P1. Anti-adhesion Coatings For Rapidly Exchangeable Bioprosthetic Valve
* Ivan . Vesely; Todd . Campbell
ValveXchange Inc, Aurora, Colorado, United States

OBJECTIVES: Bioprosthetic valves are favored over mechanical valves because they do not require chronic anticoagulation. They eventually wear out, however, and need to be surgically replaced. ValveXchange Inc. has developed a rapidly exchangeable bioprosthetic heart valve that dramatically speeds up the replacement surgery and reduces time on cardiopulmonary bypass. The valve is a two-piece design consisting of a permanent “docking station”, and an exchangeable leaflet set that clips onto the docking station in a fail-safe fashion, and is collapsible for percutaneous or minimally invasive exchange. Since fibrosis of the valve components after years of implantation could potentially impede percutaneous exchange where the tools may be catheter-based and hence not able to deliver sufficient force, we explored a number of anti-adhesion coatings.

METHODS: Test coupons fabricated from cobalt-chrome (coated and uncoated), pyrolitic carbon and glutaraldehyde-fixed pericardium were sewn to the inside of self-expanding stent grafts and implanted into the abdominal aorta of juvenile sheep. A total of 6 test coupons were implanted in each sheep. Two sheep were followed for 3 moths and three sheep were followed for 5 months – the standard time frame for valve implants. RESULTS: Explanted specimens were examined grossly, histologically and with SEM. After 5 months, the pericardium was completely covered with pannus overgrowth, confirming the hyperfibrotic nature of the sheep model. Carbon and two of the proprietary coatings on the cobalt-chrome were bare at 3 months and had little covering at 5 months.

CONCLUSIONS: Implementation of such anti-adhesion coatings is expected to facilitate minimally invasive or percutaneous valve exchange.

Summary of fibrotic overgrowth:

P2. In Vitro Model To Evaluate “the Balloon Plug Concept” For Repair Of Tricuspid Valve Regurgitation
Pietro . Bajona; * Kenton J. Zehr; Giovanni . Speziali
Division of Cardiovascular Surgery HLESI University of Pittsburgh, Pittsburgh, Pennsylvania, United States

OBJECTIVES: To evaluate the feasibility of “balloon plug concept” to treat tricuspid valve regurgitation (TVR) due to annular dilatation or leaflet retraction.

METHODS: Freshly harvested calf tricuspid valves were set up on an in-vitro mechanical right ventricular simulator. The papillary muscles were suspended in such a way as to create severe TVR by lack of central leaflet coaptation. A flexible catheter with a 4-cm long, soft, fusiform balloon was positioned across the tricuspid valve so that the balloon is suspended centrally across the tricuspid valve annular plane. After activating the mechanical ventricle, balloons were inflated with increasing quantities of saline solution until the regurgitant orifice would be “plugged”. Transvalvular gradients, degree of TVR and leaflet mechanics were evaluated for different levels of inflation. RESULTS: Fifteen experiments were performed. Mean valve diameter was 3.9 cm (range 3.3 – 4.7 cm). Increasing balloon inflation volumes of 5, 10, 15 and 20 mls were used. In all cases 5 ml inflation did not significantly reduce TVR and 20 ml inflation caused obstruction to antegrade flow (mean transvalvular gradient greater than 4 mmHg). Balloon inflation between 10 and 15 mls caused significant reduction or elimination of TVR with acceptable transvalvular gradients (less or equal to 3 mmHg). CONCLUSIONS: The “balloon plug concept” for percutaneous treatment of TVR showed good and promising hemodynamics results in this in-vitro model. Further investigation of this concept in an in-vivo model is warranted to evaluate choice of balloon material, thrombogenicity issues and effects of repeated balloon-leaflet contact on valve integrity.

Balloon Plug Concept:

P3. Transapical Aortic Valve Replacement Using Real-time Mri Guidance
* Keith A. Horvath²; Michael . Guttman²; Ming . Li²; Robert L. Lederman²; Dunitru . Mazilu²; Ozgur . Kocaturk²; Parag V. Karmarkar²; Elliot R. McVeigh^2
1National Heart Lung and Blood Institute, Bethesda, MD, United States; ²National Institutes of Health, Bethesda, MD, United States

OBJECTIVES: The principal limitations of percutaneous techniques to replace the aortic valve are detailed visualization and durable prostheses. We report the feasibility of utilizing real-time magnetic resonance imaging to provide precise anatomic detail and visual feedback to implant a proven bioprosthesis.

METHODS: Fourteen domestic pigs were anesthetized and via a minimally invasive approach using real-time MRI guidance underwent aortic valve replacement. This was accomplished on the beating heart using a commercially available bioprosthesis. MR imaging was used to precisely identify the anatomic landmarks of the aortic annulus, coronary artery ostia, and the mitral valve leaflets. Additional intraoperative perfusion, flow velocity and functional imaging were used to confirm adequacy of placement and function of the valve.

RESULTS: Under real-time MR imaging, multiple oblique planes were prescribed to delineate the anatomy of the native aortic valve and left ventricular outflow track. Enhanced by the use of an active marker wire, this imaging allowed correct placement and orientation of the valve. Via a transapical approach a series of bioprosthetic aortic valves (21-25mm) were inserted. The time to implantation after the placement of the trocar to deployment of the valve was less than ninety seconds. The average procedure duration was less than forty minutes.

CONCLUSIONS: Real-time MR imaging provides excellent anatomic detail and intraoperative assessment that permits placement of durable valve prostheses on the beating heart without the limitations of percutaneous approaches.

P4. 1000 Carpentier-edwards Pericardial Valves In Aortic Position: Determinants Of Non Cardiac Hospital Complications
* Wilhelm P. Mistiaen¹; Philip . Van Cauwelaert²; Philip . Muylaert²; Erik . De Worm^2
1University of Antwerp, Antwerp, , Belgium; ²General Hospital ZNA Middelheim, Antwerp, , Belgium

OBJECTIVES: Non-cardiac hospital complications after aortic valve replacement (AVR) have increased in the last 20 years, while cardiac complications remained at the same level. This puts healthcare resources under strain. The reason could be the increasing age and co-morbidity of the patients. The predictive factors for the increased complications need identification.

