IJTCVS 2010; 26: 52

Supplement Volume 26, Jan - Mar 2010

Abstracts of the 56th Annual Conference of IACTS, February 2010

IJTCVS, Jan–Mar, 2010

IJTCVS 2010; 26: 53 IJTCVS 2010; 26: 53

Coronary artery bypass grafting for patients with low left ventricular function

Abstracts 1

Hirotaka I, Keiichi T, Taira Y, Kenji K, Keita K, Atsushi A Department of Cardiovascular Surgery, School of Medicine, Juntendo University Background: Surgical ventricular reconstruction (LVR) and/or mitral valve surgery (MVS) are often needed for patients with coronary artery disease. We evaluated our strategy for patients undergoing coronary artery bypass grafting with low left ventricular function. Methods: We divided 192 patients with low left ventricular function (EF < 0.40) undergoing CABG between July, 2002 and June, 2009 into two groups; Group I for 123 patients undergoing isolated CABG and Group C for 69 patients undergoing CABG with concomitant surgery such as LVR, MVS. Indications for each procedure were strictly decided according to pre-operative and intraoperative precise examinations using echocardiography and operative findings. Results: OPCAB was performed in 117 patients in Group I. CABG with CPB (on pump beating heart) was performed in only 6 patients. Forty three MVSs and 21 LVRs were performed with CABG in Group C. The numbers of distal anastomoses and those performed using arterial grafts were higher in Group I (I: 3.9 and 3.1, C: 3.1 and 2.0). ICU stay and hospital stay were longer in Group C (I: 2.6 and 13.3, C: 7.6 and 18.8, days). There was no significant difference in operative mortality between the two groups (I: 4.9%, C: 11.6%). Conclusions: We showed good short term outcomes in the patients undergoing CABG with low ventricular function according to our strategy, in which we decided the surgical procedures after intraoperative precise evaluations for each patient adding to preoperative examinations. Long term outcome should be needed.

Yoga breathing technique training to reduce postoperative pulmonary complications in stable patients undergoing elective CABG surgery : A randomized clinical trial

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Bedi HS, Gupta A, Singh N Christian Medical College & Hospital, Ludhiana, Punjab Background: Morbidity and mortality after coronary artery bypass graft (CABG) surgery is increased by post-operative pulmonary complications (PPCs). PPC add to the length of hospital stay and cost. The efficacy of pre-operative yoga breathing techniques (pranayama) in reducing the incidence of PPCs in patients undergoing CABG surgery has never been studied. The aim of this study was to evaluate the prophylactic efficacy of pre-operative yoga breathing techniques on the incidence of PPCs in patients scheduled for elective CABG surgery. Methods: 20 Consecutive stable patients scheduled for elective CABG surgery at the Sigma New Life Heart Centre were randomly assigned to receive either conventional usual care respiratory therapy (Group 1), or yoga therapy in addition to usual care (Group 2). Demographic data, anesthesia, surgical and ICU protocols were similar in both groups. Pulmonary function tests, arterial blood gas analysis and chest radiographs were done pre and post-operatively. Incidence of PPCs, ventilation time, ICU stay, and duration of hospitalization were tabulated. Results: After CABG surgery, PPCs were present in 12 % of patients in Group 1 and 4 % of patients in the Group 2 (odds ratio [OR] 0.52. Pneumonia occurred in 9 % of patients in Group 1 and in 2% of patients in Group 2 (OR 0.40). Median duration of post-operative hospitalization was 8 days in the Group 1 vs 6 days in Group 2. A significant decrease of pulmonary function was observed in both groups until post-operative day 5. When compared with the

IJTCVS, Jan–Mar, 2010

percentage of the pre-operative value, the forced vital capacity was significantly lower in group 1 than in group 2 on post-operative days 1 (33.3%±8.3% versus 49.1%±8.4%, p < 0.001), 3 (45.4%±7.0% versus 62.1%±8.6%, p < 0.001), and 5 (56.1%±8.7% versus 77.5%±11.6%, p < 0.001). Similar results were found for forced expiratory volume in 1 second. The PaO2 value and the PaO2/FIO2 ratio dropped on postoperative day 1 in both groups (p < 0.05), with a higher fall in group 1 (p < 0.05). Orotracheal intubation time (p = 0.012) and hospital stay (p = 0.002) were lower in group 2. Conclusions: The addition of yoga therapy improved the oxygenation, reduced the deterioration in PFT and reduced the incidence of PPCs and duration of post-operative hospitalization in patients undergoing CABG surgery.

Combined carotid endarterectomy and coronary artery bypass grafting surgery - its outcome and association with left main coronary artery disease : A ten year experience

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Taggarse AK, Ramesh G, Shetkar V, Mullapudi RV Department of Cardiac Surgery and Anesthesiology, Usha Mullapudi Cardiac Center, Gajularamaram, Hyderabad Background: To retrospectively evaluate outcomes of combined carotid endarterectomy & coronary artery bypass grafting and ascertain risk-benefit ratio of doing two procedures in same sitting when compared to a cohort of isolated coronary disease with matched risk profile. Methods: In this retrospective study, 112 patients were operated between 2001 & 2009 by combined carotid & coronary procedure. Carotid endarterectomy was done first, followed immediately by CABG. Indication for carotid endarterectomy was stenosis > 70% or symptoms attributable to carotid disease with lesser degree of stenosis. CABG was done on CPB in all patients. One patient also underwent aortic valve replacement. Risk factors for coronary and carotid artery disease were evaluated & compared with cohort group. Outcomes including neuro-cognitive function, minor and major events including death were compared. Minitab version 14 and NCSS 2007 were used for statistical analysis. Observations: Two patients developed monoplegia which recovered over two months. One patient died on post-operative day 8 secondary to pneumonia. LMCA disease was more common in carotid endarterectomy group (p<0.05). In the cohort group of 155 patients, two patients died, one due to low cardiac output & other due to stroke followed by respiratory complications. The difference in the incidence of neurological events and death were not statistically significant. Conclusions: Combined carotid endarterectomy and coronary bypass grafting procedure can be safely performed in same sitting as evidenced by similar outcomes in both groups. Incidence of LMCA disease is higher if carotid disease is also present.

ON-Pump Beating Heart CABG (ONPBHEC) in patients with coronary artery disease with severe left ventricular dysfunction : Its place in the armamentarium of the coronary surgeon

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Taggarse AK, Gopinath, Krishna L, Satya Sridhar K, Kumar RV Department of Cardiac Surgery, Cardiology and Anesthesiology Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad Background: The ONPBHEC study evaluates CABG on perfused beating heart on CPB in select group of high risk patients with severe LV dysfunction. The rationale was to blend advantages of conventional

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IJTCVS, Jan–Mar, 2010

CABG (CCAB) & OPCAB. Uninterrupted perfusion of myocardium avoids ischemia-reperfusion injury associated with cardioplegia. Patient is pre-emptively on CPB should a catastrophic event occur. The surgeon is at ease manipulating the heart, improving the ICOR score (Index of Completeness Of Revascularization) or ratio of grafts placed to number planned. Methods: This retro-prospective study compares CCAB and ONPBHEC in EF<35%. Grafting was done on beating heart using stabilizer and intra-coronary shunt on CPB. ICU stay, mortality, neurological & renal dysfunction, IABP usage and incidence of septal akinesia were compared. Results: ICOR score was equivalent (p=0.26). The duration of IABP support was significantly less in ONPBHEC (p=0.03). Creatinine levels & ICU stay was significantly less in ONPBHEC group. Arrhythmias were less in ONPBHEC but difference was not statistically significant. There was no difference in duration of ventilatory & ionotrope support, pulmonary complications, infection and mortality. Incidence of septal akinesia was less in the ONPBHEC group. Conclusions: ONPBHEC provides the surgeon with the comfort of maintaining hemodynamics in this high risk subset of patients with severe LV dysfunction. The major drawback of ONPBHEC are the detrimental effects of CPB & must be weighed against its advantages. It’s a technique that deserves a place in the armamentarium of the coronary surgeon.

On-pump beating heart CABG for acute cardiogenic shock; Comparison with cardioplegic arrest; Analysis of 256 patients operated upon over 20 years

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Raychaudhury T, Bag TK, Das MB, Mukherjee P, Roy BC Anandalok Hospital, Salt Lake, Kolkata Background: The aim was to compare the result of emergency bypass surgery for acute cardiogenic shock between On-pump revasularisation using Cardioplegic arrest and On-pump revascularisation on beating heart. Methods: From July 1989 till June 2009 Two hundred and Fifty six patients with acute cardiogenic shock following acute myocardial infarction or failed Primary angioplasty were treated surgically using above methods. Cardiogenic shock was defined when at least two of the following criteria were present, namely, systolic blood pressure less than 90 mm of Hg requiring aggressive inotropic support, pulmonary artery pressure more than 45 mm of Hg and urine out put less than 0.5 ml/kg/hr despite normal or high central venous pressure. There were 83 patients in Cardioplegic group (group I) and 193 patients in empty beating heart group (group II). All operations were performed within 72 hrs of myocardial infarction. Important preoperative profiles such as age, sex, diabetes, hypertension, renal function, left main lesion, diffuse disease, pre-operative respiratory support and cardiopulmonary resuscitation were similar in both groups. Results: Mean number of bypass grafts in was 2.8 each group. There were 16 hospital mortality in group I (19.27%) and 18 in group II (9.32%). Mean bypass time in group I was 168 minutes (range 68 to 230) and 121 minutes in Group II (range 45 to 167). Both results are statistically significant (P <0.0001). Incidence of renal failure, prolonged ventilation and sternal dehiscence are more common in Group I. Commonest cause of death in Group I was low output state and commonest cause of death in Group II was uncontrolled bleeding (post PTCA) leading to hypotension, renal failure and hyperkalemic cardiac arrest.

Conclusions: On-pump beating heart CABG gives an acceptable result in treating patients with cardiogenic shock. It is significantly superior when compared with CABG on arrested heart. At Univariate analysis, prolonged bypass time and length of post-operative low out put state (in Group I) and PTCA related anti-coagulant therapy (in Group II) appears to be significant predictors of post-operative death.

Coronary artery bypass grafting for patients with concomitant malignancy

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Iwakura A, Furutake T, Kusuhra T, An K, Nakatsuka D, Sekine Y, Nonaka M, Yamanaka K Department of Cardiovascular Surgery, Tenri Hospital, Nara, Japan Backgrounds: There has been no definitive data about the outcome of patients with a malignant neoplastic disease who underwent coronary artery bypass grafting (CABG). The purpose of this study is to examine the effectiveness of CABG for patients with concomitant malignant neoplastic disorders. Methods: From December 2000 to December 2008, CABG was performed in 8 patients (7 males, mean age 72 years) with concomitant neoplastic disease: 7 with solitary malignant disease, 1 with low-grade lymphocytic malignancy. Results: Off-pump coronary artery bypass was performed in 7 patients and on-pump beating CABG in 1 patient who was suffered from congestive heart failure. There was no in-hospital mortality. All patients with a solitary malignancy underwent subsequent noncardiac surgery with a mean interval of 28.6 days. Two patients died in the mid-term period: One was caused by complication of malignant disease, the other was unknown in origin. Conclusions: These results demonstrate the effectiveness of CABG for patients with concomitant malignancy, mostly as a bridge to safe non-cardiac surgery that can be crucial for mid-term survival.

Surgical treatment of myocardial bridging

Qingyu Wu, Hongyin Li, Zhonghua Xu, Zhang M, Pan G, 7 Jicheng Xi Heart Centre, First Hospital of Tsinghua University, Beijing, P.R. China Background: To report our experience of surgical treatment in myocardial bridging. Methods: From December 1997 to September 2009, 38 consecutive patients (aged 32-74 years; mean 53.6 years) with myocardial bridging (MB) received surgical treatment. There were 28 males and 10 females. 16 patients were with MB only and 22 patients were MB associated with other heart diseases. In pre-operative cardiac function grading, 6 patients were in NYHA class I, 24 in NYHA class II and 8 in NYHA class III. Among them, 25 patients underwent myotomy and 13 patients underwent coronary artery bypass grafting (CABG). Results: All patients survived and recovered uneventfully. Neither hospital or late death nor major complications occurred. Follow-up time was 3-120 months (mean 41 months). All patients were asymptomatic and currently in NYHA class I-II. Conclusions: The patients who are refractory to medication should actively undergo the cardiac surgical procedures such as myotomy and CABG. Myotomy is considered as the first choice because of its safety and satisfactory results.

IJTCVS 2010; 26: 55

Excellent performance of off-pump coronary artery bypass grafting for octoge-, nonage-, and centenarians –Analysis from japanese national database

IJTCVS, Jan–Mar, 2010

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Saito A1, Motomura N1, Miyata H2, Kyo S3, Takamoto S4 Department of Cardiothoracic Surgery, Healthcare Quality Assessment, Therapeutic Strategy for Heart Failure, Adult Cardiovascular Surgery Database the University of Tokyo, Graduate School of Medicine, (JACVSD) Background: The aim of this study is to analyze the short-term surgical outcome for the elderly patients who underwent isolated coronary artery bypass grafting (iCABG) in Japan. Methods: Japan adult cardiovascular surgery database (JACVSD) was used to retrospectively review the patients over 80 years of age (Group-80) who underwent iCABG between 2005 and 2007. Preoperative patients’ characteristics, 30-day operative mortality, perioperative major morbidities (reoperation, stroke, de novo renal dysfunction, infection, prolonged ventilation and paraplegia) were investigated. A multivariate logistic regression model was developed to examine predictors of operative mortality. Results: A hundred-twenty cardiac surgery unit (CSU) participated in JACVSD during the investigation period. A total of 11948 patients underwent iCABG, and 1027 (8.6%) were Group-80 population. Yearly number of iCABG case per CSU was 41.5 ±34.4 (median 32), where the ratio of Group-80 was 8.2%. The mean age of group-80 was 88.4±5.9 years (range: 80-103), there were 415 females (40.4%), and 739 cases were performed off-pump iCABG (72.0%). Overall 30-day operative mortality was 4.58% in Group-80, 3.25% for off-pump iCABG, and 7.99% for on-pump iCABG, respectively (p < 0.05). Major morbidities were observed in 192 cases (18.7%). The major pre-operative risk factors for 30-day operative mortality were emergency operation, reoperation, and presence of aortic aneurysm as well as heart failure and renal dysfunction. Surgical volume per CSU did not affect the surgical outcome for Group-80 population. Conclusions: Surgical results of iCABG for Group-80 were excellent regardless of the low-volume CSU, and off-pump iCABG was beneficial for the elderly population.

Off-pump coronary artery bypass is a safe option in patients presenting as emergency

Conclusions: OPCAB strategy is as safe as CABG, if not a better method for revascularization of emergency patients with reasonable good short-term postoperative outcomes.

Coronary endarterctomy on the beating heart Nambiar AK, Anand KT, Jayakrishnan AG Omega Hospital & Fr. Mullers Medical College Hospital, Mangalore

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Background: Coronary endarterectomy is one of the earliest forms of treatment for occlusive coronary artery disease. Though the long term patency of endarterectomised vessels are inferior to non endarterectomised vessels, several authors have demonstrated satisfactory long term patency. Complete revascularization is the most important goal of coronary artery bypass surgery, and the technique is a useful tool in the surgeons armamentarium, in helping to achieve this. Methods: Anticipated endarterectomy has until recently been considered a contraindication to beating heart coronary artery bypass. However, with increasing experience of beating heart techniques coronary endarterectomy can safely be performed on the beating heart. Of a total of 2210 consecutive patients undergoing beating heart coronary artery bypass 242 patients under went 290 coronary endarterectomies. 126 to the LAD, 56 to the RCA, Six to the PDA and 10 to the OM and two to the diagonal. Thirty six patiens underwent two endarterectomies (LAD and RCA) and six patients underwent three endarterectomies (LAD,RCA and OM). The patients age range was between 38 and 78 years 60% of the patients were diabetic. Results: Five patients died in the immediate post operative period. Two patients suffered a perioperative myocardial infarction. Two patients had renal dysfunction which recovered with conservative management and two patients had early recurrence of angina. Follow up ranges from three to sixty three months. Intra aortic balloon pump was used electively preoperatively in twelve patients and intra operatively in two patients. Conclusions: In conclusion, coronary endarterectomy can be safely carried out on the beating heart with acceptable results and the advantages of beating heart bypass can be extended to patients with severe occlusive coronary artery disease.

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Martinez EC1, Emmert M1,2, Thomas GN, Muecke S1, Lee CN1,2, Kofidis T1,2, 1 Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital / National University of Singapore, Singapore 2 University Hospital Zurich, Switzerland Background: One of the most vividly debated issues in cardiac surgery is the applicability of off-pump coronary artery bypass (OPCAB) in high risk patients and patients who present as an emergency. The aim of this study was to explore the efficacy of offpump coronary artery bypass (OPCAB) vs. coronary artery bypass grafting (CABG) surgery in patients who present with indication for emergency surgery. Methods: A retrospective cohort of 68 OPCAB patients that presented as emergency was matched with patients who underwent CABG under emergency indications. Baseline demographics, procedural and postoperative data were collected and analyzed. Results: There were no differences between patients regarding to demographics and pre-operative morbidity, except for an increased incidence of previous myocardial infarction in the OPCAB group (43 vs. 30, p=0.0254). An increased number of patients needed blood products in the CABG group (16.2% vs. 58.8%, p<0.001). Mean ICU stay, ventilation time, postoperative complications and mortality rate were comparable between both groups.

Total arterial revascularization in patients with end stage renal disease awaiting renal transplant

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Peter S, Mahpaekar M, Archana M, Jesu K, Lall D DDMM Heart Institute, Nadiad, Gujarat, India Backgound: Achieving total arterial revascularization in patients with end stage renal disease awaiting transplant is challenging, considering that most have had AV fistulae for dialysis access. This study looks at the feasibility of achieving TAR in these patients. Methodos: 31 patients with ESRD awaiting renal transplant presented for CABG. All underwent OPCAB TAR using both internal mammary arteries as a composite Y graft. Results: TAR was achieved in all the 31 patients. 11 patients underwent Peritoneal dialysis in the immediate post op period in addition to the haemodialysis that all underwent 48 hours after surgery. 2 patient had superficial wound infection. There were no sternal infections. 3 patients developed lung infection which responded to appropriate antibiotics. There was 1 death 5 days post op and all patients underwent renal transplant as scheduled within 6 – 8 weeks of surgery. Conclusions: With better immunosuppression to prolong the function of the transplanted kidney, survival has increased. Achieving total arterial revascularization to this group of patients in order to pass the long term benefits of TAR is safe and effective.

IJTCVS 2010; 26: 56

CABG in octagenerian and nonagenarian – Our experience

IJTCVS, Jan–Mar, 2010

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Mid-term and late results of CABG For SEPTU and octogenarians with Acute coronary syndrome

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Pradhan S, Ahuja V, Sanyal MK, Bose S, Chatterjee S Department of Cardiac Science, The Mission Hospital, Durgapur, West Bengal

Musayev KK*, Abdullayev FZ**, Aliyev *RA *Central Clinic Hospital, **Topchibashev Research Centre of Surgery Baku, Azerbaijan

Background: Octagenarian and Nonagenarian are a rapidly growing segment of population. Here we analyzed the result of CABG in Octagenerian and Nonagenarian referred for CABG Methods: 98 patients(93 male/5 female), Age ( 96 patients were between 70 to 80 years and remaining 2 patients were 86 years and 94 years respectively), who underwent surgical revascularization between 2008-2009 were evaluated.. Status of procedure was elective in 96 cases, emergency in 2 cases. LIMA-RIMA was used in 52 cases, 3 were redo- CABG. Out of 98 cases, 96 cases were performed off pump. Extracorporeal circulation was used in 2 cases, where Mitral valve repair was done along with CABG. Pre-operative NYHA functional class 3 or 4 was found in 5 patient, all had EF 35-60%. Average Euroscore was 8.5 points. LIMA was used for LAD grafting in 94cases, RSVG was used in 4 cases Results: Out of 98 patients i) only 3 patients went into low cardiac output, ii) 2 patients required re-intubation, iii) 5 patients had post op AF without significant hemodynamic compromise, iv) 10 patients had moderately raised creatinine without clinical renal compromise, v) 3 had major neurological deficit while two had TIA vi) 3 patients were classified to functional class III. And finally however all the patients went home in satisfactory and stable condition. Conclusions: Advanced patients age should not on its own deter a decision to perform CABG and that older patients undergoing elective CABG procedure may experience outcomes equivalent to those of younger patient.

Background: To present outcomes of CABG for 52 pts with ACS aged 70-83 years (mean 73,5±0,4 years). Methods: Analyzed group comprised 10,4% of the 500 pts underwent CABG for ACS. 88, 5% pts underwent surgery for USAP; 11, 5%- for acute MI. Risk predictors included: AH in 71, 1% pts; early MI in 53, 8%; LV dysfunction in 23,1%(LVEF 27-35%, mean 32,9±0,7%); CHF (NYHA III-IV) in 15,4%; diabetes in 34,6%; rhythm disturbances in 3, 8%; COPD in 3, 8%; creatinin > 2mg/dl in 3,8%. Multi-vessels disease revealed in 75% pts, including left main lesion in 13, 5%. Stenosis of carotid arteries (50-90%) - in 25% pts. MV ischemic dysfunction - in 25% pts. Results: 34,6% pts. underwent ONCAB, in 11,1% combined with MV repair or carotid endarterectomy; 65,4%- OPCAB; 9,6%- OPCAB with «no-touch» technique. Composite grafting used in 32,7% cases. 36,5% pts underwent CABG on 24 hours, including 5,3% emergency for unfavorable PTCA; 38,5% and 15,4%- on second to third days, consequently; 9,6%- on fourth to fifth days. 42,3% pts. made an uneventful recovery; 57,7% - faced complicated ICU-stay. In-hospital mortality 11,5%. Mid-term outcomes studied in 46 pts up to 6 months; late - in 42 pts on 75 months (mean 35,6±2,3months). On mid-term study: all 46 pts were alive, free from MACCE. On late study: 76,2% pts were free of complaints; recurrency of coronary events in 11,9%: reinterventions (PCI) in 4,8%, need in reintervention 7,1%; CVA in 4,8%; cardiac death in 7,1%. Conclusions: We believe that CABG for elders with ACS could be performed with acceptable mid-term and late outcomes.

Skeletonized internal mammary artery for coronary bypass grafting in diabetics

1800 cases of OPCAB- Personal experience and lessons learnt

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Kapadia N, Russo P, Kumar R, Kapadia R, Venkatesh B Department of Cardiovascular Surgery, SRM Hospital Chennai, India

Raghuram AR, Krishnan RM, Kumar S, Balamurugan K, Grazy A Meenakshi Mission Hospital, Melur Road, Madurai, Tamilnadu

Background: Skeletonized internal mammary artery (IMA) harvesting gives benefits of less ischaemia to Sternum specially in high risk diabetic patients undergoing single or bilateral IMA grafting. Contraindication for BIMA harvest in our institution was in patients with severe osteoporosis, fragile sternum, Diabetes was contraindication to Bilateral LIMA harvesting. Method: Between December 2004 and September 2009, A total of 332 patients, mean age 43 years, 92 females (27.7%) underwent Coronary bypass grafting using pedicled Internal mammary artery, since July 2007, 112 patients received skeletonized internal mammry artery harvested by ordinary unipolar diathermy. The perioperative complications datas were analysed. Results: Postoperative intubation time and postoperative stay were not significantly different between the two groups. ICU stay was shorter in first group, reflecting the recent frequent use of off-pump CABG. There were six deaths in nonskeletonised group (1.8%) Perioperative myocardial infarction occurred in 5 (1.5%) of 332 cases( non skeletonised IMA ) and one (0.9 %) in skeletonised group, none of which were related to the IMA graft. The incidence of mediastinitis was 1.5% in nonskeletonised group and none in other group. Angiographic control was obtained in 50 cases from each group revealing no IMA occlusions. Conclusions: Skeletonized internal mammary artery (IMA) harvesting gives benefits of less ischaemia to Sternum specially in high risk diabetic patients undergoing single or bilateral IMA grafting.

Background: Off-Pump Coronary Artery Bypass Surgery (OPCAB) is gaining popularity all over the world because of less morbidity and equivalent results as the conventional on-pump CABG. We are reporting our experience with 1800 cases of OPCAB done in the last 11 years. Methods: Between Jan 1999 and February 2010 we have performed 1800 patients by the OPCAB technique. All the patients were operated using the Medtronic Octopus stabilizer. Coronary shunts and carbon dioxide blower were routinely used. Heparinisation was achieved with 3mg/kg of Heparin given intravenously. Half dose protaminisation was practiced. 16.7% of patients had an ejection fraction below 40%. 10% of patients had a EUROSCORE above 5. Average number of grafts was 3.06. LIMA was used in 96.7%. Results: Operative mortality was 0.69%. Conversion to cardiopulmonary bypass was required in 13 cases (0.75%). Reexploration was needed in 10 patients (0.05%). Perioperative myocardial infarction was noted in 5 patients. Inotropes were used in 15.1%. Blood transfusion was required in 25% of patients only. A follow-up study of 100 patients after 4 years of OPCAB revealed that 93% of patients were free from angina symptoms. Conclusions: OPCAB is a safe technique to achieve complete revascularization. The methods of managing hemodynamic instability, manipulating large hearts and dealing with intramyocardial LAD, closely placed vessels and diffusely diseased vessels will be discussed.

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Surgical outcome of CABGs in chronic kidney disease

IJTCVS, Jan–Mar, 2010

Use of Pre op IABP in high risk CABG’S

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Kentaro H Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan Background: Chronic Kidney Disease (CKD) is a major risk factor in cardiovascular surgery. The purpose of this study is to assess the early and long term results of isolated coronary artery bypass surgery in chronic kidney disease at our institute from January 2002 to October 2009. We used estimated glomerular filtration rate to evaluate the renal functions. Methods: Fifty hundred and ten patients underwent the isolated CABGs in this period (mean age: 68 years old, male: 393 cases). We divided the patients into two groups (CKD group: eGFR < 60 ml/ min/1.73m2 and hemodialysis, control group : eGFR >60 ml/min/ 1.73m2 ). The number of CKD patients were 250 (49% of all cases). Forty patients were on chronic hemodialysis. We evaluated the early and long term results and morbidities. Results: There were 26 all-cause deaths (mean follow up 38 months). In-hospital mortality were 1.4% (n=7, CKD group: 6, control group: 1). Late cardiac and vascular related event were observed in 19 patients. Six patients underwent the lower leg amputations later. Conclusions: In CKD group, early mortality were high compared with the normal renal function group. In CKD patients, the rate of vascular accidents, such as peripheral artery disease and amputations were high. It is important to care the systemic arteriosclerosis in CKD patients postoperatively.

Authors. 18 Bipeenchandra YB, Krishna LS, Kumar RV, Department of Cardiothoracic Surgery, Nizam’s Institute of Medical Sciences, Hyderabad Background: Improvements in coronary care and extensive use of percutaneous interventions have changed the profile of patients undergoing CABGs. More of acute coronary syndromes, severe LV dysfunction and diffuse coronary artery disease are being referred for CABGs necessitating improvement in anesthetic and surgical strategies; pre-operative use of IABP is one such intervention which has been useful to get gratifying results in such subjects. Methods: We retrospectively reviewed our experience with 20 patients who underwent high-risk CABG, such strategy during January 2006 to may 2008. Results: 20 patients underwent high risk CABG with IABP support started evening prior surgery. Mortality was 10% (2/20); ICU stay was 4.2 days with post-operative hospital stay of 11.6 days. Conclusions: Pre-operative IABP is modality of choice in high risk patients in terms of weaning from CPB, and improved haemodynamics, shorter ICU stay and hospital stay with less cost and with out additional complications.

Myoangiogenesis after omentopexy and bone marrow derived stem cells transplantation in ischemic cardiomyopathy, early and mid term results. Comparison of early and mid-term results of CABG and PCI for left main disease

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Kapadia NK, Andre K, Russo P, Verma RS, Kumar R, Venkatesh B, Kumar S, Gowri T SRM Hospital & Research Centre, Potheri Chennai

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Misato T, Tobe S, Nosho H, Matsuo T, Hino Y, Yamaguchi M Department of Cardiovascular Surgery, Akashi Medical Center, Ohkubochou Yagi, Akashi, Hyogo, 743-33, Japan Background: With the innovation of drug-eluting stents (DES), patients of coronary artery disease treated with percutaneous coronary intervention (PCI) have been increasing. This tendency is similar in the cases of left main disease (LMD) in Japan. To compare initial success rate and mid-term results between CABG and PCI for left main trunk lesion. Methods: From Jan 2005 to May 2009, we performed 47 cases of CABG for LMT lesion. During the same period, 40 cases of elective PCI were performed for LMT lesion. We compared initial success rate and mid-term results between the two groups. We assessed the mortality rate, target lesion revascularization (TLR) and major adverse cardiac event (MACE: TLR, myocardial infarction, CABG, PCI and death). Results: Initial success rate was 100% in both groups. Number of death was 3 cases in CABG-group (two post operative infection and one cerebral infarction) and 2 cases in PCI-group (one sudden death and one acute stent thrombosis) (n.s). TLR in CABG-group was 6.4% (3 cases of PCI for branch lesion and no case for LMT) and 12.5% in PCI-group (n.s). MACE was 6.4% in CABG and 17.5% in PCI (n.s). Conclusions: Initial success rate and mid-term results between CABG and PCI for LMD did not show significant difference. But primary complete revascularization rate in CABG-group was significantly higher than PCI group, except for LMT alone.

Background: Omentum being highly vascular organ with rich source of angiogenic factors, promotes myocardial angiogenesis, induced by autologous bone marrow derived mononuclear cell transplantation, both in border zone between normal myocardium and infracted area and hypokinetic tissue of the left ventricle, resulting in improved functional capacity. Method: Between March 2006 and August 2009, 36 patients (25 males, 11 females) underwent Omentopexy and Myocardial Revascularisation. Eighteen patienst (50%) had Type II Diabetes and diffuse coronary arterty disease, 66% presented in NYHA Class III, rest class VI, Left Ventricular Ejection Fraction varied 18 to 30% ( Mean 19.2%). Myocardial revascularization in one to three territories was done off pump 24 (66.3%), on pump 12 (33.3%). Omentum was wrapped around infarted area with cardiopulmonary plexectomy. Bone marrow Stem cells (CD34) (FICOL) were injected in border zone and infracted area. Results: Two patients died of low cardiac output (5.5%), 1 died after 30 days (2.75%). 3 months to 45 months (Mean 22.3 months) follow up showed significant improvements in left ventricular Ejection Fraction which increased by 0.11 to 0.14%, Mean 0.12%), in exercise tolerance and NYHA class, 33% now being in Class I. There was reduction in size of Infarcted territory as calculated by segments perfused using Thallium scan. Conclusions: Omental CD34 cells promotes angiogenesis by synthesizing angiogenic growth factors to facilitate revascularization of ischaemic myocardium specially if Bone marrow CD34+ cell are injected in Ischaemic/infracted myocardium inducing myogenesis.

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Vasoconstrictor role of vasopressin in severe left ventricular dysfunction with low cardiac out put following coronary bypass surgery

IJTCVS, Jan–Mar, 2010

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Kapadia NK, Russo P, Kumar R, Venkatesh B, Chitraleka V SRM Hospital & Research Centre, Potheri, Chennai Background: The natriuretic peptides(NP) are antagonists to reninangiotensin-aldosterone system, and their role in regulating fluid balance appears to be particularly important in patients with hemodynamic stress as heart failure, has several other responses namely Vasodilation, hypotensive effect, Promotion of natriuresis and diuresis, Inhibition of sympathetic nervous system, Facilitation of complex interactions with the neurohormonal system, including reninangiotensin-aldosterone.Vasopressin has some opposite effects, mainly reduces diuresis, and increases Systemic Vascular Resistance. Severe Left Ventriular Dysfunction with dilated Left Ventricle has high circulating levels of NP, resulting in vasoplegia in many cases after Coronary bypass surgery (CABG). Methods: One hundred cases were devided into 2 groups with age range 38-72 years and MF ratio2:1, Left Ventricular Ejection Fraction varied 20 % to 35%, Left Ventricular dimension 56 to 67 mm.First group was started on vasopressin in doses upto 1 unit per hour, as they were passing large quantity of urine 340 to 980 ml / hour requiring massive fluid /electrolyte replacement, had cold periphery with good volume pulses. Result: Vasopressin reduced urine out put to 1-2 ml /kg/hour, patients became warm at periphery, cardiac out-put improved with same doses of ionotropes ( Dopamine / Dobutamine). None of patients received any diuretic in Operating Room or ICCU. Second group without vasopressin required more ionotropes, more fluid replacement, increasing time for rewarming, and higher mortality (8%) as compared to first group with vasopressin (4%) Conclusion:Vasopressin reduces morbidity and mortality in post CABG patients with severe LV Dysfunction with low cardiac output, vasoplegia and high urine out put.

Off pump total arterial CABG in patients above 70 years: Reduced incidence of adverse neurological outomes

Conclusions: We conclude that aortic calcification is responsible for post-operative adverse neurological outcomes. Avoiding the aorta significantly reduces the incidence of adverse neurological outcomes.

Total arterial revascularization in poor LV Peter S, Mahpaekar M, Malavide A, Krupa J, Lall D DDMM Heart Institute, Nadiad, Gujarat

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Background: The Left Internal Mammary artery graft to the Left Anterior Descending artery is considered the gold standard for graft patency. While doubts exist about the longevity of other arterial conduits to different areas of the LV, it has been accepted that the patency rates are better than those of venous grafts when similarly compared. The policy in our Institution has been to offer TAR to all patients undergoing CABG, irrespective of their age, gender, LV function or other risk factors. We present our experience adopting such a policy in patients with poor LV. Methods: All patients with poor LV (less than LVEF of 30%) who presented for CABG between July 2004 and October 2009 were included in the study. The method of arterial reconstruction, use of conduits, use of inotropic and IABP, morbidity and mortality were assessed. Results: A total of 1256 patients presented for CABG of which 264 (21%) had a poor LVEF. The age ranged from 27years to 84 years with an average of 52.7 years. There were 39 (14.7%) females and 29 (11%) patients had other additional procedures. Of the patients 241 were done on a beating heart. There were 8 in hospital deaths. Conclusions: With a policy of TAR for all, the harvesting of arterial conduits – especially the radial, use of multiple sequential grafts, avoiding proximal anastamoses have together improved the efficiency of TAR. Combined with beating heart techniques, TAR has been found to be safe and effective when offered to patients with poor LV.

Off-pump coronary artery bypass (OPCAB) surgery in urgent patients with left main coronary artery stenosis

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Pradhan S, Ahuja V, Bose S, Chatterjee S The Mission Hospital, Durgapur, West Bengal

Irie Y, Saito M, Tanaka K, Rokkaku Y, Fukai R, Hara T, Imazeki T Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minamikosigaya Koshigaya, Saitama, Japan

Background: Neurological dysfunction is a common complication after cardiac surgery. Despite significant advances in CPB technology, surgical techniques and anaesthetic management, CNS complications occur in a large number of patients undergoing surgery. The objective of this study was to compare major neurological complications of the patients undergoing OPCAB using varying conduit strategies. Methods: We evaluated 52 elective consecutive patients between 71 and 86 years, undergoing primary isolated coronary artery bypass grafting (OPCABG), with LIMA RIMA Y technique at a tertiary care cardiac institute from April 2008 to October 2009, and compared it to 46 patients with LIMA and RSVG, done off pump, between 71 and 95 years to determine differences in the major neurological outcome after CABG and risk factors involved. Patients with minimal focal aortic calcifications with epiaortic ultrasound were assigned for LIMA RIMA Y. The data were analyzed by X2analysis. Continuous variables- Mann Whitney U Test, Logistic regression analysis with backward step wise calculation, Statisicia 4.1 was used. All tests were 2 sided. Results: There were no significant differences in the risk factors known to create adverse neurological outcomes. Out of the 46 patients with mixed conduit strategy 3 patients had serious neurological problems, compared to only one in the LIMA RIMA Y group with TIA. Zero manipulation of aorta significantly reduced the incidences of adverse neurological outcomes by 4%. ( p<.01)

Background: The purpose of this study was to determine whether urgent patients with left main coronary artery stenosis can undergo off-pump coronary artery bypass (OPCAB) surgery safely and successfully. Methods: Between January 2003 and March 2009, there were thirty-nine patients with severe left main trunk (LMT) stenosis had urgent OPCAB surgery performed (group L, n=39) in our institution. Patients received schedule operation without LMT stenosis in the same period were selected as control group (group C, n=128). Patient characteristics, risk factors, operative details and postoperative outcome were compared between two groups. Results: There were no significant differences in preoperative patient characteristics between two groups. Preoperative IABP placement was 79% in group L and 23% in group C (p<0.05). No significant differences were measured in number of grafts per patient (3.21 vs. 2.84), or total arterial graft use (82% vs. 87%). There were one conversion to on-pump CAB in group L and three in group C. The length of ICU and hospital stay was similar and there were no early death in group L. Conclusions: The similar operative results suggest that with frequent pre-operative IABP placement OPCAB can be performed safely and successfully in urgent patients with severe left main trunk (LMT) stenosis.

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IJTCVS 2010; 26: 59

Influence of diabetes mellitus in women undergoing coronary artery bypass surgery

IJTCVS, Jan–Mar, 2010

24

Outcome of acute conversion of OPCAB to CCAB

26

Madhu SN, Gincia R, Vajyanath P, Karthik VK, Cherian KM Frontier Lifeline Hospital, R 30 C Ambattur Industrial Estate Road, Mogappair, Chennai

Malhotra S, Choudhary AK, Gupta AK, Collison SP, Saraf N, Mishra YK, Meharwal ZS Escorts Heart Institute and Research Centre Okhla Road, New Delhi

Background: Diabetes mellitus is a stronger risk factor for coronary artery disease in women than in men,with higher incidence of small vessel disease, morbidity and mortality. Methods: Out of 2809 patients who underwent Coronary artery bypass surgery in our institution, from February 2004 to February 2009, 358 are women. The age ranged from 17 to 85 years with a mean of 59 years. Among them 254 had diabetes mellitus (Group I ) and 104 were non diabetic (Group II). We have compared the demographic variables, angiographic details, operative and post-operative variables between the two groups. The mean age was 58.6 years in Gr I and 59.98 years in Gr II. (NS). 179 patients (70.5%) had hypertension in Gr I compared to 68 (65.48 %) in Gr II (NS). Seventy one patients had previous MI compared to 28 (26.9%) in Gr II ((NS). Results: Analysis of angiographic data revealed that 180 patients (71%) had triple vessel disease in Gr I compared to 57 in Gr II. Correspondingly the average number of grafts required by the diabetic women were higher compared to non diabetic women (P< 0.006). Ninety eight (39%) patients needed 3 grafts compared to 52 (50%) in Gr II. Ninety one (35.8%) patients needed four grafts in Gr I compared to 23 (22%) in Gr II. The hospital mortality was 1.4 % in Gr I compared to 2.8 % in Gr II (NS). The complications like bleeding, low cardiac output, arrhythmias, wound infection and need for intra aortic balloon were different between the groups. Conclusions: The incidence of multivessel disease is higher among the diabetic women and correspondingly the diabetic women require more grafts. However with adequate control of diabetes mellitus, early results are equally the same between the groups.

Background: Over last few years, off pump CABG has gained wide popularity in the surgical management of coronary artery disease (CAD). Though listed as safe and reproducible one of the major intraoperative complications is acute conversion to C-CAB. Methods: In last three years (1st Sep 2006 till 31st Aug 2009), we preformed 5118 isolated CABGs of which 5062 (98.9%) were off pump CABGs and 56 pts (1.1%) were converted to C-CAB on emergency basis due to intraoeprative hemodynamic instability as defined by institutional criteria. Complete revascularization was achieved by both off pump and C-CAB techniques. Results: Patients needing emergency conversion to C-CAB had higher mortality rate (10.7% vs 1.3%), Re-exploration rate in C-CAB (10.7% vs 2%) in OPCAB. Stroke developed in 1.8% patients in CCAB group. 1.8% patients in C-CAB group needed reintubation compared to 0.4% in OPCAB group. Post operative significant hemodynamic instability needing was CPR was required in 3.6% patients in C-CAB vs 0.2% patrients in OPCAB. Mean ICU stay in CCAB group was 4.75 days compared to 3.06 days in OPCAB group. Conclusions: While OPCAB is a safe procedure in management of CAD, acute conversion to C-CAB is a major intraoperative complication and carries adverse prognosis. Optimal patient distribution for OPCAB and elective C-CAB may reduce the risk of acute intraoperative conversion to C-CAB and enhance surgical outcome.

Aortic root replacement in young adults: Disease characteristics and early outcome Open heart surgery in sickle cell disease

Choudhary AK, Gupta AK, Malhotra S, Collison SP, Saraf N, 25 Mishra YK, Meharwal ZS Escorts Heart Institute and Research Centre Okhla Road, New Delhi Background: Sickle Cell Anemia is one of the most Common genetic disorder affecting people all over the world. Doing open heart surgery is a challenge not only during surgery but also managing patients during post operative period due to induced hypoxia, acidosis and hypovolumia. Methods: Between January 2008 to October 2009, 11 cases of sickle cell anemia, 9 males (81.81%) and 2 females (18.18%), were operated for open heart surgery at Escorts Heart Institute and Research Centre. Patients were between 20-60 years of age group. All cases were done through mid sternotomy. Seven (63.63%) cases were operated for coronary artery bypass surgery (CABG), 3 patients (27.27%) were operated for mitral valve replacement (MVR) and one patient (9.09%) was operated for aortic valve replacement (AVR). Nine (81.81%) patients were from African countries and two patients (18.18%) were Indian. All cases of CABGs were operated on beating heart without pump. Aortic and mitral valve replacement were done on normothermic bypass allowing temperature to drip and using cold blood cardioplegia at 4°C. Results: All cases were operated successfully. There was no mortality. Two (18.18%) cases had fresh neurological complications during postoperative period. Mean hospital stay was 12 days. Conclusions: Taking care of hypoxia. Acidosis and hypovolumia and using exchange blood transfusion, open heart surgery can be done safely in sickle cell anemia patient.

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Collison SP, Gupta AK, Choudhary AK, Malhotra S, Saraf N, Mishra YK, Meherwal ZS Escorts Heart Institute and Research Centre Okhla Road, New Delhi Background: Aortic pathology requiring replacement of the aortic root is rare in young adults and maybe a group prone to atypical presentations and poorer outcomes. Here, we have studied the clinical features, pathological extent of aortic root disease and outcome of young adults undergoing aortic root replacement at this institution between 1995 and 2005. Methods: Retrospective study of the patients who underwent aortic root replacement at this institution between 1995 and 2005 between the ages of 18 and 40 (n=55). Preoperative, intra-operative and post-operative data were collected on a standardizes proforma. Results: There were 48 males (78%) and 5 females (13%). Mean age was 32.3±0.7 years. 44% of patients had a preoperative diagnosis of either bicuspid or rheumatic aortic valve disease; 46 (83.6%) presented with chest pain and in 34 patients (61.8%) an aortic regurgitant murmur was audible. Most patients (>70%) had aortoannular ectasia, with 17 (30%) with aortic dissection. The dissecting flap arose at the sinotubular junction (88%) and terminated in the ascending aorta (60%). 45 patients (82%) received modified Bentall’s procedure; the rest underwent separate aortic valve and supracoronary aortic replacement. In hospital mortality was 1.8%. Follow up was 96% at mean follow up of 8.56 years after surgery. Conclusions: The presentation of aortic root disease in young adults is similar to older age-groups. The disease characteristics of aortic dissection in this age group are favorable. The use of the Bentall procedure of separate aortic valve or supracoronary ascending aortic replacement offers good early and late clinical outcomes.

IJTCVS 2010; 26: 60

Risk factors analysis and out come of 1350 cases of CABG Padhy K, Kishan M, Mohan T, Maharaj S, Narasimham SBR, Satyanarayana PV Care Hospital, Cardiothoracic and Vascular Department, Visakhapatnam

IJTCVS, Jan–Mar, 2010

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Background: Coronary artery disease burden is in increasing trends in India. patients requiring CABG are of more advanced and complex category as the PCI is being offered to patients of less complex lesion. We have retrospectively analyzed the risk factor and outcome of patients undergone CABG. Methods: From April 2001 to Sep 2009, 1350 cases had undergone CABG. 1120 cases were male and 230 were females. Age ranges was from 25 to 80 years with mean of 56.4 years. 78 Patients had undergone emergency & 1272 elective operations. Left main diseases was in 193 patients, single vessel disease in 51, Double vessel in 243 and triple vessel in 1056 Patients. Associated procedures were done in 49 cases. Hypertension was in 865(64%) cases, diabetes mellitus in 650 (48%) cases, Smoking in 256(18.9%) cases, obesity in 85 (6.29%) cases, family H/o of coronary artery disease in 24 (1.7%) cases and hyperlipidimia in 607 (45%). Results: Patients undergone CABG were mostly male with age ranges 51 – 60 years. Most of them were triple vessel disease. Diabetes mellitus and hypertension and hyperlipidemia were common risk factors. IABP was used in patients 90 (6.6%) cases. 23 (1.7%) cases had peri-operative MI and mortality was in 35 (2.5%) patients. Conclusions: Male, age range of 50-60 years, diabetes mellitus, hypertension were major risk factor. Hyperlipidemia was found only in 607 (45%) cases. Mortality was high in patients with severe LV dysfunction, multiple risk factors, emergency operation and associated procedure.

