“t · martin czerny, university hospital zurich, ... eacts daily news is pleased to announce the...

Theofficialnewspaperofthe27thEACTSAnnualMeeting2013 Sunday 6 October

Martin Czerny, University Hospital Zurich, Switzerland

Diseaseoftheaortaisnowbeingrecognizedasdistinctentityincreasinginincidence.Itisacknowledgedthatthe

managementofbothacuteandchronicaorticconditionsnowhavesuchabroadevidencebasethatspecialistknowledge,trainingandskillsarerequiredtoprovidebestpatientcare.Thespecialismtraversesallagegroups;youngpatientsaremostlyaffectedbyconnectivetissuediseases(CTS),middle-agedpatientsareaffectedbydegenerationofbicuspidaorticvalveswithorwithoutaneurysmalformationofthesinusofValsalvaortheascendingaortacausedbyaccompanyingmedialdegeneration,whereaselderlypatientsmayalsodevelopthesamephenotypeofdisease(aorticvalveandascendingaorta)butduetootherunderlyingpathomechanisms,predominantlyatherosclerosisandcalcificdegeneration.

Endovascularstentinghasbroadenedaortictherapeuticsandhasledtodevelopmentofmanyalternativetreatmentapproachesusingisolatedstentingandhybridstent-surgerytechniques.Someofthemhavebecomeroutineandmaybejudgedasvalidatedandstandardized.

However,betterunderstandingofthelimitationsofendovasculartherapyaswellasacknowledgementoftheexcellentresultsforconventionalaorticsurgerymustbeconsideredbeforeexpandingendovascularoptionstoallaorticpathologiesofnewpatientpopulations.Amultidisciplinaryapproachmayclearlyservetochoosetheadequatetreatmentmodalityin

theindividualsettingascomplicationsinducedmightnotbehandledinanadequatefashionbynon-cardiacsurgeons(e.g.endovasculartreatmentofascendingaorticpathology).

Thelogicalconsequenceoftheevolutionofaorticsurgeryandtoreconcileheterogeneityoftreatmentmodalitiesisthecreationofaorticcenterscapableoftreatingtheentireorganwithalldiagnosticandtherapeuticoptions.Theleadersofsuchcentersarelikelytobecardio-vascularsurgeonswithexperienceinbothcardiacandvascularsurgicaldisciplinesincludingendovascularskills.

Byabroadsurgicaltrainingprogramwithaclearanddefinedaiminadefinedtimeperiod,leavingroomforboth,surgery,endovasculartherapyandscience,youngpeoplemusthavethechancetodevelopandmature.Itisourtasktodefinethefutureandtopavethewayforthegenerationstocome.

Wire or knife? Not to go where the puck is but to go where the puck will be

Plenary Session: Life is short and the art long 08:30 Hall D

In this issueIn this issueIntra- cardiac and vascular ultrasoundEnrico Ferrari outlines the benefits of these two imaging modalities2

Tuberculosis Piotr Yablonski discusses the tactics and results of treating patients with different forms of MDR and XDR and the role of individualised treatment4

Fallot Giovanni Stellin states that pulmonary valve integrity can be preserved during early ToF repair by utilising balloon dilation 6

Proximal TADAdriana Gittenberger-de Groot

examines thoracic aortic disease and explains the embryology of the aorta - from cells to an organ 8

Patient adherence Jo Cook reports on the role of the primary care team and the role they play in a patient’s adherence to

their medication. 12

Donor shortage Thierry Carrel argues that DCDD grafts are useful in overcoming the shortage of donor organs 18

CMR or PET for surgery?Rafael Sadaba looks at the benefits of both CMR and PET imaging modalities when assessing

a patient’s for coronary artery surgery 19

EACTS Academy Events in 2014 21

Floorplan 24

EACTS 2014 25

“T hesuccessofaValve-in-Valveprocedureisbasedoncorrectidentificationof

thesurgicalvalve,choosingthecorrectsizeoftheTAVIvalveanditssubsequentaccurateplacement,”saidBapat.“Surgicalvalvesvaryinappearanceunderfluoroscopy,structureandalsointheirinternaldiameter.Similarly,TAVIvalvesdifferintheirappearancesandavailablesizes.KnowledgeaboutallthesurgicalvalvesthathavebeenimplantedinthelasttwodecadesisminimalbutrelevanttotheValve-in-Valvetherapy.”

SHVs and TAVI valvesUsingtheValve-in-ValveApp,userscannowfamiliarisethemselveswithimportantdesigninformationaboutvariousstentedandstentlessSHVsandTAVIvalves.TheycanselectaspecificvalveandalabeledsizeandfindoutwhichsizeofTAVIvalve

couldbeusedandhowitisbestplacedduringaValve-in-Valveprocedure.Ifthevalvetypeisunknown,theappalsoguidestheuserthroughaseriesofstepswheretheycanidentifythesurgicalvalvetypeandthenusetheinformationavailableforit.

“TheValve-in-Valveappreducestheneedtotrawlthroughvastamountsofliteraturetofindinformationspecifictotheclinicalscenario,”explainedBapat.“TheapplicationnavigatestheuserthroughimportantaspectsofsurgicalandTAVIvalvedesign,whicharevitalforasuccessfulValve-in-Valveprocedureandlogicallystepsthroughthepossiblecombinationstogivetheuserspecificinformationneededtoperformtheprocedure.”

Valve-in-Valve MitralBapatandcolleagueshavealsoreleasedthesecondappinthisseries–Valve-in-ValveMitral,specifictothevalvesandringsusedinthemitralposition.Inadditiontotheinformationaboutmitral

valvesandrings,theappprovidesimportantdifferencesbetweenanaorticValve-in-ValveandamitralValve-in-Valveprocedure.

“Attheheartoftheideaiseducationthatisfreetouseandtheinformationisalsoavailablewithouttheneedforaninternetconnectionandwillenhancetheusersunderstandingofvarious

aspectsofthisprocedure,”BapattoldEACTS Daily News.“Wehopethiswillresultinimprovedresultsandbetteroutcomesforpatients.”

AnAndroidversionoftheappisplannedtobereleasedinOctober2013.

EACTS Daily News is pleased to announce the 2013 EACTS Techno College Innovation Award was won by Dr Vinayak Nilkanth Bapat (Guys and St. Thomas’ Hospital, London, UK), for the ‘Valve-in-Valve’ app that provides information specific for a clinical scenario, quickly and simply and helps in the planning of and performing, a Valve-in-Valve case.

Valve-in-Valve app wins 2013 EACTS Techno College Innovation Award

Vinayak Bapat

Martin Czerny

Domenico Pagano Chair of the QUIP

Elka Humphrys QUIP Project Manager

In2012EACTSestablishedaQualityImprovementProgramme(QUIP)toencourageimprovementofclinicaloutcomesforpatients,andtopromote

theimportanceofintegratingqualityimprovementinitiativesintodailyclinicalpractice.

TheprogrammereliesontheparticipationofEACTSmembersandsincethelaunchoftheQUIP,sixmemberledgroupshavebeenestablishedtosupportprojectswithintheprogramme;theNetworkforOutcomesResearch,PublishingOutcomes,ClinicalConsensus&Guidelines,Education,Nursing&AlliedHealthProfessions,andPerfusion.ItisthankstoyoureffortsseenthisyearthatworknowspansallfourEACTSDomainsandincludessurgeons,perfusionists,nurses,andalliedhealthprofessionalsworkingtowardsimprovingclinicaloutcomesforpatients.

Projectswithinthegroupsarenowprogressingandinitialresultswillbe

presentedinvarioussessionsduringthisyear’sAnnualMeeting,includingtheAcquiredCardiacDiseasePostgraduateEducationsessionsonSunday,Tuesday’sfocussessiononoptimisingtrainingforbetterpatientoutcome,andthroughouttheDomainprogrammes.FurtherinformationonallprojectsandgroupswillbeavailableattheEACTSexhibitionstand(HallXL,Booth148),andamemberoftheQUIPteamwillbeavailableonthestandatthefollowingtimestoansweranyspecificquestions.nSunday6October: 17:00-19:00nMonday7October: 09:00-10:00

13:00-14:00 15:45-16:30

nTuesday8October: 09:00-10:00 13:00-15:15

We thank all members currently contributing to QUIP projects, and we look forward to working with many more members in the future. Your support will lead to more quality improvement projects and will increase the difference we can make to our patients.

EACTS Quality Improvement Programme

Togetinvolvedinanyofthecurrentprojectsortojoinoneofthegroupsforfutureprojects,visittheEACTSexhibitionstand(HallXL,Booth148)atthe27thAnnualMeetingandspeaktotheQUIPteam.

Alternatively,nominateyourselfforinvolvementintheQUIPviatheMyProfiletabinyourEACTSUserArea:www.eacts.org/user-area

2 Sunday 6 October 2013 EACTS Daily News

Sunday 6 October

Postgraduate Course

Plenary Session: Life is short and the art long

Hall D

J.L. Pomar, Barcelona; T. Sundt, Boston

08:30 Attentiontodetailinadumbed-downworld Paul Sergeant

08:50 Overregulationoranarchy? David Barron

09:15 Trainingisbrokenandthereisnoquickfix Michael Dusmet

09:35 WireorKnife?Nottogowherethepuckisbuttogowherethepuckwillbe Martin Czerny

Acquired Cardiac Disease

10:30 Session 1: Imaging in Mitral valve repair

Hall D

Moderator: J Pepper, London; V. Delgado, Leiden

10:30 Does3Dchocardiographyenhancedecisionmaking? Jolanda Kluin

10:50 Howdowegetthebestoutofmagneticresonanceimaging Philip Kilner

11:10 Directvieworvideo-scopicimaging Ludwig Muller

11:30 Image-baseddecision-makingincomplexmitralvalverepair Patrick Perier

12:30 Session 2: Imaging in Transcutaneous valve interventions

Hall D

Moderators: C. Ruiz, New York; F. Beyersdorf, Freiburg

12:30 Planningtranscatheteraorticvalveimplantationprocedures:theroleofimaging Peter Wenaweser

12:55 Intraoperativeguidanceintranscatheteraorticvalveimplantationprocedures Joerg Kempfert

13:20 Intracardiacandintravascularultrasound Enrico Ferrari

13:40 Image-guidedtransseptalpuncture Alec Vahanian

14:05 Image-guideddecisionmakingformitralinterventions Joerg Seeburger

14:30 Session 3: Imaging in Coronary Artery Surgery

Hall D

Moderators: T.A. Folliguet, Nancy; A. Vahanian, Paris

14:30 Catheter-basedimaging(OCT;IVUS) Simon Davies

14:50 Assessmentofviability(magneticresonanceimaging,positronemissiontomography) Rafael Sádaba

15:10 Myocardialassessment:Echocardiography Victoria Delgado

15:30 Graftassessment:intra-operativeimaging Syed Rehman

15:50 ImagingfortheHybridapproach Rashmi Yadav

16:10 RoleoftheHeartTeamapproach Sacha Salzberg

14:00 Circulating viewpoints

Hall E2

14:00 Introduction A.P. Kappetein, Rotterdam

14:05 PrideandPrejudiceincardio-thoracicsurgery B.E. Keogh, London

14:35 TalesofatravellingsurgeoninAfrica P. Simon, Vienna

10:25 Session 1: Improving Perfusion

Hall F1

Moderators: F. Merkle, Berlin; A. Liebold, Ulm

10:30 Antegradeandretrogradeautologousprimingwithconventionalbypasssystems Korneel Vandewiele

10:50 Clinicalexperiencewithminimizedbypasssystemsinaorticsurgery:theHammersmithtechnique John Mulholland

11:10 Cellsaversduringcardiolpulmonarybypass:savingbloodandreducinginflammation Anders Jeppsson

11:30 Howtopreventairembolismduringvalvesurgery? Manuel Antunes

11:50 Toclamportoinflate:thehandlingofmyocardialperfusioninMICS Johannes Bonatti

12:10 Simultaneousbrain,heartandbodyperfusioninaorticarchsurgery Christoph Benk

12:30 Session 2: Safety in perfusion

Hall F1

Moderators: A. Jeppsson, Gothenburg; C. Hamilton, Vogtareuth

12:30 Failureduringcardiopulmonarybypass:howtohandledifficultsituations Gino Gerosa

Continued on page 4

Aorticstenosis(AS)isacommonlife-threateningcondition

thatisanunder-appreciatedyetseriousandgrowingpublichealthproblem1.Asiswidelyknowninthecardiacsurgerycommunity,manypatientswithvalvediseasearenotreferred,oftenwithdisastrousconsequences.AtEdwardsTM,wearecommittedtoraisingawarenessofASundertreatmentamongreferringcommunities,byimplementingeducationalprogramsandsymposiaacrossEuropeanconferencesthatincludeadvertisingtoreferringphysicians(GPs,cardiologists,andgeriatricians),andtargetededucationthroughscientificandlaypressarticles,e-learning,andpartnershipswithkeyprofessionalsocieties.Onceapatientisreferred,EdwardsTMisdedicatedtoprovidingyouwiththebestoptionsforminimallyinvasivetechniquesthroughcontinuedinnovationinsurgicalandtranscatheterheartvalvedevicesanddeliverysystems.

ASmayprogressrapidly.TherearenomedicationstoreverseAS,andtreatmentoptionsandtimingmatter.Withouttreatment,symptomaticpatientswithsevereASsurviveanaverageof2–3years.Surgicalaorticvalvereplacement(SAVR)isthegoldstandardtreatment

forsevereASandshouldbeperformedpromptlyaftersymptomonset2.However,whileSAVRremainstheAStreatmentofchoiceformostpatients,morethanathirdofpatientsisdeniedsurgery5-10(Figure).PractitionersarereluctanttoconsiderSAVRinolderpatientsorinthosedeemedunfitforsurgeryduetomajorcardiacdysfunctionandcomorbidities,orduetohighoperativeriskandlowlifeexpectancy2,9.Inthepast,thesepatientswouldnotbetreatedorevenreferred.However,thisischangingthankstominimallyinvasivetechniquesincludingtranscatheteraorticheartvalveimplantation(TAVI),

whichisnowperformedroutinelyatcertifiedheartcenters.Since2012,theEuropeanSocietyofCardiologyandEuropeanAssociationforCardio-ThoracicSurgeryrecommendTAVIinitsguidelinesformanagementofAS.TAVIisindicatedinpatientswithseveresymptomaticASwhoarenotsuitableforsurgery,asassessedbyamultidisciplinaryheartteam.Thisdecision-makingapproachisparticularlyadvisableinthemanagementofhigh-riskpatients2.

AllhealthcareprovidersmanagingpatientswithASsymptomsneedtoensurethatthesepatientsare

appropriatelyreferredtoamultidisciplinaryheartteam,receiveadefinitivediagnosis,andareawareoftheirtreatmentoptions,whetherSAVRorTAVI.WithEdwardsTM’rapidinnovationinbothSAVRandTAVItechnologiestocontinuallylessentheinvasivenessofAStreatment,ourgoalistoensurethatthereisaproductsuitableforeverypatient,irrespectiveoftheirdiseaseprogression.

ThereisanencouragingtrendsincetheintroductionofTAVIwhichisanincreaseinpractitionerawarenessofAS,withacorrespondingincreaseintotalreferralsandAStreatmentviaboth

surgicalandtranscathetermodalities11.

HealthcarepractitionersshouldthereforenotweakentheireffortstoreduceASundertreatment:thingsareontherightpath.References

1. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvu-lar heart diseases: a population-based study. Lancet 2006;368:1005-11.2. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-96.3. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Jr., Faxon DP, Freed MD, et al. 2008 Focused up-date incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardi-ology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardio-vascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008;118:e523-661.4. Ross J, Jr., Braunwald E. Aortic stenosis. Circu-lation 1968;38:61-7.5. Iung B, Baron G, Tornos P, Gohlke-Barwolf C, Butchart EG, Vahanian A. Valvular heart disease in the community: a European experience. Curr Probl Cardiol 2007;32:609-61.6. Bach DS, Cimino N, Deeb GM. Unoperated pa-tients with severe aortic stenosis. J Am Coll Cardiol 2007;50:2018-9.7. Bouma BJ, van Den Brink RB, van Der Meulen JH, Verheul HA, Cheriex EC, Hamer HP, et al. To oper-ate or not on elderly patients with aortic stenosis: the decision and its consequences. Heart 1999;82:143-8.8. Charlson E, Legedza AT, Hamel MB. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis 2006;15:312-21.9. Iung B, Cachier A, Baron G, Messika-Zeitoun D, Delahaye F, Tornos P, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J 2005;26:2714-20.10. Pellikka PA, Sarano ME, Nishimura RA, Malouf JF, Bailey KR, Scott CG, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aor-tic stenosis during prolonged follow-up. Circulation 2005;111:3290-5.11. Malaisrie SC, Tuday E, Lapin B, Wang E, Lee R, McGee EC, et al. Transcatheter aortic valve implanta-tion decreases the rate of unoperated aortic stenosis. Eur J Cardiothorac Surg 2011;40:43-8.

Enrico Ferrari University Hospital of Lausanne, Switzerland

Traditionally,transcatheteraorticvalvereplacementisperformedunderfluoroscopic

controlandguidance,withmultipleinjectionsofcontrastmediumduringtheprocedure.Thisapproachisrequiredfortheorientationofthefluoroscopicmachine,forthestent-valvepositioning,forthestent-valveimplantationand,attheendoftheprocedure,toidentifythepresenceofparavalvularleaksandtoconfirmtheplacementofthestent-valveintherightplace.

Elderlypatientswithimpairedkidneyfunctionareathighriskforpostoperativeacutekidneyinsufficiencyaftertranscathetervalveprocedures,andunfortunately,thisriskaugmentswhenhighdosesofcontrastmediumareinjected.Inordertoreducethisrisk,wedevelopedthesocalled“dumbbelltechnique”astratagemallowingthepositioningandthedeploymentoftheballoonexpandablestentvalveunderechocardiographicguidance,fluoroscopiccontrol,andwithoutuseofcontrastinjections(ifnotstrictlynecessary).Withthegeneralanaesthesia,thisprocedureiscarriedoutwiththeuseof2Dor3Dtransoesophagealechocardiography(leftsideofFigure).

However,insomeparticularcases(i.e.inpresenceofoesophagealvarices)andincaseofpatientsundersedationwithoutgeneralanesthesia(percutaneoustransfemoralTAVI),theuseoftheintracardiacultrasoundallowstheusageofthedumbbelltechniquewithoutemployingthestandardtransesohagealechocardiography.

Theintracardiacprobeisplacedinavenouscatheterthroughthefemoral,thesubclavianorthejugularveinandallowstheidentificationofthelandingzoneandthecrimpedstentvalve.Attheendoftheprocedures,theintracardiacultrasoundhelpsinidentifyingthepresenceofparavalvularleaksandinmeasuringthevalvehemodynamic.

Usingthistechniquewithexpertechocariographists,

transcathetervalvereplacementcanbeperformedinsedatedpatientswithoutuseofangiographies.

Theintravascularultrasoundhasbeenroutinelyemployedinourinstitutiontopositionandtoimplantaorticendoprosthesiswithoutuseofcontrastinjection.Followingthatexperience,wefusedthistechniquetothetranscatheterstentvalvereplacement.Inparticularin2010wedemonstratedforthefirsttimethatballoonexpandablestentvalvescouldbeplacedinstenoticpulmonaryconduitsusingthistechniquewithoutuseofangiographies.

