P10-11 Update of heart transplantation Cheng Hsin General Hospital

Abstracts/International Journal of Cardiology 97 SuppL 2 (2004) S1~75 and the other one due to intractable donor heart right ventricular failing. In the perioperative ECMO group, 2 (66.7%) were successfully bridge, decannulated and subsequently discharged. Three of five (60%) requl~d ECMO due to posttransplant graft failm~ were successfully decannulated and alive. All the survivors were in good functional class. C o n c l u s i o n s : ECMO is an adequate mechanical ci~vulato~3J support in various body sized pediatric patients. It can be used either in perioperatively cardiogenic shock or in post transplant graft dysfunction. The mortality rate is acceptable in this very high risk group of patients. It will not increase the rejection rate and the long term outcome is good.

P10-09 S U R G I C A L T R E A T M E N T O F A O R T I C D I S S E C T I O N AT C H E N G HSIN GENERAL HOSPITAL

Chun~ Yi Chan~, Jeng Wei, Yi4~heng Chuang, David Y. Tang. Heart

Center, Cheng Hsin General Hospital, Taipei, Taiwan, ROC B a c k g r o u n d : Aortic dissection is the most common catastrophe of the aorta, 2 3 times more common than mptme of the abdominal aorta. When left untreated, about 33% of patients die within the first 24 hours, and 50% die within 48 hours. M e t h o d : From July 1994 to June 2004, 110 cases of aortic dissection were operated on 108 patients at this hospital. Sixty eight patients were male, 40 female; their mean age was 58.0 ± 13.3 years, ranging from 22.9 to 85.0. One hundred and Nx patients had aortic dissection, and two had Marfan syndrome. Aortic dissection Stanford type A was Desent in 85 cases (77.3%), 71 were acute and 14 cllronic; 25 cases (22.7%) presented with aortic dissection Stanford type B, 16 were acute and 9 chronic. Five cases (4.5%) were converted from type A to type B. Seventeen patients underwent Bentall operation (15.5%), 11 were with modified Carbrol method and 6 conventional method. In 69 cases (62.7%), the dissected aorta was reconstructed with intraluminal graft secmed at both ends with ties. In 12 cases, the dissected aorta was reconstructed with one end of the graft secured with ties. Another ten cases (9.1%) had associated procedures of coronary artery bypass grafting. Retrograde cerebral per fusion was applied in 76 cases (69.1%), antegrade cerebral perfusion in 2 cases (1.8%). Hypothermic cardiopuhnonary bypass was also applied. Two patients underwent cardiopuhnonary resuscitation before operation. Results: There were nine cases (8.2%) of perioperative complications either of cerebrovascular event or limb weakness that required neurology and/or rehabilitation consultation, all recovered and were discharged. Twelve patients (10.9%) were surgical moriality. C o n c l u s i o n : In our experience, extended replacement of the dissected ascending aorta and aortic arch can be performed with good results with inU-aluminal graft for complete replacement of the dissected parts of the aorta.

P10-10 HEART TRANSPLANTATION WITHOUT IMMISNOSUPPRESSION A CASE REPORT D.Y. Tung, J. Wei, C.Y. Chang, Y.C. Chuang. Heart Centre, Cheng Hsin

General Hospital, Taipei, Taiwan, ROC B a c k g r o u n d : In modern histo~3J of organ transplantation, Dr. JP Merrill performed the first human kidney transplantation for identical twin in 1954. In 1960 Dr. M Woodruff discovered antilymphocyte antibody. Then in 1967, Dr. Cl~stiaan Bernard of South Africa performed the first successful human orthotopic heart transplantation (HTx) and the recipient lived for 18 days. In 1973, Dr. PK Caves performed endocardial biopsy. In 1978, Sir Roy Calne of England discovered the clinical efficacy of cyclosporin A in organ transplantation that has improved the survivability of Wansplant organs. Case Report: The ~ecipient, a 61 year old male patient, diagnosed of Arrhythmogenic Right Ventricular Dysplasia and congestive heart failure, underwent orthotopic HTx in September 1997 with a donor

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heart from a 21 year old male, both were of blood type A positive and four HLA mismatch. Posttransplantation, the recipient ~eceived triple immunosuppression therapy of mycophenolate mofetil, cyclosporine, and prednisolone. Endomyocardial biopsies (EMB) during the 4 year follow up period revealed one episode of Grade II rejection at 18 months after HTx with remaining biopsies of Grade IA or IB rejections. In May 2004, the recipient disclosed that he had withdrawn from the immunosuppression therapy since May 2003. The latest EMB revealed Grade IA rejection, echocardiography showed good function of both ventricles, and Thallium 201 scan revealed good myocardial perfusion. Discussion: For allograft survival, lifelong immunosuppression therapy is D~scribed for the ~ecipient. Majority of allograft failings are due to infection, indicating over suppression of the immune system. Tolerance means that the ~ecipient's immune system accepts a Uans planted organ as the body's own, and advances in tolerance induction may provide valuable new therapeutic strategies in Wansplantation and in t~ating a wide range of immune mediated disorders, that include (1) total lymphoid in-adiation, (2) injection of donor's stem cell to form chimerism (hybrid immune system), (3) inhibito~3J proteins ILT3 and ILT4 increased on the surface of the monocyte and dentritic cells when exposed to suppressor. In the past decade, discoveries made by scientists about the mechanisms that activate and regulate the immune response have yielded a new approach to preventing transplant rejection. Rather than suppressing the entire immune system, this new approach uses a targeted strategy designed to induce tolerance (the lack of an immune response) by turning off the specific immune cells that attack the transplant. Summary: After HTx, tolerance may occur and immunosuppressive agents may be gradually tapered. We believe that at least some of the HTx recipients may not need immuno suppressive agents long after the surgery and their life quality may be improved.

