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EFFECT OF THE LEFT INTERNAL MAMMARY ARTERY TO THE LEFT ANTERIOR DESCENDING ARTERY ON MORTALITY AND LONG-TERM SURVIVAL AFTER EMERGENCY CORONARY ARTERY BYPASS GRAFTING
S20 ORAL PRESENTATIONS
Heart, Lung and Circulation 2007;16:S13–S29
ORAL PRESENTATIONS
Conclusions. Intramyocardial APCs injection is feasible and safe in ICM patients. The randomised, double-blind, placebo-controlled trials are needed to confirm the efficacy of this cell transplantation. doi:10.1016/j.hlc.2007.02.021 THE EFFICACY OF SKELETAL MYOBLAST DELIVERY OF ANGIOPOIETIN-1 VS DIRECT ADENOVIRAL ANGIOPOIETIN-1 INJECTION FOR CARDIAC REPAIR Lei Ye 1 , Husnain Kh. Haider 2 , Shujia Jiang 2 , Rusan Tan 3 , Wee Chi Toh 1 , Ruowen Ge 4 , In Chin Song 5 , Peter K. Law 6 , Eugene K.W. Sim 7, 1 National University Medical Institutes, National University of Singapore, Singapore 2 Department of Pathology and Lab Medicine, University of Cincinnati, Ohio, USA 3 National Heart Centre, Singapore 4 Department of Biological Sciences, National University of Singapore, Singapore 5 Department of Experimental Surgery, Singapore General Hospital 6 Cell Transplants Singapore Pte. Ltd., Singapore 7 Department of Surgery, National University of Singapore & Gleneagles JPMC Cardiac Center, Brunei Darussalam
Background. We hypothesised that angiogenic response and efficacy of angiopoietin-1 (Ang-1) gene delivery in the infarcted myocardium would be influenced by the mode of delivery. Methods. Ang-1 was packaged into adenoviral vector (Ad-Ang-1) and used for either direct injection or transduction of skeletal myoblasts (SkM). Experimental myocardial infarction model was developed in 20 female pigs by coronary artery ligation. Three weeks later, the animals were grouped to receive intramyocardial injection of 5 mL DMEM alone (group 1 n = 6), or containing 1 × 1010 PFU Ad-Ang-1 (group 2 n = 7), or 3 × 108 lac-z labeled SkM transduced with Ad-Ang-1 (group 3 n = 7). Animals were maintained on 5 mg/kg cyclosporine for 6 weeks. The animals were euthanased at 6 and 12 weeks post respective treatment and their heart tissue was processed for histological studies. Results. Extensive survival of the lac-z positive SkM was observed in pig heart up to 12 weeks after cell transplantation. Blood vessel density (×100) by fluorescent immunostaining for vWF-VIII and smooth muscle actin in group 3 increased from 42.25 ± 3.82 and 34.73 ± 2.52 at 6 weeks to 46.57 ± 1.76 and 41.36 ± 1.53 at 12 weeks as compared to group 1 (16.0 ± 0.91; 7.88 ± 0.52; p < 0.01) and group 2 (30.63 ± 2.11 p < 0.01; 37.5 ± 2.04) at 6 weeks and (13.44 ± 0.9; 7.00 ± 0.58; p < 0.01) of group 1 and (37.43 ± 2.77; 35.86 ± 2.79) of group 2 at 12 weeks. Mature blood vessel index at was the highest in group 2 at 6 (98.5 ± 4.2%) and 12 (96 ± 2.2%) weeks and followed by group 3 (85.26 ± 2.86%; 91.64 ± 7.96%). These were significantly higher than those of group 1 (49.20 ± 4.7%; 52.08 ± 5.9%). The mean blood vessel diameter in groups
2 and 3 at 6 weeks were significantly smaller than those of group 1 (11.72 ± 1.67 m; p < 0.05). However, they increased to 10.9 ± 1.21 m and 10.64 ± 1.14 m at 12 weeks. Significantly improved blood flow was achieved by group 3 as compared with groups 1 and 2 at 6 weeks. Significantly improved ejection fraction was only achieved in group 3 (49.22 ± 5.92%; p = 0.037) as compared with group 1 (36.84 ± 3.02%). Conclusion. SkM-mediated Ang-1 delivery is associated with better improved regional perfusion and heart function as compared with direct Ad-Ang-1 administration for cardiac repair. doi:10.1016/j.hlc.2007.02.022 FIVE YEARS FOLLOW-UP OF LIMA-LAD GRAFTING ON PATIENTS WITH EACAB PROCEDURE UNDERWENT SCANNING WITH 64-SLICE COMPUTED TOMOGRAPHY M. Cisowski 1 , T. Waclawczyk 1 , M. Szymanski 2 , Z. Gasior 2 , A. Bochenek 1,
Skowerski 2 , L.
