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Quantitative Three Dimensional Echocardiographic Assessment of the Right Ventricle Can Identify Risk of Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Device Surgery
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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
Results: The mean age of BTT patients was younger (OHT 49 yo, BTT 41 yo, po0.01). There was a slightly lower 30-day survival in the BTT group (OHT 92%; BTT 85%) but there were no differences in 1-yr, 5-yr and q10-yr survival between groups (OHT 84%, 75%, 61%; BTT 82%, 74%, 58%, log-rank test p¼0.47). The BTT group had a higher incidence of complications post-transplant: prolonged ventilation time (hours) (20⫾35 vs. 11⫾54, po0.01), pancreatitis (5% vs. 0.04%), blood loss in the first 24h (mls.) (840⫾2000 vs. 580⫾860, po0.01) and ITU stay (days) (5⫾10.8 vs. 3⫾6.6, po0.01). There was no difference between groups regarding total hospital length of stay (22.6⫾20 vs. 22⫾17, p¼0.76).
Conclusions: The use of ventricular assist devices as bridge to transplantation provides excellent posttransplant survival when compared to standard heart transplants. However, surgery for VAD explant and heart transplant can be demanding and is accompanied by higher perioperative morbidity without increasing length of stay.
619 The Hemodynamic Effects of the MEGA Intra-Aortic Balloon Counterpulsation Pump A. Majithia, M. Jumean, H. Shih, C.D. Kimmelstiel, A. Weintraub, D.T. Pham, M.S. Kiernan, D. Denofrio, N.K. Kapur. Cardiology, Tufts Medical Center, Boston, MA. Purpose: The IABP-SHOCK II study recently questioned the clinical utility of intra-aortic balloon counterpulsation (IABP) in patients with acute myocardial infarction and cardiogenic shock. The aim of this study was to compare the hemodynamic effect of the MEGA-series (50cc) and standard (40cc) IABPs (Maquet Inc). Methods and Materials: Twenty consecutive subjects treated with a MEGA-IABP between January and November 2012 were studied. Twenty age-, gender-, and body surface area matched patients receiving a 40cc standard IABP during the same time period served as controls. All subjects presented with decompensated left heart failure or cardiogenic shock. Medical records were reviewed for demographics, hemodynamic data, laboratory data, and clinical outcomes. Hemodynamic and laboratory datat were collected within 24 hours of IABP placement. Results: Demographics, hemodynamics and laboratory values are shown in Table One. Baseline characteristics were similar between groups except for a higher incidence of diabetes mellitus in the MEGA group (76% vs 33%, po0.01). Mean duration of IABP support was longer in the MEGA group (2.6 þ1.8 vs 4.5þ3.1 days, p¼0.01). PostIABP systolic blood pressure and augmented diastolic pressure were higher in the MEGA group compared to standard IABP. A trend towards a higher mean arterial pressure was observed in the MEGA group. Platelet count was significantly lower within 24 hours of support in the MEGA group. No difference in survival to discharge or bleeding was observed between groups.
618 Durability of DeVega Tricuspid Valve Annuloplasty for Severe Tricuspid Regurgitation at the Time of Continuous-Flow LVAD Implantation S.A. Akhter, R. Salabat, M.J. Russo, T.B. Valeroso, J.D. Rich, V. Jeevanandam. Surgery, University of Chicago Medical Center, Chicago, IL. Purpose: Functional tricuspid regurgitation (TR) is common in advanced heart failure patients who undergo LVAD implant. Recent studies suggest that tricuspid valve (TV) repair may have a positive impact on long-term right ventricular function and survival. The objective of this study is to evaluate the intermediate-term durability of DeVega TV annuloplasty (TVA) for severe TR when performed at the time of continuous-flow (CF) LVAD implant. Methods and Materials: This is a retrospective study of 35 consecutive patients who underwent CF LVAD implant and DeVega TVA for severe TR and were alive at one year follow-up. Pre-operative, predischarge, and one year post-implant transthoracic echocardiograms were obtained for all patients. TR was graded as insignificant (none, trivial, or mild) or significant (moderate or severe). Results: The HeartMate II LVAD was implanted in 30 patients and 5 underwent Heartware HVAD implant. Thirty-two of 35 (91.4%, Group A) improved from severe TR preoperatively to insignificant TR at the time of discharge following DeVega TVA and 3 (8.6%, Group B) had moderate residual TR. At one year follow-up, 29 of 32 (90.6%) in Group A had insignificant TR, 2 (6.3%) had moderate TR and 1 (3.1%) had severe TR. In Group B, 2 of 3 had no progression of their moderate TR at one year and 1 had severe TR. Overall, 2 of 35 (5.7%) had severe TR at one year following DeVega TVA and LVAD implant. Conclusions: DeVega TVA appears to be an effective and durable repair for severe TR at the time of CF LVAD implant at one year follow-up. This technique requires less operative time than a formal annuloplasty ring and is also less costly. Although previous studies have shown that DeVega TVA for severe TR in conventional cardiac surgery may not be a durable procedure, unloading of the left ventricle and pulmonary circulation may contribute to the durability seen in this patient population.
