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S1

Thorac Cardiovasc Surg 2014; 62(Suppl 1): S1–S14

Congress Program

Sonntag, 9. Februar 2014/Sunday, February 9th, 2014

Advanced Surgical Techniques I Aortic disease10:00–10:12 DE | Tagungsraum 2Chair: T. Carrel (Bern) M. Pichlmaier (München)

Advanced Surgical Techniques I Coronary artery disease – Techniques 10:00–12:00 EN | Tagungsraum 1Chair: M. Mack (Plano) A. Diegeler (Bad Neustadt an der Saale)

Advanced Surgical Techniques I Congenital heart disease – Heart failure10:00–12:00 DE | Tagungsraum 3Chair: H. Akintürk (Gießen) C. Schlensak (Tübingen)

Advanced Surgical Techniques I Aortic valve disease10:00–12:00 EN | Tagungsraum 4Chair: W. Hemmer (Stuttgart) H.-J. Schäfers (Homburg)

General I Students' Meeting - Career Perspec-tives in Surgery: Facts and Fiction10:00–11:30 DE | Tagungsraum 7Chair: S. Ensminger (Bad Oeynhausen) N. Khaladj (München)

10:00 – 10:30 First steps towards a successful career: Current Problems and Solutions

A. Botzlar (Murnau)

10:30 – 11:00 Women in cardiac surgery: How does reality look like?

S. Bleiziff er (München)

11:00 – 11:30 Surgical research abroad: From Vision to practice

S. Peterß (München)

General I Residents' & Students' Lunch 13:15–14:15 in the restaurant of the congress hall

General I Patientensymposium11:00–13:00 DE | Tagungsraum 6Chair: A. Beckmann (Berlin) J. Cremer (Kiel) F. Beyersdorf (Freiburg) T. Meinertz (Frankfurt am Main)

General I Hands-on surgical techniques for students11:30–13:00 Training Village 1 & 2

Advanced Surgical Techniques I Coronary artery disease – Results12:30–14:30 EN | Tagungsraum 1Chair: K.-H. Kuck (Hamburg) J. Pomar (Barcelona)

Advanced Surgical Techniques I Aortic disease12:30–14:30 DE | Tagungsraum 2Chair: M. Karck (Heidelberg) G. Torsello (Münster)

Advanced Surgical Techniques I Congenital heart disease – Live-in-a-box12:30–14:30 DE | Tagungsraum 3Chair: C. Schreiber (München) J. Photiadis (Berlin)

Advanced Surgical Techniques I Mitral valve disease12:30–14:30 EN | Tagungsraum 4Chair: M. Grimm (Innsbruck) V. Falk (Zürich)

General I Meeting of the Scientifi c Advisory Board of the German Heart Foundation13:00–14:30 DE | Tagungsraum 8

Congress ProgramS2


Sonntag, 9. Februar 2014 / Sunday, February 9th, 2014

General I Residents' Meeting – Dream Job 'Cardiac Surgeon'?! A shift of paradigm14:30–16:45 DE | Tagungsraum 5Chair: A. Hoff meier (Münster) S. Peterß (München)

Working Groups & Committees I Working Group for Basic Science14:45–16:15 Tagungsraum 1Chair: W. Röll (Bonn)

14:30 – 14:40 News from the Committee A. Hoff meier (Münster)

14:40 – 14:50 News from the Young Forum T. Noack (Leipzig)

14:50 – 15:00 'Generation Y' and cardiac surgery: Clash of two ideologies?!

J. Seeburger (Leipzig)

15:00 – 15:10 Career perspective 'Head of department': Analysis from a personal point of view

T. Wahlers (Köln)

15:10 – 15:20 Residents survey 2013: Current status and implications for the future

A.-L. Poetini (Mainz)

15:20 – 15:30 Panel discussion: Dream Job 'Cardiac Surgeon'?! Future perspectives

H. Gulbins (Hamburg) W. Harringer (Braunschweig) A. Markewitz (Koblenz) T. Noack (Leipzig) A.-L. Poetini (Mainz)

General I Heads of Departments Meeting14:45–16:15 Tagungsraum 2

Working Groups & Committees I Working Group for Extracorporeal Circulation and Mechanical Circulatory Support14:45–15:45 Tagungsraum 4Chair: U. Boeken (Düsseldorf)

Working Groups & Committees I Working Group for Thoracic and Cardiovascular Surgery Intensive Care Medicine14:45–16:15 Tagungsraum 6Chair: G. Trummer (Freiburg)

Working Groups & Committees I Working Group for "Psyche and Heart"14:45–16:15 Tagungsraum 7Chair: K. Tigges-Limmer (Bad Oeynhausen)

Working Groups & Committees I Working Group "The Elderly Patient in Heart Surgery"14:45–16:15 Tagungsraum 8Chair: A. Simm (Halle (Saale)

Working Groups & Committees I Committee for Guidelines14:45–16:15 Meetingraum 1Chair: V. Falk (Zürich)

Working Groups & Committees I Working Group Quality Management14:45–16:15 Meetingraum 2Chair: P. Kleine (Frankfurt)

General I Meeting of the Commission for Organ Transplantation of the German Transplantation Society11:30 - 13:00 Tagungsraum 7Chair: H. Reichenspurner (Hamburg)

Working Groups & Committees I Working Group for Aortic Valve Surgery14:45–16:15 Tagungsraum 3Chair: M. Misfeld (Leipzig)

Congress Program S3


Sonntag, 9. Februar 2014 / Sunday, February 9th, 2014

General I Opening Ceremony17:00–19:00 DE | Plenum

Welcome Reception in the Industrial Exhibition19:00 - 22:00 DE | Hall 3

17:00 – 19:00 Opening Ceremony

17:00 – 17:10 Musical Opening Popchor of the Friedrich-Gymnasium Freiburg

17:10 – 17:20 Opening Address by the Congress Presi-dent

F. Beyersdorf (Freiburg)

17:20 – 17:35 Welcome Address by the Mayor of Freiburg

D. Salomon (Freiburg)

17:35 – 17:45 Welcome Address by the Rector of the University of Freiburg

H.-J. Schiewer (Freiburg)

17:45 – 18:00 Welcome Address of the Congress President

F. Beyersdorf (Freiburg)

18:00 – 18:15 Welcome Address by the President of the German Society for Thoracic and Cardiovascular Surgery

J. Cremer (Kiel)

18:15 – 18:25 Musical Intermezzo Popchor of the Friedrich-Gymnasium Freiburg

18:25 – 18:55 MAIN LECTURE: Soccer schools and sur-gical training – are there similarities?

F. Keller (President of the SC Freiburg) B. Réthy (Sports Journalist)

18:55 – 19:05 Presentation of the Award Winners J. Cremer (Kiel)

19:05 – 19:15 Musical Finale Popchor of the Friedrich-Gymnasium Freiburg

Congress ProgramS4


Main Session I Mechanical circulatory support (Joint Session DGfK) 10:30–12:00 DE | PlenumChair: C. Benk (Freiburg) C. Schlensak (Tübingen)

Main Session I Arrhythmia/Pacemaker/CRT/ICD (Joint Session DGK) 10:30–12:00 DE | Tagungsraum 1Chair: G. Hindricks (Leipzig) A. Markewitz (Koblenz)

Abstract Session I Mitral valve disease10:30–12:00 EN | Tagungsraum 2Chair: F.-W. Mohr (Leipzig) R.-Chitwood (Greenville)

Main Session I EMAH: When TGA patients get older (Joint Session DGPK)08:30–10:00 EN | Plenum Chair: D. Kececioglu (Bad Oeynhausen) J. Photiadis (Berlin)

Abstract Session I Coronary heart disease I08:00–10:00 DE | Tagungsraum 1Chair: A. Diegeler (Bad Neustadt an der Saale) G. Laufer (Wien)

Abstract Session I Thoracic Surgery08:00–10:00 DE | Tagungsraum 2Chair: R. Autschbach (Aachen) K. Wiebe (Münster)

Abstract Session I Mitral valve disease08:00–10:00 EN | Tagungsraum 3Chair: O. Alfi eri (Mailand) R. Hetzer (Berlin)

Abstract Session I Extracorporeal circulation and myocardial protection I08:00–10:00 DE | Tagungsraum 4Chair: D. Buchwald (Bochum) M. Turina (Zürich)

Short Communications I Basic science I: Tissue Engineering08:00–10:00 DE | Tagungsraum 7Chair: C. Stamm (Berlin) S. Hoerstrup (Zürich)

Short Communications I Aortic disease/Vascular surgery I08:00–10:00 DE | Poster Vortrag Chair: K. Kallenbach (Heidelberg) B. Rylski (Philadelphia)

Advanced Surgical Techniques I Echocardiography Basic course – 108:00–10:00 Meetingraum 1

Symposium OR-Nurses I Symposium Medical and Healthcare Staff 09:00–10:00 DE | Tagungsraum 5Chair: C. Abrahamson C. Fromme

Montag, 10. Februar 2014 / Monday, February 10th, 2014

09:00–09:15 Begrüßung durch den Tagungspräsidenten I

F. Beyersdorf (Freiburg) B. Fröhlich

09:15–10:00 Woher kommt die OP-Schwester in 20 Jahren?

– Weg/Ausblick Fortbildungsmöglichkeiten für OP-Schwester/Pfl eger I J. Berentzen (Osnabrück)

Congress Program S5


Abstract Session I Transcatheter valves I: Clinical results10:30–12:00 DE | Tagungsraum 3Chair: M. Pasic (Berlin) T. Walther (Bad Nauheim)

Abstract Session I Heart and lung failure I10:30–12:00 DE | Tagungsraum 4Chair: G. Laufer (Wien) A. Hoff meier (Münster)

Symposium OR-Nurses I Symposium Medical and Healthcare Staff 10:30–12:00 DE | Tagungsraum 5Chair: C. Abrahamson C. Fromme

Short Communication I Coronary heart disease10:30–12:00 DE | Tagungsraum 7Chair: H. Gulbins (Hamburg) M. Grabenwöger (Wien)

Short Communication I Organ transplantation10:30–12:00 DE | Poster Vortrag Chair: M. Siepe (Freiburg) E. Potapov (Berlin)

Advanced Surgical Techniques I Echocardiogra-phy Basic course – 210:30–12:00 Meetingraum 2

General I Ordinary General Assembly of the GSTCVS12:15–13:00 Plenum


Symposium I Lunch-Symposium „Heart but fair“ – challenged by innovations? supported by Edwards Lifesciences Services GmbH 13:30–14:30 DE | Plenum

Symposium I Lunch-Symposium Innovation in Cardiac Surgery – “Nice to Have” or Essentials for the Profession? supported by Medos Medi-zintechnik AG 13:30–14:30 DE | Tagungsraum 1Chair: V. Falk (Zürich)

13:30 – 13:40 What is the future of open heart valve surgery?

J. Seeburger (Leipzig)

13:40 – 13:50 Challenges in neonatal/pediatric cardiac surgery provoking innovation.

A. Horke (Hannover)

13:50 – 14:00 ECMO and VAD Therapies – “All Said” or is there News to Announce?

C. Schlensak (Tübingen)

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13:30–14:30 Panel discussion moderated by Renate Harrington

H. Reichenspurner (Hamburg) K.-H. Kuck (Hamburg) P.M. Wenaweser (Bochum) J.T. Strauch (Bochum)

10:30–11:15 Die Y-Generation – Grundsätze H. Guggenberger (Tübingen)

11:15–11:45 Fokus in der Herzchirurgie J. Seeburger (Leipzig)

Congress ProgramS6


Symposium I Lunch-Symposium Pitfall MECC? supported by Maquet13:30–14:30 DE | Tagungsraum 3Chair: A. Bauer (Coswig) A. Liebold (Ulm)

Symposium I Lunch-Symposium Mitral Concomitant Therapy. Three therapies. One surgical solution. supported by Medtronic GmbH13:30–14:30 DE | Tagungsraum 4Chair: R. Lange (München)

13:30 – 13:45 The mitral perspective R. Lange (München)

13:45 – 14:00 The tricuspid perspective N.N.

14:00 – 14:15 AF ablation F. Casselman (Alsat)

14:15 – 14:30 AF Monitoring T. Hanke (Lübeck)


Symposium I Lunch-Symposium Technical Forum on Lead Extraction supported by Spectranetics Deutschland GmbH 13:30–14:30 EN | Tagungsraum 5Chair: M. Knaut K.-N. Doll (Stuttgart)

Symposium I Lunch-Symposium Experience in the Treatment of Aortic Valve Replacement supported by St. Jude Medical13:30–14:30 EN | Tagungsraum 7Chair: M.A. Borger (Leipzig) I. Friedrich (Trier)

13:30 – 13:45 Minimization of ppm: The Infl uence of new bioprosthesis.

M.A. Borger (Leipzig)

13:45 – 14:00 Hemodynamic Performance of the Trifecta during Exercise and Recovery

T. Hanke (Lübeck)

14:00 – 14:15 The modifi ed Bentall procedure with Trifecta

I. Friedrich (Trier)

14:15 – 14:30 Portico: Clinical Outcome C. Butter (Bernau)

13:30 – 13:45 Clinical experience with E-vita open plus in chronic dissection

D. Hammel (Bremen)

13:45 – 14:00 Clinical experience with E-vita open plus

K. Kallenbach (Heidelberg)

14:00 – 14:15 E-vita open plus registry K. Tsagakis (Essen)

14:15 – 14:30 Totally Endovascular Repair of TAAA – A Reasonable Option

B. Zipfel (Berlin)

13:30 – 14:00 Does minimized circulation stress the surgeon and make the procedure demanding?

C. Skrabal (Ulm)

14:00 – 14:30 Are we exposing the Patient to addi-tional risk?

E. Gygax (Bern)

13:30 – 13:50 Considerations and specifi c techniques for transvenous lead extraction

B. Osswald (Düsseldorf) 13:50 – 14:10 Lead extraction in patients with occluded

veins B. Sill (Hamburg) 14:10 – 14:30 Managing cardiac device infection H. Burger (Bad Nauheim)

Symposium I Lunch-Symposium Treatment of Complex Thoracic Aortic Disease: Today and Tomorrow, supported by JOTEC GmbH13:30–13:00 EN | Tagungsraum 2Chair: G. Wimmer-Greinecker (Bad Bevensen) H. Jakob (Essen)

Congress Program S7


Symposium OR-Nurses I Symposium Medical and Healthcare Staff 15:00–16:30 DE | Tagungsraum 5Chair: G. Seidel M. Raestrup

Short Communications I Aortic valve disease I 15:00–16:30 DE | Tagungsraum 7Chair: A. Rastan (Rotenburg a.d. Fulda) F. Eckstein (Basel)

Short Communications I Transcatheter valves I: Clinical outcomes TAVI15:00–16:30 DE | Poster VortragChair: T. Wahlers (Köln) W. Wisser (Wien)


Abstract Session I Heart and lung failure II15:00–16:30 DE | Tagungsraum 4Chair: F. Beyersdorf (Freiburg) P. Mohacsi (Bern)

Abstract Session I Basic science I: Tissue Engineering & Arrhythmias15:00–16:30 DE | Tagungsraum 1Chair: S. Ensminger (Bad Oeynhausen) G. Hasenfuß (Göttingen)

Abstract Session I Congenital heart disease I: EMAH15:00–16:30 DE | Tagungsraum 2Chair: I. Dähnert (Leipzig) D. Zimpfer (Wien)

Abstract Session I Organ transplantation15:00–16:30 DE | Tagungsraum 3Chair: M. Strüber (Leipzig) K. Brehm (Freiburg)

Advanced Surgical Techniques I Echocardiogra-phy Advanced course – 115:00–16:30 Meetingraum 1

Main Session I Intensive care medicine (Joint Session DIVI/DGAI)17:00–18:30 DE | Plenum Chair: G. Trummer (Freiburg) U. Schirmer (Bad Oeynhausen)

Main Session I Young Forum17:00–18:30 DE | Tagungsraum 1Chair: T. Noack (Leipzig) A.-L. Poetini (Mainz)

Abstract Session I Transcatheter valves II: Technical aspects17:00–18:30 DE | Tagungsraum 2Chair: S. Ensminger (Bad Oeynhausen) D. Holzhey (Leipzig)

Abstract Session I Aortic valve & Ascending aorta17:00–18:30 EN | Tagungsraum 4Chair: C. Detter (Hamburg) M. Mack (Plano)

Main Session I Heart Team live – Coronary artery disease (Joint Session DGK)15:00–16:30 DE | Plenum Chair: A. Böning (Giessen) C.W. Hamm (Bad Nauheim)

15:00–15:45 Das Hypoplastische Linksherz Syndrom U. Herberg (Bonn)

15:45–16:30 Die neue ballonexpandierende Klap-pengeneration – SapIen3 supported by Edwards Lifesciences Services GmbH

Congress ProgramS8


Short Communications I Congenital heart disease17:00–18:30 DE | Tagungsraum 7Chair: J. Scheewe (Kiel) M. Hofbeck (Tübingen)

Short Communications I Heart and lung failure I17:00–18:30 DE | Poster Vortrag Chair: H. Reichenspurner (Hamburg) A. Haneya (Kiel)


Advanced Surgical Techniques I Echocardiography Advanced course – 217:00–18:30 Meetingraum 1

Congress Program S9


Symposium I Breakfast-Symposium VAD therapy – has it become clinical routine yet? supported by Thoratec Europe Ltd.07:30–08:30 DE | Tagungsraum 3Chair: C. Schlensak (Tübingen) A. Diegeler (Bad Neustadt an der Saale)

Main Session I Congenital heart disease (Joint Session DGPK)10:30–12:00 EN I PlenumChair: B. Stiller (Freiburg) B. Asfour (Sankt Augustin)

Main Session I The increasing role of women in cardiac surgery08:30–10:00 DE | Plenum Chair: H. Niehaus (Kiel) S. Eifert (Leipzig)

Abstract Session I Heart and lung failure III08:30–10:00 EN | Tagungsraum 1Chair: C. Schmid (Regensburg) M. Zimpfer (Wien)

Abstract Session I Arrhythmias08:30–10:00 DE | Tagungsraum 2Chair: T. Hanke (Lübeck) W. Jung (Villingen-Schwenningen)

Abstract Session I Transcatheter valves III: Focus on mitral valve08:30–10:00 DE | Tagungsraum 3Chair: H. Reichenspurner (Hamburg) A. Welz (Bonn)

Dienstag, 11. Februar 2014 / Tuesday, February 11th, 2014

Abstract Session I Congenital heart disease II08:30–10:00 DE | Tagungsraum 4Chair: J. Hörer (München) M. Hübler (Zürich)

Short Communications I Extracorporeal circulation and myocardial protection08:00–10:00 DE | Poster Vortrag Chair: A. Liebold (Ulm) J. Schmitto (Hannover)

Advanced Surgical Techniques I Echocardiogra-phy Heart valves: Native situation Course 108:00–10:00 Meetingraum 1

Symposium OR-Nurses I Symposium Medical and Healthcare Staff 09:00–10:00 DE | Tagungsraum 5Chair: I. Conradt P. Selbach-Fobbe

07:30–07:50 The Berlin experience – successfully running a VAD program in clinical practice

T. Krabatsch (Berlin)

07:50–08:10 ECMO, intermediate or chronic VAD therapy – which strategy?

J. Schmitto (Hannover)

08:10–08:30 Live-in-a-Box video presentation: minimally invasive VAD implantation

D. Zimpfer (Wien)

09:00–09:45 Älter werden im OP – eine Aufgabe des Managements

I. Welk (Kiel)

09:45–10:00 Erfahrungsbericht einer OP-Schwester / Best Agers

C. Buchholz (Stuttgart)

Congress ProgramS10



Main Session I Transplantation (Joint Session DTG) 10:30–12:00 DE | Tagungsraum 1Chair: B. Nashan (Hamburg) A. Haverich (Hannover)

Abstract Session I Aortic valve disease: surgical results10:30–12:00 DE | Tagungsraum 2Chair: A. Moritz (Frankfurt) C. Knosalla (Berlin)

Abstract Session I Basic science II: Cardiac cell10:30–12:00 DE | Tagungsraum 3Chair: M. Dahm (Kaiserslautern) L. Hein (Freiburg)

Abstract Session I Thoracic and Thoraco-abdominal Aorta10:30–12:00 DE | Tagungsraum 4Chair: N. Khaladj (München) M. Czerny (Zürich)


Short Communication I Basic science III: Miscellaneous10:30–12:00 DE | Poster Vortrag I Chair: S. Martens (Münster) A. Deußen (Dresden)

Advanced Surgical Techniques I Echocardiography Heart valves: Native situation Course 210:30–12:00 Meetingraum

General I Pressekonferenz11:00–12:30 DE | Tagungsraum 7Chair: A. Beckmann (Berlin) F. Beyersdorf (Freiburg) J. Cremer (Kiel) F.-W. Mohr (Leipzig) A. Welz (Bonn)

Symposium I Lunch-Symposium Evolution of TAVI supported by JenaValve Technology GmbH13:30–14:30 EN | PlenumChair: U. Schäfer (Hamburg) R. Bader (Hamburg)

13:30 – 13:45 New horizons in TAVI: Aortic insuffi -ciency and valve in valve

A. Rastan (Rotenburg a.d. Fulda)

13:45 – 14:00 Aortic annulus eccentricity and TAVI S. Ensminger (Bad Oeynhausen)

14:00 – 14:15 The TA JenaValve TAVI System: A single center experience

O. Reuthebuch (Basel)

14:15 – 14:30 Anatomical alignment goes transfemo-ral: First experience with the TF JenaV-alve TAVI system

H. Treede (Hamburg)

13:30 – 13:45 Reimbursement changes in the G-DRG 2014 catalogue and their impact on the sutureless market

W. Schiller (Bonn)

10:30–11:15 Hygiene im OP – Umsetzung der jetzigen Richtlinie

G.-C. Zinn (Ingelheim)

11:15–12:00 Patientenrechtegesetz – Auswirkungen auf die Pfl ege

A. Wienke (Köln)

Symposium I Lunch-Symposium Will sutureless valves become the new gold standard? supported by Sorin Group Deutschland GmbH 13:30–14:30 DE | Tagungsraum 1Chair: T. Fischlein (Nürnberg) M. Laß (Eimsbüttel) T. Hanke (Lübeck)

Congress Program S11


Symposium I Lunch-Symposium Embolic event or bleeding? Risk and Benefi t of antithrombotic therapies in cardiology supported by Bayer Vital GmbH13:30–14:30 EN | Tagungsraum 2Chair: F. Beyersdorf (Freiburg) D. Trenk (Bad Krozingen)

13:45 – 14:00 Cost savings after sutureless replace-ment in aortic valve stenosis: Results from a propensity-matched score analysis

G. Santarpino (Nürnberg)

14:00 – 14:15 The Leipzig experience with Perceval S M.A. Borger (Leipzig)

14:15 – 14:30 Perceval S six years after: Where are we now?

M. Shrestha (Hannover)


13:30 – 13:50 Perioperative and periinterventional anticoagulation and platelet inhibition

N.N.

13:50 – 14:10 New oral anticoagulants in DVT, PE and AF, real world data for Rivaroxaban versus VKA

N.N.

14:10 – 14:30 Rivaroxaban for secondary prophylaxis of ACS, insights and consequences from ATLAS TIMI 51

N.N.

14:00 – 14:10 New technology of surgical manage-ment of left atrial appendage- fi rst experience and standards

Y.-H. Choi (Köln)

13:30 – 13:40 Establishment of endoscopic vessel har-vesting

A. Böning (Giessen)

13:40 – 13:50 Does off -pump still play any future role – if so for which patients?

A. Diegeler (Bad Neustadt an der Saale)

13:50 – 14:00 Atrial Arrhythmia and Post-Procedural Stroke: Mechanisms and Treatment Ap-proaches

M. Emmert (Zürich)

Symposium I Lunch-Symposium Update- established and evidenced concepts in cardiac surgery supported by Maquet13:30–14:30 EN | Tagungsraum 3Chair: A. Diegeler (Bad Neustadt an der Saale)

Symposium I Lunch-Symposium ACURATE TAVI System: Design translated into Performance supported by Symetis SA13:30–14:30 DE I Tagungsraum 4Chair: R. Lange (München) E. Grube (Bonn)

13:30 – 13:36 Design translated into performance ACURATE TA™ sustained results post-approval

T. Walther (Bad Nauheim)

13:36 – 13:42 Design translated into performance Acute outcomes from the ACURATE TF™CE trial

H. Möllmann (Bad Nauheim)

13:42 – 13:48 Design translated into performance TA versus TF: so far the winner is?

13:48 – 13:54 Most challenging cases ACURATE TA™ D. Holzhey (Leipzig)

13:54 – 14:04 Most challenging cases ACURATE TF™ P. Diemert (Hamburg)

14:04 – 14:10 New Indications ACURATE TA™ for valve-in-valve

M. Hilker (Regensburg)

14:10 – 14:16 New Indications ACURATE TA™ H. Treede (Hamburg)

14:16 – 14:22 New Indications ACURATE TA™ for aortic insuffi ciency

M. Thielmann (Essen)

14:22 – 14:28 Next Gen TAVI The best on the horizon: ACURATE TA™ LP & active seal

J. Kempfert (Bad Nauheim)

Congress ProgramS12


Main Session I Evolution of surgical training program (Joint session DGCH)14:30–16:00 EN | Tagungsraum 1Chair: J. Jähne (Hannover) E. Verrier (Seattle)

Abstract Session I Coronary heart disease II14:30–16:00 DE | Tagungsraum 2Chair: A. Böning (Giessen) J. Börgermann (Bad Oeynhausen)

Abstract Session I Basic science III: ECC, vascular, endothelium, infl ammation, rejection14:30–16:00 DE | Tagungsraum 3Chair: A. Kocher (Wien) P. Kohl (Oxford)

Short Communications I Arrhythmias14:30–16:00 DE | Poster Vortrag Chair: F. Wagner (Hamburg) W. Jung (Villingen-Schwenningen)

Short Communications I Heart and lung failure II 14:30–16:00 DE | Tagungsraum 7Chair: T. Noack (Leipzig) J. Cremer (Kiel)

Main Session I Heart team live – Valves (Joint Session DGK)14:30–16:00 DE | Plenum Chair: V. Falk (Zürich) C.W. Hamm (Bad Nauheim)


Advanced Surgical Techniques I Echocardiogra-phy Valve prosthesis Course 114:30–16:00 Meetingraum 1

Short Communications I Mitral and tricuspid valve disease 14:30–16:00 DE | Tagungsraum 4Chair: K. Matschke (Dresden) J. Kempfert (Bad Nauheim)

13:30 – 13:50 Optimal VAD management in pediatric patients

O. Miera (Berlin)

13:50 – 14:10 Facilitating patient mobility and hospi-tal discharge

E. Sandica (Bad Oeynhausen)

14:10 – 14:30 EXCOR Pediatric in congenital and other challenging patients

M. Griselli (Newcatsle)

Symposium I Lunch-Symposium Mitral Valve intervention – additional option rather than competition to surgery supported by Abbott Vascular Deutschland GmbH13:30–14:30 EN | Tagungsraum 5Chair: C.W. Hamm (Bad Nauheim) H. Reichenspurner (Hamburg)

13:30 – 13:45 Evolution of surgical mitral valve repair – from the Alfi eri suture to the Mitra-Clip

O. Alfi eri (Mailand)

13:45 – 14:00 Is MitraClip a treatment option for degenerative Mitral Valve insuffi ciency?

W. Schillinger (Göttingen)

14:00 – 14:15 The Role and Timing of MitraClip in the complex treatment of Heart Failure and functional Mitral Regurgitation (MR)

J. Hausleiter (München)

14:15 – 14:30 Positive impact of a MitraClip-program on surgical volume and surgery after MC

L. Conradi (Hamburg)

Symposium I Lunch-Symposium Pediatric VAD therapy: what̓s NEXT? supported by Berlin Heart GmbH13:30–14:30 EN | Tagungsraum 7Chair: E. Sandica (Bad Oeynhausen)

Congress Program S13



15:00 – 15:45 Thorafl ex Hybrid für OP-Personal M. Shrestha (Hannover)

Main Session I Thoraco-abdominal aortic aneurysm (Joint Session DGG)16:30–18:00 DE | Plenum Chair: E. Debus (Hamburg) M.A. Borger (Leipzig)

Award Session I Award Session 2013/201416:30–18:00 DE | Tagungsraum 1Chair: F. Beyersdorf (Freiburg) A. Diegeler (Bad Neustadt an der Saale)

15:00 – 15:45 Was ist heute alles möglich im Hybridsaal? Blick aus der Erfahrung / Blick in die Zukunft

L. Conradi (Hamburg)

Abstract Session I Heart valve disease IV: New aortic valves and sutureless devices16:30–18:00 DE | Tagungsraum 2Chair: M. Grimm (Innsbruck) J.T. Strauch (Bochum)

Short Communication I Basic science II: Cardiac cell and gene therapy10:00–13:00 DE | Tagungsraum 4Chair: L. Hein (Freiburg) S. Dhein (Leipzig)


Main Session I The elderly patient in cardiac surgery – the unknown creature? (Joint Session DGGG)16:30–18:00 DE | Tagungsraum 5Chair: R. Feyrer (Erlangen) W. Jung (Villingen-Schwenningen)

Short Communication I Transcatheter valves III: TAVI / new developments16:30–18:00 DE | Poster VortragChair: A. Welz (Bonn) H. Schröfel (Karlsruhe)

Advanced Surgical Techniques I Echocardiogra-phy Valve prosthesis Course 2 16:30–18:00 Meetingraum 1

Main Session I Thoracic surgery (Joint Session DGT)16:30–18:00 DE | Tagungsraum 3Chair: K. Hekmat (Köln) C. Kugler (Großhansdorf)

Congress ProgramS14


Mittwoch, 12. Februar 2014 / Wednesday, February 12th, 2014

Abstract Session I Heart and lung failure IV10:15–11:45 DE | Tagungsraum 2Chair: C. Hagl (München) G. Trummer (Freiburg)

Abstract Session I Extracorporeal circulation and myocardial protection II10:15–11:45 DE | Tagungsraum 3Chair: C. Klopsch (Rostock) A. Bauer (Coswig)

Abstract Session I Basic Science IV: ECC vascular10:15–11:45 DE | Tagungsraum 4Chair: T. Doenst (Jena) W. Röll (Bonn)

General I Highlight Session12:00–13:30 DE | Plenum Chair: F. Beyersdorf (Freiburg) W. Harringer (Braunschweig)

Working Groups & Committees I Committee for Career Advancement, Medical Training and Continuous Medical Education08:30–10:00 Tagungsraum 4Chair: W. Harringer (Braunschweig)

Working Groups & Committees I Working Group for Congenital and Pediatric Heart Surgery08:30–10:00 Tagungsraum 5Chair: R. Cesnjevar (Erlangen)

Working Groups & Committees I Working Group for Electrophysiological Surgery08:30–10:00 Tagungsraum 7Chair: K.-N. Doll (Stuttgart)

Working Groups & Committees I Working Group for Aortic Surgery and Interventional Vascular Surgery08:30–10:00 Tagungsraum 8Chair: M. Karck (Heidelberg)

Main Session I Quality assurance and registries in cardiac surgery10:15–11:45 DE | PlenumChair: A. Welz (Bonn) S. Dittrich (Erlangen) S. Blankenberg (Hamburg)

Abstract Session I Heart valve disease V: Aortic valve repair – Durability after aortic valve replacement10:15–11:45 DE | Tagungsraum 1Chair: M. Misfeld (Leipzig) W. Hemmer (Stuttgart)

Working Groups & Committees I Working Group Coronary Heart Disease08:30–10:00 Tagungsraum 3Chair: A. Böning (Giessen)

Working Groups & Committees I Working Group for Wound Management08:30 - 10:00 Tagungsraum 2

Oral Presentation

Coronary Heart Disease I

OP1Atrial fibrillation in patients undergoing on-pump or off-pump coronary surgery - lessonslearned from GOPCABEBöning A.1, Diegeler A.2, Hilker M.3, Börgermann J.4,Zacher M.2, Reents W.21Justus Liebig-Universität Giessen, Klinik für Herz-,Kinderherz- und Gefäßchirurgie, Giessen, Germany2Herz-und Gefäßklinik, Bad Neustadt, Germany,3Universitätsklinikum Regensburg, Herz-, Thorax undherznahe Gefäßchirurgie, Regensburg, Germany4Herz- und Diabeteszentrum, Klinik für Thorax- undKardiovaskularchirurgie, Bad Oeynhausen, Germany

Objective: We sought to find out whether in patients with AF beforesurgery, off-pump coronary artery bypass surgery (CABG) is able todecrease the perioperative risk compared to on-pump surgery andwhether off-pump myocardial revascularization prevents from postop-erative atrial fibrillation (AF). Patients and methods: From 2394 pa-tients out of the German Off Pump Coronary Artery Bypass Grafting inElderly Patients (GOPCABE) study, 120 patients in the on-pump group(9.9% ) and 112 patients (9.4%) in the off-pump group were in AFpreoperatively and were included into the analysis. Results: From the1207 patients in the on-pump group, 123 patients (10.2%) had AF at thetime of discharge, from the 1187 patients in the off-pump group, 121patients (10.2%) had AF at the time of discharge. Off-pump or on-pumpsurgery in patients with AF yields clinically worse results than inpatients with SR: the combined endpoint (Death, infarction, stroke,dialysis, revascularisation) occurred more frequently (p¼0.008) in AFPatients (10% after on-pump surgery, 16.1% after off-pump surgery)than in SR patients (8.1% after on-pump surgery, 6.9% after off-pumpsurgery). 30-day mortality was significantly (p¼ 0.003) higher in AFPatients (4.2% after on-pump surgery, 8.0% after off-pump surgery) thanin SR patients (2.7% after on-pump surgery, 2.1% after off-pumpsurgery). Conclusions: The rate of patients in AF after surgery is notdifferent between on-and off pump surgery. Because AF patients carry ahigher preoperative risk they showa higher mortality after surgery. Off-pump surgery does not decrease the perioperative risk of AF patientscompared to on-pump surgery.

OP2No risk of female sex in a randomizedpopulation of patients undergoing coronarybypass surgeryFärber G.1, Zacher M.2, Doenst T.1, Sandhaus T.1, Diab M.1,Reents W.2, Breuer M.1, Börgermann J.3, Kappert U.4, Böning A.5, Diegeler A.2for the GOPCABE-Investigators1Jena University Hospital - Friedrich-Schiller-University ofJena, Department of Cardiothoracic Surgery, Jena,Germany, 2Cardiovascular Clinic Bad Neustadt, Clinic forCardiac Surgery, BadNeustadt / Saale, Germany, 3Heart andDiabetes Centre NRW, Ruhr University Bochum, Clinic forHeart, Thoracic and Cardiovascular Surgery, BadOeynhausen, Germany, 4Cardiovascular Institute,University of Dresden, Department of Cardiac Surgery,Dresden, Germany, 5University of Giessen, Department ofCardiovascular Surgery, Giessen, Germany

Objective: Female sex is a commonly accepted risk factor in coronaryartery bypass surgery that finds application in popular risk scores. TheEuroscore uses an odds ratio for women vs. men of 1.3915 and theGerman Coronary Surgery Score (KCH) uses an odds ratio of up to 4.44(increasing with age). The German Off-Pump Coronary Artery Bypassgrafting in the Elderly (GOPCABE)-Trial reported no benefit for off-pumpvs. on-pump surgery in patients above 75 years of age (n¼2394). Aboutone third of them (n¼ 755) were female. Methods: In this sub-analysisof the GOPCABE-Trial we tested the hypothesis that women wouldbenefit from off-pump surgery compared to men and analyzed whether

the anticipated increased risk of female sex was also present in thispatient population. Results: Sex specific comparisons of on- and off-pump surgery using logistic regression analyses did not reveal signifi-cant effects of either operative technique on mortality. In men, the oddsratio (OR) for on-pump (n¼818) versus off-pump (n¼821) was 0.90(95%-CI: [0.63;1.27]). In women, the OR for on-pump (n¼389) versusoff-pump (n¼366) was 1.07 (95%-CI: [0.62;1.87]). For the lack of sex-specific differences between on- and off-pump, groups were combinedfor further analyses. For the entire GOPCABE population, women hadsignificantly higher Euroscores (8.88 � 6.71 versus 7.99 � 6.69;p¼0.003) and KCH-scores (4.42 � 3.97 versus 3.57 � 3.65; p¼0.001).There were no relevant differences in perioperative variables (e.g.,number of distal anastomoses). Contrary to expectations, there was atrend towards a lower risk associated with female sex when assessingperioperative death (OR 0.69; 95%-CI: [0.39;1.22]) or a combinedendpoint of death, myocardial infarction, stroke, re-revascularisationor renal replacement therapy (OR 0.80; 95%-CI: [0.57;1.12]).Conclusions: The results from this patient population suggest that, incontrast to common belief, female sex does not appear to be a risk factorin coronary bypass surgery. However, this unexpected result is notrelated to the surgical technique of revascularisation.

OP3Complete arterial coronary revascularizationusing skeletonized bilateral mammary arteriesin T-graft technique performed in on-pump oroff-pump approach: Clinical results up to 13years in 3513 patients consecutiveHeller S.1, Amin W.1, Hansen L.1, Winkel S.1, Stripling J.1,Awwad N.1, Lehmann C.1, Cramer E.1, Rieß F.-C.11Albertinen Heart Center, Hamburg, Germany

Objectives: The clinical long-term follow-up of patients undergoingcomplete arterial coronary revascularization was investigated.Methods: Between 2/2000 and 2/2012 a total of 3513 patients under-went bilateral skeletonized IMA bypass-operation in T-graft technique.Perioperative data were collected prospectively and postoperativefollow-up was performed by a questionnaire or/and telephone inter-view between 7/2012 and 7/2013. Patients were operated by a group ofsix surgeons using the same protocol. Of those 3513 patients, 2287(65.1%) had an on-pump approach: mean age 66.7 � 9.5 (range 30 to 92years), male n¼1884 (82.4%). 1226 patients (34.9%) were operated inoff-pump technique: mean age 68.2 � 9.6 (range 34 to 91 years), malen¼973 (79.4%). Results: Follow-up was achieved in 1374/2287 on-pump patients (60.1%) and 898/1226 off-pump patients (73.2%). Inamongst them, follow-up was complete in 1223/1374 (89.0%) vs. 831/898 (92.5%) due to absence, listlessness or mortality. Early results were:stroke 0.5% (n¼11) vs. 0.4% (n¼5); myocardial infarction 0.4% (n¼9)vs. 0.2% (n¼3); rethoracotomy for bleeding 1.7% (n¼40) vs. 0.9%(n¼11); atrial fibrillation 35.1% (n¼802) vs. 30.8% (n¼378); postop-erative delirium 9.1% (n¼209) vs. 8.6% (n¼106). Late results were:mortality 7.4% (n¼101) vs. 4.7% (n¼42); stroke 5.6% (n¼69) vs. 4.3%(n¼36); myocardial infarction 1.3% (n¼16) vs. 1.3% (n¼11). Re-operation in grafted area 0.04% (n¼1) vs. 0.0% (n¼0). A coronaryangiogram was performed in 21.5% (n¼263) vs. 15.5% (n¼129) andshowed excellent patency rates. 98.0% (n¼1198) vs. 96.3% (n¼801)were satisfied with operative results. Patients claimed to be in NYHAclass I 70.4% (n¼861) vs. 71.7% (n¼596), II 12.5% (n¼153) vs. 12.6%(n¼105), III 10.1% (n¼124) vs. 8.4% (n¼70), IV 1.2% (n¼15) vs. 2.5%(n¼21). Conclusion: Complete arterial revascularization using IMAconduits in T-graft technique is a safe and effective approach in on-and off-pump operations, resulting in excellent long-term results,especially superior patency rates.

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Thorac Cardiovasc Surg 2014; 62, Suppl. 1: S15–S140

OP4Quantification of circulating endothelial cellsand perioperative outcome in less invasivecoronary surgery: Are Off-pump proceduressuperior than minimized extracorporealcirculation?Wittwer T.1, Choi Y.-H.1, Rahmanian P.1, Neef K.1,Sabashnikov A.1, Wahlers T.11Uniklinik Köln, Herz- und Thoraxchirurgie, Köln, Germany

Objective:Off-pump-coronary-artery-bypass-grafting (OPCAB) and useof minimal-extracorporeal-circulation-systems (MiniHLM) have beenproposed to avoid potentially harmful effects of full cardiopulmonarybypass (CPB). Circulating endothelial cells (CEC) are sensitive markers oftissue and endothelial damage and were shown to be significantlyelevated in conventional-CPB-procedures as compared to MiniHLM-revascularisation. Therefore, CEC are considered to be of specific interestin evaluation of effectiveness of MiniHLM and OPCAB as currentlyapplied less-invasive-coronary-procedures. Methods: 120 consecutivecoronary patients were randomly assigned either to OPCAB (n¼44) orto MiniHLM (n¼76) procedures. Perioperative data, clinical and sero-logical outcome and serial measurements of CEC-release and param-eters of endothelial function (v.Willebrand-Factor, soluble-thrombomodulin) perioperatively (pre-operative-baseline, post-Min-iHLM/release of OPCAB-stabilisator, 6 h, 12 h, 24 h and 120 h postoper-atively) were obtained and compared by ANOVA models includingrepeated-measures-analysis. Results: Generally, ventilation-, ICU- andtotal-hospital times were comparable between groups as were chest-tube-drainage, transfusion requirements, hemodynamics and catechol-aminergic support (p>0.05). CEC-release was overall comparable be-tween groups and did not show any significant increase over time,accordingly Troponin-levels where generally not significantly different(p¼0.108). Anatomically complete revascularisationwas achieved in allcases, however,mean graft-number was 3,12� 0,7 inMiniHLM-patientsand 1,85� 0,7 in OPCAB-patients (p¼0.001). Nomyocardial infarctions,strokes or deaths occurred, Neuron-specific-Enolasewas not significant-ly different between groups (p¼0.46). Conclusion: Conceptional ad-vantages of closed-minimised-CPB-systems (ROCsafe™) result inmorbidity and mortality comparable with OPCAB procedures. MiniHLMtherefore minimizes CPB-related systemic and organ injury as demon-strated by low CEC-values which indicates intact endothelial integrity.Furthermore, MiniHLM achieves all clinical OPCAB-benefits but mayallow for less demanding revascularisation than OPCAB in specialpatients with complex coronary anatomy and can therefore be usedboth on a routine basis and in all “conversion“ cases of OPCAB.

OP5Pressure controlled vein graft flushing resultsin superior histological quality - a randomizedtrialArsalan M.1, Kempfert J.1, Bader S.1, Arsalan-Werner A.F.1,Blumenstein J.M.1, Troidl C.1, Möllmann H.1, Walther T.11Kerckhoff Klinik, Bad Nauheim, Germany

Objectives: The saphenous vein is still one of the most commonly usedgrafts for coronary artery bypass grafting. Nevertheless several studiesshow an inferior long term patency compared to arterial grafts. Thiscould be due to the histologic structure of the vein as it is not intendedfor a high pressure system. Another issue might be due to the intra-operative handling of the graft. It could be shown that by flushing thegraft during harvesting and preparation accidential peak pressures over600 mmHg occur inside the vessel. This might lead to endothelialdamage of the graft and thus reduce quality and subsequently patency.Thus, controlling the flushing pressure could prevent endothelial dam-age. Therefore we investigated whether the usage of a pressure limitedsyringe influences graft quality and endothelial function.Methods: In arandomized trial 50 patients underwent vein harvesting during CABGusing a conventional or a pressure limited syringe (Vasoshield, MaquetCardiovascular LCC, Wayne, USA; limited to 250 mmHg). Vein remnantswere examined for endothelial damage and function using CD31immunostaining and eNOSWestern blot analysis. Results: CD31 immu-nostaining revealed that endothelial cell integrity in the pressure limitedsyringe group was 73.2 � 14.5% of the circumference of luminal

endothelium, compared to the conventional syringe group 46.2 �21.4% (p<0.05). ENOS Western blot analyses demonstrated a signifi-cantly greater nitric oxidase production in the pressure limited syringeGroup (eNOS immunfluorescence: Fig. 1).

Fig. 1

Conclusion: Our randomized study demonstrates that usage of apressure limited syringe is capable of reducing histological damagesand preserving endothelial function of the saphenous vein graft. Apartfrom the limited additional costs there seem to be no downsides in usingthis approach and it might lead to a better vein graft patency.

OP6Arrested heart TECAB versus MIDCAB forrevascularization of anterior wall. Acomparative analysis of perioperative andmidterm resultsBonaros N.1, Kofler M.1, Rammer M.1, Feuchtner G.1,Friedrich G.1, Grimm M.1, Bonatti J.2, Schachner T.11Medizinische Universität Innsbruck, Herzchirurgie,Innsbruck, Austria, 2Cleveland Clinic Abu Dhabi, Abu Dhabi,United Arab Emirates

Objective: The ideal method to place an internalmammary artery (IMA)graft to the anterior wall of the left ventricle is still unclear. Robotictechnology allows totally endoscopic IMA harvesting and either roboti-cally assisted placement of the anastomosis in a totally endoscopicfashion (TECAB) or hand sewn viamini-thoracotomy (MIDCAB). The aimof the study was to compare both techniques in terms of perioperativeand midterm results. Methods: Robotically assisted arrested heartTECAB was carried out in 195 patients with a median age of 59 (31-77) years and median EuroScore I of 1.5 (0-7). Robotic MIDCAB wasperformed in 43 patients with a median age of 64 (45-82) years and


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median EuroScore I of 2 (0-11). Both techniques were used for single orsequential IMA grafts to the anterior wall. Operative times, conversionrates and surgical complications as well as long-term results werecompared between the groups by Mann-Whitney test for continuousvariables and chi square or Fisher's exact test for categorical variables.Kaplan-Meier plots and log-rank test were used to compare midtermresults. Results: No perioperative deaths were noted. Surgical difficul-ties resulting in longer operative times or alteration of the operativestrategy occurred in 60 (30%) of the TECAB and 6 (14%) of the MIDCABgroup (p¼0.06). Angiographically verified anastomotic stenosis wasdetected in 6 (3%) and 3 (7%) respectively (p¼0.190). Conversions tolarger thoracic incisions were needed in 17 (9%) and 3 (7%) respectively(p¼0.887). Total operative times were longer in the TECAB vs theMIDCAB group (291 (175-690) min vs. 201 (98-510) min),(p¼0.000001). ICU and total length of stay were similar between thegroups. Maximum CK levels of 573 (59-11,462) mg/dl vs 301 (193-782)mg/dl (p¼0.957) andmaximumCK-MB levels of 21 (7-162)mg/dl vs. 17(9-26) mg/dl (p¼0.091) did not differ for the two groups. There was nodifference in survival (0 vs 2%, p¼ns), freedom from angina (5 vs. 2%,p¼0.380) and freedom from MACCE (10 vs 5%, p¼0.270) at a medianfollow up of 24 (0-100) months. Conclusions: Robotically assistedarrested heart TECAB and robotic MIDCAB perform equally in termsof perioperative results and mid-term follow up in this single centerpatient cohort.

OP7Short-term intervention to reduce anxietybefore artery coronary bypass surgery - Arandomised controlled studyHeilmann C.1, Fritzsche K.2, Beyersdorf F.1, Leonhart R.3,Imbery C.4, Starke S.1, Bigot G.1, Feuchtinger J.5, Siepe M.11Universitäts-Herzzentrum Freiburg - Bad Krozingen,Klinik für Herz- und Gefäßchirurgie, Freiburg, Germany,2Universitätsklinikum Freiburg, Abt. für PsychosomatischeMedizin und Psychotherapie, Freiburg, Germany3Albert-Ludwigs-Universität Freiburg, Institut fürPsychologie, Freiburg, Germany, 4Universitäts-Herzzentrum Freiburg - Bad Krozingen, Bad Krozingen,Germany, 5Universitätsklinikum Freiburg, StabsstelleQualität und Entwicklung in der Pflege, Freiburg, Germany

Objectives: Anxiety is experienced by most patients who face CABG.Patients with high preoperative anxiety suffer more often postoperativeadverse events. According to a recent survey, 62% of cardiosurgicalpatients would appreciate preoperative psychosocial support. There-fore, we tested an anxiety-reducing intervention that is applicable toCABG patients even in the evening before surgery. Methods: Weincluded 253 adult patients (208 male, 45 female) who were admittedfor planned CABG. Following the preoperative information by surgeonand anaesthetist and after giving informed consent, patients wererandomized to intervention (n¼139) or control (n¼114). They com-pleted the STOA questionnaire (State-Trait Operation Anxiety) and avisual analog scale for current anxiety (T0). State anxiety (STOA-S, 10items) describes cognitive and affective components of situationalanxiety, trait anxiety depends on the personality. The interventionconsisted of a 30 minute dialog with a trained nurse containinginformation on surgery and postoperative care and emotional supportwith respect to the specific anxieties of the patient. Control patientsreceived usual information only. The primary endpoint was stateanxiety (STOA-S, anxiety scale) after the intervention at the eveningbefore surgery (T1). Secondary end points were time on intensive careunit (ICU), in-hospital mortality and postoperative need for analgeticsand antiphlogistics on day 5 postop (T2). Results: There were nodifferences between intervention and control group with regard toanxiety or clinical and demographic data at T0. The interventionresulted in significantly different changes between the groups at T1.Values for cognitive anxiety fell from 10.4 at T0 to 9.1 at T1 in theintervention group and from 11.1 to 10.5 in the control group (p¼0.008between groups for difference T0-T1). Affective anxiety changed from10.0 at T0 to 8.4 after intervention and from 10.0 to 10.1 in controlpatients (p¼0.004). Anxiety scale values sank from 3.5 to 2.8 in theintervention group and from 3.7 to 3.4 in the control group (p¼0.004

between groups T0-T1). A strong influence of trait anxiety was found.The groups did not differ in time on ICU, in-hospital mortality andpostoperative need for medication at T2. Conclusion: Medical informa-tion and professional emotional support, both focussing on the patients'specific concerns, can help to reduce preoperative situational fear evenat the evening before CABG.

Thoracic Surgery

OP8Persisting pleural effusion-intrauterineintervention and post partum surgicalresection of a lung sequestrationRedwan B.1, Schmidt J.1, Mohr M.2, Müller K.M.3, SchmitzR.4, Sandkötter J.5, Werner C.5, Wiebe K.11Uniklinik Münster, Department für Herz- undThoraxchirurgie, Münster, Germany, 2Uniklinik Münster,Medizinische Klinik A - Pneumologie, Münster, Germany,3Uniklinik Münster, Gerhad-Domagk-Institut fürPathologie, Münster, Germany, 4Uniklinik Münster,Frauenheilkunde und Geburtshilfe, Münster, Germany,5Uniklinik Münster, Kinder- und Jugendmedizin -Pädiatrische Kardiologie, Münster, Germany

Introduction: Complications by lung sequestrationmay includemassivepleural effusions that can become evident already during pregnancy andrequire immediate therapy. Case presentation: We report the case of apregnant 34-year-old female, who was admitted in her 30th week ofpregnancy for severe left-sided hydrothorax of the fetus. A lung seques-trationwas suspected by ultrasound. An intrauterine double pigtail wasimplanted as a pleuro-amniotic shunt. The further course of thepregnancy was uneventful. The fetus was born spontaneously in the38thweek. Ultrasound and computed chest tomography of the newbornconfirmed the presence of a sequestration of the left lower lobe. Massiveleft-sided effusion caused complete atelectasis of the left lung und amarked rightward mediastinal shift. The double pigtail (pleuro-amni-otic shunt) was dislocated into the left hemi-thorax and had to beremoved surgically. A newpigtail catheter was inserted. However, underconservative therapy recurrent and progressive pleural effusions withrespiratory insufficiency were evident. Therefore, surgical resection ofthe lung sequestration was required on the 20th day postpartum.Intraoperatively, a single large artery directly from the distal thoracicaorta provided vascular supply for the large and lobulated sequester,which was adjacent to a normal left lower lobe. Histopathologicevaluation of the resected sequestration revealed loss of draininglymphatic vessels, which explains the massive pleural effusions. Fol-lowing an uneventful postoperative course the neonate was dischargedon postoperative day 10 with a regular x-ray. Conclusions: This casedemonstrates that severe, pleural effusion may present as a conse-quence from sequestration of the lung. Early intervention, interdisci-plinarymanagement and surgical resection allowed for a safe correctionof this rare but potentially life-threatening malformation.

OP9Prognostic significance of influence of CD-31and PDEFexpression in patientswith non-small-lung cancerEmmert A.1, Didilis V.N.1, Böhler A.1, Markus J.1, Füzesi L.2,Waldmann-Beushausen R.1, Bougioukas I.1, Schöndube F.A.1, Danner B.C.11Universitätsmedizin Göttingen, Dept. of Cardiothoracicand Vascular Surgery, Göttingen, Germany,2Universitätsmedizin Göttingen, Dept. of Pathology,Göttingen, Germany

Objectives: The aims of this study were to examine prognostic signifi-cance of microvessel density (MVD) by CD31 staining and the role ofpigment epithelium-derived factor (PEDF) in patients with stage IA-IIIBnon-small lung cancer (NSCLC) and explore associations between MVDby CD31 expression and PEDF. Methods: We used immunohistochem-istry to examine the expression of PEDF and to evaluateMVD by CD31 in


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a cohort of 69 patients who had undergone radical resection for NSCLC.Detection of the stroma around the vital tumor tissue and cancer cellswas given by the haematoxylin-eosin-stained sections and only theseregions were the target area. Results: Strong positive correlationcoefficient for all measurements of the two independent investigatorswas highly significant (p<0.001). No correlation of the CD31 immu-noexpression and PEDF intensity, PEDF area or PEDF area index wasseen. CD31 immunoexpression and PEDF staining have no correlation tothe clinicopathologic parameters mentioned above. In survival analysisthere was a significant better overall survival the higher the CD31 countare. In 29 patients (42%) the median of CD31 count was higher than themedian level and the overall survival was significant better (52 � 8 and78 � 10 months, log rank p¼0.031). In 58 patients (84%) of cases causeof death were known as primary cancer related. In these patient cohortCD31 count above median was equally present in 44.2% (26 patients)and survivalwas significant longer in high CD31 count (56� 10 and 83�10 months, log rank p¼ 0.036). After Cox-Regression analysis CD31count higher than the median level was an independent factor forsurvival. Nevertheless, there was a significant difference of PEDF inten-sity values between stage IB, IIA, IIB and IIIA. Additionally, we seen asignificant negative correlation (T¼ -0.288, p¼0.002) between patho-logic T-stage andmedian PEDF area and vice versa a positive correlation(T¼0.227, p¼0.016) to median PEDF intensity. Conclusions: We haveindependently validated CD31 and PEDF as prognostic biomarkers inNSCLC, and we demonstrate, to best of our knowledge for the first time,thatMVDmeasured by CD31 correlates positivelywith better survival inpatients with NSCLC. The expression of PEDF could be related toangiogenesis, but is presently not suitable for use in risk stratificationof NSCLC. Further studies are needed to verify the role of MVD inanticancer therapy of NSCLC.

OP10Lobe-specific mediastinal nodal dissection issufficient during lobectomy by VATS orthoracotomy for early stage lung cancerMaietta P.1, Biondo F.11Thoracic Surgery, Aorn Moscati, Avellino, Italy

Objectives: Lobectomywith completemediastinal lymphadenectomy isconsidered standard for patients with early stage non-small cell lungcancer (NSCLC). However, the benefits of complete lymphadenectomyare unproven. There is evidence suggesting predictable pattern ofmediastinal nodal drainage. This study analyzed the frequency andpattern of mediastinal nodal disease and its impact on outcome inpatients with early stage NSCLC. Methods: Patients with clinical N0/N1NSCLC staged with computed tomographic (CT) and positron emissiontomography (PET) were identified. Disease involvement of resectednodal stations was recorded. Patterns of recurrence of patients whounderwent lobectomy with complete mediastinal systematic lymphnode sampling (SLNS) were compared to those who underwent lobe-specific mediastinal SLNS. Results: From July 2004 to April 2011 370patients were identified. Complete SLNSwas performed in 282 patients.Fifteen patients (5.3%) in the group with complete SLNS were found tohave N2 disease after pathological evaluation. Patients with left sidedtumors were more likely to have pathological N2 disease than patientswith right sided tumors (p¼0.03). Only 1 patient (0.36%) had positiveN2 disease in the distal mediastinum while skipping lobe-specificmediastinal nodes. Also, patients with complete SLNS had similar rateof recurrence compared to the group that had lobe-specific mediastinalevaluation (20.6% vs. 18.2%, p¼ 0.68). Conclusions: Mediastinal N2metastases follow predictable lobe-specific patterns in patients withnegative preoperative CT and PET scans. Lobe-specific N2 nodal evalua-tion results in similar recurrence rate compared to completemediastinalevaluation. Lobe-specific mediastinal nodal evaluation appears accept-able in patients with early stage NSCLC.

OP11Thoracoscopic recovery of intrapulmonaryforeign bodies with intraoperative fluoroscopicassistanceRedwan B.1, Schmidt J.2, Kösek V.2, Bedetti B.2, Oster O.2,Wiebe K.21Universitätsklinikum Münster, Thorax-, Herz- undGefäßchirurgie, Münster, Germany, 2Uniklinik Münster,Department für Herz- und Thoraxchirurgie, Münster,Germany

Introduction: Thoracoscopic removal of nodules or other lesions in thelung parenchymamay be difficult, when these are small and not locatednear the lung surface. If digital palpation is not possible, the preoperativeradiologic placement of a coil or injection of dye at the lung surface mayfacilitate the intraoperative orientation. For radiopaque structuresintraoperative fluoroscopy may provide an alternative method forlocalization and safe removal by wedge resection. CasePresentations: We report the cases of two patients who presentedwith small foreign bodies located deeply in the lung parenchyma at ourinstitution. The first patient was a 71-year-old male with atrial fibrilla-tion. During an interventional electrophysiologic procedure, the trans-septal puncture needle (TSP-needle) broke off and the needle fragmentembolized into the left lung. An interventional attempt to recover theneedle fragment failed. The fragment was dislocated into a sub-segmentof the left lower lobe. The second patient was a 82-year-old male, whoaspirated a dental pin during a dental procedure. The dental pin waslocated in the 9th segment of the right lower lobe. Bronchoscopicrecovery of the pin was not successful. During the thoracoscopicprocedures the foreign bodies in both patients could not be palpateddigitally. By utilizing intraoperative fluoroscopy both the needle frag-ment (about 1 cm long) and the dental pin (about 0.5 cm long) weredetected easily and located by placing between endoscopic forceps.Guided wedge resections were performed. Endoscopic staplers wereplaced under intermittent fluoroscopic control and simulations intra-thoracic visual video-assistance. In both patients the foreign bodieswere removed safelywithout problems. The postoperative courses wereuncomplicated with rapid discharges from hospital in both cases.Conclusions: Utilizing intraoperative fluoroscopy may be a helpfultool to localize radiopaque foreign bodies. It allows for a safe andtargeted thoracoscopic procedure in cases, where a superficial radio-logic labeling is not sufficient. Intraoperative fluoroscopy facilitates thethoracoscopic localization and resection of deeply located foreign bodiesin the lung parenchyma.

OP12Modified chest wall reconstruction aftersternum necrosis in cardiac surgery patientsTewarie L.1, Moza A.K.1, Goetzenich A.1, Zayat R.1,Autschbach R.11Uniklinik RWTH Aachen, Klinik für Thorax-, Herz- undGefäß-Chirurgie, Aachen, Germany

Objective: Complete or partial sternal bone necrosis in poststernotomypatients leads to prolonged hospitalization, distress, reduced quality oflife and if untreated to a high mortality. Our proposed treatment of thiscomplication comprises a chest wall reconstruction with metal platesand wires combined with musculocutaneous flap wound closure.Methods: In the last 3 years, more than 3000 median sternotomieswere performed in our hospital. Only 8 (0.20%) patients (2 male/6female) developed a sternum necrosis following internal thoracic artery(IMA) harvesting. In all cases the operative preparations were similar:After vacuum assisted closure (VAC) therapy and complete necrotictissue debridement, the anterior chest wall was reconstructed withtitanium osteosynthesis plates. Two Kirschner steel wires were used inpara-median position to mobilize bilateral pectoral musculocutaneousflaps and to complete a tension-free edge-to-edge wound closure.Results: The mean patient age was 74 (� 6.3) years. In all patients, aleft IMA was harvested, in 2 patient both IMAs were used; 50% ofpatients presented with type II diabetes, 50% with COPD>GOLD II. Themean BMI was 27.6 (� 3.5). 83.3% suffered from renal insufficiency,66.6% from peripheral arterial occlusive disease. The mean operationtime was 189.3 (� 50.4) min. Overall ICU-stay was prolonged (10 � 9.9


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days). In microbiological cultures, 83.3% staphylococci (40% MRSA, 40%MRSE, 3.3% S. aureus) and 16.7% gram-negative species were isolated.The chest wall reconstruction was performed after 25.7 (� 12.9) days ofVAC-therapy. Both Kirschner wires were removed on the 6th postoper-ative day. The mean length of hospital stay after CABGwas 39.2 (� 14.2)days due to multi-resistant staphylococci mediastinitis. Patients weredischarged 10.3 (� 3.6) days after secondary wound closure. There wasno recurrent sternal wound infection. No functional and aestheticalcomplaintswere registered during the followup period (mean 22� 14.1weeks). One patient died during the follow up time due to sepsis afterhip prosthesis infection. Conclusion: A combined surgical strategy usingosteosynthesis plates to stabilize the thorax and bilateral pectoralmusculocutaneousflaps for secondarywound closure can be consideredas an effective therapeutic option for reconstruction following sternalnecrosis and mediastinitis, since functionality and aesthetic appeal ofthe chest are preserved.

OP13Latissimus dorsi flap procedure andpostoperative seroma development -Comparing two types of tissue glue (TissuGlu®,ARTISS) versus no tissue glueLunk A.1, Reutemann M.1, Eger S.11Klinikum Magdeburg gGmbH, Klinik für Plastische, Brust-und Ästhetische Chirurgie, Magdeburg, Germany

Objectives: The aim of our investigation was to use two types of tissueglue (TissuGlu® and ARTISS) versus no tissue glue (control group)during latissimus dorsi flap procedures to find out whether or not theglues could reduce or even prevent postoperative seroma production.Methods: Of 75 patients undergoing latissimus dorsi flap procedure weanalyzed the postoperative drainage volume, the number of days untildrainage removal and seroma production after removal of drainages. In30 patients we used TissuGlu® from Cohera Medical, Inc. Fifteenpatients received the two-component fibrin sealant ARTISS fromBAXTER and 30 patients received no application of tissue glue. Patientgroups were similar in size of the sternal defect, their necessary need forIntensive Care medicine and the stage of heart insufficiency. Results:Overall, drainages were removed 5 days earlier in patients havingreceived TissuGlu® in comparison to patients in the control groupduring latissimus dorsi flap procedure. Drainage volume was reducedby 50% and seroma production after drainage removal was reduced by30% in the TissuGlu® group. Patients receiving the fibrin sealant ARTISShad comparable rates of drainage volume and comparable number ofdays until drainage removal to patients receiving TissuGlu®. Seromaproduction using ARTISS was slightly elevated compared to the Tissu-Glu® group. Conclusion: Applying tissue glue to the muscular defect onthe back thorax after removing the latissimus dorsi flap to cover largesternal defects in patients with sternal osteomyelitis decreases the sizeof the wound surface in sequence reducing the amount of drainagevolume and finally resulting in much less overall seroma production.Tissue glue could be a potent tool to reduce postoperative complicationsin patients with sternal osteomyelitis having comorbidities to decreaseoverall mortality.

OP14Replacement of the complete posterior trachealwall with autologous pericardium andlatissimus dorsi flap after esophageal acid burnBedetti B.1, Schmidt J.1, Oster O.1, Wolters H.2, Lebiedz P.3,Wiewrodt R.4, Wiebe K.11Uniklinik Münster, Department für Herz- undThoraxchirurgie, Münster, Germany, 2Uniklinik Münster,Chirurgie, Münster, Germany, 3Uniklinik Münster,Department für Kardiologie und Angiologie, Münster,Germany, 4Uniklinik Münster, Medizinische Klinik A -Pneumologie, Münster, Germany

Introduction: Reconstruction of large tracheal defects are complex,simply because there are no artificial materials for replacement andautologous tissues have distinctive limitations. Case presentation: A 27year old female patient was admitted after acid ingestion with severe

acid burns of the mouth, pharynx and upper gastrointestinal tract. Thepatient developed progredient necrosis of the esophagus involving thetracheal posterior wall per continuitatem. After intubation and trache-otomy, endoscopic control documented an enormous esophagi-trachealfistula: the entire tracheal posterior wall was destroyed and thecompletely necrotic esophagus was ruptured. The reconstruction wascarried out under support of veno-arterial extracorporeal membraneoxygenation (ECMO). Via a right thoracotomy the complete thoracicesophagus and the necrotic residual posterior wall of the trachea fromthe tracheostoma via the bifurcation into the left main bronchus wereresected. The primary reconstruction of the posterior tracheal wall wasmade with an autologous pericardial patch. Subsequently the pediculedlatissimus dorsi muscle was lifted, placed in the thoracic cavity throughan incision in the 2nd intercostal space and fixated in the formeresophageal bed to sustain and support the reconstruction of the trachealwall. Postoperatively the extracorporeal lung assist was switched toveno-venous ECMO to assure a protective, low-pressure ventilation ofthe reconstructed upper airways. In a subsequent procedure, the cervi-cal esophaguswas drained out on the lateral neck. The stomach had to beresected due to necrosis with covered perforation. After prolongedweaning from mechanical ventilation the patient could be transferredto a rehabilitation clinic with a permanent tracheostomy because ofpersistent dysphagia. Further reconstructive procedures are planned.Conclusions: Autologous pericardium in combination with muscle flapcoverage allows for reconstruction of long tracheal defects. With thistechnique an instant airtight closure and an unproblematic healing ofthe pericardium without necrosis can be achieved.

Heart Valve Diseases I: Mitral Valve

OP17Right lateral mini-thoracotomy as standardapproach for procedures apart from mitralvalve surgery: a 4-year experience with 361patientsMinol J.-P.1, Boeken U.1, Weinreich T.1, Akhyari P.1,Gramsch-Zabel H.1, Kamiya H.1, Lichtenberg A.11Uni-Klinik Düsseldorf, Kardiovaskuläre Chirurgie,Düsseldorf, Germany

Objective: Over the past decade right lateral mini-thoracotomy hasbeen accepted as standard approach for isolated mitral valve surgery(MVS). However, further cardiac operations may also be realized via thisaccess. We report the results of a 4-year, single-institution experiencewith cardiac surgery via right thoracotomy. Methods: We retrospec-tively reviewed 361 cardiac operations via right lateral mini-thoracoto-my (MICS) with femoral cannulation between 8/2009 and 07/2013. Weinvestigated the short-term morbidity and mortality with regard to thesurgical procedure and 1-year-follow-up data including echocardiogra-phy. It was our particular aim to analyze and to compare the results ofnon-mitral valve procedures. Results: Of the 361 MIC-Patients, 245 hadisolated mitral valve operations (208 repairs, 37 replacements). Fur-thermore, there were 62 combined procedures with additional surgeryof the tricuspid valve (TV), 25 patients with an isolated TV-procedureand 29 patients with non-valve surgery, such as resection of atrialtumors or closure of atrial septal defects. Overall in-hospital mortality(30 d) was 2.2% (8 of 361). In the individual groups, it was 0.4% (1 of 245)and 3.7% (6 of 162) in the groups of patients with isolated MV-surgeryand with combined MV-procedures, and 4% (1 of 25) in the isolated TV-group. In patients with resection of tumors or ASD-closures no in-hospital mortality could be observed. Perioperative morbidity in allpatients included reoperation for bleeding, neurologic complications(2.2%) and disturbance of wound healing. The overall incidence of minorand major postoperative complications was significantly lower inpatients with isolated MVS compared to all other groups. Length ofICU - and hospital-stay were 2.4 � 3.6 d and 14.8 � 8.3 d in all 361patients (Isolated MVS: 1.7� 1.6 d, 13.9 � 6.2 d; other groups: 3.1� 4.1days, 15.9� 3.1 d, respectively). At follow-up, survival was 93.9% in total(Isolated MV: 96.3%; others: 88.7%). Mean left ventricular ejectionfraction decreased from 59.7 � 10.4% at hospital discharge to 59.4 �9.1% (p>0.05) at follow in all patients. Conclusions: Right lateral mini-


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thoracotomy is a routinely used access forMV-surgery.With our datawecould also confirm excellent results with this technique for a widespectrum of further cardiac procedures.

OP18Transcatheter mitral valve-in-ring procedures:Ring assessment, sizing and initial clinicaloutcome of a case seriesArzt S.1,WilbringM.1, Matschke K.1, Kappert U.1, Alexiou K.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: Catheter-based heart valve procedures are continuouslyevolving and expanding their fields of application. We describe ourexperience with valve-in-ring procedures for failed mitral repair. Opti-mal sizing of the transcatheter valve (THV) is particularly demandingdue to the non-circular shape of annuloplasty rings. Methods: Wereport four valve-in-ring procedures for failed mitral repair using theEdwards SAPIEN XT™ bioprosthesis. Applied access routes were trans-apical (n¼3) and left-atrial via right minithoracotomy (n¼1). Meanpatient's agewas 68.0� 2.2 years. Calculated STS-PROM and euroSCOREpredicted high surgical risk 11.59 � 3.10% and 54.70 � 19.51%, respec-tively). Pre-, intra- and postoperative data were prospectively collected.The follow-up was complete, ranging from 34 to 220 days with anaverage of 104� 69 days. Results:Meanprocedure time averaged 59.0�12.5 minutes. For 26 (n¼1), 28 (n¼2) and 30 mm (n¼1) CE-Physio™rings, 26mm (n¼2) and 29mm (n¼2) Edwards SAPIEN XT™ (EdwardsLifesciences, Irvine, CA) THV's were used. All procedures and subsequentpostoperative courses were uneventful. Echocardiography revealedgood hemodynamics and well prosthesis function in all patients atdischarge. Mean transvalvular pressure gradients (dPmax/mean) were14.8 � 1.7/7.0 � 1.6 mmHg and only trace transvalvular regurgitationwas seen. During mid-term follow-up no valve related events occurredand prosthesis function remained stable. All patients remained at NYHAII° during follow-up. Conclusion: The present series demonstratestechnical feasibility of transcatheter mitral valve-in-ring procedures -hereby prospecting to become an elegant alternative in selected patientssuffering from failed mitral valve repair. Nonetheless, several technicalpitfalls, especially with regard of optimal sizing, have to be respected.Finally, much more data are needed to sufficiently evaluate safetyconcerns.

OP19The Medtronic Mosaic prothesis in aortic andmitral position: Clinical perfomance in 1540patients up to 13 yearsHeller L.1, Hansen L.1, Winkel S.1, Stripling J.1, Awwad N.1,Lehmann C.1, Cramer E.1, Rieß F.-C.11Albertinen Heart Center, Hamburg, Germany

Objectives: The MOSAIC bioprosthesis is a third generation stentedporcine bioprosthesis, built upon the historical durability of the HAN-COCK-II bioprosthesis. The MOSAIC Aortic and Mitral bioprostheses arepreserved in buffered 0.2% glutaraldehyde in a zero pressure procedureand they are treated with the AOA (amino oleic acid) antimineralisationprocess, to improve hemodynamic performance and durability.Methods: Between 1/2000 and 12/2011 1540 patients received Mosaicbioprosthesis, male n¼884, female n¼656. Mean age was 68.8 years,range 11.3-92.1 years. 1347 patients received AVR (aortic valve replace-ment); male n¼791, female n¼556, mean age was 68.53 years, range11.3-92.1 years.193 patients received MVR (mitral valve replacement),male n¼93, female n¼100. Mean age was 67.8 years, range 14.2-87.6years). Perioperative data were collected prospectively and postopera-tive, follow-up was performed by a questionnaire or/and telephoneinterview between 2/2012 and 8/2013. Results: Follow-up was com-plete in 979 (72.7%) AVR patients and in 147 (76.2%) MVR patients. Earlyresults for AVR and MVR were: mortality 1.9% and 3.6%; stroke 0.1% and0.0%; rethoracotomy for bleeding 4.0% and 6.5%. Late results were:mortality 20.2% and 20.7%; stroke 0.97% and 1.04%; re-operation in1.7% (endocarditis 0.4%) and 3.6% (endocarditis 0.5%). 689 patients withAVR (97.5%) and 105 patients with MVR (98.1%) were satisfied with theoperative result. In NYHA class I 552 (78.1%) patients stayed in the AVR

group and 78 (72.9%) patients in the MVR group, in II 88 (12.5%) and 16(15.0%), in III 42 (5.9%) and 9 (8.4%), and in IV 3 (0.4%) and 0 patients.Conclusions: Our long-term results demonstrate clinical safety andexcellent performance of the MOSAIC bioprosthesis during 13 yearsfollow up. A high number of patients is satisfied with the operativeresults combined with a good late outcome.

Extracorporal circulation and myocardial protection I

OP21Acoustic spectral analysis for determiningpump thrombosis in the HeartWare HVADpumpKaufmann F.1, Hörmandinger C.1, Kretzschmar A.1,Stepanenko A.1, Krabatsch T.1, Potapov E.1, Hetzer R.11Deutsches Herzzentrum Berlin, Assist-Gruppe, Berlin,Germany

Objectives: Implantation of a rotary blood pump (RBP) is an establishedtreatment for end-stage heart failure. Patients supported by a RBP needanticoagulation medication to prevent thrombosis. Pump thrombosis isa severe complication occurring in up to 5% of patients and its early andexact detection is crucial for optimal treatment. Analysis of the acousticspectrum emitted by the HeartWare HVAD indicates the presence ofthrombi in the pump. Methods: In 163 patients the sound of theHeartWare HVAD was sequentially recorded using a data acquisitiondevice combined with a laptop. The acoustic spectra calculated byruntime-FFTwere investigated. The results were comparedwith respectto no suspicion of thrombotic complications (145 Pts.) and to clinical andtechnical signs of pump thrombosis (18 Pts.). Sixteen pumps, which hadto be exchanged due to detection of pump thrombosis, were opened andinvestigated. Two patients underwent lysis. Results: Characteristicfrequency peaks exist at the rotational speed of the pump (fundamentalfrequency - 1st harmonic), the twofold (2nd harmonic) and the fourfoldfrequency (4th harmonic), which corresponds with the frequency atwhich the blades of the rotor pass the outflow volute. For bettercomparison the amplitudes of the 1st and 2nd harmonic are normalizedto the 4th harmonic, which has the highest intensity. Thrombus forma-tionwas confirmed in all 16 exchanged pumps. The existence of a soundpeak with the threefold frequency (3rd harmonic) of the pump speedcorrelated with the presence of thrombi inside the pump (p<0.0001).An increased sound amplitude of the basic frequency of the rotatingimpeller compared to previous measurements also denotes pumpthrombosis with high significance (þ75%, P¼0.002). After pump ex-change the acoustic spectrum returned to normal: in all patients the 3rdharmonic was no longer present. In 2 patients lysis was attempted. The3rd harmonic was reduced to zero in one patient after successful lysistherapy and remained existent in the second patient, where the pumpremained thrombosed. Conclusion: Analysis of the acoustic spectrumemitted by HVAD pumps can be used as a reliable method for earlydetection of pump thrombosis even if other clinical signs (hemolysis,power increase) are not observed. The appearance of 3rd harmonics ofthe basic frequency strongly indicates the presence of thromboticparticles on the rotor of the blood pump.

OP22Retrograde autologous priming (RAP) as a safeand easy method to reduce haemodilution andtransfusion requirements during cardiacsurgery - Comparison between RAP, standardand Miniaturised Extracorporeal Circulation -Probst C.1, Trapp C.1, Schiller W.1, Mellert F.1, Halbe M.1,Welz A.11UniversitätsklinikumBonn, Klinik für Herzchirurgie, Bonn,Germany

Objective: In the last decade, there have been some exciting develop-ments in the design of cardiopulmonary bypass (CPB) systems to reducethe adverse clinical effects of the heart lung machine. Mini-extracorpo-real circulation (MECC) is one example that has shown promisingclinical results. Also the technique of retrograde autologous priming


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(RAP) of the CPB circuit has regained interest as an easymethod in orderto decrease haemodilution. The purpose of our study was to investigatethe impact of RAP on the intraoperative haematocrit level and theconsequent need for blood transfusion in comparison to standard CPB(SCPB) and a Minimal System (Terumo ROC Safe®) in elective coronaryartery bypass (CABG) patients operated by a single surgeon. Methods:Data were retrospectively collected on 3 cohorts of adult CABG patientsoperated on bya single surgeon. Group RAP (n¼30) of patients operatedusing the RAP and control groups of patients operated usingSCPBstandard crystalloid method (n¼30) and ROC Safe® (n¼30). Intra-and postoperative data of the three groups were obtained and analysedby using SPSS® for Windows. A p-value of p<0.05 was consideredsignificant. Results: There was no significant difference in the demo-graphic data of the three groups. The priming volumewas SCPB: 1608�181 ml, RAP: 946 � 212 ml and ROCSafe®: 567 � 98 ml (p<0.001).There were significant differences in hemodilution (p<0.05), intra-operative transfusion requierements (p<0,001), intraoperative lactatelevels (p<0.05), urinary excretion (p< 0.05) and postoperative trans-fusion requirements (p<0.05). Therewere no differences between the 3groups in the incidence of several other postoperative complications.Conclusion: In conclusion, RAP is a safe and low cost technique inreducing the priming volume of the cardiopulmonary bypass system,causes less haemodilution and reduces the need for intra- and postop-erative blood transfusion.

OP23Acoustic spectral analysis: a new method forthrombus detection in the HeartWare HVADpumpKaufmann F.1, Hörmandinger C.1, Hennig E.1, Potapov E.1,Hetzer R.11Deutsches Herzzentrum Berlin, Berlin, Germany

Objectives: Pump thrombosis is a severe and life-threatening compli-cation in patients supported by rotary blood pumps. Early detection andtreatment is crucial to prevent further damage caused by hemolysis orlow pump output. Analysis of the sound generated by the running HVADpump reveals thrombus formation independently of other clinical ortechnical signs. Methods: In a mock loop the sound emitted by aHeartWare HVAD was recorded using a data acquisition device com-bined with a laptop. The acoustic spectra calculated by runtime-FFTwere investigated. Measurements were taken at various rotationalspeed settings and different flow values. The spectra recorded with aclean rotor (O) were compared with those of two different artificialthrombi adhering to the rotor made from blots of silicone glue. Onethrombus was placed at one of the four flow channels, impairing theblood flow through this flow channel and causing an imbalance of therotor (A). The other artificial thrombus replicated the commonly ob-served fibrin layer on one of the hydrodynamic bearing planes (B).Results: Analysis of the clean pump (O) showed the existence ofcharacteristic frequency peaks at the rotational speed of the pump(fundamental frequency - 1st harmonic), the twofold (2nd harmonic)and the fourfold frequency (4th harmonic), which corresponds with thefrequency at which the blades of the rotor pass the outflow volute. Forbetter comparison the amplitudes of the 1st and 2nd harmonic arenormalized to the 4th harmonic, which has the highest intensity aftereliminating the underlying noise level. In both test series with artificialthrombi (A, B) the existence of a sound peak with the threefoldfrequency (3rd harmonic) was found. This finding was independent ofthe rotational speed and the created flow. Conclusion: A thrombusadhering to the rotor of the HVAD pump causes an imbalance whichleads to an eccentric rotation. Every time the deflected part of the rotorpasses one of the three driving solenoids of the stator it will be drawn tothe center by the magnetic forces thus creating the 3rd harmonicfrequency peak. Analysis of the acoustic spectrum emitted by HVADpumps can be used as an independent method for detecting thromboticdeposits on the rotor. Pump thrombosis thus can be recognized beforeclinical signs such as hemolysis or increased power consumption occur.The success of lysis therapy in these cases can be monitored withoutdelay.

OP24Driving with a drive-line: an evidence basedapproach of driving restriction afterimplantation of left ventricular assist device inend stage heart failureWelp H. A.1, Gottschalk A.2, Ellger B.2, Scherer M.1, MartensS.1, Eckardt L.3, Klotz S.4, Mönnig G.31Universitätsklinikum Münster, Thorax- Herz undGefässchirurgie, Münster, Germany, 2UniversitätsklinikumMünster, Anästhesie, Intensiv- und Schmerzmedizin,Münster, Germany, 3Universitätsklinikum Münster,Abteilung für Elektrophysiologie, Münster, Germany,4UKSH Campus Lübeck, Herz- Thorax- und Gefäßchirurgie,Lübeck, Germany

Background: Although sudden incapacitation in patients treated with aleft ventricular assist device (LVAD) is a known complication evidence isscarce to justify driving recommendations. The aim of the current studywas to retrospectively analyse the incidence of incapacitation in thesepatients. Method: A total of 285 consecutive recipients (230 male(80.7%); ischemic cardiomyopathy 50.9%; dilatative cardiomyopathy40.0%) of a left ventricular assist device (LVAD) for acute or chronicheart failure at our institution between 1995 and 2011 were included(bridge to transplantation in 241 patients (84.6%), bridge to recovery in24 patients (8.4%) and destination therapy in 20 patients (7.0%)).Patient's charts and data from the hospital information system werescreened for events with the potential of a sudden loss of consciousness.According to the risk of harm (RH) formula the annual RH wascalculated. Results: Total duration of mechanical circulatory supportwith physical ability to drive was 48401 days. During this time span atotal of 397 events with the potential for loss of consciousness occurred(equals 3% annual risk). According to the RH formula the overallcalculated annual risk to other road users posed by 100,000 car drivingpatients with LVADs in a private manner was 0.67% and therefore farbelow the generally accepted threshold of 5% per 100,000 patients peryear. This was observed for pulsatile (0.76%) as well as for continuousflow devices (0.61%) with no significant difference between the twogroups. For commercial driving the overall calculated annual RH was14.69% and therebyexceeded the accepted limit of 1%. Thiswas observedfor pulsatile (16.96%) as well as for continuous flow devices (13.70%)with no significant difference between the two groups. Conclusion:Based on this retrospective analysis, private driving should be possiblefor patients who are stable on LVAD therapy. Especially for destinationtherapy driving is an important marker for quality of life.

OP25Microvascular alterations during surgical aorticvalve replacement utilizing minimalextracorporeal circulation and conventionalcardiopulmonary bypassDonndorf P.1, Park H.1, Vollmar B.2, Alms A.3, Steinhoff G.1,Kaminski A.11Universitäres Herzzentrum Rostock, Klinik und Poliklinikfür Herzchirurgie, Rostock, Germany, 2Universität Rostock,Institut für Experimentelle Chirurgie, Rostock, Germany,3Universität Rostock, Klinik und Poliklinik fürAnästhesiologie und Intensivtherapie, Rostock, Germany

Objectives: Minimal extracorporeal circulation (MECC) systems havebeen introduced in surgical aortic valve replacement (AVR), offeringpossible perioperative benefits due to reduced hemodilution and noblood-air interface. Yet, the effects MECC systems on the intraoperativemicrovascular perfusion in comparison to conventional extracorporealcirculation (CECC) have not been studied so far.Methods: In the currentstudywe aimed to analyze alterations inmicrovascular perfusion at fourpre-defined time-points (T1-T4) during surgical AVR utilizing Orthogo-nal polarization spectral imaging (OPS). Twenty patient scheduled forelective AVRwere prospectively randomized for being operated utilizingeither MECC or CECC. Changes in functional capillary density (FCD),blood flow velocity and vessel diameter were analyzed by a blindedinvestigator. Results: After start of the extracorporeal circulation andaortic crossclamping (T2) both groups showed a significant drop of thefunctional capillary density as compared to the respective baseline


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values, but with a significantly higher FCD in patients operated with theMECC system (153.1 � 15.0 cm/cm2 in CECC group vs. 160.8 � 12.2 cm/cm2 in MECC group, p¼0.034). At T3, in the late phase of cardiopulmo-nary bypass, the FCD in both groups were still significantly impairedbelow the baseline value, (153.5 � 14.6 cm/cm2 in CECC group, p<0.05vs. 'T1'; 159.5 � 12.4 cm/cm2 in MECC group, p<0.05 vs. 'T1'). Inter-group comparison, however, did not reveal a significant difference of theFCD between the two groups at the time-point T3 (p¼0.071). Aftertermination of the cardiopulmonary bypass at the time-point T4 the FCDrecovered in both groups to baseline values. Measurements of red bloodcell velocity in post-capillary venules revealed no significant intra-operative changes during surgical AVR utilizing ether CECC or MECC.However, the blood flowvelocity tended to be higher in theMECC groupat the time-points T2 and T3 (0.542 � 0.04 mm/s in CECC group at T2 vs.0.552 �mm/s in MECC group at T2, p¼0.42; and 0.550 � 0.04 mm/s inCECC group at T3 vs. 0.554 � mm/s in MECC group at T3,p¼0.41).Conclusions: OPS imaging data reveal a certain degree of impairmentregarding nutritive microvascular perfusion, represented by the FCD,during surgical AVR. Analysis of changes in the FCD, indicate thatreduced hemodilution in MECC does not cause inferior microvasculartissue perfusion compared to conventional ECC during surgical AVR.

OP26Extracorporal membrane oxygenation:Perioperative support reduces the operativerisk for post infarction ventricular septal defectZientara A.1, Häussler A.1, Behr R.1, Löblein H.1, Odavic D.1,Genoni M.1, Dzemali O.11Stadtspital Triemli, Herzchirurgie, Zürich, Switzerland

Introduction: Mechanical complications after acute myocardial infarc-tion, such as ventricular defects (PI-VSD) are one of the most frequentcauses of sudden cardiac death. This case report describes the perioper-ative management of a 55-year-old man with sub-acute PI-VSD.Background: A 55-year-old male was admitted to our emergencydepartment after 3 days of crescendo chest pain. He presented withsinus rhythm tachycardia and ST elevation in I and AVL. Cardiac enzymesconfirmed the diagnosis of myocardial infarction. High frequencyholosystolic murmur was mainly audible in left parasternal position.Echocardiography revealed a dysfunction of left ventricle, dilatation ofright ventricle and a large posterior PI-VSD. Despite inotropes andvasoconstrictors there was still hemodynamic instability. Therefore,the percutaneous venoarterial extracorporeal membrane oxygenation(ECMO) as elective setup using the right subclavian artery and rightfemoral vein was installed. After this intervention the patient wasextubated and we obtained the stabilization and improvement of theclinical conditions (Fig.1). We arranged the operation on post-infarctionday 11 to reduce operative risk. Undermore stable condition, the patientunderwent coronary angiography before the operation showing aproximal occlusion of RCA andRCX. Then he underwent elective surgery,namely, VSD patch repair and coronary artery bypass grafting (Fig.2).The ECMO duration after surgery was 3 days and the patient wasdischarged from hospital 41 days after the operation in good clinicalcondition. Discussion: Perioperative instability and early PI-VSD carry agrave prognosis. Achieving haemodynamic stability prior to surgeryreduces operative risk. This suggests that ECMO support is reliablebefore and after definitive surgery in PI-VSD.

Fig. 1: ECMO-VSD

Heart valve diseases II: Mitral valve surgery

OP27Hemodynamic effects of new active mitral ringin treating residual regurgitation on beatingheartTozzi P.1, Siniscalchi G.1, Ferrari E.1, Gronchi F.2, Pretre R.11University Hospital Lausanne, Cardiac Surgery, Lausanne,Switzerland, 2University Hospital Lausanne,Anesthesiology, Lausanne, Switzerland

Objective: Residual mitral regurgitation is detectable in 10% to 30%mitral valve repair. Trivial or mild regurgitation is generally toleratedwhile moderate and severe mitral regurgitation led to valve replace-ment. Post-implant adjustable mitral ring could avoid re-operation. Wedesigned an animal study to test an original active ring called Mitralflexand its effects on valve pressure gradient and left outflow tract flow.Methods: Mitralflex is an original ring for mitral annuloplasty able toreshape mitral annulus on beating heart reducing septo-lateral diame-ter thanks to amechanical remote control placed under the skin. In adultswine, under CPB on beating heart, we created mitral regurgitationshortening P2 cordae and performed the annuloplasty. After weaningthe CPB, we assessed mitral regurgitation using intracardiac ultrasoundduring ring activation. Results: 10 animals survived the procedurehaving moderate (6) and severe (4) mitral regurgitation. The devicewas successfully activated in all animals displacing the posterior leaflettowards the anterior. In 5 animals regurgitation disappeared and in 5decreased to trivial. Vena Contracta decreased from 8,2 � 0,5 mm to 1,3� 0,5 mm. Maximal mitral gradient was 6 mmHg, mean 3 � 2 mmHg.Two animals showed systolic anterior leafletmotion effect. Conclusions:


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Precise and remote remodeling of annulus geometry allowed thecorrection of severe mitral regurgitation on beating heart, withoutincreasing pressure gradient across the valve. The partial occlusion ofthe left outflow tract was due to the excessive length of the posteriorleaflet. TheMitralflex ring expands the opportunity to perform effectivemitral valve repair and to correct recurrent mitral regurgitation onbeating heart.

OP28Annuloplasty in functional mitral regurgitationand concomitant coronary heart disease:Functional and clinical outcomeReiter B.1, Jemmali M.1, Schönebeck J.1, Marcsek P.1, DetterC.1, Reichenspurner H.1, Wagner F.11University Heart Center Hamburg, Department ofCardiovascular Surgery, Hamburg, Germany

Objective: The aim of the study was to analyse the impact of preopera-tive LV-function on clinical and functional outcome in patients (pts.)with functional mitral regurgitation (MR) and coronary heart disease.Methods: Out of 197 pts. receiving an annuloplasty due to functionalMR between 2002 and 2006, 102 pts. underwent concomitant bypass-grafting and were included in this retrospective analysis. We comparedgroup 1 (Gr.1) with normal left ventricular (LV) function (ejectionfraction EF 50%), n¼27 pts. to group 2 (Gr.2) with moderately reduced(EF <50% and �30%) n¼40 pts. and group 3 (Gr.3) with severelyreduced LV function (EF <30%) n¼35 pts.. Follow-up included func-tional stress-echocardiography (TTE at 50 and 100 W ergometry) andclinical examination with quality of life appraised by EuroQol 5D form.Results: Follow-up time was 41 � 23 months. All groups were compa-rable in terms ofmean age, sex and NYHA-class. Logistic EuroSCOREwassignificantly higher in Gr.3 vs. Gr.1 (9.8 � 10 vs. 6.5 � 3, p<0.05). Therewere no differences between groups regarding perioperative data.Postoperatively use of high dose inotropics was significantly morefrequent in Gr.3 vs. Gr.1 and 2 (23% vs. 11% and 8%, p<0.05). Supportwith IABP was only required in Gr.2 and 3 (12% vs. 26% p<0.05). 30 daymortality was 11.1% in Gr.1, 5% in Gr.2 and 9% in Gr.3 (p¼n.s.).Echocardiography at discharge revealed non/mild mitral regurgitation(MR) in 96% all pts. independently of LV-function. At follow-upmoderateMR occurredmore significantly in Gr. 3 vs. Gr. 1 and Gr. 2 (22% in Gr.3 vs.5% in Gr.1 and 2, p<0.05). In stress-TTE MR did not increase in any case.LV function in Gr.3 improved significantly compared to Gr. 2 (72% vs.30%, p<0.05) during follow-up. In contrast, impairment of LV functionoccurred in 5% in Gr.1 and 9% in Gr.2 (p¼n.s.). Survival at follow-upwas78% in Gr.1, 60% in Gr.2 and 57% in Gr.3 (Gr.1 vs. 3 p<0.05). Quality oflive improved significantly only in group 3 (29 � 23 vs. 78 � 18 pre- vs.postoperatively, p<0.05). Conclusion:Mitral valve repair in this patientpopulation demonstrated good functional results in almost all patients.Recovery of LV function in patientswith preoperatively severely reducedLV function was demonstrated and coincided with benefit in quality oflife.

OP29Computer-assisted mitral valve measurementusing an optical tracking system - a newapproach for planning of mitral valvereconstructionsDe Simone R.1, Engelhardt S.2, Zimmermann N.1, Al MaisaryS.1, Beller C.J.1, Wolf I.2, Wald D.2, Meinzer H.-P.2, Karck M.11Ruprecht Karls - Universität Heidelberg, Herzchirurgie,Heidelberg, Germany, 2Deutsches Krebsforschungszentrum,Medizinische und Biologische Informatik, Heidelberg,Germany

Objectives: Intraoperative mitral valve analysis is mandatory for asuccessful mitral valve repair since it helps the surgeon to choose thesurgical strategy by improving preoperative imaging findings. Wedeveloped a new method for mitral valve analysis based an opticaltracking system that improves quantitative assessment of the complex3D valve anatomy. Methods: The tips of specially developed surgicalinstruments were tracked by an infrared stereo camera system (NDIPolaris™) in order to localize 16 anatomical landmarks. The data were

processed byour ownplugin in the open-source softwareMITK to createan anatomical geometric model of mitral valve including annulus,leaflets and chordae. Four surgeons made measurements on excisedporcine hearts to assess feasibility, accuracy and variability. Annulusarea, longitudinal and anterolateral diameters, coaptation line anddistances between anterolateral and posteromedial papillary musclesto coaptation line were assessed. Results:

Table 1:

mean� SD

annulusarea(mm2)

longitudinaldiameter(mm)[point2 - 5]

antero-lateraldiameter(mm)[point7 - 8]

distanceantero-lateralpapillarymuscle (mm)[point11 - 15]

distancepostero-medialpapillarymuscle(mm)[point13 - 16]

surgeon 1 741�11 32,6�0,7 27,0�1,0 7,3�2,5 11,7�1,4

surgeon 2 629�15 30,9�1,9 25,3�1,5 12,9�3,0 12,3�1,5

surgeon 3 628�105 34,6�3,3 24,0�1,4 7,2�0,7 16,4�0,3

surgeon 4 462�30 28,6�0,6 19,7�1,6 9,3�2,8 10,1�0,9

interexpert 615�114 31,7�2,5 24,0�3,1 9,2�2,7 12,6�2,7

95%-CI 543;688 29,9;33,5 22,1;26,0 7,1;11,2 11,0;14,3

These data (see table) were used for 3D-reconstruction of the mitralvalve annulus and its relation to the subvalvular apparatus, as exempla-ry shown in the screenshot.

Fig. 1: screenshot

Conclusion: Anatomical parameters tracked by our infrared stereocamera system showed good accuracy and reproducibility. Thesecomputational models allow a more precise quantitative assessmentof mitral valve geometry and present a new method for intraoperativemitral valve analysis providing precise sizing of anatomy that may: 1)guide the surgeon to choose themost suitable reconstruction procedure,2) provide a learning tool and 3) improve outcome ofmitral valve repair.


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OP30The no-resection-technique for mitral valverepair in Barlow diseaseDayeh A.-H.1, El Gabry M.1, Al Zuhbi A.1, Moka A.1,Ramadani B.1, Sachweh J.1, Däbritz S.11Herzzentrum Duisburg, Klinik für Herz- undGefäßchirurgie, Duisburg, Germany

Objectives: The resection technique for the repair of structural mitralvalve pathology is common. However, new techniques recently per-formed follow the “Respect rather than Resect” approach. Our mitralvalve repair technique aims at avoiding any resection of valve tissue inalmost any pathology including complex cases of M. Barlow usingartificial chordae as a universal solution. The idea is to achieve thehighest possible coaptation area and preserve a normal leafletmotion toreach a repair for life. Methods: Between 2005 and 2013, 111 patientswithMorbus Barlowunderwentmitral valve surgery.Mean agewas 58.9� 12.2 years, EF was 48 � 8.5, 63% were male, 3 patients had atrialfibrillation, systolic PAP was elevated (>40 mmHG) in 20 pts.. Concomi-tant procedures were CABG (2.9%), closure of ASD / PFO (4.9%) andtricuspid anuloplasty (2.9%). Repair rate was 100%. The No-Resectionrepair technique was performed in all patients with artificial chordaeandwith closure of the indentations in the posterior leaflet. In addition,large (>34 mm) anuloplasty rings (n¼31) or bands (n¼80) were used.Results: There was no operative mortality. One patient had severebleeding and resuscitation. Minor complications included rethoracot-omy for bleeding (3 pts.) and reintubation (2 pts.). There were nocomplications concerning the mitral valve (mitral valve replacementor any reintervention). Mean CCT and CPB timeswere 56� 9min and 73� 10 min, respectively. Postoperative TEE and TTE at discharge showedno or trivial mitral regurgitation in all patients and a mean coaptationarea of �1,1 cm in all without any signs of SAM. Follow up at 4,2 � 2,1years (up to 7 years) (90% follow-up, no mortality) demonstrated astable repair without changes in the echocardiographic parameters.Conclusion: The No-Resection approach with artificial chordae andlarge anuloplasty devices is feasible for mitral valve repair in M. Barlow.The resulting large coaptation area without SAM leads to excellentoperative and mid-term results and expected long term durability.

OP31Clinical outcome in elderly patients undergoingmitral valve repair with or without tricuspidvalve repairRenner A.1, Zittermann A.1, Aboud A.1, Hakim K.1,Börgermann J.1, Gummert J.F.11Herz- und Diabeteszentrum NRW, Bad Oeynhausen,Germany

Objectives: We have recently presented data indicating that isolatedmitral valve (MV) repair is a suitablemethod in elderly patientswithMVdefects. Herewe present results on outcomes in patients undergoingMVrepair with tricuspid valve (TV) repair. Methods: We compared clinicaloutcomes in 46 younger (<75 years) and 28 older (�75 years) patientswith MV/TV repair and 416 younger and 72 older patients with isolatedMV repair. Results: EuroSCOREwas higher in older patients with MV orMV/TV repair compared with the corresponding younger age-groups(median and IQR: 9.8 [6.4-14.9] vs. 2.2 [1.5-4.5], respectively, and 17.1[12.9-24.7] vs. 8.7 [5.5.-14.6], respectively). Nevertheless, operativecomplications such as stroke and infections and the need of hemofiltra-tion and IABP-use did not differ significantly between the respective agegroups. Thirty-day mortality was excellent in both subgroups of olderpatients (0% and 0%, respectively). Six-month-mortality was 1.5% (MVgroup) and 10.7% (MV/TVgroup). Thirty-day and 6-monthmortality didnot differ from the corresponding younger subgroups (P-values:0.523->0.999). One-year mortality was however significantly higher in olderthan in younger patients with MV repair (6.6%vs.1.6%, respectively,P¼0.034) and non-significantly higher in older than in younger patientswith MV/TV repair (23.5%vs.8.9%, respectively;P¼0.162). The hazardratio for 1-year reoperation in older patients with MVandMV/TV repairwas 0.98 (95%CI:0.22-4.37;P¼0.976) and 1.67 (95%CI:0.24-11.90;P¼0.607), respectively. Conclusion: Data demonstrate excellent post-operativemortality rates in older patients undergoingMV repair with or

without TV repair. Consequently, even in older patients with more co-morbidities MV repair should be considered a suitable surgical method.

OP32Mitral valve repair with the Medtronic Profile3D® annuloplasty ring - a single centerexperienceGünzinger R.1, Günther T.1, Minkner K.1, Rondak I.2,Mazzitelli D.1, Voss B.1, Lange R.11Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, München, Germany, 2TechnischeUniversität München, Institut für medizinische Statistikund Epidemiologie, München, Germany

Objectives:Various devices have been proposed for ring annuloplasty inpatients with mitral valve disease. This study reports for the first timemidterm results with the rigid Medtronic Profile 3D® annuloplasty ring,which is supposed to preserve the 3-dimensional annular saddle-shape.Methods: Between 06/2009 and 06/2011 200 patients with severedegenerative mitral regurgitation underwent mitral valve repair usingthe Medtronic Profile 3D® annuloplasty ring. 106 patients (53.0%)underwent isolated mitral valve repair and 94 patients (47.0%) under-went a combined procedure, such as CABG (n¼21), tricuspid valverepair (n¼49), AF ablation (n¼17), and aortic valve surgery (n¼13).The follow-up is 94.5% complete (mean 2.5� 0.5 years). Results: 30-daymortality was 1.5%. Survival at 3 years was 97.1 � 1.6% for isolatedprocedures and 93.5 � 2.6% for combined procedures (n.s.). Mitralregurgitation decreased from grade 3.2 � 0.3 to grade 0.7 � 0.7(p<0.05). Freedom from mitral valve related reoperation at 3 yearswas 97.1 � 1.7% for isolated procedures and 95.5 � 2.2% for combinedprocedures (n.s.). Overall freedom from recurrent mitral regurgitation> °II was 86.4 � 4.8. Seven patients (3.5%) required a mitral valvereoperation after an average of 4.6 � 4.7 months. Two of thesereoperations were required for endocarditis, 2 for ring dehiscence, 1for progression of the native disease (flail leaflet), 1 for leaflet suturedehiscence, and 1 for persistent systolic anterior motion. Conclusions:Mitral valve repair for degenerative disease with the Medtronic Profile3D® annuloplasty ring can be performed with a low early and latemortality and an excellent functional outcome. The low incidence ofreoperation demonstrates that the Medtronic Profile 3D® annuloplastyring is a safe and effective device.

OP33Tricuspid valve surgery - should we prefer thebeating heart technique?Fleischer B.1, Saito S.1, Al Ahmad A.1, Haverich A.2, KutschkaI.1, Baraki H.11Otto-von-Guericke-Universität Magdeburg, Klinik fürHerz- und Thoraxchirurgie, Magdeburg, Germany,2Medizinische Hochschule Hannover, Klinik für Herz-,Thorax-, Transplantations- und Gefäßchirurgie, Hannover,Germany

Objectives: Tricuspid valve (TV) surgery is associated with high risks interms of morbidity and mortality. We aimed to evaluate the long-termoutcome after isolated TV surgery and thereby focused on potentialadvantages of the beating heart technique. Methods: The long-termresults of 92 consecutive patients who underwent isolated TV surgery ata single institution were evaluated and the risk factors for TV re-operation and mortality were analysed. We compared patients whounderwent beating heart (BH) surgery (n¼48) with patients undergo-ing arrested heart (AH) surgery (n¼44). Follow up analyses includedtelephone interviews and echocardiographic examinations. Results: BHsurgery was more frequently chosen in urgent/emergent operations(p¼0.029) and in redo-operations (p<0.001). Pre-operatively, the ratesof renal insufficiency (p¼0.002) and the EuroSCORE (p¼0.019) werehigher in the BH group than in the AH group. There was no difference inperioperative outcome and 30-day mortality between the groups.However, freedom from re-operation was significantly lower in theBH group compared to the AH group (p¼0.039).We observed a trend tolower survival rates at 1, 5 and 10 years in the BH group (77%, 54%, and41%) compared to the AH group (86%, 75%, and 72%, p¼0.062). A


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multivariate Cox hazard model revealed atrial fibrillation/pacemakerdependency (p¼0.014, odds ratio [OR]¼2.296) and EuroSCORE(p¼0.022, [OR]¼1.049) as independent risk factors for mortality afterisolated TV surgery. Conclusion: Isolated tricuspid valve surgery shouldbe considered early, since patients with elevated EuroSCORES, atrialfibrillation and/or pacemaker dependency have significantly highermortality rates. We did not observe any long-term benefits of thebeating heart technique.

Transcatheter valves I: Clinical results

OP343 year results of transapical versus transfemoralTAVI in 1000 patients with severe aorticstenosis in a single center registrySchröfel H.1, Wondraschek R.2, Würth A.3, Heimeshoff M.1,Bramlage P.4, Schymik J.5, Gonska B.-D.3, Schmitt C.2, PosivalH.1, Schymik G.21Klinik für Herzchirurgie Karlsruhe, Karlsruhe, Germany,2Städt. Klinikum Karlsruhe, Kardiologie, Karlsruhe,Germany, 3St. Vincentius Kliniken Karlsruhe, Kardiologie,Karlsruhe, Germany, 4IPPMED, Mahlow, Germany, 5LMUMünchen, MGSE, München, Germany

Objectives: There are two commonly used routes for TAVI and TA isgenerally perceived to be associated with increased risk. We aimed toevaluate access-related complications between transfemoral (TF) andtransapical (TA) transcatheter aortic valve implantation (TAVI) and tocompare survival. Methods: Single center registry of 1000 consecutivepatients undergoing TA and TF TAVI between May 2008 and April 2012.TA was performed in 413 patients and TF in 587 patients. Both groupswere compared.Results: Themean age inTA groupwas 81.0 years and inTF 81.6 years, p¼0.3. The TA group had more patients with peripheralartery disease (22.0% vs 10.9%), coronary artery disease (64.4% vs 58.3%),carotid stenosis (23.2% vs 15. 7%), redo-operation (25.7% vs 14.8%) andneurological dysfunction (14.8% vs 10.4%) than in TF (all p<0.05). In TFmore patients were seenwith pulmonary hypertension (22.0% vs 15.5%,p<0.05). The mean EuroSCORE I in TA was 24.2% and in TF 22.3%(p¼0.007). There was no difference in 30 day mortality (7.1%), the rateof MI (2.3%) or stroke (2.2%), bleeding complications, pacemaker im-plantation rates or moderate aortic insufficiency. Stage 1 renal compli-cations were less common in TF patients while major vascularcomplications remained elevated. Mortality at three years in TA was33.7% and 27.3% in TF.

Fig. 1

Conclusion: There was no incremental mortality risk using either TA orTF.Major vascular complicationsweremore common in patientswith TFand stage 1 acute renal complications in those with TA. The datademonstrate that in an experienced multidisciplinary heart team eitheraccess route can be safely performed and recommended.

OP35Transapical aortic valve implantation afterprevious heart surgeryDrews T.1, Pasic M.1, Buz S.1, Unbehaun A.1, Dreysse S.1,Kukucka M.1, Mladenow A.1, Hetzer R.11Deutsches Herzzentrum Berlin, Berlin, Germany

Objective: Transcatheter aortic valve implantation (TAVI) may reducesome risk in patients with previous heart surgery. The aim of the studywas to compare the outcome of transapical TAVI in patients with andwithout previous heart surgery. Methods: Between 04/2008 and 03/2013, 679 consecutive patients underwent transapical TAVI. Group Aconsisted of 519 patients without and group B of 160 patients who hadundergone previous heart operation (123 coronary artery bypass graft-ing, 37 aortic valve replacement, 12 mitral valve replacement, 2reconstructions, 1 double lung transplantation and 19 other opera-tions). Group Bwas significantly younger than group A (77� 9 vs. 80� 7years; p¼0.006], but the preoperative risk score was significantlyhigher in group B [A: EuroScore I: 48 � 23%; EuroScore II: 25 � 18%;STS PROM Score: 18 � 15; B: EuroScore: 32 � 20%; EuroScore II: 12 �13%; STS PROM Score: 14 � 17]. Results: Technical success rate was 99%in both groups. The 30-day mortality was 4.1% in group A and 6.3% ingroup B (p¼0.3). There was no statistical significance between postop-erative bleeding rate, grade of paravalvular leakage, and postoperativeventilation time and use of blood products. The 1-year survival was 80%in group A and 79% in group B and the 3-year survival was 62% and 58%,respectively (p¼0.5). Conclusions: The outcome of transapical TAVI iscomparable in patients with and without previous heart surgery.

OP36Aortic valve calcium and transcatheter aorticvalve implantation with first- and second-generation transcatheter heart valvesSeiffert M.1, Avanesov M.2, Lunau C.1, Conradi L.3, SchirmerJ.3, Kloth B.3, Sinning C.1, Adam G.2, Blankenberg S.1,Reichenspurner H.3, Lund G.2, Diemert P.1, Treede H.31Universitäres Herzzentrum Hamburg GmbH, Klinik fürAllgemeine und Interventionelle Kardiologie, Hamburg,Germany, 2Universitätsklinikum Hamburg Eppendorf,Klinik und Poliklinik für Diagnostische und InterventionelleRadiologie, Hamburg, Germany, 3UniversitäresHerzzentrum Hamburg GmbH, Klinik für Herz- undGefäßchirurgie, Hamburg, Germany

Background: A correlation between aortic valve calcium load andparavalvular regurgitation after transcatheter aortic valve implantation(TAVI) has been demonstrated for first-generation transcatheter heartvalves.With the recent availability of several second-generation devicesrelying on different fixation and sealing mechanisms within the calci-fied aortic annulus, performance remains to be investigated. We aimedto approach this issue by retrospective assessment of aortic valvecalcium and hemodynamic performance of different transcatheter heartvalves.Methods: TAVIwas performedwith first- and second-generationdevices in 281 consecutive patients with severe aortic stenosis consid-ered at high surgical risk in 2012. In 156 of these patients, preoperativecontrast-enhanced CT scans with prospective ECG gating were availablefor retrospective analysis. Three-dimensional reconstruction of CT datawas performed using the 3Mensio software platform (3Mensio MedicalImaging, Bilthoven). After calibration for contrast agent density, calciumload was quantified within the device-landing zone. Data were corre-lated with echocardiographic measurements. Results: Total aortic valvecalcium was 2468 � 1685 mm3 with eccentric distribution (> 50% ofcalcium load at one cusp) in 26.3% and calcium protruding into the leftventricular outflow tract in 41.7% of patients. Devices implanted werethe Edwards Sapien XT (n¼52), Medtronic CoreValve (n¼33), SymetisAcurate (n¼25), JenaValve (n¼20), and Medtronic Engager (n¼26)valves. Postdilatation was performed in 23.9% and transcatheter valve-in-valve implantation in 5.8% of cases, mostly for paravalvular regurgi-tation. Postprocedural paravalvular regurgitation was none or trace in65.2% and mild in 34.8%. Although a trend towards a correlation ofcalcium load and paravalvular regurgitation was observed (p¼0.054),no differences in hemodynamic performance with regard to differentvalve types and aortic valve calcium could be demonstrated.


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Conclusions: TAVI using first- and second-generation devices can beperformed with good hemodynamic results, irrespective of annularcalcification. Aortic valve calcium seemed to be associated with in-creased paravalvular regurgitation, however within this small series norelevant predictors of regurgitation for the different transcatheter heartvalve prostheses could be identified. Larger studies are required tofurther investigate this important aspect.

OP37Transapical implantation of a second-generation transcatheter heart valve for thetreatment of aortic regurgitation - initialGerman experienceSeiffert M.1, Bader R.2, Kappert U.3, Krapf S.4, Rastan A.5,Bleiziffer S.6, Hofmann S.7, Arnold M.8, Kallenbach K.9,Conradi L.10, Schlingloff F.2, Wilbring M.3, Schäfer U.11,Reichenspurner H.10, Treede H.101Universitäres Herzzentrum Hamburg GmbH, Klinik fürAllgemeine und Interventionelle Kardiologie, Hamburg,Germany, 2Asklepios Klinik St Georg, Klinik fürHerzchirurgie, Hamburg, Germany, 3HerzzentrumDresden,Klinik für Herzchirurgie, Dresden, Germany, 4KlinikumAugsburg, Klinik für Herz- und Thoraxchirurgie, Augsburg,Germany, 5Herz- und Kreislaufzentrum Rotenburg, Klinikfür Herz- und Gefäßchirurgie, Rotenburg a.d. Fulda,Germany, 6Deutsches Herzzentrum München, Klinik fürHerz- und Gefäßchirurgie, München, Germany,7Schüchtermann Klinik Bad Rothenfelde, Klinik fürHerzchirurgie, Bad Rothenfelde, Germany,8Universitätsklinikum Erlangen, Medizinische Klinik 2 -Kardiologie und Angiologie, Erlangen, Germany,9Universitätsklinikum Heidelberg, Klinik für Herzchirurgie,Heidelberg, Germany, 10Universitäres HerzzentrumHamburg GmbH, Klinik für Herz- und Gefäßchirurgie,Hamburg, Germany, 11Asklepios Klinik St Georg, Klinik fürKardiologie, Hamburg, Germany

Background: Experience with transcatheter aortic valve implantation(TAVI) for severe aortic regurgitation is limited due to the risk forinsufficient anchoring of the valve stent within the non-calcified aorticannulus. Feasibility using the JenaValve (JenaValve Technology,Munich)system has recently been demonstrated. We report on acute results ofthe initial Germanmulticenter experience using this second-generationtranscatheter heart valve (THV) in patients with pure aortic regurgita-tion.Methods: Transapical TAVI was performed in 28 patients (age 72.7� 8.8 years) employing a JenaValve THV for severe aortic regurgitation in9 German centers (off-label use). All patients were considered high riskfor surgical aortic valve replacement after evaluation by the localinterdisciplinary heart team (logistic EuroSCORE 22.7 � 14.9%, STS-PROM 5.2 � 3.6%). Aortic annulus diameters were 24.5 � 1.9 mm andrespective JenaValve prostheses implanted were 23 mm (n¼4), 25 mm(n¼6), and 27 mm (n¼18). Procedural and acute clinical outcomeswere analyzed. Results: Implantation of the JenaValve THVwas success-ful in 27/28 cases. Due to dislodgement of the device in one patient,valve-in-valve implantation with an Edwards Sapien XT (Edwards Life-sciences, Irvine, CA) was performed. Postprocedural aortic regurgitationwas none or trace in 26/28 and mild in 2/28 patients. During 30-dayfollow up, 4/28 patients died (cardiac n¼1, non-cardiac n¼3). Due toaccess site complications (n¼2), the VARC 30 day safety endpoint wasreached in 6/28 patients, overall. One patient underwent valve-in-valveimplantation 3 months after initial implantation due to increasingparavalvular regurgitation and transvalvular gradients and one patientunderwent surgical aortic valve replacement for endocarditis 6 monthsafter TAVI. Both patients exhibited good valve function afterwards. Theremaining patients displayed an unremarkable short-term follow-upwithout signs of valve failure. Conclusions: Aortic regurgitation con-tinues to be a challenging pathology for TAVI. After initial demonstrationof feasibility, this multicenter experience provides broader evidencethat the JenaValve THV is a reasonable option in these specific patientsdue to its unique stent design and fixation mechanism. Short-termfollow-up was promising with regard to valve function. However, a

significant early non-cardiac mortality related to the high-risk patientpopulation emphasizes the need for differentiated patient selection.

OP38History of cardiac surgery in patientsundergoing transcatheter aortic valveimplantation is not associated with worsepostoperative outcome compared to patientswithout previous cardiac proceduresKuhn E.W.1, Madershahian N.1, Scherner M.1, Deppe A.-C.1,Choi Y.-H.1, Wahlers T.11Universität zu Köln, Herz- & Thoraxchirurgie, Köln,Germany

Objectives: Transcatheter aortic valve implantation (TAVI) has emergedas a valuable option for patients with an unacceptable high-risk whenreferred to conventional aortic valve replacement, e.g. patients withprior cardiac surgery. The aim of the present retrospective analysis wasthe evaluation of intra- and postoperative outcomes of patients under-going TAVI with and without previous cardiac surgery (PCS). Methods:A total of 293 patients were selected undergoing TAVI in the period fromJanuary 2011 to June 2013 and retrospectively stratified according thepresence of previous cardiac surgery (PCS n¼73) and no previouscardiac surgery (NoPCS n¼220). Groups were compared with regardto procedure related variables and postoperative clinical outcomes.Results: Preoperative patient characteristics were comparable betweenthe PCS and NoPCS groups. However, history of CABG (82.2%), aortic(13.7%) and mitral valve replacement (11.0%) surgery or combinedprocedures (6.8%) among PCS patients resulted in a higher logisticEuroscore compared to the NoPCS group (26.6 � 17.4 vs. 20.4 � 14.1;p¼0.003). Access sites were transfemoral (PCS 56.2 vs. NoPCS 7.7%),transapical (PCS 24.7 vs. NoPCS 91.8%) and transaortic (PCS 19.2 vs.NoPCS 0.5%). Durations of the procedure (101 � 52 vs. 102 � 41 min;p¼n.s.) and the amount of administered contrast media (96 � 54 vs. 94� 51 mL; p¼n.s.) were comparable for PCS and NoPCS groups. Intra-operative need for IABP did not differ between groups (PCS 1.4 vs. NoPCS3.7%; p¼n.s.), whereas blood transfusions (35.4 vs. 68.5%; p<0.001)and new need for postoperative hemodialysis (1.6 vs. 10.3%; p¼0.049)were less frequent in PCS compared no NoPCS patients. Postoperativecourses did not differ among both treatment groups regarding incidenceof TIA/stroke (PCS 1.4 vs. NoPCS 4.1%; p¼n.s.), stay on the intensive careunit (3 days, interquartile range (IQR) 2-5 days) and length of stay inhospital (9 days, IQR 9-14 days). Conclusion:History of previous cardiacsurgery does not impact postoperative clinical course of patientsundergoing transcatheter aortic valve implantation compared to pa-tients without prior cardiac surgical procedures. Therefore, accurateselection of patients suitable for TAVI with previous cardiac surgery canequalize the risk for postoperative adverse events to the risk of patientswithout history of cardiac surgery.

OP39Transcatheter aortic valve implantation inpatients with severe aortic stenosis andconcomitant mitral stenosisKloth B.1, Seiffert M.2, Conradi L.1, Schirmer J.1,Reichenspurner H.1, Diemert P.2, Treede H.11Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Allgemeine und InterventionelleKardiologie, Hamburg, Germany

Objectives: Transcatheter aortic valve implantation (TAVI) is an ap-proved method in high risk patients with aortic stenosis unsuitable forsurgical intervention. There are some reservations about transcatheteraortic valve replacement in patients with concomitant mitral stenosisbecause of the risk of intraoperative or postoperative cardiac decom-pensation and a benefit for these patients that is arguable. The risk forhemodynamic decompensation in TAVI with concomitant mitral steno-sis is mainly caused by decreased periprocedural diastolic inflow inoften severely hypertophic ventricles where a high preload is needed forsufficient hemodynamics. We have analyzed the outcome of 11 patientswithmitral stenosis having undergone TAVI in our institution.Methods:


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A total of 11 patientswith concomitantmitral stenosis (mean gradient 8,range 5-12mmHg) underwent transcatheter aortic valve-implantationsbetween 08.2008 and 06.2013. All patients needed an aortic valvereplacement because of a severe stenosis (mean gradient 41 mmHg(range 27-59mmHg), EOA 05-08 cm2). Themean age of the patients was83,3 years (range, 77-93), 8 were female and 3 were male and the meanlogistic EuroSCORE, EuroSCORE II, and Society of Thoracic Surgeonsscore was 18,0; 7,2; and 7,7; respectively. Used devices were Symetis TF,Symetis TA, JenaValve, Sapien XT and Engager TA. The access route wastransapical in 5 and transfemoral in 6 cases. Results:No intraproceduralmortality occured. The technique success rate was 100%. Length of stayin intensive care unit was 2,6 days (1-10 days), in-hospital stay 11,6 days(5-21 days). The major complications within 30 days included majorvascular complication in 1 patient, stroke in 1 patient and the need ofpacemaker implantation in 2 patients. All-cause 30-day mortality was0% and 10 of 11 patients had a reduction of NYHA-classification by atleast one class. Conclusions: Transcatheter valve implantation hasbecome an established procedure in patients with aortic stenosis andhigh surgical risk. Also in patients with concomitant mitral stenosis whoare not eligible for double valve surgery TAVI is a safe and feasible option.

OP40Transapical aortic valve implantation: Clinicaloutcome during learning curve and beyondPasic M.1, Unbehaun A.1, Dreysse S.1, Buz S.1, Drews T.1,Penkalla A.1, D'Ancona G.1, Hetzer R.11Deutsches Herzzentrum Berlin, Berlin, Germany

Objectives: Our institutional structured training program was used tointroduce transcatheter aortic valve implantation (TAVI) at our institu-tion and then gradually dispersed by internal proctoring to othermembers of the team consisting of 5 surgeons, 2 cardiologists and 2anesthesiologists. The purpose of the study was to compare clinicaloutcomes during and after our learning curve. Methods: This was aretrospective, single-center, observational cohort study of prospectivelycollected data from all 679 consecutive patients undergoing transapicalTAVI at our institution between April 2008 and March 2013. There were37 patients in cardiogenic shock. We analyzed clinical outcomes duringthe learning curve (period A; n¼500 patients) and thereafter (period B;n¼179 patients). Results: There was no statistically significant differ-ence between the results during 2 different periods: overall 30-daymortality rates during periods A and B were 4.6% (95% confidenceinterval [95%CI] 3.1%-6.8%) and 5.0% (95%CI 3.2%-6.9%), respectively(Fischer's exact test 0¼0.84). For patients without cardiogenic shock,30-day mortality rates during the periods A and B were 4.0% (95%CI2.6%-6.2%) and 4.1% (95%CI 2.2%-6.3%), respectively (Fischer's exact testp¼1.0). There was no difference in survival related to the operators(p¼0.51). There was an insignificant change towards improved overallsurvival (p¼0.30). There was no difference in late survival between theperiods (p¼0.58). Conclusions: Our structured institutional trainingprogram resulted in consistently favorable clinical outcome during thelearning curve and beyond. The study results strongly recommend astructured and intensive training program before starting clinicalapplication of TAVI.

Heart and lung failure I

OP41Aortic insufficiency development in 391patients supported with four different cf-LVADs: A single center experienceÖzpeker C.U.1, Morshuis M.1, Schönbrodt M.1, BörgermannJ.1, Renner A.1, Gummert J.11HDZ NRW, Abteilung für Herz-und Thoraxchirurgie, BadOeynhausen, Germany

Objectives: The development of aortic insufficiency (AI) under contin-uousflow (cf) left ventricular assist devices (LVAD) support isworldwideunder controversial discussion. The aim of this study is to analyzeretrospectively the development of AI in pts. supported with fourdifferent cf-LVAD. Material and methods: From January 2004 until

January 2013, 391 pts. were supported with different LVADs. AV-replacement (AVR) during LVAD implantation was performed in 32pts. due to AI 1þ or greater. Therefore we retrospectively analyzed thedevelopment of different AI levels (AI trace, AI mild or AI >1) in 359 pts.(HM 2, n¼177; HVAD, n¼ 108; Duraheart, n¼66; Ventrassist, n¼41).From this cohort, 67 pts. were excluded due to not exactly defined ormissing pre-OP AI values or too short follow up (<30 days). Westratified AI development by LVAD type and also by diagnosis (analyzedwere DCM, n¼149 and ICM, n¼ 131, various n¼12 were not analyzed).Results: The pre-OPAI of 292 pts. was as follows: no AI, n¼214; trace AI,n¼71;mild AI, n¼7. One year follow upwas possible in 193 pts.Withinthis cohort 10 pts. (5.2%) developed mild AI (1) and four pts. (2.1%)developed greater mild AI (AI>1). In 123 pts. with two years of followup, 11 pts. (8.9%) developed mild AI, one patient moderate AI (AI>1). In50 pts. , a three year follow up was possible with an 18% mild AI and 4%moderate AI. There is no statistically significant difference in develop-ment of AI>1þ between the four devices. But development of AI is seenmore often in axial flow pumps after three years of support incomparison to centrifugal devices. However 63% of all pts. in this cohortdevelop an AI trace vs.9% of AI 1 and vs 1% AI>1þ after one-year offollowup Conclusion: The development of AI is a very rare device relatedcomplication in our center. We hypothesize that the reason for this lowincidence might be that the LVAD settings were only partially unloadingthe left ventricle (LV) allowing intermittent opening of the AV everysecond or third heartbeat avoiding commissural fusion. All our pts. withat least AI >1 were HTx.

