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Radiological Predictors of Recurrent Primary Spontaneous Pneumothorax Following Non-surgical Management
Heart, Lung and Circulation 2011;20:35–67
37 ABSTRACTS
Abstracts
In summary, Extra-corporeal Membrane Oxygenator a viable option in the treatment of this subgroup of patients. Our results also suggest that increasing experience (and technological) refinements with the management of such patients led to significantly better outcomes. It should be regarded as the primary treatment modality of choice when considering mechanical support in this subgroup of patients. More remains to be investigated regarding the optimum method of institution of ECMO support; and whether central or peripheral VA-ECMO would be more suitable remains to be ascertained. doi:10.1016/j.hlc.2010.10.009 Routine Vasoconstrictor Use Reduces Intraoperative Haemodilution and Transfusion Rates in Coronary Surgery Alistair Royse, Hamid Colin Royse
Mollahajian ∗ ,
Stephen Bottrell,
Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia Introduction: Red blood cell (RBC) transfusion with cardiac surgery relates primarily to reductions in haemoglobin (Hb) concentration. We hypothesised that this reduction occurred principally by haemodilution rather than substantive red blood cell mass loss. Anaesthetics, surgery, cardiopulmonary bypass and analgesics lead to vasodilation. We used vasoconstrictors in preference to crystalloid fluid selectively or routinely to counteract this iatrogenic vasodilation to attempt to reduce haemodilution. Methods: Two periods for a single surgeon, single institution experience for primary coronary surgery only were selected, 2005, where noradrenaline (NA) infusions were selectively commenced to treat a low systemic vascular resistance state (sNA) (n = 58); or used routinely from the commencement of the anaesthetic in 2008 (rNA) (n = 29). No patient in rNA group received trasylol. In both groups there was intent to minimise haemodilution. Statistical analysis for continuous variables used univariate and repeated measures analysis of variance (ANOVA) and categorical variables by Fisher’s exact test. Results: There was no difference between preoperative Hb in sNA (m ± SE) 143 ± 2.2 vs. rNA 138 ± 2.9 g/dL, P = 0.202. A trend toward higher Hb prior to CPB was evident in rNA 131 ± 3.2 vs. 124 ± 2.2, P = 0.088. Hb fell by a predictable degree in sNA 34 and rNA 33 when CPB commenced. However, the Hb on CPB when first tested was significantly higher in the rNA group, 97 ± 3.8 vs. 89 ± 1.6, P = 0.028. The Hb at the end of CPB was not different between the groups sNA 88 ± 1.5 vs. rNA 93 ± 3.4, P = 0.102; but this was due to RBC transfusion in sNA 13.8% vs. rNA 0%, P = 0.048. Repeated measures ANOVA with Greenhouse–Geisser correction revealed a significant difference between the two groups over time P < 0.001 (Fig. 1). Discussion: We found that with routine use of a vasconstrictor infusion from the commencement of the
Fig. 1. Haemoglobin (mean ± SE).
anaesthetic, there was less haemodilution resulting in a higher Hb during CPB and a significantly lower transfusion rate. doi:10.1016/j.hlc.2010.10.010 Radiological Predictors of Recurrent Primary Spontaneous Pneumothorax Following Non-surgical Management Ramanujan Ganesalingam ∗ , Ross Shadbolt, John Tharion
O’Neil, Bruce
The Canberra Hospital, Canberra, Australia Background: Studies to date have failed to identify reliable predictors of recurrent primary spontaneous pneumothorax (PSP) on plain chest X-ray. The aim of this study was to assess whether abnormalities on plain chest X-ray at first presentation of PSP can be used to predict recurrent PSP. Method: The study included all patients admitted to The Canberra Hospital between 1998 and 2004 with their first episode PSP. Patients who received surgical intervention were excluded. Chest X-rays taken at the time of diagnosis were reviewed retrospectively by an independent radiologist who was blinded to the patient outcome. Documented abnormalities included mild pleural thickening, blebs, pleural irregularity, and adhesions. Kaplan–Meier and Cox regression analyses were used to examine the relationship between observed X-ray abnormalities and PSP recurrence. Results: One hundred patients (mean age 25 years) were followed up for a mean duration of 57 months (max. 131 months). The total rate of recurrence was 54%. Thirtyfour patients had no abnormality (normal) on plain film while 66 patients had one or more abnormalities. Multivariate analysis found no individual X-ray abnormality to be predictive of recurrence. However, the presence of any abnormality increased the likelihood of recurrence and the risk of recurrence increased with the number of abnormalities present. Patients having 1, 2 and 3 or more abnormalities are 2.8 (95% CI 1.98–3.71, p = 0.018), 5.2 (95% CI 4.37–6.03, p < 0.001) and 11.1 (95% CI 9.98–12.13, p < 0.001) times more likely to develop recurrence respec-
38
Heart, Lung and Circulation 2011;20:35–67
Abstracts
ABSTRACTS
Fig. 1. Kaplan–Meier analysis shows the likelihood of recurrence increases with each additional X-ray abnormality.