Low dose landiolol in patients with impaired cardiac function in postoperatively of off-pump CABG - Examination in prevention of atrial fibrillation and effects on hemodynamics

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Tanaka K, Irie Y, Hara T, Okita Y, Saito M, Fukai R, Rokkaku K, Imazeki T Departement of Thoracic and Cardiovascular Surgery, Dokkyo Medical University, Koshigaya Hospital Background: Atrial fiblliration (AF) is common complication in postoperatively of cardiac surgery. It causes stroke, longer hospitalization, and large costs of treatment. In this study, we investigated prevention of AF and hemodynamics stabilization administering low dose landiolol (ultra short-acting ß1 blocker) in patients with impaired cardiac function in postoperatively of off-pump coronary artery bypass grafting (OPCAB). Methods: From May 2007 to October 2009, 33 patients with impaired cardiac function (LVEF<50%) underwent OPCABG in our institution. In landiolol group (18 patients), 0.3µg/kg/min landiolol was administered for 3 days. The remains were in control group (15 patients). We investigated incidence of AF until POD7, and hemodynamics condition (HR, BP, CK-MB, and more) during administration landiolol. Furthermore we investigated hospitalization and treatment costs in both groups. Results: AF was occurred 2 of landiolol group (11.1%), 6 of control group (40.0%) respectively (p=0.054). HR was lower in landiolol group. There were no significant differences in BP, CI, PAP, CK-MB, SVI, SvO2, SVR, hospitalization, and treatment costs among two groups. Conclusions: There was tendency to prevent AF by administering low dose landilol. Even though patients with impaired cardiac function, their hemodynamics was maintained stable during administration landiolol in postoperatively.

Is multi slice CT angiography adequate as the sole diagnostic criteria to proceed for CABG? Bedi HS, Gill JS Christian Medical College & Hospital, Ludhiana, Punjab, India

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Background: Rapid advances in multislice computed tomography (MSCT) have facilitated increasingly accurate noninvasive coronary imaging. The present study was designed to assess the accuracy of the 64 slice MSCT scanner with conventional coronary angiography (CCA) and to conclude whether or not MSCT angiography alone could give sufficient and accurate information to proceed with coronary artery bypass grafting (CABG). Methods: 50 stable patients with proven severe CAD on CCA for elective CABG underwent MSCT prior to CABG. The MSCT images were compared with CCA and the accuracy, sensitivity and specificity of detecting significant stenosis cross checked. Results: An excellent correlation was found between the two modalities. Comparing the maximal percent diameter luminal stenosis by MSCT versus CCA, the Spearman correlation coefficient between the two modalities was 0.99 (p < 0.0001). Bland-Altman analysis demonstrated a mean difference in percent stenosis of 0.6 ± 2.3% (95% confidence interval 5.1% to –3.9%). 93.4 % of the observations were within ± 1.96 standard deviation. Anomalous and intramural coronary arteries were easily picked up by MSCT. Conclusions: MSCT is a valuable tool for the cardiac surgeon. It helps in precise planning of the CABG especially off-pump CABG and in prejudging the length of the conduit required. On the basis of our findings we recommend MSCT as a sole criteria for proceeding for CABG without CCA in selected cases.

Antiplatelet use in post CABG patients - Dual antiplatelet versus aspirin only- Adverse events in follow up - Retrospective analysis of prospectively collected data.

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Chaudhuri SR, Mukherjee P, Chaudhuri BR, Chaudhuri T Anandalok Hospital, Block- DK, Karunamoyee, Salt Lake, Kolkata Background: Dual antiplatelet usage in western literature has been seen to have more incidences of major adverse events however our experience in Indian population was different. Methods: Patients undergoing CABG were randomly assigned to two groups one receiving only Aspirin 150 mg and the other receiving Aspirin 150 as well as clopidogrel 75 mg. Patients with known hypersensitivity to Aspirin and those with prosthetic valve were excluded. Patients were routinely followed up in OPD in 3 monthly intervals for 2 years with HB%, stool OBT and urine R/E reports. Patients were asked to report red discoloration of urine, black discoloration of stool and subcutaneous hemorrhagic spots. Major adverse events constituted hemorrhagic CVA or GI bleed causing hematemesis malena and macroscopic hematuria in absence of renal cause. Results: Drug received

No. Of patients

Adverse Major adverse Propodion event event (MAE) of MAE

Clopidogrel & Aspirin Aspirin

1200

45

11

22.4

1150

43

7

16.2

Conclusions: By calculating standard error of difference between two proportions we get a value of 6.02. The observed difference is 8.2 between the groups. Observed difference being less than twice the standard error. There is no strong evidence of any difference in occurrence of major adverse event in two groups in 2 years of follow up.

IJTCVS 2010; 26: 61

LIMA-Vein composite Y graft for multi-vessel grafting in patients with heavily calcified aorta Raychaudhury T, Mitra SN, Das MB, Roychowdhuri S, Mukherjee P Anandalok Hospital, Salt Lake, Kolkata

IJTCVS, Jan–Mar, 2010

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Background: As early as 1982 Buffolo et al reported end to side anastomosis between LIMA and saphenous vein to avoid side clamping on a heavily calcified aorta. We present here operative details, long term clinical evaluation and CT- angiographic findings of LIMA-Vein composite Y grafts and compared it with LIMA-RIMAY grafts and conventional ‘mixed conduit’ bypass surgery using aortic side clamp. Methods: From March 2004 till June 2009 we have performed Forty seven LIMA-Vein anastomosis in patients over 70 years of age. In 21 patients it was performed to avoid side clamping of heavily calcified ascending aorta and in 26 patients it was done as a method of choice when done via left anterior thoracotomy in patients with fragile osteoporotic sternum. All operations were done Off-pump. Comparison of the study group with matched groups of LIMA-RIMAY and conventional Bypass surgery, using Propensity scoring system, reduced the number to 39 in each group. Important pre-operative profiles such as age, sex, diabetes, hypertension, renal function, left main lesion, diffuse disease, presence of COAD were similar in all 3 groups. All patients were evaluated clinically as well as by Echocardiography and treadmill test every 6 months. Mean follow up was 32 months. Approximately one third patients in each group had either CT or conventional angiographic evaluation. Result: There was only one death (sepsis) and two patients had reversible embolic stroke in Conventional Bypass group. Two distal vein grafts were occluded in study group and 4 vein grafts were closed in conventional bypass surgery group. However, treadmill tests were negative in all patients and no percutaneous intervention was advised in any patient. All grafts were patent in LIMA-RIMA group. Conclusion: Clinical results and evaluation tests appear to be excellent in LIMA-Vein composite grafts up to a mean period of 3 years even when compared with LIMA-RIMA anastomosis and conventional Bypass surgery.

Multi-vessel re-do CABG on a beating heart Bedi HS, Joseph A, Gupta A, Singh M, Tevarson V Christian Medical College & Hospital, Brown Road, Ludhiana

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Background: With the onset of graft attrition and progress of native atherosclerosis more and more patients are coming for re-do CABG. Obviously this cohort is of an older age group with various co-morbid age related problems. Such patients may not tolerate the deleterious effects of CPB and would benefit greately by an off pump procedure without compromising the completeness of the revascularization. Methods: We will be presenting 72 cases from 1999 to 2009 in the age group of 55-80 yrs with male female ratio 3:1. All had angina Class II – IV with graft attrition in 70% and new lesions in 40%. 7 patients were unstable and required elective preoperative IABP support. In a few initial cases the femoral artery and vein were kept exposed for going on CPB if required. The average number of grafts were used 2.8 with single radial artery in 90%, LIMA in 50%, RIMA in 20%, bilateral radial in 20% and RGEA in 10% of the cases. IABP was used electively in the initial few cases. Results: 90% patients could be extubated within 6 hrs and received only 1 to 2 units of whole blood. There was no neurologic deficit and all these patients required minimal inotropic support. 2 patients developed a peri op MI – one needed post op IABP support . 5 patients with preoperative renal failure underwent hemodialysis pre and post CABG in the ICU.

Conclusion: Multivessel off pump redo CABG can be carried out safely without a compromise on the completeness of revascularization and with minimal morbidity.

Journey through midcab (1997 to 2009) Tyro to virtuoso (study of 159 midcab)

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Vasaiya R, Shah V 7, Devarshi Bungalow, Nr, Tulip Bunglow, Thaltej, Ahmedabad Background: MIDCAB CABG in triple vessel disease is remained dream to many cardiac surgeons. Difficulties and short comes exist. How to overcome and accomplish a complete and satisfactory revascularization, is the most important goal of a bypass surgery. Technical difficulties and its solution are described. Method: Since 1997, we started sternal sparing MIDCAB CABG. Till 2009 we have done 159 patients. 70 patients were operated for SVD (58 CABG, 12 redo CADG), 32 cases for DVD (29 CABG, 3 redo CABG), 57 cases of TVD (55 CABG, 2 redo CABG). For initial two yrs. it was limited to SVD, mostly CTO of LAD. 1st case of redo CABG was carried out in 1999. Gradually field was expanded to DVD and since last 4 yrs. TVD cases are also incorporated. It also includes 10 cases of endarterectomy. One case with CMV and CABG. Patients’ age range between 32–92 yrs. LVEF = 25% (10 – 55%), 3 patients with EF of 10% were offered CABG with stem cells implantation. As much as 4 vessels were grafted. Patients overweight have no contra indication. Additional plural adhesion is also not a contra indication. Among TVD 20% had varying degree of left main disease (50 – 96%). 1 patient weighing 114 kg was also operated. Result: There was 1 mortality in a redo CABG group. The patient died on 6th POD due to VTVF. One case of TVD shows ST-elevation for 24 hrs, post operatively which subsided later on (peri operative MI). 1 patient required re-exploration due to bleeding from mammary bed. Average requirement of BT was 1.5 bottles per patient. Transfusion requirement usually depends upon pre operative HB level. Average hospital stay was 4 days (36 hrs to 6th POD). No major wound complication is seen. Average incision size is 3.5 inches (2.54.2 in.). Conversion to mid sternotomy was required in 1 patient. Conclusion: Sternal sparing MIDCAB can be carried out in all but cardiogenic shock group of patients. We found it is particularly advantageous to old debilitating patient more so with farer sex group of patient. It can b learnt only by self indulgence. This method is not described anywhere in known literature. It is little time consuming and requires great deal of skill and patience on part of operator.

OPCAB in left main coronary stenosis : Study of 727 consequitive cases

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Rath P, Vanzara S, Rajanikant CR, Panda R Asian Heart Institute, Bandra-Kurla Complex, Mumbai Background: To evaluate the clinical profile and the immediate surgical results of 727 consecutive patients with left main coronary disease (>50%) who underwent off pump arterial coronary revascularization in a single institution. Methods: Since Jan 2003 till Sept 2009, 727 patients with left main coronary disease >50% (CAG) out of 7148 consecutive myocardial revascularizations at our Institute have been monitored collecting data in a prospective study. LMCAS 50-69%: 50.6%; 70-89%: 38.5% >90%: 10.9%. 83.5% male. Mean age: 61.9 years. Unstable angina: 31.9%. Diabetes: 49.9%. Recent MI: 17.7%. Hypertension: 51.5%; Smokers: 14.6%. LVEF <35%: 18.1%; 36–45 %: 18.0%; >45%: 64%. Average anastomoses per patient: 4.2. Conduits used : LIMA- 94.9%, RIMA20.2%, BIMA- 16.5%; Radial Artery- 81.0%. SVG- 6.6%. IABP was used in 5.21%. Cell-saver was used routinely.

IJTCVS 2010; 26: 62

IJTCVS, Jan–Mar, 2010

Results: In hospital mortality (0-30 days): 0.27% Morbidity Arrhythmias: 14.8%. (atrial 12.3%; ventricular 2.46%); LVF- 0.55%, Periop MI: 2.73%, CVA: 0.55%. Pleural Effusion: 10.9%; Re-exploration for bleeding: 0.14%. No patients required new dialysis. Mean p.o. stay in hospital: 8.88 days. Conclusions: Off-Pump Arterial Myocardial Revascularisation technique can be applied in Left Main Coronary Disease with low in hospital mortality and with low complications rate.

Effect of clopidogrel on perioperative blood loss in off pump elective coronary artery bypass surgery

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Saravanans, Kathekeyan R, Muthukumar S, Periyasamy, Saldanha R Dept. of CTVS, SRMC, Sri Ramachandra University, Porur, Chennai Background: We studied the effect of clopidogrel on perioperative blood loss in patients who stopped the drug before surgery with variable time periods. The study was designed to evaluate the effect of preoperative clopidogrel on coronary artery bypass grafting (CABG) surgery outcome in terms of perioperative blood loss. Method: Data were collected prospectively on eighty consequective patients who underwent elective CABG at our institute between Dec 2007 and May 2008. All surgeries were performed by single team of cardiac surgeons and anaesthesiologist and done off pump. The preoperative data collected include age, gender, body mass index, diabetes, chronic renal failure, prothrombin time, international normalized ratio, activated partial thromboplastin time, platelet count and European system for cardiac operative risk evaluation (EURO score). Intraoperative data collected include number of grafts, duration of surgery, amount of heparin and protamine used and amount of blood loss. Postoperative data include the amount collected in the chest tubes. Patients were divided into 3 groups- group1- clopidogrel stopped within 0-4 days of operation, group 2 - clopidogrel stopped within 5-8 days before operation and group 3 - clopidogrel discontinued more than 8 days before operation. Result: The mean total blood loss was 967.3±252.1 ml. In group 1 the mean total blood loss was 850.3±279.2 ml, group 2 the mean total blood loss was 1021.4± 220.2 ml and in group 3 the mean total blood loss was 958.13±262.10 ml. Conclusion: There is no statistically significant difference in blood loss between three groups. In our study we could not find any significant association between perioperative blood loss and clopidogrel.

Early and long term results of coronary artery bypass grafts in patients with renal replacement therapy

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Pradeep Kumar R, Nazer YA Division of Cardiovascular Surgery, The Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala Background: The aim of this study was to define peri-operative risk and long term results of coronary artery bypass grafts in renal replacement therapy patients. Methods: Retrospective study included 41 patients on renal replacement therapy who underwent CABG between 2002 and 2009. The mean age was 64±10 years (range 32-81 years), 38 (92.68%) of the patients were male and the average duration of dialysis was 48 months (range 1-148 months). Combined procedures were double valve replacement in one case, left ventricular aneurysm resection in one and mitral valve repair in 2, valve replacements (3 aortic and one mitral replacements), 1 aortic dissection repair. The operation was elective in 32 patients (71.6%) and urgent in the others. Previous

myocardial infarction was found in 36 patients (87.8%) and left ventricular ejection fraction (LVEF) at less than 45% in 16 patients (39.02%); 25patients (60.95%) were in NYHA class III or IV and regarding angina functional status. Statistical analysis used Chi-square analysis or Fisher's exact test, and the Mann-Whitney test. The estimated probability of survival was calculated by the method of Kaplan-Meyer, and the Log-Rank test used to compare the results. Results: Hospital mortality was 4.87% (n = 2). Ischemic time and ECC time were significantly lengthened in dead patients (P = 0.01). Moreover, use of internal mammary artery, and other arterial grafts was directly related to lower hospital mortality (P = 0.02). For previous myocardial infarction, LVEF at less than 45%, diabetes and combined procedure, a P-value of < or = 0.1 was calculated. The follow-up ranged from 1 to 84 months (mean 60 months). There were 3 late deaths. Improvement of their functional status was noted in all survivors. Statistical analysis showed significant difference in favor of long term survival for patients younger than 60 years, those receiving arterial grafts, LVEF > 45%, those treated with off pump surgery, when early dialysis measures were instituted within day 1 of postoperative period and NYHA class I or II. Conclusion: Off pump techniques, use of ultrafiltration, arterial grafts, early institution of renal support measures, nephro friendly medications help to offset most of the hurdles.

Carolid stenting in patients going in for CABG : Our experience

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Suresh S, Balachandran, Jamesraj J, Kurian VM, Rajan S Madras Medical Mission, 4A Dr Jayalalithaa Ngr, Mugappair, Chennai Our experience with carotid artery stenting followed by CABG during the period of 2007-09, total number of CABG during this period was 1862, of which 36(1.9%) underwent carotid stenting prior to surgery. Surgical treatment of simultaneous coronary and carotid disease is still controversial, because of the high risk of morbidity and mortality after combined or staged carotid artery endarterectomy and the coronary artery bypass grafting approach. In the staged carotid endarterectomy (CEA) with coronary artery bypass grafting (CABG) approach, which addresses the carotid lesion with CEA first, followed several days to several weeks later by CABG, the risk of stroke prior to CABG is reduced. However, the risk of acute myocardial infarction during CEA and in the period before CABG seems to be quite high. Carotid artery stenting (CAS) is rapidly evolving as an alternative to CEA, mainly in patients with severe carotid stenosis and coronary comorbidity. A staged CAS-CABG approach has been recently proposed aggressive antiplatelet therapy for approximately 1 month after stenting and stopping antiplatelet 5 to 7 days prior to surgery. Selection of patients based on neurological symptoms and severity of cardiac diseases. Symptomatic patients like TIA, more than 70% stenosis and asymptomatic patients with more than 90% stenosis are intervened. Morbidity and periprocedural events are less when compared to combined surgical procedure. Planned carotid stenting followed by staged CABG is a viable method of treatment for patients with coexistent carotid and coronary atherosclerosis

Outcome of patients after isolated coronary artery bypass grafting, prospective comparative study of three different techniques

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Raju V, Srinivasan M, Padmanapan C, Ramanathan S Dept. of CTU, GKNM Hospital, Coimbatore, Tamilnadu Background: To evaluate biochemical and hemodynamic results following three different strategies of myocardial protection in patients undergoing isolated coronary revascularization (CABG).

IJTCVS 2010; 26: 63

IJTCVS, Jan–Mar, 2010

Methods: 516 consecutive patients (from Jan 2009 to sept 2009) who underwent isolated myocardial revascularization were evaluated prospectively. Cardiopulmonary bypass was used in 319 patients of which intermittent cross clamp with fibrillatory arrest (Group A, n:140) and blood cardioplegia (group B, n:179). Group C (n:197) had CABG using off–pump technique. The mean age, sex ratio and mean Euro score of all the three groups were comparable. Group C had more patients with preoperative renal dysfunction (7.61%) and calcified aorta (2.03%). Left IMA pedicle graft was used in 513 patients. Endartrectomy was carried out in 64 (Group A : 38, Group B : 19 and Group C : 9 patients). Mean number of graft in Group A, Group B and Group C were 3.5, 3.43 and 2.49 respectively. Mean CPK-MB was lower in Group C (13.92ng/ml) than with Group A and Group B. There was no difference in the overall ICU stay, duration of ventilation, need of IABP, incidence of A.F and blood transfusion requirement in all three groups. No difference in the overall hospital stay. There was only one mortality in our total population (0.19%) Conclusion: All three techniques for isolated CABG have equally good results. Incidence of renal and neurological dysfunction were less in OPCABG group. The choice of technique is dictated by patient profile, co-morbid condition and surgeon preference.

Short- and mid-term results of off-pump coronary artery bypass grafting for patients with low ejection fraction

Re-do off-pump coronary artery bypass: Single instituition experience in 203 patients

Background: To evaluate the clinical profile and surgical results of 203 consecutive patients who underwent re-do off pump coronary revascularization in a single institution. Methods: Since Jan 2003 till Aug 2009, 203 patients with LVEF < 35% (Echo/CAG) out of 7034 consecutive myocardial revascularizations at our Institute have been monitored collecting data in a prospective study. Isolated OPCAB: 193, with associated procedure: 9. One was second time re-do. 93.1% male. Mean age: 61.07 years. Unstable angina: 27.93%. Diabetes: 49.7%. Recent MI: 19.7%. Hypertension: 52.7%, Smokers: 14.5%. LVEF <15%: 1%; 16 – 25%: 8%; 26-35%: 20.50%, 36-45%: 29.50%, >45%: 45.5%. Left Main < 50% (CAG): 15.8%; Average anastomoses per patient: 3.78. Conduits used : LIMA33.2 %, RIMA- 45.1%, BIMA- 6.9%, Radial Artery- 92.6%. SVG- 26.7%. IABP was used in 14.8%. Cell-saver was used routinely. Results: In hospital mortality (0-30 days): 2.96%. Morbidity; Overall stroke: 1%. Re-exploration for bleeding: 0%. Periop MI: 2.5% Arrhythmias: 18.7%.(AF 12.5%, VT/VF-6.25%). Pleural effusion: 9.4%. Mean p.o. stay in ICU 4.4 days; in hospital: 10.4 days. Conclusions: Off-Pump Arterial Myocardial Revascularisation can be achieved in most re-operation cases with low in hospital mortality and with low complications rate.

Preoperative renal insufficiency: Does it affect early outcomes of off-pump coronary artery bypass grafting?

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Tamenishi A, Matsumura Y, Okamoto H Yokkaichi Municipal Hospital, 2-37, Shibata 2-chome, Yokkaichi, Japan Background: In our institution, we performed off-pump coronary artery bypass grafting (OPCAB) for coronary artery bypass grafting alone. We estimated short and mid-term results of OPCAB for patients with low ejection fraction (EF). Methods: Between May 1991 from March 2009, 70 patients with coronary artery disease and impaired left ventricular function (EF less than 40%) underwent OPCAB in our institution. We investigated short- and mid-term results. Results: Mean age was 68.7 ± 9.3 years old. Mean left ventricular EF was 32.3 ± 5.6%. As preoperative comorbidities, cerebrovascular disease was 11 (15.7%), hemodialysis due to chronic renal failure was 23 (32.9%), and porcelain aorta was 27 (38.6%), and peripheral vascular disease was 10 (14.3%). Six patients were performed under intra-aortic balloon pumping including 2 cardiac shocked ventilation support preoperatively. Thirty-day mortality was 2 patients (2.9%). There was no significant factor associated with 30-day mortality. As postoperative comorbidities, cerebral infarction was 2 (2.9%), and ventilator support over 48 hours was 4 (5.7%). There was no significant factor associated with postoperative comorbidities. Sixty-three patients were followed-up with mean interval of 3.5 years. There was no cardiac death, and 5-, 10-year survival rate were 94.4, 87.2%. Congestive heart failure occurred in 6 cases as a cardiac event, and 5, 10-year cardiac event free rate were 86.7, 79.4%. Chronic renal failure proved to be a significant factor associated with cardiac event (p<0.05). Conclusions: Short- and mid-term results of OPCAB for patients with low ejection fraction were satisfactory.

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Panda R, Vanzara S, Rath P, Rajanikant CR Asian Heart Institute, Block G/N, Bandra-Kurla Complex, Mumbai-400051

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Sajja LR, Mannam G, Chakravarti R, Guttikonda J, Sompalli S Star Hospitals, Road no. 10, Banjara Hills, Hyderabad Background: Pre-existing renal insufficiency is a risk factor for acute kidney injury following on-pump CABG. This study is aimed at analyzing the impact of various stages of renal insufficiency on the early outcomes of off-pump CABG in comparison to the patients with normal renal function. Methods: A total of 2275 patients who underwent off-pump coronary artery bypass grafting between August 2004 through March 2009 were categorized into five groups (stages) according to the National Kidney Foundation guidelines based on glomerular filtration rate (GFR). Of these, 1855 patients had renal insufficiency (stage 2: 1406 patients; stage 3: 428 pts; stage 4: 21 pts) and 414 patients had normal renal function (stage 1). Six patients in stage 5 excluded from the analysis. Results: Patients with normal renal function were younger (p=0.001). There was a significant rise of serum creatinine from the baseline on the first postoperative day in renal insufficiency groups (p=0.001).There was no significant difference in the use of inotropes, re-exploration rate, postoperative stroke, wound infection and mortality rate among the various GFR groups. There was significantly higher incidence of post operative myocardial infarction (MI), need for postoperative dialysis in stage 3 and stage 4 patients compared to stage 1 patients (p=0.002, p=0.002). Conclusions: There was no significant difference in the early outcomes (mortality and need for dialysis) between normal renal function and stage 2 renal insufficiency groups except for further elevation of postoperative creatinine (p<0.05). There was a higher incidence of postoperative MI (p=0.002) and more frequent requirement for postoperative dialysis in stage 3 and 4 insufficiency groups (p=0.002).

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Off-pump coronary bypass grafting disproportionately benefits high Euro SCORE patients

IJTCVS, Jan–Mar, 2010

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Sajja LR, Mannam G, Dandu B, Pathuri S, Saikiran KVSS Star Hospitals, Road no. 10, Banjara Hills, Hyderabad Background: Off-pump coronary artery bypass grafting (OPCAB) has become an effective alternative to on-pump CABG. It is not well established which patient subgroups may benefit more from off- pump coronary artery bypass grafting rather than on-pump CABG. The aim of this retrospective study is to evaluate postoperative morbidity and mortality in patients with high Euro SCORE between OPCAB and on-pump CABG groups. Methods: The retrospective study included 1085 patients with Euro SCORE >6. who underwent isolated coronary artery bypass grafting by a single team of surgeons from January 2001 through September 2009. These patients were divided in to two groups. Group1comprised of 465 patients underwent CABG using cardio pulmonary bypass, group 2 consists of 620 patients underwent OPCAB. The operative mortality, need for IABP support, renal replacement therapy and the incidence of cerebrovascular accident in both groups were compared. Results: The preoperative characteristics between the two groups were comparable. The operative mortality in OPCAB group was 0.97% (6) and in on-pump group was 2.79% (13) (p<0.04). The IABP usage in OPCAB group was 2.2% (14) and in on-pump group 6.0% (28) (p<0.002), the need for dialysis in OPCAB group was 1.45% (9) in onpump group was 4.3% (20), (p<0.007) and the incidence of postoperative CVA was comparable between the two groups OPCAB 1.78% (11) vs on-pump 2.1% (10) (p=0.82) Conclusions: This study indicates that off-pump coronary artery bypass grafting is associated with lower operative mortality and morbidity in patients with high Euro SCORE compared to on-pump CABG.

Surgical treatment of multivessel coronary artery disease

Background: Estimation of results of coronary artery bypass grafting (CABG) and stenting at patients with multivessel coronary artery disease and clarify the indications to the both treatment methods. Methods: 105 patients with multivessel damage of a coronary arteries were treated for the period 2004 -2007 years. 1 group (CABG) were 72 (68,4%) and 2nd group (stenting) were 33 (31,4%) patients. More than 66% patients of both groups had the stable angina and other 34% patients had the various forms of unstable angina. We have performed an analysis of operations efficacy regarding on the types of damages of coronary lesions by the ACC\AHA classification (types A, B, C). Results: We have performed 105 operations: 72 CABG and 33 stenting operations. In 2nd group: there are executed Hospital mortality rate were 6,9% and 3,03% regarding to these two groups (p<0,05). It is important to note that we performed operations at acute stage of myocardial infarction. Preoperational myocardial infarction frequency was at CABG group 4,16% and 0% at stenting group. Long-term follow up (2 years after operations) “myocardial infarction free” were 92,05% stenting group patients? 95,8% patients after CABG. 89% patients after CABG and 67% after stenting were angina free after two years of follow-up. Conclusions: The efficacy of endovascular treatment of multivessel coronary artery disease composes 93,9% at A-type and 90,1% B-type lesions (p< 0,023). In the presence of C-type lesions of coronary arteries of their multivessel disease it is indicated to perform CABG.

Pregnancy and long-term outcome in women with prosthetic valve replacement Off-pump CABG in patients with poor LV (LVEF) Vanzara S, Rath PK, Rajanikant CR, Panda R Asian Heart Institute, Bandra-Kurla Complex, Bandra East, Mumbai

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Background: To evaluate the clinical profile and the immediate surgical results of 933 consecutive patients with LVEF < 35% who underwent off pump complete arterial coronary revascularization in a single institution. Methods: Since Jan 2003 till Feb 2009, 933 patients with LVEF = 35% (Echo/CAG) out of 6475 consecutive myocardial revascularizations at our Institute have been monitored collecting data in a prospective study. 85.2% male. Mean age: 61.07 years. Unstable angina: 27.93%. Diabetes: 56.6%. NYHA class III: 60.2%, class II: 39.3%. Recent MI: 19.7%. LVEF <15%: 4.3%; 16–25%: 32.7%; 26-35%: 62.9%. Left Main > 50% (CAG): 12.5%; TVD: 84.16%; DVD: 10.9%; SVD: 1.9%. Average anastomoses per patient: 4.28. Conduits used : LIMA- 96,1%, RIMA: 15%, Radial Artery- 82, 3%. SVG- 13.8%. IABP was used in 18.64%. 80% required homologous blood products. Cell-saver was used routinely. Pre-op protocols, operative strategy, logics for sequence of grafting will be presented. Results: In hospital mortality: 1.17% (11 cases total. Cardiac related: 8, Stroke: 2. Pulmonary embolism: 1). Overall stroke: 0.5%. Reexploration for bleeding: 1.4%. Arrhythmias: 8.5%. 14 (1.5%) patients required dialysis. Conversion to on pump: 6 patients. Mean p.o. stay in hospital: 9.93 days. Conclusions: Off-pump Complete Total Arterial Myocardial Revascularisation in low EF patients can be achieved in most cases with low in hospital mortality and with low complications rate.

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Khalikulov K, Mansurov A, Ahmedov U, Murtazaev S, Babadjanov S Republican Specialized Center of Surgery, 10, Farhad Street, Chilanzar district, Tashkent, Uzbekistan

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Keitaro D, Kobayashi J, Toda K, Fujita T, Nakajima H, Shimahara Y, Kamiya C, Ikeda T, Yagihara T Department of Cardiovascular Surgery, Department of Perinatology, National Cardiovascular Center Background: Pregnancy increases the risk of mechanical valve thrombosis. Warfarin is protective, but implies risks to the fetus. This study aims to identify the risks of maternal and fetal complications in women with prosthetic valves, and evaluate their long-term outcome. Methods: 49 pregnancies in 29 women with prosthetic heart valve were enrolled from April 1983 to November 2009. 25 pregnancies were in 16 women with mechanical valve (Group M), 24 pregnancies were in 13 women with biological valve (group B) and 3 pregnancies in 3 women with ross procedure (group R). In group M , warfarin was switched to heparin administration at 5-13 weeks of gestational age. Results: The pregnancies in group M resulted in 8 (32%) healthy babies delivered by cesarean section. Two babies were deceased in perinatal period. The pregnancies in group B resulted in 16 (66.7%) healthy babies and in group R resulted in 3 (100%). 5 women suffered from valve thrombosis and two required urgent valve replacement in group M. Thirteen required transfusion due to bleeding in perinatal period, while no bleeding or thrombosis events were observed in group B and R. Reoperation free rates were 41.3% in group B, 93.3% in group M at 15-year and 100% at 5-year in group R. Structural valve deterioration was observed in 7 cases (53.8%) of group B. Conclusion: Biological valve or ross procedure is recommended for young women to decrease the risks of perinatal period, however bioprosthesis may require redo operation due to early valve deterioration.

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Small aortic annulus in elderly patients: Thirteen-year experience with stentless bioprosthesis

IJTCVS, Jan–Mar, 2010

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Hisamoto K, Toyama M, Katoh M, Kotani M, Haisong WU, Kato Y, Sugimura Y Department of Cardiovascular Surgery, Kameda Medical Center, Japan Background: The purpose of this study was to evaluate the long term outcome and hemodynamic performance of stentless bioprostheses for patients with small aortic annulus. Methods: Between 1996 and 2009, 145 patients underwent aortic valve replacement with stentless bioprostheses. 38 patients (mean age, 74.5±5.2 years) with small aortic annulus were implanted either 19mm or 21mm sized bioprostheses. Follow-up was 161.7 patient-years (mean, 4.3 years per patient). Clinical and echocardiographic evaluation was obtained at the discharge, 6 months after discharge and yearly intervals thereafter. Results: There was no operative mortality or valve-related death. Overall survival rate at 10 years was 76%. Freedom from structural valve deterioration was 100% at 13 years. However, two patients received reoperation after surgery (3 years, 6 years) for pannus formation. Freedom from late cardiac complications was 62% at 10 years. Mean pressure gradient after first year was 12.8±8.9mmHg, 15±5.6mmHg in patients with a 19mm and a 21mm bioprosthesis. Effective orifice area index after first year was 0.90±0.1cm2 and 0.95±0.2cm 2, respectively. Left ventricular mass index showed significant regression (143.4±34.6g/m2 to 83.5±7.8g/m2, p<0.01, 156±51g/m2 to 117±22g/m2, p<0.01, respectively) at first year. Conclusions: Long term follow-up reveals that small size stentless bioprostheses propose excellent durability and hemodynamic performance in patients with small aortic annulus.

The long-term clinical and echocardiographic results of surgical treatment for hypertrophic obstructive cardiomyopathy

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Yonemoto Y, Kobayashi J, Nakajima H, Toda K, Fujjita T, Shimahara Y, Yagihara T National Cardio Vascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 5658565 Japan Background: Surgical resection of thickened myocardium has been playing an important role in release of obstruction in hypertrophic obstructive cardiomyopathy (HOCM). In present study, we examined early and late clinical outcomes after surgical treatment for HOCM and sought to delineate the impact of transaortic septal myectomy/ myotomy(TASM) and mitral valve replacement(MVR) concomitant with transmitral myoectomy. Methods: Between 1980 and 2009, 39 patients (M:F=17:22,59±13 years) underwent surgical treatment for HOCM in our institution. Peak preoperative pressure gradient was 104.5±51.6mmHg. Of these, 13 underwent TASM alone, 11 underwent TASM with MVR, and 15 underwent MVR alone. There was preoperative cardiogenic shock in 2, infective endocarditis in 1. The mean follow-up period was 7.8±7.3 years. Results: There were 3/39(7.7%) early death(sepsis 1,cerebral infarction 1, interstitial pneumonia 1), and 8 late death(cardiac death 3, sudden death 1,others 4). Although pressure gradient was significantly reduced upto 23.9±19.3mmHg(p<0.001), 50mmHg or more gradient remained in the mid-ventricular portion of 4 patients. Late complications occurred in 15(congestive heart failure 10, cerebral infarction 3, and aortic regurgitation 2). ICD was implanted in 4 patients, postoperatively. The overall cumulative survival rate at 10, and 15 years were 73.7% and 73.7%, respectively. The cumulative survival rate in patients with MVR was

comparable with those without MVR (78.5% vs.67.7% at 10 years, p=0.99). Conclusions: Surgical treatment was effective and reliable for reduction of pressure gradient in HOCM. MVR did not affect the longterm clinical outcomes. Additional medical or interventional therapy may be warranted for prevention of congestive heart failure and sudden cardiac death.

Redo tricuspid valve surgery: Single institutional 46 experiences

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Chen SW, Tsai FC Section of Cardiac Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan Background: Redo tricuspid valve surgery, though a simple surgical procedure has high postoperative mortality and morbidity because of delayed intervention. We reviewed our single institutional experience. Methods: From Sep 2005 to Sep 2009, 46 consecutive patients (male=19, female =27), underwent reoperative tricuspid valve surgery were reviewed. The mean age was 55.1 (29-80) years-old and 76% of them were in NYHA functional class III or IV. Preoperative comorbidities included cardiogenic shock need ECMO support (n=2), old stroke (n=5), refractory ascites & cardiac cachexia (n=22) and COPD (n=7). Etiologies of tricuspid regurgitation were annulus dilatation (n=17), failed previous tricuspid surgery (n=15), rheumatic (n=9), endocarditis (n=4), and congenital (n=1). Carpentier MC3 ring annuloplasty was performed if feasible. Otherwise, prosthetic valve replacement was implanted in stead according to patient’s preference. Results: There were 26 (56.5%) tricuspid valve implants, including 17 bioprothetic & 9 mechanical, and the other 20 (43.5%) annuloplsties. Concomitant procedures included mitral valve replacement (n=21), Mitral valve repair (n=5), aortic valve replacement (n=10) and Maze operation (n=8). The mean intensive care unit stay was 4.9 days and hospital stay was 25.1 days. Hospital mortality was 17.4% (8/46), 6 attributed to myocardial failure and 2 septic shock. Postoperative morbidities included myocardial failure which need ECMO support (n=5), reopen for check bleeding (n=5), acute renal failure (n=6), prolonged ventilator use (> 7 days) (n=7). At a mean follow-up of 25.7 (2.3-48.7) months, 95% of survival to discharged patients were alive and 79% were in functional class I or II. Conclusion: Redo tricuspid valve surgery remains challenge even in contemporary cardiac surgery era but benefits most patients if they can survive to discharge.

Bilateral papillary muscle elevation is effective for treatment of severe functional mitral valve regurgitation in dilated cardiomyopathy

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Ono M, Nishimura T, Saito A, Nawata K, Kawata M, Hisagi M, Motomura N, Kyo S Department of Cardiothoracic Surgery & Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan Background: We have applied bilateral papillary muscle elevation (BPME) to severe functional mitral regurgitation. Results were analyzed to confirm the stability of repair. Methods: Sixteen patients underwent BPME. Ages ranged from 16 to 80 years. DCM was diagnosed as idiopathic in nine, ischemic in four and end-stage valve disease in three. One patient was dependent on IABP, and three were catecholamine-dependent. Bilateral papillary muscles were pulled towards the posterior annulus. Semi-rigid ring was routinely used. Ring size was 26.7mm in early six cases, whereas larger-size ring was found to be applicable in recent ten cases (29.6mm). Concomitant procedures were CABG in four, artificial

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chord reconstruction in seven and maze procedure in three. In eight cases with severely depressed ventricular function procedures were performed on a beating heart. Results: All patients survived the surgery, and were completely followed-up for 1 to 41 months. One patient died two years after surgery due to pneumonia. MR grade was reduced from 3.3 to 0.5 immediately after the surgery, and 0.9 one year later. Tenting height was reduced from 11.0 mm preoperatively to 4.8 mm postoperatively, and this height was unchanged until late phase. Left ventricular ejection fraction did not change (33.3% vs 33.6%). NYHA class improved dramatically from 3.3 to 1.4. Conclusion: Mid-term results of BPME were satisfactory. This technique enabled us to use a larger size annuloplasty ring, which may be beneficial to avoid worsening of posterior papillary muscle tethering. Larger number of cases and further follow-up are necessary to prove a durability of this technique.

AML Length: A predictor for mitral valve repair in rheumatic population

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Gupta A, Gharde P, Kumar AS, Cardiothoracic Centre All India Institute of Medical Sciences, New Delhi Background: The length and mobility of anterior mitral leaflet (AML) are considered important for mitral valve repariability. In this study we looked at AML length as a predictor of mitral valve repairability in rheumatic population. Method: Between May and November 2008, 44 patients underwent mitral valve repair for pure mitral regurgitation, pure mitral stenosis and mixed lesions. The mean age was 26.5± 10.4 years (range, 9 to 50 years, median 23.5 years), and 15 patients were less than 20 years. There were 28 females. The mean body surface area was 1.37± 0.13 (range, 0.97 to 1.62). In all patients we measured AML length at A2 segment both by Transesophageal echocardiography (TEE) [AML (T)] and Intraoperative direct measurement [AML (D)]. Indexed AML length [AML (I)] and Indexed AML(TI) was calculated after dividing AML (D) and AML (T) with the body surface area respectively. Results: Nine patients underwent mitral valve replacement after failed repair. Thirty five patients had successful repair. There was a significant statistical difference between AML (D), AML (T), AML(TI) and AML (I) between the successful repair group and failed repair group. An AML (D) of 26 mm or more predicts repairability with 97.14% sensitivity and 100.00% specificity. TEE can predictably judge AML (D) and AML(TI) can also predict reparability. AML (I) is even stronger predictor of mitral valve reparability, especially in pediatric population. Conclusion: AML(TI) and AML (I), are very strong predictors of mitral valve repairability. With an Indexed AML length 18 mm/m2or more, repair can be accomplished in all cases.

On-pump beating heart mitral valve plasty without aortic cross-clamp

repair, a vent cannula with pressure monitoring line was inserted into the LV apex, keeping LV pressure lower than the systemic perfusion pressure to avoid ejection through the aortic valve. Results: There were no statistically significant differences between Group A and B in the duration of cardiopulmonary bypass time and aortic cross clamp time. The values for Creatinin Kinase (CK) in Group A were significantly higher than Group B (p=0.0092). The values for CK-MB were not statistically different, however the absolute values for Group A were higher (p=0.066). In Group B, 4 cases had second pump run to repair residual regurgitation, where no cases in Group A. Conclusions: Beating heart MVP is an effective technique to accomplish perfect MVP with high success because artificial chord length could be optimized under physiologically beating heart conditions and fine adjustment of leaflet coaptation could be performed under direct vision. However as this technique has potential risk for air thrombus, we need the further artifices to avoid air thrombus.

Redo cardiac surgery for valvular heart disease in patients with systolic left ventricle dysfunction

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Shmatov D, Semenov I, Astapov D, Zhelesnev S, Karaskov A Novosibirsk Federal State Research Institute of Circulation Pathology, Russia Background: Assess the immediate results of heart valves operations as redo cardiac surgery in patients with systolic left ventricle (LV) dysfunction. Methods: Since May 2000 till October 2008, in Novosibirsk Federal State Research Institute of circulation pathology 46 patients with low (< 50%) LV ejection fraction underwent redo cardiac surgery for valvular heart disease. Presence of coronary disease was an exclusion criterion. There were 22 (52.2%) men; mean age 48.9 ± 9.8 year (range 20 – 66). Preoperatively, patients were in NYHA classes II (2.2%), III (63.1%), and IV (30,4%). Lesions were of rheumatic origin in 63,1%, prosthesis dysfunction 21.7%, infective endocarditis 4.3%, degenerative 2.2%, and posttraumatic 2.2%. Previous cardiac surgeries included mitral commissurotomy (52.3%), valve replacement (37%), and various cardiac procedures (VSD closure, aortic commissurotomy, aortic valvuloplasty et al.) in 10.7% of cases. There was history of multiple thoracic reentry in 17.4%. In 1 case (2.2%) surgical access complicated with right ventricle rupture, successfully overcome. Results: Hospital mortality was 6.5% (acute heart failure in 2 cases, and intraoperative hemorrhage in 1 patients). Early complications were multiorgan failure (9.3%), heart failure (14%), surgical site infection (9.3%), renal failure (7%), pleural hemorrhage (4.7%), stroke (4.7%), and gastrorrhagia (2.3%). LV ejection fraction improvement was seen in all survivors (55±5% comparing with 43±7% preoperatively). Conclusions: Redo cardiac surgery for valvular heart disease in patients with systolic LV dysfunctions is characterized with satisfactory early results, LV ejection fraction improvement, and low complication rate.

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Kusuhara T, Furutake T, An K, Nakatsuka D, Yuji S, Michihito N, Iwakura A, Yamanaka K Department of Cardiovascular Surgery, Tenri Hospital, Nara, Japan. Background: We established a safe and secure beating heart mitral valve plasty (MVP) procedure to accomplish successful MVP since July 2009. We compared this procedure with conventional MVP. Methods: We studied 6 patients [Group A: 63.8±6.3 (SD) years] undergoing on-pump beating heart MVP and 41 patient undergoing conventional MVP [Group B: 63.0±12 years] between 2006 and 2009. On-pump beating heart MVP was performed through median sternotomy without aortic cross-clamp. To avoid air embolism during

Rheumatic tricuspid disease. It worth the repair? Bernal JM, Pérez-Negueruela C, Sarralde JA, Ponton A, 54 Diez Solórzano L, Pulitani I, Gutiérrez F, Garcia I, Arnaiz E, Tascón V, Fernández-Divar J, Revuelta JM Cardiovascular Surgery, Hospital Universitario Valdecilla, Universidad de Cantabria, Santander, Spain Background: Analyze the 30-year long-term follow up results of patients who underwent repair of the tricuspid valve for rheumatic organic valve disease, and the predictive risk factors for mortality and valve-related complications.

