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ORTIC DISSECTION, ANEURYSMS AND ATHERO-ATOUS ULCERS: TYPICAL AND ATYPICAL

MAGING FEATURESCOMPARISON OF IMAGING TECHNIQUES:

NTRAOPERATIVE LIVE 3D EPICARDIAL ECHO-ARDIOGRAPHY, MULTIPLANE TRANSESOPH-GEAL ECHOCARDIOGRAPHY AND MULTISLICEPIRAL CT

anisha Mishra , Poonam Khurana,ile Singh Meharwal, Naresh Trehan

Escorts Heart Institute & Research Centre, Okhla Road, Newelhi, India

Objective. Non-invasive imaging allows prompt andeliable diagnosis of acute aortic dissection. However,typical imaging features and diagnostic pitfalls can delayifesaving therapy. These pitfalls may be attributed to tech-ical factors: streak artifacts, aortic wall motion, aorticariations such as aortic aneurysm with thrombus andenetrating atheromatous ulcers.

Here we illustrate the spectrum of potential pitfallsin the three diagnostic modalities – Live 3D echocar-diography, multiplane transesophageal echocardiographyand multislice computed tomography (MSCT), along withtheir sensitivity in diagnosis of the aortic pathology.

Methods. Sixty-two patients with clinically suspectedaortic dissection were studied from September 2003through June 2006. They were examined preoperativelywith multiplane transesophageal echocardiography, thencontrast material-enhanced MSCT and intraoperativelywith Live 3D epicardial echocardiographic evaluation ofthe ascending aorta and arch was performed. Imagingresults in terms of detection of aortic pathology wereconfirmed at intraoperative exploration by the operatingsurgeon as the reference standard.

Results. Of the sixty-two patients studied, aortic dissec-tion was detected in 28, aortic aneurysm in 24 and aorticatheromatous ulcers in 10.

Sensitivity in the detection of thoracic aortic dissection,ascending aorta aneurysm and atheromatous ulcers was100% for all techniques. Specificity was 92%, 97%, and

1443-9506/04/$30.00doi:10.1016/j.hlc.2007.02.008

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100% for live 3D epicardial echocardiography, multiplaneTEE and MSCT imaging, respectively.

Conclusion. MSCT is the imaging technique of choice atour institution for patients with suspected aortic dissectionbefore undergoing surgery. Additional information canbe obtained from intraoperative transesophageal echocar-diography and live 3D epicardial imaging. Althoughseveral of the pitfalls and artifacts that mimic aortic dissec-tion can be easily recognised, others can pose a diagnosticchallenge. Familiarity with these common pitfalls, alongwith a knowledge of normal intrathoracic anatomy, canhelp to avoid interpretive errors by the various imagingmodalities.

doi:10.1016/j.hlc.2007.02.009

MICROWAVE ATRIAL RESTORATIVE SURGERY‘MARS’ IN RHEUMATIC MITRAL PATIENTS

M.F. Ahmed , E.L. Watidy , Abdullah Ashmeg

Prince Sultan Cardiac Centre, Riyadh and King Fahd ArmedForces Hospital, Jeddah, Saudi Arabia

Introduction. Rheumatic mitral patients are charac-terised by giant left atria (LA) and prevalence of chronicatrial fibrillation (AF). The classic ablation techniques forchronic AF in rheumatic mitral patients are associated withhigher recurrence rates of AF. Microwave atrial restorative

OR was successful in 95%, before discharge from the hos-pital in 88.2%, at 3 months 82.4%, at 6 months 82.4%, and at1 year 80%. MARS group had higher success rate by 4.8%at 1-year follow-up (p < 0.05). One patient (2.6%) neededpermanent pacemaker. Histopathology of LA appendageshowed positive correlation between the degree of leftatrial appendage wall fibrosis and endocardial thicknesstogether with the recurrence of AF after surgery. Therewas a significant drop in the postoperative atrial natri-uretic peptide (ANP) levels (23.1 pg/mL) compared withthe preoperative (86.5 pg/mL; p < 0.05).

