61.13 Perioperative Outcomes Following Cardiovascular Surgery in Patients with 22q11.2 deletion

Posted on January 18, 2016

M. E. Mitchell1,2, D. Menhke2, P. Simpson2, M. Nugent2, A. Tomita-Mitchell2, N. Ghanayem1,2, S. Clarke1,2 1Children’s Hospital Of Wisconsin,Milwaukee, WI, USA 2Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:
22q11.2 is the most common deletion syndrome with an incidence of 1:4000. Up to 75% of patients with 22q11.2 deletion syndrome (22qDS) have congenital heart disease and need of congenital heart surgery. The known associated anomalies within the endocrine, neurologic, hematologic, and airway systems can have affects on their perioperative morbidity and mortality following cardiovascular surgery. Our study was to look at our single center institution perioperative morbidity in patients with 22qDS following cardiovascular surgery.

Methods:
This was a single center retrospective chart review of 99 patients that had cardiovascular surgery at Children's Hospital of Wisconsin between 2004-2011 and were in the Congenital Heart Disease Tissue Bank. Patients with 22qDS and matched controls, for age and type of surgery were identified. Data from the perioperative period was obtained and analysis was performed using classification trees.

Results:
Patients with 22qDS and a RACHS score < 2 had more cardiopulmonary bypass time > 150 min (p < 0.001). There was an increased risk of post-operative neurologic injury in patients with 22qDS that had a cardiopulmonary bypass time > 150 min (p<0.004). Cardiopulmonary bypass time was > 150 min in patients with 22qDS, higher RACHS scores, and no prenatal diagnosis (p<0.001). Patients with 22qDS had > 5 days of mechanical ventilation similar to patients with RACHS scores > 3 and cardiopulmonary bypass time > 150 min.

Conclusion:
This study shows there are increased post-operative morbidities in patients with 22qDS related to cardiopulmonary bypass, neurologic injury, and mechanical ventilation. Prenatal diagnosis also plays a role in length of cardiopulmonary bypass in patients with 22qDS. This suggests that further investigation with a larger cohort of patients with 22qDS is needed.

61.14 Role of the Surgical Robot in an Advanced Video-Assisted Thoracoscopic Program

Posted on January 18, 2016

M. Huang1, B. Zwierzchowski1, W. Wong1, T. Demmy1, E. Dexter1, M. Hennon1, A. Picone1, W. Tan1, S. Yendamuri1, C. Nwogu1 1Roswell Park Cancer Institute,Buffalo, NY, USA

Introduction: A steadily increasing proportion of thoracic procedures are being performed via minimally invasive techniques. The literature has demonstrated that video-assisted thoracoscopic surgery (VATS) techniques have improved patient recovery time with fewer postoperative complications, and sustained long-term survivorship data equivalent to open thoracotomy for early stage lung cancer. However, the additional benefit of robotic video-assisted thoracic surgery (RVATS) remains controversial. As a prelude to a prospective trial comparing RVATS with conventional VATS for lobectomy, we conducted a retrospective review of all RVATS cases at an academic, tertiary referral center with a focus on lobectomy cases.

Methods: A review was conducted of 101 consecutive patients undergoing robotic-assisted thoracoscopic surgery between August 2005 and May 2015. Outcomes data collected include operative time, blood loss, duration of hospital and postoperative ICU stay, chest tube duration, conversion rates, and perioperative morbidity and mortality. In addition, a subset cost analysis compared direct costs and medical supply expenses for 10 lobectomy cases, each performed by RVATS, VATS, and thoracotomy.

Results: In this initial case series of 41 cases of RVATS lobectomy, patients had a median hospital length of stay of 4 days, ICU length of stay of 0 days, chest tube duration of 2 days, and an average blood loss of 151 mL. One patient (2.4%) that was electively converted to thoracotomy for a large upper and middle lobe tumor, died from pneumonia and respiratory failure. There were 6 (14.6%) cases converted to open thoracotomy. Direct costs for lobectomies performed by VATS, RVATS and thoracotomy were $23,306, $25,510 and $35,195, respectively.