METHODS: Retrospective file study of 1000 consecutive patients who underwent AVR with a pericardial valve between 1986 and 2006. All complications (valve related, other cardiac and non-cardiac) during hospital stay were recorded. Statistical analysis for the effect of 20 preoperative and 5 peroperative (cardiac as well as non-cardiac) factors on non-cardiac hospital complications included Fisher-exact, Pearsons’ chi-square (univariate) and logistic regression (multivariate) analysis with determination of probability p, odds ratio and 95% confidence interval.

RESULTS: In 280 patients, non-cardiac complications occurred, with 20 (7.1%) fatalities. Almost all non-cardiac complications were renal, pulmonary or wound problems such as infection, leakage, pneumothorax and subcutaneous emphysema. The significant predictors are shown in the table.

CONCLUSIONS: Although non-cardiac hospital complications might be less fatal, they occur frequently. Preoperative impairment of renal and pulmonary function, previous and concomitant CABG, previous carotid artery surgery and pacemaker implant are important predictors for non-cardiac hospital complications. Age over 80 is not an independent predictor and hence, not a contraindication for AVR. Co-morbidity is also not a contraindication, provided the postoperative life expectancy is otherwise reasonable. In such patients, however, extra measures have to be taken for the support of pulmonary and renal function.

determinants of complications:

factors	N	P (univariate)	P (multivariate	Odds Ratio	95% Conf Interv
previous CABG	81	0.016	0.004	2.1	1.3-3.5
concomitant CABG	610	0.009	0.006	1.1	1.1-2.1
renal impairment	109	0.001	0.008	1.9	1.2-3.0
conduction defect	270	0.002	0.010	1.5	1.1-2.1
pacemaker implant	33	0.028	0.014	2.6	1.2-5.7
chron obstr pulm disease	235	0.008	0.015	1.5	1.1-2.1
prev carot surgery	22	0.043	0.032	2.6	1.1-6.4
previous AVR	23	0.001	not signif
coron art disease	622	0.004	not signif
age over 80	186	0.018	not signif
atrial fibrillation	197	0.025	not signif

P5. Are Valve Operations In Octogenarians Still High Risk In The Current Era?
Dumbor L. Ngaage; Steven . Griffin; Michael E. Cowen; Levant . Guvendik; Alexander R. Cale
Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire, United Kingdom

OBJECTIVES: The average age of cardiac patients continue to rise. As increasingly, more octogenarians undergo surgery, we investigated the outcome of valve operation in them to determine operative risk.
METHODS: Of 350 patients ≥80years old who had surgery from 1998 through 2006, 188 underwent valve operation. We analysed prospectively collected data.
RESULTS: There were 105 females (56%); mean age 83±2 years. More than half presented with severe symptoms (NYHA III/IV, 96 patients), history of heart failure (108), hypertension (101), and coronary artery disease (108). Concomitant CABG was performed in 47% (89 patients). Perioperative haemodynamic support with inotropes (47%) was common. In-hospital death after single aortic (n=89) and mitral valve (n=10) replacements occurred in 4 (4.5%, Euroscore predicted 8.5%) and 1 patient (10%, Euroscore predicted 9.8%) respectively. Concomitant CABG doubled the operative mortality. Aortic/mitral valve patients are compared in the Table. Operative mortality for AVR declined from 5.4% to 3.8% in later half of the study period. The average length of stay was 50±77 hours in intensive care and 12±7 days postoperatively. The sex- and age-adjusted risk factors for operative mortality were urgent/emergent surgery (HR 3.27, 95% CI 1.12-9.58, p=.03), preoperative gastrointestinal disease (HR 3.15, 95% CI 1.12-8.9, p=.03), LVEF <0.30 (HR 4.37, 95% CI 1.29-14.82, p=.02), and duration of aortic crossclamp (HR 1.04, 95% CI 1.004-1.07, p=.02).

CONCLUSIONS: Elective isolated AVR can be performed with modest operative risk in octogenarians, but impaired left ventricular systolic function and additional procedures imposing long ischemic times increase the operative risk. Mitral valve operations, however, are higher risk.

Valve operations in octogenarians:

Variables	AVR patients, n=170 (%)	MVR patients, n=16 (%)	P values
Female gender	98 (58)	7 (44)	NS
Mean age (yrs)	83±2	83±2	NS
NYHA class III/IV	84 (49)	11 (69)	NS
LV ejection fraction <0.30	9 (5)	2 (12)	NS
Coronary artery disease	99 (58)	8 (50)	NS
Renal failure	6 (4)	1 (6)	NS
Urgent surgery	61 (36)	7 (44)	NS
concomitant CABG	81 (48)	6 (38)	NS
Cross clamp time (minutes)	54±13	59±12	NS
Postoperative inotropes	76 (45)	12 (75)	.03
Postoperative dialysis	4 (2)	2 (13)	.08
In-hospital mortality	11 (6.5)	4 (25)	.03
postoperative stay (days)	12±7	13±5	NS

P6. Echocardiographic Prediction Of Preservation Of Left Ventricular Function After Aortic Valve Replacement For Aortic Regurgitation
Kazuaki . Tanabe; Ayako . Yoneyama; Kazuto . Yamaguchi; Toshikazu . Yagi; Tomoko . Tani; Shigefumi . Morioka; Yasuki . Kihara; Yukikatsu . Okada
Kobe General Hospital, Kobe, , Japan

OBJECTIVES: Left ventricular (LV) dysfunction is an indication for aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR). Whether we should offer asymptomatic patients with AR a choice of elective surgery to preserve postoperative LV function, before the end points in the guidelines are met, is not known. This study sought to determine whether echocardiographic variables before AVR for AR predict postoperative LV dysfunction.

METHODS: We studied 64 patients (20-85 years old, mean 58 years old) with isolated AR who underwent AVR. Echocardiographic studies were performed in preoperative and postoperative (14.3±1.8 months after AVR) periods.

RESULTS: The incidence of postoperative LV dysfunction (LVEF<50%) was 26 % (17/64). The incidence of postoperative LV dysfunction was high in patients with preoperative LVEF<50% (12/20, 60%), LV end-systolic dimension (LVESD)>50mm (7/17, 41%), LV end-diastolic dimension (LVEDD)>70mm (2/4, 50%). The optimal cutoff value for LVESD normalized to body surface area (LVESD/BSA) to predict the postoperative normalization of LVEF was 26mm/m2 with a sensitivity of 82% and a specificity of 70%, whereas LVEDD<61mm had 65% sensitivity and 62% specificity, LVESD<47mm had 76% sensitivity and 72% specificity.