OP42Effect of recirculation on carbon dioxideremoval and patient paCO2 during veno-venousextracorporeal membrane oxygenation inadults - preliminary results of an observationalclinical trialGehron J.1, Bandorski D.2, Villanueva A.1, Bödeker R.-H.3,Röhrig R.4, Böning A.11Universitätsklinikum Gießen und Marburg GmbHStandort Gießen, Klinik für Herz-, Kinderherz- undGefäßchirurgie, Gießen, Germany, 2UniversitätsklinikumGießen und Marburg GmbH Standort Gießen, MedizinischeKlinik und Poliklinik II, Gießen, Germany, 3Justus Liebig-Universität Gießen, Institut für Medizinische Informatik,Gießen, Germany, 4Universitätsklinikum Gießen undMarburg GmbH Standort Gießen, Klinik fürAnaesthesiologie und operative Intensivmedizin - SektionMedizinische Informatik, Gießen, Germany

Objectives: Recirculation is a multifactorial event during veno-venousECMO which results in a variable fraction of oxygenated blood flowingback into the ECMO system due to the proximity of the draining and thedelivering cannula. It is thought to result in a reduced carbon dioxideremoval (VCO2) and oxygen delivery (DO2). The assumed increase inarterial pCO2 and decrease in arterial pO2would inhibit the reduction ofmechanically stressing ventilator settings and thus be clinically rele-vant. Several authors reported the recirculation fraction to be as high as50%. Quantifiable results to support the hypothesized reduced VCO2dueto a high recirculation fraction have unfortunately not been published sofar.Methods: To evaluate the relevance of recirculation we conducted aprospective study which included adult patients requiring veno-venousECMO between May 2012 and August 2013. In 5 out of 19 patients wemeasured the carbon dioxide removal within the ECMO system along-side the recirculation fraction quantified with an ultrasound dilutiontechnique. The patient arterial pCO2 was measured as a secondaryclinical endpoint to reveal a possible interdependence with the recircu-lation. Results: The VCO2 showed a reverse quadratic curve shapewithinan flow range of 2 - 7 l * min�1. It increased until the onset ofrecirculation around ECMO flows of 3 - 4 l * min�1 and markedlydecreased with a further flow rise. Despite a markedly varying VCO2 thepatient paCO2 remained nearly constant within the whole flow range(Fig. 1).


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Fig. 1

Conclusions: Although we could detect an impact of recirculation withvalues around 25 - 30% on the gas transfer characteristics of the ECMOsystem an increasing gas transfer inefficiency seems to have no negativeimpact on arterial blood gases. We hypothesize that recirculationirrespective of its magnitude does not negatively affect the arterialblood gas status of the patients and does not exclude preventiveventilatory settings.

OP43Postoperative hemodynamic benefit ofBosentan-pretreatment for high-risk patientsundergoing pulmonary endarterectomyKunihara T.1, Takahashi H.1, Gafencu L.1, Gafencu D.1,Aicher D.1, Wilkens H.2, Halank M.3, Held M.4, Schäfers H.J.11University Hospital of Saarland, Thoracic andCardiovascular Surgery, Homburg, Germany, 2UniversityHospital of Saarland, Pulmonology, Homburg, Germany,3Carl Gustav Carus University Hospital, Internal Medicine I,Dresden, Germany, 4Academic Teaching Hospital of theJulius Maximilian University of Würzburg, Mission MedicalHospital, Würzburg, Germany

Objectives: Hemodynamic instability early after pulmonary endarter-ectomy (PEA) for chronic thromboembolic pulmonary hypertension(CTPHT) can be a challenge in intensive care management. It is stillunclear whether pretreatment modifies early postoperative course andhemodynamic response after PEA. We sought to investigate the effect ofBosentan-pretreatment for high-risk patients undergoing PEA.Methods: Since 2003, 24 patients with CTPHT underwent primaryPEA following Bosentan-pretreatment (2-8 months, 4.0 � 2.1 months,group-B). Indication for pretreatment was severe PHTwith discrepancybetween pulmonary hypertension and extent of angiographic involve-ment. 24 control patients were selected using propensity score-match-ing (group-C). There were no significant differences between groups inpreoperative baseline characteristics including pulmonary hemody-namics. Results: Eearly mortality was identical between groups (3/24). Desobliterated segments were similar between groups (group-B:13.2 � 2.4 segments, group-C: 14.2 � 3.0 segments, P¼0.194). Postop-erative maximum dosage of noradrenalin was comparable (group-B:0.34 � 0.38 µg/kg/min, group-C: 0.43 � 0.44 µg/kg/min, P¼0.481).Systolic pulmonary artery pressure (PAP) at 24 and 48 h after PEA wassignificantly lower in group-B (38.5 � 9.2, 38.3 � 6.8 mmHg) comparedwith group-C (44.9 � 11.0, 46.3 � 14.7 mmHg) (P¼0.046, P¼0.025,respectively), as well as mean PAP (group-B: 22.8 � 4.5, 22.1 � 3.8mmHg, group-C: 27.5 � 6.6, 26.0 � 5.3 mmHg) (both P¼0.005).Pulmonary vascular resistance at 24 and 48 h after PEAwas significantlylower in group-B (225 � 104, 206 � 97 dynes·s/cm5) than group-C (345� 123, 286 � 95 dynes·s/cm5) (P<0.001, P¼ 0.006). There was nosignificant difference in intubation time and length of stay in intensivecare unit. Conclusions: Pretreatment with Bosentan has advantageouseffect on postoperative hemodynamic response in patients at high riskfor PEA. Its effect on vasopressor requirement is limited.

OP44Management of pump thrombosis: Deviceexchange versus thrombolysisÖzpeker C.U.1, Schönbrodt M.1, Börgermann J.2, GummertJ.1, Morshuis M.11HDZ NRW, Herz-und Thoraxchirurgie, Bad Oeynhausen,Germany, 2HDZ NRW, Bad Oeynhausen, Germany

Objectives: Pump thrombosis of especially LVAD’s is one of the mostcommon reasons for device failure leading to hemolysis, reduced floworeven acute pump stop. Systemic thrombolysis (STl) and device exchange(DEx) are the only treatment options in acute pump thrombosis. The aimof this study was to compare these two therapeutic options in outcomeand to develop a decision tree for management of pump thrombosis.Methods: Since the year 2006, 24 LVAD (gender: male n¼18;female 6)DEx were necessary due to pumpthrombosis. (n¼25,in one pt. 2exchange were necessary). STl with Tecneplase or Alteplase wereperformed with 17 sequences in twelve pts (gender male n¼8; femalen¼4, in one female patient four sequences) (see Table 1). All DExprocedures and STl treatments were retrospectively analyzed.

Table 1: Device exchange vs. Systemic thrombolysis

LVAD-Device

Thrombolysisseq/pt

Succesratepos/neg

Exchangeafter lysis

Exchangeseq/pt

Exchange(mort.<48 hrs)

HMII 5/4 2/3 2 15/14 2

HVAD 12/8 11/1 1 5 (2 RVAD) 0

HeartAssist 0 0 0 2 1

Coraid 0 0 0 1 0

Results: In the DEx cohort three pts. expired within 48 hrs after theoperation. 18 pts. could be discharged from the hospital after exchange.Six pts. expired after pump exchange due to poor preoperative status.The mean duration for MCS support was 466.8 before exchange. Thepost-operative hospital stay was mean 24 days. Redo thoracotomybecause of bleeding was necessary in 4 pts. In the thrombolysis cohort8 pts. survivedwithout major bleeding complica-tions. In 3 pts. DExwasnecessary after systemic lysis. Conclusion: HTx is still the gold standardin device failure. If this is not possible due to donor organ shortage, a DExor STl should be performed. STl is as-sociated with a minimum risk ofcomplications, but strongly depends on the device and right timing ofthe treatment. STl seems to be a good option in HVAD pts, if there is nocontraindication, this should be the first line therapy. In the HMIIpatient, STl is less efficient, DEx may be a better option. Differentcharacteristics of thrombus formation and a different thrombus struc-ture could be an explanation of the difference in successrate of STl inboth devices.

OP45High fat diet and pressure overload: Relation ofmitochondrial function and contractile functionSchrepper A.1, Schwarzer M.1, Freiberger S.1, Doenst T.11Jena University Hospital - Friedrich-Schiller-UniversityJena, Department of Cardiothoracic Surgery, Jena, Germany

Background: High fat intake is associated with obesity and cardiovas-cular disease leading to heart failure (HF). HF in term is directlyconnected to mitochondrial dysfunction. However, high fat diet (HFD)is protective in animal models of heart failure. We speculated that thiseffect of HFD under pressure overload is associated withmaintenance ofnormal mitochondrial function. Methods: Rats were fed standard diet(SD) or high fat diet ad libitum and underwent transverse aorticconstriction (TAC) to induce pressure overload (PO) HF. We assessedcardiac function by echocardiography and isolated mitochondria toassess mitochondrial function (respiratory capacity-RC) at 2, 10 and20 weeks (W) of TAC. Results: TAC resulted in cardiac hypertrophy at 2and 10 W (LV wall: 10 W C 3,45 � 0,16 vs. SD-TAC 5,22 � 0,32 vs. HFD-TAC 6,36 � 0,29 mm) and HF after 20 W. Animals fed HFD showed moresevere hypertrophy but no evidence of systolic dysfunction after 20 W(FS:48,2 � 1,2 vs. 23,6 � 0,8 vs. 44,5 � 1,4%). HFD also reduced the POinduced diastolic dysfunction (E/E': 16,6 � 1,1 vs. 33,9 � 2,6 vs. 25,0 �


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2,1). In contrast, HFD significantly diminished mean survival time afterTAC (SD-TAC 19,05 vs. HFD-TAC 12,19 W). PO significantly reducedmitochondrial function at 20W. This effect of POwas not altered by HFD(glutamate: 623� 109 vs. 186� 12 vs. 189� 12; succinate: 739� 99 vs.580 � 56 vs. 361 � 36 natmosO/min/mg). Conclusion: HFD maintainscardiac function during pressure overload but not survival and mito-chondrial function. These results argue against a direct relation ofcontractile function and mitochondrial function.

OP46Isolated RVAD implantation - first results fromthe EUROMACS registryBernhardt A.M.1, De By T.M.M.H.2, Reichenspurner H.1,Deuse T.11Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2Euromacs, Berlin,Germany

Objectives: Once, right ventricular dysfunction occurs, it is difficult totreat and associated with high mortality. Temporary short-term devicesfor right ventricular assistance are available and have been used fortemporary right heart support. Recently, isolated RVAD implantationwith HVAD devices has been reported. However, isolated implantationon the right side is rare and still an off-label use. For this study data fromthe EUROMACS database in which procedures and outcomes data forpatients receiving mechanical circulatory support are registered, wereused. Methods: Until September 2013 data of 37 patients (mean age56.0� 12.9 years, 64.9% male) with an isolated RVADwere submitted tothe EUROMACS registry. Thirty patients received a Levitronix Centri-Mag, 7 patients an HVAD, and one patient another device. All patientswere in INTERMACS class 1,2, or 3. One patient was switched fromLevitronix to HVAD. Results of the EUROMACS registry were analysed.Results: Inflow cannulas were implanted into the RA in 16 patients, theRV in 15 patients and the inflow site was not specified In 7 patients.Mean RVAD flowwas 5.0� 0.9 l/min at 3452� 627 rpm in the Levitronixgroup and 4.8 � 1.2 l/min at 2440 � 476 rpm in the HVAD group. Inpatients supported by a Levitronix CentriMag, the device was explantedin 36.7%. Mean support time on the Levitronix Centrimag device was16.3 � 23.1 days. The 30 day survival was 26.7%. One patient wasswitched from Levitronix to an HVAD. In patients with an HVAD, 30-daysurvival was 42.3%. In the surviving 3 patients, 1 patient was trans-planted after 419 days, one device was explanted after 40 days due topump thrombosis and recovered RV function, one patient is still on thedevice after 494 days. Conclusion: In this very specific and sick patientcohort, isolated RVAD implantation is associatedwith acceptable results,especially after HVAD implantation.

OP47Minimally invasive implantation of leftventricular assist devices improves theoutcome in INTERMACS -1 patientsRojas S.V.1, Fleischer B.1, Avsar M.1, Hanke J.S.1, Ahrens P.R.1,Tümler K.A.1, Deutschmann O.1, Rojas Hernandez S.2, BaraC.1, Malehsa D.1, Haverich A.1, Schmitto J.D.11Medizinische Hochschule Hannover, Klinik für Herz-,Thorax-, Transplantations- und Gefäßchirurgie, Hannover,Germany, 2Medizinische Hochschule Hannover, Klinik fürAnästhesiologie und Intensivmedizin, Hannover, Germany

Objectives: LVADs are gaining more importance in the treatment ofterminal heart failure. Nevertheless complications like bleeding or rightventricular failurewith liver impairment remainmajor hurdles in LVAD-surgery. The constant development of novel technologies has generatedconsiderably miniaturized LVAD-systems enabling minimally invasiveimplantation procedures. However, clinical experience with MIC LVADsurgery is still limited and predominantly applied to non-terminalpatients. In this comparative studywewanted to elucidate the operativeoutcome of the first series of INTERMACS I patients who received MICLVAD surgery. Methods: We reviewed the early outcome of 38 conse-cutive end-stage heart failure patients with INTERMACS-1 level whounderwent LVAD (HVAD, HeartWare) implantation in our institutionbetween 2010 and 2013. Patients whowere operated conventionally by

a median sternotomy (group A; n¼26) were compared to patientsreceiving a minimally invasive upper hemisternotomy combined withan anterolateral thoracotomy (group B; n¼12). Results: Demographics:74% male, age 52,8 � 15,2 y, ICM 63%, DCM 5%. The Intra-hospital-mortality was lower in group B (15,4% vs. 0%). The mean ICU stay wassignificantly lower (p< 0.05) in group B (24,8 � 4,0 days vs. 14,3 � 4,2days). Additionally the incidence of bleeding requiring surgery was alsosignificantly (p< 0.05) lower in group B (23,1% vs. 0%). PostoperativeBilirubin levelswere also significantly (p<0.05) lower in groupB (78,2�22,8 U/L vs. 34,2 � 10,9 U/L). Conclusions: Our data show that theapplied minimally invasive LVAD-implantation technique improved theintra-hospital outcome of INTERMACS-1 patients by reducingmortality,liver impairment, ICU stay and bleeding events.

Basic Science I: Tissue Engineering & Arrhythmias

OP48Human iPS-cell-derived engineered heart tissuefor cardiac repairPecha S.12, Weinberger F.2, Breckwoldt K.2, Geertz B.2,Starbatty J.2, Schaaf S.2, Hansen A.2, Reichenspurner H.1,Eschenhagen T.21Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitätsklinikumHamburg Eppendorf, Institut für ExperimentellePharmakologie und Toxikologie, Hamburg, Germany

Objectives: Engineered heart tissue patches might provide a futureoption for the therapy of terminal heart failure. Recent advantages instem cell biology allow the generation of large numbers of humaninduced pluripotent stem cell derived cardiomyocytes (hiPS-CM). Herewe investigated if human iPS-cell derived engineered heart tissue(hEHT) grafts support left ventricular function in infarcted hearts ofguinea pigs, a species with a relatively human-like cardiac physiology.Methods: Human iPS-cells were generated by retroviral reprogram-ming of dermal fibroblasts. Subsequent cardiac differentiation wasperformed using an embryoid body-based three-stage differentiationprotocol, resulting in �50% cardiomyocytes. EHT grafts were createdfrom hiPS-CM (7 million cardiomyocytes per EHT). Left ventricularmyocardial cryoinjury was induced in adult female guinea pigs(n¼10). 7 days after injury either hEHT grafts (2 per animal, n¼5) ornoncontractile constructs (n¼5) were implanted. Functional param-eters were examined by echocardiography at baseline and 7 and 35 daysafter cryoinfarction. Histological analysis of graft survival was assessed28 days after transplantation. Results: Histological and immunohisto-chemical staining for H&E, Massons Trichrome and dystrophin showedsurvival of iPS-cell derived cardiomyocytes 28 days after transplanta-tion. Human origin of surviving cardiomyocytes in the scar area wasdemonstrated by fluorescent-in-situ-hybridization. Echocardiographyshowed significantly reduced left ventricular ejection fraction (LVEF)and fractional area shortening (FAS) as well as left-ventricular dilatation7 d after cryoinfarction in all animals. Animals receiving cell-freeconstructs showed further left ventricular dilatation 35 day after injury,whereas hEHT-implantation attenuated dilatation of the left ventricle.Furthermore echocardiography showed significantly improved leftventricular function (EF and FAS) in the hEHT group compared toanimals receiving noncontractile constructs. Conclusion: This study ina small group of animals provides the first and still early evidence thathiPS-CM EHTs survive after transplantation in infarcted guinea pighearts and enhance cardiac contractile function in this model ofmyocardial injury.


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OP49Low-flow conditioning of decellularized and re-seeded homografts in a novel pulsatilebioreactorHaller N.12, Hollweck T.1, Koenig F.1, Thierfelder N.1,Wintermantel E.2, Hagl C.1, Akra B.11Medical Center Munich University, Department of CardiacSurgery,München, Germany, 2Technical UniversityMunich,Chair of Medical Engineering, Garching, Germany

Objective: Cardiovascular tissue engineering has emerged as a promis-ing approach to overcome the limitations of conventional heart valvesubstitutes bymimicking a native heart valve. The objective of this studywas to present the effect of long-term conditioning on the quality ofvascular tissue engineered prostheses. Methods: Cryopreserved andthawed homografts were decellularized by a detergent mixture. Decel-lularized homografts were primarily seeded with fibroblasts (FB) fol-lowed by colonization with endothelial cells (EC), both isolated fromhuman saphenous vein segments. Re-seeded homografts were exposedto low-flow conditions (750 - 1100 mL/min) for a time period of 12 d.Topographical examination was performed by scanning electron mi-croscopy (SEM). Cell layer thickness, composition of extracellular matrix(ECM) and inflammatory response was investigated by immunohis-tochemistry (IHC). Results: SEM analysis of re-seeded homograftsshowed a confluent and intact cellular coverage before and afterconditioning. IHC demonstrated a distinct thickening of cellular layer.Cell specific staining demonstrated a confluent EC lining with a multi-layer of FB underneath. The expression of ECM components, cytoskeletaland gap junctional proteins increased by conditioning. Inflammatoryproteins were expressed in a low level. Conclusion: The present studydemonstrates that long-term conditioning of decellularized and re-seeded aortic homografts in a low-flow pulsatile bioreactor results inan improved quality of tissue engineering constructs. Moreover, condi-tioning results in an increased quality of ECM in regard to connectivity,stability and cell communication, creating native-like heart valveprostheses.

OP50Towards the development of a bioartificial lung- establishment of a haemocompatibleendothelialisation on TiO coated gas exchangemembranesPflaum M.12, Kauffeldt M.3, Schmeckebier S.12, Schein J.3,Haverich A.124, Wiegmann B.124, Korossis S.121Hannover Medical School, Leibniz Research Laboratoriesfor Biotechnolgy and Artificial Organs, Hannover, Germany,2German Centre for Lung Research, Hannover, Germany,3University of Federal Armed Forces Munich, Neubiberg,Germany, 4Hannover Medical School, Department ofCardiothoracic, Transplantation and Vascular Surgery,Hannover, Germany

Objectives: Lung transplantation (Tx) remains the only curative therapyoption for end stage lung disease. Due to an increasing mismatch oforgan donors to organ recipients there is a high mortality rate on theorgan waiting list. As bridge to Tx extracorporeal membrane oxygen-ation (ECMO) is a common clinical use. Deposition of thrombus forma-tion and other blood components within the ECMO cause its clinical useup to a few weeks. Therefore, the basic idea is to improve the haemo-compatibility by endothelialisation of the poly-4-methyl-1-pentene gasexchange membranes (PMP), which necessitates the development ofcoating techniques for the mediation of endothelial cell adhesion to thehydrophobic polymeric materials. The pulsed vacuum cathodic arcplasma deposition (PVCAPD) technique has been shown to enable thecoating of thermosensitive polymers. Hence the eligibility of Titanium-oxides (TiO) deposited on PMP using PVCAPD as an effective coatingtechnique for enabling the endothelilization was assessed. Methods:PMP film samples (3 x 3 cm) were coated with TiO via the PVCAPDtechnique and analyzed with SEM and EDX. Umbilical cord bloodderived endothelial cells (hCBECs) were seeded on such samples (1 x104/cm2) and incubated for 24 h. The established monolayers weresubjected to a leucocyte adhesion assay and gene expression analysis viarealtimePCR. Flow resistance and self-healing capacity were assessed in

a laminar flow chamber applying 30 dyne/cm2 for 24 h. Results: SEMand EDX analysis confirmed the homogeneous deposition of TiO par-ticles with a diameter <10 nm. hCBECs exclusively adhered to areas of aPMP film coated with TiO. Gene expression analysis of activation-relevant marker genes revealed that the endothelial cells seeded onthe TiO coated surface retained the non-activated, anti-thrombogenicstate, additional confirmed by a leucocyte adhesion assay. Furthermore,the establishedmonolayer was resistant to a high physiologic shear rateof 30 dyne/cm2, for 24 hours. Finally besides film PMP, the coatingtechnique was successfully applied to 3D hollow fibre PMP where ECsestablished confluent monolayers. Conclusion: TiO coating via thePVCAPD is an eligible technique for the gentle coating of the thermosensitive PMP gas exchange membranes. The coating enabled thegeneration of a non-activated and flow-resistant endothelial monolayerand thus, an important step towards the development on a hemocom-patible bioartificial lung.

OP51Development of recipient-matched engineeredheart tissue using 3D printingYildirim Y.1, Pecha S.1, Hakmi S.1, Alassar Y.1, ZimmermannW.H.2, Eschenhagen T.3, Reichenspurner H.11Universitäres Herzzentrum Hamburg, Hamburg,Germany, 2Institut für Pharmakologie, Göttingen,Germany, 3Institut für Experimentelle Pharmakologie,Hamburg, Germany

Objectives: Engineered pouch-like heart muscle constructs can beapplied as heart-embracing cardiac grafts in vivo and might be usedas biological ventricular assist devices (BioVAD®). Implantation studiesshowed micro-gaps between the graft and native heart due to a shapemismatch. The incoherence can lead to electrical coupling problems andloss of support force. Here we developed a procedure to create BioVADsindividually matched to the recipient heart. Methods and Results: IngroupA, small animalmagnetic resonance imaging (MRI) heart scanwasperformed in female wistar rats (n¼10). 3D reconstruction of enddias-tolic MRI data was performed and used to create a three-dimensionalmodel of the heart by 3D printing. We used the recipient-matched 3Dheart model and grew BioVADs from neonatal rat heart cells, fibrinogenand serum-containing culture medium. In group B, instead of the 3Dheart model, a spheric glas spacer (diameter 10 mm) was used toconstruct pouch like BioVADs. The engineered tissuebeat spontaneouslyand showed contractile properties of native heart muscle includingpositive inotropic responses to calcium and isoprenaline. In group Arecipient heart matched BioVADs were implanted into the correspond-ing healthy rats (n¼10), while in group B the spheric BioVADs wereimplanted (n¼10). 14 days after implantation heartswere explanted forhistology. Histological analysis of recipient-matched BioVADs showedexcellent coverage of the epicardial heart surface, while spheric BioVADsshowed high number of micro and macro gaps. Furthermore directalignment of the BioVADs and recipients hearts was measured in cross-sectioned histological compounds. In group B, a statistically highernumber of areas with loss of contact between BioVADs and recipienthearts was seen compared to group A (67% vs 38%; p<0.001)Conclusion: We developed a novel casting technology using smallanimal MRI and 3D printing to generate artificial cardiac tissue that isperfectly matched to the recipient heart and exhibits structural andfunctional properties of native myocardium.

OP52Mechanical integrity of colonized homograftsafter stenting, crimping and perfusionEilenberger S.1, Hollweck T.1, Haas U.1, Uhlig A.1, Hagl C.1,Akra B.11Klinikum der Universität München, HerzchirurgischeKlinik, München, Germany

Objective: About 3% of the population in Germany older than 75 yearssuffers from aortic valve diseases. In high-risk patients, transcathetervalve replacement is becoming the gold standard for the treatment ofend stage aortic valve stenosis. The aim of this study was to evaluate thefeasibility of using decellularized homografts for the development of


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transcatheter heart valves. Methods: Fibroblasts and endothelial cellswere isolated from human saphenous vein segments and expanded inculture. Homografts were thawed according to a standard procedureand decellularized by detergents. After decellularization, valves werestented and consecutively seeded with fibroblasts and endothelial cellsusing a special dynamic seeding device. To evaluate the mechanicalintegrity of the new created valves, crimping and perfusion steps wereapplied. Stented homografts were exposed to physiologic flow condi-tions (t1¼24 h at 1 l/min, t2¼24 h at 1.5 l/min, t3¼24 h at 2 l/min) usinga high flow bioreactor with a computer-guided actuation unit. Sampleswere taken from the native valves and after each processing steps andfinally analyzed by scanning electron microscopy and immunohis-tochemistry. Results: Scanning electron microscopy demonstrated aconfluent cellular coating of re-seeded homografts. Perfused samplesrevealed an inhomogenous cellular coating. A partial damaged endo-thelial lining with an intact fibroblast layer underneath was alsodetected by immunohistochemistry. Conclusion: The perfusion of tissueengineered transcatheter homografts affects the integrity of the endo-thelial layer. This is probably due to the crimping process that inducesinvisible damages in the endothelial cell layer.

OP53Surface modified PTFE promotes endothelialcell adhesion and simultaneously inhibits theattachment of platelets and bacteriaGabriel M.1, Weiler H.1, Mehlhorn U.1, Vahl C.-F.11UniversitätsmedizinMainz, Klinik und Poliklinik für Herz-,Thorax- und Gefäßchirurgie, Mainz, Germany

Objectives: Thrombosis is one major cause of poor patency of syntheticvascular grafts. Amongst others, the latter is promoted by the absence ofendothelialization. In addition, commonly used prosthetic materials - e.g. polytetrafluoroethylene (PTFE) - are prone to bacterial biofilmformation. The present study aims at the development of a PTFE-surfacemodification offering antifouling as well as endothelial cell-adhesiveproperties. Polyethyleneglycol (PEG) was used as a spacer moleculesimultaneously providing antifouling effects. Additionally endothelial-cell (EC) specific adhesion peptide REDVwas used for endothelialization.Methods: PTFE was surface activated by a wet-chemical procedure,followed by direct (PTFE-REDV) or PEG-mediated (PTFE-PEG-REDV)peptide immobilization. Modified and untreated samples were seededwith ECs and monitored for a period of 2 weeks. In addition, specimenwere tested with thrombocytes and Staph. aureus. Fluorescent-stainedsamples were analyzed using ImageJ software and results were ex-pressed as percent coverage.Results:REDV-conjugationwith orwithouta PEG-spacer converts PTFE into an excellent substrate for cell-growth insharp contrast to unmodified material. Colonization of ECs on modifiedsubstrates reached appr. 21% (PTFE-REDV) and appr. 18% coverage(PTFE-PEG-REDV) respectively after 2 weeks. Thrombocyte attachmentwas reduced 35-fold (PTFE-PEG-REDV) and 26-fold on PTFE-REDV. Thelatter result may be explained by themere hydrophilicity of this surface.In addition, the modification largely prevented bacterial attachment.Conclusions: Thrombogenicity and device-associated contaminationcan effectively be reduced by an appropriate functionalization. Forvascular prosthesis, where endothelialization is desirable, the combina-tion of cell-specific adhesiveness and antifouling properties may pro-vide a basis for the development of novel (small-diameter) vasculargrafts.

Fig. 1: PTFE-PEG-REDV

OP54Late procedural success after ablation of atrialfibrillation correlates with BMI and adipokine-profilesNiemann B.1, Dominik E.1, Schweizer I.2, Roth P.1, Orhan C.2,Li L.2, Böning A.1, Rohrbach S.21Justus Liebig Universität Giessen, Klinik für Herz-Kinderherz- und Gefäßchirurgie, Giessen, Germany, 2JustusLiebig Universität Giessen, Physiologisches Institut, Giessen,Germany

Objectives: Atrial-fibrillation (Afib) is the most common arrhythmiaand one of the leading causes of death. Beside cardiac morbidity, obesityand metabolic imbalance are involved in the pathogenesis. Surgicalablation allows high rates of postprocedural freedom from Afib buttherapeutical success is counterbalanced by late recurrence of Afib. Inaddition to conventional antiarrhythmic therapy adipocytokines mightprovide additional therapeutic options to stabilize long-termproceduralsuccess.Methods:We initiated a prospective all-comers-study. Patientsunderwent pre- and postoperative monitoring and standardized left-atrial ablation (paroxysmal Afib) or bi-atrial ablation (persistent / longstanding persistent Afib) with bipolar radiofrequency. An event record-er (ER)was implanted in all patients. Left and right atrial appendices andepicardial adipose tissue were cryo-conserved together with serumsamples. Half-yearly follow-up monitoring was initiated (ER, TTE,plasma, body weight). We investigated adipocytokine profiles, param-eters of mitochondrial biogenesis and function, glucose and fat metab-olism and myocardial fibrosis in the according tissue or serum samples(ELISA, qPCR,Western Blot). Results: AMAZE procedure was performedin 105 patients (31 paroxysmal; 74 persistent). Overall freedom fromatrial fibrillation was reached in 72% of patients after 6 month and 64%after 12 month. Primary therpeutical success correlated negatively withLA diameter and LV EF but also with BMI and adipocytokine expressionbut not with patient’s age. Reduced adiponektin levels were observed inpatients who were subjected to primary therapeutical failure or recur-rence of atrial fibrillation. Those patients exhibit reducedmitochondrialfunction (complex I -20%), reduced mitochondrial biogenesis and signsof increased myocardial fibrosis (LA>RA). Levels of triglycerides andcholesterol are elevated in plasma and tissue. On the other hand, lateprocedural success (12 months) was enhanced in lean patients andindividuals that normalized body weight. Conclusions: Surgical MAZEprocedures enable high rates of freedom from Afib. Metabolic dysba-lance contributes negatively to primary procedural success but also tolate freedom from Afib. Therapeutically targeting of adipocytokinebalance might offer an additional option in MAZE patients to reach/stabilize freedom from atrial fibrillation.


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Congenital heart diseases I: EMAH

OP55The RVOT conduit registry: Freedom fromexplantation of various conduit typesHorke A.1, Hemmer W.2, Sandica E.3, Rüffer A.4, CesnjevarR.4, Ciubotaru A.1, Boethig D.11Medizinische Hochschule Hannover, Herz-, Thorax,Transplantations- und Gefäßchirurgie, Hannover,Germany, 2Sana Herzchirurgie, Stuttgart, Germany, 3Herz-und Diabeteszentrum NRW, Klinik für Kinderherzchirurgieund angeborene Herzfehler, Bad Oeynhausen, Germany,4Universitätsklinikum Erlangen, KinderherzchirurgischeAbteilung, Erlangen, Germany

Objectives: Right ventricular outflow tract (RVOT) conduits have limit-ed durability, modified by many factors. Selecting the most durable onerequires large data sets. We therefore pooled uniformly collected data of4 centres. Methods: 1695 conduits were implanted between 1980 and2013. Implantation reason: 896/ 53% Ross operations, 799/ 47% congen-ital malformations - among them 433/ 48% with Fallot tetralogy, 121/14% Truncus arteriosus, 105/ 12% pulmonary valve atresia, 81/ 9% DORV,65/ 7% pulmonary valve dysfunction, 64/7% transposition of greatarteries, 27/ 3% others. An overview on patient age and conduit typedistribution is given in the results table. Freedom from explantationwascalculated (Kaplan Meier) and compared over strata (log rank tests).Follow-up time ranges from 0 to 25 years, mean 5.7, total 9375 years.Results: see table.

Table 1: Freedom from explantation at 5/10/15 years

Age [years]Conduit(n/%)

<1 1–6 6–25 25–40 >40

Contegra(461/ 28%)

n¼100;79/54/-%

n¼10388/75/-

n¼22394/84/-

n¼2891/-/-

n¼7 -/-/-

Cryolife(73/ 4%)

0 n¼1100/0/-

n¼5 -/-/- n¼11-/-/-

n¼56 -/-/-

Freestyle(52/ 3%)

0 0 n¼5<¼33/-/-

n¼16<¼68/-/-

n¼31 100/-/-

Hancock(101/ 6%)

n¼12;43/14/-

n¼2085/45/0

n¼6096/71/71

n¼6 75/-/- n¼3 -/-/-

Homograft(856/ 52%)

n¼2858/26/16

n¼6464/41/20

n¼21492/83/64

n¼17699/94/90

n¼37499/98/92

Espoir�

(78/ 5%)n¼3 -/-/- n¼11 -/-/- n¼52

100/-/-n¼11 -/-/- n¼1 -/-/-

Tissuemed(30/ 2%)

n¼23 0/-/- n¼633/33/0

n¼1 0/-/- n¼0 0

all (n,%) n¼16610%

n¼205 12% n¼56034%

n¼24815%

n¼472 29%

p <0.001 0.002 <0.001 <0.001 0.99

Table legend: Conduit types (except 44 of rare types) are followed bynumber /% of implantations, table cells contain patient numbers fol-lowed by freedom from explantation at 5/ 10/ 15 years. *Espoir, Hann-over Medical School, Hannover, Germany: decellularized freshhomografts. Conclusion: The large data set shows important durabilitydifferences within the age stratified groups, supporting the age-specificchoice of a durable conduit. Nonetheless, further data is needed tocomplete the evidence for all age groups.

OP56Size matters: Longevity of valved RVOTconduits is mainly related to the conduitdiameterSachweh J.S.1, Rueffer A.2, Walk J.1, Biermann D.3, MuellerG.4, Reichenspurner H.3, Riso A.1, Cesnjevar R.21Universitäres Herzzentrum Hamburg, Herzchirurgie fürangeborene Herzfehler, Hamburg, Germany,2Universitätsklinikum Erlangen, KinderherzchirurgischeAbteilung, Erlangen, Germany, 3Universitäres HerzzentrumHamburg, Herz- und Gefäßchirurgie, Hamburg, Germany,4Universitäres Herzzentrum Hamburg, Kinderkardiologie,Hamburg, Germany

Objectives: Reconstruction of the right ventricular outflow tract (RVOT)deemed necessary in many cardiac anomalies and is the most frequentsurgical procedure in adults with congenital heart disease. RVOTreconstruction is often facilitated with a valved conduit; however, thetype of conduit is still a matter of debate, as are the factors affecting itslongevity. Methods: Between 03/1997 and 12/2007 145 RVOT conduits(Contegra® n¼50, Homograft n¼38, Hancock® n¼36, Shelhigh®n¼18, Labcor® n¼2, Matrix® P n¼1) were implanted in 119 patients((age 8.9� 10.1 years (4 days - 57 years); bodyweight 28.9� 24.4 kg (2.3- 103 kg)). Patients with Labcor® and Matrix® conduits were excludedfrom further investigation due to small numbers. Follow-up of thisretrospective study was obtained until 09/2013. Freedom from reoper-ation (n¼34) and intervention (Conduit dilatation or interventionalvalve replacement) (n¼10) was analysed with regard to type anddiameter of the conduit; age, body surface area (BSA), Nakata-Index,and numbers of previous cardiac operations at time of conduit implan-tation. Results: Follow-up was 5.9 � 3.4 years (1 day - 15 years; 838patient-years) and complete. Surgical mortality was 1.7% and latemortality 2.6% not related to conduit failure. Freedom from reoperationand interventionwas 96.4, 85.4, 71.4, and 54.5% after 1, 4, 8, and 10 yearswith no significant difference for aortic and pulmonary homografts(p¼0.156). Univariate analysis revealed a longer freedom from reoper-ation and intervention for the Hancock® conduit in comparison to theContegra® (p¼0.022) and Shelhigh® conduit (p¼0.031) and by trendin comparison to homografts® (p¼0.052). Freedom from reoperationand intervention was influenced by the diameter of the conduit(p¼0.001), and age (p¼0.07) and BSA (p¼ 0.08) at time of the opera-tion; it was not affected by the preoperative Nakata index (p¼0.542)and the number of previous cardiac operations (p¼0.107). Multivariateregression analysis confirmed only diameter of the conduit as factoraffecting freedom from reoperation and reintervention (p¼0.039)Conclusion: In this large series, longevity of the valved conduits inthe RVOT is influenced by the diameter of the valve substitute.

OP57Short-term experience using Cormatrix asaortic leaflet replacement or extension inpediatric patientsHofmann M.1, Schweiger M.1, Burkhardt B.2, Dave H.1,Lemme F.1, Romanchenko O.1, Schmiady M.1, Hübler M.11Kinderspital Zürich, Universitäts-Kinderkliniken,Abteilung Kinderherzchirurgie, Zürich, Switzerland,2Kinderspital Zürich, Universitäts-Kinderkliniken,Abteilung Kinderkardiologie und angeboreneHerzerkrankungen, Zürich, Switzerland

Objectives: The preservation and repair of aortic valve has emergedover the last years. The greatest benefit to avoid valve prosthesis can beexpected for the congenital population. Currently used biological patchmaterials are associated with limited longevity. A recently introducednew patch, made of decellularized porcine small intestinal submucosaextracellular matrix (CorMatrix®) presents promising characteristics.Methods: We prospective analysed our procedural success, short- andlong-term outcome in pediatric patients (<19 ys.) undergoing aorticvalve repair using Cormatrix® either as complete leaflet replacement orleaflet extension. So far (April 2013 - July 2013) we operated 6 pediatricpatients (mean age 94.4 months, range: 1 mo.- 14 ys.). Indications forsurgery were severe aortic valve stenosis (AS) (n:4) or severe aorticregurgitation (AR) (n:2). Follow-up echocardiography was done direct


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postoperatively, at the time of discharge and after three months.Results: Pathology in the 4 patients with AS were: unicuspid valve(n:2) and bicuspid valve (n:2). Preoperative mean TPGmean was 41.3mmHg (� 16.9), mean TPGmax was 82.5 mmHG (� 25.4). Mean followup period is 40.7 days (� 31.4; rang 21-104). 30 day mortality is 0%, allpatient are currently at home. Mean TPGmean is 16.75 mmHG (� 3.8),mean TPGmax is 32.75 mmHG (� 5). One patient is noticed with severeaortic regurgitation, two patients have a mild insufficiency respectivelya minimal central jet. Conclusions: Experiences using Cormatrix® foraortic cusp replacement or extension is limited. In our small populationit seems to be safe. Further investigation addressing AR and growthpotential will be evaluated.

OP58Performance of stented biological valves forpulmonary valve replacementBuchholz C.1, Koch A.M.2, Purbojo A.1, Toka O.2, Dittrich S.1,Cesnjevar R.A.1, Rüffer A.11Universitätsklinikum Erlangen, KinderherzchirurgischeAbteilung, Erlangen, Germany, 2UniversitätsklinikumErlangen, Kinderkardiologische Abteilung, Erlangen,Germany

Objective: Our experience with isolated stented biological valves (SBV)in pulmonary position without conduit was retrospectively assessed.Methods: Thirty-nine stented biological valves (17 Edwards SAV; 12Edwards CEP; 4 SorinMitroflow; 4 Sorin SOPRANO; 4 SorinMORE)wereimplanted between 2000 and 2010. Median valve size was 23 mm(range, 19-27); median patients age and weight were 20.1 years (range,5-72) and 60 kg (range, 14-110), respectively. Thirty-five patients (90%)had previous cardiac surgery. Main diagnoses were tetralogy of Fallot(54%) and pulmonary atresia (18%). Results: There was no early mortal-ity. Follow-upwas completewith amean duration of 8.9� 3.8 years. Twopatients died late after 5.8 and 6.1 years, respectively, both not SBVrelated. In 12 patients (31%) SBV has been replaced by surgery (n¼9) orintervention (n¼3). Reason for SBV failurewere valve stenosis (n¼9) orstenosis and insufficiency (n¼3). Additionally, 2 RVOT-aneurysms and1 endocarditis were diagnosed. Freedom from SBV-replacement bysurgery or intervention was 95%, 84% and 77% after 3, 5 and 10 years,respectively. Risk factors for SBV-replacement by univariate analysiswere valve size�21mm (p¼ 0.050), lower age (p<0.01) and pulmonaryatresia (p¼0.006). The only independent risk factor by cox-regressionanalysis was lower age (hazard ratio: 0.87, confidence interval: 0.76-0.99; p¼0.036). Conclusion: SBV in pulmonary position revealedencouraging long-term results. Younger patient age and pulmonaryatresia seem to be associated with higher risk of SBV failure.

OP59Aortic arch repair in a piglet model: improvedcontractility with the beating-heart techniqueRüffer A.1, Janssen C.1, Kellermann S.1, Münch F.1, CesnjevarR.A.11Universitätsklinikum Erlangen, KinderherzchirurgischeAbteilung, Erlangen, Germany

Objectives: Repair of congenital aortic arch obstruction can be per-formed on the beating heart (BH) with selective myocardial perfusion.We hypothesized an improved postoperative cardiac performance usingthe BH-technique compared to crystalloid cardioplegia (CC) in a pigletmodel.Methods: Twentymale piglets (meanweight 11.3� 1.3 kg) wereplaced on cardiopulmonary bypass (CPB) inmoderatehypothermiawithselective antegrade cerebral perfusion, and randomized to 2 groups: BH(n¼8) or CC (n¼12). Hemodynamic assessment was performed byconductance catheter technique using inflow occlusion and dobutaminstress before and after CPB. Myocardial damage was investigated byblood-levels of Troponin-I (Tn-I) during the experiment. Results: Therewas no significant difference of crude values during hemodynamicassessment before and after CPB between groups. Comparing BH toCC in relation to baseline-levels, inflowocclusion revealed higher slopesof the load independent end-systolic-pressure-volume-relationship(ESPVR: 168 � 92% vs. 95 � 41%; p¼0.047), and Dobutamin stressshowed lower increase of end-diastolic volume (EDV: 109� 20% vs. 142

� 32%; p¼0.034) with BH, respectively. Cardiac ischemia markersincreased earlier during BH, however due to a later rise of thosemarkersin group CC there was no significant difference 2 hours after CPB. Fig.1

Fig. 1

Conclusions: Cardiac protection with the BH-technique is associatedwith improved contractility, and less left ventricular diastolic dilatationunder stress. However, ischemic changes despite continuousmyocardialperfusion comparable to standard cardioplegia are surprisingly evident.

OP60Primary cardiac tumours in infants andchildren: surgical strategy and long-termoutcomeDelmoWalter E.M.1, Javier M.F.2, von Strachwitz K.3, HetzerR.11Deutsches Herzzentrum Berlin, Herz-,Thorax-u.Gefäßchirurgie, Berlin, Germany, 2Harvard University,Cambridge, United States, 3Universitätsmedizin Berlin-Charite, Berlin, Germany

Objective: This report is a comprehensive review of our 26-yearexperience with primary cardiac tumours in infants and childrenwith emphasis on surgical indications, strategies and long-term out-come. Patients and methods: Between 1986 and 2012, 46 infants andchildren (mean age 6.6� 2.4 months, range 1 day-17 years ) underwenteither subtotal or total resection of primary cardiac tumors (rhabdo-myoma n¼13, fibroma n¼10, teratoma n¼9, myxoma n¼8, heman-gioma n¼2, rhabdomyosarcoma n¼1, non-Hodgin's lymphoma n¼1,lymphangioma n¼1). In 30 (65%), the tumours were diagnosed beforethe age of 1 year. Thirty-eight patients had an atypical heart murmur.Outflow tract obstruction of >30 mmHg was present in 11. Six wereasymptomatic. Three had abnormal coronary arteries secondary topressure from tumour bulk. Indications of resection were presence ofhemodynamic/respiratory compromise, severe arrhythmia and a signif-icant risk of embolization. Strategy of resection varied according totumor location and hemodynamic status without damage to adjacentstructures. Results: Morbidity included bleeding in a patient and atransient low output state in another. A 5-month old girl with leftventricular (LV) fibroma underwent LV assist device implantationsecondary to failure from weaning off cardiopulmonary bypass andeventually underwent heart transplantation 17 days later. Early


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mortality included a 5-month old boy who underwent complete resec-tion of LV rhabdomyoma with concomitant pulmonary valve replace-ment; unfortunately, he underwent LV assist implantation for heartfailure and died on the 13th postoperative day. An 8-month old girl with3 x 4 cm fibroma compressing the right coronary artery died of severeright heart failure on the 13th postoperative day. Late mortalityoccurred in a 16-year old boy with non-Hodgkin's lymphoma whodied 7months after the surgery.Mean duration of follow-up is 11.6�3.5years. Forty-three patients are alive and well, the majority of whom arein Ross functional classification 1. All survivors were free of tumour-related symptoms and tumour recurrence or progression, even whenthe resection is incomplete. Conclusions: This study illustrates thatalthough primary cardiac tumours in infants and children have a wideand unusual spectrum of clinical presentation, individualized approachto tumour resection allows restoration of an adequate hemodynamicfunction and satisfactory long-term tumour-free outcome.

OP61Cardiomyopathy in Marfan SyndromeDelmo Walter E.M.1, Gehle P.1, Hetzer R.11Deutsches Herzzentrum Berlin, Herz-,Thorax-u.Gefäßchirurgie, Berlin, Germany

Objectives: This report evaluates the incidence of cardiomyopathy inpatients with Marfan syndrome (MFS) who underwent surgery forprimary cardiovascular sequelae of this genetic disorder. Likewise, weaim to determine the influence of myocardial protection to the suscep-tibility of myocardium to ischemia in MFS patients. Methods: BetweenApril 1986 and May 2012, 421 Marfan patients were surgically treatedfor cardiovascular manifestations. Among tthem, 47 (mean age 39.45 �12.64, median 36, range 19-66, years), without previous surgeries,eventually developed cardiomyopathy. Eleven patients underwentrevascularization for ischemic heart disease. Twenty-three patientsdeveloped end-stage cardiomyopathy, of whom 21 underwent primaryheart transplantation. Two patients are still waiting for donor hearts.Thirteen patients with poor left ventricular (LV) function are currentlyon mechanical circulatory support. Results: In this series, the incidenceof development of ischemic cardiomyopathy without prior surgery is23.4% The incidence of end-stage cardiomyopathy in MFS who under-went heart transplantation without any prior surgery is 48.93%. Theincidence of end-stage cardiomyopathy in patients with MFS whounderwentmechanical circulatory support device implantationwithoutanyprior surgery is 27.6%. At amean follow-up of 9.4� 1.37 (median 9.8,range 6.8-13.98) years, survival rate is 51.8%. Marfan patients withcardiomyopathy who underwent coronary revascularization for is-chemic heart disease had a survival rate of 54.5%. Thosewith end-stagecardiomyopathy who underwent heart transplantation had a survivalrate of 50%. The survival rate of Marfan patients with cardiomyopathywho had a ventricular assist device is likewise 50%. In these patientswho developed cardiomyopathy, there is no significant difference insurvival rates (p¼0.56) when type of myocardial protection and dura-tion of ischemia were considered. However, 6 patients, with significantaortic regurgitation, developed postoperative LV dysfunction.Conclusions: Our finding support the existence of primary cardiomy-opathy in a subset of patients with MFS. This cardiomyopathy isunrelated to any other cardiovascular manifestations of the disease,and affect both ventricles. We confirmed primary myocardial im-pairment in 11.1% of our MFS patients. The type of myocardial protec-tion and duration of ischemia do not appear to trigger the developmentof cardiomyopathy.

Organ transplantation

OP62The INSPIRE international lung trial with theorgan care system technology (OCS™) - interimreportWarnecke G.1, van Raemdonck D.2, Massard G.3, SantelmoN.3, Falcoz P.-E.4, Olland A.4, LesecheG.5,MalH.5, Thomas P.5,Rea F.6, Nicotra S.6, Schiavon M.6, Marulli G.6, Knosalla C.7,Hetzer R.7, Simon A.8, Tsui S.9, Kukreja J.10, Bermudez C.11,Moradiellos F.J.12, Varela A.12, Dhital K.13, Nagendran J.14,Mc Curry K.15, Ardehali A.16, Haverich A.11Medizinische Hochschule Hannover, THG-Chirurgie,Hannover, Germany, 2University Hospital, Leuven, Belgium,3Hospital of the University of Strassburg, Strassburg,France, 4Hospital Bichat, Paris, France, 5University Hospitalof Marseille, Marseille, France, 6University of Pavia, Pavia,Italy, 7German Heart Center, Berlin, Germany, 8HarefieldHospital, London, United Kingdom, 9Papworth Hospital,Cambridge, United Kingdom, 10University of California SanFrancisco, San Francisco, United States, 11University ofPittsburgh Medical Center, Pittsburgh, United States,12University Hospital Puerta de Hierro, Madrid, Spain, 13St.Vincent's Hopital, Sydney, Australia, 14University of AlbertaMedical Center, Edmonton, Canada, 15Cleveland Clinic,Cleveland, United States, 16University of California, LosAngeles, United States

Objectives: To assess the clinical efficacy and safety of the OCS™ deviceto preserve, recruit and assess donor lungs for transplantation ascompared to the current cold storage technique. Methods: INSPIRE isa prospective, international, multi-centred, randomized, controlled trialcomparing preservation of donor lungs using OCS-Lung perfusiondevice (Treatment Group) to cold flush and storage (Control Group). Atotal of 264 primary lung transplant recipients will be randomized intothe trial. Important donor inclusion criteria: age <65, normal gasexchange at time of final acceptance of donor lung. Recipient inclusioncriteria: age�18 years old; primary double lung transplant candidate;Donor exclusion criteria: presence of traumatic lung injury; activepneumonia. Primary study endpoint is a composite of patient and graftsurvival at day 30 post transplantation and incidence of ISHLT primarygraft dysfunction (PGD) Grade 3 at post-transplantation. Other end-points: Patient survival at day 30; PGD score at T0, T24, T48 and T72hours; duration of invasive mechanical ventilation; length of posttransplant ICU stay; length of post-transplant hospital stay; additionalhospital admission post initial discharge. Results: As of September 6th,2013, a total of 192 patients were recruited and transplanted in theINSPIRE Trial in 17 different centres in Europe, North America andAustralia. We are reporting on the first 136 patients having completedthe 30-day follow-up endpoint as of June 30th, 2013, including n¼59OCS & n¼77 Control subjects. Donor and recipient characteristics/riskfactors were equivalent in both groups. Patient survival on day 30 was98% in the OCS and 95% in the Control group and at 6 months, it wasOCS¼97% [n¼36] vs. Control¼87% [n¼46]. The incidence of PGDGrade 3 is summarized in the table below:

Table 1: PGD Grade 3

OCS Group (n¼59) Control Group (n¼77)

T-0 5% 23%

T-24 5% 14%

T-48 7% 8%

T-72 3% 5%

Conclusion: The INSPIRE Trial's interim results are encouraging as it isdemonstrating a trend towards reduction of PGD grade 3 at all timepoints post-lung transplantation. The data also suggests 6-monthsurvival benefits in the OCS treated patients. INSPIRE accrual is expand-ing and we expect completion of the trial by end of 2013/early 2014.


AbstractsS34


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OP63N-octanoyl dopamine donor treatment in abrain death model in rats improves both donorand graft left ventricular function after hearttransplantationLi S.12, Korkmaz S.1, Spindler R.3, Radovits T.4, LoganathanS.1, Hegedüs P.14, Tao L.5, Theisinger B.6, Theisinger S.6, HögerS.3, Karck M.1, Yard B.7, Szabó G.11University Hospital Heidelberg, Cardiac Surgery,Heidelberg, Germany, 2Huazhong University of Science andTechnology, Cardiovascular Surgery, Wuhan, China,3University Medical Center Mannheim, ClinicalPharmacology, Mannheim, Germany, 4SemmelweisUniversity, Budapest, Hungary, 5Wuhan Asia HeartHospital, Cardiac Surgery, Wuhan, China, 6Novaliq GmbH,Heidelberg, Germany, 7University Medical CenterMannheim, Medicine V (Nephrology/Endocrinology/Rheumatology), Mannheim, Germany

Objectives: Heart transplantation became the most effective treatmentfor end-stage heart failure. Donors after brain death are currently theonly reliable source for cardiac transplants. However, hemodynamicinstability and cardiac dysfunction have been demonstrated in brain-dead (BD) donors and this could therefore also affect the graft responseafter heart transplantation. N-octanoyl dopamine (NOD), a novel dopa-mine derivate, has been shown to protect tissue against hypothermicpreservation. We tested the hypothesis that treatment of the BD donorwith NOD improves both donor cardiac and graft function after hearttransplantation.Methods: Lewis rats were administered by continuousintravenous infusion of either NOD (14.7 µg/kg.min, BDþNOD group,n¼6) or an equal volume of physiological saline (BD group: n¼9) for 5 hafter brain death induction by inflation of a subdurally placed ballooncatheter. Control donor rats are subjected to sham-operation (controlgroup: n¼9). Then, hearts were excised, stored in cold preservationsolution, heterotopically transplanted. Left ventricular (LV) function ofthe donor heart and graft was evaluated in vivo. Results: In BD donors,decreased LV contractility and relaxation, and increased end diastolicstiffness were significantly improved after treatment with NOD (dP/dtmax: 8163 � 696 vs. 4474 � 359 vs. 6524 � 773 mmHg/s; EF: 62 � 8%vs. 30 � 4 vs. 59 � 8; Emax: 4.4 � 0.4 vs. 2.1 � 0.4 vs. 4.1 � 0.4 mmHg/µl;PRSW: 83 � 6 vs. 47 � 5 vs. 77 � 5 mmHg; dP/dtmin: -10452 � 664 vs.-3728 � 521 vs. -6208 � 839 mmHg/s; and Tau: 10.1 � 0.6 vs 14.3 � 0.5vs 11.4 � 0.5 ms; control- vs. BD- vs. BDþNOD groups, respectively;P<0.05 vs. BD group). Moreover, 90min after transplantation, impairedsystolic function and altered ventricular relaxation were also observedin BD donor group, as reflected by decreased LV systolic pressure, dP/dtmax, dP/dtmin, and prolonged Tau. NOD treatment significantly im-proved graft function after transplantation. Additionally, TNF-alpha, NF-KappaB, and caspase 3 protein levels assessed byWestern blotting weresignificantly decreased by the NOD treatment comparedwith BD group.Conclusion:Our data suggest that down regulation of apoptotic proteinscould underline the protective effect of NOD. NOD might be a noveltherapeutic approach to reduce cumulative myocardial injuries relatedto brain death and after heart transplantation.

OP64Donor oxygenation has no impact onpostoperative outcome after lungtransplantationSommer W.1, Salman J.1, Tudorache I.1, Kühn C.1, Avsar M.1,Haverich A.1, Warnecke G.11Medizinische Hochschule Hannover, Herz-, Thorax-,Transplantations- und Gefäßchirurgie, Hannover, Germany

Background: Extended criteria donor lungs are increasingly used fortransplantation. The arterial partial pressure of oxygen of donors atorgan offer is widely regarded as an important marker for the qualityand transplantability of the lung. More precise, a PaO2/FiO2<300mmHg is generally classified as marginal. At our centre, we abandonedconsidering donor oxygenation at organ offer and accept or reject organoffers solely on grounds of donor medical history and donor-recipientmatch. Here, we retrospectively compare transplantations with donorsshowing a PaO2/FiO2<300 or >300 mmHg.Methods: 340 consecutive

lung transplantations performed at our centre between 2010 and June2013 were analyzed. Outcome parameters included freedom fromprimary graft dysfunction grade 3 (PGD3; ISHLT classification) andhospital mortality. Results: 52 patients received grafts of donors withPaO2/FiO2 <300. 288 transplants were performed from donors with aPaO2/FiO2 >300. There were no significant recipient differences in age(47.5 � 1.9 vs. 46.3 � 0.9 yrs, p¼0.60) or sex (53% vs. 57% male).Postoperative parameters of the recipients including duration of me-chanical ventilation time (14 [3-1200] hours vs. 25 [3-3852] hours;p¼0.94), intensive care stay (2 [1-50] days vs. 3 [1-83] days; p¼0.42) ortotal hospital stay (22 [21-151] days vs. 24 [19-207] days; p¼0.11)showed no significant differences between both groups. Also, freedomfrom PGD3 (88.5% vs. 84.4%; p¼0.44) as well as hospital mortality (5.8%vs. 6.2%; p¼0.61) did not differ. Overall survival of the recipientsshowed no significant difference (p¼0.60). Donor characteristicsshowed longer duration of mechanical ventilation in the group with aPaO2/FiO2<300 (7.2 � 0.8 days vs. 4.9 � 0.3 days; p¼0.002). Acorrelation analysis showed no significant correlation between donorPaO2/FiO2 and recipient freedom of PGD 3 (p¼0.41), hospital mortality(p¼0.36), total postoperative mechanical ventilation time (p¼0.95) ortotal hospital stay (p¼0.89). Discussion: Donor lungs showing lowarterial PaO2 values at offer can safely be used for transplantation, if astructural damage to the organ is excluded during retrieval. We con-clude that a further increase of usage of donor organs that might have acompromised oxygenation capacity before retrieval should beattempted.

OP65Minimally invasive lung transplantation atHarefield Hospital: A novel strategy in the UKPopov A.-F.12, Marczin N.3, Zych B.2, Sabashnikov A.2, KissR.3, De Robertis F.2, Bahrami T.2, Amrani M.2, Moza A.2, McDermott G.3, Krüger H.2, Carby M.2, Dalal P.4, Simon A.R.21Universitätsmedizin Göttingen, Thorax-, Herz- undGefäßchirurgie, Göttingen, Germany, 2Royal Brompton andHarefield NHS Foundation Trust, Department ofCardiothoracic Transplantation and Mechanical Support,London, United Kingdom, 3Royal Brompton and HarefieldNHS Foundation Trust, Department of Anesthetics, London,United Kingdom, 4Royal Brompton and Harefield NHSFoundation Trust, Harefield, Department of Imaging,London, United Kingdom

Objectives:Minimally invasive lung transplantation (MILT) via bilateralanterior thoracotomies has emerged as a novel surgical strategy withpotential patient benefits when compared to transverse thoracoster-notomy (clamshell incision, CS). The aim of this report is to compareMILT to CS by focusing on operative characteristics, postoperative organfunction and support and midterm clinical outcomes at HarefieldHospital. Methods: We evaluated all bilateral sequential lung trans-plants between April 2010 and October 2011. MILTwas performed in 23patients without the use of cardiopulmonary bypass (CPB) and 9patients with the aid of CPB (MILT-CPB). The majority of clamshelloperations were performed using CPB (n¼52) as our routine surgicalapproach. Results: Skin to skin surgical time was less in the MILT groupcompared to CS and MILT-CPB. Early postoperative physiological vari-ables were similar between groups. Patients in the MILT group requiredless blood and platelet transfusion. ITU stay was a day shorter in theMILT group and therewas a tendency towards shorter total hospital stayand overall mortality in this group. FEV1 and FVC were consistentlyhigher in theMILT group compared to CS duringmidterm followup aftertransplantation. Conclusions: MILT was successfully introduced at ourcenter as a novel operative strategy. Despite a more complex operationand management, MILT appears to offer early postoperative and mid-term clinical benefits compared to our traditional approach of clamshellincision and CPB. These observations warrant larger definite studies tofurther evaluate the impact of MILTon physiological, clinical and patientreported outcomes.


Abstracts S35


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OP66Prediction of bronchiolitis obliteranssyndrome-free survival after two yearsaccording to frequencies of regulatory T cellsearly after lung transplantationSalman J.1, Sommer W.1, Knöfel A.-K.1, Kühn C.1, TudoracheI.1, Avsar M.1, Ius F.1, Jansson K.1, Böthig D.1, Gottlieb J.2,Welte T.2, Haverich A.1, Warnecke G.11Klinik für Herz- Thorax- Transplantations undGefäßchirurgie, Hannover, Germany, 2Klinik fürPneumologie, Hannover, Germany

Introduction: Regulatory T cells (Treg) play important roles in theinduction and maintenance of immunological tolerance to self andnon-self antigens. They have the potential to regulate alloantigensand thusmaycounteract the development of acute and chronic rejection(i.e. bronchiolitis obliterans syndrome, BOS) in lung transplant recipi-ents. BOS affects over 60% of lung transplant recipients within five yearsafter transplantation. Here,we present a cohort of 120 patients, inwhichwe analyzed Tregs in peripheral blood prospectively during the first 2years after lung transplantation and correlate with the onset of BOS.Materials and methods: In consecutive routine lung transplant recip-ients, the number of circulating Treg was detected by flow cytometrybefore transplantation and 3 weeks, 3 6,12, 18 and 24 months aftertransplantation. Treg were defined as CD4þCD25 high T cells and werefurther analyzed for relevant surface as well as intracellular markerssuch as, amongst others, CTLA4, CD127, FoxP3 and IL-2. Additionally,lung function results at the time points 3 weeks, 3, 6, 12, 18 and 24months after transplantationwere analyzed.We divided the cohort intotwo groups based on the development of BOS stage 0-p versus BOS stage1 or higher. From there, repeated measures ANOVA was performedmonitoring the different surface molecules. Results: A total of 120consecutive patients were included into the study. 38 patients devel-oped a BOS stage 1 or higher 2 years after lung transplantation. The other82 patients showed a good clinical course with stable lung function. Assoon as 3 weeks after lung transplantation not only a statisticallysignificant positive correlation could be detected between the frequen-cies of Tregs and the absence of BOS (p<0.05), we also built a scoredefining a cut off value composed of IL2þ/CTLA4þ/CD127 low andFoxP3þ Treg in peripheral blood 3 weeks after lung transplantation,predicting the probability of BOS development. Conclusions: Higherfrequencies of Treg early after lung transplantation are associated withprotection against development of BOS and they may thus have apredictive function for the ensuing course following transplantation.

OP67Leukocyte-Endothelium Interactions in bothnaïve and adult endothelial cells: influence ofATGBeiras-Fernandez A.1, Kanzler I.1, Hartmann I.2, KaczmarekI.2, Kur F.21Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, Thorax, Herz, und Gefäßchirurgie, Frankfurt,Germany, 2Klinikum der Universität München - CampusGroßhadern, Herzchirurgie, München, Germany

Introduction: Polyclonal antithymocyte globulins (ATGs) are immuno-suppressive drugs widely used in induction of immunosuppression andtreatment of acute rejection. The aim of this studywas to investigate thein vitro influence of ATGs on the leukocyte transmigration and theextent of endothelial response upon endothelial cells, as well as toinvestigate the underlying mechanisms. Material and methods: HU-VECs and adult endothelial cells (HMEC-1) were cultured. The cells wereactivated for 20 h (HUVECs) or 2 h (HMEC-1) prior to themigration assay.Both PBMC and HUVEC /HMEC-1 were each incubated with ATG (ATG-Fresenius©, Fresenius Biotech, Germany) or control rabbit IgG (100 µg/mL) for 30-120 minutes. The PBMC were then transferred to the HUVECcultures and incubated for 5 hours. Endothelial transmigration of PMBCswas assessed in different wells (n¼20) using trypan blue staining.Expression of ICAM-1 and MHC class I on endothelial cells was studiedby flow-cytometry. Groups were compared using one-way analysis ofvariance (ANOVA) and Tukey-Kramer multiple comparison test. Results:Naïve PBMC showed a higher level of migration: naïve PBMC plus

activated HUVEC (7.71 x 104 cells [1.95-9.03]); naïve PBMC plus naïveHUVEC (3.48 x 104 cells [3.10-3.99]); activated PBMC plus activatedHUVEC (2.08 x 104 cells [1.71-3.72]). ATG decreased migration of naïvePBMC through activated HUVEC. Migration of naïve PBMC through alayer of naïve HUVEC was slightly reduced by ATG. PMBC migration wassignificantly reduced after treatment of HMEC-1 as compared to un-treated controls (1.55Eþ 05� 1.00Eþ 04 vs. 6.85Eþ 05� 1.87Eþ 05; p<0.05). Incubation of EC with ATG significantly reduced the expressionof ICAM-1 andMHC class I on adult endothelial cells. Conclusion: Our invitro results provide a rationale supporting preconditioning with ATG inorgan transplantation, as a down-regulation of adhesion molecules byATG may decrease graft cell infiltration after transplantation.

OP68Extending donor criteria in lungtransplantation - Donors 70 years and olderWarnecke G.1, Sommer W.1, Tudorache I.1, Kuehn C.1, AvsarM.1, Ius F.1, Salman J.1, Gottlieb J.2, Haverich A.11Medizinische Hochschule Hannover, THG-Chirurgie,Hannover, Germany, 2Medizinische Hochschule Hannover,Pneumologie, Hannover, Germany

Objectives: Historically, donor age for lung transplantation must notexceed 55 years. Today, that has been increased to 65 years, however,older donors are also considered. Obviously, there is no well-definedupper cut off, and there are no convincing absolute contraindicationsagainst the transplantation of older donor lungs. Since 05/2010, weaccepted 70þ year old donor lungs on a regular basis in our program andherewe present outcomes of these transplantations and compare to thatof donors <70 years.Methods: Lung transplantations performed at ourcentre between 05/2010 and 06/2013 were retrospectively analyzed.Outcome parameters included amongst others freedom from primarygraft dysfunction grade 3 (PGD3; ISHLT classification) and 1-yearmortality. Results: Seventeen patients (lung fibrosis n¼7, emphyseman¼5, idiopathic pulmonary artery hypertension n¼2, GvHD n¼2,sarcoidosis n¼1) received lung transplants from donors 70 years ofage or older. Median donor age was 71 [range 70-76]. During the sametime period 329 lung transplantations were performed from donors 69years of age or younger (median 46 years [range 1-69]) in our program.Median recipient age was 61 [range 49-64] vs. 51 [range 4-67] years,indicating preferred allocation of 70þ donor lungs to older recipients.Important postoperative indicators of transplant outcome are freedomfrom PGD3 at any time: 14/17 (82.4%) in the older donor and 279/329(84.8%) in the regular donor cohort; and median duration of postopera-tive mechanical ventilation: 29.0 hours vs. 24.0 hours. The medianpostoperative intensive care stay was 4 vs. 3 days and the total hospitalstay 25 vs. 23 days. Hospital mortality was 0.0% vs. 5.2% (p¼0.65;Kaplan-Meier-survival curves) and overall survival of the recipients was100% in the older donor and 92.05% in the regular donor group at 1 year(p¼0.44, Kaplan-Meier-survival). Two late deaths beyond one yearoccurred in the older donor group at days 389 and 523, both in patientsthat had developed bronchiolitis obliterans syndrome. Conclusions:Lungs from donors 70 years of age and older can be used for transplan-tation. Early outcome is equivalent to what can be expected fromtransplantation of lungs from donors up to 69 years in our experienceand thus we intend to continue our practice. While common sense mayadvise to preferentially allocate older donors towards older recipients,there is no direct evidence dictating for doing so.


AbstractsS36


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Heart and lung failure II

OP69Outcomes in patients undergoing HeartMate IIvs Heartware left ventricular assist device as abridge to transplantationSabashnikov A.1, Popov A.-F.1, Hards R.1, Fatullayev J.1,Hedger M.1, Mohite P.N.1, García Sáez D.1, Zych B.1, DeRobertis F.1, Bahrami T.1, Amrani M.1, Simon A.R.11Royal Brompton and Harefield NHS Foundation Trust,Department of Cardiothoracic Transplantation andMechanical Circulatory Support, Harefield, London, UnitedKingdom

Objective: Ventricular assist devices (VAD) have become standardtreatment for patients with advanced heart failure. We present datacomparing the results after implantation of the HeartMate II (HM II) vs.the Heartware (HW) at our institution. Methods: Between 2006 and2012, 121 consecutive patients underwent LVAD implantation: 71(57.9%) HM II, 50 (42.1%) HW. Patient demographics, perioperativecharacteristics and laboratory parameters as well as postoperativeoutcome were compared. Results: Patients were significantly youngerin the HM II group: 43.4 (28.7;52.7) vs. 49.3 (44.2;57.3) years (p<0.01).Pre-implantational liver function was more deranged in HM II patients:bilirubin: 34 (18;51) vs. 24 (18;35) mmol/l (p¼0.02); ALT 39 (22;103)vs. 30 (19;42) U/L (p¼0.01). HM II patients had a significantly higherrate of preoperative infections requiring antibiotic treatment: 7 (10%)HM II vs 0HW (p¼0.02), had a higher body core temperature: 36.8� 0.6vs. 36.3 � 0.5 oC (p<0.01) and showed a trend towards higher CRPlevels: 30 (9;56) vs. 12 (5;50) mg/L (p¼0.09). Other demographic andpreoperative parameters were comparable. Postoperatively, HM II pa-tients had a significantly higher transfusion rate: 15 (6;24) vs 8 (2;18)units, but there were no differences in re-sternotomy for bleeding(p¼0.156). The groups were comparable for requirement of longterm (> 7 days) mechanical ventilation (p¼0.461) and inotropicsupport (p¼0.375), right ventricular failure requiring right ventricularassist device implantation (p¼0.384) and renal failure requiring renalreplacement therapy (p¼0.542). There was no difference in ICU lengthof stay (LOS) (p¼0.10), however, HM II patients had a longer postoper-ativehospital LOS: 54 (30;79) vs 32 (27;57) days (p¼0.02). Recovery andVAD explantation were more likely in the HM II group: 17 (24.3%) vs 2(3.9%) patients (p¼0.02). While there was no significant difference insurvival (log rank test p¼0.986, Breslow test p¼0.827), HM II patientswere more likely to develop a drive line infection requiring antibiotictherapy: 27 (38.6%) vs 6 (11.8%) (p¼0.01). Conclusion: Both HM II andHW provide similar early postoperative outcome and good long termsurvival. The differences observed between the groupsmay be related todemographic and preoperative factors rather than to the type of thedevice used. These observations should be a merit of further analysis.

OP70One-year clinical outcome in end-stage heartfailure patients listed high urgent incomparison to patients receiving ventricularassist device implantationSunavsky J.1, Zittermann A.1, Fuchs U.1, Gummert J.F.1,Schulz U.11Herz- und Diabeteszentrum NRW, Bad Oeynhausen,Germany

Objectives: Heart transplantation (HTx) is still considered the thera-peutic gold standard in end-stage heart failure. We compared clinicaloutcome in patients listed 'high urgent' (HU) for HTx with patientsreceiving ventricular assist device (VAD) implantation.Methods: In 276patients who were HU listed and 348 patients who received VADimplantation at our heart center between November 2005 and Novem-ber 2012, we assessed therapy failure (the need of VAD implantation inHU listed patients or the need of HU listing in VAD patients), theprobability of HTx and overall survival. Patients were followed up for12 months. Results: INTERMACS level differed significantly betweengroups, with higher prevalence of level 1 and 2 in VAD patientscompared with HU listed patients. In the HU and VAD group, therapy

failurewas 47.6% and 15.1%, respectively (P¼0.001). Comparedwith theVAD group, the probability of HTx was significantly higher in the HUgroup (80.1% vs. 17.4%,P<0.001) and so was 12-month overall survival(86.5% and 54.2%, respectively, P<0.001). After adjustments weremadefor INTERMACS level, age, gender and primary diagnosis, the hazardratio for not receiving HTx was in the VAD group¼12.0 (95% CI: 8.4-17.1;P<0.001) compared with the HU group. The corresponding valuefor 12-month overall mortality was 3.92 (95% CI: 2.72-5.63; P<0.001).Conclusion: In end-stage heart failure, both the probability of receivingHTx and 12-month survival is markedly higher in HU listed patientscompared with VAD patients. Results support the need of solving theproblem of donor organ shortage.

OP71Risk factors predictive of therapy refractoryright ventricular failure after continuous-flowleft ventricular assist device implantationFatullayev J.1, Sabashnikov A.1, Popov A.-F.1, Zych B.1,Hedger M.1, Hards R.1, Mohite P.1, De Robertis F.1, BahramiT.1, Amrani M.1, Banner N.R.2, Simon A.R.11Royal Brompton & Harefield NHS Foundation Trust,Department of Cardiothoracic Transplantation andMechanical Circulatory Support, Harefield, London, UnitedKingdom, 2Royal Brompton and Harefield NHS FoundationTrust, Department of Heart Failure and TransplantMedicine, Harefield, London, United Kingdom

Objectives: Left ventricular assist devices (LVADs) are increasingly usedfor treatment of therapy refractory advanced heart failure. However,right ventricular failure (RVF) represents one of the devastating post-operative complications. Furthermore a substantial portion of patientsmay develop therapy refractory RVF requiring right sided mechanicalsupport after LVAD implantation. The aim of this study was to evaluatepredictors of therapy refractory RVFwith the need for a right ventricularassist device (RVAD) support.Methods: A total amount of 139 consecu-tive patients who received a continuous-flow LVAD between 06.2006and 08.2013 were included in this study. 23% (n¼32) of patientsrequired a short-term RVAD (RVAD-group) after operation whereas77% (n¼107) did not develop RVF or could be managed with inotropicsupport (non-RVAD-group). Preoperative demographics and baselineclinical characteristics as well as intraoperative variables were com-pared. Multivariate regression analysis was performed to evaluateindependent predictors of RVF requiring right sided mechanical sup-port. Results: Univariate analysis showed that the number of femalepatients in RVAD-group was significantly higher than in non-RVAD-group (37.7% vs. 11.2%, p¼0.002). Generally, the patients in RVAD-group had significantly faster heart rate (97 � 20 vs. 86 � 20 bpm,p¼0.014), lower height (169 � 9 vs. 175 � 9 cm, p¼0.001) and weight(71 � 15 kg vs. 79 � 15 kg, p¼0.016). Furthermore, patients in RVAD-group showed higher levels of white blood cells (p¼ 0.042) and CRP(p¼0.077), had higher temperature (p¼0.033) and more derangedliver function. Also, RVAD patients were more likely to suffer fromperipheral vascular disease (9.4% vs. 0%, p¼0.012) and had a higher rateof preoperative short-term mechanical support (STMS) (25% vs. 4.7%,p¼0.001). Transfusion requirements were also significantly higher inthe RVAD-group. Multivariate regression analysis revealed higher pre-operative temperature (p¼0.045) and higher FFP use (p¼0.012) as theonly independent predictors for RVF requiring RVAD. Conclusion: Ourexperience reveals that preoperative inflammation or infection mightbe associated with significantly higher risk of postoperative RVADdependency, and should be treated preoperatively, if possible. Also,particularly in patients with increased risk of RVF FFP use should berestricted to a minimum.


Abstracts S37


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OP72Risk factors of poor outcome after surgicaltreatment of chronic constrictive pericarditis ina single-centre cohortPenov K.1, Busch C.2, Amorim P.A.3, Garbade J.1, Rastan A.4,Borger M.A.1, Schuler G.C.5, Mohr F.-W.11Heartcenter of the University of Leipzig, Cardiac surgery,Leipzig, Germany, 2University Clinical Center Leipzig,Intensive Care Unit, Leipzig, Germany, 3Jena UniversityHospital - Friedrich-Schiller-University Jena, Cardiacsurgery, Jena, Germany, 4Herz- und KreislaufzentrumRotenburg, Cardiac Surgery, Rotenburg a. d. Fulda,Germany, 5Heartcenter of the University of Leipzig,Cardiology, Leipzig, Germany

Objectives: Constrictive pericarditis (CP) is an uncommon disease withmultiple causes and discrepant clinical outcome. Till date, there is ascarcity of publications, clearly defining the risk factors of poor out-comes after surgery for CP. Therefore, we retrospectively analysed theresults of surgical intervention for CP at our institution to define the riskfactors of poor outcomes.Methods: A total of 97 patients (65male, 67%)undergoing surgery for CP at our institution from1995 to 2012 wereincluded in the study. CP was diagnosed either preoperatively by cardiaccatheterization or at surgery. The mean age was 60 � 12.5 years and theprimary etiology was idiopathic (49 patients, 50.5%), prior cardiacsurgery (15, 15.5%), prior mediastinal irradiation (9, 9.3%), and miscel-laneous (24, 24.7%). Preoperative and intraoperative risk factors for 30-day and late mortality were analyzed using stepwise multivariatelogistic and Cox regression analysis respectively. Long-term survivalwas determined by the Kaplan-Meier curve. Mean follow-up was 2.9 �3.8 years (range: 0.1-14 years). Results: All patients received eithercomplete (53 patients, 55.2%) or partial (44 patients, 44.8%) pericardiec-tomy. Concomitant procedures were performed in 38 (39,2%) patients.The total procedure time 197 � 105 minutes. Cardiopulmonary bypasswas used in 62 patients (80 � 81 minutes), cross-clamp time 26 � 43minutes. All cause mortality was 20.6% (n¼20) at 30 days, 32% (n¼31)at 1 year, 41.2% (n¼40) at 5 years and 45.5% at 10 years (n¼44). Overall30-day and 1-year survival were 79.4% and 68%, respectively, withoutsignificant difference according to the underlying etiology. Univariateanalysis showed that preoperative renal dysfunction, liver failure,respiratory insufficiency, emergency surgery and longer operatingtimes were associated with significantly higher 30-day mortality.However, multivariate analysis did not reveal any independent predic-tors for the same. Conversely, Cox analysis showed that renal dysfunc-tion (Creatinine [p¼0,0001 HR: 2,1] and Glomerular filtration rate[p¼0,001 HR: 0,97]), pre-existing coronary artery disease (p¼0,0001HR: 4,39), poor left ventricular (LV) function (p¼0,05) and NYHA classIV (p¼0,002) were associated with poor long-term survival.Conclusion: Surgery for CP is associated with poor early and long-term outcomes. Impaired preoperative LV and renal function and pre-existing coronary artery disease independently predict late mortality.

OP73Minimally invasive left ventreicular assistdevice implantation with outflowgrafttunneling through the sinus transversusAvsar M.1, Rojas S.V.1, Hanke J.S.1, Bara C.1, Malehsa D.1,Haverich A.1, Schmitto J.D.11Medizinische Hochschule Hannover, Klinik für Herz-,Thorax-, Transplantations- und Gefäßchirurgie, Hannover,Germany

Objectives: For patients with end-stage heart failure cardiac transplan-tation remains the goldstandard. However, based on donor organshortage cardiac transplantation remains limited to 300-500 operationsper year in Germany. Nevertheless, demographical changes lead to anincreasing heart failing population which demands alternative thera-peutical options. Left ventricular assist devices (LVAD) are gaining moreand more acceptance in the treatment of heart failure. Based ontechnical as well as surgical improvements in LVAD surgery, the peri-procedural risk was tremendously reduced during the past years. Theaim of our study was to assess the outcome of heart failure-patientsreceiving an LVAD through aminimally invasive implantation approach.

In addition we modified our routinely used minimally-invasive ap-proach by tunneling the outflowgraft through the sinus transversus inBTT-patients to reduce additional risks in re-do operations (e.g.cardiactransplantation) in future. Methods: We reviewed the outcome of 14end-stage heart failure patients, who underwent minimally-invasiveLVAD implantation (HVAD, HeartWare) with outflowgraft tunnelingthrough the sinus transversus as bridge-to-transplantation between2012 and 2013. The novel techniquewas only performed in elective, not-previouslyoperated patients. Results: Demographical data: 12 male, 2female mean age 45,0 � 4,2 years; DCM 64%; ICM 36%. All patientsunderwent minimally-invasively LVAD surgery electively (Intermacs 3).Perioperative as well as 30-day survival-rate was 93% (13/14). Bleedingincidence as well as postoperative bleeding incidence was 0% (0/14).LVAD parameters were presented as normal (mean rpms: 2700 rpm; 4.8l/min; 4.5 Watts). No technique associated risks or complications wereseen. Conclusions: Our data show that this modified, novel minimally-invasive LVAD-implantation technique is prooven to be feasible, safe andis associated with several positive aspects. The technique is presentedwith a low mortality, very low incidence of postoperative bleeding andless need of inotropic support when compared to patients treated by thestandard surgical technique. The biggest advantage of this technique isto prevent additional risks for future cardiac operations of the BTTpatients (e.g. cardiac transplantation) based on the fact that the out-flowgraft is far away from the sternum because of its tunneling throughthe sinus transversus.

OP74Metformin treatment during cardiac pressureoverload does not improve survivalSchrepper A.1, Schwarzer M.1, Dormann R.1, Werner C.1,Doenst T.11Jena University Hospital - Friedrich-Schiller-UniversityJena, Department of Cardiothoracic Surgery, Jena, Germany

Background: Until recently metformin was contraindicated in heartfailure and had to be discontinued in cardiac surgery for fear of lacticacidosis. In heart failure therapy, metformin has recently been foundbeneficial in symptoms alleviation. Objective: We tested the antidia-betic drug metformin in our heart failure animal model for its effect oninsulin sensitivity, contractile function and survival. Methods: Ratsunderwent transverse aortic constriction (TAC) to induce heart failure.TAC and sham (C) operated animals received an oral dose of metformin(MET - 300 mg/kg/d) or placebo. After 6 and 10 weeks of pressureoverload (PO), we investigated cardiac function by echocardiography,glucose and insulin tolerance with glucose (2 g/kg) and insulin (1 U/kg)tolerance tests and monitored survival. Results: PO and MET resulted inreduced bodyweight after 10 weeks (g: C 402� 7 vs. C-MET 351� 14 vs.TAC 314� 9 vs. TAC-MET 307� 14). Echocardiography revealedmarkedhypertrophy in both TAC groups (LVWall after 6W: 3,23 � 0,04 vs. 3,22� 0,14 vs. 5,09 � 0,25 vs. 4,76 � 0,28 mm). Diastolic dysfunction wasprevented by MET (E/A after 6 W: 1,43 � 0,06 vs. 1,64 � 0,12 vs. 7,01 �1,08 vs. 2,13� 0,66). Contractility of the left ventriclewas also preservedwith MET in (fractional shortening after 10 W: 47,4 � 1,1 vs. 43,2 � 1,7vs. 34,0 � 2,7 vs. 40,7 � 4,8%). Glucose (GTT) and insulin (ITT) tolerancetests revealed that PO alone improves insulin sensitivity and this effectwas enhanced further byMET (GTT-AUC after 6W: 713�29 vs. 705�21vs. 590� 18 vs. 383� 12). However, MET did not improvemean survivaltime after TAC (TAC: 16,1 vs. TAC-MET 15,6 W). Conclusion: Metformintreatment in an animal model of heart failure preserves both systolicand diastolic function but had no influence on survival. Metformin maytherefore be a potential tool to improve contractile function also beforecardiac surgery.


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OP75Development of a retrograde flow inhibitiondevice in continues flow VAD for emergencyrescueYildirim Y.1, Pecha S.1, Alassar Y.1, Hakmi S.1, Deuse T.1,Reichenspurner H.11Universitäres HerzzentrumHamburg, Hamburg, Germany

Objectives: Implantation of continues flow VAD is a widely used optionto handle end-stage heart failure. In case of device dysfunction (throm-bus, electrical or mechanical disorder) severe hemodynamic instabilityoccur, due to an aortic insufficiency across the device. Despite remainedcardiac function the additional retrograde flow can cause fulminantpulmonary oedema and death. ECMO implantation is not an alternative,due to increasing retrograde flow and cardiopulmonary deterioration.Methods: We developed a small implantable electrical engine, whichclamps the outflow prostheses of continues flow VAD triggered byretrograde flow or an external command system. A mock circulationincluding an introduced HeartWare HVAD was established. By simulat-ing a HVAD dysfunction retrograde flow and aortic pressure wereinvestigated with (n¼10) and without (n¼10) the retrograde flowinhibition device (RFID). Results: Retrograde flowor external commandtriggered stimulation lead immediately to occlusion of the prostheses. Inthe RFID group no retrograde flow occurred and mean aortic pressurewas 69 � 8 mmHg. Simulating HVAD dysfunction without RFID lead tomean retrogradeflowof 1,9� 0,5 L/min and amean aortic pressure of 57� 6 mmHg. Conclusion: The retrograde flow inhibition device canprevent a severe aortic insufficiency and stabilize cardiopulmonarysituation. A simultaneous use with an ECMO can lead to farther stabilityand facilitate operative intervention e.g. for a system exchange, due toVAD thrombus.

Transcatheter valves II: Technical aspects

OP78Initial and mid-term follow-up of patients withconcomitant moderate or more severe mitraland tricuspid regurgitation undergoingtranscatheter aortic valve implantationAlexiou K.1,WilbringM.1, Arzt S.1, Kappert U.1, Matschke K.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: Concomitant mitral (MR) and tricuspid regurgitation (TR)are frequently seen in patients with aortic stenosis. We assessed impactof TAVI on concomitant MR/TR and evaluated initial and mid-termresults. Methods: TAVI was performed in 615 patients, hereby in 386using a transapical approach with the Edwards SAPIEN™ bioprosthesis.Out of these, 116 (30.1%) presentedwith concomitant moderate ormoresevere MR. Mean logistic euroSCORE was 18.1�11.5%. Intra-/posthos-pital course, change in MR/TR, right ventricular systolic pressure (RVSP)and tricuspid annular plane systolic excursion (TAPSE) were analyzed.Outcomes were compared with transapical (TA)-TAVI-patients withoutconcomitant MR/TR. Mean follow-up time was 471�391 days. Results:Postoperatively, grade of MR and TR decreased significantly (2.1�0.2 to1.5�0.7;p<0.01 and 1.9�0.5 to 1.5�0.7;p<0.01, respectively). Like-wise RVSP decreased significantly from 46�16mmHg to 39�15mmHg(p<0.01), TAPSE only by trend (21.9�7.3mm to 19.5�5.5mm;p¼0.07). After 3-6 months, 68.9% of the patients were at NYHA classI° or II°, 25% at class III°; 6.0% at class IV°. Obviously no impact of grade ofMR/TR, LVEF, TAPSE or RVESP on outcome or NYHA-classification wasfound. Three patients (2.6%) died during primary hospital-stay. Estimat-ed 1-, 2-, 3- and 4-years survival was 76.7%, 75.6%, 68.3% and 50.6%,which was on the whole comparable with those observed in remainingTA-TAVI-patients (p¼0.784). Main reason for death was progressivecongestive heart failure (38.1%). Conclusion: MR, TR and PHT decreaseafter TAVI. The observed clinical and mid-term results are not inferiorcompared with TA-TAVI-patients without concomitant MR/TR. Moder-ate or more severe MR cannot be considered as contraindication forTAVI.

OP79Challenges of diagnostic coronary angiographyafter TAVI proceduresBlumenstein J.1, Liebetrau C.1, Kempfert J.2, Kim W.-K.12,Van Linden A.2, Arsalan M.2, Walther T.2, Hamm C.1,Mollmann H.11Kerckhoff-Klinik, Kardiologie, Bad Nauheim, Germany,2Kerckhoff-Klinik, Herzchirurgie, Bad Nauheim, Germany

Objectives: Transcatheter aortic valve implantation (TAVI) evolved to astandard procedure for high risk patients suffering from aortic stenosis.In these mostly elderly patients coronary artery disease may either bepresent or develop. Therefore, some patients will require coronaryangiography (CA) or percutaneous coronary intervention (PCI) imme-diately or later after TAVI. Since the beginning of the TAVI era manydifferent valves entered clinical practice. While some prostheses areimplanted fully subcoronary other devices are partially or fully placedover the coronary ostiaand may therefore potentially interfere withdiagnostic or interventional catheters. The aim of our analysis was toevaluate the feasibility of coronary angiography or coronary interven-tion in patients with prior TAVI. Methods: Over the past years 780patients received TAVI using eight different valve prostheses (SymetisAcurate TA and Acurate TF; Medtronic CoreValve and Engager; Jena-Valve, SJM Portico; Edwards Lifesciences SAPIEN and SAPIEN XT). In thisanalysis all patients were included, who had to undergo either CA or PCIafter prior TAVI in our center. A CA or PCI was rated as fully feasible,when coronary ostia could be fully intubated, partially feasible whencoronary arteries could be only displayed unselectively or not feasiblewhen coronary ostia could not be displayed. Results: In total 28 patientsreceived coronary angiography/PCI after TAVI at our hospital (17¼SAPIEN/6¼CoreValve/3¼Acurate/1¼ JenaValve/1¼Portico). In pa-tients with subcoronary valves (SAPIEN, SAPIEN XT, Jenavalve) 16/18had full accessibility with standard catheters, in 2/18 CA could beperformed using other standard catheter sizes. 5/18 patient requiredPCI, which was successfully performed in all of them. In patients withvalve types being placed in front of the coronary ostia (CoreValve,Acurate TF/TA, Portico) no selective intubation of coronary arteries(LCA¼5; RCA¼2; both¼1) were possible even with different diagnos-tic catheters in 8/10 cases. Full accessibility was only present in 2/10cases. In 2/10 cases display of RCAwas not possible at all. Conclusion: Inconclusion, coronary angiography or PCI after TAVI is usually feasible.However, especially devices being placed over the coronary ostia caninterfere with diagnostic or interventional catheters and impedestraight forward intervention. This has to be taken into account priorto TAVI implantation, especially in the treatment of younger patients.

OP80Coronary revascularization prior totranscatheter aortic valve implantation: Patientcharacteristics and influence on outcomeLoders S.1, Kondruweit M.2, Arnold M.1, Achenbach S.1,Weyand M.2, Feyrer R.21Universität Erlangen-Nürnberg, Medizinische Klinik 2,Erlangen, Germany, 2Universität Erlangen-Nürnberg,Herzchirurgische Klinik, Erlangen, Germany

Purpose: Patients with high grade coronary artery stenoses frequentlyhave concomitant coronary artery disease. This affects patients who arecandidates for transcatheter aortic valve implantation (TAVI), but theinfluence of coronary revascularization onTAVI outcome is incompletelyunderstood. Methods: We retrospectively analyzed a series of 300consecutive patients who underwent TAVI for high grade aortic valvestenosis in the presence of high operative risk. The incidence of coronaryrevascularization, patient characteristics, and influence on outcome (in-hospital mortality and clinical follow-up up to 4 years). Results: Of the300 consecutive patients, 140weremale and 160were female.Mean agewas 81 � 6 years and the mean log. Euroscore was 33 � 15%. TAVI wasperformed using a balloon-expandable valve via a transapical access in200 patients (66%) and transfemoral access in 100 patients (33%).Seventy-three patients (24%) had at least one significant coronary arterystenosis and underwent percutaneous coronary revascularization ofone vessel (n¼52), two vessels (n¼9) or three vessels (n¼1) prior toTAVI. Bypass grafts were revascularized in 6 patients and unprotected


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left main lesions were treated by PCI in 4 patients. One revascularizationwas not successful (CTO RCA), but no complications occurred due to PCI.Patients who underwent PCI were more frequently male (54% vs. 44%,p¼0.1), but not significantly older (82 � 6 vs. 81 � 6 years) and themean log. EuroScore was 35 � 15%. 30-day-mortality was 10.9% forpatients with and 11.4% for patients without coronary revascularization(n.s.). During long-term-follow up (mean period: 18 � 13 months)mortality was 34% for patients with and 26% for patients withoutcoronary intervention (p¼0.17). Conclusions: Concomitant coronaryartery stenoses are present in approximately one-quarter of patientswith high-grade aortic valve stenosis who are TAVI candidates. Percu-taneous revascularization can be performed safely and the presence ofcoronary stenoses does not impact 30-day-mortality. There is, however,a tendency towards higher long-term mortality.

OP81Influence of preoperative MDCT analysis by adedicated software on aortic insufficiency andoutcome in patients after TAVIFujita B.1, Jategaonkar S.2, Scholz W.2, Börgermann J.1,Preuss R.3, Horstkotte D.2, Gummert J.1, Ensminger S.11Herz- und Diabeteszentrum NRW, Ruhr-UniversitätBochum, Department of Thoracic- and CardiovascularSurgery, Bad Oeynhausen, Germany, 2Herz- undDiabeteszentrum NRW, Ruhr-Universität Bochum,Department of Cardiology, Bad Oeynhausen, Germany,3Herz- und Diabeteszentrum NRW, Ruhr-UniversitätBochum, Department of Radiology, Bad Oeynhausen,Germany

Background: Multidetector computed tomography (MDCT) has beenincreasingly employed for valve sizing before TAVI as it enables a 3-dimensional analysis of the aortic annulus. Therefore, the aim of thisstudy was to retrospectively analyze if image analysis has an influenceon outcomes of patients undergoing TAVI. Methods: A total of 186consecutive pre-TAVI-MDCTs of patients treated in 2010 and 2011 at ourinstitution when the minimum/maximum diameter of the aortic annu-lus as determined by MDCT was used for valve sizing, were retrospec-tively analyzed with the image analysis software (3-mensio MedicalImaging) in a blinded fashion. Parameters used for calculation of theaortic annulus size included annulus area, diameter and perimeter.Valve sizes were determined as recommended by the respective manu-facturer based on these parameters.Results: Patients either received theEdwards Sapien (n¼ 91), the Medtronic Corevalve (n¼84) or theMedtronic Engager (n¼11). In 130 patients (69.9%/Group A) imageanalysis recommended the same valve size that was actually implanted.However, in 29 patients (15.6%/Group B) image analysis revealed alarger valve size and in 27 patients (14.5%/Group C) a smaller size wassuggested. Patients of group B showed a seven-fold higher rate of aorticregurgitation (AR)�2 (n¼6/29) compared to group A (n¼4/130;p¼0.001) whereas group C did not show a higher incidence of conduc-tion disorders (p¼0.5). Interestingly, there was no difference in 30 daymortality (4.6%(A), 3.4%(B), 7.4%(C) p¼0.76) and 1-year mortalitybetween all three groups (27.5%(A), 17.2%(B), 30.4%(C); p¼0.21).Conclusion: Retrospective image analysis of pre-TAVI-MDCTs by adedicated software revealed a different valve size in about one thirdof the patient cohort. Patients with an undersized valve had a seven foldhigher risk for moderate AR but this did not translate into a reduced 1year survival of the respective patients.

Aortic valve and Ascending aorta

OP82Outcome and quality of life following surgeryfor acute type A aortic dissection in the elderly:A single center experienceHaneya A.1, Jussli-Melchers J.1, Berndt R.1, Tautorat I.1,Schmidt K.1, Schoeneich F.1, Rahimi A.1, Grothusen C.1,Schöttler J.1, Cremer J.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Klinik für Herz- und Gefäßchirurgie, Kiel, Germany

Objectives:Despite improvements in surgical and perfusion techniques,surgery for acute type A aortic dissection (AAD) remains associatedwithhigh mortality rates. The aim of our study was to evaluate outcome andquality of life (QoL) after surgery for AAD in elderly compared withyounger patients. Methods: Between 2004 and 2012, 204 patientsunderwent emergency operation for AAD using deep hypothermiccirculatory arrest. 65 patients were aged 70 years and older (elderlygroup,mean age, 76� 4 years, range 70-85 years) and 139were youngerthan 70 years old (younger group, mean age, 56 � 10 years, range 18-69years). Follow-up was 91% complete (mean, 5.1 � 2.7 years, range 0.9-10.0 years). QoL was assessed with the Short Form Health SurveyQuestionnaire (SF-36). Results: No significant differences were notedbetween the two groups with regard to preoperative risk factors onadmission (cardiogenic shock/hypotension, cardiac tamponade, limbischemia, or neurologic deficit). The surgical procedures includingisolated replacement of the ascending aorta, associated with totalroot replacement and aortic arch replacement were compared betweenthe groups. No significant differences in postoperative complicationsand major morbidity were observed. Nine patients (14%) in the elderlygroup, and 19 patients (14%) in the younger group underwent re-exploration due to excessive bleeding or cardiac tamponade (p¼1.0).The incidence of postoperative acute renal injury was 17% in the elderlygroup, and 23% in the younger group (p¼0.36). The operative mortality(elderly group 3% vs. younger group 2%; p¼0.65) and 30 days mortality(elderly group 18% vs. younger group 9%; p¼ 0.06) were withoutstatistical significance between the groups. In the elderly, survivalrate (including the operative mortality rate) were 77% at 1 year, 71%at 3 years, and 68% at 5 years. In the younger group, the rateswere 88% at1 year (p¼0.04), 88% at 3 years (p¼0.005), and 84% at 5 years (p¼0.01).The questionnaires return ratewas 73%. The quality of life survey did notreveal any significant differences between both groups. Conclusions:Surgery for AAD in the elderly resulted in acceptable mortality. Satis-factory early and long-term outcomes and generalized perception ofindependency and well-being encourage the offering of surgery inelderly patients

OP83Long-term results and postoperative aorticvalve regurgitation outcome after repair ofacute type A aortic dissection: A single-centerstudy of 836 casesTutkun B.1, Abd El Al A.1, Buz S.1, Büttner F.1, Hetzer R.11Deutsches Herzzentrum, Berlin, Germany

Objectives: Aortic valve insufficiency is usually seen in patients withtype A aortic dissection (AAD). This study examines the data on long-term outcome of aortic valve insufficiency (AI) in patients with acutetype A aortic dissection. We retrospectively evaluated our data over a15-year period starting in 1996. Methods: Between 01/1996 and 11/2011 836 patients withmean age 59.6þ�13.6 (range 18-96) underwentsurgery for AAD. Ninety-two perioperative variables were statisticallyanalyzed to identify predictors for outcome. Preoperative, postoperativeand follow-up echocardiography was considered a parameter for AIseverity. The long-term outcome of AI considered the exact date of thefollow-up echocardiography, the need for reoperation on the aorticvalve, and the surgical technique used. Results: Of the entire cohort 372patients (45%) had preoperative AI grade II or more, of which 189patients (51%) underwent aortic valve replacement (162 with Conduit),and 183 (49%) aortic root reconstruction. Of these, 4 patients hadpostoperative grade II, 38 low grade and 330 (88%) had no AI. At


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follow-up echocardiography (mean 2.6 yrs.) 35 patients had AI grade IIor more, 46 low grade and 291 (78%) no AI. Of these, 29 patients (8%)were reoperated (22 with aortic root reconstruction), 6 patients due toisolated AI and the rest because of re-dissection, endocarditis, para-valvular leak, thrombosis and prosthesis perforation. 311 patients (37%)had preoperative low grade AI, of which 203 patients (65%) underwentsurgery with aortic root reconstruction, 31 patients (10%) with aorticvalve replacement (20with Conduit). Of these, postoperatively 1 patienthad AI grade II, 56 low grade and 254 (82%) had no aortic regurgitation.At follow-up echocardiography (mean 2.1 yrs.) 26 patients had AI gradeII or more, 72 low grade and 213 (69%) no AI. Of this group 18 patients(6%) were reoperated (13 with aortic root reconstruction), 2 patientsbecause of isolated AI and the rest because of re-dissection andendocarditis. Preoperatively, 154 patients (18%) had no AI, there wasonly one patient with AI grade III at follow-up who underwent areoperation because of re-dissection. Conclusions: Although postoper-ative echocardiography after aortic root reconstruction on acute type Aaortic dissection patients shows satisfactory results, the choice ofsurgical treatment has a considerable impact on long-term aortic valveinsufficiency outcome.

OP84Aortic root replacement in the very old patient -is reluctance justified?Girrbach F.1, Etz C.D.1, Hoyer A.1, von Aspern K.1, MisfeldM.1, Borger M.A.1, Mohr F.-W.11Herzzentrum Leipzig - Universitätsklinik, Klinik fürHerzchirurgie, Leipzig, Germany

Objective: Octogenarians - the fastest growing patient group in cardiacsurgery - are frequently denied complex aortic root surgery in theabsence of reliable outcome data Methods: Between 11/1998 and 03/2011, 157 consecutive patients aged�75 years (mean: 77.9 � 3.1 years,male: N¼88) received aortic root replacement (ARR) with either astentless porcine xenograft (N¼142) or amechanical composite conduit(N¼15). Indications for ARR were: valve disease with aneurysm of theaortic root in 57%, acute Type A aortic dissection in 14%, infectiveendocarditis in 13%. Other indications were mainly technical consider-ations during aortic valve replacement (12%). Aortic valve pathologywas regurgitation in 47%, stenosis in 20%, and combined in 24%. Twenty-to percent had prior cardiac surgery, 23% were operated on an emer-gency basis. Results: Follow-up averaged 2.4 � 2.8 years (0-11 years).Mean hospital stay was 20.7 � 20.2 days, with a 30-day mortality of25.5% (elective cases: 15.2%). Concomitant procedures were performedin 64%, mostly CABG (36%) and concomitant partial arch replacement(24%). One-year survival was 62� 4%, with a cumulative 5-year survivalof 44 � 5% (elective cases vs. urgent/emergency: 72 � 5% vs. 47 � 6%after one year, 60� 6% vs. 29� 6 @ five years, p<0.01). Among patientswho could be discharged from hospital, one year survival was 84 � 4%,with a 5-year survival of 63 � 5%. Risk factors for mortality were:concomitant CABG (p¼0.05), CPB time (p¼0.01) and COPD (p<0.01).Conclusion: ARR in the elderly yields acceptable short and mid-termresults, which are almost comparable to those after AVR. Reluctanceconcerning aortic root surgery in octogenarians is therefore notjustified.

OP85Aortic valve reconstruction for aortic valveinsufficiency - a single center long termexperienceJacobs S.1, Sündermann S.1, Falk V.11University Hospital Zürich, Division of CardiovascularSurgery, Zürich, Switzerland

Objective: Aortic valve reconstruction following the Tirone Davidprinciple is a complex but efficient procedure for Aortic valve insuffi-ciency due to aortic root enlargement or other reasons like Typ-A AorticDissection with good results. Objective of this study was to retrospec-tively investigate the short- and long-term results of this procedure inour center. Methods: Data from 100 patients was retrospectivelyanalysed. Endpoints were long term survival and reoperation rate.Continuous data is given as mean with standard deviation; linear data

is given as parts. Results: Mean age of patients was 47 � 15 years, 83%were female. 51% had aortic insufficiency (AI) grade 3 or 4 preopera-tively and 22% had a bicuspide valve. 13 patients were operated asemergency because of aortic dissection Standford Typ A. 29% werediagnosed with Marfan Syndrom, 15% preoperatively, 14% postopera-tively through histology. 43% had diagnosed hypertension, 4% hadpreoperative diabetes mellitus. 4% had preoperative stroke and 1%had preoperative renal impairment. Mean ejection fraction preopera-tively was 60� 10%. Main part of the patients had no symptoms 72%. 4%were inNYHA class III. The rest in class I or II. Mean diameter of the aorticroot was 5.2 cm. The operation was performed as redo procedure in 9%of cases. 10 patients had additionally a bypass operation, 5 patients anadditional valve operation other than the aortic valve. In 7 patients,aortic arch surgerywas performed additionally. Mean CPB timewas 210� 86 min. Mean cross-clamp time was 148 � 60 min. PostoperativeEchocardiography showed no AI in 24% of cases. 40% had trivial AI and28% hadmild AI. In 6% of casesModerate AI was seen. 2 patients showedpersistent severe AI resulting in immediate conversion to valve replace-ment. 5 further patients had a reoperation due to new AI, aortic stenosisor endocarditis between 20 month to 124 month after the initialoperation. Mean follow-up time was 42 month, median follow up was27 month (0-211 month). 5-year survival was 94.1 � 3% (1.1 death/100patient years). Conclusions: Short and long term outcome of the TironeDavid procedure shows good results with high survival and lowreoperation rates also if performed in patients with aortic dissectionand bicuspid valve.

OP86Bicuspidalization of the native tricuspid AorticValve: A new experimental model to isolate theeffect of altered 'Flow-Architecture' onAscending/Root DiseaseEtz C.D.1, Haunschild J.1, LuehrM.1, Hoyer A.1, Girrbach F.F.1,von Aspern K.1, Grothoff M.2, Gutberlet M.2, Misfeld M.1,Mohr F.-W.11Herzzentrum Leipzig - Universitätsklinik, Klinik fürHerzchirurgie, Leipzig, Germany, 2Herzzentrum Leipzig -Universitätsklinik, Abteilung für Radiologie, Leipzig,Germany

Objectives: Bicuspid Aortic Valve (BAV) is associatedwith a significantlyhigher risk of ascending aortic/root pathologies at a young age. Previ-ously, associated aortic wall alterations were thought to be of geneticorigin but more recently altered flow architecture has been suggestedthe major culprit. We present the first large animal model to experi-mentally isolate the effect of flow phenomena through the BAV frompossible genetic factors.Methods: Six juvenile pigs underwent CPB andopen aortic valve (AV) surgery for cusp fusion (5-7 Prolene (7 x 0)stiches) to bicuspidalize the native tricuspid aortic valve. The two mostcommon Sievers types-1L-R (�75% of the general BAV population) andSievers type I R-N (�20%) were generated for further flow simulation(Fig.1). All pigs underwent a pre- and postoperative 4D-MRI to gatherraw data for visualization of changes in flow architecture and dynamicsand altered pressure profileswithin thewall of the ascending aorta/root.Results: After bicuspidalization of the AV typical vortex formation andchanged wall pressure profiles could be seen in the ascending aorta/aortic root. No severe artificial stenosis was created by this procedurewith invasively measured transvalvular gradients over the AV in bothSIEVERS types of 15 � 5 mmHg. No significant flow alteration butnormalized laminar flow was present again downstream, in the distalaortic arch /proximal descending (Fig.1). Conclusions: We present thefirst large animal model that allows for the systematic analysis of theprimary effects of altered flow architecture-isolated from possiblegenetic factors-caused by BAV of separate Sievers types. With lowtransvalvular gradients and negligible degree of stenosis, long-termevaluation of various helical flow patterns on changes in wall enzymeactivity, smooth muscle cell function and structural transformation ofthe extracellular matrix possibly resulting in aneurysm formation ortriggering acute dissection will be feasible.


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Fig. 1

OP87Aortic valve dynamics after valve-sparingprocedure with a new sinus prosthesisSchmidtke C.1, Richardt D.1, Karluss A.1, Sievers H.-H.11Universitätsklinikum Schleswig-Holstein, Campus Lübeck,Klinik für Herz- und thorakale Gefäßchirurgie, Lübeck,Germany

Objectives: The aim of the study was to evaluate aortic valve dynamicsand clinical results after aortic root remodeling with a new sinusprosthesis with three separate naturally shaped sinuses of Valsalva invalve sparing procedures. Methods: Between February 2009 and April2012, a total of 38 patients (32m/ 6 f;mean age 52.6� 13.1 years; 24-70y) with aortic root aneurysm (n¼5 bicuspid aortic valves) underwentreplacement of the ascending aorta with the new sinus prosthesis inaortic valve reimplantation technique according to David. Our patientsreceived clinical as well as echocardiographic follow-up examinations(mean of 20.7� 11.7 months; 1-40.5 months) including valve dynamicswhich were compared with a group of 20 healthy controls. Results:There was one death, no reoperation, no endocarditis. All patients hadno or trivial aortic regurgitation. Pressure gradients were in betweenthe normal range. Echocardiographic images demonstrated physiologi-cal values of aortic root dimensions and configuration with threeseparate sinuses of Valsalva without systolic contact of leaflets to thewall. Valve opening velocity in patients (P) was 40.9� 9.1 vs. 36.8� 21.9cm/s in controls (C) (p¼0.205), rapid valve closing velocity 26.4 � 11.0(P) vs. 14.6� 13.9 cm/s (C) (p¼0.235), slow closing displacement 11.5�5.3 (P) vs. 13.9 � 8.8 (C) (p¼0.254). Conclusions: The new sinusprosthesis is easy to implant. It mimics the native sinuses and preservesnear normal functioning aortic valve motion and function in valvesparing procedures.

OP88Graft failure two decades after a bentallprocedure with HemiArch replacementvonAspern K.1, Etz C.D.1, Seeburger J.1, Hoyer A.1, Girrbach F.F.1, Sauer M.1, Lehmkuhl L.1, Misfeld M.1, Mohr F.W.11Herzzentrum, Leipzig, Germany

Case description of a sexagenarian male patient with Marfan’s syn-drome who was referred to our clinic due to acute chest pain. Hismedical history contains complex surgery for type A aortic dissection 19years ago including composite root replacement using a mechanicalaortic valve. Immediate computed tomography indicated perforation at

the distal ascending aortic anastomosis plus complete detachment ofboth coronary ostia. The operative approach for successful rescuesurgery with ascending aortic and arch replacement using a modifiedCabrol technique is discussed.

Fig. 1

Fig. 1: (left: topþbottom) Preoperative CT showing the ascending aorticprosthesis and the surrounding hemorrhage within the former aneu-rysmal sac (black asterisk). (right: top and bottom) Postoperative CTshowing the Cabrol interposition graft (white arrows).


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Abstract Session

Heart and lung failure III

OP90Left ventricular vs biventricular assist device:Impact of load dependency of right ventricularperformance on decision making beforeventricular assist device implantationDandel M.1, Potapov E.1, Krabatsch T.1, Knosalla C.1, HetzerR.11Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefäßchirurgie, Berlin, Germany

Background: Left ventricular assist-devices (LVADs) are safer and pro-vide better quality of life than bi-ventricular devices (BVADs). The loadsensitivity of RV performance, related to the impact of pre- and afterloadon RVgeometry and tricuspid regurgitation (TR), explains the RVabilityto improve its function after LVAD insertion, but it also can bemisleadingfor preoperative prediction of RV performance during LVAD support.Thus, preoperative decisions in favor of either LVAD or BVAD support aredifficult.We assessed the impact of load dependency in RV performancebefore and after LVAD implantation aiming to improve preoperativedecision making. Methods: Laboratory, echocardiography (includingtissue-Doppler and strain imaging), and right heart catheterization data,collected prospectively from 205 patients (pts) before LVAD implanta-tion, were tested for relationship with postoperative RV function.Results:We found differences (p<0.01) in preoperative RVenddiastolicshort-/long-axis (S/LED) and long-axis/length-area ratios, tricuspid an-nulus peak systolic velocity (TAPSm), systolic pressure-gradient be-tween RV and right atrium (ΔPRV�RA), RV peak longitudinal globalsystolic strain-rate (PSSrL), TR velocity-time-integral, and pulmonaryarterial pressure (PAP) between pts with (n¼45) and without (n¼160)postoperative RV failure (RVF). The prevalence of TR >grade 2 and lowΔPRV�RA (<35 mmHg) was higher in pts with postoperative RVF (31%and 79%, respectively) than in those with postoperative freedom fromRVF (16% and 7%, respectively) High predictive values (85-92%) forpostoperative RVF were found for S/LED�0.6, TAPSm<8 cm/s, andPSSrL<0.6/s in pts with maximum ΔPRV�RA<35 mmHg. These param-eters also were predictive for RVF in pts with TR >grade 2 andpulmonary arterial pressure < 50 mmHg. S/LED<0.6, TAPSm�8 cm/s,and PSSrL�0.6 in pts with maximum ΔPRV�RA�35 mmHg showedpredictive values of �95% for postoperative freedom from RVF.PSSrL�ΔPRV�RA and the RV load-adaptation index (LAI), a pressure-load related RV size and geometry index, showed the highest predic-tivity for RV function after LVAD implantation (positive and negativepredictive values for freedom from postoperative RVF, up to 97% and93%, respectively). Conclusions: RV geometry and contraction-velocitybefore LVAD implantation become more predictive for postoperative RVfunction and can improve decision-making before VAD implantation ifpreoperative RV pressure-load and TR are also considered.

OP91Levosimendan treatment influences proteinkinase C epsilon and its mitochondria-associated downstream targetsKraemer S.1, Goetzenich A.1, Moza A.1, Hatam N.1,Bernhagen J.2, Stoppe C.2, Autschbach R.11Uniklinik RWTH Aachen, Klinik für Thorax-, Herz- undGefäß-Chirurgie, Aachen, Germany, 2Uniklinik RWTHAachen, Institut für Biochemie und molekulare Zellbiologie,Aachen, Germany

Objectives: Preoperative loading with levosimendan has proven bene-ficial and its cardioprotective effects are clinically discussed. Yet knowl-edge of the underlying pathways is still sparse. Late phasepreconditioning offers a clinically relevant window of protection withits timeframe between 24 and 72 hours after onset of the precondition-ing stimulus. As protein kinase C epsilon (PKCe) related regulation iscrucially involved in the effects of late phase myocardial precondition-ing, we hypothesized that the effects described are at least in partmediated via this pathway. Methods: In an in-vitro model of cardio-

myocyte primary culture from neonatal rat ventricles, the effect ofcontinuous administration of levosimendan was followed for 48 hrs.Phosphorylation of PKCe and adenosinemonophosphate-activated pro-tein kinase (AMPK) was measured by western blot at 6 different timepoints up to 48 hours after administration. Results: Following levosi-mendan treatment, activation of the analysed proteins by phosphory-lation differs significantly as compared to untreated controls. Both PKCeand AMPK reach a peak after 24 hrs of treatment (p<0.05 vs. baselineand sham), although the increase in PKCe phosphorylation is triggeredearlier and a significant difference to sham controls can already bemeasured 30 min after onset of treatment (p<0.05). Conclusion: Thestudy demonstrated a crucial role of PKCe and AMPK within thelevosimendan-induced cardioprotection. Comparison to known path-ways of myocardial preconditioning thereby confirms the activation ofmitochondria-related signalling pathways by continuous treatmentwith levosimendan. This might hint to the existence of a levosimen-dan-induced late phase preconditioning.

OP92Euromacs, a growing EACTS data registryDe By T.M.1, Hetzer R.2, Pomar J.L.31Euromacs, Berlin, Germany, 2Deutsches HerzzentrumBerlin, Berlin, Germany, 3European Association of Cardio-Thoracic Surgery, Windsor, United Kingdom

Objective: As the use of mechanical circulatory support in patients withend-stage heart failure increases, there is a growing need to performscientific studies using data from a large number of patients, so thatstatistical analyses gain significance. We set up a European databasewhich enables cardiac-thoracic centers, surgeons and cardiologists tocompare their data with those in the registry. Method: The Euromacsdatabase was created at the initiative of 14 European founding mem-bers. By mid-2013, the number of institutional members had grown to39. In order to obtain international acceptance, and to offer betterservice and quality assurance to members it was agreed that Euromacswould function as a committee of the EACTS. The board/committee isdemocratically elected, and as a result, the nationalities in the boardwere diversified. The creation of a European database was prompted bythe fact that a larger number of devices from different producers areused in European centers. Nevertheless, the database was to be devel-oped in such way that comparability with other registries, specificallywith Intermacs, would remain possible. Results: The database systemwas co-developed in cooperation with a professional clinical databasecompany, while using the input of experienced clinicians. The firstimplants were registered in April 2012, reaching a total of 450 by July2013. This number is expected to increase to >900 in 2014. TheEuromacs data are pseudonymized and anonymized and are thereforesuitable for scientific analyses. Professionals can access the data of theirown ventricular assist device patients in real time, via a secure Internetconnection, while all Euromacs participants register events such asbridge to transplantation, destination therapy etc. and are able to trackall ventricular assist procedures, complications and follow-ups. They candownload their own patients' data and produce specific researchreports. Studieswith the entire population can be performed by sendinga request for anonymized data to Euromacs. Such anonymized data forscientific research were made available for the first time in June 2013.Conclusion: By embedding Euromacs in the EACTS, its international andprofessional character has been confirmed. The registry has beendeveloped into a professional scientific tool with which professionalscan analyze their patient cohorts and compare their data with a largeinternational database.

OP93Sirtuins distinguish between physiological andpathological hypertrophySchrepper A.1, Zilkens K.1, Schwarzer M.1, Doenst T.11Jena University Hospital - Friedrich-Schiller-UniversityJena, Department of Cardiothoracic Surgery, Jena, Germany

Background: Cardiac hypertrophy (cHyp) develops in response todifferent stimuli such as pressure overload (PO) or exercise (EX). PO isassociated with heart failure (HF) and mitochondrial dysfunction and is


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thus considered to induce pathological cHyp. In contrast, EX inducedcHyp is reversible and is therefore considered as physiological cHyp.SirT1, an NADþ-dependent deacetylase, is discussed as a potential targetin HF development. Overall there are seven mammalian sirtuins, whoserole in cHyp is still unknown. Objective: We aimed to characterize theexpression of the seven sirtuins during cHyp to assess their role inphysiological and pathological cHyp. Methods: We analyzed cardiacmuscle during EX (repetitive treadmill running) or PO (transverse aorticconstriction). After 2, 10 and 20weeks (w) of PO and after 10 wof EXweassessed cardiac function and morphology, mitochondrial function andcardiac protein expression of SirT1-7. Results: PO resulted in cHyp asassessed by LV posterior wall thickness (10w: C 1,69� 0,17 vs. PO 2,47�0,07mm). Systolic function decreased constantly over timewith PO andafter 20 w we found HF (FS: 49,4 � 1,4 vs. 24,8 � 1,0%). Mitochondrialfunctionwas increased after 2wof PO and decreasedwhenHF occurred.Protein expression of Sirt1 and 4was increasedwith compensated cHypand remained elevatedwhen HF occurred. Expression of SirT3 and SirT5was inversely related to mitochondrial function, reduced mitochondrialfunctionwas associated with increased protein levels. The expression ofSirT2, 6 and 7 was not altered during pathological cHyp. In EX rats therewas only mild cHyp and no change in contractile or mitochondrialfunction. EX also did not change protein expression of the seven sirtuins.Conclusion: Sirtuins can distinguish between pathological and physio-logical cHyp. Furthermore, assessing the specific sirtuin expressionfurther suggests that sirtuins may be markers for cHyp as well asmitochondrial dysfunction.

Fig. 1: Sirtuins in cardiac hypertrophy

OP94Lower mortality and improved outcomefollowing minimally invasive LVADimplantation in destination therapy patientsRojas S.V.1, AvsarM.1, Hanke J.S.1, Deutschmann O.1, AhrensP.R.1, Tümler K.A.1, Rojas Hernandez S.2, Bara C.1, MalehsaD.1, Haverich A.1, Schmitto J.D.11Medizinische Hochschule Hannover, Klinik für Herz-,Thorax-, Transplantations- und Gefäßchirurgie, Hannover,Germany, 2Medizinische Hochschule Hannover, Klinik fürAnästhesiologie und Intensivmedizin, Hannover, Germany

Objectives: Cardiac transplantation for elderly patients with terminalheart failure remains restricted by donor organ shortage. However,demographical changes imply a continuously ageing population thatdemands alternative therapy options. Left ventricular assist devices(LVAD) are gaining more importance in the treatment of heart failure asdestination therapy. However, standard LVAD implantation proceduresin this high risk collective, involve surgical complications like perioper-ative bleeding and extended inotropic support. The aim of our studywasto elucidate if a minimally invasive implantation approach wouldimprove results in elderly patients receiving a LVAD. Methods: Wereviewed the 2-year outcome of 46 end-stage heart failure patientsolder than 60 years, which underwent LVAD implantation (HVAD,HeartWare) for destination therapy in our institution between 2010and 2012. Patients were divided into two groups according to the

implantation procedure: group A (full sternotomy; n¼26), group B(upper hemisternotomy and a left-sided anterolateral thoracotomy,n¼20). Results: Demographical data: 80,4% male, age 66,0 � 4,5 y;DCM 42,6%; ICM 44,4%. Survival after 2 years was higher in group B(85,0% vs. 69,2%). Patients with minimally invasive LVAD implantationshowed also minor postoperative bleeding incidence (B: 0% vs. A: 26,9%,p< 0.05) and lower rates of postoperative extended inotropic support(B: 15,0% vs. A: 46,2%, p< 0.05). Conclusions: Our data show that elderlypatients which underwent a minimally invasive LVAD implantation fordestination therapy had lower mortality, lower incidence of postopera-tive bleeding and less need of inotropic support when compared topatients treated by the standard surgical technique.

OP95Veno-arterial extracorporeal membraneoxygenation in acute heart failure followingseptic shockYildirim Y.1, Pecha S.1, Hakmi S.1, Schäfer T.1, Kubik M.1,Deuse T.1, Reichenspurner H.11Universitäres HerzzentrumHamburg, Hamburg, Germany

Objectives: Septic shockmay lead to haemodynamic and cardiac failure.In cases refractory to optimal medical therapy, veno-arterial extracor-poreal membrane oxygenation therapy may be a valuable treatmentoption. However in literature little is known on outcomes of thosepatients. We here report our single center experience of patientsundergoing veno-arterial ECMO support for septic shock. Methods:Between 01/2009 and 08/2013, 32 patients with septic shock under-went veno-arterial ECMO implantation in our institution. Data on 30-day and 12months mortality, as well as duration of in-hospital- and ICUstay were collected and retrospectively analyzed. Results: Mean pa-tients agewas 61.9� 7.8 years, 62% of patientsweremale. Prior to ECMOimplantation, mean left ventricular ejection fraction was 23 � 10%,mean systemic vascular resistance was 753 � 112 and mean cardiacindex was 1.98 � 0.87 l/min/m2. All patients had severe signs of multi-organ dysfunction, pH: 7.2 � 0.1, blood lactate 7.8 � 3.2 mg/dl,creatinine 2.3 � 0.9 mg/dl, GOT 388 � 574 U/l,GPT 333 � 614 U/l, 30day- and 12 months mortality was 62.5% and 71.8% respectively. Meanduration of ECMO support was 169.7� 64.4 hours, andmean duration ofICU- and in-hospital stay were 9.2 � 2.4 and 27.1 � 9.9 days. In patientswith successful ECMO weaning, normalization of cardiac function wasseen. Conclusion: In patients with acute cardiac failure following septicshock, veno-arterial ECMO therapy in combination with optimal medi-cal therapy is a valuable treatment option as bridge to recovery. The rateof in hospital mortality is rather high, but in patients surviving the acutephase of septic shock, a restoration of cardiac function with good long-term outcome was observed.

Arrhythmias

OP96Atrial fibrillation burden estimates derivedfrom intermittent rhythm monitoring shouldnot be used for patient follow-up or asendpoints in clinical trialsCharitos E.1, Ziegler P.2, Stierle U.1, Graf B.1, Klotz S.1, SieversH.-H.1, Hanke T.11Klinik für Herzchirurgie, UKSH, Campus, Lübeck, Germany,2Medtronic, USA, Cardiac Rhythm Disease Management,Minneapolis, United States

Objectives: Estimates of atrial fibrillation (AF) burden derived fromintermittent rhythmmonitoring (IRM) are increasingly being used as anoutcome measure after therapeutic interventions, however, their accu-racy has never been validated. The aim of this study was to compareIRM-derived AF burden estimates to the true AF burden as measured byimplantable continuous rhythm monitoring (CM) devices. Methods:Rhythm histories from 647 patients (mean AF burden:12 � 22%; 687patient*years) with CM devices were analyzed. IRM of various frequen-cies and durations were simulated and the obtained IRM-derived AFburdenswere compared to the true AF burdenmeasured byCM.Results:


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The relative error of the IRM burden estimates was dependent on theIRM length (p<0.001), frequency of IRM (p<0.001), the true AF burden(p<0.001) and its temporal aggregation (AF density, p<0.001). Inparoxysmal AF patients, the relative error even with aggressive IRMstrategies was >80% of the true AF burden. The relative error decreasedwith higher true AF burdens, lower AF densities, and higher IRMfrequency or duration (p<0.001). However, even in patients withhigh AF burdens and/or low AF densities, IRM estimates of AF burdensignificantly deviated from the true AF burden (relative error >20%,p<0.001) and resulted in substantial measurement error. Conclusion:IRM-derived AF burden estimates are unreliable estimators of the trueAF burden. Particularly for paroxysmal AF patients, IRM-derived AFburden estimates should not be used to evaluate outcomes after AFinterventions. For the scientific evaluation of AF therapies and status ofpatients, CM should be recommended.