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Methods: Between 1974 and 2008, 299 patients (mean age 50.8±13.8 years) underwent surgical repair of the tricuspid valve for a multivalvular rheumatic organic disease. From this group of patients, 184 (61.5%) had a mitro-tricuspid lesion, 108 (36.1%) a triple valve lesion, 20 an aortic and tricuspid (0.7%) and 5 an isolated tricuspid disease (1.7%). Tricuspid valve repair was accomplished by means of prosthetic ring annuloplasty in 78 patients (26.1%), commissurotomy and ring annuloplasty in 82 (27.4%), isolated commissurotomy in 10 (3.4%), De Vega annuloplasty in 105 (35.0%), commissurotomy and De Vega annuloplasty in 24 (8.4%). Results: Hospital mortality was 22 patients (7.4%). Previous valve surgery, and reoperation for bleeding were predictive risk factors for hospital mortality. Mean follow-up was 19.7 years with a complete follow-up of 96.7 %. Late mortality was 153 patients (51.2%) most of the due to cardiac causes. Date of surgery, NYHA class IV, aortic valve repair and tricuspid ring annuloplasty were detected as risk factors for late mortality. Actuarial survival curve was 10.6±4.5% at 30 years. Actual curve for a matched population of the same age and gender is 78% at 30 years. A total of 106 (35.5%) patients required a valve reoperation, 69 for tricuspid valve repair dysfunction. Age, tricuspid stenosis and mitral commissurotomy without ring annuloplasty were the predictive risk factors for valve reoperation. Actuarial curve free from valve reoperation was 29.4±6.1% at 30 years. Conclusions: Organic tricuspid valve disease associated with mitral and/or aortic valve lesions increase early and late mortality. long-term results could be considered acceptable for an incurable valve disease

Comprehensive aortic root and valve repair procedure: The early results

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Kang S1, Shin JK1, Chee HK1, Kim JS1, Song MG1 1 Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Seoul, Korea Background: A comprehensive aortic root surgical procedure that we termed comprehensive aortic root and valve repair procedure (CARVAR) involving the correction of leaflet pathology, and reduction of sinotubular junction and the annulus was performed by our group for 12 years. The aim of this study was to evaluate the efficacy, safety and short term durability of this novel approach. Methods: From Oct 2007 to May 2009, a total of 228 patients underwent CARVAR procedure addressing the three main components of the aortic root; sinotubular junction (STJ), annulus and leaflet for various aortic root wall and valve disease. Stanford type A Aortic dissection patients were excluded from this study. For leaflet correction, pericardium tailored with a specially constructed template was implanted after leaflet removal and STJ and annulus were reduced by the implantation of customized artificial rings and strips. The patients were divided into 3 groups; aortic root wall disease group (AAR n=34) which including annuloaortic ectasia and ascending aortic aneurysm, aortic regurgitation (AR) with leaflet disorder group (IAR n=80) and aortic stenosis group (IAS n=114). Results: Mean age was 50.5±15.5 (11 to 85) years of which 131 were male. There were two hospital deaths and one follow up death. Survival rate was 98.7%. There were 2 re-operations due to recurred AR. Additional procedures were performed after the first operation in 4 cases which included 3 cases of OPCAB and 1 case of PCI, possibly related to cardioplegia infusion catheter. The aortic sinus diameter was reduced from 54.5±6.6 mm to 38.7±3.7 (p<0.05) mm in AAR group, the mean AR grade was decreased from 3.1±0.8 to 0.2±0.5 (p<0.05) in IAR group, and the max/mean pressure gradient decreased from 69.9±38.7/43±23.4 mmHg to 23.3±18/12.8±12 mmHg (p<0.05) in IAS group. Conclusions: The CARVAR procedure shows favorable early results for various aortic root wall and valve diseases.

Late results with aortic valve replacement for acute infective endocarditis: impact of the stentless xenograft on re-infection over 17 years

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Patel HJ, Haft JW, Romano MA, Prager RL, Deeb GM Section of Cardiac Surgery, Assistant Professor of Surgery, University of Michigan Cardiovascular Center Background: The optimal prosthetic aortic valve choice for acute infective endocarditis (IE) is unknown. Homografts have been suggested as the preferred substitute; their main limitation is availability. Stentless xenograft valves (SAVR) obviate this difficulty. Its results for IE are not well characterized. This study contrasts outcomes for SAVR versus other valve substitutes for IE. Methods: 183 patients underwent AVR for IE (1992-2009). Mean age was 51.9 years (76.5% male). Identified sources included intravenous drug use or dialysis access sites (IVDA/HD) in 46 (25.1%). Pathogens were non-streptococcal in 118 (64.5%) or culture negative in 24 (13.1%). Prosthetic valve endocarditis was seen in 68 (37.2%); root abscess in 78 (42.6%). Prosthetic choice included SAVR(90), homograft (49), stented (34) or mechanical AVR (10). Concomitant procedures included MVR (49), TVR (15), CABG (26), or ascending aortic repair (21). Differences between SAVR and nonSAVR included more frequent ascending aortic replacement with SAVR (p=0.02). Results: Operative mortality was 7.1%(13); early morbidity included stroke (6), renal failure (17), new-onset hemodialysis (2), and mediastinitis (5), with no differences between SAVR and non-SAVR. Late survival was similar between SAVR (mean survival 102mos) and non-SAVR groups (112mos, p=0.45). Independent predictors of late mortality included non-streptococcal pathogen, IVDA/HD source, homograft AVR, history of dialysis or MI (all p<0.05). Late re-infection was seen in 17, and was independently predicted by prior MI, IVDA/ HD source and non-SAVR (all p<0.05). 5-year freedom from aortic valve re-infection was 94.8% for SAVR vs. 73.8% for non-SAVR (p=0.008). Conclusions: Xenograft SAVR in IE results in improved freedom from re-infection when compared to other valve substitutes, and represents the optimal prosthetic choice for IE since homograft AVR is an independent predictor of late mortality.

Early results of innovative approach for mitral valve repair

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Kang S1, Shin JK1, Chee HK1, Kim JS1, Song MG1 1 Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Seoul, Korea Background: A new mitral valvuloplasty technique consisting of lifting mitral annuloplasty (LMA) and posterior and/or anterior leaflet extension (PLE/ALE) to improve mitral coaptation using the Mitralift® annuloplasty strip was performed by our group for 6 years. The aim of this study was to assess the efficacy of this new mitral valvuloplasty technique. Methods: The medical record of 251 patients (156 females and 95 males) who underwent a new mitral valvuloplasty procedure from Oct 2007 to May 2009 was retrospectively reviewed. The mean age was 44±24 years. LMA is a new mitral annuloplasty technique consisting of lifting the downward displaced LV wall by the placement of a specially designed fabric annuloplasty strip (Mitralift®) on the left atrial wall along the posterior mitral annulus. PLE/ALE was applied to patients with contracted mitral leaflets utilizing appropriately tailored bovine pericardial segments designed against a pre-constructed template (SC template®), the size of which were based on that of the new annuloplasty strip. Patients were divided into two groups; MR group (n=162) and MS group (n=89).

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Results: There were two early deaths (0.8%) and three follow up deaths (1.2%). There were four re-operations for recurred infective endocarditis in 2 patients and recurred MR in 2 patients in the MR group. The mean MR grade was decreased from 2.9±1 to 0.6±1.1 (p<0.05) in the MR group. Mean effective mitral orifice area was increased from 1.3±0.4 cm2 to 1.9±0.6 cm2 (p<0.05) in MS group. Conclusions: The early outcome of this new mitral valvuloplasty strategy shows favorable early results for various mitral valve pathologies.

Role of the suture annuloplasty and kalangos biodegradable ring annuloplasty techniques used in tricuspid regurgitation in regression of tricuspid regurgitation during early postoperative period

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Gökalp O1, Lafçi B1, Yetkin U1, Bayrak S1, Özbek C2, Özsöyler I3, Yürekli I1, Yakut N4, Gürbüz A1 1: Dept. Of Cardiovascular Surgery, Izmir Ataturk Training and Research Hospital, Izmir/Turkey. 2: Dept. Of Cardiovascular Surgery, Izmir Tepecik Training and Research Hospital, Izmir/Turkey. 3: Dept. Of Cardiovascular Surgery, Adana Numune Training and Research Hospital 4: Dept. Of Cardiovascular Surgery, Izmir Gazi Hospital Background: Sixteen patients that underwent tricuspid valve repair between years 2001 and 2008 in our clinic were evaluated retroand prospectively. Methods: Tricuspid valve suture annuloplasty was performed to 8 patients with severe tricuspid insufficiency accompanying other cardiac pathologies, whereas remaining 8 patients underwent tricuspid ring annuloplasty. Eleven (68%) of cases were female, whereas 5 (32%) of them were male. Nine (56%) of these patients had a past medical history of acute rheumatic fever. All the patients possessed functional tricuspid insufficiency. There wasn’t any isolated tricuspid valvular disease. Preoperative echocardiographic values were compared with those of in 6th postoperative month statistically. Results: Improvement in tricuspid regurgitation was found to be more in cases with tricuspid ring annuloplasty than that of tricuspid suture annuloplasty. The results were found to be statistically significant (p<0.005). Conclusions: The results of this study demonstrate that residual insufficiency is less in cases with tricuspid ring annuloplasty. We think that tricuspid valve should be intervened in cases with severe tricuspid regurgitation when the left heart pathologies were being repaired. Ring annuloplasty technique is a safe and effective technique when tricuspid valve needs to be surgically corrected.

The TRACET study : Tricuspid valve repair by annuloplasty- comparative evaluation of techniques

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Taggarse AK, Amaresh RM, Dharmarakshak A, Kumar RV, Mishra RC Dept. of Cardio-Thoracic Surgery, The Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, India Background: We looked at different repair techniques of the tricuspid valve and also compared with a group of patients with moderate functional TR managed conservatively. Methods: This prospective, randomized, single-blinded, controlled study included 62 patients. Carpentier-Edwards ring (Group-1) was placed in 4 patients, customized Bard hard Teflon ring (Group-2) was placed in 29 patients, De Vega suture annuloplasty (Group-3) was done in 11 patients and 18 patients with moderate functional TR were

the control group (Group-4). Variables evaluated included type of repair, age, pre-operative NYHA class, pre-operative TR grade, LV function, pre-operative atrial fibrillation, raised CVP, pre-operative PAH, organic or functional TR, post-operative LV dysfunction, postoperative AF and persistent PAH post-operatively. Failure of repair was defined as post-operative TR of 2+ (moderate TR) or greater (range 1 to 4). Results: Variables found to significantly influence outcome included type of repair, preoperative TR grade and persistent PAH. Time to event analysis revealed progression of TR in Group-3 and Group-4. There were no failures in the Carpentier Edwards ring (Group-1). There were 2 failures in the customized felt group (Group2). Results at one year were equivalent and comparable between groups 1 and 2. Conclusions: TR must be repaired even if it’s moderate functional TR (Group-4) as it’s likely to progress. Suture based repairs are likely to fail by one year. Customized Teflon hard felt is a very cost-effective alternative to the Edwards ring and results of both these repairs were good at one year.

Results of reoperation for periprosthetic leaks Kato Y, Hattori K, Bito Y, Kotani S, Kaku D, Shibata T Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan

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Background: Periprosthetic leak (PPL) is one of the serious complications of valve surgery. The aim of this study was to evaluate the results of reoperation for periprosthetic leaks. Methods: Between 1994 and 2009, ten patients (8 men and 2 women) underwent reoperations for PPL, including aortic position in 2 patients, mitral position in 7, and aortic & mitral in 1. Prosthetic valve endocarditis was excluded. Results: Reoperations for aortic PPL were performed in 3 patients, all of whom had initial AVR for aortic regurgitation with mechanical prostheses implanted in intra-annular position. The sites of leaks were different and no specific findings were observed. Eight patients had mitral PPL. Of these, 6 patients had second re-MVR and 2 had multiple mitral valve reoperations, including 3 times in 1 patient and 4 times in 1. In total of 11 explanted prostheses (10 mechanical prostheses and 1 bioprosthesis), 9 prostheses were implanted in intra-annular position and 2 in supra-annular position at prior operations. The sites of leaks located at anterolateral or lateral annulus in 7 out of 11 reoperations. In 5 mitral reoperations, PPL occurred in the early postoperative period (mean interval from prior surgery to reoperation was 41 days). One patient undergoing mitral reoperation died on the 32 postoperative day due to pulmonary hemorrhage (hospital mortality 9.1%). Conclusions: Our study suggests that PPL of the mitral position occurs more frequently at anterolateral or lateral part of the annulus. Care to these sectors should be taken when placing valve sutures during MVR.

The on-x valve - Results at 9 years in young patients

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Williams MA, Van RS Provincial Hospital Port Elizabeth South Africa, 314 Greenacres Hospital GREENACRES, Port Elizabeth Background: This study was undertaken to evaluate the clinical performance of the On-X valve in young patients in whom anticoagulation was poorly controlled. Most patients were from socioeconomically disadvantaged backgrounds with unsatisfactory parental supervision.

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Methods: Between August 2000 and January 2009 126 valves were implanted in 104 patients aged between 3 and 16 years. There were 18 aortic valves, 86 mitral valves and 22 double valves. Patient data was censored in August 2009. Follow up was from 6 months to 8.5 years. The commonest reason for valve replacement was rheumatic valve disease (78%) followed by infective endocarditis (16%). Anticoagulation was attempted in all patients with a target INR range between 1.5 and 2.5. Results: There was 1 hospital death (not valve related). Of 18 late deaths 12 were considered to be valve related. (1 valve thrombosis, 2 systemic emboli, 4 endocarditis, 5 unknown) Linearized rates for valve related events (% patient year): Bleeding events 0.3; endocarditis 1.0; systemic emboli 1.2; valve thrombosis 0.5: Actuarially at 8 years survival was 75% and freedom from valve related events was 84%. There were no valve failures and no peri prosthetic leaks. Anticoagulation was generally poorly controlled. Anticoagulation was considered satisfactory in only 40% of patients and 25 patients were not anticoagulated at all. Conclusions: In this extremely challenging group of patients where follow up attendance and control of anticoagulation were generally erratic these results are regarded as encouraging.

Double valve replacement through right anterolateral thorocotomy approach

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Asrar Q, Ahangar AG, Zubair, Farooq, Latief M, Lone GN, Sharma ML, Majeed D, Akbar B, Shyam S Sher-I-Kashmir Institute Of Medical Sciences, Srinagar, Jammu & Kashmir Background: The usefulness of right anterolateral thoracotomy for mitral valve replacement and some congenital heart defects has been reported by several authors, but double valve replacement through right anterolateral thoracotomy has not been reported so far. Material and Methods: Five patients underwent double valve replacement through right anterolateral thoracotomy from Jan 2009 to Oct 2009. These were 3 female patients and two male patients with age ranging from 35 to 55 years. The patients were in NYHA class IIIIV with echocardiographic findings severe mitral and aortic valve disease. A right inframmary incision was given in females whereas a slanting incision was given in males and thoracic cavity was entered through right fourth intercostal space. Cardiopulmonary bypass was established with Aortic SVC and IVC cannulation. Patients were cooled to 28 degree Celsius. Left atriotomy was done and mitral valve replaced. Left atriotomy was closed and followed by aortotomy and aortic valve replacement. Patients were weaned off bypass. Postoperative course of the patients was uneventful. Conclusion: This method is cosmetically superior and acceptable to the patient besides reducing the cost factor, surgical ICU stay, blood loss, ventilatory hours, overall hospital stay and complications associated with sternotomy. We propose to adopt this procedure as an effective alternative to the conventional sternotomy approach in double valve replacement.

Long-term follow-up of autologous pericardial valved conduit

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Gajjar T, Hiremath CS, Shah G, Rao N, Neogee S, Hatibaruah N, Desai N, Choudary V Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Prashanthigram. Andhra Pradesh, India Background: The aim of this study was to evaluate the long-term results of the use of an autologous bicuspid pericardial valved conduit in the outflow tract of the venous ventricle in congenital heart malformations.

Methods: Ten patients underwent Right ventricle to Pulmonary artery autologous pericardial valve conduit in which Nine patient had diagnosis of Tetrology of fallot with absent pulmonary valve and one patient had DTGA, VSD PS who underwent Rastelli operation, All patients were followed up for a period of 3 to 84 months; 5 for more than 36 months and 5 for more than 12 months. All were evaluated clinically and by two-dimensional and Doppler echocardiography. Postoperative evaluation included serial measurement of pressure gradients and the pulmonary regurgitation. Reoperation because of stenosis was indicated when the gradient across the right ventricular outflow was greater than 50 mm Hg across the conduit. Results: Conduit survival free of reoperation for the whole group was 90 % at 3 years. Only one patient developed severe pulmonary regurgitation at 5 year follow up. None of the patient developed > 50 gradient across conduit. None of the patient needed reoperation. Conclusions: Autologous bicuspid pericardial valve conduit is a cheap, technically simple & alternative for the valve graft conduit on the venous ventricle. These results compare favorably with those of other available conduits.

Video-assisted minimally invasive mitral surgery: Our experience

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Shivanand G, Edwin R, Om Prakasham G, Chandrashekar PM, Pillai M Sagar Hospitals, #44/54, 30th Cross, Tilak Nagar, Jayanagar Extn. Bangalore Background: Over the past few years, there has been considerable progress in the field of mitral surgery with more surgeries being done less invasively. Methods: Three patients underwent Video-assisted minimally invasive mitral valve replacement from November 2009. The patients age ranged between 16 and 24years. Femoral artery was cannulated percutaneously for arterial access. Femoral vein and the right internal jugular vein were cannulated percutaneously for venous drainage. A 5cm right anterolateral thoracotomy was made. Cardioplegia cannula was placed in the aortic root. Results: A reusable transthoracic clamp designed by Chitwood was used to clamp the aorta. The delacroix-chevalier endoboy pneumatic manipulator arm was used along with long instruments for mitral valve replacement. The average post-operative drain was 50ml. There were no mortalities. Conclusion: This new technique is less invasive, aesthetic and reproducible. It is thus a valid alternative to the standard procedure.

Hemodynamic performance of the Edwards Perimount Magna bioprosthesis and the Medtronic Mosaic bioprosthesis in the aortic position

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Motokawa M, Yamamoto F, Yamamoto H, Ishibashi K, Yamaura G Department of Cardiovascular Surgery Akita University School of Medicine, Akita Background: Recently, bioprosthetic aortic valve with sufficient effective orifice area are available in small size. We need to select the valve by considering postoperative hemodynamic performance. The aim of this study is to compare the hemodynamics of Edwards Perimount Magna (EPM) 19 mm and the Medtronic Mosaic (MM) 21 mm. Methods: Between January 2007 and June 2009, ten patients underwent aortic valve replacement due to aortic stenosis were recruited to this study. Post-operative hemodynamic data were

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obtained by echocardiography 3 to 26 months after the surgery. Results: Industry-announced effective orifice area (EOA) index (EOAI: EOA was divided by body surface area (BSA)) has no significant difference between two groups, preoperatively (EPM 1.01±0.10 cm2/m2 vs. MM 0.93±0.11 cm2/m2). Pre and post operative left ventricular ejection fraction (pre; EPM 0.64±0.1 vs. MM 0.69±0.1, post; EPM 0.62±0.1 vs. MM 0.61±0.1), aortic valve peak pressure gradient (pre; EPM 92.3±16.1 mmHg vs. MM 92.8±20.6 mmHg, post; EPM 25.4±6.3 mmHg vs. MM 32.5±8.9 mmHg), and left ventricular mass index (pre; EPM 241.9±51.6g/m2 vs. MM 224.6±74.8g/m2, post; EPM 169.3±26.1g/m2 vs. MM 153.2±32.9g/m2) had no significant difference between two groups. But EPM-group showed significantly higher post-operative EOAI (EPM 1.30±0.2 cm 2 /m 2 vs. MM 0.80±0.1cm2/m2; P=0.001). Conclusions: There was no hemodynamic difference between two bioprosthesis, although Post-operative EOAI showed superior results in EPM compared with MM.

New techniques for re-replacement of the artificial valves

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Hosaka S, Fujioka S, Ozawa N, Fukuda S, Takazawa A, Akita S, Toshitaka K, Sosuke K Department of Cardiovascular Surgery, International Medical Center of Japan, Tokyo Background: In the re-replacement of artificial valves, especially bio-prosthetic one, the extirpation of the valves is difficult because of adhesion of the sawing cuff to the annulus. Sometimes the destroyed and fragile annulus brings about postoperative para-vulvular leakage. Methods: On the removal of previous implanted valve, we start to incise just outside of the structure ring or the stent. Following the extraction, sizing of the annulus reveals appropriate to choose the same or one-size smaller artificial valve. With supra-annular technique, re-replacement can be safely finished. Results: We had ever experienced 2 cases since June 2008. One patient was 74yo male who had received TVR with size-29 CEP valve due to infective endocarditis. Congestive heart failure was progressed and severe tricuspid stenosis was discovered. Though the annulus was measured just same size of previous valve, one-size smaller CEP had been selected because the stents of CEP were adhered strictly to the RV wall. Re-TVR had been succeeded without A-V block. Another patient was 31yo male, who had had emergent aortic valve replacement due to active infective endocardits with a size-19 Regent valve. The para-valvular leakage became worse, so re-AVR was done with the same mechanical valve with this technique because of the almost lack of healthy annulur structure, which had had been debrided in initial operation. Conclusions: This method is safe and durable for the rereplacement case, such as the patients with fragile annulus at previous treatment, the patients of re-TVR with sinus rhythm, and the patients with bioprosthesis.

Mitral valve replacement with ALCAPA repair in an elderly female

Diagnosis in adulthood is usually only after a myocardial infarction. Case report: A 62 yr old lady was evaluated for DOE class 4 NYHA of two months duration. Her ECG showed LBBB; chest X-ray revealed cardiomegaly and Echocardiogram was suggestive of severe mitral regurgitation. On coronary angiography, a diagnosis of ALCAPA with mitral regurgitation was made and she was prepared for surgery. She was treated successfully with closure of LCA ostium from pulmonary artery and mitral valve replacement with bio prosthetic valve, without establishment of two coronary system. Echocardiogram done postoperatively on day 6 showed normally functioning mitral valve and good LV function. She was discharged on 7th postop day and was advised to continue anticoagulation for 3 months. At 2 year followup, patient was asymptomatic doing all household work and was on antiplatelet therapy alone. Echo showed good valve function and acceptable gradients. Conclusions: ALCAPA presenting in adult life is very rare. From our literature search, this patient appears to be the oldest to undergo surgical correction of ALCAPA and mitral valve replacement with a bio prosthetic valve.

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Pillai RS, Kuriakose KM, Mikka R, Thankappan A, Nidheesh CH Department of Cardiothoracic Surgery, Medical Colleges Calicut, Kerala Background: ALCAPA is the commonest congenital anomaly involving the coronary arteries. The combination of this anomaly with mitral regurgitation is extremely rare, especially in the adult population. Origin of left main coronary artery from pulmonary artery is known to occur 1 in 300,000 live births accounting for 0.25% to 0.5% of congenital heart disease cases. Majority of them die in infancy.

Study of benefit of using H.T.K. cardioplegia in valve cases

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Kodali VKK, Prasad MV, Kumar VD, Bharadwaja Rao BB, Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Secunderabad, Hyderabad Reason: To study the benefit of H.T.K Cardioplegic solution for myocardial protection and compare it with blood cardiaplegia and crystalloid cardioplegia on the outcome. Methods: We used H.T.K cardioplegia – single dose in the valve replacements especially mitral valve replacement and double valve replacement with moderate to severe LVdysfunctionalthough we used H.T.K solution in other cases also, we studied about 50 cases of MVR and DVR, with H.T.K, blood cardioplegia and crystalloid cardioplegia (St.Thomas) in 15 cases each. We recorded pre operative and post operative (after 1 week) LA, LVdimensions, EF in all cases and also rhythm while coming off from cardiopulmonary bypass, post operative heart rate, inotropic requirement and duration, duration of ventilator and ICU & hospital stay in all cases. Results: In our study sex and age range is as follows – MVR DVR • Male 20 12 • Female - 12 6 In MVR age ranges from 9-62 years and in DVR age ranges from 13-56 years. In the three groups the mean values are as follows: -

B.C.D H.T.K Crystalloid

No. of days of inotropes

Ventilator

I.C.U

Ward

Post op. E.F

2.1 1.7 3.75

16 16 20

2.5 2.3 4.5

5 7 6.5

48.2 53.3 45.75

Conclusions: • It appears that there is definite advantage of using H.T.K Cardioplegia especially in sick and low E.F cases. • CPB time is less in H.T.K cases and number of days of using inotropes is reduced therefore reducing I.C.U stay. • Blood cardioplegia is comparable but for in between doses of delivery, interruption of main surgical procedure is the disadvantage • Although H.T.K cardioplegia is costly initially,as the number

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of days of stay and inotropic requirement is less, thereby it will be equal economically. • Crystalloid cardioplegia is not inferior, if cross clamp time is less and in selected cases.

Tricuspid valve replacement with a homovital mitral homograft

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considering in the clinical setting when predicting pre-operative mortality, our analyses have demonstrated that it’s inclusion in a predictive model does not significantly improve the model based on existing parameters.

Case series of pseudoaneurysms of mitral aortic intervalvular fibrosa (MAIVF)

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Ramakrishnan KV, Agarwal R, Cherian KM Frontier Lifeline Dr KM Cherian Heart Foundation, R 30 C Ambatur Industrial Estate Road, Chennai

Suresh S, Furtado AD, Peer SM, Seetharam Bhat PS Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore

Background: We present the video of tricuspid valve replacement in a child with infective endocarditis with a fresh mitral homograft. Case report: A 3 year old boy presented with recent onset dyspnea on exertion. Echocardiography showed a small perimembranous ventricular septal defect (VSD) and healed infective endocarditis of the tricuspid valve. Most of the valve leaflets were destroyed and there was severe tricuspid regurgitation. Surgery was performed through a midline sternotomy. Cardiopulmonary bypass was instituted with aorto bicaval cannulation. Right atriotomy was done and the valve leaflets were found to be severely affected by infective endocarditis and had to be excised. The VSD was closed directly. A fresh antibiotic preserved homograft tricuspid valve obtained from a recipient heart was sutured in place. The homograft papillary muscles were also re-implanted, one sutured to the native septal papillary muscle and another sutured to the inferior surface of the right ventricle. Intraoperative testing showed a competent valve. Post operative echocardiography showed trivial tricuspid regurgitation. At 6 months follow up, the child is doing well with no homograft dysfunction. Conclusion: Tricuspid valve replacement with a mitral homograft is a technically challenging procedure. The absence of gradient across the valve, resistance to infection and avoidance of anticoagulation make it an atteactive alternative.

Background: The aorto-mitral curtain has been implicated in the development of pseudoaneurysms, with their associated complications like angina, fistulae to other cardiac chambers, rupture, and mitral valvular dysfunction. We present our experience in the management of pseudoaneurysms of MAIVF. Methods: Records of patients of MAIVF operated at Sri Jayadeva Institute of Cardiovascular Sciences and Research, between June 2006 to June 2009 were retrospectively analysed. Results: A total number of five cases were operated. One patient presented with angina, two were status post aortic valve replacement presenting with aortic regurgitation and one with aneurysm of the ascending aorta, one patient with infective endocarditis and one patient in shock. Preoperatively, transthoracic echo was done for all patients and coronary angiogram was done for one patient. All the patients were operated. One of the patients underwent redo-aortic valve replacement with patch repair of pseudoaneurysm, one patient underwent Bentall’s procedure and patch repair. All the other three patients underwent patch repair for the pseudoaneurysm. Postoperatively, one patient died and the other four had an uneventful postoperative period and are at follow up and asymptomatic. Conclusion: Pseudoaneurysms of MAIVF have been uncommonly described. Though in most of the case reports, it has been described as a complication of infective endocarditis, in our experience, only one patient was associated with infective endocarditis. The importance of preoperative diagnosis and the awareness of this condition is very essential in the management of these patients.

Aortic valve replacements in women: Is body surface area a determinant of in-hospital mortality?

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Sudarshan CD, Aravinda Page, Pashayan N Papworth Hospital NHS Trust, Papworth Everad, Cambridgeshire, CB23 3RE, United Kingdom Background: Aortic valve surgery is the second most commonly performed cardiac surgery in the western world and aortic valve replacement (AVR) is the recommended standard surgical procedure for symptomatic aortic valve disease. A retrospective analysis of patients undergoing AVR was done in order to investigate the effectiveness of including body surface area (BSA) as a prognostic risk indicator when predicting mortality for AVRs in women. Methods: Data was collected on all female patients receiving AVRs from April 1996 to August 2008. The risk factors considered were selected based on those used for the calculation of EuroSCORE. Univariate analysis was carried out to investigate any association between BSA and outcome. A multivariate logistic regression analyses was applied, using a forward stepwise technique, to identify independent risk factors for in-hospital mortality. Results: There was an overall in-hospital mortality of 5.97% (96 of 1608 patients). Body surface area was divided in to four groups, <1.6, 1.6 - <1.8, 1.8 - <2.0 and >2.0 m². Multivariate analyses showed that BSA has significant effect on in-hospital mortality adjusted for the other study variables (p=0.008). Conclusion: BSA has a significant impact on the predictive mortality of women undergoing AVRs. Small women, with BSA under 1.6m2 have an increased risk of mortality. Although BSA is worth

Perforation of the mitral valve due to brucella endocarditis as a late complication diagnosed perioperatively

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Gurbuz A1, Yetkin U1, Lafci B1, Postaci N2, Ozcem B1, Yurekli I1 1=Izmir Ataturk Training and Research Hospital, Department of Cardiovascular Surgery, Turkey. 2=Izmir Ataturk Training and Research Hospital, Department of Cardiology, Turkey Background: Brucellosis shows various clinical signs and can affect different organs. Infective endocarditis injures the valve and causes insufficienct flow. Methods: A 63-year-old man was admitted to our hospital with exertional dyspnea. His past medical history was significant for Brucella disease that he had experienced 10 years ago with completed antibiotherapy. Transthoracic echocardiography showed severe aortic valvular stenosis and mild aortic regurgitation with the valvular calcification. Other valves’ functions included minimal mitral regurgitation. Results: He underwent operation. After aortotomy, native aortic valve was explored revealing that it was bicuspid in nature with en bloc calcification. Native aortic valve was then resected. Intraoperative examination also revealed perforation (8x7mm) of the anterior mitral leaflet. Perforated zone was repaired with native pericardial patch. There wasn’t any destruction in aortic annulus. Aortic valve

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replacement was performed with 21 mm St Jude mechanical aortic valve using pledgeted Ticron® U- sutures. The patient had an uneventful course after surgery and postoperative echocardiography showed no mitral regurgitation. Conclusions: Situations like leaflet perforation (ranging from small perforations to flail leaflets), rupture of paravalvular abscess, cardiac fistula and leaflet prolapse due to rupture of commissure are responsible for acute valve insufficieny. surgical approach increases the quality of life for a long period in the late valvular complication of Brucella endocarditis.

Early results of innovative approach for mitral valve repair

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Kang S, Shin JK, Chee HK, Kim JS, Song MG Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Seoul, Korea Background: A new mitral valvuloplasty technique consisting of lifting mitral annuloplasty (LMA) and posterior and/or anterior leaflet extension (PLE/ALE) to improve mitral coaptation using the Mitralift® annuloplasty strip was performed by our group for 6 years. The aim of this study was to assess the efficacy of this new mitral valvuloplasty technique. Methods: The medical record of 251 patients (156 females and 95 males) who underwent a new mitral valvuloplasty procedure from Oct 2007 to May 2009 was retrospectively reviewed. The mean age was 44±24 years. LMA is a new mitral annuloplasty technique consisting of lifting the downward displaced LV wall by the placement of a specially designed fabric annuloplasty strip (Mitralift®) on the left atrial wall along the posterior mitral annulus. PLE/ALE was applied to patients with contracted mitral leaflets utilizing appropriately tailored bovine pericardial segments designed against a pre-constructed template (SC template®), the size of which were based on that of the new annuloplasty strip. Patients were divided into two groups; MR group (n=162) and MS group (n=89). Results: There were two early deaths (0.8%) and three follow up deaths (1.2%). There were four re-operations for recurred infective endocarditis in 2 patients and recurred MR in 2 patients in the MR group. The mean MR grade was decreased from 2.9±1 to 0.6±1.1 (p<0.05) in the MR group. Mean effective mitral orifice area was increased from 1.3±0.4 cm2 to 1.9±0.6 cm2 (p<0.05) in MS group. Conclusions: The early outcome of this new mitral valvuloplasty strategy shows favorable early results for various mitral valve pathologies.

The surgical treatment of combined ischemic heart disease with mitral valve pathology

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Sadykov A, Mansurov AA, Ahmedov UB, Khalikulov HG, Sadykov RR Rebublican Centre of Surgery, Farhod 10, Tashkent, Uzbekistan

Background: Estimation of volume operative interventions of mitral valve pathology in different etiology. Methods: There were analyzed patients operated in 2005-2009 with mitral insuffiency. Patients with rheumatic etiology divided to 1st group and with ischemic etiology 2nd group. Each group composed of 25 patients. EchoCG data for 1st group: mitral stenosis 3-4 degree, left atrium thrombosis EDV 168±1, 5 ml, ESV- 74.2±2 ml, EF- 54,5%. Coronarography: LAD 90% stenosis, RCA 90% stenosis, LCxA – 80%. To this group were done mitral valve replacement operation with coronary artery bypass. After operation EchoCG: ESV 60±1, 0ml, EDV130±3,2 ml, EF 55±3,1%. ECHO data for 2nd group: mitral valve insuffiency 1-2 degree, EDV 200±2,6 ml, ESV- 92, 3±2ml, EF- 40%.

Coronarography: LAD 90% stenosis, RCA 90% stenosis, LCxA – 80%. In this group were done only coronary artery bypass grafting (CABG) operation without mitral valve replacement. After operation EchoCG: mitral valve insuffiency 0-1 degree ESV 80±1,0ml, EDV180±3,2 ml, EF 45±3,1%. Results: 1 st group – combination of operation mitral valve replacement with CABG - clinical improvement at 24 patients (96%), mortality in 1 patient (4%) due to heart failure. 2nd group – CABG without mitral valve replacement – clinical improvement at 25 patients -100%, maintained mitral insuffiency – 1st degree at 5 patients (20%). Conclusions: Analyzing these data we made conclusion, that operative intervention in rheumatic mitral pathology is mitral valve replacement with CABG and at ischemic etiology (mitral valve insuffiency 1-2 degree) - only CABG.

Impact of patient prosthesis mismatch on early and intermediate outcomes after aortic valve replacement

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Gopi N, Kondullu M, Ratti D, Rao A, Mishra RC Nizams Institute of Medical Sciences, Panjagutta, Hyderabad Background: To evaluate the incidence of PPM groups and its impact on adverse patient outcome. Methods: Between August 2006 and June 2008, 114 consecutive AVR performed by single surgeon, of which 55 patients who underwent isolated AVR have taken in this study and others were excluded. Prostheses included 47 mechanical valves (85.45%) and 8 bioprosthetic valves (14.65). Post-discharge survival data was obtained from regular followup which was 86% complete. Group 1 with iEOA less than 0.85cm/m2 total patients 14 (27.3%). Group 2 with iEOA more than 0.85 cm/m2 total patients 40 (72.7%). Statistical analysis: Gender, Age; year of operation; hypertension; diabetes; pulmonary disease; smoking ; aetiology pathology, CCF; EF; status (urgent, elective); endocarditis; NYHA class; valve typ; BSA, PPM (EOA / BSA < 0.6 cm2/m2). Results: Overall PPM was present in15 patients out of 55 patients 27%. PPM had a higher incidence in older age (P0.025) female sex, (P0.008), small size valves. Aortic stenosis (P0.001) compared to Aortic regurgitation or mixed pathology. Higher BSA (P0.001). Conclusions: Incidence of PPM found to have 27%. Certain preoperative predictors like older age, female sex and aortic stenosis have a stronger significance in PPM group. Patients in PPM group have found to have significant postoperative transvalvular gradients which may jeopardize left ventricular mass regression. In this study effect of PPM on survival is not significant as the followup time in this study is shorter (mean 18.2 months).

Marfan’s syndrome with aortic root aneurysm and severe pectus excavatum : single stage repair in two patients

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Dinkar S, Kaw A, Maherwal ZS, Iyer KS Escorts Heart Institute and Research Centre, Okhla Road, New Delhi Background: Patients with Marfan’s Syndrame have cardiac and bony deformities. The occurance of aortic aneurysm and severe pes excavatum is a surgical challenge. Case report: Two boys with Marfan’s syndrome were diagnosed to have severely dilated aortic roots and significant aortic regurgitation and pectus excavatum. Bentall procedure through a standard median sternotomy incision with SJM composite valved conduit was done in both cases. Simultaneous repair of the pectus excavatum was undertaken. Bilaterally affected costo-chondral cartilages were excised to free the depressed sternum. Modified Nuss procedure was done using DCP steel bar which was bent along the curvature of the anterior

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chest wall and placed behind the ribs. It was fixed to the sternum anteriorly at the point of maximum depression and to the ribs bilaterally with steel wires. Sternum was approximated with steel wires. Both patients had uneventful recovery. One child was operated a few weeks ago and the other continues to do well six years after surgery with satisfactory cosmetic results.

Transcatheter aortic valve implantation for high risk aortic valve stenosis. A viable alternative to conventional surgery?

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Sudarshan CD, Calvert P, Tsui S, Dunning J, Densem C Papworth Hospital NHS Foundation Trust, Papworth Everard, CB23 3RE, Cambridgeshire, United Kingdom Background: Determine outcome of high-risk patients with severe aortic stenosis referred to transcatheter aortic valve implantation (TAVI) multi-disciplinary team (MDT). Methods: All patients (n=111) referred were prospectively enrolled and followed up. Results are median (interquartile range) unless stated. Results: Patients (n=26) awaiting treatment/MDT decision were excluded. 19 were treated by TAVI (7 transfemoral, 12 transapical), 27 by conventional surgery (csAVR), 9 with balloon valvuloplasty (BAV) and 30 medically. Baseline characteristics were similar (except an excess of prior CABG surgery in TAVI group vs. csAVR (15/19 vs. 3/27; p <0.001)) even in logistic EuroSCORE (ES): TAVI: 18.5% (8.4– 25.3%); csAVR: 12.1% (7.5–27.1%); BAV: 30.0% (12.8–39.0%); medical: 20.4% (10.6–40.0%): p=0.35. Thirty day mortalities were: TAVI: 0/17; csAVR: 1/25; BAV: 1/9; medical: 8/30. Adjusting for ES, observed/ expected 30-day mortality indices were: TAVI: 0; csAVR: 0.33; BAV: 0.37; medical: 1.31. Valve replacement patients (TAVI & csAVR) had lower 30-day mortality than those treated palliatively(BAV & medical): 2.38% vs. 25.6%, p = 0.003. This survival benefit persisted (400 days, log rank p<0.001). TAVI patients had shorter tracheal intubation : 2.1 (1.9–5.8) hours vs. 11.9 (8.6–20.1) hours, p<0.001, shorter ICU stays : 0.97 (0.72–1.16) days vs. 1.23 (0.95–3.55) days, p=0.046; and shorter hospital stays than csAVR patients: 7.0 (5.0–8.3) days vs. 9.0 (6.3–17.3) days, p=0.016. Conclusion: MDT assessment of high-risk patients with severe aortic stenosis combined with multi-modality treatment options results in lower than predicted mortality. Patients selected for TAVI have shorter ICU and hospital stays than patients selected for csAVR despite equivalent co-morbidities.

Trans catheter aortic valve implantation in patients with previous coronary artery surgery: A less bloody, more attractive and much dearer choice

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Sudarshan CD, Jakub K Papworth Hospital NHS Trust, Papworth Everard, CB23 3RE, Cambridgeeshire, United Kingdom Background: Redo sternotomy with patent coronary grafts poses a challenge with morbidity that is not insignificant. We started transcatheter aortic valve implantation (TAVI) 18 months ago, and TAVI has been an attractive option for such patients since. We compared the early outcome of those who had TAVI (either Transfemoral (TF) or Transapical (TA)) after previous coronary revascularisation to those who underwent redo sternotomy and aortic valve replacement (csAVR) during the same period. Methods: Thirteen patients were identified in each group. All patients had had previous surgical revascularisation and subsequently presented with aortic valve pathology.

Results: TAVIs and csAVRs performed in the last 18 months as six month-periods were, 2,4,7 and 7,4,2 respectively showing an incline in TAVI with declining csAVR procedures. Basic demographics were similar. Nine had TA-TAVI. All csAVR patients had bioprosthetic implants. Risk scores (Logistic, standard Euroscores) were similar (p=0.13, p=0.23 respectively). There were 1 (on day 54) and 2 (on days 1 and 11) in–hospital deaths in TAVI (7.7%) and csAVR (15.38%). Post operative blood loss and transfusion of blood products was significantly higher after csAVR (p=0.02 and p=0.03 respectively). No differences were seen in length of either ICU or hospital stay (p=0.06 and p=0.43 respectively). Cost of TAVI was significantly more than csAVR (p<0.00003). Conclusion: TAVI and csAVR are both safe in patients with previous coronary surgery with acceptable outcomes. The csAVR patients suffer more blood loss and require more transfusions. Even though the cost is substantially higher for TAVI, the current trend is towards its favour in these patients.

Role of modified ultrafiltration on pulmonary areterial hypertension in adult patients with end stage valvular heart diseases

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Muppiri VK, Ali SN, Kumar RV Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad Background: Modified ultra filtration (MUF) in pediatric cardiac surgery is proved to be very effectve. However there is little evidence of its beneficial effects in adult patients. Our aim of this study is to explore the effect of MUF on pulmonary arterial hypertension (PAH) in patients with end stage valvular heart disease. Methods: In a prospective randomized study 40 patients scheduled to undergo valvular surgery by same surgeon were randomized into a control group (n=20) without MUF and a study group (n=20) with MUF after weaning patient from bypass using in situ arterial cannula to drain blood and a separate ¼”tubing to return blood. Pre operative, intra operative and immediate post operative various clinical variables were studied . Results: There were no MUF related complications. Average duration of filtration was 18±3 minutes Amount of fluid filtered was 1250±125 ml. The patients in the study group had significant improvement in cardiac index 2.3±0.5 to 3±0.4 (p <0.001). Mean pulmonary arterial pressures decreased from 25±1.8 to 16±1 mmHg (p<0.001). Pulmonary and systemic vascular resistance decreased significantly (p 0.001). Study patients required less ventilatory support 15±2 hours and duration of inotropic requirement 68±2 hours but not statistically significant .Bleeding and transfusion requirement was less in study group. Conclusion: MUF is very safe and effective in decreasing mean PA pressures and increasing cardiac output in adults with valvular heart disease and severe PAH. Its routine use in these sub set of patients will produce favorable clinical results.

Comparative analysis of mitral valve repair and mitral valve replacement for ischaemic mitral regurgitation in patients undergoing coronary artery bypass grafting

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Ramanathan S, Sundar A, Chandrasekar P, Muralidharan S GKNM Hospital, Nethaji Road, P.N. Palayam, Tamilnadu, Coimbatore Background: To compare mitral valve repair (MVRep) with mitral valve replacement (MVR) in ischaemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG).

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Methods: Study Period January 2004- August 2009 Inclusion Criteria–All patients who underwent MVRep or MVR for IMR (n= 54). Exclusion – Non ischaemic MR. Results: 27 had MVRep (GroupI). 14 received incomplete ring. 13 received complete ring 27 had MVR (Group II). 19 received Bioprostheses. 8 received Mechanical valves. Majority 51/54 needed Cardio pulmonary bypass (CPB). Age, Male:Female ratio, Preoperative LVfunction, Severity of MR, NYHA class, CPB time and Aortic cross clamp time were comparable between both the groups.

Ventilation duration ICU stay Hospital stay 30day mortality Followup data available Late mortality MACE NYHA class

MVRep (GroupI)

MVR (GroupII)

4-34 Hrs (20.4±10.65) 2-6 days (2.81±1.32) 7-15 days (10.22±3.54) 3/27 (11%) 15/24 (60%) 2/27 (7.4%) 6/22 (27.2%) I-12, II-2, III-1, IV-0

4-42 Hrs (18.78±13.3) 2-6 days (2.86±1.3) 7-18 days (9.31±4.92) 3/27 (11%) 21/24 (84%) 2/27 (7.4%) 6/22 (27.2%) I-15, II-4, III-2, IV-0

Mitral Regurgitation

Ni-l6, Mild-14, Nil-16, Mild- 5, Mod-2 Severe-1 MACE- Major Adverse Cardiac Events (Rehospitalization for cardiac cause, Reintervention, Myocardial infarction. Conclusions: Both MVRep and MVR carry higher risk compared to isolated CABG. Both groups continue to need rehospitalization for MACE. There is no evidence to support either method as superior to the other.

Mitral anulus calcification: To debride or not to debride?

Valve surgery for infective endocarditis Bathala MR, Ramanujam V, Padmanabhan C, Ramanathan S, Srinivasan S G Kuppuswamy Naidu Memorial Hospital, Tamil Nadu

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Background: To evaluate the results of surgical management for infective endocarditis at our hospital over the last five years. Methods: Between January 2001 and December 2008, 59 patients underwent surgical management for infective endocarditis. Results: There were a total of 59 patients. Mean age was 41.20 years (09-69 years). There were 48 males and 11 females (female: male ratio was 1:4.36). Fifty seven patients had valvular affliction (27 patients had mitral valve endocarditis, 12 had aortic valve endocarditis and 18 had double valve endocarditis) and 2 had VSD and pulmonary valve endocarditis. Three patients with mitral valve disease underwent mitral valve repair. Fifty three had native valve endocarditis and 5 had prosthetic valve endocarditis. Only 29 patients had culture positive endocarditis and received appropriate antibiotics before surgery. Mean duration of preoperative antibiotics was 4.39 weeks (range of 2-6 weeks). A total of 38 mechanical and 16 bioprosthetic valves were placed. We had 7 deaths, (12.06% mortality). Mean post operative ICU stay and duration of inotropic support were 3.16 (1-16) and 2.74 (1-16) days respectively. The most common post operative complications were neurological & renal dysfunction noted in 4 & 2 patients respectively. Mean duration of follow up was 31.92 months. Conclusion: Infective endocarditis is a life threatening cardiac valvular affliction with high mortality rates and serious morbid complications. Surgical results depend, on the adequacy of surgical debridement and clearence of the infective pathology. High mortality rate noted in our study was due to small sample size.

