Cardiac Surgery in Octogenerians: Single centre experience

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Abstracts

postoperative days, the remaining two cases occurring at postoperative days 8 and eleven. There is a higher reported incidence of torsion of left lobes compared to right lobes (7 verses 3). Predisposing factors proposed were size discrepancy between the donor lung and the thoracic cavity (1 case), presence of a complete fissure in the donor lung (3 cases), or a combination of these two factors (2 cases). Four cases did not identify a predisposing factor. Two cases were successfully managed with detorsion of the affected lobe. Six cases underwent lobectomy and one case of incomplete torsion was successfully conservatively managed. Conclusion: All the reported cases illustrate surgeons and transplant physicians should be aware of this rare complication of lung transplantation. A high degree of suspicion is required in the postoperative lung transplant recipient who experiences acute respiratory insufficiency. Lobectomy is indicated when the lobe is nonviable. Simple detorsion may be tried even in cases of late diagnosis. We recommend checking anatomical structures carefully before thoracotomy closure, especially during a second thoracotomy for haemostasis, and when the graft has a complete fissure. http://dx.doi.org/10.1016/j.hlc.2015.12.075 Pericardial Constriction Post-Lung Transplant Georgina Stephens *, Dr Krishna Bhagwat, A/Prof Silvana Marasco, Prof David McGiffin The Alfred Hospital, Melbourne, VIC, Australia Purpose: To review all cases of pericardial constriction following lung transplantation in the literature, with the addition of two further cases occurring at The Alfred Hospital. Methodology: A literature review was undertaken to find all reports of pericardial constriction following lung transplantation. Cases were examined to determine demographic details of patients, presenting symptoms and signs, underlying pathology resulting in transplantation, whether pericardiotomy occurred during transplantation, management, pathological findings and outcomes. Results: Nine cases of pericardial constriction post-lung transplantation have been reported. All cases presented with symptoms and signs of biventricular failure. Pericardiotomy at time of transplant was reported in six cases, but not mentioned in the remaining three. All cases underwent pericardiectomy. Seven cases commented on pathological findings of the pericardium. Six cases reported pericardial fibrosis. One case identified fungal infection, which was the only case with a proven aetiology for pericardial constriction. Follow-up was reported in 8 cases. Six patients returned to baseline function or were reported to be doing well post-pericardiectomy. Two patients passed away during follow-up, but not directly related to pericardial constriction. Conclusion: Pericardial constriction lung transplantation is a rare but now well-described entity, with no identified aetiology in the absence of infection. A high index of suspicion for pericardial constriction should be held in lung transplant patients who present with evidence of cardiac failure, if

more common pathologies have been excluded. Pericardiectomy is the only option for definitive management. http://dx.doi.org/10.1016/j.hlc.2015.12.076 Informed Consent: Impact of full disclosure on public reporting of surgeon specific outcome data Elizabeth Suthers *, Sonia Chanchlani, Ben Dunne, Christopher Merry Fiona Stanley Hospital, Perth, WA, Australia Purpose: To examine the history and case law surrounding informed consent with a focus on Australian law and the implications for surgeon specific outcome data. Methodology: A literature review of relevant case law, significant judgments, and legal precedents was undertaken. Results: Under the influence of common law (the doctrine of precedent), Australian medico-legal practices have evolved over time. Litigation to define informed consent first occurred in 1767 England, Slater vs Baker and Stapleton, which determined that a patient has the right to be informed of what will happen to him. The case of Schloendorff v Society of New York Hospital (1994) determined that the patient has autonomy: the right to make decisions regarding themselves. Until the 1990s, Australia’s attitude toward informed consent followed that of England taking into consideration the Bolem principle, summarised as the legal requirement of duty of care towards the patient, with the standard of care being determined by a reasonable body of medical practitioners. The major change came with the judgment of Rogers v Whitaker in 1992, which overturned the Bolem principle as inapplicable in Australian law, instead determining that the patient must be provided with all the relevant information, as it applies to the individual patient and not as deemed relevant by a reasonable body of medical practitioners. Conclusion: With the current legal requirements that the patient must be provided with all relevant information, as it applies to the individual patient and not as deemed relevant by the treating clinician, this could progress to making public reporting of surgeon specific outcome data a legal requirement. http://dx.doi.org/10.1016/j.hlc.2015.12.077 Cardiac Surgery in Octogenerians: Single centre experience Sujeeth Suvarna *, Konstantinos Pechlivanidis, Delia Clune, Alexandru Cornea, Edel Costigan, Niamh Dunne, Maria Hayes, Beata Kis, Helen O’Connell, Mary O’Gorman Blackrock Clinic, Dublin, Ireland Purpose: As the relative proportion of older persons is increasing in Ireland more octogenarians are being referred for cardiac surgery. The aim of our study is to analyse our experience concerning the immediate postoperative outcomes in this sub-group of elderly population.