Recently,wewerealsoabletodemonstratethatitispossibletoidentifythelandingzoneofthecrimpedstentvalveintheaorticpositionusinganIVUSprobe

insertedintheheartthroughtheapicalsheath(duringatransapicaltranscatheteraorticprocedure).

Inthiscase,markersareplaced(followingtheIVUSguidance)ontothepatientinordertodefine,underfluoroscopy,wherearetheinnerandtheexternalrimofthediseasedaorticvalve.Then,allkindofstentvalve(notonlytheballoonexpandableone)canbeplacedinbetweenthemarkerswithoutuseofcontrastinjections(seerightsideofFigureabove).

Inconclusion,theintracardiacechocardiographyandtheintravascularultrasoundareusefultoolsthatcanbesuccessfullyusedinsomeparticularcasesinordertodiminishoravoidtheinjectionofnephron-toxiccontrastmedium.

Intracardiac and intravascular ultrasoundSession 2: Imaging in Transcutaneous valve interventions 12:30 Hall D

Aortic stenosis undertreatment and available treatment options


Piotr Yablonskii President of the Association of Thoracic Surgeons of Russia

Relationtosurgicaltreatmenthaschangedovertime.Successoftherapeutictreatmentanddecreaseinthe

incidenceoftuberculosisintheworldinthemid-20thcentury,thatfindingsuggeststhatsurgicaltechniquemaybeexcludedfromthemanagementofpatientswithtuberculosis.However,theepidemicofMDRandXDRtuberculosishaschangedthepresentationofeventhemostactivesupportersoftheconservativeapproach.Now,WHOTaskforcegrouphasformulatedthemainindicationsforsurgicaltreatment.Whichsummarizedasfollows:1)LocalizedformsofcavitaryTBwithcontinuousmycobacteriumtuberculosisexcretionconfirmedbybacteriologicalexaminationanddrugsusceptibilitytesting(DST)after4-6monthsofsupervisedanti-TBchemotherapy.2)M/XDR-TBcharacterizedbyanti-TBchemotherapy’sfailure3)ComplicationsandsequelaeofTBprocess(includingM/XDR-TB)4)Otherindications.

Atthesametime,avarietyofclinicalformsoftuberculosiscanbeconsidered

thesurgeryintheseComplexcases.SecondandthirdpointsaremostcomplicatedcasesofTB-surgery.InourpresentationonSunday6thOctoberentitled:“Complextuberculosiscases”,wewillshowthetacticandresultsofthetreatmentofpatientswithdifferentformsofMDRandXDR-tuberculosis.Therewillbethreecases.

First case –male,45yearsoldwithrapidlyprogressionoftuberculosisintheleftlungandcavernoustuberculosisofupperlobeofrightlung.Previously,

patientwasdiagnosed,asMDRTB,complicatedwithpyopneumothorax.Periodofdrugtherapywas18months,accordingDST.Chesttubewasinsertedintothepatienttwicebeforeadmissiontothehospital.Leftpneumonectomywithextrapleuraldissectionwasdoneasfirststepofsurgicalpartoftreatment.Earlypostoperativeperiodwascomplicatedsmallbronchopleuralfistula.Itwasclosedafterconservativetreatment.Rightupperposteriorthree-ribsthoracoplastywasdoneaftertwomonths.Long-termfollow-upwasuneventful,duringallperiodMBTinsmearsabsent.

Second case–male,32yearsoldwithXDRpulmonarytuberculosis.CTscanrevealeddestructionofcompletelyleftlungandcavernoustuberculosisofupperrightlobe,complicatedpulmonarybleeding.Previousperiodoftherapywas54months,accordingtoDST.Firstly,endobronchialvalvewasinsertedintheupperrightbronchus.Thesecondstepofmanagementofpatient,leftpneumonectomywithextrapleuraldissectionwasdone.Postoperativeperiodwasuneventful.But,despiteofendobronchialblockingcavernousinupperrightlobewaspersisting.

Accordingthis,rightupperposteriorfour-ribsthoracoplastywasdone.Six-monthfollow-upnotrevealanysignsofprogressionofTB.ConversioninonemonthafterlastoperationandallperiodafterMBTinsmearsabsent.

Third case –male,59yearsoldwithMDRpulmonarytuberculosis,complicatedaspergillosisoflung.Historyofdiseasebegan36yearsago,whenpatientwastreatedthrowrightupperlobectomywithantibacterialtherapyaccordingtoDSTfromcavitarytuberculosis.Butafter27yearspulmonarybleedingwasdiagnosedanddiagnosisofMDRtuberculosisandaspergillosiswasconfirmed.Nineyearspatientdeclineallsuggestionofsurgery.Afteradmissionofpatientinclinic,CTscanrevealedcavityinlowlobeofrightlungandinthemiddleofcavityaspegillomawasdiagnosedtoo.Completionrightpneumonectomywasdone.Long-termfollow-upwasuneventful,duringallperiodMBTinsmearsabsent.

ThegoodresultsoftreatmentcanbecomethebasisforfurthercarefulstudyofallthepossibilitiesofsurgicaltreatmentofpatientswithComplexMDRandXDRpulmonarytuberculosis.

The new face of the old problem

13:50 Session 3: Transplant/mechanical assist

Hall F1

Moderators: J. Mulholland, London; G. Gerosa, Padua

13:50 Cardiactransplantationwithnon-heart-beatingheartdonors:futurestrategyorfantasy Thierry Carrel

14:10 Long-termsupportwithleftventricularassistdeviceinelderlypatients Bart Meyns

14:30 Donorextracorporeallifesupportforimprovedorganpreservation Guillaume Lebreton

14:50 TheOrganCareSystem:amulticentrestudy Martin Strüber

15:10 Session 4: Pro/ Con:Use of Intra-aortic balloon support during ECMO/ECLS

Hall F1

Moderators: T. Carrel, Berne; G. Lebreton, Paris

15:10 Pro Arnt Fiane

15:30 Con Peter Nielsen

15:50 EuropeanPerfusionRegistry:Aplatformforperfusionqualityimprovement Luc Puis

Nurses, Nurse Practitioners and Physician Assistants Programme

08:45 Session 1: Moving Borders

Hall K

Moderators; T Bartley, Birmingham; D Bordingggaard, Odense

08:45 Welcome Leslie Hamilton; Richard Van Valen

08:55 NursinginAustria M Burscher

09:05 Video-assistedthoracoscopiclobectomyenhancesrecoveryandreducestheneedforphysiotherapyinterventionscomparedtothoracotomy Paula Agostini

09:25 PatientunderstandingandexperienceoftheirSternotomyandthePromotionofWoundHealing Libby Nolan

09:45 Thepatient,theGP,theprimarycareteam:theirrelationship,adherencetotreatmentandtheimplicationsforresearch Jo Cook

10:05 Postoperativemobilisation C Brun Thorup

10:25 Transcatheraorticvalveimplantation,theEuropeanperspective Bo Kjeldsen

10:40 Thetranscatheteraorticvalveimplantationdebate;theviewfromthealliedprofessionals Nicolas Van Mieghem

11:15 Session 2: Moving Borders

Hall K

Moderators: C Bannister, Southampton; M Hoffmann, Kalsruhe

11:15 TheAmericanperspective D Lizotte

12:00 IntroducingPAsinGermanyandtheirroleinthechain Craig Matthews

12:20 Postlungsurgeryrehabilitation P Nikkelsen

12:40 Education:Thoracic:MorbusGorhan M Brunott

13:00 Lunch:UpdateonEQUIP D Pagano, T Bartley

14:00 Session 3: Non-surgical skills for teams in theatre

Hall K

Faculty: S Patterson Brown; N Maran, Edinburgh

Basic Science

10:30 Session 1: The enemy from within

Hall P

Moderators: K. T. Preissner, Giessen; J. Vaage, Oslo

10:30 MitochondrialDNA:adangeroussignalintheheart? Marte Bliksoen

11:10 Damagingnatureofendogenousribonucleicacidincardiacischaemia/reperfusioninjury. K. Preissner

13:00 Session 2: A look into the future

Hall P

Moderators: P. Dohmen, Leipzig; J. Vaage, Oslo

13:00 Thefutureofvalvesurgery P. Dohmen, Leipzig

13:30 Thefutureofmyocardialrevascularization P. Sergeant, Leuven

14:00 Transplantationofengineeredhearttissueasabiologicalcardiacassistdevice F. Schlegel, Leipzig

14:40 Session 3: Bleeding

Hall P

Moderators: T. Tonnessen, Oslo; M. Sousa Uva, Lisbon

14:40 Thebasicsofbleedingandhaemostasisincardiacsurgery A. Jeppsson

Continued from page 2

Continued on page 6

Cardiopulmonarybypass (CPB) isakeycontributor topatientoutcomes incardiacsurgeryandhasasignificantimpactondirectandindirectcostsof

healthcare.Inachangingscenariowherecardiacsurgerypatientsaremorecomplexand

costcontainmentpressureisincreasing,interestinoptimizedperfusionstrategiesisrapidlygrowing.ThegoalistominimizethenegativeimpactofCPBonpatientoutcomeswhilereducingcostsofcare.

Formorethan40years,SorinGrouphasbeenleadinginnovationincardiacsurgery, offering products and solutions to help clinicians address the keychallengesofdailyclinicalpractice.

Afewshortmonthsfollowingthe launchof itsnewlydesignedperfusionelectronic charting system, Sorin Connect™, Sorin Group reinforces itscommitment to innovation by launching a complete new family of adultoxygenator systems, Sorin INSPIRE™ along with its Goal-Directed Perfusionsystem,SorinHeartLink™atEACTS2013.

The new INSPIRE family of oxygenators has been designed to meet alladult patient needs and to support different perfusion practices. The INSPIREfamily provides clinicians with new options to improve patient outcomes incardiopulmonarybypass,allowingthemtosafelyandcomfortablyrunperfusionwithpowerfulandconsistentperformance.

ThenewINSPIREfamilyoffersseveralkeybenefitstoclinicians:nAnunprecedentedchoiceofthemostcompletefamilyofadultoxygenators,

fullymodularandflexiblen Thefirstandonly6LPMmaximumratedbloodflowoxygenatorsystems,

representingtheidealsolutionforoptimizedperfusioninawidepatientpopulation

n Highlyefficientoxygenatorswithpowerfulandconsistentperformanceupto8LPM,allowingtosafelyandcomfortablytreatalladultpatientswithonedevice

n Minimizedimpactonhemodilution,whichcontributestodecreasedbloodtransfusionsandimprovedclinicaloutcomesduringandaftercardiopulmonarybypass(CPB)

n Superiorgaseousmicroemboli(GME)handlingincomparisontocompetitivedesigns,helpingtoprotectpatientsfromapotentialsourceofneurologicaldamageafterCPB

n Adual-chamberreservoir,allowingacomprehensiveapproachtoenhancedbiocompatibilitythankstoitsuniquedesign,tothephosphorylcholinePH.I.S.I.OcoatingandtoitseasyconnectiontoSorinXTRA®

AutotransfusionSystem.n TheHeartLinkcardavailableinINSPIRE

PTSfortheactivationoftheHeartLinksystemfunctionalities,includingGDPMonitorTM

Before launching this new family, theINSPIRE oxygenator systems have beenextensivelyevaluatedclinicallyinaglobalMarketAssessmentStudyofover2.000patients.Reductioninprimingvolume,reservoirperformance,gasexchangeandheatexchangewere consistently ratedas themost compelling featuresof theINSPIREdevices.Thestudyreportedthatwhencomparedtocurrentoxygenatorsystems,INSPIREdevicesreducedprimingvolumeanddeliveredhigherhematocritduringCPB.

INSPIRE isakeycomponentofthenewHeartLinksystem,whichfacilitatesimprovementboth inpatientoutcomesand in thedailyperfusionpracticebyunlocking synergies between the key system components: S5/C5 heart-lungmachines,CONNECTperfusionchartingsystem, INSPIREfamilyofoxygenatorsandXTRAautotransfusionsystemandbyenablingtheimplementationofGoal-DirectedPerfusion.

For further information, please visit the Sorin Group booth #114.

Session 2: Challenging infectious diseases 12:30 Room I

Sorin Group launches a complete new family of adult oxygenators at eAcTS 2013

Piotr Yablonskii

Syed M Rehman John Radcliffe Hospital, Oxford

BothESC/EACTSandNICE(UK)haveissuedguidelinesrecommendingtheuseofintra-operativegraftevaluation.Technicalerrorisacontributingfactortograftfailure

andtheintra-operativegraftfailureratereportedintheliteratureis4%.Identificationoffailedgraftsbeforeleavingtheoperatingtheatregivessurgeonstheopportunitytorevisesuchgraftsandpotentiallypreventtheassociatedpoorclinicaloutcomeswhichincludemyocardialinfarctionanddeath.Conventionalangiographyisthegoldstandardfordemonstratinggraftpatency.However,itisnotpracticalforroutineintra-operativeuseduetoincreasedresourceimplicationsofpersonnel,facilities,timeandcost.Inaddition,ithasrisksduetobeinginvasiveand

requiringpotentiallynephrotoxiccontrast.Twotechniquesthataremorecommonlyusedinpracticeareintra-operativefluorescenceimaging(IFI)andtransittimeflowmetry(TTFM).

IFIusesindocyaninegreendye,which,wheninjectedintothebloodstream,bindsimmediatelytoplasmaproteinsandemitslightwhenilluminatedwithanear-infraredlightsource.Thisfluorescenceiscapturedonavideocamerawhichprovidesareal-timeimagesimilartoconventionalangiography.

TTFMisbasedontheprincipleoftransit-timeultrasoundtechnology.Itusesaflowprobe,whichholdsthegraftperpendiculartotwoultrasonictransducersandafixedacousticreflectorhousedwithintheprobe.Theultrasoundpulsesignalstransmittedfromthetransducerspropagatebothupstreamanddownstreamofthedirectionofbloodflowthroughthereflector.Theintegratedtransittime

thatmeasuresthedifferencebetweenthedurationtakenforsignaltravelbetweenthetwotransducersisusedtoprovideaprecisemeasureofflowvolume.

Specificmeasurementstakenaremeangraftflow,diastolicflowindex(thepercentageoftotalflowoccurringindiastolewhichshouldexceed50%ofmeangraftflow)andpulsatilityindexwhichisanestimateoftheresistancetograftflow.

Asummaryoftheliteraturedemonstratesthatintra-operativeimagingissafeanddoesnecessitategraftrevisionin3.4%(IFI)and5.4%(TTFM)ofcases.ThereisevidencethatahighpulsatilityindexrecordedwithTTFM,indicatingunsatisfactorygraftflow,isassociatedwithsignificantlygreatermajoradversecardiaceventsandmortality.

AnanalysisbytheUK’sNationalInstituteforHealthandClinicalExcellencesuggeststhatroutineuseofTTFMwouldresultinacostsavingofapproximately€135perpatient.Theuseofintra-operativeimagingforgraftevaluationisanimportantconceptforcardiacsurgeonstobefamiliarwithandtoconsideremployingintheirroutinepracticeofcoronaryarterybypassgraftsurgery.

Graft assessment: Intra-operative imaging

Session 3: Imaging in Coronary Artery Surgery 14:30 Hall D


Session 3: Complex surgery 15:30 Room F2

Giovanni Stellin University of Padua, Padua, Italy

earlytetralogyofFallot(ToF)repairhasbeenadvocatedsincemanyyearstoavoidthedeleteriouseffectsof:chroniccyanosisandspells,systemic-to-pulmonaryartery

shuntsandtheirconsequences,chronicRVoverloadandmyocardialcompensatoryhypertrophy.Atransatrial-transpulmonaryapproachavoidsalargerventriculotomyintotheRVbody,whenneeded.

InourInstitution,ToFrepairhasbeenperformedinyounginfantssincetheearly’80;earlyone-stagetrans-atrialrepair(within3-4monthsofage)sincetheearly’90.Afurtherevolutionofourtechniqueshasbeenrecentlydeveloped(2007)forsavingtheanatomicintegrityofthenativepulmonaryvalve(PV).

A‘classic’repairincludestheincisionofPVannulus,whenhypoplastic,leadinginevitablytoachronicpulmonaryregurgitationwithRVdilatationandfailure,inthelongterm.

BetweenJune,2007andDecember,2012,69patientsunderwentToFrepairinourInstitution.In39ofthem,balloonvalvedilatationandPVpreservationwasattempted.Itwassuccessfulin34.Thistechniqueincludes:1 PVcommissurotomy2 RVOTmusclebundlesresectionuptothePV

annulus3 TranstricuspidPVballoondilatation4 VSDpatchclosure5 PVreconstruction

Inhospitalandfollow-upresultswerecomparedtoasimilargroupof30patientswhounderwent“classicrepair”bymeansofatransannularpatch,duringthesameperiod.

Ourresultsshowthatwiththenewdilatationtechnique,PVcompetenceandRVfunctionarebetterpreserved,atdischargeandatthefollow-up.

WeconcludethatPVintegrityandfunctioncanbepreserved,inselectedpatients,duringearlyToFrepair,byconcomitantPVballoondilatationandPVreconstruction,leadingtoanimprovedRVfunction,inthemid-term.

Balloon dilatation right ventricular outflow tract in Fallots repair

Giovanni Stellin

Professional Development

10:00 Session 1: Teach the Teacher

Room 1

Moderators: G. Kitchingman, London; P. Newman, London

10:00 Introductions:Whoyouare;Yourteachingexperience;Whatyouwanttogainfromtheday

10:30 Learningstylesandteaching:Learningstyles;Overcomingbarrierstolearning

11:30 TheTeachingProcess:Whylearningobjectivesareimportant;Designingyoursessiontoengageyourlearners;Textureofcontent;Deliveringforoptimalimpact;Yourplatformskills;Measuringyourteachingeffectiveness?validation

12:15 Teachingtechniques:Afocusedstructure:‘KIM’;Gaininglearnerinteractioningroups;Usingquestions;Theeighttrainerbehaviours

14:00 Session 2: Teach the Teacher

Room 1

Moderators: G. Kitchingman, London; P. Newman, London

14:00 Whathaveyoulearned?Shortobservedtrainingsessionsandfeedback;Actionsforpersonaldevelopement

Thoracic

10:30 Session 1: Interactive Session on the Management of Challenging Mediastinal Cases

Room I

Moderator: F Melfi, Pisa; P.E. van Schil, Edegem

Illustrative cases will be presented by each speaker and discussed in an interactive way10:30 Cliff K C Choong

10:50 Jens Rückert

11:10 Pala Rajesh

11:30 Alan Sihoe

12:30 Session 2: Challenging infectious diseases

Room I

Moderators: D. Subotic, Belgrade; M. Lucchi, Pisa

12:30 Complextuberculosiscases Piotr Yablonskii

12:50 Fromaneasy-to-treattuberculosistoanightmare Alan Sihoe

13:10 Lunghydatidosis Dragan Subotic

13:30 Decendingnecrotisingmediastinitisfromodontogenicinfectiontoperitonitis Dejan Stojakov

14:00 Session 3: Controversies in sympathetic surgery

Room I

Moderator: E. Belcher, Oxford; D Mathisen, Boston

Illustrative cases will be presented by each speaker and discussed in an interactive way14:00 Gaetano Rocco

14:20 Jan Coveliers

14:40 Peter B Licht

15:15 Session 4: Major complications after thoracic surgery

Room I

Moderators: P.B. Rajesh, Birmingham; D. Mathisen, Boston

15:15 AmericanExperience(MajorAirway) Douglas Mathisen

15:30 EuropeanExperience(MajorAirwayandLung) Philippe Dartevelle

15:45 UnitedKingdomExperience(Pleura,ChestwallandBronchus) Maninder Kalkat

16:00 AustralianExperience(Airways,LungandMediastinum) Cliff K C Choong

Congenital

10:30 Session 1: Double outlet right ventricle

Room F2

Moderators: R. Jonas, Washington; B. Maruszewski, Warsaw

10:30 Morphologyofdoubleoutletrightventricle Andrew Cook

10:50 Classificationanddecisionmaking Damien Bonnet

11:10 Novel3Dimagingofdoubleoutletrightventricle Andrew Taylor

11:30 Methodsofsurgicalrepair Emile Bacha

11:50 WhatarethelimitsofBiventricularrepair Francois Lacour-Gayet

12:10 Long-termoutcomeandreoperation Virginie Lambert


Continued on page 8

S. Salzberg Heart Clinic Zurich, Klinik Hirslanden, Zurich, Switzerland

M. Emmert University Hospital Zurich, Switzerland

Surgicalrevascularizationremainsthetreatmentof choice for complex 3-vessel coronary

disease,leftmaincoronaryarteryinvolvementordiabetesmellitus.However,coronaryarterybypassgrafting (CABG) is limitedbyconcernabout thehigher stroke rate compared with PCI. Reportsof inferior neurological outcomes for CABG vs.PCIhaveprimarilyresultedfromstudiesinwhichconventional on-pump CABG techniques wereused,ratherthanoff-pumptechniqueswithaorticno-touchstrategies.

