolerability of hypoxic events by brain tissue.

Conclusions: Our data show improvement of quantitative indices, characterizing cerebral circulation, after the course of acupuncture to the grade, allowing implementation of intimectomy in patients, in whom medicinal treatment was not successful enough to tolerate carotid compression test. Continuation of the studies of cerebral flow changes and their mechanisms after acupuncture is needed.

V7-12 CHOICE OF ANESTHESIA METHOD, MONITORING AND INTERVENTION TYPE IN PERFORMING THE CAROTID ENDARTERECTOMY

M.H. Shakirov, N.A. Likhacheva, S.G. Sukhanov

Perm Heart Institute, Perm, Russian Federation

Objective: To assess choice of method of anesthesia and type of intervention during performing of carotid endarterectomy (CEAE) aiming to provide adequate prevention of perioperative and long-term specific complications.

Methods: Heart Institute has experience of more than 3500 CEAE patients with atherosclerosis. Study included 307 patients, operated from 2007 to 2009 (excluding patients with combined – stenosis and pathological tortuosity – lesions). Surgical approach was determined on basis of isolation of dominant, competing and equal syndromes according to accepted in clinic protocol. CEAE was performed stepwise or simultaneously with myocardial revascularization. Neurophysiological monitoring was performed using somatosensory evoked potentials (SSEP). Two groups of patients, with general anesthesia (n=117) and regional anesthesia (RA) (n=190), comparable on the average age, sex, nature and structure of atherosclerotic lesions, the degree of chronic cerebro-vascular insufficiency (CCVI) were analyzed. RA was performed with intravenous potentiation. Inhalation narcosis with thiopental induction was used. To assess optimal type of CEAE immediate and long-term results in three groups – open CEAE with marginal suture (n=55), open CEAE with plasty of xenopericardial patch (n=115), everting technique (n=137) were analyzed. There were no vital differences in groups on extent and nature of constrictive plaque.

Results: RA-group showed good tolerability, absence of negative emotional reactions. None of patients operated under the RA received intraoperative ACE and TIA. Contact with patient allowed early detection of transient cerebral ischemia and adequate controlling of effectiveness of measures to eliminate it. In the group with general anesthesia there were 11 cases of TIA (focal deficit in region of operated artery with regression of up to 24 h), four – seizures, three – persistent acute cerebrovascular events. In all cases either urgent selective angiography and/or open revision was performed. Surgical complications in above cases were not identified. No significant differences in immediate outcome of CEAE depending on its type were detected. Completeness follow-up was 62%. Patients operated with everting method had no specific complications in up to two years, six patients operated with patches had false aneurysm, nine cases of late strokes and TIA with formation of thrombotic ‘linings’ over whole area of a patch, in patients with marginal suture one case of thrombosis of ICA (asymptomatic), four cases of restenosis were detected.

Conclusions: Regional anesthesia is the method of choice at performing carotid endarterectomy; everting technique of CEAE has an advantage over other types of operations in the analysis of long-term results.

V7-13 SURGICAL TREATMENT OF CAROTID ARTERY PATHOLOGY IN ACUTE PERIOD OF ISCHAEMIC STROKE

E. Ponomarev, S. Maskin, N. Strepetov

VolSMU, Volgograd, Russian Federation

Objective: To estimate the possibility of active operation for patients with carotid artery pathology during acute period of ischaemic stroke.

Methods: The research was carried out on 60 patients. The index group consisted of 25 patients, who were operated during the acute period of acute cerebrovascular event. The control group comprised of 45 patients, who were given conservative treatment. There were differentiated subgroups with stable (n=15 and 9) and unstable neurological status (n=21 and 11), and also a subgroup of the patients with floating blood clots of carotid arteries (n=9 and 5, respectively). When paraoperational thrombotic complications occurred (n=8), thrombectomy was carried out.

Results: The patients with stable neurological status were examined after three weeks. Evaluation criteria were rate of recurrent strokes and case mortality. Examination revealed that stabilization of the course of the stroke against hemodynamically significant changes of carotid arteries with conservative treatment was false, as it was accompanied by high occurrence of recurrent strokes, with high mortality rate peaking during the second week. Total occurrence of recurrent acute cerebrovascular event during three weeks with the patients treated conservatively was 33.99% and mortality rate was 19.98%. The operational treatment was characterized by a long-lasting preventive effect. One complication (11.11%) and one recurrent stroke were observed in this group. Analysis of the patients with hemodynamically significant changes of carotid arteries and advances of pathology has shown that surgical treatment gives good results for 72.72% of the patients, and conservative treatment for 52.38%. Decreasing of recurrent stroke rate led to decreasing of case mortality in the index group to 18.88%, in comparison to the control group (26.80%). It should be noted that in the subgroup of the patients with floating blood clots of carotid arteries, the patients, who were given surgical treatment did not have recurrent strokes or mortality cases. The patients who were treated conservatively, within three weeks of monitoring, had four cases of recurrent acute cerebrovascular event, which accounts for 44.4% with mortality rate of 33.3%.

Conclusions: In cases without significant alterations in the brain and with hemodynamically significant changes of carotid arteries preference should be given to carotid endarterectomy. The operation should be performed within a week following ischemic stroke after stabilization of neurological status. Patients with unstable neurological status and also with a floating blood clot detected need emergent operation within the next 24 h.

V7-14 COMPARATIVE STUDY OF THE CAROTID STENTING WITH AND WITHOUT REVERSE FLOW ACROSS OF SHEATH OF IMPLANTATIoN STENT

C. Vaquero, J. Gonzalez-Fajardo, V. Gutierrez, E. San Norberto, B. Merino

University Hospital Valladolid, Valladolid, Spain

Objective: Carotid stenting like technique of treatment of the carotid stenotic pathology, has very precise indications at the present moment. Nevertheless once indicated the technique one discusses to the indication of cerebral protection and the mechanism used for such aim. A comparative study is made in the treatment of the carotid stenosis between two techniques first of protection with carotid artery flow reversal for aspiration across of sheath and without aspiration.

Methods: A comparative study between 20 patients, 10 of whom had a carotid stent implanted by means of transfemoral access of the carotid with aspiration of the sheath implanted as guide catheter for implantation of the filter and stent during the procedure against the standard procedure without suction of the blood. The criteria of inclusion of patients in both groups have been similar. The sheath employed has been the Shuttle model of the Cook of the 8 Fr size and the filter implanted in all cases the SpiderX of the EV3. Aspects like local and systemic complications have been valued, insolvent attempts of positioning of stent results. The period of pursuit has been of one month. The evaluation of the cerebral accidents have been across monitorization with transcraneal Doppler and clinical evaluation with computed tomography study in the patients with cerebral events.

Results: The percentage number of brain complications is superior in the transfemoral group without sheath aspiration (two cases 20%) against to the transfemoral group with suction of the sheath group (cases 0%) during the procedure, just like the insolvent attempts of positioning of filter and stent. The accidents you will tilt cerebral in postoperating the immediate are similar in both groups. And similar results are obtained in postoperative follow-up in the first month after the procedure.

Conclusions: The results indicate that sheath aspiration of the stenting procedure prevent distal embolization to brain and offers better results in relation standard procedure in the transfemoral approach to carotid stent implantation.

V7-15 RABBIT MODEL OF INTIMAL HYPERPLASIA AFTER CAROTID ENDARTERECTOMY

P. Kuryanov

I.P. Pavlov Medical University of St. Petersburg, St. Petersburg, Russian Federation

Objective: To study the distribution of intimal hyperplasia (IH) within the carotid artery after carotid endarterectomy (CEA) with different types of closure.

Methods: Bilateral CEA was performed in rabbits. The following types of closure were used: primary closure (PC) (10 arteries), autovenous patch closure (AVPC) (10 arteries), autoarterial patch closure (AAPC) (10 arteries), PTFE patch closure (14 arteries); there was an additional group, where CEA was accompanied by balloon injury to the proximal and distal directions and closed with a running suture. At one month the animals were sacrificed, arteries excised and their cross-sections were made through the center of CEA, its proximal and distal edges. Cross-sectional area, mean thickness, cellularity of the hyperplastic intima and the media, as well as the vessel circumference corresponding to the patch and the recipient artery were measured.

Results: At one month PTFE patch closure and PC with balloon injury were associated with lower patency. IH cross-sectional area was highest at the center of CEA. IH was thicker along the suture line both after PC and patch closure. Vessel circumference at the center of CEA was higher after patch closure vs. PC (with or without balloon injury). Total area of IH at the center of CEA was higher after autovenous, autoarterial or PTFE closure vs. PC with or without balloon injury. After CEA with balloon injury and PC the total and the mean area of IH were comparable at all the three levels studied. The mean IH thickness on the patch at the center of CEA was significantly higher after AAPC and PTFE patch closure compared to AVPC. Mean thickness of the IH at the center of CEA was higher following AVPC, AAPC and PTFE patch closure as compared to PC with or without balloon injury.

Conclusions: IH occurred along the entire injured zone and involved both the patch and the recipient artery wall. Patching was accompanied by increased IH at the recipient artery wall, possibly due to flow disturbances at the center of CEA. The type of patch seems to affect the severity of IH as well: the hyperplastic response was maximum in PTFE-patched group, probably because of the dramatic compliance mismatch between PTDE and the arterial wall. In contrast, IH was minimal after CEA with primary closure. The higher thickness of IH along the suture line might also be explained by local compliance mismatch.

11th Cardiac Surgery Session – Valve I May 21, 2011 16:30–18:00

C11-1 PROGNOSTIC VALUE OF INITIAL INDICATORS FOR CARRYING OUT TRANSLUMINAL BALLOON VALVULOPLASTY AT THE AORTAL STENOSIS

F.F. Turaev

V. Vakhidov Republican Specialized Center for Surgery, Tashkent, Uzbekistan

Objective: The aim of this research was to define factors (anatomic-hemodynamic sizes) which influence results of transluminal balloon valvuloplasty (TLBVP) AS.

Methods: Results of TLBV AS were analysed in 56 patients with congenital AS. Thirty-eight were men (67.8%), 18 women (32.2%). Mean age was 16.1±1.3 years, the area of a surface of a body – 1.3±0.06 m². The functional condition of patients were: I FC NYHA – 53.3%, II FC – 46.7%. Calculations were done with ‘STATISTICA for Windows’, 6.0 and with ‘Excel – 2000’.

Results: The correlated analysis showed, that during the years there is a growth of AVppg (r=0.303). Thus, the favorable prognosis of an operation decrease (r=–0.594). We received more than 80% of favorable outcomes in maximum 15-year-old patients, the period when clinical symptoms AS have obvious clinical display, but morphological changes on AV (r=–0.311) still allow spending adequate and effective TLBVP AS. After TLBVP at patients is more senior 15 years residual AVppg remained above 50 mmHg. The size of BSA had a reverse with the operation prognosis (r=–0.582). At the BSA <1.2–1.3 m² the favorable prognosis of operation has made more than 80%. The analysis of the influence indexed values of LV has revealed, that where the indicators were above, than more an operation prognosis (r=0.468) was. At EDD more than 3.0 cm/m², EDV more than 40 ml/m² and ESO more than 1.5 cm, ESV more than 20 ml/m² the operation prognosis above 80%. Thus, degree of expressiveness of a hypertrophy of a myocardium had a reverse with the prognosis (r<–0.357). At indicators dPLVWT and dIVST less 1.5 cm and indicator dIVST from 1.2 to 1.5 cm/m² the prognosis was more than 80%. The less there was of myocardium mass (MM) LV (r=–0.488) and expressiveness of a hypertrophy of walls of myocardium LV, the greater there was a prognosis of a favorable outcome of an operation. The analysis of diameter of a root of an aorta has not revealed connection of influence on the procedure prognosis. The estimation of dynamics of size AVppg before operation has shown that at decrease AVppg lower than 40–50 mmHg the prognosis of a favorable outcome of operation makes more than 80% and it is possible to recognize result of operation as good (r=0.684).

Conclusions: The account of these factors improved results of operation TLBVP AS.

C11-2 ACUTE KIDNEY INJURY AFTER AORTIC ROOT REPLACEMENT FOR ASCENDING AORTIC ANEURYSM

G. Mariscalco¹, C. Beghi², F. Nicolini², A. Scannapieco¹, R. Gherli¹, A. Renzulli³, T. Gherli², A. Sala¹

¹Varese University Hospital, University of Insubria, Varese, Italy; ²University of Parma Medical School, Parma, Italy; ³Magna Graecia University, Catanzaro, Italy

Objective: Acute kidney injury (AKI) following cardiac surgery is a vexing problem and a continuing source of morbidity and mortality. Although several studies have attempted to determine its etiology and prophylactic measures, limited data exist after major aortic surgery. The objective of this study was to evaluate the incidence and risk factor for AKI in patients undergoing aortic root replacement (ARR) for ascending aorta aneurysms.

Methods: A multi-center observational study of 408 patients undergoing ARR was conducted, focusing on clinical outcome and AKI defined by consensus RIFLE (risk, injury, failure, loss of function, end-stage renal disease) criteria.

Results: Mean age was 62±12 years (range: 21–82) with 322 males (79%). Emergent procedures occurred in 31 cases (8%), while 306 and 102 patients underwent isolated ARR (75%) and combined operations (25%). Incidence of postoperative AKI (all RIFLE classes) was 16.9% with 2% of patients requiring renal replacement therapy. Mortality increased with RIFLE class severity of AKI (P<0.001). Independent AKI risk factors were coexistent coronary artery disease (CAD; OR 2.72; 95% CI 1.48–5.01); transfusion requirement (OR 4.8; 95% CI 1.45–15.89) and redo procedures (OR 2.13; 95% CI 1.04–4.39). Age, deep hypothermic circulatory arrest and preoperative creatinine level were not independently associated with AKI.

Conclusions: Aortic root replacement for ascending aorta aneurysm can be performed with low rates of postoperative AKI, similarly to other common cardiac surgical procedures. Coexistent CAD transfusion requirement, and redo procedures as independent AKI predictors merit further focused researches enhancing possible preventive AKI strategies.

C11-3 ROSS TECHNIQUE FOR REDO AORTIC VALVE PROCEDURES

S.O. Lavinyukov, A.M. Karaskov, S.I. Jelesnev, A.V. Bogachev-Prokophiev, I.I. Demin, V.M. Nazarov, N.A. Kaganskaya

Novosibirsk Federal Research Institute of Circulation Pathology, Novosibirsk, Russian Federation

Objective: Controversies about the safety and efficiency of assessment of Ross procedure, as well as increasing cardiac reoperations rate all over the world, led us to study whether the Ross principle is applicable to redo aortic valve procedures.

Methods: Thirty-six cases are included into the study: 12 consecutive patients underwent Ross operation as a redo aortic valve procedure from 2006 to 2010 we compared to a cohort of 12 matched redo AVR with mechanical prostheses, and a cohort of 12 matched primary AVR with pulmonary autograft. Mean age was 40±11 years. There were 66% of men in each group. Average NYHA class was 2.45±0.5; 45.5% of patients were in NYHA Class III. Mean preoperative LVEF was 69.2±9.3. In both redo AVR groups there were three patients after aortic commissurotomy and nine patients who underwent mechanical AVR. All the Ross procedures were performed in total root replacement technique; mechanical AVR was done with ‘CardiaMed’ bileaflet prostheses (Penza, Russia). All analyses were performed with Statistica version 6.0 (StatSoft). For independent variables we used Mann–Whitney U-test and Pearson c²-test; Wilcoxon t-test was applied for depended groups. All P-values reported.

Results: X-clamp time was significantly longer (P=0.002) in redo Ross AVR patients (162±43 min), comparing to redo AVR with mechanical prostheses (88±17 min). No significant difference between the groups was found in intraoperative adverse event rate, complication rate, ICU stay and hospital stay. Postoperative AV pressure gradient was significantly lower in patients undergone Ross procedure (P=0.0009).

Conclusions: Pulmonary autograft could be safely used for redo AV procedures in young and middle-aged patients with preserved LV function. Hemodynamic effects of the Ross procedure as a redo AV surgery are shown to be as beneficial as the primary Ross AVR.

C11-4 THREE-DIMENSIONAL TEMPLATE-BASED PLANNING FOR TRANSAPICAL AORTIC VALVE IMPLANTATION

S. Jacobs, M.l. Gessat, V. Falk

University Zürich, Zürich, Switzerland

Objective: To investigate whether the onset of atrioventricular node block or aortic insufficiency after transapical aortic valve implantation can be predicted using 3D implant template based planning.

Methods: Retrograde template based planning was performed in 35 patients who underwent transapical aortic valve implantation. This included creation of a virtual 3D model of the ascending aorta from preoperatively acquired DynaCT images. Three-dimensional models (templates) of the prosthesis (Edwards Sapien and the Ventor Embracer) were virtually implanted into the 3D model and the optimal valve size was selected accordingly.

Results: Of 28 cases treated with the Edwards Sapien Valve, template based planning was consistent with the clinically selected valve size in 17 cases (61%). In 71% of these cases, no complications were reported. Three cases (18%) of aortic insufficiency and two cases (12%) of atrioventricular block were among these patients. In two patients who received a 26-mm implant, planning recommended a 23-mm valve. In both cases, atrioventricular node block grade III occurred. In two patients who received a 23-mm implant, planning recommended a 26-mm valve. In one of these cases, paravalvular leakage led to an aortic insufficiency of grade I. In seven cases, planning suggested, that the 26 mm valve would still be too small. In all seven cases, postoperative aortic insufficiency was diagnosed.

Conclusions: This study shows that improved imaging and planning using template based planning software may enhance the valve selection process for transcatheter aortic valve implantation.

C11-5 CLINICAL AND ECHOCARDIOGRAPHIC RESULTS OF AORTIC BALLOON VALVULOPLASTY (ABV) OF SYMPTOMATIC HIGH-RISK ELDERLY PATIENTS WAITING FOR TRANSCATHETER VALVE IMPLANTATION (TAVI) OR AS PALIATIVE TREATMENT – 39 PROCEDURES OF A SINGLE CENTRE EXPERIENCE

T. Niklewski, K. Wilczek, P. Chodor, M. Krason, R. Przybylski, T. Podolecki, T. Kukulski, M. Zembala

Silesian Center for Heart Diseases, Zabrze, Poland

Objective: High-risk patients with symptomatic calcified aortic stenosis (AS) who are disqualified from surgical valve replacement (AVR) for multiple risk factors often require emergent or urgent ABV, either as a bridge to transcatheter valve implantation (TAVI) as proper procedure, and rare before AVR or as a paliative treatment. We aimed to explore the echocardiography, hemodynamic and clinical early results of ABV performed in end-stage unstable elderly AS patients.

Methods: Thirty-nine patients with mean age 82 years with aortic valve area <1 cm² (mean 0.57 cm²) who were disqualified from AVR and TAVI or will be waiting for transcatheter implantation were treated with ABV through the femoral artery approach. A mean logistic EuroSCORE was 24.51%. The balloon/annulus ratio was estimated by accurate echo measurements. Under general (first 10) and local anaesthesia (next 29 patients) during rapid pacing 190–200/min the ABV with 1–3 inflations was performed in each patient.

Results: The mean perioperative EF changed from 38.6 to 38.2% (NS). Mean transvalvular gradient drop from 60.9 to 41.8 mmHg and aortic valve area increased from 0.57 to 0.86 cm² (P<0.05), degree of aortic regurgitation increased in all group from small (+) to moderate (++) and to severe in four cases. NYHA class changed from mean of 3.7 to 2.4 (P=0.047) for patients after six months. There was no neurological complication. After one-year mortality was 17.9% (seven patients). Five patients died until two months with increased symptoms of heart failure and severe AR and one three weeks after AVR because of acute regurgitation. One patient received emergent CABG with AVR after occlusion of LAD by fragment of cusp lesion. In 10 patients (25.64%) the successful TAVI procedures with three SAPIEN and seven Core Valve were done between 6 and 12 months after ABV.

Conclusions: ABV for critically ill patients with AS and high risk of surgery or otherwise inoperable is an alternative treatment modality which may alleviate symptoms and allow to prepare patients for elective TAVI especially those who had to waiting for this procedure and start become unstable. Increased AVA after balloon valvuloplasty results in significant NYHA class improvement of the treated patients.

C11-6 INFECTION COMPLICATIONS AFTER CAROTID ENDARTERECTOMY

A.A. Fokin, E.V. Babkin

Urals Postgraduate Medical Academy, Cheliabinsk, Russian Federation

Objective: The analysis of infection complications of 2240 reconstructive operations on carotid artery (CA) executed from 1988 to 2007. Infection complications developed in 22 (0.98%) cases.

Methods: The age of patients was from 48 to 71 years (average age 60.1). Fifteen men, seven women. Signs of infectious process have been registered in terms from 10 days to 30 months (mean days 158.5). Primary infection complications arose in nine patients in early terms after operation. In five patients we registered the formation of an extensive pyesis with involving of soft tissues of a neck and reconstruction area and in four patients it was shown an abscess in the field of reconstruction. Cases of abscess developed within six weeks after operation, with highly virulent microorganisms. All cases of extensive pyesis arose within the first month after operation and were bound with Gram-negative microorganisms. The secondary becoming infected arose in 13 patients, in the majority of them, in terms of more than two months after reconstruction. In five cases – formation of pseudoaneurysm CA with an accompanying septic condition was registered. The clump of a liquid along a patch and patch corrugation at ultrasound investigation were revealed in five cases in late terms of postoperative period, always combined with revealing of pathogenic microorganisms at bacteriological research. The arrosive bleeding developed in three patients. Two cases of bleeding, which developed in the early postoperative period, were massive. Others showed a formation of a hematoma in the field of reconstruction for two months after operation. In 20 cases reconstruction internal CA is executed. Prosthetics internal CA is performed by vein in 16 patients. Also in five cases prosthetics by a site external CA is performed. The ligation of internal CA is executed at development of a massive bleeding in one patient.

Results: In the early postoperative period two patients (9.1%) died. The acute myocardial infarction, in another an ischemic stroke owing to a bleeding and a ligation internal CA became a cause of death in one case. Recurrent of infection with development of an arrosive bleeding arose in two patients. All cases recurrence of infection were presented by formation of an abscess in the field of initial operation, revealing in wound Staphylococcus aureus.

C11-7 MID-TERM RESULTS OF APPLICATION OF FRESH WET-STORED hom*oGRAFT IN CHILDREN AND ADULTS DURING 18 YEARS

V.A. Bolsunovsky¹, R.R. Movsesyn¹, I.I. Chernov², V.A. Belov³, A.N. Shonbin⁴, S.E. Shorochov⁵, D.Y. Petrushenko⁶, K.V. Gorbatikov⁷

¹Children’s Hospital #1, Astrachan, Russia; ²Federal Cardiac Surgery Center, Astrachan, Russia; ³Regional Hospital, Ekaterinburg, Russia; ⁴City Hospital #1, Arkhangelsk, Russia; ⁵Regional Clinical Dispensary, Samara, Russia; ⁶Children’s Republican Hospital, Kazan, Russia; ⁷City Hospital, Tumen, Russia

Objective: The purpose of the study is an assessment of results of implantation of fresh wet-stored hom*ografts in children and adults.

Methods: In the period from 1990 to 2010 more than 750 hom*ografts were produced, they were marked by safety, by ability to preserve the biomechanical and biochemical properties of the matrix, by no fixation of the collagen matrix, by capability to recellularization in vivo. During the study 152 pulmonary hom*ografts and 93 aortic hom*ografts were implanted for the correction of congenital heart disorders in 148 children and for correction of valve defects in 97 adults in 10 cardiosurgical centers of Russia.

Results: According to the results of microscopic examination of explanted bioptic specimens the recellularization was noted by the recepient’s fibroblasts at adventitia side. These fibroblasts carry out regeneration of connective-tissue matrix of the hom*ografts. According to the results of ultrasonic examination an average annual increase of transvalvular gradient with or without residual defects was made (7.3±2.6) and (4.1±0.8) mmHg accordingly (P<0.05). During first three years (206 patients) – 2% of hom*ografts have required replacement; in five years – 9%; in 10 years 19%; in 15 years – 35%.

Conclusions: Fresh wet-stored hom*ograft can be successfully used for pulmonary artery and aorta valve replacement in various clinical situations. Results of the assessment of structural changes of the hom*ografts in the long-term are indicative for high durability of the products during the first 10 years after implantation.

C11-8 ENDOVENTRICULOPLASTY IN PATIENTS WITH MITRAL AORTIC VALVE DISEASES COMPLICATED BY LEFT VENTRICLE DILATATION

Kh.A. Abdumadjidov, Sh.M. Aliev, L.A. Pulatov, M.S. Shakarov, S.A. Babadjanov, E.A. Rizaev

RSCS named after academician V.Vakhidov, Tashkent, Republic of Uzbekistan

Objective: To analyse surgical treatment of mitral-aortic valve diseases complicated by dilatation of the left ventricle.

Methods: In RSCS named after academician V. Vahidov during the period of 2002–2010 were operated 71 patients with mitral-aortic valve diseases and left ventricle dilatation (EDD 70 mm³). Patients were divided into two groups: I group – 61 patients (85.9%) who underwent mitral and aortic prosthesis procedure. II group – 10 patients (14.1%) – mitral-aortic valves prosthesis procedure with endoventriculoplasty of the left ventricle. According to transthoracic echocardiography (TTE) in I group mean EDD was 7.3±0.8 cm, EDV 306.8±6.4 ml, ESV 142.3±6.3 ml. Mean ejection fraction was 56.5±1.4%. In II group of patients the left ventricular parameters were as follows: EDD – 8.0±0.97 cm, EDV – 347.1±30.3 ml, ESV 187.9±24.4 ml, SV – 171.6±11.2 ml. Mean left ventricle EF was – 50.6±3.3%. According to intraoperative transesophageal echocardiography (TEE) in II group the mean distance between the papillary muscles was 5.2±2.7 cm. Endoventriculoplasty technique was to approach papillary muscles with PTFE loop.

Results: Mortality in I group was 19 patients (31.1%). The cause of death in nine patients (14.7%) was acutely developed heart failure. In second group patients mortality was 10% (one patient). The cause of death was acute heart failure of myocardial origin. According to TTE a I group patients after the surgery had mean EDD 6.2±1.6 cm, EDV 240.2±13.1 ml, ESV 140.8±8.9 ml. Mean left ventricle ejection fraction was 46.2±1.5%. In II group patients had, respectively, mean EDD 6.1±1.28 cm, EDV 206.1±18.7 ml, ESV 112.9±18.1 ml. Mean left ventricle ejection fraction was 52.4±2.3%. The mean distance between the papillary muscles was 2.8±0.6 cm. Long-term results were studied in a period from six months to seven years. At the long-term period the mortality in I group was 32 patients (52.4%), of whom in 24 (75%) cases the cause of death was heart failure. In II group within three years after surgery only one patient (10%) has died because of stroke. According to TTE data in II group was obtained a significant decreasing of the left ventricle EDV 167.1±14.3 ml and increasing ejection fraction EF 57.4±0.9% (P≤0.05).

Conclusions: Surgical treatment of mitral-aortic valve diseases complicated by left ventricular dilation (EDD 70 mm³) should include a liquidation not only valve pathology, as well as active effects on left ventricular remodeling.

C11-9 IS THERE A LESS INVASIVE THORACOABDOMINAL AORTIC ANEURYSM REPAIR?

Z. Mitrev, T. Anguseva, V. Belostotckij

Special Hospital for Surgery Fillip II, Skopje, Macedonia

Objective: This paper will present our experience using DeBakey type repair for thoracoabdominal aortic aneurysm (TAAA).

Methods: Four male patients (55±7 years) were treated in our center for TAAA. They were symptomatic; aneurysm dimension of 10±2 cm. One patient had ongoing rupture for Crawford type ITAAA-aneurysm of aortic arch, developed after ascending aorta and hemiarch graft replacement previous aortic dissection. The others were CrawfordIII. Surgery was performed through thoracophrenolaparotomy, employing DeBakey type repair with construction of composite end-to-end prosthesis between tubular and bifurcated graft and proximal end-to-side prosthesis implantation on thoracic aorta. In one patient we performed proximal end-to-side prosthesis implantation on previous ascending aortic prosthesis with reimplantation of cranial vessels and end-to-end anastomosis with both iliac arteries, followed by implantation of celiac trunk, superior mesenteric and renal artery over 10 mm vascular graft.

Results: Patients remained hemodinamically stabile. Two patients had minimal blood loss discharged 8-10th postoperative day. Two patients required prolonged ventilation and postoperative use of cell-saver. One patient who had previous laparotomy developed infection. The other had prolonged ventilation, tracheostomy, intestinal bleeding, sepsis and paraplegia. He is still on intensive recovery.

Conclusions: DeBakey type repair is a less invasive approach. Without use of extracorporeal circulation and reduced ischemic time, this technique avoids inevitable operative complications encountered with hypothermic circulatory arrest, partial cardiopulmonary bypass, partial left heart bypass, or clamp-and-sew strategy.

12th Cardiac Surgery Session – Valve II May 21, 2011 16:30–18:00

C12-1 RESULTS OF SURGICAL TREATMENT OF ACTIVE INFECTIVE ENDOCARDITIS WITH THE USE OF THE TOTAL BODY CONTROLLED HYPERTHERMIA

A. Koltunova, G. Knyshov, V. Maksimenko, A. Rudenko, V. Zaharova, A. Koltunova, V. Gladkikh, A. Krikunov

M. Amosov National Institute of Cardiovascular Surgery AMS of Ukraine, Kiev, Ukraine

Objective: Active infective endocarditis (IE) is the illness with high rate of mortality and development of reinfection and recurrent endocarditis. Problems of IE treatment include: secondary immune deficiency of patients, a high rate of intracardiac abscess formation, decrease of antibiotic diffusion characteristics within vegetation, decrease of microorganisms metabolic state. To improve the results in the surgical treatment of patients with active IE we used the total body controlled hyperthermic perfusion (TBCHP).

Methods: Since 2003 we used the method of TBCHP in surgical treatment of 908 (62.9%) patients with active infective endocarditis. Mean age was 43.1±2.7 years, 81.4% male. Secondary IE was found in 97.4% of cases. Frequency of intracardiac abscesses formation was in 19.2% of cases. After bacteriological studies the agent was identified in 34.7% of cases. Secondary immune deficiency of III-IV degree was observed in 98% of patients. Surgical interventions include: aortic valve replacements (51.2%), mitral valve (MV) replacements (17.6%), tricuspid valve (TV) replacements (0.6%), bivalvular replacements (10.8%), reconstructions of MV (5.0%), TV reconstructions (5.9%) and the reoperation in the cases of the prosthetic endocarditis (8.0%). Perfusion parameters in patients who were operated in conditions of hyperthermia included: perfusion duration 132.4±7.1 min, aorta cross-clamping time was 71.6±15.4 min, patients warming time from 37 ºC to 39 ºC – 21.7 min and hypertermic period equaled 30 min. Results analysis was conducted in comparison with the control group of 539 patients (37.1%) with IE, which were operated without the use of TBCHP.

Results: In the study of biological parameters and factors of an inflammation usage of TBCHP entails activation of immunological and metabolic processes and the organism immunoreactivity increase of patients with IE. Mortality rate and rate of an early prosthetic endocarditis were in 1.1% and 0.4% in the group with TBCHP; 7.4% and 3.7% in the control group correspondingly. The usage of this method allowed decrease of mortality rate from 7.0% (24.5% patients with the TBCHP) to 1.1% (92.2% patients with the TBCHP) and rate of an early prosthetic endocarditis from 4.0% to 0.4% correspondingly.

Conclusions: The usage of the TBCHP in the surgical treatment of the acute infective endocarditis entails activation of immunological and metabolic processes and the organism immunoreactivity and allowed decrease of mortality rate and rate of an early prosthetic endocarditis to 1.1% and 0.4% correspondingly.

C12-2 CLINICAL BENEFITS AND COST-EFFECTIVENESS OF ALLOGENEIC RED BLOOD CELL TRANSFUSION IN SEVERE ANAEMIA

A.M. Beliaev

Auckland City Hospital, Auckland, New Zealand

Objective: Over the centuries it has been empirically known that blood transfusion is life-saving, even associated with risks of serious adverse events such as ABO incompatibility, transmission of HIV, hepatitis B, C and variant Creutzfeld-Jacob disease. As a result, new methods of testing for transmissible diseases, blood banking and blood dispatch regulations have been developed. An introduction of these healthcare technologies increased safety of blood products, but came at considerable costs. For example, in UK costs of blood supply increased in 1994 from £250 m to £500 m in 2004. In the current crisis characterized by worldwide shortage of blood donors and limited healthcare budgets an evaluation of benefits of blood transfusion and its alternatives is of paramount importance. The aim of the study was to assess clinical benefits and cost-effectiveness of allogeneic red blood cell (ARBC) transfusion in severe anaemia.

Methods: Multi-centre case-control study. Ten thousand eight hundred and ninety-four hospital admissions were reviewed, including 3529 Jehovah’s Witness (JW) patients admitted to four NZ hospitals in 1998–2007. Inclusion criteria were age ≥15 years, severe anaemia (Hb≤80 g/l). Palliative care patients were excluded. JW patients, who refused ARBC transfusion, were managed with iron, folic acid, vitamin B12 and erythropoietin therapy (the control group). Non-JW patients had ARBC transfusion (the cases). The cases were randomly drawn in 1:1 ratio from the same disease-related group as the controls and were matched to the controls on the main diagnosis.

Results: One hundred and eight controls were identified. The age of patients of the control group as 58.6±18.7 (mean±S.D.) and of the cases was 64.7±20.6 years (P=0.988). It has been shown that ARBC transfusion reduced mortality by relative 93% (OR 0.07; 95% CI 0.02–0.3; P<0.001), shock by 90% (OR 0.1; 95% CI 0.03–0.4; P=0.001), neurologic complications by 90% (OR 0.1; 95% CI 0.01–0.8; P=0.032), infective complications by 80% (OR 0.2; 95% CI 0.1–0.4; P=0.001), cardiac arrhythmia by 90% (OR 0.1; 95% CI 0.03–0.5; P=0.005), ischaemic cardiac injury by 70% (OR 0.3; 95% CI 0.1–0.9; P=0.024), heart failure by 70% (OR 0.3; 95% CI 0.1–0.6; P=0.002) and renal failure by 60% (OR 0.4; 95% CI 0.2–0.8; P=0.008). Compared with the controls, the cases stayed shorter in hospital, 20.7±21.8 days and 14.4±17.7 days, respectively (P=0.0197). Incremental cost-effectiveness ratio of ARBC transfusion was 2011 NZ$ 3986 per death prevented.

Conclusions: ARBC transfusion in severe anemia is clinically beneficial and cost-effective.

C12-3 BRAIN NATRIURETIC PEPTIDE MIGHT PREDICT A HEART FAILURE AFTER CARDIAC SURGERY IN PATIENTS WITH HEART VALVE DISEASE AND LEFT VENTRICULAR DySFUNCTION

E. Kuts, I. Skopin, V. Mironenko, M. Plush, N. Samsonova, L. Bockeria, M. Mironenko, Yu. Dmitrieva

Bakoulev Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: Postoperative heart failure is a major determinant for adverse outcome in cardiac surgery. Recent studies have demonstrated BNP to have diagnostic and prognostic implications in heart failure patients. The objective of this study was to assess the prognostic value of BNP in patients with valvular heart disease for the prediction of heart failure after cardiac surgery.

Methods: Between March 2006 and June 2010, 71 patients with heart valve disease and left ventricular dysfunction (left ventricular ejection fraction ≤50%, end-diastolic dimension ≥60 mm), underwent valvular surgery. Exclusion criteria were coronary artery disease. Postoperative complications were defined as follows: (i) a postoperative length of stay in the intensive care unit (ICU) exceeding 48 h; (ii) mortality at 30 days; (iii) the need for inotropic agents and/or intra-aortic balloon pump (IABP). Serum BNP values were compared for patients with and without complications.

Results: The median preoperative BNP levels was 425 (13–5653) pg/ml. Heart failure (r=0.7; P=0.001), systolic pulmonary artery pressure (r=0.47; P=0.01), left atrial diameter (r=0.36, P=0.05), serum creatinine (r=0.43, P=0.01) and LV ejection fraction (r=–0.5; P=0.0001), were associated with an increased preoperative BNP level. Preoperative serum BNP levels were significantly higher in patients needing inotropic agents (1417 pg/ml vs. 396 pg/ml, P=0.001) or IABP insertion (1251 vs. 333 pg/ml, P=0.001). There was a statistically significant positive relationship between BNP concentration and inotropic support duration (r=0.66; P=0.001), and ICU stay (r=0.43, P=0.03). Receiver–operator curve (ROC) demonstrated that BNP ≥984 pg/ml predicts postoperative heart failure with sensivity of 78%, specificity of 89% (area under the curve 0.92, P=0.001).

Conclusions: In patients with heart valve disease and left ventricular dysfunction preoperative BNP levels predict postoperative heart failure after heart valve surgery.

C12-4 EARLY AND LONG-TERM OUTCOMES IN PATIENTS WITH AORTIC STENOSIS TREATED WITH THE SOLO STENTLESS VALVE – ZABRZE’S EXPERIENCE

S. Pawlak, J. Sliwka, T. Niklewski, J. Foremny, K. Filipiak, T. Hrapkowicz, M. Zembala

Bakoulev Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: Biological stentless valves have an excellent hemodynamic profile and are an optimal choice for elderly patients with a narrow aortic ring. However, the implantation technique is more challenging than in the case of stented valves. In recent years, a new Freedom SOLO^® stentless valve, adapted for implantation with a single line of monofilament sutures, has been available on the market. The aim of the study was to analyse the early treatment outcomes in patients after implantation of the Sorin Freedom SOLO^® stentless valve.

Methods: The analysis comprised the data of 59 patients with the Freedom SOLO^® valve implanted between June 2009 and July 2010. Most of patients were operated due to complex aortic valve disease, besides they suffered from isolated stenosis or insufficiency. In 37 of the operated patients, the diameter of the aortic ring, assessed echocardiographically, was <23 mm. Twenty patients had 3–6 months follow-up with echocardiographic assessment of the valve.

Results: The mean intraoperative gradient of implanted valve was 10 mmHg, with a maximum value 22 mmHg; follow-up values were 10.3 mmHg and 21.6 mmHg, respectively. Post-hospitalization follow-up results were consistent with the intraoperative values. There was one death in a female patient after aortic stenosis balloonoplasty, complicated with infarction. None of the patients required reoperation. The reduction of the left ventricle mass about 29% was observed. No significant or moderate insufficiency of the implanted prosthesis was observed. In three patients trace insufficiency below stage I was diagnosed. The assessment also revealed that SOLO^® valve has the biggest efficient orifice area index (0.894 cm²/m²) in comparison with the group of other biological or mechanical valve implanted. In 12.5% of the patients transient thrombocytopenia (<50×103/ml) was observed postoperatively, but there was no statistically significant difference in comparison with the group of other biological or mechanical valve implanted.

Conclusions: 1. The Freedom SOLO^® valve appears to be a good prosthesis, especially in patients with a narrow aortic ring, requiring the implantation of a biological prosthesis. 2. The gradient observed in our methods was low and did not show significant differences in comparison with other stentless valves. 3. Follow-up for transient thrombocytopenia should be continued as an element of the newly introduced prosthesis.

C12-5 PREVENTION OF TYPE II ENDOLEAKS BY COILS AND FIBRIN GLUE EMBOLIZATION OF THE ANEURYSMATIC SAC

M. Menegolo, P. Frigatti, M. Antonello, S. Lepidi, I. Morelli, P. Scrivere, F. Grego

Clinic of Vascular and Endovascular Surgery, University of Padua, Padua, Italy

Objective: Type II endoleaks are the most common ‘complication’ after EVAR. Their incidence is various in many series reported and their significance and treatment have been long debated. It seems to be generally agreed that the treatment of type II endoleaks is recommended in case of growth of aneurysm diameter. The purpose of this study is to evaluate if the routinely intra-sac embolization with coils and fibrin glue during EVAR is a safe and effective procedure to reduce the incidence of type II endoleaks and the incidence of re-intervention after EVAR.

Methods: From January 2009 to August 2010 63 patients underwent EVAR, emergency procedure are not considered here. Forty-two patients have been treated in 2009 without sac embolization (group A) while, from January 2010, 21 patients underwent EVAR + routine intra sac embolization at the end of the endovascular procedure (Group B): 20 of these patients have been treated by intra sac positioning of coils (19 cases Tornado^® and one case Balt^®), 17 patients were treated also with injections of fibrin glue (TissueColl^®), one patient had only coils and one only fibrin glue. All patients underwent a 30 days postoperative CT-scan.

Results: In 30 days the incidence of type II endoleaks in Group A was 14.3% (Six cases) and in group B was 4.8% (one case). In Group B no adjunctive surgical procedure were needing and no type I endoleaks were observed.

Conclusions: The sac embolization with coils and fibrin glue at the time of endograft placement seems to be a safe procedure for prevention of type II endoleaks. Considering that literature reports a global incidence of reoperation for type II endoleaks of 55%, seen the reductions of incidence of type II endoleak after this procedure, we can estimate a reduction of re-interventions of about 5.3% with a relevant cost saving for the national health system. Moreover, the absence of type I (A or B) endoleaks in all the cases treated seems to confirm the effectiveness of the technique also in the stabilization of the sac giving high fixation to the endograft.

C12-6 MICROCIRCULATION IN THE WALLS OF THE CHAMBER HEART DURING AORTIC STENOSIS COMBINED WITH CORONARY HEART DISEASE

O.V. Kamenskaya, A.S. Klinkova, L.M. Bulatetskaya, S.I. Zheleznev, D.V. Shmatov, D.A. Astapov, I.I. Demin, A.B. Open

Federal State Institution Academican E.N. Meshalkin Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation

Objective: The aim of this study was to evaluate the state of microcirculatory blood flow (MBF) in the walls of various heart chambers in patients with aortic stenosis (AS) on a background of atherosclerotic coronary pathology.

Methods: Intraoperative study aimed to evaluate MBF in 63 patients with AS of III-IV stage before and after stenosis repair. The mean age was 54.2±1.2 years. Microcirculation was recorded using the laser-doppler flowmetry in ml/100 g/min. Microcirculation was recorded by surface sensor on the walls of the left and right atria (LA, RA) and of the left and right ventricle (LV, RV). Hemodynamic parameters were recorded: systolic and diastolic blood pressure (SBP, DBP), heart rate (HR).

Results: Patients were divided into two groups. In group 1 (51 men) patients included without atherosclerotic coronary artery. In group 2 (12 men) patients included with coronary heart disease (CHD). These patients underwent aortic valve prosthesis and coronary artery bypass grafting. A comparative analysis of the MBF in the two groups before the operation showed that in the second group with a combination of AS with CHD recorded the lowest level of MBF in the walls of LA and LV (53.6±2.4 and 67.9±2.8 ml/ 100 g/min, respectively) than in the first group (61.3±2.5 and 76.3±2.6 ml/100 g/min, respectively) (P<0.05). The level of MBF in the walls of the RA and RV did not differ between groups and was above 70 ml/100 g/min. In the second group of patients, after correction of AS and coronary bypass surgery, the trend has been found to increase the MBF in the walls of LA and LV to 60.0±2.4 and 73.0±3.3 ml/100 g/min, respectively (P>0.05). Microcirculation in the walls of the heart chambers did not change in the first group (P>0.05). Hemodynamic parameters (SBP, DBP, HR) did not differ by group.

Conclusions: The state of MBF in the walls of various chambers of the heart in patients with AS on a background of CHD is characterized by the lowest flow rate of the microcirculation in the walls of the left atrium and left ventricle in comparison with patients with AS without CHD.

C12-7 ASSESSMENT OF THE LEFT VENTRICLE REMODELING IN PATIENTS WITH AORTIC VALVE DISEASES AFTER AORTIC VALVE REPLACEMENT

I.I. Averina, O.L. Bockeria

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: To assess the left ventricle (LV) remodeling after aortic valve replacement (AVR).

Methods: Fifty-two patients (44 men) mean age 40.4±16.9 years were evaluate using echocardiography and electron beam computed tomography angiography 10–14 days before and 6–12 months after the open heart surgery. Patients were divided into three groups: group 1 – patients with aortic stenosis (n=16), group 2 – patients with aortic insufficiency (n=14), group 3 – patients with aortic stenosis and insufficiency (n=22). Based on degree of geometry LV changes all patients were separated in two subgroups: adaptive and not adaptive remodeling.

Results: Non-adaptive remodeling was saved in 25% of patients with aortic stenosis and in 22% of patients with combined aortic stenosis and insufficiency and in 7% of patients with aortic insufficiency 6–12 months after AVR. Myocardial LV volume – 374±125.07 ml, LV myocardial mass index – 206.61±65.19 g/m², LV end-diastolic volume index – 124.37±34.05 ml/m², LV end-systolic volume index – 79.29±14.5 ml/m² were prognostic sign of persistant heart failure in short-term as well as in long-term follow-up period.

Conclusions: Operation reduced number of patients with non-adaptive geometry in the average on 75%, and in group with aortic insufficiency – 88%. The prognostic signs of persistent heart failure in short-term as well as in long-term follow-up period were noted.

C12-8 INTRATHORACIC AORTIC DISEASE AFTER CARDIAC SURGERY IN LONG TERM

S.C. Murat, E. Burak, U. Tulga, O. Sertan

Turkey Yuksek Ihtisas Hospital, Ankara, Turkey

Objective: The aim of this study is to interfere to ascending aorta in patients who have borderline dilated ascending aorta. It is hard to know the true incidence of the intrathoracic aortic diseases after cardiac sugery. Sometimes surgeons do not want to interfere borderline dilated ascending aorta because of its easy way. But these patients may apply with dissected ascending aorta or ascending aorta aneurysm with high mortality risk.

Methods: We evaluated patients who underwent surgery in our hospital between 2000 and 2009. This study includes 50 patients who have intrathoracic aortic disease before cardiac surgery. Thirty-nine patients were male (78%), 11 patients were women (22%). Mean age of patients 52.1±13.9. Fourteen patients had aortic dissection, 26 patients had aortic aneurysm, eight patients had descending aortic aneurysm, two patients had ascending aortic pseudoaneurysm. Forty-one patients had aneurysm, five patients had aortic dissection without aneurysm. Forty-six patients were operated and four patients were followed by medical therapy. Between two operations, mean time was 8.5±7.4 months. First operations of patients were 11 CABG, 17 AVR, six supracoronary graft interposition, one descending aortic graft interposition, one MVR, three repair of aortic coartaction, two TOF totally correction, two AVR+CABG, one AVR+MVR, two AVR+supracoronary graft interpositions, two CABG+supracoronary graft interpositions, two Bental de bono Procedures. Second operations of patients were: 14 supracoronary graft interpositions, five CABG+supracoronary graft interpositions, 13. Bental de bono, eight descending aortic graft interpositions, six AVR+supracoronary graft interpositions.

Results: Total mortality rate was 32% (15 patients). Five patients were emergently operated and all of them became exitus. Age was statistically significant in mortality group (P=0.01). Aortic cross-clamping time was higher in mortality group (P=0.02). Total perfusion time was higher in mortality group (P=0.004). Sex was not statistically significant. In this study after AVR operations development of aortic aneurysm or dissections was higher than other groups (P=0.06). We found that preoperative aortic radius is important to development of aortic dissections or aortic aneurysm. 4.3 cm or higher aortic radius has higher risk of aneurysm and dissection after operation in mid-long term.

Conclusions: Although development of cardiac surgical procedures cardiac reoperations mortality are still high; our study showed that 32% of mortality range is extremely high and it is associated with age. Therefore, life expectancy increases, reoperation rates will increases too. To Avoid palliative treatment is best goal in first operations.

C12-9 AORTIC VALVE REPLACEMENT THROUGH A RIGHT MINI-THORACOTOMY: LESS CARDIOPULMONARY BYPASS TIME AND FOUR-TO-SIX CENTIMETERS SKIN INCISION

S. Calvi, M. Del Giglio, D. Magnano, E. Mikus, M. Lamarra

Maria Cecilia Hospital, Cotignola (RA), Italy

Objective: Minimally-invasive techniques in cardiac surgery require, at least, to obtain the same level of quality as compared to the traditional procedure while achieving a better aesthetic result. Minimally-invasive aortic valve replacement (MIAVR) through a right mini-thoracotomy is a procedure developed during the last five years; its use is not widespread because the surgical approach limits the surgeon’s view to a very tiny operating field, resulting in a more challenging procedure. Nowadays the limits of this technique, as described in literature, are longer cardiopulmonary bypass time compared to the standard approach and a skin incision of 8–6 cm. We describe our technique in 16 consecutive patients with a simplified prosthesis implantation through an extremely small skin incision during the last year.

Methods: Between January 2010 and January 2011, 18 patients – mean age of 63.3±15.3 years – were scheduled for MIAVR. Thirteen patients were affected by isolated severe aortic valve stenosis, with a mean peak gradient of 83.1±30.6 mmHg, while the remaining had severe aortic valve regurgitation. Aortic cannulation and clamping were performed through a right mini-thoracotomy while a vacuum assisted venous drainage was obtained percutaneously through the groin. Cold blood antegrade cardioplegia has been used in all cases. All patients received an aortic valve replacement with a pericardial bioprothesis sutured using three 2-0 prolene running sutures. Mean prosthesis size was 24.4 mm.