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Hussain ST, Nicholas, Smedira, Eugene, Blackstone Cleveland Clinic, 9500 Euclid Avenue, J4-133, Cleveland, 44195, Ohio, United States of America Background: Lack of consensus and evidence for dealing with mitral anular calcification (MAC) at mitral valve replacement (MVR) led us to compare early and late outcomes of MVR with and without MAC debridement. Methods: From 1980 to 2007, 253 patients with MAC underwent primary isolated MVR for degenerative disease; 99 (39%) had debridement (age 73±8.3 years), and 154 (61%) did not (age 75±7.9 years). Anular reconstruction was necessary in 23 undergoing debridement. MAC debridement was highly surgeon dependent, but additionally, such patients had greater leaflet calcification but less fibrosis, had MVR more recently (only 10% before 1990), were more likely to be female, and were younger. Therefore, propensity adjustment and matching (65 pairs) was employed for risk-adjusted outcome comparisons. Follow-up averaged 5.0±4.3 years, with 10% of patients followed more than 11 years. Results: Occurrence of in-hospital complications with or without debridement was similar, both unadjusted and in propensity-matched pairs. Unadjusted results included reoperation for bleeding, tamponade, or receipt of blood products (11% vs. 5.8%, P=.13), stroke (3.0% vs. 1.9%, P=.6), heart block (6.1% vs. 8.4%, P=.4), and death (5.1% vs. 6.5%, P=.6). Unadjusted time-related survival (Figure) was similar early (P=.9), but was worse late with no debridement (P=.03). After risk adjustment, survival was similar (Figure). Mitral valve reoperations were uncommon in both groups. Conclusions: MAC may present formidable challenges during MVR. Approaches to deal with it vary from doing nothing to performing extensive decalcification with anular reconstruction. The individualized strategies used in this study did not impact early or late outcomes.

Long term outcome of octogenarians undergoing double valve surgery (DVR) and more – a single centre experience

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Sudarshan CD, Balasubramaniam SK, Messer S, Venkateswaran R Papworth Hospital NHS Trust, Papworth Everard, CB23 3RE, Cambridgeshire, United Kingdom Background: Increasing human life span leads to increased incidence of degenerative heart valve and coronary disease. Forty percent of octogenarians have symptomatic cardiac disease. Hence cardiac surgery in octogenarians has seen a dramatic increase. We assessed the in-hospital mortality and long term outcome of octogenarians undergoing double valve surgery. Methods: Retrospective analysis of prospectively collected data for patients who underwent double valve surgery over 12 years was performed. Risk factors for in-hospital mortality were identified. Discharged patients were assessed in follow-up clinic. A telephonic survey was conducted to enquire long-term functional status. Results: Sixty nine consecutive patients were operated on between January 1997 and July 2009. Median age was 82 years. Mitral & aortic valve surgery, mitral & tricuspid valve surgery, triple valve surgery and aortic valve & tricuspid valve surgery were performed in 58%, 28%, 10% and 4% respectively. Coronary artery disease, pulmonary hypertension, renal dysfunction and atrial fibrillation were present in 32%, 26%, 39% and 67% of patients. A fifth had an urgent operation. DVR and additional procedures were performed in 42%. In-hospital mortality was 16%. One and five year survival rates were 75% and 50% respectively. Univariate and multivariate analyses predicted urgent surgical procedures as a significant risk factor for in-hospital mortality [(p=0.038) OR: 0.22 (95% CI:0.055-0.88)]. Telephonic survey revealed 70% of long term survivors showed improved NYHA status at least by one grade.

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Conclusions: Double valve surgery can be safely performed in octogenarians with acceptable in-hospital mortality and long-term survival. Majority of long-term survivors have a better functional status.

of adjuvant antibiotic therapy, he was discharged in good condition 35 days after the surgery.

Normothermic CPB in congenital heart disease: An experience of 653 cases New surgical technique for Barlow’s disease Sawazaki M, Tomari S, Kobayashi Y Komaki City Hospital, 1-20 Jhobushi, Komaki, Aichi, Japan

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Background: The typical lesion of the Barlow’s disease is severe degeneration of the leaflet and chords. The leaflet is billowing and redundant. So the basic strategy of mitral valve plasty for this disease is the volume reduction of the leaflet. Some techniques for this disease has been reported. But they are complicated. We made a new operative method using our original technique. We will show the details by video presentation. Methods: The large anterior leaflet is resected triangularly and sutured. Redundant posterior leaflets (P2 and P3) are resected as a shape of a sandclock, which is composed with upper inverted triangle and lower triangle. Then the upper triangle is closed by suturing both leaflet edges. And the lower triangle is closed by suturing the leaflet edges to the annulus so that the height of the leaflet is to be lower. Results: The operation was completed with simple resection and suture method. Post operative echocardiogram revealed no mitral regurgitation and no systolic anterior motion. And it shows that shapes and motions of the anterior and the posterior leaflets are normalized. Triangular resection for the anterior leaflet is common. But sliding leaflet technique to treat the redundant posterior leaflet is somewhat complicated and difficult to treat the plural posterior leaflet lesions. Conclusion:s Our new method of resecting each leaflet and making ideal shape is applicable to any type of Barlow’s disease.

Successfully treated quadruple valve endocarditis with ventricular septal defect- a case report

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Itoda Y, Saito A, Motomura N, Hisagi H, Nawata K, Ono M Department of Cardiothoracic Surgery, the University of Tokyo Faculty of Medicine, 7-3-1 Hongo, Bunyo-ku 113-8655, Tokyo, Japan A 69-year-old gentleman with preceding diagnosis of ventricular septal defect (VSD) was transferred from the other facility for surgical treatment on infective endocarditis (IE). Preoperative echocardiogram for his inguinal hernia at the previous hospital revealed infective endocarditis on aortic and mitral valves. He was transferred to our department and further examination detected vegetations on aortic, mitral, and pulmonary valves with mild aortic regurgitation (AR) and mitral regurgitation (MR). He was already on multiple antibiotic regimen at the time of admission, however, his infection status remained active with ongoing progression of AR due to growing vegetation on the valves. Streptococccus sanguis was isolated from the blood culture. Preoperative CT scan presented multiple emboli to the lung, spleen, and bilateral kidneys. Because of ongoing progression of infectious lesion on the aortic valve with resulting in serious heart failure status, urgent surgery was indicated. Intraoperative findings were massive vegetation on all the heart valves with severe leaflet destruction, and small perimembranous VSD without obvious infectious change. Aortic and mitral valve replacement with bioprosthetic valves, tricuspid and pulmonary valve plasty with autologous pericardium patch, and direct VSD closure were carried out. Histopathological examination on the excised leaflets showed neutrophil infiltration and accumulation of degenerated bacteria. Postoperative echocardiogram revealed good cardiac function, normal function of repaired valves and prosthetic valves. Following-4 weeks

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Padhy K, Narasimham SBR, Mohan T, Maharaj S, Satyanarayana PV Department of Cardiothoracic and Vascular, Care Hospital, Visakhapatnam Background: Lichenstein first established normothormic cardio pulmonary bypass as safe and effective method. We have been using normothromic CPB in all case including infants and neonates. The safety and efficacy in 653 congenital heart disease cases retrospectively analyzed. Materials and Methods: From March 2001 to September 2009, 653 cases of congenital heart disease operated under normothermic systemic and myocardial perfusion. The age range being from 27 days to 66 years with mean age of 16±12.5 years Weight ranges from 3.5 to 75 Kg. Ninty-five (14.5%) cases were being operated below 10 kg. The body surface area was 0.16 to 2.01 with mean of 1.04±0.41. The procedures performed includes ASD, VSD repair. Intra cardiac repair for TOF, DCRV, TAPVC, AV cannal defect, RSOV repair, Mitral repair etc. Results:The total CPB time was 19 minutes to 322 minutes with mean of 56±33.07 minutes. Arrhythmia during weaning was seen in 27 cases. 231 cases required inotropic support. No patient had complete heart block. None of the patient developed edema of heart and all cases chest was closed primarily. The average post operative ventilator duration was 8±2.3 hours, total average bleeding was 130±24 ml. Re-exploration was done in 3 cases. Post operative neurological complication occurred in one case, Hyperpyrexia in 6 cases and mortality was in 32 (4.9%) cases. Conclusion: Normothermic systemic and myocardial perfusion in congenital heart disease is safe and physiological. This can be safely performed even in infants with reduced morbidity and mortality.

Minisubmammary approach for atrial septal defect closure on fibrillating perfused heart Kapadia N, Venkatesh B, Kumar S, Russo P, Chitraleka V SRM Hospital & Research Centre, Potheri, Chennai

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Background: Impaired breast development after anterolateral or posterolateral thoracotomy impaires breast development and contour as transection of large muscles required. Mini Submammary approach through 4th Intercostal Space in Axilla give excellent exposure and no breast deformity. Methods: Between January 2000 and March 2009, 45 female patients age ranging 18 to 44, (mean 23) underwent ASD closure on fibrillating, perfused heart, through nine cms longe right submammary incision. Aorto-Bicaval cannulation was done in all avoiding Femoral cannulation. Surgical exposure was good. Atrial Septal defect, was Secundum type in 37, five had Sinus Venosus type, and 2 had Septum Primum type of defect, one was common atrium. Defect was closed using Autologous Pericardial Patch in 36 (80%) while Direct suture closure was done in nine (20%). Two patients required Mitral Valve repair. Five had Anomalous pulmonary venous return rechanelled.Only one multiperforated drain was left draining both right pleural and pericardial cavity. Intercostal nerve block was routine at the time of wound closure. Results: No early or late deaths. All the patients were extubated on table or in first four hours. Average blood loss was 185 ML. Mean ICU stay was 25.5 hours. Hospital stay varied from 4 to 7 days. Follow-

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up ranged 12 to 108 months (mean 54). All patients were happy to have small bikeny hidden scar and were satisfied 9 out of 10 scale. No patient developed any wound complications. Followup shown no residual defect or mitral valve leak. Conclusion: Mini Right Submammary trans axillary approach in females gives excellent exposure to close ASD, with satisfactory cosmetic results.

mild in hospital mortality and AVVR > mild in late death by multivariate analysis (p<0. 05). Conclusions: Our study indicated that PVO release should be waiting as much as until more than 4 kg, except for emergency. Non confluent PA and AVVR > mild were relative with poor prognosis.

Surgical outcome in ventricular septal defect with aortic regurgitation Fast tracking pediatric cardiac surgery in a moderate sized program Kapadia N, Russo P, Kumar S, Venkatesh B, Kumar R SRM Hospital & Research Centre, Potheri, Chennai

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Background: With improvements in intraoperative surgical techniques for congenital heart disease and advances in postoperative expertise, there has been a move to “fast track” approach with extubation in opertating room. These changes in approach has resulted decline in perioperative morbidity and mortality, Less ICCU Stay, and cost reduction to Hospital and patient. Method: Between February 2008 and November 2009, 121 children underwent open or closed heart surgery, age ranged from 10 months to 18 years, All procedures were performed by one cardiac surgeon and anesthetic care was provided by one pediatric anesthesiologist. Post-operative care was provided directly by attending-level pediatric ICU physicians or the pediatric CT surgeon. Results: Ninety seven of 112 patients, (67 had open and 30 had closed heart surgery) were extubated in operating room (86 %), 5 were extubated within 4 hours of completion of surgical procedure. One patient was reintubated. Of 10 patients left intubated, two were extubated in next 18 hours, prolonged ventilation >24 hours required in 5 patients. There were 4 deaths (3.5%). Mean surgical time 97, Cardiopulmonary Bypass Time 47 minutes, cross clamp time 26 minutes, duration of ICU stay 1.88 days, duration of hospital stay 5.6 days were reasonable for fast tracking. Conclusions: With experienced Cardiacthoracic Surgeon, Pediatric Anesthesiologist, Paediatric Cardiologist along with well trained perfusionist, nursing personnel, a fast track pediatric cardiac Surgical program is feasible in a moderate-sized Department. offering surgical care to all types of patients with Congenital Heart Diseases including neonates.

Surgical Results of Asplenia with TAPVR and Pulmonary Venous Obstruction

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Nakayama Y, Hiramatsu T, Iwata Y, Okamura T, Konuma T, Hobo K, Komagamine M, Kaku Y, Yamazaki K Department of cardiovascular surgery, Tokyo Women‘s Medical University, 162-8666 Kamadacho 8-1, Shinjuku, Tokyo, Japan Background: The surgical results of Asplenia with TAPVR and Pulmonary Venous Obstruction (PVO) were still poor, currently. The purpose of this study was to assess the risk factor about the surgical results. Methods: 31 patients with Asplenia were underwent PVO release at single institute from 1993 to 2009. Patients data at the operation were following: mean age: 29. 4±48. 6 months, body weight 9. 9±11. 6 kg, gender: Male (16), atrioventricular valvular regurgitation more than mild (AVVR>mild) (7), non confluent pulmonary artery (PA) (5). The risk factors were analyzed patients profiles, perioperative data, and surgical outcomes, retrospectively. Results: TCPC were done in 13 cases. Morbidity was found in 9 cases. Recurrent PVO was occurred with 7 cases. Hospital death and late death were in 13 and 7 cases, respectively (Mean follow up: 44 months). Significant differences were found for non confluent PA, less than 4 kg as operative weight, concomitant SP shunt, AVVR >

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Hiremath CS, Gajjar T, Shah G, Rao N, Neogee S, Hatibaruah N, Desai N, Choudary V Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Prashanthigram, Andhra Pradesh Background: Aortic valve prolapse is found in over 5% of children with ventricular septal defect (VSD) causing aortic regurgitation. The aim of our study is to evaluate the surgical outcome of 49 patients of ventricular septal defect (VSD) with aortic regurgitation (AR). Methods: A retrospective analysis from January 2007 to October 2009 of 49 consecutive patients of VSD with AR was done. Age ranged from 4 to 58 years, male: female ratio was 1.4:1. All patients underwent pre-operative two dimensional echocardiography (2D Echo) to determine type of VSD, morphology of aortic valve and severity of AR. Type of surgery was chosen on the basis of severity of AR, anatomy of the aortic valve and leaflets coaptation. Post op 2D Echo was done on all patients to know AR status, residual VSD and ventricular function. Follow up was done at 3 months, 1 and 2 years. Results: Out of 49 patients, 12 underwent only VSD closure, 31 underwent VSD closure with Trusler’s repair, and 6 underwent VSD closure with aortic valve replacement (AVR). Post operative 2D Echo showed no AR in 4, mild in 34, moderate in 4 and severe in 1, six patients who underwent AVR had normally functioning prosthetic valve. Six patients came for follow up at 2 years showed trivial to mild AR, 17 out of 19 patient at 1 year follow up showed trivial to mild AR, 2 patients underwent aortic valve replacement after Trusler’s repair within one year. 24 patients underwent surgery with in last 8 months awaiting their 1 year follow up. Two patients had tiny residual VSD and all patients had good biventricular function. Conclusions: Trusler’s aortic valve repair is an effective and durable technique for the surgical treatment of younger patients with VSD-AR syndrome who have preserved valve morphology. The adequacy of the initial repair is the most important determinant of the long-term results.

Impact of chromosomal abnormality on immune function around cardiac operation

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Hirotsugu K*1*2, Takashi T*3, Mikio S*1, Masahisa U*4, Takashi K*1, Yosuke T*2, Yoshiyasu E*4, Tetsuya K*1 Institutions: *1: Dept. of Cardiovascular Surgery, IHBS, The Univ. of Tokushima Graduate School, Tokushima, Japan *2: Division of Experimental Immunology, Institute for Genome Research, The Univ. of Tokushima, Tokushima, Japan *3: Division of Cardiovascular Surgery, Ehime PrefecturalCentral Hospital, Ehime, Japan *4: Division of Cardiovascular Surgery, Kagawa Children’s Hospital, Kagawa, Japan Background: It is well known that patients with 21-trisomy (Down) syndrome or 22q11. 2 deletion (CATCH) syndrome are highly associated with congenital heart defects (CHD). However, the detail of immune function of those patients with chromosomal abnormality

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remains to be elucidated. To survey the immune function in patients with chromosomal abnormality from quantitative aspects. Methods: Seven infants with CHD and chromosomal abnormality were enrolled. Three patients exhibited CATCH syndrome (Group C), 3 patients Down syndrome (group D), and 1 patient paternal uniparental disomy for chromosome 14 (UPD 14). 31 infants with CHD and without chromosomal abnormality were also enrolled as control group (Group N). Results: Among group D, the number of WBC and all B cells decreased significantly, compared to those in group N. Among group C, the number of lymphocyte, and whole T-cells, helper T-cells, and killer T-cells decreased significantly. Patient with UPD 14 showed that the number of WBC and lymphocyte, and whole T-cells, helper T-cells, killer T-cells and whole B-cells decreased. Particularly there were no early and late deaths and none with severe infective complications after repair. Conclusions: The numbers of immune cell, which play an important role in immune-system, are clearly decreased in infants with chromosomal abnormality. For elucidating the impact of chromosomal abnormality on immune function, it is necessary to perform the qualitative evaluation, whether the decrease of immunecells in infant easily leads the infective disease or not.

Single patch repair with atriocavoplasty for Sinus Venosus defects with anomalous pulmonary connections: Our experience

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Kishan M, Padhy K, Babu Kiran T, Mohan T, Maharaj S, Narasimham SBR, Satyanarayana PV Department of Cardiothoracic and Vascular, Care Hospital, Visakhapatnam Background: To assess retrospectively the early and mid term sequelae of single patch repair with atriocavoplasty in Sinus venosus ASD and PAPVC patients. Methods: Between July 2004 and June 2009 we operated 26 patients of Sinus Venosus ASD with PAPVC using single patch repair with atriocavoplasty. M:F ratio was 17:9. Mean age was 15. 6 years with 12 patients below 10 years. PAPVC was present in all patients. All patients were operated under normothermia using aortic and Bicaval cannulation. The RA was opened superiorly from the appendage to SVC – RA junction. The patch (1st 10 cases- synthetic patch; others glutarldehyde treated pericardial patch) was sewn with two interrupted and remaining continuous sutures diverting the superior pulmonary vein blood into the LA via the ASD. The RA incision was closed transversely incorporating the RA appendage into the incision thus enlarging the SVC - RA junction. Results: Immediate post-operative ECGs showed nodal rhythm in 6 patients. There were no in-hospital deaths. 23 patients could be followed-up. None of the patients had any symptoms suggestive of any rhythm abnormality or pulmonary venous or SVC obstruction. They were subjected to ECG and Echocardiography. 4 patients had nodal rhythm and 2 had prolonged PR interval. 2 patients had mild SVC obstruction and none had pulmonary vein obstruction. Conclusions: This technique of repair using atrial appendage incorporation in the closure of SVC incision for patients of Sinus venosus ASD and PAPVC has acceptable short and mid term results. It is safe and easily reproducible.

Venovenous malformation: A common finding after kawashima operation

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Mahmoud ABS*, Zahrani S**, Bahaidarah SA**, Kouatli AA**, Baslaim GA* Department of Divisions of Cardiothoracic Surgery* and Pediatric Cardiology**, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia Background: It has been reported that systemic venovenous malformation (VVM) can develop in patients with interrupted inferior vena cava (IVC) and univentricular type of congenital heart disease who undergo superior vena cava to pulmonary artery connection (Kawashima operation). These malformations can lead to profound systemic desaturation postoperatively. However, there have been few reports that characterize the prevalence, anatomic details and clinical correlations of these systemic VVM arising after Kawashima operation. In this study, we describe our experience with VVM after Kawashima operation and discuss issues regarding their preoperative evaluation and postoperative management. Methods: Eight patients (median age 19 months) who underwent Kawashima operation were subjected to postoperative angiography, prospectively. Sites of VVM origin and entry as well as their course were documented. The presence of arteriovenous malformations (AVM) was also documented. Results: During follow-up (16-72 months), a total of 14 VVM were found in different supra and infradiaphragmatic sites in 6 patients (75%); two of them had concomitant AVM. The remaining two patients had only AVM. Conclusions: Our findings suggest that Systemic VVM can occur frequently after Kawashima operation and can produce significant desaturation postoperatively. Performing detailed angiographic studies of the supra and infradiaphragmatic systemic veins in routine assessment of patients with interrupted IVC before Kawashima operation is probably warranted.

Overcome of one-stage repair of interrupted aortic arch in Neonate and infants: A 20- years experience in single cardiac center

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Qin Y, Zhi-wei X, Jin-fen L, De-ming Z, Zhen-ying S, Zhao-kang SU, Wen-xiang D Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, Medical College, Shanghai Jiao-Tong University, Shanghai 200127, P. R. China Background Surgical one-stage repair of interrupted aortic arch with other defects of Cardiac remains challenging and is associated with significant early mortality and high intervention. The aim is to review Early and med–term results of one-stage repair of interrupted aortic arch in neonate and infants, and analyze the early and midterm of results of operation and risk factors for death. Methods: Between July 1988 and June 2008, 72 patients underwent IAA single-stage repair using expandent direct anastomosis for reconstruction aortic arch without a patch (n=63) or with patch augmentation (n=9). Associated anomalies were complex congenital heart anomalies in 27 (37. 5%) patients. Results Hospital survival was 83.4%. Five-year freedom from aortic arch reintervention was 98%. Survival at 0.5 year, 2 year, 5 years and 10 years was 98%, 96%, 96% and 95%, respectively. Risk factors for death are older age (p=0.018), complex congenital heart anomalies (p=0.001), poor state in pre-operative period (p=0. 01) and pulmonary artery hypertension crisis (p=0. 014). Conclusions: Expandent direct anastomosis for reconstruction aortic arch without a patch or with reasonable patch can be applied to IAA patients, with the expectation of a minimal need for arch reintervention. This technique affords an excellent survival in the early

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and mid-term of IAA one-stage repair in neonate and infants. The status of pre-operation and age at the operation were impact the early results of IAA one-stage repair.

Surgical intervention for acquired cardiac lesion concomitantly with surgery for adult congenital heart disease

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Uchita S, Okamura Y, Nishimura Y, Hatada A, Toguchi K, Honda K, Kaneko M, Yusaki M, Nakai T Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan Background: Considerable adult congenital heart surgery cases required concomitant surgical intervention for acquired cardiac lesion. Methods: Between January 2000 and August 2009, 82 Grownup congenital heart disease (GUCH) patients underwent surgical repair for congenital cardiac lesion. In 42 surgical cases (male: 18, female: 26) of 82 patients, excluding of 40 isolated bicuspid aortic valve cases, were examined. Main diseases of CHD were ASD:23, VSD:9, TOF:5, rupture of Valsalva sinus with IE:2, Ebstein:1, partial AVSD:1 and CoA:1. Twenty-six of 42 patients (60%) required concomitant surgical intervention for acquired lesion. We investigate relation between congenital and acquired cardiac lesion. Results: Concomitant procedures were AVR:3, Aortic root replacement:1, MVR/MVP;5, PVR/P-valvotomy:4, RVOTR:2, TAP/ TVP:11 and CABG: 5. Major combinations were ASD and T-valve:7, TOF and PVR/RVOTR:4, VSD and MVP:2, VSD, TVP and IE:2. IE was revealed in two VSD and two rupture of Valsalva sinus cases. Atrial fibrillation appeared four cases and modified Maze procedure was made for two cases. Eleven of 23 ASD cases (48%) required concomitant surgical intervention for acquired lesion. Conclusion: In many GUCH cases, acquired cardiac lesion needed surgical intervention. Optimal timing of operation for main congenital lesion in adult may be able to avoid secondary change of cardiac lesion.

Congenital heart defects and long-term results of cardiac surgery for the patients with chromosome 22q11. 2 deletion 1

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Nagashima M , Shikata F , Ryugo M , Imura M , Izutani H , Yamamoto E2, Nakano T3, Ohta M2, Murao K2, Toshiyuki C2, Takashi H2, Kanji K1 1 Department of Cardiothoracic Surgery, Ehime University Graduate School of Medicine, Ehime, Japan 2 Department of Pediatrics, Ehime University Graduate School of Medicine, Ehime, Japan 3 Department of Pediatrics, Ehime Prefectural Central Hospital, Ehime, Japan Background: Chromosome 22q11. 2 deletion usually associated with congenital heart defect (CHD) which required surgical interventions. We retrospectively review anatomical characteristics of CHD and surgical experience of patients with 22q11.2 deletion at our institution. Methods: From 1985 to 2009, 13 patients with 22q11.2 deletion underwent surgical correction with average age of 3.1 years. The cardiac defect consisted of Tetralogy of Fallot (TOF) and variances (n = 8), ventricular septal defect (VSD) (n = 3), VSD with pulmonary atresia and major aortopulmonary collateral arteries (n = 2), Results: Only 3 patients had a normal aortic arch (left aortic arch (LAA)). In 9 patients, right aortic arch (RAA) were observed., mirror image of normal in 4, RAA with an aberrant left subclavian artery in 3, RAA with an aberrant left brachiocephalic artery in 1, LAA with an aberrant right subclavian artery in 1 and LAA with the isolation of a

brachiocephalic artery in 1. Five patients had palliative surgery including 4 Blalock-Taussig shunts and 4 unifocalizaton. Six patients underwent surgery for extracardiac anomalies. The average followup period was 11.4 years ranged from 1.6 to 24.5 years. There were no early and no late deaths. One patient after TOF repair required implantable cardioverter defibrillator for ventricular tachycardia. Ten patients were in NYHA class I, 2 in II and one patient in III. Conclusion: In patients with 22q11.2 deletion, aortic arch anomalies were very frequent. Surgical correction for patients with 22q11.2 deletion led to satisfactory mid-to-long term results.

Surgical treatment of complete atrioventricular septal defects associated with major cardiac anomalies

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Qingyu Wu, Hongyin Li, Wang L, Zhang M, Jicheng Xi Heart Centre, First Hospital of Tsinghua University, Beijing 100016, P. R. China Background: Complete atrioventricular septal defect (CAVD) associated with major cardiac anomalies is a big challenge in cardiac surgery. We report our experience in surgical treatment of CAVD associated with major cardiac anomalies here. Methods: From July 2000 to April 2009, 20 CAVD patients (11 males, 9 females, aged 6 months -23 years old, 5. 0±7. 0 years old) associated with major cardiac anomalies received biventricular repair by single surgeon. Among them, 4 with Tetralogy of Fallot, 9 with DORV and pulmonary stenosis, 1 with DORV and pulmonary hypertention, 2 with DOLV, 1 with pulmonary atresia, 3 with c-TGA and pulmonary stenosis; other concomitant anomalies were dextrocardia, heterotaxy syndrome, TAPVC, discordant A-V connection, common atrium, PDA, bicuspid pulmonic valve, LSVC, etc. Two-patch technique was used for total correction of CAVD in 19. For outflow tract reconstruction, 14 Rastelli (13 homograft, 1 pulmonary autograft) and 5 transannular patch procedures were performed. Concomittant procedures performed including Rerouting of TAPVC, rerouting of LSVC to LA and PDA ligation. Results: There was no hospital death. All patients had an uneventful recovery. The patients were followed up for 4 months to 8 years. There were 2 late deaths. 2 patients received reoperation due to residual VSD shunt. Other patients did well during follow up. Conclusions: Good results can be achieved with biventricular repair in selected patients with CAVD associated with major cardiac anomalies.

Repair of persistent truncus arteriosus without a conduit; sleeve resection of the pulmonary trunk from the aorta and direct pa-rv anastomosis

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Nemoto S, Ozawa H, Sasaki T, Kakita M, Katsumata T Osaka Medical College Hospital, Takatsuki, Japan Background: Establishing a new continuity between the right ventricle (RV) and the pulmonary artery (PA) is the mainstay of repair for persistent truncus arteriosus (PTA). Surgical technique of our modification of the Tran Viet-Neveux technique to construct the continuation without a conduit is shown in this presentation. Methods: A cylindrical segment incorporating the both PA branches was sleeve-resected from the truncal artery (TA). The cylindrical segment was cut in the middle and two TA flaps were combined to form the posterior floor of the new PA trunk. The edge of the floor was attached directly to the superior margin of an oblique incision made on the left-anterior wall of the RV. A PTFE monocusp was attached to the lower half margin of the RV incision. A large glutaraldehyde-treated pericardial patch was used to form the anterior

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hood of the new RV out-flow tract. Both great arteries were located in a normal spiral configuration. Results: Ten babies (range: 3 days to 9 months of age) underwent this procedure. Collett-Edwards’ classification of PTA was: 5 type I and 5 type II. There was one hospital death due to severe respiratory distress. During follow-up (24 to 58 months, median 44), one reoperation was required to enlarge the left branch PA stenosis. Current follow-up echocardiography shows pulmonary regurgitation (1 trivial, 6 mild, 2 moderate) and mild flow acceleration (1 in the left branch PA, 1 at the RV-PA connection). Conclusion: This simple modification may be an effective alternative to overcome conduit-related problems.

Oriental VSD and late aortic regurgitation our experience Kapadia N, Russo P, Urajendran, Gowri T SRM Hospital & Research Centre, Potheri, Chennai

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Background: To study the long term results of closure of Oriental type of ventricular Septal Defect (VSD) in terms of development of aortic regurgitation. Methods: Between December 2001 and October, 2009 one hundred fourty eight patients underwent isolated VSD closure. Age varied 6 months to 21 year (Mean 5.4), 98 (66%) being male and rest females. Subaortic was common location in 91 (61%), Subpulmonic 8 (5.5%), Doubly committed in 26 (17.5%), Inlet type in 18 (12%), Muscular in 5 (3.37%). Results: There were two postoperative deaths (severe pulmonary hypertension, septiaemia) (1.35%) One patient developed transient heart block, two patients (1.35%) had small residual VSD with non significant shunt, one was muscular, and another Subpulmonic. Long term follow up of 1 month to 97 months (Mean 45), shown, nine (6%) had developed aortic valve regurgitation over a period of time 1 to 7 years, severe in three (2%) other 5 (3.34%) had mild belonging to

Surgical results of PVO release for Heterotaxy syndrome with TAPVR and PVO

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Nakayama Y, Hiramatsu T, Iwata Y, Okamura T, Konuma T, Hobo K, Komagamine M, Kaku Y, Yamazaki K Department of Cardiovascular Surgery, Tokyo Women‘s Medical University 162-8666 Kamadacho 8-1, Shinjuku, Tokyo, Japan Background: The surgical results of Heterotaxy syndrome with TAPVR and PVO were not still satisfied. The purpose of study was to investigate retrospectively about the surgical results using cox proportional hazards model. Methods: 33 patients who diagnosed Heterotaxy syndrome with TAPVR and PVO were performed PVO release at single institute from July, 1993 to September, 2009. Characteristic of patients at the operation were as follows: mean age: 29.3±47. 6 months, body weight 9.5±11.4 kg, Male: Female = 18:15. Darling classifications were I (18), II (9), III (4), mixed (2). TCPC were done in 14 cases. Recurrent PVO was happened in 7 cases. Hospital death was in 13 cases (39.3%). The causes of hospital death were cardiac failure (5), respiratory failure (3), infection (2), recurrent PVO (2), pulmonary bleeding (1). Late deaths were in 7 cases (Mean follow up: 44 months). Results: Significant differences were observed for less than 4 kg as operative weight (P=0.0328) in hospital mortality by multivariate analysis and less than 1 year old as operative age (P=0.0227) in late death by univariate analysis. Conclusions: Our study indicated PVO release should be waiting as much as until more than 4 kg, except for emergency.

Surgical repair of multiple muscular ventricular septal defect

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Ju Min B, Kim WH, Choi JH, Lee YO, Lim HG, Lee JR, Kim YJ Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital Objectives: Surgical repair of multiple muscular ventricular septal defect (VSD) remains a challenge. It often makes unsatisfactory results of residual shunt, atrio-ventricular (AV) block, other significant morbidity and mortality associated with surgery. The purpose of this study is to evaluate surgical results of multiple muscular VSD and outcomes of surgical approaches. Methods: 37 patients with multiple muscular VSD underwent primary repair between 1988 and 2008. The male patients were 18 (48.6%). The age of patients at operation was 17.4±53.6 months. The follow up periods were 52.2±55.3 months. 27 patients had perimembraneous type and 7 patients had subarterial type VSD. 15 patients had other complex cardiac anomaly and underwent concomitant primary corrective surgery (DORV:4, TOF:3, CoA:2, PA:2, TGA:1, IAA:1, TAPVR:1, congenital MS:1). Initial approach was right atrium. Additional PAtomy was taken in 5 cases of subarterial or muscular outlet VSD. There were 3 cases of right ventricular apical incision and 2 cases of left ventricular apical incision for apical muscular VSD. Results: There was no early mortality. 2 complete AV block occurred and underwent pacemaker insertion during same hospitalization. Postoperative bleeding occurred in 1 case. 17 patients had no residual VSD after operation. 17 patients had trivial residual VSD after operation. 2 patients with residual VSD had persistent heart failure. One residual VSD was reoperated via previous RVtomy and the other case was closed through LV tomy. One residual VSD with marginal shunt amount (2mm) had been observed during next year, but mortality occurred because of infection. There were no late complications related to surgical approaches during follow up periods. Especially, in ventriculotomies, there was no ventricular dysfunction or deterioration on serial 2D-ehocardiogarphy. Conclusions: Our study showed acceptable surgical results for multiple muscular VSD. Although most multiple VSD were repaired without ventriculotomy but some cases needed ventriculotomy. We expect more favorable surgical results with various surgical approaches. Further study with large scale will be needed to demonstrate the outcomes of surgical approaches.

Simultaneous repair of congenital heart disease and accompanying congenital tracheal stenosis.

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Maruo A, Oshima Y, Matsuhisa H, Inoue T, Kawamura A, Kadowaki T Department of Cardiovascular Surgery, Hyogo Prefectural Kobe Children’s Hospital, 1-1-1 Takakuradai Sumaku Kobe, Hyogo, zip code 654-0081, Japan Background: Our strategy in treating patients with congenital heart diseases complicated by tracheal stenosis has been simultaneous surgical repair of both disorders. In this paper, the validity of this approach is estimated. Methods: Since 1996, 15 patients have undergone simultaneous repair for congenital heart disease and tracheal stenosis. Patients with isolated vascular anomaly were excluded. Cardiac lesions were as following; 4 ASD, 4 VSD, 1 ASD with PAPVR, 2 VSD with RVOTO, 3 TOF and 1 DORV. Nine patients (60%) had pulmonary artery sling together, which was corrected by means of reimplantation. Tracheal stenosis was repaired by either resection and end-to-end anastomosis or slide tracheoplasty. The results of surgical therapy were investigated.

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Results: Mean age at the surgery was 7.2±7. 0 month-old and the weight was 5. 6±1.7 kg. There were 2 operative deaths due to ventricular arrhythmia, and residual tracheal stenosis, respectively. Both of them required delayed sternal closure and peritoneal dialysis. One patient died of pulmonary hypertension 9 months after the surgery. Cerebral infarction occurs in one patient, and mediastinitis in 2. Extubation was successfully achieved in 7 out of 12 survived patients (58.3%). Tracheostomy was required in 6 patients for residual tracheal stenosis. Conclusions: The results of simultaneous repair were acceptable. Patients requiring delayed sternal closure or peritoneal dialysis were considered as high risk of operative death and the alternative strategy should be needed. This results support our recently started new ‘staged approach’ utilizing the balloon tracheoplasty and intubation by force.

Fontan conversion with arrhythmia surgery and pacemaker therapy

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Hiramatsu T, Iwata Y, Okamura T, Konuma T, Yamazaki K Department of Cardiovascular Surgery, Tokyo Women’s Medical University, 162-8666 Kamadacho 8-1, Shinjuko, Tokyo, Japan Background: In the long-term period after Fontan operation, atrial arrhythmia was one of the important factors to decide the postoperative QOL. We reviewed the impact of Fontan conversion with arrhythmia surgery. Methods: Thirty-five patients underwent Fontan conversion from 1992, and 20 patients with atrial arrhythmia underwent maze procedure simultaneously using cryoablation or radiofrequency ablation and pacemaker implantation and 15 patients had regular rhythm before Fontan conversion. Mean follow up period was 47 months. Preoperative and postoperative clinical course were analyzed. Average weight, age at Fontan conversion and years after first Fontan operation were 49.0 kg, 25.8 years old, 14.7 years respectively. Seventeen% of patients were in NYHA I, and 77% of patients were in NYHA II, and 6% were in NYHA III respectively. All patients underwent extra-cardiac Fontan using artificial conduit. Results: Except 3 early deaths, actual survival rate at 1 year and 5 years were 80% and 64% respectively. In survivors, 80% of the patients obtained regular heart rhythm including artificial pacemaker rhythm, although 43% of the patients had regular rhythm before the Fontan conversion. Postoperative average cardiothoracic ratio and SpO2 were 50% and 94%, and 67% of patients were in NYHA I and 33% were in NYHA II respectively after Fontan conversion. Conclusions: Mid-term results of Fontan conversion with arrhythmia surgery and pacemaker therapy were acceptable. Restoration of regular rhythm might improve the postoperative NYHA status and the activity of the daily life.

Controlling oxygenation during initiation of CPB: Can it improve immediate post operative outcomes in cyanotic children undergoing cardiac surgery? A prospective randomized study

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Babu B, Bhat S, Prabuswamy HP, Kamalapurkar G, Kumar J HV, Lokesh, Shilpa S Department of CVTS, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore Background: CPB initiated at high oxygen levels may expose cyanotic children to reoxygenation damage. Studies based on biochemical parameters shows that this may be prevented by initiating

bypass at lower oxygen levels. There are hardly any studies proving the opatimal method of bypass initiation with its postoperative clinical benefits in this setting. This study tested the hypothesis that controlling oxygenation during initiation of CPB can improve immediate post operative outcomes in cyanotic children. Methods: Prospective randomized double blinded study. Pediatric patients (<13yrs) undergoing repair of congenital cyanotic heart disease. 22 patients were randomized into group A (intervention) and group B (control). In group A CPB was initiated with an FiO2 0.21 and after one minute of full bypass FiO2 was increased at increments of 0. 1 per minute to reach 0. 6. In group B CPB was initiated using FiO2 >0. 6. ABG was done later in both groups and Fio2 adjusted to maintain Po2 of 200-300. Cross clamp time, CPB time, CPK –MB, serum lactate, ventilator support, ionotropic support, ICU stay and mortality were measured. Results: Mean age 32.4 months. Mortality was 4 (group A=2, group B=2). CPB time (p=0.74), cross clamp time (p=0.758) and mean lactate levels (p=0.741) were not different in groups. CPK-MB levels (p=0.077), ventilator support (p=0.064), ionotropic support (p=0.11)) and ICU stay (p=0.093)) was lower in group A, but not reached significance levels. Conclusions: This protocol for bypass initiation in cyanotic children may be associated with reduced myocardial injury, ventilator support, ionotropic support and ICU stay.

Surgical treatment of aortico-left ventricular tunnel: A 14-year experience

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Hiremath CS, Gajjar T, Shah G, Rao N, Neogee S, Hatibaruah N, Desai N, Choudary V Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences. Prashanthigram, Andhra Pradesh Background: Aortico-Left ventricular tunnel is an extremely rare congenital entity in which an abnormal communication between the aorta and the left ventricle bypasses the aortic valve. The condition usually results in gross aortic regurgitation, rapid cardiac decompensation, and death. The purpose of this study was to review our 14 years of experience with aortico-left ventricular tunnel (ALVT), with emphasis on diagnosis and surgical details. Methods: A retrospective analysis of seven pateints from November 1993 to August 2007 was done. Six out of seven patients presented with congestive cardiac failure and one with palpitation. Age ranged from 5 to 44 years, male to female ratio was 3:4, Pre-op Echo showed no AR (n=1), moderate AR (n=4) and severe AR (n=2). Results: All seven patients underwent open heart surgery. At operation the diagnosis was confirmed, direct suture closure at both ends (n = 1), single patch closure of the aortic end and direct closure of LV end (n=4), double patch closure of both the ends of the ALVT (n = 2), In 6 patients, the aortic end of the tunnel was to the left of Right coronary ostium and in one case above the right coronary ostium. Post-op Echo showed no residual ALVT and mild AR in all cases. Post operative recovery was uneventful. Conclusions: ALVT is a rare cardiac entity that should be treated soon after the diagnosis is made. The specific surgical operation should be individualized based on unique cardiac anomaly of each patient.

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Long-term follow-up of autologous pericardial valved conduit

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Gajjar T, Hiremath CS, Shah G, Rao N, Neogee S, Hatibaruah N, Desai N, Choudary V Department of Cardiothoracic and vascular surgery, Sri Sathya Sai Institute of Higher Medical Sciences,Prashanthigram, Andhra Pradesh Background: The aim of this study was to evaluate the long-term results of the use of an autologous bicuspid pericardial valved conduit in the outflow tract of the venous ventricle in congenital heart malformations. Methods: Ten patients underwent right ventricle to pulmonary artery autologous pericardial valve conduit in which Nine patient had diagnosis of Tetrology of Fallot with absent pulmonary valve and one patient had DTGA, VSD PS who underwent Rastelli operation, All patients were followed up for a period of 3 to 84 months; 5 for more than 36 months and 5 for more than 12 months. All were evaluated clinically and by two-dimensional and Doppler echocardiography. Postoperative evaluation included serial measurement of pressure gradients and the pulmonary regurgitation. Reoperation because of stenosis was indicated when the gradient across the right ventricular outflow was greater than 50 mm Hg across the conduit. Results: Conduit survival free of reoperation for the whole group was 90% at 3 years. Only one patient developed severe pulmonary regurgitation at 5 year follow up. None of the patient developed > 50 gradient across conduit. None of the patient needed reoperation. Conclusions: Autologous bicuspid pericardial valve conduit is a cheap, technically simple & alternative for the valve graft conduit on the venous ventricle. These results compare favorably with those of other available conduits.

Total correction for tetralogy of fallot in children below one year

Serum BNP levels and myocardial performance indices after repair of tetralogy of fallot

Background: The outcome after correction of tetralogy of Fallot (TOF) can be influenced by myocardial dysfunction. We tried to correlate serum Brain Natriuretic Peptide (BNP) levels and myocardial performance indices (MPI) by Tissue Doppler imaging (TDI) in the perioperative period with outcome. Methods: Twenty two patients with TOF (age <18 years) underwent repair. MPI were calculated by TDI preoperatively, and on first and seventh postoperative day. Serum BNP levels were simultaneously estimated. Patients with hemoglobin of >16 gm/dl and haematocrit of > 50% were considered high-risk (group 1, n=15), while others were considered low-risk (group 2, n=8). The TDI-MPI, BNP values, ventilation duration, ICU and hospital stay were compared. Results: The mean ventilation duration, ICU stay and hospital stay were higher in group 1 (23.7 vs 14 hours, 65 vs 37 hours and 12 vs 8 days respectively). Preoperative TDI-MPI and BNP levels were similar in the two groups. Group 1 patients with high preoperative TDI-MPI had elevated BNP while group 2 patients with high preoperative TDIMPI had normal BNP. Postoperative elevation in TDI-MPI was associated with marked rise in BNP in both groups. Group 1 patients with high or very high BNP on first postoperative day needed longer ventilation and ICU stay. There was no difference in TDI-MPI and BNP among patients with and without trans-annular patch. Conclusion: High peri-operative BNP values correlated better with adverse clinical outcome as compared to abnormal TDI-MPI values.

Flap valved closure of ventricular septal defect with increased pulmonary vascular resistance

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Babu V, Reddy P, Kumar A, Nagarajan, Gouthami, Rao IM, Murthy KS Innova Children’s Heart Hospital and Research Centre, Moula Ali Road, Tarnaka, Hyderabad Objective: Primary repair of TOF is generally done in the preschool period. Recently there have been several reports of early primary correction in neonates and infants. However, several authors still advocate two stage total correction. The purpose of this study was to analyze the outcome after early total correction in the first year of life. Methods: From June 2007 to May 2009 161 cases of TOF underwent total correction, of which 60 were infants. The age ranged from 3 to 12 months and weight from 4.5 to 9.5 kilograms. Eleven (18%) patients presented with cyanotic spells and required emergency surgery. Twenty two infants (36.6%) had valve sparing procedure, 12 (20%) had transannular repair and 26 (43.3%) RVOT reconstruction with monocusp pericardial patch; the corresponding numbers in older patients were 56 (55.4%), 12 (11.8%) and 33 (32.8%) respectively. Results: Four infants (6.6%) died in the post operative period. Six (10%) each had junctional ectopic tachycardia and low cardiac output and 1 patient (3.3%) had seizures. Five patients (8.3%) required ventilation for more than 3 days (overall morbidity 13.3%). No patient required reintervention for residual problems. In older patients the early mortality and overall morbidity was 4.9% and 7.9% (p >0.05). Conclusion: There is no significant difference in the mortality, morbidity and transannular patch between infants and older children, except a slight increased risk of JET and prolonged ventilation in infants. Early primary repair is possible in infants with TOF with acceptable morbidity and mortality and is comparable to the results in older patients.

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Sathe Y, Subramanyan R, Sekar P, Shanthi C, Abraham S, Agarwal R, Cherian KM Frontier Lifeline & Dr KM Cherian Heart Foundation, Chennai

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Prasanna Simha M, Varadaraju R, Madhusudana N, Austin Raj R S Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bannerghatta Road, Bangalore Background: Closure of ventricular septal defect in children with elevated pulmonary vascular resistance is associated with significant morbidity and mortality. Pulmonary hypertensive episodes continue to be a major cause of postoperative morbidity and mortality in these patients. Flap valved closure of VSD is reported to decrease morbidity and mortality associated with closure of VSD with elevated PVR. We report our experience of closure of VSD’s in patients with severe PH using a valved patch in an effort to reduce risk of operation. Methods: 15 consecutive patients with a large VSD with severe pulmonary hypertension (mean pulmonary vascular resistance > 8 Wood Units) underwent flap valved closure of the VSD using moderately hypothermic cardiopulmonary bypass and cardioplegic arrest during a one year study period. The patch was constructed using technique described by Novick et al. Results: Mean age of the patients was 8.4 years. Mean PVR was 11.9 Wood Units. All children survived operation and were weaned from inotropic and ventilator support within 48 hrs. Postoperative pulmonary artery pressures were significantly lower than preoperative values. Three patients had pulmonary hypertensive crisis postoperatively. Obvious opening and closing of the flap valve was detected by early postoperative echocardiography in five patients. All of the patients were followed up (5 months to 12 months) and the cardiopulmonary function was well improved with no late death Conclusion: Closure of a large VSD in patients with severe pulmonary hypertension could be performed with low morbidity and mortality when a flap valve patch method was used.

