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American Association
for Thoracic Surgery
ABSTRACT BOOK
89th
Annual
Meeting
May 9–13, 2009
Hynes Convention Center
Boston, Massachusetts, USA
Boston
WWW.AATS.ORG
AMERICAN ASSOCIATION
FOR THORACIC SURGERY
89th ANNUAL MEETING
Boston, Massachusetts
TABLE
OF
CONTENTS
Abstracts .................................................................................................. 54
Accreditation..............................................................................................1
Adult Cardiac Surgery Symposium ............................................................ 13
Author Index ........................................................................................... 212
Committees............................................................................................ 222
Congenital Heart Disease Symposium ....................................................... 18
Council...................................................................................................221
Developing the Academic Surgeon Symposium ...........................................11
Disclosure Policy ........................................................................................5
Future Meeting Dates ......................................................... inside back cover
General Meeting Information......................................................................1
General Thoracic Surgery Symposium ....................................................... 16
C. Walton Lillehei Resident Forum Session ................................................ 54
Scientiﬁc Program .................................................................................... 24
Speaker and Discussant Guidelines .............................................................6
AMERICAN ASSOCIATION FOR THORACIC SURGERY
2009
AATS ABSTRACT BOOK
GENERAL MEETING INFORMATION
About AATS
Promoting Scholarship in Thoracic and Cardiovascular Surgery
Founded in 1917 by the earliest pioneers in the ﬁeld of thoracic surgery,
the American Association for Thoracic Surgery (AATS) is now an international organization of over 1,200 of the world’s foremost cardiothoracic
surgeons representing 35 countries.
Surgeons must have a proven record of distinction within the cardiothoracic
surgical ﬁeld and have made meritorious contributions to the extant
knowledge base about cardiothoracic disease and its surgical treatment to
be considered for membership. The annual meeting, research grants
and awards, educational symposia and courses, and the AATS ofﬁcial
journal, the Journal of Thoracic and Cardiovascular Surgery, all strengthen
its commitment to science, education and research.
The ofﬁcers and councilors of the AATS welcome you to the 89th
Annual Meeting in Boston, Massachusetts, USA.
AATS Annual Meeting Accreditation
The American Association for Thoracic Surgery is accredited by the
Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
The American Association for Thoracic Surgery designates this educational activity for a maximum of 35 AMA PRA Category 1 Credit(s)™.
Physicians should only claim credit commensurate with the extent of
their participation in the activity.
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
The American Association for Thoracic Surgery designates the following credit hours:
Saturday, May 9, 2009 – up to 7.2 hours
❏ New Technologies and Procedures in Congenital and Acquired
Heart Surgery, up to 3.5 hours
❏ Thoracic Developmental Skills, up to 3.5 hours
❏ Developing the Academic Surgeon Symposium, up to 3.7 hours
Sunday, May 10, 2009 – up to 7.3 hours
❏ AATS/STS Adult Cardiac Surgery Symposium, up to 7.25 hours
❏ AATS/STS General Thoracic Surgery Symposium, up to 7 hours
❏ AATS/STS Congenital Heart Disease Symposium, up to 7.3 hours
❏ C. Walton Lillehei Resident Forum, up to 2 hours
Monday, May 11, 2009 – up to 7.4 hours
❏ Plenary Scientiﬁc Session, Basic Science Lecture, Presidential
Address, up to 3.8 hours
❏ Simultaneous Scientiﬁc Session – Adult Cardiac Surgery, up to
2.3 hours
❏ Simultaneous Scientiﬁc Session – General Thoracic Surgery, up
to 2.6 hours
❏ Simultaneous Scientiﬁc Session – Congenital Heart Disease, up
to 2.3 hours
❏ NHLBI STICH Trial Debate, up to 1 hour
Tuesday, May 12, 2009 – up to 7.5 hours
❏ Cardiac Surgery Forum Session, up to 1.75 hours
❏ General Thoracic Forum Session, up to 1.75 hours
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
❏ Plenary Scientiﬁc Session, Simulation Session, Honored Speaker
Lecture, up to 3.2 hours
❏ Simultaneous Scientiﬁc Session – Adult Cardiac Surgery, up to
2.25 hours
❏ Simultaneous Scientiﬁc Session – General Thoracic Surgery, up to
2.25 hours
❏ Simultaneous Scientiﬁc Session – Congenital Heart Disease, up to
2.5 hours
Wednesday, May 13, 2009 – up to 5 hours
❏ Emerging Technologies and Techniques Forum, up to 2 hours
❏ Plenary Scientiﬁc Session – Controversies, up to 1 hour
❏ Ablation vs. Surgery for Atrial Fibrillation: Antagonism or
Synergism?, up to 2 hours
❏ Pneumonectomy: A Treatment or a Disease?, up to 2 hours
For further information on the Accreditation Council for Continuing
Medical Education (ACCME) Standards of Commercial Support, please
visit www.accme.org.
CME Kiosks
All surgeons looking to obtain their Continuing Medical Education
credits may do so at the CME Pavilion located on the Second Level
of the Convention Center in the Hall D Foyer adjacent to Registration.
The CME Pavilion computers will allow attendees to log on and manage all of their CME credits for the Annual Meeting. At the conclusion
of the meeting, attendees may print their CME certiﬁcate and/or Letter of
Attendance. Following the meeting, attendees will be able to access this
material on the AATS website.
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Educational Objectives
At the conclusion of the AATS Annual Meeting, through comprehensive
lectures and discussions, participants will be able to:
❏ Implement the latest techniques and current research speciﬁcally
related to Adult Cardiac Surgery, Congenital Heart Disease,
and General Thoracic Surgery
❏ Analyze the pros and cons of each paper presented to implement
best practices in their current practices
❏ Select and apply appropriate surgical procedures and other inter-
ventions for their own patients based upon results presented
❏ Utilize basic science developments and emerging technologies
and techniques across the spectrum of Cardiothoracic Surgery
❏ Apply state-of-the art knowledge into their current practice
Target Audience
The AATS Annual Meeting is speciﬁcally designed to meet the educational needs of:
❏ Cardiothoracic Surgeons
❏ Physicians in related specialties including Cardiothoracic
Anesthesia, Cardiology, Pulmonology, Radiology, Gastroenterology
and Thoracic Oncology
❏ Fellows and Residents in Cardiothoracic and General Surgical
training programs
❏ Allied Health Professionals involved in the care of cardiothoracic
surgical patients
❏ Medical students with an interest in Cardiothoracic Surgery
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
Disclosure Policy
It is the policy of the American Association for Thoracic Surgery that
any individual who makes a presentation or is a co-author on a program
designated for AMA Physician’s Recognition Award Category 1 Credit
must disclose any ﬁnancial interest or other relationship (grant, research
support, consultant, etc.) that individual has with any manufacturer(s)
of any commercial product(s) that may be discussed in the individual’s
presentation. This policy is established neither to imply any position
regarding the propriety of such relationships nor to prejudice any individual from making a presentation but to allow the participants to
form their own judgments regarding the presentation.
Authors who may have a possible conﬂict of interest are denoted in
the disclosure index. Authors must disclose any material, ﬁnancial, or
other relationships that may pose conﬂict of interest at the time of
presentation.
Camera, Recording, Cell Phone and No-Smoking Policies
Due to privacy issues, it is the policy of AATS that no cameras are permitted in the meeting sessions or exhibit hall. Please refrain from taking
photos in these locations. Audio and videotaping are also prohibited.
For the courtesy of all faculty and participants, please ensure that cell
phone ringers are silenced during all sessions.
Smoking is not permitted in the Convention Center, Hotels or Special
Event Venues.
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
SPEAKER
AND
DISCUSSANT GUIDELINES
Presentation/Discussion Guidelines
Discussion of Papers: Members, non-member physicians and invited
speakers have the privilege of discussing papers. Discussants are limited
to 2 minutes and must limit their discussion to speciﬁc questions directly
related to the author’s presentation. All discussants should register
with the Session Moderator prior to the opening of the session during
which the paper is to be presented. All discussion will be presented
from ﬂoor microphones and may not be accompanied by slides.
Program
Presentation
Total
Discussion*
Plenary Sessions
8 minutes
12 minutes
Simultaneous Sessions
8 minutes
12 minutes
Adult Cardiac &
General Thoracic Forum
5 minutes
7 minutes
Emerging Technologies & 5 minutes
Techniques Forum
7 minutes
C. Walton Lillehei
Resident Forum
7 minutes
8 minutes
Controversies (Debates)
8 minutes each × 2 Rebuttals
20 minutes
8 minutes each × 2 Rebuttals
*All discussants are limited to 2 minutes
6
AMERICAN ASSOCIATION FOR THORACIC SURGERY
In accordance with the By-Laws of the Association:
1. Papers which are read at the meeting shall become the property of
the Association. They shall be submitted electronically to the Editor
prior to presentation (http://www.editorialmanager.com/jtcvs).
The papers submitted for consideration for publication in the
Journal of Thoracic and Cardiovascular Surgery must bear a close
relationship in length to the paper presented at the meeting.
2. Submission and acceptance of an abstract constitutes a commitment by the Author(s) to present the material at the AATS Annual
Meeting. The work must not have been submitted, presented or
published in abstract or manuscript form elsewhere prior to
the AATS 89th Annual Meeting in May 2009. Failure to meet this
requirement without prior approval of the Association will jeopardize a presenter’s further acceptance of abstracts for presentation
and/or publication. The AATS Council seriously regards and
adheres to the submission/presentation policy and will strictly
enforce sanctions upon all authors who fail to meet the policies
outlined in the rules for submission and presentation of abstracts
once submitted. Any questions should be addressed to the Secretary
of the Association.
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
PROGRAM INFORMATION
SATURDAY, MAY 9, 2009
8:00 a.m.
NEW TECHNOLOGIES AND PROCEDURES IN
CONGENITAL AND ACQUIRED HEART SURGERY
Room 302–306, Hynes Convention Center
Chairman: Mark E. Galantowicz, MD
Nationwide Children’s Hospital
8:00 a.m. – 8:10 a.m.
WELCOME AND INTRODUCTION
8:10 a.m – 8:30 a.m.
Overview of Pediatric Heart Assist
Devices in Development
Tim Baldwin, PhD
National Heart, Lung and Blood Institute
8:30 a.m. – 8:50 a.m.
A Decision Matrix to Guide Device
Selection for Pediatric Circulatory
Support
Brian W. Duncan, MD
Cleveland Clinic Foundation
8:50 a.m. – 9:10 a.m.
A Decision Matrix for Adult Mechanical
Circulatory Support
Benjamin C. Sun, MD
Ohio State University
9:10 a.m. – 9:30 a.m.
Heart Transplantation and High
Pulmonary Vascular Resistance –
Another Fallen Commandment?
Sanjiv K. Gandhi, MD
Saint Louis Children’s Hospital
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
9:30 a.m. – 10:00 a.m.
Pulmonary Assist Devices – Where Do
We Stand?
Robert H. Bartlett, MD
University of Michigan
10:00 a.m. – 10:30 a.m.
BREAK
10:30 a.m. – 10:50 a.m.
Hybrid Approach to HLHS
Mark E. Galantowicz, MD
Nationwide Children’s Hospital
10:50 a.m. – 11:10 a.m.
Hybrid Approach to Other Congenital
Heart Defects
Emile A. Bacha, MD
Children’s Hospital Boston
11:10 a.m. – 11:30 a.m.
Advanced Imaging in Coronary Surgery
and Hybrid Procedures
John G. Byrne, MD
Vanderbilt Heart Institute
11:30 a.m. – 11:50 a.m.
3-D Image Based Surgical Planning of
Aortic Valve Repair
Pedro J. del Nido, MD
Children’s Hospital Boston
11:50 a.m. –12:00 p.m.
DISCUSSION
12:00 p.m.
ADJOURN
9
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
8:00 a.m.
THORACIC DEVELOPMENTAL SKILLS
Room 312, Hynes Convention Center
Chairman: Raja M. Flores, MD
Memorial Sloan-Kettering Cancer Center
8:00 a.m. – 8:05 a.m.
WELCOME AND INTRODUCTION
Raja M. Flores, MD
Memorial Sloan-Kettering Cancer Center
8:05 a.m. – 8:25 a.m.
The Thoracic Surgeon and Endocbronchial
Ultrasound
Harvey I. Pass, MD
New York University
8:25 a.m. – 8:45 a.m.
VATS Lobectomy: Technical Details of All
Five Lobes
Raja M. Flores, MD
Memorial Sloan-Kettering Cancer Center
8:45 a.m. – 9:05 a.m.
Robotic Lobectomy
Bernard J. Park, MD
Memorial Sloan-Kettering Cancer Center
9:05 a.m. – 9:25 a.m.
Thoracoscopic LVRS and Sympathectomy
Robert J. McKenna, MD
Cedars Sinai Medical Center
9:25 a.m. – 9:45 a.m.
Resection and Reconstruction of Major
Intrathoracic Vascular Structures
Erino A.Rendina, MD
University La Sapienza
9:45 a.m. – 10:15 a.m.
BREAK
10:15 a.m. – 10:35 a.m.
Ivor Lewis Esophagectomy – Reﬁned,
Expeditious and Oncologically Sound
Manjit S. Bains, MD
Memorial Sloan-Kettering Cancer Center
10
AMERICAN ASSOCIATION FOR THORACIC SURGERY
10:35 a.m. – 10:55 a.m.
Minimally Invasive Esophagectomy
Michael S. Kent, MD
Beth Israel Deaconess Medical Center
10:55 a.m. – 11:15 a.m.
Tracheal Lesions – Initial Management
and Subsequent Surgical Treatment
Joel D. Cooper, MD
University of Pennsylvania
11:15a.m. – 11:35 a.m.
Chest Wall Resection and Reconstruction
Michae J. Weyant, MD
University of Colorado
11:35 a.m. – 12:00 p.m.
DISCUSSION
12:00 p.m.
ADJOURN
1:00 p.m.
DEVELOPING THE ACADEMIC SURGEON
SYMPOSIUM
Room 302-306, Hynes Convention Center
Chairman: A. Marc Gillinov, MD
Cleveland Clinic Foundation
1:00 p.m. – 1:10 p.m.
INTRODUCTION AND COURSE
OVERVIEW
A. Marc Gillinov, MD
Cleveland Clinic Foundation
1:10 p.m. – 1:30 p.m.
Academic Practice in Cardiothoracic
Surgery: An Outdated Concept?
Irving L. Kron, MD
University of Virginia Health System
1:30 p.m. – 1:50 p.m.
The Cardiothoracic Surgeon as Educator
Stephen C. Yang, MD
Johns Hopkins Medical Institute
1:50 p.m. – 2:10 p.m.
Basic Research in Thoracic Surgery
David R. Jones, MD
University of Virginia Health System
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
2:10 p.m. – 2:30 p.m.
Research and Medical Device Development
A. Marc Gillinov, MD
Cleveland Clinic Foundation
2:30 p.m. – 3:00 p.m.
Cardiothoracic Surgery: A Time of
Opportunity
James L. Cox, MD
Washington University
3:00 p.m. – 3:20 p.m.
BREAK
3:20 p.m. – 3:40 p.m.
Beyond Clinical Trials: Building an
Evidence Basis for Cardiothoracic
Surgery of the Future
Eugene H. Blackstone, MD
Cleveland Clinic Foundation
3:40 p.m. – 4:00 p.m.
The NIH-Sponsored Cardiothoracic
Surgical Trials Network
Timothy J. Gardner, MD
Christiana Care Health System
4:00 p.m. – 4:20 p.m.
Training for the Future
Mathew R. Williams, MD
Columbia University
4:20 p.m. – 4:40 p.m.
Cardiovascular Disease: An Integrated,
Programmatic Approach
Bruce W. Lytle, MD
Cleveland Clinic Foundation
4:40 p.m. – 5:00 p.m.
DISCUSSION
5:00 p.m.
ADJOURN
12
AMERICAN ASSOCIATION FOR THORACIC SURGERY
SUNDAY, MAY 10, 2009
8:00 a.m. – 5:00 p.m.
AATS/STS ADULT CARDIAC SURGERY
SYMPOSIUM
Ballroom A–C, Hynes Convention Center
Co-Chairmen: Michael A. Acker, MD
Joseph E. Bavaria, MD
University of Pennsylvania
SESSION I
THORACIC AORTA
8:00 a.m. – 8:20 a.m.
TEVAR: Indications, Current Trends and
Results
G. Chad Hughes, MD, Duke University
8:20 a.m. – 8:40 a.m.
TEVAR in Setting of Aortic Dissection:
Type A and B
Alberto Pochettino, MD, University of Pennsylvania
8:40 a.m. – 9:00 a.m.
Hybrid Arch
Wilson Y. Szeto, MD, University of Pennsylvania
9:00 a.m. – 9:15 a.m.
DISCUSSION
SESSION II
AORTIC ROOT/AORTIC VALVE
9:15 a.m. – 9:35 a.m.
Aortic Valve Repair/Retention with Aortic
Root Disease
G. Michael Deeb, MD, University of Michigan
9:35 a.m. – 9:55 a.m.
Aortic Valve Repair without Root Pathology
Tricuspid/Bicuspid
Gebrine El Khoury, MD, St-Luc Hospital
9:55 a.m. – 10:15 a.m.
BREAK
10:15 a.m. – 10:35 a.m.
Transcatheter Aortic Valve Replacement:
Transfemoral
Joseph E. Bavaria, MD, University of Pennsylvania
13
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
10:35 a.m. – 10:55 a.m.
Transcatheter Aortic Valve Replacement:
Transapical
Todd M. Dewey, MD, Medical City Dallas Hospital
10:55 a.m. – 11:10 a.m.
DISCUSSION
SESSION III
MITRAL VALVE REPAIR
11:10 a.m. – 11:30 a.m.
3-D Echo: Clinical Breakthrough or
Pretty Pictures?
Joseph S. Savino, MD, University of Pennsylvania
11:30 a.m. – 11:50 a.m.
Degenerative Disease: Complex Repair
Made Simple
David H. Adams, MD, Mount Sinai
Medical Center
11:50 a.m. – 12:05 p.m.
DISCUSSION
12:05 p.m. – 1:05 p.m.
LUNCH —
Hall A, Plaza Level
SESSION IV
SURGICAL DECISION MAKING: WHEN ARE TWO
VALVE PROCEDURES BETTER THAN ONE? /
ATRIAL FIBRILLATION
1:05 p.m. – 1:25 p.m.
The Surgical Treatment of Atrial Fibrillation:
Are We Ready for Prime Time?
Niv Ad, MD, Fairfax Hospital
1:25 p.m. – 1:45 p.m.
Aortic Stenosis/Mitral Regurgitation:
When to Repair the Mitral Valve?
Thomas G. Gleason, MD, University of Pittsburgh
1:45 p.m. – 2:05 p.m.
Mitral Stenosis/Mitral Regurgitation and
Tricuspid Regurgitation: When to Repair
the Tricuspid Valve?
Richard J. Shemin, MD, University of
California, Los Angeles
2:05 p.m. – 2:20 p.m.
DISCUSSION
14
AMERICAN ASSOCIATION FOR THORACIC SURGERY
SESSION V
HEART FAILURE
2:20 p.m. – 2:40 p.m.
Should Functional Mitral Regurgitation
in Heart Failure Patients be Repaired?
Patrick M. McCarthy, MD, Northwestern
University
2:40 p.m. – 3:00 p.m.
Small VADs: Solution for Heart Failure
Michael A. Acker, MD, University of Pennsylvania
3:00 p.m. – 3:20 p.m.
Indications for Surgical Revascularization
in Heart Failure Patients
Y. Joseph Woo, MD, University of Pennsylvania
3:20 p.m. – 3:35 p.m.
DISCUSSION
3:35 p.m. – 3:55 p.m.
BREAK
SESSION VI
CORONARY ARTERY BYPASS
3:55 p.m. – 4:15 p.m.
Drug Eluding Stents: Has the Pendulum
Started to Swing Back?
David P. Taggart, MD, University of Oxford
4:15 p.m. – 4:35 p.m.
Debate-Optimal Coronary Revascularization:
Off Pump (Puskas) vs. On Pump (Sabik) vs.
Hybrid (Byrne)
John D. Puskas, MD, Emory University
Joseph F. Sabik, MD, Cleveland Clinic
John G. Byrne, MD, Vanderbilt Heart Institute
4:35 p.m. – 4:50 p.m.
DISCUSSION
4:50 p.m.
ADJOURN TO WELCOME RECEPTION —
Exhibit Hall, Level 2
15
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
SUNDAY, MAY 10, 2009
8:00 a.m. – 5:00 p.m.
AATS/STS GENERAL THORACIC
SURGERY SYMPOSIUM
Room 302–306, Hynes Convention Center
Chairman:
David H. Harpole, Jr., MD
Duke University
8:00 a.m. – 8:10 a.m.
INTRODUCTION AND COURSE
OVERVIEW
David H. Harpole, Jr., MD, Duke University
SESSION I
NON-SMALL CELL LUNG CANCER
8:10 a.m. – 8:30 a.m.
New Lung Cancer Staging System
Joe B. Putnam, MD, Vanderbilt University
8:30 a.m. – 9:00 a.m.
Chemotherapy 101
Ramaswamy Govindan, MD, Washington
University
9:00 a.m. – 9:30 a.m.
Tyrosine Kinase Inhibitors
Pasi A. Janne, MD, PhD, Dana-Farber
Cancer Institute
9:30 a.m. – 10:00 a.m.
Anti-Angiogenesis and Other Molecular
Targets
Thomas J. Lynch, MD, Massachusetts
General Hospital
10:00 a.m. – 10:15 a.m.
DISCUSSION
10:15 a.m. – 10:45 a.m.
BREAK
10:45 a.m. – 11:15 a.m.
Radiotherapy 101
Jeffrey Bogart, MD, State University of
New York Upstate Medical University
11:15 a.m. – 11:45 a.m.
Current Early Stage Lung Cancer Trials
Eric Valleries, MD, Swedish Cancer Institute
11:45 a.m. – 12:00 p.m.
DISCUSSION
12:00 p.m. – 1:00 p.m.
LUNCH —
Hall A, Plaza Level
16
AMERICAN ASSOCIATION FOR THORACIC SURGERY
SESSION II
CONTROVERSIES IN LUNG CANCER
1:00 p.m. – 1:30 p.m.
Mediastinscopy or EBUS/EUS
Bryan F. Meyers, MD, MPH, Washington
University
1:30 p.m. – 2:00 p.m.
Who Is Medically Inoperable?
Robert J. Cerfolio, MD, University of Alabama
2:00 p.m. – 2:30 p.m.
Ablative Therapies for Nodules
Jo-Anne O. Shepard, MD, Massachusetts
General Hospital
2:30 p.m. – 3:00 p.m.
Upfront or Outback Chemotherapy
Ramaswamy Govindan, MD, Washington
University
3:00 p.m. – 3:30 p.m.
BREAK
SESSION III
UPDATES OF GENERAL THORACIC SURGERY
3:30 p.m. – 4:00 p.m.
STS Database Risk Adjustment
Cameron D. Wright, MD, Massachusetts
General Hospital
4:00 p.m. – 4:20 p.m.
Pulmonary Metastasectomy
Thomas A. D’Amico, MD, Duke University
4:20 p.m. – 4:40 p.m.
Interventions for Emphysema
Malcolm M. DeCamp, MD, Beth Israel
Deaconess Medical Center
4:40 p.m. – 5:00 p.m.
DISCUSSION
5:00 p.m.
ADJOURN TO WELCOME RECEPTION —
Exhibit Hall, Level 2
17
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
SUNDAY, MAY 10, 2009
8:00 a.m. – 5:00 p.m.
AATS/STS CONGENITAL HEART
DISEASE SYMPOSIUM
Room 312, Hynes Convention Center
Chairman:
J. William Gaynor, MD
Children’s Hospital of
Philadelphia
WELCOME AND INTRODUCTION
J. William Gaynor, MD
Children’s Hospital of Philadelphia
SESSION I
PRO/CON DEBATE: NIRS IS “STANDARD OF CARE”
FOR POST-OPERATIVE MANAGEMENT
8:00 a.m. – 8:15 a.m.
Pro: James S. Tweddell, MD
Medical College of Wisconsin
8:15 a.m. – 8:30 a.m.
Con: Jennifer C. Hirsch, MD
University of Michigan
8:30 a.m. – 8:35 a.m.
Rebuttal: James S. Tweddell, MD
8:35 a.m. – 8:40 a.m.
Rebuttal: Jennifer C. Hirsch, MD
8:40 a.m. – 9:00 a.m.
DISCUSSION
SESSION II
SURGICAL TECHNIQUES “HOW I DO IT”
9:00 a.m. – 9:20 a.m.
Aortic Valvuloplasty for Aortic Regurgitation
Richard A. Jonas, MD
Children’s National Medical Center
9:20 a.m. – 9:30 am
DISCUSSION
18
AMERICAN ASSOCIATION FOR THORACIC SURGERY
SESSION III
PRO/CON DEBATE: USE OF A FENESTRATION SHOULD
BE ROUTINE DURING THE FONTAN PROCEDURE
9:30 a.m.
– 9:45 a.m.
– 10:00 a.m.
10:00 a.m. – 10:05 a.m.
10:05 a.m. – 10:10 a.m.
10:10 a.m. – 10:30 a.m.
10:30 a.m. – 10:50 a.m.
9:45 a.m.
Pro: Scott M. Bradley, MD, Medical University
of South Carolina
Con: Frank L. Hanley, MD, Stanford University
Rebuttal: Scott M. Bradley, MD
Rebuttal: Frank L. Hanley, MD
DISCUSSION
BREAK
SESSION IV
CLINICAL RESEARCH IN PEDIATRIC CARDIAC
SURGERY: HOW CAN WE DO BETTER?
10:50 a.m.
– 11:05 a.m.
Uses and Limitations of Academic and
Registry Databases
William G. Williams, MD, The Hospital for
Sick Children
11:05 a.m.
– 11:20 a.m.
Randomized Treatment Trials: Lessons
Learned from the BCAS and Other Studies
Jane W. Newburger, MD, MPH, Children’s
Hospital Boston
11:20 a.m.
– 11:35 a.m.
Multi-Institutional Studies: Lessons
Learned from the CHSS Studies
Christopher A. Caldarone, MD, The Hospital
for Sick Children
11:35 a.m.
– 11:50 a.m.
Multi-Institutional Studies: Lessons
Learned from the SVR Trial
Richard G. Ohye, MD, University of Michigan
– 12:00 p.m.
12:00 p.m. – 1:00 p.m.
11:50 a.m.
DISCUSSION
LUNCH —
Hall A, Plaza Level
19
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
SESSION V
VARIABILITY IN OUTCOMES
1:00 p.m.
– 1:20 p.m.
Perioperative Genomics: Why Do “Similar”
Patients Have Different Outcomes?
Mark F. Newman, MD, Duke University
1:20 p.m.
– 1:40 p.m.
Does Protocol Driven Post-Operative
Management Improve Outcomes?
Peter C. Laussen, MD, Children’s Hospital of
Boston
1:40 p.m.
– 2:00 p.m.
Difﬁculties Comparing Outcomes Between
Institutions
Karl F. Welke, MD, Oregon Health and Science
University
2:00 p.m.
– 2:20 p.m.
How Do We Translate Clinical Research to
Clinical Practice
Gil Wernovsky, MD, Children’s Hospital of
Philadelphia
2:20 p.m.
– 2:30 p.m.
DISCUSSION
SESSION VI
SURGICAL TECHNIQUES: “HOW I DO IT”
2:30 p.m.
– 2:50 p.m.
– 3:00 p.m.
3:00 p.m. – 3:20 p.m.
2:50 p.m.
Living-Donor Lobar Lung Transplantation
Vaughn A. Starnes, MD, University of Southern
California
DISCUSSION
BREAK
20
AMERICAN ASSOCIATION FOR THORACIC SURGERY
SESSION VII
THE FONTAN/KREUTZER PROCEDURE AT 40
3:20 p.m.
– 3:30 p.m.
Surgical Repair of Tricuspid Atresia
Francis M. Fontan, MD
3:30 p.m.
– 3:40 p.m.
An Operation for Correction of Tricuspid
Atresia
Guillermo O. Kreutzer, MD, Ricardo Gutierrez
Children’s Hospital
3:40 p.m.
– 4:00 p.m.
Evolution of the Fontan/Kreutzer Procedure
Marc R. de Leval, MD, International Congenital
Cardiac Centre
4:00 p.m.
– 4:20 p.m.
Current Status of Survivors of the Fontan/
Kreutzer Procedure
Jack Rychik, MD, Children’s Hospital of
Philadelphia
4:20 p.m.
– 4:40 p.m.
The Fontan/Kreutzer Procedure: Future
Directions
Edward L. Bove, MD, University of Michigan
4:40 p.m.
– 5:00 p.m.
DISCUSSION
5:00 p.m.
ADJOURN TO WELCOME RECEPTION —
Exhibit Hall, Level 2
21
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
SUNDAY AFTERNOON
MAY 10, 2009
3:00 p.m.
C. WALTON LILLEHEI RESIDENT FORUM SESSION
Room 311, Hynes Convention Center
(7 minutes presentation, 8 minutes discussion)
Moderators: Gus J. Vlahakes, Ara A. Vaporciyan
L1.
In Vivo Structure and Function of Engineered Pulmonary
Valves
Danielle Gottlieb1, Kunal Tandon1, Sitaram Emani1, Elena Aikawa2,
David W. Brown1, Andrew J. Powell1, Arthur Nedder1, Michael S. Sacks3,
John E. Mayer1*
1. Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA;
2. Massachusetts General Hospital and Harvard Medical School, Boston, MA,
USA; 3. University of Pittsburgh, Pittsburgh, PA, USA
L2.
The Graft Imaging to Improve Patency (GRIIP) Trial Results
Steve Singh, Nimesh Desai,† Genta Chikazawa, Hiroshi Tsuneyoshi,
Visal Pen, Jessica Vincent, Jennifer Ku, Fuad Moussa, Gideon Cohen,
George Christakis,* Stephen E. Fremes*
Sunnybrook Health Sciences Centre, Toronto, ON, Canada
L3.
Tissue Engineered Pro-Angiogenic Fibroblast Matrix Improves
Myocardial Perfusion and Function and Limits Ventricular
Remodeling Following Infarction
J. Raymond Fitzpatrick, John R. Frederick, Ryan C. McCormick,
David A. Harris, Ah-Young Kim, Max J. Smith, Carine M. Laporte,
Jeffrey R. Muenzer, Alex J. Gambogi, Y. Joseph Woo*
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA, USA
L4.
Atorvastatin at Reperfusion Reduces Myocardial Infarct Size
in Mice by Activating eNOS of Bone Marrow-Derived Cells
Zequan Yang,1 Gorav Ailawadi,1† Joel Linden,2 Brent A. French,3 Irving L. Kron1*
1. Surgery, University of Virginia Health System, Charlottesville, VA, USA;
2. Medicine, University of Virginia Health System, Charlottesville, VA, USA;
3. Biomedical Engineering, University of Virginia Health System, Charlottesville,
VA, USA
*AATS
Member
Traveling Fellowship 2006
†Resident
22
AMERICAN ASSOCIATION FOR THORACIC SURGERY
L5.
Quantitative Assessment of Technical Proﬁciency of Residents
in Cardiac Surgery
Hiroo Takayama, Yoshifumi Naka,* Mehmet C. Oz,*†Allan S. Stewart,
Mathew R. Williams, Craig R. Smith,* Micheal Argenziano
Columbia University, New York, NY, USA
L6.
Divergent Impact of Osteopontin Isoforms on Lung Cancer
Angiogenesis
Justin D. Blasberg, Jessica S. Donington, Chandra M. Goparaju,
Harvey I. Pass*
New York University Medical Center, New York, NY, USA
L7.
Temporary Acute Mechanical Circulatory Support for Acute
Circulatory Collapse: Experience with 266 Patients
Kristopher B. Deatrick, Amit K. Mathur, Ann Schumar, Robert H. Bartlett,
Francis D. Pagani,* Jonathan W. Haft
Cardiac Surgery, The University of Michigan, Ann Arbor, MI, USA
L8.
Age Is an Independent Risk Factor for Aspiration Following
Thoracotomy for Pulmonary Resection
William B. Keeling1, Jonathan M. Hernandez2, Vicki Lewis3, Melissa Czapla3,
Weiwei Zhu3, Joseph Garrett2, Eric Sommers2
1. Emory University, Atlanta, GA, USA; 2. University of South Florida,
Tampa, FL, USA; 3. H. Lee Mofﬁtt Cancer Center, Tampa, FL, USA
5:00 p.m.
ADJOURN TO WELCOME RECEPTION
Exhibit Hall, Level 2
*AATS
Member
E. Gross Research Scholarship 1994
†Robert
23
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
MONDAY MORNING
MAY 11, 2009
7:30 a.m.
BUSINESS SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
7:45 a.m.
PLENARY SCIENTIFIC SESSION
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
1.
A Formidable Task: Population Analysis Predicts a Deﬁcit of 2,000
Cardiothoracic Surgeons by 2030
Thomas E. Williams,* Benjamin Sun, Patrick Ross, Andrew M. Thomas
Surgery, Ohio State University, Columbus, OH, USA
Invited Discussant: Irving L. Kron
2.
Single Center Experience in Treatment of Cardiogenic Shock of
Any Etiology in Children by Pediatric Ventricular Assist Devices
Roland Hetzer,* Evgenij V. Potapov, Oliver Miera, Yu-Guo Weng, Michael Hübler,
Felix Berger
DHZB, Berlin, Germany
Invited Discussant: Charles Fraser, Jr.
3.
Long-Term Results of Aortic Valve Sparing Operations in Patients
with Marfan Syndrome
Tirone E. David,* Susan Armstrong, Manjula Maganti, Jack Colman,
Timothy Bradley
Cardiovascular Surgery, Toronto General Hospital, Toronto, ON, Canada
Invited Discussant: Lars G. Svensson
4.
Outcomes After Laparoscopic Giant Paraesophageal Hernia Repair
in 636 Patients
James D. Luketich,* Katie S. Nason, Rodney J. Landreneau,* Samuel Keeley,
Omar Awais, Manisha Shende, Matthew J. Schuchert, Ghulam Abbas,
Blair A. Jobe, Arjun Pennathur
The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Invited Discussant: Antoon Lerut
*AATS
Member
24
AMERICAN ASSOCIATION FOR THORACIC SURGERY
9:05 a.m.
AWARD PRESENTATIONS
Ballroom A–C, Hynes Convention Center
Lifetime Achievement Award
Thomas B. Ferguson, MD
Washington University School of Medicine
C. Walton Lillehei Forum Award
TSRA McGoon Award
TSFRE Report
9:20 a.m.
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
10:00 a.m.
BASIC SCIENCE LECTURE
Ballroom A–C, Hynes Convention Center
Insights from Developmental and Stem Cell Biology
Jonathan A. Epstein, MD
William Wikoff Smith Professor of Medicine
Chairman, Department of Cell and Developmental Biology
Scientiﬁc Director, Penn Cardiovascular Institute
Founding Co-Director, Penn Institute for Regenerative Medicine
University of Pennsylvania
Introduced By:
10:40 a.m.
PLENARY SCIENTIFIC SESSION
Moderators:
5.
Thomas L. Spray, MD
Alec Patterson
Thoralf M. Sundt, III
The Relationship Between Hospital CABG Volume and Multiple
Dimensions of CABG Quality
David M. Shahian,1* Sean O’Brien,2 Sharon-Lise Normand,3 Eric Peterson,2
Fred Edwards4*
1. Massachusetts General Hospital, Boston, MA, USA; 2. Duke Clinical Research Institute,
Durham, NC, USA; 3. Harvard Medical School, Boston, MA; USA, 4. University of
Florida, Jacksonville, FL, USA
Invited Discussant: T. Bruce Ferguson, Jr.
*AATS
Member
25
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
6.
Survival After Transapical and Transarterial Aortic Valve
Implantation: Talking About Two Different Patient Populations
Sabine Bleiziffer, Hendrik Ruge, Domenico Mazzitelli, Christian Schreiber,
Andrea Hutter, Robert Bauernschmitt, Ruediger Lange*
Clinic for Cardiovascular Surgery, German Heart Center Munich, Munich, Germany
Invited Discussant: Michael J. Mack
11:25 a.m.
PRESIDENTIAL ADDRESS
The Quality Conundrum
Thomas L. Spray, MD, Philadelphia, PA
Introduced By:
12:15 p.m.
Alec Patterson, MD
LUNCH – VISIT EXHIBITS
Exhibit Hall
CARDIOTHORACIC RESIDENTS’ LUNCHEON*
Room 311, Hynes Convention Center
*Ticketed event
*AATS
Member
26
AMERICAN ASSOCIATION FOR THORACIC SURGERY
MONDAY AFTERNOON
MAY 11, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
7.
R. Duane Davis
Chuen-Neng Lee
Outcomes of Reoperative Aortic Valve Replacement Following
Previous Sternotomy
Damien J. LaPar, Zequan Yang, R. Ramesh Singh, T. Brett Reece,† Cory D. Maxwell,
Benjamin B. Peeler, John A. Kern,* Irving L. Kron,* Gorav Ailawadi∞
Surgery, University of Virginia, Charlottesville, VA, USA
Invited Discussant: Leonard N. Girardi
8.
Apical Myectomy: A New Surgical Technique for the Management
of Severely Symptomatic Patients with Apical Hypertrophic
Cardiomyopathy
Hartzell V. Schaff,1* Morgan L. Brown,1 Steve R. Ommen,1 Joseph A. Dearani,1
Martin D. Abel,1 A.J. Tajik,2 Rick A. Nishimura1
1. Mayo Clinic, Rochester, MN, USA; 2. Mayo Clinic, Scottsdale, AZ, USA
Invited Discussant: Nicholas G. Smedira
9.
Where Does AF Surgery Fail?: Implications for Increasing AF
Surgical Ablation Effectiveness
Patrick M. McCarthy,* Jane Kruse, Shanaz Shalli, Leonard Ilkhanoff,
Jeffrey Goldberger, Alan Kadish, Rishi Arora, Richard Lee
Division of Cardiothoracic Surgery, Northwestern University; Northwestern
Memorial Hospital, Chicago, IL, USA
Invited Discussant: Chuen-Neng Lee
3:00 p.m.
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
*AATS
Member
Traveling Fellowship 2008
∞Resident Traveling Fellowship 2006
†Resident
27
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
3:45 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
Moderators:
R. Duane Davis
Chuen-Neng Lee
10. Have Hybrid Procedures Replaced Open Aortic Arch Reconstruction
in High Risk Patients: A Comparative Study of Open Arch Debranching
with Endovascular Stent Graft Placement and Conventional Open
Total and Distal Aortic Arch Reconstruction
Rita K. Milewski, Wilson Y. Szeto, Alberto Pochettino, G. William Moser,
Patrick Moeller, Joseph E. Bavaria
Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Invited Discussant: Yutaka Okita
11. Effect of Partial Thrombosis on Distal Aorta After Repair of Acute
DeBakey Type I Aortic Dissection
Suk-Won Song,1 Byung-Chul Chang,2*† Bum-Koo Cho,2*∞ Kyung-Jong Yoo2
1. Yondong Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea;
2. Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
Invited Discussant: Anthony L. Estrera
12. Staged Repair Signiﬁcantly Reduces Paraplegia Rate After
Extensive Thoracoabdominal Aortic Aneurysm Repair
Christian D. Etz, Stefano Zoli, Christoph S. Mueller, Carol A. Bodian,
Gabriele Di Luozzo, Ricardo Lazalla, Konstadinos A. Plestis, Randall B. Griepp*
Mount Sinai School of Medicine, New York, NY, USA
Invited Discussant: Joseph S. Coselli
*AATS
Member
Memorial Traveling Fellowship 1987–1988
∞Graham Memorial Traveling Fellowship 1976–1977
†Graham
28
AMERICAN ASSOCIATION FOR THORACIC SURGERY
13. Preoperative Very Short Term High Dose Erythropoietin Administration
Diminishes Blood Transfusion Rate in Off Pump Coronary Artery
Bypass – A Randomized Blind Controlled Study
Luca Weltert, Stefano D’Alessandro, Saverio Nardella, Fabiana Girola,
Alessandro Bellisario, Daniele Maselli, Ruggero De Paulis
European Hospital, Rome, Italy
Invited Discussant: Colleen Koch
5:05 p.m.
ADULT CARDIAC DEBATE
NHLBI STICH TRIAL:
Coronary Bypass with Ventricular Reconstruction Does
Not Improve Survival Compared to Coronary Bypass
Surgery
Ballroom A–C, Hynes Convention Center
6:00 p.m.
Moderator:
Andrew S. Wechsler
Pro:
Robert H. Jones
Con:
Gerald D. Buckberg
ADJOURN
29
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
MONDAY AFTERNOON
MAY 11, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 302–306, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
James D. Luketich
Bryan F. Meyers
14. Thoracoscopic Lobectomy Is Associated with Lower Morbidity
than Open Lobectomy: A Propensity-Matched Analysis from the
STS Database
Subroto Paul,1† Nasser K. Altorki,1* Shubin Sheng,2 Paul C. Lee,1 David H. Harpole,2*
Mark W. Onaitis,2 Brendon M. Stiles,1 Jeffrey L. Port,1 Thomas A. D’Amico2*
1. Cardiothoracic Surgery, New York, Presbyterian-Weill Cornell Medical Center,
New York, NY, USA; 2. Duke University Medical Center, Durham, NC, USA
Invited Discussant: Neil A. Christie
15. Learning Curves for Video-Assisted Thoracic Surgery Lobectomy
in Non-Small Cell Lung Cancer
Hyun-Sung Lee, Byung-Ho Nam, Jae Ill Zo
Center for Lung Cancer, National Cancer Center, Goyang, Gyeonggi, South Korea
Invited Discussant: Bryan F. Meyers
16. Propensity Matched Comparison of Surgery Versus Stereotactic
Body Radiation Therapy in Early Stage Lung Cancer
Chadrick Denlinger, Jeffrey D. Bradley, Issam M. El Naqa, Jennifer B. Zoole,
Bryan F. Meyers,* Alec Patterson,* Daniel Kreisel, Alexander S. Krupnick,∞
Traves Crabtree
Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA
Invited Discussant: James D. Luketich
17. NETT REDUX (Accentuating the Positive)
Pablo G. Sanchez, John C. Kucharczuk, Stacey Su, Larry R. Kaiser,* Joel D. Cooper*
Department of Surgery, Division of Thoracic Surgery, University of Pennsylvania,
Philadelphia, PA, USA
Invited Discussant: Rodney J. Landreneau
3:20 p.m.
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
*AATS
Member
Traveling Fellowship 2006
∞Norman E. Shumway Research Scholarship 2008
†Resident
30
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3:55 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 302–306, Hynes Convention Center
Moderators:
James D. Luketich
Bryan F. Meyers
18. Minimally Invasive Repair of Pectus Excavatum: 10-Year Appraisal
with 1,170 Patients
Hyung Joo Park, Jongho Cho, Kwang Taik Kim, Young Ho Choi
Korea University Medical Center, Seoul, South Korea
Invited Discussant: Daniel L. Miller
19. Aggressive Surgical Treatment of Multidrug-Resistant Tuberculosis in
the Extensive Drug Resistance Era
Yuji Shiraishi, Naoya Katsuragi, Hidefumi Kita, Yoshiaki Tominaga, Kota Kariatsumari,
Takahito Onda
Chest Surgery, Fukujuji Hospital, Tokyo, Japan
Invited Discussant: Alain Chapelier
20. Reconstruction of the Pulmonary Artery for Lung Cancer: Long
Term Results
Federico Venuta,1* Anna Maria Ciccone,2† Marco Anile,1 Mohsen Ibrahim,2
Francesco Pugliese,1 Domenico Massullo,2 Tiziano De Giacomo,1
Giorgio F. Coloni,1 Erino A. Rendina2*
1. University Sapienza of Rome – Policlinico Umberto I, Rome, Italy; 2. University
Sapienza of Rome – Ospedale S. Andrea, Rome, Italy
Invited Discussant: Shaf Keshavjee
21. Tracheal Sleeve Pneumonectomy for Lung Cancer After Induction
Chemotherapy
Domenico Galetta, Piergiorgio Solli, Giulia Veronesi, Alessandro Borri,
Roberto Gasparri, Francesco Petrella, Lorenzo Spaggiari
Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy
Invited Discussant: Cameron D. Wright
5:15 p.m.
*AATS
ADJOURN
Member
Memorial Traveling Fellowship 2001–2002
†Graham
31
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
MONDAY AFTERNOON
MAY 11, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
James S. Tweddell
Vaughn A. Starnes
22. Is Cardiac Diagnosis a Predictor of Neurodevelopmental Outcome
After Cardiac Surgery in Infancy?
J.W. Gaynor,1* Marsha Gerdes,1 Alex S. Nord,2 Judy Bernbaum,1 Elaine H. Zackai,1
Gil Wernovsky,1 Robert R. Clancy,1 Patrick J. Heagerty,2 Cynthia B. Solot,1
Jo Ann D’Agostino,1 Nancy B. Burnham,1 Donna McDonald-McGinn,1
Susan C. Nicolson,1 Thomas L. Spray,1* Gail P. Jarvik2
1. The Children’s Hospital of Philadelphia, Philadelphia, PA, USA; 2. University of
Washington, Seattle, WA, USA
Invited Discussant: Ivan M. Rebeyka
23. Endothelial Nitric Oxide Synthase Gene Polymorphism and
Pulmonary Hypertension in Children with Congenital Heart
Diseases
Tsvetomir S. Loukanov,1 Christian Sebening,1 Nina Hoss,2 Pencho Tonchev,2
Matthias Karck, Matthias Gorenﬂo
1. Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; 2. Pediatric
Cardiology, University of Heidelberg, Heidelberg, Germany
Invited Discussant: Paul M. Kirshbom
24. Left Ventricular Rehabilitation Is Effective in Maintaining
Two-Ventricle Physiology in the Borderline Left Heart
Sitaram Emani, Emile A. Bacha,* Doff McElhinney, Gerald Marx, Wayne Tworetsky,
Frank A. Pigula,* Pedro J. del Nido*
Childrens Hospital Boston, Boston, MA, USA
Invited Discussant: Frank L. Hanley
*AATS
Member
32
AMERICAN ASSOCIATION FOR THORACIC SURGERY
25. A Contemporary Comparison of the Effect of Shunt Type in
Hypoplastic Left Heart Syndrome on the Hemodynamics and
Outcome at Fontan Completion
Jean A. Ballweg,1 Troy E. Dominguez,1 Chitra Ravishankar,1 Peter J. Gruber,1
Gil Wernovsky,1 J.W. Gaynor,1* Susan C. Nicolson,1 Thomas L. Spray,1* Sarah Tabbutt2
1. Children’s Hospital of Philadelphia, Philadelphia, PA, USA; 2. University of
California San Francisco, San Francisco, CA, USA
Invited Discussant: Christian Pizarro
3:20 p.m.
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
4:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
Moderators:
James S. Tweddell
Vaughn A. Starnes
26. Chronological Changes in P-Wave Characteristics After the Fontan
Procedure: Impact of Surgical Modiﬁcation
Masahiro Koh,1 Hideki Uemura,2 Akiko Kada,1 Koji Kagisaki,1 Ikuo Hagino,1
Toshikatsu Yagihara1
1. National Cardiovascular Center, Osaka, Japan; 2. Royal Brompton Hospital, London,
United Kingdom
Invited Discussant: Charles B. Huddleston
27. Depth of Ventricular Septal Defect and Impact on Reoperation for
Left Ventricular Outﬂow Obstruction After Repair of Complete
Atrioventricular Septal Defect: Does Double Patch Technique
Decrease the Incidence of Left Ventricular Outﬂow Obstruction?