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Methodology: Between January 2012 and June 2015, a total of 126 patients 80 years and over who underwent cardiac surgery at Blackrock Clinic, Ireland were analysed. Data included perioperative, intraoperative and postoperative course. Results: The mean age was 82.09 (SD1.86). 88 (70%) male, 38 female (30%), BMI mean 27.43 (SD4.19), Logistic Euro score mean 9.17(SD6.40), Diabetes 17%, Elective 79.36%, Urgent 16.66%, Emergency 3.96%. Procedures: Total % CABG Alone 43 34.13% CABG + Valve 31 24.60% Valve alone 25 19.84% CABG + valve + other 12 9.52% Valve + other 10 7.94% CABG + other 3 2.38% Other 2 1.59% Total CPB minutes mean 95.90 (SD42.00). Postoperative reoperation for bleeding/tamponade n=17(13.49%), insertion of pacemaker n=5(3.97%), tracheotomy n=5(3.97%), sternal rewiring n=1(0.79%) Length of ICU stay days mean 4.83(SD7.45), renal dialysis n=6(4.76%), stroke n=2(1.58%), length of hospital stay days mean 22.02(SD27.97). In-hospital mortality n=6 (4.76%) all had CABG+VALVE (Urgent 3, Elective 3). Conclusion: In summary, our single centre analysis suggests that cardiac surgery in octogenarians and patients aged above can be performed with acceptable morbidity and mortality. Our data also suggests that the postoperative complications rates are far greater in these elderly patients who undergo more complex combined cardiac procedures. http://dx.doi.org/10.1016/j.hlc.2015.12.078 Analysing Myocardial Dysfunction after Cardiac Surgery using CMR Strain John-Paul Tantiongco *, Craig Bradbrook, Angela Walls, Joseph Selvanayagam Flinders Medical Centre, Adelaide, SA, Australia Purpose: Myocardial deformation or strain has been useful in detecting early myocardial dysfunction even when ejection fraction is normal. This is evident in particular using Global Longitudinal Strain (GLS). Cardiac magnetic resonance imaging is the gold standard in cardiac volumetry. Historically, strain in CMR required separate tagging sequences that are labour-intensive to analyse. In this study we compare left ventricular myocardial function as analysed by CMR volumetry and CMR strain analysed using ‘tissue tracking’ in patients having cardiac surgery. Methodology: Patients undergoing CABG or CABG/AVR surgery from May 2014 and July 2015 were scanned using CMR before and after surgery. Cardiac magnetic resonance imaging was acquired using a 1.5T magnet and analysed offline using commercially available software (CVI42 v5.1). Mixed effect statistics was used to analyse any change in left ventricular volumetry and strain. Results: We report 11 patients. After surgery, we found no change in CMR left ventricular ejection fraction, with an average increase of 1.01%  1.8 which was not significant (p=0.57). However, in the same patients, CMR tissue tracking shows a reduction in left ventricular Global Longitudinal Strain of 1.5%  0.5 [95%CI 0.52, 2.46] after cardiac surgery, which was significant (p=0.003). Discussion: Strain can be derived with ease from CMR cine images using ‘tissue tracking’. Subendocardial

Abstracts

longitudinal fibres are the most susceptible especially during the early phase of myocardial dysfunction when ejection fraction remains preserved. The utility of myocardial deformation analysis in early or mild dysfunction using CMR strain shows great potential and requires further investigation. http://dx.doi.org/10.1016/j.hlc.2015.12.079 Should all Patients Receive Dual Anti-platelet Therapy following Coronary Artery Bypass Surgery? Trevor Tnay *, Nisal Perera, Siven Seevanayagam, George Matalanis, Sean Galvin Austin Health, Melbourne, VIC, Australia Objective: The benefit of dual antiplatelet therapy (DAPT) is well established in patients with acute coronary syndrome and in those following percutaneous coronary intervention. The indication for and benefits of DAPT in patients following coronary artery bypass (CABG) grafting is less clear. Methods: To investigate the role of DAPT in patients undergoing CABG a best evidence topic was constructed according to a structured protocol. This is fully described in the Interactive Cardiovascular and Thoracic Surgery Journal. Results: 506 papers were found using the reported search. From these 13 papers were identified that provided the best evidence to answer the question. Conclusions: The role of aspirin therapy post-CABG is well-established. The additional benefit of a second antiplatelet such as clopidogrel is less clear, with the majority of studies demonstrating no difference in outcomes when clopidogrel is used with aspirin postoperatively. The role for newer antiplatelets such as ticagrelor has not been established. Two relatively large RCTs have demonstrated some benefit of the addition of clopidogrel in SVG patency; however, one was limited by a lack of blinding by the investigators. The other RCT looked purely at Off Pump Coronary Artery Bypass Grafting (OPCABG) and other trials have indicated that clopidogrel may assist in overcoming the hypercoaguable state associated with OPCABG. However, the majority of RCTs demonstrated no clear benefit. We suggest that clopidogrel should not routinely be prescribed after CABG and that it should only be considered in patients undergoing OPCABG with multiple SVGs or patients with true aspirin resistance. http://dx.doi.org/10.1016/j.hlc.2015.12.080 Total Aortic Repair for Acute Type A Aortic Dissection Trevor Tnay *, Nisal Perera, Sean Galvin, Siven Seevanayagam, George Matalanis Austin Health, Melbourne, VIC, Australia Objectives: Malperfusion or persistent perfusion of the false lumen (FL) with acute type A aortic dissections is a