ABSTRACTS
Abstracts of the Netherlands Society of Thoracic Surgery (NvT)
Sessions
7 October 2005, Nieuwegein Abstracts
.v.-ergader.ig Nedeiandse Vemnigisg voov Thovh-rgie -0n9g 7 oktobe
2005,
N5og-ei.
PATENCY AND FUNCTION OF S2 CONNECTOR VERSUS SUTURE CONSTRUCTED DISTAL ANASTOMOSES IN PORCINE OFF-PUMP ARTERIAL BYPASS GRAFTING WIL Suyker (Isala Klinieken, Zwolle), JP Matonick (Ethicon Inc., Somerville, USA), PTW Suyker (IlTech BV, Amsterdam), A Brutel de la Riviere (OLVG, Amsterdam), MP Buijsrogge (AMC, Amsterdam), RP] Budde (UUMC, Utrecht), CWJ Verlaan (UUMC, Utrecht), G Pasterkamp (UUMC, Utrecht), PF Grundeman (UUMC, Utrecht), C Borst (UUMC, Utrecht)
Introduction: Anastomosis patency and function are critical to the success of coronary bypass grafting. A novel device for facilitating the construction of distal coronary anastomoses was evaluated pre-cilnically by studying efficacy, function and remodeling over time, and was compared to a conventional suturing technique. Methods: Left intemal thoracic artery to left anterior descending coronary artery anastomoses were constructed in 35 pigs (73*8 kg), using the S2 Anastomotic System (S2AS) in 21 and a conventional suturing technique In 14 animals. The anastomoses were evaluated intra-operatively, at 90 and 180 days using a multimodality approach, including Fractional Flow Reserve determination and Intravascular Ultrasound.
Results: Anastomosis construction was easier with the S2AS in one-fourth of the suture construction time. Patency was 100%. An effective remodeling response was observed in both groups, resulting in unobstructed anastomoses with excellent hemodynamic performance In all cases. The intraluminal, non-compliant connector was associated with less neointimal tissue at the vessel wall coaptatlon line than the suture. The side-to-side configuration had effectively remodeled into an end-to-side shape.
Conclusions: In the porcine model, S2AS anastomosis construction was quicker and resulted in equivalent patency and function compared to the
Tho suchwugoe -Isdag 7 oktobes 2005, NOdvwuemei Abstracts .aasna e,dge.ng Nedelanban Venmngg voorx
INTRAOPERATIVE CORONARY ARTERY AND GRAFT ASSESSMENT BY 13 NHz EPICARDIAL ULTRASOUND: INITIAL RESULTS IN 9 PATIENTS R.P.J. Budde P.F.A. Bakker, R. Meijer, C. Borst, P.F. Grundeman Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The
Netherlands Introduction: A 13 MHz epicardial ultrasound mini-transducer (15x9x6 mm) was used to assess the target coronary artery and anastomosis on all sides of the heart, in 9 patients undergolng coronary artery bypass surgery.
Methods: The mini-transducer was attached to a custom-made malleable handling tool (Figure). Scanning of 10 coronary arteries and 29 coronary anastomoses was performed during antegrade/retrograde blood cardloplegia. Results: All sides of the heart were easily accessible with the mini-transducer. Based on intraoperative scanning, the anastomotic site was altered (n=4), the decision was made to graft an additional coronary artery (n=2), and an intramural LAD was identified after incorrect conventional selection of a diagonal branch (n=1). No anastomosis construction errors were detected (Figure). In one anastomosis, a large calcified plaque was seen in the outfiow comer. No preanastomosis scanning of the coronary artery had been performed in this case. In three other anastomoses (no pre-scanning), small calcified plaques at or just distal to the anastomosis were observed in the posterior wall of the coronary artery.
Concluslon: Using an epicardial ultrasound mini-transducer, coronary arteries and anastomoses on all sides of the heart were successfully visualized and assessed. Ultrasound Information greatly aided In intraoperative decision-making that resulted in anastomotic site changes and prevented grafting of the wrong vessel. Figure: left panel: Mini-transducer (black arrowhead) with malleable handling tool; right panel: longitudinal power Doppler image of IMA-LAD anastomosis (note scattering by clip on IMA side branch: white arrow).
suture technique. Unconventional aspects like a non-compliant intraluminal ring and a converted configuration did not interfere with normal anastomosis remodeling.
Abstracts
naJangade.. Ned.abnds eVeregu,ng ,vo Thomchirurgoe
)ae
7 oktoberO25S,
Nie-wegeun
USE OF THE PUCA PUMP DURING BEATING HEART SURGERY I Grandjean, MI Kulpers, G Warkotsch, I Diephuis Medisch Spectrum Twente, Enschede
Introduction. The PUCA pump consists of a 21 Fr catheter and a single port membrane pump, driven by any IABP driver. The tip of the catheter Is positioned in the left ventricle. During aspiration the PUCA valve guides the blood from the ventricle towards the membrane pump, during ejection the blood is transported back and directed into the aorta (Figure 1). Materials and Methods. The PUCA pump (Intra-Vasc.nl, Groningen) was applied In a prospective clinical study in eight OPCAB patients with a mortality risk (Euroscore) of 6% or higher. During introduction, the position of the LV21 catheter was verified by TEE. The flow of the LV21 was measured continuously. The cardiac output was measured at certain time points. Blood samples were taken on set time points and were send to the lab for testing on blood damage and kidney and liver failure.
W
_
Results. The introduction of the LV21 lasted 25 minutes in the first patient, but decreased to 10-15 minutes after three patients. The flow generated by the LV21 was 2.4-2.8 L/min. No direct influence could be determined on the cardiac output. The blood tests did not show blood damage, except for one patient in which the pump was not positioned correctly. No kidney or liver damage was found. TEE examination after explantation of the LV21 revealed no damage of the aortic valve or other structures.
Abancts
xaWw9aeMg Nadndse VeeN.
voor Thox.chiv-e
,.)dag 7 oktob- 2005, Nib,..gei,
OFF PUMP CORONARY SURGERY SIMULATION - PRACTICAL TEACHING STATION -OLD SHOE BOX NEW TRICKS U Sonker. A Driessen, WJ van Boven, HA van Swieten. Department of cardiothoracic surgery St. Antoniusziekenhuls, Nleuwegein.
Introduction. Total revascularization without cardiopulmonary bypass continues to gain popularity. As in all surgical procedures there is a leaming curve. Cardiothoracic trainees receive limited exposure to this procedure. We describe an easy to assemble mechanical device which simulates the off pump surgical procedure in a laboratory controlled environment. Methods. A paediatric ventilation balloon, mounted on a three dimensional fixation arm is connected to a ventilator. This is then placed in an open box, simulating the thorax. The ventilator machine connected to a compressed air source Is set on the required rate and tidal volume. Rate of ventilation simulates the heart rate and tidal volume the amplitude of outward displacement. All extra pieces of graft material left over after surgical procedures were preserved. All left over suture materials were saved and used for making anastomosis. A length of graft material was fixed on the balloon simulating the coronary artery. A stabilizer of choice was then placed. A second piece of graft material was used to make the desired anastomosis.
Results. We have been performing these experiments for the last six months on a regular basis. All coronary artery positions could be adequately simulated. Partidpating trainees made better progress in the conduct of not only off pump but also conventional CABG procedures.
Conclusion. We hope to assist trainees to achieve adequate skills to practice off pump distal anastomosis and help supervising surgeons to safely teach this technique to juniors. In the future we will use video scopes to simulate thoracoscopic and robot assisted anastomosis.