A growing body of evidence supportsclampless off-pump approaches to surgical

revascularization inordertominimizeneurologicinjury. By eliminating manipulation and aorticcross-clamping required for cardiopulmonarybypass,off-pumpcoronaryarterybypass(OPCAB)results in a lower incidence of stroke comparedto conventional CABG, particularly whenperformed in combinationwith complete in-situgrafting(doubleinternalmammaryarteryand/orT-orY-Grafting).Whileoff-pumpinsitugraftinghas been proposed as the ‘standard of care’ toreduce neurological complications, it may notbe applicable in everypatient. Inmany cases toachieve complete revascularization the use offreegrafts (arterialorvenous)requiringproximalanastomosis is necessary. In these situations,proximal anastomosis can be done without apartial clampbyusing theHEARTSTRINGdevice(MAQUET,SanJose,CA,UnitedStates).

In a propensity-matched analysis of 4314patients undergoing surgical revascularization atthe University Hospital Zurich, stroke incidencewassignificantly lowerwhenHEARTSTRINGwasused to perform proximal anastomoses during

OPCAB rather than the partial camp. Of note,thestrokeratefortheHEARTSTRINGgroupwascomparable to that of patients who underwentcompletelyno-touchinsitugrafting.(Figure1)

The use of the HEARTSTRING device can besafely implemented into routine clinical practicewithlittlelearningcurveandsignificantlyminimizesthe occurrence of stroke and other neurologicalcomplications compared with partial- or sidebite clamping. The combination of OPCAB andclamplessstrategieseitherusingcompleteinsitugraftingtechniquesorclamplessdevicessuchasHEARTSTRING for proximal anastomosis reducesstroke to levels comparable to PCI, representingasignificantadvanceoverconventionalon-pumpCABG.(Figure2)

Whileaorticcrossclamping(A)duringstandardon-pumpCABGaswellaspartialclampingusinga side-bite clamp during OPCAB (B) are wellestablishedasimportantriskfactorsforstroke,aclamplesstechniqueforproximalanastomosis(C)applyingtheHEARTSTRINGdeviceisaneffectivetoolforstrokereduction.

Only by these means can surgeons achievestroke rates similar or even lower than for PCI,henceendingthedebateaboutearlyneurologicaloutcomesafterCABG.References

1 Emmert MY, Seifert B, Wilhelm M, Grünenfelder J, Falk V, Salzberg SP. Aortic no-touch

technique makes the difference in off-pump coronary artery bypass grafting. J Thorac

Cardiovasc Surg. 2011 Dec;142(6):1499-506.

2 Emmert MY, Salzberg SP, Seifert B, Scherman J, Plass A, Starck CT, Theusinger O, Hoerstrup

SP, Grünenfelder J, Jacobs S, Falk V. Clampless off-pump surgery reduces stroke in patients

with left main disease. Int J Cardiol. 2012 Jun 21. [Epub ahead of print].

cABG comes with comparable stroke to PcI if the aorta is not clamped

Figure 1 – Stroke Rate by Operative Procedure in 4314 CABG Patients Figure 2 – Alternative Approaches to Proximal Anastomosis


Session 1: Proximal thoracic aortic disease – variations on a theme 10:30 Room E1

Adriana C. Gittenberger-de Groot Leiden University Medical Center, Leiden, the Netherlands

Duringcardiovasculardevelopmentinthehumanembryotheheartstartstobeatataboutthreeweeksofdevelopment.Atthattimepointtheheart,linedby

endocardium,isconnectedtothebodyoftheembryoatthevenouspolewherebloodofthesinusvenosusenterstheheartandatthearterialpolewherethebloodispumpedintoanaorticsacwhichisconnectedtoasystemofpharyngealoraorticarcharteries.Initiallythesearteriesaresolelylinedbyendothelium,whichiscontinuouswiththeendocardium.Toaddstrengthtothevascularwall,sothatitcanmanagehaemodynamicflowandpressure(althoughextremelylowintheembryo),smoothmusclecells(SMCs)arerecruitedtothevesselwall.

TheseSMCshaveaheterogeneousmesodermaloriginthatvariesalongthelengthoftheaorta.Duetospecificaorticpathologyinthevarioussegmentsitisofinteresttoinvestigatethesecontributionsandifpossibletheirspecificmorphogeneticbackground.Itisknownthatbesidesacontributionfromthesplanchnicmesoderm(currentlyreferredtoasanteriorsecondheartfield)neuralcrestcellsplayanimportantrolebesidesincontributingSMCs,alsoinseptationoftheaorticsacintoanascendingaorta

andapulmonarytrunk.Ahithertoneglectedsourcefortheintrapericardialpartoftheaortaarethearterialepicardiumderivedcells(EPDCs).Allthreecelltypesarenotonlyrelevantfortheformationofthemediaofthegreatarteriesbutalsoplayaroleintheformationofthemyocardialoutflowtract,outflowtractseptationandtheformationofthesemilunarvalvesfromtheendocardialoutflowtractcushions.

Studyofthehistopathologyofaneurysmformation(ordilation)oftheascendingaortashowsthattheaorticwallisintrinsicallydifferentinpatientswithatricuspidvalve(TAV)orabicuspidvalve(BAV)whichmightreflectadifferenceincontributionaswellas(epi)geneticdisturbanceinoneormoresmoothcellcomponents.IngeneralthedilatedaorticwallinTAVshowsmoresignsofinflammationandageing,whereastheBAVaorticwallhasanimmaturephenotype.

Thelatterisalreadyobviousinthenon-dilatedaorticwall.Aspecificdifferenceinproteinexpressionpatternsseemstosupportadifferenceinasusceptibleandanon-susceptibleBAVaorticwallfordilation.Followingtheseobservationsthereisalsoacaseforspecificpathologyoftheaorticarch(includingcoarctationoftheaorta)anddescendingaorta.ImplicationsforthetimingandchoiceofthesurgicalapproachinaorticreconstructivesurgeryandRossprocedureswillbeshortlyeludedto.

TheworkisperformedinamultidisciplinaryandmulticentreresearchgroupconsistingoftheDepartmentofAnatomyandEmbryology(ProfessorMarcoDeRuiter,MoniqueJongbloed),DeptartmentofCellBiology(ProfessorMarieJoseGoumans),DeptartmentofSurgery(JanLindeman),Cardiology(ProfessorAdrianaGittenberger-deGroot)andThoracicSurgery(NimratGrewal,ProfessorRobertKlautz,MeindertPalmen)allfromtheLeidenUniversityMedicalCentre(LUMC),theDeptartmentofThoracicSurgery(ProfessorAdBogers)ErasmusUniversityRotterdam,theNetherlandsandfurthermoretheDeptartmentofThoracicSurgery(ProfessorHansSievers,SalahMohamed)fromtheUniversitatsklinikumSchleswig-Holstein,Germany.

Proximal thoracic aortic disease-variations on a themeembryology of the aorta – from cells to an organ

Adriana Gittenberger-de Groot

Session 3: Complex surgery 15:30 Room F2

M.G.Hazekamp Leiden University Medical Center, the Netherlands

A videoisshownwhereinasix-week-oldinfantwithaorticarchinterruptiontypeB-2,malalignmentVSD(IAA-

VSD)andLVOTobstructionundergoesrepairoftheseanomaliesbymeansofaRoss-Konnoprocedureandrepairoftheaorticarch.

AorticarchinterruptionwithVSDisknowntobeassociatedtoobstructionoftheLVOT.However,inthemajorityofcasesLVOTobstructionbecomessignificantatalaterstageandtypically,aorticarchrepairandVSDclosureissufficientasafirstprocedure.WhenLVOTobstructionoccurslaterandafterinitialrepairofIAA-VSD,theRoss-

Konnoprocedureprovidesagoodsolution,especiallywhentheaorticvalvecannolongerbepreservedand/ortheLVOTshowstunnel-likenarrowing.

Inourpatienttheaorticvalveannulardiameterwasnomorethan3,4mm’satabodyweightof4,300gram(Z-score:–4)whichimplicatedthatsimplearchrepairandVSDclosurewouldbeinsufficient.BiventricularrepaircouldonlybeobtainedbyeitherRoss-KonnowitharchrepairorbyaYasuiprocedurewhereNorwoodandRastellitechniquesarecombined.Eachofthesetechniqueshasitsadvantagesanddisadvantages:thedisadvantagesoftheRoss-KonnobeingpossiblelatedilatationofthepulmonaryautograftandahighertechnicalcomplexitywhileanextracardiacRVtopulmonaryartery

conduitisapotentialdisadvantageoftheYasuioperation1,2.

Withanexperienceofnowover30Ross-Konnoproceduresthisapproachwasdecidedfor:afterremovalofaorticandpulmonaryrootstheoutletseptumwasresected,resultinginawideopenLVOT.WhenharvestingthepulmonaryautograftpartoftheanteriorwalloftheRVhadremainedattachedandwasusedtoclosetheVSDwhileatthesametimeaugmentingtheLVOT.A14mmbovinejugularveingraft(Contegra,MedtronicInc.,Minnesota,USA)wasusedasanorthotopicRVtoPAconduit.Withtheuseofaxenopericardialpatchanewaorticarchwascreatedadaptingitsproximalparttothewiderpulmonaryautograft.FiveyearslaterthepatientremainsingoodconditionwithawideopenLVOT,noinsufficiencyofthe

pulmonaryautograftandanunalteredRVtoPAconduit.References

1 Management options in neonates and infants with critical left ven-

tricular outflow tract obstruction. Alsoufi B, Karamlou T, McCrindle BW,

Caldarone CA. Eur J Cardiothorac Surg. 2007; 31:1013-21.

2 Ross and Yasui operations for complex biventricular repair in infants

with critical left ventricular outflow tract obstruction. Hickey EJ, Yeh T Jr,

Jacobs JP, Caldarone CA, Tchervenkov CI, McCrindle BW, Lacour-Gayet

F, Pizarro C. Eur J Cardiothorac Surg. 2010; 37: 279-88

Ross-Konno operation with concomitant aortic arch repair

M.G.Hazekamp

Marte Bliksøen and Marte Guro Valen University of Oslo, Norway

T heinnateimmunesystemmaynotdistinguishbetweenselfandnon-

self,butratherreactupondanger.Wehavepatternrecognitionreceptorsinourimmunecellsandalsoinnon-professionalimmunecellssuchascardiomyocyteswhichmayreactupondanger.Onewell-knowntypeofpatternrecognitionreceptorsarethetoll-likereceptorfamily.Patternrecognitionreceptorsrecognizemolecularpatternsonbacteriaandviruses,andprobablyalsoendogenousfragmentsofinjuredcells.Toll-likereceptors2and4arewellcharacterizedascontributorstowardsinjury

inacutemyocardialischemiaandheartfailuredevelopment.Toll-likereceptor9islesswellcharacterizedintheheart.ItisknowntorecognizebacterialDNA.Toll-likereceptorssignalthroughthetranscriptionfactornuclearfactorkappaB1.

Mitochondriaareevolutionaryendosymbiotsofbacteria,andcontaintheir

ownDNAwhichissimilartobacterialDNA.WewonderedifmitochondrialDNAinjuredbymyocardialischemiacouldactasadangersignalandevokeanimmuneresponsethroughtoll-likereceptor9signaling.Incardiactissue,wefoundthatmitochondrialDNAisinjuredbyischemia.Itleaksintothecirculationinhumanswith

acutemyocardialinfarctionundergoingrevascularizationwithPCI,andfromisolatedmouseheartswithinducedischemia2.Thecardiomyocyteexpressestoll-likereceptor9.ThecardiomyocytetakesupmitochondrialDNAfragmentsandinternalizesthem.CardiomyocytesstimulatedwithmitochondrialDNAhaveanincreasedcelldeath,signalingthroughtoll-likereceptor9andnuclearfactorkappaB.Themechanismofdeathmaybethroughalteredmitochondrialmembranepotential.

Wearecurrentlyexploringifcardioplegicarrestandreperfusionduringopenheartsurgery(CABG)leadstoleakageofmitochondrialDNAintothecoronarycirculation.Pilotstudiesindicatethatthisisthe

case.Furthermore,pilotstudiesindicatethatmitochondrialDNArepairenzymesareactivatedbycardioplegiaandreperfusioninleftventricularbiopsies,wheretoll-likereceptor9isupregulated.MitochondrialDNAleakingintothecirculationafteropenheartproceduresmaypotentiallycontributetothewhole-bodyinflammatoryresponseseenaftermajorsurgery.InhibitionofmitochondrialDNAmaypotentiallyalleviatepostoperativeinflammation.References

1 Valen G, Yan Z-Q, Hansson GK. Nuclear Factor kappa-B

and the heart. Journal of American College of Cardiology

2001;38;307-314.

2 Bliksøen M, Mariero LH,Ohm I, Haugen F, Yndestad A,

Solheim S, Seljeflot I, Ranheim T, Aukrust P, Valen G, Vinge

LE. Mitochondrial DNA released into the circulation during

myocardial infarction may be immunogenic. Int J Cardiol

2012;158:132-134.

Mitochondrial DNA: a danger signal in the heart?

Guro Valen

Session 1: The enemy from within 10:30 Hall P

13:30 Session 2: Rheumatic and congenital mitral valve disease

Room F2

Moderators: C. Brizard, Melbourne; J.V. Comas, Madrid

13:30 Morphologyofrheumaticandcongenitalmitralvalvedisease Andrew Cook

13:45 Surgeryforcongenitalmitralvalvestenosis Pedro Del Nido

14:00 Surgeryforcongenitalmitralvalveregurgitation Emre Belli

14:15 Surgeryforrheumaticmitralvalvedisease Kirsten Finucane

14:30 Whatcanwelearnfromtheadultmitralvalvesurgeons? Robert Dion

15:30 Session 3: Complex surgery

Room F2

Moderators: E Bacha, New York; O Ghez, London

15:30 Ross-Konnowitharchrepair Mark Hazekamp

15:40 Doubleoutletrightventriclewithnon-committedventricularseptaldefect Emre Belli

15:50 NikaidoProcedure Viktor Hraska

16:00 TheSenningProcedure David Barron

16:10 Aorticrootrestorationwithasub-aorticring Domenico Mazzitelli

16:20 BalloondilatationrightventricularoutflowtractinFallotsrepair Giovanni Stellin

Vascular Disease Domain

10:30 Session 1: Proximal thoracic aortic disease – variations on a theme

Room E1

Moderators: M. Borger, Leipzig; M. Grabenwöger, Vienna

10:30 Embryologyoftheaorta–fromcellstoanorgan Adriana Gittenberger-de Groot

10:45 Updateonvalveandaorticguidelines Ruggero De Paulis

11:00 Bicuspidaorticvalveinaorticdissection Christian D. Etz

11:15 Aorticvalvediseaseinconnectivetissuedisorders Duke Cameron

11:30 TheRossoperation–why,who,howandhownotto Alain Prat

13:00 Session 2: EACTS/STS aortic – Part I: Circulation management, temperature and neuroprotection

Room E1

Moderators: J.E. Bavaria, Philadelphia; J. Bachet, Paris

13:00 Temperaturemanagementandneuroprotectioninaorticsurgery?TheEuropeanperspective Thierry Carrel

13:15 Visceralprotectionduringsurgeryofthethoracicaorta:thesafetyofmoderatehypothermia Davide Pacini

13:30 Selectiveantegradecerebralperfusionwithdifferentbloodflowrates:aretheredifferencesincerebraltissueoxygenationandmeancerebralbloodflowvelocity? Reto Basciani

13:45 Temperaturemanagementandneuroprotectioninaorticsurgery–theAmericanperspective Edward Chen

14:00 Anewindicatorofpostoperativedelayedawakeningaftertotalaorticarchreplacement Tomonori Shirasaka

14:15 Aorticarchsurgeryforoctogenarians:Isitjustified? Hiroshi Kurazumi

15:00 Session 3: EACTS/STS aortic – Part II: Circulation management, temperature and neuroprotection

Room E1

Moderators: J Coselli, Houston; C Mestres, Barcelona

15:00 Unilateralvs.bilateralperfusionforcerebralprotection–theneedforaprospectiverandomizedtrial Paul Urbanski

15:15 Differentialselectivehypothermicintercostalarteryperfusion:anewmethodforconfirmingspinalcordperfusionduringthoracoabdominalaorticaneurysmrepair Yoshikatsu Saiki

15:30 CurrentpracticeofneuroprotectioninEurope–TheEACTSsurveyinEurope Ruggero De Paulis

15:45 Embolismisemergingasamajorcauseofspinalcordinjuryafterdescendingandthoracoabdominalaorticrepairwithacontemporaryapproach Hiroshi Tanaka

16:00 CurrentpracticeofneuroprotectioninJapan–TheEACTSsurveyinJapan Yukata Okita

16:15 Finalremarksandclose


Marte Bliksøen

Mitochondrial DNA: a danger signal in the heart?


Klaus T Preissner Justus-Liebig-University, Giessen, Germany

Duringacutemyocardialinfarction,cardiomyocytedeathoccursandhasapredominantimpactonthequalityoflifeandsurvivalofpatientssufferingfrom

coronaryarterydisease,themosteminentsinglecauseofdeathinindustrializedcountries.Duetotheocclusionofcoronaryvesselsbyarterioscleroticplaquematerial,largelydecreasedoxygensupply(termedischemia)ofthemyocardiumdeterminesthediseaseoutcome.Despitereopening/reperfusionofstenosedvessels,amajororgandamageremains.Theinitialmechanistictriggersofthismyocardial“ischemia/reperfusion(I/R)injury”remaingreatlyunexplained.Wehaveuncoveredandcharacterizedhypoxia/ischemia-drivenmechanismsthatarethebasisforthepathogeneticphenomenaofI/Rinjuryintheheart.

