Daily News The official newspaper of the 31st EACTS Annual Meeting 2017 Issue 1 Saturday 7 October In this issue Welcome to Vienna 2 A new European VAD perspective

4 Working towards a The 31st Annual Meeting of the European NOBLE endpoint Association for Cardio-Thoracic Surgery

t is with great pleasure to During two competitions rounds on welcome you to the 31st Sunday and Monday, national teams EACTS Annual Meeting in – composed of one cardiac and Vienna, and we are honoured one general thoracic resident or two and delighted with your cardio-thoracic residents – will test presence at this conference. their cognitive skills and compete for a IThe purpose of this event is to ticket to the next STS Annual Meeting facilitate the exchange of knowledge in Fort Lauderdale in January 2018. and information for clinicians and The winning team will represent Europe 5 Implementing researchers. As you will see, this year’s and will compete against the American programme covers the many different winners for the ‘World Champion’ title. guidelines in lone AF aspects of cardio-thoracic surgery, Come to cheer on the teams and try to 5 Improving patient emphasising areas that are important in test your own knowledge! our daily clinical work. As ever, we are consent hoping to create an interactive meeting Gala Dinner with the exchange of knowledge and Join us for this year’s Gala dinner at the ideas, fostering discussions and debates Orangerie Schönbrunn on Tuesday 10 between delegates. October, located within the grounds of the magnificent Schönbrunn Palace. Honoured Guest Lecture One of the two largest Baroque On Tuesday, our honoured guest lecture orangeries in the world (the other being will be given by health economist at Versailles), the building is 189 metres Professor Pedro Pita Barros from long and 10 metres wide and dates Lisbon, who will provide his insights on back to 1754. Joseph II was especially ‘Economics meets healthcare: how can it fond of arranging banquets in the plant- be useful?’ filled Orangery, emulating those he had Join us to hear what we can learn experienced on his journey to Russia in about health economics from a national the winter garden of the imperial palace 8 Inside Vienna guide and European perspective. in St Petersburg. Join us in these historic surroundings for a fun-filled evening of 20 EACTS Agenda Guidelines fine dining and entertainment! Dress This year, we bring you three new clinical code is Lounge Suits. 25 The EACTS guidelines – which will be presented Professional during the meeting – continuing to EACTS Leadership demonstrate the importance of the If you appreciate what the EACTS Workshop application of guidelines in every day presents during this event and you clinical practice: would like to support the work of the n ESC/EACTS Guidelines for the association, I encourage you to visit the management of valvular heart disease EACTS booth and become a member. n EACTS and EACTA Joint Guidelines The membership fee is low, and you on Patient Blood Management for will receive the European Journal EACTS booth in the exhibition area. At techniques presented at this year’s Adult Cardiac Surgery of Cardio-Thoracic Surgery and the the booth you will also find information Annual Meeting will be of great interest. n EACTS Guidelines on perioperative Interactive CardioVascular and Thoracic on our new courses planned for 2018, In addition to an outstanding scientific medication in adult cardiac surgery Surgery Journal as well as a reduced our Quality Improvement Programme programme, the opportunity to explore Two of these guidelines have been rate for the Annual Meeting. Also, the and how you can learn and publish with Vienna’s rich cultural heritage, including the result of collaborative work with EACTS has developed a digital portfolio our multi-media manual MMCTS. many historical buildings and engage the European Society for Cardiology management system to keep track of Of course, we thank our industry with (new) friends over some Wiener and with the European Association of your residency training programme (for partners for their continued support Schnitzel, will make your stay in Cardiothoracic Anaesthesiology. trainees and trainers) which is simple of the Annual Meeting, and all the Vienna memorable. to use and free for members. You can presenters who have taken the time I hope you enjoy the meeting and all 38 Satellite Symposia @ Jeopardy complete your membership application to contribute to this year’s EACTS that Vienna has to offer. Special attention should also be online through the EACTS website Daily News. Domenico Pagano 31st EACTS Meeting reserved for the ‘Jeopardy’ sessions. (www.eacts.org) or by visiting the We hope the information and EACTS Secretary General 2 Issue 1 Saturday 7 October 2017 EACTS Daily News

General | EACTS Academy | First international EACTS VAD coordinators symposium A new European perspective on VAD coordinators Thomas Schlöglhofer is a biomedical engineer and “We have many centres VAD Coordinator at the Centre of Medical Physics and Biomedical Engineering and the Department of Cardiac in Europe and VAD Surgery, Medical University of Vienna, Austria, where he coordinators, but the has worked since 2010. He has served on the board of the problem is there is International Consortium of Circulatory Assist Clinicians no clear role or job (ICCAC) since 2015 and as President in 2016, and was Chair description.” for the European Society for Artificial Organs (ESAO) - Thomas Schlöglhofer VAD Coordinator Symposium for the past three years. He is coordinator and co-moderator for the first adverse events and prevent them. International EACTS Ventricular Assist Device (VAD) Co- Additionally we will look at technical ordinators Symposium, which will be held this afternoon aspects, such as how to interpret pump waveforms and parameters. And we will at the Annual Meeting. He spoke to EACTS Daily News to focus on patient management – such discuss the VAD coordination, the Symposium and its aims. as blood pressure management and how to prevent readmissions of VAD What is the role of a and caregivers in how to change the patients. This is a major goal and it VAD coordinator? driveline exit site dressings. is our job to prevent the readmission In a team, you may have a surgeon, of patients. cardiologist and a VAD coordinator, Why are you holding the first technicians or engineers, perfusionists EACTS VAD Symposium? Why is the VAD Coordinator or ICU nurses that have special EACTS has a long history in bringing role not recognised so much training to care for VAD patients in cardiologists and surgeons together to in Europe? a technical way. We do the training share their experiences. So far, the VAD In the US, the therapy started a little for the staff, for the patients and Coordinator role is not well-defined in bit earlier and I think the nursing sector caregivers so they can operate Europe. It’s been around for 10 years or is more academic, so the professional devices at home by themselves. We so in America. We have many centres in background of Coordinators in the perform the technical supervision of Europe and VAD Coordinators, but the US is different vs Europ. In Europe the device, too, and we also do ward problem is there is no clear role or job there are many small centres and rounds in the ICU. We are the first description. Perfusionists or nurses may the coordinators of many facilities level contact if there are any troubles be doing the job as VAD coordinators are perfusionists. A major problem in in the hospital, or a potential Europe is the small implant volume readmittance. Staff and in many centers: if you have a small patients can call the VAD “…it is our job to prevent the programme, with maybe 5 to 10 coordinators – we have a readmission of patients.” implantations per year that’s not 24/7 emergency hotline. If enough to hire an additional person as there are any problems at Thomas Schlöglhofer more educational meetings too. That’s to set up a VAD programme with a a VAD coordinator. So, the perfusionist home with a patient they will what we’re doing at this Annual Meeting multidisciplinary team. We will go or nurse is responsible in parallel call us and we coordinate; we decide but they have no exact role definition in Vienna. over the role of the coordinator: this to their routine duties because the if this is a problem that requires the or job description in their hospital. is really important. We will talk about management says they can’t afford to patient to come back to the hospital Our goal is to let these perfusionists What else will you be discussing anticoagulation in the course, as well as recruit a dedicated VAD coordinator. directly, for example. We can discuss or nurses know that there are other here in Vienna? VAD patient management. We will also In many big European VAD this with the patient or help the patient people out there doing the same job We want to exchange knowledge on discuss, for example, how to detect implanting centers, the role of the on the telephone or we discuss the that they do – that there is the role of a international best practices for VAD coordinator is well-defined problem with our physicians and call VAD Coordinator. VAD coordinators. Surgeons including the knowledge, the patient back. exchange knowledge during “Surgeons exchange knowledge about how to set up a VAD How do you see the future of these meetings and VAD programme and that’s the goal What other roles do VAD VAD coordination? coordinators should their during these meetings and of this symposium – to share coordinators have? Within EACTS, in the future, it could exchange their knowledge VAD coordinators should their the knowledge on how to setup We supervise the hypertension be a goal to have a standardised too, because that will improve exchange their knowledge and learn from the experiences management, because this is very certification for example. People are patient care. of bigger centers. We’d like to important for VAD patients to prevent trained, so it’s important for us to too, because that will improve help new centres so they avoid stroke and pump thrombosis, as well continue the education too. We have a Tell us more about patient care.” making the same mistakes that as training of anticoagulation self- VAD coordinator training course in Berlin the Symposium… we did, and don’t try to reinvent assessment. We also educate patients every year but additionally we want We will also discuss how Thomas Schlöglhofer the wheel.

EACTS Daily News Publishing and Production MediFore Limited EACTS President Miguel Sousa Uva Saturday’s Programme EACTS Secretary General Domenico Pagano Editor-in-Chief Peter Stevenson The first day of the 31st EACTS Annual Meeting here in Vienna is packed with Editors Rysia Burmicz Techno College and Academy sessions, a hands-on congenital drylab, and Tatum Anderson Joanne Waters a programme of Translational and Basic Science Course symposia that will Becky McCall extend into Sunday. Design Peter Williams Industry Liaison Manager Karen Wellings Head Office 51 Fox Hill Don’t miss London SE19 2XE United Kingdom Telephone: +44 (0) 7506 345 283 The Techno-College Innovation Award, held during the session [email protected]

Copyright © 2017: EACTS. All rights reserved. ‘New techniques: the developers corner’ (13:30, Hall A)! No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any other means, electronic, mechanical, photocopying, recording or otherwise without prior permission in writing from the EACTS or its associated parties. The content of EACTS Daily News does not necessarily reflect the opinion of the EACTS 2017 Annual Meeting, its Chairs, Scientific Advisors or Collaborators.

4 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Focus | What is new in left main disease Working towards a NOBLE endpoint oronary revascularisation has been the disease. CABG seems to protect against these an individualised (age, presentation, comorbidity, main area of research for consultant “I think both studies are obliged incidents, over time helping the CABG-patient to a patient wishes) heart team-based decision and the cardiac surgeon Per Hostrup Nielsen to do a long-term follow-up less distressing disease course. Left main stenosis guidelines may be changed toward 1A indication of Århus University Hospital. One of both at 10 and 15 years – then is a life-threatening condition and revascularisation for both PCI and CABG when the SYNTAX score Chis main studies was the SYNTAX-study1, where at a later date is seldom – if ever – recommended. is below 33. his was the only Danish centre to participate. we will have a better idea of If equally eligible for both treatments, both the pros Today he is working with hybrid revascularisation especially long-term survival.” and cons will be explained to the patient based on Any advice for surgeons or cardiologists and minimal invasive off-pump revascularisation the current knowledge – the NOBLE trial included. approaching their patients as a result of with LIMA to LAD through hemisternotomy Per Hostrup Nielsen this trial? (JOBCAB). In tomorrow’s session, however, Dr Should guidelines should be changed in For the younger patients with LM-stenosis and low Nielsen will talk about the important Nordic- any way? co-morbidity the CABG should be the treatment Baltic-British Left Main Revascularization modality, but more reflecting the course of the CABG and PCI remain complementary methods of of choice. Use your heart team for an unbiased Study (NOBLE)2 trial, where he was one of the arteriosclerotic disease. revascularisation. Both NOBLE and the Evaluation discussion of the individual patient and make sure key investigators. of XIENCE versus Coronary Artery Bypass Surgery to have a thorough information of the patient, so What is the most important finding for Effectiveness of Left Main Revascularization that he/she knows what to expect. What work has led to the NOBLE trial, and from your point of view. And why is this (EXCEL)3 show that repeat revascularisation is why is it important? important for patients? lower for CABG but longer follow-up is needed How did this trial differ from the EXCEL From the late nineties we saw how cardiologists Non-procedural MI and reintervention reflect to in order to discern a difference in mortality. The trial, which will also be discussed during – in a kind of off-label way – began to treat left some degree the progress of arteriosclerotic similar mortality rates up to three years call for the focus session? main stenosis with PCI. When we saw the first The major difference between the two trials is results from the SYNTAX-study which indicated the design of the combined endpoint, where equivalence between coronary-artery bypass EXCEL includes perioperative MI and excludes grafting (CABG) and percutaneous coronary reintervention. On that background EXCEL intervention (PCI) in LM, it was natural for us to concludes that PCI is non-inferior to CABG, start a regular randomised trial on this subject – leading to the NOBLE study. “CABG and PCI remain The results from the SYNTAX study concerning the treatment of LM-stenosis was purely complementary methods hypothesis-generating, but could easily be used to of revascularisation.” justify the use of PCI in these patients. Per Hostrup Nielsen How have the risks to patients changed over the years, given the improvement in technology? but evaluating the individual components of the We have seen both CABG and PCI improve composite endpoints both studies shows almost over the years with very few perioperative identical results at three years of follow-up. complications/fatalities, regardless of the kind of techniques we have used. With the newer Can we learn anything more from the trials, generations of stents we see fewer major in future, after more time has elapsed? complications and fatalities with stent thrombosis Trials of these magnitudes are expensive and but still the CABG protects against myocardial lengthy to perform. In many ways the results are in infarction and angina due to de novo lesions, accordance with previous studies like SYNTAX. We which I consider an inborn weakness of the should see some major improvement in one of the PCI technology. treatment modalities before going into a new major trial. But at the moment that major breakthrough is What surprised you about the NOBLE trial? hard to see. Thinking it over, you must be impressed that I think both studies are obliged to do a long-term over the years we have been able to develop two follow-up both at 10 and 15 years – then we will almost equally robust treatments that have been have a better idea of especially long-term survival. employed in many cardiac units in many countries. In our trial we see the results from a diversity of References 34 clinical units in 9 countries to the benefit of our 1. Morice, MC, Serruys, PW, Kappetein, AP, Feldman TE, Ståhle E, all-comers patients. We were looking at the major Colombo A et al. Five-year outcomes in patients with left main negative events over time following two different disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the SYNTAX trial circulation. and both recognised treatments of coronary Circulation. 2014;129:2388–2394. disease. Seen from a patient safety aspect, you 2. Mäkikallio, T, Holm, NR, Lindsay, M, Spence MS, Erglis A, Menown, could hope that the overall mortality was equal IB et al. Percutaneous coronary angioplasty versus coronary artery for the two treatments. Up till now that seems to bypass grafting in treatment of unprotected left main stenosis be the case. In contrast to previous studies it was (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 2016;388:2743-52. surprising that there were so few strokes in the 3. Stone GW, Sabik JF, Serruys PW, et al. Everolimus-Eluting Stents or CABG group. It might suggest a rather random Bypass Surgery for Left Main Coronary Artery Disease. New England occurrence of stroke disconnected from treatment Journal of Medicine 2016;375:2223-35.

Neo-tricuspidalisation of the aortic valve in a paediatric population – a clinical update.

Martin Kostolny1,2, Branko Mimic3, Vladimir patients received the Ozaki procedure 3 with other valve pathology. 8 had repair was preserved in one after an Milovanovic4, Slobodan Ilic4 1 Cardiothoracic Unit, at 3 institutions. Mean age at previous catheter and 5 patients had interval of conservative treatment and Great Ormond Street Hospital, UK; 2 Slovak Medical surgery was 13.5 years (2.9-19.3yrs). previous surgical interventions. the other required homograft aortic University, Bratislava, Slovakia; 3 Leicester Congenital CardioCel® or glutaraldehyde There were no early deaths. root replacement. Excluding these Heart Centre, UK; 4 University hospital Tirsova, Belgrade, treated native pericardium was used The patient with severely impaired two, the freedom from greater than Republic of Serbia according to institutional policies. ventricular function after previous mild aortic regurgitation and stenosis Indication for surgery were as heart transplant died 7 months was 100% after up to 18 months of eo-tricuspidalisation (Ozaki annular growth. Results in the adult follows: bicuspid aortic valve with after valve repair. His follow up follow up. procedure) is an aortic valve population have been excellent but stenosis and/or regurgitation was echocardiogram at that stage Neo-triscuspidalisation of the Nplasty where all valve leaflets those in the paediatric population present in 18 patients, 1 patient had showed mild aortic stenosis and aortic valve offers an alternative to are removed and replaced with have to be compared to other types a previous arterial switch operation regurgitation and moderately impaired other forms of surgical intervention pericardium or bioprosthetic material of surgical treatment for systemic and another common arterial trunk ventricular function. One patient on the diseased semilunar systemic after measuring distances between semilunar valvar stenosis and/or repair with significant semilunar valve developed a thrombus inside the right outflow valve with excellent results in commisures with commercially regurgitation. incompetence on follow up. 1 patient coronary cusp that resolved under short term. Indication criteria for the available sizers (OZAKI VRec Sizer™). We adopted this method for a came for surgery with progressive anticoagulation with preserved valve paediatric population are still evolving. It offers a standardised way of aortic selected group of patients and report valvar regurgitation and severe left function and without neurological valve plasty without the need for long on our early results. ventricular function impairment after sequel. Two patients underwent re- Disclosure: Martin Kostolny is a proctor term anticoagulation and potential for Between 01/2016 and 08/2017 24 previous heart transplantation and operation for valve endocarditis; the for Terumo and JOMDD. EACTS Daily News Issue 1 Saturday 7 October 2017 5

Cardiac | Focus | Atrial fibrillation surgery in 2017 Lone atrial fibrillation – how to implement the guidelines in daily practice

Anders Ahlsson, Associate Professor and Managing Dr Ahlsson said that implementation Director at the Cardiovascular Division of Karolinska of guidelines in daily practice is an University, Stockholm, Sweden, says setting up an atrial issue. “Some things change very easily; for instance the old anticoagulants fibrillation (AF) Heart Team is the key message from the are replaced by the new ones from ESC guidelines on AF when it comes to treating lone AF. one day to the next – people adapt these changes fairly easily, but other tand-alone AF surgery should Dr Ahlsson. recommendations such as forming AF be managed by a multi- “However, there is no point in integrated teams require manpower and disciplinary, integrated, AF Heart spending time and money to set up planning and so that’s not so easy and Team with both EP cardiologists an AF Heart Team if surgeons don’t will take more time. Basically, we need Sand heart surgeons working together, collaborate with an EP cardiologist. people who are interested, you can’t according to new guidelines from It’s useless: don’t do it. Cardiac just order these things to happen, you the ESC and EACTS. The 2016 ESC surgeons need to form alliances with need surgeons and cardiologists who guidelines for the management of AF EP cardiologists.” are motivated, and want to go in this contain new recommendations on the Dr Ahlsson said one of the big direction and explore.” best ways to treat AF with surgical advantages of working in an AF team He said that one of the most techniques, with the team approach is that it is easier to run the scientific important new ESC/EACTS AF guideline heavily emphasised. studies that are needed. “If you’re was that catheter or surgical ablation “Integrated AF care is a new thing, working as part of a network it’s much should be considered in patients with done in a multi-disciplinary setting, and easier to get the results and answers to symptomatic persistent or long-standing the idea is that all patients should be questions that you want. It’s also much persistent AF refractory to AAD therapy treated in this way. It’s also a nurse- better for the patient to be treated by a to improve symptoms, considering based approach, and has been very multi-disciplinary team. patient choice, benefit and risk, and successful in the Netherlands, in terms “My second main message would supported by an AF team. of introducing anticoagulation and be that we need to enter more patients “This is new advice. When we preventing strokes,” Dr Ahlsson, one of in large multi-centre trials, as we looked at the literature there was four surgeons on the Task Force who really don’t have enough studies. The equal evidence for the success of drew up the guidelines, told EACTS cardiologists have been much more surgery and catheter ablation. It’s a Daily News. successful in performing these studies. consensus statement, as we don’t have An AF Clinic should consist of an AF I would say we have one or two great enough evidence to make a class B nurse, cardiologist (or general physician/ studies, but we need to improve on this. recommendation, but based on what electrophysiologist) and technology “We need to learn from the we know we can’t say one is better support, and these health professionals cardiologists about how to perform large than the other. It will be for the AF Heart then work with a heart failure team, multi-centred randomised controlled Team to decide which procedure is the physiotherapists/dietitians, pharmacists, trials because they are ahead of us and best option. We do need more studies stroke physicians/neurologists, their evidence base is better. We need on this though.” nephrologists, GPs, haematologists and to collaborate and learn from them.” electrophysiologists. Difficult or complex Making up your mind on what type of “We need to learn from cases should be referred onto the AF surgical approach you are going to use When you have decided what method for patients to be informed about Heart Team. whether it be RF energy/cryo, lesion sets, to use, then you have to contact centres the risks of procedures and the cardiologists about The model for AF Heart Teams minimally invasive/totally endoscopic, that have great experience in this, and explain that this is an area where how to perform large should include an AF cardiac then you have to go the scientific evidence is not that surgeon, electrophysiologist “… there is no point in spending time there and collaborate and great and include them in studies multi-centred randomised and referring cardiologist. you have to ask them to and ask for their consent. controlled trials because These professionals and money to set up an AF Heart come to your place to get “You have to remember should also consult with Team if surgeons don’t collaborate you started. that the patients coming for they are ahead of us and heart failure specialists, “There are a handful these procedures are severely their evidence base is better. anaesthesiologists, cardiac with an EP cardiologist. It’s useless: of centres out there with handicapped by AF, and are imaging, LAA occluder don’t do it. Cardiac surgeons need to great experience, and looking for a way out, because We need to collaborate and implanters, neurologists/ you should connect with they feel so limited by it, and learn from them.” stroke physicians and other form alliances with EP cardiologists.” them.” Other important because of this they are often Anders Ahlsson medical specialists. “An AF Anders Ahlsson steps to setting up a very motivated to have surgery Heart Team is a small part of lone AF surgery include and take part,” he explained. the AF integrated care team. defining your patient “They have usually exhausted other Dr Ahlsson presents ‘Lone atrial fibrillation Integrated care really doesn’t exist in unilateral/bilateral or left atrial appendage, population, designing the protocols, and treatments, for example they have may – how to implement the guidelines in daily many places at the moment. There are is also very important, said Dr Ahlsson, getting informed consent from patients, have had catheter ablation many times practice’ during Monday’s session ‘Atrial just a few centres in Europe where this adding: “You have to pick one method he said. or it has not been possible for them to fibrillation surgery in 2017’, held at 10:15 model is working very successfully,” said and develop your knowledge and skill. Dr Ahlsson stressed that it’s important have it.” in Hall K2.

General | Focus | Health care design; opportunities and challenges for the future Improving the patient consent process: from rhetoric to reality

n 2008 the UK General Medical Council’s evidence-based practice also play a role in freeing have access to reliable resources from the medical wrong operation by accident.” guidance set out the principles upon communication between doctor and patient, noted community that will help them to understand While this does not negate the importance of which good clinical decisions should be Mr Leigh: “At the end of the war when I was born, their options, the risks, and their own individual recording the consent that a patient has given with based, in ‘Patients and doctors making the majority of medical interventions did more harm needs and desires. The autonomous patient will respect to a particular procedure, its prelude is of Idecisions together’1. It emphasised that patients than good. inevitably sometimes greater importance: “You should be advised about alternative treatments. “Right up to the 1980s there was very make decisions that need to have a record of Bertie Leigh (ex-Senior Partner at Hempsons little evidence base to support most medical surprise the doctor who is “You have to treat me…You the counselling process Solicitors, London, UK), who published last year interventions. Doctors have slowly and reluctantly advising him. cannot push me through by which the patient has on the importance of patient education in the started explaining things to us, partly because they Furthermore, explained come to take the decision decision-making process2, spoke to EACTS Daily understand them better themselves. What we are Mr Leigh, this decision- a consent process designed to have an operation. In News ahead of the meeting to discuss where talking about is a levelling of knowledge between making process needs for your own convenience.” elective surgery, that is improvements need to be made in recording the doctors and the rest of society as medicine has to be recorded more something that happens counselling process, looking towards areas where become more fit for purpose.” thoroughly than it is at Bertie Leigh slowly, over a period of this has already been done with success. Naturally, the understanding and interpretation present. “The whole weeks – long before they Mr Leigh will speak tomorrow as part of a review of the concept of the doctor-patient relationship notion of consent is come into hospital. of the latest challenges in healthcare design and continues to vary as a function of age, education, misconceived,” he said. “The one thing that “I regard a consent form, which contains a management which includes a discussion of Big and country, according to an aggregated 2012 you don’t need to bother about, when a patient list of risks that has been given to the patient on Data, value-based reimbursement, clinical trials in European Commission report3. climbs onto an operating table and asks to be the day of surgery or the day before surgery, as surgery, and technology in healthcare. Yet, as well as posing a challenge to patients, anaesthetised, is whether they consent to what is prima facie evidence of discourtesy, negligent Increasing patient engagement in the decision- drawing the patient into the decision-making happening to them. In 40 years of experience, I’ve treatment, and professional misconduct – because making process has been accelerated by the process requires change on the side of the health never defended a claim by somebody who said it is contemptuous to a patient to give them a advent of the Internet, with improvements in health profession. If the patient is to be informed about that they did not consent to an operation, except list of risks on the day of the operation, weeks literacy in the general population. Improvements in a medical procedure, it is necessary for them to where a mistake was made and they got the Continued on page 6 6 Issue 1 Saturday 7 October 2017 EACTS Daily News

General | Focus | Health care design; opportunities and challenges for the future Improving the patient consent process: from rhetoric to reality

