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451 Cardiac Retransplantation is a Valuable Option for End-Stage Coronary Artery Vasculopathy
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interventions for patients with Stage D heart failure. Understanding how patients make decisions regarding HTx or LVAD involves concepts that may not be easily captured by quantitative measures. Using qualitative methods, we asked how patients with advanced heart failure make decisions regarding HTx and LVAD. METHODS: The study was conducted while patients were making the actual decision to proceed or not with HTx or LVAD for Stage D heart failure. 17 patients were interviewed. Grounded theory was used to discover the concepts, relationships and processes associated with the decision. Findings were configured into a model that illustrates the factors affecting the decision to proceed with HTx or LVAD implant. RESULTS: Patients described how surgery would allow them to live longer, improve quality of life and symptoms as well as relieve caregiver burden and worry. While heart failure concepts were important to the decision, entrustment emerged as the most meaningful process for decision-making. Patients reported feeling ill-equipped to determine if having a HTx or LVAD was the right thing to do. They trusted the cardiologist to determine if they were candidates. They trusted the surgeon to get them safely through the surgery. CONCLUSIONS: The results of this study suggest entrustment was the most meaningful process for patients considering HTx or LVAD. The decision to proceed is based on an expert recommendation of the physicians and not on rational consideration of the risks and benefits of the surgical procedure. Understanding the process of decision-making will help clinicians support and enable treatment decisions made by patients living with advanced heart failure.
Canadian Journal of Cardiology Volume 28 2012 BACKGROUND: Polycythemia vera (PV) and essential thrombo-
cytosis (ET) are rare chronic myeloproliferative disorders (cMPD) that present clinically with thrombotic and hemorrhagic complications. The literature is sparse concerning the perioperative and peri-intervention management of these patients especially in the context of coronary revascularisation. METHODS: We present a multicenter retrospective case-control chart based study of 34 patients with either PV or ET who have undergone 56 cardiac interventions. There were 14 percutaneous coronary interventions (PCI), 9 cardiac surgeries 7 onpump, and 25 simple coronary angiograms, being our control group. Patient demographics as well as thrombotic and hemorrhagic complications where assessed by clinical follow up, average of 2.1 years post intervention. RESULTS: Most patients had at least 2 cardiovascular risk factors, and were treated with both cytoreductive and antiplatelet therapy. There was an 18% thrombotic incidence peri-PCI, two events being peri-hospitalisation and one 4 monts post intervention, compared to a 3% incidence in the control group. There was one early thrombotic mortality peri-PCI, and zero hemorrhagic complications. The thrombotic and hemorrhagic incidences in patients undergoing cardiac surgery were 33% and 22% respectively, with one early thrombotic post surgical death. All surgical complications occurred with the on-pump CABG patients. CONCLUSION: Our data suggests that patients with a cMPD have a relatively high thrombotic incidence when undergoing any form of coronary revascularization and that further research with a larger population base is needed to better study these outcomes.
451 CARDIAC RETRANSPLANTATION IS A VALUABLE OPTION FOR END-STAGE CORONARY ARTERY VASCULOPATHY M Laflamme, A Tarmiz, L Perrault, G Pelletier, M Pellerin, M Carrier Montréal, Québec
CIHR
450 OUTCOMES AFTER CORONARY REVASCULARIZATION IN PATIENTS WITH POLYCYTHEMIA VERA AND ESSENTIAL THROMBOCYTHEMIA R Wahhab, J Diodati, H Jeanmart Montréal, Québec
BACKGROUND: Retransplantation is done in only 2% to 3% of primary transplant recipient. Most of these patients have advanced coronary vasculopathy at the time of retransplantation. We report our experience with cardiac retransplantation since 1983. METHODS: We reviewed all cases of patients who underwent heart retransplantation for end-stage coronary artery vasculopathy. From April 1983 to March 2011, we performed 377 cardiac transplantations. Ten (2.6%) were retransplantations. All primary cardiac transplant recipients at our institution served as the control group. Time to event analyses included comparisons of patients undergoing primary transplantation versus patients undergoing retranplantation for patient survival, rejection and infection analyses. RESULTS: There were 7 male and 3 female patients ranging from 14 to 69 years (mean, 37 ⫾ 17 years). Indication for
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Abstracts
second transplantation was end-stage coronary vasculopathy in all cases. The Kaplan-Meier survival curves comparing our primary transplantation group with the retransplantation group are identical. The 30-day and the one year survival averaged 90 % ⫾ 9 and 88 % ⫾ 8 in retransplantation patients compared with 92 % ⫾ 1 and 85 % ⫾ 2 (p ⫽ 0.71) in primary transplant patients. The freedom rates from acute rejection (51 % ⫾ 3 and 39 % ⫾ 17, respectively) and from infection (48 % ⫾ 3 and 39 % ⫾ 17) were similar in both groups (p ⫽ 0.65 and p ⫽ 0.97) at ten year follow-up. CONCLUSION: Patients who underwent cardiac retransplantation for endstage coronary artery vasculopathy have similar outcomes when compared to primary heart transplant patients.