tively. This is independent of age, sex, smoking history, side of the PSP and type of initial management (Fig. 1). Discussion: To our knowledge this is a new finding that has not been previously reported. In view of these results we now offer surgical treatment at first presentation PSP in patients in whom we identify multiple radiological abnormalities to reduce the likelihood of recurrence and re-admission.
sion analysis was performed to identify risk factors of mortality. Results: The distribution of RV sizes was normal 16 (17%), moderate hypoplasia 50 (54%), and severe hypoplasia 27 (29%). Follow-up was 90% complete. Within the first 2 years of life, 21 patients died (22%). The end-status of the remaining patients were bi-ventricular repair in 37/93 (40%), 1(1/2) ventricle repair in 9/93 (10%), Fontan circulation in 12/93 (13%), transplantation in 1/93 (1%), and still awaiting repair in 13/93 (14%). Ten-year survival was 80% (95% CI: 71–87%) in patients with normal TV leaflets and 64% (95% CI: 30–85%) in patients with TV dysplasia. Independent predictors of mortality were lower TV annulus size Z-score and the presence of right ventricle to coronary artery connections (RVCAC). In patients without TV dysplasia; bi-ventricular repair was achieved in 90% (10/11) of those with a normal size RV, 40% (18/45) of those with moderate RV hypoplasia and 8% (2/25) of those with severe RV hypoplasia. None of the 28 patients with a TV Z-score below −2 attained a biventricular repair. Discussion: The management of PAIVS requires a selective approach based on RV morphology. A simple three tiered classification based on RV size allows initial stratification into biventricular or univentricular repair for patients with normal and severe RV hypoplasia. In patients with moderate RV hypoplasia, refraining from biventricular repair in the presence of RVCAC and a TV Z-score less than −2 may decrease mortality. doi:10.1016/j.hlc.2010.10.012
doi:10.1016/j.hlc.2010.10.011
FREE PAPERS
Finding the Right Balance Between Univentricular and Biventricular Repair for Pulmonary Atresia with Intact Ventricular Septum
Percutaneous Aotrtic Valves—Our First Twenty Cases With the Edwards Sapien Transcatheter Valve
Liava’a ∗ ,
M. d’Udekem
P. Brooks, I.E. Konstantinov, C.P. Brizard, Y.
Royal Children’s Hospital, Melbourne, Australia Introduction: Patients with pulmonary atresia and intact ventricular septum (PAIVS) present with varying degrees of right ventricular hypoplasia. Management can be directed to either biventricular repair or univentricular palliation (Fontan or 1(1/2) ventricle repair). An optimal management strategy has yet to be defined and varies between centres. Higher mortality is associated with an aggressive strategy towards biventricular repair. Methods: The records and echocardiography of all patients operated in the Royal Children’s Hospital, Melbourne for PAIVS between 1990 and 2006 (n = 93) were reviewed. Patients were stratified into a simple three tiered classification based on right ventricle (RV) size (normal, moderate, and severe hypoplasia). Those with associated tricuspid valve (TV) dysplasia and regurgitation were analysed separately (n = 12). Kaplan–Meier curves of survival were calculated and Cox regres-
Jayme Bennetts ∗ , Ajay Sinhal Flinders Medical Centre, Australia Percutaneous aortic valve replacement has seen unprecedented levels of interest within cardiac surgery and interventional cardiology over recent years. Two competing technologies are now available in Australia and New Zealand with an increasing number of sites vying for access to these devices. Flinders Medical Centre commenced implantation of the Edwards Sapien Transcatheter heart valve in November 2008 and has now undertaken 20 procedures in patients considered high risk for open aortic valve replacement. We report our experience with establishing a new program. Twenty valves have been implanted in 20 patients, 12 transapical and 8 transfemoral, with 100% procedural success. There has been no requirement for cardiopulmonary support and no emergency conversion to open surgery. One death has occurred at Day 5. There have been no cerebrovascular events and no acute myocardial ischaemia. Discussion: Includes patient demographics, case by case reasoning for selection of transcatheter valve implan-
37 ABSTRACTS
Abstracts