Conclusions: Use of the 50cc MEGA-IABP is associated with improved systemic hemodynamic variables compared to the standard 40cc IABP. Further investigation into the clinical utility of the MEGA IABP is required. 620 Quantitative Three Dimensional Echocardiographic Assessment of the Right Ventricle Can Identify Risk of Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Device Surgery A.L. French, M.S. Kiernan, D. DeNofrio, D.T. Pham, N.K. Kapur, N.G. Pandian, A.R. Patel. Tufts Medical Center, Boston, MA. Purpose: Right ventricular failure (RVF) is associated with significant morbidity following left ventricular assist device (LVAD) surgery. Hemodynamic, clinical, and 2-dimensional echocardiographic
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variables poorly discriminate patients at risk of RVF. We examined the utility of 3-dimensional echocardiography (3DE) right ventricular (RV) volumetric assessment to identify patients at risk of RVF. Methods and Materials: RVF was defined as need for inotropic infusion for 414 days following LVAD surgery or RV assist device (RVAD) placement. Preoperative RV volumes and ejection fraction (RVEF) were measured, blinded to clinical data, from transthoracic 3DE full volume data sets in 29 patients. Univariate analyses were used to compare baseline variables and 3DE RV indices among patients with and without RVF. Multivariate logistic regression was used to adjust for baseline covariates. Results: 25 patients (86%) received continuous flow LVADs. 13 patients (45%) had RVF 2 required RVAD support and 11 required prolonged inotropes. Cardiac index (CI), RV stroke work index (RVSWI), indexed RV end diastolic and systolic volumes (RVEDVI & RVESVI) and RVEF were associated with RVF. RVEDVI (OR 1.082 (1.00, 1.17), p¼0.049) and RVESVI (OR 1.117 (1.00, 1.25), p¼0.049) remained associated with RVF after adjusting for RVSWI. Conclusions: Quantitative 3DE is a promising method for pre-LVAD
Comparison of 3DE and baseline variables among patients with and without RVF.
RVEDVI (ml/m2) RVESVI (ml/m2) RVEF (%) RVSWI (mmHg ml/m2) CI (l/min/m2) Total Bilirubin (mg/dL) BUN (mg/dL) Right atrial pressure/PCWP ratio Right atrial pressure (mmHg)
No RVF (mean⫾SD) 46 ⫾ 13 30 ⫾ 9 33 ⫾ 9 644 ⫾ 267 2.3 ⫾ 0.6 1.4 ⫾ 0.8 24 ⫾ 13 0.4 ⫾ 0.1 10 ⫾ 4
RVF (mean⫾SD) 65 ⫾ 21 53 ⫾ 22 23 ⫾ 12 400 ⫾ 175 1.9 ⫾ 0.3 1.6 ⫾ 0.9 17 ⫾ 8 0.6 ⫾ 0.2 14 ⫾ 7
P-value 0.008 0.0095 0.014 0.0092 0.047 0.68 0.06 0.09 0.17
RV assessment. RV volumes assessed by 3DE are predictive of RVF in LVAD recipients, independent of RVSWI. 621
significant decline in GFR to stage II Chronic Kidney Disease, with a simultaneous rise in doppler pressure over one year in patients after LVAD implantation. It is unclear if the continuous flow LVADs contribute to this phenomenon and what role the renin-angiotensinaldosterone axis may play in this patient population, suggesting that further investigation is required. 622 Whole Blood Gene Expression of Multiorgan Dysfunction (MOD) after LVAD Implantation G. Bondar,1 M. Cadeiras,1 N. Wisniewski,1 R.K. Cheng,1 K. Shahzad,2 D. Onat,3 F. Latif,3 E. Chang,1 M.C. Deng.1 1Medicine, Division of Cardiology, UCLA Medical Center, Los Angeles, CA; 2Medicine, East Carolina University, Greenville, NC; 3Medicine, Columbia University Medical Center, New York, NY. Purpose: Early recognition of MOD has important implications in diagnosis and treatment of patients with advanced heart failure (AdHF) undergoing implantation of mechanical circulatory support devices (MCSD). We hypothesized that whole blood (WB) mRNA gene expression can be linked to systemic inflammatory response as evaluated by SOFA score. Methods and Materials: We collected WB from 29 AdHF patients undergoing MCSD implantation between 3/2010 and 5/2011 and 8 age matched controls. MOD was defined by SOFA score, with patients divided into low (r 4) (n¼8), intermediate (5-11) (n¼13), and high (Z12) (n¼8) risk groups