P10-11 U P D A T E O F H E A R T T R A N S P L A N T A T I O N AT C H E N G H S I N GENERAL HOSPITAL J. Wei, C.Y. Chang, Y.C. Chuang, D.Y. Tang. Heart Cente~ Cheng Hsin

General Hospital, Taipei, Taiwan, ROC Heart transplantation (HTx) in Talwan started in 1987. Since then, more than 530 cases of HTx have been performed. From July 1988 to July 2004, this team has performed 232 cases of orthotopic HTx, 176 recipients were nmle and 56 female, with mean age of 46.9±14.7, ranging from 2.7 to 74.9 years. Nine were paediatric cases and four combined hearbkidney transplantation. The leading etiologies are dilated cardiomyopathy (CMP) 69.4%, ischemic CMP 19.4%, and valvular CMP 3.9%. The actuarial smwival rate at 1, 5, and 10 years is 87%, 76%, and 55%, respectively. In this series, we have performed the first case of HTx in Asia after bridging for 14 days with theindigenous total artificial heart, the Phoenix 7 model; the youngest recipient underwent HTx without blood transfusion, first case known woridwide of pediatric HTx; the longest ischemic ~ n e of 13 hours for donor heart, also known to be the longest woridwide; the first case of autotransplantation of heart for repafl- of left ventricular rupture after ~rdtral valve replacement; all successfully. TNl-ty two recipients have smwived more than ten years posttransplantation. Two of these surviving recipients are in their 14th posttransplantation year. The longest surviving recipient of combined hearbkidney Wansplantation in Asia is well in his eighth posttransplantation year. We have discovered familial CMP due to mitochondrial defects in two pediatric cases. Because of scarcity of donor hearts, we used size ~rdsmatched hearts, even in pediatric cases. We also used suboptimal donor hearts and hearts from donors who were hepatitis positive, all with satisfactory outcomes. Incidence of HTx related coronary artery disease among our recipient is significantly lower than those found in HTx p r o g ~ l s in Western countries With our experience in HTx, we have identified risk factors among our Chinese recipients, diagnosed of ischemic cardiomyopathy (hazard ratio 2.43), with pretransplantation infection (2.30), requiring postoperative

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Abstracts ~International Journal of Cardiology 97 SuppL 2 (2004) S1~75

hemodialysis (2.18), with diabetes mellitus (2.05), and recipient's age g~ater than 50 (1.81). Our experience has shown that HTx has been well established in Asia with comparable results to that of Western medical centers, and also with efficacy and cosbeffectiveness. We find the technique of standard biattial anastomosis for orthotopic HTx results lower incidences of TR and conduction anomalies. The use of suboptimal and size mismatched donor hearts is also of promising outcomes.

P10-12 URGENT M-K STENTGRAFT FOR THORACIC AORTIC INJURY Keiic hi Ki mura 1, Hiroshi Ohtake 1, Ikuko Kosugi 1, Hiroshi Nagamine 1, Go Watanabe2, Junichiro Sanada 1, Osamu Matsui 3. 1Department of

General & 2Cardiothoracic Surgery, SDepartment of Radiology, Kanazawa University School of Medicine, Kanazawa, Jc~an I n t r o d u c t i o n : Poor systemic conditions caused by multiple organ injuries are frequently found in the patients with tramnatic injm2¢ of the thoracic aorta. The purpose of the study is to report our clinical experience with M K stent graft (SG) repair in emergency surgery. Patients: From January 2000 to December 2003, four patients (three males and one female, mean age: 51 years) who requhed urgent deploy ment surgery to treat the Wamnatic aortic injm2¢ were investigated in this study. All of the cases were in shock when they were admitted into our clinic, in addition to multiple organ injuries. Chest CT scanning revealed puhnonary contusion, mediastinal hematoma, and injury and dissociation of the distal aortic arch in all cases. M-K SG Deployment: The SG deployment surgery was carded out on the day of a&~tission. Under general anesthesia, the sheath covering M K SG was inserted to the distal aortic arch from the femoral artery. Angiographic assessment revealed disappearance of the false lumen after the deployment. Results & Conclusion: No cases of surgical death or hospital death were reported. No complications associated with the SG deployment were observed. Disappearance of the aneurysms and complete tllrombus formation were observed in all patients by CT scanning at one week and at three months after the surgery. In spite of the extra precautions in the selection of the patients, careful follow up after the surgery is required, and the M K SGrafting is less invasive and quite effective modality of emergency revascula~ization surgery to treat the aortic injury.