Condusion. The PUCA pump delivers approx. 2.5 L/mIn. The device can be safely introduced and explanted and functions without damaging body structures.
14
Netherlands Heart Joural, Volume 13, Supplement 3, December 2005
qC
Abstracts najaarsvergadenng Nederlandse Vereniging voor Thoraxchirurgie vrijdag 7 oktober 2005, Nieuwegeen
PATENCY AND FUNCTION OF S2 CONNECTOR VERSUS SUTURE CONSTRUCTED DISTAL ANASTOMOSES IN PORCINE OFF-PUMP ARTERIAL BYPASS GRAFTING WIL..Suyker (Isala Klinieken, Zwolle), JP Matonick (Ethicon Inc., Somerville, USA), PTW Suyker (lITech BV, Amsterdam), A Brutel de la Rivi6re (OLVG, Amsterdam), MP Buijsrogge (AMC, Amsterdam), RPJ Budde (UUMC, Utrecht), CWJ Verlaan (UUMC, Utrecht), G Pasterkamp (UUMC, Utrecht), PF Grundeman (UUMC, Utrecht), C Borst (UUMC,
Utrecht) Introduction: Anastomosis patency and function are critical to the success of coronary bypass grafting. A novel device for facilitating the construction of distal coronary anastomoses was evaluated pre-clinically by studying efficacy, function and remodeling over time, and was compared to a conventional suturing technique.
Methods: Left internal thoracic artery to left anterior descending coronary artery anastomoses were constructed in 35 pigs (73*8 kg), using the S Anastomotic System (S2AS) in 21 and a conventional suturing technique In 14 animals. The anastomoses were evaluated intra-operatively, at 90 and 180 days using a multimodality approach, including Fractional Flow Reserve determination and Intravascular Ultrasound.
Results: Anastomosis construction was easier with the S2AS in one-fourth of the suture construction time. Patency was 100%. An effective remodeling response was observed in both groups, resulting in unobstructed anastomoses with excellent hemodynamic performnance in all cases. The intraluminal, non-compliant connector was associated with less neointimal tissue at the vessel wall coaptation line than the suture. The side-to-side conflguration had effectively remodeled into an end-to-side shape.
Conclusions: In the porcine model, S2AS anastomosis construction was quicker and resulted in equivalent patency and function compared to the suture technique. Unconventional aspects like a non-compliant intraluminal ring and a converted configuration did not interfere with normal anastomosis remodeling.
Absrct na)aarsvergadenng Nederandse Vereniging voor Thoraxchirurgie vn)dag 7 oktober 2005, Nieuwegein
USE OF THE PUCA PUMP DURING BEATING HEART SURGERY JrndJen MJ Kulpers, G Warkotsch, J Diephuls Medisch Spectrum Twente, Enschede
Introduction. The PUCA pump consists of a 21 Fr catheter and a single port membrane pump, driven by any IABP driver. The tip of the catheter is positioned in the left ventricle. During aspiration the PUCA valve guides the blood from the ventricle towards the membrane pump, during ejection the blood is transported back and directed Into the aorta (Figure 1).
Materials and Methods. The PUCA pump (Intra-Vasc.nl, Groningen) was applied In a prospective clinical study in eight OPCAB patients with a mortality risk (Euroscore) of 6% or higher. During introduction, the position of the LV21 catheter was verified by TEE. The flow of the LV21 was measured continuously. The cardiac output was measured at certain time points. Blood samples were taken on set time points and were send to the lab for testing on blood damage and kidney and liver failure.
Resul. The Introduction of the LV21 lasted 25 minutes in the first patient, but decreased to 10-15 minutes after three patients. The flow generated by the LV21 was 2.4-2.8 L/min. No direct influence could be determined on the cardiac output. The blood tests did not show blood damage, except for one patient in which the pump was not positioned correctly. No kidney or liver damage was found. TEE examination after explantation of the LV21 revealed no damage of the aortic valve or other structures. Conclusion. The PUCA pump delivers approx. 2.5 /min. The device can be safely introduced and explanted and functions without damaging body structures.
Abstracts najaarsvergadering Nederlandse Vereniging voor Thoraxchirurgie vri)dag 7 oktober 2005, Nieuwegein
INTRAOPERATIVE CORONARY ARTERY AND GRAFT ASSESSMENT BY 13 MHz EPICARDIAL ULTRASOUND: INITIAL RESULTS IN 9 PATIENTS R.J.uddg, P.F.A. Bakker, R. Meijer, C. Borst, P.F. Grundeman Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The
Netherlands Introduction: A 13 MHz epicardial ultrasound mini-transducer (15x9x6 mm) was used to assess the target coronary artery and anastomosis on all sides of the heart, in 9 patients undergoing coronary artery bypass surgery. Methods: The mini-transducer was attached to a custom-made malleable handling tool (Figure). Scanning of 10 coronary arteries and 29 coronary anastomoses was performed during antegrade/retrograde blood cardioplegia. Results: All sides of the heart were easily accessible with the mini-transducer. Based on intraoperative scanning, the anastomotic site was altered (n=4), the decision was made to graft an additional coronary artery (n=2), and an intramural LAD was identified after incorrect conventional selection of a diagonal branch (n=1). No anastomosis construction errors were detected (Figure). In one anastomosis, a large calcified plaque was seen in the outflow corner. No preanastomosis scanning of the coronary artery had been performed in this case. In three other anastomoses (no pre-scanning), small calcified plaques at or just distal to the anastomosis were observed in the posterior wall of the coronary artery.
Conclusion: Using an epicardial ultrasound mini-transducer, coronary arteries and anastomoses on all sides of the heart were successfully visualized and assessed. Ultrasound information greatly aided in intraoperative decision-making that resulted in anastomotic site changes and prevented grafting of the wrong vessel.
Figure: left panel: Mini-transducer (black arrowhead) with malleable handling tool; right panel: longitudinal power Doppler image of IMA-LAD anastomosis (note scattering by clip on IMA side branch: white arrow).
Absas najaarvegadering Nedernandse Vereniging voor Thoraxchirurge vrjdag 7 oktober 2005, Nieuwegein
OFF PUMP CORONARY SURGERY SIMULATION - PRACTICAL TEACHING STATION -OLD SHOE BOX NEW TRICKS U SonkeIr A Driessen, WJ van Boven, HA van Swieten. Department of cardlothoracic surgery St. Antoniuszlekenhuis, Nleuwegein.
Introduction. Total revascularization without cardiopulmonary bypass continues to gain popularity. As in all surgical procedures there is a leaming curve. Cardiothoracic trainees receive limited exposure to this procedure. We describe an easy to assemble mechanical device which simulates the off pump surgical procedure in a laboratory controlled environment. Methods. A paediatric ventilation balloon, mounted on a three dimensional fixation arr Is connected to a ventilator. This is then placed in an open box, simulating the thorax. The ventilator machine connected to a compressed air source is set on the required rate and tidal volume. Rate of ventilation simulates the heart rate and tidal volume the amplitude of outward displacement. All extra pieces of graft material left over after surgical procedures were preserved. All left over suture materials were saved and used for making anastomosis. A length of graft material was fixed on the balloon simulating the coronary artery. A stabilizer of choice was then placed. A second piece of graft material was used to make the desired anastomosis. Results. We have been perforning these experiments for the last six months on a regular basis. All coronary artery positions could be adequately simulated. Participating trainees made better progress in the conduct of not only off pump but also conventional CABG procedures.
Conclusion. We hope to assist trainees to achieve adequate skills to practice off pump distal anastomosis and help supervising surgeons to safely teach this technique to juniors. In the future we will use video scopes to simulate thoracoscopic and robot assisted anastomosis.