OP97Long-term outcome up to 10 years afterconcomitant ablation in cardiac surgicalpatients with atrial fibrillation (AF)Subbotina I.1, Pecha S.1, Schäfer T.1, Reichenspurner H.1,Wagner F.M.11Department of Cardiovascular Surgery, University HeartCenter, Hamburg, Germany

Objectives: Concomitant ablation therapy for AF promotes the oppor-tunity to cure dysrhythmia. The one-year success of ablation by variousenergy sources are described extensively. We analyzed the rhythmstability after concomitant left atrial ablation in cardiac surgical patients(pts) during a follow-up period of up to ten years. Patients: Between 01/2003 and 07/2007 186 pts undergoing cardiac surgery (age 67 � 10,LVEF 52� 12%, LA 50� 10mm, chronic AF in 58%) received concomitantcomplete left atrial (LA) lesion set either by endomyocardial radiofrequency (n¼128) or epimyocardial cryo ablation (n¼58). Indicationfor surgery was valvular pathology (mitral 40%; aortic 20%) or coronarydisease (13%) respectively; combined procedures occurred in 23%. Aftersurgery rhythmwas annually documented by 24 hr holter ECG. Statisticsincluded Mann-Whitney and Fisher-exact test. Results: Mean durationof follow - upwas 94 � 16 month. In this time 49 pts died (26%). 14 (7%)pts were lost to follow after 10 years. Conversion to sinus rhythm (SR)was highest at 1 and 2 years post ablation but decreased continuouslythereafter. 10 years after surgical treatment 20% of ptswere free fromAF.Pts with intermittent AF had higher incidence of SR in early follow-up-period, however, beyond 6 years type of AF had no impact on rhythmoutcome. LA diameter, preoperative duration of AF, postablative drugtherapy, ablation method and performed cardiac surgery were nopredictors for stable long term SR. At the end of assessment in Juli2013 70% of all pts received anticoagulant therapy.

Fig. 1: Frequency of Pts with SR in %

Conclusion: Surgical concomitant ablation achieved up to 70% SR whichremained stable during initial 2 postoperative years Longer follow-up,however, revealed an increasing re-appearance of AF and need toreintroduce anticoagulation. No predictors for poor longterm rhythmoutcome could be identified in this cohort.

OP98Risk factors for intra-operative defibrillationtestshock failure in a multivariante analysis of4572 consecutive patientsZiegelhoeffer T.1, Siebel A.2, Markewitz A.3, Doll N.4, BärschV.5, Reinartz M.6, Oswald B.7, Bimmel D.8, Weimar T.4,Meyer A.1, Walther T.1, Burger H.11Kerckhoff Klinik, Herzchirurgie, Bad Nauheim, Germany,2Herz- und Gefäßklinik Bad Neustadt, Bad Neustadt a.d.Saale, Germany, 3Bundeswehrzentralkrankenhaus,Koblenz, Germany, 4Sana Herzchirurgie, Stuttgart,Germany, 5St. Marien-Krankenhaus, Siegen, Germany,6Katholisches Klinikum Marienhof, Koblenz, Germany,7Herz- und Diabeteszentrum NRW, Bad Oeynhausen,Germany, 8St.Marien-Hospital, Bonn, Germany

Objectives: The ongoing technical advances in development of new ICDleads, shock algorithms, rapid energy supply and high-energy ICDs ledsome investigators to question the necessity of routine intra-operativedefibrillation testing (DT). Therefore, in a multicenter study we evaluat-ed retrospectively effectiveness, safety and necessity of intra-operativeDT and identified the risk factors for DT failure on un-biased largepatient population. Methods: Data from 4572 consecutive patientsundergoing ICD primary implantation, pulse generator replacement,ICD system up- or downgrade or system revision were retrospectivelyanalyzed. Besides efficacy of DT, risk factors for DT failure were identi-fied in a multiple logistic regression analysis. Results: 3918 out of 4572patients underwent DT (5460 DT overall). 612 (13.4%) were not testedfor medical reasons (intracardial thrombus, obscure anticoagulation,unstable haemodynamics, pneumothorax), for 1.1% patients the datawere missing. DT-associated complications were not noted. Primary DTeffectiveness was 95.9%. From 155 (4,1%) patients with primary ineffec-tive DTsystemoptimization (50.2% increase of DT energy, 8.9% SQ-Array,1.2% high energy-device, 18.1% lead reposition, 3.9% lead exchange,17.8% pulse width optimization) led to successful DT in 147 cases. In 2cases intra-operatively undetected pneumothorax hampered DT suc-cess. In 4 cases DT remained ineffective, for 2 patients the data weremissing. 89.5% of ICDs were placed subpectorally, 11.0% subfascially and0.5% abdominally. DT was performed in 2465 new implantations withfailure of 4.7%, 779 ICD replacementswith failure of 3.4% and 673 systemrevisionswith failure of 4.6%. Additionally, primaryDT effectivenesswaslower in 3-chamber in comparison to 1- and 2-chamber ICDs. Besidesintra-operative undetected pneumothorax the subanalyses and logisticregression analyses identified implantation of pulse generator in anyother position than left subpectoral, age, body mass-index and leftventricular ejection fraction as independent predictors for primary DTfailure. Conclusion: The relatively high number of patients with inap-propriate intra-operative DT, including those undergoing generatorreplacement, is arguing against the abandonment of routine DT. Im-plantation of pulse generator in any other position than left subpectoral,age, body mass-index and left ventricular ejection fraction were identi-fied as independent predictors for primary DT failure.

OP99Clinical outcome of 955 patients treated withdifferent lead concepts for left ventricular/CRTpacing in 5 years follow-upBurger H.1, Opalka B.2, Göbel G.1, Sperzel J.3, Van Linden A.1,Walther T.1, Ziegelhoeffer T.11Kerckhoff-Klinik, Herzchirurgie, Bad Nauheim, Germany,2Kerckhoff-Klinik, Anästhesie, Bad Nauheim, Germany,3Kerckhoff-Klinik, Kardiologie, Bad Nauheim, Germany

Objectives: Transvenous left ventricular leads (tLV) represents goldstandard for cardiac resynchronization therapy (CRT) in adults. Epicar-dial left ventricular leads (eLV) represent an alternative if tLV implanta-tion fails. Data concerning endurance, performance, impact of surgicalaccess and optimal technical concept of eLV were recently published.However, data involving direct comparison of tLV and eLV as well asclinical outcome of patients in long-term follow-up are very limited.Methods: 955 patients with comparable pre-operative characteristicsundergoing implantation tLV (n¼834) or eLV (n¼146) were retrospec-tively analyzed for a period of 5 years. Besides patient clinical data, lead


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performance and endurance were investigated as well. Results: Bothlead concepts, tLV and eLV, showed an excellent 5 year-performance,however, with non-significant marginal lead-specific differences. Sens-ing, impedance as well as pacing threshold remained stable in all groupsduring the whole observation period. Ejection fraction (EF) was pre-operatively 24.57 in tLV vs. 27.85% in eLV group (n.s.) and remainedstable up to 5 years (28.79 vs. 27.57%). Similar stable data with non-significant differences were obtained for end-systolic LV diameter (pre:57 in tLV vs. 54.1mm in eLV; after 5 years: 54.9 vs. 58.4), end-diastolic LVdiameter (pre: 65 in tLV vs. 64 mm in eLV; after 5 years: 66.1 vs. 69.8),myocardial mass (pre: 300 in tLV vs. 288 g in eLV; after 5 years: 327 vs.343) and grade of mitral regurgitation (pre: 1.5 in tLV vs. 1.6 g in eLV;after 5 years: 1.4 vs. 1.2). NYHA class improved from 2.83 in tLV vs. 2.95in eLV pre-operatively up to 2.5 in tLV vs. 2.25 in eLV after 5 years.Conclusions: Both lead concepts, tLV and eLV, showed an excellent,durable and very similar technical long-term performance. The clinicaloutcome of patients up to 5 year after CRT implantation is satisfactory.The end-systolic and end-diastolic LV diameter, myocardial mass, mitralvalve regurgitation as well as ejection fraction remained stable in bothgroups during the whole observation period. A slight improvement inNYHA class was observed in both, tLVand eLVgroup. Taken together, theepicardial leads represents stable alternative to transvenously im-planted left ventricular leads with similar excellent clinical outcomeat least up to 5 years after CRT implantation.

OP100Rhythm outcome predictors after concomitantsurgical ablation for atrial fibrillation: Ten-yearsingle-center experiencePecha S.1, Schäfer T.1, Ahmadzade T.1, Subbotina I.1, WillemsS.2, Reichenspurner H.1, Wagner F.M.11Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Elektrophysiologie/Kardiologie,Hamburg, Germany

Objectives: Concomitant surgical ablation is a safe and feasible proce-dure, recommended in guidelines for patientswith atrialfibrillation (AF)undergoing cardiac surgery. We performed a single-center data analysisto identify predictors of rhythm outcome in such a patient cohort.Methods: Between 01/2003 and 09/2012, 586 patients with persistent(n¼342, 58.4%) or paroxysmal (n¼244, 41.6%) AF underwent concom-itant surgical AFablation. The lesionswere either limited to a pulmonaryvein isolation (n¼94, 16.0%), a more complex left atrial lesion set 373(63.7%), or biatrial lesions (n¼119, 20.3%). All follow-up rhythmevaluations were based on either 24 h-Holter ECG or event recorderinterrogation at 3, 6, and 12 months postoperatively. Sinus rhythm (SR)immediately postoperative was defined as first documented rhythmafter weaning from extracorporeal circulation. Results: Mean patientsage was 68.3þ/-9.9 years, 374 (63.8%) were men. There were no majorablation-related complications. After 1-year follow up 63.7% of allpatients were in SR, showing significantly better results in patientswith paroxysmal AF compared to those with persistent AF (70.7% vs.57.9%, p¼0.0047). Additional statistically significant factors influencingSR after 1 year were left atrial diameter (p¼0.002), duration of AF(p¼0.034), and immediate postoperative SR (p<0.001). Regarding onlypatients with persistent or longstanding-persistent AF, those withbiatrial lesion set showed significantly higher rates of conversion toSR compared to solitary left-atrial ablation (SR: 67.9%vs.50.4% p¼0.028)after 12 months. Conclusion: Statistically significant predictors for SRafter 1 year were left atrial diameter, duration of AF, preoperativeparoxysmal AF, immediate postoperative SR and biatrial ablation forpersistent AF.

OP101Hybrid ablation of long standing persistentatrial fibrillation utilizing minimally invasivesurgical and endocardial catheter approach:One year resultsPajitnev D.1, Kuniss M.1, Szalay Z.2, Neumann T.1, ZaltsbergS.1, Greis H.1, Walther T.3, Hamm C.1, Schönburg M.31Kerckhoff-Klinik, Kardiologie, Bad Nauheim, Germany,2Kerckhoff-Klinik, Bad Nauheim, Germany, 3Kerckhoff-Klinik, Herzchirurgie, Bad Nauheim, Germany

Introduction: Unfortunately the efficacy of catheter ablation of longstanding persisting atrial fibrillation (LSPAF) remains poor even aftermultiple ablation procedures. With a novel hybrid ablation strategywith combined epicardial and endocardial approach high short termsuccess rates were demonstrated. The objective of this study was toevaluate safety and efficacy outcomes after one year. Methods: 25consecutive patients (pts) (2 female, age 52 � 1 years, LA size 46 � 1x 62� 1mmwith LSPAF were included. The epicardial ablationwas firstperformed via an endoscopic subxyphoid access (Numeris®, nContactInc.) followed by conventional endocardial ablation (EnSite NavX Veloc-ity™, SJM Inc.) During the endocardial procedure voltage mapping wasperformed and detected gaps were closed. Esophageal temperature wascontinuously monitored. Pts were prospectively followed at 1, 2, 3months with 48 h holter ECG and every 3 months thereafter. Pts freeof AF after 3 months underwent implantation of loop event recorder,Reveal™, Medtronic Inc. Results: AF was persisting since 55� 9 monthsand 20 � 2 months after last cardioversion attempted. 9 pts (36%) havealready undergone repeated AF catheter ablations. All pts were highlysymptomatic with EHRA class 4. In first 5 pts endocardial voltagemapping has shown incomplete posterior box lesions with necessityof endocardial closure. After the modification of the initial epicardialablation scheme complete posterior box lesions were achieved in 20 pts.Endocardial closure of anterolateral and septal gaps with additionalapplication of anterior roof lines led also to complete isolation of thewhole roof region and all PVs. After this step 5 pts converted primaryinto SR and 10 into atrial tachycardia. After the application of anteriormitral valve lines another 5 of these 10 pts converted into SR. Electricalcardioversion was performed in 15 pts. 7 pts developed a postpericar-diotomy syndrome, which was managed conservatively. One pt hasdeveloped bleeding from the transdiaphragmal access site, whichrequired surgical revision. After a median follow up of 329 (IQR 187-509) days 21 (84%) pts were free of AF without AADs. Conclusions: Ahybrid ablation of LSPAF in pts with severe atrial enlargement repre-sents a feasible treatment option with high mid-term success rates.Further evaluation of long-term results is required.

OP102How accurate does the clinical classification ofatrial fibrillation severity reflect its temporalpersistence: Insights from 1195 patientscontinuously monitored with implantabledevices?Charitos E.1, Pürerfellner H.2, Glotzer T.3, Ziegler P.41Klinik für Herzchirurgie, UKSH, Campus, Lübeck, Germany,2Elisabethinen University Teaching Hospital, CardiologyDepartment, Linz, Austria, 3Hackensack University MedicalCenter, Cardiology Department, New Jersey, United States,4Medtronic, Cardiac Rhythm Disease Management,Minneapolis, United States

Objectives: Clinical classification of atrial fibrillation (AF) severity isemployed to communicate its persistence, to select appropriate thera-pies, and as inclusion criterion for clinical trials. We aimed to identifyhow accurately the current clinical classifications of AF severity reflectits temporal persistence in patients continuously monitored via im-plantable devices. Methods: Cardiac rhythm histories of 1195 patients(73.0 � 10.1 years, follow-up 349 � 40 days) with implantable deviceswere reconstructed and analyzed. Patients were classified as havingparoxysmal or persistent AF by physicians at baseline in accordancewith current guidelines. AF burden, measured as the proportion of timespent in AF, was obtained from the device. Results: The agreementbetween the clinical AF classification severity and the objective device-


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derived assessments of AF temporal persistence was poor (Cohen’skappa 0.12 [0.05-0.18]). Patient clinical characteristics appear to influ-ence the clinical decision to classify AF as paroxysmal or persistent.Higher ejection fraction (Odds Ratio (OR) 0.97 [0.95-0.98];p<0.0001)and presence of coronary artery disease (OR 0.53[0.32-0.88];p¼0.01)were independently associated with a lower probability of beingclassified as persistent AF for the same AF burden level. Conclusions:The currently used clinical classifications of AF severity poorly reflect AFtemporal persistence. Patient characteristics significantly influence thephysician’s classification of AF severity. Patients classified in identicalclinical categories may be inherently heterogeneous with regards to AFtemporal persistence. Further study is required to determine if patientselection based on objective criteria derived from rigorous AF monitor-ing can improve reported outcomes and better identify responders andnon-responders to treatments.

Transcatheter valves III: Focus on mitral valve

OP103Off-pump mitral valved stent implantation: A3D-transesophageal echocardiographic basedcomparison of apical and sub-annular fixationtechniquesPokorny S.1, Huenges K.1, Bähr T.1, Bax L.1, Marczynski-Bühlow M.1, Morlock M.M.2, Cremer J.1, Lutter G.11Department of Cardiovascular Surgery, Christian-Albrechts-University of Kiel, School of Medicine, Kiel,Germany, 2Institute of Biomechanics, TUHH HamburgUniversity of Technology, Hamburg, Germany

Objectives: In this study a comparison of two different designs for off-pumpmitral valved stent implantation in the beating heart is presentedto conduct a proof of concept for a sub-annular fixation technique.Methods: 16 pigs received a self-expanding valved stent in the mitralposition via a transapical approach in the beating heart. The stents werecomprised of an atrial element, a tubular ventricular body accommo-dating a bioprosthetic heart valve and an apical fixation system. Theventricular body was modified in order to evaluate the influence of asub-annular fixation technique: In the first design A (n¼8), the ventric-ular body was shaped cylindrical. In the second design B (n¼8)additional sub-annular fixation elements were included in the stentbody. A 2D and 3D transesophageal echocardiographic (TEE) and ahemodynamic evaluation following standardized protocols were con-ducted pre- (n¼16) and post implantation (n¼16). Results: All stentswere successfully deployed and positioned under sole TEE guidance. Nopersisting arrhythmia (e.g. atrial fibrillation) during the acute follow upwas observed in three (A: n¼1; B: n¼2) and hemodynamic stability inthe remaining cases. 3D TEE proved well suited to evaluate paravalvularleakages (PVL) showing trace or less PVL in all but one case. Evaluation ofthe TEE parameters (Table 1) showed a slightly decreasing EF(p�0.043), remaining within a physiological range in group A. Changesof E/A and E/E´ indicate a slightly reduced diastolic function in group B(p�0.028). An inter-group comparison showed a lower EF and E/A ingroup B compared to group A with sole apical fixation (p¼0.048;p¼0.003). Mean gradients across the mitral valve and valved stentswere low. Conclusion: Secure deployment and correct position of thevalved stents was reproducibly achieved with both designs. Low gra-dients and a normal longitudinal function were achieved and a proof ofprinciple was conducted for the sub-annular fixation technique. How-ever, a slightly decreased diastolic function and EF in the group withsub-annular fixation is indicated and a potential for improvement (e.g.sizing of fixation elements) has been identified.

Table 1: Echocardiographic comparison

EF[%]

TEIIndex[ ]

MAPSE[cm]

PmeanMV[mmHg]

E/A[ ]

E/E’[]

LVOTobstr.[%]

DesignDesignA(n¼8)(n¼8)

Pre 64� 3

0.28� 0.07

1.2� 0.1

0.5� 0.4

1.2�0.3

8.9�2.6

�

DesignA(n¼8)

Post 55�7�þ

0.37�0.19

1.0�0.1 þ

0.9�0.6

1.2�0.2

�13.1�3.6 þ

14�16

DesignB(n¼8)

Pre 64�5

0.35�0.11

1.1�0.1

0.4�0.5

1.7�0.5

9.0�2.3

�

DesignB(n¼8)

Post 47�5�þ

0.31�0.14

0.9�0.2 þ

2.7�2.1

0.9�0.1�þ

17.2�6.1 þ

9�12

EF: left ventricular ejection fraction; TEI Index: myocardial performance index; MAPSE: mitralannular plane systolic excursion, E/A: ratio of peak mitral flow velocities, E/E’: left ventricularfilling index; LVOTobstr.: obstruction of the left ventricular outflow tract; �: p<0.05 indicating astatistical significant difference between group A and B (Mann-Whitney-U-Test); þ: p<0.05indicating a statistical significant difference between pre- and post-implantation evaluation(Wilcoxon test)

OP104Percutaneous mitral valve repair using theMitraClip system: large single-centerexperience in 400 consecutive patients notamenable to surgerySchirmer J.1, Goldmann B.2, Conradi L.1, Schlüter M.2, LubosE.2, Seiffert M.2, Baldus S.2, Treede H.1, Blankenberg S.2,Reichenspurner H.11Universitäres Herzzentrum Hamburg, Klinik für Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Klinik für Allgemeine undInterventionelle Kardiologie, Hamburg, Germany

Objectives: To date, percutaneous mitral valve repair using the Mitra-Clip system is the most widely used catheter-based strategy to treatmitral regurgitation (MR). We report clinical and functional outcomeafter MitraClip therapy in patients ineligible for surgery due to contra-indications or excessive operative risk. Methods: From 9/2008 through4/2013, a total of 400 consecutive patients (age 75 � 9 years; 61% male)with symptomatic functional (66%) or degenerative (34%) MR�3 weretreatedwith theMitraClip system adjudicated by heart team consensus.Risk for mitral valve surgery was considered high by a logistic Euro-SCORE of 26� 18%. Pre-procedural left ventricular ejection fractionwasreduced to 42 � 16% (range 12-71%). Clinical and functional follow-updata were available in 360 patients with a median duration of 12 � 9months (range 0.3-47.9 months) following index procedure. Results:Successful MitraClip implantation (residual MR�2 at discharge) wasdocumented in 364 (91%) patients. Pre-procedural MR severity wasgrade 3 in 216 (54%) patients and grade 4 in 184 (46%) patients.Procedure-related reduction in MR severity was three grades in 56(14%) patients, two grades in 216 (54%) patients, one grade in 107 (27%)patients, and remained unchanged in 21 (5%) patients. Thirty-daymortality was 3.6%, whilst one-year and two-year survival rates were78.4% and 62.4%. Estimated freedom from reintervention at one year andat two years was 90.6% and 87.3%. Freedom from heart failure rehospi-talisation at one year and at two years was 47.0% and 33.3%, respectively.Conclusion: In the majority of patients, MitraClip therapy was safe andeffective in durably reducing MR. However, overall mid- and long-termmortality and rehospitalisation reflect severity of the patients comor-bidities and the natural course of the disease. Even though less effectivein reducing MR compared to surgery, treatment with the MitraClipdevice has proven to be an important therapeutic option in selectedpatients who are inoperable or at prohibitive risk for cardiac surgery.Therefore, the MitraClip system represents an essential complementarytool for an integrated mitral valve program.


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OP105First in man combined procedure of transapicalTAVI and interventional mitral valve repair bychordal replacement using the NeochordsystemTreede H.1, Lubos E.2, Conradi L.1, Seiffert M.2, ShimamuraK.1, Diemert P.2, Reichenspurner H.11Universitäres Herzzentrum Hamburg, Klinik für Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Klinik für allgemeine undinterventionelle Kardiologie, Hamburg, Germany

Objectives: We report the case of a 82 year old female patient withsevere aortic stenosis (EOA 0.8 cm2 as determined by echocardiography)and mitral regurgitation grade IV due to prolapse of the anterior mitralleaflet following chordal rupture. The patient was admitted to ourhospital with congestive heart failure. Due to co-morbidities (bilateralcarotid stenosis, porcellaine aorta, peripheral artery disease) resultingin a logistic Euro-Score of 23.4% and an STS-score of 9.8 the patient wasdeemed uneligible for conventional valve surgery. Methods: The treat-ment options were discussed within a heart team and a combinedprocedure of transapical TAVI with mitral repair using the Neochordsystem was selected. Access to the aortic and mitral valve was obtainedusing a 3 cm mini-thoracotomy at the 5th intercostal space. Pre-dilatation of the aortic valve with a 23 mm balloon was followed bythe implantation of a 25 mm JenaValve aortic bioprosthesis. Aftersuccessful deployment of the TAVI prosthesis we proceeded to mitralrepair using the Neochord-system. Using the same transapical access asfor the TAVI the prolapse of the anteriormitral leaflet was grasped underechocardiographic guidance and three chordae were implanted into theanterior mitral leaflet using controlled tension by knot fixation at theapex. Results: Using a 25 mm Jenavalve TAVI prosthesis the transaorticgradient was reduced from 78/36mmHg to 12/5mmHg. EOA followingTAVI was calculated as 2.1 cm2 with no paravalvular regurgitation. Theimplantation of three chordae into the prolapse of the anterior mitralvalve using the Neochord system resulted in a reduction of mitralregurgitation from grade IV to grade II in this inoperable patient.Conclusions: We report the first case of combined transapical TAVIplus mitral repair using the Neochord system. Since aortic stenosis andmitral regurgitation frequently occur as concomitant valvular patholo-gies, this minimally-invasive interventional approach represents atreatment option for patients not eligible for combined aortic andmitralsurgery.

OP106Transcatheter off-pump mitral valved stentimplantation: Enhanced survival and decreasedparavalvular leakagesHuenges K.1, Pokorny S.1, Bähr T.1, Bax L.1, Marczynski-Bühlow M.1, Hansen J.H.2, Fischer G.2, Cremer J.1, Lutter G.11Department of Cardiovascular Surgery, Christian-Albrechts-University of Kiel, School of Medicine, Kiel,Germany, 2Department of Pediatric Cardiology, Christian-Albrechts-University of Kiel, School of Medicine, Kiel,Germany

Objectives: Off-pump transapical implantation of a mitral valved stentis a novel approach to the treatment of mitral regurgitation. This studypresents the latest results of transapical implantation of a new mitralvalved stent design with follow up periods of up to three months.Methods:A self-expanding re-designed valved stent was implanted intothe native mitral annulus of eight pigs via transapical approach in thebeating heart. Hemodynamic- and echocardiographic parameters wereassessed before (n¼8), at 1 h (n¼8), at one month (n¼6), and atoutstanding health of the animal additionally at two (n¼2) and threemonths (n¼ 1) after implantation following a standardized protocol.Results: The stent was successfully positioned in all animals. Twoanimals died within the first month due to inadequate anchorage. Inthe remaining animals, correct stent position was achieved and themean ejection fraction (EF) was more than 50% at all time points(p�0.088). However, two animals followed up to one month had alower EF, which was related to endocarditis. Echocardiographic evalua-tion showed no paravalvular leakages (PVL) after 1 h. After one month

PVL were trace or less in five out of six animals. Echocardiographicevaluation of the mean gradients across the mitral valved stent, leftventricular outflow tract and aortic valve were within a physiologicalrange at all points in time (Table 1). The mitral annular plane systolicexcursion was �1 cm at all times indicating normal longitudinalfunction. Pulmonary artery pressure and pulmonary capillary wedgepressure (PCWP) were stable directly after implantation (p�0.101), butPCWP mildly increased after one month (p¼0.033). Gross evaluationdemonstrated correct stent position in all animals. Ingrowth within thenative structures of the left atrium was 72 � 20% after one month inthree of four animals and 90% after two months. Conclusion: Securedeployment and correct position of the valved stents was reproduciblyachieved in the off-pump implantation procedure. Trace or less PVL aswell as low gradients, and a normal longitudinal function after onemonth were achieved with this newly developed and well-alignedprototype with a post-operative period of up to three months.

Table 1: Echocardiographic evaluation

PmeanMV[mmHg]

PmeanLVOT[mmHg]

PmeanAV[mmHg]

MAPSE[cm]

PCWP[mmHg]

PAP[mmHg]

Pre 0.6� 0.5 1.0� 0.3 1.5� 0.7 1.2�0.1 7�3 14�4

Post 1.1�0.8 2.5�3.6 2.0�2.5 1.0�0.2 10�2 17�3

1 month 3.9�1.4 2.1�2.4 1.9�0.8 1.1�0.1 16�3 22�7

Pmean: mean gradient over: MV:mitral valve /mitral valved stent; LVOT: left ventricular outflowtract; AV: aortic valve; MAPSE: mitral annular plane systolic excursion; PCWP: pulmonarycapillary wedge pressure; PAP: pulmonary artery pressure

OP107Percutaneous MitraClip therapy: Early and oneyear results from the ACCESS-EU prospective,multicenter, non randomized post-approvalstudy in EuropeConradi L.1, Maisano F.2, Franzen O.3, Baldus S.4, Schäfer U.5,Hausleiter J.6, Butter C.7, Ussia G.P.8, Sievert H.9, RichardtG.10, Widder J.D.11, Moccetti T.12, Schillinger W.13,Reichenspurner H.11Universitäres Herzzentrum Hamburg, Klinik undPoliklinik für Herz- und Gefäßchirurgie, Hamburg,Germany, 2Scientific Institute San Raffaele, Milan, Italy,3Rigshospitalet, Department of Cardiology,, Copenhagen,Denmark, 4Heart Center Cologne, Department of Generaland Interventional Cardiology, Köln, Germany, 5AsklepiosKlinik St Georg, Department of Cardiology, Hamburg,Germany, 6Deutsches Herzzentrum München, Departmentof Cardiology, München, Germany, 7Heart CentreBrandenburg, Bernau/Berlin, Germany, 8InterventionalStructural and Congenital Heart Disease Programme,Invasive Cardiology Division of Cardiology, Ferrarotto, Italy,9CardioVascular Center Frankfurt, Frankfurt, Germany,10Heart Center, Segeberger Kliniken GmbH (AcademicTeaching Hospital of the Universities of Kiel and Hamburg),Bad Segeberg, Germany, 11Medizinische Hochschule,Hannover, Germany, 12Fondazione Cardiocentro Ticino,Division of Cardiology, Lugano, Switzerland, 13Heart Centre,Georg-August University, Göttingen, Germany

Objectives: Following CE mark approval, MitraClip is increasinglyperformed in Europe. The ACCESS-EU registry provides a snapshot ofreal-world clinical demographics and outcomes. We herein report earlyand mid-term outcomes of the ACCESS-EU Study, a European prospec-tive, multicenter, non-randomized post-approval study of the MitraClipdevice. Methods: From April, 2009 through April 2011, total of 567patients with significant MR underwent MitraClip therapy at 14 Euro-pean centers. Mean logistic EuroSCORE I at baseline was 23.0 � 18.3;84.9% patients were in NYHA Class III or IV, and 52.7% patients had anEF�40%. Results: The MitraClip implant rate was 99.6%. A total of 19patients (3.4%) died within 30 days after the MitraClip procedure. TheKaplan-Meier survival at 1 year was 81.8%. Intensive care unit andhospital length of staywas 2.5�6.5 days and 7.7�8.2 days, respectively.Single leaflet device attachment was reported in 27 patients (4.8%).


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There were no MitraClip device embolization. Thirty-six subjects (6.3%)required mitral valve surgery within 12 months post the MitraClipimplant procedure. There was improvement in the severity of MR at 12months compared to baseline (p<0.0001), with 78.9% of patients freefrom MR severity of >2þ at 12 months. At 12 months, 71.4% of patientshad NYHA Functional Class II or Class I. Six-minutes-walk-test improved59.5 � 112.4 meters and Minnesota-living-with-heart-failure scoreimproved 13.5 � 20.5 points. Conclusions: In a real world scenario,post-approval experience in Europe, patients undergoing the MitraCliptherapy are high risk, elderly patients, mainly affected by functional MR.In this patient population, the MitraClip procedure is effective with lowrates of hospital mortality and adverse events.

OP108Ring assessment and sizing aspects fortranscatheter mitral valve-in-ring procedures:An ex-vivo seriesArzt S.1,WilbringM.1, Matschke K.1, Kappert U.1, Alexiou K.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: Catheter-based valve-in-ring procedures have been re-ported for treatment of failed mitral repair. Optimal sizing of thetranscatheter valve (THV) is particularly demanding due to the non-circular shape of annuloplasty rings. Methods: An ex-vivo series tested23, 26 and 29mmTHV for compatibilitywith 24, 26, 28, 30, 32, 34 and 36mm CE-Physio™ annuloplasty-rings. Technical aspects and effects ofover-/undersizing are reported, particularly focusing on mechanisms ofparavalvular leakages and effects of incomplete valve expansion.Results: Ex-vivo series demonstrated, that annuloplasty-rings do notbecome a circular shape after THV-implantation. Main vulnerable spotsfor paravalvular leakage are located around the commissures of the ring.This was in particular true for undersized THV's. Oversizing of the THVcaused waisting of the valve with a potential negative impact onsufficient leaflet movement and coaptation. The non-circular shape ofthe annuloplasty-ring makes echocardiographic assessment of innerdiameters useless for sizing-purposes. For determination of the estimat-ed internal diameter of the nearly-circularized annuloplasty-ring afterTHV-implant, we propose use of the formula Diameter¼2�√(area/π),using the internal ring area, as provided by the manufacturer. Withconcern on avoiding significant waisting or paravalvular leakage, the ex-vivo series proposed the 23 mm SAPIEN XT™ to be suitable for the 28mm CE-Physio™-ring, the 26 mm SAPIEN XT™ for the 30 mm CE-Physio™-ring and the 29 mm SAPIEN XT™ for both 32 and 34 mm CE-Physio™-rings. Conclusion: Correct sizing of the THV is demanding duethe non-circular shape of the annuloplasty ring. The present seriesproposes suitable combinations of THV and annuloplasty rings andreveals several important technical aspects.

OP109MitraClip therapy for degenerative mitralregurgitation - 12 months results from theACCESS-Europe Phase I trialConradi L.1, Maisano F.2, Baldus S.3, Hausleiter J.4, TreedeH.1, Butter C.5, Schäfer U.6, Pedrazzini G.7, ReichenspurnerH.1, Schillinger W.81Universitäres Herzzentrum Hamburg, Klinik undPoliklinik für Herz- und Gefäßchirurgie, Hamburg,Germany, 2Scientific Institute San Raffaele, Milan, Italy,3Heart Center Cologne, Department of General andInterventional Cardiology, Köln, Germany, 4DeutschesHerzzentrum München, Department of Cardiology,München, Germany, 5Heart Centre Brandenburg, Bernau/Berlin, Germany, 6Asklepios Klinik St Georg, Department ofCardiology, Hamburg, Germany, 7Fondazione CardiocentroTicino, Lugano, Switzerland, 8Heart Centre, Georg-AugustUniversity, Göttingen, Germany

Objectives: Interventionalmitral valve repair using theMitraClip devicehas been established as an alternative treatment option for patientsdeemed inoperable or at high surgical risk by an interdisciplinary heartteam. We report 12-month clinical and functional outcomes following

treatment with the MitraClip device in patients with degenerativemitral regurgitation (DMR). Methods: The MitraClip Therapy Economicand Clinical OutcomesStudy Europe (ACCESS-EU) Study has completedenrollment of 567 patients as of April, 2011, 117 of whom were DMR.Baseline demographics, procedural and acute safety results at 30 daysand survival at 12 months were separately evaluated in the DMR subset.Furthermore, effectiveness results, defined by reduction in MR, andimprovement in clinical outcomes based on changes in New York HeartAssociation (NYHA) functional class, six-minute walk test (6MWT), andquality-of-life data were assessed. DMR patients were stratified intohigh- and low-risk subgroups (logistic European System of CardiacOperative Risk Evaluation I (logEuroSCORE I�or <20% respectively)and differentially evaluated. Results: 117 DMR patients underwent theMitraClip procedure with a 94.9% rate (111/117) of successful clipimplantation. Baseline characteristics and co-morbidities includedNYHA Class III/IV (74%), left ventricular ejection fraction (LVEF) <40%(9%), prior cardiac surgery (24%) and prior myocardial infarction (MI)(22%). Mean logEuroSCORE I was 15.5 � 13.3%. Mortality at 30 days and12months was 6.0% and 17.1% respectively. At 12months, 74.6% (53/71)of patients in follow-up achievedMR� grade 2þ and 80.8% (63/78)werein NYHA functional class I/II. Both Minnesota Living with Heart Failurequestionnaire (MLHFQ) scores and 6MWT distance improved signifi-cantly at twelve months compared to baseline (p¼0.03 and p<0.0001,respectively). Conclusions: The MitraClip procedure resulted in signifi-cantly reducedMR severity and improvements in clinical outcomes at 12months in selected patients with severe DMR. MitraClip therapy mayserve as a complementary non-surgical therapeutic option for DMRpatients who are considered at high risk or ineligible for surgery by aninterdisciplinary dedicated heart team. Interventional treatment shouldbe indicated following discussion of patients in an interdisciplinaryconference of cardiologists and cardiac surgeons as suggested by currentinternational guidelines.

Congenital heart disease II

OP11015 years of Giessen hybrid approach to thehypoplastic left heartValeske K.1, Müller M.2, Elmontaser H.1, Thul J.3, YerebakanC.1, Bauer J.3, Schranz D.3, Akintürk H.11Kinderherzzentrum Giessen, Kinderherzchirurgie, Giessen,Germany, 2Kinderherzzentrum Giessen, Anästhesiologie,Giessen, Germany, 3Kinderherzzentrum Giessen,Kinderkardiologie, Giessen, Germany

Objective: Since the classical Norwood pathway became treatment ofchoice for patients with hypoplastic left heart syndrome (HLH-S), thistherapy experienced a continous improvement in its technical approachas well as in its results. In Giessen we started an alternative pathway tothe therapy of HLH-S (yndrome) or -C (omplex) in 1998 consisting ofinterventional ductal stenting þ surgical bilateral pulmonary arterybanding (stage I) as an hybrid therapy followed by aortic arch recon-struction þ bidirectional Glenn anastomosis (comprehensive stage II)or, in cases of HLHC, biventricular correction (BVR) after 4 to 6 months.Methods: Between 1998 and 2013 107 patients (pts) with the diagnosisHLHS (MA/AA, MS/AA, MA/AS/ MS/AS þ variants) underwent stage I ofthe Giessen hybrid approach. 84 pts were treated after an interstageperiod of 4 to 6 months with the Stage II procedure. The creating of theFontan pathway was completed creating a total cavopulmonary anasto-mosis (Stage III) in 51 pts. Previous to Stage II, 7 patients showed anadequate growth of the left ventricle subsequently undergoing biven-tricular repair. 7 children not eligible for a further treatment weretransplanted in different stages of our approach. Results: Out of the 107patients undergoing Stage I, 105 (98,1%) survived. Interstage mortalitywas n¼7 (6,6%). 91 pts. reached Stage II (5 pts. still awaiting). Thesepatients were either treated with a Stage II procedure (n¼84), or BVR(n¼7). Comprehensive StageII mortality was n¼7 (8%), but nomortali-ty in BVR pts. Fontan circulation is completed in 54 pts, 21 pts. areawaiting the completion. Overall survival is 81% (n¼87 pts.). Thefreedom from death or HTX in our cohort is 75% after 15 years.Conclusion: The Giessen hybrid approach is an alternative to the


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conventional treatment of children with HLHS and HLHC. Due toavoiding surgery in the early postnatal period, newborns with HLHS/C have the chance of an advanced postnatal decision finding, more timeto recover from postnatal low cardiac output, a chance for biventricularcorrection or even a HTX after a prolonged waiting time. The proceduregives the patients more perspectives at a lower mortality.

OP111Modification of the Norwood procedure: Earlyexperience with patch enlargement of the leftpulmonary arteryAttmann T.1, Pardun E.2, Jussli-Melchers J.1, Grothusen C.1,Jung O.2, Fischer G.2, Cremer J.1, Kramer H.-H.2, Scheewe J.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Klinik für Herz- und Gefäßchirurgie, Kiel, Germany,2Universitätsklinikum Schleswig-Holstein, Campus Kiel,Klinik für angeborene Herzfehler und Kinderkardiologie,Kiel, Germany

Objectives: Adequately sized pulmonary arteries are crucial for thehemi-Fontan-type of circulation. The hemi-Fontan procedure is techni-cally demanding, particularly with regard to patch augmentation of theleft pulmonary artery dorsal to the neo-aorta.We have developed a newsurgical technique to create a large left pulmonary artery (LPA) alreadyduring modified Norwood stage I procedure. Methods: Our recentmodification to the Norwood procedure involves the use of a porcinepericardial patch for enlargement of the left pulmonary artery. Between10/2010 and 06/2011, 18 patients were operated with the new tech-nique (group B). We compared their outcome with those of thepreceding 18 patients (02/2010 - 09/2010) who underwent a conven-tional Norwood procedure and received enlargement of the left pulmo-nary artery not before hemi-Fontan surgery (group A). Results: Allpatients survived Norwood and hemi-Fontan surgery. No differencesbetween the groups concerning age or weight before Norwood andhemi-Fontan procedure could be found. Patch enlargement during theNorwood surgery did not significantly influence operating times (groupA 3.8� 0.5 h vs group B 4.3� 1.6 h) or bypass times (group A 2.3� 0.5 hvs group B 2.4� 0.4 h). In contrast, hemi-Fontan operation times (groupA 4.4� 0.9 hvs group B 4.0� 0.4 h) and bypass times (group A 2.4� 0.8 hvs group B 1.9 � 0.8 h) tended to be shorter in patients with previouslyimplanted LPA patch. Intensive care unit stay after Norwood procedureproved to be prolonged in group B (30 d, range 7-101) compared togroup A (20 d, range 10-68, p<0.05), but shorter after hemi-Fontanoperation (groupA 8.8 d, range 4-48 vs group B 6 d, range 3-27, p<0.01).The total lower lobe index in group B calculated before hemi-Fontanoperation was higher than in group A (163 � 44 mm2/m2 vs 148 � 56mm2/m2) without reaching statistical significance. Conclusions: Thenew technique proved to be as save as the conventional procedure withexcellent early survival. The implantation of the LPA patch duringNorwood stage I is comfortable compared to the implantation duringhemi-Fontan. This subjective notion is verified by the shorter operationand bypass times. The new technique facilitates the hemi-Fontanoperation without complicating the Norwood stage I procedure.

OP112Neonatal myocardium is more sensitive toperioperative ischemic damage thanmyocardium of elder childrenSuc J.1, Purbojo A.1, Rüffer A.1, Koch A.2, Eberle K.P.3, MünchF.1, Cesnjevar R.11Universitätsklinikum Erlangen, kinderherzchirurgischeAbteilung, Erlangen, Germany, 2UniversitätsklinikumErlangen, kinderkardiologische Abteilung, Erlangen,Germany, 3Universitätsklinikum Erlangen,anästhesiologische Klinik, Erlangen, Germany

Objectives: Determination of differences in post-ischemic myocardialperformance between neonatal myocardium and infant cardiomyocytesfollowing corrective biventricular repair in selected standard proce-dures according to patient age. Methods: Observational clinical, hemo-dynamic and laboratory data of all patients operated between 01/2010and 12/2012were transferred to a hospital registry and analyzed using a

standard protocol. Patients with TGA (IVS and VSD, n¼22) undergoingneonatal repair and patients scheduled for VSD repair (single andmultiple, n¼53) entered the study and were closely compared regard-ing laboratory changes and hemodynamic variation. Standard crystal-loid cardioplegia was used for myocardial protection in both groups(Custodiol®; 30 ml/kg) initially and a dose repetition after 60 minutescross clamping. Results: There was no operative mortality. Patientgroups differed significantly by age, Aristotle-score and cross clamptime per definition. TGA-patients were more volume-loaded than VSD-patients (NT-ProBNP: 13415 � 2528 pg/ml vs 1516 � 414 pg/ml,p<0.01). Troponin-I, Troponin-T and CK-MB immediately postCPBwere significantly higher in group TGA (TN-I: 11,4 � 2,1 ng/l vs 7,3 �1,0 ng/l, p<0,05; TN-T: 11,50 � 1,8 ng/l vs 6,4 � 1,0 ng/l, p<0,05 andCK-MB: 275,2 � 27,4 U/l vs 174,0 � 16,0 U/l, p<0,01). Perioperativemyocardial trauma resulted in lowered Cardiac-Indices post-CPB forTGA-patients compared to VSD-patients (CI: 2,0 � 0,37 l/min/m2 vs 3,1� 0,44 l/min/m2, p<0.05). Conclusions: Neonatal cardiomyocytes reactdifferently to ischemic perioperative stress than more mature myocar-dium displayed by higher CK-MB and Troponin post-surgical repair.Perioperative myocardial damage resulted in lowered hemodynamicperformance which is partly related to an exceptional preoperativevolume load, which might explain the higher perioperative risk ofneonatal corrective repairs.

OP113Is the Ross-Konno procedure the idealtreatment of congenital complex leftventricular outflow tract obstruction?Valeske K.1, Müller M.2, Elmontaser H.1, Gummel K.3,Yerebakan C.1, Schranz D.3, Akintürk H.11Kinderherzzentrum Giessen, Kinderherzchirurgie, Giessen,Germany, 2Kinderherzzentrum Giessen, Anästhesiologie,Giessen, Germany, 3Kinderherzzentrum Giessen,Kinderkardiologie, Giessen, Germany

Objective: Left ventricular outflow tract obstruction (LVOTO) in infantsand children is frequently a complex lesion. Therapy contains multileveloperative and interventional procedures, including Ross-Konno proce-dures in case of aortic valve and subvalvular obstruction. Methods:From 2001 till 2013, we performed the Ross-Konno procedure on 27 pts.(11f,16m; median age:57 mo, r:1-245 mo). All patients have beentreated surgically and/or interventionally previously. Additional proce-dures were aortic arch reconstruction n¼4 andmitral valve reconstruc-tion or replacement n¼4. The left ventricular outflow tract wasenlarged by myectomy, a septal patch was not used in any case.Results: Median follow-up is 59 mo (r.: 6-115 mo). ECMO therapywas performed in 7 pts., one pt. suffered on a transient hemiparesis.Autograft reoperation as a reconstruction of the aortic valve wasperformed in one patient 8 years after Ross-Konno operation. Thiswas the only bicuspid autograft in our series. Two patients developeda more than physiologic or mild autograft insufficiency, although in 7pts. an enlargement of the aortic root (z-score >4) could be detected.There was no operative mortality, one child died 4 years after theoperation suddenly due to unknown reason. Conclusion: Severe con-genital left ventricular outflow tract obstructions can be treated suc-cessfully performing a Ross-Konno procedure. Anatomy and physiologyof the LVOT can be restored. The growth of the aortic root is proportionalto the natural somatic growth in most patients, although some patientsshow a not proportional enlargement of the aortic root, which needs tobe monitored meticulous.


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OP114Mid-term results after repair of AnomalousOrigin of Left Coronary Artery from thePulmonary Artery (ALCAPA): Takeuchi repair vscoronary transferNeumann A.1, Böthig D.2, Bobylev D.1, Sarikouch S.3,Meschenmoser L.1, Breymann T.1, Westhoff-Bleck M.4,Scheid M.5, Tzanavaros I.5, Bertram H.2, Beerbaum P.2,Haverich A.1, Horke A.11Medizinische Hochschule Hannover, Herz-, Thorax-,Transplantations- und Gefäßchirurgie, Hannover,Germany, 2Medizinische Hochschule Hannover,Pädiatrische Kardiologie und Intensivmedizin, Hannover,Germany, 3Medizinische Hochschule Hannover, Hannover,Germany, 4Medizinische Hochschule Hannover, Kardiologieund Angiologie, Hannover, Germany, 5Sana Herzchirurgie,Zentrum für Angeborene Herzfehler, Stuttgart, Germany

Objectives: We evaluated mid-term results of two different repairstrategies of Anomalous Origin of Left Coronary Artery from PulmonaryArtery (ALCAPA) in two surgical centers. Methods: Between 1980 and2013, 30 patients (median age 0.4 years, range 0.05-37.6 years) under-went ALCAPA repair. Sixteen patients were treated with coronarytransfer, nine underwent Takeuchi repair (creation of an intrapulmo-nary tunnel) and five were treated with other procedures (tubularextension technique or ligation). One mitral valve was repaired duringprimary ALCAPA surgery. Median follow-up was 6.0 years (0.06-24.3years), total follow-up time 245 years. Results: None of the patientstreated with a coronary transfer or a Takeuchi repair died. One mori-bund patient who received coronary ligation in the 1980s died peri-operatively. Eighteen years freedom from reoperation was 70% forpatients treated with coronary transfer. For patients with Takeuchirepair, 9 year freedom from reoperation was 70% (p¼0.27). At lastfollow-up, left ventricular enddiastolic diameter and function (mean FS36%) was normal in all patients. All patients with a coronary transferwere in NYHA class I at last follow-up, one patient with a Takeuchi repairwas in NYHA class II, the others were in NYHA class I as well. Eight yearsafter Takeuchi repair, 81% of the patients suffered from at leastmoderatepulmonary regurgitation- in contrast to 0% after coronary transfer(p<0.001). In all patients operated under one year of age, mitralregurgitation was absent or trivial at last follow-up, while 4 (36%)(p<0.01) of the 11 patients operated later developed or kept at leastmoderate mitral regurgitation. One of them needed mitral valve re-placement. Conclusions: Survival rates and midterm left ventricularfunction were excellent for both surgical strategies. Takeuchi repair,however, led to significant pulmonary regurgitation. Mitral regurgita-tion resolved in all patients operated during their first year of lifeindependent from the type of repair.

OP115Is there still a role for staged surgery incorrection of complete atrioventricular septaldefect?Günther T.1, Hörer J.1, Fabry T.1, Schreiber C.1, Lange R.11Deutsches Herzzentrum München, Technische UniversitätMünchen, Klinik für Herz- und Gefäßchirurgie, München,Germany

Objectives: Primary repair within thefirst year of life is the treatment ofchoice for complete atrioventricular septal defects (CAVSD). Palliativepulmonary artery banding prior to correction has been proposed forselected patients with additional risk factors, such as pulmonaryhypertension, dysplastic left AV-valve, hypoplastic LV, and Coarctation,respectively. In this study we reviewed our patients who underwentprimary and two stage repair focusing on 30-day mortality, long-termsurvival, and incidence of reoperation.Methods: Retrospective analysisof 503 patients with isolated CAVSD who were operated on betweenOctober 1974 and March 2012. 395 patients (79%) underwent primaryrepair (¼ group 1). 108 patients (21%) underwent a two stage repair (¼group 2) 5 days to 17.8 years after palliation (median 1.8 yrs). The two-patch technique was applied in 91% of the patients. The follow upextends up to 38 years (mean 12.4 � 10 yrs, with a cumulative total of6261 patient-years). Results: Overall 30-day mortality after repair was

4.8% and decreased from 9.9% (1974 -1984) to 1.9% (2000-2012). Overall30-day mortality in group 1 and group 2 was 4.8% (19/395) and 3.7% (5/108), respectively (p¼0.86). Between 1974 and 2012 the percentage ofpatients who underwent primary repair increased from 69% (1974-1984) to 81% (2000-2012). Left AV valve anomalies (12% vs 6.6%;p¼0.06), unbalanced CAVSD (9.3% vs 2.5%; p¼0.007), elevated pulmo-nary vascular resistance Rp 5.5 � 4 vs 4.4 � 3 (p¼0.06), normalkaryotype (36% vs 25%; p¼0.033) and aortic coarctation (13% vs0,5%; p¼<0.001) were more prevalent in group 2. Actuarial survival30 years after repair in group 1 and group 2 was 73.4 � 3.5% and 78.4 �5.5%, respectively (p¼0.37). Freedom from left AV valve reoperationwas82.7 � 2.3% (group 1) and 70 � 5.3% (group 2), respectively (p¼0.02).Conclusions: Long-term survival following two stage repair in patientswith additional risk factors is not different to the survival after primaryrepair. Left AV valve anomalies are more frequent in this high riskpatients leading to a higher incidence of left AV valve reoperation. Thetwo-stage procedure is a valid option for selected patients and should beapplied.

OP116Additional decending aorta perfusion inneonates undergoing arch reconstruction withselective cerebral perfusionDuebener L.1, Stanojevic D.1, Murin P.1, Schneider M.2,Asfour B.1, Haun C.3, Hraska V.11Deutsches Kinderherzzentrum Sankt Augustin, Abt. fürKinder-Herz- und Thoraxchirurgie, Sankt Augustin,Germany, 2Deutsches Kinderherzzentrum Sankt Augustin,Abt. für Kinderkardiologie, Sankt Augustin, Germany,3Deutsches Kinderherzzentrum Sankt Augustin, Abt. fürKinderherz-Intensivmedizin, Sankt Augustin, Germany

Objectives: Recently many congenital (and adult) cardiac surgeons useselective antegrade cerebral perfusion (ACP) to avoid deep hypothermiccirculatory arrest (DHCA) and reperfusion injury related impairment ofneurological outcome during and after complex aortic arch reconstruc-tion. However, with ACP via innominate artery there is uncertainty howmuch of the CPB flow reaches the lower body. We compared theoutcomes of patients who underwent aortic arch repair with eitherhypothermic ACP alone (group I) or ACP plus descending aorta perfusion(group II) atmilder hypothermia.Methods:A total of 41 neonates (meanweight: 3.5 kg, range 2.0-4.1 kg) with an average basic Aristotle score(AS) of 14.5 � 2.0 who underwent arch repair from January 2012 to July2013 were included in the study. In both groups ACP was employedthrough a cannula in a 3.5 mm Gore-Tex graft to the innominate arterywith a flow rate of 102 � 26 ml/min per kg to maintain a right radialarterial pressure>40mmHg. In group I (n¼23) themeanminimal bodytemperature was 24.0 � 5 °C. In group II (n¼11: lowest body tempera-ture of 32 � 5 °C) ) in addition to ACP, the descending aorta was directlycannulated (8F) and perfused with 105 � 26 ml/min per kg at a highertemperature. Results: Preoperative data regarding weight, age, surgicalrisk score (AS) and preCPB lactate levels were not significantly differentbetween both groups. Group II demonstrated a significantly lowerlactate at the end of cross clamp (2.6 � 1.4 vs 3.9 � 1.4 mmol/l;p<0.005) and at the end of CPB perfusion (2.8 � 1.5 vs 4.5 � 1.5mmol/l; p<0.001) relative to group I. No complications from theadditional cannulation of the descending aorta were observed. Operat-ing times were shorter in group II. Postoperative urine output tended tobe higher in group II compared to group I without reaching statisticalsignificance. During the postoperative course, there were no clinicallyobvious neurologic events in either group. Conclusions: Direct cannu-lation of the descending aorta is surgically feasible and can be performedwith a low complication rate in patients undergoing arch repair withantegrade cerebral perfusion. The additional perfusion of the lowerbody reduces lactate accumulation which is most likely secondary toimproved splanchnic flow. The additional flow via descending aortaallows safe complex arch repairs at higher temperatures. Furtherinvestigations are needed to determine optimal flow rates and temper-atures during arch reconstruction.


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Heart valve diseases III: Aortic valve surgery: complications,redo, etc.

OP117Preoperative stroke in infective endocarditisneither independently affects mortality norshould it affect timing of surgeryDiab M.1, Färber G.1, Walther M.1, Matz A.1, Hedderich J.1,Hamadanchi A.2, Doenst T.11Universitätsklinikum Jena, Klinik für Herz- undThoraxchirurgie, Jena, Germany, 2UniversitätsklinikumJena, Klinik für Innere Medizin I, Jena, Germany

Background: Infective endocarditis (IE) requiring surgery is associatedwith high mortality (10-36%) and the frequent occurrence of stroke isconsidered a significant preoperative risk factor. When the need forsurgery is established, current recommendations suggest operatingearly rather than wait. When cerebrovascular complications (CVC)occur, a 72-hour window has been suggested for surgery timing. Weaimed to analyze the impact of preoperative CVC in our patientpopulation and the related timing of surgery on outcome. Methods:We retrospectively reviewed all charts from patients operated for left-sided endocarditis in our center between January 2010 and April 2013.We performed Chi-Square and multivariable analyses to assess theimpact of preoperative stroke and the timing of surgery on outcome.Results: A total of 174 patients underwent surgery for IE during thisperiod. The group was characterized by the preoperative presence ofabscess in 32%, septic shock in 24%, heart failure in 19%, prostheticendocarditis in 21% and mechanical ventilation in 17%. The mostcommon organisms identified were staph. aureus (20.7%), enterococcus(15.5%), and strept. viridans (13.2). 21% were culture-negative. Totalmortality was 22.4%. One third of all patients had a preoperative CVC(n¼57). Surgery was performed within 72 h after the diagnosis of CVCin 26 patients and thereafter in 31 patients. The incidence of postoper-ative CVCwas 19% in the entire population. The presence of preoperativeCVC was an independent risk factor for postoperative CVC. However,early surgery did not reduce the incidence of perioperative CVC (< 72 h:26.9%;>72 h: 29.1%, n.s.) or mortality. Althoughmortality was higher inpatients with (28%) than without (22.4%) preoperative CVC, the differ-ence was not statistically significant and preoperative CVC was not anindependent predictor of mortality. Conclusions: Our data suggest 1)that preoperative cerebrovascular complications do not significantlyincrease peri-operativemortality in patients with infective endocarditisand 2) that adhering to the 72-hour window does not reduce postoper-ative cerebrovascular complications or mortality.

OP118Incidence and determinants of stroke aftersurgical aortic valve replacement in patientswith prior cardiac surgery: Results from themulticenter RECORD initiativeSantarpino G.1, Biancari F.2, Onorati F.3, Mariscalco G.4, DeFeo M.5, Messina A.6, Santini F.7, Beghi C.4, Nappi G.5, TroiseG.6, Passerone G.7, Heikkinen J.2, Faggian G.3, Fischlein T.11Klinikum Nürnberg, Cardiac Surgery, Nürnberg, Germany,2University of Oulu, Cardiac Surgery, Oulu, Finland,3University of Verona Medical School, Cardiac Surgery,Verona, Italy, 4Varese University Hospital, Varese, Italy,5SecondUniversity of Naples, Department of Cardiothoracicand Respiratory Sciences, Napoli, Italy, 6PoliambulanzaFoundation Hospital, Brescia, Cardiac Surgery, Brescia,Italy, 7San Martino University Hospital Genoa, CardiacSurgery, Genoa, Italy

Objectives: Surgical aortic valve replacement (S-AVR) after prior cardiacsurgery is expected to be associated with a high rate of adverse events.The aim of this study was to estimate the rate and identify thedeterminants of postoperative stroke in these patients. Methods: Thisis a multicenter study including 741 patients who underwent S-AVRafter prior cardiac surgery during the last 10 years at 7 institutions. Thedeterminants of stroke were analyzed. Outcome was further investigat-ed. Results: Forty-eight patients (6.5%) suffered stroke and ten of them

died during the in-hospital stay (20.8%). At multivariate analysis,females (10.2% vs. 4.4%, OR 2.53, 95%CI 1.33-4.78), emergency procedure(15.1% vs. 4.8%, OR 2.43, 95%CI 1.23-4.82), perioperative use of intra-aortic balloon pump (22.9% vs. 5.3%, OR 2.73, 95%CI 1.18-6.33), cardio-pulmonary bypass time>210 min (15.7% vs. 5.0%, OR 2.36, 95%CI 1.16-4.82), blood products transfusion (9.3% vs. 0.8%, OR 7.30, 95%CI 1.71-31.12) and re-exploration for bleeding (24.0% vs. 5.2%, OR 4.86, 95%CI2.17-10.88) were independent predictors of postoperative stroke. Thesefindingswere confirmed bya regressionmodel including CHA2DS2-VAScscore�2, which itself was predictive of stroke (8.2% vs. 1.6%, OR 4.82,95%CI 1.42-16.34). Survival at 3 years in patients with postoperativestroke was 51.9%, whereas it was 85.0% in control patients (adjustedanalysis: RR 2.97, RR 1.86-4.72). Conclusion: The risk of postoperativestroke after S-AVR in patientswith previous cardiac surgery is extremelyhigh and has an impact on the immediate and late mortality. Excessivebleeding requiring blood transfusion and/or re-exploration, prolongedCPB, and use of intraaortic balloon pump were associated with anextremely high rate of stroke.

OP119Detrimental impact of prosthetic aorticendocarditis on early and long-term outcome:Results from a Multicenter European InitiativeSantarpino G.1, Biancari F.2, Onorati F.3, Mariscalco G.4, DeFeo M.5, Messina A.6, Santini F.7, Beghi C.3, Nappi G.5, TroiseG.6, Passerone G.7, Heikkinen J.2, Faggian G.3, Fischlein T.11Klinikum Nürnberg, Cardiac Surgery, Nürnberg, Germany,2University of Oulu, Cardiac Surgery, Oulu, Finland,3University of Verona Medical School, Cardiac Surgery,Verona, Italy, 4Varese University Hospital, Varese, Italy,5SecondUniversity of Naples, Department of Cardiothoracicand Respiratory Sciences, Napoli, Italy, 6PoliambulanzaFoundation Hospital, Brescia, Cardiac Surgery, Brescia,Italy, 7San Martino University Hospital Genoa, CardiacSurgery, Genoa, Italy

Objectives: To evaluate the impact of prosthetic aortic valve endocardi-tis (pAVE) in the multicenter European “RECORD” (Redo Cardiac Opera-tion Research Database) Initiative. Methods: Early-to-long term resultsin redo-AVR for pAVE during the last 10 years at 7 Institutions werecompared to those achieved in the absence of pAVE. Determinants ofmortality and acute heart failure (AHF) were analyzed. Results: One-hundred-fifty-four patients (21.7%) out of 711 redo-AVR had pAVE.Patients with pAVE showed higher hospital mortality (9.7% vs 3.8%,p¼ .006), highermajor cardiovascular re-entry complications (p¼ .005),transfusions (p¼ .0001), perioperative low-output syndrome(p¼ .0001), intraaortic balloon pumping (p¼ .017), stroke (p¼ .005),respiratory failure (p¼ .05), prolonged intubation (p¼ .0001), pneumo-nia (p¼ .002), acute renal insufficiency (p¼ .0001), renal replacementtherapy (p¼ .008), permanent pacemaker (p¼ .003). Ten-year actuarialsurvival was reduced by pAVE (43.3 � 7.0% vs 88.1 � 2.3%, p¼ .0001), aswell as freedom from AHF (p¼ .0001, Fig.1 left panel) and re-interven-tions (p¼ .0001, Fig.1 right panel). pAVE was an independent predictorof mortality (p¼ .0001; O.R. 8.2, 95% C.I. 4.3 - 15.8) and AHF (p¼ .003; O.R. 3.5, 95% C.I. 1.5-8.0). Results of pAVE in the last 5-years did not differfrom those of previous 5-years in all early and long-term endpoints.Interestingly, implantation of biologic (vs mechanical) prostheses forpAVE determined similar 10-year survival (p¼NS) but lower freedomfromAHF (p¼ .023). Conclusion: pAVE still represents amajor challengewith poor early and long-term results.


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OP120Tricuspid valve surgery in patientswith isolatedtricuspid valve endocarditis - Analyzation ofperioperative parameters and long-termoutcomesPfannmüller B.1, Kahmann M.1, Binner C.1, Davierwala P.1,Misfeld M.1, Garbade J.1, Dohmen P.1, Etz C.1, Borger M.A.1,Mohr F.-W.11Herzzentrum Leipzig - Universitätsklinik, Leipzig,Germany

Objectives: The aim of this study was to analyze the perioperativeparameters as well as the long-term outcomes of patients undergoingtricuspid valve (TV) surgery for isolated TV endocarditis. Methods: Atotal of 56 patients with isolated TV endocarditis underwent TV surgeryat the Leipzig Heart Center between June 1995 and February 2012. Ofthese, 39 patients (69.6%) were male, 21 patients (37.5%) suffered fromrenal failure, and 13 (23.2%) fromdiabetesmellitus.Mean agewas 53.8�17.1 years, mean left ventricular ejection fraction 60.4 � 9.9% andaverage logEuroSCORE 19.4 � 17%. Mean follow-up was 5.4 � 3.9 years.Results: Blood cultures and cultures of the TV tissue/ vegetationsobtained at surgery were positive in 52 patients (92.9%) - with staphy-lococcus aureus in 24 (42.9%) patients and 10 patients (17.9%) havingcoagulase negative staphylococcus. Foreign bodies were the source ofinfection in 19 patients (33.9%), 15 (26.8%) of these being due topacemaker leads. Intravenous drug abuse was observed as a cause in11 patients (19.6%). TV replacement was performed in 23 patients(39.3%) and TV repair with annuloplasty in 13 patients (23.2%). Leaflet(vegetectomy and patch reconstruction) repair alone was performed in21 patients (37.5%). Overall 30-day mortality was 12.7%. Five-yearsurvival was 62.8% (95% confidence interval [CI] 5.3-11.5 years). Theincidence for TV-related reoperations at 5 years was 7.5% (95% CI 6.4-8.7%) and was due to TV-reendocarditis in 4 out of 5 patients (twopatients were intravenous drug-abusers, one had pacemaker-lead infec-tion and one developed re-re TV prosthesis endocarditis with acuteleukaemia as comorbidity). Conclusions: TV surgery for TV endocarditisis often performed in patients with intravascular foreign bodies, intra-venous drug abuse, and/or patients with weak immune system. Implan-tation of foreign material should be avoided in patients undergoing TV-surgery for TV endocarditis so as to reduce the risk of reendocarditis,especially in intravenous drug-abusers.

OP121Delayed surgical therapy in patients withprosthetic valve endocarditis - risk factor ornot?Schäfer A.1, Grubitzsch H.2, Reichenspurner H.1, WerneckeK.-D.3, Konertz W.21Universitäres Herzzentrum Hamburg, Klinik fürHerzchirurgie, Hamburg, Germany, 2Charité-Universitätsmedizin Berlin, Klinik für KardiovaskuläreChirurgie, Berlin, Germany, 3Sostana, Berlin, Germany

Objects: Despite advances in diagnostics, antibiotic regimens andsurgical techniques, prosthetic valve endocarditis (PVE) remains adisease with a mortality of 20-40% and an incidence of 1% in the first

year after surgery. Symptoms are unspecific and Duke criteria are moreinsensitive than in native valve endocarditis (NVE). The German Societyof Cardiology recommends a conservative treatment of uncomplicatedPVE and late PVE. However, patients treated with antibiotics due to PVEare transferred frequently to cardiac surgery due to an acute clinicaldeterioration. In this study investigation of the influence of delayeddiagnosis and delayed surgical therapy on the outcome of patients whounderwent cardiac surgery due to PVE was performed. Methods:Between 09/2000 and 06/2010 surgery due to PVE was done in 149patients. 109 (71,8%) were male andmean agewas 63,5� 13,8 years. 65patients (43,6%) presented with early PVE (�1 year after valve replace-ment) and 84 (56,4%) with late PVE (�1 year). Data was collectedretrospectively from patient records and follow upwas performed until2011. Delayed diagnosis (symptom-diagnosis >30 d) and delayedsurgery (diagnosis-surgery >30 d) were correlated with adverse eventsand significance was analyzed with SPSS® through COX analysis.Results: 53 events (35,6%) were documented. 5 patients (3,4%) diedintraoperatively, all transferred to cardiac surgery in a state of cardio-genic shock. 30 patients (20%) died from recurrence of PVE , 7 patients(4,7%) suffered from an early re-PVE and in 11 (7,4%) patients re-surgeryhad to be performed due to recurrence of PVE. Latency betweensymptoms and diagnosis >30 days was a risk factor (HR¼3,059;p<0,05) for early events in multivariate COX Regression. Latencybetween diagnosis and surgery >30 days was no significant risk factorfor early or late events in multivariate COX regression. Conclusion:Prolonged latency between symptoms and diagnosis is a risk factors forearly events in patients with surgery due to PVE, especially for recur-rence of PVE. Since diagnosis of PVE is demanding, patients withprostheses of heart valves and symptoms of infection should betransferred to a heart center immediately.

OP122Outcome of redo surgical aortic valvereplacement in patients aged more than 80years: Results from the multicenter RECORDinitiativeSantarpino G.1, Onorati F.2, Biancari F.3, Mariscalco G.4, DeFeo M.5, Messina A.6, Santini F.7, Beghi C.4, Nappi G.5, TroiseG.6, Passerone G.7, Heikkinen J.3, Faggian G.2, Fischlein T.11Klinikum Nürnberg, Cardiac Surgery, Nürnberg, Germany,2University of Verona Medical School, Cardiac Surgery,Verona, Italy, 3University of Oulu, Cardiac Surgery, Oulu,Finland, 4Varese University Hospital, Varese, Italy, 5SecondUniversity of Naples, Department of Cardiothoracic andRespiratory Sciences, Napoli, Italy, 6PoliambulanzaFoundation Hospital, Brescia, Cardiac Surgery, Brescia,Italy, 7San Martino University Hospital Genoa, CardiacSurgery, Genoa, Italy

Objectives: Octogenarians undergoing surgical redo-aortic valve re-placement (REDO-AVR) are expected to be at high risk of adverse events,a finding that has recently popularized Transcatheter Aortic ValveImplantation (TAVI) in this cohort. Methods: This multicenter studyevaluates the outcome of 744 patients (99 aged 80 years or older) whounderwent REDO-AVR after prior cardiac surgery. The outcome be-tween older and younger patients was compared in the entire cohortand in a propensity-matched population. Results: Octogenarians andyounger patients had similar immediate outcome (in-hospital mortali-ty: 3.0% vs. 5.9%%, p¼0.34; stroke: 5.1% vs. 6.7%, p¼0.66, dialysis: 9.1%vs. 6.5%, p¼0.34). Similar findings were observed in 84 propensityscore-matched pairs. Patients �80 years-old had a similar survivalcompared to younger patients (5-year survival: 83.1% vs. 78.0%,p¼0.68, propensity score adjusted: RR 0.23, 95%C.I. 0.59-1.88). Octo-genarians and younger patients had similar freedom from heart failureepisodes (at 5-year, 84.5% vs. 89.2%, p¼0.311, propensity score adjust-ed: RR 1.37, 95%C.I. 0.62-3.04) and freedom from reoperation (at 5-year,94.9% vs. 97.9%, p¼0.51, propensity score adjusted: RR 1.93, 95%C.I.0.35-10.56). However, patients �80 years old had poorer freedom fromlate stroke (at 5-year, 89.8% vs. 97.5%, p¼0.016, propensity scoreadjusted: RR 6.137, 95%C.I. 1.776-21.208) and peripheral thrombo-embolism (at 5-year, 90.0% vs. 98.2%, p¼0.003, propensity scoreadjusted: RR 4.00, 95%C.I. 1.07-15.00). Conclusion: Octogenarians


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undergoing REDO-AVR have immediate postoperative outcome similarto younger patients, and their 5-year outcome is excellent. Indication toTAVI should not rely on the simple existence of REDO-surgery and oldage.

OP123Early failure of decellularized xenogenouspulmonary valve conduit (Matrix-P-Plus) forreconstruction of the right ventricular outflowtract in the ross procedureBreitenbach I.1, El-Essawi A.1, Pahari D.1, Kappenberg T.1,Harringer W.1, Anssar M.11Klinikum Braunschweig, Klinik für Herz-, Thorax- undGefäßchirurgie, Braunschweig, Germany

Objectives: To analyse the early to mid-term performance of thedecellularized pulmonary valve conduit Matrix-P-Plus as an alternativeto a pulmonary homograft in the Ross procedure. Methods: BetweenApril 2007 and October 2008 twenty-one patients (mean age 49 years,range: 33-56 years) underwent a Ross procedure using the Matrix-P-Plus conduit (mean conduit size 27 mm) for reconstruction of the rightventricular outflow tract in our clinic. Results: At a median follow up of56.2 months (range: 49-64 months) one patient died of liver failure.Echocardiography demonstrated severe pulmonary stenosis necessitat-ing reintervention in 9 patients (42.9%; fivehad their conduits explantedand replaced with a pulmonary homograft, two had a transcatheterpulmonary valve implantation and two are scheduled for reoperationwithin the nextmonths). One patient showed asymptomatic pulmonarystenosis (max. pressure gradient 47 mmHg, mean pressure gradient 25mmHg) and the remaining 11 patients (52.3%) had no signs of valvedysfunction or stenosis. Intraoperatively the explanted valves showedscarring stricture of the pulmonarywall in the pericardial tube. This leadto predominantly postvalvular stenosis. Histological examinationshowedmassive inflammatory reaction and necrosis. The cusps showedno calcification and no migration of any cells into the decelluarizedtissue. Conclusions: Because of a massive inflammatory reaction thatmay lead to early graft stenosis the Matrix-P-Plus biological conduitcannot be recommended for reconstruction of the right ventricularoutflow tract in adults. Furthermore, it is no alternative to a pulmonaryhomograft in the Ross procedure.

Basic Science II: Cardiac cell

OP124Identification and characterization of apostnatal Nkx2-5 enhancer positive cardiacprogenitor cell population after myocardialinfarctionDeutsch M.-A.1, Doppler S.1, Lahm H.1, Werner A.1,Schiemann M.2, Wu S.M.3, Lange R.1, Krane M.11Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, Munich Heart Alliance, München,Germany, 2Technische Universität München, Institut fürMedizinische Mikrobiologie/Immunologie und Hygiene,München, Germany, 3Institute for Stem Cell Biology andRegenerative Medicine, Stanford University, Stanford,United States

Objectives: Recent studies have demonstrated a limited capacity of thepostnatal mammalian heart to undergo cardiomyocyte renewal. Thisprocess may be mediated by stem-/progenitor cells. However, the exactcellular mechanisms remain poorly understood. By using an Nkx2-5cardiac enhancer-eGFP transgenic mouse model we sought to investi-gate cellular origins of postnatal cardiac regeneration after experimen-tal myocardial infarction (MI). Methods: MI was inducedexperimentally by LAD ligation in Nkx2-5 cardiac enhancer-eGFPmice of different ages. The number of eGFPþ cells in whole heart tissuesamples was quantified by flow cytometry at day 5 and 9 post-MI,respectively. Further characterization of FACS sorted eGFPþ cells afterMI was performed using qRT-PCR for gene expression profiling. SelectedqRT-PCR results were confirmed by antibody staining and subsequent

FACS analysis. Results: Green fluorescence in the cardiac-specific Nkx2-5 enhancer-eGFPmouse peaks around E8, fades after E11.5 and vanishesin the uninjured adult heart until 3 weeks postnatally. Interestingly, thenumber of eGFPþ cells increased to about 1% after MI induction in thismouse line (> 6 weeks of age). When compared to the GFP- cell fractionFACS sorted eGFPþ cells revealed high expression levels of severalcardiac developmental markers (Tbx20, Baf60c, Gata4, Flk1) and wereenriched for embryonic epicardial genes (Tbx18, WT1). eGFPþ cells lackthe expression of mature cardiomyocyte marker cTnT. Expression ofCD45 (panleukocyte marker) and c-Kit/CD117 (stem cell marker) wasabsent which was confirmed by antibody staining and subsequent FACSanalysis. Interestingly, the stem cell marker Sca1 was upregulated inGFPþ cells compared to the GFP- fraction. This result was also approvedby antibody staining. Screening for potential cytokine targets revealed aquite specific expression of receptors for FGF, PDGF, TGFβ and IGFwithineGFPþ cells. Conclusions: By using an Nkx2-5 cardiac enhancer-eGFPtransgenic mouse model we identified an eGFPþ population whichincreases after MI in the adult murine heart. Detailed gene expressionprofiling of isolated GFPþ cells showed that myocardial injury triggersthe expression of cardiac-specific embryonic genes implicating charac-teristics of cardiac progenitor cells for the GFPþ cells when compared tothe GFP- fraction. Moreover, we identified potential cytokine targets totherapeutically boost cardiac regeneration after myocardial infarction.

OP125The regulation of mitochondrial biogenesis inpathological hypertrophy - a role for Akt?Domrös-Zoungrana D.1, Nguyen T.D.1, Heller R.2, SchwarzerM.1, Doenst T.11Jena University Hospital - Friedrich-Schiller-University ofJena, Department of Cardiothoracic Surgery, Jena,Germany, 2Friedrich-Schiller-University of Jena, Institutefor Moledular Cell Biology, Jena, Germany

Objectives: Poor ventricular function (heart failure) affects surgicaloutcomes. At the cellular level, heart failure (HF) is characterized bymitochondrial dysfunction but the underlying mechanisms of thisdefect remain obscure. We investigated the hypothesis that mitochon-drial biogenesis is reduced in HF and that Akt signaling may account forthis impairment. Methods: Rats underwent transverse aortic constric-tion (TAC) to induce pathological hypertrophy and HF. In vitro, hyper-trophy of neonatal rat cardiomyocytes was induced by angiotensin II(Ang II). The expression of PGC-1a and its downstream target Tfam,which are key regulators of mitochondrial biogenesis, was assessed byqPCR and western blot. In cultured cardiomyocytes, we quantifiedmitochondrial content by measuring fluorescence of MitoTracker®.Akt signaling was assessed by western blot and was modulated in vitroby Akt-Inhibitor VIII. Results: At 2 and 10 weeks after TAC, cardiachypertrophy was present as shown by increased heart-to-body weightratios. Consistently, phosphorylation of Akt, a key component of hyper-trophic signaling, was markedly increased at these time points (4 and 2fold; p<0.05). In contrast, mRNAexpression of PGC-1α and Tfam tendedto decrease at 2 weeks and were significantly diminished at 10 weeks(both -52%; p<0.05), which indicates a progressive reduction of mito-chondrial biogenesis signaling. In isolated neonatal rat cardiomyocytes,1 µM angiotensin II (Ang II) increased Akt phosphorylation and causedhypertrophy, but affected neither protein expression of PGC-1α andTfam nor mitochondrial content. However, hypertrophy induced by 10µM Ang II was accompanied by a significant decrease in mitochondrialcontent (-32%; p<0.01), which suggests impaired mitochondrial bio-genesis. Importantly, Akt inhibitor VIII abolished Ang II-induced Aktphosphorylation and significantly blunted the effects of Ang II (10 µM)on cell size andmitochondrial content. Conclusion: Impairedmitochon-drial biogenesis may accompany cardiac hypertrophy and contribute tomitochondrial dysfunction in HF. Furthermore, the activation of Aktsignaling may represent a potential mechanism linking pathologicalhypertrophy to the impairment of mitochondrial biogenesis and func-tion. Targeting Akt may therefore become a tool to improve contractualfunction before surgery.


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OP126Enhanced frequency of M2 polarizedmacrophages in peri-infarct region andattenuation of scar formation aftertransplantation of mesenchymal stem cellsNeef K.1, Drey F.1, Lepperhof V.2, Saric T.2, Stamm C.3,Wahlers T.1, Choi Y.-H.11Uniklinikum Köln, Klinik und Poliklinik für Herz- undThoraxchirurgie, Köln, Germany, 2Universität zu Köln,Institut für Neurophysiologie, Köln, Germany, 3DeutschesHerzzentrum Berlin, Klinik und Poliklinik für Herz- undThorax- und Gefäßchirurgie, Berlin, Germany

Introduction: Ventricular remodelling following myocardial infarctionis strongly associated with inflammation, mainly mediated by macro-phages. In contrast to the M1 polarized type of macrophages, the M2type macrophage has been described to exhibit potent regenerative andanti-inflammatory characeristics. Since mesenchymal stem cells (MSC)can influence the M1/M2 polarization of macrophages, we tested MSCmediated M2 macrophage specific effects in a small animal model ofmyocardial infarction. Methods: Murine bone marrow derived MSCwere specifically expanded in vitro and characterized for cell typedefining characteristics. MSC were transplanted intramyocardially ina murine model of myocardial infarction. After 1 and 2 weeks heartsfrom MSC transplanted and sham operated animals were excised andanalyzed histologically for expansion of fibrotic scar (Masson's Tri-chrome staining) and distribution of M2 polarized macrophages(Relm-alpha and F4/80 expression). Tissue from the peri-infarct regionwas analyzed for expression of M2 macrophage and inflammationspecific gene expression by quantitative real-time PCR (qPCR).Results: MSC were validated by flow cytometry (CD44: 64.1 � 4.1%;Sca-1: 98.1 � 0.9%) and by successful in vitro adipo-, chondro- andosteogenic differentiation. Hearts from MSC transplanted and shamoperated animals showed no significant difference in scar size after oneweek. However, after two weeks the scar size was significantly smallerin MSC treated animals (12.4 � 2.3 mm2 vs. 17.8 � 1.8 mm2; p<0.05).Furthermore, an increase in F4/80 and Relm-alpha positive M2 macro-phages was observed histologically in the peri-infarct area after 2weeksin MSC transplanted hearts. Compared to sham treated animals qPCRanalyzes revealed an increased expression ofM2macrophage associatedgenes in the peri-infarct region of MSC treated animals after two weeks(CD206:þ51.4�8.8%; TSG6:þ11.3� 1.2%; both p< 0.05), an increase ofpan-macrophagemarker CD11b expression (þ87.2� 8.7%; p<0.05) anda strong increase in expression of anti-inflammatory cytokine IL-10(þ172.3 � 18.2%; p<0.01). Conclusion: Intramyocardial transplanta-tion ofMSC in the acute phase ofmyocardial infarction can attenuate theremodeling process and is linked to increased M2 polarization ofresident macrophages. The underlying cellular, presumably paracrinemechanisms need to be resolved in detail in order to guarantee safe andefficient potential clinical application.

OP127Human endothelial-colony forming cellsenhance cardiac repair by increasingneovascularization and the pool of Sca1þcardiac resident stem cells after myocardialinfarction in SCID/beige miceDeutsch M.-A.12, Huber B.2, Assmann G.3, Müller-Höcker J.3,Ott I.4, Franz W.-M.251Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, München, Germany, 2Klinikum der LMUGroßhadern, Medizinische Klinik und Poliklinik I, München,Germany, 3Pathologisches Institut der LMU München,Campus Großhadern, München, Germany, 4DeutschesHerzzentrum München, Klinik für Herz- undKreislauferkrankungen, München, Germany, 5MedizinischeUniversitätsklinik Innsbruck, Klinik für Innere Medizin III /Kardiologie und Angiologie, Innsbruck, Austria

Objective: The potential therapeutic role of EPCs in ischemic heartdisease is subject to intense investigation. It has been shwon that thetransplantation of unfractioned bone marrow stem cells after myocar-dial infarction (MI) is moderately effective. Selected stem cell popula-

tions may further optimize treatment. The aim of the study was toinvestigate the proregenerative potential of human endothelial colony-forming cells (ECFCs) in a murine MI model. Methods: CD34þ periph-eral blood mononuclear cells were isolated from patient blood samplesusing immunomagnetic beads. For generating ECFCs, CD34þ cells wereplated on fibronectin-coated dishes and were expanded by culture inendothelial-specific cell medium. Either human ECFCs (5 � 10 (5)) orcontrol mediumwere injected into the peri-infarct region after surgicalMI induction in SCID/beige mice. Hemodynamic function was assessedinvasively 30 days post-MI. Hearts were analyzed immunohistochemi-cally for assessing cell fate, infarct size and neovascularization (ECFCsn¼15 vs. control n¼10). Flow-cytometric analysis of enzymaticallydigested whole heart tissue was used to analyze different subsets ofhoming CD34þ/CD45þ mononuclear cells as well as CD34-/CD45-cardiac resident stem cells 2 days post-MI (ECFCs n¼10 vs. controln¼10). Results: Transplantation of human ECFCs after MI improvedhemodynamic function at day 30 post-MI (EF: 30.43� 1.20% vs. 22.61�1.73, p>0.001; dP/dTmax 5202.28 � 316.68 mmHg/sec vs. 3896.24 �534.95, p<0.05) when compared controls. Correspondingly, ECFCssignificantly reduced infarct size (50.3 � 4.5% vs. 66.1 � 4.3, p<0.05).Immunohistochemistry failed to show integration of transplanted cells.However, anti-CD31 immunohistochemistry proofed an increased vas-cular density within the infarct border zone (8.6 � 0.4 per HPF vs. 6.2 �0.5, p<0.001). Flow cytometry at day 2 post-MI showed a slightstatistical trend towards increased myocardial homing of CD45þ/CD34þmononuclear cells (1.1� 0.3% vs. 0.7� 0.1, p¼0.2). Interestingly,we detected a significant increase in CD34-/CD45-/Sca1þ cardiac resi-dent stem cells (11.7 � 1.7% vs. 4.7 � 1.7, p<0.01). Conclusions: In amurine MI model, transplantation of human ECFCs ameliorates myocar-dial function by improving adverse post-MI remodeling. Cardiac repairis enhanced by increasingmyocardial neovascularization and the pool ofSca1þ cardiac resident stem cells. The use of human ECFCs for treatingischemic heart disease warrants further investigation.

OP128Site-specific positioning of magneticnanoparticle (MNP) loaded progenitorsimproves survival of the grafted cells and long-term myocardial function upon myocardialinfarctionOttersbach A.1, Zimmermann K.2, Mykhaylyk O.3, Gleich B.4,Plank C.3, BlochW.5, Pfeifer A.2, Welz A.6, Fleischmann B.K.1,Röll W.61University of Bonn, Institute of Physiology I, Bonn,Germany, 2University of Bonn, Department ofPharmacology and Toxicology, Bonn, Germany, 3TechnicalUniversity of Munich, Institute of Experimental Oncology,Munich, Germany, 4Technical University of Munich,IMETUM, Garching, Germany, 5German Sport UniversityCologne, Institute of Cardiovascular Research and SportMedicine, Cologne, Germany, 6University of Bonn,Department of Cardiac Surgery, Bonn, Germany

Objectives: Recently we could demonstrate, that myocardial cell en-graftment was significantly increased if cells prior to transplantationwere loaded with MNP and injected under application of a magneticfield. In the present study we have investigated the underlying mech-anisms as well as the consequences on the long-term hemodynamiceffects. Methods: EGFP-transgenic murine embryonic cardiomyocytes(eCM, E 13,5 - 15,5)were isolated and incubated overnight with SOMag5MNPs (200 pg Fe/cell). Then, 200.000 MNP-loaded cells were injectedinto a myocardial cryolesion while co-applying a magnetic field. Prolif-eration and apoptosis of transplanted cells was investigated by immu-nohistochemistry 2,3,6 and 14 days postoperatively, cardiac functionwas determined by left ventricular catheterization after 2 and 8 weeks.Results: Overall cell engraftment rates were improved significantly at 2and 8 weeks after transplantation. Detailed histological as well asimmunohistochemical analysis showed a significantly increased initialcell retention rate after magnet-assisted transplantation. Furthermore,caspase3 and Ki67 staining revealed decreased apoptosis and increasedproliferation rates of the transplanted cells in the early postoperativephase. This led also to a significant enhancement of short- (14 days) and


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long-term (2 months) heart function. Discussion: Thus, MNP-loading ofeCM and consecutive magneto-assisted intramyocardial injectionstrongly improves cell engraftment and results in a long term improve-ment of hemodynamics. Besides better retentions rates upon applica-tion of the cells (less cell loss through the coronary system and theinjection channel), also biological mechanisms seem to be involved.

OP129Establishment of induced pluripotent stem cellsfrom pig adipose tissue-derived fibroblastsDreßen M.1, Lahm H.1, Adamczyk K.1, Schrambke D.1,Doppler S.1, Deutsch M.-A.1, Lange R.1, Krane M.11Department of Cardiovascular Surgery, Division ofExperimental Surgery, German Heart Center Munich,Technische Universität München, Munich Heart Alliance,Munich, Germany

Objectives: Pluripotent stem cells are one of the most promising cellsources for cardiac regenerative therapy. Nevertheless, currently nolarge animal models are available for adequate preclinical evaluation offeasibility, efficiency and safety. Therefore, we focused on the generationof porcine induced pluripotent stem cells (iPS). Methods: Adult fibro-blasts derived from porcine adipose-tissue were reprogrammed to iPSby infection with the lentiviral vector phuSTEMCCAwhich constitutive-ly expresses the four Yamanaka factors. Expression of transgenes andcorresponding endogenous counterparts was demonstrated using spe-cies-specific primers. Further porcine pluripotency markers were de-tected by qRT-PCR or fluorescent reporter probes (SmartFlares™, MerckMillipore) in live cells. Upon differentiation gene expression specific forthe three different germ layers was evaluated by qRT-PCR. Results:Approximately two weeks after transduction first iPS-like coloniesappeared which showed a flattened morphology similar to establishedhuman iPS cells. The porcine iPS cells strongly expressed the four humantransgenes (OCT4, KLF4, SOX2 and C-MYC) and the mRNA of all fourendogenous counterparts could be detected by qRT-PCR. In addition,established iPS clones also expressed the pluripotency markers REX1,NANOG and GDF3. The expression of mRNA for NANOG and GDF3 wasfurther confirmed by live staining with SmartFlares™. Establishedporcine iPS colonies could be cultured over more than 50 passages.Upon differentiation, endoderm markers AFP and FOXA2, absent inundifferentiated iPS cells, became detectable. Mesoderm-specific ex-pression ofHAND1was strongly upregulated (more than 200-fold)whileectodermal reporter genes showed a rather modest increase.Conclusion: Our results support the successful reprogramming ofsomatic fibroblasts into different porcine iPS lines as a first step towardsa large animal model for cardiac regeneration. Although the in-vitrodifferentiation is still insufficient in porcine iPS lines the expression ofall four endogenous reprogramming genes and further pluripotentmarker genes as well as the stable growth in culture confirm thepluripotent state of generated iPS lines.

OP130Cardiomyocyte dedifferentiation - A (mal)adaptive response to hypoxiaPöling J.1, Kubin T.2, Gajawada P.2, Lörchner H.2, PolyakovaV.2, Rees W.1, Richter M.3, Kostin S.2, Walther T.3, Braun T.2,Warnecke H.11Schüchtermann Klinik Bad Rothenfelde, Bad Rothenfelde,Germany, 2Max-Planck-Institut, Bad Nauheim, Germany,3Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Germany

Objectives: Previously, we found that treatment of mice with theinflammatory cytokine oncostatin M (OSM) improved cardiac functionand suppressed remodeling after myocardial infarction. Since theseresults suggested a protective role of OSM under hypoxic conditions,we assessedwhether activation of the OSM receptor (Oβ) directly affectssurvival of cardiomyocytes under hypoxia and alters morphology andexpression of genes that are responsible for O2 handling and consump-tion. Methods: To elucidate the effects of OSM on cardiac contractilecells in vitro in response to hypoxia (2% O2), we employed primarycultures of neonatal and rat adult cardiomyocytes. Results: OSM dra-matically increased the survival rate of cultured cardiomyocytes under

hypoxic conditions. Increased survival was dependent on Oβ signalingsince knock-down of Oβ by siRNA transfection reverted this effect. OSMtreatment caused a significant decrease in apoptosis, as evaluated bycleaved PARP expression and the number of TUNEL positive cardiomyo-cytes. The protective effect of OSM was neutralized by addition ofUO126, an inhibitor of Erk1/2 signaling. Administration of siRNAtargeting different components of the Oβ/gp130/Jak/Stat pathway re-vealed that OSM-dependent activation of Erk1/2 ismediated by Jak1 andnot by Jak3, Stat1, Stat3, Stat5A and Stat5B. Transcriptome analysisrevealed a strong down-regulation of sarcomeric proteins as well asevere reduction of myoglobin expression, which was fully revertible byknock-down of the Oβ using siRNA. OSM stimulated cardiomyocytesdramatically degrade mature sarcomeric structures and cells elongatetowards neighboring cells thus reestablishing cell-cell contacts. Incontrast IGF-1, a well-known stimulator of sarcomerogenesis, did notenhance the reestablishment of cell-cell contacts but induced a pro-nounced growth visible by the accumulation of sarcomeres. When OSMis timely replaced by IGF-1 cardiomyocytes start to redifferentiate andaccumulate sarcomeric proteins. However, when OSM stimulation ex-ceeded a certain “restriction point” cardiomyocytes stayed dedifferen-tiated and were not capable to form a fully redifferentiated contractiletissue sheet in the presence of IGF-1. Conclusions: A time dependentinactivation of the OSM-dependent “cell survival program” leading tocardiomyocyte dedifferentiation is instrumental to avoid adverse cardi-ac remodeling.

Thoracic and thoracoadbominal aorta

OP131Aortic remodeling in acute aortic dissectionafter frozen elephant trunkDohle D.-S.1, Tsagakis K.1, Liubov P.1, Kühl H.2, Lieder H.1,Benedik J.1, Wendt D.1, Thielmann M.1, Jakob H.11Universitätsklinikum Essen, Klinik für Thorax- undKardiovaskuläre Chirurgie, Essen, Germany,2Universitätsklinikum Essen, Institut für Diagnostische undInterventionelle Radiologie und Neuroradiologie, Essen,Germany

Objective: In acute type I aortic dissection (AAD) frozen elephant trunk(FET) is used for continuous downstream aorta treatment. The studyreports the changes of the lumen volumes along the entire downstreamaorta in AAD towards remodeling. Methods: Thirty nine AAD patientsafter FETwith at least one year aortic tomographic imaging suitable foraortic volume measurements were included in the study. Aortic (AL),true (TL) and false lumen (FL) volume changes (more than 10%) betweenthe aortic examinations were used for remodeling quantification alongthe stent graft aortic segment (A), distal to coeliac trunk (B) and tobifurcation (C). Remodeling was defined as positive (p), stable (s) andnegative (n) according to table 1. Results: In 1 year follow-up in segmentA complete FL thrombosis occurred in 35/39 (90%) followed by oblitera-tion in 10/39 (26%). FL thrombosis was associated with positive andstable remodeling. Positive remodeling occurred in A 28/39 (72%), B 18/39 (46%), C 10/39 (26%); negative remodeling in A 2/39 (5%), B 17/39(44%), C 18/39 (46%). Both patientswith negative remodeling in segmentA underwent secondary intervention distally. Thereafter, in 21/37patients (follow-up mean � SD 50 � 25 months) positive remodelingoccurred in segment A 6/21 (29%), B 6/21 (29%), C 4/21 (19%); negativeremodeling in A 3/21 (14%) , B 9/21 (43%), C 7/21 (33%). Conclusion: FETfacilitates positive remodeling in acute type I aortic dissection in earlypostoperative period towards FL stability and obliteration in stentgrafted aortic segment. The negative remodeling distally confirms thenecessity of close follow-up aortic examinations.

Table 1:

AL " AL $ AL↓

TL " n p p

TL $ n s p

TL ↓ n n n (or p�)


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Table 1: Remodeling algorithm: TL and AL volume increase ("), decrease(↓) or stable ($) were used to define stability (s), positive (p) ornegative (n) remodeling. *n if ΔTL/AL>0.

OP132Branched and fenestrated stent grafts - areasonable option for thoraco-abdominal aorticaneurysm repairZipfel B.1, Buz S.1, Baretti R.1, Bergs P.1, Hammerschmidt R.1,Hetzer R.11Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefäßchirurgie, Berlin, Germany

Objectives: To evaluate the feasibility of totally endovascular repair forpatients unfit for open thoraco-abdominal aortic aneurysm (TAAA)repair. Methods: In 31 patients, mean age 71 (45-85) years, 68% male(n¼21), TAAA of Crawford extent I-II in 39% (n¼12) and III-V in 61%(n¼19) were repaired. The procedures were part of a staged aorticrepair with previous or secondary open or endovascular repair in 74%(n¼23). All procedures were performed under general anesthesia in ahybrid OR. Customized branched and/or fenestrated stent grafts wereimplanted: 16 Zenith and 15 E-vita E-xtra. A total of 112 celiac (CA),superior mesenteric (SMA) and renal arteries (RA) were connected tothe stent grafts by 80 branches (72%) and 32 fenestrations (28%) withcovered Advanta or Fluency stents reinforced by self-expandable barestents for bridging to the target vessels. All fenestrations were stentedwith covered Advanta stents. Results: All stent grafts were implantedsuccessfully and all target vessels were connected except 1 RA due to akink at the origin, and 1 CA due to subtotal occlusion. In both cases theside branch socket at the stent graft was occluded with a plug, and 1iliaco-renal bypass was performed. The occluded celiac artery showedexcellent collaterals from the SMA. Mean procedure time was 430 (190-720) min and fluoroscopy time 103 min (52–246). In all patientsdischarge CT scans showed successful exclusion of the TAAA withoutType I or Type III endoleak: in 25 patients (80%) primary and in 6 (20%)secondary exclusion (spontaneous closure in 2, secondary interventionsin 4). Mortality at 30 days was 6.5% (1 due to pneumonia and 1 due tocerebral bleeding); incidence of spinal cord ischemia was 6.5% (n¼2)with 1 permanent paraplegia (3.2%). Conclusion: Endovascular repairwith branched and fenestrated stent grafts proved a reasonable optionfor TAAA repair in a high-risk and advanced age cohort with lowmortality and low incidence of paraplegia. This therapy is meanwhileavailable for urgent cases, since production time for the newer custom-ized device has been reduced to 2-3 weeks. The procedures are time-consuming and technically demanding and the amount of radiationexposure is a concern. The bridging stent graft issue remains unsolved.In particular there is a riskof loose renal arterieswith contemporary stiffstents. Thus further improvement of stent-graft technology, endovas-cular equipment and intraoperative imaging technology is required.

OP133Analysis of gender-specific differences inoutcome of ascending aortic aneurysm surgeryBeller C.J.1, Wannaku S.1, Farag M.1, Seppelt P.1,Zimmermann N.1, Karck M.1, Kallenbach K.11Universität Heidelberg, Herzchirurgie, Heidelberg,Germany

Objectives: Possible risk-factors for gender-specific differences in out-come of ascending aortic aneurysm surgery with respect to aneurysmsize (diameter and normalized diameter¼diameter/BSA (body surfacearea) and extent of aortic disease were evaluated. Methods: 548consecutive patients (male: n¼390, age: 58.3 � 14.4 years; female:n¼158, age: 65.3 � 12.9 years), who underwent surgery for aneurysmsof the ascending aorta from 1994 to 2011were retrospectively analysed.Results: Analysis of possible preoperative risk-factors revealed: womenwere significantly older (p<0.001) and presented with significantlymore hypertension (p¼ 0.04) and chronic obstructive pulmonary dis-ease (COPD, p¼0.017). Men had significantly more previous cardiacoperations than women (p¼0.016). No gender differences were foundregarding prevalence of aortic valve pathology, Marfan syndrome andNYHA status. Mean aortic diameters were 5.86 � 1.34 cm in men and

5.74 � 1.04 cm in women, whereas normalized diameters were signifi-cantly larger in women (3.10 � 0.6 cm vs. 2.75 � 0,5 cm, p�0.001). Theaortic arch was significantly more involved in aneurysm formation inwomen (p¼0.04), whereas no gender differences were observed forother diseased parts of the aorta. Follow-up was complete for 93% andmean follow-up time was 3.9 � 3.9 (0-17.8) years. Overall, 30-daymortality was 4.8% (n¼23): 3.5% in men (n¼12) and 7.9% in women(n¼11; p¼0.058). Kaplan-Meier analysis revealed a significantly re-duced long-term survival for women (log-rank p¼0.0052). Sevenpreoperative variables were identified as risk factors for long-termmortality by univariate regression analysis: age (HR 1.06, p<0.001),female gender (HR 2.13, p¼0.0064), creatinine (HR 1.96, p¼0.0012),urea (HR 1.02, p¼0.0022), NYHA status (HR 1.58, p¼0.0014), COPD (HR2.67, p¼0.0036) and renal insufficiency (HR 3.61, p¼<0.0001).Conclusions: Long-term survival after surgery for ascending aorticaneurysms was significantly reduced in women, whereas early mortali-ty was not significantly different between genders. The observedsignificant larger normalized aortic diameters and more involvementof the arch may reflect a more progressed state of aortic disease inwomen. Furthermore, differences in comorbidities may contribute tothe observed gender differences in outcome. However, further studiesare necessary to elucidate underlying reasons. This studywas supportedby DFG, SFB-TR 125 “Cognition-Guided Surgery” and “Dr. Rusche-Förderprojekt 2012”.

OP134Long-term results after different cerebralperfusion strategies in aortic arch surgeryBernhardt A.M.1, Jahn J.1, Brickwedel J.1, Coutandin M.1,Biermann D.1, Reichenspurner H.1, Detter C.11Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany

Objectives: Different perfusion strategies have been described forneurologic protection during open aortic arch surgery. The objectiveof this study is to compare the outcome after uni- and bilateralantegrade and retrograde perfusion technique in our institution.Methods: Between March 2000 and March 2013 172 consecutivepatients received aortic arch replacement in our institution. 110 pa-tients had proximal hemi arch with open distal anatomises and 62patients had total aortic arch replacement. Indications for arch replace-ment were aneurysms in 91 and aortic dissections in 80 patients.Perfusion strategy included uni- and bilateral antegrade (88.4%) andretrograde (11.6%) cerebral perfusion combined with deep (61.0%) ormild-to-moderate (49.0%) hypothermic arrest. Mean follow-upwere 4.3� 1.6 years. Results: Mean age was 68.9 � 4.6 years. Extracorporealcirculation timewas 207� 49.3 min. Aortic cross clamp timewas 126�38.8 min. In patients with aortic dissections the 30 day mortality was28.75% and 5- year survival was 55%. Neurologic deficit was found in17.5%. Stratified to the perfusion strategy stroke occurred in 44.4% ofpatients with retrograde and in 14.1% of patients with antegradeperfusion (p¼0.08). Deep hypothermic arrest was not associatedwith significant higher stroke rate compared to moderate hypothermicarrest (18.4% vs. 16.1%, p¼0.23). In patients with aneurysms the 30-daymortality was 4.4% and 5- year survival rate was 74.4%. Neurologicdeficit was present in 6.6%. Analyzed be the perfusion strategy strokeoccurred in 11.1% of patients with retrograde and in 6.1% of patientswith antegrade perfusion (p¼0.03). Deep hypothermic arrest was notassociated with significant higher stroke rate compared to moderatehypothermic arrest (7.1% vs. 6.4%, p¼0.36). Conclusion: Systemic mild-to-moderate hypothermia during circulatory arrest and antegradecerebral perfusion is associated with low 30 day mortality and satisfac-tory risk for permanent neurologic deficits even in complex aortic archsurgery.


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OP135Early and midterm outcome of secondary opensurgical and minimally invasive interventionsafter thoracic endovascular aortic repairNozdrzykowski M.1, Garbade J.1, Etz C.1, Misfeld M.1,Schmidt A.1, Borger M.1, Mohr F.W.11Universität Leipzig, Herzzentrum Leipzig, Herzchirurgie,Leipzig, Germany

Background: The purpose of this study is to retrospectively evaluate,with an 'all-comers' approach, the survival and the outcome of patientsfollowing secondary interventions after thoracic endovascular aorticrepair (TEVAR). Methods: Three hundred and forty-seven patients withdifferent thoracic aortic disease underwent TEVAR at our institutionbetween 2002 and 2012. A total of 45 patients (28 male, mean-age 59 �13.1 years), underwent secondary interventions. Themedian interval tosecondary intervention was 3.8 months (range, 0.03 to 64.1). Theindication for secondary intervention included stent dislocation(n¼1), procedure related perforation of the aortic valve cusp, aorticrupture (n¼ 2), endoleak type II (n¼2), visceral or limb malperfusion(n¼5), infection of the prosthesis (n¼7), aortoesophageal or aorto-bronchal fistula (n¼8) and endoleaks (type Ia or Ib) causing aorticdilatation (n¼19). Thirty three patients underwent open conversionincluding aortic valve repair (n¼1), total arch replacement (n¼1),extensive replacement of the aortic arch or descending aorta (n¼12),and thoracoabdominal aortic replacement (n¼19). Two patients re-quired carotid subclavian bypass operation to allow upper limb perfu-sion. In the remaining 10 patients minimally invasive endovascularprocedures were performed and involved stenting of aortic sidebranches to restore distal-organ perfusion (n¼3), endovascular coilingbecause of endoleak type II (n¼2) and second-time stenting in 5patients. Results: The in-hospital-mortality rate was 8.9% (4 patients;1 case of aortic rupture after second-time TEVAR, and 2 cases ofmultiorgan failure and 1 case of anew aortic rupture after openconversion). Overall 1-year survival was 84.0%. The major complica-tions, such as paraplegia (n¼3, 6.7%) and stroke (n¼3, 6.7%) occurredafter open surgical procedures. Postinterventional malperfusion syn-drome, required reintervention, was diagnosed in 2 patients (4.4%) aftersecond-time TEVAR. Eleven patients (24.4%) developed renal failureduring their early clinical course. Essential cardiac arrhythmias occurredin 5 cases. Conclusions: Secondary surgical procedures after TEVAR canbe performed with low mortality and morbidity rate, despite severepreoperative conditions of patients. Achieving acceptable outcomesafter open surgical correction suggested that many patients withcomplex aortic pathologies can benefit from conventional surgeryduring primary intervention.

OP136Spinal cord ischemia following total aortic archreplacement and endovascular stenting of thedescending thoracic aorta (TEVAR).Pathophysiological investigations in a porcinemodelHaldenwang P.1, Prochnow N.2, Baumann A.3, Häuser L.4,Schlömicher M.1, Ziebura D.4, Schmitz I.5, Strauch J.11BG University Hospital Bergmannsheil, Ruhr-University ofBochum, Department of Cardiothoracic Surgery, Bochum,Germany, 2Ruhr-University of Bochum, Department ofNeuroanatomy and Molecular Brain Research, Bochum,Germany, 3BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Department of Anesthesiology,Intensive Care, Palliative Care and Pain Medicine, Bochum,Germany, 4Ruhr-University of Bochum, Bochum, Germany,5BG University Hospital Bergmannsheil, Ruhr-University ofBochum, Institute for Pathology, Bochum, Germany

Objective: Combination of open aortic arch replacement and endovas-cular stenting of the descending thoracic aorta (TEVAR) represent thetherapy of choice for complicated aortic diseases. Aim of our study wasto analyze if 90 min selective cerebral perfusion (SCP) at 28°C followedby an endovascular stenting of the descending aorta may cause spinalcord ischemia.Methods: 14 pigs (41� 3 kg) were cooled on CPB to 28°C.After clamping of the aortic arch, SCP was established for 90 min:

randomly, in n¼7 animals the left sided vertebral artery as well as theT4-T13 thoracic segmental arteries (TSA) were clipped, in order tosimulate a TEVAR procedure, whereas the TSA of the other n¼7 animalsremained untouched. After systemic reperfusion and CPB weaning,hemodynamic data were registered for 120 min. Microspheres wereinjected at baseline, reaching of 28°C, during SCP, respectively at 60 and120min off-CPB for spinal cord blood flow (SCBF) calculation. Via trans-cranial stimulation myogenic motor-evoked potentials (MEP) wereassessed at the same time points. After sacrifice, the thoracic and lumbarspinal cord was analyzed histologically using a 9-point schematicgrading system (Kleinman-Score: 0¼normal, 8¼necrosis of the entiresection). Results: SCBF decreased in both groups during cooling and SCPto less than 40% of baseline (4 � 2 ml/min/100 g). During reperfusionSCBF recovered slowly in the non-clipped-group, with significant lowerSCBF in the L1-L5 region of the TSA-clipped animals. At 28°C the MEPamplitude showed a decrease to 80-90% from baseline. After 90 min ofSCP the MEP assessed in the m. masseter, used as stimulation outputcontrol, didn't differ significantly between groups: 90 � 3% vs. 92 � 6%.The m. external oblique (T7-T11) amplitude was comparatively lower,without significant differences between groups 76� 7% vs. 74� 5%.MEPreached significant lower amplitude levels in the L1-L5 region of theTSA-clipped-animals: 59�7% vs. 84�15% (m. vastusmedialis) and 48�6% vs. 82� 26% (m. tibialis anterior). It recovered back to baseline only inthe non-clipped-group. Histological analysis showed a significanthigher ischemia rate in the L1-L5 region of the TSA-clipped-animals(Kleinman-Score: 6.0 � 0.6 vs.2.5 � 2.3). Conclusion: 90 min of SCPprovide sufficient spinal cord protection during arch replacement at 28°C. In combinationwith TEVAR of the descending aorta the lumbar spinalcord perfusion may be altered, which causes functional and structuraldamage.

OP137Near-infrared spectroscopy monitoring of thecollateral network to detect spinal cordmalperfusion during and afterthoracoabdominal aortic repair: A clinicalupdateEtz C.D.1, von Aspern K.1, Gudehus S.2, Luehr M.1, BanuschJ.2, Ender J.2, Borger M.A.1, Misfeld M.1, Mohr F.-W.11Herzzentrum Leipzig - Universitätsklinik, Klinik fürHerzchirurgie, Leipzig, Germany, 2Herzzentrum Leipzig -Universitätsklinik, Abteilung für Anästhesie, Leipzig,Germany

Objectives: Update on the feasibility and clinical utility of non-invasiveinfra-red monitoring of the paraspinous collateral network (CN) oxy-genation in open and endovascular thoracoabdominal aortic repair: aclinical upate. Methods: Near-infrared spectroscopy optodes - posi-tioned bilaterally over the thoracic and lumbar paraspinous vasculature(Fig. 1, left) - were used to transcutaneously monitor the oxygenationstatus of the CN (Fig. 1, right) in 20 patients (age: 66 � 10 years;male¼11, between 09/10 and 04/12). Fifteen pts underwent openthoracoabdominal aortic repair (Crawford IIþIII), three had thoracicendovascular aortic repair (TEVAR,Crawford I), and two had an hybridrepair (Crawford II). CN-oxygenation was continuously recorded until48 h postoperatively. Results: Hospital mortality was 5% (N¼1), 15%suffered ischemic spinal cord injury (SCI, N¼3). Mean thoracic CN-oxygenation saturation (ThS) was 75.5 � 8% prior to anesthesia (¼baseline) without significant variations throughout the procedure(during non-pulsatile cooling on CPB and with aortic X-clamping;range¼70.6-79.5%). Lumbar CN-oxygen saturation (LbS) significantlydropped after proximal aortic X-clamping to a minimum after 11.7 � 4minutes (74 � 13%-of-baseline), but fully recovered after restoration ofpulsatile flow to 98.5%-of-baseline. During TEVAR stent-graft deploy-ment did not significantly affect LbS. Three patients developed relevantSCI (paraplegia N¼1/paraparesis N¼2). In these patients LbS reductionafter aortic X-clamping was significantly lower compared to patientswho did not experience SCI (p¼0.04). Conclusions: Non-invasivemonitoring of the paraspinal CN-oxygenation during and after thora-coabdominal aortic repair is easily applicable. Lumbar CN-oxygenation(Fig. 1, right, yellow arrow) levels directly respond to compromise ofaortic perfusion and may be utilized to guide distal aortic perfusion.


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Fig. 1

Coronary heart disease II

OP138Surgical outcomes of patients with acutecoronary syndromes undergoing coronaryartery bypass grafting: a current report of theNorth-Rhine-Westphalia surgical myocardialinfarction registryThielmann M.1, Liakopoulos O.J.1, Slottosch I.2, Welp H.3,Wendt D.1, Schiller W.4, Martens S.3, Welz A.4, Wahlers T.2,Neuhäuser M.5, Jakob H.1on behalf of the North-Rhine-Westphalia Study Group1Westdeutsches Herzzentrum Essen, Klinik für Thorax- undKardiovaskuläre Chirurgie, Essen, Germany, 2HerzzentrumUniklinik Köln, Herz- und Thoraxchirurgie, Köln, Germany,3Universitätsklinikum Münster, Klinik für Herzchirurgie,Münster, Germany, 4Universitätsklinikum Bonn, Klinik undPoliklinik für Herzchirurgie, Bonn, Germany, 5Rhein-Ahr-Campus, Hochschule Koblenz, University of AppliedSciences, Fachbereich Mathematik und Technik, Remagen,Germany

Objectives: To evaluate in-hospital mortality of patients referred tourgent coronary artery bypass grafting (CABG) with acute coronarysyndromes (ACS), including ST-elevation or non ST-elevationmyocardialinfarction (STEMI/NSTEMI) or unstable angina (UA).Methods: Between01/2010 and 05/2012 patients undergoing urgent CABG with ACS wereprospectively entered into a registry by four participating cardiacsurgery centres in North-Rhine-Westphalia. Demographic data andover one-hundred perioperative variables were recorded, includingin-hospital all-cause mortality. After univariate analysis, relevant peri-operative variables were entered into a multivariate logistic regressionmodel to identify independent predictors for in-hospital mortality.Results: A total of 1197 patients (age 68 � 11 yrs, males 78%, log.EuroSCORE 24� 21%)were admitted to CABG surgerywith STEMI (25%),NSTEMI (49%) or UA (26%). Three-vessel coronary artery disease waspresent in 80% with main-stem involvement in 46% of patients. On-pump CABG surgery was performed in 94% (CPB-time, 103 � 43 min,aortic cross-clamp time, 60 � 26 min; 53% blood cardioplegia) with amean of 2.5 � 0.7 bypass grafts and 93% LITA use. Overall in-hospitalmortality was 7.4%, with 12.8% in STEMI patients, 5.6% in NSTEMI and5.0% in patients with UA (P<0.001). Multivariate logistic regressionanalysis revealed age, gender, preoperative troponin I, LVEF, on-pumpsurgery and the need for ECMO therapy to be independently predictivefor in-hospital mortality (P<0.05). Importantly, the preoperative use ofaspirin/clopidogrel, ß-blockers, or statins, the use of preoperative IABPsupport as well as the type of cardioplegia (crystalloid/blood) were notassociated with in-hospital mortality. Conclusions: CABG in patientswith ACS is still linked to substantial in-hospital mortality. Especially forpatients with STEMI reliable identification of preoperative predictors ismandatory to improve surgery outcomes.

OP139Short-term outcome after operativemyocardialrevascularization in patients with acutemyocardial infarction and cardiogenic shockGrothusen C.1, Friedrich C.1, Ulbricht U.1, Attmann T.1,Haneya A.1, Cremer J.1, Schöttler J.11UKSH Campus Kiel, Herz-und Gefäßchirurgie, Kiel,Germany

Objectives: Patients suffering from acute myocardial infarction (AMI)complicated by cardiogenic shock (CS) are a high-risk population with aconsiderably impaired outcome. The role of coronary artery bypasssurgery (CABG) in this setting is unclear. Methods: Retrospective dataanalysis was performed in 123 patients with CS that were transferred toour Department for emergency CABG within 48 hrs after diagnosis ofAMI. CS was defined as persistent systolic blood pressure (BP) below 90mmHg or the need of continuous catecholamine infusion to maintain aBP above 90 mmHg. Results: Mean age was 66 years (� 10 yrs). 22% ofpatients were female. 61 patients were diagnosed with STEMI, 62 withNSTEMI. Logistic EuroSCOREwas 18.7 (range 11-33). Coronary 3-vessel-disease was present in 87% of all patients. 21% had undergone percuta-neous transluminal angioplasty (PTCA) within the last 24 hrs. 46% hadalready suffered from cardio-pulmonary rescuscitation, 60% had beensupplied with an intra-aortic ballon pump prior to CABG. Medianoperation time was 215 min (184-240), bypass-time was 119 � 37min, cross-clamp time 60 � 20 min. Median number of arterial graftswas 1 (0-1), the number of venous grafts 2 (2-3). Post-operatively, 85% ofpatients had to receive a continuous infusion of catecholamines formorethan 24 hrs. Median blood loss during the first 24 hrs was 700 ml (350-1080 ml). Median duration of mechanical ventilation was 73 hrs (28-184). Rate of re-thoracotomy due to bleeding was 10%. 14% of patientssuffered from sepsis during the post-operative course. In-hospitalmortality was 20%, 30-day mortality 24%. No statistically significantdifferences between STEMI and NSTEMI patients were observed.Conclusions: In this study, patients with AMI and CS showan acceptableshort-term outcome after emergency CABG. Randomized, prospectivestudies are needed to further investigate the role of operative myocar-dial revascularization in this patient population.

OP140Recover of left ventricular function followingimmediate coronary artery bypass grafting inmyocardial infarctionRojas S.V.1, Stiefel P.1, Bobylev D.1, Knigina L.1, Bara C.1,Schmitto J.D.1, Martens A.1, Haverich A.1, Cebotari S.11Medizinische Hochschule Hannover, Klinik für Herz-,Thorax-, Transplantations- und Gefäßchirurgie, Hannover,Germany

Objectives: The best time point for CABG following NSTEMI is contro-versially discussed.While keeping a time-lapse before revascularizationfor “cooling down” the infarction might improve perioperative safety,delayed revascularizations can hold the risk of prolonged ischemialeading to ventricular remodeling with loss of ventricular function.The aim of our study was to assess the outcome of patients receivingimmediate CABG in the context of acute NSTEMI with special focus onthe analysis of left ventricular function including regional wall motionpatterns previous and after revascularization. Methods: We analyzedthe data of 20 consecutive patients with NSTEMI and 3-vessel diseasethat underwent eCABG in 2012 at our institution. 3D-Echocardiography(ie33 MATRIX, Philips Healthcare) was performed at admission andbefore discharge for assessment of left ventricular function and wallmotion analysis. A semi-quantitative scale ranging from0 (no change) to5 (full recovery) categorized the changes of regional wall motionabnormalities. Results: Demographics: 90% male, age 64,9 � 9,7 y,85% 3-vessel-CAD, 70% LMSS, 10% preoperative low cardiac output.Preoperative cardiac enzymes: CK 316 � 609 U/l; CK-MB 37 � 52 U/l.Maximum postoperative enzymes: CK 1038 � 961 U/l; CK-MB 98 � 108U/l. LV-EF was 39 � 10% at admission and 49 � 8% following CABGsurgery (p< 0,05). 65% of the patients showed a recovery of regionalwallmotion abnormalities (3,1� 1,1). Mean ICU stay was 4,0� 1,2 d. 30-daysurvival was 95%. Conclusions: Our data show that eCABG can beperformed in NSTEMI with low mortality and fast convalescence.


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Moreover we observed an important gain of LV function accompaniedby a decline of wall motion abnormalities, which we associate to therecovery of stunned myocardium.

OP141MIDCAB: a safe option in high risk patientsHoffmann G.1, Barrabas M.1, Fraund-Cremer S.1, PetzinaR.1, Haneya A.1, Cremer J.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Abt. für Herz- und Gefäßchirurgie, Kiel, Germany

Objectives: Minimally invasive direct coronary artery bypass grafting(MIDCAB) offers revascularization of the left anterior descending artery(LAD) in lesions unsuitable for percutaneous coronary intervention. It ischaracterized by avoidance of sternotomy and beating heart surgery.Besides single vessel disease MIDCAB can be extended to multi vesseldisease when combined with interventional techniques. Especiallypatients with elevated perioperative risks may benefit from the reducedsurgical trauma and short duration of anesthesia, ventilator time andintensive care unit stay. Methods: From 1998 to 2012 MIDCAB wasperformed in 1060 patients. A subgroup of 36 individuals was identifiedas a high risk collective with a STS score of more than 10 respectively alogistic EuroSCORE of more than 15. Demographic data, perioperativeoutcome and annual follow-up were obtained from all patients andretrospectively analyzed. Results: Average agewas 79,5� 6.2 years witha portion of 27.7% female patients. Multi vessel disease was present in83,3% and left main disease in 30.5% of the patients. Concomitant factorsas previous cardiac surgery (33.3%), recent myocard infarction (38.8%)and acute coronary syndrome (58,3%) add up to an average STS score of15.3 � 5.0. and a average logistic EuroScore of 28.2 � 12.9. A hybridrevascularization was aspired in 25% of the cases. MIDCAB could becompleted in all patients. Three patients (8.3%) died early postopera-tively. There was no occurence of early neurologlc dysorder, myocardialinfarction or new onset renal failure. The majority of patients (87,8%)were extubated within the first 24 h. Two patients (5.5%) underwentreoperation for deep wound infection. Mean follow up was 3.1 � 2.3years, total follow-up ads up to 112 patient years. Survival rates were78.4% at 1 year and 56.7% at three years. Conclusions: Minimallyinvasive coronary revascularization offers acceptable short and mid-term results when its application is extended to high risk patients whoare not candidates for conventional bypass surgery. Mortality showed tobe significantly lower than predicted by STS- and EuroSCORE.

OP142Impact of postoperative renal failure on earlyand late survivial of patients after coronaryartery bypass grafting - a single centerexperience based on 7,366 patientsHirnle G.1, BorgerM.A.1, Etz C.D.1, Seeburger J.1, Misfeld M.1,Mohr F.-W.11Herzzentrum Leipzig - Universitätsklinik, Leipzig,Germany

Objectives: Renal failure remains a serious complication after coronaryartery bypass grafting (CABG) surgery. We assessed the hypothesis thatpostoperative renal failure (RF) influences the postoperative outcome inpatients after CABG. We also sought to identify parameters which wereassociated with the deterioration of renal function in patients undergo-ing CABG surgery. Methods: Patient characteristics and clinical datawere collected prospectively from a computer registry maintainedprospectively on 11,148 consecutive patients that underwent CABG atour institution between 2002 and 2010. Patients were followed upannually by our research personnel with a postal questionnaire, or bycontacting the referring cardiologist and / or family physician. From thisgroup, we identified 7,366 patients with normal renal function beforesurgery (eGFR� 60 mmol/L/88.4). Remaining 3782 patients with renalimpairment in stage III to V (eGFR<60 mmol/L/88.4) or with history ofpreviousmild, transitory RFwere excluded. Transitory RFwas defined asRF that occurred at least once in the patient’s history. We excludedpatients that underwent cardiac surgical procedures other than CABG,patients with normal renal function with a history of RF, and patientswith eGFR<60 mmol/L/88.4 on admission. eGFR was measured at the

time of hospital admission and was analyzed in all patients by the samelaboratory using the same methodology. Results: Early mortalityreached 15,8% in Group I and was much higher than in Group II(1,1%), p<0,001, OR 17.13. The overall 8 year mortality (including 30days mortality) also showed a significantly reduced survival in patientswho developed post-CABG RF (29,0% vs. 10,4%, p<0,001, OR 3,50). The8-year follow-up mortality (excluding 30 days mortality) also did showdifference in survival between the groups (13,8% vs. 9,5%, p¼0,004, OR1,52). Conclusions: Patients who developed post-CABG RF have signifi-cantly higher early, 8-year and overall mortality. Risk factors associatedwith postoperative RF were identified: advanced age, high BMI, im-paired LV function, high EuroSCORE, cardiogenic shock, prolonged CPBtime and aortic cross-clamping time, increased use of cardioplegicsolution, IABP/ECMO, bypass revision, sepsis. On-pump beating heartmethod does not protect against RF.

OP143Outcome of total arterial versus conventionalmyocardial revascularization in the elderly: asingle center experienceHaneya A.1, Jussli-Melchers J.1, Eckmann S.1, Berndt R.1,Thiem A.1, Hoffmann G.1, Schöttler J.1, Cremer J.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Klinik für Herz- und Gefäßchirurgie, Kiel, Germany

Objectives: Several studies demonstrated that patients receiving arte-rial grafts have superior late survival after coronary artery bypass graftsurgery (CABG). The aim of this study was to evaluate the results of totalarterial revascularization compared with conventional coronary sur-gery in the elderly.Methods: A retrospective, observational study on anage-, gender- and EuroSCORE-matched cohort of patients aged morethan 70 years, who underwent isolated CABG between 01/2005 and 12/2011, was performed. 356 patients were enrolled and assigned to Group1 (G1)¼178 patients, for total arterial revascularization or Group 2(G2)¼178 patients, for conventional CABG (left internal thoracic arteryplus saphenous veins). Major adverse cardiac and cerebrovascularevents (MACCE) were evaluated. Results: No significant differencewas noted between the two groups with regard to preoperative riskfactors. No differences between both groups were observed in terms ofmean aortic cross-clamping time (G1¼66 � 19 min vs. G2¼65 � 21min), re-exploration for bleeding (G1¼3.9% vs. G2¼2.8%), transfusionrequirements (G1¼2 [0 to 3] units vs. G2¼2 [0 to 4] units), mechanicalventilation time (G1¼16 [11 to 22] h vs. G2 16 [11 to 22] h), incidencesof postoperative acute renal injury (G1¼6% vs. G2¼6%), and sternalwound infection (G1¼5% vs. G2¼3.4%), intensive care unit (ICU) stay(G1¼2 [2 to 3] days vs. G2¼2 [2 to 3] days) and hospital stay (G1¼8 [7to 12] days vs. G2¼8 [7 to 12] days) (p>0.05). Survival free of cardiacdeath or myocardial infarction (G1¼97.2% vs. G2¼96.6%) and MACCE-free survival (G1¼94.4% vs. G2¼97.2%) at follow-up of 30 days weresimilar between the groups. At a mean follow-up of 26 � 11 months, nodifferences between both groupswere observed in terms of survival freeof cardiac death or myocardial infarction (G1: 91.6% vs. G2¼90.4%).However, G1was associatedwith lower rates of repeat revascularization(G1¼2.8% vs. G2¼8.4%; p¼0.036). Conclusions: This study suggeststhat total arterial revascularization proved to be a safe and effectiveprocedure with superior late outcome also in the elderly. Lower rate oflate cardiac events encourage the use of total arterial revascularizationfor CABG. Randomized, prospective studies are needed to furtherinvestigate the role of total arterial revascularization in this patientpopulation.

OP144Preoperative ejection fraction andpostoperative outcome in off pump coronarybypass surgeryLoeblein H.1, Dzemali O.1, Graves K.1, Haeussler A.1, OdavicD.1, Genoni M.11Triemli Hospital, Cardiac Surgery, Zürich, Switzerland

Introduction: Poor ejection fraction (EF) has been considered risk factorfor worst outcome after heart surgery and as such incorporated in manyrisk-stratification models for patient under going coronary bypass


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surgery. The purpose of this study was to investigate the effect ofpreoperative ejection fraction on postoperativemorbidity andmortalityin patients undergoing isolated off-pump coronary artery bypass graft-ing (OPCAB). Methods: The data of patients who underwent OPCABbetween 1/2008-12/2010 was retrieved form our data bank. An associ-ation between EF and postoperative outcome: troponin, Creatin-KinaseMuscle-Brain (CKMB), noradrenalin requirement, use of intra-aorticballoon pump (IABP), creatinine, atrial fibrillation, intubation time, ICUdays andmortalitywas evaluated. Results: From1/2008 to 12/2010, 494OPCAB were isolated. The average preoperative EF was 54%. Postopera-tive average values were: Troponin 3.498 mcg/L, CKMB 20.01 mcg/L,noradrenalin requirement 8.67 mcg/mi, creatinine102 mmol/L, intuba-tions time 13 hours, ICU days 2.7. 15% had postoperative atrial fibrilla-tion, 4% required postoperative IABP andmortalitywas 1%. Therewas noassociation between preoperative EF with postoperative troponin,CKMB, noradrenalin requirement, creatinine, atrial fibrillation, intuba-tion time, ICU days and mortality. EF was significantly related topreoperative IABP (p¼0.003) but not to postoperative IABP use.Conclusion: In OPCAB surgery preoperative EF has no impact onpostoperative outcome.