1 First Department of Cardiac Surgery Medical University of Silesia, Katowice, Poland 2 Second Department of Cardiology Medical University of Silesia, Katowice, Poland
Background. A postoperative bypass grafts assessment of patient underwent endoscopic atraumatic coronary artery bypass grafting (EACAB) with newest generation multi slice computed tomography (MSCT) is step beyond noninvasive imaging of the heart. Methods. Forty-four patients (6 women and 38 men) underwent 64-slice computed tomography (Aquilion Toshiba) after EACAB (performed between January 1999 and December 2001). MSCT angiography was performed using standard protocol, ECG gated. All of these patients received B-blockers accept one to reduce the heart rate. Results. In all cases anastomoses LIMA to LAD were patent. Conclusions. New technology as MSCT can very clearly show effectiveness of surgical treatment of coronary artery disease and seems to be a useful tool to imaging its results. doi:10.1016/j.hlc.2007.02.023 EFFECT OF THE LEFT INTERNAL MAMMARY ARTERY TO THE LEFT ANTERIOR DESCENDING ARTERY ON MORTALITY AND LONG-TERM SURVIVAL AFTER EMERGENCY CORONARY ARTERY BYPASS GRAFTING E.K. Slimani , R. Baker, J.L Knight Department of Cardiac and Thoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia Introduction. The beneficial effects of using the left internal mammary artery in coronary artery bypass
ORAL PRESENTATIONS
S21
Table 1. Pre-, Intra- and Postoperative Parameters by Age Euroscore corrected for age Infarct < 90 days Three vessel disease Left mainstem stenosis Unstable coronary disease Impaired left ventricular function Mean number of grafts Multiple arterial grafts Median ITU stay in days (IQR) Postoperative renal failure Postoperative stroke Prolonged ventilation (>5 days) Any non-fatal complication 30-day mortality
70–74 years (n = 547)
75–79 years (n = 349)
2 14.8% (81) 80.1% (438) 33.3% (182) 25.6% (140) 26.5% (145) 3.02 38.6% (211) 1 (1–2) 2.7% (15) 2.0% (11) 0.9% (5) 15.7% (86) 1.1% (6)
2 21.5% (75) 87.1% (304) 42.1% (147) 33.8% (118) 30.1% (105) 3.10 27.5% (96) 1 (1–2) 4.6% (16) 2.0% (7) 2.3% (8) 20.1% (70) 2.9% (10)
grafting with regard to graft patency, target vessel revascularisation and long-term survival are well documented. It is less clear whether this benefit is also imparted in patients requiring operation in an emergency setting. We aimed to quantify the impact of the left internal mammary artery on hospital and long-term outcomes in these patients. Methods. Data were collected prospectively on 203 consecutive patients aged between 40 and 88 years, who underwent isolated emergency coronary artery bypass grafting between 1992 and 2005. Emergency surgery was defined as a requirement for operation within 24 h of presentation. Mean follow-up (±standard deviation) was 74 ± 39 months with a total of 1210 patient-years. Results. The left internal mammary artery (LIMA) was used in 91 patients (45%), the remaining 113 patients (55%) received saphenous vein grafts only (SVG). Overall hospital mortality was 6.4 ± 3.4% (±95% confidence interval). Univariate analyses found patients receiving the left internal mammary artery had significantly lower hospital mortality 2.2% vs 9.8% (p < 0.03). The LIMA group also had a reduced requirement for intra-aortic balloon pump (IABP) support in order to successfully separate from cardiopulmonary bypass (p < 0.01). The use of the left internal mammary artery reduced the requirement for postoperative inotropic (p < 0.05) or IABP support (p < 0.05). Of the 190 hospital survivors there were 45 late deaths. The use of only saphenous vein grafts was a predictor of late death (p < 0.01). Excluding hospital deaths survival (Kaplan-Meier) was improved in patients who received the left internal mammary artery to the left anterior descending artery. This, however, failed to reach statistical significance (log rank analysis p = 0.08). At five years survival was 87% if the LIMA was used compared with 75% for patients receiving saphenous vein grafts only. At eight years survival was 77% in the LIMA group vs 69% for the SVG group. Discussion. In emergency coronary artery bypass grafting the use of the left internal mammary artery to the left anterior descending artery is associated with a reduced requirement for inotropic or intra-aortic balloon pump support, reduced hospital mortality, and a trend towards improved long-term survival. doi:10.1016/j.hlc.2007.02.024