CONCLUSIONS: In patients with AR, LVEF<50% and/or LVESD/BSA≥26mm/m2 should be considered at high risk of post operative LV dysfunction and need prompt evaluation for surgical intervention.

P7. Long Term Survival Of Dialysis Patients Requiring Valve Surgery Independent Of Type Of Prosthesis Implanted
* Jerry . Easo; Philipp . Hoelzl; Ehsan . Natour; Otto . Dapunt
Klinikum Oldenburg, Oldenburg, Niedersachsen, Germany

OBJECTIVES: Valve surgery in patients suffering under end stage renal disease remains controversial with guidelines recommending replacement with mechanical prostheses due to presumed accelerated calcification and structural valve deterioration of xenografts. We performed a long term followup of our patients to determine the validity of this recommendation.

METHODS: Information obtained from a computer based valve replacement database with telephone interviews and patient charts were reviewed for followup data. RESULTS: Between 1999 and 2005 56 patients underwent valve replacement. Of these patients 33 received mechanical prostheses (25 aortic, 10 mitral, 1 tricuspid) and 23 received tissue valves (18 aortic, 7 mitral and 1 pulmonary). The mean followup for the mechanical and tissue valve groups were 20.4±20.6 months and 18.2±19.8 months respectively. Freedom from reoperation at 4 years was 97%/96%. No siginificant differences in freedom from thrombembolism,(mech 1/33, bio 0/23) haemorrhage (mech 1/33, bio 1/23)), valve related mortality and morbidity could be demonstrated at 4 years. CONCLUSIONS: Dialysis patients continue to represent a high risk patient collective, valve surgery can be performed with acceptable operative results. Data analysis demonstrates the long term survival to be poor, irrespective of the type of valve prosthesis implanted. Incidences of thrombembolism, bleeding and valve related mortality and morbidity were similar in both groups.

P8. Surgical And Mid-term Outcome After Heart Valve Surgery Due To Infective Endocarditis. A Single-center 11-year Experience.
* Kyriakos . Spiliopoulos; Ayman . Haschemi; Gabriel . Fink; Maria . Costi; Joseph S. Weingartner; Bernhard M. Kemkes
Heart Center Krankenhaus Muenchen Bogenhausen GmbH, Munich, , Germany

OBJECTIVES: To evaluate outcome of patients with infective endocarditis. METHODS: We reviewed 92pts (66 male, 26 female, mean age: 58.9±13.1y., range:20-85y) with proven infective native (n:85) or prosthetic valve (n:10) endocarditis, who underwent heart valve surgery between 09/1996 and 12/2006. 53pts (57.6%) underwent aortic, 27 (29.3%) mitral, 3 (3.3%) tricuspid, 8 (8.7%) double and one patient (1.1%) triple valve surgery. In 77.5% of the procedures we implanted mechanical, in 12.7% biological prostheses and 9.8% were reconstructive procedures. 65% of the pts were preoperatively in NYHA-class III and IV. Follow up was 95.8% complete with a cumulative duration of 331py. (maximum: 11.25y.).

RESULTS: Overall hospital mortality (30d) was 7.6 % (n:7). ICU stay and ventilation time were slightly increased. Causes of early mortality were in 2 cases cerebral embolism and bleeding, in 4 cases multiple organ failure, and in one pt cardiac arrest. Overall late mortality was 27% (n:23) with a rate at 11y. of 6.9%/py. 8pts died due to cardiac, 9 due to extracardiac and 1pt due to unknown cause. 5 cases developed anticoagulant related intracerebral bleeding all of which were lethal. Kaplan Meier analysis revealed a cumulative survival rate at 11y of 52% (including early mortality); for AVR-pts and MVR-pts 52.25% and 44% respectively (p:0.047). 70% of hospital survivors were postoperatively in NYHA-class I or II. None of those developed recurrent endocarditis. CONCLUSIONS: Heart valve surgery in patients with infective endocarditis presents increased but acceptable mobidity and mortality. The mid term prognosis is nearly similar to those patients undergoing elective valve replacement surgery.

P9. Single Center Experience With The Toronto Root Bioprosthesis In 147 Patients
Sven . Lehmann; * Thomas . Walther; Ardawan . Rastan; Nicolas . Doll; Sergey . Leontjev; Jörg . Kempfert; Volkmar . Falk; Friedrich-Wilhelm . Mohr
Heart Center Leipzig, Leipzig, , Germany

OBJECTIVES: The Toronto root bioprosthesis™ with BiLinx™ anticalcification treatment (SJM, St.Paul, MN, USA) was introduced into clinical practice in 2001. Patients included in the initial clinical study with core lab data evaluation are reviewed. METHODS: 147 patients (61 ±11 years, 29 female) received full root replacement from 08/01 until 06/05. The predominant aortic valve lesion was stenosis in 40, incompetence in 68 or mixed lesions in 39 patients. Additional procedures included replacement of the ascending aorta in 82, replacement of the ascending aorta plus aortic arch in 26, CABG in 21, mitral valve repair in 16 and ASD closure in 3 patients, respectively. Previous cardiac surgery had been performed in 7 patients. Mean Follow-up is 3.4 ±1.5 years (508 patient years).

RESULTS: Mean implanted valve size was 26.6 ±1.8mm (14x23mm, 35x25mm, 67x27mm, 31x29mm). Crossclamp time was 99 ±28min. All patients showed a persistent clinical improvement according to NYHA class. Most recent echocardiographic exam revealed a maximum blood flow velocity of 2.3 ±0.6 m/s and mean pressure gradients of 8.9 ±4 mmHg. Left ventricular function was 61 ±11%. At up to 30 days reoperation was required in 2 patients and reexploration for bleeding in 5. One patient died due to cardiac related cause. During follow-up four patients died, two valve related and one suffered anticoagulant related bleeding.

CONCLUSIONS: The Toronto root bioprosthesis is safe and provides good clinical and hemodynamic function after full root replacement with or without additional aortic surgery. Based upon pre-clinical testing long-term durability will be promising.

P10. Long-term Survival After Valve Replacement For Active Infective Endocarditis: Comparison Between Native And Prosthetic Valve Disease
Daisy . Pavoni; Enzo . Mazzaro; Gianluca . Masullo; Igor . Vendramin; Giorgio . Guzzi; Vincenzo . Tursi; Ugolino . Livi
Azienda Ospedaliero Universitaria Santa Maria della Misericordia di Udine, Udine, , Italy

OBJECTIVES: To compare long-term results of valve replacement in patients with active native (NVE) and prosthetic (PVE) valve endocarditis.