Anatomical and Clinical Correlation
Anastasios C. Polimenakos,1 Shyam K. Sathanandam,2 Soraia Bharati,2
Vivian Cui,2 David Roberson,2 Mary Jane Barth,2 Chawki El Zein,2
Robert S.D. Higgins,1*Michel Ilbawi2
1. Center for Congenital and Structural Heart Disease/Rush University Medical Center,
Chicago, IL, USA; 2. The Heart Institute for Children at Hope Christ Hospital, Oak
Lawn, IL, USA
Invited Discussant: Carl L. Backer
*AATS
Member
33
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
28. Fenestration During Fontan Palliation: Now the Exception Instead
of the Rule
Jorge D. Salazar, Kashif Siddiqui, Farhan Zafar, Ryan Coleman, David L. Morales,
Jeffrey Heinle, Charles D. Fraser*
Congenital Heart Surgery, Texas Children’s Hospital, Houston, TX, USA
Invited Discussant: Scott M. Bradley
5:00 p.m.
*AATS
ADJOURN
Member
34
AMERICAN ASSOCIATION FOR THORACIC SURGERY
TUESDAY MORNING
MAY 12, 2009
7:00 a.m.
CARDIAC SURGERY FORUM SESSION
Ballroom A–C, Hynes Convention Center
(5 minutes presentation, 7 minutes discussion)
Moderators: John A. Kern, Bruce R. Rosengard
F1.
Vascularized Patch Used for Cardiac Reconstruction Stimulates
Myocardial Tissue-Speciﬁc Regeneration
Serghei Cebotari,1 Sava Kostin,2 Igor Tudorache,1 Matthias Karck,1
Christoph Bara,1 Omke Teebken,1 Tanja Meyer,1 Alexandru Calistru,1
Andres Hilﬁker,1 Axel Haverich1*
1. Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover,
Germany; 2. Max-Planck-Institute for Heart and Lung Research, Bad Nauheim,
Germany
Invited Discussant: Bruce R. Rosengard
F2.
Repair of the Right Ventricular Outﬂow Tract by a Mesenchymal
Stem Cell-Seeded Bioabsorbable Valved Patch: Medium-Term
Follow-Up in a Growing Lamb Model
David Kalfa,1 Alain Bel,2 Annabel Chen-Tournoux,1 Philippe Rochereau,1
Cyrielle Coz,1 Valérie Bellamy,1 Elie Mousseaux,3 Patrick Bruneval,4
Jérôme Larghero,5 Philippe Menasché1*
1. INSERM U633, Paris, France; 2. Hôpital Européen Georges Pompidou,
Department of Cardiovascular Surgery; University Paris Descartes, Paris, France;
3. Hôpital Européen Georges Pompidou, Department of Radiology, University
Paris Descartes, Paris, France; 4. Hôpital Européen Georges Pompidou, Department
of Pathology, University Paris Descartes, Paris, France; 5. Hôpital Saint-Louis,
Laboratory of Cell Therapy; University Paris Diderot, Paris, France
Invited Discussant: Bret Mettler
F3.
The Novel Synthetic Serine-Protease Inhibitor CU2010 DoseDependently Reduces Postoperative Blood Loss and Improves
Postischemic Recovery After Cardiac Surgery
Gábor Szabó, Tamás Radovits, Gábor Veres, Matthias Karck
Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
Invited Discussant: John A. Elefteriades
*AATS
Member
35
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F4.
3D Geometry of the Mitral Valve Determines the Success of
Secondary Chordal Cutting in Alleviating Ischemic Mitral
Regurgitation
Muralidhar Padala,1 Katherine L. Bell,1 Vinod H. Thourani,3 David H. Adams,2*†
Ajit P. Yoganathan1
1. Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA; 2.
Mt. Sinai Hospital, New York, NY, USA; 3. Emory University, Atlanta, GA, USA
Invited Discussant: Gus J. Vlahakes
F5.
Successful Resuscitation After Prolonged Periods of Cardiac
Arrest – A New Field in Cardiac Surgery
Georg Trummer,1 Katharina Foerster,1 Gerald D. Buckberg,2* Christoph Benk,1
Claudia Heilmann,1 Irina Mader,1 Friedrich Feuerhake,1 Oliver Liakopoulos,2
Kerstin Brehm,1 Friedhelm Beyersdorf1*
1. University Hospital Freiburg, Freiburg, Germany; 2. David Geffen School of
Medicine, University of California, Los Angeles, CA, USA
Invited Discussant: Ani Anyanwu
F6.
Smooth Muscle Phenotypic Modulation Is an Early Event in
Murine Aortic Aneurysms and Human Aneurysms
Gorav Ailawadi,∞ Sandra P. Walton, Hong Pei, Chris W. Moehle, Zequan
Yang, Christine Lau,‡ Mark C. Mochel, Irving L. Kron,* Gary K. Owens
TCV Surgery, University of Virginia, Charlottesville, VA, USA
Invited Discussant: John S. Ikonomidis
F7.
Biodegradable Synthetic Small-Calibre Vascular Grafts:
Long-Term Results After Replacement of the Rat Aorta
Beat H. Walpoth,1 Damiano Mugnai,1 Jean-Christophe Tille,2
Francesco Innocente,1 Benjamin Nottelet,3 Corinne Berthonneche,4
Xavier Montet,5 Sarra de Valence,3 Michael Moeller,3 Robert Gurny,3
Afksendiyos Kalangos1
1. Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva,
Switzerland; 2. Department of Pathology, University Hospital of Geneva,
Geneva, Switzerland; 3. Department of Pharmaceutics & Biopharmaceutics
EPGL, University of Geneva, Geneva, Switzerland; 4. Department of Medicine,
University Hospital of Lausanne, Lausanne, Switzerland; 5. Department of
Radiology, University Hospital of Geneva, Geneva, Switzerland
Invited Discussant: Gorav Ailawadi
*AATS
Member
Ochsner Research Scholarship 1992
∞Resident Traveling Fellowship 2006
‡John W. Kirklin Research Scholarship 2006
†Alton
36
AMERICAN ASSOCIATION FOR THORACIC SURGERY
F8.
Optimal Flow Rate for Antegrade Cerebral Perfusion
Takashi Sasaki, Shoichi Tsuda, Robert K. Riemer, Vadiyala Mohan Reddy,*
Frank L. Hanley*
Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
Invited Discussant: Randall B. Griepp
F9.
Reduced Oxidative Stress Response in the Ascending Aorta of
Bicuspid Aortic Valve Patients: Impact on the Extracellular
Matrix
Julie A. Phillippi, Michael A. Eskay, Bruce R. Pitt, Thomas G. Gleason
Division of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Invited Discussant: Frank W. Sellke
*AATS
Member
37
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY MORNING
MAY 12, 2009
7:00 a.m.
GENERAL THORACIC FORUM SESSION
Room 302–306, Hynes Convention Center
(5 minutes presentation, 7 minutes discussion)
Moderators: Yolonda L. Colson, David S. Schrump
F10.
MAGE-A3 Expression Is an Independent Determinant of
Worse Survival in Stage IA Non-Small Cell Lung Cancer
Jeffrey L. Port,1 Sacha Gnjatic,2 Otavia Caballero,2 Ramon Chua,2
Achim A. Jungbluth,2 Gerd Ritter,2 Cathy A. Ferrara,1 Paul C. Lee,1
Lloyd J. Old,2 Nasser K. Altorki1*
1. Weill Cornell Medical College/NY Presbyterian Hospital, New York, NY,
USA; 2. Ludwig Institute for Cancer Research, New York, NY, USA
Invited Discussant: Dao M. Nguyen
F11.
MicroRNA Expression Proﬁles Predict Recurrence After Surgery
for Stage 1 Non-Small Cell Lung Cancer
Sai Yendamuri,1 Steen Knudsen,2 Todd L. Demmy,1* Santosh Patnaik1
1. Roswell Park Cancer Institute, Buffalo, NY, USA; 2. Medical Prognosis
Institute, Horsholm, Denmark
Invited Discussant: Virginia R. Litle
F12.
Seventy-Two Hours Total Respiratory Support with a
Single Double-Lumen Cannula Placed in a Venousvenous
Pump-Driven Extracorporeal Lung Membrane
David Sanchez-Lorente, Tetsuhiko Go, Philipp Jungebluth, Irene Rovira,
Paolo Macchiarini*
General Thoracic Surgical Experimental Laboratory, Universitat de Barcelona,
Barcelona, Spain
Invited Discussant: Jay Zwischenberger
F13.
Replacement of the Trachea with Fully Bioengineered Graft in Pigs
Tetsuhiko Go,1 Philipp Jungebluth,1 Adelaide Asnaghi,2 Sara Mantero,2 MariaTeresa Conconi,3 Antony Hollander,4 Martin Birchall,4 Paolo Macchiarini1*
1. General Thoracic Surgical Experimental Laboratory, Universitat de Barcelona,
Barcelona, Spain; 2. Department of Bioengineering, Politecnico di Milano, Milano,
Italy; 3. Pharmaceutical Science, University of Padua, Padua, Italy; 4. Department
of Cellular and Molecular Medicine, School of Medical Sciences, Bristol, United
Kingdom
Invited Discussant: Yolonda L. Colson
*AATS
Member
38
AMERICAN ASSOCIATION FOR THORACIC SURGERY
F14.
DYRK2, a Dual-Speciﬁcity Tyrosine-(Y)-PhosphorylationRegulated Kinase Gene, Expression can be a Predictive Marker
for Chemotherapy in Non-small Cell Lung Cancer
Shin-ichi Yamashita, Katsunobu Kawahara
Surgery II, Oita University Faculty of Medicine, Yufu, Japan
Invited Discussant: David Jablons
F15.
Generation of Epigenetically-Modiﬁed Autologous Tumor Cell
Lines for Vaccines Targeting Cancer-Testis Antigens in
Thoracic Malignancies
David S. Schrump,* Julie A. Hong, Mary Zhang, Yuwei Zhang, Tricia F. Kunst,
Ana Hancox, Leandro Mercedes, King Kwong†
Thoracic Oncology Section, NCI, Bethesda, MD, USA
Invited Discussant: Stephen G. Swisher
F16.
Atrial Natriuretic Peptide Extends Lung Preservation
Attenuating Ischemia-Reperfusion Lung Injury Through
Phospholipase A2 Inhibition
Yury A. Bellido Reyes, Prudencio Díaz-Agero, Joaquin García S. Girón
Thoracic Surgery, La Paz Hospital, Madrid, Spain
Invited Discussant: Dirk E. Van Raemdonck
F17.
Comparative Glycomic Proﬁling in Esophageal Adenocarcinoma
Zane Hammoud,1 Yehia Mechref,2 Ahmed Hussein,2 Slavka Bekesova,2
Min Zhang,2 Kenneth Kesler,3* Robert Hickey,3 Milos Novotny2
1. Cardiothoracic Surgery, Henry Ford Health System, Detroit, MI, USA;
2. Indiana University, Bloomington, IN, USA; 3. Indiana University School
of Medicine, Indianapolis, IN, USA
Invited Discussant: Arjun Pennathur
F18.
Matrix Metalloproteinase Expression in Adenocarcinoma and
Squamous Cell Carcinoma of the Lung
Sonam A. Shah,1 John S. Ikonomidis,2* Robert E. Stroud,2 Eileen I. Chang,2
Francis G. Spinale,2* Carolyn E. Reed2*
1. Medical University of South Carolina, College of Medicine, Charleston, SC,
USA; 2. Medical University of South Carolina, Department of Surgery,
Charleston, SC, USA
Invited Discussant: David R. Jones
*AATS
Member
John Alexander Research Scholarship 2004
†Second
39
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY MORNING
MAY 12, 2009
8:45 a.m.
PLENARY SCIENTIFIC SESSION
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Thomas L. Spray
Thoralf M. Sundt, III
29. Non Operative Thoracic Duct Embolization for Traumatic
Chylothorax: Experience in 103 patients
Maxim Itkin, John C. Kucharczuk, Scott O. Trerotola, Andrew Kwak,
Constantin Cope, Larry R. Kaiser*
University of Pennsylvania, Philadelphia, PA, USA
Invited Discussant: Nasser K. Altorki
30. Valve Repair for Regurgitant Bicuspid Aortic Valves: A Systematic
Approach
Munir Boodhwani,† Laurent de Kerchove, David Glineur, Robert Verhelst,
Jean Rubay, Christine Watremez, Pasquet Agnes, Philippe Noirhomme,
Gebrine El Khoury
Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint Luc, Brussels,
Belgium
Invited Discussant: Hartzell V. Schaff
31. Ten-Year Experience of Off-Pump Coronary Artery Bypass; Lessons
Learned from Early Postoperative Angiograms
Ki-Bong Kim, Jun-Sung Kim, Hae-Young Lee, Hyun-Jae Kang, Bon-Kwon Koo,
Hyo-Soo Kim, Dae-Won Sohn, Byung-Hee Oh, Young-Bae Park
Seoul National University Hospital, Seoul, South Korea
Invited Discussant: Joseph F. Sabik, III
32. Pneumonectomy After Chemo- or Chemoradiotherapy for Advanced
Non-Small Cell Lung Cancer
Walter Weder,1* Stéphane Collaud,1 Thomas Krbek,2 Sven Hillinger,1 Sylvia Fechner,2
Peter Kestenholz,1 Rolf Stahel,1 Georgios Stamatis2
1. Zurich University Hospital, Zürich, Switzerland; 2. Ruhrlandklinik, Essen, Germany
Invited Discussant: Robert J. Cerfolio
10:05 a.m.
*AATS
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
Member
Traveling Fellowship 2007
†Resident
40
AMERICAN ASSOCIATION FOR THORACIC SURGERY
10:40 a.m.
PLENARY SCIENTIFIC SESSION
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Thomas L. Spray
Thoralf M. Sundt, III
33. Right Ventricle and Tricuspid Valve Function at Mid-Term
Following the Fontan Operation for Hypoplastic Left Heart
Syndrome: Impact of Shunt Type
Victor Bautista-Hernandez, Ravi Thiagarajan, Hugo Loyola, Jared Schiff,
Joshua Salvin, John E. Mayer,* Mark Scheurer, Frank A. Pigula,*
Francis Fynn-Thompson, Pedro J. del Nido,* Emile A. Bacha*
Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
Invited Discussant: Richard G. Ohye
34. Four Decades of Experience with Mitral Valve Repair: Analysis
of Differential Indications, Technical Evolution and Long-Term
Outcome
Daniel J. DiBardino, Andrew W. ElBardissi, Ann Maloney, R. Scott McClure,
Oswaldo Razo-Vasquez, Judah A. Askew, Lawrence H. Cohn*
Cardiac Surgery, Harvard Medical School, Boston, MA, USA
Invited Discussant: David H. Adams
11:20 a.m.
The Role of Simulation in Future Cardiothoracic
Surgical Education
Dan Raemer, PhD
Yolonda L. Colson, MD, PhD
Gregory S. Couper MD
Introduced By:
11:50 a.m.
Edward Verrier, MD
ADDRESS BY HONORED SPEAKER
The Creation of the Universe, String Theory, and
Time Travel
Professor Michio Kaku
Henry Semat Professor of Theoretical Physics Graduate Center of the
City University of New York
Introduced By:
12:30 p.m.
*AATS
Thomas L. Spray, MD
ADJOURN FOR LUNCH – VISIT EXHIBITS
Exhibit Hall
Member
41
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY AFTERNOON
MAY 12, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Joseph F. Sabik
David H. Adams
35. The Papillary Muscle Sling for Ischemic Mitral Regurgitation
U. Hvass, Thomas Joudinaud
Heart Surgery, Bichat Hospital, Paris, France
Invited Discussant: Robert A. Dion
36. Surgical Management of Secondary Tricuspid Valve Regurgitation:
Anulus, Commissure, or Leaﬂet Procedure?
Jose L. Navia,* Edward R. Nowicki, Eugene H. Blackstone,* Daniel E. Nento,
Jeevanantham Rajeswaran, A. Marc Gillinov,* Lars G. Svensson,* Sharif Al-Ruzzeh,
Bruce W. Lytle*
Cleveland Clinic, Cleveland, OH, USA
Invited Discussant: Farzan Filsouﬁ
37. When Is the Ross Procedure a Good Option to Treat Aortic Valve
Disease?
Tirone E. David,* Anna Woo, Susan Armstrong, Manjula Maganti
Cardiovascular Surgery, Toronto General Hospital, Toronto, ON, Canada
Invited Discussant: Lawrence H. Cohn
3:00 p.m.
*AATS
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
Member
42
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3:45 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
Moderators:
Joseph F. Sabik
David H. Adams
38. Surgical Ventricular Restoration for Anteroseptal Scars – Volume
or Shape?
Antonio M. Calaﬁore,1* Angela L. Iacò,1 Davide Amata,1 Cataldo Castello,1
Egidio Varone,1 Fabio Falconieri,1 Antonio Bivona,1 Sabina Gallina,2
Michele Di Mauro3
1. Cardiac Surgery, University of Catania, Catania, Italy; 2. University of Chieti –
Department of Cardiology, Chieti, Italy; 3. University of Catania – Villa Bianca
Hospital, Catania – Bari, Italy
Invited Discussant: Lorenzo A. Menicanti
39. Early and Late Outcome of 517 Consecutive Adult Patients Treated
with Extracorporeal Membrane Oxygenation for Refractory
Postcardiotomy Cardiogenic Shock
Ardawan J. Rastan, Andreas Dege, Matthias Mohr, Nicolas Doll, Sven Lehmann,
Volkmar Falk, Friedrich W. Mohr*
Heart Surgery, Heart Center Leipzig, Leipzig, Germany
Invited Discussant: R. Duane Davis, Jr.
40. Duration of LVAD Support Does Not Impact Post-Cardiac
Transplant Survival in the Continuous-Flow Pump Era
Ranjit John,1 Francis D. Pagani,2* Yoshifumi Naka,3* John V. Conte,4* Charles T. Klodell,5
Carmelo A. Milano,6*† David Farrar,7 O. Howard Frazier8*
1. Surgery, University of Minnesota, Minneapolis, MN, USA; 2. University of
Michigan, Ann Arbor, MI, USA; 3. Columbia University, New York, NY, USA; 4.
Johns Hopkins, Baltimore, MD, USA; 5. University of Florida, Gainsville, FL, USA; 6.
Duke University, Durham, NC, USA; 7. Thoratec Corporation, Pleasanton, CA, USA;
8. Texas Heart Institute, Houston, TX, USA
Invited Discussant: James Kirklin
5:00 p.m.
*AATS
EXECUTIVE SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
Member
John H. Gibbon Jr. Research Scholarship 2001
†Second
43
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY AFTERNOON
MAY 12, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 312, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Nasser K. Altorki
Shaf Keshavjee
41. Endobronchial Ultrasound-Guided Fine-Needle Aspiration of
Mediastinal Lymph Nodes: The Thoracic Surgeon’s Perspective
Shawn S. Groth, Natasha M. Rueth, Jonathan D’Cunha,* Michael A. Maddaus,*
Rafael S. Andrade
Surgery, University of Minnesota, Minneapolis, MN, USA
Invited Discussant: Hiran C. Fernando
42. Extracorporeal Membrane Oxygenation in Pediatric Lung
Transplantation
Varun Puri,1† Deirdre Epstein,1 Steven C. Raithal,1 Sanjiv K. Gandhi,1*
Stuart C. Sweet,2 Albert Faro,2 Charles B. Huddleston1*
1. Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA;
2. Department of Pediatrics, Washington University, St. Louis, St. Louis, MO, USA
Invited Discussant: Victor Morell
43. Lung Transplantation Using Donation After Cardiac Death
Donors: Long-Term Follow-Up in a Single Center
Satoru Osaki,1 James D. Maloney,1 Keith C. Meyer,2 Richard D. Cornwell,2
Holly K. Thomas,1 Niloo M. Edwards,1 Nilto C. De Oliveira1
1. Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin
School of Medicine and Public Health, Madison, WI, USA; 2. Section of Allergy,
Pulmonary, and Critical Care Medicine, Department of Medicine, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
Invited Discussant: Dirk E.M. Van Raemdonck
3:00 p.m.
*AATS
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
Member
Traveling Fellowship 2008
†Resident
44
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3:45 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 312, Hynes Convention Center
Moderators:
Nasser K. Altorki
Shaf Keshavjee
44. Laparoscopic Diaphragm Plication: An Objective Evaluation of
Short-and Mid-Term Results
Shawn S. Groth,1 Natasha M. Rueth,1 Amy Klopp,1 Teri Kast,1 Jonathan D’Cunha,1*
Rosemary F. Kelly,2* Michael A. Maddaus,1* Rafael S. Andrade,1
1. Surgery, University of Minnesota, Minneapolis, MN, USA;
2. Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
Invited Discussant: Sudish C. Murthy
45. Minimally Invasive Resection of Stage 1 and 2 Thymoma:
Comparison with Open Resection
Arjun Pennathur, Irfan Qureshi, Matthew Schuchert, Peter Ferson, Neil A. Christie,
Sebastien Gilbert, William Gooding, Manisha Shende, Rodney J. Landreneau,*
James D. Luketich*
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Invited Discussant: David Jablons
46. Predictive Factors for Survival in Esophageal Cancer Patients with
Persistent Lymph Node Metastases Following Neoadjuvant
Therapy and Surgery
Brendon M. Stiles,1 Subroto Paul,1† Jeffrey L. Port,1 Paul C. Lee,1 Paul Christos,2
Nasser K. Altorki1*
1. Division of Thoracic Surgery, New York Presbyterian Hospital, Weill Cornell
Medical College, New York, NY, USA; 2. Department of Biostatistics and
Epidemiology, New York Presbyterian Hospital, Weill Cornell Medical College,
New York, NY, USA
Invited Discussant: Jeffrey Hagen
5:00 p.m.
*AATS
EXECUTIVE SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
Member
Traveling Fellowship 2006
†Resident
45
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY AFTERNOON
MAY 12, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
J. William Gaynor
Richard G. Ohye
47. Genetic Factors are Important Determinants of Impaired Growth
Following Infant Cardiac Surgery
Nancy B. Burnham,1 Richard F. Ittenbach,2 Virginia A. Stallings,1 Marsha Gerdes,1
Elaine H. Zackai,1 Judy Bernbaum,1 Gil Wernovsky,1 Robert R. Clancy,1
Jo Ann D’Agostino,1 Donna McDonald-McGinn,1 Diane Hartman,1 Jennifer Raue,1
Jennifer Hufford,1 Courtney Terrili,1 Susan C. Nicolson,1 Thomas L. Spray,1*
J. William Gaynor1*
1. Children’s Hospital of Philadelphia, Philadelphia, PA, USA;
2. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Invited Discussant: Thomas J. Yeh
48. Mechanical Mitral Valve Prostheses in Children Don’t Deserve
Their Ill Repute
Roland Henaine, Joseph Nloga, Fabrice Wautot, Jacques Robin,
Jean-François L. Obadia,* Jean Ninet
Cadiothoracique Surgery, Lyon, France
Invited Discussant: Christopher A. Caldarone
49. Fate of Reconstructed Biventricular Outﬂow Tracts After Repair
for Transposition of the Great Arteries with Ventricular Septal
Defect and Left Ventricular Outﬂow Tract Obstruction: Midterm
Results and Future Implications
Sheng-Shou Hu,* Yan Li, Shoujun Li, Zhigang Liu, Zhe Zheng, Yongqing Li
Cardiovascular Surgery, National Heart Center and Fuwai Hospital, Beijing, China
Invited Discussant: Pedro J. del Nido
3:00 p.m.
*AATS
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
Member
46
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3:30 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
Moderators:
J. William Gaynor
Richard G. Ohye
50. Gene Expression Proﬁling in the Right Ventricular Myocardium of
Newborns with Hypoplastic Left Heart Syndrome
Marco Ricci,1* Bhagyalaxmi Mohapatra,2 Arnel Urbiztondo,1 Matteo Vatta2
1. Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, FL,
USA; 2. Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
Invited Discussant: Peter Gruber
51. Twenty Three Years of One-stage End-to-Side Anastomosis Repair
of Interrupted Aortic Arches
Yves d’Udekem,1 Aisyah S. Hussin,1 Ajay J. Iyengar,1 Igor E. Konstantinov,1
Suzan M. Donath,1 Gavin R. Wheaton,2 Andrew M. Bullock,3 Leeanne E. Grigg,4
Bryn O. Jones,1 Christian P. Brizard1
1. Cardiac Surgery, Royal Children’s Hospital, Parkville, Melbourne, VIC, Australia;
2. Women’s and Children’s Hospital, Adelaide, SA, Australia; 3. Princess Margaret
Hospital, Perth, WA, Australia; 4. Royal Melbourne Hospital, Melbourne,
VIC, Australia
Invited Discussant: V. Mohan Reddy
52. Unifocalisation of Major Aortopulmonary Arteries in Pulmonary
Atresia with Ventricular Septal Defect Is Essential to Achieve
Excellent Outcomes Irrespective of Native Pulmonary Artery
Morphology
Ben Davies,1 Shaﬁ Mussa,1 Paul Davies,2 John Stickley,1 John G. Wright,1
Joseph V. de Giovanni,1* Oliver Stümper,1 Rami Dhillon,1 Timothy J. Jones,1
David J. Barron,1 William J. Brawn1
1. Department of Cardiac Surgery, Birmingham Children’s Hospital, Birmingham,
United Kingdom; 2. Institute of Child Health, University of Birmingham,
Birmingham, United Kingdom
Invited Discussant: Christian Brizard
*AATS
Member
47
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
53. Impact of Comprehensive Perioperative and Interstage Monitoring
on Survival in High-Risk Infants After Stage 1 Palliation of
Univentricular Heart Disease
Nancy S. Ghanayem,1 Kathleen A. Mussatto,2 George M. Hoffman,1
Michael E. Mitchell,1 Michele A. Frommelt,1 Joseph R. Cava,1
James S. Tweddell1*
1. Medical College of Wisconsin, Milwaukee, WI, USA; 2. Children’s Hospital of
Wisconsin, Milwaukee, WI, USA
Invited Discussant: J.W. Gaynor
5:00 p.m.
*AATS
EXECUTIVE SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
Member
48
AMERICAN ASSOCIATION FOR THORACIC SURGERY
WEDNESDAY MORNING
MAY 13, 2009
7:00 a.m.
EMERGING TECHNOLOGIES AND
TECHNIQUES FORUM
Ballroom A–C, Hynes Convention Center
(5 Minutes Presentation, 7 Minutes Discussion)
Moderators: Robert J. McKenna, Lars G. Svensson
T1.
The Direct Flow Valve: First in Man Experience with a
Repositionable and Retrievable Pericardial Valve for
Percutaneous Aortic Valve Replacement
Hendrik Treede,1 Jochen Schofer,2 Thilo Tuebler,2 Olaf Franzen,1
Thomas Meinertz,1 Reginald Low,3 Steven F. Bolling,4* Hermann Reichenspurner1*
1. Department of Cardiovascular Surgery, University Heart Center Hamburg,
Hamburg, Germany; 2. Hamburg University Cardiovascular Center, Hamburg,
Germany; 3. University of California Davis, Davis, CA, USA 4. University of
Michigan Hospital, Ann Arbor, MI, USA
Invited Discussant: Tomislav Mihaljevic
T2.
Use of Subclavian-Carotid Bypass and Thoracic Stent
Grafting to Minimize Cerebral Ischemia in Total Aortic
Arch Reconstructions
Steve Xydas,1 Benjamin Wei,2 Hiroo Takayama,1 Mark J. Russo,1
Craig R. Smith,1* Matthew D. Bacchetta,1 Allan Stewart1
1. NY Presbyterian Hospital-Columbia, Division of Cardiothoracic Surgery,
New York, NY, USA; 2. NY Presbyterian Hospital-Columbia, Department of
Surgery, New York, NY, USA
Invited Discussant: John A. Kern
T3.
Transcatheter Aortic Valve Replacement in High-Risk Patients:
Superior Results Compared to Conventional Surgery
Robert Bauernschmitt, Domenico Mazzitelli, Christian Schreiber,
Hendrik Ruge, Sabine Bleiziffer, Andrea Hutter, Peter Tassani,
Ruediger Lange*
Clinic for Cardiovascular Surgery, German Heart Center Munich, Munich, Germany
Invited Discussant: Joseph E. Bavaria
*AATS
Member
49
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
T4.
Cavopulmonary Assist Using a Percutaneous, Bi-Conical, Single
Impeller Pump: A New Spin for Fontan Circulatory Support
Mark D. Rodefeld,1* Brandon Coats,2 Travis Fisher,2 John Brown,1* Steve Frankel2
1. Department of Surgery, Indiana University School of Medicine, Indianapolis,
IN, USA; 2. Purdue University Department of Mechanical Engineering, West
Lafayette, IN, USA
Invited Discussant: Glen S. Van Arsdell
T5.
Tissue Engineered Vascular Grafts in Humans: Correlating
Clinical Outcomes to Vascular Neotissue Formation in Mice
Narutoshi Hibino,1 Edward McGillicuddy,1 Tai Yi,1 Goki Matsumura,2
Uji Naito,2 Hiromi Kurosawa,2* Christopher Breuer,1 Toshiharu Shinoka1*
1. Yale University School of Medicine, New Haven, CT, USA; 2. Tokyo Women’s
Medical University, Tokyo, Japan
Invited Discussant: John E. Mayer, Jr.
T6.
Abdominal Debranching with Thoracic Endografting for the
Treatment of Thoraco-Abdominal Aneurysm in 21 Consecutive
Patients
Jacques Kpodonu,1 Venkatesh Ramaiah,2 Grayson H. Wheatley,2
Julio Rodriguez-Lopez,2 David Caparrelli,2† Rame Iberdemaj,2
Edward B. Diethrich2
1. Hoag Memorial Presbyterian, Newport Beach, CA, USA; 2. Arizona
Heart Institute, Phoenix, AZ, USA
Invited Discussant:
T7.
High Resolution Analysis of Lung Cancer Stem and Progenitor
Cells in Primary Non-Small Cell Adenocarcinoma
Vera S. Donnenberg,1 Rodney J. Landreneau,2* James D. Luketich,2*
Albert D. Donnenberg1
1. Surgery, University of Pittsburgh, Pittsburgh, PA, USA; 2. Hillman Cancer Center,
Pittsburgh, PA, USA
Invited Discussant: Thomas A. D’Amico
T8.
Robotic Lobectomy for the Treatment of Early Stage Lung Cancer
Giulia Veronesi,1 Franca Melﬁ,2 Domenico Galetta,1 Ralph A. Schmid,3
Patrick Maisonneuve,1 Nicole Rotmensz,1 Fernando Vannucci,1
Raffaella Bertolotti,1 Lorenzo Spaggiari1
1. Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy;
2. Department of Cardio-Thoracic Surgery, University Hospital, Pisa, Italy;
3. Division of Thoracic Surgery, University Hospital, Berne, Switzerland
Invited Discussant: Kemp Kernstine
*AATS
Member
Traveling Fellowship 2007
†Resident
50
AMERICAN ASSOCIATION FOR THORACIC SURGERY
9:00 a.m.
CONTROVERSIES IN CARDIOTHORACIC
SURGERY PLENARY SESSION
Ballroom A–C, Hynes Convention Center
Moderator: Alec Patterson
The Sole Pathway Leading to ABTS Certiﬁcation
Should be a Comprehensive Integrated
Cardiothoracic Surgery Training Program
Beginning Directly After Medical School
Pro: Richard H. Feins
Con: David R. Jones
51
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
10:00 a.m. –
12:00 p.m.
ABLATION VS. SURGERY FOR ATRIAL
FIBRILLATION: ANTAGONISM OR SYNERGISM?
Jointly Sponsored with the Heart Rhythm Society
Ballroom A–C, Hynes Convention Center
Chairmen: Thoralf M. Sundt, III, MD
Douglas L. Packer, MD
10:00 a.m.
The “Classic Maze”: Experimental Origins, Surgical
Lesion Sets, Alternative Energy Sources
Ralph J. Damiano, Jr., MD, Washington University
10:15 a.m.
Neurological Approaches to the AF Problem Ganglion
Mapping
James H. McClelland, MD, Oregon Cardiology, PC
Cervical Interventions
Benjamin J. Scherlag, MD, Cardiac Arrhythmia Research
Institute
10:35 a.m.
Less Invasive Approaches – Critical Step or Critical
Mistake?
Robotics as Applied to Arrhythmia Surgery
W. Randolph Chitwood, Jr., MD, East Carolina University
School of Medicine
Thoracoscopic Arrythmia Surgery
Richard Lee, MD, Northwestern University
Intravascular Approaches
Vivek Y. Reddy, MD, University of Miami Hospital
11:25 a.m.
Deﬁning Success
Richard J. Shemin, MD, University of California, Los Angeles
11:40 a.m.
Working Together Panel
Ralph J. Damiano, Jr., MD,Washington University
James H. McClelland, MD, Oregon Cardiology, PC
Benjamin J. Scherlag, MD, Cardiac Arrhythmia Research Institute
W. Randoph Chitwood, Jr., MD, East Carolina University
School of Medicine
Richard Lee, MD, Northwestern University
12:00 p.m.
ADJOURN
52
AMERICAN ASSOCIATION FOR THORACIC SURGERY
10:00 a.m. –
12:00 p.m.
PNEUMONECTOMY: A TREATMENT OR
A DISEASE?
Room 302–306
Chairman: Thomas A. D’Amico, MD
10:00 a.m. – 10:15 a.m.
Patient Selection for Pneumonectomy
Joseph P. Shrager, MD, University of
Pennsylvania
10:15 a.m. – 10:30 a.m.
Role of Thoracoscopic Pneumonectomy
Todd L. Demmy, MD, Roswell Park Cancer
Institute
10:30 a.m. – 10:45 a.m.
Managing Intraoperative Complications
Alec Patterson, MD, Washington University
10:45 a.m. – 11:00 a.m.
Early Complications After Pneumonectomy
Valerie W. Rusch, MD, Memorial
Sloan-Kettering Cancer Center
11:00 a.m. – 11:15 a.m.
Late Complications After Pneumonectomy
Douglas J. Mathisen, MD, Massachusetts
General Hospital
11:15 a.m. – 11:30 a.m.
Pneumonectomy After Induction Therapy
Walter Weder, MD, University Hospital
11:30 a.m. – 11:45 a.m.
Extrapleural Pneumonectomy
David J. Sugarbaker, MD, Brigham &
Women’s Hospital
11:45 a.m. – 12:00 p.m.
DISCUSSION
12:00 p.m.
ADJOURN
53
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
SUNDAY AFTERNOON
MAY 10, 2009
3:00 p.m.
C. WALTON LILLEHEI RESIDENT FORUM SESSION
Room 311, Hynes Convention Center
(7 minutes presentation, 8 minutes discussion)
Moderators: Gus J. Vlahakes, Ara A. Vaporciyan
L1.
In Vivo Structure and Function of Engineered Pulmonary
Valves
Danielle Gottlieb1, Kunal Tandon1, Sitaram Emani1, Elena Aikawa2,
David W. Brown1, Andrew J. Powell1, Arthur Nedder1, Michael S. Sacks3,
John E. Mayer1*
1. Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA;
2. Massachusetts General Hospital and Harvard Medical School, Boston, MA,
USA; 3. University of Pittsburgh, Pittsburgh, PA, USA
ol, Boston, MA, USA; 3University of Pittsburgh, Pittsburgh, PA, USA
OBJECTIVE: Clinical translation of engineered heart valves requires valve competency in the short and long-term. Early studies of engineered heart valves showed
promise, though lacked complete deﬁnition of valve function. Building on prior
experiments, we sought to deﬁne a time course of the in vivo changes in structure
and function of autologous engineered pulmonary valves (PV).
METHODS: Mesenchymal stem cells (MSCs) were isolated from the mononuclear fraction of bone marrow collected from nine neonatal lambs. Cells were characterized, expanded, and seeded onto a 3D heart valve scaffold composed of
polyglycolic acid (PGA) and poly-L-lactic acid (PLLA). After 4 weeks of culture,
sheep underwent autologous PV replacement on cardiopulmonary bypass. Valve
function was evaluated by epicardial echocardiography at implantation, by MRI at
the experimental midpoint, and by epicardial echocardiography at explant of the
valve at either 6 weeks (n = 3), 12 weeks (n = 3), or 20 weeks (n = 3) post-operatively.
Conduit size was measured at the time of implantation and at explantation.
Explanted tissues were processed for histology.
RESULTS: All nine animals survived and were clinically well until valve explant.
Evaluation of immediate valve function demonstrated a mean transvalvar gradient
of 15.2 mmHg (range 10–20 mmHg), and mean pulmonary regurgitation (PR)
score of 0.58 (trivial = 0, mild = 1, moderate = 2, severe = 3). Valve function
remained adequate at 3 and 6 weeks (PR fraction ≤20%), though leaﬂets appeared
increasingly immobile, resulting in an increasing regurgitant fraction over time.
*AATS
Member
54
AMERICAN ASSOCIATION FOR THORACIC SURGERY
SUNDAY
Afternoon
Figure. Representative short axis epicardial
echocardiographic view of an engineered
pulmonary valved conduit at the time of
implantation.
Conduit diameter was unchanged over 20 weeks. Engineered leaﬂets and conduit
walls underwent dynamic remodeling over the time course, as evidenced by cell
proliferation (Ki67), inﬂammation (CD45), remodeling enzyme expression (MMP1, -2, -9, -13) and microvessel formation (CD31) at the early stages, and progressive
GAG (versican) and collagen organization (anti-collagen; Masson trichrome) and
complete endothelization in long-term explants.
CONCLUSION: In the largest in vivo series published, we demonstrate reproducible
fabrication and implantation of autologous engineered pulmonary valves which
function well at implantation. In vivo valves undergo structural and functional
remodeling resulting in the onset of pulmonary regurgitation after 6 post-operative
weeks. Tissue engineered conduits stayed stable in size after 5 months with no evidence of conduit stenosis or aneurysm formation.
55
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
L2.
The Graft Imaging to Improve Patency (GRIIP) Trial Results
Steve Singh, Nimesh Desai,† Genta Chikazawa, Hiroshi Tsuneyoshi,
Visal Pen, Jessica Vincent, Jennifer Ku, Fuad Moussa, Gideon Cohen,
George Christakis,* Stephen E. Fremes*
Sunnybrook Health Sciences Centre, Toronto, ON, Canada
OBJECTIVE: The primary objective was to determine if intra-operative graft
assessment, with criteria for graft revision, can decrease the proportion of patients
with ≥1 total (100%) graft occlusions 1 year post-operatively. Secondary objectives
were to determine if intra-operative graft ﬂow assessment can decrease: i) the proportion of patients with ≥1 graft stenoses (50–99%); ii) the proportion of patients
with complete graft occlusion or stenosis; and iii) the frequency of perioperative
and 1 year major adverse cardiac events (MACE).
METHODS: This a single-centre, randomized, single-blinded controlled clinical
trial. Patients were randomized to receive intra-operative graft patency assessment
using indocyanine green ﬂuorescent angiography and transit-time ﬂowmetry and
graft revision according to speciﬁc criteria, or serve as controls receiving standard
intra-operative management. Patients underwent conventional X-ray or 64 slice
CT angiography post-operatively.
Imaging
(n = 43)
Total # grafts
Controls
(n = 41)
RR
(95% CI)
p-value
125
120
Graft occlusions, No. (%)
15/125 (12.0)
16/120 (13.3)
0.90 (0.47–1.74)
Saphenous vein grafts, No. (%)
15/59 (25.4)
14/63 (22.2)
1.14 (0.61-2.16)
0.68
Arterial grafts, No. (%)
0/66 (0)
2/57 (3.5)
0.19 (0.0–3.90)
0.28
Patients with ≥1 graft occlusion,
No. (%)
11/43 (25.6) 13/41 (31.7) 0.81 (0.41–1.59) 0.54
PRIMARY ENDPOINT
0.75
SECONDARY ENDPOINTS
Grafts with >50% stenosis, No. (%)
4/125 (3.2)
5/120 (4.2)
0.77 (0.21–2.79)
0.69
Saphenous vein grafts, No. (%)
1/59 (1.7)
4/63 (6.3)
0.27 (0.03–2.32)
0.23
0.85
Arterial grafts, No. (%)
3/66 (4.5)
1/57 (1.8)
0.86 (0.18–4.11)
Patients with ≥ 1 graft with
>50% stenosis, No. (%)
3/43 (7.0)
5/41 (12.2)
0.56 (0.14–2.19) 0.40
Grafts with > 50% stenosis or
occlusion, No. (%)
19/125 (15.2)
21/120 (17.5)
0.87 (0.49–1.53)
0.63
Saphenous vein grafts, No. (%)
16/59 (27.1)
18/63 (28.6)
0.95 (0.54–1.68)
0.86
Arterial grafts, No. (%)
3/66 (4.5)
3/57 (5.3)
0.86 (0.18–4.11)
0.85
Patients with ≥1 graft with >50% 13/43 (30.2) 17/41 (41.5) 0.73 (0.41–1.30) 0.29
stenosis or occlusion, No. (%)
*AATS
Member
Traveling Fellowship 2006
†Resident
56
AMERICAN ASSOCIATION FOR THORACIC SURGERY
CONCLUSION: Routine intra-operative graft assessment is safe, but does not
lead to a marked improvement in graft patency 1 year post-CABG. The incidence
of saphenous vein graft failure is high even with routine intra-operative graft
surveillance.
57
SUNDAY
Afternoon
RESULTS: Between September 2005 and August 2008, 156 patients undergoing
isolated CABG surgery were enroled (Imaging n = 76, Control n = 76). The groups
were similar in terms of demographic and angiographic characteristics. On-pump
CABG was performed in all but 12 patients. Operative, cross clamp and cardiopulmonary bypass times were all non-signiﬁcantly longer in the Imaging patients.
The number of grafts constructed in the 2 groups were similar (Imaging: 3.0 ± 0.7
grafts/pt; Control: 3.0 ± 0.6 grafts/pt). There were no signiﬁcant differences
between the 2 groups in the incidence of perioperative events. Overall, the 1 year
MACE (death, MI, PCI, redo CABG) was similar in the Imaging (12.7%) and the
Control (9.4%) patients (p = 0.55). Post-operative X-ray (n = 23) or CT angiography
(n = 61) was performed in 43 Imaging patients at 9.6 ± 8.7 months following surgery and 41 Control patients at 11.5 ± 8.9 months post-operatively. Graft occlusion
results are presented in the Table. The proportion of patients with ≥1 graft occlusions was similar between the 2 groups [25.6% in the Imaging group (11/43
patients) and 31.7% in the Controls (13/41 patients)] as was the incidence of the
other graft patency endpoints. The incidence of saphenous vein graft occlusion
was high in both the Imaging and Control patients.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
L3.
Tissue Engineered Pro-Angiogenic Fibroblast Matrix Improves
Myocardial Perfusion and Function and Limits Ventricular
Remodeling Following Infarction
J. Raymond Fitzpatrick, John R. Frederick, Ryan C. McCormick,
David A. Harris, Ah-Young Kim, Max J. Smith, Carine M. Laporte,
Jeffrey R. Muenzer, Alex J. Gambogi, Y. Joseph Woo*
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA, USA
OBJECTIVE: Microvascular malperfusion after myocardial infarction creates
derangements in cardiomyocyte metabolism, causing infarct expansion, adverse
remodeling, and functional impairment. Reparative mechanisms exist but are
insufﬁcient to adequately vascularize the myocardium after severe injury. We
hypothesized that a three-dimensional human ﬁbroblast matrix (3DFM), known
to secrete angiogenic cytokines such as vascular endothelial growth factor (VEGF)
and hepatocyte growth factor (HGF), would augment native angiogenesis, limiting
adverse effects of microvascular dysfunction in ischemic myocardium.
METHODS: Lewis rats (n = 24) underwent LAD ligation to induce heart failure;
experimental animals also underwent application of a 3DFM scaffold to the infarct
region. At 4 wks, cardiac function was assessed with echocardiography and pressure-volume conductance. Peri-infarct tissue was analyzed for expression of human
ﬁbroblast surface protein (HFSP), VEGF, HGF, and the angiogenic mediator NFκβ.
Hearts were sectioned for immunoﬂuorescent analysis of angiogenesis by colocalization of platelet endothelial cell adhesion molecule (PECAM) and αsmooth muscle
actin (αSMA), and digital planimetric analysis of ventricular geometry. Microvascular
angiography was performed on a subset of rats with ﬂuorescein-labeled lectin to
assess perfusion.
RESULTS: See Table. Western blot conﬁrmed presence of HFSP in experimental
rats, indicating survival of human cells. VEGF and HGF upregulation in experimental rats conﬁrmed elution by the 3DFM. Angiogenic activation was shown by
increased expression of NFκβ. Microvasculature expressing PECAM/αSMA was
signiﬁcantly increased in infarct and borderzones of experimental rats. Microvascular perfusion by lectin angiography was signiﬁcantly greater in experimental rats
in infarct (1.6 ± 0.2 v 0.4 ± 0.1%, P < 0.01) and borderzones (2.3 ± 0.4 v 0.7 ± 0.2%,
P = 0.04), while remote perfusion was equivalent (1.9 ± 0.3 v 2.7 ± 0.4%, P = NS).
3 DFM rats had increased wall thickness, smaller scar area, shorter scar length,
and smaller scar fraction. Cardiac function was preserved in 3DFM rats, with
decreased end-systolic volume and increased ejection fraction, fractional shortening,
and contractility.
*AATS
Member
58
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3D-FM
(n = 9)
HFSP (IU)
28.1 ± 9.0
57.8 ± 7.4
0.022
VEGF (IU)
18.2 ± 1.5
30.1 ± 1.4
<0.001
0.049
P-Value
HGF (IU)
28.2 ± 4.0
42.7 ± 6.0
NFκβ (IU)
59.5 ± 10.4
101.9 ± 9.4
0.012
1.4 ± 0.13
7.6 ± 0.38
<0.001
<0.001
PECAM/αSMA positive vessel density
(vessels/high power ﬁeld)
Infarct
Peri-infarct
1.6 ± 0.13
7.7 ± 0.17
Remote
7.7 ± 0.66
8.7 ± 0.58
NS
1.0 ± 0.1
1.5 ± 0.2
0.05
Scar Area (mm2)
7.83 ± 0.93
4.75 ± 0.47
0.026
Scar Length (mm)
9.6 ± 0.8
3.9 ± 0.6
<0.001
0.005
Borderzone Wall Thickness (mm)
17.1 ± 1.2
9.5 ± 1.5
End Systolic Volume (μL)
243.3 ± 4.5
103.2 ± 2.1
0.017
Fractional Shortening (%)
20 ± 3
30 ± 2
0.015
Scar Fraction (%)
Ejection Fraction (%)
Contractility Slope (mmHg/μL)
47 ± 5
65 ± 3
0.010
0.27 ± 0.06
0.98 ± 0.17
0.003
All values reported as Mean ± SEM. P-Values determined from student t-tests. Borderzone wall
thickness, scar area, scar length, and scar fraction were determined by digital planimetric analysis
of tissue sections taken from explanted hearts distended at a ﬁxed pressure. End Systolic Volume,
Fractional Shortening, and Ejection Fraction were determined by transthoracic echocardiography.