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The system of medical care for neonates with critical congenital heart diseases in Samara Region: Influence in reduction of perinatal mortality

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Avramenko AA1, 2, Goryachev VV1, 2, Kozeva IG1, Suslina EA1, Khokhlunov SM1, 2 1. Samara Regional Clinical Cardiac Hospital 2. Samara State Medical University, 443070, Aerodromnaya str., 43. Samara, Russian Federation Background: The aim of present study was to analyze the results achieved after establishment of new system of care for neonates with critical congenital heart disease (CHD). Methods: Before 2006 there were separated (based in different healthcare institutions) services for fetal diagnostic, and postnatal care for neonates with CHD in Samara region. In 2006 The Center of Perinatal Care was created on the basis of Samara Regional Cardiac Hospital and affiliated with Central Regional and Central City hospitals. This center has 3 divisions: (1) the perinatal diagnostic center with the base in the Cardiac hospital where pediatric cardiologists are dedicated to perform fetal echo; (2) the perinatal care center with the base in the Cardiac hospital; (3) mobile ICU/transportation teams based in Central regional and Central city hospitals. Perinatal care center consists of (1) fetal echocardiography for pregnant women with suspected CHD; (2) council of physicians to evaluate the diagnosis of the fetus and recommend termination or prolongation of pregnancy; (3) maternity hospital; (4) divisions of pediatric cardiology, cardiac surgery and cardiac ICU. We utilize mobile ICU teams when a child with suspected serious CHD was born at a site outside the Cardiac Hospital. The patient is transferred to the Cardiac Hospital for confirmation of diagnosis and treatment. Results: Starting in 2005 overall postoperative mortality in neonates in our institution is 16.3%. The percentage of prenatally diagnosed patients gradually rose from 26% in 2005 to 73% in 2008. Overall Samara region the mortality rate in neonates related to CHD was stable in 2004-2005-2006 at the level of 0.58-0. 57-0.59 per 1000 live births respectively. This rate has significantly decreased progressively during 2007 and 2008 – 0.49 and 0.27 per 1000 live birth respectively (p<0.05). Conclusions: This centralized system of perinatal cardiac care based in a single institution with dedicated pediatric cardiology/ cardiac surgery/ICU team provides improved survival compare to former multi-center approach in this region.

Late results of correction of sthe partial atrioventricular septal defects

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Abdurahmanov AA, Mahmudov MM Republic Specialized Center of Surgery named after academician V. Vakhidov, Tashkent Uzbekistan, director - professor Nazyrov F. G. Objectives: to estimate the late results of surgical correction of the partial atrioventricular septal defects (pAVSD). Material: From1980 to 2009 in our Center 65 patients with the diagnosis of the pAVSD were operated. Male were 31 (47,7%) and female - 34 (52,3%). Middle age of patients changed from 4 till 30 years and has on the average made 14,8+0,86 years. Surgical correction of defect was made through median sternotomy in cardiopulmonary bypass (89,1±3,6 minutes) Correction of defect consist in plasty of primary ASD with autopericardial patch and liquidations of a failure of atrioventricular valves. The late results are looked after by us at 40 patients (61,5%), in terms from 3 months till 10 years (on the average 30,6±9,5 months). The estimation of a functional condition of patients was made on NYHA classification. Results: The Analysis of the late results has shown that 26 (65%) patients were in I-II functional class NYHA, do not show complaints,

and well carry an exercise stress. At all patients good short-term results of correction were marked. Echocardiographically at them some increase of volumes of a left ventricle, a residual regurgitation on MV was marked, as a rule, was minimal, not exceeding I degree, and did not progress in dynamics. At 12 (30%) patients were marked satisfactory results. Patients of this group showed complaints to fatigability and palpitation at exercise stresses and were in II-III functional class NYHA. Echocardiographically, also increase of volumes of the LV was marked, the mitral regurgitation was comparable with preoperative and results of the nearest postoperative period, being kept within the limits of II degree, its advance has appeared statistically doubtful (> 0,05). Two patients (5%) are included in group with the unsatisfactory late result. At one patient advance of a mitral regurgitation within 3 years of the postoperative period has led to a decompensation and has demanded reoperation and there mitral replacement was done. Freedom from ðreoperations for 5 years period has made 97,5%. The late death was observed in 1 (2,5%) patient and has been bound with kept in the postoperative period complete AV block. Thus, a lethality in the late postoperative period was 2,5% (1 patient) and the cumulative lethality in investigated group was7,7% (5 patients). Conclusions: So, correction of the pAVSD with reconstruction of atrioventricular valves and plasty of ASD provides the good late results, being accompanied thus concerning a low lethality. Freedom from reoperation for 5 years period has made 97,5%.

Aortic valve repair is superior to aortic valve replacement in young patients with ventricular septal defect with aortic regurgitation – Our experience.

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Raju V, Muthubaskaran V, Muralidharan S, Muthusamy K1, Muthialu N Departments of Paediatric Cardiac Surgery and Paediatric Cardiology, G. Kuppusamy Naidu Memorial hospital, Coimbatore, Tamil Nadu Background: Perimembranous and subarterial ventricular septal defects (VSD) are associated with aortic regurgitation in 5% of patients. More than mild AR needs additional valve intervention during VSD closure. Feasibility of aortic valve repair and its superior results over aortic valve replacement have been documented well. The purpose of this study is to present our initial experience in aortic valve repair in young children with aortic regurgitation. Methods: 14 out of 31 consecutive VSD Closures had AR (45.16%) and six (19.35%) needed intervention. The median age and weight were 8. 1 years and 18.7 Kg. The VSD was perimembranous in 5 (83.33%) and sub arterial in 1. The Aortic leaflet was prolapsing in 5 (83.33%) (RCC – 3, NCC – 1, Both RCC and NCC – 1) and non prolapsing in 1. Results: Five had successful aortic valve repair (83.33%) and one underwent aortic valve replacement after failed valve repair. The technique of repair consisted of Commissural Plication with cusp shortening, resuspension and bicuspidalisation. There were no deaths. Follow-up was 100% complete at a median of 2.6 months. AR was trivial in 2, mild in 3. All are in NYHA class I. Patient with mechanical valve had major anticoagulation-related intra-cerebral bleed needing neurosurgical intervention. Conclusions: Early intervention for VSD would possibly prevent aortic valve disease. Aortic valve repair is the procedure of choice in young patients with VSD-AR syndrome and can be performed with low risk and excellent freedom from valve-related morbidity and mortality and also avoids anticoagulation related complications.

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Surgical outcome of sutureless technique as a relief of pulmonary vein stenosis after definitive repair of total anomalous pulmonary venous connection

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Saito T, Ichikawa H, Kagisaki K, Hoashi T, Yagihara T National Cardiovascular Center, Suita, Osaka, Japan Background: Pulmonary vein stenosis (PVS) after the definitive repair of total anomalous pulmonary venous connection (TAPVC) is often refractory to surgical reinterventions. Method: A retrospective review identified consecutive 33 patients with non-isomeric TAPVC underwent definitive repair over a 10-year period (1999-2009). Among the 33 patients, 9 required surgical reinterventions for postrepair PVS (27.3%). We introduced sutureless pericardial marsupialization in 3 cases since 2005. We compared the outcome of sutureless technique to conventional surgical repair without sutureless technique as a relief of postrepair PVS. Results: Almost all of the patients included in this study underwent common PV-left atrial anastomosis for supracardiac/ cardiac TAPVC and cut back of coronary sinus with atrial septoplasty for infracardiac TAPVC as an initial surigical treatment for TAPVC. There were 6 patients underwent conventional surgical repair for the postrepair PVS at the mean duration of 379±187 days after the definitive repair. There were 2 mortalities and 2 reinterventions required. There were 3 cases underwent sutureless technique at the mean duration of 84±36 days after the definitive repair. There was no case with mortality and reintervention required. Postoperative mean pulmonary arterial pressure was 28. 8±13.0 mmHg in group with conventional repair and 27.3±11. 5mmHg in group with sutureless technique, respectively. Pulmonary hypertension was recognized in 3 patients in group with conventional repair and 2 patients in group with sutureless technique. Conclusions: There were many cases with residual pulmonary hypertension even after the sutureless pericardial marsupialization. Further follow-up is required for the patients presented postrepair PVS after the definitive repair of TAPVC.

Arterial switch operation with in situ coronary reallocation for transposition of great arteries with single coronary artery

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Pramod Reddy K, Dharmapuram A, Babu V, Ramadoss N, Goutami V, Padhy S, Bakshi K, Rao IM, Murthy KS Innova Children’s Heart Hospital, Moulali Road, Tarnaka, Hyderabad Objective: Transposition of great arteries with single coronary artery pattern is one of the high-risk groups for arterial switch operation. Any traction or kinking during coronary transfer can lead to a fatal outcome. We here in describe a new technique of in situ coronary reallocation during ASO for TGA with single coronary. Methods: From 1993 to 2009, 27consecutive cases of TGA with single coronary artery were operated employing this new technique. Their age ranged from 16 days to 9 months. ASO was done by transecting the great arteries just above the commissures. For coronary reallocation, hockey stick-shaped incisions were made in the facing sinuses of the proximal aorta and the pulmonary artery. These flaps were sutured in such a way that the coronary ostium was committed to the neo-aorta with the rest of surgical procedure done in the usual manner. Results: All 27 patients had ASO. Additionally, 15 patients had closure of an associated ventricular septal defect and 3 patient had repair of the coarctation of the aorta. There was no in hospital mortality. All patients had follow – up echocardiograms at regular intervals, which showed no significant right or left ventricular outflow obstruction, no regional wall motion abnormalities and no neo-aortic

or neo-pulmonary regurgitation. Three of five patients had cardiac catheterization and angiocardiography, which showed normal coronary arteries with no obstructive lesions and no neo-aortic regurgitation. Conclusion: Coronary reallocation technique avoids problems related to coronary translocation such as traction and kinking. It spares the need for dissection of proximal coronary artery and its branches, and thereby eliminates the risk of development of fibrosis and stenosis. The same technique can be used regardless of the sinus of origin of the coronary artery.

Median sternotomy single stage complete unifocalization for pulmonary atresia, major aorto-pulmonary collateral arteries and VSD

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Kandakure PK, Dharmapuram AK, Babu V, Ramadoss N, Goutami V, Padhy S, Bakshi K, Rao IM, Murthy KS Innova Children’s Heart Hospital, Moulali Road, Tarnaka, Hyderabad Background: Tetrology with pulmonary atresia & MAPCA’s remains one of the most surgically challenging malformations. The surgical treatment for this malformation is evolving, and no standard protocols have been described. We describe our surgical technique and experience with single stage complete unifocalization and repair. Methods: From 1993 to 2009, 88 patients were treated with single stage unifocalization and repair. Age ranged from 3 months to 24 years [median 3 years]. Through median Sternotomy all MAPCA’s were dissected and looped. On Cardiopulmonary Bypass, MAPCAs were anastomosed to native pulmonary arteries or to MAPCAs. VSD was closed if possible & RV to PA continuity was established with a homograft conduit. If complete repair was not suitable, central shunt was done from ascending aorta to reconstructed PA with PTFE graft. Results: All MAPCAs were unifocalized with tissue – to – tissue anastomosis for future growth. 74 patients underwent single stage unifocalization whereas 14 patients underwent staged unifocalization. Total MAPCA’s unifocalized were 265 [Range 1-5/Patient], Origin of MAPCA’s were from descending aorta in 182 [69%], subclavian artery 56 [21%], Aortic arch 20 [8%], Ascending aorta 4 [2%]. Final correction was done in 43 cases. RV to PA conduit was placed in 13 patients whereas central shunt was done in 18 patients. Mortality was 3.5% [10 cases] Conclusion: In single stage complete unifocalization more patients will have complete repair at an earlier age. It reduces the number of operations and hospitalization,thereby is less expensive than multi stage unifocalization. It is very essential to delineate all the MAPCA’s upto the level of the diaphragm preoperatively.

Factors influencing outcome of complete correction of Tetralogy in infancy

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Krishnan GS, Vaidhyanathan K, Agarwal R, Abraham S, Sekhar P, Kaur C, Cherian KM Frontier Lifeline, R 30 C Ambattur Industrial Estate Road, Mogappair, Chennai Background: The timing of surgery of TOF is controversial, we reviewed our data about patients with Tetrology physiology who underwent complete correction in infancy (<12 months) to study factors effecting the outcome of repair. Methods: We retrospectively analysed the data of patients < 12 months of age at the time of complete correction to study factors effecting the outcome. Results: There were 71 patients, the mean age of the patients was 6.2 months the youngest was 2 months, the mean weight of the patients was 5.9 kg (range 4-10 kg). The age and the weight at the time of

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surgery, preoperative saturations, the use of transannular patch or use of monocusp, presence of pulmonary regurgitation, the presence of heart block did not correlate with mortality. The patient population was divided into two groups depending on the z scores of MPA or branch PA’s. Patients with Z score < -2 of MPA or branch PA’s or with pulmonary atresia had poorer outcome (24% vs 4% mortality). The duration of hospital and ICU stay and need for inotropes were significantly correlated with PA Z score. Presence of moderate to severe tricuspid regurgitation also negatively influenced survival. (chi < 0.05) Conclusion: The mortality following tetrology correction in infancy is influenced by pulmonary anatomy rather than the age and weight at the time of surgery. Tricuspid regurgitation is not an innocuous lesion following tetrology repair. Complete correction should be offered to symptomatic infants with good pulmonary artery anatomy (Z score > -2)

12 minutes. Dacron tube grafts of 20-22 mm were used. One patient was found to have high PA pressure intra op and a central shunt was done. There were two deaths. One on POD-1 due to an iatrogenic cause. The other expired on POD-15 due to bilateral bronchopneumonia leading to septicaemia. Two patients had pleural effusion. One required bilateral pleurodhesis and in other it settled with tube drainage. Hospital stay ranged from 8-30 days. All the seven patients are on follow up for a period of one month to one year. One patient is in NYHA II while rest six are in NYHA I. Conclusion: Extra cardiac Fontan is a reproducible technique. It can be done as a single stage in different anatomical substrates of complex congenital heart disease to achieve a univentricular state.

Veno-Venous shunt assisted cavopulmonary anastomosis

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Kandakure PR, Dharmapuram AK, Babu V, Rao IM, Murthy KS Innova Children's Heart Hospital, Whitehouse, Tarnaka, Hyderabad

Modified single patch repair compared with two patch repair for complete atrioventricular septal defect

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Ramakrishnan KV, Agarwal R, Mathew, Cherian KM Frontier Lifeline, R 30 C, Ambattur Industrial Estate Road, Chennai Background: To compare the immediate post operative outcomes following modified single patch technique for repair of complete atrioventricular septal defects with the conventional two patch technique. Methods: Fifteen consecutive patients who underwent repair of complete atrioventricular septal defects between January 2009 till October 2009 were included in this study. Seven patients underwent repair by a modified single patch technique (Group A). Eight patients underwent conventional two patch repair (Group B). Data was prospectively collected and analysed. Results: There were no differences in the demographics between the two groups. The mean CPB time and aortic cross clamp time were significantly lower for Group A (37 min vs 48 min, p=0.04). The mean duration of post op ventilation and ICU stay were not significantly different. One patient in Group B required reoperation in the immediate post operative period for VSD patch dehiscence. There was no mortality in either group. At a median follow up of 3 months all patients in both the groups did not have any significant residual defects or functional limitation or left ventricular outflow tract obstruction. Conclusion: Modified single patch repair of complete AV Septal defect can be performed safely with good early outcomes.

Background: The bidirectional Glenn shunt is commonly performed under CPB for conditions that lead to a single ventricle repair. We report our technique and experience of bidirectional Glenn shunt done without cardiopulmonary bypass. Methods: Between June 2007 and August 2009, one hundred ninety eight consecutive patients underwent offpump BD Glenn shunt for a variety of complex cyanotic congenital heart defects. Age ranged from 4 months to 6 years and weight range from 4.3–18. After systemic heparinisation, the procedure was done by creating a temporary shunt between the innominate vein and the right atrium connected across a three way connector for deairing. Fifty one patients had bilateral cavae. All cases underwent complete clinical neurological examination. Results: No case required conversion onto cardiopulmonary bypass. Four patients (2.14%) died in the immediate postoperative period due to low cardiac output syndrome. The mean internal JVP on clamping the decompressed SVC was 24.69±1.81 millimeters of Mercury. There was no intra-operative hemodynamic instability and oxygen saturation was maintained at more than 70% throughout. 74 cases had documented forward flow across the pulmonary valve. There were no neurological complications. Six patients (3.22%) developed effusions, 4 patients (2.15%) had nodal rhythm. Conclusions: Our results show that offpump BD Glenn shunt can be done safely in patients not requiring associated intra-cardiac correction. It avoids CPB and its related complications, is economical and associated with excellent results. In our opinion, this is the largest series of off pump BD Glenn shunt in the literature.

Experience with total cavo-pulmonary connection Early results with Extra Cardiac Fontan, as a single stage procedure

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Ali SN, Kumar V, Kumar RV Nizams Institute of Medical Sciences, Panjagutta, Hyderabad Background: Extra cardiac Fontan is the latest incarnation of the original Fontans operation. We present our results with this technique as a single stage procedure in children as well as adults. Methods: 10 patients with complex cyanotic congenital heart diseases were evaluated and Extra Cardiac Fontan was planned. All procedures were done using CPB without cardiac arrest. Dacron tube graft was used for extra cardiac conduit. Fenestration was done in all except one patient. DHCA was used for the distal anastomosis. Post op inotropic support was given and early extubation planned. LMW Heparin was used immediate post op and then switched to oral anticoagulants. Results: The age group ranged from 4-21 years. The PA mean pressure ranged from 8–15 mmHg. The mean duration of DHCA was

Dharmapuram A, Mannam G, Sajja L, Sompalli S Star Hospital, Road No. 10, Banjara Hills, Hyderabad

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Background: To evaluate the intermediate term results of our experience with the total cavo–pulmonary connection (TCPC) operation. Methods: From April 2001 to September 2009, 38 patients underwent TCPC in our unit. The mean age was 7.3 years (range 2to 15 years) and the mean weight 15.8 kg (range 8 to 30 kg). The common morphological subsets for the Fontan completion included the following: tricuspid atresia (TA) (n=30), double outlet right ventricle with remote ventricular septal defect (n=4). Two patients in the TA group underwent systemic to pulmonary artery shunt followed by staging with bidirectional Glenn; all other patients had a bidirectional Glenn as the initial procedure. The diagnosis was made by 2D echocardiography. Cardiac catheterization was done in all patients before Fontan completion to assess suitability. 35 patients underwent lateral tunnel procedure with fenestration and three patients had extra

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cardiac Fontan on beating heart. All patients received oral anticoagulants. Results: There were no intra operative deaths. Two patients died due to low cardiac output on postoperative day 4 and day 6. In the immediate postoperative period, 8 patients developed transient atrial arrhythmias that responded to intravenous amiadarone. Six patients developed bilateral pleural effusions requiring ambulatory intercostal drainage till discharge. No patient developed ascites. Surviving 36 patients were doing well at a mean follow-up of 4.4 years (range: 2months to 8 years) and were assessed by 2D echocardiography which demonstrated good flows in the circuit. Conclusions: TCPC can be performed with low morbidity and mortality in patients requiring this surgical option. Proper preoperative selection of the ideal hemodynamics for the Fontan completion achieves better results.

Complete reverse remodeling of coronary circulation following a translocation operation in anomalous left cornary artery presenting in adulthood

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Ravinutala VK, Krishna LSR Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad Background: Anomalous left coronary artery arising from pulmonary artery is a rare congenital anomaly. Few survive to adulthood without surgical intervention. They usually have extensive collaterals which are responsible for the survival and preservation of ventricular function. In adults many surgeons preferred ligating the origin of the ALCAPA and adding coronary bypass grafting with Left internal thoracic artery and saphenous vein. We propose that Translocation operation should be the choice as we have demonstrated complete reverse remodeling of the changes in the coronary system and avoids the problems of graft attrition. Case report: 45 yrs woman presented with stable angina and diagnosed to have an anomalous origin of left coronary artery from pulmonary artery. She underwent translocation of coronary artery back to aorta. Results: At 3 years after operation coronary arteries regressed in size but some tortuosity persisted. But at seven years follow up, coronary angiogram revealed that not only size but tortuosity of the coronary arteries also has come back to normal. Conclusion: This is the first case to report such complete reverse remodeling in adult patients with ALCAPA. Hence we recommend Tranlocation as the operation of choice in ALCAPA presenting in adulthood also.

Glenn shunt as a rescue procedure in totally transected superior vena cava

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Dasbaksi K, Mukherjee P, Hazra RN, Nayek S, Roy B Calcutta National Medical College, 24, Gorachand Road, Kolkata Background: Glenns cavo pulmonary shunt is a palliative procedure most commonly done in single ventricle pathology with tetralogy physiology. Apart from the above mentioned disease entities, it has been done as a rescue procedure in right ventricular (RV) endomyocardial fibrosis, RV tumour, acute aortic dissection with RV failure with difficulty in weaning off bypass. It has been done at our institution in cases of tricuspid atresia on the beating heart in the recent past using temporary superior vena cava to right atrial shunt during performing cavo pulmonary anastomosis. Experience with this procedure has been found to be life saving in a case of pneumonectomy due to tuberclous destroyed right lung where the superior vena cava was inadvertently severed , when a Glenns shunt was performed with a successful outcome.

Methods: An 18 year old female with destroyed right lung due to tuberculosis was undergoing right sided pneumonectomy. As expected there were gross adhesions and distortions of the vascular structures. While dissecting the right pulmonary artery, superior vena cava (SVC) was mistakenly looped and divided between ligatures. There was immediate hypotension not responsive to intra venous volume transfusion in the upper limb. A minute later, second look in the operative field after mopping up the blood revealed complete transaction of the SVC with wide retraction. Heparinisation was done, a right angled Passifico #22 cannula was introduced into the lower stump of SVC and held with purse string. Similarly a #24 size straight cannula was put into the right atrium and both the ends were joined through a 3/8th straight connector. Temporary shunt started functioning and haemodynamics improved. End to end anastomosis of the two ends of SVC was not possible due to wide retraction due to surrounding fibrosis nor there were any synthetic grafts available. Pneumonectomy was completed and at the end the stump of the severed pulmonary artery was anastomosed to the upper stump of the SVC and the lower stump of SVC closed with suture. Reversal with protamine was done and decannulation done. Chest was closed in the usual manner with a single drain and the patient extubated on table with normal haemodynamics. Results: The patient had an uneventful recovery. There was mild puffiness of the face for 2 weeks after which it normalized. Post operative echocardiography showed normally functioning glenn shunt Conclusion: Transsection of SVC is rare but not impossible while operating in cases of destroyed lung. End to end anastomosis or replacement with costly PTFE grafts or homografts are other options. SVC to pulmonary artery anastomosis was the only option for us available as a life saving procedure.

Severely pulmonary hypertensive ventricular septal defects : Can perioperative care be simplified?

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Kumar G, Dinkar S, Kaw A, Iyer KS Escorts Heart Institute and Research Centre, Okhla Road, New Delhi Background: Severely pulmonary hypertensive large ventricular septal defects in the older child continues to be a major post operative challenge in the non-industrialized world. Various surgical and expensive medical strategies are randomly used. To evolve a simple, inexpensive and reproducible model of peri-operative care which can be applied to the non-industrialized world. A prospective pilot observational case series. Methods: 9 patients (median age 8.3 years, 7.56 years– 26 years), (median weight 20 Kg, 15.5-68 Kg), underwent closure of a large ventricular septal defect in 2008. At cardiac catheterization, median PVRI was 8.2 wood units (3.4-12.1 wood units) – all responding favorably to oxygen with reduction in PVRI by 25% to 70%. Surgical strategies included decompressive PFO in 3 and flap valve ASD in 1. Serial post repair ECHO revealed varying degrees of LV systolic dysfunction in all (median EF 40%). Management of perioperative pulmonary hypertension was “highly premptive” using a simple alogorithm – optimal lung recruitment, relatively early extubation, elective CPAP, dobutamine, nitroglycerine and milrinone in 2/9. Results: In-hospital mortality was 0/9, no late deaths and insignificant morbidity -median ventilatory requirement (21 hours, 16-76 hours), length of stay (11 days, 9-18 days) and inotrope score (7.5, 5-23.5). There was no renal failure, acute lung injury or sepsis. Conclusion: Preliminary observations suggest that a simple and inexpensive model of perioperative care is feasible in patients with large sevely hypertensive ventricular septal defects.This needs to be validated in larger numbers.

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Late redo - Surgeries following tetralogy correction

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Ganapathy Subramaniam K, Vaidhynathan K, Agarwal R, Abraham S, Cherian KM Frontier Lifeline, R-30-C Ambattur Industrial Estate Road Mogappair Background: Repair of Tetralogy of fallot is a palliative procedure with patients requiring repeat surgery for a variety of indications. We analysed or experience with redo-surgeries in these group of patients who underwent previous tetralogy correction. Methods: Of 548 patients undergoing surgery for tetralogy physiology the records of 60 patients who underwent redo-surgery during Jan 2004 – July 2009 were analysed. Results: The mean age of patients undergoing redo-surgery was 22.3 years (2-56 years). The mean duration from the first surgery was 5. 7 years (1–35 years). 4 patients had sugery for the 3rd time. The indications for surgery were symptomatic patients with (1) Residual RVOT stenosis either at infundibular or branch PA level (2) Pulmonary regurgitation with varying levels of RV dysfunction (3) Stenosed or regurgitant conduits (4) Residual VSD (5) infective endocarditis (6) Severe tricuspid regurgitation (7) Wide QRS duration with ventricular tachycardia requiring AICD implantation. Many patients had more than one indication for surgery and more than one surgical procedure performed at the same time. There were 6 mortalities (10%) The followup is 80% complete. 70% of patients are in functional class I and 30% are in functional class II. Conclusion : Patients undergoing redo-surgery require careful assessment to detect the presence of branch PA problems and rhythm disturbances, which will need to be addressed at the time of repeat sugery. Redo surgery can be performed with acceptable mortality and good functional outcome.

Staged vs single stage Fontan — A comparative study

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Nasrunisha, Sudeep, Agarwal R, Cherian KM Frontier Lifeline, Dr. KM Cherian Heart Foundation, Ambattur Industrial Estate Road, Chennai Background: To analyse the patient profile, operative characteristics and post operative outcome of patients who have undergone the Fontan operation and to compare single stage with staged Fontan procedure. Methods: Retrospective audit of case records of patients who have undergone Fontan operation between Feb 2003 and Oct 2009 with prospective follow up was done. Such patients were identified. 97 patients underwent staged Fontan (Group A) and 15 patients underwent single stage Fontan (Group B). Group A patients were further subdivided into those who were palliated by a BT shunt (A130), PA band (A2-14) or no prior palliation (A3-53) prior to the Glenn operation. Results: The mean age was (Group A-9.9 years, A1-10.4 years, A2-8.6 years, Group B-10.5 years). Extracardiac Fontan was performed in 94 patients (93 Group A and 1 Group B). Lateral tunnel was performed in 18 patients (14 Group B, 4 Group A). Early post operative mortality was not significantly different between the groups (3.9% vs 0%, p=0.4). Prolonged pleural effusion was seen in 80% of the patients in Group 2, but only in 37% of patients in Group A (p<0.05). There was no significant difference in the incidence of arythmias, ICU stay or inotrope requirement. Late post operative mortality was also not different in both the groups (16% vs 13%). Conclusions: Primary Fontan operation is associated with a greater incidence of postoperative pleural effusion with no difference in the early or mid term outcomes. Standard criteria for Fontan operation after prior PA banding needs to be revised because of the higher mortality in his group.

Post Senning baffle obstruction- successful primary arterial switch conversion

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Kaw A, Dinkar S, Iyer KS Escorts Heart Institute and Research Centre, Okhla Road, New Delhi Background: Pulmonary venous obstruction allowing for left ventricle preparation enough to successfully achieve primary arterial switch conversion has not been reported but we present one such case. Case report: A 27 month old child was referred following a Senning operation for TGA, IVS done elsewhere at 2 months of age. He developed bouts of cough and facial swelling about one year after surgery. Examination showed mild facial puffiness, bilateral diffuse rales and hepatomegaly of 4 cms. Echo showed pulmonary venous baffle obstruction (PG 16 mmHg, MG 9 mmHg), systemic venous baffle obstruction (PG 18.8 mmHg, MG 6.8 mmHg), Mild TR, no outflow obstruction. LVPW thickness was 4 mm and LV mass 41 gm/ m2. At cardiac catheterization LV/RV systolic pressure ratio was 0.6, mean PAWP was 24 mmHg. Despite low LV/RV pressure ratio we opted for conversion to arterial switch relying on ECHO appearance of the left ventricle. Arterial switch was performed with take down of the Senning baffle and restoration of the atrial septum was done. Aortic clamp time was 90 minutes with CPB time 213 minutes including supportive bypass time of 60 minutes. He was weaned off CPB with 7.5 mcgs dobutamine, 0.8 mcgs milrinone and 2 mcgs NTG. Epicardial Echo showed no residual defects and LVEF 50%. Aggressive afterload reduction was the mainstay of the post-operative management. He was extubated after 60 hrs, ionotropes were weaned by the 7th day and discharged on the 14th POD.

Isolated Veno-atrial discordance? Does it exist? unsual malformation successfully corrected by modified Senning procedure

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Dinkar S, Kaw A, Iyer KS Escorts Heart Institute and Research Centre, Okhla Road, New Delhi Introduction: We present this interesting case to postulate the existence of isolated Veno-atrial discordance as a morphological entity Case report: A 15 year old asymptomatic boy was admitted with complaints of fever and cough. On examination he had mild cyanosis (SpO2- 92% on air) and grade I clubbing. Chest X-Ray showed dextrocardia, abdominal situs inversus. Echocardiogram suggested dextrocardia, left isomerism, abdominal situs inversus, common atrium, cleft anterior leaflet of mitral valve with mild mitral regurgitation, interrupted IVC with azygous continuity into a single LSVC draining to the left side of common atrium. The hepatic veins drained inferiorly into the left of the common atrium. Cardiac catheterization revealed a pulmonary artery pressure of 45/10 (24) mmHg. At surgery there was dextrocardia. The atrial chamber on the left had a morphologic left atrial appendage but received the left SVC and the hepatic veins. The pulmonary veins appeared lateralized with right sided atrium which had a morphologic right atrial appendage. There was complete absence of the atrial septum and both AV valves were at the same level as in a partial AV septal defect. Atrio-ventricular and ventriculo-arterial connections were concordant. Septation of the atrium was achieved with a modification of the Senning procedure using three separate patches of bovine pericardium resulting in both atria retaining their appropriate morphologic appendages. The cleft mitral valve was repaired. His post-op Echo revealed mild MR, Trivial TR, unobstructed systemic and pulmonary venous pathways and no baffle leak. He was discharged on the 8th POD on oral anti-coagulants and diuretics.

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Tailored surgery for ventricular septal defect, pulmonary atresia and major aortopulmonary collaterals—Evolution of a management protocol

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Ramakrishnan KV, Agarwal R, Cherian KM Frontier Lifeline, Dr KM Cherian Heart Foundaion, Chennai Background: Surgical management of children with ventricular septal defect (VSD), pulmonary Atresia (PA) and major aorto pulmonary collaterals (MAPCAs) is a challenge. Conflicting views exist regarding the optimal method of managing these children. Two radically opposed schools of thought exist—one which advocates single stage unifocalisation at the time of diagnosis for all children while the other recommends a central shunt as the first stage of a multi staged procedure for all patients. We have used a tailored approach to treat all these children and we present our management protocol that has evolved over time. Methods: We retrospectively analysed the data of all 76 patients who underwent surgical repair of VSD, PA, MAPCAs from Feb 2003 till date. Angiograms of all patients were reviewed and the anatomy of MAPCAs was extensively analysed. All patients were prospectively followed up (0-5 years). Results: The age of the patients ranged from 1 month to 28 years (median 3 months). Surgical procedures included central shunt (20), BT shunt (10), unifocalisation (with central shunt-12-, with conduit5,with augmentation of right ventricular outflow tract-2), primary conduit repair (14), staged Rastelli repair (after BT shunt-11, after unifocalisation-2), Glenn shunt (2). Additional pulmonary arterioplasty was done in 31 patients and hilum to hilum interposition graft was placed in 2 patients. Overall mortality was 16%. Risk factors for death were hypoplastic branch pulmonary arteries and operation in neonates. Conclusions: Individualised surgical approach is essential for treating children with VSD, PA. We recommend a management protocol that takes into account the patient’s age as well as the anatomy and functional significance of MAPCAs and native pulmonary arteries.

Primary arterial switch beyond 3 weeks of age : What is feasible without ECLS?

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Dinkar S, Kaw A, Iyer KS Escorts Heart Institute and Research Centre, Okhla Road, New Delhi Introduction: Infection of ruptured sinus of Valsalva aneurysm is a rare complication. Abscess formation resulting in pericarditis has not been reported before Case report: This 5 year old boy presented with h/o dyspnoea on exertion NYHA class II-III since last one month associated with palpitations on and off. There was h/o occasional low grade fever. On examination child was afebrile and mildly tachypnoeic on rest. Echo and Thoracic CT showed rupture of the sinus of Valsalva over the RCC into LV and MPA with mild to moderate AR, Mild MR, dilated LA and LV with thickened pericardium and features of effusoconstrictive pericarditis. Operative findings showed thickened pericardium and 1 cm thick layer of organized fibrinous exudates covering the entire heart. Sinus of Valsalva above the RCC was ruptured into the MPA. Aortic valve leaflets were spared. The posterior MPA wall was ruptured and was connecting to a large abscess cavity posterior to it containing necrotic material with an additional connection with the LV. The Pulmonary valve was spared. Necrotic material from the abscess cavity was cleared. The opening of the right sinus of Valsalva within the aorta was closed with a bovine pericardial patch. Opening communicating the abscess cavity to LV was closed with another bovine pericardial patch. Posterior wall of MPA was reconstructed with yet another bovine pericardial patch. Pericardium anteriorly between the two phrenic nerves was excised.

Cultures were negative and HPE showed inflamed fibrous tissue. Post operative course was uneventful but he was discharged on long term antibiotics.

Anomalous left coronary artery from the pulmonary artery with left ventricular dysfunction : Successful early outcomes without ECLS

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Dinkar S, Kaw A, Iyer KS Escorts Heart Institute and Research Centre, Okhla Road, New Delhi Background: Excellent early outcomes have been described in anomalous left coronary artery from the pulmonary artery (ALCAPA) repairs mostly with the use of assist devices or ECLS for failure of separation from CPB (del Nido PJ et al). To evaluate the early outcome of ALCAPA repair without mechanical support. A prospective observational study (1996 till March 2009). Methods: 20 patients underwent aortic re-implantation for ALCPA during this period - median age 108 days, 45 days – 45 years. 16/20 had significant left ventricular systolic dysfunction (EF < 40%) and 12/16 had severe LV dysfunction (EF <30%, median 20%). 4/16 needed preoperative stabilization (ventilation –1, inotropy –4). All 16 underwent emergency surgery. Surgical strategies included 1) Deferring mitral valve repair 2) Shorter CPB times – median 96 min, Cross clamp - 38 min 3) Delayed sternal closure (8/16), 4) Epicardial echo. Post repair ECHO revealed varying degrees of LV dysfunction in 15/16 and 3/5 had significant residual mitral regurgitation. Perioperative low cardiac output was managed preemptively using multiple, simple, inexpensive conventional strategies (milrinone, calcium infusion, corticosteroids in refractory cases, elective noninvasive ventilation). Results: In-hospital mortality was 0/16 with no late deaths. Median ventilatory requirement was 122 hours and median length of stay 15.5 days. 3/16 had significant ventricular arrhythmias. Conclusions: Successful ALCAPA repair in sick infants with severe ventricular dysfunction is feasible without ventricular assist with minimum morbidity.

TOF with absent RPA: A case report Ahuja V, Pradhan S, Sanyal MK, Bose S, Chatterjee S The Mission Hospital, Durgapur

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Introduction: TOF with absent LPA has been reported in the past but TOF with absent RPA is still to be reported. Here we report a one of the most rare anomaly, TOF with absent RPA. Case report: An 12 year old girl weighing18 kgs presented with a history of breathing difficulty and cyanotic spells. She was cyanotic with resting saturation of 80%. The principal echocardiography findings were: situs solitus, levocardia, subaortic mal-aligned VSD with RV infundibular obstruction. The branch pulmonary arteries were visualized, and assessed to be of adequate size. PDA present. CXR showed oligaemic lung fields. With a working diagnosis of Fallot’s tetralogy the patient was taken up for surgery. On table it was only LPA seen coming from MPA, RPA was not visualized.However after opening the right pleura, the lung appeared to be normal, so the decision on going a head with the total correction was made. Under cardiopulmonary bypass and cardioplegic arrest. TOF elements were managed by trans-atrial and trans annular route with infundibular resection and VSD closure with a Dacron patch. As the annulus was inadequate so the pericardium was used as transannular patch. The patient was weaned off bypass easily with good hemodynamics. Results: Post-operative progress was excellent and echocardiography on the 7th post op day showed intact VSD patch

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with good RV outflow to MPA and LPA and an estimated RV systolic pressure of 450 mm Hg. Conclusion: Surprises are known in paediatric cardiac surgery, however if other corroborating factors are favoring than one should carry on with definitive repair for on table surprises.

Tale of a migrated PDA device into abdominal aorta - Simultaneous successful transductal retrieval, with division and suturing of PDA

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Wadhwani M, Brijesh PK, Balasubramonium KR, Pillai V, Verghese PT, Jayakumar K, Unnikrishnan M Department of cardiovascular and thoracic surgery, Sri Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram Background: Minimally invasive device closure has nearly replaced the conventional open surgical approach in the management of PDA currently. Still, occasionally surgeon may be called for complications arising out of a routine PDA device closure. Methods: Two year old child was scheduled for PDA device closure after appropriate evaluation. A suitable Amplantzer device was being positioned to interrupt the ductus flow. During the procedure, the device slipped and migrated into the abdominal aorta at suprarenal position. Retrieval from femoral route was deemed inappropriate, particularly in view of age of patient. Eventually a Dormia basket was employed to disengage, retrieve and abut against the aortic ampulla of the ductus. Subsequently the child was shifted to the operating room. Under GA, left posterolateral thoracotomy was performed. The aorta above and below the ductus and the ductus itself was looped. The aorta was clamped above and below the pulmonary end of ductus and was snugged. A semicircular incision was placed at the aortic ampulla of the ductus and the device retrieved and division followed by suturing was completed. Conclusions: Device migration while attempting to interrupt ductus can be potentially dangerous and innovative measures needs to evolve for successful outcome.

Staged Yasui procedure for interrupted aortic arch, ventricular septal defect, and left ventricular outflow tract obstruction

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Inoue T, Oshima Y, Maruo A, Matsuhisa H, Kawamura A, Kadowaki T Department of Cardiovascular Surgery, Kobe Children’s Hospital, 1-1-1 Takakuradai, Suma-ku, Kobe, Hyogo 654-0081, Japan Background: There are some reports for one-stage biventricular repair (BVR) of interrupted aortic arch (IAA) or coarctation of the Aorta (CoA) with left ventricular outflow tract obstruction (LVOTO) in neonatal period, while it leads high mortality or morbidity. Alternatively, staged repair with initial Norwood followed by Rastelli has been reported in acceptable results. We report our experience with three patients to assess our strategy of surgical approach depending on VSD type. Cases: Case 1 with IAA (type A), doubly-committed VSD, and valvular aortic stenosis received BVR with valved conduit at the age of two months weighed 4. 2 kg following bilateral pulmonary artery banding (bil. PAB) at four days. Case 2 had IAA (type B), perimembranous VSD, and subvalvular stenosis with bicuspid aortic valve, and case 3 had CoA, perimembranous VSD, and valvular aortic stenosis. In both of case 2 and 3, it seemed to be difficult that intraventricular rerouting was achieved in neonatal term. They underwent Norwood (RV-PA shunt) operation at seven and four days, and additional Blalock-Taussig shunt. BVR with VSD enlargement was performed at the age of one year weighed 9 kg and 4 years weighed 10 kg, respectively.

Conclusions: Our strategy of staged BVR depending on VSD type contributes to good early outcomes. Bil. PAB followed by Yasui procedure in early infant can become an alternative to avoid a more magnitude of operation on neonate.

Can video-assisted thoracoscopic lobectomy (VATS lobectomy) be safely taught to non-board certificated trainee?

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Murakawa T, Fukami T, Nakajima J Department of Cardiothoracic Surgery, Graduate School of Medicine, The University of Tokyo, Japan Background: VATS lobectomies have been generally performed by self-trained senior surgeons. We just started to expose residents to VATS lobectomy as an operator with the ackground of ever-increasing demand for minimally invasive surgery. We compared initial results of VATS lobectomies performed by non-board certificated trainees (non-BCs) with those by board certificated surgeons (BCs) in the same period. Methods: Lobectomies performed thorough mini-thoracotomy by direct visualization were excluded in this analysis. The data of 16 consecutive VATS lobectomies performed from April 2009 to October 2009 were retrospectively analyzed. Results: Three BCs performed 9 VATS lobectomies for 8 clinical stage I lung cancers and 1 metastatic lung tumor, and three non-BCs 7 for 7 clinical stage I lung cancers. Systemic node dissections were done in 8 patients in BC group, and 4 in non-BC group. Non-BCs used 4 access-ports, while BCs generally used 3 ports. There was no conversion to open thoracotomy. Maximum skin incision length was comparable between the two groups (mean 40 mm in both groups). Non-BCs spent more time in performing VATS lobectomy as compared with BCs (mean 234 minutes vs mean 203 minutes, p= 0.04). There was no significant difference in number of resected nodes, intraoperative blood loss, duration of chest drainage, and postoperative hospital stay. Conclusions: VATS lobectomy can be safely taught to non-board certificated trainees under the supervision of experienced BC surgeons. Increase of number of access-ports may be helpful in facilitating the procedure.

The current place of tuberculosis in thoracic surgical infections: The Sri Lankan experience

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Tolusha H, Jayasinghe KRDI, Gunasekera SNDS Thoracic Surgical Unit, Chest Hospital, Welisara, Sri Lanka Background: Infections account for a considerable work load in a thoracic surgical unit. Our aim was to look at the current pattern of these infections with special emphasis on tuberculosis (TB). Methods: Admissions to our unit at the Chest hospital, the only tertiary referral center for chest diseases in the country, from April to June 2009 were retrospectively reviewed. Results: During ten weeks 100 admissions were made of which 53 were thoracic infections. There were 44 (83%) males. The mean age was 42 (range 7- 72) years. They presented as empyema 24 (45.3%), pleural effusion 9 (17%), pneumonia 6 (11.3%), mycetoma 6 (11.3%), lung abscess 3 (5.6%), post pneumonectomy space infection 3 (5.6%), localized bronchiectasis (1) and mediastinal tuberculous lymphadenopathy (1). TB was the causative factor in 19 (35.8%); nontuberculous primary infections in 18 (33.9%), blast/gunshot injury in 8 (15.1%), infection after intercostals tube insertion (ICT) in 4 (7.5%) tumour obstruction in 2 (3.8%) and infected haemothoraces following trauma (1) and snakebite (1). Treatment was by ICT 23 (43.49%), needle aspiration 9 (17%), antibiotics alone 9 (17%) embolisation for mycetomas 6 (11.3%), decortication 2 (3.8%), oncosurgical treatment

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2 (3.8%) lobectomy (1) and video assisted thoracoscopic surgery (1). Incomplete lung expansion was seen in 7 (13.2) after ICT for TB empyemas. The mortality was 1 for severe sepsis (non operative). Conclusions: TB remains the most important cause of thoracic surgical infections. The distinction between TB effusions and empyemas is important to decide between needle aspiration versus ICT to prevent permanent lung collapse.

Combined thoracoscopic and neurosurgical approach of neurogenic dumbbell tumors: Report of two cases

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Ryuta F, Yoshihito I, Kyu R, Masahito S, Koyu T, Okita Y, Imazeki T Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan Background: Thoracoscopy has already become the standard approach for the removal of neurogenic mediastinal tumors. However, there are risks for adjacent nervous structures, and approximately 10% of posterior mediastinal nerurogenic tumors include a spinal canal component, they have two portions connected by a narrow foraminal segment, so that they have been called dumbbell tumors. Method: Phase 1: Posterior neurosurgical removal of spinal component of tumor After the induction of general anesthesia with spiral tube, the patient is positioned prone and hemilaminectomy is performed at the level of tumor. Once it is adequately exposed, the nerve root from which the tumor arises is transected. Phase 2: Thoracoscopic removal of the intrathoracic tumor. The patient is reintubated with a double-lumen tube and received thoracoscopic tumor resection with an ultrasonic scalpel in lateral decubitus. Results: Case 1: A 53-year-old woman presented to our hospital because of an abnormal mass in the posterior mediastinum on CT. Axial MRI showed a paravertebral neurogenic tumor with transforaminal extension, which located at Th12/L1 level. Tumor’s diameter was 7.5cm. We resected it successfully with two-stage combined surgery cooperating with orthopedic surgeons of our hospital. Case 2: A 71- year-old man presented to our hospital with an abnormal shadow on chest X-ray. On CT, the tumor located at TH2/3 level, its diameter was 5.4cm. We removed the tumor same as Case 1 with no complication. Conclusion: Two-stage combined surgery for paravertebral neurogenic tumor enabled safe transection of nerve root and less invasive thoracoscopic tumor resection.