METHODS: From January 1990, 93 patients underwent surgery for active endocarditis as defined by Duke criteria. 65 pts had NVE (mean age 57±16 years, 82% NYHA › 3) and 27 had PVE (mean age 62±10 years, 94% NYHA › 3), with a mean interval from previous surgery of 71±101 months.

RESULTS: Aortic valve replacement was performed in 72% of NVE and 81% of PVE. Patients with NVE received more frequently a bioprosthesis (52%), while those with PVE a mechanical valve (56%). Homograft was implanted in 1.5% of NVE and 11% of PVE. Vegetations were more frequent in NVE (87% vs 38%; p<0.01), while abscess in PVE (52% vs 18%; p<0.01). The pre-operative embolic events were similar in the two Groups (9% vs 4%; p=ns). Associated procedures were splenectomy (two cases), cerebral abscess drainage (one case) and cerebral haemorrhage drainage due to mycotic aneurism rupture (one case). Mean follow-up was 44±53 months (range 1-195). 30 day mortality was 12% in NVE and 11% in PVE (p=ns). Actuarial survival at 1, 5 and 10 years was 75±6%, 58±8% and 48±11%, respectively, for NVE and 77±8%, 71±9% and 71±9%, respectively, for PVE (p=ns).

CONCLUSIONS: Despite worse conditions of patients with PVE (older patients with higher NYHA class, wider presence of abscess and previous cardiac surgery), long term survival shows a non-significant trend to be better than in patients with NVE.

P11. Aortic Valve Surgery In The Elderly Patient: A Retrospective Review
Alfredo Giuseppe . Cerillo; Massimiliano . Mariani; Filippo . Santarelli; Pier Andrea . Farneti; Marco . Solinas; Matteo . Ferrarini; Stefano . Bevilacqua; Mattia . Glauber
G Pasquinucci Hospital IFCCNR, Massa, , Italy

OBJECTIVES: This study was designed to analyze the in-hospital and short-term results of AVR in patients aged >75 years, with special emphasis on patients aged >80 years.

METHODS: We reviewed the clinical records of all patients aged >75 years undergoing AVR at our institution from January 2000 to December 2003. Follow-up was completed by a telephone interview. Patients were asked to answer a questionnaire regarding life style, symptoms, degree of independence, and therapy.

RESULTS: 185 patients were considered. Mean age was 78.2±2.8, fifty patients (27.0%) were aged >80 years, and all except 36 (19.4%) were in NYHA class >III. Hospital mortality was 6.5%. A non-elective operation (p=0.001), NYHA class >III (p=0.06), and renal failure (p=0.02) were associated with increased mortality. Of note, age >80 years did not increase the surgical risk (p=0.8). The 4-years survival was 70.5%, the event-free survival was 60.6%, and almost all (97.5%) of the interviewed patients thought that they had benefited from the operation. Age >80 years at operation did not influence survival. On the other hand, a NYHA class >III (Hazard Ratio =1.4; 95%CI 1.1–1.8; p=0.02), preoperative intubation (HR=2.9; 95%CI 1.05–6.4; p=0.03) and a non-elective operation (HR=2.6; 95%CI 1.2–4.1; p=0.001) were univariate predictors of a poorer outcome, and a preoperative NYHA class >III was associated with shorter survival at multivariate analysis (p=0.07)

CONCLUSIONS: Our data show that aortic valve replacement may be performed with low morbidity and mortality in the elderly patient, and that an age >80 years neither increases the surgical risk, nor significantly worsen the short-term outcome

P12. Determinants Of Outcome After Repeated Isolated Valvular Surgery
Nicola . Luciani; Amedeo . Anselmi; Mario . Gaudino; Franco . Glieca; Giuseppe . Nasso; Mariantonietta . Piscitelli; Gianfederico . Possati
Division of Cardiac Surgery Catholic University, Rome, , Italy

OBJECTIVES: The number of repeat valvular operations has increased steadily in the last years. We performed a retrospective review of 408 ‘pure’ valvular redo procedures performed on a total of 379 patients at our Institution between 1998 and 2005. We sought to determine the factors affecting in-hospital mortality and medium-term survival. METHODS: Patients were included if subjected to isolated redo valvular surgery through median sternotomy, and if the same approach was used at primary intervention. Postoperative morbidity was defined according to current guidelines. Time-to-event regression analyses were performed.

RESULTS: In-hospital mortality was 2.9%; overall mortality at the end of a 30-month follow-up was 8.1%. Advanced NYHA class, age > 75 years, impaired ejection fraction, non-electivity, impaired renal function, and involvement of the tricuspid valve were predictors of in-hospital and medium-term mortality. No technical factor (duration of cardiopulmonary bypass, number of previous sternotomies) was associated with increased risk.

CONCLUSIONS: In the present study particular attention is paid to avoid biases correlated to heterogeneities of the population. The main determinants of mortality are related to the degree of patients’ illness rather than to inherent technical factors of reoperations. Although highest-risk individuals (previous coronary artery bypass grafting or coexistence of aortic aneurysm) were excluded, our data confirm that patients undergoing isolated redo valvular procedures now face operative risks that are comparable to those of primary intervention.

P13. Correlation Between Late Mortality And Pre-operative Renin-angiotensin-aldosterone(raa) System And Atrial Natriuretic Factor(anp) Activities In Patients After Avr. 5 Years Follow-up.
* A . Szafranek¹; MJ . Jasinski²; R . Gocol²; * M . Kolowca²; H . Luckraz¹; J . Gawrychowski¹; S . Wos^2
1University Hospital of Wales, Cardiff, , United Kingdom; ²II Department of Cardiac Surgery, Katowice, , Poland

OBJECTIVES: Aortic valve replacement (AVR) in patients with small aortic root predispose to patient-prosthesis mismatch phenomenon and continuation of pathological remodeling of LV. In order to find physiological long term consequences of operated severe aortic stenosis in small aortic roots plasma ANP and RAA activity were analyzed preoperatively

METHODS: Thirty patients undergoing AVR were included in the study. All patient received valves with size <21mm. Echocardiography, level of RAA system and ANP activity were recorded preoperatively and 6 months postoperatively. Patients were reassessed 5 years after surgery.

