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63. Surgical Versus Endovascular Treatment Of Acute Thoracic Aortic Rupture: A Single Experience.
Mirko Doss1; Joern Balzer2; Sven Martens1; Gerhard Wimmer Greinecker1; Thomas Vogl2; Hans Gerd Fieguth1; Anton Moritz1
1Department of Thoracic and Cardiovascular Surgery J W Goethe University Frankfurt , Frankfurt am Main , Germany , 2Department of Interventional Radiology J W Goethe University Frankfurt , Frankfurt am Main , Germany

Background:

Surgical management of acute thoracic aortic ruptures is controversial, as especially in patients with preexisting comorbidities associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome.

Methods:

From November 1999 to February 2002 a total of 54 patients, aged 28-83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated typ B dissections, 16 traumatic ruptures).28 patients were managed surgically utilizing cardiopulmonary bypass( group I) and 26 patients were acutely treated with an endovascular stent graft(group II).The rescussitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospital and emergency department data, operative findings and outcomes.

Results:

There were 5/28 deaths (17.8%) in the surgical group and 1/26 (3.8%) in the endovascular group. In the surgical group 1/28 (3.6%) patients developed paraplegia, there were no cases of paraplegia in the endovascular group. There were 4/28 (14.3%) cases of renal failure in group I and 1/26 (3.8%) in group II. In group I, 8 patients (28.6%) required mechanical ventilation for more than 48 hours and 2/26 (7.7%) in group II. 3 patients required rethoracotomy for hemorrage in the surgical group. There were 2 access failures in the endovascular group.

Conclusions:

In the treatment of acute ruptures of the thoracic aorta the immediate outcome of patients treated with endovascular stent grafts seems better than the management by conventional surgical repair.

64. Enduring Challenge In The Treatment Of Non Small Cell Lung Cancer (nsclc) With Clinical Stage Iiib: Results Of A Trimodality Approach.
Pierluigi Granone1; Stefano Margaritora1; Domenico Galetta1; Alfredo Cesario1; Lucio Trodella2; Rolando Maria D'Angelillo2; Venanzio Porziella1; Giuseppe Macis2
1General Thoracic Surgery Catholic University , Rome , Italy , 2Department of Radiotherapy Catholic University , Rome , Italy

Background:

Stage IIIb (T4/N3) NSCLC is considered an inoperable disease and treatment is an enduring challenge. Surgery after induction therapy seems to improve locoregional control. We report the results of a phase II prospective trimodality trial (chemotherapy and concomitant radiotherapy + surgery) in patients with stage IIIb NSCLC.

Methods:

From November 1992 to June 2000, 39 patients (37 men and 2 women, mean age 65 years) with clinical stage IIIb (34 T4N0-1, 4 T2-3N3, 1 T4N3) entered the study. Patients with T4 for malignant pleural effusion have been escluded. They received intravenously infusion of cisplatin 20 mg/m2 and 5-fluorouracil 1000 mg/m2 (days 1-4, and 24-28) combined with 50.4 Gy radiotherapy delivered in 4 week (1.8 Gy/day). Upon clinical re-staging, responders underwent surgery.

Results:

All patients were evaluable for clinical re-staging. No complete response was observed. Twenty-one patients had partial response (53.8%), 16 stable disease (41%), and 2 progression disease (5.2%). A moderate (G2) haematological toxicity was observed in 4 patients. Twenty-two (56.4%) patients underwent surgery – 21 with partial response and 1 with stable disease - with no perioperative death. A radical resection was possible in 21 cases. Nine lobectomies, 3 bilobectomies, and 9 pneumonectomies were performed. Complications occurred in 5 patients (22%). Fourteen of the operated patients showed a pathological downstaging (66.6%). A complete pathological response was obtained in 9 cases (49%). Sixteen patients had no residual metastatic lymphadenopathy (76%). Overall five-year survival was 23%. Resected versus non resected patients showed a significant difference: 38% vs 5.6% (p = 0.028 – log rank).

Conclusions:

This trimodal approach for stage IIIb NSCLC appears safe and effective. It provides good therapeutic results with acceptable morbidity in surgical cases.