Contractility Slope was determined from invasive pressure-volume conductance measurements
during IVC occlusion. HFSP – Human Fibroblast Surface Protein; IU – intensity units; VEGF –
Vascular Endothelial Growth Factor; HGF – Hepatocyte Growth Factor; NFκβ – Nuclear Factor κβ;
PECAM – Platelet Endothelial Cell Adhesion Molecule; αSMA – α Smooth Muscle Actin.
CONCLUSION: Application of an engineered 3DFM augments native angiogenesis through focused delivery of vasculogenic cytokines to ischemic myocardium.
This yields improved microvascular perfusion, limits infarct progression and
adverse ventricular remodeling, and improves ventricular function.
59
SUNDAY
Afternoon
Control
(n = 9)
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
L4.
Atorvastatin at Reperfusion Reduces Myocardial Infarct Size
in Mice by Activating eNOS of Bone Marrow-Derived Cells
Zequan Yang,1 Gorav Ailawadi,1† Joel Linden,2 Brent A. French,3 Irving L. Kron1*
1. Surgery, University of Virginia Health System, Charlottesville, VA, USA;
2. Medicine, University of Virginia Health System, Charlottesville, VA, USA;
3. Biomedical Engineering, University of Virginia Health System, Charlottesville,
VA, USA
OBJECTIVE: Myocardial injury occurs after cardiac surgery despite optimal myocardial protective strategy. Recently, clinical and experimental studies indicate that
the advantage of early statin use after acute coronary syndromes is independent of
baseline levels of cholesterol. We hypothesized that atorvastatin could reduce infarct
size in intact mice by activation of eNOS, speciﬁcally the eNOS on bone marrowderived cells.
METHODS: C57BL/6J mice (B6) and congenic eNOS knockout (KO) mice
underwent 45 min LAD occlusion and 60 min reperfusion. Chimeric mice, created
by bone marrow transplantation to post-irradiation mice between B6 and eNOS
KO mice, underwent 40 min LAD occlusion and 60 min reperfusion. Mice were
treated either with vehicle or atorvastatin in 5% ethanol at a dose of 10 mg/kg IV 5
min before initiating reperfusion. Infarct size was evaluated by TTC and Phthalo
blue staining.
RESULTS: In B6 and eNOS KO mice, risk regions (RR, % of LV mass) were comparable among the four study groups. In vehicle-control B6 mice, post-ischemic
reperfusion resulted in an infarct size of 62 ± 2% of RR. Atorvastatin treatment
caused a 19% decrease in infarct size in B6 mice (vs. vehicle control, p < 0.05). In
eNOS KO vehicle-control mice, infarct size was comparable to that of B6 vehiclecontrol mice (65 ± 2 vs. 62 ± 2%, p = NS). Atorvastatin treatment had no effect on
infarct size in eNOS KO mice (vs. eNOS KO vehicle-control, p = NS). In chimeras,
Atorvastatin signiﬁcantly reduced infarct size in B6/B6 (donor/recipient) mice and
B6/KO mice, but not in KO/KO mice or KO/B6 mice (see ﬁgure).
*AATS
Member
Traveling Fellowship 2006
†Resident
60
AMERICAN ASSOCIATION FOR THORACIC SURGERY
61
SUNDAY
Afternoon
CONCLUSION: The results demonstrate that acute administration of atorvastatin
signiﬁcantly reduces myocardial ischemia/reperfusion injury in an eNOS-dependent
manner, probably through the post-transcriptional activation of eNOS in bone
marrow-derived cells. The results support further clinical study to test the role of
acute administration of Atorvastatin in patients undergoing cardiac surgery, even
in the absence of coronary artery disease.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
L5.
Quantitative Assessment of Technical Proﬁciency of Residents
in Cardiac Surgery
Hiroo Takayama, Yoshifumi Naka,* Mehmet C. Oz,*†Allan S. Stewart,
Mathew R. Williams, Craig R. Smith,* Micheal Argenziano
Columbia University, New York, NY, USA
OBJECTIVE: Board certiﬁcation in cardiothoracic surgery requires that trainees
perform of a minimum of 150 adult cardiac operations as “surgeon.” The aims of
this study were to identify objective variables that correlated with residents’ technical competence, and to determine the minimum number of operative cases
required for residents to achieve acceptable proﬁciency.
METHODS: The operative records of patients operated on by 12 consecutive residents and fellows at our institution between 1/2002 and 6/2008 were retrospectively reviewed. This analysis included only cases done as “surgeon” by residents in
their ﬁnal 9 months of training or during a 6 month post-residency fellowship.
RESULTS: Over the 6.5 year study period, a total of 2919 cases were analyzed. This
included 1146 isolated CABG, 944 aortic valve procedures (239 AVR+CABG, 220
isolated AVR for AS, 110 AVR for AI, 375 other), 454 mitral valve procedures, 278
heart transplants, 185 aortic operations, and 205 other procedures. Isolated AVR for
AS (n = 220) was selected for further analysis due to its standardized operative
technique and volume. The following variables were evaluated for suitability as a
surrogate of surgical skill: aortic cross-clamp time (XCL), cardiopulmonary bypass
time, mortality, morbidity, PRBC transfusion requirement, hospital and ICU
length of stay. Among these, only XCL was signiﬁcantly correlated to the operating
resident’s level of experience, with a progressive decrease in XCL (ﬁgure). Comparison of this data to the XCL for isolated AVR for AS performed by a senior attending
surgeon during the same period (57.2 ± 8 min) suggests that a minimum of 200
cases would be required to achieve similar proﬁciency.
CONCLUSION: XCL time for isolated AVR for AS is correlated to a resident’s surgical experience, and may be a reasonable surrogate of technical competence. Utilizing this metric, it appears that more than 150 cases are required for residents to
approach the proﬁciency of an attending cardiac surgeon.
*AATS
Member
E. Gross Research Scholarship 1994
†Robert
62
AMERICAN ASSOCIATION FOR THORACIC SURGERY
L6.
Justin D. Blasberg, Jessica S. Donington, Chandra M. Goparaju,
Harvey I. Pass*
New York University Medical Center, New York, NY, USA
OBJECTIVE: Osteopontin (OPN) is a multifunctional phosphoprotein with a signiﬁcant role in the pathogenesis of many solid tumors including non-small cell
lung cancer (NSCLC). NSCLC cell lines which express OPN have greater metastatic potential, but the molecular pathways for OPN tumorigenicity and the role
of the three human isoforms (OPNa, OPNb, and OPNc) are incompletely understood. Increased angiogenesis is essential for tumor growth and metastasis. We
hypothesize that the individual OPN isoforms play a divergent role in determining
the angiogenic potential of NSCLC.
METHODS: Using RT-PCR primers for the three OPN isoforms, we examined
OPN expression in nine lung cancer cell lines and correlated expression with OPN
secretion detected by ELISA of culture media. The angiogenic impact of the individual OPN isoforms were evaluated by transfecting cDNA plasmids speciﬁc to
each isoform and empty vector controls into NSCLC cell lines. Conditioned media
was compared on a bovine capillary endothelial cell (BCE) platform measuring
tubule length, and by ELISA of VEGF concentrations.
RESULTS: OPNa mRNA expression correlated with OPN secretion in the experimental cell lines (r = 0.912, p = 0.0006). OPNa transfection into NCI-H153, a
NSCLC cell line with no native OPN expression, resulted in a signiﬁcant increase
in BCE tubule length (1597u) compared to empty vector controls (719u, p <
0.0001). OPNb had a similar effect (861u, p < 0.00001). OPNc however resulted in a
signiﬁcant decrease in tubule length compared to controls (582u, p < 0.0001). (Fig)
Figure: Impact of individual osteopontin isoforms on BCE
tubule length and VEGF concentration.
*AATS
Member
63
SUNDAY
Afternoon
Divergent Impact of Osteopontin Isoforms on Lung Cancer
Angiogenesis
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
The inhibitory effect of OPNc was validated in NCI-H460 and A549, NSCLC cell
lines with high endogenous OPNa expression. OPNc overexpression decreased
tubule length 55% in NCI–H460 (1558u vs 704u, p < 0.0001), and 37% in A549
(1707 vs 1070u, p < 0.0003) compared to controls. OPNc overexpression also
resulted in a signiﬁcant decrease in VEGF secretion (ug/ml) in all cell lines compared to controls. In A549, VEGF concentration decreased from 2341 to 347 (p <
0.016), in NCI-H460 from 4506 to 2847 (p < 0.008), and in NCI-H153 from 17923 to
13885 (p < 0.007). OPNa and OPNb overexpression had no signiﬁcant impact on
VEGF secretion. (Fig)
CONCLUSION: In an in vitro angiogenesis assay we have demonstrated divergent impact of individual OPN isoforms. OPNa and OPNb increase BCE tubule
formation, while OPNc reduces tubule length and VEGF secretion. This data may
lead to therapeutic strategies which selectively inhibit OPN isoforms to potentially
alter the metastatic potential of NSCLC.
64
AMERICAN ASSOCIATION FOR THORACIC SURGERY
L7.
Kristopher B. Deatrick, Amit K. Mathur, Ann Schumar, Robert H. Bartlett,
Francis D. Pagani,* Jonathan W. Haft
Cardiac Surgery, The University of Michigan, Ann Arbor, MI, USA
OBJECTIVE: Temporary mechanical circulatory support can be offered to patients in
shock refractory to medical treatment. This report reviews our experience with
several support systems with respect to early, midterm, and late outcome, and
assesses predictors of mortality.
METHODS: We systematically reviewed the records of patients 16 years of age and
older who received temporary mechanical support due to acute circulatory collapse. Three modes of support were used: venoarterial extracorporeal membrane
oxygenation (ECMO), ABIOMED ventricular assist device (VAD) systems, or the
TandemHeart percutaneous VAD. Circulatory support was used for circulatory
collapse due one of the following: acute myocardial infarction (AMI) n = 61 (23%),
post-cardiotomy failure n = 34 (13%), pulmonary embolism (PE) n = 13 (5%), cardiomyopathy (CM) n = 77 (29%), sepsis n = 22 (8%), other acute heart failure n =
28 (11%), or heart or lung transplant graft dysfunction (GD) n = 17 (6%). Mortality
was conﬁrmed using the Social Security Death Index. Survival was estimated using
the Kaplan-Meier method. Risk-adjusted in-hospital mortality was determined
using Cox proportional-hazards models.
RESULTS: From 1997–2008, 278 patients at our center have received temporary
circulatory support; 266 patients had sufﬁcient data available for analysis. Mean
age of patients was 47.5 ± 14.1 years. 60% (n = 159) of patients were male. Average
duration on acutely placed support was 5.2 ± 5.6 days. 57% (n = 154) of patients
were successfully weaned. Survival to discharge was 40% (n = 113). Of patients
who survived to discharge, median survival was 235 days. 26% of patients (n = 68)
*AATS
Member
65
SUNDAY
Afternoon
Temporary Acute Mechanical Circulatory Support for Acute
Circulatory Collapse: Experience with 266 Patients
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
received a long term VAD, and 18% (n = 47) underwent heart transplantation.
Device-speciﬁc survival is demonstrated in ﬁgure 1. The AMI indication was
independently associated with increased in-hospital mortality (HR 2.56, 95% CI
(1.01–6.50)). Male gender (HR 0.70 95% CI (0.48–0.99)), support greater than 5
days (HR 0.62 95%CI (0.43–0.88)), and receiving a long-term VAD (HR 0.55 95%CI
(0.34–0.89)) were independently associated with lower mortality.
CONCLUSION: Reasonable survival can be expected for patients requiring temporary circulatory support with a variety of devices. Acute MI was an independent
predictor of in-hospital mortality. Multi-center data is needed to better understand
predictors of mortality following acute circulatory support.
66
AMERICAN ASSOCIATION FOR THORACIC SURGERY
L8.
William B. Keeling1, Jonathan M. Hernandez2, Vicki Lewis3, Melissa Czapla3,
Weiwei Zhu3, Joseph Garrett2, Eric Sommers2
1. Emory University, Atlanta, GA, USA; 2. University of South Florida,
Tampa, FL, USA; 3. H. Lee Mofﬁtt Cancer Center, Tampa, FL, USA
OBJECTIVE: Aspiration is an increasingly recognized complication following
thoracotomy for pulmonary resection, but mechanisms of postoperative aspiration
are poorly characterized. This study sought to evaluate risk factors to better deﬁne
post-thoracotomy aspiration.
METHODS: 321 consecutive patients underwent clinical bedside swallowing evaluations following thoracotomy for pulmonary resection on postoperative day one.
Videoﬂuoroscopic swallowing studies (VFSS) were independently reviewed by two
speech pathologists and were assigned Aspiration-Penetration (AS-PEN) scores of
either 1 (normal) or > 1 (abnormal). Operative, demographic and outcomes data
were abstracted for each patient and multivariate regression analysis was performed.
RESULTS: 73 (22.7%) patients failed bedside evaluation and proceeded to
undergo VFSS. Forty-four (60.3%) patients had an abnormal VFSS with a mean ASPEN score of 3.89 ± .29. Univariate analysis of data comparing patients with normal versus abnormal AS-PEN scores are displayed in Table 1. Multivariate analysis
showed that older age (69.2 versus 53.0) (p = .002), prior or current head and neck
cancer (p < .0021) premature spillage (p = .0006), and vallecular residuals (p <
.0002) were all associated with aspiration. Interestingly, certain variables were not
independently associated with aspiration including presence of gastroesophegeal
reﬂux disease, operative approach or degree of resection, mediastinal lymphadenectomy, preoperative radiation, same hospitalization re-operation, and
pathology.
Table 1: Results of Univariate Analysis
Variable
Odds Ratio
95% CI
P-Value
Premature Spillage
8.381
(2.850,24.646)
<0.0001
Decreased laryngeal elevation
7.913
(2.086,30.024)
0.0009
Residual in valleculae
17.762
(3.750,84.123)
<0.0001
Residual in pyriform sinus
7.714
(1.618,36.790)
0.0043
Male sex
2.924
(1.089,7.848)
0.0307
Age
1.125
(1.058,1.196)
<0.0001
Head and Neck Cancer
0.0021
67
SUNDAY
Afternoon
Age Is an Independent Risk Factor for Aspiration Following
Thoracotomy for Pulmonary Resection
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
CONCLUSION: Postoperative risk of aspiration following thoracotomy for pulmonary resection is characterized by repeatable episodes of pharyngeal dyscoordination on VFSS. We recommend routine VFSS for all patients older than 65 and
those with prior or current head and neck cancer before the initiation of oral intake
in order to diminish the incidence of postoperative aspiration.
5:00 p.m.
ADJOURN TO WELCOME RECEPTION
Exhibit Hall, Level 2
68
AMERICAN ASSOCIATION FOR THORACIC SURGERY
NOTES
SUNDAY
Afternoon
69
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
MONDAY MORNING
MAY 11, 2009
7:30 a.m.
BUSINESS SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
7:45 a.m.
PLENARY SCIENTIFIC SESSION
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
1.
A Formidable Task: Population Analysis Predicts a Deﬁcit of 2,000
Cardiothoracic Surgeons by 2030
Thomas E. Williams,* Benjamin Sun, Patrick Ross, Andrew M. Thomas
Surgery, Ohio State University, Columbus, OH, USA
Invited Discussant: Irving L. Kron
OBJECTIVE: To estimate the cardiovascular workforce needed by 2030 to meet the
needs of our population and to quantify its costs. Our ﬁeld is changing. The volume
of surgery and the nature of the surgery are changing. The nation’s population
grew from 227,000,000 to 282,000,000 between 1980 and 2000, and by 2050 the
population will be 420,000,000. At the same time, the applications for fellowship
in our specialty are decreasing at an alarming rate. The ABTS has certiﬁed 4,500
CT surgeons since 1975, but only 1300 in the last ten years. The United States
Department of Health and Human Services predicts only 3,620 full time CT surgeons in 2020.
Will we have enough cardiovascular and thoracic surgeons? While the volume of
coronary revascularization surgery may or not increase, the volume of lung surgery
will increase. Certainly the volume of heart failure surgery will increase – mitral
valve repairs, ventricular restoration, and VAD’s.
POPULATION IN 2030
364,000,000
CARDIOTHORACIC SURGEONS NEEDED
5,169
CARDIOTHORACIC SURGEONS IN PRACTICE
3,175
SHORTAGE
1,994
ESTIMATED TO BE CERTIFIED 2011 TO 2030
2,000
CERTIFICATION GOAL 2011 TO 2030
3,994
RESIDENTS CERTIFIED EACH YEAR
200
TOTAL MAN YEARS AT 7 PER RESIDENT
27,958
DME COSTS AT \$80,000 PER YEAR OF RESIDENT TRAINING
\$2,236,640,000
ANNUAL COSTS
\$111,832,000
*AATS
Member
70
AMERICAN ASSOCIATION FOR THORACIC SURGERY
METHODS: Retrospective examination of the pertinent literature and with a
modiﬁcation Richard Cooper’s economic trend analysis, a population algorithm
with a ratio of physicians to population of 1.42 /100,000. Each thoracic surgeon will
practice thirty years from Board Certiﬁcation to retirement. The Balanced Budget
Act will not be revised; therefore we will certify 100 graduates from our programs
per year. The assumed salaries will be $50,000 with beneﬁts of 30%, and $ 15,000
of additional DME costs.
CONCLUSION: 1) We must train almost 4,000 surgeons in our specialty to meet
the needs of the population by 2030, 2) That will cost almost $2,250,000,000, and
3) To do this, the Balanced Budget Act of 1997 must be revised to permit more
residents to be trained in the United States.
71
MONDAY
Morning
RESULTS: The population in 2030 will be 364,000,000 with 5,169 CT surgeons
needed at that time. Unfortunately, there will be only about 3,200 of them in practice with a shortage of almost 2,000. To maintain our current status per 100,000
population from 2011 to 2030, we will have to train 4,000 residents The total man
years would be almost 28,000. The cost for this greater than $2,000,000,000. The
annual cost for this training prorated over 20 years would be greater than
$110,000,000.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
2.
Single Center Experience in Treatment of Cardiogenic Shock of
Any Etiology in Children by Pediatric Ventricular Assist Devices
Roland Hetzer,* Evgenij V. Potapov, Oliver Miera, Yu-Guo Weng, Michael Hübler,
Felix Berger
DHZB, Berlin, Germany
Invited Discussant: Charles Fraser, Jr.
OBJECTIVE: Pediatric ventricular assist devices (VAD) are superior to ECMO for
medium- and long-term support. New devices are in development and will be
introduced into clinical routine soon. We present the development of our clinical
practice with pulsatile pediatric VAD over almost 20 years.
METHODS: Since 1990 and as of October 1, 2008, 95 pediatric Berlin Heart Excor
systems have been implanted in patients below 18 years of age at our institution.
The patients were divided into two groups according to the period of treatment:
period I – devices implanted between 1990 and 2002 (n = 45) and period II –
devices implanted since 2002 (n = 50). We compared our experience during the
earlier and later periods.
RESULTS: There were no signiﬁcant differences in the preoperative patient data
between the two periods except for time of support (median 10, range 0–111 days
vs. 37, range 1–420 days, p < 0.001). In period I more patients were supported with
a biventricular VAD (64% vs. 26%, p < 0.001). In period II more children were
extubated on the VAD (38% vs. 62%, p = 0.018). Discharge from hospital following
either weaning from the system or heart transplantation was achieved in 49% in
period I and in 70% in period II (p = 0.035). Whereas in period I 8% of children
younger than 1 year old were discharged home, in period II it increased to 44%
(p = 0.088). There was a signiﬁcant improvement in the discharge rate in period II
in patients with postcardiotomy heart failure (17% vs. 80% p = 0.028).
CONCLUSION: Earlier implantation of VAD, substantial modiﬁcations in cannula and pump design, improvement in anticoagulation and the coagulation monitoring regime have led to a signiﬁcant increase in the survival and discharge rate,
especially in children under 1 year of age. Now, the pediatric Berlin Heart Excor
VAD is an established treatment for children suffering from cardiogenic shock of
any etiology.
*AATS
Member
72
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3.
Long-Term Results of Aortic Valve Sparing Operations in Patients
with Marfan Syndrome
Tirone E. David,* Susan Armstrong, Manjula Maganti, Jack Colman,
Timothy Bradley
Cardiovascular Surgery, Toronto General Hospital, Toronto, ON, Canada
Invited Discussant: Lars G. Svensson
METHODS: From 1988 to 2006, 103 consecutive patients with Marfan syndrome
(mean age 37 ± 12 years, 72% men) with aortic root aneurysm had aortic valve
sparing operations. Emergency surgery was performed in 11 patients: 8 for acute
type A dissection and 3 for unexplained persistent chest pain. Three patients had
chronic type A dissection and previous ascending aorta replacement. Fifteen
patients had moderate or severe aortic insufﬁciency (AI) and 14 had mitral insufﬁciency. Reimplantation of the aortic valve was performed in 77 patients and remodeling of the aortic root in 26. Patients were followed prospectively and had annual
echocardiographic studies. The mean follow-up was 7.3 ± 4.2 years, and 100%
complete.
RESULTS: There was one operative death and 5 late deaths, 4 due to complications of aortic dissections. Patients’ survival at 15 years was 87.2% and that of the
general of population matched for age and gender was 95.6%. Three patients
required aortic valve replacement: 2 for AI and one for endocarditis. The freedom
from reoperation on the aortic valve at 15 years was 87.6 ± 7.7%. The latest echocardiographic study before death or reoperation showed no AI in 33 patients, trivial in
35, mild in 27, mild to moderate in 4, moderate in 2, and severe in 1. The freedom
from AI of mild to moderate or greater grade at 5-, 10- and 15-year was 100%, 94.5
± 5.4%, and 88.2 ±1 1.7% respectively. Remodeling of the aortic root was not an
independent predictor of AI. At the most recent follow-up 97 patients were alive:
86 were in functional class I and 11 in class II.
CONCLUSION: Aortic valve sparing operations provide excellent long-term valve
function and low rates of valve-related complications in patients with Marfan syndrome. Complications of aortic dissections remain problematic in these patients.
*AATS
Member
73
MONDAY
Morning
OBJECTIVE: This study examines the long-term results of aortic valve sparing
operations in patients with Marfan syndrome.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
4.
Outcomes After Laparoscopic Giant Paraesophageal Hernia Repair
in 636 Patients
James D. Luketich,* Katie S. Nason, Rodney J. Landreneau,* Samuel Keeley,
Omar Awais, Manisha Shende, Matthew J. Schuchert, Ghulam Abbas,
Blair A. Jobe, Arjun Pennathur
The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
Invited Discussant: Antoon Lerut
OBJECTIVE: Over the past decade, laparoscopic repair of giant paraesophageal
hernias (LRGPEH) has been described but has a high rate of radiographic and/or
symptomatic recurrence in some centers. Our objective was to evaluate our results
with LRGPEH.
METHODS: A retrospective review of patients undergoing elective LRGPEH
(1997–2008) was performed. Clinical outcomes, barium swallow (BaSwa) and
quality-of-life (QoL) were assessed.
RESULTS: LRGPEH was performed in 636 patients (median age 71; range 19–92).
The median percent of intrathoracic stomach by BaSwa was 66% (range 30–100%).
Hernia reduction, sac resection, crural repair (mesh-reinforcement in 13% (84/636)
and fundoplication was performed in 98% (407/636) with Collis-gastroplasty in
63% (407/636). Open conversion rate was 1.4% (9/636). Nine patients (9/636;
1.4%) required re-operation for leaks. Median length of stay (LOS) was 3 days
(range 1–63). Pleural effusion (54/636; 9%) and pneumonia (27/636; 4%) were the
most common major complications. Mortality was 2% at 30-days (11/636). Postoperative GERD-Health-related QoL scores (30-month median clinical follow-up)
were available for 470 patients with “Good” to “Excellent” results in 91% (428/470)
of patients (excellent = 0–5; good = 6–10). Recurrence requiring re-operation
occurred in 2.5% (16/636). Overall, surgical result was satisfactory in 92% (432/470).
CONCLUSION: In the largest series to date, LRGPEH was performed in 636
patients with a 1.4% open conversion rate, a 3 day LOS, and 30-day mortality rate
of 2%. At 30 months median clinical follow-up, 92% of patients were satisﬁed with
the surgical result. Re-operation for recurrence was required in 2.5%, which is
comparable to open series.
*AATS
Member
74
AMERICAN ASSOCIATION FOR THORACIC SURGERY
9:05 a.m.
AWARD PRESENTATIONS
Ballroom A–C, Hynes Convention Center
Lifetime Achievement Award
Thomas B. Ferguson, MD
Washington University School of Medicine
C. Walton Lillehei Forum Award
TSFRE Report
9:20 a.m.
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
10:00 a.m.
BASIC SCIENCE LECTURE
Ballroom A–C, Hynes Convention Center
Insights from Developmental and Stem Cell Biology
Jonathan A. Epstein, MD
William Wikoff Smith Professor of Medicine
Chairman, Department of Cell and Developmental Biology
Scientiﬁc Director, Penn Cardiovascular Institute
Founding Co-Director, Penn Institute for Regenerative Medicine
University of Pennsylvania
Introduced By:
Thomas L. Spray, MD
75
MONDAY
Morning
TSRA McGoon Award
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
10:40 a.m.
PLENARY SCIENTIFIC SESSION
Moderators:
5.
Alec Patterson
Thoralf M. Sundt, III
The Relationship Between Hospital CABG Volume and Multiple
Dimensions of CABG Quality
David M. Shahian,1* Sean O’Brien,2 Sharon-Lise Normand,3 Eric Peterson,2
Fred Edwards4*
1. Massachusetts General Hospital, Boston, MA, USA; 2. Duke Clinical Research Institute,
Durham, NC, USA; 3. Harvard Medical School, Boston, MA; USA, 4. University of
Florida, Jacksonville, FL, USA
Invited Discussant: T. Bruce Ferguson, Jr.
OBJECTIVE: Previous research suggests a weak relationship between hospital
CABG volume and risk-adjusted mortality, but the latter is only one dimension of
overall CABG quality. This study examines the relationship between hospital
CABG volume and each of the four domains of the STS CABG composite score, a
multidimensional quality measure consisting of 11 individual NQF-endorsed performance metrics.
METHODS: The study population consisted of 144, 526 patients who underwent
isolated CABG between 1/1/07 and 12/31/07 at one of 733 hospitals participating in
the STS Database. Hospitals were grouped into 6 volume categories based on total
number of procedures that included a CABG, while the analysis population consisted only of isolated CABG procedures.
Endpoints included mortality; any major morbidity (stroke, renal failure, sternal
infection, reoperation, and/or prolonged ventilation); failure to receive an IMA;
and failure to use all indicated medications. Hierarchical logistic regression models
were used to assess the association between volume categories and each endpoint,
adjusting for variables in the 2008 STS CABG risk model.
RESULTS: Unadjusted outcomes did not differ signiﬁcantly across volume categories for morbidity or medications. Unadjusted mortality ranged from 2.6% (95%
CI 2.2–3.0) for hospitals performing < 100 CABG annually to 1.7% (95% CI 1.5–1.8)
for hospitals performing 450+ cases (p < 0.001). Failure to perform an IMA ranged
from 6.9% (95% CI 5.7, 8.0) for hospitals in the 100–149 CABG group to 5.4% (95%
CI 4.7, 6.2) for hospitals performing 300–449 procedures (p = 0.0442). The adjusted
results for each volume category were compared against the results for hospitals
performing 450+ cases (Table). Only the 95% CI of the odds ratios for mortality
excluded 1.00, and the results were most striking for hospitals in the < 100 CABG
category. When the four endpoints were aggregated into a single composite endpoint, only 1% of the variation in composite score was explained by volume.
*AATS
Member
76
AMERICAN ASSOCIATION FOR THORACIC SURGERY
Adjusted Odds Ratios
(95% Conﬁdence Intervals)
Volume
Category
Number of
Hospitals
Number of
Patients
≥450
92
47147
reference = reference = reference =
1.00
1.00
1.00
reference =
1.00
300–449
114
31585
1.17
0.91
(1.01, 1.35) (0.73, 1.12)
0.87
(0.72, 1.06)
1.03
(0.90, 1.18)
200–299
157
30209
1.31
1.06
(1.14, 1.51) (0.87, 1.30
0.92
(0.76, 1.10)
1.02
(0.90, 1.16)
150–199
108
14789
1.14
0.99
(0.96, 1.35) (0.79, 1.23)
0.91
(0.74, 1.11)
1.00
(0.87, 1.15)
100–149
128
12740
1.29
1.11
(1.08, 1.53) (0.90, 1.38)
0.88
(0.72, 1.07)
1.03
(0.89, 1.18)
<100
134
8056
1.49
1.15
(1.24, 1.80) (0.92, 1.43)
0.99
(0.81, 1.20)
1.09
(0.94, 1.26)
Mortality Morbidity IMA Failure Med Failure
77
MONDAY
Morning
CONCLUSION: Of the four domains of CABG quality that constitute the STS
composite CABG score, only mortality demonstrates a statistically signiﬁcant
volume-outcome association. However, this relationship is weak, and it is most
apparent at the extremes of volume.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
6.
Survival After Transapical and Transarterial Aortic Valve
Implantation: Talking About Two Different Patient Populations
Sabine Bleiziffer, Hendrik Ruge, Domenico Mazzitelli, Christian Schreiber,
Andrea Hutter, Robert Bauernschmitt, Ruediger Lange*
Clinic for Cardiovascular Surgery, German Heart Center Munich, Munich, Germany
Invited Discussant: Michael J. Mack
OBJECTIVE: Recently, suspicion rose that survival may be impaired after antegrade
transapical valve implantation in high-risk patients with aortic stenosis compared
to the retrograde transarterial access. We analyzed survival in patients undergoing
transcatheter aortic valve implantation with regard to implantation technique.
METHODS: Between 06/2007 and 09/2008, 153 high-risk patients (EuroScore
24 ± 14%, mean age 81 ± 8 y) underwent transcatheter aortic valve implantation
transapically (n = 27) or transarterially (n = 123 transfemoral, n = 3 via subclavian
artery). The transapical implantation technique was chosen only in patients who
had no access through diseased femoral or subclavian arteries.
RESULTS: 30-day survival was 89.9% after transarterial vs 79.1% after transapical
implantation (p = 0.028, see survival curve).The transapical group had a signiﬁcantly higher preoperative BNP value, and a signiﬁcantly higher incidence of
peripheral vessel and cerebrovascular disease, pulmonary hypertension, and atrioventricular valve regurgitation. Death was valve-related in 25% (transapical) and
29% (transarterial), cardiac in 13% and 10%, and non-cardiac in 63% and 62%,
respectively (n.s.). In the transapical group, there were signiﬁcantly less postoperative
vascular complications (4% vs 20%, p = 0.009), and no neurological events (0% vs
6.5%, n.s.).
*AATS
Member
78
AMERICAN ASSOCIATION FOR THORACIC SURGERY
CONCLUSION: Survival is worse in patients in whom transapical, as opposed to
transarterial aortic valve implantation is necessary, because these patients exhibit a
signiﬁcantly higher incidence of comorbidities. The causes of death were not different in the two groups, however, more patients in the transapical group succumb
during follow-up. On the other hand, cerebrovascular complications did not occur
in patients with transapical access.
11:25 a.m.
PRESIDENTIAL ADDRESS
Introduced By:
12:15 p.m.
Alec Patterson, MD
LUNCH – VISIT EXHIBITS
Exhibit Hall
CARDIOTHORACIC RESIDENTS’ LUNCHEON*
Room 311, Hynes Convention Center
*Ticketed event
79
MONDAY
Morning
The Quality Conundrum
Thomas L. Spray, MD, Philadelphia, PA
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
NOTES
80
AMERICAN ASSOCIATION FOR THORACIC SURGERY
MONDAY AFTERNOON
MAY 11, 2009
2:00 p.m.
Moderators:
7.
MONDAY
Afternoon
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
R. Duane Davis
Chuen-Neng Lee
Outcomes of Reoperative Aortic Valve Replacement Following
Previous Sternotomy
Damien J. LaPar, Zequan Yang, R. Ramesh Singh, T. Brett Reece,† Cory D. Maxwell,
Benjamin B. Peeler, John A. Kern,* Irving L. Kron,* Gorav Ailawadi∞
Surgery, University of Virginia, Charlottesville, VA, USA
Invited Discussant: Leonard N. Girardi
OBJECTIVE: An increasing number of patients with previous sternotomy require
aortic valve replacement (AVR). We compared the outcomes of reoperative AVR
after previous sternotomy with primary AVR over time. Further, the effect of primary operation on reoperative AVR was investigated.
METHODS: Between January 1996 and December 2007, 1603 patients undergoing
elective AVR were entered prospectively into our clinical database. Patients were
divided into three eras: I: 1996–1999, II: 2000–2003, III: 2004–2000. A total of 191
patients (12% [191/1603]) had previous sternotomy for CABG (n = 88), CABG with
AVR (n = 16), AVR with or without other aortic procedure (n = 30) and other cardiac
procedures (n = 17). The mean age was 66.5 ± 13.1 years in reoperative AVR patients
and 65.5 ± 12.0 years in primary AVR patients.
Outcome
1996–1999 2000–2003 2004–2007 P-value
Primary AVR (n = 1412)
316 (22%)
554 (39%)
542 (38%)
<0.0001
Reoperative AVR (n = 191)
39 (20%)
53 (28%)
99 (52%)
<0.0001
Major Complications (Primary AVR)
10 (3.2%)
88 (16%)
89 (16%)
<0.0001
6 (15%)
9 (17%)
5 (5%)
0.04
10 (3.2%)
29 (5.2%)
19 (3.5%)
0.22
6 (15%)
8 (15%)
2 (2%)
0.005
Major Complications (Reoperative AVR)
Mortality(Primary AVR)
Mortality(Reoperative AVR)
*AATS
Member
Traveling Fellowship 2008
∞Resident Traveling Fellowship 2006
†Resident
81
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
RESULTS: The mortality for reoperative AVR patients signiﬁcantly decreased over
time (I: 15% [6/39], II: 15% [8/53], III: 2% [2/99], p = 0.005) and was equivalent to
primary AVR in the current era (3.5% [19/542] vs. 2.0% [2/99], p = 0.65). Major
complication rates also signiﬁcantly decreased over time in reoperative AVR
patients (I: 15% [6/39], II: 17% [9/53], III: 5% [5/99], p = 0.04) and was similar to
patients undergoing primary AVR (12% [23/191] vs. 15% [215/1412], p = 0.30) in the
current era. Importantly, patients had more comorbidities including dyslipidemia
(26% [10/39], 42% [22/53], 77% [76/99], P < 0.0001), coronary artery disease
(31% [12/39], 49% [26/53], 84% [83/99], P < 0.0001) and hypertension (39% [15/
39], 53% [28/53], 69% [68/99], P = 0.003) over time while other preoperative risk
factors were similar. In reoperative AVR patients, there were no differences in outcome based on primary operation. Speciﬁcally, mortality at reoperation was similar
following primary CABG + AVR (19% [3/16]), CABG (6% [5/88]) and AVR (9%
[6/70], p = 0.18). Major complication rates were also not dependent on primary
operation (CABG + AVR: 25% [4/16], CABG: 15% [13/88], and AVR: 9% [6/70],
p = 0.21).
CONCLUSION: Reoperative AVR now carries similar morbidity and mortality as
primary AVR. The risk of reoperation is not affected by the primary operation.
82
AMERICAN ASSOCIATION FOR THORACIC SURGERY
8.
Apical Myectomy: A New Surgical Technique for the Management
of Severely Symptomatic Patients with Apical Hypertrophic
Cardiomyopathy
Hartzell V. Schaff,1* Morgan L. Brown,1 Steve R. Ommen,1 Joseph A. Dearani,1
Martin D. Abel,1 A.J. Tajik,2 Rick A. Nishimura1
1. Mayo Clinic, Rochester, MN, USA; 2. Mayo Clinic, Scottsdale, AZ, USA
Invited Discussant: Nicholas G. Smedira
METHODS: From 1993 through May, 2008, 43 symptomatic patients with ApHCM
underwent apical myectomy to augment LV end-diastolic volume (EDV). Information from a prospective database was supplemented by survey information, patient
contact, and review of medical records.
RESULTS: The mean age was 50 ± 17 yr and 65% were female. All patients were
severely limited with dyspnea, 63% had angina, and 60% had syncope or presyncope. Ninety-one percent of patients were in New York Heart Association
(NYHA) class III or IV. Myectomy was performed through an apical incision, and
the LV cavity was augmented by excision of hypertrophic muscle at the apex and
mid ventricle; a mean of 16 ± 7 g of muscle was removed. In 14 patients who underwent pre- and postoperative hemodynamic catheterization, the LV end-diastolic
pressure decreased from 28 ± 9 to 24 ± 7 mmHg (P = 0.002) and the EDV index
increased from 55 ± 17 to 68 ± 18 cc/m2 (P = 0.003). Invasive measurements of
stroke volume increased from of 56 ± 17 cc to 63 ± 19 cc (p = 0.007). Forty of fortyone hospital survivors had improvement in symptoms after operation. The mean
peak maximum oxygen consumption on exercise testing (n = 5) increased from
13.5 ± 4.4 to 15.8 ± 4.6 mL/kg per minute. Survival at 1, 3, and 5 years was 95%,
81%, and 81%, respectively. At an average follow-up of 2.6 ± 3.1 years, 23 patients
(74%) were in NYHA class I or II. One patient underwent heart transplant 5 years
after apical myectomy.
CONCLUSION: For patients with ApHCM who have limiting symptoms despite
optimal medical treatment, apical myectomy can improve functional status by
decreasing LV end-diastolic pressure, thus improving the effective operative compliance of the LV and increasing stroke volume. This procedure may be of value in
other patients with HCM who have severe hypertrophy and small LV end-diastolic
volumes.
*AATS
Member
83
MONDAY
Afternoon
OBJECTIVE: Apical hypertrophic cardiomyopathy (ApHCM) is a morphologic
variant in which the hypertrophy is primarily localized to the apex of the left
ventricle (LV). A subset of patients develop progressive drug refractory diastolic
heart failure with severely limiting symptoms due to a resultant low cardiac output. Heart transplant has been the only therapeutic option available for such
patients. This study analyzes clinical and hemodynamic outcomes of a novel surgical technique to improve diastolic ﬁlling by LV cavity enlargement.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
9.
Where Does AF Surgery Fail?: Implications for Increasing AF
Surgical Ablation Effectiveness
Patrick M. McCarthy,* Jane Kruse, Shanaz Shalli, Leonard Ilkhanoff,
Jeffrey Goldberger, Alan Kadish, Rishi Arora, Richard Lee
Division of Cardiothoracic Surgery, Northwestern University; Northwestern
Memorial Hospital, Chicago, IL, USA
Invited Discussant: Chuen-Neng Lee
OBJECTIVE: We sought to identify the location of failure of atrial ﬁbrillation
(AF) surgery to determine if a pattern exists that could be used to modify the procedure and increase effectiveness.
METHODS: From April 2004 to September 2008, 386 pts (216 male; age 65.8 ±
12.4; Table 1) underwent surgical ablation by a single surgeon primarily using
bipolar radiofrequency and cryoablation. This included 339 with other procedures
(concomitant group), 47 lone AF [31 Classic; 16 High Intensity Focused Ultrasound (HIFU)]. Operative mortality was 1.8% for those with concomitant and 0%
for lone AF surgery. Since January 2006 pts were prospectively followed, and all
preceding pts were retrospectively followed as well.
Table 1
MV Surgery ± other procedure
Classic
HIFU
PVI
LA only
Biatrial
21
5
3
159
62
8
AV Surgery ± other procedure
1
0
38
8
Lone AF Surgery
31
16
0
0
0
CABG
0
3
8
2
4
Other combination
11
0
0
3
3
RESULTS: At the our center 19 pts who developed AF or Atrial Flutter >3 months
after surgery underwent electrophysiology (EP) study with ablation. Of the Classic
Maze pts 3/64 were studied and found to have mitral annular ﬂutter. Of the HIFU
patients 3/24 were studied (an additional 4 pts had ablation elsewhere) and all 7
had breakdowns in the pulmonary vein isolation (PVI) lines. Need for ablation
after HIFU was much higher (7/24, 29%) than after Classic Maze (3/64, 4.7%, p =
0.004). Of the concomitant group the location of arrhythmias was variable and
included: RA ﬂutter or RA tachycardia (8), left sided macroreentry around the PV
or mitral annulus (7), PV (5), and focal mitral annular atrial tachycardia (1).
*AATS
Member
84
AMERICAN ASSOCIATION FOR THORACIC SURGERY
CONCLUSION: Failures after HIFU were high and related to breakdown of the
PV isolation line. Failures after Classic Maze were infrequent and isolated to the
mitral isthmus. Failures after concomitant surgery include right side breakthrough
(primarily in pts with just LA lesion sets) and incomplete coronary sinus/mitral
isthmus lesions. We now perform more extensive biatrial lesions, and wider cyroablation to the mitral valve annulus and coronary sinus. Identifying the location of
failures may lead to higher future success and is being prospectively monitored.
3:00 p.m.
85
MONDAY
Afternoon
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
3:45 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
Moderators:
R. Duane Davis
Chuen-Neng Lee
10. Have Hybrid Procedures Replaced Open Aortic Arch Reconstruction
in High Risk Patients: A Comparative Study of Open Arch Debranching
with Endovascular Stent Graft Placement and Conventional Open
Total and Distal Aortic Arch Reconstruction
Rita K. Milewski, Wilson Y. Szeto, Alberto Pochettino, G. William Moser,
Patrick Moeller, Joseph E. Bavaria
Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Invited Discussant: Yutaka Okita
OBJECTIVE: Open total arch (OTA) and open distal arch plus proximal descending aortic (ODAD) procedures can be performed electively with adjunct circulatory
and cerebral perfusion management. These procedures have been associated with
signiﬁcant, even prohibitive, morbidity and mortality in patients with multiple
comorbidities. Open aortic arch debranching with endovascular stent graft placement as a single stage procedure has emerged as a surgical option in this patient
population. This study evaluates the outcomes of a contemporary comparative
series from one institution of open total arch, open total arch plus descending
aorta, and hybrid surgical procedures for extensive aortic arch pathology.
METHODS: From July 2000 to September 2008, 1196 open arch procedures were
performed: 694 elective hemiarch, 49 OTA, 42 ODAD and 350 emergent hemiarch
and open descending procedures. From 2005 to 2008, 61 open (hybrid) endovascular
procedures were performed: 37 emergent Type A dissections and 24 elective open
arch debranchings.
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
CONCLUSION: Hybrid arch debranching with endovascular stent graft placement provides a safe alternative to open repair. This study suggests that arch repair
using the hybrid approach has a lower mortality for high risk patients greater than
75 years old. This extends the indication for a hybrid arch approach to patients
with complex aortic arch pathology who were previously considered prohibitively
high risk for conventional open total arch repair.
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RESULTS: Primary outcome measures of Mortality, Transient Neurological Deﬁcit
(TND), and Permanent Neurological Deﬁcit (PND) were evaluated. Univariate
analysis revealed age > 75 years (y) as a predictor of mortality (p < .06) in the open
aortic repair group. For patients >75 y, mortality for elective hybrid was 9.09% (1/11),
elective OTA 40% (4/10), and elective ODAD 20% (1/5). For patients <75 y, mortality
for elective hybrid was 15.38% (2/13), elective OTA 9.38% (3/32), and elective
ODAD 0%. TND in elective ODAD was 3.0% (1/32) for <75 years (y) and 20% (1/5)
for >75 y. TND in elective OTA was 12.5% (4/32) <75 y and 10.0% (1/10) >75 y.
TND in the elective hybrid was 7.69% (1/13) <75 y and 18.18% (2/11) >75 y. PND in
elective ODAD was 3% (1/32) <75 y and 0% >75 y. PND in elective OTA was
9.38% (3/32) <75 y and 10% (1/10) >75 y. PND in elective hybrid was 15.38% (2/13)
<75 y and 18.18%(2/11) >75 y. Multivariate analysis did not demonstrate a difference in either TND or PND between procedure groups.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
11. Effect of Partial Thrombosis on Distal Aorta After Repair of Acute
DeBakey Type I Aortic Dissection
Suk-Won Song,1 Byung-Chul Chang,2*† Bum-Koo Cho,2*∞ Kyung-Jong Yoo2
1. Yondong Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea;
2. Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
Invited Discussant: Anthony L. Estrera
OBJECTIVE: Patency or thrombosis of the residual aorta after repair of acute
DeBakey type I aortic dissection has been found to predict long-term outcome.
However, prognostic implications of partial thrombosis of the residual aorta have
not yet been elucidated. We sought to analyze the impact of partial thrombosis on
segmental growth rates, distal reprocedures, and long-term survival.
METHODS: One hundred eighteen consecutive patients (55% male; mean age, 60
years) with acute DeBakey type I aortic dissection underwent aggressive resection
of the intimal tear and open distal anastomosis (1997–2007). Hospital mortality
was 17.8%. Survivors had serial computed tomographic scans: digitization yielded
distal segmental dimensions.
Segment-speciﬁc average rates of enlargement and factors inﬂuencing faster
growth were analyzed. Distal reprocedures and patient survival were examined.
RESULTS: Sixty-six (61%) patients had imaging data sufﬁcient for growth rate
calculations. The median diameters after repair were as follows: aortic arch, 3.5 cm;
descending aorta, 3.6 cm; and abdominal aorta, 2.4 cm. Subsequent growth rates
were 0.34, 0.51, and 0.35 mm/y, respectively. Partial thrombosis of the residual aorta
predicted greater growth in the distal aorta (p = 0.005). There were 13 distal aortic
reprocedures (8 stent graft insertions, 5 reoperations) for 10 years, and reprocedures-free survival was 66%. Partial thrombosis (p = 0.002), or complete patency
(p = 0.008) predicted greater risk of aorta-related reprocedures. Cox proportional
hazard analysis revealed eGFR lesser than 60 ml/min/1.73 m2 (p = 0.030), reintubation (p = 0.002), and partial thrombosis (p = 0.023) were independent predictors for
poor long-term outcome.
*AATS
Member
Memorial Traveling Fellowship 1987–1988
∞Graham Memorial Traveling Fellowship 1976–1977
†Graham
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
CONCLUSION: Partial thrombosis of the false lumen after repair of acute
DeBakey type I aortic dissection, as compared with complete patent or thrombosis,
is a signiﬁcant independent predictor of aortic enlargement, aorta-related reprocedures, and poor long-term outcome. Survivors who had partial thrombosis after
repair of aortic dissection require meticulous and frequent follow-up due to a high
risk of deterioration after discharge.
MONDAY
Afternoon
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
12. Staged Repair Signiﬁcantly Reduces Paraplegia Rate After
Extensive Thoracoabdominal Aortic Aneurysm Repair
Christian D. Etz, Stefano Zoli, Christoph S. Mueller, Carol A. Bodian,
Gabriele Di Luozzo, Ricardo Lazalla, Konstadinos A. Plestis, Randall B. Griepp*
Mount Sinai School of Medicine, New York, NY, USA
Invited Discussant: Joseph S. Coselli
OBJECTIVE: Paraplegia remains a devastating—and still too frequent—complication after repair of extensive thoracoabdominal aortic aneurysms (TAAA). Strategies to prevent ischemic spinal cord damage following extensive segmental artery
(SA) sacriﬁce—or occlusion, essential for endovascular repair—are still evolving.