Basic Science III: ECC, vascular, endothelium, inflammation,rejection

OP145Caloric restriction reduces sympathetic activitysimilar to beta-blockers but conveys additionalmitochondrio-protective effectsNiemann B.1, Li L.2, Simm A.3, Böning A.1, Rohrbach S.21Justus Liebig Universität Giessen, Klinik für Herz-Kinderherz- und Gefäßchirurgie, Giessen, Germany, 2JustusLiebig Universität Giessen, Physiologisches Institut, Giessen,Germany, 3Martin Luther Universität, Klinik für Herz- undThoraxchirurgie, Halle, Germany

Objective: Congestive heart failure (CHF) increases cardiomyocyteapoptosis and impairs mitochondrial (mito) function. Increased activityof the sympathetic nervous system contributes to CHF progression.Therefore, inhibition of sympathetic overactivity e.g. by beta-adrenergicreceptor blockers is used successfully in CHF patients. Caloric restriction(CR) restores myocardial and mitochondrial function and also reducessympathetic activity. Yet evidence is weak, if CR and neurohumoralsilencing target identical cardioprotective mechanisms.Methods:MaleWistar Rats (3 months) received either betablocker treatment (BB,metoprolol), diuretic medication (DF, furosemide), caloric restriction(CR, -40% kcal) or standard chow (Co) for 12weeks. Blood pressure, heartrate, activity and core temperature were recorded permanently (tele-metric device). Cardiac function was analyzed (echocardiography;Millar tip catheter). Mitochondrial function and biogenesis, markersof apoptosis and activated signaling cascades were analyzed (micro-respirometry, Western Blot, ELISA, qPCR) in tissue and serum. Results:CR reduced heart rate identical to BB and blood pressure identical to DFand BB. Heart rate variability was maintained in all groups, but CRinduced a histogram left shift in periods of rest. CR raised activity onlymildly and reduced body temperature. Co, BB and DF increased QAintervals. CR increased cardiac contractility, LV fractional shortening,ejection fraction and IVSDs. Compared to CR, BB improved LV functiononly mildly, but Co and DF induced a marked reduction of mostparameters. Diastolic function (E/A-wave) was preserved by CR andBB while DF reduced early relaxation. CR elevated phosphorylation ofthe AMPK and increased expression of mito transcription factors (Tfam,PGC-1alpha), mito biogenesis and respiration. Only CR prevented myo-cardial oxidative damage (TBARS, protein carbonylation). CR and BBreduced apoptosis markers (increased Bcl-2 / reduced Caspase 3 cleav-age) and induced phosphorylation of Akt, while BB and DF resulted inhigh phosphorylation of p44/42 MAPK. Conclusion: CR enables reduc-tion of blood pressure and heart rate and improves cardiac function evenin young animals. In addition to effects also induced by the reduction ofsympathetic activity, CR achieves protective effects on mitochondriathat appear to involve AMPK. Targeting these mechanisms mightprovide additional therapeutical benefits in patients suffering from CHF.

OP146Changes in morphometry and gene expressionin saphenous vein graft endothelium exposedto an ex vivo arterial pressure environmentKrähe K.1, Knappich C.1, Bernhard A.1, Lange R.1, Krane M.11Department of Cardiovascular Surgery, Division ofExperimental Surgery, German Heart Center Munich,Technische Universität München, Munich Heart Alliance,Munich, Germany

Objectives: Saphenous vein graft disease (SVGD), as a consequence ofvein graft adaption to the arterial environment after coronary arterybypass grafting (CABG), is still a major issue. “Arterialization” of the veinis marked by intimal hyperplasia (IH), mediated by endothelial injury.However, the complex processes of venous wall thickening are stillunder investigation. In this study an advanced ex-vivo perfusion systemis used to mimic the human in-vivo situation to investigate the under-lying physiological and molecular events involved in vein graft adapta-tion, with a special focus on morphometric changes. Methods: Humansaphenous vein grafts are divided and perfused in parallel via the ex-vivoperfusion system using venous (10 mmHg, 5 ml/min) and arterial (100mmHg, 50 ml/min) conditions for 3 and 5 days, respectively. Perfusedsamples and an unperfused control are preserved for gene expressionstudies and histological analysis. The expression of four different genes(ICAM-1, intercellular adhesion molecule-1; VCAM-1, vascular celladhesion molecule-1; KLF2, kruepple-like factor 2; E-selectin), whichproofed to be involved during arterialization, was determined by qPCR.Histological slices are evaluated using the Movat's pentachrome afterVerhöff staining. The thickness of the intima (I) is correlated to themedial thickness (M) of each vein graft resulting in a ratio value (I/M)indicating the progress of IH formation after perfusion compared tocontrol samples. Results:Morphometric analysis (55 samples) revealedan increased I/M ratio after 3 days (1.2 fold low pressure vs. 1.8 fold highpressure) as well as after 5 days (1.9 fold low pressure vs. 1.7 fold highpressure) of perfusion compared to control samples. Corresponding tothese morphometric changes gene expression of VCAM-1 (1.3 fold), E-selectin (1.54 fold) and ICAM-1 (2-fold) was increased in high pressurecompared to low pressure perfused veins. Conclusion: The early processof saphenous vein graft disease is characterized by an increasedexpression of adhesion molecules as well as an increasing intimalhyperplasia. The advanced ex-vivo perfusion system is able to mimicthis in-vivo process of arterialization and therefore providing an optimalsource for a more detailed understanding of underlying processes andtreatment studies combating saphenous vein graft disease.

OP147Do S100A4þ cells contribute to thedevelopment of obliterative airway disease?Guihaire J.1, Itagaki R.1, Deuse T.12, Hua X.1, StubbendorffM.1, Fadel E.3, Dorfmueller P.3, Laenger F.4, ReichenspurnerH.2, Robbins R.5, Schumacher U.6, Schrepfer S.151TSI Labor, Hamburg, Germany, 2Cardiovascular Surgery,UHZ, Hamburg, Germany, 3Hospital Marie Lannelongue, LePlessis Robinson, France, 4Medizinische HochschuleHannover, Hannover, Germany, 5Cardiothoracic Surgery,Stanford, United States, 6Anatomy, UKE, Hamburg,Germany

Background: Despite major advances in immunosuppressive therapiesover the last two decades, obliterative airway disease (OAD) remains amain cause of allograft dysfunction and mortality after lung transplan-tation (LTx). Increased levels of S100 family proteins have been reportedin patients suffering from OAD and over-expression of S100A4 has beenassociatedwith aggressive growth inmanymalignant tumors. This is thefirst study to assess S100A4 in OAD. Methods: Orthotopic trachealtransplantations using human bronchus grafts were performed inBrown Norway (BN) and nude (RNU) rats. Allografts were harvestedin both strains at day 7 (BN7, n¼6; RNU7, n¼7) or day 28 (BN28, n¼6;RNU28, n¼6) for general histology and staining of the S100A4 protein.Immune response of the host was assessed by ELISPOT and by screeningof donor-specific antibodies. Human samples from OAD patients wereused to compare with the histological features of this animal model.Results: Obstruction of the allograft lumen associated with significant


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infiltration of CD3þ and CD68þ cells was observed in the BN28 group.The physiological respiratory epithelium was preserved only in RNU28

animals (40% � 17% of the epithelial coverage), whereas it was notobserved in BN28 (P¼0.009). Th-1 immune response against thetracheal allograft was higher in BN animals compared to RNU animalson days 7 and 28 (P<0.001 and P¼0.035). Donor-specififc antibodieswere significantly higher at day 7 (IgM) and day 28 (IgG) in the BN groupcompared to RNU (mean fluorescence 37.6 � 6.5 vs. 5.8 � 0.7 P¼0.039and 22.4 � 3.8 vs. 6.9 � 1.6 P¼0.011, respectively). ImmunocompetentBN animals showed a stronger infiltration of S100A4þ cells inside thebronchial wall after 28 days, associated with cartilage damages rangingfrom invasion of the smooth borderline to complete destruction. Most ofthebronchial cartilages fromRNU animalswere completely preserved atthat time. In vitro expression of S100A4 protein by human fibroblastscould be markedly increased by incubating with BN mononuclear cells,but not when stimulated with T cell-deficient RNU mononuclear cells.Conclusion: OAD has been reproduced in a new xenotransplant model.Chronic airway obstruction was associated with immune activationagainst the allograft. Cartilage infiltration by S100A4þ cells might bemediated by T-cells. Further investigations may help to characterize therole of S100A4 over-expression in the development of chronic OAD.

OP148Preservation of endothelial function of vasculargrafts after short-time storage and warmreperfusion with a recently developedpreservation solution (Tiprotec)Veres G.1, Hegedüs P.1, Barnucz E.1, Radovits T.2, KorkmazS.1, Weymann A.1, Karck M.1, Szabó G.11Universität Heidelberg, Herzchirurgie, Heidelberg,Germany, 2Semmelweis University, Department of CardiacSurgery, Budapest, Hungary

Introduction: Inadequate preservation of vascular grafts results inpostoperative graft failure (early graft thrombosis, vasospasm) andpromotes late graft vasculopathy (restenosis, occlusion). Vascular graftsare often stored under hypotermic conditions in physiologic saline.However, a poor preservation capacity of saline has been demonstrated.Main goal of our study was to compare the preservation capacity of theclinically used preservation solution (saline) and the recently developedpreservation solution (Tiprotec) after short-time cold storage andwarmreperfusion with functional and molecular biological methods in an invivo model of aortic transplantation.Methods: Aortic abdominal trans-plantations are performed in Lewis rats. The donor aortic arch isharvested and placed in cold (þ4°C) physiologic saline/Tiprotec solutionand stored for 2 hours. After the 2 hours ischemia, the aortic arch isheterotopically transplanted into abdominal aorta of isogenic recipient.Two and24 hours after transplantation, the implantedgraft is harvested.In an organ baths, endothelium-dependent and -independent vaso-relaxation are investigated by using acetylcholine and sodium nitro-prusside. Gene expression analysis and CD 31 staining were alsoperformed. Results: Severely impaired endothelial function and integ-rity of implanted aortic grafts were shown after 2 and 24 hoursreperfusion in the saline group (maximal vasorelaxation: 38,56% �5,40% and 20,43%� 4,40%, CD31 positive area: 38% and 40%, respective-ly), however, Tiprotec preserved the integrity and function of theendothelium of the implanted grafts (maximal vasorelaxation: 51,04%� 7,08% and 41,52% � 7,22%, CD31 positive area: 66% and 56%,respectively) Gene expressions (Bax, Bcl-2, caspase-3, iNOS) after dif-ferent reperfusion times were also significantly different between thegroups. Conclusion: Short-time storage in the the generally usedpreservation solution (physiological saline) impairs severely the vascu-lar function of the grafts. However, storage in Tiprotec solution pre-serves effectively the integrity and function of the grafts.

OP149RAGE influences the development of aorticvalve stenosis in mice on a high fat dietYakobus Y.1, Nass N.2, Navarrete Santos A.1, Silber R.-E.1,Simm A.1, Hofmann B.11Universitätsklinikum Halle (Saale), Klinik für Herz- undThoraxchirurgie, Halle (Saale), Germany, 2Otto vonGuericke University Magdeburg, Institute of Pathology,KTF-Laboratory, Magdeburg, Germany

Background: Advanced glycation end products (AGEs) are stable prod-ucts of the condensation of an aldehyde i.e. glucose and amines such asamino acids (Maillard reaction). Their accumulation is considered asbiomarker of ageing and is also associated with several degenerativediseases. AGEs are recognized by several receptor molecules of whichthe receptor of AGEs (RAGE) is currently the most intensively studied.Activation of RAGE causes an unfavorable proinflammatory state. AGEsas well as high fat diet are associated with cardiovascular diseases. Thehypothesis of this study was that high fat diet results in development ofaortic valve stenosis and that knockout of RAGE should be protective.Materials and methods: Six week old male C57BL/6N and C57BL/6NRAGE -/-mice (n¼28) were randomly assigned to 4 groups and fedwithnormal or high fat diet for 32 weeks. Weight gain was determinedweekly. At the start of the experiment and after 2, 4 and 7 months,echocardiographic assessments of the aortic valve were made. At theend of the experiment, histological and immunohistochemical analysisof the valves was performed. Results: The absence of RAGE resulted inaccelerated weight gain. However, after 7 month, both - C57BL/6 andC57BL/6 RAGE -/- -mice on high fat diet had nearly the same weight.Immunohistochemistry analysis of the aortic valves revealed thatC57BL/6N mice on a high fat diet had significantly more calcification(p¼0.018), higher AGE accumulation (p¼0.005) and RAGE expression(p¼0.01) when compared to the normal fat control. Aortic valves ofRAGE -/- mice showed less calcification, less AGE accumulation and lesscollagen, however this was not significant. Conclusion: These datasuggest that AGE and RAGE are involved in the development of obesityand aortic valve stenosis.

OP150Dose/time-dependent modulation of theendothelial function throughimmunosuppressive agentsKanzler I.1, Bogert N.1, Guo F.1, Moritz A.1, Beiras-FernandezA.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, Thorax-, Herz-, und Gefäßchirurgie,Frankfurt, Germany

Introduction: Cardiac allograft vasculopathy (CAV) is a major complica-tion after heart transplantation. Inflammationmakesmononuclear cellsto migrate through coronary vascular endothelium causing the prolifer-ation of medial smooth muscle cells, leading to the chronic damage ofCAV. Polyclonal-antithymocyte-globulins (ATGs) and anti-CD25 anti-bodies are agents employed for induction of immunosuppression insolid organ transplantation. We aimed to investigate the effect ofdifferent regimens of these immunosuppressive induction agentsupon transendothelial migration of peripheral blood mononuclear cells(PBMC) and evaluated the endothelial apoptosis after treatment.Methods: Human microvascular endothelial-cells were either activatedwith TNF-α/IFN-γ or not and further treated with 25 or 125 µg/ml ATG(Thymoglobulin©, Sanofi-Aventis, Germany) for 2 h or 24 h, or with 5µg/ml Basiliximab (Simulect©, Novartis, Germany) for 2 h or 24 h.PBMCs were either activated with PHA or not and further treated with25 or 125 µg/ml ATG or with 5 µg/ml Basiliximab for 2 h and then usedfor transendothelial migration assays. Apoptosis of endothelial cells wasdetected by Annexin-V staining after 2 h incubation with either 25 or125 µg/ml ATG or 5 µg/ml Basiliximab. Transmigration index (tmx) wascalculated as percent of controls. p<0.0.5 was considered statisticallysignificant. Results: Prophylactic 24 h administration of ATG/Basilix-imab to naïve endothelial-cells without PBMC treatment reduced trans-endothelial migration. Prophylactic 24 h administration of ATG/Basiliximab to naïve endothelial cells after PBMC treatment with thesame agents reduced the transendothelial-migration after 24 h. In both


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cases no effect could be observed after 2 h treatment. Basiliximab,though not ATG, showed a reduction of transmigration after 2 htreatment of PBMCs without naïve EC treatment. Apoptosis of ECs afterATG was dose-dependent, increasing from 1.2% after either 25 µg/mlATG to 8.7% after 125 µg/ml ATG. Conclusion: Immunosuppressiveinduction agents can modulate the endothelial activity in a dose andtime dependent manner. Our results suggest that administration ofinduction agents over longer time periods provide a potential benefitregarding endothelial immunomodulation. Increased doses show, how-ever, a deleterious effect on endothelial survival.

OP151Endothelial damage as a predictive anddiagnostic marker in aortic valve surgery:Automated assessment of circulatingendothelial cell frequency in transcatheteraortic-valve replacement and conventionalsurgeryNeef K.1, Sabashnikov A.1, Madershahian N.1, Scherner M.1,Kuhn E.1, Lauer M.1, Chesnokova V.1, Wittwer T.1, Choi Y.-H.1, Wahlers T.11Uniklinikum Köln, Klinik und Poliklinik für Herz- undThoraxchirurgie, Köln, Germany

Introduction: Transcatheter aortic valve replacement (TAVR) representsa well-established treatment alternative to conventional aortic valvereplacement (CAVR) for high-risk patients with aortic valve stenosis(AS). Circulating endothelial cells (CEC) in the peripheral blood repre-sent a direct and unbiased marker for endothelial injury, thus, revealingpatient specific predispositions and adverse effects resulting from thesurgical treatment. Here, we used a novel, automated approach toenumerate CEC. Methods: For this pilot study, 22 consecutive patientswith severe AS were stratified for either CAVR or TAVR by heart teamdecision. Patient demographics, pre-OP characteristics and post-OPoutcome were analyzed for both groups. The assessment of CEC fre-quency was performed using an isotype controlled flowcytometricapproach, including automated pre-enrichment of a CD34 positiveblood cell subpopulation. Measurements were performed pre-OP, 1 hand 5 d post-OP. Results: CEC frequencies were significantly higher inthe TAVI group before (9.8� 4.1 vs 5.5� 2.2, p¼0.019) as well as 1 hourafter surgery (13.4 � 5.1 vs 8.2 � 4.1, p¼0.030) compared to CAVR. Fivedays post-OP CEC frequency was significantly increased in the CAVRgroup (39.0 � 13.0 vs 14.3 � 4.4, p<0.001). There was a positivecorrelation between pre-OP Euroscore (9.55� 2.98 inTAVI groupvs 5.18� 1.78 in SAVR group, p<0.001) and CEC (9.811 � 4.14 in TAVI group vs5.53 � 2.16 in SAVR group, p¼0.019) revealing a higher pre-OP risk inTAVI patients compared to CAVR patients. Additionally, pre-OP CECfrequency >10/ml was significantly correlated to concomitant coronaryheart disease, de novo post-OP atrial fibrillation and increased post-OPcreatinine levels (maximum 3.92 mg/dl), elevated blood product trans-fusion, prolonged ICU stay (maximum 13 days), higher rate of transitorypsychotic disorder and paravalvular leaks. Conclusion: Initial resultsconfirm CEC as a valid marker for the determintation of pre-OP risk,invasiveness of surgical procedure and clinical outcome. However,further studies are necessary to validate practical clinical usefulnessand potential superiority compared to conventional markers.

Heart valve disease IV: New aortic valves and sutureless devices

OP152Sutureless aortic valves - a word of cautionesingle-centre experience with the Medtronic 3fEnable™ ProsthesisMohamady K.1, Oberhoffer M.1, Laß M.1, Geidel S.1,Schmoeckel M.11Asklepios Klinik St Georg, Herzchirurgie, Hamburg,Germany

Introduction: Recent data suggest that aortic valve replacement (AVR)using the sutureless self-expandingMedtronic Enable™ bioprosthesis issafe and feasiblewith excellent hemodynamics and a short implantation

time. After experiencing 5 cases of severe paravalvular leakage/valvedislocation we critically reviewed all patients who had undergone AVRwith the Medtronic Enable™ valve at our institution. Patients andmethods: Between 10/2011 and 4/2013 48 patients (age 76� 3.5 years),25 male, received a Medtronic Enable™ aortic valve via complete(n¼36) or partial (n¼¼ 4) sternotomy or right parasternal thoracoto-my (n¼8). Intra- /perioperative and follow-up data were collected withrespect to survival, paravalvular leakage and valve dislocation leading tore-operation, atrioventricular block (AVB)with pacemaker implantationand neurologic events. Maximum and mean pressure gradients (pmax/pmean) from postoperative echocardiography were obtained. Meanfollow up time was 383 � 114 (range 116-653) days. Results: 13operations were combined procedures. Cardiopulmonary bypass timefor isolated AVR averaged 96 � 27 min., aortic crossclamp time 64 � 22min. In-hospital mortality was 8.3% (4/48);overall mortality duringfollow-up was 12.5% (6/48). Overall Redo-AVR rate was 12.5% (6/48patients). Severe paravalvular leakage/valve dislocationwas observed in5/48 patients (10.4%);one patient needed immediate revision, becauseof prosthesis dislocation and occurrence of severemitral insufficiency, 4patients underwent redo AVR within 1 week to 14 months. Prostheticvalve endocarditis occured in 1/48 patients (2.1%) after 10 months. Twoof those 6 Redo-AVR patients died. Pacemaker implantation was neces-sary in 14.6% (7/48 patients); serious neurologic events were observedin 4/48 patients (8.3%). Postoperative pmax /pmeanwas 20.5þ/-8.7mmHgand 8.8þ/-5 mmHg, respectively; mild paravalvular leakage was docu-mented in 6/48 patients (12.5%). Conclusions: Our series of 48 patientsundergoing AVR with the Medtronic Enable™ bioprosthesis showedlonger than expected cardiopulmonary bypass- and aortic crossclamptimes. Due to the high overall redo-AVR rates for leakage/dislocation aswell as the high incidence of AVB and neurologic events we could notprove superiority to the conventional procedure for AVR.

OP153Aortic valve replacement with the SorinFreedom SOLO bioprosthesis: Initial results and2-years of follow-upWilbring M.1, Asif M.1, Alexiou K.1, Knaut M.1, Matschke K.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: The study prospectively evaluated clinical outcome andhemodynamic results during primary hospital stay and further follow-up. Patients andmethods: A total of 70 patients were enrolled with theintention to treat. Mean age was 71.6 � 4.9 years. Pre-, intra- andpostoperative data were prospectively recorded. An echocardiographicfollow-up and thrombocyte-count were determined after 6-, 12- and 24months. A 2-years follow-up was completed in all survivors. Results:Intraoperatively, implantation of the SOLO bioprosthesis was rejected in14 patients (20.0%). Main reasons were severe calcification (n¼9), largeannulus (n¼2) and sizing problems (n¼1). Mean size of the implantedprostheseswas 24.8� 1.5mm.During primary hospital stay, one patientneeded reoperation due to progressive valvular regurgitation. No hos-pital mortality was observed. Discharge echocardiography revealednone, trace or mild valvular regurgitation in 63.6%, 21.8% and 14.5%and after 2-years in 42.9%, 42.9% and 14.3% of the patients, respectively.Likewise, transvalvular pressure gradients remained stable (dPmax/mean: at discharge 22 � 9.6/12.9� 5.7 mmHg and 20.5 � 7.9/12.3 � 4.8mmHg after 2-years). Significant thrombopenia (<50 Gpt/l) existed in 2patients at discharge. After 2-years 1 patient remained with thrombo-cytes <100 Gpt/l and none with <50 Gpt/l. Six patients died duringfollow-up, mostly due to non-cardiac reasons (n¼4). Prosthetic valveendocarditis occurred in 3 patients (5.4%), causing 1 death. Conclusion:Aortic valve replacement with the SOLO valve provided stable prosthe-sis-function during follow-up, but was associated with a significantnumber of (clinically dispensable) valvular regurgitation. Nonetheless,the overall impression gives no reason for euphoria, especially withregard on available well-established stented valves. Sophisticated pa-tient selection is essential.


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OP154Initial experience with the Edwards Intuityrapid deployment valveSchlömicherM.1, Haldenwang P.L.1, BechtelM.1, MoustafineV.1, Strauch J.11Ruhr-University Hospital Bergmannsheil, Department ofCardiothoracic surgery, Bochum, Germany

Background: Since March 2012 45 implants of the Edwards Intuity©rapid deployment valve were performed in our institution. This paperpresents the first short term clinical and hemodynamic results. Patientsand methods: There were 14 (31%) female and 31 (68%) male patientswith a mean age of 72,9 (� 15,3) years. Preoperatively, 12 patients (26%)were in NYHA Class II, 26 (58%) in Class III and 7 (16%) in Class IV.Concomitant Bypass Surgery was performed in 4 cases. Single AVR wasperformed using a partial upper sternotomy in 41 cases. A peak gradientof 69,5 (� 23,7) mmHg and a mean gradient of 46,7 (� 17,9) weremeasured preoperatively. Amean effective orifice area of 0,8 cm2 (� 0,3)and an ejection fraction of 58,5% (� 15,0) could be found. The meaneuroscore II was 3,5% (� 1,3). Results: 30-day mortality rate was 2,2%(n¼1). One patient died because of severe postoperative bleeding fromthe aortotomy. In one procedure intraoperative echo showed severeparavalvular leakage after implantation which led to implantation of aconventional bovine pericardial valve. No neurologic events occured.Neither myocardial infarction. By using Doppler echocardiography, thepeak and mean postoperative transprosthetic gradients were deter-mined to be 21.9 (� 7,6) mmHg and 12.1 (� 4,2) mmHg, respectively.The mean gradients of the 19 mm prostheses (n¼ 2) were 33,5 (� 4,9)mmHg / 18 (� 1,4) mmHg, of the 21mmprostheses (n¼15) 23,2 (� 8,3)mmHg / 12,2 (� 4,3 mmHg), of the 23 mm prostheses (n¼9) 20,9 (� 5,9mmHg) / 11,7 (�� 3,0 mmHg), of the 25 mm Prostheses (n¼14) 20,9(� 4,9) mmHg / 11,8 (� 3) mmHg, and 15,3 (� 4,2) mmHg / 8,5 (� 3,5)mmHg of the 27 mm Prostheses (n¼ 5). A mean efective orifice area of1,8 cm2 (� 0,3) was determined. Two Patients showed mild (AI I) aorticregurgitation at the time of discharge. No higher grade regurgitationoccured. The mean implantation time amounted 8 (� 3 ) minutes. Themean cross clamp time in single avr procedureswas 34�15minutes. Anaverage bypass time of 66 (� 22) minutes was seen. Conclusion: Shortterm results show excellent hemodynamic results. A satisfying reduc-tion of cross clamp and bypass times could be achieved. We see a clearfuture domain of this valve in MIS surgery as well as in combinedprocedures with regard to the reduction of clamping time in conven-tional valve surgery. Nevertheless future follow up investigation has tobe awaited to gain more data concerning durability and safety issues.

OP155Early hemodynamic performance of thecomplete supraannular Trifecta aortic valvebioprosthesis - a single-center experience in aseries of 608 patientsDeutsch M.-A.1, Prinzing A.1, Badiu C.C.1, Elhmidi Y.1,Wottke M.1, Krane M.1, Voss B.1, Günzinger R.1, Lange R.11Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, München, Germany

Objectives: The St. Jude Medical Trifecta bioprosthesis is a new stentedtri-leaflet pericardial valve designed for supra-annular aortic valvereplacement (AVR) incorporating several design features including atrue supra-annular sewing cuff and a stent designed to maximize valvehemodynamics. The aim of the study was to evaluate the early clinicaloutcome and the hemodynamic performance in patients undergoingAVR with the Trifecta bioprosthesis at our institution. Methods: A totalof 608 consecutive patients with severe symptomatic aortic valvedisease (mean NYHA class 2.9 � 0.9) underwent AVR between January2009 and March 2013 with the implantation of the Trifecta aortic valveprosthesis. Mean age was 69.5 � 9.3 (range 18-88 years). 387 patientswere male and 221 were female (63.7/36.3%). Mean EuroSCOREwas 6.8� 2.9%. Procedures were as follows: Isolated AVR (n¼210/34.5%), with apartial upper mini-sternotomy used in 70% of cases. AVR with one ormore concomitant procedures (n¼398/65.5%): CABG (n¼219/55%),mitral valve repair/replacement (n¼55/13.8%), tricuspid valve repair/replacement (n¼34/8.5%). All intra- and postoperative data werecollected prospectively. At discharge, hemodynamic evaluation was

performed by means of transthoracic echocardiography in all patients.Results:Mean cross-clamp and CPB times were 85.6� 32.8 and 119.8�47.1 min. There were no intraoperative deaths. Mean hospital stay was11 days. The 30-day in-hospital mortality was 3.2%. Adjusted meansystolic pressure gradients (MPG) for valve sizes 19 (n¼28/4.6%), 21(n¼147/24.2%), 23 (n¼199/32.7%), 25 (n¼140/23.0%), 27 (n¼63/10.4%) and 29 mm (n¼30/4.9%), were 9.2 � 5.8, 10.8 � 4.2, 9.5 � 3.7,8.4 � 2.8, 7.9 � 2.6 and 5.4 � 1.6 mmHg, respectively. Mean effectiveorifice area (EOA) for valve sizes 19, 21, 23, 25, 27 and 29mmwere 1.6�0.4, 1.7 � 0.4, 1.9 � 0.4, 2.0 � 0.3, 2.3 � 0.4 and 2.8 � 0.6 cm2,respectively. Severe patient-prosthesis mismatch (EOAI<0.65 cm2/m2) occurred in 4.8% of patients, mild mismatch (EOAI<0.85 cm2/m2)was observed in 21.9% of patients. No prosthesis dislocation, endocar-ditis, valve thrombosis or relevant aortic regurgitation was observeduntil discharge. Conclusions: The initial experience with the Trifectavalve bioprosthesis shows good clinical outcomes with excellent earlyhemodynamic performance. Further studies with longer follow-up areneeded to confirm these promising preliminary results.

OP156First clinical results of aortic valve replacementwith decellularized aortic allografts in childrenand adultsTudorache I.1, Ciubotaru A.1, Horke A.1, Breymann T.1,Sarikouch S.1, Boethig D.1, Meschenmoser L.1, Cebotari S.1,Haverich A.11Department of Cardiac, Thoracic, Transplantation andVascular Surgery, Hannover Medical School, Hannover,Germany

Background: The use of fresh, non-seeded, decellularized valved allog-rafts shows promising results in replacement of the pulmonary valve.Here, we report about our initial clinical results of aortic valve replace-ment using decellularized aortic homografts (DAH) in children andadults. Methods and results: From February 2008 to May 2013, 28patients with a mean age of 23 years (range, 0.19 to 65) were prospec-tively assessed after aortic valve replacement using DAH. Mean timefrom homograft harvesting to implantation of DAH was 37 days (range,25 to 69). The mean DAH diameter was 21 mm (range, 10 to 27). Meanextracorporeal circulation and aortic cross-clamp timewas 211 and 120minutes respectively (range, 113 to 397 and 64 to 180) using DAH foraortic root replacement, including coronary transfer. There was oneearly, none conduit related, death (3,5%). Echocardiography and mag-netic resonance imaging were used for postoperative evaluation. Noneof the patients required re-intervention or conduit explantation so far.In two patients (7.41%) a moderate aortic valve insufficiency was seen,no severe valve stenosis was observed so far. No dilatation of the aorticroot was seen, however the follow up is short so far (39 years in total,mean 1.2 yrs., max. 5.3 yrs). Conclusion: The early results of DAH arepromising. DAHs satisfy the requirements of the systemic circulationand provide adequate hemodynamics. For selected patients, thereforeDAH appears as an interesting alternative to conventional other grafts.

OP157Hemodynamic behavior of stentless aorticvalves in long term follow-upChrist T.1, Grubitzsch H.1, Claus B.1, Konertz W.11Charité-Universitätsmedizin Berlin, Department ofCardiovascular Surgery, Berlin, Germany

Objectives: A retrospective long-term evaluation of aortic porcinestentless valves in patients�60 years and its impact on the left ventricle.Methods: 7 to 16 years after aortic valve replacement, 54 patients (meanage at operation 53.1 � 7.7 years) received echocardiography andclinical examination. Mean follow-up time was 10.8 � 2.2 years.Evaluated were gradients, left ventricular mass and function andNYHA class. Results: At follow-up only one patient presented withNYHA class III. All other patients were in NYHA class I or II. Maximumand mean pressure gradients of prostheses were 16.3 � 7.4 mmHg and9.1 � 4.2 mmHg, respectively. Compared to echocardiography at dis-charge mean pressure gradients dropped 18.0% (2.0 � 0.9 mmHg).During the study interval pressure gradients did not change


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significantly. Only 5 patients showed relevant insufficiencies (at 13-16years after valve replacement), 49 showed no or trivial insufficiencies.Left ventricular mass decreased 26.5% (107.9 � 18.5 g) and did notchange significantly during follow-up (Fig. 1). Left ventricular functionincreased in 17 patients and decreased in only one patient. For patientswith preoperatively impaired left ventricular function an increase of13.1 � 3.1% was seen (Fig. I).

Fig. 1: Left ventricular function and mass

Conclusion: Porcine stentless aortic valves provide excellent hemody-namic long-term results without significant rise of transvalvular pres-sure gradients until 14 years leading to sustained decrease of leftventricular mass and improvement of left ventricular function.

OP158Does the new 3D tricuspid ring improveoutcome after tricuspid valve reconstruction(TVR)?Felkel K.-W.1, Kubik M.1, Gulbins H.1, Reichenspurner H.1,Wagner F.M.11Universitäres Herzzentrum Hamburg, Herzchirurgie,Hamburg, Germany

Objectives:Due to anatomic considerations new 3 -dimensional shapedrings have been introduced clinically for tricuspid valve reconstruction(TVR). In this study we analyzed efficiency of such a ring compared toresults after reconstruction using a tricuspid annuloplasty ring.Material and methods: From January 2012 until September 2013 50patients underwent valve reconstruction due high grade functionaltricuspid insufficiency (TI). A 3D Contour ring (Medtronic) was used in20 patients (Gr.I; 50% male, age 70 � 9.8 years), a Physio Tricuspid ring(Edwards) in the remaining 30 (Gr.2; 56.7% male, age 70 � 8.2 years).Preoperative incidence of atrial fibrillation was similar in both groups(70% in Gr.1; 86.7% in Gr. 2). In Gr.1 TVRwas combinedwith mitral valvesurgery in 75%, isolated TVR performed in 25%, in Gr. 2 all pats. had TVRplus mitral valve surgery. Preoperative right ventricular function wassignificantly better in the Gr.2 (36% vs. 45%; p¼0.0209). AdditionalCABG, AVR and closure of ASD was performed in isolated pats. in bothgroups. Results: Preoperative mean TI was grade 3.0 � 0.56 in Gr.1compared to 2.6 � 0.66 in Gr.2 (p¼ns?). At hospital discharge TTErevealed no significant difference of mean TI grade between groups (0.6� 0.3 (95% Gr.0 or 1, 5% Gr.2) in Gr.1, 0.7 � 0.5 (80% Gr.0 or 1, 20%) inGr.2). RV function had significantly improved in Gr.1 with no moredifference compared to Gr.2. Concomitant atrial ablationwas performedsignificantly more often in Gr.2 (80.8% vs. 42.9% in Gr.1), however,incidence of permanent pacemaker implantation was comparable be-tween groups (50% vs. 52.4% in Gr.1 vs. 2). Length of hospital stay was11.3� 1.9 days in Gr.1, and 10.76� 0.9 in Gr.2, overall length of staywas10.6 � 6.5 days with no difference between groups. Overall in hospitalmortality was 4% with one death in each group. At discharge all patientsin Gr.1 were still in atrial fibrillation, while in Gr.2 33.3% showed sinusrhythm. Conclusion: Overall outcome in the 3D-Contour ring groupwasat least as good despite preoperative poorer RV function. Both tricuspidrings achieved satisfactory functional postoperative results after annu-

loplasty. Necessity of postoperative pacemaker implantation seems highafter TVR independent of ring design. Main limitation is short termfollow up, however, longer term follow up data are currently beingcollected.


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Heart valve disease V: Aortic valve repair - Durability after aorticvalve replacement

OP159Phenotype of bicuspid aortic valve andmanagement of the ascending aorta in 1362patientsSievers H.-H.1, Stierle U.1, Hanke T.1, Klotz S.1, Schmidtke C.1,Charitos E.11Klinik für Herzchirurgie, UKSH, Campus, Lübeck, Germany

Objective: Themanagement of the ascending aorta (AA) in patientswithbicuspid aortic valve (BAV) undergoing valve surgery remains contro-versial. We analyzed our multifactorial, individualized approach to theAA during aortic valve surgery with special focus on BAV phenotypes.Methods: 1362 patients (1044 male) with surgically classified BAVundergoing valve surgery were retrospectively analyzed. Mean followup was 5.8 � 3.6 years (7977 patient-years). Our AA managementstrategy was based mainly on the diameter of the AA, age, body surfacearea and the perceived thickness and fragility of the aortic wall andresulted in three groups: no intervention, aortoplasty and AA replace-ment. Results: 33.5% of patients had AA intervention (284 replacementsand 172 aortoplasties). Hospital mortality was 0.4% in the interventiongroup and 1.1% in the no intervention group (p¼0.2). At 10 years latesurvival was similar to the general population for all three groups.Reoperation rates on the AA were low (n¼4 in no intervention group,n¼1 in aortoplasty group). BAV type 2/unicuspid were younger atoperation and had significantly more interventions on the AA at thesame diameter. BAV type 1 LR with valve insufficiency had morefrequently AA replacements. Conclusion: Individualized multifactorialdecision making for the management of the AA in BAV patients duringvalve surgery leads to a more aggressive approach with excellentmidterm results. BAV type 2/unicuspid and BAV type 1 LR with valveinsufficiency may be associated with a more malignant form of AAdisease and may warrant a more aggressive approach.

OP160David I valve-sparing aortic root replacement -impact of graft size and aortic downsizing onmitral valve functionKari F.A.1, Beyersdorf F.1, Stephens E.H.2, Schmidt K.1, RusseM.3, Blanke P.3, Rylski B.1, Siepe M.11Heart Center Freiburg University, Cardiovascular Surgery,Freiburg, Germany, 2Columbia University New York,Cardiothoracic Surgery, New York City, United States,3University Hospital Freiburg, Diagnostic Radiology,Freiburg, Germany

Objective: The choice of graft-size and the extent of annular/ aortic rootdimension-reduction during the David I valve-sparing aortic rootreplacement (V-SARR) procedure might have an impact on postopera-tive subvalvular membrane and anterior mitral geometry, potentiallyleading to mitral regurgitation (MI). Methods: Choice of graft size wasdetermined intraoperatively and mid-term follow-up TEE (mean 449days, 74 - 1427 days) was analyzedwith respect tomitral valve function.Linear and logistic regressionmodels and LogRank tests were calculatedfor valvular endpoints freedom fromMI>2þ, freedom fromMI>1þ andfreedom from newMI orMI progression. Results: 102 patients (69male,age 47 � 19, 7 to 77 years) underwent the David I procedure between2003 and 2012 (n¼93 aortic root and/or ascending aortic aneurysm,n¼9 Type A dissection). Mid-term freedom from MI >2þ was 95%(n¼97), freedom fromMI>1þwas 82% (n¼84) and freedom from newMI or MI progression was 84% (n¼86). Root prosthesis size was 28 � 4mm (24-32 mm). Aortic downsizing was from 54 � 8 mm by 26.2 � 6mm to 28� 4mm.MI>2þ at mid-term follow upwas associated with agreater degree of aortic downsizing (p¼0.023). Large aneurysm sizemight be associated with MI>2þ accordingly (p¼0.077). Conclusion:Excess aortic root/annular downsizing during David I V-SARRmight leadto distortion of the relative proportions of the posterior aortic annulus,subaortic curtain and subvalvular membrane, and thus lead to anteriormitral leaflet dysfunction. This finding supports V-SARR variants using a

larger proximal aortic graft to avoid excess downsizing while stillachieving aortic annular fixation in selected patients.

OP161Aortic leaflet interventions for aortic valverepair: How much is too much?Charitos E.1, Stierle U.1, Karluß A.1, Misfeld M.1, Hanke T.1,Klotz S.1, Sievers H.-H.11Klinik für Herzchirurgie, UKSH, Campus, Lübeck, Germany

Objectives: Aortic valve repair (AVR) is an attractive alternative to valvereplacement. We present our single center experience and lessons withisolated aortic leaflet interventions in 158 patients undergoing aorticvalve repair. Methods: Between 1993-2010, 158 patients (127 female;51 � 18 years; mean follow-up:6.5 � 3.4;range 0-18; median:6.4years;1020 patient*years) underwent isolated aortic leaflet interven-tions for AVR. Completeness of clinical follow-up was 96%. Results: 30-daymortality was 0.6%. Late survival was similar to the general Germanpopulation (p¼0.1). The number of interventions required to restorevalve function (repair score) significantly affected the durability and theincidence of reoperations (hazard ratio:1.47; 95%CI:1.1-2.0; p¼0.01)with the risk for failure being higher early after the operation. Freedomfrom reoperation at 6 years in patients who underwent <3, 3-4, and�5leaflet interventions was 95.1%, 85.4% and 77.4% respectively. Similarly,freedom from reoperation or aortic regurgitation grade II or more at 6years in patients who underwent <3, 3-4, and �5 leaflet interventionswas 91.2%, 71.6% and 46.4% respectively. Conclusion: Pathologies re-quiring multiple leaflet interventions and repair techniques may lead tosuboptimal results and should be considered with caution. Leafletquality and leaflet-adjusted root stabilization/reconstruction are keyelements for durable results.

OP162Incidence and progression of mild aorticregurgitation after the David I procedureKari F.A.1, Siepe M.1, Stephens E.H.2, Schmidt K.1, Russe M.3,Blanke P.3, Rylski B.1, Beyersdorf F.11Heart Center Freiburg University, Cardiovascular Surgery,Freiburg, Germany, 2Columbia University New York,Cardiothoracic Surgery, New York City, United States,3University Hospital Freiburg, Diagnostic Radiology,Freiburg, Germany

Background:Mild aortic regurgitation (AR) and progression of ARmightbe a significant hazard after David I valve-sparing aortic root replace-ment (V-SARR) and potentially results in the need for reoperation.Methods: Mid-term follow-up TTE (mean 449 days, 74 - 1427 days)was analyzed after David I V-SARR. Multivariable logistic and linearregression analysis and LogRank tests were calculated to identifyindependent risk factors for AR progression and to analyze comparativeevent free survival. Valvular endpoints were freedom from AR 2þ,freedom from AI Rþ and freedom from new onset AR or AR progressionover time. Results: Between 2003 and 2012, 102 patients (69 male, age47 � 19, 7 to 77 years) underwent the David I procedure (n¼93 aorticroot and/or ascending aortic aneurysm, n¼9 Type A dissection, n¼53Marfan). Median preoperative AR was 1þ to 2þ, n¼36 patients (35%)had preoperative AR�1þ and n¼ 12 patients (12%) preoperativeAR�3þ, while no patients with AI>3þ were elected for David V-SARR. AR was reduced from a preoperative median of 1-2þ to a medianof 0-1þ before discharge (p<0.001). Freedom from AR 2þwas 78% andfrom AR progression 60% at 2 years. Most patients progressed subclini-cally from no to trivial or minimal AR. Severe AR>3þ occurred in 4patients, leading to reoperation and mechanical valve replacement inthree cases. Aneurysm size and aortic downsizing were not linked tohigher incidence of mild AR (all p>0.5). Connective tissue disorder andacute type A dissection were linked to higher rates of AR progression(p¼0.043). Conclusion: The incidence of subclinical progressing AR isconsiderable after the David procedure. It might be linked to connective-tissue disorders and Type A dissection and its impact on clinical long-term outcome still has to be clarified.


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OP163The Medtronic Mosaic Prosthesis: Clinicalperformance up to 18 yearsCramer E.1, Wahl G.1, Kremer P.1, Rieß F.-C.11Albertinen-Krankenhaus, Hamburg, Germany

Objectives: The MOSAIC bioprosthesis is a third generation stentedporcine bioprosthesis, built upon the historical durability of the HAN-COCK-II bioprosthesis. The MOSAIC Aortic and Mitral bioprostheses arepreserved in buffered 0.2% glutaraldehyde in a zero pressure procedureand they are treated with the AOA (amino oleic acid) antimineralisationprocess, to improve hemodynamic performance and durability.Methods: The Mosaic post-approval long-term trial is prospectiveand non-randomized. Between 02/1994 and 10/1999 we enrolled 255patients with AVR (mean age 67 years, range 23-82 years) and 47patients with MVR (mean age 66.8 years, range 41-84 years). Thecumulative follow-up is 2062.9 patient-years (pt-yrs) for AVR and361.4 pt-yrs for MVR. Patients are followed yearly and have undergoneserial echocardiographic assessment. Results: For AVR and MVR, latemortality was 3.1% and 3.6% per pt-yr, including a valve-related/unex-plained mortality of 1.0% and 0.8% per pt-yr. The mean gradient acrossall valve sizes remained stable over the years. Freedom from structuralvalve deterioration at 18 years was in the AVR group 65.9� 27.2% and at17 years in the MVR group it was 90.0 � 28.5%. Conclusions: Our long-term results demonstrate clinical safety and excellent performance ofthe MOSAIC bioprosthesis. Interestingly freedom from SVD was higherin the MVR group compared to the AVR group.

OP164Acute decompensated aortic and mitral valvedisease: Short and long-term operativeoutcomesLeontyev S.1, Davierwala P.1, Misfeld M.1, Bakhtiary F.1,Holzhey D.1, Röhrig K.1, Borger M.A.1, Mohr F.W.11Herzzentrum Leipzig, Herzchirurgie, Leipzig, Germany

Objective: Early and late outcomes in patients undergoing surgery foracute decompensated aortic or mitral valve disease (ADVD) are not welldescribed. The aim of this study was to evaluate the early and long-termresults after surgical treatment of patients with ADVD. Methods:Between 04/95 and 06/10, 1042 patients underwent surgery forADVD in our institution. Acute decompensation was defined as patientspresenting with dyspnoea or tachycardiawith pulmonary congestion oroedema, and/or cardiogenic shock. Mean age was 64 � 14 years; 37.7%were female. On admission, 17% of patients were in cardiogenic shock,27% required inotropic support, and 11% were intubated. Eight percentof patients required cardiopulmonary resuscitation (CPR) prior tosurgery. Acute endocarditis was the primary indication for surgery in66% of patients. All patients underwent urgent (22%) or emergent (78%)surgery. Multivariate logistic and Cox regression analyses identified thepredictors of 30-day and late mortality, respectively. Results: Overall30-day mortality was 18.6%. Multivariate analysis identified preopera-tive cardiogenic shock (Odds ratio [OR]: 2.3; p<0.001 95% CI:1.6-3.6),preoperative inotrope use (OR:1.8; p¼0.002 95% CI :1.2-2.6), CPR (OR:2.3; p¼0.002, 95% CI: 1.4 - 4.2), preoperative dialysis (OR: 2.8; p¼0.00395% CI : 1.4 - 5.6) and coronary artery disease (OR: 1.8; p¼0.01; 95% CI:1.1 - 2.9). Cox regression analysis revealed age, diabetes, COPD, NYHAclass IV, active endocarditis, peripheral vascular disease, and preopera-tive dialysis to be independent predictors of long-term mortality, inaddition to the perioperative predictors listed above. Mean survival at 5and 10 years was 53 � 1% and 32 � 2%, respectively with an estimatedmean survival of 6.4 � 0.2 years. Conclusions: Surgery for ADVD isassociated with a relatively high early mortality rate, but satisfactorylong-term survial. Preoperative inotrope use, cardiogenic shock, CPR,coronary artery disease and previous cardiac surgery predict both 30-day and long-term mortality.

OP165Trends in surgical aortic valve replacementusing biological xenografts in more than 3000consecutive cases in the TAVI eraSilaschi M.1, Conradi L.1, Treede H.1, Reichenspurner H.11Universitäres Herzzentrum Hamburg, Klinik undPoliklinik für Herz- und Gefäßchirurgie, Hamburg,Germany

Objectives: Biological xenografts for aortic valve replacement (AVR) areincreasingly being considered even in younger patients <60 years ofage. Likely, preserving the option of performing a subsequent trans-catheter valve-in-valve procedure in cases of structural valve deteriora-tion has contributed to this development. We sought to assess thepattern of use of biological xenografts for AVR at our center over aneleven year period. Methods: From 2002 through 2012 a total of 3010patients received surgical AVR using biological prostheses either as anisolated or combined surgical procedure. Patients receiving mechanicalvalves and cases of acute endocarditis were excluded from analysis.Results: Mean age of all included patients was 70.4 � 10.6 years with38.3% female. From 2002 to 2012, mean valve size as specified by themanufacturers increased from 22.8 � 1.7 mm to 23.9 � 2.0 mm(p<0.001). The proportion of small valve sizes (�21 mm) decreasedsignificantly from 27.7% to 19.0%, while use of larger sizes (� 25 mm)increased significantly from 17.7% to 47.4% (p<0.001 respectively).Throughout the study period, the most commonly used single valve sizewas 23 mm even though the proportion significantly decreased inrecent years from 53.8% in 2002 to 33.4% in 2012 (p<0.001). Patients<60 years received significantly larger valves compared to patients�60years (mean valve size 24.3 � 0.1 mm vs. 23.3 � 0.1 mm, p<0.001)throughout the study period and differences in mean valve size weresimilar in all single years. Conclusion: During the last 11 years, aprofound change of use pattern in biological AVR was observed at ourcenter with significantly larger prostheses being implanted. Especiallyin younger patients optimal sizing is essential to ensure optimalhemodynamic performance and to preserve the option for subsequentvalve-in-valve procedures.

Heart and lung failure IV

OP166Cable design improvements and sintering of theinflowcannula in continuousflowLVADs reducethe occurrence of life-threatening pump stopsSoltani S.1, Kaufmann F.2, Vierecke J.2, Kretzschmar A.2,Henning E.2, Stein J.2, Krabatsch T.2, Hetzer R.2, Potapov E.V.21Deutsches Herzzentrum Berlin, Kardiochirurgie, Berlin,Germany, 2Deutsches Herzzentrum Berlin, Berlin, Germany

Objectives: Implantable continuous flow (CF) left ventricular assistdevices (LVAD) are a routine treatment for end-stage heart failure. CFLVAD type HeartMate II (HM II) and HeartWare HVAD (HW) underwentdesign changes after initial clinical experience. It is still uncertainwhether design improvements will prevent the occurrence of life-threatening pump stops. Methods: Retrospective analyses of pumpstops due to thrombosis or cable damage, which led to emergencypump exchange, explantation, heart transplant or death in patientssupported with HM II and HW, separated into patients supported withthe old and the improved design. Results: Overall 176 patients weresupported with 179 HM II (123 old and 56 new cable strain relief) and287 patients with HW (156 with non-sintered and 131 with sinteredinflow cannula). There were 241.8 cumulative years of HM II and 257.3years of HW support. The cumulative rate of events was 0.099 patient-years in HM II patients, compared to 0.1 patient-years in HW patients(p¼0.947). Since the last major changes in the pump design (improve-ment in strain relief in HM II in 2010 and titanium sintering of the inflowcannula of HW in 2011), the incidence of cable damage in HM II patientsdropped from 0.066 to 0 (p¼0.029) in the first two years, and pumpthrombosis in HW from 0.098 to 0.063 per patient-years (p¼0.269).Cable damage (n¼15) in “old” HM II pumps occurred in 9 patientsbeyond two years of support. Kaplan-Meier analysis showed no differ-ences for up to 2 years for pump thrombosis when the entire HM II


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cohort was comparedwith sintered modification of the HW (p¼0.519).Similarly, when we compared the HM II with the new cable designagainst the entire HW cohort (p¼0.445). There are no differences forroutine infection parameters and anticoagulation status in patientswithand without pump thrombosis. Conclusion: In mid-term follow up,recent modifications of both pumps demonstrated a significant de-crease in the incidence of life-threatening pump-related complications.Pump thrombosis was not associated with infection or low anticoagu-lation status.

OP167The effects of xenon and sevoflurane anesthesiaon perioperative release of macrophagemigration inhibitory factor (MIF), stromal cell-derived factor 1α (SDF-1α) and recruitment ofimmune cells in cardiac surgical patients in arandomized controlled trialEmontzpohl C.1, Stoppe C.12, Goetzenich A.3, Kraemer S.13,Bernhagen J.1, Autschbach R.31Uniklinik RWTH Aachen, Institut für Biochemie undmolekulare Zellbiologie, Aachen, Germany, 2UniklinikRWTH Aachen, Klinik für Anästhesiologie, Aachen,Germany, 3Uniklinik RWTH Aachen, Klinik für Thorax-,Herz- und Gefäß-Chirurgie, Aachen, Germany

Introduction: An increasing body of evidence suggests inhalative anes-thetics like sevoflurane to trigger a cytokine release with influence onthe immune reaction. Only little is known about the anesthetic xenonand its influence on cytokine release of macrophage migration inhibi-tory factor (MIF) and stromal cell-derived factor 1α (SDF-1α), which areknown tomediate themigration of immune- and endothelial progenitorcells (EPC). Our aim was to compare the influence of two anesthetics(xenon vs. sevoflurane) on the secretion of the cytokines macrophagemigration inhibitory factor (MIF) and stromal cell-derived factor 1α(SDF-1α) in patients that underwent cardiac surgery.Methods: Twentypatients undergoing elective coronary artery bypass grafting wereenrolled in this randomized, single blind controlled trial. Patientswere randomized to receive balanced general anesthesia with eitherxenon (45-50 vol%) or sevoflurane (1-1.4 vol%). Subsequently, sand-wich-ELISAs were performed to measure the serum levels of thecytokines MIF and SDF-1α at three different time points: pre-operative(baseline value), intra-operative (2 min after opening of cross-clamp¼onset of reperfusion) and post-operative (24 h after admission to ICU).The migration of immune cells (peripheral blood mononuclear cells)was measured by a chemotaxis assay with the sera as chemoattractant.Results:We found an intra-operative increase for both cytokines in bothgroups. There was no difference in the intra-operative MIF secretionbetween xenon and the sevoflurane group. Patients in the xenon groupshowed a significant higher SDF-1α concentration compared to sevo-flurane (851 pg/ml vs 475 pg/ml, p<0.05). Accordingly the migration ofPBMCs indicated a higher migration towards sera in the xenon group(p¼0.112). This difference decreased post-operatively, but still showeda strong trend (938 pg/ml vs 662 pg/ml, p¼0.054). Discussion: Xenonanesthesia leads to a moderately inflammatory response in cardiacsurgical patients that is comparable to the well-established anestheticsevoflurane. Present results showed significantly elevated SDF-1α levelsin the xenon group, which was associated with an enhanced migrationof PBMCs. Given the role of SDF-1α as potent chemokine, further studiesare needed to investigate the influence of xenon (and other anesthetics)on the migration of other immune cells and the resulting effects onoutcome of patients.

OP168Apical compression stitch in patients withfailing left ventricles: A new option for surgicalremodelling techniqueMonsefi N.1, Zierer A.1, Serio D.1, Miskovic A.1, Dzemali O.2,Kleine P.1, Moritz A.11Klinikum der Goethe-Universität, Thorax-, Herz- undthorakale Gefäßchirurgie, Frankfurt a.M., Germany,2Herzzentrum Triemli, Herzchirurgie, Zürich, Switzerland

Objectives: The apical compression stitch is a surgical option forpatients with dilated cardiomyopathy to preserve the geometry of theleft ventricle. We present our mid-term results of a prospective ran-domized trial. Methods: In 26 randomized patients (mean age 65 � 8)with impaired left ventricular ejection fraction (EF) mean 25 � 8%undergoing coronary artery bypass grafting (CABG) left ventricular (LV)geometry was evaluated by MRI (Magnetic Resonance Imaging) scan-ning before, after surgery and at follow up (FU). 81% of the patients werein New York Heart Association (NYHA) functional class 3 and 19% inNYHA 4 preoperatively. Seattle heart failuremodel estimated amean lifeexpectancy of 8.71� 2 years. In 12 patients the apical compression stitchwas additionally performed with special U-stitches. We compared theapical compression group (ACG) with the non ACG. Results: We couldobserve an improvement of the LVEF in the followup (50� 6% in the ACGversus 40 � 7% in the non ACG). The LVEF difference between preopera-tive to follow up was significantly higher in the ACG (p¼0.015). 71% ofthe patients were in NYHA class 1, 25% in NYHA class 2 and 4% in NYHAclass 3. Two patients died in the FU; one because of bowel cancer, theother one because of ischemia of the bowel.Mean follow up timewas 4.5� 2 years. Conclusion: Spherical distension of the left ventriculardimensions causes cardiac decompensation. After compression of theapex ventricular function and clinical status improve. Patients withimpaired LV function and apical dilatation benefit from this new surgicalremodelling technique.

OP169HeartWare left ventricular assist device:Outcome in high risk INTERMACS I patientsSaeed D.1, Albert A.1, Maxhera B.1, Westenfeld R.1, BoekenU.1, Lichtenberg A.11Düsseldorf University Hospital, Düsseldorf, Germany

Objectives: Because of the increasing number of heart failure patientsand the limited supply of donor hearts, a remarkable increase in thenumber of ventricular assist device (VAD) implantation is observedworldwide.We present our experiencewith the HeartWare VAD (Heart-Ware, Framingham, MA) and its clinical outcome in critically sickINTERMACS I patients. Methods: The clinical outcome of HeartWareVAD implantations for end-stage heart failure patients performed atsingle institution from January 2010 to September 2013 was studied.Inclusion criteria were patients with preoperative INTERMACS I. Thestudy design was a retrospective review of the prospectively collecteddata. Results: A total of forty-nine HeartWare pumpe were implanted.The inclusion criteria were met by 24 patients with a mean age of 52 �11 years. Nineteen patients were male (79%). Eighteen patients (75%)were on extracorporeal life support with a mean support of 5 � 5 daysprior toVAD implantation. Themean duration of VAD support was 135�136 days. Seven patients (29%) were successfully bridged to hearttransplantation. The survival to 1 year and/or heart transplantationwas 75%. A trend toward lower survival was observed in patients withpreoperatice ECMO support (p¼0.13) (Fig. 1). Postoperative complica-tions included right heart failure in 13 patients (54%), 5 reoperatation forbleeding (21%), 4 neurologic dysfunctions (17%), 16 respiratory failures(67%), 2 driveline infections (8%), and 1 hepatic dysfunctions (4%).


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Fig. 1

Conclusions: Considering the sick patient population included in thisstudy, the outcome following HeartWare VAD implantation is verysatisfactory with overall survival to 1 year and/or transplantation of75%. More bleeding, right ventricular and respiratory failure complica-tions were observed compared to elective implantations. HeartWareVAD is a reliable device and an outstanding outcome can be achievedeven in INTERMACS I population.

OP170A gender specific point of view on combinedfunctional mitral valve surgery and coronaryartery bypass grafting in patients with severeimpaired left ventriclesKluttig R.1, Garbade J.1, Matz L.1, Eifert S.1, Merk D.1, BorgerM.1, Mohr F.W.11Herzzentrum Leipzig, Leipzig, Germany

Background: The goal of this study was to analyze the gender specificoutcome of functional mitral valve (MV) pathology and concomitantcoronary arterial bypass graft (CABG) in patients with severe ischemiccardiomyopathy. Methods: Within the last decade 377 patients withsevere functionalMVpathology and systolic dysfunction underwentMVsurgery combinedwith CABG. 286 (76.1%) weremale patients at a meanage of 64.6� 9.1 years and 91 (23.9%) patientswere female at amean ageof 70.3 � 8.1 years. Mean ejection fraction was 25.1� 6.0 for female and24.0� 6.3 formale patients. Gender specific pre-operative and operativedata, 30-day mortality, long-term outcome and complications wereretrospectively gathered. Follow-upwasmadewith amean time span of43.7 months (range 0-350). Results: For the female population was themean logistic EuroSCOREwas 25.2. versus 16.6. for male. Preoperatively25.3% female vs 17.1% male were in cardiac shock, 14.3% vs 11.5% wereoperated on as an emergency and 9.9% vs 8.4% needed an IABPpreoperatively. Operation-, bypass- and cross clamp time was 236.4 �77.6, 134.9 � 47.1 and 80.6 � 28.4 minutes respectively (with nosignificant gender specific difference). MV repair could be done in88% of all patients (female 86.8% and male 89.2%). Of the 43 patientswith MV replacement (13.2% female vs 10.5% male), 9.9% female vs 7.3%male received a biological and 3.3% female vs 3.5% male a mechanicalvalve. Postoperatively 19.8% of the female patients vs 21.7%male neededan IABP and 4.4% vs 2.8% were obtainedwith an ECMO. 30 daymortalitywas 18.7% for female and 10.8% for male with a follow up of 99.5%. Longterm mortality for female versus male at 1, 5 and 10 years was 36.6//21.4%, 53.7/42.2% and 80.7/67.1% respectively. MV-related reoperationrate was 3.1 (2.2% female vs 3.5% male). MV replacement was done in2.8% vs and MV repair in 0% vs 0.7% with a mean postoperativereoperation time of 473 and 75 days respectively. Conclusions: Consid-ering the impaired LV function and the clinical scenario of thesepatients, we could show that our female population was significantlyolder and even more critically sick which could explain the better shortand long term outcome of male patients.

OP171Dectection of early thrombus formation in LVADby accoustic fast fourier transformation (FFT)analysis. A novel approach for monitoringvon Samson-Himmelstjerna P.1, Meyer A.1, Müller T.1,Zießnitz N.1, Garbade J.1, Lehmann S.1, Mohr F.-W.1, StrüberM.11Herzzentrum Leipzig - Universitätsklinik, Herzchirurgie,Leipzig, Germany

Objectives: Assist devices are an essential option in treatment ofadvanced heart failure. Despite all technical improvements, pumpthrombosis is a severe complication and only indirect diagnostic toolsare available. Rotation of the VAD impeller creates a specific soundpattern, that can be recorded and analyzed. In this pilot study, werecorded accoustic patterns of the HVAD (HeartWare Inc) assist deviceand analyzed the sound files to detect early thrombus formation.Methods: From May to August 2013 we recorded 53 sound files. 3patients were suspicous for thrombus formation by clinical symptomsand lab results. Sounds were recorded with an eletronic stethoscope(Littmann 3200) and analyzed with Reaper (Cockos Inc), a software forDigital Audio Workstations including Fast Fourier Transformation (FFT)analysis. To get a baseline of regular background noise, patients withoutan assist device were analyzed prior to the pilot study. Recordings weremade in a supine position at clinical pump speed (2700-2960 rpm).Results: Accoustic profiles were obtainable from all patients. Baselineanalysis of patients without assist device revealed a frequency spectrumwithout spectral peaks, ranging from 10 to 730 Hz. FFT showed specificspectral peaks for HVAD patients at 180, 370, and 560 Hz. Accousticpatterns were related to LVAD parameters speed (RPM), power (Watt),and flow (l/min) as well as lab results. Patients suspcious for thrombusformation had identical peaks, but increased accoustic pressure forhigher and particularly lower frequencies (>300 Hz and <180 Hz).Conclusion: This pilot study shows, that atypical FFT spectral peaks arelikely associated with thrombus formation in HVAD patients. Recordingand analysis can be easily performed and implemented in daily routine.FFT analysis can become a powerful tool to detect early thrombusformation. Further studies are requiered to confirm the results of thispilot study and extend this procedere to other assit devices.

Fig. 1: LVAD sound analysis

OP172Implications of fast recovery after leftventricular assist devices implantationSchibilsky D.1, Soliman A.2, Cordero-Reyes A.M.2, Bellera R.2,Haller C.1, Schlensak C.1, Estep J.D.2, Loebe M.21University Medical Center Tuebingen, Thoracic andCardiovascular Surgery, Tuebingen, Germany, 2TheMethodist Hospital, Methodist DeBakey Heart & VascularCenter, Houston, United States

Objectives: The treatment of advanced heart failure patients usingcontinuous-flow left ventricular assist devices (CF-LVAD) has becomean established therapy with low mortality and morbidity. However thecritically ill patients often require long intensive care and recoveryperiods. We sought to identify determinants of shorter recovery afterLVAD implantation. Methods: 158 patients undergoing primary CF-LVAD implantation were consecutively included in a retrospectiveanalysis regarding time of recovery after implantation. An ICU stay


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�7 days and a total hospitalization�30 dayswere defined as “fast-track”(21 patients) and compared to the remaining patients. Results: Themedian support duration was 465.1 (� 396.5) days. The patients in thefast-track group were younger (54 vs. 59, p¼0.044), had lower pre-implant creatinine values (1.0 vs. 1.3, p¼0.006) and spent less inpatientdays prior to implantation (7 vs. 11, p<0.001). No difference wasobserved regarding preoperative liver function (AST: 45 vs. 48,p¼0.715; total bilirubin: 1.1 vs. 1.4, p¼0.217) and weight (195.5 vs.196.3, P¼0.923). At time of admission end-organ function (creatinine:1.1 vs. 1.4, p¼ 0.107; AST: 51 vs. 54, p¼ 0.948) did not differ. The overallsurvival of the fast-track patients was favorable compared to the controlgroup (HR: 4.18 (95%CI:1.27 - 4.77).

Fig. 1

Conclusion: Heart failure patients with fast-track recovery after CF-LVAD implantation had a favorable long-term outcome. At time ofimplantation fast-track patients were younger, had lower creatininelevels and a shorter hospitalization prior to implantation. As end-organfunctions at time of admission were indifferent an early implantstrategy may beneficially affect post LVAD morbidity and mortality.

Extracorporeal circulation and myocardial protection II

OP173Circulatory support exceeding five years with acontinuous-flow left ventricular assist device.Identification of positive predicators for asuccessful long-time VAD therapyHanke J.S.1, Rojas-Hernandez S.V.1, Avsar M.1, Malehsa D.1,Haverich A.1, Schmitto J.D.11Medizinische Hochschule Hannover, Herz-, Thorax-,Gefäß- und Transplantationschirurgie, Hannover, Germany

Objective: Continuous-flow left ventricular assist devices (CF-LVAD) arenowallowing for years of safe circulatory support with enhanced qualityof life. Our aim was to identify positive predicators for a successfullongtime VAD therapy. Methods: We analysed retrospectively the dataof our patients with end-stage cardiac failure based on dilative andischemic cardiomyopathywhowere on LVAD support for more than fiveyears. Results: One patient continues with support at 7 years and 5months and has decided to not undergo transplant. The two otherpatients have undergone heart transplant after support times of 5-yearsand 7 months and 5 years and 9 months. Few complications occurredand the patients had very active lifestyles during support. Explantanalysis revealed very low bearing wear and minimal pannus. Wewere able to identify positive predicators for a successful long-timeVAD therapy. Regular Monitoring of patients, increased compliance, lowamount of infections, active lifestyle and well trained patients contrib-ute to a long time durability of VAD therapy. Conclusion: LVADs havegood clinical durability to over 5 years to provide long-term hemody-namic support options for patients with advanced heart failure. Com-prehensive patient education, Patient compliance and carefulmonitoring for all adverse events are important contributions to safelong-term support.

OP174Cardiopulmonary bypass in a mouse: novelsmall animal modelMadrahimov N.1, Cebotari S.1, Solovyeva A.2, Knoefel A.K.1,Hoeffler C.1, Warnecke G.1, Tudorache I.1, Haverich A.11HannoverMedical School, Dept. of Cardiovascular, Thorax-and Transplantation Surgery, Hannover, Germany,2Institute of Biomedical Problems, Moscow, RussianFederation

Introduction: In contrast to rat, mice offer the possibility of usinggenetically modified animals suffering from cardiomyopathy, coronarydiseases, aortic aneurism, cystic fibrosis, pulmonary hypertony, more-over, a much brighter spectrum of mouse antibodies and reagents areavailable on the market. We describe a novel small animal model ofcardiopulmonary bypass in mouse suited to answer many pathophysi-ological questions in an accelerated and inexpensive fashion. Methods:Experimental design involved establishment of low flow peristalticpump, micro-cannulation tubing and micro-oxygenator. Self-rebuiltperistaltic pump provided flow of 2-7 ml/min, polyethylene tubingwere from 0,36 to 0,5 mm. Micro-oxygenator had a 300 microliterchamber and incapacitating 6 hollow polypropylene fibers able toconduct oxygen at 0,5 L/min. Reservoir consisted of 2 ml chamberwith 2 inflow and 1 outflow micro connections. After the intubation,arterial inflow was connected via left common carotid artery andvenous outflow was drained through right jugular vein. For visualmonitoring median sternotomy was used. Priming consisted of 0,5 mlof HES and 1 ml of Ringer solution. Cardioplegia was done using St.Thomas solution given through carotid artery after clamping of de-scending aorta and pouring cold saline drops on a heart. At the end ofexperiment, all animals were sacrificed under isoflurane anesthesia.Results: Novel model of CPB provided sufficient circulation and oxy-genation in 5miceweighing 25 to 30 g. In all acute experiments inotropemedications were avoided. Mean arterial pressurewasmaintained at 50to 70 mmHg. Maximal HLM time used was 1 h, cardioplegia time usedwas 10 min and artificial apnoe was limited to 30 min. CPB had shownfully stable hemodynamic parameters proven on invasive blood pres-sure monitoring. BGA performed in every 10 min of experimentdemonstrated sufficient arterial and venous gas parameters comparableto the rat model. In 2 min after reperfusion heart-beat recovery wasdocumented. Conclusion: We have developed a new mouse model ofCPB that provides stable and reproducible haemodynamic and respira-tory parameters correlating to data reported for rat CPB‘s. The next stepsinvolve establishing of chronical models of knock out/in mouse CPB forclinically relevant surgical interventions and studies. Such models ofclinical relevant diseases carry an indispensable value and offer a hugenumber of benefits for animal research.

OP175Bispectral index-guided titration of sevofluraneduring on-pump cardiac surgery reducessevoflurane plasma concentration andvasopressor requirementsNitzschke R.1, Wilgusch J.1, Haas S.1, Trepte C.1, Goetz A.E.1,Reichenspurner H.2, Reuter D.A.1, Goepfert M.S.11Zentrum für Anästhesiologie und IntensivmedizinHamburg, Klinik und Poliklinik für Anästhesiologie,Hamburg, Germany, 2Universitäres HerzzentrumHamburg/ Eppendorf, Klinik und Poliklinik für Herz- undGefäßchirurgie, Hamburg, Germany

Background: During cardiopulmonary bypass it is a challenge for theattending anesthesiologist to find the optimal dosage of anestheticsbecause the commonly used parameters endtidal anesthetic gas con-centration or other vital signs indicating depth of anesthesia are notusable. Overdosage of anesthetics may be corelated with impairedoutcome (1), while insufficient depth of anesthesia results in intra-operative awareness. Electroencephalographic-based monitoring sys-tems such as the bispectral index (BIS) may reduce anaesthetic overdoserates and ensure sufficient depth of anesthesia. We hypothesized thatgoal-directed sevoflurane administration (guided by BIS monitoring)could reduce the sevoflurane plasma concentration (SPC) and intra-operative vasopressor doses during on-pump cardiac surgery.Methods:


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This single-center, prospective, controlled, sequential, 2-arm studyincluded 60 elective on-pump cardiac surgery patients. In groupSevo1.8 Vol% (n¼29), the sedation depthwasmaintainedwith a sustainedinspiratory concentration of sevoflurane 1.8 Vol% before and duringcardiopulmonary bypass (CPB). In group SevoBIS (n¼31), the adminis-tered sevoflurane concentration was titrated to maintain a BIS targetbetween 40 and 60. Results: Mean inspiratory sevoflurane concentra-tion was 0.8 Vol% in group SevoBIS, representing a 57.1% reduction (p<0.001) compared to group Sevo1.8 Vol%. The mean SPC was 42.3 µg/ml(95% CI, 40.0-44.6) in group Sevo1.8 Vol% and 21.0 µg/ml (95% CI, 18.8-23.3, p <0.001) in group SevoBIS, representing a 50.2% reduction (p<0.001). During CPB, the mean cumulative dose of norepinephrineadministeredwas 13.48 µg/kg (95% CI, 10.52-17.19) in group Sevo1.8 Vol%

and 4.06 µg/kg (95% CI, 2.67-5.97, p <0.001) in group SevoBIS. Pearson'scorrelation between the cumulative applied dosage of sevofluranecalculated from the area under the curve of the SPC over time andthe administered cumulated norepinephrine dose was 0.607 (p<0.001). No signs of intraoperative awareness were detected in anypatient during the study protocol. Conclusions: BIS-guided sevofluranetitration lowers the SPC and reduces norepinephrine requirementscompared to routine care during on-pump cardiac surgery.Reference: (1) Kertai MD, Pal N, Palanca BJ, et al. Association ofperioperative risk factors and cumulative duration of low bispectralindex with intermediate-term mortality after cardiac surgery in the B-Unaware Trial. Anesthesiology 2010;112:1116-27.

OP176Miniaturization of the Organ Care System® intorat lungs for the establishment of ex-vivotherapyWiegmann B.12, Jonigk D.23, Mägel L.23, Braubach P.23,Höffler K.1, Bachmann S.1, Janke J.1, Ciubutaro A.1, HaverichA.141Hannover Medical School, Department for Cardiothoracic,Transplantation and Vascular Surgery, Hannover,Germany, 2German Centre for Lung Research, Hannover,Germany, 3Hannover Medical School, Institute forPathology, Hannover, Germany

Objectives: The Organ Care System® (OCS) is a well-established systemused in human lung transplantation, allowing for warm perfusion andventilation of the donor lungs. Besides lung retrieval, this systemtherefore offers an innovative opportunity for clinical ex-vivo therapyof diseased lungs for different indications, e. g. tumor therapy.While thepatient is on extracorporeal membrane oxygenation, the otherwiseinoperable lungs can be treated in the OCS, followed by autotransplan-tation. For the development of ex-vivo therapy, a miniaturized OCS forsmall animals model was established. Methods: Wistar rats wereeuthanized (per group n¼5), the left lung was connected to theminiaturized OCS, while the right lung was stored on ice. The OCS lungswere ventilated and perfused at body temperature under continuousmonitoring (e. g. pressure, blood gas analysis). Four different perfusionsolutions were analyzed (Steen solution® � blood, OCS solution® �blood). Thereafter the lungs were processed histologically and exam-ined pathologically (e. g. HE staining). Results: The miniaturized OCSworked technically faultless, in particular the perfusion and ventilationwent well. For all perfusion solutions stable pH, pO2, pCO2, oncoticpressure and systemic pressure could be observed. The base excess hasto be stabilized by application of sodium hydrogen carbonate using bothperfusion solution combined with blood. Furthermore, the lactateincreased in these two combined perfusion solutions until the end ofthe experiment up to 7,0 mmol/l, while the two others indicated lactatelevels up to 1,0 mmol/l. Pathological work up revealed no significantmorphological changes, except for focal atelectasis. There were nodelimitable differences in between the examined groups.Conclusions: The miniaturized OCS is a reliably working system toestablish the ex-vivo therapies for different indiations. As ex-vivotherapies may need to be applied for more than 4 hours, extendedperfusion times and various perfusion solutions are currentlyinvestigated.

OP177Modulation of immune-mediators from donorlungs using the Organ Care System® - apotential mechanism for improved outcomeWiegmann B.12, Falk C.S.3, Müller B.3, Neudörfl C.3, AkhdarA.3, Kühn C.1, Tudorache I.1, Avsar M.1, Haverich A.12,Warnecke G.121Hannover Medical School, Department for Cardiothoracic,Transplantation and Vascular Surgery, Hannover,Germany, 2German Centre for Lung Research, Hannover,Germany, 3Hannover Medical School, Institute ofTransplant Immunology, Integrated Research andTreatment Center Transplantation, Hannover, Germany

Objectives: Release of donor-derived immune mediators (IM), trigger-ing allorecognition and inflammation after transplantation (Tx), mayimpinge on clinical outcome using warm perfusion of donor lungs(Organ-Care-System®, OCS) or standard cold preservation (SOC). IMwere analysed in preservation solutions (PS) and peripheral blood (PB),also clinical outcomes monitored. Methods: IM were quantified inperfusion solutions (PS) and plasma at protein level by multiplex-technology at the end of warm preservation (n¼12) or cold storage(n¼9) and in PB. Donor and recipient demographics and midtermoutcomeswere analysed. Results: In PS, concentrations of IL-6, IL-10, IL-16, IFN-g CXCL8, CCL4, Ang-2, PECAM-1 and PDGF-b were significantlyhigher in OCS than SOC (p<0.0001). Inverse distribution was observedfor FGF-b (p¼0.005). High concentrations in PS following OCS preser-vation correlated with lower concentrations of several IM in recipientplasma after Tx. OCS vs. SOC median donor age was 44,5 vs. 46 years.Median recipient age was 54,5 vs. 56 years, underlying diagnoses:idiopathic fibrosis (n¼6 vs. n¼5), cystic fibrosis (n¼3 vs. n¼2),idiopathic pulmonary hypertension (n¼0 vs. n¼1) and emphysema(n¼3 vs. n¼1). No significant differences of the median cross clamptimes (minutes) for the right lung (430 vs. 505) and left lung (568,5 vs.641) were seen. Shorter median ICU-staywas observed in the OCS group(3585 vs. 3750 min), as well shorter mechanical ventilation times (795vs. 1051 min). Significantly higher % predicted FEV1 at discharge (FEV1)was seen in the OCS group (71% vs. 55%, p¼0,04). PGD-scores werelower at T24 in the OCS group (p¼0.28). Six-month-survival was notdifferent in this small cohort. Correlations between Ang-2 as well as IL-6concentrations and FEV1, mechanical ventilation time, paO2/FiO2 andICU-stay were identified. Conclusion: IM remained low in PS using SOCprobably due to reduced metabolic activity in lung tissue during coldischemia. During OCS preservation, significantly higher amounts of IMwere released into PS which may potentially represent depletion fromthe organ by accumulation in PS. This 'dialysis' effect was associatedwith reduced inflammatory conditions in the recipient after Txwhich, atleast in our still limited experience, had a positive impact on the clinicaloutcome in the OCS group, in particular a tendency towards shortermechanical ventilation, ICU-stay and lower PGD-scores and significantlyhigher early FEV1.

OP178Myocardial ischemia/reperfusion reaction afterwarm vs. cold Calafiore blood cardioplegiaHagmüller S.1, Niemann B.1, Rohrbach S.2, Heep M.1,Schlüter K.-D.2, Böning A.11Justus Liebig-Universität Giessen, Klinik für Herz-,Kinderherz- und Gefäßchirurgie, Giessen, Germany, 2JustusLiebig-Universität Giessen, Physiologisches Institut,Giessen, Germany

Background: Because of conflicting reports regarding the superiority ofcold or warm blood cardioplegia, we compared the postischemicmyocardial function of rat hearts after application of blood cardioplegia(BCP) in two different temperatures. Methods: The hearts of 24 maleWistar rats were excised and inserted into a blood perfused isolatedheart apparatus. After aortic clamping, either cold (4°C, 8 hearts) orwarm (36°C, 16 hearts) Calafiore BCP was administered. During reper-fusion, functional parameters were recorded: coronary blood flow, leftventricular developed pressure (LVDP), and dp/dt max. Oxygen con-sumption und lactate production of the hearts were calculated. Theeffect on mRNA expression of genes related to post-ischemic recovery


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was evaluated by real-time PCR. Results: LVDP (warm 62% of baseline(BL), cold 46% BL) and dp/dt max (warm 82% BL, cold 69% BL) showbetterrecovery 90 min. after warm than after cold Calafiore BCP. However,coronary flow recovers better (warm 66% BL, cold 75% BL) after cold thanafter warm BCP. During reperfusion, MVO2was higher in thewarm (68%BL) than in the cold group (49% BL), and lactate productionwas higher inthe cold (1.5 ml/min) than in the warm hearts (0.8 ml/min). Warmhearts had a higher SERCA2a expression and subsequently a higherSERCA2a/NCX ratio. The significantly lower bax expression and a higherbcl-2/bax ratio in rat hearts after warm cardioplegia indicating signs ofreduced proapoptotic susceptibility in rat hearts after warm BCP.Conclusions: After warm BCP, better recovery of cardiac function, bettermyocardial oxygen utilization, lower lactate production, SERCA upre-gulation, a higher SERCA/NCX ratio and lower bax expression indicatebetter myocardial preservation than after cold BCP.

OP179124 cases of Extracorporeal MembraneOxygenation assisted mechanical resuscitationin non-postcardiotomy patientsCamboni D.1, Philipp A.1, Flörchinger B.2, Rupprecht L.2,Keyser A.2, Mueller T.2, Lunz D.3, Amann M.3, Kobuch R.1,Hilker M.1, Schmid C.11Universitätsklinikum Regensburg, Klinik und Poliklinik furHerz-Thorax-Chirurgie, Regensburg, Germany,2Universitätsklinikum Regensburg, Innere Medizin,Regensburg, Germany, 3Universitätsklinikum Regensburg,Klinik für Anästhesiologie, Regensburg, Germany

Background: Despite all medical advances the survival rate of patientsrequiring mechanical resuscitation (CPR) remains dismal. A promisingand evolving approach seems to be veno-arterial Extracorporeal Mem-brane Oxygenation assisted CPR (ECPR). Herewe report our institutionalexperience with this new technology in the field of cardiac surgery.Methods: We retrospectively analyzed a total of 124 consecutive non-postcardiotomy ECPR cases from January 2008 to July 2013. Results:Mean age of the patient population was 53 � 16 years (range 2.4 - 81years, 80% man). Half of the patient population (54%) was referred fromsurrounding hospitals. 54% of the referrals were transported onvaECMO. In 94%, vaECMO was installed utilizing the femoral vesselspercutaneously, which was complicated in 27% of the cases. In 30% acannulation associated complication occurred (20% leg ischemia, 8%bleeding, 2% others). In 27%, a cardiac surgeonwas present at the time ofimplantation together with a perfusionist. Mean duration of supportwas 4 � 4 days (range 0 - 24 days). 76% were treated on cardiac surgicalor cardiological intensive care units, and the remaining in different ICUs.Renal failure requiring renal replacement therapy occurred in 40% of thepatient population. 62% of the patient population was successfullyweaned from ECMO support, 46% survived 30 days post weaning and42% survived to hospital discharge. There was no difference in survivalbetween patients over and under 65 years (p¼0.83), and there was nodifference in mean age between survivors (54 � 14 years) and nonsurvivors (53 � 16 years, p¼0.83). Patients suffering from two or moreorgan failures showed a trend towards a higher mortality (63% com-pared to 45%, p¼0.08), which was up to 70% in case of cannulationassociated complications (p¼0.1). The survival to discharge ratereached 57% in the last two years which was higher without reachingstatistical significance compared to the first two years (33%, p¼0.08) ofour ECPR program. Conclusion: The survival rate of ECPR patients at ourinstitution reaches 57% after overcoming a learning phase. These resultsshould encourage other cardiac surgical centers to start or continue anECPR program. We expect a significant increase in the use ECPR in thefuture, and cardiac surgical units should play a key role in this interdis-ciplinary approach of resuscitation.

Basic Science IV: ECC vascular

OP180Tenascin-C enhances fibrosis and hypertrophyduring pressure overload in the mouse heartDzilic E.1,2, Kreibich M.2,3, Nagel F.2, Santer D.2,4

, Moser P.2, Krššák M.5, Podesser B.2,6, Trescher K.2,61Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, München, Germany, 2Ludwig BoltzmannCluster für Kardiovaskuläre Forschung, Vienna WorkingHeart Research Group, Wien, Austria, 3Universitäts-Herzzentrum Freiburg - Bad Krozingen, Klinik für Herz- undGefässchirurgie, Freiburg i. Br., Germany, 4KrankenhausHietzing, Herz- und Gefäßchirurgische Abteilung, Wien,Austria, 5Universitätsklinik für Innere Medizin III, Klin.Abteilung für Endokrinologie & Stoffwechsel,Wien, Austria,6LK St. Pölten, Abteilung für Herzchirurgie, St. Pölten,Austria

Introduction: The extracellular matrix protein Tenascin-C (TNC) influ-ences cell adhesion and cardiac remodeling. It is primarily expressedafter myocardial infarction (MI), but its role during ventricular hyper-trophy remains completely unclear. Therefore, a minimal invasivemouse aortic banding model was established to investigate the influ-ence of TNC during left ventricular pressure overload (PO). Methods:Aortic banding was performed in TNC-knockout (TNC-KO) and wildtype(WT) mice: Following a partial sternotomy, a ligature was placedbetween the innominate and the left common carotid artery and tiedaround a 27-gauge needle to maintain equal knot tightness. Shamsurgery was performed (TNC-KO-SHAM, WT-SHAM) respectively with-out tying the suture (n¼8 in every group). Histologic samples werecollected after 1 week, 4 weeks, and 10 weeks. Also, hearts wereassessed in vivo by cardiac magnetic resonance imaging after 10 weeks.Data are presented asmean� SEM.Results:Hemodynamic functionwassignificantly decreased only in the WT banding group: ejection fraction(WT: 48.06 � 4.48% vs. WT-SHAM: 62.20 � 1.98%, p<0.01; TNC-KO:64.78 � 3.87% vs. TNC-KO-SHAM: 72.03 � 2.85%, n.s.), cardiac output(WT: 43.68� 4.23ml/g vs.WT-SHAM: 82.80.� 4.68ml/g, p<0.01; TNC-KO: 67.18 � 7.45 ml/g vs. TNC-KO-SHAM: 83.94 � 6.52 ml/g, n.s.). Also,septum thickness was significantly enlarged solely in operatedWTmice(WT: 1.54� 0.09 mmvs. WT-SHAM: 1.11� 0.03 mm, p<0.01; TNC-KO:1.20 � 0.03 mm vs, TNC-KO-SHAM: 1.04 � 0.03 mm, n.s.). Histologicevaluation revealed increasing levels of fibrosis in the WT bandinggroup over time but minimal fibrosis in the TNC-KO banding group.Discussion: Hemodynamic function of TNC-null mice remained signifi-cantly less affected by ventricular remodeling during pressure overload.Also, there were only marginal signs of fibrosis in this group. It seemsthat TNC influences ventricular remodeling not only after MI but alsoduring PO.

OP181Prostaglandin E2 does not attenuateadrenergic-induced cardiac contractileresponsePecha S.1, Mudersbach E.2, Wagner F.M.1, Alassar Y.1, HakmiS.1, Yildirim Y.1, Reichenspurner H.1, EschenhagenT.3, ChristT.31Universitäres Herzzentrum Hamburg, Herzchirurgie,Hamburg, Germany, 2Universitätsklinikum HamburgEppendorf, Institut für Klinische Pharmakologie undToxikologie, Hamburg, Germany, 3UniversitätsklinikumHamburg Eppendorf, Institut für ExperimentellePharmakologie und Toxikologie, Hamburg, Germany

Background: Inflammation contributes to heart failure. PGE2 is sus-pected to be a major player in inflammation-induced impairment ofcardiac function. It has been recently reported that moderate concen-trations of PGE2 do not affect contractility, but desensitize for subse-quent isoprenaline inotropy, because PGE2 activates cAMP far from thecontractilemachinery but near PDE4 (1). Since in humanheart PDE3, butnot PDE4 is the predominant PDE-isoform controlling catecholamineresponse we investigated relevance of this mechanism for human heart


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function. Methods: Trabeculae were prepared from human right atrialtissue obtained during heart surgery. Muscle strips were electricallydriven and isometric force development was measured. PGE2 was givenat a single concentration (0.1 µM). Norepinephrine was used to activateβ1-adrenoceptors. In order to minimize influence of patients character-istics, muscles from the same patient were used for PGE2 treatment andtime-matched controls (TMC). All patients were in sinus rhythm.Activity of PGE2 preparation was confirmed by assessing concentra-tion-dependent vasoconstriction in mice aorta. Results: 28 musclestrips from 11 patients were examined. Basal force was 8.2 � 0.9 mN.Acute exposure to PGE2 (15 min) did not affect contractility whencompared to TMC (from 8.6 � 1.5 to 8.2 � 1.4 mN and from 8.0 � 1.4 to7.3 � 1.3). Maximum force in the presence of norepinephrine did notdiffer in PGE2 pre-treated vs. TMCmuscles (11.8� 1.4 vs. 11.9� 1.8mN,16 vs.12 trabeculae). Sensitivity to norepinephrine expressed as -Lo-gEC50 values was identical (PGE2: 7.08 � 0.13 vs. TMC: 7.06 � 0.14 M).Furthermore we measured PGE2 effects on catecholamine response inC57 Black 6mice, in order to confirm the initial report. Isoprenalinewasused to eliminate possible agonist-dependent peculiarity. Similar to theeffects on human trabeculae, neither -LogEC50 values (PGE2: 7.21 � 0.1vs. TMC 7.22� 0.13M) nor isoprenaline-stimulatedmaximum forcewasaffected by PGE2 (PGE2 (n¼9): 11.9� 1.9, vs. TMC (n¼12): 11.8 � 1.4).Conclusion: Our data do not support a role for PGE2 in regulatingcatecholamine inotropy by activating PDE4 or participating in desensi-tization of β-adrenoceptors in heart failure. (1) Liu et al. PNAS 2012(109); 6578-6583

OP182Treatment with low-dose flavonoids showsprotective effects on endothelial cellsGuo F.1, Kanzler I.1, Kiessling A.-H.1, Bogert N.1, Stock U.A.1,Moritz A.1, Beiras-Fernandez A.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, Thorax, Herz, und Gefäßchirurgie, Frankfurt,Germany

Objectives: Flavonoids are a large family of heterogeneous polyphenoliccompounds found in fruits, vegetables and wine. Recent investigationsrevealed that flavonoids may be vascular protective agents by directlyinducing nitric oxide (NO) production and arterial relaxation. This studyaimed to investigate the protective effect of flavonoids on endothelialcell (EC) apoptosis and transendothelial migration of peripheral bloodmononuclear cells (PBMCs) and to elucidate the potential mechanismaffecting these processes. Methods: EC were treated with differentdoses of the flavonoid Venoruton© (Novartis Pharma, Germany) toassess the potential effect on endothelial cell apoptosis by Annexin Vand propidium iodide staining. EC monolayers were treated withVenoruton (0.1 mM, 0.5 mM, 1 mM) for 1 hour, and further used fortransendothelial migration assay with human peripheral blood mono-nuclear cells (PBMCs). Results are expressed as percent of control(transmigration index, tmx). eNOS and iNOS expression in EC afterVenoruton treatment were analyzed by RT-PCR. Results: Venorutonexposure did not increase endothelial cell apoptosis. Treatment of ECwith low-dose Venoruton© (0.1 mM, 0.5 mM) caused a significantdecrease in transendothelial migration of PBMCs compared to control(control 1.00� 0.00 tmx vs. 0.1mM0.982� 0.004 tmx and0.5mM0.983� 0.003 tmx). In contrast, high-dose Venoruton© (1 mM) treatmentsignificantly increased transendothelial migration of PBMCs (control1.00 � 0.00 tmx vs. 1 mM 1.043 � 0.016 tmx). eNOS as well as iNOSexpressions were significantly elevated in EC with increasing Venoru-ton© dosage. Conclusion: Low-dose Venoruton reduces apoptosis ofendothelial cells and inhibit transendothelial migration of PMBCstrough endothelial monolayer, showing protective effects on ECs;however, high-dose Venoruton© inversely elevated transendothelialmigration of PMBCs. The increased transendothelial migration of PBMCsis probably related to the excessive activation of the NO-axis andrelaxation of the endothelial cells.

OP183The eNOS 894G/T gene polymorphism and itsinfluence on early and long-termmortality afteron-pump cardiac surgeryBireta C.1, Hinz J.2, Lipke C.2, Schöndube F.A.1, Mörer O.2,Quintel M.2, Sabashnikov A.3, Bergmann I.2, Popov A.-F.11Universitätsmedizin Göttingen, Thorax-, Herz- undGefäßchirurgie, Göttingen, Germany, 2UniversitätsmedizinGöttingen, Zentrum Anästhesiologie, Rettungs- undIntensivmedizin, Göttingen, Germany, 3Royal Bromptonand Harefield NHS Foundation Trust, Department ofCardiothoracic Transplantation and Mechanical Support,London, United Kingdom

Objectives: The eNOS 894G/T polymorphism (GG, GT, and TT) isassociated with cardiovascular mortality and may influence cardiovas-cular diseases as a genetic risk factor. Moreover, this polymorphism hasan impact on intraoperative hemodynamics during cardiac surgerywithcardiopulmonary bypass (CPB). In this study, we analyzed the influenceof this gene polymorphism on early clinical outcome in patients whounderwent cardiac surgery with CPB. Also, we performed a 5-yearfollow-up, assessing the impact of this polymorphism on long-termmortality.Methods: 500 patients who underwent cardiac surgery withCPB between 2006 and 2007 were included in this prospective singlecentre study. Genotyping for the eNOS gene polymorphism was per-formed by polymerase chain reaction amplification. Results: Genotypedistribution of 894G/Twas: GG 50.2%; GT 42.2%; TT 7.8%. Cardiovascularrisk factors were equally distributed between the different genotypes ofthe eNOS 894G/T polymorphism. No significant difference among thegroups was shown regarding Euroscore, SAPS II and APACHE II. Periop-erative characteristics were also not affected by the genotypes, exceptfor the consumption of norepinephrine (p¼0.03) and amiodarone(p¼0.01) which was higher in the GT allele carrier. The early postoper-ative course was quite uniform across the genotypes, except for meanintensive care unit length of stay which was significantly prolonged inGT carriers (p¼0.001). The five-year follow-up was 100% complete andshowed no significant differences regarding mortality between thegroups. Conclusions: Our results show that the eNOS 894G /T polymor-phism is not associatedwith early and late clinical outcome after cardiacsurgery. Thus, this polymorphism can actually not help to identify highrisk groups in theheterogeneous population of individualswho undergocardiac surgery with CPB.

OP184Perioperative single-dose VEGF-C/D inhibitorenhances cardiac allograft survival andprevents chronic rejection by regulatinglymphatic endothelial cell activationDashkevich A.12, Syrjälä S.O.2, Keränen M.A.2, Krebs R.2,Nykänen A.I.2, Alitalo K.3, Lemström K.B.241University Hospital Munich, Department of CardiacSurgery, München, Germany, 2Haartman Institute /University of Helsinki, Transplantation Laboratory,Helsinki, Finland, 3Wiihuri Research Institute, CancerResearch Program, Biomedicum, University of Helsinki,Helsinki, Finland, 4Helsinki University Hospital,Department of Cardiothoracic Surgery, Helsinki, Finland

Objectives:VEGF-C/D/VEGFR-3 signalingmay regulate lymphatic vesselactivation and the initiation of alloimmunity after transplantation. Weinvestigated the effect of perioperative intracoronary injection of syn-thetic VEGF-C/D inhibitor on lymphatic vessel activation, antigen-presenting cell trafficking and subsequent development of alloimmuneresponses in rat cardiac allografts.Methods:Weperfused the coronariesof DA donor rat hearts ex vivo with VEGF-C/D inhibitor or PBS andpreserved the grafts inþ4°C PBS for 4 h and then transplanted the graftsto fully MHC-mismatched WF recipient rats. We analyzed ischemia-reperfusion injury, and acute and chronic rejection responses. In acuteand chronic rejection models, the recipients received Cyclosporine A asimmunosuppression. Results: At 6 h after the reperfusion, VEGF-C/Dinhibitor did not affect themyocardial injury but reduced the number ofLYVE-1þ lymphatic vessels expressing VEGFR-3, ICAM-1 and VCAM-1 inthe allograft and reduced the number of dendritic cells migrating out of


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the allograft. VEGF-C/D inhibition enhanced allograft survival in acuterejectionmodel. In chronic rejectionmodel, VEGF-C/D inhibitor reducedallograft inflammation and prevented the development of cardiacfibrosis and vasculopathy. Conclusions: Intracoronary treatment withVEGF-C/D inhibitor prevented early activation of lymphatic endothelialcells and trapped dendritic cells into the allograft. This interfered withallorecognition resulting in reduced acute and chronic rejection re-sponses. Our results suggest donor single-dose intracoronary treatmentwith VEGF-C/D inhibitor as a novel clinically feasible lymphatic vesseltargeted immunomodulatory approach.

Fig. 1: VEGF-C/D inhibitor prevented lymphatic vessel activation (seenas reduced expression of VEGFR-3 (A), ICAM-1 (B) and VCAM-1 (C) inLYVE-1þ lymphatics) and trapped dendritic cells in the allograft (D) at6h after reperfusion. VEGF-C/D inhibitor improved cardiac allograftsurvival (H). VEGF-C/D inhibitor reduced cardiac fibrotic area (E) andarterial occlusion in the allograft (F), the incidence of arterial occlusion(G) and the influx of ED-1þ (I), CD4þ (J), CD-8þ (K) and MPOþ (L)inflammatory cells at 8 weeks after reperfusion. �p<0.05, ��p<0.01,��p<0.001.

OP185Caloric restriction and CB1 blockade activateAMP-activated protein kinase and mediatecardio-protection in a model of prematurecardiac senescenceNiemann B.1, Issa H.2, Li L.3, Silber R.-E.4, Böning A.1,Rohrbach S.31Justus Liebig Universität Giessen, Klinik für Herz-Kinderherz- und Gefäßchirurgie, Giessen, Germany,2Martin Luther Universität, Klinik für Kinderkardiologie,Halle, Germany, 3Justus Liebig Universität Giessen,Physiologisches Institut, Giessen, Germany, 4Martin LutherUniversität, Klinik für Herz- und Thoraxchirurgie, Halle,Germany

Introduction: Heart failure is associated with a loss of AMP-activatedprotein kinase (AMPK) function, dysbalanced adipocytokine-signalling,cardiac hypertrophy and loss of cardiomyocyte contractile function.Here, we investigated the impact of CR and/or antagonism of the

cannabinoid type-1 (CB1) receptor (Rimonabant) in an experimentalmodel of afterload induced cardiac dysfunction (aortic banding) on leftventricular and mitochondrial function. Hypothesis: Adipokine-medi-ated AMPK activation reduces cardiac ischemia reperfusion injury andresults in improved cardiac function. AMPK-mediated effects on cellsurvival and mitochondrial biogenesis participate in this effect. AMPK-activation (via CR/CB1-blocker) may not only be beneficial in postische-mic myocardium but also in afterload-induced heart failure. Methods:Male Wistar rats underwent aortic banding or sham operation. After 4months animals werematched accoding to their LV function and treatedwith standard chow, CR (-40%) and/or medical therapy (CB1 blockade,Rimonabant) for 12 weeks. Follow up was performed via echocardiog-raphy andMillar-Tip-catheter. Paraformaldehyde-conserved LV sampleswere stained (cross sectional area, collagen content, TUNEL). Mitochon-drial function was analyzed with a high-resolution oxygraph usingskinned fibers, while adipokine expression or markers of apoptosis,afterload and cardiac metabolism were analyzed by qPCR and WesternBlotting. Results: Aortic ligation induces congestive heart failure (LV-weight:þ23%, lung-wet-weight:þ100%). Mitochondrial respiration (py-ruvate:-15%; succinate:-10%) and AMPK-activation (-20%) are reducedin failing LVs. CR and/or Rimonabant treatment restored LV function (FS%:þ7%, dp/dt:þ15%), reduced BNP (-50%) and pro-apoptotic activation(TUNEL-positive nuclei:-50%). Cardiac hypertrophy (cross sectionalarea) and collagen content are reduced in both interventional groups.Furthermore, adiponectin release from adipose tissue (CR:þ90%,Rimonabant:þ70%) contributes to an increased AMPK-phosphorylation,induction of mitochondrial biogenesis and thus stabilization of mito-chondrial function. CR and CB1 blockade show comparable effectswithout developing additive potency. Conclusion: Metabolic optimiza-tion and AMPK activation protect the dysfunctional myocardium.Interventions, acting as CR mimetics, may be an additional option forperioperative stabilization and risk-reduction of patients suffering fromheart failure.

OP186Modulation of endothelial inflammation afterMethylene Blue: role of circulating cellsKanzler I.1, Guo F.1, Bogert N.1, Moritz A.1, Beiras-FernandezA.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, Thorax-, Herz-, und Gefäßchirurgie,Frankfurt, Germany

Objective: Vasoplegia is a frequent complication after cardiac surgerywith cardiopulmonary bypass. Within the last years the administrationof nitric oxide (NO) synthase inhibitor methylene blue (MB) became anew therapeutic strategy. NO is a signaling molecule involved inimmune response regulation, including leukocytes adhesion and mi-gration. As peripheral blood mononuclear cell (PBMC) can exert pro-and anti-inflammatory properties, we analyzed the effect of MB on thedifferent PBMC subtypes regarding their transendothelial migrationbehavior. Methods: Human endothelial cells (EC) were cultured onfilters and treated with MB or with LPS (to mimic inflammation)followed by MB for different time intervals and concentrations. PBMCwere stainedwith fluorescence labeled antibodies directed against CD3,CD19, CD14, CD16 and CD177. After transendothelial migration, themigrated PBMC subtypes (Granulocytes, T- and B-cells and monocytes)below the filter were analyzed by FACS. p<0.05 was consideredstatistically significant. Results: LPSMB treatment of EC show that MBsignificantly reduces granulocyte migration after high MB doses forshort time compared to lowMB dose (30 min: 10 µMLPSMB 38.7 � 2.7%vs. 30 µMLPSMB 19.0� 5.2% and 60 µMLPSMB 21.5� 2.9%). Significantlymore B-cells migrate after treatment with high dose MB compared toctr, LPS and low MB doses (LPS 4.1 � 1.1% and 30 min: 10 µMMB 5.2 �1.0% vs. 60 µMMB 21.4 � 4.0% and ctr 6.0� 3.7%, LPS 4.1� 1.1% and 2 h:10 µMMB 7.6 � 3.2% vs. 60 µMMB 22.8 � 3.6%). T-cell migration did notchange in any experimental group. EC treatment with LPSMB increasedCD14þ monocyte migration dose dependent. Short term LPSMB treat-ment increased migrated CD14þ monocytes significantly compared toctr and LPS (ctr 1.3� 0.1%, LPS 1.9� 0.3% vs. 30 min: 10 µMLPSMB 3.7�0.0%, 30 µMLPSMB 10.7� 0.4% and 60 µMLPSMB 11.3� 2.8%). High doseMB significantly raised CD14þCD16þ monocytes transmigration


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compared to ctr and LPS (LPS 27.7 � 1.8% vs. 30 min 60 µMMB 52.7 �4.1%; ctr 38.6 � 0.4% and LPS 27.7 � 1.8% vs. 2 h 60 µMMB 51.3 � 1.1%).LPSMB exposure significantly augmented transmigrated CD14þCD16þmonocytes in all groups compared to ctr. Conclusion: The PBMC subtypeanalyses showed an increase of transmigrated CD14þ/CD16þ mono-cytes after treatment with MB. Furthermore, the CD14þ monocyte andgranulocyte response after MB treatment is dose-dependent, and T-lymphocytes show a heterogeneous response, suggesting a predomi-nant role in migration of monocytes and granulocytes after MB

OP187Use of cold blood cardioplegia equalizes higherrisk profile in CABG patients with acutecoronary syndrome compared to warm bloodcardioplegiaKuhn E.W.1, Slottosch I.1, Liakopoulos O.J.2, Scherner M.1,Deppe A.-C.1, Choi Y.-H.1, Madershahian N.1, Wahlers T.11Uniklinik Köln, Herz- & Thoraxchirurgie, Köln, Germany,2Uniklinik Essen, Thorax-&Kardiovascularchirurgie, Essen,Germany

Objectives: Intermittent cold blood cardioplegia (ICC) offers superiormyocardial protection in high risk patients with prolonged aortic cross-clamp times when compared to intermittent warm blood cardioplegia(IWC). The aim of the present retrospective analysis was the evaluationof postoperative endpoints after coronary artery bypass surgery usingIWC or ICC in patients with acute coronary syndrome (ACS). Methods:From 7,405 consecutive cardiac surgery patients, 676 patients wereretrospectively identified that underwent isolated CABG after ACS (IWCn¼477 vs. ICC n¼199). Groups were compared with regard to therelease of markers for myocardial injury (CK-MB, cTnT) and clinicaloutcomes including 30-day mortality, perioperative myocardial infarc-tion (PMI) and major adverse cardiac events (MACE). Results: Demo-graphic data, aortic cross-clamp and CPB time were comparablebetween ICC and IWC groups. However, more patients in the IWC grouppresented with diabetes (IWC 34.7% vs. ICC 26.1%; p¼0.037), left mainstenosis>50% (IWC 58.3% vs. ICC 47.5%; p¼0.013), and a preoperativeNYHA class III-IV (IWC 73.2% vs. ICC 50.0%; p¼0.001) compared to ICCgroup. Otherwise, left ventricular ejection fraction was lower in the ICCgroup (ICC 48.3�18,0% vs. IWC 51.3�16,3%; p¼0.047), and theproportion of re-operation (IWC 1.7% vs. ICC 5.5%; p¼0.012) andpreoperative need for IABP (IWC 3.6% vs. ICC 11.4%; p¼0.006) washigher in the ICC group. Of patients without IABP preoperatively, morepatients in the ICC group (29.6%) needed postoperative IABP supportcompared to the IWC group (17.0%; p<0.001). Maximal values of CK-MB (ICC 120�192 vs. IWC 103�166U/L) and cTnT (ICC 3.8�6.7 vs. IWC3.2�8.8 ng/mL) did not differ significantly. Postoperative endpoints ofinterest were not different among tretment groups (30-day mortality:ICC 12.6% vs. IWC 9.9%; p¼n.s.; PMI: ICC 47.2% vs. IWC 43.3%; p¼n.s.;MACE: ICC 50.3% vs. IWC 47.4%; p¼n.s.). Nor ICC nor IWC was shown tobe an indepent risk factor for postoperative endpoints by multivariateanalysis. Conclusion: Among all patients with myocardial revasculari-zation due to ACS, patients in the ICC group presented with higher riskprofile compared to IWC patients, however, the incidence of postoper-ative adverse events was not markedly different of both groups.Therefore, ICC offers optimal myocardial protection in patients under-going CABG after ACS and serves as valuable alternative to IWC.

NOTE: Please note that Abstract OP187 belongs to Session"Extracorporeal Circulation and Myocardial Protection I" onMonday, Feb 10th.


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Short Communications

Basic Science I: Tissue Engineering

SC1Influence of different fixatives on themechanical properties of cell-seeded scaffoldsMayer T.1,2, Hollweck T.1, Fehrenbach D.1,2, Fano C.3, DaunerM.3, Wintermantel E.2, Hagl C.1, Akra B.11Medical Center Munich University, Department of CardiacSurgery,München, Germany, 2Technical UniversityMunich,Chair of Medical Engineering, Garching, Germany,3Institute of Textile Technology and Process Engineering,Denkendorf, Germany

Objective: Various standardized test methods are not suitable fortesting vital tissue engineered heart valves. The aim of this study wasto determine the mechanical properties of cell-seeded patches afterdifferent conservation procedures. Methods: Non-degradable polyure-thane specimens were statically seeded with human saphenous veincells: fibroblasts (Group A), endothelial cells (Group B) and Group Cwithfibroblast and endothelial cells. Specimens from Group A and B wereeither fixed in glutaraldehyde or in formalin solution for 5 d at 4 °C. Ingroup C, storagewas performed using glutaraldehyde solution, formalinsolution, medium M199 or Chillprotec® for 5 d at 4 °C as well as inmediumM199 supplementedwith 10% dimethylsulfoxide for 5 d at -20 °C. Analogously seeded samples without conservation treatment wereused as references. Mechanical properties were evaluated by determin-ing the Young's modulus according to DIN EN ISO 527-1. Confluence andtopography of seeded constructswere observed using scanning electronmicroscopy. Results: Conservation procedures affected Young's Modu-lus of seeded samples. After conservation, Young's Modulus increased inGroup A and B compared to untreated samples. The Young's Modulus ofGroup C specimens decreased after conservation with glutaraldehydesolution, formalin solution, medium M199 and medium M199 supple-mented with 10% dimethylsulfoxide. Chillprotec®-conservationshowed a comparable Young's Modulus to untreated samples. SEManalysis of all treated groups displayed a similar topography comparedto samples without conservation treatment. Conclusion: Conservationsolutions affect the mechanical properties of cell-based tissues dramat-ically. Additional tests are still required to identify the ideal solution thatallows unproblematic testing of tissue engineering devices.

SC2Tissue engineering of regenerativecardiovascular patch material based ondecellularized pericardiumMogaldea A.1, Hilfiker A.1, Schilling T.1, Haverich A.11Medizinische Hochschule Hannover, HTTG, Hannover,Germany

Objectives: Autologous pericardium is often used to substitute small ormedium sized vascular or myocardial lesions. However, its use isrestricted due to its limited availability. Hence, glutaraldehyde-fixedbovine pericardium is currently being employed more extensivelydespite potential impact of the xenogenic tissue on the host, possibletoxicity of residual fixing solution within the graft, and absence of anyregenerative and growing potential. We therefore developed a newbiological and viable matrix, based on decellularized and reseededpericardium. Methods: Decellularization of ovine pericardium wasperformed by detergent treatment for 24 hours. Detergents and celldebris were removed by washing with pure water for 24 hrs and finallywith phosphate buffered saline (PBS), supplementedwith antibiotics forfurther 72 hrs. Assessment of decellularization and preservation ofextracellular matrix was estimated. 1,5x106 ovine endothelial cells(EC), differentiated from endothelial progenitor cells (EPC) isolatedfrom ovine peripheral blood were used to reseed the decellularizedpericardial tissue (n¼ 5, passage 5-6) in custom made metallic molds.Cells were applied on the mesothelial side under static conditions.Finally, the viability and adhesion of the cells were assessed withfluorescent microscopy after 2, 5, 10 and 15 days of cultivation.Results: No macroscopically signs of destruction were detected after

decellularization. The grafts appeared acellular with intact extracellularmatrix, collagen and elastin fibersin a physiologic configuration. Re-population with EC was successful in all cases. After 2 days, some cellcolonies could be detected on the pericardial mesothelial surface. Analmost complete cell coverage could be observed between 5 and 10 days.The typical cobblestone-like pattern of the EC was noted after 15 days.The cells adhered to the matrix even during light shaking or mediumchange. Conclusion:A cell free pericardialmatrix could be obtainedwithour decellularization protocol. EC could form a robust and orientedmonolayer probably due to preservation of pericardial basal membrane.Reseeding of decellularized xenogeneic matrices with the host‘s cellscould lead to a physiological remodelling of the graft, ideally resulting ina regenerative prostheses.

SC3Human myocardial extracellular matrix directsthe differentiation of pluripotent stem cellstoward a cardiomyocyte phenotypeOberwallner B.1, Brodarac A.1, Anic P.1, Saric T.2, Bieback K.3,Stamm C.41Berlin Center for Regenerative Therapies, Berlin, Germany,2Universität zu Köln, Neurophysiologie, Köln, Germany,3Universität Heidelberg, Transfusionsmedizin, Mannheim,Germany, 4Deutsches Herzzentrum Berlin, Herz-, Thorax-und Gefäßchirurgie, Berlin, Germany

Objectives: Cross-talk between organ-specific extracellular matrix(ECM) and stem cells has often been assumed but not been directlydemonstrated.We have previously developed a protocol for preparationof cardiac ECM (cECM) that supports survival and proliferation ofcardiomyocyte-like cells, and now studied whether cECM emit differ-entiation-relevant signals to pluripotent stem cells.Methods: cECMwasprepared from human myocardium by a 3-step protocol involvinghypotonic lysis buffer, sodium dodecyl sulphate (SDS), and fetal bovineserum (FBS). Murine embryonic stem cells (ESC), induced pluripotentstem cells (iPS) and mesenchymal stromal cells (MSC) were seeded andcultured in standard culture, on cECM, or on commercially availablenon-specific ECM preparations or basement membrane extracts (Ma-trigel® or Geltrex®) for 20 days. Transcriptional activation of genesinvolved in early (Nkx2.5, Gata4, Mef2c) and late (Myh6, Tnnt2)myocardial development, pluripotency (Oct4, Sox2), endothelial (Vwf,VE cadherin), ectoderm (Ncam1) or endoderm (Sox17) commitmentwere monitored by quantitative rtPCR. Protein expression of selectedmarkers was confirmed by immunohistology. Results: In ESC and iPScells, cardiac lineage commitment was favoured when grown on cECM,as evidenced by significantly increased gene expression of Myh6(p¼0.03), Tnnt2 (p¼0.01), Nkx2.5 (p¼0.02) and Gata4 (p¼0.01) aswell as positive immunohistology for sarcomeric α-actinin and troponinT. In contrast, Matrigel or Geltrex did not induce cardiac-specificmarkers. MSC showed no evidence of cardiomyocyte differentiation.Pluripotency markers were best preserved on Matrigel, while endothe-lial development was supported by both cECM and Matrigel. cECMsuppressed endoderm and supported ectoderm development.Conclusion: Human cardiac ECM conveys signals to pluripotent stemcells that seem to direct differentiation toward a cardiomyocyte pheno-type. This phenomenon supports the use of cardiac ECM preparationsfor guided stem cell differentiation and myocardial repair.

SC4Electrophysiologically competent skeletalmyoblast based engineered tissue constructsshow cardiac-like force generationNeef K.1, Deppe A.-C.1, Srinivasan S.1, Treskes P.1, StammC.2,Wahlers T.1, Choi Y.-H.11Uniklinikum Köln, Klinik und Poliklinik für Herz- undThoraxchirurgie, Köln, Germany, 2Deutsches HerzzentrumBerlin, Klinik und Poliklinik für Herz- und Thorax- undGefäßchirurgie, Berlin, Germany

Introduction: Previously, we demonstrated that skeletal myoblast (SM)based engineered tissue constructs (ETC) applying specific cultureconditions can augment the intra-cardiac conduction system, i.e. for


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the treament of AV conduction block. However, the mechanical andcontractile properties of SM based ETC remain largely unexplored. Here,we present force measurement analyses of ETC as an essential prereq-uisite for potential treatment of the failing heart. Methods: SM wereprepared from skeletal muscle tissue, expanded in cell culture andanalyzed for cell type specific protein expression. For the fabrication ofETC, purified SM cell populations were seeded into hydrocollagenmatrices. After casting the cell/matrix mixture in specific molds poly-merization led to generation of passive longitudinal force within ETC.After submission to cell culture conditions which enabled the ETC toform myotubes, ETC were analyzed histologically. Contractile functionwas determined using a one-dimensional force transducer, with respectto stimulation frequency, maximum force generation, tetanic forcegeneration and muscular fatiguing. Neonatal skeletal muscle and myo-cardiumwere used as references to evaluate specificity of force genera-tion. Results: ETC containing 5x10E6 cell cultured expanded SMwith ata purity of 92.3 � 5.4% desmin positive cells, were submitted to cellculture conditions resulting in longitudinal organization of single cellsand could be successfully differentiated to syncytic myotubes. Forcemeasurement revealed an active contractile force of 1143 � 289 µN forETC (length: 0.9 cm; diameter: 1 mm). There was no significant changein maximum force generation for stimulation frequencies from 0.2 to 10Hz. Applying constant stimulation at 15Hz a decrease inmaximum force(-16.7 � 6.1%) was observed after 1 minute. This was comparable tomeasurements of neonatal cardiac muscle (max force: 1975 � 214 µN;constant force from 0.2-40 Hz; all p>0.05), but significantly differentfrommeasurements of neonatal skeletal muscle (max force: 3953� 871µN; constant force from 0.2-5 Hz; decrease in maximum force: -53.7 �26.2% after 1 minute; all p<0.05). Conclusion: SM based ETC exhibitforce generating properties similar to myocardial tissue. In addition tothe previous electrophysiological results, these data re-confirm SM aspotential substrate for cardiac cell therapy.

SC5Effect of natural killer cells on inducedpluripotent stem cell-derived bioartificialcardiac tissueKensah G.1,2, Baraki H.1,2, Saito S.1,2, Dahlmann J.1,2, SkvorcD.1, Hundrieser J.3, Kutschka I.12, Martin U.1, Gruh I.11Medizinische Hochschule Hannover, HTTG, Hannover,Germany, 2Otto von Guericke Universität Magdeburg,Klinik für Herz- und Thoraxchirurgie, Magdeburg,Germany, 3Medizinische Hochschule Hannover, Klinik fürAllgemein-, Viszeral- und Transplantationschirurgie,Hannover, Germany

Objectives: Reprogramming of patient-derived somatic cells into apluripotent state can be used to provide autologous induced pluripotentstem cells (iPSCs). However, in case of acute myocardial infarction (MI),it is more likely that allogeneic iPSC-derived cardiovascular cells will beused for reconstructive therapies. Therefore, a detailed understanding ofimmunological reactions of host cells to the transplant is necessary.Since we observed that natural killer (NK) cell depletion in nude rats isessential for the survival of transplanted murine iPSC-derived bioarti-ficial tissue (BCT), we examined the effect of NK cells on BCTs in vitro.Methods: Three-dimensional BCTs were prepared from geneticallyselected murine iPSC-derived cardiomyocytes (CMs) together withmitotically inactivated murine embryonic fibroblasts (MEFs). On day24 of cultivation BCTs, were incubated with rat spleen-derived andantibody-purified (90%) NK cells for five days in NK cell medium. Beforeand after incubation, BCTs were assessed for their active and passiveforces and afterwards subjected to histological examination to detectalterations on a cellular level. To discriminate the effect on isolated celltypes, alsomonolayer cultures of CMs andMEFswere incubatedwithNKcells and survival of target cells was assessed after incubation. Results:Control BCTs showed a decrease in active contraction forces, due toexposure toNK cellmedium (75� 1% of initial forces). NK cell incubationhad an additive negative effect on tissue constructs resulting in a loss of42 � 4% of contraction forces. NK cell medium showed no effect on thepassive forces of BCTs. An impact on passive forces was detected in BCTsincubatedwith NK cells, showing a decrease of 41� 0% in tissue stiffnessat Lmax. Histological analysis revealed no obvious differences between

the two groups. However, less than 5% of iPSC-derived CMs survivedafter exposure to NK cells in a monolayer and almost no viable MEFswere detectable after the same time of NK cell incubation. Conclusion: Inthis study we show for the first time that rat NK cells detect andeliminate iPSC-derived cardiomyocytes and, even to a higher degree,murine embryonic fibroblasts in monolayers. NK cells affect BCT per-formance by reducing active and passive forces. Therefore, NK cells haveto be considered as targets for immunosuppression in patients with MIreceiving iPSC-derived cardiovascular cells for myocardial restoration.

SC6Epicardial Erythropoietin patchmost efficientlyimproves myocardial regeneration andperformance after infarctionKlopsch C.1, Kleiner G.1, Skorska A.1, Ludwig M.1, Gaebel R.1,Mueller K.1, Mela P.2, Jockenhoevel S.2, David R.1, SteinhoffG.11University of Rostock, Reference and Translation Center forCardiac Stem Cell Therapy, Rostock, Germany, 2RWTHAachen, Department of Tissue Engineering and TextileImplants, Aachen, Germany

Objectives: High-dose intramyocardial Erythropoietin (EPO) therapyprotects the myocardium from ischemic injury and promotes beneficialremodelling. We investigated the therapeutic efficacy of EPO at amoderate dose level and compared local and systemic delivery routesin a rat myocardial infarction (MI) model. Methods: Following MI, EPO(300 U/kg)was delivered immediately by intraperitoneal (EPO-S, n¼25)injection, intramyocardial (EPO-L, n¼23) injection or epicardially as anEPO-plus-fibrin patch (EPO-X, n¼26). Groups were compared to eachother and MI control groups with saline injections (MIC, n¼25) orsaline-plus-fibrin patch application (MIC-X, n¼ 29). Heart functionswere examined under baseline and Dobutamine-induced stress con-ditions using conductance catheter method 6 weeks after MI. Moreover,blood and myocardium were analysed including candidate genes andproteins at early (24 hours) and late (6 weeks) stages after MI. Results:Results illustrated superior cardiac functions and healing in EPO-Xcompared with all groups at 6 weeks after MI. Pressure-volume loopsin EPO-X demonstrated 38% improved contractility (dpdtmax), 47%better elasticity (dpdtmin) and 15% enhanced ejection fraction com-pared with MIC-X. Furthermore, dpdtmax was 33% and 22% higher anddpdtmin was 32% and 23% greater in EPO-X compared with EPO-S andEPO-L, respectively. Infarction size, wall thinning, fibrosis and cardio-myocyte hypertrophy in EPO-X were reduced by 34%, 53%, 48% and 22%compared mit MIC-X, respectively. Histological improvements in EPO-Land EPO-S were only moderate. Early real-time PCR analyses in EPO-Xrevealed exclusively elevated gene levels of EPO receptor, intracardiacstem cell homing factors (SDF-1, CXCR-4, CD34), tissue-transformationfactors (TGF-beta, MMP-2), anti-apoptotic Bcl-2 and proliferation kin-ases Cyclin D1 and Cdc2. Blood analyses suggested, healing effects inEPO-X might have been hematopoiesis independent. Conclusion: Im-mediate epicardial EPO-plus-fibrin patch better than systemic or localprotein delivery restored cardiac performance after MI and earlyinduced keymolecules in myocardial regeneration. Therapeutic efficacymight be local-dose dependent.


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SC7Different degrees of protective effect by typesof fibroblasts on induced pluripotent stem cell-derived cardiomyocytes in bioartificial cardiactissue in vivoSaito S.1, Kensah G.1, Baraki H.1, Dahlmann J.1, Haverich A.2,Hundrieser J.3, Martin U.2, Gruh I.2, Kutschka I.11Universitätsklinikum der Otto-von-Guericke-UniversitätMagdeburg, Klinik für Herz- und Thoraxchirurgie,Magdeburg, Germany, 2Medizinische HochschuleHannover, Klinik für Herz-, Thorax-, Transplantations- undGefäßchirurgie, Hannover, Germany, 3MedizinischeHochschule Hannover, Klinik für Allgemein-, Viszeral- undTransplantationschirurgie, Hannover, Germany

Objectives: It is well known that the presence of supporting non-cardiaccells such as fibroblasts is crucial for survival and coupling of thepluripotent stem cell-derived cardiomyocytes in bioartificial cardiactissue (BCT) in vitro, and different types of fibroblasts may differentlyaffect the cardiomyocyte physiology. The aim of this study is to evaluatethe protective effects of the different types of fibroblasts on cardiomyo-cytes within BCT in vivo.Methods: BCTwas prepared from a mixture ofliquid collagen type I and Matrigel combined with mouse inducedpluripotent stem cell-derived cardiomyocytes (miPSC-CMs) and γ-irra-diated fibroblasts (10% of miPSC-CMs). As fibroblasts, human foreskinfibroblasts were used in Group-Xeno (n¼10) and mouse fetal fibro-blasts were used in Group-Pure (n¼10). BCTs were implanted in theheart of nude rats with chronic myocardial infarction. As control groups,rats received human foreskin fibroblast-BCTwithout miPSC-CMs (n¼5),mouse fetal fibroblast-BCT without miPSC-CMs (n¼5), or sham opera-tion (n¼10). The heart function was monitored by serial echocardiog-raphy and magnetic resonance imaging (MRI). The hearts wereexplanted 4weeks after the implantation and histological examinationswere performed.α-Actinin staining was done and the survival of miPSC-CMs was evaluated as the percentage of α-Actinin positive area to BCTarea (%α-Actinin area). CD31 staining was done and (1) the number ofvessels in the area between host myocardium and BCT and (2) thenumber of vessels within BCTwere counted. Vascularity was evaluatedas {(1) þ (2)} / BCT area (/mm2, vascularity index). Results: After BCTimplantation, the heart function was the best preserved in Group-Xeno(fractional shortening: repeated measures ANOVA p¼0.002, Xeno 29.1� 5.0%, Pure 22.6 � 7.5% at 4 weeks). At 4 weeks after the implantation,survival of cardiomyocytes within BCT (%α-Actinin area) was signifi-cantly higher in Group-Xeno than in Group-Pure (29.0 � 4.9% vs. 9.5 �6.5%, p <0.001). Vascularity index was also significantly higher inGroup-Xeno than in Group-Pure (13.8 � 5.6 vs. 3.9 � 3.7 /mm2,p¼0.002). Conclusion: Human foreskin fibroblast supplemented inBCT induced more neovascularization and resulted in higher survivalof miPSC-CMs in BCT in vivo thanmouse fetal fibroblasts, which resultedin higher beneficial effects on heart function.