Conclusion: Progressive incorporation of the surgical robot in an already advanced thoracoscopic program is feasible. The immediate postoperative outcomes after RVATS lobectomy are similar to what has been reported from our institution and others for VATS lobectomy. RVATS was modestly more expensive than VATS, but both were significantly cheaper than thoracotomy. A prospective comparison of RVATS and VATS would provide greater understanding of the precise benefits or lack thereof of the Da Vinci surgical robotic system for minimally invasive lung resections.

61.10 Evaluation of Del Nido and Conventional Blood Cardioplegia in Adult Cardiac Operations

Posted on January 18, 2016

R. Ou1, A. Zhu1, A. Ashfaq1, S. Nguyen1, S. Riazati1, R. Satou1, R. J. Shemin1, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction: The Buckberg blood cardioplegia has become the conventional solution for myocardial preservation during cadioplegic arrest. Recently, the del Nido cardioplegia solution has been utilized in pediatric cardiac operations and utilizes lidocaine rather than potassium to achieve diastolic arrest. Compared to conventional Buckberg cardioplegia it has the added benefit of only requiring one dose for up to 180 minutes of myocardial quiescence. By lowering cardioplegia volume, the del Nido method may reduce myocardial edema, hemodilution, arrhythmias and costs of care. In this study, we aimed to evaluate the safety and efficacy of del Nido cardioplegia in adult cardiac valvular operations.

Methods: The institutional Society of Thoracic Surgeons database was used to identify all adults undergoing aortic or mitral valve operations from January 2011 to May 2015. Patient demographics, operative characteristics and postoperative outcomes were gathered from the database as well as electronic medical records. Patients who received the del Nido solution (DN) were matched with those receiving conventional blood cardioplegia (CC) for procedure type as well as baseline characteristics such as age, gender, ejection fraction, diabetes, lung disease, among others. Statistical analysis was performed with STATA software (StataCorp, College Station) and P-values less than 0.05 were considered significant.

Results: During the study period, 54 patients met criteria and were included in the DN group while another 54 were assigned to the CC group after matching for baseline characteristics. The groups did not differ significantly in comorbid conditions as shown in Table 1. Compared to the CC group, DN patients exhibited a shorter crossclamp time (122 minutes vs 125 minutes, P= 0.87), higher in-hospital ICU length of stay (98 hours vs 96 hours, P= 0.59), mortality rate (9.3% vs 1.8%, P= 0.10), red cell transfusions (1.9 units vs 1.6 units, P=0.74) and readmission rates (13.2% vs 5.6%, P= 0.18). The fall in hematocrit immediately after the operation was similar between the DN (7.3%) and CC (7.9%) cohorts (P=0.63). Inotrope use between DN and CC measured by a Vasoactive Inotropic Score were also similar in the intraoperative period (7.3 vs 6.1, P=0.54) and postoperative period (2.4 vs 3.1, P=0.73).

Conclusion: Our data, although preliminary, suggests that the of del Nido cardioplegia solution was associated with a non-significant increase in mortality, readmission rate, ICU hours, and red cell transfusions. Given major differences in mechanism of action, the del Nido solution needs to be further evaluated in larger cohorts and include analysis of clinical as well echocardiographic outcomes.

61.11 Decreased Left Ventricular Function is Not a Contraindication to Transcatheter Aortic Valve Replacement

Posted on January 18, 2016

D. M. Strauss1, A. Das1, G. Savulionyte1, K. J. Oh1, N. L. Owen-Simon1, H. A. Cohen1, B. O’Murchu1, B. P. O’Neill1, G. Wheatley1 1Temple University,Philadelpha, PA, USA

Introduction: Transcatheter aortic valve replacement (TAVR) has been shown to have improved outcomes compared to surgical aortic valve replacement in high surgical risk patients with aortic stenosis. However, depressed left ventricular ejection fraction (LVEF) has been shown to be a relative contraindication to TAVR in these patients. The purpose of this study is to compare the outcomes of patients with decreased LVEF versus patients with normal LVEF.

Methods: A retrospective review of patients undergoing TAVR from December 2013 to June 2015 was performed. Institutional Review Board approval was obtained. Demographic information and outcome data were collected regarding LVEF, procedural success, and lengths of stay in the intensive care unit and hospital. Statistical analysis was performed using SPSS Statistics.