Results: MIAVR was successfully performed through a 4–6 cm skin incision at the third intercostal space. One patient was a REDO case while another one had a concomitant mitral valve annuloplasty. Reexploration for excessive bleeding has been necessary in one patient. Skin-to-skin time was 215±46.3 min. Overall cardiopulmonary bypass was 80.5±28.5 min and aortic cross-clamping was 70.5±25.2 min. Mean intensive care and hospital stay was 33.6 h and 7.6 days, respectively. Neither deaths nor wound complications were observed. Finally, all patients were satisfied with the cosmetic results.

Conclusions: Our initial series confirms that MIAVR achieved through a right mini-thoracotomy is a safe procedure with excellent results. This technique may be more complex and therefore it requires higher surgical abilities and expert surgeons. Using running sutures, cardiopulmonary bypass and cross-clamping times comparable with the standard can be obtained. The 4–6 cm incision improves safely the aesthetic result and potentially reduces the risk of wound complications.

8th Vascular Surgery Session – Peripheral Artery Disease May 21, 2011 16:30–18:00

V8-1 COMPLEX TREATMENT OF CHRONIC LOWER LIMB ISCHEMIA: COMBINATION OF RECONSTRUCTIVE SURGERY WITH ANGIOGENIC GENES TRANSFER

D.A. Voronov, A.V. Gavrilenko, N.P. Bochkov

Russian Scientific Centre of Surgery named after Academician B.V. Petrovskii RAMS, Moscow, Russian Federation

Objective: To improve results of the treatment of lower limb ischemia using gene transfer of vascular endothelial growth factor (VEGF) and angiogenin (ANG).

Methods: Overall 114 patients (103 males and 11 females, aged 43–75 years, mean age 59±6 years) with distal forms of lower limb arterial occlusive diseases were included in the study. Limb ischemia of IIB stage was diagnosed at 73 patients, III stage – at 41. Ten patients had small trophic ulcers on toes. Patients were divided into study (treated additionally with gene therapy, n=59) and control (treated only with traditional conservative or surgical methods, n=55) groups. In study group original gene constructions (naked and adenoviral recombinant plasmids) with VEGF (10 patients), ANG (35 patients) and their combination (14 patients) were administered by percutaneous intramuscular injections into tibial muscular group of affected lower extremity. This procedure was independent method of treatment in 24 patients (subgroup A), in the other 35 patients (subgroup B) this method was complementary to femoro-popliteal autovenous bypass (21), aorto-femoral bypass (9) and arterialization of calf and foot superficial venous blood system (5). Duplex scanning, tredmill-test, angiography, percutaneous detection of tissue oxygen tension, radionuclide imaging were made in all the patients before and after gene transfer procedures.

Results: There were no major side effects in our study. Long-term results were assessed in 103 (90.4%) patients, the follow-up ranged from 6 to 30 months. All the patients of subgroup A demonstrated positive clinical results increase of distance to pain in 3–5 times, healing of trophic ulcers. Special methods of examination revealed increase of ankle-brachial index (P=0.06), tissue oxygen tension (P<0.05), perfusion of lower extremities muscles (P<0.001), and reduction of restoration time during tredmill-test (P<0.01). Patients of the subgroup B demonstrated better results of the same methods of special examination (including exercise tests, perfusion, quality of life indices) compared with similar patients undergoing only reconstructive vascular operation.

Conclusions: Angiogenic genes transfer can be considered as a safe and effective method to improve results of treatment of lower limb ischemia. Combination of surgical revascularizations and gene therapy methods leads to better results compared with two independent methods of treatment.

V8-2 EARLY RESULTS OF THE DISTAL VENOUS ATERIALISATION IN THE TREATMENT OF CRITICAL LOWER LIMBS ISCHEMIA

P. Djoric, L. Davidovic

Clinic for Vascular Surgery, Serbian Clinical Center, Belgrade, Serbia

Objective: The outcome of the treatment in the patients with critical limb ischemia (CLI) is poor in keeping with morbidity and mortality, particularly in end-stage disease when the reconstructive procedure is not feasible. In the patients we may use distal venous arterialisation (DVA) as a limb salvage procedure.

Methods: In this prospective randomized study we have shown the early results of the treatment of 36 unreconstructable patients with critical lower limb ischemia. There were two groups of patients: 18 were treated with distal venous arterialisation (DVA) and 18 were conservatively (CT) using antiplatelet drugs. There were 12 men and six women with the average age 66.1±10.3 in DVA and 10 men and eight women with the average age 68.4±9.8 in CT groups of patients. The aim of the study was to estimate the validity of distal venous arterialisation (DVA) as a limb salvage procedure.

Results: During the period of observation, morbidity and mortality rates were 38.9% and 0% at DVA vs. mortality rate at CT group 27.8% (P<0.05). The mean follow-up period for DVA was 4.8±3.5 months (range 1–14) vs. 5.1±2.4 months (range 1–9) for CT group (P>0.05). Graft patency was 83.3% with three early graft thrombosis. There were significant differences between the two groups in survival (100% DVA vs. 72.2 CT, P<0.05), limb salvage (94.4% DVA vs. 16.7% CT, P<0.001), pain relief (77.8% DVA vs. 5.6% CT, P<0.001) and wound healing rate (85.7% DVA vs. 0% CT, P<0.001). Decreasing lactate level in the blood of deep venous system after successive measuring was significant after MANOVA method was applied (F=17.82, P<0.001). Also, hemodynamic parameters such as systolic pressure and digito-brachial systolic pressure index were increased after revascularisation using Student’s t-test (P<0.001).

Conclusions: DVA may significantly enhance the effects of the treatment of the patients with critical lower limbs ischemia, caused by the unreconstructable arterial disease, particularly in the selected cases.

V8-3 CD 34+ AND VEGF 165 IN TREATMENT OF CHRONIC LIMB ISCHEMIA

O.A. Demidova, L.A. Bockeria, M.V. Eremeeva, V.S. Arakelyan

Bakoulev Scientific Center of Cardiovascular Surgery, Moscow, Russian Federation

Objective: The purpose of our study was to assess the efficacy of angiogenesis stimulators in the treatment of critical limb ischemia.

Methods: Sixty-six patients, aged 30–76 years (mean age 58.2±12.1 years) with critical limb ischemia involved in the study. Atherosclerosis was determined as etiologic factor in 60 patients (91%) and thromboangiitis obliterans in six cases (9%). In all patients we revealed multisegmental lesion of lower limb arteries with high peripheral resistance. Seventeen patients (I group) received autologous endothelial progenitor cells CD 133+ and 49 patients (II group) underwent treatment with 1000 m kg of ‘angiostimulyn’. Concomitant therapy only included acetylsalicylic acid in dose 100 mg per day. Follow-up was performed in 1, 3, 6 and 12 months after injection of stimulator of angiogenesis.

Results: Clinical improvement observed in all patients at three months after the injection of an isolated stimulator of angiogenesis. After six months, the achieved effect was persisted in all patients in group I and in 39 (80%) in group II. Maximum improvement was +2 by Rutherford. By 12 months the clinical condition of the affected limbs was unchangeable. Increasing of the maximum walking duration was observed at the whole follow-up period, to a lesser extent in the first months, more – in the further ones. At six months a significant increase in the partial oxygen pressure on the skin (by 16.0 mmHg in group I, by 13.0 mmHg in group II) and ankle brachial pressure index (by 0.18 and 0.1 in group I and II, respectively) has been found. Growth of the collateral network density at the three-month, evaluated by angiography, amounted +2.28 in group I, +2 in group II. According to the SF-36 questionnaire, patients reported improvement in the quality of their life.

Conclusions: The use of stimulants can improve treatment outcomes in patients with chronic lower limb ischemia. Positive dynamics of clinical condition is limited by a moderate improvement. So it can not be used as a isolated method in patients with extended necrosis in the limbs.

V8-4 FEATURES OF ACUTE ISCHEMIA FOLLOWING ARTERIAL LIGATION OPERATIONS IN DRUG-ADDICTED PATIENTS WITH POST-INJECTION PSEUDOANEURYSMS OF PERIPHERAL ARTERIES

V.V. Karpov, S.V. Gryaznov, A.P. Shvalb, N.D. Mzhavanadze Ryazan

Ryazan Regional Vascular Surgery Center, Ryazan, Russian Federation

Objective: To study the development of acute limb ischemia following ligation of large limb arteries in drug-addicted patients with post-injection pseudoaneurysms of peripheral arteries.

Methods: This study represents the analysis of the results of treatment of 107 patients with post-injection pseudoaneurysms of peripheral arteries from 2005 to 2009.

Results: We performed 112 arterial ligation operations in 107 patients. Ninety-six (90%) patients were admitted to the hospital with aneurysmal bleeding. All of these patients required urgent surgery. After ligation of external iliac artery and resection of pseudoaneurysm, amputation was performed in 15 (14%) patients on the second day following the primary surgery due to the development of irreversible ischemia, two (1.9%) of these patients with underlying sepsis died due to the severity of the disease. Thus, 92 (86%) patients were dismissed from the hospital with the salvaged limbs which is quite uncommon in such cases and is a matter for further investigation. Analysis of the causes of ischemia showed that palpable or absent peripheral pulses might serve as a marker for the outcome of treatment as only two patients in absence of peripheral pulse required further secondary thigh amputation which is only 2.5% of patients with absent peripheral pulse. Thirteen secondary amputations were performed in patients with palpable peripheral pulse which is 46.5% out of patients with palpable peripheral pulse. We found a statistically reliable difference in secondary amputation rates after arterial ligation in patients with palpable or absent peripheral pulse (P<0.05).

Conclusions: There might be two reasons explaining the phenomena described above: 1. The presence of mobilized collateral supply developing during the process of thrombosis of large limb arteries which is found in 79 (74%) patients; 2. Neoangiogenesis developing due to constantly resuming inflammatory process in infrainguinal area verified by morphological study.

V8-5 TARGET EXTREMITY RE-INTERVENTION FOLLOWING FAILED ENDOVASCULAR INTERVENTION FOR TREATMENT OF CRITICAL LIMB ISCHEMIA

M.L. Dryjski¹, M.S. O’Brien-Irr², L.M. Harris¹, H.H. Dosluoglu³

¹University at Buffalo and Kaleida Health, Buffalo, USA; ²Kaleida Health, Buffalo, USA; ³University of Buffalo, Buffalo, USA

Objective: To evaluate outcomes following target extremity re-intervention (TER) following endovascular intervention (EVI) for critical limb ischemia (CLI): Rutherford class; RC-4: rest pain, RC-5: tissue loss.

Methods: The medical records of all EVI performed for CLI by vascular surgeons at a single institution over a three-year period were reviewed to identify those requiring TER. The following were analyzed; co-morbidities, RC, TASC, EVI type, site: infra-inguinal vs. infra-genicular, time to TER, TER type and site, post-TER limb salvage, survival and secondary sustained clinical Success (SSCS)-Rutherford improvement score (RIS)=2+, no CLI symptoms, ABI increase >0.10, no recurrent or new ulceration.

Results: TER was required in 40 (38%) of 106 EVI. No significant difference in co-morbidities, TASC, type/site of EVI was noted between those requiring TER and those who did not. The mean time to TER was 8.5 months (1–34). TER was completed for moderate-marked worsening of symptoms (RIS -2 – -3) in 21%. SSCS was not significantly influenced by RIS at TER (P=0.86). Only 18% of TER did not involve the original EVI site. Twenty-six percent were open procedures. Of these, 30% were preceded by EVI. Post-TER SSCS was comparable for open and EVI (30% vs. 46%, P=0.39). Multiple TER was completed in 18%. SSCS was poorer, but not significantly different than those requiring single TER (29% vs. 44%, P=0.49). SSCS was comparable in those who required TER vs. those who did not (41.7% vs. 57.9, P=0.13), as was 24-month limb salvage (92.2% vs. 85.6%, P=0.35) and survival (73% vs. 66%, P=0.36).

Conclusions: TER is beneficial to improving outcome following failed primary EVI. Endovascular approach may be superior to open repair. Although SSCS is inferior when multiple TER is required, nearly 1/3 of failed EVI may improve.

V8-6 PEDAL BYPASS GRAFTING IN THE TREATMENT OF CHRONIC CRITICAL LOWER LIMB ISCHAEMIA

R. Staffa, Z. Kriz, J. Bucek, T. Novotny, M. Dvorak

St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic

Objective: Patients who underwent pedal bypass grafting during the last decade were evaluated. All were at high risk for lower-extremity amputation and the possibilities of endovascular and conservative therapy were exhausted.

Methods: In the period of February 2001–July 2010, 110 pedal bypass procedures (using utogenous vein graft) were carried out in 110 patients with chronic critical lower limb ischaemia. The group included 82 men (74.5%) and 28 women (25.5%) with an average age of 67 (range 28–84) years. In this group 73 (66.4%) had diabetes. Gangrene or tissue loss was diagnosed in 93 limbs (84.5%), rest pain was recorded in 8 (7.3%), acute thrombosis of crural arteries in five (4.5%) and trauma in four (3.6%) limbs. Statistical data were analyzed to assess the influence of patient diabetes, pedal bypass length, distal anastomosis placement and spliced graft use on the long-term results. Using Kaplan–Meier survival analysis, primary and secondary bypass patency and the limb salvage rates were evaluated both in the whole patient group and in the subgroups. The results between the relevant subgroups were compared using the Log Rank test (confidence intervals 95%, level of significance α=0.05).

Results: With the exception of one patient, healing of the wound was achieved in all limbs with functioning pedal bypass. In four limbs it was necessary to use a free muscle flap whose artery was anastomosed to the pedal bypass. At follow-up period (average 30±26.4 months; range 1.2–91.2 months), bypass occlusion occurred in 21 limbs; in eight of them it was managed by early intervention. None of the patients died during the surgical procedure. The 30-day postoperative mortality was 1.8%. The cumulative primary and secondary patency rates were 67.2% and 69.5%, respectively; the cumulative probability of limb salvage was 78.0%. Diabetes mellitus has no influence on long-term bypass patency and limb salvage. Bypass grafts shorter in length showed higher both primary and secondary patency rates. The site of target artery anastomosis did not affect long-term results, but the use of spliced grafts had adverse effects on the bypass primary patency.

Conclusions: Pedal bypass grafting is safe and effective method, which provide very good long-term results in the treatment of chronic critical lower-extremity ischaemia, including diabetic gangrene, in patients with occlusive disease of the crural arteries.

V8-7 DEBITOMETRY IN OUTCOME FORECASTING OF LOWER LIMB ARTERY RECONSTRUCTIONS IN ELDERLY AND SENILE PATIENTS

F. Aghayev, G.G. Khubulava, A. Sazonov, K. Kitachov

Medico-Military Academy, Saint Petersburg, Russian Federation

Objective: Reconstructions of an aorto-femoral segment remains high-risk interventions for elderly patients. A main cause of its unsuccessfullness are postoperative thromboses in the early postoperative period, meeting in 7.2–29.5% of reconstructive operations. Graft permeability depends on type of operation, a graft material, its lengths, a condition of coagulation system, however a distal vascular patency has crucial importance. Adequacy of distal vascular throughput is one of key determinants of arterial reconstruction outcome. The most objective method of peripheral vascular throughput definition is debitometry. The method essence – flow rate of a physiological saline under constant pressure.

Methods: We work out a method of debitometry – perfusion roller debitometry. The device for liquid forcing in a vessel is roller pump, allowing to support perfusion pressure at constant level. Sixty patients were examinated by this technique during reconstructive surgery. Twenty aorto-femoral and 40 femoro-popliteal reconstructions were included in study. The age of patients was 60–75 years. Two groups of patients depending on a reconstruction outcome have been allocated: with the patentsy of grafts (I) and its early postoperative thrombosis (II). Supervision terms was one, three, six and 12 months after surgery.

Results: In first group intraoperative flow rate through aorto-femoral segment was 450–1100 ml/min, at reconstruction of a femoro-popliteal segment– 400–900 ml/min. In second group a flow rate was <400 ml/min at aorto-femoral reconstruction, and <350 ml/min at femoro-popliteal reconstruction.

Conclusions: Flow rate <400 ml/min at aorto-femoral reconstruction and <350 ml/min at femoro-popliteal reconstruction with use heparinised physiological saline leeds operation to failure.

V8-8 CRITICAL LIMB ISCHEMIA – POPULATION CHARACTERISTICS

J. Ferreira, A. Canedo, D. Brandao, J. Vasconcelos, S. Braga, R. Gouveia, A. Vaz

CHVNG/E, VilaNova de Gaia, Portugal

Objective: Characteristics of the population with critical limb ischemia in our institution.

Methods: Revision of the medical records of consecutive patients with critical limb ischemia between 1990 and 2009.

Results: From 3241 patients with peripheral arterial disease, 620 had critical limb ischemia (179 at III and 441 at IV Fontaine stages). The mean age was 70.77±11.11 years, while the age of the claudicants’ patients was 66.65±10.91 years (P<0.05). In both groups the majority of patients were males; however, the difference between genders becomes shorter with the severity of peripheral arterial disease. In this way, there was 25% females in the claudicants group, 28.5% in stage III and 42.6% in stage IV (P<0.05). The mean follow-up time was 3.19±3.30 years, and the ankle brachial pressure index at admission was 0.31±0.18. 33.71% were smokers, 36.1% had hypertension, 40.5% dyslipidemia, 52.4% diabetes. Comparing the distribution of these risk factors between the group of claudicant and critical limb ischemia, the only difference found was about diabetes (52.4% vs. 37.1%, P<0.05). There was also an increase in the prevalence of diabetes in 19.05% between 1990 and 2009. 43.39% of critical limb ischemia patients were revascularized, 15.97% were submitted to amputation and 4.84% to endovascular intervention. The age was related with the kind of surgical intervention (68.07±10.67 years in patients submitted to surgical revascularization and 70.59±10.67 primary amputation, P<0.05).

Conclusions: The mean age and the prevalence of diabetes in patients with critical limb ischemia were superior to the claudicants. With the expected increment in the prevalence of diabetes and with population aging, the number of patients with critical limb ischemia will increase.

V8-9 EFFICIENCY OF CELL THERAPY IN PATIEnTS WITH CHRONIC LIMB ISCHEMIA

V.N. Vavilov¹, V.M. Sedov¹, A.Y. Zarickyi¹, I.Y. Senchik¹, A.N. Krutikov², V.M. Lapina¹, A.V. Krilov³, D.G. Polincev³

¹SPbMU, St. Petersburg, Russian Federation; ²FC Heart, blood and endocrinology, St. Petersburg, Russian Federation; ³‘Transtehnologii’, St. Petersburg, Russian Federation

Objective: Results of autologus mesenchymal stem sell therapy in patients with critical limb ischemia.

Materials and methods. Over the last four years 18 patient with chronic limb ischemia were enrolled in the study. Age from 36 to 76 years old (average 62.5 years old), male – 15, female – 3. All patients were divided into two groups: (I group) six patients with high-grade claudication (50 m and less) or rest pain (IIb stage Leriche-Fountain), (II group) 12 patients with rest pain combined with trophic ulcer (III – IV stage Leriche-Fountain). All patients received standard pharmtherapy and 12 of them underwent unsuccessful vascular surgery before. Clinical status, angiography, ankle blood pressure, percutaneous oxygen partial pressure were estimated according to clinical protocol. Autologous mesenchymal stem cell were taken from iliac bone and cultivated in vitro then injected intramuscularly in 32–34 sites of groin (1.5 ml\site) and intravenous (1 ml/1 kg of weight in 100 saline solution).

Results: In group I all limbs have been saved, rest pains disappeared and pain free walking distance increased significantly. In seven patient of II group 2–3 months after implantation of mesenchymal cells pain-free walking distance increased, rest pain disappeared, ulcer and necrosis decreased in area. All limbs were saved. Clinical evidence we obtained consist in percutaneous oxygen partial pressure and ankle blood pressure gradually increasing. In five patients of II group ischemia and necrosis damage increased, we did not observe any changes in ankle blood pressure and finally they underwent amputation (four groin level and one femur level).

Conclusions: Cell therapy in patients with limb ischemia allowed limb salvage (13 patients from 18 (72%), in 58% patients (seven patients from 12 with critical limb ischemia) efficiency of cell implantation can be observed even 4–4.5 years after procedure.

13th Cardiac Surgery Session - Mitral Valve May 22, 2011 09:00–11:00

C13-1 MID-TERM OUTCOME OF MITRAL VALVE REPAIR WITH CONCOMITANT CORONARY ARTERY BYPASS GRAFTING FOR ISCHEMIC OR DEGENERATIVE MITRAL REGURGITATION

P. Nardi, A. Pellegrino, A. Lio, G. Chiariello, L. Ragni, A. Serrao, L. Chiariello

Tor Vergata University of Rome, Policlinico Tor Vergata, Rome, Italy

Objective: To verify the impact of etiology of mitral regurgitation on five-year survival and event-free survival after mitral valve repair and concomitant coronary artery bypass grafting surgery, and to identify independent risk factors.

Methods: One hundred and elven consecutive patients (mean age 69±8 years, 79 males) who underwent mitral valve repair (65 for ischemic, 46 for degenerative etiology) and coronary artery bypass grafting were retrospectively analysed. Transthoracic echocardiography was performed in all patients preoperatively, postoperatively and at follow-up. Mean follow-up (100% complete) was 39±28 (9–104) months. Outcomes considered were in-hospital and late all-cause mortality, event-free survival (death, postoperative low out syndrome, freedom from mitral valve reoperation, onset or worsening of congestive heart failure), late cardiac death.

Results: As compared to degenerative, ischemic etiology was associated with higher incidence of diabetes mellitus (P=0.05), peripheral vascular disease (P=0.04), and myocardial infarction (P<0.0001), lower LVEF (0.39±10 vs. 0.57±13) (P<0.0001), greater number of diseased coronary vessels (2.6±0.7 vs. 1.7±0.8) (P<0.0001) and grafts per patient (2.7±0.9 vs. 1.8±0.9) (P<0.0001). Annuloplasty prosthetic ring was performed in 84 patients (76%). Operative mortality was 7.7% (5/65) for ischemic, absent for degenerative etiology (P=0.06). Five-year survival for all patients was 77±5%. Independent predictors of overall mortality were older age at operation (75±7 vs. 68±8 years) (P<0.001), LVEF <0.45 (P<0.05), and ischemic etiology of mitral regurgitation (P<0.05). At five years survival was 87±6.5% in patients affected by degenerative as compared to 69±7.6% in those affected by ischemic etiology (P<0.05), event-free survival 75±8% vs. 58±8.4 (P=0.01), and freedom from late cardiac death 100% vs. 85±6.6% (P<0.05). Five-year freedom from reoperation was 97±2.4%. Follow-up echocardiography showed significant improvement of mitral regurgitation (0.8±0.6 vs. 3.0±0.8 preoperatively) (P<0.00001); left ventricular end-diastolic diameter decreased from 60±7.5 mm preoperatively to 55±10 mm (P=0.001), end-systolic diameter from 43±8 mm to 41±10 mm (P=0.05), systolic pulmonary artery pressure from 40±16 to 34±10 mmHg (P=0.001). NYHA class improved from 2.5±0.9 preoperatively to 1.6±0.7 at follow-up (P<0.0001). Freedom from myocardial infarction was 98%.

Conclusions: Ischemic mitral regurgitation is associated with higher incidence of multivessel coronary artery disease and comorbidity and ischemic etiology ‘per se’ predicted a worse mid-term outcome. Freedom from reoperation is higher and results after mitral valve repair are associated with a stable result in time. Coronary artery bypass grafting guarantees high freedom from myocardial infarction.

C13-2 THE RESULTS OF CONSERVATION OF THE FIBRO-VENTRICULAR CONTINUITY DURING MITRAL VALVE REPLACEMENT IN PATIENTS WITH RHEUMATIC HEART DISEASE

I.V. Abdulyanov, R.K. Dzhordzhikiya, I.I. Vagizov, M.N. Mukharyamov

MKDC, Kazan, Russian Federation

Objective: To determine the clinical and functional Results of creating artificial chords with polytetrafluoroethylene (ePTFE-Gore-Tex) sutures during mitral valve (MV) replacement in patients with rheumatic heart disease.

Methods: MV replacement was performed in 67 patients with cardiopulmonary bypass (CPB) and cardioplegia by mechanical bicuspid prosthesis ‘MEDING 2’ with the creation of neo-chords with ePTFE sutures. The mean age was 52.4±1.5 years. Twenty-nine patients had predominant mitral regurgitation (I group), 38 patients had a combined defect with the predominance of stenosis (II group). NYHA functional class in group I was 2.9±0.2, in group II – 2.8±0.1. The functional (echocardiography) and clinical data were evaluated before and 3–5 years after surgery.

Results: The posterior cusp had been left completely in 78% of patients, in all other cases it was partially excised. The anterior cusp was resected leaving one native primary chord in 32 patients, the second neo-chord was formed by ePTFE sutures (4/0, 3/0). Resection of the anterior leaflet with the chords was performed in 35 patients in whom two neo-chords with ePTFE were subsequently created. The neo-chords were fixed to the fibrous ring of the MV in the projection of the segments A1 and A3. Prior to surgery, the ejection fraction (EF) in patients in group I was 52.8±1.6%, in group II – 53.7±1.4%. Three years after the operation the EF in patients of group 1 increased and amounted to 55.8±1.1% (P=0.06), in patients with initial mitral stenosis the EF did not change – 52.7±0.5% (P=0.1). The size and volume of the LV of patients in group I underwent significant positive changes towards reduction (P≥0.05), and in group II – did not change significantly (P≥0.05). In both groups there was a linear decrease in LA size and systolic PA pressure (P≥0.005). None of patients had neither prosthesis dysfunction by neo-chord obstructions nor neo-chord flotation during systole and diastole.

Conclusions: Preservation of the fibro-ventricular connection with ePTFE sutures has a positive impact on the clinical and functional indicators. Optimally designed neo-chord do not disrupt the geometry of the LV and do not hinder the function of the bicuspid mechanical prosthesis.

C13-3 EARLY OUTCOME OF CHORDAL RECONSTRUCTION FOR THE REPAIR OF ISOLATED POSTERIOR MITRAL LEAFLET PROLAPSE

K. Nishigawa, H. Takiuchi, Y. Kubo, H. Kubo, Y. Yunoki, A. Tabuchi, H. Masaki, K. Tanemoto

Kawasaki Medical School, Kurashiki, Japan

Objective: Although mitral valve (MV) repair with leaflet resection for posterior mitral leaflet (PML) prolapse provides excellent long-term outcomes, this technique does not respect the anatomic and physiological role of PML. Recently, chordal reconstruction (CR) using expanded polytetrafluoroethylene (ePTFE) sutures has been widely applied for PML prolapse. The objective of this study was to evaluate the early outcomes of MV repair with CR for mitral regurgitation (MR) due to isolated PML prolapse.

Methods: Fourteen patients (male/female=6/8, age from 36 to 77 years) who underwent MV repair with CR for isolated PML prolapse were enrolled. Preoperative echocardiography demonstrated moderate (n=1) or severe (n=13) MR. The mean NYHA class was 2.6±1.2. Routinely, we used CV-4 ePTFE sutures as artificial chords. The annuloplasty using a semi-rigid complete ring was performed in all cases (mean ring size=30.1±1.8 mm). After the ring was implanted, the lengths of artificial chords were determined by saline infusion test. No patient required leaflet resection. Early postoperative and intermediate-term echocardiographic examination was performed 7±0.9 days (range 5–8) and 7.1±5.8 months (range 2–20) after surgery, respectively.

Results: Repair was successfully performed in all patients. Mean in-hospital stay was 14±2 (range 10–18) days and there was no operative death. Early postoperative echocardiography showed reduced MR grade of none or trivial in all patients except only one patient, who had mild MR; the patient subsequently required reoperation for recurrent MR 1.5 years after surgery. In other patients, intermediate-term echocardiography demonstrated that the residual MR is less than mild.

Conclusions: CR is an effective and highly reproducible procedure for the repair of isolated PML prolapse. Special attention should be paid not to leave the artificial chords too long, since longer artificial chords may lead to the recurrent MR for abnormal motion like systolic anterior motion of the PML after surgery.

C13-4 FIFTEEN-YEAR OUTCOMES AFTER MITRAL VALVE REPAIR SURGERY FOR DEGENERATIVE MyXOMATOUS DISEASE AND RISK FACTORS ANALYSIS

P. Nardi, A. Pellegrino, C. Olevano, A. Scafuri, P. Polisca, L. Chiariello

Policlinico Tor Vergata, Tor Vergata University of Rome, Italy

Objective: The aim of the study is to evaluate long-term results after surgery of mitral valve repair for the treatment of degenerative myxomatous mitral regurgitation and to analyse risk factors for late outcomes.

Methods: Three hundred and five patients (mean age 62±12 years, 197 males, 108 females) underwent mitral valve repair from January 1992 to February 2010 for the treatment of degenerative myxomatous mitral regurgitation. For the past five years, we have standardized repair techniques by means of intraoperative transesophageal echocardiography, routinely using annuloplasty prosthetic ring, quadrangular or triangular resection of posterior leaflet and/or edge-to-edge technique. Mean follow-up (98% complete) was 70±46 (range 2–220) months.

Results: In-hospital mortality was 0.9% (3/305). At 15 years actuarial survival was 82±4%, freedom from cardiac death 89±4%, freedom from reoperation 84±6%. Independent predictors of late all-cause mortality were elderly age at operation (P=0.0006) and annuloplasty without the use of prosthetic ring (P=0.0019). Progression to moderate-severe mitral regurgitation after mitral valve repair was observed in 23 patients (7.7%), and reoperation was required in 13 (4.4%). Independent predictors of progression to moderate-severe mitral regurgitation were annuloplasty without the use of prosthetic ring (P=0.0053) and residual mitral regurgitation of mild grade (2+) at discharge (P=0.0014). Residual mild regurgitation was more frequent after annuloplasty without use of prosthetic ring (14/85 patients vs. 11/217 with use of ring; P=0.001). At 15 years freedom from progression to moderate-severe mitral regurgitation was 55±13% for annuloplasty without the use of prosthetic ring vs. 82±6% with the use of prosthetic ring (P<0.0001), and was 38±15% in patients with residual mild regurgitation at discharge vs. 77±14% and 80±7% in patients with residual trivial or without regurgitation, respectively (P<0.0001). Freedom from late reoperation was 90±4% for isolated posterior, 56±32% for isolated anterior, 93±5% for bileaflet prolapse, and 86±9% for prevalent annular dilation (P=0.05). Follow-up echocardiography showed improvement of mitral regurgitation grade (0.95±0.9 vs. 3.5±0.5 preoperatively, P<0.00001), left ventricular end-diastolic (52±6.0 mm vs. 57±11 mm, P<0.0001) and end-systolic (34±5 mm vs. 42±9 mm, P<0.00001) diameters. NYHA functional class improved from 2.8±0.8 preoperatively to 1.5±0.7 during follow-up (P<0.00001).

Conclusions: Mitral valve repair is a low risk and durable surgical procedure. Standardized techniques of leaflet repair associated to the routine use of prosthetic ring guarantee excellent long-term results.

C13-5 MINIMAL-INVASIVE VERSUS CONVENTIONAL MITRAL VALVE SURGERY: A 3-YEAR EXPERIENCE WITH 251 PATIENTS IN A SINGLE CENTRE

A. Koch¹, Samir², A. Maisary², U. Tochtermann, F.U. Sack³, M. Karck²,

¹Westgerman Heart Centre, Essen, Germany; ²University of Heidelberg, Heidelberg, Germany; ³Heart Centre Ludwigshafen, Ludwigshafen, Germany

Objective: This study analyses a single institutional experience with isolated mitral valve procedures, reviewing short-term morbidity and mortality.

Methods: Two hundred and fifty-one consecutive patients had either conventional or minimal-invasive mitral valve procedures between October 2006 and August 2009. One hundred and twenty-eight patients (51%) underwent conventional mitral valve surgery (CG) via sternotomy (mean age 66±12 years; 38 (29.9%) preoperative NYHA-class >III) and 123 (49%) underwent minimally-invasive mitral valve surgery (MG) via a right anterior mini-thoracotomy under direct vision (mean age 63±12 years, P<0.05; 15 (12%) preoperative NYHA-class >III).

Results: Hospital mortality for MG was in two patients (1.6%) and 15 patients (11.8%) in CG. Mean cross-clamp time was 105±30 min vs. 76±35 min (n.s.) and mean cardiopulmonary bypass time was 172±57 min vs. 132±45 min (n.s.) for MG and CG. Postoperative ventilation time was 38±74 h (minimal-invasive) and 61±190 h (conventional group) (n.s.) and in-hospital stay was 11±10 days (n.s.) in both groups. The incidence of neurologic events was two (1.6%) patients in MG and three (3.4%) in CG (n.s.).

Conclusions: This study demonstrates that the minimal-invasive mitral valve approach achieves similar results as the conventional and it is associated with low morbidity and mortality. In view of the advantages in terms of postoperative ventilation time and short-term morbidity, minimally-invasive approaches for mitral valve surgery deserve expanded use.

C13-6 A RELIABLE EFFECTIVE AND ECONOMIC MITRAL ANNULOPLASTY FOR ISCHEMIC MITRAL REGURGITATION USING A SELF-MADE AND SINGLE-SIZED PTFE BAND

A. Panza, S. Iesu, P. Masiello, O. Priante, G. Mastrogiovanni, F. Itri, R. Leone, G. Di Benedetto

San Giovanni e Ruggi University Hospital, Salerno, Italy

Objective: The ideal mitral ring should contribute to correction of the MR without interfering with the dynamic properties of the left-side valves. An incomplete and flexible prosthetic ring preserves the sphincteric asset of the mitral and aortic annuli (sisto/diastolic valve area variation). In ischemic MV, anatomic studies have shown that the annulus circumference, the anterior mitral leaflet (AML) height and the intertrigonal distance have minimum variability (130 mm, 27 mm and 26 mm, respectively). A 62 mm posterior band placed trigone-to-trigone leads to a septo-lateral diameter of 20 mm, which will be entirely covered by the AML (with a good coaptation length). In this study we present our experience in the treatment of ischemic MV regurgitation (IMVR) using an incomplete self-made and single-sized PTFE band (62 mm) implanted from trigone to trigone.

Methods: From January 2009 to December 2010, 45 consecutive patients (mean age: 66.3±8.7 years; men: 65%) underwent surgery for IMVR. From a PTFE 4 mm tube a standard-sized 62 mm segment was cut. All patients received this incomplete self-made PTFE band, implanted from trigone to trigone. Mean preoperative EF was 0.45±0.9, mean logistic EuroSCORE was 12. All patients had MR >2+ and MR 4+ was present in 60%. All adequate coronary targets were revascularized using the off-pump technique whenever possible.

Results: Operative mortality was 8.8%. Mean graft/patient ratio was 2.2. At hospital discharge no patient had MR >2+. Mean preoperative MR turned from 3.4±0.5 into 1.2±0.8 (P<0.001). At follow-up only one patient presented an MR 2+. Preoperative mean mitral valve area changed from 6.7±4.3 to 2.9±0.5 cm². Mean preoperative NYHA class reduced from 3.3±0.5 to 2.2±0.6 (P<0.001).

Conclusions: In IMVR, the length of this self-made PTFE band allowed us to obtain reproducible results with good MV competence and without MV obstruction. The degree of the overreduction was always effective. We think that this standard-62-mm band anchored between right and left fibrous trigones provides a reliable, effective and economic annuloplasty in the treatment of IMVR. Long-term follow-up is required to evaluate this promising results.

C13-7 CRYOABLATION VERSUS RADIOFREQUENCY ABLATION IN SURGICAL TREATMENT OF ATRIAL FIBRILLATION – 4-YEAR DATA FROM PROSPECTIVE RANDOMISED TRIAL

P. Suwalski¹, G. Suwalski², A. Witkowska¹, J. Kochanowski³, P. Scislo³, R. Wilimski³, K.B. Suwalski¹, R. Cichon³

¹Central Clinical Hospital of the Ministry of Internal Affais, Warsaw, Poland; ²Military Institute of Medicine, Warsaw, Poland; ³Warsaw Medical University, Warsaw, Poland

Objective: This prospective randomized all-comers study was constructed to compare effectiveness of endocardial cryoablation and radiofrequency ablation in surgical treatment of atrial fibrillation (AF) in ‘real world’ not selected consecutive mitral valve patients.

Methods: Between January 2002 and June 2006, 76 patients with atrial fibrillation were submitted to different combinations of mitral valve surgery and randomized to concominant left atrial modified Maze procedure using either irrigated radiofrequency energy (RF group, n=40) or liquid nitrogen cryothermy (CRYO group, n=36). Trial was designed prospectively for two and extended to four years. Mean age (61.5±9.2 years), left atrial diameter (54±10 mm), AF duration (3.8±4.2 years), ejection fraction (50.5±11.6%), NYHA class (2.3±0.6); EuroSCORE (6.9±6.8%) did not significantly differ between groups. The identical ablation pattern using unipolar irrigated radiofrequency and self-constructed liquid nitrogen cryothermy devices was performed. Prospective follow-up was collected during hospitalization and 3, 6, 12, 24 and 48 months after discharge including 24-h Holter ECG and echocardiography.

Results: There were three in-hospital deaths, not related to ablation. Only three patients were lost to follow-up after four years. Two patients died during follow-up. Sinus rhythm rates were observed in RF group and CRYO group, respectively, at ICU discharge (63.1% vs. 74.2%), at hospital discharge (78.9% vs. 74.2%), after three months (68.4% vs. 71.4%), after six months (76.3% vs. 74.2%), after 12 months (73.7% vs. 72.4%), after 24 months (72.2% vs. 72.7%) and after 48 months (71.4% vs. 69.7%). None of differences were statistically significant (P<0.05).

Conclusions: Endocardial cryoablation and radiofrequency ablation for treatment of atrial fibrillation give similar and satisfactory results in long-term follow-up in real world non-selected population of mitral valve patients. Those findings support the thesis that, independently on the energy source, the paradigm of gaining transmurality in a particular surgical setting should be a major concern.

C13-8 PLICATION PLASTY OF THE GIANT LEFT ATRIUM AND THE FREQUENCY OF CONDUCTION DISORDERS

A. Gurschenkov, I.V. Sukhova, P.V. Gracheva, A.V. Naimushin, M.L. Gordeev

Federal Centre of Heart, Blood and Endocrinology named after V.A. Almazov the Health Ministry, St. Petersburg, Russian Federation

Objective: To assess the possible impact of plication plasty of the left atrium to the frequency of implantation of permanent pacemakers.

Methods: We studied the traditional ECG data, as well as daily ECG monitoring in 237 patients with giant left atrium undergoing correction of mitral valvular disease. Of these, 107 patients additionally was performed plication plastic of the left atrium (left atrial size reduction). One hundred and thirty patients suffered from an isolated correction of mitral valvular disease. We used data from three time points – before surgery, after surgery (before discharge), in the late period (in terms from six to 30 months after surgery). In the late period were examined 117 patients. Giant left atrium assumed increase in anterior – posterior left atrium size >50 mm. Left atrial size in the group with plication plastic of the left atrium and unlabeled before surgery was 68±13 and 64.4±6 mm, respectively, and did not differ significantly (P=0.6). Plication plastic of the left atrium included closure of the left atrium appendage, the imposition of plication paraannular suture in the zone between the pulmonary vein orifices. In some cases, superimposed plication suture on the roof of the atrium. Indication for the permanent pacing in the studied population of patients was the presence of periods of ventricular asystole lasting more than 3 s on the background of atrial fibrillation. It was compared the frequency of implantation of permanent pacemakers in the groups with and without plication plastic of the left atrium using Pearson χ²-test. Taken into account only those cases neo-implanted pacemakers at each time point.

Results: Before surgery, the number of permanent pacemakers between groups with and without plication plastic of the left atrium did not differ significantly (P=0.45) – a group with plication plastic of the left atrium pacing had two (1.87%) patients in the group without it one (0.77%). In early postoperative period there are significant differences between groups (P=0.02) – out of 105 patients with left atrial size reduction pacemakers were implanted 11 (10.5%). Out of 128 patients without left atrial size reduction pacemakers was implanted in four (3.125%) cases. In the late postoperative period also revealed significant differences between groups with left atrial size reduction and without it (P=0.03). Number of permanent pacing was, respectively, seven (14.3%) of 49 patients examined with left atrial size reduction group and two (3.2%) in 63 patients of the group without it.

Conclusions: Performing plication plasty of the left atrium was associated with significantly greater frequency of conduction disorders that require permanent pacing.

C13-9 CLINICAL SIGNIFICANCE OF DETERMINATION OF BRAIN NATRIURETIC PEPTIDE IN CARDIAC SURGERY PATIENTS

K.S. Gulyan, T.G. Nikitina, N.N. Samsonova, M.G.Plyushch

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: To investigate the prognostic significance of BNP in patients with cardiac valves diseases admitted for surgical treatment before and 6–12 months after surgery.

Methods: The study included 54 patients with valves diseases. The average age of patients was 57.8±22.5 years (32–79 years). Most patients (31–57.4%) were males, 23 (42.6%) females. Valve replacement was performed in 35 (64.81%) patients, 19 (35.2%) patients was recommended only medication.

Results: All patients were referred to the III – IV functional class (64.8% and 35.2%, respectively). Left ventricular ejection fraction was 53.1±14.3%. The average level of BNP at admission was – 1189.8 pg/ml, 2–3 days after surgery – 2069.2 pg/ml, at 10–14 days after operation – 934.3 pg/ml and in the late period was – 388.62 pg/ml. The analysis revealed the significant correlation between baseline BNP and functional class (r=0.51, P<0.05). There is a significant correlation between baseline BNP and operational risk on the EuroSCORE, % (r=0.34, P<0.05), negative significant correlation with duration of stay in intensive care unit (days) and prolonged mechanical ventilation (r=0.31 and r=0.3, P<0.05) in all patients. In addition, we showed a significant correlation between BNP levels and severity of heart failure in the late period (6–12 months after surgery): a test of 6-min walk and the scale of assessment of clinical status (r=–0.56 and r=0.43, respectively), (P<0.05). A preoperative cut-point of BNP – 1120.68 pg/ml had a sensitivity of 85.7%, a specificity of 80.0%, and area under the curve – 0.835±0.098 (95% confidence interval from 0.64 to 1.0, P=0.015), for predicting postoperative mortality. A preoperative cut-point of BNP – 484.26 pg/ml (sensitivity – 71.4%, specificity- 67.7%, area under the curve - 0.63±0.081, 95% confidence interval from 0.5 to 0.78, P<0.05) and 607.76 pg/ml (sensitivity - 67.7%, specificity of - 81.25%, area under the curve – 0.737±0.079. Ninety-five percent confidence interval 0.58–0.89, P<0.05), predict postoperative heart failure in early and 6–12 months after cardiac surgery, respectively.

Conclusions: Determining level of brain natriuretic peptide has a higher predictive marker of severe heart failure and the risk of postoperative complications (early and late postoperative period) in patients with valvular heart disease.

9th Vascular Surgery Session - Miscellaneous May 22, 2011 09:00–11:00

V9-1 DIAGNOSTICS AND SURGICAL APPROACHES IN TREATMENT OF VISCERAL ANEURYSMS AND RENAL ARTERIES

S.I. Pryadko, V.S. Arakelyan

Bakoulev Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: The purpose of the study is to evaluate methods of early precise diagnosis, prevention of complications and restoration of blood supply of organs in the abdominal cavity and kidneys.

Methods: From 1970 to 2010, 21 patients with visceral artery aneurysms and 91 patients with renal artery aneurysms were operated on. The ages of patients were from 11 to 67 years (mean age 32.7+1.4 years). Clinical manifestations of abdominal aortic aneurysms depended on the size and location. Seven patients had aneurysms of the celiac trunk, splenic artery – six patients, the general hepatic artery – two patients, the superior mesenteric artery – five patients, inferior mesenteric artery – one patient. Eighty-six patients had extra renal aneurysms and five patients had intra renal aneurysms. Diameter of aneurysms ranged from 12 to 78 (average diameter was 14.2+8.7). 83.4% cases of visceral artery aneurysms were asymptomatic and were casual findings. The manifestation of renal artery aneurysms in 100% of cases was arterial hypertension. Nineteen percent of patients complained of pains in the lumbar area, 80% had headaches, 28% macro- or microhematuria. Duplex scanning, magnetic resonance and computer tomography and angiography were used mainly for diagnostics. Method of reconstructive operation depended on the etiology, localization and the sizes of the aneurysms. Character of operations: 12 reconstructions of visceral arteries, nine graft replacement. Renal arteries: reconstructions in 34 patients, graft replacement in 29 patients, replantation in 16 patients. Nephrectomy was performed in 12 patients.

Results: Twelve patients with viscera artery aneurysms examined in the late period after surgery did not show any complaints. From 43 patients with renal artery aneurysm examined in the late period after surgery, good surgical effect (normalization of arterial pressure) was noted in 76%, 12% was satisfactory and 12% was not satisfactory (the arterial hypertension remained). Arterial reconstruction was performed in 100% of cases. According to the actual curve of the stability of the positive results of the stability result of the operation after eight years was 82.3%. According to the duplex scanning and tomography, of vessels’ diameter, a condition of arterial wall, the site of anastomosis was within normal.

Conclusions: Surgical elimination of aneurysms of abdominal aortic branches with revascularization of the digestive system and kidneys lead to normalization of their functions, parameters of hemodynamic and prevent complications (intestinal and renal infarction, rupture of the aneurysm).

V9-2 SURGICAL MANAGEMENT OF SUBCLAVIAN ARTERY ANEURYSMS

N. Jakovljevic, M. Markovic, I. Koncar, N. Ilic, M. Dragas, D. Kostic, L. Davidovic

Clinical Centre of Serbia, Clinic for Vascular and Endovascular Surgery, Belgrade, Serbia

Objective: The authors report management of 18 subclavian artery aneurysms (17 true, one false) occurring in nine male and nine female patients, average age 48.4 years (23–80). The etiology included thoracic outlet syndrome in 12, atherosclerosis in five and infection in one patient. Sixteen aneurysms were extrathoracic, while two of them were intrathoracic. Symptoms related to subclavian artery aneurysms were present in 14 patients (compression in three, haemorrhage in one, and ischaemia in 10 patients), whereas four aneurysms were asymptomatic.

Methods: All aneurysms were treated surgically. The supraclavicular approach was used in 16 cases, and the combined transsternal and supraclavicular approach was used in two cases. After aneurysm resection, the reconstruction was performed with end-to-end anastomosis in six cases and with saphenous vein or synthetic grafts in 12 cases. One infected subclavian artery aneurysm was treated with carotid to axillary saphenous vein bypass after resection of the aneurysm. Five associated brachial embolectomies and one bypass from the axillary to the distal brachial artery were performed. In all thoracic outlet syndrome cases, decompression at the thoracic outlet was also performed.

Results: There was no operative mortality, and the early patency rate was 100%. The follow-up period was from one to 10 years (mean, 4.3 years). During this period, one patient died of malignancy and one patient required reoperation due to aneurysmal degeneration of the saphenous vein graft. Surgical treatment is recommended for all patients with subclavian artery aneurysms to prevent potential complications.

V9-3 EMERGENCY SURGERY FOR VASCULAR INJURY OF THE NECK

T.U. Cohnert, S. Koter, S. Schweiger, J. Fruhmann, G. Schramayer, M. Tomka, A. Baumann

Graz Medical University, Graz, Austria

Objective: Operations for treatment of traumatic lesions are rare in vascular surgical practice with 0.3–4%. The current mortality for civilians with penetrating neck injuries ranges from 3 to 6%. Aim of this study was to analyze the results of vascular surgery in emergency procedures for penetrating neck trauma.

Methods: Between 1 January 1998 and 31 October 2010, a total of 80 patients (pts) underwent vascular surgical operations for penetrating trauma. Prospectively collected data were analyzed retrospectively.

Results: In 17 patients (17/80=31.3%) surgery was necessary for vascular lesions due to penetrating trauma of the neck. There were 14 male and three female patients with a mean age of 45.8+19.6 years. Two patient died, on 0 and 7 day postoperatively (mortality 2/17=11.8%). Surgery was required due to bleeding in all patients. In four patients the lesion was self inflicted, and in three patients a second person had injured the patient on purpose. Two patients were polytraumatized. The vascular lesions treated by the vascular surgeon involved the arterial system in eight patients (8/17=47.6%) and the venous system in nine patients (9/17=52.4%). The common carotid artery was injured in two patients, the internal carotid artery in two, the external carotid artery in two and the thyroid artery in two patients was required. Reconstruction was performed by venous graft in one patient, venous patch plasty in one and direct suture in six patients. In the nine patients with venous lesion the internal jugular vein was afflicted in six patients and the external jugular in three. Venous Ligation was performed in all patients. In the four attempted suicides, patients had lacerated the internal jugular vein and one patient the internal carotid artery. One polytraumatized died of hemorrhagic shock on the operating day. The second non-survivor died on postoperative day seven due to massive ipsilateral stroke after trauma to the internal carotid artery.