SC8Decellularized amniotic membrane for supportof left ventricular dynamicsRoy R.1, Haase T.1, Zohlnhöfer-Momm D.1, Stamm C.21Berlin Center for Regenerative Therapies, Berlin, Germany,2Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefäßchirurgie, Berlin, Germany

Objective: Placenta and amnion have been suggested as sources of largequantities of juvenile cells for use in regenerative medicine. We previ-ously determined the impact of isolated amniotic epithelial cells as wellas unmodified, viable amniotic membrane on myocardial cytoprotec-tion and regeneration, and now evaluated the suitability of decellular-ized amniotic membrane (Decell-AM) for cell-free support of leftventricular geometry and function. Methods: Human amniotic mem-brane was decellularized with hypotonic lysis buffer and sodiumdodecyl sulphate (SDS). In 6-8 week old male balb/c mice myocardialinfarction was induced by permanent LAD occlusion. Decell-AM wasthen sutured to the anterior LV surface (n¼10), and viable cellular AM,no AM, or sham-operatedmicewere used as controls (n¼10 each). After4weeks, LV pressure-volume curves were recorded using a conductancecatheter before the animals were sacrificed and the hearts analyzed by

histology. Results: Infarct size and heart weight-to-body-weight ratiowere not different between Decell-AM and cellular AM, neither wasthere a difference in myocardial capillary density or the frequency ofTUNEL positive apoptotic cells. As evidenced by CD4þ cell invasion,decell-AM elicited less of an immune response than cellular AM.However, dP/dt max (AM, 4290 � 309 vs. Decell-AM, 5642 � 341mmHg/s, p¼0.01), dP/dt min (AM, -4100 � 375 vs. Decell-AM,-5418� 335mmHg/s, p¼0.02), stroke work (AM, 375� 92 vs. Decell-AM, 667� 72, p¼0.04), and cardiac output (AM, 2601� 483 vs. Decell-AM, 4604� 367, p¼0.009) indicated better LV function in mice treated withDecell-AM, similar to those recorded in sham operated hearts. Thevolume-based parameters (LV endsystolic and end-diastolic volume aswell as LV ejection fraction) did not differ between AM and Decell-AM.Control hearts (no AM) had poorer LV function parameters throughout.Conclusion: Decellularized amniotic membrane may support post-infarction ventricular dynamics independent of actual regenerationprocesses. As a cell-free approach to support the ischemic heart, thisconcept may warrant further investigation.

SC9Combined non-thrombogenic and endothelialcell adhesive surfaces bya single step procedureGabriel M.1, Weiler H.1, Mehlhorn U.1, Vahl C.-F.11UniversitätsmedizinMainz, Klinik und Poliklinik für Herz-,Thorax- und Gefäßchirurgie, Mainz, Germany

Objectives: Blood contacting devices are prone to platelet adhesion andactivation of the coagulation cascade resulting in potentially fatalthrombosis and emboli. Consequently a non-thrombogenic surface isdesirable, what can be created by attaching highly hydrophilic polymers- eg. polyethylenglycol (PEG) - or by enabling endothelialization. Utiliz-ing a conjugate consisting of a titanium (Ti) recognizing peptide motifcoupled to the endothelial cell (EC) specific adhesive peptide REDV via aPEG-spacer, we intended to promote EC growth on Ti while simulta-neously reducing platelet adhesion. Methods: The peptide-PEG conju-gatewas synthesized by standard solid phase synthesis. Ti samples weretreatedwith the conjugate solution for 2 h. Untreated aswell asmodifiedspecimen (n¼3) were seeded with 105 ECs per sample and growth wasmonitored after 4d by Calcein staining and fluorescent microscopy. Inaddition, samples were incubated in platelet rich plasma for 45 min,stained and examined. Micrographs were analyzed using ImageJ soft-ware and data expressed as mean � sd. Results: Bare Ti was poorlycolonized by ECs after 4d (1.7 � 1.06% coverage of total area) whereasmodified material performed much better (25 � 2.6%). Thrombocyteadhesion on treated surfaces was drastically reduced by a factor ofapproximately 14.4 compared to the control (91 � 15.6 platelets/mm2

on modified Ti and 1309 � 211 platelets/mm2 on untreated Ti respec-tively). Conclusions: In a simple one-step procedure Ti surfaces can beendowed with EC adhesive properties while simultaneously reducingplatelet attachment. The concept of PEGylated material-recognizingpeptides, additionally functionalized with bioactive molecules caneasily be translated to further cardio-vascular applications.


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Fig. 1: TibP-PEG-REDV

SC10The beneficial effects of deferred delivery onthe efficiency of hydrogel therapy postmyocardial infarctionKadner K.1, Dobner S.12, Franz T.1, Bezuidenhout D.1, SirryM.1, Reichenspurner H.2, Zilla P.1, Davies N.H.11Cardiovascular Research Unit, Chris Barnard Division ofCardiothoracic Surgery, University of Cape Town, CapeTown, South Africa, 2Universitäres Herzzentrum Hamburg,Klinik und Poliklinik für Herz- und Gefäßchirurgie,Hamburg, Germany

Background: Biomaterials are increasingly being investigated as ameans of reducing stress within the ventricular wall of infarcted heartsand thus attenuating pathological remodelling and loss of function. Inthis context,wehave examined the influence of timing of deliveryon theefficacy of a polyethylene glycol hydrogel polymerised with an enzy-matically degradable peptide sequence. Methods and results: Afterpermanent ligation of the left anterior descending artery in maleWistarrats, PEG gel reagents were injected into the infarcted region andpolymerized in situ. Delivery of the hydrogel immediately after infarctinduction resulted in no observable improvements, but a delay of oneweek in delivery resulted in significant increases in scar thickness andfractional shortening, as well as reduction in end-systolic diameteragainst saline controls and immediately injected hydrogel at both 2 and4weeks post-infarction (p <0.05). Hydrogels injected at oneweek weredegraded significantly slower than those injected immediately and thismay have played a role in the differing outcomes. The hydrogel assumedmarkedly different morphologies at the two time points having either afibrillar or bulky appearance after injection immediately or one weekpost-infarction respectively. Conclusions: We argue that the differentmorphologies result from infarction induced changes in the cardiacstructure and influence the degradability of the injectates. The resultsindicate that timing of delivery is important and that very early timepoints may not be beneficial.

SC11In-vivo testing of decellularized xenogenicheart valvesmatrices on a juvenile sheepmodelAdibekian Z.1, Cebotari S.1, Tudorache I.1, Meyer T.1,Theodoridis K.1, Wendland A.-L.2, Goecke T.1, Mogaldea A.1,Waldmann K.-H.2, Haverich A.1, Hilfiker A.11Medical School of Hannover, Division of Thoracic andCardiovascular Surgery, LEBAO, Hannover, Germany,2Clinic for Swine, Small Ruminants, Forensic Medicine, andAmbulatory Service, University of Veterinary MedicineHannover Foundation, Hannover, Germany

Objectives: Decellularized allogenic grafts demonstrate superior char-acteristics in heart valve replacement therapy compared to currently

commercially available mechanical and bioprosthetic devices. However,limited availability represents the crucial drawback in utilizing acellularallogenc matrices in a sufficient extent for the clinical routine. In orderto explore the alternative application of xenogenic grafts, decellularizedporcine pulmonary heart valves were implanted into sheep and subse-quent analyzed regarding to function and histology. Methods: Porcinepulmonary heart valves (pPHV) were decellularized by the use of adetergent-based protocol (0.5% SDS/Triton X-100) and afterwards de-cellularization success was histological assessed using standard HE andMovat's Pentachrome stainings. In this manner decellularized xeno-grafts were implanted orthotopically into juvenile sheep (n¼3) inpulmonary valve position. Valve function was assessed by echocardiog-raphy after implantation and prior to euthanasia. After 9 months theimplanted grafts were removed and evaluated by histological (H&E,Pentachrome, EvG and von Cossa staining) and immunhistological(DAPI/Phalloidin, anti-CD3, anti-CD45, anti-Type I collagen and anti-alpha-SMA) meanings. Results: Histological analysis of decellularizedvalves prior to implantation showed cell-free and well- preservedextracellular matrix. After explantation the macroscopical aspect ofall three valves showed a good preservation of the initial shape, withoutany stenosis or dilation. The intimal side was shown to be covered withendothelial cells without neointima formation (H&E, DAPI/Phalloidin).Neovessel formation of the adventitia, recellularization and remodellingof extracellular matrix (Pentachrome, Weigert, anti-alpha-SMA, anti-Typ I collagen staining) was observed without any signs of calcification(von Kossa stain). The detection of inflammatory cells with granulocytecharacteristics (anti-CD3, anti-CD45 staining) is representing the exis-tence of a non-specific inflammatory reaction in the explanted tissues.Conclusion: Decellularized xenomatrices may serve as a possible valvesubstitute. They show potential for recellularization on one hand and norejection signs after mid-term postoperatively on the other hand.Further in-vitro as well as in-vivo investigation has to be performedprior to a possible clinical application.

SC12Tissue-engineering of small caliber valvularconduits under different physiological-likeconditionsMogaldea A.1, Cebotari S.1, Haverich A.1, Hilfiker A.11Medizinische Hochschule Hannover, HTTG, Hannover,Germany

Objectives: Synthetic or glutaraldehyde-fixed small caliber valvularconduits are used to repair some right heart congenital diseases.Disadvantages of these grafts are no capacity to growth and rejectreactions. We generated tissue-engineered conduits and tested them in2 different physiological conditions, mimicking venous and pulmonarycirculation. Methods: Ovine jugular venous valves were decellularized.Endothelial cells (EC) were obtained from endothelial progenitor cells(EPC), isolated from ovine peripheral blood. Decellularized valvularconduits were sutured in bioreactors. 3x106 EC were seeded on theluminal side of grafts. To distribute the EC uniformly on the endothelialsurface, reseeded conduits were cultivated into static-rotational con-ditions for 12 hrs (I group, n¼6) and 6 hrs (II group, n¼5). After rotationone vessel from each groupwas analyzed for EC distribution. Grafts fromI group were put into gradually increased flow (pulmonary-like flow),the II group - into continuous low flow (systemic venous-like flow).After 5 days of dynamic cultivation conduits were analysed. Results:After decellularization we obtained cell-free grafts with preservedvalves and extracellular matrix. After rotation and analyze of celldistribution we detected an uniformly coverage of the luminal side,valvular sinus, but not the valve. There are no significant differencesbetween cultivation time on static conditions. After cultivation underpulmonary-like flow, cell coverage on the luminal side was nearlycomplete. Valve coverage was acceptable in sinus and in the middlecusp region with some EC isles on the apex. Grafts from group IIpresented an uniformly luminal EC coverage, as well as nearly completecell layer on the cusps. In both cases orientation of EC from intimawas indirection of flow. Cells from II group showed a typically floworientationin valvular sinus. EC from I group showed only a tendency of sinusorientation, maybe due to cell detachment during flow increasing. Inboth groups were observed different sized cells, which could confirm a


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mitotic activity of EC. Conclusion: Cells could create a stable, nearlycomplete and flow orientated intimal layer, with potential antithrom-botic properties. A low continuous flowhasmore beneficial efects on ECgrowth and coverage than increased flow. To confirm the viability of thisconstructs in vivo testing in animal model would be necessary.

SC13Tube-in-stent: Minimally invasive approach fortissue-engineered aortic heart valvesMoreira R.1, Velz T.1, Malischewski A.1, Gesche V.N.2, FreseJ.1, Jockenhoevel S.1,2, Mela P.11AME-Institute of Applied Medical Engineering, HelmholtzInstitute, RWTH Aachen, Department of Tissue Engineeringand Textile Implants, Aachen, Germany, 2RWTH Aachen,Institut für Textiltechnik, Aachen, Germany

Objectives: Minimally invasive valve implantation techniques havebeen explored as an alternativemethod to replace diseased heart valves.In this study we present the realization of a fibrin-based tissue en-gineered heart valve with a tubular leaflet design, implantable bytranscatheter aortic valve implantation (TAVI) technology. The valveconsists of a tubular construct sutured into a self-expanding nitinolstent at three commissural attachment points and along a circumferen-tial line so that it forms three coaptating leaflets by collapsing underdiastolic back-pressure. Although several available bioprostheses rely ona similar concept and TAVI techniques have been increasingly imple-mented, no tissue-engineered equivalent has been reported so far.Methods: The tubular constructs (n¼3) were moulded by polymeriza-tion of fibrinogen solution in presence of calcium chloride, thrombinand cells isolated from the vein of human umbilical cords. After 7 days ofstatic cultivation, the valves were mounted into the nitinol stent andcultivated under dynamic conditions for 7 days. The valves were thenendothelialised with human umbilical vein endothelial cells (HUVECs)and dynamically cultivated for 7 more days. After harvesting, the valvesunderwent crimping by a 2.5 factor for 20 minutes (estimated time toperform the implantation). Tissue analysis included conventional his-tology, immunohistochemistry and scanning electron microscopy(SEM). Collagen content was assessed by hydroxyproline assay andmechanical propertieswere evaluated by burst strengthmeasurements.Results: The crimping did not affect the valve functionality and theextracellular matrix organization. Tissue analysis showed a homoge-neous cell distribution throughout the valve’s thickness, pronounceddeposition of collagen type I and III oriented along the longitudinaldirection. Immunohistochemical staining against CD31 and SEM re-vealed a confluent endothelial cell layer on both sides of the valvesalthough damage of the layer during crimping cannot be excluded.Conclusions: This study presents the feasibility of combining the tubularleaflet design and theminimally-invasive valve replacement technologyinto a TEHV able to remodel and self-repair, with physiological haemo-compatibility and simple to construct.

SC14Transcatheter heart valve based on a syntheticmatrix for tissue engineering applicationsSabel I.1,2, Hollweck T.1, Fano C.3, DaunerM.3,WintermantelE.2, Hagl C.1, Akra B.11Medical Center Munich University, Department of CardiacSurgery,München, Germany, 2Technical UniversityMunich,Chair of Medical Engineering, Garching, Germany,3Institute of Textile Technology and Process Engineering,Denkendorf, Germany

Objective: Stented heart valve matrices are promising as prospectivetranscatheter heart valve prostheses. The aim of this study was toanalyse the mechanical integrity of polymer-based percutaneous heartvalve prostheses after crimping and perfusion. Methods: Stented poly-urethane heart valves were consecutively seeded with human saphe-nous vein fibroblasts and endothelial cells by using a special 3D-rotatingbioreactor. Seeded valves were crimped and exposed to a flow of 1.5 l/min for three days at physiologic conditions. To evaluate the success ofseeding without damaging the valve, micro-CT imaging was applied.Endoscopicmethodswere used to observe the performance of the valves

under flow. The success of cell seeding after perfusion was analyzed byscanning electron microscopy and immunohistochemistry. Results:Micro-CT tomography showed no damage of the prostheses aftercrimping. Endoscopic analysis showed a regular, partial opening ofthe cusps. A cellular coating of the heart valve with partial damage ofthe both cell layers was demonstrated by immunohistochemistry.Scanning electron microscopy revealed a cellular layer with scatteredruptures. Conclusion: Non-invasive micro-CT tomography can be usedfor the detection of minimal variations on cell-based tissue. Crimpingprocess causes high damages of the tissue surface coated with cells.

Aortic disease/Vascular surgery I

SC15Printing of 3-dimensional models for surgicalplanning of complex aortic arch surgerySodian R.1, Juchem G.1, Weber S.2, Gerber N.2, Khaladj N.1,Hagl C.11LMU München, Herzchirurgische Klinik und Poliklinik,München, Germany, 2Universität Bern, ARTORG Center ofBiomedical Engineering Research, Bern, Switzerland

Objective: In this study, we show the use of three-dimensional printingmodels for preoperative planning of complex surgery for patients withcomplex aortic arch anomalies. Methods: A 70-year-old man withextensive arteriosclerotic aneurysm from the ascending aorta to thedescending aorta was referred to our center for complete aortic archreplacement. The patient was examined by 64-slice computed tomog-raphy. The image data were visualized and reconstructed. Afterwards, aflexible 3D-model was fabricated using a 3D-printing machine. Thepotential surgical intervention itself can be simulated preoperativelyand an additional post-interventional 3D-model was fabricated toexactly visualize the surgical result. Evaluation: Using data derivedfrom 64-slice computed tomography (CT) angiography linked to propri-etary software, we were able to create three-dimensional reconstruc-tions of the pre- and postoperative anatomy of an extended aneurysmfrom the ascending to the descending aorta. The preoperative modeldemonstrates the exact anatomy of the aortic root including valve,leaflets, coronary arteries, ascending aorta, aortic arch, carotid arteries,subclavian artery and descending aorta.

Fig. 1: 3D-Modell

Careful examination of the preoperative model and simulation of thefrozen elephant trunk procedure due to the exact and life-like illustra-tion of the native aortic arch was helpful in the preoperative planning.The postoperative model is bicoloured, showing the native aorta in red


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colour, the prosthesis and the stent material in white. Conclusions:Using the model for preoperative decision making and even simulationof the intervention can be very helpful in patients with complex aorticanomalies. Additionally, the postoperative model exactly shows thesurgical result of the frozen elephant trunk procedure.

SC16Vertebral body erosion in a 27-year old female12 years after thoracic endovascular aorticrepairLuehr M.1, Etz C.D.1, Lehmkuhl L.2, von Aspern K.1, GirrbachF.F.1, Hoyer A.1, Borger M.A.1, Mohr F.-W.11Herzzentrum Leipzig - Universitätsklinik, Klinik fürHerzchirurgie, Leipzig, Germany, 2Herzzentrum Leipzig -Universitätsklinik, Abteilung für Radiologie, Leipzig,Germany

Introduction: Twelve years after severe blunt chest trauma a 27-year oldfemale presented with persisting, medically refractory back pain. Thepatient had been one of the first adolescents to be treated by thoracicendovascular aortic repair (TEVAR) for acute rupture of the aorticisthmus-covering the distal aortic arch down to the thoracic level ofTh7. First symptoms of back pain occurred 5 years after TEVAR andbecame progressively severe and she required medical and orthopedictherapy. Background: At the age of 27, a CT scan revealed an erosion ofthe 7th thoracic vertebral body distally from the implanted stent-graft(Fig.1). Three-Dimensional CT reconstruction showed a broken barespring at the distal end eroding the vertebral body, causing a state ofchronic and progressively severe back pain. Open thoracic aortic repairwas performed urgently to remove the stent and its remnants andreplace the eroded aorta via a left lateral thoracotomy. Stent-graftremoval was aggravated due to the severe adhesions triggered bychronic inflammation in close proximity of the stent-graft due toprosthetic failure, i.e. eroding broken bare springs and dissolvingprosthetic material. The following clinical course was uneventful andthe patient was discharged on POD#5. Discussion: Open surgeryremains the gold standard to treat thoracic aortic pathologies extendingbeyond the distal arch due to acceptable postoperative mortality andmorbidity with excellent long-term outcomes. Despite a reported lowearly postoperative mortality, stent-grafts-if compared to open aorticsurgery-tend to result in a higher incidence of long-term complications,e.g. endoleaks, device failure or migration, and aneurysm-related death.Since long-term outcome after TEVAR (>10 years) remains unknown,we believe that stent-grafts-especially in the very young-should only beused in life-saving clinical emergencies as severe collateral damage toadjacent mediastinal structures might occur unexpectedly.

Fig. 1

SC17Protective function of Junctional-adhesion-molecules in the rewarming process after mildhypothermiaKanzler I.1, Bogert N.1, Stock U.A.1, Zierer A.1, Moritz A.1,Beiras-Fernandez A.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, Thorax-, Herz-, und Gefäßchirurgie,Frankfurt, Germany

Objective: During circulatory arrest in aortic surgery, patients aresubjected to therapeutic hypothermia to reduce the risks of ischemicinjury. Infiltration of pro-inflammatory cells into the surrounding tissuerepresents an additional hazard to patients undergoing aortic surgery.Junctional-adhesion-molecules (JAMs) are essential for the endothelialpermeability and consequent transmigration. We investigated theinfluence of different hypothermic cell-activation temperatures fol-lowed by rewarming to 37°C on the expression of JAM-A, and JAM-Bon endothelial cells after the rewarming process. Methods: JAM-A and-B expressionwas analyzed on endothelial cells (EC) under following co-culture conditions a) activated PBMC/not-activated EC b) not-activatedPBMC/activated EC or c) both cell types activated. Cell activation wasperformed at different temperatures: 37°, 30°C and 18°C and were thenrewarmed to 37°C for co-culture experiments. p<0.05 was consideredas statistically significant. Results: Under condition b) and c) at 37°C,significant less JAM-B was expressed on endothelial cells compared toJAM-A expression levels (b: JAM-A 1.001 � 0.079tmx vs. JAM-B 0.755 �0.080tmx; c: JAM-A 0.910 � 0.034tmx vs. JAM-B 0.701 � 0.071tmx).Significant less JAM-A and JAM-B is expressed on ECwhen either only ECwere activated at 30°C or both cell types were activated at 30°C (b: JAM-A 0.773 � 0.030tmx vs. JAM-B 0.815 � 0.062tmx; c: JAM-A 0.853 �0.058tmx vs. JAM-B 0.855� 0.027tmx. The cell activation at 18°C causedin all co-culture set-ups a significant drop in JAM-A and JAM-B expres-sion on EC compared to control. Conclusion: Our experiment shows asignificant influence of temperature on JAM expression. Our dataindicate that the lower the temperature difference in the rewarmingprocess (18°C to 37°C vs. 30°C to 37°C) is, the higher are JAMs expressedand thus the endothelial cell junction and their interaction is lessdisturbed. The positive modulation of JAMs in the endothelium undermild hypothermia supports the clinical affirmation to favor mildhypothermia instead of severe hypothermia.

SC18Underestimated: Erectile dysfunction inpatients with ascending aortic diseaseSchuster V.1, Waidelich R.2, Ueberfuhr P.1, Eifert S.3,Guenther S.1, Khaladj N.1, Hagl C.1, Pichlmaier A.M.1,Guethoff S.11Department of Cardiovascular Surgery, Ludwig-Maximilians University, Munich, Germany, 2Department ofUrology, Ludwig-Maximilians-University Hospital, Munich,Germany, 3Department of Cardiac Surgery, Heart CenterLeipzig, Leipzig, Germany

Objectives: Erectile dysfunction (ED) is correlated with cardiovasculardisease (CVD) in general and following abdominal aortic surgery inparticular. Little is known about ED in patients with ascending aortadisease (AAD). Methods: Following repair of the ascending aorta malepatients were asked about risk factors, ED, libido deficiency (LD),reproductive history and hormone disorders. The response of 330men with a follow-up of 6.4 � 3.1ys (1.8-12.5ys) were compared toan age-matched control group of 100men (age 66.2� 12.0 ys and 66.2�13.0 yrs, p¼0.934; body mass index 27.7 � 5.1 vs 27.1 � 3.8 p¼0.454;diabetes mellitus 12.1% vs 10.2%, p¼0.720; peripheral arterial disease3.6% vs 5.4%, p¼0.543; carotid disease 6.8% vs 8.7%, p¼0.646). Results:Compared to the matched control group, males with AAD were twice ascommonly affected by ED (48.0% vs 22.8%, p¼0.001) and had signifi-cantly more LD (42.9% vs 27.2%, p¼0.007). No relevant difference inadmitting ED was found in patients with aortic aneurysm as comparedto aortic dissection (p¼0.105). No impact was found on ED or LD by thesurgical procedure including coronary artery bypass graft (CABG) andvalve procedures. Males with AAD more often received CABG (16.2%, allwith aortic surgery except one patient, vs 3.4%, p¼0.001), however,


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percutaneous coronary intervention (PCI) was less commonly observed(5.4% vs 16.3%, p¼0.001) compared to controls. Interestingly, maleswith AAD were less frequently found to be smokers than controls, butmales with AAD more commonly had a previous smoking history(current 6.1% vs 17.0%, p¼0.001; additive previous and current27.4%, p¼0.022). Hypertension and hypercholesterolemia were moreprevalent in AAD (87.7% vs 47.5%, p<0.001; and 46.4% vs 33.0%,p¼0.012). Independently, a strong correlation exists between NYHAand ED (I 33.3%, II 48.8%, III 63.9%, and IV 66.7%; p< 0.001). Aorticpatients presented in worse NYHA status compared to controls (I 26.3%vs 45.9%, II 45.3% vs 38.8%, III 25.6% vs 14.3%, and IV 2.4% in both groups;p¼0.002). Comparing males with AAD to controls, no differences wereseen in reproductive history and hormone disorders. Conclusions: Thehigh prevalence of ED in patients with ascending aortic disease may bean expression of cardiac insufficency as such or amarker of a populationwith a distinctive cardiovascular risk profile. More awareness of thisassociation is required for the implementation of appropriate treatmentconcepts to address this sensitive subject.

SC19Hybrid endovascular prosthesis in complexthoracic aortic disease: A tool that reallymatters or just a toy?LiebrichM.1, Roser D.1,Maletskidis C.1,Walle U.1, CzeslaM.1,Strauss H.1, Tzanavaros I.1,Weimar T.1, Doll K.-N.1, HemmerW.B.11Sana Herzchirurgie, Stuttgart, Germany

Objective: To treat degenerative or dissecting aneurysms involving theaortic arch and descending aorta, the frozen elephant trunk technique(Evita-open, JOTEC) has been used at our institution. Material andmethods: Between 03/2009 and 09/2013, 62 patients (mean age: 65.3� 9.6 years, males 61%) were treated with the frozen elephant trunktechnique. Indications for surgery included acute type A dissection(n¼16), chronic type A dissection (n¼16), and chronic aneurysm(n¼30). Twenty-three patients (37%) had undergone previous cardio-vascular procedures. In 26 patients (42%) additional cardiac procedures(CABG n¼5; mitral valve reconstruction n¼2; tricuspid valve recon-struction n¼2; David-procedure n¼12; modified Yacoub-proceduren¼6; aortic root replacement n¼3) were performed. Brain protectionwas achieved by means of antegrade selective cerebral perfusion anddeep hypothermia (18°C) in all cases. Results: 30-daymortalitywas 11%(n¼7 patients). Follow-up was 97% complete, with mean duration of19.3 � 7.4 months. Postoperative complications included rethoracot-omy for bleeding, stroke, spinal cord injury, acute renal failure requiringtransient dialysis, and prolonged ventilator support (>72 h) 11% (n¼7),11% (n¼ 7), 6% (n¼4), 13% (n¼8), 16% (n¼9), respectively. Endovas-cular extension was required in 10 patients (16%). One open thoracoab-dominal repair was performed in a marfan patient. At last CT-control,complete thrombosis of the peri-stent false lumen was documented in93%. Conclusion: The frozen elephant trunk technique, enabling treat-ment of extensive disease of the thoracic aorta, was associated withencouraging short-term results and is potentially able to facilitate acomplex procedure.

SC20Re-rupture of calcified sinus of valsalvaaneurysm34 years after primary surgical repairBasti B.1, Saeed G.2, Ghazal M.1, Matin M.1, Peivandi A.A.11Klinikum Kassel, Klinik für Herz- und Gefäßchirurgie,Kassel, Germany, 2Klinikum Kassel, Klinik für Herz- undKreislauferkrankungen, Kassel, Germany

Objective: Sinus of valsalva aneurysm (SVA) is a rare aortic lesions andarise from congenital or acquired weakening of aortic medium at thejunction with the aortic annulus. SVA may remain asymptomatic untilthey rupture. Different surgical strategies have been evolved for thesurgical treatment of ruptured SVA. It is not much known about the longterm results of surgical treatment of ruptured SVA.Method:We presenta rare case of a 58-year-old male with a re-ruptured sinus of Valsalvaaneurysm 34 years after primary surgical repair. Results: A 58-Year-oldmale patient was admitted to our hospital because of sudden onset of

chest pain. 34 years ago, he had undergone a surgical repair of rupturedof non-coronary SVA into the right atrium via transaortic approach anddirect closure. At admission, the physical examination revealed sinustachycardia and loud continuous cardiac murmur. The chest radiographshowed cardiomegaly, pulmonary congestion and calcified contour ofthe aortic root. A transesophageal echocardiography revealed a rup-tured of a calcified aneurysm (diameter: 4 cm) of the non-coronarysinus of valsalva into the right atrium with the characteristic “windsock” appearance, a markedly dilated right atrium, left to right shuntingand a mild aortic valve regurgitation. We performed the surgical repairby a dual chamber approach (transaortic and right atrium). The calcifiedaneurysmal sac was completely excised and the resulted defect wasrepaired with Dacron patch. The non-coronary cusp of the aortic valvewas implanted at the base of the patch. Commissural resuspensionswere needed to achieve aortic valve competence. The postoperativecoursewas uneventful. At 4-year follow-up, the patient is doingwell andthe control echocardiogram showed competent aortic valve.Conclusion: Recurrence of aneurysmal formation of the sinuses ofvlsalva after primary surgical repair is not excluded. Different surgicalstrategies have been evolved for the surgical treatment of ruptured SVAfrom simple primary closure to patching of the rupture site by a dualchamber approach. Dual chamber (the involved chamber and aorta)approach is feasible and offers optimal exposure for surgical repair.However, long-term follow-up after surgical repair of SVAwith moderndiagnostic tools is recommended because of possible aneurysmalrecurrence.

SC21Late prosthetic graft infection after frozenelephant trunk presenting by hemoptysis andpositive FDG PET/CTMorjan M.1, Breitenbach I.1, Anssar M.1, Ali K.1, HarringerW.1, El-Essawi A.11Klinikum Braunschweig, Klinik für Herz-, Thorax- undGefäßchirurgie, Braunschweig, Germany

Introduction: Late prosthetic graft infection confronts a surgeon withboth diagnostic and therapeutic challenges especially in case of complexprevious surgery. Background: We present the case of a 73 year oldfemale patient who had been admitted to our hospital for recurrenthemoptysis. Her past history included a previous Bentall procedurewithtotal arch replacement and implantation of a frozen elephant trunk 2years earlier. A lung tumor was suspected and a computer tomographywas done that revealed a lesion in the left upper lobe. For furtherconfirmation an 18F-fluorodeoxyglucose-positron emission tomogra-phy (FDG-PET) was performed that suggested an infection of the wholeprosthetic material. Echocardiography showed no evidence of an endo-carditis and blood culture was negative. To confirm the infection andrule out an erosion of the lung by the elephant trunk an atypicalresection of the left upper lobe was performed via a left lateralthoracotomy. Neither histology nor microbiological examination ofintraoperative material could confirm an infection nor could the intra-operative macroscopic finding. Following an asymptomatic period of 2months the patient was again admitted for hemoptysis and finally thedecision for surgery was taken. Surgery revealed a valve endocarditisand an infection involving thewhole prostheticmaterial. The aortic root,aortic arch and proximal descending aorta were replaced with an aorticroot homograft and a homograft from the descending aorta. Crossclamping time was 236 minutes bypass time 322 minutes and theduration of surgery 8.5 hours. The patient was extubated on the firstpostoperative day and remained on the ICU for 5 days. Microbiologicalexamination of the intraoperative material revealed a staphylococcalinfection. Except for the implantation of a pacemaker the patient had anuneventful postoperative course. She was discharged to a rehab centreon the 17th postoperative day. Discussion: FDG PET/CT can be a veryuseful tool in the diagnosis of late graft infection and should always beconsidered in doubtful cases. The complexity of a reoperation in such anextensive case should not impede the decision for surgical correction.


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SC22Women with ascending aorta diseases reachmenopausal age earlierGuethoff S.1, Schuster V.1, Himsl I.2, Ueberfuhr P.1, Eifert S.3,Guenther S.1, Khaladj N.1, Hagl C.1, Pichlmaier A.M.11Department of Cardiovascular Surgery, Ludwig-Maximilians University, Munich, Germany, 2Department ofObstetrics and Gynaecology, Ludwig-Maximilians-University, Munich, Germany, 3Department of CardiacSurgery, Heart Center Leipzig, Leipzig, Germany

Objectives: Cardiovascular morbidity/mortality is comparatively low inpremenopausal women, but increase sharply following menopause.Research has been limited to women with abdominal aortic aneurysmswhere earlier onset of menopause was associated with larger aneur-ysms. The aimwas to determine whether womenwith ascending aorticdisease (AAD) have a different reproductive history compared to agedmatched controls. Methods: Women who had undergone repair of theascending aorta were asked about risk factors and reproductive history.The response of 142 women with AAD with a follow-up of 6.7 � 3.1 yrs(1.9-12.6 yrs) was compared to an age-matched control group of 64women (age 70.8 � 10.5 yrs and 70.1 � 11.4 yrs, p¼0.596; BMI 25.9 �5.6 kg/m2 vs 25.2� 4.1 kg/m2, p¼0.601). A subgroup of the AAD cohortwith validated ascending aortic aneurysms (TAA) �5cm werefurther investigated (n¼64, age 71.4 � 10.8 yrs, p¼0.331; BMI 24.4� 4.6 kg/m2,p¼0.625). Results: Hypertension and Hypercholesterol-emia were more prevalent in women with AAD compared to controls(88.7% vs 61.9%,p<0.001, and 49.3% vs 30.6%, p¼0.010). There weremore smokers amongst women with AAD (24.6% vs 6.3%, p¼0.001;current 8.5% in AAD, p¼0.419). Coronary artery disease (bypass graftsor percutaneous coronary intervention) (CAD) was more evident inwomen with AAD (12.6% vs 3.4, p¼0.037). Menopausal age had beenreached in 97.1% of women with manifest AAD and in 90.6% of controls(p¼0.054). Comparing all women with AAD and the subgroup withTAA�5 cm, to controls demonstrated the same age of menarche (firstmenstruation at 14.0 � 1.7 yrs, or 14.0 � 1.8 yrs, vs 14.2 � 1.8 yrs,p¼0.813, resp. p¼0.837), but a clearly earlier last menstruation age forwomen with AAD (menopausal age 49.7 � 5.9 yrs, or 48.1 � 4.9 yrs, vs50.6 � 5.8 yrs, p¼0.023 or p¼0.012). This results in a clear trend of ashorter time period between menarche and menopause in womenfound to have AAD and those with TAA�5 cm, both compared to thecontrols (34.9 � 5.7 yrs, and 34.2 � 5.2 yrs, both vs 36.2 � 5.7 yrs,p¼0.060, and 0.036 for TAA�5 cm). Conclusion: Women with AADmore commonly presented with known cardiovascular risk factors andrelevant CAD. In AAD and TAA a significant shortening of the reproduc-tive period and therefore an abbreviated endogenous production offemale sex hormones was observed as compared to controls. Thissuggests yet again a relevant role of the endocrine system in thedevelopment of aortic disease.

SC23Collagen analysis in aneurysmal ascendingaorta obtained from patients with bicuspidaortic valve disease compared with tricuspidaortic valve aneurysmNavarrete Santos A.1, Lochmann P.1, Yan J.Y.2, Simm A.1,Silber R.-E.1, Sievers H.H.2, Mohamed S.A.21Martin Luther University, Halle, Germany, 2UKSH CampusLuebeck, Luebeck, Germany

Aim:Aneurysm is a common occurrence in the elderly and patientswithbicuspid aortic valve (BAV) disease. The aim of the current study was tocharacterize collagen content in advanced glycation end products(AGEs) of aneurysmal aortic tissue from BAV patients and controltricuspid aortic valve (TAV) patients.Materials and methods: Aneurys-mal specimens were collected from 11 BAV patients (mean age, 52.5 �17.0 years) and 6 TAV patients (mean age, 68.0 � 6.8 years). Collagenfrom 100 mg aneurysmal aortic tissue was isolated by enzymaticdigestion using pepsin (PEF) and the non-digested material was furtherdigested using cyanogen bromide (CNBr; CNBr fraction), whereasinsoluble collagen was extracted by HCl hydrolysis (HF). The AGEcontent in the different collagen fractions was analyzed by measuringAGE fluorescence. The AGE-modified carboxymethyllysine (CML), pen-

tosidine, and argpyrimidine in the CNBr fraction were immunologicallyanalyzed via slot blot analysis. The immunological detection of carbonylgroups introduced into proteins by oxidative reactions was analyzed inthe CNBr fraction using the Oxyblot protein detection kit. The collagencontent in the different fractions was quantified using the 4-hydroxy-proline assay. Results: Samples of TAV tissue showed diminishedfluorescence of the pepsin extracted fraction compared to BAV tissue(129.8 � 53.1 vs 90.6 � 22.2 µg, p¼0,02). CML and pentosidine contentin BAV tissuewas significantly higher in comparison to that inTAV tissue(0.355 � 0.337 vs 0.127 � 0.151, p¼0,007). Conclusion: Collagenanalysis of AGE content in thoracic aortic aneurysms is critical tounderstand the nature of early BAV-associated aneurysms.

SC24Activation of endocannabinoid system isassociated with persistent inflammation inhuman aortic aneurysmGestrich C.1, Dürr G.D.1, Heinemann J.1, Meertz A.1, ProbstC.1, Röll W.1, Zimmer A.2, Bindila L.3, Lutz B.3, Welz A.1,Dewald O.11University Clinical Centre Bonn, Dept. of Cardiac Surgery,Bonn, Germany, 2Institute for Molecular Psychiatry,Life&Brain, Bonn, Germany, 3Institute of PhysiologicalChemistry, University Medical Centre Mainz, Mainz,Germany

Objectives: Inflammation has been suggested in human aortic aneur-ysms and associated with remodeling of the vessel wall. Endogenouscannabinoids and their receptors have been shown to modulate inflam-matory response and tissue remodeling in many organs. Therefore, weinvestigated components of the endocannabinoid system, inflammationand remodeling in human aortic aneurysms.Methods: Specimen of theanterior aortic wall were collected from patients undergoing electivesurgery for aortic aneurysm (n¼21) or for coronary artery disease ascontrols (n¼67). Small buttons of aortic tissue from bypass patientswere pooled for molecular analysis and mass spectrometry (n¼21-23).Histological and molecular analyses (qRT-PCR) were performed andendocannabinoids and their metabolites were measured using massspectrometry. Results: Patient characteristics were comparable be-tween the groups except for a higher incidence of arterial hypertensionand diabetes in the control group. Histological analysis revealed signifi-cantly higher density of newly recruited leukocytes (MAC 387þ) andmacrophages (CD11bþ) in the adventitia of the aneurysms. The molec-ular analysis showed a proinflammatory environment based on upregulation of TNF-α and M-CSF, without induction of chemokines.mRNA-expression of endocannabinoid receptors CB1 and CB2 wassignificantly higher in aneurysmal tissue than in controls. Concentrationof endocannabinoids 1- and 2-arachinoylglycerol was significantlyhigher, while concentration of anandamide and its metabolites arach-idonic acid and palmitoylethanolamide were significantly lower inaortic aneurysm tissue. We further investigated remodeling parametersand found significantly less mRNA-expression of osteopontin, CTGF andMMP-2 in aneurysmal tissue. The collagen stained areawas comparablebetween the aneurysms and control samples. Conclusions: Our dataprovide evidence for differential regulation of endocannabinoids, theirmetabolites and receptors being associated with a persistent low levelinflammation and vessel wall remodeling in human aortic aneurysmtissue.

SC25The treatment of patients with Type A aorticdissection - predictors for in hospital mortalityin 534 patients as two center experienceLeontyev S.1, Légaré J.-F.2, BorgerM.A.1, Buth K.J.2, Funkat A.K.1, Gerhard J.1, Mohr F.W.11Herzzentrum Leipzig, Herzchirurgie, Leipzig, Germany,2Queen Elizabeth II Health Sciences Center, Department ofSurgery, Division of Cardiac Surgery, Halifax, Canada

Objective: The aim of this study was to evaluate predictors for inhospital mortality after surgical treatment in patients with type A aorticdissection (TypeA) and create an easy to use SCORE card to predict in-


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hospital mortality. Methods: We reviewed retrospectively all consecu-tive patientswho underwent surgery for acute TypeA between 1996 and2011 at the two institution. A logistic regression model was created toidentify independent preoperative predictors of in-hospital mortality.The results were then used to create a scorecard predicting operativerisk. Results: A total of 534 consecutive patients were emergentlyoperated for acute TypeA. Mean age was 61 � 14 years and 36.3%were female. Critical preoperative state was present in 31% of patientsand malperfusion of one or more end organs in 36%. Unadjuested in-hospital mortality was 18.7% (n¼100). The most common postopera-tive complications were: low cardiac output 10.7%, neurological com-plication 19%, bleeding 22.5%, dialysis 19.7% and sepsis 8.4%. Onmultivariate analysis preoperative resuscitation (OR 2.6, p<0.02,1.14-6.1), visceral malperfusion (OR 3.3, p¼0.002, 1.5-7.1), malperfu-sion of extremities (OR 2.2, p¼0.002, 1.1-4.2) and coronary arterydisease (OR 2.08, p¼0.01, 1.1-3.6) were independent predictors for in-hospital mortality. Age lower than 50 years (OR 0.3, p¼0.01, 0.16-0.8)was protective for early survival. We created an easily usable mortalityrisk score based on these variables. The patients were stratified into treerisk categories according in-hospital mortality with ranging from <5%risk to>40%. (ROC Curve -0.76; Hosmer and Lemeshow - 0.8)Conclusion: This represents one of the largest series of patients withType A aortic dissection in which a risk model was created. Using ourapproach, we have shown that age, critical preoperative state andmalperfusion syndrome were independent risk factors for earlymortality.

SC26Effectiveness and limitation of endovascularrepair for type B aortic dissection: perspectivefrom long-term resultsShimamura K.1, Kuratani T.2, Shirakawa Y.2, Torikai K.3,Watanabe Y.3, Sakamoto T.3, Shijo T.3, Reichenspurner H.C.K.1, Sawa Y.31University Heart Center Hamburg, Hamburg, Germany,2Osaka University Graduate School of Medicine,Department of Minimally Invasive CardiovascularMedicine, Osaka, Japan, 3Osaka University Graduate Schoolof Medicine, Department of Cardiovascular Surgery, Osaka,Japan

Introduction: Thoracic endovascular aortic repair (TEVAR) has devel-oped to be the first line procedure to treat the complications of acute(within 14days from onset) type B aortic dissection, and recent studiessuggest that it could even be embraced to replace the open surgery formanaging uncomplicated chronic (after 14days form onset) dissectionby preventing late aorta-specific mortality. Moreover, several studiessuggested the impact of chronicity of the dissection to the long-termresult, however its detailed analysis is still not yet described. Patientsand method: We retrospectively analyzed 251 thoracic endovascularaortic repairs for type B dissection performed between 1993 and 2013 inOsaka University. The patients (Male 199(79.3%), average 64.5 y.o) weretreated both in acute phase (complicated or at risk for developingcomplication, n¼50) and in chronic phase (aortic diameter >50 mmor rapid enlargement, n¼201). The patients are divided into 4 groups byits treatment timing from symptom onset (Group A (n¼50): within14days, B(n¼ 49): 15days to 3 month, C(n¼28): 3 month to1 year, D(n¼84): more than 1year), and early and long-term results wereanalyzed. Result: The rate of operative mortality (A: 6.0%, B:0%, C:0%,D:1.2%) , stroke (A: 4.0%, B: 2.0%, C:0%, D:2.4%) were similar in all groups,and no spinal cord ischemia was observed. In long-term (average 40.8month) follow up, the achievement of aortic remodeling at 6 monthpostoperatively was higher in group A and B (A:66.7%, B:71.4%, C:28.6%,D:42.3%, p¼0.0018). The aorta-specific survival (A: 92.7%, B:90.0%,C:71.8%, D:97.2% at 10year) and freedom from aortic event (A: 56.5% ,B: 76.9%, C: 61.2%, D: 42.9% at 10year) were statistically similar in allgroups, however the possibility to require re-intervention for persistentfalse lumen enlargement had a tendency to be high in more chronicgroup (A: 0%, B: 8.4%, C: 23.5%, D: 37.8% at 10year). Conclusion: TEVARwas an effective procedure for type B dissection, however in morechronic dissection, the achievement of aortic remodeling could bedifficult and re- entry intervention would be required. The undergoing

prospective trial could provide important information to decide thetreatment strategy for type B dissection.

SC27Decellularized aortic allograft stabilized by anabsorbable magnesium scaffold forsubstitution of the descending aortaKaufeld K.T.1, Schilling T.1, Hinz C.1, Brandes G.2, CebotariS.1, Tudorache I.1, Mogaldea A.1, Bach F.-W.3, Hassel T.3,Biskup C.3, Bauer M.3, Hilfiker A.4, Haverich A.11Hannover Medical School, Department of Cardio-thoracic,Transplantation and Vascular Surgery, Hannover,Germany, 2Hannover Medical School, Department of CellBiology, Centre of Anatomy, Hannover, Germany, 3LeibnizUniversität Hannover, Institute of Materials Science,Garbsen, Germany, 4Hannover Medical School, LeibnizResearch Laboratories for Biotechnology and ArtificialOrgans, LEBAO, Hannover, Germany

Introduction: Several pathologies of the thoracic aorta such as bluntchest traumas, aortic aneurysms/ dissections require surgical treatmentand are associated with a high risk of rupture and organ ischemia. Asidefrom endovascular aortic repair, often invasive treatment is unavoid-able. Widely used dacron prostheses have many limitations such as theinability to grow, repair and remodel as well as the predisposition forinfections, risk of thrombosis and lack of windpipe function. Here, wereport the successful stabilization of decellularized aortic allografts withan absorbable magnesium scaffold (AMS) in descending aorta position.Material and methods: Allogenic tissue grafts of the descending aorta(DA) and pulmonary artery (PA)were harvested from juvenile sheep anddecellularized with 0.5% sodium deoxycholate (SDC) and 0.5% sodiumdodecyl sulfate (SDS). Tissue-engineered allografts of the descendingaortawere generated by connecting theDAwith the PA and implanted in18 sheep. The AMSwere employed in half of the animals to stabilize thegraft. Explantation of 6 grafts was performed 1, 3, and 6 monthsrespectively following implantation. Allografts were also histologicallyanalyzed, examined by magnetic resonance imaging (MRI) and biome-chanically tested. Biodegradation of explanted AMS was quantified byMikro-CT (µ-CT). Results: In MRI, aortic dilatation was observed pre-dominantly in PA segments of allografts without stabilization by AMS.Increased neovascularisation of the adventitia could be visualized ingrafts with AMS. Furthermore, there was a significant improvement ofcellular repopulation in magnesium supported grafts. Biomechanicaltesting revealed a decreased rigidity due to the detergent-based decel-lularisation process. Therewas no evidence for thrombotic alterations inall groups. After 6 months AMS are shown to be almost completelyabsorbed in µ - CT. Conclusions: This study shows that degradingmagnesium scaffolds can be successfully used to stabilize decellularizedallografts of the descending aorta. The biomechanical traits of thedecellularized pulmonary artery grafts restrict the applicability incardiovascular high pressure system. We demonstrate that AMS canpromote cellular ingrowth and therefore may positively influenceremodeling of decellularized aortic grafts.

SC28Re-thinking spinal blood supply of descendingaortic aneurysms: intraoperativemonitoring ofspinal cord perfusion is essential to avoidparaplegiaTozzi P.1, Siniscalchi G.1, Gronchi F.2, Pretre R.21University Hospital Lausanne, Cardiac Surgery, Lausanne,Switzerland, 2University Hospital Lausanne, Lausanne,Switzerland

Objective: The physiopathologyof spinal cord ischemia during descend-ing aortic aneurysm (DAA) repair assumes that spinal cord is normallyirrigated, which is not always the case. Monitoring spinal cord function-ing during surgery helps to understand how disease has modified spinalperfusion and drives the surgical repair. Methods: Patients scheduledfor open repair of type I DAAunder femoro-femoral CPB received lumbardrain to control Cerebrospinal Fluid (CSF) pressure and Motor EvokedPotentials (MEPs). After gathering baseline values, aorta was cross-


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clamped; MEPs detected spinal cord ischemic distress and surgeonselective irrigated intercostals arteries using retrograde cardioplegialines. Repeated MEPs associate to combinations of arteries perfusionallowed the identification of keys arteries for optimal spinal bloodsupplying. Only these arteries were re-implanted into graft. Results:20 consecutive patients showed signs of spinal cord distress duringaortic cross-clamp. Four (20%) were clearly paraplegic; 16 (80%) hadasymmetric legs motor response. CSF pressure was kept below 12mmHg. Mean CSF drained was 46 � 19 ml (range 15 to 65 ml). Oneup to 3 intercostals branches out of 4 to 6 were identified as key arteriesfor spinal cord perfusion and re-implanted into graft. 1/20 (5%) devel-oped paraplegia day 2. Conclusions: The asymmetric motor responseduring aortic cross-clamp is not physiologic and confirms that DAAcould unpredictably affect spinal cord perfusion. Blindly re-implant allintercostals arteries is technically demanding and possibly useless.Repeated MEPs with selective intercostal artery perfusion seems tobe an effective tool to select which artery provides the appropriatebloodsupply, speeding up the procedure and possibly improving results.

Coronary heart disease

SC29Direct reimplantation as an alternativeapproach for treatment of anomalous aorticorigin of the right coronary artery - A case seriesWilbring M.1, Izumi K.1, Stumpf J.2, Matschke K.1, KappertU.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany, 2Praxisklinik Herz undGefäße, Dresden, Germany

Objectives: Anomalous aortic origin of the coronary artery (AAOCA) is arare cardiac anomaly, associated with myocardial ischemia, infarctionand even sudden death. Case report: We report two cases including a22-years old male and a 49-years old female patient, both presentingwith AAOCA of the right coronary artery (RCA) originating from leftcoronary sinus with an initial intramural course. In both patients, weperformed uncomplicated direct reimplantation of the RCA into theright coronary sinus. For this purpose, the RCA was dissected from thetransmural emersion point out of the aortic wall to the crux cordis,subsequently as proximal as possible transected and directly reim-planted into the right coronary sinus. In both cases, postoperativecourse was uneventful and cardiac computed tomography confirmedexcellent postoperative result after 1-year of follow-up. Conclusion: Thistechnique is a convenient and easy performable approach, characterizedby short x-clamp times and avoidance of aortotomy and thus anexcellent alternative strategy to coronary artery bypass grafting or“unroofing-technique”.

SC30Is primarily percutaneous stent implantationjustified by worse outcome after coronaryartery bypass grafting in obese patients?Buschmann K.1, Karliova I.1, Poetini L.1, Vahl C.F.11Uniklinik Mainz, HTG-Chirurgie, Mainz, Germany

Objectives: Recent studies stress the role of an increased body massindex (BMI) associated with stent thrombosis after percutaneous inter-vention, but primarily stent implantation in obese patients has oftenbeen justified by suggested higher postoperative risk. To verify worsepostoperative outcome in obese CABG patients we initiated a clinicalsurvey and compared postoperative outcome of obese and normalweighted patients. Methods: A retrospective study was performedout of 2.355 consecutive CABG patients that were assigned to eitherthe Obese group (n¼1.717, BMI>25) or the Control group (n¼638,BMI�25). Group differences were statistically tested by student‘s T-test. Results: 30-day-Mortality was 4% in Obese and 5% in Control group(p¼0.002*). Postoperative incidence of compensated renal insufficien-cy was detected in 13% of Obese and 14% of Control patients (p¼0.027).Postoperative incidence of sepsis was 0% in Obese and 1% in Controlgroup (p<0.001*). Postoperative bronchopulmonal infection got 3% of

Obese and 4% of Control patients (p¼0.005*). Postoperative sternalwound infection was stated in 2% of Obese and in 1% of Control group(p<0.001*). Conclusion: Obese patients were only associated with anincreased risk of postoperative sternal wound infection. Based on thesedata primarily surgical CABG procedure should not be denied even inobese patients. A primarily percutaneous intervention in obese patientssuffering from CAD is not justified by the myth of worse postoperativeoutcome besides the current reported higher risk of stent restenosis inobese patients.

SC31Postoperative outcome of patients undergoingoff pump coronary bypass surgery in criticalpreoperative stateLoeblein H.1, Dzemali O.1, Haeussler A.1, Genoni M.11Triemli, Zürich, Switzerland

Introduction: Critical preoperative sate (ventricular tachycardia orventricular fibrillation or aborted sudden death, preoperative cardiacmassage, preoperative ventilation before anesthetic room, preoperativeinotropes or IABP, preoperative acute renal failure) has been consideredrisk factor for worst outcome. This studywas undertaken to see if criticalpreoperative state has any impact in postoperative outcome in patientsundergoing off pump coronary bypass surgery (OPCAB). Methods: Thedata of patients who underwent OBCAB between 1/2008-12/2010 wasretrieved form our data bank. An association between critical preoper-ative sate and postoperative outcome: troponin, Creatinine-KinaseMuscle-Brain (CKMB), noradrenalin requirement, creatinine, atrial fi-brillation, use of intra-aortic balloon pump (IABP), intubation time, ICUdays, packed red blood cell (PRBC), platelet transfusion and mortalitywas evaluated. Results: From 1/2008 to 12/2010, 540 OPCAB wereisolated. 16.3% were in critical preoperative state. Critical preoperativestate was significantly related to postoperative intubation time(p¼0.001), ICU days (p¼0.000), IABP use (p¼0.000), CKMB(p¼0.000), troponin (p¼0.000), platelet transfusion (p¼0.002), butnot to mortality, use of noradrenalin, PRBC transfusion, atrial fibrilla-tion, creatinine. Conclusion: In OPCAB preoperative critical preopera-tive state is not associated to mortality, renal failure, atrial fibrillation,PRBC transfusion and the use of noradrenalin.

SC32“Blame it on the comorbidities”A 5-year follow-up of 53 chronic dialysis-dependent patientswho underwent cardiac surgeryDeutsch O.1, Rippinger N.1, Spiliopoulos K.1, Eichinger W.1,Gansera B.11Klinikum Bogenhausen, Herzchirurgie, München,Germany

Objectives: This study evaluatesmid-term survival rates and risk factorsfor mortality of chronic dialysis-dependent patients undergoing cardiacsurgery. Methods: Fifty-three dialysis-dependent patients (34 males,age 67 � 12 years) with end-stage renal disease operated within March2007 and May 2012 were analyzed retrospectively. Twenty-threepatients received isolated CABG, 17 isolated valve replacement and 13combined procedures. Survival rates were calculated using Kaplan-Meier-methods. Predictors of mid-term survival were identified withmultivariate Cox-regression analysis. Results: Thirty-day mortality was24.5% (n¼ 13). Follow-up was complete for 94.3% (n¼50). Survival-rates at 1, 3 and 5 years were: 82, 50 and 17%, respectively. Neither age,gender, poor EF, emergency, ECC/X-clamp-time, nor use of LITA or RITAhad any influence on mid-term survival. Cause of death within mid-term follow-up period was cardiac related in 16% and related toneurological events in 16%. In themajority cause of deathwas associatedwith PAD (47%). The only comorbidity, which could be identified as asignificant riskfactor, was PAD (p¼0.035). Five patients underwentsuccessful renal-transplantation within the follow-up period.Conclusions: Although 30-day-mortality in this high-risk patient pop-ulation was increased, mid-term survival rates were comparable to theresults described in literature. Cause of death within mid-term follow-up period was mostly non-cardiac related. Predictors for enhanced 30-day mortality, like preoperative myocardial infarction, prolonged


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extracorporeal circulation and operationtime did not have an influ-ence on mid-term survival.

SC33Emergency surgical revascularisation inpatients with acute myocardial infarction withineffective or impossible PTCA requiring intra-aortic balloon pumping (IABP) preoperativelyKapsalis A.1, Sachweh J.S.1, Reusch F.1, El-Gabry M.1,Evagelopoulos N.1, Atmaca N.1, Däbritz S.11Herzzentrum Duisburg, Herz- und Gefäßchirurgie,Duisburg, Germany

Objectives: Hemodynamic instability in patients with acute myocardialinfarction (MI) referred to cardiac surgery is invariably caused byimpossible or ineffective revascularisation by PTCA or by PTCA-com-plications. Although mortality without revascularisation is high, acuteMI is generally considered a contraindication for coronary artery bypassgrafting (CABG). However, our treatment strategy in a subgroup of thesepatients requiring preoperative IABP support consists of emergentsurgical myocardial revascularisation. We retrospectively analyzed out-come and the prognostic determinants of this strategy. Methods: From1/08 to 12/10, 108 patients (73 male, age 67.1 � 11.0 years, BMI 26.9 �4.7) underwent emergent isolated CABG following acute MI and IABPimplantation. 44 had PTCA/stent prior to admission, 20 of which hadPTCA complications. 27 had NSTEMI and 81 had STEMI. 51 weredependent on inotropes and 27 had CPR prior to CardiopulmonaryBypass (CPB). Preoperative EF was 33.3 � 14.5%. CABG was performedwith a mean of 2.6 � 0.9 grafts, 61.7% with LITA, 6.6% OPCAB. Results:ECC and cross clamp times were 87 � 42 min and 36 � 18 min,respectively. 30-day survival was 67.6%. Inotropic support with epi-nenphrine was necessary in 36.3%, with other inotropes in 60.4%. 37%had lowcardiac output syndromewith a survival rate in this subgroup of17.1%, 34 (31.5%) needed dialysis, and 5 (5.5%) had Extra CorporealMembrane Oxygenation (ECMO; mean time 7 � 3d). 3.7% had IABPrelated complications. Higher age, decreased EF and STEMI decreasedsurvival significantly (multivariate: p¼0.022, p¼0.036 and p¼0.010respectively). Conclusions: Emergent myocardial revascularisation inpatients with MI and IABP carries a substantial mortality particularly inolder pts. and in the presence of low preoperative EF and STEMI.Nevertheless, surgery is justified in view of the expected high mortalityof these patients without revascularisation under medical treatment.

SC34Role of preoperative laboratory values inpredicting mortality after elective CABG: asingle center report including 6,436 patientsAlles S.G.H.1, Risso P.2, Ellger B.3, Ghezelbash F.1, Scherer M.1,Martens S.1, Dell'Aquila A.M.11Universitätsklinikum Münster, Klinik für Herzchirurgie,Münster, Germany, 2Mario Negri Institute forPharmacological Research, Epidemiology and SocialPsychiatry Unit, Milan, Italy, 3UniversitätsklinikumMünster, Klinik für Anästhesiologie und operativeIntensivmedizin, Münster, Germany

Objective: Recent literature has pointed out the predictive role of manypreoperative laboratory values on mortality after CABG. Despite theinnovative contribution of those studies, literature lacks studies regard-ing the influence of those preoperative values when analyzed alltogether. In the current study we sought to investigate the influenceof numerous preoperative laboratory values as independent predictorsfor in-hospital mortality after elective CABG. Methods: Between Janu-ary 2000 and January 2011 a total of 6436 patients (77.7% men, 22.3%women, aged 21-95 years with a mean � SD of 67.1 � 9.5 years)underwent elective CABG operation at our department. To identify adiscriminative point for every preoperative value for in-hospital mor-tality Receiver-operating characteristic (ROC) was performed. Signifi-cant variables were dichotomized and entered in multivariante logisticregression model. Results: Overall in-hospital mortality was 3.05%.Nineteen out off 33 available variables were significantly predictive ofin-hospital mortality and were retained for the multivariate analysis.

After dichotomization, multivariate regression analysis included thefollowing laboratory values in the predictive model: Creatinine>1.4mg/dl (p<0.025, OR 1.71, CI 1.07 to 2.71); Urea>20mg/dl (p¼0.042OR1.53 CI 1.02 to 2.30); Hemoglobin <13.5 g/dl (p<0.001, OR 1.98, CI 1.34to 2.96); LDH>199 U/L (p¼0.045 OR 1.52 CI 1.01 to 2.26); CK <64 U/L(p¼0.002 OR 0.53 CI 0.34 to 0.80); GOT>28 U/L (p¼0.008 OR 1.79 CI1.16 to 2.72); total serum protein <7g/dl (p¼0,05, OR 1.45, CI 1.00 to2.11). Conclusion: Preoperative laboratory values represent strongindependent predictors of in-hospital mortality after elective CABG.This constitutes a useful and easily accessible information for thesurgeon in order to quantify the preoperative risk.

SC35The impact of using warm vs. cold bloodcardioplegia in patients underwent emergentCABG procedureZeriouh M.1, Rahmanian P.1, Heider A.1, Scherner M.1,Sabashnikov A.1, Wittwer T.1, Choi Y.-H.1, Wahlers T.11Herzzentrum Uniklinik Köln, Klinik für Herz- undThoraxchirurgie, Köln, Germany

Objective: Aim of this study was to determine whether intermittentwarm (IWC) or cold bloodcardioplegia (ICC) show superior myocardialprotection in emergent CABG-patients with less than 60 minutes aorticcross-clamp time (Ao-X). Methods: Out of 1,945 consecutive patientswho underwent isolated CABG-surgery 247 consecutive emergentpatientswere identified and control-matchedwith 452 elective patients(1:2 ratio-match for emergent versus elective, regarding gender, age(<50 years, 50-70 years, >70 years) and ejection fraction (<40%, 40-50%, >50%). Results: Demographics, CPB-time, log. Euroscore, numberof distal anastomosis and LITA-use were comparable. The Ao-X wassignificantly prolonged in the IWC-group regardless of the patients'status (emergent: ICC vs. IWC: 35.4 � 12.2 min. vs. 41.1 � 13.9 min.;p¼0.05, elective: ICC vs. IWC: 39.9 � 12.7 min. vs. 44.0 � 15.9 min.;p¼0.015). There were no significant differences regarding ICU-stay,ventilation time, total-blood-loss and need for dialysis. Multivariateanalysis did not identify the type of cardioplegia as predictor for the 30-days mortality or for the incidence of a perioperative myocardial injury.However, the independent predictive factors for 30-days mortalitywere: EF<40% (OR 3.66; 95%CI: 1.79-7.52; p<0.001), AF (OR 3.33;95%CI: 1.49-7.47; p<0.003), PAD (OR 2.51; 95%CI: 1.13-5.55; p<0.023)and COPD (OR 0.26; 95%CI: 1.05-6.21; p<0.038) and for perioperativemyocardial infarction: EF< 40% (OR 2.04; 95%CI: 1.32-3.15; p<0.001),IABPpreop (OR 3.68; 95%CI: 1.34-10.13; p<0.012), and hemofiltration(OR 3.61; 95%CI: 2.22-5.87; p<0.001). Conclusion: Although the Ao-Xwas prolonged in the IWC-group our results confirm effective cardio-protection under IWC in patients requiring Ao-X less than 60 minutes,independently of the urgency status of the patient.

SC36Clinical outcomes after emergency CABG forcoronary complications following PCISlottosch I.1, Liakopoulos O.1,2, Kuhn E.1, Deppe A.1, Choi Y.-H.1, Wahlers T.11Uniklinik Köln, Klinik und Poliklinik für Herz- undThoraxchirurgie, Köln, Germany, 2UniversitätsklinikumEssen, Klinik für Thorax- und Kardiovaskuläre Chirurgie,Essen, Germany

Objectives: Coronary complications during percutaneous coronaryintervention (PCI) are uncommon. However, PCI related coronary arteryperforation, dissection or acute occlusion frequently results in severehemodynamic instability with need of urgent coronary artery bypassgrafting (CABG) to ensure revascularization. This single-centre studyaimed to investigate clinical outcomes of patients undergoing emergentCABG after life-threatening PCI complications. Methods: Data wereretrospectively obtained using our institutional patient database. Allpatients admitted for CABG after occurrence of a coronary complicationfollowing PCI from April 2010 to July 2013were included into this study.Univariate analysis using chi-square test and t-test were performed toidentify possible predictors for cardiac mortality. Results: 36 patients(66.3� 9.5 years) underwent CABG for coronary complication following


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PCI. Logistic EuroSCORE was 21.7 � 15.3% and 88.9% (32/36) hademergency CABG within 12 hours of admission. At admission 16 of 36(44.4%) presented in cardiogenic shock and 17 of 36 (47.2%) hadsignificant ECG alterations indicating STEMI. Surgical revascularizationwas performed targeting the affected coronary vessel with additionalrevascularization of other compromised vessels as indicated (number ofgrafts 2.4� 0.8). Cardiacmortality of the entire patient cohort was 13.9%(5/36) and in-hospital mortality 16.7% (6/36). Preoperative resuscita-tion, cardiogenic shock and STEMI were predictors for cardiac death inunivariate analysis. In contrast, non-cardiac comorbidities, affectedcoronary vessel and preoperative markers of myocardial injury (CK-MB, troponin T) were not associated to cardiac death. Conclusions:Emergency CABG for treatment of acute coronary complications follow-ing PCI is feasible and has acceptable clinical results despite the criticalpreoperative status of this high-risk patient cohort.

SC37The short-term outcome of bilateral internalthoracic artery use in patients undergoing offpump coronary bypass surgeryLoeblein H.1, Dzemali O.1, Odavic D.1, Graves K.1, GenoniM.11Triemli, Zürich, Switzerland

Purpose: The use of bilateral internal thoracic artery (BITA) grafting hasshown a better survival benefit when compared to single internalthoracic artery (SITA) grafting. This study was undertaken to evaluatethe short-term outcome of using BITA in patients undergoing off pumpcoronary bypass surgery. Method: The data of all patients who under-went off pump coronary bypass surgery between 1/2009-12/2010 wereretrieved from our data bank. We investigated how the use of BITAcompared to the use of SITA correlated to postoperative endpoints:troponin, creatine kinase MB (CK-MB), atrial fibrillation, blood transfu-sion, intubation time, intensive care unit (ICU) days and mortality.Result: 384 patients underwent off pump coronary bypass surgeryand of those 48.4% received BITA grafting. There was no differencebetween BITA and SITA grafting in regard to postoperative troponin, CK-MB, blood transfusion, intubation time, ICU days and mortality. Therewas a significant higher incidence of atrial fibrillation in the SITAcompared to the BITA grafting group 20% versus 9% (p<0.001).Conclusion: Our analysis shows that in off pump coronary bypasssurgery the use of BITA grafting significantly reduces the postoperativerate of atrial fibrillation.

SC38Isolated CABG in patients requiring long-termdialysisSirch J.1, Pfeiffer S.1, Fischlein T.11Klinikum Nürnberg, Herzchirurgie, Nürnberg, Germany

Ojectives: To evaluate the outcome after isolated coronary artery bypassgrafting (CABG) in patients requiring preoperative chronic dialysis forend stage renal failure (ESRF). Methods: We retrospectively analyzeddata by chart review and questionnaire from 151 patients (pts) (119male, 32 female) who were operated in our institution between April1994 and June 2013 and were on maintenance dialysis for at least 1month preoperatively. Results:Data from 151 pts. (119male, 32 female)with a mean age of 64.2 years (range 37-83), who had been on dialysisfor a mean of 46.3 months (range 1-1241) preoperatively, were ana-lyzed. 85.4% (129 pts.) suffered from triple vessel disease, 11.3% (17 pts.)had double and 3.3% (5 pts.) had single vessel disease. 2.6 grafts (range 1-6)were performed per operation, therebyusing the left internal thoracicartery (LITA) in 78.2% (118 pts) of cases. In 7 pts. (4.6%) the procedurewas performed off pump. Mean follow-up was 43.2 months (range 3-147). Mean ICU stay was 10.0 days (range 1-80), and patients weredischarged after a mean of 22.7 days (range 6-133). 8 patients diedwithin 30 days (5.3%), in hospital mortality was 6.6% (10 patients).Actuarial survival after 1, 3, and 5 years are 80.0, 72.1 and 54.5%,respectively. Actuarial survival is different when compared pts. ondialysis over and less than 24 months (see picture).

Fig. 1: Survival

Subjective quality of life was improved in 78.3% (72 pts), not changed in15.2% (14 pts.) and decreased in 6.5% (6 pts.) of long-term survivors (92pts.). Conclusions: Coronary artery bypass grafting can be performed ondialysis patients with acceptable higher perioperative morbidity andmortality, compared to the normal population. Long term survival ofESRF-patients is considerably reduced compared to patients withnormal renal function. However, improved postoperative quality oflife in the majority of patients, justifies this strategy.

SC39Predictors of mortality in patients requiringIABP support after urgent CABGSlottosch I.1, Liakopoulos O.1,2, Kuhn E.1, Deppe A.1, Choi Y.-H.1, Madershahian N.1, Wahlers T.11Uniklinik Köln, Klinik und Poliklinik für Herz- undThoraxchirurgie, Köln, Germany, 2UniversitätsklinikumEssen, Klinik für Thorax- und Kardiovaskuläre Chirurgie,Essen, Germany

Objective: Patients requiring intraaortic ballon pump (IABP) supportafter urgent coronary artery bypass grafting (CABG) for acute coronarysyndrome (ACS) are at increased risk for postoperative mortality. Thisstudy sought to evaluate pre-, intra- and postoperative predictors formortality in this high-risk patient cohort. Methods: Patients requiringIABP support after urgent CABG for ACS were retrospectively analysedbetween April 2010 and July 2013 using our institutional database. IABPsupport was either implemented before, during or after urgent CABG.Predictors for all-causemortalitywere analysed by applying a univariateandmultivariate analysis. Results:A total of 118 CABGpatientswith ACS(mean age: 66.0þ/-11.6; male 76.3%) were identified that receivedperioperative IABP support. All-cause mortality in this high-risk patientcohort was 35.6% (42/118). Univariate analysis revealed older age, ahigher logistic EuroSCORE, no preoperative IABP support and resuscita-tion after hospital admission as preoperative predictors for mortality.Intraoperative predictors were non-use of the internal thoracic arteryand increased CPB duration (p< 0.05). Higher catecholamine support,need for rethoracotomy, dialysis, myocardial infarction, resuscitation,low cardiac output syndrome and increased levels of markers formyocardial injury (troponinT; CK-MB) were identified as postoperativepredictors for mortality (p<0.05). Multivariate analysis identified onlya higher logistic EuroSCORE (OR 1.08; CI95% [1.02-1.13]) and theabsence of preoperative IABP (OR 0.10; CI95% [0.01-0.99]) as indepen-dent predictors for all-causemortality (p<0.05). Conclusion: Early IABPimplantation before patient requiring urgent CABG for ACS is anindependent predictor for decreased postoperative mortality in thesehigh-risk patients.


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SC40Single-vessel revascularization usingrobotically enhanced minimally invasive directcoronary artery bypass (ENDO-MIDCAB)compared to open offpump coronary arterybypass surgery (OPCAB)Felkel K.-W.1, Detter C.1, Deuse T.1, Reichenspurner H.1,Treede H.11Universitäres Herzzentrum Hamburg, Herzchirurgie,Hamburg, Germany

Objectives: Robotically enhanced surgery allows for minimally invasiveendoscopic harvesting of the left internal mammarian artery (LIMA).Here we describe our experiences using the robotic da Vinci system forcoronary artery bypass surgery with limited incision (ENDO-MIDCAB)in comparison to offpump coronary artery bypass surgery usingmediansternotomy (OPCAB) for single-vessel-revascularization. Methods: Inthis retrospective analysis from January 2004 to September 2013 64patients (14.06% women, 85.94% men, age 60.7 � 8.5 years) requiringENDO-MIDCAB revascularization and 225 patients (66.22% men, age67.03� 11.7 years) requiring elective offpump bypass revascularizationwere included. All patients were treated with a LIMA-bypass on the leftanterior descending (LAD) coronary artery. The procedure was per-formed without cardiopulmonary bypass on a beating heart either withthe da Vinci robotic system or in open technique with median sternot-omy. Results:Mean total operating time for ENDO-MIDCABwas 257.5�66.8 minutes compared to 143.7 � 45.9 minutes using OPCAB surgery(p¼0.0001). Hospital length of stay was 7.24 � 2.4 days for patientsrequiring OPCAB revascularization and 6.06 � 1.6 days for patientsrequiring MIDCAB surgery (p¼ 0.0003). Postoperative ventilation timefor patients requiring MIDCAB was shorter than for patients requiringOPCAB surgery (5.3 � 5.5 h vs. 6.7 � 4.0 h respectively, p¼0.0201).Overall mortality was 0.35% (n¼1/289). In the ENDO-MIDCAB group62.5% of patients had single-vessel coronary disease compared to 36% ofthe OPCAB group. Mean left ejection fraction for MIDCAB was 59.5% �4.7 compared to 53.1% � 11.2 requiring OPCAB (p<0.001). Measure-ment of bypass flow showed no significant relevant difference(p¼0.87). Conclusion: Although there is a selection bias in betweenthe two groups of patients in terms of age (p<0.0001) and LV function(p<0.001), post-operative ventilation time as well as hospital length ofstay were significantly shorter for MIDCAB compared to OPCAB surgery,despite longer mean operating time using the robotic system. Theseresults demonstrate the advantage of this technique in carefully selectedpatients.

SC41New clip remover device to prepare saphenousvein graft for coronary bypass graftingDzemali O.1, Häussler A.1, Odavic D.1, Zientara A.1, LoebleinH.1, Genoni M.11Universitäres Herzzentrum Zürich, Klinik fürHerzchirurgie, Zürich, Switzerland

Objective: The accurate prepare of the saphenous vein (SV) is elemen-tary to have good patency rates inmyocardial revascularisation. To avoidintimal hyperplasia we use the eSVS Mesh (Kipps Bay Medical™,Minneapolis, USA). Caused by endoscopic harvesting technique of SVall side branches are clipped in situ. All Clips have to be removed andreplaced by fine sutures (Prolene 6-0) in order to enable the covering theSVwith the eSVS. How to remove the Clipswithout tearing the SVand itsintima? Methods: We use a new designed clip remover in 40 patients.After harvesting the SV the distal end is intubated by a cannula withoutlet. Into the SVa solution of sodium chloride 0.9% is applicatedwith amaximum pressure of 150 cm H2O. So the clips are exposed in a goodposition and they can be reopened and removedwithout sheer stress tothe tissue by the clip remover device. Intraoperative graft patency wasverified by MediStim. Result: All clips could be removed from vein. Notear that had to be repaired. Graft patencywas 95% for eSVS treatedwiththe new device. Histologic findings showed no intima lesions.Conclusion: This new tool is very feasible and save. Wrong placed clipson mammarian artery or veins are now easy and safely removable and anew can be applicated in correct position considering the potentialintima lesion of the graft by clipping.

SC42Use of the eSVS mesh during CABG: Computedtomographic evaluation after 6 monthsAttmann T.1, Grothusen C.1, Reinsdorf A.1, Schöttler J.1,Haneya A.1, Lutter G.1, Cremer J.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Klinik für Herz- und Gefäßchirurgie, Kiel, Germany

Objectives: The aim of this study was to assess short-term graft patencyin eSVS (external Saphenous Vein Support) Mesh-covered saphenousvein grafts (SVGs) in patients undergoing coronary artery bypass graft-ing. Methods: 10 patients with coronary three-vessel disease and needfor operativemyocardial revascularisationwere randomized to receive aSVG treated with the eSVS Mesh and an untreated graft serving as anindividual patient control. Their target location was randomized toeither the right or circumflex coronary artery bed. Patency was evaluat-ed intraoperatively by transit time flow measurement and at 6 monthspostoperatively by computed tomographic angiography (CTA). In addi-tion, the 10 patients were compared with a control group matchedaccording to age, sex, number of grafts and surgeon. ESVS Meshs areavailable with a diameter of 3.5, 4.0 and 4.5 millimeters. Results:Implantation of eSVS MESH grafts was unproblematic in all patients.A total of 11 arterial and 25 venous grafts using on-pump techniqueswere anastomosed. All grafts proved to be patent as measured by transittime flow intra-operatively. 9 patients survived the follow-up period.CTA was completed in 5 patients. Patency rate of eSVS Mesh coveredgrafts as determined by CTA after 6 months was 60% (3/5). All patenteSVS Mesh grafts showed signs of partial thrombosis. 4 of 5 controlgrafts were patent after 6 months (80%). Occlusion of eSVS MESH graftswas found only in eSVS meshs with an external diameter of 3.5 mm. Allpatients were asymptomatic concerning myocardial ischemia-relatedsymptoms. Compared to the matched control group, total operationtime was significantly longer in the eSVS MESH group (268 � 28 min vs199� 29min, p>0.01). In contrast, bypass and cross-clamp time did notdiffer between the groups (59� 12min vs 58� 10min). Conclusions: Inthe present study, the promising experimental results of mesh-sup-ported venous grafts could not be reproduced.

Organ transplantation

SC43Does extent of donor smoking impactmid-termoutcomes after lung transplantation?Sabashnikov A.1, Zych B.1, Popov A.-F.1, García Sáez D.1, PatilN.P.1, Mohite P.1, Fatullayev J.1, De Robertis F.1, Bahrami T.1,Amrani M.1, Reed A.2, Carby M.2, Simon A.R.11Royal Brompton and Harefield NHS Foundation Trust,Department of Cardiothoracic Transplantation andMechanical Circulatory Support, Harefield, London, UnitedKingdom, 2Royal Brompton and Harefield NHS FoundationTrust, Department of Respiratory Failure and TransplantMedicine, Harefield, London, United Kingdom

Introduction: Lung transplantation (LTx) is significantly limited bydonor organ shortage. Donor smoking history is one of the majorguideline variables for donor selection, and a previously acceptedcriterion for an ideal donor is a smoking history of less than 20 packyears. Donor smoking history of more than 20 pack years is consideredan extended donor criterion. In this study we evaluated the impact ofdonor smoking history and extent of smoking on mid-term outcomesafter LTx.Methods: Between 2007 and 2012, 237 LTxwere performed inour institution (5 patients were excluded due to unknown donorsmoking history). Patients were divided in 3 groups receiving lungsfrom: 123 (53%) non-smoking donors (NS), 68 (29%) smoking donorswith <20 pack years (S), 41 (18%) heavy smokers with >20 pack years(HS). Donor and recipient demographics as well as perioperative dataand mid-term outcome were compared. Results: There were no sta-tistically significant differences in: donor cause of death; percentage of:DCD, abnormal CXR and bronchoscopy, Ex Vivo Lung Perfusion (EVLP);donor duration of mechanical ventilation (MV); last pre-retrieval PaO2/FiO2 ratio and total ischemic time. Donors from HS group weresignificantly older (p<0.001). Preoperative recipient demographics


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and diagnosis distribution were also comparable. There were no sta-tistically significant differences in prevalence of bronchiolitis obliteranssyndrome (p¼0.616) as well as BOS free survival (p¼0.898). 1 and 3years survival estimate was also comparable: NS vs. S vs. HS - 77.7% vs.90.8% vs. 94.9% and 68.7% vs. 82.1% vs. 68.2% (log rang p¼0.151).

Table 1: Outcomes after LTx

NS S HS p-value

PaO2/FiO2 ratio24 hours (mmHg)

348.9�109.6 328.3�108.5 344.9�105.5 0.466


351.4�112.4 352.8�123.6 346.1�95.4 0.956


348.0�120.4 341.4�114.4 364.0�109.1 0.652

Duration oflventilation (hours)

35(14;198) 50(23;474) 34(10;96) 0.136

Intensive careunit stay (days)

5(3;19) 11(3;26) 6(3;19) 0.133

Hospital stay (days) 34(21;51) 33(23;59) 39(27;56) 0.322

Fig. 1: Overall and BOS free survival

Conclusions: Our experience shows that history and extent of donorsmoking do not adversely affect LTx mid-term outcome and utilizationof lungs from even heavy smokers provides an opportunity to expandorgan availability. However, long term observation is necessary.

SC44Extended donor criteria in hearttransplantation: 4-year results of theexperience with the Organ Care systemYeter R.1, Pasic M.1, Hübler M.1, Dandel M.1, Hiemann N.1,Kemper D.1, Wellnhofer E.2, Hetzer R.1, Knosalla C.11Deutsches Herzzentrum Berlin, Departement ofCardiothoracic and Vascular Surgery, Berlin, Germany,2Deutsches Herzzentrum Berlin, Department of Cardiology,Berlin, Germany

Objectives: The Organ Care system (OCS) is a portable organ perfusionand monitoring system intended to maintain donor hearts in a near-physiological and functioning state ex-vivo for transplantation. Wereport the midterm results of our current experience with the OCS incases of extended organ transportation time andmarginal donor hearts.Methods: Between January 2009 and September 2010 21 donor heartshave been maintained on OCS. Six hearts were offered primarily, six ascompetitive rescue allocation and nine hearts were previously declinedby 1-7 (median 4) other centers. Three hearts came from countriesoutside the Eurotransplant area. Donor age ranged from 17 to 70(median 49) years. 12 recipients were bridged to transplantation bymechanical circulatory support (LVAD n¼7, BVAD n¼ 3, TAH n¼2).Early graft function was assessed by hemodynamics and daily echocar-diography. Protocol coronary angiography was performed annually.Results: The median time the heart spent ex-vivo was 388 minutes(range: 254- 502) of which 68 (range: 55-88) minutes was median totalcold ischemia time and 320 (range: 199-414) minutes representedoxygenated warm blood perfusion. All hearts were successfully trans-planted, with excellent graft function. Two patients died for cardiacrelated reasons four and 249 days after transplantation, resulting in afreedom from cardiac related death of 95% at 30 days and 6 months and87% at one year and four years, respectively. None of the follow upcoronary angiographies revealed evidence for post transplant vascul-opathy. Conclusions: TheOCS keeps hearts froman extendeddonor pooland with extended organ transportation time in healthy condition,resulting in excellent primary and mid-term graft function. The systemmay have the potential to improve donor organ availability and trans-plantation outcomes.

SC45Early reoccurrence of fetal ED-Aþ Fibronectinand Bþ Tenascin-C splicing variants after humancardiac transplantation: potential impact fortargeted therapy of chronic rejectionFranz M.1, Berndt A.2, Matusiak-Brückner M.1, Grün K.1,Maschek H.3, Richter P.2, Schulz U.4, Gummert J.4, Figulla H.R.1, Renner A.41Universitätsklinikum Jena, Klinik für Innere Medizin I,Jena, Germany, 2Universitätsklinikum Jena, Institut fürPathologie, Jena, Germany, 3Pathologie am Tiergarten,Hannover, Germany, 4Herz- und Diabeteszentrum NRW,Ruhr-Universität Bochum, Klinik für Thorax- undKardiovaskularchirurgie, Bad Oeynhausen, Germany

Objectives: Management of chronic cardiac rejection with allograftvasculopathy (CAV) and interstitial fibrosis (CIF) is still challenging.Rejection associated tissue remodelling entails the reoccurrence of fetalvariants of Fibronectin (Fn) or Tenascin-C (Tn-C) that are virtuallyabsent in adult human organs. In a rat model, ED-Aþ Fn and Bþ Tn-Ccould be shown to be extensively re-expressed in association to CAVandCIF. Since human antibodies recognizing the molecules and usable fortargeted pharmacodelivery are available, it is of great interest to analyzeED-Aþ Fn and Bþ Tn-C expression also in the human system. Methods:Tissue specimens derived from right ventricular biopsies from 69 hearttransplant recipients were available. Histopathological examination toidentify acute rejection was performed according to the ISHLT guide-lines. Protein expression of ED-Aþ Fn, Bþ Tn-C, alpha-smooth muscleactin (ASMA) and CD31 was analysed by immunohistochemistry /immunofluorescence and subjected to semi-quantitative assessmentor co-localization analysis respectively. Results: Histopathological anal-ysis of the 69 samples revealed ISHLT grade 0R in 36 cases, grade 1R in 21cases and grade 2R in 8 cases. There was a relevant re-expression of ED-


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Aþ Fn and Bþ Tn-C in the great majority of cases. Semi-quantitativeanalysis did not show any correlation to ISHLT grade for all threemarkers. But there was a significant positive correlation betweenexpression of ED-Aþ Fn and Bþ Tn-C (p¼0.000). There was a spatialassociation of ED-Aþ Fn and Bþ Tn-C to vessel structures and fibrosis asrevealed by immunofluorescence double labelling including ASMA andCD31. Conclusions: There is a relevant re-occurrence of ED-Aþ Fn and Bþ

Tn-C following human cardiac transplantation contributing to extracel-lular matrix reorganization as an initial process of tissue remodelling.Against the background of a correlation of ED-Aþ Fn and Bþ Tn-Cexpression to chronic rejection in animal models, one can postulatethat patients with an early re-occurrence of the markers are at anincreased risk to develop CAV and CIF. Moreover, the association of ED-Aþ Fn and Bþ Tn-C deposition to signs of chronic rejection and theexistence of antibodies for targeted delivery of diagnostics or bioactivepayloads, might pave the way for novel innovative strategies to image,prevent or treat the disease.

SC46Rewarming after cold ischemia and endothelialmodulation: Role of JAMsBogert N.1, Kanzler I.1, Stock U.A.1, Moritz A.1, Beiras-Fernandez A.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, Thorax-, Herz-, und Gefäßchirurgie,Frankfurt, Germany

Objective: Organs explanted for transplantation are subjected to coldischemia. Peripheral blood mononuclear cells (PBMC) under hypother-mic conditions evoke anti-inflammatory, whereas subunits of PBMCsshow pro-inflammatory effects. The role of hypothermia on trans-endothelial-migration of leukocytes is not clarified yet. We investigatedthe expression of junctional-adhesion molecules (JAMs) on endothelialcells as well as the transendothelial-migration of PBMCs through humanmicrovascular endothelial cells (HMEC-1) at 4 °C temperatures includingthe reperfusion-rewarming-process.Methods: Transendothelial migra-tion was analyzed when 1) PBMC were activated, 2) HMEC-1wereactivated, or 3) both were activated. Cell activation was done at 4°C.For transendothelial-migration, the cells were either rewarmed to 37°Cor transmigration was directly performed at 4°C. JAM-A and -B expres-sion was analyzed on endothelial cells by means of immunofluores-cence. p<0.05 was considered as statistically significant. Results:Rewarming from low (4°C) to normothermic (37°C) conditions causedno change in transendothelial-migration of activated PBMCs throughnon-activated HMEC-1. But, significantly more non-activated PBMCstransmigrated through activated HMEC-1 when activation was done at4°C and rewarmed to 37°C. The same significant outcome is observedwhen both cell types were activated. Additionally, activated endothelialcells seem to block the migration of non-activated PBMCs underhypothermic transmigration conditions. Expression of JAM-A was sig-nificantly elevated after activation of ECs, while JAM-B showed nodifferences on its expression depending on the cellular activation.Conclusion: The in vitro re-enactment of clinical practice has shown asignificant influence of low temperature on transendothelial-migration.Our data show that the rewarming processes are essential, and are abletomodulate JAMs. Endothelial protection prior to reperfusion should beconsidered.

SC47Mesenchymal stem cell pretreatment of non-heart-beating-donors in experimental lungtransplantation - initial experienceWittwer T.1, Rahmanian P.1, Choi Y.-H.1, Zeriouh M.1,Sabashnikov A.1, Neef K.1, Mühlfeld C.2, Ochs M.2, WahlersT.11Uniklinik Köln, Herz- und Thoraxchirurgie, Köln, Germany,2Medizinische Hochschule Hannover, Funktionelle undAngewandte Anatomie, Hannover, Germany

Objective: Lung transplantation (LTx) is still limited by organ shortage.To expand the donor pool, lung retrieval from non-heart-beating donors(NHBD) was introduced into clinical practice recently. However, prima-

ry graft dysfunction with inactivation of endogenous surfactant due toischemia/reperfusion-injury is a major cause of early mortality. Fur-thermore, donor-derived mesenchymal stem cell (MSC) expansion andfibrotic differentiation in the allograft results in bronchiolitis obliteranssyndrome (BOS), a leading cause of post-LTx long-term mortality.Therefore, pretreatment of NHBD with recipient-specific bone-mar-row-(BM)-derived MSC might have the potential to both improve thepostischemic surfactant function and influence the long-term develop-ment of BOS by the numerous parakrine, immunomodulating andtissue-remodeling properties especially on type-II-pneumocytes ofBM-MSC. Methods: Asystolic pigs (n¼5/group) were ventilated for 3h of warm ischemia (groups 1-3). 50x106 BM-MSC, each, were adminis-tered either in the pulmonary artery (group 2) or nebulized endobron-chially (group 3) prior to antegrade Perfadex-preservation and 3 h ofcold storage. After left-lung-transplantation, grafts were reperfused for4 h. Hemodynamics (PVR), pO2/FiO2 and dynamic compliance (DLC)weremonitored and compared to lungs without pretreatment (group 1)and sham-controls (Sham). To prove and localize the Texas-red labelledMSCs in the lung, PCR was performed and cryosections were counter-stained with WGA and DAPI. Intra-alveolar edema was determinedsterologically. Statistics comprised ANOVA with repeated measure-ments. Results: PVR and DLC were superior in endobronchially pre-treated MSC lungs as compared to endovascular MSC application andlungs without pretreatment. Oxygenationwas worst after endovascularpretreatment. Stereology revealed low intrapulmonary edema in allgroups (p>0.05), successful MSC application was proven by PCR. MSCwere localized in alveolar septa stereologically. Conclusions: Preische-mic deposition of BM-MSC in donor lungs is feasible and effective, butonly endobronchial application optimizes DLC and PVR postoperatively.Due to immunomodulatory and paracrine effects on epithelial andendothelial restitution, an autologous-BM-MSC-based donor pretreat-ment strategy for prevention or attenuation of limiting BOS is verypromising in LTx. Subsequent work with chronic experiments is initiat-ed to further elucidate this important field.

SC48RNase: A possible adjuvant in transplantation?Kleinert E.1, Reichart B.2, Mayr T.2,3, Abicht J.-M.2,4, BrennerP.2,3, Hagl C.3, Langenmayer M.5, Wanke R.5, Deindl E.1,Guethoff S.2,31Walter-Brendel-Centre of ExperimentalMedicine, Ludwig-Maximilians University, Munich, Germany, 2TransregioCollaborative Research Centre 127, Department ofCardiovascular Surgery, Ludwig-Maximilians University,Munich, Germany, 3Department of Cardiovascular Surgery,Ludwig-Maximilians University, Munich, Germany,4Department of Anaesthesiology, Ludwig-MaximiliansUniversity, Munich, Germany, 5Institut of VeterinaryPathology, Ludwig-Maximilians University, Munich,Germany

Objectives: Cell injury, particularly as consequence of ischemia/reper-fusion or acute rejection after transplantation, leads to release ofintracellular components like RNA. Extracellular RNA, causes edemaas a result of increasing permeability of blood vessels, is described as aprocoagulation factor by activation of the contact phase system leadingto thrombus formation and vessel occlusion, and promotes leukocyterecruitment in the vascular system by mobilising proinflammatorycytokines, and thus, triggers immune response. In rodent models ofstroke and thrombosis, treatment with counteracting RNasewas shownwith less edema and vessel occlusion. In search of additive drugs toprotect grafts from dysfunction, we investigated if treatment withRNase in a rat model of heterotopic heart transplantation results inless edema and less coronary occlusion, and, therefore, in improved graftsurvival. Methods: Brown Norway rat cardiac allografts were trans-planted into the abdomen of Lewis rats. Microvascular technique foraorto-aortic and pulmonary artery to inferior vena cava anastomosis(Langendorff) was used. Recipients were intravenously treated directlybefore transplantation and every other day with RNase (50µg/kg) orvehicle (saline, n¼6/group). The primary end point of the studywas thegraft survival, which was determined by daily examination of the graftfunction by palpation and in case of inconclusiveness by


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echocardiography. A tolerance study was performed treating animalsdaily with RNase 50 µg/kg, with RNase 1000 µg/kg, or vehicle, respec-tively, for 28d (n¼3/group). Results: Mean graft survival was 6.5 �0.55d in vehicle treated animals vs 10.2� 1.0d in RNase treated animals(p¼0.002). Directly after explantation donor grafts had a mean weightof 0.94� 0.03g. After been rejected donor graft weight increased to 2.06� 0.52g in vehicle treated recipients, in contrast to 1.28� 0.27g in RNasetreated recipients (p¼0.017). The tolerance study showed neithermacroscopic nor histological differences between treatment groups.Conclusions: RNase significantly improved graft survival. Histologicalanalyses in progress will help to clarify if RNasewill keep the promise toreduce edema formation even in the field of transplantation, as sug-gested due to significant less graft weight in RNase treated recipients. Onthe basis of these sweeping results, however, we suppose that RNasecould be a possible adjuvant in transplantation.

SC49Clinical outcome in heart transplant recipientsreceiving everolimus plus dosage reduction oftacrolimusFuchs U.1, Zittermann A.1, Ensminger S.1, Schulz U.1,Gummert J.F.11Herz- und Diabeteszentrum NRW, Bad Oeynhausen,Germany

Objectives: It is currently not knownwhether in heart transplant (HTx)recipients the combination of everolimus (EVL) plus dosage reduction oftacrolimus (TAC) is superior to the regular TAC dosage regimen regard-ing clinical outcomes. Methods: We compared 5-year survival andkidney function in 67 maintenance HTx patients receiving EVL plusdosage reduction of TAC (EVL group) with 67 patients matched for age,sex and transplantation date receiving the regular TAC regimen (TACgroup). Statistical analyseswere performed using Kaplan-Meier survivalestimates and 2-factor ANOVA. Results: Initial estimated glomerularfiltration rate (eGFR) was significantly lower and blood leucocyte countswere significantly higher in the EVL group comparedwith the TAC group(GFR: 38.5 � 13.2 vs. 67.3 � 29.5 ml/min/1.732; respectively, P<0.001,blood leucocyte counts: 8.4 � 2.9 vs. 7.0 � 2.1x109/l, respectively,P¼0.002). Five-year mortality did not differ between groups (19.4%vs. 17.9%; P¼0.766). There were however significant time x treatmenteffects with respect to eGFR values (P<0.001). In detail, eGFR decreasedon average by 10 ml/min/1.73 m2 during follow up in the TAC group butincreased by 8ml/min/1.73m2 in the EVL group. Blood leucocyte countsimproved significantly in the EVL group but not in the TAC group(P¼0.008). Parameters of liver function did not change significantly,either in the EVL group or in the TAC group. Conclusions: EVL plusdosage reduction of TAC is associated with improved kidney functioncompared with the regular TAC dosage regimen. Despite poorer initialkidney function and higher blood leucocyte counts in the EVL group, 5-year survival was comparable between the two groups.

SC50Binding of ATGs to endothelial cells under invivo conditionsBeiras-Fernandez A.1, Kaczmarek I.2, Schulz U.3, RichterM.4, Kanzler I.11JW Goethe University, Thoracic and CardiovascularSurgery, Frankfurt, Germany, 2Klinikum der UniversitätMünchen - Campus Großhadern, Herzchirurgie, München,Germany, 3HDZ NRW, Bad Oyenhausen, Germany,4Kerkhoff-Klinik Bad Nauheim, Bad Nauheim, Germany

Introduction: Polyclonal antithymocyte globulins (ATGs) are immuno-suppressive drugs widely used in induction of immunosuppression andtreatment of acute rejection after solid organ transplantation. We havepreviously demonstrated that ATG bind to endothelial cells in vitro, andare able to modulate ECs. The aim of this study was to investigate thebinding of ATGs to endothelial cells under in vivo conditions. Materialand methods: Muscle biopsies from extremities of cynomolgus mon-keys were obtained after ischemia/reperfusion at 4 °C. ATGs (1.5 mg/kg)were added to the blood 30 min prior to the reperfusion. Biopsies ofpatients treatedwith ATG (1.5 to 2.5 mg/kg) as induction therapy before

heart transplantation were also analyzed 6 hours and 7 days afterinduction. Binding of ATG to ECs was analyzed with an anti-rabbit IgGAntibody bymeans of immunohistochemistry. Results: Binding of ATGsto endothelial cells could be demonstrated in vivo in our animalexperiments, four hours after reperfusion, as well as in the clinicalbiopsies 6 hours after induction of immunosuppression in heart trans-plant patients, showing a preferred localisation in post-capillary veins.No expression of ATG on the endothelial surface could be observed afterseven days, suggesting that ATGs may be washed out from the endo-thelial surface time dependently. Conclusion: Our results confirm thatATGs are able to bind to endothelial cells, supporting preconditioningstrategies with ATG in solid organ transplantation, as a down-regulationof adhesion molecules by ATG may decrease graft cell infiltration andmodulate the endothelial activity.

SC51Pretreatment with donor alloantigen and anti-CD4-antibody 28 days befor lungtransplantation leads to immunization ratherthan tolerance in miniature pigsJansson K.1, Sommer W.1, Avsar M.1, Salman J.1, Knöfel A.-K.1, Falk C.2, Hewicker-Trautwein M.3, Jonigk D.4, HaverichA.1, Warnecke G.11Medizinische Hochschule Hannover, HTTG, Hannover,Germany, 2Medizinische Hochschule Hannover, IFB-Tx,Hannover, Germany, 3Tierärztliche Hochschule Hannover,Pathologie, Hannover, Germany, 4Medizinische HochschuleHannover, Pathologie, Hannover, Germany

Background: The administration of a non-depleting anti-CD4 antibody(for example clone YTS177) and donor-specific transfusion (DST) 28days before transplantation has been used extensively for the inductionof T cell regulation and long term graft survival in rodents. Here, wewished to translate this technique into our lung transplantation modelin miniature swine. Objective: To pretreat recipient minipigs withdonor alloantigen and a non-depleting anti-CD4 antibody 28 daysbefore lung transplantation to induce a pro-regulatory environmentand achieve long term lung allograft acceptance. Methods: Left-sidedsingle lung transplantation from major histocompatibility mismatchedmale donors was performed in 8 female minipigs. Recipients wereadministeredwith a single intravenous infusion ofmonoclonal antibody74-12-4, specific for CD4þ porcine T-lymphocytes, 28 days beforetransplantation. Additionally, all animals received an infusion of donorsplenocytes 24 hours after antibody administration. Six animals addi-tionally received a single intravenous infusion of monoclonal antibody76-2-11, specific for the porcine CD8 cell-surface antigen periopera-tively. Following transplantation all received a 28-day course of phar-macologic immunosuppression using Tacrolimus. Peripheral bloodleukocyte phenotypes were monitored by flow cytometry. Real timePCR was performed to analyze donor cell chimerism. Rejection wasmonitored by chest X-Ray. Results: In flow cytometry, CD4þ peripherallymphocytes were found to be coated with the antibody but notdepleted. Activation of CD4þ T-cells could be observed from day 5 afterantibody administration in all animals. Both animals that only receivedmonoclonal antibody against CD4þ lymphocytes showed rejection atpostoperative day 70. Four animals of the CD4 plus CD8 group showedhyperacute rejection during operation. One animal was electivelysacrificed 14 days post operation due to poor lung functioning fromthe beginning. One animal is currently alive at 100 days post transplan-tation. Conclusion: Administration of monoclonal antibody 76-2-11 incombinationwith donor-antigen 28 days before transplantation appearsto prime the effector arm of the adaptive immune system rather thaninducing tolerance and consecutivey leads to accelerated rejection.Future experiments will again focus on perioperative conditioning ofthe recipients rather than pretreatment 28 days before transplantationto prevent allo-immunization.


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SC52Outcomes after cardiac transplantation usingorgan care system in extended criteria donorsand high risk recipientsSabashnikov A.1, García Sáez D.1, Zych B.1, Mohite P.1, PopovA.-F.1, Maunz O.1, Fatullayev J.1, De Robertis F.1, Amrani M.1,Bahrami T.1, Simon A.R.11Royal Brompton and Harefield NHS Foundation Trust,Department of Cardiothoracic Transplantation andMechanical Circulatory Support, Harefield, London, UnitedKingdom

Background: The severe shortage of available donor organs has resultedin increasing attempts to utilize marginal organs for transplantation.While these attempts may increase organ availability, they result inhigher risk organ-recipient combinations. The individual risk-benefitratio is further affected by the increasing complexity of today's recip-ients (e.g. ventricular assist devices (VAD), severe pulmonary hyperten-sion (PHT), age or previous surgery). The Organ Care System (OCS)allows for preservation and transport of a continuously perfused heartin a near physiological environment at 34°C in a beating state. Thisallows for extended out of body times, avoids the detrimental effect ofcold ischemic storage and provides additional assessment. We describeour experience with the OCS in a consecutive series of patients trans-planted at our institution. Methods: Data was collected prospectivelyfor all patients transplanted with the OCS (n¼11) between 22ndFebruary and 9th June 2013. Donor, recipient data and postoperativeresults were analyzed. Results: One patient died 44 days after trans-plantation due to an early small bowel and colon ischemia. Otherpatients were weaned off bypass at the first attempt and none ofthem required mechanical support. In the entire patient cohort no graftdeveloped right heart failure. Among survived patients, time on inotro-pic support was 87 � 58 h, duration of mechanical ventilation 51 � 35 hand ICU stay 150 � 105 h. At follow up, 128 � 44 days (67-191) graftfunctionwaspreserved in all cases; left-ventricular ejection fractionwas72 � 5%, 68 � 7% and 69 � 5% after 1, 2 and 3 months, respectively.Conclusions: The OCS allows expanding the donor pool by eitherutilizing organs previously not considered for transplantation (e.g.marginal organ, long transport time) or transplanting higher riskgraft-recipient combinations (previous operations, VADs, PHT). In thesepatients the observedmortality andmorbidity was more favorable thanexpected given the combined risk profile of donor-recipient. If theseresults are reproducible, OCS preservation may become the standard ofcare in these types of situations.

SC53Comparison of Sirolimus and Everolimus intheir effects on kidney function and survival inheart transplant recipientsFuchs U.1, Zittermann A.1, Baralija A.1, Ensminger S.1, SchulzU.1, Gummert J.F.11Herz- und Diabeteszentrum NRW, Bad Oeynhausen,Germany

Objectives: The mammalian target of rapamycin (mTOR) inhibitorssirolimus (SRL) and everolimus (EVL) are potent immunosuppressiveagents, which allow reducing the dose of nephrotoxic calcineurin (CNI)inhibitors in solid organ transplant recipients. However, comparativedata of the two mTOR inhibitors concerning clinical outcome in hearttransplant (HTx) recipients is scarce. Methods: We assessed 5-yearmortality and kidney function in 212 maintenance HTx patients withpoor kidney function (estimated glomeralur filtration rate [eGFR] <60ml/min/1.73 m2), who were switched over to SRL (n¼64) or EVL(n¼148) between 2000 and 2007. In both groups, the CNI inhibitordose was reduced by 50%. Results: Baseline characteristics differedsignificantly between the two groups with respect to body mass index,age, duration on regular CNI inhibitor dose and year of SRL or EVLintroduction (P¼0.013-<0.001). Unadjusted 5-year mortality wasnon-significantly higher in the SRL group compared with the EVL group(26.6% vs. 23.0%;P¼0.353). However, after adjustments were made forthe aforementioned baseline parameters, the hazard ratio (HR) of 5-yearmortality was significantly higher in the SRL group compared with theEVL group (HR¼1.98, 95% confidence interval: 1.08-3.65; P¼0.028).

During follow-up, eGFR improved on average by 4-6 ml/min/1.73 m2

(P¼0.012). Results did not differ between the SRL and EVL group(P¼0.911). Conclusions: Data indicate that in HTx patients with poorkidney function, the introduction of both SRL and EVL plus CNI dosagereduction is able to maintain kidney function. Nevertheless, results alsosuggest that regarding 5-year survival EVL may be superior comparedwith SRL.

SC54Effects of ivabradine in patients with persistentsinus tachycardia early after hearttransplantationBoeken U.1, Mehdiani A.1, Ballazs C.1, Minol J.-P.1, Saeed D.1,Westenfeld R.2, Akhyari P.1, Kamiya H.1, Lichtenberg A.11Uni-Klinik Düsseldorf, Kardiovaskuläre Chirurgie,Düsseldorf, Germany, 2Uni-Klinik Düsseldorf, Kardiologie,Pneumologie und Angiologie, Düsseldorf, Germany

Objective: Inappropiate sinus tachycardia after cardiac surgery is oftentreated with b-blockers. After cardiac transplantation this treatmentmay significantly impair cardiac function, particularly regarding rightventricle. Recent studies have shown a favorable response to ivabradine,a new I (f) channel antagonist. We wanted to evaluate effects and side-effects of ivabradine in the early period after heart transplantation (htx).Methods: Between 10/2010 and 09/2013 33 patients underwent htx inour department. Of those, ivabradine was administered in 16 patientsimmediately after htx (starting on POD 5-27), in addition to ß-blockersin 4 patients. Of the other 17 patients, 8 received ß-blockers due to sinustachycardia. Ivabradine treatment was initiated in cases of a basal heartrate>100 bpm for>24 hours and after excluding all other causes of thissinus tachycardia. Results: There were no substantial adverse effects inall patients with ivabradine. Mean heart rate was reduced from 112.4 �15.3 bpm at baseline to 90.3 � 11.6 bpm before hospital discharge(p<0.05). Echocardiographic evaluation confirmed an improvement ofcardiac function, correlating to substantial clinical advances. We did notdetect relevant interactions with immunosuppressants, except from adistinct increase of mycophenolate mofetil blood levels. Conclusions:With our results we could demonstrate that patients with inappropriatesinus tachycardia after htx can be successfully treated with ivabradine.Reducing the resting heart rate, it did not negatively influence cardiaccontractility. Interactionswith immunosuppressivemedication or otheradverse effects could not be detected.

SC55Midterm clinical outcome in heart transplantrecipients receiving thymoglobin for inductiontherapyFuchs U.1, Zittermann A.1, Ensminger S.1, Gummert J.F.1,Schulz U.11Herz- und Diabeteszentrum NRW, Bad Oeynhausen,Germany

Objectives: We have recently presented data showing that hearttransplant recipients requiring induction therapy with thymoglobin(THY) have a higher 1-year mortality than heart transplant recipientswith standard therapy, especially when the patients were major histo-compatibility complex (MHC) antibody positive. Here we present dataon midterm mortality in HTx patients receiving calcineurin inhibitor-free induction therapy. Methods: We followed a group of 55 patientswho received THY (39 MHC positive patients and 16 patients withchronic kidney disease stages III-IV) and a control group (n¼55) whoreceived standard immunosuppressive therapy for up to five years.Results: Age, sex, and diagnosis were comparable between the twogroups (P>0.05), whereas body mass index was significantly higher inthe THY group compared with the control group (26.4 � 3.8 kg/m2 vs.24.1 � 4.1 kg/m2;P¼0.006). Median follow up was 43.1 months(IQR:5.0-50.4 months) in the THY group and 45.6 months (IQR:36.8-51.7 months) in the controls. Unadjusted mortality tended to be higherin the THY group compared with the controls (34.5% vs. 18.2%;P¼0.051). However, the multivariable-adjusted hazard ratio (HR) ofmortality did not differ between groups (HR for the THY group¼1.69(95%CI:0.78-3.68;P¼0.187). In the surviving patients, postoperative


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CRP levels remained longer elevated and postoperative platelets andwhite blood cell counts showed a more pronounced transient decreasein the THY group compared with the controls (P¼0.001-0.046).Conclusions: Compared with HTx patients receiving standard immuno-suppressive therapy, our data indicate an acceptablemidterm survival inhigh-risk patients requiring CNI-free induction therapy.

SC56Cardiac graft protection in the brain dead donorKremer J.1, Dzilic E.12, Haller P.1, Kreibich M.13, Moser P.1,Nagl F.1, Santer D.1, Podesser B.14, Zuckermann A.51Medizinische Universität Wien, Ludwig Boltzmann ClusterKardiovaskuläre Forschung, Wien, Austria, 2DeutschesHerzzentrum München, Technische Universität München,München, Germany, 3Universitäts-Herzzentrum Freiburg -Bad Krozingen, Bad Krozingen, Germany, 4LandesklinikumSt. Pölten, Herzchirurgie, Sankt Pölten, Austria,5Allgemeines Krankenhaus Wien, Klinische Abteilung fürHerzchirurgie, Wien, Austria

Background: Cardiac graft quality is altered by activation of systemicand intra-organ immune response due to hemodynamic and hormonalchanges after donor brain death (BD). In earlier studies, effects onmyocardial function after BDwere elucidated. A higher risk for increasedacute rejection episodes and impaired graft survival rates has beendemonstrated in grafts from brain dead donors. Antithymocyte globulin(ATG) is an immunosuppressive drug that contains cytotoxic antibodiesdirected against antigens expressed on T-lymphocytes. Methods: Fe-male OF-1 mice (n¼16) were divided in 4 randomized groups ([BD-ATG], [BD-Control], [Therapy], [Control]). BD was induced with anintracranial balloon catheter, the mice were monitored for 6 h andthe onset of BD was marked by an EEG-flatline. Myocardial tissuesections were analyzed by immunohistochemistry staining for IL-2and IL-6. Results: No structural changes after 6 h of observation couldbe demonstrated in our setting. We could not show significant inhibi-tion of IL-2 and IL-6, interleukin expressions were comparable in allgroups (n.s.). Notably, we observed a reduction of IL-6 deposition in ATGtreated specimens compared to groups not receiving ATG before organprocurement (p¼ 0,06), regardless whether BD induction preceded ornot. No IL-6 depositions were found in the coronary arteries of potentialdonors pretreated with ATG before organ procurement. Conclusion:Other studies have shown significant amelioration of tissue damageafter pretreatment with ATG before organ procurement, whereas ourresults were not significant. This study demonstrates the difficulties inaccurate dosing and application of ATG. Our datamay suggest that ATG ismore effective in reducing the activation of IL-6 and its deposition inmedia myocytes of coronary arteries. Further investigations should beconsidered, as these findings may be relevant regarding possiblemeasures to prevent later cardiac allograft vasculopathy.

Heart valve disease I: Aortic valve

SC57Hemodynamic performance of 3 differencebioprothesis: SJM Trifecta vs. Sorin Mitroflowand stentless Sorin SoloArunagirinathan U.1, Alassar Y.1, Muth A.1, Biermann D.1,Reiter B.1, Reichenspurner H.1, Detter C.11Department of Cardiovascular Surgery at the UniversityHeart Center, Hamburg, Germany

Objective: Concern about optimizing hemodynamics in tissue valveshas led to innovations in aortic valves design. This study aim to comparethe hemodynamic performance of 3 different pericardial bioprosthesis.Methods: A total of 224 consecutive patients with aortic valve diseaseunderwent aortic valve replacement between 2006 and 2013. Threedifferent bioprotheses were implanted: SJM Trifecta (group TF, n¼82),Sorin Mitroflow (group MF, n¼102), and Sorin Solo stentless biopro-thesis (group Solo, n¼40). Clinical and hemodynamic data were pro-spectively recorded and compared. Hemodynamic performance wasevaluated by transthoracic echocardiography at baseline, discharge, and

3-months follow-up. Results: Preoperative characteristic were similarbetween groups. There were no perioperative deaths in either group.Cardiopulmonary bypass timewas 100� 26min in the TF, 111� 35mininMF (p¼n.s.), and 108� 20min in the FS group (p¼n.s.). Aortic cross-clamp times were 68� 18 min in TF, 75� 25 min in MF (p¼n.s.), and 73� 14 min in the FS group (p¼n.s.). The peak and mean transvalvulargradient at discharge were superior in the TF compared to MF group(16.8� 6.6 mmHg and 8.6� 3.3 mmHg vs. 21.2 � 8.4 mmHg and 12.1 �5.4mmHg; p¼0.001), but similar to Solo group (15.3� 6.1 and 7.9� 3.4mmHg ; p¼n.s.). This could be proven at 3 months postoperatively (TF17.1� 6mmHg and 9.2� 3.5 mmHg; MF 21.45� 10.69mmHg and 11.1� 6.1 mmHg; p <0.01 and Solo 14.8 � 7.1 mmHg and 7.8� 3.8 mmHg).At 3 months follow-up, the NYHA class were significantly superior topre-op data (mean 2.6 vs. 1.5, respectively) with no differences amonggroups. Conclusions: At discharge and 3 months follow-up, hemody-namic performance of the stented TF bioprothesis seems to be superiorto the MF prosthesis and comparable to the stentless Solo prosthesis.

SC58Rare Finegoldia magna-Endocarditis leads to anearly Giant Pseudoaneurysm of the ascendingAorta compressing the left main stemZientara A.1, Dzemali O.1, Loeblein H.1, Genoni M.11Stadtspital Triemli Zürich, Herzchirurgie, Zürich,Switzerland

Introduction: Endocarditis of prosthetic valves caused by Finegoldiamagna is a rare disease. There are only seven cases published in theliterature defining this infection as a subacute, early endocarditis (60days) following valve replacement (85%), with an elevated mortality(28%). The anaerobic gram positive coccus is part of the normal flora ofhuman mucocutaneous surfaces but can also be involved in a widevariety of clinically significant infections. We present a 58year oldpatient with an incidential finding of a giant pseudoaneurysm com-pressing the left main stem 5 months after initial operation due toFinegoldia magna-Endocarditis. Case presentation: The follow-upechocardiography present a perfused pseudoaneurysm, 70 mm at itsgreatest extent. Angiography showed a complete compression of the leftmain stem and the ascending aorta during systole. The computedtomography confirmed these findings (Fig. 1). Surgical treatment andoutcome: Prior to medial re-sternotomy a cannulation of the rightsubclavian artery and right femoral vein was performed. The pulsatingmass compressing the left main stem could be exposed and opened (Fig.2). Approximately over 70% of the valves' annulus was disconnectedfrom its original placement. A 29 mm stentless biologic prosthesis wassutured into place. The postoperative course was uneventful. Viamicrobiological analyses Finegoldia magna could be isolated from theinfected valve. Pre- and postoperative bloodcultures showed no micro-bial growth. An antimicrobial therapy with Penicillin was established.Conclusion: Endocarditis with Finegoldia magna is a rare complicationafter valve implantation. Little is known about the aggressiveness andoverall clinical significance of the pathogen, especially in the setting ofcardiac procedures. Considering our findings and the notedly scarceliterature, an infection with Finegoldia magna may lead to a rapidprogression about a short time period with life-threatening complica-tions.


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Fig. 1: SC58Fig. 1: Finegoldia magna

SC59Clinical experience with the Medtronic “3F”stentless aortic bioprosthesis - ten years follow-upHoffmann S.1, Linneweber J.2, Claus B.2, Konertz W.21Klinik für Kardiologie, Charité-Universitätsmedizin Berlin,Berlin, Germany, 2Klinik für kardiovaskuläre Chirurgie,Charité Universitätsmedizin Berlin, Berlin, Germany

Objectives: The 3F aortic bioprothesis is an equine pericardial stentlessvalve for aortic valve replacement. The study aim was to evaluate thehemodynamic performance of the prosthesis and incidence of valve-related complications in up to ten years of follow-up. Methods: 35patients received the prosthesis between 2002 and 2003 at our institu-tion. This cohort was prospectively followed. Clinical outcome wasassessed by clinical examination or telephone interviews with theprimary care physicians. Hemodynamic performance of the valve wasevaluated by transthoracic echocardiography (TTE). Results: Meanfollow-up was 122 (116 to 134) months and 86% complete. Ten-yearoverall survival rate was 77%. Causes of death were unknown (n¼4) ornot valve related (n¼4). Freedom from reoperation was 97%. Onepatient required reoperation due to prosthetic valve endocarditis.Freedom from severe adverse events (SAE) was 89%. SAE includedpermanent and transient neuroembolic events. 75% of the currentsurvivors (mean age 80,1 � 5,4; range 71-88 years) received no oral

anticoagulation. A total of 166 valve years have been evaluated by TTE.No severe structural or nonstructural valve dysfunction was revealed;mean transvalvular pressure gradients (Pmean) showed no significantincrease after ten years. Pmeanwas 10.9� 5.5, 10.7� 6.0, 13.4� 5.0, and14.3 � 12.8 mmHg at one, three, five and ten years after implantation,respectively. Conclusions: The 3F aortic valve prosthesis continues todemonstrate good hemodynamic results. With minimal SAE, the pros-thesis demonstrated excellent durability and long term clinical results.

SC60Cost reduction and improve outcome by usingsutureless prosthesisPollari F.1, Santarpino G.1, Dell'Aquila A.M.2, Gazdag L.1,Alnahas H.1, Vogt F.1, Pfeiffer S.1, Fischlein T.11Klinikum Nürnberg, Cardiac Surgery, Nürnberg, Germany,2Universitätsklinikum Münster, Cardiac Surgery, Münster,Germany

Objectives: Sutureless aortic valve prostheses have the potential ofshortening surgical time. However, whether this time reduction resultsin improved patient outcomes and hospital costs remain to be estab-lished. Methods: From 2010, 547 patients underwent aortic valvereplacement (AVR) with a bioprosthesis both isolated andwith concom-itant coronary artery bypass grafting (CABG): of these, 112 patientsreceived a sutureless Preceval S bioprosthesis. Based on a propensity-score analysis, 2 groups with 82 matched-pairs were created (groupPerceval “P” and group Conventional “C”), with comparable preopera-tive characteristics. Hospital outcome, follow-up and related costs wererecorded. Results: There were 3 hospital deaths in "C" and 2 in "P"(p¼0.65). Aortic cross-clamp, cardiopulmonary bypass and operationtime were 20%, 23% and 16% shorter in "P" (each one p<0.001). "P"required less frequently blood transfusion (1.2 � 1.3 vs 2.5 � 3.7 units,p¼0.005) with a similar incidence of re-exploration (2 vs 5, p¼0.221).Moreover, "P" had a shorter intensive care unit stay (1.9 � 1.72 vs 2.4 �1.3 days, p<0.001), hospital stay (9.4 � 3.9 vs 13.3 � 17.7 days,p<0.001) and intubation time (6.5 � 4.6 vs 14.6 � 6.4 hours,p<0.001) and a lower incidence of postoperative atrial fibrillation,pleura effusions and respiratory insufficiency (p¼0.015, 0.024 and0.016, respectively). Pacemaker implantation and incidence of neuro-logical events was not different (p>0.05). The use of Sutureless valveprostheses could result - including the follow-up - in a reduction inresources consumption of about 50%. Conclusion: Perceval S Suturelessprosthesis allows a better outcome than conventional valves. A propen-sity score analysis shows a shorter hospitalization, use of blood trans-fusions and a significant cost reduction.

SC61Trifecta vs. Mitroflow: Superior hemodynamicsdespite equal designDiab M.1, Färber G.1, Tsanava F.1, Breuer M.1, Walther M.1,Bothe W.1, Amorim P.1, Doenst T.11Universitätsklinikum Jena, Klinik für Herz- undThoraxchirurgie, Jena, Germany

Purpose: Hemodynamic results of stented tissue valves are influencedby both valve design and sizing strategy. The Mitroflow and the Trifectahave an innovative designwhere the pericardium iswrapped around thestent. The goal of this study was to compare both valves giving specialconsideration to the suggested sizing strategies.Methods:We obtainedpressure gradients from discharge echocardiograms from all patientshaving received an isolated Trifecta (n¼104) or Mitroflow (n¼246)between 01/2007 and 05/2013. We compared the results by size labeland by the most likely selected size according to the suggested sizingstrategy. This is important because the prostheses, despite having asimilar design, have different diameters for the same size label anddifferent sizing strategies. Results: The majority of implanted valveswere size labels 21 and 23 (82.7% of the Trifecta and 74.8% of theMitroflow). Mean pressure gradients were lowest with Trifecta (Trifectavs. Mitroflow, label-21: 11.4� 4.65 vs 13.6� 5.23mmHg, label-23: 9.23� 3.38 vs. 11.8 � 4.42 mmHg, p<0.05, and label-25: 11.2 � 4.97 vs 12.0� 4.46mmHg, n.s.). The sizers for the Trifecta are metric, while those forthe Mitroflow are 2-3 mm larger than the corresponding size label. It is


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therefore likely that for a patient with a 23 mm aortic annulus, a 23Trifecta but often only a 21 Mitroflow is selected. Thus, comparing theTrifecta to the Mitroflow not by size label but by selected valve (e.g., 23vs. 21) would therefore only increase the difference. Conclusion: This isthe 1st comparison of Trifecta and Mitroflow. It shows that Trifectaprovides hemodynamic advantage over Mitroflow irrespective of thesizing strategy applied.

SC62Clinical and echocardiographic impact ofTrifecta™ aortic bioprosthesis: an initial single-centre experienceKammerer I.1, Wiedemann M.1, Sack F.-U.11Klinikum Ludwigshafen, Herzchirurgie, Ludwigshafen,Germany

Objectives: To face common issues such as high transvalvular pressuregradients after implanting small valve sizes and low effective orificeareas, which leads into manifestation of a patient prosthesis mismatch,the new Trifecta™ aortic valvewas designed as a stented valve for supra-annular placement to reduce the obstruction of the left ventricularoutflow tract. The present study evaluated retrospective the earlyhaemodynamic performance after implantation of the new valve.Methods: Between September 2010 and February 2013, 380 patientsunderwent an aortic valve replacement (AVR) with Trifecta™, Depart-ment of Cardiac Surgery, Academic City Hospital, Ludwigshafen,Germany. Prevalent cause of AVR was single aortic stenosis in 52%,insufficiency in 10% and combined pathology in 38%. Mean age atpatients was 73 years (range 33-93), 58% of them were male. Themean preoperatively pressure gradient was 45 mmHg with effectiveorifice area of 0.73cm2. Themajority of patients were classified as NYHAClass III (78%). Results: The 30-day-mortality was 4% (n¼16). The earlypostoperative hemodynamic date showed in Figure 1. Concomitantprocedures were most frequently coronary artery bypass grafting(n¼234), ablation of atrial fibrillation with LAA exclusion (n¼67).There were 2 cardiac depending intraoperative deaths (0.52%), but notvalve related. At discharge, there could not be determined any valvethrombosis or prosthesis failure. Conclusion: The Trifecta™ revealsexcellent early haemodynamics over all valve sizes. Especially lowgradients in small valves and large EOAs attest a satisfying outcomeafter implantation. Futher data is needed to investigate the stableness ofthese results in long time follow-up.

Fig. 1: Echocardiographic haemodynamic data for each Trifecta™aortic valve size (n¼380)

SC63Twenty-seven-year experiencewith the St. JudeMedical Biocor™ bioprosthesis in the aorticpositionGünzinger R.1, Fiegl K.1, Wottke M.1, Hettich I.1, Lange R.11Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, München, Germany

Objectives: The aim of this study was to evaluate the long-termperformance of the St. Jude Medical Biocor™ porcine stented prosthesisin the aortic position. Methods: From January 1985 to December 1996,455 consecutive patients underwent aortic valve replacement with theSt. Jude Medical Biocor™ prosthesis at our center. Mean age at time ofoperationwas 72.5� 9 years. 179 patients (37.6%) underwent concomi-tant coronary artery bypass grafting and 18 patients (3.5%) had hadprevious cardiac surgery. Event-free rates are given as mean � standarddeviation. Adverse events were recorded according to the guidelines forreporting morbidity and mortality after cardiac valvular operations.Results: Follow-upwas complete in 91%.Mean follow-up timewas 8.4�5.5 years with a total of 3804 patient-years and a maximum of 27.3years. 41 patients were lost to follow-up after a mean time of 9.3 � 3.9years. Overall survival rate at 10 and 15 yearswas 43.2� 2.4% and 18.4�2.0%, respectively. Kaplan-Meier analysis revealed 92.1 � 1.7% and 84.6� 3.1% freedom from structural valve deterioration (SVD) at 10 and 15years. Freedom from valve-related reoperation at 10 and 15 years was90.6 � 1.7% and 86.1 � 2.5%, respectively. 24 patients needed reopera-tion for SVD, 9 patients for endocarditis, 3 patients for paravalvularleakage, and 2 patients for aortic root aneurysm. At 15 years, freedomfrom major bleeding was 90.9 � 2.0% and freedom from thromboem-bolism was 72.1 � 2.8%, respectively. Conclusion: This study representsthe longest follow-up period for the St. JudeMedical Biocor™ prosthesisand shows an excellent durability with low incidence of valve-relatedcomplications.