Results: Forty-two patients (5 Low LVEF, 37 High LVEF) underwent TAVR from December 2013 to June 2015. Average age for low LVEF patients was 70.6 years and 79.8 years for high LVEF patients (p=0.22). M:F ratio was 1:4 for low LVEF patients, and 12:25 for high LVEF patients (p=0.57). Average Society of Thoracic Surgeons (STS) score for low LVEF patients was 8.5, and 9.4 for high LVEF patients (p=0.32). [Figure 1] Four (80%) patients in the low LVEF group had a diagnosis of chronic obstructive pulmonary disease (COPD), and 19 (51.4%) patients in the high LVEF group had COPD (p=0.23). The Medtronic CoreValve was used in 3 patients with low preoperative LVEF and 12 patients with high LVEF (p=0.23), while the Edward SAPIEN prosthesis was implanted in 2 patients with low LVEF and 25 patients with high LVEF. Procedural success was 100% in both groups. Operative times averaged 125.4 (84-162) minutes in the low LVEF group and 124.0 (60-207) minutes in the high LVEF group (p=0.94). Four low LVEF patients (80%) were extubated in the operating room, while 29 (78.4%) high LVEF patients extubated in the operating room (p=0.94). Average intensive care unit stay (ICU) was 2.0 (1-3) days for low LVEF patients and 2.8 (0-12) days for high LVEF patients (p=0.14). Average hospital stay for low LVEF patients was 6.6 (3-9) days and 6.1 (2-28) days for high LVEF patients (p=0.75). 30-day mortality was 0 in low LVEF group and 5.4% (n=2) in the high LVEF group (p=0.059).

Conclusion: Patients with low LVEF undergoing TVR had comparable outcomes and length of hospital stay as compared to patients with high LVEF. As a result, low LVEF should not be used as an exclusion criteria for patient selection for TAVR. Additional studies are needed to evaluate long term outcomes and quality of life indicators.

61.12 Finite element analysis: Assessing the optimal patient-specific mitral valve repair.

Posted on January 18, 2016

A. E. Morgan1, L. Ge4, W. G. Morrel5, J. L. Pantoja5, E. A. Grossi3, M. B. Ratcliffe1,2 1University Of California – San Francisco,Surgery,San Francisco, CA, USA 2San Francisco VA Medical Center,Surgery,San Francisco, CA, USA 3New York University School Of Medicine,Cardiothoracic Surgery,New York, NY, USA 4University Of California – San Francisco,Bioengineering,San Francisco, CA, USA 5University Of California – San Francisco,School Of Medicine,San Francisco, CA, USA

Introduction: Mitral valve repair is superior to replacement in terms of long-term survival, but recurrent mitral regurgitation after repair for degenerative disease occurs at a rate of ~2.6% per year, with a 20% reoperation rate at 20 years. We hypothesize that durability of repair is related to geometry of initial repair, as well as stress distribution over the mitral valve and left ventricle. Previous studies demonstrate that repair by posterior leaflet resection increases stress across the posterior leaflet; we tested the hypothesis that repair by placement of prosthetic chordae tendinae resulted in reduced overall stress as compared to leaflet resection.

Methods: Magnetic resonance imaging and intra-operative 3D trans-esophageal echocardiography were performed before surgical repair of isolated P2 prolapse in a single patient. A finite element model of the left ventricle and mitral valve was created. Stress was examined in the preoperative state for the mitral valve and left ventricle, and for the following repairs: Triangular resection; Placement of one PTFE chord; Placement of two PTFE chords.

Results: The principal findings of this study are the following: 1) Placement of prosthetic chordae resulted in stable or decreased overall posterior leaflet stress for all phases of the cardiac cycle; 2) In contrast, triangular resection resulted in increased posterior leaflet stress, most prominently in diastole; 3) All repair techniques reduced stress on the anterior leaflet; 4) All repair techniques restored normal leaflet coaptation. An example of pre- and post-repair leaflet geometry is shown in the attached figure, for placement of two prosthetic chordae.

Conclusion: All repair techniques eliminated mitral regurgitation and restored normal leaflet coaptation. Finite element analysis revealed that mitral valve repair with prosthetic chordae restored normal leaflet geometry without creation of excessive stress on the valvular tissues, in contrast to leaflet resection, which significantly increased stress across the posterior leaflet. Future studies will examine this effect across a broad range of patients with the aim of developing a patient-specific tool for mitral valve repair preoperative planning and surgical education.