Emerging paradigm in lung resectional surgery – Recent experiences at Sree Chitra Tirunal Institute for Medical Sciences and Technology.

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Wadhwani M, Balasubramonium KR, Pillai V, Panicker VT, Jayakumar K, Unnikrishnan M Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram Background: Resectional lung surgery, with excellent and proven track record offers the most appropriate therapeutic strategy for a variety of lung diseases in clinical practice. Retrospective analysis of resectional lung surgery data obtained from medical records of our institute. Methods: In our department at SCTIMST in the past ten years from November 1999 to November 2009, 381 patients underwent varieties of lung resections who were aged range between 6 months

and 72 years, mean of 40.89 years with male: female ratio was 2.46:1 in this cohort. Standard protocols were used for evaluation, preparation, surgery and post-operative care in this series. Clinical diagnosis was malignancy including bronchogenic carcinoma in 65%, Benign mass including bronchial adenoma in 2.5%, bronchiectasis in 23%, pulmonary tuberculosis and sequelae in 6.5% and miscellaneous in 3%. Specific surgical strategy included DLT intubation in all the patients. Extent of resection was lobectomy in 83%, pneumonectomy in 10%, wedge resection or segmentectomy in 7%. Results: There was 1 mortality in this series who succumbed to complications of contralateral tension pneumothorax following pneumonectomy. All the other patients were discharged between 7 to 15 days. Post-operatively 5 patients required re-exploraion. Five patients required thoracoplasty for delayed space infection. Conclusion: Over time bronchogenic carcinoma has formed major indication for surgery of the patients in our experience, in contrast to infective etiology, which has declined, leading to good, early and longterm results.

Histoculture drug response assay guided adjuvant chemotherapy in patients with ERCC1positive non-small cell lung cancer

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Yoshimitsu H, Oura S, Yoshimasu T, Tamaki T, Nakamura R, Kiyoi M, Miwako M, Yoshitaka O Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan Background: A recently reported large randomized control study revealed that cisplatin based adjuvant chemotherapy was not effective for patients with ERCC1 positive non-small cell lung cancer. According to this finding, we must decide suitable adjuvant chemotherapy protocol in ERCC1-positive, namely CDDP-resistant patients. Methods: Surgically resected fresh tumor specimens obtained from 28 patients with non-small cell lung cancer were used. Histoculture drug response assay (HDRA) were used as an in vitro drug sensitivity test. HDRA technique was the same as we previously reported (JTCVS 133: 303-8, 2007). Chemosensitivities of ten drugs were evaluated. Immunohistochemical staining for ERCC1 was done using monoclonal antibody clone 8F1. The H-score was adopted for the evaluation of ERCC1 expression. Results: ERCC1 was positive in 22 specimens and negative in 6 specimens. Squamous cell carcinoma showed higher positive rate for ERCC1 (92%) compared with adenocarcinoma. Inhibition rate for CDDP in HDRA was significantly lower (p=0.01) in ERCC1-positive specimens (43±15)% than in ERCC1-negative specimens (61±8%). All ERCC1-negative specimens were sensitive for CDDP in HDRA, and all CDDP-resistant specimens in HDRA showed positive ERCC1 staining. There were 13 patients with both CDDP-negative in HDRA and ERCC1-positive. In these patients, who showed absolutely CDDPresistant characteristics, HDRA provided average 3 (0-6) sensitive anticancer agents except for CDDP. Conclusion: The inhibition rate for CDDP evaluated by HDRA was significantly correlated with ERCC1 status evaluated by immunohistochemistry. There were several HDRA-positive chemotherapy agents in ERCC1-positive patients. HDRA may provide individualized effective non-platinum adjuvant chemotherapy protocols for patients with ERCC1-positive, i.e. CDDP resistant, NSCLC.

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“Missile cardiovascular injuries”

Lateef WM, Ahangar AG, Hakeem Z, Qadri A, Farooq D, 139 Ifat I Department of Cardiovascular and Thoracic Surgery Sher-i-kashmir Institute of Medical Sciences, Soura, Srinagar Background: Missile Cardiovascular injuries have taken epidemic proportion in Kashmir valley since the eruption of militancy in 1990. Present study was undertaken to analyse the mode, pattern, presentation and management of missile cardiovascular injuries. Prospective and retrospective. Methods: Retrospective study of patients with missile cardiovascular injury from Jan 1996 to Oct 2008. 386 patients with missile cardiovascular injury were studied. All patients of cardiovascular injury due to causes other than missiles were excluded from the study. Results: All patients of missile cardiac injuries were treated by primary cardiorrhaphy. Right ventricle was the most common chamber affected. Left anterior thoracotomy was most common approach used. Most of the patients of missile vascular group were treated by reverse saphenous vein graft or end to end anostomosis. Most common complication was wound infection (20.83%) followed by graft occlusion (1.94%) in missile vascular group. Amputation rate was 4.66%.Amputation rate was higher in patients with delay of >6 hours and associated fractures. Conclusion: Missile cardiac injuries are becoming common due to use of more sophisticated weapons in domestic violence. Results are best if operated early and outcome depends upon multiple factors including clinical status at arrival, time interval till management, nature of injury and associated injuries. Missile vascular injury needs prompt resuscitation and revascularisation. Preoperative angiography is seldom necessary. Doppler study may sometimes be needed to aid the diagnosis.

Endobronchial tumour: Sleeve resection in children

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Suvarna SH1, Tolusha H2, Walgamage T1, Jadav RK1 1 Apollo Hospital, Colombo, 2Chest Hospital Welisara, Sri Lanka

Background: Carcinoid tumours are the most commonly occurring primary tumours in childhood and it accounts to be the second commonest bronchial tumour seen within the tracheobronchial tree. Bronchial parenchymal saving procedures especially in children are usually preferred although rarely performed. Methods: An 8-year-old girl admitted with a six month history of chronic cough associated with a sudden loss of the left lung marking. She was initially treated for pneumonia and a flexible bronchoscopy was attempted to rule out any foreign body but procedure abandoned due to a hemorrhagic looking endobronchial lesion totally obstructing the left main bronchus. Virtual CT - bronchoscopy confirmed above findings with bronchieatic changes within the lung parenchyma. The differential diagnosis was a possible foreign body granulation tissue. Endo bronchial tumour approximately 2cm away from carina excised followed by sleeve resection of the left main bronchus using a single layer closure. Results: Child made an eventful recovery and was discharged home on the 8th post-operative day. At two week follow-up, repeat flexible and a virtual CT-Bronchoscopy confirmed a patent left main bronchus with good aeration of the left lung parenchyma. Histopathology confirmed carcinoid tumour with clear margin and no spread to the sub aortic hilar lymph node and lung tissue. She has been advised chest physio for treatment of chronic bronchiectasis with regular follow-up.

Conclusions: Review of the literature showed that sleeve resection in children is uncommon due to the rarity of pathology demanding it. Virtual bronchoscopy via a CT is useful when the tumour is hemorrhagic.

Use of a portable digital chest drain system in thoracic surgery: The initial Hong Kong experience

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Sihoe ADL Department of Cardiothoracic Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China Background: Portable chest drain systems are now available which promise greater patient mobility and can record invaluable digital data on air leakage, but clinical experience with such systems has thus far been limited. Methods: The Thopaz digital chest drain (Medela, Switzerland) has been used at a single institute in Hong Kong since October 2008. More recently, an ongoing prospective study has been commenced recruiting consecutive patients who have either a Thopaz or conventional water seal chest drain following thoracic surgery. Clinical data for these patients have been supplemented by questionnaire surveys of both patients and nurses on aspects of chest drain morbidity and daily use. Results: Experience with the first 50 patients using the Thopaz revealed no drain-related complications or primary equipment failure. Minor logistical issues were initially encountered but easily remedied, and the overall learning curve was short. Interim analysis of initial results from the prospective study (17 Thopaz, 15 water seal) already show that use of the Thopaz has significantly reduced incidences of inter-observer discrepancy in documenting air leakage (2% vs 25%, p=0.001) and complications due to such discrepancy. Patients using the Thopaz also reported significantly less sleep disturbance due to noise from chest drain suction (p=0.020). There were trends for earlier mobilization, shorter drain durations and hospital stay durations in patients using the Thopaz. Conclusions: Use of digital chest drains is safe and easy. They can enhance consistency in air leak management and potentially improve patient quality of life following thoracic surgery.

Aspergilloma - Clinical presentation and surgical outcome Padhy K, Narasimham SBR, Satyanarayana PV Department of Cardiothoracic and Vascular, Care Hospital, Visakhapatnam

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Background: Aspergilloma is a rare fungal infection of lung. It occurs most often as a secondary infection in a tubercular cavity. They can have a varied clinical presentations of cough with expectoration, recurrent haemoptysis to massive haemoptysis. Drugs usually do not penetrate to the cavity. Methods: From June 2005 to Sep 2009, 11 cases of Aspergilloma had undergone lung resection. Age range being from 16 to 63 years with average of 39 years. Eight were male and 3 were female. Eight had history of tuberculosis .Four patients presented with massive haemoptysis, 5 with recurrent haemoptysis and 2 with cough with expectoration. All were investigated with X –ray chest, Computed Tomography scan and fibreoptic bronchoscope. Three cases had undergone left pneumonectomy, 3 left upper lobectomy, 3 right upper lobectomy, 1 right lower lobectomy and 1 left lower lobectomy. In one case latissmusdorsi myoplasty was done in addition to left upper lobectomy. All cases were treated with antitubercular drugs perioperatively.

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Results: Excess bleeding occurred in 3 patients of which two required reexploration. One patient had bronchopleural fistula (BPF) for which open window was done later. There was no haemoptysis postoperatively. One case expired due to excess bleeding and DIC. All cases histopathological study was suggestive of Aspergilloma. Conclusion: Most of cases occurred in post tuberculosis cavity, left side was most common site. Haemoptysis was the most common presentation. BPF is a major complication.

Aerosolized endoscopic spray application of fibrin for on-table air leaks following lung resection surgery: A case-match study

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Sihoe ADL, Lee A Department of Cardiothoracic Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China Background: This study assesses the management of on-table alveolar air leak (AAL) after lung resection using aerosolized fibrin applied via a new spray device designed for minimally-invasive surgery. Methods: Between August 2007 and April 2009, 31 patients found to have AAL on-table following lung resection surgery received aerosolized fibrin application using an endoscopic spray device in addition to conventional AAL repair techniques. Video-assisted thoracic surgery (VATS) was used in 26 of these patients (83.9%). Using an array of demographic and clinical variables, the 31 patients in the Fibrin group were matched with 31 Control patients who received only conventional repair for on-table AAL after lung resection. All patients in both groups received identical peri-operative care. Results: No patient developed complications attributable to fibrin. Only 14 patients (45%) of patients in the Fibrin group had AAL after the first post-operative day compared to 23 (74%) in the Control group (p=0.020). Significantly fewer patients in the Fibrin group required prolonged hospital stays of over 9 days (29% vs 55%, p=0.039). These results were even more pronounced amongst patients who received VATS (26% vs 81%, p=0.015; and 23% vs 62%, p=0.007 respectively). In patients whose degree of on-table AAL was mild, fibrin also significantly reduced both initial post-operative AAL incidence (24% vs 58%, p=0.020) and chest drain durations longer than 7 days (24% vs 54%, p=0.037). Conclusions: For AAL found on-table following lung resection surgery, aerosolized spray application of fibrin may reduce the impact on post-operative outcomes. Patients receiving VATS and with milder on-table AAL may particularly benefit.

Clinical analysis of surgical management for deep neck infection with descending necrotizing mediastinitis

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Kang SK, Kang MW, Lee SK, Yu JH, Na MH, Lim SP Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Daejeon, South Korea Background: Deep neck infections(DNI) could be managed medically, but some of them need surgical treatment, especially in mediastinal involvement. Methods: We reviewed medical records of patients who underwent cervical drainage only (CD group) and cervical drainage combined mediastinal drainage (MD group) for DNI without descending necrotizing mediastinitis (DNM) from august 2003 to May 2009 retrospectively. Results: Among 56 patients, 12 patients need cervical and mediastinal drainage (21%). MD group was older, longer hospital stay, higher mortality and negative identification of causative organisms (P<0.05). More than two space involvement, especially

retropharyngeal space, is higher prediction about mediastinal spread. Conclusion: Despite of appropriate treatment for DNI and DNM, morbidity and mortality are not negligible in mediastinal involvement. Early diagnosis and prompt medical and surgical management is essential for better outcome.

Chondroma of the manubrium: The management challenges of the manubrial tumour

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Tolusha H1, Suvarna SH2, Thilakaratne MG1 1 Thoracic Surgical unit, Chest Hospital, Welisara, 2 Cardiothoracic Unit, Lanka Hospitals, Colombo, Sri Lanka Background: The bony mass of the manubrium presents a rare challenge with regard to its diagnosis, excision and reconstruction. We report a chondroma of the manubrium and its management challenges and review the literature. Methods: A 30-year-old lady was referred from the orthopaedeic unit with an expansile bony lesion of the manubrium with extension into the head of the right clavicle. A trucut biopsy diagnosed it as a chondroma. Complete resection of the manubrium and the head of the right clavicle were performed. Both internal mammary arteries needed ligation to control bleeding. The clavicles were stabilized with wires and reconstruction performed using a prolene mesh without using bone cement and bilateral pectoralis muscle flaps. Bilateral intercostal drainage was instituted as the apices of the pleura were breached. Results: The final cosmesis and the functional outcome were highly satisfactory. The literature shows that sternal tumours, and especially manubrial tumours, are rare. Malignant manubrial tumours are commoner than benign but clinical and radiological diagnoses are notoriously difficult which mandates pre-operative biopsy prior to excision. Massive haemorrhage has been reported after excision of some manubrial tumours. Radiotherapy alone has been reported to give good results in plasmacytomas and aneurysmal bone cysts making it also a good option in such cases. Conclusions: The histological diagnoses of manubrial tumours should be established prior to deciding on surgery. Bilateral internal mammary vessels and pleural apices are at risk during excision of the manubrium. Reconstruction with wires, mesh and pectoralis flaps gives good results.

Bilateral empyema – Sri Lankan experience Walgamage Thilan B, Suvarna SH, Jadhav RK Apollo Lanka Hospitals, Colombo-05, Sri Lanka

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Background: Although thoracic surgery probably began with the management of empyema, mismanagement of empyema are still common. We report a case of mismanaged parapnemonic effusion. Methods: A 16-years-old Sri Lankan male presented to a local hospital with fever and shortness of breath. Chest X ray revealed consolidation of the right lung. He was treated with IV antibiotics but subsequently developed bilateral pleural effusion. He was tested as MRSA positive for blood and urine cultures. Patients on going sepsis and massive bilateral hydropneumothorax were partially aspirated and he was discharged with oral antibiotics after 40 days in hospital. After one week, he was readmitted to medical ICU in the local hospital with severe shortness of breath and unable to maintain saturation more than 80% on room air. He was immediately transferred to our tertiary care hospital to undergo an emergency two staged Video Assisted Thoracoscopic (VATS) drainage of empyema and pleural abrasion on both the lungs at four day intervals since he was very ill. Results: Patient fully recovered, both lungs were completely expanded with intercostal drains in situ. This was later connected to bilateral Heimlich valve to drain the empyema and patient discharged

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home after ten days. After two months the chest drainage was minimal and both Heimlich valves removed. Both lungs remain fully expanded without any residual fluid collection. Conclusion: Empyemas are a common condition following bacterial and tuberculosis pneumonia. Tuberculosis continues to play a major source for empyema in developing countries. The management of empyema however simple when not diagnosed and treated at the correct time can lead to an increase in morbidity and mortality.

Trends and patterns of mediastinal space occupying lesions is Sree Chitral Tirunal Institute For Medical Science and Technology : Recent surgical experiences

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Brijesh PK, Wadhwani M, Balasubramaniam, Kapilamoorthy TR, Pillai VV, Panicker VT, Jayakumar K, Unnikrishnan M Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram Background: Mediastinal space occupying lesions, generally known as medistinal tumors mandate careful evaluation, imaging and judicious surgical strategy to obtain good outcome. Retrospective analysis of patients using data from medical records of SCTIMST with mediastinal tumor having undergone appropriate surgery. Methods: During study period of less than 4 years, from January 2006 to October 2009,100 consecutive patients who underwent evaluation and surgical management at SCTIMST form the basis of the report. Age of the patients ranged from 3 to 67 years, males 52 and females 48. 84 patients were symptomatic while mass was incidentally detected in 16 patients. All patients reported with clinical diagnosis and investigations proving diagnosis of mediastinal tumor. Surgical approach between sternotomy and posterolateral thoracotomy was decided on the nature of encroachment of tumor into the side of hemithorax. Total excision could be achieved in 96 cases, while debulking was done in 3 cases and open biopsy in 2 cases. Results: All patients made satisfactory early recovery and were discharged from hospital in 7-12 days. Two Patients required reexploration for early bleeding. Histopathological examination reported thymoma in 51 patients, malignant Germ cell tumors 10, Duplication cyst 11, neurogenic tumors 8 and miscellaneous 20. Myasthenia gravis was present in 35 patients with thymoma. Three patients died on follow up; rests of the patients are doing well with good quality of life. Conclusions: In contrast to reports in literature our series had high number of thymoma patients. Appropriate planning and surgical strategy provided excellent early and medium term results.

Recent experience with tracheal reconstructive surgery

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Brijesh PK, Wadhvani M, Balasubramaniam, Thomas B, Pillai VV, Panicker VT, Jayakumar K, Unnikrishnan M Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram Background: Tracheal tumors provide tremendous challenge in their surgical management due to sharing of the airway by anaesthesiologists and surgeon simultaneously Methods: Two ladies aged 45 and 51, presented with severe dyspnea and mild hemoptysis. On evaluation were found to have tumor in trachea. Principal investigation was CT chest and neck. Under general anaesthesia using 5.5 mm flexometallic endotracheal tube,

trachea was fully mobilized using a collar cervical and median sternotomy incision. Trachea was transected distal to tumor and airway obtained using sterile tubing system with endotracheal tube in operating field. Segment of trachea was excised with tumor negative margins. After making posterior continuity of resected tracheal margins, endotracheal intubation was performed and reconstruction completed. Results: Both patients made satisfactory early recovery. First patient developed pulmonary embolism on 5th postoperative day and made good recovery with medical management. Histopathological evaluation revealed adenoid cystic carcinoma in both patients. Adjuvant radiotherapy was given after 6 weeks. On follow up they are doing well at 21/2 and 1 year postoperatively. Conclusions: Tracheal resection with primary anastomosis remains a rare procedure but can be performed with low morbidity and good functional results with careful pre and postoperative management and meticulous surgical technique.

The haemorrhagic endobronchial lesion in children

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Suvarna SH1, Tolusha H2, Walgamage T1, Jadav RK1 1 Cardiothoracic Unit, Apollo Hospital, Colombo, 2Thoracic Surgical unit, Chest Hospital, Welisara, Sri Lanka Background: Diagnostic bronchoscopy is commonly performed for suspected foreign bodies in children with unresolving pneumonia. When the obstructing lesion is haemorrhagic it can be a challenge due to its potential for uncontrolled bleeding and airway compromise. If this mandates immediate definitive surgery deciding on the type of resection is problematic when the type and extent of the lesion remains unknown. Method: An eight- year old girl with chronic cough for six months and complete white -out of the left lung field on chest radiography underwent flexible bronchoscopy under general anaesthesia. A haemorrhagic endobronchial lesion totally obstructing the left main bronchus was found. The procedure was abandoned and a virtual CT bronchoscopy done which confirmed the above and also showed early bronchiectatic lung parenchymal changes. The child was prepared for surgery and on- table rigid bronchoscopy performed. Biopsy resulted in considerably bleeding mandating insertion of a double lumen endotracheal tube into the right bronchus and proceeding with thoracotomy. She underwent bronchotomy and sleeve resection. As frozen section was not available, lung biopsy was done with a plan for completion pneumonectomy if needed. Results: The histopathology showed a bronchial carcinoid tumour with clear margins and no spread of tumour to the regional lymph nodes or lung tissue. She has subsequently made a good recovery. Conclusions: Both foreign body granuloma and tumours can appear as endobronchial haemorrhagic lesions. As biopsy can cause bleeding and airway compromise this should be done in anticipation of thoracotomy where lung sparing surgery should be the aim.

VATS for spontaneous pneumothorax Padhy K, Kishan M, Narasimham SBR, Satyanarayana PV Department of Cardiothoracic and Vascular, Care Hospital, Visakhapatnam

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Background: Video associated thoracic surgery was developed as an exciting field in thoracic surgery. This has several advantage like reduced hospital stay, reducing respiratory complications and post-operative pain. Methods: A 18-yearfemale presented with left side spontaneous pneumothorax. Tube thoracostomy was done. Air leak continued. X

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– Ray chest revealed no abnormality. CT scan chest showed bullae in left upper lobe, Video Assisted Thoracic Surgery (VATS) was performed under general anaesthesia with double lumen endotracheal tube for epsilateral lung collapse. Ruptured bullae in left apical region identified. With the help of endostapling device the bullae stapled and resected. The resected specimen removed through one of the port. Results: Patient had uneventful post-operative period and discharged on 3rd post operative day. Conclusions: VATS is a very safe and useful technique for spontaneous pnemothorax.

Distal and retrograde embolism – A rare presentation of cervical rib

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Padhy K, Narasimham SBR, Satyanarayana PV Department of Cardiothoracic and Vascular, Care Hospital, Visakhapatnam Background: Cervical rib may remain asymptomatic or present with neurovascular complications.Compression of subclavian artery with subsequent aneurysm formation can lead to in-situ thrombus formation which can embolise proximally or distally. Materials and Methods: A 35-year-old male patient admitted with pain in right upper limb of sudden onset along with tingling and numbness in fingers. He had one similar episodes 4 years back and treated conservatively. On examination right upper limb pulses were absent. Tightness of fore arm was present. Neurological examination revealed right sided nystagmus with slurred speech. Computed tomography angiogram of upper limb arterial system and neck vessels revealed occlusion of right brachial artery in mid and distal arm up to bifurcation with short segment reformation at distal forearm. Right cervical rib with focal stenosis and aneurysm of subclavian artery at thoracic outlet and right external carotid and vertebral artery occlusion at origin was present. Computed tomography of brain revealed focal hypodense areas of altered attenuation of cerebellar hemisphere. Right neck collar incision given parallel to clavicle. Right subclavian artery was isolated. Cervical rib was excised. Right axillary artery was isolated in delto pectoral grove. 6mm PTFE graft anastomosed between subcalvian artery and axillary artery. Brachial artery was exposed and embolectomy done. Fore arm fasciotomy was done. Results: Vascularity improved. Limb was saved with limited deformity. Conclusions: Cervical rib can compress the subclavian artery and cause aneurysm formation. Retrograde embolisation can present with brain stroke as a fatal complication.Distal embolisation can be limb threatening.

Clinicopathological analysis of patients with coexistence of pulmonary hamartoma and lung cancer

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Matsuda E, Okabe K, Tao H, Yamamoto H, Sugi K Yamaguchi-Ube Medical Center, Higashi Kiwa 685, Ube Yamaguchi Background: Pulmonary hamartoma is most common benign tumor. There are few reports that hamartoma recurred after resection, but it is not malignancy. Therefore several authors argued the increased risk of lung cancer in patients with pulmonary hamartoma. We experienced 3 cases with coexistence pulmonary hamartoma and lung cancer.

Methods: From April 2002 to March 2009, fourteen cases of pulmonary hamartoma were operated in our hospital. Primary lung cancer was found in 3 cases (21.4%). We studied clinicopathological feature in these 3 patients. Results: All of 3 patients were underwent bronchofiberscopy. In all cases, diagnosis of lung cancer was obtained, but pulmonary hamartoma was not diagnosed by bronchofiberscopy. There is suspicion of matastasis or other malignancy in preoperative diagnosis. Operation was performed to obtain histological diagnosis. In 2 of these 3 patients, pulmonary hamartoma existed in the same side lung with lung cancer, these were resected simultaneously. In the remainder, pulmonary hamartoma existed in the other side lung, and resected one month later from the resection of lung cancer. Three pulmonary hamartomas were composed of cartilage tissue without malignancy, while adenocarcinoma, squamous cell carcinoma, large cell carcinoma were for each one case. Conclusions: Pulmonary hamartoma is benign tumor. It seemed that malignant transformation of pulmonary hamartoma do not occurred in clinically. But our finding showed that 21.4% of pulmonary hamartoma coexisted lung cancer. Patients with pulmonary hamartoma should undergo sufficient evaluations.

Recent experiences with elective open thoraco abdominal aortic aneurysm repair at sree chitra institute for medical sciences and technology

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Menon S, Shivananda S, Menon A, Pillai VV, Panicker VT, Gupta AK, Jayakumar K, Unnikrishnan M Department of Cardiovascular and Thoracic Surgery, Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram Background: Thoraco abdominal aortic aneurysm poses great challenge in management associated with high mortality and morbidity, even in current era. Retrospective single surgeon series of thoraco abdominal aneurysms, who underwent open surgical repair at our institute. Methods: 40 patients who underwent elective open repair of thoraco abdominal aneurysm during last 4 years from Sep 2005 to Sep 2009 formed the basis of this report. All except 2 were symptomatic. In this cohort, which included 5 women with age ranging from 32 to 75 years (mean 55). Aneurysms belonged to all types in modified Crawford classification. Co-morbidities included hypertension in 35 (88%). Imaging techniques included 64-slice computed tomography and coronary angiography for risk stratification. Procedures were performed under general anesthesia with double lung ventilation, thoracic epidural analgesia, cerebrospinal fluid drainage and continuous blood perfusion of visceral and renal arteries using temporary aorto-femoral bypass, blood retrieval system and home made circuitry. Results: 30-day mortality was 7 (18%) (intra-op-haemorrhage–2, disseminated intravascular coagulation in ICU–3, acute on chronic renal failure–1, dense paraplegia–1). Two patients required reexploration for haemorrhage. Transient renal dysfunction occurred in 15 patients. Conclusions: Our surgical strategy including distal circulatory support and continuous organ perfusion provided safe operating conditions during the most challenging open surgical repair of thoraco abdominal aneurysm. During the past 2 years, mortality has come down from 18% to 10% with a concerted effort to decrease haemorrhagic complications.

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Prevention of spinal code infarction after thoraco-thoracoabdominal aneurysm repair with preoperative visualization of the Adamkiewicz artery

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Saito M, Irie Y, Hara T, Ohkita Y, Tanaka Y, Fukai R, Rokkaku K, Imazeki T Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Koshigaya Hospital Background: Spinal code infarction after thoracothoracoaddominal aneurysm repair is especially miserable complication. Recently some prevent method of spinal code infarction were reported and introduced preoperative visualization of the Adamkiewicz artery(AKA) and cerebrospinal fluid (CSF) drainage during intra and post operative period in our institution. Method: Between March 2005 and September 2009, we repaired 25 thoraco-thoracoabdominal aneurysm. 22 cases among them were visualized the AKA. All cases could be analyzed AKA with threedimensional computed tomography (3DCT). Median patient age was 65.18±9.56, and 5 were women. We performed CSF drainage in 12 cases and kept CSF pressure under 20mmHg. AKA selective perfusion and reconstraction were performed in 10 cases. Results: Median operation time was 375.36±161.08 minutes. Median CPB time was 155.82±85.88 minutes. AKA reconstraction were performed 10 cases. Median postoperative intubation time and ICU stay days 104.91±314.80 hours and 3.27±4.18 days. There was no cerebral infarction and 2 cases complicated spiral code infarction. Operative mortality was 4.5%(1 case). Conclusion: Because pinal code infarction and operative mortality were only 9% and 4.5%, preoperative visualization of AKA with 3DCT was effective method for thoraco-thoracoabdominal aneurysm repair.

The frozen elephant trunk technique: New standard of care?

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Subramanian S, Borger MA, Sauer M, Höbartner M, Mohr FW Department of Cardiac Surgery, German Heart Center Leipzig, Leipzig, Germany Background: The frozen elephant trunk is a hybrid procedure enabling one-stage treatment of extensive aortic disease. Recently, several centers have reported good early and mid-term results with this technique. The objective of this report is to examine the indications, and outcomes to determine whether this strategy should be routinely adopted. Methods: A comprehensive review of the available english literature using PubMedTM was performed with the search terms “frozen elephant trunk” and “stented elephant trunk.” The latest update from each group or groups was selected for inclusion. Series with < 5 patients were excluded. Results: A total of 10 series with 711 patients were reviewed. The most common pathology was aortic aneurysm (37%), followed by aortic dissection, specifically acute type A (28%), chronic type A (21%), acute type B (5.5%), and chronic type B (8.5%). Perioperative mortality occurred in 6.6% (95% C.I. 4.8 – 8.4%) of all patients, while stroke and paraplegia occurred in 4.78% (95% C.I. 3.29 – 6.27%) and 3% (95% C.I. 2.98 – 3.02%) respectively. Although complete false lumen/peri-graft thrombosis occurred in some series, late endoleaks, aortic reinterventions, and aorticrelated deaths occurred in up to 10% of patients. Conclusions: Short-term results of the frozen elephant trunk technique reveal comparable morbidity and mortality to conventional elephant trunk series. Late reinterventions and aortic-related deaths emphasize the need for ongoing aortic surveillance, even with complete false lumen thrombosis. While sufficient data exists to establish the safety and durability of this technique, it cannot be recommended routinely for all cases of extensive aortic pathology.

Surgery for abdominal aortic aneurysm in octogenarians

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Satsu T*1, Onoe M*1, Saga T*2 *1 Department of Cardiovascular Surgery, Kishiwada City Hospital, Japan, 1001 Gakuhara-cho, Kishiwada City, Osaka 596-8501, Japan *2 Department of Cardiovascular Surgery, Kinki University, School of Medicine, Japan, 377-2 Ohno-Higashi, Osaka-Sayama City, Osaka 5898511, Japan Background: This study was undertaken to evaluate activities and cognition statues associated with abdominal aortic aneurysm (AAA) surgery in octogenarians, and the adequacy of AAA open repair from these perspectives in octogenarians. Methods: There were 64 octogenarians (mean age: 83.8 years) and 192 patients <80 years old (mean age: 70.9 years). We evaluated perioperative factors, and long-term survival. Especially, postoperative activities of daily life and cognitive status were estimated using precise criteria. Results: The number of elective cases was 45 in the octogenarian group and 164 in younger patients. Mean aneurysmal diameter was larger in octogenarians. There were no differences in intra-operative factors except for transfusion volume between two groups. In elective cases, no significant difference in 30-day mortality was shown between two groups. In emergent cases, there were no significant differences in early post-operative factors and 30-day mortality. In octogenarians, the level of the activity of daily life and cognitive statues were almost preserved (retention ratio: 92.6% and 96.3%). The survival rate at 5 years in octogenarians was 85.7% and 42.4% in elective and emergent cases. Conclusions: In this study, open surgery for AAA over octogenarians was revealed to be adequate and safe. The tendency for the proportion of emergent cases and operative aneurysmal diameter to be larger in octogenarians than in younger patients suggests that surgical therapy in octogenarians was performed only as a last resort. Thus, we must enlighten surgeons and physicians on it that patient’s age is not the factor to reject open surgery.

Mid-term results of total replacement of the aortic arch using selective cerebral perfusion in a low volume hospital

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Matsumoto M, Suzuki S, Kaga S, Sakakibara K, Kimura M, Kato K, Shiraiwa S Department of Cardiovascular Surgery, Yamanashi University Graduate School of Medicine, Yamanashi 409-3898, Japan Background: Morbidity and mortality after total arch replacement are still high. We evaluated the mid-term results of the arch operation in a hospital with relatively low volume surgeries. Methods: Between January 2005 and September 2009, 19 consecutive patients (17 men; mean age, 66.0±11.1 years) were treated with total arch replacement using antegrade selective cerebral perfusion with moderate hypothermia. Indications for operation were degenerative aneurysms in 15 patients, chronic aortic dissection in 3 and acute aortic dissection in one. Concomitant procedures were performed including coronary artery bypass in one patient and Bentall operation in one. Mean follow-up was 32.0±17.3 months and 100% complete. Results: The duration of cardiopulmonary bypass, myocardial ischemia, selective cerebral perfusion, and surgery were 199.5±42.5, 87.4±31.0, 100.8±24.1, and 361.9±64.2 minutes, respectively. No inhospital or 30-day deaths occurred. Mechanical ventilatory support for more than 48 hours was required in 2 patients (68 and 112 hours). No patient sustained a permanent neurologic dysfunction. No patient required dialysis for renal failure or re-thoracotomy for bleeding. One patient died of brain tumor 33 months after surgery. Conclusions: Total arch replacement using selective cerebral perfusion yields an excellent outcome with low morbidity and mortality rates.

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Surgical experiences with adult coarctation of aorta and its sequelae

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Vivek PV, Wadhwani M, Brijesh PK, Varghese PT, Kapilamoorthy TR, Unnikrishnan M, Neelakandhan KS, Jayakumar K Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum Background: Surgical management of coarctation of aorta in adults is challenging and needs a personalized strategy for optimal outcome. Retrospective analysis outcome from a single center surgical experience with coarctation of aorta and its sequelae in adults. Methods: From Jan 1991 to November 2009, 89 patients were operated at SCTIMST for standard as well as complex coarctation of aorta in adults. Their age ranged from 18 yrs to 69 years with a mean age of 28 years.There were 57 males and 32 females in the cohort. Clinical presentation was uncontrolled hypertension in all and headache in some. Imaging modality included trans thoracic echo, CT scan and/or MRA. Cardiac cath was done in 5 patients. 24 patients belonged to Amato type 1, 61 in Amato type 2 and 4 patients in Amato type 3. Surgical strategy employed was general anaesthesia, double lumen intubation, high thoracic epidural and of late CSF drainage in 5 patients. Surgical procedures included excision and end to end anastomosis in 18 cases, interposition graft repair 60 patients, jump graft in 10 patients and a lone case of patch aortoplasty. Post coarct aneurysm required TCA for graft replacement. Results: All patients except 1 survived the procedure who died of uncontrollable haemorhage 8 hours after surgery. 4 pateints required rexploration for early bleeding. All patients were discharged with reduced antihypertensive medications. Followup period ranged from 3 months to 18 years. There were no major systemic complications. 5 patients were noted to have significant recoarctation,3 of whom underwent balloon angioplasty. Conclusions: Surgical reapir of CoA in adults is technically challenging and needs personalized strategy individualized for optimal outcome.

Result of surgical repair for thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest

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Adachi H, Naito K, Okamura H, Kimura N, Tanaka M, Yamaguchi A Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama-city, Japan Background: Surgical repair of thoracic and thoracoabdominal aortic aneurysms is still a challenging procedure. We studied the early and late results of surgical repair for thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest via the left thoracotomy at our Medical Center. Method: From 1992 to 2007, open surgical repair for thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest via the left thoracotomy was performed in 186 consecutive patients at Saitama Medical Center. Patients include 81 atherosclerotic thoracic aneurysms (43%), 50 aortic dissections (27%), 34 thoracoabdominal aortic aneurysms (18%), 11 traumatic aortic diseases (6%) and 10 other thoracic aortic diseases (5%). Mean age was 62-year-old. The patient was cooled down to 20 degree C by the cardiopulmonary bypass with LV venting and open proximal anastomosis was performed under the hypothermic circulatory arrest. Emergency operations were performed in 42 patients (23%). Results: Mean pump time is 151 min and mean circulatory arrest time for open proximal anastomosis is 33 min. Hospital mortality rate is 3.5% (5/144) in elective cases and 19% (8/44) in emergency cases.

Over all hospital mortality rate is 7.0% (13/186). Bleeding is the most common cause of hospital death (6/13). Major complications include pneumonia (16%), stroke (8.1%), renal dysfunction (5.9%) and heart failure (2.7%). Spinal cord injury was occurred only in 2 patients (1.6%). Follow up rate was 98.4% and mean follow up period was 4 years (1 to 15 years). Five year survival is 78% and 10 year survival is 48%. Conclusion: Surgical repair of thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest shows low hospital mortality rate in elective cases and low injury rate of the spinal cord.

Are mortality and morbidity rates higher in primary acute aortic dissection than after performed coronary artery bypass surgery ?

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Cingöz F Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey Background: The aim of this study to compare the mortality and morbidity factors in aortic dissection occuring primarily or after developing open-heart surgery. Methods: 7 patients(Group-I) having cardiac surgical history before and 23 patients (Group-II) applying to our clinic as a first time with aortic dissection were included in the study between 1995 -2007 years. Dissection types were Debakey I and II in all patients. Preoperative and postoperative complications, mortality, morbidity, symptoms and signs, ventricular size and function were evaluated. Results: The average age of patients was 49±14 (35-63), and 6 of them were men, 1 of them was woman. The average ejection fraction, the left ventricular end systolic and end diastolic diameters, the root of aorta and asendan aorta diamater were %55±7, 35±3 mm, 47±7 mm, 30±6 mm, 45±4 mm respectively in group I, and the same parameters were %51±10, 38±6mm, 51±7 mm 41±4 mm ve 56±6 mm respectively. Graft interposition was applied for all patient of group I, coronary bypass surgery was performed in 1 patient. However, Group II patients, in addition to graft interposition aortic valve replacement (AVR) in 6 patient and Benthal procedure were performed in 1 patient. The average duration of cross-clamp was 55 ± 3.2 minutes in group I, and 73 ± 11 minutes in the Group-II. There was no mortality in Group I but 3 were lost in Group-II. (%12). Conclusion: Although as previously spent cardiac surgery in patients having aortic dissection have more complicated symptoms than patients with first diagnosis of aortic dissection, we are in opinion that surgical procedure is less mortal.

Open surgical repair of thoracoabdominal aortic aneurysms in octogenarians. Fujita H, Yamamoto S, Wada H, Nishimura M, Hosoda Y Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan

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Background: Endovascular approaches for thoracoabdominal aortic aneurysms (TAAA) repair are rapidly spreading now. Some patients undergo such immature treatment after refused open repair by some surgeons because of their advanced age. Our service will not take patient’s advanced age as an exclusion criterion for the open TAAA repair. We inspected our results to verify the operative indication for octogenarians.

IJTCVS 2010; 26: 96 Methods: Since 2003, perioperative data from 219 consecutive open TAAA repairs performed by our institution was retrospectively collected. The cases were divided into >80 years old group and the others. Patients’ profile and operative morbidity and mortality were compared between the two groups. The extent of each repair was categorized according to Saffi’s classification system reported in 1999. Results: TAAA repairs were performed 219 patients from September 2003 to August 2008. The mean patient age is 66 ±12 (SD). Of these cases 19 were >80 years old. There were 16 men and 3 women. Five patients (26%) underwent emergent operation for ruptured aneurysms. In-hospital mortality was 5 (26%) for all cases and 3 (21%) for elective cases. The median interval between operation and death was 47 days. Spinal cord injuries occurred in 3 cases (16%) and these three patients all died in the hospital. In-hospital mortality of younger (<80) patients was 14% and 30-day mortality was 9%. Conclusions: Our results showed significantly high mortality in aged patients. We have to manage long term complications to improve in-hospital mortality.

Results of aortic root enlargement: 13 year study Hiremath CS, Gajjar T, Shah G, Rao N, Neogee S, Navajit H, 162 Desai N, Choudary V Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Prashanthigram, Andhra Pradesh, India Background: Posterior root enlargement procedures provide the implantation of suitable-sized prosthetic valves in patients with a small aortic root to prevent a high postoperative transvalvular gradient. The aim of this study was to evaluate surgical outcome of posterior root enlargement procedures. Methods: A retrospective analysis was done from August 1997 to October 2009, of 17 patients with a small aortic annulus who underwent patch enlargement of the aortic root by Nicks’ technique (in 10),Manouguian’s method (in 6) and Kono-Rastan (in 1). The mean age of the patients was 38 years (range, 13 to 54 years), mean body surface area was 1.42 m2 (range, 0.82 to 1.7 m2), 7 were male and 10 were female. Aortic annular sizes were 9 to 20 mm (mean, 18.11 mm). The main indication was a small aortic root to patient body surface area. A autologous untreated pericardial patch was used in 14 cases, Glutraldehyde treated pericardial patch in 2 cases and Gortex patch was used in one case. Concomitant procedures were coronary artery bypass and permanent pacemaker insertion. St. Jude bileaflet valve used in 11,OnX in 2, TTK Chitra in 2, ATS and Medtronic hall in one each. Follow up of these cases was done from 3 months to 10 years. Results: All patients underwent 2D Echo immediate postoperatively and before discharge, Peak pressure gradients across the prostheses were 15 to 22 mm Hg (mean, 19.4 mm Hg) on echocardiography. The duration of follow-up was 3 months to 10 years. Mean gradient was less than 25 mmHg in15 cases. One had thrombosis of prosthetic valve with gradient of 48mmHg. One patient (6.25%) died in the early postoperative period and there were no late deaths. Both methods were found to be effective and reliable and should be performed when there is a risk of patient-prosthesis mismatch. Conclusions: Posterior aortic root enlargement techniques can be easily applied without additional risks. Long-term survival and freedom from valve-related complications are satisfactory. Surgeons should not be reluctant to enlarge the aortic root to permit implantation of adequately sized valve prostheses relative to body surface area.

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Early and mid term result of Bentall procedure at Sree Chitra Tirunal Institute for Medical Sciences and Technology.

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Menon S, Gopal K, Vivek PV, Varghese PT, Neelakanthan KS, Jayakumar K Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandram Background: This study evaluated early and mid-term results of aortic root replacement and reconstruction for patients with aneurysms and dissection involving the aortic root. Retrospective study of patients who underwent bentall procedure at our institute. Material and Methods: Seventy-five patients aged 20-65 years (mean 42; 58 male, 17 female) underwent elective or urgent aortic root surgery from 1999 to 2009 for an aortic root aneurysm / dissection. All patients underwent a composite valve conduit reconstruction. Twenty patients had Marfan syndrome. Patients in this cohort had Type –A aortic dissection (20), annulo-aortic ectasia (33), atherosclerotic aneurysm (21) and one thoraco-abdominal aneurysm extending to ascending aorta (1). Imaging techniques included computed tomography and coronary angiography. Procedures were performed under general anesthesia with cardio-pulmonary bypass. Custom made & composite valved conduits were used. Results: Over all mortality was 10 (13.3%) with In-hospital and 30-day mortality of 9. One patient died of intra cranial hemorrhage during follow up. Morbidities included re-exploration (5), pericardial effusion requiring drainage (3), complete heart block (2), left bundle branch block (1). Complications with anticoagulation occurred in 10 patients; with hemorrhage, in 5 (2 life threatening and 3 minor). Conclusions: Aortic root replacement for aortic root aneurysms/ dissection can be done with low morbidity and mortality. Custom made valved conduits yielded good results. There were few serious complications related to the need for long-term anticoagulation. During the past 3 years, 30-day mortality has come down from 18% to 3%.

Long-term survival and quality of life after cardiovascular surgery: Age and disease type dependency

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Tanaka F, Yamamoto F, Yamamoto H, Ishibashi K, Yamaura G Department of Cardiovascular Surgery, Akita University School of Medicine, Akita Objective: The purpose of this study was to investigate the longterm survival and quality of life (QOL) after surgery for thoracic aortic disease (TA), valvular disease (VA), or ischemic heart disease (IH) in patients (pts) aged 40 or older at the time of operation. Methods: The long-term survival was assessed in 578 patients who had undergone operations (TA, 143 pts; VA, 237 pts; IH, 198 pts) between November 1999 and March 2009. In 444 pts, the QOL data from SF-36 questionnaire were normalized by normal-based scoring (NBS), then analyzed by scoring physical functioning(PF), role physical, body pain, social functioning, general health perceptions, vitality, role emotional, and mental health. Results: There was a minimal difference in the 5-year survival between the disease types in the groups younger than 80 years old (76.7%, 92.3%, and 88.3% in TA, VA, and IH, respectively), whereas in the group aged 80 or older, the 5-year survival was lower in TA than in VA and IH (34.4%, 54.4%, and 71.0% in TA, VA, and IH, respectively). PF was lower than the age-matched NBS score in all age groups, and the PF in the group aged 80 or older was significantly lower than that in the younger groups in all disease types. The other scores tended to decrease age-dependently but exhibited no substantial difference between the disease types.

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Conclusions: Our results suggest that (1) considering operative indications on a case-by-case basis and (2) making efforts to improve periopeartaive management may be important strategies in cardiovascular surgery for octo-and nonagenarian patients.