65. Atrial Reduction Plasty Cox-maze: extended Indications For Atrial Fibrillation Surgery
Matthew A. Romano; Melissa A. Kovach; David S. Bach; *Francis D. Pagani; *Richard L. Prager; *G. Michael Deeb; *Steven F. Bolling
University of Michigan , Ann Arbor , Michigan

Background:

The Cox-maze procedure yields good results for atrial fibrillation (AF) in certain patient populations. However, patients with predictors of failure: chronic long standing AF, low amplitude fibrillatory waves, and large left atriums are generally thought not to benefit from a maze procedure. We report an aggressive approach to these patients, utilizing biatrial reduction plasty concomitantly with the Cox-maze for AF.

Methods:

A complete Cox-maze utilizing supplemental RF ablation was performed in 28 patients. All underwent resection of both atrial appendages and biatrial reduction plasty encompassing resection of the left atrial posterior wall from left to right pulmonary veins and from inferior pulmonary veins to the mitral annulus, as well as removal of the right atrial lateral wall. Mitral and/or tricuspid valve repair was performed on 25 patients.

Results:

These patients had a mean AF duration of 44±93 months. Pre-op, their left atria measured 53±14mm, with mean AF waves of 0.76±0.3mm. Pre-op NYHA class was 2.5±0.7 and LVEF was 48±10. Cross clamp and bypass times were 98±29 min and 128±34 min. The average posterior left atrial tissue resected was 3x6 cm. Resected mean atrial wt was 11 grams. There were no deaths and LOS was 5.6±3 days. At a follow-up time of 21±14 months, all patients were NYHA I and 25/28 were in normal sinus rhythm.

Conclusions:

Aggressive biatrial reduction plasty Cox-maze procedure was effective in 89% of these “low success” AF patients. This simple procedure can extend utilization of the Cox-maze to more patients with chronic AF.

66. Safety Of Lumbar Drains In Thoracic Aortic Operations Performed With Extracorporeal Circulation
Albert T. Cheung, M.D.; Alberto Pochettino, M.D.; Dmitri V. Guvakov, M.D.; Stuart J. Weiss, M.D.; Skandan Shanmugan, B.A.; *Joseph E. Bavaria, M.D.
University of Pennsylvania , Philadelphia , PA

Background:

The safety of cerebrospinal fluid (CSF) drainage in thoracic aortic surgery using extracorporeal circulation (ECC) with full heparinization has not been established.

Methods:

143 patients (age 67±13 yr) underwent thoracic aortic repair (1993–2002) with lumbar CSF drainage, ECC and full anticoagulation. CSF catheters were inserted at L3-5. CSF was drained to maintain pressures of 10-12 mm Hg. In the absence of neurologic deficit or coagulopathy, the catheters were capped at 24 hrs and removed at 48 hrs. CSF was drained beyond 24 hrs to reverse delayed onset paraparesis.

Results:

CSF drains were used in 122 thoracoabdominal aortic aneurysms (Crawford type I, n=59; II, n=25; III, n=29; IV, n=9) and 21 descending thoracic aortic repairs (aneurysm, n=18; traumatic aortic injury, n=2; aortic coarctation, n=1). Left atrial-femoral bypass was used in 113, full cardiopulmonary bypass in 30, with 22 requiring hypothermic circulatory arrest (HCA). Time between catheter insertion and anticoagulation was 188±76 min. Heparin achieved a maximum activated clotting time of 542±191 sec. ECC time was 109±73 min. HCA time was 39.4 ± 15.05 min. Mortality was 9.0% (13/143), permanent paraplegia was 6.3% (9/143). No epidural or spinal hematoma was observed. Catheter-related complications were 3.5% (5/143): temporary abducens nerve palsy (n=1); retained catheter fragments (n=3, 1 with meningitis); and meningitis with persistent CSF leak (n=1); all had full recovery without sequelae.

Conclusions:

CSF drainage in thoracic aortic surgery on ECC with full anticoagulation did not result in hemorrhagic complications. Permanent paraplegia rate was low and catheter-related complications had no permanent sequelae.