SC64Sutureless aortic valve replacement viaanterolateral minithoracotomyEichstaedt H.C.1, Easo J.1, Dapunt O.11Klinikum Oldenburg, Klinik für Herzchirurgie, Oldenburg,Germany

Objectives: To evaluate surgical feasibility and clinical outcome ofsutureless aortic valve replacement (SAVR) in patients (pts) using aminimally-invasive approach via anterolateral thoracotomy. Methods:in pts with severe and isolated aortic valve stenosis cardiopulmonarybypass (CPB) was installed by femoral cannulation. After right-sidedanterolateral minithoracotomy AVR was performed using two differenttypes of sutureless aortic valves prostheses (3f Enable I, Medtronic Inc;Perceval S, Sorin Inc). Surgical key times and clinical outcome wereassessed. Echocardiography was performed during surgery, beforedischarge, and during follow-up exams each year. Results: Overall, 18pts underwent SAVR via minimally-invasive approach (m:w¼8:10),mean age 78.2 ys (range 71-88 ys). Mean Euroscorewas 11.1 (range 4.3 -24.2). Mean cross clamp time was 47.1 mins (range 29-70 mins), meanCPB timewas 83.1mins (range 58 - 113mins). Prostheses sizes of 23 and25 mm were used in most pts (n¼7 and 5, respectively). Echocardio-graphic examinations did reveal no paravalvular leakage in all pts andlow pressure gradients (overall mean 10,1 mmHg). There was onepostoperative death due to respiratory failure (day 19). Postoperativepacemaker implantation due to new-onset bradycardiawas necessary in1 pt. During mean follow-up time of 332 days (range 19 to 669 days) nofurther significant complication was observed. Conclusions: In ourpreliminary experience minimally-invasive SAVR does represent avaluable option for surgical treatment of severe aortic stenosis inselected patients with acceptable surgical key times and excellentoutcome. Especially high-risk pts who do not qualify for transcathetervalve replacement may benefit significantly using this approach.


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SC65Predictive power and implication of EuroSCOREand EuroSCORE II for repeated aortic valvereplacementHolinski S.1, Jessen S.1, Neumann K.2, Konertz W.11Klinik für kardiovaskuläre Chirurgie, Charité-Berlin,Berlin, Germany, 2Institut für Biometrie, Charité-Berlin,Berlin, Germany

Objectives: We evaluated the predictive power of the EuroSCORE andEuroSCORE II for isolated redo aortic valve replacement. Methods: 94consecutive patients underwent the aforementioned procedure mainlywith a stentless valve prosthesis at our institution. Observed mortalitywas compared to the predicted mortality, ROC curves were calculatedand the area under the curve (AUC) analyzed. Results: Observedmortality was 9.6%. EuroSCORE predicted a mortality of 29.2 � 22.4%(p<0.001) and its AUCwas 0.73 (95% CI: 0.63 - 0.83), p¼0.01. Predictedmortality of EuroSCORE II was 10.8� 12.1% (p¼0.42) and AUC was 0.83(95% CI: 0.74 - 0.90), p<0.0001. Optimal youden index of the Euro-SCORE II was 0.56 refering to a predicted mortality of 10.6% (sensitivityand specifity 77%). Conclusion: EuroSCORE II calculation was not onlysuperior to EuroSCORE but led to a very realisticmortality prediction forthis special procedure at our institution. An EuroSCORE II greater 10should encourage to consider an alternative treatment like TAVI.

SC66Long-term outcome of patients with lupuserythematodes and AntiphospholipidSyndrome after cardiac valve surgeryArif R.1, Seppelt P.1, Zaradzki M.1, FaragM.1, Ruhparwar A.1,Karck M.1, Kallenbach K.11University Hospital Heidelberg, Department of CardiacSurgery, Heidelberg, Germany

Objectives: Lupus erythematodes (LE) and primary or secondary Anti-phospholipid Syndrome (APLS)may cause early degenerative changes ofcardiac valves, such as Libman-Sacks endocarditis. However, only fewreports exist about the outcome of such patients after cardiac valvesurgery. Herewe report our 10-year single-center experience.Methods:We retrospectively analyzed perioperative and follow-up data of pa-tients with diagnosed LE, primary and secondary APLS, who underwentsingle or combined valve surgery in our department between 2002 and2012. Mean follow-up time was 42 � 33 month (range from 7.7 to 119month). Results: Fifteen patients (87% female) withmean age of 54� 17years (range 16 to 77 years) were identified. 13 (11 female) patientswere diagnosed with LE, one of those had tricuspid Libman-Sacksendocarditis. Two female patients had primary APLS. Three patients(100% female) were diagnosed with combined LE and secondary APLS.Single or double mechanical valve replacement were applied to 10patients, 3 patients received biological valve prostheses. Mitral valvereconstructionwas performed in 2 patients; one patient also underwenttricuspid valve reconstruction. Mean aortic cross-clamp timewas 107�73 min (range 55 to 294 min), intraoperative IABP implantation wasrequired in one patient. 30-day and in-hospital mortality was 0%. Earlymajor cardiovascular events occurred in 3 patients (up to 6month), suchas postcardiotomy syndrome. Late non-fatal events occurred in 2patients. 12 (80%) patients are still alive. During follow-up 2 out of 3patients died due to myocardial failure, one patient died due toplasmacytoma. Actuarial survival was 90 � 9.5% at 1 year, 72 � 18%at 4 years and 36 � 27% at 10 years. Conclusions: Despite generalconcerns, our results demonstrate that patients with Lupus erythemat-odes and Antiphospholipid Syndrome can be operated on for cardiacvalve disease with favourable early results and acceptable long-termoutcome.

SC67Influence of partial vs. full median sternotomyon intra- and postoperative parameters inpatients undergoing isolated aortic valvereplacementGhezelbash F.1, Hoffmeier A.1, Scherer M.1, Welp H.1, Alles S.G.H.11Department of Cardiothoracic Surgery,Universitätsklinikum Münster, Division of Cardiac Surgery,Münster, Germany

Background: This study has been conceived to compare two groups ofpatients who underwent aortic valve replacement using the conven-tional and the minimally-invasive technique.Material and methods: Ingroup A 103 patients (mean age 71.6 (� 10.0) years; 55 male) under-went isolated aortic valve replacement through a partial upper median-sternotomy. Group B was composed of 87 patients (mean age 72.6 (�10.1) years; 40 male) who underwent the same operation through amedian-sternotomy. For both groupswe recorded the ECC and ischemic-times, postoperative intubation-time, total bleeding, ICU length of stayand total hospitalisation time. Major and minor complications werereported. Results: Operating- (188.8 � 43 min. vs. 203 � 43 min.;p¼0,023), ECC- (105.8 � 32 min. vs 112.7 � 27 min.; p¼0,018) andischemic-times (67.6 � 17.1 min. vs 80.1 � 20.2; p< 0,001) weresignificantly shorter in group B. Group A had a significantly shorterICU length of stay (3.6 � 2.9d vs 5.1 � 5d; p<0.05) and had a lower rateof prolonged (>24 h) ventilation time (5% vs 16%; p<0.01). Moreovergroup A had significantly less postoperative bleeding (771� 629.5ml vs1168 � 1133; p¼0,04) and need for transfusion of units of packed redblood cells (1.4 � 1.8U vs 2.4 � 3U; p<0.05). The rates of all othercomplications, such as re-sternotomy for bleeding (5.7%in group b and3.9%in group a), postoperative onset dialysis (2% in group b, 1% in groupa), strokes (3% in both groups) and reversible delirium (48% in group b,52% in group a) were similar in both groups. Conclusions: In ourexperience, partial uppermedian-sternotomydoes not increase surgicalrisks. Apart from an increased operating times, the surgical result iscomparable to the conventional median sternotomy.

SC68Aortic valve replacement in elderly patientswith rapid-deployment aortic valve system: 3years laterShrestha M.1, Sarikouch S.1, Maeding I.1, Przybilla K.1,Zimmermann S.1, Bara C.1, Koigeldiyev N.1, Haverich A.11Medizinische Hochschule Hannover, Hannover, Germany

Objective: The INTUITY system (Edwards Lifesciences, Irvine, CA) is astented tri-leaflet bovine pericardial bioprosthesis with a balloon-expandable, cloth-covered stent frame at the inflow aspect. We reportmidterm results of a prospective, single-arm, study in patients under-going aortic valve replacement (AVR) with and without Concomitantprocedures. Methods: From 1/2010 to 7/2012, a total of 70 patients,underwent AVR using the INTUITY system in our center. 36 patients(Group A; age 78.2 � 3.9 years; 20 female; EuroSCORE 1, 9 � 4.2)underwent isolated AVR, whereas 34 (Group B; age 77.12� 4.9 years; 14female; EuroSCORE 1 9.2 � 7) underwent AVRþ concomitant proce-dures. 35 patients in group A underwent AVR via a minimally invasiveaccess (35/36). Results: Mean cross-clamp time (CCT) and extracorpo-real circulation time (ECT) were, Group A: 38.9� 7.2minutes and 73.1�23.6minutes and group B: 52.9� 17.8minutes and 96.9� 27.1minutes,respectively. 30 day mortality was 2.8% (n¼1) in group A and 2.9%(n¼1) in Group B, respectively. No patient in both the groups developedpost-operative AV Block III requiring pace-maker implantation. Meanpostoperative gradients at discharge were 12 � 4.2 mm Hg (Group A)and 10 � 3.2 mm Hg (Group B), respectively. Postoperative meaneffective orifice areas were 1.6 � 0.3 (Group A) and 1.8 � 0.4 cm2

(Group B), respectively. Maximum andMedian follow-upwere 3.5 yearsand 1.7 years, respectively. In follow-up, there was no valve relatedexplants and no incidence of valve degeneration was observed. Themean valvular gradients remained in stable. Conclusions: Valve implan-tation led to significant improvement of patients´ symptoms. EdwardsINTUITY rapid-deployment valve system is a safe bioprosthesis that caneasily be implanted, including by a minimally invasive technique. It


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provides excellent hemodynamics with significant clinical improve-ment. These data confirm the safety and utility of this valve systemfor elderly and high-risk patients especially for complex AVRþCABGcases. These valve systems may have benefit in the elderly because oftheir increased surgical risk profile. These new valves may also helptowards broader application of minimally invasive AVR.

SC69Matched comparison of twodifferent biologicalprostheses for complete supraannular aorticvalve replacementFiegl K.1, Günzinger R.1, Rondak I.2, Vincze D.1, Voss B.1,Lange R.11Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, München, Germany, 2TechnischeUniversität München, Institut für Medizinische Statistikund Epidemiologie, München, Germany

Objectives: The aim of this study was to evaluate the hemodynamicperformance of complete supra-annular aortic valve replacement (AVR)either with the SJM Trifecta™ (St Jude Medical, St Paul, Minn) or theCarpentier-Edwards Perimount Magna (CEPM) Ease™ (Edwards Life-sciences, Irvine, Calif) biological prosthesis early postoperative and at 1year. Methods: From 10/2007-10/2008 51 consecutive patients under-went AVR with the Carpentier-Edwards Perimount Magna™ prosthesis.From a prospective cohort of 216 patients (01/2009-01/2012), whounderwent AVR with the SJM Trifecta™ valve, a matched group of 51patients was selected. Matching was conducted 1 to 1 by ejectionfraction, gender, age, and body surface. A neutral sizer (Hegar dilator)was used to define the aortic tissue annulus diameter and to allow abetter comparison of valves from different manufacturers. Data weregrouped on the basis of the patient's tissue annulus diameter (�22 mm;23-24 mm; �25 mm). All parameters were generated by 2D echocardi-ography. Results: Early postoperative and at one year mean pressuregradients (MPG) ranged from 7.2� 4.6 to 7.1� 2.4mmHg and from 10.0� 4.3 to 8.0 � 2.8 mmHg in the Trifecta™ group and from 18.0 � 5.0 to12.1 � 3.6 and from 17.7 � 4.5 to 11.8 � 3.2 in the CEPM Ease™ group,respectively (p<0.05). Likewise effective orifice area (EOA) ranged from1.7 � 0.5 to 2.0 � 0.5cm2 and from 1.5 � 0.3 to 1.7 � 0.4cm2 in theTrifecta™ group and from 1.3� 0.5 to 1.9� 0.5cm2 and from 1.2� 0.3 to1.8� 0.3cm2/m2 in the CEPM Ease™ group, respectively (n.s). A markedleft ventricularmass (LVM) regression across all annulus sizeswas notedin both groups (p<0.001). Severe patient-prosthesis-mismatch (PPM)was infrequent overall. Conclusion: The SJM Trifecta™ valve showedlower MPG‘s early postoperative and at one year. No significant differ-ences were detected with regard to EOA, LVM regression, and PPM.

SC70Is early surgical treatment for infectiveendocarditis superior to conservativeapproach?Yilmaz M.1, Häussler A.1, Löblein H.1, Odavic D.1, GenoniM.1, Dzemali O.11Stadtspital Triemli, Zürich, Switzerland

Introduction: The timing and indication for surgical intervention ininfective endocarditis (IE) remain controversial. While the Americanheart and European heart association prefer an early surgery, there arestudies that recommend conventional treatment of IE first. This trialcompares clinical outcomes of short and long-term results after earlysurgery vs. no early surgery in patients with IE. Method: We analyzedretrospectively data of 55 patients with the diagnosis of IE to determi-nate the effect of early surgery (<48 hours) on clinical outcome. 34Patients (61.8%) underwent early surgery. 19 Patients (34.5%) gotprimary antibiotic therapy for at least 2week and underwent afterwardssurgical treatment. Primary endpoints were in-hospital death andembolic events. Secondary endpoints were ICU and hospital stay, repeathospitalization, recurrence of IE and need of reoperation. Results: Therewas no significant difference in mortality (3 vs. 4 patients) and inembolic events (5 vs. 6 patients). The ICU time was significant higher inthe groupwho underwent early operation (8� 1.3 days vs. 5� 1.2 days,p<0.01). The hospitalization durationwas not significant (20� 1.7 days

vs. 17� 2.1 days). Therewas also no significant difference in the need ofErythrocytes and Thrombocytes substitution. Conclusion: Early surgeryis associated with higher ICU times. There were no significant differ-ences for mortality, embolic events and hospital stay for both ap-proaches. So it should be discussed in each case depending on theclinical findings and heart function if an early surgery approach orconservative therapy is indicated.

Transcatheter valves I: Clinical outcomes TAVI

SC71Impact of gender on frequency of contrast-induced nephropathy following transcatheteraortic valve implantationScherner M.1, Madershahian N.1, Kuhn E.1, Slottosch I.1,Deppe A.1, Choi Y.1, Strauch J.2, Wippermann J.1, Wahlers T.11Universitätsklinik Köln, Köln, Germany, 2Uni-KlinikBochum, Bochum, Germany

Background: Women who are exposed to contrast medium (CM) havehigher risk to develop contrast-induced nephropathy (CIN) than men.This has been evaluated most extensively in patients undergoingpercutaneous coronary intervention. Information concerning the influ-ence of gender on frequency of CIN following transcatheter aortic valveimplantation is scarce.Methods: From February 2008 to February 2011,128 patients (81.4 � 6.7 years) were retrospectively investigated. Theincidence of post-procedural CIN, lengths of ICU stay, hospital stay, and30-day mortality among men and women were compared. CIN wasdefined as a creatinine increase of �25% or >0.5 mg/dL from baselinewithin 3 days after CM exposure. Results: When CIN-associated factorswere compared between women and men, women were older (82.6 �6.4 vs. 79.5 � 6.8 years, p¼0.011), had a lower serum creatinine (1.1 �0.5 vs. 1.3 � 0.5, p¼0.028) and hemoglobin level (11.9 � 1.4 vs. 13.2 �1.5 g/dL, p<0.001). Men suffered more often from coronary arterydisease (75% vs. 50%, p¼0.005) and peripheral vascular disease (48% vs.29%, p¼0.029). The amount of CM given was not significantly different(107.4 � 59 vs. 111.4 � 50 mL, ns). However, CIN occurred in 47.5% inwomen and in 35.4% in men (p¼0.181, insignificant). Thirteen of the 80women (16.3%) and three of the 48 men (6.2%) required dialysis duringindex hospitalization (p¼0.08, insignificant). Although, it did not reachstatistical significance, 30-day mortality was approximately two timeshigher in women than in men (15% vs. 8.3%, p¼0.270). Subgroupanalysis of those patients with a preprocedural renal insufficiency(serum creatinine >1.1 mg/dl) revealed a significantly higher incidenceof CIN in women (62.1% vs. 26.9%, p¼0.009). 31% of women (n¼9)versus 7.7% of men (n¼2) needed haemodialysis (p¼0.031). Mortalityresults reached a significant difference at 60 days with 31% (n¼9)mortality in women compared with 7.7% (n¼2) in men (p¼0.031).Conclusions: Our results indicate a remarkable trend towards increasedrisk for CIN, need for dialysis, and higher early mortality among femalepatients following transapical TAVI reaching statistical significance inpatients with preoperative renal dysfunction.

SC72Outcome after transapical TAVI in patients withreduced left ventricular ejection fractioncomparing ballon-expandable and self-expanding prosthesesSchirmer J.1, Seiffert M.2, Conradi L.1, Koschyk D.2,Blankenberg S.2, Reichenspurner H.1, Diemert P.2, Treede H.11Universitäres Herzzentrum Hamburg, Klinik für Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Klinik für Allgemeine undInterventionelle Kardiologie, Hamburg, Germany

Objectives: The adverse impact of left ventricular dysfunction onsurvival after transcatheter aortic valve implantation (TAVI) has beendocumented. We report our experience with transapical TAVI in pa-tients with reduced left ventricular function (LVEF) comparing first(ballon-expandable) and second (self-expanding) generation TAVI de-vices. Methods: From 3/2008 through 12/2012, a total of 75 patients


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presenting with pre-procedural LVEF�45% underwent transapical TAVI,implanting either ballon-expandable valves (Edwards Sapien/ SapienXT) in 48 patients (BE; mean age 78.2 � 7.9 years, 71% male) or self-expanding valves (JenaValve, n¼12; Symetis Accurate, n¼9;MedtronicEngager, n¼6) in 27 patients (27; mean age 79.5� 6.7 years, 63%male),respectively. Calculated logistic EuroSCORE II and STS mortality scoreswere 12.6� 7.4% (BE) vs. 10.8� 5.4% (SE) (p¼ns) and 9.2� 6.6% (BE) vs.9.2 � 7.3% (SE) (p¼ns). Clinical and functional data were analysedaccording to the Valve Academic Research Consortium (VARC) end-points. Results: Cumulative survival rates at 30 days and at one yearwere 87.5% (BE) vs. 96.3% (SE) (p¼ns) and 52.0% (BE) versus 60.5% (SE)(p¼ns), respectively. VARC device success and VARC combined 30-daysafety endpoints were achieved in 87.5% (BE) vs. 85.2% (SE) (p¼ns) and31.3% (BE) vs. 18.5% (SE) (p¼ns), respectively. Post-procedural aorticregurgitation>1 did not differ between groups (8.4% (BE) vs. 11.1% (SE),p¼ns). However, aortic regurgitation�grade 1 was observed in 50.0%(BE) vs. 37.0% (SE) (p¼0.016). New onset of pacemaker indication waspresent in 10.4% BE) vs. 7.4% (SE) (p¼ns). Mean ICU stay was 2.5 � 2.6days (BE) vs. 2.0� 1.8 days (SE) (p¼ns), whilst post-procedural hospitalstay was 10.0 � 3.8 days (BE) vs. 10.6 � 6.6 days (SE) (p¼ns).Conclusion: Comparable survival rates and VARC endpoints wereachieved in patients with reduced LVEF undergoing transapical TAVIeither with ballon-expandable or with self-expanding prostheses. Fur-ther studies are required to evaluate the impact of a lower incidence ofmild aortic regurgitation following implantation of self-expanding valvetypes when compared to ballon-expandable prosthetic valves. Consid-ering one-year all-cause mortality rates above 40%, careful evaluationand selection of patients with reduced LVEF seems to be warranted.

SC73Postoperative course and survival aftertransapical aortic valve implantation inpatients with pulmonary hypertensionBuz S.1, Pasic M.1, Unbehaun A.1, Drews T.1, Dreysse S.1,Penkalla A.1, Kukucka M.1, Hetzer R.11Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefässchirurgie, Berlin, Germany

Objectives: We evaluated whether pulmonary artery hypertension(PAH) is a risk factor for adverse outcome and survival after transapicalaortic valve implantation (TAVI). Methods: A total of 532 consecutivepatients with TAVI were divided into two groups: “Group PAP>50”, 189patients (35% male, mean age, 79.8 years) with severe PAH (defined assystolic pulmonary artery pressure (sPAP) >50 mmHg) and “GroupPAP<50”, 343 patients (39% male, mean age, 79 years) with sPAP <50mmHg. Preoperatively, echocardiographic data were collected and PAPwas assessedwith echocardiography or cardiac catheterization. Results:There was positive correlation between increase of sPAP and NYHA(p<0.001), proBNP (p<0.001), left-ventricular diameter (p<0.001),tricuspid, mitral and aortic regurgitation (p<0.001 for all) and ICU stay(p¼0.001). Significant negative correlation was found for creatinineclearance (p¼0.01) and left-ventricular ejection fraction (p<0.001).The 30-day mortality (without cardiogenic shock) was 3.0% in Group<50 and 5.3% in Group>50. Late survival was significantly lower inGroup>50 with 3-year-survival of 51% � 6% vs. 68% � 3% (p¼0.003). Inadjusted analyses, patients with sPAP>50mmHg experienced increasedrisks for in-hospital (hazard ratio (HR) 1.88 [95% CI, 0.98-3.58]) and long-term-mortality (HR 1.91 [95% CI, 1.37-2.66], p<0.001). Tricuspid re-gurgitationwas also predictive formortality (HR 1.6 [95% CI, 1.16-1.84,],p¼0.001). Patients with PAH had increased length of hospital stay(p¼0.005) and prolonged ventilation time (p¼0.01). Conclusions:Pulmonary artery hypertension secondary to severe aortic stenosis iscommon and an important predictor for mortality in patients undergo-ing transapical valve implantation. Pulmonary hypertension as well astricuspid valve regurgitation should be considered in preoperative riskassessment.

SC74Transapical aortic valve implantation inpatients with EuroScore>40%Drews T.1, Pasic M.1, Unbehaun A.1, Dreysse S.1, KukuckaM.1, Mladenow A.1, Hetzer R.1, Buz S.11Deutsches Herzzentrum Berlin, Berlin, Germany

Objective: EuroScore of more than 40% has been proposed as contrain-dication for transcatheter aortic valve implantation (TAVI). The aim ofthe study was to identify early outcome and late survival after trans-apical TAVI in patientswith EuroScore I over 40%.Methods: Between 04/2008 and 03/2013, 679 consecutive patients underwent transapicalTAVI. Group I (EuroScore I>40%) consisted of 226 patients (142 womenand 84men;mean age¼81� 8 years [range 36-99]); EuroScore I¼62�16% (range 40-97), EuroScore II¼ 32� 19%; STS PROM score¼23� 14%.There were 35 (15%) patients in cardiogenic shock. Group II (controlgroup, EuroScore I <40%) consisted of 453 patients (267 women and186men; mean age 78� 8 [range 29-97] years). In this group EuroScoreIwas significantly lower (22� 9% [range 2-40]), EuroScore II was 10� 8%and STS PROM score was 10 � 7.6%. Results: In group I, in 33 (15%)patients the procedure was performed using elective femoro-femoralnormothermic CPB. Elective PCIwas performed in 28 (12%) patients. The30-day mortality in patients with EuroScore >40% (group I) was 4.7%(6.2% with cardiogenic shock) and in patients with EuroScore <40%(group II) it was 4%. One-year survival was 72% (67% with cardiogenicshock) and 86%, respectively (p< 0.01). Two-year survival was 59% (56%with cardiogenic shock) and 78%, respectively (p<0.01). Conclusions:Patients with co-morbidities, as reflected by a EuroScore of more than40%, should not be refused for TAVI.

SC75Transapical aortic valve implantation: Effects ofpoor left ventricular function on survival andmyocardial contractilityUnbehaun A.1, Pasic M.1, Buz S.1, Penkalla A.1, Dreysse S.1,Kukucka M.1, Hetzer R.1, Drews T.11Deutsches Herzzentrum Berlin, Berlin, Germany

Objectives: The purpose of this study was to identify what happens tothe left ventricular function after transcatheter aortic valve implanta-tion (TAVI) in patients with failing ventricles. Methods: We comparedleft ventricular ejection fraction (LVEF) and end-diastolic diameter(LVEDD) before TAVI and 1 week after TAVI in 96 patients with verypoor and poor left ventricular function. There were 39 patients (41%)with LVEF of 20% and 57 patients (59%) with LVEF of 21-30%. The meanEuroSCORE II was 37 � 23% (range 2-95%). Cardiogenic shock waspresent in 23 patients (24%). Results: During the first week afterTAVI, LVEF increased from 23.2 � 6.4% to 40.3 � 11.8% (p<0.001) andLVEDD decreased from 57.2 � 8.1 mm to 54.6 � 8.1 mm (p<0.001).More than 50% improvement in LVEFwas found in 62 patients (65%) and100% improvement in 37 patients (39%). Changes in LVEF were inde-pendent of the preoperative value (p¼0.208). Survival at 1, 2, and 4years was 81 � 5%, 64 � 7%, and 45 � 9%, respectively. There was nosignificant difference in survival in patientswith LVEF of 20% and LVEF of20-30% (p¼0.623). Conclusions: In the majority of patients with failingventricles, left ventricular function is quickly restored after TAVI andelimination of aortic stenosis. Without the additional trauma of car-dioplegic arrest, TAVI is the potentially superior treatment option inpatients with poor and very poor left ventricular performance.

SC76Transapical aortic valve implantation: Outcomein patients with low arithmetic risk profileUnbehaun A.1, Pasic M.1, Drews T.1, Buz S.1, Dreysse S.1,Kukucka M.1, Mladenow A.1, Hetzer R.11Deutsches Herzzentrum Berlin, Berlin, Germany

Objectives: Trancatheter aortic valve implantation (TAVI) has beenintroduced as an alternative treatment to eliminate aortic stenosis inpatients who are at high risk for conventional surgery. Classical riskscores in cardiac surgery do not always reflect the true surgical risk. Weanalyzed outcome and predictors of survival after TAVI in a large single-center cohort with low arithmetic risk profile. Methods: Between 04/


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2008 and 07/2012, 610 patients (median age 80, range 29-99 years)underwent transapical TAVI. Patients in cardiogenic shock were includ-ed (n¼33; 5.4%). In accordancewith The-Society-of-Thoracic-Surgeons-Predicted-Risk-of-Mortality (STS-PROM-score), the cut-off level be-tween study and control group was arbitrarily set at 10%. The studygroup of 274 patients (median STS-PROM-score 5.9%, interquartilerange [IQR] 4.4%-7.6%) was compared to the control group of 336patients (median STS-PROM-score 18.0%, IQR 13.5%-26.1%). Results:Thirty-day mortality rate in patients with STS-PROM-score<10% was3.3%. Survival in the study group was significantly better (p<0.001)with 1-, 2-, 3-, and 4-year survival rate of 89%� 2%, 83%� 3%, 76%� 5%,and 72% � 6%, respectively. Survival in a sub-group of 89 patients withSTS-PROM-score<5% was 95% � 3% and 91% � 5% at 1 and 3 years;p¼0.002. The strongest predictors of mortality in multivariate Cox-regression-analysis were advanced age (p¼0.003, hazard ratio [HR]1.08, 95%-confidence-interval [CI] 1.03-1.14), higher NYHA class(p¼0.027, HR 2.54, CI 1.12-5.81), and longer procedural time(p¼0.001, HR 1.01, CI 1.01-1.01). Conclusions: Regardless of theirtrue surgical risk, patients with low arithmetic risk profile have muchbetter survival after TAVI. This observation is a first prerequisite tobroadening the indication for TAVI to patients with low risk forconventional surgery.

SC77Acute kidney injury after Transcatheter aorticvalve replacement: incidence, predictors andimpact on mortalityElhmidi Y.1, Bleiziffer S.1, Mazzitelli D.1, Deutsch M.-A.1,Krane M.1, Piazza N.1, Lange R.11Deutsches Herzzentrum München, Herz-, Thorax- undGefäßchirurgie, München, Germany

Background: There is a paucity of data describing AKI following TAVRand their impact on mortality remained unknown. Methods: Wesearched Medline for studies from 2008 to 2013 evaluating AKI afterTAVR. All studies were compared according to the incidence, predictorsand impact of AKI following TAVR. AKI was defined according to thevalve academic research consortium (VARC) indications using RIFLEcriteria. Results: 13 studies with more than 1900 patients were includ-ed. AKI occured in 8.3% to 41.7%. Following factors were associated withAKI: blood transfusion, transapical access, preoperative creatinine,peripheral vascular disease, hypertension and procedural bleedingevents. The 30-day mortality in patients with AKI ranged from 13.3 to44.4% andwas 2 to 6 times higher compared to patientswithout AKI. Thecontrast amount was not associated with the occurence of AKI.Conclusions: Acute kidney injury is a common complication occuringwith an incidence of 8.3 to 41% in patients following TAVR. Patients withAKI exhibited a higher 30-day and late mortality. AKI was however, notrelated to the amount of contrast volume used.

SC78Thromboelastometie overestimate the need forhemostatic agentsKiessling A.H.1, Gillen K.1, Beiras-Fernandez A.1, KornbergerA.1, Zierer A.1, Moritz A.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, THG, Frankfurt am Main, Germany

Objectives: Thromboelastometry guided therapies have been successfulestablished over the last years. Inclusion criteria's in all major studieswere an intraoperative, major coagulopathy which was diagnosed byanaesthesiologists and/or surgeons estimation. Until now, real andobjective bleeding tests were not available. The diagnose “bleeding”was a subjective, clinical assessment. Aim of our trail was the correlationof an objective, intraoperative bleeding testing with thromboelastom-etry data (FIBTEM/EXTEM).Methods: A prospective, consecutive groupof patients (N¼27, age 56 � 4ys 70%male) undergoing cardiac surgerywere measured after weaning from cardiopulmonary bypass and estab-lishment of surgical hemostasis (ACT � 20% baseline, ph> 7.30, Ca>1mmol/l, core temperature >35C) with a 5-minute bleeding test (bloodabsorbed from the mediastinal wound area by dry swabs in 5 min).These weights were linear correlated to thromboelastometry- (RO-

TEM®, Tem International GmbH, Munich, Germany) and routine coag-ulation parameters.Results: The intraoperative swabsweights showed awide range (mean 60 � 32g range 18-133g) of bleeding situations. Theweights showed a high correlation with the subjective surgeons viewand standard coagulation parameters (Fibrinogen, PTT, INR) but notwith the results of FIBTEMMCF (mean 12,54� 4,5 range 6-22) or EXTEMCF (mean 72 � 14 range 47-107). Patients without a relevant bleedingsituation (swab<60g/5 min) showed partially transfusion relevantFIBTEM/EXTEM values. Conclusions: Thromboelastometry does notreflect the intraoperativ bleeding situation in all patients which resultsin an overestimation and over-administration of hemostatic agents.FIBTEM guided therapies should be re-evaluated with objective bleed-ing tests.

SC79Transcatheter aortic valve replacement versusconventional aortic valve replacement inpatients over 75 years of age - a 5 years singlecenter experienceKondruweit M.1, Feyrer R.1, Tandler R.1, Heim C.1, ArnoldM.2, Achenbach S.2, Weyand M.11Universität Erlangen-Nürnberg, Zentrum fürHerzchirurgie, Erlangen, Germany, 2Universität Erlangen-Nürnberg, Medizinische Klinik 2, Erlangen, Germany

Objectives: We analysed our data from our transcatheter aortic valvereplacement program (TAVR) versus conventional aortic valve replace-ment (AVR) in patients older than 75 years over the past 5-years.Methods: From December 2008 up to now, when we started ourTAVR program for patients with severe symptomatic aortic stenosiswho are at a “high risk” or deemed inoperable, we performed 382 TAVRprocedures and 172 AVR procedures in patients over 75 years of age. Weretrospectively analysed the preoperative data and the postoperativeoutcome and follow-up over a period of a maximum of 4.7 years in bothgroups. The statistical tests were performed by chi-square-test respec-tively by Student’s t-test. Results: In the TAVR group the patients weresignificantly older (79.8 � 3.2 vs. 81.9 � 5.1 years; p<0.001) and had asignificantly higher logistic Euroscore (21.1 � 14.1 vs. 18.01 � 15.3;p<0.03) than the patients in the AVR group. There was no significantdifference in the 30-day mortality (26.7% vs. 18.0%; p¼0.079, n.s.) butover thewhole follow up period of amaximumof 4.7 years themortalityafter the 30 day-mortality period differs significantly to a higher level ofthe TAVR group versus the AVR group (18.6% vs. 5.4%; p<0.001).Conclusion: Conventional aortic valve replacement in old patients isfeasible with an excellent longterm outcome. The TAVR procedure onthe other hand enables us to perform aortic valve replacement even invery old and sick patients or in patients deemed inoperable with acomparable perioperative outcome compared to the conventional aorticvalve replacement. In the longterm follow the outcome of the AVR groupis significantly better at which the comorbidities are one of the mainreasons for late mortality in the TAVR group. These patients thereforeremain an interdisciplinary challenge.

SC80Aortic valve replacement after previous heartsurgery in high-risk patients: Transapical aorticvalve implantation versus conventional aorticvalve replacement A risk adjusted andpropensity score based analysisScherner M.1, Madershahian N.1, Kuhr K.2, Choi Y.1,Rahmanian P.1, Slottosch I.1, Kuhn E.1, Strauch J.3,Wippermann J.1, Wahlers T.11Universitätsklinik, Köln, Germany, 2Medizinische Statistik,Köln, Germany, 3Uni-Klinik, Bochum, Germany

Background: Cardiac reoperations are associated with increased mor-bidity and mortality compared to first-time surgery. We analyzed ourexperience with reoperative aortic valve replacement (Redo-AVR) andcompared these results to patients who underwent transapical aorticvalve implantation (TA-AVI) as a second heart operation. Methods: Inthis retrospective observational comparative study we analyzed theoutcome of 136 patients with prior cardiac surgery who underwent


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Redo conventional AVR (n¼59; since 2006) or TA-AVI (n¼77; since2008) with respect to 30-day outcome (VARC-criteria), one-year andthree-year survival and in order to identify risk factors for bothapproaches after previous heart surgery. Results: Both groups did notsignificantly differ in their risk profile leading to similar STS- andEuroSCOREs. 30-day mortality was 3.39% (n¼2) in the Redo-AVR groupvs. 7.8% (n¼6) in Redo TA-AVI (p¼0.465). The overall combined safetyendpoint at 30 days was significantly lower in TA-AVI patients (18.1% vs.33.9% in Redo-AVR; p¼0.036). Unadjusted and adjusted one-yearsurvival showed no difference between compared groups, unadjustedthree-year survival revealed a 2.1 fold higher mortality risk after TA-AVI(p¼0.055). Adjustment viamultivariable Cox regression (HR:1.427;95%CI:0.635;3.209; p¼0.389) and propensity score HR:1.571;95%CI:0.575,4.291;p¼0.378) led to a more than 50% risk reduction result-ing in a similar three-year survival in the compared groups. Conclusion:Redo-AVR can be performed with acceptable results in high-risk pa-tients and still serves as gold standard. Reoperative valve surgery via TA-AVI is feasible and results in comparable short- and mid-term survival.

SC81Risk evaluation in transcatheter aortic valveimplantationGöbel N.1, Ahad S.1, Vöhringer M.2, Hill S.2, Schäufele T.2,Franke U.F.W.1, Baumbach H.11Robert-Bosch-Krankenhaus Stuttgart, Abteilung für Herz-und Gefäßchirurgie, Stuttgart, Germany, 2Robert-Bosch-Krankenhaus Stuttgart, Abteilung für Kardiologie,Stuttgart, Germany

Objective: Transcatheter procedures are considered as therapyof choicein high-risk patients who are not eligible for surgical aortic valvereplacement. The logistic EuroSCORE, its role is still discussed contro-versially, is themost frequently used risk calculator in cardiac surgery inEurope. We used it as a tool to identify patients with an excessive highrisk in transcatheter aortic valve surgery. Methods: This single centreretrospective study included 319 consecutive patients undergoingtransapical or transaortic transcatheter aortic valve implantation(TAVI) between September 2008 and December 2012, transfemoralTAVI patients were excluded. Those with an excessive high risk ofpredictive perioperative mortality (log EuroSCORE>40%, n¼90)were compared to patients with a lower calculated risk (log EuroSCORE<40%, n¼229) regarding perioperative complications, short-term-mortality and adverse cardiac and cerebrovascular events. Results:Overall 30-day mortality was 8.2% (26/319). In the excessive high-riskgroup 30-day-mortality was 12.2% (11 patients) and in the lower riskgroup 6.6% (15 patients), with p¼0.10; OR 1.99; 95% CI [0.88;4.51]. Alsostroke rate (0.4% vs. 3.0%; p¼0.08; OR 7.59; 95% CI [0.78;73.91]) andconversion to sternotomy (2.4% vs. 5.1%; p¼0.22; OR 2.12; 95% CI[0.63;7.11]) showed no significant differences between the groups.Postoperative acute kidney injury stage 3 (6.1% vs. 13.3%; p¼0.03; OR2.35; 95% CI [1.07;5.13]) as well as implementation of cardiopulmonarybypass (4.5% vs. 12.1%; p¼0.01; OR 2.93; 95% CI [1.25;6.90]), meanventilation time (19.1 vs. 48.6 hours; p¼0.001) and length of ICU stay(3.0 vs. 6.9 days; p<0.001) were significantly different in favour of thelow-risk group. Conclusion: These data show that transapical TAVI is asafe procedure even for patients with an excessive high risk of predictiveperioperativemortality andMACCE. Our analysis implicates the need foran individualized risk evaluation.

SC82Logistic EuroSCORE I can predict mid-termmortality after Transcatheter Aortic ValveImplantation (TAVI)Thalmann R.1, Schramm R.1, Hoffmann A.L.1, Sodian R.1,Hagl C.1, Becker C.2, Kupatt C.3, Schmitz C.11Klinikum der Universität München (LMU), Herzchirurgie,München, Germany, 2Klinikum der Universität München(LMU), Institut für Klinische Radiologie, München,Germany, 3Klinikum der Universität München (LMU),Medizinische Klinik und Poliklinik I, München, Germany

Objectives: The European System for Cardiac Operative Risk Evaluation(EuroSCORE) was actually developed in order to predict early mortalityin adult patients undergoing cardiac surgery by objective risk factors.Recently it has been used to select patients having a high risk for surgicalvalve replacement suitable for transcatheter aortic valve implantation(TAVI). We tested the prediction quality for mortality in a single centerpatient group undergoing transapical, transaxillary or transaortic TAVI.Methods: The study included 187 patients between 04/2008 and 08/2013. All patients underwent transapical, transaxillary or transaortalTAVI. Patients were divided into 4 groups according to their logisticEuroSCORE I: group 1 consisted of 83 patients with EuroSCORE <20%,group 2 of 71 patients with an EuroSCORE 20 - 40%, group 3 of 24patients with an EuroSCORE 40 - 60%, and group 4 of 9 patients with anEuroSCORE>60%. Results:Mortality up to 5 years after TAVI is depictedin Table 1 and Figure 1.

Table 1: Survival after TAVI [%]

30 d 365 d 730 d 1095 d 1460 d 1825 d

Group 1 95,2 85,7 79,1 76,3 66,7 66,7

Group 2 88,7 76,7 63,5 63,5 56,6 51,1

Group 3 87,5 69,6 57,8 38,5 25,7

Group 4 87,5 62,5 37,5 25,0 25,0

Fig. 1: EuroSCORE I KM 04/08 - 08/13, p <0,05

Conclusions: Today it is well known that logistic EuroSCORE I fails topredict operative mortality in TAVI patients. However, in our series itwas able to predict medium term mortality up to 5 years.


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SC83The transaortic approach for TAVI - first resultsPetzina R.1, Buerbaum B.1, Hoffmann G.1, Renner J.2, FrankD.3, Frey N.3, Cremer J.1, Lutter G.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Herz- und Gefäßchirurgie, Kiel, Germany,2Universitätsklinikum Schleswig-Holstein, Campus Kiel,Anästhesiologie und Operative Intensivmedizin, Kiel,Germany, 3Universitätsklinikum Schleswig-Holstein,Campus Kiel, Kardiologie und Angiologie, Kiel, Germany

Objectives: Transcatheter aortic valve implantation (TAVI) representsnowadays a well established treatment for patients with symptomaticsevere aortic valve stenosis uneligible for conventional surgery. Thetransaortic (TAo) approach for TAVI offers an interesting and goodalternative. We present our first results with TAo-TAVI. Methods:From 10-2008 until 08-2013 more than 360 TAVI procedures wereperformed at our institution exclusively using Edwards Sapien valves.The TAo-TAVI program started inNovember 2012 and until nowwehaveoperated on 30 patients. Preoperative CT scan revealed a non-calcifieddistal part of the ascending aorta. The TAo-TAVI procedure is performedunder general anaesthesia and hemodynamic monitoring. After asuperior mini-J-sternotomy through the right third intercostal spacethe pericardium is opened. Two 3-0 prolene purse string suturesreinforced with teflon pledgets are placed at the distal part of theascending aorta. A stiff wire is placed into the left ventricle through theaortic valve. Insertion of the Ascendra sheath and held at the 2 cmmark.Balloon valvuloplastie and implantation of an Edwards Sapien XTtranscatheter valve are performed in a slow stepwise manner underrapid pacing and fluoroscopy. The purse strings are tied after withdraw-al of the system. The sternum is closed with two to three sternal wires.Results: Mean age was 81.1 � 4.9 years (72-91 years) and 53.3% werefemales. Logistic EuroScore was 23.7 � 8.7%. Device success rate was100%. The 23 mm valve was used in 20% while the 26 mm valve wasimplanted in 53.3% and the 29 mm valve in 26.7%. We observed neitherneurological events nor any indication for pacemaker implantation in all30 TAo-TAVI patients. Paravalvular leakage (PVL)� I was seen in 86.7%and PVL I-II in 4 patients (13.3%), while no PVL> II was observed. Post-dilatation of the implanted valve was indicated in 40%. Conversion toopen chest surgery was required in one patient (3.3%). Operation timewas 88.5 � 22.9 min., x-ray time was 9.8 � 5.6 min. and 86.1 � 32.1 mlcontrast agent were applied. Intensive care unit and total hospital staywere 3.6 � 6.3 days and 16 � 11.2 days, respectively. Thirty-daymortality was 6.6% (two patients). Conclusions: The TAo approach forSapien XT transcatheter heart valve demonstrated excellent clinicaloutcome and is now a coequal access route for TAVI procedures besidesthe transapical and transfemoral entry in our institution.

SC84Verification of non-inferiority of the TransapicalJenavalve TAVI compared to the TransapicalEdwards Sapien TAVISchurr U.1, Rueter F.1, Zurfluh S.1, Gahl B.1, Eckstein F.1,Reuthebuch O.11University Hospital Basel, Clinic for Cardiac Surgery, Basel,Switzerland

Objectives: The Edwards Sapien (Edwards Lifesciences, Irvine, Califor-nia) valve is supposed to be the benchmark for transapical (TA) TAVI.Aim of this study was to prove non-inferiority of the self-expandableand repositionable TATAVI Jenavalve (JV) (Jenavalve,Munich, Germany)compared to the ballon-expandable Edwards Sapien (ES) for the treat-ment of severe aortic stenosis in high risk patients. Methods: Outcomecriteria were in accordance to the Valve Academic Research Consortium(VARC) criteria for 30 days outcome. Between 2008 and 2012 a total of 69consecutive patients were treated transapically in our centre (ES n¼33vs. JV n¼36). There were no significant differences in baseline charac-teristics in this retrospective study. Results: Implantation of ES and JVwas successful in all cases. Additive Euroscorewas equivalent (ES 11.3�2.3 vs. JV 10.4� 2.5, p¼0.655), aswell as 30 daysmortality (ES 12% vs. JV14%, p¼0.828), length of stay on ICU (ES 2.1 � 1.9 days vs. JV 3.0 �5.6 days, p¼1.000), max. Trop T level (ES 0.8 � 1.3 ng/ml vs. JV 0.6 � 0.5ng/ml, p¼0.861), need for pacemaker implantation (ES 9% vs. JV 6%,

p¼ 0.569), apical bleeding with revision (ES 6% vs. JV 3%, p¼0.486),wound infection (ES 3% vs. JV 0%, p¼0.285), cerebrovascular events (ES12% vs. JV 8%, p¼0.603) and onset of atrial fibrillation (ES 36% vs. JV 25%,p¼ 0.342). Occurrence of paravalvular leakage showed no significantdifference: None (ES 64% vs. JV 58%, p¼0.758), Mild (ES 15% vs. JV 22%,p¼ 0.419), Moderate (ES 9% vs. JV 3%, p¼0.275), Severe (ES 3% vs. JV 0%,p¼ 0.299). There was an advantage in the ES group concerning meanpostoperative gradient (ES 8.7 � 3.9 mmHg vs. 12.7 � 5.7 mmHg,p¼ 0.001). Conclusion: According to our data we could show non-inferiority of the Jenavalve TA TAVI compared to the Edwards SapienTA TAVI. There were no statistically significant differences among thetwo groups except an advantage for the ES TAVI in post-op gradient.However, crude gradients were on a very low level, with questionableeffect on clinical outcome. JV showed a tendency towards less para-valvular leakages and less pacemaker implantation.

Congenital heart disease

SC85LVAD Implantation in a patient withcongenitally corrected transposition of thegreat arteriesHanke J.S.1, Avsar M.1, Rojas Hernandez S.V.1, Franz B.1,Horke A.1, Haverich A.1, Schmitto J.D.11Medizinische Hochschule Hannover, Herz-, Thorax-,Gefäß- und Transplantationschirurgie, Hannover, Germany

Introduction: Improvedmedical and surgical treatment strategies led toa tremendous increase of the incidence of end-stage heart failure whichhas almost tripled during the past years. Due to the fact that, based onorgan donor shortage, cardiac transplantation can not solve this widen-ing gap between the need for organs and the annually performedtransplantations, the role of alternative treatment strategies for end-stage heart failure are significantly increasing. Consequently LVADimplantations are constantly increasing and becoming more andmore a standard in cardiac surgery. Accordingly, the number of atypicalcases is rising and there is a need for alternative approaches for uniquecases. In our case, a patient was presented to our department who wassuffering from low cardiac output failure in combination with unilateralpulmonary agenesis which is a rare congenital anomaly defined as acomplete absence of the lung parenchyma, bronchi, and pulmonaryvessels with large clinical variability. The ethological cause is unknown.In a large group of cases cardiovascular, musculoskeletal, gastrointesti-nal, and renalmalformations are common co-morbidities of this disease.Background: We present a case of a 58-year old female patient withsevere end-stage heart failure caused by congenitally corrected trans-position of the great arteries (cTGA). Due to repetitive episodes ofcardiac decompensation, progressive low cardiac output failure andsevere clinical worsening condition, the patient was referred to ourhospital for end-stage treatment of his underlying diseases. Right heartcatheterization showed a reduced cardiac index conditions (Cardiacindex: 1,89 l/min/m2 (Fick) ; heart time volume 3,07 l/min) andincreased pulmonary hypertension (PAmean 66 mmHg, PCmean 53mmHg; PVR 347 dyn). After multiple interdisciplinary discussions, leftventricular assist device (LVAD)was implanted. The patient experiencedan uneventful intrahospital stay and was successfully discharged torehabilitation on postoperative day 22. Discussion: Unique patientsrequire unique approaches. Our Patient still benefits from LVAD therapy.and is a succesful example of LVAD therapy in patients with congenitalheart diseases. Still interdisciplinary LVAD evaluation is the key to apatient orientated successful therapy in this special group of cardiomy-opathy patients.


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SC86Surgical treatment of thoracic and partialectopia cordis - A case presentationElmontaser H.1, Yerebakan C.1, Valeske K.1, Müller M.2, ThulJ.3, Schranz D.3, Akintürk H.11Children's Heart Center Giessen, Department of PediatricCardiac Surgery, Gießen, Germany, 2Children's Heart CenterGiessen, Department of Anesthesiology, Gießen, Germany,3Children's Heart Center Giessen, Department of PediatricCardiology, Gießen, Germany

Introduction: Ectopia cordis is an extremely rare malformation withpartial or complete delocation of cardiac structures outside of the thoraxcavity. This entity is most commonly associated with further severecardiac defects. The mortality remains despite some few successfullytreated cases high. Case presentation: We report on a full-term three-day-old infant (3.4 kg) with partial thoracic ectopia cordis. PreoperativeTransthoracic echocardiography revealed ectopia cordis of the heart,dysplastic but competent tricuspid valve, small right ventricle in com-parison to left ventricular dimensions, subaortic ventricular septaldefect and right ventricular outflow tract and severe pulmonary valvarstenosis without identification of the valvar orifice. There was a patentductus arteriosus with continuous left to right shunt. The patient wasoperated using a median sternotomy and opening of the skin coveringthe heart. The ectopic part of the heart was separated from adjacentfascia and peritoneum. Due to the limited space within the pericardiumfurther preparation ensued in the subfascial thoracic and abdominaltissue for creation of skin flaps. The heart was covered using a piece ofxenopericardium which was practically attached to the fascia aroundthe ectopic area. The sternum was adapted in the usual fashion usingreabsorbable sutures and the subcutaneous tissue was again recon-structedwith a piece of xenopericardium over the ectopic heart (Video).After an uncomplicated operation the patient was transferred to ourintensive care unit in a stable hemodynamic and respiratory condition.On the second postoperative day the patient developed sudden heartblock and electromechanical dissociation after endotracheal suctioningand died despite consecutive resuscitation. Discussion: The surgicaltechnique for the treatment of ectopia cordis is dependent on the type ofthe malformation and is challenging. Despite successful surgical treat-ment the mortality of these patients remains high due to accompanyingcardiac problems.

SC87Surgical correction of recurrent rupture ofcongenital sinus valsalva aneurysmSandrio S.1, Karck M.1, Gorenflo M.2, Loukanov T.11Universitätsklinikum Heidelberg, Klinik für Herzchirurgie,Heidelberg, Germany, 2Universitätsklinikum Heidelberg,Klinik für pädiatrische Kardiologie, Heidelberg, Germany

Introduction: Congenital sinus of Valsalva aneurysms (SVA) are rarethin-walled saccular or tubular outpouchings ("windsock") produced byweakness of tissues at the junction of the aortic media with the annulusfibrosus. Once rupture has occurred, surgery is the treatment of choice.Various surgical closure techniques (direct suture vs patch closure) andsurgical approaches (transaortic, via involved cardiac chamber or dualapproaches) have been reported. This video shows the surgical correc-tion of recurrent rupture of congenital sinus valsalva aneurysm.Background: We report a case of a 35 year-old patient with recurrentrupture of a sinus of Valsalva aneurysm after surgical treatment at theage of 17. Primary surgery involved transatrial direct suture of asecundum ASD and transaortic direct suture of ruptured SVA usingmultiple interrupted sutures. Three years after surgery, echocardio-graphic findings showed a minimal residual aortic to RV shunt. Despitelacking clinical symptoms, series of postoperative echocardiographiesshowedworsening biventricular function and hamodynamic significantaortic to RV shunt. Surgery was performed to address these matters.Surgery is performed using cardiopulmonary bypass, mild hypothermia(28°C), cardioplegic arrest and "dual exposure technique" where boththe aorta and the right ventricular outflow tract (RVOT) are explored.The RVOT was opened through the free wall portion, which is shear-thinned as a consequence of chronic aortic to RV shunt. The aneurysmalsac is excised and a bovine pericardial patch is used to close the hole

entering into the RV. The postoperative course was uneventful andpatient was discharged home on the sixth postoperative day. Series ofpostoperative echocardiographies showed no residual aortic to RVshunt. Discussion: Surgical treatment for ruptured sinus of Valsalvaaneurysm is safe and has satisfactory results. It is reported that directclosure of the ruptured aneurysm has resulted in a 20% to 30% preva-lence of reoperation for recurrence of thefistula or residual shunt.Whenthe defect left by excision of the ruptured aneurysm is repaired with apatch, the need of reoperation is lower. Despite a slightly longer bypasstime,we suggest adopting this technique to dealwith congenital cases ofruptured or re-ruptured sinus valsalva aneurysm.

SC88Early results of implanted heparin-coatedshunts - single center experienceCesnjevar R.A.1, Purbojo A.1, Glöckler M.2, Dittrich S.2, KochA.M.2, Rüffer A.11Universitätsklinikum Erlangen, KinderherzchirurgischeAbteilung, Erlangen, Germany, 2UniversitätsklinikumErlangen, Kinderkardiologische Abteilung, Erlangen,Germany

Objectives:Retrospective reviewof implanted shunts in the past 5 yearswith regard to different shunt types. Methods: Between September2008 and August 2013, fifty-two aorto-pulmonary shunts were im-planted in the setting of Norwood operations (n¼5), missing (n¼16) ordiminished pulmonary blood flow (n¼ 31). Heparin-coated shunts(group 1: n¼30, Gore-tex-Propaten) were implanted since 2011 in 27patients and compared to regular Gore-tex-shunts (group 2: n¼22)used previously. Results: There was a low-mortality rate in both groups(group 1: n¼1/ 3.3%; group 2: n¼1/ 4.6%; n.s.) with suspicion ofthrombosis in two patients in each group (group 1: n¼2/ 6.7%; group2: n¼2/ 9.1%; n.s.). Mortality was related to shunt physiology (pulmo-nary overcirculation), low birthweight and not to the type of shunt usedin all cases. Conclusions: Use of heparin coated shunts seems to be safeand effective. Mortality rates and the incidence of shunt thrombosisseem to be very low and should improve in the near future with moresurgical experience.

SC89Urgent implantation of the Berlin Heart Excorbiventricular assist device as a total artificialheart in a patient with single ventriclecirculationYerebakan C.1, Valeske K.1, Elmontaser H.1, Müller M.2, ThulJ.3, Schranz D.3, Akintürk H.11Children's Heart Center Giessen, Department of PediatricCardiac Surgery, Gießen, Germany, 2Children's Heart CenterGiessen, Department of Anesthesiology, Gießen, Germany,3Children's Heart Center Giessen, Department of PediatricCardiology, Gießen, Germany

Background: Themanagement of patients presenting with heart failureafter total cavopulmonary connection remains an ongoing challenge.Introduction: A 19-year-old boy with single ventricle anatomy pre-sented to our department with failing Fontan circulation and secondaryend-stage cardiorespiratory failure. Most recently he presented to ourcenter with intractable cardiac failure along withmassive dilation of thesystem ventricle in NYHA status IV. The patient was reported to Euro-transplant as a high-urgency transplant candidate. Despite high doseinotropic support and maximal therapy of cardiac failure he developedacute cardiorespiratory failure with signs of cerebral malperfusionaccording to near-infrared spectroscopy. Due to massive adhesions inthe mediastinum it was exceedingly difficult to achieve an access tocardiac structures. Besides rigidity of the tissue, extensive bleedingensued because of dense collateral vessel formation. However, aftercomplete exposure of all cardiac structures the implantation of abiventricular assist device seemed impossible due to the massivedilatation of the heart leading to extremely limited space in themediastinum. We decided for the explantation of the heart and theimplantation of the Berlin Heart biventricular assist device (Berlin HeartAG, Berlin, Germany) as a total artificial heart. After explantatation of


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the heart the left atrial remnant and the Fontan pathway includingsuperior vena cavan and the right pulmonary artery had to be recon-structed and the native aorta downsized to enable implantation of thedevice cannula. Both the aortic and pulmonary artery cannula of theassist device had to be extended using prostetic vessel grafts.Discussion: Our strategy enabled our patient's survival until the perfor-mance of heart transplantation. To our knowledge this is the first reportof the implantation of the Berlin Heart Excor biventricular assist deviceas a total artificial heart enabling a “bridge to transplant” strategy in apatient with single ventricle circulation.

SC90Giant remnant of fetal circulation leading tocyanosis: Pseudo-cor triatriatum dexterYerebakan C.1, Elmontaser H.1, Valeske K.1, Müller M.2,Esmaeli A.3, Schranz D.4, Akintürk H.11Children's Heart Center Giessen, Department of PediatricCardiac Surgery, Gießen, Germany, 2Children's Heart CenterGiessen, Department of Anesthesiology, Gießen, Germany,3University Hospital Frankfurt, Department of PediatricCardiology, Frankurt, Germany, 4Children's Heart CenterGiessen, Department of Pediatric Cardiology, Gießen,Germany

Introduction: Cor triatriatum dexter or similar entities with obstructingmembrane within the right atrium are very rare anomalies. When theright valve of the sinus venosus fails to regress during the fetal period adivided right atrium ensues instead of leaving her remnants i.e. theEustachian, Thebesian valves of the inferior vena cava and coronarysinus, respectively. Case presentation: A full-term one-week-old girlwas referred to our clinic with the symptom of cyanosis immediatelyafter an uncomplicated birth. She had a peripheral arterial saturation ofup to 65% without supplementary oxygen. Transthoracic echocardiog-raphy showed situs solitus with enlarged right atrial chamber withleftward deviation of the interatrial septum through which right to leftshunting was encountered. A crescent form floppy membrane lead topartial obstruction of the inflow through the tricuspid valve anddirected the vena cava inflow passing the defect in the interatrialseptum to the left atrium. The patient was operated on cardiopulmonarybypass with mild hypothermia and cardioplegic arrest. The floppymembrane that originated from the Eustachian valve was resectedand the atrial septal defect was closed using glutaraldehyde treatedautologous pericardium. Her postoperative course was uneventful.Discussion: The term of cor triatriatum dexter is not always an adequatedescription of the anatomical substrate in the entire spectrum of largervalve of sinus venosus with differing degrees of septation. Surgicalrepair with resection of the remnant membrane is needed in symptom-atic patients.

SC91An exceedingly rare coronary anomaly - rightcoronary artery take-off from the leftventricular outflow tractBiermann D.1, Subbotina I.1, StummM.1, Arndt F.2, SchemmA.2, Arunagirinathan U.3, Reichenspurner H.1, Riso A.3,Sachweh J.S.31Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Kinderkardiologie, Hamburg,Germany, 3Universitäres Herzzentrum Hamburg,Herzchirurgie für angeborene Herzfehler, Hamburg,Germany

Introduction: The incidence of congenital coronary anomalies in thegeneral population is 0.2-1.2% and in most cases of no hemodynamicrelevance. However, if coronary perfusion is altered, e.g. in largecoronary fistulas, myocardial malfunction will develop over time.Thus, surgical or interventional therapy is generally warranted. Wepresent an exceedingly rare case with right coronary artery (RCA) take-off from the left ventricular outflow tract (LVOT) and absent proximalostium of the RCA. Background: A 15 month-old otherwise healthy boywas presented to rule out an atrial septal defect. Initial echocardiogra-

phy revealed a large diastolic flow from the RCA to the LVOT as the onlypathological finding. Electrocardiogram (ECG) was unremarkable. Sub-sequent angiography confirmed retrograde perfusion of the heavilydilated RCA via multiple collaterals from the left coronary artery anddiastolic drainage into the LVOT. An RCA ostium in the aortic root wasnot present. Although, at this time there were no criteria for myocardialmalfunction, long-term sequaele of fistula related coronary flow arewell known. Thus, surgical therapy was recommended. Surgery wasdone on mild hypothermic cardiopulmonary bypass with cardioplegicarrest and consisted of closing the RCA-LVOT connection at ventricularlevel and creating a communication between the aortic root and theproximal RCA. The operative and postoperative course was uneventfuland the patient was discharged home on postoperative day 8. At follow-up 3 months after surgery the patient was well, ECGwas unremarkableand echocardiography revealed a closed RCA-LVOT connection and atypical diastolic perfusion of RCA via the aortic root. Discussion: Thespectrum of coronary anomalies is wide and is demanding in terms oftherapeutically decision making. This is particularly the case in patientswith no objective data for myocardial malfunction. However, if relevantpathophysiology (e.g. large fistula with massive coronary artery dilata-tion) is present, restoration of normal anatomy and physiology early inlife may prevent from myocardial deterioration over time.

SC92Subaortic stenosis after repair of completeatrioventricular septal defect: Anatomic andtechnical issuesDelmo Walter E.M.1, Javier M.F.2, Miera O.3, Hetzer R.1,Alexi-Meskishvilli V.11Deutsches Herzzentrum Berlin, Herz-,Thorax-u.Gefäßchirurgie, Berlin, Germany, 2Harvard University,Cambridge, United States, 3Deutsches Herzzentrum Berlin,Pediatric Cardiology/Congenital Heart Diseases, Berlin,Germany

Objective: This report reviews our institutional experience with sub-aortic stenosis developing after repair of complete atrioventricularseptal defects (CAVSD). It aims to analyze whether subaortic stenosisis anatomically inherent or technically preventable. Patients andmethods: Between 1986 and 2012, 383 patients (median age 2.15years, range 0-4.7 years) underwent biventricular correction of CAVSD..During a median follow-up of 16.06 years (range 1-25 years), 89 (23.8%)patient underwent first reoperations, 33 (8%) underwent second reop-erations , while 20 (5%), 10 (2.6%), 6 (1,6%) and 5 (1.3%) have had third,fourth, fifth and sixth reoperations, respectively. The most commoncauses of reoperations are left atrioventricular valve regurgitation,residual ventricular septal defect, subaortic stenosis and late onsetcomplete heart bock. Results:Nineteen patients (median age 6.25 years,range 0-23 years) developed subaortic stenosis. They had 26 reinter-ventions within 6 months-23 years after the initial surgery. Seventeenpatients had severe subaortic stenosis (mean pressure gradient of 80 �20 mmHg) to warrant resection of the left ventricular outflow tractobstruction. A spectrumof surgical approaches havebeen employed andthis will be described in detail as towhich techniques employed have ledto a higher incidence of subaortic stenosis. Freedom from reoperation is100%, 82.3%, 35.3% and 17.6% at 30 days, 1, 5 and 15 years, respectively.Cumulative survival is 100% at 30 days and 1 year, and 81.3% at 5 and 16years. The other 2 patients have mild subaorti stenosis (mean pressuregradient 10 � 3 mmHg) hence, there is still no indication for surgery. Inthis series, the prevalence of subaortic stenosis is 4.9%. Conclusion: Therisk of developing subaortic obstruction after repair of the CAVSD is realand may occur commonly than previously reported. Anatomical andtechnical issues during the initial CAVSD correction should be meticu-lously dealt with to reduce the incidence of subaortic stenosis.


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SC93Severe Coronary artery disease in 6 years oldchildDayeh A.-H.1, Taurosinov G.2, El Bahi J.1, Schranz D.3,Evagelopoulos N.1, Däbritz S.11Herzzentrum Duisburg, Klinik für Herz- undGefäßchirurgie, Duisburg, Germany, 2HerzzentrumDuisburg, Klinik für Kinderkardiologie und angeboreneHerzfehler, Duisburg, Germany, 3UniversitätsklinikumGießen, Klinik für Kinderkardiologie und angeboreneHerzfehler, Gießen, Germany

Introduction: Coronary artery disease (CAD) is a disease of the elderly.However, there are some cases reported in childhood. Treatment is still achallenge. The only option is CABG. Efficacy and long term patency ofCABG in childhood is still unknown.We present the youngest patient sofar reported with severe CAD and acute myocardial infarction.Background: 6-years-old girl (27 kg) was admitted with dyspnoe andchest pain. History revealed a small muscular VSD, trivial mitralregurgitation and a bicuspid aortic valve with mild stenosis, no hyper-cholersteremia or other metabolic disorder. The pt. had ventricularfibrillation at cardiac catheterisation with resuscitation, defibrillationand emergent percutaneous right femoral ECMO insertion. Transeso-phageal echocardiography showed hypokinesia of the anterior wall andapex with concomitant ST-elevation in I and AVL in ECG. Immediatecoronary angiography showed left main stenosis and proximal LADstenosis. Emergent surgery consisted of LITA bypass grafting to the LADand saphenous vein bypass grafting to the obtuse marginal branch oncardiopulmonary bypass. Ultrasonic flowmeasurements showed excel-lent flow rates with low PI. ECMO cannulae were swithed to thoraciccannulae into the aorta and right atrium. First attempt to wean fromECMO on p.o. day 3 failed due to ventricular failure (LA-pressureincrease and progression of mitral regurgitation). A second attempton p.o. day 6 with IABP augmentation via the left femoral artery wassuccessful only for 3 hours, so that ECMOwas re-installed. 12 hours laterthe pt. had ischemia of the left leg despite removal of the IABP.Angiography showed left femoral artery impairment and only one ofthree lower leg arteries, no signs of emboli. Several interventional andsurgical procedures failed and ended in femoral amputation. The patientwas transferred to a transplant center although transplantation wasdiscussed controversial because of the meanwhile diagnosed severefamilial hypercholesteremiawith poor long-termprognosis. The patientwas switched to an LVAD and meanwhile weaned from VAD and homedischarged. Bypass patency was proven by coronarography. Discussion:Diagnostic and treatment of CAD in childhood is challenging. There areno data about successful treatment in emergent cases with acutemyocardial infarction and about long-term patency of CABG. Hearttransplantation is intriguing because long-term prognosis of the under-lying metabolic disorder is unknown.

SC94Long term in vivo reactions to PTFE andpolyester in the cardiovascular system - whatwill be the fate of septal defect occlusiondevices?Sigler M.1, Huell S.1, Foth R.1, Ruschewski W.2, Tirilomis T.2,Paul T.11Georg-August-Universität Göttingen, PädiatrischeKardiologie und Intensivmedizin, Göttingen, Germany,2Georg-August-Universität Göttingen, Kinderherzchirurgie,Göttingen, Germany

Objectives: We examined and compared biological reactions to ex-plants containing textilefibers after surgical removal frompatients withcongenital heart disease with special attention on inflammation, calci-fications, and endothelialization which may play a significant role inlong term biocompatibility. Methods: We studied and compared tissuereactions to 3 types of implants: BTA-Shunts (n¼21, PTFE, implantationtime 6 days to 5.8 years), surgical patches (n¼16, PTFE or polyester, 8.3years to 35.2 years), and septal defect occluder (n¼13, PTFE or polyes-ter, 3 months to 15 years). After embedding in methylmethacrylate weperformed complete histology and immunohistochemistry work-up ofall specimen. Results: Inflammatory reactions consisted of lymphocytic

infiltrations and macrophages/foreign body giant cells at the implant/tissue interface and were more pronounced in the polyester group.Therewas no change in quantity of inflammatory cells over time in bothgroups. All implants with implantation times of 8 years and moreshowed significant calcifications. The shortest implantation time withcalcifications was 5,9 years in a PTFE occluder. Overall, there were morecalcified areas in PTFE containing specimen. All implants with animplantation time of more than 78 days were completely endothelial-ized. No cell dysplasia ormetaplasiawas seen in our series locally relatedto the textile fibers. Conclusions: Chronic inflammatory reactions wereseen more pronounced locally related to polyester fibers but there weremore calcifications in the PTFE group. Both reactions were seen in asimilar time pattern. Based on the results of our study one can predictthat significant calcifications will occur with time in all septal defectocclusion devices which contain textile fibers. This will definitelydeteriorate the ability to puncture the septum when left atrial accesseventually is needed for interventional treatment for example inarrhythmias.

SC95Neonatal tracheal reconstruction intracheomalacia secondary to double aortic archSandrio S.1, Springer W.2, Karck M.1, Gorenflo M.2,Loukanov T.11Universitätsklinikum Heidelberg, Klinik für Herzchirurgie,Heidelberg, Germany, 2Universitätsklinikum Heidelberg,Klinik für pädiatrische Kardiologie, Heidelberg, Germany

Introduction: Developmental abnormalities of the aortic arch systemresult in a variety of vascular anomalies. Double aortic arch (DAA) is acomplete form of vascular ring causing tracheoesophageal compressionand thus, is a rare but treatable causes of stridor in the newborn. Thisvideo shows our surgical management of a newborn with localisedtracheomalacia secondary to DAA that presented as neonatal respirato-ry distress. Background: A newborn was referred to our unit forrespiratory distress. Echocardiography and MRI showed left dominantDAA and complete vascular ring with tracheal obstruction. The rightcommon carotid and right subclavian arteries originated from the rightsided arch, while the left common carotid and left subclavian arteriesoriginated from the left sided arch. He underwent elective surgery on15th day of life. Surgical repair was approached through mediansternotomy and normothermic, beating heart cardiopulmonary bypasswas used. The ligamentum arteriosumwas found between the left sidedaortic arch and the pulmonary trunk. It was then ligated and divided.Division of the right arch was performed distally, closed to its junctionwith the descending aorta. Its ends were oversewn and then furtherdissected from underlying mediastinal tissues, resulting in immediaterelief of the complete vascular ring. Intraoperative tracheobronchoscopyshowed a localised tracheomalacia and thus, subsequent resection ofthe distal trachea was carried out. Both tracheal ends were end-to-endreanastomosed and tracheobronchoscopy showed no further obstruc-tion. The postoperative course was uneventful and patient was extu-bated on the fourth postoperative day. Discussion: Surgical division ofthe complete vascular ring was indicated in patients with clinicalsymptoms as result from the compressive effects of the adjacent airwayor part of the oesophagus. Complete decompression was accomplishedby dividing the minor arch and patent ductus or ligamentum arteriosus.Patient with coexisting localised tracheomalacia may benefit from aresection of the severely malacic tracheal segment and subsequenttracheal reconstruction.


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SC96Prolonged left ventricular mechanical supportin a seven-year-old patient following extensivemyocardial infarction enabling myocardialrecoveryYerebakan C.1, Valeske K.1, Elmontaser H.1, Thul J.2, SchranzD.2, Akintürk H.11Children's Heart Center Giessen, Department of PediatricCardiac Surgery, Gießen, Germany, 2Children's Heart CenterGiessen, Department of Pediatric Cardiology, Gießen,Germany

Background: Mechanical circulatory assistance may help patients withacute failing ventricles enabling a recovery, bridge to heart transplanta-tion or ultimately as a destination therapy. Myocardial infarction inchildren is a very rare etiology with extremely high early mortality.Introduction: We report on a seven-year-old girl familial hypercholes-terolemiawith combined heterozygous LDL-receptormutationwhowastransferred to our institution two weeks after acute severe myocardialinfarction due to left main coronary dissection during coronary angiog-raphy. The patient was initially treated by surgical coronary revascular-ization and the implantation of an extracorporeal membraneoxygenation (ECMO) with two unsuccessful weaning attempts. Initialechocardiography showed massively dilated left ventricle with severelyimpaired inhomogeneous systolic function with septal disaggregation.ECMO treatment was continued for three weeks until no recoveryseemed to be possible. We decided for the implantation of a leftventricular assist device (Berlin Heart Excor LVAD, Berlin, Germany)with the aimof bridge to a heart or combined heart liver transplantation.She was listed for heart transplantation because there was no objectiverecovery of the left ventricular function in serial transthoracic echo-cardiograms using pump flow reduction. Periodic treatment with lipidapheresis was performed due to extremely high blood lipid levels. Afterprolonged left ventricular support left ventricular function began toimprove steadily and she could be weaned from the mechanical assis-tance following diagnostic cardiac catheterization after nine weeks ofcontinuous support. The patient was discharged to a rehabilitationcenter 8 weeks after cessation of mehanical circulatory support.Discussion:Myocardial infarction in the pediatric population hasmostlya dismal prognosis leading to death within days. Mechanical unloadingof the failing heart may enable recovery even after a prolonged period ofmechanical circulatory support. Serial echocardiographic evaluationsusing reduction of mechanical assistance are necessary in decisionmaking about the time point of possible weaning.

SC97Minimally invasive surgery for congenital atrialseptum defects in adultsSchneeberger Y.1, Brickwedel J.1, Deuse T.1, Detter C.1, TreedeH.1, Reichenspurner H.11Universitäres Herzzentrum Hamburg, Klinik fürHerzchirurgie, Hamburg, Germany

Methods: Between 03/2004 and 04/2010, 52 patients underwentminimally invasive surgery for congenital ASD. Mean patient age was40.79� 13.0 years, 34 (65.4%) were female. Indications for surgery weresinus venosus defect, shunt-volume >30% or ASD >2cm as well aspersistent ASD after catheter based device-occlusion. Surgery wasperformed through a small right lateral mini-thoracotomy with cannu-lation of the peripheral vessels and video-assistance. ASD closure wasconducted through the right atrium by either direct closure or pericar-dial patch. In the cohort, 2 (3.8%) patients suffered from a persistentforamen ovale, ASD II was present in 41 (78.8%) cases. A sinus venosusdefect was found in 9 (17.3%) patients. All patients were in sinus rhythmpreoperatively. Mean follow-up time was 42.3 � 22 months. Periopera-tive parameters were analysed including stroke, arrhythmia, death andremaining ASD. Results: In all patients no remaining ASD was found inthe postoperative echocardiography. No major peri-operative compli-cations, such as stroke, cardiac ischemia or death were found. Overallminor complication rate was 17.9%. Two (2.8%) patients with additionalintervention of the superior vena cava required permanent pacemakerinsertion. One (1.9%) patient suffered from an inguinal seroma, anotherone from inguinal paresthesia. In one case rethoracotomy due to

hemorrhage had to be performed. Embolic occlusion of the femoralarterywas reported in one case, twopatients (3.8%) required drainage ofa pneumothorax. All patients were in sinusrhythm postoperatively,except the two with the new permanent pacemaker. Conclusion: Inour cohort minimally invasive surgery for ASD could be performed safeand feasible without major complications. Lack of remaining ASD andlongterm freedom from neurological complications are the majoradvantages of this procedure. Due to these favourable results minimallyinvasive surgery for atrial septal defects should be standard of care forpatients with contraindications for or failed catheter based device-occlusion.

Heart and lung failure I

SC98Extracorporeal membrane oxygenation asrescue therapy in critically ill patients - is itworth the effort?Schäfer T.1, Riedel M.2, Braune S.3, Kubik M.3, Kluge S.3,Wagner F.M.1, Reichenspurner H.1, Deuse T.11Universitäres Herzzentrum Hamburg, Klinik für Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Abteilung für Kardiotechnik,Hamburg, Germany, 3Universitätsklinikum HamburgEppendorf, Klinik für Intensivmedizin, Hamburg, Germany

Objectives: Extracorporeal membrane oxygenation (ECMO) is a com-mon therapy for patients with severe respiratory failure or cardiogenicshock. Advances in ECMO technology and intensive care medicine led toa more liberal use for ECMO as rescue therapy. We observed a markedincrease in ECMO implantations over the last 3 years. Thus, we sought toevaluate the outcome of our ECMO rescue program regarding indication,ECMO-related complications, and survival. Patients and methods:Between 01/2011 and 07/2013 150 patients underwent ECMO therapyat the University Heart Center Hamburg and the University HospitalHamburg. Irreversible and disastrous morbidity and active bleedingwere the only contraindications. A subgroup of 57 pts. received veno-venous (vv) ECMO, and 93 pts. received veno-arterial (va) ECMO. Patientdemographics and ECMO-related complications were assessed. Survivalwas defined as successful ECMO weaning and discharge from the ICU.Results:Mean patient agewas 52� 15 years, with 34% pts. being female.Median hospitalizationwas 16 days, median ECMO run-timewas 6 days.Predominant ECMO-related complications were bleeding (n¼57; 40%),lower leg ischemia (n¼16; 11%), and stroke (n¼7; 5%). Overall survivalwas 35% (n¼52). The occurrence of complications did not affectoutcome. Subgroup analysis revealed 39% (n¼22) survival in vv vs.32% (n¼32) in va pts. Indications for vv ECMOwere ARDS (n¼51; 90%)and respiratory insufficiency (n¼6; 10%), while LCO (n¼79; 85%) wasmain indication for va ECMO. MI (n¼22), post-cardiotomy heart failure(n¼16), post-intervention heart failure (n¼10), decompensatedchronic heart failure (n¼8), sepsis (n¼8), and myocarditis (n¼6)were reasons for LCO. Va ECMO as a bridge to recovery in decompen-sated chronic heart failure was prognostically favorable (75% survival;p<0.05), while infrequent causes for LCO (n¼9; intoxication, sarkoi-dosis, VAD-complications, TVP, pAH, mediastinal tumour, type A aorticdissections) showed high mortality (0% surv.; p<0.05). The va groupexhibited a higher incidence of stroke (n¼7 vs. n¼0; p<0.05) andlower leg ischemia (n¼16 vs. n¼0; p¼ 0.001). Conclusion: RescueECMO therapy is feasible as ultima ratio for critically ill patients. Despitea substantial overallmortality, approx. one third of our patients survivedandwere successfully weaned. Notably, bridging to recovery in pts. withchronic heart failure showed excellent results. We believe this justifiesour ECMO rescue strategy.


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SC99CRT-implantation in elderly patients: Is there ahigher perioperative risk?Schneeberger Y.1, Wilke I.2, Willems S.2, Reichenspurner H.1,Aydin A.21Universitäres Herzzentrum Hamburg, Klinik fürHerzchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Klinik für Kardiologie mitSchwerpunkt Elektrophysiologie, Hamburg, Germany

Objectives: Cardiac resynchronisation therapy (CRT) is an option totreat advanced heart failiure in selected patientswith left bundle branchblock. The clinical benefit has already been shown. Therefore, thistherapy is offered to awide spectrum of patients because of its favorableresults. Recently the number of elderly patients receiving a CRT hasincreased. However, little is known about the perioperative risk in thesepatients. Methods: Between 02/2008 and 12/2010 146 patients under-went CRT-implantation. Mean patient age was 64.5 � 12 years, 125(85.6%) were male. We evaluated the perioperative risk of all patientsand especially the risk of patients over 75 years. Complications such asbleeding, hematoma, tamponade, diaphragmatic twitch, pneumotho-rax, dislocation of the leads and ventricle perforation by the leads wereinvestigated, as well as comorbidities like cardiomyopathy, cardiac riskfactors, renal failure, peripheral vascular disease and the implementa-tion of oral anticoagulation. Results: Overall complication rate was12.3% (n¼18). During follow-up in 5 (27.7%) patients a diaphragmatictwitchwas recognized, 3 (16.6%) patients needed a chest tubebecause ofa pneumothorax, in 3(16.6%) patients a dislocation of the leads wasdocumented, 2 (11.1%) patients suffered from a tamponade, another 2(11.1%) had a clinical relevant pocket hematoma, 1 (5.5%) patientsuffered from a perforation of the ventricle by the lead, in 1 (5.5%)patient acute on chronic renal failure was seen and an other one (5.5%)had an arm vein thrombosis. No significant higher risk for complicationswas shown in the group of the over 75 years old (p¼0.34), although therisk of complications in this group was 17.9% compared to 11% in thegroup of the under 75 years old. Interestingly, there is a significantdifference of non-succesful CS-lead implantation. It was seen in 14.3% inthe group of the over 75years old compared to 1.7% in the younger ones(p¼0.013). No correlation between complications and comorbiditiescould be found in our cohort. Conclusion: CRT-Implantation was per-formed safe and feasible without major complications. The overallcomplication rate in patients over 75 years compared to younger onesis not significantly higher, except the implantation of the CS-lead seemsto be challenging. As CRTreducesmorbidity andmortality especially thisgroup should benefit from the therapy, as comorbidities and age,however, have no effect on the rate of complications.

SC100HVAD continuous flow ventricular assist devicefor ischemic ventricular septal rupture - thereremains no need for a total artificial heartBernhardt A.M.1, Reichenspurner H.1, Deuse T.11Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany

Objectives: Ventricular septal defect after myocardial infarction (post-MI-VSD) is a severe complication and associated with high mortality.Surgical closure is necessary for all hemodynamically-relevant shunts,but surgery has a high risk of postoperative right or left heart failure.Total artificial heart implantation is a classical indication in patientswith cardiogenic shock from post-MI-VSD. Methods: Three patients(age 46, 47 and 67 years old) received continuous flow assist devicesimplantation due to post-MI-VSD. Patients were in INTERMAC class 1and 2. All three patients had patch closure of the septal defect. Twopatients had a modified Dor plasty and received an LVAD with thesewing ring attached onto the patch. One patient was unable to weanfrom extracorporeal circulation due to right heart failure and under-went RVAD implantation. Procedural and clinical outcomes were ana-lyzed. Results: All three patients survived the first 30 days and could bedischarged. The first patient had an uneventful follow-up of six months.The second patient had a pump thrombosis of the RVAD and the devicewas explanted with partially recovered RV function after 3 months. Dueto a recurrence of right heart failure, the patient was transplanted six

months later and recovered completely. The third patient died of a fataldevice mishandling six months after LVAD implantation. Conclusion:Surgical closure of post-MI-VSD with a modified Dor plasty withconcomitant continuous flow LVAD or RVAD implantation is feasibleand might obviate the need for a total artificial heart.

SC101Effect of long-term afterload reduction on rightventricular function in patients undergoing leftventricular assist device implantation:Resurrection of the right?Sabashnikov A.1, Dhar D.2, Popov A.-F.1, García Sáez D.1,Mohite P.N.1, Zych B.1, Patil N.P.1, Fatullayev J.1, De RobertisF.1, Amrani M.1, Bahrami T.1, Banner N.R.2, Simon A.R.11Royal Brompton and Harefield NHS Foundation Trust,Department of Cardiothoracic Transplantation andMechanical Circulatory Support, Harefield, London, UnitedKingdom, 2Royal Brompton and Harefield NHS FoundationTrust, Department of Heart Failure and TransplantMedicine, Harefield, London, United Kingdom

Introduction: The HVAD is a miniaturized ventricular assist device(VAD) which is routinely used for left sided support in patient withend stage heart failure as a bridge to transplant. Amongst the reasons forimplantation are left ventricular failure as well as elevated pulmonaryvascular pressure and resistance. Many patients undergoing LVADimplantation have impaired right ventriclular (RV) function and thereis reason to suspect at least a partial longer term RV improvement. Aslittle is known about the long-term effect of LVADs on RV function, wesought to assess echocardiographic parameters with a special emphasison changes in RV function in patients on VADs. Methods: Preoperativeand 6-month-postoperative echocardiographic data of 40 patientsundergoing HVAD implantation in our institution between 2007 and2012 were retrospectively evaluated. Right and left ventricular functionwas assessed using tricuspid annular plane systolic excursion (TAPSE)and left ventricular ejection fraction (EF) / fractional shortening (FS)respectively. Estimated pulmonary artery pressure (PAP) was used forindirect assessment of pulmonary vascular resistance. Results: 6-monthmortality rate was 15% (6 patients). 12.5% (5 patients) developedimmediate postoperative right ventricular failure requiring mechanicalsupport. All echocardiographic results are presented in Table 1.

Table 1: Pre- and 6 month postoperative echocardiography

Preoperative 6month postoperative P value

TAPSE (cm) 1.34 1.17 0.110

Estimated PAP (mmHg) 38.10 19.90 <0.001

LV Ejection fraction (%) 21.67 31.50 0.051

LV Fraction shortening (%) 12.15 18.35 0.001

IVSD (mm) 19.14 19.48 0.599

LVDD (mm) 70.69 59.41 0.001

LVSD (mm) 63.03 49.06 <0.001

LVPWD (mm) 8.11 8.98 0.062

LVPWS (mm) 11.61 13.73 0.002

Conclusion: HVAD support in advanced heart failure significantlyimproves LV function indicating successful LV remodeling. Howeverand surprisingly, despite reduced PAP, HVAD LVAD support is notassociated with improved RV function 6 months after implantation.Further observations are necessary to evaluate long-term impact ofHVAD LVAD on RV function.


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SC102Perioperative whole blood levels of selenium inpatients undergoing off-pump cardiac surgery:a randomized controlled studyMoza A.K.1, Stoppe C.2,3, Stevanovic A.3, Hatam N.1, MenonA.1, Rex S.4, Goetzenich A.1, Autschbach R.11Uniklinik RWTH Aachen, Klinik für Thorax-, Herz- undGefäß-Chirurgie, Aachen, Germany, 2Uniklinik RWTHAachen, Institut für Biochemie und molekulare Zellbiologie,Aachen, Germany, 3Uniklinik RWTH Aachen, Klinik fürAnästhesiologie, Aachen, Germany, 4University HospitalsLeuven, KU Leuven, Department of Anesthesiology &Department of Cardiovascular Sciences, Leuven, Belgium

Objectives: Cardiac surgery is frequently accompanied by an increase ofoxidative stress, resulting in a significant reduced antioxidant (AOX)capacity, which is associated with postoperative inflammation, devel-opment of organ dysfunction and increased mortality. Given the pivotalrole of selenium (Se) as an essential co-factor of various antioxidantenzymes and the previously shown decrease of selenium during cardiacsurgery, we evaluated the time course of selenium levels in patientsundergoing off-pump surgery. Methods: In this prospective, random-ized, observational study, 40 patients (67 � 10 yrs) scheduled forelective coronary artery bypass grafting (CABG) were randomly as-signed to undergo either on-pumpor off-pump surgery. Clinical relevantdata and circulating whole blood levels of selenium, oxidative stress andperioperative inflammationweremeasured at predefined perioperativetime points. Results: When compared to baseline, intraoperative Sedecreasewasmost pronounced in the on-pump group (on-pump: 31.23� 13.60% vs. OPCAB: 20.23 � 16.34%; p¼0.026), whereas the inflam-matory response was comparable in both groups. In all patients,circulating Se-levels showed a negative correlation to perioperativeinflammation (interleukin-6: r¼-0.628; p¼0.000), which was compa-rable between the two study groups. Moreover, whole blood levels of Secorrelated with the measured markers for antioxidant capacity (gluta-thionperoxidase: r¼0.720; p¼0.000) and oxidative stress (asymmetricdimethylarginine levels: r¼0.244; p¼0.011), whereas the latter wassignificantly higher in the on-pump group. Se levels showed a negativecorrelation to the extent of myocardial damage (CK-MB: r¼-0.571;p¼0.000). Furthermore, low postoperative selenium levels in patientsundergoing off-pump surgery were predictive for the development ofpostoperative complications (area under the curve (AUC)¼0.711;p¼0.037). Conclusions: Patients undergoing off-pump cardiac surgeryexhibited a less pronounced decrease of selenium in comparison to on-pump procedure. Postoperative selenium levels were predictive for thedevelopment of postoperative organ dysfunctions.

SC103The Berlin experience with the first three C-Pulse® implants in EuropeHotz H.1, Schulz A.1, Krabatsch T.2, Reinartz M.1, SiniawskiH.2, Delmo Walter E.M.2, Hetzer R.21Cardio Centrum, Berlin, Germany, 2DeutschesHerzzentrum, Berlin, Germany

Objectives: The C-Pulse® heart assist system (Sunshine Heart, Inc.) is anextra-aortic balloon counterpulsation for the treatment of patients withmoderate to severe heart failure of class III or ambulatory class IVaccording to the NYHA classification refractory to optimal medicaltherapy. While a first feasibility study in the United States and Canadaalready showed promising preliminary results, we want to report ourexperience with the first implantations in Europe. Methods: BetweenMay and July 2013 we implanted the C-Pulse® heart assist system inthree male patients 54 years, 54 years and 63 years of age. All patientswere on optimal medical therapy and cardiac resynchronization thera-py. Theywere all classified as heart failure stage C as defined by the ACC/AHA classification with two patients in NYHA class III and INTERMACSlevel 5 and one patient in ambulatory NYHA class IV and INTERMACSlevel 4. Results: Surgical implantation without cardiopulmonary bypasswas successful in all patients. So far no stroke, myocardial infarction,major bleeding or major infection due to the device occurred. Onepatient developed tachycardia with worsening heart failure 12 hoursafter surgery without stabilization under medication. The tachycardia

prevented the C-Pulse® heart assist system from supporting the heartproperly. After further deterioration due to sepsis caused by pneumoniawe had to implant a left ventricular assist device 5 days after indexprocedure. The other two patients clinically improved under the C-Pulse® system. In one patient the RVEF increased from35% to 50%within10 days, the LVEF from 25% to 40% within 3 months after implantation.The third patient also showed slight increase of the RVEF after 12 daysfrom35% to 40% and the LVEF increased from 20% to 35%within 7weeks.One patient improved from NYHA class III to class II within 6 weeks ofobservation. Conclusion: The C-Pulse® heart assist system seems to be apromising therapeutic option for patientswithmoderate to severeheartfailure.

SC104Extracorporeal life support (ECLS) as bridgingtherapy in patients with cardiomyopathy andacute decompensationGuenther S.1, Peterss S.1, Fischer M.1, Born F.1, Sodian R.1,Kaczmarek I.1, Pichlmaier M.1, Hagl C.1, Khaladj N.11LMU Munich, Department of Cardiac Surgery, Munich,Germany

Objectives: Newly diagnosed or acute exacerbation of chronic cardio-myopathy (CM) may quickly lead to decompensation and cardiogenicshock. Assist device implantation in these cases is associated with pooroutcome and barely feasible under cardiopulmonary resuscitation(CPR). ECLS implantation achieves immediate cardiopulmonary stabili-zation and allows for end organ recovery. We report on the results ofpercutaneous ECLS implantation in patients with CM-related refractorycardiogenic shock after conventional therapy had failed. Methods: Weretrospectively analyzed 13 patients (2 (15%) female, mean age 47 � 12years) undergoing ECLS implantation from August 2012 until August2013 for cardiogenic shock due to CM. 6 patients (46%) suffered from adilative, 4 (31%) from various CMs. In 3 cases (23%) the pathology wasunclear. 5 patients (39%) had been resuscitated and 2 (15%) wereimplanted under ongoing CPR. In 3 cases (23%) the patient's conditionwas too critical for transport and ECLS implantation was performed inthe referring hospital by our team. After stabilization under ECLS, thepatients were transported to our center. 3 patients (23%)were consciousduring ECLS implantation and therapy. In 1, balloon atrial septostomyfor left ventricle unloading was done. Results: Overall 30-day survivalwas 54% (7 patients). Surviving patients were significantly younger (41� 8 vs. 54 � 11 years, p¼0.033). 3 patients (23%) died during ECLSsupport, 2 due to multi-organ failure (MOF), 1 of intracranial bleeding(previous CPR and systemic lysis). 1 (8%) received heart transplantduring ECLS support, 2 (15%) a biventricular assist device (B-VAD, BerlinHeart EXCOR®) of whom 1 died due to MOF. 7 patients (54%) wereweaned successfully. 2 of these diedwithin 30 days, 1 of MOF, 1 refusingVAD implantation due to heart failure. Conclusion: ECLS may serve as abridging therapy to VAD implantation (bridge-to-bridge/-destination)or heart transplant (bridge-to-transplant) in critically ill patients withCM. Even weaning is possible (bridge-to-recovery). Benefits of initialECLS therapy before VAD implantation are end organ recovery allowingVAD implantation to happen under stable conditions and after neuro-logical evaluation. VAD implantation might be performed on ECLSwithout switching to a conventional cardiopulmonary bypass to reduceits side effects. In case a univentricular VAD is possible, the ECLS systemmay remain in-situ for initial right ventricular or pulmonary support.

SC105High fat diet and pressure overload: Improvedcontractile function but reduced survivalSchrepper A.1, Schwarzer M.1, Freiberger S.1, Amorim P.A.1,Doenst T.11Jena University Hospital - Friedrich-Schiller-UniversityJena, Department of Cardiothoracic Surgery, Jena, Germany

Background: Feeding rats a diet rich in saturated fatty acids inducesinsulin resistance and a diabetic phenotype. Such a phenotype has beenassociated with worse outcome in heart failure. However, high fat diet(HFD) has also been reported to be protective under conditions ofcontractile impairment. Objective: We analyzed survival and


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contractile function in rats subjected to both HFD feeding and pressureoverload (PO). Methods: Rats at 10 weeks (w) of age maintained onstandard diet (SD) were mated. Two days after mating, female rats weregiven HFD ad libitum. Control animals were retained on normal chow.Diet was maintained during gestation and lactation. Pups were kept onHFD and glucose tolerance was assessed with i.p. glucose tolerance test(GTT). After weaning, pubs underwent transverse aortic constriction(TAC) to induce PO. After 2, 10 and 20w of PO we assessed cardiacfunction by echocardiography. Results: Weanlings showed increasedfasted blood glucose levels (mmol/l: SD 4,0 vs. HFD 5,4; p<0,05) andimpaired glucose tolerance (AUC: SD 807 � 31 vs. HFD 1063 � 31;p<0,05), suggesting the presence of impaired insulin sensitivity at timeof TAC. PO resulted in cardiac hypertrophy in SD-TAC and HFD-TACanimals as assessed by left ventricular wall thickness. Hypertrophy wasmore pronounced in HFD-TAC (mm: 10w: C 3,45 � 0,16 vs. SD-TAC 5,22� 0,32 vs. HFD-TAC 6,36 � 0,29). Left ventricular end diastolic diameterremained normal at 2 and 10w of PO but was found increased after 20wwith both diets (mm: 7,64� 0,18 vs. 8,58� 0,09 vs. 9,12� 0,18). Cardiacsystolic function as assessed by fractional shortening was increased inboth TAC groups after 2w (%: 44,4 � 1,4 vs. 60,9 � 2,1 vs. 56,4 � 2,4).After 10wcontractility began to deteriorate inTAC animalswith SD only.After 20w of PO, systolic function was significantly reduced in SD-TACand only slightly affected in HFD-TAC (%: 48,2� 1,2 vs. 23,6� 0,8 vs. 44,5� 1,4). Diastolic function was impaired after 10 and 20w in SD-TAC andless affected in HFD-TAC (20w: E/A: 1,81 � 0,11 vs. 10,7 � 0,9 vs. 8,58 �0,57; E/E': 16,6 � 1,1 vs. 33,9 � 2,6 vs. 25,0 � 2,1). In contrast to theprotective effect of HFD on contractile function long time survival wassignificantly reduced with HFD. HFD-TAC animals displayed a shortermean survival time than SD-TAC animals (SD TAC 19,05 vs. HFD-TAC12,19w, p¼0,045). Conclusion: HFD in combination with pressureoverload preserves cardiac contractile function, but shortens longtime survival.

SC106HeartWare® Assist Device - Infections,bleedings, and thrombosis dominate morbidityand mortalitySubbotina I.1, Hakmi S.1, Dobner S.1, Bernhardt A.1,Oelschner C.1, Reichenspurner H.1, Deuse T.11Department of Cardiovascular Surgery, University HeartCenter, Hamburg, Germany

Objective: The increasing number of patients (pts) awaiting hearttransplantion and the shortage of donors led to the development ofventricular assist devices (VAD). We analysed our experience with theHeartWare® HVAD in order to evaluate complications during follow-up(FU). Patients: The data were drawn from our institution's database on38 pts implanted with a HVAD between January 2010 and August 2013.Themean patient agewas 57� 12 years. Indication for implantationwasDCM (16 pts), ICM (12), postcardiothomy heart failure (4), myocarditis(3), and acute heart failure after myocardial infarction (3). Twenty pts(53%) were dependent on intravenous inotropes, 10 pts (26%) had anIABP implanted, and 7 (18%)were on ECMO. Themean cardiac indexwas1.8l/min/m2. Results: Hospital mortality was 18% (7 pts). Cause of deathwas septic multi-organ failure (MOF) in 3 cases and hemorrhagic MOF in4. Late mortality (after 3 months) accounted for 10 deaths (26%) with 6infections (2 VAD infections, 4 pneumonias), 1 VAD thrombosis, and 3accidental disconnections of the driveline. Two of 6 pts with bleedingfrom the gastrointestinal tract (GIT) developed it in the early postoper-ative episode and died. In the late FU bleeding from GIT occurredfrequently (0.23 events per pts-year), but could be controlled byoptimization of anticoagulation or endoscopic haemostasis in all cases.During the late FU, 4 VAD thromboses were observed. In 1 case,thrombolysis was successful. Two devises completely stopped and ptsrequired surgery. One VAD was explanted and the other pt died incardiogenic shock before the surgery. During a mean FU of 10 � 7months, 8 pts developed infections. Two pts underwent heart trans-plantation. In 4 pts, infections were eradicated with antibiotics and in 2cases, infections led to sepsis and the pts died. Four pts developedischemic and 3 pts hemorrhagic strokes. Six pts suffered stroke in late FUperiod. No pt died of stroke, but 5 pts retained neurological deficits.Seventeen pts are still on the device. Mean time of assistance was 247�

15 days. In this period we had no cases of device malfunction.Conclusion: Bleeding from GIT and infections were frequent complica-tions during early and late FU. Stroke and VAD thrombosis morecommonly occurred after the first 3 months of assistance. Totallyimplantable VADs with transcutaneous energy transfer should reducethe infectious complications and thus morbidity.

SC107A novel approach for perioperativeextracorporeal life support implantationSaeed D.1, Maxhera B.1, Kamiya H.1, Lichtenberg A.1, AlbertA.11Düsseldorf University Hospital, Düsseldorf, Germany

Objectives: Central veno-arterial extracorporeal membrane oxygen-ation (ECMO) is traditionally implanted using direct cannulation of theaorta and right atrium. This report summarizes the outcome of 6patients who underwent perioperative central ECMO implantationusing a novel approach which allows sternum closure and does notnecessitate resternotomy at the time of removal. Methods: We retro-spectively reviewed patients who necessitated ECMO implantationbetween January 2010 and September 2013. Inclusion criteria werepatients undergoing central ECMO implantation using the followingimplantation technique: A dacron graft was attached to the ascendingaorta and passed through a subxiphoid exit, where the ECMO outflowcannula was inserted. The inflow cannula was percutaneously cannu-lated using Seldinger's technique in the femoral vein. The sternum wasclosed primarily in all patients. Results: Six patients (62 � 14 yo) weresupported at our institution using this technique. Three patients under-went coronary bypass surgery as a primary surgery and the other 3patients had combined coronary and valve surgeries. The averageduration of ECMO support was 10 � 8 days (range 1-24 days). In 3patients (50%) the ECMO was successfully removed. Two patientsexpired on ECMO. One patient is still ongoing. No mobilization issueswere observed. On the day of ECMO explantation, the stretchableoutflow graft of the ECMOwas carefully pulled under minimal anesthe-sia, mulltiple ligations were applied and the insertion site was second-arily closed. Finally, the inflowcannulawas removed and direct pressurewas applied. The dominant postoperative complication was bleedingrequiring resternotomy which occurred in 4 patients. The in-hospitalmortality was 33%. Conclusions: This is thefirst report describing ECMOimplantation using the above described novel technique for variousforms of postcardiotomy heart failure. No technical issues were encoun-tered. Early mobilization, extubation, extended support duration andreducing resternotomy risks may explain the better outcome comparedwith conventional ECMO implantation methods.

SC108Platelet repellent properties of hydrogelcoatings on polyurethane coated glass surfacesBaghai M.1, Tamura N.2, Heilmann C.1, Henze M.3, PruckerO.3, Zieger B.4, Rühe J.3, Goto S.2, Beyersdorf F.11Heart Center Freiburg University, Department ofCardiovascular Surgery, Freiburg, Germany, 2TokaiUniversity School of Medicine, Department of Medicine,Isehara, Japan, 3University of Freiburg, Department ofMicrosystems Engineering, Freiburg, Germany, 4UniversityMedical Center Freiburg, Department of Paediatrics andAdolescent Medicine, Freiburg, Germany

Objectives: Thromboembolism is a severe complication in patients withventricular assist devices (VAD). Interactions of platelets with theartificial surface and pathological blood flow conditions may contributeto thrombus formation. Previous studies postulated that strongly swel-lable polymers, called hydrogels, are protein and cell repellent. This bio-inert behavior makes hydrogel coatings promising candidates as blood-compatible materials. However, an analysis of these polymer layersunder whole blood conditions and shear stress are rare. In our study wesystematically tested structurally similar hydrogel coatings belonging tothe poly(N-alkyl acrylamide) class under whole blood perfusion andshear stress. The structural variations of the polymers lead to differencesin their hydrophilicity and swelling behavior. Methods: Glass slides


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were coated with medical grade polyurethane (PU). Subsequently, eachof the PU-coated slides was coated with a different polymer. In a firstexperimental series, the depositied polymers differed in their swellingfactor (1.0-5.5) for structural reasons. In a second series, one represen-tative poly(N-alkylacrylamide) was further studied by varying itsdegree of crosslinking (1%-10%). The slides were perfused with humanblood containing fluoresceinated platelets at a shear rate of 1500 s�1 forthreeminutes for all experiments. Non-coated and PU coatedglass slidesserved as a reference for thrombogenic surfaces. To quantify plateletadhesion, the overall percentage of surface coverage was calculated andstatistically compared to the surface coverage on PU coatings. Results:We detected severe platelet aggregation and thrombus formation onnon-coated and PU coated glass slides. There was no visible plateletadhesion on polymers with a swelling factor of above about 1.5 to 2(p<0.001). However, a lower swelling factor resulted in severe plateletadhesion (p¼0.06). Neither very low (1%) nor medium (2.5%, 5%) orvery high degrees of crosslinking (7.5%, 10%) seemed to reverse theplatelet repellent properties of the chosen polymer (p<0.001).Conclusion: A swelling factor down to 1.5-2.5 seems to be sufficientto effectively prevent platelet adhesion under the described conditions.Moreover, different degrees of crosslinking ranging from 1% to 10% donot reverse platelet repellent properties of one representative polymer.

SC109ProBNP serum levels and mRNA expressiondecrease after VAD implantationHeilmann C.1, Geisen U.2,Weiss S.3, Trummer G.1, Berchtold-Herz M.1, Benk C.1, Hein L.3, Stiller B.4, Beyersdorf F.11Universitäts-Herzzentrum Freiburg - Bad Krozingen,Klinik für Herz- und Gefäßchirurgie, Freiburg, Germany,2Universitätsklinikum Freiburg, Institut für KlinischeChemie und Laboratoriumsmedizin, Freiburg, Germany,3Institut für Experimentelle und Klinische Pharmakologieund Toxikologie, Abt. II, Freiburg, Germany, 4Universitäts-Herzzentrum Freiburg - Bad Krozingen, Klinik fürangeborene Herzfehler und pädiatrische Kardiologie,Freiburg, Germany

Objectives: ProBNP is an established diagnostic and prognostic markerof cardiac insufficiency. It correlates to myocardial stretch and volumeload, but is also influenced by metabolic and renal clearance, immuno-logic processes and other. ProBNP data for adult patients with ventricu-lar assist devices (VAD) are scarce.Methods:We analyzed VAD patientsretrospectively for proBNP (normal: <125 pg/ml) and creatinine inserumbefore implantation (n¼32) aswell as 28�7 days (n¼15) and 60� 14 days (n¼32) postoperatively. 24 patients had left-ventricular(LVAD) and 8 had biventricular (BVAD) support. In addition, left-ventricular myocardial samples were taken at VAD implantation andexplantation for heart transplantation. BNP mRNA expression of 10patients was quantified by qPCR and normalized for 106 copies of Rps29.Data are given as mean � standard deviation (median). SPSS version 19was used for Wilcoxon tests and univariate regression analysis. Results:ProBNP decreased from 8696 � 11454 (4637) before VAD implantationto 2898� 2521 pg/ml (2148 pg/ml) after onemonth and to 3034� 3619pg/ml (1677 pg/ml) after two months on VAD. There was a decreasewithin the first month (28 days versus preop, p¼0.008), but not in thesecondmonth anymore. The LVADand BVAD groups did not differ beforeor after VAD implant. Further, BNP mRNA expression decreased duringVAD support from 80 � 78 (55) to 9 � 13 (34) copies (p¼0.005).Creatinine values developed similar to proBNP with a decrease withinthe first 4 weeks from 1.4� 0.6 (1.2) to 0.8� 0.3 (0.7) mg/dl (p¼0.002),but not in the second month (p¼0.272). However, creatinine did notexplain proBNP values according to regression analysis. Conclusion:ProBNP values in serum declined within one month after VAD implan-tation. A decrease of mRNA expression was observed during VADsupport. A relation of proBNP with cardiac unloading could be possible,but this association remains to be elucidated.

SC110CentriMag short-term ventricular assist deviceas a bridge to decision in post-cardiotomycardiogenic shockSabashnikov A.1, Mohite P.N.1, Popov A.-F.1, Fatullayev J.1,García Sáez D.1, Patil N.P.1, Zych B.1, De Robertis F.1, AmraniM.1, Bahrami T.1, Simon A.R.11Royal Brompton & HarefieldNHS Foundation Trust, Department of CardiothoracicTransplantation and Mechanical Circulatory Support,Harefield, London, United Kingdom

Introduction: The CentriMag® (Levitronix LLC, Waltham, Mass) systemis an extra corporeal short term circulatory assist device which offers veryvaluable therapeutic options in PCCS as a bridge to decision. Post-Cardiot-omyCardiogenic Shock (PCCS) is observed in patients having surgery undercardiopulmonary bypass, most commonly as a result of myocardial stun-ningorhibernation. It occurs in 2-6%ofall cardiac surgical procedures.Mostof the cases respond to conventional pharmacological and mechanicalsupport, i.e. intra-aortic balloon pump; however, there are cases in whichmyocardial recovery is refractory to these measures and would requireadditional mechanical support. This patient population has nearly 100%mortality unless treated bymechanical support, which offers the only hopeof survival. Methods: A retrospective review was performed in 28patients who were treated with CentriMag® short term VAD as bridgeto decision between years 2004 and 2011. CentriMag is a single-useextracorporeal centrifugal blood pump based on bearing-less motortechnology. The motor generates the magnetic bearing force thatlevitates the rotor in the pump housing and, at the same time, generatesthe torque to produce the unidirectional flow up to 10 L/min. Results:Between 2004 and 2011, 125 adult patients were supported with 140Levitronix devices at our institute. Twenty-eight out of themwere used totreat PCCS. Left ventricle was supported in 18 (LVAD); right ventricle wassupported in 3 (RVAD), while both the ventricles were supported in 10cases (BiVAD). The total support duration was 329 days. The meansupport time was 11.75 � 16.01 days (range: 1-65 days). 16 (57.14%)patients diedon support, 12 (42.85%) patientswereweaned from supportwhile 8 (28.57%) were actually discharged home. One patient on Levi-tronix LVAD was converted to Levitronix BIVAD while another wasconverted to Long term VAD. Of the 72 (51.42%) patients who recoveredand were discharged home, 45 (36%) are presently alive. There were nodevice failures. Conclusion: The Levitronix CentriMag has proven to be aversatile, safe and effective short-term circulatory support for patientswith post-cardiotomy cardiogenic shock as a bridge to decision.

SC111Midterm outcome after mitral valve repair andLV-remodelling in high risk patients withdilated cardiomyopathySerio D.1, Monsefi N.1, Miskovic A.1, Moritz A.11Klinikum der Goethe-Universität, Thorax-, Herz- undthorakale Gefäßchirurgie, Frankfurt a.M., Germany

Objectives: The aimof this studywas to investigatemidtermoutcomeaftermitral valve repair and additional surgical LV-remodelling in high riskpatients with cardiomyopathy. Methods: Twenty four high risk patients(mean EUROSCORE 9.5 � 1.8) with secondary mitral incompetence andheart failure due to ischemic (n¼12) and nonischemic dilated cardio-myopathy (n¼12) underwent LV-remodelling and mitral valve recon-struction. All patients had the dilated apex remodelled and 14underwent additional papillary muscle approximation. Ten had CABGand 15 tricuspid repair. Mean age was 68 � 10 years and ejection fraction(EF)was 29� 7. After 25.8� 13months patients had clinical (n¼19) andechocardiographic (n¼15) follow up. Results: Contacted patients hadan improvement in exercise tolerance (NYHA) from 2.7� 0.1 to 1.8� 0.2(p¼0.001) End diastolic and end-systolic volume (volume/BSA) de-creased from 114 � 31 to 80 � 33 (p¼0,0007) and 80.5 � 25 to 51 � 27(p¼0,0003) significantly. The mean EF increased from preoperative29.5� 7 to postoperative 39� 10% significantly (p¼0,004). Conclusion:LV-remodelling with apical compression and papillary muscle approxi-mation in cases of severe mid ventricular dilatation significantly re-duced LV volumes and improved EF as well as exercise tolerance atmidterm. Perioperative morbidity is a concern, however most patientswere not willing to or suitable for other cardiac support therapy.


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Extracorporeal circulation and myocardial protection

SC112The new St Thomas' Hospital polarizedcardioplegia: improved efficacy of myocardialprotection in pigs on CPBSanter D.1,2, Dietl W.1,3, Trescher K.1,3, Kreibich M.1, DzilicE.1, Nagel F.1, Hallström S.4, Aumayr K.5, Fallouh H.6,Chambers D.J.6, Podesser B.K.1,31LBC Cardiovascular Research, Vienna, Austria,2Department of Cardiovascular Surgery at the HospitalHietzing, Vienna, Austria, 3Department of Cardiac Surgeryat the Landesklinikum St. Pölten, St. Pölten, Austria,4Institute of Physiological Chemistry, Medical University ofGraz, Graz, Austria, 5Clinical Institute for Pathology, AKHWien, Medical University of Vienna, Vienna, Austria,6Cardiac Surgical Research, The Rayne Institute (King'sCollege London), St Thomas' Hospital, London, UnitedKingdom

Objectives: In this study, the efficacy of the new polarizing St Thomas'Hospital solution (STH-POL comprising esmolol, adenosine, magne-sium) was compared to conventional St Thomas' Hospital solution(STH2). Methods: Thirteen pigs (47 � 4kg) were anesthetized andmonitored (HR, MAP). After sternotomy, pigs were heparinized(300IU/kg) and put on normothermic CPB. Additional monitoringwas: Swan Ganz for PAP and cardiac output (CO); ultrasound flow probefor LAD flow; a Millar tip catheter for LVP; a coronary sinus catheter tosample coronary effluent. After baseline, CPB was started, the aortacross-clamped and hearts were arrested via antegrade, warm (35°C)STH-POL (n¼7) or STH2 (n¼6) cardioplegia. Sixty min of ischemia (I)were followed by 60 min of reperfusion (R), then hearts were weanedfrom CPB for another 120 min before sacrifice and determination ofmyocardial high-energy phosphate (HEP). Data as% of baseline (mean �SEM). Results: Baseline hemodynamic values were comparable. After180min R, recovery ofMAP and HRwere similar. In contrast, recovery ofLVPsys (133 � 8 vs 97 � 5%, p<0.01) and external heart work (rEHW:145 � 16 vs 88 � 10%, p<0.05) were significantly higher in STH-POLhearts. Coronary flow/heart weight reached significance during early(430 � 59 vs 211 � 59%, p<0.05) and late R (269 � 43 vs 90 � 16%,p<0.01) in STH-POL. Total CK release was significantly lower during R(2016 � 262 vs 1232 � 199 U/l, p<0.05) in STH-POL. HEP showed atendency towards improved preservation in STH-POL hearts.Conclusions: Polarized cardiac arrest was shown to be effective in largehearts, which makes it useful clinically. It was associated with improvedmyocardial protection and reduced ischemic damage.

Fig. 1: External Heart Work Recovery

SC113Less inflammation by off-pump surgery? Arandomized comparison to minimizedextracorporeal circulation and conventionalcoronary bypass graftingMüller-Eising K.1, Hönicka M.1, Rupp P.1, Deininger S.1,Kunert A.2, Liebold A.1, Gorki H.11Universität Ulm, Klinik für Herz-, Thorax- undGefäßchirurgie, Ulm, Germany, 2Universität Ulm, Klinik fürHerz-, Thorax- und Gefäßchirurgie, AbteilungKardiotechnik, Ulm, Germany

Objectives: Cardiopulmonary bypass causes systemic inflammation.Off-pump techniques and minimized systems aim for reduction ofthis reaction. However a three-sided comparison of minimized extra-corporeal circulation (MECC) and conventional extracorporeal circula-tion (ONCAB) to off-pump coronary bypass grafting (OPCAB) is missingand the results of two-sided studies are inconclusive. Methods: 60patients scheduled for non-emergency isolated coronary bypass graft-ing were randomly assigned into three different study groups (ONCAB,MECC, OPCAB). Blood samples were taken at seven different time points.Inflammation markers (differential blood count, CRP, TNFalpha, ICAM-1and P-selectin) and clinical parameters were assessed. Results: In theoverall study population leucocytes and neutrophil granulocytes in-creased already during the operation before protamine administration(p<0.001). TNF showed a significant peak at arrival on ICU (p<0.001)and stayed elevated over 72 hours. Both CRP and ICAM-1 increasedsignificantly within 12 h after ICU-arrival (p<0.001) and peaked at 24 h(p<0.001). P-selectin dropped during the operation (p<0.001) andreturned to baseline at arrival on ICU. Body temperature increasedsignificantly within 6 h after the operation (p<0.001) and stayedelevated. However, the three surgical techniques showed similar curveswithout any significant differences in any of the parameters.Conclusions: In this preliminary study OPCAB and MECC did notshow any advantage over conventional CPB regarding systemic inflam-mation. Thus, more patients and further parameters focusing also oncoagulation and organ impairment are currently investigated lookingfor the best surgical strategy.

SC114Predictive value of Euroscore II as compared tointermacs levels in patients undergoing leftventricular assist device therapyMenon A.K.1, Mechelinck M.1, Unterkofler J.1, Moza A.K.1,Tewarie L.1, Goetzenich A.1, Autschbach R.11Uniklinik RWTH Aachen, Klinik für Thorax-, Herz- undGefäß-Chirurgie, Aachen, Germany

Objectives: Left ventricular assist devices (LVAD) have become a wide-spread option for the effective treatment forheart failure. Consequently, theneed for postoperative survival estimation increases. We assumed that theEuroScore II might be useful for predicting long-term outcome after LVADuse. Methods: In this retrospective analysis, all 40 patients wereconsecutively followed for full 12 months after having received aLVAD (Thoratec HeartMate II ™) in our institution between 2008 andApril 2011. Mean age was 58 years, 13 patients were female. Theintention to treat was destination therapy in 25%. 52.5% were classifiedin INTERMACS Levels IþII. Postoperative survival was correlated both toINTERMACS™ levels and to EuroScoreII datawith patients classified in 3categories: Patients were classified via the EuroScoreII as low (<25%),middle and high (>55%) risk and in Intermacs Level groups I, II and III þIV. Results: The survival was 87.5% for 30 days and 70% for 1 year (28/40pts).Within the different INTERMACS™ levels, survival reached 58,3%for INTERMACS™ levels I and 88,9% for level II compared to 68.4% atcombined levels III and IV. On the other hand, classification by Euro-ScoreII showed a 12 month survival of 16.7% (1/6 pts) in high riskpatients compared to 89.5% (17/19pts) in low risk patients. Patients ofmedium risk (EuroScoreII between 25 and 55%) showed a survival rate of66.7%. Fisher’s exact test revealed a significant predictive value forclassification by EuroScoreII (p¼0.003) but not for INTERMACS™ levels.Conclusion: These results support the assumption that EuroScoreII riskclassification may be useful to predict long-term survival in LVAD patients.In our observation, it proved to be superior to INTERMACS™ classification.


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Fig. 1: Postoperative survival of patients classified in 3 categories ofEuroScoreII

SC115Right ventricular failure in left ventricular assistdevice (LVAD) patients. What kind oftemporary mechanical support should we use,Levitronix or ECMO?Kluttig R.1, Meyer A.1, Garbade J.1, von Samson-Himmelstjerna P.1, Matz L.1, Mohr F.-W.1, Strüber M.11Herzzentrum Leipzig, Leipzig, Germany

Background: Right ventricular (RV) failure increases morbidity andmortality in patients undergoing left ventricular assist device implan-tation. Sometimes temporary mechanical support is needed and couldlead to successful weaning. It is still controversial weather to use anECMO or a temporary right ventricular assist device (RVAD). Methods:We retrospectively analyzed our LVAD implantation between 1/2009and 8/2013. Of these, 24 patients required severe RV failure with theneed of mechanical support. In 15 patients we used an ECMO for RVsupport and in 9 patients we implanted a Levitronix temporary RVAD.Results: Ischemic cardiomyopathywas diagnosed in 20% in both groups.The mean age was 48.6 years in the ECMO group and 48.4 years in theRVAD group. ECMOwas used in combinationwith an HVAD (n¼13) andHeartMate II (n¼3). An RVAD was combined with an HVAD (n¼6),HeartMate II (n¼2), PVAD (n¼1). Themean preoperative Cardiac Index(CI) was 1.4 in both groups with no statistical difference in pulmonaryartery pressure, TAPSE and Ejection Fraction between the two groups.Themean duration ofmechanical support was 8� 9.3 days for the ECMOpatients and 37.8 � 26.4 days for the RVAD group. The ECMO wasweaned succussfully in 70% of the patients, the RVAD in 22.2%. 30 daymortality was 20% for both groups. One year mortality was 40% in theECMO group compared to 56% in the RVAD group. Conclusions: Amongpatients who developed acute RV failure after LVAD implantation, onlyhalf could be weaned from the temporary RVAD support. An ECMO is agood opportunity for short term support but as bridge to transplant aRVAD seems to be the better choice.

SC116Incidence and clinical relevance of Protamine-Heparin-antibodies in patients undergoingcardiac surgery with cardiopulmonary bypassGrieshaber P.1, Wagner A.1, Florath I.2, Böning A.1, Sachs U.31Universitätsklinikum Giessen, Klinik für Herz-,Kinderherz- und Gefäßchirurgie, Giessen, Germany,2Deutsches Krebsforschungszentrum, Heidelberg, Germany,3Justus Liebig-Universität Giessen, Institut für KlinischeImmunologie und Transfusionsmedizin, Giessen, Germany

Objectives: Not only Heparin-antibodies but also antibodies reactive toProtamine or Protamine-Heparin-complexes (PrAB) have been de-scribed in patients undergoing non-cardiac and cardiac surgery. Yet,etiology of PrAB and their clinical consequences remain unclear. Thisprospective single-center observational study aimed to describe theincidence and time-course of PrAB in patients undergoing cardiacsurgery with cardiopulmonary bypass (CPB). In addition, we analyzedpotential risk factors for preoperative presence of PrAB and periopera-

tive conversion to reactivity.Methods: 200 consecutive patients under-going cardiac surgerywith CPB at our institution between June 2012 andMay 2013 were included. Blood samples were collected preoperatively(T0), 1 h after weaning from CPB (T1), 1 day (T2) and 7 days (T3)postoperatively. All sera were tested for the presence of IgG-PrAB viaELISA. A functional Platelet (PLT)- activation assay (HIPA) protocol fordetection of Heparin-antibodies was modified in order to identifyfunctionally active PrAB. Specificity of positive reactions was confirmedby repeated testing in the presence of the FcγRIIa-blocking monoclonalantibody IV.3. Results: Samples from 185 patients were obtained, ofwhich 38 patients (20,54%) were positive for PrAB even before surgery.In all positive samples, functional reactivity was reversible in presenceof IV.3, proving specific antibody-dependent PLT activation. Whilepatients with diabetes mellitus (IDDM) showed a significant associationwith preoperative PrAB (OR 2,853 ,95%-CI 1,056-7,709) no other poten-tial risk factor had a significant association with reactivity at T0. From147 PrAB-negative patients, 27 (15,49%) converted to reactivity post-operatively. PrAB at any time point had no significant influence onpostoperative PLT count, transfusion requirement, thromboembolicevents and MACCE. Also, postoperative inflammation, liver and kidneyfunction were not different in PrAB-positive compared to negativepatients. Conclusion: Protamine-antibodies occur in patients undergo-ing cardiac surgery on CPB resulting in specific PLT activation. IDDM is arisk factor for preoperative reactivity. As PrAB showed no significantinfluence on clinical outcome parameters, the clinical relevance of PrABappears to be questionable.

SC117Which is the best coagulation management incoronary surgery? Results of a randomisedstudy on heparin concentration versusactivated clotting time and three differentsurgical techniquesRupp P.1, Müller-Eising K.1, Deininger S.1, Pleyer C.1, HönickaM.1, Liebold A.1, Gorki H.11Klinik für Herz-, Thorax- und Gefäßchirurgie,Herzchirurgie, Ulm, Germany

Objective: Heparin concentration surveillance (HEPCON) is an alterna-tive tomeasurements of the activated clotting time (ACT) during cardiacoperations. The benefit however is not unequivocally proven and themechanisms not completely understood. A better preservation of coag-ulation factors is assumed, platelets could be spared by individualizeddosing of protamine. The effects of the two measuring systems indifferent surgical strategies of coronary revascularisation are not yetinvestigated.Methods: 60 patients were randomized for intraoperativemeasurement of heparin concentration (Hepcon HMS PLUS, Medtronic)or ACT. Furthermore, the patients were randomly assigned to conven-tional cardiopulmonary bypass (ONCAB), minimized bypass (MECC) oroff-pump (OPCAB) resulting in six study groups. Clinical data (heparinand protamine dosages, blood loss, transfusions) and several markers ofthe coagulation system (platelets, factor II, factor V, factor VIII, factor X,D-dimer, thrombin-antithrombin III - complex, prothrombin fragment1.2, antithrombin III and tissue factor pathway inhibitor) were assessedat seven time points. Results:Heparin usage variedwithout significance(p¼0,87), but protamine was significantly lower dosed with the HEP-CON regimen (p<0,001) without difference between the surgicalsubgroups. Blood loss was slightly higher with the HEPCON regimenat 12 hours (p¼0,09) without significance inbetween the surgicalsubgroups (p¼0,86). Transfusions didn't differ significantly. The timecourse of the coagulationmarkers was very similar in the 6 study groupsup to 72 hours postoperatively. The only significance was found forfactor VIII comparing ONCAB and OPCAB (p¼0,02). None of the othercoagulation markers showed significant differences, neither betweenthemajor groups of anticoagulationmanagement (HEPCONvs ACT) or ofthe surgical approach (ONCAB vs MECC vs OPCAB) nor between thecombined subgroups. Conclusions: In this study of isolated coronarybypass operations, surgical technique and heparin management had noinfluence on coagulation parameters. Surprisingly, neither the avoid-ance or minimization of the extracorporeal circulation nor individual-ized heparin dosage showed the anticipated advantages in preservation


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of the coagulation system. The results, however, are possibly biased bythe small size of the study groups and need further investigations.

SC118The role of hypoxia-inducible factor-1α andvascular endothelial growth factor in late phasepreconditioning with xenon, isoflurane andlevosimendan in rat cardiac myocytesGoetzenich A.1, Hatam N.1, Preuss S.1, Bleilevens C.2, RoehlA.2, Hein M.2, Bernhagen J.3, Stoppe C.3, Autschbach R.11Uniklinik RWTH Aachen, Klinik für Thorax-, Herz- undGefäß-Chirurgie, Aachen, Germany, 2Uniklinik RWTHAachen, Klinik für Anästhesiologie, Aachen, Germany,3Uniklinik RWTH Aachen, Institut für Biochemie undmolekulare Zellbiologie, Aachen, Germany

Introduction: The protective effects of late phase preconditioning canbe triggered by several stimuli. Unfortunately, the transfer frombench tobedside has proven challenging, as the complex signalling pathwaysinvolved are easily influenced by concomitant medication or disease.Methods: In an established model of primary neonatal rat cardiomyo-cytes, we analysed the cardioprotective effects of three different stimu-lating agents that are clinically established. Twentyfour hours prior tohypoxia, cells were preconditioned either by isoflurane, levosimendanor xenon. The influence of these three stimuli on hypoxia-induciblefactor-1α and vascular endothelial growth factor were analysed bypolymerase chain reaction and western blotting. Results: 5 hours ofhypoxia reduced cell survival in unpreconditioned control cells to 0.44�0.04. Surviving cell count was significantly higher in cells precondi-tioned by either 2x15 isoflurane (0.70 � 0.16; p¼0.005) or xenon (0.59� 0.08; p¼0.049). Xenon-preconditioned cells showed a significantlyelevated content of VEGF (0.025 � 0.010 vs. 0.003 � 0.006 in controls;p¼0.0003). The protein expression of HIF-1a was increased both byLevosimendan (0.563 � 0.175 vs. 0.142 � 0.042 in controls; p¼0.0289)and Xenon (0.868 � 0.222; p<0.0001) pretreatment. Discussion: Themain finding that should be emphasized is that the stimulation of latephase preconditioning involves several distinct pathways that arevariably addressed by the different stimuli. In contrast to isofluranetreatment, Xenon-induced preconditioning does not lead to an increasein cyclooxygenase-2 gene transcription but to a significant increase inhypoxia-inducible factor-1α and subsequently vascular endothelialgrowth factor.