Continued from page 5 issue – part of good medicine. after they have decided to have an operation on “At the moment, we are raising the bar of your advice.” communication just as fast as clinical expectations, Hence, timing is crucial. That the patient be and unless we create a record of the patient’s trained in an understanding of their options by learning process, we will just be dooming their healthcare provider is a necessary condition ourselves to fall even further behind.” of a well-reasoned decision, but can healthcare Clearly, much comes under the term ‘decision providers really deliver this? “I agree that it is not record’ when different conditions and treatments, practical for doctors to convey that information let alone different specialties, are considered. And in the outpatient clinic,” said Mr Leigh. “Cardiac importantly, patients’ willingness to get involved surgeons’ outpatient clinics may be booked at can vary: Mr Leigh reports: “I talk to a lot of cardiac 15-minute intervals. Of that, about eight minutes surgeons, who tell me ‘my patients really will turn may be taken up with history, investigations, and off if I start doing detailed drawings of how I am the examination of the patient. That leaves seven going to make a power-saw incision through their minutes. In the course of seven minutes, someone sternum, break it open, tear open their pericardium who has just received the shocking news that they and start cutting their cardiac vessels…’. They may are going to need to have their chest cut open, not want to know, but they have to decide. that they will be off the road for three months, that “Whereas men who are having prostate cancer they are risking their lives, has got to be equipped surgery want to know every gory detail – for with all the information they need to make the reasons you can imagine. In orthopaedics, it decision. It is impossible to expect cardiac is a bit in-between. And neurosurgery is way surgeons to discharge those obligations, let alone beyond cardiac surgery because nobody can make an adequate record of the process. explain neurosurgery (even to neurosurgeons!). “But we have to get rid of the fiction that only You know you are going to fiddle around in white a surgeon can deliver this information. Yes, they tissue, and you know you are going to remove a have to write the text, but somebody else has got cancerous lump. But you cannot show a patient to deliver it: a teacher, armed with complex visual the precious structures adjacent to it; you cannot aids to explain the disease and the alternative tell them that a little bit of extra suction here or remedies available.” there would wipe out all of their memory of music. Such a ‘teacher’ could be a web tutorial, It is incomprehensible. So how we can deal with and, if the patient has particularly difficulties, a that? I don’t know, but what I do know is that the trained tutor. “You should provide a sophisticated, parameters have to be explicitly set by the patient.” interactive multimedia-based app with films, diagrams, and drawings, which will enable the Mr Leigh discusses consent in tomorrow’s Focus patient to explore all the information they need to Session, ‘Health care design; opportunities and know. This is an interactive process.” challenges for the future’, which takes place between It also must be a sophisticated one, given that 12:00 and 13:30 in Hall K2. the average patient simply will not understand terms such as ‘PCI’, ‘left main stem’ and ‘CABG’, shared decision-making in elective surgical care downloaded onto the clinical notes of the hospital.” References let alone have an intuitive grasp over their found the process to reduce conflict and improve This decision record, although adapting to 1. Consent: patients and doctors making decisions together. General implications to the extent a surgeon might. So decision quality, as well as leading patients to different clinical scenarios, will broadly include Medical Council. June 2008. Retrieved from http://www.gmc-uk.org/ static/documents/content/Consent_-_English_0617.pdf (September 8 communicating in the patient’s first language is choose surgery less often. the details of the patient’s health complaint, and 2017). a must, and options for the cognitively impaired Reducing uncertainty in decision-making will at the expected benefits, disadvantages and risks 2. Leigh, B. Progress towards a decision record is lamentable. Clinical need to be available. “You have to treat me,” the same time reduce the frequency of complaints as relayed by their physician, as well alternative Risk. 2016;22(1-2):16-20. 3. Patient Involvement. Aggregate Report conducted by TNS Qual+ at summarised Mr Leigh. “You cannot push therapies and recommended learning the request of the European Commission, Directorate-General for me through a consent process designed for the patient; this may take place, for health and Consumers. May 2012. Retrieved from http://ec.europa. for your own convenience.” example, in the surgeon’s outpatient clinic eu/commfrontoffice/publicopinion/archives/quali/ql_5937_patient_ “I want a record made of the patient’s en.pdf (September 2017). Some learning resources have already in cases of elective surgery. The decision 4. Cavernoma Alliance UK website. www.cavernoma.org.uk (accessed been implemented in some areas of learning process…downloaded onto record will then include the resolution of September 2017). medicine. Mr Leigh highlighted the work the clinical notes of the hospital.” any queries that the patient may have. 5. Trigeminal Neuralgia Association UK website. www.tna.org.uk of the Cavernoma Alliance UK and the It is upon this iterative basis towards (accessed September 2017). Bertie Leigh 6. Cox CE, Wysham NG, Walton B, Jones D, Cass B, Tobin M et al. Trigeminal Neuralgia Association UK understanding that the patient can make Development and usability testing of a Web-based decision aid for as examples of this4,5. These websites their decision as to treatment. families of patients receiving prolonged mechanical ventilation. Ann provide up-to-date learning resources, as well as and litigation, by providing evidence of both the The resources required to create the educational Intensive Care. 2015;5:6 7. Nishimura A, Carey J, Erwin PJ, Tilburt JC, Murad MH, McCormick patients’ stories and access to community support doctor and patient fulfilling their respective duties tools needed to implement decision records has JB. Improving understanding in the research informed consent resources. Reports of experience with web-based in the care process. “As a lawyer, what I am probably marred progress so far in the UK, as Mr process: a systematic review of 54 interventions tested in decision aids have been published in areas such concerned about is not only providing a proper, Leigh explained: “This is not driven by the trusts, randomized control trials. BMC Med Ethics. 2013;14:28. 8. Boss EF, Mehta N, Nagarajan N, Links A, Benke JR, Berger Z et al. as surrogate decision-making for patients receiving sophisticated explanation of these things,” noted even now. It is being driven by the British Society Shared Decision Making and Choice for Elective Surgical Care: A prolonged mechanical ventilation6, and for those Mr Leigh. “I want a record made of the patient’s of Cardiothoracic Surgeons. They are the ones Systematic Review. Otolaryngol Head Neck Surg. 2016;154(3):405-20. participating in clinical trials7. A 2016 review of learning process. I want their use of this app to be who take the lead, because it is a professional

Cardiac | Techno College | Transcatheter techniques and atrioventricular valves Live case: Thoracoscopic tricuspid valve repair Piotr Suwalski Central Clinical Hospital of the step in reduction of the invasiveness – in experienced hands without Ministry of Interior and Administration, Warsaw, Poland affecting the rate of complications. Tricuspid valve repair can be performed on the beating heart or urrent guidelines recommend aggressive and early surgical arrested heart. The femoral vessels are used most often (from the correction since tricuspid valve (TV) disease has significant right side), both small cut down or percutaneous. An additional impact on early and late survival, and can advance even cannula is put into the right atrium through the right internal jugular after proper surgical treatment of the mitral (or other) valves. vein. The alternative is the use of a two-stage venous cannula via CAlong with the rising experience with minimally invasive surgery, femoral access only. TV surgery is more often a focus in many centres. The TV is mainly The latest developments in 3D endoscopic vision systems are, in known by surgeons as an “additional” valve – during mostly mitral my opinion, no longer just “a toy” but are able to significantly facilitate valve surgery or as an isolated tricuspid valve disease. Another minimally invasive – especially totally thoracoscopic – surgery, and interesting indication is not only the primary approach (secondary or influence the time of procedure. They also facilitate some precise isolated insufficiency) but also the minimally invasive approach to TV manoeuvres and eye-balling in certain planes and axes, for example surgery as a reoperation after previous surgical intervention. Those movement in the ventricle or precise distance assessment for patients are often multimorbid elderly patients who can benefit from chordal replacement, which can be difficult using a 2D monitor. small surgical trauma, as well as the other advantages of minimally In conclusion, totally thoracoscopic periareolar 3D vision invasive approaches such as lower blood loss, fewer atrial fibrillation augmented surgery becomes a validated and standardised approach onsets, shorter ventilation time and quicker rehabilitation. not only for mitral, but also tricuspid, valve surgery. Totally thoracoscopic periareolar access is performed through a natural scar in the body around the nipple (mainly in males). The References operator is however usually forced to work only on the monitor, 1. Walcot N, et al. Totally endoscopic set-up for mitral valve repair. Multimed Man Cardiothorac Surg. 2015. which needs some experience and a learning curve. In comparison 2. Seeburger J, et al. Minimally invasive isolated tricuspid valve surgery. J Heart Valve Dis. to the right lateral minithoracotomy, an access seems to be the next 2010;19(2):189-92. EACTS Daily News Issue 1 Saturday 7 October 2017 7

Cardiac | Techno College | Surgery at the crossroads Live-in-a-box: Mitral valve repair in functional disease using posterior leaflet augmentation

Anno Diegeler, Fitsum Lakew Bad Neustadt-Center of Cardiac and Vascular Medicine, Germany

he repair of secondary mitral valve incompetence (MI) due to a displacementT of the papillary muscle and/or the enlargement of the left ventricle may lead to a Anno Diegeler Fitsum Lakew Figure 1 Figure 2 Figure 3 disappointing result. Acker MA et al. (NEJM 2014, 370: 23-32) of the level of coaptation. (Figure 4). In the “live-in-a-box” using a de-cellularised patch between 1.6 and 2 cm. The a reference for the size of the showed a high recurrence rate of Furthermore, it improves and case presented during the (CardioCel™) in conjunction posterior MV-leaflet is detached annuloplasty ring, which should MI already at 12 months after the stabilises the length/height of EACTS Techno College, we with a conventional annuloplasty from the respective length not be undersized. (Figure 3). surgical repair. On the basis of the area of coaptation between demonstrate the augmentation ring (Physio II™, Edwards of 5 cm from the annulus. If With this technique, we achieved echocardiographic findings, we the anterior and posterior leaflet of the posterior mitral valve Lifesciences, USA). The patch is the length of the rear ring is a sustained repair in a series of see a “tenting height” between Figure 4 available in various thicknesses larger, the detachment should already more than 100 cases. At the line of the coaptation and and sizes. We used a 30 μm be placed in the area of the first glance, at our medium-term the plane of the ring of more thickness, and the largest maximum displacement of the results (four years of follow-up), than 1 cm as a threshold for an available patch (4X4 cm). Larger leaflet. Individual “Stay-Sutures” a sustained competence of the uncertain sustained result and patches are needed and will be facilitate the presentation mitral valve < Grade II could be the risk of recurrence of MI. The available in the future. and sewing of the patch. The achieved in 95% of the patients augmentation of the posterior When assembling suture line is performed with (Grade 0, 57%; Grade I, 38%, leaflet is a surgical alternative to intraoperatively, we reach a 5/0 Prolene™ or equivalent Grade II, 5%). Only one patient the isolated annuloplasty. maximum attainable length of (Figure 2). The patch should not needed a valve replacement due The enlargement/ approximately 5 cm by means reduce the circumference of the to a recurrence of a significant augmentation of the posterior of a diagonal cutting (Figure 1). posterior annulus. The height MI. We will publish the five-year MV-leaflet leads to an elevation The height of the patch varies of the anterior leaflet serves as follow-up data soon.

Congenital | Focus | Grown-up congenital heart 1 Grown-up congenital heart = a new specialty

Laurence Iserin Adult cardiac congenital Around two thirds of them have complex to in some patients (up to 40% of the patients with Unit, Hopital Europeen Georges Pompidou, moderately severe defects, who need dedicated operated tetralogy of Fallot will need pulmonary Paris, France follow up. valve replacement before the age of 40). The most common defects seen in adult Reoperations represent technical challenges ongenital heart defects (CHD) patients are atrial septal defects, aortic stenosis, in multi-operated patients who carry specific are the most common congenital coarctation of the aorta, pulmonary stenosis, comorbidities (such as chronic cyanosis, malformations. Surgical corrections Ebstein anomaly, tetralogy of Fallot, and pulmonary hypertension, genetic syndromes, of these defects were performed for corrected transposition. Other common defects renal and hepatic failure), and in 20% adding Cmore than 50 years. Forty years ago, the mortality seen in adults are double-outlet right ventricle, to their defect-acquired heart disease such as (natural history) of these defects was extremely postoperative atrioventricular canal, subaortic coronary artery disease. Nevertheless, with high, especially for complex defects. Nowadays, stenosis, abnormal mitral valve, primum atrial dedicated teams (including congenital cardiac survival to adulthood has dramatically improved septal defect, and single ventricle. surgeons), results of these operations are because of improved foetal diagnoses, advances Th medical community has not fully anticipated acceptable (around 2% early mortality). in neonatal intensive care, improved surgical and the need for specialised care units dedicated In very complex diseases, the choice between interventional techniques, early complete surgical to these patients. Nevertheless, international catheters and specialised cardiac surgeons. heart transplantation and a new operation is repair, lower perioperative mortality, and increased guidelines have driven attention to this Non-cardiologists – such as hepatologists, always very challenging, while the number of mid-term and late survival. More than 85% of population, and they also emphasise the need obstetricians and geneticists – should also be adults with CHD requiring heart transplant is infants with CHD are now expected to reach to set up transition programmes from paediatric accustomed to these rare patients. gradually increasing. adulthood. In the world, there are now more adults to adult care. This population needs a lot of The main reasons for admission – about 10% There is a need for dedicated units and with CHD than children. different sub-specialists in order to understand of the population each year – are heart failure, specialised nurses, physicians and surgeons to The population of adult CHD patients is growing and manage complex arrhythmias, specialised arrhythmias, interventional catheterisations and offer comparable management to that which these at a rate of 5% per year (1.3 million in the US). imaging such as MRI, specialised cardiac endocarditis. Surgical procedures will be needed patients received in infancy.

EACTS Academy EACTS Academy: Fundamentals of Aortic Valve Repair n the past two decades, aortic minimal experience, but wishes to frequent scenarios – to emphasise valve preserving surgery and enter this field. The Department of important aspects. isolated aortic valve repair have Thoracic and Cardiovascular Surgery In order to enhance interaction, become an increasingly accepted in Homburg/Saar, Germany under the group will be kept small, with Ialternative to valve replacement. It has Professor Hans-Joachim Schäfers attendance limited to 20 participants. become clear that valve preserving has been actively involved in the Ample time is provided for questions aortic root replacement must be development and refinement of repair and discussion, and the organisers performed in such a way that aortic strategies over the past 20 years. They will make an effort to ensure valve form is normalised, making it – in have also been active in teaching these every participant feels welcome essence – aortic repair. principles and techniques for more and integrated. In recent years, objective information than 10 years. In cooperation with the The course is designed in such a way on normal aortic valve form has become EACTS and renowned EACTS faculty that it will provide the basic information available, facilitating the selection they now offer this course for beginners necessary to help participating of adequate substrates for repair or in aortic valve repair. surgeons actively start aortic repair valve preservation. It also provides Through lectures, the basic procedures themselves. intraoperative guidance to the surgeon knowledge necessary for understanding who can follow geometric principles the principles of aortic valve repair will The Fundamentals of Aortic Valve Repair rather than simple intuition. Thus, aortic be presented. Explorations of technique Academy course will be held on November valve repair is in transition from “surgical achieved, however, the surgeon should “Fundamentals in Aortic Valve Repair”, and surgical decision making will be 16-17, 2017 at Saarland University Medical art” to a reproducible operation, and familiarise himself with the principles of as part of the EACTS Academy highlighted by surgical videos, and Center, Homburg Saar, Germany. an increasing number of surgeons are aortic repair and the established and calendar, serves the purpose of there will be several live operations For further information, head to http:// performing such procedures. proven tools that he can apply. introducing these principles to the with repair procedures for different www.eacts.org/educational-events/ If predictable results are to be The upcoming workshop surgeon who has had no or only pathologies – focusing on the more programme/favr/ 8 Issue 1 Saturday 7 October 2017 EACTS Daily News

Inside vienna Where to go? What to do? SIGMUND FREUD MUSEUM MUSEUMS Founded in 1971, this homage to the late, great pioneer of psychoanalysis is the very same MAK building in which he lived for over 40 years. The Museum fuer angewandte Kunst, or simply MAK as it’s better known, claims to be “virtually unparalleled” in its combination of historical and contemporary exhibits. COFFEE, CAKES AND MORE… DEMEL Some say it’s the ‘Holy Grail’ for cakes and patisserie, others just enjoy the 230+ years of experience that make this Royally-appointed pastry shop a never-miss. TRY: Sachertorte – This synonymous Viennese chocolate cake is credited to Demel back in the 1800s. That is, unless you are on the side of Hotel Sacher, who engaged in a protracted legal battle regarding the cake’s origin. VIENNA SAUSAGE Würstelstands – little huts selling ART HISTORY / NATURAL HISTORY traditional wurst (sausage) – are a real gem MUSEUMS of Vienna. Bitzinger at the Albertina Facing each other across the Maria-Theresien- (www.bitzinger-wien.at) is one of the best. Platz, the outsides of the Kunsthistorisches Museum and Naturhistorisches Museum COFFEEHOUSES are both sights to behold in their own right. Coffee in a Wiener Kaffeehaus is a must. It has However, do venture in and enjoy a range of been said that the Viennese coffeehouse is exhibits, as well as the late 19th century ornate “where time and space are consumed, but decorations that adorn the interior of the only the coffee is found on the bill”. buildings themselves. There are oodles to choose from, but Café Prückel, along Ringstasse, gets FUNERAL MUSEUM the kind of “secret mention” that can Some might find it morbid, but if you’re in only pass from person to person. Bring the mood, the Bestattungsmuseum serves up cash, not card – and an open mind – a fascinating exploration of funeral customs, and sit among students, locals and the burials and a quintessentially Viennese occasional piano recital. perspective on death.

Kunsthistorisches Museum

10 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Techno College | Imaging and 3D techniques Function driven revascularisation

Filip P Casselman1, blood flow in a stenotic patients undergoing CABG using an Johan Vander artery expressed as a angiography-guided or FFR-guided Merwe1, Frank Van percentage of the normal revascularisation strategy. The study Praet1, Emmanuele maximal flow (in case no flowchart is depicted in Figure 1. Patient Barbato2 OLV Clinic Aalst, stenosis would be present enrolment has been concluded, and Belgium: 1. Department of in that vessel)3. one-year follow-up is almost completed. Cardiovasular and Thoracic Above 0.8, there is We are currently still awaiting the results Surgery; 2. Department of no functional limitation of this trial. This study is an important Cardiology of flow, and below 0.75 one since the results will give us some there is an almost 100% insights into whether we should change rom the starting days of certainty of reversible myocardial our decision-making process for CABG coronary artery bypass surgery ischaemia. The grey zone is situated – in favour of a functional analysis and till today, the decision-making between 0.75 and 0.8.3 Subsequent decision-making process rather than the of whether or not to bypass studies have demonstrated a poor angiography-based strategy that has Fa certain coronary artery has been correlation between angiographic and proven its value for years. based on a visual appreciation of the functional evaluation of stenoses in stenosis severity. This is a subjective multivessel disease.4 References interpretation, and we all have The FAME 1 study evaluated 1. Berger A, Mac Carthy PA, Siebert U, Carlier S, Wijns experienced the differences in stenosis the interventional catheter-based W, Heyndrickx G, et al. Long-term patency of internal estimation between persons, especially treatment of coronary artery stenoses mammary artery bypass grafts: relationship with preoperative severity of the native coronary artery in the intermediate range. Whether a in a randomised fashion between stenosis. Circulation 2004;110:II36-II40. certain stenosis really limits the blood angiographic-based decision making 2. Manninen HI, Jaakkola P, Suhonen M, Rehnberg S, flow through a vessel (in other words and FFR-based decision making. Vuorenniemi R, Matsi PJ. Angiographic predictors of graft patency and disease progression after coronary ‘whether a stenosis is functionally The outcomes were in favour of artery bypass grafting with arterial and venous grafts. important’) is impossible to accurately an FFR-based strategy with better Ann Thorac Surg 1998;66:1289-94. determine with this visual estimation. survival, lower MACE rate, fewer 3. Pijls JH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek J et al. Measurement This is however important information lesions treated, lower need for repeat Figure 1. The decision-making process in the GRAFFITI trial. of fractional flow reserve to assess the functional as an non-significant stenosis may revascularisation, lower use of contrast severity of coronary artery stenoses. N Eng J Med cause competition of flow through the product, fewer stents placed and lower and CABG. strategy: there was no excess in clinical 1996;334:1703-8. native coronary artery with a potential procedural costs.5 Overall, the PCI literature is endpoints in the FFR group at 36 4. Tonino PA, Fearon WF, De Bruyne B, Oldroyd KG, Leesar MA, Ver Lee PN et al. Angiographic versus bypass of this stenosis, and hence The FAME 2 trial investigated the convincingly in favour of a functional months (similar overall survival, similar functional severity of coronary artery stenoses cause subsequent bypass occlusion.1 combination of PCI (for lesions with an oriented approach towards coronary MACE-free survival, similar repeat target in the FAME study fractional flow reserve versus In addition, coronary artery disease FFR < 0.8) and optimal medical therapy intervention versus an angiographical vessel revascularisation rate and similar angiography in multivessel evaluation. J Am Coll Cardiol 2010;55:2816-21. progression has been demonstrated to for lesions with an FFR > 0.8 with approach. However, whether this myocardial infarction free survival). Yet 5. Tonino PA, De Bruene B, Pijls NH, Siebert V, Ikeno be accelerated in bypassed coronary optimal therapy alone. The combination approach is also applicable for patients in the FFR group received a F, Bornschein B et al. Fractional flow reserve versus artery vessels versus non-bypassed of PCI and optimal therapy resulted surgical intervention remains a matter lower number of grafts, had a better angiography for guiding percutaneous coronary vessels and this happens irrespective in a 44 % reduction in relative risk of of investigation. functional class at follow-up and a intervention. N Eng J Med 2009;360:213-24. 6. De Bruyne B, Fearon WF, Pijls NH, Barbato E, Tonino of the type of bypass (artery versus hard end points such as death and Toth et al. have retrospectively higher graft patency rate. P, Piroth Z et al. FAME 2 trial investigators. Fractional 2 6 vein) . Therefore, it is important to avoid myocardial infarction. Currently, the investigated CABG patients who The GRAFFITI trial (graft patency after flow reserve-guided PCI for stable coronary artery unnecessary bypass grafting. FAME 3 trial is randomising FFR-guided were either screened angiographically FFR-guided versus angiography-guided disease. N Eng J Med 2014;371:1208-17. Fractional flow reserve is a functional PCI versus angiography-guided CABG or functionally before CABG.7 Both CABG trial) is a prospective, randomised 7. Toth G, De Bruyne B, Casselman F, De Vroey F, Pyxaras S, Di Serafino L et al. Fractional flow reserve- evaluation of a stenosis severity and in patients with double or triple vessel groups were relatively comparable, and clinical trial currently investigating guided versus angiography-guided coronary artery is defined as the maximal myocardial disease and equipoise between PCI findings were in favour of an FFR-based the outcome and patency rates in bypass surgery. Circulation 2013;128:1405-11.

EBCTS European Board of Cardiothoracic Surgery (EBCTS) Examination

Tim Graham clinical judgement of a surgeon quality assured examinations in on behalf of EBCTS to the standard expected at the the three principle sub specialties end of training in the generality in cardiothoracic surgery. he EACTS council of cardiothoracic surgery. This The Level 1 examination is have approved the examination is a written MCQ led by Eduard Quintana and a new format for the examination of two papers Level 1 writing group of over European Board of of two hours duration. The 20 young European surgeons CardiothoracicT Surgery (EBCTS) first will be held at the EACTS have prepared a MCQ bank – examination, commencing Vienna meeting on Tuesday all these questions have been during this year’s Annual Meeting 10th October. standard set by a panel of in Vienna. The Level 1 examination experienced examiners for the The aspiration of the EBCTS must be successfully completed Vienna examination. is to develop a fit for purpose before continuing to the Level The Level 2 examination is high stakes professional exam 2 examination (Fellowship being led by Stephen Clark, and for patients, the profession and of EBCTS) which tests the sub specialty leads are being governance bodies. This will be knowledge, clinical judgement identified. Oral/viva clinical- a quality assured cross-border and application of the principles scenario based questions are European exam. The goal is to and practice of an independently being written for a question have an examination which is practicing surgeon in one or bank which will be standard set. at least the equivalent of the more of the three areas of EBCTS has recently engaged American Boards examinations established specialist practice Ripley systems to provide an across the breadth of the as above depending on the examination software system specialty, and also in the sub candidate’s preference. to assist with Question Banks, specialty areas of acquired This examination will be a examinations, marking and cardiac; congenital cardiac series of scenario based oral/ results administration. and thoracic surgery. The viva examinations and is due to The EBCTS website (www. European Union of Medical commence around the time of ebcts.org) has recently been Specialists (UEMS) and EACTS the EACTS Annual Meeting in revised and information can be have jointly agreed to the October 2018. obtained there regarding the governance and delivery of this The syllabus for the 2017 syllabus, standards, eligibility, European examination under EBCTS examination(s) and application processes, examiners the auspices of the EBCTS. A beyond has been completely and the Board. representative of STS/ABTS, rewritten by an international Dr David Fullerton, sits on the group with educationalist If members of EACTS are EBCTS Board. input, and is available via the interested in participating in The examination is now split EBCTS website. The syllabus MEBCTS examination assesses assesses Level 1 outcomes sub-specialty areas of the EBCTS activities please contact into two parts: The Level 1 clearly describes the purpose Level 1 outcomes across the across the entire syllabus in syllabus according to candidate Amanda Cameron, Eduard examination (Membership of and standards of the Level 1 entire syllabus and the more addition to Level 2 outcomes preference. For the first time in Quintana or Stephen Clark EBCTS) tests the knowledge and and Level 2 examinations. The advanced FEBCTS examination within general and specific Europe, there are professional at [email protected] EACTS Daily News Issue 1 Saturday 7 October 2017 11

Perceval: 10 Years of Clinical Use

fforts to develop FIM trial said Perceval we can offer to patients.” performance, which means are strongly correlated a sutureless heart has kept its promises and According to Bart low transvalvular pressure with good hemodynamic Evalve date back to delivered excellent results. Meuris, Professor, gradients and very good performance.” the early 1960’s. However, Axel Haverich, M.D., Cardiac Surgery, clinical outcomes”, said Over the past ten years, the introduction of the M.D., Professor of University Hospitals, Mattia Glauber, MD, a the self-expandable Perceval Aortic Pericardial Medicine and Surgery at Leuven, Belgium, two key surgeon with the Istituto Perceval aortic valve Heart Valve ten years ago Medizinsche Hochshule advantages of Perceval Clinico Sant’Ambrogio, bioprosthesis has and the completion of the Hannover (MHH) said: compared to traditional Milan, Italy, “Any new transformed the surgical valve’s first-in-man (FIM) “To have a stented valve valves are speed of biological prosthesis that valve landscape. With the trial in 2008 completely without suturing was implantation and the comes on the market broadest clinical history transformed the surgical a revolution in terms minimal manipulation needs to reach this type of any sutureless valve, replacement of aortic of cardiac surgery needed to position the of milestone. It needs to it has overachieved in valves. Cardiac surgeons at the time. Perceval valve inside the aortic root. demonstrate freedom from performance, establishing who participated in the has broadened the “Perceval has met reoperation and freedom itself globally as a highly foundational Perceval armamentarium of what its promise of good from degeneration, which trusted platform. 12 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Techno College | Imaging and 3D techniques Live Case: MICS-CABG with a Y-graft

LITA-RITA Y-Anastomoses

Figure 1. The incision: more lateral Figure 2a. Retractor for ITA harvest elevates the upper rib-cage Figure 2b. Subxyphoid hook to Figure 3. A completed Y-Anastomosis within the thorax than a MIDCAB incision additionally elevate the lower end stabilised on the glove-clad pods of the stabiliser of sternum during right ITA harvest

Piroze M Davierwala first described by Calafiore et al, when he reported the left ITA to multi-vessel grafting with a composite Y-graft through a left small Department of Cardiac Surgery, Leipzig Heart Center, University left anterior descending artery (LAD) through a left anterior small thoracotomy is a particularly challenging operation, which requires of Leipzig, Leipzig, Germany thoracotomy2. This procedure, which popularly came to be known appropriate patient selection, planning, skill, patience, concentration as MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) was and precision. The live case would involve tips and tricks that oronary artery bypass graft surgery (CABG) performed chiefly used in patients with isolated LAD disease to graft LIMA to the could be used to simplify various steps of the operation so that with the use of cardiopulmonary bypass (CPB) through LAD. For many years multi-vessel bypass grafting was still performed a larger number of cardiac surgeons can adopt this technique in a median sternotomy has been considered the “gold through a sternotomy, because of the ease with which all the coronary their daily practice. It would particularly stress on patient selection, standard” of treatment of patients with coronary artery vessels could be accessed through this approach and the lack of the incision site (Figure 1), harvest of the left and right ITAs through Cdisease for more than half a century. However, in a minority of instrumentation to do so through a lateral thoracotomy. Nevertheless, a left thoracotomy (Figures 2a and b), the performance of the patients CPB has been known to be associated with development development of specialised retractors to simplify the harvest of the Y-anastomosis (Figure 3) at the level of the pulmonary artery and the of bleeding complications, stroke, acute renal insufficiency, and ITAs and improvisation of heart stabilisers and positioners made safe distal anastomoses, which could involve a sequential anastomosis. occasionally severe systemic inflammatory reaction, whereas and efficacious multi-vessel coronary artery grafting through a small sternotomy results in loss of sternal integrity, which subjects patients thoracotomy incision possible3,4. Enough real-world practice data References to a potential risk of non-healing, superficial and deep sternal wound exists in literature, which demonstrates that bilateral ITAs provide 1. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z, et al. Five-year outcomes after offpump or on-pump coronary-artery bypass grafting. New Eng J Med 2016;375:2359– infections, especially with the use of bilateral internal thoracic arteries survival benefit as compared to a single ITA. However, the use of 2368. (ITA) and a delayed return to full physical activity and work. Therefore, bilateral ITAs is associated with an increased risk of sternal wound 2. Calafiore AM, Angelini GD. Left anterior small thoracotomy (LAST) for coronary artery reducing the invasiveness of CABG involved addressing not only the complications. Additionally, aortic manipulation during on- or off-pump revascularisation. Lancet 1996;347:263–264. 3. McGinn JT Jr, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M. Minimally invasive 5 avoidance of CPB, but also doing away with sternotomy. CABG is associated with an increased risk of perioperative stroke , coronary artery bypass grafting: dual-center experience in 450 consecutive patients. Off-pump CABG (without CPB) was developed to prevent or which can be reduced if not eliminated with avoidance of aortic Circulation. 2009;120:S78-84. 4. Ruel M, Shariff MA, Lapierre H, Goyal N, Dennie C, Sadel SM, et al. Results of the Minimally reduce the adverse effects of CPB and has been recently shown by manipulation. Therefore, minimally invasive coronary surgery (MICS- Invasive Coronary Artery Bypass Grafting Angiographic Patency Study. J Thorac Cardiovasc the multicentre, prospectively randomised CABG Off or On Pump CABG) with bilateral ITAs using a Y-configuration, thus avoiding aortic Surg. 2014;147:203-8. 5. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous Revascularization Study to have similar survival and freedom from manipulation would provide the best possible state-of-the-art surgical coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. repeat revascularisation to on-pump CABG at mid-term follow-up1. revascularisation strategy for at least a select group of patients. New Eng J Med 2009; 360:961–972. The initial step towards a non-sternotomy approach for CABG was The harvest of bilateral ITAs without the use of an endoscope and