METHODS: 90 patients (pts) who underwent extensive SA sacriﬁce (median:13,
range: 9–15; see ﬁgure) during open surgical repair from 06/94–12/07 were
reviewed retrospectively. 55 pts—most with extensive TAAA/Crawford type II;
mean age 65 ± 12 yrs; 49% male—had a single procedure (1-stage group). 35 pts
had two operations (2-stage-group): usually Crawford type III or IV repair after
operation for descending thoracic aneurysm (DTA)/Crawford type I; mean age:
62 ± 14 yrs; 57% male. The median interval between the 2-stage procedures was
5 yrs (3 months–17 yrs). There were no signiﬁcant differences between the groups
with regard to age, gender, etiology of the aneurysm, hypertension, COPD, urgency,
previous cerebrovascular accidents, year of procedure, or CSF drainage. In 1-stage
procedures, hypothermic circulatory arrest (HCA) was used in 29%; left heart
bypass in 40%, and distal aortic perfusion in 27%. Somato-sensory evoked potentials
(SSEP) were monitored in all pts, and motor-evoked potentials in 39%. CSF was
drained in 84%.
*AATS
Member
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
CONCLUSION: A staged approach to repair of extensive TAAA may dramatically
reduce the incidence of spinal cord injury: this is of particular importance in
designing strategies involving hybrid or entirely endovascular procedures. If a
staged approach is not possible, a single-stage procedure utilizing HCA protects
the spinal cord better than a 1-stage procedure using other perfusion techniques.
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RESULTS: Overall hospital mortality was 11.1%. There were no signiﬁcant differences in mortality, stroke, postoperative bleeding, infection, renal failure or pulmonary insufﬁciency between the groups. However, 15% (* in ﬁgure) in the 1-stagegroup suffered permanent spinal cord injury vs. none in the 2-stage-group, p = .02.
The signiﬁcantly lower rate of paraplegia/paraparesis in the 2-stage group
occurred despite a signiﬁcantly higher number of SAs sacriﬁced in this group: a
median of 14 (11–15) vs.12 (9–15), p < .0001. Pts with 1-stage procedures without
HCA were more likely to develop spinal cord injury than pts with 1-stage procedures with HCA or 2-stage procedures (p = .02).
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
13. Preoperative Very Short Term High Dose Erythropoietin Administration
Diminishes Blood Transfusion Rate in Off Pump Coronary Artery
Bypass – A Randomized Blind Controlled Study
Luca Weltert, Stefano D’Alessandro, Saverio Nardella, Fabiana Girola,
Alessandro Bellisario, Daniele Maselli, Ruggero De Paulis
European Hospital, Rome, Italy
Invited Discussant: Colleen Koch
OBJECTIVE: Human Recombinant Erythropoietin (HRE) has been used either
as a single or refracted dose, to obtain rapid increase in red blood cells count a few
days before surgery. The shortest preparatory administration interval up to now
was 4 days. In everyday routine at our Institution only 2,4 days separate average
hospitalization and surgery. We therefore propose a randomized blind trial to test
the efﬁcacy of high dose HRE in very short term administration.
METHODS: All patients presenting with diagnosis of isolated coronary vessels
disease were randomized to either HRE administration or control group. Patients
with Creatinin >2 mg/dl, Hb >14.5 g/dl or Hematocrit >44% were excluded.
Administration doses were:
Day –2, 14.000UI; Day –1, 14.000UI; Day 0 (Day of surgery), 8.000UI; Day 1,
8.000UI; Day 2, 8.000UI (average 600UI/Kg/Week). Haemoglobin (Hb) values
were collected preoperatively, and on postoperative day 1 and day 4. Blood loss and
blood transfusion rate were recorded at time of discharge.
RESULTS: Three-hundred-twenty consecutive patients were enrolled. All patients
underwent OFF-pump coronary revascularization. No signiﬁcant difference were
present in Age, Ejection Fraction, Euroscore value, incidence of COPD, peripheral
vasculopathy, instable angina, recent myocardial infarction, postoperative blood loss.
Mean preoperative Hb value were similar between the two groups (p > 0,3). Three
patients required conversion to On-Pump revascularization and were excluded
from the study. At Day 4 mean Hb was 15,5% higher in the HRE group (10.70 ± 0.72
vs 9.26 ± 0.71 g/dl; p < 0,05). The HRE group required 0,33 blood units/per patients
while the control group required 0,76 blood units/per patient (p = 0,008).
CONCLUSION: A signiﬁcant reduction in transfusion rate and a signiﬁcant
increase in Hb values in HRE group were observed. No adverse events (thrombosis, allergic reactions) related to HRE administration were recorded. A very short
preoperative HRE administration seem a safe, easy, and convenient method in
reducing the need for blood transfusions.
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
5:05 p.m.
ADULT CARDIAC DEBATE
NHLBI STICH TRIAL:
Coronary Bypass with Ventricular Reconstruction Does
Not Improve Survival Compared to Coronary Bypass
Surgery
Ballroom A–C, Hynes Convention Center
6:00 p.m.
Andrew S. Wechsler
Pro:
Robert H. Jones
Con:
Gerald D. Buckberg
ADJOURN
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Moderator:
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
NOTES
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
MONDAY AFTERNOON
MAY 11, 2009
2:00 p.m.
Moderators:
James D. Luketich
Bryan F. Meyers
14. Thoracoscopic Lobectomy Is Associated with Lower Morbidity
than Open Lobectomy: A Propensity-Matched Analysis from the
STS Database
Subroto Paul,1† Nasser K. Altorki,1* Shubin Sheng,2 Paul C. Lee,1 David H. Harpole,2*
Mark W. Onaitis,2 Brendon M. Stiles,1 Jeffrey L. Port,1 Thomas A. D’Amico2*
1. Cardiothoracic Surgery, New York, Presbyterian-Weill Cornell Medical Center,
New York, NY, USA; 2. Duke University Medical Center, Durham, NC, USA
Invited Discussant: Neil A. Christie
OBJECTIVE: Thoracoscopic lobectomy, compared to thoracotomy, may be associated
with fewer overall postoperative complications based on several single institution
series. Propensity matching using a large national database may enable a more
powerful and comprehensive analysis of postoperative outcomes.
METHODS: All patients undergoing lobectomy as the primary procedure via
thoracoscopy or thoracotomy were identiﬁed in the Society of Thoracic Surgeons
(STS) prospective database from 2002–2007. After excluding patients with prior
thoracic surgery, 6434 patients were identiﬁed (5134 thoracotomy, 1300 thoracoscopy). A propensity analysis was performed, incorporating preoperative variables
using a greedy matching algorithm.
RESULTS: Propensity scores were calculated based on age, sex, body mass index,
functional status, medical co-morbidities, smoking status, pulmonary function
tests, and preoperative therapy. Matching based on propensity scores produced
1281 patients in each group for analysis of postoperative outcomes. After thoracoscopic lobectomy, 73.8% (n = 945) had no complications, compared to only 65.3%
(n = 847) after thoracotomy (p < 0.0001). Compared to thoracotomy, thoracoscopic
lobectomy was associated with a lower incidence of arrhythmias [93 (7.3%) v 147
(11.5%); p = 0.0004], reintubation [18 (1.4%) v 40 (3.1%); p = 0.0046], and blood
transfusion [31 (2.4%) v 60 (4.68%); p = 0.0028], as well as a shorter length of stay
(4.00 v 6.00 days; p < 0.0001) and chest tube duration (3.00 v 4.00 days; p < 0.0001;
Table). Thoracoscopic lobectomy required longer operative time (173 v. 143 minutes;
p < 0.05). There was no difference in operative mortality between the 2 groups.
*AATS
Member
Traveling Fellowship 2006
†Resident
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MONDAY
Afternoon
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 302–306, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Table
Postoperative Complications
Thoracotomy Thoracoscopy
(n = 1281)
(n = 1281)
Atrial Arrhythmia, n (%)
Reintubation, n (%)
p-Value*
147 (11.48)
93 (7.26)
0.0004
40 (3.12)
18 (1.41)
0.0046
Blood Transfusion, n (%)
60 (4.68)
31 (2.42)
0.0028
No complications
847 (65.3)
945 (73.8)
<0.0001
Air Leak > 5 Days, n (%)
111 (8.67)
97 (7.57)
0.3531
Pneumonia, n (%)
56 (4.37)
38 (2.97)
0.0758
Atelectasis, n (%)
42 (3.28)
27 (2.11)
0.0722
Bleeding, n (%)
7 (0.55)
16 (1.25)
0.0931
DVT, n (%)
4 (0.31)
2 (0.16)
0.6875
Pulmonary Embolus, n (%)
3 (.23)
3 (.23)
1.000
Myocardial Infarct, n (%)
1 (0.08)
1 (0.08)
1.000
Operative mortality n(%)
12 (0.94)
12 (1.01)
1.000
6.00
4.00
<0.0001
LOS (median), days
Chest Tube Duration (median), days
OR Time (median), minutes
4.00
3.00
<0.0001
143.00
173.00
<0.0001
*p-values are based on McNemar tests for categorical outcomes and Wilcoxon signed rank tests for
continuous outcomes.
CONCLUSION: Thoracoscopic lobectomy is associated with a lower incidence of
many complications compared to thoracotomy. For appropriate candidates, thoracoscopic lobectomy may be the preferred strategy for patients with lung cancer.
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
15. Learning Curves for Video-Assisted Thoracic Surgery Lobectomy
in Non-Small Cell Lung Cancer
Hyun-Sung Lee, Byung-Ho Nam, Jae Ill Zo
Center for Lung Cancer, National Cancer Center, Goyang, Gyeonggi, South Korea
Invited Discussant: Bryan F. Meyers
METHODS: This study analyzed data from 126 consecutive patients undergoing
VATS lobectomy for lung cancer between 2005 and 2008. VATS lobectomy was
deﬁned as anatomical resection without rib spreading using utility incision (ﬁgure 1).
Mediastinal lymph node dissection was routinely performed. The learning curves
were generated using moving average method to assess changes in operation time
and cumulative sum(CUSUM) analysis to assess changes in failure rates [failure =
conversion to open surgery, major perioperative complications or mortality, or prolonged operation time over 6 hours]. Also, the learning curve was generated
according to the operation sites.
RESULTS: Mean age was 61 years old and male was 64 patients (51%). Adenocarcinoma was 93 patients (74%) with 2.7 cm in mean size of tumor. The mean number of harvested lymph nodes was 27 in eight nodal stations. Mean operation time
was 206 minutes.
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OBJECTIVE: Video-assisted thoracic surgery (VATS) demands mastery of a steep
learning curve. Deﬁning a learning curve in VATS is useful for planning training
programs or clinical trials. This study aimed to deﬁne the learning curves for VATS
lobectomy for lung cancer by evaluating early surgical outcome data from sing thoracic surgeon.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Failure occurred in 10 cases. The overall open conversion rate was 3.2%. There was
only one postoperative mortality (0.8%). Learning curves generated using CUSUM
analysis based on a 90% success rate showed that adequate learning occurred after
29 cases (Figure 2). Learning curves generated with the moving average method
indicated that the operation time reached a steady state after 45 cases.
During right sided VATS lobectomy, learning curves generated using CUSUM analysis showed that adequate learning occurred after 37 cases. The operation time
reached a steady state after 54 cases within 3 hours.
During left sided VATS lobectomy, learning curves showed that adequate learning
occurred after 20 cases. The operation time reached a steady state after 42 cases
within 3 hours (Figure 3).
CONCLUSION: Pertinent learning curves for VAS lobectomy for lung cancer can
be generated using the moving average method and CUSUM analysis. Adequate
learning for VATS lobectomy occurs around 30 cases and a steady operation time
within 3 hours can be achieved around 50 cases. These results are likely to be useful in designing VATS training programs and clinical trials aimed at investigating
outcomes of VATS lobectomy for lung cancer.
98
AMERICAN ASSOCIATION FOR THORACIC SURGERY
16. Propensity Matched Comparison of Surgery Versus Stereotactic
Body Radiation Therapy in Early Stage Lung Cancer
Chadrick Denlinger, Jeffrey D. Bradley, Issam M. El Naqa, Jennifer B. Zoole,
Bryan F. Meyers,* Alec Patterson,* Daniel Kreisel, Alexander S. Krupnick,†
Traves Crabtree
Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA
Invited Discussant: James D. Luketich
METHODS: We compared all patients treated with surgery (1/2000–12/2006) or
SBRT (2/2004–5/2007) with IA/B NSCLC clinically staged by CT and PET.
Comorbidity scores were recorded prospectively using the Adult Co-Morbidity
Evaluation (ACE-27) scoring system. Charts were reviewed to determine local
tumor recurrence, disease-speciﬁc and overall survival. A multivariable Cox proportional hazard model was utilized to adjust estimated treatment hazard ratios for
confounding effects of patient age, comorbidity index, and clinical stage.
Propensity Cox Regression Analysis of Treatment Modality (Surgery vs. SBRT)
Surgery
Events
SBRT
Events
Hazard-Ratio*
(95% Conﬁdence Interval)
Local tumor control
22
5
0.479
(0.164–1.406)
0.182
Cause-speciﬁc survival
85
12
0.776
(0.401–1.482)
0.448
Overall survival
172
41
0.637
(0.433–0.923)
0.020
Endpoint
P-value
*Adjusted for Age, Comorbidity score, and T-stage.
RESULTS: There were 462 surgery patients and 79 SBRT patients. Overall, surgical patients were older (p < 0.001), had lower co-morbidity scores (p < 0.001), and
better pulmonary function (FEV1 and DLCO) (p < 0.001). Among the surgical and
SBRT groups, 62.6% (291/462) and 75.9% (60/79) were clinical stage IA, respectively.
Final pathology upstaged 35% (62/462) of the surgery patients. In an unmatched
comparison, overall 5-year survival was 55% with surgery, and the 3-year survival
was 32% with SBRT. In clinical stage IA patients, 3-year local tumor control was
89% with SBRT and 96% with surgery (p = 0.051). There was no difference in local
*AATS
Member
E. Shumway Research Scholarship 2008
†Norman
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OBJECTIVE: Stereotactic body radiation therapy (SBRT) has been proposed as
an alternative local treatment option for high-risk patients with early stage lung
cancer. A direct comparison of outcomes between SBRT and surgical resection has
not been reported. This study compares short term outcomes between SBRT and
surgical treatment of non-small cell lung cancer (NSCLC).
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
tumor control in IB disease (p = 0.893). In patients < 75 years old, 3-year disease
speciﬁc survival was 85% with surgery and 60% with SBRT (p = 0.013), with no
survival difference in patients >75 (p = 0.14). In clinical stage IA patients, 3-year
disease speciﬁc survival with surgery was 85% vs. 71% with SBRT (p = 0.04). No
disease speciﬁc survival differences were found in patients with IB disease (p =
0.69). Table 1 summarizes the regression analysis comparing local tumor control
and survival between surgery and SBRT matched by age, comorbidity score, and
tumor stage.
CONCLUSION: In an unmatched comparison surgical patients were generally
healthier and had better local tumor control and disease-speciﬁc survival in clinical stage IA vs. SBRT patients. Propensity regression analysis in clinical stage IA/B
NSCLC revealed equivocal local recurrence and disease-speciﬁc survival between
surgery and SBRT.
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
17. NETT REDUX (Accentuating the Positive)
Pablo G. Sanchez, John C. Kucharczuk, Stacey Su, Larry R. Kaiser,* Joel D. Cooper*
Department of Surgery, Division of Thoracic Surgery, University of Pennsylvania,
Philadelphia, PA, USA
Invited Discussant: Rodney J. Landreneau
METHODS: Under the Freedom of Information Act, we received and analyzed the
NETT data set as of May 2006.
RESULTS: Between January 1998 and July 2002, 571 patients received bilateral
LVRS and 562 patients received medical therapy within the trial. Two hundred and
sixty one of the LVRS patients (46%) and 250 of the medical therapy patients
(44%) met the NETT criteria for heterogeneously distributed upper lobe predominant disease. The 90 day mortality rate for the LVRS group was 5% (13 patients)
and for the medical group 1.6% (4 patients). Subsequent mortality at 6 months was
1.5% for the LVRS group and 1.2% for the medical group and at 24 months 7.6% for
LVRS and 13.6% for the medical group. Mortality data was complete but the percentage of LVRS and medical patients with missing objective data was 8% and
24% at 6 months; 25% and 42% at 24 months; and 45% and 61% at 36 months
respectively. Results in terms of FEV1, Residual Volume (RV), 6 minute walk and
dyspnea score are shown in the following table.
CONCLUSION: For patients with upper lobe predominant emphysema, LVRS
provided both statistically and functionally signiﬁcant improvement in exercise
tolerance, measured lung function, dyspnea score and quality of life. These results
conﬁrm the hypothesis of the NETT trial and also conﬁrm the results of other
non-randomized reports as to the value of LVRS in appropriately selected patients.
*AATS
Member
101
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Afternoon
OBJECTIVE: The National Emphysema Treatment Trial (NETT), a randomized
clinical trial, was designed to determinate whether or not bilateral lung volume
reduction surgery (LVRS) was more effective than medical management (control
group) for selected patients with severe emphysema. A series of arbitrary thresholds
for improvement were applied equally to both groups and demonstrated statically
signiﬁcant beneﬁt for LVRS patients in terms of exercise capacity, increase in FEV1
and improvement in health related quality of life (p ≤ .001 for each comparison).
The established pre-trial hypothesis was that emphysema patients who have “heterogeneously distributed emphysema involving the upper lung zones predominantly” would be most likely to beneﬁt from LVRS. However NETT accrual
criteria “were crafted to include all patients who might beneﬁt from LVRS” and
therefore included many patients who did not ﬁt the hypothesis. The purpose of
this paper is to analyze the outcome of LVRS for the subgroup of patients who met
the original NETT hypothesis and to determine the magnitude and duration of
beneﬁt for this subgroup.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Patients with Heterogeneous Emphysema and UPLP†
LVRS
Medical Therapy
Pre-Op
(n = 261)
6 months
(n = 224)
24 months
(n = 167)
Pre-Op
(n = 250)
6 months
(n = 183)
24 months
(n = 121)
0.7 ± 0.3
27%
1.0 ± 0.4
37%*
0.9 ± 0.3
36%*
0.7 ± 0.2
27%
0.7 ± 0.2
27%
0.8 ± 0.3
27%
4.9 ± 1.2
226%
3.4 ± 1
158%*
3.6 ± 1
160%*
5.0 ± 1.1
227%
5.0 ± 1.2
224%
5.0 ± 1.2
217%
1166 ± 315
1351 ± 306*
1329 ± 356*
1121 ± 302
1171 ± 317
1142 ± 362
56 ± 13
39 ± 21*
42 ± 17*
57 ± 13
56 ± 14
57 ± 14
65 ± 19
41 ± 23*
46 ± 24*
66 ± 19
65 ± 20
67 ± 22
FEV1
Mean ± SD(L)
%pred
RV
Mean ± SD(L)
%pred
6 min walk
(feet)
Mean ± SD
Total score on
St George’s
Respiratory
Questionnaire‡
Mean ± SD
Total USCD
Shortness of
Breath Score¶
Mean ± SD
*p ≤ .001 for paired analyses with Pre-Op scores (two tailed t tests) UPLP: upper lobe predominance,
when both upper lobes have the highest HRCT scores in terms of parenchyma destruction.
†Difference
of 2 points in the HRCT, between the areas of at least 1 lung to deﬁne heterogeneity.
‡The
St. George’s Respiratory Questionnaire is a 51 item questionnaire on the health-related
quality of life with regard to respiratory symptoms. Total score ranges from 0 to 100, with lower
scores indicating better health related quality of life.
¶The
University of California, San Diego (UCSD), Shortness of Breath Questionnaire is a 24 item
questionnaire about dyspnea. The total score ranges from 0 to 120, with lower scores indicating
less shortness of breath.
3:20 p.m.
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
102
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3:55 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 302–306, Hynes Convention Center
Moderators:
James D. Luketich
Bryan F. Meyers
Hyung Joo Park, Jongho Cho, Kwang Taik Kim, Young Ho Choi
Korea University Medical Center, Seoul, South Korea
Invited Discussant: Daniel L. Miller
OBJECTIVE: The minimally invasive repair of pectus excavatum (MIRPE) was
introduced by Nuss in 1998. Since then, serious problems associated with lack of
experience and insufﬁcient surgical techniques have hindered this procedure to
progress. We started this new procedure in 1999, and to overcome these obstacles,
the concepts of the repair as well as surgical techniques have been modiﬁed continuously. As a result, the morphology-tailored approach with a diverse bar-shaping,
bar ﬁxation techniques, and techniques for adults were developed. To reset the
most current status of the MIRPE, our 10-year experience was appraised.
METHODS: A single surgeon (HJP) experience with 1,170 consecutive pectus
excavatum patients between August 1999 and September 2008 was analyzed. All
patients treated with the author’s modiﬁcations were enrolled to assess the efﬁcacy
of repair techniques and surgical outcomes.
RESULTS: The mean age of the patients were 10.3 years (range: 16 months to 51
years). Male to female ratio was 4.1. Adult patients (age = />15 years) were
331(28.3%). 491 patients (42.0%) had bar removal mean of 2.5 years (range: 3
months to 7 years) after the bar placement. To repair the eccentric and unbalanced
asymmetry, the asymmetric bar (n = 471, 40.3%), the seagull bar (n = 219, 18.7%),
and the crest compression technique (n = 119, 10.2%) were employed. Post-repair
symmetry of the asymmetric types was veriﬁed with the asymmetry index (AI)
(Pre: 1.10 vs. Post: 1.02, p < 0.001). Techniques for the adults were the compound bar
(n = 244, 20.9%) and the crane technique (n = 397, 33.9%). Changes of complication rates between 1999 and 2008 were: total complication (15/51, 29.4% vs. 9/185,
4.9%, p < 0.001), pneumothorax (10/51, 19.6% vs. 1/185, 0.5%, p < 0.001), and bar
displacement rate (4/51, 7.8% vs. 0/185, 0%, p = 0.037). Reoperation rate also
decreased (7/51, 13.7% vs. 1/185, 0.5%, p < 0.001). (Figure1). Satisfaction outcomes
were excellent in 1,085/1170 (92.7%), good in 69/1,170 (5.9%), and fair in 16/1,170
(1.4%). After the bar removal, 3 patients (0.6%) had minor recurrence, and two of
them were undergone reoperation.
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18. Minimally Invasive Repair of Pectus Excavatum: 10-Year Appraisal
with 1,170 Patients
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Figure 1. Changes of Complication and Reoperation rates.
Analysis of 1,170 patients from 1999 through 2008 revealed
that the Multipoint Bar Fixation technique (MPF) at Period 1
(P1), and routine Hemo-vac drainage (HVD) at Period 2 (P2)
are attributed to major reductions of complications.
CONCLUSION: The morphology-tailored approach and the techniques devised
for adults seem to be effective in repair of complex pectus excavatum, including
asymmetry and older patients. With the authors’ techniques reﬁned during the
past 10 years, this new minimally invasive procedure can be safely applied to a full
spectrum of pectus excavatum with low morbidity and favorable outcomes.
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
19. Aggressive Surgical Treatment of Multidrug-Resistant Tuberculosis in
the Extensive Drug Resistance Era
Yuji Shiraishi, Naoya Katsuragi, Hidefumi Kita, Yoshiaki Tominaga, Kota Kariatsumari,
Takahito Onda
Chest Surgery, Fukujuji Hospital, Tokyo, Japan
Invited Discussant: Alain Chapelier
METHODS: Between January 2000 and December 2006, 54 patients underwent
59 pulmonary resections for multidrug-resistant tuberculosis. Five patients underwent multiple resections (bilateral 3, ipsilateral 2). There were 41 males and 13
females with a mean age of 46 years (range: 22 to 64 years). None of the patients
was HIV-positive. Isolates were resistant to 2 to 10 anti-tuberculosis drugs (mean:
5.6 drugs). Multidrug regimens employing 3 to 7 drugs (mean: 4.6 drugs) were initiated in all patients. Indications for surgery were a high risk of relapse in 35
patients, persistent positive sputum in 18, and associated empyema in one. Procedures
performed included completion pneumonectomy (3), pneumonectomy (17),
bilobectomy (1), lobectomy (32), and segmentectomy (6). Bronchial stump was
reinforced with muscle ﬂap in 52 resections.
RESULTS: There was no operative mortality. Major postoperative complications
included bronchopleural ﬁstula (3) and empyema (2). All patients attained
sputum-negative status after the surgery. Relapse occurred in 5 patients. Three of
them were converted by the second resection; one responded to resumption of
chemotherapy; and one remained positive. Late death occurred in 2 patients without evidence of relapse. Among 52 survivors, 51 (98%) were considered cured.
CONCLUSION: Pulmonary resection under cover of state-of-the-art chemotherapy
is safe and effective for patients with multidrug-resistant tuberculosis. Since acquisition of resistance to additional drugs will likely be inevitable if relapse occurs, we
believe that liberal use of adjuvant resectional surgery is justiﬁed in patients who
have been converted by chemotherapy but are still at high risk of relapse.
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OBJECTIVE: Since extensively drug-resistant tuberculosis has emerged, adequate
control of drug-resistant tuberculosis is becoming increasingly important. We
report on our experience in using adjuvant resectional surgery liberally as part of
aggressive treatment of patients with multidrug-resistant tuberculosis.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
20. Reconstruction of the Pulmonary Artery for Lung Cancer: Long
Term Results
Federico Venuta,1* Anna Maria Ciccone,2† Marco Anile,1 Mohsen Ibrahim,2
Francesco Pugliese,1 Domenico Massullo,2 Tiziano De Giacomo,1
Giorgio F. Coloni,1 Erino A. Rendina2*
1. University Sapienza of Rome – Policlinico Umberto I, Rome, Italy; 2. University
Sapienza of Rome – Ospedale S. Andrea, Rome, Italy
Invited Discussant: Shaf Keshavjee
OBJECTIVE: Lobectomy with resection and reconstruction of the pulmonary
artery (PA) is technically feasible with low morbidity and mortality; it is a valuable
alternative to pneumonectomy with clear functional advantages and oncological
reliability. In order to assess long term results, we hereby report our 20-year experience
with 105 consecutive patients.
METHODS: Between 1989 and 2008 we performed PA reconstruction in 105
patients (87 men, 18 women; mean age 62 ± 10.5 years) with lung cancer; tangential
resections are not included in this series. The mean preoperative FEV1 was 76.1% ±
14%. Twenty-seven patients (25.7%) received induction therapy. We performed 47
sleeve resections (44.8%), 55 (52.3%) reconstructions by a pericardial patch (3 associated with pneumonectomy under cardiopulmonary by pass) and 3 (2.9%) by a
pericardial conduit. The surgical technique was uniform throughout the study
period. In 65 patients (62%) PA reconstruction was associated with bronchial
sleeve resection; in 6 cases also Superior Vena Cava reconstruction was required.
Sixteen patients were at stage IB, 36 were stage II, 29 IIIA and 24 IIIB. Sixty-one
patients had epidermoid carcinoma and 38 had adenocarcinoma. The mean follow-up
was 42.2 ± 40 months.
RESULTS: The procedure-related major complications were 1 PA thrombosis
requiring completion pneumonectomy and one massive hemoptysis leading to
death (28th postoperative day; operative mortality: 1 patient, 0.95%); 28 patients
experienced other complications; the most frequent (10 patients) was prolonged
air leaks. Overall 5-year survival was 44.3%. Five and ten-year survival for stage I-II
and III was respectively 57.1% and 27.1%; and 31.1% and 6.2%. At multivariate
analysis induction therapy, stage, histology and patch reconstruction were negative
prognostic factors.
CONCLUSION: PA reconstruction is safe and yields excellent long term survival.
Our results in a large series of patients support this technique as a viable and effective option for patients with lung cancer.
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Memorial Traveling Fellowship 2001–2002
†Graham
106
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21. Tracheal Sleeve Pneumonectomy for Lung Cancer After Induction
Chemotherapy
Domenico Galetta, Piergiorgio Solli, Giulia Veronesi, Alessandro Borri,
Roberto Gasparri, Francesco Petrella, Lorenzo Spaggiari
Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy
Invited Discussant: Cameron D. Wright
METHODS: From September 1998 to September 2008, 29 patients (19 men;
median age of 58 years) with NSCLC of the carinal or tracheo-bronchial angle
received induction chemotherapy (cisplatin based polichemotherapy) after mediastinoscopy. Patients with disease judged to be resectable at restaging underwent
surgery.
RESULTS: All patients were available for re-staging. No complete response was
observed. Twelve patients (41.4%) had a progression disease. Partial response rate
was 41.4% (n = 12), and stable disease 17.2% (n = 5). All patient with partial
response and stable disease (n = 17, all with pN2) underwent surgery. Superior
vena cava was involved and resected in 11 cases (64.7%). Complete resection was
achieved in 14 patients (82.3%). Thirty-day mortality was 5.8% (n = 1). Major complications occurred in 4 patients (23.5%): 3 bronchopleural ﬁstulas (17.6%), 2
ARDS (11.7%), and 1 cardiac hernia (5.8%). Nodal downstaging was diagnosed in 9
(53%) patients (all passed from N2 to N1). Median survival was 12 months (range,
1 to 90 months). Overall 5-year survival rate was 34%. Overall, 5-year freedom
from recurrence was 58.2%. Seven patients (41%) had recurrence: 1 local (5.8%)
and 6 systemic (35.2%). Patients receiving postoperative radiotherapy (n = 8) and
those with downstaging had a signiﬁcant 5-year survival rate (50.6% vs 0%;
logrank, p = .007, and 63.5% vs 0%; log-rank, p = .04). Patients with squamous cell
carcinoma (n = 9) had a best prognosis in respect of those with adenocarcinoma (n
= 8) (76.2% vs 0%; logrank, p = .002). At multivariate analysis, postoperative
radiotherapy inﬂuenced long-term survival (p = .04).
CONCLUSION: Induction chemotherapy improves patient selection avoiding
useless operation allowing a safety TSP with acceptable morbidity and mortality.
In or experience, downstaging and squamous cell carcinoma are associated to a
best prognosis. Postoperative radiotherapy improves long-term survival.
5:15 p.m.
ADJOURN
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OBJECTIVE: Non-small cell lung cancer (NSCLC) less than 2 cm from the carina
or invading the tracheo-bronchial angle, formerly considered inoperable, may be
amenable to an “extended” resection (tracheal sleeve pneumonectomy – TSP). In
these patients the role of induction chemotherapy (IC) and their effects on morbidity and mortality are unclear. We evaluated the surgical results and the long-term
outcome of patients who underwent TSP for locally advanced NSCLC after IC.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
NOTES
108
AMERICAN ASSOCIATION FOR THORACIC SURGERY
MONDAY AFTERNOON
MAY 11, 2009
2:00 p.m.
Moderators:
James S. Tweddell
Vaughn A. Starnes
22. Is Cardiac Diagnosis a Predictor of Neurodevelopmental Outcome
After Cardiac Surgery in Infancy?
J.W. Gaynor,1* Marsha Gerdes,1 Alex S. Nord,2 Judy Bernbaum,1 Elaine H. Zackai,1
Gil Wernovsky,1 Robert R. Clancy,1 Patrick J. Heagerty,2 Cynthia B. Solot,1
Jo Ann D’Agostino,1 Nancy B. Burnham,1 Donna McDonald-McGinn,1
Susan C. Nicolson,1 Thomas L. Spray,1* Gail P. Jarvik2
1. The Children’s Hospital of Philadelphia, Philadelphia, PA, USA; 2. University of
Washington, Seattle, WA, USA
Invited Discussant: Ivan M. Rebeyka
OBJECTIVE: To determine if cardiac diagnosis is a predictor of neurodevelopmental (ND) outcomes after infant cardiac surgery.
METHODS: Infants with ventricular septal defect (VSD), tetralogy of Fallot
(TOF), transposition of the great arteries (TGA) and hypoplastic left heart syndrome (HLHS) in a study of apolipoprotein E (APOE) polymorphisms and ND
outcome underwent ND and genetic evaluation at 4 years of age. Domains tested
included: cognition; language; speech; memory; executive function; visual-motor,
ﬁne motor and academic skills.
RESULTS: Testing was completed in 178 patients with normal genetic evaluations:
VSD (26), TOF (44), TGA (41) and HLHS (67). There were no differences in gestational age, ethnicity, APOE genotype, socioeconomic status or maternal education
among groups. Age at ﬁrst operation was signiﬁcantly lower for patients with TGA
and HLHS compared to TOF and VSD. Post-operative length of stay (LOS) was signiﬁcantly longer for HLHS compared to all other groups and for TGA compared to
TOF and VSD. HLHS was signiﬁcantly correlated with use of deep hypothermic
circulatory arrest (DHCA) and multiple operations. Mean scores for each domain
were within normal limits for all groups. (Figure) Compared to HLHS, patients
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109
MONDAY
Afternoon
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
with TGA had signiﬁcantly higher scores for cognition, ﬁne motor skills, executive
function, and math skills. Compared to HLHS patients with TOF had higher
scores for cognition and executive function. There were no signiﬁcant differences
between HLHS and VSD patients for any domain. Signiﬁcant impairments in at
least 1 domain were identiﬁed in 8% (2/25) of patients with VSD, 20% (8/41) with
TOF, 17% (7/41) with TGA and 18% (12/65) with HLHS. After correction for demographic, pre-operative, and operative variables; there were no signiﬁcant differences
among groups for any domain.
CONCLUSION: Mean scores for ND outcomes are in the normal range for preschool children with no recognized genetic syndromes after surgery for VSD, TOF,
TGA, and HLHS. ND outcomes for HLHS are comparable to VSD, TOF and TGA
in most domains. The number of children with impairments in at least 1 domain is
increased compared to the general population for all groups. Differences do exist
among diagnoses for unadjusted outcomes for some domains. However, because of
the correlation of diagnosis with factors such as age at surgery, LOS, DHCA, and
multiple operations; it is not possible to determine if cardiac diagnosis is causal in
its prediction of outcomes or related secondary to these variables.
110
AMERICAN ASSOCIATION FOR THORACIC SURGERY
23. Endothelial Nitric Oxide Synthase Gene Polymorphism and
Pulmonary Hypertension in Children with Congenital Heart
Diseases
Tsvetomir S. Loukanov,1 Christian Sebening,1 Nina Hoss,2 Pencho Tonchev,2
Matthias Karck, Matthias Gorenﬂo
1. Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; 2. Pediatric
Cardiology, University of Heidelberg, Heidelberg, Germany
OBJECTIVE: The operative correction of the congenital heart diseases in children
with left-right shunt is often associated with post operative pulmonary hypertension
(PH). This paper discusses the correlation between the Glu298Asp polymorphism
of the gene eNOS and PH in children with congenital heart diseases.
METHODS: The study group includes 80 children (m = 41; f = 39) on the average
age 3.8 [0.1–36.2] years (median [range]) with congenital heart diseases and 136
children as a control group. Patients presented with signiﬁcant left-to- right shunt
(Qp/Qs of 2.8 [1.4–7.5]). Forty out of 80 patients showed PH with mean pressure
(PAP) of 30 [13- 82] mmHg prior to the intra-cardiac repair. Fifteen out of 31 operated patients were found to have postoperative persistent PH.
RESULTS: The Glu298Asp polymorphism was identiﬁed using polymerase-chain
reaction (PCR) and Restriction Fragment Length Polymorphism (RFLP). In both
groups, the control group and the group of 80 patients, the genotypes distribution
corresponded to the Hardy-Weinberg Equilibrium (HWE) – Chi2 = 0.96 and Chi2
= 0.25. The gene frequency for Glu298Glu, Glu298Asp and Asp298Asp was not
different in control group compared with the group of patients (Chi-square = 0.79;
2 degree of freedom; p = 0.37477). The Armitage trend test showed however a
clearly signiﬁcant result (53.3% vs 25.0%; p = 0.03799) for the correlation of e-NOS
polymorphism and post-operative PH. Signiﬁcant association between the postoperative PH and the allele frequencies of the Glu298Asp was determined with Fischer’s
Exact Test (p = 0.0481, one-sided).
CONCLUSION: The investigation of the polymorphism concerning postoperative PH after intra-cardiac surgery shows that Asp- carrier patients have more
frequently persistent PH. The Glu-Asp polymorphism of the gene e-NOS would be
indicated as genetic marker for predisposition for the development of persistent
pulmonary hypertension.
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Invited Discussant: Paul M. Kirshbom
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
24. Left Ventricular Rehabilitation Is Effective in Maintaining
Two-Ventricle Physiology in the Borderline Left Heart
Sitaram Emani, Emile A. Bacha,* Doff McElhinney, Gerald Marx, Wayne Tworetsky,
Frank A. Pigula,* Pedro J. del Nido*
Childrens Hospital Boston, Boston, MA, USA
Invited Discussant: Frank L. Hanley
OBJECTIVE: In borderline left heart (BLH) disease, there is generally some
degree of endocardial ﬁbroelastosis (EFE), mitral valve dysfunction, and/or aortic
stenosis. The multilevel obstruction and impaired left ventricular (LV) systolic and
diastolic function place such patients at high risk for biventricular repair. We studied
the effects of EFE resection with mitral and/or aortic valvuloplasty on LV diastolic
and systolic function.
METHODS: All patients with BLH structures and EFE who underwent an LV
rehabilitation procedure (LV rehab) consisting of EFE resection and mitral valve
repair, with or without aortic valvuloplasty, were retrospectively analyzed to determine
operative mortality, reintervention rates, and hemodynamic status. Echocardiographic measures obtained pre- and post-operatively included ejection fraction, LV
end diastolic volume (EDV), LV mass/volume ratio, and estimated right ventricular
(RV) pressure. At cardiac catheterization, left atrial (LAp) and RV/LV pressure
ratios were obtained. Postoperative LAp was obtained from the LA line early after
LV rehab. Pre- and post-operative values were compared by paired t-test.
RESULTS: Between 1999 and 2007, 9 patients with EFE and BLH structures
underwent LV rehab at a median age of 5.6 months (range 1–38 months). None
had associated ventricular septal defects. Interventions prior to LV rehab included
coarctation repair (4/9) and aortic valve balloon dilation either in utero (5/9) or
postnatally (7/9). LV rehab consisted of mitral valvuloplasty and EFE resection
(9/9 patients), aortic valvuloplasty (4/9), and subaortic resection (2/9). There was
no operative mortality, and at a median follow up of 13 months (1 to 95 months),
there was one death from non cardiac causes (motor vehicle collision). Two
patients required reoperations, one for mitral valve replacement, and another for
aortic and mitral valve repairs. No patients required single ventricle palliation or
heart transplantation. Table 1 summarizes average pre- and postoperative hemodynamic data. Signiﬁcant increase in EF and LVEDV were observed, whereas LAp,
and RV/LV ratios decreased postoperatively.
Table 1
Preoperative
Postoperative
36 ± 12
58 ± 10
P < 0.01
LVEDV z score
–0.17 ± 1.7
2.72 ± 1.8
P < 0.05
Mass/Vol ratio z score
0.68 ± 1.15
0.10 ± 2.1
LA pressure (mmHg)
27.5 + 6.3
11 + 2.4
P < 0.01
RV/LV systolic pressure ratio
0.78 ± 0.36
0.32 ± 0.11
P < 0.05
Ejection fraction (%)
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CONCLUSION: In patients with BLH disease, LV rehab with surgical EFE resection and mitral and aortic valvuloplasty results in improved LV systolic and diastolic performance and decreased RV pressures. This approach may provide an
alternative to single ventricle management in this difﬁcult patient group.
MONDAY
Afternoon
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
25. A Contemporary Comparison of the Effect of Shunt Type in
Hypoplastic Left Heart Syndrome on the Hemodynamics and
Outcome at Fontan Completion
Jean A. Ballweg,1 Troy E. Dominguez,1 Chitra Ravishankar,1 Peter J. Gruber,1
Gil Wernovsky,1 J.W. Gaynor,1* Susan C. Nicolson,1 Thomas L. Spray,1* Sarah Tabbutt2
1. Children’s Hospital of Philadelphia, Philadelphia, PA, USA; 2. University of
California San Francisco, San Francisco, CA, USA
Invited Discussant: Christian Pizarro
OBJECTIVE: We previously reported no difference in morbidity or mortality in
infants undergoing stage 1 and stage 2 reconstruction with either a modiﬁed BT
shunt (mBTS) or a right ventricular to pulmonary artery conduit (RV-PA). We now
compare the hemodynamics and peri-operative course at the time of the Fontan
completion and report longer-term survival.
METHODS: We retrospectively reviewed the echocardiograms, catheterizations
and hospital records of all patients who previously underwent stage 1 reconstruction
(S1R) between January 2002 and May 2005 and subsequent surgical procedures,
as well as cross-sectional analysis of hospital survivors.
RESULTS: 176 pts with HLHS and variants underwent initial S1R with either
mBTS (n = 114) or RV-PA conduit (n = 62). The median duration of follow-up was
53 months (range 1–76). By Kaplan-Meier analysis, shunt type did not inﬂuence
survival or freedom from transplant at 5 years (RV-PA 61%, 95% CL: 47–72% vs.
mBTS 70%, 95% CL: 60–77%, p = 0.55). Nintey three pts underwent Fontan (62
mBTS and 31 RV-PA) with 98% (91/93) early survival. Pre-Fontan there was a trend
towards higher pulmonary artery pressure (13 ± 8 mmHg vs. 11 ± 3 mmHg, p =
0.05) and common atrial pressure (8 ± 2 mmHg vs. 7 ± 2 mmHg, p = 0.06) in pts
with RV-PA conduits. By echo evaluation, there was a trend towards more qualitative moderate to severe ventricular dysfunction (RV-PA 31% (11/35) vs. mBTS 17%
(11/65), p = 0.08) and moderate to severe atrioventricular valve regurgitation (RV-PA
38% (13/34) vs. mBTS 17% (11/65), p = 0.07) in the RV-PA group. Use of diuretic
therapy, ACE inhibition, reﬂux medications and tube feedings were no different
between groups. There was a trend towards increased digoxin use in the RV-PA
group (RV-PA 71% (25/35) vs. 65% mBTS (45/69), p = 0.06). Overall 5 pts underwent heart transplantation (RV-PA 4 vs. mBTS 1, p = 0.1) prior to Fontan. There
was no difference in age or weight at Fontan, bypass time, ICU or hospital length
of stay, post-operative pleural effusions or need for reoperation between groups.
CONCLUSION: Interim analyses continue to suggest that there is no advantage
of one shunt type over another. Longer term follow-up of a randomized patient
population remains of utmost importance.
3:20 p.m.
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Exhibit Hall
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
4:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
Moderators:
James S. Tweddell
Vaughn A. Starnes
Masahiro Koh,1 Hideki Uemura,2 Akiko Kada,1 Koji Kagisaki,1 Ikuo Hagino,1
Toshikatsu Yagihara1
1. National Cardiovascular Center, Osaka, Japan; 2. Royal Brompton Hospital, London,
United Kingdom
Invited Discussant: Charles B. Huddleston
OBJECTIVE: The Fontan procedure has undergone several modiﬁcations, however, the effect of these modiﬁcations on the prevalence of atrial arrhythmia is not
clearly demonstrated. P-wave characteristics are known as useful markers for the
risk of atrial tachyarrhythmia. We analyzed chronological changes in P-wave characteristics after total cavopulmonary connection including either extracardiac conduit
(EC) or intraatrial bafﬂing (IB), in comparison with classic atriopulmonary connection
Fontan procedure (APC).
METHODS: A retrospective analysis was done on clinical and electrocardiographic data from 40 patients with tricuspid atresia or tricuspid stenosis who
underwent the Fontan procedure and had follow-up of more than 5 years: 9 had
EC, 13 IB, and 18 APC. Mean age at operation was 1.3 ± 0.4 for EC, 3.9 ± 2.5 for IB,
and 5.3 ± 4.8 years for APC. Mean follow-up period was 8.0 ± 1.5 for EC, 13.3 ± 1.3
for IB, and 19.8 ± 4.5 years for APC. We measured P-wave duration, dispersion
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26. Chronological Changes in P-Wave Characteristics After the Fontan
Procedure: Impact of Surgical Modiﬁcation
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
(difference between maximum and minimum duration), and amplitude from consecutive postoperative 12-lead electrocardiograms. Changes in maximum P-wave
duration and P-wave dispersion were analyzed using a general linear mixed model
with years as a ﬁxed effect and patients as a random effect.
RESULTS: Atrial tachyarrhythmia was documented during follow-up in 9 APC,
but not in any EC or IB patients. Freedom from arrhythmia in APC was 88.5 ±
11.5%, 65.0 ± 35.1%, 41.2 ± 51.8% at 10, 15, and 20 years, respectively. Both P-wave
maximum duration and P-wave dispersion slightly decreased over time in EC,
while progressively increasing in IB and APC. EC patients had signiﬁcantly shorter
maximum P-wave duration (p < 0.001) and smaller P-wave dispersion (p = 0.004)
than APC. IB patients had signiﬁcantly shorter maximum P-wave duration than
APC (p = 0.001). P-wave amplitude dropped dramatically immediately after surgery in IB and EC, but remained unchanged in APC.
CONCLUSION: Changes in P-wave characteristics over time were different in EC
compared with those in APC. The IB group showed an intermediate trend. These
ﬁndings suggest that EC is the most promising modiﬁcation of the Fontan procedure in terms of rhythm prognosis.
116
AMERICAN ASSOCIATION FOR THORACIC SURGERY
27. Depth of Ventricular Septal Defect and Impact on Reoperation for
Left Ventricular Outﬂow Obstruction After Repair of Complete
Atrioventricular Septal Defect: Does Double Patch Technique
Decrease the Incidence of Left Ventricular Outﬂow Obstruction?
Anatomical and Clinical Correlation
Invited Discussant: Carl L. Backer
OBJECTIVE: In complete atrioventricular septal defect (CAVSD) left ventricular
outﬂow (LVOT) obstruction is of concern. Modiﬁed single patch technique (MSP)
has been used as an alternative to double patch technique (DP). Clinical analysis of
CAVSD repairs was conducted. Anatomical comparison between MSP and DP in
unoperated specimens was performed and the impact of the depth of ventricular
septal defect on LVOT assessed.
METHODS: From September 2002 to August 2008, 77 infants underwent CAVSD
repair. Thirteen had MSP and 64 DP. Seven of 13 had trisomy 21 vs 46 of 64 (p ns).
Mean age was 4.6 ± 1.1 months (MSP) vs 4.9 ± 1.3 months (DP) (p ns). LVOT peak
gradient (PG) and depth of the ventricular component of the AVSD (dVSD) from
AV valve annulus were measured by echocardiogram and dVSD expressed as a
ratio to the length of ventricular septum from the apex (D). Sixteen anatomy specimens were examined. Each had MSP. The repair was, then, taken down followed by
DP. Each specimen served as its own control. Measurements of LVOT were taken:
1 at the level of the free edge of AV valve anterior leaﬂet, 3 immediately in the subaortic valve area, 2 at the mid-distance. A and B indicate DP and MSP respectively.
Finally, dVSD and D ratio were measured.
RESULTS: Rastelli type A were 47 (10 MSP vs 37 DP), 3 type B (1 MSP vs 2 DP)
and 27 type C (2 MSP vs 25 DP). Patients with smaller dVSD (D ratio) preferentially
had MSP (0.21 ± 0.07 in MSP vs 0.32 ± 0.07 in DP, p < 0.001). Mean follow-up was
36.4 ± 2.3 months. Fifteen patients developed LVOT PG greater than 20 mmHg (4 of
13 had MSP, 30.8% vs 11 of 64 had DP, 20.7% – p < 0.05 ). When freedom from
reoperation for LVOT obstruction (LVOT PG greater than 50 mmHG) was analyzed
3 of 13 (23%) with MSP and 6 of 64 (9.4%) with DP (p < 0.05) required surgical
intervention. Seven had modiﬁed Konno and 2 subaortic resection. In anatomical
comparison, 1A was 20.67 ± 7.05 mm vs 1B 12.33 ± 4.96 mm (p < 0.001). 2A was
12.55 ± 3.36 mm vs 2B 8.72 ± 1.71 mm (p < 0.001). 3A was 8.99 ± 2.29 mm vs 3B 7.65
± 1.81 mm (p < 0.001). There was direct correlation between reduction of LVOT at
level 1 and dVSD (D ratio) when the MSPT was used (p 0.025, Pearson’s r 0.557).
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MONDAY
Afternoon
Anastasios C. Polimenakos,1 Shyam K. Sathanandam,2 Soraia Bharati,2
Vivian Cui,2 David Roberson,2 Mary Jane Barth,2 Chawki El Zein,2
Robert S.D. Higgins,1*Michel Ilbawi2
1. Center for Congenital and Structural Heart Disease/Rush University Medical Center,
Chicago, IL, USA; 2. The Heart Institute for Children at Hope Christ Hospital, Oak
Lawn, IL, USA
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
CONCLUSION: MSP is associated with higher incidence of LVOT gradient and
lower freedom from reoperation for LVOT obstruction. The impact of dVSD (D ratio)
on LVOT, especially at level 1 (as shown in anatomical comparison), can be essential
in selecting surgical strategy. Preoperative assessment, as described here, is warranted.
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28. Fenestration During Fontan Palliation: Now the Exception Instead
of the Rule
Jorge D. Salazar, Kashif Siddiqui, Farhan Zafar, Ryan Coleman, David L. Morales,
Jeffrey Heinle, Charles D. Fraser*
Congenital Heart Surgery, Texas Children’s Hospital, Houston, TX, USA
Invited Discussant: Scott M. Bradley
METHODS: Between January 2002 and April 2008, 209 patients underwent primary Fontan palliation. Outcomes in this retrospective cohort study were assessed
by ICU and hospital length of stay, as surrogates for early morbidity (including
pleural effusions), and early and late mortality. No patients were discharged home
with a chest drain in place.
RESULTS: Prominent morphologies were hypoplastic left heart syndrome (41;
20%), heterotaxy syndrome (38; 18%), tricuspid atresia (37; 18%) and double-inlet
left ventricle (35; 17%). A lateral tunnel connection was created in 67 patients
(32%), and an extra-cardiac connection was created in 142 patients (68%), with
extracardiac connections used increasingly in recent years and exclusively in 2008.
Concomitant AV valve repair was performed in 15 (7%) patients. Mean age and
weight at time of surgery were 5 ± 5 yrs and 18 ± 11 kg respectively.
In 2002, 14 of 16 patients (88%) received a fenestrated Fontan circulation, compared to 0 patients in 2008. Mean ICU and total hospital length of stay for all
patients were 3.5 ± 4.0 and 10.9 ± 9.0 days. Survival to hospital discharge or 30 days
was 99% (206/209). There have been no late deaths in up to 6 year follow-up. A
total of 6 patients (3%) required pacemaker insertion, and no strokes occurred.
When comparing these selected outcome measures between years, no signiﬁcant
differences were noted (p = NS). See Table.
*AATS
Member
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Afternoon
OBJECTIVE: Fenestration during Fontan palliation has been employed to
decrease surgical morbidity and mortality, particularly in high-risk patients. Though
fenestration allows for maintenance of cardiac output and decompression of the
Fontan circuit, its limitations include oxygen desaturation, risk of paradoxical
embolism, and potential need for later intervention. Recognizing these factors, our
practice has evolved away from routine fenestration of the Fontan connection. The
purpose of this study was to review one institution’s experience with Fontan palliation and assess both short and long-term outcomes in the setting of decreased fenestration utilization.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Table 1: Fenestration Utilization and Outcomes
Year
2002
2003
2004
2005
2006
2007
2008
Total
Total Fontan
cases
16
31
27
39
40
40
16
209
Fenestrated *
N (%)
14 (87)
20 (65)
12 (44)
18 (46)
14 (35)
14 (35)
0 (0)
92 (44)
ICU LOS
mean (s.d.)
4.3 (4.8) 2.7 (1.8) 3.6 (6.6)
4.4 (6.5)
3.4 (3.2)
3.5 (3.4)
Hospital
LOS mean (s.d)
11.8 (9.8) 8.4 (3.9) 11.7 (7.8) 12.3 (11.9) 10.6 (6.5) 11.3 (12.4) 9.6 (3.4) 10.9 (9.0)
Early Mortality
N (%)
0 (0)
1 (3.2)
1 (3.7)
1 (2.6)
0 (0)
0 (0)
2.8 (3.0) 3.5 (4.5)
0 (0)
3 (1.4)
*p < .05 for decreased fenestration rate LOS = length of stay (days)
CONCLUSION: Highly selective use of fenestration in patients undergoing Fontan palliation achieves excellent results with no increase in surgical morbidity or
mortality, irrespective of anatomic subtype. The potential hypoxia, systemic embolism, and need for later instrumentation that accompany fenestration can be
avoided in most patients.
5:00 p.m.
ADJOURN
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NOTES
MONDAY
Afternoon
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY MORNING
MAY 12, 2009
7:00 a.m.
CARDIAC SURGERY FORUM SESSION
Ballroom A–C, Hynes Convention Center
(5 minutes presentation, 7 minutes discussion)
Moderators: John A. Kern, Bruce R. Rosengard
F1.
Vascularized Patch Used for Cardiac Reconstruction Stimulates
Myocardial Tissue-Speciﬁc Regeneration
Serghei Cebotari,1 Sava Kostin,2 Igor Tudorache,1 Matthias Karck,1
Christoph Bara,1 Omke Teebken,1 Tanja Meyer,1 Alexandru Calistru,1
Andres Hilﬁker,1 Axel Haverich1*
1. Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover,
Germany; 2. Max-Planck-Institute for Heart and Lung Research, Bad Nauheim,
Germany
Invited Discussant: Bruce R. Rosengard
OBJECTIVE: Several patch materials are currently used to replace diseased cardiac
tissue segments in both adults and children. Most of these conduits represent
either non-viable materials or bio-artiﬁcial grafts with high susceptibility to infection, tissue degeneration and calciﬁcation. Hereby, we present our experience of
using autologous vascularized matrix (AutoVaM) as a viable graft for myocardial
tissue repair.
METHODS: AutoVaM patches based on small bowel segments without mucosa
with adjacent jejunal artery and vein were harvested and used for the replacement
of right atrial defects (2 × 3 cm) in pigs (N = 6). The AutoVaMs were revascularized
by connecting jejunal vessels to the right internal thoracic artery and vein. Autologous pericardium grafts were used as controls (N = 6).
RESULTS: Complications such as bleeding, graft rupture or dislodgement did not
occur. Intraoperative angiography revealed regular blood perfusion of the patches with
venous backﬂow. Histological investigations (up to 6 months) by using Nkx 2.5
and myosin heavy chain revealed newly formed cardiomyocytes inside of AutoVaM
explants mostly localized in a disseminated pattern in close proximity to mesenteric
capillaries. With increasing time these cells showed strong tendency to form islets
and to communicate with each other via Connexin 43 containing gap-junction. In
contrast, the explanted pericardial patches appeared as a ﬁbrotic tissue with no evidence of myocytes inside the patch. Based on these experimental results, 2 patients
*AATS
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with myocardial sarcoma underwent subtotal resection of the right artrium. The
resulting defects were grafted using AutoVaM. Postoperative Echocardiography
revealed systolic and diastolic motion of the graft along with the left atrium during
the cardiac cycle. Control angiography performed 1 month after operation revealed
patent internal thoracic-jejunal artery anastomosis and permeable capillary bed of
the cardiac neo-chamber. No signs of thromboembolic complications or endocarditis
were observed.
CONCLUSION: Vascularized intestinal graft is more superior then autologous
pericardium in terms of higher regenerative potential by repopulation with myocytes. This represents a promising method for cardiac restoration.
TUESDAY
Morning
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F2.
Repair of the Right Ventricular Outﬂow Tract by a Mesenchymal
Stem Cell-Seeded Bioabsorbable Valved Patch: Medium-Term
Follow-Up in a Growing Lamb Model
David Kalfa,1 Alain Bel,2 Annabel Chen-Tournoux,1 Philippe Rochereau,1
Cyrielle Coz,1 Valérie Bellamy,1 Elie Mousseaux,3 Patrick Bruneval,4
Jérôme Larghero,5 Philippe Menasché1*
1. INSERM U633, Paris, France; 2. Hôpital Européen Georges Pompidou,
Department of Cardiovascular Surgery; University Paris Descartes, Paris, France;
3. Hôpital Européen Georges Pompidou, Department of Radiology, University
Paris Descartes, Paris, France; 4. Hôpital Européen Georges Pompidou, Department
of Pathology, University Paris Descartes, Paris, France; 5. Hôpital Saint-Louis,
Laboratory of Cell Therapy; University Paris Diderot, Paris, France
Invited Discussant: Bret Mettler
OBJECTIVE: A major issue in congenital heart surgery is the lack of viable right
ventricular outﬂow tract (RVOT) replacement materials with a growth potential
avoiding reoperations. We assessed the feasibility of restoring a living, autologous
RVOT in a growing lamb model, using autologous mesenchymal stem cells
(MSCs) seeded on a polydioxanone (PDO) bioabsorbable valved patch.
METHODS: Autologous peripheral blood-derived MSCs were phenotypically
characterized, labeled with quantum dots, seeded onto monocusp-ﬁtted PDO bioabsorbable patches and cultured for 6 days. These patches were implanted in a
transannular position into the RVOT of 6 growing lambs (group I), with 1, 4, or
8 months of follow-up. Unseeded PDO valved patches (group II, n = 2) and autologous pericardial patches ﬁtted with a polytetraﬂuoroethylene monocusp (group III,
n = 2) were used as controls. Morphological and functional data on the RVOT
were evaluated by echocardiography (US) and MRI. Explanted specimens were
assessed by gross examination, histology, immunohistochemistry and calcium
content assays.
RESULTS: US and MRI did not show stenosis (peak gradient: 3.2 ± 1.2 mmHg,
mean ± SD) or aneurysm (pulmonary annular dilation: +18% ± 9% (16 mm →
18,9 mm) in group I. Gross examination and biochemical assays of cell-seeded
patches demonstrated a better tissue growing, less retraction, less ﬁbrosis and less
calciﬁcations compared to the standard-of-care group III (0.08% ± 0.03% Ca2+ vs.
3.6% ± 0.65%). Histology in group I revealed complete biodegradation of the PDO
scaffold, a viable, layered, endothelialized tissue (Figure) and an extracellular
matrix (with elastic ﬁbers) comparable to that native ovine tissue. The neo-tissue
that reconstituted the RVOT exhibited environment-dependent differentiation patterns: the proximal portion of the patch harbored cells expressing cardiac myosin
whereas its distal segment harbored α-smooth muscle actin (SMA)-expressing
myoﬁbroblasts. Only group I patches demonstrated cells with an endothelial
phenotype (vW factor) on the luminal surface. Quantum dots were found in vWFor α-SMA-positive cells at 1 month, thereby suggesting that at least some of them
were donor-derived.
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CONCLUSION: This study demonstrates that an autologous MSC-seeded PDO
valved transannular patch restores at mid-term a living and functional RVOT, with
synthesis of a viable layered tissue close to that of the native RVOT. Such an
approach may ultimately lead to applications in the treatment of congenital heart
diseases involving the RVOT.
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Morning
Hematoxylin-Eosin staining of the vascular (pulmonary
artery) segments of a tissue-engineered patch (group I,
panel A) and a control pericardial patch (group III,
panel B) after 4 months. Panel A: Polydioxanone is
completely degraded, and a viable layered tissue similar
to that of the native pulmonary artery (PA) is restored
(with a neo-intima, a neo-media and a neo-adventitia).
Panel B: the pericardial patch is calciﬁed, degenerated
and surrounded by a dense inﬂammatory tissue.
Magniﬁcation: ×5.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F3.
The Novel Synthetic Serine-Protease Inhibitor CU2010 DoseDependently Reduces Postoperative Blood Loss and Improves
Postischemic Recovery After Cardiac Surgery
Gábor Szabó, Tamás Radovits, Gábor Veres, Matthias Karck
Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
Invited Discussant: John A. Elefteriades
OBJECTIVE: Serine-protease inhibitors such as aprotinin reduce perioperative
blood loss and may improve post pump cardiac performance due to their antiinﬂammatory properties. After the “aprotinin era”, we investigated the efﬁcacy of
the novel synthetic serine-protease inhibitor CU2010 with improved coagulatory
and anti-inﬂammatory proﬁle on blood loss and reperfusion injuryin a canine
model.
METHODS: 36 dogs were divided into six groups: control, aprotinin (Hammersmith scheme), and CU2010 (0.5; 0.83; 1.25 and 1.66 mg/kg). All animals underwent
90-minute cardiopulmonary bypass with 60 minutes of hypothermic cardioplegic
arrest. Endpoints were blood loss during the ﬁrst two hours after application of
protamin, as well as recovery of myocardial contractility (slope of the end-systolic
pressure volume relationship, Ees), coronary blood ﬂow and vascular reactivity.
RESULTS: CU2010 dose-dependently reduced blood loss which was comparble to
aprotinin at lower doses and even further improved at higher doses (Figure 1, *p <
0.05). While aprotinin did not inﬂuence myocardial function CU2010 improved the
recovery of Ees (control: 60 ± 6 vs. aprotinin: 73 ± 7 vs. CU2010 at 1.66 mg/kg: 102
± 8%, p < 0.05). The improvement of myocardial contractility in CU2010 treated
animals was also doesedependent. Coronary blood ﬂow (52 ± 4 vs. 88 ± 7 vs. 96 ±
7, p < 0.05) and response to acethylcholine (44 ± 6 vs. 77 ± 7 vs. 81 ± 6%, p < 0.05)
was improved by both aprotinin and at all doses of CU2010.
CONCLUSION: The novel serine-protease inhibitor CU2010 signiﬁcantly reduce
blood loss after cardiac surgery comparable to aprotinin. Furthermore, an additionally improved anti-inﬂammatory proﬁle led to a signiﬁcantly improved postischemic recovery of myocardial and endothelial function.
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
F4.
3D Geometry of the Mitral Valve Determines the Success of
Secondary Chordal Cutting in Alleviating Ischemic Mitral
Regurgitation
Muralidhar Padala,1 Katherine L. Bell,1 Vinod H. Thourani,3 David H. Adams,2*†
Ajit P. Yoganathan1
1. Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA; 2.
Mt. Sinai Hospital, New York, NY, USA; 3. Emory University, Atlanta, GA, USA
Invited Discussant: Gus J. Vlahakes
METHODS: Eight porcine mitral valves (N = 8) of sizes 28 were studied in an invitro pulsatile left heart simulator at 120 mm Hg peak transmitral pressure, 5 L/min
cardiac output at 70 bpm. Each valve was ﬁrst tested with its physiological geometry
to obtain the baseline conditions. MR was induced by dilating the annulus (to size
34) and selectively displacing the PMs ﬁrst by 10 mm apically only, followed by 10
mm apically, laterally & posteriorly. MR was repaired in both cases by implanting
an annuloplasty ring (size 28) ﬁrst and then by transecting the secondary chordae
on the anterior leaﬂet. At each step, MR volume (ml/beat), and tenting area (mm2)
were measured and compared to the baseline.
Figure 1A: depicts the MR volume before and after chordal cutting for the two
PM positions; Figure 1B: depicts the reduction in tenting area with chordal cutting
for the two PM positions
*AATS
†Alton
Member
Ochsner Research Scholarship 1992
127
TUESDAY
Morning
OBJECTIVE: Mitral annuloplasty often fails in patients with dilated left ventricles
due to ischemic heart disease or cardiomyopathies, resulting in recurrence of
mitral regurgitation (MR). Sub-valvular repair using secondary chordal cutting
(CT-cut) is proposed as a solution to prevent recurrent MR by relieving leaﬂet tethering. However, current clinical literature is divided on the efﬁcacy of this technique with some studies supporting its efﬁcacy while others challenging it. In this
study, we sought to investigate if the 3D geometry of the mitral valve (ie, spatial
location of the papillary muscles in the ventricle, and extent of leaﬂet tethering)
impacts the outcomes of the chordal cutting technique.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
RESULTS: At baseline conditions none of the valves had MR, but annular dilatation
and PM displacement induced signiﬁcant MR (Fig 1A). Annuloplasty alone
decreased MR, but did not eliminate it completely at both PM locations (Fig 1A).
CT-cut technique reduced residual MR to trace levels only when the PMs were
apically displaced, but did not have a positive effect when the PMs were apicallylaterally-posteriorly displaced from their physiological positions (Fig 1A). Tenting
area was reduced to the baseline conditions after CT-cutting in the apical-displacement
case but not in the apical-lateral-posterior displacement case (Fig 1B).
CONCLUSION: This study demonstrates that the location of the PMs and the
extent of leaﬂet tethering impact the outcomes of the secondary chordal cutting
subvalvular repair technique, explaining the variability seen in clinical studies.
Therefore, pre-operative assessment of the 3D mitral valve geometry is imperative
for appropriate patient selection for the procedure, optimal surgical planning and
improved outcomes of this procedure.
128
AMERICAN ASSOCIATION FOR THORACIC SURGERY
F5.
Successful Resuscitation After Prolonged Periods of Cardiac
Arrest – A New Field in Cardiac Surgery
Georg Trummer,1 Katharina Foerster,1 Gerald D. Buckberg,2* Christoph Benk,1
Claudia Heilmann,1 Irina Mader,1 Friedrich Feuerhake,1 Oliver Liakopoulos,2
Kerstin Brehm,1 Friedhelm Beyersdorf1*
1. University Hospital Freiburg, Freiburg, Germany; 2. David Geffen School of
Medicine, University of California, Los Angeles, CA, USA
Invited Discussant: Ani Anyanwu
OBJECTIVE: Cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) will
restore normal cerebral and myocardial function only, if it is applied within 3–5
mins after CA. CPR attempted later on results in sharply increasing mortality rates
and poor neurolgic recovery. State-of-the-art CPR, which restores circulation with
inconsistent blood-ﬂow and pressure, may cause an ischemia-reperfusion injury of
the whole body and the brain.
METHODS: Eleven pigs (54.9 ± 4.5 Kg BW) were anesthesized and ventilated.
Animals were exposed to normothermic ischemia for 15 mins after induction of
ventricular ﬁbrillation (VF). Thereafter, either conventional CPR-ALS (control
group, n = 4) or peripheral extracorporal circulation (ECC) was started (experimental group, n = 7). In the ECC-group, conditions of reperfusion were controlled
regarding pressure, ﬂow and the composition of the reperfusate. ECC was stopped
after 60 mins and the animals were allowed to regain consciousness. Neurologic
assessment followed a scoring system (Neurologic Deﬁcit Score (NDS): 0 = normal;
500 = brain death) while MRI and brain histology were performed at the end of
the experiment (day 7).
RESULTS: In the experimental group all (n = 7) animals survived. 6/7 had 100%
neurological recovery within 48 hours until day 7 (NDS = 0 ± 0), 1 fully conscious
pig was not able to walk. This animal showed an incomplete recovery (NDS = 145)
and had to be sacriﬁced after 30 hours. All animals (n = 7) regained full cardiac,
kidney, liver and lung recovery, and only mild changes in ischemia-sensitive brainareas were revealed by MRI and brain histology. All animals in the control group
(n = 4) died within 20 min despite continuous CPR-ALS.
CONCLUSION: This study demonstrates for the ﬁrst time complete functional
neurologic recovery after a period of 15 mins CA. This is in contrast to currently
used conventional treatment methods, where successful resuscitation has been
reported only after 3–5 mins of CA. This new surgical technique to limit ischemiareperfusion injury of the whole body including the brain by controlling the conditions of reperfusion using ECC is a new approach toward survival and functional
recovery of patients undergoing sudden death.
*AATS
Member
129
TUESDAY
Morning
We assessed the hypothesis that whole-body controlled reperfusion using peripheral extracorporal circulation will limit reperfusion injury after 15 mins of normothermic CA with improved survival and neurologic recovery.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F6.
Smooth Muscle Phenotypic Modulation Is an Early Event in
Murine Aortic Aneurysms and Human Aneurysms
Gorav Ailawadi,† Sandra P. Walton, Hong Pei, Chris W. Moehle, Zequan
Yang, Christine Lau,∞ Mark C. Mochel, Irving L. Kron,* Gary K. Owens
TCV Surgery, University of Virginia, Charlottesville, VA, USA
Invited Discussant: John S. Ikonomidis
OBJECTIVE: Vascular smooth muscle cells (SMCs) have the ability to undergo
profound changes in phenotype, deﬁned by coordinated repression of SMC marker
genes and production of matrix metalloproteinases (MMPs), in models of atherosclerosis. In aneurysm development, studies have primarily focused on the role of
leukocytes, while little is known of the role of SMCs. We hypothesized that SMCs
undergo phenotypic modulation in experimental and human aortic aneurysms
(AAs) and that his event is an early event in disease progression.
METHODS: Abdominal aortas from wild type C57B6 mice (n = 56) were perfused with elastase or saline (control) and harvested at 1, 3, 7 or 14 days. Aortic
diameter was measured using video micrometry pre-perfusion and at harvest.
Aortas were analyzed by real time-PCR and immunohistochemistry for a number
of smooth muscle marker genes, including SM22α, SMα-actin, SM MHC, as well as
MMP-2,-9. In complimentary experiments, human ascending aneurysmal aortas
(n = 10) undergoing open repair and control aorta from patients undergoing coronary artery bypass grafting (n = 10) were harvested and analyzed by immunohistochemistry.
RESULTS: Aortic diameter in elastase perfused mice was similar to saline perfused mice at 7 days (60.0 ± 9.13% versus 53.3 ± 18.3%, P = .49). At 14 days, aortic
diameter was signiﬁcantly larger following elastase perfusion (100 ± 9.6% versus
59.5 ± 18.9%, P = .0002). By 7 days, elastase perfused mice had signiﬁcant downregulation of SM22α (0.72 ± 2.62 versus 12.19 ± 2.35, P < .0001) and SMα-actin (0.27
± 2.84 versus 10.97 ± 1.97, P < .0001) expression compared to saline perfused animals well before the aneurysm phenotype was present. At 14 days, SM22α (1.43 ±
0.88 versus 3.26 ± 1.54, P = .05) and SMα-actin (3.73 ± 0.20 vs. 6.51 ± 1.74, P = .02)
expression remained less in aneurysmal aortas. Immunohistochemistry conﬁrmed
markedly less SM22α and SMα-actin in experimental aneurysms in concert with
increased MMP2,-9 staining at 7 and 14 days. Similarly, human aneurysms had less
SM22α and SMα-actin and increased MMP-9 staining by immunohistochemistry
compared to control aorta.
CONCLUSION: Experimental murine and human aneurysms demonstrate
smooth muscle cell phenotypic modulation characterized by downregulation of
smooth muscle marker genes and upregulation of MMPs. These events in experimental models occur early prior to aneurysm formation. Targeting SMCs to a reparative phenotype may provide a novel therapy in the treatment of aortic aneurysms.
*AATS
Member
Traveling Fellowship 2006
∞John W. Kirklin Research Scholarship 2006
†Resident
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
F7.
Biodegradable Synthetic Small-Calibre Vascular Grafts:
Long-Term Results After Replacement of the Rat Aorta
Beat H. Walpoth,1 Damiano Mugnai,1 Jean-Christophe Tille,2
Francesco Innocente,1 Benjamin Nottelet,3 Corinne Berthonneche,4
Xavier Montet,5 Sarra de Valence,3 Michael Moeller,3 Robert Gurny,3
Afksendiyos Kalangos1
1. Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva,
Switzerland; 2. Department of Pathology, University Hospital of Geneva,
Geneva, Switzerland; 3. Department of Pharmaceutics & Biopharmaceutics
EPGL, University of Geneva, Geneva, Switzerland; 4. Department of Medicine,
University Hospital of Lausanne, Lausanne, Switzerland; 5. Department of
Radiology, University Hospital of Geneva, Geneva, Switzerland
Invited Discussant: Gorav Ailawadi
METHODS: Ten anaesthetised Sprague Dawley rats (male, 275g), received an
infrarenal aortic graft (5 biodegradable; 5 ePTFE) replacement (end-to-end; 2 mm
ID; 20 mm long) and 5 rats served as shame controls. Biodegradable grafts (polycaprolactone = PCL) were produced by random nano-ﬁbre (porosity 80%) electrospinning. After 1-year survival in vivo high resolution ultra-sonography (Visualsonics; see ﬁgure) and angiography were performed to assess patency, stenosis,
aneurysm formation, intimal hyperplasia and compliance. After explantation
micro CT calciﬁcation quantiﬁcation, histology, immuno-histology, scanning electron microscopy (SEM) and morphometry were carried out.
RESULTS: All grafts (PCL and ePTFE) showed 100% patency at 12 months. No
aneurysmal dilation or stenoses were found in the PCL group by angiography.
Ultra-sonography showed minimal peri-anastomotic intimal hyperplasia in PCL
131
TUESDAY
Morning
OBJECTIVE: Shelf-ready synthetic small calibre grafts are needed for coronary
artery bypass grafting. Biodegradable scaffolds resistant to degradation-induced
aneurysm formation in the systemic arterial circulation have been developed for in
vivo vascular tissue engineering. Our aim is to assess the long-term results of synthetic, biodegradable small-calibre vascular grafts compared to ePTFE for aortic
replacement in the rat model.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
compared to ePTFE grafts. In vivo compliance revealed a marked reduction
between the native abdominal aorta (7–9%) and PCL (3–5%) or ePTFE grafts
(1–2%). Micro-pet calciﬁcations were present in both grafts (2–6% of total graft
volume) and absent in the native aorta. Histologically low cellular ingrowth was
found in ePTFE grafts, whereas PCL grafts showed good homogenous cellularity
producing collagen and extra-cellular matrix replacing the PCL scaffold. SEM
revealed a conﬂuent neoendothelialisation of the PCL grafts, unlike ePTFE.
CONCLUSION: Synthetic biodegradable small calibre nano-ﬁbre polycaprolactone grafts show excellent results after 1-year of aortic replacement and compare
favourably with the clinically used ePTFE grafts. Thus, such novel in situ tissue
engineered grafts could become a future option for clinical applications such as
coronary artery bypass grafting.
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
F8.
Optimal Flow Rate for Antegrade Cerebral Perfusion
Takashi Sasaki, Shoichi Tsuda, Robert K. Riemer, Vadiyala Mohan Reddy,*
Frank L. Hanley*
Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
Invited Discussant: Randall B. Griepp
OBJECTIVE: Antegrade cerebral perfusion (ACP) is widely used yet perceived
ideal ﬂow rates vary signiﬁcantly among centers and have never been standardized.
We compared cerebral blood ﬂow (CBF) at different ACP rates to establish their
relation.
RESULTS: CBF at an ACP rate of 50 matched the CBF achieved during baseline,
(73 ± 24 vs 72 ± 24 ml/100gm/min, p = 0.93, n = 9, 8; ANOVA), but ACP at 30 only
provides about 60% of baseline CBF (44 ± 11 ml/100gm/min, p = 0.003 vs baseline,
n = 9). NIRS data revealed that ACP at 50 produces a higher rSO2 than baseline:
90 ± 4 vs 79 ± 13%, n = 9, 8, p = 0.035. However, jugular vein saturation was not different from baseline at ACP rates of 30 or 50. The distribution of CBF and rSO2
were equal in each brain hemisphere at all ACP rates.
CONCLUSION: This study demonstrates that delivery of oxygen to the brain
increases with ACP rate. We conclude that an optimal ACP rate is about 50 ml/kg/
min because it matches baseline CBF rates while an ACP rate of 30 provides only
60% of baseline CBF.
*AATS
Member
133
TUESDAY
Morning
METHODS: Nine 7-day old piglets (3.5–4.4 kg) were anesthetized and total body
cardiopulmonary bypass was established via innominate artery and right atrial
cannulation. The piglets were cooled to a nasopharyngeal temperature of 18°C
using pH stat at an initial perfusion rate of 200 ml/kg/min and hematocrit maintained between 25% and 30%. At the cooling target, total body perfusion rate was
reduced to 100 ml/kg/min (Baseline) for 15 minutes, the aorta was cross-clamped
and cardioplegia (30 ml/kg) was administered via the aortic root. CBF was then
measured under these conditions using 15-micron microspheres injected into the
pump outﬂow line, and this value was used as the standard baseline CBF. The
proximal innominate, left carotid, and left subclavian arteries were then clamped
and ACP was initiated at each of three randomly selected perfusion rates (10, 30, or
50 ml/kg/min), microspheres of different colors were injected, and perfusion was
continued for 15 minutes before switching perfusion rate. The piglets were then
euthanized, the brains were dissected and microsphere-derived CBF was expressed
as ml ﬂow/100gm tissue/min. CBF at each of the ACP rates was then compared to
the baseline cerebral ﬂow at total body perfusion (100 ml/kg/min). Bihemispheric
regional cerebral oxygen saturation (rSO2, NIRS) was monitored.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F9.
Reduced Oxidative Stress Response in the Ascending Aorta of
Bicuspid Aortic Valve Patients: Impact on the Extracellular
Matrix
Julie A. Phillippi, Michael A. Eskay, Bruce R. Pitt, Thomas G. Gleason
Division of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Invited Discussant: Frank W. Sellke
OBJECTIVE: Our goal is to reveal the mechanisms that govern extracellular
matrix (ECM) degradation and smooth muscle cell (SMC) apoptosis in the
ascending aorta of bicuspid aortic valve (BAV) patients. We recently showed that
expression and induction of metallothionein (MT) is reduced in BAV-associated
aneurysms relative to controls. MT is stimulated by oxidative stresses (OS) and
heavy metal exposure and is known to regulate cell survival via vascular endothelial growth factor (Vegf) expression in other cell systems. We hypothesize that
reduced OS responses occur among BAV-aortic SMCs that cause dysregulation of
the ECM leading to aneurysm formation. We sought to characterize the role of MT
in the OS response of BAV-aortic SMCs and examine its impact on ECM regulation.
METHODS: Ascending aorta was harvested during aortic surgery in BAV and tricuspid aortic valve (TAV) patients and from transplant donors. Aortic samples were
exclusively from males controlled for age and comorbidity. Tissue and aortic-SMCs
were analyzed for ECM and cell survival gene expression at baseline and under OS
in vitro. SMCs were cultured in the presence of CdCl2 to induce MT expression.
MT-null mice were used to help delineate the role of MT in ECM regulation in the
aorta. Data were compared by ANOVA with Tukey-Kramer post hoc tests. Age was
eliminated as a covariance by an analysis of regression.
RESULTS: Under OS conditions, BAV-aortic SMCs exhibited signiﬁcantly less
inducible Vegf than controls or TAV as did MT-null mice relative to wild-type, and
aortic SMCs from MT-null mice had signiﬁcantly lower cell viability. Treatment of
BAV-aortic SMCs with CdCl2 prior to culture under OS conditions improved cell
viability to a signiﬁcantly less extent than for controls or TAV. BAV-aorta and
murine MT-null aorta exhibited signiﬁcantly greater col I gene expression.
CONCLUSION: Limited SMC protection from OS by cadmium further supports
a role for MT in regulating OS responses in BAV-aorta. These results are consistent
with our previous report that cadmium-induced MT was lower in BAV than in
control SMCs. Increased col I is seen in BAV-aorta and MT-null aorta when MT
and Vegf expression and induction is reduced, strongly suggesting that OS response
via MT plays an important role in ECM homeostasis in the ascending aorta. These
data continue to support our hypothesis that BAV SMCs lack a sufﬁcient OS
response to maintain aortic ECM homeostasis which imparts a predisposition to
ascending aortic aneurysm formation.
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NOTES
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY MORNING
MAY 12, 2009
7:00 a.m.
GENERAL THORACIC FORUM SESSION
Room 302–306, Hynes Convention Center
(5 minutes presentation, 7 minutes discussion)
Moderators: Yolonda L. Colson, David S. Schrump
F10.
MAGE-A3 Expression Is an Independent Determinant of
Worse Survival in Stage IA Non-Small Cell Lung Cancer
Jeffrey L. Port,1 Sacha Gnjatic,2 Otavia Caballero,2 Ramon Chua,2
Achim A. Jungbluth,2 Gerd Ritter,2 Cathy A. Ferrara,1 Paul C. Lee,1
Lloyd J. Old,2 Nasser K. Altorki1*
1. Weill Cornell Medical College/NY Presbyterian Hospital, New York, NY,
USA; 2. Ludwig Institute for Cancer Research, New York, NY, USA
Invited Discussant: Dao M. Nguyen
OBJECTIVE: MAGE-A3 is a tumor speciﬁc antigen that belongs to the cancer –
testis (CT) gene family. MAGE-A3 is expressed in 40–50% of non-small cell lung
cancer (NSCLC) and its expression is negatively correlated with survival. Members
of the CT antigen family are considered ideal targets for tumor immunotherapy
and a randomized trial is currently underway to evaluate the efﬁcacy of MAGE-A3
vaccination in the adjuvant setting for stage IB-IIIA NSCLC (MAGRIT). However,
no information is available about the expression of MAGE-A3 in early stage disease. In this study we examined the expression of MAGE-A3 in patients with
resected IA disease using tumor tissues from an institutional tissue bank linked to
a prospectively established clinical database.
METHODS: Fresh tumor tissue was obtained at surgery from stage IA patients
who underwent curative resection (1996–2008) without preoperative therapy. Total
RNA was extracted for semiquanitiative RT-PCR. Univariate analysis was performed
using the Wilcoxon rank sum and the chi-square test, as appropriate. The effect of
expression on overall survival (OS) was evaluated using the Kaplan-Meier method
and differences between groups compared by the log-rank test. The independent
impact of MAGE-A3 expression on survival was calculated using a multivariable
Cox regression model. Informed consent for tissue banking was obtained and the
current study was approved by the IRB and patient consent was waived.
RESULTS: 195 stage IA patients (117 female) with a median age of 69, a median
tumor size of 2.0 cm, and a median follow-up of 3.8 years were analyzed. Positive
MAGE-A3 expression was seen in 56% of patients and was signiﬁcantly correlated
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with male gender (p = 0.013), a history of smoking (p = 0.05), and squamous histology (p < 0.0001). 5-year OS for the entire group was 75.8%. 5-yr OS for MAGE + vs
MAGE − patients was 69.1% vs 83.0%, respectively (p = 0.008) (FIGURE). A multivariate Cox regression analysis for OS determined male gender (hazard ratio [HR]
2.13, p = 0.01) and MAGE expression (HR 2.32, p = 0.01) to be signiﬁcant negative
predictors of survival.
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P = 0.0080 by log-rank test.
CONCLUSION: This study identiﬁed MAGE expression as a signiﬁcant negative
prognostic factor for survival among stage IA NSCLC patients. In addition there
appears to be a link between MAGE expression and male gender, squamous histology,
and a previous history of smoking. These results provide a rationale for immunotherapy in stage IA NSCLC patients where standard cytotoxic therapy is not justiﬁed.
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F11.
MicroRNA Expression Proﬁles Predict Recurrence After Surgery
for Stage 1 Non-Small Cell Lung Cancer
Sai Yendamuri,1 Steen Knudsen,2 Todd L. Demmy,1* Santosh Patnaik1
1. Roswell Park Cancer Institute, Buffalo, NY, USA; 2. Medical Prognosis
Institute, Horsholm, Denmark
Invited Discussant: Virginia R. Litle
OBJECTIVE: Surgery for stage 1 NSCLC has a signiﬁcant recurrence rate. A tool
for predicting recurrence in these patients may direct adjuvant therapy to high risk
patients to maximize its risk beneﬁt ratio. We studied the ability of an updated
microRNA (miRNA) microarray to predict recurrence in patients with pathologic
stage 1 NSCLC.
METHODS: Formalin ﬁxed parafﬁn embedded (FFPE) tissue specimens from 79
patients with pathologic stage 1 NSCLC were used for analysis. Tissue was deparafﬁnized and miRNA extracted. After quality control assessments of the extracted
RNA, hybridization was performed to a locked nucleic acid based array platform
containing probes for all miRs in miRBase version 11. Data from the arrays were
background corrected and Loess normalized. In a leave-one-out cross validation,
miRNAs differentially expressed between patients with recurrence and patients
without, were selected with a t-test, using a multiple testing correction leaving a
false discovery rate of 1%. The resulting miRNAs were subjected to Principal Component Analysis. The ﬁve most important components trained a multivariate classiﬁer
using the classiﬁcation algorithms: K nearest neighbor, nearest centroid, neural
network and support vector machine. The left out sample was predicted by majority
vote among the classiﬁcation algorithms into “Good Prognosis” or “Poor Prognosis”.
A Kaplan-Meier plot was prepared of the time to recurrence for the “Good Prognosis” and “Poor Prognosis” groups. A log-rank test for statistical signiﬁcance of the
difference between the two groups was performed. As a leave one out cross validation was performed, separate internal training and test sets were not created.
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RESULTS: Of 79 samples, 78 samples passed the quality control conditions for
hybridization. Data analysis performed as detailed above led to a model containing
over 100 miRNA included in the ﬁve principal components. This model predicted
outcome in a statistically signiﬁcant fashion (Figure 1). Median time to recurrence
in “Good Prognosis” tumors had not been reached, whereas the median time to
recurrence in “Poor Prognosis” tumors was 22 months (p < 0.01).
CONCLUSION: This miRNA microarray proﬁle predicts recurrence after surgery
for stage 1 NSCLC and deserves validation by datasets from other institutions.
Furthermore, ease in the handling of input material (avoiding frozen tissue) and
stability of miRNA to degradation makes this platform more practical than
mRNA-based technologies in all clinical environments.
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89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F12.
Seventy-Two Hours Total Respiratory Support with a
Single Double-Lumen Cannula Placed in a Venousvenous
Pump-Driven Extracorporeal Lung Membrane
David Sanchez-Lorente, Tetsuhiko Go, Philipp Jungebluth, Irene Rovira,
Paolo Macchiarini*
General Thoracic Surgical Experimental Laboratory, Universitat de Barcelona,
Barcelona, Spain
Invited Discussant: Jay Zwischenberger
OBJECTIVE: To investigate the safety and feasibility of obtaining total respiratory
support during 72 hours using a pump-driven (Levitronix Centrimag® centrifugal
pump) venousvenous extracorporeal lung membrane (Novalung GmbH, Hechingen, Germany) attached via a single double-lumen cannula (Novalung GmbH)
into the femoral or jugular vein in adult pigs.
METHODS: Twelve pigs were initially ventilated for 2 hours (respiratory rate, 20–25
breaths/min; tidal volume, 10–12 mL/Kg; fraction of inspired oxygen, 1.0; positive
end-expiratory pressure, 5 cm H2O). Thereafter, the extracorporeal lung membrane was attached to the right femoral (n = 6, 26 F cannula) or jugular vein (n = 6,
22F cannula) using a single double-lumen cannula having one inﬂow venous and
one outﬂow arterial channel. Ventilatory settings were then reduced to achieve
near apneic ventilation (target settings: respiratory rate, 4 breath/min; tidal volume, 1–2 mL/Kg; fraction of inspired oxygen, 1.0; positive end-expiratory pressure,
10 cm H2O) and the pump ﬂow increased hourly until maximal efﬁcacy. Blood
gases and hemodynamics were measured every hour and bronchial lavages and
plasmatic cytokines level performed 4 hourly.
RESULTS: Mean blood ﬂow through the device was 2.16 ± 0.43 L/min, and permitted an O2 transfer and CO2 removal 203.6 ± 54.6 and 590.3 ± 23.3 mL/min,
respectively. Despite static ventilation, all pigs showed optimal respiratory support
during the study period, being the mean PaO2, PaCO2 and SvO2 226.2 ± 56.4; 59.7
± 8.8 and 85.6 ± 5.3 mmHg, respectively. There was no vasoactive drugs requirement to maintain hemodynamic stability (Table 1). Animals did not develop any
signiﬁcant changes regarding cytokine release or signiﬁcant cellular trauma, and
coagulatory and inﬂammatory response over the 72 hours. The route of cannulation (femoral vs. jugular) and the size of the cannulae did not changed hemodynamic or respiratory parameters signiﬁcantly.
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Table 1. Pigs Mechanical Ventilatory and Hemodynamic Settings During Initial
Ventilation (2 Hour) and Apneic Ventilation Under Extracorporeal Support
(72 Hours)
Initial Ventilation
without Extracorporeal
Support
Apneic Ventilation
with Extracorporeal
Support
537 ± 68
115 ± 13
p < 0.05
20 ± 0
4±0
p < 0.05
MV (L/min)
10.7± 1.4
0.4 ± 0.05
p < 0.05
CI (L/min/m2)
4.8 ± 0.6
5.1 ± 0.9
NS
MAP (mmHg)
113 ± 9.9
95.4 ± 12.6
NS
MPAP (mmHg)
24 ± 5.7
34.4 ± 3.1
NS
SVR (dyne/cm5)
872 ± 252.4
1073± 273.2
NS
PVR (dyne/cm5)
120.8 ± 14.3
188 ± 40.6
NS
PCWP (mmHg)
15.3 ± 1.75
16.9 ± 2.4
NS
CVP (mmHg)
11.5 ± 2.3
12.4 ± 2.5
NS
Variables
VT (ml)
RR(breaths/min)
p-Value
CONCLUSION: The venousvenous, pump-driven extracorporeal lung membranesingle and double-lumen cannula system is an effective provider of total respiratory
support over 72 hours and does not induce hemodynamic, coagulatory or inﬂammatory inbalances.
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VT, volume tidal; RR, respiratory rate; MV, minute volume; CI, cardiac index; NS, not signiﬁcant;
MAP, mean arterial pressure; MPAP, mean pulmonary arterial pressure; SVR, systemic vascular
resistance; PVR, pulmonary vascular resistance; PCWP, pulmonary capillary wedge pressure;
CVP, central venous pressure.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F13.
Replacement of the Trachea with Fully Bioengineered Graft in Pigs
Tetsuhiko Go,1 Philipp Jungebluth,1 Adelaide Asnaghi,2 Sara Mantero,2 MariaTeresa Conconi,3 Antony Hollander,4 Martin Birchall,4 Paolo Macchiarini1*
1. General Thoracic Surgical Experimental Laboratory, Universitat de Barcelona,
Barcelona, Spain; 2. Department of Bioengineering, Politecnico di Milano, Milano,
Italy; 3. Pharmaceutical Science, University of Padua, Padua, Italy; 4. Department
of Cellular and Molecular Medicine, School of Medical Sciences, Bristol, United
Kingdom
Invited Discussant: Yolonda L. Colson
OBJECTIVE: Evaluate the outcome of a fully bioengineered tracheal graft in pigs.
METHODS: Non-immunogenic tracheal matrices were obtained via detergentenzymatic method (DEM) from pig donors. MHC-unmatched animals (weighing
65 ± 4 Kg) were divided into four groups (each, n = 5) and 6 cm of their tracheas
replaced with a DEM matrix alone (group I) or seeded with recipients autologous
chondrocytes (group II) or epithelial cells (group III), or both (groupIV). Epithelial
cells (via bronchial-epithelial biopsies) and stem cells (bone marrow aspiration)
were harvested from recipients and in-vitro cultured. Stem cells were differentiated
into chondrocytes using speciﬁc growth factors. Both cell types were seeded simultaneously using a novel bioreactor allowing dynamic and physiological cell culture.
Pigs were observed during study period of 60 days via bronchoscopy, blood samples and biopsies. Grafts were evaluated mechanically and immunohistologically
pre-implantation and post-mortem.
RESULTS: Matrices were completely covered with both chondrocytes and epithelial cells within 72 hours using the new device. Extent of seeding affected animals
life time and outcome signiﬁcantly (p < 0.05) (group I: 11 ± 2days; II: 29 ± 4 days;
III: 34 ± 4 days; IV: 60 ± 1 days). Animals died due to severe respiratory disorders
(group I), grafts bacteria contamination (group II) or stenosis and anastomotic
failure (group III). Group IV animals showed bronchoscopically healthy and bland
covered graft surface without any collapse of the graft. No rejection signs occurred
in this immunosuppression-free model. Grafts strain abilities were equal to native
tracheas (tissue deformation: 211 ± 13 vs 206 ± 12%).
CONCLUSION: The obtained bioengineered tracheal graft demonstrated its
high potential as airway replacement.
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F14.
DYRK2, a Dual-Speciﬁcity Tyrosine-(Y)-PhosphorylationRegulated Kinase Gene, Expression can be a Predictive Marker
for Chemotherapy in Non-small Cell Lung Cancer
Shin-ichi Yamashita, Katsunobu Kawahara
Surgery II, Oita University Faculty of Medicine, Yufu, Japan
Invited Discussant: David Jablons
OBJECTIVE: Several predictive markers of treatment and survival beneﬁt were
reported such as ERCC1 in NSCLC (non-small cell lung cancer). We report here
the correlation between clinicopathological factors in non-small cell lung cancer
(NSCLC) and expression of DYRK2, a dual-speciﬁcity tyrosine-(Y)-phosphorylation
regulated kinase gene, furthermore, the possibility to predict beneﬁt from chemotherapy for patients in recurrent NSCLC.
RESULTS: We could not ﬁnd any correlation between age, sex, pathological stage,
tumor size, histological type and DYRK2 expression. However, this gene expression
was signiﬁcantly related to nodal metastases (P < 0.05). Overall response rate is
22.2% (4 out of 18) in DYRK2 positive group compared with 4.5% (1 out of 22) in
negative group. On the other hand, 17 PD (progressive disease) is consisted of 3
DYRK2 positive patients and 14 DYRK2 negative patients.(p = 0.0086) The median
time to the progression of disease was 120 days in the DYRK2 negative group, as
compared with 310 days in the DYRK2 positive group(HR = 1.984, 95% CI =
[1.039–3.788], p = 0.034).
CONCLUSION: Our study showed that DYRK2 has the critical role of nodal
metastases in NSCLC. Furher, patients with recurrent NSCLC and DYRK2positive tumors derived a substantial beneﬁt from chemotherapy, as compared
with patients with DYRK2-negative tumors.
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METHODS: DYRK2 expression in 157 patients with NSCLC were evaluated by
immunohistochemistry (IHC) and quantitative RT-PCR. The correlation between
the expression levels of this gene and clinicopathological factors were investigated.
In the other series, forty patients with recurrent disease after surgery received several
combinations of platinum-based chemotherapy. Chemotherapy effectiveness was
evaluated according to RECIST criterion and the relationship between clinical
effectiveness and the expression levels of this gene by IHC were evaluated.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
F15.
Generation of Epigenetically-Modiﬁed Autologous Tumor Cell
Lines for Vaccines Targeting Cancer-Testis Antigens in
Thoracic Malignancies
David S. Schrump,* Julie A. Hong, Mary Zhang, Yuwei Zhang, Tricia F. Kunst,
Ana Hancox, Leandro Mercedes, King Kwong†
Thoracic Oncology Section, NCI, Bethesda, MD, USA
Invited Discussant: Stephen G. Swisher
OBJECTIVE: Cancer-testis antigens (CTA) are highly diverse immunogenic proteins
encoded by germ cell restricted genes, which are aberrantly activated by epigenetic
mechanisms in human cancers. One potential strategy to target CTAs in thoracic
malignancies involves utilization of epigenetically-modiﬁed autologous tumor
lines to immunize patients against multiple CTAs that can be up-regulated in primary cancers by systemic gene induction regimens. The present study was undertaken to assess the feasibility of this approach as a prelude to a phase I clinical trial.
METHODS: Primary tumor tissues were harvested from 21 patients with thoracic
malignancies including 10 NSCLC, 2 SCLC, 4 EsC, 3 MPM, and 2 sarcomas, and
processed for cell culture. Quantitative RT-PCR, western blot, and immunohistochemistry (IHC) techniques were used to assess BORIS variant, MAGE-A1,-A3,
NY-ESO-1, and CT-45 expression in cell lines cultured in normal media with or
without the DNA demethylating agent, Decitabine (DAC), the histone deacetylase
inhibitor, Depsipeptide (DP), or sequential DAC/DP. Cytokine release assays were
used to assess recognition of tumor lines by MAGE-A3 and NY-ESO-1-speciﬁc
cytolytic T lymphocytes (CTL) before and after drug exposure.
RESULTS: Primary tumor lines were successfully generated and continuously
propagated from 12 of 21 individuals (57%), including 3 NSCLC, 2 SCLC, 3 EsC,
2 MPM, and 2 sarcoma patients. Quantitative RT-PCR and IHC analysis revealed
heterogeneous, time- and dose-dependent gene induction proﬁles in cell lines following treatment with DAC, DP, or sequential DAC/DP under exposure conditions
greatly exceeding those achievable in clinical settings. Induction levels of cancertestis genes frequently approximated or exceeded those observed in control testes,
as well as thresholds for CTL recognition in cultured cancer lines.
CONCLUSION: Generation of autologous epigenetically-modiﬁed cancer lines
from thoracic oncology patients is feasible. These data support phase I evaluation
of epigenetically-modiﬁed autologous tumor cell vaccination as a means to broadly
immunize thoracic oncology patients against a variety of potentially relevant CTAs
that can be targeted using gene induction protocols.
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F16.
Atrial Natriuretic Peptide Extends Lung Preservation
Attenuating Ischemia-Reperfusion Lung Injury Through
Phospholipase A2 Inhibition
Yury A. Bellido Reyes, Prudencio Díaz-Agero, Joaquin García S. Girón
Thoracic Surgery, La Paz Hospital, Madrid, Spain
Invited Discussant: Dirk E. Van Raemdonck
OBJECTIVE: Phospholipase A2 (PLA2), a key enzyme in the regulation of the
arachidonic acid metabolism, is potentially involved in the physiopathology of
ischemia-reperfusion (IR) injury. In the present study, we hypothesized that
supplementation of low potassium dextram (LPD) solution with atrial natriuretic
peptide (ANP) extends lung preservation attenuating IR lung injury through inhibition of the PLA2 cascade.
Edema Formation, Neutrophil Extravasation, and Phospholipase A2 Metabolism
After Ischemia-Reperfusion
Wet-to-Dry Proteins
Ratio
BALF
mg/mL
MPO
Activity
cPLA2
Activity
sPLA2 Thromboxan Leukotriene
Activity
A2
B4
OD/mg/ nmol/mg/ nmol/mg/
min
min
min
pg/mL
pg/mL
Vehicle
group
6.22 ±
LPD
group
10.97 ± 1.40 1.01 ± 0.15 1.21 ± 0.15 1.63 ± 0.18 350.3 ± 84.3 826.1 ± 213.0 392.3 ± 77.3
0.37§
0.17 ±
0.07§
0.44 ±
0.06§
1.15 ±
0.14§ 171.8
±
38.2§
203.3 ±
70.9§
132.4 ± 68.8§
LPD+ANP 6.62 ± 1.24§ 0.38 ± 0.09¶ 0.62 ± 0.05§ 1.12 ± 0.21§ 239.3 ± 62.0§ 495.5 ± 97.9§,¶ 253.6 ± 63.0§,¶
group
Values are mean ± SEM (n = 6, per group). BALF, bronchoalveolar lavage ﬂuid; MPO, myeloperoxidase;
cPLA2, cytosolic phospholipase A2; sPLA2, soluble phospholipase A2. (§) p < 0.01 vs LPD group,
(¶) p < 0.05 vs vehicle group.
RESULTS: Isquemia-reperfusion reduced PO2 from 615.7 ± 28.5 to 452.1 ± 28.2
mmHg (p < 0.001), at the end of reperfusion in the LPD group. Compared to the
vehicle group the pulmonary artery pressure, airway pressure, wet-to-dry ratio,
proteins in BAL, and myeloperoxidase activity increased signiﬁcantly in the LPD
group, (p < 0.05) respectively. In addition, IR increased signiﬁcantly cytosolic and
soluble phospholipase A2 activity together with thromboxane and leukotriene
formation in the LPD group compare to vehicle; while supplementation of the
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METHODS: To test the hypothesis, we examined the effects of ANP in an isolated
rat lung model. Three groups were deﬁned (n = 6, each): in the vehicle group,
lungs were perfused for 2 hours without an ischemic period. In two ischemic
groups, lungs were ﬂushed with low potassium dextram solution (LPD group) or
LPD containing 10 nM of ANP (LPD+ANP group), cold-stored 18 hours, and
reperfused for 2 hours.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
preservation solution with ANP decreased all these maintaining the PO2 at a level
similar to the vehicle group throughout reperfusion and decresed signiﬁcantly the
alveolar-capillary leakage, edema formation and neutrophil extravasation.
CONCLUSION: Supplementation of the preservation solution with atrial natriuretic
peptide extends the preservation properties of LPD solution attenuating IR injury
through inhibition of the phospholipase A2 cascade.
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F17.
Comparative Glycomic Proﬁling in Esophageal Adenocarcinoma
Zane Hammoud,1 Yehia Mechref,2 Ahmed Hussein,2 Slavka Bekesova,2
Min Zhang,2 Kenneth Kesler,3* Robert Hickey,3 Milos Novotny2
1. Cardiothoracic Surgery, Henry Ford Health System, Detroit, MI, USA;
2. Indiana University, Bloomington, IN, USA; 3. Indiana University School
of Medicine, Indianapolis, IN, USA
Invited Discussant: Arjun Pennathur
METHODS: Serum samples from patients with Barrett’s metaplasia (N = 5), highgrade dysplasia (HGD, N = 11) and esophageal adenocarcinoma (EAC, N = 50)
were collected; samples from 18 healthy volunteers were used as control. Serum
N-glycans were enzymatically released using PNGase F. Samples were then applied
to both C18 Sep-Pak® cartridges and activated charcoal cartridges. N-glycans were
permethylated and then spotted directly on the MALDI plate and mixed with
equal volume of DHB-matrix. Mass spectra were acquired using the Applied
Biosystems 4800 MALDI TOF/TOF Analyzer. The obtained MALDI-MS data were
processed using DataExplorer ﬁles listing m/z values and intensities.
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OBJECTIVE: Aberrant glycosylation has been implicated in various types of cancers
and changes in glycosylation may be associated with signaling pathways during
malignant transformation. Cancerous cells with altered glycosylation of their surface proteins shed such proteins into the circulating ﬂuids. Glycomic proﬁling of
such ﬂuids would reveal the altered glycosylation. We performed glycomic proﬁling
of serum from patients with no known disease, patients with high grade dysplasia,
and patients with esophageal adenocarcinoma in an attempt to delineate distinct
differences in glycosylation between these groups.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
RESULTS: The intensities of 98 glycans were signiﬁcantly different among the 3
groups; 26 of these correspond to known glycan structures. Pairwise comparisons
showed that 8 glycans are signiﬁcantly different in all three pairwise comparisons.
Figure 1 shows the mass spectra plots obtained for each category.
CONCLUSION: We have demonstrated that comparative glycomic proﬁling of
EAC reveals a subset of glycans that can be selected as candidate biomarkers.
These markers can differentiate normal from HGD, normal from EAC, and HGD
from EAC. Further validation will be necessary to determine the clinical utility of
these glycan biomarkers.
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F18.
Matrix Metalloproteinase Expression in Adenocarcinoma and
Squamous Cell Carcinoma of the Lung
Sonam A. Shah,1 John S. Ikonomidis,2* Robert E. Stroud,2 Eileen I. Chang,2
Francis G. Spinale,2* Carolyn E. Reed2*
1. Medical University of South Carolina, College of Medicine, Charleston, SC,
USA; 2. Medical University of South Carolina, Department of Surgery,
Charleston, SC, USA
Invited Discussant: David R. Jones
OBJECTIVE: Non-small cell lung cancer (NSCLC) is the leading cause of cancer
deaths. Matrix metalloproteinases (MMPs) are an endogenous proteinase system
shown to facilitate cancer invasion and metastasis. The purpose of this study was
to evaluate MMP expression in the two most common histologies of NSCLC,
squamous cell (SCC) and adenocarcinoma (AC), relative to normal lung tissue.
MMP Levels: Squamous Cell Carcinoma vs. Adenocarcinoma.
MMP-1: SCC: 30.8* ± 9.3, AC: 6.8 ± 2.1; MMP-2: SCC: 128.2* ± 30.1,
AC: 52.1 ± 8.1; MMP-3: SCC: 13.9* ± 4.3, AC: 0.9 ± 0.2; MMP-8:
SCC: 396.0* ± 93.5, AC: 31.2 ± 8.6; MMP-9: SCC: 209.9* ± 19.5, AC:
65.1 ± 16.2; MMP-12: SCC: 24.7* ± 5.7, AC: 4.9 ± 1.2; MMP-13: SCC:
3.4* ± 1.9, AC: 1.4 ± 0.4, *p < 0.05. All values in pg of MMP/mg tissue.
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METHODS: A comprehensive MMP multiplex plate analysis was run on homogenates of 23 SCC and 22 AC surgically resected tumor specimens and compared
(pg of MMP/mg tissue) to MMP concentrations in adjacent normal tissue. A subset analysis of patients who recurred versus those who did not was performed.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
RESULTS: Analysis of the combined tumor groups showed increased MMP
abundance compared to normal tissue, with the exception of MMP-9 (MMP-1:
tumor: 19.4* ± 5.1, normal: 0.4 ± 0.1; MMP-2: tumor: 103.8* ± 18.3, normal: 39.2 ± 5.0;
MMP-3: tumor: 7.7* ± 2.4, normal: 0.4 ± 0.1; MMP-8: tumor: 189.5* ± 41.3, normal:
61.0 ± 8.9; MMP-9: tumor: 150.2 ± 16.6, normal: 163.7 ± 18.4; MMP-12: tumor: 16.1*
± 3.4, normal: 0.2 ± 0.1; MMP-13: tumor: 2.6* ± 1.0, normal: 0.0 ± 0.0; * p < 0.05) ).
Analysis of SCC tumor groups versus AC tumor groups revealed a distinct MMP
proﬁle for each histological subtype (data not shown). The proﬁles of histologic
subtypes were then compared to each other (see ﬁgure). The subset analysis
showed that only MMP-9 was signiﬁcantly elevated in patients whose tumor
recurred (MMP-1: recurred: 14.1 ± 7.5, not: 14.4 ± 3.5; MMP-2: recurred: 86.8 ± 25.7,
not: 76.2 ± 11.4; MMP-3: 18.1 ± 13.6, not: 4.4 ± 1.4; MMP-8: recurred: 233.0 ± 78.3,
not: 109.3 ± 27.2; MMP-9: recurred: 223.3* ± 31.7, not: 118.9 ± 19.4; MMP-12:
recurred: 27.7 ± 11.9, not: 14.7 ± 4.0; MMP-13: recurred: 10.1 ± 7.3, not: 1.0 ± 0.3; *p <
0.05). All MMP values are listed in picograms of MMP per milligrams of tissue.
CONCLUSION: The results of this unique study demonstrated that MMP abundance and proﬁles for NSCLC are increased in tumor tissue over normal, and that
there are disparate MMP concentration proﬁles for SCC versus AC. The subset
analysis underscores that MMP-9 may be useful as a marker for recurrence. Continued understanding of the biochemical basis for lung cancer invasion and
metastasis could be helpful in developing histology-speciﬁc screening tools, imaging
modalities, and adjuvant therapy protocols for patients with stage I and II nonsmall cell lung cancer.
150
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NOTES
TUESDAY
Morning
151
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY MORNING
MAY 12, 2009
8:45 a.m.
PLENARY SCIENTIFIC SESSION
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Thomas L. Spray
Thoralf M. Sundt, III
29. Non Operative Thoracic Duct Embolization for Traumatic
Chylothorax: Experience in 103 patients
Maxim Itkin, John C. Kucharczuk, Scott O. Trerotola, Andrew Kwak,
Constantin Cope, Larry R. Kaiser*
University of Pennsylvania, Philadelphia, PA, USA
Invited Discussant: Nasser K. Altorki
OBJECTIVE: To demonstrate the efﬁcacy of a minimally invasive, non-operative
catheter based approach to the treatment of traumatic chylothorax
METHODS: A retrospective review of 103 patients (52 male, 51 female, average age
59) was conducted to assess the efﬁcacy of thoracic duct (TD) embolization or
interruption for the treatment of high output chyle leak caused by injury to the
thoracic duct.
RESULTS: Causes of the chyle leak in 103 patients are listed in the Table. 101
patients presented with chylothorax (left 46, right 44, bilateral 11), while one
patient had chylopericardium and one had a cervical lymphocele following neck
dissection. 17 patients (16%) had previous unsuccessful attempts at thoracic duct
ligation. In 102/103 patients lymphangiogram was able to be performed successfully. Catheterization of the TD was achieved in 68 (66%) patients. Catheterization
List of the Causes of the Chylous Leaks
Chest surgery
33
Mediastinal surgery
32
Cardiac surgery
17
Aortic surgery
11
Trauma
4
Head and Neck
4
Spinal surgery
1
Radiation
1
Total
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of the duct is dependent on being able to achieve puncture of the cisterna chyli. In
66 of these 68 patients embolization of the TD was performed; in 2 patients it was
not attempted. Endovascular coils and/or ﬁbrin glue was used to occlude the TD.
In 18 of 35 cases where catheterization of the duct was unsuccessful, TD needle
interruption was attempted. Resolution of the chyle leak was observed in 60/66
(91%) patients post embolization (3 failed, 2 were lost to follow-up, and 1 died
within several days post-procedure from unrelated causes). Needle interruption of
the TD was successful in 13/18 (72%). patients. In 14 of the 17 patients who had
previous attempts at TD ligation, embolization or interruption was attempted in
14 and was successful in 11 (78%). The overall success rate for the entire series was
72% (73/103). There were three minor (3%) complications: 1 asymptomatic embolization of glue into the pulmonary artery and 2 patients developed transient lower
extremity edema.
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CONCLUSION: Catheter embolization or needle interruption of the thoracic
duct was safe, feasible and successful in eliminating a high output chyle leak in the
majority (72%) of cases. This minimally invasive, though technically challenging,
procedure should be the initial approach employed for the treatment of a traumatic
chylous.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
30. Valve Repair for Regurgitant Bicuspid Aortic Valves: A Systematic
Approach
Munir Boodhwani,† Laurent de Kerchove, David Glineur, Robert Verhelst,
Jean Rubay, Christine Watremez, Pasquet Agnes, Philippe Noirhomme,
Gebrine El Khoury
Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint Luc, Brussels,
Belgium
Invited Discussant: Hartzell V. Schaff
OBJECTIVE: Young patients with bicuspid aortic valves (AV) can present with
aortic insufﬁciency (AI) due to disease of the leaﬂet or of the aortic root and functional aortic annulus. Valve repair is emerging as an attractive and feasible alternative to valve replacement for bicuspid aortic valve insufﬁciency. We present a single
center experience with a functional approach to bicuspid aortic valve repair focusing on valve assessment and systematic application of repair techniques (Figure 1).
METHODS: Between 1995 and 2008, 121 consecutive patients (mean age: 44 ± 12
years) with bicuspid aortic valves underwent non-emergent valve repair for isolated
AI (43%), aortic root dilatation (13%), or both (44%). Preoperative echocardiography
identiﬁed aortic dilatation (n = 75), cusp prolapse (n = 96), and cusp restriction
(n = 45) as contributory mechanisms of AI which were conﬁrmed on surgical
inspection. Conjoint cusp raphe repair was performed in 97 patients by shaving
(22%) or resection of the raphe with primary closure (60%) or pericardial patch
augmentation (18%). Cusp prolapse (n = 80) was repaired by free margin plication
and/or free margin reinforcement with PTFE suture. All patients underwent a
†Resident
Traveling Fellowship 2007
154
AMERICAN ASSOCIATION FOR THORACIC SURGERY
functional aortic annuloplasty using sub-commissural annuloplasty (n = 52),
ascending aortic replacement (n = 17) or aortic root replacement (n = 54) using a
reimplantation (76%) or remodelling technique (24%). Clinical (median: 57
months, range [1–147]) and echocardiographic (median: 40 months, range [1–143])
follow-up was complete in 99% of patients. Kaplan-Meier and Cox regression analyses
were used.
RESULTS: There was no operative mortality. Five patients underwent early aortic
valve reoperation (3 re-repairs, 2 Ross procedure). Post-repair, intraoperative
echocardiography revealed AI grade 0/1 in all patients. On discharge echocardiography, 92% of patients had AI grade 0/1 and 8% had grade 2 AI. Three additional
patients underwent aortic valve replacement during follow-up. Overall survival
was 97 ± 3% at 8 years. At 5 and 8 years follow-up, freedom from AV reoperation
was 95 ± 4% and 92 ± 7% and freedom from AV replacement was 97 ± 3% and 94
± 6%. Freedom from recurrent AI (>2+) was 94 ± 5% and from valve related events
was 88 ± 4% at 5 years.
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Morning
CONCLUSION: A systematic approach to bicuspid aortic valve repair yields good
early and mid-term results. Repair of bicuspid valves for AI is a feasible and attractive
alternative to mechanical valve replacement in young patients.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
31. Ten-Year Experience of Off-Pump Coronary Artery Bypass; Lessons
Learned from Early Postoperative Angiograms
Ki-Bong Kim, Jun-Sung Kim, Hae-Young Lee, Hyun-Jae Kang, Bon-Kwon Koo,
Hyo-Soo Kim, Dae-Won Sohn, Byung-Hee Oh, Young-Bae Park
Seoul National University Hospital, Seoul, South Korea
Invited Discussant: Joseph F. Sabik, III
OBJECTIVE: We have performed early postoperative angiograms to assess the
accuracy and patency of the anastomosis after off-pump coronary artery bypass
(OPCAB).
METHODS: One thousand and three hundred forty ﬁve patients who underwent
OPCAB between January 1998 and December 2007 were studied. The grafts used
for distal anastomoses were left internal thoracic artery (n = 1278), right internal
thoracic artery (n = 677), right gastroepiploic artery (n = 837), radial artery (n = 14),
and saphenous vein (n = 190). Early postoperative (1.8 ± 1.7 days) angiographies
were performed in 1306 patients (97.1%). The patients were divided into group I
(n = 234), which underwent OPCAB without using intraoperative graft ﬂow
measurement, and group II (n = 1111), which underwent OPCAB with ﬂow
measurement.
RESULTS: Operative mortality was 1.6%. The average number of distal anastomoses
was 3.0 ± 1.0. Early postoperative patency rates were 98.8% (3554/3597) for arterial
grafts and 88.2% (285/323) for vein graft (p = 0.00). In group II, intraoperative
ﬂowmeter-guided graft revision was performed in 2.6% (84/3239) of anastomoses.
Patency rate of arterial grafts was signiﬁcantly higher in group II than in group I
(97.2%, 455/468 vs 99.0%, 3099/3129; p = 0.001); however, patency rates of vein
graft was not different between the two groups (86.4%, 184/213 vs 91.8%, 101/110;
p = ns). Early postoperative reoperation for graft revision was performed in 33
patients (6.4%, 15/234 in group I vs 1.6%, 18/1111 in group II; p = 0.001) based on
the angiographic ﬁnding.
CONCLUSION: The early postoperative patency rate of vein graft after OPCAB
was signiﬁcantly lower than that of arterial grafts. Intraoperative ﬂow measurement signiﬁcantly improved the patency rate of arterial grafts and decreased the
reoperation rate for graft revision. There were 1.6% of patients requiring reoperation
based on the early angiographic ﬁndings in spite of the intraoperative ﬂowmeterguided revision.
156
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32. Pneumonectomy After Chemo- or Chemoradiotherapy for Advanced
Non-Small Cell Lung Cancer
Walter Weder,1* Stéphane Collaud,1 Thomas Krbek,2 Sven Hillinger,1 Sylvia Fechner,2
Peter Kestenholz,1 Rolf Stahel,1 Georgios Stamatis2
1. Zurich University Hospital, Zürich, Switzerland; 2. Ruhrlandklinik, Essen, Germany
Invited Discussant: Robert J. Cerfolio
OBJECTIVE: Pneumonectomy after chemo- or chemoradiotherapy is reported to
be associated with a mortality of up to 20%. We retrospectively reviewed medical
records of patients who underwent standard or extended pneumonectomy after
induction therapy for advanced NSCLC.
RESULTS: 176 pneumonectomies were performed. 117 (66%) were extended
resections including pericardium in 108 (60%), left atrium in 31 (18%), diaphragm
in 10 (6%), chest wall in 8 (5%), superior vena cava in 7 (4%), aorta in 7 (4%) and
oesophageal muscle in 5 (3%) patients. R0-resection was achieved in 165 (94%).
Pre-induction clinical stage was IIB in 8 (5%), IIIA in 96 (54%), IIIB in 71 (40%)
and IV in 1 (1%) patient. Post-induction pathological stage was a complete response
in 36 (20%), stage I in 31 (18%), II in 39 (22%), III in 58 (33%) and IV in 12 (7%).
There were 6 perioperative deaths (3% mortality) due to pulmonary embolism in
3, respiratory failure (pneumonia/ARDS) in 2 and cardiac failure in 1 patient.
Within 90 post-operative days, 22 major complications occurred in 19 patients
(11%): 6 (27%) broncho-pleural ﬁstulas (BPF), 6 (27%) pneumonias/ARDS, 5
(23%) empyemas without BPF, 4 (18%) pulmonary embolism and 1 (5%) gastric
herniation due to displacement of the diaphragmatic repair.
3- and 5-year survivals for the overall population were 55% and 38%, respectively.
CONCLUSION: Pneumonectomy after chemo- or chemoradiotherapy as induction
for advanced NSCLC can be performed with a perioperative mortality rate of 3%
and should not exclude patients from surgical resection. The achieved 5-year survival rate of 38% justiﬁes aggressive surgery within a multimodality concept for
selected cases.
10:05 a.m.
*AATS
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
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157
TUESDAY
Morning
METHODS: 827 patients underwent induction therapy for NSCLC after staging
with CT, PET-CT and/or mediastinoscopy in two different centers from 1998–2007.
Induction chemotherapy consisted mainly of 3 cycles of a platin-based regimen.
Chemoradiotherapy consisted of an additional radiation of 45 Gy. Re-staging was
performed with CT, PET-CT and/or re-mediastinoscopy prior to surgical resection.
Patients who underwent a pneumonectomy were further analyzed.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
10:40 a.m.
PLENARY SCIENTIFIC SESSION
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Thomas L. Spray
Thoralf M. Sundt, III
33. Right Ventricle and Tricuspid Valve Function at Mid-Term
Following the Fontan Operation for Hypoplastic Left Heart
Syndrome: Impact of Shunt Type
Victor Bautista-Hernandez, Ravi Thiagarajan, Hugo Loyola, Jared Schiff,
Joshua Salvin, John E. Mayer,* Mark Scheurer, Frank A. Pigula,*
Francis Fynn-Thompson, Pedro J. del Nido,* Emile A. Bacha*
Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
Invited Discussant: Richard G. Ohye
OBJECTIVE: Concerns exist about late ventricular dysfunction and tricuspid
valve (TV) function in patients with hypoplastic left heart syndrome (HLHS) palliated
initially with a right ventricle-pulmonary artery conduit (RV-PA). The aim of this
study was to evaluate the mid-term RV, TV and neo-aortic valve (neo-AV) function
and clinical outcomes in patients with HLHS after completion of staged palliation
based on the type of shunt used at stage I reconstruction.
METHODS: Retrospective review of records of all patients with HLHS who had
completed Fontan palliation between 2000 through 2007. The outcome variables
were: RV function, TV and neo-AV regurgitation (from latest post-Fontan echocardiogram), cardiac index (CI), pulmonary vascular resistance (PVR) and pressure
Table 1. Latest Echocardiographic Data in Patients with HLHS After Completion
of Staged Palliation Based on the Type of Shunt Used at Stage I Reconstruction
Shunt Type
RV Function
None or
Trivial
Mild
Moderate
Severe
Total
Fisher’s
Exact Test
0.315
RV-PA conduit 20 (55.6%)
12 (33.3%)
3 (8.3%)
1 (2.8%)
36 (100%)
BTS
14 (17.7%)
7 (8.9%)
5 (6.3%)
79 (100%)
53 (67.1%)
TV regurgitation
RV-PA conduit 15 (41.7%)
19 (52.8%)
2 (5.6%)
0 (0%)
36 (100%)
BTS
47 (60.3%)
10 (12.8%)
1 (1.3%)
78 (100%)
20 (25.6%)
0.271
Neo-aortic
regurgitation
RV-PA conduit 26 (83.9%)
5 (16.1%)
0 (0%)
0 (0%)
31 (100%)
BTS
18 (25%)
0 (0%)
0 (0%)
72 (100%)
*AATS
54 (75%)
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158
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
(PAp) and right ventricular end diastolic pressure (RVEDp) (from latest post-Fontan
catheterization). Clinical status was obtained from medical records and by contact
with the referring cardiologist if necessary.
CONCLUSION: Contemporary results after Fontan palliation for HLHS are
excellent. At mid-term after the Fontan, there were no differences in terms of RV
function, TV or neo-AV function or survival based on type of shunt used at stage I
palliation.
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TUESDAY
Morning
RESULTS: Of 118 HLHS patients (76 males) undergoing a Fontan for HLHS, 116
had a fenestrated lateral tunnel and 2 an extra-cardiac conduit. At stage I, 36
patients had an RV-PA conduit and 82 patients a Blalock-Taussig shunt (BTS). All
patients survived the Fontan and were discharged home. Three patients were lost
to follow-up. At a mean follow-up post Fontan of 27.6 months (range 0.2 to 88.9
months), 4 patients had died and 1 had the Fontan circulation taken-down. No
patient underwent a heart transplant. Most recent follow-up echocardiograms
from 115 patients (mean f/u in months of 14.5 for RV-PA and 34.8 for BTS) and
catheterizations from 66 (mean f/u in months of 18.8 for RV-PA and 43.6 for BTS)
were reviewed. Hemodynamic results for RV-PA conduits versus BTS were, CI 3.3 ±
0.69 vs 3.4 ± 1.15, PVR 2.0 ± 0.8 vs 1.7 ± 0.8, PAp 13.7 ± 3.1 vs 13.6 ± 4.4, RVEDp 8 ± 4.3
vs 9.1 ± 4.8, respectively. No statistically signiﬁcant differences were found between
shunt types in terms of survival, degree of RV dysfunction, TV or neo-AV regurgitation, CI, PVR, PAp or RVEDp. Latest echocardiographic data is shown in table I.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
34. Four Decades of Experience with Mitral Valve Repair: Analysis
of Differential Indications, Technical Evolution and Long-Term
Outcome
Daniel J. DiBardino, Andrew W. ElBardissi, Ann Maloney, R. Scott McClure,
Oswaldo Razo-Vasquez, Judah A. Askew, Lawrence H. Cohn*
Cardiac Surgery, Harvard Medical School, Boston, MA, USA
Invited Discussant: David H. Adams
OBJECTIVE: The objective was to determine the long-term outcome of mitral
valve repair (MVP) in 1,469 patients from 1972 to 2007. We compare performance of
evolving differential repair strategies among MV disease types.
METHODS: Patients having MVP by a single surgeon were retrospectively
reviewed and current survival and reoperation data were collected. Emphasis was
on repair strategy and long-term survival/reoperation status by MV disease etiology.
RESULTS: There were 1,469 MV repairs since 2/23/1972; overall mean age was 60
yrs and 57% were male. Etiologies included 1,010 myxomatous (mean age 60 ± 13
yrs, 66% male), 193 rheumatic (mean 55 ± 15 yrs, 85% female), 129 ischemic (mean
70 ± 10 yrs) and 93 functional/cardiomyopathic (FCM, mean 67 ±1 1 yrs). Repair
strategies evolved over four decades and included commissurotomy, papillary muscle
splitting, leaﬂet resection with reconstruction and ring annuloplasty, commissuroplasty, fold-o-plasty, Gortex chord creation and edge-to-edge repair. The 30 day
mortality was n = 19/1,469 (1.29%) while overall 10, 20 and 30 year actuarial survival was 72%, 47% and 35%. Rheumatic and myxomatous actuarial survival was
similar at 10, 20 and 30 years (77%, 55%, 38% versus 77%, 55%, 27%, respectively)
while Cox proportional hazards modeling determined ischemic [Hazard Ratio
(HR) 4.671, p < 0.0001] and FCM etiology [HR 3.298, p < 0.0001] as signiﬁcant
predictors of poor survival. Combined MVP/CABG had decreased survival versus
isolated MVP at all time points (61% versus 33% at 20 years, p < 0.0001). Length of
stay was less for right parasternal (5.9 days) and lower mini-sternotomy (6.5 days)
than for right thoracotomy (10.9 days) and full sternotomy (8.6 days, p < 0.0001).
Overall actuarial 10, 20 and 30 year freedom from reoperation was 84%, 60% and
18%; 83% of myxomatous valves remained free from reoperation at 20 years (versus
32% of rheumatics) while only 9% of rheumatics remained so at 30 years. Cox
proportional hazard estimates of freedom from reoperation found rheumatic disease
(HR 18.52, p < 0.001, ﬁgure 1) and prolonged cardiopulmonary bypass time (HR
1.020, p = 0.0004) among signiﬁcant predictors of reoperation.
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11:20 a.m.
The Role of Simulation in Future Cardiothoracic
Surgical Education
Dan Raemer, PhD,
Yolonda L. Colson, MD, PhD
Gregory S. Couper MD
Introduced By:
11:50 a.m.
Edward Verrier, MD
ADDRESS BY HONORED SPEAKER
The Creation of the Universe, String Theory, and
Time Travel
Professor Michio Kaku
Henry Semat Professor of Theoretical Physics Graduate Center of the
City University of New York
Introduced By:
12:30 p.m.
Thomas L. Spray, MD
ADJOURN FOR LUNCH – VISIT EXHIBITS
Exhibit Hall
161
TUESDAY
Morning
CONCLUSION: These follow-up data up to 36 years support repair as the procedure of choice for the majority of MV disease. Disease etiology strongly determines
survival and durability; rheumatics enjoy the longest survival but require reoperation more frequently. Myxomatous MVP demonstrates the longest proven durability,
approaching 30 years postoperatively.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
NOTES
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
TUESDAY AFTERNOON
MAY 12, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Joseph F. Sabik
David H. Adams
35. The Papillary Muscle Sling for Ischemic Mitral Regurgitation
U. Hvass, Thomas Joudinaud
Heart Surgery, Bichat Hospital, Paris, France
OBJECTIVE: Evaluate long-term stability of mitral repair and reverse remodelling
in patients with severe ischemic left ventricular dysfunction (LVD) and functional
mitral regurgitation (FMR).
METHODS: Since June 2000, thirty-seven patients with ischemic FMR have
beneﬁted from a double-level mitral repair associating an intra-ventricular peripapillary muscle sling completed by a classical intra-atrial mitral annuloplasty
ring. (mean age 64 yrs, LVEDD 70 ± 0 mm LVESD 55 ± 5,6 mm, ejection fraction
15 to 45%, pulmonary hypertension >60, NYHA III-IV). All patients had both
papillary muscles (PM) encircled with a 4 mm gore-tex tube, correcting their lateral
and downwards displacement. Annuloplasty rings are moderately undersized or
normal. Efﬁciency was evaluated on mitral stability or recurrence rates of FMR,
ventricular parameters and functional status. According to the Leyden algorhythm
based on pre-operative end diastolic and end systolic left ventricular diameters,
only a minority of our patients were expected to experience reverse remodelling.
RESULTS: Regurgitation is none to trivial in 33, mild to moderate in four. Follow-up,
3 to 74 months, mean 53 ± 22 months shows stability of all initially successful double
level mitral repairs. Ventricular diameters, ejection fraction, volume, and sphericity
index signiﬁcantly improve. Two patients died during follow-up and one was
transplanted.
CONCLUSION: Re-approximating the PM has an immediate effect on mitral
leaﬂet mobility by suppressing the tethering due to displacement of the PM. It has
an effect in preventing recurrent MR by forbidding further PM displacement. In
this cohort of severely disabled patients, reverse remodelling can be expected.
163
TUESDAY
Afternoon
Invited Discussant: Robert A. Dion
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
36. Surgical Management of Secondary Tricuspid Valve Regurgitation:
Anulus, Commissure, or Leaﬂet Procedure?
Jose L. Navia,* Edward R. Nowicki, Eugene H. Blackstone,* Daniel E. Nento,
Jeevanantham Rajeswaran, A. Marc Gillinov,* Lars G. Svensson,* Sharif Al-Ruzzeh,
Bruce W. Lytle*
Cleveland Clinic, Cleveland, OH, USA
Invited Discussant: Farzan Filsouﬁ
OBJECTIVE: Anuloplasty has been the main technique used to manage tricuspid
valve (TV) regurgitation (TR) accompanying left-sided heart valve disease, but
techniques at the commissure or leaﬂet level may also be useful. This study sought
to compare early and long-term success of procedures performed at anular, commissural, leaﬂet, and combined levels.
METHODS: From 1990 to 2008, 2,277 patients underwent TV procedures for
secondary TR concomitantly with mitral (n = 1,527, 67%), aortic (n = 180, 8.0%), or
combined (n = 570, 25%) valve surgery. These included anulus (rigid prosthesis
[n = 584, 26%], ﬂexible prosthesis [n = 1,052, 46%], DeVega suture [129, 5.7%], and
Peri-Guard [n = 185, 8.1%] anuloplasty), commissure (Kay [n = 248, 11%]),
and leaﬂet (edge-to-edge suture [n = 79, 3.5%]) procedures. 4,745 postoperative
transthoracic echocardiograms in 1,965 patients were analyzed (median follow-up
20 days) and TV reoperations identiﬁed at follow-up (median 1.2 years).
RESULTS: At 3 months, prevalence of 3+/4+ TR was least for combined Kay and
leaﬂet procedures (2.4%) and Peri-Guard anuloplasty (3.8%), and similar (8.7% to
11%) for other procedures (Figure). However, by 5 years, 3+/4+ TR had increased
only slightly to 12% for isolated rigid prothesis anuloplasty. It was progressively
greater for all other anular procedures (ﬂexible prosthesis [16%], DeVega [24%],
and Peri-Guard [44%]), and 19% for the Kay procedure. Freedom from TV reoperation
was 98% at 5 years, similar for all procedures (P = .3).
CONCLUSION: Early success of treatment for TR secondary to left-sided heart
valve disease is best sustained over time by rigid prosthesis anuloplasty alone. The
protracted failure pattern after Peri-Guard anuloplasty suggests abandoning this
procedure.
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37. When Is the Ross Procedure a Good Option to Treat Aortic Valve
Disease?
Tirone E. David,* Anna Woo, Susan Armstrong, Manjula Maganti
Cardiovascular Surgery, Toronto General Hospital, Toronto, ON, Canada
Invited Discussant: Lawrence H. Cohn
OBJECTIVE: To identify suitable patients for the Ross procedure.
METHODS: A cohort of 212 patients (mean age 34 ± 9 years, 66% men, 82% with
bicuspid aortic valve disease = BAV) had the Ross procedure and was prospectively
followed with clinical evaluations and echocardiography from 1 to 19 years, mean
of 9.5 ± 3.7 years. In addition to longitudinal outcomes by Kaplan-Meier analysis,
numerous perioperative variables were entered into a multivariable analysis to
identify predictors of failure of the procedure.
CONCLUSION: The Ross procedure should not be performed in patients with AI
due to BAV. The long-term results in patients with aortic stenosis with or without
BAV are excellent. This operation is an option for young adults with aortic stenosis
who choose a tissue valve.
3:00 p.m.
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Exhibit Hall
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TUESDAY
Afternoon
RESULTS: There were one operative and four late deaths, none valve-related. The
survival at 15 years was 96.6 ± 1.5% and identical to the general population
matched for age and gender. There were 18 reoperations: 11 in the pulmonary
autograft, 3 in the pulmonary homograft and 4 others. At 15 years the freedom
from reoperation in the pulmonary autograft was 93.0 ± 2.2%, and the freedom
from moderate or severe aortic insufﬁciency (AI) was 90 ± 3%. Cox regression
analysis identiﬁed preoperative AI due to BAV as independent predictors of AI >
2+ (H.R. = 3.9; 95% C.I. 2.4–5.4). The technique of implantation of the autograft
had no effect on the development of late AI > 2+. There was no reoperation due to
AI in patients with aortic stenosis. At 15 years the freedom from moderate to severe
pulmonary insufﬁciency and/or peak gradient >40 mmHg was 88.8 ± 2.6%, and
the event-free survival was 87.0 ± 2.8%.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
3:45 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
ADULT CARDIAC SURGERY
Ballroom A–C, Hynes Convention Center
Moderators:
Joseph F. Sabik
David H. Adams
38. Surgical Ventricular Restoration for Anteroseptal Scars – Volume
or Shape?
Antonio M. Calaﬁore,1* Angela L. Iacò,1 Davide Amata,1 Cataldo Castello,1
Egidio Varone,1 Fabio Falconieri,1 Antonio Bivona,1 Sabina Gallina,2
Michele Di Mauro3
1. Cardiac Surgery, University of Catania, Catania, Italy; 2. University of Chieti –
Department of Cardiology, Chieti, Italy; 3. University of Catania – Villa Bianca
Hospital, Catania – Bari, Italy
Invited Discussant: Lorenzo A. Menicanti
OBJECTIVE: Surgical ventricular restoration (SVR) has, as a target, reduction
of left ventricular (LV) volume. More recently maintaining a conical shape was
considered as important as volume reduction. This retrospective analysis compared
the results of these two strategies
METHODS: From January 1988 to February 2008, 276 patients with anteroseptal
scars underwent elective SVR. Before 2002 a Dor procedure was performed in 107
cases (favoring volume reduction, group A). From 2002, 169 patients underwent
SVR to maintain a conical LV chamber (favoring shaping, group B); a Dor procedure (when the scar was septoapical) was used in 29 cases and septal reshaping
(when the septum was more involved than the anterior wall) in 140. Preoperatively
the 2 groups were similar but age (A 62 ± 10 vs B 66 ± 10 years, p = 0.001), ejection
fraction (EF) (A 38 ± 10 vs B 33 ± 8, p < 0.001), mitral regurgitation grade (A 0.9 ±
0.9 vs B 1.7 ± 1.4, p < 0.001) and mitral valve surgery (MVS) rate (A 22.4% vs B
46.2%, p < 0.001). Late events included death any cause, NYHA Class III-IV and
heart transplantation; cardiac events included cardiac death instead of death any cause.
RESULTS: Early mortality was 7.6%, 11.2% (A) versus 5.3% (B) (p = 0.072). Logistic regression, adjusted for age, EF, and MVS showed that the choice of volume
reduction (A) more than shape (B) was signiﬁcantly related to higher early mortality (OR = 5.1, p = 0.002). Four-year freedom from any death was 79.2 ± 2.5 (A 75.7 ±
4.1 vs B 81.6 ± 3.2, p = 0.232), from cardiac death was 83.9 ± 2.3 (A 78.3 ± 4.0 vs B
87.6 ± 2.8, p = 0.037), from cardiac events was 72.9 ± 2.9 (A 65.8 ± 4.6 vs B 78.3 ± 3.7,
p = 0.023) and from any event was 68.8 ± 3.0 (A 63.6 ± 4.7 vs B 72.7 ± 3.8, p = 0.117).
Cox analysis, adjusted for age, EF and MVS showed that volume reduction rather
than LV reshaping provided lower survival (HR = 2.1, p = 0.011), cardiac survival
(HR = 3.0, p < 0.001), cardiac event-free survival (HR = 2.7, p < 0.001) and event-free
survival (HR = 2.2, p < 0.001).
CONCLUSION: Maintaining a conical ventricular shape provides better results
when compared with pure volume reduction.
*AATS
Member
166
AMERICAN ASSOCIATION FOR THORACIC SURGERY
39. Early and Late Outcome of 517 Consecutive Adult Patients Treated
with Extracorporeal Membrane Oxygenation for Refractory
Postcardiotomy Cardiogenic Shock
Ardawan J. Rastan, Andreas Dege, Matthias Mohr, Nicolas Doll, Sven Lehmann,
Volkmar Falk, Friedrich W. Mohr*
Heart Surgery, Heart Center Leipzig, Leipzig, Germany
Invited Discussant: R. Duane Davis, Jr.
OBJECTIVE: PCS occurs in 1–2% of adult cardiac surgery patients. Hospital and
long-term results of 517 consecutive patients receiving perioperative ECMO
implantation were analyzed regarding preoperative and procedural risk factors that
effect outcomes.
TUESDAY
Afternoon
Overall cumulative survival after ECMO implantation
in adults PCS
METHODS: Between 05/96 and 06/08 517 of 40.538 pts (1.3%) undergoing cardiac
surgery (37.1% elective, 24.4% urgent, 38.5 emergency) received perioperative
ECMO support. Data were prospectively recorded. Procedures were isolated
CABG (32.4%), CABG + valve surgery (19.3%), valve surgery (38.1%), thoracic
organ transplantation (6.4%) and others (3.8%). Fifty-four preoperative, 26 procedural and 37 postoperative risk factors were evaluated by uni- und multivariate
logistic regression analyses to identify risk factors for early and late mortality.
Cumulative survival was estimated by Kaplan-Meier methods. Mean follow-up
was 2.9 y (0.0–11.4 y).
*AATS
Member
167
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
RESULTS: Age was 61.3 y, 73.0% were male, ejection fraction was 44.2 ± 17.3%.
ECMO implantation was performed through thoracic (56.7%) or extrathoracic
(42.3%) cannulation using femoral or axillary arterial and femoral venous cannulation. Additional IABP support was employed in 77.0%. Mean drainage loss was,
3.2 and 4.4 liter 24 and 48h, respectively. 52.7% were successfully weaned from
ECMO after mean 86h and 24.4% were discharged from the hospital after 41 ± 25 d.
Hospital mortality was 75.6%. Neurological complications occurred in 21.3%,
renal replacement therapy was indicated in 62.6%. Multivariate risk factors for
hospital mortality were emergency indication (odds ratio OR 2.4), preoperative
cardiogenic shock (OR 1.7), EF < 30% (OR 3.5), preoperative renal dysfunction
(OR 4.2) and combined coronary and valve procedure (OR 5.7, p < 0.01 each), while
age >70 y and diabetes were none. Estimated cumulative survival was 18.1 ± 2.9%
after 6 months, 16.7 ± 2.7% after one, 15.5 ± 1.6. and 16.1 ± 3.3% after ﬁve years. Risk
factors for late death were age, combined CABG + MV surgery and diabetes.
CONCLUSION: Temporary ECMO support it is an acceptable option for patients
with PCS that otherwise would die and justiﬁed by the good long-term survival of
hospital survivors. However, because of high morbidity and mortality individual
ECMO indication has to be made on the speciﬁc risk proﬁle.
168
AMERICAN ASSOCIATION FOR THORACIC SURGERY
40. Duration of LVAD Support Does Not Impact Post-Cardiac
Transplant Survival in the Continuous-Flow Pump Era
Ranjit John,1 Francis D. Pagani,2* Yoshifumi Naka,3* John V. Conte,4* Charles T. Klodell,5
Carmelo A. Milano,6*† David Farrar,7 O. Howard Frazier8*
1. Surgery, University of Minnesota, Minneapolis, MN, USA; 2. University of
Michigan, Ann Arbor, MI, USA; 3. Columbia University, New York, NY, USA; 4.
Johns Hopkins, Baltimore, MD, USA; 5. University of Florida, Gainsville, FL, USA; 6.
Duke University, Durham, NC, USA; 7. Thoratec Corporation, Pleasanton, CA, USA;
8. Texas Heart Institute, Houston, TX, USA
Invited Discussant: James Kirklin
METHODS: The HeartMate II LVAD was implanted in 459 patients as a bridge-totransplant at 33 centers in a multicenter trial. Patients were divided into 5 groups
based on duration of LVAD support as shown in the Table. The median age was 55
(range 15–77), 45% had ischemic etiology, and 23% were females. Survival was
determined at 30 days and 1 year post post-transplantation.
Transplanted Patients Who Have Reached 30 Days or 1 Year Since Transplantation
LVAD
Duration (Days)
LVAD Patients at
Start of Interval
Patients Transplanted
in Interval
30 Days
1-year
0–30
459
19
100%
93%
30–89
408
60
100%
91%
90–179
311
63
95%
88%
180–365
249
69
93%
93%
>365
109
24
100%
86%
97%
90%
Overall
Post-Transplant
Survival
RESULTS: Of 459 patients, 236 underwent cardiac transplant after a median
duration of LVAD support of 143 days (longest: 3.2 yr), 87 died (19%), 12 (2.6%)
recovered ventricular function and the device was removed, and 121 (26%) are still
on LVAD support. There were no signiﬁcant differences in baseline demographics
among the 5 groups. The overall 30 day and 1-year post-TX survival was 97% and
90%. As shown in the Table, there were no signiﬁcant differences in survival based
on the duration of LVAD support.
*AATS
Member
John H. Gibbon Jr. Research Scholarship 2001
†Second
169
TUESDAY
Afternoon
OBJECTIVE: Previous evaluations of pulsatile left ventricular assist devices
(LVADs) have shown that transplantation either early after LVAD implantation
(<6 weeks) or late (>6 months) adversely affected post-cardiac transplant survival.
We sought to determine if the post-transplant survival of patients supported with
newer continuous ﬂow LVADs was related to the duration of LVAD support.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
CONCLUSION: Post-cardiac transplant survival is not inﬂuenced by the duration
of LVAD support with continuous-ﬂow devices. Their improved durability and
reduced short and long-term morbidity has reduced the need for urgent cardiac
transplantation which may have adversely inﬂuenced survival in the pulsatile
LVAD era. This data may allow for better donor selection for patients on continuousﬂow devices independent of LVAD duration, thereby favoring improved post-transplant
outcomes.
5:00 p.m.
EXECUTIVE SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
170
AMERICAN ASSOCIATION FOR THORACIC SURGERY
NOTES
TUESDAY
Afternoon
171
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
TUESDAY AFTERNOON
MAY 12, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 312, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
Nasser K. Altorki
Shaf Keshavjee
41. Endobronchial Ultrasound-Guided Fine-Needle Aspiration of
Mediastinal Lymph Nodes: The Thoracic Surgeon’s Perspective
Shawn S. Groth, Natasha M. Rueth, Jonathan D’Cunha,* Michael A. Maddaus,*
Rafael S. Andrade
Surgery, University of Minnesota, Minneapolis, MN, USA
Invited Discussant: Hiran C. Fernando
OBJECTIVE: To assess our results with endobronchial ultrasound-guided ﬁneneedle aspiration (EBUS-FNA) of mediastinal lymph nodes (MLNs) and to
describe the number and types of additional procedures we performed in the same
anesthetic setting as EBUS-FNA.
METHODS: We performed an Institutional Review Board-approved review of our
prospectively maintained database of all patients who underwent EBUS-FNA of
MLNs by thoracic surgeons at our institution from September 1, 2006 through
September 30, 2008.
We included patients in our analysis if (1) EBUS-FNA cytology revealed malignancy or (2) non-malignant cytology (normal lymph node, benign pathology, or
nondiagnostic samples) was veriﬁed with a conﬁrmatory procedure (i.e., mediastinoscopy, thoracoscopy, or thoracotomy) that sampled the same MLN stations as
sampled by EBUS-FNA. We excluded the 10 initial procedures required to overcome our learning curve. These criteria ensured the most accurate representation
of our sensitivity, speciﬁcity, negative predictive value (NPV), positive predictive
value (PPV), and accuracy.
RESULTS: Over the study period, 166 patients underwent EBUS, 155 with FNA.
Of these, 77 met our inclusion criteria. We report a sensitivity of 91.1%, a speciﬁcity of 96.8%, a NPV of 88.2%, a PPV of 97.6%, and a diagnostic accuracy of 93.4%.
We performed an additional procedure in 59% of patients in the same anesthetic
setting as EBUS-FNA: 41% underwent a diagnostic procedure (mediastinoscopy
*AATS
Member
172
AMERICAN ASSOCIATION FOR THORACIC SURGERY
[21%], endoscopic ultrasound-guided FNA [11%], thoracoscopy [9%], thoracotomy [0.2%]) and 35% underwent a therapeutic procedure (pulmonary resection
[23%], tracheostomy [5%], intravenous port placement [5%], gastrostomy tube
placement [4%], and pleurodesis [1%]).
CONCLUSION: Thoracic surgeons can perform EBUS-FNA with excellent
results and have the distinct ability to combine EBUS-FNA with additional diagnostic and therapeutic procedures in a single anesthetic setting. EBUS-FNA adds
to the thoracic surgeon’s unique capacity to expedite diagnostic work-up and treatment thereby streamlining patient care.
TUESDAY
Afternoon
173
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
42. Extracorporeal Membrane Oxygenation in Pediatric Lung
Transplantation
Varun Puri,1† Deirdre Epstein,1 Steven C. Raithal,1 Sanjiv K. Gandhi,1*
Stuart C. Sweet,2 Albert Faro,2 Charles B. Huddleston1*
1. Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA;
2. Department of Pediatrics, Washington University, St. Louis, St. Louis, MO, USA
Invited Discussant: Victor Morell
OBJECTIVE: To study Extracorporeal Membrane Oxygenation (ECMO) support
in the perioperative period in pediatric lung transplantation (LTx).
METHODS: Review of an institutional database of pediatric LTx from 1990 to 2008.
RESULTS: Three hundred forty-two patients underwent LTx over the study period.
Thirty-three of 342 (9.6%) patients required ECMO support in the perioperative period.
Fifteen patients (mean age 2.7 ± 4.4 years) required 16 ECMO runs in the pretransplant period (PRE). Their diagnoses were; Pulmonary hypertension n = 4, Surfactant
deﬁciency n = 3, Graft failure n = 3, others n = 4. The indications for ECMO were
respiratory failure 8/16 (50%), severe pulmonary hypertension 5/16 (31%) and cardiopulmonary collapse 3/16 (19%). Vascular access was V-A (veno-arterial) (16/16,
100%) with neck vessels the preferred cannulation site (14/16, 87%). Mean duration
of ECMO support was 226 ± 159 hours. All patients survived through LTx and 4/15
(27%) required ECMO support postoperatively. The mean time to LTx from institution
of ECMO was 516 ± 631 hours and 6/15 (40%) patients were weaned off ECMO
prior to LTx. Six of 15 (40%) PRE patients survived to hospital discharge. Complications (sepsis, reexploration and massive bleeding) were seen in 10/16 (63%)
ECMO runs. Survival to discharge was higher in patients weaned off ECMO prior
to LTx (4/6, 66%) than patients on ECMO going into LTx (2/9, 22%). All PRE
patients requiring ECMO support postoperatively, or undergoing redo LTx died.
Twenty-two patients (mean age 8.9 ± 7.5 years) underwent 24 ECMO runs after
LtX (POST). Their diagnoses were; Cystic ﬁbrosis n = 6, Pulmonary hypertension n
= 5, Obliterative bronchiolitis n = 4 and others n = 7. The indications for ECMO
support were; Primary graft dysfunction 16/24 (67%), pneumonia 4/24 (16%) and
others 4/24 (16%). The mean time between LTx and institution of ECMO was 222
± 312 hours. Access was predominantly V-A (23/24, 96%) and mean duration of
ECMO support was 158 ± 125 hours. Four of 22 (18%) patients survived to hospital
discharge (median survival 5.8 years). Amongst the non-survivors, the causes of
death were intractable respiratory failure (13/18, 72%) and infectious complications (3/18, 17%). No speciﬁc risk factors were identiﬁed to predict poor outcomes
in the POST group.
CONCLUSION: The need for perioperative ECMO support is associated with signiﬁcant morbidity and mortality in pediatric LTx. A subset of patients who can be
weaned off ECMO in the preoperative setting have greater likelihood of survival.
*AATS
Member
Traveling Fellowship 2008
†Resident
174
AMERICAN ASSOCIATION FOR THORACIC SURGERY
43. Lung Transplantation Using Donation After Cardiac Death
Donors: Long-Term Follow-Up in a Single Center
Satoru Osaki,1 James D. Maloney,1 Keith C. Meyer,2 Richard D. Cornwell,2
Holly K. Thomas,1 Niloo M. Edwards,1 Nilto C. De Oliveira1
1. Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin
School of Medicine and Public Health, Madison, WI, USA; 2. Section of Allergy,
Pulmonary, and Critical Care Medicine, Department of Medicine, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
Invited Discussant: Dirk E.M. Van Raemdonck
METHODS: Between 1993 and 2007, 365 consecutive patients underwent LTx at a
single center. Among these patients, 17 (4.7%) patients had LTx from DCD donors.
Patients transplanted from DCD donors (DCD group, n = 17) were compared to
patients transplanted from brain dead donors (BDD group, n = 348).
RESULTS: Patient demographics, donor age, and cold ischemic time did not differ
between the groups: recipient age (DCD: 49 ± 12 yrs vs BDD: 49 ± 12 yrs, p = 0.89),
distribution of diagnosis (% of chronic obstructive lung disease; 47% vs 38%, p =
0.97), donor age (28 ± 13 yrs vs 31 ± 14 yrs, p = 0.29), bilateral LTx procedure (40%
vs 41%, p = 0.55), and cold ischemic time (363 ± 145 min vs 381 ± 106 min, p = 0.70).
Warm ischemic time (from withdrawal of support to reperfusion of organs) was
33 ± 17 min (range: 18–89 min, 10 DCDs < 30 min). The survival rates in the DCD
group at 1, 2 and 5 yrs were 88%, 88% and 80%, respectively (median follow-up,
1075 days; range, 1–3210). These survival rates were not different from those of the
BDD group (Log-rank test; p = 0.81, Figure). In the DCD group, 5 patients died.
Causes of death were: small bowel infarction and multiple system organ failure
(MSOF) on day 1, bronchiolitis obliterans (BOS) on day 305, metastatic colon cancer after 2.91 yrs, non-small cell cancer on native lung after 5.59 yrs, and MSOF
after 8.79 yrs. 3 DCD patients required redo LTx (2 for BOS on day 91 and 8.55 yrs
and 1 for bronchial dehiscence on day 22).
175
TUESDAY
Afternoon
OBJECTIVE: The shortage of donor organs is the most critical problem in solid
organ transplantation. In an attempt to solve this, donation after cardiac death
(DCD) donors have been proposed as an additional source of donor organs.
Although short-term outcomes after DCD lung transplantation (LTx) have been
described, there are no long-term survival reports and the susceptibility to injury
and post-transplant reliability of DCD lung allograft are unclear. This study examines our institutional experience in DCD LTx after 1993.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
CONCLUSION: Our data shows that the long term patient survival after DCD
LTx was equivalent to that after BDD LTx. Although the number is small and further evaluation is necessary to conﬁrm our ﬁndings, our data substantiated excellent short-term survival. The use of DCD donors will substantially expand the
donor pool for LTx.
3:00 p.m.
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
176
AMERICAN ASSOCIATION FOR THORACIC SURGERY
3:45 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
GENERAL THORACIC SURGERY
Room 312, Hynes Convention Center
Moderators:
Nasser K. Altorki
Shaf Keshavjee
44. Laparoscopic Diaphragm Plication: An Objective Evaluation of
Short-and Mid-Term Results
Shawn S. Groth,1 Natasha M. Rueth,1 Amy Klopp,1 Teri Kast,1 Jonathan D’Cunha,1*
Rosemary F. Kelly,2* Michael A. Maddaus,1* Rafael S. Andrade,1
1. Surgery, University of Minnesota, Minneapolis, MN, USA;
2. Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
Invited Discussant: Sudish C. Murthy
METHODS: We performed an Institutional Review Board-approved prospective
cohort study of symptomatic patients with HPE who underwent LDP from April
2005 through September 2008. Patients with primary neuromuscular disorders
were excluded from our analysis. We evaluated patients with pulmonary functions
tests (PFT) and the St. George’s Respiratory Questionnaire (SGRQ) preoperatively
and 1 and 12 months postoperatively. The SGRQ is a standardized questionnaire
that evaluates the health impairment from respiratory disease; we report the total
score (range, 0 to 100; normal score, ≤ 6; highest score = maximum impairment). A
change of >4 points after an intervention is considered signiﬁcant. Matched pairs t
tests were utilized to evaluate the changes between preoperative and postoperative
PFT results and SGRQ scores. A 2-sided signiﬁcance level of 0.05 was used for all
statistical testing.
RESULTS: During the study period, 22 patients underwent LDP. We had 1 conversion to open. Two patients developed pleural effusions that required drainage;
we found no other complications. Preoperative and 1-month postoperative PFTs
were obtained from 20 patients; 11 of these patients also completed 12-month postoperative PFT. As compared with preoperative values, we noted a signiﬁcant
improvement in the 1-month postoperative % predicted forced vital capacity
(FVC%), % predicted forced expiratory volume in 1 second (FEV1%), and maximum
forced inspiratory ﬂow (FIFMAX) (Table). The improvement in these PFT parameters
persisted at 12 months.
*AATS
Member
177
TUESDAY
Afternoon
OBJECTIVE: To objectively assess laparoscopic diaphragm plication (LDP) for
hemidiaphragm paralysis or eventration (HPE) using pulmonary function tests
(PFTs) and a respiratory quality of life questionnaire.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Pulmonary Function Tests and St. George’s Respiratory Questionnaire Scores
Before and After Laparoscopic Diaphragm Plication
SGRQ
Total Score
FVC%
FEV1%
Preoperative
65.2 ± 23.8
58.6 ± 12.4
54.9 ± 13.5
3.6 ± 1.5
1 Month Postoperative
36.6 ± 15.9*
65.1 ± 10.3*
63.0 ± 12.7*
4.5 ± 1.4*
12 Month Postoperative
30.8 ± 18.8*
62.6 ± 10.9*
62.8 ± 10.5*
4.6 ± 1.4*
FIFmax (L)
Results are presented as mean ± standard deviation
*Postoperative means that are signiﬁcantly different (p < 0.05) from preoperative means.
SGRQ: St. George’s Respiratory Questionnaire FVC%: Percent predicted forced vital capacity
FEV1%: Percent predicted forced expiratory volume in 1 second FIFmax: Maximum forced
inspiratory ﬂow
Preoperative SGRQ and 1 month-postoperative SGRQ were collected from 12
patients; 12-month postoperative SGRQ were obtained from 6 patients. The SGRQ
total score improved signiﬁcantly at 1 month when compared to the preoperative
score (Table). The SGRQ score showed a trend towards further improvement at
12 months.
CONCLUSION: Our objective evaluation of LDP for HPE demonstrates a signiﬁcant
short- and mid-term improvement in PFTs and quality of life. This novel minimally
invasive approach represents a potential paradigm shift in the surgical management
of the diaphragmatic paralysis and eventration.
178
AMERICAN ASSOCIATION FOR THORACIC SURGERY
45. Minimally Invasive Resection of Stage 1 and 2 Thymoma:
Comparison with Open Resection
Arjun Pennathur, Irfan Qureshi, Matthew Schuchert, Peter Ferson, Neil A. Christie,
Sebastien Gilbert, William Gooding, Manisha Shende, Rodney J. Landreneau,*
James D. Luketich*
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Invited Discussant: David Jablons
OBJECTIVE: The minimally invasive thoracoscopic (VATS) approach to resection
of the thymus is practiced in benign disease, but a VATS approach for thymoma
remains controversial. The objective of this study was to evaluate the results of
VATS thymectomy for the treatment of early stage thymoma and compare these
results with open resection
RESULTS: Thymectomy was performed for 38 patients with Stage I (n = 14) and
Stage II (n = 24) thymoma. There were 16 men and 22 women (median age 64;
range 35–86 years). Open thymectomy was performed in 22 patients, VATS resection
was performed in 16. Margins of resection were negative in over 90% in both
groups and the operative mortality was 0%. Stages were equivalent in both surgical
groups, and there was no signiﬁcant difference in the number receiving adjuvant
radiotherapy for stage II disease. Median length of stay was shorter in the VATS
group. During follow-up (mean follow-up: 34.8 months) there was one death in
the VATS group at 7. 1 years. Estimated cancer-speciﬁc 5-year survival was 100% in
both groups (Table).
Comparison of VATS vs. Open Approach for Early Stage Thymoma
Thoravoscopic
Approach (n = 16)
Open
Approach (n = 22)
Stage I
5 (31.3%)
9 (40.9%)
0.4227
Stage II
11 (68.7%)
13 (59.1%)
0.8383
15/16 (93.8%)
20/22 (90.9%)
0.8634
2.5
5
0.0057
0/16 (0%)
2/22 (9.1%)
NS
100%
100%
NS
R0 Resection
Median Length of Stay (Days)
Recurrence
Estimated Overall 5 Year Survival
p-Value
CONCLUSION: VATS resection of early stage thymoma appears safe, with a
shorter length of stay. Oncologic outcomes were excellent and equivalent in the
open and VATS groups during intermediate term follow-up. Further follow-up is
required to evaluate the long term results of thoracoscopic thymectomy for early
stage thymoma.
*AATS
Member
179
TUESDAY
Afternoon
METHODS: A retrospective review of patients undergoing surgical resection of
early stage thymoma over a 9 year period was conducted. Data on complications,
recurrence and survival were collected. The primary endpoint studied was overall
survival.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
46. Predictive Factors for Survival in Esophageal Cancer Patients with
Persistent Lymph Node Metastases Following Neoadjuvant
Therapy and Surgery
Brendon M. Stiles,1 Subroto Paul,1† Jeffrey L. Port,1 Paul C. Lee,1 Paul Christos,2
Nasser K. Altorki1*
1. Division of Thoracic Surgery, New York Presbyterian Hospital, Weill Cornell
Medical College, New York, NY, USA; 2. Department of Biostatistics and
Epidemiology, New York Presbyterian Hospital, Weill Cornell Medical College,
New York, NY, USA
Invited Discussant: Jeffrey Hagen
OBJECTIVE: In esophageal cancer (EC) patients, a complete pathologic response
following neoadjuvant therapy is associated with a favorable survival. Less is known
regarding factors predictive of outcome in patients with persistent nodal disease
after induction therapy. The purpose of this study is to determine which variables
affect survival in this patient population.
METHODS: We reviewed a prospectively maintained EC database (1989–2008).
Patients with positive lymph nodes after preoperative therapy were selected by
review of surgical pathology. Demographic, surgical, and staging data were reviewed.
Overall survival (OS) was determined by the Kaplan Meier method. Predictors
of survival were examined univariately using the log-rank test. Factors identiﬁed at
p < 0.20 by univariate analysis were selected for inclusion in a multivariate cox proportional hazards regression model.
RESULTS: Ninety-six patients (median age 62 yrs; 85% male; 73% adenoCA)
with 1 or more positive nodes received preoperative chemotherapy, including 9 who
also had induction radiation. pT-stage was 0–2 in 25 (26%) and 3 or 4 in 71 (74%)
patients. In 28 (30%) patients, nonregional nodal disease was present (M1a). Final
pathologic stages were: IIB in 18 (19%); III in 49 (51%); and IVA in 29 (30%). Postoperatively, 44 (46%) patients received additional chemotherapy. OS was 46% at
2 years and 30% at 5 years. On univariate analysis, pathologic stage, pathologic
T status, and number of positive nodes (range 1–31, median 4) signiﬁcantly
impacted OS (Table 1). Patient age, gender, histology, and total lymph nodes
resected had no effect on OS. On multivariate analysis, clinical stage (HR 2.43, p = .028),
pathologic T status (HR 3.42, p = 0.004) and number of positive nodes (HR 1.047
per node, p = 0.029) were signiﬁcant predictors of OS.
CONCLUSION: Long term survival can be achieved in a meaningful proportion
of EC patients with persistent nodal disease after neoadjuvant therapy and surgical
resection. Pathological T stage and number of positive nodes resected best predict
survival. Nonregional nodal disease does not adversely affect outcome. Postoperative
chemotherapy appears to confer no additional survival beneﬁt.
*AATS
Member
Traveling Fellowship 2006
†Resident
180
AMERICAN ASSOCIATION FOR THORACIC SURGERY
Variable
Clinical Stage*
Pathologic Stage
pT Status
Subgroups
2-Year OS
I, II (n = 20)
60%
III, IV (n = 65)
42%
IIB (n = 18)
70%
III (n = 49)
31%
IVA (n = 29)
55%
0,1,2 (n = 25)
74%
3,4 (n = 71)
35%
Number of Positive Nodes
(by quartile)
pM Status
Adjuvant Chemotherapy
58%
56%
4–7
44%
>7
19%
<22
40%
23–32
40%
33–42
50%
>42
43%
M0 (n = 68)
42%
M1a (n = 28)
55%
No (n = 52)
41%
Yes (n = 44)
50%
*In 11 patients clinical stage was not recorded.
5:00 p.m.
EXECUTIVE SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
181
.07
.01
.001
.009
.66
.25
.86
TUESDAY
Afternoon
Total Nodes Resected
(by quartile)
1
2–3
p-Value
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
NOTES
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
TUESDAY AFTERNOON
MAY 12, 2009
2:00 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
(8 minutes presentation, 12 minutes discussion)
Moderators:
J. William Gaynor
Richard G. Ohye
47. Genetic Factors are Important Determinants of Impaired Growth
Following Infant Cardiac Surgery
Invited Discussant: Thomas J. Yeh
OBJECTIVE: To estimate the prevalence and identify predictors of impaired
growth following infant cardiac surgery.
METHODS: Secondary analysis of a prospective study of the role of apolipoprotein E
(APOE) gene polymorphisms on neurodevelopment in young children following
infant cardiac surgery. Prevalence estimates for growth velocity were derived using
anthropometric measures [weight (WT) and head circumference (HC)] obtained
at birth and at 4 years of age. Growth measure z-scores were calculated using the
World Health Organization Child Growth Standard. Growth velocity was evaluated using two different techniques: ﬁrst by clustering the children into one of
three growth velocity subgroups based on z-score differences between birth and
4 yrs (impaired growth [>0.5σ], stable [–0.5σ to 0.5σ], growth improving [<0.5σ]),
and, second, using continuous difference scores. Statistical analyses were conducted
using a combination of proportional odds models for the ordered categories and
simple linear regression for the continuous outcomes. Genetic evaluation was also
performed.
RESULTS: Three hundred and nineteen full term (gestational age of 37 weeks or
greater) subjects had complete anthropometric measures for WT and HC at birth
and at four yrs. The cohort was 56% male. Genetic examinations were available for
97% (309/319) of the cohort (normal, 74% [229/309]; deﬁnite or suspected genetic
abnormality, 26% [80/309]). Frequency counts for WT categories were: impaired
*AATS
Member
183
TUESDAY
Afternoon
Nancy B. Burnham,1 Richard F. Ittenbach,2 Virginia A. Stallings,1 Marsha Gerdes,1
Elaine H. Zackai,1 Judy Bernbaum,1 Gil Wernovsky,1 Robert R. Clancy,1
Jo Ann D’Agostino,1 Donna McDonald-McGinn,1 Diane Hartman,1 Jennifer Raue,1
Jennifer Hufford,1 Courtney Terrili,1 Susan C. Nicolson,1 Thomas L. Spray,1*
J. William Gaynor1*
1. Children’s Hospital of Philadelphia, Philadelphia, PA, USA;
2. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
growth 37% (117/319), stable growth 31% (100/319), and improving growth 32%
(102/319). Frequency counts for HC categories were: impaired growth 39% (126/319),
stable growth 28% (88/319), and improving growth 33% (105/319). Presence of a
deﬁnite or suspected genetic syndrome (p = 0.04) was found to be a predictor of
impaired growth for WT, but not HC. When growth z-scores were used as continuous
outcomes, the APOE ε2 allele was found to be predictive of lower z-scores for both
WT (p = 0.02) and HC (p = 0.03).
CONCLUSION: Impaired growth for both WT and HC is common (both > 30%)
in this cohort of children following infant cardiac surgery. Both the APOE ε2 allele
and the presence of a deﬁnite or suspected genetic syndrome were associated with
impaired WT growth velocity. The APOE ε2 allele was also associated with impaired
growth velocity for HC. Persistent poor growth may have long-term implications
for the health of children with CHD.
184
AMERICAN ASSOCIATION FOR THORACIC SURGERY
48. Mechanical Mitral Valve Prostheses in Children Don’t Deserve
Their Ill Repute
Roland Henaine, Joseph Nloga, Fabrice Wautot, Jacques Robin,
Jean-François L. Obadia,* Jean Ninet
Cadiothoracique Surgery, Lyon, France
Invited Discussant: Christopher A. Caldarone
OBJECTIVE: There is no doubt that in children with congenital mitral valve
(MV) disease reconstructive surgery is the ﬁrst choice. When repair is not possible,
however, MV replacement is an alternative which could beneﬁt from better evaluation. Few data exists in the literature and we here report the long-term MV replacement results in the largest series ever published: 30 children <5 years old followed
up over a period of 20 years.
TUESDAY
Afternoon
METHODS: From 1975 to 2007, 30 MV replacements (29 mechanical + 1 biological) were performed in 30 children aged 95 days to 4.6 years (mean, 1.9 ± 1.3 year),
weighing 4.7 to 15 kg (mean, 8.2 ± 2.9 kg). Mitral regurgitation was present in 25
children, including 1 endocarditis and 5 mitral stenoses. Seventeen patients (27%)
had had at least one previous operation before MVR. Prosthesis size ranged
between 16 and 27 mm.
RESULTS: Overall hospital mortality was 17% (5/30). None of the children were
lost to follow-up, which totaled 373 patient-years (mean = 12.4 years ± 8.6).
Eleven patients required re-operation 4 to 23 years latter (mean = 12 ± 5.6 years).
During this reoperation a larger mechanical valve was implanted (+2 sizes) with no
postoperative death.
Valve-related complications comprised thrombo-embolism in 2 patients (minor
neurologic sequelae) and structural deterioration of the bioprosthesis in 1. Atrioventricular block was present in 4 patients who had already been operated on at
least once before MV Replacement. Overall ﬁfteen-year survival was 83%, with no
late deaths. At the time of writing, 23 patients were in New York Heart Association
(NYHA) class I and two in class II.
*AATS
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185
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
CONCLUSION: In contrast to conventional wisdom, MVR gives excellent results
in children. Postoperative mortality is mainly due to severe and complex congenital
pathologies in children who have often undergone multiple operations. Long-term
results in those who do survive the ﬁrst month are excellent. Anticoagulants are
well tolerated, with little thrombo-embolic complication.
186
AMERICAN ASSOCIATION FOR THORACIC SURGERY
49. Fate of Reconstructed Biventricular Outﬂow Tracts After Repair
for Transposition of the Great Arteries with Ventricular Septal
Defect and Left Ventricular Outﬂow Tract Obstruction: Midterm
Results and Future Implications
Sheng-Shou Hu,* Yan Li, Shoujun Li, Zhigang Liu, Zhe Zheng, Yongqing Li
Cardiovascular Surgery, National Heart Center and Fuwai Hospital, Beijing, China
Invited Discussant: Pdefro J. del Nido
OBJECTIVE: Three techniques have been used as the surgical repair for patients
with transposition of the great arteries with ventricular septal defect and left ventricular outﬂow tract obstruction (TGA/VSD/LVOTO): Rastelli, Lecompte (REV),
and root translocation procedures. This study was designed to compare the midterm results of these 3 procedures with respect to echocardiographic analysis of the
reconstructed biventricular outﬂow tracts.
RESULTS: There were 7 in-hospital deaths (Rastelli: 4, REV: 2, DRT: 1). Within a
median follow-up of 24 months (range 3 to 54 months) there were no late deaths.
Concerning neo-LVOT, the follow-up gradient was 4 to 52 mm Hg (median 24) in
Rastelli group and 2 to 44 mm Hg (median 18) in REV group. In DRT group the
follow-up LVOT gradient was 2 to 20 mm Hg (median 8), unchanged from early
postoperative condition. Rastelli procedure, VSD/aortic size discrepancy and duration
of follow-up time were main precursors of recurrent LVOTO (gradient > 25 mmHg).
Aortic regurgitation of 2 or greater developed in 10.9% in Rastelli group, 7.7% in
REV group and none in DRT group. Concerning the neo-RVOT, the follow-up gradient was 9 to 35 mmHg (median 16) in Rastelli group, 4 to 25 mm Hg (median 10)
in REV group, and 2 to 24 mmHg (median 10) in DRT group. Moderate or greater
pulmonary regurgitation developed in 15.9% in Rastelli group versus 7.7% in REV
group and 5.1% in DRT group. Rastelli procedure and duration of follow-up time
were the principal determinant of moderate or greater pulmonary regurgitation.
CONCLUSION: Midterm results of DRT procedure, a more anatomic repair
compared with Rastelli or REV procedure, indicate effective relief of LVOTO and
better hemodynamic performance of both reconstructed outﬂow tracts. Because
“time” is a principal predictor of the fate of outﬂow tracts, strict follow-up after
operation is mandatory.
3:00 p.m.
*AATS
INTERMISSION – VISIT EXHIBITS
Exhibit Hall
Member
187
TUESDAY
Afternoon
METHODS: Between 2004 and 2008, 103 consecutive patients with TGA/VSD/
LVOTO underwent biventricular repair: Rastelli (n = 48), REV (n = 15), and double
(aortic and pulmonary) root translocation (DRT, n = 40). The median age at operation was 5.2 years (range 0.7 to 19). The operative technique of DRT includes that
both native aortic and pulmonary roots were excised and translocated. In REV and
DRT group, right ventricular outﬂow tract (RVOT) reconstruction was achieved
with a single-valved bovine jugular vein patch. All these patients were reviewed for
in-hospital and follow-up echocardiographic assessment of reconstructed biventricular outﬂow tracts.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
3:30 p.m.
SIMULTANEOUS SCIENTIFIC SESSION –
CONGENITAL HEART DISEASE
Room 312, Hynes Convention Center
Moderators:
J. William Gaynor
Richard G. Ohye
50. Gene Expression Proﬁling in the Right Ventricular Myocardium of
Newborns with Hypoplastic Left Heart Syndrome
Marco Ricci,1* Bhagyalaxmi Mohapatra,2 Arnel Urbiztondo,1 Matteo Vatta2
1. Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, FL,
USA; 2. Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
Invited Discussant: Peter Gruber
OBJECTIVE: Hypoplastic left heart syndrome (HLHS) is characterized by an
underdeveloped left ventricle (LV), which leaves the right ventricle (RV) exposed to
pressure/volume overload and hypoxemia due to single ventricle physiology. We
investigated the molecular plasticity of the neonatal RV in response to the developmental, mechanical, and biochemical stress induced by HLHS.
METHODS: In order to test the role of developmental pathways in the neonatal
HLHS-RV subsequent to pathophysiological adaptation, we obtained RV tissue
from 6 neonates undergoing stage 1 Norwood procedure (age 1–7 days; mean 4 days).
Quantitative Real-Time PCR (QPCR) was used to compare RV gene expression in
HLHS with RV and LV tissue obtained from 5 age-matched human controls (age
range 1–135 days: mean 85 days). A panel of 84 genes involved in TGF/BMP-mediated
cardiac development, cell growth, and differentiation was analyzed.
Differences in Gene Expression Proﬁles Between HLHS-RV Versus
Control-RV and Control-LV
Gene Name
Anti Mullerian hormone
Anti Mullerian hormone Recptor 2
Bone morphogenetic protein 5
BMP binding endothelial regulator
Growth differentiation factor 3
Symbol
Fold Change
(RV Control)
Fold Change
(LV control)
–1.8
AMH
2.3
AMHR2
18.7
3.3
BMP5
4.5
no change
BMPER
5.6
2.5
GDF3
8.5
no change
Inhibin, alpha
INHA
11.4
5.7
Inhibin, beta A
INHBA
–1.7
no change
Inhibin, beta B
Serpin peptidase inhibitor, clade E
*AATS
INHBB
–9.7
–7.9
SERPINE
–4.1
no change
Member
188
AMERICAN ASSOCIATION FOR THORACIC SURGERY
RESULTS: We ﬁrst compared the gene expression proﬁles of control LV and RV
due to their physiological differences, and demonstrated signiﬁcant depression of
TGFβ/BMP signaling in RV compared to LV. Further, we compared HLHS-RV to
control RV, and found signiﬁcant up regulation of anti mullerian hormone (+2.34
fold), anti mullerian hormone receptor 2 (+18.79 fold), down regulation of Activin
genes (–9.76 fold), and over expression of BMP3 (+2.16 fold) and BMPER (+5.62
fold). These genes antagonize Activins, BMP2, BMP4, BMP6 and BMP7, leading to
aberrant RV development. Also, we found GDF3 (+8.59 fold) and Nodal (+2.32
fold) up regulation, enhancing cell growth in HLHS-RV. Cell survival was
enhanced by CDC25A (+2.18 fold) and CDKN1A (-3.64 fold) changes in HLHS-RV.
These differences were less prominent when HLHS-RV was compared to control
LV, suggesting that HLHS induces RV gene expression proﬁles similar to the axial
patterning and development of control LV.
189
TUESDAY
Afternoon
CONCLUSION: Our results suggest that the mechanical/biochemical stress
induced by HLHS causes depression of cardiac development pathways and
enhancement of cell growth and differentiation pathways in the neonatal RV. The
RV molecular proﬁles in HLHS are reminiscent of those observed in normal LV
maturation in the early post-natal period. This work provides the basis for future
studies to understand the molecular mechanisms of RV remodeling and failure in
HLHS.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
51. Twenty Three Years of One-stage End-to-Side Anastomosis Repair
of Interrupted Aortic Arches
Yves d’Udekem,1 Aisyah S. Hussin,1 Ajay J. Iyengar,1 Igor E. Konstantinov,1
Suzan M. Donath,1 Gavin R. Wheaton,2 Andrew M. Bullock,3 Leeanne E. Grigg,4
Bryn O. Jones,1 Christian P. Brizard1
1. Cardiac Surgery, Royal Children’s Hospital, Parkville, Melbourne, VIC, Australia;
2. Women’s and Children’s Hospital, Adelaide, SA, Australia; 3. Princess Margaret
Hospital, Perth, WA, Australia; 4. Royal Melbourne Hospital, Melbourne,
VIC, Australia
Invited Discussant: V. Mohan Reddy
OBJECTIVE: To deﬁne the long-term results of a policy of one-stage repair of
interrupted aortic arches with end-to-side (ETS) anastomosis.
METHODS: Records of all pts undergoing interrupted aortic arch repair after the
introduction of the ETS technique were reviewed. From 1985 to 2007, 113 pts (60 males)
were operated at a median of 6 days (1 d–2 y). Interruption was type A in 37 pts
(33%), type B in 73 (64%), and type C in 3 (3%). Associated conditions were VSD
(86), truncus (13), DORV (8), AP window (4), single ventricle (13). Subaortic stenosis
was suspected in 36 pts (31%). Fifty-ﬁve pts (49%) required ventilation and 33
(30%) inotropic support prior surgery. One-stage repair was performed in 100 pts
(89%), 93 having ETS repair. Before 2000, one-stage repair was performed under
deep hypothermic circulatory arrest, and thereafter with moderate hypothermia
and selective cerebral perfusion.
RESULTS: There were 12 hospital deaths (11%). The only predictive factor of hospital mortality was repair different than ETS (25% (5/20) vs 8% (7/93); p < 0.05).
Twelve pts needed arch reintervention during the same hospital stay: 8 for residual
arch obstruction (5 ETS), and 4 for left main bronchus obstruction (3 ETS).
Nine pts were lost to follow-up. After a mean of 10 ± 7 years, there were 6 late
deaths for a 18 year survival of 94% (95% CI: 84–97%). Pts operated with ETS had
better chances of survival (18 year survival 95% (95% CI: 86–98%) vs 77% (95%
CI: 44–92%). By multivariate analysis the only predictive factor of late mortality
was post-operative occurrence of left main bronchus compression (p < 0.005). Following hospital discharge, 18 pts had to undergo further aortic arch intervention
by surgery (5), catheter intervention (7), or both (3). The only factor predictive of
early or late arch reintervention was initial procedure performed through thoracotomy (p = 0.001). Freedom from arch reintervention after ETS repair was 75% at 18
years (95% CI: 56–87%). On echocardiography, an additional 16 pts were identiﬁed to have a residual gradient higher than 25 mm Hg. The 18 year freedom from
hypertension was 88% (95% CI: 72–95%).
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
191
TUESDAY
Afternoon
CONCLUSION: One-stage repair with end-to-side anastomosis seems to be the
optimal approach for neonates born with interrupted aortic arch. It provided longlasting relief of the arch obstruction with low early mortality. After two decades of
experience with this approach, the incidence of late hypertension seems minimal.
The need for further arch reintervention warrants close follow-up of these patients.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
52. Unifocalisation of Major Aortopulmonary Arteries in Pulmonary
Atresia with Ventricular Septal Defect Is Essential to Achieve
Excellent Outcomes Irrespective of Native Pulmonary Artery
Morphology
Ben Davies,1 Shaﬁ Mussa,1 Paul Davies,2 John Stickley,1 John G. Wright,1
Joseph V. de Giovanni,1* Oliver Stümper,1 Rami Dhillon,1 Timothy J. Jones,1
David J. Barron,1 William J. Brawn1
1. Department of Cardiac Surgery, Birmingham Children’s Hospital, Birmingham,
United Kingdom; 2. Institute of Child Health, University of Birmingham,
Birmingham, United Kingdom
Invited Discussant: Christian Brizard
OBJECTIVE: Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals (MAPCAs) is a complex lesion with a high rate of natural
attrition. We evaluated the outcomes of our strategy of unifocalisation in the management of these patients.
METHODS: From 1989 to 2008, 236 patients (109 male) entered a pathway aiming
for complete repair by unifocalising major aortopulmonary arteries to an RV-PA
conduit with VSD closure. Where ventricular septation was not possible, deﬁnitive
repair was considered to include pulmonary artery reconstruction and a limiting
RV-PA conduit or systemic shunt. Native pulmonary artery morphology was classiﬁed into conﬂuent intrapericardial (n = 154), conﬂuent intrapulmonary (n = 54)
and non-conﬂuent intrapulmonary (n = 28).
*AATS
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192
AMERICAN ASSOCIATION FOR THORACIC SURGERY
RESULTS: Follow-up was 94% complete. 30-day and late mortality after deﬁnitive surgery in all 236 patients was 6% (n = 13) and 6% (n = 14), respectively. Overall survival was 89% at 3 years following deﬁnitive repair. 203 patients (85%) had
deﬁnitive repair at a median age of 2.0 years. There was no signiﬁcant difference in
survival following complete repair between patients from any of the three morphological pulmonary artery groups (P = 0.18). 132 (56%) patients had complete repair
with VSD closure, as a single or staged procedure in 111 and 21 patients, respectively. Focalisation of MAPCAs with proven long-term patency with the RV was
associated with a survival beneﬁt compared to 14 patients in whom unifocalisation
was not possible and had only systemic shunts. In the follow-up period, 190
patients required 196 catheter and 60 surgical re-interventions.
CONCLUSION: Using a strategy of unifocalisation, intrapericardial pulmonary
artery reconstruction and RV-PA conduit, excellent long-term survival can be
achieved in this group of patients even in the absence of native intrapericardial
pulmonary arteries.
TUESDAY
Afternoon
193
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
53. Impact of Comprehensive Perioperative and Interstage Monitoring
on Survival in High-Risk Infants After Stage 1 Palliation of
Univentricular Heart Disease
Nancy S. Ghanayem,1 Kathleen A. Mussatto,2 George M. Hoffman,1
Michael E. Mitchell,1 Michele A. Frommelt,1 Joseph R. Cava,1
James S. Tweddell1*
1. Medical College of Wisconsin, Milwaukee, WI, USA; 2. Children’s Hospital of
Wisconsin, Milwaukee, WI, USA
Invited Discussant: J.W. Gaynor
OBJECTIVE: Survival after Norwood palliation for high-risk patients with
univentricular congenital heart disease is reduced compared to standard-risk
patients. We hypothesized that early goal directed monitoring with venous oximetry
and near infrared spectroscopy, and noninvasive interstage monitoring, would offset
the increased vulnerability of high-risk patients and improve survival.
METHODS: An IRB-approved prospective database of patients with univentricular
cardiac defects undergoing stage 1 palliation was used to study outcomes since
incorporation of a comprehensive goal-directed monitoring program. Patients were
considered high-risk if ≤35 weeks gestation, birth weight <2.5 kg, or extracardiac
anomalies were present. Early (30 day) survival, survival to stage 2 palliation,
1 year survival, and survival to date were compared between high-risk and standardrisk groups utilizing chi-square and Kaplan-Meier survival analyses.
Kaplan-Meier Curve by Risk Category
RESULTS: From 9/2000–9/2008 162 patients underwent stage 1 palliation. Patients
were 24% (39/162) high-risk and 76% (123/162) standard-risk. Univentricular lesions
other than hypoplastic left heart syndrome were more common in high-risk
patients: 38% (15/39) versus 16% (20/123), p = 0.006. Early survival was similar
*AATS
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194
AMERICAN ASSOCIATION FOR THORACIC SURGERY
between groups: 97% (38/39) in high-risk versus 97% (119/123) in standard-risk.
Survival to stage 2 palliation was 87.2% (34/39) in high-risk versus 93.5% (115/123)
in low risk groups, p = 0.2. High-risk patients discharged from ICU were more
likely to require inpatient treatment until stage 2 palliation: 26% (9/34) versus 10%
(12/118), p = 0.003, although age at stage 2 palliation was not different (126 ± 33
days versus 116 ± 38 days, p = 0.2). High-risk patients had lower 1 year survival
(76% versus 93%, p = 0.001) and survival to date (72% versus 92%, p = 0.004).
5:00 p.m.
EXECUTIVE SESSION
(AATS Members Only)
Ballroom A–C, Hynes Convention Center
195
TUESDAY
Afternoon
CONCLUSION: With an intensive monitoring strategy, identical high early survival was achieved in both patient risk strata. Prolonged interstage hospitalization
for intensive non-invasive monitoring in high-risk patients until stage 2 palliation
conferred similar survival to standard-risk patients monitored at home. Mortality
beyond stage 2 palliation when level of monitoring is reduced is a relatively unique
feature of high risk patients. Although mortality is reduced with enhanced monitoring, high resource utilization and late attrition of high-risk patients after stage 2
palliation suggests an ongoing need to evaluate our current palliative strategy for a
subset of patients with univentricular heart disease.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
NOTES
196
AMERICAN ASSOCIATION FOR THORACIC SURGERY
WEDNESDAY MORNING
MAY 13, 2009
7:00 a.m.
EMERGING TECHNOLOGIES AND
TECHNIQUES FORUM
Ballroom A–C, Hynes Convention Center
(5 Minutes Presentation, 7 Minutes Discussion)
Moderators: Robert J. McKenna, Lars G. Svensson
T1.
The Direct Flow Valve: First in Man Experience with a
Repositionable and Retrievable Pericardial Valve for
Percutaneous Aortic Valve Replacement
Hendrik Treede,1 Jochen Schofer,2 Thilo Tuebler,2 Olaf Franzen,1
Thomas Meinertz,1 Reginald Low,3 Steven F. Bolling,4* Hermann Reichenspurner1*
1. Department of Cardiovascular Surgery, University Heart Center Hamburg,
Hamburg, Germany; 2. Hamburg University Cardiovascular Center, Hamburg,
Germany; 3. University of California Davis, Davis, CA, USA 4. University of
Michigan Hospital, Ann Arbor, MI, USA
Invited Discussant: Tomislav Mihaljevic
METHODS: 31 patients were enrolled in this clinical trial. 9 patients were excluded
due to excessive calciﬁcations or other reasons. A total of 22 patients underwent
percutaneous valve replacement. All patients had a high risk for operation (Mean
Log. Euroscore 28 ± 7%, mean STS score 24 ± 9%). Mean pre-interventional
gradients were 50 ± 13 mmHg, mean aortic oriﬁce area was 0.55 ± 0.16 cm2. The
device was placed transfemoral in the left ventricle by a ﬂexible sheath under
ﬂouroscopic control. The lower ring was inﬂated and the valve was positioned in
the LV outﬂow tract and then pulled against the aortic annulus. After inﬂation of
the upper ring valve performance was controlled and eventual repositioning
performed. Polymer media were infused in the rings once correct position was
conﬁrmed.
*AATS
Member
197
WEDNESDAY
Morning
OBJECTIVE: Percutaneous aortic valve replacement is a considerable alternative
for patients carrying a high risk for operation. The Direct Flow percutaneous aortic
valve is the ﬁrst that is not based on stent technology. The stentless tissue valve
with bovine pericardial leaﬂets is connected to two inﬂatable rings showing a high
ﬂexibility and deliverability. It is immediately competent upon initial inﬂation.
Implantation does not require rapid pacing or cardiac support. The valve is repositionable, retrievable and available in two sizes.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
RESULTS: Permanent implantation could be achieved in 20 of 22 patients with
good hemodynamic result. Two patients had to be converted to surgical aortic
valve replacement due to increased gradients caused by distortion of the prosthesis.
Implanted valves showed a good post-procedural performance with a mean gradient
of 14.7 mmHg (mean) and a mean oriﬁce area of 1.53 cm2. 50% of patiens showed
small paravalvular leaks without hemodynamic inﬂuence. 4 patients died due to
intraprocdural septal rupture, pulmonary embolism, non device related myocardial
infarction and decompensated congestive heart failure. One patient developed a
major stroke, 3 patients underwent pacemaker implantation due to av-blockage.
13 patients showed no peri- or post-procedural complications.
CONCLUSION: The Direct Flow aortic valve prosthesis gives the operator unprecedented freedom of handling the device during implantation process. Despite the
patients’ high surgical risk proﬁle, implantation without hemodynamic compromise
during the procedure appears safe. The amount and distribution of leaﬂet and
LVOT calciﬁcation impacts procedural outcome, therefore sufﬁcient patient selection
is crucial.
198
AMERICAN ASSOCIATION FOR THORACIC SURGERY
T2.
Use of Subclavian-Carotid Bypass and Thoracic Stent
Grafting to Minimize Cerebral Ischemia in Total Aortic
Arch Reconstructions
Steve Xydas,1 Benjamin Wei,2 Hiroo Takayama,1 Mark J. Russo,1
Craig R. Smith,1* Matthew D. Bacchetta,1 Allan Stewart1
1. NY Presbyterian Hospital-Columbia, Division of Cardiothoracic Surgery,
New York, NY, USA; 2. NY Presbyterian Hospital-Columbia, Department of
Surgery, New York, NY, USA
Invited Discussant: John A. Kern
OBJECTIVE: Total aortic arch replacement (TAAR) typically requires either a
period of hypothermic circulatory arrest (HCA) and/or the use of antegrade selective cerebral perfusion (SCP), carrying the risks of cerebral ischemia. We recently
introduced the use of left subclavian-carotid bypass (SCB) prior to TAAR with
staged thoracic stent grafting to achieve total arch reconstruction with relatively
short periods of SCP. We compared our institutional experience of TAAR with and
without SCB.
RESULTS: Patient characteristics are shown in Table 1. The mean duration of SCB
time in Group I was 34 minutes, compared to 16 minutes in Group II (p = 0.007).
50% of the patients in Group I required HCA, compared to 0% in group II. The
mean cardiopulmonary bypass (218 min vs 154 min, p = 0.03) and aortic crossclamp times (109 min vs 76 min, p = 0.04) were longer in Group I than Group II.
The incidence of neurological complications, deﬁned as stroke or spinal cord
ischemia within 48 hours of surgery, was 18% in Group I (5/28), compared to 0%
(0/6) in Group II (p = 0.28). There were no signiﬁcant differences in the mortality
rate or the length of ICU or hospital stay between Groups I and II.
CONCLUSION: Left SCB prior to TAAR with staged thoracic stent grafting to
achieve total arch reconstruction was associated with a signiﬁcant decrease in the
duration of SCP and eliminated the need for HCA. This technique may prove to
decrease the risk of neurological complications associated with TAAR and provide
a viable hybrid approach to patients with aortic arch aneurysms.
*AATS
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199
WEDNESDAY
Morning
METHODS: From July 2004 to August 2008, 329 patients at our institution
underwent ascending aorta or arch replacements. Of these, 34 patients (64% male,
36% female; mean age 66 years) underwent TAAR. TAAR was performed with
cannulation of the right axillary artery to establish SCP after cooling to 28 degrees
C and/or HCA at 18 degrees C. In 2008, we began performing left SCB prior to a
debranching procedure of the aortic arch involving use of a bifurcated aortic graft
with aorta to innominate and aorta to left carotid artery bypass. These patients
then underwent staged thoracic aortic stenting with deployment into the aortic
graft to complete arch reconstruction. 28 patients received TAAR without left SCB
(Group I). 6 patients received TAAR with left SCB and aortic stent grafting (Group II).
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Table 1. Comparison of Preoperative, Intraoperative, and Postoperative
Variables for Patients Receiving Taar Only (Group 1) Versus TAAR with
Subclavian-Carotid Bypass and Thoracic Stent Grafting (Group 2)
Preoperative
Age (mean), years
Male, n (%)
Female, n (%)
Hypertension, n (%)
Coronary artery disease, n (%)
Diabetes mellitus, n (%)
Atrial ﬁbrillation, n (%)
Previous stroke, n (%)
COPD, n (%)
Congestive heart failure, n (%)
Reoperative surgery, n (%)
Elective surgery, n (%)
Operative
Concomitant CABG, n (%)
Concomitant valve surgery, n (%)
Descending thoracic stent graft, n (%)
Use of HCA, n (%)
HCA time (mean), min
Use of SCP, n (%)
SCP time (mean), min
CPB time (mean), min
Aortic cross-clamp time (mean), min
Packed red blood cells (mean), units
Postoperative
ICU stay (median), days
Hospital stay (median), days
Stroke, n (%)
Spinal cord ischemia, n (%)
Neurological complications (stroke or spinal cord
ischemia), n (%)
Death, n (%)
Group I
(n = 28)
Group II
(n = 6)
p-Value
69
17 (61)
11 (39)
25 (89)
11 (39)
6 (21)
3 (11)
2 (7)
4 (14)
3 (11)
6 (21)
14 (50)
65
5 (83)
1 (17)
4 (67)
3 (50)
2 (17)
2 (33)
2 (17)
0 (0)
0 (0)
0 (0)
2 (33)
0.57
0.39
0.39
0.21
0.67
0.79
0.20
0.45
0.94
0.42
0.22
0.67
6 (21)
3 (11)
4 (14)
14 (50)
19
14 (50)
34
218
109
3.1
0 (0)
3 (50)
6 (100)
0 (0)
n/a
6 (100)
16
154
76
3.8
0.22
0.05
n/a
n/a
n/a
n/a
0.007
0.03
0.04
0.65
3.5
10
3 (11)
2 (7)
5 (18)
3
10
0 (0)
0 (0)
0 (0)
0.31
0.49
0.42
0.51
0.28
5 (18)
1 (17)
0.89
CABG – coronary artery bypass graft, CPB – cardiopulmonary bypass, HCA – hypothermic
circulatory arrest, SCP – selective cerebral perfusion, n/a – not applicable
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AMERICAN ASSOCIATION FOR THORACIC SURGERY
T3.
Transcatheter Aortic Valve Replacement in High-Risk Patients:
Superior Results Compared to Conventional Surgery
Robert Bauernschmitt, Domenico Mazzitelli, Christian Schreiber,
Hendrik Ruge, Sabine Bleiziffer, Andrea Hutter, Peter Tassani,
Ruediger Lange*
Clinic for Cardiovascular Surgery, German Heart Center Munich, Munich, Germany
Invited Discussant: Joseph E. Bavaria
OBJECTIVE: To compare the early results of transcatheter aortic valve replacement
(THV) in high-risk patients with aortic stenosis to the outcome of conventional
surgery in a single center.
METHODS: In 90 patients (mean age: 81.3 ± 7 y, 48% female, mean logistic EuroScore 25 ± 15.6%), THV using vascular approach (femoral: 87, subclavian: 3) was
performed between 7/2007 and 5/2008 using the 18-french-CoreValve system.
Outcome data were compared to a patient cohort matched according to EuroScore
values (mean age 78.8 ± 7.7 y, 46% female) treated by conventional surgical aortic
valve replacement (SAVR) with heart-lung machine performed by the same surgical
team between 2001 and 2008.
CONCLUSION: Except the higher rate of total AV-blocks, the early postoperative
mortality and morbidity of THV is lower as compared to SAVR. While long-term
results are still pending, we consider THV the treatment of choice in aged, highrisk patients with aortic stenosis.
*AATS
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201
WEDNESDAY
Morning
RESULTS: Procedural success was 98% in patients undergoing THV. Early mortality
(30d) was 6.6% in THV-patients vs. 17% in the SAVR-group (p < 0.05), late mortality
8.8% vs. 12%. Postoperative stroke rate was comparable in both groups (THV:
5.5%, SAVR: 3%). New postoperative dialysis-dependent renal failure occurred in
20% of SAVR-patients, but only in 3.3% of THV-patients. Total AV-block requiring
pacemaker implantation was more frequent in the THV-group (20.7% vs. 4%), the
rate of postoperative myocardial infarctions was low in both groups (THV: 0,
SAVR 2%).
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
T4.
Cavopulmonary Assist Using a Percutaneous, Bi-Conical, Single
Impeller Pump: A New Spin for Fontan Circulatory Support
Mark D. Rodefeld,1* Brandon Coats,2 Travis Fisher,2 John Brown,1* Steve Frankel2
1. Department of Surgery, Indiana University School of Medicine, Indianapolis,
IN, USA; 2. Purdue University Department of Mechanical Engineering, West
Lafayette, IN, USA
Invited Discussant: Glen S. Van Arsdell
OBJECTIVE: In a univentricular Fontan circulation, a delicate balance exists between
the systemic venous and pulmonary arterial circulations. Modest augmentation
(2–5 mmHg) of existing cavopulmonary ﬂow would reduce systemic venous pressure, improve ventricular ﬁlling, and substantially improve hemodynamic status. A
reasonable means of providing high-volume, low-pressure ﬂow in this unique situation does not exist. We hypothesized that an expandable single impeller pump,
based on the von Karman viscous pump principle, is ideal for this function.
METHODS: A 3-dimensional computational ﬂuid dynamics (CFD) model of the
total cavopulmonary connection (TCPC) was created. The impeller was represented
by an actuator disk (a 2-sided conical disk) positioned in the center of the TCPC
intersection with rotation in the vena caval axis. Flow was modeled under 3 conditions: 1) passive ﬂow with no disc present; 2) passive ﬂow with a non-rotating disk,
and 3) ﬂow with a rotating disc (1K, 5K, and 10K rpm). Flow patterns, pressure
gradient, and ﬂow rate were estimated for each case. In vitro performance of a ﬂexible 2-sided conical disk impeller and protective cage was assessed by measuring
pressure rise and induced ﬂow rate at 5K, 10K, and 15K rpm.
Cavopulmonary assist
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RESULTS: The presence of an actuator disc alone (nonrotating) stabilizes TCPC
ﬂow patterns and offsets the hydraulic energy loss which occurs when no disk is
present at all. Disk rotation (5K, 10K, and 15K rpm) from a dynamic ﬂow of 4.4 L/min
(adult Fontan cardiac output) induced signiﬁcant ﬂow increases (1.1, 1.7, and 1.9 L/min)
with a pressure differential of 1.4, 1.8, and 2.0 mmHg across the TCPC. In vitro
videography conﬁrms bidirectional inﬂow and outﬂow augmentation. Experimental
ﬂow rates correlate closely to CFD predictions.
CONCLUSION: A simple percutaneous rotary pump, comprised of a single
expandable bi-conical disk impeller and protective cage, is ideal to provide cavopulmonary assist. With a single impeller, ﬂow is augmented in all 4 axes, in the
ideal pressure range, with no venous pathway obstruction. It can apply to both the
3-way “T” (bidirectional Glenn) and the 4-way “+” (TCPC) conditions. In patients
with established univentricular Fontan circulations, this provides a previously
unavailable bridge-to-recovery or -transplant option. It can also provide temporary
perioperative support and enable compression of univentricular palliative procedures at any stage by substantially improving physiologic status after Fontan conversion.
WEDNESDAY
Morning
203
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
T5.
Tissue Engineered Vascular Grafts in Humans: Correlating
Clinical Outcomes to Vascular Neotissue Formation in Mice
Narutoshi Hibino,1 Edward McGillicuddy,1 Tai Yi,1 Goki Matsumura,2
Uji Naito,2 Hiromi Kurosawa,2* Christopher Breuer,1 Toshiharu Shinoka1*
1. Yale University School of Medicine, New Haven, CT, USA; 2. Tokyo Women’s
Medical University, Tokyo, Japan
Invited Discussant: John E. Mayer, Jr.
OBJECTIVE: The development of a tissue engineered vascular graft (TEVG) that
possesses the ability to grow holds great promise for advancing the ﬁeld of cardiac
surgery. In 2001, we initiated a human trial evaluating the use of TEVGs as conduits in patients with single ventricle physiology. Concurrently, we developed and
optimized a murine model to investigate the mechanisms underlying vascular neotissue formation. This study correlates the clinical feasibility and long term outcomes of TEVGs in humans with the basic biology of vascular neotissue formation
in mice.
METHODS: Human Trial: Autologous bone marrow (BM) mononuclear cells
were seeded onto a biodegradable tubular scaffold fabricated from a polyglycolic
acid (PGA) mesh coated with a co-polymer of l-lactide and -caprolactone (P(LA/CL)).
Twenty-ﬁve TEVGs were implanted as extracardiac total cavopulmonary connections
(EC TCPCs) in patients with single ventricle abnormalities. Patient age ranged
from 1 to 24 years (median: 5.5 years). Post-operatively, patients were followed by
serial angiography and/or CT. Mouse Model: Biodegradable PGA-P(LA/CL) scaffolds, 0.6 mm in diameter, were implanted into the IVC in mice (N = 12). Six scaffolds were seeded with murine BM prior to implantation and six scaffolds were
implanted unseeded. Following implantation, grafts were followed with serial
ultrasonography. All mice were sacriﬁced 14 days following implantation for histological analysis of the grafts.
RESULTS: Human Trial: There was no graft-related mortality during the followup period (mean 4.2 years). There was no evidence of aneurysm formation, graft
rupture, or ectopic calciﬁcation. Five patients (20%) developed silent graft stenoses
which did not require intervention. Two conduits (8%) developed critical graft
stenoses that were successfully treated with balloon angioplasty. Mouse Model:
All seeded grafts remained patent, while 5 unseeded grafts (83%) developed signiﬁcant stenoses. Seeded grafts expressed von Willebrand factor on the luminal
aspect, consistent with early endotheliazation. Unseeded grafts, however, demonstrated dense populations of cells expressing smooth muscle actin, transforming
growth factor-beta, and macrophage-3 antigen consistent with macrophage-driven
inﬂammation.
CONCLUSION: In humans undergoing EC TCPC, use of TEVGs is associated
with acceptable morbidity and mortality. In mice, BM seeded grafts demonstrate
increased patency, early endotheliazation, and an attenuated inﬂammatory
response compared to unseeded grafts.
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T6.
Abdominal Debranching with Thoracic Endografting for the
Treatment of Thoraco-Abdominal Aneurysm in 21 Consecutive
Patients
Jacques Kpodonu,1 Venkatesh Ramaiah,2 Grayson H. Wheatley,2
Julio Rodriguez-Lopez,2 David Caparrelli,2† Rame Iberdemaj,2
Edward B. Diethrich2
1. Hoag Memorial Presbyterian, Newport Beach, CA, USA; 2. Arizona
Heart Institute, Phoenix, AZ, USA
Invited Discussant: Roy K. Greenberg
OBJECTIVE: Hybrid revascularization techniques combining visceral debranching with endovascular stent graft placement provides a less invasive approach to
treat thoracoabdominal aneurysms. We review our clinical experience with this
hybrid technique.
RESULTS: Patient demographics included hypertension (100%), coronary artery
disease (64%), peripheral vascular disease (100%), diabetes (7%), obesity (21%),
chronic obstructive lung disease (78%) renal insufﬁciency (28.6%). Mean operating time and blood loss were 4.25 hours and 0.9L respectively. Debranched vessels
included right renal n = 15, left renal n = 16, celiac n = 15 superior mesenteric n = 18.
One endograft was deployed in 9 patients and 2 endografts in 12 patients. 30 day
mortality was 5.7% (n = 1/21) from complications relating to surgery. At follow up
1.5%(n = 1/64) vessel (renal) was lost. Complications included transient left
extremity weakness n = 1, renal insufﬁciency requiring hemodialysis n = 2, lower
*AATS
Member
Traveling Fellowship 2007
†Resident
205
WEDNESDAY
Morning
METHODS: Twenty-one consecutive patients (11 males and 10 females) with
mean age 70 years range (35–93) underwent hybrid surgical reconstructions for
complex thoraco abdominal aneurysms over a 24 month period (March 2005–
March 2007). Elective repair was performed on 20 patients with 6 patients having
prior aortic surgery. Mean proximal neck, distal neck and aortic sac diameter
were 30.3 mm, 23 mm and 6.7 cm respectively. Hybrid repair was performed on
Crawford type 1 n = 1, Crawford type II n = 3, Crawford type III n = 7, Crawford
type IV n = 4, Crawford Type V n = 6. Endograft deployment was transfemorally
n = 13 and dacron conduit graft n = 8 using standardized endovascular techniques.
Inﬂow conduit was descending thoracic aorta n = 10, aorta bifemoral graft n = 3,
tube graft n = 3, right iliac artery n = 4, left iliac artery n = 1. Procedure was staged
in 3 patients. Outcome variables including treatment failures (endoleak, aortic
rupture, reintenvention) or aortic related deaths were assessed. Follow-up included
clinical examination, chest and abdominalradiographic, CT scan at discharge, 6
months, 1 year and yearly thereafter.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
limb ischemia n = 2, mesenteric ischemia n = 1 and respiratory failure n = 2. distal
type I endoleak n = 1, There was no peri operative myocardial infarction, paraplegia,
graft migration, graft collapse or aortic rupture.
CONCLUSION: Repair of complex thoraco abdominal aneurysms using a hybrid
technique is safe in an elderly and high risk population of patients at short term.
Long term data regarding the hybrid techniques remain to be determined.
206
AMERICAN ASSOCIATION FOR THORACIC SURGERY
T7.
High Resolution Analysis of Lung Cancer Stem and Progenitor
Cells in Primary Non-Small Cell Adenocarcinoma
Vera S. Donnenberg,1 Rodney J. Landreneau,2* James D. Luketich,2*
Albert D. Donnenberg1
1. Surgery, University of Pittsburgh, Pittsburgh, PA, USA; 2. Hillman Cancer Center,
Pittsburgh, PA, USA
Invited Discussant: Thomas A. D’Amico
OBJECTIVE: Recurrence following initial response to therapy can occur after long
intervals suggesting that therapy resistant cells can lay dormant and subsequently
reactivate. Distinguishing cancer and normal stem cells is important from the
standpoint of therapy. Here we characterize normal and cancer stem/progenitor-like
cells in non-small cell adenocarcinomas of the lung (NSCLCA).
RESULTS: We are able to assign these immunophenotypic proﬁles: Stem cells
were resting (low light scatter, 2N DNA), cytokeratin negative and either CD90dim
or CD117+. The major progenitor population was morphologically complex and
CD90 positive. Largely non-overlapping populations of cytokeratin dim CD117+
and CD133+ progenitor cells were detected. This complex pattern is retained intact
in well differentiated adenocarcinoma, but is deranged in poorly differentiated and
metastatic lung cancer; the most common pattern being overexpression of cytokeratin on stem/progenitor populations. Stem and progenitor cells are 10 to 100 times
more prevalent in lung tumors than in normal lung. Cytokeratin+ stem/progenitor
cells were not detected in bone marrow samples isolated from rib fragments
obtained during lung resection.
CONCLUSION: According to the cancer stem cell paradigm, we hypothesize that
among the minority of tumor cells capable of propagating a tumor, only those
which retain the tissue stem cell properties responsible for self-renewal and selfprotection will survive therapy. Of these, cells with a normal stem-like phenotype
remain in a predominantly resting mode, and can be reactivated to cause late recurrent disease after apparently successful therapy. Therefore it is of great importance
to determine phenotypic differences that distinguish tumor stem cells from normal
tissue stem cells, both for differential targeting and for evaluation of clinical
responses.
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207
WEDNESDAY
Morning
METHODS: We used multiparameter ﬂow cytometry to examine tissue stem cell
markers CD44, CD90, CD117, and CD133, and epithelial markers cytokeratin and
EpCAM (TACSTD1), on freshly isolated from untreated NSCLCA (15 malignant
effusions, 82 tumor and adjacent far tissue, 65 bone marrows, 4 normal BM,) 0.5 to
10 million cells were stained (nucleated cells: DAPI; Hematopoietic: CD45APC.Cy7, CD14+CD33+glycophorin-PE.Cy5; Adhesion molecule CD44-PE; Epithelial: HEA-APC, intracellular pancytokeratin (CK)-FITC; Stem/Progenitor:
CD90-PE.TxRed, CD117-PE.Cy7, CD133-PE).
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
T8. Robotic Lobectomy for the Treatment of Early Stage Lung Cancer
Giulia Veronesi,1 Franca Melﬁ,2 Domenico Galetta,1 Ralph A. Schmid,3
Patrick Maisonneuve,1 Nicole Rotmensz,1 Fernando Vannucci,1
Raffaella Bertolotti,1 Lorenzo Spaggiari1
1. Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy;
2. Department of Cardio-Thoracic Surgery, University Hospital, Pisa, Italy;
3. Division of Thoracic Surgery, University Hospital, Berne, Switzerland
Invited Discussant: Kemp Kernstine
OBJECTIVE: We analysed the feasibility and safety of robotic approach for the treatment of early stage lung cancer with standard lobectomy and describe the technique
of robotic assisted lobectomy (RAL) and mediastinal lymph node dissection (MLD).
METHODS: During a 21 months period (Dec 2006–Sept 2008), 54 patients
underwent RAL for early stage lung cancer at our Institute. The approach included
three ports and one utility incision. Dissection and isolation of the hilar structures
was performed using the four arms Da Vinci System. Vascular and bronchial resections were done with the use of standard endoscopic staplers. Standard MLD was
performed after completion of the lobectomy. The 54 patients were individually
matched for age (±5 years), sex, stage, nodal status and forced expiratory ventilation in 1 sec with patients who underwent open lobectomy in the same institute
during the same period and were divided into three series based on the learning
curve according to duration of surgery.
RESULTS: In 7 patients (13%) conversion from RAL to open surgery was necessary
because of absence of ﬁssure in 5, oncological reason and anatomical reason of the
chest in each one. The number of overall postoperative complications (20%, p =
0.88) and the mean number of lymph nodes removed (18.1 ± 7.9 in open versus
16.8 ± 7.5 in RAL, p = 0.43) were similar in both groups. The median time for RAL
208
AMERICAN ASSOCIATION FOR THORACIC SURGERY
decreased by 52 minutes between the ﬁrst and the last two series of interventions
(p = 0.01). The median length of post-operative stay was signiﬁcantly shorter after
RAL than after open interventions (4.5 days robotic in the third series vs. 6 days
open, p = 0.006).
CONCLUSION: RAL with MLD is a feasible and safe procedure. It is an acceptable
treatment for early stage lung cancer with equal results to open surgery during the
early postoperative course. The beneﬁt in terms of postoperative pain, respiratory
function and quality of life are under evaluation in a prospective case control study
and oncological long term results will be evaluated.
9:00 a.m.
CONTROVERSIES IN CARDIOTHORACIC
SURGERY PLENARY SESSION
Ballroom A–C, Hynes Convention Center
Moderator: Alec Patterson
The Sole Pathway Leading to ABTS Certiﬁcation
Should be a Comprehensive Integrated
Cardiothoracic Surgery Training Program
Beginning Directly After Medical School
209
WEDNESDAY
Morning
Pro: Richard H. Feins
Con: David R. Jones
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
10:00 a.m. –
12:00 p.m.
ABLATION VS. SURGERY FOR ATRIAL
FIBRILLATION: ANTAGONISM OR SYNERGISM?
Jointly Sponsored with the Heart Rhythm Society
Ballroom A–C, Hynes Convention Center
Chairmen: Thoralf M. Sundt, III, MD
Douglas L. Packer, MD
10:00 a.m.
The “Classic Maze”: Experimental Origins, Surgical
Lesion Sets, Alternative Energy Sources
Ralph J. Damiano, Jr., MD, Washington University
10:15 a.m.
Neurological Approaches to the AF Problem Ganglion
Mapping
James H. McClelland, MD, Oregon Cardiology, PC
Cervical Interventions
Benjamin J. Scherlag, MD, Cardiac Arrhythmia Research
Institute
10:35 a.m.
Less Invasive Approaches – Critical Step or Critical
Mistake?
Robotics as Applied to Arrhythmia Surgery
W. Randolph Chitwood, Jr., MD, East Carolina University
School of Medicine
Thoracoscopic Arrythmia Surgery
Richard Lee, MD, Northwestern University
Intravascular Approaches
Vivek Y. Reddy, MD, University of Miami Hospital
11:25 a.m.
Deﬁning Success
Richard J. Shemin, MD, University of California, Los Angeles
11:40 a.m.
Working Together Panel
Ralph J. Damiano, Jr., MD,Washington University
James H. McClelland, MD, Oregon Cardiology, PC
Benjamin J. Scherlag, MD, Cardiac Arrhythmia Research Institute
W. Randoph Chitwood, Jr., MD, East Carolina University
School of Medicine
Richard Lee, MD, Northwestern University
12:00 p.m.
ADJOURN
210
AMERICAN ASSOCIATION FOR THORACIC SURGERY
10:00 a.m. –
12:00 p.m.
PNEUMONECTOMY: A TREATMENT OR
A DISEASE?
Room 302–306
Chairman: Thomas A. D’Amico, MD
Patient Selection for Pneumonectomy
Joseph P. Shrager, MD, University of
Pennsylvania
10:15 a.m. – 10:30 a.m.
Role of Thoracoscopic Pneumonectomy
Todd L. Demmy, MD, Roswell Park Cancer
Institute
10:30 a.m. – 10:45 a.m.
Managing Intraoperative Complications
Alec Patterson, MD, Washington University
10:45 a.m. – 11:00 a.m.
Early Complications After Pneumonectomy
Valerie W. Rusch, MD, Memorial
Sloan-Kettering Cancer Center
11:00 a.m. – 11:15 a.m.
Late Complications After Pneumonectomy
Douglas J. Mathisen, MD, Massachusetts
General Hospital
11:15 a.m. – 11:30 a.m.
Pneumonectomy After Induction Therapy
Walter Weder, MD, University Hospital
11:30 a.m. – 11:45 a.m.
Extrapleural Pneumonectomy
David J. Sugarbaker, MD, Brigham &
Women’s Hospital
11:45 a.m. – 12:00 p.m.
DISCUSSION
12:00 p.m.
ADJOURN
211
WEDNESDAY
Morning
10:00 a.m. – 10:15 a.m.
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
AUTHOR INDEX
(Note: Authors are listed by last name, ﬁrst name and ﬁnal ID)
A
Abbas, Ghulam
Abel, Martin
Adams, David
Agnes, Pasquet
Aikawa, Elena
Ailawadi, Gorav
Al-Ruzzeh, Sharif
Altorki, Nasser
Amata, Davide
Andrade, Rafael
Anile, Marco
Argenziano, Micheal
Armstrong, Susan
Arora, Rishi
Askew, Judah
Asnaghi, Adelaide
Awais, Omar
4
8
F4
30
L1
7, F6, L4
36
14, 46, F10
38
41, 44
20
L5
3, 37
9
34
F13
4
B
Bacchetta, Matthew
Bacha, Emile
Ballweg, Jean
Bara, Christoph
Barron, David
Barth, Mary Jane
Bartlett, Robert
Bauernschmitt, Robert
Bautista-Hernandez, Victor
Bavaria, Joseph
Bekesova, Slavka
T2
24, 33
25
F1
52
27
L7
6, T3
33
10
F17
Bel, Alain
Bell, Katherine
Bellamy, Valérie
Bellido, Reyes Yury
Bellisario, Alessandro
Benk, Christoph
Berger, Felix
Bernbaum, Judy
Berthonneche, Corinne
Bertolotti, Raffaella
Beyersdorf, Friedhelm
Bharati, Soraia
Birchall, Martin
Bivona, Antonio
Blackstone, Eugene
Blasberg, Justin
Bleiziffer, Sabine
Bodian, Carol
Bolling, Steven
Boodhwani, Munir
Borri, Alessandro
Bradley, Jeffrey
Bradley, Timothy
Brawn, William
Brehm, Kerstin
Breuer, Christopher
Brizard, Christian
Brown, David
Brown, John
Brown, Morgan
Bruneval, Patrick
Buckberg, Gerald
212
F2
F4
F2
F16
13
F5
2
22, 47
F7
T8
F5
27
F13
38
36
L6
6, T3
12
T1
30
21
16
3
52
F5
T5
51
L1
T4
8
F2
F5
AMERICAN ASSOCIATION FOR THORACIC SURGERY
Bullock, Andrew
Burnham, Nancy
51
22, 47
C
Caballero, Otavia
Calaﬁore, Antonio
Calistru, Alexandru
Caparrelli, David
Castello, Cataldo
Cava, Joseph
Cebotari, Serghei
Chang, Byung-Chul
Chang, Eileen
Chen-Tournoux, Annabel
Chikazawa, Genta
Cho, Bum-Koo
Cho, Jongho
Choi, Young
Christakis, George
Christie, Neil
Christos, Paul
Chua, Ramon
Ciccone, Anna Maria
Clancy, Robert
Coats, Brandon
Cohen, Gideon
Cohn, Lawrence
Coleman, Ryan
Collaud, Stéphane
Colman, Jack
Coloni, Giorgio
Conconi, Maria-Teresa
Conte, John
Cooper, Joel
Cope, Constantin
F10
38
F1
T6
38
53
F1
11
F18
F2
L2
11
18
18
L2
45
46
F10
20
22, 47
T4
L2
34
28
32
3
20
F13
40
17
29
Cornwell, Richard
Coz, Cyrielle
Crabtree, Traves
Cui, Vivian
Czapla, Melissa
43
F2
16
27
L8
D
D’Agostino, Jo Ann
D’Alessandro, Stefano
D’Amico, Thomas
David, Tirone
Davies, Ben
Davies, Paul
D’Cunha, Jonathan
De Giacomo, Tiziano
de Giovanni, Joseph
de Kerchove, Laurent
De Oliveira, Nilto
De Paulis, Ruggero
de Valence, Sarra
Dearani, Joseph
Deatrick, Kristopher
Dege, Andreas
del Nido, Pedro
Demmy, Todd
Denlinger, Chadrick
Desai, Nimesh
Dhillon, Rami
Di Luozzo, Gabriele
Di Mauro, Michele
Díaz-Agero, Prudencio
DiBardino, Daniel
Diethrich, Edward
Doll, Nicolas
Dominguez, Troy
213
22, 47
13
14
3, 37
52
52
41, 44
20
52
30
43
13
F7
8
L7
39
24, 33
F11
16
L2
52
12
38
F16
34
T6
39
25
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Donath, Suzan
Donington, Jessica
Donnenberg, Albert
Donnenberg, Vera
d’Udekem, Yves
51
L6
T7
T7
51
Fremes, Stephen
French, Brent
Frommelt, Michele
Fynn-Thompson, Francis
L2
L4
53
33
G
E
Edwards, Fred
Edwards, Niloo
El Naqa, Issam
ElBardissi, Andrew
El Zein, Chawki
Emani, Sitaram
Epstein, Deirdre
Eskay, Michael
Etz, Christian
5
43
16
34
27
24, L1
42
F9
12
F
Falconieri, Fabio
Falk, Volkmar
Faro, Albert
Farrar, David
Fechner, Sylvia
Ferrara, Cathy
Ferson, Peter
Feuerhake, Friedrich
Fisher, Travis
Fitzpatrick, Raymond J
Foerster, Katharina
Frankel, Steve
Franzen, Olaf
Fraser, Charles
Frazier, O. Howard
Frederick, John
38
39
42
40
32
F10
45
F5
T4
L3
F5
T4
T1
28
40
L3
Galetta, Domenico
Gallina, Sabina
Gambogi, Alex
Gandhi, Sanjiv
Garrett, Joseph
Gasparri, Roberto
Gaynor, J.W.
Gerdes, Marsha
Ghanayem, Nancy
Gilbert, Sebastien
Gillinov, Marc A
Girola, Fabiana
Girón, Joaquin García
Gleason, Thomas
Glineur, David
Gnjatic, Sacha
Go, Tetsuhiko
Goldberger, Jeffrey
Gooding, William
Goparaju, Chandra
Gorenﬂo, Matthias
Gottlieb, Danielle
Griepp, Randall
Grigg, Leeanne
Groth, Shawn
Gruber, Peter
Gurny, Robert
214
21, T8
38
L3
42
L8
21
22, 25, 47
22, 47
53
45
36
13
F16
F9
30
F10
F12, F13
9
45
L6
23
L1
12
51
41, 44
25
F7
AMERICAN ASSOCIATION FOR THORACIC SURGERY
H
Haft, Jonathan
Hagino, Ikuo
Hammoud, Zane
Hancox, Ana
Hanley, Frank
Harpole, David
Harris, David
Hartman, Diane
Haverich, Axel
Heagerty, Patrick
Heilmann, Claudia
Heinle, Jeffrey
Henaine, Roland
Hernandez, Jonathan
Hetzer, Roland
Hibino, Narutoshi
Hickey, Robert
Higgins, Robert S.D.
Hilﬁker, Andres
Hillinger, Sven
Hoffman, George
Hollander, Antony
Hong, Julie
Hoss, Nina
Hu, Sheng-shou
Hübler, Michael
Huddleston, Charles
Hufford, Jennifer
Hussein, Ahmed
Hussin, Aisyah
Hutter, Andrea
Hvass, U.
I
L7
26
F17
F15
F8
14
L3
47
F1
22
F5
28
48
L8
2
T5
F17
27
F1
32
53
F13
F15
23
49
2
42
47
F17
51
6, T3
35
Iacò, Angela
Iberdemaj, Rame
Ibrahim, Mohsen
Ikonomidis, John
Ilbawi, Michel
Ilkhanoff, Leonard
Innocente, Francesco
Itkin, Maxim
Ittenbach, Richard
Iyengar, Ajay
38
T6
20
F18
27
9
F7
29
47
51
J
Jarvik, Gail
Jobe, Blair
John, Ranjit
Jones, Bryn
Jones, Timothy
Joudinaud, Thomas
Jungbluth, Achim
Jungebluth, Philipp
22
4
40
51
52
35
F10
F12, F13
K
Kada, Akiko
Kadish, Alan
Kagisaki, Koji
Kaiser, Larry
Kalangos, Afksendiyos
Kalfa, David
Kang, Hyun-Jae
Karck, Matthias
Kariatsumari, Kota
Kast, Teri
215
26
9
26
17, 29
F7
F2
31
23, F1, F3
19
44
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Katsuragi, Naoya
Kawahara, Katsunobu
Keeley, Samuel
Keeling, William
Kelly, Rosemary
Kern, John
Kesler, Kenneth
Kestenholz, Peter
Khoury, Gebrine
Kim, Ah-Young
Kim, Hyo-Soo
Kim, Jun-Sung
Kim, Ki-Bong
Kim, Kwang
Kita, Hidefumi
Klodell, Charles
Klopp, Amy
Knudsen, Steen
Koh, Masahiro
Konstantinov, Igor
Koo, Bon-Kwon
Kostin, Sava
Kpodonu, Jacques
Krbek, Thomas
Kreisel, Daniel
Kron, Irving
Krupnick, Alexander
Kruse, Jane
Ku, Jennifer
Kucharczuk, John
Kunst, Tricia
Kurosawa, Hiromi
Kwak, Andrew
Kwong, King
19
F14
4
L8
44
7
F17
32
30
L3
31
31
31
18
19
40
44
F11
26
51
31
F1
T6
32
16
7, F6, L4
16
9
L2
17, 29
F15
T5
29
F15
L
Landreneau, Rodney
Lange, Ruediger
LaPar, Damien
Laporte, Carine
Larghero, Jérôme
Lau, Christine
Lazalla, Ricardo
Lee, Hae-Young
Lee, Hyun-Sung
Lee, Paul
Lee, Richard
Lehmann, Sven
Lewis, Vicki
Li, Shoujun
Li, Yan
Li, Yongqing
Liakopoulos, Oliver
Linden, Joel
Liu, Zhigang
Loukanov, Tsvetomir
Low, Reginald
Loyola, Hugo
Luketich, James
Lytle, Bruce
4, 45, T7
6, T3
7
L3
F2
F6
12
31
15
14, 46, F10
9
39
L8
49
49
49
F5
L4
49
23
T1
33
4, 45, T7
36
M
Macchiarini, Paolo
Maddaus, Michael
Mader, Irina
Maganti, Manjula
Maisonneuve, Patrick
216
F12, F13
41, 44
F5
3, 37
T8
AMERICAN ASSOCIATION FOR THORACIC SURGERY
Maloney, Ann
Maloney, James
Mantero, Sara
Marx, Gerald
Maselli, Daniele
Massullo, Domenico
Mathur, Amit
Matsumura, Goki
Maxwell, Cory
Mayer, John
Mazzitelli, Domenico
McCarthy, Patrick
McClure, R. Scott
McCormick, Ryan
McDonald-McGinn, Donna
McElhinney, Doff
McGillicuddy, Edward
Mechref, Yehia
Meinertz, Thomas
Melﬁ, Franca
Menasché, Philippe
Mercedes, Leandro
Meyer, Keith
Meyer, Tanja
Meyers, Bryan
Miera, Oliver
Milano, Carmelo
Milewski, Rita
Mitchell, Michael
Mochel, Mark
Moehle, Chris
Moeller, Michael
Moeller, Patrick
Mohapatra, Bhagyalaxmi
34
43
F13
24
13
20
L7
T5
7
33, L1
6, T3
9
34
L3
22, 47
24
T5
F17
T1
T8
F2
F15
43
F1
16
2
40
10
53
F6
F6
F7
10
50
Mohr, Friedrich
Mohr, Matthias
Montet, Xavier
Morales, David
Moser, G. William
Moussa, Fuad
Mousseaux, Elie
Mrowczynski, Wojciech
Mueller, Christoph
Muenzer, Jeffrey
Mugnai, Damiano
Mussa, Shaﬁ
Mussatto, Kathleen
39
39
F7
28
10
L2
F2
F7
12
L3
F7
52
53
N
Naito, Uji
Naka, Yoshifumi
Nam, Byung-Ho
Nardella, Saverio
Nason, Katie
Navia, Jose
Nedder, Arthur
Nento, Daniel
Nicolson, Susan
Ninet, Jean
Nishimura, Rick
Nloga, Joseph
Noirhomme, Philippe
Nord, Alex
Normand, Sharon-Lise
Nottelet, Benjamin
Novotny, Milos
Nowicki, Edward
217
T5
40, L5
15
13
4
36
L1
36
22, 25, 47
48
8
48
30
22
5
F7
F17
36
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
O
Obadia, Jean-François
O’Brien, Sean
Oh, Byung-Hee
Old, Lloyd
Ommen, Steve
Onaitis, Mark
Onda, Takahito
Osaki, Satoru
Owens, Gary
Oz, Mehmet
48
5
31
F10
8
14
19
43
F6
L5
P
Padala, Muralidhar
F4
Pagani, Francis
40, L7
Park, Hyung Joo
18
Park, Young-Bae
31
Pass, Harvey
L6
Patnaik, Santosh
F11
Patterson, Alec
16
Paul, Subroto
14, 46
Peeler, Benjamin
7
Pei, Hong
F6
Pen, Visal
L2
Pennathur, Arjun
4, 45
Peterson, Eric
5
Petrella, Francesco
21
Phillippi, Julie
F9
Pigula, Frank
24, 33
Pitt, Bruce
F9
Plestis, Konstadinos
12
Pochettino, Alberto
10
Polimenakos, Anastasios
27
Port, Jeffrey
14, 46, F10
Potapov, Evgenij
Powell, Andrew
Pugliese, Francesco
Puri, Varun
2
L1
20
42
Q
Qureshi, Irfan
45
R
Radovits, Tamás
Raithal, Steven
Rajeswaran, Jeevanantham
Ramaiah, Venkatesh
Rastan, Ardawan
Raue, Jennifer
Ravishankar, Chitra
Razo-Vasquez, Oswaldo
Reddy, Vadiyala Mohan
Reece, T. Brett
Reed, Carolyn
Reichenspurner, Hermann
Rendina, Erino
Ricci, Marco
Riemer, Robert
Ritter, Gerd
Roberson, David
Robin, Jacques
Rochereau, Philippe
Rodefeld, Mark
Rodriguez-Lopez, Julio
Ross, Patrick
Rotmensz, Nicole
Rovira, Irene
Rubay, Jean
218
F3
42
36
T6
39
47
25
34
F8
7
F18
T1
20
50
F8
F10
27
48
F2
T4
T6
1
T8
F12
30
AMERICAN ASSOCIATION FOR THORACIC SURGERY
Rueth, Natasha
Ruge, Hendrik
Russo, Mark
41, 44
6, T3
T2
S
Sacks, Michael
Salazar, Jorge
Salvin, Joshua
Sanchez, Pablo
Sanchez-Lorente, David
Sasaki, Takashi
Sathanandam, Shyam
Schaff, Hartzell
Scheurer, Mark
Schiff, Jared
Schmid, Ralph
Schofer, Jochen
Schreiber, Christian
Schrump, David
Schuchert, Matthew
Schumar, Ann
Sebening, Christian
Shah, Sonam
Shahian, David
Shalli, Shanaz
Shende, Manisha
Sheng, Shubin
Shinoka, Toshiharu
Shiraishi, Yuji
Siddiqui, Kashif
Singh, Ramesh R
Singh, Steve
Smith, Craig
Smith, Max
Sohn, Dae-Won
L1
28
33
17
F12
F8
27
8
33
33
T8
T1
6, T3
F15
4, 45
L7
23
F18
5
9
4, 45
14
T5
19
28
7
L2
L5, T2
L3
31
Solli, Piergiorgio
Solot, Cynthia
Sommers, Eric
Song, Suk-Won
Spaggiari, Lorenzo
Spinale, Francis
Spray, Thomas
Stahel, Rolf
Stallings, Virginia
Stamatis, Georgios
Stewart, Allan
Stickley, John
Stiles, Brendon
Stroud, Robert
Stümper, Oliver
Su, Stacey
Sun, Benjamin
Svensson, Lars
Sweet, Stuart
Szabó, Gábor
Szeto, Wilson
21
22
L8
11
21, T8
F18
22, 25, 47
32
47
32
L5, T2
52
14, 46
F18
52
17
1
36
42
F3
10
T
Tabbutt, Sarah
Tajik, A
Takayama, Hiroo
Tandon, Kunal
Tassani, Peter
Teebken, Omke
Terrili, Courtney
Thiagarajan, Ravi
Thomas, Andrew
Thomas, Holly
Thourani, Vinod
Tille, Jean-Christophe
219
25
8
L5, T2
L1
T3
F1
47
33
1
43
F4
F7
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
Tominaga, Yoshiaki
Tonchev, Pencho
Treede, Hendrik
Trerotola, Scott
Trummer, Georg
Tsuda, Shoichi
Tsuneyoshi, Hiroshi
Tudorache, Igor
Tuebler, Thilo
Tweddell, James
Tworetsky, Wayne
19
23
T1
29
F5
F8
L2
F1
T1
53
24
26
50
V
Vannucci, Fernando
Varone, Egidio
Vatta, Matteo
Venuta, Federico
Veres, Gábor
Verhelst, Robert
Veronesi, Giulia
Vincent, Jessica
T8
38
50
20
F3
30
21, T8
L2
W
Walpoth, Beat
Walton, Sandra
Watremez, Christine
Wautot, Fabrice
Weder, Walter
Wei, Benjamin
Weltert, Luca
F7
F6
30
48
32
T2
13
2
22, 25, 47
T6
51
L5
1
37
L3
52
X
Xydas, Steve
U
Uemura, Hideki
Urbiztondo, Arnel
Weng, Yu-Guo
Wernovsky, Gil
Wheatley, Grayson
Wheaton, Gavin
Williams, Mathew
Williams, Thomas
Woo, Anna
Woo, Y. Joseph
Wright, John
T2
Y
Yagihara, Toshikatsu
Yamashita, Shin-ichi
Yang, Zequan
Yendamuri, Sai
Yi, Tai
Yoganathan, Ajit
Yoo, Kyung-Jong
26
F14
7, F6, L4
F11, F14
T5
F4
11
Z
Zackai, Elaine
Zafar, Farhan
Zhang, Mary
Zhang, Min
Zhang, Yuwei
Zheng, Zhe
Zhu, Weiwei
Zo, Jae
Zoli, Stefano
Zoole, Jennifer
220
22, 47
28
F15
F17
F15
49
L8
15
12
16
AMERICAN ASSOCIATION FOR THORACIC SURGERY
2008–2009
COUNCIL
President
Thomas L. Spray, Philadelphia, PA
President-Elect
Alec Patterson, St. Louis, MO
Vice President
Irving L. Kron, Charlottesville, VA
Secretary
Thoralf M. Sundt, III, Rochester, MN
Treasurer
David J. Sugarbaker, Boston, MA
Editor
Lawrence H. Cohn, Boston, MA
Councilors
Walter Klepetko, Vienna, Austria
D. Craig Miller, Stanford, CA
John D. Puskas, Atlanta, GA
Valerie W. Rusch, New York, NY
Craig R. Smith, New York, NY
Vaughn A. Starnes, Los Angeles, CA
Historian
Tirone E. David, Toronto, ON, Canada
221
89TH ANNUAL MEETING MAY 9–MAY 13, 2009
BOSTON, MASSACHUSETTS
2008–2009
COMMITTEES
Annual Meeting
Program Committee
Ad Hoc Program
Committee Reviewers
Thomas L. Spray, Chair Philadelphia, PA
David H. Adams
New York, NY
Robert J. Cerfolio
Birmingham, AL
Lawrence H. Cohn
Boston, MA
Yolonda L. Colson,
Boston, MA
R. Duane Davis, Jr.
Durham, NC
J. William Gaynor
Philadelphia, PA
Irving L. Kron
Charlottesville, VA
Chuen-Neng Lee
Tokyo, Japan
James D. Luketich
Pittsburgh, PA
Robert J. McKenna, Jr. Philadelphia, PA
Alec Patterson
St. Louis, MO
Joseph F. Sabik, III
Cleveland, OH
Vaughn A. Starnes
Los Angeles, CA
Thoralf M. Sundt, III
Rochester, MN
Lars G. Svensson
Cleveland, OH
James S. Tweddell
Milwaukee, WI
Ludwig K. Von Segesser
Lausanne,
Switzerland
James S. Allan
Boston, MA
Nasser K. Altorki
New York, NY
Emile A. Bacha
Boston, MA
John A. Elefteriades
New Haven, CT
T. Bruce Ferguson, Jr.
St. Louis, MO
Raja M. Flores
New York, NY
James S. Gammie
Baltimore, MD
Eugene A. Grossi
New York, NY
David H. Harpole, Jr.
Durham, NC
Robert S.D. Higgins
Chicago, IL
John S. Ikonomidis
Charleston, SC
Michael E. Jessen
Dallas, TX
David R. Jones
Charlottesville, VA
John A. Kern
Charlottesville, VA
Kemp Kernstine
Duarte, CA
Shaf Keshavjee
Toronto, ON, Canada
Robert L. Kormos
Pittsburgh, PA
Patrick M. McCarthy
Chicago, IL
Bryan F. Meyers
St. Louis, MO
Sudish C. Murthy
Cleveland, OH
Richard G. Ohye
Ann Arbor, MI
Frank A. Pigula
Boston, MA
Joe B. Putnam
Nashville, TN
Vadiyala Mohan Reddy
Stanford, CA
John Stulak
Rochester, MN
Glen S. Van Arsdell Toronto, ON, Canada
Ara Vaporciyan
Houston, TX
Gus Vlahakes
Boston, MA
Joseph Y. Woo
Philadelphia, PA
222
AATS FUTURE MEETINGS
May 1–5, 2010
Metro Toronto Convention Centre
Toronto, ON Canada
May 7–11, 2011
Pennsylvania Convention Center
Philadelphia, PA
April 28–May 2, 2012
Moscone West Convention Center
San Francisco, CA
May 4–8, 2013
Minneapolis Convention Center
Minneapolis, MN
April 26–30, 2014
Metro Toronto Convention Centre
Toronto, ON Canada
April 25–29, 2015
Washington State Convention and Trade Center
Seattle, WA
SCHEDULE AT A GLANCE
(All scientiﬁc sessions and exhibits will take place at the Hynes Convention Center)
FRIDAY, May 8, 2009
1:00 p.m.–5:00 p.m. Registration Open
SATURDAY, May 9, 2009 | Skills Courses and Symposium
7:00 a.m.–5:00 p.m.
8:00 a.m.–12:00 p.m.
8:00 a.m.–12:00 p.m.
1:00 p.m.–5:00 p.m.
Registration Open
New Technologies and Procedures in Congenital and Acquired Heart Surgery
Thoracic Developmental Skills
Developing the Academic Surgeon Symposium
SUNDAY, May 10, 2009 | AATS/STS Postgraduate Symposia
6:30 a.m.–6:00 p.m.
8:00 a.m.–5:00 p.m.
8:00 a.m.–5:00 p.m.
8:00 a.m.–5:00 p.m.
3:00 p.m.–5:00 p.m.
5:00 p.m.–7:00 p.m.
7:00 p.m.
Registration Open
Adult Cardiac Surgery Symposium
General Thoracic Surgery Symposium
Congenital Heart Disease Symposium
12th Annual C. Walton Lillehei Resident Forum
Welcome Reception—Exhibit Hall
Various Satellite Post-Activity Symposia
MONDAY, May 11, 2009 | Annual Meeting
7:00 a.m.–5:00 p.m.
9:00 a.m.–4:30 p.m.
7:30 a.m.–7:45 a.m.
7:45 a.m.–12:15 p.m.
12:15 p.m.–2:00 p.m.
12:15 p.m.–2:00 p.m.
2:00 p.m.–5:15 p.m.
5:05 p.m.–6:00 p.m.
Evening
Registration Open
Exhibits Open
Business Session (AATS Members Only)
Plenary Scientiﬁc Session
Basic Science Lecture— Jonathan A. Epstein, MD, University of Pennsylvania
Presidential Address—Thomas L. Spray, MD, Children’s Hospital of Philadelphia
Lunch—Exhibit Hall
Cardiothoracic Residents’ Luncheon
Simultaneous Scientiﬁc Sessions
Adult Cardiac Debate
Various Satellite Post-Activity Symposia
TUESDAY, May 12, 2009 | Annual Meeting
6:30 a.m.–5:00 p.m. Registration Open
9:00 a.m.–4:00 p.m. Exhibits Open
7:00 a.m.–8:45 a.m. Cardiac Surgery Forum
General Thoracic Surgery Forum
8:45 a.m.–12:30 p.m. Plenary Scientiﬁc Session
“The Role of Simulation in Future Education”
Honored Speaker Lecture—Dr. Michio Kaku, City University of New York
12:30 p.m.–2:00 p.m. Lunch—Exhibit Hall
2:00 p.m.–5:00 p.m. Simultaneous Scientiﬁc Sessions
5:00 p.m.–5:45 p.m. Executive Session (AATS Members Only)
7:00 p.m.–10:00 p.m. Attendee Reception—The Institute of Contemporary Art (ticketed event)
WEDNESDAY, May 13, 2009 | Annual Meeting
6:30 a.m.–12:00 p.m. Registration Open
7:00 a.m.–8:45 a.m. Emerging Technologies and Techniques Forum
9:00 a.m.–10:00 a.m. Controversies in Cardiothoracic Surgery Plenary Session
10:00 a.m.–12:00 p.m. Ablation vs. Surgery for Atrial Fibrillation: Antagonism or Synergism?
10:00 a.m.–12:00 p.m. Pneumonectomy: A Treatment or a Disease?
American Association for Thoracic Surgery
900 Cummings Center, Suite 221-U, Beverly, Massachusetts 01915
Phone: (978) 927-8330 | Fax: (978) 524-0498 | www.aats.org | Email: [email protected]