Abstracts
Sessions
00de009 Nededamn VeornogWg
Abstrs &o,I
voorw Thoedyirwgle,b 7 oktober 2005, Neovgec
Abust.
PRESERVED HYPERAEMIC SUPRACLAVICULAR DOPPLER RESPONSE DEMONSTRATES FUNCTION ON DEMAND OF THE UMA TO LAD STRING SIGN GRAFT 1M Hartman. JC Kelder2, RGA Ackerstaff', HA van Swieten4, FEE Vermeulen', AJJC Bogers'.1 Department of Cardlothoradc Surgery, Erasmus Medkcal Centre Rotterdam. 2 Department of Cardiology, St. Antonius Hospital, Nleuwegeln. 3 Department of Clinical Neurophysiology, St. Antonius Hospital, Nleuwegein. 4 Department of Thoracic and Cardiovascular Surgery, St. Antonius Hospital,
Heart center, Radboud University
Methods: 16 patients (13 M, 63 * 8 yr) with a single UMA to the LAD were prospectively entered in a follow up study. The supraclavicular duplex of the UMA origin was studied ECG controlled preoperatively and at 5.3 * 3.6 m. and 1.7 * 0.4 yr. postoperatively. Duplex parameters analysed: systolic and diastolic
Resufts: 1 patient was excluded. Control anglography showed in 12 pts. (group I) patent and in 3 pts. (group It) string sign UMA grafts. No objective or subjective ischemia could be detected at rest or during hypersemic response. ost I 33414
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Nijmegen
Methods: This study included 627 patients undergoing an isolated CABG between January 2003 and September 2004. Patients were divide in Group A-Scr, 576 patients (91.1%) with a good renal function, Scr S1,20mg/dl for women and S1,40 mg/di for men. Group B-Scr, with Impaired renal function, 51 Patients (8.1%). A CrCl s 50ml/min was chosen to reflect renal Impairment, Group A-CrCl, 555 patients (88.5%) wlth a normal renal function and group B-CrCl, 72 patients (11.5%) with an impaired renal function. The studied outcomes were hospital mortality, hospital morbidity and postoperative renal failure and dialysis.
peak velocity (SPV, DPV), systolic and diastolic velocity integral (SVI, DVI), diastollc/systolic peak velocity ratio (DSVR) and diastollc/systolic total velocity Integral ratio (DSTVIR). At the late postoperative duplex hyperaemic response was also studied during adenosine Infusion (o.14 mg/kg/min.) for 6 min. Control angiography (native and UMA) was done at 1.5 * 0.9 yr. Differences within groups were tested with paired -and between groups with unpaired t-tests.
11 12*2
Irijdpag 7 oktober 2005, NiWn-g.Wm
Background: Preoperative renal failure is a risk factor for adverse events In cardiac surgery. Serum creatinine (SCr) is the most used test for renal failure, however patients can have significantly decreased glomerular filtration rates with normal SCr levels. More accurate approximation of renal function can be obtained using creatinine clearance (CICr) calculated by the Cockcroft-Gault equitation from SCr.
Introduction: To demonstrate functionality of string sign LIMA to LAD grafts compared to patent LIMA to LAD grafts by supraclavkcular duplex.
onus
o
ESTIMATED CREATININE CLEARANCE INSTEAD OF PLASMA CREATININE LEVEL AS SCREENING TEST FOR RENAL FAILURE IN PATIENTS UNDERGOING A MYOCARDIAL REVASCULARIZATION. I. Plesiewicz, L. Noyez, FWA Verheugt
Nleuwegein
GrtDI 14*8
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Results: There was no statistical significant difference between A-Scr and B-Scr-group according to the studied outcomes. Using the CrCl, there was a statistical significant differences between A-CrCl and B-CrCL for the percentage of postoperative renal failure (p=0.00), dialysis (p=0.00), hospital morbidity (p=0.04). Regression analysis shows a significant relation between A CrCI s 50ml/min and postoperative renal failure and
dialysis.
Conclusion: The association adverse outcomes after CABG with the routinely used Scr. glomerular flltration rate should
between preoperative renal function and is stronger with the estimated CICr than Routine estimation or measurement of be the preferred to Scr.
Condusion: Patients wlth patent as well as string sign UMA grafts showed a shift towards a coronary flow profile at rest and in hyperaemic response postoperatively. The hyperaemic response test revealed the functionality of the string sign LIMA graft demonstrating the adaptability responding to lower resistance of the coronary artery.
Abt5 n0a005.0207
50ded0randse Ve.eiging
Thnorchqeru, ,Jdug 7 okuto 2005, Nws0gqsn
PRIMARY SYMPATHiECTOMY FOR THORACOSCOPIC HYPERHIDROSIS: 1999-2004 MS de ionfg LA de Leeuw, MP de Jong, HEJ Sinninghe Damstd, P]H Smits Twenteborg Hospital Almelo
Introduction. Hyperhidrosis can cause significant professional and social handicaps. Although treatments such as oral medication, botox and iontophoresis are available, surgical treatment Is being increasingly utilized. The purpose of our study was to review patient characteristics, surgical technique, and outcome of patients undergoing thoracoscopic sympathectomy for severe hyperhidrosis. Methods. Between January 1999 and January 2005 fifty-five patients with palmar, axillary, facial or plantar hyperhidrosis underwent a thoracoscopic sympathectomy. Surgical technique Included coagulation of the sympathetic ganglia at T2, T3 or T4 using monopolar cautery. Clinical charts were reviewed for patient demographic data, location of symptoms. All patients were contacted by telephone to asses early and late operative outcome, degree of compensatory sweating, persistent complications and degree of satisfaction with the treatment.
Results. Patient demograplcs Included 45% (25/55) males and 55% (30/55) females, with a mean age of 27 years old (range 20 tot 51 years old). Preoperatively, 15% (8/55) had palmar sweating only, 29% (16/55) axillary only, 25% (14/55) palmar and axillary, 31% (17/55) had a combination of above mentioned with/without facial/plantar sweating. Mean follow up was 38 months. Complications included a mild temporary Homer's Syndrome (n=1; 2%), air leak requiring chest drainage (n =8; 15%), bleeding (n = 3; 5%) requiring thoracotomy. EIghty-four percent experienced compensatory hyperhidrosis. Overall satisfaction was 90%.
Condusion. Thoracoscopic sympethectomy is a safe, effective and definite solution for primary hyperhldrosis. Although overall satisfaction is high, patients should be folly Informed about the potential for complications and compensatory sweating.
A5.t,co
n pamrs.erdws Nedavd, Veengivg ,voo Th-hinurge
SURGICAL ASSESSMENT OF THE PULMONARY INTRAVASCULAR VOLUME FOR DRUG DOSE CALCULATION IN ISOLATED LUNG PERFUSION BP van Putte2.3 E5 A Huisman4, JMH Hendriks2, PEY van SchIl2, WJ van Boven5, F Schramel and G Folkerts3 Department of 4clinical chemistry, University Medical Center, Utrecht, the Netherlands. 2Department of thorack and vascular surgery, University Hospital Antwerp, Anttwerp, Belgium. 3Department of pharmacology and pathophysiology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Nethertands. Departments of scardiothoraclc surgery and 'pulmonology, St. Antonlus hospital, Nieuwegein, the Netherlands
Introduction: Isolated lung perfusion (ILuP) is an experimental technique for the treatment of pulmonary metastases. Clinical trials showed a wide range in drug lung levels. This may be due to the variance of lung size and pulmonary intravascular volume (PIV). Therefore, we developed a method to assess PIV and Investigated the relation of PIV and dry lung weight (DLW). Methods: Thirty-two rats of 555±8g (groups 1-3) and 199t5g (group 4) underwent cannulatlon of the pulmonary vessels without blood loss. Subsequently, groups 1 and 3 had ILuP with starch during two and eight minutes while groups 2 and 4 during 4 minutes. Effluent was analyzed for haemoglobin, red blood cells (RBC), leucocytes, platelets, albumin and creatinin. PIV was calculated by dividing the product of the perfusate volume and a post-ILuP biochemical parameter by the difference between post-ILuP and pre-ILuP biochemical parameter. Statistical analysis was performed using ANOVA and Ttest.