Cardiac | Abstract | Coronary artery bypass grafting - Intraoperative graft flow assessment A novel classification of intraoperative fluorescence imaging for on-site assessment of coronary bypass graft patency

Table 1. Anastomosis location and graft type (n) classified 5 (0.9%) in the I group, 481 (83.9%) in the G group, 23 RITA LITA GEA SVG (4.0%) in the S group, 39 (6.8%) LAD 132 29 1 1 in the CA group, 15 (2.6%) in the CR group, and 10 (1.7%) in the Diagonal 6 68 0 12 CC group. All anastomoses in Circumflex 3 110 27 25 the I group were intraoperatively reanastomosed. Postoperative RCA 7 0 128 24 early occlusion occurred in 2 anastomoses (0.4%) in the G Total 148 207 156 62 group, 4 (17.4%) in the S group, RITA: right internal thoracic artery; LITA: left internal thoracic artery; GEA: gastroepiploic artery; SVG: none in the CA group, 1 (6.7%) in saphenous vein graft; LAD: left anterior descending artery; RCA: right coronary artery. the CR group, and 3 (30%) in the CC group. Table 2. Relationship between each classification and early graft occlusion Discussion Group No of No. of HR 95% CI anastomoses occlusions In this study, we classified the intraoperative patterns of graft AG I 5 – using IFI in CABG into six groups. G 481 2 (0.4%) 1 We investigated the relationship S 23 4 (17.3%) 37.15 7.12–193.62 between early graft patency and Shinya Terada, Tohru Asai, Reo Methods CA 39 0 0 0 patterns of graft AG. Few early Sakakura, Takeshi Kinoshita A total of 573 distal anastomoses in graft occlusions in the G and CA CR 15 1 (6.6%) 16.1 1.54–167.94 and Tomoaki Suzuki Division 167 patients received IFI analysis, groups were confirmed, while of Cardiovascular Surgery, Shiga intraoperative transit-time flowmetry, CC 10 3 (30.0%) 55.73 10.15–305.76 the numbers in the S and CC University of Medical Science, Otsu, and predischarge X-ray angiography Total 573 10 (1.7%) groups were significantly high. The Japan between January 2012 and December HR: hazard ratio; CL: confidence limit. importance of this classification lies 2016. Six groups were classified as in its indicating the relationship with Objectives follows. (1) Invisible group (I): the graft postoperative early graft patency. The purpose of this study is to define was not visualised. (2) Good flow group group (CA): graft flow was superior to angiographic visualisation as coronary- intraoperative fluorescence imaging (IFI) (G): <10 s was required for a graft to coronary artery flow. (5) Retrograde coronary bypass. Conclusions patterns and devise evaluation criteria, appear uniformly. (3). Slow flow group group (CR): coronary artery flow was Our novel classification of IFI offers the and to research the impact on early (S): >10 s duration required for a graft superior to graft flow. (6) Coronary- Results possibility of improving graft patency graft patency. to be visualised uniformly. (4) Antegrade coronary (CC) group: cases with Among 573 anastomoses, we after CABG. EACTS Daily News Issue 1 Saturday 7 October 2017 13

Cardiac | Focus | News from the trials world SurTAVI: the final word in intermediate risk?

Michael J Reardon Houston the cases were done with a transfemoral of life and six-minute walk. Methodist DeBakey Heart & Vascular approach. The primary endpoint was all TAVI is now well accepted in the Center, TX, USA cause mortality or disabling stroke at two intermediate risk population in Europe years. A Bayesian statistical approach and the US for those anatomically ranscatheter aortic valve was used which allowed an early valid appropriate. With the strong data implantation (TAVI) has determination of this endpoint. A two-year provided by the SURTAVI trial this will be enjoyed rapid adoption and primary endpoint was reached in 12.6% the last intermediate risk trial randomised growth for the treatment of the TAVI patients and 14% of the against surgery. Future intermediate ofT symptomatic severe aortic stenosis surgery group. This yielded a Bayesian risk trials will randomize newer TAVI in patients with an increased risk posterior probability of > 0.999 showing a valves against accepted valves in the for surgery. This initially began with very strong non-inferiority. The other two- intermediate risk population. With the patients who were either not surgical year endpoint of interest is the all-cause accepted value of randomized trials, candidates1,2 or considered at high mortality of 11.4% vs 11.6% for TAVI vs SURTAVI will indeed be the last word. surgical risk3,4, defined as a potential surgery. This occurred despite the fact operative mortality of 10% or greater. that the 30-day surgical mortality was References Randomised, well-adjudicated trials in 1.7% with an STS PROM of 4.5% yielding 1. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in the high-risk population showed TAVI to an O:E of 0.38. This is the best surgery patients who cannot undergo surgery. N Engl J Med. be non-inferior3 or superior4 to surgery. survival seen in any of the randomised 2010;363(17):1597-1607. Randomised, well-adjudicated trials trials and is unlikely to matched or beaten 2. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self- have also been done in the intermediate in the future. The 30-day outcomes of expanding bioprosthesis in patients with severe aortic risk population, defined as an estimated interest were superior outcomes in TAVI stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014;63(19):1972-1981. surgical mortality of 3% to 10%. for all stroke, transfusions, cardiogenic 3. Smith CR, Leon MB, Mack MJ, et al. Transcatheter The first intermediate risk trial to be shock, acute kidney injury and atrial versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187-2198. completed and reported was PARTNER fibrillation. Surgery had less major vascular 4. Adams DH, Popma JJ, Reardon MJ, et al. IIA which showed TAVI to be non-inferior injury, pacemaker and paravalvular leak. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. to surgery for the primary endpoint of Haemodynamic flow parameters were 2014;370(19):1790-1798. all-cause mortality or disabling stroke at the subject of this manuscript.6 794 underwent surgery. This was mainly superior to surgery at all time points 5. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk two years (TAVI 19.3% vs. Surgery 21%, SURTAVI randomised 1,746 patients a first-generation device trial with 84% with TAVI showing EOA of over two, Patients. N Engl J Med. 2016;374(17):1609-1620. P = 0.253)5. The second randomised from June of 2012 to June 2016 in a receiving the first generation Corevalve and mean gradients in the single digits. 6. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or Transcatheter Aortic-Valve Replacement intermediate risk trial to finish and be 1:1 fashion between TAVI and surgery. and 14% the second generation Evolut Other secondary endpoints at 30 days in Intermediate-Risk Patients. N Engl J Med. reported was the SURTAVI trial and is Ultimately, 863 patients had TAVI and valve. Interesting is the fact that 94% of showed superior improvement in quality 2017;376(14):1321-1331.

Cardiac | Abstract | Structural valve deterioration in aortic valve Can bioprosthetic valve thrombosis be promoted by aortic root morphology? An in vitro study

Silje Ekroll Jahren1, Paul along the sinus wall towards the Philipp Heinisch2, David sinotubular junction. No vortex Hasler1, Bernhard Michael structure was observed in the Winkler2, Stefan Stortecky3, patient-specific phantom. In Thomas Pilgrim3, Martina both phantoms, CA transport Correa Londono4, Thierry toward the sinus was driven Carrel2, Hendrik von Tengg- by a retrograde flow along Kobligk4, Dominik Obrist1 the ascending aortic wall. CA 1. ARTORG Center for Biomedical arrives at the aortic sinus of Engineering Research, University the two phantoms at different of Bern, Bern, Switzerland; 2. time points during systole Department of Cardiovascular (0.09 s and 0.16 s after valve Surgery, University Hospital Bern, opening in the symmetric Bern, Switzerland; 3. Department and the patient-specific of Cardiology, University Hospital phantom, respectively; Figure Bern, Bern, Switzerland; 4. 2). This delayed CA arrival University Institute of Diagnostic, was also observed in the two Interventional and Paediatric TAVI patients. Radiology, University Hospital The different arrival times of Bern, Bern, Switzerland CA (later in the patient-specific root) and the different flow Figure 1. Overview of the in vitro flow loop. Panel (A) shows the 3D-printed negative model of the patterns in the sinus portion ioprosthetic valve A sutureless bioprosthetic two aortic root phantoms, and panel (B) shows the aortic root phantoms. (vortex in the symmetric aortic thrombosis (BPVT) 21 mm aortic valve (Edwards root; no vortex in the patient- has been considered INTUITY Elite, Edwards specific aortic root) indicates uncommon, but Lifesciences, USA) was inserted that the wash-out of the sinus Brecent studies have shown that in both phantoms. The flow in portion does not only depend on BPVT is a much more frequent the aortic root was visualised the bioprosthetic valve design event than previously thought. by continuously injecting red and its positioning in the aortic Regions with low blood flow dye, as contrast-agent (CA), root, but also on the patient’s or stasis, as well as regions directly upstream of the valve. aortic root morphology (Figure with turbulent flow, have been The results were compared 2). Furthermore, the analysis of linked to thrombus formation. with angiographic images angiographies from TAVI patients Insufficient wash-out of the sinus after transcatheter aortic valve indicates that at least some of portions is believed to be a risk implantation (TAVI) showing these in vitro effects are also factor for BPVT.1,2 The objective the contrast-enhanced flow in present in vivo. This suggests of this in vitro experiment was to the aortic root of two patients, that prosthesis selection and investigate the impact of aortic who received a balloon- positioning should also consider root morphology on blood flow expandable transcatheter patient-specific aortic root in the aortic root. Two aortic aortic valve (Edwards Sapien 3, morphology to find the best fit root phantoms with different Edwards Lifesciences). for each patient. Furthermore, morphologies (one symmetric We found that blood flow it is likely that the risk for and one patient-specific) were distal to the aortic valve was BPTV is also affected by aortic fabricated using transparent significantly affected by aortic root morphology. silicone (Figure 1). The 3D root morphology. This had also Figure 2. Normalised concentration of CA (solid line: ascending aorta; dotted line: aortic sinus) dataset of the patient-specific a direct effect on the wash- over normalised time for three consecutive heart beats in one of the sinus portions and in the References aortic root was extracted from an out of the sinus portions: in ascending aorta in the symmetric aortic root phantom (A), and in the patient-specific phantom 1. Puri R, Auffret V, Rodés-Cabau J. the symmetric phantom, we (B). The red arrows indicate the delayed arrival of the CA in the sinus portion compared to in the Bioprosthetic Valve Thrombosis. J Am Coll electrocardiogram synchronised Cardiol. 2017;69(17):2193–211. computed tomography observed a vortex starting from ascending aorta (A and B). The red and green squares (C and D) show the area used to calculate 2. Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R. Prosthetic Heart angiography from a vascular the leaflet tip towards the base the sum of concentration over time for the ascending aorta and the sinus, respectively, for the Valve Thrombosis. J Am Coll Cardiol. healthy patient. of the sinus, and returning two different aortic roots. 2016;68(24):2670–89. 14 Issue 1 Saturday 7 October 2017 EACTS Daily News

Vascular | Abstract | Getting to the root Aortic elongation and the risk of type A aortic dissection

Samuel Heuts1,2, Bouke P. Adriaans2,3,4, Suzanne Gerretsen4, Ehsan Natour1,5, Rein Vos6, Harry J.G.M. Crijns2,3 et al. 1. Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; 2. Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; 3. Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; 4. Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; 5. Department of Thoracic and Cardiovascular Surgery, Uniklinik RWTH Aachen, Aachen, Germany; 6. Department of Methodology and Statistics, Maastricht University, Maastricht, the Netherlands

ndication for prophylactic patients who were referred surgery to prevent acute for contrast-enhanced CT of type A aortic dissection the chest between December (ATAAD) is solely based on 2015 and December 2016. Ian ascending aortic diameter Patients with known conditions of >55 mm in patients without that might cause distortion of elastopathy. Recent literature aortic shape were excluded. A shows 70-90% of ATAAD three-dimensional model of the Figure 1. Length measurements of different aortic segments. A: segmental division of the aorta (yellow: patients fail to meet this thoracic aorta was created and ascending aorta, red: aortic arch, green: descending aorta); B: Three-dimensional length measurement indication criterion. Elongation divided into three anatomical of the ascending aorta; C: Two-dimensional length measurement of the ascending aorta. of the ascending aorta could segments following current potentially act as a predictor guidelines (Figure 1). Age related patients (85.8 ± 9.4 mm vs an insufficient stand- for ATAAD as well. Ascending elongation was studied in the 65.6 ± 8.2 mm respectively, p < alone predictor for the aortic length seems to be age- healthy control group alone. 0.001) and increased by a mean occurrence of ATAAD. associated, but is poorly studied. Ascending aortic, aortic arch and of 3 mm/decade (Figure 2). The We found a significant Therefore, we investigated descending aortic length was lengths of the aortic arch (35.9 relation between age and the normal aortic length in a compared between the ATAAD ± 10.4 mm vs 33.0 ± 6.1 mm, ascending aortic length healthy control group after group and the healthy control p = 0.18) and descending aorta and we demonstrated which we compared this with group using a propensity score (210.3 ± 28.4 mm vs. 212.3 ± that the ascending ATAAD patients to evaluate the matching analysis in order to to be significantly correlated with 36.6 mm, p = 0.81) did not differ aorta of ATAAD patients potential role of elongation in the create statistically equal groups. ascending aortic length (R=0.50, between the two groups (Table is significantly longer occurrence of ATAAD. Aortic diameters were measured p < 0.001). By use of propensity 1). Seventy percent of ATAAD compared to their The study group consisted in the ATAAD group as well. score matching, 32 statistically patients had a maximal ascending propensity matched of all consecutive adult patients Forty patients were included in equal pairs were created. aortic diameter of <55 mm. counterparts. No who were diagnosed with ATAAD the ATAAD group, and 210 in the Ascending aortic length was To conclude, ascending aortic difference was found based on CT angiography healthy control group. Age proved significantly increased in ATAAD diameter has proven to be between the lengths (CTA) findings between January of the aortic arch and Figure 2. Ascending aortic 2010 and December 2016. All descending aorta, length of ATAAD patients and patients with known elastopathy Table 1. Aortic length per segment. ATAAD: Acute Type A Aortic Dissection implying ATAAD to have a healthy controls. Scatter plot (Marfan’s, Ehlers-Danlos, Control group (n = 32) ATAAD group (n = 32) p-value specific pathophysiological origin depicting the length of the ascending aorta in healthy Loeys-Dietz, Familial TAAD in the ascending aorta. Future Ascending aorta (mm) 65.6 ± 8.2 85.8 ± 9.4 <0.001 controls (orange) and ATAAD and bicuspid aortic valve) were studies need to be conducted Aortic arch (mm) 33.0 ± 6.1 35.9 ± 10.4 0.18 patients (blue). ATAAD: Acute excluded. The control group to confirm elongation as an Type A Aortic Dissection consisted of all consecutive Descending aorta (mm) 212.3 ± 36.6 210.3 ± 28.4 0.81 additional risk factor for ATAAD.

Cardiac | Focus | Perfusion session 1: Heater cooler induced infections Heater-cooler devices and Mycobacterium chimaera infections

P. W. Schreiber Division of Infectious sarcoidosis has often be suspected, which 2. Sax H, Bloemberg G, Hasse B, Sommerstein R, Kohler P, Diseases and Hospital Epidemiology, University prompted unfavourable immunosuppressive Achermann Y et al. Prolonged Outbreak of Mycobacterium chimaera Infection After Open-Chest Heart Surgery. Clinical infectious diseases Hospital Zurich and University of Zurich, treatment. A diagnostic hint can be : an official publication of the Infectious Diseases Society of America Switzerland ophthalmological examination revealing frequently 2015;61:67-75. choroidal lesion.6 Despite aggressive treatment 3. Chand M, Lamagni T, Kranzer K, Hedge J, Moore G, Parks S et al. Insidious risk of severe Mycobacterium chimaera infection in cardiac his presentation will focus on a efforts consisting of combination antibiotic therapy surgery patients. Clinical infectious diseases : an official publication of prominent, recently discovered, and revision surgery, curability remains uncertain.7 the Infectious Diseases Society of America 2016. 4. Sommerstein R, Rüegg C, Kohler P, Bloemberg G, Kuster S, Sax H. infectious problem associated with the Investigation of water samples from HCDs Transmission of Mycobacterium chimaera from Heater–Cooler Units use of heater-cooler-devices. All cardio- manufactured by different brands gathered growth during Cardiac Surgery despite an Ultraclean Air Ventilation System. surgeons,T cardiologists and infectious diseases of M. chimaera.8 Remarkably, only Sorin HCDs Emerging Infectious Disease journal 2016;22. 5. Kohler P, Kuster SP, Bloemberg G, Schulthess B, Frank M, Tanner physicians should be alert to cardiac surgery- were associated with cases of M. chimaera FC et al. Healthcare-associated prosthetic heart valve, aortic associated M. chimaera infections. infection. However, one must be aware that M. vascular graft, and disseminated Mycobacterium chimaera infections subsequent to open heart surgery. Eur Heart J 2015;36:2745-53. The uncommon diagnosis of M. chimaera chimaera infections after cardiac surgery are overall 6. Zweifel SA, Mihic-Probst D, Curcio CA, Barthelmes D, Thielken infection of two patients in 2011 at the University rare and Sorin has the largest market share.9 A, Keller PM et al. Clinical and Histopathologic Ocular Findings in Disseminated Mycobacterium chimaera Infection after Cardiothoracic Hospital Zurich triggered an outbreak investigation. Recent studies addressed the question of Surgery. Ophthalmology 2017;124:178-88. The common element for both affected patients initial contamination of these devices. A report on 7. Schreiber PW, Sax H. Mycobacterium chimaera infections associated with heater-cooler units in cardiac surgery. Current opinion in was prior cardiosurgery and implantation of detection of M. chimaera at the production site infectious diseases 2017;30:388-94. prosthetic material.1 As M. chimaera belongs to favoured the hypothesis of a point-source.10 A 8. van Ingen J, Kohl TA, Kranzer K, Hasse B, Keller PM, Katarzyna Szafranska A et al. Global outbreak of severe Mycobacterium nontuberculous mycobacteria (NTM) and knowing large whole genome sequencing study concurred chimaera disease after cardiac surgery: a molecular epidemiological that NTM prefer water as habitat, water-bearing this hypothesis but, in addition found that HCD study. The Lancet infectious diseases 2017. 9. Sommerstein R, Schreiber PW, Diekema DJ, Edmond MB, Hasse devices were tested for Mycobacteria sp. These contamination can also occur at the local hospital B, Marschall J et al. Mycobacterium chimaera Outbreak Associated investigations identified M. chimaera in water level.8 The risk of local HCD contamination with With Heater-Cooler Devices: Piecing the Puzzle Together. Infect samples of Sorin (Milan, Italy; now LivaNova, NTM was reinforced by outbreaks caused by other Control Hosp Epidemiol 2016:1-6. 10. Haller S, Holler C, Jacobshagen A, Hamouda O, Abu Sin M, Monnet 11 London, UK) 3T heater-cooler devices (HCDs). If Mycobacteria sp such as M. abscessus and DL et al. Contamination during production of heater-cooler units by contaminated HCDs were operating, air samples M. wolinskyi12. Mycobacterium chimaera potential cause for invasive cardiovascular infections: results of an outbreak investigation in Germany, April also grew M. chimaera – this insight resulted in the Today, strict separation of air volumes between 2015 to February 2016. Euro surveillance : bulletin Europeen sur les hypothesis of an airborne transmission from HCD operating rooms (and other critical medical areas) maladies transmissibles = European communicable disease bulletin 2 2016;21. to implants during surgery. Later experiments and the potentially contaminated exhaust air from 11. Baker AW, Lewis SS, Alexander BD, Chen LF, Wallace RJ, Jr., were able to locate aerosol generation within Sorin by a poor prognosis with a case fatality rate of HCDs is the only proven method of prevention. Brown-Elliott BA et al. Two-Phase Hospital-Associated Outbreak HCDs.3 The considerable airflow generated by the approximately 50%. Diagnosis is often delayed due of Mycobacterium abscessus: Investigation and Mitigation. Clinical infectious diseases : an official publication of the Infectious Diseases fan in the lower part of Sorin HCDs proved to be to unspecific symptoms such as fever, dyspnoea References Society of America 2017. able to disrupt the ultraclean air ventilation system and weight loss, and a latency of months to years 1. Achermann Y, Rossle M, Hoffmann M, Deggim V, Kuster S, 12. Nagpal A, Wentink JE, Berbari EF, Aronhalt KC, Wright AJ, Krageschmidt DA et al. A cluster of Mycobacterium wolinskyi surgical in an operating room.4 between surgery and manifest infection.5 Given Zimmermann DR et al. Prosthetic valve endocarditis and bloodstream infection due to Mycobacterium chimaera. J Clin Microbiol site infections at an academic medical center. Infect Control Hosp Sadly, M. chimaera infections are characterised the histological pattern of granuloma formation, 2013;51:1769-73. Epidemiol 2014;35:1169-75. EACTS Daily News Issue 1 Saturday 7 October 2017 15

General | Focus | Research in medicine: the ultimate currency for every academic career? Leveraging social media: Getting the attention you want for your academic work

Mara B Antonoff International General Surgery Journal subsequent citations.4 promotion, recognising that changing Department of Thoracic and Club and the Thoracic Surgery Not only can you use social media paradigms have increased the emphasis Cardiovascular Surgery, UT MD Social Media Network.1 There are a to promote your peer-reviewed on digital platforms and social media, Anderson Cancer Center, Houston, number of helpful strategies to help publications, but it’s also an outstanding suggesting that scholars should make TX, USA. disseminate your paper, after it’s been way to share content from meetings. their impact in these new spaces as published: 1) ask the journal and your This avenue allows sharing of your own well as classical venues.5 Of course, ocial media use continues to this type of progressive cultural change explode globally, with currently requires evolution on the parts of more than 2.8 billion registered institutions, academic promotions users of such networks. This committees, and scholars themselves. Srepresents more than 37% of the In particular, scholars are advised to world’s population, with the highest create digital portfolios detailing their penetration in North America, where activities, how they align with their 66% of the population possesses strategic priorities, and metrics of their active social media accounts. It’s social media work. estimated that more than 80% of these There are enormous benefits to account holders engage in regular use. one’s academic advancement that While social media use has grown can be derived from engagement in worldwide, exploitations of its social media. Once one familiarises him benefits by medical professionals, or herself with some basic strategies and surgeons in particular, has been for participation, it’s possible to get somewhat delayed. Despite initial considerable mileage for traditional work concerns regarding oversharing and nontraditional outreach that are of private health information, already being performed. public image, and unprofessional interactions, skepticism among References surgeons has been dissipating, and 1. Antonoff MB. Thoracic Surgery Social Media Network: with good reason. Leaders in health Bringing Thoracic Surgery Scholarship to Twitter. Ann care social media have broadened Thorac Surg 2015;100(2):383-4. 2. Gallo T. Congratulations! Your article has been our minds regarding the potential accepted. Now what? Media, Social Media, and benefits of social media activity to for original social media content. institution to tag your handle in Tweets research, promoting your colleague’s other outlets for promoting your work. Acad Med our practices, our scholarly activity, about the article; 2) tag the journal’s presentations, connecting with others 2016;91(12):e9. 3. Choo EK, Ranney ML, Chan TM, et al. Twitter as a and the public and patients whom Promoting traditional handle and those of your co-authors, with shared interests, and forming tool for communication and knowledge exchange in we serve. scholarship on social media institution, and subject experts in collaborations. Again, using the academic medicine: a guide for skeptics and novices. In order to receive academic Social media is a great tool to improve your posts; 3) use relevant hashtags appropriate hashtags will increase the Medical Teacher 2015;37:411-16. 4. Eysenbach G. Can Tweets predict citations? Metrics recognition for your work on social visibility of your publications and to to capture a broad audience; and 4) breadth of reach. of social impact based on Twitter and correlation with media, there are essentially two initiate meaningful interdisciplinary include links to the article and visuals traditional metrics of scientific impact. J Med Internet important arms to consider (Figure conversations regarding impactful from the paper.2 Sharing on Twitter Getting academic credit for Res 2011;13(4):e123. 1). Traditional scholarship may be work. There are even online journal has been a proven format for post- social media activities 5. Cabrera D, Vartabedian BS, Spinner RJ, et al. More than Likes and Tweets: Creating Social Media 3 promoted via social media, while it’s clubs and TweetChats dedicated publication peer review, and has In 2016, the Mayo Clinic began using Portfolios for Academic Promotion and Tenure. J also possible to receive academic credit to these endeavors, such as the further served as a reliable predictor of social media scholarship metrics for Grad Med Ed 2017;9(4):421-5. 16 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Abstract | Heart transplantation is still the best long-term option Clinical outcomes of heart transplantation with thirty years follow-up

Figure 1. Actuarial survival of patients undergoing primacy heart Figure 2. Survival without graft coronary artery disease Figure 3. Proportion of severe renal function requiring dialysis or transplantation between 1985 and 1991 renal transplantation

P Lacoste, CH David, B Marie, patients who had undergone heart angiography, was 50.7% (n = 56) at 10 T Sénage, A Mugniot, C Périgaud, transplantation between 1985 and 1991 years, 31% (n = 17) at 20 years, and 7 O AlHabash, M Michel, S Pattier, at a single centre. Operative technique (5.3%) patients required re-transplantation T Leproivre, B Rozec, JN Trochu, and immunosuppressive treatment were (Figure 2). Malignancies developed in 79 JC Roussel Department of Cardiothoracic comparable in all patients. patients (60%), including skin cancers Surgery, University Hospital Nantes, France in 43 (54%), solid tumours in 33 (42%), Results and haematologic malignancies in 17 Objectives The cause of end-stage heart failure (21%). Proportion of severe renal function he study was conducted to determine and the indication for HTx was dilated requiring dialysis or renal transplantation is the long-term outcome of patients cardiomyopathy in 67 patients (45.3%), 13.5% at 10 years, and 35.5% at 20 years who underwent heart transplantation ischaemic cardiomyopathy in 60 (40.5%), (median 13.4 years; Figure 3). 30 years ago, in the cyclosporine era. valve-related disease in 3 (2%), and ThisT improved graft and patient survival, however, other causes in 18 (12.2%). Actuarial Conclusions has led to an increase incidence of serious survival rates were 75% (n = 110), 58% Long-term survival after cardiac adverse effects related to the long-term use of (n = 86), 42% (n = 61), 26% (n = 38) and transplantation remains excellent in immunosuppressants. This retrospective study 11% (n = 16) at 5, 10, 15, 20 and 25 the cyclosporine era. In our series, was undertaken to: years, respectively (Figure 1). The mean a history of smoking is the sole n determine the long-term survival of patients who follow-up period was 14.7 ± 7.7 years for preoperative risk factor of late death. underwent heart transplantation (HTx) at our patients who survived more than three A tritherapy associated with induction institution more than 25 years ago months after transplantation (n = 131). of immunosuppression with cytolytic n describe the incidence of rejection, allograft The major causes of death were antibodies allows optimal control of vasculopathy, malignancy and renal dysfunctions malignancy (31.2%) and cardiac allograft acute rejections. Nevertheless, a high n identify risk factors adversely affecting survival vasculopathy (22%). No death related level of immunosuppression seems to to acute rejection was reported during be associated with a high incidence of Methods the follow-up. The survival without graft neoplastic complications and long-lasting A retrospective analysis was performed in 148 coronary artery disease, detected on renal insufficiencies.