at median 8 days (IQR 7 - 14) postoperatively. After globin reduction, total mRNA was purified, amplified and hybridized on Illumina Whole Genome Expression Chips. Expression data was extracted and analyzed using GeneSpring GX 12 (Agilent). Results: Mean age was 57⫾15 years. After normalization with Kruskal-Wallis testing, 440 transcripts were differentially expressed (Figure B) (Benjamini-Hochberg correction, FDR 0.05, fold change 1.5). Hierarchical clustering (A, C) (Pearson absolute distance) organized samples in ascending SOFA risk groups. Gene ontology and pathway analysis revealed significant enrichment of genes representing regulation of immune response including pathways of innate and adaptive immunity. Comparison with PBMC showed 475% overlapping genes (D).
Type 2 Cardiorenal Syndrome in the Left Ventricular Assist Device (LVAD) Population S. Feitell,1 J. Patel,1 P. Pirlamarla,1 J. Whittier,1 E. Gongora,1 T. Rowe,2 S. Hankins,1 H.J. Eisen.1 1Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA; 2Center for Advanced Heart Failure Care, Hahnemann University Hospital, Philadelphia, PA. Purpose: Type 2 Cardiorenal Syndrome after LVAD has not been well evaluated in patients with Mechanical Circulatory Support. It has been observed over time that a subset of patients continues to develop worsening renal function over time despite maximal medical therapy and LVAD support. It also appears that these patients maintain higher Doppler pressure recordings over time despite aggressive blood pressure management. Methods and Materials: We performed a retrospective chart review of all 27 Destination Therapy patients who survived more than one year after HeartMate II implantation between 2008 and 2011. Doppler pressure readings were obtained via manual blood pressure cuff and Doppler Ultrasound and recorded at time of discharge after LVAD implantation and again at one year follow up visit. Renal function was assessed via Modification of Diet in Renal Disease (MDRD) equation to estimate GFR at time of discharge and again at one year follow up. Results: The mean Doppler pressure recorded at time of discharge post-LVAD implantation was 86.2 mm Hg. The mean doppler pressure recorded at one year post implant was 98.3 mm Hg (p ¼ 0.0191). The mean GFR at time of discharge was 96.28 þ 5.99 ml/min while at one year was 71.30 ml/min (p¼ 0.015). The average increase in beta blocker dose over one year was 82% (p ¼ 0.0091). The average increase in ACE/ARB dose over one year was 114% (p¼0.08, NS). Conclusions: Cardiorenal Syndrome in the LVAD population is not well understood. We have demonstrated that there is a statistically
Conclusions: WB transcriptome analysis can be used to evaluate the inflammatory response after MCSD. The use of WB without need for PBMC extraction provides a rapid tool that may eventually be performed close to bedside for early prediction of MOD. 623 Acuity Adaptable Patient Care Unit Shortens Length of Hospital Stay after Ventricular Assist Device Placement S. Osaki,1 N.M. Edwards,2 M.R. Johnson,3 M.A. Murray,1 J.H. Blabaum,1 S. Ulschmid,1 L. Lozonschi,1 T. Kohmoto.1 1Surgery, Cardiothoracic Surgery, University of Wisconsin, Madison, WI;
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
Results: The mean age of BTT patients was younger (OHT 49 yo, BTT 41 yo, po0.01). There was a slightly lower 30-day survival in the BTT group (OHT 92%; BTT 85%) but there were no differences in 1-yr, 5-yr and q10-yr survival between groups (OHT 84%, 75%, 61%; BTT 82%, 74%, 58%, log-rank test p¼0.47). The BTT group had a higher incidence of complications post-transplant: prolonged ventilation time (hours) (20⫾35 vs. 11⫾54, po0.01), pancreatitis (5% vs. 0.04%), blood loss in the first 24h (mls.) (840⫾2000 vs. 580⫾860, po0.01) and ITU stay (days) (5⫾10.8 vs. 3⫾6.6, po0.01). There was no difference between groups regarding total hospital length of stay (22.6⫾20 vs. 22⫾17, p¼0.76).