Results. No significant differences In PIV were observed between different perfusion times for haemoglobin, RBC, leucocytes and platelets. No significant differences In PIV for all perfusion times were noted between the biochemical variables (p=0.14). Based on haemoglobin (p 40 mm) and extemal cardlac support (CorCap) may further improve outcome.
Abstrs naJaarsvergadrn Nied&ndse Verening voor Thoraxchirurgie vrijdag 7 oktober 2005, Nieuwegen
MYOCARDIAL LYMPHOID CHEMOKINE EXPRESSION AFFECTS CD8+ T-CELL RECIRCULATION IN REJECNG RECIPIENTS A R CLINICAL HEART TRANSPLANTATION A. peeteisb, LMB Vaeen b, APWM Maata, CC Baanb, A AHMM Balkc, W Weimarb and AJJC Bogers! Departments of "Cardiothoracic Surgery, bIntemal Medkine and cCardiology Erasmus MC, Rotterdam, The Netherlands.
Introduction: Recirculation of allo-reactive T-cells is regulated by concerted action of chemokines (CCLs) and their receptors (CCRs). We investigated blood T-cell subset CCR expression and intragraft CCR & CCL mRNA levels in relation to acute rejection (AR) after heart transplantation
(post-HTx). Methods: Twenty cardiac allograft recipients under triple maintenance immunosuppression were studied prospectively in a 9-month follow-up post-HTx. At the time of endomyocardial biopsy, CCR5 and CCR7 expression on peripheral blood CD4+ and CD8+ T-cells was measured by flow-cytometry. Intragraft CCRS, CCR7, inflammatory (CCL5) and lymphold (CCL19) CCL mRNA levels were measured by Q-PCR. Thirteen biopsy-proven AR episodes (AR+: ISHLT 23A) were compared to 127 samples fom non-rejection episodes (AR-: ISHLT 0, n=70; ISHLT 1, n=41; ISHLT 2, n=16).
Results: In circulating CD4+ cells, no signiflcant differences in the % CCR5+ or % CCR7+ cells were found between AR- and AR+ episodes. For the CD8+ subset, during AR+ the %CCR5+ cells was higher (p 5,0 mmol/l bij de start van de behandeling Patienten met matige tot ernstige nierinsufficientie. Patienten met ernstige lecerinsufficientie Patienten die worden behandeld met kalaumsparende diufetica, kaliumsupplementen of met sterke CYP3A4-remmers zoals itraconazol, ketocona7a1, ritonavif, nelfinavir, claritromycine, telitromypine en nefazodon. Waarschuwingen en voorzorgen: Overeenkomstig het werkingsmechanisme van eplerenone kan hyperkaliemie optreden. Kaliumspiegels dienen bij elke patient gecontroleerd te worden bij aanvang van de behandeling, bij verandering van de dosering en indien nier- of leverfunctiestoornissen aanwezig ziln. Gelijktijdige toediening van eplerenone met sterke CYP3A4-inductoren wordt niet aanbevolen en toediening gelijktijdig met lithium, cyclospofine en tacrolimus dient vermeden te worden. De tabletten bevatten lactose en mogen niet gebruikt worden bij patienten met zeldzame, erfelijke problemen van galactose-intolerantre, Lapp-lactase-deficientie of gluaosegalactose-malabsorptie Interacties: Ge1iqktijdige toediening van eplerenone met amiodaron, diltiazem en verapamil hebben geleid tot significante farmacokinetische interacties. De dosering van eplerenone dient niet hoger te nijn dan 25 mg als deze zwakke tot matige CYP3A4-remmers gelijktijdig met eplerenone worden toegediend. Voot een volledig overzicht van de interacties dient de volledige productinofamatie (SPC) te worden geraadpleegd. Bijwerkingen: In de EPHESUS-studie was de totale incidentie van bijwerkingen die gemeld werden bij gebruik van eplerenone (78,9%) vergelijkbaar met placebo (79,5A). Vaak 1/100, 1t /10) kwamen voof hyperka/r-mie, duizeligheid, hypotensie, diarree, misselijkheid en nierfunctiestoornissen. Soms 1/1000, 1t /100) kwamen voon eosinotilie, dehydratie, hypefcholesterolemie, hypertriglyceridemre, hyponatriemie, slapeloosheid, hoofdpijn, atriumfibrilleren, myocardinfarat, systolisch hartfalen, orthostatische hypotensie, arteriele trombose in het been, faryngitis, flatulentie, braken, jeuk, toegenomen transpiratie, rugpijn, beenkrampen, asthenie, algehele malaise, verhoogde 8UN-waarden, verhoogde serumcreatininespregels en pyelonefritis. Afleveeingsstatus: U.R. Verpakking: Inspra is verkrijgbaar in verpakkingen met 30 en 50 tabletten in doordrukstrips. Datum: november 2004. Registratienummert: inspra 25 RVG 29963: Inspra 50/ RVG 29964. Vergoeding en prijzen: inspra wordt volledig vergoed binnen het GVS. Voof pfijzen wordt verwezen naaf de l-Index taxe. De volledige productinfofmatie is op aanvraag verkrijgbaat bij de registratiehouder Pfizer bv, Postbus 37, 2900 AA Capelle a/d Ijssel. Referentie: 1. Pitt B et al. N Fag/I Med 2003 34&1309-21
m
b
/Voor medische informatie over dit product belt u met 0800-MEDINFO (6334636) Pfizer bv, Postbus 37, 2900 AA Capelle a/d ljssel
Abstracts najaarsvergadering Nederlandse Vereniging voor Thoraxchirurgte vr)dag 7 oktober 2005, N.euwegein
programma juniorkamer, voorzitter A. Driessen
11.00 uur
EPICARDIAL SURGERY
ULTRASOUND
IN
CORONARY
ARTERY
BYPASS
R.P.). Budde, Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
The aim of the research described in this thesis was to evaluate epicardial ultrasound as a means to locate and assess coronary arteries and assess the quality of the distal coronary anastomosis in (totally endoscopic, offpump) coronary artery bypass grafting. The main conclusions of the studies in this thesis are: 1. The 13 MHz epicardial ultrasound mini-transducer enables successful endoscopic localization and assessment of the major target coronary arteries for bypass grafting within a median of 3 minutes per artery.
2. The conventionally sutured distal coronary anastomosis can be assessed in high detail by 13 MHz ultrasound in both open- and closedchest off-pump CABG. Anastomosis construction errors are detected by epicardial ultrasound with higher sensitivity (0.98) and specificity (1.00) than by the gold standard angiography (0.75 and 0.81,
respectively). 3. Epicardial 13 MHz ultrasound enables intraoperative assessment of the S2AS coronary connector anastomosis in considerable detail, in spite of some metal induced echo artefacts. 4. The 13 MHz epicardial ultrasound mini-transducer can be used on all sides of the heart for coronary artery and coronary anastomosis assessment and provides valuable information to aid in intraoperative descision making.