Conclusions: Penetrating trauma to the neck is a serious and potentially lethal injury. Emergency surgery by an experienced vascular surgeon can help to determine the extent of trauma and its treatment. In arterial trauma to the carotid arteries a complete intraoperative exposure with external and internal inspection of the vessel including the intimal layer is recommended.

V9-4 TUNNELED BASILIC VEIN HARVESTING TO CREATE TRANSPOSED BRACHIOBASILIC ARTERIOVENOUS FISTULA

R. Onoglu, N. Gormus, K. Durgut, T. Yuksek

Selcuk University Meram Medical School, Selcuk, Turkey

Objective: Hemodialysis and vascular access are the most preferred routes in patients with end-term kidney disease. Basilic vein transposition is preferred after failed or non-functional forearm and elbow fistulas. It requires large incision, extensive surgical dissection and usually – general anesthesia. Morbidities like edema and infection are not seen rarely. To avoid such complications, we described a minimally-invasive technique to create transposed brachiobasilic arteriovenous fistula.

Methods: The technique involves multiple longitudinal skin incisions in the upper arm. The first incision is made over the medial aspect of the cubital fossa and the basilic vein is identified. A subcutaneous tunnel is created as far as possible up to a Langenbeck retractor (Aesculap AG, Tuttingen, Germany) held by an assistant, with an overhead light focused on the skin over the tunnel. The side branches are ligated or clipped under vision and the vein is freed. Once it is felt that further dissection is not possible from this incision, another longitudinal incision is made 2 cm proximally in where the scissors are reached. Dissection of the basilic vein is continued proximally. Through the second incision, a similar subcutaneous tunnel is made proximally and distally. The side branches are ligated or clipped under vision and the vein is freed. Until reaching to axillary vein, this procedure is replicated. After the basilic vein is divided at elbow, the vein lies free and can be pulled out via the last incision. It is transposed in the anterior surface of the arm in the subcutaneous plane and end to side anastomosis is performed to the brachial artery which is identified in the first incision.

Results: Twelve outpatients were treated with this technique from November 2009 to October 2010. The mean age was 56.2±12.2. Local anesthesia with lidocain 2% alone was enough to perform surgery in all patients and sedation was not needed. The mean follow-up period was 10.4±1.5 months. At 10 months follow-up, mean primary patency rates was 83.3% (n=10), secondary patency rate was 91.6% (n=11). Primary failure was 16.6% (n=2) secondary to poor maturation. None of the patients had an infection and arm edema. All patients are still using their fistulas uneventfully for hemodialysis.

Conclusions: Tunneled basilic vein harvesting to create transposed brachiobasilic arteriovenous fistula can be considered as a new, effective, comfortable and simple technique.

V9-5 LONG-TERM RESULTS OF BRACHIOCEPHALIC ARTERIES SURGERY IN PATIENTS SUFFERING FROM TAKAYASU’S ARTERITIS

A. Pokrovsky, A. Zotikov, V. Kulbak, E. Burtseva

A.V. Visnievsky’s Surgery Institute, Moscow, Russian Federation

Objective: At present only a few clinics have experience in surgical treatment of patients suffering from Takayasu’s arteritis. There is no reliable statistical information on the possibility of redo surgery in this group of patients.

Methods: One hundred and seventeen patients suffering from Takayasu’s arteritis were operated at the Vascular Surgery Department of A.V. Vishnevsky’s Surgery Institute during the the period from January 1984 until December 2010. One hundred and forty-nine primary arterial reconstructions were performed in this group of patients. Forty-nine patients underwent the aortic arch branches surgery and in 51 primary reconstructions were performed (extrathoracic surgery in 32 cases and transthoracic surgery in 19 cases).

Results: Long-term results were studied at 32 patients. The average observation time was 91.8 months (7.7 years). In that period 30 patients (93.8%) have been alive. Eleven patients were diagnosed with graft thrombosis, eight of them had a relapse inflammation. Fifteen patients underwent a redo surgery, total 19 operations were performed. The most frequent types of surgery were thrombectomy or reconstruction of distal anastomosis. In five cases we had to carry out transthoracic surgery. In five-year period the patency of reconstructed arteries of patients who had no inflammation was 80.1%, in 10-year period the patency was 75.4%; the patency of grafts of patients who had inflammatory relapse was 56.8% and 28.4%, correspondingly. In five-year period the primary patency of reconstructed brachiocephalic artery grafts was 68.7%, in 10-year period the primary patency was 52.3%. The secondary patency was 80.1% and 65.2%, correspondingly.

Conclusions: Extrathoracic surgery in patients suffering from Takayasu`s arteritis has satisfactory results. Long-term results of aortic arch branches surgery depend on inflammation activity. Redo surgery is indicated in case of graft thrombosis.

V9-6 ROBOT-ASSISTED LAPAROSCOPIC VASCULAR RECONSTRUCIONS IN THE AORTOILIAC REGION

M. Dvorák, T. Novotný, R. Staffa

St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic

Objective: The objective of the study was to evaluate the results of the robot-assisted laparoscopic aortoiliofemoral reconstructions in a group of 56 patients.

Methods: Between May 2006 and December 2010 we operated on 56 patients at a mean age of 58 years for aortoiliac occlusive disease using robot-assisted laparoscopic approach. We assessed operative and hospitalization data, patency of reconstructions and complication rate.

Results: We created 28 aortobifemoral, 26 aortofemoral and two iliofemoral bypasses. In 54 cases, we completed the procedure successfully. We had to convert to open surgery twice. The median proximal anastomosis time, median clamping time and median total operative time were 25, 60 and 280 min, respectively. The median ICU stay was two days. During the follow-up period (median 16 months; range 1–57 months), we observed three early occlusions (5%) and one graft infection (2%). The secondary patency was 100%. The 30-day mortality was 0%. No renal, cardiovascular or pulmonary complications were observed.

Conclusions: The da Vinci robotic system enables us to achieve acceptable proximal anastomosis and clamping time. The whole procedure remains an advanced laparoscopic surgery and previous laparoscopic experience is necessary. Robot-assisted laparoscopic aortoiliofemoral bypass grafting seems a safe method with a low complication rate.

V9-7 EARLY AND LONG-TERM RESULTS IN SURGERY FOR ACUTE MESENTERIC ISCHEMIA

T.U. Cohnert, S. Koter, J. Fruhmann, P. Konstantiniuk, A. Baumann

Graz Medical University, Graz, Austria

Objective: Acute mesenteric ischemia is a life-threatening surgical emergency associated with high morbidity and mortality rates. Presentation, physical exam, laboratory values and non-invasive imaging may all be non-specific. Treatment includes resuscitation, revascularization and bowel resection. Aim of this study was analyse our results and to determine long-term outcome in patients surviving the acute event.

Methods: In 39 patients (pts) surgery for acute mesenteric ischemia (AMI) between January 1988 and October 2010 was performed by the Vascular Surgery Department. Prospectively collected clinical data and additional follow-up were analyzed retrospectively. Statistical data are shown as mean values and standard deviation.

Results: Of the 39 patients with a mean age of 71.3+11.6 years (range 27–90 years) there were 19 female and 20 male patients. Operative mortality was 48.7% (19/39 patients). Diagnosis was established by CT angiography, arteriography or laparotomy. Underlying disease was arterial embolism in 27 patients (mortality 40.7%=11/27 patients) and arterial thrombosis in 12 patients (mortality 66.7%=8/12 patients). Operative procedures consisted of revascularization without bowel resection in 24 patients (mortality 45.8%=11/24 patients), revascularization and additional bowel resection in 10 patients (mortality 40.0%=4/10 patients), resection without revascularization in one patient and exploratory laparotomy without further procedure in four patients (mortality 100%). Revascularization was achieved by embolectomy/thrombectomy in 28 patients, additional patch implantation in three patients and bypass implantation in three patients. Second look laparotomy was performed in five patients. Postoperatively three patients suffered from short bowel syndrome. All patients underwent postoperative anticoagulation. After a follow-up of 1–267 months (mean 62.4+79.2 months) 17 patients were alive and well whereas one patients was lost to follow-up. Two patients had died (one liver cirrhosis, one stroke) during follow-up. The longest surviving patient is alive and well after 22 years and three months.

Conclusions: Long-term survival in patients after successful surgical revascularization in acute mesenteric ischemia appears not limited. However, perioperative morbidity and mortality rates in patients presenting with this condition are still unacceptably high. Early diagnosis and treatment protocols to avoid delay of revascularization are important to improve the prognosis in patients with acute mesenteric ischemia.

V9-8 MANAGEMENT OF VASCULAR INFECTION IN THE GROIN

J. Pasternak, D. Nikolic, V. Popovic

Clinical center of Vojvodina, Novi Sad, Serbia

Objective: Although its incidence is low, localized groin infection of a limb of an implanted prosthetic is a serious clinical problem, and the best management remains controversial.

Methods: Twenty consecutive patients underwent surgical treatment of such infections from 1998 through 2010 in our institution. The mean age was 53±12 years. Twelve of the 20 patients underwent emergency operation due to bleeding or acute ischemia. The events that caused inguinal infection were synthetic graft implantation in 16 patients, vascular trauma in two, arterial catheterization in one, femoropopliteal saphenous vein bypass operation in one.

Results: These operations included lateral femoral bypass (6), autologous great saphenous vein tailored graft to replace an infected prosthetic graft-in situ position (6), obturator bypass (5), revascularization with hom*ograft (2), autovenous extra-anatomic femorofemoral bypass (3), arterial reconstruction with TEA and autologous great saphenous vein patch (5), only removing the infected prosthetic graft without further arterial reconstruction (4). All inguinal infections were completely cured after surgery. Early complications included poor wound healing (six patients), amputation (three patients), and extension of infection to the distal anastomosis and false aneurysm formation (three patients). There was no operative mortality, late mortality is 10% (two patients). All patients were followed up for a mean of 48.1±24.7 months.

Conclusions: Vascular infections of the groin can be cured by proper selection and application of one of the above techniques. Total graft excision and extraanatomic revascularization is still probably the most effective method for dealing with infected prostheses to eradicate infection while ensuring limb salvage and long-term graft patency.

V9-9 ENDOVASCULAR RECONSTRUCTION OF AORTIC BIFuRCATION IN OCCLUSIVE DISEASE: THE ‘DOUBLE BARREL’ TECHNIQUE

P. Frigatti, S. Lepidi, M. Menegolo, P. Scrivere, C. Maturi, M. Antonello, F. Grego

Clinical of Vascular and Endovascular Surgery, University of Padua, Padua, Italy

Objective: To present the early results of endovascular reconstruction of the occluded aorto-iliac segment by deployment of two covered endografts (Viabhan-Gore) applying the ‘double-barrel’ technique.

Methods: Between December 2009 and January 2011, six patients (mean age 73 years, male/female ratio: 5/1) with occlusion of the infrarenal aorta extending to common or external iliac arteries underwent endovascular recanalization and carrefour reconstruction, simultaneously delivering two covered stent grafts (Viabhan-Gore) extending from the iliac arteries up to the open infrarenal aorta. Indication to treatment was critical limb ischemia, including severe claudication. Follow-up consisted of physical examination and duplex scan every three months as well as CT-scan 30 days after surgery.

Results: Postoperative mortality and complications were not observed. Technical and clinical success rate was 100% at the early follow-up. Mean operating time was 97 min (range 55–123 min) and in-hospital length of stay was 1.5 days (range 1–2). The mean follow-up was seven months (range 1–13) demonstrating a primary patency of 100%, with no requirement for secondary interventions.

Conclusions: Endovascular repair of the occluded infrarenal aorta and bilateral iliac arteries using covered endografts applying the ‘double-barrel’ technique is feasible and durable in the short-term follow-up. This method allows reconstruction of the aortic bifurcation with covered stent of appropriate sizes and lengths. This technique represents a low invasivity alternative to the open surgery, which is still potentially feasible in case of failure.

V9-10 THE EFFECT OF INTENSIFIED LIPID LOWERING THERAPY ON ONE-YEAR PROGNOSIS IN PATIENTS UNDERGOING VASCULAR SURGERY

G. Kouvelos, H. Milionis, E. Arnaoutoglou, C. Kostara, N. Papa, V. Koulouras, M. Peroulis, M. Matsagkas

University of Ioannina, Ioannina, Greece

Objective: Cardiovascular complications are a major cause of morbidity and mortality in patients undergoing vascular surgery, compromising both short and long-term prognosis. This prospective randomized, double blind clinical trial was performed to analyze the effect of intensive lipid lowering therapy on the occurrence of a 12-month composite of cardiovascular events after vascular surgery.

Methods: We randomly assigned patients in addition to a β-blocker to receive 10 mg rosuvastatin or 10 mg rosuvastatin plus 10 mg ezetemibe once daily irrespective of their serum cholesterol levels. The primary end point was the occurrence of a 12-month composite of cardiovascular events after vascular surgery, including death from cardiovascular causes, non-fatal acute MI, ischemic stroke, and unstable angina. The secondary study outcome was the effect of statin therapy alone in comparison with intensive lipid lowering therapy with ezetimibe on levels of biomarkers including lipids and high-sensitivity C-reactive protein.

Results: A total of 136 patients were assigned to rosuvastatin, and 126 to a combination of rosuvastatin plus ezetimibe. Nine of the 136 patients (6.6%) in the rosuvastatin group had a major adverse cardiovascular event within 30 days postoperatively, as compared with seven of the 126 patients (5.6%) in the rosuvastatin plus ezetimibe group (P=0.72). During the following 11-month period, a primary end point was observed in 11 of the remaining 293 patients (3.4%): nine patients in the rosuvastatin group and two patients in the rosuvastatin plus ezetimibe group (P=0.04). Intensive lipid lowering therapy with ezetimibe was associated with a significant decrease in mean LDL levels (75.87±31.64 vs. 87.19±31.7, P=0.004), while there was no significant change noted in triglycerides and HDL levels between the study groups in the same time frame. There was no significant decrease in hs-CRP levels between the two groups (P=0.09). Intensive statin therapy was not associated with an increase in the rate of adverse events.

Conclusions: These results indicate that the incidence of cardiovascular events in the first 12 months after surgery can be reduced with intensive lipid reducing therapy by combining rosuvastatin with ezetimibe. This beneficial effect is translated in the late postoperative period after the first month of the vascular procedure. Future larger prospective studies are needed to confirm the beneficial effect of intensified lipid lowering therapy on cardiovascular risks after vascular surgery.

10th Vascular Surgery Session - EVAR May 22, 2011 09:00–11:00

V10-1 TREATMENT OF ENDOLEAK AFTER EVAR

J. Szmidt, Z. Galazka, T. Jakimowicz, B. Solonynko

Medical University of Warsaw, Warsaw, Poland

Objective: The main goal of endovascular treatment of abdominal aortic aneurysm is to protect the aneurysm from rupture. Endoleak (EL), the most common complication after EVAR, can be the reason of aneurysm rupture so its occurrence means EVAR was unsuccessful. Therefore, management of EL is crucial for EVAR efficacy. The aim of the study was to evaluate various methods of endoleak treatment after EVAR.

Methods: Since 1998 in our department, 928 patients were treated endovascularly for abdominal aortic aneurysm. All patients were followed-up with spiral CT-scan or Doppler-ultrasound (in cases with stabile aneurysm diameter). We found endoleak in 141 cases in various postoperative time periods: 66 type I, 68 type II and seven type III. For EL type I we have performed balloon angioplasty with or without coils implantation in 30 patients and implanted additional stentgraft segment in 36 patients. In two cases it was ineffective and we performed open aneurysm neck banding. For EL type II in 39 patients with stable or shrinking aneurysm we have observed the aneurysm and EL disappeared in 24 cases. In growing aneurysm EL type II cases (29 patients) we performed endovascular treatment usually with coils implantation with 23/29 success rate; in the remaining six cases there was a necessity to perform open surgery to ligate lumbar arteries. In seven cases with EL type III we implanted additional stentgraft.

Results: None of the aneurysms with diagnosed endoleak ruptured. Nevertheless during the follow-up we have also four cases of late aneurysm rupture after EVAR: three patients that were lost in follow-up and one without visible EL during follow-up but present at the time of rupture.

Conclusions: Patients after EVAR need strict follow-up protocol to in order find endoleaks. Their management is effective and it can protect the aneurysm from rupture.

V10-2 ENDOVASCULAR APPROACH IN OPEN AORTIC SURGERY COMPLICATIONS

G. Marcucci, F. Accrocca, R. Antonelli, A.G. Giordano, R. Gabrielli, G. De Vivo, A. Siani

Ospedale San Paolo, Civitavecchia (Rome), Italy

Objective: An endovascular approach for the management of aorto-iliac surgery complications has recently shown its safety and efficacy. We retrospectively investigated our endovascular experience in these challenging cases.

Methods: Between 2006 and 2010, 98 patients underwent open aortic surgery for aneurysmatic and occlusive disease. In four patients (4.1%), we observed late postoperative complications: one aorto-enteric fistula, one rupture of proximal anastomotic pseudoaneurysm and two limb occlusions of aortobifemoral bypasses. Aorto-duodenal fistula with haematemesis in a patient with an aorto-aortic bypass for the treatment of a ruptured abdominal aortic aneurysm was treated by an endovascular stent-graft implantation and a late extra-anatomic bypass, aortic graft removal and duodenal derotation. An endovascular cuff was positioned for the ruptured proximal anastomotic pseudoaneurysm of aorto-bisiliac bypass. Recanalization of a one-month prosthetic limb occlusion of two different aorto-bifemoral bypasses was associated to a Wallstent implantation at the proximal limb level.

Results: All cases were at high surgical risk and treated under local anaesthesia. Technical success was achieved in all patients, and no periprocedural complications occurred.

Conclusions: Particularly in high-risk patients, it is reasonable to avoid open reintervention in a hostile abdomen. Endovascular approach may offer an immediate and safe solution or represent a ‘bridge’ technique for a complete resolution of open aortic surgery complications.

V10-3 ENDOVAScULAR AORTIC ANEURYSM REPAIR – INITIAL EXPERIENCE IN THE SERBIAN MULTICENTRIC STUDY

I. Koncar¹, D. Radak², M. Jeftic³, I. Marjanovic³, D. Sagic², M. Colic¹, I. Banzic¹, L. Davidovic¹

¹Clinic for Vascular and Endovascular Surgery. Clinical Centre of Serbia; ²Clinic for Vascular Surgery, Institute for Cardiovascular Diseases ‘Dedinje’, Serbia; ³Military Medical Academy, Belgrade, Serbia

Objective: Introduction of novel procedures depends on the socioeconomic situation in the society. The first endovascular aortic repair (EVAR) in Serbia was performed in 2004, and this activity was routinely continued in 2007. Aim of the study is to present the results after introduction and development of endovascular program in Serbia, and to report the mid-term results of the three main vascular centers in Belgrade, capital of Serbia.

Methods: From March 2007 to November 2010, 1900 patients were operated due to abdominal aortic aneurysm (AAA), and 110 patients due to thoracic aortic diseases in the three main vascular centers in Belgrade, the capital of Serbia. Out of them 201 (10%) were treated by implantation of the endograft and are included in this Serbian multi-centric study that analyzed results as well as developing process.

Results: Out of 201 patients, 41 were treated with thoracic endograft implantation (36 Medtronic Valiant, four Gore TAG and one Bolton Relay), and 160 patients were treated with abdominal stent graft (97 Medtronic Talent, one Medtronic Endurant, 62 Gore, Excluder). Among thoracic aortic pathology there were 21 atherosclerotic, six false posttraumatic, four ruptured, three dissected, and one anastomotic aneurysm due to aorto bronchial fistula, as well as six patients with penetrating aortic ulcer. In patients with AAA there were two patients with ruptured aneurysms and eight patients with isolated iliac aneurysm. Early mortality rate was 1.2% in elective cases. Two patients (1.2%) suffered postoperative stroke, four (2.4%) patients suffered limb thrombosis, and one patient suffered iliac artery perforation and consecutive conversion. In the early postoperative time and after mid term follow-up of 17.9 months (range 2–40 months) there was no aneurysm related death, one patient suffered aorto esophageal fistula, and one patient had endograft migration treated with conversion.

Conclusions: Introduction of endovascular program is safe and efficient in high volume centers faced with complicated pathology and capable to treat all possible early and late complications.

V10-4 ENDOLEAKS AFTER ENDOVASCULAR RECONSTRUCTION OF INFRARENAL AORTIC ANEURYSM DEPENDING ON THE TYPE OF PROSTHESIS

P. Konstantiniuk, S. Koter, M. ho*rletzberger, S. Schweiger, H. Portugaller, T. Cohnert

University Hospital Graz, Graz, Austria

Objective: Endoleak after infrarenal aortic stentgraft implantation is a well-known and investigated complication. The goal of our study was to evaluate the dependency on the type of prosthesis.

Methods: From October 1996 to January 2010 there were 171 primary infrarenal aortic stentgraft implantations at the University Hospital of Graz. We analysed endoleak free survival using the Kaplan-Meier method and performed Cox-regression to find differences between the different types of prostheses.

Results: Twenty-nine patients developed an endoleak type I. The Excluder^® prosthesis had a trend to fewer endoleaks (P=0.07 in pairs). Thirty-five patients showed an endoleak II. In this situation the Excluder^® prosthesis had a worse outcome (in pairs up to P=0.05). There were 12 patients with Endoleak III, mainly seen with the Vanguard^®-prosthesis. Two patients experienced an endoleak IV with a Talent^® prosthesis (due to the low number a statistical calculation is useless).

Conclusions: Our data show the strength and weakness of the different types of prostheses. This analysis can be used for a targeted advancement.

V10-5 EARLY INFLAMMATORY RESPONSE AFTER ELECTIVE ABDOMINAL AORTIC ANEURYSM REPAIR: A COMPARISON BETWEEN ENDOVASCULAR PROCEDURE AND OPEN SURGERY

M. Jevtic, I. Marjanovic, S. Misovic, A. Tomic, M. Sarac, M. Mihajlovic, I. Lekovic

Military Medical Academy, Belgrade, Serbia

Objective: The development of endovascular surgery (EVAR), especially in the last decade, provided one more opportunity for reconstruction of the aortic aneurysm. The aim of this study is to compare the early inflammatory response following endovascular and conventional AAA repair.

Methods: Comparative clinical retrospective study included 39 patients divided into two groups that are electively operated on for AAA between December 2008 to February 2010. Of the total number of patients included in the study, 18 patients (16 male and two female) aged 49 to 82 years (mean 66, 78 years) underwent open conventional, transabdominal aortic reconstruction (OR), while the 21 patients (19 men and two women) aged 58–87 years (mean 74, three years) underwent endovascular reconstruction of AAA (EVAR). Patients were allocated to endovascular or conventional aneurysm repair according to aneurysm morphology as determined by preoperative computed tomography (CT). The study does not include patients who were operated as emergencies due to rupture, symptomatic or inflammatory aneurysm. We analyzed the clinical, biochemical parameters and inflammatory reaction in the early postoperative period. Parameters were monitored preoperatively, then one, two, three and at the seven postoperative day. The study was approved by the Local Ethics Committee.

Results: The study showed statistically significant shorter duration of surgery in the EVAR group (average 75 min) compared to OR (average 136 min, from 75). Significantly less blood loss in EVAR group (average 60 ml), compared to the OR group (average 495 ml), as well as a shorter postoperative hospitalization of patients, EVAR group average of four days in the OR group, eight days. The study also analyzed the number of white blood cells, thormbocite platelets, level of serum urea, creating, potassium and the level of circulating serum cytokines which has major role in acquired immunity: interleukin (IL) -2, IL-4, IL-6 and IL-10. These parameters showed that after endovascular reconstruction leads to significantly less inflammatory reaction of the organism in the early postoperative period than during open AAA reconstruction and thus fewer opportunities to the development of SIRS (systemic inflammatory response syndrome) in the early postoperative period.

Conclusion: Our study showed that the both open and endovascular AAA repair provoke an early inflammatory response after elective abdominal aortic aneurysm repair. This response is greater during open repair than during endovascular aortic aneurysm exclusion.

V10-6 ANEURYSM SAC ‘THROMBIZATION’ AND STABILIZATION IN EVAR: UPDATE

S. Ronsivalle, F. Faresin, F. Franz, C. Rettore, M. Zanchetta, A. Olivieri

Department of Cardiovascular Disease, Vascular Surgery and Diagnostic, Cittadella Hospital, Padua, Italy

Objective: To estimate the reduction of type II endoleak by preventing thrombization of the aneurysm sac during EVAR vs. standard EVAR technique alone.

Methods: During the interval September 1999 to December 2009 545 patients underwent endovascular abdominal aortic aneurysm repair (EVAR). We enrolled all patients who were treated from September 1999 to December 2008 in order to allow at least 12 months follow-up. Group 1 consists of 228 patients who underwent standard EVAR from September 1999 to May 2003. Group 2 consists of 253 patients who underwent EVAR combined with aneurysm sac thrombization, a procedure that entails the use of fibrin glue with or without the insertion of inconel coils, from June 2003 to December 2008. A computed tomography (CT) scan assessment was performed on all patients before having the operation EVAR. When necessary, digital angiography was done. After EVAR all patients were followed up with cadenced Color Duplex Ultrasound (CDU) and an X-ray of the abdomen. And we performed a Spiral CT-scan when CDU imaging was not clear.

Results: The risk of a type II endoleak was lower in group 2 than in group 1. Both groups have similar anatomic parameters. There were no allergic or anaphylactic reactions to biomaterial used. In group 1, EL II was detected in 34 patients (14.9%), EL I A in eight patients (3.5%), EL I B in eight patients (3.5%) and EL III in one patient (0.4%). In group 2, EL II was found in seven patients (2.7%), EL I A in three patients (1.1%) and EL I B in five patients (1.9%).

Conclusions: The preventive method of intra-sac thrombization using fibrin glue injection with or without the insertion of coils proves to be a simple, low cost, safe, and effective technique, aside from the endograft used, allowing to reduce significantly the risk of type II endoleaks.

V10-7 LIMB GRAFT THROMBOSIS AFTER ENDOVASCULAR TREATMENT OF ABDOMINAL AORTIC ANEURYSM

J. Szmidt, Z. Galazka, B. Solonynko, T. Jakimowicz

Medical University of Warsaw, Warsaw, Poland

Objective: Limb graft thrombosis (LGT) is one of the most frequent severe complications after endovascular repair of abdominal aortic aneurysms and its occurrence ranges from 2.7 to 23.8%. The aim of the study was to assess the local risk factors and methods of treatment of LGT.

Methods: Since 1998 in our department 928 patients were treated endovascularly for abdominal aortic aneurysm. The study group consisted of 564 consecutive patients treated by means of bifurcated stentgraft implantation. Patients with inflammatory, ruptured and false aneurysms as well as those with the observation period below 12 months were excluded from the study.

Results: In the mean follow-up 55.1 months (range: 13–114 months) LGT occurred in 43 of 564 (7.6%) patients. In 27/43 (62.8%) of them the complication occurred during the first postoperative month. Among the local probable risk factors of LGT, the atherosclerosis in ilio-femoral segment, the kink or stenosis of stentgraft limb, angulation between endoprosthesis limb and the external iliac artery, stentgraft deployed in the external iliac artery and the intraluminal thrombus in the stentgraft occurred significantly more frequently (P<0.0001) in patients with LGT history. The treatment of LGT included thrombolysis (successful in three of five cases, used only after the 30th postoperative day) or thrombectomy (successful in 21 of 40 cases) combined with stenting (16 patients). In case of failure the cross-over femoro-femoral bypass was implanted (17 cases). Two (4.7%) patients required leg amputation. The recurrent lower limb ischemia in patients treated for LGT occurred in four (9.3%) cases (in one – after trombectomy and stenting; in three – after femoro-femoral bypass implantation). Its incidence did not differ statistically with the number of the primary stentgraft thrombosis (P=0.68).

Conclusions: Local thrombolysis or thrombectomia combined with stenting and in case of failure, cross-over femoro-femoral bypass implantation seems to be the successful method of LGT treatment.

V10-8 POSTINTERVENTIONAL DIAGNOSTIC AND THERAPEUTIC ISSUES FOLLOWING INFRARENAL AORTIC STENTGRAFT IMPLANTATION

P. Konstantiniuk, S. Koter, M. ho*rletzberger, J. Fruhmann, H. Portugaller, T. Cohnert

University Hospital Graz, Graz, Austria

Objective: Since endovascular aortic repair was performed for the first time, a lot of studies have been performed to prove feasibility and safety of the method. In contrast, nearly nothing has been published focussing on postinterventional efforts and unevitable consequences.

Methods: In the period of October 1996 to January 2010 there were 171 primary infrarenal aortic stent graft implantations performed. We analysed number and types of postinterventional diagnostic procedures (CT-scans, diagnostic angiographies) as well as therapeutic procedures (PTA, stent, stentgraft, open surgery) carried out. Furthermore, we investigated the development of postoperative renal insufficiency.

Results: Forty-three patients experienced one or more therapeutic procedures (29 patients with 41 endovascular interventions, 34 conversions, 20 patients with 22 other operations). Postinterventionally there were 9.99 examinations using ionic contrast agent (CT-scans or conventional angiography, minimum one, maximum 35). In six cases we found renal insufficiency with haemodialyses after 29.7 months (mean). In another 12 cases we had to quit postinterventional CT-scans due to a moderate renal insufficiency. The last application of ionic contrast agent appeared 40.5 months after the primary endovascular procedure.

Conclusions: In the future we will have to include postinterventional and postoperative efforts whenever we compare the costs of open surgery with endovascular repair.

V10-9 EVAR TREATMENT IN COMPLICATED ABDOMINAL AORTIC ANEURYSMS

G. La Barbera, M. Vallone, G. Ferro, F. Valentino, D. M. Parsaei, D. Mirabella, G. Tutone, G. La Marca

Benfratelli Civic Hospital, Palermo, Italy

Objective: Because of the complex anatomy, not all patients are fit for EVAR. Authors compare prospectively EVAR treatment in complicated AAA Group 1 and normal AAA Group 2.

Methods: From January 2005 to December 2010, 109 patients underwent EVAR. Mean age=72.4 years. Group 1=48 patients: aortic anastomotic AAA (four patients), diameter more than 7 cm (17 patients), class C – D – E AAA (22 patients), an aortic and/or iliac angulation more than 60° (23 patients) and an associated iliac aneurysm (17 patients), and Group 2=61 patients. End point: postoperative major complications (acute limb ischemia, end stage renal insufficiency, infections, stroke, paraplegia) and mortality, matched with preoperative variable.

Results: Group 1 mean age was higher (74.8 vs. 70.6) P<0.05. Group 1 had older patients (58% vs. 32%) P<0.005, more cardiac patients (88% vs. 80%) P=ns, the AAA was more than 6 cm (48% vs. 16%) P<0.005, more branch graft occlusion (6.5% vs. 5%) P=ns, more leaks (10.5% vs. 6.5%) P=ns, more hybrid procedure (15% vs. 3%) P<0.05, more technical pitfalls (8.5% vs. 6.5%) P=ns, more aorto-uniliac graft (10.5% vs. 5%) P=ns and higher mortality (4.5% vs. 3.5%) P=ns. Higher postoperative major complication rate was found in: Group 1 young patients (15% vs. 3.5%) P=ns, than Group 2 (12% vs. 11%) P=ns; Group 2 big AAA (20% vs. 10%) P=ns, than Group 1 (9% vs. 8%) P=ns; Group 1 cardiopatic patients, (17% vs. 7%) P=ns, than Group 2 (8% vs. 12%) P=ns; Group 1 aorto-uniliac graft (40% vs. 5%) P<0.01, than Group 2 (0% vs. 12%) P=ns; Group 2 hybrid procedures (50% vs. 10%) P<0.05, than in Group 1 (14% vs. 7%) P=ns. Higher postoperative mortality rate was found in: Group 1 young patients (15% vs. 0%) P<0.05, than Group 2 (5% vs. 0%) P=ns; Group 1 little AAA (12% vs. 5%) P=ns than Group 2 (4% vs. 0%) P=ns; Group 1 cardiopatic patients, (17% vs. 2.5%) P=ns, than Group 2 (0% vs. 4%) P=ns; Group 1 aorto-uniliac graft patients (20% vs. 5%) P=ns, than Group 2 (0% vs. 4%) P=ns; Group 1 hybrid procedures (14% vs. 5%) P=ns, than in Group 2 (0% vs. 3.5%) P=ns. During the FU, we obtained 98% cumulative survival rate at five years in Group 1, and 86% at nine years in Group 2.

Conclusions: Patients with complex AAA are significantly older, with bigger AAA, require more hybrid procedures and have higher mortality.

V10-10 EFFICACY OF EVAR SURVEILLANCE: DOES ONE PROTOCOL FIT ALL?

H. Sekhar, J.J. Barnes, M. Welch, C.N. McCollum, M.S. Baguneid

Hospital of South Manchester, Manchester, UK

Objective: Endovascular aneurysm repair (EVAR) requires life-long follow-up to detect post-implantation device failures. There is no current consensus on the optimal follow-up imaging programme. This study aims to ascertain the complication rate of EVAR as detected in our EVAR surveillance follow-up programme.

Methods: All patients who had EVAR between June 2007 and November 2009 were identified and preoperative scans, operative course and follow-up scans were analysed. Our follow-up is a widely used schedule consisting of pre-discharge ultrasound scan (USS), a three months CT, one year CT, two year CT and if satisfactory further follow-up by USS.

Results: Seventy-nine patients undergoing EVAR were identified. Mean age was 75.7 (60–89) years and the mean size of AAA was 6.4 cm (4.5–10.5). The mean total surveillance time was 15.3 months. The pre-discharge USS was performed in 69 (87.3%) patients. Ten (12.7%) were reported as inconclusive. An abnormal finding was identified in eight (10.1%) of patients in the pre-discharge USS. A total of 184 CT-scans were performed, 26 (14.1%) outside the protocol. Twenty-three (29.1%) patients had an abnormal vascular finding detected during CT follow-up. Sixteen (69.6%) of these were identified in protocol scans, and seven (30.4%) on CT-scans outside the routine protocol. Five (6.3%) patients underwent re-intervention, two of whom had abnormal findings detected during routine surveillance, one was detected on an scan outside protocol and two patients had their re-intervention in the absence of a CT-scan having presented as an emergency. Overall 30-day mortality was one (1.3%) and this was an intraoperative death. one-year mortality was five (6.3%).

Conclusions: EVAR has a low 30-day and one-year mortality rate. However, it remains troubled by the need for re-intervention. A widely used imaging follow-up programme will identify 69.6% of abnormal findings. However, 30.4% still occur outside the defined protocol. Scrutiny of large data sets will be required to gain a better understanding of appropriate follow-up for these patients.

14th Cardiac Surgery Session – Arrhythmia May 22, 2011 11:30–13:00

C14-1 PREVALENCE AND CHARACTERISTICS OF REGULAR TACHYCARDIAS DEVELOPING AFTER DIFFERENT STRATEGIES OF LEFT ATRIAL ABLATION IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION

E.N. Mikhaylov, M.L. Abramov, D.S. Lebedev

Almazov Federal heart, blood and endocrinology centre, Saint Petersburg, Russian Federation

Objective: New regular atrial tachycardias (ATs) frequently develop after persistent atrial fibrillation (AF) ablation, and are well described. However, there is a lack of data regarding prevalence and mechanisms of AT after different strategies for left atrial (LA) ablation in patients with paroxysmal AF. The aim of this study was to identify LA ablation procedure with the least frequent development of atrial tachycardias; and to predict the most probable mechanism of tachycardia occurring after each ablation strategy.

Methods: Three hundred and sixty-two patients with paroxysmal AF and no structural heart disease comprised the study population. Circumferential pulmonary vein isolation (CPVI) at antral level was performed in 270 patients; CPVI plus linear ablations were performed in 57 patients; excessive LA ablation at four areas of major ganglionated plexi concentrations (anatomic GP ablation) was performed in 35 patients. After a three-month blanking period detection of recurrences was performed by 24-h Holter monitoring every three months and using unscheduled ECG registration in case of any symptoms. Redo ablations were carried out if a symptomatic drug-refractory recurrence was detected beyond the blanking period.

Results: A mean follow-up period was 23.3±2.2 months. In 35 (9.7%) patients ambulatory ECG registration revealed sustained ATs. Redo procedures were conducted in 68 (19%) patients due to symptomatic recurrence of AF and/or AT. In 30 of these patients AT were documented during a redo procedure: in 7% of patients of the CPVI group; in 15.7% patients of the CPVI plus linear lesions group; in 5.7% patients of anatomic GP ablation group.

Conclusions: In a patient after AF ablation ATs frequently develop if CPVI plus linear ablations have been performed during the index procedure. Macro re-entrant ATs can develop after anatomic GP ablation.

C14-2 VIDEO-ASSISTED PULMONARY VEIN ISOLATION FOR LONE ATRIAL FIBRILLATION USING IRRIGATED BIPOLAR RADIOFREQUENCY SYSTEM – MID- AND LONG-TERM RESULTS

P. Suwalski¹, G. Suwalski², A. Witkowska¹, J. Kochanowski³, P. Scislo³, R. Wilimski³, K.B. Suwalski¹, R. Cichon³

¹Central Clinical Hospital of the Ministry of Internal Affairs, Warsaw, Poland; ²Military Institute of Medicine, Warsaw, Poland; ³Warsaw Medical University, Warsaw, Poland

Objective: Atrial fibrillation (AF) is the most common arrhythmia, having a strong impact on long-term stroke and heart failure prevalence and mortality. Nowadays, rapid development in the field of minimizing the invasiveness of surgical ablation of AF can be observed. The objective of the study is to report on the feasibility and mid-term results of the novel technique of minimally-invasive video-assisted beating heart bilateral surgical ablation for lone paroxysmal AF using irrigated bipolar radiofrequency technique.

Methods: Between February 2006 and November 2010, 45 patients (mean age of 54±7 years) with highly symptomatic paroxysmal or persistent (but not long-standing persistent) AF, resistant to pharmacological treatment, underwent video-assisted beating heart bilateral pulmonary vein isolation using cardioblate BP or Gemini (Medtronic, MN, USA) irrigated bipolar radiofrequency systems combined with vein of Marshall dissection and left atrial appendage occlusion. In 17 patients at least one unsuccessful percutaneous ablation had previously been performed. In all patients follow-up using Holter ECG and echocardiography 3, 6, 12, 24 and 48 months postoperatively was performed.

Results: There was no in-hospital and follow-up mortality. There was no conversion to sternotomy. There were no major complications except for one TIA on the fourth postoperative day. Ablation time was on average 88±12.1 s. At least one recurrence of AF was observed in 35 (78%) patients in the early postoperative period; in 21 (60%) of them an electrical cardioversion was performed. All patients were discharged home in stable sinus rhythm. Mean follow-up was 30.2 (2–48) months and revealed 11 (24%) patients on antiarrhythmic drugs, one (2%) patient converted to persistent atrial fibrillation, five (11%) patients with periodical onsets of atrial fibrillation.

Conclusions: Minimally-invasive video-assisted beating heart bilateral surgical ablation for lone paroxysmal and persistent atrial fibrillation using irrigated bipolar radiofrequency system is effective and safe. These promising results have to be confirmed by larger, randomised studies.

C14-3 ACCURACY OF ELECTROCARDIOGRAPHIC ALGORITHMS IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME AND CONCOMITANT CARDIAC DISEASE

D.S. Novikov¹, M.L. Kandinskiy¹, S.V. Popov², A.S. Samoilov¹, E.A. Taran¹, M.V. Latkin¹

¹Clinical Regional Hospital, Krasnodar, Russian Federation; ²Scientific Research Institute of Cardiology, Tomsk, Russian Federation

Objective: The aim of the study was to evaluate the efficacy of electrocardiographic algorithms application in patients with Wolff-Parkinson-White syndrome and concomitant heart disease.

Methods: Four hundred and eighty-six consecutive patients with manifest accessory pathways (62% male, mean age 35±16 years) where included in our study. Patients were divided into two groups: first group – 143 patients with concomitant heart disease (coronary heart disease, hypertensive disease, congenital heart defects etc.), second group – 343 patients without any concomitant disorder. Three algorithms (J.J. Gallagher, M.S. Arruda and T. Iwa) where used to determine accessory pathway location before radiofrequency ablation. After ablation these preliminary determined locations where compared with the sites of effective ablation in each case. Accuracy of algorithms (the ratio of successfully determined locations to the overall number of accessory pathways) was calculated in each location separately for patients of first and second group.

Results: The accuracy of three algorithms in the second group was 20.9%, 45.5% and 14.7% (J.J. Gallagher, M.S. Arruda and T. Iwa). Statistical analysis (χ²-test) did not show any differences between accuracy of algorithms in two groups. Although when we compared accuracy for definite accessory pathway location, we found some difference. J.J. Gallagher’s algorithm in right posteroseptal accessory pathways was more precise in the first group (23.7% and 6.3%; P=0.006). M.S. Arruda’s algorithm in right posteroseptal accessory pathways was more precise in the first group (89.5% and 56.9%; P=0.01). M.S. Arruda’s algorithm in oblique posteroseptal accessory pathways was more precise in the second group (40.1% and 8.3%; P=0.043).

Conclusions: Although structural cardiac disorders may change depolarization of ventricles, electrocardiographic algorithms created by J.J. Gallagher, M.S. Arruda and T. Iwa can be successfully used in patients with manifest Wolff-Parkinson-White syndrome and concomitant heart disease.

C14-4 RADIOFREQUENCY ABLATION OF IDIOPATHIC VENTRICULAR TACHYCARDIA

V.A. Bazaev, L.A. Bockeria, A.S. Kovalev, A.G. Filatov, S.I. Stupakov, I.A. Temirbulatov

Bakoulev Scientific Center for Cardiovascular Surgery Russian Academy of Medical Sciences, Moscow, Russian Federation

Objective: The majority of idiopathic ventricular tachyarrhythmias (VT) originate from the right ventricular outflow tract (RVOT) and the left posterior His-bundle branch. The efficacy of catheter radiofrequency ablation (RFA) for these kinds of VT reaches 95–100%. However, there is a subgroup of patients with ventricular tachycardia from other sites in which, the efficacy and safety of RFA is still studied (such as VT around mitral and tricuspid valve rings, epicardial ventricular tachycardia from the great cardiac vein).

Methods: During the period from 1998 to 2010 in EP laboratory there had been carried out 148 RFA procedures of ventricular arrhythmia with 95.1% of efficiency. To determine the localization of the arrhythmia origin, the methods of local activation and pace-mapping were performed. VT that occurred around mitral and tricuspid valve rings were verified by the ratio of A/V <1 spikes at the earliest possible point, to determine the localization of accessory pathway was also used non-fluoroscopic 3D navigation system CARTO.

Results: VT from RVOT was estimated in 46.34%, from left ventricle – in 3.7%, ventricular tachycardia from sinus of Valsalva – in 9.75%, VT from the interventricular septum from the RV – in 9.75%, ventricular tachycardia around the mitral valve ring – in 3.7%, ventricular tachycardia around tricuspid valve ring – in 6%, fascicular arrhythmia of LV – in 3.7%, ventricular tachycardia from the RV free wall – in 2.43%, VT in the transition region of great cardiac vein to anterior interventricular branch – in 7.31%, VT of the anterolateral LV wall – 2.42%. Ventricular arrhythmias wasn’t resolved in six patients (4.9%). There were not any complications related to RFA technique during the research period (3–72 months).

Conclusions: Idiopathic VT may originate from different parts of the right and left ventricular and tachycardia focus may be located both endocardial and epicardial. The successful mapping and effective treatment required the use of multichannel electrodes in the coronary sinus and mapping of activation around the rings of the MV and TV, and also over the valves of pulmonary artery and aorta. Selective right and left coronary angiography should be used for safety treatment of arrhythmias from the ventricular outflow tracts.

C14-5 SURVIVAL AND COMPLICATION RATE AFTER LONG-TERM FOLLOW-UP OF ICD IMPLANTATION

N.N. Lomidze, A.Sh. Revishvili, L.A. Bockeria, G.R. Matsonashvili

A.N. Bakoulev Scientific Center, Moscow, Russian Federation

Objective: The purpose of the study was to analyse the efficacy of ICD during long-term follow-up, to estimate survival of patients with ICD and to evaluate complications rate in early and late postoperative periods.

Methods: Four hundred and twenty-four ICD were implanted in our clinic from February 1990 to October 2010. Primary implantations were performed in 391 patients, in 125 cases ICD were replaced due to battery depletion.

Results: We evaluated long-term results of 292 patients (237 males, age 12–82 years, in average 50.5±15.3 years, follow-up period 1–178 months, in average 39.9±34.5). During this period 168 patients (57.5%) received ICD therapy, the interval between the implantation and the first therapy was 0.2–70 months, average follow-up time in this group was 24.1±19.3 months, in group of patients who did not get an ICD therapy – 15.5±12.2 months (P=0.04). Most of episodes of VT were determinated by electrical shocks (156), which was determined by tachycardia behavior and hemodynamic condition of patients. ATP was successful for 68 patients. Multivariate analysis revealed that the only variable which influenced rate of ICD therapy was left ventricle ejection fraction (LVEF) which in group of patients who got ICD therapy was the average of 41.3±16.8%, and in group of patients who did not get ICD therapy - 57.4±15.7% (P<0.03). LVEF appeared to be the most important factor of survival. Total cumulative proportional survival (Kaplan–Meier) was 73% during 150 months. Multi-chamber ICD were shown to improve not only LV function but quality life (LVEF increasing from 37.3±10.1% to 45.0±10.9%, NYHA class changing from 2.87±1.01 to 2.12±0.64). Patient survival rate was 94% among patients with multi-chamber ICD and 67% among those with single-chamber ICD (P<0.001). No intraoperative complications were observed. There was no statistically significant difference for late surgical complications rate between patients with single-chamber and dual-chamber ICD. Incidence of unmotivated discharges with single-chamber devices was twice as high as with multychamber devices.

Conclusions: LVEF and the type of device (single-chamber vs. multi-chamber) are two most significant factors influencing patients survival rate, VT occurrence and life quality.

C14-6 META-ANALYSIS AND EVALUATION OF MAZE-III PROCEDURE IN PATIENTS WITH LONE ATRIAL FIBRILLATION

A.S. Mordvinova, L.A. Bockeria, O.L. Bockeria, A.Y. Zavarina

Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: To evaluate the results of maze III procedure in patients with lone atrial fibrillation (AF) on the basis of meta-analysis according to reported data.

Methods: Nine studies (seven international) which included 624 patients have been analysed. The procedure considered to be effective in case of restoration of stable sinus or atrial rhythm within 12 months after it. The analysed parameters were: age, type of AF, AF duration, left ventricular ejection fraction (LVEF), left atrium (LA) size, mortality after surgery, analysis of postoperative complications, sick sinus syndrome and necessity of the permanent pacemaker implantation, the % age of sinus rhythm restoration. Meta-analysis has been performed by the program ‘Comprehensive meta-analysis’.

Results: The evaluated parameters were hom*ogeneous in all studies. Mean age was 54±6.5 years (27–63). Chronic AF was in 57% of cases. Mean duration of AF was 8.0±0.9 years. Mean size of the LA was 60.4±5.6 mm. Mean LVEF was 58±9.8%. Restoration of a stable sinus or atrial rhythm has been observed in 87.3% of all cases. Hospital mortality was 0.2%. Mortality in long-term period (five years) was 4.2% and has not been presented by cardiac events. The frequency of thromboembolic complications was in 0.6%, the rate of postoperative bleeding has reached 4.5%. In 13.8% permanent pacemaker was implanted in patients with concomitant sick sinus syndrome.

Conclusions: The data of Meta-analysis confirm the high efficacy of ‘Maze III’ procedure in patients with long time existing lone atrial fibrillation and minimal hospital and annual mortality. Chronic AF is usually associated with sick sinus syndrome which requires permanent pacemaker implantation to maintain physiological rhythm.

C14-7 SUCCESSFUL TREATMENT OF LONE PERSISTENT AF BY MEANS OF A HYBRID THORACOSCOPIC-TRANSCATHETER APPROACH

G. Bisleri¹, A. Curnis¹, L. Bontempi¹, F.H. Cheema², C. Muneretto¹

¹University of Brescia Medical School, Brescia, Italy; ²Columbia College of Physicians and Surgeons, New York, NY, USA

Objective: Ablation strategies for the treatment of lone persistent atrial fibrillation (AF) have rapidly evolved during the past decade either with the electrophysiological (EP) and surgical approaches. We therefore sought to investigate the outcome of a novel hybrid approach combining surgical and EP ablation in patients with lone persistent AF.

Methods: Twenty-four consecutive patients with either persistent (three patients, 12.5%) or long-standing persistent (21 patients, 87.5%) isolated AF were enrolled: mean age was 63.2±9.3 years, mean left atrial dimension was 50.5±8 mm, mean AF duration was 82.7 months (range: 7–240). The surgical procedure consisted of a monolateral, right-sided, closed-chest approach to perform a ‘box’ lesion set with a temperature controlled, internally cooled radiofrequency monopolar device with suction adherence (COBRA ADHERE XL, Estech).