Conclusions: The use of ventricular assist devices as bridge to transplantation provides excellent posttransplant survival when compared to standard heart transplants. However, surgery for VAD explant and heart transplant can be demanding and is accompanied by higher perioperative morbidity without increasing length of stay.
619 The Hemodynamic Effects of the MEGA Intra-Aortic Balloon Counterpulsation Pump A. Majithia, M. Jumean, H. Shih, C.D. Kimmelstiel, A. Weintraub, D.T. Pham, M.S. Kiernan, D. Denofrio, N.K. Kapur. Cardiology, Tufts Medical Center, Boston, MA. Purpose: The IABP-SHOCK II study recently questioned the clinical utility of intra-aortic balloon counterpulsation (IABP) in patients with acute myocardial infarction and cardiogenic shock. The aim of this study was to compare the hemodynamic effect of the MEGA-series (50cc) and standard (40cc) IABPs (Maquet Inc). Methods and Materials: Twenty consecutive subjects treated with a MEGA-IABP between January and November 2012 were studied. Twenty age-, gender-, and body surface area matched patients receiving a 40cc standard IABP during the same time period served as controls. All subjects presented with decompensated left heart failure or cardiogenic shock. Medical records were reviewed for demographics, hemodynamic data, laboratory data, and clinical outcomes. Hemodynamic and laboratory datat were collected within 24 hours of IABP placement. Results: Demographics, hemodynamics and laboratory values are shown in Table One. Baseline characteristics were similar between groups except for a higher incidence of diabetes mellitus in the MEGA group (76% vs 33%, po0.01). Mean duration of IABP support was longer in the MEGA group (2.6 þ1.8 vs 4.5þ3.1 days, p¼0.01). PostIABP systolic blood pressure and augmented diastolic pressure were higher in the MEGA group compared to standard IABP. A trend towards a higher mean arterial pressure was observed in the MEGA group. Platelet count was significantly lower within 24 hours of support in the MEGA group. No difference in survival to discharge or bleeding was observed between groups.
618 Durability of DeVega Tricuspid Valve Annuloplasty for Severe Tricuspid Regurgitation at the Time of Continuous-Flow LVAD Implantation S.A. Akhter, R. Salabat, M.J. Russo, T.B. Valeroso, J.D. Rich, V. Jeevanandam. Surgery, University of Chicago Medical Center, Chicago, IL. Purpose: Functional tricuspid regurgitation (TR) is common in advanced heart failure patients who undergo LVAD implant. Recent studies suggest that tricuspid valve (TV) repair may have a positive impact on long-term right ventricular function and survival. The objective of this study is to evaluate the intermediate-term durability of DeVega TV annuloplasty (TVA) for severe TR when performed at the time of continuous-flow (CF) LVAD implant. Methods and Materials: This is a retrospective study of 35 consecutive patients who underwent CF LVAD implant and DeVega TVA for severe TR and were alive at one year follow-up. Pre-operative, predischarge, and one year post-implant transthoracic echocardiograms were obtained for all patients. TR was graded as insignificant (none, trivial, or mild) or significant (moderate or severe). Results: The HeartMate II LVAD was implanted in 30 patients and 5 underwent Heartware HVAD implant. Thirty-two of 35 (91.4%, Group A) improved from severe TR preoperatively to insignificant TR at the time of discharge following DeVega TVA and 3 (8.6%, Group B) had moderate residual TR. At one year follow-up, 29 of 32 (90.6%) in Group A had insignificant TR, 2 (6.3%) had moderate TR and 1 (3.1%) had severe TR. In Group B, 2 of 3 had no progression of their moderate TR at one year and 1 had severe TR. Overall, 2 of 35 (5.7%) had severe TR at one year following DeVega TVA and LVAD implant. Conclusions: DeVega TVA appears to be an effective and durable repair for severe TR at the time of CF LVAD implant at one year follow-up. This technique requires less operative time than a formal annuloplasty ring and is also less costly. Although previous studies have shown that DeVega TVA for severe TR in conventional cardiac surgery may not be a durable procedure, unloading of the left ventricle and pulmonary circulation may contribute to the durability seen in this patient population.