Abstracts of the Netherlands Society of Thoracic Surgery (NvT)
Sessions
7 October 2005, Nieuwegein Abstracts
.v.-ergader.ig Nedeiandse Vemnigisg voov Thovh-rgie -0n9g 7 oktobe
2005,
N5og-ei.
PATENCY AND FUNCTION OF S2 CONNECTOR VERSUS SUTURE CONSTRUCTED DISTAL ANASTOMOSES IN PORCINE OFF-PUMP ARTERIAL BYPASS GRAFTING WIL Suyker (Isala Klinieken, Zwolle), JP Matonick (Ethicon Inc., Somerville, USA), PTW Suyker (IlTech BV, Amsterdam), A Brutel de la Riviere (OLVG, Amsterdam), MP Buijsrogge (AMC, Amsterdam), RP] Budde (UUMC, Utrecht), CWJ Verlaan (UUMC, Utrecht), G Pasterkamp (UUMC, Utrecht), PF Grundeman (UUMC, Utrecht), C Borst (UUMC, Utrecht)
Introduction: Anastomosis patency and function are critical to the success of coronary bypass grafting. A novel device for facilitating the construction of distal coronary anastomoses was evaluated pre-cilnically by studying efficacy, function and remodeling over time, and was compared to a conventional suturing technique. Methods: Left intemal thoracic artery to left anterior descending coronary artery anastomoses were constructed in 35 pigs (73*8 kg), using the S2 Anastomotic System (S2AS) in 21 and a conventional suturing technique In 14 animals. The anastomoses were evaluated intra-operatively, at 90 and 180 days using a multimodality approach, including Fractional Flow Reserve determination and Intravascular Ultrasound.
Results: Anastomosis construction was easier with the S2AS in one-fourth of the suture construction time. Patency was 100%. An effective remodeling response was observed in both groups, resulting in unobstructed anastomoses with excellent hemodynamic performance In all cases. The intraluminal, non-compliant connector was associated with less neointimal tissue at the vessel wall coaptatlon line than the suture. The side-to-side configuration had effectively remodeled into an end-to-side shape.
Conclusions: In the porcine model, S2AS anastomosis construction was quicker and resulted in equivalent patency and function compared to the
Tho suchwugoe -Isdag 7 oktobes 2005, NOdvwuemei Abstracts .aasna e,dge.ng Nedelanban Venmngg voorx
INTRAOPERATIVE CORONARY ARTERY AND GRAFT ASSESSMENT BY 13 NHz EPICARDIAL ULTRASOUND: INITIAL RESULTS IN 9 PATIENTS R.P.J. Budde P.F.A. Bakker, R. Meijer, C. Borst, P.F. Grundeman Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The
Netherlands Introduction: A 13 MHz epicardial ultrasound mini-transducer (15x9x6 mm) was used to assess the target coronary artery and anastomosis on all sides of the heart, in 9 patients undergolng coronary artery bypass surgery.
Methods: The mini-transducer was attached to a custom-made malleable handling tool (Figure). Scanning of 10 coronary arteries and 29 coronary anastomoses was performed during antegrade/retrograde blood cardloplegia. Results: All sides of the heart were easily accessible with the mini-transducer. Based on intraoperative scanning, the anastomotic site was altered (n=4), the decision was made to graft an additional coronary artery (n=2), and an intramural LAD was identified after incorrect conventional selection of a diagonal branch (n=1). No anastomosis construction errors were detected (Figure). In one anastomosis, a large calcified plaque was seen in the outfiow comer. No preanastomosis scanning of the coronary artery had been performed in this case. In three other anastomoses (no pre-scanning), small calcified plaques at or just distal to the anastomosis were observed in the posterior wall of the coronary artery.
Concluslon: Using an epicardial ultrasound mini-transducer, coronary arteries and anastomoses on all sides of the heart were successfully visualized and assessed. Ultrasound Information greatly aided In intraoperative decision-making that resulted in anastomotic site changes and prevented grafting of the wrong vessel. Figure: left panel: Mini-transducer (black arrowhead) with malleable handling tool; right panel: longitudinal power Doppler image of IMA-LAD anastomosis (note scattering by clip on IMA side branch: white arrow).
suture technique. Unconventional aspects like a non-compliant intraluminal ring and a converted configuration did not interfere with normal anastomosis remodeling.
Abstracts
naJangade.. Ned.abnds eVeregu,ng ,vo Thomchirurgoe
)ae
7 oktoberO25S,
Nie-wegeun
USE OF THE PUCA PUMP DURING BEATING HEART SURGERY I Grandjean, MI Kulpers, G Warkotsch, I Diephuis Medisch Spectrum Twente, Enschede
Introduction. The PUCA pump consists of a 21 Fr catheter and a single port membrane pump, driven by any IABP driver. The tip of the catheter Is positioned in the left ventricle. During aspiration the PUCA valve guides the blood from the ventricle towards the membrane pump, during ejection the blood is transported back and directed into the aorta (Figure 1). Materials and Methods. The PUCA pump (Intra-Vasc.nl, Groningen) was applied In a prospective clinical study in eight OPCAB patients with a mortality risk (Euroscore) of 6% or higher. During introduction, the position of the LV21 catheter was verified by TEE. The flow of the LV21 was measured continuously. The cardiac output was measured at certain time points. Blood samples were taken on set time points and were send to the lab for testing on blood damage and kidney and liver failure.
W
_
Results. The introduction of the LV21 lasted 25 minutes in the first patient, but decreased to 10-15 minutes after three patients. The flow generated by the LV21 was 2.4-2.8 L/min. No direct influence could be determined on the cardiac output. The blood tests did not show blood damage, except for one patient in which the pump was not positioned correctly. No kidney or liver damage was found. TEE examination after explantation of the LV21 revealed no damage of the aortic valve or other structures.
Abancts
xaWw9aeMg Nadndse VeeN.
voor Thox.chiv-e
,.)dag 7 oktob- 2005, Nib,..gei,
OFF PUMP CORONARY SURGERY SIMULATION - PRACTICAL TEACHING STATION -OLD SHOE BOX NEW TRICKS U Sonker. A Driessen, WJ van Boven, HA van Swieten. Department of cardiothoracic surgery St. Antoniusziekenhuls, Nleuwegein.
Introduction. Total revascularization without cardiopulmonary bypass continues to gain popularity. As in all surgical procedures there is a leaming curve. Cardiothoracic trainees receive limited exposure to this procedure. We describe an easy to assemble mechanical device which simulates the off pump surgical procedure in a laboratory controlled environment. Methods. A paediatric ventilation balloon, mounted on a three dimensional fixation arm is connected to a ventilator. This is then placed in an open box, simulating the thorax. The ventilator machine connected to a compressed air source Is set on the required rate and tidal volume. Rate of ventilation simulates the heart rate and tidal volume the amplitude of outward displacement. All extra pieces of graft material left over after surgical procedures were preserved. All left over suture materials were saved and used for making anastomosis. A length of graft material was fixed on the balloon simulating the coronary artery. A stabilizer of choice was then placed. A second piece of graft material was used to make the desired anastomosis.
Results. We have been performing these experiments for the last six months on a regular basis. All coronary artery positions could be adequately simulated. Partidpating trainees made better progress in the conduct of not only off pump but also conventional CABG procedures.
Conclusion. We hope to assist trainees to achieve adequate skills to practice off pump distal anastomosis and help supervising surgeons to safely teach this technique to juniors. In the future we will use video scopes to simulate thoracoscopic and robot assisted anastomosis.
Condusion. The PUCA pump delivers approx. 2.5 L/mIn. The device can be safely introduced and explanted and functions without damaging body structures.