SC119Custodiol-N versus custodiol: A prospectiverandomized double blind multicenter phase IIItrialSzabó G.1, Weymann A.1, Schmack B.1, Badowsky-Zyla D.1,Veres G.1, Wagner F.2, Rastan A.3, Doenst T.4, Karck M.11Universität Heidelberg, Klinik für Herzchirurgie,Heidelberg, Germany, 2Universitäres HerzzentrumHamburg/ Eppendorf, Klinik und Poliklinik für Herz- undGefäßchirurgie, Hamburg, Germany, 3Herz- undKreislaufzentrum Rotenburg, Rotenburg a.d. Fulda,Germany, 4Universität Jena, Klinik und Poliklinik für Herz-und Thoraxchirurgie, Jena, Germany

Objectives: HTK-Solution (Custodiol) is a well established cardioplegicand organ preservation solution. We currently developed a novel HTKbased solution Custodiol-N which includes iron chelators to reduceoxidative injury aswell as L-arginine, to improve endothelial function. Inthe present first-in-human study, Custodiol-N was compared withCustodiol in patients undergoing elective coronary bypass surgery.Methods: The study was designed as prospective randomized doubleblind non-inferiority trial. Primary end-point was area under the curve(AUC) of creatine kinase MB (CKMB) within the first 24 hours aftersurgery. Secondary endpoints included, peak CKMB and troponin-T andAUC of troponin-T release, cardiac index, cumulative catecholaminedose, ICU-stay andmortality. All values are given as mean� SD, p<0.05was considered as statistically significant. Results: 101 Patients wereincluded into the trial. Patient characteristics,medical history, operationand crossclamp times did not differ between the groups. CKMBAUC (878

� 549 vs. 778 � 439 h*U/l, non-inferiority p<0.001) and Troponin-TAUC (12990 � 8347 vs. 13498 � 6513 h*pg/ml, non-inferiorityp<0.001) were similar in both groups. While peak Troponin-T (888 �554 vs. 847� 380 pg/ml) did not differ between the groups, peak CKMB(52� 40 vs. 41� 30 U/l, superiority p<0.002) was significantly lower inthe Custodiol-N group. Cardiac index, catecholamines ICU-stay andmortality (1 death in the control group) was similar in both groups.Conclusions: This study shows that Custodiol-N is safe and providessimilar cardiac protection as the established HTK-Custodiol solution.Although the study was powered for non-inferiority, significantlyreduced peak CKMB levels were observed in the Custodiol-N groupwhich may implicate a beneficial effect on ischemia/reperfusion injuryin the setting of coronary bypass surgery.

SC120Neurologic outcome following axillary arteryversus classic aortic cannulation in high riskpatients: Preliminary results fromaprospectiverandomized studyIllioska P.1, Brendel L.1, Krüger N.1, Navratil D.1, Kiessling A.H.1, Moritz A.1, Zierer A.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, THG, Frankfurt am Main, Germany

Objectives: The right axillary artery has been proven an excellentcannulation site for complex aortic surgery. Aim of the current ongoingprospective randomized study is to evaluate whether this approachoffers superior neurologic outcome as compared to routine aorticcannulation in high risk patients undergoing cardiac surgery.Methods: Prospective, randomized study of patients at high risk forstroke undergoing coronary artery surgery and/or valve repair/replace-ment. Between 2010 and 2013, 59 patients (mean age 72 years, range51-85) underwent a pre- and postoperative (day 5 and 30) neuro-cognitive test battery (Mini-Mental-Status-Test, the Montreal CognitiveAssessment, Test of Attentional Performance, Neecham confusion scale)and diagnostic procedures (EEG, brain MRI and near-infrared-spectros-copy). Primary end point of the studywas neurologic outcome includingincidence of delirium. Results: Delirium was observed in 12 patients,being equally distributed among the axillary (n¼6/28) and aortic(n¼6/31) group. Adverse outcomes in terms of major neurologicdysfunction and hospital mortality were comparable. 2 patients withhemiparesis and 2 deaths in the aortic group (n¼4) and 1 patient withhemiparesis and 2 deaths in the axillary group (n¼3). Conclusions: Inhigh risk patients undergoing cardiac surgery our preliminary resultssuggest that axillary artery cannulation as a single factor may not besufficient to optimize neurologic outcome. At the same time we have toremind that this ongoing study is still underpowered for the primaryendpoint and not all secondary endpoints were analysed thus far.

SC121Effects of retrograde autologous priming inadult patients undergoing cardiac surgeryHofmann B.1, Petrov A.1, Stiller M.1, Kraus F.B.2, Raspe C.3,Silber R.-E.1, Ludwig-Kraus B.21Universitätsklinikum Halle (Saale), Klinik für Herz- undThoraxchirurgie, Halle (Saale), Germany,2Universitätsklinikum Halle (Saale), Department ofLaboratory Medicine, Halle (Saale), Germany,3Universitätsklinikum Halle (Saale), Department ofAnesthesiology and Operative Intensive Care Medicine,Halle (Saale), Germany

Background: Adult cardiac surgery with extracorporeal circulation(ECC) is known to be associated with increased risk of blood transfusionand systemic inflammatory response leading to adverse outcomes.Modern procedures like retrograde autologous priming (RAP) mayreduce these negative side effects of ECC. This randomized prospectivestudy was initiated to assess whether RAP using specifically designedRAP bag (Terumo) has immediate effects on patient outcome.Methods:Sixty adults undergoing elective CABG or elective aortic valve replace-ment were randomly assigned by a computer program into two groups:the RAP group (n¼30) inwhich the retrograde autologous priming was


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applied and the non-RAP (n¼30) group in which the same setting wasused but without the possibility to save priming volume in RAP bag.Patient demographics, preoperative characteristics and postoperativeoutcomes were analyzed for both groups. Results: There were nosignificant differences in operation time, blood loss and transfusionrates. No deaths and nomyocardial infarctionswere observed. However,RAP could reduce the priming volume of the ECC up to 490 ml. RAPmanaged patients had a significantly lower platelet decline (p¼0.03)after ECC, less catecholaminergic support (p¼0.04) and a shorterintensive care unit stay (p¼0.05). Conclusion: Retrograde autologouspriming is a safe and less invasive procedure which achieves clearbenefits for adult cardiac surgery patients. Larger, sufficiently powered,study is needed to assess full benefit of this approach.

SC122Dispersive aortic cannulas reduce aortic wallshear stress affecting atherosclerotic plaqueembolisationAssmann A.1, Gül F.2, Benim A.C.2, Joos F.3, Akhyari P.1,Lichtenberg A.11Heinrich Heine University, Medical Faculty, Department ofCardiovascular Surgery, Duesseldorf, Germany,2Duesseldorf University of Applied Sciences, CFD Lab,Department of Mechanical and Process Engineering,Duesseldorf, Germany, 3Helmut Schmidt University,Laboratory of Turbomachinery, Hamburg, Germany

Objectives: Neurologic complications during on-pump cardiovascularsurgery are prevalently induced by mobilisation of atheroscleroticplaques, which is directly related to enhanced wall shear stress. In thepresent study, we numerically evaluated the impact of dispersive aorticcannulas on aortic blood flow characteristics, with special regard to theresulting wall shear stress profiles. Methods: An idealized numericalmodel of the human aorta and its outlets was created, and straight aswell as bent aortic cannulas with dispersive tips were inserted in thedistal ascending aorta. Standard straight or bent cannulas served ascontrols. Using a validated computing method, simulations of pulsatileand non-pulsatile extracorporeal circulation were performed. Results:Dispersive aortic cannulas reduced the maximum and average aorticwall shear stress values to approximately 50% as compared to controlcannulas, while the difference of local values was even larger. Moreover,at pulsatile circulation, dispersive cannulas shortened the time period ofhigh wall shear stress values. The turbulent kinetic energy was dimin-ished by utilizing dispersive cannulas. Conclusion: Dispersive aorticcannulas decrease aortic wall shear stress during extracorporeal circu-lation, and may therefore reduce the risk of endothelial damage andneurologic complications caused byatherosclerotic plaquemobilisation.

SC123Coronary artery revascularization with aminimized extracorporeal circulation system(MECC): The inflammatory response incomparison to conventional cardiopulmonarybypassSrndic E.1, Kiessling A.H.1, Guo F.1, Keller H.2, Beiras-Fernandez A.1, Moritz A.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, THG, Frankfurt am Main, Germany,2Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, THG-Maquet Service, Frankfurt am Main,Germany

Objectives: Extracorporeal circulation can lead to a systemic inflamma-tory response (SIRS). Aim of the study was the evaluation of inflamma-tory markers in different cardiopulmonary bypass techniques..Methods: In a prospective study, 72 patients (73 � 5,3 years) wererandomized in 3 subgroups: MECC (priming 550 ml, only cell saversuction), ECC (priming 1250 ml, CBP suction) and no-suction ECC(priming 1250 ml, cell saver suction). Evaluation of inflammatoryparameters IL6, IL10, TNF-alpha and PNM elastase was performedpreoperative (t1), 60 minutes after extracorporeal circulation start(t2), 4-6 h (t3), 24 h (t4) and 48 h postoperative (t5) and before discharge

from hospital (t6). Results: Patients were well comparable for allpreoperative variables. Proinflammatory cytokines were significantlyelevated by CPB during and after cardiac surgery procedures comparedto t1. However, MECC or No-Suction ECC could not attenuate systemicinflammation derived by CPB. Operation time (MECC 261� 79min; ECC264� 75min; No-suction ECC 231� 68 min) and perfusion time (MECC115� 49min; ECC 107� 37min; No-suction ECC 99� 22min) showed afaster performance trend in the no-suction-ECC group (p>0,05).Conclusions: Neither the hemodilution and suction technique (MECC)nor the blood air interface (no-Suction ECC) could show benefits for thesystemic inflammatory reaction induced by cardio-pulmonary bypass.

SC124Cardioprotection with Captopril added toBretschneider-Solution: An in vitro rabbit heartstudyHoyer A.1, Pritzwald-Stegmann P.1, Kempfert J.1, Etz C.1,Mohr F.W.1, Dhein S.11Herzzentrum Leipzig, Herzchirurgie, Leipzig, Germany

Objective: Angiotensin-converting enzyme inhibitors have recentlybeen shown to attenuate left ventricular dysfunction after cardioplegicarrest, however, evidence as to how this effect is mediated is scarce.Methods: Rabbit hearts were perfused using a Langendorff apparatus.The Control group underwent cardioplegia with conventional HTK-Bretschneider solution (n¼6) Whereas the other groups recieved thefollowing adjuncts added to the cardioplegic solution (each n¼6):captopril (100µmol/l), Losartan (100 nmol/l) for selective AT-II receptortype 1 blockade or BQ123 (100 nmol/l) for selective Endothelin-receptortype A blockade. 45 minutes of equilibration were followed by 90minutes of cardioplegic arrest and 30 minutes of reperfusion. Indicesfor myocardial contractility, coronary flow, heartrate and O2-consump-tion were recorded before and after ischemic arrest. Tissue ATP andmalondialdehyde (MDA) contents were measured to evaluate energycontent and oxidative stress. Results: The treatment with Captopriladded to the cardioplegic solution improved substantially the recoveryof myocardial contractility after arrest (Control vs. Captopril: 5 minP<0.001, 10 min P¼0.002, 20 min P¼0.002, 30 min P¼0.002) whileconsuming less oxygen (P¼0.004). Moreover the ATP content of thereperfused tissue was significantly elevated compared with controlgroup (24 � 2 µmol/g vs. 16 � 2 µmol/g P¼0.033), whereas the levelof MDAwas substantially decreased (0,58 � 0,163 µmol/g vs. 1,5 � 0,28µmol/g P¼0.009). This effect could not be reproduced neither byselective ATII-receptor type 1 nor by selective ETA-receptor blockade.

Fig. 1: Development of left ventricular pressure

Conclusions: Adding Captopril to HTK cardioplegia solution leads to asignificantly greater and faster recovery of myocardial contractility afterprolonged global ischemia and reperfusion, while consuming lessoxygen. These effects seem not to be mediated through ATII-receptortype 1 by Angiotensin II nor crossactivation of Endothelin-receptor typeA by Endothelin.


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SC125Successful fast track anaesthesia in leftventricular assist device implantation - it isfeasible!Menon A.K.1, Unterkofler J.1, Schälte G.2, HatamN.1,Moza A.K.1, Goetzenich A.1, Autschbach R.11Uniklinik RWTH Aachen, Klinik für Thorax-, Herz- undGefäß-Chirurgie, Aachen, Germany, 2Uniklinik RWTHAachen, Klinik für Anästhesiologie, Aachen, Germany

Objective: Left ventricular assist device (LVAD) implantation has be-come a crucial option in end-stage heart failure therapy. Especiallypostoperative right ventricular failure (RVF) is feared. Fast track proce-dures have been well established in cardiac surgery and were proven tobe effective. We assumed that “fast track”-LVAD implantations is possi-ble in INTERMACS level 3 and 4 patients and might prevent RVF.Methods: From 01/2008 to 11/2012 we implanted 77 continuousflow LVADs in our institution. Out of these, 13 patients in INTERMACSlevel 3 or 4 were treated as "fast-track" (12 Thoratec Heartmate™ II, 1Heartware HVAD™). This included extubation in the theatre or up to 6hours postoperatively. 10/13 patients were male, average age was 61 �10 yrs on day of implantation, the intention to treat was destinationtherapy in 6 and bridge to transplantation or candidacy in 7 cases. Themain diagnosis was ischemic cardiomyopathy (10/13). Mean left ven-tricular ejection fraction was 18 � 4%. 9/13 patients suffered from animpaired RV function. Results: All operations were done via a standardsternotomy, the use of cardiopulmonary bypass and a beating-heartprocedure. All patientswere extubatedwithin 4 hours. Themean stay onICU was 53 � 41 hours and the mean stay in hospital after implantationwas 23� 9days. We did not record any postoperative RV failure. The 30-day-survival was 100%. After one year of support, 11 of 13 patients werealive. The current mean time on device is 413 days. Conclusion: In thispilot study, we demonstrated the feasibility of “fast-track” anaesthesiain LVAD implantation in selected patients. Prospective investigationsshould examine if this approach contributes to sustainable protection ofright ventricular function in a larger trial.

Basic Science III: Miscellaneous

SC126Testing long termperformance ofmurine aorticallografts after cold storage in TiProtec®

Jannasch A.1, Neumärker L.1, Biener A.1, Deußen A.2,Waldow T.11Herzzentrum Dresden, Herzchirurgische Forschung,Dresden, Germany, 2Medizinische Fakultät Carl GustavCarus, Institut für Physiologie, Dresden, Germany

Objectives: Until today, autologous vessel grafts are representing thebest form of transplant in coronary artery bypass grafting (CABG) interms of recovery rate. In literature there is evidence that an injured andfunctional impaired endothelium increases risk of graft thrombosis,intimal hyperplasia and consecutive accelerated graft vasculopathy.Herewe address improvement of current storage protocols, in particularwith respect to the maintenance of endothelial cell function. Methods:16 week old female Apoe-/- mice were feed a high fat diet (10 weeks)reflecting conditions of underlying disease of multiple coronary heartdisease were used. Donor grafts were stored in TiProtec® for either 1 or6-8 hours (4 °C) before transplantation, sodium chloride (NaCl) servedas control. Abdominal aortic transplantation was performed using amodified technique initially described by Koulack et al. 6 weeks aftertransplantation transplanted grafts were harvested and vessel functionwith respect to vessel tone development, endothelium- dependent andendothelium- independent relaxation and tissue reductive capacity inaddition to morphological analyses of paraffine- embedded graft sec-tions were performed. Results: 1 hour storage before transplantationhad no significant impact on vessel function but intimal thickness wassignificantly lower in TiProtec® versus control group. Prolonged storageof 6-8 hours in TiProtec® showed a well-preserved vessel tone develop-ment as well as endothelial dilatative function. Furthermore intimalthickness was lower and endothelial integrity determined by CD31staining was preserved in TiProtec® stored grafts compared to control.

Conclusion: In contrast to traditional NaCl storage, TiProtec® protectedendothelium-dependent vessel function, reduces intimal hyperplasiaand offers potential for intraoperative cold storage of arterial grafts.

SC127What about the rewarming duringreperfusion? Influence of hypothermicconditions on endothelial activityBogert N.1, Kanzler I.1, Schack S.1, Moritz A.1, Beiras-Fernandez A.11Klinikum der Johann Wolfgang Goethe UniversitätFrankfurt aM, Thorax-, Herz-, und Gefäßchirurgie,Frankfurt, Germany

Objective: Patients with risks of ischemic injury, e.g. during circulatoryarrest in aortic surgery, are subjected to therapeutic hypothermia. Thebody is cooled down to 18°C and rewarmed again to body temperature.Peripheral blood mononuclear cells (PBMC) under hypothermic con-ditions evoke anti-inflammatory, whereas subunits of PBMC show pro-inflammatory effects. First we investigates the influence of, mild andsevere hypothermic conditions on transendothelial migration of acti-vated or inactivated PBMC through activated or inactivated humanendothelial cells (EC). Secondly we analyzed the influence of thereperfusion-rewarming-process upon endothelial cells. Methods: Fol-lowing experimental groups were analyzed according to transendothe-lial migration: 1) activated-PBMC 2) activated-EC 3) activated-EC/activated-PBMC. Cells were activated at either 37°C, 30°C or 18°C.Transendothelial migration was either performed at the corresponding-ly activation temperature or the cells were rewarmed to 37°C. Resultsare expressed as transmigration index (tmx, mean � SEM) whereasp<0.05 was considered statistically significant. Results: Transendothe-lial migration of non-activated PBMC through activated-EC significantlyincreased at 37°C and 30°C compared to 18°C. At 30°C, the activation ofEC alone, and the activation of EC and PBMC, caused a significant boost oftransmigration compared to activated-PBMC alone. In contrast, at 18°Cthe activation of PBMC alone and the activation of EC and PBMC caused asignificant raise of transmigration compared to activated-EC alone.Rewarming from low (18°C, 30°C) to normothermic (37°C) conditionscaused no change in transendothelial migration of activated-PBMCthrough non-activated-EC. However, significantly more non-activat-ed-PBMC transmigrated through activated-EC with decreasing activa-tion temperature of EC [act. EC 37°C 1,18 � 0,03tmx vs. 18°C 1,61 �0,07tmx and 30°C 1,27 � 0,07tmx vs. 18°C 1,61 � 0,07tmx]. The samesignificant effect is seen when both cell types were activated andrewarmed to 37°C. Conclusion: The in vitro re-enactment of clinicalpractice has shown that transendothelial migration of PBMC through ECis not only modulated by cell-activation itself but that the activationtemperature is essential. Hypothermic conditions during cell-activationseem to influence transendothelial migration of leukocytes via an ECdependent mechanism. Endothelial protection prior to warm reperfu-sion should be considered.

SC128Epinephrine application in ischemia-reperfusion injury-induced ventriculardysfunction promotes myocardialmitochondrial dysfunctionSommer S.1, Leistner M.1, Siemers S.1, Schimmer C.1, AleksicI.1, Hamouda K.1, Leyh R.G.1, Sommer S.-P.11Universitätsklinikum Würzburg, Thorax-, Herz- undthorakale Gefäßchirurgie, Würzburg, Germany

Objectives: Epinephrine-application in acute myocardial insufficiencyincreases the myocardial oxygen demand, impacting on clinical out-come. We analyzed the impact of epinephrine on healthy and failingmyocardium during ischemia reperfusion injury. Methods: Wistar ratswere divided into 4 groups consisting of controls (IR0-30) and animalsreceiving IR (IR15/30), epinephrine (IR0/30 Epi) and the combination ofboth (IR15/30 Epi). During pressure-controlled Langendorff reperfusionleft ventricular performance was recorded (LVPmax, LVPdp/dtmax). Afterreperfusion myocardium was analyzed regarding mitochondrial func-tion (electron transport chain, Ca2þ-mMTP-opening), marker enzymes


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(CK/MB, HFABP, Cyr61) and redox states (GSH, NOx) and injury due toROS or inflammation (TBARS, MPO). Results: Compared to IR0/30 inIR15/30 myocardial performance deteriorated and was significantlyenhanced in IR0/30 Epi (P¼ .037). During IR epinephrine significantlyimproved LVdp/dtmax (P¼ .011) and LVPmax (P¼ .06). Analysis of SSM-and IFM-fraction of mitochondria revealed adverted IR-dysfunction ofSSM-complexes I-V, II-V and II-IV in presence of epinephrine (P< .001,P< .01, P< .05). Ca2þ-induced swelling was performed in presence of 50µmol (w/o 5 µmol pyruvate) and 100 µmol Ca2þ. In IR15/30 SSMsusceptibility towards Ca2þ-induced swelling increased, in presenceof epinephrine swelling was inhibited significantly (P< .001). RegardingIFM results remained less significant.

Fig. 1: Ca-induced SSM-swelling

HFABP determined from eluate demonstrated insignificantly increaseddamage in IR0/30 Epi and foremost in IR15/30 Epi, CK/MB was elevatedin both groups undergoing IR. Cyr61tissue was insignificantly suppressedin IR15/30 Epi. A significant loss of GSH occurred during ischemia inpresence of Epinephrine (P<0.005). TBARS was high in IR15/30 Epi(P>.05) and MPO increased in IR15/30 with or without Epi (P¼ .037).Conclusions: Epinephrine-treatment of IR-induced LV-failure exacer-bates myocardial mitochondria and tissue injury.

SC129Smooth muscle cell derived adiponectin and itsrole in storage induced vascular dysfunctionEbner A.1,2, Wilbring M.3, Poitz D.M.2, Alexiou K.3, DeussenA.11TU Dresden, Medizinische Fakultät, Institut fürPhysiologie, Dresden, Germany, 2TU Dresden, MedizinischeFakultät, Labor für experimentelle und molekulareKardiologie, Dresden, Germany, 3Herzzentrum, Dresden,Germany

Objective: Availability of adiponectin plays a crucial role in cardiovas-cular function. The present study was conducted to evaluate thepresence, alterations and impact of the various adiponectin isoformsin vascular tissue under clinically relevant in vitro conditions (coldstorage).Methods: Presence of various adiponectin isoforms in vascularsmooth muscle cells and their regulation during cold storage wasevaluated by PCR, western blot, ELISA and immunohistochemistry.Impact of the various isoforms for vessel preservation was assessedusing isometric force measurement as an in vitro assay for vascularfunction. Results: Adiponectin is expressed in smoothmuscle cells frommurine aortae and human saphenous veins. Following two days of coldstorage adiponectin mRNA expression in mouse aorta is reduced, whichappears to be regulated indirectly by miR-292-3p. Despite the reducedmRNA expression, adiponectin accumulated in cold storage supernatantover two days indicating a net release of adiponectin. Two days coldstorage resulted in an impairment of endothelium-dependent relaxa-tion which was prevented by addition of full-length adiponectin inconcentrations similar to normal plasma levels during storage. Incontrast, addition of recombinant adiponectin which is unable toform high order multimers failed to improve vessel function. Highconcentrations (20 µg/mL) of this trimeric isoform even reduced the

vasorelaxation response and facilitated uncoupling of endothelial nitricoxide synthase. Conclusions: Endothelial injury by cold storage maypartly be prevented by addition of high molecular weight adiponectin.This effect may support graft patency to avoid coagulation- and athero-sclerosis-associated impairment of perfusion.

SC130Expression of the Hippo effectors YAP and TAZin valvular interstitial cells from porcine aorticvalvesWitt W.1, Selle A.1, Jannasch A.1, Matschke K.1, Waldow T.11TU Dresden, Herzzentrum, Dresden, Germany

Objectives: YAP and TAZ, the effectors of the Hippo signalling kinasecassette, are activators or inhibitors of several transcription factors likeTEAD, Runx2, SMADs, and PPAR. Recent investigations have shown thatthese transcription cofactors are involved in coupling upstream eventslike activation of G-protein-coupled receptors (GPCRs), cell density andsize, stiffness of the matrix, with cellular responses like growth,differentiation, and apoptosis. Expression and functions of the Hippopathway have not yet been analyzed in heart valves. In this in vitroinvestigation, expression and potential roles of YAP and TAZ in celldifferentiation were analyzed using valvular interstitial cells (VICs), thefibroblastic cell fraction from aortic valves.Methods: VICs from porcineaortic valves were cultured in DMEM/fcs on standard cell culturesurfaces or on soft gels with defined elasticity moduli of 4 to 25 kPa.Proteins were analyzed by Western blotting, and mRNAs were quanti-fied by real time PCR. Nuclear and cytoplasmic cell fractions wereseparated by a standard procedure using passage through a sucrosecushion. Results: YAP and TAZ are expressed in VICs from aortic valves.A screen for inhibitory compounds based on literature data showed thatonly verteporfin resulted in a block of expression at a reasonableconcentration of 5 µM. Only 5HT and sphingosine-1-phosphate exertedmoderate (2fold) increase of YAP and TAZ expression in a screen of GPCReffectors. In contrast, pronounced effects were observed in relation tomechanical cues. Expression of TAZwas low in VICs growing on soft gelswith an elastic modulus close to the stiffness of the extracellular matrixin healthy valves (8 kPa), whereas a 16fold increase of expression wasobserved at the stiffness of fibrotic valve tissue (25 kPa). Especially theactive, non-phosphorylated formof TAZ in nucleiwas affected bymatrixstiffness, and TAZ abundance in nuclei was correlated with markers ofosteoblastic differentiation. Accordingly, culture of VICs in an osteogenicmedium resulted in induction of TAZ expression. Conclusion: Theresults suggest that Hippo signalling may be involves in the mechanismof osteoblastic differentiation of valve interstitial cells. Further studiesare warranted to evaluate the role of this pathway in valve calcification.

SC131Interleukin 33 as a mechanically responsivecytokine secreted by living cellsKakkar R.1,2, Hei H.1, Dobner S.1,3, Reichenspurner H.3, Lee R.T.11Harvard Stem Cell Institute and the CardiovascularDivision, Department of Medicine, Brigham and Women'sHospital and Harvard Medical School, Cambridge, UnitedStates, 2Division of Cardiology, Massachusetts GeneralHospital, Boston, United States, 3UniversitäresHerzzentrum Hamburg, Klinik und Poliklinik für Herz- undGefäßchirurgie, Hamburg, Germany

Background: Interleukin 33 (IL-33), a member of the Interleukin 1cytokine family, is implicated in numerous human inflammatory dis-eases such as asthma, atherosclerosis and rheumatoid arthritis. Despiteits pathophysiologic importance, fundamental questions regarding thebasic biology of IL-33 remain. Nuclear localization and lack of an exportsignal sequence are consistent with the view of IL-33 as a nuclear factorwith the ability to repress RNA transcription. However, signaling via thetransmembrane receptor ST2 and documented caspase-dependentinactivation have suggested IL-33 is liberated during cellular necrosisto effect paracrine signaling. Methods and results: We determined thesub-cellular localization of IL-33 and tracked its intracellular mobilityand extracellular release. In contrast to published data, IL-33 localized


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simultaneously to nuclear euchromatin and membrane-bound cyto-plasmic vesicles. Fluorescent pulse-chase fate-tracking documenteddynamic nucleocytoplasmic flux, which was dependent on nuclearpore complex function. In murine fibroblasts in vitro and in vivo,mechanical strain induced IL-33 secretion in the absence of cellularnecrosis. Conclusions: These data document IL-33's dynamic inter-organelle trafficking and release during biomechanical overload. Assuch we recharacterize IL-33 as both an inflammatory as well asmechanically responsive cytokine secreted by living cells.

SC132Does human myocardium show a genderdependent modification of oxidative stressparameters?Buschmann K.1, Gramlich Y.2, Oelze M.2, Daiber A.2, MünzelT.2, Vahl C.F.11Universitätsmedizin Mainz, Herz-, Thorax- undGefäßchirurgie, Mainz, Germany, 2UniversitätsmedizinMainz, 2. Medizinische Klinik und Poliklinik, Mainz,Germany

Objectives: The number of women suffering from Coronary ArteryDisease (CAD) and undergoing Coronary Artery Bypass Grafting (CABG)is rising. Gender dependent morpho-physiological alterations of themyocardial texture are well-known. This study was performed as anattempt to proof gender dependent modifications of oxidative stressparameters inmyocardium of CABG patients (women postmenopausal).Methods: From 60 subsequent CABG patients (male: n¼42; female:n¼18) we harvested excessive, right atrial myocardial tissue emergingfrom operative connection to extracorporeal circulation. In myocardialtissue we looked for altered levels of reactive oxygen species (Ethidiumund 2-HE) via HPLC. ALDH-2 activity was assessed by HPLC using themitochondrial fraction and monal 62 as a fluorescent substrate. ROSformation was detected via high performance liquid chromatography(HPLC). Mean values of superoxide concentrations and antioxidantenzyme expression in women were compared with men. For Statisticalanalysis the Mann-Whitney-U-test was used. Results: In myocardiumout of female CAD patients superoxide levels were increased versus inmale myocardium (p¼0.02). Resulting in functional enzymatic changesthe ALDH2 activity showed the trend to be higher inmale than in femaleCAD patients, but there was no significant difference.

Table 1: Statistical analysis

Statistik für Test�

HE ETHID Monal

Mann-Whitney-U 234,000 242,000 109,000

Wilcoxon-W 1137,000 1145,000 340,000

Z -2,323 -2,194 -,636

Asymptotische Signifikanz (2-seitig) ,020 ,028 ,525

Exakte Signifikanz [2�(1-seitig 8lg.)] ,542�

a. Nicht für Bindungen korrigiert

b. Gruppenvariable: Sex

Conclusion: The present data provide clear evidence, that the biochem-ical pathways related with oxidative stress are significantly differentbetween male and female tissue. Currently the data do not allow todecide, whether this dramatic difference is only typical for myocardialdisease or whether a gender specific phenotypewas detected that holdstrue for normal patients.

SC133Dedifferentiation of adult cardiomyocytesserves as a mechanism of cardiac regenerationRichter M.H.1, Polyakova V.1,2, Pöling J.3, Kubin T.2,Warnecke H.3, Braun T.2, Walther T.11Kerckhoff-Clinic, Department of Cardiac Surgery, BadNauheim, Germany, 2Max-Planck Institute for Heart andLung Research, Bad Nauheim, Germany, 3Schüchtermann-Clinic, Department of Cardiac Surgery, Bad Rothenfelde,Germany

Objectives: Heart transplantation is the only curative option in patientswith end-stageheart failure (HF). The explanted hearts are an importantsource of information concerning regenerative abilities of the myocar-dium. One of the known but yet not well studied types of cardiacregeneration is the dedifferentiation of cardiomyocytes (CM). Moreknowledge in this field could open new diagnostic and therapeuticapproaches. Material and methods: To analyze different aspects of CMdedifferentiation we studied heart explants of patients with ischemiccardiomyopathy (ICM), dilated cardiomyopathy (DCM) and myocarditis(Myo). In addition mouse models of myocardial infarction (MI) andinflammatory cardiomyopathy (MCP1-mice), hearts of neonatal miceand rats as well as cell cultured mouse CM were examined. Results:Dedifferentiation is a re-expression of one or several fetal cardiacproteins in adult CM under different stress conditions to improve thesurvival of CM. We examined more than ten markers of CM dedifferen-tiation and revealed that smoothmuscle actin (SMA) and smoothmuscleactinin (SMact) are the most reliable among them, since they werepresent and most widespread in all examined types of cardiac patholo-gy. The number of dedifferentiated CM was significantly upregulated inmyocardium of all patients with cardiac diseases and in both mousemodels in comparison to appropriate control groups. Moreover wefound that dedifferentiated CM showed a certain expression-patternwith an increased incidence of SMact-positive CM in acute phases of MI.This pattern changed into an enhanced expression of SMA during latephases of MI as well as in chronic inflammation represented by MCP1-mice. Mouse CM displayed the same dedifferentiation pattern in vitro:SMact expression was followed by the appearance of SMA in long-termcell culture. After detailed analysis of rodent hearts we observed thatdedifferentiated CM were not only present in embryonic but also inneonatal myocardium. In addition we revealed that the sequence ofdedifferentiation markers expression in the postnatal period was re-verse to that found in stress conditions. A visible SMA appears in CMalready in 3-days old mice and rats, while SMact-positive CM first arisein 14-days old rodents. Conclusion: Dedifferentiation of adult CM is asign of return to a postnatal state of ontogenesis within the cardiomyo-cyte lineage and may serve as a mechanism of regeneration underpathological conditions.

SC134Enhanced Ca2þ influx through cardiac L-typeCa2þ channels maintains the systolic Ca2þtransient in early cardiac atrophy induced bymechanical unloadingBiermann D.1, Bernhardt A.2, Neef S.3, Broichhausen I.3,Jacubeit J.3, Didié M.4, Zimmermann W.-H.4, Sachweh J.S.2,Reichenspurner H.1, El-Armouche A.4, Ehmke H.3,Schwoerer A.P.31Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Herzchirurgie für angeboreneHerzfehler, Hamburg, Germany, 3UniversitätsklinikumHamburg-Eppendorf, Institut für Zelluläre und IntegrativePhysiologie, Hamburg, Germany, 4UniversitätsmedizinGöttingen, Institut für Pharmakologie, Göttingen, Germany

Introduction: Cardiac atrophy as a consequence of mechanical unload-ing develops following exposure to microgravity or prolonged bed rest.It also plays a central role in the reverse remodelling induced by leftventricular unloading in patients with heart failure. Surprisingly, theintracellular Ca2þ transients which are pivotal to electromechanicalcoupling and to cardiac plasticity were repeatedly found to remainunaffected in early cardiac atrophy. Methods: To elucidate the


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mechanisms underlying the preservation of the Ca2þ transients, weinvestigated Ca2þ cycling in cardiomyocytes from mechanically un-loaded (heterotopic abdominal heart transplantation) and control (or-thotopic) hearts in syngeneic Lewis rats. Results: Following 2 weeks ofunloading, sarcoplasmic reticulum (SR) Ca2þ content was reduced by�55%. Atrophic cardiac myocytes also showed a much lower frequencyof spontaneous diastolic Ca2þ sparks and a diminished systolic Ca2þ

release, even though the expression of ryanodine receptors was in-creased by �30%. In contrast, current clamp recordings revealed pro-longed action potentials in endocardial as well as epicardial myocyteswhich were associated with a two to fourfold higher sarcolemmal Ca2þ

influx under action potential clamp. In addition, Cav1.2 subunits whichform the pore of L-type Ca2þ channels (LTCC) were upregulated inatrophic myocardium. Conclusion: These data suggest that in earlycardiac atrophy induced by mechanical unloading, an augmentedsarcolemmal Ca2þ influx through LTCC fully compensates for a reducedsystolic SR Ca2þ release to preserve the Ca2þ transient. This interplayinvolves an electrophysiological remodelling as well as changes in theexpression of cardiac ion channels.

SC135Clopidogrel preserves microvascular integrityin orthotopic tracheal transplants affected byobliterative bronchiolitisHeim C.1, Khan M.A.2, Motsch B.1, Müller S.1, StammingerT.3, Nicolls M.R.2, Weyand M.1, Ensminger S.M.1,41Universität Erlangen-Nürnberg, Herzchirurgie, Erlangen,Germany, 2Veterans Affairs Palo Alto, Stanford University,Stanford, United States, 3Universität Erlangen-Nürnberg,Virologie, Erlangen, Germany, 4Herz- und DiabeteszentrumNRW, Bad Oeynhausen, Germany

Introduction: Survival after lung transplantation is mainly limited bythe development of chronic lung allograft dysfunction (CLAD). The aimof this studywas to investigate if platelet inhibition by clopidogrel has aninfluence on themicrovascular integrity of orthotopic tracheal allograftsand the formation of obliterative bronchiolitis, present in themajority ofpatients suffering from CLAD. Methods: C57Bl/6 (H2b) donor tracheaswere orthotopically transplanted into CBA. J (H2k) recipients. Micereceived clopidogrel alone or in combination with everolimus. Graftswere analyzed by serial tissue PO2 monitoring by a fluorescencequenching technique. Blood flow monitoring was performed by laserDoppler flowmetry and a Lectin-binding assay to analyze the function ofthe microvasculature on postoperative days 4, 10 and 30. Results:Isografts showed a stable tissue PO2 and blood flow during the initialtimepoints after transplantations. In contrast, allografts showed asteady decline in tissue PO2 and blood flow in rejecting airway allograftsuntil the PO2 nadirs 10-12 days after transplantation. Continous ad-ministration of clopidogrel (Clopi) or Everolimus (Evero) alone and incombination (EC) significantly improved tissue oxygenation, limitedmicrovascular leakiness, and prevented airway ischemia (Fig. 1).

Fig. 1

Conclusions: These data demonstrate that clopidogrel alone and incombination with everolimus ameliorates microvascular injury duringacute airway rejection and subsequently reduces post-transplant oblit-erative bronchiolitis.

SC136Do we need another inflammation marker incardiac surgery?Maurus M.1, Liewald C.1, Gorki H.1, HönickaM.1, Liebold A.11Ulm University Medical Centre, Department ofCardiothoracic and Vascular Surgery, Ulm, Germany

Objectives: The inflammatory status following cardiac surgery is trig-gered by the release of vasodilating effector molecules such as kynur-enine (KYN), which is formed from the amino acid tryptophanmediatedby the enzyme indolamine-2,3-dioxygenase (IDO). KYN blood levelsindicate IDO activity and can be quantified by a simple colorimetric test.In contrast, commonly used proinflammatory cytokines must be deter-mined using ELISA technique. We investigated the time course of KYNduring and after cardiac bypass surgery to evaluate it as an early markerof inflammation in comparison to established inflammatory markers.Methods: This pilot study included 12 patients undergoing coronarybypass surgery with conventional extracorporeal circulation. Bloodsamples were taken 24 h before surgery, at the beginning of anaesthesia,seven times during surgery, at the arrival on ICU, and 12, 24, and 48 hafter arrival. Leukocytes, CRP, ICAM-1, P-selectin, TNF-alpha and KYNweremeasured at all points of time. All blood valueswere normalised tohaematocrit. Results: KYN concentrations were significantly increasedat 12, 24, and 48 h after arrival on ICU compared to preoperative values(p<0.001). In 4/12 patients KYN levels increased transiently afterreleasing the cross-clamp. Of the traditional markers leukocytes peakedearliest at 3 h after onset of anaesthesia (p<0.001) followed by TNF-alpha at ICU arrival (p<0.001). CRP and ICAM-1 rose significantly abovebaseline (p<0.001) starting at 12 and 24 h after ICU arrival, respectively.P-selectin levels showed no statistically relevant changes. Conclusion:Serum levels of kynurenine indicating IDO activity can be used as a newinflammation marker following cardiac surgery. Individual early re-sponse to intraprocedural maneuvers in a subset of patients, which wasnot seen in established markers, needs to be clarified. Knowing KYNtime course, next step would be testing its kinetics under differentperfusion conditions. Quantification of KYN is cheaper and faster thanconventional ELISA-based assays of inflammationmarkers andmay thusbe preferable to established markers.


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SC137Microvascular integrity plays a role in graftsurvival after skin transplantationHeim C.1, Motsch B.1, Koch N.1, Ramsperger-Gleixner M.1,Weyand M.1, Ensminger S.M.1,21Universität Erlangen-Nürnberg, Herzchirurgie, Erlangen,Germany, 2Herz- und Diabeteszentrum NRW, BadOeynhausen, Germany

Introduction: Every transplanted organ relies on a reliable and soundvascular system. Therefore, our study focused on the investigation ifplatelet inhibition alone or combined with mTOR-inhibition has abeneficial effect on the microvascular integrity in murine skin grafts.Methods: The skin of fully MHC-mismatched C57 BL/6 (H2(b)) donorswas transplanted into CBA Jri (H2(k)) mice. The animals were divided inseveral groups and according to their group treated with Clopidogrel,Everolimus or both. Grafts were harvested after 8 days and analyzed byimmunohistology. For this purpose the frozen sectionswere taggedwithanti-CD31 and anti-C4d, respectively. Results: Untreated allograftsdisplayed in comparison to isografts a reduced amount of CD31 onpostoperative day 8 as well as an increase in C4d. All treated animalsshowed a significant improvement regarding CD31 [1748,78 � 155,71(Clopidogrel) / 1702,83 � 151,13 (Clopidogrel þ Everolimus) vs. 479,68� 184,17 (control), n¼8, p<0,05] and c4d [248,86 � 54,73 (Clopidog-rel) / 324,45 � 77,31 (Clopidogrel þ Everolimus) vs. 772,40 � 159,72(control), n¼8, p<0,05]. The skin grafts of animals treated withClopidogrel and Everolimus survived significantly longer than untreatedcontrols [19.2 � 4.2 d vs. 12.8 � 2.4, n¼10, p<0.05]. Conclusions:Clopidogrel alone and in combination with Everolimus substantiallyimproved the microvascular integrity and resulted in extended skingraft survival.

SC138Matrix Metalloproteinase-9 Promoterpolymorphism in primary spontaneouspneumothoraxBaalash A.1,2, Ibrahim B.31Faculty of Medicine, KFMC, Medical Biochemistry, Riyadh,Saudi Arabia, 2Tanta University- Faculty of Medicine,Medical Biochemistry, Tanta, Egypt, 3Tanta University-Faculty of Medicine, Cardiothoracic Surgery, Tanta, Egypt

Primary spontaneous pneumothorax (PSP) is a common clinical prob-lem occurring in apparently healthy subjects. However emphysema likechanges (ELC) in patients with (PSP) has been demonstrated, which isassociated with the degradation of extracellular matrix (ECM). MMP-9has been proposed to play a role in the development of emphysema andis involved in the digestion of (ECM). Among several polymorphicchanges reported in MMP-9 regulatory region, the C-1562T polymor-phism increases its promoter activity. Aim: To test the hypothesis thatthe MMP-9 C-1562T polymorphism has a role in the occurrence of PSP.Subjects andMethods:MMP-9 (C-1562T) genotypes of 104 PSP patientsand 97 healthy subjects (control) were determined by the polymerasechain reaction, followed by a restriction fragment length polymorphismanalysis. Results: This study showed that the genotype frequency forMMP-9 1562 C >T differed significantly between healthy individualsand PSP patients, with higher T allele in MMP-9 promoter in PSPpatients, and the C/T þ T/T genotypes significantly modified the riskof developing PSP, and were associated with increased risk for PSP.Conclusion: MMP-9-1562C/T genotype may be a potentially indicativefactor for susceptibility to PSP, that is, genotypes with the T allelesignificantly increase the risk of development of PSP.

SC139Correlation of DNA, LPS-binding-protein andCD14 of periodontal microbes and cardiactissue-preliminary resultsDanner B.C.1, Ziebolz D.2, Rost C.2, Schmidt J.2, Waldmann-Beushausen R.1, Jahn C.2, Semper E.2, Mausberg R.F.2,Schöndube F.A.11Universitätsmedizin Göttingen, Dept. of Cardiothoracicand Vascular Surgery, Göttingen, Germany,2Universitätsmedizin Göttingen, Dept. of PreventiveDentistry, Periodontology and Cariology, Göttingen,Germany

Objective: Periodontitis is common as well as cardiac disease. Coinci-dental or casual correlation of these diseases is a pivotal question. In anexperimental setting we evaluated methods to detect correlations ofperiodontal disease and effect on cardiac tissue. Methods: Out of 10patients with more than 6 teeth a complete dental and periodontalstatus with oral microbiological testing and removal of tissue specimenwhile cardiac operation (left ventricle, right atriumand aortic valve)wasperformed. The detection of 11 periodontal pathogens in the oral andheart samples was carried out with PCR. The heart samples wereprepared for detecting LPS-binding protein (Western Blot), sections oftissue for inflammation scoring by H&E staining (score 0-3), and fordetermining immunohistochemical parameters: macrophages (CD68),LPS-binding protein (big42) and LPS-binding protein-receptor (CD14).Results: All 10 patients had aortic valve disease and 5 had concomitantcoronary heart disease. 6 were male and mean age was 69 years.Periodontitis was severe in 7, moderate in 2 and mild in 1 patient.Finding of microbial DNAwas high (>70%) in oral periodontal specimenand decreased in cardiac tissue (atrium of 10-40%; in ventricle 10-20%and valve 0-20%). IHC revealed high inflammation scores in all cardiactissue specimens, and big42, CD14 and CD68 immuno-staining showedhigher scores in atrial tissue than in ventricle. Conclusions: IHC,western-blot and DNA-PCR findings showed a relationship and occur-rence of periodontal microbial affection in cardiac tissue with subse-quent immunoreaction by high LPS reaction and macrophageinfiltration. We suspect a casual correlation of periodontal and cardiacdisease, and further investigations are initiated to verify this hypothesis.

Heart valve disease II: Mitral and tricuspid

SC140Posterior annulus shortening increases leafletcoaptation in ischemic mitral incompetence: anew and valid techniqueDelmo Walter E.M.1, Amiri A.1, Solowjowa N.2, SiniawskiH.3, Hetzer R.31Deutsches Herzzentrum Berlin, Department ofCardiovascular and Thoracic Surgery, Berlin, Germany,2Deutsches Herzzentrum Berlin, Berlin, Germany,3Deutsches Herzzentrum Berlin, Herz-,Thorax-u.Gefäßchirurgie, Berlin, Germany

Objective: We introduce a valid concept and strategy of a posteriorannulus shortening to augment leaflet coaptation which addresses therestrictivemitral leafletmobility in ischemicmitral incompetence (IMI),and report its long-term outcome. Patients and methods: The tech-nique consists of posterior annulus shortening reducing the annulardiameter between 23 and 25 mm and decreasing its orifice to between3.5 to 4.5 cm2. This size is sufficient to ensure an adequate leafletcoaptation area. The shortened annulus is reinforced by an untreatedautologous pericardial strip to avoid redilatation. This augments theposterior leaflet by increasing the ratio of leaflet area/valve orificewhere the gap in coaptation is the greatest. The areawhich the posteriorleaflet offers to the anterior leaflet for coaptation during closure isincreased and heightened by the tissue strip, making valve closurepossible even in advanced leaflet restriction. Results: Between 1992 and2012, 75 patients (mean age 64.56 � 10.37, median 66.0, range 35.0-86.1, years) underwent posterior annulus shortening to augment leafletcoaptation surface area in repair of ischemic MI. At a mean follow-up of7.62 � 0.66 ((median 8.53, range 3.6-20.9) years, NYHA functional class


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significantly improved, LVEFF increased and there was a tremendousabatement of MI (p<0.01). Annular area was reduced from 9.2 cm2 to5.8 cm2. From a complete absence of coaptation area, it was increased to6.6 mm after the repair. CT showed posterior annulus size reductionfrom 70.4 mm to 64 mm and an increase in posterior leaflet length from15.92 to 19.6 mm. A most remarkable CT finding was the increase incoaptation length from 5.2 to 8.2 mm. Freedom from reoperation was97.3� 1.9.%, 95.3� 2.7% and 86.4� 5.6%, and survival rates were 84.9�4.2%, 71.9� 5.5%, and 65.1� 6.3% at 30 days, 1 and 18 years, respectively.Freedom from moderate or greater MI is 80.7 � 9% at 10 years.Conclusion: Posterior shortening annuloplasty with pericardial stripaugmentation addressing the lack of leaflet coaptation, is a simple,reproducible and highly effective repair technique to restore valvecompetence in ischemic MI.

SC141Mitral valve and left ventricular reverseremodeling after surgical repair of submitralleft ventricular aneurysms assessed with multi-slice computed tomographySolowjowa N.1, Penkalla A.1, Dandel M.1, Pasic M.1, WengY.1, Hetzer R.1, Knosalla C.11Deutsches Herzzentrum Berlin, Department ofCardiothoracic and Vascular Surgery, Berlin, Germany

Objectives: Surgical repair of submitral aneurysms may present atechnical challenge especially if the mitral valve (MV) apparatus isinvolved. We present the single center surgical experience with thepotential of multi-slice computed tomography (MSCT) in assessment ofMVand LVgeometry and aneurysmmorphology.Methods: Between 05/06 and 08/13, 24 patients (m:w¼20:4, ages 38-78, mean 62.3 years;mean NYHA class 2.91) with submitral LV aneurysm were operatedupon. Echocardiography and MSCT were performed before and a shorttime after surgery. LV and aneurysm end-diastolic/end-systolic volumewere measured and indexed to body surface area (LV-EDVI/LV-ESVI, A-EDVI/A-ESVI, respectively). LV ejection fraction (LVEF), cardiac output(CO) and cardiac index (CI) were calculated on the basis of MSCT data.MV geometry was characterized by intercommissural and anteropos-terior MV annulus diameter (ICD and APD respectively), MV annulusarea (MVAA), coaptation distance (CD), tenting area (TA), MV closureangle (MVCA), interpapillary muscle distance (IMD) and coaptation-to-septum distance (CSD). Results: Thirty-day and 5-year survival was91.3% and 78.3%, respectively. Aneurysms were prevalently localized inmyocardial segments 4/10/11. Preoperative A-EDVI showed a slightsystolic increase, demonstrating adverse volume shift during systole(70.6� 20.9 to 75.5� 21.4 ml/sqm, p¼0.001). There were reductions ofLV-EDVI (160.9 � 21.6 to 86.5 � 7.8 ml/sqm, p¼ 0.002) and LV-ESVI(121.4 � 26.3 to 51.2 � 6.4.9 ml/sqm, p¼0.006) and LVEF improvement(29.9� 4.2% to 42.5 � 3.1%, p¼0.001) after surgical repair. Mitral repairand replacement was necessary in three patients in each case. Postop-erative reduction of mitral regurgitation in the remaining 17 patients(1.26 � 0.23° to 0.21 � 0.08°, p¼0.000) corresponded with improve-ment of MV geometry (ICD 38.8 � 1.4 mm to 35.0 � 1.6, p¼003, APD24.9� 1.3 to 23.0� 1.1mm, p¼0.103, MVAA 8.8� 0.5 to 8.1� 0.5 sqcm,p¼0.011, CD 10.0 � 0.5 to 7.9 � 0.5, p¼0,006, TA 1.8 � 0.1 to 1.5 � 0.1sqcm, p¼0.022, MVCA 104 � 3.6° to 114.5 � 2.2°, p¼0.015) andreduction in MV tethering (IMD 35.18 � 1.88 to 28.23 � 0.98,p¼0.000, CSD 31.9� 1.4 to 28.7� 1.7, p¼0.012). Conclusions: Surgicalreconstruction of submitral LV aneurysms can be performed with goodmid-term results. Advantages of MSCT, with possibilities to analyze thecoherence of ventricular remodeling and subtle geometrical changes inmitral valve apparatus, make it a useful tool for analysis and planning ofsurgical restoration approaches.

SC142Severity score for mitral valve repair in activestage infective endocarditisOmoto T.1, Aoki A.1, Maruta K.1, Sakurai S.1, Iizuka H.1,Kawaura H.11Showa Universität, Herzchirurgie, Tokio, Japan

Objective: While the feasibility of MV repair in the healed stage of IE isreasonably high, repair in active stage IE associated with extensiveleaflet lesion requires complex valve procedures, which may result inrecurrent mitral regurgitation (MR) or re-operation in the long term.Our objectivewas to identify the predictive capability and cutoff value ofintraoperative assessment of severity score for MV repair for patientswith active stage IE. Methods: From July 2005 to September 2013, 29patients (55.1 � 16.0 year old, male:female¼21:8) underwent MVoperation for active stage IE in our institute. We have defined severityscore of the MV destruction according to intraoperative assessment ofleaflet destruction, as 2 points for A1,A2, and A3 lesions, and 1 point forP1,P2,P3, and both commissure lesions. Patients with feasibility for MVrepair (group F) were comparedwith thosewithout (group non-F). Totalscore was calculated and associations between severity score andfeasibility of MV repair were evaluated. Results: MV repair was per-formed in 20/29 patients, and 3/20 underwent redoMVoperation due torecurrence of MR less than one year after the operation, so that MVrepair was considered to have been feasible in 17/29 patients (58.6%,group F). Surgical techniques of MV repair was leaflet resection (LR,n¼5), LRþartificial chordae replacement (ACR) or autologous patchreconstruction (APR) (n¼6), and LRþACRþAPR (n¼9). There was nohospital mortality in both groups. Two patients who underwentLRþACRþAPR have developed recurrent MR, and required redo MVoperation. Between Group F and patients without MV feasibility (Groupnon-F, n¼12), cardiopulmonary bypass time (156.4� 39.9min vs.158.1� 50.7 min, respectively) and aortic cross clamping time (120.8 � 63.5min 122.4 � 48.0 min, respectively) were similar. However, severityscore was higher in group non-F than in group F (4.5 � 1.1 points vs. 3.1� 1.0 points, p¼0.021). Using cutoff value was set as 4.0 points withsensitivity of 58.8% and specificity of 91.7%. Concomitant aortic valveoperationwas performedmore in group non-F than in group F (50.0% vs.11.7%, p¼0.023). Severity score of patients with concomitant aorticvalve operation was 4.8 � 1.1 points. Conclusions: Use of a cutoffseverity score predictive of feasibility of MV repair could help to guidethe intraoperative decision between MV repair and MV replacement inactive stage IE.

SC143Simplified minimally-invasive technique forsafe isolated tricuspid re-do surgeryFärber G.1, Kirov H.1, Diab M.1, Doenst T.11Jena University Hospital - Friedrich-Schiller-University ofJena, Department of Cardiothoracic Surgery, Jena, Germany

Objectives: Isolated tricuspid valve surgery is still considered a high riskprocedure with perioperative mortality rates of up to 30%. Recentreports describe minimally invasive approaches with improved out-comes. However, total cardiopulmonary bypass (CPB) with occlusion ofthe caval veins is still standard for accessing the tricuspid valve, arequirement that may be technically challenging in redo cases. Wereport a minimally-invasive technique and its outcomes for isolatedtricuspid valve redo-surgery on partial CPB with the heart beating.Methods: From April 2011 to June 2013, 8 patients with severe isolatedtricuspid regurgitation and previous cardiac surgery for various reasonsunderwent tricuspid repair (n¼7) or replacement (n¼1). CPB wasestablished percutaneously through groin cannulation. The only thorac-ic incision was a 5 cm anterolateral minithoracotomy. The pericardiumcovering the right atriumwas exposed. The principle of the procedure isa relatively anterior atriotomy and the creation of a “right atrialreservoir” allowing exposure of the tricuspid valve and adequate venousdrainage despite the lackof caval occlusion. Specifically, the pericardiumis incised together with the wall of the right atrium. Exposition suturesare placed on the upper rim of the incision and the table is slightly tiltedto the right. Results: The procedures were performed successfully in all8 patients. Postoperatively, therewas no bleeding that required revision.There was no evidence for hemolysis. There was no new stroke. One


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patient with recurrent preoperative strokes suffered from temporarydelirium. One patient required re-intubation for pneumonia. Impor-tantly, there was no adverse event that could be related to the use ofpartial CPB and there was no mortality. Conclusion: Performing tricus-pid valve surgery as reoperation without caval occlusion and on thebeating heart significantly facilitates surgical access to the tricuspidvalve. The procedure is safe and allows performing both repair andreplacement.

SC144Midterm outcomes ofminimally invasivemitralvalve surgeryReser D.1, Pavicevic J.1, TolboomH.1, Seifert B.2, SündermannS.1, Jacobs S.1, Falk V.11Unversity Hospital Zurich, Clinic for CardiovascularSurgery, Zurich, Switzerland, 2University of Zurich, Divisionof Biostatistics, Zurich, Switzerland

Objectives: Minimally invasive valve surgery has gained widespreadacceptance in cardiac surgery. At our institution we use video assistedminimally invasive mitral valve surgery (MIMVS) as a standard ap-proach in isolated mitral valve disease. Our aim was to examine theoutcomes of our patients. Methods: We conducted a retrospectivedatabase review of all patients undergoing MIMVS through a rightlateral mini-thoracotomy between January 1st 2009 and December31st 2012. Results: We identified a total of 312 consecutive patients.Mean agewas 60� 13 years, median Euroscore 4 (1-12). Therewere 202men in the group (64.7%). Mean length of operation was 3.4 hours (�1.1), CPB time 148.3 � 43 minutes and aortic cross clamp time 94 � 29minutes. In 279 patients (89.4%) the mitral valve was successfullyrepaired, 33 patients (10.6%) received a prosthesis. Additional proce-dures included left atrial cryoablation in 68 patients (21.8%), tricuspidvalve repair in 12 (3.8%) and closure of a patent foramen ovale on 30(9.6%). 8 patients (2.8%) had to be converted to median sternotomy.Median ventilation time was 6.8 hours (0-460), ICU stay 1 day (0-96).Four patients had a wound infection (1.3%). One patient died in hospitaldue to ARDS (0.3%) and five suffered a stroke (1.6%). For 287 patients(92%) Follow-Up was complete for a median of 22 months (0-53) with96.5% � 0.1 survival, 97.8% � 0.1 major adverse cardiac and cerebrovas-cular event (MACCE)-free survival and 94.6% � 0.1 freedom of reopera-tion. Conclusion: Our data suggest that MIMVS is a safe and durableapproach that allows a high rate of successful repair and results withgood short- and mid-term event-free survival.

SC145Functional assessment of different mitral valverepair philosophies in Carpentier type IIposterior leaflet prolapse: Shouldwe respect orresect?Grapow M.1, Winkler B.1, Bergner M.2, Matt P.1, Rüter F.1,Reuthebuch O.1, Eckstein F.11University Hospital Basel, Cardiovascular Surgery, Basel,Switzerland, 2University Hospital Basel, Cardiology, Basel,Switzerland

Introduction: In Western countries Carpentier type II prolapse of theposterior leaflet is the most common pathology of mitral valve disease.Recently Perrier introduced a new technique with posterior leafletovercorrection using neochords in combination with annuloplasty,which simplifies repair with potential impact on education of residents.Aim of our study was to compare this method (overcorrection-group,OG) with the standard repair technique introduced by Carpentier(control-group, CG) regarding safety defined by functional outcome.Patients and methods: From 11/2011 to 01/2013 40 patients wereoperated using both techniques (CG n¼20; OG n¼20) for Carpentiertype II regurgitation but with isolated posterior leaflet prolapse. Com-bined surgery like CABG, AVR, TVR and cryoablation was performed in10 patients (25%). 11 female patients (22.5%) and 16 patients (35%) withminimally-invasive anterolateral approach were included. Transthorac-ic and transesophageal echocardiography were used for analysis ofmitral valve morphology, mobility and hemodynamic parameters peri-operatively and at discharge. Results: Mean annuloplasty ring size was

around one size larger in the control- compared to the overcorrection-group (33.4� 2.3 vs.31.3� 3.3, n.s.). No differences for leafletmobility ofthe posterior leaflet were observed. Mean pressure gradients in theovercorrection-group were lower by trend without reaching statisticalsignificance (3.4 � 1.2 vs. 4.5 � 2.0, n.s.). Length of coaptation betweenthe anterior and posterior leaflet was significantly enhanced in theovercorrection-group (9.1 � 1.8 vs. 6.8 � 1.6, p<0.01) Although allpatients were in the range between no, trace or mild regurgitation, asignificantly less regurgitation was noted in the overcorrection-group(p<0.005). Conclusion: Our study demonstrated non-inferiority of theovercorrection- compared to the standard-group after short-term func-tional analysis. The over-correction technique resulted in a significantlyenhanced length of coaptation, a generally accepted indirect marker oflong-term durability, without increasing the transvalvular gradient. Theease of this techniquemay lead to earlier application in resident trainingas well as increased minimal invasive access techniques.

SC146Surgical outcome of right-sided infectiveendocarditis (IE): Which patients for whichprocedure?Ballazhi F.1, Tandler R.1, Harig F.1, Feyrer R.1, KondruweitM.1, Seitz T.1, Strecker T.1, Weyand M.11Universität Erlangen-Nürnberg, Herzchirurgische Klinik,Erlangen, Germany

Objective: The goal of this retrospective study was to analyze thecurrent genesis and long-term surgical outcome of right-sided infectiveendocarditis (IE). Patients and methods: Between 2000 and 2012, 150patients underwent tricuspid valve (TV) surgery in our institution, 33 ofthese patients (27 male; mean age 60 years) were associated with IE. Atricuspid valve repair was performed in 24 (73%) patients and TV-replacement in 9 (27%). Pacemaker and ICD infections were mostcommon cause for right-sided IE (n¼18, 55%). Further, i.v. drug abuse(n¼3, 9%) was rare observed in our population than in previous studies.Staphylococcus aureus was the most common microorganism. Results:Four patients died in a period of 30 days, the IE of these patients wasprimarily a left-sided endocarditis. No mortality was noted in patientswith isolated tricuspid valve surgery. Mean follow up was 6 years. Thesurvival rate for all patients was 85%. Mean Follow up in patients withTV-replacement was 3,5 years with a survival rate of 77%. Mean followup in patients with TV-repair was 3,3 years with a survival of 95%. Inpatients with removal of vegetation and partially leaflets resectionwereprovided the best long term results, mostly used at young patients.These patients are alive for over 10 years without any clinical problemsor redo surgery. Conclusion: Right-sided IE is most frequently observedin patients with pacemakers or ICD. Surgical treatment of isolated TV-surgery in right-sided IE is associated with low mortality and lowrequirement of a postoperative pacemaker. A removal of vegetationand partially leaflets resection is particularly preferable in youngpatients with TV-IE.

SC147Simple technique of repair for Barlowsymdrome with minimally invasive approach;primary experience with 22 patientsKamiya H.1, Minol J.-P.1, Boeken U.1, Weinreich T.1,Gramsch-Zabel H.1, Akhyari P.1, Lichtenberg A.11Uni-Klinik Düsseldorf, Kardiovaskuläre Chirurgie,Düsseldorf, Germany

Objective: The Barlow syndrome defined as prolaps of the both leafletwith excessive tissue is sometimes difficult to repair. Here we presentour technique for surgical treatment of the Barlow syndrome withminimally invasive approach. Methods: At first, the whole mitral valveis inspected. Then, the P2-segment will be widely resected as triangularor quadrangular. The resected P2-segment will be trimmed leaving theshortest chordae, normally the basal chordae at the P2-segment. Thistrimmed P2-segment will be transferred to the A2-segment. For thischordal transfer, the trimmed P2-segment will be sutured onto the topof the A2-segment on the ventricular side. In cases of quadrangularresection of the P2-segment, the annulus will be locally plicated. Then,


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the resected margins will be sutured in a running fashion. If theposterior annulus is severe calcified, the whole posterior leaflet willbe detached from the annulus and annular decalcification will be done.Then, the P2-segment will be resected and chordal transfer will be doneas above described and the posterior leaflet will be reconstructed as thesliding plasty including suturing the resected margins and re-attach-ment of the whole posterior leaflet to the annulus. Thereafter, an openannuloplasty prosthesis (Medtronic Future-Band) will be implanted.Results: Between August 2009 and August 2013, 22 patients (11 males,mean age 56 years old) with the Barlow syndrome underwent video-assisted minimal-invasive mitral valve surgery via right mini-thoracot-omywith this technique. No residualmitral valve regurgitationwas seenin all patients. A slight systolic anterior motion (SAM) was seen in onlyone patient, which could be treated successfully with a β-blocker.Conversion to full sternotomy was necessary in one patient (4.5%)and due to injury of the circumflex artery. Early mortality was 0%.During follow-up, one patient died due to abdominal bleeding. Nopatients needed reoperation for reccurence. Conclusions: This tech-nique facilitates repair of Barlow syndrome with complex morphologyand is durable in midterm follow-up.

SC148Surgical technique does not influence the longterm mortality after tricuspid valve surgeryFelkel K.-W.1, Kampmann K.1, Hahnel F.1, ReichenspurnerH.1, Gulbins H.11Universitäres Herzzentrum Hamburg, Herzchirurgie,Hamburg, Germany

Objectives: In the current studywe focused on the question if predictorslike co-morbidities or the etiology of tricuspid valve disease as well asthe different surgical techniques of tricuspid valve reconstruction (deVega ring annuloraphy vs. tricuspid ring annuloplasty) as well as valvereplacement have influence on the long-termmortality over a period of6 years after intervention.Material andmethods: From2003 until 2010162 patients (54.8% female, mean age 69.5 � 10.3 years) underwenttricuspid valve reconstruction (TVR) due high grade functional tricuspidinsufficiency (TI). 92.6% of the patients received a TVR, in 7.4% (10patients) a reconstruction was not possible and a TV replacement wasperformed. 54.4% of patients treated with TVR underwent a de Vegaplastic while 45.6% received a ring annuloplasty. There were 6.7% withisolated TV interventions and 93.3% combinative interventions, mostlycoronary artery bypass (CABG) or mitral valve surgery. Data werecollected from the patients' files as well as from telephone contactmeanly 3.4 years after intervention. Results: The perioperative mortali-ty was 3.7%, long-term mortality was 28.9%. Predictors for poor longterm outcome were age (p¼ 0.002), diabetes mellitus II (p¼0.021),length of stay on an intensive care unit (p¼ 0.004), dialysis (p¼0.039),ventilation time (p¼0.033), preoperative NYHA classification(p¼0.004) and wound healing disorders (p¼0.015). The mean abilityof performance upgraded from 2.92 � 0.8 to 1.89 � 1.01. More malepatients underwent additional CABG (p¼0.024). The incidence ofendocarditis was also significantly higher for male patients(p¼0.030). Preoperative had 14.8% a sinus rhythm (SR), at discharge56%were in SR. The preoperative incidence of atrial fibrillation (AF) was85.2%, while only 40 patients (44%) were still in AF after intervention.The average survival time of the patients receiving a de Vega plastic was5.1 years, for ring annuloplasty 5.6 years, so there was no significantdifference in between both techniques. Conclusion:Despite thehigh riskcollective, tricuspid valve surgery is performedwith a low perioperativemortality of 3.7%, and is independent of the surgical techniques of repair.Incidence of AF as well as the NYHA classification improved afterintervention. With a long-term mortality after 6 years of 28.9%, bothtechniques achieved satisfactory results.

SC149Tricuspid valve surgery in high risk patients: Asingle institutional experience with thetechnique of minimally invasive surgery viaright mini-thoracotomyMinol J.-P.1, Boeken U.1, Weinreich T.1, Akhyari P.1,Gramsch-Zabel H.1, Kamiya H.1, Lichtenberg A.11Uni-Klinik Düsseldorf, Kardiovaskuläre Chirurgie,Düsseldorf, Germany

Objective: Isolated tricuspid valve surgery (TVS) is still a challenge.Despite improvements in perioperativemanagement, there is still a highmortality associated with TVS due to concomitant complications andnumerous re-do operations. Especially the often occurring right-heartfailure requires a postoperative care with extraordinary attention. Inthis study we sought to evaluate the early results of 25 patients havingreceived isolated tricuspid surgery with minimally-invasive access(MIC-procedure). Methods: Of the 361 MIC-Patients, 25 had isolatedtricuspid valve operations. (19 repairs, 6 replacements, repair rate 76%).Four patients (14%) have received cardiac operation before. Sevenpatients (28%) suffered active endocarditis at admission. A ring wasinserted in 11 cases. 10 patients received additional surgery such asremoval of infected leads, resection of atrial tumors or closure of atrialseptal defects. In-hospital mortality (30d) was 4% (1 of 25). This singlepatient received the surgical procedure as fourth operation on thetricuspid valve. Postoperative mortality was due to intracranial airembolism. Analysis of perioperative morbidity patients included reop-eration for bleeding (8%), stroke (none) and disturbance of woundhealing (none). Length of ICU - and hospital-stay were 2.0 � 1.2 dand 14.5 � 6.9 d. At follow-up (1 year), survival was 84%. Mean leftventricular ejection fraction remained unchanged (58.9 � 16.9% athospital discharge to 57.6 � 9.9% (p>0.05)). Conclusions: Right lateralmini-thoracotomy as routinely used access for mitral valve surgeryenabled us to realize very good results in high-risk patients undergoingtricuspid valve surgery. Even as cardiac re-operation this technique isfeasible for TVS.

SC150Mitral valve surgery; Right lateralminithoracotomy or sternotomy? A systematicreview and meta-analysisSündermann S.H.1, Sromicki J.1, Rodriguez Cetina Biefer H.1,Emmert M.Y.1, Seifert B.2, Holubec T.1, Falk V.1, Jacobs S.11Klinik für Herz- und Gefässchirurgie, Universitäts Spital,Zürich, Switzerland, 2Abteilung für Biostatistik, Institut fürSozial und Präventivmedizin, Universität, Zürich,Switzerland

Objective: To update the current evidence of mitral valve surgerythrough a lateral minithoracotomy versus median sternotomy.Methods:We performed a comprehensive literature research regardingstudies comparing mitral valve surgery through a right-lateral mini-thoracotomy and median sternotomy in MEDLINE, EMBASE, CochraneCentral, CTSnet and Google Scholar for the most recent literature up toApril 2013. From the studies found in the literature we performed asystematic review and meta-analysis. Endpoints were stroke and mor-tality up to 30-days and procedure and resource related outcomes.Results: 42 papers were found. Four included more then one studypopulation resulting in 46 studies that were analyzed. Stroke rate andall-cause mortality up to 30 days was similar in both groups. The lengthof stay in the ICU, respirator dependence and hospital stay weresignificantly shorter in the minimally invasive (MIVS)-group. Further-more, blood drainage volume and blood transfusions were decreased inthe MIVS-group. On the contrary cardiopulmonary bypass time, crossclamp time and procedure's length were longer in the MIVS-group.Postoperative new atrial fibrillation was less in the MIV-group. Aorticdissections occurred more in the MIVS-group. The rate of re-thoracoto-mies and postoperative renal failure was similar in both groups.Conclusions:MIVS and conventional mitral valve surgery showa similarstroke andmortality rate.Minimally invasivemitral valve surgery seemsto be favorable in regards of resource related outcome. It should be thegold standard therapy for the treatment of mitral valve disease.


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SC151Neurological tests and quality of lifemeasurements in patients after minimal-invasive mitral valve surgeryKammerer I.1, Vomend A.1, Freundt M.2, Kiessling A.-H.3,Sack F.-U.11Klinikum Ludwigshafen, Herzchirurgie, Ludwigshafen,Germany, 2Universitätsklinikum Regensburg,Herzchirurgie, Regensburg, Germany,3Universitätsklinikum Frankfurt, Herzchirurgie, Frankfurt,Germany

Objective: Clinical benefit of mitral valve reconstruction (MVR) is welldocumented, but comparative data of long term follow-up (> 12monthsperiod) in postoperative quality of life (QoL) and mental power aremissing. We hypothesised that mitral valve reconstructionwith isolatedmitral valve disease have neuropsychological benefits in 1-years follow-up. Methods: Since 2011 40 patients (mean 60years, 75% male) afternon-emergent MVR were enrolled. In a prospective trial, psychologicalmeasurements like SF-36 with 8 scaled scores about physical andmental health, depressive analysis (BDI), neuropsychological tests likeMini-Mental test (KMS), Trial A, B tests and 6-minute-walk (6 MWT) forexercise tolerance was assessed before (n¼38), 9days (n¼34) and 12months (n¼19) after surgical intervention. Results: In a paired t-testmodel correcting for physical function SF-36 headings were detectedsignificant lower scores, especially in period before vs. 9 days after theoperation (p>0,001) and vs. after 12 months (p>0,001) without sig-nificances in mental power scores during the time. The 6-minute-walkmeasure decreased to hospital discharge date: 516 m preOP vs. 438 mpostOP (p>0,038) vs. 526 m 12 months later (n.s.). Significant differ-ences showed Part B in postoperatively period: 88 min pre OP vs. 111min post OP (p>0,001) vs. 100 min 12 months after OP (p>0,01).Conclusions: The differences of QoL and neurological testing in patientswith MVR in 1-years period outcome showed significant improvementas well in physical fitness (6 MWT) as in SF-36 measures.

SC152Tricuspid valve repair in patients with mild-to-moderate tricuspid regurgitation undergoingmitral valve repair/replacement improves in-hospital outcomeZientara A.1, Häussler A.1, Löblein H.1, Odavic D.1, GenoniM.1, Dzemali O.11Stadtspital Triemli, Herzchirurgie, Zürich, Switzerland

Objectives: Significant tricuspid regurgitation (TR) in patients (pts)undergoing surgery for mitral valve (MV) does increase their morbidityand mortality. The early postoperative period demonstrates the mostvulnerable phase for hemodynamic stabilisation at ICU afterMV surgery.Does reconstruction of mild-to-moderate insufficiency of the tricuspidvalve (TV) in pts undergoing MV surgery lead to a benefit in earlypostoperative outcome? Methods: From January 2010 to September2012, 22 patientswithmild-to-moderate functional TR underwent first-time mitral valve repair/replacement and concomitant TV repair. Theseverity of TR was assessed echocardiographically by using colour-Doppler flow images. Additional procedures included coronary arterybypass in 9 pts and maze procedure in 15 pts. Following parameterswere compared: postoperative doses and peak doses of noradrenaline(NA), pre-/postoperative systolic pulmonary arterial pressure (sPAP),extubation time, operation time, cross-clamp time, cardiopulmonarybypass (CPB) time, pre-/postoperative ejection fraction (EF), ICU-Stay,hospital-stay, cellsaver transfusion, blood transfusion intra-/postopera-tive, postoperative TR. Results: Themean agewas 67 years (� 14,8), 45%were male. All pts underwent successful mitral valve repair. Meanejection fraction was 47% (� 16.2), postoperative 52% (� 12.4). Preoper-ative sPAP 46 mmHg (� 20.1), postoperative sPAP 40.6 mmHg (� 9.4),postoperative NA 12 mcg/min (� 10), peak NA 18 mcg/min (� 11),operation time 275 min (� 92), CPB time 145 min (� 49), ICU stay 2.4days (� 2.4), hospital stay 10.8 days (� 3.5), cellsaver 736 ml (346 � ),blood transfusion 2.5 (� 1,6) intraoperative. 2 pts needed bloodtransfusion after operation. 19 pts were extubated at first postoperativeday, 2 pts at second day and 1 at fourth postoperative day afterreoperation because of bleeding complications. 2 pts required a perma-

nent pacemaker for heart block. No reintubation, no in-hospital mor-tality, one reoperation because of bleeding complications. 14 pts had nosign of TR, 7 pts mild TR and 1pt moderate TR at the dischargeechocardiogram. Conclusion: Correction of mild-to-moderate function-al TR at the time of MV repair doesmaintain TV function and avoid RightVentricular dysfunction in the early postoperative period. This strategyimproves clinical outcomes at ICU and hospital stay.

SC153Evolution of minimally invasive mitral valverepair: Feasibility of a non-rib-spreading, fullyendoscopic, mini incision techniqueWesthofen F.S.1, Treede H.1, Conradi L.1, Deuse T.1, Detter C.1,Reichenspurner H.11Universitäres Herzzentrum, Hamburg, Germany

Objectives:Minimally invasive surgery is an increasingly used approachfor mitral valve repair and replacement. Further reduction in surgicaltrauma can be achieved by non-rib-spreading fully endoscopic accessthrough a 3-4 cm right lateral mini-thoracotomy, claiming that an evenless invasive procedure helps to reduce postoperative pain and improvecosmetics thereby maintaining the same quality of surgery. Methods:Since June 2013 non-rib-spreading minimally invasive mitral valverepair was performed in 10 patients (83% male, mean age 44 years).Rib spreading was avoided using only a soft-tissue-retractor. Operativevisualization was provided by an endoscope placed through a port justlateral to the working incision, a 5 mm parasternal incisionwas used forthe dynamic left atrial retractor. Valve pathologies included myxoma-tous degeneration, annular dilatation, chordal rupture, bileaflet pro-lapse in cases of Barlow valves and valvular calcification, mostlypresented as combined defects. 9 patients underwent mitral valverepair, 1 patient mitral valve replacement. Reparative techniques in-cluded correction of prolapsed AML and PML by chordal replacement,triangular posterior leaflet resection, leaflet sliding plasty and ringannuloplasty. In most cases more than one technique was applied.Follow-up echocardiography was used to obtain ejection fraction, MR,MS, pericardial effusion and other valve pathologies. Clinical outcomewas judged by NYHA stage and postoperative pain. Results: The proce-dure was successful in all patients without limitations in surgical repairtechniques. Mortality was 0%. Perioperative morbidity included pace-maker implantation in 2 patients and mild pericardial effusion in 1patient. There was no incidence of new atrial fibrillation,wound infec-tion, myocardial infarction or stroke. None underwent blood transfu-sion. All patientswere discharged fromhospital in good condition after amean length of stay of 8 days. Up to now there were no postoperativecomplications or deaths. Postoperative echocardiography showed suffi-cient repair in all patients. Only 1 of 10 patients complained aboutpostoperative pain treated by pain medication. Conclusion: Non-rib-spreading mitral valve repair is feasible and safe, reduces postoperativepain, improves cosmetic results and shows no limitations in surgicalrepair techniques.

Heart and lung failure II

SC154Phenprocoumon in HeartWare venrticularassist device patients - a new regimen for earlypostoperative anticoagulationSchneeberger Y.1, Kubik M.2, Oelschner C.1, ReichenspurnerH.1, Deuse T.11Universitäres Herzzentrum Hamburg, Herzchirurgie,Hamburg, Germany, 2Zentrum für Anästhesiologie undIntensivmedizin, Hamburg, Germany

Objective: Implantation of a mechanical circulatory support system isone of the surgical options for end-stage heart failure. The new Heart-Ware ventricular assist device system (HVAD), a magnetically levitatedcentrifugal blood pump, shows a low complication rate. Advantages ofthis new system are less hemolysis, reduced neurological and throm-boembolic events, simplified implantation procedure and less bleedingsbased on lower levels of anticoagulation compared to pulsatile assist


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devices. Due to these facts we evaluated a new regimen for earlypostoperative anticoagulation for HVAD implantation. Methods: Be-tween 01/2010 and 07/2013 41 patients underwent HVAD implantationfor left-, right-, or biventricular support. Indications were dilatedcardiomyopathy in 16 (39.0%) patients, ischemic cardiomyopathy in14 (34.1%) cases, cardiogenic shock or acute myocardial infarction in 7(17.0%) patients, myocarditis in 3 (7.3%) patients as well as right heartfailure in one (2.4%) long-term heart transplant recipient. No anti-coagulation was given for the first twelve hours postoperatively. Then,oral phenprocoumonwas started according to INR. Intravenous heparinbridging was performed in 6 (14.6%) patients only. The INR course wasmonitored from postoperative day one to five and early postoperativecomplications such as mortality, stroke, thrombosis and bleeding wererecorded. Results: Mean patients age was 58.48 � 12.10 years, 36(87.8%) patients were male, five (12.1%) female. When patients weretransferred to ICU, an anticoagulation profile was taken. The first INR onarrival was 1.39 � 0.57 (1.0-3.1). Mean dosage of the first phenprocou-mon administration was 6.0 � 2.1 mg, given on postoperative day one.Mean INR level was 1.43 � 0.77 (1.1-5.0) on postoperative days 1 and2.18 � 1.03 (0.9-5.0) on day 5. The average time needed to reach targetINR levels of 2-3 was 3.8� 1.8 days. Two (4.8%) patients did not survivedthe early postoperative period and died ofmulti organ failure. No stroke,thrombosis ormajor bleeding complication occurred. One (2.4%) patientrequired re-thoracotomy for bleeding andminor gastrointestinal bleed-ing occurred in 1 (2.4%) patient. Conclusion: Early postoperative anti-coagulation regimenwithout heparin bridging can be performed safely,thereby avoiding potential bleeding complications due to the additiveeffects of phenprocoumon and heparin. Despite lower anticoagulationlevels, no stroke or thrombosis occurred in any of the patients.

SC155First clinical experience with combinedHeartWare ventricular assist device andimplantable cardioverter defibrillator therapyPecha S.1, Wilke I.2, Bernhardt A.1, Hakmi S.1, Yildirim Y.1,Arunagirinathan U.1, Treede H.1, Willems S.2,Reichenspurner H.1, Deuse T.1, Aydin M.A.21Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Kardiologie/Elektrophysiologie,Hamburg, Germany

Objectives: The Heartware continuous flow ventricular assist device(HVAD) is used in an increasing number of heart failure patients forbridge to recovery, bridge to transplant, or as destination therapy. Inheart failure patients, ventricular arrhythmias are common and conse-quentlymany patients already have an implanted ICD in place or receiveICD implantation after LVAD implantation. However, little data onfeasibility and necessity of combined ICD and HVAD therapy is available.In this study we present our technical and clinical experience in thosepatients.Methods: Between 01/2010 and 06/2013 41 patients receivedHVAD implantation. Twenty-six HVAD patients, who already had an ICDdevice placed prior to HVAD implantation or received ICD implantationafterwards, were prospectively enrolled in this study. Phenprocoumontherapy was maintained during ICD implantation with INR levelsbetween 2.0 and 2.5, avoiding potential bleeding complications ofoverlapping heparin bridging therapy. Peri- and postoperative compli-cations as well as ICD interrogations were documented. Results: Meanpatients age was 58.4 � 12.6 years, 88.5% of patients were male. Ninepatients were implanted with a new single- (n¼6) or dual-chamber(n¼3) ICD. During ICD implantation, no major, but two minor compli-cations occurred. During follow-up (12.2� 8.9months), appropriate ICDinterventions occurred in 9 patients (34.6%) due to ventricular tachyar-rhythmia (n¼7) or ventricular fibrillation (n¼2). An inappropriate ICDintervention was seen in one patient (3.9%) due to tachycardic atrialfibrillation, which did not re-appear after re-programming of the ICDdevice. During HVAD support, patients with a history of ventriculartachycardia had a significantly higher incidence of ICD interventionscompared to patients with primary preventive indication for ICD (57.1%vs. 8.3% p¼0.015). New onset of VA after HVAD implantation wasobserved in one patient only, where VAs were mechanically triggeredby impingement of the inflow cannula on the left ventricular (LV)

myocardium after LV remodeling. No disturbance of ICD function wasseen after HVAD implantation. Conclusion: Combined ICD and HVADtherapy was safe and feasible, without disturbance of ICD function bythe ventricular assist device. The incidence of ICD interventions washigh in patients with a history of VAs, but low in patients with ICDimplantation for primary prevention.

SC156Complication rates in long-term survivors afterimplantation of magnetically levitated leftventricular assist devicesTandler R.1, Kondruweit M.1, Heim C.1, Weyand M.11Universitätsklinikum Erlangen, Klinik für Herzchirurgie,Erlangen, Germany

Objectives: Due to the dramatic shortage of donor organs, the stage isset for implantation of a VAD as an alternative to heart transplantation.For decision making in destination therapy VAD-surgery, it is importantto know about the device-specific complications in long-term survivors.Because of the theoretically unlimited durability of magnetically levi-tated devices, these VAD's seem to be the best option for destinationpatients. Methods: We have therefore analysed the adverse-event ratein all patients surviving at least 6 months after implantation of amagnetically levitated LVAD in our institution. Results: 41 Patientswith magnetically levitated LVAD's who survived at least 6 monthswere included in this study. In 14 patients, a Heartware LVAD and in 27patients an INCOR was implanted. Follow-up for the Heartware-groupwas 23.02 years and 33.34 years for the INCOR-group. In the Heartware-group, 57.1% patients were event-free in comparison to 25.9% in theINCOR-Group. The event-rate per patient-year for ischemic strokes was0.09 for the Heartware and 0.21 for the INCOR. GI-bleedings occurredwith a rate of 0.17 for the Heartware and 0.09 for the INCOR. A severedriveline infectionwith positive blood cultures had an event rate of 0.04and 0.27 for the different devices. A device thrombosis with the need forlysis or device exchange was observed with an event-rate per patient-year of 0.09 in the Heartware-group and 0.06 in INCOR-patients.Discussion: Long-term survivors after implantation of magneticallylevitated blood pumps reveal acceptable and comparable complicationrates. The Heartware device seems do have less ischemic strokes butmore GI-bleeding episodes with more patients being completely event-free. It is important to keep in mind that the INCOR-group included alarge patient cohort with the first generation INCOR-device, so that infuture studies the rate of severe driveline infections and the rate ofneurological complications should be much lower due to improvementsin device software, inflow cannula- and driveline design.

SC157Platelet function in patients with leftventricular assist devicesBaghai M.1, Heilmann C.1, Nakamura L.2, Geisen U.3,Berchthold-HerzM.1, Trummer G.1, Zieger B.2, Beyersdorf F.11Heart Center Freiburg University, Department ofCardiovascular Surgery, Freiburg, Germany, 2UniversityMedical Center Freiburg, Department of Paediatrics andAdolescent Medicine, Freiburg, Germany, 3UniversityMedical Center Freiburg, Institute of Clinical Chemistry andLaboratory Medicine, Freiburg, Germany

Objectives: Unexplained bleeding events are a severe complication inpatients with left ventricular assist devices (LVAD). Platelet dysfunctionmay contribute to bleeding tendencies. However, comprising data ofplatelet function in LVAD patients with regards to bleeding events arescarce. In specific, previous publications did not employ LVAD patientswithout implanted device but different patients for controls. Methods:We analysed 39 patients with a HeartMate II: in a native state (n¼19:before implantation, n¼11, after explantation, n¼8), in an earlypostoperative (�14 day, n¼28) and in a late postoperative state (�30days, n¼30). Data of at least two time points were available for eachpatient. Platelet function was measured via Born’s aggregometry (colla-gen 2 µg/ml, ristocetin 1.2 mg/ml, ADP 4µmol/l, epinephrine 8 µmol/ml)in percent of normal values. Overall mean values were classified intofour categories: normal, �70%, and mild, 50-69%, medium, 30-49%, or


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severe dysfunction, �29%. Additionally, bleeding events after LVADimplantationwere recorded in all patients. Results: Platelet dysfunctionwas detectable in 18 of 19 patients without LVAD (7 mild, 9 medium, 2severe) and in all patients following LVAD implantation (early: 8mild, 11medium, 9 severe; late: 9 mild, 16 medium, 5 severe). According to thisclassification, platelet function did not change over the course of thestudy (native-early, p¼0.27, n¼ 14; early-late, p¼0.17, n¼21). Bleed-ing events occurred in 17 of 39 patients (44%) in the early and in 25 of 33patients (64%) in the late period. Reexplorations were necessary in 9 ofthem early and in 9 patients late. Conclusions: According to our data,platelet aggregation values are most often impaired in LVAD patientseven without implanted LVAD and do not change after LVAD implanta-tion. A possible contribution of platelet dysfunction to the occurrence ofbleeding events in LVAD patients remains to be elucidated.

SC158Biocompatibility profile of the HeartMate II leftventricular assist device and the centrimagadult centrifugal pumpSchibilsky D.1, LenglingerM.1, Haller C.1, Walker T.1, WendelH.-P.1, Schlensak C.11University Medical Center Tuebingen, Thoracic andCardiovascular Surgery, Tuebingen, Germany

Objectives: In the management of heart failure patients ECLS/ECMO, aswell as LVAD have proofed their clinical benefit. However the develop-ment of Sepsis/SIRS in the course of treatment leads to relevantmorbidity and mortality. We therefore investigated the biocompatibleproperties of both devices.Methods: Both deviceswere investigated in awhole human whole blood mock loop circuit for 180 min using thepumps as driving component (CentriMag, n¼3; HeartMateII, n¼2).Blood samples were taken from the arterial site of the blood line.Changes in markers of coagulation, complement activation and bloodcell release factors were measured by ELISA (thrombin-antithrombinIII(TAT), Polymorphonuklear-Elastase(PMN-Elastase) and activated-com-plement-factor-SC5b-9(SC5b-9)). Results: There was a time dependentactivation of the coagulation system (TAT), complement system(SC5b-9) and inflammation system (PMN-Elastase). The mean valueof TAT increased from baseline value of 3.68to14.55 at 180 minutes inthe CentriMag group and respectively from 2.7to41.63 in the Heart-MateII group. Regarding themean value of SC5b-9 therewas an increasefrom baseline value of 146.5to597.8 at 180 minutes in the CentriMaggroup and respectively from 61.79 to 740.2 in the HeartMateII group.PMN-Elastase mean values increased from baseline value of 54.4to163.0at 180 minutes in the CentriMag group and respectively from18.26to359.6 in the HeartMateII group(Fig1). There are no significantdifferences between these values in CentriMag and the HeartMate IIgroup.

Fig. 1

Conclusion: The activation of complement, coagulation and inflamma-tion system was comparable between both devices. Therefore there is agreat opportunity to gain a clinical benefit by developing techniques tolower the blood surface interaction of these devices. Techniques, which

lead to an endothelial monolayer on different foreign surfaces arepromising to enhance the biocompatibility.

SC159Effect of recombinant-BNP-infusions on renalfunction following total artificial heart-implantationSpiliopoulos S.1, Serrano M.R.1, Guersoy D.1, Dogan G.1,Koerfer R.1, Tenderich G.11Klinik für Herz- und Gefässchirurgie Duisburg, Abteilungfür die chirurgische Therapie der terminalenHerzinsuffizienz und Kunstherzversorgung, Duisburg,Germany

Objectives: Excision of the native ventricles results into depletion ofBNP and compromise of renal function following Total Artificial Heart(TAH) implantation. BNP substitution could ameliorate this effect andreduce the need for haemodialysis. Methods: We retrospectively re-viewed 22 TAH-implantations performed from 2011 to 2013 in ourinstitution with regard to renal function. 11 patients received continu-ous recombinant BNP infusions (1,5 g/250 ml NaCl) directly after theexcision of the native ventricles. Depending on urine output BNP-therapy was gradually withdrawn. We focused on the need for haemo-dialysis, urine output and GFR. Results: In patients treated with recom-binant BNP the need for haemodialysis was lower (p¼0,008) and urineoutput was higher (p¼0,006). Furthermore in-hospital stay wasshorter. Conclusions: Infusions with recombinant BNP ameliorate theeffects of BNP-depletion in TAH patients and contribute to a better renalfunction and a significantly decreased need for haemodialysis.

SC160Is an upgrade to a cardiac resynchronisationtherapy-ICD safe? A single center experienceSchneeberger Y.1, Wilke I.2, Willems S.2, Reichenspurner H.1,Aydin A.21Universitäres Herzzentrum Hamburg, Klinik fürHerzchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Klinik für Kardiologie mitSchwerpunkt Elektrophysiologie, Hamburg, Germany

Objectives: Due to extended indication we see an increase in upgradesof existing pacemakers or ICDs. The clinical benefit of CRT has alreadybeen shown. Therefore this therapy is offered to a wide spectrum ofpatients because of its favorable results. However little is know aboutthe surgical risk and perioperative outcome of upgrads. Methods:Between 02/2008 and 12/2010 146 patients underwent CRT-implanta-tion. Mean patient age was 64.5 � 12 years, 125 (85.6%) were male. Inour cohort 58 (39.7%) patients received an upgrade to a CRT-ICD. 40(68.9%) patients had an upgrade of a pre-existing ICD-system, respec-tively 18 (31.0%) patients of a pre-existing pacemaker. We evaluated theperioprative risk in both groups defined as tamponade, diaphragmatictwitch, pneumothorax, lead dislocation and ventricle perforation byleads as well as frustrane CS-lead implantation. Results: There were nosignificant differences in both groups regarding comorbidities, age orgender. In the upgrade group significantly more patients (p¼0.02)received an ICD due to secondary prevention. The overall rate of adverseevents in both groups did not show a significant difference (p¼0.44).The rate of procedure related complications was 10.2% in the de-novoimplantation group compared to 15.5% in the upgrade group. Weregistered as significant difference the unseccessful CS-lead implanta-tion. In the de-novo implantion group no frustrane CS-lead implantationwas seen compared to 6 (10.3%) in the upgrade group (p¼0.003). All sixpatients were providedwith epicardial leads. In total 12 (20.6%) patientsin the upgrade group had a cardiacthoracic intervention to receiveepicardial leads. Conclusion: CRT-implantation was performed safe andfeasible without major complications. Both groups did not show asignificant difference in procedure related adverse events. However,in the upgrade group a significant higher number of unseccessful CS-lead implantation with consecutive epicardial lead surgery was seen.Therefore an upgrade of a pre-existing ICD or pacemaker to a CRT-ICDshould be discussed by the heart team to provide best care for thepatients.


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SC161Lysis in patient with a pump thrombosis afterimplantation of a left ventricular assist deviceMeyer A.L.1, Hahn J.1, Kluttig R.1, Samson-HimmelstjernaP.1, Garbade J.1, Mohr F.W.1, Strüber M.11Herzzentrum Leipzig, Herzchirurgie, Leipzig, Germany

Background: Left ventricular assist device implantation is an estab-lished therapy in patients with end-stage heart failure. Limitations inthe durability of these pumps are the development of a pump thrombo-sis. A lysis therapy may avoid a surgical pump exchange. In a retrospec-tive study we analyzed the efficacy of a lysis therapy in LVAD patients.Methods: A pump thrombosis was diagnosed to high power or flow,increased LDH levels (>500 U/L) and hematuria. Low dose of Actilysewere given if two of three criteria were fulfilled. Results: Between 4/12and 8/2013, 30 lysis were done in 11 patients with different leftventricular assist device (HVAD, HeartMate II, Synergy). In 36% the lysistherapy was successful with normalization of LVAD parameter and LDHlevel. An exchange of the pump was necessary in 6 patients in spite oflysis therapy. Bleeding complications occurred in 13% after lysis therapy.One patient died due to intracerebral bleeding. Conclusion: Low doselysis therapy has a low complications rate but has to be done in most ofthe patients several times. An exchange of the LVAD pump is a high risksurgical procedure but can be avoided by using lysis therapy only in onethird of the patients with a pump thrombosis.

SC162Off-pump implantation of left ventricular assistdevice under extracorporeal life support inpatients suffering from heparin-inducedthrombocytopenia type IIHillebrand J.1, Schmidt C.2, Sindermann J.1, Hoffmeier A.1,Martens S.1, Scherer M.11Westfälische Wilhelms-Universität Münster, Klinik fürHerzchirurgie, Münster, Germany, 2WestfälischeWilhelms-Universität Münster, Klinik und Poliklinik für Anästhesieund operative Intensivmedizin, Münster, Germany

Objectives: Heparin induced thrombocytopenia type II (HIT II) is a rarebut life threatening side effect of heparin therapy that occurs in up to 3%of all heparin-treated patients and it is a demanding therapeuticchallenge in patients undergoing left ventricular assist device (LVAD)implantation. We present our experience with off-pump LVAD implan-tation under extracorporeal life support (ECLS) in patients sufferingfrom HIT II. Methods: Between March 2012 and 2013, five patients(mean age 51.2 � 18.1 years, 1 female, 4 male patients) suffering fromacute heart failure were stabilized with ECLS. Patient populationcomprised 1 case of dilative and 4 cases of ischemic cardiomyopathy.During ECLS support all patients showed a sudden decrease of throm-bocytes. Due to the clinical suspicion of HIT II, anticoagulation wasswitched from heparin to argatroban (aPTT 70-80 sec.). Despite ECLSrelief, no improvement of cardiac function could be detected, so LVADimplantation was indicated. To avoid heparin exposition for surgicalprocedurewith the use of extracorporeal circulation, we decided for off-pump technique. Results: Under ECLS mean platelet count decreasedfrommaximum values of 222 � 51 x103/µl down to a minimum of 29 �16 x103/µl. HIT II was confirmed by a heparin-induced platelet aggre-gation (HIPA), but could only be proved in 4 cases postopearatively. In 4cases, we could successfully perform off-pumpLVAD implantation underargatroban therapy. All 5 patients needed postoperative re-explorationfor bleeding. Postoperatively we observed one patient with a minorneurological impairment (prolonged wake-up phase). One patientdeveloped massive thrombus formations within the left and rightventricle during the implantation procedure and the LVAD had to beremoved. He died due to multi-organ failure caused by an uncontrolla-ble coagulation disorder withmassive ubiquitary intravasal thrombosis.One patient died two days after LVAD implantation due to not devicerelated sepsis, so the overall survival was 60%. Conclusion: Although wecannot derive a definitive surgical or anticoagulation strategy forpatients suffering from HIT II requiring LVAD implantation, we cannotice that we could achieve acceptable clinical results by off-pumpLVAD implantation under ECLS and argatroban anticoagulation.

SC163Which critical hemodynamic patients should beconsidered for VAD implantation?Dell'Aquila A.M.1, Risso P.2, Alles S.G.H.1, Schneider S.R.1,Sindermann J.R.1, Scherer M.11Universitätsklinikum Münster, Klinik für Herzchirurgie,Münster, Germany, 2Mario Negri Institute forPharmacological Research, Epidemiology and SocialPsychiatry Unit, Milan, Italy

Objectives: Poor survival has been demonstrated after VAD implanta-tion for INTERMACS profile 1 and 2 patients comparedwith more stablelevels. However, risk factors of this high risk cohort have not beendetermined so far. The aim of the present study was to identifydeterminants associated with this very high mortality rate. Methods:Between February 1993 and January 2013 158 hemodynamic criticalpatients out of 298 underwent VAD implantation in our institution.Hemodynamic critical patients were defined as patients in INTERMACSLevel of 1 (109 pts) or INTERMACS Level of 2 (49 pts) respectively. Assistdevices implanted were: HVAD Heartware n¼18; INCOR n¼11; VEN-TRASSIST n¼2; DEBAKEY n¼22 and pulsatile systems n¼105. Results:After cumulative support duration of 815.35 months Kaplan-Meieranalysis revealed a survival of 63.9%, 48.8%, and 40.3% at 1, 6, and 12months, respectively. Cox regression analyses identified age>50(p¼0.001, OR 2.48), WBC count>13.000/µl (p¼0.01, OR 2.06), preop-erative renal replacement therapy (p¼0.001, OR 2.63) and postcardiot-omy failure (p<0.001, OR 2.79) as independent predictors of mortality.Of note, last generation VADs were not associated with significantly 6month better survival (p¼0.59). Patients without the aforementionedrisk factors could yield a survival of 79.2% at 6months. Conclusions: Thissingle-center experience shows that VAD implantation in hemodynamicunstable patients generally results in early poor outcome, even in thirdgeneration pumps. However, avoiding the aforementioned risk factorssurvival could result in improved outcome.

SC164Short-term outcome after surgicalembolectomy in pulmonary embolism: A single-center experienceGrothusen C.1, Thiem A.1, Engler A.1, Matz K.1, Schöttler J.1,Cremer J.1, Attmann T.11UKSH Campus Kiel, Herz-und Gefäßchirurgie, Kiel,Germany

Objectives: Although pulmonary embolism (PE) may represent a life-threatening condition with a persisting high mortality the optimalpatient management in cases where thrombolysis is contraindicatedor has failed is still uncertain. We here report the short-term outcomeafter surgical embolectomy at our department.Methods: Retrospectivedata from 44 patients who underwent surgical pulmonary embolecto-my for submassive or massive PE using cardio-pulmonary bypass at ourdepartment between 2002 and 2013was analysed. Results:Mean age ofpatients was 56 years (� 17, range 18-90). 20 Patients were female(45%). In 23 patients (52%), PE occurred in association with a recentsurgical procedure. 8 patients (20%) had undergone unsuccessful throm-bolysis. 10 patients (27%) reached the operating theatre under mechan-ical resuscitation. Mean operating time was 197 (� 83) minutes, meanbypass time was 107 (� 47) minutes. Mean intensive care unit (ICU)admission for these patients was 8 (� 9, range 1-30) days. Intra-hospitalmortality was 22% (10/44). 50% of these patients had suffered fromcirculatory arrest pre-operatively. 4 Patients received ECMO treatmentpost-operatively of which 2 died during the post-operative course.Meanfollow-up was 4 (� 3, range 0.5-9) years. 3 patients died after discharge(9%). Conclusions: Although any interpretation of the data presentedhere is limited by the small number of patients and the retrospectivedesign, surgical pulmonary embolectomy is a feasible option in a clinicalbail-out situation. However, further studies are needed to improvepatient selection and thus, outcome.


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SC165Challenging treatment of an infected CircuLiteSynergy micro-pump after pump thrombosisdue to subtherapeutic anticoagulation therapy.Pushing the limits?Bireta C.1, Danner B.1, Grossmann M.1, Zenker D.1, SeidlerT.2, Unsöld B.2, Sabashnikov A.3, Schöndube F.A.1, Popov A.-F.11Universitätsmedizin Göttingen, Thorax-, Herz- undGefäßchirurgie, Göttingen, Germany, 2UniversitätsmedizinGöttingen, Kardiologie und Pneumologie, Göttingen,Germany, 3Royal Brompton and Harefield NHS FoundationTrust, Department of Cardiothoracic Transplantation andMechanical Support, London, United Kingdom

Introduction: Due to the shortage of donor organs for heart transplan-tation, left ventricular assist device (LVAD) therapy has been proven tobe safe and efficient as bridge to transplant for patients awaiting donororgans. A vast progress has been achieved in this field over the last yearsand new generations of small-size assist devices became standard ofcare for end-stage heart failure (HF). The new CircuLite Synergy micro-pump which provides partial hemodynamic support can be easilyimplanted via a small right-sidedmini-thoracotomy and a small incisionnear right clavicular groove without cardiopulmonary bypass (CPB).Background: We report on a 52-years old male who had a CircuLiteSynergy micro-pump thrombosis due to a subtherapeutic anticoagula-tion therapy with the necessity of pump exchange after initial uncom-plicated postoperative course. The pump exchange could be doneelectively in a stable clinical condition without any surgical complica-tions. However, four weeks after pump exchange, the patient developeda pump infection which resulted in an open dressing, vacuum-therapy,and a challenging antibiotic regime. Ten weeks after onset of theinfection, the patient underwent successful heart transplantationwith excellent clinical outcome. Discussion: With our aggressive ap-proach we were able to achieve rapid clean wound conditions, and thebloodstream infection could be controlled, evidenced by a number ofnegative blood cultures, lack of fever and normal white cell counts.Furthermore after htx the antibiotic therapy was continued for 4 weeksand the patient could be discharged without any problems. As in othercases of LVAD infections we found such aggressive medical and surgicaltherapyof those complications to be a very appropriate strategy in orderto prevent further devastating complications such as LVAD endocarditis.In our case we could demonstrate to deal with an infected CircuLiteSynergy micro-pump infection without any major problems. One of theadvantages is no previous sternotomy allowing easy cardiac accesswithout need for excessive dissection. In addition, the patient showedgood clinical outcome after htx. This fact may relate to the success of theCircuLite micro-pump as partial support in normalization of the hemo-dynamic situation and improvement in end-organ function until htx.

SC166Transcranial detection of signals (HITS/ MES) incases with a ventricular assist device(preliminary study in Japan)Sato K.1,2, Ono M.3, Kyo S.4, Yamazaki K.5, Nakajima T.6,Krabatsch T.1, Hetzer R.11Deutsches Herzzentrum, Berlin, Germany, 2Niigata Univ.,Thorac & CV Surgery, Niigata, Japan, 3The Univ. of Tokyo,Cardiac Surgery, Tokyo, Japan, 4The Univ. of Tokyo,Therapeutic Strategy forHeart Failure, Tokyo, Japan, 5TokyoWomen's Med Univ., Cardiovasc Surgery, Tokyo, Japan,6Niigata Hospital, Neurological Int. Medicine, Kashiwazaki,Japan

Though the nature of HITS/ MES (high intensity transient signals/ micro-embolic signals) has not been entirely clarified as yet, transcranialdetection of HITS/ MES for the prevention of cerebral infarction isclinically performed in patients with neuro-vascular disease. In cardiacsurgery, HITS/ MES have been reported during cardiopulmonary bypass,after aortic valve replacement and, in just a few reports, in patients withleft ventricular mechanical support.1,2,3,4 The present preliminary studyshows that, in patients supported with Nipro-Toyobo-LVAS (Left Ven-tricular Assist System), the high-frequency counts in HITS/ MES were

greater than the low-frequency counts (P¼0.025) and the counts mayincrease with time, which may imply air microemboli. In the long-termfollow-up period, no HITS/ MES were determined in the new devicescompared to many HITS/ MES in the old device (intra-corporeal ventric-ular assist devices vs. Nipro-Toyobo-LVAS¼3 vs. 3, with significance).This suggests superiority for the prevention of thrombo-embolic eventsof the newnon-pulsatile devices and better intensive care in these cases.Transcranial HITS/ MES detection may be more useful for patients withan intra-corporeal ventricular assist device, partly because the devicecannot be directly seen. References: (1) Potapov EV et al. ASAIO J. 2001;47(3):249-53. Transcranial detection ofmicroembolic signals in patientswith a novel nonpulsatile implantable LVAD. (2) Nabavi DG et al. J ThoracCardiovasc Surg. 2003; 126(1):160-7. Doppler microembolic load pre-dicts risk of thromboembolic complications in Novacor patients. (3)Thoennissen NH et al. ASAIO J. 2006; 52(3):243-7. Influence of inflam-mation and pump dynamic on cerebral microembolization in patientswith Continuous-Flow DeBakey LVAD. (4) Sato K et al. J Artif Organs2008; 11(4): 201-3. Frequency Analysis in High-Intensity TransientSignals by Transcranial Doppler in patients supported with a LeftVentricular Assist Device.

SC167First clinical results of the novel Heartmate IIpocket controllerRojas S.V.1, AvsarM.1, Hanke J.S.1, Rojas Hernandez S.2, BaraC.1, Malehsa D.1, Haverich A.1, Schmitto J.D.11Medizinische Hochschule Hannover, Klinik für Herz-,Thorax-, Transplantations- und Gefäßchirurgie, Hannover,Germany, 2Medizinische Hochschule Hannover, Klinik fürAnästhesiologie und Intensivmedizin, Hannover, Germany

Objectives: The incidence of end-stage heart failure becomes, based onrecent demographical changes, increasingly important. Therefore, leftventricular assist device (LVAD)-therapy becomes more and more analternative therapeutical option and is gaining more and more accep-tance in the treatment of heart failure. Based on several technicalimprovements in LVAD surgery, the perioperative as well as postopera-tive riskwas tremendously reduced during the past years. The aimof ourstudy was to assess the outcome of heart failure-patients who receivedHeartmate II-implantation with the use of the new pocket controller.Methods: At our institution, between December 2012 and August 2013we reviewed the outcome of 30 end-stage heart failure patients,underwent LVAD implantation (Heartmate II, Thoratec) and receivedthe novel pocket controller. The aim of this study was to asses thefeasibility and safety of this novel pocket controller. All operationeswereperformed in elective patients suffering from end-stage heart failure(NYHA IV, Inermacs 3). Results: Between December 2012 and August2013 26 newly implanted Heartmate II-LVADs as well as 4 controller-changes (old controller to novel pocket controller) were being per-formed at our institution. 22 male, 8 female mean age 52 � 4,2 years;DCM 62%; ICM 38%. All patients suffered from end-stage heart failure(NYHA IV) and underwent LVAD-surgery (Heartmate II) electively(Intermacs 3). Perioperative as well as 30-day survival-rate was 92%(24/26). Bleeding incidence (4%; 1/26) as well as postoperative rightheart failure (4%; 1/26) remained low. No technical failure and/orcontroller change became necessary. LVAD parameters were presentedas normal (mean rpms: 8800 rpm; 4.5 l/min; 5.6 Watts). No device-related risks or complications were seen. Conclusions: Our data shownovel pocket controller is prooven to be feasible, safe and is associatedwith several positive benefits. The perioperative risk remains un-changed and is presented with a low mortality, very low incidence ofpostoperative bleeding and low incidence of right heart failure. Despitethe fact, that this new controller is as safe as its previuos version, thebiggest advantage of the novel device is the customer friendly displayand its miniaturized size.


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Arrhythmias

SC168Arrhythmogenic effects by local left ventricularstretchDhein S.1, Englert C.1, Mohr F.W.11Herzzentrum Leipzig, Klinik f. Herzchirurgie, Leipzig,Germany

Objectives: Since ventricular mechanical load is considered to be animportant arrhythmogenic factor we wanted to analyse this type ofstretch-induced arrhythmia. Methods: Isolated rabbit hearts perfusedaccording to the Langendorff techniquewere submitted to increased leftventricular stretch at the left wall by insertion of an additional intra-ventricular balloon and adjusting the end-diastolic pressure (EDP) to 25mmHg for 10minutes followed by 20minutes recovery at normal EDP of5-8 mm Hg. Activation and repolarization processes were investigatedby ventricular 256 electrode epicardial mapping. The hearts weretreated during the whole procedure either with vehicle, 0.5 µM flecai-nide or 100 µM streptomycin. Results: Stretch resulted in a local slowingof the activation process at the stretched left wall, in a change in theactivation pattern, and in ventricular arrhythmia. The ventricular ar-rhythmias originated from the border between the stretched area andthe non-stretched region. General slight slowing of the activationprocess by the sodium-channel blocker flecainide and application ofthe stretch-activated ion channel blocker streptomycin prevented fromthe relative prolongation of the activation process at the stretched leftwall and partially prevented arrhythmia. Conclusion: Local stretch canelicit ventricular arrhythmias which do not origin from the stretchedarea but from the border. Pathogenetically local slowing of conductionseems to be involved so that total activation time of the stretched freeleft wall and the non-stretched areas drifted apart. The antagonizationof this effect by streptomycin indicates that stretch-activated channelsmay be involved.

SC169Atrial ablation in combinedmitral and tricuspidvalve surgery - associated with increasedpacemaker implantation rate?Felkel K.-W.1, Kubik M.1, Gulbins H.1, Reichenspurner H.1,Wagner F.M.11Universitäres Herzzentrum Hamburg, Herzchirurgie,Hamburg, Germany

Objectives: Due to atrial dilatation combined mitral and tricuspid valvedisease is often associated with atrial fibrillation (AF). To reduce likeli-hood of postoperative AF persistence tricuspid (TV) and mitral valve(MV) surgery are often combined with atrial ablation. In our study weanalyzed outcome of such combined procedures with regards to rhythmoutcome and necessity of permanent pacemaker implantation.Materialand methods: From January 2012 until September 2013 45 patients,underwent combined MV and TV surgery due to high grade insufficien-cies on both valves, 81.8% of these had atrial fibrillation prior to surgery.All patients were in NYHA class III-IV. Preoperative LV-EF was 49%� 13,with no significant difference between groups. Concomitant bi-atrial RFablation was performed in 29 pats. (Gr.1: 54.5% male, age 70.4 � 8.4 ys).4 pats. in this group had a pacemaker before surgery. No ablation wasperformed in the other 16 pats. (Gr.2, 62.5% male, age 70.6 � 9.5 ys),despite AF in 7, the other 9 patients had sinus rhythm. Additional aorticvalve surgery, coronary bypass and atrial or ventricular septum defectclosure was performed in n¼5 in Gr.1 and n¼ 8 in Gr.2. Results: Therewas no ablation related complication. Overall mortality was 2.2% (n¼1)with no difference between groups. In Gr.1 ablation terminated AF in37.9% (11/29), however, all but one of these (34.5%; 10/29) needed aDDD-pacemaker due to sick sinus, sinus arrest or intermittent SR withAV-block III°. 62.1% in Gr.1 (18/29) had persistent AF, of these 13.8% (4/29) required a VVI-pacemaker due to intermittent bradyarrhythmias, inanother case an ICD was implanted due to postop. ventricular tachycar-dia. In Gr.2 pacemaker implantation rate was 12.5% (2/16), both in pats.with AFand intermittent AV-block and bradyarrhythmia. All 9 pats. withpreoperative SR were discharged with SR. There was no significantdifference between groups for duration of operation, time on ventilator

or on ICU. Length of hospital staywas 11.9 days� 7.4 days in Gr.1 and 9.3days � 2.2 in Gr.2 (p¼ns). Conclusion: Surgical AF ablation can beperformed safely even in patients with persistent AF and combinedMV/TV disease. Post ablation requirement of permanent pacemaker implan-tation, however, is significantly elevated in case of successful AFtermination. Combined surgical intervention on MV and TV withoutatrial ablation required significantly less postoperative pacemakerimplantation.

SC170Rationale and trial design of the Left AtrialAppendage Occlusion Study (LAAOS III)Reents W.1, Diegeler A.1, Babin-Ebell J.1, Böning A.2,Whitlock R.P.3 LAAOS III Collaborators1Herz- und Gefäßklinik Bad Neustadt, Herzchirurgie, BadNeustadt, Germany, 2Universitätsklinik Giessen, Klinik fürHerz-, Kinderherz- und Gefäßchirurgie, Giessen, Germany,3McMasters University, Hamilton, Department of Surgery,Hamilton, Canada

Objectives: Stroke prevention in atrial fibrillation (AF) may be achievedby elimination of AF itself, prevention of clot formation by medicaltherapy and physical elimination of the left atrial appendage (LAA), thesite of clot formation. Elimination of AF has actually not been effectiveagainst stroke, probably because no AF therapy has been able tosuppress all AF episodes. Anticoagulant therapy is effective, but islimited by bleeding, patient non-compliance, suboptimal anticoagula-tion control and need for therapy discontinuation during lifelongtreatment. Occlusion of the LAA is a logical idea that has receivedconsiderable recent attention due to positive results from a small trial ofdevice closure. Methods: LAAOS III is planned as a large international,multicenter, randomized blinded trial comparing surgical left atrialappendage occlusion to no occlusion in patients with AF who areundergoing cardiac surgery. The primary hypothesis is that LAA occlu-sion will reduce stroke or systemic embolic events compared to noocclusion over a 4 year follow-up period. Exclusion criteria are mechan-ical valve implantation, off-pump cardiac surgery, reoperation, hearttransplantation or LVAD insertion and previous placement of a LAAclosure device. The primary outcome is the first occurrence of stroke orsystemic arterial embolism over the duration of follow-up. All patientswill receive the best medical therapy for AF, including anticoagulationaccording to current guidelines. The shortcomings of lifelong anticoag-ulant treatment will result in sub-optimal anticoagulation in at least 30%of all patients during the study period. Here LAA occlusion can have aadditive or even synergistic effect.With enrollment of 4700 patients thetrial will allow to detect a 25% relative risk reduction in the primaryoutcomewith an expected control event rate of 2.5% per year. The studyhas begun with a vanguard phase in July 2012 and is funded by theCanadian Institutes for Health Research. Conclusion: The proof ofconcept, that LAA occlusion can reduce the burden of stroke in patientswith AF would substantially influence clinical surgical practice andstimulate further research for the treatment of AF. Commitment andtrial participation of further institutions would be highly appreciated.


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SC171Ventricular arrhythmia in patients with FBN1gene mutationsArunagirinathan U.1, Aydin A.2, Adsay B.A.3, SheikhzadehaS.2, Keyserd B.4, Rybczynskia M.3, Detter C.1, Steven D.3,Robinsone P.N.5, Berger J.6, Schmidtke J.4, Blankenberg S.2,Willems S.3, von Kodolitsch Y.2, Reichenspurner H.1,Hoffmann B.A.31Department of Cardiovascular Surgery at the UniversityHeart Center, Hamburg, Germany, 2Department ofCardiology at the University Heart Center, Hamburg,Germany, 3Department of Electrophysiology at theUniversity Heart Center, Hamburg, Germany, 4Institute ofHuman Genetics, Hannover Medical School, Hannover,Germany, 5Institute of Human Genetics and MedicalGenetics, Charité Universitätsmedizin, Berlin, Germany,6Department of Medical Biometry and Epidemiology, at theUniversity Hospital Eppendorf, Hamburg, Germany

Objectives: The frequency of and risk factors for ventricular arrhythmiaare unknown in patients with FBN1 gene mutations. Methods: Weassessed ventricular arrhythmia on baseline ambulatory electrocardi-ography as>10 premature ventricular complexes per hour (>10 PVC/h),and as ventricular couplets, or as nonsustained ventricular tachycardia,or both (Couplet/NSVT), and during 31 � 18 months of follow-up asventricular tachycardia (VT) events (VTE) comprising sudden cardiacdeath (SCD), sustained ventricular tachycardia (SVT), ventricular fibril-lation, or arrhythmogenic syncope in an observational study of 80consecutive adults (30 men, 50 women aged 42 � 15 years) withFBN1 mutations. Results: We identified >10 PVC/h in 28 (35%), Cou-plet/NSVT in 32 (40%), and VTE in 6 patients (8%), including 3 with SCD(4%). PVC >10/h (P¼ .029), Couplet/NSVT (P¼ .051), and VTE (P< .001)exhibited increased N-terminal pro-brain natriuretic peptide serumlevels (NT-proBNP), with decreased left ventricular (LV) ejection frac-tions (P¼ .022 and P¼ .016), increased indexed end-systolic LV diame-ters (P¼ .022 and P¼ .009), and with moderate mitral valveregurgitation (P¼ .018 and P¼ .003) in PVC >10/h and in Couplet/NSVT, respectively. Moreover, VTE related to mutations in exons 24-32, the so-called neonatal region (P¼ .021), and to the number of PVC(P< .001) and NSVT (P< .001). Kaplan-Meier analysis corroborated anassociation of VTE with increased NT-proBNP (P< .001) and withmutations in exons 24-32 (P< .001). Conclusions: FBN1 qualifies as adisease gene of genetic arrhythmia, and persons with FBN1 mutationsmay require life-long monitoring. Ventricular arrhythmia on electrocar-diography, signs of myocardial dysfunction and mutations in exons 24-32 are risk factors of VTE.

SC172Laser lead extraction allows for safe andeffective removal of single- as well as dual coilICD leadsPecha S.1, Hakmi S.1, Sill B.1, Reiter B.1, Yildirim Y.1, ConradiL.1, Aydin M.A.2, Willems S.2, Reichenspurner H.1, Treede H.11Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany, 2UniversitäresHerzzentrum Hamburg, Kardiologie/Elektrophysiologie,Hamburg, Germany

Objectives: Laser lead extraction in patients with multiple- or oldimplantable cardioverter defibrillator (ICD) leads is challenging. Follow-ing renewed guidelines the number of implanted ICD/CRT devices hasbeen rising in recent years. In the sameway the number of ICD leads thatneed to be extracted is emerging. Single- as well as dual coil leads arefrequently used. As adhesions are very common at the side of the shockcoils, we investigated success- and procedural complication rates oflaser lead extraction procedures in single versus dual coil leads.Methods: Between January 2001 and July 2013, 41 single coil and145 dual coil ICD leadswere treated in 171 patients using SLS II 40 Hz- orGlideLight 80 Hz laser sheaths. Indications for lead removals werepocket infection (35.7%), septicaemia or endocarditis (18.1%), leaddysfunction (43.3%), venous occlusion (1.2%), lead migration (0.6%)and chronic pain (1.2%). Data on procedural success rates, intra- andpostoperative outcomes, as well as 30-day mortality were collected into

a database and retrospectively analyzed. Results: Mean patient's agewas 58.2� 16.1 years, and 70.8% were male. Mean time from initial leadimplantation was 50.3� 18.4 and 45.8� 14.5 months in single coil- anddual coil group respectively (p¼0.1). Mean laser treatment timewas 1.8� 1.5 for single coil group and 2.5 � 1.2 min in dual coil group(p¼0.002). In group of single coil leads, 39 out of 41 leads (95.1%)were completely removed, partial removal was achieved in 2 (4.9%)leads and no failure of extraction occurred. In group of patients withdual coil leads rate of complete- and partial removal was 94.5% (n¼137)and 4.1% (n¼6), failure ratewas 1.4% showing no statistically significantdifferences compared to single coil group. Overall complication ratewas2.7% in single- and 3.7% in dual coil group respectively (p¼1.0). In singlecoil patients one major (2.7%) and no minor complication occurred,while in dual coil group one major and four minor complicationsoccurred. No significant p-values were observed. During 30-day fol-low-up no death occurred in any of the groups. Conclusion: Laser leadextraction allows for safe and effective removal of ICD leads. Comparedto single coil leads, the extraction of dual coil leads is associated withlonger laser treatment times but without statistically significant differ-ences in complication- and procedural success rates.

SC173Medical conversion with Vernakalant forpostoperative cardio-surgical patientsDalyanoglu H.1, Behlau C.1, Yilmaz E.1, Schipke J.D.1,Lichtenberg A.1, Korbmacher B.11Heinrich-Heine Universität Düsseldorf, Klinik f. Thorax-und Kardiovaskularchirurgie, Düsseldorf, Germany

Objectives: Postoperative atrial fibrillation (AF) is a frequent complica-tion after cardio-surgical operations. Besides electric cardioversion,different medical therapies exist to attenuate atrial fibrillation andnormalize heart rhythm. One of these - Amiodaron -suffers frommultiple side effects, as it affects non-selectively several atrial andventricular ion channels. In contrast, the more recent Vernakalantaffects selectively the atrium, inhibiting Kþ and Naþ channels.Methods: In a clinical prospective study the conversion rate of Verna-kalant in postoperative cardio-surgical patients was assessed. Between10/2011 and 8/ 2013, 50 (15 females) patientswith newAFafter surgery,received a first i.v.-administration of Vernakalant (3mg/kg over 10min).In case, sinus rhythm (SR) was not achieved within 15 min uponcompletion of the infusion, a second administration followed (2 mg/kg). The patients (47 to 90 years; mean: 71 years) underwent thefollowing interventions: CABG: 30, MV surgery: 6, AV surgery: 8,CABG þ MV: 2, CABG þ AV: 3, AV þ MV: 1. Primary outcome was theconversion of AF to SR for at least the following 90 min. Secondaryoutcome was the proportion of those responders with maintained SR 8days after surgery. Results: After the first Vernakalant i.v.-administra-tion, 25 patients (50%) converted to SR, and additional 12 patients (24%)were normalized after the second intake. One patient converted to SRafter thefirst intake, but started fibrillating again after someminutes, sothat he received Vernakalant a second time. Thus, AF was converted in37 patients (74%) after Vernakalant. With respect to the non-respond-ers, 6 further patients have developed SR at day 8. This can be wellexplained by spontaneous conversion (n¼1) or by measures such asAmiodaron (n¼4) or electric cardioversion (n¼1). Early postoperative-ly predischarged, 43 patients (86%) of the patients were converted to SR.There were no deaths during the in-hospital stay. Taking strict accounton the indication supplied by the manufacturer, there were no sideeffects within the subject group. Conclusions: Administration of Verna-kalant with a conversion rate of 86% appears a safe, promising optioncompared to current methods. It permits a medical conversion with alow side-effect profile. Positive effects with regard to the stay on the ICUand the entire in-patient stay can be expected.