Cardiac | Focus | Will mini aortic valve replacement become the gold standard? Propensity matched comparison between minimally invasive and conventional sternotomy in aortic valve resuspension

Nadejda Monsefi1, Petar and ascending aorta. The minimally Risteski1, Aleksandra Miskovic1, invasive approach was performed in Andreas Zierer2, Anton Moritz1 120 patients. 1. Department of Thoracic- and To compensate for differences in Cardiovascular Surgery, University preoperative patient characteristics, Hospital Frankfurt a.M., Germany; propensity matching was done 2. Department of Thoracic- and between the complete and partial upper Cardiovascular Surgery, Kepler sternotomy group so that 103 patients University Hospital, Linz, Austria of each group could be identified. Patients’ mean age was 57±14 years inimally invasive valve in the minimally invasive group and surgery has become 57±13 years in the complete sternotomy more and more popular group; 23% were female in each group. as patients benefit from In 99 (96%) patients (minimally invasive Mreduced pain and surgical trauma. group), and 42 (41%) patients (complete Faster recovery, wound healing and sternotomy group) a modification of need for packed red blood cells (pRBC) the David technique was performed may also be advantageously affected by by creating a neosinus (p<0.01). There the minimal access approach. was only one in-hospital death (in the In selected cases of aortic valve complete sternotomy group, p = 0.5). insufficiency and aneurysm of the The applied amount of pRBC was ascending aorta, the David technique significantly higher in the complete can be applied. A minimally invasive David procedure and review outcome sternotomy group (3.4±4 vs 1±0.5, approach in aortic valve resuspension between the two groups. Therefore p<0.01). Mean follow up time was 3±2 Figure 1: Approach through partial upper sternotomy showing the aortic valve. procedures like the David technique we report our propensity matched years (minimally invasive group) and 8±4 has also been reported. After earning results of the David procedure and years (complete sternotomy group). more experience with minimally invasive its modifications via partial upper Late mortality was zero in the 95% vs 79% at 10 years (p<0.01). team, the minimally invasive David isolated aortic valve replacement, we ministernotomy up to the left fourth minimally invasive group but 14 The minimally invasive aortic valve procedure is technically feasible. Intra- moved on and performed the David intercostal space vs a complete died during longer follow-up in the reimplantation technique for selected and perioperative application of pRBCs technique via a minimally invasive sternotomy approach. From 1991 complete sternotomy group (p<0.01). patients with ascending aortic is significantly lower in the minimally access through a ministernotomy up to to 2016, we performed the David Freedom from reoperation or aortic aneurysm and aortic valve insufficiency invasive group. However, comparison the left, fourth intercostal space. procedure and its modifications in 327 valve insufficiency ≥ 2° was 95% vs is a durable procedure with low valve- of long-term follow-up data in both The aim of our study was to compare patients with aortic valve insufficiency 93% (minimally invasive vs complete related morbidity and mortality at mid- groups is necessary to evaluate two different ways of approach for the (AI) and aneurysm of the aortic root sternotomy group) at five years and term follow-up. With an experienced valve function. EACTS Daily News Issue 1 Saturday 7 October 2017 17

Cardiac | Abstract | Coronary artery bypass grafting - Intraoperative graft flow assessment Computational fluid dynamic study of sequential coronary artery bypass grafting in the native coronary occlusion model: Distribution of flow and energy efficiency

K. Matsuura1, W Jin2, L Hao2, G Matsumiya1 1. Department of cardiovascular surgery, Chiba University Hospital / Department of Cardiovascular Surgery, Chiba City, Japan; 2. Department of mechanical engineering, graduate school engineering, Chiba University, Chiba, Japan

ecent surgical candidates for coronary artery bypass grafting R(CABG) have more complex coronary lesions, that is, they have higher SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) scores. To achieve total revascularisation for these patients, an optimal anastomosis design that includes sequential bypass grafting is necessary. It is crucial However, only a few studies in to be totally occluded. The The anastomosis length was to maintain optimal flow to literature have compared the diameter of both native and longer and the total energy both the target native artery different types of anastomosis graft vessels were set to be efficiency was higher in end-side and the bypass conduit outflow using CFD models. The 2 mm. The inlet boundary anastomosis. However, the total in sequential anastomosis, to objective of this study was condition was set by a sample energy efficiency plateaued and avoid competition or insufficient to evaluate which types of of the transient time flow ceased to increase after the graft flow. Additionally, to sequential anastomoses render measurement which was anastomosis length become achieve long-term patency, better haemodynamics, flow measured intraoperatively. more than 6 mm. The energy it is also very important to distribution, and lower wall Diamond anastomosis was efficiency at the native outlet avoid intimal hyperplasia or shear stress using CFD models. observed to reduce flow to was lower but that at the bypass anastomosis would be an anastomosis for moderately atherosclerosis progression, Fluid dynamic computations the native outlet and increase outlet was higher in diamond effective option for multiple stenotic vessels because of believed to be induced by high were carried out with ANSYS flow to the bypass outlet; anastomosis. A high oscillatory sequential bypasses because worsened flow to the native wall shear stress (WSS) or CFX (ANSYS Inc., USA) the opposite was observed shear index was observed of the better flow to the outlet. Care should be taken to turbulent flow. Computational software. The incision lengths in parallel anastomosis. Total at the bypass inlet in parallel bypass outlet than with parallel ensure that the fluid dynamic fluid dynamic (CFD) models for parallel and diamond energy efficiency was higher anastomosis and at the native anastomosis. However, flow patterns are optimal and prevent allow the evaluation of these anastomoses were fixed at 2 in diamond anastomosis inlet in diamond anastomosis. competition should be kept future native and bypass vessel values in each anastomosis. mm. Native vessels were set than parallel anastomosis. Diamond sequential in mind while using diamond disease progression.

Cardiac | Focus | Decision making in mitral surgery: trying to fill the gaps in evidence! Surgical management of moderate ischaemic mitral regurgitation at the time of CABG remains controversial

Robert E Michler Department of The Cardiothoracic Surgical Trials Network and analytical approaches; e.g., the CTSN trial trials did not specify pre-operative evaluation of Cardiothoracic & Vascular Surgery, Montefiore (CTSN) conducted a multicentre randomised trial included patients who died as treatment failures in myocardial viability, echocardiographic assessment Medical Center, Albert Einstein College of comparing CABG alone to CABG plus restrictive the primary endpoint analysis, while the other trial of regional and global LV systolic function can Medicine, New York, NY, USA annuloplasty (RA) in 301 patients with moderate used a survivor analysis. Third, persistent IMR in predict the effectiveness of revascularisation in IMR. RA resulted in a significant reduction in the CTSN trial was largely moderate in severity and specific patient populations and may be useful in schaemic mitral regurgitation (IMR) is a mitral regurgitation at one and two years with no never progressed to severe IMR in the RA group. this setting. Cardiac Magnetic Resonance (CMR) consequence of myocardial ischaemia progression to severe MR. There was no difference Fourth, the CTSN trial was rigorous in defining MR imaging with gadolinium hyperenhancement is or infarction induced regional wall motion in left ventricular reverse remodelling (left ventricular and excluding patients with degenerative mitral an appropriate tool when echo or radionuclide abnormalities. Adverse left ventricular end-systolic volume index [LVESVI]), survival, or valve disease. Fifth, the CTSN trial had significantly imaging is equivocal. Iremodelling develops in approximately 50% of major adverse cardiac and cerebrovascular events lower rates of baseline prior MI and thus, Individual treatment decisions require balancing patients after a myocardial infarction and moderate (MACCE) at one and two years. RA was associated possibly less LV scar. Finally, and probably most the risks of adverse perioperative events against regurgitation occurs in upwards of 10% of patients. with a longer hospital stay after surgery, a higher importantly, baseline LV size was significantly larger the predicted benefits of a lower incidence of Mitral regurgitation results from a combination of incidence of post-operative supraventricular in the Fattouch and RIME trials, which may have post-operative IMR. Effective revascularisation, papillary muscle displacement, leaflet tethering, arrhythmias and more neurologic events. Among favoured patients who received a restrictive as reflected in improved regional and global LV reduced closing forces and annular dilatation. survivors and irrespective of treatment arm, annuloplasty, especially if more scar function, plays an important role independent Most patients have multi-vessel coronary artery patients with resolution of IMR had greater reverse was present. of restrictive annuloplasty repair. In certain disease requiring revascularisation, so surgeons remodelling than those who did not. Improvements in global and clinical settings, the anticipated low must consider whether to add a mitral valve repair Two previous randomised trials showed that regional wall motion as well as likelihood of generating significant reverse procedure to coronary artery bypass grafting the addition of a restrictive annuloplasty provided reverse LV remodelling following remodelling should lead to the performance (CABG) in patients with moderate IMR. improvement in LV reverse remodelling, LVEF, CABG alone are indicative of viable of a mitral valve reparative procedure. The appropriate surgical management of NYHA Class, and MR grade, but not survival. myocardium. These findings imply Such circumstances include patients moderate IMR at the time of CABG remains Fattouch and colleagues randomly assigned 102 that many patients enrolled in the with documented scar or basal aneurysm/ controversial. Some experts advocate patients to CABG alone or CABG plus RA. These CTSN trial had IMR on the basis of dyskinesia in the inferior-posterior- revascularisation alone for moderate IMR, authors demonstrated that the addition of RA reversible ischaemia rather than from lateral LV, a large ventricle (LVESVI expecting improvements in regional and global left significantly reduced LVESD ( 8 mm vs 2 mm). The non-viable scar. Therefore, future > 70 ml/m2 and LVEDD > ventricular (LV) function and geometry following Randomized Ischemic Mitral Evaluation (RIME) trial surgical decision-making 50 mm) or poor coronary CABG to lead to a reduction in MR. Others randomly assigned 73 patients to CABG alone or could be enhanced by targets in the circumflex/ support restrictive mitral annuloplasty repair at the CABG plus RA and demonstrated a 28% reduction pre-operatively identifying right coronary distribution. time of CABG to address more directly the IMR, in LVESVI over baseline (baseline mean 78 ml/m2) those patients most Whether a restrictive mitral expecting to prevent further adverse remodelling compared to only a 9% reduction in the CTSN trial likely to have an annuloplasty repair will and decrease the risk of heart failure. Importantly, from baseline (baseline mean 57 ml/m2). improvement in predictably benefit patients the addition of a mitral valve procedure to CABG There are a few comparative points to regional wall motion with baseline inferior- surgery necessitates open-heart exposure and is emphasise. First, the sample sizes differed and global LV posterior-lateral wall associated with longer durations of aortic cross- greatly, with the CTSN trial enrolling over three function following motion abnormalities that clamp and cardiopulmonary bypass that can times the number of patients than the other trials. CABG alone. are considered to be scar increase perioperative risk. Second, the clinical trials had different endpoints Although these remains unknown. 18 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Abstract | LV restoration and hypertrophic cardiomyopathy surgery – Healing the LV Surgical correction of hypertrophic obstructive cardiomyopathy in patients with mid-ventricular obstruction after failed alcohol septal ablation.

Konstantin V. Borisov1, complete AV block occurrence corresponding to the zone of rhythm without block of His right ventricle myectomy for D Lassner2 after surgery.4 delayed enhancement imaging. bundle left branch was noted patients after failed alcohol 1. German-Russian Cardiac We proposed the technique Septal scar was detected in all patients after surgery. septal ablation. Clinic, Moscow, Russia; 2. of HOCM surgical correction by cardiovascular magnetic Ventricular tachycardia was not Institute Cardiac Diagnostics without damage to the heart resonance. The follow-up period registered. None of the patients References and Therapy, Berlin, Germany conduction system in patients was 32 ± 19 months. needed the implantation of 1. Maron BJ, Nishimura RA. Surgical septal with severe hypertrophy In the present study of a pacemaker. myectomy versus alcohol septal ablation. Assessing the status of the controversy in lcohol septal ablation after unsuccessful ASA. Five five HOCM patients with The tissue necrosis after ASA 2014. Circulation. 2014;130(18):1617–24. (ASA) is ineffective symptomatic HOCM patients midventricular obstruction and was extended into the inferior 2. Quintana E, Sabate-Rotes A, Maleszewski JJ, Ommen S, Nishimura RA, Dearani JA, in patients with with obstruction in the left severe hypertrophy after failed portion of the septum at the Schaff HV. Septal myectomy after failed substantial LV ventricular midcavity and severe ASA, there were no early or late midventricular level involving ablation: Does previous pecutaneous hypertrophyA (>25 mm wall septal hypertrophy (mean NYHA deaths after surgery. Patients primarily the right ventricular intervention compromise outcomes of myectomy? J Thorac Cardiovasc Surg thickness), since sufficient septal Class 3.0) underwent surgical showed significant improvements portion.5. Our technique of 2015;150(1):759–67. thinning cannot be reliably procedure at 14.0 ± 7.0 months in clinical status. After surgery HOCM surgical correction 3. Sorajja P, Valeti U, Nishimura RA, Ommen SR, Rihal CS, Gersh BJ et al. Outcome 1 2 achieved. Quintana et al. after failed septal ablation. The all five patients were free of provides the effective elimination of alcohol septal ablation for obstructive observed a strong correlation excision of the hypertrophied symptoms (NYHA class 1.0). of LV intraventicular obstruction hypertrophic cardiomyopathy. Circulation 2008(2);118:131–139. between more advanced area of the interventricular The mean echocardiographic in patients after unsuccessful 4. Nagueh SF, Buergler JM, Quinones MA, degrees of interstitial fibrosis septum (IVS) septum causing intraventricular gradient in ASA. The possibility of precise Spencer WH, Lawrie GM. Outcome of and worsening diastolic function ventricular tachyarrhythmia and midventricular obstruction was LV decreased from 77.8 ± removal of areas of septal surgical myectomy after unsuccessful septal ablation for the treatment of measured by strain at the septal complications rate of 20% with performed from the conal part 8.8 to 10.4 ± 2.1 mmHg. scarring simultaneously, and patients with hypertrophic obstructive level in patients after failed ASA.3 Given the development of of the right ventricle, in the Echocardiographically- avoidance of damages to cardiomyopathy. J Am Coll Cardiol 2007;50:795–798. septal ablation. In addition to left bundle branch block in many middle part of the right side of determined septal thickness the conduction system, are 5. Valeti US, Nishimura RA, Holmes DR, diastolic dysfunction, septal HOCM patients after Morrow the IVS and corresponding to was reduced from 32.8 ± 3.1 important advantages of the Araoz PA, Glockner JF, Breen JF et al. Comparison of surgical sepatal scar from alcohol septal ablation myectomy, patients who develop the area of LV intraventricular to 15.6 ± 2.0 mm, and follow- surgical technique. However, myectomy and alcohol septal ablation may contribute to rhythm right bundle branch block after obstruction. The septal scar up echocardiography showed number of patients is small. with cardiac magnetic resonance imaging in patients with hypertrophic obstructive abnormalities. An earlier Mayo alcohol septal ablation (ASA) area from septal ablation was reduction of atrial size from 46.7 Future studies could further cardiomyopathy. J Am Coll Cardiol 2007; Clinic study also showed a have a higher likelihood of removed simultaneously and ± 1.5 to 42.7 ± 1.3 mm. Sinus clarify the significance of 49: 350–357.

Vascular | Focus | Facing complications during and after emergent surgery for aortic dissection

Ascending aortic central cannulation for acute type A aortic dissection with cerebral malperfusion 1). Full recovery of consciousness at 90 days was achieved in 11 patients (85%). Of six subjects with preoperative hemiplegia, four tended to have improved motor function of MMT ≥4 at 90 days (Figure 2). Postoperative mRS significantly improved from 5.0±0 to 1.7±1.9 (p = 0.005) in follow-up, and independence in ADL (mRS ≤2) was achieved in nine patients (69%). The mean follow-up period was 92±7 months and the cumulative five-year survival rate was 93%. A representative case is showed in Figure 3: a 68-year- S Shimura1, S Odagiri1, H old woman who was in a coma (GCS 7) Furuya2, K Okada1, C Tanaka2, with left hemiplegia on arrival. Total arch K Ozawa1, H Nagase1, A graft replacement was performed three Yamamoto1, G Kishinami1, hours after onset. She fully recovered T Naiki1, M Yamaguchi2, T consciousness and had improvement Ueda2, and Y Cho1 1. Department of hemiplegia postoperatively. Finally, of Cardiovascular Surgery, School she was able to drive a car again at six of Medicine, Tokai University, months after operation. Kanagawa, Japan; 2. Department of Figure 1. GCS scores of patients with preoperative coma. Figure 2. MMT scores of patients with preoperative Ascending aortic central cannulation Cardiovascular Surgery, Tokai University In these patients, the postoperative GCS score improved hemiplegia. POD: Postoperative day. for TAAAD presenting with cerebral Hachioji Hospital, Tokyo, Japan significantly at 30 days. POD: Postoperative day. This figure malperfusion provides a rapid and was made based on the design of a similar figure in Tsukube reliable route of antegrade central et al.1 ype A acute aortic systemic perfusion. dissection (TAAAD) with cerebral malperfusion (CM) deficits due to CM, including seven was assessed using GCS scores and CPB were 331 (192-561) minutes from References has poor outcomes and in a comatose state (Glasgow Coma motor function of the paralytic side in onset, and 34 (30-40) minutes from the 1. Tsukube T, Hayashi T, Kawahira T, Haraguchi resultingT in higher in-hospital mortality Scale (GCS) ≤8) and six with hemiplegia subjects with preoperative hemiplegia start of surgery. Ascending aortic graft T, Matsukawa R, Kozawa S et al. Neurological outcomes after immediate aortic repair for acute type or a longer stay. TAAAD patients with (manual muscle test (MMT) ≤1) at arrival. was evaluated using MMT scores. The replacement was performed in seven A aortic dissection complicated by coma. Circulation comas who undergo immediate aortic The true lumen of the ascending aorta Modified Rankin Scale (mRS) was used patients, and TAR in six. The 30-day 2011;124:S163–7. 2. Inoue Y, Takahashi R, Ueda T, Yozu R. Synchronized repair have improved consciousness was immediately cannulated. Deep to evaluate the degree of independence mortality was 8% (1/13). In patients with epiaortic two-dimensional and color Doppler and neurological function.1 We use hypothermic circulatory arrest was used in activities of daily living (ADL) at the preoperative coma, the postoperative echocardiographic guidance enables routine ascending aortic central cannulation to protect the brain. Consciousness later stage. GCS score improved significantly to ascending aortic cannulation in type A acute aortic dissection. J Thorac Cardiovasc Surg (AAC) as a supportive technique for of patients with preoperative coma The median times to establishment of 14.0±1.8 (p = 0.016) at 30 days (Figure 2011;141:354–60. surgery for TAAAD because AAC promptly provides antegrade blood flow which improves dynamic obstruction in the true lumen due to increased pressure in the false lumen through prompt core cooling.2 This mechanism appears to relieve CM associated with dynamic obstruction in TAAAD, but there is no evidence for this effect. The purpose of this study was to examine the efficacy of AAC for TAAAD presenting with CM. Between April 2009 and May 2017, 173 patients with TAAAD were treated using AAC. The subjects were 13 of Figure 3. Preoperative enhanced CT scan of the thorax (A-C) and a plain CT scan of the brain (D) in a representative case. A. Occluded right common carotid these patients (7.5%; median age 64 artery (arrow). B. Intimal tear in the aortic arch (arrow). C. Compressed true lumen of the ascending aorta (arrow). D. A preoperative brain CT scan showed no years, six males) with neurological ischaemic findings. EACTS Daily News Issue 1 Saturday 7 October 2017 19

Cardiac | Rapid Response | Aortic valve replacement in a nutshell The effect of prosthesis-patient mismatch on perioperative and early outcomes in patients receiving a novel stented bovine pericardial tissue valve

Vivek Rao on behalf of the Trial is a prospective, non-randomised, 10 early deaths (1.2%) and an additional References Perigon Investigators; Division of multicentre, international study of 28 late deaths (>30 days from implant). 1. Leon MB, Smith CR, Mack M, et al. Transcatheter Cardiovascular Surgery, Peter Munk the safety and early clinical and A total of 577 had completed one-year aortic valve implantation for aortic stenosis for Cardiac Centre, Toronto General hemodynamic performance of the of follow-up and were available for patients who cannot undergo surgery. NEJM 2010; 363: 1597-1607 Hospital, Toronto, Ontario, Canada. Avalus valve. The trial was conducted review. There were a range of implanted 2. Reardon MJ, Kleiman NS, Adams DH, et al. at 19 sites in the United States, 13 sites valve sizes from 17-29 mm with a 23 Outcomes in the randomized CoreValve US pivotal espite the advent of in Europe and four sites in Canada. mm valve being the most commonly high risk trial in patients with a Society of Thoracic Surgeons risk score of 7% or less. JAMA Cardiol transcatheter aortic valve Recruitment began in 2014 and the implanted size. 2016; 1: 945-949 technology, surgical aortic trial is designed to provide five years Using a previously defined cut- 3. David TE, Armstrong S, Maganti M. Hancock II valve replacement remains of postoperative follow-up on all point of 0.75 cm/m2 as evidence of bioprosthesis for aortic valve replacement: the gold Da cornerstone for the management of surviving patients. prosthesis-patient mismatch,7,8 PPM standard of bioprosthetic valve durability? Ann Thor Surg 2010; 90: 775-781 patients with congenital and acquired The goal of this study was to remained quite prevalent across all 4. Colli A, Marchetto G, Salizonni S, et al. The TRIBECA valve disease.1,2 examine the prevalence of prosthesis- valve sizes at one year (44%) with an study: (TRI)fecta (B)ioprosthesis (E)valuation versus Commonly implanted tissue valves patient mismatch (PPM) and its impact increased prevalence in the smaller (C)arpentier Magna Ease in the (A)ortic position. Eur J include the Medtronic Hancock on clinical outcomes with this next sized valves (87% in sized 19 mm Cardiothorac Surg 2016:49: 478-85 5. Klautz RJM, Kappetein AP, Lange R, et al. Safety, 7,8 II porcine valve (Medtronic Inc; generation pericardial valve. We valves). While PPM continues to be effectiveness and haemodynamic performance Minneapolis, MN), the TriFecta (St. Jude goal of combining early haemodynamic compared haemodynamic performance prevalent in this series of patients of a new stented aortic valve bioprosthesis. Eur J Medical; St. Paul, MN) and the Edwards performance with long-term durability.5 with echocardiographic assessments at receiving a novel pericardial tissue Cardiothorac Surg; 2017: In press (epub ahead of print) Magna (Edwards LifeSciences; Irvine, The Avalus is a trileaflet, stented, low- discharge and at one-year. Parameters aortic valve, there was a minimal effect 6. Sabik J, Rao V, Lange R, et al. One year outcomes associated with a novel bovine pericardial stented 3,4 CA) pericardial valves. Arguably, the profile bovine pericardial valve with a measured included effective orifice on mean transvalvular gradients and aortic bioprosthesis: Perigon pivotal trial. J Thorac Hancock II porcine valve has proven flexible sewing cuff, a polyester-covered, area (EOA), EOA index (EOAI), peak most patients reported resolution of Cardiovasc Surg 2017; In press. to have superior durability while the barium sulfate-impregnated base frame, pressure gradient, mean pressure symptoms, even in those patients with 7. Rahimtoola SH. The problem of valve prosthesis- TriFecta valve has demonstrated and alpha amino oleic acid (AOA)- gradient, valvular regurgitation and PPM. This novel pericardial tissue valve patient mismatch. Circulation 1978; 58: 20-24 8. Rao V, Jamieson WRE, Ivanov J, Armstrong S, David superior early haemodynamics.3,4 The treated, laser-cut leaflets. paravalvular regurgitation. provides excellent haemodynamics TE. Prosthesis-patient mismatch affects survival Avalus valve is a novel, pericardial valve The PERIGON (PERIcardial SurGical At the time of data analysis, 864 and resolution of symptoms across a following aortic valve replacement. Circulation 2000; manufactured by Medtronic Inc with the AOrtic Valve ReplacemeNt ) Pivotal patients had received a study valve with range of implanted valve sizes. 102: III-5-9

EACTS/ESVS EACTS/ESVS Endovascular Skills Course for cardiac surgeons

Ruggero De Paulis Tilo Kölbel Konstantinos Tsagakis

Course Directors: landing zone of the distal arch. and vascular surgeons will give delegate groups spending Ruggero De Paulis In addition, the use of modern a comprehensive review of 90 minutes training on each Rome, Italy fenestrated and branched various aspects of endovascular training unit. The training will Tilo Kölbel grafts facilitates a complete treatment, specifically designed then be followed by specialist- Hamburg, Germany endovascular treatment of the to help experienced and led discussion, focussing on the Konstantinos Tsagakis aortic arch. ambitious cardiac surgeons get change in paradigms. Essen, Germany These emerging endovascular acquainted with this technology. Different features and techniques require special skills The programme includes basic characteristics of the various owadays, in order to effectively plan and and advanced skills on wires, stent-grafts available in the endovascular perform the aortic treatment, catheters and artery access. market will be also be presented, stent-graft treatment and knowledge is important The participants will learn how with participants learning which represents the first in order to define the best to plan a TEVAR based on features are preferred for peculiar Nchoice in the treatment of various therapeutic approach for each imaging technology, and how anatomical conditions, and how descending aorta pathologies, given aortic pathology. Thus, to smoothly go through the they can choose between two including aneurysms, trauma acquisition of endovascular skill steps of insertion and delivery different stent grafts. and dissections. Its minimal becomes more important for a of an endovascular stent- The programme concludes invasiveness nature is reflected surgeon aiming for a complete graft, while avoiding or dealing with an up-to-date by a reduced postoperative and safe treatment of thoracic with potential complications. overview of endovascular mortality and morbidity, and aortic disease. Indications for the use of TEVAR techniques, treatment of the this makes the treatment In this context, the European in various clinical and anatomical thoracoabdominal aorta, and attractive both in elective and Association of Cardio-Thoracic scenarios will also be presented the potential for fenestrated and emergency situations. Surgery, in cooperation with and discussed. branched devices. Hybrid-room technologies the European Society for Basic or advanced techniques The course is followed by are used to facilitate such Vascular Surgery (ESVS) has will be presented step by step, the 4th Aortic Live Symposium current trends and future of procedures to be able to offer endovascular procedures, and organised an endovascular and participants will then have (23-24 October, Hamburg, aorta treatment. the best modality of treatments support the extension of the course for cardiac surgeons, the chance to get their ‘hands- Germany) www.aortic-live.com, to their patients. Interested treatment in the arch or in the which will take place for the on’ with the help of a high-fidelity in which the participants will The EACTS Vascular Domain colleagues can proceed to online ascending aorta. Combination first time on 21-22 October, simulator. Both faculty members have the opportunity to follow encourages the participation of registration at: http://www. with a surgical approach makes 2017 in Hamburg, Germany. and training specialists will assist live advanced endovascular cardiac surgeons in this unique eacts.org/educational-events/ it possible to implement stent- In this two-day course, an throughout a ‘real-life simulator and surgical techniques course. Cardiac surgeons must programme/endovascular-skills- graft technology in the marginal international faculty of cardiac procedure’, with three separate and discussions about the get their hands on endovascular course Rapid Response