Results: Successful completion of the procedure was achieved in all cases with a mean ablation time of 29±9 min and overall procedural time of and 84±16 min. During surgical ablation, exit block was documented in all cases, while entry block was achieved in 87.5% (21/24 patients). A continuous monitoring rhythm device (REVEAL XT, Medtronic) was implanted at the time of surgery. No ICU stay was required nor any complications occurred postoperatively; hospital mortality was 0%. At a mean interval of 33±2 days following surgery, an EP study was performed: entry-exit block was confirmed in 79.1% (19/24) while gaps at the level of the box lesion were observed in 20.8% (5/24) of patients, respectively. Additional transcatheter endocardial right- and left-sided lesions were performed in 62.5% of cases (15/24 patients). At a mean follow-up of 28 months (range: 1–55), 87.5% (21/24) of patients are in sinus rhythm and the incidence of left atrial flutter was 0%.

Conclusions: The combination of surgical (box lesion) and transcatheter ablation in a hybrid approach provided excellent clinical outcomes in patients with long-standing, isolated persistent AF. Moreover, the implantable loop recorders documented such incremental benefits in terms of sinus rhythm restoration up to 28 months.

C14-8 STATISTIC MODEL OF ATRIAL FIBRILLATION OCCURRENCE IN LONG-TERM PERIOD AFTER SUCCESSFUL MITRAL VALVE SURGERY

M. Shaydakov, G. Khubulava, S. Marchenko, M. Didenko, I. Averkin

Kuprianov Cardiovascular Surgery Clinic, Military Medical Academy, Saint Petersburg, Russian Federation

Objective: The aim of the study was to analyse the development of the statistic model, which can estimate the probability of atrial fibrillation in long-term period after successful mitral valve surgery using some preoperative factors.

Methods: We retrospectively analysed 96 consecutive patients from 2006 to 2008 years. Patients with implanted pacemakers were not included. Multiple correlation analysis and logistic regression analysis were used. Those factors with moderate and strong correlation with outcome (atrial fibrillation) were used as dependent variables in logistic regression. Logistic regression coefficients were calculated by maximal likelihood method. ROC-analysis was performed to establish the predictive value of logistic regression model.

Results: The relationship between atrial fibrillation in long-term postoperative period after mitral surgery and 21 preoperative factors was evaluated with multiple correlations analysis. The correlation (r=0.713) was found with duration of preoperative atrial fibrillation and atrial fibrillation form (r=0.733). Also moderate correlations with age, fibrillation wave (f) amplitude in V1 lead, heart disease history, rheumatic disease, other than mitral valve pathology, atria size and LV EF were founded. The logistic regression model is: AF probability=1/(1+2.71-z), Z=–11.237+13.951×x¹+1.079×x²+1.081×x³+9.525×x⁴ [x¹ – atrial fibrillation before operation (0 – no, 1 – yes), x² – age, years, x³ – left atrial size, mm, x⁴ – rheumatic disease (0 – no, 1 – yes)]. ROC-analysis showed the sensitivity of model to be 90.7% and specificity 88.7%.

Conclusions: The equation of the logistic regression function allowed to set up indications for surgical ablation of AF and selection of patients for concomitant surgical treatment.

C14-9 RESULTS OF SURGICAL TREATMENT OF ATRIAL FIBRILLATION IN PATIENTS WITH ASSOCIATED HEART PATHOLOGY

A.Sh. Revishvili, L.A. Bockeria, S.Y. Serguladze, A.V. Shmul, B.I. Kvasha

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: At present the maze-3 operation is considered as a gold standard of surgical procedure for restoration of sinus rhythm and atrial contractility in atrial fibrillation (AF). It is unknown which type of operation is the most effective and safe in patients with chronic AF, including that associated with congenital and acquired heart disease. This study presents long-term results of different modifications of surgical treatment for chronic AF.

Methods: From February 2000 to September 2010 we performed 180 combined operations for chronic AF and mitral valve disease (MV plasty or replacement), including 112 radical operation for chronic AF: 35 patients (pts) underwent Maze-3 operation, 60 – a RF modification of Maze-3 and 17 – a cryo-modification of Maze-3 operation. Mean age of patients was 45.7±12.6 years (range 27–67 years), AF duration was 3±2.3 years (six months to seven years). Average preoperative LA dimension was 6.34±1.5 cm (4.5–8.4 cm). All patients were NYHA class III–IV.

Results: From the 112 patients who underwent radical surgery for reversal of chronic AF, one patient (0.8%) died in hospital as a result of spontaneous rupture of the LV posterior wall after RF modification of the Maze-3 operation and LA plication. In general, by the time of discharge 82% of patients had sinus rhythm. None of our patients needed pacemaker implantation for postoperative AV block or sinus node dysfunction at hospital discharge. Results of the different types of the Maze-3 operations were evaluated after 60±10.3 months by Santa Cruz scale (Melo J. et al. 1998) with scores ranging from zero to four. All patients with sinus rhythm (n=91, 81%) had score 4, atrial contractile function of both atria was preserved in all of them up to five years after surgery. Four patients who had score 3 needed permanent pacemaker implantation at long-term follow-up, as their atrial function was preserved.

Conclusions: Our experience shows the reproducibility of different modifications of Maze-3 operation with overall long-term effectiveness over 80%. The cryo-modification of the ‘maze’ operation are currently preferable in patients with moderately increased LA. It is necessary to strictly follow the protocol of procedure technique, as well as to combine the operation with the reduction of LA cavity and left atrial appendages closure.

15th Cardiac Surgery Session – VAD/Heart Failure May 22, 2011 11:30–13:00

C15-1 SURGICAL VENTRICULAR RESTORATION FOR ISCHEMIC CARDIOMYOPATHY USING AN ALTERNATIVE TECHNIQUE TO DOR OPERATION AND TRANSPLANT OF AUTOLOGOUS STEM CELLS

G. Stefanelli

Cardiac Surgery Department, Hesperia Hospital, Modena, Italy

Objective: The aim of the study was to compare the results after surgical ventricular restoration (SVR) using the DOR technique (group A) and an alternative approach (group B), developed to reduce the progression of the left ventricular remodeling and limit the worsening of the diastolic function with time.

Methods: Between March 2003 and March 2010, 54 patients affected by ischemic cardiomyopathy received a SVR at our unit, along with surgical myocardial revascularization. The STICH trial criteria have been used as indication to SVR. The patients were divided in two groups. Twenty-eight patients (group A) underwent a classical DOR operation, using a bovine pericardial patch. In the remaining 26 patients (group B), a double-line ‘Horseshoe’ semicircular, pledged at purse-string and a second incomplete double-line suture more proximal to the apex were accomplished, in order to reduce the ventricular diameter at the equatorial level. Aggressive approach to the mitral valve incompetence and direct closure by Guilmet technique of the ventriculotomy completed the operation. Harvesting and processing of autologous sternal bone marrow and subsequent subendocardic implant of the collected stem cells was added in 15 patients of the group B.

Results: Early mortality was 7.6% in group A, 3.1% in group B. Reduction of LVED diameters, improvement of EF and NYHA class were more significant in group B (P<0.05). Residual mitral incompetence was more frequent in group A. Late mortality (mean FU time 5.4 years) was 28% in group A, 8.1% in group B. Freedom from re-hospitalization was 81% in group A, 92% in group B. No adverse reactions to the stem cells implant was observed, in terms of malignant arrhythmias or infection.

Conclusions: Patients affected by ischemic cardiomyopathy seem to have a better short and intermediate-time outcome after SVR accomplished by using the reported surgical protocol, when compared to those treated by the classical DOR operation. Adding transplant of autologous stem cells to the procedure could improve the left ventricular function by promoting myocardial regeneration.

C15-2 RADIONUCLIDE IMAGING PERFUSION AND METABOLISM ASSESSMENT OF MYOCARDIUM IN HEART FAILURE PATIENTS WITH CARDIAC RESYNCHRONIzATION THERAPY

D. Lebedev, G. Savenkova, S. Minin, Yu. Saushkina, S. Popov

Research Institute of Cardiology SB of RAMS, Moscow, Russia

Objective: Cardiac resynchronization therapy (CRT) had been demonstrated as an extremely effective approach that improves congestive heart failure (CHF) symptoms, provides ventricular reverse remodeling and reduces mortality in patients with a wide QRS complex. However, not all patients respond to CRT and shows positive haemodynamic and contractility effects. The objective of the study was to assess the possibilities of single-photon emission computer tomography (SPECT) with 99mTc-MIBI and Iodine-123-b-methyl-p-iodophenylpentadecanoic acid (123I-BMIPP) to evaluate cardiac resynchronization therapy effect.

Methods: We studied 19 patients (mean age 55.4±8.3 years) with CHF [NYHA class III or IV, left ventricular ejection fraction (LVEF) <35%, QRS duration >120 ms] and left bundle-branch block. All patients underwent SPECT with 99mTc-MIBI at rest to evaluate myocardial perfusion and 123I-BMIPP to evaluate myocardial metabolism before implantation of CRT device. In addition, all patients underwent gated blood pool single photon emission computer tomography (GBPS) with marked in vivo 99mTc-stanneus pyrophosphate erythrocyte to assess LVEF before and 12–18 months after CRT.

Results: After CRT all patients were divided into two groups according to GBPS. The first group included 10 patients with increase of LVEF <15%, the second group – nine patients with increase in LVEF more than 15%. Before CRT, both investigated groups were not significantly different according to the LVEF. The size of 123I-BMIPP accumulation defect was significantly greater in first group comparing to second group (20±9.74% and 15.57±3.1%, respectively, P<0.05). In the first group the myocardial perfusion defect with 99mTc-MIBI had significantly been more expressed comparing to second group (15.66±10.82% and 9±3.46%, respectively, P<0.05).

Conclusions: Results of this study indicated, that defects of myocardial perfusion and metabolic accumulation had a predictive value of CRT efficiency. Thus, accumulation defects size of both 99mTc-MIBI and 123I-BMIPP can be used for CRT candidates selection in addition to guidelines indications.

C15-3 ANTIMICROBIAL PROPHYLAXIS AND INFECTION CONTROL IN PATIENTS WITH MECHANICAL CARDIAC SUPPORT DEVICES

J. Skrlin, Z. Sutlic, I. Rudez, D. Baric, D.I. Unic

Dubrava University Hospital, Zagreb, Croatia

Objective: Ventricular assist devices (VAD) are increasingly being used in patients with end-stage heart failure. Infection represents a frequent and one of the major complications associated with the use of device support. Factors such as critical patient status, a driveline wound allowing for ascending bacterial colonization, and a large intravascular polymer surface may all contribute to infection. The aim of this study were to investigate microbiological findings and consequences of infection in patients with VADs.

Methods: Between October 2008 and February 2010, four patients received mechanical circulatory support (one patient was implanted PVAD and the others LVAD) either as bridge to transplantation or as destination therapy. Microbiological surveilance included screening prior to device implantation and, in accordance with a patient’s clinical status, pre and/or postoperative samples. Usual perioperative prophylaxis was prescribed, in accordance with REMATCH trial, except for substituting Levofloxacin by Ciprofloxacin, in cases where the control swabs were negative.

Results: Two patients died due to infectious complications and two developed driveline site infections. First patient, in whom the Thoratec PVAD was implanted for heart failure after myocarditis, was successfully weaned from support and device eventually explanted. During VAD supported period, central venous line infection was the only infectious complication. After VAD explant, he developed sternal wound infection, supported by permanent pacemaker leads infection. He eventually developed sepsis and recurrent heart failure and expired. Second patient died only two days following the operation, due to a fulminant sepsis of unknown aetiology. The third patient was released from hospital soon after the operation with adequate antimicrobial therapy based on the microbiological samples. Nine months later she developed a drive-line site infection successfully treated with dressings and antibiotics. The fourth patient also developed driveline site infection four months after VAD implantation. It was successfully treated with antibiotics, and patient was successfully transplanted eight months postVAD implantation.

Conclusions: Timing of intervention, optimization of the preimplantation patient status, adherence to evidence-based infection control and prevention guidelines, meticulous surgical technique and optimal postoperative surgical site care form the foundation for VAD-associated infection prevention. Microbiological monitoring and prevention strategies (especially in Pseudomonas aeruginosa suspected infections) with medical (targeted strong antibiotic therapy) and surgical management of infections may increase survival and decrease morbidity among VAD patients.

C15-4 CARDIAC RESYNCHRONIZATION THERAPY: THE META-ANALYSIS OF MODERN CLINICAL TRIALS AND FOLLOW-UP RESULTS OF ITS APPLICATION

L.A. Glushko, L.A. Bockeria, O.L. Bockeria

Bakoulev Scientific Centre of Cardiovascular Surgery, Moscow, Russian Federation

Objective: To determine the follow-up results of cardiac resynchronization therapy (CRT) alone and with implantable cardioverter defibrillators (ICD) in patients with left ventricular systolic dysfunction (LVSD). A systematic and comprehensive literature research was conducted to identify randomized controlled trials (RCTs) evaluating efficacy and observational studies evaluating effectiveness or safety of CRT alone and with ICD in patients with LVSD.

Methods: Study selection, quality assessment, and data extraction were completed from several randomized clinical trials and observational studies. Statistical software was comprehensive meta-analysis.

Results: From 11,345 citations, were identified 14 RCTs (4420 patients) for the CRT efficacy review, 106 studies (9209 patients) for the CRT effectiveness review, 89 studies (9677 patients) for the CRT safety review, 12 RCTs (8516 patients) for the ICD efficacy review, 48 studies (15,097 patients) for the ICD effectiveness review, and 49 studies (12,592 patients) for the ICD safety review – all studies enrolled only patients with LVSD. All patients in the CRT studies had LVSD (mean LVEF from 21 to 30%) and prolonged QRS duration (mean from 155 to 209 ms), and 91% had III or IV class (NYHA) symptoms. In patients with LVSD and heart failure symptoms, CRT improved ejection fraction [weighted mean difference 3.0% (95% CI, 0.9–5.1)], quality of life [weighted mean reduction in MLHFQ 8.0 points (95% CI, 5.6–10.4 points)], and function (59% of CRT recipients vs. 37% of controls improved by at least one NYHA class in the RCTs and between 63% and 82% of CRT recipients improved by at least one NYHA class in observational studies. The proportion of patients hospitalized for HF was reduced by 37% (95% CI, 7–57%) and all-cause mortality was reduced by 22% (95% CI, 9–33%; NNT=29 over six months). Implant success rate was 93%, 0.3% of patients with LVSD died during implantation. Over a median 11-month follow-up, 6.6% of CRT devices exhibited lead problems and 5% malfunctioned.

Conclusions: CRT reduce all-cause mortality in patients with LVSD meeting RCT entry criteria. The incremental benefit of CRT plus ICD over CRT alone in patients with LVSD remains uncertain. Examination of individual patient trial data is urgently needed to define which clinical subgroups are most likely to benefit from these devices.

C15-5 ROLE OF LEVITRONIX CENTRIMAG SYSTEM IN BRIDGING PATIENTS

A.F. Popov, B. Zych, D. Rajaruthnam, S. Hossein, M. Kuppuswamy, N. Banner, M. Hedger, A.R. Simon

Royal Brompton and Harefield Hospitals, London, UK

Objective: At present the most definitive therapeutic option for end-stage heart failure is cardiac transplantation. However, this method is limited in its availability due to a lack of available organs. This is why ventricular assist devices (VADs) capable of supporting the circulation are playing taking an increasingly important role in the management of heart failure therapy. The CentriMag (Levitronix LLC, Waltham, Mass) system is a device for bridging patients to decision or directly to transplant. This study evaluates our clinical experience of temporary mechanical support in patients who were bridged to a long-term assist device or to heart transplantation.

Methods: A retrospective review was performed in 35 patients from March 2004 to January 2009. Initially they were treated with Levitronix CentriMag system as bridge to decision or directly to transplantation. All patients had ultimately undergone an implantation of long-term assist device.

Results: The etiology of heart failure was dilated cardiomyopathy in 28 patients, ischemic cardiomyopathy in six patients, and in one cardiogenic shock. Mean age was 37±13.54 years (range, 13–59 years), mean duration of CentriMag assistance was 33.88±34.02 days (range 3–167 days) and was used as biventricular support (n=10), left ventricular support (n=6) and right ventricular support (n=19). There was one mechanical device failure. All patients were upgraded to long-term devices: Jarvik=6, HeartMate I=5, and HeartMate II=24. Mean duration of long-term support was 302.70±220 days (range, 4–1380 days) and the long-term survival rate was 65%. Out of them, 10 patients were bridged to heart transplantation and one-year mortality in these patients after heart transplantation was 7% (n=1).

Conclusions: The Levitronix CentriMag has proven to be a versatile, safe and effective short-term circulatory support for patients with end-stage heart failure as a bridge to decision or to heart transplantation.

C15-6 A PRACTICAL APPROACH OF EARLY EXTUBATION AFTER HEART TRANSPLANTATION

V.N. Poptsov, E.A. Spirina, O.V. Voronina, S.G. Uchrenkov, A.I. Magilevetch

Shumakov Federal Research Center of Transplantology and Artificial Organs, Moscow, Russian Federation

Objective: Early extubation (EE) after cardiac surgery was introduced as attempt to minimize cost, postoperative recovery time, infectious and other complication associated with prolonged lung ventilation. EE is a feasible strategy of perioperative care in selected category heart transplant recipients.

Methods: In our institute the practice of the protocol of EE has been implemented since 1 September 2009. We examined 46 patients: six (13%) female, 40 male (87%); mean age 48±2, range 18–69 years; ischemic cardiomyopathy in 13 (28%) patients, dilated cardiomyopathy in 33 (72%) patients. Thirty-four (74%) patients were in NYHA class 3, 12 (26%) NYHA class 4. One (2%) patient was in UNOS 1A status, 16 (35%) were in UNOS 1B status, 29 (63%) were in UNOS 2 status. Pretransplantate value of transpulmonary gradient was 9.8±0.4 mmHg, pulmonary vascular resistance 3.9±0.2 Wood’s units. Forty-four patients underwent primary orthotropic heart transplantation, one patient heart-kidney transplantation and one patient heart retransplantation. Criteria for EE in operative room after surgery: CVP <14 mmHg, PAWP <15 mmHg, CI >2.7 l/min/m², dopamine or dobutamine <7.5 μg/kg/min or adrenaline <50 ng/kg/min; PaCO₂ <40 mmHg, PaO₂/FiO₂ >300 mmHg, BEa >–4 mmol/l, lactate <7 mmol/l, postoperative bleeding (drainage) <75 ml/h, normothermia, diuresis >1 ml/kg/h.

Results: Thirty-seven (80%) from 46 heart transplant recipients were extubated in operative room (included patient after heart retransplantation and patients after heart-kidney transplantation). Duration of surgery in this category of patients was 314±24 min, ischemic time 158±10 min, duration of CPB 140±10 min, interval between the end of surgery and the extubation was 51±7 min. All recipients were extubated in operative room. After extubation in operative room and ICU vital sings, haemodynamic and metabolic status, blood gases were acceptable. There was not the need of some kind of ventilatory support or reintubation in this category of patients. Survival was 100%. ICU length of stays 4.6±0.4 days.

Conclusions: This single-center study showed that early extubation immediate after heart transplantation is possible and safety in selected category of recipients.

C15-7 THYROID DYSFUNCTION IN POSTOPERATIVE COURSE IN PATIENTS AFTER HEART TRANSPLANTATION?

A. Kowalczuk, A. Baranska-Kosakowska, M. Zakliczynski, M. Zembala

Silesian Center for Heart Diseases, Zabrze, Poland

Objective: Untreated thyroid dysfunction can lead to severe complications. There are few studies on the impact of impaired thyroid function on post-heart transplantation course. The objective of the study was to assess the impact of thyroid dysfunction detected de novo after heart transplantation on postoperative follow-up in heart transplant recipients with no thyroid disease history before the operation.

Methods: We analysed 98 patients (77 M/21 F, 48±13 years old) transplanted in the Silesian Center for Heart Diseases between 2 September 2004 and 1 April 2010. An impaired thyroid hormones level, below or above the norm (TSH: 0.47–4.64 uIU/ml, fT3: 1.45–3.48 pg/ml, fT4: 0.4–1.37 ng/ml) was detected in 47 patients (43 M/9 F, 47±10 years old). Hyperthyroidism was recognized in 21 patients (19 M/2 F, 52±7 years old), hypothyroidism in 13 patients (10 M/3 F, 46±12 years old), low fT3 syndrome in 18 patients (14 M/4 F, 43±12 years old). Every patient with thyroid dysfunction was treated due to incorrect hormones level. The control group consisted of 46 patients (34 M/12 F, 48±12 years old) with a correct level of thyroid hormones.

Results: –

Conclusions: The incidence of postoperative complications in heart transplant recipients in the studied group was similar regardless the levels of thyroid hormones detected after the operation. Early treatment of thyroid dysfunction can prevent such postoperative complications.

C15-8 BONE-MARROW PROGENITOR STEM CELLS FOR THE TREATMENT OF PATIENTS WITH CONGESTIVE HEART FAILURE OF DIFFERENT ETIOLOGY IN A PLACEBO CONTROLLED CLINICAL TRIAL

T. Kakuchaya, E. Golukhova, M. Eremeeva, N. Chigogidze, I. Aslanidi, T. Nikitina, I. Shurupova, L. Bockeria

Bakoulev Center, Moscow, Russian Federation

Objective: To evaluate effects of autologous bone-marrow (BM) derived CD133+ progenitors on cardiac remodeling in patients with congestive heart failure (CHF).

Methods: Fifty CHF patients in NYHA class III-IV [24 patients with ischemic dilative cardiomyopathy (ICMP) and 26 patients with idiopathic dilative cardiomyopathy (IDCMP)] were divided into groups by CD133+/placebo transcatheter delivery technique: selectively intracoronary or transendocardially. Patients with acute heart failure were excluded from the trial. We used all the contemporary.

Methods: Of investigation in the study protocol along with lab tests. CD133+ were obtained by clinimacs technology of magnetic separation, which allowed to extract pure cell populations with high survival rate.

Results: According to the single photon emission computed tomography single isolated transendocardial injection of CD133+ progenitors at average dosage 2 ml was more effective in patients with ICMP than in patients with IDCMP compared to placebo in the regions with profoundly reduced perfusion but viable myocardium in six months after the procedure. This was associated with significantly reduced left ventricular (LV) volumes and increased ejection fraction in ICMP patients in that period of time, however there were no significant changes in such LV remodeling indices as LV mass, left atrial volume, myocardial performance index and mitral insufficiency. Mentioned positive changes were offset in one year following the procedure. There were no significant changes in IDCMP group. In order to evaluate stem cells paracrine effects we performed enzyme-linked immunoelectrodiffusion assay of patients plasma samples for 11 biological markers before and after elective CD133+ treatment. Paracrine effects manifested transiently in ischemic scarred viable myocardium and did not exhibit in non-ischemic dilated myocardium.

Conclusions: CD133+ progenitors were more efficient, though temporarily, in ICMP patients than in IDCMP patients. This phenomenon was due to the significant expression and up-regulation of stem cell homing factors in a scarred ischemic myocardium. Thus, isolated percutaneous transendocardial delivery of CD133+ progenitors at average dosage 2 ml may have some positive effects in patients with CHF secondary to coronary artery disease and can be repeated in six months following the first procedure.

16th Cardiac Surgery Session – AAA May 22, 2011 11:30–13:00

C16-1 MODIFIED BIO-BENTALL PROCEDURE WITH A DOUBLE SEWING RING TECHNIQUE: A FIVE-YEAR EXPERIENCE

E. Mikus, S. Calvi, M. Del Giglio, T.M. Aquino, A. Tripodi, D. Magnano, M. Lamarra, A. Albertini

Maria Cecilia Hospital, Cotignola (RA), Italy

Objective: Biological aortic valve conduits are rarely used because of the concern that possible structural valve deterioration would require complete conduit replacement and a technically demanding operation. The aim of the study was to evaluate our five years’ experience of complete aortic-root replacement with a modified composite graft built using the double sewing ring technique in which a biological valve prosthesis is located inside a vascular Valsalva graft.

Methods: Since January 2006, a total of 71 patients (60 males, 11 females; mean age 68.1±8.5 years, range: 41–79) underwent an aortic root replacement using the double sewing ring technique. A Valsalva graft 5 mm larger than the bioprosthesis size has been used in most of patients. Concomitant procedures included coronary artery bypass grafting (n=2), other valves (n=4) and arch replacement (n=3). All pre-, intra- and postoperative data were collected. Four patients (5.6%) had been previously operated. The mean EuroSCORE was 7.7±3.1. In seven patients (9.9%) a J-shaped ministernotomy has been chosen as surgical approach.

Results: Mean cardiopulmonary bypass time was 122±52.3 min and mean cross-clamp time was 98±35.3 min. Hospital mortality was 4.2% (3/71). Early postoperative outcome, in terms of intensive care unit stay (median 41 h; range: 21–188 h), mechanical ventilation time (median 8 h; range: 3–61 h) and complications, have been analysed. Re-operation for valve deterioration occurred in one patient and was performed easily by valve replacement within the graft. One patient required reoperation for aortic bioprosthesis endocarditis four months after the operation.

Conclusions: In our experience this technique seems to be simple and reproducible without increasing the operative risk and postoperative mortality. Aortic composite graft with biological valve prosthesis located inside a Valsalva graft offers the possibility of considerable valve oversizing, excellent haemostatic characteristics and simple replacement of the valve prosthesis in case of its deterioration and can therefore be recommended for younger patients.

C16-2 SURGERY FOR THE ACUTE AORTIC DISSECTION STANFORD TYPE A

D. Cvetkovic¹, M. Kocica¹, L. Soskic¹, T. Kocica¹, M. Ristic¹, M. Vranes¹, V. Lackovic², V. Kanjuh²

¹Clinical Centre of Serbia, Clinic for Cardiac Surgery, Belgrade, Serbia; ²Serbian Academy of Science and Arts – Section of Medical Sciences, Belgrade, Serbia

Objective: To evaluate the clinical characteristics, management, and outcomes of patients with acute type A aortic dissection during a period of seven years.

Methods: From January 2003 to December 2009, 257 patients (186 men and 71 women) aged from 18 to 78 years (mean 56.1) underwent emergency operation for type A aortic dissection in our institution. Mean admission-to-table time was 2.7 h. Arterial cannulation was accomplished in 242 (94.2%) patients through the femoral artery. Supracommissural replacement of the ascending aorta was applied to 144 (56%) patients. In 65 patients (25.3%), the aortic valve was replaced either independently (11 patients, 4.3%) or as a composite graft (54 patients, 21.0%). ‘Open distal anastomosis’ strategy was applied in 35 patients (13.6%) with isolated replacement of the ascending aorta, 46 patients (17.9%) with transverse arch, and 16 patients (6.2%) with total arch replacement, five (1.9%) of whom had an ‘elephant trunk’ graft extension.

Results: Overall early mortality was 23.7% (61 patients): operative mortality 7.4% (19 patients) and hospital mortality 16.3% (42 patients). The most frequent postoperative complications were: low cardiac output syndrome 35 patients (13.6%), hemorrhage 27 patients (10.1%) and neurological 29 patients (11.3%).

Conclusions: During this period, we adopted a strategy of ‘the earliest possible surgery’, reducing preoperative diagnostic algorithm on careful clinical examination and the least possible number of imaging tools. Open distal anastomosis strategy resulted safe and feasible in terms of intraoperative diagnosis (arch tears) and outcome. Our results, comparable with leading centers and IRAD, justified our present strategy. The more efficient and more successful strategy of AoD treatment should focus on: earlier clinical suspicion and diagnosis, decrease in ‘pain-to-table’ time, improvements in surgical strategy/technique and establishment of National AoD registry.

C16-3 TRICOMMISSURAL AORTIC VALVE ANNULOPLASTY FOR ADVANCED AORTIC REGURGITATION DURING SURGICAL REPAIR OF ASCENDING AORTA ANEURYSM

C. Mve Mvondo, F. D’Auria, C. Bassano, F. Bertoldo, S. Grego, A. Pellegrino, A. Scafuri, L. Chiariello

Tor Vergata University of Rome, Rome, Italy

Objective: The aim of our study was to verify if tricommissural aortic valve annuloplasty as an adjunct to sinotubular junction (STJ) reduction is relieving advanced, secondary aortic insufficiency (AI) in patients with degenerative aneurysm of the ascending aorta.

Methods: Forty consecutive patients (mean age 65±7.8 years, 22 females and 18 males) with grade III (32 patients) or IV (eight patients) AI, secondary to thoracic ascending aorta aneurysm (TAAA), electively underwent STJ reduction obtained with appropriate size vascular prosthesis, after performing tricommissural aortic valve plasty, in order to prevent leaflet prolapse and stabilize the aortic annulus. All patients were evaluated with Doppler echocardiograms to identify residual or recurrent AI. The mean follow-up was 37 months, its completeness was 100%.

Results: One patient died at follow-up from extracardiac cause. Among 39 survivors, three patients had residual mild AI, no one had residual or recurrent moderate or severe AI, requiring reoperation. Actual freedom from significant AI at three-year follow-up was (39/39). Global reduction of left ventricular end diastolic diameter at follow-up was 7±3 mm. Postoperative and follow-up Doppler echocardiographic examinations excluded pathological transvalvular gradient in all patients.

Conclusions: Tricommissural aortic annuloplasty is an easy and safe adjunctive procedure in patients with AI secondary to TAAA, contributing to achieve stable results even in patients with relatively advanced grade of valve incompetence. It does not add risk to isolated thoracic ascending aorta repair (TAAR) and it is definitively not detrimental compared to isolated TAAR since it does not cause any mechanical obstacle to left ventricle outflow. Prospective randomized studies and prolonged follow-up are necessary to verify if the association of this technique constitutes a real improvement compared to isolated TAAR.

C16-4 CEREBROVASCULAR ACCIDENTS AFTER AORTIC ROOT REPLACEMENT FOR ASCENDING AORTIC ANEURYSM

G. Mariscalco¹, C. Beghi², F. Nicolini², A. Rubino³, P. Borsani¹, T. Gherli², A. Renzulli³, A. Sala¹

¹Varese University Hospital, University of Insubria, Varese, Italy; ²University of Parma Medical School, Parma, Italy; ³Magna Graecia University, Catanzaro, Italy

Objective: Cerebrovascular accidents (CVAs) are an important and widespread problem after cardiac surgery. Although different risk factors behind CVAs after thoracic aortic surgery have been identified, several of them have been confounded by patient selection, including type of aortic surgery, deep hypothermic circulatory arrest employment or emergency procedures. In a multicenter study we attempted to study the predictors of CVAs in patients undergoing aortic root replacement (ARR).

Methods: Data from 408 patients operated on ARR for ascending aortic aneurysms were obtained from a multicenter registry over a 10-year period. All patients were screened for CVAs, with reference to possible predictors and impact on clinical outcome.

Results: The studied population had an average age of 62±12 years and contained 79% men. Postoperative CVAs developed in 18 patients (4.4%): stroke occurred in five patients (1.3%), transient ischemic attack in 10 (2.5%), and delirium in seven cases (1.7%). Independent CVA predictors were postoperative cardiac failure (OR 6.61; 95% CI 1.55–28.26), body mass index (BMI; OR 1.15; 95% CI 1.02-1-29), and postoperative acute kidney injury (AKI) defined by RIFLE criteria (OR 3.19; 95% CI 1.15–8.86). Age, deep hypothermic circulatory arrest, or associated aortic arch surgery were not independent CVA predictors. Postoperative CVAs were also associated with hospital mortality (OR 54.12; 95% CI 1.28–93.28).

Conclusions: In this multicenter study, postoperative cardiac failure, BMI, and AKI appeared as novel and independent predictors of CVAs. These results provided new data insight on CVA occurrence after ARR for ascending aorta aneurysms.

C16-5 DEEP HYPOTHERMIA AND BRAIN RETROGRADE PERFUSION FOR ASCENDING AORTA AND ARCH ANEURYSMS CORRECTION

I.N. Kravchenko, G.V. Knyshov, L.L. Sytar, V.B. Maximenko, V.I. Kravchenko, O.A. Tretjak, M.Y. Atamanyuk, V.Ye. Duplyakina

National M.M. Amosov Institute of Cardiovascular Surgery of the Academy of Medical Sciences of Ukraine, Kiev, Ukraine

Objective: To present efficiency of brain protection for arch dissecting aneurysms and surgical treatment experience.

Methods: One hundred and forty-two operations with cardiopulmonary bypass, deep hypothermia (DH), cardioplegia, retrograde cerebral perfusion (RCP) through superior vena cava (SVC) were performed. In all cases femoral artery (FA) was cannulated. Absolute majority of patients (133) had acute dissection. Clinical results, standard hemodynamic and biochemical parameters were measured. Supracoronary aorta grafting was performed in 99 (69.7%) patients, Bentall’s operation – in 33 (23.2%) patients, isolated aortic arch grafting – in six (4.3%) patients, aortic arch plasty – in one (0.7%) patient, AVR+supracoronary+arch grafting – three (2.1%) patients.

Results: First group 28 operations with DH (16–18 °C), cardiopulmonary bypass perfusion index (CPBPI) 500–750 ml/min/m², SVC pressure 15–25 mmHg, RCP time 34.6+8.8 min. Hospital mortality in this group was 25.0%. Second group 66 operations with DH (12.5–14 °C), CP BPI – 250–500 ml/min/m², SVC pressure <12–15 mmHg, FA perfusion during the whole RCP period, RCP time was 45±10 min. Perftorane was used in this group during bypass. Hospital mortality – 17.4%. Third group 51 operations with DH (18–20 °C), CP BPI – 250–500 ml/min/m², SVC pressure <12–15 mmHg, FA perfusion during the whole RCP period, RCP time was 42±8 min. Perftorane was used during bypass. Hospital mortality – 13.7%.

Conclusions: RCP with DH (in limits of 18–20 °C) and lower SVC pressure than in previous groups (10–12 mmHg) and CPBPI (250–500 ml/min/m²) with permanent perfusion through FA is a safe method of the brain protection during ascending aorta and arch dissecting aneurysms correction.

C16-6 AN INNOVATIVE HYBRID STRATEGY FOR EXTENSIVE TREATMENT OF ACUTE ‘DE BAKEY TYPE I’ AORTIC DISSECTION

C. Muneretto¹, F. Cheema², G. Bisleri¹

¹University of Brescia Medical School, Brescia, Italy; ²Columbia College of Physicians and Surgeons, New York, USA

Objective: The standard treatment of De Bakey type I aortic dissection is usually limited to replacement of the ascending aorta, thereby often creating a type III chronic dissection. Recently, more aggressive procedures involving replacement of the aortic arch and stenting of the descending aorta have been proposed in patients with multiple re-entry tears. We investigated a novel hybrid approach based on replacement of the ascending aorta, endovascular treatment of the aortic arch with an uncovered stent and finally delivering a covered stent into the descending aorta (ArStAD procedure).

Methods: Two patients with De Bakey type I acute dissection and with multiple re-entry tears at the level of the aortic arch and proximal descending aorta were planned to undergo the ArStAD procedure. Both patients first underwent a Bentall procedure; then, during circulatory arrest (at moderate hypothermia of 30 °C) and with antegrade perfusion (via the right axillary artery and selective perfusion of the left carotid artery) through the open aorta, an E-vita Thoracic Stentgraft (Jotec) was delivered into the descending aorta, distal to left subclavian artery. The distal anastomosis of the vascular graft replacing the ascending aorta was sutured to the native aorta, and finally, through a side-hole into the vascular prosthesis, an uncovered, self-expandable nitinol stent (E-XL, Jotec) was released with a proximal landing into the vascular prosthesis and a distal landing into the thoracic stent graft.

Results: Both patients survived the procedure. Mean CPB time was 207 min and mean aortic cross-clamp time 102 min with a mean circulatory arrest of 16 min. Mean ICU stay and hospital stay were 2.5 and 9.5 days, respectively. There were no major postoperative complications. Early CT-scan (POD#4) demonstrated a complete obliteration of the false lumen in the aortic arch and in the proximal thoracic aorta.

Conclusions: Extensive treatment of De Bakey type I acute aortic dissections still remains a technical challenge. Albeit further studies are warranted in order to assess the long-term safety and efficacy of the ArStAD procedure, this novel hybrid approach provides further possibilities of combining conventional and endovascular strategies, therefore offering potential advantages in long-term outcomes.

C16-7 MID-TERM RESULTS OF E-VITA OPEN PLUS IN COMPLEX CHRONIC AORTIC DISEASES

V.G. Ruggieri, I. Abouliatim, E. Flecher, X. Beneux, H. Corbineau, T. Langanay, A. Leguerrier, J.P. Verhoye

Thoracic and Cardiovascular Surgery, Rennes University Hospital, Rennes, France

Objective: Aortic arch and descending aorta surgery could represent a challenge in case of complex aortic pathologies. Comparing to the classic elephant trunk technique, the frozen elephant trunk represents a simpler strategy to perform complex aortic operations. We report our mid-term results with the hybrid device E-Vita Open Plus (Jotec Inc, Hechingen, Germany) in chronic complex aortic diseases.

Methods: Between February 2009 and December 2010 we performed a frozen elephant trunk technique in six different and particular cases (mean age 55±14 years old). Aortic pathologies were represented by chronic type A aortic dissection in two cases (aneurysmal evolution after ascending aorta surgery), chronic type B aortic dissection in two cases and thoraco-abdominal aneurysms in two cases. Associated procedure were Tyrone David procedure in one case, double endovascular descending aorta stent graft in one case, mitral valve replacement in one case and ascending aorta replacement in one case. We used the hybrid prosthesis E-Vita Open Plus, consisting of a proximal woven polyester tube and a distal self-expandable nitinol stent graft. The stent was implanted under visual guidance and through the open aortic arch into the true lumen, during a circulatory arrest in moderate hypothermia (26°) using a selective antegrade cerebral perfusion (10 ml/kg/min).

Results: All patients were successfully treated without any intraoperative procedure related complication. We did not cut the polyester tube of the hybrid prosthesis and we used it for arch replacement obtaining a good haemostasis. Mean 24 h postoperative bleeding was 630 ml. Transient neurological dysfunction were observed in two cases. In one case we registered a pulmonary complication. No other major postoperative complications were registered. Postoperative CT-scan showed a good result of the aortic arch replacement and of stent deployment in all cases.

Conclusions: In our experience the E-vita Open Plus hybrid prosthesis represents a feasible and effective option for the treatment of complex chronic aortic diseases. Moreover, the reduced porosity of the new device allows a more efficient postoperative haemostasis comparing to first generation.

C16-8 EVALUATION OF ANASTOMOTIC LEAKS IN THE SURGICAL TREATMENT OF ASCENDING AORTIC ANEURYSMS

R.K. Dzhordzhikiya, I.I. Vagizov, M.N. Mukharyamov, I.V. Abdulyanov

MKDC, Kazan, Russian Federation

Objective: To conduct a comparative evaluation of anastomotic leakage after surgical treatment of ascending aortic aneurysms by the Bentall procedure and without preservation of the aneurysmal sac.

Methods: Ninety-two operations for aneurysms of the ascending aorta were conducted from 2003 to 2010. Sixty-nine patients had a chronic aneurysm, 23 patients were operated for acute type I or type II dissections (De Bakey classification). AR was observed in 92% of patients. Sixty-two patients were males, 30 – females. The mean age was – 51.9 years. All operations were performed with the use of cardiopulmonary bypass (CPB), hypothermia and cardioplegia. Two groups of patients were identified: first – preserving the aneurysmal sac, second – without preserving the aneurysmal sac.

Results: In the first group replacement of the AV and ascending aorta with a valve conduit (MedIng-Vascutek) by the Bentall procedure was performed in 64 cases. Anastomosis between the RA appendage and the aneurismal sac was needed and performed in 51 patients. Clamping time in this group was 156.0±13.6 min, CPB time – 182.6±18.3 min. Postoperative mortality in this group was 6.2%. In the second group of 28 patients excision of the aneurysmal sac with the sinuses of Valsalva and preparation of the ostia of the coronary arteries (‘buttons’) was performed. Eight patients underwent a valve-sparing David procedure. The anastomotic line between the prosthesis and the aortic root was initially formed by U-shaped sutures with the felt strips facing the LV, and then sealing with a continuous prolene suture between the rim and the conduit. The coronary buttons were implanted using a continuous suture and felt washers. The line of anastomoses from the outside was enforced by biological glue (Bio Glue). Clamping time in this group was 128.0±12.4 min, CPB time – 146.5±15.7 min. Neither bleeding from the proximal anastomoses nor deaths were observed in this group of patients. Patient follow-up for periods ranging from two to seven years showed good functional and hemodynamic results.

Conclusions: Surgical correction of ascending aortic aneurysms with a well-differentiated approach is accompanied by good immediate and long-term outcomes. Excision of the aneurismal sac with the use of anastomosis sealing techniques can reduce the time of the operation without compromising the outcomes and results.

11th Vascular Surgery Session – Thoracic Aorta May 22, 2011 11:30–13:00

V11-1 ACUTE TRAUMATIC TRANSECTION OF THE AORTA. FIFTEEN YEARS OF EXPERIENCE IN A SINGLE INSTITUTION

L. Canaud, P. Alric, C. Marty-Ané

A de Villeneuve Hospital, Montpellier, France

Objective: To compare the outcome between open and endovascular repair of acute traumatic rupture of the thoracic aorta.

Methods: Seventy-five patients (mean age 38.6±10.7 years) with an acute traumatic aortic rupture were referred to our hospital between January 1990 and November 2010. Thirty-six patients (34 men, mean age 34.2±10.8 years) underwent surgical repair using cardiopulmonary bypass. Endovascular repair was performed in 45 patients (33 men, mean age 40.3±11 years). The two groups were statistically comparable.

Results: The overall mortality for the surgical was significantly lower for the endovascular group (P=0.03) and was, respectively 11.1% (intraoperative mortality: 8.3%) and 2.2% (intraoperative mortality: 0%). The mortality rate related to aortic repair for the surgical and endovascular groups was, respectively 11.1% and 0%. In the surgical group, the morbidity rate was 13.8%: four cases of recurrent nerve palsy and one false anastomotic aneurysm diagnosed at 52 months. In the endovascular group, the morbidity rate was 15.5%: three cases of intraoperative inadvertent coverage of supra-aortic trunks (requiring in two cases a secondary procedure after one and two years to revascularize the supra-aortic trunks), one proximal type I endoleak (requiring deployment of a second stent-graft at day 2), two stent-graft collapses in the first postoperative month (treated by open repair and explantation in one case and by the deployment of a second stent-graft in the other case) and one intraoperative iliac rupture (surgically repaired). No cases of paraplegia or stroke were observed. The median follow-up was 8.7 years (range 0.2–15 years).

Conclusions: When compared with open repair, endovascular repair of traumatic thoracic aortic rupture is associated with a lower rate of death and therefore should be considered as the first line therapy for acute traumatic rupture of the thoracic aorta, except in some rare but challenging anatomic situations.

V11-2 STENTING OF AORTIC COARCTATION AND RE-COARCTATION

B.G. Alekyan, M.G. Pursanov, T.S. Sandodze, A.H. Davtyan

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: To show immediate and late results of stenting in patients with coarctation and re-coarctation of the aorta.

Methods: By December 2010 stenting for aortic coarctation (CoA) and re-coarctation (reCoA) has been performed in 60 patients. There were 37 patients with CoA and 23 with reCoA. The patient’s age varied from five months to 41 years, and the weight – from 5 to 90 kg. Depending on angiocardiographic semiotics we have conditionally divided the stenoses of aortic isthmus into four types. The first angiographic type was seen in 28.6%, the second – in 32.2%, the third – in 21.4%, and the fourth – in 17.8% of patients. In aortic isthmus stenoses of the first, second and third types we have implanted bare stents: ‘PALMAZ’, ‘PALMAZ XL’, ‘Palmaz- Genesis’ (Cordis, USA) and ‘CP’ (NuCed, Canada).

Results: Stenting of CoA and reCoA was effective in all cases. Good immediate angiographic, clinical and hemodynamic results were obtained in 58 patients. In two cases satisfactory results were obtained. Three patients (5%) had post-stenting thrombosis of the femoral artery, necessitating surgical intervention. After the stenting of the CoA mean systolic pressure gradient at the stenotic site decreased from 47±9.6 mmHg to 3.1±1.3 mmHg, in patients with the reCoA – from 46± 4.6 mmHg to 2.7±1.8 mmHg (P<0.001). Systolic pressure in the ascending aortia decreased from 147.6±32.5 to 134.5±22.1 mmHg, and diastolic pressure increased from 82.1±20.8 to 91.2±21.4 mmHg. Systolic pressure in the descending aorta increased, respectively, from 103.9±28.2 to 125.9±26.4 mmHg, and diastolic pressure – from 81.7±17.1 to 83.8+17.9 mmHg. In the long-term (13 months after the stenting) one patient had a complication in the form of aneurysm in the stented area. The patient underwent successful endografting of the thoracic aorta with ‘Valient’ stent-graft (Medtronic, USA).

Conclusions: Aortic isthmus stenting is feasible in most patients with coarctation and re-coarctation of the aorta. In aorthic isthmus stenosis of the first, second and third types it is possible to use bare stents, while in cases of the fourth type stenoses and in the presence of para-coarctation aneurysms coated stents are preferable. Technical success of the procedure was 100%. Stenting in aortic coarctation and re-coarctation is a safe method of treatment, which can serve as an alternative to surgical correction in most cases.

V11-3 SURGICAL CONVERSION AFTER THORACIC AND ENDOVASCULAR AORTIC REPAIR

L. Canaud, P. Alric, T. Gandet, J.P. Berthet, K. Hireche, F. Joyeux, C. Marty-Ané

A de Villeneuve Hospital, Montpellier, France

Objective: Improved early and late outcomes of thoracic endovascular aortic repair (TEVAR) compared with open repair has changed the therapeutic paradigm of thoracic aortic lesions. However, rare but serious complications either due to device failure or adverse events may occur, which will require conversion to open repair.

Methods: In our experience, 186 patients underwent TEVAR. Seven of these patients (3.7%) required open repair because of three retrograde type A dissections, one thoracic stent-graft collapse, one aneurysm enlargement without endoleak, one aortoesophageal fistula and one stent-graft infection. All but one underwent surgical repair using cardiopulmonary bypass. Four stent-grafts were totally removed, and three endografts were left in situ. Three patients underwent supracoronary ascending aorta replacement through sternotomy. Three patients had descending aortic replacement through left thoracotomy. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass and stent-graft explantation.

Results: All patients survived the surgical procedure. Four patients had an uneventful postoperative course. One patient was treated for a postoperative sternitis. Two patients with stent-graft infections died from multi-organ failure in the early postoperative course. No stroke, paraplegia, renal failure occurred. With a mean follow-up of 21.4 months (range 2–60 months), fives patients did not presented any adverse events.

Conclusions: Complications after TEVAR either due to device failure or adverse events may occur and require conversion to open repair. Open conversion can be performed with encouraging results by experienced team in management of diseases of the thoracic aorta. With the increasing use of TEVAR, more and more patients will present with indications of surgical conversion.

V11-4 STRATEGIES TO PREVENT NEUROLOGIC DEFICIT IN TYPE I AND II THORACOABDOMINAL ANEURYSM REPAIR

K.T. Koichi Tabayashi

Tohoku Kosei Nenkin Hospital, Sendai, Japan

Objective: The purpose of this study is to review the differences in the spinal cord injury and mortality between the groups of patients operated upon mild hypothermia with or without epidural perfusion cooling (EPC) and cerebrospinal fluid drainage (CSFD) in extent I and II thoracoabdominal aneurysm repair.

Methods: From 1988 to 2009, 125 patients underwent replacement of thoracoabdominal aorta, in which 41 patients performed with an aid of mild hypothermia (MH) (group A), and 84 patients underwent with an aid of MH with EPC and CSFD (group B). We inserted two catheters for epidural perfusion cooling, in which one catheter was inserted into the epidural space to infuse the chilled saline, and the other was inserted into the subdural space to drain the cerebrospinal fluid and to maintain the temperature and pressure. There was no significant differences of mean age and distribution of cause of aortic disease and aneurysm extent between the two study groups.

Results: There were no significant differences of the cardiopulmonary bypass time, the lowest nasopharyngeal temperature and operation time between the two study groups. The incidence of spinal cord injury of groups A and B were 15.4% and 3.6%, respectively. The difference between the two study groups was significant (P=0.03). Hospital mortality of groups A and B were 12.2% and 2.4%, respectively. There was significant difference of hospital mortality (P=0.04).

Conclusions: EPC and CSFD was effective in lowering the incidence of postoperative spinal cord injury in extent I and II thoracoabdominal aneurysm repair.

V11-5 LONG-TERM RESULTS OF TRANS-AORTIC STENT GRAFTING FOR DISTAL AORTIC ARCH ANEURYSM

T. Sueda, K. Orihashi, K. Imai, T. Kurosaki, T. Takasaki, S. Takahashi, Z. Naychov

Hiroshima University, Hiroshima, Japan

Objective: Before introduction of catheter endovascular stent-grafting, we performed the trans-aortic stent-grafting for distal aortic arch aneurysm. The purpose of this study to evaluate the long-term results of trans-aortic stent grafting for distal aortic arch aneurysms and the feasibility of this method for true distal aortic arch aneurysm.