61.08 National Contemporary Outcomes of Open Throacoabdominal Aneurysm Repair in an Endovascular Era

Posted on January 18, 2016

T. Obeid1, K. Yin1, A. Kilic1, I. Arhuidese1, B. Nejim1, M. Malas1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:
Open repair of thoracoabdominal aneurysm (TAA) and descending thoracic aneurysm (DTA) carries significant operative morbidity and mortality. Despite improved patient selection, evolving operative and anesthesia techniques, and better control of comorbid conditions, patient-level risk factors of open repair remain to be fully understood. We sought to evaluate risk factors affecting operative mortality of open TAA and DTA repair in a nationally validated multi-specialty dataset.

Methods:
We identified all TAA – including all Crawford extent types – and DTA cases in the National Surgical Quality Improvement Program (NSQIP) database between years 2005 to 2013. Operative mortality was defined as death within 30 days of surgery. A logistic regression model was constructed to evaluate the risk of patient’s age, gender, race, body mass index (BMI), comorbid conditions, functional status, American Society of Anesthesiologists (ASA) class, smoking status, alcohol intake, preoperative blood transfusion, rupture status, DTA vs combined Crawford extents, operating surgical specialty, preoperative hematocrit and creatinine levels.

Results:

A total of 1,048 patients had open TAA or DTA repair during the 9-year study period. Mean patient age was 67±12 years, BMI average was 27±6 and males comprised 60% of the dataset. Nearly 12.0 % of the patients presented with ruptured aneurysms. DTA comprised 10.6% of all aneurysms and concomitant dissection occurred in 12.7% of all cases.

Operative mortality was 14.0% (non-ruptured 11.4% vs. ruptured 34.2%, P<0.001) and the total proportion of patients with postoperative acute renal failure requiring dialysis was 12.6% (non-ruptured 11.8% vs ruptured 19.2%, P<0.001).

Each additional year in patient age or one unit increase in BMI increased the risk of death by 4% (OR 1.04, 95%CI 1.02-1.06, P<0.001, OR 1.04, 95%CI 1.00-1.08, P=0.03, respectively). Ruptured aneurysms had double the operative mortality risk (OR 2.26, 95%CI 1.26-4.03, P=0.010).

Being totally dependent had the highest effect on operative mortality, tripling the risk of death (OR 3.39, 95%CI 1.60-7.19, P<0.001), while preoperative chronic renal insufficiency added 26% mortality risk per 1 unit increase in creatinine level (OR 1.26, 95%CI 1.04-1.52, P=0.020).

Being a smoker and ASA class ≥4 versus ≤3 each increased the chances of death by 60% and 70%, respectively (both P < 0.05) (Table).

Conclusion:
Despite corseted efforts, open repair of thoracoabdominal aneurysm carries significant morbidity and mortality. Patient age and BMI equally affect the risk of operative mortality. Ruptured aneurysms and patients’ functional status have the highest effect on risk of operative death.

61.09 Timing and Frequency of Unplanned Readmissions after Heart Transplant Does Not Impact Long-term Survival

Posted on January 18, 2016

E. Lushaj1, T. Kohmoto1, L. Lozonschi1, S. Osaki1, A. Badami1, S. Ulschmidt1, S. Akhter1 1University Of Wisconsin,Cardiothoracic/Surgery,Madison, WI, USA

Introduction: Complications often occur long after heart transplantation (HT), requiring hospital readmission. Our goal was to identify the rate and etiology of unplanned readmissions following HT. We also analyzed the impact of unplanned readmissions on post-transplant survival.

Methods: We retrospectively reviewed 133 patients undergoing HT at our institution from 01/2004 to 05/2014. Six patients who expired during the index hospitalization were excluded from the analysis.