Childhood renal tumours extending in to the inferior vena cava and/ cardiac chambers

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Harischandra T1& 2, Firmin R2, Stewart R3 1 Thoracic Surgical Unit, Chest Hospital, Welisara, Sri Lanka 2 Department of Cardiothoracic Surgery, University Hospitals of Leicester NHS Trust, UK 3 Department of Paediatric Surgery, Queen’s Medical Centre Nottingham, UK Background: Childhood renal tumours extending though the inferior vena cava, into the right atrium and / right ventricle is a therapeutic challenge. They pose a high risk due to their potential for tumour embolism as well as the complexity of the surgery required. We review our unit’s experience with regard to the cardiothoracic approach to these tumours. Methods: We identified all patients under16 years who had undergone surgery for cavo-atrioventricular extensions of renal tumours from June 1986 to June 2009. Their case records and /or microfilm copies were retrieved and the required data reviewed retrospectively. Results: Over the past 23 years, eight patients were identified with a mean age of 6.2 years (range 1.8- 15.6) and male to female ratio 1:1. There were six Wilms’ tumours, one rhabdoid tumour and one clear cell carcinoma. Four had caval and four had cardiac extensions of the tumour. All underwent median sternotomy and laparotomy – seven as a single and one as a two-staged procedure. Four underwent cardiopulmonary bypass and two also needed deep hypothermic circulatory arrest. After a median follow up of 40 months (range 3- 276 months) the in-hospital mortality was zero; the overall mortality was three, all of which were advanced tumours. The overall survival rate was 62.5%. Conclusions: This is a very rare group of patients. The prognosis is related to the tumour type and degree of infiltration. Good results are obtainable despite extensive cavo atrioventricular extension provided that they are completely resected. A multi-disciplinary team approach essential.

Family presence in PICU rounds: A nonrandomized controlled trial at the Khan University Hospital

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Ladak L1, Premji S1,2, Amanullah M1, ul Haq A1, Ajani K1, Siddiqui FJ1 1 The Aga Khan University Hospital Karachi, Pakistan; 2University of Calgary, Calgary, Canada Background: Family centered rounds have been shown to help families developed countries get timely information about their child and take decisions accordingly. Hence the objective of this study was to determine whether family centered rounds implemented in the PICU and PCICU improves parents’ and health care professionals’ satisfaction, decrease patients’ length of stay, and improves time utilization. Methodos: A non randomized control trial, where during phase I (April to May, 2009) traditional bedside rounds were practiced, and during phase II (June to July, 2009) family centered rounds were practiced. A convenient sample of 41 parents and 25 health care professionals were recruited in each phase. Data were collected on the second day of rounds.

Results: Overall, parents were satisfied with traditional as well as family centered rounds; however parents’ ratings during the family centered rounds were significantly higher for some parental satisfaction items including use of simple language during the rounds (p=0.002), and preference for family centered rounds (p=0.000). No significant differences were found in health care professionals’ satisfaction between rounds. Patients’ length of stay was significantly reduced in family centered rounds group while no significant difference was found in the time duration of rounds. Family centered rounds served as an opportunity for parents to correct patient history or documentation. Conclusions: Parents preferred family centered rounds as it served as a resource for parents for information, communication, and involvement in decision making. Future studies needs to explore the use of family centered as quality care measure.

The Incidence of definitive ulcer in upper gastrointestinal tract caused from low dose aspirin therapy after cardiovascular surgery

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Fukuda S, Ozawa N, Akita S, Kashima T, Hosaka S, Kimura S, Takazawa M, Fujioka S, Akiyama J*, Uemura N*, Mizoue T** Department of Cardiovascular Surgery and Gastroenterology*, International Medical Center of Japan, Department of Epidemiology & International Health**, Research Institute International Medical Center of Japan, Tokyo, Japan Background: Aspirin has been often needed for patients after CVS (cardiovascular surgery) in any country. The incidence of UGI (upper gastrointestinal) injury caused from low dose aspirin (LDA) was several percent to 20% in United States and Europe based on the study for the patients with some symptoms, many reports showed. The aim of this research is to know the incidence of UGI events in Japanese caused from LDA therapy after CVS and also to know what prevents it. Methods: Consecutive 125 outpatients of our CVS department were approached between 1st of September, 2007 and 30th of November, 2007. The administering term of LDA (< 330mg/day) was 4 weeks or more for them. For 94 patients who obtained consent to this study, UGI endoscopy to evaluate the UGI events with modified LANZA score, blood examination to measure anti-H. pylori antibody and other values, and interview or questionnaires to assess their complains and characteristics were given. The study protocol is approved by the ethics committee of our hospital. Results: The incidence of definitive gastrointestinal ulcer due to LDA was 1.1% (one patient/94). The odds ratio (OR) of modified LANZA score was 0.26 for non-high-dose H2 blocker (p=0.01) and 0.069 for PPI (proton pump inhibitor) (p<0.01) by ordered logistic regression analysis. Conclusions: The incidence of definitive UGI ulcer in patients with LDA therapy after CVS in Japanese was almost 1%. To prevent UGI events due to LDA therapy, non-high-dose H2 blocker may be effective as well as PPI for Japanese.

Experimental research on cell-biocompatibility of tissue engineering blood vessel scaffolds

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Rongdong X, Guoxin W Surgical Department of Cardiaovascular Disease Research Institute, Fujian Provincial Hospital, Fuzhou China (350001) Background: To evaluate the cell-biocompatibility between three scaffolds and vascular endothelial cells,smooth muscle cells ; To screen the material fit to be used in tissue engineering vessel construction and provide experimental parameter for vascular tissue engineering construction.

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Methods: 1. The method of cell seeding : adopt two-step seeding method to plant seed cell to scaffolds. Firstly, seeding smooth muscle cell onto the scaffolds and repeat cell planting for 3 times with the interval of 24 hours; after 2 weeks cultured, endothelial cells were seeded onto the cell-material compound surface for 2 times with the interval of 24 hours. The compounds were cultured for another week. LM and SEM were used to observe the mature progress of engineering tissue on culturing day of 7,14,21. 2. WST-1 method was used to tested the adhesion and proliferation of smooth muscle and scaffolds. 3. WST-1 method was used to tested cell proliferation during the phase of cultivation. 4. 3H-TDR method was used to tested the synthesis of DNA. 5. Compare the cell adhesion, cell proliferation, configuration we observed by LM,SEM in three scaffolds. Results: 1. LM and SEM show that seeding cells grow increasingly with the culture time and planting times increase in these three scaffolds. Among it the collagen-sodium hyaluronic acid membrane and gelatin-chistosan membrane were better. 2. The adhesion and proliferation of cell on collagen-sodium hyaluronic acid membrane is better than gelatin-chistosan membrane and gelatin sponge is poor. 3. The result of WST-1 test shows that cell growth increases by repeating seeding times. 4. The synthesis of DNA on collagen-sodium hyaluronic acid membrane is highest among three scaffolds and the second is gelatin-chistosan membrane, which is better than gelatin sponge. Conclusions: 1. Tissue engineering patches were constructed using the two-step planting method. 2. Repeating seeding with proper interval could increase the adhesion and proliferation of cells on scaffolds. 3. The cell-biocompatibility of collagen-sodium hyaluronic acid membrane is the best in three materials. 4. Cell-collagen-sodium hyaluronic acid membrane and cell-gelatin-chistosan membrane we constructed afford the basis for further experiment.

Is it safe to do minimally invasive open heart surgery without aortic cross clamp?

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Kumar S1, Petracek MR2, Ball SK2, Greelish JP1, Ahmad RM1, Balaguer JM1, Byrne JG1 1 Vanderbilt Heart Institute, Nashville, Tennessee; 2 Vanderbilt Heart Institute and St. Thomas Heart, Institute, Nashville, Tennessee, USA Background: We developed a technique for open heart surgery through a small right antero lateral thoracotomy without aortic cross clamp. This study reports our combined St. Thomas and Vanderbilt Heart Institutes 6 years experience with this technique. Methods: Seven hundred and forty six patients (396 M /350 F; aged 22 - 75 median of 62.2 years) underwent minimally invasive open heart surgery between August 2001 and March 2008. Through a 5 centimeter right lateral thoracotomy along the 4th intercostal space access to the pericardium and the left or right atrium was obtained. Cardiopulmonary bypass was instituted through femoral or axillary cannulation. Under cold fibrillatory arrest (28°C) without aortic cross clamp, mitral valve repair (n=253), replacement (n=490), rereplacement(n=6), tricuspid valve repair/replacement (n=69), ASD/ PFO closure (n=355), Maze (n=256), removal of cardiac tumors/ foreign bodies(n=12). Mean pre operative New York Heart Association function class was 2.2± 0.9. Fifty eight patients had ejection fraction less than 20%. Results: Thirty-day mortality was 1.7% (n=12), Operating time, bypass time, and fibrillatory time averaged 189±52, 113±35 and 78±14 minutes, respectively. Four patients had conversion to sternotomy. Twenty two patients (2.9%) underwent reexploration for bleeding through the same wound. Median length intensive care stay was 36±12 hours. Hospital stay was 6.9±3 days. Fourteen patients (1.8%) had neurological events. Renal failure required hemodialysis in 5 patients (0.81%). There were no wound infection.

Conclusions: This study demonstrates that this simplified technique of minimally invasive open heart surgery is safe and reproducible. Avoidance of aortic cross clamp may be valuable in recovery of the high risk patient with poor ejection fraction without increasing the neurological complications.

Control of atrial fibrillation in post CABG patients - A RCT testing efficacy of sotalol and amiodarone

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Chaudhuri SR, Kaushik S, Roy BK, Chaudhuri TR Anandalok Hospital, Block- DK, Karunamoyee, Salt Lake, Kolkata, India Background: Post operative atrial fibrillation is a common complication in CABG patient. This study aims to compare the efficacy & safety of Sotalol & Amiodarone in such patients. Methods: Post operative patients of CABG in the immediate 72 hours of post operative period were studied for occurrence of atrial fibrillation. Patients excluded were 1. Patients of COAD / ASTHMA. 2. Patients of valvular heart disease and / or heart block. 3. Patients of creatinine clearance<40 ml / min 4. Patients with hypothyroidism. 5. Patients with documented episodes of arrhythmia presurgically. 6. Patients with LVEF < 35% 7. Patients with LA size > 40 8. Patients with dyselectrolytaemia (checked at onset of Atrial Fibrillation). Patients assigned were randomised into two groups to receive Sotalol and Amiodarone, and were studied for time required to terminate arrhythmia, episodes of break through atrial fibrillation after achieving sinus rhythm, and were then followed up in outpatient department for side effects for 6 months (hepatic impairment, appearance of severe bradycardia or block in ECG, thyroid profile) at 3 monthly intervals. Results: 90 patients received Amiodarone and 68 reverted to sinus rhythm in 24 hours and 86 patients received Sotalol & 72 reverted to sinus rhythm in 24 hours. Applying chi square test and by testing null hypothesis we arrive at a conclusion that neither Sotalol nor Amiodarone is superior to one another in restoring sinus rhythm at 24 hours. However the time required to achieve sinus rhythm was less with Sotalol and breakthrough runs of atrial fibrillation for next 24 hours was more with Sotalol. Conclusions: In the follow up period, heart block in ECG or significant bradycardia are more with Sotalol, where as deranged LFT and thyroid dysfunction is more with Amiodarone.

Surgical excision of cardiac myxomas. A single centre experience over 15 years Prasad RMV, Kumar KVK, Satish MS, Kumar VD, Rao BB Krishna Institute of Medical Sciences, Hyderabad

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Background: We studied the clinical presentation of cardiac myxomas and the morbidity, mortality and recurrence rate following surgery at our institution over a 15 year period. Methods: Between January1995 through January2009, 75 patients (age ranging from 4 years to 62 years) underwent complete surgical excision of primary or recurrent intracardiac myxomas. Of these 75 patients 42 were females and 33 were males. Pre operative diagnosis was established by echocardiography. All myxomas were excised completely either through right atrial or biatrial approach with the use of cardiopulmonary bypass.

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Results: Myxomas most commonly occurred in the 4th decade. The commonest location was LA (80%) followed by RA (19%)and RV(1%).Patients with LA myxomas presented with symptoms of mitral stenosis clinically where as patients with RA myxomas presented with features of right heart failure. Thrombo embolism observed in 7 patients. Few percentage of patients presented with constitutional symptoms. Seventy one patients survived surgery. One patient died due to massive pulmonary embolism which was discovered at an autopsy. One patient died due to CVA.Two patients were died due to low cardiac output of which one was a recurrent myxoma. Seven patients lost follow up. Sixty four patients were followed up at regular intervals for the recurrences. Three recurrences were noticed one at 3rd year, second one at 5th year and third one at 8th year after the surgery. Conclusion: Atrial myxoma should be removed as soon as possible after diagnosis and the complete excision gives good result. However, the possibility of recurrence warrants long-term echocardiographic follow up.

operation held by the Department of General Surgery about 3 weeks ago after investigating the etiology for obstructive jaundice. Histopathological examination revealed adenocarcinoma at the duedonal papilla and adenocarcinoma of the liver with chronic cholecystitis. His physical examination showed findings consistent with DVT of the right upper and lower extremities. Results: Color Doppler ultrasound examination of the venous systems of the extremities was done. It defined that right popliteal vein was filled with thrombus which extended into the crural veins. Again, the same investigation identified that the axillary vein was filled with thrombus which extended proximally into subclavian vein and distally into the brachial vein. Our patient was then hospitalized and we started to apply our medical treatment strategy. He has been hospitalized for 5 days. He was kept under low-molecular-weight heparin(tinzaparin sodium SC) anticoagulation therapy for 3 months. He is asymptomatic and his control color Doppler ultrasound showed no recurrence or post-thrombotic sequelae. Conclusions: Development of DVT is clearly associated with decreased survival because DVT reflects the presence of a biologically aggressive cancer. Correct diagnosis and treatment of DVT are crucial.

Portal vein aneurysm due to traumatic etiology Sarsilmaz A2, Apaydin M2, Yetkin U1, Oziz E2, Varer M2, 172 Yurekli I1, Uluc E2, Gurbuz A1 1 Dept of Cardiovascular Surgery, Izmir Ataturk Training and Research Hospital, Turkey 2 Dept of Radiology, Izmir Ataturk Training and Research Hospital, Turkey Background: Portal vein aneurysm is a rare clinical entity. Methods: Our case was a 65-year-old male. He was suffering from flatulance and dyspepsia for 2 years. His past medical history was significant for a blunt trauma to the right upper quadrant of the abdomen he had experienced 19 years ago due to a traffic accident. Upper abdominal ultrasound imaging was carried out for a possible diagnosis of cholelithiasis. A venous aneurysm of 28x24 mm corresponding to the proximal zone of left branch of portal vein next to the falciform ligament. Color Doppler ultrasound imaging revealed venous aneurysmal dilation with continuous flow pattern as in the case with portal flow. Magnetic resonance portography showed excessive high signal intensity consistent with an aneurysmal dilation in the proximal zone of left portal vein. Main and right portal vein calibrations and hepatic veins were normal. Results: With these findings, conservative follow-up controls with annual abdominal ultrasound and, if necessary, with MR portography was the decision made for this case. Conclusions: Our patient had no signs suggestive of portal hypertension; the lesion was incidentally detected by ultrasound. It appears that these aneurysms can be found at any age and that there is no sexual preference. This pathology is increasingly encountered with the frequent use of radiological imaging modalities.

A case with ipsilateral upper and lower extremities deep venous thrombosis developed after surgery for gastrointestinal malignancy

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Yetkin U, Ozcem B, Sahin A, Yurekli I, Yazman S, Gurbuz A Department of Cardiovascular Surgery (CVS), Izmir Ataturk Training and Research Hospital, Turkey Background: Deep vein thrombosis (DVT) is reported to be common among patients undergoing surgery for gastrointestinal cancer. Methods: Our case was a 67-year-old male. His chief complaints at admission were increases in warmth and diameter of the right upper and lower extremities. His past medical history was significant for an

LV thrombectomy – An easy and safe approach! Shivanand G, Edwin R, Das S, Chandrashekar PM, Pillai M 44/54, 30th Cross, Tilaknagar, Jayanagar, Bangalore, Karnataka

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Background: Thrombus formation on the left ventricular endocardial surface occurs following acute myocardial infarction, especially if there is a large anterior wall infarction. These thrombi are most often smooth, conform to the cavity shape and are relatively stable. Rarely they may be mobile or pedunculated when they are at greater risk of embolization. Thrombectomy is then recommended. Left ventriculotomy has been the standard approach for removal of left ventricular thrombus. This approach has produced an unacceptable incidence of ventricular dysfunction, arrhythmias, and left ventricular aneurysm formation. We describe an easily applied transatrial method that can allow avoidance of a ventriculotomy. Case Reports: Case 1: A 51-year-old gentleman presented with angina. He was evaluated and found to have coronary artery disease with extensive anterior wall MI. Echocardiography revealed a pedunculated LV thrombus. He underwent LV thrombus removal via left atrium using 0º cardioscope, followed by coronary artery bypass grafting. Case 2: A 30 year old gentleman presented with left hemiparesis secondary to embolic stroke. On evaluation he was found to have an LV thrombus. In spite of the recent neurological event he underwent emergency LV thrombus removal via left atrium using 0º cardioscope. Both patients at followup were doing well and were on oral anticoagulants. Conclusions: Video-assisted cardioscopy allowed visualization and removal of the thrombus via left atrium, thereby avoiding a left ventriculotomy. There was an excellent view of all intracardiac structures. The surgeons and operating room staff could follow the entire procedure. Handling is easy and does not increase operative risk.

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Cardiac lipoma presented as cardiac tamponade in a 60 year old man - A case report

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Pandian Sivakumar R, Sundaram K, Damodharan, Titus Dept of Cardio Thoracic Surgery, Government General Hospital, Madras Medical College, Chennai Background: Primary tumors of the heart are rare. Lipomas account for approximately 10% of all neoplasms of the heart and represent 14% of benign cardiac tumors. Case report: A 60-year-old gentleman was evaluated for breathlessness, his chest X ray showed cardiomegaly. ECHO cardiogram showed presence of solid mass occupying the pericardial cavity with evidence of cardiac tamponade. He was taken for emergency surgery; an epicaridal lipoma measuring 13 X 23 cms was seen attached to the lateral wall of left ventricle. It was excised in total and it weighed 750 grams. Patient improved clinically after the surgery. Discussion: Benign lipomatous tumours of the heart include: (i) Solitary well defined lipoma and its variant intra and intermuscular lipoma. - Multiple large lipomas encircling the whole heart and compromising all cardiac chambers is extremely rare. - Subendocardial lipoma with intra-cavity extension may cause valve stenosis or insufficiency. (ii) Lipomatous hypertrophy of the atrial septum is associated with myocardial atrophy and fibrosis. This lesion usually causes cardiac arrhythmias. (iii) Lipomatous hamartoma of atrioventricular valve involves both mitral and tricuspid valve and may involve papillary muscle. It causes valvular insufficiency. (iv) Hibernomas of heart and pericardium have been reported Surgical treatment provides cure and prevents complications. Conclusions: We are reporting this rare primary tumour of heart which presented as cardiac tamponade, in a 60 year old gentleman who was successively treated surgically and is on follow up.

Surgical treatment of a giant external iliac vein aneurysm in a patient with a post-traumatic femoral arteriovenous fistula

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Tetik O, Ergunes K, Yurekli I, Gokalp O, Bademci M, Gurbuz A Department of Cardiovascular Surgery, Atatürk Training and Research Hospital, Izmir-Turkey Background: Iliac venous aneurysms are rare vascular abnormalities that have been reported as primary aneurysms with an unknown cause or have been referred to as secondary iliac venous aneurysms whene an underlying cause can be identified. Occasionally, iliac venous aneurysms have been described in association with a distal arteriovenous fistula. We present a case with a giant external iliac vein aneurysm in a patient with a post-traumatc femoral arteriovenous fistula that we operated in our clinic. Case report: A 34 years old man was injured with gunshot 15 years ago. He made a full recovery and did not notice any sequelae of the trauma in the following years. He was admitted to our clinic because of his left leg swelling and numbness. Angiographic examination showed an arteriovenous fistula at the level of distal third of the superficial femoral artery and a giant aneurysm of the left iliac vein. Management consisted of separation of the arteriovenous fistula, lateral repair in femoral vein and end-to-end anastomosis in femoral artery. Then, left flank incision for retroperitoneal approach was performed reaching left inguinal incision. A vascular clamp was placed tangentially, and aneurysm was resected. After declamping, a lateral venorraphy was created with a continuous 5-0 polyprolene suture.

Conclusion: We conclude that it had satisfactory results to excise the fistula and reconstruct the iliac vein aneurysm developing after posttraumatic arteriovenous fistula formation with lateral venorraphy within the same session.

Perioperative management of cardio-thoracic surgery in renal transplant recipients

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Nakayama T*1*2, Maisawa K*1, Isshiki S*1, Sasaki H*1, Kanou M*1, Tominaga T*1, Ishitoya H*1, Kurobe H*2, Kitagawa T*2, Hiratani K*1, Hori T*1 *1Division of Cardiovascular Surgery, Ehime Prefectural Central Hospital, Ehime, Japan *2Department of Cardiovascular Surgery, IHBS, the University of Tokushima, Graduate School, Tokushima, Japan Background: As renal transplantation is now performed frequently, there have been an increasing number of patients who undergo cardio-thoracic surgery. This report describes the perioperative management of cardio-thoracic surgery in renal transplant recipients. Case report: Casa 1 : A 46-year-old man underwent renal transplantation on his left pelvic cavity because of acute renal failure due to aortic dissection type IIIVb. The thoracoabdominal aorta had been dilated between 3 years after the aortic dissection. The graft replacement of the aneurysm was performed under cardiopulmonary bypass with venous drainage through the right femoral vein on contralateral side of kidney graft and arterial perfusion through the left femoral artery on the ipsilateral side of that, for avoiding malperfusion of that. Intravenous prednisolone and tacrolimus were administered for 8days and 4days respectively. Thereafter, the oral supplemental mycophenolate mofetil was restarted. He required hemodialysis only 1-postoperative day, and was discharged in good condition on 16-postoperative day. Casa 2 : A 59-year-old man with prednisolone administration after renal transplantation underwent coronary artery bypass grafting because of dyspnea on effort. His postoperative course was uneventful. Intravenous prednisolone and tacrolimus were administered for 2days. Thereafter, the oral supplement was restarted like case 1. He was discharged on 28postoperative day with normal general status. Conclusion: Cardio-thoracic surgery could be performed safely in renal transplant recipients by providing adequate perioperative management.

Effect of magnesium correction on reversal of atrial fibrillation in post operative CABG patients

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Chaudhuri SR, Kaushik S, Chakraborty S, Chaudhuri TR Anandalok Hospital, Block-DK, Karunamoyee, Salt Lake, Kolkata, India Background: Very often in post CABG patients in atrial fibrillation the time taken for reversal to sinus rhythm is hastened by magnesium administration. This study aims to look at the effect of magnesium correction on the time required to achieve sinus rhythm in post CABG patients in atrial fibrillation. Methods: Post CABG patients who went into atrial fibrillation during their post operative period having magnesium deficiency at the onset of arrhythmia were included. Randomisation was done using card drawing method. Patients excluded at the onset were 1. Patients of valvular heart disease. 2. Patients with gross hypothyroidism. 3. Patients with documented episodes of arrhythmia presurgically.

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4. Patients with LVEF < 35% 5. Patients with LA size > 40 6. Patients with hypokalemia (checked at onset of atrial fibrillation). 7. Patients developing hemodynamic instability during arrhythmia. 40 patients were assigned to each group, one in which magnesium correction was promptly done and amiodarone infusion was started simultaneously and the other received only amiodarone. Results: Patients Magnesium correction & Amiodarone IV Only Amiodarone IV

Mean Time for Standard – reversal (min) Deviation

40

318

30.6 min

38

360

72 min

Standard error between means is 12.64. Conclusions: Actual difference between means is 42 which is more than 2 times greater than the standard error between means which is significant. Hence it can be concluded that administration of IV magnesium sulphate did influence the time to achieve sinus rhythm.

Methods: The mobile cath lab is set up in the OR. A small submammary anterolateral thoracotomy is made. Femoral and internal jugular venous and femoral arterial cannulation is done in a percutaneous manner under fluoroscopic control. CPB is instituted and the procedure performed. Results: A safe and secure cannulation allowed the incision to be small without compromising on safety. The flouro control gives an exact and safe placement of cannulae. We have used this technique in 16 cases (ASD repair : 7, MVR: 5, MVrepair :1, MVR + TV repair 3) in the age group 18 to 48 years with no need to convert to standard incision or to enlarge the incision. Conclusions: We advocate the routine use of the cath lab / flouro in the OR to make safe minimally invasive open heart surgery possible.

Transcranial stimulation – Intercostal nerve recorded motor evoked potential (Tcic-MEP) reflects spinal cord ischemia in dog

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Takahashi S, Orihashi K, Mizukami T, Herlambang B, Sueda T Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan

Case report: A 38-year-old woman with two children and no medical history of note had routine laboratory tests ordered by her gynaecologist in the course of an annual control visit. The platelet count was 46 x 109/L. Results of the remaining haematological parameters, biochemical profile and urinalysis were within normal limits. Physical examination was unrevealing. The abdominal ultrasound showed a tumor in the uterus with occupation of the inferior vena cava. An abdominal CT scan, echocardiogram and thoracic CT showed an intravenous tumor occupying the iliac veins, inferior vena cava, right atrium, right ventricle, main pulmonary artery and right and left pulmonary arteries. The tumor, 50 cm in length, was removed in one-stage through incisions made in the inferior vena cava, right atrium and main pulmonary artery with the patient under cardiopulmonary bypass, deep hypothermia (15°C) and cardiac arrest. Total hysterectomy and bilateral salpingo-ophorectomy was also performed. Diagnosis: intravenous uterine leiomyomatosis with extension to both pulmonary arteries.

Background: To ascertain the feasibility of transcranial motor evoked potential (MEP) recoreded by intercostal nerve. Methods: Four dogs were examined under general anesthesia with muscle relaxant. Stimulating electrodes were fixed on the head, above the motor cortis region. Recording electrodes of conventional transcranial MEP (Tc-MEP) were inserted into the intrathecal space of T12 and L1. The electrodes to record the potential of intercostal nerves were anchored as follows: electrodes of T2, T6 and T10 were anchored from out side, 10 cm far from spinal cord (Tcic-MEPo). Electrodes of T4 and T8 were anchored from inside the thorax, 2cm far from vertebra (Tcic-MEPi). All MEPs were recorded simultaneously. Waveforms were compared before, during and after the cross clamp of thoracic aorta (T3 – T9 level). Results: MEPs were recorded clearly on all electrodes. Tcic-MEPo and -MEPi showed similar waveform, small negative wave followed by large positive wave. Latencies depended on the distance from stimulating electrodes, ranged from 2.0ms to 2.5ms. Duration of TcicMEP was 1.5ms in all records. Amplitude of epidural electrodes, TcicMEPo and Tcic-MEPi were 5µV, 0.2 – 0.5 µV and 2-3µV, respectively. After aortic clamp, amplitude of Tc-MEP and Tcic-MEP at T10 level were reduced simultaneously, and the other Tcic-MEP between T2 and T8 didn’t change. After the aortic declamp, reduced amplitudes restored immediately. Conslusions: Tcic-MEP reflected the MEP changes accurately in the ischemic segments of spinal cord. This technique can be useful for intraoperative monitoring during thoracoabdominal aortic surgery.

Use of flouro to facilitate a really minimally invasive and safe open heart surgery

A novel non-small cell lung carcinoma therapy using siRNA targeting mTOR

Intravenous leiomyomatosis extending to both pulmonary arteries. A tumor that escapes from the reality

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Pérez-Negueruela C, Bernal JM, Arnaiz ME, Gutierrez F, Pontón A, Tascón V,Fernández-Divar J, Revuelta JM Cardiovascular Surgery, Hospital Universitario Valdecilla, Universidad de Cantabria, Santander, Spain

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Bedi HS, Gupta A Christian Medical College & Hospital, Ludhiana, Punjab, India

Background: Right antero-lateral thoracotomy has been is use for minimally invasive repair of atrial septal defect and mitral valve repair/replacement. However there is some concern about the safety of venous and arterial cannulation due to the limited working area. The use of femoral or jugular cannulation requires additional incisions which can be of cosmetic concern. We have used a mobile catherisation laboratory in the Operating Room to facilitate safe and secure cannulation with a very small thoracic incision.

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Matsubara H University of Yamanashi Faculty of Medicine, 1110 Shimokato Chuo Yamanashi, Japan Background: In non-small cell lung cancer (NSCLC), the current molecular targeting agents elicit side-effects. Current molecular targeting agents inhibit the mammalian target of Rapamycin (mTOR) pathway. We hypothesized that a small-interfering RNA (siRNA) which inhibits mTOR, should have minimal side effects. Methods: NSCLC cells (RERF-LC-AI) and mTOR siRNA (SignalSilence® mTOR siRNA Kit) were used for evaluating siRNA

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anti-tumor effects, including measurement of cell proliferation, apoptosis, and migration. Control group (group C) and study group (group S ; 100 nM siRNA) were compared after 48hours following transfection and experiments were performed in triplicate. The number of cells after 48 hours culture was counted for proliferation and apoptosis was assessed by using a Cell Death Detection ELISA (PLUS) kit. Cell migration was determined by a Boyden chamber assay. Results: Cell proliferation was inhibited in group S (94.7±3.0 x 104 cells) compared with group C (151±8.6 x 104 cells) (p<0.05). Group S showed a 1.2±0.2 fold increase in apoptosis as compared to control group C (p<0.05). Cell migration was reduced in group S (96±3.4 cells) for group C (158±7.4 cells) (p<0.01). Conclusions: We confirm that siRNA-mTOR inhibits proliferation, induces apoptosis, and retards migration of NSCLC cells in vitro. The therapy using siRNA targeting mTOR could be a novel therapy for NSCLC.

Three-dimensional culture of vascular smooth muscle cell (VSMC) using a thermoreversible polymer (Mebiol gel)

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Sakakibara K, Matsumoto M, Kato K, Kaga S, Suzuki S Second Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi, 409-3898, Japan. Background: Although technological improvements continue to advance with designs of synthetic vascular grafts, a concrete method has not been established until today. Such attempts have failed largely due to neointimal hyperplasia and thrombosis. In the past, inner layers of grafts have been seeded with normal VSMCs to avoid graft thrombosis. However, when cells grow to confluence, and attach to each other, growth arrest is induced. As a result, the inner surface of artificial vessels could only be covered with a monolayer of cells. Mebiol gel is a copolymer that is liquid at low temperatures, immediately turns to gel upon heating and returns to liquid upon cooling. The nature of this gel has been adapted for the use in threedimensional culture matrix for various cells. In this study, we attempted to obtain a multilayered cell culture with VSMCs using the thermoreversible polymer, Mebiol gel. Methods: VSMCs from Human saphenous vein were cultured on a 24-well culture dish in media containing 10% fetal bovine serum with or without Mebiol gel. For our present study, cells were embedded in a liquid Mebiol gel solution at 40C and cultured threedimensionally in the hydrogel state at 370C. Results: VSMCs grown in control media with or without Mebiol gel began attachment after 2 hours, (control:313±21 vs. Mebiol gel:332±44 cells/5 high-powered fields: P=0.21) continued to increase in number until two weeks. VSMCs in only control media began detachment thereafter. On the other hand, VSMCs grown in threedimensional Mebiol gel continued to grow after 3 weeks. (2.7±0.2fold increase: P<0.05) Conclusions: Our study demonstrated that Mebiol gel is a potent matrix for three-dimensional culturing of VSMCs. In the future, the use of Mebiol gel could enable multilayer growth of VSMCs, leading to the development of a safe artificial vascular graft with high patency.

External saphenous vein support prevents graft occlusion in CABG surgery – First human implantations: A promising concept for coronary artery bypass grafting?

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Kofidis T1, Ong CS1, Lee DH1, Emmert MY1,2, Klima U1, Lee CN1 1 Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital / National University of Singapore, Singapore 2 Department of Cardiac and Vascular Surgery, University Hospital Zurich, Switzerland Background: The most promising therapy for patients with advanced ischemic heart disease is coronary-artery bypass grafting. The mainly used graft material are autologous saphenous veins. However, they are prone to occlude at high rates, causing infarctions and the necessity for high risk redo-surgery. Recently, a Nitinol-based external vein support mesh (eSVS™) was developed and tested in animals. It revealed superb patency and long term lack of intimal hyperplasia in supported grafts. Here we report the first in-the-human implantations in patients undergoing coronary-artery bypass grafting. Methods: In the frame of a prospective, randomized clinical multicentre trial we have performed the first human implantations in 20 patients with 3-vessel coronary-artery disease after informed consent. Either the Right Coronary (RCA)- or the Circumflex Artery (CX) were included as target vessels in the randomization process. Results: One of these two vessels received an eSVS™, the other one received a regular SVG only. The supported grafts displayed a superb surgical handling and did not kink. Early postoperative 64slice CT-angiography proved patency, while the endpoint is 1-year angiographic patency. Conclusion: The eSVS™ improves SVG patency by significant downsizing of SVG and mimicking compliance of arterial conduits. Its long term superb patency proven, this new device may have vast prospects for patients destined for bypass surgery. It could spare them the arterial harvest, reoccurrence of cardiac events, as well as redo surgery. Further it would allow for complete revascularization without compromise and with the quality of arterial grafts.

Implications of sickle cell anemia in cardiac surgery : 4 case reports with their peri-operative surgical and anesthetic considerations.

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Taggarse AK, Amaresh RM, Gopinath, Kumar RV Department of Cardiac Surgery and Anesthesiology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, India. Background: Sickle cell anemia can present a challenge to the cardiac surgeon and anesthetist. Overt disease or trait can manifest as sickling crises during stress induced by the cardiac procedure and use of cardio-pulmonary bypass. A proper strategy should prevent a catastrophe. Though many interventions have been described including exchange transfusion, plasmapheresis, hemofiltration, platelet sequestration, use of nitric oxide and hydroxyurea, etc, careful management of fluid and electrolytes ensuring adequate hydration still remains of paramount importance. Method: Four cases of sickle cell anemia were operated, an atrial septal defect, a mitral and aortic valve replacement and a CABG. Preoperative work-up included a hematologist opinion and hemoglobin electrophoresis to determine HbS fraction. Pre-operatively patients were adequately sedated and fluids administered. Electrolytes, especially potassium, and acid-base status were monitored peri-operatively. Care was taken to prevent hypotension during induction and maintenance of anesthesia. CPB was instituted and perfusate was kept warm during the procedure. Warm sanguinous cardioplegia was given. Ultrafiltration was done and 30% of calculated plasma volume was removed (about 1 liter).

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Precautions of hydration, acid-base, oxygenation, sedation, antibiotic prophylaxis and folic acid supplementation were continued postoperatively. Results: All four patients recovered well. Post-operative renal function was well preserved and no hemoglobinuria was encountered. Conclusions: Sickle cell disease and trait requires caution when contemplating a cardiac procedure. Ultrafiltration which is thought to remove complement mediators C3a, C5a, Interleukin 6 and TNF alpha, was useful. CPB with warm perfusate, warm sanguinous cardioplegia and proper hydration has yielded good results.

Using of levosimendan in a redo cardiac pediatric operation

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Aksun M2, Gurbuz A1, Yetkin U1, Damar E2, Lafci B1, Ozelci A1, Goktogan T1, Karahan N2 1: Department of Cardiovascular Surgery, Izmir Ataturk Training and Research Hospital, Izmir/Turkey 2: Department of II. Anesthesiology, Izmir Ataturk Training and Research Hospital, Izmir/Turkey Background: Levosimendan (LS), a new inodilator used in the treatment of decompensate heart failure, has been reported to be effective in patients with high perioperative risks, with abnormal left ventricular function, and who face difficulties in weaning off cardiopulmonary bypass. Cause of its many beneficial effects, the use of LS in cardiac surgery arises. However, experiences about the use of LS in pediatric patients are limited. We administered LS in a case of 3 years old child who developed heart failure during cardiopulmonary bypass removal period. Methods: A 3 years old, 11 kg female child was admitted in our center who had a total revision of tetralogy of Fallot four months ago. Any postoperative complaints or symptoms were not present since we find out a large progressive aneurysm in the echocardiographic evaluation of the otogen pericardial patch which was prepared with gluteraldehide. Induction of anesthesia was done with 2 mg/kg ketamin and 0.5 mg/kg atracurium, 20µg/kg atropin was administered also. After endotracheal entubation, invasive blood pressure of the left radial artery and central venous pressure monitoring of the right internal jugular vein was successfully. After the excision of the pericardial patch, the repair of the right ventricular outflow was done with e-PTFE graft. At the end of cardiopulmonary bypass (CPB) surgery deep hypotension occurred. In spite of dopamine (15 µg/kg/min), dobutamine (15µg/kg/min) and adrenalin (1mg/h) infusions, myocardium failed to maintain normotension. Diuresis was suboptimal in our patient also. Results: Upon these LS infusion was started with the loading dose of 12 µg/kg over 10 minutes. Later, 0.2 µg/kg/min maintenance dosage was applied. In an hour we observed 200 cc diuresis and the vital signs were taken under control. LV infusion was completed after 24 hours postoperatively in our intensive care unit. Six hours later we started to reduce the analogous inotropic support (dopamine 10µg/ kg/min, dobutamine 10µg/kg/min, adrenalin 0.5mg/h) since the hemodynamic parameters were satisfactory. Twelve hours later another reduction was applied. Since the well tolerance of the myocardium, we were able to stop the other inotropic drug infusions after 48 hours and the patient was discharged from the hospital 10 days after the surgery. Conclusions: Our clinical experiences with LS has shown that it reduces conventional inotropic agents dosages and could be a satisfactory agent in myocardial depression therapy which occurred in CPB surgery intraoperatively also in pediatric patients. However the need for serial randomized controlled studies in pediatric patient about the use of LS is indisputable.

Comparison of extracranial carotid computed tomographic angiography with digital subtraction angiography

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Yetkin U1, Yurekli I1, Bademci M1, Ozbek C2, Gurbuz A1 1: Department of Cardiovascular Surgery(CVS), Izmir Ataturk Training and Research Hospital, Turkey. 2: Department of Cardiovascular Surgery(CVS), Izmir Tepecik Training and Research Hospital, Turkey. Background: Noninvasive screening for detecting extracranial carotid arteries stenosis is often limited by artifact. Methods: Our case was a 65-year-old male. His past medical history was significant for hypertension for 5 years. He had suffered from cerebrovascular accident twice, one for 4 years and one for 2 months ago. His chief complaints were numbness of left leg and vertigo for 1 year. Another factor of morbidity was that he had a chronic renal disease with a glomerular filtration rate of 20 ml/min. His carotid computed tomographic angiography revealed severe stenosis in his left common carotid artery. Results: He was hospitalized by our clinic for further investigations and for carotid endarterectomy if necessary. His carotico-vertebral DSA and conventional selective arteriography of aortic arch and its branches revealed nothing but 60% stenosis of left external carotid artery.Medical therapy was the recommended treatment since our case possessed no significant lesion in left common and internal carotid arteries. Conclusions: DSA was used as the gold standard. 36% of patients referred for endovascular intervention based on noninvasive imaging did not meet criteria by angiography. This emphasizes the need for carotid angiography prior to carotid intervention.

Clinical utility of magnetic resonance angiography for femoro-popliteal arterial occlusive disease

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Yetkin U, Ergunes K, Ozelci A, Goktogan T, Gurbuz A Department of Cardiovascular Surgery (CVS), Izmir Ataturk Training and Research Hospital, Turkey Background: Magnetic resonance angiography (MRA) has recently become instrumental in the diagnosis of arterial disease and is gaining an important role in the study of plaining revascularization. Methods: Our case was a 71 years old patient and MRA image was consistent with occlusive lesions of bilateral superficial femoral arteries. In the same patient MRA of popliteal artery and distal part showed that popliteal arteries and anterior and posterior tibial arteries and peroneal arteries are in normal calibrations and all patent. Results: We performed successful bilateral femoro-popliteal bypass operation with 8mm-80cm ringed e-polytetrafluoroethylene graft and postop 5th day he was discharged.All distal pulses were patent. Conclusions: MRA is a safe and accurate assessment of the lower extremity arterial system in patients with occlusive disease. MRA has a high sensitivity for detecting femoro-popliteal arteries stenoses. MRA allows a fast, safe, and accurate assessment of the arterial system in patients with arteriosclerosis and can be considered an alternative to DSA in the management of patients with steno-obstructive disease of the peripheral arteries.

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Surgical management of aorta – Right atrial tunnel

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Trushar G, Hiremath CS, Shah G, Rao N, Neogee S, Hatibaruah N, Desai N, Choudary V Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences,Prashanthigram. Andhra Pradesh, India Background: Aorta right atrial tunnel (ARAT) is a rare congenital anomaly (Only 8 such cases reported in the world literature till now). Morphologically it is classified into two types depending on the course of the tunnel in relation to the ascending aorta as anterior variety and posterior variety. Aim of the study is to describe various operative techniques of this rare but curable congenital anomaly. Methods: From June 1994 to April 2009, 16 patients underwent treatment at our institute. Age ranged from 2 years to 45 years; There were 6 male subjects and 10 female subjects. Morphologically posterior type of tunnel was present in 10 and anterior type in 6 patients.15 patients were treated surgically and one patient underwent coil embolisation. Post operative echocardiogram obtained for all patients before discharge confirmed complete obliteration of the tunnel. Results: Eight patients underwent on pump closure of the tunnel, seven patients underwent off pump ligation of the tunnel, one patient underwent coil embolisation, one patient died perioperatively and the other 15 patients were discharged in stable condition. During follow up at 3 months, 6 months and one year all patients were in NYHA class I and echocardiography showed no residual shunt. Conclusion: Treatment options for ARAT are simple ligation off pump, Ligation with implantation of coronary ostium, on pump bicameral closure of the tunnel or Coil embolisation. The location of the coronary ostium dictates technical details, ARAT can be safely ligated under hypotensive anaesthesia, irrespective of the type anterior or posterior. Immediate post op and follow up reveals excellent functional recovery.

Effect of using fresh frozen plasma in cardiac surgery on postoperative serum creatinine values Gokalp O, Yurekli I, Kestelli M, Aslan O, Gurbuz A Izmir Ataturk Training and Research Hospital, Turkey

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Background: In this study, we evaluated the effect of fresh frozen plasma use on postoperative serum creatinine values. Methods: A total number of 160 patients that underwent coronary artery bypass surgery (88 off-pump and 72 on-pump cases) between October 2006 and March 2009 were evaluated. Fresh frozen plasma or whole blood was administered when necessary. Preoperative and postoperative serum creatinine values were then compared. Results: In off-pump group where only whole blood was administered, postoperative serum creatinine values were significantly increased. In off-pump group where whole blood and fresh frozen plasma were administered, postoperative creatinine values did not change significantly. In on-pump group where whole blood and fresh frozen plasma were administered, postoperative creatinine values dropped significantly. Conclusions: In cardiac surgery, fresh frozen plasma does not deteriorate renal functions when compared to whole blood.

Left atrial appendage aneursym – Our experience Kumar A, Moorthy P, Kasinathan, Shakir H The Institute of Child Health and Hospital for Children, Madras Medical College Egmore, Chennai

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Background: Left atrial appendage aneurysm is a very rare entity seen in cardiac practice.

Methods: A 11 yr old boy presented with cough, cold and fever for 1 year duration. X-RAY chest revealed cardiomegaly with mass occupying almost whole of left hemithorax. Echocardiogram revealed large left atrial appendage aneurysm measuring 10 *6 cms. There was no evidence of mitral valvular lesions. Patient taken for openheart operation with cardiopulmonary bypass support. Aneursymal left atrial appendage was excised and redundant atrium repaired with 40 prolene. Results: Patient had a stormy postoperative period and had hyperpyrexia not responding to antipyretics. Patient succumbed to his condition and breathed last the morning after surgery. Conclusion: Left atrial appendage aneursym is a very rare entitiy seen in our cardiac practice and high index of suspicion is needed to diagnose it and plan for surgery.

Angiofibroma presenting as a pedunculated right ventricular outflow tract tumour

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Mukherjee P, Dasbaksi K, Hazra RN, Nayek S, Mondal M Calcutta National Medical College, 24, Gorachand Road, Kolkata

Background: Angiofibromas are benign but locally aggressive vascular tumours that occurs in neck, face, nasopharynx These are rare soft tissue hamartomas which contain mainly blood vessels and fibrous tissues often found in association with tuberous sclerosis (TS) an autosomal dominant disorder characterized by seizures, mental retardation and multi organ hamartoma, and cardiac rhabdomyoma. Cardiac angiofibromas are even rarer in comparison to rhabdomyomas which are the commonest cardiac tumours in the children. We report a 10 year old adolescent girl diagnosed having a pedunculated right ventricular tumour by echocardiography and excised under cardiopulmonary bypass. The histopathology was consistent with the diagnosis of angio fibroma. She is leading a normal life one year after operation. Case report: A 10 year old female patient was admitted in our department with the symptoms of frequent chest pain and fatigue for the last two years. There was no such family history in the parents and siblings. She was normotensive, with a pulse rate of 80 per minute. There was right ventricular heave and an ejection systolic murmur. Electrocardiogram showed right ventricular strain pattern. Chest X-ray showed normal cardio thoracic ratio. Haemogram and blood biochemistry were within normal limits. Echocardiography with Doppler study showed a space occupying lesion in the right ventricular outflow tract moving in and out of the RVOT in systole and diastole and was diagnosed as a pedunculated right ventricular (RV) tumour. Median sternotomy was done, aortic and bicaval cannulation made and the patient was taken into cardiopulmonary bypass. Aorta was cross clamped, cardioplegic arrest of heart achieved and right ventriculotomy was made. The solid tough pedunculated 3 by 2 cm rounded mass was excised from the sub pulmonary area of inter ventricular septum and ventriculotomy was closed. X clamp time was 15 minutes. Weaning off bypass ,decannulation and closure and recovery was uneventful. The histopathology was reported as angiofibroma. Results: The patient is doing well after a one year follow up. Echocardiography done 8 months after operation was normal without any right ventricular obstruction. Conclusions: Pedunculated tumours in right ventricle has been found to be myxoma, fibroma, rhabdomyoma. Only a few references of cardiac angiofbroma has been found in the literature as epicardial angiofibromas, endocardial angiofibroma simulating a mitral heart defect. We did not find any evidence of tuberous sclerosis in our patient in discussion nor any family history of such disease was found in the parents and siblings. It was a sporadic case of RVOT angiofibroma.