67. Thoracoscopic-guided Heller Myotomy For The Treatment Of Achalasia: Results Of A Minimally Invasive Technique
*Kenneth A. Kesler1; Stacey E. Tarvin1; Jo Ann Brooks1; *Karen M. Rieger1; Glen A. Lehman2; *John W. Brown1
1Indiana University School of Medicine Dept of Surgery Thoracic Division , Indianapolis , IN , 2Indiana University School of Medicine Dept of Medicine Gastroenterology Division , Indianapolis , IN

Background:

Several surgical methods have been described to treat achalasia with recent trends utilizing minimally invasive techniques. Since 1998, our institution has favored a minimally invasive thoracoscopic-guided technique (TGM) utilizing the thoracoscope for illumination and video screen guidance for the first assistant. Myotomy is performed by the primary surgeon under direct visualization through a 8-10 cm incision in the intercostal space without rib spreading. Only the chest wall soft tissues are closed without rib approximation.

Methods:

From 1992 to 2002, 57 patients (32 males, 25 females; mean age 47±17)underwent transthoracic Heller myotomy at our institution. Thirty-eight (67%) patients who underwent TGM were compared to 19 (33%) who previously underwent myotomy through a standard open left thoracotomy (OM).

Results:

There was no operative mortality in the TGM group (n=38) and 4 patients (11%) experienced minor morbidity. Of 38, four (11%) required conversion to open thoracotomy and 2 suffered either late death or are lost to follow-up. Of the remaining 32 TGM patients, 28 (87%) have little/no residual dysphagia at a mean follow-up of 17 months (range 1-49). Four patients (13%) are being treated for reflux. Compared to the OM group, TGM patients experienced shorter surgery time (96±24 min. vs. 139±54;p<.01), less blood loss (81±58 cc vs. 155±107;p<.01), less postoperative narcotic requirement (21±63 days vs. 66±116;p=.02) and shorter recovery to normal activity (29±20 days vs. 78±59;p<.01).

Conclusions:

TGM results in excellent relief of dysphagia in the short term and would be expected to have long-term results similar to OM techniques. Less blood loss, operating and recovery times as compared to OM techniques, without the need for a concomitant antireflux procedure required with laparoscopic approaches, makes TGM an attractive minimally invasive technique.

68. Brain Protection Using Antegrade Selective Cerebral Perfusion: A Multi-center-study.
Marco Di Eusanio1; Marc AAM Schepens1; Wim J Morshuis1; Karl M Dossche1; Roberto Di Bartolomeo2; Davide Pacini2; Angelo Pierangeli2; Teruhisa Kazui3; Kazuhiro Ohkura3; Naoki Washiyama3
1Department of Cardiopulmonary Surgery St Antonius Hospital , Nieuwegein , Netherlands , 2Department of Cardiac Surgery Policlinico S Orsola University of Bologna , Bologna , Italy , 3First Department of Surgery Hamamtsu University School of Medicine , Hamamatsu , Japan

Background:

To evaluate the results of Antegrade Selective Cerebral Perfusion (ASCP) as a method of brain protection during surgery of the thoracic aorta and to determine predictors of hospital mortality and adverse neurological outcome.

Methods:

Between October 1995 and March 2002, 588 patients underwent surgery of the thoracic aorta with the aid of ASCP. There were 334 men (56.8%); the mean age was 63.7 ± 11.8 years. One-hundred-sixty-two patients (27.6%) underwent urgent operation.The extent of the aortic tissue replacement is shown in table 1. The separated graft technique was employed to re-implant the arch vessels in 230 patients (65.3%) out of the 352 requiring aortic arch replacement. One-hundred-twelve patients underwent elephant trunk procedures. The mean ASCP time was 67±37 minutes.
Results:

The overall hospital mortality rate was 8.7%. A logistic regression analysis revealed urgent operation, recent central neurologic event, tamponade, unplanned CABG and CPB time>200 minutes to be independent predictors of hospital mortality.
The Permanent Neurological Dysfunction (PND) rate was 3.8%. A logistic regression analysis showed tamponade and CPB time>200 minutes to be independent predictors of PND.
The Transient Neurological Dysfunction (TND) rate was 5.6%. Recent central neurologic event, tamponade, coronary disease and aortic valve replacement were indicated as independent predictors of TND by logistic regression.
Conclusions:

In our experience, the utilisation of ASCP resulted in encouraging results in terms of hospital mortality and brain complications. Neither the extent of the replacement nor the duration of the cerebral perfusion had an impact on hospital mortality and neurological outcome.
Extent of aortic replacement:
n %
ascending aorta/hemiarch 230 39.1
ascending aorta+arch 222 37.8
aortic arch 32 5.4
aortic arch+descending aorta 16 2.7
total thoracic aorta 82 13.9
other 6 1.1

69. The Nuss Procedure For Pectus Excavatum: An Evolution Of Techniques And Early Results On 322 Patients.
Hyung Joo Park; Seock Yeol Lee; Cheol Sae Lee; Wook Youm; Kihl Roh Lee
Soonchunhyang University Chunan Hospital , Chunan , Korea (South)

Background:

The Nuss procedure is a recently developed technique for minimally invasive repair of pectus excavatum using a metal bar. Although its technical simplicity and cosmetic advantages are remarkable, applications have been limited to children with standard pectus excavatum. We report a single center experience of the technique that has been evolving in order to correct asymmetric pectus configurations and adult patients.

Methods:

Between August 1999 and June 2002, 322 consecutive patients underwent repair by the Nuss technique and its modifications. Of them, 71(22%) were adult. For the precise correction, morphology of the pectus was classified as symmetric and asymmetric types. Asymmetric type was subdivided into eccentric and unbalanced types. In repair, differently shaped bars were applied to individual types of pectus to achieve symmetric correction.

Results:

Symmetric type was 57.5%(185/322) and asymmetric type was 42.5%(137/317). Eccentric, unbalanced, and combined types were 71, 47 and 19, respectively. Major modifications were bar shaping and fixation. In asymmetric group, different shapes of asymmetric bars were applied (n=125, 38.8%). For adult patients, double bar or compound bar technique was used (n=51, 15.8%). To prevent bar displacement, multipoint wire fixations to ribs were used. Results were excellent in 299(92.9%) and good in 21(6.5%). Major postoperative complications were pneumothorax (n=24, 7.5%) and bar displacement (n=11, 3.4%). The bar was removed after 2 years in 42 patients.

Conclusions:

The Nuss procedure is safe and effective. Modifications of techniques in accordance with precise morphological classification enabled the correction of all variety of pectus excavatum including asymmetric types and adult patients.

70. Mitral Repair Techniques And Outcome In Patients With Coronary Disease
Peter S Dahlberg2; *Thomas Orszulak1; *Charles J Mullany1; *Hartzell V Schaff1
1Mayo Clinic and Foundation , 55905 , MN , 2University of Minnesota , 55455 , MN

Background:

The purpose of the study was to determine the impact of repair techniques and the presence of residual regurgitation (MR) on the outcome of surgery for patients undergoing combined mitral valve repair and CABG.

Methods:

From 1987 to 1995, 226 patients underwent mitral valve repair for ischemic or degenerative MR and simultaneous CABG. Dismissal echocardiograms were available in 197 patients. Repair techniques were divided into subgroups for analysis. The endpoint of the study was survival free from recurrent NYHA class III/IV symptoms (event free survival).

Results:

Patients dismissed with MR of grade II or higher had a decreased event-free survival compared to patients with absent or trivial MR. Other multivariate risk factors for a poor outcome included preoperative NYHA class III/IV symptoms and the need for emergency surgery.
Ring or commissural annuloplasty were the most common repair techniques used for repair of ischemic mitral disease. Leaflet resection or plication with annuloplasty were used most frequently for repair of degenerative mitral valves. All other forms of repair, including chordal and bileaflet procedures, were considered as complex repairs. For the overall group of patients a complex repair was not associated with any significant difference in the study endpoint. However, 11 of the 15 (73%) complex repairs in patients with ischemic MR failed (reoperation or MR > grade II).