RESULTS: There was no early mortality in the group. 5-year survival was 90% with 20 asymptomatic patients. Seven patients (23%) were in NYHA >II. There was significant correlation between late mortality, preoperative activation of plasma rennin and left ventricle hypertrophy. (p<0.01) Multivariate analysis showed that preoperative rennin plasma level >4 ng/ml/h (control 0.3-5.3 ng/ml/h) and LV mass index >300 g/m2 were independent risk factors for late mortality (p<0.03). No similar correlation was found with aldosterone or ANP plasma levels. Deactivation of all natriuretic peptides was observed after surgery (p<0.01).

CONCLUSIONS: Activation of natriurectic peptides is a physiological response to cardiovascular instability. In our study high level of rennin plasma activity correlate with late mortality and LVH. We believe that period of time since aortic stenosis become heamodynamicaly significant and cardiovascular damage irreversible has influenced late outcome.

P14. Annular Dilatation And Aortic Insuffuciency After The Ross Procedure In Children
Kirk R. Kanter¹; William T. Mahle²; Paul M. Kirshbom¹; Brian E. Kogon^1
1Emory University School of Medicine, Atlanta, GA, United States; ²Childrens Healthcare of Atlanta at Egleston, Atlanta, GA, United States

OBJECTIVES: Aortic valve replacement (AVR) with a pulmonary autograft (Ross procedure) is appealing in growing children. There are concerns about late aortic insufficiency (AI) and annular dilatation. We modified our surgical technique to address these problems.

METHODS: From 1994-2003, 43 children 7 days-20.6 years (mean 9.7±6.4 years) underwent a Ross AVR (10 with a Konno). The proximal autograft was reinforced with a buttressing suture from the aortic root remnant to the autograft adventitia to improve hemostasis and prevent annular dilatation. Aortic dimension z-values were calculated and LVOT gradient and degree of AI were measured by echocardiogram.

RESULTS: There was one death 32 days postoperatively of aspiration pneumonia with no late deaths or redo AVR. Pre-discharge echocardiograms were compared with follow-up echocardiograms 3.5±2.5 years after operation (Table). The mild LVOT gradient present postoperatively was significantly less on follow-up. Aortic annulus z-values were within normal range (±2 standard deviations) postoperatively and on follow-up. The vast majority of patients had mild or less AI on both exams with none having more than moderate AI. Aortic sinus and sino-tubular ridge diameters were already enlarged on the early echocardiogram and were significantly more enlarged on follow-up. CONCLUSIONS: Reinforcing the proximal autograft suture line during the Ross procedure appears to retard development of aortic annulus dilatation with a low incidence of AI. Nonetheless, aortic sinus and sinutubular ridge diameters are abnormally dilated early postoperatively and even more on follow-up. Hopefully, this method of annular fixation will prevent longterm problems in children with the Ross procedure despite ongoing aortic root dilatation.

Echocardiographic Comparisons:

Timing of Echo	LVOT Gradient (mmHg)	Aortic Annulus z-value	Aortic Sinus z-value	Sino-tubular Ridge z-value	% with Mild or Less AI
Pre-Discharge after Ross	12.3±7.4	-1.11±3.0	1.2±2.8	2.83±3.2	95%
Most Recent Echo	8.0±6.7	-0.21±2.7	3.7±2.7	4.95±3.4	89%
P-Value	0.001	0.167	<0.001	0.0009	NS

P15. Valve Preservation In Acute Type A Aortic Dissection : 12 – Year Experience
Pasquale . Mastroroberto; Antonio . di Virgilio; Francesco . Onorati; Francesco . Pezzo; Attilio . Renzulli
Cardiovascular Surgery University Magna Graecia, Catanzaro, , Italy

OBJECTIVES: Aortic dissection is frequently complicated by regurgitation of the aortic valve resulting from leaflet prolapse or tearing of the annulus or leaflet.We have evaluated our results using the technique of aortic valve preservation in patients with acute type A aortic dissection (AAD).

METHODS: In a consecutive series of 71 AAD observed from January 1994 to December 2005, 43 (57.7%) presented aortic valve insufficiency(AI).All patients were emergency operated on via a median sternotomy and femoral(46/71,64.8%)or axillary artery-right atrium (25/68,35.2%) cardiopulmonary bypass with 52 (76.1%) antegrade selective cerebral perfusion.The dissected aorta was resected and the aortic valve was replaced in 2 patients/43 and was preserved in the remaining cases as follows: 34/41 (82.9%) commissural resuspensions due to commissural prolapse, 3/41 (7.3%) resuspensions due to cusp prolapse, 3/41 (7.3%) commissural plicatio and 1/41 (2.5%) circumclusion due to annular dilatation.

RESULTS: The overall hospital mortality was 21.1% (15/71)and 20.9% (9/43) in the AI group. 1 patient presented a type B dissection at 1 months and died after reoperation.The remaining 33 patients with a preserved native valve were followed by echocardiography and computed tomography (follow-up ranged from 3 to 139 months) with 4 late deaths. Actually we have found no AI in 21 cases and moderate insufficiency (2+) in 8.

CONCLUSIONS: The experience with this operation demonstrates the effectiveness of valve conservative treatment within a vascular graft. Although this technique is not applicable to every patient, we firmly believe that is a valid option when a morphologically intact valve is present.

P16. Mitral Valve Repair For Ischemic And Non-ischemic Regurgitation: is A Semi-rigid Partial Ring Adequate?
Vaughn A. Starnes; Eric J. Yavrouian; Becky M. Lopez; Megan . Moody; Mark J. Cunningham
Keck School of Medicine of the University of Southern California, Los Angeles, California, United States

OBJECTIVES: This study was conducted to report a unique group of patients who received a semi-rigid partial annuloplasty ring for correction of ischemic versus non-ischemic mitral regurgitation (NIMR).

METHODS: 94 patients presented with moderate to severe MR and underwent mitral valve repair (MVRpr) with insertion of an
annuloplasty ring only; 53 males and 41 females (44%); mean age 67 ± 12 years (range 34-86). 54 (57%) were classified with ischemic MR (IMR). The mean length of follow-up (FU) was 26 ± 21 months. FU was 100%.