20 Issue 1 Saturday 7 October 2017 EACTS Daily News EACTS 2017 Agenda

Saturday 7 October 10:15 Left ventricular restoration and Hall Abstract 14:00 Coronary artery bypass graft: Hall F1 Rapid hypertrophic cardiomyopathy K2 Miscellaneous, robotics and Response 08:00 Translational and Basic 0.31/ Academy surgery – Healing the left off-pump Science Course – Theory and 0.32 ventricle reality of university-based 14:00 The 2017 EACTS/ESC Hall D Focus enquiry 10:15 Facing complications during Hall Focus Guidelines on valvular heart Session and after emergent surgery for E1 Session disease 08:00 Surgery at the crossroads Hall A Techno aortic dissection College 14:30 The Quality Improvement 0.49/ Focus 10:15 Grown-up congenital heart 1 Hall F2 Focus Programme 0.50 Session 09:00 Update on the Thymus Hall Techno Session K1 College Exhibition Opens 10:15 Current and future options in Hall Focus 15:45 Thoracic Rapid Response 1 Hall Rapid 10:00 Translational and Basic 0.31/ Academy the treatment of aortic valve G2 Session E2 Response Science Course – Cardiac: 0.32 stenosis Alpha Gal and Bio valve Immunology 10:15 End-stage emphysema Hall Focus 15:45 Congenital Rapid Response Hall F1 Rapid management K1 Session Response 10:00 Imaging and 3D techniques Hall A Techno College 10:15 Perfusion session 2: Improving 0.14 Focus perfusion Session 12:00 Translational and Basic 0.31/ Academy Science Course – Thoracic: 0.32 10:15 Allied Health Professionals – 2.32/ Focus Monday 9 October Quality improvement initiatives 2.33 Session The tissue is the issue: 08:15 Risk score 0.14 Abstract Building translational… 10:15 Research in medicine: your 2.31 Focus 12:30 1st International EACTS 0.11/ Academy manuscript as the next Session Ventricular Assist Device (VAD) 0.12 scientific breakthrough 08:15 Coronary artery bypass 0.31/ Abstract Co-ordinators Symposium grafting: Factors effecting 0.32 10:15 Young Investigator Award – Hall Rapid outcomes and anti-c… Semi Final 2 E2 Response 13:30 New techniques: the Hall A Techno 08:15 Late breaking clinical trials & 0.49/ Abstract developers corner College 10:15 Jeopardy Hall Rapid evidence 0.50 F1 Response 14:00 Translational and Basic 0.31/ Academy 08:15 Robotics in general thoracic 2.32/ Abstract Science Course – Cardiac: 0.32 Cash lunch available surgery 2.33 Repair medicine and 12:00 Minimally invasive coronary Hall Focus 08:15 Coronary problems Hall F2 Focus Application: from expe… artery bypass grafting D Session Session 14:00 Hands-on arterial switch Hall Advanced 12:00 Complications after Hall Focus 08:15 Endocarditis surgery Hall Focus operation – Congenital drylab K2 Techniques endovascular aortic repair: E1 Session G1 Session 16:00 Translational and Basic 0.31/ Academy new challenge for open surgery 08:15 Work in progress Hall Focus Science Course - Regulatory 0.32 G2 Session aspects of Innovation: What 12:00 Grown-up congenital heart 2 Hall F2 Focus do we have to know as Session 08:15 Anatomical segmentectomies Hall Focus innovative surgeons K1 Session 12:00 Hot topics in transcatheter Hall Focus 16:00 Transcatheter techniques and Hall A Techno aortic valve implantation G1 Session 08:15 Ethical and surgical issues in Hall Focus atrioventricular valves College organ transplantation K2 Session 12:00 Mitral Repair – Decision Hall Focus making in mitral surgery: trying G2 Session 08:15 Research in medicine: 0.11/ Focus increasing the impact of your 0.12 Session Sunday 8 October to fill the gaps in evidence! study 08:30 Getting to the root 0.11/ Abstract 12:00 Health care design; Hall Focus 08:15 EACTS/PASCaTS – 0.94/ Focus 0.12 opportunities and challenges K2 Session for the future Controversies in Rheumatic 0.95 Session Heart Valve Surgery: Valve 08:30 Translational and basic 0.31/ Academy 12:00 Perfusion session 3: 0.14 Focus Selection science course – when 0.32 Mechanical circulatory support Session regulatory where overcome: – state of the art 08:15 Rhythm issues Hall Rapid Human trials E2 Response 12:00 Interdisciplinary competency 0.11/ Focus 08:30 Challenges in patients with Hall Focus training: Standardisation, 0.12 Session 08:15 Aortic valve repair Hall F1 Rapid connective tissue disorders E1 Session assessment and risk reduction Response 08:30 Controversies on perioperative Hall F2 Focus in the tra… 08:15 A snapshot on transcatheter Lnge 6 Postgraduate management of infant Session 12:00 Allied Health Professionals – 2.32/ Focus aortic valve implantation Education undergoing procedure Abstracts 2.33 Session 08:15 Minimally invasive mitral and Hall D Professional 08:30 Making vein grafts great again Hall Focus 12:00 C. Walton Lillehei Young Hall Rapid G1 Session tricuspid valve surgery – Challenge Investigator Award / EACTS/ E2 Response standard of care? 08:30 Optimal antithrombotic Hall Focus LivaNova Cardiac Surgery 08:15 Challenges in the Hall Professional management in patients G2 Session Innovation A… management of aortic arch E1 Challenge undergoing coronary artery 12:00 The icing on the cake Hall F1 Rapid diseases bypass grafting; … Response Break. Exhibition Halls 08:30 Pleural empyema Hall Focus 12:00 How to set up thoracic Hall Focus management K1 Session surgery research trials K1 Session 10:15 Valves Hall F2 Abstract 08:30 Will mini aortic valve Hall Focus 14:00 Surgical Videos Hall F2 Abstract replacement become the gold K2 Session 10:15 Lung cancer – controversies Hall Abstract standard? K1 08:30 Perfusion session 1: Heater 0.14 Focus 14:00 Short-term mechanical 0.14 Abstract support 10:15 Conduction disturbances after 0.14 Abstract cooler induced infections Session aortic valve interventions 08:30 Research in medicine: 2.31 Focus 14:00 Heart transplantation is still the 0.31/ Abstract best long-term option 0.32 10:15 Cardiac tumours 0.31/ Abstract getting acquainted with a Session 0.32 scientific meeting as a starting 14:00 An old battlefield with Hall Focus researcher casualties: infection of the E1 Session 10:15 Lung transplant advanced 2.32/ Abstract techniques 2.33 08:30 Young Investigator Award – Hall Rapid aorta Semi Final 1 E2 Response 14:00 What is new in left main Hall Focus 10:15 The poor right ventricle in Hall Focus combination with tricuspid G1 Session 08:30 Coronary artery bypass Hall F1 Rapid disease G1 Session regurgitation grafting – a bit of science Response 14:00 Work life balance in cardio- Hall Focus thoracic surgery G2 Session 10:15 Rarities in cardio-thoracic Hall Focus 08:30 Arterial revascularisation after Hall D Professional surgery G2 Session the ART trial Challenge 14:00 Update on chest trauma Hall Focus K1 Session 10:15 Atrial fibrillation surgery in Hall Focus 08:45 Allied Health Professionals – 2.32/ Focus 2017 K2 Session Prevention and management 2.33 Session 14:00 Personalised external aortic Hall Focus of wounds root support K2 Session 10:15 Statistics in medicine: 0.11/ Focus ‘learning the basics’ for 0.12 Session Break 14:00 Evolution in bioprosthetic 0.11/ Focus clinicians 10:15 Translational and basic 0.31/ Academy valve design 0.12 Session 10:15 Rapid deployment valves: 0.49/ Focus science course – Discussion 0.32 New evidence & clinical cases 0.50 Session and outcomes 14:00 Allied Health Professionals – 2.32/ Focus Hands on session 2.33 Session discussion 10:15 Innovative techniques for Hall Abstract 10:15 SBCCV – Clinical, social and 0.94/ Focus mitral valve therapy G1 14:00 Research in medicine: the 2.31 Focus ultimate currency for every Session economic impact of the new 0.95 Session academic career? valve technologies in southern hemisp… EACTS Daily News Issue 1 Saturday 7 October 2017 21

Congenital Vascular Cardiac Thoracic Plenary All

10:15 Coronary artery bypass Hall Rapid 08:15 Ventricular assist device Hall D Focus 14:15 Surgery for Stage IIIAN2 Hall Focus surgery – latest updates E2 Response therapy – choose the Session NSCLC K1 Session treatment and deal with the 10:15 Extra corporeal life support – Hall F1 Rapid complications 14:15 Statistics in medicine: from 0.11/ Focus Always a good solution Response ‘simple’ multivariable models 0.12 Session 08:15 PROs and CONs arena on Hall Focus to complex 11:50 Presidential Address Hall D Plenary aortic controversies E1 Session 14:15 Alternative surgical 0.31/ Focus Lunch. Exhibits. Satellite Symposia 08:15 Outside the box of Hall Focus approaches for aortic valve 0.32 Session cardiothoracic surgery G2 Session replacement 14:15 Management of miscellaneous Hall F2 Abstract aortic valve disease 08:15 VATS-lobectomy adoption Hall Focus 14:15 New aspects in mitral valve Hall F1 Rapid rates – why aren’t we all K1 Session surgery Response 14:15 Minimally invasive aortic valve 0.31/ Abstract doing VATS and how can we Break. Exhibition Halls replacements 0.32 improve this? 16:00 Outcomes in arterial and off- Hall Abstract 14:15 Meet the Experts 0.94/ Abstract 08:15 Everything on randomized trial 0.11/ Focus 0.95 pump coronary artery bypass F2 design and data interpretation 0.12 Session grafting 14:15 Chest wall 2.32/ Abstract 08:15 Challenging issues in Fontan Hall Professional 16:00 Growing needs: ablation, Hall Abstract 2.33 pathway: Part 1 K2 Challenge lead extraction and left atrial G1 appendage- closure 14:15 How to approach the aortic Hall Focus 08:15 Long-term follow-up after Hall Rapid valve in a dilated root E1 Session cardiac surgery E2 Response 16:00 Improving transcatheter aortic Hall Abstract valve implantation G2 14:15 2017 Perioperative blood Hall Focus 08:15 Risk scores; indications, Hall F1 Rapid management guidelines G1 Session contraindications and side Response 16:00 Preoperative assessment of Hall Abstract lung cancer patients K1 14:15 Nightmares in cardiothoracic Hall Focus effects surgery G2 Session 08:15 A snapshot on transcatheter Lnge Postgraduate 16:00 Coarctation Hall Abstract aortic valve implantation 6 Education K2 14:15 Metastasectomy Hall Focus K1 Session 08:15 Improving outcomes of Hall Professional 16:00 Managing degenerated aortic 0.11/ Abstract coronary artery bypass F2 Challenge prosthesis 0.12 14:15 Short-term mechanical Hall Focus grafting circulatory support K2 Session 16:00 Controversies in left ventricular 0.31/ Abstract 08:15 Cardiac crossroads: deciding Hall Professional assist device therapy 0.32 14:15 Aviation medicine and cardiac 0.14 Focus between mechanical or G1 Challenge surgery Session bioproshetic heart valve 16:00 Surgical management of 0.49/ Abstract replacement effective endocarditis: analysis 0.50 14:15 Statistics in medicine: more 0.11/ Focus of early and late outcomes 2 advanced statistics for the 0.12 Session Break. Exhibition Halls clinician 10:15 Oncology lymph nodes and Hall Abstract 16:00 Airway 2.32/ Abstract 2.33 14:15 Beating heart mitral valve 0.49/ Focus staging K1 repair 0.50 Session 10:15 The challenges of 0.14 Abstract 16:00 Secondary mitral regurgitation Hall D Focus – still a surgical problem? Session 14:15 Awards Final Hall Rapid endovascular approach in E2 Response thoracic aorta 16:00 The changing trend in Hall Focus 10:15 Ross / Homograft 0.31/ Abstract the treatment of thoraco- E1 Session 14:15 Jeopardy Final Hall Rapid abdominal aortic aneurysm F1 Response 0.32 10:15 Sternal wound complications 0.49/ Abstract 16:00 Is no-suture the future for Hall Rapid 14:15 News from the trials world Hall D Focus aortic valves? E2 Response Session 0.50 16:00 Advances in mitral valve Hall F1 Rapid Break. Exhibition Halls 10:15 Oncology – Lung cancer: 2.32/ Abstract Outcome 2.33 surgery Response 16:00 Surgical management and Hall F2 Abstract 16:00 Thoracic Rapid Response 2 0.14 Rapid outcomes 10:15 Complex mitral valve repair Hall D Focus video session Session Response 16:00 Patient blood management to Hall Abstract reduce surgical risk G2 10:15 How far away are we from Hall Focus setting guidelines for arch E1 Session 16:00 Oncology-preoperative Hall Abstract surgery? Wednesday 11 October assessment K1 10:15 How to use coronary, valvular Hall Focus 09:00 Outcome of mitral valve Hall Abstract 16:00 Light and shades of the arch 0.14 Abstract and aortic guidelines in clinical G2 Session surgery G1 practice 09:00 Thoracic Case Session 1 0.49/ Abstract 16:00 Structural valve deterioration 0.11/ Abstract 10:15 Statistics in medicine: meta- 0.11/ Focus 0.50 in aortic valve 0.12 analysis from start to finish 0.12 Session 09:00 Nightmares in cardiac surgery 2.31 Abstract 16:00 Coronary artery bypass 0.31/ Abstract 10:15 Challenging issues in Fontan Hall Professional grafting – Intraoperative graft 0.32 pathway: Part II K2 Challenge 09:00 Tricuspid valve: surgery for 0.31/ Advanced flow assessment 10:15 Current developments in Hall Rapid who, when and how 0.32 Techniques 16:00 Non-Oncology pleura/ 2.32/ Abstract transcatheter aortic valve E2 Response pneumothorax 2.33 implantation 09:00 Wetlab – Chest Wall 2.91 Advanced Reconstruction & “Bronchial Techniques 16:00 Bicuspid aortic valve repair Hall Focus 11:50 Honoured Guest Lecture Hall D Plenary Sleeve Resections” as primary option in young E1 Session 09:00 Aortic root pathology Hall D Focus patients Lunch. Exhibits. Satellite Symposia Session 16:00 Catastrophic complications Hall Focus Residents Luncheon, Crystal Lounge, Level 1 and super saves G1 Session 09:00 Multi-arterial coronary 2.32/ Focus 12:45 Nightmare cases Hall Focus revascularisation in coronary 2.33 Session 16:00 The surgeons role in cardiac Hall Focus K1 Session artery bypass grafting: State implantable electric devices K2 Session of the art an… 14:15 Tetralogy of Fallot / Pulmonary Hall Abstract 09:00 Introduction to mitral valve Hall Advanced 16:00 Beyond artificial chords 0.49/ Focus atresia K2 0.50 Session repair & Wetlab K2 Techniques 14:15 Surgical management of 0.49/ Abstract 09:00 Controversies & Catastrophes Hall Advanced 16:00 Aortic valve replacement in a Hall Rapid effective endocarditis: analysis 0.50 in Adult Cardiac Surgery G2 Techniques nutshell E2 Response of early and late outcomes 1 16:00 Welcome to the machine – Hall F1 Rapid 14:15 Oesophageal Surgery 2.32/ Abstract 10:45 Innovative strategies for Hall Advanced new concepts in ventricular Response 2.33 surgical AVR G1 Techniques assist device therapy 14:15 Left atrial appendage Hall D Focus 10:45 Surgical challenges in bicuspid Hall D Advanced occlusion when and how Session aortic valve syndrome Techniques Tuesday 10 October 14:15 How to cope with the aberrant Hall Focus 11:00 Thoracic Case session 2 0.49/ Abstract right subclavian artery (ARSA) E1 Session 0.50 08:15 “La terra di mezzo” The 0.14 Abstract in aortic surgery middle earth of aortic surgery 11:00 Dealing with complex adult 0.31/ Advanced 14:15 2017 Perioperative medication Hall Focus cardiac surgery including 0.32 Techniques 08:15 Tricuspid valve: no longer 0.31/ Abstract guidelines F2 Session transplantation. Live-in-a-box forgotten 0.32 14:15 Everything you need to know Hall Focus 11:00 Wetlab – Chest Wall 2.91 Advanced 08:15 Mitral valve surgery: Complex 0.49/ Abstract about transcatheter mitral G1 Session Reconstruction & “Bronchial Techniques issues 0.50 valve replacement Sleeve Resections” 14:15 How to do it; Live in a box Hall Focus 11:00 When saphenous veins are 2.32/ Focus G2 Session a necessary choice use 2.33 Session them wisely and for the appropriat… 22 Issue 1 Saturday 7 October 2017 EACTS Daily News

Thoracic | Abstract | Robotics in general thoracic surgery Ten years’ experience in robotic thoracic surgery for early stage lung cancer: Evolution and lessons learned

Monica Casiraghi1, Domenico in eight patients (2.4%), with 30-day operative assisted thoracoscopic surgery for stage I lung cancer. Thorac Surg 1 1 Clin 2007;17:223-31. Galetta , Alessandro Borri , Adele mortality of 0%. 2. Whitson BA, Groth SS, Duval SS, Swanson SJ, Maddaus Tessitore1, Rosalia Romano1, Our nodal upstaging rate for N1 (cN0-to-pN1) MA. Surgery for early stage non-small cell lung cancer: a Cristina Diotti1, Daniela Brambilla1, and N2 (cN0/N1-to-pN2) was 8.8% and 8.8%, systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approach to lobectomy. Ann Thorac Surg 2 Patrick Maisonneuve , Lorenzo respectively, with an overall upstaging rate of 2008;86:2008-18. Spaggiari1,3 1. Division of Thoracic 17.6% in line with literature data, also considering 3. Yan TD, Black D, Bannon PG, McCaughan M. Systematic review and meta-analysis of randomized and non-randomized trials on safety Surgery, European Institute of Oncology, the open surgery outcomes. and efficacy of video-assisted thoracic surgery lobectomy for early University of Milan, Milan, Italy; 2. Division of Park et al. in 201210 evaluated long-term stage non-small-cell lung cancer. J Clin Oncol 2009;27:2553-62. 4. Park BJ, Flores RM, Rusch VW. Robotic assistance for video- Epidemiology and Biostatistics, European oncological outcomes after robotic lobectomy assisted thoracic surgical lobectomy: technique and initial results. J Institute of Oncology, Milan, Italy; 3. for NSCLC10, showing that robotic surgery had Thorac Cardiovasc Surg 2006;131:54-9. University of Milan, Department of Oncology acceptable long-term and stage-specific survival 5. Gharagozloo F, Margolis M, Tempesta B, Strother E, Najam F. Robot- assisted lobectomy for early-stage lung cancer: report of 100 cases. and Hematology (DIPO), School of Medicine, Figure 1. Incisions and rates (five-year OS of 91% and 88% for stages Ann Thorac Surg 2009; 88:380-4. Milan, Italy robotic positions. IA and IB, respectively, and 49% for stage II), 6. Ninan M, Dylewski MR. Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg comparable with the recently published outcomes 2010;38:231-2. inimally-invasive surgery is future development. We retrospectively reviewed for VATS12 and open surgery13. Our study showed 7. Veronesi G, Galetta D, Maisonneuve P, Melfi F, Schmid RA, Borri A et al. Four-arm robotic lobectomy for the treatment of early-stage lung undoubtedly the future of thoracic the outcomes of 339 patients who underwent excellent five-year OS and cancer-specific survival cancer. J Thoracic Cardiovas Surg 2010;140:19-25. surgery. The feasibility and safety of anatomical pulmonary resection performed by rates of 90% and 91.5% (Figure 2), respectively, 8. Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. Initial consecutive both video-assisted thoracic surgery RATS (four-arm robotic approach with utility with five-year stage-specific survival of 96.4% and experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011;142:740-6. M(VATS) and robotic-assisted surgery (RATS) have incision) for clinical stages I and II NSCLC (Figure 1). 76.4% for stages I and II, respectively, and 57.8% 9. Kent M, Wang T, Whyte R, Curran T, Flores R, Gangadharan S. already been demonstrated in the treatment of Twenty-nine patients underwent for stage IIIA (Figure 3). Open, video-assisted thoracic surgery, and robotic lobectomy: review of a national database. Ann Thorac Surg 2014;97:236-44. 1-7 early stage lung cancer. segmentectomy, 307 lobectomy and three In conclusion, besides the well-known short- 10. Park BJ, Melfi F, Mussi A, Maisonneuve P, Spaggiari L, Da Silva RK et VATS lobectomy has not yet become the pneumonectomy. Conversion occurred in 22 term outcomes showing very low morbidity and al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long- standard approach to early-stage lung cancer patients (6.5%): 15 (4.4%) due to technical mortality rates, mediastinal lymph node dissection term oncologic results. J Thorac Cardiovasc Surg 2012;143:383-9. 11. Toosi K, Velez-Cubian FO, Glover G, Ng EP, Moodie CC, Garrett JR treatment probably related to technical limitations, issues, four (1.2%) for oncological reasons, and during RATS adequately assesses lymph node et al. Upstaging and survival after robotic-assisted thoracoscopic such as two-dimensional imaging and the limited three (0.9%) for bleeding. Median operative stations detecting occult lymph node metastasis lobectomy for non-small cell lung cancer. Surgery 2016;160:1211-18. 12. Flores RM, Park BJ, Dycoco J, Aronova A, Hirth Y, Rizk NP manoeuvrability of instrumentation. To address time was 192 minutes for lobectomy, 172 and leading to excellent oncologic results. et al. Lobectomy by video-assisted thoracic surgery (VATS) the limitations of conventional thoracoscopy, minutes for segmentectomy, and 275 minutes However, these results await longer follow- versus thoracotomy for lung cancer. J Thorac Cardiovasc Surg a telesurgical system was developed offering for pneumonectomy. Median length of hospital up studies. 2009;138:11-8. 13. Goldstraw P, Crowley J, Chansky K, Giroux DJ, Groome PA, Rami- surgeons the benefits of three-dimensional high- stay was five days (2-191). The most common Porta R et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) definition imaging and greater hand movements postoperative complication was prolonged air leak References edition of the TNM classification of malignant tumours. J Thorac using wristed instruments and the master-slave (12.1%), whereas major complications occurred 1. Mahtabifard A, DeArmond DT, Fuller CB, McKenna RJ Jr. Video- Oncol 2007;2:706-14. surgical cart, and computer-assisted scaling down of motion and reduction of hand-related tremors Figure 2. a) Overall survival; b) cancer-specific survival. Figure 3. Overall survival according to pathological stage. (da Vinci system, Intuitive Surgical, Sunnyvale, CA, USA); this new technique offers surgeons an innovative approach to lung cancer resection and staging with a more precise dissection and theoretically better oncological results. Although different studies have demonstrated that RATS is associated with reduced mortality, shorter hospital stay, and fewer overall complications8,9, few studies have hitherto evaluated oncological outcomes in terms of long-term survival10,11 showing acceptable results compared to VATS and open surgery. In our study, we analyse the short and long- term outcomes of RATS for early stage non- small cell lung cancer (NSCLC) to evaluate the oncological impact of this technique and its

Cardiac | Rapid Response | Coronary artery bypass grafting – a bit of science Five-year patency of no-touch saphenous vein grafts in on-pump versus clamp-less off-pump coronary artery bypass surgery: A sub-study of a multicentre randomised trial

Mikael Arbeus1, Domingos Souza1, Lennart Bodin2, Supported by the Key Research Håkan Geijer3, Mats Lidén3, Ninos Samano1; 1. Fund Örebro and the Local Department of Cardiothoracic and Vascular Surgery, Faculty Research Fund Department of of Medicine and Health, Örebro University, Örebro, Sweden; Cardiothoracic and Vascular 2. Intervention and Implementation Research, Institute of Surgery, Örebro University Environmental Medicine, Karolinska Institute, Stockholm, Hospital, Sweden. No disclosures. Sweden; 3. Department of Radiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden References 1. Souza D. A new “no-touch” preparation andomised controlled pump CABG at five-year follow- technique. Scand J Thorac Cardiovasc Surg. 1996;30:41-4. studies (RCT) have up. 2. Souza DS, Johansson B, Bojö L, et al. shown high long- Forty-nine patients were alive Harvesting the saphenous vein with term patency for at the final five-year follow-up, surrounding tissue for CABG provides long-term graft patency comparable to Rno-touch saphenous vein and were asked for written the left internal thoracic artery: Results of grafts (NTSVGs), comparable informed consent to participate a randomized longitudinal trial. J Thorac to the internal thoracic artery in the additional study of graft were performed by two surgeons Cardiovasc Surg. 2006;132:373-8. 3. Samano N, Geijer H, Lidén M, Fremes in on-pump coronary artery patency. Forty patients were who were experienced in Figure 1. Total patency (LITA+NTSVG) according to the coronary S, Bodin L, Souza D. The no-touch bypass grafting (CABG)1-3. included. Twenty-one patients both techniques. artery targets. saphenous vein for coronary artery bypass RCTs on patency in NTSVGs in the on-pump group and 19 Crude graft patency was grafting maintains a patency, after 16 years, comparable to the left internal in off-pump CABG have not patients in the off-pump group. numerically higher in on-pump descending artery (LAD) and In conclusion, no significant thoracic artery: A randomized trial. J Thorac been published yet. Our centre All patients received NTSVGs. CABG but not statistically diagonal targets were patent. difference in overall patency Cardiovasc Surg. 2015;150(4):880-8. participated in the CABG Off- or Clamp-less aortic technique significant. The patency rate Lowest patency for the NTSVG between on-pump and off- 4. Lamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or on-pump coronary-artery On-pump Revascularization (Heartstring) was used in all for the NTSVGs was 57/64 was to the right coronary pump CABG was seen. High bypass grafting at 30 days. N Engl J Med study (CORONARY, ClinicalTrials. off-pump patients. Computed (89.1%) in on-pump vs 37/45 territory, particularly in off-pump patency rate was found in all 2012; 366:1489-97. gov number, NCT00463294)4- Tomography Angiography (82.2%) in off-pump p = 0.781. surgery (80.0/62.5%, on/off- grafts (LITA+NTSVGs) to the 5. Lamy A, Devereaux PJ, Prabhakaran D, et al. Effects of off-pump and on-pump 6 and included 56 patients. (CTA) was used to evaluate All left internal thoracic arteries pump). The overall five- year left coronary territory in both coronary-artery bypass grafting at 1 year. N Accordingly, this is a sub-study graft patency. Two independent (LITAs) were patent except for patency rate was 122/137, techniques. Graft patency in Engl J Med 2013; 368:1179-88. and the aim was to assess the radiologists that were blinded one anastomosed to a diagonal 89.1%. The total patency rate off-pump CABG was jeopardised 6. Lamy A, Devereaux PJ, Prabhakaran D, et al. Five-year Outcomes after Off-pump or midterm patency in NTSVGs in to the technique evaluated the branch in the off-pump group. for LITA was 96.6% and for the when anastomosed to the right On-pump Coronary-Artery Bypass Grafting. clamp-less off-pump versus on- graft patency. All operations All NTSVGs to the left anterior NTSVGs it was 87%. coronary artery. N Engl J Med 2016;1-10.