Basedonpreviouslyreporteddatafromourgroup,extracellularRNA(eRNA,derivedduringvascularinjury,celldeathetc.)servesasanimmediatealarmsignalofstressedordamagedtissue,therebypromotingthrombosis,inflammationoroedemaunderpathologicalconditions.Hereweshowthatfactorsfromthedamagedcardiactissueitself,inparticulareRNAandtumor-necrosis-factor-a(TNF-a),maydictateI/Rinjury.Followingmyocardialischemia/reperfusion(I/R)inmiceorI/RinducedintheisolatedLangendorffratheart,increasedeRNAlevelswerefoundtogetherwithcardiacinjurymarkers.Likewise,eRNAwasreleasedfromcardiomyocytesunderhypoxiaandsubsequentlyinducedTNF-aliberationbyactivationofTNF-aconvertingenzyme(TACE)andprovokedcardiomyocytedeath.Conversely,TNF-apromotedeRNAreleaseespeciallyunderhypoxia,feedingaviciouscelldamagingcycleduringI/R.AdministrationofRNase1orTAPI(TACE-inhibitor)preventedcelldeathandmyocardialinfarction.Likewise,RNase1

significantlyreducedI/R-mediatedenergyexhaustion,openingofmitochondrialpermeabilitytransitionporesaswellasoxidativedamageincardiomyocytes.Finally,adramaticincreaseofendogenousvascularRNase1inhumansubjectswasachievedbyinducingnon-invasiveintermittentlimbI/Rusinganexternaloccluder,therebyprovingtheimpactoftheeRNA/RNasesysteminremoteischemicpreconditioning.

Basedontheaccumulationofinvitroandin vivofindings,non-toxic,thermostableRNase1orTAPI(inhibitorofTACE/ADAM17)mayoffernovelandsafetreatmentstopreventtissueandorgandamage,asshownherefortheheart.Theuncoveredfundamentalpatho-mechanismsarelikelyoperativeinotherorgansandtissuesaswell,suchthattheproposedinterventionshavemajorimpactfortheapplicationofnoveltherapeuticregimeninmedicine.AlthoughendothelialcellsasamajorsourceofvascularRNase1doproduceandsecretethenucleaseintothebloodstream,itsnormalconcentrationisinsufficienttocombattheacutelife-threateningsituationofI/Rinjury.However,initialclinicalstudiesrevealedadramaticincreaseofendogenousvascularRNase1inhumansubjectsbyinducingnon-invasiveintermittentlimbI/Rusinganexternaloccluder.

Damaging nature of endogenous RNA in cardiac ischemia/reperfusion injury

Session 1: The enemy from within 11:10 Hall P

Klaus Preissner

Session 2: EACTS/STS aortic session: Part I 13:00 Room E1

Davide Pacini Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Antegradeselectivecerebralperfusion(ASCP)providesexcellentprotectionofthebrainduringaorticarchsurgery1-5and

differentstrategiesarecurrentlyinusebasedonindividualsurgicalexperience6-10.Althoughtheidealdegreesofsystemichypothermiaandtheoptimalflowrateofcerebralperfusionarenotfullyestablished,moderatesystemichypothermiaappearstobeasafeandreliabletoolforbrainprotection11,12.

However,theissueofdistalorganprotectionwiththistechniqueremainstobeclarified.TheaimofthestudywastoretrospectivelyevaluatetheoutcomeofaorticarchsurgeryusingASCPatdifferentsystemictemperaturesinordertoassesstheeffectivenessofthemoderatehypothermia(26°Cofnasopharyngealtemperature)invisceralorganprotection.Forthisreasonweincludedpatientswhounderwentelectivethoracicaortarepair;andexcludedpatientswhohadearlypost-operativelowcardiacoutputsyndromebecausethisconditionaffectsvisceralorganfunction.

Threehundredandfourpatientswere

enrolledinthestudyanddividedintotwogroupsbasedondegreeofsystemichypothermiaduringHCA:GroupAwithnasopharyngealtemperaturemaintainedat25°Corlower(194patients)andGroupBwithnasopharyngealtemperaturehigherthan25°C(110patients).

Theoverallin-hospitalmortalitywas4.6%(14patients)withoutsignificantdifferencebetweengroups.Therewerealsonodifferencesintheincidenceof

postoperativecomplications.Creatinine,aspartateaminotransferase

(AST),alanineaminotransferase(ALT)andbilirubin,wereexaminedpreoperativelyandpostoperativelyasbiochemicalmarkersofvisceraldysfunction.Renaldysfunctionwasdefinedbyapostoperativeserumcreatininelevelofatleast2.0mg/dloranincreaseincreatininetotwicethebaselinelevel.Liverdysfunctionwasdefinedasapostoperativebilirubinlevelgreaterthan2.5mg/dloranincreaseofASTandALTvaluesgreaterthantwicethebaselinelevel.

Twenty-fivepatients(8.2%)hadisolatepostoperativerenaldysfunctionandforty-one(13.5%)hadassociatedrenalandliverdysfunctionwithoutsignificantdifferencesinincidencebetweenthetwogroups.Isolatedliverdysfunctionoccurredin69patients(22.7%).TheincidencewashigheringroupA(25.8%)thaningroupB(17.3%);however,thedifferencedidnotreachstatisticalsignificance.

Atmultivariateanalysis,CPBtimelongerthan180minuteswastheonlyindependentriskfactorofrenalandhepato-renaldysfunction(OR=2.16;CI1.21-3.86;P=0.010),andtemperaturewasnotfoundtobeariskfactor.Instead,atemperature>25Cwasshowntobeanindependentprotectivefactorforliver

dysfunction(Figure1).Thissuggeststhereductionofreperfusionorganinjuriesinwarmertemperatures,especiallywhensurgicalproceduresarecompletedwithinatimeperiodofvisceralcirculatoryarrestnotexceeding60minutes13.

Inconclusion,moderatesystemichypothermiaatanasopharyngealtemperature>25°Chasbeendemonstratedtobenolesseffectivethanlowerhypothermiclevelsinvisceralorganprotection.Moreover,moderatehypothermiaat26°Cshouldbepreferred

forperiodsofvisceralischemialessthan60minutesbecauseitmayreducereperfusionorganinjury.References

1. Bachet J, Guilmet D, Goudot B, Dreyfus GD, Delentdecker P, Brodaty D, Dubois C: Antegrade cerebral perfusion with cold blood: a 13-year experience. Ann Thorac Surg 1999, 67(6):1874-1878; discussion 1891-1874.2. Griepp RB: Cerebral protection during aortic arch surgery. J Thorac Cardio-vasc Surg 2001, 121(3):425-427.3. Kazui T, Yamashita K, Washiyama N, Terada H, Bashar AH, Suzuki K, Suzuki T: Aortic arch replacement using selective cerebral perfusion. Ann Thorac Surg 2007, 83(2):S796-798; discussion S824-731.4. Harrington DK, Walker AS, Kaukuntla H, Bracewell RM, Clutton-Brock TH, Faroqui M, Pagano D, Bonser RS: Selective antegrade cerebral perfusion at-tenuates brain metabolic deficit in aortic arch surgery: a prospective random-ized trial. Circulation 2004, 110(11 Suppl 1):II231-236.5. Pacini D, Di Marco L, Leone A, Tonon C, Pettinato C, Fonti C, Manners DN, Di Bartolomeo R: Cerebral functions and metabolism after antegrade selec-tive cerebral perfusion in aortic arch surgery. Eur J Cardiothorac Surg 2010, 37(6):1322-1331.6. Di Bartolomeo R, Pacini D, Di Eusanio M, Pierangeli A: Antegrade selective cerebral perfusion during operations on the thoracic aorta: our experience. Ann Thorac Surg 2000, 70(1):10-15; discussion 15-16.7. Urbanski PP, Lenos A, Bougioukakis P, Neophytou I, Zacher M, Diegeler A: Mild-to-moderate hypothermia in aortic arch surgery using circulatory arrest: a change of paradigm? Eur J Cardiothorac Surg 2012, 41(1):185-191.8. Spielvogel D, Etz CD, Silovitz D, Lansman SL, Griepp RB: Aortic arch re-placement with a trifurcated graft. Ann Thorac Surg 2007, 83(2):S791-795; discussion S824-731.9. Misfeld M, Leontyev S, Borger MA, Gindensperger O, Lehmann S, Legare JF, Mohr FW: What is the best strategy for brain protection in patients undergoing aortic arch surgery? A single center experience of 636 patients. Ann Thorac Surg 2012, 93(5):1502-1508.10. Zierer A, Detho F, Dzemali O, Aybek T, Moritz A, Bakhtiary F: Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: sin-gle-center experience in 245 consecutive patients. Ann Thorac Surg 2011, 91(6):1868-1873.11. Pacini D, Leone A, Di Marco L, Marsilli D, Sobaih F, Turci S, Masieri V, Di Bartolomeo R: Antegrade selective cerebral perfusion in thoracic aorta surgery: safety of moderate hypothermia. Eur J Cardiothorac Surg 2007, 31(4):618-622.12. Khaladj N, Peterss S, Oetjen P, von Wasielewski R, Hauschild G, Karck M, Haverich A, Hagl C: Hypothermic circulatory arrest with moderate, deep or pro-found hypothermic selective antegrade cerebral perfusion: which temperature provides best brain protection? Eur J Cardiothorac Surg 2006, 30(3):492-498. 13. Qing M, Vazquez-Jimenez JF, Klosterhalfen B et al. Influence of tempera-ture during cardiopulmonary bypass on leukocyte activation, cytokine balance, and post-operative organ damage. Shock 2001; 15:372-377.

Visceral organ protection in aortic arch surgery: safety of moderate hypothermia

Davide Pacini

Figure 1: Multivariate analysis

NeW smartcanulas® for MIcS and ecMOBy Prof. Ludwig K. von Segesser Cardio-Vascular Research, CHUV, Lausanne, Switzerland

The original idea for the developmentof the smartcanula® was to build a

peripheral vascular access device providingfull flow with gravity drainage alone.The consecutively developed “collapsedinsertion and expansion in situ” principleresulted in temporary caval stenting withshape-memorymaterials(Fig.1),andprovedto be most promising for superior venousdrainageduringcentralandremoteaccessCPB for standard and minimally invasivecardiac surgery, complex cardio-thoracicprocedures,andECMO.Fiftypercenthigherflowsandcompletecardiacunloading(Fig.2)canbeachievedwiththeself-expandingsmartcanula® S although introducedthroughperipheralveins.Lateron,itturnedout that smaller smartcanulas® compatiblewithcentrifugalpumpsorvacuumprovidealso superiorperformanceas compared to

traditionalpercutaneouscannulas:The MICS smartcanula® ST is designed

forperipheralcannulationofthecavalaxiswithpercutaneous techniquesandcanbeused in combination with a centrifugalpump or vacuum for augmentation. TheMICS smartcanula® ST comes in 24F, and20F configurationswith several lengths. ItisCE-markedforroutineuseup-to6hours.

The ECMO smartcanula® STC isdesigned forperipheral cannulationof thecavalaxiswithpercutaneoustechniquesandcanbeconnecteddirectlytoan integratedpump-oxygenator structure. The ECMOsmartcanula® STC comes in 24F, and 20Fconfigurationswithseverallengths.ItisCE-markedforlongertermuseup-to28days.

The original smartcanula® S designedfor gravity drainage can also be used incombination with the smart dilator set(8F-24F)whereasthesyntheticsmartcanula®Pismadeforroutineusewithcentralaccess.Forbetterflow,checkout:

www.smartcanula.com

Fig. 1: The smartcanula® is built from shape-memory materials and changes its configuration once inserted into a vessel:

superior performance results!


Jo Cook John Radcliffe Hospital, Oxford, UK

AsaResearchNursecurrentlyworkingontheArterial

RevascularisationTrial(ART),followinguppatientsfor10yearspostcardiacsurgery;Ihaveidentifiedseveralinterestingtrendsthroughthetelephoneconversations,withpatients,aspartoftheirfollow-up:nPatient’snon-adherencetomedicationand

treatmentpostdischargefollowingCABGnVariationinGP’smonitoringof

cardiovascularrisknImplicationsforresearchIhaveusedthedatafromourcohortof427patients,recruitedattheJohnRadcliffehospitalinOxfordandhavechosentolookataspirinandstatinmedicationandGPsurgeryvisits

nTheArterialRevascularisationTrial(ART)isaUniversityofOxford,multi-centre,international,randomisedcontroltrial;fundedbyboththeMRCandBHF.

nProfessorDPTaggartistheprincipleinvestigatorforARTandhasbeenextremelysupportiveandencouragingwiththiswork.

nTheaimofARTistoevaluatewhethertheuseofbothIMA’sduringCABGimprovessurvivalandreducestheincidenceofrecurrentchestpainand/ortheneedforfurtherintervention,comparedtousingoneIMA.

n3,102patientswererecruitedin28centresandsevencountries.

nPatientswererandomisedtoeitherSIMA(SingleIMA)orBIMA(BilateralIMA)andondischargearefollowedupbytelephoneandpostyearlyfor10years.

nTheprimaryoutcomeissurvivalat10years;secondaryendpointsincludeclinicalevents,reinterventionandcost

effectiveness.MypresentationhighlightstheimportanceofsecondarypreventionandbothGPandpatientapproachestothis;datafromourpatientcohort

regardingthereasonsfor‘nottakingmedication’and‘notregularlyseeingtheirGP/practicenurse’.

Ihavealsoidentifiedsomefutureconsiderations,namely,whatpercentageofdataisaffectedbythepatient’snon-adherenceandGP’svaryingadherencetoguidelinesandhowsignificantisthiswhenanalysingcardiacevents,readmissionsandreinterventions.

ItisimportanttonotethatalthoughthefigurespresentedshowahighcompliancewithbothmedicationandGPsurgeryvisits,forthepurposesofthispaperandcertainlyfromanursingperspective,IamfocusingonthepercentageofpatientsNOTadheringandexaminingthereasonsbehindthiswhichmayhaveimplicationsforbothresearchandnursingpractice.Thisisacommentarypaperonlyaimedtoraisesomeinterestingpointsfordiscussion.

The patient, the GP, the primary care team: their relationship, adherence to treatment and the implications for research

Figure 1

Nicolas M Van Mieghem Thoraxcenter, ErasmusMC, Rotterdam, The Netherlands

ItonlytookonedecadefortheTranscatheterAorticValveImplantation(TAVI)technologytosurgetoanestablishedtreatmentstrategyforapotentiallyvastgroupofpatientswithsymptomaticaorticvalvestenosis.Afteragradualbuild-upbymeansofcasereportsand

single-centrecohortstudies,largenationalandinternationalregistriespavedthewaybydemonstratingproceduralsafetyandshort-termefficacy.TherandomizedPlacementofAorticTranscatheterValves(PARTNER)trialcreatedtheevidentrationalfundamentsfortheEuropeanSocietyofCardiology(ESC)andEuropeanAssociationofCardio-ThoracicSurgery(EACTS)toformulateastrongrecommendationforTAVIinpatientswithsymptomaticsevereASwhoaredeemedinoperableandidentifyTAVIasalternativetosurgicalvalvereplacementiftheoperativeriskisconsideredtobehigh.Absolutelyfundamentaltotheserecommendationsisthe

installmentofatruemulti-disciplinaryheartteamconsistingofacoreminimumofinterventionalcardiologistsandcardiacsurgeonsandideallycompletedbycardiacimagingspecialistsand(cardiac)anesthesiologists.AsaninterventionalcardiologistIthereforeshouldconsidermyselfanalliedprofessionaltomycardiacsurgerycolleagues.Butbordersarefading.TransfemoralTAVIproceduresareconsideredthestrategyoffirstchoiceinmostcentersandcanbeperformedbybothcardiologistsandsurgeons.InErasmusMedicalcenter–asintheHeliosCenterinHamburg-alsothetransaxillaryapproachhasbeenexecutedincompletepercutaneousfashionusingpercutaneoussuturebasedclosuredevices.Inallhonesty,we,inErasmusMC,haveabandonedthispercutaneousapproach;theaxillaryarterydidnotseemappropriateforthesekindsofsuturebasedclosuredevicesanddefinitelyprovedinferiortoasurgicalcut-downandcontrolledaccess.

Maybefuturedevelopmentsindedicatedclosuredevicesforlargearteriotomiesprovemorereliable.Thatbeingsaidinthetransapicalscene,

interestingnewclosuredevicesseemtoworkandmayconverttransapicalTAVIintoacompletelypercutaneoustechnique.Itmayevenrejuvenatethetransapicalaccessoption,makingitmoreaccessibletocardiologistsandimportantlylesspainfultopatients.

Onadifferentnote,three-dimensionalimagingmaycontributesignificantlytobetterTAVIoutcomebydemonstratingreductionsintheincidenceofmoderatetosevereparavalvularaorticregurgitationandevenimprovingsurvival.ClearlythestagehasbeensettoexploretheefficacyandsafetyofTAVIinpatientswithaloweroperativerisk.Howtodetermineapatient’sriskisstillamatterofdebate.ClearlytheestablishedriskmodelsliketheSocietyofThoracicSurgeons(STS)scoreorthe(logistic)EuropeanSystemforCardiacOperativeRiskEvaluation(EuroSCORE)comeshortinrisk-estimatingoctogenarianswithascalaofco-morbidities.Still,thecurrentlyongoingorrecentlycompletedSURgicalreplacementandTranscatheterAorticValveImplantation(SURTAVI)andPARTNERIIhavebeenrelyingontheSTSscoreof4toidentifyapatientashavingatleastintermediateoperativerisk.TheuseofanSTSscoreforriskstratifyingpotentialTAVIcandidatesmaybeaflawasitignoresrelativelycommonriskvariablessuchasfrailty,hostilechestandporcelainaorta.Regardless,ifPARTNERIIandSURTAVIconfirmthenon-inferiorityofTAVItoSAVRthenextimportantmissinglinkwillbethedurabilityofTHV.ThefollowingyearswillcertainlyzoominonthispieceoftheTAVIpuzzle.

The transcatheter aortic valve implantation debate The view from the allied professionals

Session 1: Moving Borders 08:45 Hall K



David Lizotte Rockingham Memorial Hosptial, Harrisonburg, VA, USA

Inthemid-1960s,physiciansandacademicsintheUnitedStatesrealizedtherewasashortageofprimarycarephysicians.EugeneA.SteadJr.,MD,oftheDukeUniversityMedicalCenter,puttogether

thefirstclassofPhysicianAssistants(PA)in1965,basingthecurriculumofthisfirst-of-its-kindprogramonhisknowledgeofthefast-tracktrainingofdoctorsduringWorldWarII.Inkeepingwiththistheme,heselectedNavycorpsmenwhohadreceivedconsiderablemedicaltrainingduringtheirmilitaryserviceasmembersofhisfirstclass.ThefirstPAclassgraduatedfromtheDukeUniversityPAprogramonOct.6,1967.ThePAconceptgainedacceptanceandbackingbytheUSgovernmentasearlyasthe1970sforitwasseenasacreativesolutiontophysicianshortages.Thephysiciancommunityhelpedsupporttheprofessionandfacilitatedthedevelopmentofaccreditation

standards,establishinganationalcertificationandstandardizedexamination,anddevelopingcontinuingmedicaleducationrequirements.