RESULTS: The IMR group had 9 deaths with 3 in the NIMR group. Survival for the IMR group at 1, 3, and 5 years was 89%, 85%, and 73%; NIMR group survival for 1, 3, and 5 years was 94%, 89%, and 89%. Diabetes (P< .001), a lower ejection fraction (≤42%) (P=.025), and prior coronary operations (P< .0001) were present in significantly greater numbers in the IMR group. Female sex (P< .001) was present in significantly greater numbers in NIMR. Post operative MR for IMR was meaned at +1.15 and for NIMR +.94 (P= 0.37).

CONCLUSIONS: Patients with IMR have a lower survival than NIMR. The series had similar outcomes as related to the recurrence of MR. With effective MVRpr in both IMR and NIMR, the lower survival rate in the IMR group is likely related to patient attributes and confounding medical conditions. We believe the semi-rigid partial ring provides adequate molding of the mitral annulus to prevent recurrence of MR in both IMR and NIMR.

P17. Aortic Valve Repair In Surgery Of Laubry-pezzi Syndrome
Muslim . Mustaev; Kalandar . Babadjanov; Otabek . Karimov; Khakim . Abrolov
Vakhidov Republican Specialized Centre of Surgery, Tashkent city, , Uzbekistan

OBJECTIVES: To evaluate early and late results of the aortic valve repair in patients with Laubry-Pezzi syndrome (ventricular septal defects with aortic insufficiency (AI). METHODS: Twenty three patients with Laubry-Pezzi syndrome underwent aortic valve repair and VSD closure. The patients’ age ranged from 3.5 to 42 years (mean 17.15+9.91). Eighteen patients were males (78.3%); five were females (21.7%). Aortic valve repair included commissures plication (6 pts), plasty by Trusler (5 pts), Hisatomi (3 pts), Spencer (2 pts), sinus of Valsalva’s aneurism suturing (2 pts) and their combination (5 pts). VSD were closed by synthetic patch (13 pts), xenopericardium (7 pts) or direct closure (3 pts).

RESULTS: General mortality in our series was 4.35% (1 pt). Aortic regurgitation in 12 patients (52.2%) after AV repair was minimal or of the 1st -2nd grade. In the early postoperative period, aortic insufficiency was absent in 11 patients (47.8%), minimal in 7 (30.5%) and of 1nd – 3rd grade in 5 patients (21.7%). Aortic valve mechanical replacement was performed in 2 patients (8.7%) in late postoperative period (16 – 21 months after primary operation). Unsatisfactory results were caused by malfunctioning of the repaired aortic valve.

CONCLUSIONS: Aortic valve repair for Laubry-Pezzy syndrome can be successfully used in children without severe incompetence of the aortic valve. Commissural plication by Trusler and aortic valvuloplasty by Hisatomi provide good early and late results for AI of the 1st – 3rd grade with minimal residual aortic regurgitation. AV replacement remains a firm option for patients with 3rd – 4th grade of AI.

P18. Aortic And Mitral Valve Repair In Patients With Rheumatic Heart Disease
Sachin . Talwar; Ankit . Mathur; * Arkalgud S. Kumar
All India Institute of Medical Sciences, New Delhi, , India

OBJECTIVES: To assess the results of combined aortic and mitral valve repair in rheumatic patients.

METHODS: Between April 1991 and August 2006, 55 patients with rheumatic heart disease underwent aortic and mitral valve repair.Mean age was 21±9.4 years (range, 9 to 54 years).Five patients had aortic stenosis (AS), 42 had aortic regurgitation (AR), and 8 had AS and AR. Seven had mitral stenosis (MS), 16 had mitral regurgitation (MR) and 32 had MS and MR. Aortic valve was repaired by cuspal thinning (n=49), commissurotomy (n= 13), subcommissural annuloplasty (n=31), commissural plication (n=12), cusp decalcification (n=4) and cusp extension (n=1). Mitral valve was repaired by cuspal thinning (n=41), Commissurotomy (n=35), annuloplasty (n=40) and decalcification (n=5). Nine patients had tricuspid valve repair.

RESULTS: There were three early deaths due to severe left ventricular dysfunction (n=2) and re-operation following severe AR (n=1). Mean follow-up was 79.1± 53.2 months (2 - 169 months, median 92 months). 44 had no significant AR, five had moderate and three had severe AR; one had moderate AS. 42 had no significant MR, six had moderate and four had severe MR. Late re-operation was required in eight patients for severe AR (n=2), severe MR (n=2) and AR and MR (n=4). There were no late deaths. Actuarial and re-operation-free survival, at 92 months was 93.2%±3.6%, 79.6%±10.9%, respectively. Freedom from AS or AR was 84.3±3.9% and that from MS or MR was 84.2±2.8 %. Event free survival was 71.4±6.9%.

CONCLUSIONS: Combined aortic and mitral valve repair valve repair is a complex procedure & offers satisfactory mid-term results in selected patients.

P19. Attempt To Precisely Locate The Mitral Valve Prolapse By Transthoracic Echocardiography
Jiong . Wang¹; Zhi-An . Li¹; Chun . Zhang¹; Yong-Qiang . Lai¹; Guo . Li¹; Xuan . Zhang²; Li . Fang²; Xu . Meng^1
1Capital University of Medical Sciences Beijing Anzhen Hospital, Beijing, , China; ²University of Texas Medical Branch, Galveston, TX, United States

OBJECTIVES: Try to accurately locate the extent and the site of mitral valvular lesions by transthoracic echocardiography (TTE) in patients with mitral valvular prolapse.

METHODS: 48 patients with mitral valve prolapse underwent TTE examination for primary diagnosis in the parasternal non-standard short axis view at mitral valvular level and other views before surgical intervention. The diagnosis was compared with the inspection during surgery.

RESULTS: The overall diagnostic accuracy using individual scallop was 85.6%, with a sensitivity of 85.6% and a specificity of 97.9% using the Duran’s cardiac surgical terminology for mitral valve. 83 prolapsed scallops were found overall, and chordea rupture was observed in 15 patients by TTE before operations, compared with 97 prolapsed scallops and tendon rupture in 24 cases confirmed surgically. Vegetations on the prolapsed leaflets were diagnosed in 7 patients with both TTE and surgery. In this non-standard short axis view, color Doppler flow imaging can further validate the location(s) of the prolapsed scallop(s) by using the proximal flow convergence phenomena and reversely tracing the origin(s) along the regurgitations jet(s). Generally, the regurgitation jets owing to the prolapsed A1, A2 scallop or the combined prolapse with adjacent commissural segment are along the diagonal，the jets come from prolapsed P1, P2 scallop present bifurcation.