Methods: Forty-three patients (male/female: 35/8) with true distal aortic arch aneurysm were repaired with the stent-graft introduced through the incision on the proximal arch aorta under selective cerebral perfusion and circulatory arrest. The Gianturco Z-stent (diameter 40 mm, length 75 mm, Cook corp.) was sutured to woven Dacron graft distally and introduced into descending thoracic aorta via hemicircular aortotomy on the proximal arch aorta under transesophageal echocardiography guide. The proximal end of the stent-graft was sutured intraluminally and transluminally in the arch aorta and the hemicircular aortotomy was closed by buttress suture with Dacron felt. The maximum distension of the excluded space and the maximum diameter of aneurysm were measured and evaluated to determine whether the aneurysmal space decreased or disappeared after this alternative procedure. Long-term survival and complication was evaluated by the observation in the outpatients clinic.

Results: Patient’s age ranged from 66 to 88 years old (mean 75 years old). Mean follow-up period was 8.7 years. There were two operative deaths (4.7%) by cerebral infarction and cardiac failure. Perioperative complications, such as endoleak (3/43:7%), paraplegia (1/43:2.3%) occurred during the initial period. Aneurysmal shrinkage was observed in every case except two cases with endoleak. Long-term survival could be achieved 78.1% at five-year. Major causes of death were cerebral infarction (2), cardiac failure (3) and cancer (4). New aneurysms were observed in four proxysmal aorta, two descending thoracic aneurysms and six abdominal aortic aneurysms. However, there was no patients with late aneurysmal rupture of stent-grafting aneurysm. Late coronary intervention could be feasible through both brachial arteries in three patients.

Conclusions: Long-term results of trans-aortic stent grafting were acceptable. Perioperative complications occurred during the initial period, which meaned this procedure required learning curve in the initial period. There were several patients who developed new coronary artery disease and aneurysm in other aorta.

V11-6 ARTERIA-LUSORIA AS A RISK FACTOR FOR SPINAL CORD ISCHEMIA DURING OPERATIONS ON THE THORACIC AORTA

N. Gidaspov, V. Arakelyan

Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Reduction of the frequency of spinal complications in patients with an aberrant right subclavian artery.

Methods: From 1986 to 2010 various types of congenital anomalies of the aortic arch was detected in 61 patients. In 20% of cases isolated anomalies of aortic arch not accompanied by hemodynamic instability was diagnosed. Eighty percent of patients had abnormalities of the aortic arch in conjunction with other pathology of the thoracic aorta. Anomalous origin of the right subclavian artery from the descending thoracic aorta was diagnosed in 65% of them.

Results: All patients with an aberrant right subclavian artery underwent surgery for aneurysm of the thoracic aorta or coarctation syndrome. The incidence of spinal complications were analyzed according to the type of performed operation, time of aortic clamping, using of cardiopulmonary bypass (CPB), blood pressure gradient between upper and lower extremities. Twelve patients during surgery showed the need for a simultaneous clamping of both subclavian arteries and in six cases spinal cord complications occurred. All these patients with paraplegia were operated on without CPB and other protection techniques, and only in two patients local hypothermia as a preventive method was used. CPB with other protective methods was used in six patients. No spinal cord or other significant ischemic complications in this group were noted.

Conclusions: Simultaneous clamping of both subclavian arteries is a real threat for paraplegia in surgery of the aortic arch anomalies. The main predictive method against this devoting complication is CPB.

V11-7 SURGICAL APPROACH IN PREVENTION of SPINAL CORD ISCHEMIA DURING OPERATIONS IN THE AORTA

V. Papitashvili, V. Arakelyan

Bakoulev Scientific Center of Cardiovascular Surgery, Moscow, Russian Federation

Objective: Postoperative paraplegia or paraparesis is a serious complication of reconstructive surgery of the thoracoabdominal or descending aorta. The reimplanting all patent arteries in ‘critical segmental arteries’ zone has the following problems: (1) reattaching all of the arteries from Th8 to L1 prolongs the clamping time, and (2) some of the arteries not need to be reattached.

Methods: Forty-one patients underwent multi-detector row CT for detection of the artery of Adamkiewicz (AKA). Thirty (73.2%) patients had thoracoabdominal aortic dissection, six (14.6%) patients had thoracoabdominal aortic aneurysm and five (12.2%) patients had descending thoracic aortic aneurysm.

Results: AKA were detected in 32 (78.1%) of 41 patients, and in 17 patients it originated from intercostal arteries branching from the left side and 28 (87.5%) originated between Th9 and Th11. All patients underwent repair of an aneurysm. When the AКA existed in the region of graft replacement, only the intercostal or lumbar artery in the aneurysm that was detected as the origin of the AKA was reconstructed by intimectomy (46.3%), reimplantation by an island cuff technique (9.8%) or preservation in a beveled distal or proximal aortic anastomosis (31.7%). When the AKA did not exist within the graft replacement region no intercostal or lumbar arteries were reconstructed (12.2%). Paraplegia did not occur in any of the patients in whom the AKA was detected preoperatively.

Conclusions: Preoperative detection of the AKA is possible by multi-detector row CT, and is very useful for reducing the incidence of ischemic injury of the spinal cord.

V11-8 TEVAR WITH INTENTIONAL COVERAGE OF THE LEFT SUBCLAVIAN ARTERY FOR TRAUMATIC INJURIES OF THORACIC AORTA: RESULTS OF A PROSPECTIVE STUDY

M. Antonello, P. Frigatti, C. Maturi, M. Menegolo, F. Grego

University of Padua, Padua, Italy

Objective: This study was conducted to analyze prospectively the sequelae of the intentional left subclavian artery (LSA) coverage during emergent thoracic endovascular aortic repair (TEVAR) for post-traumatic injuries.

Methods: To assess the functional status of the left arm, the following tests were performed: clinical evaluation of the arm (temperature, presence or absence of radial pulse, motility), brachial pressure and duplex scan examination. At one, three and six months these examinations were repeated and, to assess the capability of using the left arm, a functional test and a questionnaire were performed. During the follow-up an angio-CT was performed at 1–3 to 6–12 months and thereafter early.

Results: From January 2005 to June 2011, 24 patients underwent TEVAR with intentional coverage of LSA for traumatic rupture of the thoracic aorta. Mean age was 35 years old. In four cases (16.6%) the LSA coverage was partial. Two patients (8.3%) died in the postoperative period for associated hepatic and cerebral trauma. No signs of left arm ischemia, vertebral insufficiency, strokes, or paraplegia were observed in the early postoperative period. The duplex scan examination revealed in the 20 patients (83.4%) with a complete LSA coverage a reperfusion of the left arm through the vertebral artery (inverted flow). In those cases a reduction of the left brachial pressure >20%, with respect to the controlateral was observed. At follow-up (mean 30 months, range 4–66), only one patient (4.2%) showed an impairment of left arm function (ischemic pain after 2.5 min of arm exercise), without any impediment in his normal life activity at the questionnaire. No signs of endoleaks or graft migrations were observed at the angio-CT.

Conclusions: LSA coverage during TEVAR for traumatic aortic injuries seems a feasible and safe solution to extend endograft-landing zone, without an adjunctive risk of paraplegia, stroke or left arm ischemia. Further larger studies are required to confirm those results.

V11-9 SURGICAL MANAGEMENT OF THE VISCERAL ORGANS MALPERFUSION SYNDROME IN PATIENTS WITH ACUTE AORTIC DISSECTION

V. Starodubtsev, A. Karpenko, A. Cherniavskiy, S. Alsov, A. Edemskiy

Novosibirsk Research Institute of Circulation Pathology named by Meshalkin, Novosibirsk, Russian Federation

Objective: To evaluate the effectiveness of surgical interventions in patients with acute distal aortic dissection, acute renal failure and acute abdominal ischemia.

Methods. We observed 14 patients with acute aortic dissection one and three type (De Bakey), men – 12, women – 2. The mean age was 54.5±5.3 years. In nine cases we revealed acute type 3 dissection (according to De Bakey classification), in five cases acute type 1 dissection (by De Bakey). All 14 patients preoperatively were underwent duplex scanning of the aorta and visceral arteries in the ultrasound scanner and multislice computer angiography in the computer tomograph, renal scintigraphy. In all 14 patients acute renal failure (ARF) was verified. Acute abdominal ischemia was revealed in four patients with acute type 3 dissection. In five patients with the type 1 dissection at first stage replacement of ascending aorta was performed: in four cases supracoronary aortic arch replacement with vascular prostheses ‘Vascutek-Plexus’, in one case replacement of aortic valve, aortic arch and branchiocephalic trunk with valved conduit.

Results: At the first stage two patients with type 3 dissection and malperfusion of visceral organs against progressive acute renal failure and acute abdominal ischemia were underwent fenestration between true and false lumen in the infrarenal aorta. In one case there was progression of the dissection to the superior mesenteric artery with the development of mesenteric thrombosis and total necrosis of the intestine. In another case there was rupture of the thoracic aorta. Both patients died. Thereafter, for relief of acute renal failure in patients with one and three types of aortic dissection we performed iliac-renal artery bypass, and in four cases in patients with type 3 dissection with symptoms of acute renal failure and acute abdominal ischemia we performed iliac-renal-mesenteric bypass with bifurcational synthetic graft. In the long-term postoperative period in time from one to six months among the remaining 12 patients in the control renal scintigraphy documented improved perfusion of the kidneys, symptoms of abdominal ischemia cropped.

Conclusions: Performing bypass surgery in patients with acute distal aortic dissection can effectively arrest the development of acute renal failure and acute abdominal ischemia.

V11-10 VISCERAL ISCHEMIA IN TYPE IV THORACOABDOMINAL AORTIC ANEURYSMS (TAAA) REPAIR: HYBRID VS. OPEN REPAIR

N. Rousas, G. Spinella, B. Pane, F. Persi, E. Marrano, D. Musio, A. Signori, D. Palombo

San Martino University Hospital, Genoa, Italy

Objective: Our retrospective study compared hepatic-pancreatic function between open vs. hybrid repair type IV TAAA patients.

Methods: Twenty-seven patients underwent elective repair of a type IV TAAA. Hybrid group (HG): 10 high-risk (3–4 classes ASA) patients with a median age of 76.4 years. All operations were performed via midline laparotomy. The inflow site was infrarenal aortic in all cases. In all cases celiac axis (CA), superior mesenteric artery (SMA), and renal arteries (RA) revascularization was performed. Two stages procedure was performed in all cases. Conventional surgery group (CSG): 17 patients (two class ASA) with a median age of 69.2 years. Operative technique consisted of thoracophrenolaparotomy, clamp-and-sew technique with visceral and right renal revascularization by inclusion technique. Direct reimplantation or bypass for revascularization of the left renal artery was performed. Cold renal perfusion was performed. Preoperative and postoperative (1, 3, 5 days) serum levels of ALT, AST, ALP, GGT, lipase, amylase, PT, PPT were measured in both groups.

Results: HG, CA, SMA, cross-clamp mean time was 23.4 and 17.6 min, respectively. CSG, visceral cross-clamp mean time was 44.6 min. Changes of all parameters were observed in both groups by comparison between pre- and postoperative state (P<0.05) except lipase (P=0.60), and GGT for only hybrid group. Continuous-distributed analysis demonstrated: AST, ALP, PTT, PT, lipase, no significant difference between the two groups. GGT and ALT, significant difference was checked (P=0.03).

Conclusions: No difference has been shown regarding both hepatic and pancreatic function. Our results do not show evidence of superiority of hybrid than open repair as far as the considered functions are concerned.

12th Vascular Surgery Session – Research May 22, 2011 11:30–13:00

V12-1 DO HEMOGLOBIN-BASED OXYGEN CARRIERS HAVE ISCHEMIA-RELATED TOXICITIES?

C.F. Mackenzie¹, G.P. Dubé², A.N. Pitman³, A. Shander⁴

¹STAR Center, University of Maryland, Baltimore, MD, USA; ²Cambridge, MA, USA; ³Independent Consultant, Peabody, MA, USA; ⁴Englewood Medical Center, Englewood, NJ, USA

Objective: To understand safety of hemoglobin-based oxygen carriers (HBOCs), we tested the hypothesis that the relative efficacy of HBOC to increase the circulating total hemoglobin concentration (THb) compared to packed red blood cells (pRBC) is a major cause of ischemia-related serious adverse events (SAEs) in HBOC clinical trials.

Methods: The relative abilities (relative efficacy, RE) of HBOC-201 containing 13 g/dl hemoglobin and pRBCs (∼24–32 g/dl hemoglobin) to increase (THb) were compared in a phase III randomized, controlled, multicenter, elective surgery trial. RE=Δ (THb) HBOC/Δ (THb) RBC where Δ (THb) HBOC and Δ (THb) RBC=increases in (THb) resulting from infusion of one unit of HBOC or pRBC, respectively. Anemia magnitude and duration (hours) were captured for each patient in a single measure by calculating area under the line demarked by the (THb) 20% below each laboratory’s defined lower limit of normal. SAE and (THb) were compared using the two-tailed Fisher’s exact and t-tests.

Results: Infusion of HBOC-201 (1 unit=32.5 g hemoglobin) increased (THb) by 0.18±0.03 g/dl (n=121) which was four-fold less efficacious than the 0.87±0.07 g/dl (n=115) increase following 1 unit of pRBCs (∼80 g hemoglobin), yielding a RE of 0.21. The incidence of SAEs was greater in those patients receiving HBOC-201 at 0.34 SAEs/patient vs. 0.25 SAEs/patient in those randomized to pRBCs (P=0.016). Average (THb) over six infusions following HBOC administration remained lower than that of the original transfusion decision. Anemia magnitude (g Hb/dl*h), normalized to time, yielded hemoglobin deficits of 1.31±0.06 g/dl vs. 0.4±0.03 g/dl in patients randomized to HBOC and pRBC, respectively (P<0.05). When hemoglobin deficit was evaluated across all subjects as a categorical variable with a cut-off of 1.37 g/dl, hemoglobin deficit demonstrated an odds ratio=1.84 (P=0.035) for the risk of cardiac SAEs (comprising most of the SAE imbalance) vs. subjects <1.37 g/dl.

Conclusions: The relationship between hemoglobin deficit and cardiac SAE risk after HBOC-201 or pRBC suggests that the observed SAE imbalance between treatment arms is not attributable to intrinsic HBOC toxicity. Although (THb) decreases were generally avoided postoperatively, lower HBOC (Hb) and insufficient re-dosing by clinicians unfamiliar with HBOC-201’s 19-h half-life likely caused anemia under-treatment. HBOC-201 should, therefore, be used when (THb) of alternative fluids is low and red cells are not available or an option. THb should be monitored and maintained by infusions of HBOC-201 at half-life intervals or less to ensure maintenance of oxygen transport and avoidance of ischemic SAEs, particularly in patients with high hemoglobin needs.

V12-2 TRANSPLANTATION OF MOBILIZED PERIPHERAL BLOOD MONONUCLEAR CELLS FOR PERIPHERAL ARTERIAL DISEASE OF THE LOWER EXTREMITY

M.V. Plotnikov¹, A.V. Maksimov², S.D. Mayanskaya², A.P. Kiyasov³, I.M. Gazizov³, M.O. Mavlikeev³

¹Vascular Surgery, Republican Clinical Hospital, Kazan, Russian Federation; ²Kazan State Medical Academy, Kazan, Russian Federation; ³Kazan State Medical University, Kazan, Russian Federation

Objective: Peripheral arterial disease (PAD) is characterized by progressing ischemia which causes high frequency of invalidization. Preclinical studies have proved effectiveness of stem cell cellular therapy. We studied influence of autologous transplantation of mobilized peripheral blood mononuclear cells (PBMNCs) on capillary net density in muscular tissue and dynamics of functional changes in patients with PAD in clinical trial which was performed within the framework of Republican Program ‘Development of cellular medicine in Tatarstan Republic’ in Republican Clinical Hospital of Tatarstan Republic.

Methods: Autologous PBMNCs transplantation was performed in 30 patients with PAD stage IIb according to the Fontaine Classification (27 with diagnosis of atherosclerosis and three – Buerger’s disease). Stimulation of autologous stem cells with recombinant granulocyte colony-stimulating factor (G-CSF) lasted five days. On sixth day peripheral blood stem cells were separated on MSC+ (Haemonetics, USA) and one half of its volume was intramuscularly injected in diseased limb, second half was stored in cryobank. We took biopsy of gastrocnemius muscle in all patients before and three months after the treatment and further studied them immunohistochemically. We diagnosed degree of ischemia by functional probes [ankle-brachial index (ABI), treadmill test] and distal arteriography.

Results: Median number of transplanted mononuclear cells was 6.73±2.2. 109, CD34+ cells 2.94±2.312. 107. Estimation of treatment results after three and six months has showed significant increase of ankle-brachial index [from 0.59±0.04 to 0.66±0.04 (P=0.001) at third month, to 0.73±0.08 (P=0.035) at sixth-month]. Painless walking distance increased from 102.2±11.55 m to 129.4±11.13 m (P<0.001) at third month, to 140.3±13.11 m (P=0.021 from initial) at sixth month. Immunohistochemical study showed that autologous stem cell injection induces increase of capillary/muscular fiber density ratio to 33.75% (P<0.05). We selected best marker for visualization of capillaries – CD34 which is stably expressed by endothelia of larger vessels as well as by endothelia of capillaries.

Conclusions: Transplantation of autologous PBMNCs showed high efficiency and safety for treatment of patients with PAD. Autotransplantation of peripheral blood stem cells increases vascularization of ischemia limb by stimulation of neoangiogenesis.

V12-3 VASCULAR ENDOTHELIAL GROWTH FACTOR-INDUCED ANGIOGENIC GENE THERAPY IN PATIENTS WITH PERIPHERAL ARTERY DISEASE, PHASE I-IIA AND IIB-III STUDY

R.E. Kalinin¹, P.G. Schvalb¹, Yu.V. Chervyakov², I.N. Staroverov², E.G. Nersesian², R.V. Deev³, S.L. Kiselev³, A.A. Isaev³

¹Ryazan State Medical University, Ryazan, Russia; ²Yaroslavl Regional Clinical Hospital, Yaroslavl, Russia; ³Human Stem Cells Institute, Ltd. Moscow, Russia

Objective: Phase I-III randomized multicentral clinical trial tested the safety of intramuscular gene transfer by using naked plasmid DNA encoding the gene for VEGF165 (‘Neovasculgen TM’) was performed to analyze safety the potential therapeutic benefits in patients with chronic limb ischemia.

Methods: One hundred and forty-five patients were included in the study (45 patients – I-IIa phase, 100 – IIb-III phase), 25 of which were selected in control group. The trial was performed in accordance with national clinical studies regulations. Gene therapy treatment was performed in combination with conventional therapy applied in clinics participated in the trial. ‘Neovasculgen TM’ contained clinically purified supercoiled plasmid DNA encoding human VEGF165 gene under control of minimal CMV promoter element. Patients with the Fontein 2–3° disease were included in the trial. ‘NeovasculgenTM’ was administered twice in a dose 1.2 mg intramuscular with a period 7–14 days. Patients were monitored for three months. Ankle-brachial index, ultrasound Doppler examination, blood coagulation, transcutaneious oxygen pressure, painless walking time and general biochemical analysis were performed.

Results: As a result, I-IIa phase clinical trials have shown positive trends. No side effects were observed. The drug was well tolerated with no impact on biochemical parameters. At the same time statistically significant increase in ABI (19–23%), TcPO₂ (15–18%), and in painless walking time (260–290%) was observed. These data provide solid basis for the phase III clinical evaluation of anti-ischemic gene therapeutic drug ‘Neovasculgene^TM’. Data obtained during the IIb-III phase clinical trials will be reported in the oral report.

Conclusions: Thus, the study demonstrated the safety and efficacy trends.

V12-4 THE EFFECT OF β-GLUCAN ON KIDNEY INJURY IN EXPERIMENTAL AORTIC ISCHEMIA REPERFUSION

S. Gulmen¹, D. Kumbul Dogus¹, B. Gokce Ceylan¹, N. Kahraman Cetin², I. Meteoglu², H. Okutan¹, A. Ocal³

¹Suleyman Demirel University Medical School, Isparta, Turkey; ²Adnan Menderes University Medical School, Aydin, Turkey; ³Konak Hospital, Kocaeli, Turkey

Objective: In this experimental study, we investigated the effect of β-glucan on ischemia–reperfusion injury (IR) in kidneys occurring after occlusion-reperfusion of rat infrarenal abdominal aorta (IAA).

Methods: Thirty-two Wistar-albino rats were randomized into four groups (eight per group) as follows: the control group (sham laparotomy), control+β-glucan, aortic IR, aortic IR+β-glucan. Two groups underwent aortic IR designed as 120 min of ischemia by clamping of the microvascular clamp, followed by 120 min of reperfusion after removal of the aortic clamp. β-glucan 50 mg/kg per oral was administered by intragastric gavage twice a day for 10 days. The rats are capitated under deep anesthesia, and the kidneys tissue were removed. Tissue levels of malondialdehid (MDA), superoxide dismutase (SOD), catalase and myeloperoxidase (MPO) were measured, and kidneys specimens were examined histopathologically.

Results: Biochemical analysis showed that aortic IR significantly increased (P<0.05 vs. control) while β-glucan significantly decreased (P<0.05 vs. aortic IR) the kidney tissue levels of malondialdehyde, superoxide dismutase, catalase and myleperoxidase. Histological in aortic IR group; focal glomerular necrosis, dilatation of Bowman’s capsule, degeneration of tubular epithelium, necrosis in tubular epithelium, tubular dilatation interstitial inflammatory infiltration and congestion were significantly increased when compared to control group (P<0.05 vs. control). However in aortic IR+β-glucan group, all of the parameters significantly decreased when compared to aortic IR group (P<0.05 vs. aortic IR).

Conclusions: The results of this experimental study showed that β-glucan attenuates kidney injury induced by infrarenal abdominal IR in rats. We think that effect of β-glucan may decrease oxidative stress, lipid peroxidation and, leucocyte infiltration.

V12-5 RECONSTRUCTION OF INFERIOR VENA CAVA WITH AMNIOTIC MEMBRANE

F. Salimi, A. Keshavarzian, M. Heidarpoor

Isfahan University of Medical Sciences, Isfahan, Iran

Objective: This study was conducted to check the feasibility of using amniotic membrane to reconstruct inferior vena cava as a vascular conduit.

Methods: An oval shape patch 2×2.5 cm was excised from the anterior wall of the infrarenal vena cava of eight dogs. The amniotic membrane patch-graft fitting the defect of the vein was used to repair it. The observation periods were one day, one week, two and four weeks after surgery.

Results: All the grafts were macroscopically, venographically and microscopically patent at the end of study. Partial endothelialization was seen in 24 h and one week after surgery and it was completed two and four weeks after surgery.

Conclusions: The amniotic membrane is considered to be a good and safe alternative for reconstruction of inferior vena cava and large veins.

V12-6 VIPS TECHNIQUE

S. Bonvini, M. Piazza, L. Ferretto, M. Menegolo

Clinic of Vascular and Endovascular Surgery, University of Padua, Padua, Italy

Objective: To describe a novel technique (ViPS, Viabhan Padova Sutureless) that connects a vascular prosthetic graft to a target artery in a sutureless fashion without arterial cross-clamping.

Methods: A 74-year-old male with a non-healing leg ulcer presented for revascularization. Angiography demonstrated complete superficial femoral artery occlusion with reconstitution of a circumferentially calcified above-knee popliteal artery. Ultrasound revealed no adequate vein for autogenous bypass creation. A 7 mm Viabahn^® endoprosthesis was partially deployed and its proximal end was sutured to a 7 mm polytetrafluoroethylene (PTFE) graft. After surgical exposure, the circumferentially calcified popliteal artery, which could not be safely cross-clamped or sutured, was transected and the undeployed distal portion of the Viabahn was inserted into the popliteal artery supported by a stiff guidewire. The distal portion of the Viabahn graft was then deployed 2.5 cm into the popliteal artery with optimal apposition. The proximal end of the PTFE graft was then sutured to the common femoral artery. The distal portion of the Viabahn was ballooned to ensure apposition with the popliteal artery.

Results: Completion angiogram demonstrated a patent graft with no sign of dissection. The total operative time was 60 min. The patient’s ulcer resolved after two weeks and a CT angiogram at three months demonstrated a patent graft.

Conclusions: The ViPS technique is simple and easily performed with common commercially available devices. It provides an alternative for bypass creation in patients with inadequate autogenous conduit and may significantly reduce operative time, particularly in cases where challenging arterial anastomoses are required.

V12-7 HUMAN CD34+ STEM CELLS PROMOTE HEALING OF DIABETIC FOOT ULCERS IN RATS

M. El Sharawi, M.M. Naim, S.M. Greish

Suez Canal University, Ismailia, Egypt

Objective: Diabetic patients with foot ulcers usually manifest with high amputation and mortality rates. Preliminary evidence supports the effectiveness of stem cell therapy on diabetic foot ulcers. The objective of this study was to evaluate the efficacy of this therapy in the healing of wound among streptozotocin induced diabetic albino rats.

Methods: Diabetes was induced in 20 male albino rats by intra-peritoneal injection of streptozotocin. Another 10 rats were used as control. A full thickness circular wound of about 1 cm in diameter was performed in the front of right legs of all rats. The diabetic group was randomly sub-divided into two equal sub-groups; diabetic control group and diabetic stem cell group. The wound of the latter group was treated by injection of umbilical cord blood derived CD34+ stem cells into the wound bed. Half of diabetic rats were sacrificed after one week and the rest after two weeks and the wound areas were used for histopathology and immunocytochemistry studies. Assessment of wound surface area, epidermal thickness, blood vessel proliferation and collagen deposition were performed.

Results: There was significant decrease in mean wound surface area, increase in mean epidermal thickness, blood vessel proliferation and collagen deposition in the diabetic stem cell group compared to the diabetic control group.

Conclusions: Treatment with CD34+ enriched cells decreased wound size, accelerated epidermal healing and dramatically accelerated revascularization of the wounds compared to diabetic controls.

V12-8 CELL THERAPY OF LOW EXTREMITY ISCHEMIA IN THE EXPERIMENT

O.V. Maslyanyuk, G.G. Khubulava

Surgery Clinic of Excellence No.1, Military Medical Academy, Moscow, Russia

Objective: To estimate the safety and efficiency of transplantation of bone marrow mononuclear cells in ischemia of extremities in experiment.

Methods: Experiments are performed on 72 females of Wistar rats of 250-260 g. All animals had been tied up a femoral artery on one extremity under thiopental anesthesia. Depending on a method of cell introduction the animals were divided into three subgroups, 24 animals each. In each subgroup the control group has been allocated. To rats of the first subgroup cells were introduced intramuscularly (10 injections×20 ml), to the second, intrarterially (into the central end of ligated femoral artery, 200 ml), to the third, intramuscularly (5 injections×20 ml), and intrarterially (100 ml). Animals of control group were subjected to similar interventions, except for cell administration. They were introduced buffered 0.95% solution of sodium chloride by methods and in volumes similar to those in experimental group. Angiography was performed in dynamics (days 10, 20, 30) after cell transplantation in four animals of every subgroup in experimental and control groups, for microcirculation visualization in the damaged extremity and an extremity was sampled after euthanasia for histological research of the specific microcirculation area in its muscles.

Results: The first is an absence of dynamics of the selected indicator in all animals of control group. The second, statistically significant increase in the microcirculation area in rats of experimental group that received cellular therapy. Effect of cellular therapy, as for speed of its development, and the end result depends on a method of cell introduction. The combined method of delivery of a cellular material has appeared the best. It favourably differs from usually preferred purely intramuscular cell introduction. First of all, as for speed of increase of the microcirculation area, without conceding the end result, and even slightly exceeding that in a compared subgroup of animals.

Conclusions: Mononuclear cell transplantation initiates angiogenesis, promoting microcirculation area increase by 2.5-3.5 times in an ischemic extremity. Speed of microcirculation increase and final effect of cell transplantation depend on a method of cell material delivery. By criterion of angiogenesis speed and by its final level, the combined method of cell introduction is an optimum variant of cell delivery. Its ‘intramuscular’ component provides, obviously, formation of relatively long-term local angiogenesis centers and ‘intrarterial’ of regional quickly maturating few-celled centers.

V12-9 TREATMENT OF INTERMITTENT CLAUDICATION USING HUMAN MESENCHYMAL STEM CELLS FOR THE RESTORATION OF NORMAL ENDOTHELIAL FUNCTION OF AORTA

V.A. Chernyak, V.G. Mishalov, B. Koval

National Medical O.O. Bogomolets University of Ministry of Public Health of Ukraine, Department of Surgery No 4, Kiev, Ukraine

Objective: The chronic ischemia of lower extremities on a background multifocal atherosclerosis is the major social and medical problem discussed in society. The aim was to develop a model of standard ischemia of lower extremities in white rats and analysis effect of mesenchymal human stem cells transplantation.

Methods: Therapeutic effect of mesenchymal human stem cells (MSC) transplantation has been evaluated by means large conductance calcium-dependent potassium channels (BKCa) activity measurements in thoracic aorta smooth muscle cells (SMC) obtained from non-fatal whole-body irradiated rat using patch clam technique in whole-cell modification and standard acetylcholine (ACh) test to evaluate functional endothelium integrity using smooth muscle contractile recording. MSC were transplanted intraperitoneally to irradiated (6 Gy) rats on the seventh day of post-irradiation in a single dose of 16–20×106 cells per rat. Groups of 12 animals were allocated to one of the following treatments with sacrifice on the 30th day postirradiation: i) non-irradiated a phosphate-buffered saline age-matched control group; ii) irradiated phosphate-buffered saline group; iii) MSC treated irradiated group.

Results: Stimulation of isolated SMC from control group with depolarizing voltage steps showed that outward K+ currents sensitive to BKCa inhibitor, paxilline, were expressed. Outward currents in SMC obtained from irradiated animals demonstrated a significant decrease in K+ current density: radiation-induced BKCa suppression was clearly evident 30 days after irradiation when paxilline (500 nM) demonstrated a sharply decreased effect on outward current suggesting the lack of BKCa channels. In aortic tissues obtained from irradiated animals ACh-induced relaxation responses were significantly suppressed as compared to control group. Being injected intraperitoneally, MSC effectively restored BKCa current density and amplitude of ACh-induced endothelium-dependent vasodilatation in vascular tissues obtained from post-irradiated rats up to control values. SMC obtained from irradiated rats and treated with MSC demonstrated a significantly increased paxillin-sensitive component of outward potassium conductance indicating that BKCa activity had restored.

Conclusions: The data obtained suggest that MSC demonstrate a clearly expressed ability to normalize BKCa function and endothelium-dependent vascular relaxation in vascular tissues and isolated cells obtained from irradiated animals. Thus, MSC appear to be worthwhile therapeutic approach in case of ionizing irradiation accident.

V12-10 DOES TYPE OF CONDITIONING PROTECT THE SPINAL CORD FROM THE ISCHEMIA-REPERFUSION INJURY?

A.T. Ulus¹, A. Sapmaz², S. Yavas², N.N. Turan², F. Figen Kaymaz², Hija Yazicioglu², S. Ersöz², C. Koksoy²

¹Turkiye Yuksek Ihtisas Education and Research Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey; ²University of Ankara, Department of General Surgery, Ankara, Turkey

Objective: Ischemic pre- or postconditioning has been shown to have powerful protective effects against ischemia-reperfusion injury in different organ systems. This study was designed to test the effects of different types of preconditioning and postconditioning methods on neuroprotection in a rabbit model.

Methods: Aortic ischemia was caused by infrarenal clamping of the aorta. Rabbits were divided into six groups. Sham operated, ischemia, ischemic preconditioning (IPre), remote ischemic preconditioning (RIPre), simultaneous aortic and ischemic remote preconditioning (SAIRPre), postconditioning (IPost). Blood samples were collected before ischemia, as baseline and beginning of the reperfusion for myeloperoxidase (MPO) measurements. After neurological evaluations, all animals were sacrificed; lumbar part of the spinal cords excised for malonyldialdehyde (MDA) activity and ultrastructural analysis. Immunohistochemical staining for caspase-3 was also performed for apoptosis evaluation.

Results: The neurological outcomes of the groups 4 and 6 were only significantly different groups when we compare with the ischemia group. When we compare the last measurements of all groups, they are significantly higher then the group sham group according to MDA and MPO analysis. Immunohistochemical analysis revealed that the lowest percent of the positive staining cells for the apoptosis is group 3. Electron microscopic analysis showed that group 2 has the highest scores for the ultrastructural analysis. When we compare the intracellular edema, groups 3, 4 and 6 had significantly lower values than the group 2. Mitochondrial injury in groups 3, 5 and 6 was significantly different than the group 2.

Conclusions: The conditioning methods attanuates the ischemia-reperfusion injury. Both functional outcome and ultrastructural findings support this result. The results of the remote preconditioning subjects were also better, which is easy to use, non-invasive and cheap when its used.

V12-11 DEVELOPMENT OF AUTOLOGOUS TISSUE SMALL CALIBER VASCULAR GRAFTS (BIOTUBES) CONSTRUCTED BY SIMPLE, SAFE AND ECONOMICAL IN VIVO TISSUE ENGINEERING

M. Yamanami¹, T. Watanabe¹, K. Kanda¹, K. Takamizawa², H. Ishibashi-Ueda², H. Yaku¹, Y. Nakayama²

¹Kyoto Prefectural University of Medicine, Kyoto, Japan; ²National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan

Objective: There are actually no small-caliber synthetic vascular grafts (<6 mm) with acceptable patency rate for the use of coronary bypass or peripheral vascular repair below the knee in case the autologous vessels are not available. We have developed autologous small-caliber vascular grafts, named ‘BIOTUBEs’, by simple, safe and economical ‘in-body tissue architecture technology’, which is a novel concept of regenerative medicine and one of the in vivo tissue engineering. This technology needs neither special sterile facilities nor complicated in vitro cell treatment processes. In this study, we summarize the development of BIOTUBEs with variations of diameters, implantation terms and animal species.

Methods: Silicone rod molds (diameter: 1.5–5 mm, length: 20–50 mm) were placed into subcutaneous pouches of Wister rats, Japan white rabbits or beagle dogs. After one month, the implants were harvested. BIOTUBEs were obtained from the implants after pulling out the molds. After anti-thrombogenic coating with argatroban, they were auto-implanted to the aorta (1.5 mm; rats) or the carotid arteries (2 mm; rabbits and 5 mm; dogs) of the respective animals. After pre-determined periods of implantation, BIOTUBEs were harvested and histologically evaluated.

Results: Irrespective of animal species, all BIOTUBEs before implantation had thin walls (ca. 0.1 mm) and mainly consisted of randomly oriented fibroblasts and collagen fibers. They had adequate mechanical properties including burst strength and elasticity equivalent to those of native arteries. Their compliance could also be adjusted to the different portions of arteries by changing the materials of the molds. Rats: after 12-week implantation, BIOTUBE walls already had hierarchical structures mimicking native arterial walls. Luminal surface was completely covered with longitudinally oriented endothelial monolayer. Medial to outer layers were composed of circumferentially oriented smooth muscle cells and collagen fibers where elastin fiber formation was also observed. Rabbits: quick tissue regeneration was also observed. There was no excessive intimal thickening which reached the plateau of 0.2 mm. During two years-implantation, neither formation of aneurysms nor rupturing was observed in BIOTUBEs. Borders between the native arteries and BIOTUBES could hardly be recognized. Dogs: even with the larger diameter of 5 mm, BIOTUBEs endured the for up to three years with no degenerative changes, such as aneurysm formation or rupturing.

Conclusions: Irrespective of animal species in this series, BIOTUBEs could be used as small caliber vascular prostheses that greatly facilitate healing process and exhibit excellent biocompatibility in vascular regenerative medicine.

Cardiac Posters

CP-1 COMBINED TREATMENT OF TERMINAL HEART FAILURE BY EXTRACORPOREAL BLOOD PURIFICATION

M. Yaroustovsky, L. Bockeria, K. Shatalov, M. Abramyan, N. Koloskova, H. Nazarova, O. Stupchenko, Z. Popok

Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Heart transplantation (HT) still remains the basic treatment method for terminal heart failure and in a number of cases it is preceded by installation of mechanical circulatory assist devices (RVAD and LVAD) serving as a bridge to transplantation. Patients at both preoperative and postoperative stages often require application of extracorporeal blood purification methods (EBP) which is conditioned by the development of multiple organ dysfunction syndrome and sepsis.

Methods: The center performed 24 HT procedures and to seven patients were implanted VADs. To that, 11 patients with multiple organ dysfunction syndrome (MODS), application of various EBP methods was required. The objective of the study is to analyse the application of the EBP methods in treatment of patients with severe heart failure by dilated cardiomyopathy. In preoperative period all patients were diagnosed with low cardiac output syndrome (EFLV – 7–15%) that determined MODS development, including renal insufficiency (Cr level – 180–350 ?mol/l) and/or hepatic failure (bilirubin >50 ?mol/l, ammonia >80 ?mol/l, fibrinogen <200 g/l). APACHE-II severity score for these patients exceeded 30.

Results: Group 1 consisted of seven patients after HT. Four patients underwent EBP within the intensive care complex from the second day after operation; for one patient EBP procedures were introduced at preoperative stage and continued in postoperative period. Due to development on the 12th day of acute kidney injury against concurrent high cyclosporine level in one of the patients, renal replacement therapy was initiated in the mode of daily hemofiltration with fluid exchange volume more than 35 ml/kg/h. The seventh patient with developed hepatorenal syndrome received MARS^® therapy. Group 2 was formed by four patients who were emergency connected to VAD. These patients had following indications for EBP procedures: water-electrolytic imbalance, azotemia and necessity to provide adequate transfusion and nutritive support. For two patients renal replacement therapy was introduced at preoperative stage and continued in postoperative period. For five patients with concomitant liver insufficiency (three patients from Group 1 and two patients from Group 2) albumin dialysis procedures (MARS^® therapy) were performed alongside with membrane and discrete plasmapheresis. In three patients after HT we observed development of sepsis, which demanded objective of selective LPS-sorption with Toraymixin-PMX. Mortality of patients in the survey amounted to 36% (n=4).

Conclusions: Objective of modern EBP methods into intensive therapy complex allows to reach considerably improved results in the treatment of multiple organ dysfunction in patients with terminal heart failure after heart transplantation and implantation of ventricular assist devices.

CP-2 CLINICAL AND PROCEDURAL OUTCOMES IN PATIENTS OLDER THAN 70 YEARS UNDERGOING RESCUE PCI FOR ST-ELEVATION MI

D. Fettser¹, T. Batyraliev², I. Pershukov³, A. Arystanova², A. Omarov⁴, B. Sidorenko³, Y. Belenkov⁵

¹Regional Clinical Hospital, Lipetsk, Russian Federation; ²Sani Konukoglu Medical Center, Gaziantep, Turkey; ³Presidential Medical Center, Moscow, Russian Federation; ⁴A.N. Syzganov’s National Scientific Center for Surgery, Almaty, Kazakhstan; ⁵Lomonosov Moscow State University, Moscow, Russian Federation

Objective: The aim of our study was to evaluate clinical and procedural outcomes of patients with STEMI above and under the age of 70 years who have undergone rescue PCI.

Methods: During the period of January 2004 to December 2006 we enrolled 536 patients with ST-elevation myocardial infarction (STEMI), who underwent primary percutaneous coronary interventions. All patients were divided into two groups: group I (<70 years) and group II (≥70 years). We evaluated immediate procedural and six-month clinical outcomes through the clinical examination of the patients. We analysed demographic data, procedural success and MACE at six months. MACE was defined as death, MI, stroke or target vessel revascularization.

Results: Group I and II contained 394 (73.5%) and 142 (26.5%) patients respectively. There was no significant difference in the baseline characteristics of the patients. Procedural success was obtained in 94.9% (group I) and 92.3% (group II) of patients. Mortality in group II was higher as compared to group I (16.9% vs. 6.1%, P<0.001). Procedural complications (dissection, no-reflow or distal embolization) were lower in group I (2.8% vs. 9.2% in group II, P<0.001). MACE was higher in group II (22.5% vs. 8.1% in group I, P<0.001). Age ≥70 years was a multivariate predictor of procedural complications (OR=1.51, 95% CI: 1.18–2.94, P<0.001), MACE (OR=2.78, 95% CI: 1.37–6.39, P<0.001) and death (OR=2.76, 95% CI: 1.35–6.81, P<0.001).

Conclusions: This study revealed that patients ≥70 years old undergoing rescue PCI for STEMI have worse outcomes than patients <70 years old. The age remains a multivariate predictor of procedural complications, MACE and death in such patients.

CP-3 PROTECTION OF ARTIFICIALLY INDUCED MYOCARDIAL ISCHEMIA BY MEANS OF ENDOVASCULAR RETROGRADE MYOCARDIAL PERFUSION OF HEART VENOUS SYSTEM

N.A. Chigogidze, B.R. Martirosyan, M.K. Musaev, M.V. Muradyan, T.M. Djincharadze, L.A. Bockeria

Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: To evaluate selective retrograde myocardial perfusion (SRMP) via anterior interventricular vein (AIV) as a method for myocardial protection in artificially induced ischemia of the myocardium, perfused by left anterior descending artery (LAD).

Methods: In 10 dogs (weight: 15–20 kg) myocardial ischemia was induced by occluding LAD artery. LAD artery was occluded in proximal segment by balloon coronary catheter. 5 Fr two-lumen latex balloon catheter was placed AIV via jugular route. After that SRMP via AIV was performed. Arterial blood sample was drawn from a femoralis. The volume velocity of perfusion was 20–40 ml/min. First, after LAD occlusion we defined the period of time until clear markers of myocardial ischemia appeared (life-threatening arrhythmia and myocardial contractility disorders). Second, SRMP was performed and its effects on jeopardized myocardium were studied. Each step was followed by ECG and echocardiography.

Results: Average time until myocardial ischemia appeared without SRMP was 2 min±25 s. After SRMP was performed in seven out of 10 cases ischemia markers disappeared in average of 4±1 min. In three cases myocardial ischemia remained. On the basis of results obtained in experimental study, in a patient with ischemic heart disease and severe lesions in three coronary arteries involving a trunk of LCA, we successfully performed endovascular implantation of stents in the LCA, LAD and CA under protection with SRMP.

Conclusions: SRMP via AIV may be used as an adequate protection in patients with severe risk of heart fibrillation during coronary stenting.

CP-4 SIMULTANEOUS CAROTID ENDARTERECTOMY AND CORONARY ARTERY BYPASS GRAFTING

D.V. Bendov, M.L. Gordeev

Almazov Federal Heart, Blood and Endocrinology Centre, Saint Petersburg, Russian Federation

Objective: To estimate the results of simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG).

Methods: Three thousand four hundred and fifty-seven patients (mean age 61.3±7.3 years) underwent CABG during 2003–2010. Simultaneous CEA was performed in 113 (3.3%) of these cases. Considering cerebral vascular system, 83.2% of patients preoperatively showed no neurological manifestation. In all patients the first stage performed was CEA, then CABG.

Results: One hundred and thirteen patients experienced simultaneous CEA and CABG, all surgical procedures were performed using cardiopulmonary bypass and warm blood cardioplegia. Mean duration of surgery – 298±46 min, cardiopulmonary bypass – 102±38 min, anoxia – 62±28 min, carotid cross-clamping – 13.3±3.5 min. Mean distal anastomosis number – 3.1±0.9. Judging by carotid arteries involvement, two groups of patients were reviewed: Group 1 – 52 patients with unilateral carotid lesions; Group 2 – 61 patients with bilateral carotid lesions. In Group 1 no severe neurological complications (ischemic stroke, TIA) on the operation side were registered; 11.4% of patients suffered dyscirculatory encephalopathy; mortality rate was 1.9%. Patients in Group 2 suffered more neurological complications (stroke rate was 9.8%), though statistical significance in stroke+death parameter was observed (14.7%). Taking first steps in performing simultaneous procedures we faced a considerable number of neurological complications in patients with bilateral carotid disease. For instance, 11.2% of patients with 75% contralateral carotid stenosis developed ischemic stroke. Patients with 50% stenosis suffered no neurological events. Since 2005 in patients with 75% contralateral carotid stenosis and cerebral blood flow decompensation we have performed CEA phase in system hypothermia with 26–32 °C, which resulted in reduction of neurological complications. Thirty-three patients of the total 61 in Group 2 were presented with combination of 75% contralateral carotid stenosis and cerebral blood flow decompensation; those were operated in 19 cases using standard procedure, in 14 cases using hypothermia. The application of differentiated approach towards cerebral protection in simultaneous operations of CEA and CABG allowed us to decrease the complication rate from initial measure of 16.6% to 0% at present.

Conclusions: The results of simultaneous CEA and CABG in patients with unilateral carotid lesions can be considered comparable with isolated CABG (mortality rate – 1.9%, myocardial infarction – 2.8%, stroke – 0%), and the duration of postsurgical rehabilitation is shorter.

CP-5 THE RESULTS OF BALLOON DILATATION OF MEMBRANOUS SUBAORTIC STENOSIS

M.M. Zufarov, Sh.N. Salakhitdinov, F.A. Iskandarov, K.R. Saatova, F.F. Turaev

Republic Specialized Surgery Centre named after V. Vakhidov, Tashkent, Uzbekistan

Objective: The aim of this study was to analyse the results of balloon dilatation of congenital discrete subaortic stenosis.

Methods: Thirteen balloon dilatations (BD) of congenital discrete membranous subaortic stenosis (DMSS) were carried out on 12 patients aged from six to 30 years (16.8±7.5 on average) during the period from 2005 to 2009. There were eight (66.7%) male and four (33.3%) female patients in total. Associated cardiovascular anomalies were observed in two patients: patent ductus arteriosus (PDA) in one case, left-formed right-sided heart in one case. One of the patients had underwent PDA ligation in anamnesis. According to echocardiography the systolic peak gradient (SPG) at left ventricle outflow tract (LVOT) ranged from 82 to 113 mmHg, 103.2±9.9 mmHg on average. Left ventriculography and aortography in all 12 patients has shown DMSS, located 15–20 mm below the aortic fibrous ring, eight (66.6%) patients had aortic insufficiency (AI) below stage I. According to tensiometry LVOT peak gradient ranged from 60 to 145 mmHg, with average of 115.8±25.8 mmHg. Balloon dilatation of DMSS was carried out in all 12 patients.

Results: After BD (n=12) according to the angiography the SPG decreased to 59%, on average from 115.8±25.8 to 47.1±20.2 mmHg (P<0.05). At two (16%) patients the initial AI after the intervention did not change, at two (16%) patients it increased to stage II. Long-term results were tracked at five (41.7%) patients for the periods ranging from four months to five years. In a 13-year-old patient, after first BD, SPG fell from 132 to 25 mmHg, in 2.5-years we had found remaining SPD and BV was re-performed. The SPG fell from 85 to 45 mmHg. AI stage did not change. In a 6-year-old patient SPG fell from 120 to 100 mmHg. We had recommended her for open surgery, but she did not undergo surgery, and by EchoCG in four years after first intervention we found remaining SPG 80 mmHg.

Conclusions: Correction of discrete subvalvular aortic stenosis results in positive changes of haemodynamics indicators. High frequency of occurrence of associated anomalies requires open-heart surgery. In case of the isolated membranous subvalvular aortic stenosis endovascular intervention is required. Unquestionable benefits of endovascular interventions are relative safety, low invasiveness, possibility of repeated interventions.

CP-6 EVALUATION OF THE EFFICIENCY OF ENDOVASCULAR TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROME

M.M. Zufarov, Sh.N. Salakhitdinov, F.A. Iskandarov, Kh.A. Akhmedov, D.A. Alimov

Republic Specialized Surgery Centre named after V. Vakhidov, Tashkent, Uzbekistan

Objective: Evaluation of efficiency of endovascular treatment (ET) in patients with acute coronary syndrome (ACS).

Methods: ET of coronary arteries were performed in 53 patients with ACS, including 41 patients with an instable angina and 12 patients with myocardial infarction (MI) without Q wave aged from 42 to 74 (54±7.9) years. All patients with MI and also three patients with instable angina underwent emergency ET. The LV ejection fraction of more than 50% was in 35 (66.0%) patients, in 41 to 50% – in 13 (24.5%), in 5 <40% (9.4%).