24 Issue 1 Saturday 7 October 2017 EACTS Daily News

Thoracic | Rapid Response | Thoracic Rapid Response 1 The Pectoscope: A novel scopic device for pectus surgery

Figure 1: The Pectoscope. Contact view plus dissection for passage of Pectus Bar Figure 2: The curved pectoscope provides a critical view to the heart to avoid injury

at the critical point of injury. other internal organ injuries that might the mediastinum, with no blind spot scope to pass the pectus bar guide, Hyung Joo Park A main reason for failure in happen inherently in pectus repair. After a throughout the track the whole procedure was simplified Seoul St. Mary’s Hospital, The thoracoscopic visualisation appears hard time harnessing the optical science 4. It provides a forward view at the by eliminating additional procedures, Catholic University of Korea, Seoul, to be that its body is straight, which is to develop the scope, at last I could apply critical point such as introducer passage, single South Korea not suitable to follow targets because it to my patients in 2011. Therefore, if we use it correctly, it can lung ventilation, CO2 insufflations, or the heart is often concealed behind The unique features of this novel guarantee 100% safety during the additional thoracoscopic ports, which he most dreadful concern the excavated chest wall, especially in endoscope are listed below, and mediastinal pass. Furthermore, no made the procedure an uniportal single for pectus surgeons is heart deep chest wall depressions. Second, illustrated in Figures 1 and 2. additional introducer is necessary; only pass surgery. injury during bar passing, the thoracoscope loses the view when 1. It has a curved body to follow the a single transit of the scope suffices the In conclusion, the pectoscope is because once it happens, the contacting the object where there is no curvature of the excavated chest wall introduction of the guide, followed by an effective pectus surgery-specific consequencesT could be catastrophic. open space at the interface between easily: descending and ascending the pectus bar. endoscopic device that offers Thoracoscopy was one way to visualise the depressed chest wall and the heart. along the slopes of the chest wall As a result, with the aid of the visualisation of the critical point at the the internal thoracic structures during To avoid this lethal cardiac event, I have 2. It is designed to view the contacted pectoscope I have had no mortality interface between the heart and the pectus surgery, however there has been a developed a novel pectus surgery-specific surface of the heart and the chest or any case of internal organ injuries depressed chest wall for pectus bar worry that the conventional thoracoscope scoping device. I first conceived the idea wall. Even the lens touches the object in 1,215 consecutive de novo pectus passage. The pectoscope could play a would not be accurate enough to show a of the pectoscope is in 2006, aiming to in the path repairs. Also, since the pectoscope vital role to keep our patients safe from correct path, thus misleading the surgeon achieve 100% safety from cardiac or 3. It provides a continuous view through is designed for single travel of the catastrophic cardiac injury.

Thoracic | Abstract | Non-Oncology pleura/pneumothorax VATS decortication for stage-3 empyema: A trial of a minimally invasive approach in a delayed-presentation disease

Hussein Elkhayat1, Mahmoud Sallam1, Maiada Kamal2, postoperative pain and hospital Esam M. abdalla3 Assiut University, Faculty of Medicine, stay for patients with stage-3 Assiut, Egypt; 1. Cardiothoracic surgery ; 2. Chest disease empyema by trial of VATS department; 3. Anesthesia and intensive care department decortication in every case. In this prospective study, ate presentation of thoracotomy to access into the we included all cases (from pleural infection is chest cavity. Mini-thoracotomy a single, assigned surgeon) still a problem that and muscle sparing techniques with diagnosis of turbid and/or thoracic surgeons then developed, aiming to haemorrhagic pleural effusion Lshould deal with in everyday decrease post-operative pain that showed loculations with practice. Traditionally, the and hospital stay. VATS has thick peel or failed simple surgical option for management become a golden tool for chest tube drainage admitted of advanced stage empyema the surgical management for to our thoracic surgery was open thoracotomy for fibropurulent pleural space service. An informed consent decortication with posterolateral disease. We try to reduce the was used, noting a trial for a thoracoscopic procedure, with the possibility of open surgery in cases where thoracoscopy failed. The operative technique was to completely remove the fibrous peel at the surface of the lung without parietal decortication. Forty-seven patients who met the inclusion criteria were assigned for the study, comprising 38 males and Figure 1. Thoracoscopic view of thick adhesions with entrapped lung 9 females. Mean age was 45.32, the youngest 17, and minutes (Table 1). decortication with the benefits hospital stay and postoperative the oldest 82 years. Twenty- With advancement of VATS of reasonable operative time, morbidities and mortalities. eight cases needed only procedures and equipment, drainage and debridement together with the learning with lysis of fine adhesions curve, VATS decortication Table 1. without the need for visceral showed significantly less VATS VATS decortication. The remaining morbidity and mortality as debridement decortication 19 cases were subjected to well as decreasing conversion Number of cases 28(59.57%) 19(40.43%) VATS decortication (Figure rates from 41.67% in previous Age 47.71 41.79 1). All decortication cases studies to 10.52% in this study. Sex 6;1 3.8;1 performed during the last year Stage-3 empyema is of the study were via uniportal no longer an absolute Previous intervention 10 11 approach. Of the 19 cases contraindication for VATS; not Number of ports of decortication, two cases all cases with a preoperative Uniportal 15 8 (10.52%) needed conversion diagnosis of stage-3 empyema 2 ports 12 11 to open thoracotomy, and need decortication. We one case was converted from encourage a trial of VATS 3 ports 1 uniportal to two-port approach. decortication for empyema Treatment delay 52.93 days 57.16 days All cases were discharged despite the delay in presentation Operative time (minutes) 90.93 116.68 with mean drainage of 5.42 or radiological findings, Drainage days 2.68 5.42 days. Mean operative time for considering that the results decortication cases was 116.68 are comparable with open Conversion to thoracotomy 2(7.14%) 2(10.52%) EACTS Daily News Issue 1 Saturday 7 October 2017 25

EACTS The EACTS Professional Leadership Workshop

t’s often said that ‘soft’ people skills are the hardest, but they are a critical part of the mix for high-performing individuals and teams. Following the success of a two-day Ileadership workshop in Windsor last year, EACTS is repeating the offering for consultant surgeons this autumn, held on 27–28 November. The word from the majority of participants last year was that it was “A good investment”, and “Something they would definitely recommend to a colleague or friend.” The programme will be delivered once again by the warm, self-effacing master of emotional intelligence, Roger Delves, together with leadership coach and Britain’s first woman to climb Mount Everest, Rebecca Stephens. And as an added input over last year, it will also feature Dr Jane Stevens, a consultant haematologist with special interest in the personal development of doctors and the sustainability of the NHS. The course aims not to be too ‘clinical’, rather to explore the core values of leadership of people. It aims to be inspirational, and is certainly interactive, fully engaging participants Jane Stevens, MB ChB, MD (Res), with the objective of increasing self-awareness MCRP, FRCPath and developing leadership skills for the benefit of Studied medicine at Manchester University, and themselves, the team – and most importantly – the specialised in malignant haematology. With 20 patient. Ethics is a key theme throughout, and it is years experience in the NHS, it became apparent understood that in today’s environment, hospital to her that even the best physician was unable departments are in a continuous state of flux, and to excel if working in a failing system. A need to understand the challenges facing the healthcare thus navigating the politics and managing high- Rebecca Stephens, MBE sector led her into clinical leadership within the performance teams is critical if the best outcome Roger Delves First British woman to climb Everest and the NHS, and to take a Master’s degree in Business for the patient is to be ensured. Professor of Leadership Practice and Dean of Seven Summits, the highest mountain on each Administration (MBA). In 2016, she stepped down But the uniqueness of the course is that it Qualifications at Ashridge Business School. of the seven continents. Writer, lecturer and from her role as divisional director for Cancer and touches both the intellectual and emotional Member of the Global Academic Team and Hult leadership coach, Visiting Fellow at Ashridge Clinical Support in a large acute Trust in London core of our beings, drawing on tested academic Ashridge Academic Board, teaching across Business School and leader of The Rotterdam to prepare for a Doctorate in Organisational behavioural models for the following: emotional a range of Ashridge and Hult qualification School of Management Kilimanjaro MBA Change at Ashridge Hult Business School, where intelligence and authenticity, building and programmes. Leadership elective. she is an Associate. maintaining high-performance teams, integrity and ethical decisions and – particularly popular last year – a highly interactive workshop organisational barriers, and engage actively in the prepared, and expect to be stretched. This is a http://www.eacts.org/educational-events/programme/ on ‘Political Savvy’, designed to equip and political sphere in an ethical and systematic way. course for consultant surgeons serious to further professional-leadership-workshop/ encourage individuals to steer a course around There’ll be reading beforehand, so come every aspect of their careers.

EACTS Awards @ the 31st EACTS Annual Meeting in Vienna In 2017 we will be introducing a new format for the Awards Selection Process. After review, the Programme Committee has selected the best abstracts submitted for the Young Investigator Award, as well as the C. Walton Lillehei Young Investigator Award/EACTS/LivaNova Cardiac Surgery Innovation Awards. These abstracts will be presented in one or more Rapid Response sessions with the Award Panel present. The best nine abstracts from these sessions (decided by the Jury) will then move forward to the ‘Final’. In the Final, abstracts will be presented without slides, instead taking the format of a five-minute oral presentation followed by an additional five-minute discussion. The Award Winner/s will be announced at the end of the Final session.

PROGRAMME – All held in Hall E2 Sunday 08:30–11:00 Young Investigator Award – Semi-final 1 10:15–11:45 Young Investigator Award – Semi-final 2 12:00–13:30 C. Walton Lillehei Young Investigator Award/ EACTS/LivaNova Cardiac Surgery Innovation Award – Semi Final Monday 14:15–15:45 Awards Final 26 Issue 1 Saturday 7 October 2017 EACTS Daily News

General | Focus | Statistics in medicine: ‘learning the basics’ for clinicians How to learn statistics as a starting researcher

Milan Milojevic of becoming a doctor gives context. The randomised 1. Start off by reading ‘the study correlation and regression, Department of Cardiothoracic priority to the understanding controlled trials (RCTs) are the design’ papers or buy a book the logistic regression model, Surgery, Erasmus University of pathophysiology/treatments currently the most valuable on the topic to understand the Cox proportional hazard Medical Center, Rotterdam, with no particular interest in source for data on the effects the main concept of patient regression model and just the Netherlands lectures about ‘significance of treatment for evidence- follow–up and different types keep going. testing of two different based medicine. Because of studies. 4. In the last step, start with your hen considering variables’. Over time, there is randomisation evenly distributes 2. Take the basic statistical study and perform statistical the title of this no easy way to correct this gap. known and unknown factors course which usually lasts analyses by yourself. It may lecture, many will Many clinicians are not able among two treatment groups, a week to learn: descriptive not be easy, but consult your only think of the to reflect critically on studies RCTs are an excellent source of statistics, statistical hypothesis book(s), the lecture notes, ask applicationW of statistical methods conclusions and therefore basic statistics. testing, statistical inferences for help from your colleagues to the analysis of data arising in ‘blinded for their judgment’ How much effort and time are on means and proportions, and move slowly toward your your medical studies. However, if follow straightforwardly mainly necessery to learn an essential and estimates for association goal. Also, a useful source of there’s one aspect of education underpowered guidelines or statistical skill is hard to answer. measures. During the lectures, knowledge – that is sometimes for clinicians that I consider to make significant barriers to the Remember, once you are already you will spend part of the ignored is Youtube. be paramount, at least when it application of research evidence past statistical courses I think time on practical exercises Basic biostatistics knowledge comes great responsibility for to daily practice. you are totally on your own. In using the published articles is worth your best effort to treatment decision-making and students interested in scientific I advocate evidence-based the beginning, the biggest tip and statistical programmes; successfully build a bridge use the guidelines or findings research. In fact, it is pretty medicine in which the highest I can give you is to emphasise pick an analytical software like between research evidence and published in majors journals, it hard to be focused on the quality scientific data are theory over practice to SPSS. clinical decision making, and also is a firm grounding in the basic research courses together with undergoing judgment by the understand what are you doing. 3. Continue reading or taking as a motivation to start seeking statistical methods. major medical exams such experts of the field in term of its I recommend a four step process lessions for more advanced your answers through research. Unfortunately, in medical as anatomy, internal medicine trustworthiness, scientific value to picking up the needed basic statistical methods, including Therefore, let’s start learning school, there are not many and surgery. A lifelong dream and relevance in a particular statistics skills: time-to-event analysis, linear biostatistics together now!

General | Focus | Research in medicine: increasing the impact of your study Follow-up data from national government registries: the Sweden experience

Ulrik Sartipy1,2 1 Heart and Vascular the merge of four distinct cardiac care Registry-based randomised potential study subjects for the trials and Theme, Karolinska University Hospital, quality registers, including the Swedish clinical trials collected endpoints and other data. The Stockholm, Sweden; 2 Department Heart Surgery Register. Although quality A randomised controlled trial is trials were carried out successfully at a of Molecular Medicine and Surgery, registers, such as SWEDEHEART, holds considered the gold-standard for fraction of the cost associated with a Karolinska Institutet, Stockholm, valuable information in themselves, the a clinical trial testing the effect of a traditional randomised clinical trial. We Sweden real power is unleashed given treatment or expect that this powerful, efficient, and when registers are Main message intervention. Assuming cost-effective study design will assist National registries – quality linked to other sources the randomisation the cardiac surgical scientific community registers and government of information in order High-quality national procedure was in providing the best possible care to health-data registers to tackle specific health-data registers can successful, it has the our patients in the near future. weden has a universal and research questions. be utilised for acquisition important potential publicly financed health This strategy may be of robust outcome data in to effectively reduce References insurance coverage that employed to investigate large observational studies or eliminate bias in 1 Ludvigsson JF, Otterblad-Olausson P, Pettersson BU, guarantees equal access research questions not and in registry-based treatment assignment, Ekbom A. The Swedish personal identity number: possibilities and pitfalls in healthcare and medical Sto health services, regardless of possible to address in randomised clinical trials. most importantly research. Eur J Epidemiol 2009;24:659-67. employment status, individual financial they may lack details regarding prospective randomised selection bias and 2 Jernberg T, Attebring MF, Hambraeus K, Ivert situation or regional residency. Every disease- or intervention-specific data, trials, e.g. the association between confounding. Is it possible to integrate T, James S, Jeppsson A et al. The Swedish Web-system for enhancement and development 3 individual who has resided in Sweden laboratory findings, and patient reported income and prognosis. Information the concept of randomisation into the of evidence-based care in heart disease on a permanent basis is assigned a outcome measures. Complementing the from SWEDHEART was combined field of register-based research? By evaluated according to recommended therapies personal identity number.1 The personal government administered health-data with government registries holding adding a randomisation module to a (SWEDEHEART). Heart 2010;96:1617-21. 3 Dalen M, Ivert T, Holzmann MJ, Sartipy U. Household identity number is an important registries in Sweden are more than one- information on household disposable large, clinical quality register with broad Disposable Income and Long-Term Survival After prerequisite for register linkages for hundred healthcare quality registers with income, educational level and other and consecutive patient enrolment, Cardiac Surgery: A Swedish Nationwide Cohort research purposes, and is used as the purpose of examining and improving socio-economic variables. Linkage was some of the most important features Study in 100,534 Patients. J Am Coll Cardiol the key number in all national registers the delivery of healthcare, monitoring possible through the personal identity of a traditional prospective randomised 2015;66:1888-97. 4 Edgren G, Rostgaard K, Vasan SK, Wikman A, in Sweden. the adherence to guidelines, and to number. Other data sources may include trial could be integrated into the infra- Norda R, Pedersen OB et al. The new Scandinavian Government administered health- support clinical research. multinational databases such as the structure of an established clinical Donations and Transfusions database (SCANDAT2): data registries obtain information on, for The Swedish Web-system for Scandinavian Donations and Transfusions register. This concept is known as a a blood safety resource with added versatility. Transfusion 2015;55:1600-6. 4 6 example, hospital-based inpatient and Enhancement and Development of database. Such an approach could be registry-based randomised clinical trial . 5 Sartipy U, Holzmann MJ, Hjalgrim H, Edgren G. Red outpatient care, prescribed medications, Evidence-based care in Heart disease useful in order to acquire a sufficiently As demonstrated by the innovative Blood Cell Concentrate Storage and Survival After cancer diagnoses, and cause of death. Evaluated According to Recommended sized study population, sometimes design in the recent TASTE, VALIDATE- Cardiac Surgery. JAMA 2015;314:1641-3. 2 6 James S, Rao SV, Granger CB. Registry-based Although the government administered Therapies (SWEDEHEART) is a national necessary to reach enough statistical SWEDEHEART, and DETO2X trials, randomized clinical trials--a new clinical trial registries cover the total population, healthcare quality register resulting from power to demonstrate a lack of effect.5 the SWEDEHEART register identified paradigm. Nat Rev Cardiol 2015;12:312-6. EACTS Daily News Issue 1 Saturday 7 October 2017 27

S5™ Min.I. MICS and Pediatric Perfusion System

ptimized with the and leadership in Heart- VBT 8 bubble trap and APC positioning during adult LivaNova is redefining goal of improving Lung Machine design and ERC air management; minimally invasive and the minimally invasive Ooutcomes during and manufacture. reduced inflammatory pediatric surgery. approach to perfusion extracorporeal circulation Combined with reaction design with the With LivaNova’s S5 with the S5 and S5 in minimally invasive and the superior gaseous Inspire HVR Dual venous Min.I., clinicians benefit Min.I. perfusion systems, pediatric surgery, the microemboli performance reservoir; and gentle from minimal hemodilution,1 now optimized for LivaNova S5 Min.I. isn’t just of our Inspire oxygenator perfusion with a new, optimized air management, minimally invasive and another configuration of modules, the S5 and innovative, completely goal-directed perfusion2 pediatric surgery. our flagship S5 perfusion S5 Min.I. feature more closed system. and optimized ergonomics.4 1. Ranucci M, et al. Perfusion. 2014 May 19. [Epub ahead of print]. systems. It reflects options to better suit Featuring optimized Patients benefit from 2. Ranucci M, et al. Ann Thorac Surg 2,3 our global approach minimally invasive therapy ergonomics, flexibility reduced transfusions, 2015 to minimally invasive needs, including: reduced and modularity, the reduced acute kidney 3. Starck CT, et al. Perfusion 2,3 2014;28(4):292-7.

perfusion and represents priming volume for minimal S5 and S5 Min.I. also injury, maximized News 4. Frank Münch F. University hospital 5 a culmination of more hemodilution; system-level enable ideal equipment neurological protection Erlangen, Germany than 40 years’ experience safety using the Inspire configuration and patient and reduced complications. 5. Seyfelt T, et al. Transfusions 2015 Daily Daily

Issue 2 Available Sunday! |

28 Issue 1 Saturday 7 October 2017 EACTS Daily News

Thoracic | Abstract | Oncology-preoperative assessment Comparison of new (Pro-gastrin-releasing peptide) versus old (NSE, CEA, CYFRA 21-1 and LDH) circulating biomarkers in the differential diagnosis of lung cancer

Domenico Galetta data are available concerning the utility Division of Thoracic Surgery, of ProGRP as a marker for monitoring European Institute of Oncology, the disease and for the detection Milan, Italy of recurrences. In this study, we assessed the relative umour markers have been diagnostic accuracy of ProGRP for the extensively studied in differential diagnosis of small cell lung patients with lung cancer cancer (SCLC) and compared it with as means to differentiate more conventional biomarkers. betweenT the two major subtypes of We enrolled a cohort of 489 lung cancer – non-small cell lung cancer consecutive patients with a clinical (NSCLC) and small cell lung cancer GRP is a neuropeptide hormone suspicion of lung cancer and for (SCLC) – and thereby improve diagnosis originally isolated from porcine gastric whom a histologic assessment was and treatment selection. tissue. Because of its short half-life available. Serum or plasma samples A number of serum components which is about two minutes, GRP is were assayed for ProGRP, CEA, CYFRA have been proposed as markers for not suitable in laboratory practice. 21-2, LDH, and NSE. The performance Figure 1. ROC curves for ProGRP (A), and NSE (B) lung cancer: carcinoembryonic antigen On the other hand, ProGRP, a serum of each biomarker in discriminating the (CEA), squamous cell carcinoma antigen precursor peptide of GRP, is stable in SCLC and squamous cell carcinoma SCLC from SCC/ADK was assayed by a neuroendocrine differentiation within a (SCC), tissue polypeptide antigen (TPA) serum and it may be used as a possible (SCC) / adenocarcinoma (ADK) from ROC curve analysis. tumour may be present. and cytokeratin 19 fragment (CYFRA tumour marker of SCLC.5 Only few non-malignant lung disease (NMLD) and At the cut-off levels recommended 21-1) have been investigated in NSCLC by the manufacturers, ProGRP showed References and neuron specific enolase (NSE) in Table 1. Sensitivity and Specificity of biomarkers with respect to NMLD the higher sensitivity (93.5%) (Table 1) 1. Molina R, Filella X, Augé JM, Fuentes R, Bover I, Rifa SCLC.1-3 None of these markers is Biomarker Histology True Positive Sensitivity % and accuracy (AUC = 83.1%) (Figure 1, J et al. Tumor markers (CEA, CA125, CYFRA 21-1, SCC and NSE) in patients with non small cell lung specific for lung cancer and there is no Rate Counts (95% CI) A) in discriminating SCLC with respect cancer as aid in histological diagnosis and prognosis: clear relationship with the histological ProGRP SCLC 43/46 93.5 (82.1,98.6) to NMLD, while NSE was less sensitive comparison with the main clinical and pathological (Cut-off = 37.7) prognostic factors. Tumor Biol 2003;24:209-18. type. Some studies demonstrate SCC/ADK 230/371 62.0 (56.8,67.0) (51.2%) (Table 1) and showed an AUC 2. Foa P, Fornier M, Miceli R, Seregni E, Santambrogio CYFRA 21-1 is a prognostic and of 77.5% (Figure 1, B). L, Nosotti M et al. Tumor markers CEA, NSE, SCC, ProGRP SCLC 21/46 45.6 (30.9,61.0) TPA and CYFRA 21.1 in resectable non – small cell predictive marker mainly in the Regarding the discrimination between lung cancer. Anticancer Res 1999;19:3613-8. (Cut-off = 100) squamous subtype on the contrary SCC/ADK 5/371 1.3 (0.4,3.1) SCLC and SCC/ADK, all the biomarkers 3. Jorgensen LGM, Osterlind K, Genolla J, Gomm SA, NSE in SCLC. NSE alone has a low CEA SCLC 10/29 34.5 (17.9,54.3) showed a good accuracy with the Hernandez JR, Johnson PWM et al. Serum neuron specific enolase (S-NSE) and the prognosis in small sensitivity especially in patients with SCC/ADK 100/285 35.1 (29.6,40.9) exception of CEA and CYFRA 21-1. cell lung cancer (SCLC): a combined multivariable limited disease therefore it is frequently In conclusion, ProGRP appears analysis on data from nine centres. Br J Cancer CYFRA 21-1 SCLC 15/46 32.6 (19.5,48.0) 1996;74:463-7. combined with other tumour markers as more accurate than NSE and other 4. Wòjcik E, Kulpa JK, Sas-Korczynska B, Korzeniowski

CEA and CYFRA 21-1.3,4 SCC/ADK 83/371 22.4 (18.2,27.0) conventional biomarkers for SCLC and S, Jakubowicz J. ProGRP and NSE in therapy In recent years, studies have been NSE SCLC 22/43 51.2 (35.5,66.7) the addition of NSE does not increase monitoring in patients with small cell lung cancer. Anticancer Res 2008;28:3027-34. focused on a new marker: gastrin SCC/ADK 28/358 7.8 (5.2,11.1) accuracy. The positivity in NSCLC could 5. Yamaguchi K, Abe K, Kameya T Adachi I, Taguchi releasing peptide (GRP), a bombesin- be due to difference in histology: it may S, Otsubo K, et al. Production and molecular size LDH SCLC 45/46 97.8 (88.5,100) heterogeneity of immunoreactive gastrin releasing like peptide present in the adult human be speculated that in patients with peptide in fetal and adult lungs and primary lung gastrointestinal and respiratory tract. SCC/ADK 358/370 96.8 (94.4,98.3) NSCLC and increased levels of ProGRP tumors. Cancer Res 1983;43:3932-9.

Dates for your Diary Cardio-Thoracic Event Listings

27-31 January 2018 28 April-1 May 2018 54th Annual Meeting of the Annual Meeting of the Society of Thoracic Surgeons American Association for (STS) Thoracic Surgery (AATS) Fort Lauderdale, USA San Diego, USA www.sts.org www.aats.org

17-20 February 2018 24-27 May 2018 Annual Meeting of the German 26th Annual Meeting Society for Thoracic and of the Asian Society for Cardiovascular Surgery Cardiovascular and Thoracic Leipzig, Germany Surgery (ASCVTS) www.dgthg-jahrestagung.de Moscow, Russia www.ascvts2018.org 18-20 March 2018 Annual Meeting of the Society 18-20 October 2018 of Cardiothoracic Surgery in 32nd Annual Meeting of Great Britain and Ireland the European Association Glasgow, UK for Cardio-Thoracic www.scts.org Surgery (EACTS) Milan, Italy www.eacts.org

30 Issue 1 Saturday 7 October 2017 EACTS Daily News

General | Focus | Research in medicine: increasing the impact of your study Working together: upgrade from single- to multi-centre and the role of data sharing

Fabio Barili Department of Cardiac Surgery, to enroll a larger number of participants and to from clinical trials has two principal purposes, S. Croce Hospital, Cuneo, Italy guarantee a sample size that is sufficiently large evaluation of new aims and verification of the to ensure statistical power. External validity and original analysis; 35% of reanalyses led to different orking together”, is a mantra that consequently the generalisability of outcomes may interpretations compared with the original article4. repeatedly comes into a surgeon’s be enhanced by conducting studies at multiple It has become an ethical and scientific imperative, “Wlife. Surgeons are trained to work sites. Again, multicentre studies lead to faster rate as the potential for leveraging existing results for together in the operative field, and the updated enrollment, potentially reducing costs and logistical even more benefit pays appropriate increased definition of “Heart Team” has further emphasised difficulties that may be related with a longer tribute to the patients who put themselves at risk the adjunctive value of cooperation for obtaining recruitment period. to generate data, according to a recent position sharable decisions and increasing benefits Nonetheless, all that glitters is not gold, and statement from the International Committee of for patients. multicentre studies intrinsically carry some potential Medical Journal Editors5. The data sharing process The concept of teamwork is gaining a more and drawbacks and difficulties1,2. Both multicentre has obviously generated new controversies; more critical role also in clinical and basic research, observational studies and trials are considerably nonetheless it is increasingly mandated by trial and cardiothoracic surgery is participating to more complex in coordination, quality control sponsors and supported by influential groups, and this dynamic evolution in all fields of research. and data management and it is essential to have it will grow in the coming years. Debated issues that have not been clarified in the efficient central coordination of all study activities. The scale tips towards “working together”. last decades are calling for an increased number They could have high costs and therefore require of multicentre trials and the wide development adequate funding from the onset. In prospective definitions of matched variables among centres. References of multicentre registries has been facilitated by studies, data collection should be standardised Multicentre studies also give rise to numerous 1. Guthrie LB, Oken E, Sterne JA, Gillman MW, Patel R, Vilchuck K, et al. Ongoing monitoring of data clustering in multicentre studies. BMC the advent of new technologies, such as TAVR. as much as possible and adhesion to study ethical challenges, related to privacy protection Med Res Methodol. 2012 Mar 13;12:29. Moreover, methodological limitations of single protocols should be similarly implemented and and operationalisation of informed consent. 2. Appel LJ. A primer on randomized controlled trials. Clin J Am Soc Nephrol. 2006;1(6):1360-7. observational studies have led a higher quote of monitored in all centres, as inter-site variability The new frontier is data sharing: the availability 3. Tenopir C, Allard S, Douglass K, Aydinoglu AU, Wu L, Read E, et al. researchers to link singular clinical databases to can result in a high degree of clustering and in of data from published trials for new analyses. The Data sharing by scientists: practices and perceptions. PLoS One. 2011;6(6):e21101. overcome all potential drawbacks. substantially reduced study power. A similar amount of data collected, analysed and stored has 4. Ebrahim S, Sohani ZN, Montoya L, Agarwal A, Thorlund K, Mills Multicentre studies show several advantages1. issue of standardisation of data collection widely increased enormously and they can provide inputs EJ, et al. Reanalyses of randomized clinical trial data. JAMA. 2014;312(10):1024-32. They enhance the ability to investigate low- emerges in multicentre retrospective studies, as to new hypotheses, enabling new scientific inside 5. Bauchner H, Golub RM, Fontanarosa PB. Data Sharing: An Ethical incidence disease or exposure, as they permit linkage-related biases could depend on different and driving innovation3. Sharing data produced and Scientific Imperative. JAMA. 2017;317(1):33-34.