JohnWebsterKirklin,MD,awellknowcardiothoracicsurgeon,foundedthefirstformaleducationalprogramtotrainsurgicalphysicianassistants.Dr.Kirklinandhiswife,Dr.MargaretKirklin,theprogram’sfirstAcademicDirector,startedtheUniversityofAlabamaatBirmingham’sSurgeonAssistanttrainingprogramin1967.ThefocusoftheprogramwasinspiredbyDrKirklin’spositionasaleaderincardiacsurgeryandprovidedanemphasisoncardiacsurgicaltraining.ThisenabledmanyPAstoenterthespecialtyofcardiothoracicsurgeryintheUnitedStates.Overthecourseofthenext46years,PAsbecameanintegralpartofthecardiothoracicsurgicalteam.Wearefirstassistantsinallcardiothoracicsurgeriesfromthesimplestmediastinoscopiestothemostcomplexaorticsurgeriesandtransplantation.Wehavebeenpartnersinthe

developmentandimplementationofnewandexcitingtechnologiesthatdirectlybenefitcardiothoracicsurgerypatients,themostnotablebeingendoscopicvesselharvesting.Weperforminvasiveproceduresindependentlysuchaschesttubeplacement,centralandarteriallineplacement,thoracentesis,Swan-GanzplacementandIABPplacement.WeareactiveparticipantsinthecareofthecardiothoracicsurgicalpatientinallarenasincludingtheICUandstepdownfloorswheretheyoftenfunctionashouseofficers.PAservicesarebillabletoinsuranceandPAsareabletoprescribemedicationsinall50states.

AswefaceagrowingphysicianshortageintheUnitedStatesforourspecialty,ourservicesareevermoreindemand.Weareproudofourhistoryandanticipatewithgreatexcitementourfuture.Inatimeofneedphysicianswithgreatvisioncreatedapathforthedevelopmentofourprofessionthatremainsgroundedintheteamapproach.Aswefaceournext50yearsasaprofession,wearepoisedtoplayanevengreaterandexpandingroleinhealthcaredeliveryintheUnitedStates.

The American perspective

David Lizotte

European Quality Improvement Programme

T heNursing&AlliedHealthProfessionsgroupisoneofthesixgroupssupportedbytheEACTSQualityImprovementProgramme,toimproveoutcomesforpatientsacrossEurope.ThegroupischairedbyTaraBartley(Birmingham,UK)andaimsto

createaframeworkfordeliveringhighqualitynursingcareacrossEurope.Thegrouparecurrentlyworkingwithnursingandalliedhealth

professionalteamstodefinepracticesthatarealreadyinplacetodeliverqualitycaretopatients,andtoidentifykeyareasforimprovingcarefor

patients.Colleagueshavebeenaskedtoprovidedetailsofanycurrentdepartmentalprotocolsthatareinplacetodeliverqualitystandardcare,andtosuggestareaswherequalityimprovementinitiativescouldimproveoutcomesforpatients.Anonlinesurveyhasalsobeendevelopedtoseekpractitionerperspectiveonqualityissuesinrelationtopatientoutcomes(www.eacts.org/quip/outcomes-survey).Colleaguesfromnursing,surgicalcarepractitioners,physicianassistants,pharmacists,physiotherapistsandmembersofthemultidisciplinaryteamareencouragedtoparticipate,asthesurveywillprovidevaluableinformationfortheproject.

AnupdateontheEuropeanQualityImprovementProgrammewillbegivenaspartoftoday’sPostgraduateEducationsession:Nurse,NursePractitionersandPhysicianAssistantsProgramme.Amemberofthe

qualityimprovementteamwillalsobeavailableattheEACTSexhibitionstand(HallXL,Booth148)atthefollowingtimestoanswerquestions:nSunday6October: 17:00–19:00nMonday7October: 09:00–10:00

13:00–14:00 15:45–16:30

nTuesday8October: 09:00–10:00 13:00–15:15

JenavalveAdvert


Charlotte Brun Thorup Aalborg University Hospital

Aftertheimplementationofsupportiveprecautionsforpatients,followingsternotomyincardiacsurgery,aneedfor

knowledgeaboutthepatients’experiencesaroseAliteraturereviewrevealedthatnostudiesexistedwhichfocusedonthepatients’experiences,livingwithprecautionsaftercardiacsurgery.Aim:Toexplore.

Aftermidlinesternotomypatientsare

instructedonactivityprecautionstoavoidsternalwoundcomplications.InDepartmentofCardiothoracicSurgery,CenterforCardiovascularResearch.AalborgUniversityHospital,wedidquestionhowrestrictivethoseprecautionsshouldbe,sincetheymightleadtoadecreaseinqualityoflifeinthepostoperativeperiod.Aliteraturereview(CINAHL,PubMed,CochraneLibraryandPedro)weremaderesultinginthefollowingprecautions:navoidstretchingbotharmsbackwardsat

thesametimefor10days

nloadedactivityshouldbedonewiththeelbowsclosetothebody

nonlymovearmswithinpainfreerangenuselegrollingwithcounterweighting

whengettinginandoutofbednprotectsternumwhencoughingby

crossingthearmsina“selfhugging”posture

nusesupportivesternalvestwhencoughingconstantlyorwhenBMI≥35,and

nusesupportivebrawhenbreastcup≥D.Wefoundnoevidencetosupportweightlimitationregardingactivity,aslongastheupperarmsarekeptclosetothebody,andactivitywithinpain-freerange.Coughisconsideredthemostimportantsinglemechanicalstressfactorcausinginstability.

Afterimplementingtheseprecautions

weperformedastudyonhowpatientsexperiencelivingwiththeseprecautionsaftercardiacsurgery.Thestudyconsistedofsemi-structuredinterviewswithpatientssixtoeightweeksaftercardiacsurgery.Patients’experienceswereexpressedinthefollowingthemes.“Logicalorbodilyexperiencedmeaningoftheprecautions”,“Cognitiveorphysicalcomprehensionoftheprecautions”and“difficultyinmanagingtheprecautions”.Alltogether,thepatientsexperienceddifficultieswithmanagingtheprecautionsinthepostoperativeperiod,butstilltheyusedtheprecautionsasguidelines.Theyweremotivatedbythepromiseofapositiveachievement,oravoidanceofnegativeresults.Thepatientsalsosuggestedamoreindividualfocus.

Postoperative mobilisation after sternotomy

Bart Meyns University Hospital Leuven, Leuven, Belgium

Forambulatorychronicheartfailure

patientsrefractorytomedicationandwhoarenotappropriatecandidatesfor,orhavefailed,cardiacresynchronization,therearefewoptionsavailable.LVADsareintendedforthesickestpatients,butduetotheinvasivenessofthesurgery,oftenarenotconsideredforelderlypatientswhomayalsobefrail.

ArecentanalysisfromtheINTERMACSdatarevealedthatolderage(definedas

>70years)isanindependentpredictorofmortalityduringfollow-upafterLVADimplantation.Nonetheless,midtermsurvivalintheoldercohortwasstillreasonable(63%attwoyears)1.

Withthisinmind,theconceptofalessinvasivesupportoptionisattractiveforthefrailelderlypatient.

TheSYNERGYCirculatorySupportSystemissuchadevice.Asamicro-bloodpump–approximatelythesizeandweightofaAAbattery–theSYNERGYSystempumpsupto4.25L/minofbloodandreducestheheart’sworkload,improvingbloodflowtovitalorgans.Thesystemissurgicallyimplantedusingamini-thoracotomy,withthemicro-pumpplacedinapacemaker-likepocket.Itisdesigned

totreatambulatorychronicheartfailurepatientsclassifiedasINTERMACS4-6(i.e.non-inotropedependent).

WerevieweddatafromtheCEMarkEuropeantrialoftheSYNERGYSystem,andcomparedoutcomesforpatients≥70yearsandthose<70years,in54patientsoverafive-yearenrollmentperiod2.

Themaindifferencebetweengroupswasthebaselinetherapy;theolderpatientshadagreatertendencytobetreatedwithallpossibledevicetherapiespriortoconsideringcirculatorysupport.Additionally,itwasobservedthattheyoungerpatientsdemonstratedashorterlengthofsupport(averagedurationof188days)inabridgetotransplantscenarioasopposedtoolderpatients(averagedurationof337days),

wherecirculatorysupportwasmostcertainlyviewedasdestinationtherapy.

Thedatashowthatolderandyoungerpatientsexperiencesimilarimprovementsinhemodynamics(pulmonarycapillarywedgepressure-9±16vs-10±8mmHg;CO+1.0±0.7vs0.9±1.0l/min;PVR-1.2±1.5vs0.8±1.7Wood)andfunctionalstatus,includingsimilaraverageimprovementinthesix-minutewalktest(107±120vs130±121m).Theoveralladverseeventratewascomparable,althougholderpatients,asobservedinpreviousanalyses,hadasomewhathigherrateofbleeding.Infectionsrelatedtothedeviceordrivelinealsowerelimitedintheoldercohorttoaratecomparabletotheyoungerpopulation.Despiterenalfunctionbeingcompromised

intheolderpatients,thisdidnotresultinahigherrateofacutefailurepost-operativelyorinthelongrunofchronicsupport.

Theseoutcomesshowusthatminimally-invasivecirculatorysupport,benefitsyoungerandolderpatientsequallywell,andiswell-suitedasbothanearlyinterventionandanefficacioustreatmentforfrailambulatorychronicheartfailurepatients.References

1 Atluri P, Goldstone A, Kobrin D, Cohen J, MacArthur J, Howard J, Jessup

M, Rame E, Acker M, Woo J. Ventricular assist device implant in the elderly is

associated with increased, but respectable risk: a multi-institutional study. Ann

Thorac Surg 2013;96:141-147.

2 Barbone A, Pini D, Rega F, Ornaghi D, Vitali E, Meyns B. Circulatory support

in elderly chronic heart failure patients using the Circulite Synergy system. Eur

J Cardiothorac Surg 2013;44:207-212.

Long-term assist with LVAD in elderly patients

John Mulholland Hammersmith Hospital, Imperial College Health Science Centre, London, UK

TheHammersmithHospitaloffersminiaturecardiopulmonarybypass(mCPB)toahighproportionofitspatientpopulation.Thehospital’smCPBprogrammehasevolvedtoapositionwhereneitherthecomplexityofthesurgerynorthepropositionofthehighriskpatientareconsidered

contraindications.Wesummariseourdataonthesub-groupofpatientswhorequiremajoraortic

surgery.Thissub-grouprepresentsthemostchallengingformofaorticsurgeryandispertinentasitisofferedbyallcardiaccentersworldwide.Figure1showstherangeofaorticproceduresperformedusingmCPB.

Givenourownexperience,andconsideringourdataalongsidepatientshavingmajoraorticsurgeryusingconventionalCPBattheBristolHeartInstitute,webelievethatmCPBisasafeandfeasibleoptionforuseinmajoraorticsurgery.

ThepresentationaddresseshowtheHammersmithtechniquehasevolvedtobecomeclinicallyapplicableforthistypeofoperation,aswellasfortherangeoflesscomplicatedoperationsthatourspecialtyoffers.

Threetypesofminiaturesystemaredescribeddetailingtheadvantagesanddisadvantagesofeachone.Itiscrucialtounderstandandbalancethemaintenanceofclinicalbenefits,againstfactorsthatwecancontrolinordertoimproveclinicalapplicabilityandusability.Gettingthecorrectbalanceallowsthecardiacteamtoevolvethesystemandofferthetechnologytoawiderpatientpopulation.Extracorporealbloodprimemixing,apatientresponsiveclosedsystem,appropriate

utilisationofforeignsurfaceareaandgoodairhandlingallneedtobemaintainedthroughoutthisevolutionprocess.TheHammersmithtechniqueformCPBachievesallthesegoalswhilstprovidingaflexibleenoughsystemtosupportthesurgicalteamduringmorecomplexsurgery.

clinical experience with mcPB Systems in Aortic Surgery: The Hammersmith Technique

John Mulholland

Figure 1: Range of aortic procedures performed using mCPB, (ARR: Aortic Root Replacement)


Charlotte Brun Thorup

Session 3: Transplant/mechanical assist 13:50 Hall F1

Session 1: Improving Perfusion 10:30 Room F1

TheEuropeanPerfusionRegistry(EPR)iscontinuingitseffortstocreateaninfrastructureforqualityimprovementinitiativesinperfusion,andhasjoinedthe

EACTSQualityImprovementProgramme(QUIP)toformthePerfusionGroup.ThegroupischairedbyLucPuis(Brussels,Belgium)andIanJohnson(Liverpool,UK),andsupportedbyTimothyJones(Birmingham,UK).

Currentprojectsfocusondevelopingqualityimprovementinitiativesandtoolsondifferentlevels.AnupdateonrecentprogresswillbegivenbyLucPuisaspartoftoday’sPostgraduateEducationPerfusionProgramme.

Quality Improvement DomainsThroughasystematicapplicationofadaptedPlan-Do-Study-Act(PDSA)cycles,qualityimprovementprojectswillbedevelopedindifferentdomainsofcardiacsurgerythatcanbeinfluencedandimprovedbytheperfusionist.Thedomainsforimprovementwillinitiallyincludebloodtransfusion,renal,cerebralandmyocardialprotection,andstrategiestoreducetheimpactofperfusion.

Literaturereviewswillbeusedtogatherevidenceandknowledge,andconsensusviewswillbedetermined,withtheintentiontodefinespecificgoalsforimprovementaswellasthestrategiesthatcanbeusedtoachievethesegoals.Evaluationtoolswillthen

bedevelopedtohelpperfusionistsestimatetheimpactoftheappliedstrategies.

Perfusion Registry ThedomainimprovementinitiativeswillbesupportedbythecreationofaPerfusionRegistryfromaminimumdataset.Thedatasetisintendedtobesmallenoughtoencouragedatacollection,butalsocontainenoughparameters,basedonliteratureandevidence,tobeabletoperformqualityimprovementinitiatives.

Perfusion Practice SurveyAninternationalsurveyonperfusionpracticeiscurrentlyon-goingwhichwillidentifyvariabilityinperfusionpracticeandinformthedevelopmentofthedataset.Toparticipateinthesurvey,goto:www.eacts.org/quip/perfusion-survey

Futureinitiativeswillbedevelopedascurrentprojectsexpandandwillincludethedevelopmentofimprovementtoolstoassessperfusionperformance,creationofguidelinesorrecommendationsforqualityimprovement,andestablishingaPerfusionNetworkGrouptosupportclinicaltrialsonspecificaspectsandproceduresinperfusion.

Colleaguesareencouragedtoparticipateintheperfusionprojects.YoucangetinvolvedbynominatingyourselfforinvolvementintheQUIPviatheMyProfiletabinyourEACTSUserArea.

An update from the EPR

EACTS Daily News Sunday 6 October 2013 15

Virginie Lambert Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France

Double-outletrightventricle(DORV)includesawidespectrumofanatomicsubtypesrequiringavarietyofsurgicalapproachesforrepair.Themostcomplexformsremain

asurgicalchallengeintermsofoperativetechniquesandregardingthechoiceofthesurgicalprocedure.

Indeed,thewisdomofextendingbiventricularrepairtoborderlineanatomiccandidateswithhypoplasticleft-sidedstructuresoranon-subaorticventricularseptaldefectisstillquestioned.Someauthorspromotesingle-ventriclerepairsincesomebiventricularrepair,especiallyRastelli-typereconstruction,isassociatedwithhigherlatemortalityandreinterventionthaninFontanrepair.Bycontrast,othersarguethat,althoughtheFontanoperationhaveledtoimprovedearlyandmidtermresults,the

functionalstateofpatientsfollowingtheFontanoperationdeteriorateswithtime,andpushtheindicationsofbiventricularrepairasfaraspossible.

However,moststudiesshowedanimprovementinlong-termoutcomesforpatientswithDORVandafavourableinfluenceofcontemporaryeraextendedtoeventhosepatientswithcomplexforms.Latemortalityislowwithanoverall10-and15-yearsurvivalof80-90%reportedinthelargestseries.Arrhythmiashavebeenrecognizedasacauseforlatedeathswithincreasingsurgicalage,postoperativeventriculararrhythmiasandcompleteheartblockassignificantriskfactors.

Moreover,mortalityandmorbidityareassociatedwithanyreoperationwhetherexpected(eg,rightventricle-pulmonaryarteryconduitchange)orunplanned.Theneedforreoperationafterrepairremainsanimportantchallengesincerisksanalysispredictthatathirdofpatientswillundergo

reinterventionwithin15yearsfromrepair.Themajorityofreinterventionsweredirectedatreliefofrightventricleoutflowtractobstruction,butresidualorrecurrentleftventricleoutflowtractobstructionisalsodocumentedin13-15%ofpatients.Patientswithsubaorticventricularseptaldefectsareatlowestriskforreoperationatcontrarytothosewithnon-committedventricularseptaldefect.

Inthelatter,amongthemostsevere,theprogressivelydevelopingsubaorticstenosisisamajorconcern,involving26%ofthem.Inthesecases,thereoperationshouldnotonlyaimtorelievetheobstruction,butalsotostreamlinetheleftventricleoutflowpathwayusinganextendedseptoplasty,anadaptedtechniquetotreatthiscomplicationwithgoodresults.FunctionalstatusremainspromisinginserieswiththebigmajorityofpatientsinNewYorkHeartAssociationclassIorIIwithoutanymedicaltreatmentatlastcontrol.

Double outlet right ventricle: long-term outcome and reoperations

SorinGroupispleasedtoannouncetheEuropeanlaunchofSoloSmart,abiologicalaorticpericardialheartvalve.

Solo Smart is the evolution of the SorinFreedomSolo valvewhichhasbeenon themarket since 2004. Designed to maximizehemodynamic performance and ease ofimplantation,SoloSmartbehavesjustlikeahealthynativevalve restoringthequalityoflifeofpatients.

Solo Smart features a temporarystent that gives support and facilitatesimplantation.Thetemporarystentmaintainsvalve geometry and symmetry within theaortic root to simplify implant procedureand suturing. Once the valve is suturedto the aortic root, the temporary stent isremovedleavingthestentlessvalveinplace.Solo Smart provides all the benefits of anative-like valve, now with a stented-likeimplantability.

Solo Smart was designed to mimic thenative aortic valve and preserve the aorticroot physiology to maximize hemodynamicperformance. This unique bioprosthesisis a totally biological heart valve withno synthetic material and it is implantedin supra-annular position which allowsthe alignment of the valve orifice to thepatient annulus. It ensures a physiologicalblood flow through the annulus providingexcellent hemodynamics in terms of EOAandmeanandpeakgradientswhichremainstableover the follow-upperiod.This leadsto a remarkable clinical improvement aswellastosignificant leftventricularreverseremodeling with a fast left ventricularrestoration.

SorinGroup isveryproudofthecomingintroduction of Solo Smart valve to themarket,anuniquetechnologythatprovidesan excellent alternative to physiciansmanaging the care of patients with aorticvalve disease. The introduction of SoloSmartisanimportantmilestoneforSorinasitcontinuesthelegacyofprovidingsurgeonswithmarket-leadingheartvalveoptions.

Forfurtherinformation,pleasevisittheSorinGroupbooth#114.

Sorin Group Solo Smart Tissue Heart Valve: Introducing New Treatment Options

Session 1: Double outlet right ventricle 10:30 Room F2


Sarah Longnus, Hendrik Tevaearai, Thierry Carrel University Clinic for Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Switzerland

Althoughthenumberofpatientswithindicationstocardiactransplantationhasconsistentlyincreasedoverthelastdecade,

donororganavailabilityhasremainedstable,resultinginachronicshortageofcardiacgrafts1.InEUcountriesattheendoftheyear2010,3,290patientswereregisteredonwaitinglistsforhearttransplantation2.Inthefollowingyear,atotalof2,024hearttransplantswereperformedand412patientsdiedwhileawaitingcardiactransplantation1,indicatingawaitinglistmortalityofapproximately12%peryear.

Onestrategyforincreasingcardiacgraftavailabilityistouseorgansobtainedwithdonationafterdeclarationofcirculatorydeath(DCDD),inadditiontothose

obtainedwithconventionaldonationafterbraindeath.WithDCDD,increasesindonorsupplyareexpectedtoincreasebyapproximately17%foradults3and42%forpediatricpatients4.Furthermore,recentreportsoftransplantationandex vivoresuscitationofDCDDheartsattesttothefeasibilityofthisapproach.However,giventheexquisitesensitivityofthehearttoinjuryfollowingwarmischemia,useofDCDDcardiacgraftsrequiresparticularconsideration.