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Bronchial carcinoid tumors - Surgical management Sowmya Ramanan V, Mathew KK, Rajesh S, Thankappan A, Nideesh CH Department of CVTS, Medical College, Calicut, Kerala

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Arasappa A, Rajavenkatesh, Nagaraj, Ragavendran Madras Medical College, Chennai

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Menon PP Dr. Kamakshi Memorial Hospital, Chennai

Background: Bronchial carcinoids are locally invasive neoplasms that usually involve the central airways and exhibit well-defined margins. They account for 1–2% of all lung neoplasms. Surgical resection is the treatment of choice for bronchial carcinoids and parenchyma saving resections (sleeve or bronchoplastic procedures) are being used in central carcinoid tumors. Methods: Between 2006 and 2009, 12 cases of bronchial carcinoid were diagnosed in our institution. Main symptoms at presentation were cough, hemoptysis and evidence of bronchial obstruction such as pneumonia or atelectasis. There were no cases with carcinoid syndrome. Preoperative evaluation included chest X-ray, bronchoscopy, computed tomography, pulmonary function tests and cardiac evaluation. All patients underwent surgery by postero-lateral thoracotomy. 9 of the patients underwent lobectomy of which 6 cases were classic lobectomies and 3 cases were sleeve lobectomies. Pneumonectomy was performed in 3 patients in whom there was destruction of underlying lung parenchyma. Results: We did not have any perioperative surgical complications. Margins of resection were found to be clear in all cases. The longterm follow-up was complete, ranging from 6 months to 3 years. All patients are currently alive, and no local tumor recurrence was observed. Conclusions: Bronchoscopy is the most important diagnostic tool and surgery is the mainstay of treatment. Bronchial sleeve resections permit pulmonary function restoration and long-term local control of the disease without an increase in the operative risk.

A case of left bronchus tumour

Solitary lung carcinoid - A case of masquerading tumor

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Introduction: Tumours in left bronchus present with hemoptysis, dyspnoea or stridor. Non small cell carcinoma of left bronchus with neuroendocrine. Differentiation is very rare. Methods: A 48 year old female patient presented with cough with expecteration, dyspnoea and hemoptysis for 6 months duration. Her investigations by FOB revealed a tumour in left main bronchus close to carina with excessive bleeding. Hence FOB was not completed and patient taken up for bronchial artery embolization procedure. But patient’s symptoms were not relieved and patient was taken a CT chest with contrast to identify the exact location of the tumour. Tumour was located in left main bronchus, 3 cm from carina. Hence patients was planned for resection of tumour with bronchoplasty. Patient was operated under double lumen endotracheal tube and bronchial tumour was excised by the left posterolateral thoracotomy approach. The excised tumour was subjected to HPE which showed features of non small cell carcinoma with neuroendocrine differentiation. Results: Patient had good postoperative recovery and tumour subjected to immunohistochemical analysis which showed positive for synaptophysin and chromogranin. Patient is under chemoradiation therapy is in regular follow up. Conclusion: Non small cell carcinoma of left main bronchus with neuroendocrine differentiation has been included recently in 2004 WHO classification. No proper treatment guidelines or investigations has been propounded so far. Case is presented for its rarity.

Background: Lung carcinoid constitutes 3 to 5% of lung tumors. Diagnosis is often confused with carcinoma of lung due to the clinical features and many times wrongly treated especially so if manifested as isolated lesion without any regional extension and systematic sign and symptoms. Our patient was diagnosed and treated with chemotherapy and steroids, etc. in the pretext of inoperable lung cancer. She was treated successfully with left upper lobectomy and she is doing well till date. Methods: PET CT and Bronchoscopic Biopsy, showed isolated carcinoid of the left upper lobe bronchus with no extension. Post operative biopsy proved it and the resected margin were clear of the tumor filtration. Result: Patient had uneventful recovery and was discharged on 10th PO day. Conclusion: Carcinoid of the lung is wrongly diagnosed and treated many times. With proper treatment results are excellent (94 – 100% with five year survival). Prognosis depends on the histopathology (KCC–I, II, III).

Successful repair of right sided traumatic diaphragmatic hernia with displacement of liver and intestines into the right hemithorax

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Kallol KD, Mukherjee P, Hazra RN, Roy B, Nayek S Calcutta National Medical College, Part Circus, Kolkata Background: Traumatic diaphragmatic hernia (TDH) due to blunt abdominal trauma is much lesson the right side (10%) when compared to left side (90%) as the right dome is cushioned off by the underlying liver. A massive rise of intra abdominal pressure like vehicular run over injuries or fall from a height is required to produce rupture of the right dome, a situation, where other major organs like spine, great vessels or liver, spleen, pelvic bones are simultaneously injured resulting in a high pre hospitalization mortality. Even on abdominal exploration attention to damaged vital organs results in missing a traumatic diaphragmatic hernia in 30% of these patients. A partial run over vehicular abdominal trauma where a wheel of a medium sized backing truck ascends over the right side of the abdomen and then moves away on hearing the shouts of people resulting in a TDH without any vascular or bony injury and thereafter successfully operated is indeed rare. Methods: A 24 year old male was knocked down by a backing truck while the rear wheel climbed on to the right side of the abdomen and then rolled forwards on hearing the shouts of people. After resuscitation X ray chest revealed right basilar opacity. Chest tube was put and it yielded little blood. But from the third day bile started coming out of the tube. The patient was stable albeit with a silent abdomen and maintained on intravenous alimentation and naso gastric decompression. MRI was then done. It revealed liver and coils of intestines reaching up to the apical region of the right hemi thorax. Exploration was done on the 6th day. Right thoracoabdominal incision was made keeping the heart lung machine ready to institute CPB if required as there could be an avulsion injury to the hepatic veins due to rotation and high migration of the liver almost reaching the apex of the right lung. Exploration revealed torn right dome of diaphragm. Liver was rotated with the right lobe displaced into the right hemi thorax with biliary and vascular pedicle acting as the fulcrum. There was no injury to the liver and the adjoining vessels as apprehended. A coil of ruptured jejunum was found entrapped into the thorax effectively sealing off the peritoneal cavity from biliary stained the right hemi thorax preventing peritonitis. There was no other intra abdominal injury. The liver was pushed down into the abdomen, cut

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ends of the jejunum were anastomosed and diaphragm repaired with # 1 polypropylene and reinforced with a Prolene mesh. Closure of the wound was a usual one. Results: Patient had a stormy post operative period with post operative atelectasis of right lung, burst thorax treated by resuturing, endo bronchial aspiration and respiratory physiotherapy. He developed a draining sinus with an osteomylitic rib segment which was removed. There was complete healing of the wound within 4 months and he joined works within 6 months. Conclusion: The purpose of presenting this paper is to highlight (i) The unusual mechanism of injury, (ii) The intermediate time of diagnosis of TDH and accuracy of MRI. It was not an “immediate” diagnosis nor was it inordinately “delayed” which are the two varieties usually reported, (iii) The unique manner in which the liver and chest was effectively sealed off the peritoneal cavity from the infected biliary stained thoracic cavity, (iv) Keeping cardiopulmonary bypass ready to deal with hepatic vein–inferior vena caval junction injury which should be suspected when there is high displacement of the liver in right sided TDH.

Technology transfer by the Indian surgeons in the development of cardiac surgery in Bangladesh

received rFVIIa from Jan 2007-Oct 2009. Patients who underwent mitral valve replacement (3), aortic valve replacement (1), coronary artery bypass grafting (2), intracardiac repair (3) were included in our study. 2 of these patients were reoperated . All of these patients underwent standard heparinisation (300IU/kg) before cardiopulmonary bypass and reversal with protamine. Results: All the patients underwent reexploration for mediastinal hemorrhage before treatment. 3 of them were reexplored twice. rFVIIa was administered as an intravenous bolus of 60 to 90mic/kg. None of them required second dose. A definitive hemostatic effect was seen after rFVIIa administration in all the patients. In these series of patients hospital mortality was 2 (22%). Mean amount of bleeding and amount of platelet and fresh frozen plasma transfusions decreased significantly after rFVIIa administration. Conclusion: rFVIIa was successfully used as an rescue therapy when bleeding was refractory to conventional methods. Bleeding stopped in all the patients, preventing reexploration and transfusion requirements.

A rare intra pharyngeal presentation of carotid body tumor producing dysphagia

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Sarkar BK, Saha DK, Banerjee P NRS Medical College & Hospital, Kolkata

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Hosain N, Maruf F, Rasheed H, Amin F Chittagong Medical College, 66/5 West Rajabazar, Indira Road, Dhaka Background: Cardiac surgery developed as a specialty in Bangladesh basically in the eighties. First open heart surgery of the country was performed on 18th September 1981, much latter than that of India. From there the total number of open heart surgery has reached 5100 in the year 2008. A few Indian surgeons made significant contribution in the development of cardiac surgery by means of technology transfer. This paper is an attempt to recognize and thank them. The aim of this study is to record the contribution of Indian cardiac surgeons in the development of cardiac surgery in Bangladesh. Publishing this would inspire new generation of Indian and Bangladeshi surgeons to continue cooperation in future. Methods: The study involves interviewing 8 old cardiac surgeons, cardiologists and cardiac anesthetists, who were part of development. Hospital records are checked for available data. Likely Indian sources are contacted and requested for information. Information gathered from sources are crosschecked, analyzed and organized for presentation. Results: The interviews, hospital records and Indian information sources identified the contribution of Indian surgeons in the development of cardiac surgery in Bangladesh. The list includes famous Indian surgeons like K M Cherian, A Sampath Kumar and Anil G Tendolkar. Their contribution in technology transfer is identified, analyzed and presented with respect and gratitude.

Background: Carotid body tumours are the most common tumours at the carotid bifurcation. There is usually externally visible swelling with transmitted pulsation on palpation. Radiologically, the mass shows widening of the bifurcation with vascular enhancement. Splaying of the carotid bifurcation may also be produced by a schwannoma of the cervical sympathetic plexus. Schwannomas usually displace the carotid artery anteriorly. Methods: A 29-year-old male presented with pulsatile swelling over the right side of neck and dysphagia with a bulging through the right pharyngeal wall. Computed tomography (CT) showed a large well defined mass (6.6 cm/4.8 cm/6 cm) at the region of the angle of the mandible, suggestive of neurogenic tumor, displacing the carotid artery laterally and compressing the pharyngeal structures medially. Surgical excision of the tumor was performed via a right cervicalparotid approach. Results: Although the imaging features suggested a schwannoma, histopathology of the excised tumor revealed a carotid body tumor. Carotid body tumor with pharyngeal swelling producing dysphagia and displacing carotid artery outwards is a rare exception. Conclusions: Carotid body tumours (CBT) cause a pulsatile neck mass with widening of the carotid bifurcation In our case, the carotid body tumor over the right side of neck which was hardly visible externally produced an intra pharyngeal swelling with dysphagia. This is a rare presentation of the tumor which displaced the carotid artery laterally and compressed the pharyngeal structures medially.

Clinical assessment of prolonged myocardial preservation for patients with severely diseased heart—the custodial solution and our experience

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Suresh S, Sujatha DI, Varghese R, Krishna M, Rajan S Madras Medical Mission, 4A Dr Jayalalithas Ngr, Mugappair, Chennai

Srivastva PK, Sindhu DR, Agarwal S, Radhakrishnan S, Cherian KM St Gregoious Cardiovascular Center, A Unit of Dr KM Cherian Heart Foundation, Parumala, Ernakulam, Kerla

Background: Intractable massive perioperative bleeding is a potential complication of cardiac surgery despite conventional intervention. The aim of the present study is to describe our experience in the management of life threatening bleeding with rFVIIa as a rescue therapy for adult and pediatric cardiac surgical patients in our institution. A prospective study Methods: We analysed 9 cardiac surgical patients who have

Background: Myocardial preservation during open heart operations has been well estabilished, & various cardioplegic methods have been clinically introduced. However, questions still arise as to what method is appropriate for hearts severely injured due to valvular disease or severely diseased coronary arteries, & what is the maximum duration of ischemia that can be tolerated by the myocardium. To answer these questions, we focused on patients who needed

Factor seven in cardiac surgical postoperative bleeding - Do we justify?

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prolonged cross clamp period & evaluated the efficacy of preservation using two different cardioplegic methods. One is commonly used blood cardioplegia (cold or isothermic/tepid ) & the other is Histidine – Tryptophan – alpha ketoglutarate (HTK) crystalloid solution- a multiorgan preservative used as cardioplegia. HTK solution, a crystalloid cardioplegic solution, allows us to operate without interruption for about 120 minutes. Methods: Twenty eight patients who underwent cardiac procedure between Jan 2007 to Oct 2009 were enrolled in this study. Patients with aortic cross clamp time near or more than 2 hrs with blood cardioplegia were randomly choosed (n= 14) and compared with custodial group (n=14). There were no difference between the two groups with regard to age, BSA & bypass time (> 3 hrs) & cross clamp time (>2 hrs). To prepare cold blood cardioplegia, crystalloid solution contain potassium concentrate, mannitol & sodium bicarb was mixed with blood at a ratio of 1: 4 & temperature was lowered to 15° C. And the tepid type utilizes calafiore technique. Both type were infused at an initial dose of 15-20 ml / Kg after the aorta was clamped. Maintenance dose was repeated every 15 minutes thereafter in tepid type & every 30 min in cold blood cardioplegia. In CABG, multiport cardioplegia perfusion set was used to perfuse through grafts after every distal anastomosis. HTK was cooled to 4° C & infused for 6 to 10 min at a perfusion pressure of 50 – 100 mmHg. If cross clamp time exceeded 120 min, 1000 ml of the solution was added. Both cardoiplegic solutions were infused into the aortic root using a roller pump (antegrade or retrograde depending on the case). Both groups used hemofilter considering its long pump time & hemodilution by custodial solution. Results: Our clinical evaluation, reveals the superiority of HTK solution over the blood cardioplegia in the following context : 1. Onset of spontaneous sinus rhythm after removal of cross clamp 2. Nil or very minimal inotropic support 3. Postoperative ejection fraction was very similar or improved more with respective to its preoperative value 4. Temporary pacing was not at all needed 5. Atrial or ventricular arrhythmia were almost absent through out the postoperative period irrespective of the prolonged ischeamic period & complex procedure. Conclusions: In our institution, blood cardioplegia has been used as the standard to protect the myocardium. However, cold blood cardioplegia must be administered every 30 min & the surgical procedure has to be suspended during the infusion. For reducing the total extra corporeal circulation time, & more over some procedure requires a continuing quiet field, it might be desirable to perform the procedure without interruption. A single high dose of HTK is apparently adequate to protect the myocardium for an extended period. In conclusion, the results of the present study suggest that the protective effect of the HTK solution may be significant in patients with very low ejection fraction when ischeamic time is longer than 2 hrs.

Clinical effect of polymyxin-B immobilized fiber (PMX-DHP) for after cardiac surgery of infective endocarditis

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Tominaga T, Hori T, Kano M, Sasaki H, Isitoya H Ehime Prefectual Central Hospital, 83, Kasuga, Mastuyama, Ehime, Japan Background: Endotoxin adsorption treatment (direct hemoperfusion using polymyxin-B immobilized fiber: PMX-DHP) is generally used to treat severe septic cases and improve survival rates, but there are few reports that describes about clinical result of this method during cardiac surgery of infective endocarditis(IE). We investigated the clinical effect of PMX-DHP. Methods: From September 2007 to May 2009, seven of 13 patients

were used PMX-DHP after the operation of IE. Preoperative blood culture revealed Gram-negative rod of two patients, Gram-positive bacteria of four and Candida of one. In all patients, emergency operation was done; aortic valve replacement was feasible in one, mitral valve replacement in one, tricuspid valve replacement in one, double valve replacement in two and resection of vegetation in two, one of whom closed ventricular septal defect additionally. The clinical assessment was established using the values of the hemodynamics with heart rate, systolic blood pressure, catecholamine index [(Dopamine+Dobutamine+(Epinephrine+Norepinephrine)×100(µg/ kg/min)] and amount of urine. Results: Each clinical data with pre-and post-PMX-DHP treatment was as follows; heart rate was 114.3±18.7 bpm vs 105.0±21.8 bpm, systolic blood pressure 100.1±17.4 mmHg vs 123.1±15.8 mmHg, catecholamine index; 12.1±6.8 ug/kg/min vs 10.7±6.6 ug/kg/min, and amount of urine 91.5±67.5 ml/hr vs 164.3±122.9 ml/hr, respectively. One patient died of acute cardiac failure due to aortic valve insufficiency after mitral valve replacement, whose family denied re-operation. Other six patients made an uneventful recovery on discharge. Conclusions: Initiation of PMX-DHP during the postoperative course of patients with IE can improve the hemodynamics and clinical outcome.

Left atrial booster function after the MAZE procedure: Quantitative assessment with 320multidetector computed tomography

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Yamanaka K, Iwakura A, Nakatsuka D, Kenta An, Takayoshi K Tenri Hospital, Mishima-cho, Nara, Japan Tenri Hospital, Mishima-cho 200, yenri, Nara, Japan Background: We quantitatively assessed LA size and function after the MAZE procedure in patients with chronic AF and mitral valve disease (MVD), and compared with those in patients with sinus rhythm. Methods: We studied 8 patients [MAZE group: 66.5±11.0 (SD) years] undergoing the MAZE procedure for chronic AF and mitral valve surgery and 6 patients having normal sinus rhythm NSR group: 60.7±9.0 years). The MAZE procedure was conducted by RF ablation and LAA was preserved in all cases. LA and LAA volume and booster function were quantitatively evaluated by 320-multidetector computed tomography at 10.2±8.4 months (MAZE group after the surgery. Results: In all 8 patients of MAZE group, sinus rhythm was well restored. LAA was clearly visualized without thrombi in all 14 patients. The maximal LA size in MAZE group was 106.5±30.0 ml, being larger than 99.8±36.1 ml in NSR group. LA ejection fraction(EF) in the MAZE group was 17.9±6.1%, being significantly lower than 28.4±6.2% in the NSR group. Meanwhile, the maximal LAA size in the MAZE group was larger (16.6±7.2 ml vs. 8.8±5.0 ml), but LAA EF (35.1±14.8% vs. 34.5±6.5 %) was comparable in the two groups. Conclusion: LAA largely contributes to LA booster function particularly in the MAZE group because LA booster function is deteriorated in this group of patients.

The Importance of the sternal intramedullar bleeding control in open heart surgery

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Guler A, Sahin MA, Bingöl H, Cingöz F, Demirkiliç U Gulhane Military Medical Academy, Department of Cardiovascular Surgery, Ankara, Turkey Background: The aim of this study is to emphasis the effect of sternal intramedullar hemostatic control in open heart surgery. Methods: 191 patients who were undergone open heart surgery in cardiovascular department between January 2008 and January 2009

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were choosen for this study. Patients were divided in 3 Groups. Bonewax was used for intramedullar bleeding control in Group-1. Sellulose was used in group-2. Electrocoteterisation was used in all groups and also just group-3. Drenaj amounts were recorded on 1.3.5. 12. Hours and just before removing the chest tubes in intensive care unit. Blood and blood materials, revision due to hemoragia, sternal fixation and infection were recorded as well. Results: Mean drenaj volumes were 225±65 mL in group-1,100±30 mL in group-2, 400±150 mL in group-3 (P<0.05). There was so less bleeding in all control times in group-1 than the other groups and no bleeding was detected in group-1 but group-2 and group-3 after twelve hours the surgery. Total drenaj amounts on 12nd and 24th hours were 476,5±384,7 and 626,8±178,1 in group-1, 279,6±357,1 and 339, 4±571,9 in group-2, 511,394,5 and 747,2±576,4 in group-3. Revision was needed for 5 patients who were in group-1 (two patients) and in group-2 (three patients). Superficial sternal infection was noted in six patients. Three of them were in group-1, two of them were in group-3, and one patient was in group-1. Conclusions: This study demonstrated that sternal intramedullar hemostatic control is an important issue to decrease amount of bleeding and blood transfusion after open heart surgery.

Geometrical left ventricular reconstruction with indigenous decellularised bovine pericardiumEarly results

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Vaijyananth P, Madhu Sankar N, Guhathakurta S, Kirthivasan V, Cherian KM Frontierlifeline Dr KM Cherian Heart Foundation, TN, Chennai Background: Complex ventricular reconstruction (CVR) is a surgical option designed to restore left ventricular shape and volume in patients with ischaemic heart disease and heart failure. The endoventricular patch technique is versatile and we have successfully used this technique in six emergent postinfarction cases, two with left ventricular free-wall rupture and three with anterior and one with posterior septal rupture. In addition we have also routinely employed this technique in 24 cases of post-infarct anterolateral, one posteroInferior & one Non-Ischemic Submitral LV aneurysm The aim of this report is to illustrate the flexibility of the endoventricular patch technique utilizing Decelluralised Bovine Pericardium. Interestingly, Post operative PET studies revealed that the Bovine Pericardium got incorporated in native myocardium & almost became indistinguishable, restoring the helico-elliptical shape of left ventricle. Methods: From May 2008 to April 2009, surgical ventricular restoration was performed in 32 patients (25 males), mean age 63.5 (40–78) years. 24 patients presented with angina and/or heart failure with Postinfarction left ventricular aneurysm, one patient had NonIschaemic Submitral Aneurysm. The preoperative left ventricular ejection fraction was 20–45)%. Multi-vessel disease was present in 22 patients. Results: All patients underwent Surgical Ventricular Restoration, which in 6 emergent patients included Infarctectomy, closure of Ventricular Septal Defect by an Infarct exclusion Technique. Coronary artery bypass grafting was performed in 26 patients and a mitral valve repair procedure was performed in 2. Intra-aortic balloon pump was used in 5 cases and 7 patients needed inotropic support for more than 24 h. Mean time on the ventilator was 12 hours (6-72) hours and mean stay in the intensive care unit was (2–16) days. Out of 5 emergency cases, one patient died early postoperatively, autopsy revealed infarct extension & expansion with consequent lateral free wall rupture. 19 patients were followed up with serial echocardiography & PET Conclusions: Complex ventricular reconstruction is a robust, versatile option, we have successfully employed this strategy utilizing in-house Decllularised Bovine Pericardium. Early results are good in terms of survival.

Cranial and lower body oximetry during antegrade cerebral perfusion using near-infrared spectroscopy

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Sasaki T, Boni L, Yeung JT, Ramamoorthy C, Riemer RK, Hanley FL, Reddy VM Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Department of Anesthesiology#, Stanford University 300 Pasteur Drive, Stanford, California Background: Near-infrared spectroscopy (NIRS) is widely used to monitor cerebral oxygenation noninvasively during antegrade cerebral perfusion (ACP). However, lower body oxygenation during ACP has rarely been investigated with the equipment. Methods: Six neonatal piglets were put on cardiopulmonary bypass. After cooling to 18C, ACP was initiated at three different flow rates, 10, 30, 50 ml/kg/min, in random order. Each ACP flow was continued for 15 minutes before switching to the next flow rate. At each flow rate, blood samples were obtained from left jugular vein (JV) and inferior vena cava (IVC) for venous saturation. Data were compared to tissue oxygen saturation (SO2) obtained by NIRS from brain and lower body. Hemodynamics were also monitored. Results: JV and IVC saturation were strongly correlated with ACP flow rate (y= 0.8945x + 46.117, R2= 0.5154, p= 0.0017, y= 0.8625x+ 8.7583, R2= 0.6276, p= 0.0004). Cranial SO2 was strongly correlated with JV saturation (y= 0.6471x+25.592, R2= 0.683, p< 0.0001), cerebral perfusion pressure (y= 1.1977x+33.951, R2= 0.526, p=0.0007), and ACP flow rate (y= 0.8063x+45.229, R2= 0.44, p= 0.0027). However, lower body SO2 was not correlated with IVC saturation (y= -0.0688x + 30.083, R2= 0.0711, p= 0.3368), lower body perfusion pressure (y= -0.9167x+ 29.167, R2= 0.3288, p= 0.0254), nor ACP flow rate (y= 0.1354x+27.91, R2= 0.0358, p= 0.4518). Conclusions: Cerebral and lower body oxygenation increased with ACP flow rate. NIRS detected changes of cerebral oxygenation susceptibly, but did not reflect lower body oxygenation accurately during ACP.

Tranexamic acid can reduce blood transfusion requirements in Thoracic Aortic surgery

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Ahn KT, Yamanaka K, Iwakura A, Nonaka M, Sekine Y Tenri Hospital, 200 Mishima Nara, Tenri-city, Japan Background: The purpose of this study was to examine the effectiveness of tranexamic acid (TA) to reduce blood loss in Thoracic Aortic Surgery (TAS). Methods: From August in 2008 to August in 2009, 49 patients (22 male, 71.0±10.1 y.o., 22 Acute Aortic Dissection and 17 true Aneurysm) underwent TAS (exclude combined surgery). Operative procedures were Total Arch Replacement (T=5, N=12), Hemi Arch Replacement (T=4, N=3) and Ascending Aorta Replacement (T=5, N=20). Patients were divided into two groups: 14 patients receiving tranexamic acid are T group (9 male, 70.2±10.5 y.o.) and 35 patients receiving no tranexamic acid are N group (13 male, 71.3±10.1 y.o.). T group received 16 mg/kg/hr of TA during the operation. We compared with two groups. Results: We made a comparative study of amount used of blood transfusion. Red Cell Concentrate 780.0±738.2 ml (T group) vs 2062.4±1695.1 ml (N group); Fresh Frozen Plasma 737.1±806.8 ml vs 1789.7±1502.3 ml; Platelet Concentrate 214.3±199.4 ml vs 537.1±163.2 ml. In all case, amount of use transfusion in T group was significantly less than N group (P<0.05). Postoperative thrombotic complications (cerebral infarction, myocardial infarction etc.) were no significant differences in two groups. Conclusions: The use of TA in patients who undergoing TAS led to a significant reduction of amount use of blood transfusion. Moreover, the use of TA didn’t increase thrombotic complications.

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Impact of emergency aortic repair on neurological function in patients with acute aortic dissection complicated with cerebral malperfusion

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Yoshitsugu N, Osamu T, Yoshimasa S, Satoru D, Yujiro I 1. Department of Cardiovascular Surgery, Kanto Medical Center NTT EC 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo 141-8625, Japan Background: Surgical treatment for acute type A aortic dissectioncomplicated with cerebral malperfusion (ADCM) remains debatable. Our strategy was to perform emergency aortic repair for ADCM, in case the cerebral infarction lesion was limited in the right hemicerebrum or one third of hemicerebrum in preoperative computed tomography (CT). Methods: From April 2007 to August 2009, 8 patients with ADCM underwent emergency aortic repair. Mean age of the patients was 69±8 years old (57-78). Male/female was 5/3. Preoperative neurological symptoms were hemiplegia in 7 patients (left 5, right 2) and motor aphasia in 1. Mean Glasgow Coma Scale Score was 14±1. Mean National institutes of health stroke scale was 9.0±4.1(4-13). Of 5 patients with left hemiplegia, 4 patients had cerebral infarction of right hemicerebrum, remaining 1 had no infarction due to collateral blood supply. In 2 patients with right hemiplegia, no cerebral infarction was detected in CT. Hemiarch aortic replacement was performed in 7 and total arch replacement in 1. Antegrade cerebral perfusion was used except for 1 patient with total occlusion of the right carotid artery. Results: There was no hospital death. Mean ventilation time was 92±94 hours. ICU and hospital stay was 7.7±4.7 and 26±14 days, respectively. Mean modified Rankin Scale was 1.6±1.3 at discharge. There was no deterioration in the brain CT findings in all the patients. During mean follow-up of 16±5 months, there was no late death, 7 patients were ambulant and 1 was wheelchaired. Conclusion: Emergency aortic repair did not have a negative impact on neurological function in patients with ADCM.

Aortic root replacement in young adults: Disease characteristics and early outcome

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Paul S, Choudhary AK, Gupta AK, Malhotra S, Saraf N, Mishra YK, Meharwal ZS Escorts Heart Institute and Research Centre, Okhla Road, New Delhi Background: Aortic pathology requiring replacement of the aortic root is rare in young adults and maybe a group prone to atypical presentations and poorer outcomes. Here, we have studied the clinical features, pathological extent of aortic root disease and outcome of young adults undergoing aortic root replacement at this institution between 1995 and 2005. Methods: Retrospective study of the patients who underwent aortic root replacement at this institution between 1995 and 2005 between the ages of 18 and 40 (n=55). Preoperative, intra-operative and postoperative data were collected on a standardizes proforma. Results: There were 48 males (78%) and 5 females (13%). Mean age was 32.3±0.7 years. 44% of patients had a preoperative diagnosis of either bicuspid or rheumatic aortic valve disease; 46 (83.6%) presented with chest pain and in 34 patients (61.8%) an aortic regurgitant murmur was audible. Most patients (>70%) had aortoannular ectasia, with 17 (30%) with aortic dissection. The dissecting flap arose at the sinotubular junction (88%) and terminated in the ascending aorta (60%). 45 patients (82%) received modified Bentall’s procedure; the rest underwent separate aortic valve and supracoronary aortic replacement. In hospital mortality was 1.8%. Follow up was 96% at mean follow up of 8.56 years after surgery. Conclusion: The presentation of aortic root disease in young adults is similar to older age-groups. The disease characteristics of aortic dissection in this age group are favorable. The use of the Bentall

procedure of separate aortic valve or supracoronary ascending aortic replacement offers good early and late clinical outcomes.

Renal function after abdominal aortic surgery requiring suprarenal aortic clamping

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Ito M, Furukawa K, Okazaki Y, Morita S Saga Medical School, Nabeshima 5-1-1, Saga, Kyushu, Japan Background: Endovascular stent grafting is difficult for a high abdominal aortic aneurysm near a branch of the renal artery. Artificial vascular grafting is indicated in many cases. We examined renal function after surgery requiring suprarenal aortic clamping. Methods: The subjects were 208 patients who had undergone elective abdominal aortic surgery between March 1997 and June 2009: 175 males and 23 females with a mean age of 71.5±6.6 years. There were 13 patients requiring bilateral suprarenal clamping (group A), 24 patients requiring unilateral suprarenal clamping (group B), and 171 patients requiring infrarenal clamping (group C). In groups A and B, one patient had bilateral renal artery reconstruction, two patients had unilateral renal artery reconstruction, and three patients had unilateral renal artery bypass. Results: The mean durations of renal ischemia were 56.8±14.6 and 51.0±13.6 min for groups A and B, respectively. The mean preoperative creatinine levels were 1.20±0.57 and 1.10±0.35 mg/dl for groups A and B, respectively. The mean maximum postoperative creatinine levels were 1.73±0.64 and 1.56±0.59 mg/dl, respectively. The creatinine levels were significantly elevated in these groups compared to group C (p=0.015 and 0.024, respectively). The mean creatinine levels of these three groups did not differ significantly before hospital discharge. Conclusions: Good results were obtained from abdominal aortic surgery requiring suprarenal aortic clamping. Groups with bilateral suprarenal clamping and unilateral suprarenal clamping had temporary, significant aggravation of renal function compared to a group with infrarenal clamping. However, their recovery was uneventful.

Motor evoked potential (MEP) monitoring in the descending thoracic aneurysm (TAA) repair: Is it no need to reimplant the segmental arteries in supra-celiac descending aneurysm repair?

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Kikuchi Y, Shiiku T, Mitube K Institute: National Obihiro Hospital, Hokkaido, Japan Background: Monitoring of MEPs allows for the early detection of spinal cord ischemia and is currently becoming an integral part of spinal cord protective strategies during thoracoabdominal or descending thoracic aneurysm (TAA/A) repair. Sacrifice of segmental arteries (SGA) simplifies TAA/A surgery. However, little is known about alterations in cord perfusion after SGA sacrifice in descending thoracic aneurysm repair in which most of the SGA is routinely sacrificed. We report our experience with monitoring of MEP during extended repair of TAA (eTAA: distal anastomosis was performed at the level of diaphragum or just above the celiac artery) in 28 patients in whom spinal cord artery reattachment was not carried out. Methods: From April 1999 to November 2009, 107 patients underwent the descending thoracic artery replacement in our instutute. Among those, intraoperative monitoring of MEP during eTAA repair involving serial segmental artery sacrifice were reviewed. The distal anastomosis was performed at the level of diaphragm in 17 (normothermia, open-distal anastomosis: 6) and at the level of just above the celiac artery in 11 cases. A decrease of 50% in amplitude of the leg MEPs in the presence of stable hand MEPs was considered to reflect a lower body ischemic event (Reduction+). Results: There were no operative death and there were no paraplegia or paraparesis. The decrease of MEP amplitude was

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occurred in 7 patients (29%). The causes of the reduction were as follows; leg ischemia due to femoral artery cannulation: 2, ASO: 1, open distal: 3, anesthesia: 1. All of the decreased amplitude was recovered with the increment of distal perfusion flow or after reperfusion with releasing aortic cross-clamp. Conclusion: This experience suggests that routine surgical implantation of segmental vessels is not indicated at least in the TAA repair.

Can a safe cardiac surgery be performed in patient with hematologic malignancy within acceptable mortality and morbidity rates?

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Guler A, Sahin MA, Bingöl H, Cingöz F, Demirkiliç U Gülhane Military Medical Academy, Ankara, Turkey Background: The patient with hematologic malignant disease may require cardiac operations with or without cardiopulmonary bypass support. Aim of this study is to emphasis our clinical experiences to predict in their postoperative morbidity factors. Methods: The patient diagnosed hematologic malignity, who underwent cardiac surgery in our department between 2003 and 2007 were retrospectively analysed. 15 patients with hematologic malignancy had cardiac surgery in this period. 8 patients had Chronic Lymphocytic Leukemia, 6 patient had Chronic Myelocytic Leukemia, and the remaining patient had Non-Hodgkin’s Lymphoma. Fourteen patients were performed coronary artery bypass grafting and one patient had mitral valve replacement. Their hospital charts, demographics, perioperative data and complications were reivewed. They were followed up 24 months after the surgery. Results: 11 of them were male, 4 of them were female. Mean age was 65±14 (range between 27 and 81) years. There was no hospital mortality. Average follow up period was 35±11 months. Three patients required reoperation because of mediastinal bleeding, the one patient admitted to the hospital due to prosthetic valve endocarditis within 30 days. There were 5 (33.3%) late deaths during follow-up period. The cause of death was intracranial hemoragia in three patients. The other two patients had sudden death at 8th and 55th months and their death reason could not be detected. Conclusions: Cardiac surgery should be performed in patients with hematologic malignancy. Patient selection is very important issue to deal with their potential risks. Intracranial bleeding is an important mortality factor after the surgery.

Management of congenital bronchopulmonary cysts in pediatric population- A single institute experience

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Sarkar BK, Saha DK, Banerjee P N R S Medical College & Hospital, Sultan Alam Road, lake Gardens Kolkata Background: Congenital bronchopulmonary cysts are infrequently found but these lesions are potentially life-threatening in pediatric population. These lesions mostly include bronchogenic cyst, congenital lobar emphysema, pulmonary sequestration and cystic adenomatoid malformation. They show a wide range of clinical and radiologic manifestations but they share similar embryologic and clinical characteristics. These congenital lesions can usually be diagnosed by plain chest x-ray films. The diagnosis is often aided by ultrasonography or computed tomography. The purpose of this study is to review our institutional experience with congenital cystic lung disease in young patients. Methods: We have operated a total of nine patients (four bronchogenic cysts including one bronchial cyst, two congenital lobar emphysema, two cystic adenomatoid malformation and one pulmonary sequestration) from July, 2008 till September, 2009. Of which 7 were males and 2 were females (the age ranged from the 2

months to 3 years). Breathing difficulty, recurrent respiratory tract infections, stridor, poor feeding and intermittent cyanosis were the symptoms in these patients. All these cases were treated surgically. Results: Out of nine patients, seven patients underwent lobectomy and enucleation was possible in two cases. There was no mortality with minimal postoperative morbidity. Conclusions: Delayed diagnosis of these congenital lesions results in recurrent respiratory infections, repeated hospitalizations and related morbidity. Surgical excision is essential for histological diagnosis, symptomatic relief and prevention of future complications. The surgical intervention did not retard growth and development. Early diagnosis and prompt surgery remains the mainstay of management of congenital bronchopulmonary cysts.

Innovative hybrid procedure for dissection thoracic aorta in a patient with a previous Bentall procedure

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Bedi HS, Sheth R Christian Medical College & Hospital, Brown Road, Ludhiana, Punjab Background: A 42 year old man with Marfans syndrome, with a previous Bentall procedure, presented with acute chest pain. Investigations revealed a dissection of the aorta, starting just distal to the left common carotid artery to the renal level. A complete surgical repair would have carried a high mortality, while an isolated endovascular procedure was contraindicated due to the absence of a safe proximal landing zone for the stent. A hybrid combination of surgical and endovascular treatment was planned for sealing the dissection. Methods: A redo sternotomy was performed and under femorofemoral CPB a short segment of Dacron graft was interposed between the previous Bentall graft and the arch of aorta. On to this graft 2 additional grafts were anastomosed – a 14 X 9 mm bifurcated graft, one to the right common carotid and one to the left common carotid – and a 9 mm side arm to facilitate the positioning of the endograft. After coming off CPB a guide wire was manipulated from the femoral artery into the newly anastomosed graft, and snared into the side conduit with a 20 mm Microvena snare. A 32 x 200 mm Zenith stent graft (Cook, USA) was deployed just distal to the bifurcated graft upto T9 level. Surgical ligation of the distal innominate and the proximal left common carotid were done. Results: The false lumen was successfully obliterated with a complete recovery and no neurological deficit and both radials well palpated. Conclusions: Surgical treatment for dissections entails a high morbidity and mortality; we present a hybrid surgical and endovascular technique which is technically successful with a lower rate of complications.

Three stage hybrid procedure in a patient with aneurysm of the ascending arch, descending thoracic and pseudo aneurysm of the abdominal aorta with severe AR and MR.

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Nair KR, Vasu H, Jacob A, Bashi VV Department of cardiovascular and thoracic surgery, MIOT Hospitals, Chennai, Tamilnadu A 23-year old female patient from Rwanda presented to us with class III NYHA dyspnoea and back pain. Investigations revealed that she had aneurysm of the ascending, arch and descending thoracic aorta. In addition she had pseudoaneurysm of the abdominal aorta at the left renal artery origin with absent function of the left kidney. She had severe AR and MR also. She was operated in three stages and the video will be presented.

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Stage I: Aortic root and arch replacement with elephant trunk procedure and mitral valve repair under circulatory arrest and profound hypothermia. Stage II: Endovascular Stenting of the thoracic aorta with stent deployment in the elephant trunk. Stage III: Occlusion of pseudo aneurysm with an ASD closure device. Patient had an uneventful recovery and doing well after 1 year.

Acinic cell carcinoma in Left Bronchus in an 11 year old boy - A Case Report

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Pandian RS, Moorthy P, MuruganT, Vinodh, Kailash DA Department of PCTVS, The Institute of Child Health and Hospital for Children, Madras Medical College, Chennai Background: Primary acinic cell carcinomas of the lung are rare tumours, accounting for about 0.5 % of all lung malignancies. Case report: An 11-year-old boy was evaluated for breathlessness, his chest X ray showed complete collapse of left lung. CT chest and Fiber optic bronchoscope showed an endobroncheal tumour occluding the left main bronchus. Surgery was through, left postero lateral thorocotomy. Tumour was seen eroding the left main bronchus and was occupying the entire lumen. Hence a left pneumnectomy was done and the bronchus was cut with tumour free margin. Post operatively the child received chemo radiation and now is on follow up. Acinic cell carcinomas arise most frequently in the parotid gland. Other sites of primary tumours have included the submandibular gland and other major and minor salivary glands. There have been rare cases of primary tumours involving the parapharyngeal space and the sublingual gland and very occasionally in the pancreas, or of the lung. These tumours characteristically manifest as intraluminal polypoid masses in the trachea or major bronchi. Symptoms usually are related to large airways irritation or obstruction, cough, hemoptysis, fever, and pneumonia. Surgery is the main line of treatment. Post operative radiation improves disease free interval. Conclusions: We are reporting this rare primary tumour of bronchus, which is reported to account for less than 0.5% of all lung neoplasm, in an 11 year old boy who was treated surgically and was covered with post op chemo radiation.

Cystic mediastinal lymphangioma Suvarna S, Thilan W, Srinivasan M Apollo Lanka Hospital, Colombo-05, Sri Lanka

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Background: Lymphangioma, also known as cystic hygroma or lymphatic cyst originate from the lymphatic system and are common tumours of the neck. Mediastinal cystic lymphangiomas however constitute only 1% of all mediastinal tumour. Here we present a Sri Lankan patient who presented to us with this rare tumour. Methods: A 20-year-old male, with no previous medical history presented with a two month history of progressive shortness of breath, associated with bilateral gross pedal oedema. Full blood count, renal, liver blood profile, TB and other routine inflammatory markers were all within normal values. Chest x-ray followed by CT-chest confirmed a multiloculated homogenic anterior and middle cystic mediastinal tumour associated with bilateral pleural effusion. Anterior mediastinotomy and biopsy confirmed diagnosis leading to sternotomy and excision of thymic fat, drainage of bilateral effusion. Intraoperatively the tumour was found to be inoperable as it had completely encased the heart and all the major vessels. Results: Bilateral chest drainage confirmed chylothorax. Post operative period patient needed ventilator support and increasing inotropic support eventually leading to cardiorespiratory arrest and death.

Conclusions: Mediastinal cystic lymphangioma are very rare benign tumour with no reported malignant transformation, although mainly asymptomatic, dyspnea was the common presentation in our case. Complete surgical resection has the best chance of cure since incomplete resection, especially of the mediastinal lymphangioma may increase the likelihood of the lesion to grow and engulf or incorporate vital structures over time.Chylothorax are also common complication.

30 years experience of septal myomectomy in indian subcontinent

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Vaijyanath P, Madhu Sankar N, Guhathakurta S, Kirthivasan V, Cherian KM Department of Cardiothoracic & Vascular Surgery, Cardiac Anaesthesiology, Cardiovascular Research, Frontier – Lifeline, K M Cherian Heart Foundation, Mogappair, Chennai Background: Over the last three decades (from Sept. 1976 till 2009 to date) interventional treatment of hypertrophic obstructive cardiomyopathy has considerably developed and in western countries primary surgical approach is nowadays considered for a minority of patients with insufficient relief of obstruction following catheter intervention, This trend is despite the paradox of conclusively proven superior results of surgery over interventional therapy. However, in lesser developed nations, surgery is still the mainstay of therapy, partly because,economic compulsions effectively dictates the patient to seek a complete-long term-single window clearance. Herewith,we present a single surgical team three decade data of our operative experience in Indian subcontinent spreading 3 Institutions from patients varying to 5 countries. Methods: Between Sept. 1976 and 2009, 98 patients underwent surgical treatment for Hypertrophic cardiomyopathy,the operative team essentially comprised of consistently a senior member(DR KMC) 9 of these patients underwent MVR + Myomectomy, 3 patients underwent MVR along (during the early experience) and 86 patients underwent extended septal Myomectomy (shaving off white fibrous tissue from base of the papillary muscles resulting the mitral apparatus), 3 patients had concomitant surgical procedures like CABG. One month mortality was 3 out of 98. 71 patients were male and 21 female. Results: The gradient dropped between 21±6 and 10 year follow up the mortality was 6%. 90% of the patients in both groups continue to experience marked symptomatic improvement. More than 60% of the patients had been assigned to New York Heart Association (NYHA) functional class III or IV before surgery and only 10% remained in these two classes post-operatively (p less than 0.01). The maximum gradient observed was 214 mm. A comparison of both preoperative and postoperative hemodynamic findings reveal that left ventricular end-diastolic pressure was significantly reduced from 21±6 Septal Myomectomy alone and from 28±3 MVR + Myomectomy. There was also a significant post-operative reduction in left ventricular outflow gradient at rest. The age of the patients varied from 21 to 62 years (Male 71 & Female 27). Iatrogenic VSD was created in 3 and all had Trans atrial direct closure with pledgets. All the patients had transverse low aortotomy and there was no additional ventriculotomy. 64 patients had direct follow up and 20 patients had follow up through letters, telephone, etc. Rest are lost for follow up. Patient population comprise of Srilanka 4, Kenya 2, Tanzania 1 & Iraq 3. There was recurrence by increase in gradient in 8 patients ranging from 14 mm to 44 mm. Heart block was observed in 3 patients who required Permanent Pacemaker. Conclusions: These findings indicated that any patients with hypertrophic cardiomyopathy who require surgical treatment of stand alone procedures or MVR alone or in conjunction with septal myomectomy offers significant improvement of symptoms and hemodynamic values. Of the 4 patients who died, 3 had developed atrial fibrillation post-operatively which obviously is a risk factor.