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Tuesday At-A-Glance Tuesday At-A-Glance
T U E S D AY, J A N UA R Y 2 9 , 2 0 0 7 T U E S D AY, J A N UA R Y 29, 2007

6am 6:30 am – 4:30 pm Registration: STS Annual Meeting
7:00 am – 8:00 am Ticketed Breakfast Sessions
7am 7:00 am – 8:00 am Health Policy Forum: Improving Physician Outcomes:
Ticketed Health Policy
Conﬁdential Peer Review Versus Federal Government-
Breakfast Sessions Forum
Sponsored Public Reporting System
8am
7:00 am – 5:45 pm Scientiﬁc Posters Open
8:15 am – 12:15 pm General Scientiﬁc Session II
General Scientiﬁc Session II

9am
9:00 am – 4:30 pm STS Exhibits Open
9:45 am – 10:30 am Break – Visit Exhibits and Scientiﬁc Posters
Registration: STS Annual Meeting

10am Break
11:45 am – 12:30 pm Thomas B. Ferguson Lecture:
Creating a High-Value Health Care System
11am 12:40 pm – 1:40 pm Break – Visit Exhibits and Scientiﬁc Posters
Scientiﬁc Posters Open

12:40 pm – 1:40 pm Ethics Debate: No Heroic Measures –
How Soon is Too Soon to Stop?
STS Exhibits Open

12pm Thomas B. Ferguson Lecture

12:40 pm – 1:40 pm Residents Luncheon

1pm Break
Ethics Residents 1:45 pm – 5:45 pm Parallel Surgical Forum I: General Thoracic I
Debate Luncheon
Parallel Surgical Forum II: General Thoracic II

2pm Parallel Surgical Forum III: Adult Cardiac I
Parallel Surgical Forums I-V
Parallel Surgical Forum IV: Adult Cardiac II

T U E S D AY AT  A  G L A N C E
3pm Parallel Surgical Forum V: Congenital
Break
3:00 pm – 3:45 pm Break – Visit Exhibits and Scientiﬁc Posters
4pm 7:00 pm – 10:00 pm Tuesday Evening Dinner Reception

Parallel Surgical Forums I-V
5pm

6pm

7pm

8pm Tuesday Evening Dinner Reception

9pm

128 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 129
Tuesday, January 29, 2008 Tuesday, January 29, 2008

7:00 am – 8:00 am Location printed on ticket Welcome and Introductions
Health Policy Forum Kevin D. Accola, Orlando, Florida
Public Reporting is Coming: How to Safeguard Your Reputation FINANCIAL DISCLOSURE Edwards Lifesciences (speaker/consultant), speakers bureau/honoraria.
The federal government, health plans, and consumer groups are seeking to rank
physicians using unadjusted Medicare claims data. Experts will debate whether public Moderator: Jeﬀery B. Rich, Norfolk, Virginia
reporting or performance feedback systems work best and if claims data accurately Physician performance is greatly improved through strong peer review programs, which
portray a physician’s performance. help avoid some of the serious consequences of public reporting, such as risk aversion of
Among the biggest questions in health policy today is “What motivates physicians to the sickest patient population.
improve performance?” Some maintain that the threat of public embarrassment through
reporting results publicly is the best way. Others insist that providing each physician Richard L. Prager, Ann Arbor, Michigan
feedback on their performance is suﬃcient to improve care equally. Who is right? And FINANCIAL DISCLOSURE Blue Cross/Blue Shield of Michigan (fee received by the section of cardiac surgery at the
what is the result of the national policy debate for cardiothoracic surgeons? Experts University of Michigan from BCBS of Michigan for my directing quality collaborative), research grant.
will debate public reporting programs and their eﬀect in the states where they were David F. Torchiana, Boston, Massachusetts
attempted. Other experts believe that conﬁdential performance feedback systems,
based upon clinical data, provide a better method to improve health care quality. Hear The Medicare database provides a large set of data covering millions of patients and
the leading experts in quality improvement debate the issue and provide your own most of the practicing physicians in the U.S. By utilizing the data and measuring physician
insight and experience. performance, public reporting will spur quality improvement in the physician community
and health care system.
Learning Objectives: Upon completion of this program, participants will be able to:
Arnold Milstein, San Francisco, California
1. Describe why, outside of the physician community, many experts are calling
for the use of public reporting as a tool for performance improvement
2. Explain the diﬀerence between reporting systems based upon administrative
claims data and those based upon clinical data
3. Describe each reporting system's ability to risk-adjust, provide accurate and
thorough data, and provide data in a timely manner
4. Describe the diﬀerent public reporting methods employed by several states
including their respective approaches to the type of information that gets
reported, to whom the information is reported, the format of the reports,

T U E S D AY M O R N I N G
and the methodologies used to measure each physician
5. Compare public reporting as a motivational factor to performance feedback models
6. Assess what reporting model works best

130 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 131
Tuesday, January 29, 2008 Tuesday, January 29, 2008

7:00 am – 8:00 am Locations printed on ticket Session 4: The Aging Congenital Patient
Joseph A. Dearani, Rochester, Minnesota
Ticketed Breakfast Sessions
Session 5: Advances in Thoracic Surgery:
Endoscopic Management of Barrett’s Esophagus
Session 1: Retirement and the Aging Surgeon
Daniel L. Miller, Atlanta, Georgia
Ronald Weintraub, Cambridge, Massachusetts
FINANCIAL DISCLOSURE Ethicon Endo-Surgery (speaker), speakers bureau/honoraria; Power
Lawrence I. Boncheck, Lancaster, Pensylvania Medical Interventions (speaker), speakers bureau/honoraria; Synovis, Inc. (scientiﬁc advisor), consultant/
David D. Corbett, Boston, Massachusetts advisory board.
Richard H. Feins, Chapel Hill, North Carolina
Session 6: Advances in Thoracic Surgery: Update on VATS Lobectomy
Session 2: Money on the Table: Maximizing Reimbursements Scott J. Swanson, New York, New York
Peter K. Smith, Durham, North Carolina FINANCIAL DISCLOSURE Ethicon, Inc (consultant re: stapler), consultant/advisory board.
Session 3: Robotics Session 7: Endovascular Surgery
Sudhir Srivastava, Odessa,Texas R. Scott Mitchell, Stanford, California
FINANCIAL DISCLOSURE Intuitive Surgical, Inc. (clinical trial), research grant; Intuitive Surgical, Inc.
FINANCIAL DISCLOSURE W. L. Gore & Associates, Inc. (previous PI consultant), research grant.
(clinical trial), other research support; Intuitive Surgical, Inc. (invited speaker), speakers bureau/honoraria;
Medical CV, Inc. (advisory board and consultant), consultant/advisory board. REGUL ATORY DISCLOSURE This presentation describes the oﬀ-label use of Gore TAG which is
investigational. The use of the “TAG” for other than aneurysms.
REGUL ATORY DISCLOSURE This presentation describe the use of the da Vinci Surgical System and
Surgical U-Clip which are FDA approved. Session 8: Hybrid OR Models
Moderators: W. Randolph Chitwood, Jr., Greenville, North Carolina John G. Byrne, Nashville, Tennessee
FINANCIAL DISCLOSURE Intuitive Surgical, speakers bureau/honoraria; Edwards Lifesciences,
speakers bureau/honoraria; St. Jude Medical, speakers bureau/honoraria.
Roxanne V. Newman, Fargo, North Dakota

T UU S DD AY MT ER N IO O N
T E E S AY A F O R N N G
132 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 133
Tuesday, January 29, 2008 Tuesday, January 29, 2008

8:15 am – 12:30 pm Hall A
General Session II Notes
Moderators: John E. Mayer, Jr., Boston, Massachusetts and Douglas E. Wood, Seattle, Washington
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
8:15 am

32. USA Feasibility Study of Transcatheter Insertion of Stented Aortic Valve Via
Left Ventricular Apex
L.G. Svensson1; J. Moses2; M.J. Mack3; T.M. Dewey3; A. Stewart2; D. Brown3;
S. Kapadia1; E. Roselli1; M. Tuzcu1; M. Williams2; M. Leon2; B.W. Lytle1; C.R. Smith2
1
Cleveland Clinic, Cleveland, Ohio; 2Columbia Presbyterian Medical Center,
New York, New York; 3CSANT, Dallas, Texas
FINANCIAL DISCLOSURE L.G. Svensson, Edwards Lifesciences, honoraria; Medtronic, honoraria; M.J. Mack,
Edwards Lifesciences, consultant; E. Roselli, Edwards Lifesciences, honoraria; M. Williams, Edwards Lifesciences,
honoraria; M. Leon, Edwards Lifesciences, research grant.
REGUL ATORY DISCLOSURE This presentation describes the use of the Edwards Sapien THV. The FDA
status is investigational.

Discussant: Thomas A. Vassiliades, Atlanta, Georgia
Background: Recent United States and European registries have indicated that 30%
to 60% of patients with critical valvular AS are not surgically treated, usually due to
advanced age and comorbidities. We report on an FDA approved feasibility study of
a less invasive transcatheter approach to potentially treat these high-risk patients.
Methods: Between December 2006 and April 2007, 20 patients underwent
transcatheter insertion of a balloon expandable stainless steel stent with an
internally mounted 3 leaﬂet equine pericardial valve (Edwards Sapien THV™ Valve)

T U E S D AY M O R N I N G
into the aortic annulus using a transapical left ventricular approach. Patients were
inoperable by conventional surgery or extremely high risk (STS score >15%, mean
13.2 % SD 4.8%, for all patients).
Results: All valves were successfully delivered, however, 1 valve embolized and
required open AVR and 1 case of severe regurgitation later required AVR. There
were 3 (15%) 30-day in-hospital deaths, none related to device placement but to
renal failure. There was 1 stroke (5%, 1/20), 5 days after implant. Valve area improved
from 0.62 cm2 (SD 0.14) to 1.61 cm2 (SD 0.44) at 30 days, p<0.0001, with mean
perivalvular regurgitation of 1.38 (SD 0.81). Mean follow-up was 50.1 days (SD 37.3
days) with 3 further deaths from comorbid disease, none valve-related, for a 3
month Kaplan-Meier survival of 70%.
Conclusion: Transapical insertion of a balloon expandable stented valve is feasible
and will be evaluated further in the ongoing FDA approved randomized pivotal
study (PARTNER trial), currently evaluating a retrograde transfemoral arterial approach.

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8:30 am

33. Pumpless Extracorporeal Lung Assist (PECLA): Notes
A 10-Year Institutional Experience
B. Flörchinger; A. Philipp; A. Klose; T. Bein; M. Hilker; T. Mueller; K. Lehle; F. Schmid; C. Schmid
University Hospital, Regensburg, Germany
REGUL ATORY DISCLOSURE This presentation describes the use of Novalung. FDA status is not approved.

Discussant: Joseph B. Zwischenberger, Lexington, Kentucky
FINANCIAL DISCLOSURE MC3, research grant; MedArray, Inc., research grant.

Background: Pumpless extracorporeal lung assist (PECLA) was developed to
stabilize pulmonary function and to allow various surgical procedures in patients
with severe respiratory insuﬃciency.
Methods: Since 1996, 159 patients with an age ranging from 7-78 years were
provided with a PECLA system. Fifteen patients were referred to us by air or ground
transport after insertion of the system in a city hospital.
Results: Underlying lung diseases were ARDS (70%), with and without previous
trauma and/or surgery, and pneumonia (30%), mainly caused by bacteria. PECLA
lasted for 0.1-33 days, mean 7.0±6.2 days; cumulative experience was >1,200 days.
Weaning criteria were FiO2 ≤0.45 with a pO2 >80 mmHg for 24 hours. Successful
weaning and survival was achieved in 33.1% of patients after a mean PECLA support
of 8.5±6.3 days. During PECLA, 48.7% of patients died, mainly of sepsis (42%) and
multi-organ failure (25%) after a mean interval of 4.8±5.1 days. Inability to stabilize
pulmonary function was noted in 7% of patients only. Post PECLA, 30-day mortality
was 13.6%, with a mean PECLA support interval of 9.7±8.8 days in this group. In
a subgroup analysis best outcome was obtained in patients following trauma,
bacterial pneumonia, and aspiration pneumonia.
Conclusion: PECLA is a relatively simple and highly eﬃcient method to support

T U E S D AY M O R N I N G
patients with deteriorated gas exchange for prolonged periods to allow
transportation, surgical procedures and recovery of pulmonary function. Best
indication is severe hypercapnia and moderate hypoxia.

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8:45 am

34. Determinants of Survival and Surgical Intervention for Children With Notes
Congenital Supravalvular Aortic Stenosis Over Three Decades
E.J. Hickey; H. Wong; W.G. Williams; C. Manlhiot; C.A. Caldarone; G. Van Arsdell;
B.W. McCrindle
The Hospital for Sick Children, Toronto, Ontario, Canada
Discussant: Gary K. Loﬂand, Kansas City, Missouri
Background: Supravalvular aortic stenosis (SVAS) is the most uncommon stenotic
lesion of the left ventricular outﬂow tract (LVOT). We sought to characterize
predictors and outcomes of surgical intervention.
Methods: All 95 children diagnosed with SVAS at our institution between
1976 and 2006 were included in a review involving procedural and repeated
echocardiography reports. Analysis utilized parametric multivariable models with
bootstrapping and regression analysis adjusted for repeated measures.
Results: Stenosis was discrete in 82% and diﬀuse in 18%. The incidence of
pulmonary artery stenosis was 34% and coronary artery stenosis 6%. Williams
Syndrome (WS) was present in 62% and was not associated with diﬀuse stenosis.
Surgical intervention was undertaken in 47, reﬂecting a steep early hazard phase
and constant hazard thereafter (1%/year). Type of repair (Doty=30, 1-patch=16,
3-patch=1) was independent of WS or diﬀuse morphology. WS was associated with
reduced risk of surgical intervention (p=.01, ﬁgure). Higher mean LVOT gradient
(p<.001) and smaller aortic sinus z-score (p=.004) were the only independent
predictors of surgery, with thresholds >30mmHg and <-2, respectively. Surgery
eﬀectively reduced gradient progression (p<.001) and improved the rate of aortic
growth (p<.001). Doty repair and diﬀuse disease were independently associated
with less eﬀective LVOT gradient reduction. Overall survival was 94%±3 and 85%±7

T U E S D AY M O R N I N G
at 10 and 15 years after diagnosis respectively. No robust independent predictors of
death were identiﬁed.
Conclusion: Overall mortality in SVAS is low and independent of morphology
or management strategy. The need for surgical intervention is high, although
signiﬁcantly less in WS. Patch augmentation and discrete stenosis may be associated
with improved hemodynamic outcome.

138 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 139
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9:00 am

35. Pathologic Stage 0-1 After Induction Therapy for Clinical Stage III Non-Small Notes
Cell Lung Cancer: Is it Really an Early Stage?
V. Porziella1; S. Margaritora1; M. Congedo1; R. D’Angelillo2; G. Cusumano1; S. Ramella2;
E. Meacci1; A. Cesario1; L. Trodella2; P. Granone1
1
Catholic University of Rome, Rome, Italy; 2Libera Università Campus Bio-Medico,
Rome, Italy
Discussant: Douglas E. Wood, Seattle, Washington
Background: To verify if patients aﬀected by locally advanced (IIIa-IIIb) non-small
cell lung cancer (NSCLC) treated with multi-modality approach (concurrent radio-
chemotherapy induction treatment followed by surgery) and downstaged to
pStage 0-1 have the same prognosis of patients with early stage (pStage I) disease.
Methods: Eighty of 226 patients with cStage III NSCLC, treated from 1992 to 2005
with multi-modality approach, were downstaged to pStage 0-1 (A-group). Forty-four
patients had cStage IIIa and 36 had cStage IIIb NSCLC; 41 patients were downstaged
to pStage 0 and 39 to pStage I. Disease-free survival was calculated with the Kaplan-
Meier method and compared with survival of 367 patients undergone to surgery for
early stage NSCLC from 2001 to 2005.
Results: Three- and 5-year survival was, respectively, 48% and 46% in A-group and
82% and 76% in B-group (p=0.000 and 0.000). In A-group, survival of patients with
cStage IIIa and of those with cStage IIIb NSCLC was, respectively, 48% and 42%
(p=NS). Patients downstaged to pStage 0 and to pStage I had similar 5-year survival
(45% and 47%, p= NS).
Conclusion: In our experience, multi-modality approach seems to oﬀer good
results in terms of overall survival for patients with cStage III NSCLC, especially in
those downstaged to pStage 0-1; nevertheless, early stage NSCLC has a statistically

T U E S D AY M O R N I N G
signiﬁcant better 3- and 5-year survival. In patients treated with multi-modality
approach and downstaged to pStage 0-1, 3-year and 5-year survival are similar; no
diﬀerence were noted between cStage IIIa and IIIb and between pStage 0 and I.

140 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 141
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9:15 am

36. Infant Heart Transplantation Utilizing Donors After Cardiac Death Notes
A. K. Kaza; M. M. Boucek; M. B. Mitchell; B. A. Pietra; S. Miyamoto; C. Mashburn; D. M. Hall;
D. N. Campbell
University of Colorado/ The Children’s Hospital, Denver, Colorado
Discussant: Robert M. Sade, Charleston, South Carolina
Background: Heart transplantation remains the treatment of choice for various
structural heart defects. The number of heart transplants, however, remains
stagnant over the years owing to the limited number of organ donors. We sought to
examine the viability of heart transplantation done utilizing donation after cardiac
death protocol.
Methods: Experimental evidence has shown the feasibility of organ transplantation
utilizing organs procured after cardiac death. We have devised a protocol for
procuring cardiac allografts from donors after cardiac death. We present our series
of 3 patients who underwent heart transplantation utilizing organs procured from
donors after cardiac death.
Results: Three infants underwent heart transplantation utilizing organs from donors
after cardiac death. The ﬁrst child had severe cardiac dysfunction after arterial
switch operation. The second child was born with hypoplastic left heart syndrome
and severe polyvalvar dysplasia. The third child had dilated cardiomyopathy. The
three infants are three years, six months and three months, respectively from their
transplantation. The are all doing well with their most recent echocardiogram
demonstrating good graft function.
Conclusion: We believe that utilizing cardiac allografts from donors after cardiac
death is a viable option. The allografts have demonstrated good function in the
three infants who underwent the transplantation. In conclusion, we believe that

T U E S D AY M O R N I N G
utilizing donation after cardiac death protocols can help expand the donor pool
available for transplantation.

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9:30 am

37. Results of A New Surgical Paradigm: Notes
Endovascular Repair for Acute Complicated Type B Aortic Dissection
W.Y. Szeto; M. McGarvey; A. Pochettino; G.W. Moser; A. Hoboken; K. Cornelius; E.Y. Woo;
R.M. Fairman; J.E. Bavaria
Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
FINANCIAL DISCLOSURE R.M. Fairman, Medtronic, Inc., principal investigator; J.E. Bavaria, W.L. Gore,
principal investigator; Medtronic, Inc., principal investigator.
REGUL ATORY DISCLOSURE This presentation describes the oﬀ-label use of the Gore® TAG endovascular
stent. The FDA status is approved. The oﬀ-label use is aortic dissection.
Discussant: Grayson H. Wheatley, III, Phoenix, Arizona
FINANCIAL DISCLOSURE W. L. Gore (advisory board), consultant/advisory board;
Medtronic, Inc. (consultant), consultant/advisory board.
REGUL ATORY DISCLOSURE This presentation describes the use of the Gore TAG. The FDA status is approved.
The oﬀ-label use being discussed is aortic dissection.

Background: Thoracic endovasulcar aortic repair (TEVAR) has emerged as an
eﬀective therapy for acute thoracic aortic syndromes. We examined the results of
TEVAR in acute type B aortic dissection complicated with rupture or malperfusion.
Methods: From 2004 to 2007, 28 patients with acute complicated type B dissection
were treated with TEVAR. Indications included rupture (n=14) and malperfusion
(mesenteric/renal, n=5; lower extremity n=3; all, n=6). Intravascular ultrasound was
used in 11 patients. In patients with malperfusion, adjunct procedures included
infrarenal aortic wall stents (n=2), mesenteric/renal stents (n= 3), axillary stent (n=1)
and iliac stents (n=4). The mean follow up was 11 months.
Results: Technical success deﬁned by coverage of the primary tear site was
achieved in all 28 patients. Coverage of the left subclavian artery was performed
in 19 patients. Thirty-day mortality was 3.5% and 1-year survival was 92.4%.

T U E S D AY M O R N I N G
Complications occurred in 9 patients and included renal failure (n=2), stroke (n=2),
spinal cord ischemia (n=2), and vascular access (n=3). During follow up, complete
thrombosis of the false lumen was seen in 10 patients and partial thrombosis
occurred in 10 patients. Freedom from reintervention, extension of dissection,
malperfusion, or rupture at 1-year was 84.2%.
Conclusion: At our institution, TEVAR has emerged as the therapy of choice for
acute type B aortic dissection complicated by rupture or malperfusion syndrome,
representing a dramatic change in therapeutic paradigm. Although perioperative
morbidity and mortality rates are encouraging, long term investigation is needed to
examine the eﬀect of TEVAR on the fate of distal aorta and aortic remodeling.

144 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 145
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10:30 am

38. Overall Hospital Surgical Case Volumes and Raw Mortality Rates Inaccurately Notes
Assess Quality in Pediatric Cardiac Surgery
K. F. Welke; B. S. Diggs; T. Karamlou; R. M. Ungerleider
Oregon Health and Science University, Portland, Oregon
Discussant: J. William Gaynor, Philadelphia, Pennsylvania
Background: Overall surgical volumes and raw mortality rates are frequently
used to compare pediatric cardiac surgical programs. However, the broad variety
of pediatric cases performed makes such unadjusted comparisons potentially
unreliable. We sought to quantify the relationship between hospital volume and
pediatric cardiac surgery mortality.
Methods: Pediatric cardiac surgical operations were retrospectively identiﬁed
by ICD-9 diagnosis and procedure codes from the Nationwide Inpatient Sample
Database 1988-2003. Hospitals were grouped by yearly pediatric cardiac surgical
volume (very small <=20, small 21-100, medium 101-200, large >200). Logistic
regression adjusted mortality rates for surgical volume, surgical case mix (RACHS-1
categories), patient age, and year of surgery.
Results: 46,717 operations from 778 hospitals were identiﬁed. 375 hospitals (48%)
performed <= 20 cases/year. The overall, raw mortality rate at very small hospitals
was lower than at large hospitals (4.2% versus 5.5%). However, after adjustment for
RACHS-1 category and age, large hospitals performed signiﬁcantly better. Patients at
very small hospitals were 1.8 times more likely to die than patients at large hospitals
(95% CI 1.3-2.6). As a discriminator of mortality, volume performed signiﬁcantly worse
than a model with RACHS-1 category and age (ROC curve area 0.58 versus 0.80).
Conclusion: As a discriminator of mortality, volume alone was only marginally
better than a coin ﬂip (ROC curve area of 0.50). However, large volume hospitals are

T U E S D AY M O R N I N G
performing more complex operations and achieving superior results. Therefore, the
use of overall, unadjusted mortality rates to evaluate institution quality is misleading.
Pay-for-performance initiatives must be based on robust risk-adjusted comparisons.

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10:45 am

39. Lobectomy for Early Stage Non-Small-Cell Lung Cancer: Notes
A Systematic Review and Meta-Analysis Comparison of the
Video-Assisted Thoracoscopic Approach to Thoracotomy
B. A. Whitson; S. S. Groth; S. J. Duval; M. A. Maddaus
University of Minnesota, Minneapolis, Minnesota
Discussant: Thomas A. D’Amico, Durham, North Carolina
FINANCIAL DISCLOSURE Covidien, speakers bureau/honoraria.

Background: Video-assisted thoracoscopic (VATS) lobectomy has been promoted
as providing superior patient outcomes compared to thoracotomy for early stage
non-small-cell lung cancer (NSCLC). However, supporting data are limited to single
institutional series and small studies. We hypothesized that a meta-analysis of the
literature would increase the statistical power to permit a better evaluation of the
potential superiority of the VATS approach compared to thoracotomy in terms of
short-term morbidity and long-term survival.
Methods: To identify relevant articles for inclusion in our meta-analysis, we
performed a systematic review of the MEDLINE database to identify randomized,
controlled trials, observational studies, and case series that reported outcomes
following either VATS or open lobectomy for NSCLC. Statistical testing was
performed using a one-sided approach (α = 0.05) under the alternative hypothesis
that VATS lobectomy was superior to open lobectomy.
Results: A total of 17,098 studies were screened. After independent review of the
abstracts by 2 reviewers, 41 studies were included in the analysis. In aggregate,
there were 3,256 thoracotomy patients and 3,114 VATS patients. The demographics
of the two groups were not signiﬁcantly diﬀerent. Compared to thoracotomy, VATS
lobectomy was associated with fewer overall complications and superior 1-year

T U E S D AY M O R N I N G
through 5-year survival rates. In addition, VATS lobectomy was associated with
shorter chest tube duration and a shorter length of stay.
Conclusion: Compared to open lobectomy, VATS lobectomy for early stage NSCLC is
associated with lower morbidity and improved survival.

Meta-Analysis of Short-Term Morbidity and Long-Term Survival

Numbers of
Video-Assisted Number of
Video-Assisted
Thoracoscopic Thoracotomy Thoracotomy P-Value
Thoracoscopic
Surgery Studies
Surgery Studies
Overall Survival 1 Year 9 98.2% 10 93.4% 0.0055
2 Year 11 92% 8 85.5% 0.034
3 Year 13 87.1% 12 83.2% 0.027
4 Year 8 89% 10 73.8% 0.0075
5 Year 5 77.3% 16 67% 0.030
Complications 12 17.3% 9 27.6% 0.32
Chest Tube Duration
9 3.3 7 5.9 0.017
(Days)
Length of Hospital
15 5.4 12 12.3 0.011
Stay (Days)

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11:00 am

40. Increased Mortality Rates at Low Volume Orthotopic Heart Transplantation
Centers: Should the Optimal Volume for Deﬁning Centers of Excellence Be
Increased?
E. S. Weiss; R. A. Meguid; N. D. Patel; S. D. Russell; A. S. Shah; W. A. Baumgartner; J. V. Conte
Johns Hopkins University School of Medicine, Baltimore, Maryland
Discussant: Nicholas Smedira, Cleveland, Ohio
Background: The Centers for Medicare and Medicaid Services (CMS) mandate that
orthotopic heart transplantation (OHT) centers perform 12 transplants per year to
qualify for funding. We sought to determine whether this cutoﬀ is meaningful and
establish recommendations for optimal center volume using the United Network for
Organ Sharing (UNOS) registry.
Methods: We reviewed UNOS data (years 1999-2006) identifying 14,401 ﬁrst time
adult OHT’s conducted at 189 centers. Stratiﬁcation was by mean annual institution
volume. Primary outcomes of 30-day and 1-year mortality were assessed by
multivariable logistic regression (adjusted for co-morbidities and risk factors for
death). Sequential volume cutoﬀs were examined to determine optimal institutional
volume. Pseudo r2 and AIC assessed goodness of ﬁt. Notes
Results: Mean annual volume ranged from 1-118. One-year mortality was 12.5%
(n=1,800). Increased center volume was associated with decreased 1-year mortality
(Odds ratio(OR) p<0.001). Volume eﬀects were conﬁned to 30-day mortality (OR
1.02, p<0.001) as 1-year mortality conditional on 30-day survival eliminated the
eﬀect (OR 0.99, p=0.45) (Figure). The greatest mortality risk occurred at very low
volume centers (<=5 cases =16% increase in death, p=0.03). Although annual
volume of <12 increased 30 day mortality by 5% (OR 1.05 (95%C.I. 1.03-1.06),
p<0.001) the greatest goodness of ﬁt in sequential multivariable analyses occurred

T U E S D AY M O R N I N G
at 18 transplants/year and all centers performing greater than 40 transplants/year
demonstrated <1% 30-day mortality.
Conclusion: Annual center volume is an independent predictor of short-term
mortality in OHT. These data support reevaluation of the current CMS volume cutoﬀ
for OHT as high volume centers achieve lower mortality.

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12:40 pm – 1:40 pm (Session includes lunch) Location printed on ticket 12:40 pm – 1:40 pm Floridian Ballroom A

STS Ethics Debate: No Heroic Measures – How Soon is Too Soon to Stop? Residents Luncheon
The title question will be debated by two surgeons taking opposing sides in resolving the There are several organizations that impact the training and ultimately career
following diﬃcult case. A patient has a complicated course after surgery for lung cancer. considerations for cardiothoracic surgery residents. This symposium will feature
He has severe respiratory and renal failure and needs dialysis. His wife says he wanted presentations by the leadership of each of these important organizations, including
no heroic measures to keep him alive, so refuses dialysis. The surgeon sees a reasonable The Society of Thoracic Surgeons, Thoracic Surgery Directors Association, Residency
chance of survival and wants to keep going. After much negotiation, the wife still refuses Review Committee, and the American Board of Thoracic Surgery. Each will summarize
dialysis, and the surgeon must decide whether to accept the surrogate’s decision or to do their organization’s perspective on resident issues and give an update on activities that
what is in the patient’s best interest by seeking a court order to continue treatment. residents should be aware of and understand. In addition, the presenters will facilitate
a panel discussion with questions and comments from the resident participants. As in
Learning Objectives: Upon completion of this program, participants will be able to: previous years, table seating will allow residents to meet and interact one-on-one with
leaders in the cardiothoracic surgery community.
1. Explain the advisability of discussing and planning to deal with potentially
life-threatening complications, with patients facing medium-to-high risk operations
Moderator: Walter H. Merrill, Cincinnati, Ohio
2. Analyze and manage disagreements with family surrogate decision makers
more eﬀectively 12:40 pm Introductory Remarks
Walter H. Merrill, Cincinnati, Ohio
Speakers: Thomas A. D’Amico, Durham, North Carolina and Mark J. Krasna, 12:45 pm TSDA Perspectives
Towson, Maryland John W. Brown, Indianapolis, Indiana
FINANCIAL DISCLOSURE T.A. D’Amico, Covidien (speakers bureau), speakers bureau/honoraria.
12:52 pm RRC Perspectives
Moderator: Robert M. Sade, Charleston, South Carolina Irving L. Kron, Charlottesville, Virginia
12:59 pm ABTS Perspectives
Richard H. Feins, Chapel Hill, North Carolina
1:06 pm STS Perspectives
John E. Mayer, Jr., Boston, Massachusetts

T U E S D AY A F T E R N O O N
1:13 pm Panel Discussion
John W. Brown, Richard H. Feins,
Irving L. Kron, John E. Mayer, Jr. and Walter H. Merrill
1:40 pm Adjourn

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1:45 pm – 5:45 pm Palm A
Parallel Surgical Forum I: General Thoracic I Notes
Moderators:
David R. Jones, Charlottesville, Virginia and David H. Harpole, Jr., Durham, North Carolina
FINANCIAL DISCLOSURE D. Jones: Coviden Healthcare, Inc., (advisory board for thoracic surgery) consultant/
advisory board.

41. Survival of Patients With Unsuspected Microscopic N2 (Stage IIIa) Non-Small
Cell Lung Cancer
R. J. Cerfolio; A. S. Bryant
University of Alabama at Birmingham, Birmingham, Alabama
FINANCIAL DISCLOSURE R.J. Cerfolio, E-plus Health Care, speaker/honorarium; Millicore, advisory board
member; Medela, advisory board member.

Background: The survival of patients who have microscopic (PET and CT
non-detected) N2 non-small cell lung cancer (NSCLC) followed by adjuvant
chemotherapy is unknown and the advantage of neoadjuvant therapy for these
patients is also unknown.
Methods: A retrospective cohort study using a prospective database. All
patients underwent PET scan, CT scan with contrast, R0 resection with thoracic
lymphadenectomy and had unsuspected, pathologic N2 NSCLC.
Results: Between 6/98 and 6/06 there were 132 patients (71 men). The most

T U E S D AY A F T E R N O O N
common pulmonary resection was right upper lobectomy in 53 (40%) patients.
The most common lymph node station for unsuspected N2 diseased was 4R. One-
hundred and ﬁve (93%) patients received adjuvant chemotherapy. The overall 2 and
5 survivals were 56% and 37%, respectively. The 5-year survival for the 98 patients
with single nodal disease compared to patients with multiple nodal involvement
was 52% versus 14%, respectively (p=0.008). The number of lymph nodes involved
(p = 0.032) was an independent predictor of survival on multivariate analysis.
Median follow up was 54 months.
Conclusion: The survival for patients with unsuspected N2 disease who undergo
complete resection followed by adjuvant therapy is satisfactory. Therefore, the
discovery of microscopic N2 disease prior to thoracotomy is controversial. Therefore,
the role of mediastinoscopy, EUS-FNA, or EBUS in patients who are clinical N2
negative after PET and CT is unknown, since the beneﬁt of neoadjuvant therapy for
this type of N2 disease is unproven. A randomized study is needed.

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2:00 pm

42. Which is the Best Surgical Approach for N2 Positive Epithelial Malignant Notes
Mesothelioma? Long-Term Outcome After Extrapleural Pneumonectomy
Versus Radical and VATS Decortication/Pleurectomy
D. Trousse, Jr.; A. Nakas; A. E. Martin Ucar; D. A. Waller
Glenﬁeld Hospital, Leicester, United Kingdom
Background: Debate exists over which is the best surgical option for Malignant
Mesothelioma (MM) between Extrapleural Pneumonectomy (EPP) and Pleurectomy/
Decortication (P/D) especially in the presence of positive N2 nodal involvement.
We have audited our diﬀerent approaches to this situation with speciﬁc reference
to the epithelial cell type which has a favorable outcome compared to biphasic or
sarcomatoid.
Methods: We reviewed 127 patients (104 male, mean age: 62.2 years) operated
on for epithelial MM. Overall survival of 35 EPP with N2 disease, 37 Radical P/D and
55 VATS P/D was analysed using the Kaplan Meier method. Diﬀerences in survival
between the 3 groups were tested with the log-rank test
Results: In the VATS and Radical P/D groups, patients were signiﬁcantly older (mean
age: 66.6 and 63.1 years) than those for EPP (mean age: 54.4 years, p=0.04 and
p=0.004). Overall 30-day and 90-day mortality rates were 3.9% and 10.2%. 30-day
mortality rates were comparable between the groups (p=0.56). 90-day mortality rate
was signiﬁcantly lower for VATS P/D (p=0.024). P/D was associated with a signiﬁcant
shorter hospital stay (14 and 9 v 27 days, p=0.007, p=0.009). The 1-year and 2-year
survival rates were 55% and 18% for EPP, 67% and 22% for VATS P/D, 83% and 73%
for Radical P/D. Signiﬁcantly better survival was seen after radical P/D (p=0.003).
Conclusion: These data support the preferential choice of radical pleurectomy/
decortication in surgery for N2 positive epithelial MM.

T U E S D AY A F T E R N O O N
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2:15 pm
Patient Characteristics
43. Salvage Lung Resection Following Deﬁnitive Radiation (>59 Gy) for Non-Small
Cell Lung Cancer: Surgical and Oncologic Outcomes Male 12 (50%)

J. E. Bauman; M. S. Mulligan; R. G. Martins; K. D. Eaton; D. E. Wood Median age 60 years (36-73)
University of Washington, Seattle, Washington
FINANCIAL DISCLOSURE J.E. Bauman, Novartis, research grant (principal investigator); R.G. Martins, Amgen, Median FEV1 2.3 L (0.66-3.55)
research grant (principal investigator); Eli Lilly and Company, research grant (principal investigator); Lilly speaker’s
bureau; Lilly advisory board; Genentech, research grant (principal investigator); GENIE speaker’s bureau; ImClone,
Referred from community 23 (96%)
research grant (principal investigator); Novartis, research grant (principal investigator); OSI Pharmaceuticals, research
grant (principal investigator); K.D. Eaton, Genentech, research grant (principal investigator); Wyeth Pharmaceuticals, 9 (38%); 4 (17%) evaluated by a cardiothoracic
research grant (principal investigator); Boehringer Ingelheim Pharmaceuticals, research grant (principal investigator). Incorporation of surgeon into original staging
surgeon
Background: Isolated local relapse occurs in 24-25% of patients after deﬁnitive Mediastinoscopy 4 (17%)
chemoradiation (>59 Gy) for locally advanced non-small cell lung cancer. Although
originally considered inoperable, select patients are referred for surgical salvage. Stage I-II 2 (8%)
We describe the largest series of salvage lung resection following curative-intent
radiation. Stage IIIA 14 (58%)
Methods: Twenty-four consecutive patients from 1997-2005 were identiﬁed
Stage IIIB 6 (25%)
retrospectively, and medical records reviewed. Patients were grouped by surgical
indication: A) local relapse, n=7; B) persistent abnormal FDG-PET, n=12; C) Stage IV, oligometastatic 2 (8%)
conversion to trimodality, n=4; D) bronchopleural ﬁstula, n=1.
Results: All patients received deﬁnitive radiation (median 63.9 Gy), and 22/24 Median radiation dose 63.9 Gy (59.4-70.2)
had concurrent chemotherapy. Original staging included cardiothoracic surgical
consultation in 4/24. Median time from last radiation to resection was 21 weeks. Reason for exclusion of primary surgery
Twenty-four patients underwent 25 resections: one wedge, 10 lobectomies, 4
Considered inoperable, due to advanced tumor stage 12 (50%)
bilobectomies, and 10 pneumonectomies. Viable tumor was present in 19 patients
(7/7 Group A; 10/12 Group B; 2/4 Group C). Nineteen ﬂaps were performed, 16
Serious medical comorbidities 2 (8%)
omental. Complications were observed in 15/24, including one death from adult

T U E S D AY A F T E R N O O N
respiratory distress syndrome. Median overall survival was 30 months (12 months Deﬁnitive chemoradiation preferred 10 (42%)
group A; 43 months group B). Estimated 3-year survival was 47%. Kaplan-Meier
survival curves for groups A and B were signiﬁcantly diﬀerent (p=0.019).
Conclusion: Salvage lung resection after deﬁnitive chemoradiation is feasible, with
encouraging survival. Surgical indication is predictive, with higher survival observed
among patients undergoing resection for persistent abnormal FDG-PET than for Notes
obvious relapse. Systematic staging, including multidisciplinary evaluation with an
experienced thoracic surgeon, may have increased primary incorporation of surgery
and minimized the need for late surgical salvage.

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2:30 pm

44. Results of Primary Surgery in 271 Patients With T4 Non-Small Cell Lung Cancer Notes
Over a 25 Year Period in a Single Center: The Beneﬁt is Worth the Risk
P. G. Dartevelle; B. Yildizeli; E. Fadel; S. Mussot; A. Chapelier
Marie Lannelongue Hospital, Paris, France
Background: To assess operative mortality, morbidity, and long-term results of
patients with surgically resected T4 non-small cell lung carcinoma (NSCLC).
Methods: A retrospective review of 271 patients with T4 NSCLC between 1981-2006
was undertaken. They were divided into four subgroups: 126 patients with superior
sulcus tumors,92 with carinal involvement, 39 with superior vena cava (SVC)
replacement and 14 with the tumor invading other mediastinal structures. There
were 221 men and 50 women with a mean age of 56.3 years. A total of 75 patients
underwent induction therapy. Resection was complete in 249 (92%) patients. The
pathologic N status was N0/N1 in 208, N2/N3/M1 in 63 patients.
Results: Operative mortality and morbidity rates were 4% and 35%,respectively.
Overall 5-year survival rate was 38.4%. It was 36.6% for superior sulcus tumor;42.5%
for carinal involvement; 29.7% for SVC replacement and 59.3% for mediastinal
group. By multivariate analysis, only two factors inﬂuenced survival: nodal status
(N0-N1 vs. N2-3M1; p=0.003; 43% vs. 17.7% at 5 years, respectively),and complete
resection (R0 vs. R1; p=0.01; 40.4% vs. 15,9%, respectively). Complete resection and
long term survival were not improved by neoadjuvant treatment.
Conclusion: In highly qualiﬁed centers, radical surgery of T4 N0-N1 NSCLC can be
performed with a 4% mortality rate and may yield a 43% ﬁve year survival rate.
These results seem to indicate primary surgery as the treatment of choice for T4
NSCLC, whenever a complete resection is thought to be technically feasible and
patient’s condition compatible with the extent of the planned surgery.

T U E S D AY A F T E R N O O N
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2:45 pm

45. Tumor Inﬁltrating Lymphocytes (TIL): Notes
Prevalence, Correlations and Prognostic Signiﬁcance in Lung Neoplasms
E. Ruﬃni; P. Filosso; L. Daniele; L. Macrì; S. Asioli; A. Oliaro
University of Torino, Torino, Italy
Background: Tumor inﬁltrating lymphocytes (TIL) are inﬂammatory cells
spontaneously present in the tumor stroma. Few reports exist about their clinical
importance in lung neoplasms. We examined prevalence, correlations and
prognostic signiﬁcance of TIL among our population of resected lung neoplasms.
Methods: From 1993 to 2006, 1,290 patients were evaluated: 495 adenocarcinomas
(AK), 549 squamous-cell carcinomas (SCC), 86 bronchiolo-alveolar carcinomas
(BAC), 34 typical carcinoids (TC), 14 atypical carcinoids (AC), 56 large-cell anaplastic
carcinomas (LCC), 16 large-cell neuroendocrine carcinomas (LCNEC). Prevalence
diﬀerences (chi-square), logistic regression and survival analysis (log-rank) were applied.
Results: TIL was detected in 294 patients (23%). TIL prevalence by histology was:
AK 27% (133/495); SCC 24% (134/549); BAC 8% (7/86); TC 0% (0/34); AC 7% (1/14);
LCC 25% (14/56); LCNEC 19% (3/16). A signiﬁcant prevalence diﬀerence was found
between non-small cell lung carcinomas (NSCLC) and neuroendocrine carcinomas
(24% vs 5% p=0.0001). Logistic regression analysis evidenced a signiﬁcant
correlation between TIL and tumour dimension (OR 0.11, CI 0.03-0.38), and vascular
invasion (OR 1.63, CI 1.21-2.17). A trend towards a better survival in the presence
of TIF was noted in AK and LCC. The diﬀerence was statistically signiﬁcant in SCC
(p=0.03).
Conclusion: TIL are rare in neuroendocrine lung tumours. Prevalence is similar
among AK, SCC and LCC, while it is lower in BAC. A correlation exists between TIL
and tumour size and vascular invasion. TIL confers a survival advantage among AK

T U E S D AY A F T E R N O O N
and LCC, which was signiﬁcant in SCC. This preliminary results may target further
molecular analysis on TIL in lung neoplasms.

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1:45 pm – 5:45 pm Palm A
Parallel Surgical Forum I: General Thoracic I – Continued Notes
Moderators: Joe B. Putnam, Jr., Nashville, Tennessee and Gaetano Rocco, Naples, Italy
FINANCIAL DISCLOSURE J.B. Putnam, Jr.; Bayer (PI), research grant; EnturiaTM (speakers bureau), speakers bureau/
honoria; Genentech, Inc., (advisory board), consultant/advisory board.
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
3:45 pm Palm A
Featured Lecturer: Evolution/History of Staging for Non-Small Cell Lung Cancer
Peter Goldstraw, London, United Kingdom
4:30 pm

46. Long-Term Clinical and Immunological Outcome of Cryopreserved Arterial
Allograft Revascularization of Intrathoracic Vessels Invaded by Thoracic
Malignancies
A. Gomez-Caro1; E. Martinez1; A. Rodriguez1; D. Sanchez1; A. Haverich2;
W. Harringer3; J. Martorell1; J. M. Gimferrer1; J. L. Pomar1; P. Macchiarini1
1
Hospital Clinico y Provincial, Barcelona, Spain; 2Hannover Medical School, Hannover,
Germany; 3Klinikum Braunschweig, Braunschweig, Germany
Background: Evaluate the long-term clinical and immunological outcome of
cryopreserved arterial allograft (CAA) used to revascularize intrathoracic vessels
invaded by malignancies.
Methods: Since January 2002, all consecutive patients whose intrathoracic vessels
were invaded by malignancies were treated using human lymphocyte antigen-

T U E S D AY A F T E R N O O N
(HLA) and ABO-mismatched CAA for revascularization. Immunological studies were
performed pre-, and 1, 3, 6, 12, and 24 months post-operatively. Post-operative
anticoagulation therapy was not given.
Results: Twenty patients aged 51.6±17 years were operated. Indications were
non-small cell lung cancer (n=7), invasive mediastinal tumors (n=7), pulmonary
artery sarcoma (n=3), and other rare lung neoplasms (n=3). The intrapericardial
(n=5) or extrapericardial (n=2) pulmonary artery, superior vena cava (n=5), left
innominate vein (n=2), ascendent (n=1) or descending (n=3) aorta, and subclavian
artery (n=2) were revascularized using a total of 22 CAAs. Cardiopulmonary bypass
was employed in 50% of cases. All patients had a complete pathological resection.
Major complications occurred in 4 patients (20%), and all were unrelated to CAA
interposition. Hospital mortality was 5% (n=1). With a median follow-up of 18
months (range, 6 to 54+ months), 4-years survival and allograft patency were
80 and 95%, respectively. Two (10%) patients had anti-HLA antibodies already
preoperatively. An anti-HLA antibody response of clinical irrelevance was detected
in only 1 (6%) of the remaining 17 patients.
Conclusion: Revascularization of intrathoracic vessels in patients with intrathoracic
malignancies using HLA- and ABO-mismatched CAA is technically feasible, does not
require anticoagulation therapy postoperatively, and results in excellent long-term
survival and patency, and clinically irrelevant immunogeneicity.

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4:45 pm

47. A Phase II Trial of Tetrathiomolybdate (TM) After Cytoreductive Surgery for Notes
Malignant Pleural Mesothelioma (MPM): Final Results
H. I. Pass1; G. Brewer2; D. Smith2; S. Merajver2
1
NYU School of Medicine, New York, New York; 2University of Michigan,
Ann Arbor, Michigan
FINANCIAL DISCLOSURE G. Brewer, Attenuon, consultant; S. Merajver, Attenuon, consultant.
REGUL ATORY DISCLOSURE This presentation describes the oﬀ-label use of Tetrathiomolybdate. The oﬀ-label
use is antiangiogenesis for mesothelioma.

Background: Progression of disease commonly occurs at a median of 7-12 months after
MPM resection. TM is an oral copper (Cu)-depleting agent that inhibits angiogenesis, a
known predictor of poor prognosis in MPM. We hypothesized that cytoreduction of MPM
followed by TM may increase survival and delay progression in MPM.
Methods: Between November 2000 and August 2003, 34 MPM patients had
cytoreduction followed by postoperative TM beginning 4-6 weeks after surgery
to keep serum ceruloplasmin (Cp) between 5-15mg/dL. Chest/abdominal CTs
were performed every 4 months and TM was continued until progression. Time
to progression and survival for TM were compared to 54 Stage I/II patients and 81
Stage III patients previously cytoreduced by the author (HP).
Results: Four patients were unevaluable due to progression prior to reaching target
Cp. The remaining 30 patients (25 male, 5 female, 13 Stage I/II, 17 Stage III), remained
on TM for 2 to 57 months (mean, 14.9). 5 patients remain alive, a mean of 65 months
from surgery. All patients reached target Cp levels at a mean of 34+2 days (95% CI 30-
39 days), and VEGF levels at baseline (Cp=45.2+2 mg/dL) decreased from 2086+390
pg/ml to 1250+712 pg/ml (p<0.002) at target Cp [13+2 mg/dL (p<0.0001 from
baseline)]. Stage I/II time to progression was longer with TM (p<0.05), as seen below.

T U E S D AY A F T E R N O O N
Conclusion: In this Phase II trial, TM exhibited minimal toxicity and comparable eﬃcacy
to previous multimodality trials. TM should be evaluated for eﬃcacy in combination
with standard MPM regimens, as well as for postsurgical maintenance therapy.

Progression and Survival

Progession (Months) Survival (Months)

TM+ TM- TM+ TM-

Stage I/II 20 10 41 35

Stage III 7 8 15 12

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5:00 pm

48. Subcategorization of T3 Non-Small Cell Lung Cancer Notes
Based on the Involved Neighboring Structures
N. Sakakura1; S. Mori1; F. Ishiguro1; T. Fukui1; S. Hatooka1; M. Shinoda1; K. Yokoi2;
T. Mitsudomi1
1
Aichi Cancer Center Hospital, Nagoya, Japan; 2Nagoya University Graduate School
of Medicine, Nagoya, Japan
Background: Although the prognoses of patients with resected T3 lesions vary, the
current classiﬁcation system does not elucidate criteria for tumor subclassiﬁcation.
Methods: Tumors from 159 consecutive patients with completely resected T3
non-small cell lung cancer were divided into seven groups based on the involved
neighboring structures: main bronchus, parietal or mediastinal pleura, pericardium,
diaphragm, subpleural fat tissue, intercostal muscle, and ribs.
Results: The 5-year survival rates were 55% for the bronchus group (n = 28), 54%
for the pleura group (n = 53), 27% for the pericardium group (n = 11), 40% for the
diaphragm group (n = 9), 41% for the subpleural fat tissue group (n = 27), 25%
for the intercostal muscle group (n = 12), and 26% for the rib group (n = 19). The
bronchus and pleura groups were deﬁned as T3a, and the pericardium, diaphragm,
subpleural fat tissue, intercostal muscle, and rib groups were deﬁned as T3b. The
5-year survival rates were 54% and 33% for T3a (n = 81) and T3b (n = 78) tumors,
respectively (p = 0.0044). Additionally, the 5-year survival rates for T3N0 tumors were
62% and 30% for T3aN0 (n = 47) and T3bN0 (n = 44) tumors, respectively (p = 0.0009).
Conclusion: Subcategorization of T3 tumors resulted in the T3a (involving
bronchus or invading pleura without inﬁltration of deeper structures) and T3b
lesions (involving pericardium or diaphragm, or inﬁltrating subpleural structures
of the chest wall). These tumor characteristics should be considered for lung

T U E S D AY A F T E R N O O N
cancer classiﬁcation.

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5:15 pm

49. Extent and Quality of Lymphadenectomy in Esophageal Cancer Resection: Notes
Review of the American College of Surgeons Oncology Group Z0060 Trial
N. K. Veeramachaneni1; J. B. Zoole1; J. B. Putnam2; B. F. Meyers1
1
Washington University School of Medicine, St. Louis, Missouri; 2Vanderbilt
University, Nashville, Tennessee
Background: The American Joint Committee on Cancer staging of esophageal
cancer has been criticized for not establishing a minimum standard for
lymphadenectomy and for relying upon location of nodes involved rather than their
number. The objective of this study was to review the current practice of American
surgeons with regard to lymph node assessment during esophageal resection.
Methods: The operative and pathology reports of patients who underwent staging
by CT and PET imaging, and subsequent resection for esophageal cancer (multi-
institutional ACOSOG Z0060 trial) were analyzed.
Results: 145 patients underwent resection. Operative and pathology reports were
unavailable in 11 patients. The results of the remaining 134 resections (Ivor-Lewis,
n=64; transhiatal, n=59; other, n=11) were reviewed. Overall, 13±9 (mean±SD)
lymph nodes were evaluated per patient. In 11% (15/134) of patients, three or
fewer lymph nodes were analyzed. More lymph nodes were evaluated in patients
undergoing Ivor-Lewis (15 ± 9) than transhiatal esophagectomy (9 ± 7; p=0.004).
The mean number of distinct lymph node stations analyzed per patient was 3 ± 2. In
38% (51/134) of patients, nodes attached to the specimen were evaluated without
distinction between nodal stations. The practice of submitting named packets
of nodal material resulted in 17±9 nodes per case, as opposed to the practice of
submitting an entire specimen for pathologists to dissect which yielded 10±8
nodes(p=0.775).

T U E S D AY A F T E R N O O N
Conclusion: There is considerable variability and room to improve in the extent
of resection and pathological evaluation of esophagectomy specimens. A uniform
standard for esophageal cancer resection is warranted to improve the precision and
value of pathological staging.

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5:30 pm

50. Radiofrequency Ablation of Lung Neoplasm in Notes
100 Consecutive Patients by a Thoracic Surgical Service
A. Pennathur; G. Abbas; W. E. Gooding; S. Gilbert; N. A. Christie; R. J. Landreneau;
J. D. Luketich
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Background: Surgical resection is the standard of care for patients with resectable
non-small cell lung cancer (NSCLC) or limited pulmonary metastases (LPM).
However, for high risk patients who are not surgical candidates, Radiofrequency
Ablation (RFA) may oﬀer an alternative option. The objective of this study was
to evaluate computed tomography (CT-guided) radiofrequency ablation as an
alternative treatment option for high-risk patients with lung neoplasm. We report
our initial experience with RFA for Lung Neoplasm in 100 consecutive patients by a
Thoracic Surgical Service
Methods: Medically inoperable patients were oﬀered RFA. Thoracic surgeons
evaluated and performed RFA primarily under CT guidance. Patients were followed
in the thoracic surgery clinic. The primary endpoint studied was overall survival.
Results: One hundred patients underwent RFA for lung neoplasm (36 men, 64
women; median age 73.5 years; range 25-85). There were 52(52%) patients with
NSCLC, 13 (13%) with recurrent cancer and 35 (35%) with pulmonary metastases
who underwent RFA. The mean follow-up was 14.4 months. The median overall
survival for the entire group of patients was 25.2 months. The probability of 1 year
overall survival for the entire group, primary lung cancer, recurrent cancer and
metastatic cancer were 75% ( CI.66-.85), 75% ( CI.64-.89), 84% ( CI.66-.1.0) and 70%
(CI.5-0.9) respectively.
Conclusion: Our experience indicates RFA is feasible in high-risk patients with lung

T U E S D AY A F T E R N O O N
neoplasm with reasonable results in patients who are not ﬁt for surgery. Surgery
should continue to remain the standard treatment, and RFA may oﬀer an option in
medically inoperable.

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1:45 pm – 5:45 pm Palm B
Parallel Surgical Forum II: General Thoracic II Notes
Moderators: Michael S. Mulligan, Seattle, Washington and Scott J. Swanson, New York, New York.
FINANCIAL DISCLOSURE S. Swanson: Ethicon, Inc. (consultant), consultant/advisory board.

Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
1:45 pm Palm B
Featured Lecturer: Contemporary Surgical Approaches to Benign Esophageal Disease
Claude Deschamps, Rochester, Minnesota
2:30 pm

51. Eﬀects of Bronchial Transection and Cyclosporine A on
Mucociliary Transport in Rats
R. Pazetti; P.M. Pêgo-Fernandes; G. Lorenzi-Filho; P.H.N. Saldiva; F.B. Jatene
São Paulo University Medical School, São Paulo, Brazil
Background: Post-transplant infection remains the leading common cause of
morbidity and mortality following lung transplantation. We hypothesized that both
surgery and immunosuppression play a key role in the development of infectious
complications by impairing airway mucociliary clearance. This study focused on
the assessment of the impact of bronchial transection and immunosuppression by
cyclosporine A (CsA) on mucociliary transport in rats.
Methods: Sixty-four rats were assigned to four groups (n=16 each): sham-operated
and saline; bronchial transection and saline; sham-operated and CsA; bronchial
transection and CsA (10mg/kg/day). Eight animals from each group were killed

T U E S D AY A F T E R N O O N
either on 30th or 90th postoperative day. In vitro transportability, in situ mucociliary
transport (MCT) and ciliary beating frequency (CBF) were measured.
Results: There was a signiﬁcant impairment (p<0.001) on CBF due to either
bronchial transection or CsA therapy. In vitro transportability was impaired only in
CsA-treated groups (p<0.001). In situ MCT was reduced in CsA-treated animals as
well as in those submitted to bronchial transection (p<0.001). This impairment was
signiﬁcantly recovered 90 days after surgery. In contrast, the eﬀects of CsA did not
change over 90 days of treatment. There was a synergistic eﬀect between CsA and
bronchial transection on mucociliary transport.
Conclusion: These results support our hypothesis that mucociliary clearance is
impaired after bronchial transection and CsA therapy. Further studies are necessary
to relate this ﬁnding with post-transplant infection and also to test some drugs
aiming to protect airway mucociliary system.

174 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 175
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2:45 pm

52. Objective Evaluation of Thoracoscopic Sympathectomy Notes
for Palmar Hyperhidrosis
H.A. Tetteh; T. Kast; M.M. Maddaus; B.A. Whitson; S.S. Groth; D.M. Radosevich; R.S. Andrade
University of Minnesota, Minneapolis, Minnesota
FINANCIAL DISCLOSURE R.S. Andrade, Delﬁn Technologies, research grant, collaborator.

Background: Evaluation of palmar hyperhidrosis (PH) patients and estimation
of their response to bilateral thoracoscopic sympathectomy (BTS) are subjective.
We hypothesize that measurement of transepidermal water evaporation rates
(TWER) and use of standardized questionnaires can provide an objective pre and
postoperative assessment of patients with PH.
Methods: IRB-approved prospective study of healthy volunteers (controls) and of
all PH patients evaluated in 2006. We measured palmar TWER(g/m2/h) with a hand-
held closed-chamber device (Vapometer®). Study subjects answered 3 standardized
quality-of-life (QOL) questionnaires: Dermatology Life Quality Index (DLQI),
Hyperhidrosis Disease Severity Scale (HDSS), and SF36. The DLQI scores the eﬀect
of symptoms on life (0=no eﬀect;30=extremely large eﬀect), and the HDSS rates
hyperhidrosis severity (1=unnoticeable;4=intolerable). TWER and questionnaires
were re-evaluated 1 month after BTS. We used t-tests to compare controls vs PH
patients, and preoperative vs postoperative values in PH patients undergoing
BTS(α=0.05).
Results: TWER and questionnaire scores were signiﬁcantly higher in PH patients
(n=20) than in controls (n=22). 10 patients had BTS during the study period. BTS
decreased TWER and questionnaire scores signiﬁcantly (Table).

T U E S D AY A F T E R N O O N
Controls(n=22) Preop PH(n=20) Postop PH(n=10)

TWER(g/m2/h)* 125+53 167+33a 40.5+9.9b

DLQI* 0.2+0.5 14.2+5.1a 1.5 +2.0b

HDSS(mean) 1.0 3.6a 1.2b

*Mean+standard deviation
ap<0.005 vs controls
bp<0.001 vs preop

PH patients had lower SF36 physical (p=0.032) and mental health dimensions
(p=0.001) than controls. BTS signiﬁcantly improved mental health dimensions
(p=0.045).

Conclusion: TWER and standardized QOL questionnaires are objective, clinically
practical tools to evaluate patients with PH and their response to BTS. Normal
reference TWER values may be helpful for future standardization of results.

176 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 177
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3:00 pm

53. Performance at Symptom-Limited Stair Climbing Test is Associated With Notes
Increased Cardiopulmonary Complications, Mortality, and Costs Following
Major Lung Resection
A. Brunelli; M. Refai; F. Xiumé; M. Salati; V. Sciarra; L. Socci; A. Sabbatini
Umberto IO Regional Hospital, Ancona, Italy
Background: Exercise tests are increasingly used during preoperative evaluation
before lung resection. The objective of this study was to assess the association
between performance at symptom-limited stair climbing test and postoperative
cardiopulmonary morbidity, mortality, and costs after major lung resections.
Methods: 640 patients submitted to lobectomy (533) or pneumonectomy (107)
for lung cancer from January 2000 through April 2007 performed a preoperative
symptom-limited stair climbing test as part of their routine preoperative evaluation.
ROC analysis was used to identify the best cut-oﬀ values of climbed height (number
of stepsXheight of the step, m) associated with outcome (<12m, 12-22m, >22m).
Univariate and multivariate regression analyses (validated by bootstrap) were
used to test associations between several preoperative and operative factors and
postoperative cardiopulmonary complications, mortality and postoperative costs.
Results: Multivariate regression analyses and bootstrap showed that the
height reached at stair-climbing test was reliably associated with increased
cardiopulmonary complications, mortality and costs. The table shows that in
patients climbing less than12 m cardiopulmonary complications, mortality and
costs were 2-fold (p<0.0001), 13-fold (p<0.0001) and 2.5-fold higher than in patients
climbing more than 22 m, respectively.
Conclusion: Performance at maximal stair-climbing test was reliably associated
with postoperative morbidity and mortality. We recommend the use of this simple

T U E S D AY A F T E R N O O N
and economic test in all lung resection candidates. Those patients showing a poor
performance at stair-climbing test should undergo a formal cardiopulmonary-
exercise-test with measurement of oxygen consumption in order to optimize their
perioperative management.

Height reached at stair climb and outcomes

Outcome measures < 12m (54 patients) 12-22m (294 patients) > 22m (292 patients) p-value

Mortality (n,%) 7 (13%) 11 (3.7%) 3 (1%) <0.0001

Cardiopulmonary
20 (37%) 84 (29%) 46 (16%) <0.0001
morbidity (n,%)
Postop hospital stay
10.9 9.4 8 <0.0001
(days)

Postop Costs ($) 7,012 3,591 2,838 <0.0001

178 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 179
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1:45 pm – 5:45 pm Palm B
Parallel Surgical Forum II: General Thoracic II – Continued Notes
Moderators: Daniel L. Miller, Atlanta, Georgia and Jessica S. Donington, Stanford, California
FINANCIAL DISCLOSURE: D. Miller; Ethicon Endo Surgery, Inc. (speaker), speaker bureau/honoria; Power Medical
Interventions (speaker), speaker bureau/honoria. Scientiﬁc Advisory Services, Inc., consultant/advisory board; J. Donnington;
Curry Rockefeller Group, LLC (speaker), speaker bureau/honoria. ONI Medical Systems, Inc. (speaker), speaker bureau/honoria.
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
4:00 pm

54. Lung Volume Reduction Surgery for Non-Heterogeneous Emphysema
W. Weder; W. Jungraithmayr; D. Lardinois; S. Hillinger; K. Bloch; E. Russi
University Hospital Zurich, Zurich, Switzerland
Background: Severely impaired patients with a heterogeneous type of pulmonary
emphysema experience remarkable clinical and functional improvement after
lung volume reduction surgery (LVRS). We reasoned that individuals with non-
heterogeneous emphysema might also beneﬁt if they are severely hyperinﬂated
(RV/TLC > 0.60) and if the emphysematous destruction is not too advanced: diﬀusing
capacity for carbon monoxide (DLCO) > 20% predicted (pred) and FEV1 > 20% pred.
Methods: From May 1994 until March 2007, 243 consecutive patients (101 women),
mean (±SD) age: 64±9y, with advanced emphysema, an FEV1 of 27.7±7.9% pred
and a dyspnoe score (MRC) of 3.4±0.7 were prospectively followed after bilateral
thoracoscopic LVRS. In 142 patients (58,4%), emphysema distribution was non-
heterogeneous assessed by CT and perfusion scan.
Results: Perioperative mortality was 2.5%. Improvement in FEV1% at 3 months

T U E S D AY A F T E R N O O N
was larger but declined faster in heterogeneous compared to non-heterogeneous
emphysema (Figure). At 3 months FEV1% was 45±15.5% in heterogeneous and
37.4±9.8% in non-heterogeneous emphysema. The eﬀect of LVRS lasted for at
least 5 years in the heterogeneous and up to 3 years in the non-heterogeneous
emphysema group. Overall survival (non-heterogeneous) estimates at 1, 3 and 5
years were 91.2% (92%), 77.4% (73.3%) and 66.3% (59.5%) respectively.
Conclusion: Patients with a heterogeneous type of emphysema proﬁt most from
LVRS, particularly early after LVRS. However we found that selected patients with
non-heterogenous emphysema may beneﬁt from LVRS as well and should not
unvaryingly be excluded from surgery despite a somewhat higher long term mortality.

180 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 181
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4:15 pm

55. Reconstructing the Airways With Extracellular Matrix Scaﬀolds Notes
1 2 3 3
S. Gilbert ; T. W. Gilbert ; S. D. Reynolds ; S. F. Badylak
1
University of Pittsburgh & VAMC, Pitttsburgh, Pennsylvania; 2McGowan Institute
for Regenerative Medicine, Pittsburgh, Pennsylvania; 3University of Pittsburgh,
Pittsburgh, Pennsylvania;
Background: Optimal management of benign tracheal stricture is surgical
resection. Surgery may not be an option because of challenges posed by
anastomotic tension and tenuous blood supply. Porcine extracellular matrix (ECM)
scaﬀolds have been demonstrated to promote neovascularization and constructive
tissue remodeling when used to repair injured tissues.
Methods: In 15 mongrel dogs, a 1cm x 2cm cartilaginous tracheal defect was
repaired with a 2cm x 3cm ECM graft. Three graft types were implanted: urinary
bladder matrix patch (UBM), UBM patch cross linked with carbodiimide (UBMc), and
decellularized porcine trachea (DPT). For each group, 3 animals were evaluated at 2
months, and 2 at 6 months. The ECM grafts were evaluated histologically.
Results: The UBM, UBMc and DPT groups showed no evidence of stenosis or
tracheomalacia at 2 and 6 months. The UBM, UBMc, and DPT groups all showed
deposition of organized collagen tissue and an intact epithelial layer with scattered
of mucociliary diﬀerentiation, occuring primarily at the edges of the graft site. There
was no cartilage formation within the newly remodeled tissue at 6 months.
Conclusion: The present results show that ECM scaﬀolds can promote the formation
of some of the necessary structures required for tracheal reconstruction, including
dense organized collagenous tissue and a ciliated epithelial layer. The ECM scaﬀold
also promotes healing of signiﬁcant size tracheal defects with complete surface
epithelialization and absence of stricturing. Ongoing eﬀorts are aimed at promoting

T U E S D AY A F T E R N O O N
graft structural integrity and complete regeneration of the mucociliary apparatus.

182 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 183
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4:30 pm

56. Bar Repair of Pectus Excavatum in the Adult Population: Should it be Done? Notes
1 1 1 1 1 1
V.A. Olbrecht ; M.A. Arnold ; R. Nabaweesi ; D.C. Chang ; K.H. McIltrot ; F. Abdullah ; C.N.
Paidas2; P.M. Colombani1
1
Johns Hopkins Medical Institutions, Baltimore, Maryland; 2University of South
Florida, Tampa, Florida
Background: While extensive literature exists on the bar repair of pectus excavatum
(PE) in pediatric patients, little data examines this repair in adults or compares
long-term outcomes in adults to the pediatric population. We have identiﬁed
the preoperative characteristics, postoperative complications, and outcomes of
adult patients undergoing pectus bar repair of PE who have had bar removal and
compared these outcomes to a pediatric population undergoing the same procedure.
Methods: A retrospective review (1997-2006) of patients undergoing primary repair
of PE with a pectus bar identiﬁed 107 individuals over the age of 18 and 137 patients
between the ages of 6 and 14, of whom 52 and 80 had their bar(s) removed, respectively.
These latter patients were the focus of analysis. Data collected included demographics,
preoperative symptoms, operative characteristics, and postoperative outcomes.
Results: The median (IQR) age and pectus index of adult patients at the time
of repair was 23 years (18-30) and 3.8 (3.5-4.3), respectively. The majority (81%)
of patients were male. Two (3.9%) adult patients experienced recurrence of PE
following bar removal and 6 (11.6%) experienced bar displacement or upper
sternal depression requiring surgical revision. These rates of complications were not
statistically diﬀerent than those found in children undergoing pectus bar repair of
PE at our institution (Table 1).
Conclusion: Pectus bar placement to correct PE in adults can be performed safely
and eﬀectively, with rates of bar displacement, sternal depression, recurrence,

T U E S D AY A F T E R N O O N
and reoperation that are not statistically diﬀerent than those found in a younger
pediatric population.

Table 1. Comparison of Postoperative Outcomes Between Adults and a Pediatric Population
Adults Age > 18 Children Ages
P value*
(n=52) 6 -14 (n=80)

Postoperative Complications, n (%)

Bar Displacement 4 (7.7) 4 (5.0) NS

Recurrence 2 (3.9) 5 (6.3) NS

Upper Sternal Depression 2 (3.9) 1 (1.3) NS

Reoperation 6 (11.5) 5 (6.3) NS

Patient Follow-Up

Median (IQR), years 2.5 (2.1 - 3.2) 2.5 (2.1 - 3.2) NS

* NS = Not signiﬁcant (p>0.05)

184 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 185
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4:45 pm

57. Revisional Surgery Following Esophagectomy: An Analysis of 42 Cases Notes
M.S. Kent; J. Luketich; W. Tsai; P. Churilla; M. Federle; R. Landreneau; M. Alvelo-Rivera;
M. Schuchert
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
FINANCIAL DISCLOSURE J. Luketich, US Surgical, grant and research support; Stryker, grant and research
support stock holder; Boston Scientiﬁc, stock holder; Rita Medical, stock holder; Johnson & Johnson, stock holder;
Smith-Nephew, stock holder.

Background: Reﬂux and postprandial fullness are common following
esophagectomy. On occasion these symptoms have an anatomic basis that
requires operative correction. Two such conditions are: 1) a diaphragmatic hernia
in which bowel herniates into the chest, and 2) a redundant conduit that impairs
gastric emptying. The recognition of these conditions and the results of operative
correction are the subject of this analysis.
Methods: A retrospective review from 1995-2007 identiﬁed patients who
developed either a diaphragmatic hernia or a redundant gastric conduit following
esophagectomy. The presenting symptoms, operative approach and outcomes
following surgery were recorded.
Results: Forty-two patients (representing 0.4% of the esophagectomy volume
in this time period) were identiﬁed with either a diaphragmatic hernia (n=19),
redundant gastric conduit (n=20), or both (n=3). Mean time from esophagectomy
to diagnosis was 32 months for diaphragmatic hernia and 18 months for redundant
conduit. Hernias occurred to the left of the gastric conduit in 95% of cases. Pyloric
narrowing was present in 4 patients with a redundant conduit. 38 patients
underwent revisional surgery (minimally invasive: 35, open: 3). Recurrence rates
after repair of a diaphragmatic hernia and gastric conduit revision were 30% and

T U E S D AY A F T E R N O O N
15% respectively.
Conclusion: A diaphragmatic hernia or redundant conduit may occur years
after esophagectomy. Hernias almost always occur adjacent to the greater curve
of the stomach. The development of a redundant conduit may be associated
with a functional outﬂow obstruction. These conditions can be repaired using
minimally invasive techniques although the recurrence rate following repair of a
diaphragmatic hernia is high.

186 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 187
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5:00 pm

58. Incidence, Risk Factors and the Use of Pleurodesis in the Management Notes
of Persistent Air Leak Following Major Pulmonary Resection
M. Liberman; C.D. Wright; J.C. Wain; D.M. Donahue; J.S. Allan; H.A. Gaissert; D. J. Mathisen;
M. Lanuti
Massachusetts General Hospital, Boston, Massachusetts
Background: Persistent air leak (PAL, deﬁned as air leak >5 days) following major
pulmonary resection is prevalent (≤26%) and associated with signiﬁcant morbidity.
This study examines an incompletely characterized treatment for the management
of PAL - pleurodesis/sclerosis.
Methods: A retrospective case-control study examining all isolated lobectomies
and bilobectomies performed via thoracotomy at a single institution was
performed. PALs (1997-2006) and controls (2002-2006) were identiﬁed from a
prospective database. Incidence, risk factors, management and outcome were deﬁned.
Results: Over 9 years 78 PALs were identiﬁed in 1,393 patients (5.6%). Controls
consisted of 700 patients. PAL risk factors are shown in Table 1. Multivariable logistic,
regression analysis demonstrated that right-sided resection was the only predictive
risk factor (O.R.=2.56, C.I.-1.026-6.387, p=0.044). Treatment of PAL consisted of
observation (N=33, 42.3%), pleurodesis (N=43, 55.1%) and Heimlich valve (N=2,
2.6%). Seventy-three patients (93.6%) required no further intervention. One patient
required a muscle ﬂap, one readmission for pneumothorax, and one developed
empyema resulting in death. Sclerosis was successful in 40/43 patients (93.0%).
Mean time to treatment was 8.4±3.6 days, mean duration of air leak was 10.7±4.5,
and mean duration of air leak post-sclerotherapy was 2.8±2.2 days. There were no
adverse events related to pleurodesis. Post-operative pneumonia occurred with
increased frequency in PAL patients (6/45-13.3% vs. 34/700-4.9%,p=0.014). PAL was

T U E S D AY A F T E R N O O N
associated with increased length of stay (14.2 vs. 7.1,p<0.001) and time with chest
tube (11.5 vs. 3.4,p<0.001).
Conclusion: Air leaks remain an important cause of morbidity. Pleurodesis is
eﬀective and safe in the management of PAL after major pulmonary resection.

Table 1 - Prolonged Air-Leak Risk Factors

Risk Factor Air Leak Present Air Leak Absent P-Value

Male Sex (N, %) 44/78 (56.4%) 303/700 (43.3%) 0.018

Age (mean, SD) 65.6 ± 10.7 65.2 ± 11.7 0.808

Right-Sided (N, %) 57/78 (73.1%) 452/700 (64.6%) 0.083

Steroids (N, %) 2/45 (4.4%) 9/700 (1.3%) 0.089

Smoking History (N, %) 42/45 (93.3%) 563/700 (80.4%) 0.018

Pack/Years (mean, SD) 57.3 ± 36.1 48.2 ± 27.8 0.060

FEV1.0 (mean, SD) 2.0 ± 0.7 2.3 ± 0.8 0.022

% Predicted FEV1.0 (mean, SD) 74.5 ± 21.9 83.6 ± 20.4 0.001

188 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 189
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5:15 pm

59. Surgical Results of a Multi-Center Trial of the Laparoscopic Motor Point Notes
Diaphragm Pacing Stimulation (DPS) System in Ventilator Dependent
Tetraplegics
S. Khansarinia1; J. Yee2; R. Onders3
1
Piedmont Hospital, Atlanta, Georgia; 2Vancouver General Hospital, Vancouver,
British Columbia, Canada; 3University Hospitals Case Medical Center, Cleveland, Ohio
FINANCIAL DISCLOSURE R. Onders, Synapse Biomedical, co-founder of the Synapse Biomedical company.

Background: Patients with high spinal cord injuries (SCI) face the risk and
inconveniencies of dependency on mechanical ventilators. This report outlines the
multi-center surgical experience with the diaphragm pacing stimulation (DPS) system.
Methods: In a FDA trial, patients underwent laparoscopic diaphragm motor point
mapping with electrode implantations. Stimulus/output characteristics of each
electrode were determined and diaphragm conditioning initiated with home based
ventilator weaning.
Results: At total of 39 patients were implanted (31 males, 8 females), with a failure to
pace in the second patient due to a false positive phrenic nerve study. Motor vehicle
accidents accounted for 46% of patients and sporting activities 45%. Patient age
ranged from 18 to 74 with time from injury to implantation ranging from 6 months
to 27 years. The average operating room time was 133 minutes with no signiﬁcant
diﬀerence between any of the sites. There was no perioperative morbidity with the
most commonly tracked adverse event being a capnothorax which was handled
with simple aspiration. DPS provided tidal volumes to free 97% of tetraplegics from
ventilators. Additional ﬁndings of DPS use include: reduction of airway pressure
decreasing risks with synchronization with ventilators; appropriate conversion of the
diaphragm to the functional slow twitch oxidative muscle (Type I) ﬁbers; improved

T U E S D AY A F T E R N O O N
posterior lobe lung ventilation with over 60% reduction in secretions and need for
suctioning; and increased lung compliance leading to decreased work of breathing.
Conclusion: The DPS system is safe and should replace the ventilator for SCI
patients providing them more natural negative pressure ventilation.

190 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 191
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5:30 pm
Postoperative spirometric values comparing patients with normal and abnormal diaphragms
60. Ipsilateral Diaphragmatic Motion and
Immobile Paradoxical
Lung Function in Long-Term Pneumonectomy Patients Normal diaphragm
diaphragm diaphragm
N Group I: p
P.A. Ugalde; S. Miro; M. Quévillon; L. Chau; D. Deslauriers; Y. Lacasse; S. Ferland; S. Group II: Group III:
N : 44 (51 %)
N:22 (25 %) N:21 (24 %)
Provencher; J. Deslauriers
Hôpital Laval, Quebec City, Quebec, Canada Age, m (SD) 70 (10) 64 (9) 68 (8) 0.05
FINANCIAL DISCLOSURE P.A. Ugalde, research grant, Fondation J.D. Bégin (pulmonology chair);
S. Miro, research grant, Fondation J.D. Bégin (pulmonology chair); M. Quévillon, research grant, Fondation J.D. Follow-up months, m (SD) 103 (34) 121 (32) 104 (27) 0.09
Bégin (pulmonology chair); L. Chau, research grant, Fondation J.D. Bégin (pulmonology chair); D. Deslauriers,
research grant, Fondation J.D. Bégin (pulmonology chair); Y. Lacasse, research grant, Fondation J.D. Bégin FEV, (% pred, %-SD) 69 (16) 48 (11) 52 (10) < 0.001
(pulmonology chair); S. Ferland, research grant, Fondation J.D. Bégin (pulmonology chair); S. Provencher,
research grant, Fondation J.D. Bégin (pulmonology chair); J. Deslauriers, research grant, Fondation J.D. Bégin
(pulmonology chair). FVC (% pred, %-SD) 87 (18) 58 (13) 60 (13) < 0.001

Background: It is common belief that intraoperative injury to phrenic nerves DLCO (% pred, %-SD) 62 (11) 53 (11) 57 (10) 0.008
during the course of pneumonectomy has little impact on residual pulmonary
function. Since there are no objective data supporting this belief, we undertook a
study designed to correlate diaphragmatic motion (DM) as assessed with magnetic
resonance imaging (MRI) with objective parameters of lung function in long-term
pneumonectomy patients. Notes
Methods: Among 523 patients who underwent pneumonectomy for lung cancer
between 91.01.01 and 01.09.30, 117 were alive at the time of study in 2006. Of these,
17 were excluded and 13 could not undergo MRI leaving 87 individuals available
for study. DM was assessed during deep breathing and patients were classiﬁed as
having normal diaphragmatic motion (Group I), an immobile diaphragm (Group
II), or a diaphragm with paradoxical motion (Group III). Findings were correlated
by cross-sectional comparisons with expiratory volume measurements, room air
arterial blood gases, and 6-minute walk test.

T U E S D AY A F T E R N O O N
Results: All patients had varying degrees of mediastinal shift and contralateral
compensatory emphysema. The results of the comparison between DM and
spirometric studies are shown in the table. Long-term eﬀects of paralyzed
diaphragms were characterized by signiﬁcantly reduced expiratory lung volumes
and DLCO but no eﬀect on gas exchange (pO2, p:0.89) or exercise tolerance as
assessed by the 6-minute walk test (p:0.55).
Conclusion: Because the long-term eﬀects of a paralyzed hemidiaphragm in
pneumonectomy patients are characterized by signiﬁcant alterations in expiratory
lung volumes, it is imperative that surgeons avoid any technical error that could lead
to injuries to these nerves.

192 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 193
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Conclusion: All patients requiring surgery after attempted or completed MitraClip
1:45 pm – 5:45 pm Grand Floridian Ballroom A
implantation had successful operations. The majority of patients undergoing
Parallel Surgical Forum III: Adult Cardiac I planned MV repair were repaired successfully, and repair was feasible after
Moderators: John V. Conte, Baltimore, Maryland and Joseph C. Cleveland, Jr., Denver, Colorado 12 months in the majority and as late as 18.5 months after clip implantation.
FINANCIAL DISCLOSURE J. Conte, Thoratec Corporation (PI) research grant, St. Jude Medical Institute (consultant), Standard surgical options were preserved in patients who had surgery following a
consultant/advisory board, CryoLife, Inc. (consultant), consultant/advisory board, Abiomed (PI) research grant; J. Cleveland, percutaneous repair procedure with the MitraClip device.
Thoratec (PI for Pivitol Trial at University of Colorado), research grant.

61. Surgical Revision After Percutaneous Mitral Repair
With the MitraClip™ Device: Preservation of Surgical Options
M. Argenziano1; J.C. Alexander2; M. Davidson3; T.A. Vassiliades4; D. Heimansohn5;
E. Skipper6; Y. Woo7; E. Sako8; P. Tibi9; K. Krieger10; J. Cleveland11; G.V. Letsou12; F. Cheema1;
B. Kong13; T. Fudge14; A. Galloway15; E. Foster16; T. Feldman2; D. Glower17
1
Columbia University Medical Center, New York, New York; 2Evanston Hospital,
Evanston, Illinois; 3Brigham and Women’s Hospital/Interventional, Boston,
Massachusetts; 4Emory University, Atlanta, Georgia; 5The Care Group Heart Center,
Indianapolis, Indiana; 6Carolina Heart Institute, Charlotte, North Carolina;
7
University of Pennsylvania Hospital, Philadelphia, Pennsylvania; 8University of
Texas Science Health Center, Houston, Texas; 9Banner Good Samaritan Medical,
Phoenix, Arizona; 10Cornell University-NYPH, New York, New York; 11University of
Colorado Health Sciences Center, Denver, Colorado; 12University of Texas - Houston
Medical School, Houston, Texas; 13St. Joseph’s Mercy Hospital, Ann Arbor, Michigan;
14
Terrebone General Medical Center, Houma, Louisiana; 15New York University
Hospital, New York, New York; 16UCSF, San Franscisco, California; 17Duke University

T U E S D AY A F T E R N O O N
Medical Center, Durham, North Carolina
FINANCIAL DISCLOSURE M. Argenziano, Evalve, research grant: J.C. Alexander, Evalve, Evalve research
grant; M. Davidson, Evalve, Evalve research grant; T.A. Vassiliades, Evalve, Evalve research grant; D. Heimansohn, Evalve,
Evalve research grant; E. Skipper, Evalve, research grant; Y. Woo, Evalve, research grant; E. Sako, Evalve, Evalve research
grant; P. Tibi, Evalve, research grant; K. Krieger, Evalve, Evalve research grant; J. Cleveland, Evalve, Evalve research grant;
G.V. Letsou, Evalve, Evalve research grant; F. Cheema, Evalve, research grant; B. Kong, Evalve, Evalve research grant;
T. Fudge, Evalve, Evalve research grant; A. Galloway, Evalve, Evalve research grant; E. Foster, Evalve, Evalve research
grant; T. Feldman, Evalve, Evalve research grant; D. Glower, Evalve, Evalve research grant.

Background: Percutaneous mitral valve repair has been reported with the MitraClip.
In the event of treatment failure, preserving conventional surgical options is
important. We describe surgical treatment following the percutaneous procedures
in 28 patients.
Methods: 106 patients with moderate-severe/severe MR (3+-4+) were enrolled
in the EVEREST studies; 28 patients (26%) required surgery subsequent to the
percutaneous mitral repair procedure.
Results: Seven patients had no clip and 21 had clips implanted. Of the 21 clip
patients, 5 with immediate residual MR>2+, 14 with MR>2+ within 30 days,
and 2 with 2+ MR underwent surgery. The interval between percutaneous and
surgical intervention was 1-60 days (no clip) and 0-954 days (clip). Mitral repair
was accomplished in 4/7 no clip patients and 15/21 clip patients, with MVR in
the remaining 9. MVR was associated with advanced age, co-morbidities and/or
complex leaﬂet pathology and was planned in 6/9 cases (67%). Repair was successful
in 19/22 (86%) of attempted cases. 4/5(80%) of operations >12 months after clip
placement resulted in repair, and 7/19 mitral repairs (37%) included had leaﬂet repair
at the clip site. There was no operative mortality or unexpected morbidity.

194 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 195
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2:00 pm

62. Impact of Aprotinin on Adverse Clinical Outcomes Notes
and Mortality up to 12 Years in a Registry of 3,337 Patients
S.A. Olenchock, Jr.1; P. Lee1; T. Yehoshua1; S.A. Murphy2; G. Tolis, Jr.1
1
Tufts University School of Medicine, Boston, Massachusetts; 2Brigham and Women’s
Hospital and Harvard Medical School, Boston, Massachusetts
Background: Recent studies have suggested increased renal complications and
long-term mortality with aprotinin use in CABG patients, but these studies have
been criticized for including multiple centers with diﬀerent dosing strategies. We
analyzed prospectively collected data from a large, single-center hospital utilizing
a full-dose aprotinin regimen to evaluate if aprotinin was associated with increased
mortality and adverse outcomes versus amicar.
Methods: Data were prospectively collected for the STS National Database from 1994
to 2006 at a teaching hospital. Long-term mortality was collected from a Social Security
database. To account for diﬀerences between aprotinin and amicar-treated patients,
propensity score was generated and included in multivariate Cox model for mortality.
Results: Compared with amicar-treated patients (n=1,830), aprotinin-treated patients
(n=1,507) were older, more often female, had lower EF, lower creatinine clearance
and more baseline risk factors. Blood loss was lower in aprotinin-treated patients
(median 715ml vs. 918ml, p<0.001). Post-operative renal failure was >3x higher with
aprotinin (9.8% versus 3.1%,p<0.001). At mean 5.4 year follow-up (up to 12.2 years),
aprotinin-treated patients had higher mortality versus amicar-treated patients. After
multivariate adjustment including propensity-score, aprotinin remained associated
with increased mortality (HR 1.55, 95%CI 1.33-1.81, p<0.001). There was a stepwise
relationship between weight-based aprotinin dose and mortality (20.4%, 26.2%, 33.7%
for lowest-to-highest tertile of weight-based dose, p-trend <0.001).

T U E S D AY A F T E R N O O N
Conclusion: Among patients undergoing CABG in this large registry, aprotinin use
was associated with increased renal failure and higher mortality through 12 years in
a propensity-adjusted analysis, possibly due to higher concentrations of aprotinin
received. Although aprotinin was eﬀective in reducing blood loss, the excess
mortality suggests aprotinin should be used very selectively.

196 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 197
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2:15 pm

63. Transplanting High-Risk Recipients With Marginal Donor Hearts is Notes
Clinically Eﬀective
M.J. Russo; K.N. Hong; R.R. Davies; I. George; A.S. Stewart; M. Argenziano; M.C. Oz;
A. Moskowitz; A. Gelijns; Y. Naka
Columbia-Presbyterian Medical Center, New York, New York
Background: In any given year, less than 2,500 patients – of an estimated 60,000
potential beneﬁciaries – receive a heart transplant due to a critical scarcity of organs.
Alternate Listing Transplantation (ALT) strategies have been promoted as a means
to oﬀer the beneﬁt of transplantation to a greater number of candidates. Under
this strategy, high-risk recipients (HR) are considered candidates for “marginal”
donor (MD) organs. The purpose of this study is to determine the clinical outcomes
associated with using HR and MD.
Methods: UNOS provided de-identiﬁed patient-level data. Primary analysis
focused on patients undergoing heart transplantation between January 1, 1999,
to December 31, 2005 (n=11,154). HR criteria included age [gt] 65 years old,
retransplantation, HepC+, HIV+, CrCl [lt] 30 ml/min, DM with PVD, DM with Crcl [lt]
40 ml/min. MD criteria included age [gt] 55 years old, DM, HIV+, HepC+, EF [lt] 45%,
and donor: recipient weight [lt] 0.7.
Results:

Clinical Outcomes Statistics by Transplant Group (Recipient : Donor)

NR : ND NR : MD HR : ND HR : MD

6,938 1,861 1,778 577
n

T U E S D AY A F T E R N O O N
(62.2%) (16.7%) (15.9%) (5.2%)

30-day Survival % 89.5 87.4 81.8 79.6

5-year Survival % 76.0 72.8 65.1 57.3

Length of Stay days 18.6 21.3 24.4 25.6

Infection during Implant Hospitalization % 22.4 22.0 30.9 36.7

Dialysis during Implant Hospitalization % 6.6 8.2 19.4 19.9

Cardiac Reop during Implant Hospitalization % 10.9 12.2 14.5 12.8

Transplant Coronary Artery at 5 years % 69.0 63.0 70.1 64.6

NR = normal recipient; ND = normal donor; HR = high-risk recipient; MD = marginal recipient

Conclusion: Pairing high-risk recipients with marginal donors is associated with
greater morbidity and resource utilization compared with standard recipients and
donor. Nevertheless, this strategy oﬀers 5 years or more of additional survival to
patients who otherwise would be expected to live 1 year or less. Further analysis will
oﬀer further insights into which subgroups achieve the greatest beneﬁts.

198 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 199
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2:30 pm

64. Outcomes After Repair of the Anterior Mitral Leaﬂet for Degenerative Disease Notes
A. Gillinov; A. Alaulaqi; E.H. Blackstone; E.R. Nowicki; A. Salemi; J.F. Sabik, III; T. Mihaljevic;
L.G. Svensson; B. W. Lytle
Cleveland Clinic, Cleveland, Ohio
FINANCIAL DISCLOSURE A. Gillinov, research grant: State of Ohio, principal investigator, the Atrial
Fibrillation Innovation Center. The Atrial Fibrillation Innovation Center is an Ohio Wright Center of Innovation
supported by a grant from the State of Ohio’s Third Frontier Project.; Medtronic, research support for clinical trials,
honoraria (<$10,000), consultant (<$10,000); St. Jude, research support for clinical trials, honoraria (<$10,000); Edwards
Lifesciences, honoraria (<$10,000), consultant (>$10,000); Guidant, honoraria (<$10,000); AtriCure, honoraria
(<$10,000), former consultant (<$10,000); Viacor, stock ownership (>$10,000).

Background: Anterior mitral leaﬂet repair is said to be less durable than posterior
leaﬂet repair. Therefore, we sought to 1) identify factors predisposing to anterior
leaﬂet replacement rather than repair, 2) determine durability of repair and
associated risk factors, and 3) compare outcomes with those after posterior repair.
Methods: From January 1985 to January 2006, 3,525 patients underwent a primary
isolated mitral valve procedure for degenerative mitral valve disease, including 307
isolated anterior (251 repairs, 82%) and 2,748 isolated posterior (2,644 repairs, 96%)
leaﬂet procedures. Logistic regression analysis was used to identify predictors of
valve replacement and to form propensity scores for risk-adjusted comparisons.
Durability was assessed by reoperation and return of mitral regurgitation.
Results: Among patients with anterior prolapse, advanced age was the strongest
predictor of replacement rather than repair (P<.0001). Ten-year freedom from
reoperation was 90% after anterior leaﬂet repair versus 96% after posterior repair
(P<.0001). Return of MR was more common after anterior leaﬂet repair (P=.03, Figure).
Conclusion: In contrast to posterior mitral leaﬂet repair, anterior leaﬂet repair remains
challenging and is less durable. Thus, development of a more durable repair technique

T U E S D AY A F T E R N O O N
applicable to the broader spectrum of isolated anterior disease is warranted.

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2:45 pm

65. Towards a New Paradigm for the Reconstruction of Posterior Leaﬂet Prolapse: Notes
Long-Term Results of the ‘Respect Rather Than Resect’ Approach
P. Perier; W. Hohenberger; F. Lakew; G. Batz; P. Urbanski; M. Zacher; A. Diegeler
Herz und Gefäss Klinik, Bad Neustadt/Saale, Germany
FINANCIAL DISCLOSURE P. Perier, Edwards Lifesciences, consultant contract for education.

Background: The aim of mitral valve reconstruction (MVR) is restoration of good
surface coaptation (SC). Resection of the prolapsed area has been the undisputed
technique to repair posterior leaﬂet prolapse (PLP). However, since leaﬂet tissue
is the basic component of SC, the logical corrective approach was thought to be
the transformation of the posterior leaﬂet (PL) into a smooth and vertical buttress
without resection, the “respect rather than resect” approach (RRR).
Methods: Between 1994 and 2004, 225 patients underwent a PLP reconstruction for
severe mitral regurgitation (MR) with RRR approach, the prolapse being corrected
with artiﬁcial chordae. In 193 patients the prolapse was limited to PL, and in 32
patients, the anterior leaﬂet was involved. A ring annuloplasty was performed in all
patients. Associated procedures were myocardial revascularization (18 patients) and
tricuspid repair (14 patients). Patient demographics: mean age, 60.72±12.95; 146
male; 104 (46%) asymptomatic.
Results: Three patients died postoperatively (1.3%). Long-term survival was 89±6%
at 10 years, similar to expected survival rates; 97±1.9 for asymptomatic patients, and
83±10% for symptomatic patients (p<0.005). Eleven patients were reoperated for a
freedom from reoperation rate of 94±5% at 10 years. At echo follow-up 172 patients
over 195 (88%) showed MR ≤1 and 194 over 203 (96%) of the patients were in NYHA
functional class I or II.
Conclusion: The RRR approach is safe, eﬀective, and durable, it enhances technical

T U E S D AY A F T E R N O O N
possibilities. The surgical strategy was focused on the restoration of SC instead of on
the location and extent of leaﬂet resection.

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3:00 pm

66. Programmed Cell Death in Idiopathic Dilated Cardiomyopathy is Mediated by Notes
Suppression of the Apoptosis Inhibitor Apollon
S. Aharinejad; O. Andrukhova; A. Zuckermann; G. Wieselthaler; E. Wolner; M. Grimm
Medical University of Vienna, Vienna, Austria
Background: Idiopathic dilated cardiomyopathy (DCM) is characterized by
ventricular wall remodeling and concurrent increased frequency of cardiomyocyte
apoptosis. Apollon is a 528kD cell membrane anchored protein. Its task is the
inhibition of apoptosis by ubiquitinylation facilitating the degradation of SMAC/
Diablo or caspases -3 and -9. The aim of the study was to test the hypothesis that the
Apollon/SMAC/caspase system may mediate programmed cell death in DCM.
Methods: Apollon protein expression was assessed in left ventricular biopsies of
explanted failing hearts using Western blotting in 36 DCM patients undergoing
cardiac transplantation and in 10 controls. Human and rat cardiomyocytes were
transfected with a plasmid containing the human Apollon cDNA or control vector
and were subsequently stressed by hypoxia. Apollon mRNA expression was then
examined in cell lysates by real time RT-PCR, and a TUNEL assay was used to
determine the apoptotic index.
Results: In DCM myocardial tissue, Apollon expression was down-regulated
compared to control hearts (p<0.01). Cell stress resulted in increased apoptosis
in cardiomyocytes in vitro and down-regulation of Apollon mRNA expression
compared to control cells (p<0.001). Transfection increased Apollon mRNA
expression in cell lysates (p<0.001) and this treatment completely prevented
hypoxia-induced apoptosis.
Conclusion: These results suggest for the ﬁrst time that Apollon down-regulation
plays a role in the programmed cell death associated with DCM. Up-regulation of

T U E S D AY A F T E R N O O N
Apollon might therefore represent a novel therapeutic strategy in the treatment of DCM.

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1:45 pm – 5:45 pm Grand Floridian Ballroom A
Parallel Surgical Forum III: Adult Cardiac I – Continued
Moderators: Andrea J. Carpenter, San Antonio, Texas and Marc R. Moon, St. Louis, Missouri
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
5:30 pm Grand Floridian Ballroom A
Featured Lecturer: Does Early Introduction of Technology Into Patient Care
Compromise Patient Safety?
Friedrich W. Mohr, Leipzig, Germany
FINANCIAL DISCLOSURE Edwards Lifesciences (consultant PI), consultant /advisory board, Boston Scientiﬁc
Corporation, (consultant PI), consultant /advisory board.

4:00 pm

67. Long-Term Outcomes After Isolated Aortic
Valve Replacement in Octogenarians: A Modern Perspective
V.H. Thourani; R. Myung; O.M. Lattouf; P. Kilgo; J.D. Puskas; K. Thompson; E.P. Chen; R.A. Guyton
Emory University, Atlanta, Georgia Short- and Long-Term Outcomes Following Aortic Valve Replacement
FINANCIAL DISCLOSURE: V.H. Thourani, Boston Scientiﬁc, speaker consultant; Bayer Corporation, speaker
consultant; CardioMems, scientiﬁc advisory board; J.D. Puskas, Medtronic, speaker consultant; Boston Scientiﬁc, Age Group In-Hospital Survival LOS (days) 5-Year Survival 10-Year Survival
medical advisory board; R.A. Guyton, Medtronic, medical advisory board.
60-69 years 97.1% (200/206) 7.7±9.1 88.8% (183/206) 71.8% (148/206)
Background: With the recent advent of percutaneous valve therapy there is
increased scrutiny of the outcomes following open aortic valve replacement (AVR) in 70-79 years 95.0% (210/221) 8.0±6.3 76.0% (168/221) 63.8% (141/221)
elderly patients. This study compares the short and long-term survival outcomes of
octogenarians after aortic valve replacement (AVR) to the outcomes of younger age 80-89 years 95.5% (84/88) 9.8±10.7 67.0% (59/88) 38.6 (34/88)
groups in the modern surgical era.

T U E S D AY A F T E R N O O N
Methods: A single institution retrospective review was performed on patients
who underwent isolated, primary AVR from 1996-2006. Patients were divided into
three age groups; 60-69 (n=206), 70-79 (n=221), and 80-89 (n=88). In-hospital
Notes
mortality and hospital length of stay (LOS) were compared among the age groups
using logistic regression and analysis of variance (ANOVA) techniques, adjusted
for 24 pre-operative covariates. Adjusted long-term survival between age groups
was compared using the Cox proportional hazards model and Kaplan-Meier plots
determined both 5-year and 10-year survival rates.
Results: The groups were similar with respect to adjusted in-hospital mortality
(p=0.25), hospital LOS (p=0.12) and observed to expected mortality (p=0.16) (See
Table). As expected, age signiﬁcantly impacted long-term survival (p<0.001).
Other predictors of long-term survival included ejection fraction and preoperative
creatinine level. The Kaplan-Meier curve (Figure) estimate of median survival for
octogenarians was 7.8 years.
Conclusion: In the modern era, octogenarians have acceptable short- and
mid-term results following AVR compared to younger patient groups. Comparisons
of less invasive techniques for AVR should rely on outcomes based in the modern
era, rather than historical controls. Decisions regarding surgical intervention in
patients requiring AVR should not be based on age alone.

206 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 207
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4:15 pm

68. Minimally Invasive Atrial Fibrillation Surgery: Six-Month Results Notes
J.R. Edgerton; T. Weaver; K.E. Reed; S.L. Prince; M.J. Mack
Cardiopulmonary Research Science and Technology Institute, Dallas, Texas
Background: Recent advances in enabling technology have allowed the
development of a minimally invasive surgical procedure for ablation of atrial
ﬁbrillation (AF). We report the early outcomes of a single center series of minimally
invasive bilateral pulmonary vein (PV) isolation and partial autonomic denervation
for ablation of atrial ﬁbrillation
Methods: Seventy-four patients (46 paroxysmal, 14 persistent, 14 longstanding
persistent) underwent bilateral PV antral electrical isolation using a bipolar
radiofrequency clamp. Conduction block was conﬁrmed by checking for entrance
block into the PV. Autonomic ganglionated plexi at the junction of the PV and left
atrium (LA) were located by high frequency stimulation and ablated. The procedure
was performed using a bilateral approach with video imaging using a 5mm scope
in the sixth or seventh intercostal space (ICS) at the mid axillary line. Access to pass
instruments into the chest was with bilateral 6cm minithoracotomies without rib
spreading in the third ICS with video assistance. Selective amputation of the LA
appendage was performed. Interval follow up included an ECG and longer term
monitor (Holter or 14 day event monitor or pacemaker interrogation) at 6 months.
Success was deﬁned as <15 seconds of AF at 6 months.
Results: There was 1 (1.4%) operative mortality, and 3 (4.1%) readmissions for
rhythm related problems. ECG criteria overestimated success by 20%.
Conclusion: Minimally invasive AF surgery is eﬀective treatment of paroxysmal AF
at 6 months. Longer term monitoring is necessary to accurately assess treatment
results. A more extensive lesion set is likely required for treatment of persistent and

T U E S D AY A F T E R N O O N
longstanding persistent AF.

Rhythm Outcomes

Paroxysmal AF Patients Persistent/Longstanding Persistent
(N=46) AF Patients (N=28)

ECG Holter/PM Interrogation/ ECG Holter/PM Interrogation/
(N=43) Event Monitor (N=43) (N=27) Event Monitor (N=23)

Follow Up: NSR NSR NSR NSR

43 36 22 13
6 Months
(100%) (83.7%) (81.5%) (56.5%)

6 Months oﬀ Anti-arrhythmic 33 30 13 8
Meds (76.7%) (69.8%) (48.1%) (34.8%)

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4:30 pm

69. Long-Term Outcome Following Stentless Aortic Valve Replacement: Notes
14 Years Cumulative Experience
P. Bonde; M. Jones; D. Lovell; G. Campalani
Royal Victoria Hospital, Belfast, United Kingdom
Background: Stentless prostheses in the aortic position produces a superior
hemodynamic proﬁle in comparison to that with stented valves. The potential
beneﬁt of stentless aortic valve replacements (AVR) comes at the cost of greater
complexity of insertion, which may increase operative mortality and reduce long-
term survival due to technical errors.
Methods: Between 1993 and 2004, 345 patients (168 male), mean age 68.6 years,
underwent stentless AVR using the Toronto stentless porcine valve (n=140), Elan
(n=83), Cryolife O’Brien (n=58), Medtronic Freestyle (n=42) and homograft (n=22).
Concomitant CABG was performed in 36.5% (n=126) and previous cardiac surgery
had been performed in 5.2% (n=18). Clinical follow-up was 100% over a 70-day
closing interval and patients underwent regular echocardiography. Kaplan-Meier
and Cox regression survival analyses were performed.
Results: Operative mortality was 2.9%. Mean cross-clamp and cardiopulmonary
bypass (CPB) times were 106 and 148 minutes, respectively. Follow-up was 4 months
to 14 years (median 7.1 years). Actuarial survival at 1, 5, and 10 years was 92.8%,
81.5%, and 59.7%, respectively. Reoperation was performed in 12 patients (0.69%/
patient/year), structural valve deterioration occurred in 21 patients (1.21%/patient/
year), endocarditis in 11 patients (0.63%/patient/year), major hemorrhage in 6
patients (0.34%/patient/year), and major thrombo-embolism in 5 patients (0.29%/
patient/year). Multivariable analysis identiﬁed advanced age (p<0.01), operation
for endocarditis or prosthetic valve dysfunction (p<0.01), prolonged bypass time

T U E S D AY A F T E R N O O N
(p<0.01) as independent risk factors for reduced long-term survival.
Conclusion: Stentless AVR can be inserted with low operative mortality. Risk factors
for reduced long-term survival were advanced age, presence of endocarditis or
prosthetic valve dysfunction, and prolonged CPB.

210 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 211
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4:45 pm

70. Mitral Valve Replacement in Rheumatic Patients: Eﬀects of Chordal Notes
Preservation on Ventricular Remodeling and Pulmonary Hypertension
R. García-Fuster; V. Estevez; O. Gil; S. Canovas; J. Martinez-León
University General Hospital of Valencia, Valencia, Spain
Background: Chordopapillary apparatus preservation is beneﬁcial in patients
undergoing mitral valve replacement. Many surgeons only retain the posterior
leaﬂet because of concerns over potential interference with the prosthesis or greater
technical complexity, especially in rheumatic patients. Our aim was to study the
feasibility of chordal-sparing techniques and the eﬀects on clinical outcome, LV
mechanics and pulmonary hypertension.
Methods: 566 patients underwent mitral valve replacement because of rheumatic
disease between 1996 and 2006. 156 patients had complete excision of the
subvalvular apparatus (Group 1), 248 had preservation of posterior leaﬂet (Group 2)
and 162 had total chordal preservation (Group 3). Echocardiography was performed
preoperatively, at discharge, at 1 year and at late follow-up.
Results: A signiﬁcant reduction of LV end-diastolic diameter (>10%) at 1 year was
more frequent in Groups 2 and 3: 92/248 (37.0%) and 59/162 (36.4%) versus 30/156
(19.2%), p<0.05. “Complete excision” was predictive of less reduction (OR: 0.42,
p<0.05). Late mortality was doubled without reduction (13 versus 7.1%, p<0.05).
It was even higher with complete excision: 29/156 (18.5%) versus 31/410 (7.6%),
p<0.01. Persistence of pulmonary hypertension (PSAP>40mmHg at 1 year) was
higher in Group 1: 76/156 (48.7%) versus 81/248 (32.7%) and 38/162 (23.4%), p<0.01.
Reduction of LV volumes was signiﬁcant in chordal-preservation groups (p<0.01).
LVEF continued to decline over time in the nonchordal group.
Conclusion: Total chordal preservation is possible in a large percentage of

T U E S D AY A F T E R N O O N
rheumatic patients. Higher reductions in LV volumes and pulmonary hypertension
was obtained with chordal preservation procedures. LV ejection continues to
improve over time because of more favorable LV remodeling.

212 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 213
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5:00 pm

71. Prevalence and Impact of Preoperative Anemia and Red Blood Cell Notes
Transfusion in Women: Twelve-Year Experience in 6,000 Isolated Coronary
Artery Bypass Surgeries
L.U. Nwakanma; D.A. Alejo; D.D. Yuh; W.A. Baumgartner; C.W. Hogue
Johns Hopkins Medical Institutions, Baltimore, Maryland
Background: Operative mortality is higher for women compared with men after
coronary artery bypass (CABG) surgery. We investigated how pre-operative anemia
and RBC transfusion impacts 30-day operative mortality in women.
Methods: Preoperative risk factors from consecutive patients ≥ 30 years old
undergoing isolated CABG from 1995 to 2006 were prospectively entered into our
institutional database. Multivariable logistic regression predictive models for 30-day
mortality were generated using the STS risk variables without (Model 1) and with
the inclusion of preoperative anemia (hemoglobin <12g/dl in women and <13g/dl
in men) and transfusion (Model 2).
Results: There were 6,348 patients (28% female), mean age 65±11 years old (range,
32 to 95 years). Unadjusted 30-day mortality was higher for women than men (4.5%
versus 2.8%, p<0.001). Preoperative anemia was more prevalent in women than
men (76% versus 65%, p<0.001; mean Hgb 11±1.5 versus 12.4±1.7 g/dl). Women
(87% versus 51%, p<0.001) received more intra-operative RBC transfusions (2.7±1.8
versus 1.3±1.6 units, p<0.001). In Model 1, female gender was an independent
predictor of 30-day mortality (OR 1.6, CI 1.05-2.3, p=0.03), but not in Model 2. The
discriminatory power of the modeling increased from a c-index of 0.77 to 0.79.
Further, there was no gender diﬀerence in mortality when anemic patients and
those receiving blood transfusions were excluded in Model 1.
Conclusion: The increased risk of death in women after CABG may be related

T U E S D AY A F T E R N O O N
to an increased prevalence of preoperative anemia and intra-operative blood
transfusions. Correction of anemia prior to CABG surgery might lead to better
outcomes for women.

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5:15 pm

72. Cardiowest (Jarvik) Total Artiﬁcial Heart: Notes
A Single-Center Experience With 42 Patients
J.C. Roussel; T. Senage, Sr.; O. Baron; O. Habash; S. Pattier; T. Petit; M. Treilhaud; P. Despins;
D. Duveau
Service de Chirurgie Thoracique et Cardiovasculaire, Nantes, France
Background: Retrospective study to assess the outcome and the safety of the
CardioWest Total Artiﬁcal Heart in transplant-eligible patients.
Methods: From 1990 to December 2006, 42 patients received a CardioWest total
artiﬁcial heart at our center. The mean age was 45.7± 9.5 years and 40 patients (95%)
were men. Idiopathic/dilated cardiomyopathy was diagnosed in 45.2 % (n=19)
of the patients and ischemic cardiomyopathy in 42.8% (n=18). The average body
surface area was 1.9 ±0.22 m² (ranged between 1.5 to 2.5 m²). Heparin, ﬂuindione,
and aspirin were used for anticoagulation.
Results: Duration of support was 1 to 292 days (mean 101 ±86). Twelve patients
died while on device support and 30 patients (72%) were transplanted. Six heart
transplanted patients died during the follow-up of the study. Actuarial survival rates
for the entire cohort (n=42) were 64% at 1 year (n=25), 58% at 5 years (n=15) and
54% (n=10) and for the transplanted patients 90% (n=25), 81% (n=14) and 76%
(n=10) at 1, 5 and 10 years respectively. Causes of death during device support
included multi-organ failure in 6 (50%), sepsis in 2 (16%) and bleeding in 1 (8.3%).
Adverse events included stroke in 3 patients (7%) and infections in 35 patients (85%)
during support.
Conclusion: CardioWest is a bridge-to-transplant device of choice in patients with
biventricular failure with a reasonable risk of thrombo-embolic events and an
excellent reliability. Outcome after transplantation is also excellent in our study with

T U E S D AY A F T E R N O O N
a long-term survival of 76% at 10 years for patients who reached transplantation.

216 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 217
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1:45 pm – 5:45 pm Grand Floridian Ballroom B
Parallel Surgical Forum IV: Adult Cardiac II
Moderators: Robert S.D. Higgins, Chicago, Illinois and Gus J. Vlahakes, Boston, Massachusetts
FINANCIAL DISCLOSURE R. Higgins; Sanoﬁ Aventis speaker bureau/honoraria.
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
1:45 pm

73. Eight-Year Outcomes of Autologous Pericardial Strip-Tricuspid Annuloplasty
for Functional Tricuspid Regurgitation
B. Chang; S. Song; K. Yoo
Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea
Background: Various kinds of tricuspid annuloplasty (TAP) have been developed
for tricuspid regurgitation(TR). However, TR can persist or recur after TAP with
re-dilatation of tricuspid annulus or progression of the diseases. We sought to
compare the long-term results of newly developed TAP using autologous pericardial
strip with conventional suture annuloplasty.
Methods: From January 1997 to April 2006, 334 patients (mean age 52.6 years)
underwent TAP for functional TR. Concomitant procedures were mitral valve
replacement in 261 and mitral-aortic valve replacement in 73 patients. Conventional Univariate and Multivariate Logistic Regression Analysis of Recurrent Tricuspid Regurgitation
suture annuloplasty (DeVega or Kay) was performed in 117 and autologous
pericardial strip annuloplasty (AP-TAP) in 217 patients. Univariate Multivariate Logistic Regression
Variables
Results: There were 8 in-hospital mortalities (2.4%). Mean follow-up period was 41.1 p Value OR 95% C.I. p Value OR 95% C.I.
months and total follow-up duration was 1142.9 patient-years. Signiﬁcant TR, 1 week

T U E S D AY A F T E R N O O N
after annuloplasty was noted in 34 patients (11.1%). The severity of regurgitation Hepatomegaly 0.013 3.667 1.380-9.745 0.178 3.814 0.545-26.712
was improved with time in the AP-TAP group, on the other hand, it was worsened
in the suture annuloplasty group (p=0.05). There was no signiﬁcant diﬀerence Neck Vein Engorgement 0.017 2.385 1.146-4.962 0.440 1.762 0.419-7.413
in right ventricular pressure between the two groups (p=0.967). Multivariate
analysis demonstrated that preoperative severity of TR and conventional suture Suture TAP < 0.0001 3.353 1.709-6.579 0.003 6.307 1.843-21.580
annuloplasty were signiﬁcant predictors for recurrent TR. Overall survival was
comparable between the two groups up to 8 years after the surgery (p=0.742). LA Diameter 0.046 0.788 1.007 0.957-1.059
However, recurrence-free survival was more favorable for AP-TAP compared to that
of conventional suture annuloplasty (86.9 versus 71.8%, p=0.039). Preoperative TR < 0.0001 < 0.0001 8.743 3.232-23.652

Conclusion: The long-term recurrence-free survival of patients with AP-TAP was
higher than those with conventional suture annuloplasty. AP-TAP appeared to be a
simple, easily reproducible, and valid option for surgical treatment of TR.
Notes

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2:00 pm

74. The Safety of Aprotinin Use During OPCAB: Notes
Results From a Randomized, Prospective Trial
M.C. Grant; Z. Kon; E. Christenson; S. Kallam; N. Burris; J. Gu; R. Pierson; R.S. Poston
University of Maryland School of Medicine, Baltimore, Maryland
FINANCIAL DISCLOSURE R.S. Poston, Guidant/Boston Scientiﬁc, scientiﬁc research support less than
$50,000; Bayer, scientiﬁc research support less than $100,000.
REGUL ATORY DISCLOSURE This presentation describes the oﬀ-label use of Aprotinin which is FDA approved.
The oﬀ-label use is oﬀ-pump Coronary Artery Bypass.

Background: Recently published phase IV, observational studies have suggested
that aprotinin use during cardiac surgery increases the risk of thrombotic/adverse
events. We performed a randomized study in order to investigate the safety of
aprotinin in OPCAB.
Methods: During OPCAB, patients were randomized to receive an infusion of
saline (n=60) or aprotinin (2x106 KIU loading dose, 0.5x106 KIU/h [n=60]). Plasma
aprotinin levels (KIU/ml) were monitored before, 30 minutes after and 4 hours after
drug administration. Myocardial infarction (troponin I level) and renal dysfunction
(glomerular ﬁltration rate (GFR) based on Cockcroft equation) were monitored daily.
Graft patency (CT angiography) and DVT (duplex ultrasound) were analyzed on day 5.
Results: The aprotinin group showed a decrease in postoperative GFR versus
placebo (P<0.03) which resolved by day 5. (Figure) Peak aprotinin level was
linearly correlated with GFR on day 3 (R=0.55, p<0.03) and strongly predicted the
development of renal dysfunction (c-statistic=0.9400, P<0.02) with 265 KIU/ml
providing the cutoﬀ value with the optimal sensitivity and speciﬁcity. The aprotinin
group showed lower postoperative Tn-I levels (2.1±1.3 v 4.3±3.1 ng/ml, P<0.02); DVT
and vein graft occlusion at one week were 3.5% and 5.6% in the placebo group and

T U E S D AY A F T E R N O O N
3.2% and 3.6% in the aprotinin group (p=NS for both).
Conclusion: Consistent with data from prior randomized trials, aprotinin did not
lead to thrombotic events after OPCAB and reduced myocardial release of Tn-I.
However, a peak aprotinin level of >265 KIU/ml strongly predicted transient renal
dysfunction, supporting the adoption of weight-based dosing strategies.

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2:15 pm

75. Impact of Ichemic Mitral Regurgitation on Long-Term Outcome of Notes
Patients With Ejection Fraction Above 30 Percent Undergoing
First Isolated Myocardial Revascularization
A.M. Calaﬁore1; V. Mazzei2; A.L. Iaco’1; M. Contini1; A. Bivona1; M. Gagliardi1; P. Bosco1;
S. Gallina3; M. Di Mauro1
1
University of Catania, Catania, Italy; 2Papardo Hospital, Messina, Italy; 3University of
Chieti, Chieti, Italy
Background: To evaluate the impact of ischemic mitral regurgitation (IMR) on
long-term outcome of patients with ejection (EF) fraction above 30% undergoing
isolated coronary artery bypass grafting (CABG).
Methods: From November 1994 to December 2002, 4,226 patients with EF>30%
underwent ﬁrst isolated CABG. Preoperative IMR was found in 1,421 (33.6%)
patients (Group IMR); it was mild (1+) in 1,254 and moderate (2+) in 167. No IMR
(group no-IMR) was assessed in the remaining 2,805 (66.4%). A non-parsimonious
regression model was built to realize propensity score. Ten-year freedom from
death any cause, from cardiac death, from cardiac events were evaluated by
Kaplan-Meier method. Results of Cox analysis were adjusted entering propensity
score as independent variables.
Results: No diﬀerences were found between patients with or without IMR
concerning early mortality (59, 2.1% no-IMR versus 36, 2.5% IMR, p=0.502) and
morbidity (182, 6.5% no-IMR versus 94, 6.6% IMR, p=0.840); these ﬁndings were
conﬁrmed among diﬀerent IMR grade: mortality (59, 2.1% no-IMR versus 30, 2.4%
mild-IMR versus 5, 3.0% moderate-IMR p=0.764) and morbidity (182, 6.5% no-IMR
versus 82, 6.5% mild-IMR versus 15, 9.0% moderate-IMR p=0.714). Table 1 reports
10-year actuarial outcomes; no statistical diﬀerences were found. Cox analysis

T U E S D AY A F T E R N O O N
conﬁrmed that presence of IMR or IMR any grade did not impact on long-term results.
Conclusion: Presence of mild or moderate IMR in patients with EF>30% undergoing
ﬁrst isolated CABG does not inﬂuence long-term outcome.

Table 1
No-IMR IMR Mild-IMR Moderate-IMR
10-Year Freedom From
2,805 1,421 1,254 167

Death, any cause 91.6+/-0.7 90.8+/-0.8 91.1+/-0.8 87.9+/-4.0

Cardiac deaths 95.3+/-0.6 94.9+/-0.6 95.1+/-0.6 92.4+/-3.3

Cardiac events 89.8+/-0.9 90.2+/-0.8 90.3+/-0.9 89.4+/-3.8

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2:30 pm

76. Extent of Aortic Coverage and Incidence of Spinal Cord Ischemia in TEVAR:
A 3D-CTA Analysis
R.J. Feezor; T.D. Martin; P.J. Hess, Jr.; T.M. Beaver; C.T. Klodell; M.P. Brown; T.S. Huber;
J.M. Seeger; W. Lee
University of Florida, Gainesville, Florida
FINANCIAL DISCLOSURE W. Lee, Cook, Inc., consultation, honoraria; Medtronic, consultation, honoraria.
REGUL ATORY DISCLOSURE This presentation describes the oﬀ-label use of the thoracic graft to extend use to
other thoracic aortic pathologies. The thoracic graft is FDA approved.

Background: Risk factors for spinal cord ischemia (SCI) after thoracic aortic
endovascular repair (TEVAR) remain unclear. We examined aortic coverage as a risk
factor for SCI using quantitative 3D analysis.
Methods: We reviewed a single institution’s TEVAR database. CT angiograms were
analyzed using curved planar reformations along centerline paths. SCI was deﬁned
as transient/permanent lower extremity neurologic deﬁcit without hemispheric
events. Spinal drainage was not performed prophylactically.
Results: Of 196 TEVAR cases, satisfactory imaging was available on 132 (67.3%)
eligible patients. Nine had SCI (6.8%). All patients with SCI were male versus 68.3%
of patients without SCI (p<0.05). More patients with SCI had prior AAA repair (33.3%
versus 17.9%, p=NS). Despite similar total lengths of native thoracic aorta (left
common carotid artery to celiac artery) (304.1±31.0 mm versus 287.1±37.3 mm),
patients with SCI had greater absolute length of aortic coverage (252.6±41.1 mm
versus 192.7±79.3 mm, p=0.002). SCI patients had greater proportionate coverage
(83.6±14.7% versus 65.7±22.5%, p=0.006). The average length of uncovered aorta Notes
proximal to the celiac artery in patients who developed SCI was 26.8±25.3 mm
compared to 69.3±62.9 mm in patients without SCI (p=0.0008). Neither the patency

T U E S D AY A F T E R N O O N
of the left vertebral nor left subclavian artery was associated with SCI.
Conclusion: Patients who sustained SCI after TEVAR tended to have prior AAA
repairs. The proportionate and total length of aortic coverage was associated with
an increased risk of SCI. The proximity of the distal extent of the stent graft to the
celiac artery was associated with SCI.

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2:45 pm

77. Perfusion and Cerebral Protection in Aortic Surgery: Notes
The Role of the Right Axillary Artery
F.F. Immer; B. Moser; E.S. Krähenbühl; F.S. Eckstein; J. Schmidli; T.P. Carrel
University Hospital, Bern, Switzerland
Background: We have shown that selective antegrade cerebral perfusion (SACP)
improves mid-term quality of life (QoL) in patients undergoing surgical repair for
acute Type A aortic dissection (AADA) and aortic aneurysms. Aim of the study was
to assess the impact of continuous cerebral perfusion through the right subclavian
artery (RAACP) on immediate outcome and QoL.
Methods: Perioperative data of 567 consecutive patients who underwent surgery
of the aortic arch using deep hypothermic circulatory arrest (DHCA) have been
analyzed. Patients were divided into 3 groups, according to the management
of cerebral protection; 387 patients (68.3%) had DHCA with pharmacological
protection with pentothal only, 91 (16.0%) had SACP and pentothal, and 89 (15.7%)
had RAACP and pentothal.
Results: All in-hospital data were assessed and QoL was analyzed prospectively
2.4±1.2 years after surgery with the short form 36 health survey questionnaire
(SF-36). Major perioperative cerebrovascular injuries (CVI) were observed in 1.1%
of the patients with RAACP, compared to 9.8% with SACP (p<0.05) and 6.5% in the
group with no ACP (p<0.05). Average QoL following arrest time between 30 and 50
minutes with RAACP was signiﬁcantly better than SACP (90.2+/-12.1 versus 74.4+/-
40.7 (p<0.05)).
Conclusion: RAACP improves considerably perioperative brain protection during
DHCA. Irreversible perioperative neurological complications can be signiﬁcantly
reduced and duration of DHCA can be extended up to 50 minutes without

T U E S D AY A F T E R N O O N
impairment in QoL.

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3:00 pm

78. Saddle Ring Annuloplasty Dramatically Increases Mitral Leaﬂet Curvature Notes
L.P. Ryan; B.M. Jackson; H. Hamamoto; T.J. Eperjesi; T.J. Plappert; M.G. St. John-Sutton;
R.C. Gorman; J.H. Gorman, III
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
FINANCIAL DISCLOSURE M.G. St. John-Sutton, Medtronic, consulting < $10,000; R.C. Gorman, Medtronic,
consulting > $10,000, grant > $10,000; J.H. Gorman, III, Medtronic, consulting > $10,000, grant > $10,000.

Background: Recently, we presented a ﬁnite element model describing the
contribution of annular non-planarity to leaﬂet curvature and stress reduction.
We hypothesize that annuloplasty ring shape inﬂuences both leaﬂet curvature
and stress as well as potentially impacting repair durability. We describe a novel
methodology for quantifying mitral leaﬂet geometry and apply it to the description
of mitral leaﬂet geometry following annuloplasty utilizing two distinct ring types.
Methods: Epicardial real-time three-dimensional (3D) echocardiographic data sets
were acquired in 8 adult male sheep at baseline. Four animals then underwent
mitral annuloplasty utilizing a 30 mm Physio ring while the remaining 4 animals
underwent mitral annuloplasty utilizing a 30 mm “saddle” ring. Echocardiography
was repeated in all animals following annuloplasty. Hybrid 3D renderings were
constructed for each cohort with color contouring determined by Gaussian
curvature (K), septolateral curvature (KSL) and intercommissural curvature (KIC).
Results: K, KSL, and KIC increased across both anterior and posterior leaﬂets
when compared to baseline (Panel A) following implantation of the saddle ring
(Panel B). While KIC increased across both anterior and posterior leaﬂets following
implantation of the 30 mm Physio ring (Panel C), K was increased only across the
posterior leaﬂet, and KSL did not increase across any leaﬂet region.
Conclusion: Mitral annuloplasty utilizing a custom designed saddle shaped

T U E S D AY A F T E R N O O N
annuloplasty ring augmented K, KSL, and KIC across both anterior and posterior
leaﬂets, while that utilizing a Physio ring augmented only KIC. These ﬁndings
conﬁrm that ring design inﬂuences leaﬂet curvature and potentially repair durability.

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3:15 pm
Independent Predictors of Mortality [p-value and hazard ratio (HR)]
79. Eﬀect of Patient-Prosthesis Mismatch on Long-Term Survival With
Mitral Valve Replacement: Assessment to 15 Years Age 51-60 p=0.0002 1.68 CHF p=0.010 1.19
1 2 2 1 1 1 1
W. Jamieson ; P. Pibarot ; J.G. Dumesnil ; J. Ye ; A. Cheung ; E. Germann ; F. Chan ; 61-70 p=0.00000001 2.12 NYHA Post p=0.012 0.71
J.S. MacNab1; E.A. Stanford1; L.A. Bryson1; S.V. Licthentstein1
1
University of British Columbia, Vancouver, British Columbia, Canada; 71-80 p=0.00000001 2.23 Major TE p=0.00001 1.65
2
Laval University, Sainte-Foy, Quebec, Canada
FINANCIAL DISCLOSURE W. Jamieson, Sorin Biomedica, speakers bureau/honoraria; Edwards Lifesciences, >80 p=0.0001 2.38 Thrombosis Non-Reop p=0.027 2.38
speakers bureau/honoraria; Medtronic, speakers bureau/honoraria; St. Jude Medical, speakers bureau/honoraria.
EOAI < or =0.9cm2/m2 p=0.046 0.77 Reop - SVD p<0.0001 0.27
Background: Patient-prosthesis Mismatch (PPM) has been considered a
determinant of early and late mortality following aortic valve replacement (AVR),
NYHA Pre p=0.024 1.26 Reop PVE p=0.013 0.32
but there has been limited attention to PPM with mitral valve replacement (MVR).
Impact of PPM in overall risk analysis of long-term mortality is evaluated in 2,732 Con CABG p=0.00000002 1.49 Non-Reop PVE p=0.00001 2.25
patients (mechanical prostheses (MP) -1,214; bioprostheses (BP) -1,518) to 15 years.
Methods: PPM eﬀective oriﬁce area index (EOAI) grades were: (A) normal >1.2cm2/ EF<35% p=0.020 1.32 VR-Morbidity p=0.0003 0.60
m2=13.1%, (B) mild-to-moderate ≤1.2->0.9=70.9%, and (C) severe ≤0.9=16.0% of
patients. Total follow-up was 18,240 years mean 6.68±4.82 years (median 6.04 years). BP > MP p=0.0003 1.31
Mean age for MP=59.0±11.5 years and BP=67.5±11.2 years. Analysis was based on
initial intent to treat. Twenty variables evaluated risk analysis, p<0.25 considered
multivariate analysis.
Results: Early mortality: A-5.6%, B-6.9%, and C-8.9% (p=0.0002). Overall survival at Notes
15 years: A-25.1±3.7%, B-30.5±1.7% and C-19.8±5.0% (p=0.201). Patients with severe
PPM (C) had higher incidence of early mortality, larger BSA, larger BMI, concomitant
CABG, LV dysfunction, congestive heart failure, and greater percentage of size 25mm
prostheses. Freedom from valve related mortality at 15 years: A-75.8±4.9%, B-82.1±1.9%,
C-82.0±5.1% (p=0.554). Freedom from cardiac related mortality at 15 years by EOAI

T U E S D AY A F T E R N O O N
grades: A-56.5±5.3%, B-56.0±2.3%, and C-46.3±7.9% (A versus C p=0.039).
Conclusion: Severe PPM (EOAI <0.9cm2/m2) is not an independent predictor of
mortality (survival) to 15 years following MVR. Besides severe PPM, there were 6
other baseline (operative or preoperative) factors and 8 postoperative factors (4
protective) that were independently associated with survival. However, as opposed
to other variables, PPM alone may be modiﬁable at the time of operation. Severe
PPM is predictive of cardiac related mortality but not of overall survival or valve-
related mortality.

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1:45 pm – 5:45 pm Grand Floridian Ballroom B
Parallel Surgical Forum IV: Adult Cardiac II - Continued
Notes
Moderators: Y. Joseph Woo, Philadelphia, Pennsylvania and T. Bruce Ferguson, Greenville,
North Carolina
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
4:15 pm

80. What is the Optimal Surgical Treatment for Obstructive Hypertrophic
Cardiomyopathy and Myxomatous Mitral Regurgitation?
C.K.N. Wan; J.A. Dearani; T.M. Sundt, III; S.R. Ommen; H.V. Schaﬀ
Mayo Clinic, Rochester, Minnesota
Background: Many believe that mitral valve replacement (MVR) is the preferred
treatment for patients with obstructive hypertrophic cardiomyopathy (HCM) and
myxomatous mitral regurgitation (MR).
Methods: We reviewed 32 cases of extended septal myectomy for HCM with
concomitant mitral valve repair (MVrep) or MVR for myxomatous MR from 1990
to 2006 (4% of myectomies and 3% of isolated MVrep). Mean age was 60.7±16.7
years and 56% were male. NYHA class III/IV was present in 63%. Preoperative mean
ejection fraction was 73.4±6.3% and peak left ventricular outﬂow tract (LVOT)
gradient was 63.7±37.6mmHg. Systolic anterior motion (SAM) was present in 94%
and severe MR in 88%.
Results: All patients underwent extended septal myectomy; 28 (88%) with
concomitant MVrep and 4 (12%) mechanical MVR. MVrep was performed with
leaﬂet resection in 11 (39%), Alﬁeri stitch in 6 (21%), and leaﬂet plication in 8 (29%).

T U E S D AY A F T E R N O O N
Annuloplasty ring/band was utilized in 18 (64%) and commissural annuloplasty in 2
(7%). There was one early death (3%). At time of dismissal, resting LVOT gradient was
reduced to 10.2±19.0mmHg (p<0.005) and SAM was observed in 6 (21%, p<0.005).
Dismissal echocardiography demonstrated no or mild MR in 21 (75%) and moderate
MR in 6 (21%) patients in MVrep group(p<0.005) and normally functioning prostheses
in MVR group. Mean follow-up was 3 years. Late echocardiography demonstrated peak
LVOT gradient of 8.2±12.4mmHg and 84% were in NYHA class I/II(p<0.005).
Conclusion: Concomitant MVrep with myectomy for HCM and myxomatous MR
can be performed successfully with low early mortality. Satisfactory relief of LVOT
obstruction and MR can be obtained. Most have signiﬁcant relief in symptoms. MVR
can be avoided in most patients with myxomatous MR and HCM.

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4:30 pm

81. Early Graft Patency and Clinical Freedom From Graft Failure in 214 Consecutive Notes
Patients Undergoing Beating Heart Totally Endoscopic Coronary Artery Bypass
With da Vinci Surgical System
S. Srivastava1; S. Gadasalli2; M. Agusala3; R. Kolluru4; Z. Barrera1; S. Quismundo1;
U. Kreaden5
1
Cardiac Surgical Assoc. of West Texas, Odessa, Texas; 2Healthy Heart Center, Odessa,
Texas; 3Madhava Agusala, MD, PA, Odessa, Texas; 4Permian Heart Clinic, Odessa,
Texas; 5Intuitive Surgical Inc., Sunnyvale, California
FINANCIAL DISCLOSURE S. Srivastava, Intuitive Surgical Inc., consultant; Medtronic Inc., consultant;
Medical CV, advisory board; U. Kreaden, Intuitive Surgical Inc., employee.

Background: Graft patency and clinical freedom from graft failure remain a subject
of investigation in beating heart totally endoscopic coronary artery bypass (BH
TECAB)
Methods: A total of 214 patients underwent successful BH TECAB from July
2004 to June 2007. Single, double, and triple vessel BH TECAB was performed
in 139, 68, and 7 patients respectively. Fifty patients underwent planned hybrid
revascularization. Eighty percent (172/214) patients underwent CT or conventional
angiography within 3 months from the time of surgery. On CT angiography (CTA),
the analysis included gross patency, stenosis within the graft, and contrast in the
grafted coronary artery. A FitzGibbon score was used to analyze graft patency and
anastomosis in patients undergoing conventional angiography. Clinical follow up
was done in all patients for any major adverse cardiac event (MACE) in relation to the
revascularized coronary arteries.
Results: There was no myocardial infarction, operative mortality, or conversion to
cardiopulmonary bypass. All patients who had CTA were found to have grossly patent

T U E S D AY A F T E R N O O N
graft without stenosis and demonstrated opaciﬁcation of the grafted coronary artery.
Fifty-seven grafts were studied in 39 patients by conventional angiography post
operatively during hybrid revascularization. All grafts except one had FitzGibbon A
grade anastomosis and TIMI 3 ﬂow at the time of study. Three (1.4%) patients required
reintervention at 2, 3, and 13 months following initial BH TECAB.
Conclusion: Clinical freedom from graft failure noted in 98.6% patients appears to
be excellent. Further angiographic and clinical follow up is required to determine
the long-term results.

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4:45 pm

82. A Novel Minimally Invasive Method for Notes
Left Ventricular Epicardial Pacing Lead Placement
A. Damle
MeritCare Heart Center, Fargo, North Dakota
FINANCIAL DISCLOSURE A. Damle, Boston Scientiﬁc, one of the investigators for a clinical trial for
epicardial pacing leads; Medtronic, speaker; Enpath Medical, consultant.
REGUL ATORY DISCLOSURE This presentation describes the use of steriod eluting epicardial lead by Boston
Scientiﬁc. The FDA status is investigational.

Background: Endoscopic approach has less morbidity than a thoracotomy for
epicardial leads. However, it may not be feasible in patients with very large hearts,
lung adhesions, or intolerance to one lung ventilation. Therefore a novel minimally
invasive method was developed for this subset of patients.
Methods: No new incisions are necessary. Retracting the inferior margin of the
existing pacemaker incision, access to the thoracic cavity is gained, sometimes
dividing the third rib. The pericardial fat and the anterior margin of lung are
retracted laterally. The pericardium is divided anterior to the phrenic nerve. The
patient is tilted laterally to expose the basal posterolateral surface of the heart. This
“straight shot” view can now be used to implant a lead. One lung anesthesia, chest
tube drainage are usually not necessary.
Results: In the 5 year period starting May 2002, 126 patients received an epicardial
left ventricular lead at our institution. Of these, 102 patients had surgery by the
above method. The procedure was successful in all. Pacing thresholds were very
low, below 1 volt in 91/102 patients. There was 1 death due to refractory ventricular
tachycardia, 2 patients needed repositioning of the lead. There were no other major
complications. Intensive care unit stay was needed in only 22 patients. Average

T U E S D AY A F T E R N O O N
length of stay was 2.1 days, and only 1 day in 41 patients.
Conclusion: This previously unreported minimally invasive method is simple, safe,
eﬀective, and a good alternative for a subset of patients. It can be considered a
primary option.

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5:00 pm

83. Resident Working Pattern as a Predictor of Mortality After Cardiac Surgery Notes
J.H. Shuhaiber; K. Goldsmith; S. Nashef
Papworth Hospital, Cambridge, United Kingdom
Background: To determine whether cardiac surgical outcomes are aﬀected by
major turnover of the trainee surgical staﬀ.
Methods: This observational cohort study analysed data from cardiac operations
between April 1996 and March 2006 at a single institution. In-hospital mortality was
compared between operations done during months of major change in medical
staﬀ (July, August, January, February, N =5,517) and the rest of the year (N =10,773).
Adjustment was made for EuroSCORE, year of operation and surgeon trainee status.
Analyses were done within surgery type subgroups of isolated CABG and more
complex operations (CABG combined with other procedures).
Results: Patient populations in the groups were similar. After risk adjustment, there
was a signiﬁcant increase in hospital mortality for the complex cases during doctor
service change months compared to rest of the year (OR 1.3, 95% CI, 1.3, 1.4, p =
0.02). There was, however, no signiﬁcant diﬀerence in mortality for the CABG only
cases (OR 1.1, 95% CI, 0.8, 1.4, p=0.61). During the change months, the surgery
time was 2.2 minutes longer in CABG operations (95% CI, 0.3, 4.0, p=0.02), and no
diﬀerent in combined cases.
Conclusion: Periods of major change in trainee surgical staﬀ are associated with
increased risk-adjusted in-hospital mortality after complex cardiac operations but
not after CABG alone.

T U E S D AY A F T E R N O O N
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5:15 pm

84. Improvement in Results of Open Aortic Arch Replacement in 300 Patients Notes
T.M. Sundt, III; T. A. Orszulak; D.J. Cook; H.V. Schaﬀ
Mayo Clinic, Rochester, Minnesota
FINANCIAL DISCLOSURE T.M. Sundt, Medtronic, research support; St. Jude Medical, research support;
Sorin Group, research support; Boston Scientiﬁc, consultant; T.A. Orszulak, Medtronic, research support; St. Jude
Medical, research support; Sorin Group, research support; H.V. Schaﬀ, Medtronic, research support; St. Jude Medical,
research support; Sorin Group, research support.

Background: The rapid evolution of endovascular approaches to arch
reconstruction such as brachiocephalic de-branching and stenting renders an
accurate understanding of contemporary outcomes of conventional arch surgery
particularly relevant.
Methods: Cases of arch reconstruction were identiﬁed by search of the
computerized cardiovascular surgical database and perioperative (30 day) outcomes
as per the STS National Database evaluated.
Results: Between February 11, 1993, and August 23, 2006, 300 patients (168 male,
132 female, median age 70 years range 21 to 88) underwent aortic arch replacement.
Procedures were elective in 202 cases, with 224 performed for degenerative
disease or chronic dissection, 52 for acute dissection, 14 for infectious or traumatic
pseudoaneurysm, 8 for Marfans syndrome, and 2 for congenital conditions. Total
arch replacement was performed in 81, including 10 with concomitant replacement
of the descending thoracic aorta via bilateral thoracosternotomy. Adjunctive
cerebral protection during circulatory arrest has been introduced over time via
retrograde cerebral perfusion (RCP) and, more recently, antegrade cerebral perfusion
(ACP). The overall mortality rate was 9.3% (elective procedures 6.4%) and stroke
rate 8.7% (elective 7.9%). The mortality rate for total arch replacement has declined
with adjuncts, [zl1] from 36% (9/25) to 21.1% (4/19) with RCP (p=0.33) and to 2.7%

T U E S D AY A F T E R N O O N
(1/37) with SAP (p<0.0001); corresponding stroke rates were 20% (5/25), 5.3% (1/19)
(p=0.21), and 8.1% (3/37) (p=0.25) respectively.
Conclusion: Currently, open aortic arch replacement can be accomplished under
elective circumstances with low operative mortality, particularly with adjunctive
measures for cerebral protection. The results of endovascular therapies should be
measured against contemporary surgical series.

240 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 241
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5:30 pm

85. Can Epicardial Three Dimensional Echocardiography Notes
Give Better Understanding of Mitral Valve Anatomy and
Improve Feasibility of Repair in the Future?
B.S. Rana; O. Wendler; J. Desai; A. El Gamel; A. Bhan; M.J. Monaghan
King’s College Hospital, London, United Kingdom
FINANCIAL DISCLOSURE M.J. Monaghan, Philips, other research support; GE, other research support;
TomTec, other research support.

Background: Epicardial real-time three-dimensional echocardiography (RT3DE) may
oﬀer superior anatomical information and improve surgical repair of the mitral malve
(MV). The aim was to evaluate the feasibility and potential value of this technique.
Methods: Intra-operative 2D transesophageal echocardiography (2DTEE) and
epicardial RT3DE were performed in patients undergoing MV surgery. The two
methods were compared with surgical inspection.
Results: Twenty-six consecutive patients underwent mitral valve repair (22
degenerative, 2 rheumatic, 2 ischaemic). RT3DE imaging was feasible in all patients
(good quality 23, adequate 2). Acquisition time was 4.4.mins (±2.7). Qualitatively,
RT3DE was superior in accurately assessing scallop lesions, mitral annular and
subvalve morphology, and the relationship to the left ventricular outﬂow tract. Both
methods accurately predicted surgical ﬁndings RT3DE r=0.93, p<0.001 versus 2DTEE
r=0.72, p<0.001. RT3DE was superior to 2DTEE in diagnosing leaﬂet lesions (accuracy
98% versus 88%).
Conclusion: RT3DE is feasible, oﬀering additional information to 2DTEE. RT3DE
imaging gives better understanding of MV morphology and may improve feasibility
of repair in the future.

T U E S D AY A F T E R N O O N
Ability of 2D TEE and 3D RT3DE in correctly diagnosing lesion, p<0.001 ,except* where P<0.05

Sensitivity Speciﬁcity Sensitivity Speciﬁcity
Lesion 2DTEE Lesion RT3DE
(%) (%) (%) (%)

P1* /P2/P3* 86/91/86 67/71/91 P1/P2/P3 100/100/100 100/100/100

A1/A2* /A3 100/76/91 100/91/80 A1/A2/A3 100/100/91 100/100/87

Post/Ant* com 100/67 100/100 Post/Ant com 100/100 100/93

242 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 243
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1:45 pm – 5:45 pm Grand Floridian Ballroom D
Parallel Surgical Forum V: Congenital
Moderators: Charles D. Fraser, Jr., Houston, Texas and James Jaggers, Durham, North Carolina
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
1:45 pm Grand Floridian Ballroom D
Featured Lecturer: Mitral Valve Disease in Children
Robert H. Anderson, London, United Kingdom
2:00 pm

86. Outcomes of Reparative and Transplantation Strategies for Multilevel Left
Heart Obstructions With Mitral Stenosis
S. P. Malhotra; F. Lacour-Gayet; D. N. Campbell; S. Miyamoto; D. R. Clarke; M. L. Dines;
D. D. Ivy; M. B. Mitchell
Children’s Hospital, Denver, Denver, Colorado Notes
Background: Conventional management for multilevel left heart obstructions
and mitral stenosis (Shone’s anomaly) involves multiple operations that carry
additive risks. The role of heart transplantation as a treatment option has not been
studied. This study reviews our experience with reconstructive and transplantation
approaches for Shone’s anomaly.
Methods: Between 1987 and 2007, 43 patients with mitral stenosis and 1 or more
left-sided obstructions were identiﬁed: supramitral ring (12), subaortic stenosis
(25), aortic stenosis (23), hypoplastic arch (19), and coarctation (38). Thirty patients
underwent a staged reparative (SR) approach, which included 27 mitral and 51 LV
outﬂow tract operations. Thirteen patients were referred for transplantation (TX).

T U E S D AY A F T E R N O O N
Patients with HLHS were excluded.
Results: There was 1 in-hospital mortality (2.5%) and 6 late deaths (14.2%). Actuarial
5-year and 10-year survival for SR and TX was 88% versus 58.3% and 83.1% versus
58.3% (p=0.035). At a mean follow-up of 7.9 years, freedom from mitral reoperation
was 83.3% and from reoperation for subaortic stenosis was 78.0%. In the TX group,
mean PA pressure at time of listing was 45.8 ± 12.0 mm Hg. Waitlist mortality was
13.3% (2/13). Waitlist time greater than 90 days was an incremental risk factor for
post-transplant mortality (p=0.005).
Conclusion: Despite the challenges of a reparative strategy for Shone’s anomaly,
favorable survival and durability outcomes can be expected. Heart transplantation,
while avoiding the pitfalls of staged repair, confers increased risks from ongoing
physiologic derangements due to uncorrected left heart inﬂow and outﬂow
obstructions during the wait for donor heart availability.

244 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 245
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2:15 pm

87. Mitral Valve Repair for Rheumatic Valve Disease in Children: Notes
Long-Term Results and Impact of the Use of a Biodegradable Mitral Ring
A. Kalangos; J. T. Christenson; M. Beghetti; D. Kamentsidis; M. Cikirikcioglu; Y. Aggoun
University Hospital of Geneva
FINANCIAL DISCLOSURE A. Kalangos, Bioring SA, Lonay, Switzerland, consultant, royalty holder.
REGUL ATORY DISCLOSURE This presentation describes the use of Annuoplasty Ring, Bioring. The FDA
status is investigational.

Background: Mitral valve (MV) repair for rheumatic MV disease in children is
the preferred surgical modality. A standard annuloplasty ring was compared to
a biodegradable annuloplasty ring.
Methods: Between January 1994 and March 2006, 220 children, 143 girls and
77 boys, mean age 11.8±3.0 years (2-16), underwent MV repair for rheumatic MV
disease. MV insuﬃciency was predominant in 198 (90%) patients. 57 (22%) had
associated AV insuﬃciency and 51 (23%) tricuspid valve insuﬃciency simultaneously
addressed. Annuloplasty ring was used in 213 patients (173 Carpentier-Edwards,
and 40 biodegradable, Bioring). During follow up echocardiography was performed
after 6 months and thereafter once yearly.
Results: No hospital death or major morbidity occurred. Follow up was complete in
96%. No late deaths occurred. Mean follow up: 76.4 months (1-13 years). One patient
(0.5%) had immediate MV repair failure. Twelve patients (5.5%) required reoperation
during follow up. Recurrent MV insuﬃciency/stenosis-free survival was 95% (CL70%:
94-98%) at 5 years and 93.2% (CL70%:90-96%) at 10 years. Mean gradient was
5.2±1.9, 6.2±2.0 and 7.0±2.3 mmHg at 7 days, 6 months and 1 year postoperatively
for Carpentier-Edwards and signiﬁcantly lower (p<0.001) for Bioring; 2.8±0.5, 3.1±0.7
and 3.3±0.5 mmHg, respectively. Unchanged gradient during the ﬁrst year was 65%

T U E S D AY A F T E R N O O N
(26/40) Bioring and 20% (35/173) Carpentier-Edwards, p<0.001.
Conclusion: MV repair in children with rheumatic valve disease has low operative
risk and satisfactory long-term results. The use of biodegradable annuloplasty ring
results in a signiﬁcant lower mean gradient during the ﬁrst year of implantation
compared to the Carpentier-Edwards ring, particularly interesting in children.

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2:30 pm
Comparison between survivors and non-survivors
88. Results Following Mitral Valve Replacement With Mechanical Prostheses in
Young Children Survivors (n=65) Non- survivors (n=14) P-value

B. Alsouﬁ; A. Sallehuddin; C. C. Canver; F. Khouqeer; S. Al-Ouﬁ; E. Saad; B. Fadel; Mean age (days) 1110 566 0.01
Z. Al-Halees
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia Mean weight (Kg) 10.2 7.1 0.01
Background: We examine outcomes following mitral valve replacement (MVR)
Male gender % 36% 51% NS
with mechanical prostheses in children <8 years old and report valve-related
morbidity over time.
Etiology NS
Methods: Medical records of patients who underwent MVR (96% Carbomedics) were
examined. Demographics and operative variables aﬀecting outcome were analyzed. Isolated mitral disease 45% 36%

Results: Seventy-nine patients, median age and weight: 24.4 months (46 days to Atrioventricular septal defect 28% 28%
7.95 years), 9.5Kg (3-22.8Kg), underwent at least one MVR. Underlying pathology
was congenital in 95%: isolated mitral disease (n=34), atrio-ventricular septal- L-transposition of great arteries 14% 21%
defect (n=22), L-transposition (n=12), Shone’s complex (n=4). Sixty (76%) had
primarily regurgitation, 11 (14%) stenosis, 8 (10%) both. Forty-ﬁve (57%) have Shone’s complex 5% 4%
undergone previous surgery. Operative mortality was 14 (17.7%): < 2 years (30%),
> 2 years (6%). Age-adjusted multi-variable predictors of death included increased Prior surgery % 50% 60% NS
cardiopulmonary bypass time (P=0.02), increased prosthetic valve size/patient
Cardiopulmonary bypass time
weight ratio (P=0.012). Survival was as follows: 1 year 80+5%, 5 years 73+5%, (minutes)
108 205 0.007
10 years 63+7%. Ten-year freedom from valve thrombosis, thrombo-embolism,
bleeding, and endocarditis was 90+5%, 100%, 90+4%, and 100%, respectively. Nine Ischemic time (minutes) 73 105 0.03
survivors underwent second MVR at 6.4+3.9-years interval after initial MVR. Ten-year
freedom from mitral prosthesis replacement was 70+10%. At time of second MVR, Average prosthesis size 21 20 NS
larger prosthesis sizes were implanted (mean 24 mm versus 19 mm, initially). Overall,
Prosthesis size/patient weight 2.4 3.4 0.09
10-year freedom from death or prosthesis replacement was 44+8%. No predictors

T U E S D AY A F T E R N O O N
were identiﬁed using multi-variable analysis.
Conclusion: MVR in children <8 years is associated with signiﬁcant mortality
especially those younger than 2 years and receiving relatively large prosthesis.
Overall, time-related morbidity is acceptable; however, late mortality arises and is Notes
due to valve-related complications. Mitral prosthesis replacement is often required
and usually a larger prosthesis can be implanted suggesting continued annular growth.

248 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 249
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2:45 pm

89. Should We Address the Neo-Pulmonic Valve?: Signiﬁcance of Right-Sided Notes
Obstruction After Surgery for Transposition of the Great Arteries and Coarctation
Y. Hirata; J. M. Chen; J. M. Quaegebeur; R. S. Mosca
Children’s Hospital of New York-Presbyterian, New York, New York
Background: The combination of transposition of the great arteries and coarctation
(TGA/CoA) presents a surgical challenge. We have adopted a strategy of concurrent
aortic arch repair and arterial switch with excellent results. Although these patients
tend to have a small aortic (neo-pulmonic) annulus, few studies have been
performed to evaluate its signiﬁcance. This study examines the signiﬁcance of right-
sided obstruction after single-stage repair of TGA/CoA.
Methods: Between May 1991 and May 2006, 53 patients with TGA/CoA underwent
complete single-stage repair. Twenty (38%) patients had Taussig-Bing anomaly.
Surgical technique involved the arterial switch and VSD closure when present in 51
(96%) patients.
Results: There was 1 hospital death (operative mortality, 1.9%) and 1 late death.
The aortic arch was enlarged with patch augmentation in 36 (75%) patients and
end-to-end anastomosis in 17 (25%) patients. Only 2 (4%) patients underwent the
augmentation of the right ventricular outﬂow tract (RVOT) at the ﬁrst operation.
There was a signiﬁcant diﬀerence between the preoperative aortic and pulmonic
annulus (6.7mm versus 10.4mm, p<0.0001). The immediate postoperative peak
pressure gradient across the RVOT was 26 mmHg ± 21mmHg (0-71). There have
been 5 reoperations and 3 catheter interventions for right-sided obstruction.
Freedom from reintervention/reoperation for right-sided obstruction at 5, 10, and 15
years was 92%, 85%, and 78%, respectively.
Conclusion: Neonatal single-stage repair for TGA /CoA achieves excellent survival

T U E S D AY A F T E R N O O N
without addressing the neo-pulmonic valve at the ﬁrst operation. Although some
patients had pressure gradients across the RVOT at the completion of repair, these
lesions were amenable to reintervention/reoperation with minimal morbidity

250 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 251
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1:45 pm – 5:45 pm Grand Floridian Ballroom D
Parallel Surgical Forum V: Congenital – Continued
Notes
Moderators: Marshall L. Jacobs, Philadelphia, Pennsylvania and Joseph M. Forbess, Dallas, Texas
FINANCIAL DISCLOSURE M.L. Jacobs Medtronic, Inc. (data safety management board) consultant/advisory board.
Unless otherwise noted in this program book or by the speakers, speakers have no relevant
ﬁnancial relationships to disclose and will only be presenting information on devices,
products, or drugs that are FDA-approved for the purposes they are discussing.
3:45 pm

90. Arrhythmia Surgery in Patients With Normal and
Congenitally Malformed Hearts Not Undergoing Fontan Conversion
C. Mavroudis; C. L. Backer; B. J. Deal
Children’s Memorial Hospital, Chicago, Illinois
Background: Arrhythmia surgery has favorably impacted the clinical course of
debilitating atrial and ventricular arrhythmias in patients with structurally normal
hearts and those with congenital heart disease (CHD). The purpose of this study is
to review the long-term outcome of patients who had arrhythmia surgery alone
or in association with congenital heart repairs. Patients with Fontan conversion,
arrhythmia surgery, and pacemaker placement are excluded from analysis.
Methods: Between 1987 and 2007, 100 patients had arrhythmia surgery; without
associated CHD (n=11) or in association with congenital heart repairs (n=89).
Mean age at surgery was 15.8±12.3 years (range, 7 days-48 years); 7 were infants
(mean age 23±16 days). Resternotomy was performed in 65/100 patients (65%).
Two functional ventricles were present in 67, and 33 patients had one functional
ventricle. Arrhythmias included: atrial reentry tachycardia (45), concealed accessory
connections (19), ventricular tachycardia (14), atrial ﬁbrillation (11), A-V nodal reentry

T U E S D AY A F T E R N O O N
tachycardia (6), and automatic atrial tachycardia (5).
Results: Operative mortality was 3/100 (3.0%). Deaths occurred in an infant with
severe Ebstein’s malformation, in a 36 year old with unoperated single ventricle,
and in a 16 year old with transposition after conversion from atrial to arterial switch.
There were 4 late deaths (4.0%) and 2 late cardiac transplants (2.0%). Freedom from
arrhythmia recurrence for atrial versus ventricular tachycardia patients was 86%
versus 76% at 1 year, and 69% versus 38% at 5 years.
Conclusion: Successful surgical therapy of arrhythmias can be performed safely
with a high freedom from recurrence rate in patients with atrial arrhythmias but not
ventricular arrhythmias.

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4:00 pm

91. Mid- to Long-Term Outcome of Total-Cavo-Pulmonary Connection in Notes
High-Risk Adult Candidates
Y. Fujii; S. Sano; T. Akagi; Y. Oshima; K. Yoshizumi; S. Kasahara; H. Mitsui
Okayama University Hospital, Okayama, Japan
Background: Adult patients who don’t fulﬁll classical Fontan criteria are presenting
as candidates for total-cavo-pulmonary connection (TCPC). However, limited
information was available on the results in high-risk adult TCPC candidates.
Methods: To identify the risk factors (RF) which inﬂuence on the mortality of this
patient population, 25 consecutive adult patients (more than 16 years old) who
underwent TCPC were retrospectively reviewed. Mean age at operation was 27
years (16-52). Following 11 items were considered as the potential RF according
to previous reports: 1) Age > 30 years old (7/25), 2) Heterotaxy (9/25), 3) Systemic
ventricular EF < 50% (6/25), 4) AVVR ≥ moderate (6/25), 5) PAI < 200 (7/25), 6)
mean PAP ≥15 mmHg (2/25), 7) PVR ≥ 2.0 wood units (10/25), 8) Signiﬁcant atrial
arrhythmias (13/25), 9) PLE (2/25), 10) NYHA class ≥ 3 (9/25), 11) previous Fontan
procedure (10/25).
Results: The mean follow-up period was 57 months (3-150). All patients had at least
1 risk item (1-7, median 3). There was 1 early death (cardiac tamponade) and 2 late
deaths (1 liver cirrhosis, 1 heart failure). Comparing late survivors and non-survivors,
no statistical signiﬁcance was identiﬁed in the above items. However, patients who
had ≥ 5 risk items had signiﬁcantly higher mortality rate compared to patients who
had < 5 risk items (p=0.01). Age (P=0.08), NYHA (P=0.13) and PLE (P=0.08) may be RF
for late death.
Conclusion: Most adult TCPC candidates tolerated TCPC the early post-operative
period. However, accumulation of risk items may inﬂuence late mortality.

T U E S D AY A F T E R N O O N
254 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 255
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4:15 pm

92. Continuous Pulmonary Infusion of L-Arginine During Deep Hypothermia
and Circulatory Arrest Improve Pulmonary Surfactant Integrity in Piglets
Y. Yang1; J. Cai2; S. Wang2; H. Zhang2; J. Liu2; Z. Xu2; Z. Su2
1
Institute for Biodiagnostics, National Research Council of Canada, Winnipeg,
Manitoba, Canada; 2Shanghai Children’s Medical Center, School of Medicine,
Shanghai Jiao Tong University, Shanghai, China
Background: The integrity of pulmonary surfactant (PS) is impaired during deep
hypothermia and circulatory arrest (DHCA), a preferred bypass strategy for infants
undergoing complex cardiac operation, due mainly to bypass-induced systemic
inﬂammation. The requirement of L-arginine, a precursor of nitric oxide (NO), is
elevated during acute pulmonary inﬂammation. We hypothesized that continuous
intrapulmonary supplementation of L-arginine during DHCA can maintain the
integrity of PS metabolism and thus protect pulmonary function.
Methods: Sixteen piglets underwent 90-minute circulatory arrest at 18° Celsius
before rewarming. During circulatory arrest, Ringer solution alone (n=8) or its
mixture containing L-arginine (1mg·kg-1·min-1, n=8) was antegradely infused
into the pulmonary circulation. Disaturated phosphatidylcholine (DSPC), total
phospholipids (TPL), and total proteins (TP) from tracheal aspirates were measured
serially until the end of bypass (normothermia perfusion for 4 hours after
rewarming). Various variables of pulmonary function were also monitored.
Results: L-arginine led to less decrement of DSPC/TPL and DSPC/TP after DHCA
(Figure). L-arginine signiﬁcantly mitigated deterioration of pulmonary static
compliance (3.6 ± 0.5 mL·cmH2O-1 versus 3.3 ± 0.3 mL·cmH2O-1 at the fourth hour
after rewarming) and PaO2/FiO2 (330 ± 48 mm Hg versus 296 ± 32 mm Hg at the
fourth hour after rewarming). Pulmonary retention of water (6.2 ± 1.0 versus 5.5 ±

T U E S D AY A F T E R N O O N
1.2) was signiﬁcantly reduced after its use. The L-arginine-treated group showed an
increase in NO metabolites (NO2/NO3) from the pulmonary circulation, the extent of
which is correlated to PS content.
Conclusion: Continuous L-arginine supplementation during DHCA attenuated PS
depletion and, therefore, ameliorated postoperative pulmonary dysfunction.

Notes

256 The Society of Thoracic Surgeons Exhibit Break New | Special Interest Parallel Sessions Ticketed Event 44th Annual Meeting 257
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4:30 pm

93. A Novel Bioresorbable Film Reduces Postoperative Adhesions After Infant Notes
Cardiac Surgery
A. J. Lodge1; W. J. Wells2; C. L. Backer3; J. E. O’Brien4; E. H. Austin5; E. A. Bacha6; T. Yeh7;
S. Weinstein8
1
Duke University Medical Center, Durham, North Carolina; 2Children’s Hospital
Los Angeles, Los Angeles, California; 3Children’s Memorial Hospital, Chicago, Illinois;
4
Children’s Mercy Hospital, Kansas City, Missouri; 5University of Louisville, Louisville,
Kentucky; 6Children’s Hospital Boston, Boston, Massachusetts; 7University of Texas
Southwestern, Dallas, Texas; 8Children’s Hospital at Monteﬁore, Bronx, New York
FINANCIAL DISCLOSURE C.L. Backer, SyntheMed, Inc., consultant to company, J.E. O’Brien, SyntheMed, Inc.,
consultant to company, S. Weinstein, SyntheMed, Inc., consultant to product development.
REGUL ATORY DISCLOSURE: This presentation describes the use of Repel-CV. The FDA status is investigational.

Background: Adhesions encountered in reoperative cardiac surgery can prolong
operating time and increase risk. This study was designed to evaluate the ability of a
novel bioresorbable barrier ﬁlm to reduce adhesions in infants.
Methods: A comparative, evaluator-masked, randomized, multicenter study design
was used. Before chest closure, infants undergoing initial sternotomy for eventual
staged palliative cardiac operations were randomized to Barrier ﬁlm placement
(n=54) or Control (no treatment, n=49) at 15 centers. At repeat sternotomy 2-13
months later, the extent and severity of adhesions at the investigative surgical site
(ISS) were assessed. A four-grade adhesion severity scoring system was standardized
as follows: None, Mild (ﬁlmy, non-cohesive, requiring blunt dissection), Moderate
(ﬁlmy, non-cohesive, requiring sharp and blunt dissection), and Severe (dense,
cohesive, requiring extensive sharp dissection).
Results: There were signiﬁcantly fewer patients with Severe adhesions (29.6%

T U E S D AY A F T E R N O O N
versus 71.4%, p<0.0001), and a signiﬁcantly lower percentage of the ISS had Severe
adhesions (21.1±36.9% versus 49.5±42.7%, p=0.0005) in the Barrier group compared
to the Control group at the second sternotomy. Delayed chest closure (p=0.0101),
Norwood procedure (p=0.0449), and cardiopulmonary bypass (p=0.0001) were
univariate risk factors for more severe adhesions. Multivariate analysis revealed only
Control group to be a signiﬁcant risk factor for more severe adhesions (p=0.003).
There were no statistically signiﬁcant diﬀerences in adverse events between the
groups. No adverse events were deﬁnitely attributed to the study device.
Conclusion: Use of a novel bioresorbable ﬁlm was safe and eﬀective in reducing
the extent and severity of postoperative adhesions in infants undergoing repeat
median sternotomy.

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4:45 pm
Table 1: Complexity Stratiﬁed Outcome Data - Florida and the STS
94. Regional Congenital Heart Surgery Outcomes Analysis Under the Auspices of
the State of Florida (5,026 Operations) and The Society of Thoracic Surgeons Florida STS
National Database (45,635 Operations)
Operations Submitted 5,026 45,635
J. P. Jacobs1; J. A. Quintessenza1; R. P. Burke2; E. L. Ceithaml3; W. M. DeCampli2;
R. A. Perryman4; E. R. Rosenkranz5; B. Byrne3; M. S. Bleiweis3; S. Steverson6; G. Wolﬀ5; Patients in analysis 3,382 34,432
W. P. Blanchard7
1
The Congenital Heart Institute of Florida (CHIF) All Children’s Hospital and Discharge Mortality for patients eligible for mortality analysis 111/3,053 1,222/31,719
St. Joseph’s Children’s Hospital of Tampa and Cardiac Surgical Associates (CSA),
St. Petersburg and Tampa, Florida; 2The Congenital Heart Institute of Miami Discharge Mortality Percentage (95% Conﬁdence Interval [CI]) 3.6 (3.0, 4.4) 3.9 (3.6, 4.1)
Children’s Hospital and Arnold Palmer Children’s Hospital, Miami and Orlando,
Florida; 3University of Florida, Gainesville and Jacksonville, Florida; 4Joe DiMaggio Mean Aristotle Basic Complexity (ABC) Level 2.2 2.4
Children’s Hospital, Hollywood, Florida; 5University of Miami, Miami, Florida; 6Florida
Children’s Medical Services (CMS), Tallahassee, Florida; 7Sacred Heart Children’s ABC Level 1 Discharge Mortality Percentage (95% CI) 1.7 (0.8, 3.0) 1.6 (1.3, 2.0)
Hospital, Pensacola, Florida
ABC Level 2 Discharge Mortality Percentage (95% CI) 2.3 (1.6, 3.3) 2.6 (2.3, 2.8)
FINANCIAL DISCLOSURE J.P. Jacobs, Cardio Access, medical advisor; Children’s Heart Foundation, research
grant; R.P. Burke, Cardio Access, medical advisor; I. Rounds, medical advisor.
ABC Level 3 Discharge Mortality Percentage (95% CI) 4.3 (2.9, 6.1) 4.1 (3.7, 4.5)
Background: Florida is the fourth largest state in the United States, with a 2005
population of 17,789,684. In 2004, 218,045 live babies were born in Florida, ABC Level 4 Discharge Mortality Percentage (95% CI) 8.9 (6.2, 12.3) 9.9 (9.0, 10.9)
accounting for approximately 1,744 new cases of congenital heart disease per year.
Our objective is to develop and implement the elements necessary for establishing
state-wide oversight of pediatric cardiac programs through collaboration amongst
the multiple centers caring for patients with congenital heart disease in Florida with
the ultimate goal of improving the care of children with heart disease. Notes
Methods: Eight congenital heart surgery centers exist in Florida. Florida’s Children’s
Medical Services (CMS) provides a framework for quality improvement collaboration
between centers. All Florida programs have voluntarily agreed to submit data to the

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STS National Database. STS and Duke Clinical Research Institute (DCRI) prepared a
Florida Congenital Regional Report to allow detailed regional analysis of congenital
heart surgery outcomes.
Results: The 2006 STS Congenital Database Report includes 45,635 submitted
operations performed during the 4-year data harvest window (2002-2005); 5,026
(11%) of these operations were performed in Florida. Table 1 documents complexity
stratiﬁed outcome data.
Conclusion: A regional consortium of congenital heart surgery centers in
Florida under the framework of Florida’s CMS has allowed for inter-institutional
collaboration with the goal of quality improvement. This experience demonstrates
the following principles:
1. The STS Congenital Heart Surgery Database can provide the framework for
Regional Congenital Heart Surgery Outcomes Analysis.
2. Voluntary regional collaborative eﬀorts to pool data for regional outcomes
analysis are feasible for congenital heart surgery programs.

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5:00 pm

95. Superior Vena Cava to Pulmonary Artery Anastomosis as an Adjunct to Notes
Biventricular Repair: Early and Late Results of a 38-Year Experience With 114 Patients
S. Kim1; G. S. Van Arsdell1; O. Al-Radi1; E. Oechslin2
1
The Hospital of Sick Children, Toronto, Ontario, Canada; 2Toronto General Hospital,
Toronto, Ontario, Canada
Background: We assessed the long-term clinical results of 114 patients who had
SVC-PA anastomosis as an adjunct to biventricular repair in the 38-year period from
1965 to 2003.
Methods: The medical records were reviewed. Patient’s median age was 3.8 years
(2 months to 59 years). There were 14 diﬀerent underlying primary diagnoses and
multiple associated anomalies. One hundred eighty-nine concomitant procedures
were done simultaneously.
Results: Operative mortality was 6.1%. There was no operative death during the
recent decade. There has been a signiﬁcant reduction in late mortality during the
most recent decade (p=0.02). Median follow-up period is 92.3 months (0.6-444.3).
Eighty-three (98.8%) patients are in NYHA class I or II. Forty-ﬁve (53.6%) of late
survivors are currently under no cardiac medication. Arterial O2 saturation was
increased in the whole patients (from 83.5 to 94.5 %, p <0.001) and those who
had the fenestrated ASD (from 84.1% to 93.9%, p < 0.001). Twenty-six of 51 (51%)
ASDs which had been left were closed and 18 of 26 were closed surgically. Ten-year
probability of keeping the shunt thru fenestrated ASD was 17.3%. Two patients
had late morbidities and no protein-losing enteropathy has been detected. The
cumulative survival rates were 83.4%, 80.1%, and 71.1% at 5, 10, and 30 years. The
10-year survival rate (93%) of cases during the recent 10 years is better than those
from previous era (73.7%) (P= 0.078).

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Conclusion: The initial 38-year long-term clinical results with SVC-PA connection
as an adjunct to biventricular repair were acceptable and encourage continued
application to selected patients.

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5:15 pm

96. Clinical Utility of Near Infrared Spectroscopy in Neonates Prior to Notes
Stage 1 Palliation of Hypoplastic Left Heart Syndrome
B. Johnson1; J. S. Tweddell1; J. R. Cava1; G. M. Hoﬀman1; M. Basir1; K. A. Mussatto2;
M. C. Scanlon1; M. E. Mitchell1; N. S. Ghanayem1
1
Medical College of Wisconsin, Milwaukee, Wisconsin; 2Children’s Hospital of
Wisconsin, Milwaukee, Wisconsin
FINANCIAL DISCLOSURE G.M. Hoﬀman, Somanetics, honoraria (speaker).

Background: Neonates with hypoplastic left heart syndrome (HLHS) often have
circulatory imbalance and are at risk for shock prior to intervention. High arterial
saturation (SpO2) often results in invasive support to balance circulation. We
hypothesize that preoperative use of near infrared spectroscopy (NIRS) reduces the
use of controlled ventilation and inspired gases.
Methods: IRB approved retrospective review of patients who had stage 1 palliation
(S1P) from January 2000 to January 2006 was conducted. Preoperative support, lab
results, SpO2, and demographics were collected for all patients. Hourly cerebral and
somatic tissue saturations were recorded for patients who had preoperative NIRS.
Data were analyzed with SPSS 14.0.
Results: The cohort has 92 patients: 47 without and 45 with preoperative NIRS.
Demographics, initial labs and support at admission were similar between groups.
Controlled ventilation (37 versus 23 patients, p=0.005) and inspired nitrogen use
were less common in the NIRS group (33 versus 7 patients, p=0.001). Carbon dioxide
use was infrequent (n=2). NIRS monitored patients had higher mean SpO2 (88 versus
92%, p=0.001) and lower serum creatinine levels (0.7 versus 0.6, p=0.02). Age at S1P
was similar between groups (5.7±3.2 versus 6.5±5.2 days in NIRS group, p=0.3). Thirty
day survival was also similar: 98% (1/47) versus 96% (2/45) in NIRS group.

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Conclusion: Two-site NIRS in patients awaiting S1P provides non-invasive
assessment of tissue oxygen delivery, and decreased the use of controlled ventilation
and inspired gas. Higher SpO2 in the NIRS group did not result in earlier S1P, and was
not associated with increased preoperative morbidity or early mortality.

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5:30 pm

97. Recurrent Coarctation: Notes
Is Surgical Repair of Recurrent Coarctation of the Aorta Safe and Eﬀective?
J. W. Brown; M. Ruzmetov; M. Hoyer; M. D. Rodefeld; M. W. Turrentine
Indiana University School of Medicine, Indianapolis, Indiana
Background: Persistence or recurrence of stenosis is a complication of coarctation
(CoA) repair associated with major long-term morbidity. The rate of recurrence
varies signiﬁcantly, depending on the age and technique at initial repair. We
reviewed our experience with surgical repair of recurrent CoA and compared it
with balloon aortoplasty.
Methods: We reviewed our experience with 1,005 patients undergoing initial
repair of CoA between 1970 and 2007. During that time we have reoperated on 64
patients (6%). Mean age was 8.4+5.6years (range, 2 months to 43 years). These 64
surgical re-CoA patients were compared to 47 patients treated with balloon re-CoA
angioplasty with/without stent placement undergoing procedure since 2000.
Results: All 64 patients survived surgery and none presented signiﬁcant
postoperative complications (phrenic or recurrent nerve injury, chylothorax, or
spinal cord ischemia). Ninety-ﬁve percent of patients who were followed-up (mean
time, 8.6+5.3 years; range, 6 months to 19 years) are normotensive and are on
no medications for hypertension. Invasive blood pressure monitoring revealed
residual arm-to-leg gradient (more than 15mmHg) in three patients and all are
currently followed. None of the surgical patients has required a second operation for
recurrence. Eight of the 47 (17%) balloon+stent patients have required a subsequent
surgical or balloon intervention with one mortality (2%) and one stent resection for
a mycotic infection during follow-up.
Conclusion: Our study demonstrates that surgical repair of recurrent CoA can

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be performed safely and with excellent results. The recurrence rate is low, and
most patients will not require any further intervention. Balloon aortoplasty as an
alternative method of managing re-CoA is certainly a less invasive method of
re-intervention, although well-described complications do occur and recurrence
rates are signiﬁcant.

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