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SC174Body Mass Index can influence Connexin 43distribution in patients with atrial fibrillationor sinus rhythmDhein S.1, Rothe S.1, Busch A.1, Bittner H.2, Kostelka M.1,Mohr F.W.11Herzzentrum Leipzig, Klinik f. Herzchirurgie, Leipzig,Germany, 2Florida Hospital, Thoracic and CardiovascularSurgery, Orlando, United States

Objectives: Increased body mass index (BMI) is often found to be a riskfactor for cardiac disease. However, it is unclear whether BMI also affectsthe remodeling process in AF. Wewanted to test whether increased BMImay affect AF-induced connexin43 (Cx43) distribution in patients withsinus rhythm (SR) or AF.Methods: 51 patients of both gender (mean age:69 y, 30% diabetesmellitus, EF>50%, ca. 170 cm tallness)with SRorwithAF, with either BMI<27 or >27 undergoing cardiac surgery for mitralvalve repair, aortic valve repair or coronary heart disease, were includ-ed. Right atrial tissue (free wall) was processed for immunhistochem-istry and weinvestigated the CX43 positive polar and lateral membranelength in the different BMI (BMI<27, BMI>27) and rhythm groups (SRor AF). Secondly we estimated differences in Cx43 distribution inpatients with SR, paroxysmal AF and chronic AF. Results: In lean SRpatients Cx43 is normally foundmainly at the cell poles, while the lateralmembrane is mostly negative for Cx43. However, in patients withBMI<27 (all groups) Cx43 is localized 6,87 � 0,68% at the lateralmembrane. In contrast the other group BMI>27 (both SR and AF)16,10� 1,49% are staining at the lateral membrane (p<0.05). Regardingthe effect of rhythm, in SR at the polar membranes 36% stained positivefor Cx43. Interestingly, even in SR we found that in patients withBMI>27 about 6 � 1% of the lateral membrane were positive, while inlean patients (BMI<27) only 2% were positive (p<0.05). In AF, polarCx43 staining was slightly reduced to about 30% in both BMI groups.However, lateral membrane increased to 14 � 1% (p<0.05), while inBMI>27-AF-patients this was significantly enhanced to 22 � 2%(p<0.05). Of note, left atrial diameter was nearly identical in both AFgroups (AF-BMI<27: 49.5� 3.1; AF-BMI>27: 49.4� 2.7). EF, underlyingcardiac disease and blood pressure were also not significantly differentbetween these two groups. Additionally to these observations, we saw aprogressive remodeling in AF. In patientswith paroxysmal AFwe found asignificant rise in lateral Cx43 vs. SR while in patients with chronic AF(permanent AF; duration >1 year) there was an additional loss in polarCx43 as compared to pAF. Conclusions: Enhanced BMI increases theremodeling effects of AF on irregular Cx43 distribution. This effect ofBMI was independent from left atrial diameter, EF, hypertension orunderlying cardiac disease.

SC175One-year results after concomitant surgical AFablation in the era of event-recordermonitoringSchlingloff F.1, Oberhoffer M.1, Schmoeckel M.1, Geidel S.11AK St. Georg, Herzchirurgie, Hamburg, Germany

Objectives: Surgical ablation of atrial fibrillation (AF) concomitant toopen heart surgery has become an established strategy although resultsremain variable due to different techniques used to detect AF recur-rence. We report on our results in a continuously monitored group ofpatients using the Medtronic Reveal XT device. Methods: Between 02/2012 and 02/2013 we implanted Event-Recorders in 70 consecutivepatients (71 � 8 years) undergoing AF ablation concomitant to openheart surgery. Atrial fibrillation duration time was 37 � 54.8 months.Ablation was performed either by a left atrial or biatrial lesion set. Datawere obtained via telemonitoring at one-month-intervals postopera-tively and AF burden was calculated at 3, 6, 9 and 12 months. Ablationsuccess was defined as AF burden <0.5% determined by the implantedrecorder. Results: At time of surgery, 22 of 70 patients (31%) hadparoxysmal, 20/ 70 persistent (29%) and 28/ 70 (40%) longstanding-persistent AF. The left atrial (LA) diameter was 49 � 10.3 mm (range 38-70 mm). Ten patients died during the follow-up period (14%). Explan-tation of the device was necessary in 8 cases (11%) at different stages offollow-up. At 3 months, 46% were responders (25/ 54) with an AFburden <0.5%; at 6 month follow-up 60% (23/ 53), at 9 months 62% (29/

47) and at 1 year 68% (23/ 34) were in stable sinus rhythm (SR). At thattime, 88% patients were off antiarrhythmic drugs. AF burden amongnon-responders dropped noticeably at 1-year follow-up from 32% to17%. Conclusion: The success of concomitant AF ablation surgeryimproves over time with the best result (stable SR) at 1-year follow-up. AF burden can be reduced significantly even in non-responders atthis stage. The success rate is satisfactory, considering the long AFduration and the high ratio of patients with longstanding-persistentAF in this group. Results can only be compared once the same techniqueis used for detection of AF recurrence.

SC176Omega-3 polyunsaturated fatty acids reducethe incidence of postoperative atrial fibrillationin patients with history of prior myocardialinfarction undergoing isolated coronary arterybypass graftingWilbring M.1, Plötze K.1, Bormann S.1, Waldow T.1,Matschke K.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: The impact of omega-3-polyunsaturated-fatty-acids forprevention of atrial fibrillation (AF) is still part of a lively debate. Ourobjective was to assess the impact of orally administered omega-3-ethylester-concentrate (Omacor®) on postoperative onset of AF inpatients with recent myocardial infarction undergoing isolated coro-nary artery bypass grafting (CABG). Patients and methods: The studywas designed as a prospective single-center parallel-group trial, enroll-ing a total of 198 patients with recent (�3 months) myocardial infarc-tion. The treatment-group consisted of 99 prospectively and randomlyassigned patients. A corresponding control-group was generated bymatching out of the entirety of patients undergoing isolated CABGduring the same time-period. Primary end-point was onset of postop-erative AF. Patients of the treatment-group received a daily dose of 2gOmacor®, initiated five days before surgery. Results: Patients of thetreatment-group suffered less frequently from new onset AF aftersurgery (31.3% vs. 48.0%; p¼0.017). The reduction of relative risk was34.8% in the treatment-group,which conforms a number needed to treat(NNT) of 6.0 patients. A more pronounced effect with a NNT of 4.1 wasobserved in patients �70 years (p¼0.007). Beside this, patients of thetreatment-group had a shorter ICU-stay (p¼0.001) and suffered lessfrequently from impaired wound healing by trend (p¼0.063). Onepatient out of treatment- and two out of control-group died duringhospital stay (p¼1.000). Conclusion: Preoperative administration of 2gOmacor® reduces incidence of postoperative AF in patients with recent(�3 months) myocardial infarction undergoing isolated CABG. A morepronounced effect was seen in patients �70 years.

SC177Preoperative atrial natriuretic peptide level andatrial fibrosis as predictors of outcome afterepicardial ablation for atrial fibrillationPizonM.1, Friedel N.2, Rzewuska E.2, ViethM.3, WeyandM.4,Feyrer R.41Klinikum Bayreuth/ Friedrich-Alexander-UniversitätErlangen-Nürnberg, Herzchirurgische Klinik, Bayreuth,Germany, 2Klinikum Bayreuth, Herzchirurgische Klinik,Bayreuth, Germany, 3Klinikum Bayreuth, Institut fürPathologie, Bayreuth, Germany, 4Friedrich-Alexander-Universität Erlangen-Nürnberg, Herzchirurgische Klinik,Erlangen, Germany

Objectives: Although preoperative left atrial size and duration of atrialfibrillation (AF) have been associated with ablation results, these factorsare not sufficient to predict the outcome in long standing persistent AF(LsPeAF). The aim of this study was to investigate whether preoperativeplasma Atrial Natriuretic Peptide (ANP) may reflect atrial fibrosis andhas predictive value for outcome after epicardial ablation. Methods: 62patients, who underwent elective cardiac surgery, were included pro-spectively. 42 consecutive patients with AF (11.9% paroxysmal [Pa],23.8% persistent [Pe], 64.8% LsPeAF) underwent concomitant HIFU


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ablation (ablation group) and 20 had preoperatively normal sinusrhythm (SR controls). We measured plasma ANP level before surgeryand performed histological examination from right atrial tissue toquantify atrial fibrosis by collagen volume fraction (CVF). Cardiacrhythm was checked at 3 and 6 months follow-up using 24-hour-ECG.Results: In ablation group 68.4% of patients presented with SR at 6months, 92.8% in Pa and Pe, and 56% in LsPe AF. Baseline ANP levels andCVF were higher in patients with LsPeAF, as compared to the Pa and PeAF and to the SR controls (ANP: 9.22 vs 6.4 vs 5.04 nmol/l, p<0.001;CVF:13.4 vs 9.6 vs 9.0%, p<0.05, respectively). We found positive linearcorrelation between duration of AF and CVF (r¼0.54; p<0.003). CVFwas not a significant predictor of rhythm after ablation. There was norelationship between preoperative plasma ANP level and CVF of rightatrium. Moreover, patients with LsPeAF who converted to SR hadpreoperatively higher ANP level (p¼0.009) than those who remainedin AF at 6 months after ablation, but no significant differences weredetected in individuals with Pa and Pe AF. Patients with LsPeAF andpreoperative ANP >7.5 nmol/l presented with SR in 80%, in contrast tothose with ANP <7.5 nmol/l who converted to SR in 20% (85.7%sensitivity, 80% positive predictive value at cut-off 7.5 nmol/l). Inmultivariate regression analysis only preoperative ANP level was anindependent predictor of cardiac rhythm after ablation in LsPeAF.Conclusion: Our results indicate that preoperative ANP level may be auseful biochemical predictor of outcome of epicardial ablation inpatients with concomitant LsPeAF. Preoperative plasma ANP leveldoes not reflect the degree of right atrial fibrosis in patients with AF.Fibrosis of right atrium has no predictive value in term of ablationsuccess.

SC178Effects on antiarrhythmic and anticoagulationtherapy after concomitant epicardial left atrialablation procedure - one year resultsThiem A.1, Ernst K.1, Kowalski A.1, Hoffmann G.1, HaneyaA.1, Schoeneich F.1, Cremer J.1, Schöttler J.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Herz- und Gefäßchirurgie, Kiel, Germany

Objectives: A growing number of patients undergoing cardiac surgerypresent with atrial fibrillation (AF). Concomitant epicardial ablationcreating a box lesion could be offered to these patients as a safe andstandardized, surgeon-independent procedure. After restoring a stablesinus rhythm themedical treatment has to be re-evaluated. In this studywe report our results focusing on the rhythm analysis and effects onantiarryhthmic and anticoagulation therapy one year after surgery.Methods: Between March 2009 and July 2012 we performed a concom-itant epicardial ablation in a total number of n¼133 patients undergo-ing diverse cardiac surgery procedures. The left atrial box lesion wascreated in all cases by a high intensity focused ultrasonic system(Epicor®, SJM). Continuous rhythm monitoring was achieved by im-planting an event recorder (Reveal XT®, Medtronic) in 74 patients.Rhythm analysis and drug treatment anamnesis were assessed atdischarge and twelve months postoperatively in 64 patients. For theanalysis only the patients with complete follow-up and event-recorderreading data were included (n¼43). We categorized Reveal XT-docu-mented AF-burden in four groups (I¼0-<0,1%, II¼0,1-0,5%, III¼0,5-5%, IV¼5%-100%). Results: The distribution of preoperative type of AFwas paroxysmal in 46,5%, persistent in 25,6% and long-persistent in27,9%. No device-related intraoperative complications occurred. Atdischarge 46,5% of the patients had SR, the median CHADS2-score was2 (range 1-5) and 95,3% were on phenprocoumon therapy, 20,9% onamiodarone, 83,7% on ß-blockers, 4,7% on cardiac glycosides. Twelvemonths postoperatively the actual calculated CHADS2-score was similar(median¼2, range 1-6). In the 12-lead ECG sinus rhythmwas present in55,8%. Phenprocoumon treatment was stopped in 31,7% until follow-up.76,9% of patients with suspended anticoagulant therapy had an AF-burden of class I. Despite ongoing indication for oral anticoagulation onthe basis of AF-burden and CHADS2-score three patients presentedwithout phenprocoumon. At follow-up 9,3% continued amiodaronetherapy, 74,4% were still on ß-blockers and 9,3% had cardiac glycosides.Conclusions: A successful concomitant epicardial ablation is associatedwith a minor use of phenprocoumon, amiodarone and ß-blockers after

one year. Postoperative continuous rhythm control management byevent recorder reading and repeated CHADS2-score calculation allows awell-directed use of anticoagulants and antiarrhythmics.

SC179Call for concomitant ablation: Native course ofpreexisting persistent atrial fibrillation aftercardiac surgeryWilbring M.1, Matschke K.1, Knaut M.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: Despite evidence-based guideline recommendations forperforming concomitant ablation in case of preexisting symptomaticatrial fibrillation, the real-life implementation remains slow-moving.The presentmonocentric registry gives information of truth and legendsof the assumption that extracorporal circulation; functionally equaling acardioversion, as well as surgical treatment of the underlying cardiacdisease could be sufficient for restoring stable sinusrhythm. Patientsand methods: The present monocentric, prospective registry included287 patients with persistent atrial fibrillation undergoing cardiacsurgery and being not concomitantly ablated. The enrollment datedback into the early ablation era (2003). Postoperative visits evaluatingthe heart rhythm by 24-hours ECGwere performed 30, 90, 180 and 360days after the procedure. Study end-point was stable sinusrhythm at theend of the follow-up period. Results: Performed procedures were CABG(51.6%), aortic valve replacement (39.0%), mitral valve repair/replace-ment (34.8%) and tricuspid valve repair (8.4%), including 57.1% com-bined procedures. Permanent pacemaker implantation becamenecessary in 18 patients (6.3%). Standard medical treatment includedmetoprolol in each patient. Hospital- and 1-year mortality was 6.99%and 14.98%, respectively. At discharge, 29 patients (10.1%) had stablesinusrhythm. During follow-up, 16 of these converted into atrial fibril-lation and at the end of follow-up only 13 patients (4.5%) remained insinusrhythm. Conclusion: Spontaneous conversion rate into stablesinusrhythm after cardiac surgery is negligible low. Since even worstestimations of efficacy of concomitant ablation therapy report 10-timeshigher conversion rates into stable sinusrhythm than observed in thenative course, concomitant ablation therapy should routinely be appliedin patients presenting with atrial fibrillation.

SC180Laser-based lead extraction of an accidentallyleft ventricular placed ICD leadBurger H.1, Ihnken O.2, Sperzel J.3, Arsalan M.1, Walther T.1,Ziegelhoeffer T.11Kerckhoff Klinik, Herzchirurgie, Bad Nauheim, Germany,2Kerckhoff-Klinik, Anästhesie, Bad Nauheim, Germany,3Kerckhoff-Klinik, Kardiologie, Bad Nauheim, Germany

Introduction: Accidentally left ventricular (LV) placed pacemaker or ICDleads are rarely events. Recently, we successfully extracted an acciden-tally left ventricular placed ICD lead by use of an excimer laser device.Case report: 68-year-old woman with history of dilated cardiomyopa-thy, an ejection fraction of 40%, episodes of syncope, ventricularfibrillation and cardio pulmonary reanimation received a single cham-ber ICD in May 2000 for secondary prophylaxis. Following ”uncompli-cated” implantation a generator exchange was performed in September2005. In October 2012, an impairment of ventricular sensing was notedduring a routine ICD follow-up examination and therefore lead revisionscheduled. In order to pre-operatively rule out lead vegetations atransesophageal echocardiography (TEE) was conducted. Surprisingly,the single coil ICD screw-in lead was located in left ventricular malpo-sition. Immediately, warfarin was decreed to prevent thrombotic em-bolism. Subsequently patient was admitted to our hospital in order toextract the malpositioned ICD lead and to implant a new lead into theright ventricle. The procedure was performed under general anaesthe-sia, TEE control and stad-by extracorporeal circulation (ECC) unit. Firstwe intended to extract the lead by moderate mechanical traction. Thisapproachwas due tomassive adhesions in subclavianvein, superior cavavein and in the passage through atrial septum not successful. In TEE amarginal left-right shunt next to the lead while passing the atrial


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septum, as well as mitral regurgitation grade I were diagnosed. Wedecided to extract the lead via excimer laser. First, a new right ventric-ular screw-in ICD leadwas placed. Afterwards, an EZ lead-locking devicewas introduced and 14 Fr. laser sheath instead of usually used 16 Fr. wasused in order prevent arterial air embolism and to minimize risk ofwidening atrial PFO. After mobilization of massive adhesions in leftsubclavian vein and superior vena cava, and relatively easy passagethrough atrial septum and mitral valve we struggled to release theadhesions in LV. After complete lead removal no signs of mitral valveregurgitation increase and only small left-right shunt in atrial septumwas documented. There were no complications observed in the post-operative course. Conclusion: Excimer laser-based extraction of anaccidentally LV placed ICD lead is possible. Two-plane X-ray controlafter ICD implantation may prevent lead malposition in the LV.

SC18112-months late procedural success afterablation of atrial fibrillation correlates withenergy source and patient characteristicsNiemann B.1, Dominik E.1, Rohrbach S.2, Roth P.1, Orhan C.1,Li L.2, Böning A.11Justus Liebig Universität Giessen, Klinik für Herz-Kinderherz- und Gefäßchirurgie, Giessen, Germany, 2JustusLiebig Universität Giessen, Physiologisches Institut, Giessen,Germany

Objectives: Nowadays freedom from atrial fibrillation (Afib) is consid-ered as protective regarding congestive heart failure, stroke and reduc-tion of quality of life. Although procedural advance is taken to reachfreedom from atrial fibrillation therapeutical success still depends onpatient’s individual characteristics and risk factors but on the other handas well on surgical strategy. Here we investigated the chance of successto reach freedom from atrial fibrillation depending on patient-charac-teristics and surgical ablation system.Methods:We initiated a prospec-tive all comers-study. Patients underwent pre- and postoperativemonitoring and standardized left-atrial ablation (paroxysmal Afib) orbi-atrial ablation (persistent/long standing persistent Afib) with bipolarradiofrequency.We used either theMedtronicCardioblate© (MC) deviceor the Estech Cobra Revolution© (ECR) system as specified by theindividual manufacturer. An event recorder (ER) was implanted in allpatients. Left and right atrial appendices were removed and cryo-conserved together with serum samples. We provided standardizedin-department ambulance service for follow-up monitoring at intervalsof 6 month (ER-readout, ECG, TTE, serology). Results: 105 patientsunderwent ablation (31 paroxysmal; 74 persistent Afib). Overall 30-daymortality was 6/105, without correlation to Afib type, Afib duration,echo parameters, age. Female sex and high Euro-Score correlated withmortality. In all patients freedom from atrial fibrillation was reached in72% of patients after 6 months and in 64% of patients after 12 months.Freedom from stroke was ubiquitous. Left-atrial-diameter, body massindex (BMI>33) and disturbance in adipokine balance (lowadiponectin,high leptin) correlated to Afib persistence. We observed recurrence ofparoxysmal Afib in only 1/31 patients (MC treatment), who underwentsuccessful catheter ablation after 3 months resulting in a 100% freedomfrom Afib after 12 months in paroxysmal fibrillation. In persistent Afibonly 19% ofMC-treated but 82% of ECR-treated patients reached freedomfrom Afib after 12 months. Conclusions: Therapeutical success can beestimated by patient characteristics as LA diameter, LV ejection fractionand BMI. Evenwhen used as specified by themanufacturer, the availabledevices differ regarding long-term success. Temperature-controlledbipolar radiofrequency showed therapeutical advantages in our study.

Basic Science II: Cardiac cell and genetherapy

SC182Cannabinoid receptor CB2 delays developmentof cardiac failure caused bypressure overload ina murine model of transverse aorticconstrictionDürr G.D.1, Heinemann J.C.1, Kley J.1, Ottersbach A.2, RöllW.1, Zimmer A.3, Lutz B.4, Welz A.1, Dewald O.11Klinik und Poliklinik für Herzchirurgie,Universitätsklinikum, Bonn, Germany, 2Institut fürPhysiologie I, Life&Brain Center, Universität, Bonn,Germany, 3Institut für molekulare Psychiatrie, Life&BrainCenter, Universität, Bonn, Germany, 4Institut fürphysiologische Chemie, Universitätsklinikum, Mainz,Germany

Purpose: Inflammatory reaction has been experimentally associatedwith cardiac adaptation to pressure overload leading to myocardialfibrosis and heart failure. We have recently demonstrated that endoge-nous cannabinoids and the cannabinoid receptor 2 (CB2) are activatedand accompanied by persistent inflammation inmyocardiumof patientswith aortic valve stenosis. Therefore, we investigated the role of the CB2in a pressure overload mouse model. Methods: Transverse aorticconstriction was performed in CB2�/�-mice and their wildtype litter-mates (CB2þ/þ; n>8/group). After M-mode echocardiography andMillar® pressure-volume left ventricular catheter measurements atdays 7 and 21, hearts were harvested and subjected to immunohisto-chemical and Taqman® RT-qPCR analysis. Results: Collagen area meas-urements using picrosirius red planimetry revealed a significantlylarger collagen deposition in CB2�/�-mice after 7 and 21 days, andthis deposition resulted morphologically in more frequent confluentinfarcted areas with cardiomyocyte loss than in CB2þ/þmice. Functionalevaluation revealed early development of ventricular dysfunction inCB2�/�-mice after 7 days, while both genotypes had comparabledysfunction level after 21 days. Heart weight/tibia length-ratio ashypertrophy parameter was significantly higher in CB2�/�-mice after7 days, and then comparable between the genotypes after 21 days.Macrophage density was significantly higher in CB2�/�-mice after 7days than in CB2þ/þ, and it decreased in both genotypes after 21 days.Preliminary data of chemokine and cytokine mRNA-expression showeddelayed modulation of inflammatory response in CB2�/�-mice after 7days when compared to their littermates. Conclusions: Our studysuggests a cardioprotectivemechanism of CB2 receptor being associatedwith modulation of inflammatory response and subsequent develop-ment of left ventricular dysfunction in a murine model of transverseaortic constriction.

SC183Detection of pluripotency gene expression andvalidation of true iPS cell reprogramming byfluorescent reporter probes in live cellsLahm H.1, Doppler S.1, Dreßen M.1, Schrambke D.1,Adamczyk K.1, Werner A.1, Deutsch M.-A.1, Lange R.1, KraneM.11Department of Cardiovascular Surgery, Division ofExperimental Surgery, German Heart Center Munich,Technische Universität München, Munich Heart Alliance,Munich, Germany

Objectives: Induced pluripotent stem cells (iPS) hold a great promise fornew strategies in cardiac regeneration. The generation of iPS cells fromsomatic cells has been achieved in many different species. However, thecharacterization of truly reprogramed colonies still remains a laboriousand time-consuming process as many genes can only be analyzed afterfixation of cells. We sought to establish an approach in which theexpression of pluripotency genes can be monitored in live cells usinga fluorescent reporter. Methods: The detection of gene expression wasaccomplished by adding Cy3-labeled reporter probes (SmartFlares™)directly to living cells. Expression of a gene of interest yields an orangefluorescence. The reporter sequences used for GAPDH,NANOG and GDF3span sequences homologous between human, mouse and pig, thereby


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allowing the simultaneous detection of gene expression in cells ofdifferent species. Results:We first established the technology by addingGAPDH-specific probes at 100 pM to fibroblasts of different species. Astrong fluorescent signal could be detected in human 293 cells and inprimary murine, porcine and ovine fibroblasts for at least 72 hours. In anext step we used NANOG- and GDF3-specific probes to evaluate theexpression of pluripotency genes in establishedmurine ES cell lines. Theexpression of both genes was readily detected in these cells though theeffective concentration of SmartFlares™ had to be raised to 400 pM.Using these conditions the expression of NANOG and GDF3 could also beshown in iPS clones of human, murine and porcine origin. Finally, wereprogramed murine tail tip fibroblasts with a lentiviral constructcontaining the four Yamanaka factors. When developing iPS coloniesstarted to appear in culture NANOG- and GDF3-specific probes wereadded to the cells. A strong fluorescence was obtained in manydeveloping iPS colonies indicating that they have been properly reprog-ramed to a pluripotent state. Conclusion: Our results show that fluores-cent gene-specific reporter probes are able to reliably monitor geneexpression in live cells across different species. This approach allows arapid and easy screening process for truly reprogramed iPS colonies.

SC184Cardiomyocyte derived from inducedpluripotent stem cells are more sensitive toischemia then naïve cardiomyocytesBrodarac A.1, Oberwallner B.1, Saric T.2, Choi Y.-H.3,Hescheler J.2, Stamm C.41Berlin Center for Regenerative Therapies, Berlin, Germany,2Universität zu Köln, Neurophysiologie, Köln, Germany,3Universität zu Köln, Herzchirurgie, Köln, Germany,4Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefäßchirurgie, Berlin, Germany

Objectives: Cardiomyocytes derived from induced pluripotent stemcells (iPS-CM) may be suitable for myocardial repair. While theirphenotype and function in standard culture conditions is comparableto that of naïve cardiomyocytes, the iPS-CM response to ischemia has sofar not been investigated. Methods: iPS-CM were differentiated andpurified from murine iPS cells expressing GFP and α-myosin-inducedpuromycin resistance, while naïve cardiomyocytes (NMC) were ob-tained from neonatal mouse hearts. The simulated in vitro ischemiamodel consisted of 3 h hypoxia (1%O2) and glucose/serum deprivation.Cell damage was quantified by caspase 3/7, 8 and 9 activation, TUNELand 7-Aminoactinomycin D presentation (7-AAD), visualization of themitochondrial potential (JC-1), metabolic activity (MTS test) and ATPmeasurement. Activation of intracellular signaling cascades was evalu-ated by qRT-PCR and Western blotting. Finally, the protective effect ofmultipotent stromal cell-conditioned medium on iPS-CM and NMC insimulated ischemia was assessed. Results: In response to simulatedischemia, 48 � 5% iPS-CM and 23 � 3% NMC displayed poly-caspaseactivation (p<0.01), with a similar pattern for individual activities ofcaspase 3/7, 8 and 9. Ten � 3% iPS-CM and 2.7 � 0.1% NMC were 7-AADpositive (p¼0.02), while the proportion of TUNEL-positive cells wassimilar. The average mitochondrial membrane potential was reduced iniPS-CM as compared with normoxic cells, but remained unchanged inNMC. The MTS conversion rate was significantly more reduced in“ischemic” iPS-CM than in NMC (p¼0.001), as was the average cellularATP content (p¼0.01). Transcriptional upregulation of heat shockprotein 70 (Hsp70) was blunted in iPS-CM compared to NMC, as wasthe phosphorylation of STAT3 and PKCε. MSC-conditioned mediumrestored metabolic activity in iPS-CM and NMC to similar extent(p<0.05 vs. normoxia, intergroup p¼0.6), but only iPS-CM reactedalso with a significant increase in ATP synthesis (p<0.05) Conclusions:The response of iPS-CM to simulated ischemia is not identical to that ofnaïve cardiomyocytes. It remains to be determined whether this is areprogramming-induced phenomenon or a reflection of cellular matu-rity. Concomitant treatment with MSC conditioned medium may helpimprove the iPS-CM resistance to ischemia.

SC185Exercise affects mitochondrial function andinsulin response in skeletal muscle and fatdifferentially depending on geneticpredispositionSchwarzer M.1, Molis A.1, Werner C.1, Schrepper A.1, BrittonS.L.2, Koch L.G.2, Doenst T.11Jena University Hospital - Friedrich-Schiller-University ofJena, Department of Cardiothoracic Surgery, Jena,Germany, 2University of Michigan, Department of PhysicalMedicine and Rehab, Ann Arbor, United States

Background: Patients with metabolic syndrome show an increasedincidence of heart failure and worse outcome in cardiac surgery. Ratsselectively bred for low (LCR) intrinsic aerobic exercise capacity showsigns of the metabolic syndrome with reduced systemic insulin sensi-tivity, compared to their counterparts bred for high intrinsic aerobiccapacity (HCR). Exercise has been described to improve survival, musclefunction and insulin sensitivity in patients. Objective:We tested in LCRand HCR the impact of exercise on mitochondrial function in skeletalmuscle and fat. Methods: We applied aerobic interval training to maleHCR and LCR rats for 4weeks.We performed echocardiography to assesscardiac function. Mitochondrial function was assessed using citratesynthase assay as marker. We studied insulin response, glucose metab-olism and glucose uptake in exercised and sedentary HCR and LCR ratsusing the hyperinsulinemic-euglycemic clamp. Results: After 28 gen-erations of selective breeding, LCR displayed a diabetic phenotype(fasting glucose 4.0 � 0.1 mmol/l vs. 3.5 � 0.1, p< 0.01) compared toHCR. LCR and HCR differed in their exercise capacity (LCR vs. HCR 194�26 m vs. 1717 � 37) and body weight (523 � 16g vs. 379 � 19).Echocardiography did not reveal differences in cardiac function ormorphology before or after exercise. Exercise decreased body weightin both LCR and HCR (-17.4% vs. -15.7%) and increased heart to bodyweight (þ12.6% vs. þ11.4%). Exercise reduced epididymal fat pads andliver weight significantly. LCR displayed higher random glucose, fastingglucose as well as lower glucose infusion rate and glycolysis rate duringclamp. Thesefindings were not affected by exercise. Basal mitochondrialcitrate synthase activity and insulin induced glucose uptake of skeletalmuscle and fatwas not different betweenHCR and LCR. Exercise inducedan increase in mitochondrial activity and in 2-deoxy glucose uptake ingastrocnemius of HCR only (31.9%). Similarly, exercise increased mito-chondrial activity in epididymal fat of HCR. The increase of 2-DG uptakein epididymal fat was more pronounced in HCR (29.0% LCR vs. 51.5%HCR). Conclusion: Rats with metabolic syndrome show less response toexercise. Our results suggest that genetic predetermination for aerobicexercise capacity also affects the individual's response to exercise. Thesefindings require further investigation because they may affect theapplication of exercise in heart failure patients.

SC186Direct in vitro lineage reprogramming ofmurine fibroblasts into cardiomyocytes inducescell deathBachamanda-Somesh D.1, Klose K.1, Protze S.2, Kurtz A.1,Gossen M.1, Stamm C.31Berlin Center for Regenerative Therapies, Berlin, Germany,2Technische Universität Dresden, Institut fürPharmakologie und Toxikologie, Dresden, Germany,3Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefäßchirurgie, Berlin, Germany

Objective: Direct reprogramming of fibroblasts into cardiomyocytes(rCM) is a novel concept for de novo creation of contractile cells thatavoids the problems associated with pluripotent stem cell technology.However, in vitro and in vivo reprogramming efficiency is low, and thereasons for this are unknown to date. Methods: High titer IRES-GFPlentiviral vectors for delivery of the cardiomyocyte transcription factorsGata4 (G), Mef2c (M), Tbx5 (T) and Myocardin (My) were produced inHEK293TN cells using a 2nd generation lentiviral packaging system.Transduction efficiency (FACS) and correct transgene expression (west-ern blot, immunocytochemistry) upon infection of murine embryonicfibroblasts (MEF) and murine adult cardiac fibroblasts (CF) were exam-ined. To initiate cardiac reprogramming, mouse fibroblasts, were


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transduced with the factor cocktails GMT, MyMT and GMTMy with amultiplicity of infection (MOI) of three for each virus particle. Thefollowing day, infection medium (DMEM) was replaced by reprogram-ming medium (DMEM:M199 3:1). Cell morphology, GFP fluorescence,cardiac marker expression (α-MHC, c-Tnt, α-actinin; immunochemis-try), contractions and cell viability were monitored throughout thereprogramming process. Results: Within 4 weeks of reprogramming,both infected MEF and CF displayed GFP fluorescence indicating suc-cessful transfection. Lentiviral transduction efficiencies in MEF and CFwere>90%. Expression of correctly sized transgenes and their nuclearlocalization was confirmed for all transcription factors in GFPþ (virustransduced) cells. Individual transgene expression (G, M, T, My) wasconfirmed by Western blotting, and MEF or CF changed their morphol-ogy from the original spindle shape to flattening and multi-directionalspreading. However, prior to the onset of relevant cardiomyocytemarker gene expression (α-MHC, c-Tnt, α-actinin), cell viability de-creased markedly compared to that of non-infected fibroblasts, and theproportion of cells detached cells increased in the Gata4, Mef2c, Tbx5,and Myocardin groups. Conclusion: Direct cardiomyocyte reprogram-ming of fibroblasts induces to cell death upon transfection and trans-gene expression. Strategies to counteract this loss of cells are required tooptimize reprogramming efficiency, because rCM, in contrast to re-programmed pluripotent stem cells, have little or no proliferativepotential.

SC187Exogenous Mesp1 expression induces a cardiacprogenitor fateKrane M.1, Doppler S.1, Deutsch M.-A.1, Werner A.1,Zgudziak P.1, Wu S.2, Lange R.11Deutsches Herzzentrum München, Klinik für Herz- undGefäßchirurgie, Experimentelle Chirurgie, Munich HeartAllince, München, Germany, 2Dept. of Medicine/Division ofCardiovascular Medicine Stanford Cardiovascular Institutefor Stem Cell Biology & Regenerative Medicine StanfordUniversity School of Medicine, Lokey Standford, UnitedStates

Objectives: Direct conversion of fibroblasts into cardiomyocyte-likecells was reported by using Gata4, Mef2c and Tbx5 (GMT) as reprog-ramming transcription factors. Beside us, many other investigatorsreported the insufficient reprogramming capacity of GMT to induce acomplete phenotype conversion into cardiomyocyte like cells.Mesp1, anearly temporarily expressed transcription factor is regulating mesen-dodermal cell fate during development. Transient expression of Mesp1in embryonic stem cells (ES) leads to a significantly increased cardiacprogenitor number during in-vitro differentiation. Methods: A murineNkx 2.5 cardiac enhancer GFP transgenic line was used as reporter lineto detect transdifferentiation of somatic cells into cardiac progenitor-like cells. Tail tip fibroblasts as well as satellite cells isolated from theupper limb were used as starting cell material. Transduction of Mesp1was achieved by using retro - and lentiviral systems. After transductioncells were cultured for additional 14 days. Fluorescence microscopy,FACS analysis, quantitative RT-PCR and gene-expression microarrayanalysis were performed to evaluate the influence of exogenousMesp1 overexpression on somatic cells. Results: Retroviral as well aslentiviral transduction led to a significantly increased expression ofMesp1 (> 80-fold) in somatic cells over untransduced control cells 7 and14 days after transduction. No activation of theNkx 2.5 cardiac enhancerGFP reporter transgene could be detected by fluorescencemicroscopyorFACS analysis after singular transduction ofMesp1. Quantitative RT-PCRrevealed a significant induction of theNkx2.5 expression (12.6-fold after7 days; 3.5-fold after 14 days). Additionally a significantly increasedTroponinT expression (6.1-fold after 7 days; 29.9-fold after 14 days) wasdetected in Mesp1 transduced fibroblasts over untransduced controlcells. Gene-expression microarray analysis showed a similar expressionpattern forMesp1-transduced satellite cells compared to Nkx2.5 cardiacenhancer GFP positive progenitor cells isolated from differentiatedNkx2.5 cardiac enhancer GFP ES cells suggesting a more general induc-tion of a progenitor-like cell expression pattern by Mesp1. So far, nobeating cells could be observed after singular transduction of Mesp1.Conclusion:Mesp1 seems to play an important but not sufficient role for

the induction of cardiac progenitor-like cells during direct reprogram-ming of somatic cells.

SC188Protective effect of apigenin in a rat model oflung ischemia-reperfusionBougioukas I.1, Jebran A.F.1, Stojanovic T.1, Didilis V.1, BiretaC.1, Waldmann-Beushausen R.1, Schöndube F.A.1, Danner B.C.11Universitätsmedizin Göttingen, Dept. of Cardiothoracicand Vascular Surgery, Göttingen, Germany

Objectives: Ischemia-reperfusion injury describes the sequence ofpathological alterations occurring after cessation and reinstitution ofblood circulation in a tissue. Lung Ischemia-Reperfusion Injury (LIRI)may result from trauma, pulmonary embolism, pulmonary thrombosis,and surgical procedures, such as lung transplantation and cardiopul-monary bypass during heart operations. The aim of our study was toexamine the protective function of the flavonoid apigenin in a rat modelof LIRI of the left lung. Material and methods: For our purpose 32 maleWistar rats of 250-300g, were used and divided into eight groups:baseline and sham group, and 6 investigation groups with ischemia ofeither the left lung hilum or the left pulmonary artery. This includes 2control groups without studymedication (NaCl) and 2 groups each withone or two doses of apigenin intraperitoneally. In investigation animalsthirty minutes of ischemia and 60 minutes of reperfusion were applied,whereas all vital parameters were continuouslymonitored. The animalswere sacrificed at the end of reperfusion; the heart and both lungs wereextracted and examined for morphological changes and blood sampleswere obtained. The phosphorylation of NF-κB was measured by West-ern-blot, as well as levels of IL-1β, Il-6, IL-10, iNOS and TNFα wereanalyzed. Results: The Western-blot analysis revealed a markedlyactivation of NF-κB in the sham group and in the intervention groupusing NaCl, while the activation was suppressed in the apigenin-applicated groups. Levels of TNFα, iNOS and IL-6 also showed correlatedvalues. The light microscopy confirmed the induction of tissue injury inboth lungs in all but the baseline groups. The results suggest that thesurgical procedure itself can induce a large damage to the lung tissue.The application of apigenin, especially in a single dose, had a beneficialeffect confining the tissue damage. Conclusion: The surgical procedureitself can induce a large damage to the lung tissue, with the effect beingdetrimental in both lungs. Administration in a single dose of apigenincan limit the ischemia-reperfusion damage.

SC189MZF1 is differentially expressed in humancardiac tissue of different age and c-KITþ

progenitor cells in the human adult heartDoppler S.1, Dreßen M.1, Lahm H.1, Werner A.1, Deutsch M.-A.1, Kornek M.1, Hörer J.1, Voss B.1, Schreiber C.1, Lange R.1,Krane M.11Deutsches Herzzentrum, München, Germany

Objectives: The paradigm of a quiescent myocardium is obsolete sinceseveral resident progenitor cell populations have been identifiedwithinthe heart by well-known stem cell surface markers like Sca1 or c-Kit.Recently we identified a potential role of the transcription factormyeloid zinc finger 1 (Mzf1) during murine embryonic heart develop-ment. Therefore, we investigated the role of MZF1 in human cardiactissue of various age and in resident c-KITþ progenitor cells obtainedfrom the human adult heart.Methods: Human tissue was derived fromatrial or ventricular biopsies of patients (aged from 4month to 75 years)undergoing heart surgery at the German Heart Center Munich. For geneexpression analysis by qRT-PCR biopsies were directly snap-frozen inliquid nitrogen after the surgical procedure. For magnetic activated cellsorting (MACS) heart biopsies from adults were put into physiologicalRinger's Solution. Single cell suspension was prepared and MACS wasperformed with an anti-c-KIT antibody. Gene expression within the c-KITþ and the c-KIT� cell population was compared by qRT-PCR. Results:MZF1 expressionwas increased about 160-fold in cardiac tissue samplesfrom infants (<7 months) compared to aged adults (> 65 years). Anaverage amount of 3.1%� 1.1% c-KITþ cells could be isolated fromhuman


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adult heart tissue by MACS. An 18-fold elevated c-KIT expression wasconfirmed by qRT-PCR in the c-KITþ over the c-KIT� cells (p¼0.002).MZF1 was increased about 3-fold in the c-KITþ resident progenitor cellscompared to their c-KIT� counterparts (p¼0.035). Conclusion: It couldbe shown that MZF1 expression levels were increased in infantilecompared to aged cardiac tissue which is in line with previous resultsobtained from a mouse model. Furthermore MZF1 was differentiallyexpressed in a human c-KITþ cardiac progenitor cell population, whichshowed a significant improvement of cardiac function and a reduction ofinfarct size in the recently published SCIPIO trial. These facts mayindicate a role of MZF1 in the infantile human heart and in resident c-KITþ cardiac progenitor cells.

SC190Stem cell transplantation: Are there age-dependent differences in stem cell behaviour?Stubbendorff M.1, Deuse T.1,2, Lange C.3, Hua X.1,Reichenspurner H.2, Robbins R.4, Volk H.-D.5, Schrepfer S.1,41TSI Labor, Hamburg, Germany, 2Cardiovascular Surgery,UHZ, Hamburg, Germany, 3Stem Cell Transplantation,Hamburg, Germany, 4Cardiothoracic Surgery, Stanford,United States, 5Medical Immunology and Berlin-Brandenburg Center for Regenerative Therapies, Berlin,Germany

Aims: Mesenchymal stromal cells (MSCs) are utilized in cell-basedtherapies. In this study we compared phenotype, proliferation rate,migration, immunogenicity, and immunomodulatory capabilities ofbone marrow derived MSCs from a healthy 6 month old infant(iMSC), and multimorbid donors above 70 years (sMSC).Methods: Cellswere characterized by FACS and mesenchymal lineage differentiation.Their proliferative and migratory potential was compared and theimmunogenicity of the MSCs was assessed using FACS, ELISPOT, anddonor specific antibodies. Results: Both groups of MSCs showed thesame potential to differentiate into cells of themesenchymal lineage andthe expression of typical MSC surface markers. However, iMSCs showedhigher proliferation (p<0.001) and migration (p<0.001) rates. Nosignificant difference was observed in fold change between iMSCs andsMSCs for HLA class I- (24.5 vs. 21.7), β2 microglobulin- (20.6 vs. 14),HLA class II- (1 vs. 2.4), and co-stimulatory molecule expression. Both,iMSCs as well as sMSCs, provoked similar TH1 and TH2 responses inunidirectional ELISPOT (spotfrequencies IFNγ iMSC 106 � 49 vs. sMSC80� 73 and IL-4 108� 70 vs. 105� 107) assays. Conclusions:Our resultssuggest that donor age does not seem to influence the immunogenicityand immunomodulatory properties of bone marrow derived MSCs, buttheir proliferation and migration capacity.

SC191How do cardiomyocytes sense stretch? Effectsof cyclic mechanical stretch on cardiomyocytecellular organizationDhein S.1, Schreiber A.1, Steinbach S.1, Kostelka M.1, Mohr F.W.11Herzzentrum Leipzig, Klinik f. Herzchirurgie, Leipzig,Germany

Objectives: We wanted to find out how cardiomyocytes sense stretchand how stretch affects cytoskeleal organization.Methods:Neonatal ratcardiomyocytes cultured on felxible membranes, were subjected tocyclic mechanical stretch (1 Hz, 10% eliongation) for 24 h, either ascircular or as longitudinal stretch, using the FlexCell stretch system. Cellswere treated either with vehicle, the focal adhesion kinase (FAK)inhibitor PF-573,228 (100 nM), or the stretch-activated ion channelblocker gadolinium (Gd3þ; 10 µM). Results: Cyclic mechanical stretchinduced elongation of the cardiomyocytes together with accentuation ofCx43 at the cell poles, and with an orientation of the cell axis transverseto the radial stretch, or -in other words- near to the circumferentialstretch axis. Moreover, stretch resulted in ca. 1.4 fold increased Cx43expression. FAKwas found to be phopshorylated at the edges of the cells.In order to find out, how cardiomyocytes might sense stretch, we firstinvestigated a possible effect of Gd3þ. It became obvious that Gd3þ hadno effect on elongation or polarization and did not affect stretch-

induced Cx43 expression. Next, we tested a possible influence of theFAK-inhibitor on the stretch -induced changes. Interestingly, the FAKinhibitor antagonized completely the stretch-induced elongation, ori-entation and Cx43-polarization. However, the stretch-induced Cx43expression was insensitive to this treatment. In order to clarify thefinding that the cells in circular stretch did not exactly organize eithertransverse or longitudinal to the stretch axis, we decided to use alongitudinal stretch protocol. In longitudinally stretched cells, we foundthat the cardiomyocytes also showed elongation, Cx43 polarization, andorientation near to the stretch axis, but -as in circular stretch- notexactly in the stretch axis but ca. 25° to it. This means that this directedstretch gives the cell a vector of force. In order to test whether this leadsto an orientation, we investigated the tubular system, the Golgi appara-tus, the SR and the nucleus. We found that the microtubules orientatednear to the stretch axis (i.e. in longitudinal cell axis), the Golgi movedtowards the vertex of the stretch angle, while the nucleus movedtowards the rear of the cell. The plus motor protein kinesin accentuatedat the cell poles. Conclusions: Stretch is sensed via FAK and leads tointracellular re-organization and orientation.

SC192Sternal bone marrow is a suitable autologouscell source for cardiac stem cell therapiesArar M.1, Rotärmel A.1, Knoefel A.-K.1, Baraki H.1, KutschkaI.1, Shrestha M.1, Haverich A.1, Martens A.11Medizinische Hochschule Hannover, Klinik für Herz-,Thorax-, Transplantations- und Gefäßchirurgie, Hannover,Germany

Background: Autologous intramyocardial transplantation of CD133positive bone marrow derived stem cells (BMSC) is currently investigat-ed in cardiac regenerative therapy. Since sternal bone marrow is readilyaccessible during cardiac surgery procedures, it might be a suitablesource for autologous stem cell harvest. However, little is known aboutthe factors influencing stem cell yield and quality after sternal bonemarrow aspiration. Material and methods: Between 09/2012 and 09/2012 sternal bone marrow was harvested from 39 cardiac surgerypatients after informed consent and CD133/CD34 double positiveendothelial progenitor cells (EPC) were isolated. Patients were dividedinto two groups (Group A: N¼18, 09/12-04/12; Group B: N¼21, 07/13-09/13). Harvesting and isolation protocols were refined between thetwo series. In Group B stem cell yield was additionally correlated withclinical data. Results: Groups did not differ in age (P¼0.92). Totalvolume of harvested bone marrow and CD133 positive BMSC yieldper ml BM was significantly higher in Group B (Volume [ml]: GroupA¼113� 13, Group B¼169� 32, P<0.0001; cell yield [CD133 positivecells/ml BM]: Group A¼3.5*10^3 � 2.3*10^3; Group B¼7.8*10^3 �3.6*10^3, P<0.0001). Total amount of CD133 positive cells was 0.3 �0.2*10^6 in Group A and 1.0 � 0.5*10^6 in Group B, respectively(P<0.0001). Cell vitality after separationwas 95� 4%. Total cell amounttended to decreased with age (Group B, R2¼0.43, P¼0.001) and Euro-score (Group B, R2¼0.19, P¼0.045). Discussion: After meticulouslyestablishing harvesting techniques and separation protocols, sternalbone marrow is a suitable autologous BMSC source for cardiac regener-ative therapies with sufficient cell yield and vitality. With automatedGMP conform separators available in the near future cell therapy andcardiac operation could be combined in one procedure, limiting cellhandling and transportation.

SC193Factors released by cord blood-mesenchymalstromal cells protect endothelial cells throughactivation of STAT3 signalingBader A.1, Kang K.-S.2, Kurtz A.1, Stamm C.31Berlin Center for Regenerative Therapies, Berlin, Germany,2Seoul National University, Seoul, Korea, Republic of,3Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefäßchirurgie, Berlin, Germany

Objectives: Soluble factors secreted by stem cells are known to conveypro-survival signals. We have previously analyzed the anti-ischemiceffects of cord blood mesenchymal stromal cells (MSC) on


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cardiomyocytes and now studied their impact on endothelial cells thatmediate the coronary vascular response to acute infarction and chronicischemia. Methods: Human CBMSC or foreskin fibroblasts were hypox-ia-stimulated and the thus conditionedmedium (MSC-CM or F-CM)wascollected and processed. Then, human umbilical vein endothelial cells(HUVEC) were subjected to varying models of simulated in vitroischemia with glucose/serum deprivation at normoxia or hypoxia(0.5% or 21% O2) in the presence of CM or naïve control medium.Metabolic activity (WST-8 conversion), proliferation (BrdU uptake),apoptosis (triple morphology assay), and necrosis (CytoTox-ONE LDHrelease assay) were measured. Phosphorylation of Akt, ERK and STAT3protein was assessed byWestern blotting, and mRNA expression of Bcl-2, Bcl-XL, Mcl-1, and BAG-1 was studied by qPCR. Experiments wererepeated in the presence of small molecule signaling inhibitors. Results:HUVEC damagewasmost pronounced under glucose serum deprivationat 21% O2. Here, bothMSC-CM and F-CM induced significantly increasedHUVEC viability (MSC-CM 89%� 7%; F-CM 95 � 5%; control 69%� 3%, p<0.05), higher proliferation index (MSC-CM 0.92 � 0.03; F-CM 0.95 �0.02; control 0.42 � 0.08, p <0.001), and a reduced frequency ofapoptotic cells (5� 1-fold increase vs. baseline; F-CM 6� 1-fold, control10 � 1-fold, p <0.05). This was associated with amplified phosphory-lation of STAT3 (7.1 � 0.9-fold, p <0.001) and expression of STAT3target genes Bcl-2 (2.9� 0.2-fold, p <0.001) andMcl-1 (1.5� 0.2-fold, p<0.05). When STAT3 phosphorylationwas blocked, the beneficial effectof CBMSC-CM on endothelial cell viability was completely abolished.With F-CM, HUVEC displayed a comparable signaling throughout.Conclusions: Factors released by CB-MSC protect endothelial cellsfrom the deleterious impact of glucose/serum deprivation by activationof the STAT3 survival pathway. However, this phenomenon is not stemcell specific and can be reproduced using mature fibroblasts.

SC194The impact of hypoxia on heart failure-induceddepression of multipotent stromal cells frombone marrow or cord bloodKlose K.1, RoyR.1, Bader A.1, Brodarac A.1, Kurtz A.1, KangK.-S.2, Bieback K.3, Choi Y.-H.4, Stamm C.51Berlin Center for Regenerative Therapies, Berlin, Germany,2Seoul National University, Seoul, Korea, Republic of,3Universität Heidelberg, Transfusionsmedizin, Mannheim,Germany, 4Universität zu Köln, Herzchirurgie, Köln,Germany, 5Deutsches Herzzentrum Berlin, Herz-, Thorax-und Gefäßchirurgie, Berlin, Germany

Objective: There is significant discrepancy between the disappointingoutcome of clinical cell therapy for myocardial regeneration and thepositive data from animal experiments. We have previously shown thatone possible explanation is the negative impact of heart failure (HF)serum factors on “healthy” stem cells. Tomimic the situation in ischemicmyocardiummore closely, we now studied this phenomenon in hypoxiain both bone marrow multipotent stromal cells (BM-MSC) from heartfailure patients and healthy neonatal cord blood MSC (CB-MSC).Methods: Serum was obtained from patients with severe HF requiringcardiac surgery (n¼21) and from healthy volunteers (n¼12), and thesystemic quality of HF was confirmed by elevated IL-6, TNF-α (ELISA).CB-MSC and BM-MSC were cultivated for up to 14 days in DMEM-LGsupplemented with 10% protein-normalized human HF or non-HFserum. For control, assays were run parallel with fetal calf serum(FCS). After confirming MSC morphology, tri-lineage mesodermal dif-ferentiation potential and immunophenotype (FACS), cell proliferation(MTS test) and necrosis (LDH release) were quantified daily. All experi-ments were done in normoxia and under hypoxia (1%O2) and glucosedeprivation. Results: Overall, CB-MSC and BM-MSC proliferation rate inHF and non-HF serum were similar that in FCS at normoxia butsignificantly suppressed in hypoxia. In normoxia, CB-MSC proliferationin HF serum was equivalent that of non-HF serum, while BM-MSCproliferation was accelerated by HF. In hypoxia, however, both CB-MSCand BM-MSC proliferation were stimulated by HF. In contrast, LDHrelease was higher in hypoxic BM-MSC than in CB-MSC. The prolifera-tion block displayed features of G1 arrest in the cell cycle analysis andwas associated with expression of cell cycle inhibitors (p21, p27),apoptosis markers (pp53, Caspase3), as well as JNK and ERK1/2 signal-

ling. Conclusion: While heart failure serum factors may suppress“donor” CB-MSC activity, “autologous” BM-MSC proliferation is stimu-lated but their susceptibility to hypoxia is increased. This phenomenonshould be considered when choosing the optimal MSC product for celltherapy in heart failure patients.

SC195Role of micro RNAs in obesity-mediatedpremature cardiac ageing in patientsHecker F.1, Niemann B.2, Christov V.3, Simm A.4, Li L.1,Böning A.2, Rohrbach S.11Justus Liebig Universität Giessen, Physiologisches Institut,Giessen, Germany, 2Justus Liebig Universität Giessen, Klinikfür Herz- Kinderherz- und Gefäßchirurgie, Giessen,Germany, 3Martin Luther Universität, Zentrum fürmedizinische Grundlagenforschung, Halle, Germany,4Martin Luther Universität, Klinik für Herz- undThoraxchirurgie, Halle, Germany

Background: Obesity results in signs of increased oxidative stress, pro-apoptotic activation, impairedmitochondrial biogenesis and function incardiomyocytes and disturbances in whole-body glucose metabolismand adipocytokine release in young obese patients. These disturbancesresemble many of the changes otherwise observed in older patients,suggesting a prematurely aged phenotype in young obese patients.MicroRNAs are small noncoding RNAs that posttranscriptionally controlgene expression. They have emerged as diagnostic tools and arecurrently investigated as novel therapeutic options to preserve cardiacfunction. Here, we investigated the effect of obesity on expressionalpatterns of micro RNAs (miRNAs) in right atrial (RA) tissue of patients.These data were compared with data obtained from the RA of ratsundergoing caloric restriction (CR, -40%) in order to identifymicro RNAsmutually regulated by CR or obesity. Methods: We obtained samplesfrom the right atrium (RA) of male young (50.2 � 5.2 years) andnormosome/obese (BMI 24.0� 1.1 / BMI 33.8� 4.3) patients undergoingcardiac surgery and male rats undergoing CR (6 months, -40%). Thescreens for differentially expressed micro RNA's was performed withmiRCURY LNA™microRNA Arrays (Exiqon) and confirmed by real-timePCR. Target gene predictionwas performed by three independent onlinetools and confirmed with luciferase reporter gene assays and Westernblotting. Results: Obesity resulted in the differential expression of 31miRNAs in human RAs, while altered the expression of 24 miRNAs.Among these miRNAs, 8 miRNAs (let7a, let7c, miR143, miR23a, miR26a,miR26b, miR29a and miR-292-5p) were mutually regulated by obesityand by CR. The differential expression ofmany of thesemiRNAs could beconfirmed by qPCR in RA tissue from patients and rats. Among theconsistent target genes of these differentially expressed miRs weregenes involved in cardioprotection and in ageing processes such asPGC-1alpha, SIRT3 and IGF1. Theses target genes were confirmed byreporter gene analyses and Western blotting. First functional analysessuggest an influence of the differentially expressed miRNAs on cellviability and apoptosis in vitro. Conclusion: Differential expression ofmiRNAs is induced by obesity in RA tissue of young patients and maycontribute to the prematurely aged phenotype of cardiomyocytes.

Transcatheter valves III: TAVI / new developments

SC196Early onset valve thrombosis due to insufficientanticoagulation therapy after transapical valve-in-valve TAVI for failed mitral bioprosthesisAlexiou K.1,WilbringM.1, Arzt S.1, Matschke K.1, Kappert U.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: Valve-in-valve TAVI has been demonstrated to be an effec-tive treatment option in selected high-risk patients. In most reportedcases, anticoagulation therapy solely consists of acetylsalicyclic-acid 100mg/day - as recommended in other bioprostheses. We describe twopatients suffering from beginning valve thrombosis due to insufficientanticoagulation. Case report: Two 74-years old patients presented with


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high graded mitral regurgitation (MR) after combined mitral repair andcoronary artery bypass grafting (CABG) for ischemic MR 5 and 8 yearsago, respectively. The “Heart Team” decided for TAVI due to prohibitivesurgical risk, mainly based on severely impaired ventricular functionand a broad spectrum of scoring-relevant comorbidities. Coronaryangiography revealed patent bypasses. Both patients underwent trans-apical valve-in-valve TAVI using 29 mm Edwards SAPIEN XT™ biopros-thesis. The procedures themselves and further hospital stay wereunremarkable. Echocardiography revealed well prosthesis functionwith trace transvalvular regurgitation. Because of stable sinus rhythmand absence of further indications for oral anticoagulation, both patientswere dismissed with acetylsalicyclic-acid 100 mg/day. After 2 and 3months, respectively, both patients were readmitted to hospital due toincreasing transvalvular pressure gradients. Echocardiography showedthickening of the leaflets by means of a beginning valve thrombosis.Endocarditis was ruled out by lab-testing. Subsequently oral antico-agulation therapy targeting an INR of 2.5 was started and valve functionas well as transvalvular pressure gradients completely normalizedwithin 2 weeks. Conclusion: Sole therapy with acetylsalicyclic-acid isnot sufficient and thus, permanent oral anticoagulation is advocatedafter mitral valve-in-valve TAVI. Dead spots between the scaffold of thetranscatheter valve and struts of the bioprosthesis might cause relevantflow deceleration.

SC197Transapical transcatheter aortic valveimplantation using a sutureless access andclosure device: 6-months results of the multi-center CE mark studyConradi L.1, Holzhey D.2, Kempfert J.3, Diemert P.4, Linke A.5,Reichenspurner H.1, Blumenstein J.6, Möllmann H.6, TreedeH.1, Walther T.31Universitäres Herzzentrum Hamburg, Klinik undPoliklinik für Herz- und Gefäßchirurgie, Hamburg,Germany, 2Herzzentrum, Leipzig, Germany, 3Kerckhoff-Klinik Bad Nauheim, Klinik für Herzchirurgie, BadNauheim, Germany, 4Universitäres HerzzentrumHamburg,Klinik für Allgemeine und Interventionelle Kardiologie,Hamburg, Germany, 5Herzzentrum Leipzig, Klinik fürKardiologie, Leipzig, Germany, 6Kerckhoff-Klinik BadNauheim, Klinik für Kardiologie, Bad Nauheim, Germany

Objectives: Transapical transcatheter aortic valve implantation (TA-AVI) has become clinical routine for treatment of severe aortic stenosisin inoperable or high-risk patients. We sought to assess feasibility andsafetyof a newsutureless apical access and closure device.Methods: Theapical access and closure device (ASC™, Apica Cardiovascular Ltd.,Galway, Ireland) consists of a low-profile titanium coil which is pre-mounted onto the introducer sheath of a balloon-expandable TAVIdevice and inserted into the apical left-ventricular myocardium byrotation. Subsequent to the TAVI procedure, a closure cap is introducedfor sealing. Results: A total of 31 high-risk elderly patients (age 82 (68-90), 51.6% male, additive EuroSCORE I�9% 31/31 patients) wereallocated to receive TA-AVI by the local interdisciplinary Heart Teamand recruited for the trial at three German sites after written informedconsent. In all 31 patients placement of the ASC™ device, subsequentTA-AVI and final sealing were successfully achieved. Mean proceduretime was 62.4 (43-91) minutes, mean total intraprocedural blood lossassociated with the use of the device was 97 (20-250) ml. No patientdied during the periprocedural phase, one patient suffered a majorstroke. Pre-discharge Holter-ECG monitoring revealed no severe ar-rhythmia in any patient (0/24). Overall mortality was 9.7% (3/31) both at30-days and at 6 months. During a follow-up of 6 months, there was nopericardial effusion or evidence of apical pseudo-aneurysm formation,mean left ventricular function was not adversely affected by the proce-dure. Conclusions: The present study demonstrated safety and feasibil-ity of TA-AVI using the ASC™ device which provided secure access andclosure in all patients treated. By its ease of use and reliability inachieving complete hemostasis the device has the potential to furtherfacilitate and standardize transapical access. It allows for a minimalincision, non-ribspreading procedure further decreasing surgical trau-ma in TA-AVI.

SC198Development of a risk score predicting 1-yearmortality after transcatheter aortic valveimplantationSeiffert M.1, Sinning J.-M.2, Meyer A.3, Conradi L.4, Wilde S.1,Vasa-NicoteraM.2, GhanemA.2, Kempfert J.3, HammerstinglC.2, Ojeda F.1, Kim W.-K.5, Koschyk D.1, Schirmer J.4, BaldusS.6, Grube E.2, Möllmann H.5, Nickenig G.2, Walther T.3,Werner N.2, Blankenberg S.1, Reichenspurner H.4, DiemertP.1, Treede H.4, Schnabel R.11Universitäres Herzzentrum Hamburg GmbH, Klinik fürAllgemeine und Interventionelle Kardiologie, Hamburg,Germany, 2Herzzentrum Universität Bonn, Klinik undPoliklinik für Kardiologie, Bonn, Germany, 3Kerkhoff-KlinikBad Nauheim, Klinik für Herzchirurgie, Bad Nauheim,Germany, 4Universitäres Herzzentrum Hamburg GmbH,Klinik für Herz- und Gefäßchirurgie, Hamburg, Germany,5Kerkhoff-Klinik Bad Nauheim, Klinik für Kardiologie, BadNauheim, Germany, 6Herzzentrum Uniklinik Köln, Klinikfür Kardiologie, Köln, Germany

Background: Transcatheter aortic valve implantation (TAVI) is an estab-lished procedure in patients with aortic stenosis and high surgical risk.Adequate patient selection is acknowledged to be crucial for the successof this approach. However, beyond surgical risk scores predicting short-term outcomes, a pre-procedural risk evaluation scheme aiming at 1-year outcomehas not been implemented.Methods:Wedeveloped a riskalgorithm for 1-year mortality in two cohorts consisting of 845 patientsundergoing routine TAVI procedures by commercially available devices,mean age 80.9 � 6.5, 51% women. Clinically available variables weredetermined at baseline. Multivariable Cox regression related clinicaldata tomortality (n¼207 deaths). Results: Age and sexwere forced intothe score. Body mass index, estimated glomerular filtration rate, hemo-globin, pulmonary hypertension, mean transvalvular gradient and leftventricular ejection fraction at baseline were most strongly associatedwith mortality and entered the risk prediction algorithm (C-statistic0.66, 95% confidence interval [CI] 0.61 to 0.70, calibration Chi2 statistic¼6.51; P¼0.69). Net reclassification improvement compared to exist-ing surgical risk predication schemes was positive. The score showedreasonable model fit and calibration in external validation in 333patients, N¼55 deaths (C-statistic 0.60, 95% CI 0.52 to 0.68; calibrationChi2-statistic¼16.2; P¼0.06). Additional measurement of B-type na-triuretic peptide and troponin I did not improve the C-statistic. Frailtyincreased the C-statistic to 0.71, 95% CI 0.65 to 0.76. Conclusions:Predicting mid-term outcome will be of major importance to guidedecision-making when patients are evaluated for TAVI. We present afirst risk score based on common baseline variables specific for 1-yearmortality after TAVI derived and validated in routine cohorts.

SC199In vivo force measurement on apically fixatedmitral valved stentsPokorny S.1, Bähr T.1, Huenges K.1, Engel A.1, Marczynski-Bühlow M.1, Morlock M.M.2, Cremer J.1, Lutter G.11Department of Cardiovascular Surgery, Christian-Albrechts-University of Kiel, School of Medicine, Kiel,Germany, 2Institute of Biomechanics, TUHH HamburgUniversity of Technology, Hamburg, Germany

Objectives: Aim of this study was the assessment of the fixation forceapplied to apicallyfixatedmitral valved stents in an experimental in vivosetting. Methods: To measure the force acting on the apical fixation ofmitral valved stents, a test set-up was developed consisting of a forcesensor aligned to the stent long axis and connected to a computer fordata recording. 16 pigs received a self-expanding valved stent in themitral position via transapical approach in an off-pump procedure. Allstents were apically anchored with a fixation system comprised of fourneochords attached to the rim of the stents. Thefirst design A (n¼8)wassolely apically anchored. The second design B (n¼8) included additionalsub-annular fixation elements. After successful stent deployment, cor-rect stent position was adjusted under control of paravalvular leakages(PVL), mitral annular plane systolic excursion (MAPSE) and hemody-namic parameters. The neochords were attached to the force sensor and


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forces were recorded during expiratory breath hold following a stan-dardized protocol. Forces were normalized to the mean systolic atrio-ventricular pressure difference of all animals. Results: Force measure-ments were successfully conducted in 13 of 16 animals (design A: n¼7;design B: n¼6). In the remaining three animals, forcemeasurement wasnot conducted due to their dysrhythmia. In group A with sole apicalfixation the forces were higher compared to the group B with additionalsub-annular fixation (p�0.048, Table1). No PVL were observed duringthe force measurement and the MAPSE showed good longitudinal heartfunction in both groups. The capillary wedge pressure (PCWP) waswithin a normal range after implantation (Table1). Conclusion:An intra-procedural force measurement systemwas developed and reproduciblyapplied to evaluate the forces acting upon the apical fixation system ofnovel mitral valved stents during the off-pump implantation procedure.This study shows, that the subanular fixation reduced the force actingupon the apex of the heart compared to the sole apical fixation.Measurement of the in vivo forces provides important informationand has impact on different prototype designs, the heart function aswell as on information for later clinical stent positioning.

Table 1: Force measurement on mitral valved stents

FMaxnorm[N]

FMinnorm

[N]FMeannorm

[N]ΔP[mmHg]

PCWP[mmHg]

MAPSE[cm]

Group A(n¼7)

4.3 �1.5 2.2 �1.2 3.3 �1.3 47 �5 10 �2 1.0�0.1

Group B(n¼6)

2.9 �1.3 1.4 �0.9 2.1 �0.9 45 �17 11 �4 1.0�0.2

Group A: sole apical fixation; Group B: additional sub-annular fixation; FMax / FMin / FMean:maximal, minimal andmean force recorded throughout the heart cycle normalized to the meanΔP(n¼13); ΔP: left atrio-ventricular pressure gradient (left atrial pressure approximated bymeanwedge pressure and left ventricular pressure approximated bymaximal arterial pressure);PCWP: pulmonary capillary wedge pressure during force measurement, MAPSE: mitral annularplane systolic excursion recorded during force measurement[Table 1: Force measurement onmitral valved stents]

SC200Eccentricity of the aortic annulus is notassociated with functional impairment of thetransapical Jenavalve in an in vitrohydrodynamic test modelEnsminger S.1, Utzenrath M.2, Kütting M.2, Achenbach S.3,Schuhbäck A.3, Jategaonkar S.4, Börgermann J.1, GummertJ.1, Steinseifer U.21Herz- und Diabeteszentrum NRW, Ruhr-UniversitätBochum, Department of Thoracic- and CardiovascularSurgery, Bad Oeynhausen, Germany, 2Institute of AppliedMedical Engineering, Helmholtz Institute, Department ofCardiovascular Engineering, Aachen, Germany, 3Universityof Erlangen-Nürnberg, Department ofMedicine 2, Erlangen,Germany, 4Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Department of Cardiology, BadOeynhausen, Germany

Background: CT analyses of patients with aortic stenosis reveal that inmany patients the aortic annulus is eccentric. Therefore, the aim of thisstudy was to assess the performance of the transapical Jenavalve® in anin vitro hydrodynamic test method comparing circular and eccentricaortic annulus geometry. Methods: Based on CT-data from 123 conse-cutive TAVI-patients, a mean annulus eccentricity (eccentricity¼ shortdiameter/long diameter) of 0.84 was determined. Two models of aorticroots with valve leaflets, one circular in shape and one displaying aneccentricity of 0.84 were created with orifice areas corresponding to acircular 27 mm annulus. Valve hydrodynamics were evaluated atdifferent flow rates and frequencies simulating various physiologicalconditions. Experiments were repeated after transferring prosthesesthat had been implanted in circular annuli to eccentric annuli. Results:Analysis was performed with transapical Jenavalve prostheses (27 mm)implanted in circular annuli (n¼ 3) or annuli with 0.84 eccentricity(n¼3). Hydrodynamic testing under both conditions showed no signif-icant difference in valve performance under both conditions. In thecircular annulus the Jenavalve showed an average regurgitation volumeof 3.49ccm � 0.12ccm [4.69% � 0.20% of total stroke volume]. An

increase of regurgitation volume to 3.57ccm � 1.61ccm [4.81% �2.05% of total stroke volume] was seen in the oval annulus, indicatingonly a small increase by 0.08ccm or 0.12% of the total stroke volume.After switching the valve groups, no difference was seen in valveperformance. Conclusion: This is the first experimental in vitro studydemonstrating no significant difference in valve performance withregard to regurgitation volume for a commercially available percutane-ous valve implanted in an eccentric annulus.

SC201Transcatheter mitral valve implantation - Thenext revolution in mitral valve therapy?Schmitz C.1, Schramm R.1, Hoffmann A.L.1, Sodian R.1, HaglC.1, Schachtner T.2, Becker C.3, Hausleiter J.4, Kupatt C.41Klinikum der Universität München - Campus Großhadern,Klinik und Poliklinik für Herzchirurgie, München, Germany,2Klinikum der Universität München - Campus Großhadern,Klinik für Anaesthesiologie, München, Germany, 3Klinikumder UniversitätMünchen - Campus Großhadern, Institut fürKlinische Radiologie, München, Germany, 4Klinikum derUniversität München - Campus Großhadern, MedizinischeKlinik I, München, Germany

Objectives: Transcatheter aortic valve implantation (TAVI) has becomean accepted treatment option for patients with an increased risk ofmortality by conventional open heart surgery. At present an approvedtranscather valve prostheses for the mitral valve does not exsist. Weanalyzed our data of patients implanted with a commercially availabletranscatheter aortic valve prosthesis in mitral position. Methods:Between 05/2008 and 09/2013 199 patients received transapical, trans-axillary or transaortic transcatheter valve implantations, 11 of them viaa transapical approach in mitral position. 5 patients had a previousmitral valve replacement, 2 a mitral valve repair (1 CE Physio ring, 1Duran ring). In 4 patients the valve was implanted in the stenotic nativevalve. 3 patients had an additional TAVI during the same procedure.Results: Procedural success was 100%. All patients received a Sapien XTTHV either 26 or 29 mm diameter. 2 patients died early postoperatively(day 0 and 2) due to right or left heart failure. Kaplan-Meier estimated 1-year survival was 82%. Conclusions: Although there are no approvedtanscatheter protheses currently available for themitral valve, in certaincircumstances the Edwards Sapien XT can be used successfully in mitralposition.

SC202Hybrid TAVR procedures for complexpathologiesSchlingloff F.1, Frerker C.2, Schäfer U.2, Schmoeckel M.1,Bader R.11AK St. Georg, Herzchirurgie, Hamburg, Germany, 2AK St.Georg, Kardiologie, Hamburg, Germany

Objectives: In the past, transcatheter aortic valve replacement (TAVR)procedures were restricted to the treatment of aortic stenosis (AS). Newaccess sites and second-generation devices allow complex hybridtreatment of multiple pathologies. We report on a series of high-riskpatients who have been treated successfully by a combination of trans-catheter procedures using new devices and different access sites in asingle session. Methods: Between November 2011 and May 2013, ourheart team treated 11 cases with complex pathologies in a hybridapproach. Procedures such as transcoronary ablation of septal hyper-trophy (TASH), percutaneous transvenous mitral commissurotomy(PTCM), MitraClip® implantation and transfemoral (TF), transapical(TA) or transaortal (TAO) valve or valve-in-valve implantation werecombined to treat multiple pathologies in a single session (table 1). Inthree patients with additional coronary artery disease (CAD), trans-aortic TAVR was combined with off-pump or beating heart coronaryartery bypass surgery (CABG), performing complete arterial revascular-ization using skeletonized bilateral IMA with T-graft technique (BIMA-TG). Results:Mean age was 81 � 5 years and mean log euroSCORE 38 �17%. Mean follow-up was 14 � 8 months (range 4-22) and 100%complete. 30-day mortality was 9% (1/11); mortality over-all was 18%(2/11). Intraprocedural success was 100% with no complications, no


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strokes, and no paravalvular leak greater than trace. So far, follow-updata demonstrated excellent results without paravalvular leakagesgreater than I°. Conclusion: Different access sites and new second-generation devices can be combined successfully in hybrid approachesto treat old patients with complex pathologies at high risk.

Table 1:

ComplexPathology...................

FirstAccess

TAVR /TMVR

Size SecondAccess

ConcomitantProcedure....................

N¼11

ASþMS TA Sapien XT 26mm26 mm

TA PTMC 2

ARþMR TA JenaValve 25 mm TF MitraClip® -Implantation

1

ASþCAD TAO CoreValve 31mm31 mm

Sterno-tomy

CABG(BIMA-TG)off_pump

2

ASþCAD TAO Sapien XT 29 mm Sterno-tomy

CABG(BIMA-TG)beatinghearton_pump

1

ASþ PVLaftermechanicalMVR

TA JenaValve 27 mm TA Implantationof 2occluders

1

ASþMSafterbiologicalMVR

TF / TA ViV-CoreV.Sapien XT

23mm26 mm

TA ViV - TMVR(Sapien_XT)

2

MS afteranuloplastyþ PVL afterTMVR

TA Sapien XT(ViR_TMVR)

23 mm TA Implantationof 1 occluder

1

ASþHOCM TA Sapien XT 26 mm TF TASH 1

Table 1: AR¼aortic regurgitation; HOCM¼hypertrophic obstructivecardiomyopathy; MR¼mitral regurgitation; MS¼mitral stenosis; MVR¼mitral valve replacement; PVL¼ paravalvular leakage; TMVR¼ trans-catheter mitral valve replacement; ViR¼ valve in ring; ViV¼ valve invalve.

SC203Trans-axillary (TAX) access is a valuable and safealternative for transcutaneous aortic valveimplantation (TAVI)Lausberg H.F.1, Sontag B.2, Friedrich I.1, Hauptmann K.E.21Krankenhaus der Barmherzigen Brüder, Herz- undThoraxchirurgie, Trier, Germany, 2Krankenhaus derBarmherzigen Brüder, Innere Medizin III - Kardiologie/Pneumologie, Trier, Germany

Objective: Transcutaneous aortic valve implantation (TAVI) has becomea rroutinely applied therapeutic alternative for a high-risk patientcohort with aortic stenosis.With transfemoral (TAF) access as a standardapproach only patiente with favorable anatomy can be treated. Moreinvasive alternatives such as trans-apical (TAP) or trans-aortic (TAO)access requiring thoracotomy appear to be less desirable in this fragilehigh-risk patient cohort. Therefore, trans-axillary (TAX) access appearsto be a less invasive alternative. Methods: Between January 2009 andJuly 2013 a total of 510 patients have undergone TAVI for aortic valvepathology in our center. Of these, 451 were implanted as TAF-TAVI and42 as TAX-TAVI. We have retrospectively analyzed our experience withTAF- and TAX-TAVI. Results: Patients were similar regarding demo-graphic data and preoperative risk analysis (p¼ns). Procedures could besuccessfully completed in 449 patients with TAF- (99,5%) and in 41patients with TAX-TAVI (97.6%; p¼ns). Stroke rate was 2.4% after TAF-and 2,3% in TAX-TAVI (p¼ns). Need for pacemaker implantation was53.9% in TAF- and 48.7 in TAX. In-hospital mortality was similar in bothgroups (TAF: 3.1%, TAX:2.4%; p¼ns). Vascular complications requiringtreatment occured in 30.8% after TAF-TAVI, There were no such compi-cations after TAX-TAVI (p<0.001). Discussion: In our experience, TAX-

TAVI is a feasible and safe procedure and has proven to be a valuablealternative access sitewhenever trans-femoral access is not feasible. Theobvious disadvantages of a more invasive access can thus be avoided.Due to the size of the delivery systems, however, only few devices aresuitable for TAX-TAVI.

SC204Transcatheter aortic valve implantationcombined with coronary artery stenting: Asimultaneous approachPenkalla A.1, Pasic M.1, Drews T.1, Buz S.1, Dreysse S.1,Kukucka M.1, Mladenow A.1, Hetzer R.1, Unbehaun A.11Deutsches Herzzentrum Berlin, Herz-, Thorax- undGefäßchirurgie, Berlin, Germany

Objective:Many patients referred for transcatheter aortic valve implan-tation need coronary stent implantation. The aim of the study was toidentify if combined treatment of both pathologies has comparableresults to patientswithout CADandwith non-significant CAD.Methods:Between 04/2008 and 03/2013, 786 consecutive patients underwenttranscatheter TAVI. Group A (without CAD) consisted of 291 patients(209 women and 82 men; mean age¼79 � 9 years [range 29-99]);EuroScore¼29 � 20% (range 4-97), STS PROM score¼12 � 9% (range1.2-73). Group B (with non-significant CHD) consisted of 418 patients(209 women and 209 men; mean age¼79 � 8 years [range 37-93]);EuroScore¼38 � 22% (range 2-94), STS PROM score¼16 � 19% (range1.2-81). Themean syntax-scorewas 11� 7.4 (range 2-35). GroupC (withsignificant CHD and treated during TAVI) consisted of 77 patients (52women and 25 men; mean age¼81 � 8 years [range 36-99]); Euro-Score¼39� 24% (range 8-97), STS PROM score¼18� 16% (range 4-90).The mean syntax-score was 9 � 6.5 (range 1-38). Results: In group C, in29 patients the RCA, in 18 the LAD, in 13 the LCX, and in 17 combinedstenting of two vessels was performed. The 30-day mortality in group Awas 5.8%, in group B 5.7% and in group C 5.1%; the 1-year survival was83%, 78% and 77%, respectively; the 2-year survival was 78%, 67% and67%, respectively (p<0.01). Conclusions: Although patients with CADhave a worse long-term outcome, transcatheter aortic valve implanta-tion and coronary artery stenting can be performed simultaneouslywith good postoperative results.

SC205The transaortic approach for TAVI - How we doit (video presentation)Petzina R.1, Frank D.2, Renner J.3, Frey N.2, Cremer J.1, LutterG.11Universitätsklinikum Schleswig-Holstein, Campus Kiel,Herz- und Gefäßchirurgie, Kiel, Germany,2Universitätsklinikum Schleswig-Holstein, Campus Kiel,Kardiologie und Angiologie, Kiel, Germany,3Universitätsklinikum Schleswig-Holstein, Campus Kiel,Anästhesiologie und Operative Intensivmedizin, Kiel,Germany

Objectives: Transcatheter aortic valve implantation (TAVI) representsnowadays a well established treatment for patients with symptomaticsevere aortic valve stenosis uneligible for conventional surgery. Apartfrom the two most common access routes for TAVI, the antegradetransapical (TA) and the retrograde transfemoral (TF) access, the trans-aortic (TAo) approach offers an interesting and good alternative. Thevideo presentation demonstrate how we perform TAo-TAVI. Methods:The TAo-TAVI program started in November 2012 and until July 2013wehave operated on 30 patients. The TAo-TAVI procedure is performedunder general anaesthesia and hemodynamic monitoring. After a skinincision of 4-5 cm and a superior mini-J-sternotomy through the rightthird intercostal space a small sternum retractor is inserted. Thepericardium is opened in front of the ascending aorta. In the meantimean arterial and a venous sheath are inserted into the femoral vessels forplacing a pigtail catheter into the aortic root and a pacing wire for rapidventricular pacing into the right ventricle. Two 3-0 prolene purse stringsutures reinforced with teflon pledgets are placed at the distal part ofthe ascending aorta. A stiff wire is placed into the left ventricle throughthe aortic valve. Insertion of the Ascendra sheath and held at the 2 cm


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mark. Balloon valvuloplastie of the aortic valve and implantation of anEdwards SapienXT transcatheter valve are performed in a slowstepwisemanner under rapid pacing and fluoroscopy. The purse strings are tiedafter withdrawal of the system. A drainage is inserted into the pericar-dium and the sternum is closedwith two to three sternal wires. Results:Device success rate of the Sapien XT valve was 100%. We observedneither neurological events nor any indication for pacemaker implan-tation in all 30 TAo-TAVI patients. Thirty-day mortality was 6.6% (twopatients). Paravalvular leackage (PVL)� I was seen in 86.7% and PVL I-IIin 13.3%, while no PVL> II was observed. Conversion to open chestsurgery was required in one patient (3.3%). Operation time was 88.5 �22.9 min., x-ray time was 9.8 � 5.6 min. and 86.1 � 32.1 ml contrastagent were applied. Intensive care unit and total hospital staywere 3.6�6.3 days and 16� 11.2 days, respectively. Thirty-daymortality was 6.6%.Conclusions: The TAo approach for TAVI demonstrated excellent clinicaloutcome and is now a coequal access route for TAVI procedures besidesTA and TF in our institution.

SC206Transapical aortic valve implantation:Predictors of paravalvular leakage and impacton survival in 679 patientsUnbehaun A.1, Pasic M.1, Drews T.1, Penkalla A.1, DreysseS.1, Kukucka M.1, Hetzer R.1, Buz S.11Deutsches Herzzentrum Berlin, Berlin, Germany

Objectives: In line with our institutional strategy and the “surgical wayof thinking,” we do not accept paravalvular leakage after transcatheteraortic valve implantation (TAVI). Apart from very limited initial experi-ence, predictors of leakage in large cohorts are still lacking. Theintention of this study was to define strategies on how to anticipateand how to avoid post-procedural regurgitation. Methods: Since 2008,679 patients have undergone transapical TAVI at our institution. Thestudy group consisted of 409 female (60%) and 207 male (40%) patients.Based on the EuroSCORE II model, the estimated risk for surgery was 16� 16% (1-95%), and 5% of patients (37/679) were in cardiogenic shock.Results: To minimize leakage after initial valve deployment, re-dilationwas performed in 50/679 patients (7%) and a second valve was im-planted in 16/679 (2%). The post-procedural grade of regurgitation wasabsent or trace in 542/679 patients (80%), mild in 131/679 (19%), andmoderate in 6/679 (<1%); there was no severe post-procedural regur-gitation. Patients with more than trace post-procedural regurgitationpresented with smaller body-mass indices (p¼0.006) and received alarger prosthesis (p¼0.005), with more oversizing in terms of annulararea (p<0.001) as derived from multi-slice computed tomography. Inpatients with mild regurgitation, survival up to 5 years was identical topatients without leakage or trace regurgitation jets (p¼0.530).Conclusions: In transapical TAVI, the risk of relevant paravalvularleakage may be eliminated completely. There is no negative impact onsurvival in patients with irrelevant, lesser grades of regurgitation.

SC207Open implantation of an Edwards Sapien 29mmin an insufficient Medtronic Freestyle stentlessbiological prosthesisKloth B.1, Conradi L.1, Schirmer J.1, Reichenspurner H.1,Treede H.11Universitäres Herzzentrum Hamburg, Herz- undGefäßchirurgie, Hamburg, Germany

Introduction: In long-term follow-up structural valve degenerationbecomes one of the most frequently occuring problems in patientswith bioprosthetic aortic valves. Known risk factors for early degenera-tion are patient-prosthesis mismatch, valve design, valve tissue, anti-calcification treatment and age of the recipient. The stentless aorticbioprosthesis provides hemodynamic superiority over a stented biopro-thesis since the obstruction caused by sewing ring and the stent iseliminated. The disadvantage of a stentless valve is the implantationtechnique which is more demanding and also the removal in the case ofreoperation. Background: We report the case of a 64 year old malepatient who was readmitted with progressive dyspnea due to severeaortic insufficiency. 12 years before patient underwent surgical aortic

valve replacement (Medtronic Freestyle, Minneapolis, USA) Transoeso-phageal echocardiography revealed severe regurgitation of the aorticvalve prosthesis, a trivial mitral and tricuspid regurgitation and amoderately decreased left ventricular function. A severely calcifiedascending aorta was excluded by thoracic CT-scan. Considering theage of the patient we decided against an interventional procedure butfor redo operation. Intraoperatively we saw a severe degeneratedbioprothesis with multiple leaflet perforations. Unfortunately therewere heavy calcifications of the lowermargin of the stentless prosthesis,which was implanted in subcoronary position. Because of these calci-fications between prosthesis and natural aortic wall there was nochance of explantation without destroying the aortic root and also nopossibility of implanting a new bioprosthesis with normal sutures. As abailout on the basis of these findings we decided to implant a trans-catheter aortic valve through the open aorta. We implanted a 29 mmEdwards Sapien under direct vision. After full expansion the prosthesisshowed a perfect position and both coronary ostia were explored. Thegood result was confirmed by postoperative transoesophageal echocar-diography. After a hospital stay with no complications the patient wasdischarged 6 days later in good condition. Discussion: Reoperation afterstentless aortic valve replacement is a challenging procedure that oftenrequires aortic root replacement. Open implantation of a TAVI is a quickand effective bailout solution for patients with an unexpected calcifiedaortic root to avoid complex root replacement.

SC208Imaging based decision making: Outcome ofpatients screened for TAVI undergoing AVR dueto unfavorable anatomyKempfert J.1, Kim W.-K.1, Meyer A.1, Möllmann H.2, vanLinden A.1, Arsalan M.1, Schönburg M.1, Walther T.11Kerckhoff Klinik, Herzchirurgie, Bad Nauheim, Germany,2Kerckhoff Klinik, Kardiologie, Bad Nauheim, Germany

Objectives: Indication for TAVI is typically discussed within a HeartTeam based on age, risk-scores and individual patient factors. Cardiac CTimaging is suggested to obtain most precise annulus measurements. Inaddition, sophisticated CT analysis allows for exact visualization of apotential “hostile” anatomy for TAVI. Those patients have been system-atically identified during TAVI evaluation and subsequently underwentconventional AVR. Methods: Since 2013 unfavorable calcification pat-terns have become a major factor in our imaging based decision makingprocess during TAVI evaluation. Cardiac CT scans have been analyzedwith a dedicated software tool (3mensio). In case of “hostile” TAVIanatomy, patients were scheduled for standard or minimally-invasiveAVR. Results: A total of 31 patients were identified with unfavorableanatomy (Fig. 1) during a 9 months time frame of TAVI screening andreceived standard AVR. During this period 183 patients were deemedwell suitable based on the CT imaging and underwent TAVI as intended.Reasons not to proceed with TAVI were: LVOT calcification in 9 (29%),borderline large annulus in 8 (26%), annular calcifications in 5 (16%),borderline low valve calcification in 5 (16%) and eccentric calcificationpatterns in 4 (13%) patients. Mean age was 82 � 6 years; mean logES I19,3 � 9,5% and mean STS-Score 6,4 � 5,7%. 30-day mortality was 6,4%(n¼2); stroke rate was 3,2% (n¼1) and a new pacemaker had to beimplanted in 6 patients (19%). Performance of implanted bioprosthesiswas excellent with no relevant paravalvular leaks and ameangradient of12,8 � 5,5 mmHg. Conclusion: The concept of “imaging based decisionmaking” during TAVI evaluation might have the potential to betterpredict a good TAVI outcome by avoiding procedural risks in case of“hostile” anatomy. Although in patients with severe annular calcifica-tions frequent pacemaker implantations has to be anticipated, conven-tional AVR in these high risk patients leads to excellent outcome.


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Fig. 1

SC209Transapical transcatheter aortic valveimplantation using a repositionable second-generation device: Initial clinical results andfurther follow-up of patients treated with theJenaValve™Wilbring M.1, Alexiou K.1, Kappert U.1, Matschke K.11Herzzentrum Dresden GmbH Universitätsklinik, Klinik fürKardiochirurgie, Dresden, Germany

Objectives: No data concerning TAVI using JenaValve™ is available,except the CE-study and insular case reports. The present study

describes our initial experience with the JenaValve™. Patients andmethods: Out of the regular patients, identified as TAVI-candidatesby a Heart Team, 30 patients were randomly chosen for the JenaValve™.Preoperatively, two of these turned out to be unsuitable because ofsevere calcified and bicuspidalized aortic valves. Follow-up averaged143 � 92 days, ranging up to 320 days. Results: Procedural success was96.4% with one patient needing surgical aortic valve replacement inconsequence of valve-dislocation. All patients experienced significantincrease of effective orifice area (0.8 cm2 to 1.7 cm2; p<0.001) anddecrease in transvalvular pressure gradient (p<0.001). Observed 30-day mortality was 7.4%, 6-month survival 88.9%. Major postoperativemorbidity consisted of delirium (37.0%), renal failure (14.8%), perma-nent pacemaker implantation (11.1%), stroke (3.7%) and respiratoryfailure (11.1%). Major bleeding from the apex occurred in one patient(3.7%). Two patients with severe calcified native aortic valves (7.4%)presented with progressive paravalvular leakage after 11 and 6 weeks,being successfully treated by valve-in-valve TAVI with an EdwardsSAPIEN XT™ and balloon valvuloplasty, respectively. Conclusion: Trans-apical TAVI with the JenaValve™ provided acceptable clinical results,generally in the range of those reported for other TAVI devices. TheJenaValve™ is hooked on a tricuspid anatomy of the native valve andpotentially not perfectly suitable in severely calcified valves. A potentialstrength is the use in patients with a short distance between the valveand the coronary ostia and in case of isolated aortic regurgitation.


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11th,

2014

AAbd El Al A S40Abicht J-M S90Aboud A S24Achenbach S S39, S99, S137Adam G S25Adamczyk K S56, S131Adibekian Z S79Adsay BA S128Ahad S S100Ahmadzade T S46Ahrens PR S29, S44Aicher D S28Akhdar A S71Akhyari P S19, S92, S113, S120, S121Akintürk H S49, S50, S102, S103, S105Akra B S30, S76, S80Al Ahmad A S24Al Maisary S S23Al Zuhbi A S24Alassar Y S30, S39, S72, S93Albert A S68, S108Aleksic I S114Alexi-Meskishvilli V S103Alexiou K S20, S39, S49, S63, S115, S135,

S140Ali K S82Alitalo K S73Alles SGH S86, S96, S125Alms A S21Alnahas H S94Amann M S72Amin W S15Amiri A S118Amorim P S94Amorim PA S38, S107Amrani M S35, S37, S88, S92, S106, S109Anic P S76Anssar M S54, S82Aoki A S119Arar M S134Ardehali A S34Arif R S96Arndt F S103Arnold M S26, S39, S99Arsalan M S16, S39, S130, S139Arsalan-Werner AF S16Arunagirinathan U S93, S103, S123, S128Arzt S S20, S39, S49, S135Asfour B S51Asif M S63Assmann A S113Assmann G S55Atmaca N S86Attmann T S50, S59, S88, S125Aumayr K S110Autschbach R S18, S43, S68, S107, S110,

S112, S114Avanesov M S25Avsar M S29, S35, S36, S38, S44, S70, S71,

S91, S101, S126Awwad N S15, S20Aydin A S106, S124, S128Aydin MA S123, S128

BBaalash A S118Babin-Ebell J S127Bach F-W S84Bachamanda-Somesh D S132Bachmann S S71

Bader A S134, S135Bader R S26, S137Bader S S16Badiu CC S64Badowsky-Zyla D S112Baghai M S108, S123Bähr T S47, S48, S136Bahrami T S35, S37, S88, S92, S106, S109Bakhtiary F S67Baldus S S47, S48, S49, S136Ballazhi F S120Ballazs C S92Bandorski D S27Banner NR S37, S106Banusch J S58Bara C S29, S38, S44, S59, S96, S126Baraki H S24, S77, S78, S134Baralija A S92Baretti R S57Barnucz E S62Barrabas M S60Bärsch V S45Basti B S82Bauer J S49Bauer M S84Baumann A S58Baumbach H S100Bax L S47, S48Bechtel M S64Becker C S100, S137Bedetti B S18, S19Beerbaum P S51Beghi C S52, S53Behlau C S128Behr R S22Beiras-Fernandez A S36, S62, S73, S74, S81,

S90, S91, S99, S113, S114Beller CJ S23, S57Bellera R S69Benedik J S56Benim AC S113Benk C S109Berchthold-Herz M S123Berchtold-Herz M S109Berger J S128Bergmann I S73Bergner M S120Bergs P S57Bermudez C S34Berndt A S89Berndt R S40, S60Bernhagen J S43, S68, S112Bernhard A S61Bernhardt A S108, S116, S123Bernhardt AM S29, S57, S106Bertram H S51Beyersdorf F S17, S66, S108, S109, S123Bezuidenhout D S79Biancari F S52, S53Bieback K S76, S135Biener A S114Biermann D S32, S57, S93, S103, S116Bigot G S17Bimmel D S45Bindila L S83Binner C S53Biondo F S18Bireta C S73, S126, S133Biskup C S84Bittner H S129Blanke P S66

Blankenberg S S25, S47, S97, S128, S136Bleilevens C S112Bleiziffer S S26, S99Bloch W S55Blumenstein J S39, S136Blumenstein JM S16Bobylev D S51, S59Bödeker R-H S27Boeken U S19, S68, S92, S120, S121Boethig D S32, S64Bogert N S62, S73, S74, S81, S90, S114Böhler A S17Bonaros N S16Bonatti J S16Böning A S15, S27, S31, S61, S71, S74, S111,

S127, S131, S135Borger M S58, S69Borger MA S38, S41, S53, S58, S60, S67, S81,

S83Börgermann J S15, S24, S27, S28, S40, S137Bormann S S129Born F S107Bothe W S94Böthig D S36, S51Bougioukas I S17, S133Bramlage P S25Brandes G S84Braubach P S71Braun T S56, S116Braune S S105Breckwoldt K S29Breitenbach I S54, S82Brendel L S112Brenner P S90Breuer M S15, S94Breymann T S51, S64Brickwedel J S57, S105Britton SL S132Brodarac A S76, S132, S135Broichhausen I S116Buchholz C S33Buerbaum B S101Burger H S45, S130Burkhardt B S32Busch A S129Busch C S38Buschmann K S85, S116Buth KJ S83Butter C S48, S49Büttner F S40Buz S S25, S27, S40, S57, S98, S138, S139

CCamboni D S72Carby M S35, S88Cebotari S S59, S64, S70, S79, S84Cesnjevar R S32, S50Cesnjevar RA S33, S102Chambers DJ S110Charitos E S44, S46, S66Chesnokova V S63Choi Y S97, S99Choi Y-H S16, S26, S55, S63, S75, S76, S86,

S87, S90, S132, S135Christ T S64, S72Christov V S135Ciubotaru A S32, S64Ciubutaro A S71Claus B S64, S94Conradi L S25, S26, S47, S48, S49, S67, S97,

S122, S128, S136, S139

Authors' Index


Authors' Index S141

Cordero-Reyes AM S69Coutandin M S57Cramer E S15, S20, S67Cremer J S40, S47, S48, S50, S59, S60, S88,

S101, S125, S130, S136, S138Czesla M S82

DDäbritz S S24, S86, S104Dahlmann J S77, S78Daiber A S116Dalal P S35Dalyanoglu H S128D'Ancona G S27Dandel M S43, S89, S119Danner B S126Danner BC S17, S118, S133Dapunt O S95Dashkevich A S73Dauner M S76Dave H S32David R S77Davierwala P S53, S67Davies NH S79Dayeh A-H S24, S104De By TM S43De By TMMH S29De Feo M S52, S53De Robertis F S35, S37, S88, S92, S106, S109De Simone R S23Deindl E S90Deininger S S110, S111Dell'Aquila AM S86, S94, S125DelmoWalter EM S33, S34, S103, S107, S118Deppe A S86, S87, S97Deppe A-C S26, S75, S76Detter C S23, S57, S88, S93, S105, S122, S128Deuse T S29, S39, S44, S61, S88, S105, S106,

S108, S122, S123, S134Deussen A S115Deußen A S114Deutsch M-A S54, S55, S56, S64, S99, S131,

S133Deutsch O S85Deutschmann O S29, S44Dewald O S83, S131Dhar D S106Dhein S S113, S127, S129, S134Dhital K S34Diab M S15, S52, S94, S119Didié M S116Didilis V S133Didilis VN S17Diegeler A S15, S127Diemert P S25, S26, S48, S97, S136Dietl W S110Dittrich S S33, S102Dobner S S79, S108, S115Doenst T S15, S28, S38, S43, S52, S54, S94,

S107, S112, S119, S132Dogan G S124Dohle D-S S56Dohmen P S53Doll K-N S82Doll N S45Dominik E S31, S131Domrös-Zoungrana D S54Donndorf P S21Doppler S S54, S56, S131, S133Dorfmueller P S61Dormann R S38Dreßen M S56, S131, S133Drews T S25, S27, S98, S138, S139Drey F S55

Dreysse S S25, S27, S98, S138, S139Duebener L S51Dürr GD S83, S131Dzemali O S22, S60, S68, S85, S87, S88, S93,

S97, S122Dzilic E S72, S93, S110

EEaso J S95Eberle KP S50Ebner A S115Eckardt L S21Eckmann S S60Eckstein F S101, S120Eger S S19Ehmke H S116Eichinger W S85Eichstaedt HC S95Eifert S S69, S81, S83Eilenberger S S30El Bahi J S104El Gabry M S24El-Armouche A S116El-Essawi A S54, S82El-Gabry M S86Elhmidi Y S64, S99Ellger B S21, S86Elmontaser H S49, S50, S102, S103,

S105Emmert A S17Emmert MY S121Emontzpohl C S68Ender J S58Engel A S136Engelhardt S S23Engler A S125Englert C S127Ensminger S S40, S91, S92, S137Ensminger SM S117, S118Ernst K S130Eschenhagen T S29, S30, S72Esmaeli A S103Estep JD S69Etz C S53, S58, S113Etz CD S41, S42, S58, S60, S81Evagelopoulos N S86, S104

FFabry T S51Fadel E S61Faggian G S52, S53Falcoz P-E S34Falk C S91Falk CS S71Falk V S41, S120, S121Fallouh H S110Fano C S76, S80Farag M S57, S96Färber G S15, S52, S94, S119Fatullayev J S37, S88, S92, S106, S109Fehrenbach D S76Felkel K-W S65, S88, S121, S127Ferrari E S22Feuchtinger J S17Feuchtner G S16Feyrer R S39, S99, S120, S129Fiegl K S95, S97Figulla HR S89Fischer G S48, S50Fischer M S107Fischlein T S52, S53, S87, S94Fleischer B S24, S29Fleischmann BK S55Florath I S111

Flörchinger B S72Foth R S104Frank D S101, S138Franke UFW S100Franz B S101Franz M S89Franz T S79Franz W-M S55Franzen O S48Fraund-Cremer S S60Freiberger S S28, S107Frerker C S137Frese J S80Freundt M S122Frey N S101, S138Friedel N S129Friedrich C S59Friedrich G S16Friedrich I S138Fritzsche K S17Fuchs U S37, S91, S92Fujita B S40Funkat AK S83Füzesi L S17

GGabriel M S31, S78Gaebel R S77Gafencu D S28Gafencu L S28Gahl B S101Gajawada P S56Gansera B S85Garbade J S38, S53, S58, S69, S111, S125García Sáez D S37, S88, S92, S106, S109Gazdag L S94Geertz B S29Gehle P S34Gehron J S27Geidel S S63, S129Geisen U S109, S123Genoni M S22, S60, S85, S87, S88, S93, S97,

S122Gerber N S80Gerhard J S83Gesche VN S80Gestrich C S83Ghanem A S136Ghazal M S82Ghezelbash F S86, S96Gillen K S99Girrbach F S41Girrbach FF S41, S42, S81Gleich B S55Glöckler M S102Glotzer T S46Göbel G S45Göbel N S100Goecke T S79Goepfert MS S70Goetz AE S70Goetzenich A S18, S43, S68, S107, S110,

S112, S114Goldmann B S47Gonska B-D S25Gorenflo M S102, S104Gorki H S110, S111, S117Gossen M S132Goto S S108Gottlieb J S36Gottschalk A S21Graf B S44Gramlich Y S116Gramsch-Zabel H S19, S120, S121


Authors' IndexS142

Grapow M S120Graves K S60, S87Greis H S46Grieshaber P S111Grimm M S16Gronchi F S22, S84Grossmann M S126Grothoff M S41Grothusen C S40, S50, S59, S88, S125Grube E S136Grubitzsch H S53, S64Gruh I S77, S78Grün K S89Gudehus S S58Guenther S S81, S83, S107Guersoy D S124Guethoff S S81, S83, S90Guihaire J S61Gül F S113Gulbins H S65, S121, S127Gummel K S50Gummert J S27, S28, S40, S89, S137Gummert JF S24, S37, S91, S92Günther T S24, S51Günzinger R S24, S64, S95, S97Guo F S62, S73, S74, S113Gutberlet M S41

HHaas S S70Haas U S30Haase T S78Haeussler A S60, S85Hagl C S30, S76, S80, S81, S83, S90, S100,

S107, S137Hagmüller S S71Hahn J S125Hahnel F S121Hakim K S24Hakmi S S30, S39, S44, S72, S108, S123, S128Halank M S28Halbe M S20Haldenwang P S58Haldenwang PL S64Haller C S69, S124Haller N S30Haller P S93Hallström S S110Hamadanchi A S52Hamm C S39, S46Hammerschmidt R S57Hammerstingl C S136Hamouda K S114Haneya A S40, S59, S60, S88, S130Hanke JS S29, S38, S44, S70, S101, S126Hanke T S44, S66Hansen A S29Hansen JH S48Hansen L S15, S20Hards R S37Harig F S120Harringer W S54, S82Hartmann I S36Hassel T S84Hatam N S43, S107, S112, S114Haun C S51Haunschild J S41Hauptmann KE S138Häuser L S58Hausleiter J S48, S49, S137Häussler A S22, S88, S97, S122Haverich A S24, S29, S30, S34, S35, S36, S38,

S44, S51, S59, S64, S70, S71, S76, S78, S79,S84, S91, S96, S101, S126, S134

Hecker F S135Hedderich J S52Hedger M S37Heep M S71Hegedüs P S35, S62Hei H S115Heider A S86Heikkinen J S52, S53Heilmann C S17, S108, S109, S123Heim C S99, S117, S118, S123Heimeshoff M S25Hein L S109Hein M S112Heinemann J S83Heinemann JC S131Held M S28Heller L S20Heller R S54Heller S S15Hemmer W S32Hemmer WB S82Hennig E S21Henning E S67Henze M S108Hescheler J S132Hettich I S95Hetzer R S20, S21, S25, S27, S33, S34, S40,

S43, S57, S67, S89, S98, S103, S107, S118,S119, S126, S138, S139

Hewicker-Trautwein M S91Hiemann N S89Hilfiker A S76, S79, S84Hilker M S15, S72Hill S S100Hillebrand J S125Himsl I S83Hinz C S84Hinz J S73Hirnle G S60Hoeffler C S70Höffler K S71Hoffmann AL S100, S137Hoffmann BA S128Hoffmann G S60, S101, S130Hoffmann S S94Hoffmeier A S96, S125Hofmann B S62, S112Hofmann M S32Hofmann S S26Höger S S35Holinski S S96Hollweck T S30, S76, S80Holubec T S121Holzhey D S67, S136Hönicka M S110, S111, S117Hörer J S51, S133Horke A S32, S51, S64, S101Hörmandinger C S20, S21Horstkotte D S40Hotz H S107Hoyer A S41, S42, S81, S113Hraska V S51Hua X S61, S134Huber B S55Hübler M S32, S89Huell S S104Huenges K S47, S48, S136Hundrieser J S77, S78

IIbrahim B S118Ihnken O S130Iizuka H S119Illioska P S112

Imbery C S17Issa H S74Itagaki R S61Ius F S36Izumi K S85

JJacobs S S41, S120, S121Jacubeit J S116Jahn C S118Jahn J S57Jakob H S56, S59Janke J S71Jannasch A S114, S115Janssen C S33Jansson K S36, S91Jategaonkar S S40, S137Javier MF S33, S103Jebran AF S133Jemmali M S23Jessen S S96Jockenhoevel S S77, S80Jonigk D S71, S91Joos F S113Juchem G S80Jung O S50Jussli-Melchers J S40, S50, S60

KKaczmarek I S36, S91, S107Kadner K S79Kahmann M S53Kakkar R S115Kallenbach K S26, S57, S96Kaminski A S21Kamiya H S19, S92, S108, S120, S121Kammerer I S95, S122Kampmann K S121Kang K-S S134, S135Kanzler I S36, S62, S73, S74, S81, S90, S91,

S114Kappenberg T S54Kappert U S15, S20, S26, S39, S49, S85, S135,

S140Kapsalis A S86Karck M S23, S35, S57, S62, S96, S102, S104,

S112Kari FA S66Karliova I S85Karluß A S66Karluss A S42Kaufeld KT S84Kauffeldt M S30Kaufmann F S20, S21, S67Kawaura H S119Keller H S113Kellermann S S33Kemper D S89Kempfert J S16, S39, S113, S136, S139Kensah G S77, S78Keränen MA S73Keyser A S72Keyserd B S128Khaladj N S80, S81, S83, S107Khan MA S117Kiessling AH S99, S112, S113Kiessling A-H S73, S122Kim W-K S39, S136, S139Kirov H S119Kiss R S35Kleine P S68Kleiner G S77Kleinert E S90Kley J S131


Authors' Index S143

Klopsch C S77Klose K S132, S135Kloth B S25, S26, S139Klotz S S21, S44, S66Kluge S S105Kluttig R S69, S111, S125Knappich C S61Knaut M S63, S130Knigina L S59Knoefel AK S70Knoefel A-K S134Knöfel A-K S36, S91Knosalla C S34, S43, S89, S119Kobuch R S72Koch A S50Koch AM S33, S102Koch LG S132Koch N S118Koenig F S30Koerfer R S124Kofler M S16Koigeldiyev N S96Kondruweit M S39, S99, S120, S123Konertz W S53, S64, S94, S96Korbmacher B S128Korkmaz S S35, S62Kornberger A S99Kornek M S133Korossis S S30Koschyk D S97, S136Kösek V S18Kostelka M S129, S134Kostin S S56Kowalski A S130Krabatsch T S20, S43, S67, S107, S126Kraemer S S43, S68Krähe K S61Kramer H-H S50Krane M S54, S56, S61, S64, S99, S131, S133Krapf S S26Kraus FB S112Krebs R S73Kreibich M S72, S93, S110Kremer J S93Kremer P S67Kretzschmar A S20, S67Krššák M S72Krüger H S35Krüger N S112Kubik M S44, S65, S105, S122, S127Kubin T S56, S116Kuehn C S36Kühl H S56Kühn C S35, S36, S71Kuhn E S63, S86, S87, S97, S99Kuhn EW S26, S75Kuhr K S99Kukreja J S34Kukucka M S25, S98, S138, S139Kunert A S110Kunihara T S28Kuniss M S46Kupatt C S100, S137Kur F S36Kuratani T S84Kurtz A S132, S134, S135Kutschka I S24, S77, S78, S134Kütting M S137Kyo S S126

LLaenger F S61Lahm H S54, S56, S131, S133Lange C S134

LangeR S24, S51, S54, S56, S61, S64, S95, S97,S99, S131, S133

Langenmayer M S90Laß M S63Lauer M S63Lausberg HF S138Lebiedz P S19Lee RT S115Légaré J-F S83Lehmann C S15, S20Lehmann S S69Lehmkuhl L S42, S81Leistner M S114Lemme F S32Lemström KB S73Lenglinger M S124Leonhart R S17Leontyev S S67, S83Lepperhof V S55Leseche G S34Leyh RG S114Li L S31, S61, S74, S131, S135Li S S35Liakopoulos O S86, S87Liakopoulos OJ S59, S75Lichtenberg A S19, S68, S92, S108, S113,

S120, S121, S128Liebetrau C S39Liebold A S110, S111, S117Liebrich M S82Lieder H S56Liewald C S117Linke A S136Linneweber J S94Lipke C S73Liubov P S56Löblein H S22, S97, S122Lochmann P S83Loders S S39Loebe M S69Loeblein H S60, S85, S87, S88, S93Loganathan S S35Lörchner H S56Loukanov T S102, S104Lubos E S47, S48Ludwig-Kraus B S112Ludwig M S77Luehr M S41, S58, S81Lunau C S25Lund G S25Lunk A S19Lunz D S72Lutter G S47, S48, S88, S101, S136, S138Lutz B S83, S131

MMadershahian N S26, S63, S75, S87, S97, S99Madrahimov N S70Maeding I S96Mägel L S71Maietta P S18Maisano F S48Mal H S34Malehsa D S29, S38, S44, S70, S126Maletskidis C S82Malischewski A S80Marcsek P S23Marczin N S35Marczynski-Bühlow M S47, S48, S136Mariscalco G S52, S53Markewitz A S45Markus J S17Martens A S59, S134Martens S S21, S59, S86, S125

Martin U S77, S78Marulli G S34Maruta K S119Maschek H S89Massard G S34Matin M S82Matschke K S20, S39, S49, S63, S85, S115,

S129, S130, S135, S140Matt P S120Matusiak-Brückner M S89Matz A S52Matz K S125Matz L S69, S111Maunz O S92Maurus M S117Mausberg RF S118Maxhera B S68, S108Mayer T S76Mayr T S90Mazzitelli D S24, S99Mc Curry K S34Mc Dermott G S35Mechelinck M S110Meertz A S83Mehdiani A S92Mehlhorn U S31, S78Meinzer H-P S23Mela P S77, S80Mellert F S20Menon A S107Menon AK S110, S114Merk D S69Meschenmoser L S51, S64Messina A S52, S53Meyer A S45, S69, S111, S136, S139Meyer AL S125Meyer T S79Miera O S103Minkner K S24Minol J-P S19, S92, S120, S121Misfeld M S41, S42, S53, S58, S60, S66, S67Miskovic A S68, S109Mladenow A S25, S98, S138Moccetti T S48Mogaldea A S76, S79, S84Mohamady K S63Mohamed SA S83Mohite P S37, S88, S92Mohite PN S37, S106, S109Mohr FW S42, S58, S67, S69, S83, S113, S125,

S127, S129, S134Mohr F-W S38, S41, S53, S58, S60, S69, S81,

S111Mohr M S17Moka A S24Molis A S132Mollmann H S39Möllmann H S16, S136, S139Mönnig G S21Monsefi N S68, S109Moradiellos FJ S34Moreira R S80Mörer O S73Moritz A S62, S68, S73, S74, S81, S90, S99,

S109, S112, S113, S114Morjan M S82Morlock MM S47, S136Morshuis M S27, S28Moser P S72, S93Motsch B S117, S118Moustafine V S64Moza A S35, S43Moza AK S18, S107, S110, S114Mudersbach E S72


Authors' IndexS144

Mueller G S32Mueller K S77Mueller T S72Mühlfeld C S90Müller B S71Müller KM S17Müller M S49, S50, S102, S103Müller S S117Müller T S69Müller-Eising K S110, S111Müller-Höcker J S55Münch F S33, S50Münzel T S116Murin P S51Muth A S93Mykhaylyk O S55

NNagel F S72, S110Nagendran J S34Nagl F S93Nakajima T S126Nakamura L S123Nappi G S52, S53Nass N S62Navarrete Santos A S62, S83Navratil D S112Neef K S16, S55, S63, S76, S90Neef S S116Neudörfl C S71Neuhäuser M S59Neumann A S51Neumann K S96Neumann T S46Neumärker L S114Nguyen TD S54Nickenig G S136Nicolls MR S117Nicotra S S34Niemann B S31, S61, S71, S74, S131, S135Nitzschke R S70Nozdrzykowski M S58Nykänen AI S73

OOberhoffer M S63, S129Oberwallner B S76, S132Ochs M S90Odavic D S22, S60, S87, S88, S97, S122Oelschner C S108, S122Oelze M S116Ojeda F S136Olland A S34Omoto T S119Ono M S126Onorati F S52, S53Opalka B S45Orhan C S31, S131Oster O S18, S19Oswald B S45Ott I S55Ottersbach A S55, S131Özpeker CU S27, S28

PPahari D S54Pajitnev D S46Pardun E S50Park H S21Pasic M S25, S27, S89, S98, S119, S138, S139Passerone G S52, S53Patil NP S88, S106, S109Paul T S104Pavicevic J S120

Pecha S S29, S30, S39, S44, S45, S46, S72,S123, S128

Pedrazzini G S49Peivandi AA S82Penkalla A S27, S98, S119, S138, S139Penov K S38Peterss S S107Petrov A S112Petzina R S60, S101, S138Pfannmüller B S53Pfeifer A S55Pfeiffer S S87, S94Pflaum M S30Philipp A S72Piazza N S99Pichlmaier AM S81, S83Pichlmaier M S107Pizon M S129Plank C S55Pleyer C S111Plötze K S129Podesser B S72, S93Podesser BK S110Poetini L S85Poitz DM S115Pokorny S S47, S48, S136Pöling J S56, S116Pollari F S94Polyakova V S56, S116Pomar JL S43Popov A-F S35, S37, S73, S88, S92, S106,

S109, S126Posival H S25Potapov E S20, S21, S43Potapov EV S67Pretre R S22, S84Preuss R S40Preuss S S112Prinzing A S64Pritzwald-Stegmann P S113Probst C S20, S83Prochnow N S58Protze S S132Prucker O S108Przybilla K S96Purbojo A S33, S50, S102Pürerfellner H S46

QQuintel M S73

RRadovits T S35, S62Rahimi A S40Rahmanian P S16, S86, S90, S99Ramadani B S24Rammer M S16Ramsperger-Gleixner M S118Raspe C S112Rastan A S26, S38, S112Rea F S34Redwan B S17, S18Reed A S88Reents W S15, S127Rees W S56Reichart B S90Reichenspurner H S23, S25, S26, S29, S30,

S32, S39, S44, S45, S46, S47, S48, S49, S53,S57, S61, S65, S67, S70, S72, S79, S88, S93,S97, S103, S105, S106, S108, S115, S116,S121, S122, S123, S124, S127, S128, S134,S136, S139

Reichenspurner HCK S84Reinartz M S45, S107

Reinsdorf A S88Reiter B S23, S93, S128Renner A S24, S27, S89Renner J S101, S138Reser D S120Reusch F S86Reutemann M S19Reuter DA S70Reuthebuch O S101, S120Rex S S107Richardt D S42Richardt G S48Richter M S56, S91Richter MH S116Richter P S89Riedel M S105Rieß F-C S15, S20, S67Rippinger N S85Riso A S32, S103Risso P S86, S125Robbins R S61, S134Robinsone PN S128Rodriguez Cetina Biefer H S121Roehl A S112Rohrbach S S31, S61, S71, S74, S131,

S135Röhrig K S67Röhrig R S27Rojas SV S29, S38, S44, S59, S126Rojas Hernandez S S29, S44, S126Rojas Hernandez SV S101Rojas-Hernandez SV S70Röll W S55, S83, S131Romanchenko O S32Rondak I S24, S97Roser D S82Rost C S118Rotärmel A S134Roth P S31, S131Rothe S S129Roy R S78, S135Rueffer A S32Rueter F S101Rüffer A S32, S33, S50, S102Rühe J S108Ruhparwar A S96Rupp P S110, S111Rupprecht L S72Ruschewski W S104Russe M S66Rüter F S120Rybczynskia M S128Rylski B S66Rzewuska E S129

SSabashnikov A S16, S35, S37, S63, S73, S86,

S88, S90, S92, S106, S109, S126Sabel I S80Sachs U S111Sachweh J S24Sachweh JS S32, S86, S103, S116Sack F-U S95, S122Saeed D S68, S92, S108Saeed G S82Saito S S24, S77, S78Sakamoto T S84Sakurai S S119Salman J S35, S36, S91Samson-Himmelstjerna P S125Sandhaus T S15Sandica E S32Sandkötter J S17Sandrio S S102, S104


Authors' Index S145

Santarpino G S52, S53, S94Santelmo N S34Santer D S72, S93, S110Santini F S52, S53Saric T S55, S76, S132Sarikouch S S51, S64, S96Sato K S126Sauer M S42Sawa Y S84Schaaf S S29Schachner T S16Schachtner T S137Schack S S114Schäfer A S53Schäfer T S44, S45, S46, S105Schäfer U S26, S48, S49, S137Schäfers HJ S28Schälte G S114Schäufele T S100Scheewe J S50Scheid M S51Schein J S30Schemm A S103Scherer M S21, S86, S96, S125Scherner M S26, S63, S75, S86, S97, S99Schiavon M S34Schibilsky D S69, S124Schiemann M S54Schiller W S20, S59Schilling T S76, S84Schillinger W S48, S49Schimmer C S114Schipke JD S128Schirmer J S25, S26, S47, S97, S136, S139Schlensak C S69, S124Schlingloff F S26, S129, S137Schlömicher M S58, S64Schlüter K-D S71Schlüter M S47Schmack B S112Schmeckebier S S30Schmiady M S32Schmid C S72Schmidt A S58Schmidt C S125Schmidt J S17, S18, S19, S118Schmidt K S40, S66Schmidtke C S42, S66Schmidtke J S128Schmitt C S25Schmitto JD S29, S38, S44, S59, S70, S101,

S126Schmitz C S100, S137Schmitz I S58Schmitz R S17Schmoeckel M S63, S129, S137Schnabel R S136Schneeberger Y S105, S106, S122, S124Schneider M S51Schneider SR S125Schoeneich F S40, S130Scholz W S40Schönbrodt M S27, S28Schönburg M S46, S139Schöndube FA S17, S73, S118, S126, S133Schönebeck J S23Schöttler J S40, S59, S60, S88, S125, S130Schrambke D S56, S131Schramm R S100, S137Schranz D S49, S50, S102, S103, S104,

S105Schreiber A S134Schreiber C S51, S133Schrepfer S S61, S134

Schrepper A S28, S38, S43, S107, S132Schröfel H S25Schuhbäck A S137Schuler GC S38Schulz A S107Schulz U S37, S89, S91, S92Schumacher U S61Schurr U S101Schuster V S81, S83Schwarzer M S28, S38, S43, S54, S107, S132Schweiger M S32Schweizer I S31Schwoerer AP S116Schymik G S25Schymik J S25Seeburger J S42, S60Seidler T S126Seifert B S120, S121Seiffert M S25, S26, S47, S48, S97, S136Seitz T S120Selle A S115Semper E S118Seppelt P S57, S96Serio D S68, S109Serrano MR S124Sheikhzadeha S S128Shijo T S84Shimamura K S48, S84Shirakawa Y S84Shrestha M S96, S134Siebel A S45Siemers S S114Siepe M S17, S66Sievers HH S83Sievers H-H S42, S44, S66Sievert H S48Sigler M S104Silaschi M S67Silber R-E S62, S74, S83, S112Sill B S128Simm A S61, S62, S83, S135Simon A S34Simon AR S35, S37, S88, S92, S106, S109Sindermann J S125Sindermann JR S125Siniawski H S107, S118Siniscalchi G S22, S84Sinning C S25Sinning J-M S136Sirch J S87Sirry M S79Skorska A S77Skvorc D S77Slottosch I S59, S75, S86, S87, S97, S99Sodian R S80, S100, S107, S137Soliman A S69Solovyeva A S70Solowjowa N S118, S119Soltani S S67Sommer S S114Sommer S-P S114Sommer W S35, S36, S91Sontag B S138Sperzel J S45, S130Spiliopoulos K S85Spiliopoulos S S124Spindler R S35Springer W S104Srinivasan S S76Srndic E S113Sromicki J S121Stamm C S55, S76, S78, S132, S134, S135Stamminger T S117Stanojevic D S51

Starbatty J S29Starke S S17Stein J S67Steinbach S S134Steinhoff G S21, S77Steinseifer U S137Stepanenko A S20Stephens EH S66Stevanovic A S107Steven D S128Stiefel P S59Stierle U S44, S66Stiller B S109Stiller M S112Stock UA S73, S81, S90Stojanovic T S133Stoppe C S43, S68, S107, S112Strauch J S58, S64, S97, S99Strauss H S82Strecker T S120Stripling J S15, S20Strüber M S69, S111, S125Stubbendorff M S61, S134Stumm M S103Stumpf J S85Subbotina I S45, S46, S103, S108Suc J S50Sunavsky J S37Sündermann S S41, S120Sündermann SH S121Syrjälä SO S73Szabó G S35, S62, S112Szalay Z S46

TTakahashi H S28Tamura N S108Tandler R S99, S120, S123Tao L S35Taurosinov G S104Tautorat I S40Tenderich G S124Tewarie L S18, S110Thalmann R S100Theisinger B S35Theisinger S S35Theodoridis K S79Thielmann M S56, S59Thiem A S60, S125, S130Thierfelder N S30Thomas P S34Thul J S49, S102, S105Tirilomis T S104Toka O S33Tolboom H S120Torikai K S84Tozzi P S22, S84Trapp C S20Treede H S25, S26, S47, S48, S49, S67, S88,

S97, S105, S122, S123, S128, S136, S139Trepte C S70Trescher K S72, S110Treskes P S76Troidl C S16Troise G S52, S53Trummer G S109, S123Tsagakis K S56Tsanava F S94Tsui S S34Tudorache I S35, S36, S64, S70, S71, S79,

S84Tümler KA S29, S44Tutkun B S40Tzanavaros I S51, S82


Authors' IndexS146

UUeberfuhr P S81, S83Uhlig A S30Ulbricht U S59Unbehaun A S25, S27, S98, S138, S139Unsöld B S126Unterkofler J S110, S114Ussia GP S48Utzenrath M S137

VVahl CF S85, S116Vahl C-F S31, S78Valeske K S49, S50, S102, S103, S105van Linden A S139Van Linden A S39, S45van Raemdonck D S34Varela A S34Vasa-Nicotera M S136Velz T S80Veres G S62, S112Vierecke J S67Vieth M S129Villanueva A S27Vincze D S97Vogt F S94Vöhringer M S100Volk H-D S134Vollmar B S21Vomend A S122von Aspern K S41, S42, S58, S81von Kodolitsch Y S128von Samson-Himmelstjerna P S69, S111von Strachwitz K S33Voss B S24, S64, S97, S133

WWagner A S111Wagner F S23, S112Wagner FM S45, S46, S65, S72, S105, S127Wahl G S67Wahlers T S16, S26, S55, S59, S63, S75, S76,

S86, S87, S90, S97, S99Waidelich R S81Wald D S23Waldmann K-H S79Waldmann-Beushausen R S17, S118, S133Waldow T S114, S115, S129Walk J S32Walker T S124Walle U S82

Walther M S52, S94Walther T S16, S39, S45, S46, S56, S116,

S130, S136, S139Wanke R S90Wannaku S S57Warnecke G S34, S35, S36, S70, S71, S91Warnecke H S56, S116Watanabe Y S84Weber S S80Weiler H S31, S78Weimar T S45, S82Weinberger F S29Weinreich T S19, S120, S121Weiss S S109Wellnhofer E S89Welp H S59, S96Welp H A S21Welte T S36Welz A S20, S55, S59, S83, S131Wendel H-P S124Wendland A-L S79Wendt D S56, S59Weng Y S119Wernecke K-D S53Werner A S54, S131, S133Werner C S17, S38, S132Werner N S136Westenfeld R S68, S92Westhofen FS S122Westhoff-Bleck M S51Weyand M S39, S99, S117, S118, S120, S123,

S129Weymann A S62, S112Whitlock RP S127Widder JD S48Wiebe K S17, S18, S19Wiedemann M S95Wiegmann B S30, S71Wiewrodt R S19Wilbring M S20, S26, S39, S49, S63, S85,

S115, S129, S130, S135, S140Wilde S S136Wilgusch J S70Wilke I S106, S123, S124Wilkens H S28Willems S S46, S106, S123, S124, S128Winkel S S15, S20Winkler B S120Wintermantel E S30, S76, S80Wippermann J S97, S99Witt W S115

Wittwer T S16, S63, S86, S90Wolf I S23Wolters H S19Wondraschek R S25Wottke M S64, S95Wu S S133Wu SM S54Würth A S25

YYakobus Y S62Yamazaki K S126Yan JY S83Yard B S35Yerebakan C S49, S50, S102, S103, S105Yeter R S89Yildirim Y S30, S39, S44, S72, S123,

S128Yilmaz E S128Yilmaz M S97

ZZacher M S15Zaltsberg S S46Zaradzki M S96Zayat R S18Zenker D S126Zeriouh M S86, S90Zgudziak P S133Ziebolz D S118Ziebura D S58Ziegelhoeffer T S45, S130Zieger B S108, S123Ziegler P S44, S46Zientara A S22, S88, S93, S122Zierer A S68, S81, S99, S112Zießnitz N S69Zilkens K S43Zilla P S79Zimmer A S83, S131Zimmermann K S55Zimmermann N S23, S57Zimmermann S S96Zimmermann WH S30Zimmermann W-H S116Zipfel B S57Zittermann A S24, S37, S91, S92Zohlnhöfer-Momm D S78Zuckermann A S93Zurfluh S S101Zych B S35, S37, S88, S106, S109


Authors' Index S147

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