14
Netherlands Heart Joural, Volume 13, Supplement 3, December 2005
qC
Abstracts najaarsvergadenng Nederlandse Vereniging voor Thoraxchirurgie vrijdag 7 oktober 2005, Nieuwegeen
PATENCY AND FUNCTION OF S2 CONNECTOR VERSUS SUTURE CONSTRUCTED DISTAL ANASTOMOSES IN PORCINE OFF-PUMP ARTERIAL BYPASS GRAFTING WIL..Suyker (Isala Klinieken, Zwolle), JP Matonick (Ethicon Inc., Somerville, USA), PTW Suyker (lITech BV, Amsterdam), A Brutel de la Rivi6re (OLVG, Amsterdam), MP Buijsrogge (AMC, Amsterdam), RPJ Budde (UUMC, Utrecht), CWJ Verlaan (UUMC, Utrecht), G Pasterkamp (UUMC, Utrecht), PF Grundeman (UUMC, Utrecht), C Borst (UUMC,
Utrecht) Introduction: Anastomosis patency and function are critical to the success of coronary bypass grafting. A novel device for facilitating the construction of distal coronary anastomoses was evaluated pre-clinically by studying efficacy, function and remodeling over time, and was compared to a conventional suturing technique.
Methods: Left internal thoracic artery to left anterior descending coronary artery anastomoses were constructed in 35 pigs (73*8 kg), using the S Anastomotic System (S2AS) in 21 and a conventional suturing technique In 14 animals. The anastomoses were evaluated intra-operatively, at 90 and 180 days using a multimodality approach, including Fractional Flow Reserve determination and Intravascular Ultrasound.
Results: Anastomosis construction was easier with the S2AS in one-fourth of the suture construction time. Patency was 100%. An effective remodeling response was observed in both groups, resulting in unobstructed anastomoses with excellent hemodynamic performnance in all cases. The intraluminal, non-compliant connector was associated with less neointimal tissue at the vessel wall coaptation line than the suture. The side-to-side conflguration had effectively remodeled into an end-to-side shape.
Conclusions: In the porcine model, S2AS anastomosis construction was quicker and resulted in equivalent patency and function compared to the suture technique. Unconventional aspects like a non-compliant intraluminal ring and a converted configuration did not interfere with normal anastomosis remodeling.
Absrct na)aarsvergadenng Nederandse Vereniging voor Thoraxchirurgie vn)dag 7 oktober 2005, Nieuwegein
USE OF THE PUCA PUMP DURING BEATING HEART SURGERY JrndJen MJ Kulpers, G Warkotsch, J Diephuls Medisch Spectrum Twente, Enschede
Introduction. The PUCA pump consists of a 21 Fr catheter and a single port membrane pump, driven by any IABP driver. The tip of the catheter is positioned in the left ventricle. During aspiration the PUCA valve guides the blood from the ventricle towards the membrane pump, during ejection the blood is transported back and directed Into the aorta (Figure 1).
Materials and Methods. The PUCA pump (Intra-Vasc.nl, Groningen) was applied In a prospective clinical study in eight OPCAB patients with a mortality risk (Euroscore) of 6% or higher. During introduction, the position of the LV21 catheter was verified by TEE. The flow of the LV21 was measured continuously. The cardiac output was measured at certain time points. Blood samples were taken on set time points and were send to the lab for testing on blood damage and kidney and liver failure.
Resul. The Introduction of the LV21 lasted 25 minutes in the first patient, but decreased to 10-15 minutes after three patients. The flow generated by the LV21 was 2.4-2.8 L/min. No direct influence could be determined on the cardiac output. The blood tests did not show blood damage, except for one patient in which the pump was not positioned correctly. No kidney or liver damage was found. TEE examination after explantation of the LV21 revealed no damage of the aortic valve or other structures. Conclusion. The PUCA pump delivers approx. 2.5 /min. The device can be safely introduced and explanted and functions without damaging body structures.
Abstracts najaarsvergadering Nederlandse Vereniging voor Thoraxchirurgie vri)dag 7 oktober 2005, Nieuwegein
INTRAOPERATIVE CORONARY ARTERY AND GRAFT ASSESSMENT BY 13 MHz EPICARDIAL ULTRASOUND: INITIAL RESULTS IN 9 PATIENTS R.J.uddg, P.F.A. Bakker, R. Meijer, C. Borst, P.F. Grundeman Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The
Netherlands Introduction: A 13 MHz epicardial ultrasound mini-transducer (15x9x6 mm) was used to assess the target coronary artery and anastomosis on all sides of the heart, in 9 patients undergoing coronary artery bypass surgery. Methods: The mini-transducer was attached to a custom-made malleable handling tool (Figure). Scanning of 10 coronary arteries and 29 coronary anastomoses was performed during antegrade/retrograde blood cardioplegia. Results: All sides of the heart were easily accessible with the mini-transducer. Based on intraoperative scanning, the anastomotic site was altered (n=4), the decision was made to graft an additional coronary artery (n=2), and an intramural LAD was identified after incorrect conventional selection of a diagonal branch (n=1). No anastomosis construction errors were detected (Figure). In one anastomosis, a large calcified plaque was seen in the outflow corner. No preanastomosis scanning of the coronary artery had been performed in this case. In three other anastomoses (no pre-scanning), small calcified plaques at or just distal to the anastomosis were observed in the posterior wall of the coronary artery.
Conclusion: Using an epicardial ultrasound mini-transducer, coronary arteries and anastomoses on all sides of the heart were successfully visualized and assessed. Ultrasound information greatly aided in intraoperative decision-making that resulted in anastomotic site changes and prevented grafting of the wrong vessel.
Figure: left panel: Mini-transducer (black arrowhead) with malleable handling tool; right panel: longitudinal power Doppler image of IMA-LAD anastomosis (note scattering by clip on IMA side branch: white arrow).
Absas najaarvegadering Nedernandse Vereniging voor Thoraxchirurge vrjdag 7 oktober 2005, Nieuwegein
OFF PUMP CORONARY SURGERY SIMULATION - PRACTICAL TEACHING STATION -OLD SHOE BOX NEW TRICKS U SonkeIr A Driessen, WJ van Boven, HA van Swieten. Department of cardlothoracic surgery St. Antoniuszlekenhuis, Nleuwegein.
Introduction. Total revascularization without cardiopulmonary bypass continues to gain popularity. As in all surgical procedures there is a leaming curve. Cardiothoracic trainees receive limited exposure to this procedure. We describe an easy to assemble mechanical device which simulates the off pump surgical procedure in a laboratory controlled environment. Methods. A paediatric ventilation balloon, mounted on a three dimensional fixation arr Is connected to a ventilator. This is then placed in an open box, simulating the thorax. The ventilator machine connected to a compressed air source is set on the required rate and tidal volume. Rate of ventilation simulates the heart rate and tidal volume the amplitude of outward displacement. All extra pieces of graft material left over after surgical procedures were preserved. All left over suture materials were saved and used for making anastomosis. A length of graft material was fixed on the balloon simulating the coronary artery. A stabilizer of choice was then placed. A second piece of graft material was used to make the desired anastomosis. Results. We have been perforning these experiments for the last six months on a regular basis. All coronary artery positions could be adequately simulated. Participating trainees made better progress in the conduct of not only off pump but also conventional CABG procedures.
Conclusion. We hope to assist trainees to achieve adequate skills to practice off pump distal anastomosis and help supervising surgeons to safely teach this technique to juniors. In the future we will use video scopes to simulate thoracoscopic and robot assisted anastomosis.
Abstracts
Sessions
00de009 Nededamn VeornogWg
Abstrs &o,I
voorw Thoedyirwgle,b 7 oktober 2005, Neovgec
Abust.