Conclusions: Use of the 50cc MEGA-IABP is associated with improved systemic hemodynamic variables compared to the standard 40cc IABP. Further investigation into the clinical utility of the MEGA IABP is required. 620 Quantitative Three Dimensional Echocardiographic Assessment of the Right Ventricle Can Identify Risk of Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Device Surgery A.L. French, M.S. Kiernan, D. DeNofrio, D.T. Pham, N.K. Kapur, N.G. Pandian, A.R. Patel. Tufts Medical Center, Boston, MA. Purpose: Right ventricular failure (RVF) is associated with significant morbidity following left ventricular assist device (LVAD) surgery. Hemodynamic, clinical, and 2-dimensional echocardiographic
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variables poorly discriminate patients at risk of RVF. We examined the utility of 3-dimensional echocardiography (3DE) right ventricular (RV) volumetric assessment to identify patients at risk of RVF. Methods and Materials: RVF was defined as need for inotropic infusion for 414 days following LVAD surgery or RV assist device (RVAD) placement. Preoperative RV volumes and ejection fraction (RVEF) were measured, blinded to clinical data, from transthoracic 3DE full volume data sets in 29 patients. Univariate analyses were used to compare baseline variables and 3DE RV indices among patients with and without RVF. Multivariate logistic regression was used to adjust for baseline covariates. Results: 25 patients (86%) received continuous flow LVADs. 13 patients (45%) had RVF 2 required RVAD support and 11 required prolonged inotropes. Cardiac index (CI), RV stroke work index (RVSWI), indexed RV end diastolic and systolic volumes (RVEDVI & RVESVI) and RVEF were associated with RVF. RVEDVI (OR 1.082 (1.00, 1.17), p¼0.049) and RVESVI (OR 1.117 (1.00, 1.25), p¼0.049) remained associated with RVF after adjusting for RVSWI. Conclusions: Quantitative 3DE is a promising method for pre-LVAD
Comparison of 3DE and baseline variables among patients with and without RVF.
RVEDVI (ml/m2) RVESVI (ml/m2) RVEF (%) RVSWI (mmHg ml/m2) CI (l/min/m2) Total Bilirubin (mg/dL) BUN (mg/dL) Right atrial pressure/PCWP ratio Right atrial pressure (mmHg)
No RVF (mean⫾SD) 46 ⫾ 13 30 ⫾ 9 33 ⫾ 9 644 ⫾ 267 2.3 ⫾ 0.6 1.4 ⫾ 0.8 24 ⫾ 13 0.4 ⫾ 0.1 10 ⫾ 4
RVF (mean⫾SD) 65 ⫾ 21 53 ⫾ 22 23 ⫾ 12 400 ⫾ 175 1.9 ⫾ 0.3 1.6 ⫾ 0.9 17 ⫾ 8 0.6 ⫾ 0.2 14 ⫾ 7
P-value 0.008 0.0095 0.014 0.0092 0.047 0.68 0.06 0.09 0.17
RV assessment. RV volumes assessed by 3DE are predictive of RVF in LVAD recipients, independent of RVSWI. 621
significant decline in GFR to stage II Chronic Kidney Disease, with a simultaneous rise in doppler pressure over one year in patients after LVAD implantation. It is unclear if the continuous flow LVADs contribute to this phenomenon and what role the renin-angiotensinaldosterone axis may play in this patient population, suggesting that further investigation is required. 622 Whole Blood Gene Expression of Multiorgan Dysfunction (MOD) after LVAD Implantation G. Bondar,1 M. Cadeiras,1 N. Wisniewski,1 R.K. Cheng,1 K. Shahzad,2 D. Onat,3 F. Latif,3 E. Chang,1 M.C. Deng.1 1Medicine, Division of Cardiology, UCLA Medical Center, Los Angeles, CA; 2Medicine, East Carolina University, Greenville, NC; 3Medicine, Columbia University Medical Center, New York, NY. Purpose: Early recognition of MOD has important implications in diagnosis and treatment of patients with advanced heart failure (AdHF) undergoing implantation of mechanical circulatory support devices (MCSD). We hypothesized that whole blood (WB) mRNA