Cardiac | Focus | EACTS/PASCaTS - Controversies in Rheumatic Heart Valve Surgery: Valve Selection Shaving the rheumatic mitral valve: For how long?

Taweesak Chotivatanapong live in remote areas, and many of them for cardiac surgery. Because of the improves pliability and attenuates valve Bangkok Heart Hospital, BDMS have problems with warfarin compliance complexity of lesions which in turn end repair. With better understanding of Hospital Network, Bangkok, Chest – needed for optimal anticoagulation up in malfunction, surgical approaches the integrated function of the mitral Disease Institute of Thailand, in those who receive mechanical valve and techniques need to be adapted complex, the scope of mitral valve repair Nonthaburi, Thailand replacement. Although prosthetic valve and applied to restore normality in mitral has been progressively expanded with replacement offers immediate and good valve dynamics and function. gratifying results. These techniques alvular heart disease remains function, there are many disadvantages, Through this presentation, several will be illustrated in detail through the major heart problem major setbacks and problems for good innovative techniques for treating video presentations. in this region, with the long-term outcomes. rheumatic mitral valve disease will be In conclusion, rheumatic mitral valve mitral valve being the most Although mitral valve repair has demonstrated from MR, mixed MS MR repair in this region has been improved commonlyV affected valve. Rheumatic proven to be better than valve and predominantly MS. One of these impressively. Several advances and valvular heart disease is the main replacement in many aspects, is the Peeling-plasty of the thickened innovative approaches have greatly causative factor and unfortunately, most rheumatic valve disease poses a special leaflets of rheumatic mitral valves. expanded the scope of mitral valve of the patients in this group are young, entity, and has become a big challenge Shaving of the leaflets significantly repair with gratifying outcome.

Pick up your copy of Daily News Issue 1 Saturday 7 October The official newspaper of the 31st EACTS Annual Meeting 2017 In this issue Welcome to Vienna 2 A new European VAD perspective The 31st Annual Meeting of the European 4 Working towards a EACTS NOBLE endpoint Association for Cardio-Thoracic Surgery

t is with great pleasure to During two competitions rounds on welcome you to the 31st Sunday and Monday, national teams EACTS Annual Meeting in – composed of one cardiac and Vienna, and we are honoured one general thoracic resident or two and delighted with your cardio-thoracic residents – will test presence at this conference. their cognitive skills and compete for a The purpose of this event is to ticket to the next STS Annual Meeting I in Fort Lauderdale in January 2018. facilitate the exchange of knowledge and information for clinicians and The winning team will represent Europe researchers. As you will see, this year’s and will compete against the American winners for the ‘World Champion’ title. Daily News 5 Implementing programme covers the many different guidelines in lone AF aspects of cardio-thoracic surgery, Come to cheer on the teams and try to emphasising areas that are important in test your own knowledge! 5 Improving patient our daily clinical work. As ever, we are consent hoping to create an interactive meeting Gala Dinner with the exchange of knowledge and Join us for this year’s Gala dinner at the ideas, fostering discussions and debates Orangerie Schönbrunn on Tuesday 10 October, located within the grounds of AVAILABLE EVERY DAY between delegates. the magnificent Schönbrunn Palace. Honoured Guest Lecture One of the two largest Baroque On Sunday, our honoured guest lecture orangeries in the world (the other being will be given by health economist at Versailles), the building is 189 metres Professor Pedro Pita Barros from long and 10 metres wide and dates Lisbon, who will provide his insights on back to 1754. Joseph II was especially ‘Economics meets healthcare: how can it fond of arranging banquets in the plant- be useful?’ filled Orangery, emulating those he had Join us to hear what we can learn experienced on his journey to Russia in about health economics from a national the winter garden of the imperial palace and European perspective. in St Petersburg. Join us in these 8 Inside Vienna guide historic surroundings for a fun-filled Guidelines evening of fine dining and entertainment! 20 EACTS Agenda This year, we bring you three new clinical Dress code is Lounge Suits. guidelines – which will be presented 25 The EACTS during the meeting –continuing to EACTS Professional demonstrate the importance of the If you appreciate what the EACTS Leadership application of guidelines in every day presents during this event and you Workshop clinical practice: would like to support the work of the n ESC/EACTS Guidelines for the association, I encourage you to visit the management of valvular heart disease EACTS booth and become a member. The membership fee is low, and you n EACTS and EACTA Joint Guidelines EACTS booth in the exhibition area. At techniques presented at this year’s on Patient Blood Management for will receive the European Journal Annual Meeting will be of great interest. of Cardio-Thoracic Surgery and the the booth you will also find information Adult Cardiac Surgery on our new courses planned for 2018, In addition to an outstanding scientific n EACTS Guidelines on perioperative Interactive CardioVascular and Thoracic programme, the opportunity to explore Surgery Journal as well as a reduced our Quality Improvement Programme medication in adult cardiac surgery and how you can learn and publish with Vienna’s rich cultural heritage, including Two of these guidelines have been rate for the Annual Meeting. Also, the many historical buildings and engage EACTS has developed a digital portfolio our multi-media manual MMCTS. the result of collaborative work with Of course, we thank our industry with (new) friends over some Wiener the European Society for Cardiology management system to keep track of Schnitzel, will make your stay in Vienna your residency training programme (for partners for their continued support and with the European Association of of the Annual Meeting, and all the memorable. Cardiothoracic Anaesthesiology. trainees and trainers) which is simple I hope you enjoy the meeting and all to use and free for members. You can presenters who have taken the time to contribute to this year’s EACTS that Vienna has to offer. complete your membership application Domenico Pagano Jeopardy Daily News. 38 Satellite Symposia @ online through the EACTS website EACTS Secretary General Special attention should also be We hope the information and 31st EACTS Meeting reserved for the ‘Jeopardy’ sessions. (www.eacts.org) or by visiting the EACTS Daily News Issue 1 Saturday 7 October 2017 31

Vascular | Abstract | Light and shades of the arch Unilateral or Bilateral Antegrade Cerebral Perfusion? A Report from the ARCH Multi-Institutional Database

Martin Misfeld, David H Tian, Roberto Di Bartolomeo, Himanshu J Patel, Deniz Goksedef, Alberto Pochettino, Scott LeMaire, Aung Oo, Michael Borger, Tristan Yan and Sergey Leontyev on behalf of the International Aortic Arch Surgery Study Group

here has been a ACP cannulation via either the gradual preferential innominate or axillary artery, shift favouring while 1556 patients received antegrade cerebral bilateral ACP through the perfusionT (ACP) as the primary innominate or axillary artery with neuroprotection strategy in aortic left common carotid and/or left arch surgery. However, significant subclavian artery perfusion. No variations in ACP techniques discrimination was made with exist, with opinions differing regards to the temperature or regarding whether to perfuse the duration of circulatory arrest. brain unilaterally or bilaterally. After one-to-one propensity The current study analysed the matching, 140 patient-pairs similar in both groups. The unilateral ACP cohort, as was similar postoperative outcomes, Subgroup analysis of impact of unilateral ACP (uACP) were identified. Proportions of duration of lower body and cerebral perfusion time (19 vs with comparable rates of circulatory arrest time compared to bilateral ACP total arches and descending brain circulatory arrest time 27 mins, p < 0.001). The two mortality and PND, as well as longer than 30 minutes (bACP) in elective aortic arch aortic graft procedures were was significantly reduced in the matched groups demonstrated ICU and hospital lengths of stay. These patients were surgery. It is one of the projects separately analysed to of the International Aortic Arch determine whether uACP Table 1 Overall Propensity-matched Surgery Study Group (IAASSG). or bACP has any impact in Unilateral (n=44) Bilateral (n=1004) P value Unilateral (n=38) Bilateral (n=38) P value complex cases. Within this IAASSG Operative durations cohort, thirty-eight propensity- The IAASSG has been formed CPB time (mins) 197 (150-265) 197 (158-242) 0.543 201 (150-280) 206 (163-264) 0.568 matched patient pairs were by 41 academic surgeons from identified. CPB and circulatory Cross-clamp time 120 (81-164) 116 (82-155) 0.609 120 (87-182) 113 (78-143 0.268 34 cardiac centres and 10 (mins) arrest durations were similar countries (Figure 1). The rationale between both groups, but Lower body 50 (37-64) 50 (40-67) 0.640 49 (37-61) 56 (42-80) 0.158 of this collaboration is to evaluate cerebral perfusion time was circulatory arrest optimal neuroprotection strategies time (mins) significantly longer for bACP and surgical techniques, to patients (42 vs 63 minutes, Brain circulatory 9 (2-30) 2 (1-4) <0.001 6 (1-29) 3 (0-7) 0.041 assess perioperative mortality arrest time (mins) p = 0.003). Comparable and morbidities and formulate outcomes, including mortality Cerebral perfusion 39 (30-49) 69 (52-89) <0.001 42 (30-54) 63 (41-88) 0.003 predictors for operative risk, time (mins) and neurological deficits, were as well as to evaluate long- seen in both groups (Table Clinical outcomes term survival and quality-of-life 1). This study demonstrates in patients undergoing aortic Mortality 6 (12.2) 86 (8.4) 0.330 5 (13.2) 5 (13.5) 0.558 that in patients undergoing arch surgery. PND 3 (6.1) 57 (5.6) 0.879 2 (5.3) 1 (2.6) 0.455 elective hemiarch or total TND 1 (2.0) 68 (6.7) 0.182 1 (2.8) 4 (11.4) 0.248 arch replacements, clinical uACP versus bACP outcomes following uACP and Myocardial infarct 0 (0.0) 13 (1.3) 0.482 0 (0.0) 1 (3.3) NA Patients from the ARCH Multi- bACP are comparable. Institutional Database 5, who Arrhythmia 14 (28.6) 268 (26.2) 0.698 11 (31.4) 9 (34.6) 0.629 underwent elective hemiarch AKI 5 (10.2) 100 (9.8) 0.755 4 (13.8) 4 (11.4) 0.704 The ARCH project promotes or total arch aneurysmal Wound infection 0 (0.0) 34 (3.3) 0.153 0 (0.0) 3 (9.4) NA closer collaboration of centres replacement with ACP as the focusing on aortic arch surgery to Bleeding 5 (10.2) 97 (9.5) 0.602 4 (12.9) 4 (10.8) 0.570 sole neuroprotection strategy improve patient outcome. At this between 2000-2015 were ICU LOS 3 (1-6) 3 (2-6) 0.142 2 (1-5) 4 (2-9) 0.216 year’s EACTS Annual Meeting, two identified for subsequent papers from the ARCH project will Hospital LOS 11 (8-15) 18 (11-28) <0.001 11 (8-17) 13 (8-22) 0.457 analysis. From this cohort, 148 be presented. patients underwent unilateral AKI, acute kidney injury; CPB, cardiopulmonary bypass; ICU, intensive care unit; LOS, length of stay; PND, permanent neurological deficit; TND, temporary neurological deficit

Thoracic | Abstract | Lung cancer – controversies Survival rate and prognostic factors of surgically resected clinically synchronous multiple primary non-small-cell lung cancer (SMP-NSCLC) and further differentiation from intrapulmonary metastasis

Fei Xiao, Xiaowei Wang, Martini-Melamed criteria. A total of stage (p = 0.022) were independent metastasis. Semiconductor sequencing Zhenrong Zhang, Deruo Liu, 106 tumours were surgically removed, risk factors identified in the multivariate based on the Ion Personal Genome Chaoyang Liang National Clinical and were all subjected to pathological analysis. Lung adenocarcinomas were Machine (PGM™) System was Research Center for Respiratory examination. The perioperative morbidity classified as pre-invasive lesion such performed with the Ion AmpliSeq Cancer Diseases; Department of Thoracic rate was 5.8%, without any perioperative as atypical adenomatous hyperplasia Panel v2 to sequence more than 2,800 Surgery, China-Japan Friendship death. Close follow-up and survival (AAH) and adenocarcinoma in situ (AIS), loci from 50 oncogenes and tumour Hospital, Beijing, China analysis for risk stratification were minimally invasive adenocarcinoma (MIA), suppressor genes in tumour DNA. performed. The overall five-year survival and invasive adenocarcinoma classified Our work indicated that the ynchronous multiple primary rate was 40.6%, the cancer-specific by a predominant pattern after using postoperative survival rates in SMP- non-small-cell lung cancer five-year survival rate was 54.5%, and comprehensive histologic subtyping with NSCLC were satisfactory. Non-radical (SMP-NSCLC) is a rare entity, the median survival time was 52 months. lepidic, acinar, papillary, micropapillary resection might improve the prognosis but there has been a gradual Older age (p = 0.553), sex (p = 0.600), and solid patterns. Variants of invasive for patients with a tolerable general Sincrease in the number of patients smoking history (p = 0.496), tumour adenocarcinomas were included as condition and pulmonary function. diagnosed with SMP-NSCLC as a distribution (p = 0.461), video-assisted well. Different pathological subtypes Higher pT stage might result in poorer result of advances in the diagnostic thoracoscopic surgery (p = 0.398), and were identified in 13 of 18 cases of survival rates. Larger sample size and methods. However, the staging and adjuvant chemotherapy (p = 0.078) multiple adenocarcinomas. future study are still needed to identify therapeutic strategy for SMP-NSCLC did not affect survival. Preoperative Next generation sequencing was the independent prognostic factors. remains unclear. Distinguishing SMP- and prognoses. percentage of forced expiratory volume applied to six cases of multiple primary Comprehensive histologic assessment NSCLC from intrapulmonary metastasis Our single-centre, retrospective study in the first second (p = 0.022), Charlson lung adenocarcinoma with similar and next generation sequencing is difficult but of great importance enrolled 52 patients diagnosed with comorbidity index (p = 0.034), surgical pathological subtypes for further could be effective methods for for selecting the surgical procedure SMP-NSCLC according to the modified procedure (p = 0.040), and highest pT differentiation from intrapulmonary screening SMP-NSCLC. 32 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Focus | Rapid deployment valves: New evidence & clinical cases discussion What can we say after five years, and five hundred implants?

Martin Andreas1, Iuliana Magna 21 Magna 21 pledgets Coti1, Raphael Rosenhek2, Shiva Shabanian1, Stephane Mahr1, Keziban Uyanik-Uenal1, Dominik Wiedemann1, Thomas Binder2, Alfred Kocher1, Guenther Laufer1 1. Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; 2. Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria

he Edwards INTUITY follow-up was 12 months and the total valve system is a balloon- accumulated follow-up was 818 patient expandable bioprosthesis years. Preoperative characteristics, inspired from the Edwards operative specifications, survival, MagnaT valve and transcatheter valve related adverse events and valve technologies, with a subvalvular stent haemodynamics were assessed. frame to enable rapid-deployment Implantation success was 99% Figure 2: Effect of pledgets on transvalvular flow pattern. (Figure 1). We participated in early and (500/504), 30-day mortality was Calculated by Chiara Corsini and Claudio Capelli, UCL2 recent clinical trials and selected the 0.8% (4/500) and overall survival INTUITY valve as our standard valve at one, three and five years was 12±5 and 11±3 mmHg. Pacemaker disturbances requiring pacemaker paravalvular leakage or valve pop-out. for surgical aortic 94%, 89% and 81% (Figure 3). implantation was performed in 43 implantations remain a matter of Long-term survival and valve durability valve replacement1. Minimally invasive surgical patients (8.6%). A single case (0.2%) concern and are currently under further is excellent and underlines the value We previously approach was chosen of structural degeneration (6 years study. Implantation requires correct of this technique for surgical aortic compared this in 236 patients FU) was registered and treated with a sizing and proper training to avoid valve replacement. rapid-deployment (47%), of which valve-in-valve (ViV) implantation. valve to standard 122 (24%) were The INTUITY prosthesis appears References bioprostheses through anterior to be a low-risk prosthesis for ViV 1. Laufer G, Haverich A, Andreas M, Mohr FW, Walther and analysed right thoracotomy. procedures compared to other T, Shrestha M et al. Long-term outcomes of a rapid the effects of Cross-clamp and surgical valves. Valve explantation deployment aortic valve: data up to 5 years. Eur J Cardiothorac Surg 2017;52:281-87. the anchoring cardiopulmonary for non-structural dysfunction 2. Capelli C, Corsini C, Biscarini D, Ruffini F, Migliavacca mechanism bypass times or endocarditis occurred in nine F, Kocher A et al. Pledget-Armed Sutures Affect on transvalvular for isolated AVR cases (1.8%). the Haemodynamic Performance of Biologic Aortic Valve Substitutes: A Preliminary Experimental and gradients (Figure 2)2,3. Figure 1: Edwards INTUITY were 53±17 and The implantation of a RD-AV has Computational Study. Cardiovasc Eng Technol Herein, we report ELITE valve. Copyright 89±29 minutes shown excellent results concerning 2017;8:17-29. our experiences after Edwards Lifesciences for full sternotomy haemodynamic performance, is 3. Andreas M, Wallner S, Habertheuer A, Rath C, more then 500 implants between May and 75±23 and 110±31 minutes for feasible, safe and reduces the Schauperl M, Binder T et al. Conventional versus rapid-deployment aortic valve replacement: a single- minimally invasive approaches. The cross-clamp and cardiopulmonary 2010 and July 2017 (mean age 73.6 Figure 3: Single centre long-term centre comparison between the Edwards Magna ±7.9 years, 45.6% female) in patients mean gradients at discharge, one year, bypass times, facilitating minimally survival. Standard access (blue line), valve and its rapid-deployment successor. Interact with severe aortic stenosis. Median three and five years were 13±5, 11±4, invasive approaches3. Rhythm minimally invasive approach (green line) Cardiovasc Thorac Surg 2016;22:799-805.

Congenital | Abstract | Surgical management and outcomes Outcomes of double-patch and Warden techniques in patients with supracardiac partial anomalous pulmonary venous connection: a prospective randomised study

by some retrospective studies. According to this data and lack of prospective studies in this field, we decided to perform a prospective trial, comparing double-patch (DP) and Warden techniques in terms of SND and stenosis of pulmonary and systemic veins. Between September 2013 and March 2016 we enrolled 80 patients with PARPVC to the SVC, which were randomly assigned into DP and WP group. Preoperative 24-hour Holter ECG monitoring and contrast Figure 1. Sinus node dysfunction dynamics during the study cardiac CT were performed in all patients. SND was defined of the SVC and PV anatomy. occurred in either group. No as a change in rhythm from No mortality occurred in the significant SVC or PV stenosis sinus to nodal or low atrial after early and late postoperative were revealed in any patient. surgery and, in cases of sinus period. Immediately after surgery Surgical correction of the rhythm with inappropriately low SND was observed in 27.5% PARPVC to the SVC with Alexey Zubritskiy, Yuriy Naberukhin, Alexey Arkhipov, Yuriy Gorbatykh, Timur heart rate requiring temporary of cases after DP correction any technique has excellent Khapaev, Nataliya Nichay, Yuriy Kulyabin, Alexander Bogachev-Prokophiev, atrial pacing. There were and in 5% after the WP. The outcomes in terms of survival Alexander Karaskov National Medical Research Center, Novosibirsk, Russian Federation patients in each group who multivariate logistic regression and has a low rate of serious were operated on through right analysis revealed that the DP complications, independent mong pulmonary the SVC correction are sinus pacemaker implantation. Up to midaxillary thoracotomy (17 method was an independent from the surgical approach venous return node dysfunction (SND) and 18.1% of patients have SND at in the DP and 19 in the WP risk factor for SND in the early used. Warden procedure had anomalies, a systemic and pulmonary venous midterm follow-up. Up to 6% group). Intraoperatively and in period. At follow-up (22.5 (range, benefits in transient SND in partial anomalous (PV) obstruction. Any surgical of patients with PAPVC were the early postoperative period, 12-39) months) SND persisted the early postoperative period connectionA of the right technique could pose the risk of reported to undergo pacemaker heart rhythm was assessed by in 2 (5%) patients after DP compared to those for the DP pulmonary veins (PARPVC) to the these events, which is caused implantation at late follow-up. online ECG monitoring with trend correction and was manifested technique. SND after PARPVC superior vena cava (SVC) is the by the specific anatomy in the Hypothetically, procedures recording. At discharge and at as an atrioventricular nodal to the SVC correction tends to most frequent type, occurring in region of this anomaly. Trauma (excluding cavoatrial incision) midterm follow-up all patients rhythm with a sufficient heart rate disappear spontaneously. There approximately 10% of patients to the sinus node or its blood such as the Warden procedure underwent 24-hour Holter ECG. during all monitoring periods. was no significant difference in with atrial septal defects supply elements can cause (WP) or the transcaval technique Also, cardiac contrast CT was All patients had normal sinus SND after the DP technique and (ASDs). The most significant serious rhythm disturbances, could minimise the risk of performed in all patients at rhythm after the WP (Figure 1). Warden procedure at the mid- complications after PARPVC to which can require permanent arrhythmias, which is supported follow-up for precise assessment No late pacemaker implantation term follow-up. EACTS Daily News Issue 1 Saturday 7 October 2017 33

Cardiac | Abstract | Managing degenerated aortic prosthesis Technical feasibility does not guarantee clinical improvement: A word of caution for valve-in valve procedures in small surgical prosthesis

1 ME Stelzmueller , B. addition, life expectancy is diameter TAV-Prostheses uneventful resulting in an Table 1. Dimensions of aortic bioprostheses Mora2, G Laufer1, W increasing. That is why we will (20 mm) are available for excellent positioning of the valve Aortic bioprosthesis Labelled Inner External 1 be facing a growing number bioprosthetic valves with an prosthesis and no paravalvular Wisser 1. Department of size (mm) diameter diameter/ Cardiac Surgery, Medical of patients with a degenerated inner diameter of at least leakage. Despite of this technical (mm) incl. University Vienna, Austria; 2. aortic valve prosthesis. 17 mm. success, the invasively measured sewing Department of Cardiothoracic Although it is technically This case report points out peak to peak gradient remained ring (mm) Anesthesia and Intensive Care feasible to implant a small the problem of TAVI in small as high as 21 mmHg, the Edwards Magna Ease 18 24 transcatheter aortic valve in a bioprosthetic heart valve. The echocardiography revealed a Edwards Magna 18 24 he reoperation of a degenerated bioprosthesis, we patient, an 85-year-old woman, peak gradient of 13 mmHg. Edwards Perimount 18 26 degenerated small are still dealing with the problem presented with NYHA III and The postoperative hospital aortic bioprothesis of the high postoperative fatigue six years after aortic stay was uneventful and the Medtronic Mosaic 19 17.5 25 is challenging for gradients, especially in the valve replacement (Mitroflow patient was discharged on the Medtronic Mosaic Ultra 17.5 24 standardT cardiac surgery as well treatment of frail octogenarians. 19 mm) and coronary bypass 10th post-operative day, with Sorin Mitroflow 15.4 21 as for transcatheter aortic valve Use of a small diameter surgery. The echocardiography marginal regression of dyspnoea SJM Epic Supra 19 25 implantation (TAVI). To heart valve ends up in a examination revealed a and a discharge mean gradient avoid a more complex higher gradient after severe degeneration of the of 37 mmHg, which was similar aortic root anuloplasty surgery, due to a bioprosthesis with a mean to the preoperative gradient. Edwards Magna Ease 20 26 to enlarge the native small inner diameter gradient of 40 mmHg and an Almost one year after surgery, Edwards Magna 20 26 aortic annulus, and consecutively AVVmax 4.4 m/s, and preserved the patient still suffers from Edwards Perimount 20 28 many surgeons smaller aortic valve left ventricular function. Due dyspnoea with a mean gradient tend to rather area. Additionally to her risk profile with a log. of 26 mmHg and reduced left Medtronic Mosaic/ implant smaller there is a significant EuroScore of 38.7% and ventricular ejection fraction. HancockII 18.5 27 21 aortic valves. Because variety between an EuroScore II of 15%, we Although it is technically Medtronic Mosaic Ultra / 18.5 26 of the promising the different deemed the patient inoperable. feasible to implant a small TAVI HancockII Ultra developments and companies Because of severe peripheral prosthesis (like Edwards Sapien Sorin Mitroflow 17.3 23 longer durability of (Table 1). artery disease, the patient 20 mm) into a small bioprothesis, SJM Epic Biocor 19 25 bioprostheses, However, was rejected for TF-TAVI, so we have to pay attention to they were small we decided to perform an off achievable haemodynamic SJM Epic Biocor Supra 21 28 used more label implantation of a 20 mm improvement postoperatively. generously TF Edwards Sapien prosthesis Knowing these results, we in younger patients. Furthermore, operation should be avoided, to even in younger through a transapical approach. have to address these findings the implantation of small surgical leave the option of a valve-in- patients. In The implantation was when implanting bioprostheses valves in the context of the first valve TAVI open.

