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S22 Heart, Lung and CirculationORAL PRESENTATIONS 2007;16:S13–S29

CARDIAC SURGERY IN PATIENTS WITH END-STAGERENAL DISEASE—TEN-YEAR EXPERIENCE

Pankaj Goel , Sylvio Provenzano, Sharon Chu, MarkEdwards, David Andrews, Robert Larbalestier

Department of Cardiothoracic Surgery, Royal Perth Hospital,Perth, WA, Australia

Introduction. Cardiac disease remains a significantcause of mortality in patients with end-stage renal diseaseand patients on haemodialysis constitute a challenginggroup of patients for cardiac surgery.

Methods. The preoperative, operative and postoper-ative results of 96 haemodialysis patients undergoingcardiac surgery from 1996 to 2005 were reviewed retro-spectively.

Results. Fifty-nine (61.5%) of the patients had iso-lated coronary artery bypass grafting, 22 (23%) hadrepair/replacement of one or two valves and 14% under-went combined coronary artery bypass grafting andvalve replacement. Thirty-five percent of the patients hadmoderate to severe left ventricular dysfunction (ejectionfraction < 35%). Fifty-three percent of the patients hadtheir operation done as an emergency or urgent proce-dure. The operative mortality was 3.1%. Ninety percentof the patients required ventilation for more than 24 h.The re-exploration rate was 10.4%. On multiple logisticregression, of the various factors examined, emergency

1. Does TMR improve clinical and resource outcomescompared with maximum medical therapy (MMT) inpatients with refractory angina and coronary morphol-ogy not amenable to conventional revascularisation?

2. Does TMR adjunctive to CABG improve clinical andresource outcomes compared with CABG alone inchronic angina patients with coronary morphology onlypartially amenable to revascularisation by conventionalrevascularisation?

Methods. A comprehensive meta-analysis and system-atic review of randomised and non-randomised controlledtrials comparing TMR with MMT or comparing TMRadjunctive was undertaken. Three outcomes categoriesof angina symptom/QOL, perioperative and long-termcomplications, and resource utilisation were assessed.An international consensus panel of experts was con-vened to create consensus statements based on evidence.ACC/AHA classification was used to grade the statementsand recommendations.

Results. In comparing TMR vs MMT, six RCTs (967patients) and in comparing TMR + CABG vs CABG, threeRCTs (327 patients) were included in analysis. The detailoutcomes categories will be presented.

Conclusions. Based on the evidence, the following con-sensus statements were made:

1. In stable patients with refractory severe angina not

procedure and re-exploration and were significantly asso-ciated with the risk of mortality (p = 0.044 and 0.006,respectively). Patients who underwent emergency oper-ation had a significantly higher risk of re-exploration(p = 0.014).

Discussion. Cardiac operations can be performed safelyin patients with end-stage renal disease. Patients who needan emergency/urgent procedure are a high-risk group forbleeding, re-exploration and mortality.

doi:10.1016/j.hlc.2007.02.026

A META-ANALYSIS, SYSTEMATIC REVIEW ANDCONSENSUS CONFERENCE OF TRANSMYOCAR-DIAL LASER REVASCULARISATION

Davy C.H. Cheng

Professor and Chair/Chief, Department of Anesthesia and Peri-operative Medicine, The University of Western Ontario, London,Ontario Canada

Introduction. Transmyocardial laser revascularisation(TMR) has demonstrated inconsistent results in clinicaltrials, and consensus in practice is lacking regarding itsappropriate role in the management of refractory anginaunresponsive to conventional revascularisation.

Objectives. A meta-analysis and systematic review ofTMR was performed. Evidence-based consensus state-ments were formulated by an International Expert Panel(Chair: Dr. Anno Diegeler) to address the following clinicalquestions:

amenable to conventional revascularisation, TMR canbe recommended instead of MMT alone to improve sus-tained angina relief [Class I, Level A], reduce MACE andprolong exercise testing time [Class I, Level A], reducereadmissions and re-interventions [Class I, Level A].

2. In patients with diffuse CAD who cannot be com-pletely revascularised by CABG alone, adjunctiveTMR + CABG can be recommended to improve long-term (5 years) angina relief [Class IIa, Level A], to reduce30-day mortality and MACE [Class IIa, Level A] and toimprove 1-year exercise performance [Class IIa, LevelA].

doi:10.1016/j.hlc.2007.02.027

INITIAL CLINICAL EXPERIENCE WITH THE VEN-TRASSIST LEFT VENTRICULAR ASSIST DEVICE: THEPILOT TRIAL

Franklin Rosenfeldt , Don Esmore, David Kaye, RobertSalamonson, Mark Buckland, John Begg, Justin Negri,Peter Ayre, John Woodard

Alfred Hospital, and Ventracor Ltd., Sydney, Australia

Introduction. The pilot trial was a Phase 1 trial ofThe VentrAssist left ventricular assist device (LVAD) –a centrifugal pump with a unique hydrodynamic bear-ing. The first VentrAssist implant in humans was in June2003 and followed an extensive implant program in 40sheep over a four-year period (61 implants animal witha cumulative support time of eight years). The pilot trialwas performed at the Alfred Hospital, Melbourne. Fivepatients were enrolled as destination therapy with no

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Heart, Lung and Circulation S232007;16:S13–S29 ORAL PRESENTATIONS

option for transplantation and four were high risk bridge-to-transplantation, having associated co-morbidities thatplaced them outside the acceptance criteria for a Thor-atec or Novacor device. Their mean age was 65 years witheight males and one female. Four had idiopathic dilatedcardiomyopathy and five had ischaemic cardiomyopathy.Implants were done on cardiopulmonary bypass followedby anticoagulation on warfarin and antiplatelet agents.