452 MINIMALLY INVASIVE MITRAL VALVE SURGERY: INFLUENCE OF AORTIC CLAMPING TECHNIQUE ON EARLY OUTCOMES A Mazine, M Laflamme, D Bouchard, H Jeanmart, J Lebon, M Pellerin Montréal, Québec
Several methods of aortic clamping have been described for minimally invasive mitral valve surgery (MIMVS). The aim of this study was to compare the endoaortic balloon occlusion technique with the transthoracic clamp approach in terms of perioperative outcomes. METHODS: Between May 2006 and October 2011, a total of 259 patients underwent MIMVS via a 4-5 cm right anterolateral minithoracotomy. In 243 (93.8%) of these, the aorta was clamped using either the endoaortic balloon occlusion technique (Endoballoon, n⫽140) or the transthoracic clamp technique (Chitwood, n⫽103). RESULTS: Patients in the Endoballoon group had significantly longer operating time (4.3⫾1.0 hours versus 3.2 ⫾ 0,8 hours, p ⬍ 0.001), CPB time (143.1⫾44.1 min versus 111.3⫾28.9 min, p⬍0.001) and cross-clamp time (113.9⫾37.9 min versus 86.0⫾23.1 min, p⬍0.001). Perioperative blood loss was higher in the Endoballoon group (286.5⫾239.3 mL versus 212.8⫾189.4 min, p⫽0.008) as was the mean postoperative CK-MB level (36.3⫾44.1 g/L versus 26.3⫾12.1 g/L, p⫽0.011). The repair rate was ⬎99% in both groups (p⫽ns). In the Endoballoon group, there was one stroke and 5 myocardial infarctions (3.6%), compared to 2 strokes in the Chitwood group (p⫽ns). All patients left the operating room with no or trivial residual MR on transesophageal echocardiography evaluation. In-hospital mortality occured in 2 patients from each group (p⫽ns). CONCLUSIONS: MIMVS can be performed successfully using either the endoaortic balloon technique or the Chitwood transthoracic clamp approach. However, the Chitwood technique results in shorter operation time, less peroperative bleeding and better myocardial protection. BACKGROUND:
Canadian Cardiovascular Society (CCS) CCS192 Highlighted Poster CLINICAL AND TRANSLATIONAL EP Monday, October 29, 2012 462 SIMVASTATIN IN THE SETTING OF INOS DELETION IMPROVES SURVIVAL IN MICE WITH VENTRICULAR HYPERTROPHY SECONDARY TO CALCINEURIN OVEREXPRESSION AM Gillis, HJ Mathison, J Lees-Miller, H Duff Calgary, Alberta BACKGROUND: Overexpression of calcineurin (CN) causes cardiac
hypertrophy and arrhythmic deaths secondary to either heart block or ventricular tachyarrhythmias (VT). Statins have been reported to prevent the development of left ventricular hypertrophy (LVH) in some experimental models and in patients with heart disease. We have previously reported that simvastatin prevented VT associated with CN overexpression but did not improve survival or modify the magnitude of LVH. Inducible nitric acid (NO) synthase (INOS) has been implicated in cardiac injury. Here, we tested the hypothesis that simvastatin would improve survival in transgenic mice with CN overexpression and INOS deletion. METHODS: Double recombinant mice with CN overexpression and INOS deletion were treated daily with 2mg/kg simvastatin (n⫽10) or placebo (n⫽11) up to 270 days of age. ECGs were monitored for 5 minutes every 10 days commencing at age 35 days. Heart rate, P-R interval, AV block and spontaneous VT were compared between groups at ages 46 and 126 days. Heart weight, heart septum thickness and left ventricle wall thickness were compared between groups at death. Survival was also compared between the two groups. RESULTS: Simvastatin did not significantly reduce cardiac mass or dimensions. Simvastatin improved survival in the INOS-CN mice (Figure) and increased resting heart rate. Simvastatin did not modify AV conduction or magnitude of heart block but tended to reduce ventricular arrhythmia frequency.