Results:Of the sample (n=127) 98 (77%) patients were readmitted 324 times (3.3 times/patient) as of end of follow-up. The median follow-up period was 56 (IQR: 21-105) months. Median time to first readmission was 59 (IQR: 10-185) days. Over half of readmissions (n=186; 57%) were within the first year post-discharge at index hospitalization. Of those, 52 (28%) were within 30 days post-discharge. Freedom from first readmission was observed for 66% of patients at 1 month, 51% at 3 months, 29% at 6 months and 18% at 12 months (Figure). Median hospital length of stay at readmission was 3 (IQR: 2, 6) days. Age, gender, BMI, previous LVAD support, surgery or CPB time at transplant, hospital and ICU length of stay were not risk factors for readmission. Readmission etiology included infections (23%), GI complications (15%), respiratory (14%), rejection (11%), cardiac (10%), renal (7%), cardiac allograft vasculopathy (2%). Readmissions due to infections included respiratory (32%), GI (22%), wound (16%), cytomegalovirus (5%). There was no significant difference in the long-term survival between readmitted and non-readmitted patients (Log-rank test: p=0.68).

Conclusion:The first year after discharge remains a high risk period for transplanted patients. Infections and GI complications were the leading causes of readmission. Readmissions did not negatively impact long-term survival of transplanted patients.

61.06 Clincal Significance Of Spontaneous Pneumomediastinum

Posted on January 18, 2016

B. A. Potz1, L. Chao1, T. T. Ng1, I. C. Okereke1 1Brown University,Surgery/Cardiothoracic Surgery/ Warren Alpert Medical School,Providence, RHODE ISLAND, USA

Introduction: Spontaneous pneumomediastinum (SPM) is classified as the presence of free air in the mediastinum in the absence of any precipitating cause. SPM is relatively uncommon, and the clinical significance and risk associated with SPM is not well understood and has not been widely documented in the literature. Our goals were to determine the outcomes of patients who presented with SPM and to determine predictors of severe pathology associated with SPM.

Methods: From 2004 through 2013, a retrospective review was conducted of all patients who were discovered to have SPM during presentation to our institution. Patient demographics, co-morbidities, laboratory values and presence of esophageal perforation were recorded.

Results: Over the 10 year span of the study 249 patients who presented to our institution were discovered to have spontaneous pneumomediastinum on chest x-ray or computerized tomography (CT) scan. Mean age was 38.7 years (1—93). Sixty-one percent (151/249) of patients were male. Subcutaneous emphysema was appreciated in 16 percent (39/249) of patients. Ten percent (24/249) of all patients were ultimately discovered to have esophageal perforation, determined by upper endoscopy, upper gastrointestinal series or intraoperatively during emergent surgery. Age (p <0.01), presence of pleural effusion (p < 0.01) and elevated white blood count (p < 0.01) were the only significant risk factors for presence of esophageal perforation (Table 1). Other variables, such as subcutaneous emphysema, elevated creatinine level and oxygen saturation were not associated with esophageal perforation.

Conclusions: SPM is usually associated with a benign clinical course. Risk factors for presence of esophageal perforation in these patients include age, elevated white blood count and presence of a pleural effusion. In the absence of abnormal laboratory values or associated radiologic findings, the majority of patients with SPM can be safely observed without the need for further diagnostic testing.

61.07 Direct Aortic Access for Transcatheter Aortic Valve Replacement is a Suitable Delivery Alternative

Posted on January 18, 2016

G. Savulionyte1, D. M. Strauss1, A. Das1, K. J. Oh1, N. L. Owen-Simon1, H. A. Cohen1, B. O’Murchu1, B. P. O’Neill1, G. Wheatley1 1Temple University,Cardiovascular Surgery,Philadelpha, PA, USA

Introduction: Transcatheter aortic valve replacement (TAVR) has become standard of care for high surgical-risk patients with severe, symptomatic aortic valve stenosis. However, these patients have a high associated incidence of peripheral vascular disease which can preclude delivery from a transfemoral (TF) approach. Alternative delivery options include transapical (TA) and trans-aortic (TAo). The purpose of this study was to compare the outcomes of TAVR procedures performed via a TAo approach versus a non-TAo approach.

Methods: A retrospective review of patients undergoing TAVR from December 2013 to June 2015 was performed. Institutional Review Board approval was obtained. Demographic information and outcome data were collected regarding type of vascular access, procedural success, and lengths of stay in the intensive care unit and hospital. Statistical analysis was performed using SPSS Statistics.