Oneoftheseveralfocusesofourresearch(www.cardiovascular-research.ch)isaimedatidentifyingclinicallyapplicableapproachesthati)limitcardiacinjuryfollowingwarmischemiaandreperfusion,andii)enableearlyevaluationofDCDDcardiacgraftsfortransplantsuitability.Inthiscontext,wehaveachievedkeymilestonesthatsupportourvisionofDCDD-basedcardiactransplantationbecoming,oneday,areality:1.Clinicallyapplicablemeansofprolonging

thetoleranceofheartstowarmischemia

provideagreaterwindowofopportunityfortheapplicationofadditionalprotectivemeasuresanduseofDCDDcardiacgrafts.Wehavedemonstratedthatslightlyreducingmyocardialtemperaturedramaticallyincreasesthisperiodofischemictolerance(40minutesforalocaltemperatureof32°C,versus20minutesat37°C)5.

2.Clinicallyapplicablemeansthatpreventthedevelopmentofreperfusioninjuryenableimprovedpost-ischemichemodynamicrecovery.Wealsoreportthatmechanical-postconditioning–inducedmechanisms,appliedtonormothermichearts(37°C)placedunderglobal(noflow)ischemiaformorethan25minutes,permitdramaticincreasesinfunctionalrecoveryrates(manuscriptinpreparation).

3.Clinicallyapplicablemeanstoevaluategraftsatthetimeofprocurementreliablyandreproduciblypredictfunctionalrecoveryaftertransplantation.Alistofbiochemicalandhemodynamic

parametershasbeenidentifiedthat,whenmeasured5–10minutesafterprocurementofischemichearts,enablespredictionsubsequentpost-ischemicrecovery6,7.

TheuseofDCDDgraftsisanattractiveandrealisticapproachtowardsovercomingthedonororganshortageandhasrecentlymotivatedthedevelopmentofseveralclinicalprotocolsforprocurementoforgansotherthantheheart.DeterminingthepreciseinterventionsthatwouldguaranteeoptimalcontractilefunctionoftransplantedDCDDheartsiscertainlyachallenge.Nevertheless,basedon

laboratoryexperienceandencouragedbyrecentclinicalresults,wefeelconfidentthatcardiactransplantationwillsoonrelyonasignificantpercentageofDCDDorgans.References

1. Council of Europe, Ed: R. Matesanz. (2012) Newsletter Transplant. in Inter-national Figures on Donation and Transplantation – 20112. Council of Europe, Ed: R. Matesanz. (2011) Newsletter Transplant. in Inter-national Figures on Donation and Transplantation – 2010 3. Osaki S, Anderson JE, Johnson MR, Edwards NM and Kohmoto T. (2010) Eur J Cardiothorac Surg 37: 74-79

4. Koogler T and Costarino AT Jr. (1998) Pediatrics 101: 1049-1052

5. Stadelmann M, Dornbierer M, Clément D, Gahl B, Dick F, Carrel TP, Tevaearai

HT, Longnus SL. (2013) Transplant Int 26(3):339-48

6. Dornbierer M, Stadelmann M, Sourdon J, Gahl B, Cook S, Carrel TP, Tevaea-

rai HT, Longnus SL. (2012) PLoS One 7(8):e436-42

7. Sourdon J, Dornbierer M, Huber S, Gahl B, Carrel TP, Tevaearai HT, Longnus

SL. (2013) Eur J Cardiothorac Surg 44(1):e87-96

Thierry Carrel, Sarah Longnus, Hendrik Tevaearai

Session 3: Transplant/mechanical assist 13:50 Room F1

Heart transplantation with donation after circulatory declaration of death (DCDD)

Hiroshi Kurazumi Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan

Theprogressanddevelopmentofthemedicaltherapyledtheincreasinglifespanallovertheworld,whichhasresultedina

significantincreaseinthenumberofpeopleagedmorethan80years.Elderlypatientsoftenpresentadditionalco-morbidconditions,andpastreportshaveindicatedthatcardiacsurgeryinelderlypatientsisassociatedwithsignificantoperativemortalityandmorbidity.Cardiovascularsurgeonsoftenhesitatetoperformaorticarchsurgeryonelderlypatients,assumingpoorclinicaloutcomes,becausethoracicaorticsurgeryisthoughttobeamoreinvasiveprocedurerelativetoothertypesofcardiacsurgery.Consequently,elderlypatientsmightbedeniedaorticarchsurgerydespitetheriskofsuddendeathduetotheruptureofaneurysm.

Inthisstudy,weevaluatedearlyclinicaloutcomesofsurgicaltreatmentforaorticarchdisease,mid-termsurvivalandQOLinoctogenarianpatients.49consecutivepatientsolderthan80

yearswhowerereferredtoourinstitutionsenrolledthisstudy.Ofthesepatients,20underwentsurgicalintervention(surgicalgroup)and29weretreatedmedically(medicalgroup).Kaplan-Meiersurvivalanalysiswasperformedbetweentwogroups,andresultswerecomparedwith

age-matchedpopulationdata.TheriskfactorsformortalityweredeterminedbyaCoxregressionanalysis.

Thepatientcharacteristicsatbaselinewerenotsignificantlydifferentbetweenthetwogroups.Inthesurgicalcases,conventionaltotalaorticarchreplacement

wasperformedin15patients,debranchedTEVARintwo,andChimneyTEVARinthree.Emergencyprocedurewasperformedinthreepatients.Nohospitaldeathsoccurredinthesurgicalgroup.Reoperationforbleedingwasobservedintwopatientsandprolongedmechanicalventilationwas

observedinfourpatients.Five-yearsurvivalwas61.5%inthesurgicalgroupand13.6%inthemedicalgroup(p=0.02).Freedomfromaorta-relateddeathatfive-yearwas92.3%inthesurgicalgroupand32.4%inthemedicalgroup(p=0.01).Therewerenodifferencesinthefive-yearsurvivalbetweenpatientsundergoingsurgicalinterventionandthoseintheage-matchedpopulation(p=0.08),whereasthefive-yearsurvivalwassignificantlylowerinpatientswhoreceivedmedicaltherapyrelativetotheage-matchedpopulation(P<0.001).Medicaltherapywasthesoleriskfactorformortality(Oddsratio:3.19,p=0.03).

Theoverallsurvivalwashigherinthesurgicalgroup,aswasthefreedomfromaorta-relateddeath,suggestingthattheavoidanceofaorta-relateddeathduetothesurgicalinterventioncontributestothesuperiorlong-termsurvivalofthesurgicalgroup.Ourdataclearly

indicatethatsurgicaltreatmentforthoracicarchaneurysmreversestheprognosis,eveninoctogenarians.

Inconclusion,surgicalinterventionforaorticarchdiseaseinoctogenarianscanyieldsatisfactoryearlyclinicaloutcomesandacceptablemid-termsurvivalwithadequatedailyactivity.Ourstudyindicatesthatamongoctogenarians,agealoneshouldnotdisqualifyapatientfromreceivinganaorticarchintervention.

Edward Chen Emory University, Atlanta, USA

Aorticarchsurgeriesrepresentcomplexprocedures.Successfuloutcomedependsonawell-plannedandcoordinated

operativestrategytowardcerebralprotection,myocardialprotectionandlowerbodyperfusion.Neurologicinjuryfollowingtheseoperationscanbeduetothromboembolicdiseaseresultinginfocalorpermanentneurologicdeficitsorglobalcerebralischemiaresultinginnonfocalortemporaryneurologicdeficits.Contemporarymethodsofbrainprotectionareaimedatreducingbothtypesofinjury.

Cerebralprotectiontechniquesduringaorticarchsurgeryhavetraditionallyincludeddeephypothermiccirculatoryarrestaloneorincombinationwithretrogradecerebralperfusionandmorerecently,selectiveantegradecerebralperfusion(SACP).Theoptimalstrategyofcerebralprotectioncontinuestobedebatedwithoutstandingresultsbeingreportedwithuseofbothretrogradeandantegradecerebralprotectionfromhighvolumecentersofexcellence.Nonetheless,therehasbeentremendousshiftinthepreferredcirculationmanagementstrategyoverthelast10yearsacrosstheworldandcertainlyintheUnitedStates.

Moderatehypothermiccirculatoryarrestincombinationwithselectiveantegradecerebralperfusionhasrecentlyemergedasanacceptabletechniqueofcirculationmanagementandcerebralprotectionforaorticarchsurgeryrequiringanopendistalanastomosis.Since2004,atourinstitution,althoughwecontinuetousedeephypothermiaandretrogradecerebralperfusionforisolatedspecificclinicalandanatomicsituations,weprimarilyemployatechniqueofmoderatehypothermiccirculatoryarrestusinguSACPviarightaxillaryarterycannulationforthemajorityofarchreconstructioncases.

Inourinstitutionalexperience,we

foundthatselectiveantegradecerebralperfusioncombinedwithmoderatehypothermiccirculatoryarrestresultedinpermanentandtemporaryneurologicdeficitratesof3.2%and4.1%,respectively,forhemiarchreconstruction.Theaveragetemperatureatwhichcirculatoryarrestwasoriginallyinitiatedwas26.5degreesCelsius.Inadditiontodiscussingourresultsinthesettingofelectivesurgery,theresultsofthiscirculationmanagementstrategyinthesettingofemergenttypeAdissectionwillalsobereviewed.Finally,wewillalsopresentourexperiencewhenutilizingthesetechniqueswithmorecomplextotalarchreconstruction.

Aortic arch surgery in octogenarians: Is it justified?

Hiroshi Kurazumi

Edward Chen

Session 2: EACTS/STS aortic session: Circulation management, temperature and neuroprotection 13:00 Room E1

Session 2: EACTS/STS aortic – Part I: Circulation management, temperature and neuroprotection 13:00 Room E1

Temperature management and neuroprotection in aortic surgery – the American perspective



Alan D L Sihoe The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.

TherearemanyreasonswhyTuberculosis(TB)isnotconsideredamajorconcernbymanythoracicsurgeonsnowadays.ItsprevalenceintheDevelopedWorldhasfallendramatically

sinceitsheydayacenturyago.AndwhenpatientsdopresentwithTB,themainstayofmanagementisoverwhelminglybypharmacotherapy.Onlyrarelyaretherecasesofmulti-drugresistantTBforwhichanti-microbialsareinsufficientandthoracicsurgeonsarecalledupontotreat.

Ontheotherhand,therearealsomanyreasonswhyTBremainsanever-presentpartofthoracicsurgicalpractice.Firstly,itispreciselybecauseoftheeffectivenessofpharmacotherapythatmostTBpatientssurvivetheiracuteinfection–buttheflipsideofthiscoinisthatmorethenliveonwiththesequelaeand

complicationsofTB.Theseincludemanypresentationsforwhichthoracicsurgicalmanagementisrequired:empyema,pneumothorax,airwaystenosis,andsoon.Secondly,theeaseoftravelaroundtheworldmeansthatitwillneverbepossibletocompletelyeliminateTBinanygivenregion,providedcarriersfromTB-prevalentregionscanstillenter.Eveninthe21stCentury,itmaycomeasasurprisetosomethatmanycountrieslistedasendemicforTBarefoundintheDevelopedWorld,andthattheincidenceofTBinsomecountriesintheWestisactuallyrisingratherthanfalling.Clearly,TBwillcontinuetofeatureinthecasemixofthoracicsurgerycentersworldwideformanyyearstocome.

ThemajorityofTB-relatedconditionsrequiringthoracicsurgeryarerelativelybenignandeasy-to-treat.Theoperativetechniquesaresimilartothoseusedforsimilarconditionswithnon-TBetiology.However,thechallengeposedtothoracicsurgeonsliesinthenatureofthemycobacteriumitselfand

theparticularinfluenceithasoninflammationandhealing.Therelativedifficultyineradicatingtheinfection,thegranulomatousreactionandsooncanquicklyturnacaseof‘simple’surgicalmanagementintoaclinicalquagmire.

Inthesession,DrAlanSihoewillbepresentingacasefromHongKongthatillustrateshowTBcantransformeventhemostseeminglystraightforwardmanagementintoadrawn-outmarathonoffrustration.Treatingayoungmanwithapneumothoraxspiralledintomonthsofcomplications–whichthoughnotlife-threateningbecamequality-of-life-damaging.Delegateswillbewelcometodiscussexperiencesandopinionsonthiscase.

Clinical dangers are caused not just by danger, but also frustration

A nightmare with TB begins with a simple chest X -ray

TheE-vitaOPENPLUShybridstentgraftsystemcombines surgical vascular reconstruction

withmodern,minimallyinvasiveaorticstenting.This unique prosthesis simplifies previoustherapeutic techniques which impose a severestrain on the patients with their two-stageprocedureandinvasiveness.ByusingE-vitaOPENPLUS, theoperativeprocedure canbe reducedtoasingleinterventionfromwhichbothpatientandsurgeon,benefitinequalmeasure.

E-vita OPEN PLUS allows the so calledoptimized “Frozen Elephant Trunk Technique”to treat complex lesions of the thoracic aortaduring a single-stage procedure by combiningendovascularstentingofthedescendingthoracicaorta with conventional surgery. After mediansternotomyandundercirculatoryarrestthearchis opened. The E-vita OPEN PLUS stent graftsystemisintroducedinanantegradefashionintothe descending aorta over a previously placedstiff guide wire. By using the proven Squeeze-to-Release deployment mechanism the hybridstentgraft canbedeployed safeandprecisely.Aftersurgicalfixationofthestentgraftportionby a circumferential suture line the infoldedsurgical cuff canbeeasily evertedand suturedtoanothervasculargraftorusedforaorticarchreconstruction.

The E-vitaOPENPLUS stentgraft system isavailableindiametersfrom24to40mmaswellasindifferentlengthsofthesurgicalcuffportion(50, 70mm) and stent graft portion (130mm,150mm and 170mm). The one-piece hybridstentgraftismadeofbloodtightpolyesterandsupported by nitinol springs in the stent graftsection. Thanks to a special weaving processthesurgicalcuffisprimarilybloodtightwithoutanyimpregnationorpre-clotting.Thenewmorecompact delivery system allows easy handlingandprecisepositioningofthestentgraft.

Foundedin2000,JOTEChasbecomefirmlyestablished on the market as a specialist foraortic disease. The product portfolio containsnumerous solutions for life-threateningaortic and peripheral vascular diseases. TheproductionisbasedinGermany,atthecompanyheadquarters inHechingen.Direct salesunitesarelocatedinSwitzerland,Italy,SpainandPolandand an international network of distributorsguaranteeworldwidemarketpresence.

PleasevisittheJOTECboothno.29and30atEACTS2013tolearnmoreabouttheE-vitaOPENPLUSstentgraftsystem.

From an easy-to-treat tuberculosis to nightmare

The Hybrid Stent Graft System e-vita OPeN PLUS


Thierry Carrel University Hospital Berne, Switzerland

Themethodsofcerebralprotectionandneuromonitoringofthebrainfunctionduringsurgeryinvolvingtheaorticarchhave

beenconsiderablyrefinedduringthelast15years;thefavourableeffecthasbeenatremendousdecreaseofmortalityandneurologicalmorbidityinexperiencedcenters.However,theoptimalmanagementisstillmatterofdiscussion;therearemainlythreetopicstobediscussed:1.Thelevelofhypothermia2.Thetypeofcerebralperfusion3.ThemethodsofmonitoringHistorically,deephypothermiccirculatoryarresthasbeenthegoldstandardforproceduresontotheaorticarchbutthereareseveralnegativeeffects,forinstanceprolongedperfusiontimeanddisturbancesofthecoagulationsystem.Thisisoneofthemainreasonwhymoderatehypothermiahasmostrecentlygainedincreasingconsideration.Nowadays,asubstantialnumberofsurgicalteams

avoiddeephypothermiaandproceedwithcoretemperaturearound26to30°C,evenifprolongedperiodofcirculatoryarrestarerequired.Insomeinstances,distalperfusionisperformedtoavoidadverseeffectsonthespinalchordandtheabdominalorgans.

Antegradeselectivecerebralperfusionhasbeendemonstratedtoattenuatepostoperativeneurologicalinjury,whichstillremainsthemaincauseofmortalityandmorbidityfollowingsurgicalaorticproceduresincludingtheaorticarch.Protectiveeffectsofhypothermiccerebralperfusionincludeinhibitionofneuronexcitationaswellasdischargeofexcitableamino-acids,andthereby,preventionofanincreaseinintercellularcalciumions,hyperoxidationoflipidsincellmembranes,andfinallyfreeradicalproduction.However,perfusionpressure,flowmanagementaswellastemperatureoftheperfusatearestillunderdiscussionaswellasthetypeofperfusion(throughbothcommoncarotidarterieswithspecialcatheters(bilateral)orusingthearterialinflowcanulaofthecardiopulmonary

bypasscircuit(unilateral)).Mosteffortstodocumenttheuse

andefficacyofretrogradedeliveryofcerebralperfusionforbrainprotectionhavefailed.Infewstudies,advantagesrelatedonlytotheremovalofembolicdebrisfromthebackflowthroughthearterialsystem.

Finallytheoptimaltechniqueofneuromonitoringhasnotbeendefinedyet.Themostcommonmethodsare:EEG,nearinfraredspectroscopy(NIRS),TranscranialdopplerandjugularSO

2assessment.

Onepromisingapproachtoimprovethequalityofneuromonitoringmightbethesocalled“wholeheadmonitoringofcerebraloxygenation“,asusedalreadytodayforneurovascularinterventions.Thesettingincludes16transmitters/receiversand52NIRSchannelswithcontinuouswavetechnologyusingthreewavelengthsof780,805and830nm:thismethodsallowingsimultaneousassessmentofcerebraloxygenationinallbrainsegmentshasbeenvalidatedduringneuro-angiographicprocedures.


Neuroprotection and neuromonitoring during surgery involving the aortic arch: the European perspective

Figure: a multichannel registration system can increase the sensitivity of

detection of cerebral mal-oxygenation during hypothermia and selective

cerebral perfusion

Dejan Stojakov Clinic for digestive surgery, Clinical center of Serbia, Belgrade, Serbia

Descendingnecrotizingmediastinitis(DNM)islife-threateningdisease,originatingfrominfectioninoralcavityandneck.Fascialplansinneckdivideneckin

severalcompartments,and,desendingdeepintomediastinum,createpathwayforspreadingoddeepneckinfectiontomediastinum.UnusualcaseofDNMtypeIIB(accordingEndo’sclassification),originatingfromodontogenicinfection,withbilateralpleuralempyema,anddiffuseperitonitisduetosubdiaphragmalextensionofmediastinalinfection.InthisreportseveralimportantissuesindiagnosisandtreatmentofDNMaredisscused.

Young(33yearsold),otherwisehealthy,femalepatient,sufferedfromtoothache,swellingandpaininleftsubmandibularregion,andincreasebodytemperature.Aftertwodaysshewasadmittedinregionalhospital,andtreatmentwithwidespectrumantibioticsandtransoralincisionanddrainageofsubmandibularabscessarestarted.Patientconditionwasimproved.Leftparapharyngealabscesswasrevealedbyneckultrasoundaftersevendays,butclinicallytherewerenoobviuossignsofdeepneckinfection,patientwasafebrileandingoodgeneralcondition.Threedayslaterpatientsufferredfromdyspnea,cough,withoutincreaseofbodytemperature,withoutclinicalyevidentsignsofdeepneckinfection.Afteranothertwodaysgeneralconditionofpatientwasrapidlyworsenedand

CPCRprocedurewereappliedaftercardiacarrest.ChestX-raxconfirmedmassivebilateralpleuraleffusions.