P10-13 THE SURGICAL EXPERIENCE IN A PATIENT WITH LEFT UPPER LUNG C A N C E R AND INTRA-LEFT ATRIAL INYASIVE MASS EXTENDED VIA THE PULMONARY YEIN-A CASE REPORT Hsu Ting Yen, Ming Jang Hsieh, Fan Yen Lee, Hung Yi Lu, Jen Ping Chang. Division of Thoracic and Cardiovascular Surgery, Dept.

of Surgery, Chang Gung Memorial Hospital at Kao~tsiung, Taiwan, ROC In the terminal stage lung cancer patient is often non surgical treatment, and they usually received the chemotherapy and medical treatment at first. Now we report a 67 year old female presented as dyspnea and orthopnea, the image study revealed a left upper lung mass with a huge invasive mass extended via the left upper puhnonary vein. We used the surgical intervention to treat the patient via a full mediasternotomy, performed the left upper lobectomy, mediastinal lymph node dissection and removal the left atrial tumor under the cardiopuimonary bypass support. Due to the patient also had the severe tricuspid regurgitation, we also performed the tricuspid annuloplasty (De Vega's method). The patient stood the procedures well, and smootlfly discharged at the postoperative 15th days. The pathological result showed left upper lung cancer the NO stage. Then she ~eceived the radiotherapy only. Now was postoperative 11th month, she got free from recurrence. To present the case, much preoperative T4 lesion we may over stage, and give up the surgical intervention. We should take more aggressive attitude to treat this patient.

P10-14 TOTAL A R T E R I A L R E Y A S C U L A R I Z A T I O N V I A L E F T ANTERIOR THORACOTOMY

Kuan Min~ Chiu. Shao4ung Li, Chih Yang Chan, Shu Hsun Chu.

Cardiovascular Center, Far-Eastern Memorial Hospital, pan-Chian, Taiwan I n t r o d u c t i o n : More and more effort was focused on sternum sparing catdiac surgery. Although offpump coronaty attery bypass has been proven its benefits, midine sternotomy for complete revascula~ization is still required. We proposed a method to cover the following advantages: sternum sparing, off pump, no aortic manipulation and total arterial complete revascularization. Methods: Patients with multi vessel coronary at-tery disease proposed to have coronaty at-tery bypass surgery were offered tNs alternative approach. Patients with huge heart size, poor LVEF and poor lung function were excluded. The patient was put in supine position with a pillow under left chest. Doublequmen endotracheal intubation was done to facilitate the procedures. The left upper extremity was prepared for endoscopic radial at-tery harvest. Left anterior thoracotomy around 10 to 15 cm was made to enter left pleural cavity usually via 5th intercostals space. The left internal mammary artery (LIMA) harvested like MIDCAB manner. Then LIMA and radial artery were anastomosed in the Y or T fashion. Off pump complete ~evascularization with this composite graft was performed sequentially using commercially available staNllzer. Results: 15 patients underwent the operation. The average graft per patient was 2.2. The postoperative pain was controlled by intercostals block and patienbcontrolled analgeNa. All patients recovered well without complications. C o n c l u s i o n s : We found this approach was simple and effective to achieve the goal of less invasiveness. The wound length was less than midline sternotomy. Less risk of neurological event and atrial fibrillation was the additional benefit. Patients prefers this approach rather than the inciNon on the chest bone,

P10-15 ENDOSCOPIC RADIAL ARTERY HARVEST FOR CORONARY ARTERY SURGERY

Kuan Ming Chiu. Shao4ung Li, Chih Yang Chan, Shu Hsun Chu.

Cardiovascular Center, Far-Eastern Memorial Hosp., Pan-Chiao, Taiwan I n t r o d u c t i o n : Coronat-y at-tery bypass grafting (CABG)provides the better long term patency than percutaneous interventions. Previous studies had shown arterial conduits were better than venous ones, Radial at-tery is the second most common arterial conduit used for CABG. However, the hatvest of radial attery carries large surgical wound and gains less patients' acceptance in subtropical area, Methods: From September 2003, we stat-ted our endoscopic harvest program for radial artery, 117 patients underwent this procedme. The pre operative screening includes Allen's test and modified pahnat- arch perfusion test with plethysmography The ages of patients range from 32 to 88 years old, End stage renal disease and documented peripheral attery occlusive disease were excluded, The Vasoview system (Guidant, USA)was applied for the procedure, Detailed surgical techniques would be reported, Results: 117 radial at-teries were harvested successfully by tNs tech nique. The mean length of radial at-teries was 17.5 cm. No obvious at-terial injury was visually confirmed, All except 2 radial at-teries were used for CABG. The 2 radial at-teries were noted to have atherosclerotic plaques causing stenoses. 47 patients presented with mild paresthesia over the dorsum of thumb base which improved significantly after 3 months follow up, No at-terial insufficiency in forearms and hands was noted, C o n c l u s i o n s : Endoscopic hat'vest for radial at'tery is technical demand ing, but excellent results could be achieved after a period of learning curve. We believe that providing the better conduits in a less invasive way would be the key issue of coronat-y at-tery surgery,