Results: Forty-two patients (10 TAo, 30 TF, 2 TA) underwent TAVR. Average age for TAo patients was 73.6 years and 80.3 years for non-TAo patients (p=0.11). M:F ratio was 1:9 for TAo patients, and 3:5 for non-TAo patients (p=0.10). Average Society of Thoracic Surgeons (STS) score for TAo patients was 11.8, and 8.5 for non-TAo patients (p=0.18). [Figure 1] Seven (70%) patients in the TAo group had a diagnosis of chronic obstructive pulmonary disease (COPD), and 16 (50%) patients in the non-TAo group had COPD (p=0.27). The Medtronic CoreValve was used in 4 patients undergoing TAo and 11 patients with non-TAo (p=0.75), while the Edward SAPIEN prosthesis was implanted in 6 patients receiving TAo and 21 patients in the non-TAo group. Procedural success was 100% in both groups. Operative times averaged 144.2 (99-203) minutes in the TAo group and 117.9 (60-207) minutes in the TF/TA group (p=0.048). Four TAo patients (40%) were extubated in the operating room, while 29 (90.6%) non-TAo patients were extubated in the operating room (p=0.00066). Average intensive care unit stay (ICU) was 4 (2-12) days for TAo patients and 2.35 (0-11) days for non-TAo patients (p=0.14). Average hospital stay for TAo patients was 10.2 (4-28) days and 4.9 (2-14) days for non-TAo patients (p=0.035). 30-day mortality was 10% (n=1) in TAo group and 3.1% (n=1) in the non-TAo group (p=0.37). 1-year mortality was 10% (n=1) in TAo group and 9.3% (n=3) in the TF/TA group (p=0.95).

Conclusion: TAo is a suitable alternative access point for TAVR patients unable to undergo a TF approach due to severe peripheral vascular disease. Although TAo patients have a longer length of hospital stay, the outcomes are comparable to non-TAo patients. Future studies are needed to assess the financial impact of this approach.

61.01 Effects of Diabetes and CPB on Adherens-Junction-Protein Expression of Human Peripheral Tissue

Posted on January 18, 2016

J. Feng1, A. K. Singh1, J. Liang1, Y. Liu1, F. W. Sellke1 1Brown University School Of Medicine,Cardiothoracic/Surgery,Providence, RI, USA

Introduction: Cardiac surgery with cardiopulmonary bypass (CPB) is often associated with the increased vascular permeability/tissue edema, microvascular endothelial cell injury/dysfunction. Especially, these disturbances are more pronounced in patients with poorly controlled diabetes. Recent study has demonstrated that the increased permeability after cardiopleogic arrest/CPB is associated with changes in the expression/phosphorylation of adherence-junction-proteins in the coronary vasculature in patients with type-2 diabetes (T2DM). We hypothesized that T2DM may be associated with altered adherence-junction-protein expression/phosphorylation of skeletal muscle/vessel in the setting of CPB . The aim of the current study was to investigate the changes in adherens-junction-proteins, such as VE-cadherin, and β-catenin of skeletal muscle and vessels in patients with or without T2DM in the setting of CPB and coronary artery bypass graft (CABG) surgery.

Methods: Chest wall skeletal muscle tissue was harvested pre- and post-CPB from the controlled diabetic (HbA1c: 6.3 ± 0.1), uncontrolled diabetic (HbA1c: 9.6 ± 0.3) and non-diabetic patients (HbA1c: 5.4 ± 0.1) undergoing CABG surgery (n = 6/group). The expression/phosphorylation of adherence-junction-proteins such as, VE-cadherin and β-catenin were assessed by immunoblotting and immuno-histochemistry. Skeletal-muscle-arteriolar endothelial function was assessed by videomicroscopy in response to the endothelium-dependent vasodilator substance P.

Results:There were no significant differences in basal protein expression of VE-cadherin between UDM and CDM or ND patients or between pre- and post-CPB among groups. The level of pre-CPB phosphorylated VE-cadherin tends to be 25% higher in the UDM group compared with ND (P = 0.03). CPB induced more phosphorylation of VE-cadherin (21% in ND; 30% in CDM and 43% vs. pre-CPB; P<0.05, respectively) and this effect was more pronounced in the UDM group (P<0.05 vs. ND or CDM). The post-CPB β-catenin was significantly decreased as compared with pre-CPB in all three groups (P<0.05) and the decrease was more pronounced in the UDM group (P<0.05). There were significantly decreases in vasodilatory response of skeletal muscle arterioles to substance P after CPB in all three groups (P<0.05). This alteration was more pronounced in the UDM patients (P<0.05).