Thoracocenthesisconfirmedpusinbothpleuralcavities,andbilateralchesttubewasplacedandbigammountofpusevacuated(left-2,500ml;right-1,500ml).CTscanoftheneck,thoraxandupperabdomenrevealedabscessintheleftparapharyngealspace,gasinleftcarotidsheet,signsofinfectioninallmediastinalcompartments,smallammountofeffusioninbothpleuralcavities,bilaterallunginfiltrates,gasbellowtheleftlobeoftheliverandfluidinomentalbursa.DiagnosisofDNMwithbilateralpleuralempyema,andperitonitiswasestablished,andtheneedforaggressivesurgicaldebridement.

Weperformedagressivesurgicaldebridementusingbilateralanteriorcervicotomy,bilateralsynchronousanterolateralthoracotomy,anduppermedianlaparotomy.Bilaterallungdecorticationwasperformed,debridementofnonviableinfectedneckandmediastinaltissue,cervicomediastinalandabdominallavage,withplacementofmultipleneck,mediastinal/chestandabdominaldrains,tracheostomyandgastrostomy.Postoperativecervicomediastinalirrigationcontinuedfortwoweeks.PatientdevelopedbilateralVAPandwasmechanicalventilationofthelungwasperformedfor26days.Steadyimprovementwasnoticed,andsixfollow-upMDCTscansshowedrecoveryofintrathoracicandabdominalinfection.Patientwasdischargedhomeaftertwomonths.Aftersixmonthsshedevelopedstenosisofdistaltrachea,whichsuccessfullytreated.

Thisillustrativecaseshowsrareclinicalentity,difficultiesinestablishingdiagnosisduringatypicalclinicalpresentationofDNM,possibilityofsubdiaphragmalextensionofmediastinalnecrotizinginfection,andchallengiesinthetreatment.

Descending necrotizing mediastinitis — from odontogenic infection to peritonitis



Session 2: Imaging in Transcutaneous valve interventions 12:30 Hall D

Jörg Kempfert Keckhoff Clinic Bad Nauheim, Germany

Transcatheteraorticvalveimplantation(TAVI)hasseenarapidevolutionduringthe

lastfewyears.Today,ithastobeconsideredasastandardalternativetotreatelderlyhigh-riskpatientssufferingfromaorticstenosis.Incomparisontosurgicalaorticvalvereplacement(AVR),TAVIchallengestheoperatorwitha‘closedchest’situationnotallowingforanydirectviewontotheoperatingfield.Thus,sophisticatedimagingtoolsarecrucialinordertoobtainthemostoptimaloutcome.

Inregardtopreoperativeplanningmulti-dimensionalaorticannulusmeasurementsiskey

toobtainexactTAVIprosthesissizingwhichiscrucialtoavoidrelevantparavalvularleaks.Typically,thisisperformedbasedonmultislice-CT(MSCT)and2D/3Dtransesophagealechocardiography(TEE).Inaddition,anatomicalsuitabilityofthedesiredaccesshastobeassessedespeciallyincaseofatransvascularapproachtominimizeratesofmajorvascularcomplications.Again,MSCTplaysacrucialroleforthatpurposesupplementedbypotentialangiographyorMRI-scans.

Intraoperatively,“classic”imageguidanceismainlybasedonhigh-qualityfluoroscopytopreciselypositionandimplantthevariousTAVIprosthesesavailabletoday.Inaddition,TEEishelpfulduringtheimplantationitselfandespeciallyforfunctionalassessmentofthevalveperformance.

Overthelastyears,several‘new’imageguidanceoptionshavebeendeveloped.Thesesystemseitherrelyonare-registrationofthepreoperativeMSCTdataset(PhillipsHeartNavigator),utilizeconventionalrootangiographyindifferentplanes(PaieonC-THV)orfacilitateautomaticsegmentationbasedonarotationangiographyspin(SiemensSyngoValveGuide).TheseadvancedimagingconceptshelptofindthemostoptimalC-armangulation,allowfordedicatedoff-lineplanningandofferadditionalreal-timeoverlayguidanceduringpositioningandimplantationoftheTAVIdevices.

Insummary,TAVIoutcomeisclearlylinkedtosophisticatedimaging.AvarietyofdifferentconceptareconstantlydevelopingtoprovideadditionalimagebasedguidanceduringTAVIprocedures.

Example of the Siemens Syngo ValveGuide system: (A) root reconstruction and detection of landmarks including visualization of calcification patterns (B) template planning (C) online overlay

Intraoperative guidance in TAVI procedures

Rafael Sádaba Hospital de Navarra, Pamplona, Spain

P atientswithchronicischemicleftventriculardysfunctionmayhaveasubstantialamountofviable,hibernating

myocardium.Theconceptofhibernationimpliesadownregulationofcontractilefunctionasanadaptationtoareductioninmyocardialbloodflowthatservestomaintainmyocardialintegrityandviabilityduringpersistentischemia

Coronaryrevascularizationinthesepatientsmayresultinimprovementofleftventricularfunction.Onthecontrary,intheabsenceofviability,leftventricularfunctionwillnotimprovefollowingrevascularization.

Thepresenceofmyocardialviabilityisalsorelatedtoprognosis.Patientswithviablemyocardiumwhoundergorevascularizationappeartohavebetterprognosisthanpatientswithviablemyocardiumwhoaretreatedmedically.Reciprocally,patientswithischemicheartdiseasewhoarerevascuralizedandhaveviablemyocardium,appeartohavebetteroutcomesthanthosewithnoviablemyocardium.

Accordingly,assessmentofviabilityisimportantinthetherapeuticdecision-makingprocessofpatientswithchronicischemicleftventriculardysfunction.

Variousnoninvasiveimagingtechniquesareavailableforthedetectionofviablemyocardium,includingnuclearimagingwithpositronemissiontomographyandmagneticresonanceimaging.

Positron emission tomographyPositronemissiontomography(PET)isaradionuclideimagingtechniquethatallowsquantitativeassessmentofregionalmyocardialfunction.Itismainlyusedtoassessviabilityofdissynergicmyocardium,bymeansofcombinedimagesofflow

(commonlywith13NammoniumorRubidium82)andmetabolism(withfluordeoxyglucose).Themismatchpattern,withanincreaseinfluordeoxyglucosemetabolisminhypoperfusedregions,isindicativeofviability.Thematchpattern(adecreaseinflowandmetabolisminthesameareas)isindicativeofnecrosis.

Cardiac magnetic resonanceCardiacmagneticresonance(CMR)isanimportanttoolfortheevaluationofmyocardialviabilityandscarinpatientswithischemicleftventriculardysfunction.Thereareanumberofparameters

whichareusefulInordertoevaluatemyocardialviability.Theseareend-diastolicwallthickness,contrast(gadoliniumbased)perfusion,delayedcontrastenhancementanddobutamineevaluationofcontractilereserve.Myocardialsegmentswithanend-diastolicwallthicknesslessthan5,5mmmostlikelyrepresenttransmuralscarformation,andcontractilefunctionwillnotimproveaftermyocardialrevascularization.Gadoliniumlateenhancementgivesanideaofscartransmurality.Scarringoflessthan

25%ofwallthicknessisagoodindicatorofviability,whereasifitismorethan75%thelikelihoodoffunctionalrecoveryispoor.

Inischemicheartfailure,CMR

hyperenhancementasamarkerofmyocardialscarcloselyagreeswithPETdata.Althoughhyperenhancementcorrelateswithareasofdecreasedflowandmetabolism,itseemstoidentifyscartissuemorefrequentlythanPET.WhileCMRiscontraindicatedinpatientswithmetallicimplants,ithastheadvantagesoflessexpenseandnoradiationoverPET.Therefore,CMRisconsideredapromisingdiagnostictoolfordetectingnonviabletissueinpatientswithadvancedcoronaryarterydisease.

Imaging in coronary artery surgery: Assessment of viability with cardiac magnetic resonance and positron emission tomography

Session 3: Imaging in Coronary Artery Surgery 14:30 Hall D

Assessment of viability is important in the therapeutic decision-making process

of patients with chronic ischemic left ventricular dysfunction.


Session 1: Proximal thoracic aortic disease – variations on a theme 10:30 Room E1

Session 2: A look into the future 13:00 Room P

Ruggero De Paulis, Raffaele Scaffa European Hospital, Rome, Italy

Newevidenceiscontinuouslyaccumulatingonriskstratification,diagnosticmethodsandtherapeuticoptionsjustifyingtheneedforanupdateonpracticeguidelines.The

EuropeanSocietyofCardiologypresentedguidelinesformanagementofvalvediseasein2007andupdatedin2012.DuringthesameperiodaseriesofAmericanSocietypublishedtheirguidelinesinthetreatmentofthoracicaorticdiseaseandjustrecently(2013)theSocietyofThoracicSurgeonsreportedcombinedguidelinestooptimalmanagementofaorticvalveandascendingaorta.Asmalldifferenceamongreports

representsanaturalchangeovertimeoraslightlydifferentpractice.

Howaorticvalvediseaseismanagedcontinuestoevolve,withnovelapproachesforbothaorticvalvestenosisandregurgitation.Thereisacompleteconsensusthattheseverityofaorticvalvedisease,whetherstenosisorinsufficiencyneedstobeassessedbyquantitativemeasurementandthesevaluesaremoreandmorebetterdefined.Foranaorticvalvestenosis(AS)thetimingofsurgicaltreatmentisbasedonthesymptomaticstatusandtheseverityofthedisease.Currentguidelinesrecommendaorticvalvereplacement,asaclassIindication,onlyinsevereASforsymptomaticpatientsorforasymptomaticpatientswithsystolicLVdysfunction.Hence,anaccurategradingofASseverity

ismandatoryforclinicaldecision-making.Todate,noneoftheparametersdefinedtogradeAScanbeappliedasasinglecriterion.AcrucialstepintheevaluationoftheseverityofASistheanalysisoftheflowacrossthevalve.Indailypractice,theassessmentofASseverityshouldintegratetheflow-gradientpatterntotheclassicmeasurementofAVA.Innormalflow-highgradientandinlowflow-highgradientthesymptomaticpatientsareclassicallyreferredforAVR,whereaswhenasymptomatic,themanagementofthesepatientsunderlinestheneedforoptimizedriskstratification.Insymptomaticpatientswithlow-flow,low-gradientandreducedEF,indicationwillmainlydependonevidenceofflowreservewhileitisimportanttorecognizetheparadoxicallow-flow,low-gradientwithnormalEFin

ordernottodenysurgerytoasymptomaticpatient.Quitesimilarly,inseverechronicaorticregurgitation

(AR)asdefinedbyquantitativemeasuresofvenacontracta,effectiveregurgitantorificeorregurgitantvolume,allsymptomaticpatientsrequiresurgery,regardlessoftheirLVfunctionanddilation;inasymptomaticpatientsAVRisindicatedwhenLVejectionfractionEF<50%(classI).

Aneurysmaldilationoftheascendingaortaand/oraorticrootisoneoftheprimarypathologiesnecessitatingsurgicalinterventionontheascendingaorta.Nowadaysoutcomesforascendingaortaandarchreplacementareexcellentforelectiverepair;however,resultsdeterioratefornon-electivestatus,suggestingthatincreasedscreeningand/orloweringthresholdsforelectiveinterventioncouldpotentiallyimproveoutcomes.Forpatientswithoutconnectivetissuedisorders,currentguidelinesstillrecommendedsurgeryatmaximumdiameterof5.5cmorforayearlyincrease>0.5cm/yr.(ClassI,levelC)whetherdegenerative,chronicdissection,orpenetratingulcers.Forpatientswithbicuspidvalveelectivesurgeryisrecommendedwhenthediameterexceed5cmor2.5cm/m2(ClassI,levelC).Onlyincasethepatientsneedsurgerybecauseofvalvediseasethisthresholdisloweredto4.5cm.InpatientswithMarfansyndromethethresholdremainat5.0cm(ClassI,levelC)butisloweredto4.5cmasClassIIa,settingthebasisforamorerestrictiveapproachthatisalreadyplacedat4.2cmforpatientswithLoeys-Dietzsyndrome(ClassIIa,levelC).Inthispeculiargroupofpatientswithconnectivetissuedisorders(andsomesubgroupsofbicuspidvalvecouldalsobeassimilated)othermorerestrictiveformulasbasedoncross-sectionalareatoheightratiooronageandindividualriskfactorsarecurrentlyunderevaluationandmightcontributetofurtherrefiningcurrentguidelines.Lowerthresholdsofaorticdiametersbegintobeconsideredinlow-riskpatientsandinanexperiencedCentres.

Finally,forcompletenessitmustbesaidthattheusageofTAVIhasintroducedthemultidisciplinaryapproachintotheguidelinesandisexpectedtocontributetosomechangestothecurrentapproachbasedoncosts,newerdevices,andcompetition.

Schlegel F.1,2,3#, Leontyev S.1#, Spath C.1,4, Schmiedel R.1, Nichtitz M. 1, Boldt A.3, Rübsamen R.2 , Salameh A.1, Kostelka M. 1, Mohr F.-W.1, Dhein S.1 1 Heart Centre Leipzig, Germany; 2 University Leipzig, Germany; 3 Translational Centre for Regenerative Medicine, Leipzig, Germany

Weestablishedamethodforengineeringhearttissueforthetreatmentofdilativecardiomyopathy(DCM)inan

in vivoratmodel.Therefore,engineeredhearttissue(EHT)wascreatedasaringfromneonatalratcardiomyocytes,collagen,matrigelandmedia.AftercultivationtimeelectricallystimulatedEHTcontractedspontaneously(0.5-2Hz)anddevelopedforceof0.444±0.124mN.HistologicalinvestigationshowedthepresenceofTroponinIandCx43positiveelongatedcross-straitedcardiomyocytesandpreformedvascularstructuresintheEHTinvitro(figure1).EHTwasimplantedaroundthebeatingheartof

13SpraqueDawleyratswithdoxorubicininducedDCM.Additionally,12animalswithDCMunderwentashamsurgery.Priorandaftersurgerytheheartfunctionwascontrolledbyechocardiographyandinvasivehaemodynamicmeasurement(dp/dtmax)byMillarcatheterundercontrolconditionsandunderdobutamine(0.2mg/kg)forstimulationofβ-adrenergicsystem.SubsequentlytheheartswereexplantedandpreparedfortheLangendorffsystemandelectricalmappinganalysis.Therefore,256electrodeswereplacedaroundtheheartandwemeasuredthecardiacactivationtime.Finally,histologicalinvestigationsoftheEHTandtheheartwereperformed.InEHT-treatedDCMrats84%survivedandinshamtreatedanimals58%(p=0.3).Priortosurgery,fractionalshortening(FS)wassignificantlydecreasedascomparedtohealthyanimals(healthy:43.2±1.3%vs.DCM32.9±0.9%,p<0.05).30daysafterEHTimplantationFSincreasedby+4.61.3%.Incomparison,shamtreatedanimalsexhibitedfurtherdecreaseinFS(-

7.53.7%,p=0.002).Contractilityanalysisrevealed

thatthedobutamineinducedincreaseincontractility(healthy:12350±1619mmHg/s)wascompletelyabolishedinDCM(+7050±1045mmHg/s),butwasrestoredbyEHT-therapy(12579±2892mmHg/s),butnotbyshamtherapy(+5824±543mmHg/s).Furthermore,mappinganalysisrevealed

anelectricalsynchronisationofEHTwiththenativemyocardium.TherewerenoarythmogenicfociandnosignificantdelaysintotalactivationtimeandnochangesinpeaktopeakamplitudedetectablebetweenEHTandnativeheart.Moreover,EHTwasmacroscopically(seefigure2)andhistologicallyintegratedintotherecipientheartandconnectedtothecoronarysystemwhichwasshown

byintracoronarydyeinjectionandredbloodcellscontainingvesselsinEHTin vivo.Additionally,wefoundsignificantinductionofvascularendothelialgrowthfactor(VEGF)-expressionafterEHT-therapy,comparedtoshamtreatedanimals.TheseresultsareinagreementwiththefindingofsignificantlyenhancedcapillarydensityinEHT-treatedheart,sothatthataparacrineVEGFproductionmaycontributetothebeneficialeffectsofEHT-therapyviaanangiogeneticeffectintherecipientheart.ImplantedEHTshowedorganisedcollagenstructure,elasticfibres,andcontainsTroponinIandCx43positiveelongatedcardiomyocytes.

Inconclusion,thiscouldmeanthatthetherapeuticeffectprobablyisnotonlyduetoenhancedcontractility,butmaybeexplainedbyacombinationofincreasedelasticforces(elasticfibresintheEHT),paracrineeffectslikeincreaseinVEGF,aslightlyincreasedcoronaryflowinDCM-EHTvs.DCM-shamhearts,andthecontractilityoftheEHTitself.

Treatment of dilated cardiomyopathy using engineered heart tissue (eHT) as biological cardiac assist device

Session 1: Imaging in Mitral valve repair 10:30 Hall D

Jolanda Kluin UMC Utrecht, The Netherlands

Anatomicandfunctionalstudyofthepreoperativeregurgitatingmitralvalveisessentialfordecidingthetimingandsuitabilityofsurgicalrepair.Althoughstandard

techniquesformitralregurgitationevaluationhavebeenofvalue,theirreproducibilityandaccuracyarelimitedinsomepatientgroups.

Thegoalofdiagnosticimagingistoprovideaquantitativemeasureofthesizeoftheregurgitantlesion.Reproducibleandaccuratequantificationofmitralvalveregurgitationremainsanongoingclinicalchallenge.AssessingthedegreeofmitralregurgitationmightbedifficultwithTTEor2DTEEespeciallyincaseswitheccentricormultiplejets.

From3DcolorDopplervolumetricdatasets,wecannowroutinelymeasurethevenacontractaarea,ameasurethataccuratelyquantifies

theeffectivefloworificearea(ERO)inbothfunctionalandorganicmitralvalvedysfunction.Inaddition,methodstorapidlyderivethree-dimensionalPISAmeasureshaverecentlybeencommercializedandcliniciansandinvestigatorsarecurrentlygainingexperiencewiththesepromisingnewtechniques.Thereisanexcellentcorrelationbetween3DanatomicEROderivedregurgitantvolumeandmitralregurgitantvolumecalculatedbycardiacmagneticresonance.

Precisecharacterizationofthemitralvalveiscrucialforguidingthemanagementofpatientswithmitralvalveprolapse.Fromwatchfulwaitingtovalverepair,differentoptionsmaybeconsideredonthebasisofthepossibilityofrepair.Echocardiographyremainstheexaminationofchoiceforsuchevaluation.Accurateechocardiographicevaluationofthemitralvalvemightbecomplexandrequiresadvancedoperatortrainingandexperiencetoprovideanaccurate3Danalysisofthevalve.Withexperience,thisanalysisisusuallyachievedfrommultiple2Dimages,mentallyreconstructedtoforma3Dimage.Byusing3DTEEimages,less-

experiencedcardiologistsandcardiothoracicsurgeonscanbypassthestepofmentalreconstructionfrom2Dimagesanddescribeandunderstandmitralvalveprolapsemoreaccurately.Furthermore,2DTEEislimited,especiallyinthediagnosisofmorecomplexvalvesforwhichrepairismoredifficult.3DTEEmaybeofvalueinsuchselectedcasestoimprovecharacterizationofmitralvalvephysiopathologyandtoalertsurgeonstotheneedformorecomplexoperation(egcommissuralprolapse)thanmaybeindicatedby2Dexamination.Finally,infunctionalmitralregurgitation,quantitative3Dechocardiographicparametersmeasuringleafletdeformation,asaresultoftethering,canoffermechanisticcluesalongwithprognosticinformationonthedurabilityofcertainmitralvalveapproaches.