>80 years (n = 135) 3 28.9% (39) 91.9% (124) 45.9% (62) 47.4% (65) 32.6% (44) 3.27 23.7% (32) 1 (1–2) 3.0% (4) 0.7% (1) 0.7% (1) 26.7% (36) 2.2% (3)
CORONARY REVASCULARISATION IN GENARIANS: IS AGE JUST A NUMBER? Philip Hayward 1 , Gunaratnam Valencia 2 , Venkatachalam Kanagasabay 2
p-value ns 0.001 0.03 0.004 0.001 ns ns 0.02 ns ns ns ns 0.008 ns
OCTO-
Niranjan 1,2 , Oswaldo Chandrasekaran 2 , Robin
1 Austin 2 St
Hospital, Heidelberg, Victoria, Australia Georges Hospital, London, United Kingdom
Introduction. Coronary surgery in octogenarians may invoke perceptions of higher perioperative risk and greater comorbidity. We sought to establish whether our experience justifies any age related concerns. Methods. Retrospective analysis of prospectively compiled pre-, peri- and postoperative data from 2737 patients undergoing isolated coronary surgery over a 4-year period. Data were analysed comparing three age groups (70–74, 75–79, >80 years) comprising 547, 349 and 135 consecutive patients, respectively. Results. Most preoperative risk factors for perioperative mortality or complications did not differ significantly between age groups (exceptions noted in Table 1). There were no significant operative differences other than lower usage of multiple arterial grafts in octogenarians. Use of off-pump technique did not differ significantly between age groups (41, 40 and 47% of cases). Postoperative mortality did not increase with age (1.1, 2.9 and 2.2%; p = ns), and medians of postoperative stay range from 6 to 8 days (p < 0.001). There was no significant increase in the incidence of any single complication, although octogenarians were more likely overall to sustain a non-fatal complication (p = 0.008). On logistic regression analysis, age > 80, on pump technique and unstable angina were independent predictors of non-fatal complication. Discussion. The higher incidence of recent infarction, urgent operation, left mainstem and multivessel disease among octogenarians might imply some bias against less pressing cases in this age group. Outcomes, however, indicate that octogenarians do not necessarily carry unacceptable risk, and equivalent mortality can be achieved with only a modest increase in hospital stay and complications. The effect of off-pump technique in octogenarians merits further investigation. doi:10.1016/j.hlc.2007.02.025
ORAL PRESENTATIONS
Heart, Lung and Circulation 2007;16:S13–S29
Heart, Lung and Circulation 2007;16:S13–S29
ORAL PRESENTATIONS
Conclusions. Intramyocardial APCs injection is feasible and safe in ICM patients. The randomised, double-blind, placebo-controlled trials are needed to confirm the efficacy of this cell transplantation. doi:10.1016/j.hlc.2007.02.021 THE EFFICACY OF SKELETAL MYOBLAST DELIVERY OF ANGIOPOIETIN-1 VS DIRECT ADENOVIRAL ANGIOPOIETIN-1 INJECTION FOR CARDIAC REPAIR Lei Ye 1 , Husnain Kh. Haider 2 , Shujia Jiang 2 , Rusan Tan 3 , Wee Chi Toh 1 , Ruowen Ge 4 , In Chin Song 5 , Peter K. Law 6 , Eugene K.W. Sim 7, 1 National University Medical Institutes, National University of Singapore, Singapore 2 Department of Pathology and Lab Medicine, University of Cincinnati, Ohio, USA 3 National Heart Centre, Singapore 4 Department of Biological Sciences, National University of Singapore, Singapore 5 Department of Experimental Surgery, Singapore General Hospital 6 Cell Transplants Singapore Pte. Ltd., Singapore 7 Department of Surgery, National University of Singapore & Gleneagles JPMC Cardiac Center, Brunei Darussalam
Background. We hypothesised that angiogenic response and efficacy of angiopoietin-1 (Ang-1) gene delivery in the infarcted myocardium would be influenced by the mode of delivery. Methods. Ang-1 was packaged into adenoviral vector (Ad-Ang-1) and used for either direct injection or transduction of skeletal myoblasts (SkM). Experimental myocardial infarction model was developed in 20 female pigs by coronary artery ligation. Three weeks later, the animals were grouped to receive intramyocardial injection of 5 mL DMEM alone (group 1 n = 6), or containing 1 × 1010 PFU Ad-Ang-1 (group 2 n = 7), or 3 × 108 lac-z labeled SkM transduced with Ad-Ang-1 (group 3 n = 7). Animals were maintained on 5 mg/kg cyclosporine for 6 weeks. The