Conclusion: These findings suggest that poorly controlled diabetes down-regulates endothelial adherence-junction-protein expression of skeletal muscle/vessel tissues in the setting of CPB. The enhanced tyrosine phosphorylation of VE-cadherin and degradation of β-catenin indicates deterioration of these proteins and the damage of the cell-cell endothelial junctions, specifically in the diabetic vessels. These alterations may lead to the increases in periphral vascular permeability and endothelial dysfunction and affect the outcomes in diabetic patients after CPB/cardiac surgery.

61.02 Is Local Anesthesia a Better Approach for Transcatheter Aortic Valve Replacement Procedures?

Posted on January 18, 2016

A. Das1, D. M. Strauss1, G. Savulionyte1, N. L. Owen-Simon1, K. J. Oh1, H. A. Cohen1, B. O’Murchu1, B. P. O’Neill1, G. Wheatley1 1Temple University,Cardiovascular Surgery,Philadelpha, PA, USA

Introduction: Optimal anesthetic strategy for transcatheter aortic valve replacement (TAVR) procedures has yet to be determined. Currently, general anesthesia (GA) is the accepted approach in those patients requiring transfemoral vascular access, however emerging data suggests that outcomes can be improved using local anesthesia (LA). The purpose of this study is to compare outcomes of patients with severe, symptomatic aortic valve stenosis undergoing transfemoral TAVR using general versus local anesthesia.

Methods: A retrospective review of patients undergoing TAVR from December 2013 to June 2015 was performed. Institutional Review Board approval was obtained. Demographic information and outcome data were collected regarding type of anesthesia, procedural success, respiratory complications and lengths of stay in the intensive care unit and hospital. Statistical analysis was performed using SPSS Statistics.

Results: A total of 30 patients (12 GA, 18 LA) underwent transfemoral TAVR. Average age for GA patients was 80.6 years and 81.3 years for LA patients (p=0.82). M:F ratio was 1:1 for GA patients, and 5:13 for LA patients (p=0.22). Average Society of Thoracic Surgeons (STS) score for GA patients was 9.6, and 7.8 for LA patients (p=0.30). [Figure 1] Five (41.7%) patients in the GA group had a diagnosis of chronic obstructive pulmonary disease (COPD), and 10 (55.6%) patients in the LA group had COPD (p=0.46). The Medtronic CoreValve was used in 2 patients undergoing GA and 9 patients with LA (p=0.06), while the Edward SAPIEN prosthesis was implanted in 10 patients receiving GA and 9 patients receiving LA. Procedural success was 100% in both groups. Operative times averaged 125.3 (88-207) minutes in the GA group and 109.6 (60-168) minutes in the LA group (p=0.13). No LA patient required conversion to GA. Ten GA patients (83.3%) were extubated in the operating room, while 1 (5.6%) LA patient required intubation on post-operative day 8 due to COPD exacerbation. Average intensive care unit stay (ICU) was 3.1 (1-8) days for GA patients and 2.4 (0-11) days for LA patients (p=0.32). Average hospital stay for GA patients was 6.9 (2-14) days and 5.5 (2-12) days for LA patients (p=0.36). 30-day mortality was 0 in GA group and 5.6% (n=1) in the LA group.

Conclusion: LA for transfemoral TAVR procedures is feasible and yields similar procedural outcomes as GA techniques. Although patients receiving LA had a higher incidence of COPD, fewer of these patients had post-operative respiratory complications and there were shorter ICU and hospital lengths of stay. Future studies will need to compare procedural and total hospital costs between these two anesthetic approaches.

61.03 Does Pre-operative Amiodarone Exposure Impact Outcomes in Cardiac Transplant Recipients?

Posted on January 18, 2016

E. Lushaj1, R. Dhingra2, S. Akhter1, T. Kohmoto1, S. Ulschmidt1, S. Osaki1, A. Badami1, L. Lozonschi1 1University Of Wisconsin,Cardiothoracic/Surgery,Madison, WI, USA 2University Of Wisconsin,Cardiovascular/Medicine,Madison, WI, USA

Introduction: Pre heart transplant (HTx) amiodarone use is very common. Concerns, however, still exist about increased complications related to use of amiodarone in the perioperative period.