CONCLUSIONS: It is feasible that the locations of deformities can be demonstrated comprehensively by TTE. The significance of the parasternal non-standard short axis view at the mitral valvular level was emphasized on diagnoses. This new view is also applicable to Carpentier’s functional classification.

Parasternal nonstandard short axis view -MV level:

Defect location	TTE findings No. of lesion	Surgical findings No. of lesion	Agreement（%）	Sensitivity（%）	Specificity（%）
A1	21	25	84.0	84.0	91.3
A2	19	23	82.6	92.0	92
P1	9	10	90.0	90.0	97.4
P2	13	14	92.9	82.4	100.0
PM	14	17	82.4	92.9	100.0
C1	4	5	80.0	80.0	100.0
C2	3	3	100.0	100.0	100.0
Total	83	97	85.6	85.6	97.9

Different prolapsed scallops and MR:

P20. Minimally Invasive Mitral Valve Surgery Through Partial Upper Sternotomy In 182 Patients
Thomas . Wittlinger; * Petar . Risteski; Selami . Dogan; Sven . Martens; Peter . Kleine; Gerhard . Wimmer-Greinecker; Anton . Moritz
Dep of Thoracic and Cardiovasc Surgery University Hospital, Frankfurt, , Germany

OBJECTIVES: Minimally invasive mitral valve surgery (MIMVS) has considerably evolved in the last several years. We report on our experience with MIMVS through partial upper sternotomy (PUS) in the initial 182 patients.
METHODS: During the last 3 years , 182 patients (62% males, aged 58±13 years) underwent MIMVS. Mean ejection fraction was 62±13%. Atrial fibrillation was present in 60 patients. The approach was through a 6-8 cm incision and division of the sternum down to the 4th left intercostal space.

RESULTS: The operative, cardiopulmonary and cross-clamp times averaged 249±53, 149±39 and 101±25 minutes, respectively. Primary replacements were performed in 31 (17%) patients. 151 valves were repaired. Concomitant procedures included tricuspid valve repair in 34 (19%), atrial septum defect closure in 20 (11%) and radiofrequency ablation in 47 (26%) patients. Conversions to full sternotomy were performed in 3 patients. Ventilation, intensive care and hospital times averaged 7.4±4.6h, 23±10h, and 8.0±3.6 days.3 (1.6%) patients required reexplorations for bleeding. The rates of sternum instability/infection and operative mortality were 0%. All patients were discharged with none or trace residual regurgitation, except one. Sinus rhythm was restored in 13 (72%) patients. The 2 year follow up showed excellent echocardiographic results, except in 2 patients with MR III° and the need of reoperation.

CONCLUSIONS: MIMVS via UPS is safe and reproducible in majority of patients. Complex mitral repairs with concomitant procedures are feasible. This approach brings excellent cosmetic results with preservation of chest stability and comparable efficiency to the conventional technique.

P21. Treatment Of Anterior Leaflet Prolapse : Do We Need Artificial Chordae For Rheumatic Mitral Valve Incompetence ?
Phan v. Nguyen
Heart Institute, Ho Chi Minh, Ho Chi Minh, Viet Nam

OBJECTIVES: - Anterior leaflet prolapse presented in about 20% of Rheumatic Mitral Valve incompetence and the technique of choose is transposition of chordae and/or chordal shortening technique.

METHODS: - From 1992 TO 2006 , 1558 patients with severe mitral insufficiency underwent repair techniques in the Heart Institute, Ho Chi Minh City, Vietnam.
- Rheumatic Fever presented in 86.8% of patients and Anterior Leaflet Prolapse was found in 261 patients.
- The cause of Anterior Leaflet Prolapse composed : distension of free edge (171) , elongation of chordae (63) , rupture of chordae (27).
- Surgical procedures : Transposition of chordae (198), Chordal shortening technique (45) and Sliding plasty of papillary muscle (18) .
RESULTS: - Mean time of follow-up = 78+_ 1.26 months
- Reoperation was required in 45 patients (2.9%) .
- Finding at reoperation : Transposed chordae dehiscence (5) , rupture of previously shortened chordae (4).
- Most of these patients required reoperation during 02 years after the initial mitral valve repair .
CONCLUSIONS: - The chordae in Rheumatic Disease are thick and strong enough for chordal transfer .
- Transposition of chordae is a safe technique for correction anterior leaflet prolapse, especially in rheumatic mitral incompetence.
- Artificial chordae is not necessary to use in case of rheumatic mitral valve incompetence.

P22. Outcome Of Mitral Valve Repair Combined To Coronary Revascularization In Patients With Advanced Ischemic Cardiomyopathy And Moderate-severe Mitral Regurgitation.
Bruno . Chiappini; Ugo . Minuti; Renato . Gregorini; Licia . Petrella; Franco . De Remigis; Marco . Ciocca; Mauro . Di Eusanio; Alessandro . Mazzola
Division of Cardiac surgery and Cardiology Department of high specialization for the treatment of the cardiovascular diseases Giuseppe Mazzini Hospital, Teramo, , Italy

OBJECTIVES: Clinical and echocardiographic results were investigated to evaluate mitral valve repair in patients undergoing coronary artery bypass grafting for advanced ischemic cardiomyopathy with moderately severe mitral regurgitation.

METHODS: 78 patients with ischemic mitral regurgitation underwent mitral valve repair and coronary artery bypass grafting. Mean patients age was 69.5±7.8 years. There were 21 women (26.9%) and 57 men (73.1%). Mean ejection fraction was 42.4±12.4%. Nineteen patients (24.4%) had preoperative congestive heart failure. For 5 patients (6.4%) it was a second operation. The mitral regurgitation was 3+ in 28 patients (35.9%) and 4+ in 50 patients (64.1%). Mean number of grafts was 3.6 per patient.