Results. The 30-day mortality was 22% (n = 2). The meanduration of hospital stay was 55 days. Overall mean sup-port duration was 293 days. Four patients died, yieldinga cumulative survival of 2.8 years. The commonest causeof death was haemorrhage (n = 3); other causes includedrenal failure and gut ischaemia. One device developedthrombus in the rotor and had to be removed and replacedwith a pulsatile device. There were no other primarydevice failures. Nearly all patients developed some degreeof driveline infection, mostly manageable by antibiotictherapy. Three survivors with permanent implants weredischarged home and lived a relatively normal life forperiods up to 900 days.

Discussion. Experience with the VentrAssist is accumu-lating rapidly Australasia, Europe and the USA with 65implants recorded up to August 2006 and 1–2 new implantsbeing performed per week. Most new implants are bridge-to-transplant. One device was able to be removed aftercardiac recovery without transplantation.

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contributing to donor haemodynamic instability and mor-bidity/mortality in the transplant recipient.

Hormone resuscitation (HR) may ameliorate some ofthese negative effects, and has been advocated as a treat-ment to increase donor organ quality and utilisation. Toour knowledge, there have been no prospective, ran-domised controlled trials testing HR in organ donors. Theaim of this study was to investigate the effects of HR onthe heart, lungs, kidney, liver and pancreas.

Methods. A porcine model of the brain-dead multi-organ donor was used. One hour after induction of BD,animals were commenced either on noradrenaline (NA;n = 9), HR (triiodothyronine, methylprednisolone, vaso-pressin and insulin; n = 9) or continued on IV fluids alone(FL; n = 9) to maintain circulatory haemodynamics, andwere managed for a further 5 h. Haemodynamic data,organ blood flows, and blood and physiological markersof organ function were assessed.

Results. At 6 h post-BD, and despite NA animals receiv-ing 3.5 ± 1.5 �g/kg/min noradrenaline to support bloodpressure, mean arterial pressure (MAP) was highest inthe HR group (64 ± 5 mmHg) compared with FL and NAanimals (38 ± 12 and 36 ± 14 mmHg; p < 0.05). Cardiac out-put was higher in HR animals compared with NA animals(5.4 ± 1.4 vs 1.9 ± 1.5 L/min; p < 0.05) and cardiac contrac-tility (preload recruitable stroke work relationship) wassuperior in HR and NA animals compared with FL ani-mthpgc1

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Conclusions.

. From the initial implant experience the main complica-tions associated with the device, in order of frequencyof occurrence are, anticoagulant-related haemorrhage,infection and device thrombosis.

. Permanent implantation is extremely demanding forthe device, the patient and the carers.

. The VentrAssist shows great promise as a left ven-tricular assist device both for bridge-to-transplant andpermanent implantation.

oi:10.1016/j.hlc.2007.02.028

HE EFFECTS OF DONOR PRE-TREATMENT ON THEEART AND OTHER SOLID ORGANS FOR TRANS-LANTATION: A COMPARISON BETWEEN HOR-ONE RESUSCITATION, NORADRENALINE AND

NTRAVENOUS FLUIDS TO IMPROVE ORGAN QUAL-TY

lfred Hing 1, Mark Hicks 1, Ling Gao 1, Steven Faddy 1,eter Tran 2, Scott Kesteven 3, Alexandra Sharland 2, Gra-am Stewart 2, Peter Macdonald 1

Transplant and The Victor Chang Cardiac Research Institute,arlinghurst, NSW, AustraliaThe Collaborative Transplant Research Group, The Universityf Sydney, Sydney, NSW, AustraliaCardiovascular Mechanics Programs, The Victor Chang Car-iac Research Institute, Darlinghurst, NSW, Australia

Introduction. The systemic effects of brain deathBD) are major mediators of donor organ dysfunction,

als. Troponin I release was similar between groups. Inerms of lung function at 6 h post-BD, PaO2/FiO2 wasigher in HR (470 ± 95) and FL (464 ± 63) animals com-ared with NA animals (345 ± 106; p < 0.05) and the Aaradient was higher in the NA (311 ± 101 mmHg) animalsompared with both HR and FL animals (192 ± 91 and99 ± 62 mmHg; p < 0.05).

Renal arterial blood flow was higher in HR thanA animals at 6 h (204 ± 96 vs 41 ± 42 mL/min; p < 0.05),

s was the creatinine clearance (132 ± 54 mL/min vs0 ± 34 mL/min; p < 0.05). There was no difference inepatic arterial or portal venous blood flow, and thereas no difference in liver function tests (ALT, AST andilirubin) or bile production between groups. There waslso no difference between groups in amylase or lipaseelease.

Discussion. These results demonstrate that HR canmprove MAP, and cardiac, pulmonary and renal functionn the brain-dead donor. HR does not appear to have anyetrimental effects on the liver or pancreas.This study supports the use of HR to resuscitate and

upport the brain-dead donor, and improve donor organuality. Clinical trials of HR are needed to confirm its clin-

cal efficacy.

oi:10.1016/j.hlc.2007.02.029