CONCLUSION: Simvastatin treatment improved survival in dou-
ble recombinant INOS deletion x CN mice in the absence of
interventions for patients with Stage D heart failure. Understanding how patients make decisions regarding HTx or LVAD involves concepts that may not be easily captured by quantitative measures. Using qualitative methods, we asked how patients with advanced heart failure make decisions regarding HTx and LVAD. METHODS: The study was conducted while patients were making the actual decision to proceed or not with HTx or LVAD for Stage D heart failure. 17 patients were interviewed. Grounded theory was used to discover the concepts, relationships and processes associated with the decision. Findings were configured into a model that illustrates the factors affecting the decision to proceed with HTx or LVAD implant. RESULTS: Patients described how surgery would allow them to live longer, improve quality of life and symptoms as well as relieve caregiver burden and worry. While heart failure concepts were important to the decision, entrustment emerged as the most meaningful process for decision-making. Patients reported feeling ill-equipped to determine if having a HTx or LVAD was the right thing to do. They trusted the cardiologist to determine if they were candidates. They trusted the surgeon to get them safely through the surgery. CONCLUSIONS: The results of this study suggest entrustment was the most meaningful process for patients considering HTx or LVAD. The decision to proceed is based on an expert recommendation of the physicians and not on rational consideration of the risks and benefits of the surgical procedure. Understanding the process of decision-making will help clinicians support and enable treatment decisions made by patients living with advanced heart failure.
Canadian Journal of Cardiology Volume 28 2012 BACKGROUND: Polycythemia vera (PV) and essential thrombo-
cytosis (ET) are rare chronic myeloproliferative disorders (cMPD) that present clinically with thrombotic and hemorrhagic complications. The literature is sparse concerning the perioperative and peri-intervention management of these patients especially in the context of coronary revascularisation. METHODS: We present a multicenter retrospective case-control chart based study of 34 patients with either PV or ET who have undergone 56 cardiac interventions. There were 14 percutaneous coronary interventions (PCI), 9 cardiac surgeries 7 onpump, and 25 simple coronary angiograms, being our control group. Patient demographics as well as thrombotic and hemorrhagic complications where assessed by clinical follow up, average of 2.1 years post intervention. RESULTS: Most patients had at least 2 cardiovascular risk factors, and were treated with both cytoreductive and antiplatelet therapy. There was an 18% thrombotic incidence peri-PCI, two events being peri-hospitalisation and one 4 monts post intervention, compared to a 3% incidence in the control group. There was one early thrombotic mortality peri-PCI, and zero hemorrhagic complications. The thrombotic and hemorrhagic incidences in patients undergoing cardiac surgery were 33% and 22% respectively, with one early thrombotic post surgical death. All surgical complications occurred with the on-pump CABG patients. CONCLUSION: Our data suggests that patients with a cMPD have a relatively high thrombotic incidence when undergoing any form of coronary revascularization and that further research with a larger population base is needed to better study these outcomes.
451 CARDIAC RETRANSPLANTATION IS A VALUABLE OPTION FOR END-STAGE CORONARY ARTERY VASCULOPATHY M Laflamme, A Tarmiz, L Perrault, G Pelletier, M Pellerin, M Carrier Montréal, Québec
CIHR
450 OUTCOMES AFTER CORONARY REVASCULARIZATION IN PATIENTS WITH POLYCYTHEMIA VERA AND ESSENTIAL THROMBOCYTHEMIA R Wahhab, J Diodati, H Jeanmart Montréal, Québec
BACKGROUND: Retransplantation is done in only 2% to 3% of primary transplant recipient. Most of these patients have advanced coronary vasculopathy at the time of retransplantation. We report our experience with cardiac retransplantation since 1983. METHODS: We reviewed all cases of patients who underwent heart retransplantation for end-stage coronary artery vasculopathy. From April 1983 to March 2011, we performed 377 cardiac transplantations. Ten (2.6%) were retransplantations. All primary cardiac transplant recipients at our institution served as the control group. Time to event analyses included comparisons of patients undergoing primary transplantation versus patients undergoing retranplantation for patient survival, rejection and infection analyses. RESULTS: There were 7 male and 3 female patients ranging from 14 to 69 years (mean, 37 ⫾ 17 years). Indication for
S269
Abstracts
second transplantation was end-stage coronary vasculopathy in all cases. The Kaplan-Meier survival curves comparing our primary transplantation group with the retransplantation group are identical. The 30-day and the one year survival averaged 90 % ⫾ 9 and 88 % ⫾ 8 in retransplantation patients compared with 92 % ⫾ 1 and 85 % ⫾ 2 (p ⫽ 0.71) in primary transplant patients. The freedom rates from acute rejection (51 % ⫾ 3 and 39 % ⫾ 17, respectively) and from infection (48 % ⫾ 3 and 39 % ⫾ 17) were similar in both groups (p ⫽ 0.65 and p ⫽ 0.97) at ten year follow-up. CONCLUSION: Patients who underwent cardiac retransplantation for endstage coronary artery vasculopathy have similar outcomes when compared to primary heart transplant patients.