In summary, Extra-corporeal Membrane Oxygenator a viable option in the treatment of this subgroup of patients. Our results also suggest that increasing experience (and technological) refinements with the management of such patients led to significantly better outcomes. It should be regarded as the primary treatment modality of choice when considering mechanical support in this subgroup of patients. More remains to be investigated regarding the optimum method of institution of ECMO support; and whether central or peripheral VA-ECMO would be more suitable remains to be ascertained. doi:10.1016/j.hlc.2010.10.009 Routine Vasoconstrictor Use Reduces Intraoperative Haemodilution and Transfusion Rates in Coronary Surgery Alistair Royse, Hamid Colin Royse
Mollahajian ∗ ,
Stephen Bottrell,
Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia Introduction: Red blood cell (RBC) transfusion with cardiac surgery relates primarily to reductions in haemoglobin (Hb) concentration. We hypothesised that this reduction occurred principally by haemodilution rather than substantive red blood cell mass loss. Anaesthetics, surgery, cardiopulmonary bypass and analgesics lead to vasodilation. We used vasoconstrictors in preference to crystalloid fluid selectively or routinely to counteract this iatrogenic vasodilation to attempt to reduce haemodilution. Methods: Two periods for a single surgeon, single institution experience for primary coronary surgery only were selected, 2005, where noradrenaline (NA) infusions were selectively commenced to treat a low systemic vascular resistance state (sNA) (n = 58); or used routinely from the commencement of the anaesthetic in 2008 (rNA) (n = 29). No patient in rNA group received trasylol. In both groups there was intent to minimise haemodilution. Statistical analysis for continuous variables used univariate and repeated measures analysis of variance (ANOVA) and categorical variables by Fisher’s exact test. Results: There was no difference between preoperative Hb in sNA (m ± SE) 143 ± 2.2 vs. rNA 138 ± 2.9 g/dL, P = 0.202. A trend toward higher Hb prior to CPB was evident in rNA 131 ± 3.2 vs. 124 ± 2.2, P = 0.088. Hb fell by a predictable degree in sNA 34 and rNA 33 when CPB commenced. However, the Hb on CPB when first tested was significantly higher in the rNA group, 97 ± 3.8 vs. 89 ± 1.6, P = 0.028. The Hb at the end of CPB was not different between the groups sNA 88 ± 1.5 vs. rNA 93 ± 3.4, P = 0.102; but this was due to RBC transfusion in sNA 13.8% vs. rNA 0%, P = 0.048. Repeated measures ANOVA with Greenhouse–Geisser correction revealed a significant difference between the two groups over time P < 0.001 (Fig. 1). Discussion: We found that with routine use of a vasconstrictor infusion from the commencement of the
Fig. 1. Haemoglobin (mean ± SE).
anaesthetic, there was less haemodilution resulting in a higher Hb during CPB and a significantly lower transfusion rate. doi:10.1016/j.hlc.2010.10.010 Radiological Predictors of Recurrent Primary Spontaneous Pneumothorax Following Non-surgical Management Ramanujan Ganesalingam ∗ , Ross Shadbolt, John Tharion
O’Neil, Bruce
The Canberra Hospital, Canberra, Australia Background: Studies to date have failed to identify reliable predictors of recurrent primary spontaneous pneumothorax (PSP) on plain chest X-ray. The aim of this study was to assess whether abnormalities on plain chest X-ray at first presentation of PSP can be used to predict recurrent PSP. Method: The study included all patients admitted to The Canberra Hospital between 1998 and 2004 with their first episode PSP. Patients who received surgical intervention were excluded. Chest X-rays taken at the time of diagnosis were reviewed retrospectively by an independent radiologist who was blinded to the patient outcome. Documented abnormalities included mild pleural thickening, blebs, pleural irregularity, and adhesions. Kaplan–Meier and Cox regression analyses were used to examine the relationship between observed X-ray abnormalities and PSP recurrence. Results: One hundred patients (mean age 25 years) were followed up for a mean duration of 57 months (max. 131 months). The total rate of recurrence was 54%. Thirtyfour patients had no abnormality (normal) on plain film while 66 patients had one or more abnormalities. Multivariate analysis found no individual X-ray abnormality to be predictive of recurrence. However, the presence of any abnormality increased the likelihood of recurrence and the risk of recurrence increased with the number of abnormalities present. Patients having 1, 2 and 3 or more abnormalities are 2.8 (95% CI 1.98–3.71, p = 0.018), 5.2 (95% CI 4.37–6.03, p < 0.001) and 11.1 (95% CI 9.98–12.13, p < 0.001) times more likely to develop recurrence respec-
38
Heart, Lung and Circulation 2011;20:35–67
Abstracts
ABSTRACTS
Fig. 1. Kaplan–Meier analysis shows the likelihood of recurrence increases with each additional X-ray abnormality.