gene expression can be linked to systemic inflammatory response as evaluated by SOFA score. Methods and Materials: We collected WB from 29 AdHF patients undergoing MCSD implantation between 3/2010 and 5/2011 and 8 age matched controls. MOD was defined by SOFA score, with patients divided into low (r 4) (n¼8), intermediate (5-11) (n¼13), and high (Z12) (n¼8) risk groups at median 8 days (IQR 7 - 14) postoperatively. After globin reduction, total mRNA was purified, amplified and hybridized on Illumina Whole Genome Expression Chips. Expression data was extracted and analyzed using GeneSpring GX 12 (Agilent). Results: Mean age was 57⫾15 years. After normalization with Kruskal-Wallis testing, 440 transcripts were differentially expressed (Figure B) (Benjamini-Hochberg correction, FDR 0.05, fold change 1.5). Hierarchical clustering (A, C) (Pearson absolute distance) organized samples in ascending SOFA risk groups. Gene ontology and pathway analysis revealed significant enrichment of genes representing regulation of immune response including pathways of innate and adaptive immunity. Comparison with PBMC showed 475% overlapping genes (D).
Type 2 Cardiorenal Syndrome in the Left Ventricular Assist Device (LVAD) Population S. Feitell,1 J. Patel,1 P. Pirlamarla,1 J. Whittier,1 E. Gongora,1 T. Rowe,2 S. Hankins,1 H.J. Eisen.1 1Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA; 2Center for Advanced Heart Failure Care, Hahnemann University Hospital, Philadelphia, PA. Purpose: Type 2 Cardiorenal Syndrome after LVAD has not been well evaluated in patients with Mechanical Circulatory Support. It has been observed over time that a subset of patients continues to develop worsening renal function over time despite maximal medical therapy and LVAD support. It also appears that these patients maintain higher Doppler pressure recordings over time despite aggressive blood pressure management. Methods and Materials: We performed a retrospective chart review of all 27 Destination Therapy patients who survived more than one year after HeartMate II implantation between 2008 and 2011. Doppler pressure readings were obtained via manual blood pressure cuff and Doppler Ultrasound and recorded at time of discharge after LVAD implantation and again at one year follow up visit. Renal function was assessed via Modification of Diet in Renal Disease (MDRD) equation to estimate GFR at time of discharge and again at one year follow up. Results: The mean Doppler pressure recorded at time of discharge post-LVAD implantation was 86.2 mm Hg. The mean doppler pressure recorded at one year post implant was 98.3 mm Hg (p ¼ 0.0191). The mean GFR at time of discharge was 96.28 þ 5.99 ml/min while at one year was 71.30 ml/min (p¼ 0.015). The average increase in beta blocker dose over one year was 82% (p ¼ 0.0091). The average increase in ACE/ARB dose over one year was 114% (p¼0.08, NS). Conclusions: Cardiorenal Syndrome in the LVAD population is not well understood. We have demonstrated that there is a statistically
Conclusions: WB transcriptome analysis can be used to evaluate the inflammatory response after MCSD. The use of WB without need for PBMC extraction provides a rapid tool that may eventually be performed close to bedside for early prediction of MOD. 623 Acuity Adaptable Patient Care Unit Shortens Length of Hospital Stay after Ventricular Assist Device Placement S. Osaki,1 N.M. Edwards,2 M.R. Johnson,3 M.A. Murray,1 J.H. Blabaum,1 S. Ulschmid,1 L. Lozonschi,1 T. Kohmoto.1 1Surgery, Cardiothoracic Surgery, University of Wisconsin, Madison, WI;