Thoracic | Abstract | Lung transplant advanced techniques The Munich Lung Transplant Group: Five-year experience with the Lung Allocation Score

Barbara Schuba1, Miriam Table 1. Characteristics of patients undergoing lung transplantation 2011-2016 2 2 Scheklinski , Christian Hagl , mean LAS n Waiting ILD COPD CF Others 1-year Christian Schneider3, Vera von time survival 1 3 Dossow , Gerhard Preissler , 2012 50.6 ± 18.0 73 205 ± 507 27.4% 28.8% 32.8% 11.0% 84.9% Nikolaus Kneidinger4, Claus Neurohr4, Sebastian Michel2 2013 47.6 ± 17.4 57 205 ± 386 33.3% 33.3% 26.3% 7.0% 77.2% and Rene Schramm2,5 2014 48.2 ± 14.6 57 141 ± 230 35.1% 21.1% 35.1% 8.8% 86.0% 1. Department of Anesthesiology; 2015 47.3 ± 16.0 37 248 ± 461 43.2% 18.9% 29.7% 8.2% 84.0% 2. Clinic of Cardiac Surgery; 3. 2016 45.2 ± 16.2 63 194 ± 300 54.0% 19.0% 20.6% 6.4% - Department of Thoracic Surgery; 4. Medical Clinic V; 5. Transplantation Values are n (%) or mean ± SD. Center Munich, Ludwig-Maximilians- University Munich, Marchioninistr. 15, centre after implementation of the proportion of patients with COPD and mortality compared to double lung D-81377 Munich, Germany LAS until December 2016. Patients CF undergoing lung transplantation transplantation at our cohort. were divided into four groups declined over a period of 5 years. We conclude that our five-year he Lung Allocation Score according to their primary diagnosis: In reverse, patients with interstitial experience with the LAS confirm (LAS) was first introduced i.e. obstructive lung disease, e.g. lung disease were transplanted with previous findings from the United States in the United States in 2005 chronic obstructive pulmonary disease increased frequency. Consequently, we demonstrating that the LAS recognizes with satisfactory results, the effect of the LAS five years after (COPD) or emphysema; interstitial observed an increasing proportion of well the disease specific rapid andT was consequently implemented in its implementation on waiting list lung disease (ILD), e.g. idiopathic COPD patients on the waitlist without deterioration in patients with interstitial Germany in December 2011.There are characteristics and posttransplant pulmonary fibrosis; cystic fibrosis (CF) relevant changes in waiting times. lung disease. The LAS did not shorten only limited and short-term data on the outcomes at our clinic, a high-volume and others, e.g. sarcoidosis or primary However, overall survival outcome overall waiting times in transplanted effect of the LAS on lung transplantation lung transplant centre. Our study pulmonary hypertension. was independent of the underlying patients. Further multicentre long-term programs within the influential area of included 294 patients who underwent We noted a shift of lung transplant disease entity or the height of the LAS. data respecting differential transplant the Eurotransplant Foundation (ET). single or bilateral lung transplantation procedures performed within the Notably, single lung transplantation centre activities are required for The aim of this study was to evaluate for end-stage lung disease at our groups of underlying diagnosis. The was associated with significantly higher additional evaluation. 34 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Abstract | Patient blood management to reduce surgical risk Bloodless cardiac surgery in Jehovah’s Witness Patients: 20-year single-centre experience

Emilio Monguió, Nieves de Antonio, Daniel Muñoz, procedures in JW patients may Corazón M Calle, Anás Sarraj, Mar Orts, Carlos be performed with acceptable Figueroa and Guillermo Reyes Hospital Universitario de La results respecting their blood Princesa, Madrid, Spain transfusion refusal. Early referral to surgery, preoperative lthough transfusion preoperative haemoglobin and optimisation, intraoperative blood is a major concern iron metabolism, discontinuation saving and a multidisciplinary in cardiac surgery, it of antiplatelet or anticoagulant management in experienced still occurs in up to therapy, prevention of excessive centres are the key aspects to halfA of patients undergoing this haemodilution and inadvertent treat these patients safely. A procedure. Multivariate analyses blood loss, systematic use of cut-off of 12 g/dL of preoperative have identified transfusion as an cell saver, aggressive treatment haemoglobin may be useful to independent factor for mortality. of post-CPB coagulopathy, schedule patients for surgery. There are more than 1,500,000 and early reoperation in case of Jehovah’s Witnesses (JW) across postoperative bleeding. References Europe. In order to conform In-hospital mortality occurred 1. Vasques F, Kinnunen EM, Pol M, to their strongly held beliefs, in 12 patients (8.7%): four Mariscalco G, Onorati F, Biancari F. Outcome of Jehovah’s Witnesses after JW refuse to receive blood or due to cardiogenic shock, adult cardiac surgery: systematic review its derivates. three due to A-V groove and meta-analysis of comparative studies. A retrospective study involving disruption, two of postoperative From left to right: Anas Sarraj, Guillermo Reyes, Mar Orts, Emilio Monguió and Carlos Figueroa. Transfusion 2016;56:2146-2153. 2. Vaislic CD, Dalibon N, Ponzio O, Ba M, nearly 20 years and 138 JW from haemorrhage. There was one Jugan E, Lagneau F et al. Outcomes the beginning of our surgery fatal cerebrovascular accident, EuroScore I and NYHA class haemoglobin <12g/dl OR 11.5 outcomes. Transfusion and in cardiac surgery in 500 consecutive Jehovah’s Witness patients: 21 year programme was conducted. one sudden cardiac arrest and IV were significantly related (1.7-78.8), p = 0.01. anaemia also increase mortality, experience. J Cardiothorac Surg 23.9% of patients had previous one iatrogenic haemothorax. to mortality and a tendency To our knowledge, the most especially in patients with major 2012;7:95. cardiac surgery and 18.8% left Regarding morbidity, 13 patients was observed in patients with important aspect of surgery in bleeding following surgery. We 3. Ranucci M, Baryshnikova E, Castelvecchio S, Pelissero G; Surgical and Clinical ventricular dysfunction. NYHA (9.4%) required early reoperation preoperative haemoglobin JW is preoperative optimisation did not find any complication Outcome Research (SCORE) Group. Major class III or worse was observed for bleeding, AKI requiring renal <12g/dL. Multivariate analysis to avoid anaemia at the time with systematic use of bleeding, transfusions and anemia: the in 65.2% of patients. substitution therapy in 8 patients confirmed these three variables of surgery and to correct any preoperative intravenous iron deadly triad of cardiac surgery. Ann Thorac Surg 2013;96:478-85. We applied our JW institutional (5.7%), sternal complications in 8 related to mortality: EuroScore deficiency of blood components. and erythropoietin suggesting 4. Tanaka A, Ota T, Uriel N, Asfaw Z, Onsager protocol, of which the main patients (5.7%), cerebrovascular I OR 1.1 (1.03-1.2), p = 0.01; It has been established that that this strategy may be applied D, Lonchyna VA et al. Cardiovascular surgery in Jehovah’s Witness patients: The lines are: Specific informed accident in 7 (5.1%), and IABP NYHA IV OR 23.2 (1.5- anaemia is an important risk more widely. role of preoperative optimization. J Thorac consent, optimisation of insertion in 5 patients (3.6%). 364.9), p = 0.03; preoperative factor for bad postoperative Usual cardiac surgery Cardiovasc Surg 2015;150:976-83.

Cardiac | Rapid Response | Aortic valve repair Aortic cusp free edge often plicated but never measured: A clinical study in aortic valve sparing and repair surgery

Laurent de Kerchove1, Stefano echocardiography. Patients were divided FEL was similar between two cusps (p = ns) and Mastrobuoni1, Silvia Solari1, Michel van depending on AV function: 1/ normal (control increased by 35% compared to control group (p < Dyck2, Christine Watremez2, Phillipe group, TAV=8), 2/ dilated aorta (±central AI) 0.001). In BAV with eccentric AI, FEL of fused cusp Noirhomme1, Parla Astarci1, Gebrine (TAV=28, BAV=16), 3/ eccentric AI (±aorta (prolapsing) was increased by 19% compared to el Khoury1 1. Université Catholique de dilatation) (TAV=27, BAV=17). The FEL and gH non-fused cusp (non-prolapsing; p < 0.001) and Louvain and Division of Cardiothoracic and were compared between groups and between by 74% compared to control group (p < 0.001). Vascular Surgery, Cliniques Universitaires prolapsing and non-prolapsing cusp. “Cusp In all BAV patients, gH of non-fused cusp was Saint-Luc, Brussels, Belgium; 2. Division of mobility ratio” was defined as FEL/STJ (sinotubular significantly larger compared to gH of fused cusp Anesthesiology, Cliniques Universitaires Saint- junction diameter) and was calculated for and control group (p < 0.001). Cusp mobility ratio Luc, Brussels, Belgium each group. was 1.2 in dilated root and 1.7 for fused cusp in The results are summarised in Figure 2. In eccentric AI group. ortic valve (AV) repair and sparing TAV, FEL and gH were increased by 30% and This study shows that in dilated aorta and surgery is an attractive option to treat 10% respectively in patients with dilated aorta cusp prolapse, the FEL increases significantly selected young patients with severe compared to control group (FEL p < 0.001, gH compared to patients with normal AV function. The aortic insufficiency (AI) and dilated root. p = ns). In those two groups, FEL and gH were gH increases only slightly in those pathological DuringA the last two decades, intense developments similar between three cusps (p = ns). In patient circumstances and its size seems to depend more have standardised surgical techniques improving with eccentric AI, FEL and gH of the prolapsing on valve anatomy (TAV vs BAV). The so called reproducibility and long-term results. Still, better cusp were increased by 15% and 3% respectively “cusp mobility ratio” decreases in dilated aorta knowledge of anatomy and morphopathology compared to non-prolapsing cusp (FEL p < 0.001, as an expression of restricted cusp motion and must help to improve further AV assessment and gH p = ns) and by 43% and 12% respectively it increases in cusp prolapse as an expression develop more objective repair techniques. compared to control group (FEL p < 0.001, gH p of excessive cusp motion. These data can The systematic measure of geometric = ns). Cusp mobility ratio was 1.3 in controls, 1.1 help to develop more objective techniques of height (gH) help to assess the quantity of cusp but echo is relatively imprecise in measuring the in dilated aorta and 1.4 for the prolapsing cusp in cusp assessment and repair using eventually a tissues, orient the decision to repair and guide FEL especially in prolapsing cusp and bicuspid the eccentric AI group. In BAV with dilated aorta, dedicated free edge sizer. annuloplasty sizing. Free edge length (FEL) AV (BAV). The aim of this study was to analyse, shortening with central plication aims to treat for the first time, the FEL (and gH) in normal and Figure 2. Mean values of FEL and gH for TAV and BAV in the different functional groups. cusp prolapse and optimises valve configuration pathological circumstances. and coaptation (Figure 1). We already know Therefore, we intraoperatively measured from an echocardiographic study by Thubrikar the FEL and gH in 96 patients operated for AI, et al. (Eur J Cardiothor Surg,2005;28:850-856) dilated aorta, endocarditis or fibroelastoma. Root that the FEL increases in dilated aorta with AI dimensions were recorded from transoesophageal

Figure 1. Intraoperative picture of a right coronary cusp prolapse (FEL elongation) treated by central plication of the cusp (FEL shortening) EACTS Daily News Issue 1 Saturday 7 October 2017 35

Cardiac | Focus | Endocarditis surgery What type of valve prosthesis should be used in patients with endocarditis

A Leite-Moreira University of Porto Medical School and Hospital São João, Porto, Portugal

nfective endocarditis (IE) is a clinically and surgically challenging condition, and remains Iassociated with substantial morbidity and mortality despite improvements in medical management and innovative operative techniques. Surgical intervention is the end treatment, aiming for total removal of the infected and necrotic tissues, reconstruction of cardiac structures (including repair or begins frequently in the sewing replacement of the affected ring or annulus. In contrast, valves) and the prevention of bioprostheses show higher systemic embolisation. The infection of the leaflets leading to choice of the ideal prosthesis vegetations, cusps rupture and in native valve IE (NVE) or perforation as late pathological prosthetic valve IE (PVE) remains process, similar to what happens controversial. It is, however, with native valves. generally accepted that it should In IE, most authors emphasise be tailored based namely on the importance of an adequate patient’s age, life expectancy, removal of infected tissue and comorbidities and compliance antibiotic therapy over the with anticoagulation therapy. type of prosthesis chosen. PVE, which represents When periannular abscesses benefit that is more evident in bioprostheses are good as well as a trend to lower should follow the same criteria 20% of all cases of IE, are present, mechanical patients under 65-years-old, and alternatives as they show cumulative survival. used in patients without IE. carries, as expected, a and biological prostheses disappear in older subgroups. similar results to homografts In mitral valve IE, both In conclusion, similar to what worse prognosis than NVE. performance is similar, if radical In extensive aortic valve with the advantage of easier mechanical and biological happens in other causes valvular The pathological process is debridement is performed IE, however, homografts and implantation technique, protheses show similar survival heart disease, choice of the different, depending both on and the prosthesis anchored patch reconstruction are availability in multiple sizes and rates and freedom from re- type of prosthesis in both NVE, the type of contamination and in healthy and strong tissue. recommended despite its anti-calcification treatment. infection. However, a higher risk PVE shall follow a personalised type of prosthesis, while its Nonetheless, some reports durability, more demanding Stented bioprostheses present of reoperation was associated approach based on careful diagnosis is more challenging. In showed survival benefit with surgical implantation technique higher reinfection rate than with bioprostheses. In tricuspid evaluation of the patient, the mechanical prosthesis, infection mechanical prosthesis, a and limited availability. Stentless homografts and stentless ones, valve IE, prosthesis choice valve and adjacent structures. 36 Issue 1 Saturday 7 October 2017 EACTS Daily News

Cardiac | Rapid Response | Coronary artery bypass surgery - latest updates Are men from Mars and women from Venus (or surgeons from Pluto)? Gender-related differences in CABG practice of a prospective European Registry

Francesco Onorati1, Daniel Reichart2, Antonino S. Rubino3, Andrea Perrotti4, contradictory findings stem from based on preoperative risk- worse 30-day outcome (higher Francesco Nicolini5, Giuseppe Gatti6, Marisa De Feo7, Giuseppe Santarpino8,9, retrospective studies, single- factors, the latter on preoperative mortality, transfusions of red Giovanni Mariscalco10, Riccardo Gherli11, Antonio Salsano12, Saverio Nardella13, centre analyses, and/or limited risk-factors plus intraoperative packed cells, sternal wound Matteo Saccocci14, Sidney Chocron4, Theodor Fischlein8, Francesco Santini12, sample size cohorts. Therefore, surgical factors – aimed at infections and overall rate of Giuseppe Faggian1 on behalf of E-CABG Investigators. 1. Division of Cardiovascular Surgery, all these data – together with clarifying if differences in complications, leading to a Verona University Hospital, Verona, Italy ; 2. Hamburg University Heart Center, Hamburg, Germany; their evident limitations – leave outcome must be ascribed longer ICU length of stay; all p 3. Centro Clinico-Diagnostico “G.B. Morgagni”, Centro Cuore, Pedara, Italy; 4. Department of the debate still unaddressed. to preoperative risk-factors < .01) (Figure 1) Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France ; 5. The recent institution of a different from gender (with 2) Propensity-matching for Division of Cardiac Surgery, University of Parma, Parma, Italy; 6. Division of Cardiac Surgery, large, prospective, all-comers, different prevalence in females preoperative risk-factors Ospedali Riuniti, Trieste, Italy; 7. Division of Cardiac Surgery, Department of Cardiothoracic Sciences, multicentre European Registry and males), to differences in the selected a comparable Second University of Naples, Naples, Italy; 8. Cardiovascular Center, Paracelsus Medical University, of all isolated CABG performed quality of surgery performed in population of 1,038 patients Nuremberg, Germany; 9. Città di Lecce Hospital, GVM Care & Research, Lecce, Italy; 10. at 16 different European the two categories, or to really still showing higher mortality Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Institutions (University Hospitals unexplained and unaddressed (4.0% vs 1.7% in male, p = Hospital, Leicester, UK; 11. Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. of Verona, Hamburg, Besancon, physiologic risk-factors (again, .02) and transfusion rates Camillo-Forlanini Hospital, Rome, Italy; 12. Division of Cardiac Surgery, University of Genoa, Genoa, Parma, Naples, Genoa, Oulu, the Mars/Venus argument). (57.4% vs 37.4%, p < .01) in Italy; 13. Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy; 14. Department of Stockholm, Nuremberg, In the study presented here females, but even reporting Cardiac Surgery, Centro Cardiologico–Fondazione Monzino IRCCS, University of Milan Leicester, Milan, Rennes, Civic at the 31st EACTS Annual less distal anastomoses (p = Hospitals of Rome, Trieste, Meeting, we were able to .01), less BIMA-grafting (p = emale gender is female gender incremental risk of distal anastomoses – thus Pedara, Catanzaro) allowed the demonstrate that: .02) and higher OPCABG (p = traditionally considered is actually linked to a global attributing the worse outcome to collection of 3,788 consecutive 1) Compared to males, females .03) (Figure 2) a risk-factor for worse risk profile, shifting the suboptimal surgery. Finally, some CABG outcomes during the have a worse preoperative 3) Propensity-score matching augmented early core of the debate to other evidences seem to support first five months. In order risk-profile (older age, higher for both preoperative risk Fmortality after CABG. Indeed, baseline risk factors. Other the existence of yet-undefined to understand if a negative EuroSCORE-II, lower renal factors and intraoperative the literature has presented studies have shown the physiologic risk-factor differences prognostic role of female gender filtration rate, worst NYHA, surgical factors selected a contradictory findings on the opposite: a higher prevalence between genders, which are on early outcome really exists, etc.; all p < .01), and a comparable population of 746 topic, with studies confirming of surgical confounders in the real factors responsible 30-day mortality and major lower quality of surgery (less patients showing no mortality female gender as incremental females – e.g. less left or for outcome differences (the morbidity were stratified by LIMA-grafting, less BIMA- difference (p = .24) between risk-factor for mortality, and double internal mammary so-called theory that “men are gender. Moreover, two different grafting, higher OPCABG, genders (Figure 3) others denying that. Recent grafting, more incomplete from Mars, women are from propensity-score matchings less mean number of distal We concluded that the studies suggested that the revascularisation, lower number Venus”). However, most of these were employed – the former anastomoses), resulting in a traditional opinion about a female gender-related unexplained factor responsible for a higher mortality early after CABG is not supported by these data. Indeed, gender seems an important baseline confounder on hospital mortality, because of the worst preoperative risk-profile and the lower quality of surgery offered to female patients. In the presence of comparable baseline and surgical factors, there is no female-gender related worsening of outcome, thus proving the proof that there are Figure 1. Thirty-day outcome stratified by gender in Figure 2. Thirty-day outcome in a comparable Figure 3. Thirty-day outcome in a comparable no females coming from Venus 3788 consecutive CABG at 16 study sites population of female and male CABG-patients after population of female and male CABG-patients after and men from Mars, but only propensity-matching for preoperative characteristics. propensity-matching for preoperative characteristics men and women coming from Differences in surgical factors still persisted. and surgical factors. the same planet.

Cardiac | Abstract | Risk score EuroSCORE II and STS score are more accurate in transapical TAVI than in transfemoral TAVI

Markus Kofler1*ª, Sebastian J Reinstadler2*, Lukas Stastny1, Julia Dumfarth1, Martin Reindl2, Kristina Wachter3, Christian J Rustenbach,3 Silvana Müller2, Gudrun Feuchtner4, Guy Friedrich2, Bernhard Metzler2, Michael Grimm1, Hardy Baumbach3, Nikolaos Bonaros1 1. University Clinic of Cardiac Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria; 2. University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria; 3. Robert Bosch Hospital, Auerbachstrasse 110, 70376 Stuttgart, Germany; 4. University Clinic of Radiology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria * These authors contributed equally, ª Corresponding author

he European System for are conflicting and inconclusive3,4. Cardiac Operative Risk Furthermore, the individual predictive Evaluation II (ES-II) and ability of both the ES-II and the STS- the Society of Thoracic score considering different access SurgeonsT (STS) score are currently sites has never been investigated in a considered by the heart team to large, adequately powered, consecutive estimate periprocedural risk following cohort. Therefore, we aimed to transcatheter aortic valve replacement investigate the value of ES-II and at two centres between 2008 and 2016. regression analysis was performed. 607), TA access in 49% (n = 585). The (TAVI), and to shift high-risk patients STS-score in predicting perioperative The primary study endpoint was 30-day Predictive discrimination for 30-day median ES-II and the median STS-score – which were planned for surgical mortality according to access site in a all-cause mortality. Odds ratios (OR) all-cause mortality (C-statistic) of ES-II were significantly lower in TF patients aortic valve replacement – to the large two-centre population. with 95% confidence intervals (CI) were and STS-score were measured by the compared to TA patients (ES-II TF: transcatheter route1,2. Results regarding We prospectively included 1192 calculated for outcome analysis. To quantification of ROC curves integral 6.0 [4.3-8.6] vs TA: 8.7 [5.8-13.8]; p < the value of surgical scores in predicting consecutive patients undergoing identify predictors of 30-day all-cause (area under the curve; AUC). 0.001), (STS-score TF: 5.8 [4.4-8.3]; periprocedural outcome following TAVI transfemoral (TF) or transapical (TA) TAVI mortality univariable and multivariable TF access site was used in 51% (n = TA: 7.5 [5.4-10.8]; p < 0.001). In TA EACTS Daily News Issue 1 Saturday 7 October 2017 37

TAVI, ES-II (OR: 1.038; 95% CI [1.009-1.068]; p = 0.010) and STS-score (OR: 1.063; 95% CI [1.025-1.102]; p = 0.001) were the only independent predictors of 30-day mortality. In TF TAVI, neither the ES-II (OR: 1.046; 95% CI [0.992-1.103]; p = 0.096) ISMICS – the International Society for Minimally nor the STS-score (OR: 1.035; 95% CI [0.969-1.104]; p = 0.305) revealed to be associated with 30-day mortality. On the basis Invasive Cardiothoracic Surgery of ROC-analysis, the AUC for 30-day mortality of ES-II (AUC = 0.577; p = 0.146) and STS-score (AUC = 0.574; p = 0.164) Are you an Innovator and Early Adopter? Want to Cardiothoracic Surgeons Can ISMICS is an inclusive society were lower in TF patients compared to TA patients (ES-II: AUC = discuss what’s new in CT/CV surgery in an open Learn from Vascular Surgery: – welcoming members from all 0.628; p = 0.001; STS-score: AUC = 0.664; p < 0.001). and open-minded forum rather than review the Experience from Development areas of the world and inviting By providing a superior value of ES-II and STS score in same old studies with slightly different cohorts of of Endovascular Techniques them to attend our Annual prediction of mortality in TA TAVI, our data may improve risk by Surgeons – for Surgeons”. Meetings, as well as our Winter patients? Are you looking for a place where healthy stratification for patients at particular high risk. Dr. Lumsden congratulated Workshops, and to publish Our study is limited by the fact that although we performed debate on issues is embraced and the atmosphere ISMICS on having the foresight their work in our indexed and multivariable regression analyses including numerous key risk is inclusive? Then you should be a part of ISMICS. and open-mindedness to citable journal, INNOVATIONS. factors, with a large sample size and a high event rate, we are ow often have you eventually be swallowed up by have a vascular surgeon ISMICS 2018 will be not able to incorporate novel, important variables like quality attended a scientific larger organizations. That has present a keynote lecture. held 13 to 16 June 2018 of life measures or variables gained from imaging studies in Hmeeting and listened to not happened – ISMICS has The Rome Annual Meeting at the Westin Bayshore in our analysis. In the same context, frailty was recently shown to presentations and thought – not only lasted, but has grown, also featured an outstanding Vancouver, Canada. The be a valuable predictor of postoperative outcome in patients I’ve heard this before, I’ve seen and embraces an international Presidential Address by Dr. Abstract Submission site, undergoing TAVI. Due to the long timeframe of prospective this before. Where can I learn membership around the world, Johannes Bonatti, who spoke including award categories patient inclusion, the availability of such novel variables is about what’s new? What’s welcoming innovators and early on “Pathways to Innovation in and instructions, is open now. inconsistent, precluding the consideration in our analysis5,6. cool? What is the next thing adopters in cardiac, thoracic Cardiothoracic Surgery.” The Submit your work, come to In conclusion, we provide – for the first time – evidence of in innovative cardiac, thoracic and cardiovascular surgery. ISMICS tradition of honoring Vancouver and be part of the superior prognostic value of ES-II and STS-score in patients and cardiovascular surgery? ISMICS remains the true forum innovation was expanded the society that embraces scheduled for TA TAVI, by revealing a significant association with If you want to be part of the for the latest, the newest, and in Rome with the first ever innovation, and continues 30-day mortality and better discrimination compared to TF TAVI. Society that embraces what’s the “out there on the edge” awarding of the Subramanian to push the envelope new, what’s cool, and wants to of what is happening, always Innovation Award, supported by forward in a welcoming and References have open and healthy debate willing to ask “what’s next?” in a generous grant from ISMICS inclusive atmosphere.

1. Stahli BE, Tasnady H, Luscher TF, Gebhard C, Mikulicic F, Erhart L, et al. Early and late on everything that’s innovative our specialty. Past President Dr. Valavanur ISMICS will be at EACTS! mortality in patients undergoing transcatheter aortic valve implantation: comparison of the in our specialty – then you The ISMICS Annual A. Subramanian. The 2017 Please visit us at Booth 22 novel EuroScore II with established risk scores. Cardiology. 2013;126(1):15-23. should be a part of ISMICS. Scientific Meeting in Rome recipient was Dr. Muralidhar – and learn more about this 2. Hemmann K, Sirotina M, De Rosa S, Ehrlich JR, Fox H, Weber J, et al. The STS ISMICS was created over in June celebrated our 20th Padala of Emory University in young, growing, and dynamic score is the strongest predictor of long-term survival following transcatheter aortic valve implantation, whereas access route (transapical versus transfemoral) has no 20 years ago by a group of Anniversary, and had record- Atlanta. Dr. Padala was selected society that continues to shape predictive value beyond the periprocedural phase. Interact Cardiovasc Thorac Surg. first adopters, pioneers in breaking attendance. Our through a detailed application the future of cardiac, thoracic 2013;17(2):359-64. minimally invasive cardiac largest meeting to date featured process, which culminated in and cardiovascular surgery. 3. Watanabe Y, Hayashida K, Lefevre T, Chevalier B, Hovasse T, Romano M, et al. Is surgery, literally the “cowboys” a keynote address about three finalists presenting their Don’t miss being a part of your EuroSCORE II better than EuroSCORE in predicting mortality after transcatheter aortic of their era in the new frontier “Creativity Principles: How work in Rome, and being judged surgical specialty’s future. Join valve implantation? Catheter Cardiovasc Interv. 2013;81(6):1053-60. of innovative and minimally to Challenge the State of the by a panel of innovators, as well ISMICS today! 4. Silaschi M, Conradi L, Seiffert M, Schnabel R, Schon G, Blankenberg S, et al. Predicting Risk in Transcatheter Aortic Valve Implantation: Comparative Analysis of EuroSCORE II invasive surgery. Many who Art” presented by Professor as a live audience vote. ISMICS – be a part of the and Established Risk Stratification Tools. Thorac Cardiov Surg. 2015;63(6):472-8. watched ISMICS’ birth believed Giovanni E. Corazza of Bologna ISMICS embraces its world’s leading society on 5. Hermiller JB, Jr., Yakubov SJ, Reardon MJ, Deeb GM, Adams DH, Afilalo J, et al. that the innovation would fade and the Kit Arom Lecture was partnership with industry innovative cardiac, thoracic Predicting Early and Late Mortality After Transcatheter Aortic Valve Replacement. J Am and the traditional ways would given by Dr. Alan B. Lumsden in seeking the newest and cardiovascular surgery. Coll Cardiol. 2016 ;68(4):343-52. triumph, or that ISMICS would of Houston, Texas on “What technologies and treatments. Visit us today and apply! 6. Edwards FH, Cohen DJ, O’Brien SM, Peterson ED, Mack MJ, Shahian DM, et al. Development and Validation of a Risk Prediction Model for In-Hospital Mortality After Transcatheter Aortic Valve Replacement. JAMA Cardiol. 2016;1(1):46-52.b 38 Issue 1 Saturday 7 October 2017 EACTS Daily News

Satellite Symposia @ the 31st EACTS Annual Meeting

Company Room Time Title Saturday 7 October European Board of Cardiovascular Perfusionists E1 08.30–17.30 17th European Conference on Perfusion Education and Training (EBCP) Monday 9 October Abbott K2 12:45–14:00 40 years of partnership in Cardiac Surgery: from valves to NEW ABBOTT structural heart portfolio AtriCure 0.31/0.32 12:45–14:00 Surgical ablation: Why, when and how in the face of an epidemic Auto Tissue -2.31 12:45–14:00 5 years experience with the decellularized Matrix Patch Boston Scientific International 0.15 12:45–14:00 ACURATE neo TA: Unique low-profile, self-expanding transapical TAVI system Edwards Lifesciences E1 12:45–14:00 The New Inspiris Resilia Aortic Valve: Current Evidence and its Early Clinical Application Getinge 0.49/0.50 12:45–14:00 Circulatory Support in Heart Failure Patients – Review of Current Clinical Evidence and Guidelines in Cardiac Surgery JOTEC -2.47/-2.48 12:45–14:00 Catching a glimpse of Frozen Elephant Trunk specialties LivaNova K1 12:45–14:00 That’s Why Innovation Matters Medtronic G1 12:45–14:00 Learning The Technique: Concomitant Mitral Therapy Medtronic G2 12:45–14:00 The Next Revolution: New Interventions for Advanced Chronic Heart Failure Nordic Pharma -2.32/-2.33 12:45–14:00 Patient Blood Management in Cardiac Surgery: past, present, future Vascular Graft Solutions 0.11/0.12 12:45–14:00 CABG: Back to the Future Vascutek F2 12:45–14:00 Aortic arch surgery – what should we be doing? Treatment options and practicalities Tuesday 10 October Abbott K2 12:45–14:00 Improving your outcomes with the HeartMate 3™ LVAD Edwards Lifesciences E1 12:45–14:00 Contemporary TAVI and SAVR indications and future perspectives Medtronic F2 12:45–14:00 Aortic Complex Cases: Current Options & Outcomes

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