PRESERVED HYPERAEMIC SUPRACLAVICULAR DOPPLER RESPONSE DEMONSTRATES FUNCTION ON DEMAND OF THE UMA TO LAD STRING SIGN GRAFT 1M Hartman. JC Kelder2, RGA Ackerstaff', HA van Swieten4, FEE Vermeulen', AJJC Bogers'.1 Department of Cardlothoradc Surgery, Erasmus Medkcal Centre Rotterdam. 2 Department of Cardiology, St. Antonius Hospital, Nleuwegeln. 3 Department of Clinical Neurophysiology, St. Antonius Hospital, Nleuwegein. 4 Department of Thoracic and Cardiovascular Surgery, St. Antonius Hospital,
Heart center, Radboud University
Methods: 16 patients (13 M, 63 * 8 yr) with a single UMA to the LAD were prospectively entered in a follow up study. The supraclavicular duplex of the UMA origin was studied ECG controlled preoperatively and at 5.3 * 3.6 m. and 1.7 * 0.4 yr. postoperatively. Duplex parameters analysed: systolic and diastolic
Resufts: 1 patient was excluded. Control anglography showed in 12 pts. (group I) patent and in 3 pts. (group It) string sign UMA grafts. No objective or subjective ischemia could be detected at rest or during hypersemic response. ost I 33414
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p: dlfferences between groups for values in time at rest postoperatively pl: differences between groups for Increasing values In hyperaemic response.
Nijmegen
Methods: This study included 627 patients undergoing an isolated CABG between January 2003 and September 2004. Patients were divide in Group A-Scr, 576 patients (91.1%) with a good renal function, Scr S1,20mg/dl for women and S1,40 mg/di for men. Group B-Scr, with Impaired renal function, 51 Patients (8.1%). A CrCl s 50ml/min was chosen to reflect renal Impairment, Group A-CrCl, 555 patients (88.5%) wlth a normal renal function and group B-CrCl, 72 patients (11.5%) with an impaired renal function. The studied outcomes were hospital mortality, hospital morbidity and postoperative renal failure and dialysis.
peak velocity (SPV, DPV), systolic and diastolic velocity integral (SVI, DVI), diastollc/systolic peak velocity ratio (DSVR) and diastollc/systolic total velocity Integral ratio (DSTVIR). At the late postoperative duplex hyperaemic response was also studied during adenosine Infusion (o.14 mg/kg/min.) for 6 min. Control angiography (native and UMA) was done at 1.5 * 0.9 yr. Differences within groups were tested with paired -and between groups with unpaired t-tests.
11 12*2
Irijdpag 7 oktober 2005, NiWn-g.Wm
Background: Preoperative renal failure is a risk factor for adverse events In cardiac surgery. Serum creatinine (SCr) is the most used test for renal failure, however patients can have significantly decreased glomerular filtration rates with normal SCr levels. More accurate approximation of renal function can be obtained using creatinine clearance (CICr) calculated by the Cockcroft-Gault equitation from SCr.
Introduction: To demonstrate functionality of string sign LIMA to LAD grafts compared to patent LIMA to LAD grafts by supraclavkcular duplex.
onus
o
ESTIMATED CREATININE CLEARANCE INSTEAD OF PLASMA CREATININE LEVEL AS SCREENING TEST FOR RENAL FAILURE IN PATIENTS UNDERGOING A MYOCARDIAL REVASCULARIZATION. I. Plesiewicz, L. Noyez, FWA Verheugt
Nleuwegein
GrtDI 14*8
,fiaJae,gde.rg lNdd Ve.nmgiug voor
Results: There was no statistical significant difference between A-Scr and B-Scr-group according to the studied outcomes. Using the CrCl, there was a statistical significant differences between A-CrCl and B-CrCL for the percentage of postoperative renal failure (p=0.00), dialysis (p=0.00), hospital morbidity (p=0.04). Regression analysis shows a significant relation between A CrCI s 50ml/min and postoperative renal failure and
dialysis.
Conclusion: The association adverse outcomes after CABG with the routinely used Scr. glomerular flltration rate should
between preoperative renal function and is stronger with the estimated CICr than Routine estimation or measurement of be the preferred to Scr.
Condusion: Patients wlth patent as well as string sign UMA grafts showed a shift towards a coronary flow profile at rest and in hyperaemic response postoperatively. The hyperaemic response test revealed the functionality of the string sign LIMA graft demonstrating the adaptability responding to lower resistance of the coronary artery.
Abt5 n0a005.0207
50ded0randse Ve.eiging
Thnorchqeru, ,Jdug 7 okuto 2005, Nws0gqsn
PRIMARY SYMPATHiECTOMY FOR THORACOSCOPIC HYPERHIDROSIS: 1999-2004 MS de ionfg LA de Leeuw, MP de Jong, HEJ Sinninghe Damstd, P]H Smits Twenteborg Hospital Almelo
Introduction. Hyperhidrosis can cause significant professional and social handicaps. Although treatments such as oral medication, botox and iontophoresis are available, surgical treatment Is being increasingly utilized. The purpose of our study was to review patient characteristics, surgical technique, and outcome of patients undergoing thoracoscopic sympathectomy for severe hyperhidrosis. Methods. Between January 1999 and January 2005 fifty-five patients with palmar, axillary, facial or plantar hyperhidrosis underwent a thoracoscopic sympathectomy. Surgical technique Included coagulation of the sympathetic ganglia at T2, T3 or T4 using monopolar cautery. Clinical charts were reviewed for patient demographic data, location of symptoms. All patients were contacted by telephone to asses early and late operative outcome, degree of compensatory sweating, persistent complications and degree of satisfaction with the treatment.
Results. Patient demograplcs Included 45% (25/55) males and 55% (30/55) females, with a mean age of 27 years old (range 20 tot 51 years old). Preoperatively, 15% (8/55) had palmar sweating only, 29% (16/55) axillary only, 25% (14/55) palmar and axillary, 31% (17/55) had a combination of above mentioned with/without facial/plantar sweating. Mean follow up was 38 months. Complications included a mild temporary Homer's Syndrome (n=1; 2%), air leak requiring chest drainage (n =8; 15%), bleeding (n = 3; 5%) requiring thoracotomy. EIghty-four percent experienced compensatory hyperhidrosis. Overall satisfaction was 90%.
Condusion. Thoracoscopic sympethectomy is a safe, effective and definite solution for primary hyperhldrosis. Although overall satisfaction is high, patients should be folly Informed about the potential for complications and compensatory sweating.
A5.t,co
n pamrs.erdws Nedavd, Veengivg ,voo Th-hinurge
SURGICAL ASSESSMENT OF THE PULMONARY INTRAVASCULAR VOLUME FOR DRUG DOSE CALCULATION IN ISOLATED LUNG PERFUSION BP van Putte2.3 E5 A Huisman4, JMH Hendriks2, PEY van SchIl2, WJ van Boven5, F Schramel and G Folkerts3 Department of 4clinical chemistry, University Medical Center, Utrecht, the Netherlands. 2Department of thorack and vascular surgery, University Hospital Antwerp, Anttwerp, Belgium. 3Department of pharmacology and pathophysiology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Nethertands. Departments of scardiothoraclc surgery and 'pulmonology, St. Antonlus hospital, Nieuwegein, the Netherlands
Introduction: Isolated lung perfusion (ILuP) is an experimental technique for the treatment of pulmonary metastases. Clinical trials showed a wide range in drug lung levels. This may be due to the variance of lung size and pulmonary intravascular volume (PIV). Therefore, we developed a method to assess PIV and Investigated the relation of PIV and dry lung weight (DLW). Methods: Thirty-two rats of 555±8g (groups 1-3) and 199t5g (group 4) underwent cannulatlon of the pulmonary vessels without blood loss. Subsequently, groups 1 and 3 had ILuP with starch during two and eight minutes while groups 2 and 4 during 4 minutes. Effluent was analyzed for haemoglobin, red blood cells (RBC), leucocytes, platelets, albumin and creatinin. PIV was calculated by dividing the product of the perfusate volume and a post-ILuP biochemical parameter by the difference between post-ILuP and pre-ILuP biochemical parameter. Statistical analysis was performed using ANOVA and Ttest.