Results: Among 41 patients with instable angina coronarography we revealed 24 (58.5%) cases of one vascular, and 17 (41.5%) cases of multivascular coronary lesion. Occlusions of coronary arteries were in 12 (29.3%) patients, critical stenosis close to оcclusion – in 29 (70.7%) patients. Stenting of coronary arteries was performed in 35 (85.4%) patients, including stenting of one artery – in 20 (48.8%), of two arteries – in eight (19.5%). Seven patients (17.1%) with multivascular lesion in addition to stenting of one artery underwent angioplasty of the second damaged vessel. In eight (19.5%) patients a direct stenting was undertaken, including the stenting of the left coronary artery trunk – in one, LAD – in five patients, RCA – in two. Recanalization of occlusion with subsequent coronary angioplasty and stenting was performed in 12 (29.3%) patients with early postinfarction stenocardia, including LAD – in nine (75.0%), RCA – in three (25.0%). In the group of patients with MI without Q wave three patients revealed to have the critical stenosis close to occlusion of LAD, seven patients – occlusion of LAD, two – occlusion of RCA. Patients with critical LAD stenosis underwent BP and stenting. In patients with coronary occlusions the attempt of recanalization with subsequent BP and stenting was successful in 11 cases. In one case with repeated MI recanalization was not possible.

Conclusions: ET in patients with ACS is a highly effective method of treatment, allowing to stabilize the condition and in the most of cases to prevent or involute the development of MI.

CP-7 CORONARY STENTING WITH DEDICATED BIFURCATION STENTS BY GUIDING OF INTRAVASCULAR ULTRASOUND

V.V. Demin, A.V. Demin, M.M. Fedorova, A.K. Almakaev, A.N. Zheludkov, S.A. Lavrenko, D.V. Demin, S.A. Dolgov

Orenburg Regional Clinical Hospital, Orenburg, Russian Federation

Objective: The purpose of this research was the analysis of the results of implantation of various dedicated bifurcation stents under the control of intravascular ultrasound (IVUS).

Methods: We operated 37 patients, in whom 38 stents with a special bifurcation design were implanted to. Four kinds of dedicated bifurcation stents were used: Multi-Link Frontier (20), Twin Rail (7), Nile CroCo (8), Nile Pax (3). In 20 patients intervention was performed on bifurcation of the left anterior descending coronary artery (LAD) and a large diagonal branch, in 12 – of the left circumflex coronary artery (LCA) and the branch of obtuse margin, in two – in the area of bifurcation of the right coronary artery; two patients had lesions in the area of bifurcation of the left main coronary artery and a large intermediate branch respectively; and bifurcations of LAD and of LCA were operated simultaneously in one patient. Lesion of type 1-1-1 by Medina classification was noted in 10 cases (26.3%), 1-1-0 – in eight (21.1%), 1-0-1 – in four (10.5%), 1-0-0 – in one (2.6%), 0-1-1 – in nine (23.7%), 0-1-0 – in five (13.2%).

Results: Dedicated bifurcation stents were used when diameter of a lateral branch exceeded 2.5 mm and the latter had a large region of blood supply. The length of the lesion in the basic branch was limited to the sizes of stents – of 15 up to 24 mm. In 33 of operated patients (89.2%) IVUS was used at different stages of operation. A total of 61 three-projective IVUS at different stages of intervention was performed. IVUS use allowed picking up precisely the sizes of stents, well visualizing its structure and confirming an optimum position towards bifurcation. Major lesion was localized in 55.6% of cases in the main artery and in 44.4% – in the side branch. The follow-up results were analysed up to five years. Restenoses, demanded repeated revascularization, were noted in six patients (16.2%): in five – in Multi-Link Frontier stents, in one – in Nile CroCo stent. In all cases repeated endovascular reconstructions were successful.

Conclusions: The use of dedicated bifurcation stents allows receiving an optimum anatomic and clinical result in coronary bifurcation. IVUS provides a more precise and safer implantation of such stents.

CP-8 THE IMPACT OF CORONARY ARTERY TYPE LESIONS TO THE RATE OF MYOCARDIAL MICROLESIONS AFTER PERCUTANEOUS CORONARY INTERVENTIONS

A.V. Vorobyeva, E.V. Kuleshova, V.V. Dorofeykov, D.A. Zverev, I.D. Esipovich, D.A. Shaposhnikov, A.E. Pavlov, O.N. Cashek

Federal Centre of Heart, Blood and Endocrinology named after V.A. Almazov, Saint Petersburg, Russian Federation

Objective: To determine the rate of myocardial microlesions developing after percutaneous coronary interventions (PCI) in patients with stable angina and to show the connection with type of coronary artery stenosis.

Methods: Thirty patients (mean age 59.1±9.4 years) with stable angina classes II–III NYHA (83.3%) and silent ischemia (16.7%) were examined. Sixteen patients (53.4%) had severe one-vessel disease, seven patients (23.3%) – two-vessel disease and seven (23.3%) patients – three-vessel disease. Type A lesions were revealed in six patients (21.4%), type B lesions – in 15 (53.6%) patients, type C lesions – in seven (25%). One PCI with stenting was performed in 22 (73.3%) cases, two coronary artery PCI with stenting was made in eight (26.7%) cases. Balloon predilation of the stenosis was done in 19 (63.3%) patients, balloon postdilation – in seven (23.3%) patients. There was the only complication in one patient (coronary artery dissection type D). Myocardial microlesions were estimated on the base of troponine fraction I (Tn I) and creatine phosphokinase fraction MB (CK-MB) concentration. The Tn I and CK-MB concentration were defined before and 24 h after PCI using immune-enzyme analyser ‘AxSYM’ (Abbott). It was considered that the upper limit for Tn I and CK-MB were 0.4 ng/ml and 3.8 ng/ml, respectively. The increase of the biomarkers higher this limit indicated PCI-associated myocardial damage. The increase of the biomarkers more than three times indicated PCI-associated myocardial infarction.

Results: There was no changes of Tn I concentration in 15 (50%) cases, eight (26.6%) patients had the concentration of Tn I until 0.4 ng/ml, four (13.3%) patients had the level of Tn I ranged from 0.41 to 1.2 ng/ml and three (10%) patients had Tn I concentration more than 1.2 ng/ml. The postoperative CK-MB concentration did not change in 15 (50%) patients, seven (23.3%) patients had the rise of CK-MB level from 1.5 up to 2.5 times, eight (26.7%) patients had the increase of CK-MB concentration more than three times as compared with preoperative level. The CK-MB concentration exceeds 11.4 ng/ml in two (6.7%) cases. All patients with myocardial infarction had type C lesions and it was necessary to implant two and more stents with pre- and postdilation.

Conclusions: Myocardial microlesions were detected in 50% of the patients, but the PCI-associated myocardial infarction was revealed in patients who had type C lesions only.

CP-9 SURGICAL CARDIAC REVASCULARIZATION IN PATIENTS WITH IN-STENT RESTENOSIS – OWN OBSERVATIONS

J.P. Tomaszewski, J. Kaperczak, E. Szwedowska, J. Stupala, Z. Brzezinski

Regional Medical Center (WCM), Opole, Poland

Objective: Although it has been demonstrated that stent implantation in human coronary arteries reduces restenosis compared to balloon angioplasty, in-stent restenosis occurs in about 10–60% of cases.

Methods: In the present study 70 patients who underwent CABG in our department due to in-stent restenosis were analysed for factors predisposing to in-stent restenosis. There were 57 males and 13 females, on age 43 to 82 years, with DM t.2 (41%), hypertension (61%), obesity (41%) and chronic nicotinism (78%).

Results: In 64 patients it was multi-vessel disease, 43 patients received one, 17 patients – 2, three patients – 3 and one patient – 4 stents. More typical implantation place were segments 11 (38%) and six (29%) in LCA and segments two (67%) and one (25%) in RCA. Fifty-two percent of stents were with 3 mm and 31% with more than 3 mm diameter. Restenosis in-stent occurs in period from 1 to 2303 days after implantation, in the majority of patients (39%) it occurs in the first month, 29% in six months period and 14% in first year. All patients were operated in warm blood cardioplegic heart arrest with conventional CPB. In all cases LITA was used for LAD grafting, the average number of grafts were 2.9 (range 2–4), logistic EuroSCORE range from 2.6 to 63.2%. For eight patients surgery was performed on urgent basis and two patients died after the operation due to cardiac insufficiency (there were operated in cardiogenic shock due to acute MI).

Conclusions: The major risk factors for in-stent restenosis are: diabetes, hypertension, nicotinism, stent size and implantation site. Despite reports of poorer results of CABG in patients with stents in our methods we did not observe these differences.

CP-10 ENDOVASCULAR CLOSURE OF CONGENITAL AND ACQUIRED PATHOLOGICAL COMMUNICATIONS USING AMPLATZER OCCLUDERS

B.G. Alekyan, V.P. Podzolkov, M.G. Pursanov, S.V. Gorbachevsky, K.E. Kardenas, A.V. Tkacheva, A.M. Grigorian, G.A. Brutyan

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: To show the possibilities of AMPLATZER occluders in the management of patients with different congenital and acquired cardiac and vascular communications.

Methods: AMPLATZER occluders have been implanted in 46 patients with different pathological cardiac and vascular communications. In 15 cases the occluder was used for the closure of antegrade blood flow in the pulmonary artery trunk after hemodynamic Fontan correction and bidirectional cavapulmonary anastomosis, in six – for the closure of large aortic pulmonary collateral arteries (LAPCA), in five – for the closure of coronary-cardiac fistula, in four – for the closure of aortic pulmonary septal defect (APSD), in two – for the closure of pulmonary veins collector after radical correction of total anomalous pulmonary veins return, in two – for the closure of Valsalva sinus rupture into the RV after radical correction of tetralogy of Fallot, in two – for the closure of veno-venous fistula, in two – for the closure of arterio-venous fistula, in two – for the closure of a communication between the RA and the LV of the oblique canal type after mitral (1 case) and tricuspid (1 case) valve replacement, in two – for the closure of paraprosthetic fistula after MV replacement, in two – for the closure of an additional left-sided SVC with hemiazygos continuation draining into the left pulmonary artery, in one – for the closure of recanalized systemic-pulmonary anastomosis, in one patient – for the closure of a giant aneurysms of the right vertebral artery.

Results: AMPLATZER occluder was successfully implanted in all 46 patients. After the closure of antegrade blood flow in the PA trunk clinical improvement was noted in all patients. Occluder implantation also led to successful closure of coronary-cardiac fistula, iatrogenous communication between the LV and the RA, paraprosthetic fistula, aortic pulmonary septal defect and other communications mentioned above. Occluder-related complications were not encountered neither in early, nor in late postoperative period.

Conclusions: The use of Amplatzer occluders is an effective and safe therapeutic procedure for the closure of different pathological cardiac and vascular communications provided the respect of indications.

CP-11 USING THE PAcl*tAXEL–COATED BALLOON IN TREATING OF IN-STENT RESTENOSIS

A.G. Osiev, S.P. Mironenko, O.V. Krestyaninov, M.A. Vereshagin, A.V. Birukov, E.I. Kretov, D.D. Zubarev, V.I. Baistrukov

Federal State Institution Academician E.N. Meshalkin Novosibirsk State Research Institute of Circulation Pathology Rosmedtechnology, Novosibirk, Russian Federation

Objective: Drug eluting balloons could offer a viable alternative to drug eluting stents (DES) in the treatment of coronary artery disease. The balloon technology concept is that pacl*taxel would be more evenly distributed along the vessel wall compared with being eluted from stent struts.

Methods: The study included 90 endovascular interventions performed from 2007 to 2010 for the treatment of in-stent restenosis (ISR). The patients were classified into two equal groups based on an endovascular technique used. Patients of group I (n=35) were managed using a coronary balloon catheter coated with pacl*taxel (Dior, BBraun). ISR in group II (n=55) were revasculated with standard balloon angioplasty. Patients developed ISR and required the repeated revascularization in 9.64±4.7 months after primary stent implantation. Angina pectoris II–III (angina upon exertion II–III) presented in 26 (74%) patients in group I and 41 (74.6%) patients in groups II. Intercurrent DM was diagnosed in three (9%) patients and six (11%) patients of the respective groups. The length of stented segments varied from 12 to 114 (31.4±18.2) mm in group I, and from eight to 110 (32.4±21.4) mm in group II. The ISR severity has been estimated with digital angiography as 82.6±11.6% and 74±11.6% of the respective groups. PTCA of the repeat lesions was performed in all cases. Patients in group I were treated with PTCA using a standard balloon with the mean length=26.9±5.7 mm. PTCA in group II was performed with pacl*taxel-coated technique with the mean length of the balloon=23.7±5.7 mm. The residual stenosis was <10% in all groups.

Results: Long-term outcome after angioplasty was assessed in 18 (51.4) and 24 (43.6%) patients of the divided groups. The digital angiography was repeated within 6.4±1.1 months. Angiographic restenosis was revealed in four (22.2%) cases in group I and in 13 (54.2%) cases in group II (P<0.05).

Conclusions: Pacl*taxel balloon coating is safe, it effectively inhibits restenosis after coronary angioplasty.

CP-12 TREATMENT OF SOME CONGENITAL HEART DISEASES BY ENDOVASCULAR METHOD

B.M. Shukurov

Volgograd Medical University, Volgograd, Russian Federation

Objective: To determine the efficiency of endovascular treatment of some congenital heart defects.

Methods: Study patients underwent clinical, laboratory and instrumental examination, and transthoracic and transesophageal echocardiography.

Results: Two hundred and thirty-seven interventions have been analysed: in 140 operations elimination of congenital atrial septal defect (ASD) by Amplatzer device and 137 of the patent ductus arteriosus (PDA) (79 by coils and 58 embolization of large PDA by Amplatzer device). Age of patients ranged from eight months to 64 years. Among patients who eliminated ASD 104 were female and 36 male. Age of patients ranged from seven months to 62 years (average age 11.2±1.3 years). All patients had complaints of weakness, poor exercise tolerance and shortness of breath. Most patients had a history marked by frequent inflammation of the tracheobronchial tree, and 15 – pneumonia. All atrial septal defects were central. Dimensions of atrial septal defect ranged from 5 mm minimum, maximum to 37 mm (mean diameter was 1.1±0.5 cm). The pressure in the pulmonary artery ranged from 37 to 46 mmHg (average 37±10 mmHg). Resetting blood in the pulmonary circulation ranged from 38 to 53% (average 41±8%). In all cases, the removal of atrial septal defect was performed by echocardiography (transthoracic 113, 22-transesophageal) and fluoroscopic control. Ninety-eight percent of the endovascular operations were successful, in three cases were unsuccessful (2%). After operation seven patients had minimal residual A–V the shunt within one and three months which has subsequently stopped. Also are eliminated 137 PDA, 79 by coils, and 58 big PDA by Amplatzer devices. Diameters of the PDA varied from 1 to 6 mm. All operations were effective, the discharge of blood through the PDA usually stopped on the operating table after 5–20 min, and in three cases within a day after the operation. In the late period of observation, complications were not registered, the condition of patients improved markedly.

Conclusions: Thus, the use of invasive treatment of ASD and PDA showed a high clinical efficiency, low trauma and rapid rehabilitation of patients after intervention. The use of endovascular techniques, especially in children, is the method of choice and the correct definition of reading to them is key to the success of interventions.

CP-13 THE IMMEDIATE RESULTS OF STENTING OF LEFT CORONARY ARTERY IN PATIENTS WITH ACUTE CORONARY SYNDROME

M.M. Vyborova¹, A.G. Osiev², S.P. Mironenko², D.Y. Romashchenko², A.V. Biryukov², N.V. Koleda²

¹Federal State Institution Academician E.N. Meshalkin Novosibirsk State Research Institute Novosibirsk, Russian Federation; ²Federal State Institution, Novosibirsk, Russian Federation

Objective: To estimate the immediate results in stenting of trunk of the left coronary artery (TLCA) of patients with acute coronary syndrome (ACS).

Methods: The study included 63 patients with ACS, who underwent stenting of SLKA on the background ACS for the period from 2008 to 2010. The indication for stenting was angiographically significant stenosis of TLCA, as an isolated [without the involvement of the outfall of its branches (n=14)] in 22.2% cases, as well as with their involvement (n=49) – 77.8%. Group with acute myocardial infarction (AMI) with ST and without ST included 36 (57.1%) patients. Group with unstable angina included 27 (42.9%) patients. Lesion of TLCA and one coronary artery (CA) met in 19 (30.2%) cases; lesion of TLCA and two coronary arteries in 13 (20.6%), lesion of TLCA and three coronary arteries in 17 (27%) cases. Twenty-three patients (36.5%) had occlusion of the right coronary artery (unprotected TLCA). Age of patients varied in the range from 45 to 80 years. Thirteen (20.6%) patients had a lesion localized in level of TLCA outfall, eight (12.7%) patients – in the middle segment (trunk body), 42 (66.7%) – in the terminal part of TLCA (bifurcation). In 12 (19%) cases, during TLCA stenting drug-eluting stents (DES) were implanted, in the remaining cases – 51 (81%) were used bare-metal stents (BMS). In four cases (6.3%) was used intraaortic balloon counterpulsation (IABC).

Results: Immediate clinical and angiographic success of coronary stenting of TLCA observed in 60 patients (95.2%). This was manifested in the stabilization of hemodynamic parameters, the positive dynamics of ECG, decreasing areas of hypo- and akinesis and a trend toward increase in myocardial contractility (by echocardiography data). Fatal outcome occurred in three cases (4.8%). Two (3.2%) patients among a group of patients with AMI. In one case (1.6%) patient with unstable stenocardia (cause of death was acute stent thrombosis emerged in SLKA).

Conclusions: Endovascular intervention during lesion of TLCA is clinically effective and safe method of myocardial revascularization of patients with ACS, patients with AMI as with ST, and without ST, as with ‘protected’ and with ‘unprotected’ TLCA. The method of coronary stenting of patients with developed AMI-ST during lesion of TLCA can be considered as the method for selecting endovascular treatment of these patients.

CP-14 RESULTS OF BALLOON VALVULOPLASTY OF CONGENITAL VALVULAR AORTIC STENOSIS

M.M. Zufarov, Sh.N. Salakhitdinov, F.A. Iskandarov, F.F. Turaev, K.R. Saatova

Republican Specialized Center of Surgery named after V. Vakhidov, Tashkent, Uzbekistan

Objective: The aim of this study was to assess the effectiveness of balloon valvuloplasty of congenital valvular aortic stenosis.

Methods: Sixty balloon valvuloplasty (BV) of valvular aortic stenosis (VAS) were carried out in 55 patients during the period from 2000 to 2010. The youngest patient was five years old and the oldest was 37 years old. Median age was 15±27.0 years. Left ventriculography and aortography have shown VAS in 55 patients, aortic insufficiency (AI) at stage I was observed in 12 (21.8%) patients. According to tensiometry in patients with VAS the systolic peak gradient (SPG) between left ventricle and aorta ranged from 60 to 205 mmHg with average of 122.6±37.7 mmHg.

Results: Immediately after the BV in patients with VSA (n=56) the systolic pressure in left ventricle decreased on average from 225.0±38.7 to 159.8±25.7 mmHg (P<0.05) and increased in aorta on average from 102.5±14.5 to 112.0±13.7 mmHg (P>0.05). The SPG between left ventricle and aorta fell to 61.3%, on average from 122.6±37.7 to 47.4±22.1 mmHg (P<0.05). In eight (14.5%) patients BV caused AI below stage I, in six (10.9%) – up to stage II. In the group of patients with initial AI below stage I (n=12) after BV it remained at the same level in 10 patients, and increased to stage II – in two patients. BV was re-performed in five patients with remaining SPD during the period from one week to six months after the first intervention. There was either inadequate balloon catheter size or refractory ventricular arrhythmias during first intervention. The SPG between left ventricle and aorta fell on average from 120.1±40 to 46.5±24.6 mmHg (P<0.05). The postoperative period was characterized by the improvement of general condition, with no complaints. Long-term results were tracked in 37 (61.6%) patients of this group for the periods ranging from four months to five years. All patients noted positive dynamics of the left ventricle volume indicators.

Conclusions: Analysis of the research has shown that BV of VAS has relative safety, persistent clinical and hemodynamic effect, and in many cases may be an alternative to traditional surgery. The results of correction depend on proper selection of patients with this pathology and the adequacy of implemented interventions.

CP-15 IMPACT OF POSTOPERATIVE DELIRIUM ON SURVIVAL IN CARDIAC SURGICAL PATIENTS

L.J. Krzych, M. Wilczynski, A. Bochenek

Medical University of Silesia, Katowice, Poland

Objective: Delirium is a serious complication after cardiac surgical procedures with a significant impact on postoperative morbidity and length of in-hospital stay. The purpose of the study was the assessment of the short-term and long-term survival in patients with delirium, with the identification of its predictors.

Methods: A retrospective cohort study was designed. The study group included consecutive patients hospitalized from 2003 to 2008. Eight thousand one hundred and seventy-five cardiac surgeries were conducted. The exclusion criteria were as follows: any psychiatric disorders in the past, any drugs affecting central nervous system used preoperatively and alcohol abuse. Finally, 5781 persons were included into the analysis (1750 women and 4031 men). The occurrence of postoperative cerebral ischemia was taken into account in analysis because it may modify the process of psychiatric disturbances.

Results: Total in-hospital case-fatality ratio was 3.46% (95% CI 2.99–3.93) and patients who developed delirium was 15.25% (95% CI 10.66–19.84). The sub-group analysis showed that in patients with delirium and cerebral ischemia case-fatality ratio was 38.46% (95% CI 26.63–38.46) and in patients with no episode of ischemia it was 6.43% (95% CI 2.75–10.11). The occurrence of delirium increased the risk almost six times of death (OR=5.9, 95% CI 4.011–8.697) and postoperative cerebral ischemia increased the risk almost 17 times (OR=16.667, 95% CI 11.383–14.405). Multi-variable analysis revealed that, apart from delirium (OR=3.735) and stroke/TIA (OR=5.698), the risk factors of early death were: urgent or emergency surgery (OR=13.018), hypertension (OR=0.333), preoperative fasting glucose level (OR=0.987), protein plasma concentration (OR=0.481) and blood transfusions (OR=2.772). In a prospective observation, including 23,127.24 person-years, the case-fatality ratio was 7.91% (95% CI 7.21–8.61). In those with delirium it was 23.31% (95% CI 17.92–28.70). Sub-group analysis showed that the case-fatality ratio among patients without postoperative stroke/TIA was 15.2% (95% CI 9.82–2058) and in those with cerebral ischemia it was 44.62% (95% CI 32.54–56.7). The results of Cox regression analysis showed that the predictors of death were: postoperative stroke/TIA (HR=3.968), urgent or emergency surgery (HR=27.643), chronic obstructive pulmonary disease (HR=2.526), preoperative fasting glucose level (HR=0.979), protein plasma concentration (HR=0.575) and any blood transfusion (HR=1.85). The impact of postoperative delirium was statistically not important (P=0.2).

Conclusions: The results showed that delirium has important impact on the risk of death either in early or late observation however after adjustment for potential confounders, the survival in a long-term follow-up in modified rather by the occurrence of cerebral ischemia and several comorbid conditions.

CP-16 RESULTS of OFF-PUMP CORONARY ARTERY BYPASS GRAFTING IN CASES OF CONVERSION TO CARDIOPULMONARY BYPASS

V.Y. Merzlyakov, A.A. Melikulov, I.V. Klyuchnikov, A.I. Skopin, M.V. Gelyhageva

Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: To analyse the results of minimally invasive surgery in cases concluded by conversion tom cardiopulmonary bypass (CPB).

Methods: The investigation comprised 124 patients with IHD (average age – 57.7±9.0 years) who underwent CABG (24 conversions to CPB, 50 patients were operated with CPB as per operation plan and 50 patients were operated by OPCABG). Canadian Cardiovascular Society (CCS) angina class I–II was found in 2.2% cases, III–IV – in 75.8% patients. Myocardial infarction was indicated in the anamnesis of 47.8% patients. Decrease in LV ejection fraction was noted in 18.5% patients. Stenosis of left main was detected in 33.7% cases.

Results: We have analysed the immediate results of 719 operations of OPCABG. In 3.4% (24) of cases the CPB was connected up as it was required in the operation course. The causes of conversion to CPB were as follows: rhythm disorders resistant to medication or cardioversion [14 patients (60%)], hypotension resistant to medication [four patients (17.4%)], ascending aorta exfoliation [two patients (8.7%)], hypothermia [two patients (8.7%)], anaphylactic shock [one patient (4.3%)]. Out of those 24 patients who required the transfer to PB, in 18 (75%) patients the conversion was performed during exposition and putting distal anastomosis. In 12 (50%) cases conversion to CPB was performed when putting a distal anastomosis to the branches of left coronary artery, and in the rest six (25%) cases when putting an anastomosis to the exterior descending artery of right coronary artery. Percentage of conversion from OPCABG to CPB in dynamics: year 2003 – 10%, 2004 – 8.5%, 2005 – 3.5%, 2006 – 1.8%, 2007 – 3.6%, 2008 –1.12%. Average period of stay in intensive care unit department in the patients of conversion group was 66.5±4.5 h, in OPCABG group – 20.9±4.8 h, and in CPB group – 23.1±3.6 h. Duration of artificial pulmonary ventilation in conversion group was 18.7±4 h, in OPCABG group – 7.4±1.3 h, in CPB group – 9.4±1.3 h. Average in-hospital period in conversion group was 22±4 days. Mortality in conversion group amounted to 15.4%, in OPCABG group – 2%, in CPB group – 5%.

Conclusions: The immediate postoperative period in patients after conversion from OPCABG to CPB is characterized by a large number of complications and longer artificial pulmonary ventilation period. Urgent transfer to CPB when putting an anastomosis results in the increase of mortality and in-hospital stay duration.

CP-17 EARLY OUTCOME OF OFF-PUMP CORONARY ARTERY BYPASS GRAFTING IN PATIENTS OVER 70 YEARS

V.A. Podkamenniy, D.I. Likhandi, E.E. Chepurnikh

Irkutsk Region Clinic, Irkutsk, Russian Federation

Objective: It is traditional to use minimally invasive techniques of coronary revascularization, including off-pump coronary artery bypass grafting (OPCAB) in patients over 70 years. We present a retrospective study based on the experience of our clinic in the performance of OPCAB in this group of patients. The aim of the study was to compare the early results of OPCAB in patients over 70 years with early postoperative results of patients operated up to 70 years.

Methods: We present the results of 1146 coronary bypass operations we performed in our clinic from January 2001 to December 2009. Early postoperative outcomes of patients elder than 70 years, compared to results of operated patients whose age at surgery did not exceed 69 years. Patients were divided into two groups. Group 1 – 70 years old or more at time of surgical intervention, Group 2 – age at the time of surgical intervention no more than 69 years. Comparative analysis was carried out according to the criteria: number of complications, hospital mortality, during hospitalization and ICU.

Results: From January 2001 to December 2009 we performed OPCAB in 1256 patients with coronary artery disease. Two groups of patients operated without cardiopulmonary bypass were organized: group 1 – over 70 years (n=63), group 2, to 70 years (n=100). In Group 1 was 76.1 years (70–87), Mean age of patients of group 2 was 58.2 years (26–69). Patients in both groups had no statistically significant differences by gender, comorbidities and major clinical manifestations of coronary artery disease. More frequent postoperative complications were significant among patients of group 1: arrhythmias (AF, SVT) 46% vs. 11% in group 2 (P=0.0009), neurological disorders (stroke) 3.2% vs. 0% in group 2 (P=0.0439). The average time spent in ICU was significantly higher in patients of group 1 and amounted to 3.67±0.51 days vs. 1.17±0.83 days in group 2 (P=0.0004). The average time of hospitalization was also significantly higher for patients of group 1 9.17±2.38 days vs. 7.12±0.58 days. Hospital mortality did not differ significantly (P=0.18) in group 1 was 3.2%, in group 2 was 1%.

Conclusions: Coronary bypass surgery without cardiopulmonary bypass in patients over 70 years, have an acceptable risk of early complications and a low risk of hospital mortality.

CP-18 COMPLETE ARTERIAL REVASCULARIZATION IN PATIENTS WITH DOUBLE AND TRIPLE-VESSEL DISEASE

L. Grichuk, K. Kondrashov, D. Boykachov, E. Idov

Regional Clinical Hospital #1, Yekatherinburg, Russian Federation

Objective: The arterial revascularization is a preferable approach to achieve better long-term outcomes in patients with coronary disease. Still it is not adopted extensively due to the complicity and presence of defined indications for performance. The objective of the study was to assess the results of solely arterial grafts usage according to clinical status of patients, numbers and severity of vessel lesion, accepted conduits and elected surgical techniques.

Methods: Two hundred and eighty-six consecutive patients with double and triple-vessel disease were enrolled to the study. Mean age was 58.2±8.6, male 86.6%, over 70 years 10.5%, obesity 29.7%, diabetes mellitus 14.6%, peripheral vascular disease 12.2%. In 3–4 angina class CSS were 75.5% of patients and 4.8% unstable. Ejection fraction was normal except 4.8% of ones below 0.30. Redo operations 14.6%, left stem stenosis – 20.9%, triple-vessel disease – 65.7%. The off-pump technique was accepted in 20% of patients. Bilateral IMA grafting was used in 89.2% of patients as in-situ or composite grafts (62.9%), radial artery – 10.5%, mean number of distal anasthom*osis – 2.8±0.8. Aorto to coronary arterial anasthom*osis comprised 0.25% of patients. Mean cross-clamp time was 42.1±11 min, mean CPB – 75.1±25 min.

Results: The BIMA usage was a preferable technique to achieve complete arterial revascularization. T-graft was chosen when it was necessary to perform three and more distal anasthom*osis. In some cases prevalence of peripheral disease and dilated hearts were restriction for this technique because insufficient graft length was encountered. There was only one postoperative death due to myocardial infarction (0.3%). Mediastinitis was observed in 0.7%, superficial infection in 2.8%, and non-fatal MI in 0.7%. The postoperative angiography was done in 23.9% of patients at mean term of one year. LIMA patency rate was 100%, RIMA – 98.4%. The string-sign was detected in 1.6%. RA patency rate was 90.9%.

Conclusions: Multiple arterial revascularization especially with both ITA is an acceptable choice for treatment of double and triple coronary lesions. The mortality and morbidity are low in all categories of patients. Off-pump technique is eligible as well with the same postoperative outcomes.

CP-19 FEATURES OF NON-SIGNIFICANT CORONARY LESIONS IN CHRONIC CHD PATIEnTS ASSESSED BY INTRAVaSCULAR ULTRASOUND RADIOFREQUENCY DATA ANALYSIS

M. Safarova, M. Ezhov, M. Mitroshkin, Yu. Matchin, V. Kukharchuk

Russian Cardiology Research Center, Moscow, Russian Federation

Objective: Plaque disruption depends on its composition and phenotype (vulnerability) rather than on plaque size (degree of stenosis). Today’s challenge in patients with chronic CHD is to identify and treat the dangerous vulnerable plaques (VPs) responsible for myocardial infarction and sudden coronary death. The objective of our study was to evaluate the plaque characterization and arterial remodeling process in non-significant stenosis of patients with chronic coronary heart disease (CHD) assessed by intravascular ultrasound (IVUS) radiofrequency (RF) data.

Methods: We recruited 22 patients [15 men (68%), mean age 54±6 years] with clinical indications for coronary angiography. Diameter stenosis of the target coronary artery for IVUS procedure had to be <60%. Automated IVUS-RF was performed in the target segment±5 mm borders using the Volcano EagleEye Gold 45 MHz IVUS probe with ECG-gated RF acquisition. IVUS-RF classified the color-coded tissue into four major components: fibrous tissue (FT), fibro-fatty (FF), necrotic core (NC), dense calcium (DC). Percentage of the area of each component in each cross-sectional plaque area was determined. Thin-cap fibroatheroma (TCFA) was defined as plaque burden >40% and amount of NC >10% without detectable overlying fibrous cap segment. Correlations were determined between the percentages of four different plaque components, % area stenosis, and remodeling index (RI) using Spearman’s rank correlation coefficient.

Results: Sample size calculations based on the IVUS evaluation showed 54 atheromas in 29 target arteries. Features of vulnerability determined as TCFA were detected in 14 lesions (26%). Compared with stable lesions Ps were associated with a greater plaque burden (48.5±8.0 mm² vs. 55.8±9.3 mm², P=0.03). The composition of unstable plaques significantly differed from the stable ones in the following components: FT 34.8±7.0% vs. 0.4±12.4% (P<0.0001), NC 37.1±9.1% vs. 24.0±12.6% (P=0.0045), and DC 22.7±8.5% vs. 5.6±5.2% (P<0.0001), respectively. No difference was revealed between plaque type and RI: 1.00±0.20 in VPs and 0.98±0.17 in stable plaques, P=0.78. Significant correlation was obtained only between positive remodeling (defined as RI>1.05) and C % area (r=0.389, P=0.005). In two patients, angiographically borderline coronary stenosis were significant IVUS measurement. Thus, coronary stenting was performed with good clinical effect that was sustaining in one-year follow-up.

Conclusions: In chronic CHD patients about 1/4 of atherosclerotic lesions creating a stenosis <60% could be classified as vulnerable plaques. These plaques have significantly more necrotic and calcium components compared to stable atheromas. Plaques with unstable phenotype are associated with positive arterial remodeling in stable CHD patients.

CP-20 THE IMPORTANCE OF CEREBRAL OXIMETRY FOR PREDICTION OF NEUROLOGICAL DYSFUNCTION IN CARDIac SURGERY PATIENTS

A. Shepelyuk, T. Klypa

Hospital 119, Moscow, Russian Federation

Objective: Cerebral complications is still an actual problem in cardiac surgery, because of the increase in hospital and ICU stay, cost of treatment and it is the cause of each fifth death in cardiac surgery.

Methods: Four hundred and sixty-one patients undergoing on-pump cardiac surgery in 2007–2010 were included (59±0.5 years, NYHA 3.4±0.3, CBP 98±1.6 min, cross-clamp 60±1.3 min) and were divided into 2 groups: group 1 – patients with decrease in cerebral oxygenation below 45% (n=152) during CBP and group two patients without cerebral oxygenation decrease (n=309). Patients of the two groups had similar features with relation to age, type of operation, CBP and cross-clamp time, the initial state, anesthetics and CPB technique. There were three types of cardioplegia – Calafiory technique, crystalloid and Custodiol. All patients had invasive monitoring of hemodynamics, non-invasive cerebral oximetry and depth of anesthesia. Data of preoperative examination was also analysed. Deferens were significant with P<0.05.

Results: 13.2% of patients of first group and 3.2% of second group had postoperative cerebral complications (P<0.05). Patients of second group had a decrease of cerebral oxygenation not more than 20% (comparing with initial data 100%), first group – about 30% during CPB. Patients of first group had initially lower (P<0.05) Hb (132.6±2.7 and 140.7±1.7), more frequent stenosis carotid arteries (more than 50%) – 17.8 and 9.7% and before surgery encephalopathy – 16.3 and 3.8%, respectively (in first and second groups) (P<0.05), also lower Hb, Ht and РСO₂ during CPB (P<0.05). There was no difference in arterial pressure, central venous pressure, lactate, blood glucose, РO₂a, oxygen transport and temperature. First and second groups underwent cardoplegia: performing technique Calafiore – 56.6% and 72.2% (P<0.05), crystalloid – 33.6% and 14.9% (P<0.05), Custodiol – 9.9% and 12.9%, respectively.

Conclusions: 1. Intraoperative decrease of cerebral oxygenation <45% and reduction more than 20% (comparing with initial data 100%) are predictors of postoperative cerebral complications. 2. Patients with preoperative level of Hb <130 g/l, before surgery stenoses of carotid arteries more than 50% and anamnesis encephalopathy are concerned to have risk of cerebral complications. 3. Among patients in risk group it is necessary to avoid significant hemodilution and hypocapnia during CBP and Calafiore blood cardioplegia is may be preferable.

CP-21 THE INFLUENCE OF HEPARIN RESISTANCE ON POSTOPERATIVE COMPLICATIONS IN PATIENTS UNDERGOING CORONARY SURGERY

P. Knapik¹, R. Przybylski¹, S. Mafa², K. Tabor², E. Prokop², M. Gaska², J. Wladyszewska²

¹Silesian Centre for Heart Diseases, Zabrze, Poland; ²Student Scientific Society by the Department of Cardiac Anesthesia and Intensive Care, Zabrze, Poland

Objective: Heparin resistance is relatively frequent in patients undergoing coronary surgery. We aimed to assess the impact of heparin resistance on the outcome of patients undergoing coronary surgery with cardiopulmonary bypass (CABG). Three definitions of heparin resistance were adopted.

Methods: We performed a retrospective review of 756 consecutive patients undergoing isolated CABG. All anaesthesia records were reviewed manually. Heparin resistance was recognized if: ACT was <400 s after 300 U/kg heparin (local criteria), ACT was <480 s after 400 U/kg or more heparin (stringent criteria), or if heparin sensitivity index was lower than 1.3. Postoperative assessment included perioperative morbidity and mortality. Multiple logistic regression model was used to investigate the influence of all demographic, preoperative and surgical variables, as well as heparin resistance (variably defined) on hospital mortality and postoperative complications.

Results: Heparin sensitivity index, local criteria and stringent criteria identified 64.8%, 12.0% and 4.3% heparin resistant patients, respectively. Heparin resistant patients more frequently had preoperative heparin administration, unstable course of coronary artery disease and higher coronary symptoms scoring. Heparin resistance expressed by the ACT <480 s after 400 U/kg heparin (stringent criteria) was an independent predictor of death (OR 4.92; CI 1.11–21.89).

Conclusions: Mild forms of heparin resistance are relatively frequent and not associated with increased morbidity and mortality. The isolation of severe heparin resistance as an independent predictor of death in our large cohort of coronary patients suggests that in future studies it should be given more attention.

CP-22 LATE RESTENOSIS AFTER DRUG-ELUTING STENT IMPLANTATION

A. Omarov¹, T. Batyraliev², I. Pershukov³, D. Fettser⁴, J. Ramazanov², E. Merkulov⁵, B. Kadyrov², B. Sidorenko³

¹A.N. Syzganov’s National Scientific Center for Surgery, Almaty, Kazakhstan; ²Sani Konukoglu Medical Center, Gaziantep, Turkey; ³Presidential Medical Center, Moscow, Russian Federation; ⁴Regional Clinical Hospital, Lipetsk, Russian Federation; ⁵Cardiology Research Center, Moscow, Russian Federation

Objective: This non-randomised prospective study evaluated the incidence and predictors of late restenosis following sirolimus-eluting stent (SES) or pacl*taxel-eluting stent (PES) implantation. Previous studies showed late restenosis (i.e. late catch-up phenomenon) after implantation of non-polymeric drug-eluting stents (DES).

Methods: Between July 2003 and December 2005 DES implantation was performed in 1082 patients (SES in 463, PES in 619) with 1559 lesions, in whom nine-month and two-year follow-up coronary angiography were planned.

Results: Of 1559 lesions, 1201 (77%) underwent nine-month follow-up angiography (9.3±2.1 months). Restenosis was observed in 103 lesions (8.6%). Coronary angiography at two years (1.8±0.4 years) after DES deployment was performed in 988 lesions (68% of lesions without restenosis at nine-month follow-up angiography). Late restenosis was observed in 67 lesions (6.8%). There was significant decrease in minimum luminal diameter (MLD) between nine-month and two-year follow-up (2.67±0.59 mm vs. 2.32±0.74 mm, P<0.001). Logistic regression analysis showed in-stent restenosis before DES implantation and MLD at nine-month follow-up as independent predictors of late restenosis.

Conclusions: Between nine-month and two-year follow-up after DES implantation MLD decreases that results in late restenosis in some lesions. In-stent restenosis before SES or PES implantation and MLD at nine-month follow-up are independent predictors of late restenosis.

CP-23 CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH ACUTE CORONARY SYNDROME

P.N. Goncharov, A.M. Kuznetsov, D.I. Levikov

Botkin S.P. City Clinical Hospital, Moscow, Russian Federation

Objective: The aim of this study was to determine the results of CABG in patients with recurrence of acute coronary syndrome after coronary stenting.

Methods: Between January 2008 and January 2011, 28 patients with recurrence of acute myocardial infarction, undergoing coronary stenting and then CABG were selected. They were divided into two groups: patients with stable haemodynamics (A), patients with unstable haemodynamics (B). All patients first underwent stenting of responsible to AMI coronary artery and then operated (CABG) within eight days after admission to the hospital.

Results: The average length of stay in the ICU was 3.1±6.2 days. Non-fatal postoperative complications occurred in 32.1% (9 of 28) of patients. The overall in-hospital mortality was 10.7% and that was related to primary cardiac events. Hospital mortality was higher in Group A (5.2%) than in Group B (22.2%).

Conclusions: Patients with acute coronary syndrome and myocardial infarction have a high mortality rate. Full revascularization, intraaortic balloon pump usage can provide good results in patients with stable haemodynamics.

CP-24 HYBRID TECHNOLOGY – A NEW STEP IN THE TREATMENT OF PATIENTS WITH CORONARY AND CAROTID ARTERIES

A.M. Cherniavskiy, A.G. Edemskiy, M.A. Cherniavsky, T.E. Vinogradova, A.A. Karpenko

E.N. Meshalkin Novosibirsk State Research Institute, Novosibirsk, Russian Federation

Objective: To evaluate the first experience of hybrid surgery in combined atherosclerotic lesion of coronary and carotid arteries.

Methods: During the period 2009–2010 we performed 51 hybrid procedures simultaneous carotid artery stenting and coronary bypass surgery. Among patients there were men – 44, women – 7, the mean age was 63±10.4 years. Forty-six patients of them (90%) had III–IV functional class of cardiac insufficiency (NYHA), 47 (92%) patients had symptoms of chronic cerebrovascular insufficiency II–IV degree, and four (8%) patients were asymptomatic. The technique of the hybrid procedure was as follows. Sternotomy was performed and the allocation of internal thoracic artery and venous conduit were performed. After systemic administration of heparin through a place in the ascending aorta where we install cardioplegia cannula introducer 6 Fr was placed. With this introducer we catheterized common carotid artery on the affected side, and angiography was performed. Through this introducer in ascending aorta embolic protection device was conducted on the guidewire distal site of stenosis of internal carotid artery at 5–6 cm. Next stage we performed stenting of internal carotid artery with self-extracting stent. With a residual stenosis of more than 30% we carried further dilatation with balloon 5 mm, and then the control angiography. We performed stenting of the internal carotid artery with Acculink stents in 24 patients (47.6%), Cordis Precise in 19 patients (38%), Protégé RX in eight patients (14.3%).

Results: We registered mortality in one case (1.9%) in connection with the development in the postoperative period of acute disorders of cerebral circulation in the area blood supply with occluded contralateral artery with respect to the stented carotid artery. Under the hybrid interventions there were no perioperative myocardial infarction and damage of the cranial nerves. Posthypoxic encephalopathy was registered in three patients (5.8%).

Conclusions: Hybrid surgical interventions in patients with combined arterial lesions (coronary and carotid arteries) can become an alternative to traditional surgical procedures, and in some cases – the only method of treatment. Hybrid surgical interventions do not require reoperations and hospitalization, there were no complications from access to carotid arteries. These interventions psychologically easier tolerated by patients and are more cost-effective, since they allow curing for single hospitalization, not at the same time extending the duration of stay in hospital.

CP-25 SIMULTANEOUS HYBRID REVASCULARIZATION USING CAROTID ARTERY STENTING FOLLOWED BY CORONARY ARTERY BYPASS GRAFT

J. Konstanty-Kalandyk, P. Rudzinski, J. Piatek, P. Pieniazek, P. Musialek, K. Dzierwa, R. Motyl, J. Sadowski

John Paul II Hospital, Krakow, Poland

Objective: Patients with concomitant carotid and cardiac disease requiring cardiac surgical procedure are at risk of perioperative stroke during cardiac surgery. Choice of carotid revascularisation method [endarterectomy (CEA) or carotid artery stenting (CAS)] and the timing of the procedures (synchronous or staged) should be individualized after discussion by a multidisciplinary team. Unfortunately, delaying heart surgery after CAS could lead to cardiac deaths and dual antiplatelet therapy after CAS increase the risk of postoperative bleeding. To avoid this adverse event, a new therapeutic strategy consisting of a simultaneous hybrid revascularization by (CAS), immediately followed by coronary artery bypass graft (CABG) was investigated.

Methods: Nine patients with severe carotid and coronary artery disease and a standard EuroSCORE >5 were included in this study. The neurologist was responsible for the initial evaluation and neurological follow-up of the patients. The CAS procedures were performed under local anesthesia through a percutaneous transfemoral access with the use of stents and protection devices approved by the Accreditation Committee. Heparin was administered intra-arterially immediately before the stent implantation procedure and before the cardiopulmonary bypass. Activated clotting time (ACT) was constantly maintained >250 s until the CABG procedure. Cardiac surgery was performed immediately after CAS. Clopidogrel, 300 mg as a loading dose, followed by 75 mg/day for one month was started in the intensive care unit 6 h after the end of CABG surgery, providing that surgical bleeding from the thoracic drains had definitely stopped.

Results: At the time that procedures were performed, the mean age was 71±4.5 years and only 13% were women. All patients were in CCS III or CCS IV, four was diabetic and five (55.5%) had a previous cerebrovascular accident. Mean ICA stenosis was 82% and 77% had three-vessel CAD. Carotid stenting technical success was achieved in all patients. After carotid stenting procedures, all patients immediately underwent CABG. Three procedures (33%) were off-pump and seven (77%) were total arterial revascularization. There was neither stroke nor myocardial infarction or death at 30-day follow-up. No patient needed a cardiac or carotid reintervention. Mean ICU stay was 1.5 days and one patient required rethoracotomy due to bleeding.

Conclusions: In patients with combined carotid and coronary disease, the proposed combined hybrid approach seems to be a possible therapeutic strategy with a low periprocedural complication rate and no neurological or cardiac complications in 30-day follow-up period.

CP-26 THE RESULTS OF THE DISPENSARY CABINET PERFORMANCE

E. Milovanova

Regional Cardiological Clinic Center Diagnostic and Cardiovascular Surgery, Surgut, Russian Federation

Objective: To study the results of surgical treatment of patients with cardiovascular diseases.

Methods: In 2000 the dispensary cabinet for monitoring operated patients and evaluating surgical treatment results was established. All postoperative patients visit cardiologist in Cardiological Clinic Center once a year or more often if necessary. In addition, physicians of 26 regional clinics observe patients at the places once a year and provide follow-up reports.

Results: There were 2985 patients operated for coronary artery bypass surgery (CABG). Hospital mortality was 2.1% (63 patients died). In long-term period (mean observation period 5.3 years) 136 patients (4.7%) died due to cardiac causes. Five-year survival rate after CABG and 10-year survival were 90% and 87.5% correspondingly. Hospital mortality among 1732 patients who underwent percutaneous coronary intervention (PCI) was 1.2% (22 cases). Long-term mortality after PCI was 1.9% (32 cases). Five hundred and seventeen patients (11%) underwent coronary reintervention in long-term period. Patients with PCI demanded reintervention five times more often than CABG patients: 22.5% (389 patients) and 4.3% (128 patients) correspondingly (P<0.001). Among 994 patients operated with heart valve replacement 57 died in hospital (hospital mortality 5.7%). Long-term mortality (5.5 years mean observation period) was 10.9% (102 patients). Twenty-seven of them (26.5%) died within one year after surgical treatment. Five-year survival rate after valve replacement and 10-year survival were 79% and 68% correspondingly. Long-term mortality did not depend on the complexity of intervention (13% one valve replacement, 12.4% two valves replacement and 15.5% valve replacement+CABG, P=0.19). Also mortality did not depend on valve position (10.6% of mitral valve and 9.5% of aortic valve replacement, P=0.65). Reoperation in late period suffered 18 (2%) patients. Twenty patients (2.1%) suffered of bleeding while taking anticoagulants in the follow-up period. The levels of temporary incapacity and disability in the whole group of operated patients (CABG, PCI and valve replacement) were lower 1.6 and 1.5 times correspondingly than in non-operated patients.

Conclusions: The dispensary cabinet performance allows to evaluate the results of surgical treatment patients with cardiovascular diseases.

CP-27 VALVE-IN-VALVE HEMODYNAMICS OF SIZE MATCHED 20 MM TRANSCATHETER AORTIC VALVES FOR SMALL DEGENERATED BIOPROSTHESES

E. Tseng

University of California at San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA

Objective: Transcatheter aortic valves (TAVs) have been used successfully to treat bioprosthetic degeneration as a valve-in-valve (VIV). However, current TAVs are available in limited sizes. We have previously shown that optimal TAV function requires full stent expansion to its nominal size since oversizing can lead to TAV-bioprosthesis size mismatch. Current 23 mm TAV implantation (TAVI) in 19 mm Carpentier-Edwards Perimount valves resulted in unacceptable hemodynamics while TAVI in 21 mm valves had elevated mean gradients. Development of a new 20 mm TAV size is planned, therefore our study objective was to determine if 20 mm TAVs would provide acceptable hemodynamics in small degenerated pericardial and porcine bioprostheses.

Methods: Twelve 20 mm TAVs were created based upon Edwards SAPIEN valve design using stainless steel stents with trileaflet pericardial valve. Bioprosthetic degeneration of pericardial valves was simulated using BioGlue to achieve a mean pressure gradient of 50 mmHg, while porcine degeneration was simulated using BioGlue on two leaflets and cutting the third leaflet to yield stenosis and regurgitation. TAVs were implanted within degenerated 19 and 21 mm Carpentier-Edwards pericardial and porcine bioprostheses (n=3). Degenerated bioprostheses were sutured in situ into human hom*ograft roots of matched sizes. VIV hemodynamics were studied in a custom-built pulse duplicator.