Conclusions:

Residual MR is a risk factor for a poor outcome following combined mitral/coronary procedures. Mitral replacement should be considered when repair of an ischemic valve requires chordal or bileaflet procedures in addition to an annuloplasty.

71. Da Vinci Robotic Mitral Valve Repair: Outpatient Procedure?
*Mark S. Slaughter; *Antone J. Tatooles; *Patroklos S. Pappas
Advocate Christ Hospital and Medical Center , Oak Lawn , Illinois

Background:

Minimally invasive mitral valve (MV) repair with home discharge in one day is the ultimate goal for robotically assisted surgery. We evaluated our Da Vinci robotically assisted MV repair experience towards achieving this goal.

Methods:

All procedures were performed with peripheral cardiopulmonary bypass (CPB), transthoracic aortic crossclamp and antegrade cardioplegia. Three ports and a 4 cm intercostal incision in the right chest were used for access. All patients had posterior leaflet resection and ring annuloplasty. The entire repair and all knot tying were performed robotically.

Results:

Between October 2001 and July 2002, 22 patients (18 men) underwent robotic MV repair. The mean age was 54 yrs (range 37-81). There were no incisional conversions, deaths, strokes, or re-op for bleeding. 19 of 22 patients were extubated in the OR. Overall mean study times: procedure 193 min (range 160-287), CPB 124 min (range 95-186) and crossclamp 86 min (range 66-143). 8 patients were discharged home in less than 24 hrs with average stay of 2.6 days. Comparing the first 10 patients to the last 12 there was a significant reduction of times: procedure 210 vs 179 min, CPB 137 vs 113 min and cross-clamp 98 vs 76 min. LOS decreased from 4.2 to 1.25 days. Five patients had post-op a-fib. Three patients (14%) required readmission (2 a-fib, 1 cellulitis) within 30 days of surgery.

Conclusions:

Complex mitral valve repair can be successfully performed with the Da Vinci system. Currently, the majority of patients can be safely discharged within 30 hours.

72. Do Hospitals With Low Mortality Rates In Coronary Artery Bypass Also Perform Well In Valve Replacement?
Philip P. Goodney1; *Gerald T. O'Connor2; David E. Wennberg3; John D. Birkmeyer1
1VA Outcomes Group , White River Junction , Vermont , 2Center for the Evaluative Clinical Sciences and Dartmouth Medical School , Hanover , New Hampshire , 3Center for Outcomes Research and Evaluation and Maine Medical Center , Portland , Maine

Background:

Although variation in hospital mortality rates for CABG is well described, it is unknown whether hospital performance with CABG is correlated with performance with heart valve replacement.

Methods:

We studied operative mortality after aortic and mitral valve replacement (AVR, MVR) using the 1994-1999 national Medicare database. Hospitals performing these procedures were divided into ten evenly-sized groups (deciles) according to their adjusted mortality rates for isolated CABG (range 2.9%, decile 1 to 8.3%, decile 10). Using logistic regression models to adjust for patient characteristics, we then examined operative mortality rates with AVR and MVR across these deciles of CABG mortality.

Results:

Overall, 126,210 AVRs (54% with concomitant CABG) and 52,436 MVRs (46% with CABG) were performed in 910 hospitals. Patient characteristics did not differ substantially across deciles of CABG mortality. Adjusted mortality rates with both AVR and MVR were closely correlated with CABG mortality rates (see figure 1). With AVR, operative mortality increased from 5.7% at hospitals in decile 1 to 12.4% at hospitals in decile 10 (p trend <0.001, r2=0.35). Similarly, with MVR, adjusted operative mortality increased from 9.5% for hospitals in decile 1 to 19.7% for hospitals in decile 10 (p trend <0.001, r2=0.27).

Conclusions:

Hospital mortality rates with CABG are closely correlated with mortality rates with valve replacement. These findings suggest that shared processes and systems of care are important determinants of performance in cardiac surgery.

Figure: