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O87

Minimally invasive CABG with BITAS - a chronological review Pradeep Nambiar1_{, Sanjay Kumar}2

1

Moolchand Hospital, Gurgaron, India;2Benares Hindu University, Benares, India

Correspondence:Pradeep Nambiar

Journal of Cardiothoracic Surgery2017,12(Suppl 1):O87 Background

Minimal access total arterial multivessel CABG using BITAs is being increasingly adopted and has demonstrated the myriad advantages of not only internal thoracic arteries but also the minimally invasive approach. In this approach harvesting of bilateral internal thoracic arteries (BITAS) are carried out under direct vision through a left mini-thoracotomy and the harvested BITAS are used for multi vessel revascularization as a LITA–RITA Y composite conduit. The aim was

to review the chronological adoption and outcome of this novel technique

Methods

From August 2011 to December 2012, (Phase 1) 150 patients and from Jan 2013 to August 2016 (Phase 2) 669 patients underwent off- pump minimally invasive multivessel CABG using BITAs, through a 2- in left mini-thoracotomy incision.Both internal thoracic arteries were harvested under direct vision and complete revascularization was done using the LITA-RITAY composite conduit, followed by flow study of the grafts.

Results

150 patients had minimally invasive CABG in Phase 1 and 669 in phase 2. The mean number of grafts was 2.8. in phase 1 and 3.4 in phase 2 resulting in an overall mean of 3.1 . EF was 40.5 +/- 5.2. The mean hospital stay was 3.1 days in both phases. There was 1 mortality (0.6%) and 5 (0.7%) in phases 1 and 2. 1 (0.6%) patient and 3 (0.4%) had an elective conversion to sternotomy in the respective phases. 4 (0.5%) patients required reintervention angioplasty in phase 2.

Conclusions

Minimally invasive multivessel total arterial revascularization was done using the LITA - RITA Y composite conduit through a left minthoracotomy. The outcomes have been good in both phases and with a very low re-intervention rate. We feel, that this technique is a safe and reproducible option in coronary artery bypass grafting.

Topic: Minimally Invasive Cardiac

O88

Transapical off-pump mitral valve repair with implantation of artificial chordae: single centre midterm results (case series of 78 patients)

Arturas Lipnevicius, Vilius Janusauskas, Agne Drasutiene, Viktorija Bleizgyte, Diana Zakarkaite, Rita Kramena, Sigita Aidietiene, Kestutis Rucinskas, Audrius Aidietis

Vilnius University, Vilnius, Lithuania Correspondence:Arturas Lipnevicius

Journal of Cardiothoracic Surgery2017,12(Suppl 1):O88 Objectives

Transapical off-pump implantation of artificial mitral valve chordae using NeoChord DS1000 device is an alternative approach to treat severe mitral regurgitation. This study presents mid-term results after this procedure in a single center patients’cohort.

Methodology

From 2011 to 2016 78 patients underwent transapical mitral valve repair in our center. Patients were stratified into 4 anatomical types of mitral pathology: type A (15 patients) - isolated P2 prolapse, type B (43 patients) - P2 and adjacent segments disease, type C (16 patients) - single or bileaflet prolapse with pericommissural segments being involved, type D (4 patients) - isolated A2 prolapse. The mitral valve regurgitation more than 2+ was considered to be a failure.

Results

Mean age of our patients was 59.5±12.8 years, 67.9% - male. Preoperative median risk values according to STS score and EuroSCORE II were 0.47% (0.24%-0.74%) and 0.83% (0.67%-1.35%) respectively. Median duration of the surgery was 120min (110-146), postoperative ventilation - 4h (2.5-5), length of ICU stay was 22h (20-24), while postoperative hospital stay was 8 days (7-9). Median postoperative blood loss was 200ml (150-300), blood products were used in 6 (7.7%) patients. Three (3.9%) patients underwent re-exploration for bleeding. There were no stroke or wound infection. Transitory acute renal failure occurred in two cases. There was one early postoperative death. New atrial fibrillation was observed in 11.7% of the patients and 2.6% needed permanent pacemaker insertion. Mean follow-up time was 34±19

months. Kaplan-Meier method was used to calculate estimated freedom from MR >2+: it was 93%, 75%, 28% and 50% for types A, B, C and D re- spectively at 5 years_’follow-up.

Conclusion

Transapical off-pump chordae implantation is feasible and safe pro- cedure. Procedure is beneficial for type A and B groups of patients only, therefore patients should be carefully selected according to the mitral pathology.

Topic: Minimally Invasive Cardiac

O89

Early and mid-term results of randomised trial MICSREVS - direct, indirect and intangible costs

Aliaksandr A. Ziankou1, Mikalaj Laiko1, Kyril Vykhrystsenka1, Vjacheslau Chuyashou1_{, Aliaksandr Zhyhalkovich}2_{, Yuri Ostrovsky}2 1

Vitebsk Regional clinical hospital, Vitebsk State Medical University, Vitebsk, Belarus;2_{Republic Research-Practical Center“Cardiology", Minsk,}

Belarus

Correspondence:Aliaksandr A. Ziankou

Journal of Cardiothoracic Surgery2017,12(Suppl 1):O89 Objective

We evaluated hospital and mid-term results of the prospective random- ized controlled trial MICSREVS - Minimally Invasive Cardiac Surgery Revas- cularization Strategy (http://www.clinicaltrials.gov/show/NCT02047266) from the point of view of direct, indirect and intangible costs.

Methods

In accordance with the trial design, 150 patients were included, divided into 3 groups of 50 people. In group I, the multivessel small thoracotomy coronary artery bypass grafting (MVST-CABG) strategy was directed to perform arterial revascularisation via a left minithoracotomy on the beating heart, using the aortic no-touch technique. In control groups II - off-pump (OPCABG) and III - on- pump coronary artery bypass grafting (ONCABG), conventional sur- gery was performed via median sternotomy.

Results

MVST-CABG was associated with less perioperative blood loss, lower number of blood transfusions, shorter hospital length of stay, compared with other groups; less postoperative ventilation time and intensive care unit stay versus ONCAB group (p<0.05); fewer deep wound infections versus OPCABG patients (p<0.1). In treatment groups, the average direct cost (hospital) per patient were $2.732, $3.454 and $4.808, respectively. Patients who visited a rehabilitation center stayed an average of 12.8±4.5 days and incurred an average cost of $186.8 per patient. The mean follow-up duration constituted 24.7±8.2 months. Cumulative midterm survival and freedom from MACCE did not differ significantly between treatment groups (p>0.05). During the 1-year period after surgery an average of 87 ±31, 98±36 and 117±47 workdays per patient were lost, respectively. MVST-CABG patients demonstrated shorter time to return to full physical activity and greater improvement in 30-days physical health component (SF-36) of quality of life.

Conclusions

Application of the MVST-CABG leads to the reduction of the direct, indirect and intangible costs during the hospital period and after hospital discharge.

Table 1 (abstract O89).Operative Characteristics and Postoperative Results Characteristic MICS-CABG (n=50) OPCABG (n=50) ONCABG (n=50) MVST- CABG vs OPCABG MVST- CABG vs ONCABG Intraoperative blood loss (ml) 250 (162.5; 300) 475 (350; 587.5) 400 (300; 500) <0.001 <0.001 First twenty-four hours

postoperative blood loss (ml) 450 (252.5; 587.5) 575 (450; 800) 500 (400; 800) 0.002 0.007 9 (18.0) 20 (40.0) 33 (66.0) 0.015 <0.001

Table 1 (abstract O89).Operative Characteristics and Postoperative

Results(Continued) Transfusion of blood and/or derivatives, n (%) Postoperative ventilation time (h) 3.5 (2.5; 5.0) 4.3 (2.1; 6.0) 5.3 (3.5; 7.9) 0.399 0.007 Intensive care unit stay

(h) 18 (16.0; 20.8) 18 (17.0; 27.8) 19.3 (16.1; 43.6) 0.315 0.042

Deep wound infection, n (%) - 3 (6.0) - 0.079 - Postoperative length of stay (d) 12.0(9.3;14.0) 14.0 (13.0; 17.0) 14.0 (12.0; 17.8) <0.001 0.004

Time to return to full physical activity (d) 14 (7; 21) 56 (42; 77) 56 (44; 79) <0.001 <0.001 Physical health component SF-36 Health Status Survey quality of life 50.9 (45,3; 52,8) 47.3 (44.9; 50.2) 48.3 (45.4; 50.5) 0.026 0.079

Topic: Minimally Invasive Cardiac

O90

Right anterior thoracotomy for aortic valve surgery: evolution of myocardial protection strategies

Arthur Martella, III, Atiq Rehman

Our Lady of Lourdes Medical Center, Camden, PA, USA Correspondence:Arthur Martella, III

Journal of Cardiothoracic Surgery2017,12(Suppl 1):O90 Background

Due to the growth of transcatheter techniques, patients needing aortic valve surgery(AVR) are more likely to have aortic insufficiency or require associated procedures. Interest in right anterior thoracotomy (RAT) AVR continues to grow. Improved exposure techniques and perfusion and myocardial protection strategies offer opportunity to manage more complex problems with this approach.

Methods

We retrospectively reviewed all patients undergoing RAT AVR through a 4 - 8 cm skin incision at a single institution. From January 2014 to January 2017, 194 patients with aortic valve disease underwent RAT AVR. During the same period 255 patients underwent TAVR. Mean age was 67.4 ± 10.0 years, and 112 (57.7%) were male.

Results

All patients received a bioprosthesis. Eight of the last 16 patients utilized minimal suture valves. Combined procedures included: 12 robotic LIMA to LAD, 7 SVG to RCA, 6 PVI, 8 LAA ligations, 3 MVRs, 4 TVRs. One patient required reoperation for bleeding. CBT was 84 min, and ACC was 73 min. In-hospital mortality was 1.5% (3/194) with no conversions to sternotomy. 38 patients had primary AI. Perfusion strategy: the first 24 patients utilized a groin incision for arterial and venous access. All further cases utilized percutaneous vacuum- assisted venous drainage and central arterial cannulation was adopted in the subsequent 170 patients. Supplemental venous drain- age was utilized with a floppy suction in 10 pts. Histadine- tryptophan-ketoglutarate (HTK) was utilized in 94 percent of cases and Del Nido in the remaining. TAVR CT scans were utilized to deter- mine the location of the incision.

Conclusions

Evolution of perfusion, myocardial protection and exposure techniques have allowed for safer management of more complex aortic disease. Management of more complex cardiac disease and patients with aortic insufficiency requires a patient-specific team strategy for exposure, perfusion access and myocardial protection.

Topic: Minimally Invasive Cardiac

O91

Aortic valve replacement through a right mini-thoracotomy: single center experience

Mauro Del Giglio, Elisa Mikus, Marco Panzavolta, Marco Paris, Diego Magnano, Simone Calvi

Maria Cecilia Hospital, Cotignola (RA), Italy Correspondence:Elisa Mikus

Journal of Cardiothoracic Surgery2017,12(Suppl 1):O91 Objective

Aortic valve replacement through a right mini-thoracotomy is a min- imally invasive procedure developed during the last years. It is not frequently used because of a tiny operating field, limiting surgeon’s view resulting in longer cardiopulmonary bypass and cross clamping times compared to the standard full sternotomy.

Methods

We retrospectively reviewed 488 patients (273 male 55.9% with median age of 75; range 16-93 years) who received an aortic valve replacement between January 2010 and February 2017 through a right mini-thoracotomy In the first 45 patients the aortic cannulation and clamping were performed through the right minithoracotomy while a vacuum assisted venous drainage was obtained percutan- eously through the groin. A total central arterial and venous cannula- tion was adopted in the last 443 patients. All patients received an aortic valve replacement with a pericardial bioprosthesis sutured using three 2-0 Prolene running sutures. Mean prosthesis size was 24.4 mm

Results

Aortic replacement was performed through a 4 to 6 cm skin incision at the third intercostal space. One patient was a REDO case. Overall median cardiopulmonary bypass and aortic cross clamping time was respectively 54 minutes (range 25-121) and 42 minutes (range 16-134). Median ventilation time and intensive care stay were 7 and 44 hours. Patients transfused were 42%. Hospital mortality was 1.4% (7/488).

Conclusions

This single center experience show that aortic valve replacement achieved through a right mini-thoracotomy is a safe procedure with excellent results. Thanks to a standardized technique cardiopulmo- nary bypass and cross-clamping times comparable with the standard can be obtained and peripheral cannulation avoided.

Advantages of this technique include early mobilization and rehabilitation, excellent aesthetic result and lower risk of wound complications

Topic: Minimally Invasive Cardiac

O92

Cor-Knot, an automated knot-tying device: first experience in Asia Evangelos Papadimas, Mohammad Armane Wadud, Peggy Hu, Theo Kofidis

National University Hospital, Singapore, Singapore Correspondence:Evangelos Papadimas

Journal of Cardiothoracic Surgery2017,12(Suppl 1):O92 Background

This study compared the CPB, Cross-clamp and total operation time between minimally invasive and conventional cardiac surgery cases in which The Cor-Knot automated fastener (LSI SOLUTIONS, Victor, NY, USA) was used versus those in which a traditional knot pusher was used.

Methods

The Cor-Knot was used in a total of 30 cases, of which 20 were through median sternotomy, and 10 minimally invasive. The 30 pa- tients who underwent surgery using this novel automated fastener

(January 2016-December 2016) were compared to 30 patients cor- rected with a traditional knot pusher (January 2015-December 2015). No significant differences regarding demographic data (age, gender, NYHA class, ejection fraction, BMI, cardiovascular risk factors) be- tween the two groups were found. The two groups were compared for CPB time, Aortic Cross-clamp time, total OT time. Differences be- tween groups were calculated with the Student_’st-test. Overall sig- nificance is attained with ap< 0.05.

Results

Transesophageal and transthoracic echocardiography at the end of operation and at discharge revealed no (n= 28) or mild (n= 2) residual regurgitation of the respective valve, without any evidence of ring dehiscence, paravalvular leaks and without any significant differences between the two groups. Cross-clamp time (83.2 ± 12.7 vs. 98.4 ± 13.8; p< 0.01), CPB time (131.7 ± 21.7 vs. 149.4 ± 22.7;

p< 0.05) and operation time (201.8 ± 29.4 vs. 225.2 ± 27.02;p< 0.01) were significantly reduced in the automated fastener group compared to the group using a traditional knot pusher.

Conclusions

The results of our study show that with the introduction of the Cor- Knot device to a diverse Asian population, cross-clamp time, CPB time and total operation time were significantly reduced compared to our control group. Time saved varied from 15 (cross-clamping) up to 18 min (operation). With an estimated 100SGD/minute operating theater time in our country, an average of at least 1000SGD is saved per case; thereby making this an efficient and cost-saving solution.

Topic: Cardiac Surgery

O93

Bio-Bentall Procedure in Aortic Root Pathology Using both Full or Mini Sternotomy

Elisa Mikus, Simone Calvi, Marco Paris, Alberto Tripodi, Marco Panzavolta, Mauro Del Giglio

Maria Cecilia Hospital, Cotignola (RA), Italy Correspondence:Elisa Mikus

Journal of Cardiothoracic Surgery2017,12(Suppl 1):O93 Objective

Bentall and De Bono described a surgical technique to treat aortic root pathology. Alternative, less-common procedures, such as reim- plantantion and remodelling, have been proposed in an effort to avoid anticoagulation therapy. We describe our experience with a biological conduit for aortic root pathology.

Methods

Between January 2010 and November 2015, 94 patients (84% men; mean±standard deviation age 63.8±13.0 years) underwent an isolated Bio-Bentall procedure at our institution, for an elective or ur- gent indication. None had previously undergone cardiac surgery. Pa- tients were divided into those who underwent a minimally invasive approach through an upper ministernotomy and patients who underwent standard full sternotomy. Follow-up data up to 5 years were obtained retrospectively from hospital and office records and through telephone contacts. Overall survival curves after discharge were estimated using the Kaplan−Meier product-limit estimator and were compared using the log-rank test.

Results

Of the 94 patients, 45 (48%) underwent a full sternotomy and 49 (52%) underwent a minimally invasive approach through a ministernotomy. Both groups of patients showed similar results in terms of postoperative mortality and morbidity. Mean cardiopulmonary bypass (97.4±35.2 vs 115.3±44.5; P=0.023) and cross-clamp (82.8±29.4 vs 97.7±38.2; P=0.046) times were shorter in the minimally invasive group. During the early postoperative period, 51% of patients in both groups were free from complications. Two (4%) patients in the full sternotomy group died in hospital versus none in the minimally invasive group (P=0.22). The

hospital mortality rate was 2% (2/94). Five-year overall survival after hos- pital discharge was 91% in the minimally invasive group and 89% in the full sternotomy group.

Conclusions

Our single centre experience shows that a biological prosthesis inserted into the Dacron graft for aortic root replacement has low mortality and good durability. In a selected population, minimally invasive surgery appears to have a role.