Results: 20 mm TAVs in 21 mm pericardial valves migrated retrograde into the left ventricle, whereas TAVI in 19 mm pericardial valves significantly reduced mean pressure gradient (54.9±5.4 to 23.5±3.9 mmHg), increased effective orifice area (0.69±0.03 to 1.07±0.1 cm²), and decreased total energy loss (809±52.1 to 582.3±27.5 mJ/stroke). Mild regurgitation was seen and energy loss was significantly higher than surgical re-replacement with normal 19 mm valves. On the other hand, 20 mm TAVI in 21 mm porcine valves did not migrate and significantly reduced mean pressure gradient (35.2±8.9 to 16.8±4.1 mmHg), increased effective orifice area (0.87±0.13 to 1.28±0.15 cm²), and decreased total energy loss (1072.3±213.4 to 381.0±33.8 mJ/stroke). However, 20 mm TAVI in 19 mm porcine valves was not effective in reducing pressure gradient or energy loss and did not increase effective orifice area due to TAV-bioprosthesis size mismatch.

Conclusions: Development of a 20-mm TAV would improve VIV hemodynamics of degenerated 19 mm pericardial valves but not 19 mm porcine valves. On the other hand, 20 mm TAVI in 21 mm pericardial valves would lead to migration in the left ventricle, but is effective for 21-mm porcine degenerated valves. While increased availability of TAV sizes allows a greater spectrum of VIV implantation, changes in TAV design are required to yield optimal hemodynamics in 19 mm porcine valves.

CP-28 FACTORS WHICH DETERMINE THE PROGNOSIS OF CORONARY ARTERY BYPASS GRAFT SURGERY IN PATIENTS WITH ACUTE CORONARY SYNDROME

N.L. Bayandin, K.N. Vasilyev, A.G. Krotovsky, A.S. Vishchipanov, C.Yu. Tyurin, I.B. Bragin

O.M. Filatov Municipal Clinical Hospital No. 15, Moscow, Russian Federation

Objective: To determine risk factors affecting results of surgical treatment in patients with early postinfarction angina pectoris.

Methods: Two hundred and seven patients with early postinfarction angina pectoris have been operated in the Cardiosurgical Department of O.M. Filatov Municipal Clinical Hospital no. 15 from 2000 to 2009. The average age was 59.0±9.2 years; there were 164 (79%) men and 43 (21%) women. Q-wave myocardial infarction (MI) was diagnosed in 116 (56%) patients and non-Q-wave MI – in 91 (44%) patients. Basing on ECG data, ejection fraction (EF) was, on average, 49.1±13.5% (minimum – 16%, maximum – 83%): in 102 (49%) patients it was normal (>0.5), and in 83 (40%) patients it was moderately decreased; 22 (11%) patients had severe global contractile function disorders (EF<0.3). Affection of more than 50% of left coronary artery trunk was found in 75 (36.2%) patients, 120 (57.9%) patients had affection of three and more coronary arteries. Indications for urgent surgery were the following: persistent myocardial ischemia with ECG abnormalities in patients with unstable hemodynamics (despite proper conservative treatment), cardiogenic shock with relapsing MI (with technical incapability, unreasonableness or complications of angioplasty of infarction-dependent artery). Patients were divided into groups basing on the time period from first MI clinical presentations to surgical intervention. The first group consisted of patients with time period from zero to seven days, the second group – 8–14 days, and the third group – from 15 days and more.

Results: Total mortality was 8.7% (18 patients) in the group of patients with post infarction angina pectoris. Eleven (23.4%) patients died in the I group, two (6.8%) patients – in the II group, and five (3.8%) patients – in the III group, P=0.0003. Duration of artificial pulmonary ventilation, stay in ICU, need in long-lasting cardiotonic support, frequency of acute renal insufficiency was significantly higher in the first group (P<0.01). Multifactorial analysis demonstrated that low LV EF (<30%) and cardiogenic shock affected the survival rate.

Conclusions: Left ventricle ejection fraction <30% and cardiogenic shock at the moment of the surgery in patients in acute MI period is the main risk factor of unfavorable outcome. In the early postoperative period, these patients need assisted circulation (counterpulsation) and treatment of multiple organ failure (long-lasting artificial pulmonary ventilation, hemodialysis and plasmapheresis).

CP-29 RESULTS OF ENDOVASCULAR TREATMENT IN PATIENTS WITH EARLY POSTINFARCTION STENOCARDIA

M.M. Zufarov, Sh.N. Salakhitdinov, F.A. Iskandarov, Kh.A. Akhmedov, D.A. Alimov

The Republican Specialized Center of Surgery named after V. Vahidov, Tashkent, Uzbekistan

Objective: Evaluation of the efficiency of endovascular treatment (ET) in patients with early postinfarction stenocardia (EPS).

Methods: ET of coronary arteries was performed in 85 EPS patients aged from 42 to 72 years (53±4.7 years). The patients had a myocardial infarction (MI) from four days up to one month (13.2±2.4 days) in anamnesis. MI with Q wave was in 24 (28.2%) patients, without Q wave – in 61 (71.8%). Acute MI with Q wave (n=24) of LV anterior wall was in six (7.1%) patients, of anterio-lateral wall and apical – in 11 (12.9%), of posterior wall – in seven (8.2%). Among 61 OBJECTIVE patients without Q wave anterior wall ischemia with ST segment depression was in 22 (25.9%) patients, of anterio-lateral wall and apical – in 28 (32.9%), of posterior wall – in 11 (12.9%). Thirty (35.3%) patients were in class I (NYHA) and 17 (20.0%) – in class II. One artery stenting was performed in 48 (56.5%) patients, two arteries stenting – in 29 (34.1%), three – in eight (9.4%) patients. In 25 (29.4%) cases of coronary artery occlusion recanalization with subsequent angioplasty and stenting was performed. Recanalization of LAD occlusion was performed in 12 (14.1%), RCA – in eight (9.4%), CA – 5 (5.9%) patients.

Results: All cases successfully restored a good coronary blood flow (ТIMI III) with no complications or deaths. After the ET patients it has been observed a clinical status stabilization with absence of angina even at significant loadings. Thirty-four (40.0%) patients showed positive ECG dynamics within the first day after intervention: ST segment elevation decrease was observed in eight (9.4%) and ST depression increase to an isoline – in 26 (30.6%) patients. In 38 (44.7%) patients the ST segment depression has decreased in 2–3 days after stenting. According to EchoCG the EF of LV has increased from 41.8±4.8% to 50.1±6.1%. All patients were discharged from the hospital 2–3 days after the ET. Results of ET showed that 52 (61.2%) patients achieved full stabilization of status without angina even at significant physical loadings. Fourteen (16.5%) patients were identified to have a class I exertional angina, and 18 (21.2%) class II.

Conclusions: Coronary arteries angioplasty and stenting result in stabilization of the clinical status, improvement of the prognosis and quality of life of patients, these suggest to recommend its application in all patients with postinfarction stenocardia.

CP-30 IMPACT OF TIGHT GLYCEMIC CONTROL ON PERIOPERATIVE OUTCOMES IN DIABETIC PATIENTS UNDERGOING PERCUTANEOUS CORONARY

INTERVENTIONS AND BYPASS SURGERY

T.V. Zavalikhina, E.Z. Golukhova, G.E. Chebotareva, N.M. Magomedova

Bakoulev Scientific Center of Cardio-Vascular Surgery, Moscow, Russian Federation

Objective: This study sought to determine whether tight glycemic control with a continuous glycemic monitoring system (CGMS) in diabetic patients undergoing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) would improve perioperative outcomes.

Methods: Ninety-two diabetic patients undergoing PCI or CABG were prospectively randomized to tight glycemic control with CGMS or standard control of plasma glucose after operation. It was studied fasting plasma glucose, impaired fasting glucose, glyceted hemoglobin A1c. Glycemic control was conducted in perioperative period. Glycaemia correction was carried out by insulin infusion combined with isotonic solution.

Results: Hyperglycemia was revealed in 92.3% of patients with CGMS. Hyperglycemia was found in 65.3% (P=0.025) patients with standard control of plasma glucose after operations. Most significant glycaemia changes in perioperative period were observed in patients operated under cardiopulmonary bypass. In diabetic patients who underwent off-pump CABG, glycaemia levels were lower than in diabetic patients, who underwent on-pump CABG.

Conclusions: Hyperglycemia is a specific factor associated with increased risk of adverse outcomes after PCI or CABG. The intensive control glycaemia allowed improving surgery outcomes by reducing perioperative complications.

CP-31 EVALUATION OF ELECTRO-MECHANICAL DYSSYNCHRONY IN PATIENTS WITH ISCHEMIC HEART FAILURE

E. Golukhova, D. Mrikaev, T. Mashina, I. Polyakova, T. Kakuchaya

Bakoulev Center, Moscow, Russian Federation

Objective: The objective of our study was the identification and prognostic evaluation of segmental contractility and intraventricular dyssynchrony in patients with ischemic heart failure (IHF).

Methods: Forty-six patients with various forms of IHF– left ventricular (LV) aneurysm, myocardial scar without LV aneurysm and angina pectoris without myocardial scar were examined. Patients were divided into three groups by NYHA classification: group 1 (I functional class-FC), group 2 (II FC) and group 3 (III–IV FC). We performed three-dimensional echocardiography (3D Echo) to calculate LV systolic dyssynchrony indices – SDI and Tmsv 16-Diff. By strain rate imaging (SRI) we calculated following dissynchrony indices: Ts-SD, Ts-Diff and kinetic heterogeneity index (KHI). QRS duration and internal deviation time (IDT) were calculated by body surface potential mapping (BSPM) to estimate intraventicular conduction.

Results: Dyssynchrony indices (SDI, Tmsv-Diff-16, KHI) significantly differed in all three groups (P<0.05). LV dyssynchrony indices negatively correlated with LV ejection fraction (EF) and NYHA FC. Significant differences in QRS duration and IDT were revealed between groups 1 and 3 and 2 and 3. We found high positive significant correlation of LV aneurysm area, calculated by isointegral QRST maps, with deformation indices (r=0.76, P<0.05). We also found significant positive correlation of KHI with LV EF and its negative correlation with NYHA FC.

Conclusions: Intraventricular dyssynchrony indices (SDI, Tmsv-Dif-16, Ts-SD), LVEF, mitral regurgitation and KHI are most informative parameters, significantly correlating with HF FC.

CP-32 OUTCOMES OF STAGED TREaTMENT IN PATIENTS WITH CORONARY ARTERY DISEASE AND PERIPHERAL ATHEROSCLEROSIS

V. Ganyukov, A. Shilov, P. Shushpannikov, N. Bokhan, O. Barbarash, L. Barbarash

State Research Institute for Complex Studying of Cardiovascular Diseases, Kemerovo, Russian Federation

Objective: Outcomes of staged revascularization of combined (surgical and endovascular) treatment of patients with coronary artery disease (CAD) and peripheral atherosclerosis (PA) were analysed.

Methods: We conducted a retrospective study on combined treatment of 57 patients with CAD+PA performed between 2007 and 2009. Mean age of patients was 62.7±6.5 years old, male-dominated in 86% of cases. The 47 (82.5%) patients had a clinic stable angina, nine (15.8%) unstable angina, one patient (1.8%) underwent endovascular treatment in acute myocardial infarction (AMI). Six patients (10.5%) had diabetes mellitus, 33 patients (57.9%) suffered from arterial hypertension, 35% of patients had myocardial infarction in the medical history. Inclusion criteria was: 1. Hemodynamically significant (70% stenosis) lesion of two or more vascular regions (coronary, extracranial arteries, the vessels of the lower extremities, the arteries of the abdominal aorta). 2. The time between the stages of revascularization ≤3 months (mean interval between stages of revascularization was 31±29.6 days). Hemodynamically significant stenosis of two and three vascular regions had 48 (84.2%) and eight (14%) patients, respectively. There was one patient (1.8%) with four vascular regions stenosis. Percutaneous coronary intervention (PCI) and internal carotid artery (ICA) stenting was performed in 16 (28.1%) patients, ICA stenting and coronary artery bypass grafting (CABG) was performed in 12 (21%) patients and PCI with carotid endarterectomy was performed in 12 (21%) patients.

Results: The success of intervention (technical success of surgical treatment in the absence of significant cardiovascular complications) was observed in 56 (98.2%) patients. One patient (1.8%) died during the second stage of treatment – CABG with aorto-femoral prosthesis after ICA successful stenting. Three patients (5.2%) had stent thrombosis during treatment with heparin without dual antiplatelet therapy before the second stage of revascularization.

Conclusions: Combined (surgical and endovascular) and staged revascularization within three months had a satisfactory hospital outcomes in CAD+PA patients. Endovascular procedure and follow-up (31±29.6 days) surgical revascularization without dual antiplatelet therapy in hospital period before the second stage of treatment associated with high rate (5.2%) stent thrombosis.

CP-33 OUTCOMES IN PATIENTS WITH DE NOVO LEFT MAIN DISEASE TREATED WITH PERCUTANEOUS CORONARY INTERVENTION WITHOUT ONSITE CARDIAC SURGICAL BACKUP

I.P. Zyrianov, I.S. Bessonov, V.A. Kuznetsov, M.V. Semukchin, E.A. Gorbatenko, A.V. Panin, V.A. Bukhvalov

Tyumen Cardiology Center – Branch of Institute of Cardiology, Russian Academy of Medical Sciences, Siberian Branch, Tyumen, Russian Federation

Objective: Favorable outcomes for percutaneous coronary intervention (PCI) performed in facilities without cardiac surgery backup on site have been reported. However, few data exist concerning the PCI for left main coronary artery stenosis. The aim of this study was to evaluate the safety and efficacy of PCI for the treatment of left main coronary artery stenosis in facilities without on site cardiac surgical backup.

Methods: We evaluated 59 consecutive patients who underwent elective PCI for left main coronary artery stenosis from 1 February 2006 to 31 October 2010 in our center. Our cardiac surgery backup was a district hospital 10 km away.

Results: Mean age of patients was 53.3±1.1 years, and the majority of them were men (81.4%). Patients had high-risk clinical profile, with diabetes mellitus in 20.4% and prior myocardial infarction in 38.1%. Fifty-five patients (93.2%) underwent PCI for unprotected left main coronary artery stenosis. Sixteen patients (27.1%) had ostial or midshaft lesions while the remaining 43 (72.9%) patients had distal bifurcation disease. Patients were stratified according to their SYNTAX score into three tertiles: 43 patients (72.9%) with low (0–22), 12 patients (20.3%) with intermediate (22–32), and four patients (6.8%) with high (−33) complexity. Percutaneous coronary intervention success rate was 100%. There were no periprocedural or in-hospital deaths, and no patients required emergency transfer for cardiac surgery. In-hospital event was postprocedural non-Q-wave acute myocardial infarction in one case. At 14.5±1.5 months of follow-up total mortality was 4.1%, target lesion revascularization rate was 2%.

Conclusions: Non-emergent PCI for de novo left main coronary artery stenosis can be performed effectively and safely in facilities without onsite backup cardiac surgery.

CP-34 REGIONAL FLOW MATHEMATICAL MODELING FOR ASSESSING REQUIREMENTS OF DIRECT CORONARY REVASCULARIZATION

E.V. Fomichev, A.A. Dugikov, G.V. Chudinov, A.A. Nikitchenko, V.V. Nesterov, V.V. Korshunov, A.A. Kornienko, S.V. Papchenko

Rostov Regional Cardiovascular Surgery Center, Rostov-on-Don, Russian Federation

Objective: Contemporary methods of myocardial revascularization allow improving survival and quality of life in patients with coronary heart disease. At the same time, there is still no satisfactory answer where and when one should perform complete myocardial revascularization, because many factors exist reducing the rate achieving the complete myocardial revascularization. The latter is often a difficult task, and we consider well-reasoned incomplete adequate revascularization to be a valid alternative. This study presents several methods of coronary flow assessment where regional ischemic deficiency is calculated in mathematical model, evaluating thereby hemodynamic significance of coronary stenoses. Decision of complete or adequate incomplete revascularization can be rooted in these data.

Methods: Investigation included 182 patients with different form of coronary heart disease. This patients underwent myocardial revascularization from 2005 to 2008 at Rostov Regional Cardiovascular Surgery Center. General group had been divided into two groups of patients: first (98 patients) group included patients, who underwent complete myocardial revascularization and the second one included 84 patients who underwent incomplete myocardial revascularization. The mathematical simulation was invented based on equation of Navye-Stoks. We calculated the coefficient which describe adequacy of circulation of the blood after myocardial revascularization. This coefficient cannot be more than two.

Results: Some kinds of myocardial revascularization were executed: coronary artery bypass graft – 137 patients and 45 patients who underwent coronary stenting. The coefficient which describing adequacy of myocardial revascularization in group with complete myocardial revascularization was 1.702±0.21, and this factor in group with incomplete myocardial revascularization was 1.39±0.41. Analysis of results let us make a decision, that the calculating of the coefficient of adequacy revascularization allows to predict result of myocardial revascularization. If this coefficient is <1.33 – negative effect can be expected in case of incomplete myocardial revascularization. If this coefficient is more than 1.34 – positive effect can be expected in case incomplete myocardial revascularization, and if it is more than 1.61 – best effect can be expected.

Conclusions: The used simulation allows assessing of quantitative blood flow alteration in presence of stenosis in the blood flow bed. The findings make it possible to draw a conclusion about the necessity to perform either complete or adequate coronary artery bypass grafting in the patient.

CP-35 THE ACUTE MARGINAL ARTERY – AN AGGRESSIVE APPROACH ON THE REVASCULARIZATION OF THE RIGHT VENTRICLE

G. Tinica¹, M. Enache², A. Ciucu¹, D. Anghel¹, O. Bartos¹, V. Prisacari¹, D. Dascalescu¹

¹Cardiovascular Institute, Iasi, Romania; ²University of Medicine and Pharmacy ‘Gr. T. Popa’, Iasi, Romania

Objective: The right ventricular dysfunction has often hemodynamic consequences, especially in the perioperative period of CABG procedures. Through this study we want to demonstrate that a more rigorous revascularization approach on the right coronary system through the acute marginal artery is more beneficial to the perioperative and short-term outcome.

Methods: We evaluated 24 patients who underwent CABG with the subsequent revascularization of the acute marginal artery. The criteria for the revascularization of the acute marginal artery are: arterial diameter >1 mm, right coronary artery occlusion in the first segment, occlusion or severe stenosis of the acute marginal artery, occlusion of the right coronary artery in the case of a hypoplastic right coronary artery, right ventricular infarction.

Results: The majority of patients (19 patients, 79.16%) had an aggressive approach of revascularization of the right ventricle by bypassing the acute marginal artery alongside another arterial branch of the right coronary system. Twenty patients (83.33%) received bilateral internal thoracic arteries plus the radial artery, three patients (12.5%) received the left internal thoracic artery, the radial artery and the internal saphenous vein and one patient (4.16%) had bilateral internal thoracic arteries plus the internal saphenous vein. All the patients had multi-vessel coronary disease. Three patients (12.5%) were women. The average age was 61.56±8.99 years and the mean number of grafts used was 4.79±0.75. A percentage of 29.16% patients underwent other surgical procedures besides CABG, 41.66% of patients had congestive heart failure, 37.5% had low left ventricular ejection fraction (<50%), 79.16% had arterial hypertension and 41.66% were diabetic. Arterial peripheral disease was present in three patients (12.5%) and one patient (4.16%) had chronic renal failure. The overall mortality was 0%. At follow-up, all patients are free from angina and have no clinical signs of right heart failure.

Conclusions: In order to achieve a more rigorous revascularization of the right ventricle, we observed that by grafting the acute marginal branch of the right coronary artery patients spend less time in the ICU unit, require diminished doses of inotropic agents and have a better outcome. The revascularization of the acute marginal artery is an interesting novel approach on the revascularization of the right ventricle, as we could not find any reference to this in the literature.

CP-36 COMPARATIVE ANALYSIS OF THE EARLY OUTCOMES OF SURGICAL VENTRICULAR RESTORATION BY DOR AND MENICANTI

V.M. Shipulin, A.A. Lezhnev, V.E. Babokib, R.V. Aimanov, E.N. Pavlukova, V.H. Vaizov

Tomsk Institute of Cardiology, Tomsk, Russian Federation

Objective: The aim of the study was to compare the efficacy of surgical ventricular restoration (SVR) by Dor and Menicanti techniques.

Methods: Twenty-three patients (mean age 53.5±9.2 years) with a previous left ventricle (LV) infarction, LV EF <40% and with hemodynamically significant stenosis of coronary arteries were enrolled into the study. LV EF comprised 34.2±5.2%, EDV – 210.3±47.1 ml, ESV – 140.2±30.2 ml. Initially all patients had from mild-to-moderate mitral regurgitation. The maximum level of oxygen consumption was 11.4±2.93 mg/kg/min. Patients were randomized between two groups: patients of the first group (n=12) were subjected to SVR by V. Dor technique; second group patients (n=11) were treated by L. Menicanti SVR technique using of a Chase Medical mannequin (USA). Restoration of an obturative function of a mitral valve was not performed. The groups did not differ significantly by the initial clinical and intraoperative data. In 273.4±93.2 days after the surgery the patients underwent EchoCG and veloergospirometry (Shiller CS – 200) examination.

Results: EDV did not differ significantly between the groups: in the first group it was 143.1±51.3 ml and in the second – 131.4±58.1 ml. The significant differences that were found are the following: in the first group patients IS comprised 0.72±0.2 while in the second group it was significantly lower – 0.65±0.2. Statistically more pronounced residual regurgitation on a mitral valve was noticed in the first group patients. ESV in the first group patients was 79.5±21.6 m; in the second group it was less significant – 73.4±18.4. In the first group EF comprised 40.4±12.6% while in the second group it was statistically higher – 51.6±13.7%. After surgical treatment the growth of maximum oxygen consumption was 1.1±0.5 ml/kg/min in the first group and 0.86±0.4 mg/kg/min in the second group i.e. did not differ statistically between the groups.

Conclusions: SVR by Menicanti provides better restoration of LV geometry in comparison with Dor technique. This restoration is accompanied by the improvement of an obturative function of a mitral valve and by the sphericity index going toward normal values, which is also reflected in significantly lower ESV values and higher EF values after Menicanti procedure in the early follow-up period.

CP-37 EEG DYNAMICS IN PATIENTS WITH CORONARY ARTERY DISEASE UNDERGOING ON-PUMP CORONARY BYPASS SURGERY

I.V. Tarasova, O.A. Trubnikova, I.D. Syrova, O.L. Barbarash

Research Institute for Complex Issues of Cardiovascular Diseases, Siberian Branch of the Russian Academy of Medical Sciences, Kemerovo, Russian Federation

Objective: It is known that the characteristics of the background electroencephalogram (EEG) reflect the state of higher nervous activity both in healthy people and in patients having, in particular, coronary heart disease (CHD) and co-morbid chronic cerebral ischemia or acute ischemia, which may occur during cardiac surgery under extracorporeal circulation. The objective of the study was to investigate the EEG dynamics in patients with coronary artery disease before and after coronary bypass surgery (CABG).

Methods: The study included a total of 14 males, right-handers with a clinically and instrumentally verified diagnosis of CHD and a mean age of 57.0±6.61 years. All EEG studies were performed 3–5 days before and 8–11 days after CABG. Cognitive deficits were assessed by the mini-mental state examination (MMSE). Psychometric tests of voluntary and involuntary attention were also performed. Monopolar EEG was recorded with closed and open eyes in 62 standard sites of 10–20 system with NEUVO encephalograph (Compumedics, USA). The values of EEG spectral power in the range of 0–50 Hz using the fast Fourier transformation were obtained. Statistical processing of the data was performed with the non-parametric Wilcoxon’s test.

Results: No development of focal neurological symptoms and other neurological complications was observed in patients after CABG. The average MMSE score in patients after CABG did not differ from baseline values (26.8±1.40 and 26.5±1.04, respectively). Involuntary attention test revealed the acceleration of the reaction time to repeated stimuli (P=0.04) and the increase of the number of errors in performing the task (P=0.03) after CABG compared to preoperative data. The power of θ₂, α₁ and β₁ rhythms increased in patients after CABG with their eyes open in comparison to the preoperative data (P=0.04, P=0.03 and P=0.05, respectively).

Conclusions: CABG has a significant influence on the electrical activity of the cerebral cortex in patients with coronary artery disease. The functional significance of the changes in EEG parameters requires further studies.

CP-38 DOES THE PATENCY DIFFER ACCORDING TO THE ANASTOMOTIC SITE, RIGHT CORONARY ARTERY OR THE POSTERIOR DESCENDING BRANCH?

S.Ç. Murat, B. Erdolu, S. Özyalçin, A.T. Ulus, K. Vural

Turkey Yüksek Ihtisas Hospital, Ankara, Turkey

Objective: The aim of the study was to compare the right coronary artery and posterior descending artery bypasses long-term outcomes by using coronary angiography.

Methods: We retrospectively analysed the angiographic data of the patients who had coronary angiographic evaluation after coronary artery bypass graft surgery because of anginal symptoms. We have screened 138 patients who had CABG included right coronary artery bypasses. Among them 102 patients had right coronary artery trunk bypass and 36 patients had posterior descending coronary artery bypasses.

Results: Graft failure was seen in 89 bypasses. Sixty-seven (75%) of them were due to right coronary artery bypass grafts and 22 (25%) of them posterior descending coronary artery bypass grafts. The average time between the operation and angiography was 67.3±47.4 months. There were no significant differences between the patency rates of coronary artery bypass site. The patency rate of the bypass grafts were also not differ in diabetic, hypertensive and hypercholestrolemic patients. The 10-year graft patencies were 51.6±7.4% and 49.6±12.9% in right coronary artery and posterior descending coronary artery bypass groups (P>0.05).

Conclusions: According to the current results both groups have acceptable patencies in all patients.

CP-39 CORONARY REVASCULARIZATION IN ELDERLY PATIENTS

L. Grichuk, K. Kondrashov, D. Boykachov, E. Idov

Regional Clinical Hospital #1, Yekatherinburg, Russian Federation

Objective: The coronary revascularization in elderly patients is still a challenge because of frequent presence of concomitant diseases and poor general physical condition. To improve results different operative approach may be reasonable.

Methods: We reviewed the clinical records of 200 consecutive patients 70 years of age and older, who underwent CABG at our clinic between January 2009 and August 2010. The mean age was 72.4±2.4 years, male/female ratio 148/52, obese patients 19%, diabetes mellitus 19%, cerebrovascular lesion – 66%, insult – 8.5%, renal failure – 16.5%, arrhythmia – 21.5%. 64.5% of patients had 3–4 CCA angina class, 15% were unstable and 7.5% presented with acute MI. EF<0.30 was detected in 5%, left stem stenosis – 31%. Triple- and double-vessel disease had 68.5% and 24% of patients, respectively. Redo operations – 11.5%. Simultaneous operations due to carotid or peripheral vascular disease – 6.5%.

Results: We used auxiliary circulation and beating heart in 12% of cases, off-pump technique in 27% and CPB with cardioplegia in 61% of cases. The mean number of distal anasthom*osis was 2.97±0.8, proximal anasthom*osis – 1.5±0.8, number of grafts – 2.5±0.7. Hospital mortality was 1.5% (3/200). We observed postoperative stroke in two cases (1%), myocardial infarction in three (1.5%), bleeding in three (1.5%), mediastinitis in three (1.5%), superficial wound infection in five (2.5%), atrial fibrillation in 54 (27%). There were no differences between groups with relation to mortality and complications except for lower rate of supraventricular arrhythmia in off-pump operated patients.

Conclusions: Elderly patients may undergo coronary revascularization with different operative approach without increasing mortality and morbidity.

CP-40 THE ROLE OF GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS IN PATIENTS WITH STEMI WHO UNDERGO RESCUE PCI AFTER THE UNSUCCESSFUL THROMBOLYSIS

T. Batyraliev¹, D. Fettser², D. Preobrazhensky³, I. Pershukov³, J. Ramazanov¹, B. Kadyrov¹, B. Sidorenko³

¹Sani Konukoglu Medical Center, Gaziantep, Turkey; ²Regional Clinical Hospital, Lipetsk, Russian Federation; ³Presidential Medical Center, Moscow, Russian Federation

Objective: The purpose of the study was to estimate the safety and the efficacy of the use of glycoprotein IIb/IIIa inhibitor (tirofiban), its influence on the function of the left ventricle and the clinical outcome of patients with ST-elevation MI during the rescue PCI after the unsuccessful thrombolysis.

Methods: The study included 168 patients who were randomized in 2006 into two groups: in group I there was rescue PCI with stenting, patients in group 2 were administered with tirofiban, and rescue PCI was performed after the unsuccessful thrombolysis. Only bare-metal stents were implanted during PCI.

Results: The estimate of the recent events (0–30 days) showed that in the frequency (group I – 14.7%, group II –17.2%) and intensity of bleeding there were no significant differences between the groups (P>0.05). In the tirofiban group the distinct growth was recorded in the ejection fraction LV: 7±3% vs. 4±5% in group I (P=0.005). Long-term (14.1±2.5 months) major adverse cardiac events occurred significantly more rarely in group II (10.2% vs. 22.1% in group I, P<0.05). Multivariate analysis showed that the development of cardiogenic shock (OR=6.4, 95% CI: 1.6–18, P=0.005) was an independent predictor of major adverse cardiac events during the 12 months after PCI. Under such conditions only the use of tirofiban during PCI had a significant effect on the decrease of the major adverse cardiac events during the 12 months after PCI (OR=0.19, 95% CI: 0.06–0.57, P=0.004).

Conclusions: PCI in combination with glycoprotein IIb/IIIa inhibitors allows reaching the optimal results of the treatment of the patients with STEMI. The long-term outcomes after the rescue PCI improve if a patient receives glycoprotein IIb/IIIa receptors inhibitor. Long-term outcomes are considerably worse, if the cardiogenic shock takes place.

CP-41 CLINICAL RESULTS OF THE ENDOVASCULAR TREATMENT OF PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION

A.V. Arablinsky, Y.R. Khairutdinov, B.M. Tankhielevich

Botkin Hospital, Moscow, Russian Federation

Objective: The purpose of this study is to compare the different strategies of treatment of ST-elevation myocardial infarction (STEMI).

Methods: From January 2008 to October 2010, 452 patients (76% male) were treated with percutaneous coronary intervention (PCI). Mean age of the patients was 68.1+8.3 years, range from 29 to 85 years. Major risk factors included arterial hypertension (78%), hypercholesterolemia (68%) and smoking (66%). Diabetes mellitus was diagnosed in 81 (18%) patients. The most common affected artery was left anterior descending artery 232 (51%), then right coronary artery 146 (32%) and left circumflex artery 74 (17%). In the vast majority of cases PCI was completed with the stent implantation (bare metal stent or drug eluting stent). Before the procedure all patients received clopidogrel 600 mg and aspirin 325 mg. All patients were randomized into the three groups. The first group (primary PCI) consisted of 123 patients (27%) in whom primary PCI was performed in 12 h from the beginning of angina. The second group consisted of 214 patients (47%) in whom fibrinolytic therapy was started first. Depending on the results of fibrinolytic therapy the second group was divided into the two subgroups: 2-a subgroup – 164 patients (76%) with the successful fibrinolytic therapy and 2-b subgroup – 50 patients (24%) with the failure of fibrinolytic therapy. In the 2-a subgroup PCI was performed in the 6–24 h period from the beginning of fibrinolytic therapy (pharmaco invasive strategy) and in the 2-b subgroup rescue PCI was performed in the 2–3 h period from the beginning of fibrinolytic therapy. The third group consisted of 115 patients (26%) in whom fibrinolytic therapy was started first and reperfusion of infarct-related artery was achieved. In this group PCI was performed during hospitalization in the case of recurrence of the angina or positive results of the stress test.

Results: Primary angiographic success was achieved in 441 (97%) of patients. During hospitalization 14 (3%) patients died: 6 (4.8%) in the first group, three (1.8%) in the 2-a group, three (6%) in the 2-b group and two (1.7%) in the third group. In the 18 (4%) patients recurrent myocardial infarction happened: four (3.2%) in the first group, two (1.2%) in the 2-a group, four (8%) in the 2-b group and eight (6.9%) in the third group (P>0.05). Among these patients emergent PCI was performed. The risk factors of the hospital mortality was: cardiogenic shock, multivessel coronary artery disease, ejection fraction lower than 40%, myocardial infarction of the anterior wall of the heart.

Conclusions: The current analysis demonstrates efficiency and safety of endovascular procedures in the treatment of patients with STEMI. Pharmacoinvasive strategy of treatment of patients with STEMI was characterized with decrease in hospital mortality rate and recurrence of angina, however large randomize studies are needed to confirm this results.

CP-42 IMPACT OF BORDERLINE NON-CORONARY STENOSIS ON ADVERSE CARDIOVASCULAR EVENT DEVELOPMENT IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING

K. Shafranskaya, O. Barbarash, V. Kashtalap, L. Barbarash

Institution of the Russian Academy of Medical Sciences, Research Institute for Complex Issues of Cardiovascular Diseases, Siberian Branch of the Russian Academy of Medical Sciences, Kemerovo, Russian Federation

Objective: Evaluate the impact of borderline significant non-coronary lesions on the long-term outcomes of patients who underwent coronary artery bypass surgery (CABG).

Methods: The study enrolled 232 patients who underwent CABG in 2006. All patients had an ultrasound examination of extracranial arteries and lower limb arteries done preoperatively with the degree of non-coronary atherosclerosis measured. Group I included patients with hemodynamically significant stenosis of 50% and more (n=25, 11%), group II, patients with borderline significant stenosis of 30–50% (n=81, 35%) and group III, patients with hemodynamically insignificant stenosis of <30% (n=126, 54%). The patients of group I and II showed an higher functional classes of angina pectoris and heart failure (HF), than the patients of group III. All patients underwent on-pump CABG. All the groups were assessed for the frequency of major adverse cardiovascular events, such as cardiac death, myocardial infarction (MI), stroke, rehospitalization for unstable angina or decompensated heart failure. These events were considered to be adverse outcomes of CABG.

Results: Group III patients less often developed MI than group II patients: three (2%) vs. 12 (15%), respectively (P=0.002). Only three (2%) patients of group III developed strokes compared with nine (11%) patients of group II and five (20%) patients of group I (P<0.05). Unstable angina episodes were less often observed in patients with no polyvascular disease than in the patients with hemodynamically significant or borderline significant stenosis (P=0.000). Cardiac death was less often observed in the patients with no polyvascular disease than in patients with borderline significant lesions: one (0.8%) vs. nine (11%), respectively (P=0.002). Thus, combined long-term adverse outcome of CABG was more often seen in patients with more than 50% and borderline stenosis than in the patients without any non-coronary lesions: 21 (84%) and 70 (86%) individuals (P>0.05) vs. 34 (27%) patients (P=0.0001).

Conclusions: Borderline significant non-coronary stenosis of 30–50%, as well as haemodynamically significant stenosis, are associated with adverse long-term CABG outcomes and should be taken into account preoperatively.

CP-43 TRANSCATHETER OCCLUSION OF THE CORONARY-RIGHT VENTRICULAR FISTULA

D.A. Zverev, A.E. Pavlov, D.L. Monosov

Almazov Federal Centre Heart, Blood and Endocrinology, Saint-Petersburg, Russian Federation

Objective: To evaluate acute results of transcatheter occlusion of the coronary-right ventricular fistula (CRVF).

Methods: During the period from December 2009 to February 2010, three patients (aged from 36 to 42 years) with a loud constant noise in the middle third of the sternum, with moderate dilatation of the heart chambers (but not impaired ejection fraction) and clinical manifestations of heart failure and angina underwent attempted transcatheter occlusion CRVF. Selective coronary angiography (CA) with catheterization of the heart chambers and calculation of the degree of dumping blood into the bypass was performed in patients. In all patients, the magnitude of pulmonary pressure slightly exceeded the upper limit of normal (37–39 mmHg). After assessing the hemodynamic significance of the shunt (Qp/Qs ratio from 1.98 to 2.39) and evaluating the technical possibility of intervention, antegrade access through micro catheter ‘Transit’ (Cordis) 2.4 F, with coils ‘Trufill’, was performed transcatheter embolization of the CRVF. All major branches of the fistula embolize selectively with the two series of implanted coils. Patients constantly took aspirin (100 mg) and for the prevention of thrombolytic complications during the intervention intravenous heparin (100 IU per kg body weight). To assess the effect of all patients through 30 min after implantation of coils selective CA was performed. Puncture clip hole with a device ‘StarClose SE’. Before the intervention and before discharge echocardiography with the assessment pressure in the right chambers of the heart and the calculation of pulmonary artery pressure (PA) was performed.

Results: In all patients, fistula fell into the right ventricle: for one patient – fistula began in the distal right coronary artery and continued for one barrel to the confluence, at other – started short common trunk, retreating from the proximal LAD divided into two equivalent of the receptacle, at third – started a short single trunk departing from proximal LCx and then divided into two equivalent of the vessel. The total number of implanted coils was six, with the diameter of 3–5 mm. All patients achieved complete occlusion of the fistula. There were no complications during the intervention. After a day according to echocardiography in all patients, the pressure in PA was not exceeded.

Conclusions: Transcatheter closure of the CRVF is an effective and safe method of treatment, which reduces the risk of perioperative complications. It may be a good alternative to operations in terms of artificial circulation.

CP-44 OUTCOME OF CARDIAC SURGICAL INTERVENTION FOR COMPLICATED ACUTE MYOCARDIAL INFARCTION

V. Kertsman, M. Bozhko, Z. Beckerman, O. Cohen, A. Ziser, A. Kopit, S. Diab, G. Bolotin

RAMBAM Medical Center, Haifa, Israel

Objective: In-hospital mortality rate for patients with complicated ST-elevation myocardial infarction, cardiogenic shock, mitral papillary muscle rupture, ventricular septal rupture, and post-myocardial infarction VSD varies between 9 and 55%. Treatment of acute myocardial infarction had the major evolution since the aim of percutaneous coronary intervention, but mortality is still extremely high. The objective of this study was to evaluate early and late results and the surgical approach to the treatment of complicated acute myocardial infarction.

Methods: Retrospective analysis of patients with complicated acute myocardial infarction that underwent urgent or emergent cardiac surgery in our institute was performed. Preoperative, intraoperative and postoperative data was collected and analysed.

Results: Between 2000 and 2009, a total of 328 patients were admitted to our department for cardiac surgery due to complicated myocardial infarction. Out of which 145 (44.21%) patients (mean age 64.93±8.13 years) underwent emergent surgery. Sixty-five (44.82%) patients had a complicated ST-elevation myocardial infarction with one or more of the following complications: cardiogenic shock, papillary muscle rupture, pulmonary edema, myocardial rupture, post-myocardial infarction VSD and post-myocardial infarction unstable angina. Forty-six (31.72%) patients required the support of an intra-aortic balloon pump prior to surgery. Thirty-day mortality in patients who underwent an emergent surgery was 13.1%. Six patients (4.13%) were operated due to ventricular septal rupture, six (4.13%) due to post-myocardial infarction VSD, 25 (17.24%) due to acute mitral regurgitation, and 37 (25.51%) due to post-myocardial infarction cardiogenic shock. Their respective 30-day mortality rates were: 16.6%, 50%, 24%, and 31.13%.

Conclusions: Among patients with post-myocardial infarction VSD, emergent operation did not significantly reduce their 30-day mortality. In patients with acute ST-elevation myocardial infarction and acute myocardial rupture, emergent operation significantly reduced 30-day mortality, and prevented possible serious complications.

CP-45 FUNCTIONAL STATE of SURGICALLY AND MEDICALLY TREATED PATIENTS WITH LEFT VENTRICULAR ANEURYSM AND MULTIVESSEL CORONARY DISEASE

L.N. Ivanova

Nikityuk T.G., Saint Petersburg, Russian Federation

Objective: A comparative study of functional state and survival rate was performed in 234 patients with left ventricular aneurysm (LVA) and multivessel coronary disease over 10-year period. Mean age of these patients were 48.2±8 (29–69 years old). One hudred and twenty-four patients underwent surgery. Sixty-two of these (1 group) had aneurysm resection and one coronary artery bypass grafting (CABG), 62 patients had aneurysm resection and three and more CABG (2 group) 110 patients received medical therapy (3 group). The groups of medically and surgically treated patients were functionally comparable. Before surgery most patients belonged to 3–4 functional grade of NYHA: in group 1 – 85.5%; 2 – 80%; 3 – 80.6%. Heart failure with ejection fraction below 0.4 was found in 48.8%; 59.7%; 36.6% in groups 1, 2, 3, respectively.

Methods: Graded exercise tests with gas analysis were conducted before and after surgery to evaluate the changes of cardiorespiratory function.

Results: In long-term period surgically treated groups of patients showed marked remission both of angina and heart failure. 62.1% (group 1), 88.7% (group 2) entered 1–2 NYHA functional grade. Patients who had graded exercise tests done before and after surgery improved in peak VO₂, peak workload, and peak MET levels, their peak exercise double product and systolic blood pressure in both groups. Nevertheless, these changes were more pronounced and reliable in patients of second group (P<0.01). We believe that coronary artery bypass surgery improves exercise capacity in selected patients with compromised left ventricular function. Medically treated group of patients did not show marked dynamics in functional state. The actuarial survival rate in five-year period was in group 1 – 44.9%; 2 – 74.1%; 3 – 46.4%, in 10 years – 38.4%; 63.9% and 7% correspondingly.

Conclusions: Thus, surgical treatment with complete revascularization improves functional state and survival rate in patients with LVA and multivessel coronary disease.

CP-46 DYNAMICS OF NEUROPHYSIOLOGIC PARAMETERS IN CORONARY HEART DISEASE PATIENTS WITH INTERNAL CAROTID ARTERY STENOSIS UNDERGOING CORONARY BYPASS SURGERY

O.A. Trubnikova, I.V. Tarasova, A.I. Artamonova, I.D. Syrova, O.L. Barbarash

Research Institute for Complex Issues of Cardiovascular Diseases, Siberian Branch of the Russian Academy of Medical Sciences, Kemerovo, Russian Federation

Objective: Cognitive function impairment is often present in patients with internal carotid artery (ICA) stenosis but the details of this dysfunction have been rarely reported. The purpose of this study was to evaluate the dynamics of neurophysiologic parameters depending on the presence or absence of ICA stenosis in patients with coronary heart disease (CHD) undergoing coronary artery bypass grafting (CABG).

Methods: The study enrolled two groups of CHD males, 30 patients without ICA stenosis and 14 individuals with the disease. The patients of both groups were comparable in clinical characteristics, as well as psychosomatic status. The mean age of patients was 55.1±5.31 years in the group without ICA stenosis and 55.8±5.78 years in the group with the disease. The following neurophysiologic characteristics were evaluated: a simple visual-motor reaction (SVMR), the level of functional mobility of nervous processes with and without extrinsic rhythm (FMNP and FMNP ER) using a modified automated Status-PF method (Ivanov, 2001). The study was conducted by ICA color duplex scanning device (Hewlett-Packard, USA). ICA stenosis did not exceed 50%, and bilateral lesions of the internal carotid arteries were found in 29% of patients. All the studies were performed before and 10 days after CABG. Statistical processing of the data was done with the non-parametric Wilcoxon’s test.

Results: No development of focal neurological symptoms and other neurological complications was observed in both groups after CABG. The patients without ICA stenosis showed better results at day 10 after CABG compared with baseline data on the reaction rate by SVMR test (P=0.002), reaction time and speed by FMNP test (P=0.0007 and P=0.004) and the number of missed signals by FMNP ER test (P=0.02). No dynamics of neurophysiologic parameters or even a tendency to their impairment was found in patients with ICA stenosis.

Conclusions: The results showed that even the presence of 50% ICA stenosis leads to the absence of postoperative dynamics of neurophysiologic parameters in patients undergoing CABG, in contrast to patients without ICA lesions. This finding lets us assume that the group of patients with ICA disease is a high-risk group for cerebrovascular complications after CABG.

CP-47 REAL-TIME GRAFT FLOW ASSESSMENT BY EPIGRAPHIC ULTRASOUND IN OFF-PUMP CABG

S. Takahashi, M. Kuroda, K. Orihashi, K. Imai, T. Sueda

Hiroshima University Hospital, Hiroshima, Japan

Objective: Real-time graft flow assessment using ultrasound echo in the operative field has been performed to immediately ascertain the patency in off-pump CABG (OPCAB).

Methods: OPCAB was performed in 47 patients from January 2010 to December 2010. The number of harvested grafts were 43 of LITA, 25 of RITA, 10 of GEA and 42 of SVG. In 43 patients perioperative graft flow was measured by epigraphic ultrasound. Measured parameters were as follows: peak and mean velocity and velocity ratios (pV, mV, pVR, mVR, respectively), velocity time integral (VTI) and integral ratios (VTIR). pVR and mVR were determined by dividing the diastolic pV by systolic pV and the diastolic mV by systolic mV, respectively. TVIR was determined by dividing the diastolic VTI by the systolic VTI. Parameters used for calculations were obtained by averaging over five cardiac cycles. These parameter was analysed in each type of grafts.

Results: The number of distal anastomoses was 139 and overall patency by coronary angiography was 96.4% (134/139). In all grafts, graft flow was observed clearly. The causes of occlusion were as follows; almost no flow in one (SVG), flow competition in three (2 SVG and 1 GEA), and native coronary injury in one (SVG). In the case of no flow, native coronary flow was very few in coronary angiography. Flow competition was clearly observed by epigraphic ultrasound. The pVRs were 1.736, 0.954 and 0.919 in ITA, SVG and GEA, respectively. The mVRs were 1.947, 1.389 and 1.097. The pVR and mVR in SVG is significantly smaller than that in ITA. TVIRs were 5.208, 2.314 and 3.468. The TVIR in SVG is significantly smaller than that in ITA. Epigraphic flow pattern reflected in the postoperative angiograftic flow pattern.

Conclusions: In this series, epigraphic ultrasound depicted graft flow clearly. To-and-fro flow pattern predicted graft occlusion. Although SVG graft flow showed systolic velocity dominant pattern due to graft and native coronary size mismatch, no graft occlusion occurred without to-and-fro. Although competitive flow in angiography does not always mean the graft occlusion, epigraphic ultrasound may be useful to prevent graft occlusion in off-pump coronary artery bypass and in case of no flow and to-and-fro flow, immediate re-repair can be performed to salvage the involved coronary artery. To improve the patency, further investigation is needed.

CP-48 ECHOCARDIOGRAPHIC PREDICTORS OF HEART FAILURE IN PATIENTS WITH CORONARY ARTERY DISEASE (CAD) IN SHORT-TERM PERIOD AFTER THE GEOMETRICAL RECONSTRUCTION OF LEFT VENTRICLE POSTINFARCTION ANEURYSM

N.O. Sokolskaya, L.A. Bockeria, M.D. Alshibaya, A.V. Naumova

Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: To study the intraoperative peculiarities of the left ventricle (LV) function using transesophageal echocardiography (TEE) in patients with CAD and postinfarction aneurysm after the geometrical reconstruction of left ventricle in combination with coronary artery bypass grafting (CABG); to reveal echocardiographic predictors of postoperative complications.

Methods: Intraoperative TEE has been performed in 76 patients (mean age – 52 years) with CAD and postinfarction aneurysm. Eight-three percent of patients were in class III/IV by NYHA. All patients underwent geometrical reconstruction of the left ventricle with the use of synthetic patch in combination with CABG. TEE was performed on ACUSON CV70 (SIEMENS) with the transesophageal V5M transducer from the standard four-chamber view. The following indices have been estimated: CI, ESVI, EDVI, SI, EF of LV, indices of obliquity and sphericity, degree of LV reduction, velocity parameters and the property of blood flow in the chamber of LV.

Results: All patients were divided into two groups. The first group included 56 patients with non-complicated postoperative period. Twenty patients with complicated postoperative period due to HF formed the second group. The first group showed adequate pumping and contractile myocardium ability: SI – 44.7±9 ml/m², CI – 3.9±0.8 l/min/m², LVEF – 46.4±6%. The degree of LV reduction was 27±10%. Structural-geometrical parameters of LV normalized as the result of the performed operation. In the second group of patients with complicated postoperative period low pumping ability of LV has been observed (LVEF – <40%). After the reconstruction, the LV reduced to 37±11%, geometrical parameters of LV were not normalized. During the study we found out regularities of velocity parameters of blood flow in the chamber of LV in patients with non-complicated and complicated postoperative period. In patients with complicated postoperative period considerable decrease of blood flow velocity in LV was observed, mosaic phenomenon was registered.

Conclusions: Echocardiographic predictors of complicated early postoperative period in patients after geometrical reconstruction of postinfarction left ventricle aneurysm in combination with CABG are: LVEF <40%, LV reduction more than 37%, absence of normalization of structural-geometrical parameters of LV, low velocity parameters of the intraventricular blood flow – all measurements being collected immediately after the main operation stage with the application of intraoperative TEE method.