animals were euthanased at 6 and 12 weeks post respective treatment and their heart tissue was processed for histological studies. Results. Extensive survival of the lac-z positive SkM was observed in pig heart up to 12 weeks after cell transplantation. Blood vessel density (×100) by fluorescent immunostaining for vWF-VIII and smooth muscle actin in group 3 increased from 42.25 ± 3.82 and 34.73 ± 2.52 at 6 weeks to 46.57 ± 1.76 and 41.36 ± 1.53 at 12 weeks as compared to group 1 (16.0 ± 0.91; 7.88 ± 0.52; p < 0.01) and group 2 (30.63 ± 2.11 p < 0.01; 37.5 ± 2.04) at 6 weeks and (13.44 ± 0.9; 7.00 ± 0.58; p < 0.01) of group 1 and (37.43 ± 2.77; 35.86 ± 2.79) of group 2 at 12 weeks. Mature blood vessel index at was the highest in group 2 at 6 (98.5 ± 4.2%) and 12 (96 ± 2.2%) weeks and followed by group 3 (85.26 ± 2.86%; 91.64 ± 7.96%). These were significantly higher than those of group 1 (49.20 ± 4.7%; 52.08 ± 5.9%). The mean blood vessel diameter in groups
2 and 3 at 6 weeks were significantly smaller than those of group 1 (11.72 ± 1.67 m; p < 0.05). However, they increased to 10.9 ± 1.21 m and 10.64 ± 1.14 m at 12 weeks. Significantly improved blood flow was achieved by group 3 as compared with groups 1 and 2 at 6 weeks. Significantly improved ejection fraction was only achieved in group 3 (49.22 ± 5.92%; p = 0.037) as compared with group 1 (36.84 ± 3.02%). Conclusion. SkM-mediated Ang-1 delivery is associated with better improved regional perfusion and heart function as compared with direct Ad-Ang-1 administration for cardiac repair. doi:10.1016/j.hlc.2007.02.022 FIVE YEARS FOLLOW-UP OF LIMA-LAD GRAFTING ON PATIENTS WITH EACAB PROCEDURE UNDERWENT SCANNING WITH 64-SLICE COMPUTED TOMOGRAPHY M. Cisowski 1 , T. Waclawczyk 1 , M. Szymanski 2 , Z. Gasior 2 , A. Bochenek 1,
Skowerski 2 , L.
1 First Department of Cardiac Surgery Medical University of Silesia, Katowice, Poland 2 Second Department of Cardiology Medical University of Silesia, Katowice, Poland
Background. A postoperative bypass grafts assessment of patient underwent endoscopic atraumatic coronary artery bypass grafting (EACAB) with newest generation multi slice computed tomography (MSCT) is step beyond noninvasive imaging of the heart. Methods. Forty-four patients (6 women and 38 men) underwent 64-slice computed tomography (Aquilion Toshiba) after EACAB (performed between January 1999 and December 2001). MSCT angiography was performed using standard protocol, ECG gated. All of these patients received B-blockers accept one to reduce the heart rate. Results. In all cases anastomoses LIMA to LAD were patent. Conclusions. New technology as MSCT can very clearly show effectiveness of surgical treatment of coronary artery disease and seems to be a useful tool to imaging its results. doi:10.1016/j.hlc.2007.02.023 EFFECT OF THE LEFT INTERNAL MAMMARY ARTERY TO THE LEFT ANTERIOR DESCENDING ARTERY ON MORTALITY AND LONG-TERM SURVIVAL AFTER EMERGENCY CORONARY ARTERY BYPASS GRAFTING E.K. Slimani , R. Baker, J.L Knight Department of Cardiac and Thoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia Introduction. The beneficial effects of using the left internal mammary artery in coronary artery bypass
ORAL PRESENTATIONS
S21
Table 1. Pre-, Intra- and Postoperative Parameters by Age Euroscore corrected for age Infarct < 90 days Three vessel disease Left mainstem stenosis Unstable coronary disease Impaired left ventricular function Mean number of grafts Multiple arterial grafts Median ITU stay in days (IQR) Postoperative renal failure Postoperative stroke Prolonged ventilation (>5 days) Any non-fatal complication 30-day mortality
70–74 years (n = 547)
75–79 years (n = 349)
2 14.8% (81) 80.1% (438) 33.3% (182) 25.6% (140) 26.5% (145) 3.02 38.6% (211) 1 (1–2) 2.7% (15) 2.0% (11) 0.9% (5) 15.7% (86) 1.1% (6)
2 21.5% (75) 87.1% (304) 42.1% (147) 33.8% (118) 30.1% (105) 3.10 27.5% (96) 1 (1–2) 4.6% (16) 2.0% (7) 2.3% (8) 20.1% (70) 2.9% (10)