452 MINIMALLY INVASIVE MITRAL VALVE SURGERY: INFLUENCE OF AORTIC CLAMPING TECHNIQUE ON EARLY OUTCOMES A Mazine, M Laflamme, D Bouchard, H Jeanmart, J Lebon, M Pellerin Montréal, Québec
Several methods of aortic clamping have been described for minimally invasive mitral valve surgery (MIMVS). The aim of this study was to compare the endoaortic balloon occlusion technique with the transthoracic clamp approach in terms of perioperative outcomes. METHODS: Between May 2006 and October 2011, a total of 259 patients underwent MIMVS via a 4-5 cm right anterolateral minithoracotomy. In 243 (93.8%) of these, the aorta was clamped using either the endoaortic balloon occlusion technique (Endoballoon, n⫽140) or the transthoracic clamp technique (Chitwood, n⫽103). RESULTS: Patients in the Endoballoon group had significantly longer operating time (4.3⫾1.0 hours versus 3.2 ⫾ 0,8 hours, p ⬍ 0.001), CPB time (143.1⫾44.1 min versus 111.3⫾28.9 min, p⬍0.001) and cross-clamp time (113.9⫾37.9 min versus 86.0⫾23.1 min, p⬍0.001). Perioperative blood loss was higher in the Endoballoon group (286.5⫾239.3 mL versus 212.8⫾189.4 min, p⫽0.008) as was the mean postoperative CK-MB level (36.3⫾44.1 g/L versus 26.3⫾12.1 g/L, p⫽0.011). The repair rate was ⬎99% in both groups (p⫽ns). In the Endoballoon group, there was one stroke and 5 myocardial infarctions (3.6%), compared to 2 strokes in the Chitwood group (p⫽ns). All patients left the operating room with no or trivial residual MR on transesophageal echocardiography evaluation. In-hospital mortality occured in 2 patients from each group (p⫽ns). CONCLUSIONS: MIMVS can be performed successfully using either the endoaortic balloon technique or the Chitwood transthoracic clamp approach. However, the Chitwood technique results in shorter operation time, less peroperative bleeding and better myocardial protection. BACKGROUND:
Canadian Cardiovascular Society (CCS) CCS192 Highlighted Poster CLINICAL AND TRANSLATIONAL EP Monday, October 29, 2012 462 SIMVASTATIN IN THE SETTING OF INOS DELETION IMPROVES SURVIVAL IN MICE WITH VENTRICULAR HYPERTROPHY SECONDARY TO CALCINEURIN OVEREXPRESSION AM Gillis, HJ Mathison, J Lees-Miller, H Duff Calgary, Alberta BACKGROUND: Overexpression of calcineurin (CN) causes cardiac
hypertrophy and arrhythmic deaths secondary to either heart block or ventricular tachyarrhythmias (VT). Statins have been reported to prevent the development of left ventricular hypertrophy (LVH) in some experimental models and in patients with heart disease. We have previously reported that simvastatin prevented VT associated with CN overexpression but did not improve survival or modify the magnitude of LVH. Inducible nitric acid (NO) synthase (INOS) has been implicated in cardiac injury. Here, we tested the hypothesis that simvastatin would improve survival in transgenic mice with CN overexpression and INOS deletion. METHODS: Double recombinant mice with CN overexpression and INOS deletion were treated daily with 2mg/kg simvastatin (n⫽10) or placebo (n⫽11) up to 270 days of age. ECGs were monitored for 5 minutes every 10 days commencing at age 35 days. Heart rate, P-R interval, AV block and spontaneous VT were compared between groups at ages 46 and 126 days. Heart weight, heart septum thickness and left ventricle wall thickness were compared between groups at death. Survival was also compared between the two groups. RESULTS: Simvastatin did not significantly reduce cardiac mass or dimensions. Simvastatin improved survival in the INOS-CN mice (Figure) and increased resting heart rate. Simvastatin did not modify AV conduction or magnitude of heart block but tended to reduce ventricular arrhythmia frequency.
CONCLUSION: Simvastatin treatment improved survival in dou-
ble recombinant INOS deletion x CN mice in the absence of