CP-49 FUNCTIONAL STATE OF THE MYOCARDIUM AS JUDGED BY THE DATA OF TISSUE MYOCARDIAL DOPPLEROGRAPHY IN EARLY POSTOPERATIVE PERIOD AFTER VARIOUS TECHNIQUES OF CABG

I.V. Koksheneva

Bakoulev Scientific Center for Cardiovascular Surgery Moscow, Russian Federation

Objective: To analyse the state of the myocardium on the base of tissue myocardial Dopplerography in early postoperative period after CABG performed with the use of various techniques.

Methods: The study comprised 74 patients with coronary artery disease (CAD). The patients were divided into four groups depending on the technique and the extent of performed surgery: Group 1 (7 patients) – coronary artery bypass grafting on the beating heart. Group 2 (36 patients) – CABG on the beating heart under normothermia and parallel EC. Group 3 (12 patients) – CABG under EC, hypothermia and pharmaco-cold CP. Group 4 (19 patients) – CABG and the correction of concomitant structural cardiac pathology (resection of postinfarction LV aneurysm, correction of valvular pathology) under EC, hypothermia and pharmaco-cold CP.

Results: Early after CABG without cardiopulmonary bypass, patients developed disturbances of LV myocardial function, mainly in the form of disturbed diastolic characteristics, manifested by the decrease of segmental late diastolic velocities A, with preserved contractile myocardial function. The patients operated on beating heart under parallel EC developed systolic and diastolic (decrease of late diastolic velocities A) dysfunction of ventricular myocardium. By the ninth day after the operation there was a stepwise but incomplete restoration of segmental contractility of LV myocardium with the maintenance of its diastolic disturbances. The patients operated under EC and CP had no significant disturbances of LV myocardial function after surgery. At the same time, they had developed late diastolic dysfunction of LV myocardium (decrease of late diastolic velocities A). By the ninth day after the operation a reliable improvement of systolic and diastolic function of LV myocardium as compared with the preoperative indices, was registered.

Conclusions: The comparison of functional state of the myocardium after different techniques of CABG revealed the best myocardial indices in patients after coronary artery bypass grafting without cardiopulmonary bypass: systolic function of the LV remained non-disturbed, and only the disturbances of segmental diastolic function in late diastole. The comparison of functional state of the myocardium in the groups of patients operated on the beating heart with hemodynamic support using EC and under EC and CP did not reveal the advantages of the technique of surgery on beating heart using parallel EC over the ‘standard’ technique of CABG, in terms of postoperative state of the myocardium.

CP-50 THE GIANT SAPHENOUS VEIN GRAFT ANEURYSM RESOLVED ON THE BEATING HEART

I. Bilbija, S. Putnik, M. Velinovic, B. Nikolic, A. Djordjevic, V. Jovicic, M. Vranes, M. Ristic

Clinic for Cardiac Surgery, Belgrade, Serbia

Objective: The true vein graft aneurysm is a rare late complication of CABG surgery. The treatment of choice is aneurysm resection and re-revascularization of the area of the myocardium previously supplied by the diseased graft. To the moment all reported cases were operated on using CPB on the arrested heart. Due to the advanced age, former cerebrovascular accident, renal dysfunction and low ejection fraction we decided to perform aneurysm resection and bypass grafting on the beating heart.

Methods: Seventy-three years old male patient with renal dysfunction and former cerebrovascular accident was admitted to thoracic surgery clinic because of chronic cough, haemoptysia and dyspnea. Twenty-seven years ago he underwent CABG with vein grafts to LAD and RCA. RTG, CT and transesophageal echo revealed solid mass in the lower front mediastinum with dimensions 8×10 cm. Coronarography showed a giant aneurysm of the otherwise patent vein graft for RCA with good distal runoff.

Results: After sternotomy and adhaesiolysis the aneurysm was located and the diagnosis confirmed. The proximal anastomosis of the new vein graft on the ascending aorta was done first following by the aneurysm resection and distal anastomosis on the proximal PD performed off-pump.

Conclusions: The true vein graft aneurysms in CABG surgery are extremely rare (<1%), with late manifestation. They should be included in the differential diagnosis of mediastinal masses in patients, who formerly underwent CABG. Usually they present complications as rupture, atheroembolisation – myocardial infarction, compression. The treatment of choice is aneurysm resection with re-revascularization.

CP-51 FACTORS ASSOCIATED WITH 24-Hour MORTALITY IN ACUTE MYOCARDIAL INFARCTION PATIENTS

R. Tarasov, V. Ganyukov, N. Bokhan, P. Shushpannikov, G. Moiseenkov, O. Barbarash, L. Barbarash

State Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation

Objective: Unfortunately, even among a cohort of patients with acute myocardial infarction (AMI) admitted to a cardiac clinic with Percutaneous Coronary Intervention Centre (PCI-Centre) where it is possible to perform PCI, CABG and thrombolysis 24/7, the hospital mortality may exceed 10%. The factors associated with 24-h mortality in AMI patients were analysed.

Methods: There were 1008 AMI patients treated in our Cardiac Clinic with 24/7 PCI capacity in 2009. Overall hospital mortality was 12%. A retrospective analysis of 121 patients with a verified diagnosis of AMI with fatal outcome was completed. The patients were assigned into two groups: Group 1 (<24) included patients with a fatal outcome during 24-h after admission to hospital (n=40) and Group 2 (>24) included patients with a fatal outcome occurred 24 h after admission to the clinic (n=81). There was a multifactorial analysis done on the basis of comparison groups. Demographic, clinical and angiography factors were analysed.

Results: The study showed statistically significant differences between Group 1 (<24) and Group 2 (>24) in the following: percentage of women (63% vs. 57%, respectively), time ‘symptom-to-door’ <12 h (73% vs. 63%), left ventricular ejection fraction (LVEF) (34.5% vs. 40.8%, respectively), the proportion of patients who underwent coronarography and PCI (28% vs. 16%, respectively), percentage of use intra-aortic balloon counterpulsation (IABC) (30% vs. 1.23%), left main coronary artery (LMCA) stenosis+3 vessel (LMCA+3) (21% vs. 3%, respectively), unsuccessful PCI (36% vs. 23%, respectively), ‘no-reflow’ syndrome (27% vs. 7.7%, respectively) (P<0.05).

Conclusions: The following factors associated with 24-h hospital mortality in AMI patients in a cardiac clinic: 1. Demographic: female (OR 1.23; 95% CI). 2. Clinical: time ‘symptom-to-door’ <12 h (OR 1.55; 95% CI), LVEF <40%, a significant proportion of patients with completed coronarography, PCI (OR 2.0; 95% CI) and IABC (OR 3.44; 95% CI) using. 3. Angiographic: LMCA+3 (OR 10; 95% CI), ‘no-reflow’ syndrome during PCI (OR 4.75; 95% CI). 4. Predictors, associated with PCI: unsuccessful PCI (OR 1.8; 95% CI).

CP-52 ULTRASOUND TRANSCRANIAL MONITORING DURING ON-PUMP CARDIAC SURGERY UNDER CARDIOPULMONARY BYPASS

E.F. Dutikova, S.V. Fedulova, T.U. Kulagina, O.M. Arutunyan, I.O. Shederkina

Russia National Research Centre of Surgery, Moscow, Russian Federation

Objective: To develop an algorithm estimation of cerebral blood flow based on transcranial ultrasound and Doppler embolodetection.

Methods: Two hundred and ten patients (men – 191, women – 19). The average patient age was 63±5 years. One hundred and seventy-eight patients underwent CABG surgery, 18 – combined surgery CABG+CEA, 8 – CABG+resection of an aneurysm of the left ventricle, and 6 – CABG+mitral valve plastic reconstruction. Algorithm research – ultrasound extra and intracranial arteries, transcranial monitoring of the holding of functional load tests (BIOSS, Russia). Performed intraoperative registration of hemodynamic parameters, bilateral monitoring in the MCA; automatic detection.

Results: Before surgery in patients without circulatory disorders and in patients with pathological signs impaired blood flow in the brain, stress tests are one-way action. During hypocapnic sample blood flow velocity in MCA is reduced in patients without signs of disease on average by 42% compared with the outcome, whereas in patients with vascular pathology, it decreases by 17%. Isometric load – accompanied by the increase of the average flow velocity by 49% and 11%, respectively. Intraoperatively, in all patients enrolled in the study was registered microembolic signals (MES). ‘Red’ embolus, consists of many agglomerated dense particles (sludge). Such MES are well localized in the bloodstream, slight excess of power, the distribution of frequency response from 190 to 400 Hz. The maximum duration of such MES is 100 ms. ‘White’ MES – 15–35 ms and a capacity of up to 35–40 dB. When details an MES, it was noted that the nucleus is well localized in the spectrum of blood flow, has clear path, expressed as the excess signal power, frequency response is distributed from 400 to 600 Hz, maximum duration of such a signal up to 100 ms. Studying the dynamics of the velocity of blood flow in conditions of artificial circulation during perfusion were registered awarded a lower speed in moderate hypothermia, is not beyond the permissible values. The critical threshold to reduce the blood flow velocity during cardiopulmonary bypass – 25 cm/s.

Conclusions: The monitoring during cardiac surgery allows the timely detection of episodes of hyper- and hypoperfusion of the brain microemboli cerebral arteries and timely implementation of curative measures for protecting the brain. Stress tests to assess blood flow in the vessels of the brain and transcranial monitoring is a highly sensitive diagnostic technique and it is an integral part of the protocol before and during operations with artificial circulation.

CP-53 OUTCOMES OF EMERGENCY CORONARY ARTERY BYPASS GRAFTING IN ACUTE CORONARY SYNDROME

K. Bhandari¹, P.N. Kordatov², A.A. Kozlov², Y.V. Kordatova², V.G. Petrenko², A.L. Maksimov², M.V. Ryazanov², A.P. Medvedev¹

¹Nizhny Novgorod State Medical Academy, Nizhny Novgorod, Russian Federation; ²Specialized Cardiac and Vascular Surgery Clinical Hospital, Nizhny Novgorod, Russian Federation

Objective: To evaluate the short-term outcomes of emergency coronary artery bypass grafting (CABG) in patients with acute coronary syndrome.

Methods: Over a six-year period from 2005 to 2010 total 1142 CABGs were performed, out of which 52 (4.5%) operations were emergency CABG in patients with acute coronary syndrome (ACS). The inclusion criteria were: acute coronary syndrome (unstable angina, non-Q myocardial infarction), acute Q myocardial infarction (AMI) without cardiogenic shock. 76.92% male, mean age 58.038±776 years (ranged from 39 to 73 years). Among patients 92.3% (48) with ACS, and four (7.7%) with AMI. Comorbidities: hypertension 100%, type 2 diabetes mellitus 11.53% (6) and extracardiac arteriopathy 53.84% (28). At the time of admission, all patients were assigned to the III–IV functional class according to NYHA. Standard preoperative examinations including emergency selective coronary angiography were performed, among them 96.15% had 2–3 vascular lesions with occlusion of 1–2 main arteries. Logistic EuroSCORE value was used to assess preoperative risk (mean value 19.48±13.02%, ranged from 7.33 to 71.68%). In connection with acute heart failure and hemodynamic instability in 19.23% (10) patients intra-aortic balloon counterpulsation (IABP) was introduced in perioperative period.

Results: Complete revascularization was done in all patients (revascularization index 2.98±1.09). In 59.61% (31) cases arterial and venous conduits were used. On-pump CABG in normothermia with cardioplegic solutions (Consol, Kustadiol) was carried out in 94.23% (49) cases. Extended anterior descending artery anastomosis was performed in eight patients including endarterectomy in two cases. Mean bypass time – 89.42±30.61 min, mean aortic cross-clamping – 53.3±18.22 min. LVEF 53±6.64% (vs. 49.19±8.14% preoperative); EDV 108.15±31.33 ml (vs. 110.34±34.2 ml preoperative); ESV 52.84±22.53 ml (vs. 57.69±27.12 ml). Total hospital mortality was 15.38% (8). Causes of death were congestive heart failure due to repeated extensive transmural MI – 5, multiple organ failure – 1, ventricular fibrillation – 1, and acute heart failure due to aortic cannulation site bleeding – 1.

Conclusions: Emergency CABG is accompanied by higher mortality rates and technical difficulties during operation. Active surgical management of patients with ACS and AMI without cardiogenic shock gives a satisfactory result. Excellent outcomes with low mortality can be achieved with Introducing standard protocol in the management including: preoperative IABP, perioperative cardiac output monitoring with Swan–Ganz catheter, immediate complete revascularization and adequate myocardial protection.

CP-54 THE USE OF ARTERIAL GRAFTS DURING OFF-PUMP CORONARY ARTERY BYPASS GRAFTING

D. Kartashev, S. Lutinskiy, A. Naimushin, M. Gordeev

Federal Almazov Heart, Blood and Endocrinology Center, St. Peterburg, Russian Federation

Objective: The effect of coronary artery bypass grafting (CABG) lasts as long as the grafts are patent. The internal mammary artery has been considered the ‘golden’ graft due to the superb long-term patency, exceeding 90% at 10 years. The saphenous vein grafts, unfortunately, tend to occlude with a rate of 10–15% within a year after surgery, and eventually, at 10 years after the operation, as much as 60–70% of these vein grafts are either occluded or have angiographic evidence of atherosclerosis. The research of another ‘arterial conduit’, the radial artery, has intensified through the last 15 years in hope to provide a better graft than the saphenous vein for CABG. This article reviews the current knowledge for the radial artery as a conduit in CABG.

Methods: The effect of coronary artery bypass grafting (CABG) lasts as long as the grafts are patent. Between January 2006 and September 2010, a total of 231 patients underwent CABG at our center. They were divided into two groups. The first group (n=117) underwent off-pump coronary artery bypass grafting (OPCAB). In the second group (n=120) on-pump coronary artery bypass grafting with cardioplegia was performed. All patients underwent complete revascularization using arterial grafts (internal thoracic arteries, radial arteries) and saphenous vein grafts.

Results: The purpose of this research is to show an opportunity of successful performance of OPCAB with arterial grafts. We concluded that the absence of anoxic period during OPCAB decrease the risk of myocardium damage. It allows avoiding complications, decreasing the time of artificial ventilation and ICU stay.

Conclusions: The use of arterial grafts during OPCAB will be the perspective way.

CP-55 EMERGENCY MANAGEMENT FOR ACUTE TOTAL LEFT MAIN CORONARY ARTERY OCCLUSION

E. Kurc, O. Sokullu, N.A. Aydemir, B. Ozay, M. Sargin, A. Aykut, M.M. Demirtas

Dr. Syam ERSEK Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey

Objective: Acute left main coronary artery occlusion is rare but often fatal. The purpose of this study is to delineate the survival rates of patients with acute left main coronary artery occlusion who underwent myocardial revascularization.

Methods: The survival outcome of 32 patients with acute left main coronary artery occlusion (mean age 62.87±10.85 years; 81.3% males), who underwent surgical revascularization, were examined. The preoperative clinical and demographic variables and postoperative follow-up were collected retrospectively to detect predictors of outcome and risk-adjusted survival rates of the patients.

Results: Early mortality was 37.5% with 12 patients. Early mortality rate was found significantly higher in patients above 65 years of age and patients with retrograde collateralization from the right coronary artery. The effect of female gender, diabetes mellitus, hypertension and intraaortic balloon pump usage were not found as significant risk factors for early mortality (P>0.05).

Conclusions: Although the early mortality rate is high, coronary artery bypass graft operation is still the technique of choice for myocardial revascularization in patients with acute left main coronary artery occlusion. In patients with hemodynamic instability and without good collateral flow from right coronary artery, percutaneous intervention may be performed as bridge to the operation.

CP-56 EARLY AND LATE OUTCOME AFTER CORONARY ARTERY BYPASS GRAFT SURGERY WITH CORONARY ENDARTERECTOMY

V.A. Podkamennyy, A.V. Eroshevich, D.I. Lichandi, E.E. Chepurnih

Irkutsk Regional Clinical Hospital, Irkutsk, Russian Federation

Objective: To compare early and late of coronary endarterectomy (CE) performed in addition to traditional coronary artery bypass grafting (tCABG) and off-pump coronary artery bypass graft surgery (OPCAB).

Methods: Between 2001 and 2008, 131 patients underwent CABG with coronary endarterectomy. Seventy-nine patients (60.3%) underwent OPCAB with CE (first group), 52 (39.7%) – tCABG with CE (second group). The retrospective analysis of early and late results of operations has been made. The following outcomes were compared: perioperative myocardial infarction, postoperative ventricular arrhythmias, bleeding, cerebrovascular accident, early and late mortality. The patients of the first group had a higher incidence of poor left ventricular function. At the majority sick – 81.67% CE it was carried out from the right coronary artery. The average size arteriotomy has made 1.8 mm (1–3.5 mm). In 90 cases (that makes 68.7%) conduit used – saphenous vein. Radial arteries it was used in six (7.6%) cases.

Results: In the results of operations there were significant differences on means of intensive therapy unit stay (one group – 1.67±0.51, two groups – 2.55±0.89 days, P<0.01), length of postoperative hospital stay (one group – 7.67±0.58, two groups – 10.29±3.53 days, P<0.01), occurrence of complications, such as postoperative a bleeding (one group – 0, two groups – 3 (5.77%), P<0.01) and cerebrovascular accident (one group – 0, two groups – 1 (1.92%), P<0.01). Differences were not significant on such parameters, as early mortality, postoperative myocardial infarction and unsuccessful CE. Actuarial analysis at three years and longer has shown no significant difference in the long-term survival rate (one group – 86.4%; two groups – 89.26%), and freedom from reoperation and myocardial reinfarction (one group – 89%; two groups – 91.2%).

Conclusions: Coronary endarterectomy performed in addition to traditional coronary artery bypass grafting and off-pump coronary artery bypass graft surgery have no significant difference the early and late outcome, however tCABG are accompanied by a great number of complications in the early postoperative period.

CP-57 FACTORS OF SURGICAL RISK IN PATIENTS UNDERGOING REPEAT CORONARY ARTERY BYPASS GRAFTING

V.K. Grebennik, M.L. Gordeev

Almazov Federal Heart, Blood and Endocrinology Center, St. Petersburg, Russian Federation

Objective: To analyse the factors of surgical risk in patients who underwent repeat coronary bypass surgery.

Methods: From 1991 to 2010 in the clinic Almazov Federal Heart, Blood and Endocrinology Center, 48 reoperations of coronary artery bypass grafting were performed. Among patients undergoing repeat coronary artery bypass surgery, 40 were men (95.3%), two were women (4.7%), average patient age was 53.3±8.6 years (range 42–68 years). Two patients (4.8%) had I–II functional class of angina, 40 patients (95.2%) III–IV functional class of angina (CCS). Myocardial infarction occurred in history in 28 (66.7%) patients. Index of revascularization was 2.6±1.1. As the grafts were used – internal thoracic artery in 22 (52.4%) patients, radial artery in eight (19.0%) patients, venous graft in 36 (85.7%) patients. The average time of surgery was 308.7±70.1 min. In the IR re-coronary artery bypass grafting was performed in 40 (95.2%) patients. The duration of the IR was 118, 4±45.1 min, aortic clamping time – 62.2±41.5 min. Hospital mortality was 4.7% (2), one (2.4%) patient died from acute cardiovascular insufficiency (operated on urgently) and one (2.4%) died of multiple organ failure. Low cardiac output syndrome was observed in 10 (23.8%), perioperative myocardial infarction in two patients (4.8%). Postoperative bleeding which required resternotomy was noted in two (4.8%) patients. In-hospital period clinic angina was absent in all patients. To fulfil this goal in patients undergoing repeat coronary artery bypass grafting were analysed 78 parameters by univariate correlation analysis for the presence of predictors of risk of cardiac events (death, myocardial infarction, intraoperative, low cardiac output syndrome).

Results: The analysis found that among patients – associated factors influence the lethal outcome are: low ejection fraction (correlation coefficient r-0.56), prior percutaneous coronary intervention (r-0.89), urgency of surgery (r-0.7). Among factors which influence the development of intraoperative myocardial infarction there are – acute coronary syndrome (r-0.5); form cardioplegia (r-0, 71), number of grafts (r-0.45), endarterectomy (r-0.66). Factors correlated with the appearance of a small release syndrome were as follows – the duration of anoxia (r-0.54); type of cardioplegia (r-0.6), number of grafts (r-0.49).

Conclusions: The results of factor analysis identified predictors of high surgical risk, among which most are operating factors. Further improvement of surgical approach and technique will significantly reduce the incidence of cardiac events in patients undergoing repeated coronary artery bypass grafting.

CP-58 WHAT ARE THE ADVANTAGES OF ADDITIONAL SURGICAL REVASCULARIZATION CORRECTION OF MODERATE MITRAL INSUFFICIENCY IN PATIENTS WITH ISCHEMIC CARDIOMYOPATHY?

E.N. Orekhova, S.G. Sukhanov

Perm Heart Institute, Perm, Russian Federation

Objective: Estimation of survival, echocardiographic data of postoperative remodeling and heart failure in patients with ischemic cardiomyopathy and moderate mitral insufficiency.

Methods: The study involved 402 patients aged 59.9±9.5 with LVEF 31±5.1% with moderate ischemic mitral insufficiency (24.4±4.5%), with three-vessel disease of coronary arteries, heart failure not lower than functional class III and echocardiographic signs of ischemic cardiomyopathy. Patients with postinfarction aneurysms of the left ventricle (LV) were excluded. In Group I (n=212) CABG (3.8±1.4 shunts) and mitral valve plasty were performed. In group II (n=190) isolated CABG (4±1.64 shunts) were performed. The mean observation time was 79±11 months (6.5 years).

Results: The cumulative survival rate in group I was 92.6%, in group II – 94.6% (P=0.61). In the dynamics in I, LVEF increased from 30.1±3.1% to 35±5.6% (P=0.001); ESV decreased (from 106.7±10.9 ml to 88±2.9 ml, P=0.003), EDV decreased (from 182.7±18.2 ml to 155±12 ml, P=0.0000), mitral regurgitation decreased (from 28±5.1% to 3.1±0.1%, P=0.001), functional heart failure class decreased (from 3.3±0.18 to 2.1±0.3). In patients of group II: EF did not change significantly (initially 30.9±2.9%, repeatedly – 30.6±3.7%, P=0.3), ESV (from 104, 7±18.7 ml to 106±9, 9 ml, P=0.45), EDV (from 169.2±14.6 ml to 167.8±10.4 ml, P=0.48), mitral regurgitation increased (from 21.7±5.3% to 30.1±6.6%, P=0.04), severity class of heart failure increased (from 3±0.3 to 3.5±0.1, P=0.001).

Conclusions: Surgical revascularization and correction of mitral insufficiency in patients with ischemic cardiomyopathy is accompanied by high clinical efficacy against the symptoms of heart failure, improves the structural, geometric and functional characteristics of the left ventricle in comparison with isolated coronary artery bypass surgery, which has a limited effect on controlling the symptoms of heart failure, and the processes of reverse remodeling of LV. Survival in groups during the observation time is comparable.

CP-59 SYSTEMIC USAGE OF TRANEXAMIC ACID IS SUPERIOR TO TOPICAL: RANDOMIZED PLACEBO-CONTROLLED TRIAL

D. Baric, D. Unic, I. Rudez, V. Bacic-Vrca, M. Planinc, D. Jonjic, Z. Sutlic

Dubrava University Hospital, Zagreb, Croatia

Objective: Tranexamic acid (TA) effectively reduces postoperative bleeding and transfusion requirements after cardiac surgery. Literature reports both systemic and topical usage of TA. We designed randomized, double-blinded, placebo-controlled trial to directly compare efficacy of systemic and topical TA usage.

Methods: Sixty adult patients scheduled for elective cardiac surgery with use of cardiopulmonary bypass were randomized into three groups to receive 2.5 g TA topically before sternal closure and placebo intravenously (group T), TA intravenously (6.5 mg/kg/h) and placebo topically (group S) or only placebo (group P). Redo and emergency cases were excluded. Groups were similar with respect to all preoperative and intraoperative comparisons. We evaluated postoperative bleeding, transfusion requirements and laboratory data.

Results: Postoperative bleeding within first 12-h period (group T 378±199 ml, group S 326±292 ml, group P 490±334 ml) showed statistically significant inter-group differences (P=0.027) with significant differences between group S and group P (P=0.008). Transfusion requirements were significantly lower (P=0.005) after systemic application: in group S 9 (47%), in group T 18 (95%) and in group P 14 patients (74%) received packed red blood cells. Postoperative values of d-dimers were lower after systemic TA usage, both immediately (group T 0.46 mg/l, group S 0.15 mg/l, group P 0.45 mg/l; P<0.001) and 24 h after surgery (group T 0.22 mg/l, group S 0.17 mg/l, group P 0.27 mg/l; P=0.006).

Conclusions: Although both methods of TA application reduce postoperative bleeding (39% in group S and 27% in group T), the reduction is significant only after systemic usage. Systemic application of TA is superior to topical usage in prevention of postoperative bleeding and reduction of blood product requirements apparently due to the more effective inhibition of fibrinolysis.

CP-60 ‘DON’T TOUCH AORTA’ TECHNIQUE IN OFF-PUMP CORONARY ARTERY BYPASS GRAFTING REDUCES THE INCIDENCE OF POSTOPERATIVE NEUROLOGICAL COMPLICATIONS

A.N. Shonbin, A.S. Zavolozhin, D.O. Bystrov, M.V. Elisarov, M.A. Yarkovoy

Department of Cardiac Surgery, Arkhangelsk Regional Hospital, Arkhangelsk, Russian Federation

Objective: To evaluate the efficacy of ‘don’t touch aorta’ technique in off-pump coronary artery bypass grafting (OPCAB) to prevent of postoperative neurological morbidity.

Methods: We included 283 patients who underwent primary OPCAB during 2010 with not <2 distal anastomoses in a retrospective study. The patients with simultaneous carotid endarterectomies were excluded. Proximal anastomoses were performed on ascending aorta using partial clamping in 170 (60.1%) patients and ‘don’t touch aorta’ technique in 113 (39.9%) patients, respectively. Data were analysed by SPSS 11.5 using parametric and non-parametric tests.

Results: The groups of partial clamping and ‘don’t touch aorta’ were comparable according to their demographic data. The EuroSCORE and the number of distal anastomoses for one patient were four (3–6) and three (2–3) for each group, respectively (median and 25th–75th percentiles). The use of left mammary artery in the partial clamping and the ‘don’t touch aorta’ groups was 98.8% vs. 100%, (P=0.25), bimammary grafting – 1.2% vs. 64.6%, (P<0.001), total arterial grafting – 4.1% vs. 68.1% (P<0.001), respectively. Hospital mortality was 0.6% vs. 1.8%, P=0.3. The incidence of postoperative neurological complications was higher when the operation was performed by partial clamping of aorta compared with ‘don’t touch aorta’ technique (3.5% vs. 0%, P=0.04). The partial clamping of aorta technique was also associated with a tendency to increased rate of strokes (2.3% vs. 0%, P=0.1) and delirium (1.2% vs. 0%, P=0.25).

Conclusions: Using ‘don’t touch aorta’ technique in OPCAB surgery reduces the incidence of postoperative neurological complications and it can improve the clinical outcome.

CP-61 COMPARISON OF THE RESPONSE OF THE RIGHT VENTRICLE WITH ENDOVASCULAR OCCLUSION AND SURGICAL CLOSURE IN ADULTS WITH ATRIAL SEPTAL DEFECT – ONE-YEAR FOLLOW-UP

M. Moradi, N. Samiei

Tehran University of Medical Sciences, Tehran, Iran

Objective: Right ventricle (RV) function is an important prognostic factor in patients with an atrial septal defect (ASD) after treatment besides quantitative assessment of RV is still a challenging due to its complex anatomy and thin wall structure, therefore RV is not incorporated into daily clinical practice and RV is a ‘forgotten ventricle’; tissue-Doppler-based techniques allow for quantification of myocardial function and measurements are mainly based on myocardial velocities and deformations which assess strain and strain rate. The objective of the present study was to compare strain and strain rate of RV in patients with an ASD after their endovascular occlusion and surgical after one year.

Methods: This cross-sectional study was performed between March of 2007 and November 2008 in the Shaheed Rajaei Cardiovascular Medical Centre. Totally, 38 patients (who had ASD one year before) were conveniently enrolled to this study and separated into two different groups: 20 (27±4 years 13/7 female/male) in a group with isolated surgical closure of secundum ASDs and other 18 patients (25±4 years and 12/6 female/male) in a group with percutaneous closure of secundum ASDs. At the same time, 31 age-matched normal subjects (age=26±6 years, 23 females, 9 males) were included as the control group. Age, size of shunt and RV function did not have any significant difference between two groups before intervention. Our study included patients with ≥18 years of age, significant left-to-right shunt, pulmonary and systemic blood flow (Qp/Qs) ratio >1.5 measured and the patients had sinus rhythm. Patients with moderate or severe valvular heart disease, or clinical evidence suggestive of coronary artery disease, hypertension, diabetes mellitus, or atrial fibrillation were excluded. Strain and strain rate of base and mid portion of free wall of the RV were measured one year after intervention. Analysis was performed based on paired t-test and one-way ANOVA.

Results: The mean values of strain of the midportion were – 26±11.7%, – 8.9±4.2%, and 24.5±7.4% (P, 0.001). Strain rates of the midportion were – 2.19±0.6 s^-1, – 1.2±0.4 s^-1, – 1.9±0.6 s^-1 (P, 0.001) in ASO, surgery, and control groups, respectively.

Conclusions: Strain rate imaging indices could provide new, non-invasive, clinically relevant insight into regional changes in RV function, based on this technique it seems RV may show better response to transcatheter approach than surgery in a long duration of time after procedure in adults.

CP-62 SURGICAL CORRECTION OF CONGENITAL HEART DISESASE COMBINED WITH TACHYARRHYTHMIAS

T. Kakuchaya, E. Golukhova, A. Revishvili, M. Dadasheva, F. Rzaev, L. Bockeria

Bakoulev Center, Moscow, Russian Federation

Objective: To assess the efficacy of surgical treatment of congenital heart diseases (CHD) combined with tachyarrhythmias (TA).

Methods: Two hundred and seventy-seven patients with CHD combined with TA at the mean age of 22.9±12.8 years old were operated in a 25 year period of time. All patients underwent surgical correction of CHD (septum defects, Ebstein’s anomaly, pulmonary veins anomalous drainage, atrioventricular canal) and TA (Wolff-Parkinson-White syndrome, ectopic supraventricular and ventricular arrhythmias, atrial fibrillation, nodal tachycardias). Routine examination, electrophysiological investigation and angiography were undertaken. For surgical elimination of TA in patients with CHD were used the same techniques as for the removal of isolated cardiac arrhythmias: cryoablation, Sealy operation, surgical isolation, epicardial electro destruction, laser isolation, radio frequency catheter ablation.

Results: Hospital mortality was 3.7%. In early postoperative period positive results were obtained in 85.7% of patients, in long-term follow-up – in 70.5% patients.

Conclusions: Based on the analysis of short- and long-term follow-up results, it can be assumed that simultaneous surgical correction of CHD and TA is efficient management tactics of combined pathology, which substantially prolongs patients’ lives and improves quality of life.

CP-63 ANALYSIS OF LONG-TERM RESULTS OF CELL THERAPY FOR THE MYOCARDIAL REGENERATION IN PATIENTS WITH EBSTEIN’S ANOMALY

L. Bockeria, M. Eremeeva, U. Kolesnikova, A. Svobodov, V. Cheban, S. Aleksandrova, V. Makarenko

Bakoulev Scientific Center for Cardiovascular Surgery Russian Academy of Medical Science, Moscow, Russian Federation

Objective: The objective estimation of the long-term results of the intramyocardial delivery of stem cells in patients is one of the unsolved problems nowadays. The research data cannot always be extrapolated to the clinical situation. The main value of this investigation was the choice of the clinical ‘model’ for the research. We have been studying effectiveness of cell therapy using the nature model since 2006: atrialized part of right ventricle (RV) in Ebstein’s anomaly. The main method of treatment of patients with Ebstein’s anomaly is the surgical correction of congenital defects. But as a rule restoration of the structure and function of the tricuspid valve and normalization of intracardiac hom*odynamic does not lead to the increase of thickness of RV, which could be attained due to the stimulation of the proliferation activity of the cardiomyocytes of thin RV wall. The injection of autologic progenitor stem cells can become a factor for stimulation of myocardial regeneration and improvement of results of surgical treatment. The objective of our study is to investigate the effectiveness and reasonability of stem cell therapy for myocardial regeneration.

Methods: In our study we have involved 11 patients suffering from the Ebstein’s anomaly (six males/five females; mean age 30.3±19.7 years old). Reconstructive tricuspid valve surgery and intramyocardial delivery of autologic progenitor stem cells into the atrialized wall of RV was made in all cases. The autologic population of СD133±progenitor cells was extracted from patient’s bone marrow on the prior day. We used general clinical and lab methods of investigation including electrocardiography, echocardiography and magnetic resonance imaging (MRI) before operation and during the follow-up period from one to three years after operation.

Results: The analysis of the data of MRI has shown a significant decrease of ESVRV (130.3+45.95 vs. 75.2+13.7 ml) and EDVRV (265.5+89.2 vs. 144.3+12.13 ml), improvement of global ejection fraction of RV (41.8+6.7 vs. 55.5+7.7%); increase of the RV mass (36.3+7.9 vs. 41.6+8.6).

Conclusions: Intramyocardial delivery of autologic CD133±progenitor cells into the atrialized part of RV in patient with Ebstein’s anomaly during reconstructive tricuspid valve surgery leads to the significant improvement of systolic and diastolic function and increase of mass of RV.

CP-64 HEMODYAMIC CORRECTION OF A FUNCTIONALLY SINGLE VENTRICLE WITH CONCOMITANT HETEROTAXY SYNDROME AND ASSOCIATED ATRIOVENTRICULAR VALVES REGURGITATION. SURGICAL TACTICS AND THE RESULTS OF THE HEMODYNAMIC CORRECTION

D.V. Kovalev, I.A. Yurlov, V.P. Podzolkov, M.M. Zelenikin, G.K. Babaev, N.A. Putiato, T.V. Shinkareva, V.V. Plakchova, S.B. Zaets

Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation

Objective: Patients with heterotaxy syndrome have multiple cardiac and visceral anomalies that lead to increased mortality and morbidity. Heterotaxy syndrome is considered to be a risk factor for partial or complete right heart bypass. This retrospective study is aimed to analyze results of hemodynamic correction of a functionally single ventricle in patients with concomitant heterotaxy syndrome associated with atrioventricular valves regurgitation in order to determine the surgical tactics and the results of the hemodynamic correction.

Methods: During the period from 1989 to 2009 twenty-nine patients with functionally single ventricle and concomitant heterotaxy syndrome associated with atrioventricular valves regurgitation underwent hemodynamic correction (Fontan operation or bidirectional Glenn shunt). Patients’ age ranged from three to 29 years (mean 9.8±6.1 years). Twenty-three patients underwent bidirectional cavopulmonary anastomosis, in 10 cases with interrupted IVC, and six – Fontan operation (three after primary BCPA with interrupted IVC). Severity of regurgitation was graded on a scale from 1+ to 4+ by color Doppler echocardiography and was considered as severe in 10 patients of the BCPA group (in four with interrupted IVC) and four in Fontan group. Methods of AVVR repair included annuloplasty, leaflet cleft repair, plastic reconstruction of common AV valve, closure of the valve or its replacement. Results of interventions were compared in two groups of patients in which AVVR was corrected (n=12) or remained untreated (n=17). The duration of follow-up in groups with corrected and non-corrected AVVR did not differ and reached 5.3±5.1 years and 5.4±3.9 years, respectively.

Results: Hospital mortality in patients with and without AVVR repair reached 16% (2/12) and 17% (3/17), respectively (NS). At follow-up period one patient died in the first group and one in the second. The degree of the AVVR at mean decreased from 3.3±0.48 before surgery to 2.1±0.9 at follow-up period in patients of the first group and subsequently increased from 2.1±0.5 to 2.9±0.7 in patients of the second group. The number of non-lethal complications did not differ in both groups. At the last follow-up examination, the majority of patients in both groups were in I–II functional NYHA class.

Conclusions: Repair of the AVVR during hemodynamic correction of a single ventricle in patients with heterotaxy syndrome can be considered as an effective procedure that allows to significantly improve their quality of life.

CP-65 Ten-YEAR EXPERIENCE IN SURGICAL CORRECTION OF COARCTATION OF THE AORTA IN INFANTS

M.A. Abramyan, M.R. Tumanyan, I.I. Trunina, A.A. Esayan, A.A. Gandgaliev, A.V. Kharkin, G.S. Netalieva

Bakoulev Scientific Centre for Cardiovascular Surgery RAMS, Moscow, Russian Federation

Objective: Obstructions of the aortic arch with concern coarctation of the aorta and interruption of the aortic arch are critical congenital heart disease of neonatal period. The rate among other critical congenital heart disease forms 10% and 1%, respectively. In recent years the number of neonates entering hospital for cardiac surgery has increased due to improvements in diagnostic capabilities and early CHD detection. We present analysis of a 10-year experience of cardiac surgery in infants with aortic arch obstructions. All these operations were performed in one department in Bakoulev scientific centre.

Methods: From 2000 to 2010, 311 patients with coarctation of the aorta were treated in our department, which formed 8.9% of all patients. In this group were 191 males and 10 females. One hundred and ten (37.6%) were newborns, 94 (30.%) were from one to three months old, 63 (20.6%) infants from three to six months and 44 (14.1%) from six to 12 months of age. Weight varied from 1.3 to 13 kg (average – 4.49±1.77 kg). For a detailed analysis we have chosen 86 (91.6%) patients with coarctation of the aorta, which were operated by one surgeon. By anatomy coarctation had different localisation: 113 – preductal, 146 – just ductal, 27 – postductal. Forty patients have hypoplastic distal part of the aortic arch. Usually, we have preferred repairing aortic arch making large oblique anastomosis ‘end to end’. This modification was made in 280 (97.9%) patients. In four cases, we performed direct anastomosis ‘end to end’ without isthmus enlargment or plastics. We used Valdhausen technique in two cases and De Mendosa method in one case.

Results: Total hospital mortality formed 3.5%. Distant follow-up period varied from one month to 10 years. Four (1.4%) patients, in which recoarctations were detected underwent reoperations (one angioplasty and three balloon dilatations).

Conclusions: We conclude, that repairing the coarctation of the aorta by extended end-to-end anastomosis gives good short-term and long-term results.

CP-66 INVASIVE MONITORING OF PULMONARY ARTERY PRESSURE AS THE GOLD STANDARD IN INDICATION FOR HEART SURGERY OF CONGENITAL HEART DISEASE AND PULMONARY HYPERTENSION

M.V. Belkina, D.G. Koledinsky, A.A. Shmaltz, A.V. Tkacheva, S.V. Gorbachevsky, L.A. Bockeria

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: Assessment of the possibility of using surgery to treat congenital heart disease (CHD) complicated by pulmonary hypertension (PH) requires specific examination methods. The aim of this study is to show advantages of invasive monitoring of pulmonary artery pressure (PAP) to assess reversibility of PH and operability of CHD.

Methods: A total of 205 patients (113 females and 92 males aged between six months and 62 years) with CHD complicated by PH participated in this research. Eighty-five of them had VSD, 27 – AVCD, seven patients had persistent truncus arteriosus, three had valve disease, 19 had PDA, five had coarctation of the aortic arch, 10 – TGA and VSD, 26 – DORV and VSD, 11 – ASD and 12 had other congenital heart defects. A total of 116 patients (Group 1) had equal systemic and PAP; 37 (Group 2) had suprasystemic pressure; and in 38 cases (Group 3) systemic pressure was higher. PH testing included oxygen therapy in each patient, Nitric oxide in 168 cases, diltiazem in 132 cases and enalapril in 34 cases. There were no complications.

Results: Most positive results (82%) were obtained in the group of patients whose initial PAP was less than systemic one and these patients were operated successfully. In another seven patients of this group testing results were negative. In five of them pulmonary artery was banded. In the first group the positive results was only in 42% (48 patients). Complete repair of heart defects was performed in 43 cases, and in five other cases pulmonary artery was banded. In the group of patients with suprasystemic pressure, only in 10% of cases (four patients) drug reaction tests were positive and were followed by surgical treatment.

Conclusions: Traditional methods of examining patients with CHD complicated by PH, such as echocardiography, endoscopy and pulmonary biopsy, do not always provide a real picture of pulmonary vessels condition. Before the method of invasive monitoring of blood pressure in the pulmonary artery was developed, CHD with equal or suprasystemic PAP was almost always considered inoperable. The results of this research showed that 40% of CHD in such cases can be operated on successfully.

CP-67 PREOPERATIVE PREDICTORS OF EARLY MORTALITY IN PATIENTS AFTER FONTAN SURGERY

W. Pietrzykowski

Lodz, Poland

Objective: Influence of preoperative predictors in patients after Fontan operation on early postoperative period and hospital mortality remains still poorly defined although several clinical studies had examined these factors.

Methods: Total of 96 patients with functionally single ventricle underwent a Fontan procedure from January 1996 to December 2009. From this analysis 33 patients with HLHS were excluded. Data were obtained from other 63 non-HLHS patients (37 males and 26 females). Median age at Fontan operation in analysed patients was 72 months (range 20–212 months). Five patients underwent direct cavopulmonary anastomosis as second stage Fontan palliation. Remaining 58 patients underwent other types of Fontan operation, mostly as second stage palliation (in five patients bilateral biderectional Glenn was performed). Mostly, extracardiac conduit Fontan were used in 54 patients.

Results: There were five hospital deaths (8% early mortality) and the age of deceased patients ranged from 20 to 163 months. Early mortality after Fontan operation was connected with dominant left ventricle failure in 3/45 patients (7%) and with dominant right ventricle failure in 2/18 patients (11%), differences was not statistically significant. Preoperative predictor of poor function of single ventricle, diagnosed as ejection fraction below 45%, was found in six patients, including three patients with dominant left ventricle and three patients with dominant right ventricle. Mortality of 3/6 (50%) ranked this predictor for significant risk factors. In all patients, except one patient (with right ventricle morphology) this predictor occurred alone. Atrioventricular valve dysfunction alone was no predictor of mortality risk factor. Among the analysed three predictors, most often occurred invalid development of pulmonary artery branches, assessed by the index of McGoon. Its value equal to or lower than two, exhibited in 14 patients (22%). This predictor characteristically, although not significantly predominated in patients with a left ventricle morphology (11/45, 24%) rather than patients with dominant right one (3/18, 17%).

Conclusions: We found failure of dominant single ventricle, with both right and left morphology, to be an independent risk factor for hospital death in patients after Fontan operation. Our review shows that dysfunction of atrioventricular valve of dominant single ventricle alone and invalid development of pulmonary arterial branches alone do not comprise the risk factors of hospital death after Fontan operation.

CP-68 ANATOMO-TOPOGRAPHIC CRITERIA OF ULTRASOUND FETAL HEART DEFECTS

A. Duzhikov, A. Duzhikova, N. Mozhaeva, I. Loginova, D. Vasilihina

Rostov Cardiovascular Surgery Center, Rostov-on-Don, Russian Federation

Objective: Determine the value of anatomo-topographic landmarks along with the segmental approach to prenatal diagnosis of heart defects.

Methods: One hundred and twenty-seven women were examined in 19–24 weeks of gestation during the last year. To diagnose congenital heart diseases, we used not only sequential segmental analysis of cardiovascular anatomy, but knowledge of normal anatomical relationships intrathoracic structures. Moving the beam up and down parallel to the diaphragm then right to left on sagittal axis perpendicular to the diaphragm of the fetus, we get optimal anatomical views on echo. The first stage is verification of position and lateralization, the second one is verification of the inlet and the third one is verification of outlet.

Results: All fetus had normal situs. Inlet anomalies were found using the four-chamber view: complete AVSD, mitral stenosis, Ebstein’s malformation, ventricular septal defect. In these cases abnormalities of structure are one of the possible deviations of four–chamber view from normal, because the right ventricle was at anterior and to the right (closer to the front of the chest) and the left-posterior and to the left; pulmonary veins connected to the back of the left atrium on either side of descending aorta, which was the only vessel there. Outlet anomalies were found using all views that explore outlet flow. In our cases these are: aortic stenosis, pulmonary stenosis, common arterial trunk, pulmonary override in double outlet right ventricle, transposition of great arteries with AV concordance and coarctation. In case of transposition of great arteries pulmonary valve was lying close to the diaphragm of the fetus, compared with aortic valve; aorta was positioned in front of the pulmonary artery and the first from the anterior chest wall. Considering the location of the pulmonary artery below the ascending aorta was not possible to get a cut through three vessels. All congenital malformations were confirmed after birth.

Conclusions: Fetal echo, based on segmental analysis together with the anatomo-topographic approach is an informative method for diagnosis of heart defects.

CP-69 ATRIAL SEPTOSTOMY WITH STENTING IN PATIENTS WITH IDIOPATHIC PULMONARY ARTERIAL HYPERTENSION

L.A. Bockeria, B.G. Alekian, M.G. Pursanov, M.V. Tolstih, A.I. Kosenko, N.I. Koroleva, A.V. Tkacheva, S.V. Gorbachevsky

Bakoulev Scientific Center for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: Atrial septostomy (AS) can be beneficial in patients with severe pulmonary arterial hypertension (PAH) because it produces a pathway by which systemic cardiac output can increase. The biggest problem is the creation of an appropriate size of ASD without any deterioration. The aim of this study was to analyze the result of this procedure.

Methods: Between January 2006 and January 2010, AS was performed in 19 patients with idiopathic PAH. Median age at the time of AS was 14 years (range, 5–34 years). Indication for AS was class III or IV modified NYHA classification with right ventricular dysfunction but normal or slightly decreased cardiac output. The procedure was performed using fluoroscopy, intubation, general anesthesia and TEE. ‘Palmaz’ stents were inserted in all cases. In all cases but one atrial septum was intact.

Results: Cardiac catheterization revealed PAH in all patients. Median systolic pulmonary artery pressure (PAP) was 105+45 mmHg (range, 80–188 mmHg). Median systemic blood saturation was 90+2% (range, 88–94%). Sizes of created ASD were 5 mm in 10 patients, 6 mm in 4 and 8 mm in a patient 34 years old. Immediately after procedure there was increasing of PAP in all patients even in patient with PAP of 188 mmHg (203 mmHg) and moderate decreasing of systemic blood saturation – 89+2% (range, 84–95%). One patient died in the time of ASD creation (5%). The cause of death was damage of the right atrial wall. Ten patients were followed up for a mean period of 25.3 months (range, five months to four years). There were two late deaths (one month and two years after procedure). The estimated probability of survival at one year was 93%, and at two years – 87%. In follow-up there was functional improvement in six patients with slightly decreasing of PAP.

Conclusions: AS with stent improves clinical status, hemodynamic variables and possibly survival in selected patients with idiopathic PAH. It may be a real bridge to lung transplantation.

CP-70 MYOCARDIAL FUNCTION IN INFANTS WITH TETRALOGY OF FALLOT

I.Yu. Baryshnikova, A.A. Kupryashov, V.V. Plahova, M.A. Zelenikin

Scientific Centre for Cardiovascular Surgery, RAMS, Moscow, Russian Federation

Objective: Tissue Doppler imaging (TDI) has the important clinical application in early detection of global and regional systolic and diastolic ventricular dysfunction in children with congenital heart disease. The aim of the study is to assess the ventricular function in young children with tetralogy of Fallot (TF) and to identify predictors of complicated postoperative course.

Methods: Fifty patients (20.8±11.2 months) undergoing repair of TF were prospectively studied in order to assess left and right ventricular diastolic function. The control group included 26 healthy children of the same age. All patients were examined over an extended 2D echocardiogram protocol. Assessment of systolic and diastolic function was performed by several ultrasonic methods: pulsed-wave Doppler, the longitudinal systolic and diastolic myocardial velocity, the temporal and deformation parameters, Tei-index.

Results: There are no differences in the peak diastolic transannular blood flow between patients with TF and the control group. Patients with TF with the uncomplicated postoperative course are characterized by the following TDI parameters: 1) lower boarder TDI indices of the LV functional status, 2) normal TDI indices of the LV functional status after surgery; 3) reduction of the longitudinal systolic myocardial motion in all RV segments before and after the operation, 4) deformation properties of the LV and RV were not significantly different from the normal, 5) LV diastolic dysfunction was observed in 75%, 6) RV diastolic dysfunction was observed in 100%, 7) children with TF without overlapping previously the systemic-pulmonary shunt (SPS) have a slight decrease of myocardial contractility and LV ‘restrictive physiology’ in 73% in the postoperative period; 8) children with TF with SPS have more severely impaired RV myocardial contractility compared with patients without SPS in the postoperative period. 9) LV Tei-index before surgery was 0.6±0.05, RV Tei-index – 0.7±0.05. Patients with TF with complicated earlier postoperative course are characterized by the following TDI parameters: 1) a high velocity RV myocardial motion in diastole does not decrease in amplitude toward the apex, 2) the restrictive type of the RV diastolic dysfunction was observed in 100%.</