grafting with regard to graft patency, target vessel revascularisation and long-term survival are well documented. It is less clear whether this benefit is also imparted in patients requiring operation in an emergency setting. We aimed to quantify the impact of the left internal mammary artery on hospital and long-term outcomes in these patients. Methods. Data were collected prospectively on 203 consecutive patients aged between 40 and 88 years, who underwent isolated emergency coronary artery bypass grafting between 1992 and 2005. Emergency surgery was defined as a requirement for operation within 24 h of presentation. Mean follow-up (±standard deviation) was 74 ± 39 months with a total of 1210 patient-years. Results. The left internal mammary artery (LIMA) was used in 91 patients (45%), the remaining 113 patients (55%) received saphenous vein grafts only (SVG). Overall hospital mortality was 6.4 ± 3.4% (±95% confidence interval). Univariate analyses found patients receiving the left internal mammary artery had significantly lower hospital mortality 2.2% vs 9.8% (p < 0.03). The LIMA group also had a reduced requirement for intra-aortic balloon pump (IABP) support in order to successfully separate from cardiopulmonary bypass (p < 0.01). The use of the left internal mammary artery reduced the requirement for postoperative inotropic (p < 0.05) or IABP support (p < 0.05). Of the 190 hospital survivors there were 45 late deaths. The use of only saphenous vein grafts was a predictor of late death (p < 0.01). Excluding hospital deaths survival (Kaplan-Meier) was improved in patients who received the left internal mammary artery to the left anterior descending artery. This, however, failed to reach statistical significance (log rank analysis p = 0.08). At five years survival was 87% if the LIMA was used compared with 75% for patients receiving saphenous vein grafts only. At eight years survival was 77% in the LIMA group vs 69% for the SVG group. Discussion. In emergency coronary artery bypass grafting the use of the left internal mammary artery to the left anterior descending artery is associated with a reduced requirement for inotropic or intra-aortic balloon pump support, reduced hospital mortality, and a trend towards improved long-term survival. doi:10.1016/j.hlc.2007.02.024
>80 years (n = 135) 3 28.9% (39) 91.9% (124) 45.9% (62) 47.4% (65) 32.6% (44) 3.27 23.7% (32) 1 (1–2) 3.0% (4) 0.7% (1) 0.7% (1) 26.7% (36) 2.2% (3)
CORONARY REVASCULARISATION IN GENARIANS: IS AGE JUST A NUMBER? Philip Hayward 1 , Gunaratnam Valencia 2 , Venkatachalam Kanagasabay 2
p-value ns 0.001 0.03 0.004 0.001 ns ns 0.02 ns ns ns ns 0.008 ns
OCTO-
Niranjan 1,2 , Oswaldo Chandrasekaran 2 , Robin
1 Austin 2 St
Hospital, Heidelberg, Victoria, Australia Georges Hospital, London, United Kingdom
Introduction. Coronary surgery in octogenarians may invoke perceptions of higher perioperative risk and greater comorbidity. We sought to establish whether our experience justifies any age related concerns. Methods. Retrospective analysis of prospectively compiled pre-, peri- and postoperative data from 2737 patients undergoing isolated coronary surgery over a 4-year period. Data were analysed comparing three age groups (70–74, 75–79, >80 years) comprising 547, 349 and 135 consecutive patients, respectively. Results. Most preoperative risk factors for perioperative mortality or complications did not differ significantly between age groups (exceptions noted in Table 1). There were no significant operative differences other than lower usage of multiple arterial grafts in octogenarians. Use of off-pump technique did not differ significantly between age groups (41, 40 and 47% of cases). Postoperative mortality did not increase with age (1.1, 2.9 and 2.2%; p = ns), and medians of postoperative stay range from 6 to 8 days (p < 0.001). There was no significant increase in the incidence of any single complication, although octogenarians were more likely overall to sustain a non-fatal complication (p = 0.008). On logistic regression analysis, age > 80, on pump technique and unstable angina were independent predictors of non-fatal complication. Discussion. The higher incidence of recent infarction, urgent operation, left mainstem and multivessel disease among octogenarians might imply some bias against less pressing cases in this age group. Outcomes, however, indicate that octogenarians do not necessarily carry unacceptable risk, and equivalent mortality can be achieved with only a modest increase in hospital stay and complications. The effect of off-pump technique in octogenarians merits further investigation. doi:10.1016/j.hlc.2007.02.025
ORAL PRESENTATIONS
Heart, Lung and Circulation 2007;16:S13–S29