Conclusion. ‘MARS’ procedure can be safely done andmay provide superior results in maintaining sinus rhythmcompared with AF ablation alone in rheumatic mitralpatients.

Long-term follow-up is needed.

doi:10.1016/j.hlc.2007.02.010

MODIFIED MAZE PROCEDURE USING SALINEIRRIGATED COOLED TIP RADIOFREQUENCY FORCHRONIC ATRIAL FIBRILLATION IN PATIENTSWITH MITRAL VALVE DISEASE—5-YEAR FOLLOW-UP STUDY

Ramesh Bapna , Anil Agarwal, Vijay Kohli, Zile SinghMeharwal, Yugal Mishra, Rajneesh Malhotra, NareshTrehan

surgery (MARS) is a surgical technique, which combinesmitral valve (MV) surgery, ablation of chronic AF usingmicrowave energy, together with left atrial appendectomyand reduction of the left atrial size. This technique is basedon the concept that both mitral valve and left atrium areconsidered as one physio-anatomical unit and, therefore,restoration of size, shape and function of left atrium alongwith correction of the underlying mitral pathology mayprovide better outcome.

Objective. To evaluate the early results of ‘MARS’ inrheumatic MV patients with chronic AF.

Patients and methods. From March 2002 to March 2005,38 patients were operated upon for mitral valve diseaseand chronic AF. Twenty-six patients (68.4%) had ‘MARS’procedure and 12 patients (31.6%) had AF ablation alonewith mitral valve surgery.

Results. The age of the patients ranged from 24 to70 years (mean 40.8); 76.5% were female patients. Theaetiology was rheumatic in 93.4% of patients, degen-erative disease 3.3% and SBE 3.3%. The percentage ofpatients who had mitral valve repair was 38.4%, biolog-ical mitral valve replacement 34.6%, mechanical mitralvalve replacement 19.2%, associated tricuspid valve repair38.4%, tricuspid valve replacement 3.8%, aortic and mitralvalve repairs 3.8% and redo surgery in 15.3%. The pre-operative left atrial size ranged from 6.2 to 10.8 cm (mean7.64). The mean cross-clamp time was 84.6 min. Meanbypass time was 96.5 min and mean ablation time was27.6 min. The mean hospital stay was 8.5 days and meanventilation time was 10.4 h. The operative mortality was0%, 1-year mortality 2.6% and 2-year mortality 2.6%. Theoverall rate of restoring sinus rhythm immediately in the

Escorts Heart Institute And Research Centre, New Delhi, India

Objective. Atrial fibrillation (AF) is present approxi-mately in 50–70% of patients with mitral valve disease.Chronic AF not only impairs cardiac function by loss ofatrial kick but also increases the risk of thrombo-emboliccomplication. The aim of this study is to demonstrate thelong-term effectiveness of modified Maze procedure usingSCITRA in eliminating chronic AF and restoring the atrialcontractility in patients with mitral valve disease.

Methods. Twenty-five patients with mitral valve diseaseand chronic AF were studied from January 2001 and fol-lowed for 5 years. There were 70% females. The age rangedfrom 38 to 67 years. They were in class III and IV NYHA.Twenty-five percent of the patients had clot in LA or LAA.The left atrial size was 4.5–6.2 cm.

Linear intra-atrial lesions were made around pul-monary veins, connecting lesions to inter pulmonaryveins and mitral valve using RFA catheter (SCITRA) onconventional cardiopulmonary bypass (CPB) with mildhypothermia and cardioplegic arrest of the heart alongwith mitral valve surgery (repair or replacement). Thecross-clamp time was 60 ± 15 min and ablation time was10–15 min.

Results. Seventy percent of the patients were in sinusrhythm immediately after surgery. All these patients hadvariable rhythm in immediate postoperative period.

All 25 patients were followed for a period of 5 yearsand found the success of ablation was 92% at 1 year, 88%at 2 years and 80% at the end of 3 and 5 years. Threepatients went into atrial flutter which was successfullycardioverted.