RESULTS: Hospital mortality was 11.5% (9/78 patients). Risk factors for early mortality were preoperative NYHA class ≥ III (p= 0.014), preoperative heart failure ( p < 0.001) and reoperation ( p= 0.002). Five-year survival was 82.6%±5.9% and freedom from 2+ or more mitral regurgitation was 93.1%±4.1%. Sixty patients (89.6%) were in New York Heart Association (NYHA) class I and 7 (9.4%) were in NYHA class II, showing a statistically significant postoperative improvement (p= 0.03). Late echocardiograms showed a significant improvement of the postoperative ejection fraction (51.7%±10.9% versus 42.4%±12.4%, p= 0.01) and pulmonary artery pressure (29.3mmHg±7.4 mmHg versus 37.6 mmHg±11.9 mmHg, p= 0.004). CONCLUSIONS: We conclude that in patients with advanced ischemic cardiomyopathy, mitral valve repair combined to complete coronary artery bypass grafting provides a dramatic improvement in ejection fraction and in congestive heart failure, with excellent long-term survival, even in patients with low left ventricle ejection fraction.

P23. Clinical Evaluation Of Quadrangular Resection With Double Teflon No Ring Technique. 12 Year Results.
* Pablo M. Pomerantzeff; Carlos M. Brandao; Marco A. Guedes; Marcos F. Silva; Marcelo A. Vieira; Noedir A. Stolf
Heart Institute University of Sao Paulo Medical School, Sao Paulo, SP, Brazil

OBJECTIVES: The purpose of this paper is to present the late clinical results of a modification in the technique of mitral valve repair with quadrangular resection, the DOUBLE TEFLON TECHNIQUE, which consists in quadrangular resection of the posterior leaflet, annulus plication with "pledgetted" stitches over a Teflon patch, and leaflet suture, without ring annuloplasty.

METHODS: One hundred and sixty four patients with mitral insufficiency due to myxomatous degeneration and ruptured or elongated chordae tendineae underwent mitral valve repair with this technique in the Heart Institute of University of São Paulo Medical School, between 1994 and 2004. The mean age was 60.0 +/- 13.1 years and 64.0% patients were male. In the preoperative period, 29.3% of the patients were in New York Heart Association functional class IV, 55.7% in class III and 15.0% in class II. Associated techniques of mitral repair were employed in 17 patients (10.4%), the most common was chordal shortening.
Associated procedures were performed in 33 patients (20.1%).

RESULTS: There was one operative death (0.6%). Actuarial survival at 12 years was 96.2 +/- 2.6%. Linearized rates of reoperation, thromboembolism and endocarditis were 0.8%, 0.5% and 0.1% patient/year, respectively. There were no episodes of hemolysis. In the late postoperative period, 95.1% of the surviving patients were in New York Heart Association functional class I.
CONCLUSIONS: Mitral repair with the DOUBLE TEFLON TECHNIQUE without annuloplasty rings presented good clinical evolution in 12 years.

P24. Mitral Annulus Force
Zhaoming . He; Shamik . Bhattacharya
Texas Tech University, Lubbock, Texas, United States

OBJECTIVES: Mitral Annulus supports leaflets in mitral valve coaptation and controls left ventricular inflow hemodynamics. Mitral valve annulus forces were investigated in order to understand mitral valve function.

METHODS: A novel apparatus was developed to measure the annulus tension in a hydrostatic condition. A native porcine valve was installed in the apparatus with mitral annulus resting on the top of a rubber ring and papillary muscles (PM) held properly at the normal, slack and taut conditions. The mitral annulus was allowed to slide on the rubber ring and was pulled by multiple circumferential sutures in the valve closure preventing the valve shrinking. Suture tensions were measured by load cells under hydrostatic pressures of 120 and 145 mmHg. Leaflet tensions were calculated by suture tension divided by annulus segment length. Preliminary experiments were performed on four native valves.

RESULTS: The annulus tensions in a small segment of the anterior and posterior annulus regions were shown in the Table.

CONCLUSIONS: Annulus tensions increase with the transvalvular pressures. They range from 97 to 75 mN/mm in the normal PM condition for anterior and posterior annulus regions. Tensions on the anterior annulus region are significantly larger than on the posterior annulus regions in 120mmHg in the normal and taut PM conditions, but not in the slack PM condition.

Annulus tension (mN/mm):

	Anterior annulus	Anterior annulus	Anterior annulus	Posterior annulus	Posterior annulus	Posterior annulus
Transmitral pressures (mmHg)	Normal PM	Taut PM	Slack PM	Normal PM	Taut PM	Slack PM
121±1	97±51	115±59	71±35	75±45	89±50	64±27
144±1	125±62	139±69	85±53	98±52	111±57	71±39

P25. Quality Of Mitral Valve Repair: Median Sternotomy Versus Port-access Approach
Dan . Spiegelstein; Probal . Ghosh; Ateret . Malachy; Leonid . Sternik; Amihai . Shinfeld; * Ehud . Raanani
Chaim Sheba Medical Center, Ramat Gan, , Israel

OBJECTIVES: The feasibility and safety of minimally invasive mitral valve repair using Port-Access was previously demonstrated. However long term quality of the repair, is not well investigated.

METHODS: We selected 101 consecutive patients that underwent mitral valve repair for isolated posterior leaflet prolapse. Patients with other segments pathology or concomitant procedures were excluded. 50 patients underwent Port-Access approach, and 51 median sternotomy approach. In Port-Access approach we used endoclamp (32) or Chitwood clamp (18). Patients in Port-access group were younger; mean age of 55.2±11.5 versus 60.8±12.9 (p<0.05). Other patient's characteristics including mitral valve pathology and mitral repair technique were comparable.

RESULTS: Operative, bypass and aortic clamp times were significantly longer in the Port-Access group. There was no early death. There were more early postoperative pulmonary complications in Port-Access group. Early post operative echocardiography showed none of patients in both groups, had more then grade 2 mitral regurgitation. Mean hospital stay was 6.2±5.0 days in Port-Access group versus 7.6±4.2 in sternotomy group (NS). At mean follow-up of 28 months, NYHA improved from 1.9±0.9 to 1.4±0.6 in Port-Access group (p<0.01), versus 2.4±0.9 to 1.6±0.6 in sternotomy group (p<0.01). There were four (8%) late deaths in sternotomy group, versus none in Port-Access group (p=0.04). Freedom from reoperation was 100% in both groups. Echocardiography follow-up revealed 88% (44/50) and 86% (44/51) of patients (Port-Access and sternotomy groups, respectively) were free from moderate or severe mitral regurgitation (NS). CONCLUSIONS: In mid term follow-up, quality of simple posterior mitral valve repair via Port-Access approach compares well with conventional sternotomy approach.

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