Results. No significant differences In PIV were observed between different perfusion times for haemoglobin, RBC, leucocytes and platelets. No significant differences In PIV for all perfusion times were noted between the biochemical variables (p=0.14). Based on haemoglobin (p 40 mm) and extemal cardlac support (CorCap) may further improve outcome.
Abstrs naJaarsvergadrn Nied&ndse Verening voor Thoraxchirurgie vrijdag 7 oktober 2005, Nieuwegen
MYOCARDIAL LYMPHOID CHEMOKINE EXPRESSION AFFECTS CD8+ T-CELL RECIRCULATION IN REJECNG RECIPIENTS A R CLINICAL HEART TRANSPLANTATION A. peeteisb, LMB Vaeen b, APWM Maata, CC Baanb, A AHMM Balkc, W Weimarb and AJJC Bogers! Departments of "Cardiothoracic Surgery, bIntemal Medkine and cCardiology Erasmus MC, Rotterdam, The Netherlands.
Introduction: Recirculation of allo-reactive T-cells is regulated by concerted action of chemokines (CCLs) and their receptors (CCRs). We investigated blood T-cell subset CCR expression and intragraft CCR & CCL mRNA levels in relation to acute rejection (AR) after heart transplantation
(post-HTx). Methods: Twenty cardiac allograft recipients under triple maintenance immunosuppression were studied prospectively in a 9-month follow-up post-HTx. At the time of endomyocardial biopsy, CCR5 and CCR7 expression on peripheral blood CD4+ and CD8+ T-cells was measured by flow-cytometry. Intragraft CCRS, CCR7, inflammatory (CCL5) and lymphold (CCL19) CCL mRNA levels were measured by Q-PCR. Thirteen biopsy-proven AR episodes (AR+: ISHLT 23A) were compared to 127 samples fom non-rejection episodes (AR-: ISHLT 0, n=70; ISHLT 1, n=41; ISHLT 2, n=16).
Results: In circulating CD4+ cells, no signiflcant differences in the % CCR5+ or % CCR7+ cells were found between AR- and AR+ episodes. For the CD8+ subset, during AR+ the %CCR5+ cells was higher (p 5,0 mmol/l bij de start van de behandeling Patienten met matige tot ernstige nierinsufficientie. Patienten met ernstige lecerinsufficientie Patienten die worden behandeld met kalaumsparende diufetica, kaliumsupplementen of met sterke CYP3A4-remmers zoals itraconazol, ketocona7a1, ritonavif, nelfinavir, claritromycine, telitromypine en nefazodon. Waarschuwingen en voorzorgen: Overeenkomstig het werkingsmechanisme van eplerenone kan hyperkaliemie optreden. Kaliumspiegels dienen bij elke patient gecontroleerd te worden bij aanvang van de behandeling, bij verandering van de dosering en indien nier- of leverfunctiestoornissen aanwezig ziln. Gelijktijdige toediening van eplerenone met sterke CYP3A4-inductoren wordt niet aanbevolen en toediening gelijktijdig met lithium, cyclospofine en tacrolimus dient vermeden te worden. De tabletten bevatten lactose en mogen niet gebruikt worden bij patienten met zeldzame, erfelijke problemen van galactose-intolerantre, Lapp-lactase-deficientie of gluaosegalactose-malabsorptie Interacties: Ge1iqktijdige toediening van eplerenone met amiodaron, diltiazem en verapamil hebben geleid tot significante farmacokinetische interacties. De dosering van eplerenone dient niet hoger te nijn dan 25 mg als deze zwakke tot matige CYP3A4-remmers gelijktijdig met eplerenone worden toegediend. Voot een volledig overzicht van de interacties dient de volledige productinofamatie (SPC) te worden geraadpleegd. Bijwerkingen: In de EPHESUS-studie was de totale incidentie van bijwerkingen die gemeld werden bij gebruik van eplerenone (78,9%) vergelijkbaar met placebo (79,5A). Vaak 1/100, 1t /10) kwamen voof hyperka/r-mie, duizeligheid, hypotensie, diarree, misselijkheid en nierfunctiestoornissen. Soms 1/1000, 1t /100) kwamen voon eosinotilie, dehydratie, hypefcholesterolemie, hypertriglyceridemre, hyponatriemie, slapeloosheid, hoofdpijn, atriumfibrilleren, myocardinfarat, systolisch hartfalen, orthostatische hypotensie, arteriele trombose in het been, faryngitis, flatulentie, braken, jeuk, toegenomen transpiratie, rugpijn, beenkrampen, asthenie, algehele malaise, verhoogde 8UN-waarden, verhoogde serumcreatininespregels en pyelonefritis. Afleveeingsstatus: U.R. Verpakking: Inspra is verkrijgbaar in verpakkingen met 30 en 50 tabletten in doordrukstrips. Datum: november 2004. Registratienummert: inspra 25 RVG 29963: Inspra 50/ RVG 29964. Vergoeding en prijzen: inspra wordt volledig vergoed binnen het GVS. Voof pfijzen wordt verwezen naaf de l-Index taxe. De volledige productinfofmatie is op aanvraag verkrijgbaat bij de registratiehouder Pfizer bv, Postbus 37, 2900 AA Capelle a/d Ijssel. Referentie: 1. Pitt B et al. N Fag/I Med 2003 34&1309-21
m
b
/Voor medische informatie over dit product belt u met 0800-MEDINFO (6334636) Pfizer bv, Postbus 37, 2900 AA Capelle a/d ljssel
Abstracts najaarsvergadering Nederlandse Vereniging voor Thoraxchirurgte vr)dag 7 oktober 2005, N.euwegein
programma juniorkamer, voorzitter A. Driessen
11.00 uur
EPICARDIAL SURGERY
ULTRASOUND
IN
CORONARY
ARTERY
BYPASS
R.P.). Budde, Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
The aim of the research described in this thesis was to evaluate epicardial ultrasound as a means to locate and assess coronary arteries and assess the quality of the distal coronary anastomosis in (totally endoscopic, offpump) coronary artery bypass grafting. The main conclusions of the studies in this thesis are: 1. The 13 MHz epicardial ultrasound mini-transducer enables successful endoscopic localization and assessment of the major target coronary arteries for bypass grafting within a median of 3 minutes per artery.
2. The conventionally sutured distal coronary anastomosis can be assessed in high detail by 13 MHz ultrasound in both open- and closedchest off-pump CABG. Anastomosis construction errors are detected by epicardial ultrasound with higher sensitivity (0.98) and specificity (1.00) than by the gold standard angiography (0.75 and 0.81,
respectively). 3. Epicardial 13 MHz ultrasound enables intraoperative assessment of the S2AS coronary connector anastomosis in considerable detail, in spite of some metal induced echo artefacts. 4. The 13 MHz epicardial ultrasound mini-transducer can be used on all sides of the heart for coronary artery and coronary anastomosis assessment and provides valuable information to aid in intraoperative descision making.