3Dechocardiographyisonitswaytobeavaluabletoolinmitralregurgitationassessment.Itassuresbetterquantificationinpatientswitheccentricormultiplejets,andbettercharacterizationinpatientswithfunctionalmitralregurgitationorinpatientswithcomplexvalves.

Does 3D echocardiography enhance decision making?

Valve and aortic guidelines




Paul P. Urbanski Cardiovascular Clinic Bad Neustadt, Germany

Althoughdeephypothermiaallowedthedevelopmentofmodernaorticarchsurgery,itensuresabrainprotectionforaverylimited

timerange.Therootsofantegradecere-bralperfusioncanbetracedtothe1950’s,whentemporaryorpermanentbypassingofthearcharterieswasperformed.Nowadays,separatearteriallinesareusedforcerebralperfusion,whichoffersimprovedprotection,andtherefore,arerecommendedbymanysurgicalguidelines1.Nevertheless,thismethodisnotuseduniversally.Apollof29EditorialBoardmembersofthejournalAortarevealedthatonly45%ofthemusecerebralperfusionduringarchrepairexclusively2.Becausemanysurgeonsstillusecerebralperfusionasanadjuncttodeephypothermia,itseemsthattheyarecon-cernedifcerebralperfusionprovidessufficientprotection.A

reviewofseveralreportsrevealsthattheflow,pressure,andespecially,temperaturemanagementsusedduringcerebralperfusionareverydifferentinparticularinstitutions3,4.Soalsoaretheresults,whichsupportproponentsofthoracicendovascularaorticrepair(TEVAR),postulatingabroadeningtheindicationsforusingthistechnique5.

Currently,twomodalitiesofantegradecerebralperfusionaregenerallyusedduringcirculatoryarrest:bilateral(BCP)andunilateral(UCP).Evenifthevarietyofflow,pres-sureandtemperaturemanagementusedduringapplyingthesetechniqueshardlyallowsanycomparison,Malvindietal.triedtodojustthisinameta-analysisof17paperspublishedupto20084.Thegeneraloutcomes,includingneurologicalmorbidi-ty,seemedtobecomparable;however,thisanalysisbroughtforthmorequestionsthananswers.Forexample,whydosurgeonsusingUCPneed30-50minutesofcerebralperfusionforarchrepair,which

actuallyreflectsthegeneralrequirement,andothersusingBCPneed140toover160minutes,onaverage!And,wouldtheresultsofUCPhaveremainedunchangedifitsdurationwerelonger?

Fourpapers,includingmulticenterstudies,havebeenpublishedrecentlyinwhichbothtechniquesarecomparedtoeachotherusingatleast100patientspermodality6-9.Theresultsaftertheuseofantegradecerebralperfusionweregenerally

verysatisfac-tory,buttheresultsvaryamongstthereports,simplybecausethesharesofacutedissectionweredifferentinparticularcohorts.Nevertheless,noneofthemdocumentedasignificantdifferencebetweenbothtechniques,regardlessoftheperfusionduration.Intwoofthem,therewasevenaslighttendencytowardabetterneurologicaloutcomeafterUCP,andoneadditionallyrevealedthatalowflowandpressurecorrelatewithimpairedoutcome.Theonlymatchstudyuptodate,whichwaspresentedatthelastAATSMeetingandhasbeensubmittedtotheJTCVSforpublication,compared246pairs(UCPandBCP)identifiedfromatotalof750patientsusingpropensityscorematching10.Themortalityandtherateoftransientneurologicaldefectswerealmostidentical,regardlessoftheextensionofsurgeryordurationofcerebralperfusion.How-ever,withap-valueof6%,therewasacleartendencytowardsahigherrateofperma-nentneurologicinjuriesintheBCPgroup10.

Admittedly,regardingthecompletenessofbrainperfusion,theunilateralperfusionisnotphysiological,butneitheristheintubationofarcharterieswithperfusioncannulas.Thelattercancausecerebralembolismorseverevascularinjuries.The

questionre-mains:whichriskisclinicallymorerelevant,theriskofembolismortheriskofinsuffi-cientcollateralflow?Inmyopinion,onlyarandomizedstudycanbringenoughlightontothisaspect.References

1. Svensson LG, Adams DH, Bonow RO, et al. Aortic valve and ascending aorta guide-lines for management and quality measures. Ann Thorac Surg 2013; 95:1491-505.2. Ziganshin BA. Which method of cerebral perfusion do you prefer to use for aortic arch surgery? Aorta 2013; 1: 69-70. 3. Tian DH, Wan B, Bannon PG, et al. A meta analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2: 148-58. 4. Malvindi PG, Scrascia G, Vitale N. Is unilateral antegrade cerebral perfusion equiva-lent to bilateral cerebral perfusion for patients undergoing aortic arch surgery? Interact CardioVasc Surg 2008; 7: 891-7.5. Czerny M, Weigang E, Sodeck G, et al. Targeting landing zone 0 by total arch re-routing and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg 2012; 94:84-92. 6. Krüger T, Weigang E, Hoffmann I, Blettner M, Aebert H. Cerebral protection during surgery for acute aortic dissection type A. Circulation 2001; 124: 434-43.

7. Lu S, Sun X, Hong T, et al. Bilateral versus unilateral antegrade cerebral

perfusion in arch reconstruction for aortic dissection. Ann Thorac Surg 2012;

93: 1917-20.

8. Misfeld M, Leontyev S, Borger M et al. What is the best strategy for brain

protection in patients undergoing aortic arch surgery? Ann Thorac Surg 2012;

93: 1502-9.

9. Zierer A, Ahmad AE, Papadopoulos N, Moritz A, Diegeler A, Urbanski PP.

Selective antegrade cerebral perfusion und mild (28°C-30°C) systemic

hypothermic circulatory arrest for aortic arch replacement. J Thorac

Cardiovasc Surg 2012; 144:1042-50.10. Zierer A, Risteski P, Ahmad AE, Moritz A, Diegeler A, Urbanski PP. The impact of unilateral versus bilateral antegrade cerebral perfusion on surgical outcomes following aortic arch replacement: A propensity matched analysis. J Thorac Cardiovasc Surg; submitted.

Unilateral vs. bilateral perfusion for cerebral protection: The need for a prospective randomized trial

Tomonori Shirasaka Kobe, Japan

Delayedwakeningafteraorticsurgerycanindicateanintraoperativecerebrovasculareventhasoccurred,whichisstillaconcernintotalaorticarchreplacement(TAR),eventhoughimprovedsurgicalstrategieshavedecreasedthe

postoperativecomplication.Near-infraredspectroscopy(NIRS)iswidelyusedtomonitorregionalintraoperativecerebraloxygensaturation(rSO2),canhelpsurgeonsminimizethedecreaseincerebraloxygenationthatcanoccurduringcardiovascularsurgery.However,itisdifficulttocorrelateclinicaloutcomesandrSO2valuesmeasuredduringsurgery,becausetheinitialrSO2levelvarieswidelyamongpatients,andbecausemanyfactorsareinvolvedindeterminingtherSO2level.Manyresearchershavesuggestedthattheriskofneurologiccomplicationsmightincreasebelowapreliminarycut-offvalueforrSO2,butthisisstillcontroversial.

Shirasakaandthecolleagues(KobeUniversity,Japan)reportedtheimpactofthechangeofregionalcerebraloxygensaturation(rSO2)intheearlyperiodofrewarmingonneurologicdisturbanceincludingdelayedwakeningafterTAR.Inthisresearch(N=143),thetimecourseofrSO2inTARwasanalyzedindetail.Especially,theyhavepaidattentiontothedegreeofcerebraloxygendesaturationratepossiblycausedbymetabolichyperactivityofthebrain,andfoundthatadecreaseinrSO2immediatelyafterrewarmingpredictsdelayedwakeningafterTAR.

TheysetanindicatorofdelayedwakeningafterTARcalculatedbythechangeofrSO2(Figurei.Figureii-iiishowstypicaltimecourseof2group),called‘%-decrease(=%-D)`,thatshowedapositivelinearrelationshiptowakeningtimeatdifferenttime(samplingnumber101;y=0.8x-2.0,r=0.32,P=0.001,samplingnumber143;y=0.67x-0.7,r=0.23,P=0.007)andROCanalysisshowed%-Dhadagoodpredictivevaluefordelayedwakening(AUC=0.94(N=101),and0.84(N=143),respectively).

Asanotheroptionofintraoperativemonitoringforcerebraloxygensaturation,theyhaverecentlystartedthesimultaneousmonitoringofcentralvenoussaturation(SvcO2)withtheinstrumentattachedtothevenousdrainagecatheterfromSVC.ThechangeofSvcO2intheearlyperiodofrewarming(=%-SvcO2)issignificantlyparalleledto%-Dinthecorrespondingpatients(N=19,y=0.67x+4.8,r=0.55,p<0.001).

Theirresearchalsorevealedsignificantdifferencesinhospitalmortality(p=0.04),theoccurrenceoftransientneurologicdeficit,theperiodofICU

stay(p=0.04),andhospital-to-homedischargerate(p=0.03),butnotwithregardtotheoccurrenceofpermanentneurologicdeficitbetweenpatientswithnormalanddelayedwakening.

TheabsolutevalueofrSO2doesnotalwayspredicttheoccurrenceofpostoperativeneurologiceventsbecauseitdifferslargelyamongindividualsinspiteofthestandardizationofthetargetedrangeof

hemoglobin,bodytemperatureandtotalflowofselectivecerebralperfusionwhenlowercirculationarrested.ItislogicallynaturalthattherSO2decreasesonthecommenceofrewarming.However,asteep,decreaseinrSO2inducedbyrapidrewarmingreflectstheinbalanceofoxygendemandandsupplyinthebrain,hence,itmightberelatedtoneurologicaldamageevenifitisnotalwaysvisible.

A new indicator of postoperative delayed awakening after total aortic arch replacement

Paul Urbanski

Delayed wakening (-)

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Ifyoumissed the2013 ISMICSAnnualScientificMeetinginPrague,youmissedanopportunityto

interactwiththeworld’sleadersininnovationandlessinvasivecardiacandthoracicsurgery.FromDr.JosephBavaria’sKeynoteaddresstoDr.BillyCohn’s“Innovation 101” presentation – the theme inPraguewaswhat’snew,what’scomingdowntheroad,andmoreimportantly,howanyonewhohasapassionforinnovationcangetthere.

ISMICS celebrates innovation, embraces newideas, and welcomes surgeons from around theworld. First time attendees always comment onthefactthatISMICSisanopen,collegial,andwarm

societywherecardiac,thoracic,andcardiovascularsurgeons come together to share their ideas andtheir latest challenges and successes in the ever-changingcardiothoracicandcardiovascularspecial-ty.ISMICSmembersareinnovators–whethertheyarepursuinglessinvasivesurgicaltechniques,em-bracing the newest technologies, or pushing theboundariesofmedicalscience.

WeinviteyoutojoinISMICStoday–makeplanstosubmityourworkforconsiderationforour2014AnnualMeetinginBostonnextMay,andalsovol-unteer to serve on one of our committees. The2014AnnualMeetingwillfeaturedaylonghands-

on training sessions forResidentsandFellows, inan intimate setting that allows face to face dia-loguewiththemastersinthefield.ItwillcontinuetheenhancedMastersDaysessionswhichcombineplenary lectures and smaller topic-based break-outs.AndISMICSalwaysofferspodiumandpost-er competitionpresentationswhicharenot limit-edtostudieswithhugepatientcohorts,butfocusmoreonnewlooksatwhatcanbedoneincardi-acandthoracicsurgery,ratherthanwhathasbeendoneinthepast.

ISMICSmembersareearlyadopters–theywanttoknowwhat isthe latest,thebest,andwhat is

comingnext.Theyhavenever losttheirsenseofcuriosity, and they never, ever represent the sta-tusquo.Ourexhibithallisfilledwithinformationaboutthelatestdevicesandtechniquesinthefield.Wehaveextendedexhibithourstoallowformoreinteractionbetweenourattendeesandourindus-trypartners.

JoinISMICS,joinusinBostonnextyear,andgetonboardwiththesocietythatcontinuestofosterthefutureofcardiothoracicandcardiovascularsurgery.

Visit our booth - #145 in the EACTS hall today!

2014 ISMIcS Annual Scientific Meeting

• Track all cardiac surgery procedures• Automated op notes/discharge summaries• Integrated risk modelling – EuroScore II• CUSUM, VLAD and Funnel Plot analysis• Unlimited longitudinal follow-up• Export to national registries

CardiaC Surgery databaSe Software for HoSpitalS aNd NatioNal regiStrieS

Delete

OM2 Routine graft Long SV Average (1.5–2.0mm) Scattered disease

Procedure Site Local Procedure Graft Conduit Coronary VesselSize

Coronary Vessel Quality

Distal RCA Routine graft Radial artery Average (1.5–2.0mm) Diffuse disease

Prox LAD Endarterectomy Free LIMA Average (1.5–2.0mm) Diffuse disease

Date of Operation: 07 September 2012 Selected Patient : John Nemo

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The Hub – Station Road – Henley-on-Thames – RG9 1AY – United KingdomPhone: +44 1491 411 288 – e-mail: [email protected] – www.e-dendrite.com

PleasevisitDendrite onStand 97hereatEACTS 2013foradatabasedemonstration


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10 SHVD–TheSocietyforHeartValveDisease

77 Siemens,HealthcareSector

108 Smartcanula

114 SorinGroupItalia

116 StJudeMedical

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137 STS–TheSocietyofThoracicSurgeons

21 SunshineHeart

79 Symetis

128 TerumoEuropeCardiovascularSystems

132 ThoratecCorporation

66 TianjinPlasticsResearchInstitute

4 TianjinWelcomeMedicalEquipment

80 TransonicEurope

105 ValveXchange

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149 WisepressOnlineBookshop

6 WLGore&Associates

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50 WSPCHS–WorldSocietyforPediatricandCongenitalHeartSurgery

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138 3-DMatrixEurope

24 A&EMedicalCorporation

144 AATS–AmericanAssociationforThoracicSurgery

126 AbbottVascularInternational

8 ACUTEInnovations

46 Admedus

19 AdvancisSurgical

51 AndocorNV

9 APACVS–AssociatonofPhysicianAssistantsinCardiovascularSurgery

93 AsanusMedizintechnik

88 AtriCureEurope

122 BBraunSurgical

27–28BaxterHealthcare

69 BerlinHeart

67 BioCerEntwicklungs

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61 BiometMicrofixation

17 BioVentrix

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81 CardiaInnovation

37 CardiaMed

101 CardioMedical

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157 ClearCatheterSystems

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12 CorMatrixCardiovascular

74b Correx

58 CryolifeEuropa

136 CTSNet

20 DeSoutterMedical

98 Delacroix-Chevalier

97 DendriteClinicalSystems

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148 EACTS–TheEuropeanAssociationforCardio-ThoracicSurgery

112 EdwardsLifesciences

111 Estech

73 Ethicon–Johnson&JohnsonMedical

130 Eurosets

1 FehlingInstruments

91a gebemedDeutschland

35 GebruederMartin

75 GeisterMedizintechnik

3 GeneseeBioMedical

32 GEOMEDMedizin-Technik

92a GlobalCommunication

146 Gunze

82 HamamatsuPhotonicsDeutschland

49 HeartandHealthFoundation

52 HeartHugger/GeneralCardiacTechnology

124 HeartWare

91b ImaCor

83 Integra

145 ISMICS–InternationalSocietyforMinimallyInvasiveCardiothoracicSurgery

140 JenaValveTechnology

29–30JOTEC

63–64KarlStorz

95–96LepuMedicalTechnology

99 LSISolutions

5 Mani

59 MaquetCardiopulmonary

22 MasterSurgerySystems

147 MDDMedicalDeviceDevelopment

53 Medafor

74a MedexResearch

84 Medistim

90 MedosMedizintechnik

60 MedtronicInternationalTrading

154–5MiCardiaCorporation

23 NeoChord

86 On-XLifeTechnologies

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Floor plan

ENTRANCE


Learnmoreabout thedesign, implantationandclinicalresultsofthe3fEnable®SuturelessValve

and Engager®, the next generation surgical TAVIplatformthroughpresentationsbyexpertsfollowedbyawetlabandasimulationworkshop.

Over the past few years, new technologieshave expanded the treatment options forcardiacsurgeonstotreatpatientssufferingfromaortic stenosis such as transcatheter aortic valvereplacementandmorerecentlywithnewsurgicalsuturelessvalves.

Following the recent introduction of theEngagertransapicalaorticvalvesysteminEuropeand the growing interest in sutureless valves

such as the 3f Enable® valve, Medtronic seizesthe opportunity of this year’s EACTS to inviteattendeestotheMedtronicExperienceCentretoattendaseriesofpracticalworkshopsfocusedonthesenewtechnologies.

Each workshop will start with a presentationof the 3f Enable® sutureless valve by professorOttoDapunt1followedbyawet-labduringwhichparticipants will have the opportunity to implantthevalveonpighearts.

The workshop will then continue with apresentationofthenewEngagertransapicalaorticvalve system by Dr. Hendrik Treede2, Pr. MichaelHilker3andPr.EhudSchwammenthal4followedby

sizingandimplantationsimulation.More than offering a practical experience,

each workshop will be an opportunity to helpsurgeons use their best judgement to matchthe appropriate product with the appropriatepatientthroughdiscussionswithexpertsonpre-proceduralplanning,scientificresultsandpatientindications.

EACTSattendeeswillingtoparticipatetooneoftheseworkshopsareinvitedtocontactaMedtronicrepresentativeattheMedtronicboothordirectlyatthereceptionoftheMedtronicExperienceCentrelocatedintheLounge3atlevel01oftheAustriaCentre.

3 Workshops:nMonday07October:

from09:00to11:00n Tuesday08October:

from09:00to11:00andfrom14:00to16:00

Please visit the Medtronic Experience Centreat your convenience for simulation stationson minimally invasive OPCAB, cannulation,perfusionsystemsand transcatheteraorticvalvereplacementsystems.1 Pr. Otto Dapunt, Clinic for Heart Surgery at Klinikum Oldenburg, Germany

2 Dr. Hendrik Treede- Hamburg University Hospital, Germany

3 Pr. Michael Hilker- Universität Klinikum Regensburg, Germany

4 Pr. Ehud Schwammenthal- Tel Aviv University- Israël

Test-Drive Medtronic’s Latest Solutions for Patients with Aortic Stenosis

PublisherDendriteClinicalSystems

Editor in ChiefPieterKappetein

Managing [email protected]

Industry [email protected]

Design and [email protected]

Managing [email protected]

Head OfficeTheHubStationRoadHenley-on-Thames,RG91AY,UnitedKingdomTel+44(0)1491411288Fax+44(0)1491411399Websitewww.e-dendrite.com

Copyright2013©:DendriteClinicalSystemsandtheEuropeanAssociationforCardio-ThoracicSurgery.Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,transmittedinanyformorbyanyothermeans,electronic,mechanical,photocopying,recordingorotherwisewithoutpriorpermissioninwritingoftheeditor.

EACTSDaily News

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