tively. This is independent of age, sex, smoking history, side of the PSP and type of initial management (Fig. 1). Discussion: To our knowledge this is a new finding that has not been previously reported. In view of these results we now offer surgical treatment at first presentation PSP in patients in whom we identify multiple radiological abnormalities to reduce the likelihood of recurrence and re-admission.
sion analysis was performed to identify risk factors of mortality. Results: The distribution of RV sizes was normal 16 (17%), moderate hypoplasia 50 (54%), and severe hypoplasia 27 (29%). Follow-up was 90% complete. Within the first 2 years of life, 21 patients died (22%). The end-status of the remaining patients were bi-ventricular repair in 37/93 (40%), 1(1/2) ventricle repair in 9/93 (10%), Fontan circulation in 12/93 (13%), transplantation in 1/93 (1%), and still awaiting repair in 13/93 (14%). Ten-year survival was 80% (95% CI: 71–87%) in patients with normal TV leaflets and 64% (95% CI: 30–85%) in patients with TV dysplasia. Independent predictors of mortality were lower TV annulus size Z-score and the presence of right ventricle to coronary artery connections (RVCAC). In patients without TV dysplasia; bi-ventricular repair was achieved in 90% (10/11) of those with a normal size RV, 40% (18/45) of those with moderate RV hypoplasia and 8% (2/25) of those with severe RV hypoplasia. None of the 28 patients with a TV Z-score below −2 attained a biventricular repair. Discussion: The management of PAIVS requires a selective approach based on RV morphology. A simple three tiered classification based on RV size allows initial stratification into biventricular or univentricular repair for patients with normal and severe RV hypoplasia. In patients with moderate RV hypoplasia, refraining from biventricular repair in the presence of RVCAC and a TV Z-score less than −2 may decrease mortality. doi:10.1016/j.hlc.2010.10.012
doi:10.1016/j.hlc.2010.10.011
FREE PAPERS
Finding the Right Balance Between Univentricular and Biventricular Repair for Pulmonary Atresia with Intact Ventricular Septum
Percutaneous Aotrtic Valves—Our First Twenty Cases With the Edwards Sapien Transcatheter Valve
Liava’a ∗ ,
M. d’Udekem
P. Brooks, I.E. Konstantinov, C.P. Brizard, Y.
Royal Children’s Hospital, Melbourne, Australia Introduction: Patients with pulmonary atresia and intact ventricular septum (PAIVS) present with varying degrees of right ventricular hypoplasia. Management can be directed to either biventricular repair or univentricular palliation (Fontan or 1(1/2) ventricle repair). An optimal management strategy has yet to be defined and varies between centres. Higher mortality is associated with an aggressive strategy towards biventricular repair. Methods: The records and echocardiography of all patients operated in the Royal Children’s Hospital, Melbourne for PAIVS between 1990 and 2006 (n = 93) were reviewed. Patients were stratified into a simple three tiered classification based on right ventricle (RV) size (normal, moderate, and severe hypoplasia). Those with associated tricuspid valve (TV) dysplasia and regurgitation were analysed separately (n = 12). Kaplan–Meier curves of survival were calculated and Cox regres-
Jayme Bennetts ∗ , Ajay Sinhal Flinders Medical Centre, Australia Percutaneous aortic valve replacement has seen unprecedented levels of interest within cardiac surgery and interventional cardiology over recent years. Two competing technologies are now available in Australia and New Zealand with an increasing number of sites vying for access to these devices. Flinders Medical Centre commenced implantation of the Edwards Sapien Transcatheter heart valve in November 2008 and has now undertaken 20 procedures in patients considered high risk for open aortic valve replacement. We report our experience with establishing a new program. Twenty valves have been implanted in 20 patients, 12 transapical and 8 transfemoral, with 100% procedural success. There has been no requirement for cardiopulmonary support and no emergency conversion to open surgery. One death has occurred at Day 5. There have been no cerebrovascular events and no acute myocardial ischaemia. Discussion: Includes patient demographics, case by case reasoning for selection of transcatheter valve implan-