Methods: Of all consecutive patients who received HTx at our institution between 1/2004 to 12/2014 (n=208), we compared the peri- and post-operative outcomes of 137 (66%) patients who were taking amiodarone (group 1) for at least 30 days before HTx to 71 (34%) patients not taking amiodarone (group 2).

Results:Age at transplant, BMI, gender, ischemic etiology, diabetes, hypertension status and donor ischemic time, were not different between the two groups (all p>0.05). Similar number of patients had implantable defibrillators prior to transplant (p=0.30). 72% of patients in group 1 and 48% in group 2 had a ventricular assist device prior to transplant (p=0.001). 51% of patients in group 1 and 37% in group 2 had COPD pre-HTx (p=0.058). Median operative time, aortic cross clamp time, intensive care unit time, prolonged ventilation and median hospital length of stay did not differ between groups (p>0.05). Higher cardiopulmonary bypass time was observed in group 1 (203 vs. 187 min; p=0.013). Patients in group 1 had more pneumonias (7% vs. 0%; p=0.024) and a tendency to develop post-transplant atrial fibrillation (7% vs. 1.4%; p=0.085). None of the patients was implanted with a permanent pacemaker. Patients in group 2 had a higher rejection rate (21% vs. 9%; p=0.017). Both groups had similar 30-day readmission and mortality rates (p>0.05). 1-year survival was not affected by use of amiodarone (p=0.98).

Conclusion:Our study showed that pre-operative amiodarone exposure did not protect from post-transplant atrial fibrillation and unexpectedly resulted in even a higher rate compared to control group. As previously reported lower rejection rates were found in patients exposed to pre-transplant amiodarone. Amiodarone use did not impact post-transplant short and long-term survival (p>0.05).

61.04 Late Durability of Decellularized Allografts for Aortic Valve Replacement: a Word of Caution

Posted on January 18, 2016

M. R. Helder1, N. T. Kouchoukos4, K. Zehr2, J. A. Dearani1, C. N. Heins3, H. V. Schaff1 1Mayo Clinic,Cardiovascular Surgery,Rochester, MN, USA 2Johns Hopkins University School Of Medicine,The John Hopkins Heart & Vascular Institute,Baltimore, MD, USA 3Mayo Clinic,Biomedical Statistics And Informatics,Rochester, MN, USA 4Missouri Baptist Medical Center,St. Louis, MO, USA

Introduction: Decellularized bioprostheses utilized for aortic valve replacement (AVR) have the theoretical advantage of reduced antigenicity and increased durability. Prior studies demonstrated satisfactory early outcome and negative panel reactive antibody in >90% of pt with DAVA 1 year postoperatively. However, long-term durability of DAVA is unknown.

Methods: We reviewed 42 consecutive pt who underwent AVR with a decellularized allograft from March 12, 2002 to October 6, 2004 at 2 institutions. We compared this cohort to 29 consecutive control pt who underwent AVR with a standard cryopreserved allograft during the same interval. The primary outcome was aortic valve reoperation, and secondary outcome was overall mortality.

Results:In pt undergoing AVR with DAVA, aortic reoperation was required in 37% (15/41) of survivors, and the most common indication was allograft regurgitation (7/15, 47%). In the 29 control pt receiving standard cryopreserved allografts, aortic valve reoperation was required in 17% (4/24), and aortic regurgitation was the indication in 2 (50%). Freedom from reoperation 5 yr postoperatively was 92% (95% CI, 84%-100%) in the DAVA group compared to 100% in the control group. Freedom from reoperation at 10 yr postoperatively was 51% (95% CI, 34%-76%) in pt receiving DAVA compared to 80% (95% CI, 60%-100%) in the control group (p=0.06). Overall 5 and 10-yr survival were 90% (95% CI, 80%-100%) and 76% (95% CI, 61%-93%) in the decellularized group compared the 72% (95% CI, 57%-90%) and 57% (95% CI, 38%-79%) in the control group (p=0.09).

Conclusion: Late survival of pt receiving DAVA was similar to that of pt with standard cryopreserved allografts. This study identified a strong trend for late allograft deterioration and reoperation beyond 5 yr postoperatively in the DAVA group. These findings should be considered when designing clinical trials of tissue-engineered bioprostheses.

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